Faculty Bibliography

OBJECTIVE:The Mobile Universal Lexicon Evaluation System (MULES) is a test of rapid picture naming under investigation. Measures of rapid automatic naming (RAN) have been used for over 50 years to capture aspects of vision and cognition. MULES was designed as a series of 54 grouped color photographs (fruits, random objects, animals) that integrates saccades, color perception and contextual object identification. We examined MULES performance in youth, collegiate and professional athletes at pre-season baseline and at the sidelines following concussion. METHODS:Our study teams administered the MULES to youth, collegiate and professional athletes during pre-season baseline testing. Sideline post-concussion time scores were compared to pre-season baseline scores among athletes with concussion to determine degrees and directions of change. RESULTS:Among 681 athletes (age 17 ± 4 years, range 6-37, 38% female), average test times at baseline were 41.2 ± 11.2 s. The group included 280 youth, 357 collegiate and 44 professional athletes; the most common sports were ice hockey (23%), soccer (17%) and football (11%). Age was a predictor of MULES test times, with longer times noted for younger participants (P < .001, linear regression). Consistent with other timed performance measures, significant learning effects were noted for the MULES during baseline testing with trial 1 test times (mean 49.2 ± 13.1 s) exceeding those for trial 2 (mean 41.3 ± 11.2 s, P < .0001, paired t-test). Among 17 athletes with concussion during the sports seasons captured to date (age 18 ± 3 years), all showed increases (worsening) of MULES time scores from pre-season baseline (median increase 11.2 s, range 0.6-164.2, P = .0003, Wilcoxon signed-rank test). The Symptom Severity Score from the SCAT5 Symptom Evaluation likewise worsened from pre-season baseline following injury among participants with concussion (P = .002). CONCLUSIONS:Concussed athletes demonstrate worsening performance on the MULES test compared to their baseline time scores. This test samples a wide network of brain pathways and complements other vision-based measures for sideline concussion assessment. The MULES test demonstrates capacity to identify athletes with sports-related concussion.

History: A 40 year old male presents for evaluation of bilateral calf pain, left worse than right. The pain has been ongoing for one year and is localized to the lateral calf. He denies trauma or acute injury. The pain is worse with activity and is relieved by rest. For activity, he does daily walking and heavy lifting. He also often feels pain after prolonged standing. The pain does not improve with acetaminophen/ibuprofen. He denies swelling, numbness, tingling or weakness of the legs. He has been to several physicians for this pain and his work-up so far includes negative DVT and exertional ABI studies. He has been out of work for the past month due to a recent appendectomy, with a relative improvement in pain during this time. He recalls he broke his right leg when he was 13 while horse-back riding, after the horse fell on him. Physical Exam: Bilateral Lower Extremity: No redness, swelling or bruising. No knee effusion. No medial or lateral joint line tenderness. (1) TTP left lateral gastrocnemius (1) TTP over left fibular head. No tenderness along the right gastrocnemius or fibular head. Knees/ankles with FROM without pain. Negative varus/valgus stress test. Negative Lachman's, posterior drawer, McMurray. 5/5 knee and ankle strength. No pain with resisted strength testing of knee or ankle. Neutral standing alignment. Low medial longitudinal arches. Walking without a limp. (1) hop reproduces pain on left. Neuro: sensation intact to light touch, 2/4 patellar and Achilles reflexes. Skin: 21 peripheral pulses, cr < 2 seconds, no edema. Differential Diagnosis: Gastrocnemius Strain Popliteus Tendinopathy Chronic Exertional Compartment Syndrome - Lateral Common Peroneal Neuropathy Fibular Stress Reaction Test Results: XR Left Knee: No acute fracture or dislocation; MRI Tibia/Fibula: Transversely oriented incomplete stress type fracture within the left fibular head with surrounding bone marrow edema. Healed fracture deformity of the right mid/distal tibial diaphysis. Mild deformity of the right proximal fibular diaphysis which may reflect a healed fracture deformity. DXA Scan (T-score): Spine 22.3, L Femoral Neck 22.7, R Femoral Neck 22.6; Ca: 9.9 ICal: 1.40 PTH: 36 Vit D 25-OH: 50.6 Vit D 1,25-OH: 25 BMP wnl. Final Diagnosis: Incomplete Left Fibular Head Stress Fracture. Healed Right Proximal Fibular Fracture. Osteoporosis. Vitamin D Insufficiency.
Discussion(s): Most fibular stress fractures occur in the distal 1/3 of the fibula. Proximal fibular stress fractures are uncommon, making this an unusual case. In a 2009 study in Clinics in Orthopedics Surgery, 10 proximal fibular stress fractures were identified in 635 military recruits undergoing 6 weeks of training with repetitive walking/jumping in a squatting position. Our patient did not have this type of biomechanical stress. His medical history was reviewed and no risk factors for osteoporosis were identified other than poor diet. It is difficult to determine whether his healed right proximal fibular fracture occurred during his injury at age 13 or whether it was a subsequent stress fracture.
Outcome(s): He was started on calcium and vitamin D. Physical therapy and insoles were recommended to help correct bio-mechanical forces contributing to his injury. He was unwilling to be non-weight bearing. He took additional weeks off from work with reported improvement in pain. He underwent rheumatology and endocrine consultations for osteoporosis. Further lab testing was sent which was unremarkable. Follow-up: Given the improvement in his pain with relative rest, he has returned to work which requires prolonged standing and walking. He continues to avoiding heavy lifting and impact activities. He has follow-up scheduled with rheumatology for a denosumab injection to treat his osteoporosis. He is scheduled to follow-up with us in 6 weeks. He has not yet started a course of physical therapy

Orthobiologics are organic and synthetic materials that are used in and outside of the operating room to augment both bone and soft tissue healing. The orthobiologics portfolio has vastly expanded over the years, and it has become imperative for orthopedic surgeons to understand the role and function of this new class of biologic adjuvants. This review will highlight key components and product groups that may be relevant for the practicing orthopedic surgeon in any subspecialty. This by no means is an extensive list of the available products but provides an important overview of the most highlighted products available in the market today. Those discussed include, bone void fillers, extracelluar matrix (ECM) products, platelet-rich plasma (PRP), bone morphogenetic protein-2 (BMP-2), bone marrow aspirate (BMA), bone marrow aspirate concentrate (BMAC), and mesenchymal stem cells (MSCs). These are further categorized into their uses in several subspecialties including, traumatology, sports medicine, sports surgery, and spine surgery.

OBJECTIVE:Measures of rapid automatized naming (RAN) have been used for over 50 years to capture vision-based aspects of cognition. The Mobile Universal Lexicon Evaluation System (MULES) is a test of rapid picture naming under investigation for detection of concussion and other neurological disorders. MULES was designed as a series of 54 grouped color photographs (fruits, random objects, animals) that integrates saccades, color perception and contextual object identification. Recent changes to the MULES test have been made to improve ease of use on the athletic sidelines. Originally an 11 × 17-inch single-sided paper, the test has been reduced to a laminated 8.5 × 11-inch double-sided version. We identified performance changes associated with transition to the new, MULES, now sized for the sidelines, and examined MULES on the sideline for sports-related concussion. METHODS:We administered the new laminated MULES to a group of adult office volunteers as well as youth and collegiate athletes during pre-season baseline testing. Athletes with concussion underwent sideline testing after injury. Time scores for the new laminated MULES were compared to those for the larger version (big MULES). RESULTS:Among 501 athletes and office volunteers (age 16 ± 7 years, range 6-59, 29% female), average test times at baseline were 44.4 ± 14.4 s for the new laminated MULES (n = 196) and 46.5 ± 16.3 s for big MULES (n = 248). Both versions were completed by 57 participants, with excellent agreement (p < 0.001, linear regression, accounting for age). Age was a predictor of test times for both MULES versions, with longer times noted for younger participants (p < 0.001). Among 6 athletes with concussion thus far during the fall sports season (median age 15 years, range 11-21) all showed worsening of MULES scores from pre-season baseline (median 4.0 s, range 2.1-16.4). CONCLUSION/CONCLUSIONS:The MULES test has been converted to an 11 × 8.5-inch laminated version, with excellent agreement between versions across age groups. Feasibly administered at pre-season and in an office setting, the MULES test shows preliminary evidence of capacity to identify athletes with sports-related concussion.

OBJECTIVE: This study investigated the utility of sideline concussion tests, including components of the Sports Concussion Assessment Tool, 3rd Edition (SCAT3) and the King-Devick (K-D), a vision-based test of rapid number naming, in an outpatient, multidisciplinary concussion center treating patients with both sports-related and non-sports related concussions. The ability of these tests to predict clinical outcomes based on the scores at the initial visit was evaluated. METHODS: Scores for components of the SCAT3 and the K-D were fit into regression models accounting for age, gender, and sport/non-sport etiology in order to predict clinical outcome measures including total number of visits to the concussion center, whether the patient reached a SCAT3 symptom severity score