Management of Bone Loss in Posterior Glenohumeral Shoulder Instability: Current Concepts.

¼ Posterior glenohumeral instability is relatively uncommon compared with anterior instability, but is becoming an increasingly recognized and surgically managed shoulder pathology.¼ Soft-tissue stabilization alone may not be sufficient in patients who present with substantial bone loss to the posterior glenoid and/or the anterior humeral head.¼ For posterior glenoid defects, posterior glenoid osteoarticular augmentation can be used, and posterior glenoid opening wedge osteotomy can be considered in cases of posterior instability with pathologic retroversion.¼ For humeral head lesions, several surgical treatment options are available including subscapularis transposition into the humeral head defect, autograft or allograft reconstruction, humeral rotation osteotomy, and shoulder arthroplasty.

Decreased Prevalence of New-Onset Adhesive Capsulitis in Patients Prescribed Angiotensin Receptor Blockers.

BACKGROUND: Angiotensin receptor blockers (ARBs) are commonly prescribed antihypertensive agents that have well-known antifibrotic properties. The purpose of this study was to examine the association between ARB use and the rates of new-onset adhesive capsulitis as well as adhesive capsulitis requiring operative treatment. METHODS: Using a large national insurance database, a randomly generated cohort of patients with at least 3 continuous months of ARB use between January 2010 and December of 2019 (n=1,000,000) was compared to a separate randomly generated cohort without ARB use (n=3,000,000) . Rates of newly diagnosed adhesive capsulitis and associated manipulation under anesthesia and/or arthroscopic capsulotomy were calculated over a one- and two-year period following the completion of at least 3 continuous months of ARB therapy. Rates were compared using multivariable logistic regression to control for demographics and comorbidities. Both unadjusted and adjusted odds ratios (aOR) and 95% confidence intervals (CI) were calculated and reported for each comparison. Statistical significance was set at P<0.05. RESULTS: The mean age in the ARBs cohort was 61.8 years (SD = 10.0), while in the control cohort, it was 54.8 years (SD = 12.3) (p < 0.001). The ARBs cohort had significantly lower rates of newly diagnosed adhesive capsulitis compared to the control cohort at both one year (0.15% vs. 0.55%, p < 0.001) and two years (0.3% vs. 0.78%, p < 0.001). Similar findings were observed for the arthroscopic capsular release/MUA cohort associated with adhesive capsulitis. After adjusting for confounding factors, the lower rates of adhesive capsulitis and arthroscopic capsular release/MUA associated with adhesive capsulitis in the ARBs cohort remained statistically significant (p < 0.001). CONCLUSION: Patients prescribed ARBs experienced a decrease rate of newly diagnosed adhesive capsulitis, as well as adhesive capsulitis requiring surgical intervention when compared to a control cohort. These findings suggest a potential protective effect of ARBs against the development of adhesive capsulitis. Further investigations are warranted to elucidate the underlying mechanisms and establish a causal relationship.

A Posterior Acromial Bone Block Augmentation Is Biomechanically Effective at Restoring the Force Required To Translate the Humeral Head Posteriorly in a Cadaveric, Posterior Glenohumeral Instability Model.

PURPOSE: To assess the biomechanical utility of a posterior acromial bone block (PABB) for the treatment of posterior glenohumeral instability. METHODS: Ten fresh-frozen cadaveric specimens were obtained based upon an a priori power analysis. A 2.5-cm scapular spine autograft was harvested from all shoulders. A custom robot device was used to apply a 50-N compressive force to the glenohumeral joint. The humeral head was translated 10 mm posteroinferiorly at 30 degrees from the center of the glenoid at a rate of 1.0 mm/s in 6 consecutive conditions: (1) intact specimen, (2) intact with PABB, (3) posterior capsulolabral tear, (4) addition of the PABB, (5) removal of the PABB and repair of the capsulolabral tear (LR), and (6) addition of the PABB with LR. The maximum force required to obtain this translation was recorded. Paired t tests were performed to compare relevant testing conditions. RESULTS: Ten cadavers with a mean ± SD age of 54.4 ± 13.1 years and mean ± SD glenoid retroversion of 6.5 ± 1.0 degrees were studied. The PABB provided greater resistance force to humeral head translation compared to the instability state (instability, 29.3 ± 15.3 N vs PABB, 47.6 ± 21.0 N; P = .001; 95% confidence interval [CI], -27.6 to -10.0). When comparing PABB to LR, the PABB produced higher resistance force than LR alone (PABB, 47.6 ± 21.0 N; LR, 34.2 ± 20.5 N; P = .012; 95% CI, -23.4 to -4.1). An instability lesion treated with the PABB, with LR (P = .056; 95% CI, -0.30 to 20.4) or without LR (P = .351; 95% CI, -6.8 to 15.7), produced resistance forces similar to the intact specimen. CONCLUSIONS: A PABB is biomechanically effective at restoring the force required to translate the humeral head posteriorly in a cadaveric, posterior glenohumeral instability model. A posterior acromial bone block is a biomechanically feasible option to consider in patients with recurrent posterior instability. CLINICAL RELEVANCE: Augmentation of the posterior acromion may be a biomechanically feasible option to treat posterior shoulder instability.

Rotator Cuff Tears to Shoulder Instability: The Relationship Between Acromial Morphology and Shoulder Pathology.

¼ The acromion is a well-studied region of the scapula that has demonstrated substantial relationships to various shoulder pathologies.¼ Abnormal acromial morphology is associated with rotator cuff pathology, and our understanding of this risk factor inspired acromioplasty as an adjunctive treatment for rotator cuff tears.¼ The acromion is linked closely to shoulder kinematics and biomechanics, as it serves as the origin for the deltoid muscle.¼ In degenerative shoulder disease, eccentric glenohumeral osteoarthritis has been associated with a higher, flatter acromial roof.¼ Increasing literature is emerging connecting morphology of the acromion with shoulder instability.

Arm Health in Elite Collegiate Summer League Baseball Players Assessed by the Kerlan-Jobe Orthopaedic Clinic Score.

CONTEXT: Collegiate baseball players with professional aspirations often participate in summer leagues; foremost among them is the Cape Cod Baseball League (CCBL). Injuries acquired during the collegiate baseball season can be carried into the CCBL season and vice versa. OBJECTIVE: To assess the history of throwing arm injury and current functionality in midseason CCBL players. DESIGN: Cross-sectional study. SETTING: Online questionnaire. PATIENTS OR OTHER PARTICIPANTS: A total of 123 CCBL players participated. Qualifying athletes were ≥18 years old and were rostered CCBL players with remaining collegiate eligibility. MAIN OUTCOME MEASURE(S): After collecting background information, we used the Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow questionnaire to assess the history of throwing arm injury and current functionality. The maximum KJOC score is 100.0; higher scores correspond with greater functionality. RESULTS: The mean KJOC score was 86.6 ± 14.5 (n = 92); 24.5% (23/94) of players reported a prior diagnosis of throwing arm injury other than a strain or sprain. A total of 49 (49/96, 51.0%) players had undergone rehabilitation for a throwing arm injury, and 7 (7/96, 7.3%) had experienced a medical procedure. Players with no previous treatment (n = 41, mean KJOC score = 88.9 ± 19.0) more frequently demonstrated KJOC scores of ≥90 than players with such treatment (n = 55, 80.9 ± 17.1; P < .001). The 18 players with time-loss arm injury in the last year had lower mean KJOC scores (71.3 ± 20.0) than players with no injury or time loss (90.3 ± 9.8; P < .001). Similarly, players who reported current arm trouble (n = 15) had lower KJOC scores (71.6 ± 17.5) than players with healthy arms (89.5 ± 11.9; P < .001). CONCLUSIONS: The average KJOC score of the CCBL players was <90, with particularly low scores in athletes with prior arm injury and treatment.

Postoperative Angiotensin Receptor Blocker Use is Associated With Decreased Rates of Manipulation Under Anesthesia, Arthroscopic Lysis of Adhesions, and Prosthesis-Related Complications in Patients Undergoing Total Knee Arthroplasty.

BACKGROUND: The cellular mechanisms underlying excess scar tissue formation in arthrofibrosis following total knee arthroplasty (TKA) are well-described. Angiotensin receptor blockers (ARB), particularly losartan, is a commonly prescribed antihypertensive with demonstrated antifibrotic properties. This retrospective study aimed to assess the rates of 1- and 2-year postoperative complications in patients who filled prescriptions for ARBs during the 90 days after TKA. METHODS: Patients undergoing primary TKA were selected from a large national insurance database, and the impact of ARB use after TKA on complications was assessed. Of the 1,299,106 patients who underwent TKA, 82,065 had filled at least a 90-day prescription of losartan, valsartan, or olmesartan immediately following their TKA. The rates of manipulation under anesthesia (MUA), arthroscopic lysis of adhesions (LOA), aseptic loosening, periprosthetic fracture, and revision at 1 and 2 years following TKA were analyzed using multivariable logistic regressions to control for various comorbidities. RESULTS: ARB use was associated with decreased rates of MUA (odds ratio [OR] = 0.94, 95% confidence interval (CI), 0.90 to 0.99), arthroscopy/LOA (OR = 0.86, 95% CI, 0.77 to 0.95), aseptic loosening (OR = 0.71, 95% CI, 0.61 to 0.83), periprosthetic fracture (OR = 0.58, 95% CI, 0.46 to 0.71), and revision (OR = 0.79, 95% CI, 0.74 to 0.85) 2 years after TKA. CONCLUSIONS: ARB use throughout the 90 days after TKA is associated with a decreased risk of MUA, arthroscopy/LOA, aseptic loosening, periprosthetic fracture, and revision, demonstrating the potential protective abilities of ARBs. Prospective studies evaluating the use of ARBs in patients at risk for postoperative stiffness would be beneficial to further elucidate this association.

Significant Association between a Diagnosis of Hypovitaminosis D and Rotator Cuff Tear, Independent of Age and Sex: A Retrospective Database Study.

PURPOSE: As high rates of vitamin D deficiency have been demonstrated in orthopedic patient cohorts, this study aimed to characterize the association between a diagnosis of hypovitaminosis D and primary rotator cuff tear (RCT), primary rotator cuff repair (RCR), and postoperative complications in different sex and age cohorts. METHODS: In this retrospective cohort study using PearlDiver, a nationwide administrative claims database, records for all patients aged 30 to 89 yr who received a diagnosis of hypovitaminosis D between January 1, 2011, and October 31, 2018, were queried. Rates of primary RCT, primary RCR, and postoperative complications including subsequent surgery were calculated within sex- and age-specific cohorts and compared with matched control cohorts using multivariable logistic regression. RESULTS: Among the 336,320 patients included in the hypovitaminosis D cohort, these patients were significantly more likely to experience an RCT (odds ratio (OR), 2.70; 95% confidence interval (CI), 2.55-2.85) as well as a full-thickness RCT (OR, 2.36; 95% CI, 2.17-2.56) specifically within 2 yr of their diagnosis. Women with hypovitaminosis D were more likely to undergo surgery to address their full-thickness tears (OR, 1.37; 95% CI, 1.09-1.74). There was no difference in the rates of revision RCR or irrigation and debridement. However, women with hypovitaminosis D were significantly more likely to undergo manipulation under anesthesia (OR, 1.16; 95% CI, 1.03-1.31). CONCLUSIONS: Patients diagnosed with hypovitaminosis D were significantly more likely to suffer from a primary RCT and to undergo manipulation under anesthesia within a year of their RCR. Although many risk factors for RCT are unmodifiable, vitamin D deficiency is a readily modifiable risk factor with several treatment regimens demonstrating positive effects on musculoskeletal health.

Testosterone replacement therapy is associated with increased odds of Achilles tendon injury and subsequent surgery: a matched retrospective analysis.

BACKGROUND: Prescription of testosterone replacement therapy (TRT) has increased in the United States in recent years, and though anabolic steroids have been associated with tendon rupture, there is a paucity of literature evaluating the risk of Achilles tendon injury with TRT. This study aims to evaluate the associative relationship between consistent TRT, Achilles tendon injury, and subsequent surgery. METHODS: This is a one-to-one matched retrospective cohort study utilizing the PearlDiver database. Records were queried for patients aged 35-75 who were prescribed at least 3 consecutive months of TRT between January 1, 2010 and December 31, 2019. Achilles tendon injuries and subsequent surgeries were identified using ICD-9, ICD-10, and CPT billing codes. Multivariable logistic regression was used to compare odds of Achilles tendon injury, Achilles tendon surgery, and revision surgery, with a p-value < 0.05 representing statistical significance. RESULTS: A sample of 423,278 patients who filled a TRT prescription for a minimum of 3 consecutive months was analyzed. The 2-year incidence of Achilles tendon injury was 377.8 (95% CI, 364.8-391.0) per 100,000 person-years in the TRT cohort, compared to 245.8 (95% CI, 235.4-256.6) in the control (p < 0.001). The adjusted analysis demonstrated TRT to be associated with a significantly increased likelihood of being diagnosed with Achilles tendon injury (aOR = 1.24, 95% CI, 1.15-1.33, p < 0.001). Of those diagnosed with Achilles tendon injury, 287/3,198 (9.0%) of the TRT cohort subsequently underwent surgery for their injury, compared to 134/2,081 (6.4%) in the control cohort (aOR = 1.54, 95% CI, 1.19-1.99, p < 0.001). CONCLUSIONS: There is a significant association between Achilles tendon injury and prescription TRT, with a concomitantly increased rate of undergoing surgical management. These results provide insight into the risk profile of TRT and further research into the science of tendon pathology in the setting of TRT is an area of continued interest.

Indication matters: effect of indication on clinical outcome following reverse total shoulder arthroplasty-a multicenter study.

BACKGROUND: As the utilization and success of reverse total shoulder arthroplasty (RTSA) have continued to grow, so have its surgical indications. Despite the adoption of RTSA for the treatment of glenohumeral osteoarthritis (GHOA) with an intact rotator cuff and irreparable massive rotator cuff tears (MCTs) without arthritis, the literature remains sparse regarding the differential outcomes after RTSA among these varying indications. Thus, the purpose of this study was to examine the postoperative clinical outcomes of RTSA based on indication. METHODS: A retrospective review of 2 large institutional databases was performed to identify all patients who underwent RTSA between 2015 and 2019 with minimum 2-year follow-up. Patients were stratified by indication into 3 cohorts: GHOA, rotator cuff tear arthropathy (CTA), and MCT. Baseline demographic characteristics were collected to determine differences between the 3 cohorts. Clinical outcomes were measured preoperatively and postoperatively, including active range of motion, American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation score, and visual analog scale pain score. Multivariate linear regression was performed to determine the factors independently predictive of the postoperative ASES score. RESULTS: A total of 625 patients (383 with GHOA, 164 with CTA, and 78 with MCTs) with a mean follow-up period of 33.4 months were included in the analysis. Patients with GHOA had superior ASES scores (85.6 ± 15.7 vs. 76.6 ± 20.8 in CTA cohort [P < .001] and 75.9 ± 19.9 in MCT cohort [P < .001]), Single Assessment Numeric Evaluation scores (86 ± 20.9 vs. 76.7 ± 24.1 in CTA cohort [P < .001] and 74.2 ± 25.3 in MCT cohort [P < .001]), and visual analog scale pain scores (median [interquartile range], 0.0 [0.0-1.0] vs. 0.0 [0.0-2.0] in CTA cohort [P < .001] and 0.0 [0.0-2.0] in MCT cohort [P < .001]) postoperatively. Postoperative active forward elevation (P < .001) and improvement in active external rotation (P < .001) were greatest in the GHOA cohort compared with other indications. Multivariate linear regression demonstrated that the factors independently associated with the postoperative ASES score included a diagnosis of GHOA (ß coefficient, 7.557 [P < .001]), preoperative ASES score (ß coefficient, 0.114 [P = .009]), female sex (ß coefficient, -4.476 [P = .002]), history of surgery (ß coefficient, -3.957 [P = .018]), and postoperative complication (ß coefficient, -13.550 [P < .001]). CONCLUSION: RTSA for the treatment of GHOA generally has superior patient-reported and functional outcomes when compared with CTA and MCTs without arthritis. Long-term follow-up is needed to identify the lasting implications of such outcome differences.

Role of Quadriceps Tendon Autograft in Primary and Revision Anterior Cruciate Ligament Reconstruction.

¼ The quadriceps tendon (QT) autograft is becoming increasingly popular in both primary and revision anterior cruciate ligament reconstruction (ACLR).¼ The biomechanical properties of the QT are similar to those of the native ACL, the hamstring tendon (HT), and bone-patellar tendon-bone (BTB) autografts.¼ QT autograft allows surgeons to be flexible with their graft size and reconstruction technique.¼ The QT autograft performs in a similar fashion to the BTB and HT autografts, with excellent patient-reported outcomes, consistent postoperative knee stability, and low rates of postoperative complications including graft failure and donor site morbidity.¼ There are emerging data that the QT autograft is a viable option in revision ACLR.

Medial Calcar Restoration Using Femoral Head Autograft in Conversion Hip Arthroplasty for Failed Fixation after an Unstable Intertrochanteric Hip Fracture: A Case Report and Technique Description.

Introduction: The calcar femorale helps manage compressive loads on the femoral head and is an essential component in determining intertrochanteric (IT) femur fracture stability. Fracture fixation can be complicated when primary fixation techniques, such as cephalomedullary nailing fail. Unstable IT femur fractures involving disruption of the medial calcar present additional fixation challenges. Case Report: This case reports a patient with unstable IT fracture due to medial calcar disruption that experienced failure of a short cephalomedullary nail. Secondary fixation involved total hip arthroplasty (THA) with medical calcar reconstruction using femoral head autograft. Outcomes were good at 2-year follow-up with a full return to baseline activities. Conclusion: The results indicate that femoral head autografting can be a viable option, with good outcomes, for medial calcar reconstruction in cases of failed IT fracture fixations without calcar support, converted to THA.

The effect of pre-operative shoulder injections on post-operative opioid use, infection and revision following shoulder arthroplasty.

Background: Treatment of glenohumeral osteoarthritis (GHOA) may include conservative management with use of intraarticular injections, prior to considering total shoulder arthroplasty (TSA). The purpose of this study was to assess trends in the use of preoperative cortisone (CO) and hyaluronic acid (HA) injections, as well as investigate the relationship between injection use and infection or revision arthroplasty following TSA. Methods: Pearl Driver was used to identify all patients undergoing TSA for GHOA between 2010 and 2018. Patients were categorized based on the type and number of injections they received. Outcomes of interest included post-operative opioid use, post-operative infection, and risk of revision surgery within 1 year of the index procedure. Results: The incidence of patients receiving a CO or HA injections within 1 year of their TSA decreased by 83% and 54%, respectively. Patients who had received 1 or more steroid injections had higher odds of prolonged opiate use following surgery. Patients that received 1 or 2 CO injection prior to TSA had an increased risk of needing revision surgery. Discussion: Use of intraarticular injections for the management of GHOA has declined. Patients receiving preoperative injections had increased odds of prolonged opiate use and the need for revision surgery.

Arthroscopic Simulation in Orthopaedic Surgery Training.

Surgical simulation has become a commonly utilized and well-researched training adjunct in nearly all surgical specialties. Balancing high-quality orthopaedic surgical training in the face of work hour restrictions and efficiency pressures has become a challenge to educators and trainees alike. Surgical simulation is an opportunity to enhance such training and potentially permit trainees to be better equipped for the operating room. In orthopaedics, various low-fidelity, high-fidelity, and virtual reality simulation platforms are readily available to almost all trainees and permit simulation of a wide array of arthroscopic surgeries. In this review, we seek to highlight the potential utility of simulation-based training in orthopaedic surgery, the various types of available simulators, and review the evidence for simulator use.

Arthroscopic Training: Historical Insights and Future Directions.

Arthroscopy is an orthopaedic technique that provides surgical solutions in a minimally invasive fashion. Since its introduction, arthroscopy has become a preferred surgical approach for treating various orthopaedic pathologies, such as meniscal tears, anterior cruciate ligament ruptures, rotator cuff tears, and wrist, elbow, ankle, and hip conditions. Despite its ubiquity, surgical training in arthroscopy poses several challenges for educators and trainees. Arthroscopy involves neuromotor skills which differ from those of open surgery, such as the principles of triangulation, bimanual dexterity, and the ability to navigate a three-dimensional space on a two-dimensional screen. There remains no universally implemented curriculum for arthroscopic education within orthopaedic residency or fellowship training programs, permitting the potential for highly variable training experiences from institution to institution. Therefore, the current review seeks to highlight the history of arthroscopic education, strategies and current teaching modalities in modern arthroscopic education, and avenues for future educational pathways.

Testosterone Therapy Is Associated With Increased Odds of Quadriceps Tendon Injury.

BACKGROUND: Anabolic steroid use at supraphysiologic doses has been associated with an increased risk of tendon injury. However, the musculoskeletal effects of testosterone therapy in the clinical setting are not well understood. QUESTIONS/PURPOSES: (1) Is prescription testosterone associated with a higher odds of subsequent quadriceps muscle or tendon injury? (2) Is prescription testosterone associated with a higher odds of surgical repair of the quadriceps tendon? METHODS: The PearlDiver Database, which contains data on Medicaid, Medicare, and commercially insured patients, allows for a large representative sample of the US population including both publicly and privately insured patients. The database was queried for all patients between 2011 and 2018 who filled a testosterone prescription. Additionally, all quadriceps injuries using ICD-9 and ICD-10 codes between 2011 and 2018 were queried. Propensity score matching based on age, sex, Charlson comorbidity index, and specific comorbidities allowed us to create matched control groups. We used the t-test and chi-square analysis to compare the unmatched and matched cohorts. A total of 151,797 patients (123,627 male patients and 28,170 female patients) with a history of filled testosterone prescriptions were included in the study after matching with the control group, which was of equal size and representation of age, male-female proportions, and comorbidities. Chi-square and logistic regression analyses were performed to compare odds of quadriceps injury and quadriceps tendon repair among the testosterone groups to that of their respective control groups by age and sex. RESULTS: Within 1 year of filling prescriptions for testosterone, 0.06% (97 of 151,797) of patients experienced a quadriceps injury compared with less than 0.01% (18 of 151,797) of patients in the control group (OR 5.4 [95% CI 3.4 to 9.2]; p < 0.001). Within the sex-specific matched groups, filling a testosterone prescription was associated with an increase in the odds of quadriceps injury in male patients within 1 year of the prescription (OR 5.8 [95% CI 3.5 to 10.3]; p < 0.001). Additionally, patients who filled a testosterone prescription were at increased risk of having quadriceps tendon repair within a year of the injury than were patients in the matched control group (OR 4.7 [95% CI 2.0 to 13.8]; p = 0.001). CONCLUSION: Considering these findings, it is important for physicians to counsel patients receiving testosterone replacement therapy of the substantially increased odds of quadriceps tendon injury. Future investigations into the mechanisms of influence of exogenous anabolic steroids on tendon injury remains of interest. LEVEL OF EVIDENCE: Level III, therapeutic study.

A Bibliometric Analysis of the Most Cited Research on Humeral Avulsions of the Glenohumeral Ligament: A Paucity of High-Level Evidence.

Purpose: To identify the 25 most-cited articles on humeral avulsion of the glenohumeral ligament (HAGL) lesions and characterize them based on number of citations, citation density, source journal, year of publication, geographic origin, article type, and level of evidence. Methods: The Science Citation Index Expanded database was queried for all possible publications regarding HAGL lesions. The 25 most-cited articles from 1976 to 2021 relevant to the topic were selected for further analysis. Articles were characterized based on the number of citations, citation density, year of publication, source journal, country of origin, article type, article subtype, and level of evidence. Results: The number of citations for individual articles ranged from 21 to 182 (mean ± standard deviation: 44.72 ± 36.87). Ten countries contributed to the 25 most cited articles, with 14 of the 25 (56%) articles published in the United States. Furthermore, the top 25 cited articles were published in 9 journals, with the majority in Arthroscopy-The Journal of Arthroscopic and Related Surgery (n = 15, 60%). There were 15 (60%) articles classified as "Clinical," 9 (36%) as "Review/Expert Opinion," and 1 (4%) as "Basic Science." All clinical studies met the standard for level IV evidence. Conclusions: This bibliometric analysis provides a list of the 25 most cited articles related to HAGL lesions, providing a reference of impactful articles for medical educators. The lack of high level of evidence "Clinical" studies demonstrates that higher-quality research is needed to establish guidelines for the treatment and management of HAGL lesions. Clinical Relevance: A list of the 25 most-cited articles regarding recurrent glenohumeral instability can serve as a comprehensive reference for practitioners, educators, researchers, and orthopaedic trainees.

The Effect of Surgeon and Hospital Volume on Morbidity and Mortality After Femoral Shaft Fractures.

OBJECTIVES: The aim of this study was to characterize the case volume dependence of both facilities and surgeons on morbidity and mortality after femoral shaft fracture (FSF) fixation. METHODS: Adults who had an open or closed FSF between 2011 and 2015 were identified in the New York Statewide Planning and Research Cooperative System database. Claims were identified by International Classification of Disease-9, Clinical Modification diagnostic codes for a closed or open FSF and International Classification of Disease-9, Clinical Modification procedure codes for FSF fixation. Readmission, in-hospital mortality, and other adverse events were compared across surgeon and facility volumes using multivariable Cox proportional hazards regression, controlling for patient demographic and clinical factors. Surgeon and facility volumes were compared between the lowest and highest 20% to represent low-volume and high-volume surgeons/facilities. RESULTS: Of 4,613 FSF patients identified, 2,824 patients were treated at a high or low-volume facility or by a high or low-volume surgeon. Most of the examined complications including readmission and in-hospital mortality showed no statistically significant differences. Low-volume facilities had a higher 1-month rate of pneumonia. Low-volume surgeons had a lower 3-month rate of pulmonary embolism. CONCLUSION: There is minimal difference in outcomes in relation to facility or surgeon case volume for FSF fixation. As a staple of orthopaedic trauma care, FSF fixation is a procedure that may not require specialized orthopaedic traumatologists at high-volume facilities.

Local anesthetic with monitored anesthesia care in cephalomedullary nailing of proximal femur fractures.

INTRODUCTION: Proximal femur fractures have high rates of morbidity, mortality, and perioperative complications. Limiting anesthesia, especially in the elderly population, is a priority from a medical perspective. The goal of the current study is to present a technique of using local anesthetic with monitored anesthesia care (MAC) for the fixation of intertrochanteric (IT) femur fractures with cephalomedullary nailing (CMN), provide early clinical results in a small series of patients, and evaluate the safety, efficiency, and anesthetic efficacy of our technique. HYPOTHESIS: The use of only local anesthetic with MAC for the fixation of IT fractures is safe and leads to decreased operative times when compared to spinal and general anesthesia. MATERIALS AND METHODS: Patients undergoing cephalomedullary nailing (CMN) with a long nail for IT femur fractures by a single surgeon from January 2020 to June 2021 were identified retrospectively from a prospectively-collected patient registry. Patient demographics, operative time, length of hospital stay, perioperative medication use, and complications were collected. Analysis of variance, Chi2, linear regression, and two-sampled T-tests were performed to analyze potential differences between the local anesthesia group and the general or spinal anesthesia group. RESULTS: Thirty-seven patients were identified. Eleven patients underwent CMN using local anesthesia with MAC, 11 using spinal anesthesia, and 15 using general anesthesia. The local anesthesia group demonstrated significantly lower operating room times and anesthesia induction to incision time compared to other anesthesia techniques. The local anesthesia group also trended towards less need for vasopressors during surgery and less postoperative delirium. No differences were identified in intraoperative narcotic use, complications, patient mortality, or hospital readmissions. CONCLUSIONS: Local anesthesia with MAC for the treatment of IT fractures with CMN was associated with decreased operating room times and had similar complication rates including blood transfusions, readmissions, and mortalities, when compared to spinal and general anesthesia. LEVEL OF EVIDENCE: III, therapeutic.

Hospital Courses Differ Amongst Hip Fracture Patients With or Without Coronavirus-19 Positive Status Upon Admission.

INTRODUCTION: The purpose of this study was to compare the hospital course and disposition of COVID-19 positive versus negative patients following an operatively managed hip fracture. MATERIALS AND METHODS: This retrospective cohort study evaluated patients presenting to a university medical center with a hip fracture who underwent surgical management between February 1, 2020 and April 1, 2021. COVID-19 diagnosis was obtained using PCR testing. Hospital length of stay, disposition, readmission, and mortality were compared between patients with and without COVID-19. RESULTS: 399 total patients were identified who met inclusion criteria, with 14 patients who were COVID-positive (3.1%). There was a 6.1 day increase in length of hospital stay for COVID-19 positive patients compared to those who were COVID negative (p = 0.002), without significant changes in disposition, readmission rates, or mortality. CONCLUSIONS: A positive COVID-19 test at the time of admission can significantly increase hospital admission duration. LEVEL OF EVIDENCE: III, Retrospective Cohort Study.

The use of prescription testosterone is associated with an increased likelihood of experiencing a distal biceps tendon injury and subsequently requiring surgical repair.

BACKGROUND: In the United States, the use of testosterone therapy has increased over recent years. Anabolic steroid use has been associated with tendon rupture, although there is a paucity of evidence evaluating the risk of biceps tendon injury (BTI) with testosterone therapy. The aim of this study was to quantify the risk of BTI after the initiation of testosterone therapy. METHODS: This was a retrospective cohort study using the PearlDiver database. Records between 2011 and 2018 were queried to identify patients aged 35-75 years who filled a testosterone prescription for a minimum of 3 months. A control group was created, comprising patients aged 35-75 years who had never filled a prescription for exogenous testosterone. International Classification of Diseases, Ninth Revision, International Classification of Diseases, Tenth Revision, and Current Procedural Terminology codes were used to identify patients with distal biceps injuries and those undergoing surgical repair. Three matching processes were completed: one for the overall cohort, one for the cohort comprising only male patients, and one for the cohort comprising only female patients. Each cohort was matched to its control on age, sex, Charlson Comorbidity Index, diabetes, tobacco use, and osteoporosis. Multivariate logistic regression was used to compare rates of distal BTI and subsequent surgical repair in the testosterone groups with their control groups. RESULTS: A total of 776,974 patients had filled a prescription for testosterone for a minimum of 3 consecutive months. In the overall matched analysis between the testosterone and control groups (n = 291,610 in both), the mean age of the patients was 53.9 years and 23.1% were women. Within 1 year of filling exogenous testosterone prescriptions for a minimum of 3 consecutive months, 650 patients experienced a distal BTI compared with 159 patients in the control group (odds ratio [OR], 4.10; 95% confidence interval [CI], 3.45-4.89; P < .001). At any time after testosterone therapy, patients with testosterone use were more than twice as likely to experience a distal BTI as their matched controls (OR, 2.07; 95% CI, 1.94-2.38). Patients who filled prescriptions for testosterone were more likely to undergo surgical repair within a year of the injury compared with the control group. A similar trend was seen in the cohort comprising male patients (OR, 1.63; 95% CI, 1.29-2.07). CONCLUSION: Patients with prior prescription testosterone exposure have an increased rate of BTI and biceps tendon repair compared with patients without such exposure. This finding provides insight into the risk profile of testosterone therapy, and doctors should consider counseling patients about this risk, particularly male patients.