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Many fixation techniques have been described to manage intraoperative greater trochanteric (GT) fractures during revision total hip arthroplasty (rTHA), but complications such as broken hardware and bursitis are common. The purpose of this study was to determine whether surgical fixation of an intraoperative GT fracture resulted in improved outcomes in rTHA. We reviewed a consecutive series of 1442 rTHA patients at our institution from 2008 to 2019. We identified all patients with an intraoperative GT fracture and noted whether the fracture was fixed surgically or left without fixation. Demographics, comorbidities, complications, radiographic union, and dislocations were compared between the groups. Of the 44 (3%) intra-operative GT fractures identified, 23 (52%) underwent fixation, most commonly with claw plates (8 patients) and cables (10 patients). There were no differences in the rates of radiographic union (86% vs 100%, P =.100), dislocations (4% vs 10%, P =.599), or re-revision (10% vs 13%, P =1.000) between the groups. Patients undergoing fixation had a higher rate of bursitis postoperatively, but it was not significant with the numbers available (35% vs 10%, P =.072). Our cohort of GT fractures at a large revision referral institution represents the largest reported series of GT fractures during rTHA. Surgical fixation in rTHA did not show improved outcomes in terms of dislocation, re-revision, and radiographic union compared with those fractures that were not fixed. There was a trend toward increased postoperative bursitis in the group undergoing surgical fixation. Further research is needed on this topic, as the number of rTHAs continues to increase. [ Orthopedics . 202x;4x(x):xx–xx.]

The Centers for Medicare and Medicaid Services (CMS) now requires hospitals to publish charges for commonly performed procedures. This study aimed to evaluate compliance with the price transparency mandate and to determine if there is a correlation between hospital charges and episode-of-care claims costs and outcomes after total hip arthroplasty (THA) and total knee arthroplasty (TKA).We identified a consecutive series of 2476 Medicare patients who underwent primary THA or TKA from 2018 to 2019 at one of 18 hospitals. Each hospital website was explored to assess compliance with the new price transparency requirements. Demographics, comorbidities, complications, and readmissions were recorded. Ninety-day episode-of-care claims costs were calculated using CMS claims data. Multivariate regression was performed to determine whether hospital charges had any association with complications, readmissions, or episode-of-care costs.There was no correlation between published hospital charges and inpatient costs (r = 0.087), postacute care costs (r = 0.126), or episode-of-care costs (r = 0.131). When controlling for demographics and comorbidities, there was no association between published charges and complications (P = .433) or readmissions (P = .141). All hospitals posted some shoppable services information online, but only 7 (39%) were fully compliant by publishing all price data. Of the 11 hospitals (61%) publishing hospital THA and TKA charges, the mean charge was $48,325 (range, $12,625-$79,531).Published charges for TKA and THA had no correlation with episode-of-care claims costs and were not associated with clinical outcomes. Despite efforts by CMS to increase price transparency, few hospitals were fully compliant, and a wide range in published charges was found.

Surgical specialty hospitals provide patients, surgeons, and staff with a streamlined approach to elective surgery but may not be equipped to handle all complications arising postoperatively. The purpose of this study is to evaluate the immediate postoperative and 90-day outcomes of patients who were transferred from a high-volume specialty hospital following primary total hip arthroplasty (THA) or total knee arthroplasty (TKA).All patients who were admitted to one orthopedic specialty hospital for primary THA or TKA between January 2015 and December 2019, and subsequently transferred to a tertiary care hospital, were identified and propensity matched to nontransferred patients. Emergency department visits, complications, readmissions, mortality, and revisions within 90 days of surgery were identified for each group.There were 26 TKAs (0.78%) and 20 THAs (0.48%) transferred, representing 0.62% of all primary THAs and TKAs performed over the study duration. Arrhythmia and chest pain were the most common reasons for transfer. Ninety-day readmissions were significantly higher in the transfer group (15.2% vs 4.3%, P = .020) with an odds ratio for readmission after transfer of 3.9 (95% confidence interval 1.3-12.4). Overall complications and orthopedic complications did not differ significantly, although transferred patients had a higher rate of medical complications (13.0% vs 2.2%, P = .008) with an odds ratio of 6.7 (95% confidence interval 1.6-28.2).Transfer from a specialty hospital is rarely required following primary TKA and THA. Although not at increased risk for orthopedic complications, these transferred patients are at increased risk for readmissions and medical complications within the first 90 days of their care, necessitating increased vigilance.

BACKGROUND Our orthopedic practice recently implemented a system that enables patients to schedule outpatient visits through an online portal without the need for traditional communication with office staff. Previous studies have found that the use of web-based scheduling correlates with reduced no show rates, staff labor, waiting time, and improved patient satisfaction. The appropriateness of the web-based scheduling and the rate of progression to surgery is unclear, as patients may not be appropriate candidates for surgical consultation. The purpose of this study was to compare the no show and surgical progression rates between online-scheduled and traditionally scheduled outpatient visits in our practice. OBJECTIVE Our primary hypothesis was that there is no significant difference in the rate of progression to surgery within three months after the initial ‘new visit’ between online-scheduling and traditionally scheduling services. The secondary hypothesis was that there was no significant difference in the no-show rate between the two scheduling services. METHODS All outpatient visits at a single large multispecialty orthopedic practice from 2/1/2022 through 2/28/2022 were collected. Scheduled visits were identified as either “online -scheduled” indicating patients scheduled their own visit through the new web-based patient portal system, or “traditionally scheduled,” indicating that the visit was scheduled with office staff. All visits were further categorized as either a “new visit” or a “follow-up visit.” Surgical records were reviewed to identify patients that underwent surgery within three months of their scheduled office visits. RESULTS Within the one-month timeframe, there were 71,673 traditionally scheduled visits and 3,058 patient scheduled visits. The rate of progression to surgery within three months after the new visit showed a significant difference (18% of online-scheduled vs. 21% of traditionally scheduled new visits; P=0.036). There was no difference in no-show rates between the two scheduling groups (4.5% of online-scheduled vs. 4.4% of traditionally scheduled visits; P=0.79). Subgroup analysis showed no significant difference in no-show rate when comparing new patients and follow-up visits separately. CONCLUSIONS Online-scheduling systems allow for greater patient autonomy and access to care, while reducing the administrative burden of office staff. A small but significant difference in the surgery rate with the traditional scheduling might be explained by the fact that the older generation still has more confidence in phone call scheduling than in using electronic applications. Moreover, the new office visits following urgent care referrals can be squeezed more rapidly into the schedule via the traditional scheduling because it is impossible to haggle with the system.

Hip fracture in older patients leads to high morbidity and mortality. Patients who are treated surgically, but fail acutely face a more complex operation with conversion total hip arthroplasty (THA). This study investigated mortalities and complications in patients who experienced failure within one year following hip fracture surgery requiring conversion THA.Patients 60 years or older undergoing conversion THA within one year following intertrochanteric or femoral neck fracture were identified and propensity-matched to patients sustaining hip fractures treated surgically, but not requiring conversion within the first year. Patients who had two-year follow-up (91 conversion; 247 comparison) were analyzed for 6-, 12-, and 24-month mortalities, 90-day readmissions, surgical complications, and medical complications.Nonunion and screw cutout were the most common indications for conversion THA. Mortalities were similar between groups at 6 months (7.7 conversion vs 6.1% non-conversion, p=0.774), 12 months (11 conversion vs 12% non-conversion, p=0.999), and 24 months (14 conversion vs 22% non-conversion, p=0.163). Survivorships were similar between groups for the entire cohort and by fracture type. Conversion THA had a higher rate of 90-day readmissions (14 vs 3.2%, p=0.001 and medical complications (17 vs 6.1% p=0.006). Inpatient and 90-day orthopaedic complications were similar.Conversion THA for failed hip fracture surgery had comparable mortality rates to hip fracture surgery, with higher rates of perioperative medical complications and readmissions. Conversion THA following hip fracture represents a potential "second hit" that both surgeons and patients should be aware of with initial decision making.

STUDY DESIGN Correlational study. OBJECTIVE In spine trauma patients, we aimed to assess the correlation of patient-reported outcome measurement information system (PROMIS) physical function (PF), pain interference (PI), and Depression scores with Oswestry Disability Index (ODI) and Neck Disability Index (NDI) ODI/NDI scores. SUMMARY OF BACKGROUND DATA The ODI and NDI were intended as patient-reported outcome measures (PROMs) to evaluate clinical outcomes in patients seeking spine care. To date, the PROMIS has not been studied in the spine trauma population. METHODS Between January 1, 2015 and December 13, 2017, patients presenting to a single, level 1 trauma center spine clinic with known spine trauma were identified. A total of 56 patients (52 operative, 4 nonoperative) representing 181 encounters were identified. PROMIS PF, PI, and Depression, as well as the ODI or NDI, were administered to patients. Spearman rho (ρ) were calculated between PROMs. RESULTS A strong correlation exists between PROMIS PI and the ODI (ρ = 0.79, P

To retrospectively compare return to sport rates and subjective outcomes of patients who underwent open or endoscopic compartment release for the surgical management of chronic exertional compartment syndrome.This was a retrospective review of patients who underwent lower-extremity fasciotomy for chronic exertional compartment syndrome from June 2012 to June 2020. Eligibility included patients 15 to 45 years of age who identified as an athlete and had at least 6 months of follow-up. Fasciotomies for trauma or infection were excluded. One surgeon exclusively performed each type of surgery. Postoperative outcome measures included the Lower Extremity Functional Scale, the Marx Activity Scale, and a return to play survey.In total, 24 patients (13 endoscopically assisted fasciotomies, 11 open fasciotomies) had a mean follow-up of 3.8 ± 2.1 years; 19 patients returned to their sporting activity. No significant difference existed between return to play rates (In this small sample of heterogenous groups of patients, we found no significant differences in return to sport rates or subjective results after surgery. Patients experienced a high subjective recurrence rate. The endoscopically assisted fasciotomy group reported greater subjective patient satisfaction compared with the open fasciotomy group.Level III, comparative study, retrospective.

Our objective was to describe a measurement to assess sagittal tibial tuberosity (TT)-trochlear groove (TG) distance and to compare this between asymptomatic (control) patients and patients with symptomatic patellar instability.We compared static CT images of 22 fully extended knees of patients with symptomatic patellar instability with images of 22 asymptomatic knees. TT-TG distance was measured to quantify lateralization of the TT, and anteroposterior TT-TG distance was used to quantify the sagittal distance between these two points. Lateral trochlear inclination, sulcus angle, and trochlear depth were measured. Groups were compared using paired t tests (alpha = 0.05). Correlations of anteroposterior TT-TG distance with lateral trochlear inclination, sulcus angle, and trochlear depth were assessed using linear and multivariate regression.Mean TT-TG distances were 19.9 ± 4.4 mm (symptomatic) and 16.8 ± 5.5 mm (control) (mean ± std deviation) (P = 0.002). Mean anteroposterior TT-TG distances were 8.3 ± 7.8 mm (symptomatic) and -0.5 ± 4.6 mm (control) (P 0.0001). The symptomatic group had greater measurements of trochlear dysplasia, with lower lateral trochlear inclination, greater sulcus angle, and lower trochlear depth (all P 0.0001). Anteroposterior TT-TG distance and trochlear depth were strongly negatively correlated (r = 0.62, RIn asymptomatic patients, the anteroposterior TT-TG distance was -0.5 mm, indicating that the TG and TT were nearly in the same coronal plane. In patients with symptomatic patellar instability, the TG was almost nine millimeters anterior, and this distance correlated with measurements of trochlear dysplasia.III, case control study.

The average background radiation exposure in the United States has nearly doubled over the previous quarter century, with almost all the increase derived from medical imaging. Nearly 2% of all cancers in the United States may be attributable to radiation from computerized tomography (CT) scans. Given the nondiagnostic nature of CT scans that are used in elective knee and hip arthroplasty today, special consideration should be given to the inherent risk of radiation exposure with routine use of this technology. Methods to decrease radiation exposure including modulating the settings of the CT machine and using alternative non-CT-based systems can decrease patient exposure to radiation from CT scans. The rapid evolution of CT technology in arthroplasty has allowed for expanded clinical applications, the benefits of which remain controversial.

Although studies have compared the claims costs of simultaneous and staged bilateral total hip arthroplasty (THA) and total knee arthroplasty (TKA), whether a simultaneous procedure is cost-effective to the facility remains unknown. This study aimed to compare facility costs and perioperative outcomes of simultaneous vs staged bilateral THA and TKA.We reviewed a consecutive series of 560 bilateral THA (170 staged and 220 simultaneous) and 777 bilateral TKA (163 staged and 451 simultaneous). Itemized facility costs were calculated using time-driven activity-based costing. Ninety-day outcomes were compared. Margin was standardized to unadjusted Medicare Diagnosis Related Group payments (simultaneous, $18,523; staged, $22,386). Multivariate regression was used to determine the independent association between costs/clinical outcomes and treatment strategy (staged vs simultaneous).Simultaneous bilateral patients had significantly lower personnel, supply, and total facility costs compared with staged patients with no difference in 90-day complications between the groups. Multivariate analyses showed that overall facility costs were $1,210 lower in simultaneous bilateral THA (P.001) and $704 lower in TKA (P.001). Despite lower costs, margin for the facility was lower in the simultaneous group ($6,569 vs $9,225 for THA; $6,718 vs $10,067 for TKA; P.001).Simultaneous bilateral TKA and THA had lower facility costs than staged procedures because of savings associated with a single hospitalization. With the increased Medicare reimbursement for 2 unilateral procedures, however, margin was higher for staged procedures. In the era of value-based care, policymakers should not penalize facilities for performing cost-effective simultaneous bilateral arthroplasty in appropriately selected patients.

Objectives: Superior labrum from anterior to posterior (SLAP) tears are increasingly common shoulder injuries in adolescent athletes who participate in repetitive overhead throwing. The purpose of this study is to evaluate adolescent baseball athletes who undergo SLAP repair in order to determine their long-term progression of play, surgical outcomes, and overall satisfaction with surgery. Methods: Patients between the ages of 10-19 who underwent a SLAP repair over a 10-year period from 2008-2018 with minimum two year follow-up were identified by a database query in the medical records of a single institution. From this cohort, non-baseball athletes and injuries to non-throwing shoulders were excluded. After identifying the cohort, patients were contacted via phone to complete functional outcome scores including Conway Score, Western Ontario Shoulder Instability (WOSI) Index, Kerlan-Jobe Orthopedic Clinic (KJOC) Shoulder and Elbow Score, Short Form 12 Mental (MCS)/Physical (PCS) survey and a custom return to play questionnaire. Results: During this time period, 59 baseball players met the inclusion criteria for this study and 76.3% (45/59) of patients were available to be contacted to complete final follow-up surveys at a minimum of 2 years. All patients were male with a mean age of 17.4 +/- 1.5 (14-19) years. The mean follow-up of this cohort was 5.3 +/- 2.6 (2.1-12.1) years. The overall return to play rate was 75.6% (34/45). The average time from surgery to initiation of throwing was 5.9 +/- 2.0 (2-12) months and the average time to return to full competition was 11.3 +/- 3.5 (6-22) months after the surgery. After the SLAP repair, those who returned to play continuing playing baseball competitively for 3.0 +/- 1.9 (0.5-8.0) years after surgery. At the time of final follow-up, 71.1% (32/45) of players had stopped playing baseball. Of those who had stopped playing competitive baseball, 12 (37.5%) reported it was because they were not recruited to the next level, 10 (31.3%) reported they lost the desire to play and 10 (31.3%) reported their shoulder prevented them from playing. The overall mean KOJC, WOSI, SF-12 MCS and SF-12 PCS scores were 60.0 +/- 27.4 (range, 0-100), 21.0+/-20.6% (0-73.8%), 55.2+/-3.9 (37.4-59.8) and 55.2+/-5.6 (range, 37.9-65.7) respectively. The overall satisfaction score was 83.2% with 86.7% (39/45) saying they given the opportunity they would undergo surgery again. Conclusions: The results of this study demonstrated a low return to play rate and low patient reported outcomes on baseball specific surveys among adolescent baseball players who underwent a SLAP repair. Mean functional outcome scores between pitchers and position players were not found to be significantly different. Based on these findings, orthopedic surgeons can better counsel their adolescent baseball players on expectations for future return to play and functional outcomes after SLAP repair.

Objectives: While results following ulnar collateral ligament (UCL) injury in baseball players has been well documented, results following UCL injury in gymnasts are not well documented. As such, the purpose of this study was to report the operative and non-operative outcomes of UCL injury in gymnasts. Methods: Gymnasts who underwent UCL injury treatment whether non-operative or operative at a single institution were evaluated at a minimum of 2 years post-operatively. Patients were assessed with Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow Score (KJOC), Mayo Elbow Performance Score (MEPS), Andrews-Timmerman (A-T) Elbow score, Quick Disabilities of the Arm, Shoulder and Hand (qDASH) score and a custom return to play survey. Results: There were 11 patients who met inclusion criteria and complete follow-up was available in 9 patients. Overall, 6 patients were treated operatively (4 UCL reconstructions (UCLR) and 2 UCL repairs) and 3 patients were treated non-operatively. One UCLR was performed after 2 months of failed non-operative management. All patients were female with a mean age of 16.1 (range, 12-20) and mean BMI of 24.46 (range 19.2-34.1) at time of surgery or initial visit. Average follow-up was 4.04 years. Overall, 66.7% of operative versus 100% of non-operative were able to RTP at an average of 7.5 and 7 months, respectively. One re-injury was reported in the non-operative group, which was a re-dislocation of the elbow unrelated to gymnastics and was ultimately treated non-operatively. The mean KJOC, MEPS, A-T and qDASH scores for the operative group were 70.0 (range, 48.5-89), 97.5 (range, 95-100), 90.8 (range, 75-100) and 24.6 (range, 22.7-29.5), respectively. The mean scores for the non-operative group were 75.9 (range, 61-91.2), 71.7 (range, 65-75), 71.7 (range, 55-80) and 34.1 (range, 22.7-40.9), respectively. Conclusions: Both operative and non-operative treatments can be offered as successful treatment options for UCL injuries in gymnasts. Further investigation is needed to determine the optimal management of UCL injuries in gymnasts.

In an attempt to improve price transparency, the Centers for MedicareMedicaid Services (CMS) now requires hospitals to post clear, accessible pricing data for common procedures. We aimed to determine how many top orthopaedic hospitals are compliant with the new regulation and whether there was any correlation between hospital charges and outcomes after total hip arthroplasty (THA) and total knee arthroplasty (TKA).The hospital websites of the top 101 orthopaedic hospitals per the US NewsWorld Report 2020-2021 were explored to assess compliance with the price transparency requirement. We recorded the gross inpatient charge, cash price, payer-specific negotiated charge, and deidentified maximum and minimum payer rates for THA and TKA. Outcome metrics included hospital ranking and Medicare risk-adjusted arthroplasty readmission and complication rates.Although 94 hospitals (93%) posted some shoppable service information as required by CMS, only 21 hospitals (20%) were fully compliant. The mean inpatient charge for THA and TKA was $72,111 (range, $14,716 to $195,264), cash price was $39,027 (range, $2,920 to $110,858), and minimum and maximum payer rates were $16,140 and $57,949, respectively. Better hospital ranking was weakly correlated with higher charges (coefficient 0.223; P = 0.049). No correlation between charges and complications (P = 0.266) or readmissions (P = 0.735) was observed.Few hospitals are fully compliant with the new CMS price transparency regulations. We found a wide range of hospital charges for THA and TKA without correlation with complications or readmissions. Although efforts by CMS to increase price transparency should be welcomed, increased costs should be justified by quality in the era of value-based care.

Background: Injury to the ulnar collateral ligament (UCL) leading to medial elbow instability and possible ulnar neuritis is common in overhead-throwing athletes. Treatment may require UCL reconstruction (UCLR) and concomitant ulnar nerve transposition (UNT) for those with preoperative ulnar neuritis. Purpose: To evaluate the return-to-play (RTP) rates, clinical outcomes, and rates of persistent ulnar neuritis after concomitant UCLR and UNT in a cohort of baseball players with confirmed preoperative ulnar neuritis. Study Design: Case series; Level of evidence, 4. Methods: Eligible patients were those who underwent concomitant UCLR and UNT at a single institution between January 2008 and June 2018 and who had a minimum of 2 years of follow-up. Additional inclusion criteria were athletes who identified as baseball players and who had a confirmed history of ulnar neuritis. Patients were contacted at a minimum of 2 years from surgery and assessed with the Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow Score, Andrew-Timmerman (A-T) Elbow Score, Mayo Elbow Performance Score (MEPS), Single Assessment Numeric Evaluation (SANE) score, and a custom RTP questionnaire. Results: Included were 22 male baseball players with a mean age of 18.9 ± 2.1 years (range, 16-25 years). The mean follow-up was 6.1 ± 2.4 years (range, 2.5-11.7 years). Preoperatively, all 22 patients reported ulnar nerve sensory symptoms, while 4 (18.2%) patients reported ulnar nerve motor symptoms. At the final follow-up, 7 (31.8%) patients reported persistent ulnar nerve sensory symptoms, while none of the patients reported persistent ulnar nerve motor symptoms. Overall, 16 (72.7%) players were able to return to competitive play at an average of 11.2 months. The mean postoperative patient-reported outcome scores for the KJOC Shoulder and Elbow Score, MEPS, A-T Elbow Score, and SANE score were 77.9 ± 20.9 (range, 14-100), 92.7 ± 12.7 (range, 45-100), 86.1 ± 17.1 (range, 30-100), and 85.5 ± 14.8 (range, 50-100), respectively. Conclusion: This study demonstrated that after concomitant UCLR and UNT for UCL insufficiency and associated ulnar neuritis, baseball players can expect reasonably high RTP rates and subjective outcomes; however, rates of persistent sensory ulnar neuritis can be as high as 30%.

Preoperative coagulopathy is a risk factor for perioperative blood loss. The antifibrinolytic effects of tranexamic acid (TXA) could negate the association between preoperative coagulopathy and adverse outcomes in patients undergoing total joint arthroplasty (TJA). However, no studies have evaluated this relationship. This study compared the perioperative outcomes of coagulopathic patients undergoing TJA who did and did not receive TXA.We retrospectively reviewed 2123 primary TJAs (975 knees and 1148 hips) performed in patients with a preoperative coagulopathy. Coagulopathy was defined as international normalized ratio1.2, partial thromboplastin time35 seconds, or platelet count150,000/μL. TXA was administered in 240 patients and not administered in 1883 patients. Demographics, comorbidities, and surgical details including operative time, blood loss, and thromboprophylaxis agent were recorded. Multivariate regression was used to identify factors associated with 90-day outcomes.Patients who received TXA had less intraoperative blood loss and 2.3 times decreased risk of 90-day complications (odds ratio [OR] 0.43, 95% confidence interval [CI] 0.20-0.85, P = .021), especially cardiovascular (2.92% vs 12.1%, P.001) and wound complications (0.0% vs 1.59%, P = .042). TXA was also associated with shorter length of stay (beta 0.74, 95% CI 0.67-0.82, P.001) and decreased risk of nonhome discharge (OR 0.50, 95% CI 0.29-0.83, P = .009). There was no difference in mortality or 90-day readmissions between the groups.TXA administration decreased the incidence of perioperative complications and resource utilization in patients undergoing arthroplasty with a preoperative coagulopathy identified on preadmission testing. These findings support the broader adoption of TXA in patients undergoing TJA, particularly when the patient has a preoperative coagulopathy.

Background: Injury to the quadriceps tendon is rare and most commonly occurs in middle-aged men. Few reports are available regarding outcomes after quadriceps tendon rupture in younger patients. Purpose/Hypothesis: To review the clinical outcomes of patients who underwent quadriceps tendon repair at age ≤40 years. We hypothesized that this cohort would experience better clinical outcomes in comparison to historical older controls. Study Design: Case series; Level of evidence, 4. Methods: Using an institutional database, we retrospectively identified patients who underwent quadriceps tendon repair between January 2009 and December 2017. Patients were included in the study if they were aged ≤40 years at the time of surgery and had sustained an isolated, complete tendon rupture. Patient and injury characteristics were recorded. Patients were contacted to complete a custom survey, the 2000 International Knee Documentation Committee (IKDC) form, the Lysholm scale, and the Tegner scale. Results: Included were 38 patients (86.8% male; mean age, 32.0 ± 6.9 years; age range, 15-40 years), with a mean follow-up of 5.9 ± 2.3 years (range, 2.4-11.3 years). At final follow-up, the mean IKDC score was 74.1 ± 22.6 (range, 26.4-100.0), and the mean Lysholm score was 85.4 ± 20.0 (range, 30-100), which were similar if not inferior to historical controls of patients >40 years. Only 16 patients (42.1%) had unchanged or higher Tegner scores after surgery, whereas 22 patients (57.9%) reported lower postoperative activity level. Overall, 91.2% (31/34) of workers returned at a mean 3.9 months after surgery, whereas 63% (12/19) of athletes were able to return to play at 8.8 months. At final follow-up, 12 patients (31.6%) reported persistent pain and stiffness in their knees. Additionally, 3 patients (7.9%) reported pain without stiffness, and 4 (10.5%) reported stiffness without pain. Patients reporting pain or stiffness had significantly lower IKDC scores, Lysholm scores, postoperative Tegner scores, and change in their Tegner score at final follow-up in comparison to those who did not report pain or stiffness. Conclusion: Although patients aged ≤40 years had satisfactory outcomes after quadriceps tendon repair, this injury resulted in significant long-term sequelae in a substantial percentage of patients, despite their youth. Further, this group did not have better outcomes compared with historical controls aged > 40 years.

Background: While the incidence of ulnar collateral ligament reconstruction (UCLR) has increased across all levels of play, few studies have investigated the long-term outcomes in nonprofessional athletes. Purpose: To determine the rate of progression to higher levels of play, long-term patient-reported outcomes (PROs), and long-term patient satisfaction in nonprofessional baseball players after UCLR. Study Design: Case series; Level of evidence, 4. Methods: We evaluated UCLR patients who were nonprofessional baseball athletes aged Results: A total of 91 baseball players met the inclusion criteria, and 67 (74%) patients were available to complete the follow-up surveys at a mean follow-up of 8.9 years (range, 5.5-13.9 years). At the time of the surgery, the mean age was 18.9 ± 1.9 years (range, 15-24 years). Return to play at any level was achieved in 57 (85%) players at a mean time of 12.6 months. Twenty-two (32.8%) of the initial cohort returned to play at the professional level. Also, 43 (79.1%) patients who initially returned to play after surgery reported not playing baseball at the final follow-up; of those patients, 12 reported their elbow as the main reason for eventual retirement. The overall KJOC, MEPS, and T-A scores were 82.8 ± 18.5 (range, 36-100), 96.7 ± 6.7 (range, 75-100), and 91.9 ± 11.4 (range, 50-100), respectively . There was an overall satisfaction score of 90.6 ± 21.5 out of 100, and 64 (95.5%) patients reported that they would undergo UCLR again. Conclusion: In nonprofessional baseball players after UCLR, there was a high rate of progression to higher levels of play. Long-term PRO scores and patient satisfaction were high. The large majority of patients who underwent UCLR would undergo surgery again at long-term follow-up, regardless of career advancement.

The frequency of prosthetic total wrist arthroplasty continues to increase. With this increase comes the expected subsequent increase in need for revision or salvage procedures. The technique presented here involves the use of a cortical allograft interposition graft to restore bone stock and length for failed total wrist arthroplasty.

Purpose Complications after upper-extremity surgery are generally infrequent. The purpose of this study was to assess the rate of early unplanned return to the operating room (URTO) within 3 months after surgery) in upper-extremity surgical procedures. Our hypotheses were that the rate of URTO in upper-extremity surgery would be low and that surgically treated fractures would be at greatest risk for complications. Methods We performed a retrospective review of all upper-extremity surgical procedures performed at a large academic practice of fellowship-trained hand surgeons over a 5-year period. A chart review was conducted of all patients who underwent a second surgery within 3 months of the initial surgery. The surgical billing database was queried to determine the incidence of URTO per Current Procedural Terminology code. Results There were 422 Current Procedural Terminology codes with URTO out of a total of 62,608, for an incidence of 0.6%. The most frequently performed procedures were carpal tunnel release (10,674; 0.1% URTO), trigger finger release (4,549; 0.5% URTO), and open reduction internal fixation (ORIF) for distal radius fracture (2,728; 1.2% URTO). Procedures with the highest incidences of URTO were open reduction and internal fixation of the ulna (4.9%) and excision of the olecranon bursa (4.1%). Traumatic injuries were more commonly associated with URTO compared with elective procedures. Bony trauma and soft tissue trauma had URTO incidences of 1.4% and 1.1%, respectively, whereas bony elective and soft tissue elective cases were 0.6% and 0.4%, respectively. Conclusions The 90-day URTO rate after upper-extremity surgery was low but higher than previously reported 30-day reoperation rates. Elbow procedures were most likely to result in URTO, as were procedures relating to bony and soft tissue trauma. Based on these results, we are able to counsel patients that the most common procedures we perform have low URTO rates, but surgically treated fractures are at greatest risk. Type of study/level of evidence Prognostic II.

Correlational study.In spine trauma patients, we aimed to assess the correlation of patient-reported outcome measurement information system (PROMIS) physical function (PF), pain interference (PI), and Depression scores with Oswestry Disability Index (ODI) and Neck Disability Index (NDI) ODI/NDI scores.The ODI and NDI were intended as patient-reported outcome measures (PROMs) to evaluate clinical outcomes in patients seeking spine care. To date, the PROMIS has not been studied in the spine trauma population.Between January 1, 2015 and December 13, 2017, patients presenting to a single, level 1 trauma center spine clinic with known spine trauma were identified. A total of 56 patients (52 operative, 4 nonoperative) representing 181 encounters were identified. PROMIS PF, PI, and Depression, as well as the ODI or NDI, were administered to patients. Spearman rho (ρ) were calculated between PROMs.A strong correlation exists between PROMIS PI and the ODI (ρ = 0.79, P 0.001), while a strong-moderate correlation exists between PROMIS PF and the ODI (ρ = -0.61, P 0.001). A moderate correlation exists between PROMIS Depression and the ODI (ρ = 0.54, P 0.001). Strong correlations exist between PROMIS PI and the NDI (ρ = 0.71, P 0.001) and PROMIS Depression and the NDI (ρ = 0.73, P 0.001). A poor correlation exists between PROMIS PF and the NDI (ρ = -0.28, P = 0.005).PROMIS PF, PI, and Depression domains significantly correlate with the ODI and NDI; however, only PROMIS PI strongly correlates with both the NDI and ODI. This suggests that PROMIS PI can be used to capture similar information to that of the ODI or NDI but that PROMIS PF and Depression may offer additional clinical information.2.

Background: Chordomas are rare malignant tumors of the spinal column often afflicting the upper cervical spine and sacrum. There are few large single center series on chordomas due to its rarity. The purpose of this study is to report a single center’s experience with the operative and non-operative management of chordomas. Methods: We evaluated our institution’s pathology database from 1994 to 2016 to identify patients diagnosed with chordomas. Inclusion criteria were chordomas of the mobile spine and sacrum. Exclusion criteria were chordomas of the clivus and resection performed at another institution. We collected patient demographics as well as the type of resection performed, intra-operative complications, wound complications and recurrence/prognosis. Results: We identified 18 patients diagnosed with chordomas at our institution, and 12 met our inclusion criteria. There were four females and eight males with an average age of 64 [32–87] years. All patients were Caucasian and 10 of the 12 had surgery. Of the two patients with sacral chordomas that did not have surgery, one received chemotherapy and the other did not elect for any treatment. One is alive 161 months following diagnosis and the second died 96 months following diagnosis. Five of the lesions were in the mobile spine (one cervical, two thoracic, two lumbar) and seven were in the sacrum. Six patients underwent an en bloc resection [two via total en bloc spondylectomy (TES)]. Average length of follow up is 60 [3–161] months and eight of 12 patients are alive at latest follow up. Intraoperative complications included cardiac arrest, pleural tear, and excessive blood loss (8 L). Two patients, with sacral chordomas, had wound complications. Recurrence occurred in one patient with piecemeal resection and one patient with incomplete resection had post-operative metastatic lesions to the liver and lung. Conclusions: We found less recurrence in patients managed with an en bloc resection as opposed to piece meal or intralesional resections. Sacral chordoma patients had higher wound complication rates as compared to chordomas of the mobile spine. The long life expectancy of non-surgically managed patients underscores the indolent nature of chordomas.

Alternative payment models, such as bundled payments, have grown in popularity to align incentives among providers to provide quality care at a reduced cost. Early data demonstrated success at reducing post-acute care resources and episode-of-care costs in total knee arthroplasty (TKA), but concerns regarding target price methodology and lack of appropriate risk-adjustment may limit the future of these bundled payment programs. This review will address specific drivers of episode-of-care costs in TKA. Modifiable medical comorbidities such as uncontrolled diabetes and malnutrition can be optimized prior to elective TKA. Minimizing in-hospital medical complications and unplanned ICU admissions can help drive down inpatient TKA costs. Finally, reducing rates of home health and discharge to skilled nursing facilities has the highest impact of episode-of-care cost reduction following TKA.

Objectives: Injury to the ulnar collateral ligament (UCL)—leading to medial elbow instability and concomitant ulnar neuropathy symptoms—is common in the overhead throwing athlete secondary to the repetitive stress that these individuals place on the elbow during the throwing motion. Treatment customarily involves UCL reconstruction (UCLR) and for those with preoperative ulnar neuropathy symptoms, concomitant ulnar nerve transposition (UNT) may also be warranted. The purpose of this study was to evaluate the return to play rates, clinical outcomes and more specifically rates of persistent ulnar nerve symptoms after concomitant UCLR and UNT in a cohort of baseball players with confirmed preoperative ulnar neuropathy symptoms. Methods: Patients who underwent concomitant UCLR and UNT from January 2008 to June 2018 were identified at one institution with a minimum of 2 years of follow-up. Additional inclusion criteria included athletes who identified as baseball players with a confirmed history of ulnar neuropathy symptoms. Exclusion criteria included patients who had any other concomitant open procedures at the time of surgery. After identifying the cohort, patients were contacted via phone to complete a Kerlan-Jobe Orthopedic Clinic Shoulder and Elbow Score (KJOC), Andrews-Timmerman (AT) Elbow Score, Mayo Elbow Performance Score (MEPS), Single Assessment Numeric Evaluation (SANE) score and a custom return to play questionnaire. Evidence for preoperative and postoperative ulnar nerve symptoms was elicited within the custom survey and corroborated with the provider’s clinical notes. Sensory ulnar nerve symptoms were defined as having numbness and/or tingling sensations in the 5th and ulnar half of the 4th fingers. Motor ulnar nerve symptoms were defined as either exhibiting 1st dorsal interosseous muscle weakness by inability to maintain finger abduction resistance, ulnar-sided hand grip weakness of inability to control precise movement of the 5th digit. Results: During this time period, a total of 22 male baseball players underwent concomitant UCLR and UNT at a mean age of 18.9+/-2.1 years (range, 16-25). The mean follow-up was 6.1+/-2.4 years (range, 2.5-11.7 years). The cohort consisted of 15 pitchers and 7 position players. In total, 7 players competed in high school and 15 competed in college. Preoperatively, all 22 patients reported ulnar nerve sensory symptoms while only 4 (18.2%) patients reported ulnar nerve motor symptoms. Overall, 16 (72.3%) players were able to return to competitive play at an average of 11.2 months. Of the 6 that failed to return to play after surgery, 3 reported that persistent elbow symptoms were the reason for not returning to play while the other 3 reported losing the desire to return to play. At final follow-up, 7 (31.8%) patients reported of persistent sensory ulnar nerve sensory symptoms while 1 (4.5%) of these patients additionally reported persistent ulnar nerve motor symptoms. The mean postoperative patient reported outcome scores were as follows: KJOC: 77.9+/-20.9 (range, 14-100); MEPS: 92.7+/-12.7 (range, 45-100); AT Elbow Score: 86.1+/-17.1 (range, 30-100); SANE score: 85.5+/-14.8 (range, 50-100). Conclusions: While patient-reported outcome scores and return to play rates are reasonably high, this study demonstrates that following concomitant UCL reconstruction and ulnar nerve transposition for UCL insufficiency and associated ulnar neuropathy, rates of persistent ulnar neuropathy symptoms are persistently present in over 30% of patients. Currently, handling of the ulnar nerve in the setting of UCL insufficiency is debated and thus further investigation is warranted to optimize outcomes for this group of patients.

Background:The application of continuous passive motion (CPM) after anterior cruciate ligament reconstruction (ACLR) was popularized in the 1990s, but advancements in the understanding of ACLR rehabilitation have made the application of CPM controversial. Many sports medicine fellowship–trained surgeons report using CPM machines postoperatively.Purpose:To determine the efficacy of CPM use for recovery after ACLR with respect to knee range of motion (ROM), knee swelling, postoperative pain, and postoperative complications.Study Design:Systematic review; Level of evidence, 3.Methods:The PubMed (MEDLINE), EMBASE, Cochrane, Cumulative Index of Nursing, and Allied Health Literature databases were searched from inception to January 1, 2020, for studies with evidence levels 1 to 3 on the use of CPM for ACLR rehabilitation. Included studies were those that comparatively evaluated postoperative outcomes after ACLR between at least 2 groups of patients, with 1 having received CPM rehabilitation and the other not having received CPM.Results:A total of 12 studies from 1989 to 2019 met the inclusion criteria. These studies included 808 patients who underwent ACLR. There was no evidence of CPM improving knee stability, final postoperative ROM, or subjective pain scores. Additionally, CPM did not lead to decreased muscle atrophy or improved International Knee Documentation Committee scores. Regarding pain medication intake during postoperative hospitalization, 2 studies found that the CPM group used less pain medication, 1 study found the CPM group used more pain medication, and 1 study found that there was no difference between the 2 groups. Complications varied widely, with 2 of 12 studies reporting complications that required a return to the operating room.Conclusion:A clinical benefit of postoperative CPM use after ACLR was not identified in this review. While our systematic review identified a number of studies that suggest CPM use may be associated with lower usage of pain medication in hospitalized patients, this cannot be confirmed without further investigation with standardized CPM protocols and larger sample sizes. Routine CPM use after ACLR was not supported by this systematic review.

Objectives:. Most patients can tolerate a hemoglobin (Hgb) > 8 g per deciliter. In some cases, however, transfusion will delay physical therapy and hospital discharge. This study aims to review Hgb and transfusion data for a large volume of recent hip fracture patients in order to identify new opportunities for decreasing the length of hospital stay. Our hypotheses are that in some cases, earlier transfusion of more blood will be associated with shorter hospital stays, and that Hgb levels consistently decrease for more than 3 days postoperatively. Design:. Retrospective chart review. Setting:. Two academic medical centers with Geriatric Fracture Programs. Patients:. Data was collected from patients 50 years and older with hip fractures April 2015 and October 2017. Intervention:. Operative stabilization of the hip fractures according to standard of care for the fracture type and patient characteristics. Transfusion according to established standards. Main Outcome Measurements:. Electronic records were retrospectively reviewed for demographic information, Hgb levels, and transfusion events. Results:. One thousand fifteen patients with femoral neck or intertrochanteric hip fractures were identified. Eight hundred sixty met the inclusion criteria. The average length of hospital stay was 6.7 days. The mean patient age was 82 years. The average American Society of Anesthesiologists score was 2.9. The average Hgb level consistently decreased for 5 days postoperatively before beginning to increase on day 6. There was poor consistency between intraoperative Hgb levels and preoperative or postoperative Hgb levels. Three hundred sixty-eight (42.8%) patients were transfused an average of 1.9 (range 1–6) units. One hundred five patients required a transfusion on postoperative day (POD) 1: 72 received only 1 unit of blood: 36 (50%) of the 72 required a second transfusion in the following days, compared to 9 of 33 (27%) who received 2 units on POD 1 (χ2 = 3.8898; P 2.5 days longer than those who received a transfusion earlier (P = 0.005). Conclusions:. Our findings do not support earlier transfusion of more blood. Although in some cases, there is an association between earlier transfusion of more blood and shorter hospital stay, routine transfusion of more blood would incur higher transfusion risks in some patients who would not otherwise meet criteria for transfusion. After hip fracture surgery, the Hgb usually decreases for 5 days and does not begin to increase until POD 6. This information will provide utility in the population health management of hip fracture patients. Level of Evidence:. Level III, Retrospective Cohort Study

Background: Children are more vulnerable to ionizing radiation which increases health risks later in life including cancer. An interdepartmental team developed an algorithm to guide providers ordering extremity radiographs in pediatric patients with musculoskeletal (MSK) injuries. Purpose: Reduce unnecessary pediatric radiation/extremity radiographs through development and implementation of an interdepartmental designed algorithm. Determine utility, safety, and efficacy of the algorithm through retrospective and prospective analysis. Methods: Our study was performed at an academic pediatric trauma center. An interdepartmental committee including pediatric orthopedic surgery, emergency medicine, trauma, and radiology providers created a MSK injury imaging algorithm (Figure 1). We retrospectively validated the algorithm for efficacy and safety through chart review of pediatric patients seen in the ED with MSK extremity injury, identified through CPT code, from 6/24/2016 through 8/31/2016. We determined the number of extra radiographs per patient and identified if injuries would be missed utilizing our protocol. After retrospective validation, guideline implementation was undertaken through multidisciplinary education. The imaging guideline was prospectively implemented in the pediatric ED from 6/24/2018 through 8/31/2018. We continued to prospectively evaluate through selecting one week every month over the following eight months to determine sustainability of the implemented algorithm. Results: Our interdepartmental team in 2016 developed a pediatric MSK radiograph protocol (Figure 1). A retrospective chart and radiograph review of 295 pediatric patients between 6/24/2016 through 8/31/2016 was analyzed correlating physical examination to appropriate radiographs. Utilizing the protocol, the review revealed an average of 2.75 extra radiographs per patient. No injuries were missed. Providers including orthopedic and emergency medicine attendings, mid-levels, and residents were educated through meetings, emails, and having the protocol posted and easily accessible. Our protocol was implemented 6/24/18 and underwent prospective enrollment and review through 8/31/18 which revealed a reduction to 0.72 radiographs per patient (P-value Conclusion: Reduction of unnecessary radiation to pediatric patients with MSK extremity injuries was accomplished through development and implementation of a safe and effective imaging algorithm. The multidisciplinary approach combined with widespread education of pediatric providers improved buy-in driving a sustainable system improvement. [Figure: see text][Figure: see text][Figure: see text]

Objectives: Tibial tuberosity osteotomy is often performed to correct excessive lateralization of the tuberosity in patients with patellar instability. An anteriorizing component has been recommended in the setting of chondral pathology, yet the ideal anterior-posterior relationship of the tibial tuberosity to the trochlear groove is unknown. Methods: Patients with symptomatic patellar instability underwent static CT imaging, and were compared to age- and gender-matched controls. All knees were imaged in full extension. Tibial-tuberosity-trochlear-groove (TTTG) distance was measured to quantify lateralization of the tuberosity, as well as the anterior-posterior distance between these two points (APTTTG distance). Lateral trochlear inclination (LTI), sulcus angle (SA) and trochlear depth (TD) were measured as indicators of trochlear dysplasia. Measurements were compared between the symptomatic and control groups using paired t-tests. Correlations between APTTTG with LTI, SA and TD were assessed using linear regression analyses. Results: 22 knees in 18 patients with symptomatic patellar instability were included in the study group, with 22 control knees. TTTG and APTTTG distances were 19.9 mm and 8.3 mm in the symptomatic group, versus 16.8 mm and -0.5 mm in the control group, with a difference of 3.1 mm (p=0.002) and 8.8 mm (pConclusion: Our findings demonstrate that the trochlear groove is almost 9mm more anterior to the tibial tuberosity in patients with symptomatic instability, and this distance correlates with measurements of trochlear dysplasia. While further studies are needed to determine the relationship between APTTTG distance and patellar instability, these findings suggest that the anterior-posterior relationship between the trochlea and tuberosity may be a factor to consider when planning for tibial tuberosity osteotomy in patients with trochlear dysplasia.

BACKGROUND CONTEXT The Oswestry Disability Index (ODI) and Neck Disability Index (NDI) were not intended for spine trauma patients but are routinely used for such purposes. To date the Patient-Reported Outcome Measurement Information System (PROMIS) has not been studied in the spine trauma population. A patient reported outcome (PRO) instrument that is efficient and applicable to spine trauma patients would be ideal. PURPOSE To identify correlation between legacy outcome questionnaires (ODI, NDI) with PROMIS physical function (PF), pain interference (PI) and depression. STUDY DESIGN/SETTING Retrospective cross-sectional analysis, Level I trauma center. PATIENT SAMPLE Sixty-three spine trauma patients with 384 office encounters where PROs were completed. OUTCOME MEASURES Correlation between PROMIS and ODI/NDI METHODS Sixty-three spine trauma patients treated by one surgeon at a level 1 trauma center between 1/1/15 and 12/31/17 were enrolled. Patient-reported outcome from 384 encounters was used for analysis. Fifty-seven patients underwent surgical intervention and 6 patients had a halo vest applied. The ODI was administered for thoracic/lumbar/sacral trauma while the NDI was administered for cervical trauma. Normality of distributions were assessed with Shapiro-Wilk test. PROMIS scores were not normally distributed in our cohort, therefore the nonparametric Spearman rho correlation was performed between ODI and NDI with PROMIS PF, PI and depression scores. Coefficients of determination were reported for bivariate regression models RESULTS PROMIS PF was moderately (ρ=−0.6254, R2=0.266) and poorly (ρ=−0.259, R2=0.501) correlated with the ODI and NDI, respectively. PROMIS PI was highly (ρ=0.7345, R2=0.537) and moderately (ρ=0.6912, R2=0.556) correlated with ODI and NDI, respectively. PROMIS Depression was moderately (ρ=0.528, R2=0.182) and highly (ρ=0.7234, R2=0.378) correlated with OWI and NDI, respectively. CONCLUSIONS PROMIS PI is most highly correlated with ODI/NDI in spine trauma patients. While PROMIS PF shows moderate correlation with the ODI, a negligible correlation was found with the NDI. PROMIS tools allow for more effective data collection across multiple domains and, moving forward, may be better poised to monitor changes in function, pain and depression in spine trauma patients. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.