Prolonged Weakness and Paresthesia After Revision Total Hip Arthroplasty in a Patient with Sickle Cell Anemia Receiving Spinal Anesthesia: A Case Report.

CASE: This report describes a case of prolonged neurologic deficit of primarily the nonoperative lower extremity in a patient with sickle cell disease (SCD) who received spinal anesthesia during revision total hip arthroplasty (THA). The patient initially showed bilateral lower extremity neurologic deficits localized to the L5/S1 nerve root, with the eventual persistence of symptoms in the nonoperative extremity for >1 year. CONCLUSIONS: This report describes an unusual complication after THA and spinal anesthesia. This case highlights the rare occurrence of nerve root injury after spinal anesthesia and emphasizes the importance of close perioperative monitoring in patients with SCD undergoing orthopaedic surgery.

The financial burden associated with multiple shoulder dislocations and the potential cost savings of surgical stabilization.

INTRODUCTION: Shoulder dislocation is a costly problem and can have a high risk for recurrent instability after initial dislocation based on well-defined patient characteristics. Patients with recurrent instability can be treated with shoulder stabilizing procedures. Although more costly, surgery may decrease the overall health care burden of managing a patient with multiple shoulder dislocations nonoperatively. METHODS: We performed a retrospective chart review of all patients who presented to the emergency department (ED) with a diagnosis of a shoulder dislocation at a level 1 academic trauma center during the year 2016. Patient information regarding the current dislocation episode, previous dislocations, shoulder surgeries, and postreduction follow-up was gathered. These data were then used to determine the average cost of an ED presentation for a shoulder dislocation episode as obtained from the hospital finance department. The average cost of shoulder stabilization surgery was used to conduct a cost-benefit analysis of operative vs. nonoperative management. RESULTS: Data were collected on 104 individuals who presented to the ED with shoulder dislocations. Of these, 65 were primary dislocations and 39 were recurrent dislocations. Twelve patients underwent shoulder stabilization surgery after their ED presentation. The average cost to the institution for an ED visit requiring the closed reduction of a shoulder dislocation was $2207 ($973.21 without sedation and $3744 with conscious sedation). The average cost of a shoulder stabilization procedure performed at this same institution was $7807. DISCUSSION AND CONCLUSION: Although shoulder stabilization has a higher cost on the front end, this intervention results in cost savings if it prevents 2-3 future shoulder dislocations resulting in ED visits. These findings suggest that, for patients with a high risk for recurrent instability, not only would stabilization surgery help prevent subsequent dislocation events but would also minimize health care costs.

Synovial Cell Count Poorly Predicts Septic Arthritis in the Presence of Crystalline Arthropathy.

Introduction: A synovial cell count greater than 50,000/mm3 is the threshold most commonly used to diagnose septic arthritis. This lab value may be nonspecific in the setting of crystalline arthropathy. The purpose of this study was to evaluate the accuracy of diagnosing septic arthritis using a synovial cell count cut-off of 50,000/mm3 in the setting of crystalline arthropathy. Methods: This was a retrospective review of joint aspirations performed between July 1st, 2013 and June 30th, 2016. Synovial fluid samples were evaluated for cell count, crystals, Gram stain, and culture. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the synovial markers were calculated. Results: During the study period, 738 joint aspirations were sent for testing, of which 358 aspirations in 348 patients met inclusion criteria. There were 49 (13.7%) cases of culture-positive septic arthritis, and 47 patients underwent surgical irrigation and debridement. Gout and pseudogout crystals were present in 163 aspirates (45.5%). Three joints (0.8% overall rate) had concomitant crystalline arthropathy and septic arthritis, each of which had a synovial WBC ≥85,000/mm3. Increasing the WBC count cutoff to 85,000/mm3 demonstrated a specificity of 100%, but a PPV of 12.0%. Conclusions: A cut-off of 85,000/mm3 may be more appropriate to diagnose concomitant septic arthritis and crystalline arthropathy. We recommend medical management and observation in patients with crystal-positive joint aspirations unless the synovial cell count is elevated above 85,000/mm3. Prospective studies using this treatment guideline are needed to evaluate its validity and accuracy.

Return-to-Play and Performance Outcomes of Professional Athletes in North America After Hip Arthroscopy From 1999 to 2016.

BACKGROUND: The effect of hip arthroscopy on athletic performance compared with preinjury levels for professional athletes in different sports remains unknown. In addition, while return rates have been reported for professional baseball, football, and hockey players, return rates have not been reported for professional basketball players. HYPOTHESIS: Professional athletes in 4 major North American sports would be able to return to their sport and preoperative level of performance at a high rate after arthroscopic hip surgery. STUDY DESIGN: Descriptive epidemiology study. METHODS: Major League Baseball (MLB), National Basketball Association (NBA), National Football League (NFL), and National Hockey League (NHL) athletes who underwent hip arthroscopy were identified through a previously reported protocol based on public sources. Successful return to play (RTP) was defined as returning for at least 1 professional regular season game after surgery. Performance scores were calculated by use of previously established scoring systems. Each player served as his own control, with the season prior to surgery defined as baseline. To make comparisons across sports, the authors adjusted for expected season and career length differences between sports and calculated percentage changes in performance. RESULTS: The authors identified 227 procedures performed on 180 professional athletes between 1999 and 2016. Successful RTP was achieved in 84.6% (192/227) of the procedures. Compared with all other athletes, NBA athletes returned at a similar rate (85.7%, P ≥ .999). NFL offensive linemen returned at a significantly lower rate than all other athletes (61.1%, P = .010). NHL athletes returned at a significantly higher rate than all other athletes (91.8%, P = .048) and demonstrated significantly decreased performance during postoperative season 1 compared with baseline (-35.1%, P = .002). Lead leg surgery for MLB athletes (batting stance for hitters, pitching stance for pitchers) resulted in a 12.7% reduction in hitter performance score ( P = .041), a 1.3% reduction in pitcher fastball velocity ( P = .004), and a 60.7% reduction in pitch count ( P = .007) one season after surgery compared with baseline. Players in nearly every sport demonstrated significant reductions in game participation after surgery. CONCLUSION: This study supports the hypothesis that hip arthroscopy in professional athletes is associated with excellent rates of return at the professional level. However, postoperative performance outcomes varied based on sport and position.