Femoral shaft displacement and Winquist classification provide predictive characteristics for combined femoral neck and femoral shaft fractures.

OBJECTIVES: The goal of this study is to establish radiographic features and characteristics of patient injury in cases of femoral shaft fractures that predict the presence of ipsilateral femoral neck fractures (IFNFs). METHODS: Patient data was retrospectively assessed from a single level I trauma center through the electronic health record using (Current Procedural Terminology) CPT codes for both isolated and combined ipsilateral femoral shaft and neck fractures. Demographic information, injury characteristics, and independently reviewed radiographic features were collected and compared against the same information from a group of isolated femoral shaft fractures. Multivariable logistic regression was performed to identify risk factors for concomitant IFNFs and their respective odds ratios. A probability algorithm for assessing ipsilateral femoral neck fractures based on independent multivariate predictors was constructed and used. RESULTS: A total of 113 patients with either isolated femoral shaft fractures or combined femoral shaft and IFNF (n = 33) met inclusion criteria and were identified for this study. Fracture displacement was most strongly associated with increased risk of combined injury with an aOR of 25.64 (95 %CI = 5.96-110.28) for every 100 % displacement. Motorcycle crash (MCC) was the mechanism associated with the highest risk of combined injury, with an aOR of 9.85 (95 % CI = 1.99-48.74). Combined injury was also correlated with lower Winquist score and presentation with a closed fracture, with aORs of 0.38 (95 %CI = 0.21 - 0.68) and 11.61 (95 %CI = 1.93-69.94), respectively. Presence of at least 3 of the statistically significant variables produced a positive predictive value (PPV) of ≥ 89 % for combined femoral shaft and IFNF. CONCLUSIONS: Identification of combined femoral shaft and IFNF is of critical importance when caring for orthopedic trauma patients. While diagnosis remains a challenging task, MCC mechanism, >100 % fracture displacement, and lower Winquist classification were found to be associated with combined injuries. The combination of these variables might assist in predicting the probability of combined injury and potentially guide decision making on the appropriateness of obtaining single sequence MRI or implementing prophylactic femoral neck fixation. LEVEL OF EVIDENCE: Level III.

Poor Bone Mineral Density Is Associated With Increased Risk of Urological Bone Metastases.

OBJECTIVE: To investigate whether a diagnosis of precancer poor bone mineral density (PBMD) is associated with higher risk of urological cancer bone metastasis. METHODS: The PearlDiver Database was utilized to conduct a retrospective, propensity-matched cohort analysis of adult patients diagnosed with kidney, bladder, prostate, and testicular cancer with and without a prior diagnosis of PBMD, defined as osteopenia or osteoporosis. Unadjusted and adjusted odds ratios (OR) and 95% confidence intervals are used to compare the rate of newly diagnosed bone metastases between 6months and 3years of the initial cancer diagnosis between the experimental and control cohorts. RESULTS: Among 685,066 patients with urological cancers, precancer PBMD was associated with increased odds of bone metastasis at various time periods (1week, 6months, 1, 2, and 3years). The strongest association was appreciated within 1week of cancer diagnosis (kidney: adjusted odds ratio [aOR], 2.37, P <.001; bladder: [aOR], 2.37, P <.001; prostate: [aOR], 2.84, P <.001; testicular: [aOR], 4.45, P <.001). Bisphosphonates were associated with reduced risk of kidney ([aOR], 0.46, P <.001), bladder ([aOR], 0.61, P <.001), and prostate ([aOR], 0.66, P <.001) cancer bone metastasis. CONCLUSION: Our findings suggest urology patients with PBMD may be predisposed to forming bone metastases as well as presenting with metastatic disease at time of cancer diagnosis. As such, further studies are needed to elucidate whether PBMD plays a role in bone tropism and whether bone health pertains to prolonging bone-free metastasis.

Testosterone Replacement Therapy and Associated Rates of Trigger Finger, de Quervain Tenosynovitis, and Their Subsequent Management.

PURPOSE: Anabolic steroid therapy has been associated with tendon injury, but there is a paucity of evidence associating physiologic testosterone replacement therapy (TRT) with tenosynovitis of the hand, specifically trigger finger and de Quervain tenosynovitis. The purpose of this study was to evaluate the relationship between TRT and tenosynovitis of the hand. METHODS: This was a one-to-one exact matched retrospective cohort study using a large nationwide claims database. Records were queried between 2010 and 2019 for adult patients who filled a prescription for TRT for 3 consecutive months. Rates of new onset trigger finger and de Quervain tenosynovitis and subsequent steroid injection or surgery were identified using ICD-9, ICD-10, and Current Procedural Terminology billing codes. Single-variable chi-square analyses and multivariable logistic regression were used to compare rates in the TRT and control cohorts while controlling for potential confounding variables. Both unadjusted and adjusted odds ratios (OR) are reported for each comparison. RESULTS: In the adjusted analysis, patients undergoing TRT were more than twice as likely to develop trigger finger compared to their matched controls. TRT was also associated with an increased likelihood of experiencing de Quervain tenosynovitis. Of the patients diagnosed with either trigger finger or de Quervain tenosynovitis over the 2-year period, patients with prior TRT were roughly twice as likely to undergo steroid injections or surgical release for both trigger finger and de Quervain tenosynovitis compared to the controls. CONCLUSIONS: TRT is associated with an increased likelihood of both trigger finger and de Quervain tenosynovitis, and an increased likelihood of requiring surgical release for both conditions. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Social deprivation index affects time to MRI after knee injury in pediatric patients and is predicted by patient demographics.

OBJECTIVES: This study aims to characterize the association between the timing of MRI ordering and completion for pediatric knee injuries and Social Deprivation Index (SDI), which is a comprehensive, validated, county-level, measure of socioeconomic variation in health outcomes based upon combining geography, income, education, employment, housing, household characteristics, and access to transportation. METHODS: A retrospective chart review was completed of patients 21 years old and younger from our institution with a history of knee sports injury (ligamentous/soft tissue injury, structural abnormality, instability, inflammation) evaluated with MRI between 5/26/2017 and 12/28/2020. Patients were from three states and attended to by physicians associated with an urban academic institution. Patients were assigned SDI scores based on their ZIP code. Excluded from the study were patients with a non-knee related diagnosis (hip, foot, or ankle), patients from ZIP codes with unknown SDI, and non-sports medicine diagnoses (tumor, infection, fracture). RESULTS: In a multivariate regression analysis of 355 patients, increased SDI was independently associated with increased time from clinic visit to MRI order (p = 0.044) and from clinic visit to MRI completion (p = 0.047). Each 10-point increase in SDI (0-100) was associated with a delay of 7.2 days on average. SDI itself was found to be associated with a patient's race (p < 0.001), ethnicity (p < 0.001), and insurance category (p < 0.001). CONCLUSION: Increased SDI is independently associated with longer time from clinic visit to knee MRI order and longer time from clinic visit to knee MRI completion in our pediatric population. Recognizing potential barriers to orthopedic care can help create the change necessary to provide the best possible care for all individual patients.

Postoperative Angiotensin Receptor Blocker Use is Associated With Decreased Rates of Manipulation Under Anesthesia, Arthroscopic Lysis of Adhesions, and Prosthesis-Related Complications in Patients Undergoing Total Knee Arthroplasty.

BACKGROUND: The cellular mechanisms underlying excess scar tissue formation in arthrofibrosis following total knee arthroplasty (TKA) are well-described. Angiotensin receptor blockers (ARB), particularly losartan, is a commonly prescribed antihypertensive with demonstrated antifibrotic properties. This retrospective study aimed to assess the rates of 1- and 2-year postoperative complications in patients who filled prescriptions for ARBs during the 90 days after TKA. METHODS: Patients undergoing primary TKA were selected from a large national insurance database, and the impact of ARB use after TKA on complications was assessed. Of the 1,299,106 patients who underwent TKA, 82,065 had filled at least a 90-day prescription of losartan, valsartan, or olmesartan immediately following their TKA. The rates of manipulation under anesthesia (MUA), arthroscopic lysis of adhesions (LOA), aseptic loosening, periprosthetic fracture, and revision at 1 and 2 years following TKA were analyzed using multivariable logistic regressions to control for various comorbidities. RESULTS: ARB use was associated with decreased rates of MUA (odds ratio [OR] = 0.94, 95% confidence interval (CI), 0.90 to 0.99), arthroscopy/LOA (OR = 0.86, 95% CI, 0.77 to 0.95), aseptic loosening (OR = 0.71, 95% CI, 0.61 to 0.83), periprosthetic fracture (OR = 0.58, 95% CI, 0.46 to 0.71), and revision (OR = 0.79, 95% CI, 0.74 to 0.85) 2 years after TKA. CONCLUSIONS: ARB use throughout the 90 days after TKA is associated with a decreased risk of MUA, arthroscopy/LOA, aseptic loosening, periprosthetic fracture, and revision, demonstrating the potential protective abilities of ARBs. Prospective studies evaluating the use of ARBs in patients at risk for postoperative stiffness would be beneficial to further elucidate this association.

A Diagnosis of Vitamin D Deficiency Is Associated With Increased Rates of Anterior Cruciate Ligament Tears and Reconstruction Failure.

PURPOSE: To characterize the association between a diagnosis of hypovitaminosis D and primary anterior cruciate ligament (ACL) tear, primary anterior cruciate ligament reconstruction (ACLR), and revision ACLR in different sex and age cohorts. METHODS: In this retrospective cohort study of the PearlDiver claims database, records were queried between January 1, 2011, and October 31, 2018 for all patients aged 10 to 59 years who received a diagnosis of hypovitaminosis D. Rates of primary ACL tears, primary reconstruction, and revision reconstruction were calculated for sex- and age-specific cohorts and compared with a control of patients without a diagnosis of hypovitaminosis D. Incidence rates for primary ACL injuries were calculated, and multivariable logistic regression was used to compare rates of ACL injury, primary reconstruction, and revision reconstruction while controlling for age, sex, Charlson Comorbidity Index, and several other comorbidities. RESULTS: Among the 328,011 patients (mean age 41.9 ± 12.6 years, 65.8% female) included in both the hypovitaminosis D and control cohorts, the incidence of ACL tears was 115.2 per 100,000 person-years (95% confidence interval [CI] 107.2-123.7) compared with 61.0 (95% CI 55.2-67.2) in the demographic- and comorbidity-matched control cohort. The study cohort was significantly more likely to suffer an ACL tear over a 1- (aOR 1.67, 95% CI 1.41-1.99, P < .001) and 2-year (aOR 1.81, 95% CI 1.59-2.06, P < .001) period. This trend remained for both male patients at the 1- (aOR 1.66, 95% CI 1.29-2.14, P < .001) and 2-year (aOR 1.68, 95% CI 1.37-2.06, P < .001) mark and female patients at the 1- (aOR 1.69, 95% CI 1.33-2.14, P < .001) and 2-year (aOR 1.80, 95% CI 1.51-2.14, P < .001) mark. Finally, patients with vitamin D deficiency had a significantly increased likelihood of undergoing a revision ACLR within 2 years of a primary reconstruction (aOR 1.28, 95% CI 1.05-1.55, P = .012). CONCLUSIONS: This study reports an association between patients previously diagnosed with hypovitaminosis D and significantly increased rates of both index ACL tears (81% increase within 2 years of diagnosis) and revision ACLR (28% within 2 years). These results identify a population with increased odds of injury and provide valuable knowledge as we expand our understanding of the relationship between vitamin D and musculoskeletal health. LEVEL OF EVIDENCE: Level III, retrospective database study.

The brief resilience scale is associated with pre- and short-term postoperative outcomes following hip arthroscopy.

BACKGROUND: Despite improving diagnostic and surgical techniques, some patients do not respond as well as others following hip arthroscopy. In most musculoskeletal studies, predictors for surgical outcomes focus solely on physical health prior to surgery. However, there likely exists a relationship between a patient's mental health and their postoperative patient-reported outcome measures (PROMs). METHODS: 40 patients who met indications for hip arthroscopy were enrolled in this prospective cohort study. All patients completed a baseline Brief Resilience Scale (BRS) and 4validated PROMs: modified Harris Hip Score (mHHS), visual analogue scale for pain (VAS), Hip Outcomes Score for Activities of Daily Living (HOS-Daily), and Hip Outcomes Score for Sports-Related Activities (HOS-Sport). For a secondary measure of psychometric evaluation, past medical histories of anxiety/depression were recorded. Patients were stratified into Low Resilience (LR < 21), Normal Resilience (NR 22-24), and High Resilience (HR > 25) by tertile to determine differences in PROMs. Comparisons and correlations of pre- and postoperative outcomes between resilience groups were performed. RESULTS: In comparing the LR and HR groups, there was a significant relationship between resilience and all PROMs both preoperatively and 6 months postoperatively (p < 0.05), with the exception of the HOS-Sports. Pearson Correlation Coefficients confirmed this trend in the mHHS and the HOS-Daily. Additionally, there were sixteen patients who were discharged prior to 6-month follow-up with an average resilience above the mean of total population (p < 0.0001). Resilience was associated with return to activity (p = 0.017). A past history of anxiety/depression was associated with lower resilience (p = 0.039). CONCLUSIONS: This study showed that HR hip arthroscopy patients had better PROMs than LR patients both preoperatively and postoperatively. HR patients were able to return to activity earlier and had lower rates of preoperative anxiety/depression. The BRS is a simple in-office screening tool, which may help guide patient and doctor communication and expectations.

Transforaminal 360° lumbar endoscopic foraminotomy in postfusion patients: technical note and case series.

OBJECTIVE: This report describes a minimally invasive lumbar foraminotomy technique that can be applied in patients who underwent complex spine decompression procedures or in patients with severe foraminal stenosis. METHODS: Awake, endoscopic decompression surgery was performed in 538 patients over a 5-year period between 2014 and 2019. Transforaminal endoscopic foraminal decompression surgery using a high-speed endoscopic drill was performed in 34 patients who had previously undergone fusions at the treated level. RESULTS: At 2-year follow-up, the mean (± SD) preoperative visual analog scale score for leg pain and the Oswestry Disability Index improved from 7.1 (± 1.5) and 40.1% (± 12.1%) to 2.1 (± 1.9) and 13.6% (± 11.1%). CONCLUSIONS: A minimally invasive, awake procedure is presented for the treatment of severe lumbar foraminal stenosis in patients with lumbar radiculopathy after lumbar fusion.

Machine Learning Prediction of Length of Stay in Adult Spinal Deformity Patients Undergoing Posterior Spine Fusion Surgery.

(1) Background: Length of stay (LOS) is a commonly reported metric used to assess surgical success, patient outcomes, and economic impact. The focus of this study is to use a variety of machine learning algorithms to reliably predict whether a patient undergoing posterior spinal fusion surgery treatment for Adult Spine Deformity (ASD) will experience a prolonged LOS. (2) Methods: Patients undergoing treatment for ASD with posterior spinal fusion surgery were selected from the American College of Surgeon's NSQIP dataset. Prolonged LOS was defined as a LOS greater than or equal to 9 days. Data was analyzed with the Logistic Regression, Decision Tree, Random Forest, XGBoost, and Gradient Boosting functions in Python with the Sci-Kit learn package. Prediction accuracy and area under the curve (AUC) were calculated. (3) Results: 1281 posterior patients were analyzed. The five algorithms had prediction accuracies between 68% and 83% for posterior cases (AUC: 0.566-0.821). Multivariable regression indicated that increased Work Relative Value Units (RVU), elevated American Society of Anesthesiologists (ASA) class, and longer operating times were linked to longer LOS. (4) Conclusions: Machine learning algorithms can predict if patients will experience an increased LOS following ASD surgery. Therefore, medical resources can be more appropriately allocated towards patients who are at risk of prolonged LOS.