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Neuromuscular scoliosis is commonly associated with a large pelvic obliquity. Scoliosis in children with cerebral palsy is most commonly managed with posterior spinal instrumentation and fusion. While consensus is reached regarding the proximal starting point of fusion, controversy exists as to whether the distal level of spinal fusion should include the pelvis to correct the pelvic obliquity.To assess the role of pelvic fusion in posterior spinal instrumentation and fusion, particularly it impact on pelvic obliquity correction, and to assess if the rate of complications differed as a function of pelvic fusion.This was a retrospective, cohort study in which we reviewed the medical records of children with cerebral palsy scoliosis treated with posterior instrumentation and fusion at a single institution. Minimum follow-up was six months. Patients were stratified into two groups: Those who were fused to the pelvis and those fused to L4/L5. The major outcomes were complications and radiographic parameters. The former were stratified into major and minor complications, and the latter consisted of preoperative and final Cobb angles, L5-S1 tilt and pelvic obliquity.The study included 47 patients. The correction of the L5 tilt was 60% in patients fused to the pelvis and 67% in patients fused to L4/L5 (Including the pelvis in the distal level of fusion for cerebral palsy scoliosis places patients at an increased risk of postoperative complications. The added value that pelvic fusion offers in terms of correcting pelvic obliquity is not clear, as these patients had similar percent correction of their pelvic obliquity and L5 tilt compared to children whose fusion was stopped at L4/L5. Therefore, in a select patient population, spinal fusion can be stopped at the distal lumbar levels without adversely affecting the surgical outcomes.

Giant cell tumor of the distal radius presents a significant challenge in management due to high risk of recurrence and potential loss of function. Shared decision-making guides management, particularly for more advanced lesions. Intralesional curettage can optimize wrist function but at the cost of a higher recurrence risk. Wide resection decreases local recurrence but has higher complication rates regardless of reconstruction method. No functional difference exists between motion-preserving procedures and arthrodesis; therefore, patients should be clearly informed of the risks and benefits of each treatment option.

STUDY DESIGN: This was a case series. OBJECTIVE: The authors sought to examine the high-risk population of COVID-positive patients with acute cervical spinal cord injury (SCI) in a large level 1 trauma and tertiary referral center. SUMMARY OF BACKGROUND DATA: There are limited studies regarding the surgical management of patients with acute SCI in the setting of the recent coronavirus pandemic. METHODS: The authors describe the cases of 2 patients who died from COVID-related complications after acute cervical SCI. RESULTS: Patients with SCI are at increased risk of pulmonary complications. COVID-19 infection represents a double hit in this patient population, increasing potential morbidity and mortality in the perioperative time frame. Careful consideration must be made regarding the timing of potential surgical intervention in the treatment of acute SCI. CONCLUSIONS: Nationwide database of COVID-positive patients with acute spinal cord injury should be collected and analyzed to better understand how to manage acute SCI in the COVID-19 era. The authors recommend preoperative discussion in patients with acute cervical SCI with COVID-19, specifically emphasizing the increased risk of respiratory complications and mortality.

Background The indications and technique for the transfibular approach to the tibiotalar joint have evolved since its initial popularization in 1942. The purpose of this systematic review is to assess the indications, techniques, and postoperative outcomes among procedures performed with the transfibular approach. Methods A comprehensive search of PubMed, Medline, and Embase databases from 1942 to 2018 was performed in accordance with PRISMA guidelines. After an initial broad search of transfibular approach indications, articles were stratified into 4 major surgical categories for assessment: (1) tibiotalar arthrodesis (2) tibiotalocalcaneal arthrodesis (3) total ankle replacement and (4) distal tibial tumor excision. Data was analyzed according to these 4 categories. Results A total of 32 studies (874 ankles) were included. Fibular non-union rates were 0.7 % (5 of 672) across all studies, 0.6% (2 of 329) for tibiotalar arthrodesis, 0.0% (0 of 12) for tibiotalocalcaneal arthrodesis, 1.0 % (3 of 296) for total ankle arthroplasty and 0.0% (0 of 15) for other procedures. Rates of deep infection were 2.5% (23 of 903) across all studies, 3.2% (15 of 466) for tibiotalar arthrodesis, 3.7% (4 of 106) for tibiotalocalcaneal arthrodesis, 1.3% (4 of 296) for total ankle arthroplasty, and 0.0% (0 of 15) for other procedures. Conclusions The transfibular approach is useful for cases requiring extensile exposure of the tibiotalar joint. This study provides evidence that the transfibular approach yields satisfactory results, with low complication and infection rates. Level of evidence IV

Background: No study has examined the incidence of risk factors for postoperative falls following foot and ankle surgery. We investigated the incidence and risk factors for postoperative falls in foot and ankle surgery using inpatient and outpatient population. Methods: A single fellowship-trained foot and ankle surgeon instituted collection of a postoperative fall questionnaire at 2 and 6 weeks postoperatively. A retrospective review of 135 patients with complete prospectively collected fall questionnaire data was performed. Patient demographic information, injury characteristics, comorbidities, baseline medications, length of hospital stay, visual analog scale (VAS) pain scores were collected. After univariable analysis, a multivariable binary logistic regression was conducted to assess independent risk factors for postoperative falls. Results: The median (interquartile range) age was 52 (21) and body mass index was 32.7 (11.1). A total of 108 patients (80%) underwent outpatient procedures. Thirty-nine of the 135 patients (28.9%) reported experiencing a fall in the first 6 weeks after surgery. In multivariable analysis, antidepressant use (adjusted odds ratio 3.41, 95% CI 1.19-9.81) and higher VAS pain scores at 2 weeks postoperatively (adjusted odds ratio 1.27, 95% CI 1.08-1.50) were found to be independent risk factors for postoperative falls. Conclusion: This study found a high incidence of postoperative falls in the first 6 weeks after foot and ankle surgery. Baseline antidepressant use and higher 2-week VAS pain scores were associated with postoperative falls. Foot and ankle surgeons should discuss the risk of falling with patients especially those with risk factors. Level of Evidence: Level III, retrospective cohort study at a single institution.

OBJECTIVES This study compares the intraoperative and postoperative outcomes of the traditional technique of femoral canal reaming to placement of an unreamed 10-mm nail. DESIGN Retrospective cohort study. SETTING Academic Level I Trauma Center, Southeastern US. PATIENTS/PARTICIPANTS Intertrochanteric femur fractures treated with a CMN (January 2016-December 2018) were retrospectively identified. Inclusion criteria were as follows: low-energy mechanism, at least 60 years of age, and long CMN. Exclusion criteria were as follows: short CMN, polytrauma, and subtrochanteric fractures. OUTCOME MEASUREMENTS Records were reviewed for demographics, hematologic markers, transfusion rates, operative times, and postoperative complications. Variables were assessed with a χ or Student T-test. Significance was set at 0.05. RESULTS Sixty-five patients were included (37 reamed and 28 unreamed), with a mean age of 76.2 years and mean body mass index of 25.1. Between the reamed and unreamed groups, respectively, mean nail size was 11.0 (SD 1.1) and 10.0 (SD 0.0), P < 0.001; mean blood loss was 209.1 mL (SD 177.5) and 195.7 mL (SD 151.5), P = 0.220; 55% (21/38), and 43% (12/28) were transfused, P = 0.319; operative time was 98.2 (SD 47.3) and 81.5 minutes (SD 40.7); P = 0.035. Changes in hemoglobin/hematocrit were not significant between the study groups. Two patients from the reamed group experienced implant failure due to femoral head screw cut out and returned to the operating room. Two patients from the unreamed group returned to operating room for proximal incision infection, without implant removal. One reamed patient and 2 unreamed patients died before 6-month follow-up. CONCLUSIONS Unreamed CMNs for geriatric intertrochanteric femur fractures provide shorter operative times with no difference in perioperative complications. Both reamed and unreamed techniques are safe and effective measures for fixation of these fractures. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Traumatic hemipelvectomy (THP) is a catastrophic injury associated with high-energy trauma and high mortality. THP has been defined as a complete dislocation of the hemipelvis, often with disruption through the symphysis pubis and sacroiliac joint with concurrent traumatic rupture of the iliac vessels. Despite recent advances in prehospital resuscitative techniques, the true incidence of THP is difficult to ascertain because many patients die before hospital arrival. The leading causes of death associated with THP include blood loss, infection, and multiple system organ failure. Recognition and immediate intervention for these injuries is imperative for survival. The initial assessment includes a thorough physical examination assessing for signs of arterial damage and other associated injuries. Hemorrhage control and vigorous resuscitation should be prioritized to combat impending exsanguination. Emergent amputation has been found to be a lifesaving operation in these patients. The basis of this approach is rooted in achieving complete hemostasis while reducing complication rates. Understanding the nature of these massive pelvic injuries, the role of early amputation, and the importance of subspecialty communication can improve survivability and optimize patient outcomes.

Introduction The aim of this study was to anatomically compare distal clavicle and coracoid autografts and their potential to augment anterior-inferior glenoid bone loss. Methods Ten millimeters of distal clavicle and 20 mm of coracoid were harvested bilaterally from 32 cadavers. Length, weight, and height were measured and surface area and density were calculated. For each graft, ipsilateral measurements were compared and the ability to restore corresponding glenoid bone loss was calculated. Results Distal clavicle grafts were larger than coracoid grafts with respect to length (22.3 mm versus 17.7 mm; p 3 versus 1.96 cm3; p = 0.002). Coracoid grafts had larger widths (14.56 mm versus 10.52 mm; p 3 versus 1.18 g/cm3; p 2 versus 1.5 cm2; p 2 versus 1.5 cm2; p Discussion Distal clavicle grafts were larger and restored larger bony defects but had greater variability and lower density than coracoid grafts. Clinical studies are needed to compare these graft options.

Context Injuries in professional ultimate Frisbee (ultimate) athletes have never been described. Objective To determine injury rates, profiles, and associated factors using the first injury-surveillance program for professional ultimate. Design Descriptive epidemiology study. Setting American Ultimate Disc League professional ultimate teams during the 2017 season. Patients or Other Participants Sixteen all-male teams. Main Outcome Measure(s) Injury incidence rates (IRs) were calculated as injuries per 1000 athlete-exposures (AEs). Incidence rate ratios were determined to compare IRs with 95% confidence intervals, which were used to calculate differences. Results We observed 299 injuries over 8963 AEs for a total IR of 33.36 per 1000 AEs. Most injuries affected the lower extremity (72%). The most common injuries were thigh-muscle strains (12.7%) and ankle-ligament sprains (11.4%). Running was the most frequent injury mechanism (32%). Twenty-nine percent of injuries involved collisions; however, the concussion rate was low (IR = 0.22 per 1000 AEs). Injuries were more likely to occur during competition and in the second half of games. An artificial turf playing surface did not affect overall injury rates (Mantel-Haenszel incidence rate ratio = 1.28; 95% confidence interval = 0.99, 1.67). Conclusions To our knowledge, this is the first epidemiologic study of professional ultimate injuries. Injury rates were comparable with those of similar collegiate- and professional-level sports.

OBJECTIVE To determine whether patient height correlates with implant length selection of antegrade or retrograde femoral intramedullary implants. DESIGN Case-control Study. SETTING A single level 1 trauma center. PATIENTS/PARTICIPANTS All patients with operatively treated femoral shaft fractures from 2011 to 2017. INTERVENTION All fractures were treated with an intramedullary nail. Retrograde or antegrade insertion was decided at the discretion of the surgeon and fracture location. MAIN OUTCOME MEASUREMENTS Length of femoral implant and patient height. RESULTS Five hundred sixty-seven operatively treated fractures were reviewed, 322 antegrade and 245 retrograde. The correlation between patient height and actual nail length was 0.55 for antegrade implants (P < 0.01) and 0.59 for retrograde implants (P < 0.01). Separate prediction equations for nail length based on patient height were estimated for antegrade and retrograde implants and found accurate prediction of length 86% and 88% of the time, respectively. CONCLUSIONS Intramedullary nail length can be accurately predicted based on patient height and the technique using the equations below. This is the first study to establish a simple equation to serve as an adjunct for selecting the most appropriate length implant. This equation can be used in cases of bilateral femur fractures, templating to have appropriate sized implants in close proximity to the odds ratio, and in remote environments where surgical planning is critical for determining implant needs.

Context:Lyme disease is the most common tick-borne illness in North America and Europe, and Lyme arthritis is a frequent late-stage manifestation in the United States. However, Lyme arthritis has rarely been reported as a postoperative complication.Evidence Acquisition:The PubMed database was queried through June 2018, and restricted to the English language, in search of relevant articles.Study Design:Clinical review.Level of Evidence:Level 3.Results:A total of 5 cases of Lyme arthritis as a postoperative complication have been reported in the literature.Conclusion:These cases highlight the importance for providers practicing in Lyme-endemic regions to keep such an infection in mind when evaluating postoperative joint pain and swelling. We propose herein an algorithm for the workup of potential postoperative Lyme arthritis.Strength of Recommendation Taxonomy (SORT):C

Objective: To identify independent risk factors, complications and early hospital readmission following total knee arthroplasty. Methods: Using the ACS-NSQIP database, we identified patients who underwent primary TKA from 2012-2015. The primary outcome was early hospital readmission. Patient demographics, preoperative comorbidities, laboratory data, operative characteristics, and postoperative complications were compared between readmitted and non-readmitted patients. Logistic regression identified independent risk factors for 30-day readmission. Results: 137,209 patients underwent TKA; 3.4% were readmitted within 30 days. Advanced age, male sex, black ethnicity, morbid obesity, presence of preoperative comorbidities, high ASA classification, and increased operative time were independently related risk factors. Asian and no reported race were negative risk factors. Postoperative complications: acute myocardial infarction, acute renal failure, stroke, pneumonia, pulmonary embolism, and deep vein thrombosis show positive associations. Conclusions: Advanced age, male sex, black ethnicity, morbid obesity, presence of comorbidities, high ASA classification and long operative time are independent risk factors for postoperative complications and early hospital readmission following total knee arthroplasty. Level of Evidence III, Case control study. RESUMO Objetivo: Identificar fatores de risco independentes, complicações e reinternação precoce após artroplastia total do joelho. Métodos: A partir de banco de dados ACS-NSQIP, identificamos pacientes submetidos à ATJ primária de 2012 a 2015. O desfecho primário foi a reinternação hospitalar precoce. Dados demográficos, comorbidades pré-operatórias, dados laboratoriais, características cirúrgicas e complicações pós-operatórias foram comparadas entre os pacientes reinternados e não reinternados. A regressão logística identificou fatores de risco independentes para a reinternação em 30 dias. Resultados: Foram identificados 137.209 pacientes submetidos à ATJ, sendo que 3,4% foram reinternados no período de 30 dias. A idade avançada, o sexo masculino, a raça negra, a obesidade mórbida, a presença de comorbidades pré-operatórias, a alta classificação ASA e o aumento do tempo cirúrgico foram fatores de risco relacionados independentemente. A raça asiática e as não relatadas foram fatores de risco negativos. As complicações pós-operatórias infarto agudo do miocardio, insuficiência renal aguda, acidente vascular cerebral, pneumonia, embolia pulmonar e trombose venosa profunda apresentaram associações positivas. Conclusões: Idade avançada, sexo masculino, raça negra, obesidade mórbida, presença de comorbidades, classificação ASA elevada e tempo cirúrgico prolongado são fatores de risco independentes de complicações pós-operatórias e reinternação precoce após artroplastia total do joelho. Nível de evidência III, Estudo de caso de controle.

Introduction Distal radius fractures are common, but the results and complications of treatment with early external fixation and staged open reduction internal fixation have not been previously reported. Materials and methods Patients who received staged distal radius fracture treatment from 1/1/2008 to 12/31/2015 at the University of Alabama at Birmingham were identified. Patient, injury, and treatment characteristics, as well as complications, were collected from the medical record. Results There were 50 fractures in 47 patients, with mean follow-up of 9.3 months. Thirty-eight were open and 45 were intra-articular. For definitive treatment, 41 received a volar approach and nine a dorsal approach. Twenty wrists experienced one or more complications, including two non-unions. Five patients developed infections – one Kirschner wire site infection, one external fixator (ex-fix) pin site infection, and three deep infections. All deep infections occurred in tobacco users. The rate of deep infection with volar approach was 2.4%, compared to 22.2% with dorsal approach. Ex-fix pin sites overlapped radiographically with the plate in 20 fractures, with three deep infections in this group (15%) and no deep infections in the group without overlap. None of these differences reached statistical significance. Conclusions This protocol results in reliable healing of complex fractures, with a 96% union rate. However, 40% sustained complications. We conclude that this protocol is useful for temporizing complex fractures but caution that the complication rate is high. Since recent literature indicates that low-grade open distal radius fractures do not require emergent debridement and that immediate internal fixation is safe, complications might be avoided by restricting this protocol to complex or physiologically unstable patients.

Background: Studies of patient retention at student-run free clinics (SRFCs) are lacking. We determined variables associated with clinic retention at Equal Access Birmingham (EAB), an urban SRFC that aims to provide acute care for clients with transitory health needs and longitudinal care for patients with chronic diseases. Methods: We retrospectively analyzed EAB patient data from March 1, 2013 to July 1, 2015, including demographic, social, medical history, and clinical care variables. The primary outcome was retention in care, defined as attendance at a follow-up appointment 6 to 12 months after the initial new patient visit. Potential predictors of retention were examined using stepwise multivariate logistic regression.Results: Patient retention rate was 25.2%. Positive predictors of retention included receipt of medication at the initial visit (odds ratio [OR] 15.40, 95% confidence interval [CI] 1.56-152.82), more kept appointments within 6 months of initial visit (OR 2.00, 95% CI 1.51-2.66), and longer time to follow-up (OR 1.14, 95% CI 1.04-1.26). Negative predictors included receiving only acute care at initial visit (OR 0.10, 95% CI 0.01-0.95), any appointment no-shows (OR 0.33, 95% CI 0.13-0.86), and cancellations (OR 0.29, 95% CI 0.09-0.87) within 6 months of an initial visit.Conclusion: This study is one of the first to analyze predictors of patient retention at a SRFC. Although we analyze a relatively small sample size in a single SRFC, our results inform strategies to better retain SRFC patients who have high rates of chronic illness and are vulnerable to loss to follow-up.

Myositis ossificans is a benign, solitary, frequently self-limiting, ossifying soft-tissue mass encountered often in the active sporting population. Typically occurring within skeletal muscle - most often the brachialis, quadriceps and adductor muscle groups - lesions may arise with or without a traumatic history. The exact pathophysiology of these ossifying lesions is still poorly understood. Patients present with localized pain and swelling with loss of range of motion. Plain radiographs may not be able to detect early lesions, which allows for an expanded role of ultrasonography as an early screening modality, despite magnetic resonance imaging remaining the gold standard for imaging of soft tissue masses. Conservative treatment is implemented for most patients with excellent outcomes, with surgical excision being an option for persistent symptoms or progressive disease. Typically, athletes are able to progress to light activity at 2 to 3 months, full activity by 6 months, and back to their preinjury level by 1 year.

Category: Ankle, Ankle Arthritis, Hindfoot Introduction/Purpose: A variety of operative approaches and fixation techniques have been described for tibiotalar (TT) and tibiotalocalcaneal (TTC) arthrodesis. In the past two decades, authors have begun to more robustly examine outcomes of the transfibular approach for TT arthrodesis and expanded its indication to include TTC fusion. The transfibular technique is broadly divided into two categories: 1) Complete excision of fibula 2) Soft tissue preservation techniques with retention of fibula. The purpose of this study was to retrospectively assess the surgery outcomes in transfibular approach and compare the fibula excision versus fibula retention techniques and examine the factors that play into the risk. Methods: Following institutional review board approval, a retrospective review was performed on all patients who underwent TT and TTC arthrodesis through a lateral transfibular approach with minimum 1 year clinical and radiologic follow up. All other operative approach and fixation combinations for arthrodesis were excluded. Primary outcomes examined were union rate, revisions, and complications related to fibula excision versus retention group. Sixteen patients underwent TT and TTC arthrodesis with fibular retention and twelve with fibular excision techniques. Results: The overall union rate was 89%, 87% (14 of 16 ankles) for the fibula retention group, and 91% (11 of 12) for fibula excision group (P = .72). Symptomatic nonunion requiring revision arthrodesis occurred in 6% (1 of 16) of the retention group versus 8% (1 of 12) in the excision group (P = .83). There were no significant differences in individual tibiotalar or subtalar union, reoperation, superficial wound problems, infection and symptomatic hardware rates. Elective hardware removal was performed in 12%(2of 16) in fibular retention group versus 25%(3 of 12) in fibula excision group (P = .39), none of the hardware removal was related to the fibula fixation. Each group had three episodes of reoperation due to non-union, osteomyelitis and painful hardware. Conclusion: Union, reoperation rates were similar in fibula resection versus retention groups. The frequency of infection and wound complication was not significantly different in both groups, despite the wide variety of patient population and preoperative indications.

Case Extraskeletal myxoid chondrosarcoma (EMC) is a rare soft tissue malignancy that very seldomly presents in the foot or ankle and as a result is not commonly in the differential of patients presenting with foot pain. We cite a case of EMC presenting in the atypical location of the midfoot. Because of its location and similarities, this tumor was initially misdiagnosed and mistreated by multiple medical providers as midfoot Charcot arthropathy. Conclusions Neoplastic etiologies, including EMC, should remain in the differential for atypical, refractory foot pain that presents in a manner similar to Charcot foot.