bluuebunny/crossref_metadata_2025_split huggingface dataset:
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.
Clinical Utility Of An MRI Based Classification For Operative Versus Non-operative Management Of UCL Tears: Two-year Follow Up
Authors: Ramkumar Prem N. , Haeberle Heather S. , Navarro Sergio M. , Frangiamore Salvatore Joseph , Farrow Lutul D. , Schickendantz Mark S. 
Published: July 2019

Objectives: A recently introduced classification of medial ulnar collateral ligament (UCL) tears accounting for location and severity has demonstrated high interobserver and intraobserver reliability, but little is known about its clinical utility. The purpose of this study was to assess the relationship of the MRI-based classification system in predicting which athletes succeeded non-operative versus operative treatment after completing a standardized rehabilitative program. Secondary objectives included sub-analysis of baseball players, including return-to-play (RTP) and return-to-prior performance (RPP). Methods: After a priori power analysis, 58 consecutive patients with UCL tears and a minimum of two-year follow-up were retrospectively classified into those succeeding operative versus non-operative treatments. The MRI-based classification system accounting for UCL tear location and severity were correlated with non-operative and operative cohorts. Sub-analyses for baseball players, including RTP and RPP, were performed. Results: A total of 58 patients (40 baseball players, 34 pitchers) met inclusion criteria. A total of 35 patients (32 baseball players, 27 pitchers) underwent surgery, and 23 patients (8 baseball players, 7 pitchers) completed non-operative management. No patients in the non-operative arm crossed over to surgery after completing the rehabilitative program. Patients with distal (OR: 48.0, p=0.0004) and complete (OR: 5.4, p=0.004) tears were more likely to undergo surgery. Baseball players, regardless of position, were confounding determinants of operative management, although there was no difference in RTP and RPP between treatment arms. Conclusion: A six-stage MRI-based classification addressing UCL tear grade and location may confer early decision-making as patients likely to fail non-operative treatment have complete, distal tears whereas those with proximal, partial tears may be more amenable to non-operative modalities. [Table: see text]
Early Surgical Intervention for Femoroacetabular Impingement Syndrome Provides Clinically Significant Outcome Improvement
Authors: Kunze Kyle N. , Beck Edward C. , Nwachukwu Benedict Uchenna , Ahn Junyoung , Nho Shane Jay 
Published: July 2019

Objectives: The purpose of the current study is to assess the outcomes of hip arthroscopy for FAIS according-timing of surgical intervention. Methods: Patients undergoing arthroscopic intervention for FAIS with minimum two year follow-up were included. All patients completed the hip outcome score (HOS)-activities of daily living (ADL), HOS-sports subscale (HOS-SS), modified Harris hip score (mHHS), international hip outcome tool-12 (IHOT-12), and visual analog scales (VAS) for pain and satisfaction. Patients were stratified by time with FAIS symptoms until surgical intervention. We compared 3-6 months of symptoms with other subsequent time frames (6-12 months, 12-24 months, and >24 months). Clinically significant outcome was determined using the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS). Results: A total of 1,094 patients with mean (+ standard deviation) age 32.3+12.4 years and follow-up 30.8+6.7 (range:24-58) months were included. Patients undergoing surgery at 3-6 months of symptoms had no significant differences in outcome compared-those in the 6-12 month group except for the IHOT-12 (p:0.028). Patients with symptom duration of 12-24 months and greater than 24 months had worse outcome across all outcome measures (p<0.0001 for symptoms >24 months). Patients in the 3-6 month symptom group had increased likelihood for achieving MCID on HOS ADL (OR:1.81; 1.20-2.73), and HOS-SS (OR:1.90; 1.11-3.17), as well as PASS on the HOS-ADL (OR:1.85; 1.34-2.56) and HOS-SS (OR:1.58; 1.14-2.18). In multivariate regression analysis, symptom duration was the most predictive of VAS pain (Beta:3.10, 95% Confidence Interval [95%CI]:1.56-4.63; p<0.001) and satisfaction scores (Beta:-4.16, 95%CI:-6.14- -2.18; p<0.001). Conclusion: In patients with FAIS, surgical intervention early after the onset of symptoms (3-6 months) is associated with superior outcomes when compared to patients who underwent surgical intervention beyond this time frame. This information may help guide preoperative decision making on behalf of surgeons and patients who are considering delaying intervention. [Table: see text]
Comparison of Tendon Lengthening with Traditional vs. Accelerated Rehab Following Achilles Tendon Repair: A Randomized Controlled Trial
Authors: Okoroha Kelechi , Ussef Najib , Eller Erik , Zeni Ferras , Moutzouros Vasilios 
Published: July 2019

Objectives: Operative repair of Achilles tendon ruptures have shown successful outcomes. However, little is know about the amount of tendon or repair site lengthening after repair and if lengthening is affected by rehab protocols. The purpose of our study was to compare lengthening of the Achilles tendon after surgical repair, comparing traditional and accelerated rehab protocols. Methods: Twenty patients undergoing primary repair of Achilles tendon ruptures were assessed for participation. We performed a prospective randomized controlled trial in accordance with the CONSORT (Consolidated Standards of Reporting Trials) 2010 statement. The study arms included operative repair of Achilles tendon rupture with either accelerated (graduated weight bearing at 2 weeks) or traditional rehab (weight bearing at 6 weeks). During repair, two 2-mm tantalum beads with laser-etched holes were sutured to the Achilles tendon at the repair site. Beads were evaluated via CT scans immediately post-operatively and at 12 weeks. X-rays were obtained at time 0 and then at 2, 6, and 12 weeks. The primary outcome of the study was the difference in tendon or repair site lengthening between the study arms. Randomization was by a computerized algorithm. The observer was blinded and the patient was not blinded to the intervention. Results: Zero patients declined participation and all 20 patients were included for final analysis. All patients showed statistically significant lengthening at two weeks following surgery. There was a trend toward increased lengthening at 6 weeks in the accelerated rehab group (9.9 mm, range 2.6 -13.9 mm) compared to the traditional rehab group (4.1 mm, range 1.5 -9.0 mm), although this was not statistically significant; p = .07. However the final amount of tendon lengthening at 12 weeks after surgery was not different between the accelerated rehab group (14.4 mm, range 11.7 -17.0 mm) and the traditional rehab group (13.4 mm, range 10.7 -17.0 mm); p = .38. Conclusion: This study’s findings suggest that all patients undergoing operative repair of Achilles tendon ruptures have significant lengthening after surgery. Although there was a trend toward increased lengthening at 6 weeks in the accelerated rehab group, there was no difference in tendon lengthening at final follow up between the two groups.
Electromyographic Evidence of Excessive Achilles Tendon Elongation During Isometric Contractions After Achilles Tendon Repair
Authors: McHugh Malachy P. , Orishimo Karl F. , Kremenic Ian J. , Adelman Julia , Nicholas Stephen J. 
Published: July 2019

Objectives: It has been proposed that increased tendon elongation after Achilles tendon repair contributes to selective weakness in end-range plantar flexion (Mullaney et al 2006). Excessive tendon elongation during maximum voluntary contraction (MVC) means greater muscle fiber shortening. Since mean frequency (MF) of the electromyogram (EMG) increases with muscle fiber shortening, it was hypothesized that during isometric plantar flexor MVCs MF would be higher on the involved versus non-involved side. Therefore, the purpose of this study was to examine MF during isometric MVCs in patients with Achilles tendon repairs. Methods: Maximum isometric plantar flexion torque was measured at 20° and 10° dorsiflexion, neutral, and 10° and 20° plantar flexion in 17 patients (mean±SD age, 39±9 years; 15 men, 2 women) 43±24 months after surgery (range, 9 months to 8 years). Surface EMG signals were recorded during strength tests. MF was calculated from Fast Fourier Transforms of medial gastroc (MG) lateral gastroc (LG) and soleus (S) EMG signals. Effect of weakness on MF was assessed using analysis of variance. Based on reported plantar flexor MF values it was estimated that with 17 subjects there would be 80% power to detect a 16% difference in MF between involved and noninvolved legs at P<0.05. Results: Patients had marked weakness in 20° plantar flexion (deficit 28±18%, P<0.01; 14 of 17 deficit >20%) but no significant weakness in 20° dorsiflexion (deficit 8±15%, P=0.20; 4 of 17 deficit >20%). MF increased moving from dorsiflexion to plantar flexion (P<0.001) but overall was not different between involved and noninvolved sides (P=0.22). However, differences in MF between the involved and noninvolved sides were apparent in the patients with marked weakness. At 10° plantar flexion 8 of 17 patients had marked weakness (>20% deficit). MF at 10° plantar flexion was significantly higher on involved versus noninvolved side in patients with weakness but this was not apparent in patients with no weakness (side by group P=0.014; Table 1). MF at 10° plantar flexion average across the 3 muscles was 13% higher on the involved versus noninvolved side in patients with weakness (P=0.012) versus 3% lower in patients with no weakness (P=0.47). Conclusion: Higher MF on the involved versus noninvolved side in patients with significant plantar flexion weakness is consistent with greater muscle fiber shortening. This indicates that weakness was primarily due to excessive lengthening of the repaired Achilles tendon. If weakness were simply due to atrophy, a lower MF would have been be expected and patients would have had weakness throughout the range of motion. Surgical and rehabilitative strategies are needed to prevent excessive tendon elongation and weakness in end-range plantar flexion after Achilles repair. [Table: see text]