Republication of "Assessment of Recovery From Geriatric Ankle Fracture Using the Life Space Mobility Assessment (LSA): A Pilot Study".

Background: The Life Space Assessment (LSA) is a validated outcomes measure that aims to assess the level of mobility and physical functioning within one's own environment following a medical event. We sought to study the recovery of geriatric ankle fracture patients utilizing the LSA. We hypothesized that the LSA would provide improved assessment of these patients and help identify key differences in operative and nonoperatively treated patients. Methods: Prospective observational study of geriatric patients age 65 years and older with an ankle fracture with 1-year follow-up. Operative versus nonoperative intervention was determined by the attending physician on a patient-specific basis. The LSA, Short Form-36 (SF-36), and visual analog pain scale (VAPS) were administered at predetermined intervals postinjury and scores were analyzed for significance. Results: 20 patients were enrolled in this study. 11 underwent surgery whereas 9 were treated nonoperatively. Regardless of treatment, the preinjury LSA score was 86.7. This significantly dropped to 20.6 at 6 weeks and recovered to 73.6 at 12 months. In the operative cohort, the LSA scores preinjury were 91.4 and improved to 87.6 after 1 year. The nonoperative group recorded 80.9 preinjury and only improved to 59.5 at 1 year (P = 0.007). There was no statistically significant difference when comparing the results of the SF-36 and VAPS to the LSA. Conclusion: The LSA was effective in assessing recovery in geriatric ankle fracture patients. A severe deficit in mobility was seen for the first 6 months of recovery regardless of treatment. Operative patients ultimately returned to their baseline LSA at 1 year while nonoperative patients did not. Outcomes from the VAS and SF-36 mirrored the LSA but were not found to be statistically significant. Level of Evidence: Level II.

Factors influencing time to return to sport following clavicular fractures in adolescent athletes.

BACKGROUND: There is a trend toward increased surgical treatment of displaced clavicle fractures in the adolescent population presumably because of extrapolation of adult-derived best practice guidelines. The purpose of this study was to compare return to sport between nonoperative and operative treatment of clavicle fractures in high school athletes. METHODS: A retrospective review of clavicle fractures sustained in scholastic athletes participating in school-sponsored athletics in the upstate South Carolina was performed from 2015 to 2019. Injury circumstances, demographics, radiographs, treatment, and return to sport data were documented for all patients. Radiographs were evaluated for fracture location, comminution, displacement, shortening, and angulation. Patients were followed until complete return to sport, and results were compared based on sport participation, injury mechanism, fracture morphology, treatment type, and time to return to sport. RESULTS: Forty-seven patients (44 were male; average age 15.6 years) were included who all returned to sport within the original or subsequent season. Thirty-six patients (73%) were managed conservatively (30 middle third fractures, 4 medial third fractures, 2 distal third fractures), whereas 11 were managed surgically (11 middle third fractures). Eighty-one percent of fractures occured in collision athletes (55% in football). There was no difference in time loss based on participating in collision vs. noncontact sports (P = .4). Conservatively managed fractures returned to sport faster (61 ± 38 days vs. 100 ± 49 days; P = .008) compared with surgically managed patients. Fracture displacement ≥100% (100 ± 51 days vs. 54 ± 27 days; P = .001), greater comminution (128 ± 50 days vs. 59 ± 31 days; P = .001), and angulation (86 ± 52 days vs. 54 ± 22 days; P = .001) all were statistically significant for slower return to sport. Athletes presenting with clavicular shortening <2 cm returned to sport within a similar time frame as athletes with ≥2 cm (P = 0.1). CONCLUSION: Our results show that adolescent athletes with clavicular fractures predictably return to athletics, including collision sports. Athletes conservatively managed returned 40% faster than those with surgery. However, this appears to be associated with the severity and complexity of fractures treated surgically. This study provides evidence to counsel adolescent athletes following clavicular fractures on return to sport expectations.

Effect of Preoperative Gabapentin With a Concomitant Adductor Canal Block on Pain and Opioid Usage After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: An adductor canal block (ACB) and preoperative oral gabapentin have each been shown to decrease postoperative pain scores and opioid usage in patients undergoing anterior cruciate ligament (ACL) reconstruction. PURPOSE/HYPOTHESIS: This study evaluated the efficacy of preoperative gabapentin on postoperative analgesia in patients who received an ACB. We hypothesized that patients undergoing ACL reconstruction with an ACB who utilized a single dose of preoperative oral gabapentin would have decreased pain and opioid consumption in the 24 to 72 hours after surgery compared with patients who did not utilize gabapentin. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Between January and October 2016, patients at a single institution who underwent ACL reconstruction and received an ACB were identified. Patients who underwent surgery before May 2016 were placed in the control group, and patients seen after May 2016 received a preoperative dose of gabapentin and were placed in the gabapentin group. All patients completed a pain log via a smartphone application to record pain scores and opioid usage after surgery. RESULTS: A total of 74 patients were identified: 41 in the gabapentin group and 33 in the control group. There were no significant differences between groups in demographics and operative characteristics. There were no differences in pain scores on postoperative day 1 (gabapentin vs control: 5.53 vs 5.56; P = .95), day 2 (4.58 vs 4.83; P = .59), or day 3 (4.15 vs 3.87; P = .59). The mean opioid consumption in oral morphine equivalents was not different on postoperative day 1 (gabapentin vs control: 47.2 vs 48.1; P = .90), day 2 (29.9 vs 33.5; P = .60), or day 3 (17.4 vs 18.7; P = .80). CONCLUSION: Preoperative gabapentin did not reduce pain scores or opioid usage in patients who received an ACB and underwent ACL reconstruction in this retrospective cohort study.

Traumatic Brachial Plexopathy in Athletes: Current Concepts for Diagnosis and Management of Stingers.

Traumatic upper trunk brachial plexopathy, also known as a stinger or burner, is the most common upper extremity neurologic injury among athletes and most commonly involves the upper trunk. Recent studies have shown the incidence of both acute and recurrent injuries to be higher in patients with certain anatomic changes in the cervical spine. In addition, despite modern awareness, tackling techniques, and protective equipment, some think the incidence to be slowly on the rise in contact athletes. The severity of neurologic injury varies widely but usually does not result in significant loss of playing time or permanent neurologic deficits if appropriate management is undertaken. Timely diagnosis allows implementation of means to minimize the risk of recurrent injury. It is important for treating physicians to understand the pathogenesis, evaluation, and acute and long-term management of stingers to improve recovery and minimize chronic sequela.

Unusual presentation of failed metal-on-metal total hip arthroplasty with features of neoplastic process.

Metal-on-metal (MoM) total hip arthroplasty (THA) is associated with increased incidence of failure from metallosis, adverse tissue reactions, and the formation of pseudotumors. This case highlights a 53-year-old female with an enlarging painful thigh mass 12 years status post MoM THA. Radiographs and advanced imaging revealed an atypical mass with cortical bone destruction and spiculation, concerning for periprosthetic malignancy. Open frozen section biopsy was performed before undergoing revision THA in a single episode of care. This case illustrates that massive pseudotumors can be locally aggressive causing significant femoral bone destruction and may mimic malignancy. It is important that orthopaedic surgeons, radiologists and pathologists understand the relative infrequency of periprosthetic malignancy in MoM THA to mitigate patient concerns, misdiagnosis, and allow for an evidence based discussion when treating massive pseudotumors.

Ankle fractures in the elderly: risks and management challenges.

Ankle fractures are the third most common osseous injury in the elderly, behind hip and distal radius fractures. While there is a rich history of clinical advancement in the timing, technique, perioperative management, and associated risks of hip fractures, similar evaluations are only more recently being undertaken for ankle fractures. Traditionally, elderly patients were treated more conservatively; however, nonoperative management has been found to be associated with increased mortality. As such, older and less healthy patients have become operative candidates. The benefits of geriatric/orthopedic inpatient comanagement that have been well elucidated in the hip fracture literature also seem to improve outcomes in elderly patients with ankle fractures. One of the orthopedist's roles is to recognize the complexities of osteoporotic bone fixation and optimize wound healing potential. Though the immediate cost of this surgical approach is inevitably higher, the ultimate cost of long-term care has been found to be substantially reduced. It is important to consider the mortality and morbidity benefits and cost reductions of operative intervention and proper inpatient care of geriatric ankle fractures when they present to the emergency department or the office.

Costs Associated With Geriatric Ankle Fractures.

INTRODUCTION: Ankle fractures are the third most common orthopaedic injury seen in the geriatric patient. Studies have identified mortality benefits with operative management, but treatment must be considered on a case-by-case basis. In the era of value-based analysis, a thorough of understanding of outcomes and costs of treatment is required. The purpose of this study was to analyze the inpatient and readmission costs associated with operative and nonoperative management of geriatric ankle fractures. METHODS: Patients were identified using diagnosis codes for ankle fractures from all 2008 Part A Medicare claims. Patients younger than 65 years and those who sustained an ankle fracture during the previous year were excluded. Operative patients were then identified by ICD-9 procedure codes. Other variables collected included age, comorbidities, and the incidence of hospital readmissions. Inpatient costs were determined using Medicare reimbursement data. RESULTS: A total of 19 648 patients with ankle fractures were identified. Of these, 15 193 (77.3%) underwent operative intervention. The mean cost for initial fracture admission was $5097.20 for nonoperative management compared with $8798.10 for operative management ( P < .05). The mean inpatient costs associated with readmission for nonoperative intervention was $5161.50 and for operative treatment, it was $5071.40 ( P > .05). The reimbursement for hospital readmissions for both groups combined for approximately $29.7 million. The total cost of initial treatment plus readmission for both treatment groups combined was approximately $185 million. DISCUSSION: The total expenditure estimate of $185 million in this study has likely increased given the steady growth of the geriatric population. Expenditures associated with these readmissions was approximately $30 million-nearly a sixth of total costs. Future work must focus on determining which patients will benefit from operative intervention and optimizing care to decrease readmissions and their associated cost in this growing cohort of patients. LEVELS OF EVIDENCE: Therapeutic, Level III: Retrospective study.