Bilateral Lesser Tuberosity Fractures: Technique and a Case Report with Literature Review.

Isolated lesser tuberosity fractures are a rare subset of proximal humerus fractures and are often associated with seizures. Displaced fractures can lead to chronic pain, reduced shoulder function, and posterior instability. Operative treatment is frequently recommended with the displacement of more than 5 mm or angulation of more than 45 degrees. We report on a 31-year-old man with bilateral lesser tuberosity fractures who underwent operative fixation for 1 fracture and nonoperative fixation for the other.

Comparison of Risk Factors and Postoperative Outcomes in Syndesmosis Injuries with Various Ankle Fracture Types.

There is a lack of understanding of risk factors and postoperative outcomes of syndesmotic injuries with singular versus multipart fractures. A retrospective analysis was done between 2008 and 2016, utilizing the American College of Surgeons National Surgical Improvement Program database. Patients with open reduction and internal fixation of isolated lateral malleolus fractures, bimalleolar fractures, or trimalleolar fractures were identified. A total of 2045 patients underwent syndesmotic fixation. Subjects with bimalleolar or trimalleolar fractures were more likely than those with unimalleolar fractures to be Caucasian (odds ratio [OR] = 1.5 and 1.9), female (OR = 1.8 and 2.9), aged > 65 years (OR = 1.6 and 1.9), or have American Society of Anesthesiologists (ASA) classification III (OR =1.5 and 1.4) (all, P ≤ 0.028). Patients with a unimalleolar fracture were more likely than those with a bimalleolar or trimalleolar fracture to be male (OR = 1.8 and 2.9), African American (OR = 1.5 and 1.8), aged < 30 years (OR = 1.4 and 1.8), or present with an ASA I classification (OR = 1.6 and 2.0) (all, P ≤ 0.004). Subjects with bimalleolar or trimalleolar fractures were more likely than those with unimalleolar fractures to have lengthier hospital stays (OR = 1.8 and 2.1), while patients with trimalleolar fractures were more likely than those with unimalleolar fractures to have hypoalbuminemia (OR = 2.3), develop a complication (OR = 2.2) or an open wound (OR = 1.9), or to be readmitted (OR = 2.2) (all, P ≤ 0.036). In this study, comorbidity rates and adverse postoperative outcomes significantly increased as the number-part fractures increased in syndesmotic fixation patients. Risk factors also varied across fracture severity.

A Systematic Review of the Management of Upper Extremity Orthopaedic Injuries in Epileptic Patients.

Background: During seizures, injury of the upper extremities may occur. Standardized guidelines are deficient for diagnosis and perioperative care. Methods: PubMed, Embase, Cochrane, Scopus, and Web of Science databases were systematically screened using predefined search terms. Results: Of the 59 patients included, 36 (61.0%) involved a posterior shoulder dislocation. Associated fractures were observed in 34 (57.6%) cases with surgical procedures performed in 30 (50.8%) patients. Functional outcomes were reported in 44 patients, with over half (23 of 44, [52.2%]) endorsing range of motion deficits. Conclusion: Standardized guidelines, to guarantee timely management of injury in post-seizure patients, are needed with a customized treatment approach that accommodates the various aspects of their condition.

Management of lower extremity orthopaedic injuries in epileptic patients: A systematic review.

Lower-extremity injuries may occur during seizures. There is a lack of standardized guidelines when diagnosing and planning perioperative care. Databases were systematically screened using predefined search terms. Of the 13 patients included, seven (53.8%) involved bilateral femoral neck fractures. Associated fractures were observed in all cases with surgical intervention performed in eight (61.5%) patients. Eleven patients reported functional outcomes, with over a quarter (three of 11, [27.3%]) endorsing mild range of motion deficits or issues with ambulation. Post-seizure patients may require standardized diagnostic protocols to ensure prompt management with a specialized treatment approach that accommodates the nuances of their condition.

Increases in Firework-Related Upper Extremity Injuries Correspond to Increasing Firework Sales: An Analysis of 41,195 Injuries Across 10 Years.

INTRODUCTION: Between 2008 and 2017, the American Pyrotechnics Association reported a 41% increase in revenue from firework sales, with 2017 showing $885 million US dollars in consumer sales. We sought to evaluate the epidemiology of firework-related upper extremity injuries during this 10-year period, hypothesizing that hand/upper extremity injuries from fireworks were increasing in the United States. METHODS: Observational epidemiologic assessment of a weighted cohort of patients via the National Electronic Injury Surveillance System from 2008 to 2017. The National Electronic Injury Surveillance System provides a nationwide probability sample of injuries related to consumer products based on emergency department visits collected from a cohort of about 100 US hospitals. RESULTS: A total of 1,079 patients representing an estimated 41,195 firework-related upper extremity injuries presented to US emergency departments from 2008 to 2017. The number of injuries increased significantly from 2,576 in 2008 to 5,101 in 2017 (R2 = 0.85, R = 0.92, P < 0.001). A Spearman rank-order correlation determined that there was a strong, positive correlation between the increase in firework sales and the increase in injuries (rs = 0.939, P < 0.01). The overwhelming majority of firework-related injuries were seen in males (77%) aged 11 to 29 years (48%). The hand and fingers accounted for 85.8% of injuries, with the thumb being the most commonly injured body part (51.3%). Burns were the most common injury across all body sites except the wrist, where fractures were most common. CONCLUSION: Ten-year firework-related upper extremity injuries increased, corresponding to increased consumer sales across the same period. This study provides previously absent population-level data to provide a framework for discussion among policy makers and physicians alike in an attempt to mitigate the use of fireworks and their associated upper extremity injuries. LEVEL OF EVIDENCE: Level III.

Ankle Fracture Epidemiology in the United States: Patient-Related Trends and Mechanisms of Injury.

Current nationwide epidemiological data regarding ankle fractures are scarce. Such information is important towards better quantifying the mortality associated with such injuries, financial impact, as well as the implementation of preventative measures. This study evaluated the epidemiology of ankle fractures that occurred during a 5-year period. Specifically, we evaluated demographics, mechanism of injury, and disposition. The National Electronic Injury Surveillance System was queried to identify all patients with ankle fractures that presented to US hospital emergency departments between 2012 and 2016. Census data were used to determine the incidence rates of ankle fractures in terms of age, sex, and race. There was an estimated total of 673,214 ankle fractures that occurred during this period, with an incidence rate of 4.22/10,000 person-years. The mean age of patients with an ankle fracture was 37 ± 22.86 (SD) years; 23.5% of ankle fractures occurred in patients aged 10 to 19 years (7.56/10,000 person-years). In addition, 44% of ankle fractures occurred in men (3.81/10,000 person-years), whereas 56% occurred in women (4.63/10,000 person-years). Data on race/ethnicity were available for 71% of the subjects, with incidence rates of 2.85/10,000 person-years for whites, 3.01/10,000 person-years for blacks, and 4.08/10,000 person-years for others. The most common mechanism of injury was falls (54.83%), followed by sports (20.76%), exercise (16.84%), jumping (4.42%), trauma (2.84%), and other (0.30%). For disposition, 81.84% of patients were treated and released, 1.43% were transferred, 16.01% were admitted, 0.59% were held for observation, and 0.13% left against medical advice. The highest incidence of ankle fractures in men occurred in the 10-to-19-years age group, but women were more commonly affected in all other age groups.

Characterizing Hand Infections in an Underserved Population: The Role of Diabetic Status in Antibiotic Choice and Infection Location.

Introduction Patients with diabetes mellitus (DM) in underserved communities are at greater risk for hand infections. We aimed to describe the features of hand infections presenting to an urban hospital via laboratories, microbiology, and antibiotic choice with respect to diabetic status. Materials and Methods Patients presenting with any hand infection were reviewed and stratified by DM status and infection location. Labs, culture results, antibiotic regimens, and significant predictors of laboratories or infection location were analyzed. Results Fifty-three patients were included: DM ( n = 24), no-DM ( n = 24), and unknown status ( n = 5). Culture rates were comparable between all groups. Mean erythrocyte sedimentation rate (ESR) was significantly higher in DM (76.19 vs. 51.33); mean white blood cell count (WBC) and C-reactive protein (CRP) were comparable. Diabetics had higher odds of increased ESR (odds ratio [OR] = 1.03). Diabetics received vancomycin/piperacillin/tazobactam (VAN/PTZ) significantly more often (52% vs. 8%). Providers treated DM with VAN/PTZ or any VAN-containing regimen more often than with any other regimen. Proximal infections had significantly higher mean CRP (136.9 vs. 50.5) and WBC (5.19 vs. 3.9) and higher CRP (OR = 1.02). Conclusion This study highlights the need for systematic criteria to better risk- stratify patients for appropriate antibiotic treatment. It may not be appropriate to treat both groups differently, as overly aggressive antibiotic selection may contribute to drug-resistance development.

Radial Nerve Sensory Branch Anatomical Variant: A Case Report and Literature Review.

CASE: Two patients sustained comminuted extra-articular distal humerus fractures. One patient was neurovascularly intact preoperatively. The other patient had a complete radial motor palsy with preserved sensation. Intraoperatively, both exhibited anatomic variants of the radial sensory nerve of the arm that pierced the triceps rather than branching from the distal third of the radial nerve proper, as is traditionally reported. CONCLUSIONS: Although rare, variations in the radial nerve may exist about the distal humerus. Surgeons should be aware of these variations to avoid iatrogenic injury.

Are inferior facetectomies adequate and suitable for surgical treatment of adolescent idiopathic scoliosis?

STUDY DESIGN: Retrospective review. BACKGROUND: Inferior facetectomies, with the utilization of segmental pedicle screw constructs for corrective fixation, can provide adequate flexibility and post less risk of neural tissue and blood loss. We analyzed outcomes of surgical treatment for adolescent idiopathic scoliosis (AIS) using inferior facetectomies and segmental pedicle screw constructs. We hypothesized that adequate main curve correction and suitable surgical outcomes would be observed using this technique. METHODS: We reviewed 38 AIS patients who underwent inferior facetectomies and segmental pedicle screw constructs by 2 surgeons at a single institution between May 2014 and December 2016. Coronal and sagittal radiographic measurements were evaluated over 1-year follow-up by 2 trained observers not associated with the surgeries. Surgical details, complications, and hospital length of stay (LOS) were also recorded. RESULTS: Mean fusion levels were 11.0 ±â€Š1.7. The mean Cobb angle of main AIS curves improved from 48.6±â€Š10.1 degree preoperatively to 11.8±â€Š6.2 degree postoperatively and 12.4±â€Š6.2 degree at 1-year follow-up, which percentage correction was 75.9% and 74.6%, respectively. The mean thoracic kyphosis (T5-12) angle was 20.7±â€Š11.6 degree preoperatively, 17.4±â€Š8.0 degree postoperatively, and 16.8±â€Š8.4 degree at 1-year follow-up. The mean surgical time, estimated blood loss, and LOS were 232.4 ±â€Š35.7 minutes, 475.0 ±â€Š169.6 mL, and 3.5 ±â€Š1.3 days. Twelve patients received blood transfusion. There were no neurological or wound complications. CONCLUSIONS: This case series demonstrated adequate correction of main AIS curves, acceptable thoracic kyphosis and blood loss, and short surgical time and LOS in AIS patients treated with inferior facetectomies and segmental pedicle screw constructs, potentially indicating that inferior facetectomies are adequate and suitable for AIS surgery when segmental pedicle screw constructs are utilized.

Survivorship and complications of total hip arthroplasty in patients with dwarfism.

BACKGROUND: Total hip arthroplasty (THA) is a common procedure used to treat bony hip deformities and skeletal dysplasia in dwarfism. These surgeries are often more difficult than conventional THA as they may involve malformed joints and poor bone quality, and may require smaller prostheses. This study aims to investigate whether implant survivorship and revision rates vary among patients with and without dwarfism undergoing THA. METHODS: A retrospective case-control study was performed for 102 THAs completed between 1997 and 2014 in patients under the height threshold of 147.32 cm. This cohort was matched 1:1.5 with patients of normal height with respect to age, gender, year of surgery, and Charlson comorbidities. All cases had a minimum follow-up of 1 year. A chart review was performed to identify patient and surgical characteristics, including outcomes. Radiographs were assessed for deformity, loosening, and periprosthetic fractures among other factors. RESULTS: The 2-, 5-, and 10-year survivorship of THA in patients with dwarfism was 92.9%, 92.9%, and 80.7%, respectively; and 94.4%, 86.4%, and 86.4% for controls, respectively (p = 0.95). The dwarfism cohort demonstrated an OR of 3.81 and 3.02 for revision for periprosthetic fractures (p = 0.11) and mechanical wear (p = 0.21), respectively. CONCLUSIONS: THA in patients with dwarfism achieves comparable results to a non-dwarfism population with regards to implant survivorship; however, there is a trend toward increased periprosthetic fractures and wear-related failures. Surgeons should be aware of this potentially higher risk in this population and take morphological differences into account during surgical planning and technique.

Demographics of Tennis-Related Injuries that Presented to Emergency Departments in the United States.

INTRODUCTION: Tennis injuries are not uncommon, and efforts have been made to reduce the risk of these injuries. There are a number of different factors that have been shown to influence injury rates of tennis players, in particular patient-related risks. Therefore, the purpose of this study was to investigate the epidemiology of tennis-related injuries. Specifically, we evaluated: 1) demographics; 2) incidence and trends of injuries; and 3) incidence and trends of body parts that were injured. MATERIALS AND METHODS: This study utilized the National Electronic Injury Surveillance System (NEISS) database to collect all tennis-related sprains/strains that occurred between January 1, 2010 and December 31, 2016. Patients were stratified into four groups based on their age: 13 years and younger, 14 to 29 years, 30 to 54 years, and 55 years and older. Race was reported as white, black, Hispanic, Asian, Native Hawaiian, American Indian, Multiracial, and not stated. The various types of tennis-related injuries that occurred, and the different body parts that were affected were identified. RESULTS: There were a total of 150,747 tennis-related injuries that occurred during the study period. Thirty-nine percent of all injuries occurred in patients aged 55 years and older, 25% in patients between the ages of 14 and 29 years, 24% occurred between the ages of 30 and 54 years, and 12% occurred in patients aged 13 years and younger. In terms of gender, 56% were men and 44% were women. In terms of race, injuries most commonly occurred in patients who were white (48%). The most common overall injury pattern was sprains/strains, which represented 32% of all reported injuries, followed by fractures (15%) and contusions (11%). The most commonly injured body parts were the ankle (13%), wrist (9.4%), upper-trunk (8.5%), knee (7.8%), and lower-trunk (6.7%). Over the study period, there was a significant decrease in ankle injuries (R2=0.691, p=0.021) and a significant increase in upper-trunk injuries (R2=0.695, p=0.020). CONCLUSION: The present study provided important insight regarding tennis-related injuries in terms of demographics, injury types, and injury patterns. This information is paramount for the future treatment of all tennis-related injuries and for the implementation of prevention strategies for those injuries which are most prevalent.

A Current Procedural Terminology Code for "Knee Conversion" Is Needed to Account for the Additional Surgical Time Required Compared to Total Knee Arthroplasty.

BACKGROUND: Previous knee injury requiring surgical intervention increases the rate of future arthroplasty. Coding modifiers for removal of previous hardware or increased complexity offer inconsistent results. A Current Procedural Terminology code for knee conversion does not currently exist as it does for conversion hip arthroplasty. We investigate the extra time associated with conversion knee arthroplasty. METHODS: Sixty-three total knee arthroplasty (TKA) cases in the setting of previous knee hardware were identified from our institution between 2008 and 2015. Knee conversions were matched to primary TKA by age, gender, body mass index, Charlson Comorbidity Index, and surgeon, in a 3:1 ratio. Patients who underwent knee conversions were compared to matched TKA with regard to operative time, length of stay, discharge destination, readmission, and repeat procedures within 90 days from index procedure. RESULTS: The mean operating room time for primary TKA was 71.7 minutes (range 36-138). The mean operating room time for knee conversion was significantly greater by an additional 31 minutes; mean 102.1 minutes (range 56-256 minutes, P < .0001). Rates of readmission, 0.5% vs 3.2%, and repeat procedures, 5.3% vs 12.7%, within 90 days were greater for knee conversions. There was no difference in length of stay or discharge destination. CONCLUSION: Total knee conversion results in a 43% increase in operative time and more than twice the rate of readmission and repeat procedures within 90 days compared to TKA. This suggests the need for an additional Current Procedural Terminology code for knee conversion arthroplasty to compensate surgeons for the extra time required for conversions.