Elbow Dislocations in the National Football League: Epidemiology and Management.

Background Currently, it is not known how the combined osseous and ligamentous injury of a traumatic elbow dislocation in a National Football League (NFL) athlete affects management and return to play. In this study, we aimed to describe the epidemiology, management, and return to play for elbow dislocations in NFL athletes. Methodology This is a descriptive observational study. A retrospective review of all elbow dislocations between 2000 and 2014 (15 seasons) was performed using the NFL Injury Surveillance System (NFLISS). Results Over 15 NFL seasons, 82 elbow dislocations were recorded in the NFLISS. Among players who reported surgery (n = 5), players missed an average of 73.8 days of play. Among those who did not report surgery, players missed an average of 36.1 days. The overall incidence was 0.26 dislocation events per 10,000 athlete exposures. The majority of these injuries occurred during regular-season games, in defensive linebackers and linemen, during tackling contact with another player, and most commonly on a running play. Conclusions This study demonstrates that an elbow dislocation is not a career-ending or season-ending injury in an NFL cohort. Information regarding incidence, positions affected, whether surgical management is utilized, and return to play will help players who sustain and physicians who treat these injuries in elite football athletes understand the impact of their injuries.

Editorial Commentary: Hip Arthroscopy in the Professional Athlete Back in the Game.

With improved outcomes and expanding indications, the rate of hip arthroscopy for treatment of numerous pathologies has increased. There is significant interest from patients and providers alike regarding return to meaningful play after surgical intervention, particularly for the professional athlete. Although each athlete and each sport have unique obstacles, the literature suggests hip arthroscopy has a high success rate and allows for elite athletes to return to play without significant differences in postoperative performance scores.

Significance of Perioperative Tests to Diagnose the Infection in Revision Total Shoulder Arthroplasty.

BACKGROUND: The purpose of this study was to evaluate the value of perioperative tests for the diagnosis of infection in revision shoulder arthroplasty. METHODS: A retrospective analysis was performed on 537 shoulder arthroplasties (429 patients) that underwent revision shoulder arthroplasty at our institution. Periprosthetic tissue cultures were positive in 169/537 surgeries. RESULTS: White-blood cell count (WBC) was elevated in 3.8% revision arthroplasties. Erythrocyte sedimentation rate (ESR) was elevated in 23.1% revision arthroplasties. The C-reactive protein (CRP) was elevated in 20.8% revision arthroplasties. Bone scans (technetium, indium) were performed on 9.9% patients and it was positive for osteomyelitis in just one revision arthroplasty. Intra-operative pathology was read as consistent with acute inflammation in 11.9% revision arthroplasties. The positive and negative predictive values for intra-operative pathology were 56.7% and 71.6% respectively. CONCLUSION: All of the perioperative tests had a high specificity and negative predictive value, but low sensitivity and positive predictive value.

The Effect of Smoking on Thirty-Day Postoperative Complications After Total Joint Arthroplasty: A Propensity Score-Matched Analysis.

BACKGROUND: Total joint arthroplasty (TJA) is a highly successful treatment, but is burdensome to the national healthcare budget. National quality initiatives seek to reduce costly complications. Smoking's role in perioperative complication after TJA is less well known. This study aims to identify smoking's independent contribution to the risk of short-term complication after TJA. METHODS: All patients undergoing primary TJA between 2011 and 2012 were selected from the American College of Surgeon's National Surgical Quality Improvement Program's database. Outcomes of interest included rates of readmission, reoperation, mortality, surgical complications, and medical complications. To eliminate confounders between smokers and nonsmokers, a propensity score was used to generate a 1:1 match between groups. RESULTS: A total of 1251 smokers undergoing TJA met inclusion criteria. Smokers in the combined total hip and knee arthroplasty cohort had higher 30-day readmission (4.8% vs 3.2%, P = .041), were more likely to have a surgical complication (odds ratio 1.84, 95% confidence interval 1.21-2.80), and had a higher rate of deep surgical site infection (SSI) (1.1% vs 0.2%, P = .007). Analysis of total hip arthroplasty only revealed that smokers had higher rates of deep SSI (1.3% vs 0.2%, P = .038) and higher readmission rate (4.3% vs 2.2%, P = .034). Analysis of total knee arthroplasty only revealed greater surgical complications (2.8% vs 1.2%, P = .048) and superficial SSI (1.8% vs 0.2%, P = .002) in smokers. CONCLUSION: Smoking in TJA is associated with higher rates of SSI, surgical complications, and readmission.

Avascular Necrosis Is Associated With Increased Transfusions and Readmission Following Primary Total Hip Arthroplasty.

Avascular necrosis (AVN) may confer an increased risk of complications and readmission following total hip arthroplasty (THA). However, current risk-adjustment models do not account for AVN. A total of 1706 patients who underwent THA for AVN from 2011 to 2013 were selected from the American College of Surgeon's National Surgical Quality Improvement Program database and matched 1:1 to controls using a predetermined propensity score algorithm. Rates of 30-day medical and surgical complications, readmissions, and reoperations were compared between cohorts. Propensity-score logistic regression was used to determine independent associations between AVN and outcomes of interest. Patients with AVN had a higher rate of medical complications than those without AVN (20.3% vs 15.3%, respectively; P<.001). Bleeding transfusion was the most common medical complication, occurring at a significantly higher rate in patients with AVN than those without AVN (19.6% vs 13.9%, respectively; P<.001). Patients with AVN were also twice as likely to experience a readmission after THA (odds ratio, 2.093; 95% confidence interval, 1.385-3.164). Avascular necrosis of the femoral head is an independent risk factor for transfusion up to 72 hours postoperatively and readmission up to 30 days following total hip replacement. [Orthopedics. 2017; 40(3):171-176.].

Is Outpatient Arthroplasty as Safe as Fast-Track Inpatient Arthroplasty? A Propensity Score Matched Analysis.

BACKGROUND: In the emerging fiscal climate of value-based decision-making and shared risk and remuneration, outpatient total joint arthroplasty is attractive provided the incidence of costly complications is comparable to contemporary "fast-track" inpatient pathways. METHODS: All patients undergoing total hip arthroplasty or total knee arthroplasty between 2011 and 2013 were selected from the American College of Surgeons-National Surgical Quality Improvement Program database. A propensity score was used to match 1476 fast-track (≤2 day length of stay) inpatients with 492 outpatients (3:1 ratio). Thirty-day complication, reoperation, and readmission rates were compared, both during and after hospitalization. Logistic regression was used to calculate propensity score adjusted odds ratios. RESULTS: After matching, outpatients had higher rates of medical complication (anytime, 10.0% vs 6.7%, P = .018; post discharge, 6.3% vs 1.1%, P < .001). Most complications were bleeding requiring transfusion, which occurred at similar rates after surgery but at higher rates post discharge in outpatients (anytime, 7.5% outpatients vs 5.6% inpatients, P = .113; post discharge, 4.1% outpatients vs 0.1% inpatients, P < .001). There was no difference in readmission rate (2.4% outpatient vs 2.0% inpatient, P = .589). CONCLUSION: Outpatients experience higher rates of post-discharge complications, which may countermand cost savings. Surgeons wishing to implement outpatient total joint arthroplasty clinical pathways must focus on preventing post-discharge medical complications to include blood management strategies.

Humeral windows and longitudinal splits for component removal in revision shoulder arthroplasty.

BACKGROUND: Removal of a humeral component during revision shoulder arthroplasty can be difficult. If the component cannot be extracted from above, an alternative approach may compromise bone integrity. Two potential solutions are a humeral window and a longitudinal split. This review was performed to determine complications and outcomes associated with these osteotomies during revision arthroplasty. METHODS: We reviewed records of 427 patients undergoing revision shoulder arthroplasty, identifying those requiring a window or longitudinal split. Outcomes were intraoperative and postoperative complications, rate of healing, and security of implant fixation. RESULTS: Twenty-six patients underwent creation of a window. Six intraoperative fractures were documented: 5 in greater tuberosity and 1 in humeral shaft. At radiographic follow-up, 23 of 26 windows healed; 2 patients had limited follow-up, and 1 did not have follow-up at our institution. Nineteen patients underwent longitudinal osteotomy. One had intraoperative fracture in greater tuberosity. At radiographic follow-up, 17 of 19 longitudinal splits healed; 1 had limited radiographic follow-up, and 1 did not have follow-up at our institution. Three patients underwent formation of both window and longitudinal osteotomy. At radiographic follow-up, all shoulders healed, and there were no intraoperative or postoperative fractures or malunions. CONCLUSIONS: In both groups, there were no cases of malunion or clinical loosening. These data suggest that windows and longitudinal splits facilitate controlled removal of well-fixed components with high rate of union and low rate of intraoperative or postoperative sequelae.

The incidence and risk factors for blood transfusion in revision shoulder arthroplasty: our institution's experience and review of the literature.

HYPOTHESIS: The purposes of this study were to determine the incidence of blood transfusion after revision shoulder arthroplasty and to assess risk factors associated with an increased risk of transfusion. MATERIALS AND METHODS: Between 1994 and 2008, 566 consecutive revision shoulder procedures were performed at our institution, which formed the basis of this study. The patient's age, sex, body mass index, comorbidities, preoperative and postoperative hemoglobin level, details of the surgery, operative time, and transfusion details were documented retrospectively from medical records. RESULTS: Overall, 11.3% of patients (64 of 566) required a transfusion. An increased transfusion rate was associated with age (odds ratio [OR] per 10 years, 1.5 [95% confidence interval (CI), 1.2 to 2.0]; P = .002), operative time (≤ 5 hours vs >5 hours) (OR, 3.3 [95% CI, 1.9 to 5.8]; P < .001), diabetes (OR, 2.3 [95% CI, 1.2 to 4.4]; P = .01), and cardiac disease (OR, 2.7 [95% CI, 1.5 to 5.0]; P < .001). There were significant associations between preoperative hemoglobin level (OR, 0.4 per 1 point [95% CI, 0.3 to 0.5]; P < .001) and a decreased odds of transfusion. The type of surgery (surgery on humeral component) also had an impact on the need for transfusion (P < .001). CONCLUSIONS: Older age, low preoperative hemoglobin level, increased operative time, diabetes, presence of cardiac disease, and type of revision surgery are associated with higher postoperative transfusion rates. These factors should be taken into consideration to more accurately predict the need for transfusion and modify preoperative blood-ordering protocols.

Treatment of a thoracic dural-pleural fistula with a vascularized omental flap: a case report.

STUDY DESIGN: Case report. OBJECTIVE: To report an unusual case of pseudomeningocele with dural-pleural fistula formation and spinal cord herniation after anterior thoracic decompression, as well as a unique surgical method for treating this complication. SUMMARY OF BACKGROUND DATA: Thoracic pseudomeningocele with fistula formation is a rare but serious complication of spinal surgery. The negative pressure environment created in the pleural space can complicate management and result in dural-plural fistula formation. We report on the use of a vascularized omental flap to treat this complication after failure of more traditional techniques. METHODS: A 76-year-old man presented with complaints of myeloradiculopathy, including weakness of lower extremities, with gait and bowel and bladder dysfunction after 2 previous decompressions at the T6-T7 level. Revision surgery was complicated by a dural-plural fistula and spinal cord herniation with neurological deterioration requiring reoperation. RESULTS: Treatment with vascularized omental flap successfully treated the fistula, and the patient had resolution of all symptoms with the exception of some lower extremity neuropathic pain. Postoperative imaging showed excellent decompression of the spinal canal and a small, stable pseudomeningocele without evidence of cerebrospinal fluid hypotension or active dural-pleural fistula. CONCLUSION: Treatment of thoracic psuedomeningoceles and fistulas can be difficult due to the unique negative intrathoracic pressure environment that complicates closure using traditional methods. Alternative treatment options may be necessary when more traditional techniques fail. Our report highlights one such option, a vascularized omental flap, which was used to successfully treat the patient.