Fracture blisters: predictors for time to definitive fixation in pilon fractures.

PURPOSE: Fracture blisters, a common soft-tissue complication of pilon fractures, are associated with post-operative wound infections, delays in definitive fixation, and alterations in surgical plan. The purpose of this study was to (1) identify the delay in surgery attributable to the presence fracture blisters and (2) investigate the relationship of fracture blisters to comorbidities and fracture severity. METHODS: Patients with pilon fractures at an urban level 1 Trauma center from 2010 to 2021 were identified. The presence or absence of fracture blisters was noted, along with location. Demographic information, time from injury to external fixator placement, and time to definitive open reduction internal fixation (ORIF) were collected. Pilon fractures were classified according to AO/OTA guidelines using CT imaging and plain radiographs. RESULTS: 314 patients with pilon fractures were available for analysis, eighty (25%) of whom were found to have fracture blisters. Patients with fracture blisters had longer time to surgery compared to those without fracture blisters (14.2 days vs 7.9 days, p < 0.001). A greater proportion of patients with fracture blisters had AO/OTA 43C fracture patterns, compared with those without fracture blisters (71.3% vs 53.8%, p = 0.03). Fractures blisters were less likely to be localized over the posterior ankle (12%, p = 0.007). CONCLUSION: The presence of fracture blisters in pilon fractures are associated with significant delays in time to definitive fixation and higher energy fracture patterns. Fracture blisters are less commonly located over the posterior ankle which may support the implementation of a staged posterolateral approach when managing these injures.

Management of Pediatric and Adolescent Sublime Tubercle Injuries: Isolated and Complex Patterns Demonstrate Distinct Etiologies and Radiographic Outcomes.

BACKGROUND: The aim of this study was to assess the patient demographics, epidemiology, mechanism of injury, and natural history of sublime tubercle avulsion injuries. METHODS: A multicenter retrospective study was performed in which sublime tubercle avulsion injuries were identified by surgeon records and database query of radiology reports. Demographic data and imaging were reviewed for each case, and injuries were classified as type 1 (isolated injuries with a simple bony avulsion or periosteal stripping) or type 2 (complex injuries with an associated elbow fracture or dislocation). Treatment modality and evidence of radiographic healing at a minimum of 3 months were collected. RESULTS: Forty patients (78% male) with a median age of 15 years (range, 8 to 19 years) were identified with sublime tubercle avulsion injuries. Sixty-eight percent of cases (n=27) were determined to be type 1 injuries, and 32% (n=13) were classified as type 2 injuries. The majority of type 1 injuries (59%) occurred via a noncontact mechanism in overhead-throwing athletes, whereas 100% of the type 2 injuries were sustained via a contact mechanism. Type 1 injuries presented in a delayed manner in 19% of cases, whereas no type 2 injuries (0%) were delayed in presentation. Type 1 injuries infrequently underwent surgical intervention (19%), whereas 54% of type 2 injuries required surgery. Of those that did not undergo initial surgical management at a minimum of 3-month radiographic follow-up, 9/11 (82%) of type 1 injuries and 0/4 (0%) of type 2 injuries demonstrated evidence of healing. Only 1 case required reoperation (type 2 injury). CONCLUSIONS: This series of adolescents with sublime tubercle avulsion injuries expands our understanding of the epidemiology of this rare injury, which was previously only described as a noncontact injury in baseball players. Type 1 injuries are more likely to occur via a noncontact mechanism and generally demonstrate radiographic evidence of healing after a period of rigid immobilization. Conversely, type 2 injuries are more likely to undergo initial surgical intervention, and those managed nonoperatively are less likely to achieve radiographic healing. Further studies are needed to elucidate treatment protocols and long-term functional outcomes. LEVEL OF EVIDENCE: Level IV-case series.

Do associated proximal fibula fractures help predict the severity of tibial plateau fractures?

PURPOSE: Proximal fibula fractures are often associated with tibial plateau fractures, but their relationship is poorly characterized. The purpose of this study was to better define the relationship between tibial plateau injury severity and presence of associated soft tissue injuries. METHODS: A retrospective review was performed on all operatively treated tibial plateau fractures at a Level 1 trauma center over a 5-year period. Patient demographics, injury radiographs, CT scans, operative reports and follow-up were reviewed. RESULTS: Queried tibial plateau fractures from 2014 to 2019 totaled 217 fractures in 215 patients. Fifty-two percent were classified as AO/OTA 41B and 48% were AO/OTA 41C. Thirty-nine percent had an associated proximal fibula fracture. The presence of a proximal fibula fracture had significant correlation with AO/OTA 41C fractures, as compared with AO/OTA 41B fractures (chi-square, p < 0.001). Of the patients with a lateral split depression type tibial plateau fracture, the presence of a proximal fibula fracture was associated with more articular comminution, measured by number of articular fragments (mean = 4.0 vs. 2.9 articular fragments, p = 0.004). There was also a higher rate of meniscal injury in patients with proximal fibula fractures (37% vs. 20%, p = 0.003). CONCLUSIONS: There was a significant relationship between the higher energy tibial plateau fracture type (AO/OTA 41C) and the presence of an associated proximal fibula fracture. The presence of a proximal fibula fracture with a tibial plateau fracture is an indicator of a higher energy injury and a higher likelihood of meniscal injury.

BRAF and Epithelial-Mesenchymal Transition: Lessons From Papillary Thyroid Carcinoma and Primary Cutaneous Melanoma.

The increased prevalence of BRAF mutations in thyroid carcinoma and primary cutaneous melanoma (PCM) hint that dysregulation of BRAF might contribute to the noted association between PCM and thyroid carcinoma. A recent study evaluating the rate of BRAFV600E mutations among patients who had been diagnosed with primary papillary thyroid carcinoma (PTC) and PCM showed that patients with either PCM or PTC were at an increased risk of developing the other as a second primary malignant neoplasm. Furthermore, the authors noted that samples from patients suffering from both malignancies exhibited a higher rate of incidence of the BRAFV600E mutation, compared with patients not suffering from both malignancies. These studies support the hypothesis that the pathogenesis of these 2 malignancies might share a conserved molecular pattern associated with dysregulation of the BRAF protein. One mechanism through which BRAF might contribute to PCM and thyroid carcinoma progression is through induction of epithelial-mesenchymal transition (EMT). Specifically, the Snail/E-cadherin axis has been demonstrated as a pathway dysregulated by BRAF, leading to EMT in both malignancies. Our analysis focuses on the results of these recent investigations, and through a review of select molecules relevant to EMT, looks to provide a context by which to better understand the relevance and role of stromal-parenchymal signaling and the BRAF mutation in the pathogenesis of PTC and PCM.

Neurotrophin receptors and perineural invasion in desmoplastic melanoma.

BACKGROUND: Perineural invasion (PNI) in desmoplastic melanoma is associated with increased local recurrence and reduced disease-free survival. The biological mechanisms underlying PNI remain unclear although several lines of evidence implicate neurotrophins and their receptors. OBJECTIVES: We investigated the expression of p75NGFR and TrkA, and the presence of functional RET polymorphism (RETp) as they relate to PNI in desmoplastic melanoma. METHODS: In all, 43 cases of desmoplastic melanoma were immunohistochemically evaluated for TrkA and p75NGFR expression and RETp was detected by direct DNA sequencing. RESULTS: PNI was present in 67% of cases. On univariate analysis, p75NGFR was associated with PNI (expression detected in 79% of PNI-positive cases compared with 36% of PNI-negative cases, P = .005), increased Breslow depth (P = .007), and greater Clark level (P = .01). RETp was noted in 28% of cases but was not significantly associated with PNI (P = .27) or other histopathologic variables. TrkA expression was absent in all cases. PNI was associated with increased Breslow depth and Clark level (P = .01 and P = .009, respectively). Controlling for the association between p75NGFR and depth, p75NGFR remained associated with an increased propensity for PNI (odds ratio 4.68, P = .04). LIMITATIONS: The sample size was limited. CONCLUSION: In desmoplastic melanoma, p75NGFR expression is significantly associated with PNI and a more locally aggressive phenotype.

An Evidence-Based Approach to Managing Adolescent (Ages 10 to 19 Years) Diaphyseal Clavicle Fractures.

Diaphyseal clavicle fractures occur most frequently in adolescents (defined as ages 10 to 19 years by the World Health Organization). Multiple prospective comparative studies exist in the adult literature, whereas studies focusing on adolescents are limited. Given the notable differences in healing potential between pediatric, adolescent, and adult diaphyseal clavicle fractures, treatment algorithms tailored specifically to children, adolescents, and adults are required. In the past two decades, there has been a dramatic rise in surgical fixation of adolescent diaphyseal clavicle fractures, largely influenced by adult literature. The remodeling potential of the clavicle throughout adolescence and into early adulthood exceeds that of the adult population. Furthermore, prospective outcomes studies of displaced diaphyseal clavicle fractures have demonstrated that, when compared with surgical management, nonsurgical management portends equivalent functional outcomes but a nearly four times greater rate of complications. Even those injuries with comminution and notable shortening, nonsurgical treatment yields good functional outcomes, high rates of return to sport, and low incidence of complications, such as nonunion, symptomatic malunion, and refracture. In rare cases of unsatisfactory nonsurgical treatment, secondary surgical fixation most often results in union and good functional outcomes.

Anterior Tibial Artery Danger Zone During Anterolateral Plate Fixation of the Distal Tibia: A 3D Computed Tomography Angiogram Modeling Study.

OBJECTIVES: The objective of this study was to define the danger zone at which the anterior tibial artery (ATA) is at risk during anterolateral plating of the distal tibia using a novel 3D computed tomography angiography (CTA) modeling technique. METHODS: 116 patients (232 lower extremities) who underwent lower extremity CTAs between April 2020 and April 2022 were identified. Those with lower extremity trauma, evidence of a previously healed tibial fracture, or poor visualization of the ATA were excluded. The remaining 150 lower extremities (92 patients) were modeled with an anterolateral distal tibia plate using Sectra IDS7 software. The distance of the ATA from bony landmarks was measured perpendicular to the level at which the vessel intersected the plate. RESULTS: The ATA intersected the plate proximally at a mean distance of 10.5 cm (95% confidence intervals, 10.2-10.9) and at a mean distance of 4.6 cm (95% confidence intervals, 4.4-4.9) distally from the central tibial plafond. The ATA intersected with the plate as far distal as hole number 1 and as proximal as hole 14 of the plate. The greatest injury risk was associated with plate holes 3-8. In this region, the artery was at risk in 46-99 percent of specimens. CONCLUSIONS: The ATA is at risk when screws are placed percutaneously in an anterolateral distal tibia plate. The artery can be as close as 4.4 cm and as far as 10.9 cm proximal to the tibial plafond when crossing the plate, correlating to a risk of injury to the ATA at plate holes 1 through 14.

Review of perioperative outcomes and management of hip fracture patients on direct oral anticoagulants.

Anticoagulation use is common in elderly patients presenting with hip fractures and has been shown to delay time to surgery (TTS). Delays in operative treatment have been associated with worse outcomes in hip fracture patients. Direct oral anticoagulants (DOACs) comprise a steadily increasing proportion of all oral anticoagulation. Currently, no clear guidelines exist for perioperative management of hip fracture patients taking DOACs. DOAC use is associated with increased TTS, with delays frequently greater than 48 h from hospital presentation. Increased mortality has not been widely demonstrated in DOAC patients, despite increased TTS. Timing of surgery was not found to be associated with increased risk of transfusion or bleeding. Early surgery appears to be safe in patients taking DOACs presenting with a hip fracture, but is not currently widely accepted due to factors such as site-specific anesthesiologic protocols that periodically delay surgery. Direct oral anticoagulant use should not routinely delay surgical treatment in hip fracture patients. Surgical strategies to limit blood loss should be considered and include efficient surgical fixation, topical application of hemostatic agents, and the use of intra-operative cell salvage. Anesthesiologic strategies have utility in minimizing risk and a collaborative effort to minimize blood loss should be undertaken by the surgeon and anesthesiologist. Anesthesia team interventions include considerations regarding positioning, regional anesthesia, permissive hypotension, avoidance of hypothermia, judicious administration of blood products, and the use of systemic hemostatic agents.

Comparing Propofol With Fentanyl and Midazolam for Sedation in Closed Reductions of Traumatic Hip Dislocations.

Traumatic native hip dislocations require prompt reduction of the dislocation to limit the risk of avascular necrosis and resultant hip arthrosis. Although closed reduction under sedation is frequently attempted, there is minimal evidence about which sedative agent is most safe and effective. The goal of this study was to compare the efficacy of propofol vs combination fentanyl/midazolam for closed reduction under sedation of traumatic native hip dislocations. This was a single-center retrospective review. The main outcome measures were the rate of successful closed reduction with propofol vs combination fentanyl/midazolam and time from the start of sedation to radiographic evidence of reduction. Fifty-four patients with traumatic native hip dislocations were identified. Closed reduction under sedation with propofol was successful in 11 of 14 attempts compared with 4 of 11 attempts with combination fentanyl/midazolam (P=.04). The fentanyl/midazolam group had 6.4 times the odds (95% CI, 1.1-37.7) of failed closed reduction compared with the propofol group. The median time to reduction in the propofol group was 14 minutes vs 45 minutes for the fentanyl/midazolam group (P=.18). Patients who had failed closed reduction with fentanyl/midazolam had a median time to reduction of 100 minutes. There was no difference in sedation-related complications between the 2 groups. We therefore conclude that sedation with propofol is significantly more effective than combination fentanyl/midazolam for closed reduction of native hip dislocations. To minimize unsuccessful reduction attempts and shorten total time to reduction, we recommend against the use of combination fentanyl/midazolam because of the high risk of failure. [Orthopedics. 2023;46(2):86-92.].

The Influence of Industry Affiliation on Randomized Controlled Trials of Platelet-Rich Plasma for Knee Osteoarthritis.

BACKGROUND: Industry funding and corporate sponsorship have played a significant role in the advancement of orthopaedic research and technology. However, this relationship raises concerns for how industry association may bias research findings and influence clinical practice. PURPOSE: To determine whether industry affiliation plays a role in the outcomes of randomized controlled trials (RCTs) investigating platelet-rich plasma (PRP). STUDY DESIGN: Meta-analysis; Level of evidence, 2. METHODS: A search of the PubMed, Cochrane, and MEDLINE databases for RCTs published between 2011 and the present comparing PRP versus hyaluronic acid, corticosteroid, or placebo for the treatment of knee osteoarthritis was performed. To determine industry affiliation, the conflict of interest, funding, and disclosure sections of publications were assessed, and all authors were assessed through the American Academy of Orthopaedic Surgeons disclosure database and the Centers for Medicare & Medicaid Services open payments database. Studies were classified as industry affiliated (IA) or non-industry affiliated (NIA). The outcomes of each study were rated as favorable, analogous, or unfavorable according to predefined criteria. RESULTS: A total of 37 studies (6 IA and 31 NIA) were available for analysis. Overall, 19 studies (51.4%) reported PRP as favorable compared with other treatment options, while 18 studies (48.6%) showed no significant differences between PRP and other treatment methods. There was no significant difference in qualitative conclusions between the IA and NIA groups, with the IA group having 3 favorable studies and 3 analogous studies and the NIA group having 16 favorable studies and 15 analogous studies (P = .8881). When comparing IA versus NIA studies using 6- and 12-month Western Ontario and McMaster Universities Arthritis Index and International Knee Documentation Committee scores, there were no significant differences in outcomes. CONCLUSION: The results of this study demonstrated that qualitative conclusions and outcome scores were found to not be associated with industry affiliation. Although the results of this study suggest that there is no influence of industry involvement on RCTs examining PRP, it is still necessary to carefully evaluate pertinent commercial affiliations when reviewing recommendations from studies before adopting new treatment approaches, such as the use of PRP for knee osteoarthritis.

Ambulation Distance Within 72 Hours after Surgical Management Is a Predictor of 90-Day Ambulatory Capacity in Elderly Patients with Hip Fracture.

INTRODUCTION: The inability to mobilize after surgical intervention for hip fractures in the elderly is established as a risk factor for greater morbidity and mortality. Previous studies have evaluated the association between the timing and distance of ambulation in the postoperative acute care phase with postoperative complications. The purpose of this study was to evaluate the association between ambulatory distance in the acute postoperative setting and ambulatory capacity at 3 months. METHODS: Patients aged 65 and older who were ambulatory at baseline and underwent surgical intervention for hip fractures from 2014 to 2019 were retrospectively reviewed. Consistent with previous literature, patients were divided into two groups: those who were able to ambulate 5 feet within 72 hours after surgical fixation (early ambulatory) and those who were not (minimally ambulatory). RESULTS: One hundred seventy patients (84 early ambulatory and 86 minimally ambulatory) were available for analysis. Using a multivariable ordinal logistic regression model, variables found to be statistically significant predictors of ambulatory status at 3 months were the ability to ambulate five feet in 72 hours (P < 0.0001), ambulatory distance at discharge (P = 0.012), and time from presentation to surgery (P = 0.039). Patients who were able to ambulate 5 feet within 72 hours had 9 times the odds of being independent ambulators rather than a lower ambulatory class (cane, walker, and nonambulatory). Pertrochanteric fractures were less likely than femoral neck fractures to independently ambulate at 3 months (17.2% vs. 42.3%; P = 0.0006). DISCUSSION: Ambulating 5 feet within 72 hours after hip fracture surgery is associated with an increased likelihood of independent ambulation at 3 months postoperatively. This simple and clear goal may be used to help enhance postoperative mobility and independence while providing a metric to guide therapy and help counsel patients and families.

A Retrospective Study of the Impact of COVID-19 Pandemic Related Administrative Restrictions on Spine Surgery Practice and Outcomes in an Urban Healthcare System.

The study objective is to characterize the impact of COVID-19 related hospital administrative restrictions on patient demographics, surgical care, logistics, and patient outcomes in spine surgery. This was a retrospective study of 331 spine surgery patients at UCSD conducted during 1 March 2019-31 May 2019 (pre-COVID-19) and 1 March 2020-31 May 2020 (first COVID-19 surge). All variables were collected through RedCap and compared between pre- and during-COVID groups. There were no significant differences in patient demographics, operating room duration, and skin-to-skin time. However, length of stay was 4.7 days shorter during COVID-19 (p = 0.03) and more cases were classified as 'urgent' (p = 0.04). Preoperative pain scores did not differ between groups (p = 0.51). However, pain levels at discharge were significantly higher during COVID (p = 0.04) and trended towards remaining higher in the short- (p = 0.05) but not long-term (p = 0.17) after surgery. There was no significant difference in the number of post-operative complications, but there was an increase in the use of the emergency room and telemedicine to address complications when they arose. Overall, the pandemic resulted in a greater proportion of 'urgent' spine surgery cases and shorter length of hospital stay. Pain levels upon discharge and at short-term timepoints were higher following surgery but did not persist in the long term.

Can Laser-Assisted Indocyanine Green Angiography Be Used to Quantify Perfusion Changes During Staged Fixation of Pilon Fractures? A Pilot Study.

OBJECTIVE: To quantify soft tissue perfusion changes in pilon fractures during staged treatment using laser-assisted indocyanine green angiography (LA-ICGA). SETTING: Level 1 trauma center. DESIGN: Prospective cohort study. PATIENTS/PARTICIPANTS: Twelve patients with 12 pilon fractures participated in the study. Seven patients had OTA/AO classification of 43-C3, 3 had 43-C2, and 2 had 43-B2. MAIN OUTCOME MEASURES: LA-ICGA was performed with the SPY fluorescence imaging platform. Analysis via ImageJ was used to generate a fractional area of perfusion (FAP) based on fluorescent intensity to objectively quantify soft tissue perfusion. Anterior, medial, and lateral measurements were performed at the time of initial external fixation (EF) application and then at the time of definitive fixation. RESULTS: FAP within the region of interest was on average 64% medially, 61% laterally, and 62% anteriorly immediately before EF placement. Immediately before definitive open reduction internal fixation, fractional region of interest perfusion was on average 86% medially, 87% laterally, and 86% anteriorly. FAP increased on average 24% medially ( P = 0.0004), 26% laterally ( P = 0.001), and 19% anteriorly ( P = 0.002) from the time of initial EF to the time of definitive open reduction and internal fixation. CONCLUSIONS: Quantitative improvement in soft tissue perfusion was identified through the course of staged surgical management in pilon fractures. LA-ICGA potentially may be used to determine appropriate timing for definitive surgical intervention based on the readiness of the soft tissue envelope. Ultimately, these findings may influence clinical outcomes with respect to choice of surgical approach, soft tissue management, surgical timing, and wound healing. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes After Hamstring ACL Reconstruction With Suture Tape Reinforcement in Adolescent Athletes.

Background: Previous studies have suggested that suture tape-reinforced anterior cruciate ligament (ACL) grafts may have higher ultimate failure loads without stress-shielding. In patients at high risk for graft failure, such as adolescents, the addition of suture tape could have beneficial outcomes. Hypothesis: Suture tape reinforcement (STR) of ACL grafts in adolescent patients would lead to fewer graft ruptures during early recovery, without hindering subjective outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review was performed on adolescent patients with a minimum 2-year follow-up after hamstring tendon autograft ACL reconstruction; enrolled were patients from both before (n = 40) and after (n = 40) a shift in surgical technique that added STR. Both the no-STR and the STR cohorts were contacted yearly to obtain patient-reported outcome data for visual analog scale (VAS; range, 0-10) for pain score, Single Assessment Numeric Evaluation, Lysholm score, Tegner activity score, patient satisfaction score (range, 0-100), and return to previous level of sport (yes/no). The cohorts were then matched based on follow-up duration, excluding those with follow-up of <2 years and >3 years to maintain consistency in duration of follow-up. Graft failure was defined as either graft rupture or recurrent instability symptoms, and failures occurring from index procedure to the 3-year mark were recorded for calculations of failure rate. Results: There were no differences between cohorts in mean age [STR, 15.7 years (range, 9.5-18.7 years); no STR, 14.9 years (range, 9.3-18.8 years)], follow-up duration, laterality, or graft size. While not statistically significant, 2 (5%) patients in the STR cohort experienced graft rupture compared with 7 (17.5%) patients in the no-STR cohort. The Tegner score was significantly higher in the STR cohort (P = .017); no between-group differences were seen on the other outcome scores. A subanalysis of the STR cohort comparing small-diameter grafts (<8 mm) with grafts ≥8 mm also demonstrated no difference in outcome measures, with 1 graft failure in each cohort. Conclusion: Study outcomes indicated that patients treated with ACL reconstruction and STR experienced a significant improvement in Tegner scores while at the same time maintaining the other subjective outcomes.

An Anatomic Study of the Sural Nerve Using 3-Tesla MRI: A Comparison to Cadaveric Data With Surgical Applications.

BACKGROUND: The sural nerve (SN) is a sensory cutaneous nerve that is at risk of iatrogenic injury during surgery at the lateral ankle. Prior anatomic studies of the SN are limited primarily to cadaveric studies with small sample sizes. Our study analyzed a large cohort of magnetic resonance images (MRIs) of the ankle to obtain a more generalizable, in vivo sample of distal SN course. METHODS: A total of 204 3-tesla MRI studies of the ankle were analyzed. Three reviewers measured the distance from the SN to various landmarks including the distal tip of the lateral malleolus (DTLM) and the lateral border of the Achilles tendon (LBA). RESULTS: Mean vertical distance from SN to DTLM was 2.2 cm (range, 0.9-3.6 cm). Mean horizontal distance from SN to DTLM and to LBA at the level of DTLM was 1.7 cm (range, 0.8-3.0 cm) and 1.9 cm (range, 1.0-2.9 cm), respectively. Mean horizontal distance from SN to LBA at the level of superior Achilles tendon insertion onto the calcaneus (SAI) was 2.6 cm (range, 1.4-3.7 cm), and mean horizontal distance from SN to LBA at 5 cm above SAI was 0.9 cm (range, 0.4-1.8 cm). CONCLUSION: The variation in SN course observed in our study allowed us to propose "safe zones" for several surgical approaches including the extensile lateral approach to the calcaneus (ELAC), the sinus tarsi approach (STA), the direct lateral approach to the lateral malleolus (DLA), and the posterolateral approach to the ankle (PLA), which we hope will minimize iatrogenic injury to the SN. LEVEL OF EVIDENCE: Level IV, case series.

Reduction of Opioid Consumption After Outpatient Orthopaedic Trauma Surgeries Using a Multimodal Pain Protocol.

INTRODUCTION: Because of the dearth of literature in the orthopaedic trauma population, we aimed to analyze how a multimodal pain protocol after outpatient surgery affects opioid consumption, pain scores, and patient satisfaction. METHODS: This was a cohort study with a historical control at an urban level 1 trauma center. Forty consecutive outpatients were given a peripheral nerve block and a multimodal pain protocol between September 2019 and March 2020 and compared with 70 consecutive preprotocol patients who received a peripheral nerve block and hydrocodone-acetaminophen. The primary outcome was morphine milligram equivalents (MMEs) consumed. Our secondary aims were pain scores and satisfaction. RESULTS: Patients in the protocol were younger (36.45 versus 45.09 years, P = 0.007), butthere was no difference in sex, body mass index, American Society of Anesthesiologists, or surgical duration. There was a 59% reduction in opioids consumed in the first 4 days after surgery (3.83 MME versus 9.29 MME, P < 0.001). At the postoperative day-14 time point, protocol patients consumed a total of 5.59 MMEs, which is 40% less than just the first 4 days of the preprotocol (P = 0.02). Protocol patients assigned a higher rating of "least pain" on postoperative day 1 (1.24 versus 0.52, P = 0.04) but had higher satisfaction scores on day 1 (9.68 versus 8.54, P < 0.001) and day 2 (9.66 versus 8.61, P < 0.001). CONCLUSION: Implementation of a multimodal pain management protocol after outpatient orthopaedic trauma surgeries reduced opioid consumption by >50% in the first 4 days postoperatively. Additional studies are needed to refine the multimodal pain protocol used in this study. LEVEL OF EVIDENCE: II.

An Anatomic Study of the Lateral Dorsal Cutaneous Nerve Using 3-Tesla MRI: A Comparison to Cadaveric Data With Surgical Applications.

BACKGROUND: The lateral dorsal cutaneous nerve (LDCN) and the anastomotic branch of the sural nerve (AB) are cutaneous sensory nerves at risk of iatrogenic injury during lateral foot surgery. This study is the first to use a large cohort of high-resolution magnetic resonance images (MRIs) of the ankle to better describe the course of these nerves in vivo in order to aid surgeons intraoperatively. Our study intends to build on the "high and inside" approach to the proximal 5MT by accounting for variations in course of the LDCN and AB. METHODS: One hundred twenty-five 3-tesla (T) MRI studies of the ankle were analyzed. Three reviewers measured the distance from the LDCN and AB to landmarks including the most proximal aspect of the fifth metatarsal tuberosity (5MT) and the peroneus brevis tendon (PBT). RESULTS: Mean vertical distance from the LDCN to the 5MT was 0.8 ± 0.2 cm. Presence of an AB was visualized in 59 of 125 studies (47.2%) and was found 2.2 ± 0.5 cm dorsal to the 5MT. The AB was found to become superior to PBT at a horizontal distance 1.9 ± 0.5 cm proximal to the 5MT. The LDCN was found superior to the PBT at its insertion onto the 5MT in approximately 10% (n = 12) of our studies. During these instances, the LDCN was located an average of 0.3 cm dorsal to the PBT. CONCLUSION: Our proposed "safe zone" for the approach to the proximal 5MT remains superior to the LDCN and inferior to the AB and avoids crossing directly over either nerve in >95% of analyzed MRI studies. This incision begins 1.5 cm dorsal to the most proximal aspect of the 5MT and extends no more than 1 cm posteriorly. Careful dissection and identification of the LDCN and possible AB is necessary prior to further extension of incision. LEVEL OF EVIDENCE: Level IV, case series.

Clinical Outcomes, Survivorship, and Return to Sport After Arthroscopic Capsular Repair With Suture Anchors for Adolescent Multidirectional Shoulder Instability: Results at 6-Year Follow-up.

BACKGROUND: Multidirectional shoulder instability (MDI) refractory to rehabilitation can be treated with arthroscopic capsulolabral reconstruction with suture anchors. To the best of our knowledge, no studies have reported on outcomes or examined the risk factors that contribute to poor outcomes in adolescent athletes. PURPOSE: To identify risk factors for surgical failure by comparing anatomic, clinical, and demographic variables in adolescents who underwent intervention for MDI. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: All patients 20 years or younger who underwent arthroscopic shoulder surgery at a single institution between January 2009 and April 2017 were evaluated. MDI was defined by positive drive-through sign on arthroscopy plus positive sulcus sign and/or multidirectional laxity on anterior and posterior drawer tests while under anesthesia. A 2-year minimum follow-up was required, but those whose treatment failed earlier were also included. Demographic characteristics and intraoperative findings were recorded, as were scores on the Single Assessment Numeric Evaluation (SANE), Pediatric and Adolescent Shoulder Survey (PASS), and short version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH). RESULTS: Overall, 42 adolescents (50 shoulders; 31 female, 19 male) were identified as having undergone surgical treatment for MDI with minimum 2-year follow-up or failure. The mean follow-up period was 6.3 years (range, 2.8-10.2 years). Surgical failure, defined as recurrence of subluxation and instability, was noted in 13 (26.0%) shoulders; all underwent reoperation at a mean of 1.9 years (range, 0.8-3.2 years). None of the anatomic, clinical, or demographic variables tested, or the presence of generalized ligamentous laxity, was associated with subjective outcomes or reoperation. Number of anchors used was not different between shoulders that failed and those that did not fail. Patients reported a mean SANE score of 83.3, PASS score of 85.0, and QuickDASH score of 6.8. Return to prior level of sport occurred in 56% of patients. CONCLUSION: Adolescent MDI refractory to nonsurgical management appeared to have long-term outcomes after surgical intervention that were comparable with outcomes of adolescent patients with unidirectional instability. In patients who experienced failure of capsulorrhaphy, results showed that failure most likely occurred within 3 years of the index surgical treatment.

Classifying Ischial Tuberosity Avulsion Fractures by Ossification Stage and Tendon Attachment.

BACKGROUND: We propose a new classification system for ischial tuberosity fractures in adolescents that is based on the ossification pattern of the apophysis. METHODS: We performed a retrospective review of patients who were diagnosed with ischial tuberosity avulsion fractures at a single institution from 2008 to 2018. Skeletal maturity and fracture location, size, and displacement were recorded based on initial injury radiographs. The fractures were classified by location as being lateral (type 1) or complete (type 2). Pelvic computed tomography (CT) review demonstrated 5 stages of ossification. We then reviewed pelvic CT and magnetic resonance imaging scans to assess the tendinous insertions at the ischial tuberosity apophysis. Reliability analysis was performed. RESULTS: We identified 45 ischial tuberosity fractures. The mean patient age was 14.4 years (range, 10.3 to 18.0 years). Boys accounted for 82% of the cohort. Forty-seven percent of the fractures were classified as type 1, and 53% were classified as type 2. Type-1 fractures were associated with younger age (p = 0.001), lower Risser score (p = 0.002), lower modified Oxford score (p = 0.002), less displacement (p = 0.001), and smaller size (p < 0.001) when compared with type-2 fractures. Of the 45 patients, 18 had follow-up of >6 months, with 56% going on to nonunion. Nonunion was associated with greater displacement (p = 0.016) and size (p = 0.027). When comparing union rates by fracture type, 33% of type-1 fractures progressed to nonunion, while 78% percent of type-2 fractures progressed to nonunion; however, this difference was not significant (p = 0.153). A review of the advanced imaging indicated that type-1 fractures involved the semimembranosus and conjoined tendons, whereas type-2 fractures also involved the adductor magnus tendon. CONCLUSIONS: We propose a new classification system based on the ossification pattern of the ischial tuberosity apophysis that reflects the skeletal maturity of the patient, the size and location of the fracture, and the amount of displacement, and likely predicts the probability of subsequent nonunion. The ischial tuberosity ossifies in a pattern similar to the iliac crest as described by Risser, and this pattern of ossification dictates the size of the ischial tuberosity avulsion fracture fragments and the involved tendons.