Manish S. Noticewala

The Impact of Body Checking on Youth Ice Hockey Injuries

Background: Body checking is a common cause of youth ice hockey injuries. Consequently, USA Hockey raised the minimum age at which body checking is permitted from the Pee Wee level (11-12 years old) to the Bantam level (13-14 years old) in 2011. Purpose/Hypothesis: The purpose of this investigation was to determine the impact of body checking on the distribution of injuries reported in youth ice hockey players. We hypothesized that the elimination of body checking at the Pee Wee level would lower the frequency of serious injuries, particularly concussions. Study Design: Descriptive epidemiology study. Methods: Injury data from the National Electronic Injury Surveillance System (NEISS), a United States Consumer Product Safety Commission database, were analyzed for Pee Wee and Bantam players between January 1, 2008 and December 31, 2010 and again between January 1, 2013 and December 31, 2015. Data on the location of injury, diagnosis, and mechanism of injury were collected. The location of injury was categorized into 4 groups: head and neck, upper extremity, lower extremity, and core. Diagnoses investigated included concussions, fractures, lacerations, strains or sprains, internal organ injuries, and other. The mechanism of injury was broken down into 2 categories: checking and other. Results: Between the 2008-2010 and 2013-2015 seasons, overall injuries decreased by 16.6% among Pee Wee players, with injuries caused by body checking decreasing by 38.2% (P = .012). There was a significant change in the distribution of diagnoses in the Pee Wee age group during this time frame (P = .007): strains or sprains, internal organ injuries, and fractures decreased in frequency, while the number of concussions increased by 50.0%. In the Bantam age group, recorded injuries decreased by 6.8%, and there was no change in the distribution of the location of injury, diagnosis, or mechanism of injury (P > .05). Conclusion: There was an observed reduction in the total number, mechanism, and type of injuries when body checking was eliminated from the Pee Wee level. There was, however, an unexpected increase in the number of concussions.

Double-row Rotator Cuff Repair: The New Gold Standard

Arthroscopic rotator cuff repair is an increasingly prevalent procedure. Maximizing postoperative outcomes is directly dependent on the integrity of the surgical fixation of tendon-to-bone. Double-row repair utilizes 2 rows of suture anchor fixation of tendon-to-bone: 1 row medially near the articular margin of the humeral head, and a second row laterally near the greater tuberosity. Among the biomechanical and biophysical benefits of double-row repair (as compared with single-row repair) are: a more anatomic footprint reconstruction, decreased strain and increased stiffness across the repair, smaller gap formation and “dog ear deformities,” and a more encouraging healing environment. Furthermore, the clinical and radiographic benefits of double-row repair are improved functional outcome scores and decreased retear rates.

Prevalence of Posttraumatic Stress Disorder Symptoms Among Young Athletes After Anterior Cruciate Ligament Rupture

Background: The risk of depression and the fear of reinjury were documented in recent investigations of patients after anterior cruciate ligament (ACL) ruptures. The extent of psychological trauma accompanying these injuries among young athletes, however, has never been assessed. Hypothesis: Posttraumatic stress disorder (PTSD) symptoms after ACL injury are present among young athletes with high athletic identities. Study Design Case series; Level of evidence, 4. Methods: Patients ≤21 years of age who had suffered an acute ACL rupture were consecutively recruited at a tertiary care center. Patients completed the Horowitz Impact of Event Scale - Revised (IES-R) to analyze for PTSD symptomatology, the Athletic Identity Measurement Scale, and an athlete specialization instrument created at the authors’ institution. Results: A total of 24 patients were consecutively recruited. The mean patient age was 14.5 ± 2.7 years, and 50% of patients were male. More than 87.5% of patients experienced avoidance symptoms, 83.3% acknowledged symptoms of intrusion, and 75% had symptoms of hyperarousal. Patients aged 15 to 21 years incurred a higher severity of PTSD symptoms than younger patients (P = .033). Female patients experienced greater emotional trauma than male patients (P = .017). Finally, patients with high athletic identities experienced greater emotional trauma than those with lesser athletic identities, but this finding was not statistically significant (P = .14). Conclusion: Following ACL rupture, young athletes experience significant emotional trauma, including symptoms of avoidance, intrusion, and hyperarousal. High school and college athletes, female athletes, and patients with high athletic identities may be most susceptible.

Elbow Arthroscopy for Treatment of Valgus Extension Overload

Valgus extension overload syndrome (VEO) is the result of supraphysiologic stresses placed across the posterior elbow during pitching. Following failure of nonoperative measures, surgical options consist of arthroscopic or limited incision posteromedial decompression. Although technically challenging, arthroscopic treatment offers many advantages over open treatment, including improved joint visualization, decreased soft-tissue dissection, decreased postoperative pain, and quicker rehabilitation. Arthroscopic treatment of VEO consists of soft tissue and bony debridement, loose body removal, and osteophyte resection. This technique report details the steps of arthroscopic treatment of VEO in a patient with a subluxating ulnar nerve.

The Psychosocial Trauma of ACL Ruptures in Young Athletes

Objectives: Sustaining severe injuries requiring operative fixation causes emotional harm in addition to physical damage in young athletes. While the fear of re-injury following an anterior cruciate ligament ruptures and reconstruction has been established, the extent of the psychosocial trauma, including hyperarousal and intrusion, is largely unknown. We hypothesize that post-traumatic stress disorder symptoms are present young athletes with strong athletic identities following ACL ruptures. Methods: The impact of events scale, the athletic identity measurement score, and a novel specialization instrument were administered to 7 to 21 year old patients following ACL rupture. These instruments represent a modified post-traumatic stress disorder screening tool psychometrically validated in children, a validated tool to measure athletic identity, and an athlete specialization questionnaire designed by the authors respectively. Athletes were recruited from the sports medicine clinic at the senior authors’ academic institution and the instruments were administered upon the patients’ first orthopedic visit following the diagnosis of an ACL rupture. The full extent of the knee injury and any history of prior knee injuries were also assessed. Results: Twenty-one patients with a mean age of 14.9 ± 2.9 years completed the emotional trauma assessment and 52.2% of respondents were female. The most common concurrent injury was a meniscal tear (47.8%) and 9.5% of patients reported a prior ACL rupture and reconstruction. Regarding specialization, one-third of athletes played one sport only, 52.4% of athletes played multiple sports while focusing on one above the others, and 14.2% of athletes balanced their sports equally. Single-sport athletes scored significantly higher on the athletic identity questionnaire (single-sport mean 57.2; multi-sport mean 52.1; p = .02). The majority of patients experience traumatic symptoms in all three major categories as 86.4% endorsed avoidance symptoms, 81.8% admitted intrusion symptoms, and 81.8% admitted hyperarousal symptoms. Older athletes were significantly more likely to experience stronger emotionally traumatic symptoms (p = .03) as 16 - 21 year old athletes scored a mean of 62.6 on the Impact of Events Scale compared to 39.6 for 7 - 15 year old athletes. While male patients experienced stronger traumatic symptoms than female patients, the separation was not found to be statistically significant (male 50.2; female 43.6; p = .12). Conclusion: The emotional trauma for young athletes following ACL ruptures extends beyond the avoidance symptoms that have been previously established. Psychological evaluation and support is imperative to providing holistic care following this injury. Demographics and Psychosocial Symptom Prevalence Age 14.9 ± 2.9 Female 52.8% Male 47.2% Meniscal Injury 47.2% Prior ACL Injury 9.5% Traumatic Symptoms: Avoidance 86.4% Intrusion 81.8% Hyperarousal 81.8%

Arthroscopic Elbow Osteocapsular Arthroplasty

Treatment of primary elbow osteoarthritis in the young active patient less than 50 years old presents a treatment challenge to the practicing orthopaedic surgeon. Following failure of nonoperative management, surgical goals are aimed at reducing pain and improving joint mobility from bony impingement. Arthroscopic osteocapsular arthroplasty is a viable treatment option with few post-operative limitations. In contrast, total elbow arthroplasty is considered a salvage option in this patient population given the activity restrictions imposed. Osteocapsular arthroplasty combines soft tissue and bony debridement, osteophyte/loose body removal, synovectomy, capsular release, and bony contouring of the humerus and ulna to allow impingement-free range of motion.

Ulnar Collateral Ligament Repair With Suture Augmentation

Reconstruction of the ulnar collateral ligament (UCL) remains the gold standard for treating overhead throwing athletes with valgus instability secondary to UCL pathology. Although surgical techniques for reconstruction have evolved over time, current methods allow 90% of patients to return to their preinjury level of activity. Despite encouraging results with reconstruction, UCL repair remains a valuable treatment option for patients with UCL pathology fitting specific criteria. There are a number of advantages associated with a direct repair, and further, the development of collagen-coated sutures for ligament repair augmentation makes this procedure an attractive surgical option under the correct circumstances. This article provides a detailed description and video demonstration of the surgical steps used to perform a UCL repair with suture augmentation.