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Background: Recognition of the symbiotic relationship between the meniscus and articular cartilage is critical to the success of meniscal allograft transplantation. Simultaneous combined meniscal allograft transplantation and cartilage restoration procedures have been proposed for patients with a symptomatic postmeniscectomy knee with a focal chondral defect that would have traditionally been considered a contraindication to meniscal allograft transplantation.Hypothesis: Combined meniscal allograft transplantation and cartilage restoration procedures can be used to neutralize traditional contraindications to meniscal allograft transplantation with results comparable to either procedure performed in isolation.Study Design: Case series; Level of evidence, 4.Methods: Thirty patients underwent 31 combined meniscal allograft transplantation and cartilage restoration procedures between 1997 and 2004. These patients were prospectively studied, and completed standardized outcome surveys (including Lysholm, International Knee Documentation Committee, and Short Form-12 scales) preoperatively and annually thereafter for a minimum of 2-year follow-up. Patients were grouped according to concomitant procedure: 16 (52%) underwent meniscal allograft transplantation combined with autologous chondrocyte implantation; 15 (48%) had meniscal allograft transplantation combined with an osteochondral allograft. Two patients were lost to follow-up, leaving 29 procedures for review.Results: As a combined group, statistically significant improvements were observed in all standardized outcomes scores and satisfaction scales, except Short Form-12 mental, at a mean 3.1-year follow-up. Excluding the 2 lost to follow-up, 76% of all study participants (80% autologous chondrocyte implantation; 71% osteochondral allograft) reported that they were completely (31%) or mostly (45%) satisfied with their results. Overall, 48% of patients (60% autologous chondrocyte implantation; 36% osteochondral allograft) were classified as normal or nearly normal at their most recent follow-up using the International Knee Documentation Committee examination score. Ninety percent of patients would have the surgery again.Conclusion: Combined meniscal allograft transplantation and cartilage restoration offers a safe alternative for patients with persistent symptoms after meniscectomy and focal cartilage injury. Results of combined procedures were comparable to published reports of these procedures performed in isolation. Long-term follow-up is needed to define the survivorship of these procedures in a young patient population. [ABSTRACT FROM AUTHOR]

Background: We implemented a pediatric Brain Injury Guideline (pBIG) to stratify traumatic brain injuries (TBI) and allow management of less severe cases without repeat CT imaging or neurosurgical consultation. Injuries were classified as mild (pBIG1), moderate (pBIG2), severe (pBIG3) or isolated skull fracture (ISF) based on neurologic status, size and number of bleeds. We hypothesize that pediatric TBIs can be safely managed with this guideline., Methods: Isolated TBIs (<18 years) were queried from the Pediatric Trauma Registry after pBIG implementation from July 2021-March 2023. Datasets included age, injury specifics, repeat head CTs, neurosurgical consultations and interventions. Analysis was performed with Stata, with significance set at p < 0.05., Results: A total of 139 children with a median age of 2.8 years were included. Skull fractures (113, 81%) and subdural hematomas (54, 39%) were the most common injuries. Repeat head CTs were obtained in 44 (32%) and neurosurgical consultation in 89 (64%). Overall guideline compliance was 83.5%, with best performance in the pBIG3 category (96%). One pBIG1 patient had increasing symptoms requiring upgrade, neurosurgical consultation and repeat head CT, but no intervention. Five children (3.6%; 4 isolated skull fracture, 1 pBIG3) had post-discharge ED visits and 1 (0.7%, ISF) had a post-discharge CT. Three (2.2%) children, all in the pBIG3 group, died from their TBIs., Conclusions: Adherence to the algorithm was 83.5%, with the lowest compliance in the moderate TBI (pBIG2) category. This group had a high rate of neurosurgical consultation suggesting uneasiness with independent management of moderate injuries when compared to minor TBIs or isolated skull fracture. Outcomes with the use of the pBIG algorithm were otherwise acceptable., Level of Evidence: Level IV, Therapeutic/Care Management., Competing Interests: Conflict of interest There are no conflicts of interest with this work., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Retained hemothorax (rHTX) requiring intervention occurs in up to 20% of patients who undergo chest tube (TT) placement for a hemothorax (HTX). Thoracic irrigation at the time of TT placement decreases the need for secondary intervention in this patient group but those findings are limited because of the single-center design. A multicenter study was conducted to evaluate the effectiveness of thoracic irrigation., Methods: A multicenter, prospective, observational study was conducted between June 2018 and July 2023. Eleven sites contributed patients. Patients were included if they had a TT placed for a HTX and were excluded if: younger than 18 years, TT for pneumothorax, thoracotomy or video-assisted thoracoscopic surgery performed within 6 hours of TT, TT >24 hours after injury, TT removed <24 hours, or death within 48 hours. Thoracic irrigation was performed at the discretion of the attending. Each hemithorax was considered separately if bilateral HTX. The primary outcome was secondary intervention for HTX-related complications (rHTX, effusion, or empyema). Secondary intervention was defined as: TT placement, instillation of thrombolytics, video-assisted thoracoscopic surgery, or thoracotomy. Irrigated and nonirrigated hemithoraces were compared using a propensity weighted analysis with age, sex, mechanism of injury, Abbreviated Injury Scale chest, and TT size as predictors., Results: Four hundred ninety-three patients with 462 treated hemothoraces were included, 123 (25%) had thoracic irrigation at TT placement. There were no significant demographic differences between the cohorts. Fifty-seven secondary interventions were performed, 10 (8%) and 47 (13%) in the irrigated and non-irrigated groups, respectively ( p = 0.015). Propensity weighted analysis demonstrated a reduction in secondary interventions in the irrigated cohort (odds ratio, 0.56 (0.34-0.85); p = 0.005)., Conclusion: This Western Trauma Association multicenter study demonstrates a benefit of thoracic irrigation at the time of TT placement for a HTX. Thoracic irrigation reduces the odds of a secondary intervention for rHTX-related complications by 44%., Level of Evidence: Therapeutic/Care Management; Level II., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Laparoscopy has demonstrated improved outcomes in abdominal surgery; however, its use in trauma has been less compelling. In this study, we hypothesize that laparoscopy may be observed to have lower costs and complications with similar operative times compared to open exploration in appropriately selected patients., Methods: We retrospectively reviewed adult patients undergoing abdominal exploration after blunt and penetrating trauma at our level 1 center from 2008 to 2020. Data included mechanism, operative time, length of stay (LOS), hospital charges, and complications. Patients were grouped as follows: therapeutic and nontherapeutic diagnostic laparoscopy and celiotomy. Therapeutic procedures included suture repair of hollow viscus organs or diaphragm, evacuation of hematoma, and hemorrhage control of solid organ or mesenteric injury. Unstable patients, repair of major vascular injuries or resection of an organ or bowel were excluded., Results: Two hundred ninety-six patients were included with comparable demographics. Diagnostic laparoscopy had shorter operative times, LOS, and lower hospital charges compared to diagnostic celiotomy controls. Similarly, therapeutic laparoscopy had shorter LOS and lower hospital costs compared to therapeutic celiotomy. The operative time was not statistically different in this comparison. Patients in the celiotomy groups had more postoperative complications. The differences in operative time, LOS and hospital charges were not statistically significant in the diagnostic laparoscopy compared to diagnostic laparoscopy converted to diagnostic celiotomy group, nor in the therapeutic laparoscopy compared to the diagnostic laparoscopy converted to therapeutic laparoscopy group., Conclusions: Laparoscopy can be used safely in penetrating and blunt abdominal trauma. In this cohort, laparoscopy was observed to have shorter operative times and LOS with lower hospital charges and fewer complications., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: One of the significant complications of operative liver trauma is intra-abdominal abscesses (IAA). The objective of this study was to determine risk factors associated with postoperative IAA in surgical patients with major operative liver trauma., Methods: A retrospective multi-institutional study was performed at 13 Level 1 and Level 2 trauma centers from 2012 to 2021. Adult patients with major liver trauma (grade 3 and higher) requiring operative management were enrolled. Univariate and multivariate analyses were performed., Results: Three hundred seventy-two patients were included with 21.2% (n = 79/372) developing an IAA. No difference was found for age, gender, injury severity score, liver injury grade, and liver resections in patients between the groups (P > 0.05). Penetrating mechanism of injury (odds ratio (OR) 3.42, 95% confidence interval (CI) 1.54-7.57, P = 0.02), intraoperative massive transfusion protocol (OR 2.43, 95% CI 1.23-4.79, P = 0.01), biloma/bile leak (OR 2.14, 95% CI 1.01-4.53, P = 0.04), hospital length of stay (OR 1.04, 95% CI 1.02-1.06, P < 0.001), and additional intra-abdominal injuries (OR 2.27, 95% CI 1.09-4.72, P = 0.03) were independent risk factors for IAA. Intra-abdominal drains, damage control laparotomy, total units of packed red blood cells, number of days with an open abdomen, total abdominal surgeries, and blood loss during surgery were not found to be associated with a higher risk of IAA., Conclusions: Patients with penetrating trauma, massive transfusion protocol activation, longer hospital length of stay, and injuries to other intra-abdominal organs were at higher risk for the development of an IAA following operative liver trauma. Results from this study could help to refine existing guidelines for managing complex operative traumatic liver injuries., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Timing to resume feeds after percutaneous endoscopic gastrostomy (PEG) placement continues to vary among US trauma surgeons. The purpose of this study was to assess differences in meeting nutritional therapy goals and adverse outcomes with early versus late enteral feeding after PEG placement., Methods: This retrospective review included 364 trauma and burn patients who underwent PEG placement. Data included patient characteristics, time to initiate feeds, rate feeds were resumed, % feed volume goals on postoperative days 0-7, and complications. Statistical analysis was performed comparing two groups (feeds ≤ 6 h versus > 6 h) and three subgroups (< 4 h, 4-6 h, ≥ 6 h) based on data quartiles. Chi-square/Fisher's exact test, independent-samples t-test, and one-way analysis of variance were used to analyze the data., Results: Mean time to initiate feeds after PEG was 5.48 ± 4.79 h. Burn patients received early feeds in a larger proportion. A larger proportion of trauma patients received late feeds. The mean % of goal feed volume met on postoperative day 0 was higher in the early feeding group versus the late (P < 0.001). There were no differences in adverse events, even after subgroup analysis of those who received feeds < 4 h after PEG placement., Conclusions: Patients with early initiation of feeds after PEG placement achieve a higher percentage of goals on day 0 without an increased rate of adverse events. Unfortunately, patients routinely fall short of their target tube feeding goals., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The management of major liver trauma continues to evolve in trauma centers across the US with increasing use of minimally invasive techniques. Data on the outcomes of these procedures remain minimal. The objective of this study was to evaluate patient complications after perioperative hepatic angioembolization as an adjunct to management of major operative liver trauma., Study Design: A retrospective multi-institutional study was performed at 13 level 1 and level 2 trauma centers from 2012 to 2021. Adult patients with major liver trauma (grade 3 and higher) requiring operative management were enrolled. Patients were divided into 2 groups: angioembolization (AE) and no angioembolization (NO AE). Univariate and multivariate analyses were performed., Results: A total of 442 patients were included with AE performed in 20.4% (n = 90 of 442) of patients. The AE group was associated with higher rates of biloma formation (p = 0.0007), intra-abdominal abscess (p = 0.04), pneumonia (p = 0.006), deep vein thrombosis (p = 0.0004), acute renal failure (p = 0.004), and acute respiratory distress syndrome (p = 0.0003), and it had longer ICU and hospital length of stay (p < 0.0001). On multivariate analysis, the AE had a significantly higher amount intra-abdominal abscess formation (odds ratio 1.9, 95% CI 1.01 to 3.6, p = 0.05)., Conclusions: This is one of the first multicenter studies comparing AE in specifically operative high-grade liver injuries and found that patients with liver injury that undergo AE in addition to surgery have higher rates of both intra- and extra-abdominal complications. This provides important information that can guide clinical management., (Copyright © 2023 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Penetrating cardiac injuries (PCI) are often fatal despite rapid transport and treatment in the prehospital setting. Although many studies have identified risk factors for mortality, few studies have included non-transported field mortalities. This study analyzes penetrating cardiac injuries including hospital and coroner reports in the current era., Methods: Seventeen years of data were reviewed, including the trauma center (TC) registry, medical records, and coroner reports from 2000-2016. PCI were graded using American Association for the Surgery of Trauma (AAST) cardiac organ injury score (COIS). Subjects were divided into three groups: field deaths, hospital deaths, and survivors to hospital discharge. The primary outcome is survival to hospital discharge overall and among those transported to the hospital., Results: During the study period, 643 PCI patients were identified, with 52 excluded for inadequate data, leaving 591 for analysis. Mean age was 38.1 ± 17.5 years, and survivors (n=66) were significantly younger than field deaths (n=359) (32.6 ± 14.4 vs 41.1 ± 18.5, p<0.001). Stab wounds had higher survival than gunshot wounds (26.6% vs. 4.3%, p<0.001). COIS grades 4 to 6 (n=602) had lower survival than grades 1 to 3 (n=41) (8.3% vs. 39.0%, p<0.001). Survivors (n=66) had lower median COIS than patients who died in hospital (n=218) (4 vs. 5, p<0.001). Single chamber PCI had higher survival than multiple chamber PCI (13% vs. 5%, p=0.004).  The left ventricle is the most injured (n=177), and right ventricle PCI has the highest survival (p<0.001).  Of field deaths, left ventricular injuries had the highest single chamber mortality (60%), equaling multi-chamber PCI (60%)., Conclusions: Survival to both TC evaluation and hospital discharge following PCI is influenced by many factors including age, mechanism, anatomic site, and grade. Despite advances in trauma care, survival has not appreciably improved., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to declare for this work., (Copyright © 2023. Published by Elsevier Ltd.)

Objectives: Physical examination and computed tomography (CT) are useful to rule out cervical spine injury (CSI). Computed tomography scans increase lifetime cancer risk in children from radiation exposure. Most CSI in children occur between the occiput and C4. We developed a cervical spine (C-spine) clearance guideline to reduce unnecessary CTs and radiation exposure in pediatric trauma patients., Methods: A pediatric C-spine clearance guideline was implemented in September 2018 at our Level 2 Pediatric Trauma Center. Guidance included CT of C1 to C4 to scan only high-yield regions versus the entire C-spine and decrease radiation dose. A retrospective cohort study was conducted comparing preguideline and postguideline of all pediatric trauma patients younger than 8 years screened for CSI from July 2017 to December 2020. Primary endpoints included the following: number of full C-spine and C1 to C4 CT scans and radiation dose. Secondary endpoints were CSI rate and missed CSI. Results were compared using χ 2 and Wilcoxon rank-sum test with P < 0.05 significant., Results: The review identified 726 patients: 273 preguideline and 453 postguideline. A similar rate of total C-spine CTs were done in both groups (23.1% vs 23.4%, P = 0.92). Full C-spine CTs were more common preguideline (22.7% vs 11.9%, P < 0.001), whereas C1 to C4 CT scans were more common post-guideline (11.5% vs 0.4%, P < 0.001). Magnetic resonance imaging utilization and CSIs identified were similar in both groups. The average radiation dose was lower postguideline (114 vs 265 mGy·cm -1 ; P < 0.001). There were no missed CSI., Conclusions: A pediatric C-spine clearance guideline led to increasing CT of C1 to C4 over full C-spine imaging, reducing the radiation dose in children., Level of Evidence: Level IV, therapeutic., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Brain Injury Guidelines (BIG) were developed to stratify traumatic brain injuries (TBIs) by severity to decrease unnecessary CT imaging and neurosurgical consultation in low-risk cases. This study evaluated the potential effect of a modified pediatric BIG (pBIG) algorithm would have on resource utilization., Methods: Isolated TBIs (<18 years) were queried from our Pediatric Trauma Registry from 2017 to 2020. Injuries were classified as mild (pBIG 1), moderate (pBIG 2), or severe (pBIG 3) based on neurologic status, skull fractures, size, and the number of bleeds. Modifications from the institutional adult algorithm were upgrading <4 mm epidural hematomas to pBIG 2 and eliminating interfacility transfer as a pBIG 2 criteria. The proposed pBIG 1 and 2 care plans do not include routine repeat CTs or neurosurgical consultation., Results: A total of 314 children with a mean age of 4.9 years were included. Skull fractures (213, 68%) and subdural hematomas (162, 52%) were the most common injuries. 89 (28%) children had repeat head CTs (2 (7%) pBIG 1, 26 (25%) pBIG 2, 61 (34%) pBIG 3). Neurosurgical consultation was obtained in 306 (98%), with 50 (16%) requiring intervention (1 (1%) pBIG 2 and 49 (27%) pBIG 3). Following the proposed pBIG would decrease neurosurgical consults to 181 (58%) and repeat CTs to 63 (20%). Following the algorithm, 91 (29%) kids would have been admitted to a higher level of care and 45 (14.3%) to a lower level., Conclusions: Implementation of our pBIG algorithm would decrease neurosurgery consults (40% reduction) and repeat head CTs (29% reduction)., Competing Interests: Conflict of Interest There are no conflicts of interest with this work., (Copyright © 2022. Published by Elsevier Inc.)

Introduction: Irrigation of the thoracic cavity at tube thoracostomy (TT) placement may decrease the rate of a retained hemothorax (RHTX); however, other resource utilization outcomes have not yet been quantified. This study evaluated the association of thoracic irrigation during TT with the length of stay and outcomes in patients with traumatic hemothorax (HTX)., Methods: A retrospective chart review was performed of adult patients receiving a TT for HTX at a single, urban Level 1 Trauma Center from January 2019 to December 2020. Those who underwent irrigation during TT at the discretion of the trauma surgeon were compared to a control of standard TT without irrigation. Death within 30 d, as well as TTs, placed at outside hospitals, during traumatic arrest or thoracic procedures, and for isolated pneumothoraces were excluded. The primary outcome was the length of stay as hospital-free, ICU-free, and ventilator-free days (30-day benchmark). Subgroup analysis by irrigation volume was conducted using one-way ANOVA testing with P < 0.05 considered statistically significant., Results: Eighty-two (41.4%) of 198 patients underwent irrigation during TT placement. Secondary interventions, thoracic infections, and TT duration were not statistically different in the irrigated cohort. Hospital-free and ICU-free days were higher in the irrigated patients than in the controls. Groups irrigated with ≥1000 mL had significant more hospital-free days (P = 0.007) than those receiving less than 1000 mL., Conclusions: Patients with traumatic HTX who underwent thoracic irrigation at the time of TT placement had decreased hospital and ICU days compared to standard TT placement alone. Specifically, our study demonstrated that patients irrigated with a volume of at least 1000 mL had greater hospital-free days compared to those irrigated with less than 1000 mL., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: Literature on outcomes after SSRF, stratified for rib fracture pattern is scarce in patients with moderate to severe traumatic brain injury (TBI; Glasgow Coma Scale ≤ 12). We hypothesized that SSRF is associated with improved outcomes as compared to nonoperative management without hampering neurological recovery in these patients., Methods: A post hoc subgroup analysis of the multicenter, retrospective CWIS-TBI study was performed in patients with TBI and stratified by having sustained a non-flail fracture pattern or flail chest between January 1, 2012 and July 31, 2019. The primary outcome was mechanical ventilation-free days and secondary outcomes were in-hospital outcomes. In multivariable analysis, outcomes were assessed, stratified for rib fracture pattern., Results: In total, 449 patients were analyzed. In patients with a non-flail fracture pattern, 25 of 228 (11.0%) underwent SSRF and in patients with a flail chest, 86 of 221 (38.9%). In multivariable analysis, ventilator-free days were similar in both treatment groups. For patients with a non-flail fracture pattern, the odds of pneumonia were significantly lower after SSRF (odds ratio 0.29; 95% CI 0.11-0.77; p = 0.013). In patients with a flail chest, the ICU LOS was significantly shorter in the SSRF group (beta, - 2.96 days; 95% CI - 5.70 to - 0.23; p = 0.034)., Conclusion: In patients with TBI and a non-flail fracture pattern, SSRF was associated with a reduced pneumonia risk. In patients with TBI and a flail chest, a shorter ICU LOS was observed in the SSRF group. In both groups, SSRF was safe and did not hamper neurological recovery., (© 2022. The Author(s).)

Introduction: Many critically ill trauma and surgical patients require nutritional support. Patients needing long-term enteral access often undergo placement of surgical feeding tubes, including percutaneous endoscopic gastrostomy tube, laparoscopic gastrostomy tube, and open gastrostomy tube. This study was performed to determine national practice patterns for feeding after feeding tube placement., Methods: A 16-question online survey was administered to members of the Eastern Association for the Surgery of Trauma via Qualtrics about feeding practices after placement of the feeding tube. Questions included demographics, training, current practice, annual procedural volume, timing to resume feeds: <2, 6, 12, or 24 h, methods to advance feeds, and reasons behind management decisions. For comparison, responses were grouped into "early" (≤6 h) and "late" (18-24 h) groups. The chi-square test was used, and P < 0.05 was significant., Results: Five hundred sixteen Eastern Association for the Surgery of Trauma members completed the survey. Most (95%) respondents worked at a level 1 or 2 trauma center, and 68% are in academic practice. The most common feeding tube placement was percutaneous endoscopic gastrostomy (median = 25/y, interquartile range = 15-40). Responses showed variability in timing of when feeds were resumed after procedure. Early feeding was not affected by age (≤42 y), trauma center designation, volume, or training programs at the respondent's hospital. Graduates of surgical critical care fellowship were less likely to feed early (P = 0.043)., Conclusions: There is wide variability in feeding practices after surgical feeding tube placement. Given the large quantity of procedures performed, a randomized controlled trial should be performed to determine the optimal timing to resume feeds in critically ill patients., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: This study examines the rates of pediatric auto versus pedestrian collision (APCs) and determined ages and periods of greatest risk. We hypothesized that the rate of APC in children would be higher on school days and in the timeframes correlating with travel to and from school., Methods: Retrospective case-control study of APC on school and nonschool days for patients younger than 18 years at an urban Level II pediatric trauma center from January 2011 to November 2019. Frequency of APC by hour of the day was plotted overall, for school versus nonschool days and for age groups: 0 year to 4 years, 5 years to 9 years, 10 years to 13 years, and 14 years to 17 years. t Test was used with a p value less than 0.05, which was considered significant., Results: There were 441 pediatric APC in the study period. Frequency of all APC was greater on school days (0.174 vs. 0.101; relative risk [RR], 1.72, p < 0.001), and APC with Injury Severity Score greater than 15 (0.039 vs. 0.024; p = 0.014; RR, 1.67; 95% confidence interval, 1.10-2.56). Comparing school day with nonschool day, the 0-year to 4-year group had no significant difference in APC frequency (0.021 vs. 0.014; p = 0.129), APC frequency was higher on school days in all other age groups: 5 years to 9 years (0.036 vs. 0.019; RR, 1.89; p = 0.0134), 10 years to 13 years (0.055 vs. 0.024; RR, 2.29; p < 0.001), and 14 years to 17 years (0.061 vs. 0.044; RR, 1.39; p = 0.045). The greatest increase in APC on school days was in the 10-year to 13-year age group., Discussion: All school age children are at higher risk of APC on school days. The data support our hypothesis that children are at higher risk of APC during transit to and from school. The age 10-year to 13-year group had a 129% increase in APC frequency on school days. This age group should be a focus of injury prevention efforts., Level of Evidence: Prognostic and Epidemiologic; Level IV., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Tourniquet use for extremity hemorrhage control has seen a recent increase in civilian usage. Previous retrospective studies demonstrated that tourniquets improve outcomes for major extremity trauma (MET). No prospective study has been conducted to date. The objective of this study was to evaluate outcomes in MET patients with prehospital tourniquet use. We hypothesized that prehospital tourniquet use in MET decreases the incidence of patients arriving to the trauma center in shock., Methods: Data were collected prospectively for adult patients with MET at 26 Level I and 3 Level II trauma centers from 2015 to 2020. Limbs with tourniquets applied in the prehospital setting were included in the tourniquet group and limbs without prehospital tourniquets were enrolled in the control group., Results: A total of 1,392 injured limbs were enrolled with 1,130 tourniquets, including 962 prehospital tourniquets. The control group consisted of 262 limbs without prehospital tourniquets and 88 with tourniquets placed upon hospital arrival. Prehospital improvised tourniquets were placed in 42 patients. Tourniquets effectively controlled bleeding in 87.7% of limbs. Tourniquet and control groups were similarly matched for demographics, Injury Severity Score, and prehospital vital signs (p > 0.05). Despite higher limb injury severity, patients in the tourniquet group were less likely to arrive in shock compared with the control group (13.0% vs. 17.4%, p = 0.04). The incidence of limb complications was not significantly higher in the tourniquet group (p > 0.05)., Conclusion: This study is the first prospective analysis of prehospital tourniquet use for civilian extremity trauma. Prehospital tourniquet application was associated with decreased incidence of arrival in shock without increasing limb complications. We found widespread tourniquet use, high effectiveness, and a low number of improvised tourniquets. This study provides further evidence that tourniquets are being widely and safely adopted to improve outcomes in civilians with MET., Level of Evidence: Therapeutic/Care Management; Level IV., (Copyright © 2022 American Association for the Surgery of Trauma.)

Motor vehicle crashes are one of the leading causes of death among teenagers. Many of these deaths are due to preventable causes, including impaired and distracted driving. You Drink, You Drive, You Lose (YDYDYL) is a prevention program to educate high school students about the consequences of impaired and distracted driving. YDYDYL was conducted at a public high school in Southern Nevada in March 2020. A secondary data analysis was conducted to compare knowledge and attitudes of previous participants with first-time participants. Independent-samples-t test and χ2 test/Fisher’s exact test with post-contingency analysis were used to compare pre-event responses between students who had attended the program one year prior and students who had not. Significance was set at p < 0.05. A total of 349 students participated in the survey and were included for analysis; 177 had attended the program previously (50.7%) and 172 had not (49.3%). The mean age of previous participants and first-time participants was 16.2 (SD ± 1.06 years) and 14.9 (SD ± 0.92 years), respectively. Statistically significant differences in several self-reported baseline behaviors and attitudinal responses were found between the two groups; for example, 47.4% of previous participants compared to 29.4% of first-time participants disagreed that reading text messages only at a stop light was acceptable. Students were also asked how likely they were to intervene if a friend or family member was practicing unsafe driving behaviors; responses were similar between the two groups. The baseline behaviors and attitudes of participants regarding impaired and distracted driving were more protective among previous participants compared to first-time participants, suggesting the program results in long-term positive changes in behaviors and attitudes. The results of this secondary retrospective study may be useful for informing the implementation of future impaired and distracted driving prevention programs.

Background: Trauma center staff and trainees are often assigned to a day and night shift. However, for adult trauma, the swing shift has been found to offer superior clinical exposure compared with a standard day or night shift for trainees. We characterized patterns in pediatric trauma arrival times based on the hour, weekday, and month and studied whether or not the swing shift also maximizes exposure to hands-on experiences in managing pediatric trauma., Methods: We performed a retrospective review of the trauma database at our urban, level 2 pediatric trauma center. We identified all the pediatric trauma activations in the last 13 years (2006-2018). A retrospective shift log was created, which included day (7:00 am to 7:00 pm), night (7:00 pm to 7:00 am), and swing (noon to midnight) shifts. The shifts were compared using the Wilcoxon match-pairs signed rank test. Weekends data were also compared with weekdays, and comparisons were also made for pediatric patients with Injury Severity Scores (ISS) >15., Results: There were 3532 pediatric patients identified for our study. The swing shift had 1.98 times more activations than the night shift, and 1.33 more than the day shift (P < 0.001). The swing shift was also superior to both the day and night shifts for exposure to patients with Injury Severity Score greater than 15 (P < 0.001). Weekend days had 1.28 times more trauma than the weekdays (P < 0.001). Peak arrival time was between the hours of 3:00 pm and 9:00 pm, and patient age did not have an effect on this trend., Conclusions: Experience in managing pediatric trauma patients will improve for trainees who utilize the swing shift. In addition, the hours between 3:00 pm and 9:00 pm on weekends may represent a time of particularly high likelihood of pediatric trauma arrivals, which may require extra staff and hospital resources.Level of Evidence: Therapeutic Study, Level IV., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Traumatic hemothorax poses diagnostic and therapeutic challenges both acutely and chronically. A working group of the Eastern Association for the Surgery of Trauma convened to formulate a practice management guideline for traumatic hemothorax., Methods: We formulated four questions: whether tube thoracostomy vs observation be performed, should pigtail catheter versus thoracostomy tube be placed to drain hemothorax, should thrombolytic therapy be attempted versus immediate thoracoscopic assisted drainage (VATS) in retained hemothorax (rHTX), and should early VATS (≤4 days) versus late VATS (>4 days) be performed? A systematic review was undertaken from articles identified in multiple databases., Results: A total of 6391 articles were identified, 14 were selected for guideline construction. Most articles were retrospective with very low-quality evidence. We performed meta-analysis for some of the outcomes for three of the questions., Conclusions: For traumatic hemothorax we conditionally recommend pigtail catheters, in hemodynamically stable patients. In patients with rHTX, we conditionally recommend VATS rather than attempting thrombolytic therapy and recommend that it should be performed early (≤4 days)., Competing Interests: Declaration of competing interest None of the authors have any conflict of interest or funding to disclose., (Copyright © 2020. Published by Elsevier Inc.)

Background: Although there is evidence that self-inflicted abdominal stab wounds are less severe than those from assault, it is unclear if this is true in other anatomic regions. This study compares severity and injury pattern between self-inflicted stab wounds (SISWs) and wounds from assault (ASW)., Materials and Methods: Stab wounds from our level I trauma registry from 2013 to 2018 were reviewed. Data included age, gender, self-inflicted versus assault, psychiatric or substance use history, anatomic location, operative intervention, injury severity, length of stay, and outcomes., Results: Over the study period, 1390 patients were identified. History of psychiatric diagnoses or previous suicide attempts was more frequent in SISWs (47% versus 6.5%, P < 0.01; 35% versus 0.4%, P < 0.01). SISWs had a higher incidence of wounds to the neck and abdomen (44% versus 11%, P < 0.01; and 34% versus 26%, P = 0.02). Overall, injuries from ASW had a higher injury severity score, but more procedures were performed on SISWs (46% versus 34%, P < 0.01). SISWs to the neck were more likely to undergo procedures (26% versus 15%, P = 0.04). Median hospital charges were higher in patients with SISWs ($58.6 K versus $39.4 K, P < 0.01)., Conclusions: SISWs have a distinct pattern of injuries, more commonly to the neck and abdomen, when compared with injuries resulting from ASW. The patients with SISWs have a higher rate of procedures, longer length of stay, and higher hospital charges despite low injury severity overall., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Outcomes after surgical stabilization of rib fractures (SSRF) have not been studied in patients with multiple rib fractures and traumatic brain injury (TBI). We hypothesized that SSRF, as compared with nonoperative management, is associated with favorable outcomes in patients with TBI., Methods: A multicenter, retrospective cohort study was performed in patients with rib fractures and TBI between January 2012 and July 2019. Patients who underwent SSRF were compared to those managed nonoperatively. The primary outcome was mechanical ventilation-free days. Secondary outcomes were intensive care unit length of stay and hospital length of stay, tracheostomy, occurrence of complications, neurologic outcome, and mortality. Patients were further stratified into moderate (GCS score, 9-12) and severe (GCS score, ≤8) TBI., Results: The study cohort consisted of 456 patients of which 111 (24.3%) underwent SSRF. The SSRF was performed at a median of 3 days, and SSRF-related complication rate was 3.6%. In multivariable analyses, there was no difference in mechanical ventilation-free days between the SSRF and nonoperative groups. The odds of developing pneumonia (odds ratio [OR], 0.59; 95% confidence interval [95% CI], 0.38-0.98; p = 0.043) and 30-day mortality (OR, 0.32; 95% CI, 0.11-0.91; p = 0.032) were significantly lower in the SSRF group. Patients with moderate TBI had similar outcome in both groups. In patients with severe TBI, the odds of 30-day mortality was significantly lower after SSRF (OR, 0.19; 95% CI, 0.04-0.88; p = 0.034)., Conclusion: In patients with multiple rib fractures and TBI, the mechanical ventilation-free days did not differ between the two treatment groups. In addition, SSRF was associated with a significantly lower risk of pneumonia and 30-day mortality. In patients with moderate TBI, outcome was similar. In patients with severe TBI a lower 30-day mortality was observed. There was a low SSRF-related complication risk. These data suggest a potential role for SSRF in select patients with TBI., Level of Evidence: Therapeutic, level IV., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: The most widely accepted grading system for blunt traumatic aortic injury (BTAI) by the Society of Vascular Surgery (SVS) recommends endovascular repair for grade 2 and greater. Non-operative management in grade 2 injuries has been shown to be reasonable in certain circumstances. The natural history of low-grade injuries (1, 2) when managed non-operatively is not well defined., Methods: Utilizing our trauma registry, patients from 2013 to 2016 with blunt traumatic injury who underwent initial computed tomography were identified. Aortic pathology was graded and grouped by SVS classification. Clinical courses were reviewed for timing of interventions, repeat imaging, concurrent injuries, and outcomes. Analysis of variance and Chi-square tests of significance were utilized to compare between groups., Results: Out of 10,178 patients, we identified 32 with BTAI (grade: 1 (n = 13), 2 (n = 5), 3 (n = 3), 4 (n = 11)). High-grade injuries (3, 4) resulted only from motor vehicle, motorcycle, and pedestrian mechanisms. Initially, 9 patients (28%) required intervention, 5 (16%) were treated non-operatively, and 18 (56%) underwent repeat imaging. On repeat imaging, injuries that did not resolve remained stable and no injuries were found to progress. Of these patients, 9 (50%) required delayed intervention and 9 (50%) successfully underwent non-operative management. Patients with low-grade injuries were more likely to have successful non-operative management than those with high-grade injuries (72% vs 7%; p < 0.01)., Conclusions: While low-grade injuries generally have good outcomes, some ultimately do require delayed intervention, and short-term imaging is not reliable in identifying these cases.

Background: Cadaveric and older radiographic studies suggest that concurrent cervical spine fractures are rare in gunshot wounds (GSWs) to the head. Despite this knowledge, patients with craniofacial GSWs often arrive with spinal motion restriction (SMR) in place. This study quantifies the incidence of cervical spine injuries in GSWs to the head, identified using computerized tomography (CT). Fracture frequency is hypothesized to be lower in self-inflicted (SI) injuries., Methods: Isolated craniofacial GSWs were queried from this Level I trauma center registry from 2013-2017 and the US National Trauma Data Bank (NTDB) from 2012-2016 (head or face abbreviated injury scale [AIS] >2). Datasets included age, gender, SI versus not, cervical spine injury, spinal surgery, and mortality. For this hospital's data, prehospital factors, SMR, and CTs performed were assessed. Statistical evaluation was done with Stata software, with P <.05 significant., Results: Two-hundred forty-one patients from this hospital (mean age 39; 85% male; 66% SI) and 5,849 from the NTDB (mean age 38; 84% male; 53% SI) were included. For both cohorts, SI patients were older (P < .01) and had increased mortality (P < .01). Overall, cervical spine fractures occurred in 3.7%, with 5.4% requiring spinal surgery (0.2% of all patients). The frequency of fracture was five-fold greater in non-SI (P < .05). Locally, SMR was present in 121 (50.2%) prior to arrival with six collars (2.5%) placed in the trauma bay. Frequency of SMR was similar regardless of SI status (49.0% versus 51.0%; P = not significant) but less frequent in hypotensive patients and those receiving cardiopulmonary resuscitation (CPR). The presence of SMR was associated with an increased use of CT of the cervical spine (80.0% versus 33.0%; P < .01)., Conclusion: Cervical spine fractures were identified in less than four percent of isolated GSWs to the head and face, more frequently in non-SI cases. Prehospital SMR should be avoided in cases consistent with SI injury, and for all others, SMR should be discontinued once CT imaging is completed with negative results.

Introduction: Gunshot wounds to the brain (GSWB) confer high lethality and uncertain recovery. It is unclear which patients benefit from aggressive resuscitation, and furthermore whether patients with GSWB undergoing cardiopulmonary resuscitation (CPR) have potential for survival or organ donation. Therefore, we sought to determine the rates of survival and organ donation, as well as identify factors associated with both outcomes in patients with GSWB undergoing CPR., Methods: We performed a retrospective, multicenter study at 25 US trauma centers including dates between June 1, 2011 and December 31, 2017. Patients were included if they suffered isolated GSWB and required CPR at a referring hospital, in the field, or in the trauma resuscitation room. Patients were excluded for significant torso or extremity injuries, or if pregnant. Binomial regression models were used to determine predictors of survival/organ donation., Results: 825 patients met study criteria; the majority were male (87.6%) with a mean age of 36.5 years. Most (67%) underwent CPR in the field and 2.1% (n=17) survived to discharge. Of the non-survivors, 17.5% (n=141) were considered eligible donors, with a donation rate of 58.9% (n=83) in this group. Regression models found several predictors of survival. Hormone replacement was predictive of both survival and organ donation., Conclusion: We found that GSWB requiring CPR during trauma resuscitation was associated with a 2.1% survival rate and overall organ donation rate of 10.3%. Several factors appear to be favorably associated with survival, although predictions are uncertain due to the low number of survivors in this patient population. Hormone replacement was predictive of both survival and organ donation. These results are a starting point for determining appropriate treatment algorithms for this devastating clinical condition., Level of Evidence: Level II., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Timely tourniquet placement may limit ongoing hemorrhage and reduce the need for blood products. This study evaluates if prehospital tourniquet application altered the initial transfusion needs in arterial injuries when compared with a non-tourniquet control group., Methods: Extremity arterial injuries were queried from our level I trauma center registry from 2013 to 2017. The characteristics of the cohort with prehospital tourniquet placement (TQ+) were described in terms of tourniquet use, duration, and frequency over time. These cases were matched 1:1 by the artery injured, demographics, Injury Severity Score, and mechanism of injury to patients arriving without a tourniquet (TQ-). The primary outcome was transfusion within the first 24 hours, with secondary outcomes of morbidity (rhabdomyolysis, renal failure, compartment syndrome), amputation (initial vs. delayed), and length of stay. Statistical tests included t-test and χ 2 for continuous and categorical variables, respectively, with p<0.05 considered as significant., Results: Extremity arterial injuries occurred in 192 patients, with 69 (36%) having prehospital tourniquet placement for an average of 78 minutes. Tourniquet use increased over time from 9% (2013) to 62% (2017). TQ+ patients were predominantly male (81%), with a mean age of 35.0 years. Forty-six (67%) received blood transfusion within the first 24 hours. In the matched comparison (n=69 pairs), TQ+ patients had higher initial heart rate (110 vs. 100, p=0.02), frequency of transfusion (67% vs. 48%, p<0.01), and initial amputations (23% vs. 6%, p<0.01). TQ+ patients had increased frequency of initial amputation regardless of upper (n=43 pairs) versus lower (n=26 pairs) extremity involvement; however, only upper extremity TQ+ patients had increased transfusion frequency and volume. No difference was observed in morbidity, length of stay, and mortality with tourniquet use., Discussion: Tourniquet use has increased over time in patients with extremity arterial injuries. Patients having prehospital tourniquets required a higher frequency of transfusion and initial amputation, without an increase in complications., Level of Evidence: Therapeutic study, level IV., Competing Interests: Competing interests: None declared.

Background: Bariatric surgery is a significant investment for the patient and weight loss team. In some cases, this includes a requirement for pre-operative weight loss despite the lack of evidence for a correlation with successful outcomes. We sought to determine whether weight loss on a short, immediate pre-operative diet, as well as across the medical weight loss program, would correlate with 1-year outcomes of patients undergoing laparoscopic sleeve gastrectomy (LSG)., Methods: All patients having a LSG between March 2013 and March 2016 were reviewed. Demographics and biometrics [weight, body mass index (BMI)] were collected at initial, day of surgery and follow-up (2 weeks, 6 weeks, 4 months, and 1 year). Pre-operative weight loss was determined both cumulative (initial to day of surgery) and for the pre-operative diet (2 weeks). Weight loss and percent excess weight loss (%EWL) were calculated and correlated at all time points., Results: A total of 127 patients were reviewed for this study. The mean %EWL at 1-year follow-up was 47 ± 18%. Weight loss achieved on a 2-week pre-operative diet did not correlate with weight outcomes at 1-year follow-up (r = 0.134, p = 0.40); however, cumulative pre-operative weight loss had a modest correlation (r = 0.443, p < 0.01). Post-operative %EWL at 4 months had the best correlation with longer term weight loss (r = 0.730, p < 0.01)., Conclusions: Pre-operative performance is not a good predictor for 1-year outcomes in LSG. Better correlation was observed in %EWL at post-surgery visits. Following the patient's trajectory post-operatively may provide a window for intervention to improve weight loss.

Highly purified capsaicin has emerged as a promising injectable compound capable of providing sustained pain relief following a single localized treatment during orthopedic surgical procedures. To further assess its reliability for clinical use, the potential effect of highly purified capsaicin on articular cartilage metabolism as well as tendon structure and function warrants clarification. In the current study, rabbits received unilateral supraspinatus transection and repair with a single 1 ml injection of capsaicin (R+C), PEG-only placebo (R+P), or saline (R+S) into the glenohumeral joint (GHJ). An additional group received 1 ml capsaicin onto an intact rotator cuff (I+C). At 18 weeks post-op, cartilage proteoglycan (PG) synthesis and content as well as cell viability were similar (p>0.05) across treatment groups. Biomechanical testing revealed no differences (p>0.05) among tendon repair treatment groups. Similarly, histologic features of both cartilage and repaired tendons showed minimal differences across groups. Hence, in this rabbit model, a single injection of highly purified capsaicin into the GHJ does not induce a deleterious response with regard to cartilage matrix metabolism and cell viability, or rotator cuff healing. These data provide further evidence supporting the use of injectable, highly purified capsaicin as a safe alternative for management of postoperative pain following GHJ surgery., (© 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.)

Background: The abnormal kinematics, contact pressures, and repeated episodes of instability observed in chronic anterior cruciate ligament (ACL) deficiency suggest that these patients may be predisposed to early degenerative changes and associated pathologies such as meniscal tears and chondral injury. Injury to the cartilage and associated structures at the time of ACL rupture, in combination with the inflammatory mediators released at the time of injury, may create irreversible damage to the knee despite restoration of normal knee kinematics with an ACL reconstruction., Hypothesis: Patients undergoing acute ACL reconstruction have a higher incidence of lateral meniscal tears and less severe chondral changes when compared with patients undergoing late ACL reconstruction. Older patients likely have a higher incidence of chondral and meniscal pathology compared with younger patients., Methods: A retrospective chart review of a single surgeon's ACL practice over 20 years was performed. A surgical data packet was used to record patient demographics, location, grade, and number of chondral injuries as well as location and pattern of meniscal injuries at the time of ACL reconstruction. Patients (N = 709) were divided into three subgroups according to their time from injury to surgery; acute (less than 4 weeks, N = 121), subacute (4 to 8 weeks, N = 146), and chronic (8 weeks or more, N = 442)., Results: Older patients had a higher incidence of more severe chondral grade and number of chondral injuries at the time of ACL reconstruction. Patients undergoing surgery more than 8 weeks after injury had a statistically significant more severe chondral grade in the medial compartment when compared with those that had surgery less than 8 weeks after injury. A similar observation was not found in the lateral compartment. With regard to meniscal pathology, full-thickness medial meniscal tears were likely to be bucket-type tears regardless of the chronicity of the injury. Similarly, full-thickness lateral meniscal tears were more often flap-type tears independent of the time interval between injury and surgery. Partial-thickness tears were common both medially and laterally., Conclusions: Patient's age and chronicity of ACL tear greater than 8 weeks are both significant factors in medial compartment chondral pathology. Patients with delayed reconstruction may have greater associated pathology., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Rotator cuff repair retear rates range from 25% to 90%, necessitating methods to improve repair strength. Although numerous laboratory studies have compared single-row with double-row fixation properties, little is known regarding regional (ie, medial vs lateral) suture retention properties in intact and torn tendons., Hypothesis: A torn supraspinatus tendon will have reduced suture retention properties on the lateral aspect of the tendon compared with the more medial musculotendinous junction., Study Design: Controlled laboratory study., Methods: Human supraspinatus tendons (torn and intact) were randomly assigned for suture retention mechanical testing, ultrastructural collagen fibril analysis, or histologic testing after suture pullout testing. For biomechanical evaluation, sutures were placed either at the musculotendinous junction (medial) or 10 mm from the free margin (lateral), and tendons were elongated to failure. Collagen fibril assessments were performed using transmission electron microscopy., Results: Intact tendons showed no regional differences with respect to suture retention properties. In contrast, among torn tendons, the medial region exhibited significantly higher stiffness and work values relative to the lateral region. For the lateral region, work to 10-mm displacement (1592 ± 261 N-mm) and maximum load (265 ± 44 N) for intact tendons were significantly higher (P < .05) than that of torn tendons (1086 ± 388 N-mm and 177 ± 71 N, respectively). For medial suture placement, maximum load, stiffness, and work of intact and torn tendons were similar (P > .05). Regression analyses for the intact and torn groups revealed generally low correlations between donor age and the 3 biomechanical indices. For both intact and torn tendons, the mean fibril diameter and area density were greater in the medial region relative to the lateral (P ≤ .05). In the lateral tendon, but not the medial region, torn specimens showed a significantly lower fibril area fraction (48.3% ± 3.8%) than intact specimens (56.7% ± 3.6%, P < .05)., Conclusion: Superior pullout resistance of medially placed sutures may provide a strain shielding effect for the lateral row after double-row repair. Larger diameter collagen fibrils as well as greater fibril area fraction in the medial supraspinatus tendon may provide greater resistance to suture migration., Clinical Relevance: While clinical factors such as musculotendinous integrity warrant strong consideration for surgical decision making, the present ultrastructural and biomechanical results appear to provide a scientific rationale for double-row rotator cuff repair where sutures are placed more medially at the muscle-tendon junction.

Purpose: The purpose of this study was to evaluate whether a correlation exists between patient height and soft-tissue patellar tendon length., Methods: Magnetic resonance imaging (1.5 T) was performed for knee pathology on 403 patients. The patellar tendon length was measured in the midsagittal plane by a board-certified musculoskeletal radiologist. Patient height was recorded to the nearest inch. Patients were grouped into 6 subgroups with 4-inch range intervals based on height. The entire study group was analyzed. Subgroup analysis and gender analysis were performed to determine statistical significance., Results: The mean patellar tendon length was 45 +/- 7 mm (range, 30 to 66 mm). Wide ranges were noted among each height subgroup irrespective of gender. Significant differences were noted between most height subgroups independent of gender., Conclusions: This study showed that a correlation exists between patient height, gender, and patellar tendon length. Although variation occurs among patients of the same height, significant differences in mean patellar tendon lengths do exist between patients in different height subgroups., Clinical Relevance: Parameters are provided using patient gender and height to reduce the potential for graft-construct mismatch when ordering bone-patellar tendon-bone allografts for anterior cruciate ligament reconstruction.

Background: Determination of appropriate treatment options for adult osteochondritis dissecans is difficult, as most published papers on surgical osteochondritis dissecans treatment report outcomes in a population consisting of both adult and juvenile patients., Purpose: This study examines the outcomes of surgical procedures in patients with adult osteochondritis dissecans., Study Design: Case series; Level of evidence, 4., Methods: The cohort included 46 adult patients (48 knees) with adult osteochondritis dissecans of the knee who had undergone surgical treatment (debridement, drilling, loose-body removal, arthroscopic reduction and internal fixation, microfracture, osteochondral allograft, or autologous chondrocyte implantation). The average patient age was 34 +/- 9.5 years (range, 20-49) and patients were followed for 4.0 +/- 1.8 years. The mean defect size was 4.5 +/- 2.7 cm(2). Outcomes were assessed via clinical assessment and established outcome scales, including the Lysholm, International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), Tegner, Cincinnati, and Short Form-12., Results: Statistically significant improvement (P < .05) was noted in all outcome scales, including Noyes, Tegner, Lysholm, IKDC, KOOS (subdivided into 5 categories including Pain, Symptoms, Activities of Daily Living, Sport, and Quality of Life), Short Form-12 Physical, and Short Form-12 Mental. Seven knees (14%) had clinical failure of the initial treatment and underwent a revision procedure at a mean follow-up of 14 months. Patients treated with arthroscopic reduction and internal fixation and loose-body removal demonstrated a statistically higher postoperative percentage score increase for the KOOS Sport (P = .008) and KOOS Quality of Life (P = .03) categories than those treated with an osteochondral allograft., Conclusion: Patients with adult osteochondritis dissecans of the knee, treated with surgical cartilage procedures, show durable function and symptomatic improvement at a mean 4.0 years of follow-up. Patients treated with arthroscopic reduction and internal fixation and loose-body removal demonstrated a greater improvement in outcome scores than those treated with osteochondral allograft.

Background: Chondrolysis has been reported as a sequela of arthroscopic shoulder surgery. Although the causes have yet to be fully elucidated, basic science and clinical evidence suggest a multifactorial origin. Surgical treatment in young patients with glenohumeral chondrolysis is particularly challenging, with little outcome data., Hypothesis: Glenohumeral chondrolysis has several causes and patterns of presentation. Biological resurfacing is a viable treatment option for symptomatic glenohumeral arthritis. Study Design Case series; Level of evidence, 4., Methods: Twenty patients (mean age, 19.7 years; range, 13.1-33.8) were referred for management of extensive glenohumeral arthritis after arthroscopy glenohumeral surgery (mean time postoperatively, 26 months; range, 3-73). Sixteen patients had an intra-articular pain pump placed for 2 to 3 days; 2 patients demonstrated prominent implants; and 2 had thermal treatment. Patients underwent revision surgery, including 7 biological resurfacings of the glenoid and humeral head, 4 biological resurfacings of the humeral head alone, and 7 other procedures. Eight patients having biological resurfacing were assessed just before the revision surgery, at a mean time of 3.1 years after revision (range, 1.9-6.5), with the American Shoulder and Elbow Surgeon scale and Simple Shoulder Test, Short Form 12 (physical and mental components), and visual analog scale score for pain., Results: Patient outcomes scores improved from 51 to 71 (American Shoulder and Elbow Surgeon scale, P < .01), 7 to 10 (Simple Shoulder Test, P < .02), and 5 to 3 (visual analog scale, P < .01). Preoperative range of motion demonstrated modest improvements from 119 degrees to 132 degrees of flexion, 42 degrees to 41 degrees of external rotation, and internal rotation from L2 to T12 level. Two patients required an additional surgery: 1 total shoulder arthroplasty and 1 capsular release with debridement., Conclusion: Severe glenohumeral arthritis is a devastating postoperative complication of glenohumeral arthroscopy. Although not a universal finding, the use of glenohumeral pain pumps is a concern, as well as suboptimal anchor placement. Biological resurfacing permits modest functional improvement in a challenging shoulder condition.

Osteochondritis dissecans of the knee is identified with increasing frequency in the young adult patient. Left untreated, osteochondritis dissecans can lead to the development of osteoarthritis at an early age, resulting in progressive pain and disability. Treatment of osteochondritis dissecans may include nonoperative or operative intervention. Surgical treatment is indicated mainly by lesion stability, physeal closure, and clinical symptoms. Reestablishing the joint surface, maximizing the osteochondral biologic environment, achieving rigid fixation, and ensuring early motion are paramount to fragment preservation. In cases where the fragment is not amenable to preservation, the treatment may include complex reconstruction procedures, such as marrow stimulation, osteochondral autograft, fresh osteochondral allograft, and autologous chondrocyte implantation. Treatment goals include pain relief, restoration of function, and the prevention of secondary osteoarthritis.

Meniscus transplantation is indicated for persistent pain in a meniscectomized knee. Currently, grafts are prepared aseptically, which provides limited protection against donor-derived infection. The performance of a novel, sterilized meniscus was compared with an aseptically prepared one in an experimental model. Twenty-two sheep were divided into three groups: aseptic meniscal allograft, sterile meniscal allograft, and medial meniscectomy. Animals were euthanized 2 and 4 months after surgery. Meniscal assessments included cell viability, histology, and biomechanical testing. Articular cartilage was evaluated through histology and Outerbridge scoring. Aseptic and sterile allografts had cell viabilities of 59.7% and 58.7%, respectively, at 4 months, which was less than native controls. Grafts had decreased compressive strength at 4 months compared with their preimplantation moduli and were weaker than native menisci. In operated knees, the tibial plateau had more severe degenerative changes, although Outerbridge scores were similar between operated groups. Overall, the allografts were similar in their cellularity and biomechanical properties but were inferior to the native tissue at these end points. The severity of chondral damage in the allograft knees could not be distinguished from meniscectomized joints. The sterilization process does not appear to compromise tissue integrity and provides additional allograft safety.

Background: Autologous chondrocyte implantation is indicated as a second-line treatment of large, irregularly shaped chondral defects after failure of first-line surgical intervention. This study examines the clinical results of a patient cohort undergoing autologous chondrocyte implantation and elucidates factors associated with subjective improvement after implantation., Hypothesis: Autologous chondrocyte implantation will result in long-term functional and symptomatic improvement., Study Design: Case series; Level of evidence, 4., Methods: The cohort included 137 subjects (140 knees) who underwent autologous chondrocyte implantation of the knee. Mean defect size per patient was 5.2 +/- 3.5 cm(2) (range, 0.8-26.6 cm(2)). Patients averaged 30.3 +/- 9.1 years of age (range, 13.9-49.9 years) and were followed for 4.3 +/- 1.8 years (range, 2.0-9.7 years). Outcomes were assessed via clinical assessment and established outcome scales, including the Lysholm scale, International Knee Documentation Committee scale, and Short Form-12., Results: A significant improvement after surgery was observed in all outcome assessments including the Lysholm (41 to 69; P < .001) and International Knee Documentation Committee (34 to 64; P < .001) scales. Subjectively, 75% of patients indicated they were completely or mostly satisfied with the outcome and 83% would have the procedure again. Preoperatively, 32% of patients had a Tegner score of 6 or greater, compared with 82% before injury and 65% at most recent follow-up. Multivariate analysis identified age (P < .021) and receiving workers' compensation (P < .018) as independent predictors of follow-up Lysholm score. Twenty-one patients (16%) required debridement of the autologous chondrocyte implantation site secondary to persistent symptoms, whereas 9 knees (6.4%) clinically failed and underwent a revision procedure., Conclusion: Autologous chondrocyte implantation is a viable treatment option for chondral defects of the knee, resulting in durable functional and symptomatic improvement. Age and workers' compensation status are independent predictors of outcome.

Background: Patients with osteoarthritis of the knee are at risk for poorer outcomes after arthroscopic meniscectomy. Intra-articular corticosteroid injections have been shown to be efficacious both in patients with osteoarthritis and postarthroscopy patients., Hypothesis: A postoperative, intra-articular methylprednisolone and lidocaine injection in patients with chondromalacia undergoing meniscectomy will improve patient-rated pain and function compared with control patients., Study Design: Randomized, controlled trial; Level of evidence, 1., Methods: A total of 58 patients (59 knees) were randomized in a double-blinded fashion to receive either saline plus lidocaine (saline) or methylprednisolone plus lidocaine (steroid) after arthroscopic meniscectomy in which chondromalacia (modified Outerbridge grade 2 or higher) was confirmed. Preoperatively and at follow-up-6 weeks and 6, 9, and 12 months-patients underwent an examination and completed a subjective functioning survey. Scores were calculated using several validated scoring systems including the Lysholm, International Knee Documentation Committee (IKDC), and Short Form-12 (SF-12)., Results: No statistically significant differences were observed between the saline (n = 30) and steroid (n = 29) groups in their demographics and preoperative scores. At 6 weeks, the steroid group had higher scores than the saline group on multiple scales, including the IKDC. No differences in outcome scores existed at later time points. At 12 months, 86% of the steroid and 69% of the saline group were completely or mostly satisfied with the procedure (P = .01). In the saline group, 4 patients required reinjection and 2 underwent joint replacements within 12 months, while the steroid group had 3 reinjections and 2 meniscus transplants., Conclusion: The addition of a postoperative corticosteroid injection resulted in improved pain and function at an early time point; however, it provided no lasting difference compared with only local anesthetic injection.

Currently, autologous chondrocyte implantation and osteochondral grafting bridge the gap between palliation of cartilage injury and resurfacing via arthroplasty. Emerging technologies seek to advance first generation techniques and accomplish several goals including predictable outcomes, cost-effective technology, single-stage procedures, and creation of durable repair tissue. The biologic pipeline represents a variety of technologies including synthetics, scaffolds, cell therapy, and cell-infused matrices. Synthetic constructs, an alternative to biologic repair, resurface a focal chondral defect rather than the entire joint surface. Scaffolds are cell-free constructs designed as a biologic "net" to augment marrow stimulation techniques. Minced cartilage technology uses stabilized autologous or allogeneic fragments in 1-stage transplantation. Second and third generation cell-based methods include alternative membranes, chondrocyte seeding, and culturing onto scaffolds. Despite the promising early results of these products, significant technical obstacles remain along with unknown long-term durability. The vast array of developing technologies has exceptional promise and the potential to revolutionize the cartilage treatment algorithm within the next decade.

Patients with chronic rotator cuff tears frequently have anterior shoulder pain attributed to the long head of the biceps brachii (LHBB) tendon. In this study, tenodesis or tenotomy samples and cadaveric controls were assessed by use of immunohistochemical and histologic methods to quantify inflammation, vascularity, and neuronal plasticity. Patients had moderate pain and positive results on at least 1 clinical test of shoulder function. The number of axons in the distal LHBB was significantly less in patients with biceps tendinitis. Calcitonin gene-related peptide and substance P immunostaining was predominantly within nerve roots and blood vessels. A moderate correlation (R = 0.5) was identified between LHBB vascularity and pain scores. On the basis of these results, we conclude that, in the context of rotator cuff disease, the etiology of anterior shoulder pain with macroscopic changes in the biceps tendon is related to the complex interaction of the tendon and surrounding soft tissues, rather than a single entity.