Vitamin D is critically important to numerous physiologic functions, including bone health. Poor vitamin D status is a common but underrecognized problem that predisposes the military population to stress fracture and completed fracture. This has significant implications for force health protection, warfighter readiness, attrition, and cost. Despite this, vitamin D deficiency is still underdiagnosed and undertreated in the military. This is a major hindrance to military readiness and one that could easily be modified with awareness, prevention, and early treatment. In this commentary, we review the literature on vitamin D deficiency and critically examine the current status of policies and clinical practice related to vitamin D in the military health system. We offer several practical recommendations to increase awareness and readiness while decreasing musculoskeletal injury and the associated costs.
Background Intestinal and multivisceral transplantations are treatment options for patients with intestinal failure. Transplantation is often complicated by abdominal and/or bloodstream infections in the post‐operative period. Methods A retrospective chart review of all adults who underwent intestinal or multivisceral transplantation at our institution from 2003 to 2015 was performed. Data were collected for 2 years post transplant. Results A total of 106 intestinal or multivisceral transplants were performed in 103 patients. The median age at the time of transplant was 44 (IQR: 34‐52) with 55% (n = 58) male and 45% (n = 48) female. There were 46 (43%) intra‐abdominal infections post transplant among the 103 patients, and six transplant recipients (13%) developed concurrent bloodstream infections. The median time to first intra‐abdominal infection was 23 days (IQR: 10‐48). For those with organisms isolated in culture, forty‐seven percent of the isolates were gram negative, 39% gram positive, 7% anaerobes, and 7% yeast. The most common isolates were enterococci at 28%, E. coli at 14%, and Klebsiella spp at 13%. Sixty‐three percent of the enterococci were vancomycin‐resistant enterococci (VRE), and 22% of the gram‐negative isolates were extended spectrum beta‐lactamases (ESBLs). Patients with intra‐abdominal infections had longer hospital post‐transplant length of stays at a median of 35 days (IQR: 25‐48) vs 23 days (IQR: 17‐33) for those without infections, P = .0012. There was no difference in all‐cause mortality in patients with or without intra‐abdominal infections, P = .654. Conclusions Intra‐abdominal infections are common in intestinal or multivisceral transplant recipients, but despite this complication, we found no increased risk of mortality. These transplant recipients are also at risk for infection with drug‐resistant organisms.
Background: The objective of this study was to evaluate sex differences in the incidence and risk of ankle–foot complex (AFC) stress fractures among U.S. military personnel, which could assist in developing management strategies as females assume a greater role in U.S. military operations. Methods: The Defense Medical Epidemiological Database was used to identify all diagnosed AFC stress fractures in military personnel from 2006 to 2015. Cumulative incidence of AFC stress fractures was calculated and compared by year, service branch, and military rank. Sex differences in the risk of AFC stress fractures by occupation were examined, and integrated (i.e., male and female) occupations were compared with non-integrated (i.e., male–only) occupations. Results: A total of 43,990 AFC stress fractures were identified. The overall incidence rate was 2.76 per 1,000 person-years for males and 5.78 per 1,000 person-years for females. Females consistently had higher incidence of AFC stress fractures across all subgroups, particularly among enlisted personnel. Female enlisted service members had the highest risk of AFC stress fractures in aviation [relative risk (RR) = 5.74; 95% confidence interval [CI] 4.80–6.87] and artillery/gunnery (RR = 5.15; 95% CI 4.62–5.75) occupations. Females in integrated occupations had significantly higher rates of AFC stress fractures than males in both integrated and non-integrated occupations (i.e., special forces, infantry, and mechanized/armor). Conclusions: Females in the U.S. military have a higher risk of AFC stress fractures than males. As integration of females into previously sex-restricted occupations continues, focused prevention efforts may be needed to reduce injury burden and maximize medical readiness.
Background: There are findings in the adult and adolescent literature regarding anatomic variation that may lead to traumatic disruption of the anterior cruciate ligament (ACL). Previous studies have found an interaction between age and various morphologic risk factors but have been underpowered in assessing younger pediatric patients. Hypothesis/Purpose: The purpose of this study was to evaluate morphologic features of the knee in younger children to determine if any of these factors may contribute to risk of ACL injury in this age group. Methods: A retrospective review of knee MRIs was performed on pediatric patients evaluated at our facility for confirmed ACL rupture. Seven measures were performed and three ratios were calculated, which were compared to an age-matched control cohort previously used to establish and publish normative data of childhood knee MRIs. They were then grouped for statistical purposes by age: “child” aged 5 – 11 years, and “adolescents” aged 12 – 19 years. A generalized linear model was used to assess interaction between age and ACL status. Results: A total of 49 children age <12 years with ACL rupture were identified during the data collection period that met criteria for review. While intercondylar width and notch height index (NHI) were significant in the ACL-torn cohort at large (p=0.015 and p=0.001 respectively), this difference was not present in children. Conversely, tibial plateau to anterior tibial spine (ATS) height was different in ACL-torn children but not in adolescents (p=0.003). Notch Width Index (NWI) was significantly smaller in ACL torn children and adolescents (p<0.0001). When comparing age groups, NWI was the only variable that had minimal to no difference in the normal group, but a significant difference between children and adolescents in the ACL-torn group. No difference was found in Critical Notch Stenosis. Conclusion: Children and adolescents demonstrate the effect of multiple morphologic parameters on ACL tear risk. While there is overlap, there are risk factors specific to each age group. Uniquely, increased TP to ATS height was a risk factor for ACL tear in children. Despite the effect of age and ACL tear on NWI, there was no difference for Critical Notch Stenosis, suggesting that the current definition of critical notch stenosis should be adjusted. Given the difference between NWI in children and adolescents with ACL tear, it may be more appropriate to have age-based cutoffs for critical notch stenosis.
Objectives: Avulsion fractures of the sublime tubercle of the ulna have been reported as a cause of medial elbow pain and instability in overhead athletes in adolescence and early adulthood. While the management of ulnar collateral ligament (UCL) and medial epicondyle injuries have been extensively described and reported, little has been published on the treatment of the less common bony avulsion fracture of the sublime tubercle. The objective of this study was to characterize injury pattern, treatment, and outcomes for sublime tubercle avulsion fractures in adolescent throwing athletes. Methods: A multicenter retrospective review was conducted from July 2005 to December 2020. Sublime tubercle avulsion fractures were identified by surgeon records or a database query of radiology reports. Inclusion criteria included throwing athletes age ≤19 years old with a sublime tubercle avulsion fracture sustained from a throwing mechanism, identified on at least one radiologic study (radiograph, CT, or MRI). Data collected included demographics, clinical presentation including mechanism of injury, acuity, initial treatment; and outcomes including complications, final range of motion, patient reported symptoms, radiographic union, and return to activities or sport. Results: 14 baseball players were identified with sublime tubercle avulsion fractures with a median age of 16.5 years (range, 15-19). Median duration of follow up was 2.26 years. All athletes were initially managed non-operatively with either rigid immobilization (casting, n=7), or no rigid immobilization (activity modification alone, sling, or removable brace, n=7). Six of the seven athletes treated with casting had favorable outcomes and were able to return to sport; one suffered a reinjury at 10 months and was unable to return to his previous level of play, but declined operative management. Of the seven initially managed without rigid immobilization, two had success and were able to return to sport without additional intervention, one had persistent pain and associated UCL tear but declined surgery; four ultimately proceeded to UCL reconstruction. For the athletes that underwent surgery, two did so for continued pain and associated tearing of the UCL, one for nonunion of displaced sublime tubercle, and one for a reinjury 10 months after full healing of the initial fracture and return to sport. All were able to return to their previous level of throwing postoperatively. Conclusions: As the largest case series of adolescent throwing athletes with sublime tubercle avulsion fractures to date, this study expands our understanding of management of this rare injury. Our results challenge the historical findings that the majority of sublime tubercle avulsion fractures fail non-operative management, and highlight the role for a diligent non-operative protocol with rigid immobilization, which has much better success than removable forms of immobilization or activity modification alone. Unlike purely ligamentous injuries, bony avulsions may be treated nonoperatively with good results and return to high level throwing in adolescent patients. [Figure: see text]
Objectives: Shoulder instability among adolescent athletes remains a complex challenge with high recurrence rates. Knotted suture anchors have provided consistently reliable biomechanical and clinical results. In recent years, the advent of the knotless suture anchor technology has come with proposed advantages of minimizing technical difficulty and knot migration, as well as reducing subsequent intra-articular cartilage irritation and damage. While several studies have analyzed the utility of knotless suture anchors in the adult population, to our knowledge, there has not been a direct comparison within this more at risk for surgical failure adolescent population. The purpose of this study was to compare the effect of knotted versus knotless suture anchor use on postoperative outcomes of arthroscopic shoulder instability surgery in the adolescent athlete. Methods: A multicenter comparative cohort was conducted of patients that underwent primary arthroscopic shoulder labral repair with suture anchor implants for shoulder instability between June 2015 and November 2017. Additional inclusion criteria included patient age <20 years and minimum follow up duration of 3.5 years. Data collected included demographics, number and type of suture anchor (knotted or knotless), number of instability events, type of instability, and presence of bony Bankart lesions. All included patients had <20% glenoid bone loss at the time of surgery. Type of instability was also recorded and was classified as either: anterior, posterior, or multidirectional (MDI). The primary outcome measure was surgical failure, which was defined as any recurrent instability event post-surgery. Incidence of secondary surgery (including revision or need for additional procedure), surgical times, and return to sport (RTS) data were also recorded. Patient-reported outcomes were evaluated using the Pediatric and Adolescent Shoulder Survey (PASS), SANE (Single Assessment Numeric Evaluation) scores, and the Quick version of Disabilities of the Arm, Shoulder and Hand (QuickDASH) survey. Results: Eighty-eight shoulders (54 male, 34 female) from 84 patients met inclusion criteria and were analyzed. 43 received knotless anchors and 45 received knotted anchors. Mean follow-up duration was 4.5 years (range, 3.5-6 years) for the knotless cohort and 4.8 years (range, 3.7-5.8 years) for the knotted cohort. Demographics and type of instability by suture anchor type is shown in Table 1. Surgical failure rate was significantly lower in the knotless cohort (knotless, 16%; knotted, 53%; P<.001). Patients with knotless suture anchors reported significantly higher mean PASS scores (knotless, 90.2; knotted, 81.3; P=.002 ). There was no difference in both RTS rates (knotless, 86%; knotted, 68%; P=.055) and incidence of repeat surgery between cohorts (knotless, 9%; knotted, 13%; P=.551). Surgical times, SANE scores, and QuickDASH scores were available for approximately three-quarters of shoulders (total, 65; knotless, 36; knotted, 29) in the cohort. Mean surgical time was approximately 18 minutes shorter for knotless anchors (knotless, 84.4 minutes; knotted, 102.7 minutes; P<.001). SANE scores were significantly higher in the knotless group (knotless, 88.8; knotted, 74.3; P=0.004). QuickDASH scores, of which a lower score is considered a better outcome, were not different (knotless, 5.7; knotted, 11.4; P=.063). Conclusions: Our initial intent was to demonstrate that knotless anchors would be just as successful as labral repairs with knotted anchors, but our results indicate several promising advantages, including: better patient reported outcome measures (PASS and SANE scores), reduced surgical times, and lower failure rates at a mean 4.5 years. There were some non-significant differences in the two cohorts regarding the type of instability that likely contributed to the differences in the number of anchors utilized. Future studies with larger sample sizes may serve to confirm our observed benefits associated with knotless anchors. In summary, the utilization of knotless suture anchor constructs for the repair of labral tears in adolescent shoulder instability may be safely considered with potentially improved outcomes over knotted anchors. [Table: see text]
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