Plate osteosynthesis of midshaft clavicle fractures in adolescent contact sports athletes - adolescent clavicle fracture.

Surgical treatment of mid-shaft clavicle fractures via anatomical plates in adult athletes is documented to be safe and effective. Functional and cosmetic outcomes in adolescent contact sports athletes have not been well documented. Adolescent athletes (age 11-19) surgically treated for mid-shaft clavicle fractures between 1 May 2011 and 30 October 2017 were included in this study. Twenty-one adolescent athletes with a mean follow-up of 44 months were reviewed. Retrospective chart reviews were performed. Functional and cosmetic outcomes, return to sports time/rate were analyzed using Nottingham Clavicle Scores and a 'Custom Questionnaire'. Return of function and healing, evidenced on radiographs, was achieved in all 21 patients. All patients returned back to competitive sports. The mean time to return back to training was 45.9 ± 16 (24-76) days. Sixteen (76.1%) of the patients reported Nottingham Clavicle Scores with a mean score of 91.7 (85-98). In the Custom Questionnaire, 16 patients who participated in the phone interview were satisfied with the cosmetic outcomes. The most common complaint was implant prominence and irritation in 6 (40%) patients, subsequently requiring implant removal in 3 (18.8%). Surgical fixation of mid-shaft clavicle fractures can lead to excellent union and cosmetic outcomes and a rapid return to sports in adolescent contact sport athletes. However, one should consider the outcomes of implant-related complaints and the possibility of implant removal surgery in the future.

Treatment Modality of Distal Ulnar Head and Neck Fractures Associated With Operatively Treated Distal Radius Fractures Does Not Affect Outcomes.

Background: This study compares the functional outcomes and complications between operatively and nonoperatively treated distal ulnar head and neck fractures associated with internal fixation of concomitant distal radius fractures. Methods: A 7-year retrospective chart review was performed to identify patients with operatively treated distal radius fractures associated with distal ulnar head and neck fractures. Ulnar styloid fractures were excluded. Fifty-eight patients who had a minimum of 6 months of follow-up were identified. Patients were divided into 3 treatment groups: nonoperative, open reduction internal fixation (ORIF), and distal ulna resection. Reviewed data included demographics, injury and treatment details, complications, and patient-reported outcome measures. Outcomes measures included Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity and Patient-Rated Wrist Evaluation (PRWE) surveys. Due to inadequate power, 5 patients treated with distal ulna resection were excluded from statistical analysis. Results: The average patient age was 56 years, with an average follow-up of 27 months. All patients underwent ORIF of the distal radius fracture. Distal ulna fractures were treated nonoperatively in 25 patients, with ORIF in 28 patients, and with distal ulna resection in 5 patients. There were no statistically significant differences in wrist or forearm range of motion, complication rates, secondary procedure rates, PRWE scores, or PROMIS scores between ORIF and nonoperative treatment. Conclusion: No differences in wrist or forearm range of motion, complication rates, secondary procedure rates, PRWE scores, or PROMIS scores were observed between ORIF and nonoperative treatment of distal ulnar head and neck fractures associated with operatively treated distal radius fractures.

Opioid Requirement following Arthroscopic Knee Surgery: Are There Predictive Factors Associated with Long-Term Use.

The purpose of this study is to identify patterns of postoperative narcotic use and determine the impact of psychosocial and perioperative factors on postoperative opioid consumption following arthroscopic knee surgery. Fifty consecutive patients undergoing arthroscopic knee surgery were prospectively enrolled. Patients were contacted via telephone at 1 week postoperatively to report their pain level and opioid consumption. The patient was contacted again at 2 weeks, 4 weeks, and 90 days as necessary until opioid cessation, at which time the patient's plan for unused pills was inquired. Opioid consumption was compared using t-tests and one-way analysis of variance for demographic and surgical factors. Linear regression was used to determine whether the Pain Catastrophizing Scale (PCS), Resilience Scale (RS-11), International Knee Documentation Committee questionnaire, or patient-reported pain at 1 week predicted higher opioid consumption. The average morphine equivalent dose of opioid consumption was 142 mg. Sixty-four percent consumed less than 100 mg, and 68% discontinued opioid use by 1 week postoperatively. Seventy-four percent reported surplus pills, and 49% of those patients plans for pill disposal. Factors associated with higher consumption included undergoing a major procedure, having a regional anesthesia block, and higher area deprivation index score (p < 0.05). Higher PCS scores and reported average pain level at 1 week were predictive of higher opioid consumption (p < 0.05). In conclusion, a majority of patients undergoing outpatient knee surgery did not require the entirety of their narcotic prescription. The majority of patients consumed less than 100 mg of morphine equivalents and discontinued opioid use by 1 week postoperatively. Ligament reconstruction, living in an area with a higher index of deprivation, and higher score on the PCS were associated with greater opioid consumption. Overall, patient knowledge regarding opioid disposal was poor, and patients would likely benefit from additional education prior to surgery.

Wait Times in Musculoskeletal Patients: What Contributes to Patient Satisfaction.

INTRODUCTION: The purpose of this study was to determine how wait time duration is associated with patient satisfaction and how appointment characteristics relate to wait time duration and patient satisfaction in the orthopedic surgery clinic. METHODS: Two hundred sixty-four patients visiting one of 3 ambulatory orthopedic surgery clinics were asked to estimate their wait time and to rate their satisfaction with the visit. The associations between appointment characteristics, wait time, and satisfaction were analyzed using t tests, 1-way analysis of variance, and Pearson correlation coefficients. RESULTS: Wait times were significantly different based on visit type, appointment time, whether an X-ray was required, and whether a trainee was involved (P < .001). Patients with wait times less than 30 minutes had higher satisfaction scores (P < .001). Satisfaction ratings were significantly different based on the surgeon's management recommendation (P = .0211), but were not significantly different based on sex, age, office location, visit type, appointment time subsection, or time spent with the physician (P > .05). CONCLUSION: Wait times negatively correlated with satisfaction. New patient visits, appointment times in the later third of the day, appointments requiring an X-ray, and appointments involving a trainee had significantly longer wait times. Care should be taken to inform patients with visits involving these characteristics that they may experience longer than average wait times.

Return to Sport and Sports-Specific Outcomes Following Ulnar Collateral Ligament Reconstruction in Adolescent Athletes: A Systematic Review.

BACKGROUND: The incidence of elbow injuries and ulnar collateral ligament (UCL) reconstruction in adolescent athletes is increasing. Knowledge and expectations of outcomes following this procedure are necessary for proper counseling and decision-making in this age group. QUESTIONS/PURPOSES: We sought to report patient-reported outcomes, rate of return to sport, and rate of complications and reoperation following UCL reconstruction in adolescent athletes. METHODS: A systematic review was conducted for adolescent athletes undergoing UCL reconstruction. The primary outcome measure was patient-reported outcome scores, specifically the Conway Scale, the Andrews-Timmerman score, and the Kerlan-Jobe Orthopaedic Clinic (KJOC) score. Secondary outcome measures included return to sport, rate of subsequent procedures, and complication rate. A descriptive analysis was performed. RESULTS: Seven studies met the inclusion criteria. The average patient-reported outcome scores ranged from 81 to 87% (Conway, "excellent"), 83.6 to 92.7 (Andrews-Timmerman), and 76 to 89.3 (KJOC). The average rates of return to sport were 84% to preinjury level or higher, 93% to any level, and 57% to a higher level. Complication rates ranged from 0.7 to 11%. Rate of subsequent elbow procedures ranged from 0 to 10%. CONCLUSIONS: This systematic review demonstrates favorable outcomes in adolescent athletes following UCL reconstruction. Patient-reported outcome scores and rates of return to sport were comparable with those reported in adult athletes. The procedure is not without risk of complications, and patients and parents should be counseled regarding this risk prior to surgery.

Time to Surgery and Patient Mortality in Geriatric Acetabular Fractures.

OBJECTIVES: To determine whether surgical intervention within 48 hours of injury results in decreased mortality in geriatric patients who have sustained acetabular fractures. DESIGN: Retrospective case series. SETTING: University Level 1 Trauma Center. PATIENTS/PARTICIPANTS: One hundred eighty-three patients 65 years of age and older who were operatively treated for acetabular fractures between 2002 and 2017. The average age was 76 years. INTERVENTION: Operative fixation of acetabular fracture. MAIN OUTCOME MEASUREMENTS: Chi square tests were used to compare 30-day, 6-month, and 1-year mortality after operative intervention between patients treated within 48 hours and after 48 hours. A Cox proportional hazard model was used to determine predictors of mortality. RESULTS: The overall 1-year morality was 15%. When patients were grouped by time to surgery (fracture fixation within 48 hours or after 48 hours), there were no statistically significant differences in 30-day, 6-month, or 1-year mortality between groups. In addition, there were no statistically significant differences in age, sex, mechanism of injury, fracture pattern, Charlson comorbidity index, length of hospital stay, presence of deep vein thrombosis, or quality of reduction. In the final multivariate Cox regression model of survival, increasing age was associated with a significantly increased hazard of death with a hazard ratio (HR) of 1.09 (95% confidence interval, 1.05-1.13) per year of age (P < 0.001). Patient sex, mechanism of injury, fracture pattern, estimated blood loss, and Charlson comorbidity index were not significant predictors of mortality. CONCLUSION: In contrast to the clear mortality benefits of early surgical intervention in geriatric patients with proximal femur fractures, the results of our study suggest that surgical intervention after 48 hours of injury is not associated with increased mortality rates in geriatric patients with acetabular fractures. Increased mortality was independently associated with advancing age. Sex, mechanism of injury, and facture pattern were not associated with mortality. Time to surgery in geriatric patients with acetabular fractures should be determined on an individual basis. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Narcotic Use and Resiliency Scores Do Not Predict Changes in Sleep Quality 6 Months After Arthroscopic Rotator Cuff Repair.

BACKGROUND: Patients with rotator cuff disease commonly complain of difficulty sleeping. Arthroscopic repair has been associated with improved sleep quality in many patients with rotator cuff tears; however, some individuals continue to suffer from sleep disturbance postoperatively. PURPOSE: To determine whether changes in sleep quality following rotator cuff repair are predicted by a patient's narcotic use or ability to cope with stress (resilience). STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 48 patients undergoing arthroscopic rotator cuff repair were prospectively enrolled and completed the Connor-Davidson Resilience Scale (CD-RISC) preoperatively. The Pittsburgh Sleep Quality Index (PSQI) was administered preoperatively and at multiple intervals postoperatively for 6 months. Narcotic utilization was determined via a legal prescriber database. Pre- and postoperative sleep scores were compared using paired t tests and the McNemar test. Linear regression was used to determine whether narcotic use or CD-RISC score predicted changes in sleep quality. RESULTS: An increased number of patients experienced good sleep at 6 months postoperatively (P < .01). Mean ± SD nocturnal pain frequency improved from 2.5 ± 1.0 at baseline to 0.9 ± 1.1 at 6 months. CD-RISC score had a positive predictive value on changes in PSQI score (R 2 = 0.09, P = .028) and nocturnal pain frequency (R 2 = 0.08, P = .041) at 2 weeks. Narcotic use did not significantly predict changes in PSQI score or nocturnal pain frequency (P > .05). CONCLUSION: Most patients with rotator cuff disease will experience improvement in sleep quality following arthroscopic repair. Patients demonstrated notable improvements in nocturnal pain frequency as soon as 6 weeks following surgery. CD-RISC resiliency scores had a significant positive predictive value on changes in sleep quality and nocturnal pain frequency at 2 weeks. Narcotic use was not associated with change in sleep quality.

Return to Sport Following Revision Anterior Cruciate Ligament Reconstruction in Athletes: A Systematic Review.

PURPOSE: To report the rate of return to sport following revision anterior cruciate ligament (ACL) reconstruction in athletes. METHODS: A systematic review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted for athletes undergoing revision ACL reconstruction at a minimum 1-year follow-up. The primary outcome measure was return to sport following revision ACL reconstruction. Secondary outcomes were International Knee Documentation Committee score, Knee Injury and Osteoarthritis Outcome Score, Tegner and Lysholm scores, KT-1000 arthrometer measurements, and rates of ACL rerupture. A subjective analysis was performed, and data were summarized using forest plots, ranges, and tables. RESULTS: Thirteen studies met the inclusion criteria. The rate of return to sport at any level ranged from 56% to 100%. The rate of return to sport at preinjury level ranged from 13% to 69%. The average time to return to sport ranged from 6.7 to 12 months. The average patient-reported outcome scores ranged from 43% to 86% (International Knee Documentation Committee score), 45% to 95% (Knee Injury and Osteoarthritis Outcome Score), 4.3 to 9 (Tegner), and 84% to 91% (Lysholm). KT-1000 arthrometer measurements ranged from 1.2 to 3.1 mm. Rates of ACL rerupture ranged from 0% to 20%. CONCLUSIONS: This systematic review demonstrated a relatively high rate of return to sport at any level in patients who underwent revision ACL reconstruction, but a relatively low rate of return to sport at preinjury level of play. Patient-reported outcomes were favorable, showing improvement at follow-up from preoperative scores. Rates of ACL rerupture were high relative to those reported for primary ACL reconstruction. This study suggests that athletes may have difficulty resuming their previous level of sport following revision ACL reconstruction but have a good chance of returning to a lower level of play. LEVEL OF EVIDENCE: Level IV, systematic review of Level II-IV studies.

Return to Sport After Coracoid Transfer in Athletes With Anterior Shoulder Instability: A Systematic Review.

CONTEXT: Recurrent shoulder instability in young athletes can lead to a spectrum of soft tissue and bony lesions that can be bothersome and/or disabling. Coracoid transfer is a treatment option for athletes with recurrent instability. OBJECTIVE: To report the rate of return to sport for athletes after coracoid transfer. DATA SOURCES: An electronic search of the literature was performed using the PubMed (MEDLINE) and Cochrane Databases (1966-2018). STUDY SELECTION: Studies were included if they evaluated return to sport after treatment with coracoid transfer at a minimum 1-year follow-up. STUDY DESIGN: Systematic review. LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: Data were extracted by 2 authors and included study design, level of evidence, patient demographics (number, age, sex), procedure performed, duration of clinical follow-up, rate of return to sport, patient-reported outcome measures, reoperations, and complications. RESULTS: Fourteen studies met the inclusion criteria. The rate of return to sport at any level ranged from 80% to 100% in all but 1 study (38%), and the rate of return to the previous level of play ranged from 56% to 95% in all but 1 study (16%). Patients returned to sport at an average of 3.2 to 8.1 months. The average patient-reported outcome scores ranged from 78% to 94% (Rowe), 223.6 to 534.3 (Western Ontario Shoulder Instability Index), and 75% to 90% (subjective shoulder value). The rate of postoperative dislocation ranged from 0% to 14%, and the reoperation rate ranged from 1.4% to 13%. CONCLUSION: There was a high early rate of return to sport in patients who underwent coracoid transfer for anterior shoulder instability, although patients did not reliably return to the same level of play. The procedure had very favorable outcomes for treatment of instability, with low rates of recurrent dislocation and reoperation.

Return to Sport and Sports-Specific Outcomes After Osteochondral Allograft Transplantation in the Knee: A Systematic Review of Studies With at Least 2 Years' Mean Follow-Up.

PURPOSE: To report current data on return-to-sport rates and sports-specific patient-reported outcomes after osteochondral allograft (OCA) transplantation for cartilage defects of the knee. METHODS: We performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines that included studies from 1975 to 2018 with a minimum 2-year mean follow-up that reported return-to-sport rates or sports-specific patient-reported outcomes. Outcomes, reoperations, and complications were provided in table format, and a subjective analysis was performed. RESULTS: This review included 13 studies with 772 patients who underwent OCA transplantation at a mean of 24 to 91 months' follow-up. The return-to-sport rate ranged from 75% to 82%. For patient-reported outcomes, the Knee Injury and Osteoarthritis Score Sport increased in 4 studies, the Tegner activity scale score increased in 3 studies but decreased in 1, and the Marx activity scale score increased in 1 study but decreased in 2. Studies reporting improvements in the Cincinnati Knee Score and Knee Injury and Osteoarthritis Score Sport reached the minimal clinically important difference. The reoperation rate was high (ranging from 34% to 53% in more than half of studies), with reoperations primarily performed for loose body removal or debridement. CONCLUSIONS: This systematic review of 13 studies suggests that OCA transplantation for cartilage defects allows most athletes to return to sport (range, 75%-82%). Most studies reported improvements in sports-specific patient-reported outcomes at follow-up and reached the minimal clinically important difference. However, the reoperation rate was high in several studies, with a large percentage of patients requiring loose body removal or debridement. The long-term survival of the allografts is largely unknown, but this study suggests OCA transplantation consistently improves function in athletes with chondral injuries. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Outcomes With a Focus on Return to Play for Revision Ulnar Collateral Ligament Surgery Among Elite-Level Baseball Players: A Systematic Review.

BACKGROUND: Ulnar collateral ligament (UCL) reconstruction is commonly performed among overhead throwing athletes. Previous studies demonstrated relatively high rates of return to sport after primary reconstruction. Outcomes after revision UCL reconstruction have not been widely studied. PURPOSE: To report the rate of return to sport after revision UCL reconstruction among elite-level baseball players. STUDY DESIGN: Systematic review. METHODS: A systematic review of the literature following the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines was performed for high-level baseball players undergoing revision UCL reconstruction. Study bias was assessed with the Methodological Index for Non-Randomized Studies scoring system. The primary outcome measure was whether the study participants were able to return to sport after revision UCL reconstruction. Secondary outcome measures included career length after revision and pitching performance statistics. Data were summarized with ranges, tables, and weighted averages. A subjective analysis was performed. RESULTS: A total of 5 studies met inclusion criteria. The rate of return to sport at preinjury level was 62.8%. Among Major League Baseball pitchers, the rate of return to sport at the preinjury level was 68.8%. The rate of return to sport at the same level or lower (Major League Baseball, minor league, collegiate) was 78.1%. Time to return to sport ranged from 1.3 to 1.7 years. Mean earned run average after revision ranged from 4.87 to 5.04. Mean number of innings pitched per season after revision ranged from 36.95 to 50.5. CONCLUSION: This systematic review demonstrated a limited rate of return to preinjury level of sport among elite-level baseball players who underwent revision UCL reconstruction. Pitching durability and career longevity were inferior to results that were reported for players who underwent primary UCL reconstruction alone. This study suggests that outcomes after revision UCL reconstruction are not reliable and elite-level players should be counseled accordingly.

Patterns in Opioid Prescription for Patients Operatively Treated for Ankle Fractures Following Implementation of 2017 Ohio Opioid Prescriber Law.

BACKGROUND: The purpose of this study was to report patterns of opioid prescription for patients treated operatively for ankle fractures after implementation of the 2017 Ohio Opioid Prescriber Law in comparison to the previous year. METHODS: A total of 144 patients operatively treated for isolated ankle fractures during two 6-month periods, January 2017 to July 2017 (pre-law) and January 2018 to July 2018 (post-law), were retrospectively identified. Preoperative and postoperative patient narcotic use was reviewed using a legal prescriber database. Total number of prescriptions, quantity of pills, and morphine milligram equivalents (MMEs) per patient prescribed during the 90-day postoperative period were compared between those treated before and those treated after implementation of the Ohio prescriber law. RESULTS: The average number of opioid prescriptions prescribed per patient in the 90-day postoperative period was 2.3 in the pre-law group and 2.1 in the post-law group (P = .625). The average MMEs prescribed per patient dropped from 942.4 MME pre-law to 700.5 MME post-law (P = .295). Differences in the average number of pills per prescription pre- and post-law (49.7 vs 36.2) and average MME per prescription (382.1 mg vs 275.2 mg) were statistically significant (P < .001 and P = .016, respectively). CONCLUSION: Following the implementation of the 2017 Ohio Opioid Prescriber Law, there was a downward trend in the number of pills per prescription and MMEs per prescription in patients operatively treated for isolated ankle fractures. The presence of a downward trend in the quantity of opioids prescribed in this patient cohort suggests the effectiveness of the state law. LEVEL OF EVIDENCE: Level III, comparative study.

Effect of Deformity and Malunion of the Anterior Pelvic Ring.

Pelvic fractures are common after high-energy trauma and are often associated with ligamentous injury. Treatment is guided by assessing stability of the pelvic ring, and unstable injuries frequently require surgery to achieve a desirable outcome. Assessment of pelvic ring stability is often possible with physical examination and standard imaging studies (plain radiographs and computed tomography); however, these "static" imaging modalities may not adequately identify dynamically unstable pelvic injuries that require surgery. Cadaveric and clinical data suggest that the injured pelvis may recoil significantly from the point of maximal displacement, and some unstable injuries may not be recognized until patients present with clinical symptoms. This article presents the case of a patient who sustained a minimally displaced pelvic ring injury that was stable on bedside examination and static imaging, but ultimately was unstable. She developed a substantial pelvic malunion with significant pain and activity limitations. The patient subsequently underwent successful pelvic ring reconstruction, and she remains asymptomatic at 2 years.