Midterm Outcomes of Operatively and Nonoperatively Managed Achilles Tendon Ruptures in Young Adults.

Background: There continues to be controversy regarding treatment options for Achilles tendon ruptures (ATR). The aim of our study is to compare outcomes between operatively and nonoperatively managed Achilles ruptures in young adults (age 18-30 years), which has not been previously evaluated. Methods: At a single institution, all patients aged 18-30 years at time of injury who underwent treatment for an acute ATR from 2014 to 2021 were evaluated. Medical records were reviewed to collect demographics, dates of injury and treatment, smoking status, body mass index (BMI), Charlson Comorbidity Index (CCI), rate of deep venous thrombosis (DVT) after treatment, and rate of rerupture. Patients then completed Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) questionnaires. Mann-Whitney nonparametric testing was used to evaluate for any statistical differences in PROMIS scores. Results: Sixty-six operative patients qualified and 28 (42%) participated. Thirty-seven nonoperative patients qualified and 14 (38%) participated. All patients had a CCI of 0. One patient in the operative cohort and 2 in the nonoperative reported active smoking. In the operative and nonoperative cohorts, respectively, the average age was 24.4 and 27.8 years; average BMI 26.5 (SD = 4.8) and 27.3 (SD = 4.3, P = .52); DVT rates 4 (6.1%) and 2 (5.4%); and rerupture rates 2 (3.0%) and 1 (2.7%), respectively. PROMIS scores did not differ in the operative and nonoperative groups: PROMIS PF mean of 60.4 (SD = 9.8) and 62.9 (SD = 9.1), respectively (P = .33); as well as PROMIS PI mean of 44.6 (SD = 5.9) and 43.9 (SD = 6.5), respectively (P = .59). Conclusion: This study should be interpreted with the understanding that we had a considerable loss to follow-up rate. In the study cohort, we found that young adults with ATR may be considered for either operative or nonoperative management. Rates of DVT, rates of rerupture, and PROMIS scores were not dissimilar between the 2 cohorts. Level of Evidence: Level III, retrospective cohort study.

Lateral Talar Subluxation Measurements in Nonoperatively Managed Weber B Ankle Fractures.

Background: Lateral talar subluxation (LTS) was introduced as a measurement tool for evaluating isolated Weber B ankle fractures, with LTS >4 mm on gravity stress (GS) radiographs possibly indicating need for surgery. This study reviews LTS measurements in nonoperatively managed isolated Weber B fibula fractures to further investigate the validity of this previously stated cutoff. Methods: The senior authors previously reported outcomes of a novel algorithm for nonoperative management of isolated Weber B ankle fractures. Outcome scores reported include American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot, Olerud-Molander (OMA), Foot and Ankle Ability Measure for activities of daily living (FAAM/ADL), and visual analog scale (VAS) scores. All patients achieved union of their fracture. LTS was measured on GS radiographs of both injured and contralateral uninjured extremities. Results: Forty-two patients were included with minimum 1-year follow-up. Average age was 49 years (range 19-72). Mean measurements on injury GS radiographs were as follows: medial clear space (MCS) 4.45 mm (SD = 0.93), superior clear space (SCS) 3.46 mm (SD = 0.70), and LTS 2.33 mm (SD = 1.57, range 0-4.7 mm), with 35 (83.3%) patients having injury LTS ≤4 mm. Mean measurements on contralateral (uninjured) GS radiographs were as follows: MCS 3.39 mm (SD = 0.63), SCS 3.15 mm (SD = 0.50), and LTS 1.30 mm (SD = 1.28, range 0-4.8 mm). There was no statistically significant difference in all outcome measures based on amount of LTS (<2 mm, 2-4 mm, >4 mm). Conclusion: Most patients had injury LTS ≤4 mm, although those with LTS >4 mm had excellent outcome scores. LTS measurements on normal ankles reveal a large range. LTS may be a useful adjunct in evaluating isolated Weber B ankle fractures but the 4-mm cutoff may not be entirely reliable. Further studies are required to validate LTS as a decision-making tool. Level of Evidence: Level IV, case series.

Civilian Gun Shot Wounds Associated With Spinal Injuries.

STUDY DESIGN: Retrospective. OBJECTIVE: To evaluate functional outcomes and characteristics associated with gunshot wound (GSW) to the spine. METHODS: Patients with GSW to the spine managed at a Level 1 Trauma Center from January 2003 to December 2017 were enrolled. Patient demographics, diagnoses, level of injury, American Spinal Injury Association (ASIA) score, ambulatory status at follow-up, bowel and bladder function, clinical improvement, and mortality were evaluated. Clinical improvement was defined as a progression in ambulatory status category at latest follow up. RESULTS: 51 patients with GSW of the spine were identified. 48 (94.1%) were male and 3 (5.9%) were female, with a mean age of 27 years-old (range 15-56). 38 (74.5%) were Caucasian, 7 (13.7%) were African American, 1 (2.0%) Asian-American, and 5 (9.8%) were Other/Unknown. 46 (90.2%) patients had GSW related spinal fractures and 44 (86.3%) had neurological deficits. Among patients with neurologic deficits, 5 (9.8%) had Cauda Equina Syndrome, 1 (2%) had Brown-Sequard Syndrome, and 38 (74.5%) spinal cord injuries: ASIA A 26 (68.4%); ASIA B 3 (7.9%); ASIA C 7 (18.4%); ASIA D 2 (5.3%). At mean follow-up time of 4.2 years (SD 3.9), 27 (52.9%) patients were wheelchair bound, 11 (21.6%) were ambulating with assistance, and 13 (25.5%) had normal ambulation. ASIA grade (A or B) was significantly, P < 0.00001, associated with being wheelchair bound and having neurogenic bowel or bladder at follow-up. CONCLUSIONS: Most spinal GSW patients (70.6%) did not have any clinical improvement in ambulatory status and most injuries were ASIA A.

Etiology and Outcomes of Spinal Cord Infarct: A Case Series From a Level 1 Trauma Center.

STUDY DESIGN: Retrospective study. OBJECTIVES: To evaluate the demographics, prevalence, etiology, severity, and outcomes of spinal cord injuries (SCIs) resulting from ischemic infarction. METHODS: All patients with SCI and a diagnosis of cord infarct who were admitted to the inpatient rehabilitation unit at a level 1 trauma center from January 2003 to January 2014 were identified using an administrative billing database. Outcomes measures were evaluated. RESULTS: Among 685 unique SCI patients who were identified, 30 (4.4%) had SCI due to spinal ischemic infarction. The mean age was 59 years (range 17-80 years). Fifty percent of patients had ASIA (American Spinal Injury Association) A and B severity. Most common causes were the following: 6 (20%) abdominal aortic aneurysm (AAA) repairs, 6 (20%) arteriovenous fistulas, and 6 (20%) with an unknown cause. Surgical complications led to 4 (13.3%) cord infarcts and was associated with a higher severity of injury (P = .02) compared with other etiologies. Other causes included systemic hypotension, AAA rupture, trauma, diabetic ketoacidosis, and after radiation therapy. At follow-up, 6 (20%) of patients were able to ambulate normally without assistance, 7 (23.3%) were ambulating with assistance, and 17 (56.7%) were still wheelchair bound. Clinical improvement in ambulatory status was noted in 6 (20%) patients and was associated with less severe initial injury (P = .02). CONCLUSIONS: While the existing literature associates spinal cord infarction with aortic pathologies and surgery, these caused less than 30% of cases, while nonaortic surgical complications were associated with the most severe injuries. Outcomes were worse than previously reported in the literature.

Surgical Management of the Lumbar Spine in Rheumatoid Arthritis.

STUDY DESIGN: Narrative review. OBJECTIVE: To provide an overview on the diagnosis and surgical management of rheumatoid involvement of the lumbar spine. Rheumatoid arthritis (RA) is a chronic inflammatory disease of synovial joints, most commonly appendicular followed by axial. Although cervical spine involvement of RA is well documented, data on lumbar spine involvement and surgical management remains limited. METHODS: Using PubMed, studies published prior to November 2018 with the keywords "RA, etiology"; "RA, spine management"; "RA, surgical management"; "RA, treatment"; "RA, DMARDs"; "RA, lumbar spine"; "RA, spine surgical outcomes"; "RA, imaging" were evaluated. RESULTS: The narrative review addresses the epidemiology, manifestations, imaging, surgical complications, and operative and nonoperative management of RA involvement of the lumbar spine. CONCLUSIONS: Rheumatoid involvement of the lumbar spine can present with lower back pain, neurogenic claudication, radiculopathy, spinal deformity, and instability. Patients with RA have significantly higher rates of vertebral fractures and complications following surgical intervention. However, in the setting of instability and spinal deformity, thoughtful surgical planning in conjunction with optimal medical management is recommended.

Traumatic spinal cord injuries in geriatric population: etiology, management, and complications.

BACKGROUND: The relationship of traumatic spinal cord injury (SCI) and the geriatric population is not emphasized in current literature. Our objective was to evaluate mechanisms of injury, outcomes, and complications of geriatric patients with traumatic SCI. METHODS: Patients with traumatic spinal cord injuries admitted to the inpatient rehabilitation unit of a level I trauma center from 2003 to 2013 were reviewed. Inclusion criteria were ages ≥65 years old and availability of complete medical records. Patient demographics, mechanism of injury, diagnoses, American Spinal Injury Association (ASIA) grade, management (surgical, nonsurgical), complications, and mortality were evaluated. RESULTS: Seven hundred and fifty-seven SCI patients were identified and 53 met our inclusion criteria, with 35 (66.0%) males and 18 (34.0%) females. The average age was 74-years (range, 65 to 91 years). A proportion of 24.5% were 65-69 years of age, 30.2% were 70-74, 22.6% were 75-79, and 22.6% were 80 or older. Thirty-four (64.2%) underwent surgery. The two most common diagnoses of SCI were fractures (43.4%) and central cord syndrome (28.3%). ASIA grading was: A 5 (9.4%); B 3 (5.7%); C 5 (9.4%); D 40 (75.5%). The most severe SCI (ASIA score A and B) primarily occurred in the younger geriatric populations (ages 65-74), as did the highest rates of major complications or major and minor complications (15.4% and 46.2%, respectively, in the 65-69 group). Surgical management increased with age from 46.2% in the 65-69 group to 83.3% in the 75-79 group but subsequently decreased in the ≥80 group (66.7%). CONCLUSIONS: Fractures and central cord syndrome were the most common diagnoses and typically due to falls. The complication rate in this population is high and due to complex causes. SCI in patients aged 65-69 was associated with increased rate of ASIA score A and increased rate of major complications.

Spinal Cord Injury From Spinal Tumors: Prevalence, Management, and Outcomes.

BACKGROUND: With the aging population in the United States, it can be anticipated that the prevalence of spinal cord injuries (SCIs) and cancer will increase. Primary or metastatic spine tumors sit at a unique intersection of these 2 realms. Our objective was to evaluate the prevalence, outcomes, and complications after the management of SCI arising from spinal tumors. METHODS: In the present retrospective evaluation, all patients with SCI and a diagnosis of primary or metastatic spinal cancer who had been admitted to the inpatient rehabilitation unit at a level 1 trauma center from January 2003 to January 2014 were evaluated. The demographic data (age, sex, race/ethnicity), tumor characteristics, American Spinal Injury Association score, and complications were evaluated. RESULTS: A total of 757 SCI entries were identified, and 685 unique patients met our inclusion criteria. Of those, 81 had SCIs due to spinal tumors (11.8% of all SCIs and 19.2% of nontraumatic SCIs). Most tumors were located in the thoracic region (65.4%) and were primary central nervous system in origin (21.0%), including meningioma (7.4%), schwannoma (3.7%), and ependymoma (2.5%). The next most common origins of the spinal tumors were metastases from the lung (17.3%), prostate (9.9%), kidney (8.6%), lymphoma (7.4%), and multiple myeloma (7.4%). Of these patients, 76.5% underwent surgical management, with a complications rate of 61.3%. The overall mortality rate at the latest follow-up examination was 63.0%. CONCLUSIONS: SCI associated with spinal tumor is often managed surgically and associated with high rates of complications. The present study has demonstrated longer survival rates compared with the existing data.

Traumatic and Nontraumatic Spinal Cord Injuries.

OBJECTIVE: Owing to the aging of the population in the United States, it is anticipated that injury mechanisms, treatment, and outcomes of spinal cord injuries (SCI) will change. There is a scarcity of literature on nontraumatic SCI. Our goal in this study was to evaluate the causes, management, complications, and outcomes after SCI. METHODS: In a retrospective review, patients with traumatic and nontraumatic SCI admitted to the inpatient rehabilitation unit at a level 1 trauma center from 2003 to 2013 were reviewed. RESULTS: In all, 757 entries were identified, and 685 unique patients met our inclusion criteria; 17.4% were <35 years of age, 51.7% were 35 to 64 years of age, and 30.9% were at least 65 years old. The young adults had the highest proportion of fractures (60.5%) and subluxations (21.8%), whereas the oldest group had the highest rates of stenosis (35.4%), spondylotic myelopathy (16.5%), and cancer (15.1%). In SCI patients <35 years of age, 66.6% of injuries were caused by traumatic mechanisms of injury compared with 30.2% in the geriatric cohort. In the total of all SCI, 61.6% were nontraumatic. Surgical management was more prevalent with increasing age (58.8%, 73.7%, 82.1% from youngest to oldest group), as were overall rates of complications (58.6%, 59.4%, 66.7%). Mortality rates significantly increased with age (2.5%, 18.9%, 40.6% overall mortality rates in the 3 age groups). The overall mortality rate in nontraumatic SCI patients was 27.7% compared with 14.8% in traumatic SCI patients. CONCLUSIONS: Falls caused significantly more SCIs than expected, but most SCIs were predominantly nontraumatic in cause. The epidemiology of SCI is shifting rapidly.