Fluid and Solute Intakes Show Minimal Association With Serum Sodium Levels in a Mixed ICU Population.

BACKGROUND:  Hyponatremia is common among hospital inpatients. It is generally due to excess free body water resulting from increased water intake and decreased water elimination due to underlying pathology and hormonal influence. However, supporting evidence is lacking for treating mild hyponatremia with fluid restriction. Our study examines the association between hyponatremia and fluid intake in acutely ill inpatients. We hypothesize that fluid intake is not closely associated with serum sodium (SNa). METHODS:  We conducted a retrospective study of hyponatremia using the Multiparameter Intelligent Monitoring in Intensive Care (MIMIC) III dataset, a public ICU registry. We analyzed fluid, sodium, and potassium intake with a mixed model linear regression with SNa as the outcome for hyponatremic and non-hyponatremic patients and cumulative total input from one to seven days. In addition, we compared a group of patients receiving less than one liter of fluid per day to a group receiving more than one liter. RESULTS:  The association of SNa with fluid intake was negative and statistically significant for most cumulative days of intake from one to seven for the total population and those with sporadic hyponatremia. For those with uniform hyponatremia, the negative association was significant for three and four days of cumulative input. The change in SNa was almost always less than 1 mmol/L of additional fluid intake across all groups. SNa for hyponatremic patients who received less than one liter of fluid per day were within one mmol/L of those who received more (p<0.001 for one, two, and seven cumulative intake days). CONCLUSIONS:  SNa is associated with a change of less than 1 mmol/L across a wide range of fluid and sodium intake in adult ICU patients. Patients who received less than one liter per day had SNa almost identical to those who received more. This suggests that SNa is not tightly coupled with fluid intake in the acutely ill population and that hormonal control of water elimination is the predominant mechanism. This might explain why the correction of hyponatremia by fluid restriction is often difficult.

Proposed management of traumatic blunt gallbladder injuries: A case of a pre-emptive laparoscopic cholecystectomy for suspected gallbladder avulsion after blunt traumatic liver injury.

Trauma is the leading cause of death among people aged 1-45 in the United States with the abdomen being the third most commonly injured anatomic region. The incidence of gallbladder trauma in the setting of abdominal injury ranges between 0.5 and 2.1 %. While gallbladder injuries secondary to penetrating abdominal wounds are found intra-operatively owing to the likely progression towards laparotomy, due to the paradigm shift of non-operative management of blunt liver injuries, the diagnosis of blunt gallbladder injuries are commonly delayed upwards of 1 to 6 weeks. 4 We present a case of a pre-emptive cholecystectomy less than 36 h after sustaining a grade V liver injury status post blunt abdominal trauma in effort emphasize the importance of critical review of diagnostic images, and support the utilization of diagnostic laparoscopy to definitively diagnose and manage traumatic blunt gallbladder injuries. When operative intervention is not performed, the nonspecific findings suggestive of gallbladder injuries can lead to delayed diagnosis and subsequent increased morbidity and mortality. Due to the lack of previous guidelines we propose a diagnostic algorithm for the approach of traumatic blunt gallbladder injuries.

Do we need neuroimaging in every case of near-hanging?: experience from a level 1 trauma center and analysis of the National Trauma Data Bank.

PURPOSE: Our study analyzes imaging results in near-hanging to determine what neuroimaging workup is necessary. We evaluate GCS as a clinical predictor to help guide imaging choice. METHODS: This is a retrospective study of patients from a level one trauma center and from the National Trauma Data Bank (NTDB). We classified injuries into categories based on the likelihood that CT played an important role in their diagnosis and management. We assessed whether a normal Glasgow Coma Scale (GCS) could exclude clinically important injuries. Chi square was used to test for significance for categorical variables. Multivariate logistic regression was used for multivariate analysis. RESULTS: CT showed structural brain findings in 0% of patients from our facility (local patients) and 11.7% of NTDB patients. Of local patients and NTDB patients, 1.4% and 6.6% had blunt cerebral vascular injury (BCVI) respectively. Of local patients and NTDB patients, 1.4% and 3.3% had a cervical spine fracture or dislocation, respectively. Mortality for patients with GCS 15 versus GCS < 15 was 0 versus 26.9% for local patients (p = 0.004) and 0 versus 43.8% for NTDB (p < 0.001). Structural brain injury for patients with GCS 15 versus GCS < 15 for isolated hanging was 0 versus 14.9% for NTDB (p < 0.001). GCS 15 was an independent predictor of survival and freedom from brain injury (p < 0.001), but not neck injury. CONCLUSION: GCS 15 is a significant independent predictor of survival and freedom from brain injury in near-hanging. GCS 15 rules out intracranial injury likely to require intervention with negative predictive value of 100%. GCS of 15 does not rule out critical neck injury.

Eosinophilic Gastroenteritis Causing Small Bowel Diverticulosis and Volvulus: A Case Report.

BACKGROUND Eosinophilic gastroenteritis is a broad classification of disease characterized by eosinophilic infiltration of the gastrointestinal tract in the absence of a stimulatory cause. Given the ability of eosinophilic gastroenteritis to affect the entire gastrointestinal tract, it can present in a variety of ways, from chronic intermittent pain to mechanical obstruction. We present a rare case in which eosinophilic gastroenteritis of the jejunum led to small bowel diverticulosis and volvulus, requiring surgery. CASE REPORT An 83-year-old woman with a history of chronic abdominal pain, nausea, and early satiety presented to our clinic after a thorough gastrointestinal workup and radiologic diagnosis of partial midgut volvulus. She underwent an exploratory laparotomy and was found to have normal rotational anatomy with prominent small bowel diverticulosis. A section of 70 cm of proximal jejunum was resected, encompassing all visible diverticula, and a primary anastomosis was performed. The patient recovered without complication. She was seen at follow-up with complete resolution of her presenting symptoms. CONCLUSIONS We propose that this patient's pathology was caused by chronic intermittent obstructions related to eosinophilic gastroenteritis, leading to repeated periods of increased intraluminal pressure and severe small bowel diverticulosis. This case highlights the importance of maintaining an index of suspicion for small bowel diverticulosis in the setting of chronic eosinophilic gastroenteritis.

Urine drug screen positive for cocaine and amphetamine is not an adverse risk factor for cardiovascular morbidity or mortality in trauma.

BACKGROUND: Urine drug screening (UDS) is a component of trauma workup and of perioperative risk evaluation. Illicit stimulant use has been associated with cardiovascular complications. This study investigates the impact of stimulant use and its interaction with surgery on cardiovascular complications in trauma patients. METHODS: Patients were identified from the 2017 National Trauma Data Bank. Univariate and multivariate analyses were used to evaluate the effect of amphetamine and cocaine on mortality, myocardial infarction (MI), and stroke. We evaluated three subsets: all screened patients, those who underwent surgery, and those whose surgery was immediate. Significance was tested with χ2 test for categorical variables, Student's t-test for continuous variables, and logistic regression for multivariate analysis. RESULTS: 317 688 (32.1%) patients underwent UDS. Multivariate analysis showed protective association between cocaine and mortality OR 0.9 (p=0.028). Cocaine was a non-significant predictor of MI and stroke: OR 0.63 (p=0.065) and 0.91 (p=0.502), respectively. Amphetamine was a non-significant predictor of mortality, MI, and stroke: OR 0.97 (p=0.405), 0.80 (p=0.283), and 1.02 (p=0.857), respectively.On univariate analysis, amphetamine showed a protective association with MI for all screened patients: relative risk (RR) 0.58 (p=0.005), and for surgical patients: RR 0.58 (p=0.019). Amphetamine showed a protective association with mortality for all three subsets: RR 0.83 (p<0.001), 0.78 (p<0.001), and 0.71 (p<0.001), respectively. Cocaine showed a protective association with MI for all screened patients: RR 0.45 (p=0.001), and for surgical patients: RR 0.44 (p=0.005). Cocaine showed a protective association with mortality for all three subsets: RR 0.76 (p<0.001), 0.71 (p<0.001), and 0.63 (p<0.001), respectively. DISCUSSION: UDS positive for cocaine or amphetamine is not an adverse risk factor in trauma, including trauma patients who underwent surgery. The apparent protective effects of illicit drugs warrant further investigation. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

Area Deprivation Index Score is Associated with Lower Rates of Long Term Follow-up after Upper Extremity Vascular Injuries.

The Area Deprivation Index (ADI) has been shown to be a determinant of healthcare outcomes in both medical and surgical fields, and is a measure of the socioeconomic status of patients. We sought to analyze outcomes in patients with upper extremity vascular injuries that were admitted over a five-year period to a Level I trauma center sorted by ADI. All patients with upper extremity vascular injury presenting to a level one trauma center between January 2013 and January 2017 were retrospectively collected. The patients were divided into two groups based on their ADI with the first group representing the lowest quartile of patients and the second group the higher three quartiles. Patient's demographics were analyzed as well as modes of trauma, hospital transfer status prior to receiving care, type of intervention received, follow-up rates and outcomes including both complication and amputation rates. Over this time period, a total of 88 patients with traumatic upper extremity vascular injuries were identified. The majority of injuries were due to penetrating trauma (74/88, 84%) with 41% (10/24) of patients in the lower ADI being victims of gunshot wounds compared to 27% (17/64) of those in the higher ADI (P = 0.19). Patients in the lowest ADI quartile were more likely to be African Americans (P= 0.0001), and more likely to be transferred to our university hospital prior to receiving care (P= 0.007). Arrival Glasgow Coma Scale and Injury Severity Score were similar as was time spent in the emergency room. Length of stay trended longer in the lowest ADI quartile as compared to the higher ADI (7.5 vs. 11.8, P= 0.59). The rates of long term follow-up were significantly lower in patients with the lowest ADI scores as opposed to the higher ADI group (P= 0.0098), however, there was no statistically significant difference in outcomes between the two groups including both complication and amputation rates. The ADI is associated with lower rates of long term follow-up after upper extremity vascular injuries, despite patients in both the high and low ADI groups having similar outcomes in regards to complication and amputation rates. Further study is warranted to investigate the role of the socioeconomic status in outcomes following traumatic injury.

Analysis of Predictors of Myocardial Infarction in Trauma With Development of a Trauma Cardiac Risk Index.

STUDY OBJECTIVE: Trauma has historically been considered a disorder of the young and healthy, with a low risk of cardiac ischemia; hence most research on myocardial infarction in trauma has focused on direct cardiac damage from blunt chest trauma. However, the age and comorbidity of trauma patients are increasing, making the trauma population more vulnerable to myocardial infarction (MI). Cardiac risk assessment has emphasized morbidity and mortality in an elective surgical setting, but it is also important in acute trauma. Our study analyzes the risk factors for MI in a trauma population to create a scoring system to predict the risk of MI. DESIGN:  Retrospective cohort analysis of a national trauma registry over a five-year period. Potential predictors of MI in trauma patients were identified and tested with univariate and multivariate statistics. A numerical score was created to predict the risk of MI based on these criteria. SETTING: The National Trauma Data Bank (NTDB) is a large registry of selected trauma centers in the United States. Data include demographic, injury, treatment, and outcome variables pertaining to the index admission of each patient. The institutions range from community hospitals through level 1 trauma centers. The time period is the entire inpatient hospital admission from arrival from the field, through the emergency department, ICU, and floor up to discharge. PATIENTS: 3,437,959 trauma patients aged 18 years and older from various US trauma centers. 62.8% were male. The median age is 50 years with a standard deviation of 21.25. The median Injury Severity Score is 9 with a standard deviation of 9.04. MEASUREMENTS: Demographic, traumatic, and comorbidity variables were collected from the NTDB. The primary outcome was MI during the initial trauma admission. Multivariate analysis was performed with logistic regression. MAIN RESULTS: Over 8010 (0.23%) suffered an MI. The strongest risk factors for MI were a history of MI with an adjusted odds ratio (OR) of 7.0, and angina with an OR of 3.4. A procedure under general anesthesia (GA) conferred an OR of 2.3. Minor risk factors included torso injury and 10-year age interval over 50, both with an OR of 1.7, a 20-point interval of the Injury Severity Score (ISS) with OR 1.6, male gender with OR of 1.5, and various chronic disease comorbidities with OR ranging from 1.4 to 1.9. A Trauma Cardiac Risk Index (TCRI) was derived from these risk factors. The model showed good discrimination with a C statistic of 0.85. CONCLUSIONS: Overall the trauma population has a low risk of MI. However, the risk is much higher for older patients with chronic comorbidity. The TCRI can be used to assess cardiac risk in trauma patients to help direct monitoring, testing, and risk reduction measures to those at the highest risk.

The Effect of Illegal Drug Screening Results and Chronic Drug Use on Perioperative Complications in Trauma.

CONTEXT: Illegal drug use and need for surgery are common in trauma. This allows examination of the effects of perioperative drug use. AIM: The aim was to study the effects of illegal drug use on perioperative complications in trauma. SETTING AND DESIGN: Propensity-matched analysis of perioperative complications between drug screen-positive (DSP) and drug screen-negative (DSN) patients from the National Trauma Data Bank (NTDB). METHODS: The NTDB reports drug screening as a composite. We compared complications for DSP, DSN, and specific chronic drug disorders. Time to first procedure was analyzed to determine whether delay to surgery was associated with reduced complications. STATISTICS: Logistic regression with 11 predictor variables was used to calculate propensity scores. Categorical and continuous variables were compared using Chi-square and Student's t-test, respectively. RESULTS: 752,343 patients (21.9%) were tested for illegal drugs. DSP was protective for mortality-relative risk (RR) 0.84 (P < 0.001) and arrhythmia RR 0.87 (P = 0.02). All complications (AC) were higher for DSP with a RR of 1.08 (P < 0.001). Cocaine, cannabis, and opioids were associated with reduced mortality. Cocaine was associated with increased myocardial infarction (MI). All four chronic drug disorders were associated with markedly higher arrhythmia. All except cannabis were associated with higher AC. Mortality was significantly lower for DSP for every time interval until first procedure. Continuous-time until procedure was associated with increased MI and arrhythmia. CONCLUSIONS: DSP was protective of mortality and cardiac complications. Drug disorders were protective for mortality but increased arrhythmia and AC. Delay until the surgery does not diminish cardiac or overall risk.

A comparison between the TEG 6s and TEG 5000 analyzers to assess coagulation in trauma patients.

BACKGROUND: Trauma-induced coagulopathy is a major driver of mortality following severe injury. Viscoelastic goal-directed resuscitation can reduce mortality after injury. The TEG 5000 system is widely used for viscoelastic testing. However, the TEG 6s system incorporates newer technology, with encouraging results in cardiovascular interventions. The purpose of this study was to validate the TEG 6s system for use in trauma patients. METHODS: Multicenter noninvasive observational study for method comparison conducted at 12 US Levels I and II trauma centers. Agreement between the TEG 6s and TEG 5000 systems was examined using citrated kaolin reaction time (CK.R), citrated functional fibrinogen maximum amplitude (CFF.MA), citrated kaolin percent clot lysis at 30 minutes (CK.LY30), citrated RapidTEG maximum amplitude (CRT.MA), and citrated kaolin maximum amplitude (CK.MA) parameters in adults meeting full or limited trauma team criteria. Blood was drawn ≤1 hour after admission. Assays were repeated in duplicate. Reliability (TEG 5000 vs. TEG 6s analyzers) and repeatability (interdevice comparison) was quantified. Linear regression was used to define the relationship between TEG 6s and TEG 5000 devices. RESULTS: A total of 475 patients were enrolled. The cohort was predominantly male (68.6%) with a median age of 49 years. Regression line slope estimates (ß) and linear correlation estimates (p) were as follows: CK.R (ß = 1.05, ρ = 0.9), CFF.MA (ß = 0.99, ρ = 0.95), CK.LY30 (ß = 1.01, ρ = 0.91), CRT.MA (TEG 6s) versus CK.MA (TEG 5000) (ß = 1.06, ρ = 0.86) as well as versus CRT.MA (TEG 5000) (ß = 0.93, ρ = 0.93), indicating strong reliability between the devices. Overall, within-device repeatability was better for TEG 6s versus TEG 5000, particularly for CFF.MA and CK.LY30. CONCLUSION: The TEG 6s device appears to be highly reliable for use in trauma patients, with close correlation to the TEG 5000 device and equivalent/improved within-device reliability. Given the potential advantages of using the TEG 6s device at the site of care, confirmation of agreement between the devices represents an important advance in diagnostic testing. LEVEL OF EVIDENCE: Diagnostic test, level II.

Alcohol is a predictor of mortality in motor vehicle collisions.

INTRODUCTION: It is well recognized that driving while intoxicated increases the probability of a motor-vehicle collision (MVC). The effect of alcohol on the chance of surviving the MVC is less clear. METHOD: Using data from the Fatality Analysis Reporting System (FARS) we conducted analyses for the outcome of mortality using alcohol and other variables as predictors. We also selected alcohol positive (AP) and alcohol negative (AN) persons from the same MVC and vehicle to control for confounding characteristics. RESULTS: The odds ratio (OR) for mortality for alcohol positive drivers was 2.57, (p < 0.001 for all the following OR). Other harmful predictive factors were age OR 1.01 per year, vehicle age OR 1.05 per year, male sex OR 1.23, avoidance maneuver OR 1.09, speed related OR 2.89, rollover mechanism OR 2.75, and collision with a fixed object OR 6.70. Protective factors were proper restraint use - OR 0.19 and collision with another moving vehicle, OR 0.21. In the multivariate analysis the OR of mortality for AP vs AN was 1.46. Proper restraint use (OR 0.27) remained protective along with collision with another moving vehicle. When AP and AN persons from the same MVC and the same vehicle were compared, the adjusted OR's for mortality were 1.46 and 2.08, respectively. CONCLUSIONS: Alcohol is an independent predictor of mortality in an MVC. Proper restraint use is the strongest protective factor. This finding allows a more complete understanding of the risks of driving while intoxicated, not only a higher probability of an MVC, but decreased survival once the MVC occurs. Practical Applications: Identification of alcohol as an independent predictor of mortality in an accident may improve risk assessment and influence drivers to avoid driving while intoxicated.

Labral Ossification and Sacroiliac Joint Disease: Could There Be a Link to an Autoimmune Etiology?

PURPOSE: To determine the prevalence of ipsilateral sacroiliac (SI) joint disease among patients with symptomatic femoroacetabular impingement (FAI) associated with labral ossification (LO) who underwent hip arthroscopy compared with a matched control group of patients with symptomatic FAI and no LO. METHODS: Computed tomography (CT) scans of all patients undergoing arthroscopic correction of FAI were obtained. The inclusion criterion for the study group was a diagnosis of FAI with a secondary diagnosis of LO made by plain radiography, CT, or magnetic resonance imaging or made intraoperatively. The exclusion criterion was the absence of evidence of LO. We reviewed 52 patients (56 hips) with LO to assess the SI joint and compared them with a control group matched by age, sex, and FAI type. The SI joints were graded according to the modified New York criteria. RESULTS: CT scans were available for evaluation of the ipsilateral SI joint in 28 patients (29 hips) with LO: 17 women and 11 men with an average age of 44.6 years (range, 26-56 years). Of the hips, 23 had combined FAI and 6 had pincer-type FAI. The control group consisted of 29 hips, exactly matched for sex and FAI type, with an average age of 44.8 years (range, 21-58 years). Grade 3 SI joint abnormalities were significantly more prevalent in the LO group (28%) than in the control group (7%, P = .037), and grade 0 or 1 changes (relatively normal SI joints) were significantly less common in patients with LO (38%) than in controls (72%, P = .008). Subanalysis showed that 35% of the LO group aged 45 years or younger had ipsilateral grade 3 SI joint abnormalities compared with none of the control patients aged 45 years or younger (P = .041). Grade 3 changes were found in 42% of male patients with LO compared with 8% of male controls (P = .155). Grade 3 changes were noted in 18% of women in the LO group compared with 6% of female controls (P = .601). CONCLUSIONS: Patients with symptomatic FAI and LO are more likely to show associated SI joint pathology than patients with FAI not involving LO. These differences are greatest among men and among patients aged 45 years or younger. LEVEL OF EVIDENCE: Level III, retrospective case-control study.

Nonoperative Management of Blunt Splenic Trauma: Outcomes of Gelfoam Embolization of the Splenic Artery.

CONTEXT: Nonoperative management (NOM) is the standard of care in hemodynamically stable trauma patients with blunt splenic injury. Gelfoam splenic artery embolization (SAE) is a treatment option used in trauma patients. AIMS: The primary aim of this study was to retrospectively examine the use and outcomes of Gelfoam SAE in adult patients with blunt splenic injury. SETTINGS AND DESIGN: One hundred and thirty-two adult patients with blunt splenic injury admitted to a Level 1 trauma center between January 2014 and December 2015 were included in the study. Patients treated with Gelfoam SAE, NOM, and splenectomies were reviewed. Descriptive statistics including patient age, Glasgow Coma Scale, Injury Severity Score (ISS), hospital days, Intensive Care Unit (ICU) days, splenic grade, and amount of blood products administered were recorded. Complications, defined as any additional factors that contributed to the patient's overall length of hospital stay, were compared between the three groups. Technical aspects of Gelfoam SAE and associated complications were reviewed. SUBJECTS AND METHODS: Gelfoam SAE was performed in 25 (18.9%) of the 132 patients. Gelfoam SAE patients had fewer ICU days compared with those patients who had a splenectomy or NOM. There was no statistical difference in complications between patients who underwent Gelfoam SAE and those who did not. Patients who underwent Gelfoam SAE tended to have fewer complications including deep venous thrombosis's, PE, and infections and yielded no complications in 64% of the Gelfoam group. STATISTICAL ANALYSIS: Statistical analysis included descriptives, ANOVA, and nonparametric tests as appropriate. CONCLUSION: Gelfoam SAE can be used for blunt splenic injury for intermediate ISS and splenic grade as it reduced hospital and ICU days.

Outcomes of renal salvage for penetrating renal trauma: a single institution experience.

INTRODUCTION: Conservative management of penetrating renal trauma is emerging, with data originating from centers with variable level of trauma care. This study reviews the outcomes of renal salvage after penetrating trauma at a level I trauma center. MATERIALS AND METHODS: An institutional review board approved trauma registry at Saint Louis University Hospital was retrospectively analyzed, for patients with penetrating renal trauma from 2009 to 2014. Patients were divided into nephrectomy group (NG) or non-nephrectomy group (non-NG), and compared. A multi-variable analysis was performed to determine predictors of nephrectomy, with cross validation to evaluate the performance of the multi-variable model. Data was analyzed using R version 3.3.2. A p value of < 0.05 was considered as significant. RESULTS: A total of 121 patients were identified with penetrating renal trauma. Gunshot injury was the leading cause of injury (87%). Eighteen (15%) patients required nephrectomy. The overall mean injury severity score (ISS). was 20. High grade (grade 4-5) renal injuries were noted in 41 patients (34%). Among these, 14 patients (34%) underwent a nephrectomy, while 27 patients (66%) were managed conservatively to salvage renal units. CT grade of renal injury was the only predictor of nephrectomy, on multi-variable analysis (OR 17.09 CI 2.75-105.99, p = 0.002). CT grade of injury and injury severity score were predictors of endoscopic intervention on a sub group analysis of non-NG. CONCLUSIONS: CT grade of injury predicts nephrectomy after penetrating renal trauma. Conservative management is a feasible option in penetrating renal trauma even with a higher grade of injury.

Surgical Outcome of Pincer Femoroacetabular Impingement With and Without Labral Ossification.

PURPOSE: To describe the clinical findings associated with labral ossification (LO), report the outcomes of arthroscopic treatment, and compare this condition to a control group with femoroacetabular impingement (FAI). METHODS: A retrospective review of hip arthroscopy patients from 2004 to 2013 was performed to identify patients with a diagnosis of pincer FAI with LO and at least 2 years of follow-up. Diagnosis was made by plain radiograph, computed tomography, magnetic resonance imaging, or intraoperatively. The LO cohort was compared to a chronologically matched control group of FAI patients with pincer FAI but no LO. Patients were prospectively assessed with modified Harris Hip Score (mHHS) preoperatively and then postoperatively at 3, 12, 24, 60, and 120 months. RESULTS: The LO group included 56 hips in 52 patients whereas the control group included 56 hips in 56 patients. Mean follow-up was 36 months for the LO group and 38 for the control group (P = .28). Patients in the LO group were older than those in the control group, with a mean age of 45 versus 30 years (P < .0001), and had more women: 58% female versus 32% male (P < .0001). The LO group patients were more likely to have pain while sitting (65% v 18%) and restricted activities of daily living (40% v 11%) than the control group (P < .0001), and more likely to have pain during a flexion, abduction, external rotation (FABER) test (67% v 36%) (P = .002). Both groups experienced a similar magnitude of improvement in mHHS, but the LO group had a significantly lower preoperative mHHS (49 v 63, P < .001) and final postoperative mHHS (75 v 87, P < .0001) than the control group. CONCLUSIONS: Patients with LO represent a unique subset of pincer FAI and are more likely to be older, female, and have more severe symptoms. Hip arthroscopy can be used to treat LO with excision of the ossified fragments or rim, with a reasonable expectation of improvement of symptoms. LEVEL OF EVIDENCE: III, retrospective case-control.

Hip preservation surgery: surgical care for femoroacetabular impingement and the possibility of preventing hip osteoarthritis.

Despite its widespread usage, the hip preservation surgery can be most accurately described as a hypothesis that surgery can preserve a hip and prevent the need for arthroplasty. This premise has not been fully investigated to date, and there exist few summaries of the underlying evidence in regard to the basis of this terminology. This study seeks to define the hip preservation surgery, and then examines this premise critically in the context of treatment for its most commonly treated condition-femoroacetabular impingement. Finally, we report the current level of preservation of the hip that can be expected with current techniques.

Hip arthroscopy for Legg-Calvè-Perthes disease: minimum 2-year follow-up.

PURPOSE: The purpose of this study is to report the results of arthroscopy for the treatment of adolescents and adults with hip pain cause by sequelae of Legg-Calvè-Perthes disease. METHODS: All patients undergoing hip arthroscopy were prospectively assessed with the modified Harris Hip Score at 3, 6, 12, 24, 60, 120, and 180 months. We identified a cohort of 22 consecutive patients (23 hips) with Legg-Calvè-Perthes disease who had undergone arthroscopy with at least 2-year follow-up; this cohort represents the substance of this report. RESULTS: There was 100% follow-up at 24 months (range, 24 to 180 months). The median age was 27 years (range, 7 to 58 years) with 14 male and 8 female patients. Findings during arthroscopy included 18 labral tears, 17 hypertrophic or torn ligamentum teres, 9 femoral and 8 acetabular chondral lesions, 5 loose bodies, 3 osteochondral defects, and 2 cam lesions. The mean improvement at 24 months was 28 points (56.7 preoperatively and 82 postoperatively). All patients were improved, although this improvement was negligible in 2 patients who underwent repeat arthroscopy. There were no complications. CONCLUSIONS: This series reports the results of arthroscopy for Legg-Calvè-Perthes disease and reflects that it does have a role in the management of painful sequelae. Successful outcomes can often be expected with minimal morbidity. Reduced symptoms and improved quality of life are reasonable expectations, although these data do not suggest that hip arthroscopy alters the natural history of the disease process. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Nonoperative treatment of distal biceps tendon ruptures compared with a historical control group.

BACKGROUND: Few data are available regarding the results of nonoperative treatment of distal biceps ruptures. The present study was designed to assess the outcomes associated with unrepaired distal biceps tendon ruptures. METHODS: Eighteen patients with twenty unrepaired distal biceps tendon ruptures were assessed retrospectively. The median duration of follow-up was thirty-eight months. Sixteen of the eighteen patients were male, and the median age at the time of the injury was fifty years (range, thirty-five to seventy-four years). Supination strength and elbow flexion strength were measured bilaterally, and patient outcomes were assessed with use of the Broberg and Morrey Functional Rating Index, the Mayo Elbow Performance Index, and the Disabilities of the Arm, Shoulder and Hand questionnaire. Data were compared with historical controls compiled from six published series of operatively treated patients. RESULTS: The median supination and elbow flexion strengths for the injured arm were 63% (mean, 74%; range, 33% to 162%) and 93% (mean, 88%; range, 58% to 110%) of those for the contralateral arm, compared with values of 92% (mean, 101%; range, 42% to 297%) and 95% (mean, 97%; range, 53% to 191%) for the historical controls that had been treated surgically. The difference between the mean values was significant for supination strength (p = 0.002) but not for flexion strength (p = 0.164). Patients had satisfactory outcomes overall, with median scores on the Broberg and Morrey Functional Rating Index, the Mayo Elbow Performance Index, and the Disabilities of the Arm, Shoulder and Hand questionnaire of 85, 95, and 9, respectively. CONCLUSIONS: Nonoperative treatment of distal biceps tendon ruptures can yield acceptable outcomes with modestly reduced strength, especially supination.