Danielle S. Chun

The NFL Orthopaedic Surgery Outcomes Database (NO-SOD) The Effect of Common Orthopaedic Procedures on Football Careers

Background: Injuries are inherent to the sport of American football and often require operative management. Outcomes have been reported for certain surgical procedures in professional athletes in the National Football League (NFL), but there is little information comparing the career effect of these procedures. Purpose: To catalog the postoperative outcomes of orthopaedic procedures in NFL athletes and to compare respective prognoses and effects on careers. Study Design: Case series; Level of evidence, 4. Methods: Athletes in the NFL undergoing procedures for anterior cruciate ligament (ACL) tears, Achilles tendon tears, patellar tendon tears, cervical disc herniation, lumbar disc herniation, sports hernia, knee articular cartilage repair (microfracture technique), forearm fractures, tibial shaft fractures, and ankle fractures were identified through team injury reports or other public records. Game and performance statistics during the regular season were collected before and after surgery. Statistical analysis was performed with significance accepted as P < .05. Results: A total of 559 NFL athletes were included. Overall, 79.4% of NFL athletes returned to play after an orthopaedic procedure. Forearm open reduction and internal fixation (ORIF), sports hernia repair, and tibia intramedullary nailing (IMN) led to significantly higher return-to-play (RTP) rates (90.2%-96.3%), while patellar tendon repair led to a significantly lower rate (50%) (P < .001). Athletes undergoing ACL reconstruction (ACLR), Achilles tendon repair, patellar tendon repair, and ankle fracture ORIF had significant declines in games played at 1 year and recovered to baseline at 2 to 3 years after surgery. Athletes undergoing ACLR, Achilles tendon repair, patellar tendon repair, and tibia IMN had decreased performance in postoperative season 1. Athletes in the Achilles tendon repair and tibia IMN cohorts recovered to baseline performance, while those in the ACLR and patellar tendon repair cohorts demonstrated sustained decreases in performance. Conclusion: ACLR, Achilles tendon repair, and patellar tendon repair have the greatest effect on NFL careers, with patellar tendon repair faring worst with respect to the RTP rate, career length after surgery, games played, and performance at 1 year and 2 to 3 years after surgery.

Sulfated glycopeptide nanostructures for multipotent protein activation

Biological systems have evolved to utilize numerous proteins with capacity to bind polysaccharides for the purpose of optimizing their function. A well-known subset of these proteins with binding domains for the highly diverse sulfated polysaccharides are important growth factors involved in biological development and tissue repair. We report here on supramolecular sulfated glycopeptide nanostructures, which display a trisulfated monosaccharide on their surfaces and bind five critical proteins with very different polysaccharide binding domains. Binding does not disrupt the filamentous shape of the nanostructures or their internal β-sheet backbone, but must involve accessible adaptive configurations to interact with such different proteins. The glycopeptide nanostructures amplified signaling of bone morphogenetic protein 2 significantly more than the natural sulfated polysaccharide heparin, and promoted regeneration of bone in the spine with a protein dose that is 100-fold lower than expected. These super-bioactive nanostructures may enable many therapies in the horizon involving proteins.

Lumbar pseudarthrosis: a review of current diagnosis and treatment

OBJECT Failed solid bony fusion, or pseudarthrosis, is a well-known complication of lumbar arthrodesis. Recent advances in radiographic technology, biologics, instrumentation, surgical technique, and understanding of the local biology have all aided in the prevention and treatment of pseudarthrosis. Here, the current literature on the diagnosis and management of lumbar pseudarthroses is reviewed. METHODS A systematic literature review was conducted using the MEDLINE and Embase databases in order to search for the current radiographie diagnosis and surgical treatment methods published in the literature (1985 to present). Inclusion criteria included: 1) published in English; 2) level of evidence I-III; 3) diagnosis of degenerative lumbar spine conditions and/or history of lumbar spine fusion surgery; and 4) comparative studies of 2 different surgical techniques or comparative studies of imaging modality versus surgical exploration. RESULTS Seven studies met the inclusion criteria for current radiographie imaging used to diagnose lumbar pseudarthrosis. Plain radiographs and thin-cut CT scans were the most common method for radiographie diagnosis. PET has been shown to be a valid imaging modality for monitoring in vivo active bone formation. Eight studies compared the surgical techniques for managing and preventing failed lumbar fusion. The success rates for the treatment of pseudarthrosis are enhanced with the use of rigid instrumentation. CONCLUSIONS Spinal fusion rates have improved secondary to advances in biologies, instrumentation, surgical techniques, and understanding of local biology. Treatment of lumbar pseudarthrosis includes a variety of surgical options such as replacing loose instrumentation, use of more potent biologies, and interbody fusion techniques. Prevention and recognition are important tenets in the algorithm for the management of spinal pseudarthrosis.

Intra-articular Vancomycin Powder Eliminates Methicillin-resistant S. aureus in a Rat Model of a Contaminated Intra-articular Implant

Background: Periprosthetic joint infection following hip and knee arthroplasty leads to poor outcomes and exorbitant costs. Topical vancomycin powder has been shown to decrease infection in many procedures such as spine surgery. The role of vancomycin powder in the setting of total joint arthroplasty remains undefined. Our aim was to evaluate the efficacy of intra-articular vancomycin powder in preventing infection in a rat model of a contaminated intra-articular implant. Methods: Thirty-two female Sprague-Dawley rats underwent knee arthrotomy and implantation of a femoral intramedullary wire with 1 mm of intra-articular communication. The knee joint was also inoculated with 1.5 × 107 colony forming units (CFU)/mL of methicillin-resistant Staphylococcus aureus (MRSA). Four treatment groups were studied: (1) no antibiotics (control), (2) preoperative systemic vancomycin, (3) intra-articular vancomycin powder, and (4) both systemic vancomycin and intra-articular vancomycin powder. The animals were killed on postoperative day 6, and distal femoral bone, joint capsule, and the implanted wire were harvested for bacteriologic analysis. Statistical analyses were performed using Wilcoxon rank sum and Fisher exact tests. Results: There were no postoperative deaths, wound complications, signs of vancomycin-related toxicity, or signs of systemic illness in any of the treatment groups. There were significantly fewer positive cultures in the group that received vancomycin powder in combination with systemic vancomycin compared with the group that received systemic vancomycin alone (bone: 0% versus 75% of 8, p = 0.007; Kirschner wire: 0% versus 63% of 8, p = 0.026; whole animal: 0% versus 88% of 8, p = 0.01). Only animals that received both vancomycin powder and systemic vancomycin showed evidence of complete elimination of bacterial contamination. Conclusions: In a rat model of a contaminated intra-articular implant, use of intra-articular vancomycin powder in combination with systemic vancomycin completely eliminated MRSA bacterial contamination. Animals treated with systemic vancomycin alone had persistent MRSA contamination. Clinical Relevance: This animal study presents data suggesting that the use of intra-articular vancomycin powder for reducing the risk of periprosthetic joint infections should be investigated further in clinical studies.

Mechanistic insight into the effects of Aryl Hydrocarbon Receptor activation on osteogenic differentiation

While inhibition of bone healing and increased rates of pseudarthrosis are known adverse outcomes associated with cigarette smoking, the underlying mechanisms by which this occurs are not well understood. Recent work has implicated the Aryl Hydrocarbon Receptor (Ahr) as one mediator of the anti-osteogenic effects of cigarette smoke (CS), which contains numerous toxic ligands for the Ahr. 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD, dioxin) is a high-affinity Ahr ligand frequently used to evaluate Ahr pathway activation. The purpose of this study was to elucidate the downstream mechanisms of dioxin action on bone regeneration and investigate Ahr antagonism as a potential therapeutic approach to mitigate the effects of dioxin on bone. Markers of osteogenic activity and differentiation were assessed in primary rat bone marrow stromal cells (BMSC) after exposure to dioxin, Ahr antagonists, or antagonist + dioxin. Four Ahr antagonists were evaluated: α-Naphthoflavone (ANF), resveratrol (Res), 3,3′-Diindolylmethane (DIM), and luteolin (Lut). Our results demonstrate that dioxin inhibited ALP activity, migratory capacity, and matrix mineralization, whereas co-treatment with each of the antagonists mitigated these effects. Dioxin also inhibited BMSC chemotaxis, while co-treatment with several antagonists partially rescued this effect. RNA and protein expression studies found that dioxin down-regulated numerous pro-osteogenic targets, whereas co-treatment with Ahr antagonists prevented these dioxin-induced expression changes to varying degrees. Our results suggest that dioxin adversely affects bone regeneration in a myriad of ways, many of which appear to be mediated by the Ahr. Our work suggests that the Ahr should be investigated as a therapeutic target to combat the adverse effects of CS on bone healing.

Factors Associated with Financial Relationships between Spine Surgeons and Industry

Study Design. A retrospective review of Centers for Medicare and Medicaid Services Database. Objective. Utilizing Open Payments data, we aimed to determine the prevalence of industry payments to orthopedic and neurospine surgeons, report the magnitude of those relationships, and help outline the surgeon demographic factors associated with industry relationships. Summary of Background Data. Previous Open Payments data revealed that orthopedic surgeons receive the highest value of industry payments. No study has investigated the financial relationship between spine surgeons and industry using the most recent release of Open Payments data. Methods. A database of 5898 spine surgeons in the United States was derived from the Open Payments website. Demographic data were collected, including the type of residency training, years of experience, practice setting, type of medical degree, place of training, gender, and region of practice. Multivariate generalized linear mixed models were utilized to determine the relationship between demographics and industry payments. Results. A total of 5898 spine surgeons met inclusion criteria. About 91.6% of surgeons reported at least one financial relationship with industry. The median total value of payments was

Performance-Based Outcomes after Anterior Cruciate Ligament Reconstruction in Professional Athletes Differ between Sports

994.07. Surgeons receiving over

Do Demographic Factors of Spine Surgeons Affect the Rate at Which Spinal Fusion Is Performed on Patients

1,000,000 from industry during the reporting period represented 6.6% of the database and accounted for 83.5% of the total value exchanged. Orthopedic training (P < 0.001), academic practice setting (P < 0.0001), male gender (P < 0.0001), and West or South region of practice (P < 0.0001) were associated with industry payments. Linear regression analysis revealed a strong inverse relationship between years of experience and number of payments from industry (r = -0.967, P < 0.0001). Conclusion. Financial relationships between spine surgeons and industry are highly prevalent. Surgeon demographics have a significant association with industry-surgeon financial relationships. Our reported value of payments did not include ownership or research payments and thus likely underestimates the magnitude of these financial relationships. Level of Evidence: 3

Effects of Conflicts of Interest on Practice Patterns and Complication Rates in Spine Surgery

Background: Excellent outcomes have been reported for anterior cruciate ligament (ACL) reconstruction (ACLR) in professional athletes in a number of different sports. However, no study has directly compared these outcomes between sports. Purpose: To determine if differences in performance-based outcomes exist after ACLR between professional athletes of each sport. Study Design: Cohort study; Level of evidence, 3. Methods: National Football League (NFL), National Basketball Association (NBA), National Hockey League (NHL), and Major League Baseball (MLB) athletes undergoing primary ACLR for an acute rupture were identified through an established protocol of injury reports and public archives. Sport-specific performance statistics were collected before and after surgery for each athlete. Return to play (RTP) was defined as a successful return to the active roster for at least 1 regular-season game after ACLR. Results: Of 344 professional athletes who met the inclusion criteria, a total of 298 (86.6%) returned to play. NHL players had a significantly higher rate of RTP (95.8% vs 83.4%, respectively; P = .04) and a shorter recovery time (258 ± 110 days vs 367 ± 268 days, respectively; P < .001) than athletes in all the other sports. NFL athletes experienced significantly shorter careers postoperatively than players in all the other sports (2.1 vs 3.2 years, respectively; P < .001). All athletes played fewer games (P ≤ .02) 1 season postoperatively, while those in the NFL had the lowest rate of active players 2 and 3 seasons postoperatively (60%; P = .002). NBA and NFL players showed decreased performance at season 1 after ACLR (P ≤ .001). NFL players continued to have lower performance at seasons 2 and 3 (P = .002), while NBA players recovered to baseline performance. Conclusion: The data indicate that NFL athletes fare the worst after ACLR with the lowest survival rate, shortest postoperative career length, and sustained decreases in performance. NHL athletes fare the best with the highest rates of RTP, highest survival rates, longest postoperative career lengths, and no significant changes in performance. The unique physical demand that each sport requires is likely one of the explanations for these differences in outcomes.

Factors Associated With Financial Relationships Between Spine Surgeons and Industry: An Analysis of the Open Payments Database

Study Design. Retrospective study. Objective. The purpose of this study was to evaluate associations between spine surgeon demographics and the rate at which elective spine fusion is performed. Summary of Background Data. Rapidly increasing rates of elective spinal fusion in the United States have given rise to important questions about what factors may drive spine surgeon decision making. Methods. Publicly available spine surgeon practice pattern data from Centers for Medicare and Medicaid Services were reviewed retrospectively. Fusion rate was defined as the number of fusion procedures performed on Medicare beneficiaries by a surgeon per total number of unique Medicare beneficiaries seen. Inclusion criteria were neurological or orthopedic spine surgeons who performed 11 or more separate spine fusion procedures on Medicare patients between 2011 and 2013 as defined by this database. Demographic information was collected from public record. The increased probability of a surgeon performing spine fusion was assessed using a relative risk (RR) and corresponding 95% confidence interval (CI). Results. A total of 3979 spine surgeons who practice in the United States and performed spine fusion on 171,676 Medicare patients from 2011 to 2013 met the inclusion criteria. The average rate of spine fusion for surgeons in this database was 7.5%. Surgeons with higher fusion rates practiced in an academic versus private setting (RR = 1.44, 95% CI [1.35–1.53]; P < 0.0001), were more likely neurological versus orthopedic surgeons (RR = 1.10, 95% CI [1.05–1.15]; P < 0.0001), and practiced in the West versus Midwest, South, and Northeast region of the United States (RR = 1.20, 95% CI [1.14–1.27]; P < 0.0001). Number of years in practice was significantly associated negatively with fusion rate (P < 0.0001). Conclusion. Significant variation in the rate of spine fusion based on practice type, training, region, and experience suggests poor consensus on indications for this procedure. Knowledge of these relationships may help identify underlying reasons for variations in surgical care and improve surgical outcomes. Level of Evidence: 3