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.

What Was the Change in Telehealth Usage and Proportion of No-show Visits for an Orthopaedic Trauma Clinic During the COVID-19 Pandemic?

BACKGROUND: In response to the coronavirus disease 2019 (COVID-19) pandemic, the Centers for Medicare and Medicaid Services pledged payment for telehealth visits for the duration of this public health emergency in an effort to decrease COVID-19 transmission and allow for deployment of residents and attending physicians to support critical-care services. Although the COVID-19 pandemic has vastly expanded telehealth use, no studies to our knowledge have analyzed the implementation and success of telehealth for orthopaedic trauma. This population is unique in that patients who have experienced orthopaedic trauma range in age from early childhood to late adulthood, they vary across the socioeconomic spectrum, may need to undergo emergent or urgent surgery, often have impaired mobility, and, historically, do not always follow-up consistently with healthcare providers. QUESTIONS/PURPOSES: (1) To what extent did telehealth usage increase for an outpatient orthopaedic trauma clinic at a Level 1 trauma center from the month before the COVID-19 stay-at-home order compared with the month immediately following the order? (2) What is the proportion of no-show visits before and after the implementation of telehealth? METHODS: After nonurgent clinic visits were postponed, telehealth visits were offered to all patients due to the COVID-19 stay-at-home order. Patients with internet access who had the ability to download the MyChart application on their mobile device and agreed to a telehealth visit were seen virtually between March 16, 2020 and April 10, 2020 (COVID-19) by three attending orthopaedic trauma surgeons at a large, urban, Level 1 trauma center. Clinic schedules and patient charts were reviewed to determine clinical volumes and no-show proportions. The COVID-19 period was compared with the 4 weeks before March 16, 2020 (pre-COVID-19), when all visits were conducted in-person. The overall clinic volume decreased from 340 to 233 (31%) between the two periods. The median (range) age of telehealth patients was 46 years (20 to 89). Eighty-four percent (72 of 86) of telehealth visits were postoperative and established nonoperative patient visits, and 16% (14 of 86) were new-patient visits. To avoid in-person suture or staple removal, patients seen for their 2-week postoperative visit had either absorbable closures, staples, or nonabsorbable sutures removed by a home health registered nurse or skilled nursing facility registered nurse. If radiographs were indicated, they were obtained at outside facilities or our institution before patients returned home for their telehealth visit. RESULTS: There was an increase in the percentage of office visits conducted via telehealth between the pre-COVID-19 and COVID-19 periods (0% [0 of 340] versus 37% [86 of 233]; p < 0.001), and by the third week of implementation, telehealth comprised approximately half of all clinic visits (57%; [30 of 53]). There was no difference in the no-show proportion between the two periods (13% [53 of 393] for the pre-COVID-19 period and 14% [37 of 270] for the COVID-19 period; p = 0.91). CONCLUSIONS: Clinicians should consider implementing telehealth strategies to provide high-quality care for patients and protect the workforce during a pandemic. In a previously telehealth-naïve clinic, we show successful implementation of telehealth for a diverse orthopaedic trauma population that historically has issues with mobility and follow-up. Our strategies include postponing long-term follow-up visits, having sutures or staples removed by a home health or skilled nursing facility registered nurse, having patients obtain pertinent imaging before the visit, and ensuring that patients have access to mobile devices and internet connectivity. Future studies should evaluate the incidence of missed infections or stiffness as a result of telehealth, analyze the subset of patients who may be more vulnerable to no-shows or technological failures, and conduct patient surveys to determine the factors that contribute to patient preferences for or against the use of telehealth. LEVEL OF EVIDENCE: Level III, therapeutic study.

Comparison of Quadriceps-Sparing and Medial Parapatellar Approaches in Total Knee Arthroplasty: A Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: The quadriceps-sparing (QS) technique for total knee arthroplasty (TKA) was introduced to improve outcomes associated with the medial parapatellar (MP) approach. There is no clear consensus on what advantages, if any, QS provides. METHODS: We performed a meta-analysis of randomized controlled trials (RCTs) comparing the QS and MP techniques. PubMed, Ovid, and Scopus were assessed for relevant literature. Long-term (primary) outcomes and short-term (secondary) outcomes from 8 RCTs (579 TKAs) were analyzed using OpenMetaAnalyst (2016). RESULTS: The QS approach did not demonstrate clinically significant advantages, but was associated with statistically and clinically significant increases in the primary outcomes of femoral (odds ratio [OR] 4.92, P = .005), tibial (OR 4.34, P = .01), and mechanical axis outliers (OR 4.77, P = .004). Secondary outcome assessments demonstrated increased surgical (mean differences [MD] 19.54, P < .001) and tourniquet time (MD 23.30, P < .001) for QS. Although statistically significant advantages for QS were identified in Knee Society Function scores at 1.5-3 months (MD 2.31, P = .004) and 2 years (MD 1.86, P < .001), these were not clinically significant (fell below the 6-point minimal clinically important difference). CONCLUSION: The QS approach to TKA fails to demonstrate clinically significant advantages, but shows increased malalignment. This increased incidence of implant malalignment may predispose QS patients to early prosthesis failure. Because the QS approach may increases the risk of malalignment while providing no clear benefit compared to MP, we recommend against the routine use of the QS TKA approach.

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.].

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.

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.

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.

Intra-articular Morphine and Ropivacaine Injection Provides Efficacious Analgesia As Compared With Femoral Nerve Block in the First 24 Hours After ACL Reconstruction: Results From a Bone-Patellar Tendon-Bone Graft in an Adolescent Population.

BACKGROUND: Opioid consumption and patient satisfaction are influenced by a surgeon's pain-management protocol as well as the use of adjunctive pain mediators. Two commonly utilized adjunctive pain modifiers for anterior cruciate ligament (ACL) reconstruction are femoral nerve blockade and intra-articular injection; however, debate remains regarding the more efficacious methodology. HYPOTHESIS: We hypothesized that intra-articular injection with ropivacaine and morphine would be found to be as efficacious as a femoral nerve block for postoperative pain management in the first 24 hours after bone-patellar tendon-bone (BTB) ACL reconstruction. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Charts were retrospectively reviewed for BTB ACL reconstructions performed by a single pediatric orthopaedic surgeon from 2013 to 2019. Overall, 116 patients were identified: 58 received intra-articular injection, and 58 received single-shot femoral nerve block. All patients were admitted for 24 hours. Pain scores were assessed every 4 hours. Morphine milligram equivalents (MMEs) consumed were tabulated for each patient. RESULTS: Opioid use was 24.3 MMEs in patients treated with intra-articular injection versus 28.5 MMEs in those with peripheral block (P = .108). Consumption of MMEs was greater in the intra-articular group in the 0- to 4-hour period (7.1 vs 4.6 MMEs; P = .008). There was significantly less MME consumption in patients receiving intra-articular injection versus peripheral block at 16 to 20 hours (3.2 vs 5.6 MMEs; P = .01) and 20 to 24 hours (3.8 vs 6.5 MMEs; P < .001). Mean pain scores were not significantly different over the 24-hour period (peripheral block, 2.7; intra-articular injection, 3.0; P = .19). CONCLUSION: Within the limitations of this study, we could identify no significant difference in MME consumption between the single-shot femoral nerve block group and intra-articular injection group in the first 24 hours postoperatively. While peripheral block is associated with lower opioid consumption in the first 4 hours after surgery, patients receiving intra-articular block require fewer opioids 16 to 24 hours postoperatively. Given these findings, we propose that intra-articular injection is a viable alternative for analgesia in adolescent patients undergoing BTB ACL reconstruction.

Association Between Rotator Cuff Tears and Superior Migration of the Humeral Head: An MRI-Based Anatomic Study.

BACKGROUND: Superior humeral migration has been established as a component of rotator cuff disease, as it disrupts normal glenohumeral kinematics. Decreased acromiohumeral interval (AHI) as measured on radiographs has been used to indicate rotator cuff tendinopathy. Currently, the data are mixed regarding the specific rotator cuff pathology that contributes the most to humeral head migration. PURPOSE: To determine the relationship between severity of rotator cuff tears (RCTs) and AHI via a large sample of magnetic resonance imaging (MRI) shoulder examinations. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A search was performed for 3-T shoulder MRI performed in adults for any indication between January 2010 and June 2019 at a single institution. Three orthopaedic surgeons and 1 musculoskeletal radiologist measured AHI on 2 separate occasions for patients who met the inclusion criteria. Rotator cuff pathologies were recorded from imaging reports made by fellowship-trained musculoskeletal radiologists. RESULTS: A total of 257 patients (mean age, 52 years) met the inclusion criteria. Of these, 199 (77%) had at least 1 RCT, involving the supraspinatus in 174 (67.7%), infraspinatus in 119 (46.3%), subscapularis in 80 (31.1%), and teres minor in 3 (0.1%). Full-thickness tears of the supraspinatus, infraspinatus, or subscapularis tendon were associated with significantly decreased AHI (7.1, 5.3, and 6.8 mm, respectively) compared with other tear severities (P < .001). Having a larger number of RCTs was also associated with decreased AHI (ρ = -0.157; P = .012). Isolated infraspinatus tears had the lowest AHI (7.7 mm), which was significantly lower than isolated supraspinatus tears (8.9 mm; P = .047). CONCLUSION: Although various types of RCTs have been associated with superior humeral head migration, this study demonstrated a significant correlation between a complete RCT and superior humeral migration. Tears of the infraspinatus tendon seemed to have the greatest effect on maintaining the native position of the humeral head. Further studies are needed to determine whether early repair of these tears can slow the progression of rotator cuff disease.

Predictive Value of the Magnetic Resonance Imaging-Based Coronal Lateral Collateral Ligament Sign on Adolescent Anterior Cruciate Ligament Reconstruction Graft Failure.

BACKGROUND: The coronal lateral collateral ligament (LCL) sign is the presence of the full length of the LCL visualized on a single coronal magnetic resonance imaging (MRI) slice at the posterolateral corner of the knee. The coronal LCL sign has been shown to be associated with elevated measures of anterior tibial translation and internal rotation in the setting of anterior cruciate ligament (ACL) tear. HYPOTHESIS: The coronal LCL sign (with greater anterior translation, internal rotation, and posterior slope of the tibia) will indicate a greater risk for graft failure after ACL reconstructive surgery. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Retrospective review was performed of adolescent patients with ACL reconstruction: a cohort without graft failure and a cohort with graft failure. MRI was utilized to measure tibial translation and femorotibial rotation and to identify the coronal LCL sign. The posterior tibial slope was measured on lateral radiographs. Patient-reported outcomes were collected. RESULTS: We identified 114 patients with no graft failure and 39 patients with graft failure who met all criteria, with a mean follow-up time of 3.5 years (range, 2-9.4 years). Anterior tibial translation was associated with anterolateral complex injury (P < .001) but not graft failure (P = .06). Internal tibial rotation was associated with anterolateral complex injury (P < .001) and graft failure (P = .042). Posterior tibial slope was associated with graft failure (P = .044). The coronal LCL sign was associated with anterolateral complex injury (P < .001) and graft failure (P = .013), with an odds ratio of 4.3 for graft failure (95% CI, 1.6-11.6; P = .003). Subjective patient-reported outcomes and return to previous level of sport were not associated with failure. Comparison of MRI before and after ACL reconstruction in the graft failure cohort demonstrated a reduced value in internal rotation (P = .003) but no change in coronal LCL sign (P = .922). CONCLUSION: Our study demonstrates that tibial internal rotation and posterior slope are independent predictors of ACL graft failure in adolescents. Although the value of internal rotation could be improved with ACL reconstruction, the presence of the coronal LCL sign persisted over time and was predictive of graft rupture (without the need to make measurements or memorize values of significant risk). Together, these factors indicate that greater initial knee deformity after initial ACL tear predicts greater risk for future graft failure.

Coronal Lateral Collateral Ligament Sign: A Novel Magnetic Resonance Imaging Sign for Identifying Anterior Cruciate Ligament-Deficient Knees in Adolescents and Summarizing the Extent of Anterior Tibial Translation and Femorotibial Internal Rotation.

BACKGROUND: Incompetence of the anterior cruciate ligament (ACL) confers knee laxity in the sagittal and axial planes that is measurable with clinical examination and diagnostic imaging. HYPOTHESIS: An ACL-deficient knee will produce a more vertical orientation of the lateral collateral ligament (LCL), allowing for the entire length of the LCL to be visualized on a single coronal slice (coronal LCL sign) on magnetic resonance imaging. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: Charts were retrospectively reviewed from April 2009 to December 2017 for all patients treated with ACL reconstruction (constituting the ACL-deficient cohort). A control cohort was separately identified consisting of patients with a normal ACL and no pathology involving the collateral ligaments or posterior cruciate ligament. Patients were excluded for follow-up <2 years, incomplete imaging, and age >19 years. Tibial translation and femorotibial rotation were measured on magnetic resonance images, and posterior tibial slope was measured on a lateral radiograph of the knee. Imaging was reviewed for the presence of the coronal LCL sign. RESULTS: The 153 patients included in the ACL-deficient cohort had significantly greater displacement than the 70 control patients regarding anterior translation (5.8 vs 0.3 mm, respectively; P < .001) and internal rotation (5.2° vs -2.4°, P < .001). Posterior tibial slope was not significantly different. The coronal LCL sign was present in a greater percentage of ACL-deficient knees than intact ACL controls (68.6% vs 18.6%, P < .001). The presence of the coronal LCL sign was associated with greater anterior tibial translation (7.2 vs 0.2 mm, P < .001) and internal tibial rotation (7.5° vs -2.4°, P = .074) but not posterior tibial slope (7.9° vs 7.9°, P = .973) as compared with its absence. Multivariate analysis revealed that the coronal LCL sign was significantly associated with an ACL tear (odds ratio, 12.8; P < .001). CONCLUSION: Our study provides further evidence that there is significantly more anterior translation and internal rotation of the tibia in the ACL-deficient knee and proves our hypothesis that the coronal LCL sign correlates with the presence of an ACL tear. This coronal LCL sign may be of utility for identifying ACL tears and anticipating the extent of axial and sagittal deformity.

Electric Scooter Orthopaedic Injury Demographics at an Urban Level I Trauma Center.

OBJECTIVES: This study highlights demographics and orthopaedic injuries of electric scooter-related trauma that presented to our institution over a 27-month period. DESIGN: Retrospective review. SETTING: Urban Level 1 trauma center. PATIENTS: Patients presenting to the emergency department, trauma bay, or outpatient clinic after electric scooter injury were identified from November 2017 through January 2020 using ICD-10 diagnosis codes. MAIN OUTCOMES: Patient charts were reviewed for demographics, injury characteristics, imaging, treatment, perioperative data, and Injury Severity Scores. RESULTS: Four hundred eighty-five patients presented during the study period. Of these, 44% had orthopaedic injuries, including 30% with pelvis or extremity fractures. There were 21 (10%) polytraumatized patients in the orthopaedic cohort. The age ranged from 16 to 79 years (average 36 years), with 58% men, and 18% were visitors from out of town. Of 49 patients requiring orthopaedic surgery, 8 underwent surgery on an urgent basis. The average Injury Severity Score for orthopaedic patients was 8.4 with a median of 5.0 for nonoperative injuries versus a significantly higher median of 16.0 for operative injuries. Twenty-nine percent of patients were intoxicated and only 2% wore a helmet. CONCLUSIONS: Electric scooter injuries are increasing, and many patients sustain high-energy injuries. As electric scooter use continues to increase, the prevalence of orthopaedic injuries is also likely to rise. Further studies are needed to fully understand the impact scooter-related injuries have on individual patients and the health care system. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Identifying the axillary nerve during shoulder surgery: an anatomic study using advanced imaging.

BACKGROUND: The axillary nerve (AXN) is one of the more commonly injured nerves during shoulder surgery. Prior anatomic studies of the AXN in adults were performed using cadaveric specimens with small sample sizes. Our research observes a larger cohort of magnetic resonance imaging (MRI) studies in order to gain a more representative sample of the course of the AXN and aid surgeons intraoperatively. METHODS: High-resolution 3T MRI studies performed at our institution from January 2010 to June 2019 were reviewed. Four blinded reviewers with musculoskeletal radiology or orthopedic surgery training measured the distance of the AXN to the surgical neck of the humerus (SNH), the lateral tip of the acromion (LTA), and the inferior glenoid rim (IGR). Intraclass correlation coefficient was calculated to assess reliability between reviewers. The nerve location was assessed relative to rotator cuff tear status. RESULTS: A total of 257 shoulder MRIs were included. Intraclass correlation coefficient was excellent at 0.80 for the SNH, 0.90 for the LTA, and 0.94 for the IGR. All intraobserver reliabilities were above 0.80. The mean distance from the AXN to SNH was 1.7 cm (range, 0.7-3.1 cm; interquartile range, 1.38-2.00) and that from the AXN to IGR was 1.6 cm (range, 0.6-2.6 cm; interquartile range, 1.33-1.88). The mean AXN to LTA distance was 7.1 cm, with a range of 5.2-9.0 cm across patient heights; there was a large effect size related to the LTA to AXN distance and patient height with a correlation of r = 0.603 (P < .001). Rotator cuff pathology appears to affect nerve location by increasing the distance between the AXN and SNH (P = .027). DISCUSSION/CONCLUSION: The AXN is vulnerable to injury during both open and arthroscopic shoulder procedures. This injury can be either a result of direct trauma to the nerve or secondary to traction placed on the nerve with reconstructive procedures that distalize the humerus. Our study demonstrates that the AXN can be found as little as 5.6 mm from the IGR and 6.9 mm from the SNH. In addition, we illustrate the relationship between patient height and the LTA to AXN distance and complete rotator cuff tears and the SNH to AXN distance. Our study is the first to demonstrate the nerve's proximity to important surgical landmarks of the shoulder using a large sample size of high-resolution images in living human shoulders.

Developments in the treatment of Chiari type 1 malformations over the past decade.

BACKGROUND: Chiari malformations type 1 (CM-1), a developmental anomaly of the posterior fossa, usually presents in adolescence or early adulthood. There are few studies on the national incidence of CM-1, taking into account outcomes based on concurrent diagnoses. To quantify trends in treatment and associated diagnoses, as retrospective review of the Kid's Inpatient Database (KID) from 2003-2012 was conducted. METHODS: Patients aged 0-20 with primary diagnosis of CM-1 in the KID database were identified. Demographics and concurrent diagnoses were analyzed using chi-squared and t-tests for categorical and numerical variables, respectively. Trends in diagnosis, treatments, and outcomes were analyzed using analysis of variance (ANOVA). RESULTS: Five thousand four hundred and thirty-eight patients were identified in the KID database with a primary diagnosis of CM-1 (10.5 years, 55% female). CM-1 primary diagnoses have increased over time (45 to 96 per 100,000). CM-1 patients had the following concurrent diagnoses: 23.8% syringomyelia/syringobulbia, 11.5% scoliosis, 5.9% hydrocephalus, 2.2% tethered cord syndrome. Eighty-three point four percent of CM-1 patients underwent surgical treatment, and rate of surgical treatment for CM-1 increased from 2003-2012 (66% to 72%, P<0.001) though complication rate decreased (7% to 3%, P<0.001) and mortality rates remained constant. Seventy percent of surgeries involved decompression-only, which increased neurologic complications compared to fusions (P=0.039). Cranial decompressions decreased from 2003-2012 (42.2-30.5%) while spinal decompressions increased (73.1-77.4%). Fusion rates have increased over time (0.45% to 1.8%) and are associated with higher complications than decompression-only (11.9% vs. 4.7%). Seven point four percent of patients experienced at least one peri-operative complication (nervous system, dysphagia, respiratory most common). Patients with concurrent hydrocephalus had increased; nervous system, respiratory and urinary complications (P<0.006) and syringomyelia increased the rate of respiratory complications (P=0.037). CONCLUSIONS: CM-1 diagnoses have increased in the last decade. Despite the decrease in overall complication rates, fusions are becoming more common and are associated with higher peri-operative complication rates. Commonly associated diagnoses including syringomyelia and hydrocephalus, can dramatically increase complication rates.