Acute clavicle fixation after blunt chest trauma: effect on pulmonary outcomes and patient disposition.

PURPOSE: Clavicle fractures are common in patients who sustain blunt chest trauma (BCT). Recently, surgical fixation of rib fractures in patients with BCT has been shown to improve pulmonary and clinical outcomes. Therefore, the purpose of this study is to assess the role of early clavicle fixation (ECF) versus non-operative (NO) treatment for midshaft clavicle fractures in this same population. METHODS: A retrospective chart review was performed in patients with midshaft clavicle fractures and BCT at a Level I Trauma Center between 2007 and 2017. Patients with pre-existing pulmonary conditions and head injuries necessitating mechanical ventilation were excluded. Demographic data, injury mechanisms, and Thoracic Trauma Severity Scores (TTS) were analyzed. Inpatient pulmonary outcomes were assessed with serial vital capacity (VC) measurements, intubation, mechanical ventilation, and pulmonary complications data. In addition, intensive care unit (ICU) and hospital length of stay (LOS), mortality, discharge location, and incidence of postoperative complications in the ECF group were also measured. RESULTS: Thirty-six patients underwent ECF, and 24 underwent NO treatment. The ECF cohort was statistically younger and had a greater incidence of clavicle fracture shortening than the NO group. There was no difference in pulmonary outcomes, ICU or hospital LOS, or mortality between groups. There were no complications associated with ECF. Patients who underwent ECF were more likely to discharge to home. There were no postoperative complications associated with ECF. CONCLUSION: ECF of midshaft clavicle fractures does not improve pulmonary outcomes in patients with BCT. However, despite the lack of pulmonary benefit, there appears to be no added risk of harm. Therefore, ECF is a reasonable consideration in this patient population who otherwise meet clavicle fracture operative indications.

Management of Bleeding Diathesis in Elective and Orthopaedic Trauma: A Review.

There is a general need among orthopaedic surgeons for practical advice on managing patients with bleeding disorders. Appropriate diagnosis and management of these disorders is paramount once discovered before, during, or after the patient's surgical course. Bleeding disorders disrupt the body's ability to control bleeding, commonly through platelet function and blood clotting. Normally, the vessel contracts and retracts once disruption of blood vessels occurs, limiting blood loss. Blood platelets adhere to exposed collagen, aggregate at the site, and obstruct blood loss. Because platelet aggregates are temporary, blood clotting is needed to back up the platelet plug and provide a milieu for the healing process that completes the hemostatic events. Disorders that interfere with any of these events can result in hemorrhage, drainage, or rebleeding. Bleeding disorders are a group of conditions, either hereditary or acquired, marked by abnormal or excessive bleeding and/or bruising. The most effective methods for assessing coagulation disorders include a detailed history and a series of blood tests. Clinical examination findings are notable but may be less specific. If a surgical patient has a bleeding disorder discovered preoperatively, postoperatively, or intraoperatively, treatments exist with medications, surgical management, interventional radiology procedures, and replacement therapy.

Orthopaedic Personal Statement Thematic Review: Does Topic Matter?

Introduction: In the process of applying into medical residency, the Electronic Residency Application Service (ERAS) requires critical documents including a personal statement. Utility of personal statements are questioned based on suspected congruity of the content within personal statements among those who apply into orthopaedic surgery. The goal of this study was to identify and categorize the thematic elements found within the 2021 to 2022 personal statements of orthopaedic surgery applicants at a single institution and assess a correlation to interview invitation. Methods: Deidentified personal statements among 2021 to 2022 ERAS applicants were reviewed by the research staff and categorized into one of the proposed themes. Three hundred ninty-four applications passed initial screening filters, and 49 applicants were granted an interview. Proposed themes that were collected included: family of physician, working with hands, history of injury/disease, prior professional setting, immigration/travel, athlete/sports, reapplication, previous clinical experience, and other. χ2 test was used to analyze categorical themes and additional univariate group-to-group comparisons. Multivariate principal component analysis was performed to determine which themes were associated with interview invitation. Results: There was a significant difference in theme selection for an applicant's personal statement (χ2 = 209.5, p < 0.001), but no statistical difference was observed between each individual categorical themes and interview selection. Univariate group-to-group comparison demonstrated greater interview rates between immigration/travel compared with reapplicant and family of physician compared with working with hands. Multivariate principal component analysis demonstrated immigration/travel as the theme with a positive correlation toward an interview invitation. Conclusion: Despite a significant focus of the application process into orthopaedic surgery residencies, our single-institution study did observe specific themes that were more prevalent. There was an increased interview rate between applicant's themes for immigration/travel and family of physician when comparing groups. Immigration/travel was also identified as the only significant theme associated with interview invitation which may be due to the recent emphasis on promoting diversity within orthopaedic surgery.

Hamstring Anterior Cruciate Ligament Autograft Contributes to a Delayed Symptomatic Cyclops Lesion: A Case Report.

Cyclops lesions are characterized as fibroid nodules with granulation tissue that looks similar to a cyclops eye during arthroscopy. These are rare postoperative complications following anterior cruciate ligament reconstruction (ACLR), presenting typically within six months of their reconstruction. This case report presents a 21-year-old male, three years following hamstring autograft ACLR, with a symptomatic cyclops lesion. Contrary to the reported literature, this delayed presentation showed a painful flexion contracture of the knee and intraoperative findings consistent with a cyclops lesion. The treatment consisted of surgical debridement and notchplasty with subsequent posterior medial and lateral meniscal horn repairs. This case report presents a lesson to indicate that cyclops lesions can occur in a delayed setting following ACLR and to show a technique for successful surgical management of the lesion.

The lesser trochanter profile is an accurate and reliable measure of femoral rotation for intramedullary nailing.

INTRODUCTION: The lesser trochanter profile (LTP) method is an intraoperative fluoroscopic technique that can assess the femoral version and limit malrotation. The purpose of this study was to directly assess the accuracy and reliability of the LTP method, as well as determine the incidence of malrotation produced by this technique. METHODS: Three groups of observers (fellowship-trained orthopedic surgeons, orthopedic residents, and medical students) utilized the LTP method to replicate pre-imaged rotation angles on a cadaveric femur bone. Recorded outcomes include rotational error and number of attempts. Accuracy and interobserver reliability were assessed by rotational error and the interclass correlation coefficient (ICC), respectively. RESULTS: Accuracy was within 3° for all three groups. ICC between each group was greater than 0.99. There was no statistical difference between the accuracy of fellowship-trained surgeons, orthopedic residents, and medical students. Medical students on average required more attempts to obtain their final image compared to fellowship-trained surgeons. There was no statistical difference in the number of attempts between residents and fellowship-trained surgeons. CONCLUSION: None of the LTP measurements were greater than 15°, the clinical threshold for malrotation. The average error of the observers was less than 3°, demonstrating that the LTP is an effective method of assessing the femoral version. There was no statistically significant difference between the observers, indicating that this technique is reliable and easy to use. Ultimately, the LTP method is easily reproducible for surgeons to avoid femoral malrotation.

The Impact of Clinical Practice Guidelines on Preoperative Antibiotic Administration for Carpal Tunnel Release.

Background: In 2015, the American Association of Plastic Surgeons (AAPS) published a consensus statement against the routine use of preoperative antibiotic prophylaxis to prevent surgical site infection in clean hand surgery. The American Academy of Orthopaedic Surgeons (AAOS) similarly cited "insufficient evidence" in its Appropriate Use Criteria guidelines to support the use of antibiotics in carpal tunnel surgery. Nonetheless, its administration remains a common practice during clean hand surgery. We sought to evaluate the impact of the above guidelines on preoperative antibiotic administration. Methods: An institutional review board-approved retrospective chart review of consecutive patients with carpal tunnel syndrome treated with open carpal tunnel release (CTR) at our institution was performed in the 2 years before and after publication of AAPS/AAOS guidelines. Patient demographics and surgical outcomes were reviewed. Incidence of antibiotic administration, patient demographics, and surgeon factors were collected. Results: A total of 770 primary open CTR procedures were performed in the studied years. In 2013 and 2014, 83.9% of patients received preoperative antibiotics. In 2017 and 2018, 48.2% of patients received preoperative antibiotics. Of the variables analyzed, immunosuppression, history of diabetes, and poorly controlled diabetes (A1c > 7) were found to be statistically significant in its positive correlation to prophylactic preoperative antibiotic use. Diabetes was not associated with surgical site infections. Conclusion: Patients were more likely to receive preoperative antibiotics before the publication of the AAPS/AAOS clinical practice guidelines. Patients with diabetes regardless of their glycemic control are more likely to receive preoperative antibiotics.

Improved performance of machine learning models in predicting length of stay, discharge disposition, and inpatient mortality after total knee arthroplasty using patient-specific variables.

BACKGROUND: This study aimed to compare the performance of ten predictive models using different machine learning (ML) algorithms and compare the performance of models developed using patient-specific vs. situational variables in predicting select outcomes after primary TKA. METHODS: Data from 2016 to 2017 from the National Inpatient Sample were used to identify 305,577 discharges undergoing primary TKA, which were included in the training, testing, and validation of 10 ML models. 15 predictive variables consisting of 8 patient-specific and 7 situational variables were utilized to predict length of stay (LOS), discharge disposition, and mortality. Using the best performing algorithms, models trained using either 8 patient-specific and 7 situational variables were then developed and compared. RESULTS: For models developed using all 15 variables, Linear Support Vector Machine (LSVM) was the most responsive model for predicting LOS. LSVM and XGT Boost Tree were equivalently most responsive for predicting discharge disposition. LSVM and XGT Boost Linear were equivalently most responsive for predicting mortality. Decision List, CHAID, and LSVM were the most reliable models for predicting LOS and discharge disposition, while XGT Boost Tree, Decision List, LSVM, and CHAID were most reliable for mortality. Models developed using the 8 patient-specific variables outperformed those developed using the 7 situational variables, with few exceptions. CONCLUSION: This study revealed that performance of different models varied, ranging from poor to excellent, and demonstrated that models developed using patient-specific variables were typically better predictive of quality metrics after TKA than those developed employing situational variables. LEVEL OF EVIDENCE: III.

Predicting Factors for Blood Transfusion in Primary Total Knee Arthroplasty Using a Machine Learning Method.

INTRODUCTION: Acute blood loss anemia requiring allogeneic blood transfusion is still a postoperative complication of total knee arthroplasty (TKA). This study aimed to use machine learning models for the prediction of blood transfusion after primary TKA and to identify contributing factors. METHODS: A total of 2,093 patients who underwent primary TKA at our institution were evaluated using data extracted from the hospital quality improvement database to identify patient demographics and surgical variables that may be associated with blood transfusion. A multilayer perceptron neural network (MPNN) machine learning algorithm was used to predict risk factors for blood transfusion and factors associated with increased length of stay. Statistical analyses including bivariate correlate analysis, Chi-Square test, and Student t-test were performed for demographic analysis and to determine the correlation between blood transfusion and other variables. RESULTS: The results demonstrated important factors associated with transfusion rates, including preoperative hemoglobin level, preoperative creatinine level, length of surgery, simultaneous bilateral surgeries, tranexamic acid usage, American Society of Anesthesiologists Physical Status score, preoperative albumin level, ethanol usage, preoperative anticoagulation medications, age, and TKA type (conventional versus robotic-assisted). Patients who underwent a blood transfusion had a markedly greater length of stay than those who did not. The MPNN machine learning model achieved excellent performance across discrimination (AUC = 0.894). DISCUSSION: The MPNN machine learning model showed its power as a statistical analysis tool to predict the ranking of factors for blood transfusion. Traditional statistics are unable to differentiate importance or predict in the same manner as a machine learning model. CONCLUSION: This study demonstrated that MPNN for the prediction of patient-specific blood transfusion rates after TKA represented a novel application of machine learning with the potential to improve preoperative planning for treatment outcomes.

Neuroforaminal Stenosis in the Lumbosacral Spine: A Scoping Review of Pathophysiology, Clinical Manifestations, Diagnostic Imaging, and Treatment.

OBJECTIVE: To conduct the first scoping review of lumbosacral neuroforaminal stenosis with respect to the pathophysiology, symptomatic manifestations, diagnostic imaging, and treatment options. METHODS: A scoping literature review was conducted in accordance with the recommendations set forth by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), with English language restrictions stipulated to include articles pertaining to lumbosacral neuroforaminal stenosis. Databases maintained by PubMed, National Library of Medicine, Cochrane Central Register of Controlled Trials (Ovid), Scopus (Elsevier), Web of Science (Thomson Reuters), and Google Scholar were queried from their inception date through December 2022. SUMMARY OF THE EVIDENCE: A total of 276 articles were reviewed and 29 articles were included within the study. Within these articles, the anatomic origins of neuroforaminal stenosis were reviewed in detail and the resulting clinical manifestations were discussed. Recent studies evaluating the efficacy of existing diagnostic imaging modalities were summarized, along with potential future methods to improve sensitivity for detecting this entity and measuring foraminal stenosis via novel imaging techniques. Based on the literature, the conservative management and surgical treatment of lumbosacral foraminal stenosis were discussed. CONCLUSIONS: Lumbar neuroforaminal stenosis represents a significant source of radicular pain that is often compounded by delayed diagnosis and incomplete treatment. This article represents the first scoping review of lumbosacral neuroforaminal stenosis with focus on diagnosis, management, and treatment for associated radicular pain. The goal is to reduce the incidence of untreated or unrecognized neuroforaminal stenosis in the setting of a complex decompression and fusion, as well as to promote minimally invasive surgery to address radicular pain from neuroforaminal stenosis. Recent advances in diagnostic imaging and surgical techniques have the potential to improve the timeliness and durability of patients' treatment options. Future directions for the diagnostic imaging of foraminal stenosis include efforts aimed at developing the nascent field of computerized mapping to reliably quantify stenosis and its impact on the exiting nerve root and associated dorsal root ganglia.

Assessing the predictive capacity of machine learning models using patient-specific variables in determining in-hospital outcomes after THA.

Background: Machine learning is a subset of artificial intelligence using algorithmic modeling to progressively learn and create predictive models. Clinical application of machine learning can aid physicians through identification of risk factors and implications of predicted patient outcomes. Aims: The aim of this study was to compare patient-specific and situation perioperative variables through optimized machine learning models to predict postoperative outcomes. Methods: Data from 2016 to 2017 from the National Inpatient Sample was used to identify 177,442 discharges undergoing primary total hip arthroplasty, which were included in the training, testing, and validation of 10 machine learning models. 15 predictive variables consisting of 8 patient-specific and 7 situational specific variables were utilized to predict 3 outcome variables: length of stay, discharge, and mortality. The machine learning models were assessed in responsiveness via area under the curve and reliability. Results: For all outcomes, Linear Support Vector Machine had the highest responsiveness among all models when using all variables. When utilizing patient-specific variables only, responsiveness of the top 3 models ranged between 0.639 and 0.717 for length of stay, 0.703-0.786 for discharge disposition, and 0.887-0.952 for mortality. The top 3 models utilizing situational variables only produced responsiveness of 0.552-0.589 for length of stay, 0.543-0.574 for discharge disposition, and 0.469-0.536 for mortality. Conclusions: Linear Support Vector Machine was the most responsive machine learning model of the 10 algorithms trained, while decision list was most reliable. Responsiveness was observed to be consistently higher with patient-specific variables than situational variables, emphasizing the predictive capacity and value of patient-specific variables. The current practice in machine learning literature generally deploys a single model, it is suboptimal to develop optimized models for application into clinical practice. The limitation of other algorithms may prohibit potential more reliable and responsive models.Level of Evidence III.

Systematic Review of Ligament Reconstruction of Traumatic Isolated Thumb Carpometacarpal Joint Dislocation.

INTRODUCTION: Thumb carpometacarpal (CMC) joint dislocations are rare with minimal agreement on surgical management. The dorsoradial ligament (DRL) is the primary joint stabilizer but has not historically been reconstructed. We hypothesize that the reported reconstruction of first CMC joint dislocations primarily uses the flexor carpi radialis (FCR) without collective agreement on a surgical technique. METHODS: A systematic review of the PubMed database from 1996 to 2022 was done. Keywords were "thumb dislocation," "thumb carpometacarpal dislocation," and "carpometacarpal joint ligament repair." Inclusion criteria included isolated, unstable thumb CMC dislocations with reconstruction. The Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines were used. RESULTS: Four hundred thirty-seven records were identified, and nine met inclusion criteria. Two articles were cohort studies, and seven were case reports. Thirty-seven patients were included, and 26 patients had reconstruction with tendonous autograft. Twenty-five (96.2%) used the FCR and 1 (3.9%) from the palmaris longus. Three patients had reconstruction with a suture anchor. Surgical techniques varied between studies. DISCUSSION: The recommendation of the authors recreates the DRL during autograft repair. Current repair techniques that recreate the DRL use the FCR, but quantitative comparisons of tendonous autografts or suture anchors have not been done.

Rare popliteal mass following retrograde nailing of ballistic femur fracture: a case report.

INTRODUCTION: Civilian ballistic injuries are commonly associated with fracture, vascular injury, and soft tissue trauma. Posttraumatic pseudoaneurysms represent an extremely rare subset of vascular injuries following ballistic fractures. CASE: We present the rare case of a posttraumatic pseudoaneurysm that occurred after retrograde femoral nailing of a ballistic distal femur fracture. The patient presented in clinic postoperatively with a pulsatile popliteal mass. Distal pulses were intact but subsequent ultrasound and angiography revealed a pseudoaneurysm of the distal superficial femoral artery. The pseudoaneurysm was subsequently treated with a covered stent and the patient's recovery was uncomplicated. CONCLUSION: Due to the potential life and limb-threating complications from pseudoaneurysm rupture, this case report emphasizes the early recognition and expeditious management of vascular complications following ballistic fractures in the civilian population.

Cannabidiol: A Brief Review of Its Therapeutic and Pharmacologic Efficacy in the Management of Joint Disease.

Cannabis use in the management of musculoskeletal diseases has gained advocacy since several states have legalized its recreational use. Cannabidiol (CBD), a commercially available, non-neurotropic marijuana constituent, has shown promise in arthritic animal models by attenuating pro-inflammatory immune responses. Additional research has demonstrated the benefit of CBD in decreasing the endogenous pain response in mice subjected to acute arthritic conditions, and further studies have highlighted improved fracture healing following CBD use in murine mid-femoral fractures. However, there is a lack of high-quality, novel research investigating the use of CBD in human musculoskeletal diseases aside from anecdotal accounts and retrospective reviews, perhaps due to legal ramifications limiting the enrollment of patients. The purpose of this review article is to highlight the extent of current research on CBD and its biochemical and pharmacologic efficacy in the treatment of joint disease, as well as the evidence for use of CBD and cannabis in patients undergoing joint arthroplasty. Based on available literature relying on retrospective data and case reports, it is challenging to propose a recommendation for CBD use in perioperative pain management. Additionally, a number of CBD products currently available as supplements with different methods of administration, and it is important to remember that these products are non-pharmaceuticals. However, given the increased social relevance of CBD and cannabis-based medicines, future, prospective controlled studies evaluating their efficacy are needed.

Pulmonary Blastomycosis: Pediatric Cases Emphasizing Prompt Identification Using C-Reactive Protein and Procalcitonin to Distinguish Fungal vs Bacterial Origin.

INTRODUCTION: Pulmonary blastomycosis is a rare fungal disease with increased prevalence in states such as Wisconsin. Clinical manifestations of blastomycosis may vary from asymptomatic infection to multiorgan, disseminated disease. CASE PRESENTATION: We present 2 pediatric patients with blastomycosis who were initially worked up secondary to cough and fever of suspected bacterial origin, though whose subsequent hospital course was notable for deterioration until antifungal treatment was initiated. DISCUSSION: In each case, the disease burden was monitored concurrently with serum procalcitonin and C-reactive protein levels, the former of which remained relatively normal throughout the hospital course signifying lack of bacterial involvement. CONCLUSION: We emphasize the importance of obtaining an early C-reactive protein and procalcitonin, which may distinguish a bacterial from fungal pulmonary infection such as blastomycosis. This, in turn, may shorten hospital stay and reduce hospital inpatient cost, morbidity, and mortality by means of prompt antifungal intervention.

From ER to OR: Results After Implementation of Multidisciplinary Pathway for Fragility Hip Fractures at a Level I Trauma Center.

INTRODUCTION: Hip fractures are one of the most common indications for hospitalization and orthopedic intervention. Fragility hip fractures are frequently associated with multiple comorbidities and thus may benefit from a structured multidisciplinary approach for treatment. The purpose of this article was to retrospectively analyze patient outcomes after the implementation of a multidisciplinary hip fracture pathway at a level I trauma center. MATERIALS AND METHODS: A retrospective review of 263 patients over the age of 65 with fragility hip fracture was performed. Time to surgery, hospital length of stay, Charlson Comorbidity Index (CCI), American Society of Anesthesiologists, complication rates, and other clinical outcomes were compared between patients treated in the year before and after implementation of a multidisciplinary hip fracture pathway. RESULTS: Timing to OR, hospital length of stay, and complication rates did not differ between pre- and postpathway groups. The postpathway group had a greater CCI score (pre: 3.10 ± 3.11 and post: 3.80 ± 3.18). Fewer total blood products were administered in the postpathway group (pre: 1.5 ± 1.8 and post: 0.8 ± 1.5). DISCUSSION: The maintenance of clinical outcomes in the postpathway cohort, while having a greater CCI, indicates the same quality of care was provided for a more medically complex patient population. With a decrease in total blood products in the postpathway group, this highlights the economic importance of perioperative optimization that can be obtained in a multidisciplinary pathway. CONCLUSION: Implementation of a multidisciplinary hip fracture pathway is an effective strategy for maintaining care standards for fragility hip fracture management, particularly in the setting of complex medical comorbidities.