The Impact of Total Hip Arthroplasty Surgical Approach on Patient-Reported Outcomes Measurement Information System Computer Adaptive Tests of Physical Function and Pain Interference.

BACKGROUND: The present study examines Patient Reported Outcomes Measurement Information System (PROMIS) Computer Adaptive Test (CAT) scores for domains of physical function (PF) and pain interference (PI) in patients undergoing elective THA from either a direct anterior or posterior surgical approach. METHODS: A total of 1358 patients who underwent THA at our institution from 1/1/2015 to 12/1/2018 were identified. Visual analog scale (VAS) pain scores, PROMIS CAT PF and PI data were collected at the last preoperative visit as well as 6 weeks, 6 months, and 1-2 years postoperatively. Literature-derived minimum clinically important difference (MCID) for PROMIS CAT PF metric with regard to THA was used for data comparison. RESULTS: Four hundred nine patients were included in the final analysis. Fifty-one percent underwent a posterior approach, and 49% underwent a direct anterior approach. Both approaches led to a significant improvement in PROMIS CAT PF and PI scores. Patients undergoing a direct anterior approach had significantly higher preoperative and postoperative PROMIS CAT PF scores as well as significantly lower preoperative PROMIS CAT PI scores. Each approach yielded similar interval improvements of PROMIS CAT PF and PI. One hundred three direct anterior approach THA patients (51%) and 119 posterior approach THA patients (57.5%) achieved PROMIS PF MCID at 1- to 2-year follow-up. CONCLUSION: Neither the direct anterior nor posterior THA surgical approach conferred an advantage to postoperative improvements of PROMIS CAT PF and PI scores. Adult reconstructive surgeons should continue to execute the direct anterior or posterior THA surgical approaches based upon personal preference. Despite surgeon confidence in THA, the potential for further innovation exists given the number of THA patients who failed to achieve PROMIS PF MCID.

Iliopsoas snapping hip: improving the diagnostic value of magnetic resonance imaging with a novel parameter.

OBJECTIVE: To illustrate an advanced imaging parameter that describes the course of the iliopsoas tendon, and evaluate its correlations with iliopsoas internal hip snapping syndrome. METHODS: This retrospective cohort study reviewed hip MRI images of all patients seen by a single surgeon between January 2015 and March 2016. The comparison group included all patients with clinical internal hip snapping, versus the control group that did not. MRI images were processed using minimum intensity projection. Measurements obtained of the pelvis and course of the iliopsoas tendon included: pelvic incidence, coronal angle, and sagittal opening angle (SOA). Comparison of measurements between the groups was performed with Mann-Whitney U analysis and receiver operator curve (ROC) plotting, with a significance cutoff of p = 0.05. RESULTS: The control group (n = 85) and comparison group (n = 48) demonstrated no difference in age or gender. Pelvic incidence was similar [51.3 (± 10.7) degrees control versus 52.2 (± 7.7) degrees comparison (p = 0.36)], as was coronal angle [13.9 (± 4.6) degrees control versus 14.8 (±4.8) degrees comparison (p = 0.15)]. There was a significant difference in SOA [137.0 (± 5.9) degrees control versus 141.9 (± 6.5) degrees comparison (p < 0.01)]. ROC analysis revealed SOA threshold of 140 degrees for clinical IP hip snapping (p < 0.01), with odds ratio 5.2 (2.4-11.3) for SOA > 140 degrees. CONCLUSIONS: Iliopsoas hip snapping is often part of a more complex disease process. While challenging to diagnose, advanced imaging parameters, like the sagittal opening angle, relate with clinical pathology. The SOA offers diagnostic value, with a threshold of greater than 140 degrees significantly correlating with clinical presentation.

The Effect of Intra-articular Cocktail Versus Femoral Nerve Block for Patients Undergoing Hip Arthroscopy.

PURPOSE: To compare clinical efficacy and complication rate as measured by postoperative falls and development of peripheral neuritis between intra-articular blockade and femoral nerve block in patients undergoing arthroscopic hip surgery. METHODS: An institutional review board approved retrospective review was conducted on a consecutive series of patients who underwent elective arthroscopic hip surgery by a single surgeon, between November 2013 and April 2015. Subjects were stratified into 2 groups: patients who received a preoperative femoral nerve block for perioperative pain control, and patients who received an intra-articular "cocktail" injection postoperatively. Demographic data, perioperative pain scores, narcotic consumption, incidence of falls, and iatrogenic peripheral neuritis were collected for analysis. Postoperative data were then collected at routine clinical visits. RESULTS: A total of 193 patients were included in this study (65 males, 125 females). Of them, 105 patients received preoperative femoral nerve blocks and 88 patients received an intraoperative intra-articular "cocktail." There were no significant differences in patient demographics, history of chronic pain (P = .35), worker's compensation (P = .24), preoperative pain scores (P = .69), or intraoperative doses of narcotics (P = .40). Patients who received preoperative femoral nerve blocks reported decreased pain during their time in PACU (P = .0001) and on hospital discharge (P = .28); however, there were no statistically significant differences in patient-reported pain scores at postoperative weeks 1 (P = .34), 3 (P = .64), and 6 (P = .70). Administration of an intra-articular block was associated with a significant reduction in the rate of postoperative falls (P = .009) and iatrogenic peripheral neuritis (P = .0001). CONCLUSIONS: Preoperative femoral nerve blocks are associated with decreased immediate postoperative pain, whereas intraoperative intra-articular anesthetic injections provide effective postoperative pain control in patients undergoing arthroscopic hip surgery and result in a significant reduction in the rate of postoperative falls and iatrogenic peripheral neuritis. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Differences in the Treatment of Distal Radius Fractures by Hand Fellowship Trained Surgeons: A Study of ABOS Candidate Data.

PURPOSE: The management of distal radius fractures differs based on the nature of the fracture and the experience of the surgeon. We hypothesized that patients requiring surgical intervention would undergo different procedures when in the care of a surgeon with subspecialty training in hand surgery as compared with surgeons with no subspecialty training in hand surgery. METHODS: We queried the ABOS database for case log information submitted for part II of the ABOS examination. Queries for all codes involved with distal radius fracture management were combined with associated codes for the management of median nerve neuropathy, triangular fibrocartilage complex tears, ulnar shaft, and styloid fractures. Hand fellowship trained orthopedic surgeons were compared with those completing other fellowships and non-fellowship trained orthopedic surgeons during their board collection period. RESULTS: During the study period, 2,317 orthopedic surgeons reported treatment of 15,433 distal radius fractures. Of these surgeons, 411 had hand fellowship training. On a per surgeon basis, fellowship trained hand surgeons operatively treated more multifragment intra-articular distal radius fractures than their non-hand fellowship trained counterparts (5.3 vs 1.2). Additional procedures associated with the management of distal radius fractures were also associated with the fellowship training of the treating surgeon. CONCLUSIONS: Among orthopedic surgeons taking part II of the ABOS certifying examination, differences exist in the type, management, and reporting of distal radius fractures among surgeons with different areas of fellowship training. CLINICAL RELEVANCE: This study describes the association of hand surgery fellowship training on the choice of intervention for distal radius fractures and associated conditions.

Trends in lumbar interbody fusion: A study of American Board of Orthopedic Surgery (ABOS) candidate data.

Background: There has been an increase in posterior-based interbody fusions over the past two decades. Our objective was to evaluate trends in interbody fusion use among the American Board of Orthopedic Surgery (ABOS) Part II candidates. Methods: The ABOS database from 2003 to 2012 was queried for common procedural terminology (CPT) codes indicating lumbar interbody fusion (22,558 anterior lumbar interbody fusion [ALIF] and 22,630 and 22,633 posterior lumbar interbody fusion [PLIF] or transforaminal lumbar interbody fusion [TLIF]). Trends in the use of interbody fusion technique, associated complications, and geographical variation were evaluated. We also queried utilization of the anterior and posterior interbody fusions by the International Classification of Diseases-9 code. Results: 6841 interbody fusion cases were identified (2329 ALIF and 4512 PLIF/TLIF). There was a significantly higher use of PLIF/TLIF than ALIF over the study period (P < 0.001). As compared to patients in the Midwest, those in the Northwest had significantly higher odds of undergoing PLIF/TLIF (odds ratio [OR]: 4.79, 95% confidence interval [CI]: 3.61-6.35, P <0.001), and those in the Southwest had significantly lower odds of PLIF/TLIF (OR: 0.81, 95% CI: 0.69-0.95, P = 0.01). The overall complication rate was 22.2% (n = 1,519). Vascular-related complications were significantly higher among patients undergoing ALIF (31 vs. 1, P <0.001), while those undergoing TLIF/PLIF were more likely to experience unspecified medical complications. On multivariate analysis, patients undergoing PLIF/TLIF had lower odds of experiencing a complication (P = 0.03, OR 0.87, CI 95%). Conclusion: Over the 10-year study period, there has been a significantly increased rate of posterior interbody fusion among candidates taking part II ABOS examination.

The Treatment of Periprosthetic Distal Femoral Fractures After Total Knee Replacement: A Critical Analysis Review.

Periprosthetic distal femoral fracture after total knee arthroplasty carries substantial morbidity and mortality regardless of fixation technique. Surgical treatment is favored in most patients compared with conservative therapy because of high rates of nonunion, malunion, and reoperation after casting or bracing. Internal fixation techniques including retrograde intramedullary nailing and locked plating are favored for surgical treatment in most fractures when bone stock in the distal fragment allows for appropriate fixation. In the setting of deficient distal femoral bone stock or femoral component loosening, revision arthroplasty with distal femoral replacement is the favored technique. Further studies with regard to the use of intramedullary nailing, locked plating, and distal femoral replacement are necessary to refine the indications for each technique and to define the use of combinations of these fixation techniques.

Evaluating Patients for Elective Outpatient Foot and Ankle Surgery: Insurance as a Predictor of Patient Outcomes.

Background. Elective surgical procedures necessitate careful patient selection. Insurance level has been associated with postoperative outcomes in trauma patients. This study evaluates the relationship insurance level has with outcomes from elective foot and ankle surgery. Methods. Retrospective chart review was performed on patients who underwent elective surgery at a single center with 1-year follow-up. Patients were classified by insurance: under-/uninsured (Medicaid, Option plans) versus fully insured. Outcomes included narcotic refills, patient-reported outcomes (PROMIS) of pain, function, and mood, and compliance with follow-up visits. Statistical analysis involved mean comparison and multivariate regression modeling, with significance P < .05. Results. Cohort groups included 220 insured and 47 under-/uninsured. Outcomes between the insured and under-/uninsured groups differed significantly in narcotic refills (0.72 vs 1.74 respectively, P < .01), missed appointments (0.13 vs 0.62, P < .01), and PROMIS results (pain 54.5 vs 60.2; function 44.3 vs 39.5; mood 44.6 vs 51.3; P < .01). The change in PROMIS scores from preoperative to 1-year postoperative were different in pain (-7.3 vs -2.5, P = .03) and function (+6.3 vs +1.3, P = .04). Regression results confirm insurance as a significant factor (coefficient 0.27, P < .01). Conclusion. These results establish that under-/uninsured patients have worse pain, patient-reported outcomes, and functional outcomes after elective foot and ankle surgery, which may inform patient selection. Levels of Evidence: Level III: Retrospective cohort study.

Patient-Specific 3-Dimensional Modeling and Its Use for Preoperative Counseling of Patients Undergoing Hip Arthroscopy.

BACKGROUND: Femoroacetabular impingement (FAI) represents complex alterations in the bony morphology of the proximal femur and acetabulum. Imaging studies have become crucial in diagnosis and treatment planning for symptomatic FAI but also have limited patient understanding and satisfaction. Exploration of alternative patient counseling modalities holds promise for improved patient understanding, satisfaction, and ultimately for outcomes. PURPOSE: To compare perceived understanding of functional anatomy and FAI pathomorphology among patients counseled with routine computed tomography (CT), generic hip models, and a 3-dimensional (3D) model printed in accordance with a patient's specific anatomy. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A prospective randomized analysis of patients presenting with radiographically confirmed FAI was conducted between November 2015 and April 2017. Patients were randomized into groups that received preoperative counseling with CT imaging alone, a generic human hip model, or a haptic 3D model of their hip. All groups were subjected to a novel questionnaire examining patient satisfaction and understanding on a variety of topics related to FAI. Data were compared with bivariate and multivariate analyses. Statistical significance was determined as P < .05. RESULTS: Thirty-one patients were included in this study (25 men, 6 women). Ten patients were randomized to the CT-only group, 11 to the generic hip model group, and 10 to receive custom 3D-printed models of their hips. Patients preoperatively counseled with isolated CT imaging or a generic hip model reported greater understanding of their pathophysiology and the role of surgical intervention when compared with those counseled with haptic 3D models (P = .03). At final follow-up, patients counseled with the use of isolated CT imaging or haptic 3D models reported greater increases and retention of understanding as compared with those counseled with generic hip models alone (P = .03). CONCLUSION: Preoperative counseling with haptic 3D hip models does not appear to favorably affect patient-reported understanding or satisfaction with regard to FAI when compared with the use of CT imaging alone. Continued research into alternative counseling means may serve to further improve patient understanding and satisfaction on this complex anatomic phenomenon.

Validity of QuickDASH at day of surgery versus day of initial consultation: Does informed consent make a difference?

INTRODUCTION: The trend toward requiring explicit consent from patients participating in observational research increases time and resources required to perform such research. Informed consent introduces the potential for "consent bias"-either through selection bias or through the "Hawthorne effect," where patients may alter responses based upon the awareness of participation in a study, thus potentially limiting its applicability to a generalized orthopedic practice. We hypothesized that administering Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) to patients on the day of surgery with informed consent would alter responses in a statistically and clinically meaningful way compared to patients who complete QuickDASH as a quality control measure. METHODS: We previously instituted the QuickDASH questionnaire as the standard new patient intake and postoperative questionnaire for quality assurance purposes. We retrospectively reviewed data on a cohort of patients who underwent isolated carpal tunnel release (CTR) who had completed preoperative and postoperative QuickDASH forms without providing consent for study participation. Next, a cohort of patients scheduled to undergo isolated CTR who completed the intake questionnaire was approached on the day of surgery for consent to participate in the study. After obtaining consent but prior to surgery, these patients completed a second questionnaire and then completed a postoperative questionnaire on follow-up at a mean of 8 weeks postoperatively. RESULTS: Thirty-nine patients and 35 patients were included in the retrospective and prospective cohorts, respectively. No significant differences were observed in age, gender, symptom duration, nerve conduction study/electromyography results, or disease severity between the two groups. We identified no statistically significant difference in preoperative or postoperative QuickDASH score between the retrospective and prospective cohorts (39.8 ± 22.7 vs. 39.7 ± 19.1 preoperatively; 27.3 ± 24.7 vs. 18.7 ± 13.3 postoperatively) or within the prospective cohort before and after obtaining informed consent. CONCLUSION: Informed consent did not significantly alter patient responses to the QuickDASH questionnaire. These results suggest that both "opt-in" and "opt-out" approaches to observational research in hand surgery provide results that may be applicable to a generalized orthopedic practice. CLINICAL RELEVANCE: This study provides evidence that will inform the interpretation of observational research findings in hand surgery.

Lumbar Spine Infection by Granulicatella and Abiotrophia Species.

BACKGROUND: The Granulicatella and Abiotrophia species are streptococci and natural inhabitants of the oral and urogenital flora. They are uncommonly associated with human pathology, although they can cause septicemia, endocarditis, or bacteremia. These microorganisms are difficult to culture and identify due to particular microenvironment requirements. Rarely, presentation is osteomyelitis or infections of the spine. CASE DESCRIPTION: The case report referenced patient notes, laboratory values, and imaging from the electronic health record. In this 48-year-old male with a history of hepatitis C and intravenous drug use, back pain was a relatively common presentation of an uncommon infection. His hospital course was significant for low back pain that did not resolve with conservative measures. Imaging was concerning for infection of the lumbar spine. Biopsies, negative early on, were ultimately positive for Granulicatella and Abiotrophia species, a rare infectious etiology. This infection uncommonly affects the lumbar spine and has not been previously documented in IV drug users. Intravenous antibiotics were prescribed for 6 weeks, after which the patient demonstrated significant clinical improvement. CONCLUSION: With such an uncommon pathogen, there are no universal protocol changes indicated. However, awareness of such unusual microbes and their potential role as the etiology of more common infections, such as lumbar osteomyelitis, is crucial in developing a thorough infectious workup in cases resistant to treatment targeting typical microorganisms.

Combined Cubital and Carpal Tunnel Release Results in Symptom Resolution Outside of the Median or Ulnar Nerve Distributions.

BACKGROUND: Resolution of symptoms including pain, numbness, and tingling outside of the median nerve distribution has been shown to occur following carpal tunnel release. We hypothesized that a similar effect would be found after combined release of the ulnar nerve at the elbow with simultaneous release of the median nerve at the carpal tunnel. METHODS: 20 patients with combined cubital and carpal tunnel syndrome were prospectively enrolled. The upper extremity was divided into six zones and the location of pain, numbness, tingling, or strange sensations was recorded pre-operatively. Two-point discrimination, Semmes-Weinstein monofilament testing, and validated questionnaires were collected pre-operatively and at six-week follow-up. RESULTS: Probability of resolution was greater in the median nerve distribution than the ulnar nerve for numbness (71% vs. 43%), tingling (86% vs. 75%). Seventy percent of the cohort reported at least one extra-anatomic symptom pre-operatively, and greater than 80% of these resolved at early follow-up. There was a decrease in pain as measured by validated questionnaires. CONCLUSION: This study documents resolution of symptoms in both extra-ulnar and extra-median distributions after combined cubital and carpal tunnel release. Pre-operative patient counseling may therefore include the likelihood of symptomatic improvement in a non-expected nerve distribution after this procedure, assuming no other concomitant pathology which may cause persistent symptoms. Future studies could be directed at correlating pre-operative disease severity with probability of symptom resolution using a larger population.

The impact of residual angulation on patient reported functional outcome scores after non-operative treatment for humeral shaft fractures.

PURPOSE: To determine if residual angular deformity following non-operative treatment of humeral diaphyseal fractures correlates with patient reported outcomes. METHODS: Skeletally mature patients treated by one of three orthopaedic trauma surgeons at a level 1 trauma centre with humeral shaft fractures treated without surgery were retrospectively identified over a 7 year period. After inclusion and exclusion criteria, 42 patients were eligible for the study. Disabilities of the Arm, Shoulder, and Hand (DASH); Simple Shoulder Test (SST); General health questionnaire SF-12 physical component summary (SF-12 PCS) and mental component summary (SF-12 MCS) were obtained from study participants. Healed angular deformity was obtained from patient charts. RESULTS: Thirty two subjects were successfully recruited (32/42 or 76%). Average age was 45 ± 22 with average study follow up being 47 ± 29 months. Average outcome scores were DASH 12 ± 16, SST 10 ± 2.7, SF-12 PCS 50 ± 7.9, and SF-12 MCS 54 ± 8.8. Healed sagittal plane deformity averaged 8 ± 5.7° [range 0-18], and 15 ± 7.9° [range 2-27] in the coronal plane. There was no correlation between residual sagittal or coronal plane deformity and outcome scores (DASH and SST for both p>0.05). Patients with at least 20° (n=7; 22%) of healed coronal deformity had similar outcomes to those with <20° ([DASH (13.2 ± 18.7 vs 11.7 ± 16.1; p=0.83]; [SST (10.3 ± 2 vs 10.0 ± 2.9; p=0.81]). Higher SF-12 PCS and MCS scores correlated with better DASH and SST scores (p<0.05 for all). CONCLUSION: Residual angular deformity ranging from 0 to 18° in the sagittal plane and from 2 to 27° in the coronal plane after non-operative treatment for humeral shaft fractures had no correlation with patient reported DASH scores, SST scores, or patient satisfaction. Instead, overall physical and mental health status as measured by the SF-12 significantly correlated with patient reported outcomes.

Prospective cohort study of symptom resolution outside of the ulnar nerve distribution following cubital tunnel release.

BACKGROUND: Resolution of symptoms including pain, numbness, and tingling outside of the median nerve distribution has been shown to occur following carpal tunnel release. We hypothesized that a similar effect would be found after release of the ulnar nerve at the elbow. METHODS: Twenty patients with isolated cubital tunnel syndrome were prospectively enrolled. The upper extremity was divided into six zones, and the location of pain, numbness, tingling, or strange sensations was recorded pre-operatively. Two-point discrimination, Semmes-Weinstein monofilament testing, and validated questionnaires were collected. The same data were collected at 6-week follow-up. Paired t tests or non-parametric Wilcoxon Signed-Rank tests were used where appropriate to examine for significant (p ≤ 0.05) changes between pre- and post-operative scores. RESULTS: Probability of resolution was greater outside of the ulnar nerve distribution than within at early follow-up. There was a decrease in pain, numbness, and tingling symptoms both within and outside the ulnar distribution after cubital tunnel release. There was a decrease in pain as measured by several validated questionnaires. CONCLUSION: This study documents resolution of symptoms in an extra-ulnar distribution after cubital tunnel release. Improvement in pain and function after cubital tunnel release may be associated with an improvement in symptoms both within and outside the ulnar nerve distribution. Future studies could be directed at correlating pre-operative disease severity with probability of extra-territorial symptom resolution using a larger sample population.

Factors predicting patient-reported functional outcome scores after humeral shaft fractures.

PURPOSE: The aim of this study was to determine patient variables that are independent predictors of validated functional outcome scores after humeral diaphyseal fractures. METHODS: Adult patients with humeral shaft fractures were retrospectively recruited from a level 1 trauma centre over an 8-year period. Basic demographic information was obtained along with Disabilities of the Arm, Shoulder and Hand (DASH), Simple Shoulder Test (SST) and Short Form 12 (SF-12) physical component summary (PCS) and mental component summary (MCS). Regression analysis was performed to identify patient factors associated with satisfactory outcomes, defined as DASH<21; SST≥10; PCS≥40; and MCS≥40. Of 95 eligible patients, 77 were recruited. Participants had an average age of 47±20 years. Forty-five patients were treated with surgery and 32 healed non-operatively. The average follow-up was 48±29 months. RESULTS: Satisfactory DASH scores decreased with increase in age (odds ratio (OR) 0.95; P=0.023). Satisfactory SST scores were more likely in patients without a history of psychiatric illness (OR 6.3; P=0.01). Satisfactory SF-12 PCS scores were more likely with no psychiatric history (OR 12; P=0.007) and in patients with private insurance (OR 11.4; P=0.03), but these scores decreased with rising Charlson comorbidity index (CCI; OR 0.50; P=0.023). Satisfactory SF-12 MCS scores increased in the absence of psychiatric history (OR 39; P=0.003), and decreased with rising CCI score (OR 0.54; P=0.035). Analysis of patients younger than 50 years of age (n=38) revealed that the absence of psychiatric history increased the odds of satisfactory DASH scores (OR 10.4; P=0.04). Patients aged ≥50 (n=39) had worse DASH scores with increasing age (OR 0.89; P=0.037), better SST scores with middle-third fractures compared to proximal (OR 7.8; P=0.039), better SF-12 PCS with no psychiatric history (OR 16.1; P=0.018) and worse scores with rising CCI (OR 0.50; P=0.036), while rising CCI decreased the odds of satisfactory SF-12 MCS scores (OR 0.47; P=0.046). Treatment modality, associated fractures and classification as "high energy" mechanism were not associated with outcome. CONCLUSION: Patient age, history of psychiatric illness, insurance type, fracture location and Charlson comorbidity index scores had a statistically significant effect on patient-reported functional outcomes following treatment of humeral shaft fractures, regardless of treatment modality, injury mechanism and associated fractures. The impact of these variables may be age dependent.

Hourly neurologic assessments for traumatic brain injury in the ICU.

OBJECTIVES: Hourly neurologic assessments for traumatic brain injury (TBI) in the critical care setting are common practice but prolonged use may actually be harming patients through sleep deprivation. We reviewed practice patterns at our institution in order to gain insight into the role of frequent neurological assessments. METHODS: A 6-month retrospective review was performed for patients who were admitted to an intensive care unit (ICU) with the diagnosis of TBI. Electronic medical records were reviewed based on billing codes. Variables collected included but were not limited to patient demographics, frequency of nursing neurologic evaluations, Glasgow coma scale (GCS), length of stay (LOS), and disposition. RESULTS: A total of 124 patients were identified, 71% male with the average age of 52 years (range 19-96). Traumatic brain injury was classified as severe in 44, moderate in 18, and mild in 62 patients. A total of 89 (71.8%) patients underwent hourly nursing assessments for an average of 2.82 days. The median LOS for all patients was 7 days (range 0-109). There were 18 patients who remained on hourly neurological assessments for greater than 4 days and had a greater LOS (23 days vs 9 days, P  =  0.001). Only two patients required surgery after 48 hours, both for chronic subdural hematomas. DISCUSSION: Hourly neurologic checks are necessary in the acute period for patients with potentially expansible intracranial hemorrhages or malignant cerebral edema, but prolonged use may be harmful. Patients with a low probability of requiring neurosurgical intervention may benefit from reducing the total duration of hourly assessments.

Bipartite atlas in a collegiate football player - Not necessarily a contraindication for return-to-play: A case report and review of the literature.

BACKGROUND: Congenital malformations of the posterior arch of the atlas are rare, occurring in 4% of the population. Anterior arch aplasia is extremely rare and often only coexists with posterior arch anomalies, resulting in a split or bipartite atlas. This congenital anomaly is believed to be present in only 0.1% of the population. CASE DESCRIPTION: A 19-year-old male collegiate football player presented with neck pain and upper extremity paresthesias after sustaining a tackle that forced neck hyperextension. Computed tomography revealed significant congenital bony anomalies of the cervical spine, with incomplete fusion of the anterior and posterior arches of the atlas; however, there was no evidence for of any acute traumatic injury or fracture. Magnetic resonance imaging revealed increased edema in pre-vertebral soft tissues around C1-C2, with a possible increase in signal within the fibrous ring of the anterior C1 ring. Flexion and extension imaging confirmed reduced range of motion and no instability. Patient was treated non-operatively, and was able to resume normal activity and training regimens, and continued to do well clinically. CONCLUSION: We describe a rare case of split or bipartite atlas in collegiate football athlete who sustained a neck injury during a tackle. The patient had no atlanto-axial instability or other clinical contraindications and was managed non-operatively, resuming full participation shortly thereafter with a full resolution of symptoms.