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Thromboelastography (TEG) is a point-of-care venipuncture test that measures the elasticity and strength of a clot formed from a patient's blood, providing a more comprehensive analysis of a patient's coagulation status than conventional measures of coagulation. TEG includes four primary markers: R-time, which measures the time to clot initiation and is a proxy for platelet function; K-value, which measures the time for said clot to reach an amplitude of 20 mm and is a proxy for fibrin cross-linking; maximum amplitude (MA), which measures the clot's maximum amplitude and is a proxy for platelet aggregation; and LY30, which measures the percentage of clot lysis 30 minutes after reaching the MA and is a proxy for fibrinolysis. Analysis of TEG-derived coagulation profiles may help surgeons identify patient-related and disease-related factors associated with hypercoagulability. TEG-derived coagulation profiles of patients with musculoskeletal oncology conditions have yet to be characterized.(1) What TEG coagulation profile markers are most frequently aberrant in patients with musculoskeletal oncology conditions presenting for surgery? (2) Among patients with musculoskeletal oncology conditions presenting for surgery, what factors are more common in those with TEG-defined hypercoagulability? (3) Do patients with musculoskeletal oncology conditions with preoperative TEG-defined hypercoagulability have a higher postoperative incidence of clinically symptomatic venous thromboembolism (VTE) than those with a normal TEG profile?In this retrospective, pilot study, we analyzed preoperatively drawn TEG assays on 52 patients with either primary bone sarcoma, soft tissue sarcoma, or metastatic disease to bone who were scheduled to undergo either tumor resection or nail stabilization. Between January 2020 and December 2021, our orthopaedic oncology service treated 410 patients in total. Of these, 13% (53 of 410 patients) had preoperatively drawn TEG assays. TEG assays were collected preincision as part of a division initiative to integrate the assay into a clinical care protocol for patients with primary bone or soft tissue sarcoma or metastatic disease to bone. Unfortunately, failures to adequately communicate this to our anesthesia colleagues on a consistent basis resulted in a low overall rate of assay draws from eligible patients. One patient on therapeutic anticoagulation preoperatively for the treatment of active VTE was excluded, leaving 52 patients eligible for analysis. We did not exclude patients taking prophylactic antiplatelet therapy preoperatively. All patients were followed for a minimum of 6 weeks postoperatively. We analyzed factors (age, sex, tumor location, presence of metastases, and soft tissue versus bony disease) in reference to hypercoagulability, defined as a TEG result indicating supranormal clot formation (for example, reduced R-time, reduced K-value, or increased MA). Patients with clinical concern for deep vein thrombosis (DVT) (typically painful swelling of the affected extremity) or pulmonary embolism (typically by dyspnea, tachycardia, and/or chest pain) underwent duplex ultrasonography or chest CT angiography, respectively, to confirm the diagnosis. Categorical variables were analyzed via a Pearson chi-square test and continuous variables were analyzed via t-test, with significance defined at α = 0.05.Overall, 60% (31 of 52) of patients had an abnormal preoperative TEG result. All abnormal TEG assay results demonstrated markers of hypercoagulability. The most frequent aberration was a reduced K-value (40% [21 of 52] of patients), followed by reduced R-time (35% [18 of 52] of patients) and increased MA (17% [9 of 52] of patients). The mean ± SD TEG markers were R-time: 4.3 ± 1.0, K-value: 1.2 ± 0.4, MA: 66.9 ± 7.7, and LY30: 1.0 ± 1.2. There was no association between hypercoagulability and tumor location or metastatic stage. The mean age of patients with TEG-defined hypercoagulability was higher than those with a normal TEG profile (44 ± 23 years versus 59 ± 17 years, mean difference 15 [95% confidence interval (CI) 4 to 26]; p = 0.01). In addition, female patients were more likely than male patients to demonstrate TEG-defined hypercoagulability (75% [18 of 24] of female patients versus 46% [13 of 28] of male patients, OR 3.5 [95% CI 1 to 11]; p = 0.04) as were those with soft tissue disease (as opposed to bony) (77% [20 of 26] of patients with soft tissue versus 42% [11 of 26] of patients with bony disease, OR 4.6 [95% CI 1 to 15]; p = 0.01). Postoperatively, symptomatic DVT developed in 10% (5 of 52; four proximal DVTs, one distal DVT) of patients, and no patients developed symptomatic pulmonary embolism. Patients with preoperative TEG-defined hypercoagulability were more likely to be diagnosed with symptomatic postoperative DVT than patients with normal TEG profiles (16% [5 of 31] of patients with TEG-defined hypercoagulability versus 0% [0 of 21] of patients with normal TEG profiles; p = 0.05). No patients with normal preoperative TEG profiles had clinically symptomatic VTE.Patients with musculoskeletal tumors are at high risk of hypercoagulability as determined by TEG. Patients who were older, female, and had soft tissue disease (as opposed to bony) were more likely to demonstrate TEG-defined hypercoagulability in our cohort. The postoperative VTE incidence was higher among patients with preoperative TEG-defined hypercoagulability. The findings in this pilot study warrant further investigation, perhaps through multicenter collaboration that can provide a sufficient cohort to power a robust, multivariable analysis, better characterizing patient and disease risk factors for hypercoagulability. Patients with TEG-defined hypercoagulability may warrant a higher index of suspicion for VTE and careful thought regarding their chemoprophylaxis regimen. Future work may also evaluate the effectiveness of TEG-guided chemoprophylaxis, as results of the assay may inform selection of antiplatelet versus anticoagulant agent.Level III, therapeutic study.

Purpose: To analyze graduating U.S. orthopaedic resident case logs to determine temporal trends in knee and shoulder arthroscopic case volumes, as well as changes in the variability of caseload volumes since the implementation of Accreditation Council for Graduate Medical Education (ACGME) minimum case requirements (“case minimums”) in 2013. Methods: We abstracted ACGME-published case log data for all U.S. orthopaedic surgery residents who graduated from 2007 to 2013 (before implementation of case minimums) and from 2014 to 2019 (after implementation). Using a case–control study design, we compared mean numbers of arthroscopic knee and shoulder cases reported per resident between the 2 time periods by using unpaired 2-tailed t tests. P values < .05 were considered significant. Results: The mean number of arthroscopy knee cases reported by residents decreased from 164 before implementation of case minimums to 107 after implementation (P < .001). The mean number of shoulder cases decreased similarly from 98 to 66 (P < .001). Among residents with caseload volumes in the 90th percentile (“high-volume caseloads”) the decrease was greatest, with 38% fewer knee cases and 41% fewer shoulder cases logged. The ratio of the number of cases in the 90th percentile of caseload to the number in the 10th percentile decreased significantly after implementation of case minimums (P < .001). Conclusions: After implementation of ACGME case minimums in 2013, the numbers of arthroscopic knee and shoulder cases reported by graduating U.S. orthopaedic surgery residents decreased significantly. The disparity between the number of cases that constitutes a high-volume caseload and the number that constitutes a low-volume caseload narrowed, suggesting greater uniformity in resident exposure to these procedures across training programs. Level of Evidence: Level III, retrospective comparative study.

Purpose of Review Clinically significant malunion of forearm diaphyseal fractures is an uncommon but potentially disabling condition amongst children and adolescents. We present the preoperative evaluation, including imaging, and discuss surgical indications and contemporary approaches to manage such patients, including an illustrative case. Recent Findings While advances in three-dimensional (3D) simulation, modeling, and patient-specific instrumentation have expanded the surgical armamentarium, their impact on long-term outcomes compared to traditional methods remains unknown. Summary Successful outcome following surgical correction of malunion following a both-bone forearm fracture can be achieved with careful patient selection, appropriate indications, and a well-planned surgical execution.

BACKGROUND: Supracondylar humerus fractures are the most common type of pediatric elbow fracture, accounting for 60–70% of all elbow fractures in children. Initial trauma and subsequent fracture displacement may damage surrounding neurovascular structures, leading to reports of associated neurovascular injury at rates as high as 49%, with vascular compromise reported in 3–19% of cases. This may be attributable to complete transection, kinking of the artery with reduced flow, thrombosis, intimal tear, arterial contusion or spasm, entrapment of the vessel within the fracture site or traumatic aneurysm of the brachial artery with subsequent thrombus formation. PURPOSE: While there is general agreement that a child presenting with a pulseless white (dysvascular) hand associated with a displaced supracondylar humerus fracture requires emergent operative management, whether or not surgical exploration of the brachial artery is warranted in a patient with a pulseless pink hand is debatable. Given the lack of consensus, an individualized approach based on clinical findings at initial presentation, including quality of distal perfusion including doppler signal, associated median nerve injury, availability of a surgeon with microvascular skill-set, and access to vigilant post-operative monitoring, combined with an open discussion of the pros and cons of various treatment options with the family is prudent. METHODS: Herein we outline our management principles, developed with careful consideration of the available literature and informed by practical experience. RESULTS: We recommend emergent management of pulseless supracondylar fractures, especially those that present with a pulseless white hand or with a dense median nerve palsy, with operative fracture reduction and fixation. In all children presenting with a pulseless supracondylar humerus fracture, the vascular status should be reassessed after adequate fracture reduction and fixation, and in patients with continued signs of abnormal distal perfusion, such as weak or absent Doppler signals or sluggish capillary refill, surgical exploration of the brachial artery with reestablishment of adequate distal flow should be conducted immediately. CONCLUSION: Much of the existing evidence surrounding the supracondylar humerus fracture associated with a pink, pulseless hand is of low quality. This shortcoming should serve as an impetus for establishment of an international registry of all dysvascular pediatric supracondylar fractures, with adequate documentation of the vascular exam before and after reduction, intra-operative and post-operative management and long term follow-up, to provide optimal management guidelines based on robust evidence.

Ongoing concern for declining Medicare payment to surgeons may incentivize surgeons to perform more cases to maintain productivity goals. The authors evaluated trends in physician payment, patient charges, and reimbursement ratios for the most common hand and upper extremity surgical procedures.The authors examined Medicare surgeon payment, patient charges, and surgical volume from 2012 to 2017 for 83 common surgical procedures, incorporating the year-to-year Consumer Price Index to adjust for inflation. The reimbursement ratio was calculated by dividing payment by charge. Weighted (by surgery type and volume) averages were calculated.Total Medicare surgeon payment increased 5.6 percent to $272 million for the studied procedures. Patient charges were seven times greater than payment, growing 24 percent to $1.9 billion. Despite growth of total payment, the average overall weighted payment for a single surgery decreased 3.5 percent. The average weighted patient charge increased 8 percent, whereas the reimbursement ratio decreased 13 percent. A hand surgeon would need to perform three more cases per 100 in 2017 to maintain the same reimbursement received in 2012. After categorizing these 83 surgical procedures, distal radius fixation (3 parts, 21 percent increase;2-part intra-articular, extra-articular, and percutaneous pinning, 17 percent increase), bony trauma proximal to the distal radius (10 percent increase), and upper extremity flap (5 percent increase) were subject to the greatest increases in payment. Payment for forearm fasciotomy (39 percent decrease), endoscopic carpal tunnel release (30 percent decrease), and mass excisions proximal to the wrist (18 percent decrease) decreased the most.From 2012 to 2017, despite a disproportionate increase in procedure charges, Medicare surgeon payment has not decreased substantially; however, total reimbursement is multifactorial and involves multiple sources of revenue and cost.

Background: We sought to assess whether select domains of the Patient-Reported Outcomes Measurement Information System (PROMIS) significantly correlate with the Disabilities of the Arm, Shoulder, and Hand (DASH) score and the Defense and Veterans Pain Rating Scale (DVPRS) among transhumeral amputees. Methods: We prospectively administered DASH, DVPRS, and PROMIS (including Upper Extremity, Pain Interference, and Pain Behavior domains) testing to patients presenting for consideration of osseointegration after transhumeral amputation. Concurrent validity was assessed via Pearson correlation testing. Results: The mean DASH score of the cohort was 32.8. The mean DVPRS score was 1.8. The mean PROMIS scores were 33.8, 50.5, and 50.6 for Upper Extremity, Pain Interference, and Pain Behavior domains, respectively. Pearson testing demonstrated a significant, inverse correlation between DASH and PROMIS Upper Extremity scores ( r = −0.85, P = .002). There was also significant correlation between DVPRS and PROMIS Pain Interference scores ( r = 0.69, P = .03). The PROMIS Pain Behavior domain did not significantly correlate with either DASH or DVPRS. Conclusions: Patient-Reported Outcomes Measurement Information System Upper Extremity and Pain Interference scores demonstrated significant concurrent validity with traditional measures (DASH and DVPRS) of patient-reported outcome in our population of transhumeral amputees.

A 12-year-old boy presented to the pediatric emergency department with a 5-day history of atraumatic, progressively worsening right hip pain and inability to ambulate. He was afebrile and had elevated inflammatory markers (Erythrocyte Sedimentation Rate [ESR]: 42 mm/hr, C-Reactive Protein [CRP]: 6.6 mg/dL) with a normal white blood cell count of 6050 cells/mm3. Given the clinical concern for septic arthritis, joint aspiration of the right hip was done and demonstrated a bloody appearance with a WBC count of 54,999 cells/mm3 and RBC count of 7,000 cells/mm3. MRI of the right hip demonstrated an intra-articular mass suggestive of tenosynovial giant cell tumor/pigmented villonodular synovitis. Subsequent biopsy and excision of the mass confirmed the diagnosis. The acute presentation of tenosynovial giant cell tumor with features mimicking septic arthritis is uncommon. This rare presentation of an already uncommon diagnosis should be considered in a child with an equivocal presentation for severe hip pain because misdiagnosis may lead to unnecessary or inadequately planned surgical treatment of the condition.

We present the case of an 81-year-old woman who developed profound hypercalcemia requiring admission to the intensive care unit after calcium sulfate bead use during revision hip arthroplasty. The patient's serum calcium level peaked at 21.0 mg/dL and was associated with acute encephalopathy. After treatment with calcitonin and bisphosphonates, her serum calcium level normalized and her mentation improved.The risk of clinically significant hypercalcemia should be considered when using calcium sulfate during orthopaedic surgery.

In 2013, the Accreditation Council for Graduate Medical Education (ACGME) mandated orthopedic surgery residents to perform at least 1000 surgical cases during residency and specified “case minimums” for 15 core procedure categories. We assessed trends in the volume and variability of graduating orthopedic surgery resident caseload since the implementation of these case minimums. We performed a retrospective linear regression analysis of ACGME-published case log data of US orthopedic residents graduating from 2014 to 2019, with trend analysis, comparison of case volume between residents in 10th and 90th percentiles, and comparison of logged cases vs case minimums for core procedures. Median total procedures performed increased from 1464 (range, 592–2842) in 2014 to 1709 (range, 870–3318) in 2019, representing a 17% increase in case volume ( P Orthopedics . 2022;45(1):25–30.]

To evaluate whether the Questionnaire for Persons with a Transfemoral Amputation (Q-TFA) significantly correlates with select Patient-Reported Outcomes Measurement Information System (PROMIS) domains and self-reported prosthetic wear time in transfemoral amputees presenting for consideration of osseointegration.This was a prospective study.Osseointegration Clinic, Walter Reed National Medical Center, Bethesda, MD.Patients who presented between 2017 and 2020 for consideration of osseointegration after transfemoral amputation.We prospectively administered Q-TFA (including use, mobility, problems, and global health subscores) and PROMIS (including physical function, pain interference, and pain behavior domains) questionnaires. We also asked participants to self-report prosthetic wear time.The main outcome measurement was concurrent validity, which was assessed through the Pearson correlation testing.Among our 39 patients, the Pearson testing demonstrated significant correlation between the following: Q-TFA use and self-reported prosthetic wear time (r = 0.81, P0.001); Q-TFA mobility and PROMIS physical function (r = 0.44, P = 0.009); Q-TFA problems and PROMIS pain interference (r = 0.60, P0.001); and Q-TFA global health and PROMIS physical function (r = 0.35, P = 0.04).Across all 4 domains of Q-TFA, correlation testing established significant concurrent validity with select PROMIS domains and self-reported prosthetic wear time among our population of transfemoral amputees. Given its ease of administration and reduction of question burden, PROMIS may better serve our efforts to track the outcomes of future interventions-including osseointegration-for these patients.

Injection drug use (IDU) is a risk factor for septic arthritis (SA) of native joints. Amid the opioid crisis, IDU rates have increased. This study assessed differences in pre-operative characteristics, microbial characteristics, and postoperative outcomes of 177 cases of SA treated operatively from 2015 to 2019 at 3 US hospitals, by self-reported IDU status. Forty cases (23%) involved patients who reported IDU. Patient characteristics, comorbidities, microbial characteristics, duration of hospital stay, discharge destination, follow-up rates, and rates of persistent/secondary infection were compared by self-reported IDU status. Compared with non–IDU-associated SA (non–IDU-SA), IDU-associated SA (IDU-SA) was associated with female sex ( P =.001), younger age ( P P P P =.04) and was more likely to involve methicillin-resistant Staphylococcus aureus ( P P P =.01). The 2 groups did not differ in terms of American Society of Anesthesiologists classification, joint involved, Gram stain positivity, presence of bacteremia, peripherally inserted central catheter placement, return to hospital within 3 months, or persistent/secondary positive results on culture within 3 months. Patients with IDU-SA were younger, were more likely to be female, had lower body mass index, and had fewer medical comorbidities but were more likely to use tobacco and to have a psychiatric diagnosis compared with patients with non–IDU-SA. Methicillin-resistant S aureus was more common in the IDU-SA group, as was discharge to a skilled nursing facility or against medical advice. Patients with IDU-SA were less likely to return for follow-up than patients with non–IDU-SA. [ Orthopedics . 2021;44(6):e747–e752.]

» Fractures that result from radiation-induced bone damage are a recognized adverse effect of radiation therapy (RT). » The mechanisms of damage from RT are thought to be related to impaired vascularity, aberrations in osteoclast and osteoblast-mediated bone turnover, and compromise of cortical and trabecular microarchitecture. » Treatment of radiation-associated fractures is challenging, with rates of delayed union and nonunion of >50%. » Fracture management strategies, each with its own profile of risks and benefits, include prophylactic intramedullary nailing of long bones, open reduction and internal fixation with adjunctive iliac crest or vascularized fibular grafting, and endoprosthetic reconstruction.

Objective: To compare the influence of objective and subjective measures of the three learning programs (OrthoBullets [OB], ResStudy [RS], and Clinical Classroom [CC]) on resident test performance and study platform preference. Methods: Sixty residents from three orthopaedic residencies were included in this study during May 2020. Trauma, pediatrics, and hip/knee reconstruction (joints) were chosen as testing topics. Residents took a standardized pretest of 30 questions per topic, followed by the completion of 50 questions per day for 5 days using one of the three web-based programs, followed by a standardized subject-specific posttest. This cycle was repeated for all the three topics. Bivariate statistics and a mixed-effects linear regression model were used to compare improvements in the scores. Results: Across all learning platforms, topics, and postgraduate year classes, posttest scores were 4.4% higher than the pretest score (73.3% vs. 68.9%, P < 0.001): 6.8% higher with OB, 5.4% with RS, and 1.0% with CC. The score improvement with OB was significantly greater than the score improvement with CC (P < 0.001). In total, 100% of residents reported that using OB would improve their score on the orthopaedic in-training examination, compared with 95% with RS and 67% with CC. Conclusion: OB demonstrated the greatest improvement in scores, followed closely by RS and then CC.

The purpose of this study was to examine a level 1 trauma center's 12-year experience treating frontal sinus fractures with regards to patient demographics, management strategies, and treatment outcomes.An institutional review board-approved retrospective review of all facial fractures at a level 1 trauma center was performed for the years 2000 to 2012. Patient demographics, location of fractures, concomitant injuries, use of antibiotics, surgical management strategies and outcomes were collected for all frontal sinus fractures. A significance value of 5% was used.There were 291 frontal sinus fractures treated at our institution. The mean age of patients was 34.4 years with a male predominance (90%). The most common mechanisms of injury were assault in 82 (28.2%) and motor vehicle accidents in 80 (27.5%). Anterior table fractures were seen in 261 patients (89.7%) and posterior table fractures were seen in 181 (62.2%). Treatment included ORIF with sinus preservation in 18 (6.2%), ORIF with sinus obliteration in 20 (6.9%), and cranialization in 18 (6.2%). Antibiotics were started on admission in 152 patients (52.2%). Fatality occurred in 9.3% of patients and complications included meningitis (1%), frontal sinusitis (1%), early wound infection (0.3%), and mucopyelocele (0.3%).Frontal sinus fractures in our center are most often caused by interpersonal violence. Anterior table fractures were more common than posterior table fractures and ORIF with sinus obliteration was the most common surgical intervention. Most frontal sinus fractures at our institution (82%) were treated conservatively with no surgical intervention and we observed a low rate of long term complications.

Case A 30-year-old man presented with progressive lower right extremity pain and swelling, initially diagnosed as a deep venous thrombosis. He returned 18 months later after 2 episodes of gross hemoptysis, with chest computed tomography angiography findings concerning for tumor thrombus in the left pulmonary artery. Subsequent advanced imaging showed a lesion arising from his right femoral vein, which open biopsy revealed to be a primary intravascular mesenchymal chondrosarcoma. He underwent medical therapy, with improvement of pain and swelling and successful return to work. Conclusion Mesenchymal chondrosarcoma is a rare pathology, and its intravascular origin makes this case extraordinarily uncommon.

While fractures of the hip have affected elderly patients since time immemorial, advances in the mid-twentieth century rapidly changed the landscape of fracture treatment. Emergence of safe operative modalities, advances in implant design and machining, and recognition of metabolic bone disease and the importance of perioperative medical optimization fundamentally changed our management approach. By contextualizing the history of care, we may better appreciate the current treatment of the geriatric patient with a hip fracture.

HIGHLIGHTS • We implemented a modified schedule in response to the COVID-19 pandemic • Staff are consolidated in 2 teams, alternating remote and on-site duty • We adopted an augmented didactic curriculum, completed remotely, Objective To describe the modified operational plan we implemented for residents and faculty in our orthopaedic surgery department to allow continuation of resident education and other core activities during the novel coronavirus (COVID-19) pandemic. Design Description of educational augmentation and programming modifications Setting The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center, Baltimore, MD Participants Residents and faculty, Department of Orthopaedic Surgery Methods In response to the COVID-19 pandemic, we developed and implemented a modified operational schedule and remote curriculum in the orthopaedic surgery department of our health system. Our plan was guided by the following principles: protecting the workforce while providing essential clinical care; maintaining continuity of education and research; and promoting social distancing while minimizing the impact on team psychosocial well-being. Results The operational schedule and remote curriculum have been implemented successfully and allow resident education and other core departmental functions to continue as our health care system responds to the pandemic. Conclusions We have been proactive and deliberate in implementing these operational changes, without compromise of our workforce. This experience provides residents exposure to real-life systems-based practice. We hope that our early experience will provide a framework for other surgical residency programs facing this crisis.

BACKGROUND: There is a high demand for shoulder/elbow experience among hand-fellowship trainees due to the perception that this exposure will improve their professional “marketability” in a subspecialty they perceive as having higher compensation. METHODS: Using Medicare data, we investigated the most common surgeries from these fields and determined which have the highest compensation [work relative value unit (wRVU), payment, charge, and reimbursement (payment-to-charge percentage] rates per operative time. We then determined whether the overall non-weighted and weighted (by surgical frequency/volume) compensation rates of shoulder/elbow surgery are greater than that of hand surgery. RESULTS: Among 30 shoulder/elbow procedures, arthroplasty and arthroscopic rotator cuff repair had the highest payment and wRVU assignments. Among 83 hand procedures, upper-extremity flaps, carpal stabilization, distal radius open reduction internal fixation (ORIF), both-bone ORIF, and interposition arthroplasty had the greatest wRVU assignments with correspondingly high payments. A non-weighted comparison of the two subspecialties showed that hand surgery has a higher mean payment/min ($10.46±3.22 vs. $7.52±2.89), charge/min ($51.02±17.11 vs. $41.96±11.32), and reimbursement (21±4.7% vs. 18±5.1%) compared with shoulder/elbow surgery (all, P

Background and objectives The development of desmoid fibromatosis after tumor resection may mimic local recurrence. To our knowledge, this phenomenon has not been reported after extremity sarcoma resection. We report four cases of desmoid-type fibromatosis ("desmoid tumors") mimicking local recurrence after extremity sarcoma resection. Methods We retrospectively reviewed the records of patients treated for extremity sarcoma by our orthopedic oncology service from 2014 to 2019 and identified four patients with biopsy-proven desmoid tumors. We extracted clinical, pathologic, radiographic, and operative data for the primary neoplasms and desmoid tumors. Results Four patients with postresection surveillance magnetic resonance imaging suspicious for local recurrence underwent further analysis showing desmoid tumors. Patients underwent image-guided needle biopsy, with specimens demonstrating fibromatosis-type histologic characteristics. Two cases were β-catenin positive. Desmoid tumors were managed with observation. No patient had experienced local or distant recurrence of the primary tumor at a mean follow-up of 30 months after resection (range, 23-34 months); none underwent surgery for symptoms of desmoid tumors. Conclusions Desmoid tumors should be considered part of the differential diagnosis when assessing patients with radiographic concern for postresection local recurrence of extremity bone and soft-tissue sarcoma. An image-guided needle biopsy can inform diagnosis and management.

Background: The presence of growth plates at the ends of long bones makes fracture management in children unique in terms of the potential risk of developing angular deformities and growth arrest. Materials wand Methods: We discuss three distinct cases depicting various aspects of physeal injury of the lower extremity in children. Results: The case illustrations chosen represent distinct body regions and different physeal injuries: Salter–Harris II fracture of the distal femur, Salter–Harris VI perichondrial injury of the medial aspect of the knee region, and Salter–Harris III fracture of the distal tibia. The clinical presentation, pertinent history and physical findings, imaging studies, management, and subsequent course are presented. Conclusions: Growth plate injuries of the lower extremity require a high index of suspicion and close monitoring during skeletal growth. Early recognition and proper management of these injuries can minimize long term morbidity. The treatment plan should be individualized after a comprehensive analysis of the injury pattern in each patient. Establishing a long term treatment plan and discussing the prognosis of these injuries with the child's caretakers is imperative.

Objective: To determine the prevalence and variation of inferior vena cava filter (IVCF) use in the spine trauma population and evaluate patient and facility level factors associated with their use. Study Design: Retrospective cohort. Participants/Outcome Measures: Patients with spinal injuries were identified by ICD-9 codes from the National Trauma Data Bank (NTDB), the best validated national trauma database. Patients whose spine injuries were operatively treated and those who received IVCF were identified from procedure description fields. Additional information compiled included patient demographics, injury severity score (ISS), time until surgery, concomitant fractures, and facility level information. Multivariate logistic regression analyses were conducted to examine the relationship of associated factors for IVCF use. Results: Of the 120,920 patients identified with spinal injuries, 2.4% received prophylactic IVCF. Of the 13,273 patients with operatively treated spinal injuries, 8.2% received prophylactic IVCF. Of the 7,770 patients with spinal cord injury (SCI), 10.8% received prophylactic IVCF. The interquartile ranges of placement rates among centers demonstrated greater than 10 fold variation. Based on multivariate logistic regression, ISS score >12 demonstrated the strongest association with prophylactic IVCF (adjusted OR = 4.908). Concomitant pelvic and lower extremity fractures (adj OR 2.573 and 2.522) were also associated with their use. Conclusions: Currently the only data regarding existing IVCF use in the spine trauma population amounts to surveys. The present study provides the most detailed and objective information regarding their use in this setting. Even in the operatively treated and SCI subgroups, prophylactic filters were used in only a small percentage of cases but placement rates varied widely among centers. More severely injured patients (ISS >12) had highest odds of receiving prophylactic IVCF. Further study is needed to clarify their role in this vulnerable population.

Limb salvage in the presence of posttraumatic tibial bone loss can be accomplished using the traditional Ilizarov method of distraction osteogenesis with circular external fixation. Internal fixation placed at the beginning of the consolidation phase, so-called integrated fixation, may allow for earlier removal of the external fixator but introduces concerns about cross-contamination from the additional open procedure and maintenance of bone regenerate stability.Among patients deemed eligible for integrated fixation, we sought to determine: (1) Does integrated fixation decrease the time in the external fixator? (2) Is there a difference in the rate of complications between the two groups? (3) Are there differences in functional and radiographic results between integrated fixation and the traditional Ilizarov approach of external fixation alone?Between January 2006 and December 2012, we treated 58 patients (58 tibiae) with posttraumatic tibial bone loss using the Ilizarov method. Of those, 30 patients (52%) were treated with the "classic technique" (external fixator alone) and 28 (48%) were treated with the "integrated technique" (a combination of an external fixator and plating or insertion of an intramedullary nail). During that period, the general indications for use of the integrated technique were closed physes, no active infection, and a healed soft tissue envelope located at the intended internal fixation site; the remainder of the patients were treated with the classic technique. Followup on 30 (100%) and 28 (100%) patients in the classic and integrated techniques, respectively, was achieved at a minimum of 1 year (mean, 3 years; range, 1-8 years). Adverse events were reported as problems, obstacles, and complications according to the publication by Paley. Problems and obstacles are managed by nonoperative and operative means, respectively; in addition, they resolve completely with treatment. Complications, according to the Paley classification, result in permanent sequelae. Functional and radiographic results were reported using the Association for the Study and Application of Methods of Ilizarov scoring system.Overall, there was a mean of four (range, 2-5) surgical procedures to complete the tibial reconstruction with a similar incidence of unplanned surgical procedures (obstacles) between the two groups (p = 0.87). Patients treated with integrated fixation spent less time in the external fixator, 7 months (range, 5-20 months) versus 11 months (range, 1-15 months; p0.001). There were seven problems, 15 obstacles, and zero complications in the classic group. Ten problems, 15 obstacles, and one complication occurred in the integrated fixation group. There was no difference in the severity (p = 0.87) or number (p = 0.40) of complications between both groups. Good to excellent Association for the Study and Application of Methods of Ilizarov function and bone scores were obtained in 100% and 98% of patients, respectively.The integrated fixation method allows for a more efficient limb salvage surgical reconstruction in patients carefully selected for that approach, whereas the frequency of adverse events and ability to restore limb lengths was not different between the groups with the numbers available. Careful placement of external fixation pins is critical to decrease cross-contamination with planned internal fixation constructs. In this study of posttraumatic tibial bone defect reconstruction, good/excellent results were found in all patients after a mean of four surgical procedures; however, a larger multicenter prospective study would allow for more robust and generalizable conclusions.Level III, therapeutic study.

Although the core principles of managing infantile Blount disease generally remain unchanged, treatment modalities have evolved over the years. Consensus has yet to be reached regarding the efficacy of bracing. Children with Blount disease commonly have advanced bone age, which may impact the timing and magnitude of (over) correction of angular deformity. Techniques of growth modulation, based on the tension band principle, continue to gain popularity. Although there are limited reports in the last decade on proximal tibial osteotomy for this developmental disorder, both acute and gradual correction remain viable treatment options in the appropriate setting. In certain older children (>7 y old) with advanced stages of the disease, a medial hemiplateau elevation combined with lateral proximal tibial hemiepiphysiodesis may be needed to address the epiphyseal deformity. Given the possibility of unpredictable proximal tibial physeal activity, all children with Blount disease should be followed at regular intervals till skeletal maturity. To provide sufficient granularity for pooled analyses and help establish evidence-based clinical guidelines, standardization of reporting clinical outcomes among children with Blount disease is encouraged.

Background:. The impact of left-handedness on orthopaedic surgeons and trainees has not been well described. We investigated the prevalence and perceived impact of left-handedness among orthopaedic surgeons and trainees. Methods:. We distributed a survey regarding handedness to active members of the American Orthopaedic Association and the Council of Orthopaedic Residency Directors affiliates, including department chairs, program directors, and residency and fellowship program coordinators. Program coordinators were asked to distribute the survey to their current residents and fellows. Results:. Of 510 survey respondents, 78 (15%) were identified as left hand dominant (LHD). Regarding scalpel/cautery use, 64% of LHD respondents reported using their left hand primarily and 10% reported using their right hand primarily; 26% of LHD respondents described themselves as ambidextrous in scalpel/cautery use, compared with 4.7% of right hand dominant (RHD) respondents (p < 0.001). Regarding suturing, 53% of LHD respondents reported using their left hand primarily and 38% reported using their right hand primarily; 9.0% of LHD respondents described themselves as ambidextrous when suturing, compared with 1.9% of RHD respondents (p = 0.012). Only 5.1% of LHD respondents reported having received laterality-specific psychomotor training, whereas 17% perceived a need for such training during residency; RHD respondents reported similar rates. Ambidexterity in scalpel/cautery use or suturing among LHD respondents was not associated with the perception that their left-handedness was advantageous. LHD attending surgeons were more likely than LHD trainees to perceive their handedness as advantageous (p = 0.007). Conclusions:. Fifteen percent of orthopaedic surgeons and trainees who responded to our survey were LHD. LHD respondents reported significantly higher rates of ambidexterity in both scalpel/cautery use and suturing compared with RHD respondents. Ambidexterity was not associated with a self-perception that left-handedness was advantageous. LHD-attending surgeons were significantly more likely than LHD residents/fellows to perceive their left-handedness as advantageous. There may be benefits to pairing LHD residents with LHD faculty surgeons early in their training to provide mentorship and insight regarding performing surgical procedures left handed. Level of Evidence:. Level IV.

Using the 2012 Kids Inpatient Database, we assessed records of pediatric patients (