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Rising health care costs in the United States, besides evolving payment models that place emphasis on value instead of volume, have led to an increasing number of studies evaluating hand surgery from an economic perspective. To better understand such economics-based studies, this review provides a foundational understanding of what value entails by defining its features of quality and cost. Principles of evaluating value through cost-benefit, cost-effectiveness, and cost-utility analyses are discussed. Models of discounting and clinical decision analyses are also discussed. Understanding such concepts and their evaluation in economic analyses will provide greater insight into the economic landscape of hand surgery and improving patient care.

The purpose of the study is to examine presentation, injury patterns, and clinical course, for COVID-19-related peripheral nerve injury following mechanical ventilation.A multicenter retrospective study of patients with COVID-19 complicated by acute respiratory distress syndrome (ARDS) that required mechanical ventilation was undertaken. Patient records were reviewed for intensive care unit and intubation characteristics, prone or lateral decubitus positioning, and the onset of neuropathy diagnosis.Between September 2020 and January 2022, 11 patients were diagnosed with peripheral neuropathy, including 9 with brachial plexopathy following COVID-19 infection. Each patient developed ARDS requiring mechanical ventilation for a median of 39 days. Six patients (54.5%) underwent prone positioning and 1 lateral decubitus. Neuropathies involved 5 brachial pan-plexopathies, 2 incomplete brachial plexopathies, 2 lower trunk plexopathies, 1 radial neuropathy, and 1 bilateral ulnar neuropathy. At a mean follow-up of 10.2 months, patients with brachial pan-plexopathies demonstrated signs of reinnervation proximally, and 1 resolved to a radial mononeuropathy; however, the majority have demonstrated minimal clinical improvements.Our series demonstrates that peripheral neuropathies and especially brachial plexopathies have occurred following mechanical ventilation for ARDS-related COVID-19 infections. Contrary to prior COVID-19 studies, only 54.5% of these patients underwent prone positioning. Aside from a traumatic disturbance of prone positioning, the increased incidence of neuropathy may involve an atraumatic effect of COVID-19 via direct invasion of nerves, autoantibody targeting of nervous tissue, or hypercoagulation-induced microthrombotic angiopathy.

Introduction This article compares opioid use patterns following four-corner arthrodesis (FCA) and proximal row carpectomy (PRC) and identifies risk factors and complications associated with prolonged opioid consumption. Materials and Methods The PearlDiver Research Program was used to identify patients undergoing primary FCA (Current Procedural Terminology [CPT] codes 25820, 25825) or PRC (CPT 25215) from 2007 to 2017. Patient demographics, comorbidities, perioperative opioid use, and postoperative complications were assessed. Opioids were identified through generic drug codes while complications were defined by International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modification codes. Multivariable logistic regressions were performed with p < 0.05 considered statistically significant. Results A total of 888 patients underwent FCA and 835 underwent PRC. Three months postoperatively, more FCA patients (18.0%) continued to use opioids than PRC patients (14.7%) (p = 0.033). Preoperative opioid use was the strongest risk factor for prolonged opioid use for both FCA (odds ratio [OR]: 4.91; p < 0.001) and PRC (OR: 6.33; p < 0.001). Prolonged opioid use was associated with an increased risk of implant complications (OR: 4.96; p < 0.001) and conversion to total wrist arthrodesis (OR: 3.55; p < 0.001) following FCA. Conclusion Prolonged postoperative opioid use is more frequent in patients undergoing FCA than PRC. Understanding the prevalence, risk factors, and complications associated with prolonged postoperative opioid use after these procedures may help physicians counsel patients and implement opioid minimization strategies preoperatively.

The number of arthroplasty procedures has been rising at a significant rate, contributing to a notable portion of the nation's health care spending. This growth has contributed to an increase in the number of health care economic studies in the field of adult reconstruction surgery. Although these articles are filled with important information, they can be difficult to understand without a background in business or economics. The goal of this review is to define the common terminology used in health care economic studies, assess their value and benefit in the context of total joint arthroplasty, and highlight shortcomings in the current literature. [ Orthopedics . 2022;45(4):e174–e182.]

INTRODUCTION A comprehensive understanding of the trends for financial reimbursement of shoulder arthroplasty is important as progress is made toward achieving sustainable payment models in orthopaedics. This study analyzes Medicare reimbursement trends for shoulder arthroplasty. We hypothesize that Medicare reimbursement has decreased for shoulder arthroplasty procedures from 2000 to 2020 and that revision procedures have experienced greater decreases in reimbursement. METHODS The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was queried for each Current Procedural Terminology code used in shoulder arthroplasty, and physician reimbursement data were extracted. All monetary data were adjusted for inflation to 2020 US dollars. Both the average annual and the total percentage change in surgeon reimbursement were calculated based on these adjusted trends for all included procedures. Mean percentage change in adjusted reimbursement among primary procedures in comparison to revision procedures was calculated. The mean reimbursement was assessed and visually represented by geographic state. RESULTS The average reimbursement for all shoulder arthroplasty procedures decreased by 35.5% from 2000 to 2020. Revision total shoulder arthroplasty (TSA) experienced the greatest mean decrease (-44.6%), whereas primary TSA (-23.9%) experienced the smallest mean decrease. The adjusted reimbursement rate for all included procedures decreased by an average of 1.8% each year. The mean reimbursement for revision procedures decreased more than the mean reimbursement for primary procedures (-41.1% for revision, -29.9% for primary; P < 0.001). The mean reimbursement for TSA in 2020, and the percent change in reimbursement from 2000 to 2020, varied by state. DISCUSSION Medicare reimbursement for shoulder arthroplasty procedures has decreased from 2000 to 2020, with revision procedures experiencing the greatest decrease. Increased awareness and consideration of these trends will be important as healthcare reform evolves, and reimbursements for large joint arthroplasty are routinely adjusted.

The effect of spinopelvic fixation in addition to lumbar spinal fusion (LSF) on dislocation/instability and revision in patients undergoing primary total hip arthroplasty (THA) has not been reported previously.The PearlDiver Research Program was used to identify patients aged 30 and above undergoing primary THA who received (1) THA only, (2) THA with prior single-level LSF, (3) THA with prior 2-5 level LSF, or (4) THA with prior LSF with spinopelvic fixation. The incidence of THA revision and dislocation/instability was compared through logistic regression and Chi-squared analysis. All regressions were controlled for age, gender, and Elixhauser Comorbidity Index (ECI).Between 2010 and 2018, 465,558 patients without history of LSF undergoing THA were examined and compared to 180 THA patients with prior spinopelvic fixation, 5,299 with prior single-level LSF, and 1,465 with prior 2-5 level LSF. At 2 years, 7.8% of THA patients with prior spinopelvic fixation, 4.7% of THA patients with prior 2-5 level LSF, 4.2% of THA patients with prior single-level LSF, and 2.2% of THA patients undergoing only THA had a dislocation event or instability (P.0001). After controlling for length of fusion, pelvic fixation itself was associated with higher independent risk of revision (at 2 years: 2-5 level LSF + spinopelvic fixation: aHR = 3.15, 95% CI 1.77-5.61, P.0001 vs 2-5 level LSF with no spinopelvic fixation: aOR = 1.39, 95% CI 1.10-1.76, P.0001).At 2 years, spinopelvic fixation in THA patients were associated with a greater than 3.5-fold increase in hip dislocation risk compared to those without LSF, and an over 2-fold increase in THA revision risk compared to those with LSF without spinopelvic fixation.III.

Introduction Utilize a national pediatric database to assess whether hospital characteristics such as location, teaching status, ownership, or size impact the performance of pediatric digit replantation following traumatic digit amputation in the United States. Materials and Methods The Kid's Inpatient Database (KID) was used to query pediatric traumatic digit amputations between 2000 and 2012. Ownership (private and public), teaching status (teaching and non-teaching), location (urban and rural), hospital type (general and children's), and size (large and small-medium) characteristics were evaluated. Replantations were then divided into those that required subsequent revision replantation or amputation. Fisher's exact tests and multivariable logistic regressions were performed with p Results Overall, 1,015 pediatric patients were included for the digit replantation cohort. Hospitals that were privately owned, general, large, urban, or teaching had a significantly greater number of replantations than small-medium, rural, non-teaching, public, or children's hospitals. Privately owned (odds ratio [OR]: 1.80; 95% confidence interval [CI]: 1.06–3.06; p = 0.03) and urban (OR: 2.29; 95% CI: 1.41–3.73; p = 0.005) hospitals were significantly more likely to perform replantation. Urban (OR: 4.02; 95% CI: 1.90–8.47; p = 0.0003) and teaching (OR: 2.11; 95% CI: 1.17–3.83; p = 0.014) hospitals were significantly more likely to perform a revision procedure following primary replantation. Conclusion Private and urban hospitals were significantly more likely to perform replantation, but urban and teaching hospitals carried a greater number of revision procedures following replantation. Despite risk of requiring revision, the treatment of pediatric digit amputations in private, urban, and teaching centers provide the greatest likelihood for an attempt at replantation in the pediatric population. The study shows Level of Evidence III.

STUDY DESIGN Retrospective Study. OBJECTIVE This investigation examined matched cohorts of lumbar spinal fusion (LSF) patients undergoing robot-assisted and conventional LSF to compare risk of revision, 30-day readmission, 30-day complications, and postoperative opioid utilization. SUMMARY OF BACKGROUND DATA Patient outcomes and complication rates associated with robot-assisted LSF compared to conventional fusion techniques are incompletely understood. METHODS The PearlDiver Research Program (www.pearldiverinc.com) was used to identify patients undergoing primary LSF between 2011 and 2017. Patients receiving robot-assisted or conventional LSF were matched using key demographic and comorbidity variables. Indication for revision was also studied. Risk of revision, 30-day readmission, 30-day complications, and postoperative opioid utilization at 1 and 6 months was compared between the cohorts using multivariable logistic regression additionally controlling for age, sex, and Charlson Comorbidity Index. RESULTS The percent of LSFs that were robot-assisted rose by 169% from 2011 to 2017, increasing linearly each year (p = 0.0007). Matching resulted in 2528 patients in each cohort for analysis. Robot-assisted LSF patients experienced higher risk of revision (adjusted odds ratio [aOR] = 2.35, P ≤ 0.0001), 30-day readmission (aOR = 1.39, P = 0.0002), and total 30-day complications (aOR = 1.50, P

Background: There is a paucity of literature exploring the epidemiology of finger infections presenting to emergency departments (EDs) on a national scale. The purpose of this study was to determine the national incidence of and risk factors for finger infections. Methods: Finger infections presenting to EDs between 2012 and 2016 were identified in the National Electronic Injury Surveillance System database. Finger infections were characterized by mechanism and type, with subanalyses for sex, race, and age. Results: Over this 5-year period, finger infections accounted for 80 519 visits to EDs in the United States. The annual incidence increased significantly from 4.4 per 100 000 person-years in 2012 to 6.2 in 2016. The 3 most common causes of finger infections were nail manicuring tools, knives, and doors. The most common diagnosis was finger cellulitis (46.3%). Significantly more men developed finger infections than women (relative risk of 1.4). The highest overall incidence was observed in 40- to 59-year-old men (7.8 per 100 000 person-years). Tenosynovitis resulted in the largest proportion of admissions (25%). Conclusions: We have demonstrated a rising incidence of finger infections presenting to EDs, with 40- to 59-year-old patients most at risk. The most common mechanism was the use of nail manicuring tools, such as nail clippers. Patient education may decrease finger infection incidence from these activities, and early detection of finger infections may be crucial to minimizing hospital admissions and invasive treatments.

Objective The purpose of this study was to compare differences in the outcomes of patients who undergo anterior cervical diskectomy and fusion (ACDF) with and without a history of shoulder arthroscopy. Methods The PearlDiver Patient Records Database ( www.peardiverinc.com ) from 2007 to 2017 was used to query patients by Current Procedural Terminology, isolating those who underwent ACDF with and without prior shoulder arthroscopy. Postoperative complications within 30 days of the index procedure, opioid use, and revision procedures were assessed for each cohort using ICD-9/10 and Current Procedural Terminology coding. Results A total of 39,969 ACDF patients were queried, of which 38,859 (97.2%) underwent ACDF alone and 1110 (2.8%) underwent ACDF with prior shoulder arthroscopy. ACDF revision rates were significantly greater in patients with prior shoulder arthroscopy compared with ACDF alone (5.8% vs. 3.6%, aOR = 1.64, P = 0.0002). Patients with prior shoulder arthroscopy were also significantly more likely to fill opioid prescriptions at 3 months (aOR 1.19, P = 0.02), 6 months (aOR 1.22, P = 0.01), and 12 months (aOR 1.18, P = 0.04). Conclusions Patients who undergo ACDF with a prior shoulder arthroscopy have significantly greater revision rates, respiratory complications, and prolonged opioid use compared with patients without prior shoulder arthroscopy. With efforts to limit narcotic use and the importance of maximizing patient satisfaction, this analysis improves on the surgeon's ability to set expectations and postoperative plans for patients undergoing ACDF who have a history of shoulder arthroscopy.

The understanding of how normal cells transform into tumor cells and progress to invasive cancer and metastases continues to evolve. The tumor mass is comprised of a heterogeneous population of cells that include recruited host immune cells, stromal cells, matrix components, and endothelial cells. This tumor microenvironment plays a fundamental role in the acquisition of hallmark traits, and has been the intense focus of current research. A key regulatory mechanism triggered by these tumor-stroma interactions includes processes that resemble epithelial-mesenchymal transition, a physiologic program that allows a polarized epithelial cell to undergo biochemical and cellular changes and adopt mesenchymal cell characteristics. These cellular adaptations facilitate enhanced migratory capacity, invasiveness, elevated resistance to apoptosis, and greatly increased production of ECM components. Indeed, it has been postulated that cancer cells undergo epithelial-mesenchymal transition to invade and metastasize.In the following discussion, the physiology of chronic inflammation, wound healing, fibrosis, and tumor invasion will be explored. The key regulatory cytokines, transforming growth factor β and osteopontin, and their roles in cancer metastasis will be highlighted.

Background: Patients with carpal tunnel syndrome (CTS) may also have cervical radiculopathy (CR) or vice versa, potentially requiring carpal tunnel release (CTR) and anterior cervical discectomy and fusion (ACDF). This study evaluates whether there is an increased risk of complications following CTR or ACDF in patients with concurrent CTS and CR (CTS-CR) compared with those with only CTS or CR. Methods: A multipayer database was used to identify patients with CTS-CR. From this cohort, patients who underwent CTR and/or ACDF were identified. Patients with CTS-CR undergoing surgery were compared with those undergoing surgery with only CTS or CR. Multivariable logistic regression was used to compare matched populations to assess postoperative complications and risk of undergoing both procedures. Results: A total of 110 379 patients with CTS-CR were identified. Carpal tunnel release was performed in 21 152 patients (19.2%) with CTS-CR, from which 835 (0.76%) underwent ACDF. Anterior cervical discectomy and fusion was performed in 6960 patients (6.31%) with CTS-CR followed by CTR in 1098 patients (0.99%). Patients with CTS-CR were at greater risk of reoperation and complex regional pain syndrome following CTR. In ACDF, patients with CTS-CR were at greater risk of reoperation. Obesity and tobacco use were significant risk factors in patients with CTS-CR who underwent both CTR and ACDF rather than a single surgery. Conclusions: Examination of more than 100 000 patients with CTS-CR found a greater likelihood of reoperation and perioperative complications following surgery than those without concurrent diagnoses. Obesity and smoking increased the risk for patients undergoing both procedures. Patients presenting with CTS-CR are high risk and should be counseled on risk of complication and reoperation and optimized to reduce risk of undergoing both CTR and ACDF.

Background: A ruptured Achilles tendon (AT) can sideline a player for 6 to 12 months and reduce their power rankings by more than 50%. Previous research has compared AT rupture rates in different game conditions. Purpose: To determine environmental and physiological risk factors for AT tears, given the minimal amount of research on AT ruptures in the National Football League (NFL). Study Design: Case series; Level of evidence, 4. Methods: NFL players with a diagnosed AT tear between 2009 and 2016 were selected as the study population for this retrospective analysis. Data on NFL injury were collected from an established database composed of publicly available information. Player profiles were employed to determine position, team, and game statistics at the time of injury. The proportion of NFL rookies was approximated by summing the number of draft picks and the number of signed, undrafted free agents and measured against the number of roster spots before the season. Results: Between 2009 and 2016, there were 101 documented AT tears. Of these, 64% (65/101) occurred before the official season, including preseason games. Of the 36 tears that occurred in-season, 34 were during games. Overall, 29% (19/65) of the preseason tears occurred in rookies and 100% (36/36) of the in-season tears affected nonrookies. Of the rookies with AT ruptures, 42.11% returned to play in the NFL, while 62.20% of the nonrookies came back to partake in future seasons. Despite an average age of 26.7 years, the tear distribution was bimodal with players aged 24 and 36 years exhibiting the highest rates of tear. Conclusion: In our review of AT tears in NFL athletes, a large percentage of the tears occurred in rookie players, especially during the preseason. We also found that tears during the season occurred in only nonrookies, suggesting that the preseason is when rookies experience the greatest risk for injury.

STUDY DESIGN Retrospective study. OBJECTIVE To determine how lumbar spinal fusion-total hip arthroplasty (LSF-THA) operative sequence would affect THA outcomes. SUMMARY OF BACKGROUND DATA Outcomes following THA in patients with a history of lumbar spinal degenerative disease and fusion are incompletely understood. METHODS The PearlDiver Research Program (http://www.pearldiverinc.com) was used to identify patients undergoing primary THA. Patients were divided into four cohorts: 1) Primary THA without spine pathology, 2) remote LSF prior to hip pathology and THA, and patients with concurrent hip and spinal pathology that had 3) THA following LSF, and 4) THA prior to LSF. Postoperative complications and opioid use were assessed with multivariable logistic regression to determine the effect of spinal degenerative disease and operative sequence. RESULTS Between 2007 and 2017, 85,595 patients underwent primary THA, of whom 93.6% had THA without lumbar spine degenerative disease, 0.7% had a history of remote LSF, and those with concurrent hip and spine pathology, 1.6% had THA prior to LSF, and 2.4% had THA following LSF. Patients with hip and lumbar spine pathology who underwent THA prior to LSF had significantly higher rates of dislocation (aOR = 2.46, P

PURPOSE: The purpose of this study was to characterize the influence of SDF-1 on cell migration/adhesion and temporal gene expression of human cartilage mesenchymal progenitor cells (C-PCs); and to utilize SDF-1 conditioned mesenchymal progenitors to stimulate reintegration of human meniscus fibrocartilage breaks. MATERIALS AND METHODS: Characterization of SDF-1-induced cell migration was achieved using hydroxypropyl cellulose (HPC) scaffolds pretreated with SDF-1. Fluorescence microscopy and cell counting were used to visualize and quantify the extent of cell migration into scaffolds, respectively. Relative mRNA expression analysis was used to characterize the temporal effects of SDF-1 on C-PCs. Tissue reintegration experiments were conducted using cylindrical human meniscal tissue punches, which were then placed back together with an HPC scaffold embedded with C-PCs. Tensile testing was used to evaluate the extent of tissue reintegration stimulated by human mesenchymal progenitors. RESULTS: C-PCs migrate into scaffolds in response to SDF-1 with the same efficiency as mesenchymal progenitors from human marrow (BM-MSCs). SDF-1 treatment of C-PCs did not significantly alter the expression of early and late stage chondrogenic differentiation genes. Scaffolds containing SDF-1 preconditioned C-PCs successfully adhered to fibrocartilage breaks and migrated from the scaffold into the tissue. Tensile testing demonstrated that SDF-1 preconditioned C-PCs stimulate reintegration of fibrocartilage tears. CONCLUSION: C-PCs migrate in response to SDF-1. Exposure to SDF-1 does not significantly alter the unique mRNA profile of C-PCs that make them desirable for cartilaginous tissue repair applications. SDF-1 pretreated mesenchymal progenitors successfully disperse into injured tissues to help facilitate tissue reintegration.

Background: Indications for replantation following traumatic digit amputations are more liberal in the pediatric population than in adults, but delineation of patient selection within pediatrics and their outcomes have yet to be elucidated. This study uses a national pediatric database to evaluate patient characteristics and injury patterns involved in replantation and their outcomes. Methods: The Healthcare Cost and Utilization Project Kid’s Inpatient Database was queried for traumatic amputations of the thumb and finger from 2000 to 2012. Participants were separated into those who underwent replantation and those who underwent amputation. Patients undergoing replantation were further divided into those requiring revision amputation and/or microvascular revision. Patient age, sex, insurance, digit(s) affected, charges, length of stay, and complications were extracted for each patient. Results: Traumatic digit amputations occurred in 3090 patients, with 1950 (63.1%) undergoing revision amputation and 1140 (36.9%) undergoing replantation. Younger patients, those with thumb injuries, females, and those covered under private insurance were significantly more likely to undergo replantation. Cost, length of stay, and in-hospital complications were significantly greater in replantation patients than in those who had undergone amputation. Following replantation, 237 patients (20.8%) underwent revision amputation and 209 (18.3%) underwent vascular revision, after which 58 required revision amputation. Risk of revision following replantation involved older patients, males, and procedures done recently. Conclusions: Pediatric patients who underwent replantation were significantly younger, female, had thumb injuries, and were covered by private insurance. Our findings demonstrate that in addition to injury factors, demographics play a significant role in the decision for finger replantation and its outcomes.

Aims The aim of this study was to utilize a national paediatric inpatient database to determine whether obesity influences the operative management and inpatient outcomes of paediatric limb fractures. Patients and Methods The Kids’ Inpatient Database (KID) was used to evaluate children between birth and 17 years of age, from 1997 and 2012, who had undergone open and closed treatment of humeral, radial and ulna, femoral, tibial, and ankle fractures. Demographics, hospital charges, lengths of stay (LOS), and complications were analyzed. Results Obesity was significantly associated with increased rates of open reduction and internal fixation (ORIF) for: distal humeral (odds ratio (OR) = 2.139, 95% confidence interval (CI) 1.92 to 3.44; p < 0.001); distal radius and ulna fractures (OR = 1.436, 95% CI 1.14 to 2.16; p < 0.05); distal femoral (OR = 2.051, 95% CI 1.69 to 3.60; p < 0.05); tibial and fibula shaft (OR = 2.101, 95% CI 2.10 to 3.50; p < 0.001); and ankle (OR = 1.733, 95% CI 1.70 to 2.39; p < 0.001). Older age was significantly associated with ORIF for all fractures (p < 0.05). LOS, hospital charges, and complications were significantly increased in obese patients following ORIF for upper and lower limb fractures (p < 0.05). Conclusion Obese paediatric patients are more likely to undergo ORIF in both upper and lower limb fractures and have more inpatient complications. These findings may assist in informing obese paediatric fracture patients and their families regarding the increased risk for open operative fixation and associated outcomes. Cite this article: Bone Joint J 2019;101-B:491–496.

» The United States has faced substantial increases in health-care expenditure, with specifically large increases in spine surgery costs. » Many different formulas are utilized to determine value in spine surgery, including cost- benefit analyses, cost-effectiveness analyses, and cost-utility analyses, with the overall determination of value being quality/cost. » Quality often is calculated indirectly using either process measures or outcome measures and represents the potential benefit of a given intervention, usually over a specific time period to yield quality-adjusted life years. » Costs are particularly difficult to calculate given the interhospital, regional, national, and global variability, as well as indirect costs of an intervention, and many different methods are utilized to estimate costs. » Spine surgeons should be familiar with the elements that compose cost-effectiveness and their potential shortcomings in order for providers and health-care policy makers to identify the highest-quality studies and interventions that provide the greatest benefit to patients.

Peripheral nerves are crucial to the motor and sensory function provided by our upper and lower extremities to our brain and spinal cord. Following trauma or illness, these nerves may be injured, leading to a loss of function that can be significantly debilitating. Fortunately, given the type of injury and under the right conditions, peripheral nerves can regenerate through well-coordinated biochemical processes. However, as individuals age, the ability for nerves to regenerate becomes less efficient, reducing nerve's potential for the nerve to return to its prior level of function. In this article, we review the research that has been conducted to illustrate the reasons for such a decline in regenerative capacity. In doing so, we explore the concept of inflammaging alongside aging-related impairments of the macrophage and Schwann cell during nerve regeneration.

To assess rates of peripheral nerve injuries (PNI) in sport, exercise, and recreational activities.The National Electronic Injury Surveillance System (NEISS) was used to query nerve injuries presenting to emergency departments across the United States. Identified injuries were stratified to those with product codes associated with exercise, sports, or recreation. Injuries only to the upper and lower extremities were included as cranial and spinal cord injuries were excluded. PNI was analyzed by age, sex, sport/recreational activity, race, and evaluated for incidence rates by year and activity. Statistical significance was considered to be P 0.05.Between 2009-2018, 551,612 patients presented with PNI from which 120,675 (21.9%) were associated with exercise, sports, or recreation. PNI significantly increased between 2009-2018 (p = 0.002) with an overall incidence rate of 36.9 (95% confidence interval: 28.6, 45.2) per 1,000,000 person-years. A majority of PNI occurred through exercise (n = 56,328, 46.7%). PNI peaked in the fourth and fifth decades in males and females, respectively, with males accounting for significantly more than females (incidence rate ratio: 1.52, 95% confidence interval: 1.18, 1.86; p 0.0001). White patients had a majority of PNI at 49.3% though African-Americans carried the highest incidence rate at 30.4 (95% confidence interval: 23.8, 36.9) per 1,000,000 person-years. Football had the highest proportion of PNI until age 19 (17.3%) as exercise carried the highest proportion for those 20 and older ranging from 27.9% to 53.8% of PNI.PNIs are rising with participation in exercise, sports, and recreation over this 10-year study period. Injuries predominantly occurred in football for those under 20 and exercise for those 20 and older. Precautions and appropriate training are necessary for individuals participating in high-intensity exercise, sports, or recreation to limit the risk of a devastating neurological injury.

Healthcare expenditures in the United States continue to rise without corresponding improvements in outcomes. Because of this, there is increasing pressure on physicians to consider the economic impacts of their medical decisions. Unfortunately, physicians in general are unfamiliar with interpreting and performing various health economic analyses. A basic understanding of health economics may help physicians understand and participate in key policy discussions which may shape the future of medicine and surgery. In the field of pediatric orthopaedics specifically, the literature involving health economic evaluation is sparse. This may be due to a combination of unfamiliarity with the topic and also difficulties with applying economic evaluation methods to the pediatric population. However, many interventions in this field are low cost with many potential benefits that accrue over a child’s long lifespan. Economic evaluation can help objectively quantify the impact of these interventions, as well as bolster responsible medical decision-making. To that end, the purpose of the current review is to introduce the pediatric orthopaedic community to commonly utilized healthcare economic tools including cost-benefit analysis, cost-effectiveness analysis, and cost-utility analysis with a focus on several key concepts including value, quality, time, cost, and discounting. To help illustrate these concepts, health economic literature relevant to pediatric orthopaedics is discussed. Finally, we highlight limitations inherent to health economic evaluations in general and those applicable to pediatric orthopaedics specifically. This discussion may help lay the groundwork for future studies and for further involvement in policy-making.

Chondrocyte hypertrophy is a hallmark of osteoarthritis (OA) pathology. In the present study, we elucidated the mechanism underlying the relationship between the hypertrophy/apoptotic phenotype and OA pathogenesis in bone marrow-derived mesenchymal stem cells (BM-MSCs) via gene targeting of distal-less homeobox 5 (DLX5). Our primary objectives were (1) to determine whether DLX5 is a predictive biomarker of cellular hypertrophy in human osteoarthritic tissues, (2) To determine whether modulating DLX5 activity can regulate cell hypertrophy in mesenchymal stem/progenitor cells from marrow and cartilage. Whole transcriptome sequencing was performed to identify differences in the RNA expression profile between human-cartilage-derived mesenchymal progenitors (C-PCs) and bone-marrow-derived mesenchymal progenitors (BM-MSCs). Ingenuity Pathway Analysis (IPA) software was used to compare molecular pathways known to regulate hypertrophic terminal cell differentiation. RT-qPCR was used to measure DLX5 and hypertrophy marker COL10 in healthy human chondrocytes and OA chondrocytes. DLX5 was knocked down or overexpressed in BM-MSCs and C-PCs and RT-qPCR were used to measure the expression of hypertrophy/terminal differentiation markers following DLX5 modulation. Apoptotic cell activity was characterized by immunostaining for cleaved caspase 3/7. We demonstrate that DLX5 and downstream hypertrophy markers were significantly upregulated in BM-MSCs, relative to C-PCs. DLX5 and COL10 were also significantly upregulated in cells from OA knee joint tissues, relative to normal non-arthritic joint tissues. Knocking down DLX5 in BM-MSCs inhibited cell hypertrophy and apoptotic activity without attenuating their chondrogenic potential. Overexpression of DLX5 in C-PCs stimulated hypertrophy markers and increased apoptotic cell activity. Modulating DLX5 activity regulates cell hypertrophy and apoptosis in BM-MSCs and C-PCs. These findings suggest that DLX5 is a biomarker of OA changes in human knee joint tissues and confirms the DLX5 mechanism contributes to hypertrophy and apoptosis in BM-MSCs.

To evaluate the effect of a recent history of total hip arthroplasty (THA) on primary lumbar spine fusion (LSF) for concurrent hip and spine disease.A total of 98,242 patient records from the PearlDiver Database were evaluated and divided into 3 cohorts: 1) patients with a history of LSF alone, 2) patients with a history of LSF for newly diagnosed lumbar disease after having a remote THA2 years previously, and 3) patients with a history of LSF after having recent THA2 years before LSF who initially presented with concurrent hip and lumbar spine disease and underwent THA before LSF. Postoperative outcomes were assessed with multivariable logistic regression to determine the effect of THA on outcomes after LSF with respect to postoperative complications, LSF revision rates, and opioid use.Patients who had LSF after a recent THA had increased risk of deep venous thrombosis (adjusted odds ratio [aOR], 1.39; P = 0.0191), neurologic complications (aOR, 1.81; P = 0.0459), prolonged opioid use (aOR, 1.22; P = 0.0032), and revision LSF (12.8%; P = 0.0004 vs. 9.9%; OR, 1.41; P0.0001; hazard ratio, 1.69; P0.0001). Patients who underwent LSF after a remote history of THA had no significant difference in DVT (4.2% vs. 2.6%, aOR, 1.31; P = 0.2190), neurologic complications (1.0% vs. 0.5%, aOR, 2.02; P = 0.1220), revision surgery (9.6% vs. 9.9%, aOR, 1.06; P = 0.7197), or prolonged opioid use (36.5% vs. 24.4%, aOR, 1.17; P = 0.1120).Patients who undergo LSF with a history of THA may be at increased risk of postoperative complications, revision LSF, and prolonged opioid use if their THA was performed for concurrent hip-spine disease in the recent past (2 years).

Background: Complication rates following occipitocervical and atlanto-axial fusion are high. While methods to fuse the upper cervical spine levels have evolved, complication rates and surgical survivorship of occipitocervical fusion versus atlanto-axial fusion are incompletely understood. Methods: The PearlDiver Research Program (www.pearldiverinc.com) was used to identify patients undergoing primary occipitocervical or atlanto-axial fusion between 2007 and 2017. Incidence of each fusion procedure was studied across time. Multivariable logistic regression was used to compare 30-day readmission, 30-day medical complications, and post-operative opioid utilization at 1, 3, 6, and 12 months between cohorts, controlling for age, gender, Charlson Comorbidity Index (CCI), and indication for surgery. Risk of revision was compared through Cox-proportional hazards modeling, Kaplan-Meier survival, and log-rank test. Results: Cohorts of 483 occipitocervical fusions and 737 atlanto-axial fusions were examined. From 2008 to 2016, incidence of occipitocervical fusion rose 55.9%, whereas atlanto-axial fusion rose 21.6%. A greater percentage of atlanto-axial fusions were due to trauma (69.9% vs. 50.5%), whereas a greater percentage of occipitocervical fusions were due to degenerative disease (41.6% vs. 29.4%) (p = 0.0161). Total 30-day complications were seen in 40.9% of occipitocervical fusion patients compared to 26.3% of atlanto-axial fusion patients (aOR=2.06, p < 0.0001). Risk of surgical site infection was increased (aOR=2.59, p = 0.0075). Kaplan Meier survival analysis and Cox-proportional hazards demonstrated greater risk of revision following surgery for occipitocervical fusion (log rank: p < 0.0001, aHR=2.66, 95%CI 1.73–4.10, p < 0.0001). Conclusions: Rates of occipitocervical and atlanto-axial fusion are rising, while complication and revision surgery rates remain high, with occipiticervical fusion leading to higher rates even after controlling for patient characteristics and surgical indication. Spine surgeons should be cautious when considering fusion of the occipitocervical levels if atlanto-axial fusion could be performed safely and provide adequate stabilization to treat the same pathology.

Meniscus injuries are among the most common orthopedic injuries. Tears in the inner one-third of the meniscus heal poorly and present a significant clinical challenge. In this study, we hypothesized that progenitor cells from healthy human articular cartilage (chondroprogenitor cells [C-PCs]) may be more suitable than bone-marrow mesenchymal stem cells (BM-MSCs) to mediate bridging and reintegration of fibrocartilage tissue tears in meniscus. C-PCs were isolated from healthy human articular cartilage based on their expression of mesenchymal stem/progenitor marker activated leukocyte cell adhesion molecule (ALCAM) (CD166). Our findings revealed that healthy human C-PCs are CD166+, CD90+, CD54+, CD106- cells with multilineage differentiation potential, and elevated basal expression of chondrogenesis marker SOX-9. We show that, similar to BM-MSCs, C-PCs are responsive to the chemokine stromal cell-derived factor-1 (SDF-1) and they can successfully migrate to the area of meniscal tissue damage promoting collagen bridging across inner meniscal tears. In contrast to BM-MSCs, C-PCs maintained reduced expression of cellular hypertrophy marker collagen X in monolayer culture and in an explant organ culture model of meniscus repair. Treatment of C-PCs with SDF-1/CXCR4 pathway inhibitor AMD3100 disrupted cell localization to area of injury and prevented meniscus tissue bridging thereby indicating that the SDF-1/CXCR4 axis is an important mediator of this repair process. This study suggests that C-PCs from healthy human cartilage may potentially be a useful tool for fibrocartilage tissue repair/regeneration because they resist cellular hypertrophy and mobilize in response to chemokine signaling. Stem Cells 2019;37:102–114

Background: The objective of this study was to determine the comparative cost-effectiveness of performing initial revision finger amputation in the emergency department (ED) versus in the operating room (OR) accounting for need for unplanned secondary revision in the OR. Methods: We retrospectively examined patients presenting to the ED with traumatic finger and thumb amputations from January 2010 to December 2015. Only those treated with primarily revision amputation were included. Following initial management, the need for unplanned reoperation was assessed and associated with setting of initial management. A sensitivity analysis was used to determine the cost-effectiveness threshold for initial management in the ED versus the OR. Results: Five hundred thirty-seven patients had 677 fingertip amputations, of whom 91 digits were initially primarily revised in the OR, and 586 digits were primarily revised in the ED. Following initial revision, 91 digits required unplanned secondary revision. The unplanned secondary revision rates were similar between settings: 13.7% digits from the ED and 12.1% of digits from the OR ( P = .57). When accounting for direct costs, an incidence of unplanned revision above 77.0% after initial revision fingertip amputation in the ED would make initial revision fingertip amputation in the OR cost-effective. Therefore, based on the unplanned secondary revision rate, initial management in the ED is more cost-effective than in the OR. Conclusions: There is no significant difference in the incidence of unplanned/secondary revision of fingertip amputation rate after the initial procedure was performed in the ED versus the OR.

Background: Examination of the incidence of shoulder season-ending injury (SEI) in the collegiate athlete population is limited. Purpose: To determine the incidence of shoulder SEI in the National Collegiate Athletic Association (NCAA) and to investigate the risk factors for a shoulder injury ending an athlete’s season. Study Design: Descriptive epidemiology study. Methods: All shoulder injuries from the NCAA Injury Surveillance Program database for the years 2009-2010 to 2013-2014 were extracted, and SEI status was noted. The incidences of SEI and non-SEI were calculated for athlete, activity, and injury characteristics and compared via univariable analysis and risk ratios to determine risk factors for an injury being season ending. Results: Shoulder injuries were season ending in 4.3% of cases. The overall incidence of shoulder SEI was 0.31 per 10,000 athlete exposures (AEs), as opposed to 7.25 per 10,000 AEs for all shoulder injuries. Shoulder instability constituted 49.1% of SEI, with an incidence of 0.15 per 10,000 AEs, while fractures had the highest rate of being season ending (41.9%). Men’s wrestling had the highest incidence of shoulder SEI (1.65 per 10,000 AEs), while men’s soccer had the highest proportion of shoulder injuries that ended a season (14.6%). Overall, men had a 6.3-fold higher incidence of SEI than women and a 2.4-fold increased likelihood that an injury would be season ending. Conclusion: Injury to the shoulder of an NCAA athlete, while somewhat infrequent, can have significant implications on time lost from play. Incidence of these injuries varies widely by sport and injury, with a number of associated risk factors. Athletes sustaining potentially season-ending shoulder injuries, with their coaches and medical providers, may benefit from these data to best manage expectations and outcomes.

Interhospital competition has been shown to influence the adoption of surgical techniques and approaches, clinical patient outcomes, and health care resource use for select surgical procedures. However, little is known regarding these dynamics as they relate to spine surgery.This investigation sought to examine the relationship between interhospital competitive intensity and perioperative outcomes following lumbar spinal fusion.This study used the Nationwide Inpatient Sample dataset, years 2003, 2006, and 2009.Patients were included based on the presence of the International Classification of Disease, Ninth Edition, Clinical Modification (ICD-9-CM) codes corresponding to lumbar spinal fusion, as well as on the presence of data on the Herfindahl-Hirschman Index (HHI).The outcome measures are perioperative complications, defined using an ICD-9-CM coding algorithm.The HHI, a validated measure of competition within a market, was used to assess hospital market competitiveness. The HHI was calculated based on the hospital cachement area. Multiple regression was performed to adjust for confounding variables including patient age, gender, primary payer, severity of illness score, primary versus revision fusion, anterior versus posterior approach, national region, hospital bed size, location or teaching status, ownership, and year. Perioperative clinical outcomes were assessed based on ICD-9-CM codes with modifications.In total, 417,520 weighted patients (87,999 unweighted records) were analyzed. The mean cachement area HHI was 0.31 (range 0.099-0.724). The average patient age was 55.4 years (standard error=0.194), and the majority of patients were female (55.8%, n=232,727). The majority of procedures were primary spinal fusions (92.7%, n=386,998) and fusions with a posterior-only technique (81.5%, n=340,271). Most procedures occurred in the South (42.5%, n=177,509) or the Midwest (27.0%, n=112,758) regions. In the multiple regression analysis, increased hospital competitive intensity was associated with an increased total complication rate (odds ratio [OR] 1.52, p.0001), device-related complications (OR 1.46, p=.0294), genitourinary complications (OR 2.15, p=.0091), infection (OR 3.48, p.0001), neurologic complications (OR 1.69, p=.0422), total charges (+29%, p=.0034), and inpatient hospital length of stay (LOS) (+16%, p=.0012). The likelihood of complications at state-owned hospitals (OR 2.81, p=.0001) was more highly associated with HHI than at private, non-profit hospitals (OR 1.39, p=.0050). The occurrence of complications at urban teaching hospitals (OR 2.14, p.0001) was generally more associated with HHI than at urban non-teaching hospitals (OR 1.19, p=.2457).Increased interhospital competitive intensity is associated with increased odds of complications, increased total charges, and prolonged LOS following lumbar spine fusion. These differences are generally highest among state-owned and urban teaching hospitals. Differences in outcome related to hospital competition may be due to suboptimal resource allocation. Identifying differences in perioperative outcomes associated with hospital market competition is important in the contemporary environment of health care reimbursement reform and hospital consolidation. Perioperative outcome disparities between highly competitive and minimally competitive areas should be monitored and further studied.

Background: Trapezium dislocations are rare injuries. Methods: A PubMed search of the term “trapezium dislocation” was conducted. Publications reporting a complete trapezium dislocation were included in the review. Results: The PubMed search resulted in 168 results. Fourteen publications reporting on 16 complete trapezium dislocations met inclusion criteria. A case of delayed diagnosis of a trapezium dislocation is presented. The literature is reviewed for pertinent clinically relevant information with respect to trapezium dislocations. A systematic method for radiographic analysis of trapezium dislocations and classification are described, and a treatment algorithm is presented. Conclusions: Trapezium dislocations are infrequent injuries with few cases reported in the literature. Given the rarity of this injury, diagnosis and appropriate treatment may be delayed due to difficulty in recognition. Using the described method of radiographic analysis, delayed diagnosis may be avoided with implementation of timely treatment.

Category: Sports, Trauma, Ankle, Achilles Introduction/Purpose: Injuries are an ever-present entity in the National Football League, with recent research highlighting American football with the highest injury incidence among all major sports. A torn Achilles can sideline a player for six to twelve months and reduce their power rankings by over fifty percent. Within Achilles tears, there was a focus on comparing rookie rates to the rest of the players, examining tear rates for different game conditions and studying the day of the week the injury occurred. Due to the impact of the injury and limited research, we sought to examine Achilles tears in the NFL from 2009-2016 to identify trends correlating tears with game and player demographics. Methods: NFL players with a diagnosed Achilles tear between 2009 and 2016 were selected as the study population for this retrospective analysis. Data on NFL injury was collected from an established database, previously comprised of publicly available athlete information. NFL player profiles were then employed to determine position, team and game statistics at time of injury. Injury rates were calculated as a percentage of total league games on Thursdays and Sundays. The proportion of rookies in the NFL was approximated by summing the number of draft picks and the number of signed, undrafted free agents and measured against the total number of roster spots before the commencement of the season. Game surface was discerned at time of injury by consulting a timeline of the field surfaces and cross referencing the date of the game. Game conditions, such as weather and temperature, were discerned from the game logs published on the NFL website. Results: There were 101 documented Achilles tears. Sixty-four percent (65/101) occurred before the official season, in training or pre-season games. Only 1% (1/101) of tears occurring during post-season play-offs. Twenty-nine percent (19/65) of the pre- season tears occurred in rookies and 97% (35/36) of the in-season game tears affected non-rookies. Thirty-six percent (36/101) of all documented tears occurred in undrafted free agents. Of players with Achilles tear, 58.41% (59/101) returned to play in the NFL after injury. Despite an average age of 26.7 years, the tear distribution was bimodal with players, ages 24 and 36, exhibited the highest rates of tear. With regard to tears during games, 43.18% occurred on grass and 56.82% occurred on turf. These values mirror their field representation in games. The average game temperature was 67.04 degrees Fahrenheit with wide stratification (range: 1-91 degrees). When examining rate of tears for players during away versus home games, there was not a significant difference of note; of the 45 in-game tears, 21 (46.67%) occurred in home games and 24 (53.33%) during away games. Conclusion: In our focused analysis of the Achilles in NFL athletes, we show no significant difference in tear rates when comparing grass and artificial turf surfaces and in comparing Thursday and Sunday games. When reviewing experience level, a large percent of the tears occurred in rookie players, especially during the pre-season, despite these players making up less than a quarter of the athletes. We also show that tears were not restricted to certain weather conditions. When analyzing career length post tear, most players that returned to play continued to perform at a high level. This challenges the perception of AT tear as a career-ending injury.

Background:The management and outcomes of elbow ulnar collateral ligament (UCL) injuries in throwing athletes have been well investigated. However, less is known regarding the management, severity, and outcomes of such injuries in contact athletes.Purpose:To compare the incidence, severity, and outcomes of elbow UCL injuries between throwing and contact athletes in collegiate sports.Study Design:Descriptive epidemiology study.Methods:Elbow UCL injuries were queried from the National Collegiate Athletic Association (NCAA) Injury Surveillance Program between the seasons of 2009-2010 and 2013-2014 in 25 varsity sports. The rates and distribution of injuries by mechanism, participation restriction time, and outcomes (eg, season-ending injury, surgery) were examined. A severe injury was defined as loss of ≥21 days from participation, a season-ending injury, or requiring a surgical intervention. The injury frequency, incidence per 10,000 athlete-exposures (AEs), and injury proportion ratio comparing throwing and contact athletes were calculated with 95% CIs.Results:Over the course of 5 seasons, 109 UCL injuries were recorded, for an overall injury rate of 0.29 per 10,000 AEs. Of these injuries, 83 (76.1%) were a result of contact and 26 (23.9%) from throwing. Men’s wrestling (1.78 per 10,000 AEs) and men’s baseball (1.12 per 10,000 AEs) sustained the highest injury rates. A larger proportion of throwing (n = 8; 36.4%) compared with contact (n = –7; 9.1%) ( P < 0.01) injuries results in >21 days of time loss. Additionally, more throwing-related UCL injuries required surgery (n = 2; 11.1%) compared with contact-related injuries (n = 1; 1.3%) ( P < 0.01). As a result, throwing athletes demonstrated a significantly higher proportion of severe injuries than contact athletes (injury proportion ratio, 4.62 [95% CI, 1.72-12.40]).Conclusion:The evaluation of athletes in 25 collegiate varsity sports across 5 seasons found over 3 times more elbow UCL injuries in contact versus throwing athletes. However, the number of severe injuries in throwing athletes was significantly higher than in contact athletes. These findings demonstrate that although elbow UCL injuries are prone to occur in both contact and throwing athletes, their prevention, management, and outcomes must be framed on a sport-by-sport basis.

To compare postoperative complications, rates of revision, and opioid use of those who undergo shoulder arthroscopy with and without previous anterior cervical discectomy and fusion (ACDF).The PearlDiver database from 2007 to 2017 was used to query all patients who underwent shoulder arthroscopy as determined by Current Procedural Terminology (CPT). Patients were then separated among those who had a previous instance of ACDF and those who did not as filtered by CPT. Postoperative complications within 30 days, readmission rates, opioid use, and revision procedures were assessed for each cohort using a mix of International Classification of Diseases Ninth and Tenth Revision Clinical Modification codes, CPT, as well as generic drug codes.A total of 91,029 patients undergoing shoulder arthroscopy were identified, of whom 1,267 (1.4%) had a history of ACDF. Compared with patients without previous ACDF, patients with a history of ACDF had significantly greater respiratory complication rates (1.3% vs 0.5%: adjusted odds ratio [aOR] 2.16, 95% confidence interval [CI]1.30-3.59, P = .003), 30-day complication rates (3.7% vs 2.2%: aOR 1.48, 95% CI 1.10-1.99, P = .011), 1-year revision rates (15.2% vs 7.7%: aOR 2.00, 95% CI 1.71-2.33, P.0001), and greater opioid use at 1 month, 3 months, 6 months, and 12 months (P.0001).This study revealed that patients who undergo shoulder arthroscopy with a history of ACDF are twice as likely to undergo revision arthroscopy within 2 years of surgery and are at an increased risk of complications within 30 days postoperatively as well as prolonged opioid use compared with those without a history of ACDF. With these findings, both spine and shoulder surgeons should aim to be more aware of surgical history, especially of the cervical spine, to better counsel patients' clinical course and expected outcomes following shoulder arthroscopy.III, retrospective cohort study.

In this case report, we present a young female patient with a history of Gorham disease, who sustained pathologic fractures of the left radius and ulna after a low-impact fall. Massive osteolysis of the left forearm and wrist was noted on plain radiographs. The patient had had 8 previous left upper-extremity fractures without evidence of disease in any other area of the body.

BACKGROUND CONTEXT Surgeons have increasingly adopted robotic-assisted spinal fusion in efforts to increase accuracy of pedicle screw placement, but its effect on postoperative complication and revision rates has yet to be established. PURPOSE The purpose of this study was to compare risk of revision surgery, readmission, complications, and prolonged opioid utilization between robotic-assisted lumbar spine fusion (LSF) and conventional LSF. STUDY DESIGN/SETTING The study was a retrospective study from a large, national database. PATIENT SAMPLE A total of 2,528 patients undergoing robot-assisted LSF and 2,528 patients undergoing conventional LSF were matched from Humana Inc. insurance claims and Medicare records from 2007 to the first quarter of 2017. OUTCOME MEASURES Occurrence of revision surgery, readmission, complications, or prolonged opioid use following index surgery. METHODS The PearlDiver Research Program ( www.pearldiverinc.com ) was used to identify patients undergoing primary LSF between the years of 2007 and 2017. These patients were divided into two cohorts: LSF with robotic assistance (CPT-0054T, CPT-0055T, CPT-20985, CPT-61783 coded the same day as surgery) and without. Statistical matching was performed using demographic and relevant comorbidity variables. Postoperative outcomes were assessed for each cohort with multivariable logistic regression, controlling for age, sex, race, and Charlson Comorbidity Index. A p-value of .05 was set as the level of significance. RESULTS The percent of LSFs that were robot-assisted rose by 169% from 2011-2017, increasing linearly each year (p=0.0007). Matching resulted in 2,528 patients in each cohort for analysis. Robot-assisted LSF patients experienced higher risk of revision (aOR=2.35, p= CONCLUSIONS Robotic-assisted posterior lumbar spinal fusion is independently associated with increased risk of revision surgery, infection, instrumentation complications, and postoperative opioid utilization compared to conventional fusion techniques. Further research is needed to investigate long-term postoperative outcomes following robot-assisted LSF. Spine surgeons should be cautious when considering immediate adoption of this emerging surgical technology. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Background: Achilles tendon (AT) ruptures are one of the most common tendon ruptures, but there have been no studies investigating these injuries in the United States (US) using data representative of the entire US population. Purpose/Hypothesis: The purpose of this study was to determine the incidence and risk factors for AT ruptures in the US. We hypothesized that male sex, older age, and sport participation would increase the risk for AT ruptures. Study Design: Descriptive epidemiology study. Methods: All patients presenting to an emergency department with ruptured AT in the US from 2012 through 2016 were selected from the National Electronic Injury Surveillance System (NEISS) database. Incidence was calculated for sex, race, and age. AT ruptures were characterized based on the mechanism of injury, with subanalyses performed on sport-related AT ruptures to examine sex-, race-, and age-related differences. Results: From 2012 to 2016, a significant increase in the incidence of AT ruptures was observed, from 1.8 per 100,000 person-years in 2012 to 2.5 per 100,000 person-years in 2016 ( P < .01), for an overall incidence of 2.1 per 100,000 person-years. The majority of AT ruptures occurred in male compared with female patients, with an incidence rate ratio of 3.5 ( P < .01). The largest overall incidence of AT ruptures occurred in those aged 20-39 years for male patients (5.6/100,000 person-years) and in those aged 40-59 years for female patients (1.2/100,000 person-years). The largest rise in the incidence of AT ruptures during the study period was observed in patients aged 40-59 years (78% increase). The most common injury mechanism was participation in a sport or recreational activity (81.9% of all injuries), with basketball being the most common overall cause of AT ruptures. Conclusion: While AT ruptures in the US most commonly occur in young male patients (20-39 years old), the largest rise in the incidence was observed in middle-aged patients (40-59 years old), with participation in recreational sports being the most likely mechanism. Recognizing high-risk patients can help physicians counsel them and recommend strategies for injury prevention.

BACKGROUND As childhood obesity remains an ongoing issue for the United States there has been an increasing number of studies detailing its effect on fracture complexity, management, and outcomes. This study utilizes a national database to examine whether obese children with supracondylar humerus fractures are more likely to require open reduction and internal fixation than nonobese children. METHODS The Healthcare Cost and Utilization Project Kid's Inpatient Database of 2003, 2006, 2009, 2012 were queried for pediatric supracondylar humerus fractures [International Classification of Disease (ICD-9), 812.41] between 2 and 12 years. Patients were separated into those undergoing closed reduction percutaneous pinning (CRPP), open reduction internal fixation (ORIF), or both. Obesity was determined by comorbidity and ICD-9 coding (ICD-9, 278.00, 278.01). Univariable and multivariable logistic regression models were utilized with P

Purpose: Lyme arthritis is a common cause of knee pain in children, especially in endemic areas such as the Northeastern United States. Although Lyme arthritis presents similarly to septic arthritis, it is important to differentiate the two because of the drastically different methods of treating them. The purpose of this study was to quantify and compare inflammatory serum markers, as well as, the results of synovial fluid analysis in patients with both Lyme and septic arthritis of the knee. Methods: Retrospective review of records was performed in patients who presented to …

Pyogenic flexor tenosynovitis (PFT) is a well known infectious condition of the hand, involving the inoculation of the flexor tendon sheath with microorganisms. Many cases have been reported, common causes including direct inoculation by a puncture wound and deep lacerations extending into the flexor tendon sheath. In this report, we present a case of a 50 year old female with PFT resulting from autophagia (consuming one's own body parts, in our case, fingers) successfully treated with irrigation and debridement, amputation of the index finger at the metacarpophalangeal joint and antibiotic therapy.

Interactions between tumor cells and cancer-associated fibroblasts (CAFs) in the tumor microenvironment (TMEN) significantly influence cancer growth and metastasis. Transforming growth factor-β (TGF-β) is known to be a critical mediator of the CAF phenotype, and osteopontin (OPN) expression in tumors is associated with more aggressive phenotypes and poor patient outcomes. The potential link between these two pathways has not been previously addressed. Utilizing in vitro studies using human mesenchymal stem cells (MSCs) and MDA-MB231 (OPN+) and MCF7 (OPN−) human breast cancer cell lines, we demonstrate that OPN induces integrin-dependent MSC expression of TGF-β1 to mediate adoption of the CAF phenotype. This OPN-TGF-β1 pathway requires the transcription factor, myeloid zinc finger 1 (MZF1). In vivo studies with xenotransplant models in NOD-scid mice showed that OPN expression increases cancer growth and metastasis by mediating MSC-to-CAF transformation in a process that is MZF1- and TGF-β1-dependent. We conclude that tumor-derived OPN engenders MSC-to-CAF transformation in the microenvironment to promote tumor growth and metastasis via the OPN-MZF1-TGF-β1 pathway.

Background: Although nonoperative management after shoulder instability injury allows an athlete to return to play sooner than operative intervention, higher rates of recurrence have been observed after nonoperative management. However, no study has investigated the differences in performance of National Basketball Association (NBA) players after index shoulder instability events managed nonoperatively versus operatively. Purpose/Hypothesis: The purpose of this study was to identify shoulder instability events in NBA athletes and assess differences in performance after injury with nonoperative versus operative management. We hypothesized that players who undergo operative intervention have reduced risk of recurrence and are able to continue their elite level of play as opposed to those who undergo nonoperative management. Study Design: Cohort study; Level of evidence, 3. Methods: Publicly available injury data from the 1986-1987 through 2017-2018 seasons were reviewed to identify NBA athletes sustaining a shoulder instability event. In addition to characteristics, player performance information, including games played, player efficiency rating (PER), and win shares, was analyzed before and for 3 seasons after injury. Statistical learning models were applied to identify performance variables that have the greatest predictive value to determine players who would benefit from surgery. Results: A total of 60 players with shoulder instability events were identified between 1986 and 2018. After injury, 37 players (61.7%) eventually underwent surgery and 23 players (38.3%) did not. Players who were treated nonoperatively had significantly decreased PER, games played, and offensive win shares in the season after injury ( P < .05). Players who underwent surgery did not see a decline in PER, games played, or win shares. Random forest modeling found that true shooting percentage and win shares per 48 minutes were the performance variables most predictive in determining which players would benefit from surgery after shoulder instability. Conclusion: Players who underwent surgical intervention for shoulder instability maintained their PER, games played, and win share performance characteristics, whereas players who did not undergo surgery had declines in these parameters. Given the demands of shoulder function in basketball and the risk of recurrence after an instability event, surgery enhances a player’s opportunity to maintain a high level of performance after injury.

Background Matching into orthopaedic surgery residency in the United States has become an increasingly competitive process because of the large number of well-qualified applicants. Over the past several years, applicants have sought to maximize their chances of matching by submitting an increasing number of applications. The purpose of this study was to assess trends in application numbers, applicant qualifications, and application reviews, with the goal of obtaining data to help inform future improvements in the orthopaedic surgery residency application process. Methods Applicant data were obtained from the Electronic Residency Application Service (ERAS, www.aamc.org/services/eras/stats) and the National Resident Matching Program (NRMP, www.nrmp.org/report-archives). These included residency application data from 2000 to 2017. In addition, we analyzed available NRMP Applicant Survey Reports between 2008 and 2017, Program Director Survey Reports between 2008 and 2016, and NRMP's Charting Outcomes in the Match between 2006 and 2016. Results The number of U.S. senior medical student applicants per orthopaedic surgery residency position was stable from 2000 to 2017 (1.13 vs. 1.16 for 2000 and 2017, respectively). A significant increase in the United States Medical Licensing Examination (USMLE) Step-1 and Step-2 scores and self-reported research activity was present over the same time period. The number of applications submitted per applicant significantly increased, by 71.7%, from 48.4 in 2006 to 83.1 in 2017. Additionally, applications per program increased 46.4% from 457 in 2010 to 669 in 2016. In 2010, programs performed in-depth reviews for 54% of applications; however, in 2016, in-depth reviews had decreased to 45% of applications. Conclusions Orthopaedic residency applicant USMLE scores and research productivity have increased over time. Concurrently, the average number of applications submitted per applicant has increased, with the average applicant applying to nearly half of all orthopaedic residency programs. Consequently, programs have seen more than double the number of applications over this study period. The accompanying decline in the proportion of applications undergoing in-depth review, along with the applicant and program resources associated with these changes, warrants the development of strategies to enhance the efficiency of the application process for orthopaedic residency.

Category: Ankle, Ankle Arthritis Introduction/Purpose: Opiate pain medication is frequently prescribed following foot and ankle surgery for post-operative pain management. Opioid abuse has now reached epidemic levels and unfortunately become an all too common occurrence following small prescriptions of opiate pain medication. Total ankle arthroplasty and ankle fusion are two commonly performed procedures for the treatment of ankle arthritis. Understanding postoperative pain medication requirements following these procedures is useful both in the counseling of patients pre-operatively as well as in assisting surgeons with the management of postoperative pain. We aim to examine patient opioid usage following total ankle arthroplasty compared to ankle fusion and assess for potential clinical factors associated with increased post-operative opioid use. Methods: Adult patients (over 18 years of age) undergoing total ankle arthroplasty or ankle fusion were identified using CPT codes (27700, 27702, 27870, 29899) to query the Pearl Diver patient record database, a private insurance database. 1127 patients undergoing total ankle arthroplasty and 2695 patients undergoing ankle fusion were identified. Demographic data including age, sex, and medical history was collected. Patients were examined for opioid usage at pre-operative, 1-month, 3-month, 6-month, and 1-year time points. Post-operative complications and need for revision procedures within 1-year were also examined. Multivariate logistic regression analysis was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) with pResults: The most common age group amongst ankle arthroplasty patients was 70-74 (21.9%) and 65-69 (21.6%) for fusion. Patients undergoing fusion were more likely to have DM, HTN, morbid obesity, tobacco use, CHF, CKD, and CAD, (pConclusion: Our analysis of opiate prescription data indicates that a higher number of patients utilized opiate medication both pre-operatively and following fusion compared to arthroplasty patients at 1-month, 3-month, 6-month, and 1-year time points. Patients undergoing fusion also demonstrated worse pre-operative medical comorbidities. Additionally, patients undergoing fusion were more likely to suffer a complication including DVT and surgical site infection. This information indicates that fusion patients may require more opiate pain medication and are at increased risk for prolonged opiate use, and the potential complications of opiate use. Further analysis is indicated to determine potential risk factors for prolonged opioid use.

This final section walks students through every step of the residency application process – from the contents of application, interviewing, ranking – offering considerations to keep in mind along the way.