Dysphagia is associated with increased mortality risk after hip fracture surgery.

PURPOSE: This study aims to explore the prevalence of dysphagia, as well as mortality associated with dysphagia in the elderly population receiving surgical treatment for a hip fracture. METHODS: A retrospective cohort study was completed at an academic level 1 tertiary care center. Patients older than or equal to 65 admitted with a hip fracture diagnosis from January 2015 to December 2020 (n = 617) were included. The main outcome was the prevalence of dysphagia and association with mortality. Secondary analysis included timing of dysphagia and contributions to mortality. RESULTS: Fifty-six percent of patients had dysphagia, and the mortality rates were higher in patients with dysphagia (8.9%) versus those without dysphagia (2.6%), chi-square p = 0.001, and odds ratio 3.69 (CI 1.6-8.5). Mortality rates in patients with acute dysphagia were also higher (12.4%) than those with chronic dysphagia (5%) and chi-squared p = 0.02. Mortality rates in patients with a perioperative dysphagic event (13.9%) were higher than those with non-perioperative dysphagia (4%) and chi-squared p = 0.001. Mortality rates in patients who had acute perioperative dysphagia (21.2%) were higher than those with chronic dysphagia that presented perioperatively (6.8%) and chi-squared p = 0.006. CONCLUSIONS: This study demonstrates high rates of dysphagia in the elderly hip fracture population and a significant association between dysphagia and mortality. Timing and chronicity of dysphagia were relevant, as patients with acute perioperative dysphagia had the highest mortality rate. Unlike other identified risk factors, dysphagia may be at least partially modifiable. More research is needed to determine whether formal evaluation and treatment of dysphagia lowers mortality risk.

Postoperative pain score does not correlate with injury severity in isolated tibial plateau fractures.

PURPOSE: Appropriate management of acute postoperative pain is critical for patient care and practice management. The purpose of this study was to determine whether postoperative pain score correlates with injury severity in tibial plateau fractures. METHODS: A retrospective review of prospectively collected data was completed at a single academic level one trauma center. All adult patients treated operatively for tibial plateau fractures who did not have concomitant injuries, previous injury to the ipsilateral tibia or knee joint, compartment syndrome, inadequate follow-up, or perioperative regional anesthesia were included (n = 88). The patients were split into groups based on the AO/OTA fracture classification (B-type vs C-type), energy mechanism, number of surgical approaches, need for temporizing external fixation, and operative time as a proxy for injury severity. The primary outcome measure was the visual analog scale (VAS) pain score (average in the first 24 h, highest in the first 24 h, two- and six-week postoperative appointments). Psychosocial and comorbid factors that may affect pain were studied and controlled for (history of diabetes, neuropathy, anxiety, depression, PTSD, and previous opioid prescription). Additionally, opioid use in the postoperative period was studied and controlled for (morphine milligram equivalents (MME) administered in the first 24 h, discharge MME/day, total discharge MME, and opioid refills). RESULTS: VAS scores were similar between groups at each time point except the two-week postoperative time point. At the two-week postoperative time point, the absolute difference between the groups was 1.3. The groups were significantly different in several injury and surgical variables as expected, but were similar in all demographic, comorbid, and postoperative opioid factors. CONCLUSIONS: There was no clinical difference in postoperative pain between AO/OTA 41B and 41C tibial plateau fractures. This supports the idea of providers uncoupling nociception and pain in postoperative patients. Providers should consider minimizing extended opioid use, even in more severe injuries.

Outcomes Following Hemiarthroplasty for Femoral Neck Fracture in Patients Who Have Hemiparesis.

BACKGROUND: Hemiparesis increases the risk of femoral neck fracture (FNF) in the elderly, which frequently necessitates hemiarthroplasty. There are limited reports on the outcomes of hemiarthroplasty in patients who have hemiparesis. The purpose of this study was to evaluate hemiparesis as a potential risk factor for medical and surgical complications following hemiarthroplasty. METHODS: Hemiparetic patients who have concomitant FNF and underwent hemiarthroplasty with at least 2 years of follow-up were identified using a national insurance database. A 10:1 matched control cohort of patients who did not have hemiparesis was created for comparison. There were 1,340 patients who have and 12,988 patients who did not have hemiparesis undergoing hemiarthroplasty for FNF. Multivariate logistic regression analyses were used to evaluate rates of medical and surgical complications between the 2 cohorts. RESULTS: Aside from increased rates of medical complications including cerebrovascular accident (P < .001), urinary tract infection (P = .020), sepsis (P = .002), and myocardial infarction (P < .001), patients who have hemiparesis also experienced higher rates of dislocation within 1 and 2 years (Odds Ratio (OR) 1.54, P = .009; OR 1.52, P = .010). Hemiparesis was not associated with higher risk of wound complications, periprosthetic joint infection, aseptic loosening, and periprosthetic fracture, but was associated with higher incidence of 90-day ED-visits (OR 1.16, P = .031) and 90-day readmission (OR 1.32, P < .001). CONCLUSION: While patients who have hemiparesis do not have increased risk of implant-related complications other than dislocation, they are at increased risk of developing medical complications following hemiarthroplasty for FNF.

A standardized method of measuring screw breach on postoperative computed tomography scans following percutaneous fixation of the posterior pelvic ring.

PURPOSE: To assess the reliability of a standardized measurement of screw breach on postoperative computed tomography (CT) scans following percutaneous fixation of the posterior pelvic ring. METHODS: Three orthopedic trauma surgeons independently utilized a standardized method of measuring posterior pelvic ring screw breaches on post-operative CT scan images. Breaches were measured as a continuous variable on sagittal images reformatted to be perpendicular to the screw on axial images. The inter-rater and intra-rater reliability of screw breach distance measurements was assessed. RESULTS: Measurements were performed on 42 screws in 20 patients. Screw types included S1-iliosacral (IS) (n = 16), S1-transsacral (TS) (n = 8), S2-IS (n = 2), and S2-TS (n = 16). Patients with varying degrees of screw breaches were chosen to test measurements across breach severities, including 0 mm (n = 10), ≤ 2 mm (n = 12), > 2 to 4 mm (n = 11), and > 4 mm (n = 9). The mean difference and 95% confidence interval (CI) between screw breach measurements between the three surgeons was - 0.13 mm (CI - 0.48 to 0.20), 0.05 mm (CI - 0.6 to 0.7), and 0.18 mm (CI - 0.47 to 0.85), respectively. The inter-rater reliability of the measurements was considered excellent (intraclass correlation coefficient (ICC), 0.93). The mean intra-rater reliability for the observers was considered good (ICC 88.5, CI 82 to 95). CONCLUSIONS: This simple standardized method of measuring screw breaches had excellent inter-rater reliability and would support comparisons of screw breach severity across studies. LEVEL OF EVIDENCE: Level III.

Native tibia valga: a potential source of varus malreduction during intramedullary tibial nail fixation of tibial shaft fractures.

PURPOSE: To determine the effect of native tibia valga on intramedullary nail (IMN) fixation of tibial shaft fractures. METHODS: Retrospective comparative cohort analysis of 110 consecutive patients with tibial shaft fractures undergoing IMN fixation at an urban level one trauma centre was performed. Medical records and radiographs were reviewed for demographics, tibia centre of rotation of angulation (CORA), nail starting point, incidence of varus malreduction, and nail/canal proportional fit. RESULTS: Tibia valga (CORA of ≥ 3 degrees) was present in 37 (33.6%) patients. The anatomic nail starting point distance (in relation to the lateral tibial spine) was significantly greater in the tibia valga group (12.0 mm vs. 5.0 mm, mean difference: 7.1 mm, 95% CI: 5.8 to 8.3 mm, p < 0.0001). Varus malreduction was more common in the tibia valga group (10.8% vs. 1.4%, proportional difference: 9.4%, 95% CI: - 1.0 to 21.3%, p = 0.04). Varus malreduction in the tibia valga group was associated with a decreased nail width/inner canal width proportion on multivariate analysis (OR = 0.683, 95% CI: 0.468 to 0.995, p = 0.0004). CONCLUSION: Native tibia valga is common, and the use of a standard coronal IMN starting point with poor nail fit can lead to iatrogenic varus malreduction. In patients with tibia valga, maximizing nail fit or utilization of a medial starting point should be considered.

Treatment of intertrochanteric nonunion after sliding hip screw fixation with a short cephalomedullary nail.

Intertrochanteric femur fracture nonunions are a rare complication that can be difficult to treat with limited evidence regarding treatment options. Revision fixation is typically reserved for well-aligned nonunions with sufficient femoral head bone stock. The most common implant used for revision fixation is a sliding hip screw implant. The use of a short cephalomedullary nail (CMN) for revision fixation has not been previously reported. This article presents a technique for reamed short CMN revision fixation of well-aligned nonunions with sufficient bone stock that is a simpler and potentially less morbid treatment option compared to open procedures with fixed-angle devices. For nonunions with poor femoral head bone stock and/or malaligned fractures, a fixed-angle implant, with or without a valgus osteotomy, may be necessary, while arthroplasty is reserved for nonunions with poor proximal femur bone stock that are not amenable to fixed-angle implant fixation.

The utilization of intraoperative contralateral ankle images for syndesmotic reduction.

PURPOSE: To evaluate the variability in ankle syndesmotic morphology on contralateral ankle fluoroscopic images and the reductions obtained utilizing these images. METHODS: A retrospective cohort study was performed at a level one trauma center including 46 adult patients undergoing operative fixation of malleolar ankle fractures that also had anteroposterior (AP) and lateral fluoroscopic images of the uninjured contralateral ankle intraoperatively. Contralateral and post-fixation fluoroscopic images were used to measure the tibiofibular clear space (TFCS) as a proportion of the superior clear space (SCS) on mortise images and the posterior tibiofibular distance (PTFD) as a proportion of the lateral superior clear space (LSCS) on lateral images. Differences between contralateral and post-fixation ankle measurements were compared between those patients with syndesmotic injuries and those without (control group). RESULTS: The mean TFCS/SCS and PTFD/LSCS ratios measured on contralateral ankle images were 1.2 (95% confidence interval (CI) 1.1 to 1.3; range 0.7 to 1.8) and 1.8 (95% CI 1.5 to 2; range 0.5 to 3.4). The mean difference between the contralateral and post-fixation TFCS/SCS and PTFD/LSCS in patients with and without syndesmotic fixation was 0.07 vs. 0.13 (F-ratio 0.3, p = 0.5) and -0.2 vs 0.5 (F ratio 5.2, p= 0.02). CONCLUSIONS: Contralateral syndesmotic measurements varied widely and the utilization of these images allowed for syndesmotic reductions with similar measurements. Intraoperative contralateral ankle images should be considered to assess syndesmotic reduction.

Need for syndesmotic fixation and assessment of reduction during ankle fracture fixation, with and without contralateral fluoroscopic images, has poor interobserver reliability.

PURPOSE: To determine the interobserver reliability of syndesmosis assessment using intraoperative ankle mortise fluoroscopic images, with and without contralateral images. METHODS: A survey of 19 operative ankle fracture cases was administered to 17 orthopedic surgeons. Respondents were presented with fluoroscopic mortise and stress images of the ankle after fracture fixation and asked if they would fix the syndesmosis. Final fluoroscopic mortise images were then shown, and respondents were asked to assess the reduction of the syndesmosis. Six weeks later, the survey was administered again with the addition of contralateral fluoroscopic ankle mortise images. Responses were compared to a standard response agreed upon by fellowship-trained orthopedic trauma surgeons. RESULTS: Interobserver reliability for syndesmosis fixation and reduction, with and without contralateral images, was considered weak (kappa 0.48 and 0.43; mean difference 0.05, 95% confidence interval (CI) 0.01 to 0.1) and minimal (kappa 0.25 and 0.22; mean difference 0.02, CI - 0.02 to 0.08). With the addition of contralateral mortise images, the number of surgeons who changed their response for syndesmosis fixation and reduction quality ranged from 0% to 41% and 0% to 88%; with the number of responses matching the standard increasing for both fixation (proportional difference (PD) 7%, CI 1% to 14%) and reduction (PD 14%, CI 7% to 21%); CONCLUSIONS: Interobserver reliability of syndesmosis fixation and reduction remained weak to minimal between surgeons, with and without contralateral images. Future studies are necessary to understand the variability in surgeon responses in order to improve the intraoperative assessment and fixation of syndesmotic injuries.

Comparison of iliac crest versus supraacetabular external fixator in hemodynamically unstable patients with a pelvic ring injury.

PURPOSE: External fixation has been widely implemented as a resuscitation strategy in combination with pelvic packing for high energy, hemodynamically unstable, pelvic ring injuries. The primary aim of this study is to compare urgent iliac crest (IC) versus supraacetabular (SA) external fixation in the setting of haemodynamic instability. METHODS: This is a retrospective review of a prospectively gathered registry at an urban level one trauma centre comparing placement of pelvic external fixator by SA or IC technique. Outcomes assessed were accuracy of pin placement, duration of procedure, and the effect on true pelvic circumference depending on type of fracture by Young and Burgess Classification system. RESULTS: Ninety-three haemodynamically unstable patients with a pelvic fracture included. Pin malpositioning was more common with IC than SA groups (proportional difference, - 40%; 95% CI, - 57 to - 20%; p < 0.0001). For APC injuries, there was a larger median reduction in pelvic circumference in the SA group than the IC group (median difference [MD], - 12.85 cm; 95% CI, - 27 to 0.1; p = 0.0485). In LC injuries, the SA group had an overall increase in pelvic circumference compared to an overall decrease in IC group (MD, 6.5 cm; 95% CI, 1.5 to 16.8; p = 0.0221). There was no difference in the operating room (OR) time (mean difference, - 5.4 min; 95% CI, - 32 to 22; p = 0.68). CONCLUSIONS: In this clinical setting, we recommend placement of SA external fixator (versus IC) with similar operative times, fewer pin malpositions, and improved stabilization of pelvic circumference in APC and LC injuries.

From Dr. Miller E. Preston (1879-1928) to the Department of Orthopaedics at Denver Health Medical Center in Denver, CO.

Dr. Miller Edwin Preston was a surgeon with a deep interest in trauma and orthopaedics who practiced in Denver in the early 1900s. Dr. Preston arrived in Denver shortly after the creation of Denver's first city hospital in 1860. This hospital would later be renamed to Denver General Hospital and then Denver Health Medical Center. It excels for the quality of its emergency medicine residency program, a very high survival rate for severely injured patients and the clinical pathways and algorithms pertinent to the management of haemodynamically unstable pelvic ring injuries among others. Today, Dr. Preston's legacy of excellence in the management of trauma patients is alive and well at Denver Health Medical Center, the city's only level-one safety net hospital and academic affiliate of the University of Colorado Medical School.

Lateral compression type 1 (LC1) pelvic ring injuries: a spectrum of fracture types and treatment algorithms.

Lateral compression type 1 (LC1) fractures are the commonest pelvic ring injury. However, they represent a heterogenous spectrum of injury mechanisms and fracture patterns, resulting in a lack of strong evidence for a universally agreed treatment algorithm. Although consensus exists that LC1 fractures have a preserved posterior ligamentous complex and are vertically stable, controversy persists around defining internal rotational instability. As such, treatment strategies extend from routine non-operative management through to dynamic imaging such as examination under anaesthetic (EUA) or stress radiographs to guide fixation algorithm. Multiple protocols sit between these two, all with slightly different thresholds for advocating surgery or otherwise, exemplifying a broad lack of consensus that is not seen for other, more severe, grades of pelvic ring injury. In the following review we discuss the evolving concepts of pelvic ring instability and management, starting from a historical perspective, through to current trends and controversies in LC1 fracture treatment. Emerging directions for research and emerging pharmacological and surgical treatments/technologies are also considered and expert commentary from 3 leading centres provided. The distinction is made between LC1 fracture arising from high-energy trauma and those following low-energy falls from standing height (so-called fragility fractures of the pelvis-FFP), since these two patient groups have different functional requirements and medical vulnerabilities. Issues pertaining to FFP are considered separately.

Varus displacement of intertrochanteric femur fractures on injury radiographs is associated with screw cutout.

INTRODUCTION: The purpose of this study was to determine if varus displacement of intertrochanteric femur fractures on injury radiographs is associated with screw cutout after fixation. METHODS: A retrospective review performed at two urban level 1 trauma centers identified 334 patients with intertrochanteric femur fractures treated with either a cephalomedullary nail (CMN) or a sliding hip screw (SHS). Median patient age was 75 years, 69% were female and 46% had unstable fractures. Varus fracture displacement on injury radiographs, defined as the most proximal aspect of the femoral head being at or below the most proximal aspect of the greater trochanter, was present in 38% of patients. Screw cutout was recorded. RESULTS: Varus displacement was associated with unstable fracture patterns (62% vs. 37%, difference (D) 25%, 95% confidence interval (CI) 15-35%), female gender (77% vs. 64%, D 13%, CI 3-22%) and poor/adequate reductions (54% vs. 41%, D 13%, CI 2-23%). Cutout occurred in 9 (3%) patients, 8 of which had varus displacement. There was no detectable difference, with wide confidence intervals, between patients that did and did not experience cutout in terms of age, gender, unstable fractures, implants, tip-apex distance (TAD) or poor/adequate reductions. On univariate and multivariate analysis, varus displacement was the only variable associated with cutout. Patients with and without varus displacement had a cutout incidence of 6 and 0.5% (Odds ratio 13, CI 1.6-108). CONCLUSION: Intertrochanteric fractures presenting with varus displacement were more likely to experience cutout. This potential risk factor for cutout warrants further study. LEVEL OF EVIDENCE: Level 3, retrospective cohort.

Predictors of Osteochondral Lesions of the Talus in Patients Undergoing Broström-Gould Ankle Ligament Reconstruction.

Chronic ankle instability is associated with intra-articular and extra-articular ankle pathologies, including osteochondral lesions of the talus. Patients with these lesions are at risk for treatment failure for their ankle instability. Identifying these patients is important and helps to guide operative versus nonoperative treatment. There is no literature examining which patient characteristics may be used to predict concomitant osteochondral lesions of the talus. A retrospective chart review was performed on patients (N = 192) who underwent a primary Broström-Gould lateral ankle ligament reconstruction for chronic ankle instability from 2010 to 2014. Preoperative findings, magnetic resonance imaging, and operative procedures were documented. Patients with and without a lesion were divided into 2 cohorts. Fifty-three (27.6%) patients had 1 lesion identified on preoperative magnetic resonance imaging. Forty (69.0%) of these lesions were medial, 18 (31.0%) were lateral, and 5 patients had both. Female sex was a negative predictor of a concomitant lesion (p = .013). Patients were less likely to have concomitant peroneal tendinopathy (30.2% vs 48.9%; p = .019) in the presence of a lesion. However, sports participation was a positive predictor of a concomitant lesion (p = .001). The remainder of the variables (age, body mass index, smoking, trauma, duration, contralateral instability, global laxity) did not show a significant difference. In patients who underwent lateral ankle ligament reconstruction, females were less likely to have a lesion than males. Patients with peroneal tendinopathy were less likely to have a lesion compared with patients without. Additionally, athletic participation was a positive predictor of a concomitant lesion.

Peroneal Nerve Dysfunction due to Multiligament Knee Injury: Patient Characteristics and Comparative Outcomes After Posterior Tibial Tendon Transfer.

OBJECTIVE: To objectively compare outcomes of nonoperative management and posterior tibial tendon (PTT) transfer for peroneal nerve injury due to multiligament knee injury (MLI). DESIGN: Retrospective cohort study with prospective follow-up. SETTING: Tertiary care institution. PATIENTS: Ten patients with peroneal nerve injury due to MLI (5 managed nonoperatively, 5 with PTT transfer) were evaluated and a control group of 4 patients without peroneal nerve injury. INTERVENTIONS: Clinical examination, subjective questionnaires, and 3-D motion capture gait analysis during flat-ground walking and stair descent. MAIN OUTCOME MEASURES: The primary outcome measure was the result of gait analysis. The results of subjective questionnaires were a secondary outcome measure. RESULTS: Dorsiflexion was significantly reduced at initial contact and mid-late swing phase in the nonoperative cohort. The PTT transfer cohort demonstrated increased dorsiflexion at each of these time intervals compared with patients managed nonoperatively, restoring symmetry between limbs. The PTT transfer cohort demonstrated similar gait patterns to controls but tended to be more everted. Ground reaction force was increased in the uninvolved limb in the PTT transfer group during gait and step down. There were no statistically significant differences in AOFAS, FAAM, IKDC, or Lysholm results. CONCLUSIONS: Posterior tibial tendon transfer is an option to restore dorsiflexion and eliminate the need for an orthosis in patients with foot drop due to MLI. Gait analysis demonstrates a significant improvement in sagittal plane ankle kinematics after PTT transfer. The trade-off is subtle instability, highlighting the dynamic stability that the PTT provides.

Platelet-rich plasma in meniscal repair: does augmentation improve surgical outcomes?

BACKGROUND: Increased contact stresses after meniscectomy have led to an increased focus on meniscal preservation strategies to prevent articular cartilage degeneration. Platelet-rich plasma (PRP) has received attention as a promising strategy to help induce healing and has been shown to do so both in vitro and in vivo. Although PRP has been used in clinical practice for some time, to date, few clinical studies support its use in meniscal repair. QUESTIONS/PURPOSES: We sought to (1) evaluate whether PRP augmentation at the time of index meniscal repair decreases the likelihood that subsequent meniscectomy will be performed; (2) determine if PRP augmentation in arthroscopic meniscus repair influenced functional outcome measures; and (3) examine whether PRP augmentation altered clinical and patient-reported outcomes. METHODS: Between 2008 and 2011, three surgeons performed 35 isolated arthroscopic meniscus repairs. Of those, 15 (43%) were augmented with PRP, and 20 (57%) were performed without PRP augmentation. During the study period, PRP was used for patients with meniscus tears in the setting of no ACL reconstruction. Complete followup at a minimum of 2 years (mean, 4 years; range, 2-6 years) was available on 11 (73%) of the PRP-augmented knees and 15 (75%) of the nonaugmented knees. Clinical outcome measures including the International Knee Documentation Committee (IKDC) score, Tegner Lysholm Knee Scoring Scale, and return to work and sports/activities survey tools were completed in person, over the phone, or through the mail. Range of motion data were collected from electronic patient charts in chart review. With the numbers available, a post hoc power calculation demonstrated that we would have expected to be able to discern a difference using IKDC if we treated 153 patients with PRP and 219 without PRP assuming an alpha rate of 5% and power exceeding 80%. Using the Lysholm score as an outcome measure, post hoc power estimate was 0.523 and effect size was -1.1 (-2.1 to -0.05) requiring 12 patients treated with PRP and 17 without to find statistically significant differences at p = 0.05 and power = 80%. RESULTS: There was no difference in the proportion of patients who underwent reoperation in the PRP group (27% [four of 15]) compared with the non-PRP group (25% [five of 20]; p = 0.89). Functional outcome measures were not different between the two groups based on the measures used (mean IKDC score, 69; SD, 26 with PRP and 76; SD, 17 without PRP; p = 0.288; mean, Tegner Lysholm Knee Scoring Scale, 66, SD, 32 with PRP and 89; SD, 10 without PRP; p = 0.065). With the numbers available there was no difference in the proportion of patients who returned to work in the PRP group (100% [six of six]) compared with the non-PRP group (100% [nine of nine]) or in the patients who returned to their regular sports/activities in the PRP group (71% [five of seven]) compared with the non-PRP group (78% [seven of nine]; p = 0.75). CONCLUSIONS: Patients who sustain meniscus injuries should be counseled at the time of injury about the outcomes after meniscus repair. With our limited study group, outcomes after meniscus repair with and without PRP appear similar in terms of reoperation rate. However, given the lack of power and nature of the study, modest size differences in outcome may not have been detected. Future larger prospective studies are needed to definitively determine whether PRP should be used with meniscal repair. Additionally, studies are needed to determine if PRP and other biologics may benefit complex tear types. LEVEL OF EVIDENCE: Level III, therapeutic study.

Medial injury in knee dislocations: what are the common injury patterns and surgical outcomes?

BACKGROUND: When associated with a knee dislocation, management of the medial ligamentous injury is challenging, with little literature available to guide treatment. QUESTIONS/PURPOSES: We (1) compared MRI findings of medial ligament injuries between Schenck KDIIIM and KDIV injuries, (2) compared clinical outcomes and health-related quality of life as determined by Lysholm and Veterans Rand 36-Item Health Survey (VR-36) scores, respectively, of reconstructed KDIIIM and KDIV injured knees, and (3) determined reoperation rates of reconstructed KDIIIM and KDIV injured knees. METHODS: Over a 12-year period, we treated 65 patients with knee dislocations involving bicruciate ligament injury and concomitant medial ligament injuries, without or with posterolateral corner injuries (Schenck KDIIIM and KDIV, respectively); 57% were available for followup at a mean of 6.2 years (range, 1.1-11.6 years). These patients were contacted, and prospectively measured clinical outcomes scores (Lysholm and VR-36) were obtained and compared between subsets of patients. Preoperative MRIs (available for review on 49% of the patients) were rereviewed to characterize the medial ligament injuries. RESULTS: KDIIIM injuries more frequently had complete deep medial collateral ligament tears and posterior oblique ligament tears compared to KDIV injuries. KDIIIM knees had better Lysholm scores (88 versus 67, p = 0.027) and VR-36 scores (88 versus 70, p = 0.022) than KDIV knees. Female sex (Lysholm: 55 versus 85, p = 0.005; VR-36: 59 versus 85, p = 0.003) and an ultra-low-velocity mechanism (injury that occurs during activity of daily living in obese patients) (Lysholm: 55 versus 80-89, p = 0.002-0.013; VR-36: 60 versus 79-88, p = 0.001-0.017) were associated with worse outcomes. The overall reoperation rate was 28%, and the most common indication for reoperation was stiffness. CONCLUSIONS: Medial ligament injury is common in knee dislocations. Females who sustain these injuries and patients who have an ultra-low-velocity mechanism should be counseled at the time of injury about the likelihood of inferior outcomes. As ROM deficits are the most commonly encountered complication, postoperative rehabilitation should focus on early ROM exercises as stability and wound healing allow. Future prospective studies are needed to definitively determine whether operative or nonoperative management is appropriate for particular medial ligamentous injury patterns.

Return to football and long-term clinical outcomes after thumb ulnar collateral ligament suture anchor repair in collegiate athletes.

PURPOSE: To evaluate return to play after complete thumb ulnar collateral ligament (UCL) injury treated with suture anchor repair for both skill position and non-skill position collegiate football athletes and report minimum 2-year clinical outcomes in this population. METHODS: For this retrospective study, inclusion criteria were complete rupture of the thumb UCL and suture anchor repair in a collegiate football athlete performed by a single surgeon who used an identical technique for all patients. Data collection included chart review, determination of return to play, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) outcomes. RESULTS: A total of 18 collegiate football athletes were identified, all of whom were evaluated for follow-up by telephone, e-mail, or regular mail at an average 6-year follow-up. Nine were skill position players; the remaining 9 played in nonskill positions. All players returned to at least the same level of play. The average QuickDASH score for the entire cohort was 1 out of 100; QuickDASH work score, 0 out of 100; and sport score, 1 out of 100. Average time to surgery for skill position players was 12 days compared with 43 for non-skill position players. Average return to play for skill position players was 7 weeks postoperatively compared with 4 weeks for non-skill position players. There was no difference in average QuickDASH overall scores or subgroup scores between cohorts. CONCLUSIONS: Collegiate football athletes treated for thumb UCL injuries with suture anchor repair had quick return to play, reliable return to the same level of activity, and excellent long-term clinical outcomes. Skill position players had surgery sooner after injury and returned to play later than non-skill position players, with no differences in final level of play or clinical outcomes. Management of thumb UCL injuries in collegiate football athletes can be safely and effectively tailored according to the demands of the player's football position. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Patient age is a factor in early outcomes after shoulder arthroplasty.

BACKGROUND: Elderly and young patients alike are undergoing shoulder replacement at increased rates. In an era of outcomes reporting, risk adjustment, and cost containment, identifying patients likely to have adverse events is increasingly important. Our objective was to determine whether patient age is independently associated with postoperative in-hospital complications or increased hospital charges after shoulder arthroplasty. METHODS: We used the Nationwide Inpatient Sample to analyze 58,790 patients undergoing total shoulder arthroplasty or hemiarthroplasty between 2000 and 2008. Multivariate analysis with logistic regression modeling was used to compare groups. Our objective was to determine whether age had an independent impact on the likelihood of postoperative in-hospital complications, mortality rate, length of stay, or charges after shoulder arthroplasty. RESULTS: Patients aged 80 years or older had an increased in-hospital mortality rate (0.5%) compared with patients aged 50 to 79 years (0.1%) and patients aged younger than 50 years (0.1%). Predictors of death included female gender, total shoulder arthroplasty versus hemiarthroplasty, and Deyo score. Increased age was associated with slightly increased hospital charges. Length of stay was longer in patients aged 80 years or older compared with younger patients. After shoulder arthroplasty, postoperative anemia occurred more often in patients aged 80 years or older. Other postoperative complications including pulmonary embolism, infection, and cardiac complications were similar among groups. CONCLUSION: Older patients tend to have longer hospital stays, an increased incidence of postoperative anemia, and slightly higher charges after shoulder arthroplasty. Advanced age is not associated with an increased incidence of pulmonary embolism, infection, and cardiac complications. Further research is warranted to explain the relationship between age and early postoperative outcomes.

Peripheral Nerve Blocks for Hip Fractures.

The incidence of hip fractures has continued to increase as life expectancy increases. Hip fracture is one of the leading causes of increased morbidity and mortality in the geriatric population. Early surgical treatment (<48 h) is often recommended to reduce morbidity/mortality. In addition, adequate pain management is crucial to optimize functional recovery and early mobilization. Pain management often consists of multimodal therapy which includes non-opioids, opioids, and regional anesthesia techniques. In this review, we describe the anatomical innervation of the hip joint and summarize the commonly used peripheral nerve blocks to provide pain relief for hip fractures. We also outline literature evidence that shows each block's efficacy in providing adequate pain relief. The recent discovery of a nerve block that may provide adequate sensory blockade of the posterior capsule of the hip is also described. Finally, we report a surgeon's perspective on nerve blocks for hip fractures.

Traumatic brain injury is common and undertreated in the orthopaedic trauma population.

INTRODUCTION: Traumatic brain injuries (TBIs) can be difficult to diagnose and are often marginalized when compared to more obvious physical injuries. Despite this, recognition and early treatment can lead to improved outcomes. Even mild TBIs have the potential to cause significant long-term consequences for patients, which may affect their physical recovery from orthopaedic injuries. The objective of this study was to examine the incidence and treatment of TBI within the orthopaedic trauma population. METHODS: Inclusion criteria were all patients presenting after an acute trauma with an orthopaedic surgery consult over a continuous 3 month timeframe (n = 187). A retrospective review was completed at an academic tertiary referral trauma center. The primary outcome was the rate of TBI. Secondary outcomes included rate of TBI listed as a discharge diagnosis and rate of follow up plan. Several secondary variables were noted and their associations with TBI evaluated. RESULTS: 27 % of the 187 patients had an acute TBI. 61 % of TBI patients had the diagnosis listed in their discharge summary. 6 % had a follow up plan. The positive TBI group was associated with more high energy injuries (p = 0.032), average limbs involved (p = 0.007), upper extremity injury (p < 0.001), bilateral lower extremity injury (p = 0.004), and Injury Severity Score (p < 0.001). 82 % of patients with an acute TBI had an occupational therapy consult and 39 % had a neurosurgery consult. 24 % of patients with a TBI were admitted to the orthopaedic primary service. CONCLUSIONS: Patients presenting after an acute trauma with orthopaedic injuries have high rates of TBI, but low rates of diagnosis and treatment. This lack of diagnosis and treatment can negatively impact recovery from orthopaedic injuries. Orthopaedic providers should be aware of the diagnostic criteria and initial treatment steps for TBI to ensure prompt and effective treatment, which has been shown to improve outcomes.