Limited Durability of Extensor Mechanism Reconstruction Following Total Knee Arthroplasty: Mesh and Allograft Show Equivalent Outcomes at Five-Year Follow-Up.

BACKGROUND: Extensor mechanism disruption is a challenging complication following total knee arthroplasty. The purpose of this study was to compare outcomes between patients who received mesh versus allograft extensor mechanism reconstruction. METHODS: All patients who underwent extensor mechanism reconstruction at a single institution were screened. Demographic and surgical variables were recorded, including technique (ie, synthetic mesh versus allograft reconstruction). Patients were assessed for preoperative and postoperative extensor lag, revision, and duration of follow-up. Analyses, including Kaplan-Meier survivorships, were performed to compare mesh to allograft reconstruction. In total, 50 extensor mechanism reconstructions (30 mesh and 20 allograft) were conducted between January 1st, 2001, and December 31st, 2022. RESULTS: There were no differences between the cohorts with respect to revision (26.7 [8 of 30] versus 35.0% [7 of 20], P = .680) or failure defined as above knee amputation or fusion (6.7 [2 of 30] versus 5.0% [1 of 20], P = .808). There were also no differences in time to reoperation (average 27 months [range, 6.7 to 58.8] versus 29 months [range, 1.2 to 84.9], P = .910) or in postoperative extensor lag among patients who did not undergo a reoperation (13 [0 to 50] versus 11° [0 to 30], P = .921). The estimated 5-year Kaplan-Meier survival with extensor mechanism revision as the endpoint was similar between the 2 groups (52.1, 95% confidence interval [CI] = 25.4 to 73.3 versus 55.0%, 95% CI = 23.0 to 78.4%, P = .990). CONCLUSIONS: The purpose of this study was to present the findings of a large cohort of patients who required extensor mechanism reconstruction. Regardless of the reconstruction type, the 5-year outcomes of patients requiring extensor mechanism reconstruction are suboptimal.

Occupational Outcomes and Return to Running After Operative Management of Lisfranc Injuries in a High-Demand Population.

Background: Literature evaluating outcomes following operative fixation of Lisfranc injuries has demonstrated high rates of chronic disability, particularly in those returning to prior levels of physical function. The purpose of this study is to evaluate the occupational outcomes and return to running after open reduction and internal fixation (ORIF) or arthrodesis for Lisfranc fracture-dislocations in a moderate- to high-demand military cohort. Methods: All active-duty servicemembers undergoing ORIF or primary arthrodesis (Current Procedural Terminology 28615 and 28730, respectively) for confirmed Lisfranc fracture-dislocations (International Classification of Diseases, Ninth Revision codes 838.03 or 838.13) with minimum 2-year follow-up were isolated from the Military Health System. Demographic and surgical variables were recorded. Return to military function, return to running, perioperative morbidity, and rates of reoperation for complication were the outcomes of interest. Univariate analysis followed by multivariate logistic regression determined the association between patient demographics, type of fracture fixation (ie, ORIF vs arthrodesis) and functional outcomes, including medical separation. Results: Among Lisfranc injuries, 64 patients underwent ORIF while 6 underwent primary arthrodeses with a mean age of 28.1 years. At mean follow-up of 3.5 years (range, 2.0-6.3 years), 20% of servicemembers underwent medical separation due to limitations related to their injuries. body mass index (BMI) ≥30 kg/m2 (OR 17.67; 95% CI, 3.69-84.53) and Army or Marines service branch (OR 3.86; 95% CI, 1.08-13.86) were significant independent predictors for medical separation. Among servicemembers undergoing ORIF or primary arthrodeses, 69% returned to occupationally required daily running during the follow-up period. Servicemembers with a BMI <30 kg/m2 were more likely to return to running (OR 13.14, 95% CI, 2.50-69.19). Radiographic evidence of posttraumatic Lisfranc osteoarthritis occurred in 10 (16%) servicemembers who underwent internal fixation, and 82% of ORIF patients underwent implant removal. Conclusions: At mean 3.5-year follow-up, 80% of servicemembers undergoing ORIF or primary arthrodeses for Lisfranc injuries remained on active duty or successfully completed their military service, and 69% were able to resume occupationally required daily running. Surgeons should preoperatively counsel patients with these injuries on the possibility of persistent long-term disability.Levels of Evidence: Level IV: Retrospective series.

Lateral Ulnar Collateral Ligament Reconstruction for Posterolateral Rotatory Instability of the Elbow: A Systematic Review.

Background: Posterolateral rotatory instability (PLRI) is a common form of recurrent elbow instability. The aim of this systematic review is to present the outcomes and complications of lateral ulnar collateral ligament (LUCL) reconstruction surgery for PLRI. Methods: A literature search of LUCL reconstructions was performed, identifying 99 potential papers; 11 of which met inclusion/exclusion criteria, accounting for 148 patients. Papers were included if they reviewed cases of PLRI from 1976 to 2016 with reported outcome measures. Data were pooled and analyzed focusing on patient demographics as well as subjective and objective patient outcomes and complications. Results: The average age of patients was 34 years with a mean follow-up time of 49.8 months. The most common mechanism of injury was a traumatic elbow dislocation (66%), followed by cubitus varus deformity (7%), and unknown mechanisms (7%). Overall, 90% of patients achieved elbow stability and 2.7% experienced a failed reconstruction that necessitated an additional surgery. Furthermore, 93% were satisfied with the outcome of the reconstruction, and 83% reported good to excellent outcomes with 11% reporting moderate to severe persistent pain. Nearly half (45%) of reconstructions were done using a palmaris longus tendon graft, 24% with a triceps tendon graft, and 7% with a synthetic graft. Conclusions: Outcomes following LUCL reconstruction for PLRI are excellent and revision rates are low. LUCL reconstruction is a safe and reliable procedure.Level of Evidence: IV Therapeutic.

Orthopaedics and neurosurgery: Is there a difference in surgical outcomes following anterior cervical spinal fusion?

OBJECTIVE: The superiority of neurosurgical over orthopaedic spinal procedures is a point of contention. While there is the perception that neurosurgeons are more specifically trained to deal with spinal pathology, no study has directly compared outcomes of spinal surgeries performed by both groups. METHODS: We sought to evaluate the differences in length of surgery, hospital stay, complications, mortality, and readmission for anterior cervical decompression and fusion (ACDF) performed by neurosurgeons versus orthopaedic surgeons. RESULTS: 17,967 ACDF procedures were analyzed. Neurosurgeons performed 74.3% of the fusions with a trend towards longer operative times and significantly more patients that were discharged to extended care facilities. There was no significant difference in the length of stay, overall complications, mortality, readmission, or reoperation when comparing the two specialties. CONCLUSION: Despite a significantly higher volume of ACDF performed by neurosurgeons, outcomes are comparable following orthopaedic and neurosurgical procedures.

Outcomes and Predictors of Postoperative Pain Improvement Following Particulated Juvenile Cartilage Allograft Transplant for Osteochondral Lesions of the Talus.

BACKGROUND: Particulated juvenile cartilage allograft transfer (PJCAT) is an emerging treatment option for management of osteochondral lesions of the talus (OCLTs). This series reports on outcomes and identifies predictors for success following PJCAT for isolated OCLTs. METHODS: We reviewed 33 consecutive patients who underwent PJCAT by a single surgeon from 2013 to 2017. Preoperative demographic factors (age, body mass index [BMI], tobacco use, behavioral health comorbidity, and ankle pain visual analog score [VAS]) and OCLT morphologic data were collected. Outcomes included postoperative improvements in VAS and American Orthopaedic Foot & Ankle Society (AOFAS) score and clinical success/failure. Results of 7 second-look arthroscopies and complications are provided. Categorical data are reported as frequencies, and statistical means with P values are reported for continuous variables. We had a mean 3.5 years of follow-up. RESULTS: Improvement in ankle pain VAS following isolated PJCAT was 51% (P < .001). For the first 16 consecutive patients in whom complete AOFAS scores were available, 40% (P < .001) improvement occurred. Presence of 1 or more behavioral health diagnoses was a risk factor for decreased pain relief, while moderate to severe preoperative pain (VAS >5.9) predicted improved postoperative pain relief. Age, BMI, tobacco use, and OCLT morphology did not affect outcomes. CONCLUSION: For treatment of large, high-stage OCLTs, PJCAT resulted in 40% to 50% improvement in ankle pain and disability within 3.5 years. The results may be better in patients with moderate to severe preoperative pain but worse in those with preexisting behavioral health diagnoses. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Return to Weightbearing and High-Impact Activities Following Jones Fracture Intramedullary Screw Fixation.

BACKGROUND: Although the benefit of primary intramedullary (IM) screw fixation of fifth metatarsal Jones fractures in athletes is clear, limited data support its use in conventional patient populations. This study evaluated radiographic and functional outcomes following primary IM screw fixation in a series of Jones fractures to determine if similar excellent outcomes were achievable. METHODS: We reviewed the data of 32 consecutive patients who underwent Jones fracture primary IM screw fixation by a single surgeon. Demographic risk factors of interest (age, gender, tobacco use, pertinent medical comorbidities, military service status, and prior nonoperative management) were collected prospectively. Primary outcomes included times to return to full weightbearing, radiographic union, and resumption of high-impact or restriction-free activities. Complications including reoperations were recorded. Categorical data are reported as frequencies, and statistical means with P values are reported for continuous variables. Mean age for the 32 patients was 33.4 years. RESULTS: All 32 fractures healed uneventfully, and at mean follow-up time of 24.2 months, overall patient-reported satisfaction was 100%. Overall mean postoperative outcomes are as follows: 3.7 weeks return to full weightbearing, 10.8 weeks to radiographic union, and 13.0 weeks to resumption of restriction-free activities. Among the risk factors assessed, only preoperative peripheral vascular disease (PVD) and/or diabetes mellitus (DM) and active duty military service resulted in significantly increased and decreased time to resumption of restriction-free activities, respectively, but did not impact overall weightbearing or union times. Patient age, gender, and tobacco use had no effects on radiographic or functional outcomes. CONCLUSION: Primary IM screw fixation was a safe, reliable option for all appropriate operative candidates with Jones fractures and may result in similar early weightbearing, osseous healing, and expeditious return to full activities consistently reported in high-level athletes. LEVEL OF EVIDENCE: Level IV, case series.

Functional Outcomes and Complications Following Pectoralis Major Tendon Allograft Reconstruction in a Military Population.

BACKGROUND: There are limited data available regarding outcomes following pectoralis major tendon (PMT) reconstruction with allograft. PURPOSE: To evaluate the functional outcomes and complication profile following PMT reconstruction with allograft in a military population. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: All active duty military personnel who underwent PMT allograft reconstruction between 2008 and 2013 were identified. Demographics, injury characteristics, and surgical technique were recorded from the electronic medical record. Self-reported pain scores and manual strength were evaluated pre- and postoperatively, as recorded in physician electronic medical record notes, in addition to the ability and degree to which each patient was able to return to function. Standardized outcome measures included the Bak criteria; visual analog scale for pain; Disabilities of the Arm, Shoulder and Hand (DASH) score; American Shoulder and Elbow Surgeons (ASES) score; and 36-Item Short Form Health Survey (SF-36). Complications, including rerupture and reoperation, were additionally recorded. RESULTS: Nine male patients (mean ± SD age, 35.7 ± 5.8 years) underwent allograft PMT reconstruction. Mean improvement in self-reported pain score at a mean 53.5 months (range, 31.1-110.9 months) was 2.1 ± 1.3 points (P = .08). Improvements in manual strength during forward flexion (0.5 ± 0.7; P = .03), adduction (0.6 ± 0.6; P = .01), and internal rotation (0.5 ± 0.7; P = .03) were significant. Seven patients (78%) returned to full preinjury level of occupational function, and 88% returned to performing the bench press, although maximum weight decreased by a self-reported mean of 141.3 lb. According to the Bak criteria, 5 (56%) patients had excellent outcomes, 2 (22%) had fair outcomes, and 2 (22%) had poor outcomes. Mean visual analog scale for pain (1.9 ± 2.8), DASH (10.8 ± 17.4), ASES (88.1 ± 20.3), and SF-36 scores (96.3% ± 6.9%) were obtained for the 8 patients available at final follow-up. Complications included 2 cases (22%) of persistent shoulder pain leading to military separation, 1 rerupture (11%), and 1 (11%) surgical scar revision. CONCLUSION: While allograft reconstruction is a reliable option to decrease pain and improve function in patients with tears not amenable to primary repair, patients should be educated about the risk profile and fitness limitations after surgery.

Early Stabilization of Femur Fractures in the Setting of Polytrauma Is Associated With Decreased Risk of Pulmonary Complications and Mortality.

Timing of definitive fixation of femoral shaft fractures is a subject of continued controversy. The purpose of this study was to determine if early definitive fixation of femoral shaft fractures in the setting of polytrauma decreased the risk of pulmonary complications and mortality. The 2009-2012 National Sample Program of the National Trauma Data Bank was queried for all patients 18 to 65 years with Injury Severity Scores (ISS) >15 who underwent definitive fixation of femoral shaft fractures. Mortality, perioperative complications, and length of intensive care unit (ICU) and hospital stay were the primary outcome measures of interest. Following multivariate analyses, increased time to surgery was found to portend a statistically significant increased risk of acute respiratory distress syndrome(ARDS), mean ventilator time, length of ICU and hospital stay, and mortality. Earlier definitive fixation of femoral shaft fractures in the setting of polytrauma is associated with significantly decreased risk of ARDS, mean ventilator time, length of ICU and hospital stay, and mortality. (Journal of Surgical Orthopaedic Advances 28(2):137-143, 2019).

Distal femoral osteotomy in a young symptomatic population: Outcomes correlate to concomitant pathology.

BACKGROUND: There is a paucity of literature describing distal femoral osteotomies (DFO) in regards to complications and outcomes with previously studied cohorts containing primarily older, arthritic subjects. There has been no study to date focusing on younger, pre-arthritic patients. METHODS: All service members indicated for distal femoral osteotomy for coronal plane malalignment were isolated from military treatment centers between 2007 and 2013. Demographic and surgical variables were extracted, and perioperative complications, clinical course, and return to military function were extracted using clinical notes and radiographs. RESULTS: A total of 22 knees in 19 patients were identified at an average 3.2 year follow-up, with the exclusion of 16 individuals. Statistical analysis revealed worse outcomes associated with smoking, over correction, breach of the medial cortex, and prior surgeries. Overall 58% of patients left the military as the result of knee dysfunction despite an average improvement in visual analog scores (VAS) from 4.0 to 1.9 (p = 0.004). CONCLUSIONS: While offloading the lateral compartment improves symptoms at short to midterm follow-up preventing progression to arthroplasty, young active duty military members have suboptimal return to duty rates.

Orthopaedic and Plastic Surgery Training Differences Manifested in the Analysis of Distal Radius Fracture Fixation.

All patients undergoing open reduction and internal fixation of a distal radius fracture (DRF) between the years 2010 and 2015 were isolated from the National Surgical Quality Improvement Program database. Patient demographics, respective surgical volume, outcome variables, and complications were extracted. The primary outcomes were surgical time, hospital length of stay, and unplanned reoperation. A total of 6691 patients were included in the study, the majority of whom were treated by orthopaedic surgeons. While there were no significant differences in baseline demographics between the patients treated by orthopaedic and plastic surgeons, the overall operative time was significantly less for DRFs fixed by orthopaedic surgeons. While there was a significant difference for extra-articular fractures, this difference increased significantly for complex intra-articular fractures. Additionally, hospital length of stay was significantly shorter for patients treated by orthopaedic surgeons. To produce well-rounded, technically skilled surgeons, plastic surgery programs should incorporate fixation principles into their training programs. (Journal of Surgical Orthopaedic Advances 28(1):53-57, 2019).

Unstable Ankle Fracture Fixation Using Locked Fibular Intramedullary Nail in High-Risk Patients.

Open reduction internal fixation is the gold standard for unstable ankle fracture fixation; however, complications in patients with multiple medical comorbidities are common. Intramedullary nail fixation of the fibula can help to mitigate these difficulties. A retrospective chart review was performed on all patients who underwent fixation for unstable ankle fracture between January 2015 and March 2016 at our level I trauma center. Comorbidities in the patient sample included were one or several of diabetes, renal disease, hypertension, advanced age with osteoporosis, hemorrhagic blisters, and alcoholism. The primary outcomes studied were wound complications, infections, and hardware failure or failure of fixation. Eighteen patients with a mean age of 61 years underwent fibular intramedullary nail fixation, all of whom were considered at high risk for postoperative complications. Patients presented with Weber B or C fracture patterns. All patients had syndesmotic fixation through the nail by one or two 3.5-mm tricortical screws. A medial malleolus was added if needed for stability. The average follow-up time was 291.1 (range 9 to 14 months) days. The prescribed range of time to weightbearing was 2 to 6 weeks. All patients maintained reduction of the fracture and had no wound complications. No syndesmotic screws broke postoperatively, although most patients to failed comply with the postoperative non-weightbearing restrictions. Intramedullary nailing of the fibula with syndesmotic intranail fixation is minimally invasive, quick, and provides adequate fixation strength. It offers a viable treatment option for patients at high risk for complications or who are suspected to have difficulty with follow-up or compliance.

Incidence of Cubital Tunnel Syndrome in the U.S. Military Population.

PURPOSE: Cubital tunnel syndrome (CuTS) is the second most common peripheral nerve entrapment syndrome. However, existing epidemiological evidence regarding the estimated incidence of the CuTS disease burden in specific populations is sparse, especially among the U.S. military. The purpose of this study was to describe the demographics and determine the incidence of CuTS among active duty U.S. military service members. METHODS: All first-time occurrences for CuTS among military members were identified using International Classification of Diseases, Ninth Revision, clinical modification code 354.2 for ulnar nerve lesions in the U.S. Defense Medical Epidemiology Database. A multivariable Poisson regression analysis was used to estimate the incidence rate ratio (IRR) per 1,000 person-years and 95% confidence intervals (95% CI), while controlling for sex, race, age, rank, and service. Rate-ratios were calculated using different referent factors based on differences in sex, race, age, rank, and service branch. RESULTS: During the 10-year study period, the total number of incident cases of CuTS was 31,568, and a total of 13,745,456 person-years were documented. The overall unadjusted IRR of CuTS during the study period was 2.3 per 1,000 person-years (95% CI, 2.27-2.33). The 35- to 39-year age group had the highest adjusted IRR of CuTS. In addition, females, Caucasians, and junior enlisted service members showed significantly higher IRRs. CONCLUSIONS: Our study was able to provide baseline epidemiological data on IRRs and influential risk factors in CuTS. We demonstrated an incidence of CuTS that is comparable with previously reported IRRs, which have varied from 0.08 to 8.0 cases per 1,000 person-years. This study also found significantly higher risk for the development of CuTS with increased age and among U.S. Army service members. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Contemporary Surgical Trends in the Management of Symptomatic Meniscal Tears among United States Military Servicemembers from 2010 to 2015.

The purpose of this investigation is to report on trends over time in the treatment of meniscal pathology among military orthopaedic surgeons, as well as to evaluate the impact of patient demographics and concomitant procedure on the type of meniscal procedure performed. We performed a retrospective analysis of all active-duty United States military servicemembers who underwent a meniscal procedure from 2010 to 2015 within the Military Health System. Patient demographics and surgical variables were extracted from the electronic medical record. Treatments were categorized by location and by type of intervention (i.e., repair or debridement). Chi-square and linear regression analyses were performed to identify temporal trends in meniscal procedures and factors that were correlated with the type of meniscal procedure performed. Out of 29,571 meniscal procedures analyzed, partial meniscectomy was performed in 81.3% (n = 24,343) of cases, meniscal repair in 20.3% (n = 6,073), and meniscus allograft transplantation (MAT) in 0.7% (n = 206). The rates of debridement, repair, and concomitant surgeries did not demonstrate any significant temporal trends, whereas MAT demonstrated a significant decrease in overall utilization. Nearly two-thirds of all meniscal procedures were performed in the medial compartment. MAT occurred equally between the medial and lateral compartments. Lateral meniscal lesions demonstrated significantly higher rates of debridement. With each year of advancing age, there was a 3.7% increasing likelihood of meniscectomy and 6.5% decreasing likelihood of repair. Females were more likely to undergo meniscal repair than males. Patients in the military population were more likely to undergo meniscal repair compared with previously reported rates in the civilian population. In this physically active cohort of nearly 30,000 military patients, 1 in 5 meniscal tears were treated with meniscal repair. Meniscal repairs were performed at a higher rate for all age groups compared with previously reported rates in the civilian population. Further research is required to elucidate the causative factors behind these differences and the effect on postoperative outcomes. LEVEL OF EVIDENCE: : IV, cross-sectional study.

Outcome measures after medial ulnar collateral ligament reconstructions in a military population.

BACKGROUND: Medial ulnar collateral ligament (MUCL) reconstruction outcomes are well described in competitive throwers but not in nonthrowers. This investigation elucidated epidemiologic variables, functional outcomes, and prognostic factors after MUCL reconstruction in young active patients. METHODS: United States military service members undergoing MUCL reconstruction were isolated using the Management Analysis and Reporting Tool (M2) database from 2009 to 2016. Demographics, injury characteristics, and surgical variables were extracted. Multivariate analysis was performed, discerning variables predictive of postoperative functional outcomes, complications, and reoperation. RESULTS: Sixty-six patients met inclusion criteria, and 47% participated in throwing sports. Of these, 36.4% reported a throwing mechanism of injury (MOI), 60.6% reported an acute trauma MOI, 59% reported preoperative ulnar nerve symptoms, and 39.4% experienced symptoms postoperatively. At final follow-up, average Disabilities of the Arm, Shoulder and Hand (DASH) and Mayo Elbow Performance Score (MEPS) scores were 10.8 ± 16.2 and 87.6 ± 17.1, respectively. A total of 86.4% reported no disability (DASH < 30), and 83.3% experienced good or excellent outcomes (MEPS >74). Age < 30 years, dominant arm injury, competitive throwing history, and throwing MOI correlated with improved DASH and MEPS scores, push-up count, postoperative pain and instability, and rates of ulnar nerve symptoms (P < .05). Psychiatric diagnosis and preoperative stiffness and instability were associated with lower outcome scores (P < .05). Ulnar nerve interventions did not correlate with presence or absence of postoperative ulnar nerve symptoms. CONCLUSIONS: MUCL reconstruction demonstrates a high good-to-excellent outcome rate and low complication and revision rates in young active individuals with intense upper extremity demands. Nonthrowing MOIs and psychiatric pathology are associated with postoperative complications and poorer outcomes.

Perilunate Dislocations and Perilunate Fracture Dislocations in the U.S. Military.

Background Perilunate dislocations and perilunate fracture dislocations (PLDs/PLFDs) are rare and often associated with poor outcomes. Heretofore, these outcomes have not been evaluated in a high-demand military population. Questions/Purpose The purpose of this study was to evaluate the outcomes in a young, active population after sustaining PLD/PLFD injuries. Patients and Methods We retrospectively reviewed the U.S. military service members who underwent surgical treatment for a PLD/PLFD (Current Procedural Terminology codes 25695 and 25685) between June 1, 2010, and June 1, 2014 through the Military Health System Management Analysis and Reporting Tool (M2) database, capturing patients with a minimum 2-year follow-up. Patient characteristics and outcomes were gathered; however, radiographic analysis was not possible. Results In this study, 40 patients (40 wrists) were included with an average follow-up of 47.8 months. The average age was 28.8 years. Twenty-two injuries (55%) were PLFD and 22 (55%) cases involved the nondominant extremity. On initial presentation, 11 (27.5%) were missed and 50% of patients were presented with acute carpal tunnel syndrome. Range of motion (ROM) was 74% and grip strength was 65% compared with the contralateral wrist; 78% reported pain with activity and only 55% remained on active duty status at final follow-up. Injuries to the nondominant extremity were significantly more likely to experience a good to excellent outcome and regained a more ROM. Patients with ligamentous PLD had less pain at rest and were more likely to return to sport. Conclusion Worse outcomes can be expected for PLD/PLFD of the dominant extremity, transscaphoid PLFD, greater arc injuries, and those undergoing pinning alone. A high-demand patient may expect worse functional results with a higher degree of limitation postoperatively. Level of Evidence The level of evidence is therapeutic IV.

Anterior Cruciate Ligament Graft Removal Versus Retention in the Setting of Septic Arthritis After Reconstruction: A Systematic Review and Expected Value Decision Analysis.

PURPOSE: To provide further guidance on the optimal decision between anterior cruciate ligament (ACL) graft removal versus retention in the setting of septic arthritis following reconstruction using an expected value decision analysis. METHODS: A systematic review and expected value decision analysis and sensitivity analyses were performed to quantify the clinical decision. A decision tree was created with 5 outcomes of interest: nonoperative complications, revision surgery, early reoperation, late reoperation, and "well." Pooled probabilities of each outcome were generated through a systematic literature review. We included only peer-reviewed studies, published in English, with at least 6 months of follow-up. One hundred randomly selected volunteers were given descriptions of the clinical scenario, the 2 treatment options, and outcomes of interest. Patients younger than 18 and older than 50 years and those previously treated for either ACL injury or septic arthritis, or both, were excluded from the analysis to minimize bias. These hypothetical patients indicated preferences for each outcome on a visual analog scale and responses were averaged to generate overall "utility values." Fold-back analysis summed products of pooled outcomes probabilities with respective averaged utility values. The resulting overall expected values for graft removal and debridement were compared, with the highest expected value considered to be superior. We then performed 1-way sensitivity analyses to mitigate sample bias. RESULTS: Fold-back analysis revealed graft removal to be strongly favored over retention, with overall expected values of 17.2 and 8.64, respectively. The most important contributor to the difference in overall expected values was late reoperation (8.59 vs 2.50 for removal and retention, respectively). Despite adjustments made to the rates of revision and early reoperation during the 1-way sensitivity analyses, graft removal remained the optimal strategy. CONCLUSIONS: This expected value decision analysis revealed that ACL graft removal was strongly favored by patients over graft retention in the setting of postoperative septic arthritis when consideration was given to the probabilities of wellness, nonoperative complications, revision surgery, early reoperation, and late reoperation. Sensitivity analysis revealed that although variation in rates of other outcomes did not impact this preference, the rate of late reoperation had a substantial impact. Only a sizable increase in the probability of late reoperation (from 0% to 60%) after graft removal would cause potential patients to favor graft retention. LEVEL OF EVIDENCE: Level IV, systematic review and decision analysis.

Functional outcomes following lateral ulnar collateral ligament reconstruction for symptomatic posterolateral rotatory instability of the elbow in an athletic population.

HYPOTHESIS: The purpose of this investigation was to characterize the functional and surgical outcomes following lateral ulnar collateral ligament (LUCL) reconstruction for posterolateral rotatory instability in an athletic population. METHODS: All US military service members who underwent LUCL reconstruction between 2008 and 2013 were identified. A retrospective chart review was performed, and the prospective Mayo Elbow Performance Score and QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) score were obtained. The primary outcomes were return to preinjury activity and resolution of symptoms. RESULTS: We identified 23 patients with a mean age of 31.6 ± 7.2 years (range, 19-46 years), and 87% were men. A history of instability and/or dislocation was reported by 11 patients (48%), and 8 patients (35%) had undergone prior elbow surgery. At final follow-up of 4.6 ± 1.8 years (range, 2.2-7.6 years), all patients demonstrated significant decreases in pain (average pain score, 4 vs 1.34) with resolution of instability and achieved a functional arc of motion. After surgical reconstruction, 83% were able to return to prior activity, whereas 4 patients (17%) underwent medical separation, including 3 with elbow disability precluding continued service (13%). Overall 83% of patients reported good to excellent outcomes by the Mayo Elbow Performance Score, and 96% of patients reported no significant disability by the QuickDASH disability evaluation. Postoperatively, 4 patients (17%) experienced complications, with 3 (13%) requiring reoperation. CONCLUSION: Although the diagnosis and surgical management of isolated LUCL injury are relatively infrequent, LUCL reconstruction for posterolateral rotatory instability offers a reliable return to preinjury level of function among active individuals with intense upper extremity demands. However, although function reliably improves, the rate of perioperative complications is greater than 15%.

The Shift to Same-Day Outpatient Joint Arthroplasty: A Systematic Review.

BACKGROUND: Hip and knee arthroplasties length of stay continues to shorten after advances in perioperative and intraoperative management, as well as financial incentives. Some authors have demonstrated good results with outpatient arthroplasty, but safety and general feasibility of such procedures remain unclear. Our hypothesis is that outpatient arthroplasty would demonstrate higher readmission and complication rates than inpatient arthroplasty. METHODS: We performed a systematic review of all publications on outpatient arthroplasty between January 1, 2000 and June 1, 2016. Included publications had to demonstrate a specific outpatient protocol and have reported perioperative complications and unplanned readmissions. Patient demographics, surgical variables, and protocol details were recorded in addition to complications, readmission, and reoperation. RESULTS: Ten manuscripts accounting for 1009 patients demonstrated that 955 (94.7%) were discharged the same day as planned, with the majority of failures to discharge being secondary to pain, hypotension, and nausea. There were no deaths and only 1 major complication. Only 20 patients (1.98%) required reoperation and 20 (1.98%) had readmission or visited the emergency room within 90 days of their operation. In the 2 series recording patient outcomes, 80% and 96% of patients reported that they would choose to undergo outpatient arthroplasty again. CONCLUSION: For carefully selected patients with experienced surgeons in major centers, outpatient arthroplasty may be a safe and effective procedure. Although our data is promising, further study is required to better elucidate the differences between inpatient and outpatient arthroplasty outcomes.

Current Evidence Regarding Routine Antibiotic Prophylaxis in Hand Surgery.

Background: Although routine antibiotic prophylaxis immediately preceding an orthopedic surgery has become the standard of care in most cases, this practice is poorly defined in hand surgery. The purpose of this analysis is to review the most current literature of antibiotic use in hand surgery. Methods: A careful review of the literature regarding routine antibiotic prophylaxis in hand surgery was made. Current relevant resources were used in the construction of this review. Results: There is a mixed consensus on the role for prophylactic antibiotics in hand surgery with some resources and data showing support and others opposed. Conclusions: Based on the current literature, the authors recommend the following patient characteristics not receive antibiotics: clean hygienic patients, without autoimmune disease, and those not taking steroid medication. Surgical characteristics that would render prophylaxis unnecessary include those without hardware, those without reasonable risk of hematoma formation, or those performed at an ambulatory surgery center as opposed to a large hospital. However, the decision should be made on a case-by-case basis weighing the evidence presented.

Operative Management of Unstable Radial Head Fractures in a Young Active Population.

BACKGROUND: Radial head and neck fractures are the most common elbow fracture in the general adult population; however, the optimal treatment for radial head fractures remains a topic of ongoing clinical controversy. The purpose of this study was to determine the rate of return to function, complications, and reoperation following operative management of unstable radial head fractures in a young, active patient population with intense upper extremity demands. METHODS: A military health care database was queried for all US military servicemembers undergoing open reduction with internal fixation (ORIF; Current Procedural Terminology [CPT] code: 24665) and radial head arthroplasty (RHA; CPT code: 24666) between 2010 and 2015. All patients with minimum 2-year follow-up were included. Univariate and chi-square analyses were performed to evaluate the association between potential risk factors and the primary outcome measures. RESULTS: A total of 67 ORIF (n = 69 elbows) and 10 RHA patients were included. The average age was 31 ± 8.0 years. At mean follow-up of 3.5 ± 1.1 years, 90% of patients overall were able to return to active military service, 96% of which with unrestricted upper extremity function. Nearly one-third (31.2%) of patients developed at least 1 postoperative complication. RHA has higher overall complication rates (70% vs 48%) when compared with ORIF, but this finding did not reach statistical significance ( P = .073). However, RHA had significantly higher rates of implant failure (20% vs 2.9%, P = .0498). Seventeen (21%) individuals required reoperation, 5 of which (6.3%) were revision procedures. Dislocation, coronoid fracture, and concomitant ligamentous repair portended a significantly increased risk of sustaining 1 or more complications ( P < .05), while dislocation and requirement for ligamentous repair independently predicted revision surgery ( P < .05). CONCLUSIONS: Arthroplasty and ORIF are both viable options for treating unstable radial head fractures in a young, athletic population, offering comparable return to function despite increased complications with RHA.