Peter D. Fabricant

Sport-Specific Yearly Risk and Incidence of Anterior Cruciate Ligament Tears in High School Athletes A Systematic Review and Meta-analysis

Background: Anterior cruciate ligament (ACL) injury rates are affected by frequency and level of competition, sex, and sport. To date, no study has sought to quantify sport-specific yearly risk for ACL tears in the high school (HS) athlete by sex and sport played. Purpose: To establish evidence-based incidence and yearly risk of ACL tears in HS athletes by sex for sports performed at the varsity level across the majority of US high schools. Study Design: Meta-analysis. Methods: PubMed, EMBASE, and Cochrane Central Register of Controlled Trials were searched to identify all articles reporting ACL tears per athletic exposure in HS athletes. ACL injury incidence rates (IRs) by sex and sport were calculated via meta-analysis. State athletic association guidelines were used to determine the number of exposures per season to calculate yearly risk of ACL tears. Results: The search recovered 3779 unique articles, of which 10 met our inclusion criteria, for a total of 700 ACL injuries in 11,239,029 exposures. The IR was 0.062 injuries per 1000 exposures (95% CI, 0.058-0.067). Although more injuries were recorded in males than females, females had a higher rate of injury per exposure (relative risk, 1.57; 95% CI, 1.35-1.82). Relative risk was highest in basketball (3.80; 95% CI, 2.53-5.85) and soccer (3.67; 95% CI, 2.61-5.27). While boys’ football had the highest number of ACL injuries at 273, girls’ soccer had the highest IR (0.148; 95% CI, 0.128-0.172). In girls, the highest injury risks per season were observed in soccer (1.11%; 95% CI, 0.96%-1.29%), basketball (0.88%; 95% CI, 0.71%-1.06%), and lacrosse (0.53%; 95% CI, 0.19%-1.15%). In comparison, the highest risks for boys were observed in football (0.80%; 95% CI, 0.71%-0.91%), lacrosse (0.44%; 95% CI, 0.18%-0.90%), and soccer (0.30%; 95% CI, 0.22%-0.41%). Conclusion: There is an approximately 1.6-fold greater rate of ACL tears per athletic exposure in HS female athletes than males. However, there is significant risk in both sexes, particularly in high-risk sports such as soccer, football, basketball, and lacrosse. Knowledge of sport-specific risk is essential for future injury reduction programs, parent-athlete decision making, and accurate physician counseling.

Change in Size of Hamstring Grafts During Preparation for ACL Reconstruction: Effect of Tension and Circumferential Compression on Graft Diameter.

BACKGROUNDnThere is good consensus that anterior cruciate ligament (ACL) grafts should be pretensioned to remove creep prior to implantation, but the literature contains little information on the influence of graft preparation or circumferential compression on graft size. The purpose of this study was to investigate how the size of hamstring allografts changes as they are prepared for ACL reconstruction. We hypothesized that grafts decrease in diameter as they are prepared with both tension and circumferential compression. We also investigated the interrater reliability of graft diameter measurements during each step of graft preparation.nnnMETHODSnTwenty pairs of fresh-frozen human hamstring tendons obtained from an allograft supplier were prepared in a standardized fashion for ACL reconstruction (suturing followed by longitudinal tensioning followed by circumferential compression followed by relaxation). Four blinded raters measured each graft in a sequential manner after each graft preparation step. Interrater reliability was assessed using the intraclass correlation coefficient ICC(2,1). The mean allograft diameter at each time point was calculated and compared across all time points using repeated-measures analysis of variance (ANOVA).nnnRESULTSnSubjecting the grafts to both tension and circumferential compression significantly decreased their mean diameter (to 7.38 mm compared with 8.28 mm at baseline; p = 0.044). Interrater reliability revealed almost perfect agreement at each measurement interval, with the ICC ranging from 0.933 to 0.961.nnnCONCLUSIONSnThe average diameter of hamstring ACL grafts decreases by almost 1 mm after they are subjected to both tension and circumferential compression within a standard cylindrical sizing block.nnnCLINICAL RELEVANCEnBecause ACL bone tunnels are drilled in 0.5-mm increments, preparing soft-tissue grafts with circumferential compression in addition to tension may allow creation of tunnels that are one to two incremental sizes smaller. This could permit less bone removal, which may be particularly applicable for certain reconstruction techniques such as pediatric, double-bundle, or revision ACL reconstruction, in which limited space is available for tunnel drilling.

Rehabilitation Following Anterior Cruciate Ligament Tears in Children: A Systematic Review.

Background: Anterior cruciate ligament (ACL) tears are increasingly prevalent in the pediatric population. ACL rehabilitation is an essential component of recovery following injury and reconstruction, yet there are few explicit descriptions of pediatric‐specific ACL rehabilitation protocols in the literature, especially in the context of varying treatment interventions. Our aim was to systematically review the literature on rehabilitation following ACL tears in children in order to describe common principles among different treatment options and areas of future research. Methods: Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta‐Analyses) guidelines, we performed a systematic review of the PubMed, EMBASE, and Cochrane databases (for the past five years) to identify detailed rehabilitation protocols described in the pediatric population following ACL rupture. When available, the following aspects of rehabilitation were extracted: “prehabilitation” (exercises prior to surgery), bracing, weight‐bearing status, range of motion, strength, modalities (ice, heat, electrical stimulation, etc.), plyometrics/proprioceptive exercises, return‐to‐sport criteria, and suggested ACL injury‐prevention programs. Results: Two hundred and two unique articles were identified. Twenty‐seven articles meeting inclusion criteria with extractible rehabilitation data were included. A table, categorized by differing orthopaedic intervention, was designed to detail the components and duration of the different aspects of rehabilitation. While there are substantial differences across protocols, several trends emerged, particularly regarding weight‐bearing, bracing, range of motion, and strength training. Interestingly, we found that many current protocols are based on time frame alone rather than on functional milestones; of the fourteen unique articles that addressed return‐to‐sport criteria by specific orthopaedic intervention, seven were based on temporal progression whereas seven also involved achievement of physical milestones. In addition, only three of the eight articles that mentioned a future ACL injury‐prevention plan described a formal prevention program. Conclusion: We systematically identified, and subsequently outlined and compared, the current trends of the various components of pediatric‐specific ACL rehabilitation protocols, categorized by orthopaedic intervention. Several protocols are based on time frames rather than milestones achieved, with newer protocols involving milestone‐based progression. Newer protocols are also incorporating formal prevention programs. Just as skeletally immature patients require unique methods of operative fixation, so too do they require catered rehabilitation protocols. To effectively prevent re‐rupture or contralateral injury, future research should focus on prospectively evaluating each component of the rehabilitation protocols described and return‐to‐sport criteria for young patients.

Is There Truly "No Significant Difference"? Underpowered Randomized Controlled Trials in the Orthopaedic Literature.

BACKGROUNDnRandomized controlled trials (RCTs) are considered the gold standard in evidence-based medicine. Underpowered RCTs that describe comparative outcomes without significance are of questionable benefit. The present study hypothesizes that a substantial proportion of RCTs in the orthopaedic literature that do not note significant differences between groups are inadequately powered.nnnMETHODSnUsing the ISI Web of Science database, we searched all English-language journals in the orthopaedic category for RCTs published from January 2012 to December 2013. Qualifying articles were analyzed with regard to whether the null hypothesis was rejected (a positive study) for the primary outcome or if it was not (a negative study), whether a power analysis was performed, and whether the study was adequately powered. We performed a power analysis based on the primary outcome or outcomes of interest for the studies that did not describe a power analysis.nnnRESULTSnAfter inclusion and exclusion criteria were applied, 456 RCTs were selected for complete review. Of those studies, 215 (47.1%) had negative findings and 241 (52.9%) had positive findings for primary outcomes. Twenty-five studies that failed to reject the null hypothesis noted inadequate power in the study. On the basis of our own power analyses, we found an additional thirty-five negative studies without power calculations to be underpowered. Sixty (27.9%) of the 215 negative studies were underpowered. Following binary logistic regression, only the journal impact factor was a significant predictor of whether a study was underpowered.nnnCONCLUSIONSnIf an RCT lacks adequate statistical power to identify a clinically meaningful absence of a difference between groups, there is an unacceptable risk of inappropriately failing to reject the null hypothesis. The present study found that a sizable proportion of RCTs in orthopaedic surgery in which the null hypothesis is rejected are inadequately powered. Researchers should consider this when designing clinical trials, and journal editors and reviewers should be wary of underpowered RCTs when considering manuscripts for publication.

Medial Epicondyle Fractures in Children and Adolescents: Shifting Care from General Hospitals to Children's Hospitals?

OBJECTIVESnTo determine if there is a shift in the treatment of children with medial epicondyle fractures toward childrens hospitals, and to explore potential confounders of any observed effect.nnnSTUDY DESIGNnThe Healthcare Cost and Utilization Project Kids Inpatient Database was used to examine the epidemiology of medial epicondyle fractures, particularly with attention to whether they were admitted to a general hospital or a childrens hospital (defined as free-standing childrens hospitals, specialty childrens hospitals, and childrens units within general hospitals). Age and insurance payer status were also collected and evaluated as potential confounders.nnnRESULTSnThe proportion of medial epicondyle hospital discharges from childrens hospitals increased (from 29%-46%; Pxa0<xa0.001), and the proportion of discharges from general hospitals declined over the study period (from 71%-42%; Pxa0<xa0.001). Age and insurance payer status both remained consistent throughout the study period and did not contribute to this finding.nnnCONCLUSIONSnThis study demonstrates an increase in the proportion of discharges for pediatric medial epicondyle fractures from childrens hospitals. Although this finding is likely multifactorial, it may represent increasing subspecialization and increasing medical liability when treating children. Childrens hospitals should identify those conditions which will continue to increase in number and consider constructing clinical pathways in order to optimize delivery of care and resource utilization.

Open-Access Video-Based Orthopaedic Instructional Content is Inaccurate

Objectives: The internet has an increasing role in both patient and physician education. While several recent studies critically appraised the quality and accuracy of web-based written information available to patients, no studies have evaluated such parameters for open access video content designed for provider use. The present study sought to determine utilization of video resources by orthopaedic residents and assess the quality and accuracy of their content Methods: Surveys were distributed to orthopaedic surgery residents to to determine their use of open access instructional video content. An assessment of quality and accuracy of said video content was performed using the basic shoulder examination as a suragate for the “best-case scenario” due to its widely accepted components that are stable over time. Three search terms (“shoulder”, “examination” and “shoulder exam”) were entered into the four online video resources most commonly accessed by orthopaedic surgery residents (VuMedi, G9MD, Orthobullets, and YouTube). Videos were captured and independently reviewed by three orthopedic surgeons. Quality and accuracy were assessed in accordance with previously published standards. Results: Of the 72 orthopaedic residents surveyed, 70% use open-access videos as a resource monthly and 25% weekly. Over 70% or respondents perceived the video content to be accurate and informative. We reviewed 39 unique video tutorials on physical examination. Of the 39 videos, 61% rated poor (<25% accurate) or fair (<50% accurate). Specific shoulder tests such as Hawkins, O’Brien Sign, and Neer Impingement were accurately demonstrated in only 50%, 36%, and 27% of videos respectively. Inter-rater reliability was excellent (mean Kappa 0.80, range 0.79-0.81). Conclusion: We demonstrated that orthopaedic surgery residents often turn to open-access video tutorials as a supplemental education tool. While the majority residents believed the content is accurate, our results suggest an alarming inaccuracy of these video tutorials. Trainee exposure to inaccurate information has far reaching implications on the education process. As such, training programs should help guide their residents to pre-screened or peer-reviewed video resources.