The Modified Fels and Abbreviated Modified Fels Knee Skeletal-Maturity Systems in the Prediction of Leg-Length Discrepancy.

BACKGROUND: The Modified Fels (mFels) and Abbreviated Modified Fels (abFels) knee systems have been recently developed as options for grading skeletal maturity without the need for a separate hand radiograph. We sought to determine the interobserver reliability of these systems and to compare their prediction accuracy with that of the Greulich and Pyle (G-P) atlas in a cohort managed with epiphysiodesis for leg-length discrepancy (LLD). METHODS: Three reviewers scored 20 knee radiographs using the mFels system, which includes 5 qualitative and 2 quantitative measures as well as a quantitative output. Short leg length (SL), long leg length (LL), and LLD prediction errors at maturity using the White-Menelaus (W-M) method and G-P, mFels, or abFels skeletal age were compared in a cohort of 60 patients managed with epiphysiodesis for LLD. RESULTS: Intraclass correlation coefficients for the 2 quantitative variables and the quantitative output of the mFels system using 20 knee radiographs ranged from 0.55 to 0.98, and kappa coefficients for the 5 qualitative variables ranged from 0.56 to 1, indicating a reliability range from moderate to excellent. In the epiphysiodesis cohort, G-P skeletal age was on average 0.25 year older than mFels and abFels skeletal ages, most notably in females. The majority of average prediction errors between G-P, mFels, and abFels were <0.5 cm, with the greatest error being for the SL prediction in females, which approached 1 cm. Skeletal-age estimates with the mFels and abFels systems were statistically comparable. CONCLUSIONS: The mFels skeletal-age system is a reproducible method of determining skeletal age. Prediction errors in mFels and abFels skeletal ages were clinically comparable with those in G-P skeletal ages in this epiphysiodesis cohort. Further work is warranted to optimize and validate the accuracy of mFels and abFels skeletal ages to predict LLD and the impact of epiphysiodesis, particularly in females. Both the mFels and abFels systems are promising means of estimating skeletal age, avoiding additional radiation and health-care expenditure. LEVEL OF EVIDENCE: Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.

The Reliability of the Modified Fels Knee Skeletal Maturity System.

BACKGROUND: The recently described Modified Fels knee skeletal maturity system (mFels) has proven utility in prediction of ultimate lower extremity length in modern pediatric patients. mFels users evaluate chronological age, sex, and 7 anteroposterior knee radiographic parameters to produce a skeletal age estimate. We developed a free mobile application to minimize the learning curve of mFels radiographic parameter evaluation. We sought to identify the reliability of mFels for new users. METHODS: Five pediatric orthopaedic surgeons, 5 orthopaedic surgery residents, 3 pediatric orthopaedic nurse practitioners, and 5 medical students completely naïve to mFels each evaluated a set of 20 pediatric anteroposterior knee radiographs with the assistance of the (What's the Skeletal Maturity?) mobile application. They were not provided any guidance beyond the instructions and examples embedded in the app. The results of their radiographic evaluations and skeletal age estimates were compared with those of the mFels app developers. RESULTS: Averaging across participant groups, inter-rater reliability for each mFels parameter ranged from 0.73 to 0.91. Inter-rater reliability of skeletal age estimates was 0.98. Regardless of group, steady proficiency was reached by the seventh radiograph measured. CONCLUSIONS: mFels is a reliable means of skeletal maturity evaluation. No special instruction is necessary for first time users at any level to utilize the (What's the Skeletal Maturity?) mobile application, and proficiency in skeletal age estimation is obtained by the seventh radiograph. LEVEL OF EVIDENCE: Level II.

Acetabular fractures in elderly patients are associated with high rates of complications during the initial admission.

Background: Acetabular fractures among the elderly are common. Identification of risk factors predisposing elderly patients to in-hospital complications is critical to mitigating morbidity and mortality. Methods: A retrospective cohort study was performed including 195 patients ≥60 years old who sustained acetabulum fractures treated at a single level 1 trauma center. Operative (n=110, 56.4%) or non-operative management was undertaken, and complications during the index hospitalization were defined. Results: Seventy-three patients (37%) developed a complication during their hospitalization. Most common complications were acute respiratory failure: 13.3%, pneumonia: 10.3%, urinary tract infection: 10.3%, cardiac dysrhythmia: 9.7%, and acute kidney injury: 6.2%. On multivariable analysis, factors associated with in-hospital complications were increased age (adjusted OR (AOR): 1.06, 95% CI: 1.01 to 1.11, p=0.013), more comorbidities (AOR: 1.69, 95% CI: 1.07 to 2.65, p=0.024), operative management (AOR: 0.3, 95% CI: 0.12 to 0.76, p=0.011), and increased length of stay (AOR: 1.34, 95% CI: 1.2 to 1.51, p<0.001). Conclusions: Acetabular fractures in the elderly are associated with high rates of in-hospital complications. Advanced age, more medical comorbidities and longer lengths of stay predicted higher risk of developing complications. Whereas operative management was associated with lower risk of developing complications during the initial admission, it is important to note the selection bias in which healthier patients with improved baseline functionality may be more likely to undergo operative management. Level of evidence: Level III therapeutic.

Impact of novel psychosocial programming on readmission and recidivism rates among patients with violence-related trauma.

INTRODUCTION: The Victims of Crime Advocacy and Recovery Program (VOCARP) provides advocacy, mental health resources, and educational materials. This study will report complications, readmissions, and recidivism among crime victims, and who used or did not use victim services. MATERIALS AND METHODS: Patients engaged with programming from 3/1/17 until 12/31/18 were included. Control groups were patients injured by violent trauma without VOCARP use (N = 212) and patients injured by unintentional injuries (N = 201). Readmissions, complications, reoperations, and trauma recidivism were reported. RESULTS: 1019 patients (83%) used VOCARP. VOCARP users were less often male (56% vs. 71%), less commonly married (12% vs. 41%), and had fewer gunshot wounds (GSWs, 26% vs. 37%) and sexual assaults (4.1% vs. 8%), all p < 0.05. Of all 1,423 patients, 6.6% had a readmission and 7.4% developed a complication. VOCARP patients had fewer complications (4.5% vs. 13.7%), infections (2% vs. 9%), wound healing problems (1% vs. 3.3%), and deep vein thromboses (0.3% vs. 1.9%), all p < 0.05, but no differences in unplanned operations (4.5%). GSW victims had the most complications, readmissions, and unplanned surgeries. Prior trauma recidivism was frequent among all groups, with crime victim patients having 40% prior violence-related injury (vs 9.0% control, p < 0.0001). Trauma recidivism following VOCARP use occurred in 8.5% (vs 5.7% for non-users, p = 0.16). CONCLUSION: Crime victims differ from other trauma patients, more often with younger age, single marital status, and unemployment at baseline. Complications were lower for VOCARP patients. GSW patients had the most complications, readmissions, and unplanned secondary procedures, representing a population for future attention.

Intramedullary Fixation for Pediatric Femoral Nonunion in Low- and Middle-Income Countries.

BACKGROUND: Pediatric femoral shaft nonunion after use of a plate or intramedullary nail (IMN) is uncommon in the United States. In low and middle-income countries, as defined by The World Bank, these complications may occur with greater frequency. We assessed the rates of union and painless weight-bearing after IMN fixation of pediatric femoral shaft nonunion in lower-resource settings. METHODS: We queried the SIGN (Surgical Implant Generation Network) Fracture Care International online database to identify all pediatric femoral shaft nonunions that had occurred since 2003 and had ≥3 months of follow-up after their treatment; our query identified 85 fractures in 83 patients. We defined nonunion as failure of initial instrumentation >90 days following its placement, lack of radiographic progression on radiographs made >3 months apart, or the absence of signs of radiographic healing >6 months after initial instrumentation. We evaluated the most recent follow-up radiograph to determine a Radiographic Union Scale in Tibial fractures (RUST) score. We also recorded rates of painless full weight-bearing as assessed by the treating surgeon. RESULTS: Fifty-seven patients with pediatric femoral shaft nonunions (including 42 male and 15 female patients from 18 countries) were included. The average age (and standard deviation) at the time of revision surgery was 13.8 ± 3.0 years (range, 6 to 17 years). The median duration of follow-up was 67 weeks (range, 13 weeks to 7.7 years). The initial instrumentation that went on to implant failure included plate constructs (56%), non-SIGN IMNs (40%), and SIGN IMNs (4%). At the time of the latest follow-up, 52 patients (91%) had a RUST score of ≥10 and 51 (89%) had painless full weight-bearing. No patient had radiographic evidence of femoral head osteonecrosis at the time of complete fracture-healing or the latest follow-up. CONCLUSIONS: Pediatric femoral shaft nonunion can occur after both plate and IMN fixation in low and middle-income countries. IMN fixation is an effective and safe treatment for these injuries. LEVEL OF EVIDENCE: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Recidivism after orthopaedic trauma has diminished over time.

PURPOSE: The purpose was to analyze our trauma population during two periods to assess for predictors of recidivism. METHODS: Prior (2007-2011, n = 879) and recent (2014-2019, n = 954) orthopaedic trauma patients were reviewed. Recidivists were those returning with an unrelated injury. Recidivism rates were compared, and factors associated with recidivism were identified. RESULTS: Recidivism decreased: 18.7% to 14.3% (p = 0.01). Mean age and sex of the two cohorts were not different. Recent recidivists were more likely to sustain gunshot wound (GSW) injuries (22.1% vs 18.9%, p = 0.09), and mental illness was more common (56.6% vs 28.1%, p < 0.0001). The recent recidivist population was less often married (12.9% vs 23.8%, p = 0.03), and both recidivist groups were often underinsured (Medicaid or uninsured: (60.6% vs 67.0%)). CONCLUSION: Recidivism diminished, although more GSW and mental illness were seen. Recidivists are likely to be underinsured. The changing profile of recidivists may be attributed to socioeconomic trends and new programs to improve outcomes after trauma.

Value Challenge: A Bottoms-Up Approach to Minimizing Cost and Waste in Orthopaedic Surgery.

Astronomical increases in medical expenses and waste produce widespread financial and environmental impacts. Minor changes to minimize costs within orthopaedics, the most used surgical subspecialty, could result in substantial savings. However, few orthopaedic surgeons are educated or experienced to implement cost containment strategies. This study aims to investigate cost containment opportunities and provide a framework for educating and incorporating residents into cost-saving initiatives. Methods: Orthopaedic surgical residents from an academic program with a Level I trauma center were queried during 2019 to 2022 regarding suggestions for cost containment opportunities. Based on feasibility and the estimated impact, 7 responses were selected to undergo cost-saving analyses. Results: The proposed initiatives fell into 2 categories: minimizing waste and optimizing patient care. Eliminating nonessential physical therapy/occupational therapy consults led to the greatest estimated savings ($8.6M charges/year), followed by conserving reusable drill bits ($2.2M/year) and reducing computed tomography scans on lower extremity injuries ($446K/year). Conclusion: Current medical training provides limited formal education on cost-effective care. Efforts to mitigate the growing financial and environmental costs of health care should include encouraging and incorporating resident feedback into cost reduction strategies. This tactic will likely have a positive impact on the behavior of such resident surgeons as they enter practice and have more awareness of costs and value. Level of Evidence: V (cost-minimization study).

Effect of Smoking on Motor Recovery After Cervical American Spinal Injury Association Grade D Traumatic Spinal Cord Injury.

BACKGROUND: Smoking is a known neurotoxin that has been shown to negatively impact neurological function and recovery in multiple animal studies. Patients who smoke have been shown to have decreased rates of motor improvement, fusion, and overall successful outcomes after elective spinal surgery, but the effect of smoking on outcomes after traumatic spinal cord injury (TSCI) has not been demonstrated in prior literature. This study aims to investigate how smoking effects motor recovery after TSCI. METHODS: Using the National Spinal Cord Injury Statistical Center database, patients who underwent surgical management of American Spinal Injury Association grade D cervical TSCI between 2009 and 2016 were included. Patients were grouped by smoking or nonsmoking status. Overall total motor score and change in motor scores at rehabilitation admission, rehabilitation discharge, and 1-year follow-up visits were compared between groups. Multiple linear regression analysis was completed, including any possible confounding demographic or injury variables. RESULTS: A total of 152 patients (121 smokers and 31 nonsmokers) completed their 1-year follow-up interview and physical examination and were included in the study. There were no differences in motor score between groups at rehabilitation admission or discharge. Smokers had worse improvement in motor score at 1 year (7.99 nonsmokers vs 4.61 smokers; P = 0.019 on multivariate analysis) and worse overall total motor score at 1 year (94.0 nonsmokers vs 90.0 smokers; P = 0.018 on multivariate analysis) after controlling for confounders. CONCLUSIONS: These results indicate diminished motor recovery in patients who continue to smoke after TSCI. These patients should be targeted for aggressive smoking cessation and require intervention from providers and peers in order to maximize recovery after injury. CLINICAL RELEVANCE: This study demonstrates that smoking cessation may be beneficial for patients with cervical ASIA grade D spinal cord injury and may be a focus for providers of these patients.

Anterior and superior plate positions in diaphyseal clavicle fractures produce similar patient outcomes.

PURPOSE: While diaphyseal clavicle fractures can be treated with plate fixation on either the superior or anteroinferior aspect of the clavicle, the optimal plate position remains controversial. The purpose of this study was to determine if anteroinferior vs. superior plating for clavicle fracture fixation leads to better patient outcomes. METHODS: A retrospective review of patients who sustained clavicle fractures (OTA/AO 15.2) treated with superior or anteroinferior plating at a tertiary Level I trauma center from 2015 to 2021 was performed. The clinical outcomes of clavicle fractures were compared between groups treated with an anterior versus a superior approach via Mann-Whitney U and Chi-squared tests as appropriate to evaluate for differences in outcomes between the two plate positions. RESULTS: A total of 315 diaphyseal clavicle fractures were identified. One hundred and forty patients were excluded due to inadequate follow-up. Of the remaining 175 patients, 25 were treated with an anteroinferior approach (14%) and 150 were treated with a superior approach (86%). There were no differences in age, BMI, tobacco use, or substance use between the two groups (p > 0.05 for all). On univariate analysis, there was no difference in rate of union (p = 0.60), nerve injury (p = 0.60), infection (p = 1.0), implant-related irritation (p = 0.42), implant removal (p = 0.26), or revision (p = 1.0) based on approach. Contoured plates had an association with risk of nerve injury (p = 0.04). CONCLUSION: There are no differences in union, nerve injury, infection, symptomatic implant, or revision rate between anteroinferior and superior clavicle approaches. Plate positioning during diaphyseal clavicle fracture fixation can reasonably be dictated based on surgeon preference and ideal reduction quality.

Which Application Factors Are Associated With Outstanding Performance in Orthopaedic Surgery Residency?

BACKGROUND: Identifying ideal candidates for orthopaedic surgery residency is difficult. Data available for applicant selection are evolving; preclinical grades and the Alpha Omega Alpha (AOA) honors society are being phased out at some medical schools. Similarly, three-digit United States Medical Licensing Examination (USMLE) Step 1 scores have been eliminated. There is renewed interest in improving resident selection to provide a diverse, comprehensive educational opportunity that produces orthopaedic surgeons who are prepared for practice. QUESTIONS/PURPOSES: We sought to identify whether (1) academic achievements, (2) letters of recommendation, (3) research activity, and (4) miscellaneous factors available on Electronic Residency Application Service (ERAS) applications were associated with outstanding residency performance. METHODS: Ten faculty members (22% of all full-time faculty) with extensive educational involvement for at least 7 years, whose expertise covered all subspecialty departments at an urban, academic orthopaedic surgery residency program, were given an anonymous survey on the performance of the four most recent classes of residency graduates (24 residents). This survey was developed due to the lack of a validated residency outcomes tool or objective metrics for residency performance. The evaluated criteria were decided upon after discussion by a relatively large group of academic orthopaedic surgeons considering the factors most important for graduating orthopaedic residents. The faculty were selected based on their long-term knowledge of the residency, along with their diversity of specialty and backgrounds; there were no nonresponders. Faculty graded each resident on a scale from 1 to 10 (higher is better) on six criteria: surgical technical skills, research productivity, clinical knowledge, professionalism, personality, and fellowship match. The mean of the faculty ratings made by all faculty for all six criteria was calculated, producing the overall residency performance score. Factors available on each resident's ERAS application were then correlated with their overall residency performance score. Categorical ERAS factors, including AOA status, five or more honors in core clerkships, at least three exceptional letters of recommendation, collegiate athletics participation, expertise with a musical instrument, and research (6-year) track residents, were correlated with overall residency performance score via point biserial analysis. Continuous ERAS factors including USMLE Step 1 and Step 2 scores, number of publications before residency, number of research years before residency, medical school ranking, and number of volunteer experiences were correlated with overall residency performance score via Pearson correlation. USMLE Step 1 three-digit scores were evaluated despite their recent elimination because of their historic importance as a screening tool for residency interviews and for comparison to USMLE Step 2, which retains a three-digit score. Application factors with a p < 0.2 on univariate analysis (five or more honors in core clerkships, at least three exceptional letters of recommendation, research track residents) were included in a stepwise linear regression model with "overall residency performance score" as the outcome variable. All p values < 0.05 were considered significant. RESULTS: The mean overall residency performance score was 7.9 ± 1.2. Applicants with at least five honors grades in core clerkships had overall residency performance scores 1.2 points greater than those of their peers (95% confidence interval (CI) 0.3 to 2.0; p = 0.01, Cohen ƒ 2 = 0.2, representing a small effect size). ERAS applications including at least three exceptional letters of recommendation were associated with a 0.9-point increase in residency performance (95% CI 0.02 to 1.7; p = 0.046, Cohen ƒ 2 = 0.1, representing a small effect size). Participation in the residency research (6-year) track was associated with a 1-point improvement in residency performance (95% CI 0.1 to 1.9; p = 0.03, Cohen ƒ 2 = 0.2, again, representing a small effect size). Together, these three factors accounted for 53% of the variance in overall residency performance score observed in this study. CONCLUSION: Past clinical excellence, measured by core clerkship grades and exceptional letters of recommendation, is associated with slightly improved overall orthopaedic residency performance scores. Applicants meeting both criteria who also complete a research track residency may perform substantially better in residency than their counterparts, as these three factors accounted for half of all the variance observed in the current study. Although minimum requirements are necessary, traditionally used screening factors (such as USMLE scores, AOA status, medical school rank, and number of publications) may be of less utility in identifying successful future residents than previously thought. LEVEL OF EVIDENCE: Level III, therapeutic study.

Biologics, Stem Cells, Growth Factors, Platelet-Rich Plasma, Hemarthrosis, and Scaffolds May Enhance Anterior Cruciate Ligament Surgical Treatment.

Biologics including mesenchymal stem cells (MSCs), growth factors, and platelet-rich plasma may enhance anterior cruciate ligament (ACL) reconstruction and even ACL primary repair. In addition, hemarthrosis after acute ACL injury represents a source of biologic factors. MSCs can differentiate into both fibroblasts and osteoblasts, potentially providing a transition between the ligament or graft and bone. MSCs also produce cytokines and growth factors necessary for cartilage, bone, ligament, and tendon regeneration. MSC sources including bone marrow, synovium, adipose tissue, ACL-remnant, patellar tendon, and umbilical cord. Also, scaffolds may represent a tool for ACL tissue engineering. A scaffold should be porous, which allows cell growth and flow of nutrients and waste, should be biocompatible, and might have mechanical properties that match the native ACL. Scaffolds have the potential to deliver bioactive molecules or stem cells. Synthetic and biologically derived scaffolds are widely available. ACL reconstruction with improved outcome, ACL repair, and ACL tissue engineering are promising goals. LEVEL OF EVIDENCE: Level V, expert opinion.

Trauma recidivism is pervasive and is associated with mental and social health opportunities.

INTRODUCTION: Recidivism after orthopedic trauma results in greater morbidity and costs. Prior studies explored the effects of social and medical factors affecting the frequency of return to the hospital with new, unrelated injury. Identification of mental, social and other risk factors for trauma recidivism may provide opportunities for mitigation. The purposes of this study are to determine the rates of subsequent, unrelated injury noted among orthopedic trauma patients at a large urban trauma center and to evaluate what patient and injury features are associated with greater rates of trauma recidivism. We hypothesize higher rates of new injuries will be related to ballistic trauma and other forms of assault, alcohol and recreational drug use, unemployment, and unmarried status among our trauma patients. METHODS: A series of 954 skeletally mature patients at a level 1 trauma center over a 5 year period were included in the study. All were treated operatively for thoracolumbar, pelvic ring, acetabulum, and/or proximal or shaft femoral fractures from a high energy mechanism. Retrospective review of demographic, injury, medical, and social factors, and subsequent care was performed. Trauma recidivism was defined as returning to the emergency department for treatment of any new injury. A backward stepwise logistic regression statistical analysis was used to identify independent predictors of recidivism. RESULTS: Mean age of all patients was 41.2 years, and 73.2% were male. 136 patients (14.3%) returned with a new injury within a mean of 21 months. These trauma recidivists were more likely to sustain a GSW (22.1% vs 11.4%, p = 0.001). They had higher rates of substance use, including tobacco (57.4% vs 41.8%, p = 0.001) and recreational drugs (50.7% vs 34.4%, p = 0.001), and were less likely to be married (10% vs 25.9%, p<0.001). Mental illness was pervasive, noted in 56.6% of patients with new injury (vs 32.8%, p<0.001). Medicaid insurance was most common in the trauma recidivist population (58.1% vs 35.0%, p = 0.001), and 12.5% were uninsured. Completing high school or more education was protective (93% non-recidivist (vs 79%, p = 0.001). Sixty-nine patients (50.7%) were repeat trauma recidivists within the study period. Independent predictors of new injury included recreational drug use (OR 1.64, p = 0.05) and history of assault due to GSW or other means (OR 1.67, p = 0.05). History of pre-existing mental illness represented the greatest risk factor for trauma recidivism (OR 2.55, p<0.001). DISCUSSION: New injuries resulting in emergency department presentation after prior orthopedic trauma occurred in 14.3% and were associated with history of assault, lower education, Medicaid insurance, tobacco smoking and recreational drug use. Mental illness was the greatest risk factor. Over half of patients with these additional injuries were repeat trauma recidivists, returning for another new injury within less than 2 years. Awareness of risk factors may promote focused education and other interventions to mitigate this burden. LEVEL OF EVIDENCE: Level 3 retrospective, prognostic.

The Systematic Isolation of Key Parameters for Estimating Skeletal Maturity on Lateral Elbow Radiographs.

BACKGROUND: Skeletal maturity estimation is central in the management of scoliosis and lower-limb deformity. Utilizing demographic characteristics and modern computing, we sought to create a reliable, rapid, and accurate method for measuring skeletal maturity on an elbow radiograph. METHODS: Utilizing the Bolton-Brush Collection, 4 parameters from the modified Sauvegrain method and 7 novel parameters were screened. Ten parameters were evaluated on serial peripubertal elbow radiographs, using Greulich and Pyle (GP) skeletal age from corresponding hand radiographs as a comparison. Stepwise linear regression and generalized estimating equations were used to identify radiographic and demographic parameters for estimating skeletal maturity based on 90% of final height. The elbow system was compared with GP only; olecranon apophysis only; age, sex, and GP; age, sex, and olecranon apophysis; age, sex, and elbow system with anteroposterior and lateral parameters; age, sex, and elbow system with anteroposterior parameters; and age, sex, and elbow system with lateral parameters. RESULTS: In this study, 367 radiographs from 77 patients (40 girls and 37 boys) were included. Following stepwise linear regression, 4 radiographic parameters were included in the anteroposterior and lateral elbow system; 3 were included in the anteroposterior elbow system; and 4 were included in the lateral elbow system. The lateral elbow system predicted skeletal maturity with a mean discrepancy of 0.41 year and produced similar mean discrepancies to GP with age and sex (0.42; p = 0.93), and it trended toward better performance than the olecranon apophysis system with age and sex (0.43; p = 0.06). The lateral elbow system had the lowest percent of outlier predictions >1 year discrepant from the skeletal maturity reference (4.6%), although it was only significantly better than the GP-only group (29.4%) and the olecranon apophysis-only group (21.0%) (p < 0.001 for both). CONCLUSIONS: We systematically developed a lateral elbow system that performed equivalently to GP using 4 simple parameters and trended toward outperforming the olecranon apophysis systems in skeletal maturity estimation. Future clinical validation will be necessary to understand the utility of this system. CLINICAL RELEVANCE: The lateral elbow system may be a more accurate prediction of skeletal maturity compared with the previously described olecranon apophysis system and can be used to guide the management of many pediatric orthopaedic conditions.

Preoperative and Postoperative Patient-Reported Outcome Measurement Information System Scores in Patients Treated for Benign Versus Malignant Soft Tissue Tumors.

BACKGROUND: The Patient-Reported Outcomes Measurement Information System (PROMIS) assesses multiple aspects of patient well-being but has not been thoroughly studied amongst orthopedic oncology patients. QUESTIONS/PURPOSES: How do preoperative/early postoperative PROMIS scores compare in patients with benign versus malignant soft tissue tumors (STTs) for (1) physical function, (2) pain interference, and (3) depression? Are the differences clinically relevant? What other patient/tumor factors impact PROMIS? METHODS: This retrospective cohort study included 314 STT patients who underwent resection of a benign (n = 187) or malignant (n = 127) STT over a period of 4.25 years at a single institution. PROMIS physical function, pain interference, and depression scores were collected preoperatively and at two and six weeks postoperatively. Scores for each time point were compared between groups and to preoperative baselines. Backward-stepwise linear mixed-effects models were produced to identify independent predictors of change in each PROMIS domain. The minimal clinically important difference (MCID) was 4 points. RESULTS: The malignant cohort, but not the benign cohort, demonstrated clinically relevant worsening of physical function postoperatively. Malignant diagnosis (△ = -4.4, p < 0.001) and lower extremity tumors (△ = -4.5, p < 0.001) were identified as clinically relevant, independent predictors of worse physical function at all time points. No predictors of clinically relevant changes in pain interference or depression scores, including malignancy, were identified. CONCLUSIONS: In STT patients, malignancy and lower extremity STT location are associated with clinically relevant worsening in physical function but do not significantly impact pain interference or depression in the early postoperative period. These findings may help establish the utility of PROMIS in an orthopedic oncology population.

Do Patients With Chronic Diabetes Have Worse Motor Outcomes After Cervical ASIA C Traumatic Spinal Cord Injury?

STUDY DESIGN: This was a level IV retrospective prognostic study. OBJECTIVE: The objective of this study was to determine if patients with chronic diabetes have worse functional outcomes and motor recovery after cervical traumatic spinal cord injury (TSCI). SUMMARY OF BACKGROUND DATA: Diabetes mellitus has multiple deleterious neurological effects and has been shown to worsen elective cervical spine surgery outcomes. Prior literature has scarcely characterized the impact of chronic diabetes on motor and functional outcomes after TSCI. METHODS: The National Spinal Cord Injury Statistical Center (NSCISC) database was utilized to retrospectively collect data on cervical American Spinal Injury Association (ASIA) C TSCI between 2011 and 2016. Patients were divided into diabetes and nondiabetes groups. Primary outcomes included wheelchair requirement and ambulatory status 1 year after injury. Secondary outcomes were motor score collected at the time of rehab admission, rehab discharge, and 1-year follow-up. All outcome variables were analyzed using univariate and multivariate regression to assess for differences between diabetes and nondiabetes groups and possible confounders. RESULTS: A total of 219 patients met the inclusion criteria for the study: 193 without diabetes and 26 with diabetes (12.0%). After controlling for confounders, patients with diabetes had had significantly increased wheelchair requirement (83.3% vs. 51.8%, relative risk=1.63, 95% confidence interval: 1.20-1.83, P =0.009 multivariate) and decreased ambulatory rates (50% vs. 67.9%, relative risk=0.55, 95% confidence interval: 0.25-0.98, P =0.042 multivariate) at 1 year. They also had no difference in average total motor scores at rehab admission but significantly worse total motor scores at rehab discharge (50.6±23.3 vs. 60.3±21.4, P =0.033 univariate, P =0.002 multivariate). CONCLUSIONS: Patients with diabetes have increased wheelchair requirement and decreased ambulatory ability at 1 year after the injury as well as diminished recovery in motor scores after motor-incomplete cervical TSCI. These patients may be targets for aggressive diabetic screening and intervention to minimize negative outcomes.

Systematic Isolation of Key Parameters for Estimating Skeletal Maturity on Anteroposterior Wrist Radiographs.

BACKGROUND: The ability to make a continuous skeletal maturity estimate from a wrist radiograph would be useful in the treatment of adolescent forearm fractures, scoliosis, and other conditions. We attempted to create a reliable, rapid, and accurate method to do this. METHODS: Many anteroposterior wrist radiographic parameters from 3 skeletal maturity systems were simplified to 23 based on relevance to the peripubertal age range, univariate correlation with skeletal maturity, and reliability. These 23 parameters were evaluated on serial peripubertal anteroposterior hand-wrist radiographs. We determined the Greulich and Pyle (GP) skeletal age and Sanders hand system (SHS) stage. We used stepwise linear regression and generalized estimating equation (GEE) procedures to identify important radiographic and demographic parameters for estimating skeletal maturity, creating the "Modified Fels wrist skeletal maturity system." Its accuracy predicting skeletal maturity was evaluated and compared with that of 4 other systems: (1) GP system, (2) SHS, (3) GP parameters along with age and sex, and (4) SHS parameters along with age and sex. RESULTS: Three hundred and seventy-two radiographs of 42 girls (age range, 7 to 15 years) and 38 boys (age range, 9 to 16 years) were included. Fifteen radiographic parameters were excluded from the Modified Fels wrist system by stepwise regression and GEE analyses, leaving age, sex, and 8 radiographic parameters in the final model. Use of the Modified Fels wrist system resulted in more accurate skeletal maturity estimations (0.34-year mean discrepancy with actual skeletal maturity) than all other systems (p < 0.001 for all). The Modified Fels wrist system had a similar rate of outlier skeletal maturity estimations as the age, sex, and SHS model (1.9% versus 3.5%, p = 0.11) and fewer outliers than all other systems (p < 0.05 for all). CONCLUSIONS: A system that included demographic factors and 8 anteroposterior wrist radiographic parameters estimates skeletal maturity more accurately than the 2 most-used skeletal maturity systems in the United States. CLINICAL RELEVANCE: The Modified Fels wrist skeletal maturity system may allow for more accurate, reliable, and rapid skeletal maturity estimation than current systems, and also may be used when treating adolescent forearm fractures as it does not require imaging past the metacarpals. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Single dose IV Antibiotic for Low-Energy Extremity Gunshot Wounds: A Prospective Protocol.

Objective: To prospectively determine infection rate following low-energy extremity GSWs with a single dose IV antibiotic protocol. Summary Background Data: Previous work suggests that a single IV antibiotic dose, without formal surgical debridement, mitigates infection risk. Methods: Over 35 months 530 adults with low-energy GSWs to the extremities were included. Three hundred fifty-two patients (66%) had ≥30 days follow-up. Patients were administered a single dose of first-generation IV cephalosporin antibiotics, and those with operative fractures received 24-hour perioperative antibiotics. Injury characteristics, treatment, protocol adherence, and outcomes (infection) were assessed between the protocol group (single-dose antibiotics) and the non-protocol group (no antibiotics or extra doses of antibiotics). Results: Compliance with the single-dose protocol occurred in 66.8%, while 33.2% received additional antibiotics or no antibiotics. The deep infection rate requiring surgical debridement was 0.8%, while the combined rate of all infections was 11.1%. Age, sex, injury location, multiple injuries, fracture presence, and type of surgery did not affect infection rate. Adherence to the antibiotic protocol was associated with a reduction in infection risk (odds ratio = 0.39, 95% confidence interval 0.19-0.83, P = 0.01). Receipt of additional antibiotics outside of our single-dose protocol did not predict further reduction in rate of infection (P = 0.64). Conclusions: A standardized protocol of single-dose IV antibiotic appears effective in minimizing infection after low-energy GSW to the extremities. Level of Evidence: Therapeutic Level II.

Survivorship of the Hip Joint After Acetabulum Fracture.

PURPOSE: The purposes of this study were to determine the rate of failure of the hip joint after acetabulum fracture and to identify risk factors. METHODS: Acetabulum fractures treated over 17 years at a level-1 trauma center were reviewed. Patient, injury, and treatment factors were assessed regarding possible association with failure of the hip joint: end-stage arthrosis and/or total hip arthroplasty (THA). RESULTS: Seventy percent were treated with primary open reduction and internal fixation (ORIF). Seventy-two (12.5%) of 575 fractures underwent THA; 64 were after initial ORIF. The mean follow-up was 80 months, and the median time to THA was 14 months (range 10-200 months). Age, body mass index, fracture type, marginal impaction, and hip dislocations were independent predictors of hip joint failure. The mean injured age of THA patients was 53 versus 43 (P < 0.001). T-type fractures were most likely to fail (21% within 2 years, 45% within 10 years, P = 0.001). Other injury features: marginal impaction and posterior hip dislocation were associated with failure with odds ratios 2.79 and 1.73, respectively (P < 0.001). CONCLUSION: Eighty-five percent of native hips survived; the median time to THA was 14 months. Most who had THA had initial posterior fracture-dislocations. Older age, elevated body mass index, T-type pattern, marginal impaction, and hip dislocation increase the likelihood of hip joint failure.

The Relationship of Olecranon Apophyseal Ossification and Sanders Hand Scores with the Timing of Peak Height Velocity in Adolescents.

BACKGROUND: The onset of peak height velocity (PHV) guides the timing of interventions in the growing child. The purpose of the present study was to validate the Diméglio olecranon grading system and to compare these scores with the Risser/triradiate closure (TRC), proximal humerus, and Sanders hand scores. METHODS: Eighty children with annual serial radiographs were selected from the Bolton-Brush collection. The olecranon apophysis was graded with use of lateral radiographs of the elbow. The mean age to PHV was determined for each stage, and reliability was calculated with use of an intraclass correlation coefficient (ICC). Olecranon stage was combined with age, sex, and height in a generalized estimating equation (GEE) model to predict PHV. Predictive performance of this model was evaluated with use of tenfold cross-validation such that the model was trained on 90% of the radiographs and was asked to predict the PHV of the remaining 10%. RESULTS: PHV is closely associated with olecranon stage, with stage 1 occurring 3.0 years before PHV and stage 7 occurring 3.4 years after PHV. Stage 5 was found to occur at PHV. Scoring system reliability was high across an array of observers (ICC = 0.85 ± 0.07). The GEE model showed that this olecranon system outperforms the Risser/TRC system in predicting PHV and is comparable with the humerus and Sanders hand systems. When combined with age and sex, the olecranon system successfully predicted PHV such that 62% of PHV predictions were accurate within 6 months and 90% of PHV predictions were accurate within a year. CONCLUSIONS: Our data show that stage 5 occurs at PHV, contrary to previously published data. When combined with age and sex, the olecranon system successfully predicts PHV within a year in 90% of cases, establishing a single lateral view of the olecranon as a simple alternative to more complex grading systems. Last, we describe novel 3 variations in olecranon morphology and provide a guide for accurate olecranon staging. CLINICAL RELEVANCE: Understanding PHV is critical in the treatment of many pediatric orthopaedic disorders. The revised olecranon staging system will allow for more accurate determination of this variable.

The value of preoperative labs in identifying "at-risk" patients for developing surgical site infections after pediatric neuromuscular spine deformity surgery.

STUDY DESIGN: This is a retrospective cohort study via a single surgeon, two-hospital database. OBJECTIVE: PSF in NMS patients is a high-risk surgery, with rates of SSI up to 24%. There is conflicting evidence in the literature regarding a possible association between low preoperative nutritional lab values and heightened risk of SSI after PSF. A retrospective analysis of a 20-year cohort of 111 pediatric neuromuscular scoliosis (NMS) patients that underwent posterior spinal fusion (PSF) with instrumentation was performed. Overall, seven patients (6.3%) developed a postoperative surgical site infection (SSI). With the possible exception of transferrin, low preoperative lab values (prealbumin, Hgb/Hct, WBC, TLC, total protein, albumin) were not associated with SSI. These findings question the utility of the current methodology of preoperative laboratory evaluation in identifying patients at elevated risk for SSI following PSF. METHODS: A single-surgeon, two-hospital database was reviewed to identify all patients who underwent PSF for NMS. Diagnoses included cerebral palsy (n = 82), myelomeningocele (n = 13), spinal muscular atrophy (n = 4), and other (n = 12). Medical records for 117 patients were examined; 6 were excluded due to missing lab values. SSI was defined as an infection necessitating a return to the operating room for irrigation and debridement of the surgical site. Demographic information, preoperative lab values, spinal deformity magnitude, and surgical procedure data were recorded. RESULTS: There were 50 males and 61 females with a mean age of 14 years and 2.5 months (8-20 years). Seven patients (6.3%) experienced postoperative SSI. SSI rate for PSF to pelvis was 7.7% vs. PSF to lumbar spine, 3.0% (NS; p = 0.672). Length of PSF was not statistically associated with SSI (p = 0.172). SSI due to gram positives and polymicrobial gram negatives occurred with equal incidence. Preoperative lab values of transferrin, prealbumin, albumin, WBC count, total lymphocyte count, and total protein were not associated with SSI. Patients with postoperative SSI had higher mean Hct compared to controls (p = 0.041). While 40.6% of controls had low Hgb (< 13.8 g/dl), all patients who developed SSI had Hgb within the normal range (p = 0.043). Similarly, while 37.6% of controls had low Hct (< 40.7%), all patients who developed SSI had Hct within the normal range (p = 0.05). CONCLUSION: Low preoperative nutritional labs, Hgb/Hct, and TLC values were not found to be associated with an increased incidence of SSI in this analysis. These findings question the utility of preoperative lab values in identifying "at-risk" populations for SSI after PSF for NMS. LEVEL OF EVIDENCE: IV Therapeutic.