Elizabeth C. Gardner

Risk Factors for Short-term Adverse Events and Readmission After Arthroscopic Meniscectomy Does Age Matter?

Background: Recent studies have questioned the efficacy of meniscectomy in older patients with and without evidence of osteoarthritis; however, it continues to be frequently performed. There is limited information about age and other risk factors for adverse events and readmission after the procedure. This knowledge is vital to understand the true risk profile of this common surgery. Purpose: To investigate if age and medical comorbidities were risk factors for postoperative adverse events and readmission after meniscectomy. Study Design: Case-control study; Level of evidence, 3. Methods: Patients who underwent arthroscopic meniscectomy between 2005 and 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Age ≥65 years and medical comorbidities were evaluated as risk factors for any adverse event (AAE), severe adverse events (SAEs), and readmission after meniscectomy using univariate and multivariate analyses. Results: A total of 17,774 patients who underwent meniscectomy were identified. The mean age was 53.0 ± 13.6 years. A total of 3420 patients (19.2%) were ≥65 years. Overall, 208 patients (1.17%) had AAE, 203 patients (1.14%) had an SAE, and 102 patients were readmitted (0.97%). Multivariate logistic regression analyses demonstrated no significant differences between age groups for the occurrence of AAE, SAEs, and readmission. Patients with American Society of Anesthesiologists classification ≥3 had increased odds of AAE (odds ratio [OR], 1.58), SAEs (OR, 1.59), and readmission (OR, 1.99). Patients with diabetes had increased odds of AAE (OR, 1.57) and SAEs (OR, 1.51). Smokers had increased odds of readmission (OR, 1.67). Patients with pulmonary disease had increased odds of AAE (OR, 1.76) and SAEs (OR, 1.70). Conclusion: Meniscectomy is a safe procedure in older patients, as age over 65 years did not increase the odds of any of the adverse events studied. However, regardless of age, patients with an increased comorbidity burden and those with a history of smoking are at increased risk of adverse events and/or readmission after the procedure. Clinical Relevance: Knowledge of these risk factors for adverse events and readmission provides essential information for patient selection and preoperative counseling.

Shoulder Injuries in Men’s Collegiate Lacrosse, 2004-2009

Background: Men’s lacrosse has been one of the fastest growing team sports in the United States, at both the collegiate and high school levels. Uniquely, it combines both continuous overhead and contact activity. Thus, an understanding of its injury epidemiology and mechanisms is vital. Shoulder injuries have been shown to be common in the sport, but thus far there has been no dedicated analysis of these injuries with which to better inform injury prevention strategies. Study Design: Descriptive epidemiology study. Methods: All athlete exposures (AEs) and shoulder injuries reported to the National Collegiate Athletic Association (NCAA) Injury Surveillance System for intercollegiate men’s lacrosse athletes from 2004-2005 through 2008-2009 were collected. Type of injury was documented and the injury incidence per 1000 AEs was calculated. Event type, injury mechanism, specific injury, outcome, and time lost were recorded. Statistical analysis was performed using 95% CIs, calculated based on a normal approximation to Poisson distribution. Results: There were a total of 124 observed shoulder injuries during 229,591 monitored AEs. With weights, this estimates 1707 shoulder injuries over 2,873,973 AEs, for an incidence of 0.59 per 1000 AEs (95% CI, 0.56-0.62). The incidence of shoulder injury during competition was 1.89 per 1000 AEs (95% CI, 1.76-2.02), compared with 0.35 per 1000 AEs (95% CI, 0.33-0.38) during practice. Acromioclavicular joint injuries were most common (0.29 per 1000 AEs; 95% CI, 0.27-0.31). Labral injuries and instability events were also frequent (0.11 per 1000 AEs; 95% CI, 0.10-0.13). Player-to-player contact caused 57% of all shoulder injuries, with 25% due to contact with the playing surface. The average time lost was 11.0 days, with 41.9% of all shoulder injuries requiring ≥10 days. Clavicle fractures and posterior shoulder dislocation were particularly severe, with no athletes returning to play during the same season. Conclusion: Shoulder injuries are common in NCAA men’s lacrosse and are an important source of lost playing time. Acromioclavicular injuries were the most frequent injury in this series, but labral and instability injuries were also common. In this increasingly popular contact sport, an understanding of the epidemiology and mechanism of shoulder injuries may be used to improve protective equipment and develop injury prevention.

Head, Face, and Eye Injuries in Collegiate Women’s Field Hockey

Background: While there is concern regarding head, face, and eye injuries in field hockey, prompting some to recommend the use of protective equipment such as goggles and helmets, little has been written about their incidence and mechanism of injury in the modern game of field hockey. The elucidation of this information will better inform the development of maximally effective injury prevention schemes to protect the athlete while maintaining the integrity of the game. Purpose: To determine the incidence and epidemiology of head, face, and eye injuries in United States collegiate women’s field hockey players from 2004-2005 to 2008-2009. Study Design: Descriptive epidemiological study. Methods: All head, face, and eye injuries reported to the National Collegiate Athletic Association Injury Surveillance System for collegiate women’s field hockey athletes from the 2004-2005 through 2008-2009 seasons were analyzed. Data regarding the event type, injury mechanism, body part injured, type of injury, outcome, and time lost were reviewed. The weighted injury incidence per 1000 athlete-exposures (AEs) was calculated using the exposure data set for the same years; 95% CIs were calculated based on a normal approximation to the Poisson distribution. Results: There were 150 reported traumatic injuries during this time period, with a weighted occurrence of 1587.3 injuries. The overall incidence of head, face, and eye injuries in collegiate women’s field hockey was 0.94 per 1000 AEs (95% CI, 0.86-1.19). Injuries to the head or face, other than the mouth, nose, and eye, accounted for 75.3% of these injuries. The incidence of eye injuries was 0.07 per 1000 AEs (95% CI, 0.03-0.12); nose injuries occurred at a rate of 0.10 per 1000 AEs (95% CI, 0.05-0.15). The rate of traumatic dental injuries was 0.06 per 1000 AEs (95% CI, 0.04-0.14). Contact with an apparatus caused 72.9% of all injuries; specifically, contact with an elevated ball accounted for 47.9% of all injuries, and contact with an elevated stick caused 21.7% of all injuries. While the majority of players suffering a head, face, or eye injury were able to return to sport that season (90.0%), the remaining athletes suffered season-ending injuries (10%). Concussions accounted for 42.8% of all head, face, and eye injuries reported (0.40 per 1000 AEs; 95% CI, 0.32-0.53). Conclusion: Head, face, and eye injuries occur regularly in women’s field hockey. This description of the injury profile and mechanisms of injury may be used to design appropriate injury prevention schemes for the sport.

Accuracy of Femur Angles Estimated by IMUs During Clinical Procedures Used to Diagnose Femoroacetabular Impingement

We present a novel method for quantifying femoral orientation angles using a thigh-mounted inertial measurement unit (IMU). The IMU-derived femoral orientation angles reproduce gold-standard motion capture angles to within mean (standard deviation) differences of 0.1 (1.1) degrees on cadaveric specimens during clinical procedures used for the diagnosis of Femoroacetabular Impingement (FAI). The method, which assumes a stationary pelvis, is easy to use, inexpensive, and provides femur motion trajectory data in addition to range of motion measures. These advantages may accelerate the adoption of this technology to inform FAI diagnoses and assess treatment efficacy. To this end, we further investigate the accuracy of hip joint angles calculated using this methodology and assess the sensitivity of our estimates to skin motion artifact during these tasks.

The Epidemiology of Hip/Groin Injuries in National Collegiate Athletic Association Men's and Women's Ice Hockey: 2009-2010 Through 2014-2015 Academic Years.

Background: There is limited research regarding the epidemiology of hip/groin injuries in ice hockey, the majority of which is restricted to time-loss injuries only. Purpose: To describe the epidemiology of hip/groin injuries in collegiate men’s and women’s ice hockey from 2009-2010 through 2014-2015. Study Design: Descriptive epidemiology study. Methods: Hip/groin injury data from the National Collegiate Athletic Association Injury Surveillance Program (NCAA-ISP) during the 2009-2010 through 2014-2015 seasons were analyzed. Injury rates, rate ratios (RRs), and injury proportion ratios (IPRs) were reported with 95% confidence intervals (CIs). Results: During the 2009-2010 through 2014-2015 seasons, 421 and 114 hip/groin injuries were reported in men’s and women’s ice hockey, respectively, leading to injury rates of 1.03 and 0.78 per 1000 athlete-exposures (AEs), respectively. The hip/groin injury rate was greater in men than in women (RR, 1.32; 95% CI, 1.08-1.63). In addition, 55.6% and 71.1% of hip/groin injuries in men’s and women’s ice hockey, respectively, were non–time loss (NTL) injuries (ie, resulted in participation restriction time <24 hours); 7.6% and 0.9%, respectively, were severe (ie, resulted in participation restriction time >3 weeks). The proportion of hip/groin injuries that were NTL injuries was greater in women than in men (IPR, 1.28; 95% CI, 1.11-1.48). Conversely, the proportion of hip/groin injuries that were severe was greater in men than in women (IPR, 8.67; 95% CI, 1.20-62.73). The most common hip/groin injury diagnosis was strain (men, 67.2%; women, 76.3%). Also, 12 (2.9%) and 3 (2.6%) cases of hip impingement were noted in men’s and women’s ice hockey, respectively. Conclusion: Hip/groin injury rates were greater in men’s than in women’s ice hockey. Time loss varied between sexes, with men sustaining more injuries with time loss over 3 weeks. Despite increasing concerns of femoroacetabular impingement in ice hockey players, few cases of hip impingement were reported in this dataset.

Patient-Centered Perioperative Care for a Victim of Military Sexual Trauma

INTRODUCTION The patient population seen in our nations Veterans Affairs Healthcare system is increasingly female and an alarming percentage of our veterans, male and female alike, report a history of military sexual trauma (MST), which is associated with an increased burden of morbidities including post-traumatic stress disorder (PTSD) and substance abuse. The experience of surgery can produce symptoms of PTSD in a clinically significant percentage of patients. This article describes the challenges of achieving a patient-centered perioperative care plan in the case of a female veteran who suffers from PTSD as a result of MST. METHODS We provide a brief background on the changing demographics of our nations veterans, a review of MST and patient-centered care, and a description of the interdisciplinary care plan created and implemented for our patient. We note how this care model employs key elements of the Perioperative Surgical Home Model as developed by the American Society of Anesthesiologists. Finally, we propose an agenda for improving perioperative care for this group of veterans. No institutional review board was required for this case report-based discussion. RESULTS The patient-centered care plan developed and implemented by an interdisciplinary team was well received by the patient and enabled her to comply with her postsurgical physical therapy. This recent interdisciplinary experience was in stark contrast to her experience of former surgical procedures, and produced much higher patient satisfaction. CONCLUSION Improvements are needed in patient-centered perioperative care for victims of MST, both within the Veterans Affairs system and in the larger health care system. We suggest an agenda to improve care for these patients including: (1) increasing provider awareness and education about MST and about the potential psychological trauma of surgery per se, (2) employing elements of the Perioperative Surgical Home to encourage patient-centered care involving collaboration within an interdisciplinary team, (3) and measurement of patient centered outcomes. Perioperative care for the victim of MST is heretofore not addressed in the literature. We hope this case report and review will stimulate further research into optimizing care for these vulnerable patients.

The epidemiology of back/neck/spine injuries in National Collegiate Athletic Association men’s and women’s ice hockey, 2009/2010 to 2014/2015

ABSTRACT This study describes the epidemiology of back/neck/spine injuries in National Collegiate Athletic Association (NCAA) men’s and women’s ice hockey. Data from 66 NCAA men’s and 29 women’s ice hockey programmes (total of 147 and 67 team-seasons, respectively) were analysed from the NCAA Injury Surveillance Program during the 2009/2010–2014/2015 academic years. In the study period, 226 and 97 back/neck/spine injuries were reported in men and women, respectively, for injury rates of 0.56 and 0.65/1000 athlete exposures. Injury rates were higher in competitions than practices in men (injury rate ratio [IRR] = 4.22; 95% confidence interval [CI]: 3.24–5.49) and women (IRR = 2.49; 95% CI: 1.67–3.70). Most injuries occurred in the lower back/lumbar spine (men: 52.2%; women: 48.5%). There were notably low rates of fractures and severe spinal injuries for both sexes. This study enhances our understanding of the incidence, mechanisms and factors influencing these injuries and can ultimately lead to more effective injury prevention.

The effect of a preoperative education class on the rate of manipulation under anesthesia after total knee arthroplasty in a veterans population

Background Arthrofibrosis after total knee arthroplasty (TKA) is a common complication, potentially occurring in up to 25% of patients, and may be treated during the early recovery period by manipulation under anesthesia (MUA). The majority of preoperative factors that predispose patients to postoperative stiffness are patient specific and not modifiable. The United States Veteran Affairs is a particularly challenging group given a higher baseline rate of medical comorbidities and opioid dependence than the general population. Patient education about postoperative expectations and complications has been shown to improve outcomes in certain orthopedic procedures. This retrospective study aims to determine if preoperative counseling for veterans undergoing primary TKA reduces the rate of postoperative stiffness, and consequently MUA, in this subset of patients. Methods We evaluated the medical records of 244 veterans at a single veteran affairs hospital who underwent 278 TKAs during a 6-year period under one surgeon. Patients were separated into groups based on attendance in the preoperative counseling session. Effects of various factors, including age, sex, body mass index, preoperative knee range of motion, and history of previous knee surgery, were compared between these 2 cohorts. Results Attendance in the preoperative course did not have a statistically significant impact on the rate of manipulation (odds ratio [OR], 1.07). Female gender and prior manipulation had an increased OR of knee manipulation, whereas age > 65 years had a decreased OR that did not reach significance. Conclusions Our results show that preoperative counseling did not have a benefit in terms of postoperative MUA rates in veterans. Preoperative education may be helpful for setting appropriate expectations of pain, recovery, and function after total joint arthroplasty and may be useful in an online or video format in small practices in which cost may be prohibitive. Further studies are needed to determine whether they provide any benefit in postoperative arthrofibrosis rates.

Ulnar Collateral Ligament Injury in Female Athletes

Though infrequently reported, female athletes do suffer injuries to the ulnar collateral ligament (UCL) of the elbow. These occur during participation in a wide variety of sports, including softball, tennis, javelin, and gymnastics. The mechanism of injury is often chronic microtrauma; however, ligament avulsion is commonly seen as well. Extensive damage to the ligament necessitates reconstruction. To this point, there has not been any research to suggest a different approach to reconstruction in the female athlete, and thus the procedure performed is the same one classically described in the male athlete. However, when the ligament is not as extensively injured, Argo has reported excellent results with primary repair, although his study is limited by a small sample size. For this reason, in contrast to current literature regarding the treatment of male throwers, repair should be considered in these female patients competing at or below the college level. This offers the benefit of a less invasive procedure and potentially an earlier return to sport. However, treatment recommendations for the female athlete with a UCL injury are limited by the paucity of literature regarding both the biomechanics of the female ligament and the outcome data in this patient population.