Comparison of Open and Closed Hand Fractures and the Effect of Urgent Operative Intervention.

PURPOSE: To establish and compare the incidence of 30-day postoperative infection in surgically managed open and closed metacarpal and phalangeal fractures, and to determine whether open fractures treated urgently had a lower incidence of postoperative infection. METHODS: We conducted a retrospective analysis of patient demographics, comorbidities, and 30-day infection rates of patients undergoing operative fixation of metacarpal, proximal, or middle phalanx fractures from 2008 to 2015 using the American College of Surgeons' National Surgical Quality Improvement Program database. A total of 3,506 patients were identified and patient variables and infection incidence were compared between open and closed injuries, as well as open injuries managed within 1 day of admission and those treated on an elective basis or treated more than 1 day after admission. Bivariate analysis was used to determine independent risk factors for postoperative infection. RESULTS: Although 34.2% of open hand fractures were taken urgently to the operating room, the diagnosis of open fractures along with nonurgent surgical treatment for open fractures was associated with a low incidence of postoperative infection. In addition, smoking was a risk factor for postoperative infection although anatomic location (phalanx vs metacarpal) was not. CONCLUSIONS: Patients undergoing surgery for metacarpal or proximal/middle phalangeal fractures are not at greater risk for infection based on the diagnosis of open fracture alone. In addition, patients with open fractures who are taken to the operating room more than 1 day from presentation did not have a higher incidence of infection. Smoking is associated with increased 30-day infection rates after surgery, and surgeons should identify these patients for preoperative risk stratification, counseling, and postoperative wound monitoring. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Athletic performance and career longevity following anterior cruciate ligament reconstruction in the National Basketball Association.

PURPOSE: To identify the impact of anterior cruciate ligament (ACL) reconstruction on performance and career longevity for National Basketball Association (NBA) players. METHODS: Seventy-nine players (80 knees) with acute ACL tears in the NBA between the 1984-2014 seasons, and 112 age, height, weight, and performance-matched controls were identified. Pre- and post-injury performance outcomes including seasons played, games played, games started, minutes per game, points per game, field goals, 3-point shots, rebounds, assists, steals, blocks, turnovers, personal fouls, usage percentage and player efficiency ratings were compared between cases and controls using independent samples t tests and Fisher's exact tests. RESULTS: Sixty-eight of seventy-nine players (86.1 %) returned to play in the NBA following ACL reconstruction. Mean length of post-operative play was 1.84 years shorter than matched controls (P = 0.001). There was a significantly higher rate of attrition from professional basketball for players with a history of ACL reconstruction (P = 0.014). In the first full season following surgery, players started in 15.5 fewer games (P = 0.001), they played in 17.3 fewer games (P < 0.001), and had combined player efficiency ratings 2.35 points lower (P = 0.001) when compared to matched controls. Over the length of their careers, players competed in 22.2 fewer games per season (P = 0.009). CONCLUSIONS: There is a high rate of return to sport in the NBA following ACL reconstruction, although playing time, games played, player efficiency ratings and career lengths are significantly impacted in the post-operative period. These data should be used to manage patients' expectations regarding their abilities to return to elite levels of athletic performance.

What are the Risk Factors for Cerebrovascular Accidents After Elective Orthopaedic Surgery?

BACKGROUND: Perioperative cerebrovascular accidents (CVAs) are one of the leading causes of patient morbidity, mortality, and medical costs. However, little is known regarding the rates of these events and risk factors for CVA after elective orthopaedic surgery. QUESTIONS/PURPOSES: Our goals were to (1) establish the national, baseline proportion of patients experiencing a 30-day CVA and the timing of CVA; and (2) determine independent risk factors for 30-day CVA rates after common elective orthopaedic procedures. METHODS: Patients undergoing elective TKA, THA, posterior or posterolateral lumbar fusion, anterior cervical discectomy and fusion, and total shoulder arthroplasty, from 2006 to 2012, were identified from the American College of Surgeons National Surgical Quality Improvement Program(®) database. A total of 42,150 patients met inclusion criteria. Thirty-day CVA rates were recorded for each procedure, and patients were assessed for characteristics associated with CVA through univariate analysis. Multivariate regression models were created to identify independent risk factors for CVA. RESULTS: A total of 55 (0.13%) patients experienced a CVA within 30 days of the procedure, occurring a median of 2 days after surgery (range, 1-30 days) with 0.08% of patients experiencing a CVA after TKA, 0.15% after THA, 0.00% after single-level anterior cervical discectomy and fusion, 0.38% after multilevel anterior cervical discectomy and fusions, 0.20% after single-level posterior or posterolateral lumbar fusion, 0.70% after multilevel posterior or posterolateral lumbar fusion, and 0.22% after total shoulder arthroplasty. Independent risk factors for CVA included age of 75 years or older (odds ratio [OR], 2.50; 95% CI, 1.44-4.35; p = 0.001), insulin-dependent diabetes mellitus (OR, 3.08; CI, 1.47-6.45; p = 0.003), hypertension (OR, 2.71; CI, 1.19-6.13; p = 0.017), history of transient ischemic attack (OR, 2.83; CI, 1.24-6.45; p = 0.013), dyspnea (OR, 2.51; CI, 1.30-4.86; p = 0.006), chronic obstructive pulmonary disease (OR, 2.33; CI, 1.06-5.13; p = 0.036), and operative time of 180 minutes or greater (OR, 3.25; CI 1.60-6.60; p = 0.001). CONCLUSIONS: Numerous nonmodifiable patient comorbidities and increased operative time were associated with CVA after elective orthopaedic procedures. However, the American College of Surgeons National Surgical Quality Improvement Program(®) database does not code for cardiac arrhythmia or atrial fibrillation, which other studies have suggested may be important predictor variables; those may be important risk factors, although we were unable to evaluate them in our study. Surgeons should counsel patients with these risk factors and limit their operative time to reduce the risk of these adverse events, and future studies should examine other patient characteristics such as arrhythmia and noncoronary heart disease and assess the role of pharmacologic prophylaxis in patients with these risk factors. LEVEL OF EVIDENCE: Level III, prognostic study.

The Effect of Body Mass Index on Postoperative Morbidity After Orthopaedic Surgery in Children With Cerebral Palsy.

BACKGROUND: Although a plethora of literature exists on the impact of body mass index (BMI) in orthopaedic surgery, few have examined its implications in the pediatric cerebral palsy (CP) population. The aim of this study is to evaluate the effect of BMI class on 30-day complications after orthopaedic surgery on children with CP. METHODS: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric participant use files from 2012 to 2013 was conducted. Patients with a diagnosis of CP undergoing any orthopaedic procedure were included and subclassified according to BMI classes: underweight, normal weight, overweight, and obese. Multivariate logistic regressions were performed to evaluate the independent effect of BMI class on total, surgical site, and medical complications as well as unplanned reoperations. RESULTS: A total of 1746 patients were included in our study. These included 345 (19.8%) underweight, 952 (54.5%) normal weight, 209 (12.8%) overweight, and 240 (13.7%) obese children and adolescents. In hip and lower extremity osteotomies, underweight class was an independent risk factor for total complications (P=0.037) and medical complications (P=0.031). Similarly, underweight class was a risk factor for total complications (P=0.022) and medical complications (P=0.019) in spine procedures. Weight class was not independently associated with complications in tendon procedures. Overweight and obesity classes were not associated with any independent increased risk for complications. CONCLUSIONS: With respect to the pediatric CP population, underweight status was deemed an independent predictor of increased complications in osteotomies and spine surgery with no independent increased risk in the overweight or obese cohorts. This information can greatly aid providers with risk stratification, preoperative counseling, and postoperative monitoring as it relates to orthopaedic surgery. LEVEL OF EVIDENCE: Level III-Prognostic.

Total Knee Arthroplasty for Posttraumatic Osteoarthritis: Is it Time for a New Classification?

BACKGROUND: Total knee arthroplasty (TKA) is often the best answer for end-stage, posttraumatic osteoarthritis after intra-articular and periarticular fractures about the knee. Although TKA in this setting is often considered more technically demanding, outcomes are typically worse for patients. This study examines the intraoperative differences and 30-day outcomes in posttraumatic vs primary TKA cohorts. METHODS: Patients undergoing TKA were selected from the National Surgical Quality Improvement Program database from 2010 to 2013. Patients were stratified on the basis of concurrent procedures and administrative codes indicating posttraumatic diagnoses. Thirty-day complications were recorded, and multivariate analyses were performed to determine whether posttraumatic arthritis was a risk factor for poor outcomes. RESULTS: A total of 67,675 primary and 674 posttraumatic TKAs were identified. Posttraumatic TKA patients were on average younger and healthier than the primary TKA population. The posttraumatic TKA group had higher rates of superficial surgical site infections and bleeding requiring transfusion. History of posttraumatic knee osteoarthritis was found to be an independent risk factor for prolonged operative time, increased length of hospital stay, and 30-day hospital readmission. CONCLUSION: We have demonstrated increased intraoperative times, heightened transfusion requirements and surgical site infections, and higher readmission rates after conversion TKA in the posttraumatic cohort. In contrast to total hip arthroplasty, current diagnosis and reimbursement schemes do not differentiate posttraumatic patients from primary osteoarthritis groups undergoing TKA. We believe that classification reform would improve medical documentation and improve patient care.

A Predictive Risk Index for 30-day Readmissions Following Surgical Treatment of Pediatric Scoliosis.

BACKGROUND: Pediatric scoliosis often requires operative treatment, yet few studies have examined readmission rates in this patient population. The purpose of this study is to examine the incidence, reasons, and independent risk factors for 30-day unplanned readmissions following scoliosis surgery. METHODS: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement-Pediatric database from 2012 to 2013 was performed. Patients undergoing spinal arthrodesis for progressive infantile scoliosis, idiopathic scoliosis, or scoliosis due to other medical conditions were identified and divided between 2 groups: patients with unplanned 30-day readmissions (Readmitted) and patients with no unplanned readmissions (Non-Readmitted). Multivariate logistic regression models were created to determine independent risk factors for readmissions. RESULTS: A total of 3482 children were identified, of which 120 (3.4%) had an unplanned readmission. A majority of patients had a readmission due to a surgical site complication regardless of scoliosis etiology. Risk factors for readmission included obesity (P<0.001) and posterior fusion of 13 or more vertebrae (P=0.029) for idiopathic scoliosis, impaired cognition (P=0.009) for progressive infantile scoliosis, and pelvic fixation (P=0.025) and American Society of Anesthesiologist ≥3 (P=0.048) for scoliosis due to other conditions. CONCLUSIONS: We present 30-day readmissions risk factors based on independent patient and procedural risk factors. This may be useful in the clinical management of patients following scoliosis surgery, specifically for the role of preoperative and predischarge risk stratification.

Current Practice in the Management of Type I Open Fractures in Children: A Survey of POSNA Membership.

BACKGROUND: Treatment of pediatric type I open fractures is controversial. Centers have reported good success with emergency room (ER) treatment of low-energy (type I) open pediatric fractures. The purpose of this study was to ascertain the treatment preferences of pediatric orthopaedic surgeons for type I open fractures. We hypothesize that surgeons will have different treatment protocols and preferred location for these injuries. METHODS: A questionnaire was given to Pediatric Orthopaedic Society of North America (POSNA) members at the 2012 annual meeting. Demographic questions inquired about surgeon's practice environment and experience, whereas clinical questions queried opinions regarding the typical treatments and past experiences with open fractures. Clinical scenarios questioned preferred management of open fractures. RESULTS: A total of 181 surveys were collected from the 503 POSNA members in attendance (36%). Years in practice were well represented with 34%: <10 years, 37%: 10 to 19 years, and 29%: >20 years. Most respondents' practices comprised over 80% pediatric patients (86%), were academic (68%), and worked with residents (77%). After initial treatment of an open fracture, 86% of respondents admitted patients for intravenous antibiotics and 57% gave oral antibiotics. There was no consensus regarding the amount or type of irrigation preferred, use of antibiotics in the irrigation, or whether the bone ends are delivered during irrigation and débridement. Soft-tissue infections and delayed union were noted by 13% and 8%, respectively, of respondents in type I open fractures treated in the ER and in 16% and 30% treated in the operating room (OR). ER treatment was preferred in 19% to 31% of respondents for type I open fractures. When queried if level 1 evidence existed that demonstrated equivalent results between ER and OR management, 92% of respondents would change their practice. CONCLUSIONS: Treatment methods of type I open fractures are variable. Many surgeons prefer to treat type I open fractures in the ER as opposed to the traditional OR irrigation and débridement. On the basis of this survey, either children are going to the OR when ER treatment would be adequate or they may be receiving inadequate care when they avoid OR management. This survey establishes the equipoise necessary for a randomized, prospective trial comparing ER and OR management in the treatment of pediatric type I open fractures.

Understanding Acute Distal Radioulnar Joint Instability.

Acute instability of the distal radioulnar joint (DRUJ) is often underestimated but can cause devastating loss of forearm and wrist form and function. These traumatic injuries can be caused by disruption of the triangular fibrocartilage complex, the interosseous membrane, or fractures of the radius or ulna, and a comprehensive understanding of the anatomy involved is paramount to the adequate treatment of these injuries. While stable DRUJ instability can be treated with immobilization, often surgical intervention is required and is based on the anatomical restraints to the DRUJ that are disrupted.

Evaluation and Management of Carpal Fractures Other Than the Scaphoid.

Fractures of the carpus can be debilitating injuries and often lead to chronic pain and dysfunction when not properly treated. Although scaphoid fractures are more common, fractures of the other carpal bones account for nearly half of all injuries of the carpus. Often missed on initial presentation, a focused physical examination with imaging tailored to the suspected injury is needed to identify these fractures. In addition to plain radiographs, advanced imaging such as CT and MRI are helpful in diagnosis and management. Treatment of carpal fractures is based on the degree of displacement, stability of the fracture, and associated injuries. Those that require surgical fixation often affect the congruency of the articular surfaces, are unstable, are at risk for symptomatic nonunion, are associated with notable ligamentous injury, or are causing nerve or tendon entrapment. Surgical strategies involve percutaneous Kirschner wires, external fixation, screws and/or plates, excision, or fusion for salvage. Owing to the intimate articulations in the hand, small size of the carpal bones, and complex vascular supply, carpal fracture complications include symptomatic nonunion, osteonecrosis, and posttraumatic arthritis.

Surgical Site Infection After Open Upper Extremity Fracture and the Effect of Urgent Operative Intervention.

OBJECTIVES: To identify which factors are predictive of surgical site infection in upper extremity fractures, and to assess whether the timing of operative debridement influences infection risk. DESIGN: Retrospective database review. SETTING: Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. PATIENTS: Patients in the NSQIP database with fractures involving the upper extremity. INTERVENTION: Surgical management of upper extremity fracture, including operative debridement for open injuries. MAIN OUTCOME MEASUREMENTS: Surgical site infection, including both superficial and deep infections. RESULTS: A total of 22,578 patients were identified, including 1298 patients with open injuries (5.7% of total). The overall wound infection rate was 0.79%. Patients with open injuries were found to have a higher incidence of infection compared with those with closed injuries (1.7% vs. 0.7%, P < 0.001). Independent risk factors for 30-day infection included open fracture diagnosis, obesity, smoking, and American Society of Anesthesiolgists class >2 (all P < 0.05). Of patients with open fractures, 79.7% were taken expediently to the operating room. The rate of infection did not differ based on whether surgery was performed expediently or not (1.8% vs. 1.1%, P = 0.431). CONCLUSIONS: Based on an analysis of the NSQIP database, the overall risk of surgical site infection following intervention for open or closed upper extremity fractures remains low. Risk factors for infection include open injury, obesity, and cigarette smoking. There was no difference in the infection rate based on the urgency of operative debridement. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Performance and Return to Sport After Hand, Wrist, and Forearm Fractures in the National Hockey League.

PURPOSE: To examine finger, thumb, hand, wrist, and forearm fractures in the National Hockey League (NHL) and determine: (1) basic demographic data, (2) return to sport (RTS) rates, (3) performance after RTS, and (4) the difference in RTS between players treated operatively versus conservatively. METHODS: NHL players with finger, thumb, hand, wrist, and forearm fractures between the 1995-1996 and 2014-2015 seasons were identified through team injury reports and archives on public record. Player demographics, RTS rate, games played per season, and performance score for each player were recorded and compared between the preinjury season and one season following injury. RESULTS: A total of 247 total NHL players with hand, wrist, and forearm fractures were identified, consisting of 30.8% finger, 38.5% hand, 13.8% thumb, 14.6% wrist, and 2.4% forearm fractures. Defenseman comprised the majority of players (40.1%). The overall RTS rate was 98.0%, with no significant difference between players with surgery or between injury location groups. In total, 52 players (21.1%) underwent surgery with no significant correlation of surgery rates based on fracture location. The mean number of missed games was 13.8 ± 9.9, with players sustaining wrist and forearm fractures missing the largest number of games (21.6 ± 17.7and 22.8 ± 7.5 games missed, respectively). There was no significant change in games played or performance scores 1 year after injury for players with any of the fracture types compared with baseline preoperative games played and performance. CONCLUSIONS: NHL players have a high RTS rate following hand, wrist, and forearm fractures. Players were able to return to preinjury performance within 1 year, regardless of treatment or type of fracture. LEVEL OF EVIDENCE: Level IV, case series.

Effect of Shoulder Stabilization on Career Length and Performance in National Basketball Association Athletes.

PURPOSE: Untreated episodes of shoulder instability can have major consequences on athletic careers. Operative shoulder stabilization reduces the rate of recurrent instability and allows for high rates of return to sport (RTS). Basketball players who experience an episode of instability have high rates of recurrence, though little is known about postoperative player performance. The purpose of this study was to identify the impact of shoulder instability and surgical stabilization on player performance and career lengths in the National Basketball Association (NBA). METHODS: NBA players who had episodes of shoulder instability between 1994-2014 were identified using the NBA Injury Surveillance and Analytics Database. Players were stratified according to operative versus nonoperative treatment of shoulder instability. Two demographic- and performance-matched controls were chosen for each test subject. Univariate analyses were used to compare pre- and postoperative player performance metrics. Survival analysis was used to assess the effect of shoulder surgery on postoperative career lengths. RESULTS: Fifty athletes were identified, 46 (92.0%) returned to play in the NBA. Compared to controls, there was no significant difference in postoperative performance according to either 1- or 3-year averages. Survival analysis demonstrated no significant difference in postoperative career lengths between athletes with a history of shoulder surgery for instability and matched controls. CONCLUSION: NBA players return to professional basketball in high numbers following orthopedic surgery for shoulder instability. Shoulder instability may not be a career-altering event, as there are highly effective methods of shoulder stabilization available to athletes.

Etiology, Evaluation, and Management Options for the Stiff Digit.

The stiff digit may be a consequence of trauma or surgery to the hand and fingers and can markedly affect a patient's level of function and quality of life. Stiffness and contractures may be caused by one or a combination of factors including joint, intrinsic, extensor, and flexor tendon pathology, and the patient's individual biology. A thorough understanding of the anatomy, function, and relationship of these structures on finger joint range of motion is crucial for interpreting physical examination findings and preoperative planning. For most cases, nonsurgical management is the initial step and consists of hand therapy, static and dynamic splinting, and/or serial casting, whereas surgical management is considered for those with more extensive contractures or for those that fail to improve with conservative management. Assuming no bony block to motion, surgery consists of open joint release, tenolysis of flexor and/or extensor tendons, and external fixation devices. Outcomes after treatment vary depending on the joint involved along with the severity of contracture and the patient's compliance with formal hand therapy and a home exercise program.

Nationwide 30-Day Readmissions After Elective Orthopedic Surgery: Reasons and Implications.

INTRODUCTION: Reducing readmissions after orthopedic surgery is important for decreasing hospital costs and patient morbidity. Our goals were to establish national rates and reasons for 30-day readmissions after common elective orthopedic procedures. METHODS: Patients undergoing total knee arthroplasty, total hip arthroplasty, posterior lumbar fusion, anterior cervical discectomy and fusion, or total shoulder arthroplasty were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Thirty-day readmission rates, timing, and reasons were recorded for each procedure. Multivariate analysis was used to identify risk factors of readmissions. RESULTS: A total of 3.8% of patients had an all-cause readmission, 3.6% had an unplanned readmission, and 2.4% had an unplanned readmission related to surgery (URRS). The most common reason was surgical site complication followed by venous thromboembolism and bleeding. Only 3.2% of all patients with a URRS were readmitted because of a predischarge complication. Independent predictors of URRS were current smoking, any inpatient complication, and non-home discharge. CONCLUSIONS: Unplanned readmissions were a proxy for new postdischarge complications rather than a re-exacerbation of previous inpatient events. Emphasis should be on more effective prevention strategies for surgical site infections, continuing to prevent inpatient complications and focusing on home discharge.

Outcomes After Lumbar Disc Herniation in the National Basketball Association.

BACKGROUND: Professional basketball players are at risk for lumbar disc herniation (LDH), yet the evidence guiding treatment after operative or nonoperative management of this condition in the National Basketball Association (NBA) is limited. HYPOTHESIS: NBA players with LDH will have different performance outcomes based on treatment type. STUDY DESIGN: Case-control study. LEVEL OF EVIDENCE: Level 4. METHODS: Athletes in the NBA with an LDH were identified through team injury reports, transaction records, and public sports archives. A 1:2 case-control study was performed in which LDH players and players without LDH were matched for player variables. Statistical analysis was employed to compare pre- and postindex season performance (games played and player efficiency rating [PER]) and career longevity between test subjects and controls in the operatively treated (OT) and nonoperatively treated (NOT) cohorts. RESULTS: A total of 61 NBA players with LDH were included, of whom 34 underwent discectomy and 27 were managed nonoperatively. Return-to-play (RTP) rates did not differ between NOT and OT players (77.8% vs. 79.4%). When compared with controls, OT players played significantly fewer games and had a lower PER than controls during the first postoperative season, but no difference was seen 2 and 3 years after surgery, with no difference in postoperative career length. In contrast, no difference in games played or PER was seen between NOT players and controls, although NOT players played significantly fewer postindex seasons. CONCLUSION: NBA players have a high RTP rate regardless of type of treatment for LDH; however, postindex performance differs between surgically and nonoperatively managed patients when compared with players without an LDH. However, further studies with a larger sample size are required for more definitive recommendations. CLINICAL RELEVANCE: There is a high RTP rate after LDH in the NBA, although postindex performance may differ based on operative versus nonoperative treatment.

Administrative Databases in Orthopaedic Research: Pearls and Pitfalls of Big Data.

The drive for evidence-based decision-making has highlighted the shortcomings of traditional orthopaedic literature. Although high-quality, prospective, randomized studies in surgery are the benchmark in orthopaedic literature, they are often limited by size, scope, cost, time, and ethical concerns and may not be generalizable to larger populations. Given these restrictions, there is a growing trend toward the use of large administrative databases to investigate orthopaedic outcomes. These datasets afford the opportunity to identify a large numbers of patients across a broad spectrum of comorbidities, providing information regarding disparities in care and outcomes, preoperative risk stratification parameters for perioperative morbidity and mortality, and national epidemiologic rates and trends. Although there is power in these databases in terms of their impact, potential problems include administrative data that are at risk of clerical inaccuracies, recording bias secondary to financial incentives, temporal changes in billing codes, a lack of numerous clinically relevant variables and orthopaedic-specific outcomes, and the absolute requirement of an experienced epidemiologist and/or statistician when evaluating results and controlling for confounders. Despite these drawbacks, administrative database studies are fundamental and powerful tools in assessing outcomes on a national scale and will likely be of substantial assistance in the future of orthopaedic research.

The Effect of an Orthopaedic Surgical Procedure in the National Basketball Association.

BACKGROUND: Professional basketball players have a high incidence of injuries requiring surgical intervention. However, no studies in the current literature have compared postoperative performance outcomes among common injuries to determine high- and low-risk procedures to these athletes' careers. PURPOSE: To compare return-to-play (RTP) rates and performance-based outcomes after different orthopaedic procedures in National Basketball Association (NBA) players and to determine which surgeries are associated with the worst postoperative change in performance. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Athletes in the NBA undergoing anterior cruciate ligament reconstruction, Achilles tendon repair, lumbar discectomy, microfracture, meniscus surgery, hand/wrist or foot fracture fixation, and shoulder stabilization were identified through team injury reports and archives on public record. The RTP rate, games played per season, and player efficiency rating (PER) were determined before and after surgery. Statistical analysis was used to compare the change between pre- and postsurgical performance among the different injuries. RESULTS: A total of 348 players were included. The RTP rates were highest in patients with hand/wrist fractures (98.1%; mean age, 27.0 years) and lowest for those with Achilles tears (70.8%; mean age, 28.4 years) (P = .005). Age ≥30 years (odds ratio [OR], 3.85; 95% CI, 1.24-11.91) and body mass index ≥27 kg/m(2) (OR, 3.46; 95% CI, 1.05-11.40) were predictors of not returning to play. Players undergoing Achilles tendon repair and arthroscopic knee surgery had a significantly greater decline in postoperative performance outcomes at the 1- and 3-year time points and had shorter career lengths compared with the other procedures. CONCLUSION: NBA players undergoing Achilles tendon rupture repair or arthroscopic knee surgery had significantly worse performance postoperatively compared with other orthopaedic procedures.

The NFL Orthopaedic Surgery Outcomes Database (NO-SOD): The Effect of Common Orthopaedic Procedures on Football Careers.

BACKGROUND: Injuries are inherent to the sport of American football and often require operative management. Outcomes have been reported for certain surgical procedures in professional athletes in the National Football League (NFL), but there is little information comparing the career effect of these procedures. PURPOSE: To catalog the postoperative outcomes of orthopaedic procedures in NFL athletes and to compare respective prognoses and effects on careers. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Athletes in the NFL undergoing procedures for anterior cruciate ligament (ACL) tears, Achilles tendon tears, patellar tendon tears, cervical disc herniation, lumbar disc herniation, sports hernia, knee articular cartilage repair (microfracture technique), forearm fractures, tibial shaft fractures, and ankle fractures were identified through team injury reports or other public records. Game and performance statistics during the regular season were collected before and after surgery. Statistical analysis was performed with significance accepted as P < .05. RESULTS: A total of 559 NFL athletes were included. Overall, 79.4% of NFL athletes returned to play after an orthopaedic procedure. Forearm open reduction and internal fixation (ORIF), sports hernia repair, and tibia intramedullary nailing (IMN) led to significantly higher return-to-play (RTP) rates (90.2%-96.3%), while patellar tendon repair led to a significantly lower rate (50%) (P < .001). Athletes undergoing ACL reconstruction (ACLR), Achilles tendon repair, patellar tendon repair, and ankle fracture ORIF had significant declines in games played at 1 year and recovered to baseline at 2 to 3 years after surgery. Athletes undergoing ACLR, Achilles tendon repair, patellar tendon repair, and tibia IMN had decreased performance in postoperative season 1. Athletes in the Achilles tendon repair and tibia IMN cohorts recovered to baseline performance, while those in the ACLR and patellar tendon repair cohorts demonstrated sustained decreases in performance. CONCLUSION: ACLR, Achilles tendon repair, and patellar tendon repair have the greatest effect on NFL careers, with patellar tendon repair faring worst with respect to the RTP rate, career length after surgery, games played, and performance at 1 year and 2 to 3 years after surgery.

Assessing the Rates, Predictors, and Complications of Blood Transfusion Volume in Posterior Arthrodesis for Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine predictors of and 30-day complications associated with blood transfusion volume after posterior spinal fusion for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Posterior arthrodesis is a common procedure performed for AIS, and patients frequently require perioperative blood transfusions. Few studies, however, have examined the rates and potential complications associated with blood transfusion volume. METHODS: Patients undergoing posterior arthrodesis for AIS were selected from the National Surgical Quality Improvement Program pediatric database from 2012 to 2013. Patients were stratified on the basis of blood transfusion volume and patient demographics and comorbidities, operative characteristics, and 30-day complications were recorded. Multivariate analyses were performed to determine predictors of transfusion as well as the effect of transfusion volume on 30-day complication rates. RESULTS: A total of 1691 patients were included. Male sex (P = 0.010), esophageal or gastrointestinal disease (P = 0.016), cardiac risk factors (P = 0.037), preoperative inotrope requirement (P = 0.031), total operative time of 300 minutes or more (P < 0.001), and posterior arthrodesis of 13 or more vertebral segments (P < 0.001) were independent risk factors for requiring blood transfusion. Total transfusion volume of 20 mL/kg or more was the minimum volume independently associated with increased rates of total complications (P = 0.018), with a complication rate of 5.9%. CONCLUSION: We present the first large, comprehensive analysis of complications related to blood transfusion events and transfusion volume on short-term postoperative complications after posterior arthrodesis for AIS. Although transfusion in general is not associated with 30-day adverse events, a volume of 20 mL/kg was associated with higher complication rates. LEVEL OF EVIDENCE: 4.

A comparison of 30-day complications following plate fixation versus intramedullary nailing of closed extra-articular tibia fractures.

BACKGROUND AND PURPOSE: Tibial shaft fractures are often treated by intramedullary nailing (IMN) or plate fixation. Our purpose was to compare the 30-day complication rates between IMN and plate fixation of extra-articular tibial fractures. MATERIALS AND METHODS: We conducted a retrospective analysis of prospectively collected patient demographics, comorbidities, and 30 day complications of isolated closed extra-articular tibial shaft fractures from 2006 to 2012 using the American College of Surgeon's National Surgical Quality Improvement Program (ACS-NSQIP) database. A 1:2 propensity-matched dataset was created to control for differences in preoperative demographics and comorbidities across the plate fixation and IMN groups. Univariate and multivariate analyses were used to assess differences in complications between the groups and the independent effects of plate fixation or IMN on complications. RESULTS: A total of 771 patients were identified with 234 (30.4%) in the plate fixation and 537 (69.6%) in the IMN group. We found no statistical difference in rates of wound complications, medical complications, reoperation, or mortality in our propensity matched analyses. Plate fixation was found to be independently associated with a lower risk of postoperative blood transfusion compared to IMN (odds ratio 0.326, p=0.032). Plate fixation was not independently associated with any other examined complications. CONCLUSIONS: We found no difference in 30-day postoperative complications between plate fixation and intramedullary nailing of isolated extra-articular tibia fractures with the exception of decreased postoperative transfusion requirements with plate fixation. We conclude that both procedures offer a similar short-term complication profile.