bluuebunny/crossref_metadata_2025 huggingface dataset:
Attitudinal modalities of citizenship representation styles in Georgia
Authors: Mestvirishvili Maia
Published: July 2019

This study investigates citizenship representation styles and their compositional modalities in contemporary Georgia. The article starts with a discussion of legal, social, and political influences that shaped conceptions of citizenship in post-Soviet countries, including Georgia. The study presents the results of a survey of 700 students from 10 universities in Georgia. They completed questionnaires exploring citizenship styles and associated predictor variables. The study suggests that a cultural citizenship style is dominant among Georgian students. It is best predicted by the level of national identification, followed by patriotism, nationalism, in-group attitudes, and religious orthodoxy. The data also show the opposing roles of nationalism and patriotism on ethnic and civic citizenship styles. The article argues that a cultural citizenship representation style could be the compromise solution in the ethnic versus civic citizenship dichotomy and might be more appropriate for societies characterized by ethno-nationalist tendencies.
Ethnobotanical Survey of Medicinal Plants Used to Treat Mental Illnesses in the Berea, Leribe, and Maseru Districts of Lesotho
Authors: Mabaleha Mohale B. , Zietsman Pieter C. , Wilhelm Anke , Bonnet Susan L.
Published: July 2019

Mental illnesses (MIs) such as anxiety, epilepsy, major depression, schizophrenia, sleep disorder, and pain influence the quality of life severely. According to the World Health Organization Atlas for Mental Health (2014), the formal health sector in Lesotho has only 13.7 mental health workers per 100 000 of the population, which breaks down to 0.1 psychiatrist and other medical doctors, 0.3 psychologists, 4.7 nurses, and 5.2 social workers. Traditional health practitioners (THPs) have always played a significant role in the prevention and treatment of MIs, via utilization of Lesotho’s vast diversity of plants. This investigation aims to determine which medicinal plants are used for the treatment of MIs in the Berea, Leribe, and Maseru districts of Lesotho. A combination of unstructured and semistructured one-on-one interviews were conducted with 27 THPs. They were interviewed about the status of MIs in Lesotho, diagnostic methods, medicinal plants used, and preparation and administration of the herbal remedies in the treatment of MIs. A total of 43 different plant species (indigenous and exotic) were indicated by the THPs as commonly used to treat neurological disorders. With the exception of one unidentified plant, the plants represented 26 families and 42 genera. The most common families are the Asteraceae (9 species), Fabaceae (5 species), and Rosaceae (3 species). The most cited plant species were Morella serrata (Myricaceae) (26%), followed by Xysmalobium undulatum (Asclepiadaceae) (22%), and Afroaster hispidus (Asteraceae) (15%). This survey provides, for the first time, a database of Lesotho’s medicinal plants that are used to treat MIs.
Improving Cosmetic Activity by Optimizing Centella asiatica Extraction Process
Authors: Seo S.B. , Kim Y.M.
Published: July 2019

This study showed the use of Centella asiatica as a good source of compounds for skin therapy and antioxidant activation cosmetics. The goal of this study was to provide cosmeceutical activity data about the extraction yield and total phenol content of C. asiatica by optimizing the focused high ultrasound (INEFU) and ultrasound extraction (UE) conditions. Under optimal extraction conditions, that is, 1800 W for 45 minutes and 500 W for 45 minutes, 28.73% and 30.21% (w/w) of the highest extraction yields and polyphenol contents were obtained, respectively. For the skin whitening activity, tyrosinase inhibitory activity was observed at 61.52% in INEFU extracts, which was circa 20.3% higher than that of UE extracts (51.11%). To reduce melanin production in Clone M-3 cells, 86.9% melanin production was observed following the addition of control, water extraction relative to the control without a sample, and 79.6% and 74.5% were found in UE and INEFU conditions, respectively. In conclusion, the highest total phenol secretion was obtained under optimal conditions and resulted in a significant improvement in the cosmetic activities of C. asiatica extracts.
Sudden Onset Fluent Aphasia: Stroke or Seizure?
Authors: Beach Paul A. , Dhakar Monica B. , Kase Carlos S.
Published: July 2019

Conventional understanding of acute onset language deficits indicates that fluent aphasias are due to perisylvian lesions in the dominant hemisphere, most often in the setting of acute stroke. Case studies and retrospective analyses, however, suggest the need to keep ictal phenomena as an alternative diagnostic possibility. The following case illustrates an epileptic mechanism of sudden onset fluent aphasia mimicking an acute stroke presentation. We utilize the case to illustrate means by which to differentiate stroke versus ictal etiology by way of electroencephalography/response to antiseizure drugs as well as perfusion/diffusion imaging. We review the literature case reports to demonstrate that isolated fluent aphasia typically localizes to left-hemispheric, temporal foci. Finally, we provide a brief synthesis of potential neurologic mechanisms by which left temporal lesions may cause fluent aphasia.
Rethinking mechanism and process in the geographical analysis of uneven development
Authors: Yeung Henry Wai-chung
Published: July 2019

Speaking directly to economic and political geographers working on uneven development, this article critically examines the deployment of two key concepts, mechanism and process, as analytical tools for causal explanation in geographical analysis during the past two decades. Drawing upon critical realism to develop a theory of mechanism, this article clarifies the conceptual distinction between mechanism and process. Whereas process is conceived as a contingent change in the sequential series of entities and their relations, mechanism serves as a necessary relation to connect an initial causal condition with its particular socio-spatial outcomes in context. This analytical distinction between a contingent process of change and a necessary mechanism for an outcome requires a careful specification of the concrete outcomes to be explained and the working of various mechanisms. Illustrating my case through existing studies of neoliberalization and, briefly, path dependence, I argue that there is a tendency in the literature to conflate mechanism and process in different meso-level theories of socio-spatial change. This conflation, in turn, distorts the causal links in core concepts and reduces their explanatory efficacy in accounting for uneven development. Rethinking mechanism and process can therefore help revitalize systematic explanations of uneven development as one of geography’s core intellectual projects and contributions to the social sciences; it can also allow geographers to engage more productively with the rapidly growing mechanistic thought in analytical sociology, political science and the philosophy of social science during the past two decades.
Predicting Immigrants’ Fear of Crime Based on Ethnicity, Acculturation, and Coping
Authors: Cohen-Louck Keren
Published: July 2019

This research focuses on fear of crime and acculturation strategies in two immigrant groups in Israel: Ethiopians and those from the former Soviet Union (FSU). Relative contributions of various individual and social factors that predict fear of crime were examined. Five hundred and fourteen immigrants were interviewed, half from each group. All participants completed questionnaires on their fear of crime levels, perceived neighborhood disorder, social integration, coping styles, acculturation strategies, and prior criminal victimization. Both Ethiopian ( M = 4.44) and FSU ( M = 4.20) immigrants preferred integration to other acculturation strategies ( p < .05). However, for Ethiopian immigrants, their high integration scores coexist with separation from Israeli society. There were no significant differences between the two groups of immigrants as for fear of crime. Several explanations for these findings are discussed. These results challenge notions of a single acculturation strategy. Ethiopian immigrants show a pattern of “cultural ambivalence” where both integration and separation are used, while FSU immigrants demonstrate patterns of “cultural modularity,” where integration and assimilation strategies coexist.
The Impact of Entrepreneurial Orientation on Spin-Offs’ Performance: A Cross-Cultural Study
Authors: Khadhraoui Mariem , Plaisent Michel , Lakhal Lassaad , Prosper Bernard
Published: July 2019

Previous studies considered entrepreneurial orientation as a determinant of firms’ growth and performance. In this research, we are interested in spin-offs. Indeed, we aim to study the relationship between their entrepreneurial orientation and their performance. Therefore, we carried out a cross-cultural study in three different countries; Tunisia, Canada, and Morocco. We opted for a personal survey. We addressed our questionnaire to 180 managers of spin-offs and we analyzed the research variables using SPSS 20.00 (Statistical Packages for Social Sciences) and Smart PLS 3 (Partial Least Squares). Our findings highlight a positive correlation between entrepreneurial orientation and performance of spin-offs within the three samples.
Analysis of State Insurance Coverage for Nonpharmacologic Treatment of Low Back Pain as Recommended by the American College of Physicians Guidelines
Authors: Bonakdar Robert , Palanker Dania , Sweeney Megan M
Published: July 2019

Background

In 2017, the American College of Physicians (ACP) released guidelines encouraging nonpharmacologic treatment of chronic low back pain (LBP). These guidelines recommended utilization of treatments including multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (MBSR), tai chi, yoga, progressive relaxation, biofeedback, cognitive behavioral therapy (CBT), and spinal manipulation.

Objective

We aimed to determine status of insurance coverage status for multiple nonpharmacological pain therapies based on the 2017 Essential Health Benefits (EHB) benchmark plans across all states.

Methods

The 2017 EHB benchmark plans represent the minimum benefits required in all new policies in the individual and small group health insurance markets and were reviewed for coverage of treatments for LBP recommended by the ACP guidelines. Additionally, plans were reviewed for limitations and exclusionary criteria.

Results

In nearly all state-based coverage policies, chronic pain management and multidisciplinary rehabilitation were not addressed. Coverage was most extensive (supported by 46 states) for spinal manipulation. Acupuncture, massage, and biofeedback were each covered by fewer than 10 states, while MBSR, tai chi, and yoga were not covered by any states. Behavioral health treatment (CBT and biofeedback) coverage was often covered solely for mental health diagnoses, although excluded for treating LBP.

Conclusion

Other than spinal manipulation, evidence-based, nonpharmacological therapies recommended by the 2017 ACP guidelines were routinely excluded from EHB benchmark plans. Insurance coverage discourages multidisciplinary rehabilitation for chronic pain management by providing ambiguous guidelines, restricting ongoing treatments, and excluding behavioral or complementary therapy despite a cohesive evidence base. Better EHB plan coverage of nondrug therapies may be a strategy to mitigate the opioid crisis. Recommendations that reflect current research-based findings are provided to update chronic pain policy statements.
Effect of a Nutrition Support Formula in Adults With Inflammatory Bowel Disease: A Pilot Study
Authors: Ryan Jennifer J , Hanes Douglas A , Bradley Ryan D , Contractor Nikhat
Published: July 2019

Background

Due to the high prevalence of nutrient deficiencies in patients with inflammatory bowel disease (IBD), routine monitoring of nutrient status and supplementation are recommended.

Objective

This preliminary study was implemented to prospectively identify potential effects of a nutrition support formula on blood nutrient parameters in adults with IBD.

Methods

Ten adults with Crohn’s disease or ulcerative colitis were recruited from the Portland, Oregon, metropolitan area into a single-arm, open-label pilot study. Participants consumed a nutrition support beverage twice daily for 12 weeks. The formula contained a mixture of micronutrients (including methylated forms of folate and vitamin B12), macronutrients, and phytonutrients (including curcumin, xanthohumol, ginger compounds, and quercetin). Primary measures were the following parameters: folate, vitamin B12, red blood cell (RBC) count, hemoglobin, hematocrit, electrolytes, and albumin. Exploratory measures included a food frequency questionnaire, circulating blood cell counts, and inflammatory markers.

Results

Nine participants completed the study and one withdrew. Adherence was 98%. Serum folate increased 48.7% ( P = .029), serum vitamin B12 increased 17.4% but did not reach statistical significance ( P = .053), and red cell distribution width (RDW) decreased 9.2% ( P = .012) over the 12-week study period. There were minimal shifts in total white blood cell (WBC) counts (−1.0%, P = .845), but percent neutrophils decreased 10.4% ( P = .042) and absolute lymphocyte count increased 18.6% ( P = .048). RBC count, hemoglobin, hematocrit, electrolytes, albumin, and inflammatory markers did not change significantly. Post hoc analysis demonstrated that neutrophil–lymphocyte ratio (NLR) decreased 18.4% (not significant, P = .061).

Conclusion

Serum folate and RDW improved in adults with IBD after 12 weeks. Modulation of leukocyte subtypes was also observed, including a decrease in neutrophils and an increase in lymphocytes, with no change in total WBC count. A randomized, controlled study to further examine effects of the nutrition support formula will be initiated to follow up on this promising, but preliminary investigation.
Attachment Security Moderates Effects of Uncontrollable Stress on Preadolescent Hypothalamic–Pituitary–Adrenal Axis Responses: Evidence of Regulatory Fit
Authors: Bendezú Jason José , Loughlin-Presnal John E. , Wadsworth Martha E.
Published: July 2019

This study examined whether perceived attachment security (i.e., perceptions of caregivers as responsive, available, and open to communication during times of need) and effortful coping work in concert to buffer against uncontrollable life event effects on hypothalamic–pituitary–adrenal axis (HPA) response patterns in preadolescent boys and girls ( N = 121, mean age = 10.60 years). Children completed the Trier Social Stress Test (TSST) and were immediately thereafter exposed to one of two randomly assigned coping conditions: distraction and avoidance. Piecewise growth multilevel modeling of children’s salivary cortisol levels over the course of the experimental protocol suggested that uncontrollable life events in the year prior were associated with exaggerated cortisol reactivity, though this pattern was buffered against by children’s secure attachment beliefs. Furthermore, perceived attachment security, uncontrollable life event, and coping condition interactive effects on cortisol recovery emerged. As expected, distraction supported efficient cortisol recovery for those uncontrollable stress-exposed children with secure beliefs, and avoidance worked in this fashion for those with insecure beliefs. Findings point to perceived attachment security as a putative buffer of stress-exposed preadolescents’ HPA reactivity and possible contributor to regulatory fit, informing how specific coping skills work or backfire in supporting these children’s HPA recovery efficiency.
Fifteen-Year Prevalence, Trajectories, and Predictors of Body Dissatisfaction From Adolescence to Middle Adulthood
Authors: Wang Shirley B. , Haynos Ann F. , Wall Melanie M. , Chen Chen , Eisenberg Marla E. , Neumark-Sztainer Dianne
Published: July 2019

Body dissatisfaction is common in adolescence and associated with negative outcomes (e.g., eating disorders). We identified common individual trajectories of body dissatisfaction from midadolescence to adulthood and predictors of divergent patterns. Participants were 1,455 individuals from four waves of Project EAT (Eating and Activity in Teens and Young Adults), a population-based, 15-year longitudinal study. Aggregate body dissatisfaction increased over 15 years, which was largely attributable to increases in weight. Growth mixture modeling identified four common patterns of body dissatisfaction, revealing nearly 95% of individuals experienced relatively stable body dissatisfaction from adolescence through adulthood. Baseline depression, self-esteem, parental communication/caring, peer dieting, and weight-based teasing predicted differing trajectories. Body dissatisfaction appears largely stable from midadolescence onward. There may be a critical period for body image development during childhood/early adolescence. Clinicians should intervene with clients experiencing body dissatisfaction before it becomes chronic and target depression, self-esteem, parent/child connectedness, and responses to teasing and peer dieting.
Assessing distal radius malrotation following fracture using computed tomography
Authors: Filer Joshua , Smith Adam , Giddins Grey
Published: July 2019

Hypothesis:

When the distal fracture fragment in distal radius fractures displaces, it commonly rotates as well as shortens and angulates.

Aim:

The aim of this study was to assess the frequency and magnitude of malrotation of the distal fracture fragment using computed tomography (CT).

Methods:

A retrospective radiological assessment of 85 CT scans of the distal radius, 35 following fracture and 50 normal radii, was carried out. We developed and applied a simple method for measuring rotation of the distal radius relative to the diaphysis using routine CT scans of the wrist. A Mann–Whitney analysis was used to identify differences in radial rotation between fractures and controls. Intra- and inter-observer reliability were analyzed using intra-class correlation coefficients (ICCs) and Bland–Altman plots.

Results:

The articular surface of the distal radius is normally rotated in the long axis of the forearm relative to the diaphysis, either into pronation or into supination. The median radial rotation angle of controls was 1° pronation (range −15° to 4°) compared to 3° pronation (range −24° to 31°) in the fracture group. The absolute rotation angle was significantly greater in the fracture group (median 10°, range 0–31° vs. 3°, range 0–15°; p < 0.001) and outside the “normal range” of controls in 26 cases indicating that 75% had rotated appreciably following injury. Intra- and inter-observer reliability of measurements were good with ICCs of 0.99 and 0.98, respectively.

Conclusions:

Malrotation of the distal radius appears common following distal radius fracture. Malrotation of the distal fracture fragment has been shown to affect distal radio-ulnar joint function. Despite this, rotational deformity is rarely addressed in clinical practice as it is difficult to appreciate on simple radiographs. The simplified method described here is easy to use in routine clinical practice and also appears reliable. Measuring radial rotation may be an important consideration when planning both primary treatment and corrective osteotomy for patients with distal radial malunion.
Platelet-Rich Plasma: Does It Decrease Meniscus Repair Failure Risk?
Authors: Everhart Joshua Scott , Flanigan David C. , Magnussen Robert A. , Kaeding Christopher C.
Published: July 2019

Objectives:

(1) To determine whether intraoperative PRP affects meniscus repair failure risk. (2) To determine whether the effect of PRP on meniscus failure risk is influenced by ACL reconstruction status or by PRP preparation.

Methods:

550 patients (mean age 28.8 years SD 11.3) who underwent meniscus repair surgery with PRP (n=203 total, n=148 prepared with GPS III system, n=55 Angel system) or without PRP (n=347) and with (n=399) or without (n=151) concurrent ACL reconstruction were assessed for meniscus repair failure within 3 years. The independent effect of PRP on meniscus repair failure risk was determined by multivariate Cox proportional hazards modeling with adjustment for age, sex, body mass index (BMI), ACL status, tear pattern, tear vascularity, repair technique, side (medial or lateral) and number of sutures or implants utilized.

Results:

Failures within 3 years occurred in 17.0% of patients without PRP and 14.7% of patients with PRP (p=0.52) (Angel PRP: 14.6%; GPS III PRP: 12.0%; p=0.59). Increased patient age was protective against meniscus failure regardless of ACL or PRP status (per 5-year increase in age: adjusted Hazard Ratio [aHR] 0.90, 95% confidence interval [CI] 0.81, 1.0; p=0.047). The effect of PRP on meniscus failure risk was dependent upon concomitant ACL injury status (Figure). Among isolated meniscus repairs (20.3% failures at 3 years), PRP was independently associated with lower risk of failure (aHR 0.18, 95% confidence interval (CI) 0.03, 0.59; p=0.002) with no difference between PRP vendors (p=0.84). Among meniscus repairs with concomitant ACLR (14.1% failures at 3 years), PRP was not independently associated with risk of failure (aHR 1.39 CI 0.81, 2.36; p=0.23) with no difference between PRP venders (p=0.78).

Conclusion:

Both PRP preparations utilized in the current study had a substantial protective effect on isolated meniscus repair failure risk over 3 years. In the setting of concomitant ACL reconstruction, intraoperative PRP does not reduce meniscus repair failure risk. [Figure: see text]
Patient Satisfaction and Return to Sports after Meniscal Allograft Transplantation
Authors: Cvetanovich Gregory Louis , Christian David R. , Garcia Grant Hoerig , Liu Joseph N. , Redondo Michael L. , Southworth Taylor Marie , Naveen Neal Bhojraj , Yanke Adam Blair , Cole Brian J.
Published: July 2019

Objectives:

To investigate the ability of patients to return to sport following arthroscopic meniscal allograft transplantation (MAT).

Methods:

Patients undergoing arthroscopic MAT between 2013 and 2015 were retrospectively reviewed. Patients completed an outcome survey regarding return to sports in addition to patient reported outcome measures. Subsequent surgery and failure (total meniscectomy, revision MAT, or total or partial knee arthroplasty) were also evaluated.

Results:

Of 117 MAT performed, 87 patients (74.4%) were available at average 3.6 year follow-up. The average age at time of surgery was 29.0+/-8.3. All 84 patients underwent prior ipsilateral knee surgery with an average of 3.5+/-2.1 prior procedures. MAT was lateral in 44 cases (50.6%), medial in 42 cases (48.3%), and combined medial and lateral in one case (1.1%). Concomitant procedures were performed in 72 patients (82.7%) including cartilage restoration (65, 74.7%), realignment (9, 10.3%), and ACL reconstruction (9, 10.3%). Patients experienced significant improvement compared to preoperative Lysholm, IKDC, KOOS, WOMAC, and SF-12 physical scores (p < 0.001). Within three years prior to MAT, 82 patients (94.3%) reported participation in sporting activities. Due to knee symptoms, 62 patients (75.6%) discontinued at least one sport prior to MAT. Of the 82 patients participating in sports preoperatively, 62 patients (75.6%) returned to at least one sport at an average of 12.3 months after MAT. Rates of return to specific sports were highest for light weight lifting, yoga, swimming, and cycling and all RTS rates are shown in Table 1. The percentage of patients participating in sports above the recreational level declined significantly (46.0% prior to symptoms versus 8.2% after MAT, p < 0.001). The most common reasons for decreasing level of sport postoperatively were: to prevent further damage (73.6%), pain or swelling with sports (51.4%), fear of further injury (48.6%), surgeon recommendation (33.3%), and decision to pursue other activities (11.1%). Patients reported being satisfied with their ability to participate in sports at a rate of 63.2%, and 78.8% reported they would still undergo MAT with the benefit of hindsight. Reoperation was performed in 26 patients (29.9%) with 12 patients experiencing failure (13.7%; 1 TKA, 2 UKA, 9 total meniscectomy).

Conclusion:

In a complex patient population undergoing arthroscopic MAT, 75.6% of patients were able to return to at least one sport at an average of 12.3 months postoperatively. Level of sport declined compared to baseline, with most patients restricting involvement to recreational sports after MAT. The most common reasons for decreasing level of sport were: to prevent further damage, pain or swelling with sports, and fear of further injury. [Table: see text]
Adductor Canal Block versus Femoral Nerve Block for Pain Control After Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Trial
Authors: Okoroha Kelechi R. , Lynch Jonathan , Lizzio Vincent , Yu Charles Cong , Jildeh Toufic Raja , Moutzouros Vasilios
Published: July 2019

Objectives:

Regional anesthesia in the form of a femoral nerve block (FNB) is a commonly performed technique that has been proven to provide effective analgesia following anterior cruciate ligament (ACL) reconstruction. The adductor canal nerve block (ANB) employs a similar sensory block around the knee while avoiding motor blockade of the quadriceps. The purpose of our study was to compare the efficacy of FNB versus ANB for pain control following ACL reconstruction. Our hypothesis was that there would be no difference in pain levels or opioid requirements between the two groups.

Methods:

We performed a prospective, double-blinded, randomized controlled trial. Sixty patients undergoing primary ACL reconstruction using bone-tendon-bone autograft were randomized to receive either an ANB or FNB preoperatively. The primary outcomes assessed were pain levels (visual analog scale) and narcotic requirements for 4 days following surgery. Secondary outcomes included ability to perform a straight leg raise in the recovery room and difference in thigh circumference between the operative and nonoperative leg measured at 7 days postoperatively.

Results:

Morphine requirements were less in ACB in the first 4 hours postoperatively (p = .02). Aside from this time interval, there were no differences between the 2 groups with regard to opioid requirements and pain scores at any other time. Similarly, no differences were noted in the patient’s ability to perform a straight leg raise in the recovery room (p = .13) or in thigh circumference at the first postoperative visit (p = .09)

Conclusion:

The results of our study suggest similar efficacy in perioperative pain control with the use of an ANB for ACL reconstruction when compared to FNB. The potential long-term benefit of quadriceps preservation with the ACB is worthy of future study.
Risk Factors for Opioid Use Following Anterior Cruciate Ligament Reconstruction (ACLR) in a Cohort of 21,202 ACLR
Authors: Rao Anita G. , Prentice Heather A. , Chan Priscilla Hannah , Paxton Liz W. , Funahashi Tadashi Ted , Maletis Gregory B.
Published: July 2019

Objectives:

The misuse of opioid medication has contributed to a significant national crisis affecting public health, as well as patient morbidity and medical costs. We sought to determine baseline opioid utilization in patients undergoing ACLR and examine demographic, patient characteristics, and medical factors associated with postoperative opioid utilization.

Methods:

Primary elective ACLR were identified using an integrated healthcare system’s ACLR registry (January 2005-January 2015). Patients with cancer or those who had other knee surgery in the preceding year were excluded. We studied the effect of preoperative and intraoperative risks factors on number of dispensed opioid medication prescriptions (Rx) in the early (0-90 days) and late (91-360 days) postoperative periods using logit regression. Risk factors studied included: number of opioid Rx in preceding year, age, gender, race, American Society of Anesthesiologists (ASA) classification, body mass index (BMI), activity at the time of injury, time from injury to ACLR, concomitant procedure or injury, medical comorbidities, and opioid-use comorbidities.

Results:

Of 21202 ACLR from 20813 patients, 25.5% used at least 1 opioid Rx in the one-year preoperative period. 17.7% and 2.7% used ≥2 opioid Rx in the early and late recovery periods, respectively. The risk factors associated with greater opioid Rx in both the early and late periods included: preoperative opioid use, age >20 years, ASA classification of ≥3, other activity at the time of injury, repaired cartilage injury, chronic pulmonary disease, and substance abuse. Risk factors associated with opioid Rx use during the early period only included: other race, acute ACL injury, repaired meniscal injury, multi-ligament injury, and dementia/psychoses. Risk factors associated with greater opioid Rx during the late period included: female gender, BMI >25 kg/m2, motor vehicle accident as the mechanism of injury, and hypertension.

Conclusion:

We identified several risk factors for postoperative opioid usage after ACLR. The strongest predictors of postoperative prescription opioid usage after ACLR included preoperative opioid use, increasing age, ASA classification of 3 or more, other activity at the time of injury, repaired meniscal injury, cartilage repair, chronic pulmonary disease, and substance abuse. Awareness of risk factors for postoperative opioid usage may encourage more targeted utilization of opioids in pain management. Surgeons may consider additional support or referral to a pain specialist for patients with these risk factors. [Figure: see text]
Predictors of Clinical Outcomes after Proximal Hamstring Repairs
Authors: Bowman Eric N. , Marshall Nathan E. , Michael Gerhardt Brenton , Banffy Michael B.
Published: July 2019

Objectives:

Proximal hamstring avulsions cause considerable morbidity. Operative repair results in improved pain, function, and patient satisfaction; however, outcomes remain variable. The purpose of this study was to evaluate the predictors of clinical outcomes after proximal hamstring repairs.

Methods:

A retrospective review of proximal hamstring avulsions undergoing repair between January 2014 and June 2017 was performed. Patients were excluded for skeletal immaturity, previous tear, revision surgery, allograft reconstruction, fracture, subsequent extremity injury or surgery. Independent variables included: patient demographics, medical comorbidities, tear characteristics, and repair technique. Primary outcome measures were the Single Assessment Numerical Evaluation (SANE), International Hip Outcome Tool (iHOT-12), and the Kerlan-Jobe Orthopaedic Clinic (KJOC) Athletic Hip Score. Secondary outcome measures included satisfaction, visual analog scale (VAS), and level and timing of return to running or sports.

Results:

Of 86 eligible patients, 58 were analyzed (67%), with 29-month mean follow-up. Average age was 51; 57% were female. Acute tears accounted for 66%; 78% were complete avulsions. Open repair was performed on 90%. Overall satisfaction was 94%, though runners were less satisfied (p=0.029). At 7.6 months on average, 88% returned to sports, 72% at the same level. Runners less often returned to the same level, and at a decreased number of miles (15.7 vs. 7.8, p<0.001). Post-operatively, SANE scores improved, but average Tegner decreased (5.5 to 5.1). Acute repairs had higher SANE Activity scores. Higher satisfaction without functional difference for those over 50 years (p=0.024).

Conclusion:

Overall, patient satisfaction and functionality were high. There were no significant differences in functional outcome scores based on age, sex, body-mass index, smoking status, medical comorbidities, tear grade, activity level, or open versus endoscopic technique. Acute repairs had better SANE Activity scores. Runners should be cautioned that they may be unable to return to the same pre-injury activity level following proximal hamstring repair. [Table: see text]
The 6 O’Clock Anchor Increases Labral Repair Strength in a Biomechanical Shoulder Instability Model
Authors: Bokshan Steven L. , DeFroda Steven F. , Gil Joseph , Crisco J.J. Trey , Owens Brett D.
Published: July 2019

Objectives:

Despite a growing body of literature regarding optimal repair configurations, little is known about inferior suture anchor placement (6 o’clock position). Here, we determine the biomechanical strength of adding a 6’oclock anchor to a “standard” Bankart repair in a normal glenoid and a 13% anterior bone loss model.

Methods:

12 cadaveric shoulders were tested on a six axis industrial robot to measure the peak resistance to translation force with anterior displacement (1 centimeter). The rotator cuff muscles were loaded during testing to simulate physiological conditions. Test conditions included intact shoulder, Bankart lesion, Bankart repair (3, 4, and 5 o’clock anchors), and Bankart repair with a 6 o’clock anchor. A 13% anterior bone defect was then created (based on pretest CT scan) and all conditions were repeated. Repeated measures ANOVA was used to test for significant differences among groups.

Results:

In the no bone loss group, the addition of a 6 o’clock anchor yielded the highest peak resistance force (52.8 N, SD: 4.5 N) and was significantly stronger than the standard Bankart repair by 15.8% (7.2 N, p = 0.003). With 13% bone loss from the anterior glenoid, both the standard Bankart repair (peak force 49.3 N, SD: 6.1 N, p = 0.02) and repair with the addition of the 6 o’clock anchor (peak force 52.6 N, SD: 6.1 N, p = 0.006) had a significantly higher peak resistance force compared to the bone loss with Bankart lesion group (35.2 N, SD: 5.8 N). While the 6 o’clock anchor did increase the strength of the standard repair by 6.7%, this was not statistically significant (p = 0.9) in the bone loss model.

Conclusion:

The addition of a 6 o’clock suture anchor to a ”standard” Bankart repair increases to the peak resistance to translation force (no bone loss), although this additional strength is lost with creation of a 13% anterior glenoid bone defect.
The Cost Variability of Orthobiologics
Authors: Ponce Brent , McGee Andrew , Dombrowsky Alex , Waldrop Raymond , Wild Joshua , Faroqui Naqeeb , Huntley Samuel Roswell , McCollough Kennieth Charles , Brabston Eugene W. , Momaya Amit Mukesh
Published: July 2019

Objectives:

Despite limited clinical data, many orthopedic practices offer orthobiologic injections. Such injections are not covered by insurance, and thus patients pay out of pocket for these treatments. The purpose of this study was to assess the variability in costs for platelet rich plasma (PRP) and stem cell (SC) injections across practices and evaluate for variables that influence pricing.

Methods:

A list of 1,345 orthopedic sports medicine practices across the United States was compiled. Calls were made inquiring into the availability of PRP or SC knee injections and associated costs. In addition to pricing, practice type (academic or private), number of providers, and population and income demographics were recorded. Univariate statistical analyses were used to identify differences in availability and cost between variables.

Results:

Of the contacted offices, 268 (20.2%) offered both treatments, 550 (41.5%) offered only PRP injections, 20 (1.5%) offered only stem cell injections, and 487 (36.2%) did not offer either treatment. The mean (± SD) cost of a PRP injection was $707 ± $388 (range, $175 to $4,973), and the mean cost of a SC injection was $2,728 ± $1,584 (range, $300 to $12,000). Practices offering PRP and SC injections tended to be larger (for PRP - 11.6 physicians per practice vs. 8.1, P<0.001; for SC - 12.3 vs. 9.7, P=0.006). In addition, practices that offered PRP injections were located in areas with higher mean income ($67,500 vs. $64,300, P=0.047). Variables associated with higher cost of PRP injection included city population (P<0.001) and mean income of residents (P<0.001).

Conclusion:

While the majority of sports medicine practices across the United States offer some type of orthobiologic injection, there exists significant variability in the cost of these injections. The cost for PRP injections is higher in practices located in highly populated areas and in areas with greater mean incomes.
The Effect of Tibial Slope on Anterior Cruciate Ligament Reconstruction: A Matched Case-Control Study Including 317 Revisions
Authors: Cooper Joseph D. , Wang Wei , Prentice Heather A. , Funahashi Tadashi Ted , Maletis Gregory B.
Published: July 2019

Objectives:

There is evidence the slope of the tibial plateau may play a role in need for revision following ACL reconstruction (ACLR), however, previous studies are limited by small sample sizes, radiographic measurement, single surgeon experience, lateral tibial posterior slope (LTPS) only, or a lack of confounder adjustment. Further, the role of the medial posterior tibial slope (MTPS) on revision risk has yet to be evaluated. We sought to (1) determine the relationship of revision status following ACLR and LTPS, (2) determine the relationship of revision status and MTPS, and (3) determine the relationship of revision status and the difference between MTPS and LTPS.

Methods:

We conducted a nested case-control study of 317 matched pairs using an integrated U.S. healthcare system’s ACLR registry (2006- 2014). Cases were defined as patients who underwent a revision following primary unilateral ACLR; controls were defined from the same cohort as non-revised patients during the same time frame. Controls were matched to cases according to age, gender, body mass index, race, graft type, femoral fixation device, and follow-up time. Magnetic resonance imaging (MRI) images were used by a single blinded reviewer to measure tibial slopes. Wilcoxon signed rank test was applied to compare the slopes between revised and non-revised groups continuously and McNemar test to compare slopes of ≥12° between groups.

Results:

No difference was observed between revised and non-revised patients in LTPS (mean: 6.1 vs. 6.1, p=0.972) or MTPS (mean: 4.6 vs. 4.9, p=0.281) measurement. When comparing revised ACLR to non-revised ACLR, a greater proportion of revised ACLR had a LTPS of ≥12° (7.6% vs. 3.8%, P=0.034), while no difference was found in the proportion of ACLR with a MTPS ≥12° (1.6% vs. 2.5%, P=0.405). No difference was found when evaluating the medial-to-lateral slope difference (-1.5 vs. -1.2, p=0.289).

Conclusion:

In our nested case-control study of over 300 revised ACLR patients matched to non-revised patients, we did not find an association between the slope of the lateral and medial tibial plateaus and revision. [Figure: see text][Table: see text]
Delay in Surgical Management of Multiligament Knee Injuries is Associated with Cartilage and Meniscus Injury
Authors: Shamrock Alan G. , Hall James , Hajewski Christina , An Qiang , Duchman Kyle R.
Published: July 2019

Objectives:

Multiligament knee injuries (MLKIs) are potentially devastating injuries and can lead to significant functional impairment. Long-term outcomes and reconstructive options for MLKIs have been well described, however limited data exists on meniscus and chondral injuries in the setting of a multiligament deficient knee. The purpose of this study was to describe the pattern of meniscus and cartilage pathology in operative MLKIs and determine the relationship between surgical timing and degree of intra-articular injury.

Methods:

Consecutive patients with surgically treated MLKIs involving two or more ligaments (ACL, PCL, MCL, or PLC) over a 15-year period at a single large academic institution were retrospectively reviewed. Subjects were grouped based on their ligament injury pattern and the presence or absence of meniscus and chondral injury were recorded. Surgical intervention within 6 weeks of injury was deemed acute, while surgery occurring more than 6 weeks from injury was classified as delayed. Chi square and logistic regression were utilized for statistical analysis, with significance set at p<0.05.

Results:

In the 15-year study period, 207 patients with MLKIs (age: 28.4 +/- 12.1 years; 74.9% male) were surgically treated at our institution. There were 104 meniscal (50.2%) and 70 chondral (33.8%) injuries in the cohort. The most common ligamentous injury pattern was ACL/MCL (n=47, 22.7%) and ACL/PCL (n=47, 22.7%), followed by ACL/PCL/MCL (n=35, 16.9%) [Table 1]. Meniscectomy (n=52, 50.0%) was the most frequently performed procedure for meniscus injuries followed by meniscus repair (n=32, 30.8%). Compared to acutely managed patients, the delayed intervention group had significantly more meniscus pathology (57.1% vs 42.1%, p=0.03) and were more likely to undergo meniscectomy compared to repair (p=0.002). Of the 70 cartilage injuries, 11 (15.7%) required surgical debridement. Chondral pathology was more frequently present in the delayed intervention group compared to the acutely managed group (p=0.003). Meniscus injury rates in MLKIs sustained during sporting activity did not differ from non-sporting injuries (p=0.59) however, the non-sporting group had significantly more cartilage injuries (42.0% vs 18.1%, p<0.001).

Conclusion:

Surgical reconstruction of MLKIs delayed for more than 6 weeks was associated with increased meniscus and cartilage pathology. This may be the result of the severity of the initial injury, which may warrant surgical delay in more severe cases, or persistent knee instability placing the meniscus and chondral surface at risk for injury.
Incidence Of Elbow Ulnar Collateral Ligament Surgery In Collegiate Baseball Players
Authors: Rothermich Marcus A. , Conte Stan A. , Fleisig Glenn S. , Cain E. Lyle , Dugas Jeffrey R.
Published: July 2019

Objectives:

Recent studies in the literature have highlighted the progressive increase in the incidence of ulnar collateral ligament (UCL) injuries to the elbow in baseball players of all levels. However, knowledge of the incidence and other epidemiological factors regarding UCL injuries, specifically in college baseball players, is currently lacking. In 2016, we launched a prospective, multi-year study to evaluate the incidence of UCL injuries requiring surgery in National Collegiate Athletic Association (NCAA) Division I baseball programs.

Methods:

We invited 157 Division I collegiate baseball programs after the 2017 season, and 155 agreed to participate in the study. After the 2018 season, all 297 programs were invited and 294 participated. At the conclusion of the 2017 and 2018 collegiate baseball seasons, the athletic trainer for each program entered anonymous, detailed information on injured players through an electronic survey into a secured database.

Results:

We obtained a 100% completion rate in the first two years of this ongoing study (155/155 respondents in the first year, 294/294 in the second year). Of the 5,364 collegiate baseball players tracked in Year 1 (2016-2017), 134 underwent surgery for an injured UCL, resulting in a team surgery rate of 0.86 per program. In Year 2 (2017-2018), there were 230 surgeries reported from 10,019 players tracked, resulting in a team surgery rate of 0.78 per program. A majority of schools experienced at least one surgery during both years (56.8% in Year 1, 50.7% in Year 2). Pitchers experience a vast majority of the surgical injuries (85.8% in Year 1, 84.3% in Year 2). Underclassmen made up 65.7% of surgeries in Year 1, which fell slightly to 56.1% in Year 2. Nearly half of the surgeries occurred during an ongoing baseball season in Year 1 (48.5%), but this fell in Year 2 to 41.3%. In both years, a non-significant majority of players were from warm-weather states (65.4% in Year 1, 52.9% in Year 2). Revision surgical rates remained nearly constant with 3.0% revision surgeries in Year 1 compared with 2.6% revisions in Year 2. Interestingly, the percentage of UCL repairs with internal brace augmentation rose from 9.5% in Year 1 to 19.9% of all procedures in Year 2.

Conclusion:

The incidence of UCL surgeries in NCAA Division I collegiate baseball players represents substantial morbidity to this young athletic population. This multi-year prospective study has been established to assess the incidence of surgical UCL injuries in collegiate baseball. Also, importantly, with multiple years of data we will identify trends in the demographics of players undergoing surgery and in surgical details over time. Awareness of these factors should be considered in injury prevention programs in the future.
Major League Baseball Pitching Performance after Tommy John Surgery and the effect of Tear Characteristics, Technique, and Graft Type
Authors: Marshall Nathan E. , Keller Robert A. , Limpisvasti Orr , Schulz Brian M. , ElAttrache Neal S.
Published: July 2019

Objectives:

Return to play and player satisfaction has been quite high after ulnar collateral ligament reconstruction (UCLR), however, there has been little reported on how outcomes are affected by surgical technique, graft type and tear characteristics. The purpose was to evaluate surgical techniques, graft type and tear characteristics on MLB performance after UCLR.

Methods:

MLB pitchers that underwent primary UCLR at a single institution were included. Tear characteristics included tear location, tear grade and acuity. Surgical technique and graft type was also collected. Pitching performance statistics, including earned run average (ERA), Walks hits per innings pitched (WHIP), innings pitched, and fastball velocity were evaluated 3 years pre- and post-UCLR.

Results:

46 MLB pitchers were identified having primary UCLR. Return to play was 96%, with 82% returning to MLB play. Technique performed showed no difference in performance. Pitchers with palmaris grafts were younger (p=0.043), played longer after surgery (p=0.007), and returned to play at 100% (35/35) vs. 82% (9/11) of gracilis grafts (p=0.011). Pitchers with distal tears pitched at higher velocity (93.0 vs. 90.6 mph)(p=0.023) and had better performance (ERA, p=0.003; WHIP, p=0.003) prior to surgery, with proximal tears improving to match this performance and velocity after reconstructionhigher . Pitchers with complete tears played longer after surgery (5.9 vs. 4.0 years)(p=0.033), had better ERA (p=0.041) prior to injury and better WHIP (p=0.037) and strikeouts/9 innings (p=0.025) after reconstruction vs. partial tears. Chronic tears had a significant improvement in ERA from 4.49 to 3.80 (p=0.040) postoperatively.

Conclusion:

Technique performed and graft type used did not affect performance, however, palmaris grafts returned at a higher rate than gracilis grafts. Distal tears occurred in pitchers with greater velocity and better performance prior to injury with proximal tears matching this performance after reconstruction. Pitchers with complete tears played longer after reconstruction. Pitchers who had partial tears had worse performance prior to injury and after reconstruction and chronic tears saw a significant improvement in ERA with reconstruction.