Background:Nursemaid's elbow injuries occur in young children, with axial traction on the arm as a commonly-described mechanism. Prior demographic studies have noted a significant increase in this injury over the last three decades. We sought to examine incidence of nursemaid's elbow over time and assess the impact of COVID-19 on injury frequency. Additionally, certain household products and female gender have been frequently seen in cases presenting to emergency departments. The present study aims to further investigate injury scenarios to better understand the difference in injury rates and mechanisms. Methods:Using the National Electronic Injury Surveillance System database, this study analyzed 4,075 cases of nursemaid's injuries presenting to emergency departments from 2019-2023 in children from birth to six-years-old. The events' narrative case descriptions were searched for keywords to identify terms used to describe the injury. Cases were examined in groups by age, gender, location of the injury event, mechanism of injury ("fall" versus "pull"), and product involved. Results:There was no significant change in rate of cases during the time period, although there was a non-significant drop in 2020. Females had a higher incidence of injury. Two-year-olds represented the largest affected age group. Common injury mechanisms were "falls" (44% of events) and "pulls" (29%), with twisting motions rarely described. The most common household products involved in injuries were beds and bed frames (21% of cases). The higher incidence in females compared to males persisted across age groups, mechanisms, and most products involved, with the exception of more daywear-related "fall" injuries in males. Conclusion:Unlike previous studies, incidence of nursemaid's elbow did not statistically increase during the pandemic. Females continued to account for most injuries, a trend that remained largely stable when data were subdivided by product, age, and mechanism. This could be due to a possible anatomic difference in young female elbows compared to those of males, which represents an area for future investigation. Educating caretakers about nursemaid's elbow and implementing household safeguards may help prevent injury.Level of Evidence: III.
Background:Spine infections are associated with significant morbidity and mortality. Despite Infectious Diseases Society of America (IDSA) guidelines recommending treatment be assessed through clinical examination and inflammatory markers rather than routine magnetic resonance imaging (MRI), repeat MRIs are frequently obtained. The clinical utility and consequences of repeat MRI in this setting remain unclear. Methods:We performed a retrospective singleinstitution study of adult patients with infectious spine pathology who underwent repeat MRI between January 2019 and December 2023. Patients were stratified by timing of repeat MRI (≤90 days vs >90 days from index MRI). The primary outcome was surgical intervention prompted by repeat MRI findings. Secondary outcomes included changes in physical examination prior to repeat MRI, need for fast-acting anxiolytic medication, and acute kidney injury. Results:A total of 222 repeat MRIs were identified in 141 patients. Of these, 163 (73%) were performed ≤90 days and 59 (27%) were performed >90 days from the index MRI. Patients undergoing repeat MRI >90 days were significantly more likely to undergo spine surgery (p=0.04) and to have a documented change in physical examination prior to imaging (p<0.001). Repeat MRI ≤90 days was not associated with increased surgical intervention. Overall, 30% of repeat MRIs required pre-procedure anxiolytic medication, with higher rates in the ≤90-day cohort (p=0.04). AKI occurred after 9/164 (5%) repeat MRIs, with no difference between groups. Conclusion:Repeat MRI within 90 days in patients with spine infections rarely alters surgical management and is often obtained in the absence of clinical deterioration. Clinical examination appears to be a more reliable indicator of treatment response. These findings support IDSA guidelines recommending selective use of repeat MRI and highlight potential patient-centered consequences of unnecessary imaging.Level of Evidence: III.
Background:This study aimed to comprehensively assess the most recent data on the prognostic effects of hematologic markers, including the neutrophil to lymphocyte ratio (NLR), monocyte to lymphocyte ratio (MLR), platelet to lymphocyte ratio (PLR), and systemic immune inflammation index (SII), on deep vein thrombosis (DVT) following lower limb fractures. Methods:We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. This study was registered in PROSPERO (CRD420251006336). We performed a comprehensive search in the PubMed, EMBASE, Web of Science, and Scopus electronic databases. Date of publication and language were not restricted. Standardized mean difference (SMD) with 95% confidence interval (CI) was calculated and all statistical analyses were performed using Stata 18 software. Results:Ten studies, involving a total of 6183 patients with lower extremity fractures, of whom 896 developed DVT, were included in the final analysis. The results indicated that, compared to the non-DVT group, patients with DVT had higher levels of NLR (SMD = 0.48, 95% CI = 0.02-0.94, p = 0.04) and SII (SMD = 1.01, 95% CI = 0.121.89, p = 0.02). However, PLR and MLR level was not different between the two groups. Among the evaluated biomarkers, SII demonstrated the highest specificity (80%, PLR = 74%), while NLR had the highest sensitivity (68%). Conclusion:The literature supported that, compared to the non-DVT group, patients with DVT had higher levels of NLR and SII. Among these biomarkers, SII demonstrated the highest specificity, while NLR had the highest sensitivity. Composite inflammatory markers, particularly SII, may hold value in DVT risk stratification during post-fracture period.Level of Evidence: II.
Background:Supracondylar humerus (SCH) fractures comprise about 20% of pediatric fractures. Displaced SCH fractures require reduction and percutaneous pinning, most commonly making use of conventional C-arm (CCA) fluoroscopy. Many authors have proposed the use of mini C-arm (MCA) in the upper extremity, given multiple proposed benefits including decreased radiation. We investigated the utility of MCA in the operative treatment of pediatric SCH fractures. Methods:Patients who underwent operative fixation of SCH fractures using MCA from 20202022 were reviewed. Demographic, surgical, and radiographic data were collected, along with clinical outcomes through final follow-up. Data were analyzed to assess rates of fluoroscopy use depending on various patient and fracture characteristics. Complication rates were quantified to assess the safety and efficacy of MCA for this procedure. Results:171 patients were included with an average age of 5.5 years. 55% of fractures were Gartland type 3/4, and most were treated with three lateral pins (69%). The median fluoroscopy time per case was 113 seconds with 61 images taken. Fluoroscopy use increased both with fracture severity and number of pins used. The overall complication rate was 2% with only one patient requiring reoperation (0.6%). Conclusion:Utilizing MCA fluoroscopy in the treatment of SCH fractures is associated with a low rate of complications, consistent with previously reported rates when using CCA. We report a higher rate of fluoroscopy use compared to CCA which does not necessarily translate to an increase in radiation exposure. Utilizing MCA to surgically treat SCH fractures may have benefits over CCA, especially in certain practice settings. Level of Evidence:IV.
Background:Total hip arthroplasty (THA) has continued to increase in incidence. With expanding focus on value-based care and adoption of bundled payments at some facilities, cost containment measures, including discharging patients to home as soon as possible postoperatively, have gained attention. Therefore, it is important to determine patient characteristics associated with discharge disposition. The purpose of this study was to develop and utilize an artificial neural network (ANN) model to determine the most important non-modifiable and modifiable factors that can predispose patients to be discharged to a non-home destination following primary THA.. Methods:The National Surgical Quality Improvement Program database was used to identify patients who underwent primary THA from 20162019. Demographic, comorbidity, preoperative, and intraoperative variables were analyzed in this study. Statistically significant variables, with a p-value < 0.05, were inputted into the ANN model. Results:In total, 124,691 patients were analyzed in the study, of which 19,275 (15.5%) were discharged to a non-home destination. The ANN reached a Receiver Operating Characteristic (ROC) Area-Under-the-Curve (AUC) of 0.793. The five most important variables which helped to predict non-home discharge following primary THA were age, operative time, preoperative hematocrit, functional status, and preoperative international normalized ratio (INR). Conclusion:The present study used an ANN model and identified several significant factors which can help predict patients being discharged to a non-home location following primary THA. Clinical Relevance:Clinicians should be aware of these variables and explore reductions to nonhome discharges through preoperative patient optimization, where possible.
Background:Observe how summative maximum joint and segment velocities, dependent and independent of sequence order, may impact ball velocity and throwing arm kinetics in professional pitchers. Methods:Professional (n=338) pitchers threw 8-12 fastball pitches while evaluated with 3Dmotion capture (480 Hz). Pitches (independent and dependent of sequence order) were classified as 'Overall Fast* or 'Overall Slow' with kinematic and kinetic parameters compared between groups. A regression model for ball velocity dependent on maximum joint and segment velocities was also calculated. Results:In-sequence pitches with 'Overall Fasf velocity consisted of smaller mass (p<0.001, d=0.9) pitchers that achieved faster ball velocity by on average, 1.6m/s or 3.6 mi/hr (p<0.001, d=1.1). When comparing throwing arm kinetics, the 'Overall Fast' pitches had significantly higher absolute shoulder internal rotation torque (p<0.001, d=1.1), shoulder distractive force (p<0.001, d=1.4), elbow medial force (p=0.014, d=0.7), and elbow flexion torque (p<0.001, d=0.7). A multi-regression prediction model for ball velocity based on maximum joint and segment velocities achieved a R2=0.132. Maximum lead knee extension velocity (B: 0.004 0:0.263 p<0.001) and maximum trunk rotation velocity (B: 0.003 0: 0.223 p=0.045) achieved the highest standardized regression coefficients. For every one standard deviation increase in maximum lead knee extension velocity (125 °/sec), ball velocity increased by 0.5 m/s (1.1 MPH). Conclusion:Professional pitchers with increasing summative maximum joint and segment velocities demonstrated faster ball velocity at the cost of increased throwing arm kinetics, irrespective of sequence order. Level of Evidence:IV.
Background:The ankle joint is one of the most frequently injured joints in the athletic population. Some articles estimate that it accounts for approximately 40% of all sports injuries, with lateral ankle sprains accounting for approximately 85% of injuries whereas medial ankle and syndesmosis injuries account for approximately 4-5% and 1-11%, respectively.1-4 Incidence of ankle sprains has been reported to be as high as 7 per 1,000 exposures for court sports and 1 per 1,000 exposures for field sports with lateral ankle sprains being more common than medial or syndesmotic ankle inju-ries.5 While high ankle sprain, or syndesmosis injury, is less prevalent than lateral ankle sprain, it still accounts for a high injury burden. Among athletes from the National Collegiate Athletic Association (NCAA), the incidence of syndesmosis injury was found to be 1.00 per 10,000 athleteexposures, with men's football, wrestling and ice hockey having the highest rates of injury.3 Optimizing treatment of syndesmosis injury is important as they typically require a longer recovery period and have a high recurrence rate.3,6,7 The purpose of this article is to review the pertinent anatomy and diagnostic features of syndesmosis injury, discuss the indications and goals of operative and non-operative management, and discuss return to play recommendations following these injuries. Level of Evidence:V.
Background:Metallosis is a known complication of joint arthroplasty, but its role in failures of spinal fusion procedures likely remains underrecognized. The release of metallic debris from implant interfaces may impair osteogenesis by triggering local inflammatory responses. To date, no in vivo models have been developed to investigate this process in the context of spinal fusion. Using a unique modelling system, we sought to determine whether high local concentrations of metal particles impair spinal fusion, and whether particle load correlates with inflammatory response. Methods:Twelve rabbits underwent posterolateral lumbar spinal fusion using autologous iliac crest bone grafts. Six weeks postoperatively, animals received bilateral paraspinal injections of Ti/Cr/ Co alloy at high, low, or zero concentrations immediately dorsal to the graft site. At twelve weeks, specimens were euthanized, and the grafts were assessed by radiography, manual palpation, and histopathology. A custom image analysis algorithm was used to quantify metal debris in histologic sections, and inflammatory responses were evaluated. Fusion outcomes and metal burden were compared between groups using unpaired t-tests. Results:Five of eight evaluable specimens exhibited non-fusion, most of which contained higher levels of visible metal debris than fused counterparts upon histologic analysis. Fused grafts, in contrast, demonstrated minimal particle burden and continuous trabecular bridging. Lymphocytes were found to be localized near metal particles, and fibrotic tissue was observed to replace bone at non-fused sites. No significant differences in inflammatory cell counts were observed between groups. Conclusion:Elevated metal particle burden in the posterolateral fusion environment was associated with impaired osteogenesis and increased localized inflammation, particularly in non-fused specimens. These results establish this model's utility for investigating metallosis-driven spinal fusion failure and suggest its potential as a predictive platform for assessing particle-related risk in spinal instrumentation. Clinical Relevance:This study provides a reproducible in vivo model to explore how metallic debris may contribute to spinal fusion failure. It offers a platform for testing future interventions targeting metallosis-related complications in spinal fusion surgery.
Background:Effective pain management is critical for recovery after spine surgery, as inadequate control can delay mobilization, prolong hospitalization, and raise opioid consumption.1-4 Among the strategies available, patient-controlled analgesia (PCA) enables patients to self-administer intravenous opioids within preset safety limits. Inconsistencies in opioid use, pain scores, and length of stay suggest that the effectiveness of PCA may be shaped by contextual and institutional variables. One example being the significant strain the COVID-19 pandemic placed on hospital staffing and perioperative workflows, potentially undermining the effectiveness of provider-administered analge-sia.9-10 Although postoperative pain management has been previously studied, few investigations have examined how pandemic-related staffing shortages may have impacted the comparative effectiveness of PCA versus non-PCA strategies. Methods:This retrospective cohort study included 5,528 adult patients who underwent one of four spine procedures between January 2018 and December 2023. Patients were stratified by analgesia type (PCA vs. non-PCA) and time period (pre-COVID vs. post-COVID). Primary outcomes included total opioid consumption (measured in morphine milliequivalents, MME) and average Visual Analog Scale (VAS) pain scores in the first 24 hours postoperatively. Multivariable regression adjusted for demographics including age, sex, obesity, and smoking. Results:PCA use was associated with a 52.1% reduction in opioid consumption compared to non-PCA (p < 0.001). This effect was most pronounced post-COVID (74.2% reduction), though not statistically significant. Despite reduced opioid use, PCA patients reported slightly higher VAS scores (+0.814, p = 0.0013). Subgroup analyses revealed higher opioid use and pain scores among smokers and obese patients, while male sex predicted lower pain scores. PCA was particularly beneficial in more invasive procedures, and its expanded use in less complex surgeries post-COVID did not increase pain scores. Conclusion:PCA significantly reduced opioid use following spine surgery, though pain scores were modestly higher. During staffing shortages, PCA may offer operational and clinical advantages. Patient-specific risk factors should guide individualized pain protocols. Level of Evidence:III.
Background:Postoperative weightbearing management of patients surgically treated for femoral neck fractures is controversial. This study aimed to compare the outcomes of patients treated with a fixed-angle implant, the Femoral Neck System (FNS), as a function of their postoperative weightbearing protocol. Methods:A comparative cohort study of patients with intracapsular femoral neck fractures who underwent fixation with the FNS at a Level I trauma center from 2019 to 2023 was conducted. Patients were assigned to either the weightbearing as tolerated (WBAT) group or the toe-touch weightbearing (TTWB) group based on surgeon preference after each procedure. Primary outcome measures were postoperative complications and the need for revision surgery. Secondary outcomes included visual analog scale (VAS) pain score, SF-12 score, and Western Ontario and McMaster Universities Osteoarthritis (WOMAC) score. Results:There were 25 patients in the WBAT group and 19 in the TTWB group. Ten of 25 (40%) fracture union complications occurred in the WBAT cohort compared with 6 of 19 (32%) in the TTWB group (p = 0.565). Revision surgeries were required in 7 of 25 cases (28%) in the WBAT cohort compared with 3 of 19 (16%) in the TTWB group (p = 0.339). No statistically significant differences in VAS pain scores, SF-12 scores, or WOMAC scores between the groups were found. Conclusion:There were no statistically significant differences in radiographic complications, reoperations, or functional outcome scores between the two postoperative weightbearing protocols. Our findings suggest that WBAT may be permitted in this patient cohort, thereby simplifying postoperative care for patients and surgeons. Level of Evidence:III.
Background:Interbody cage subsidence following anterior cervical discectomy and fusion (ACDF) surgery can be associated with increased pain, segmental kyphosis, accelerated adjacent segment disease, and decreased rates of fusion. This study investigated the incidence of cage subsidence following the use of cages using Tritanium technology as cage-only (CO) or cage-plate (CP) constructs in patients undergoing ACDF. Methods:This was a retrospective multicentre cohort study. Data was collected from hospital records and radiographs. All patients undergoing ACDF for cervical myelopathy or radiculopathy were included. Patients were divided into two groups by ACDF construct: CO and CP groups. Outcome measures included postoperative cage subsidence, presence of fusion, and surgical complications. Cage subsidence was calculated as the decrease in intervertebral height. Statistical analysis was performed by Student's t-test for continuous data and Fisher's exact test for categorical data. Results:76 patients were included with mean age 56.5 years at surgery (SD: + 12; range: 2981), comprising a total of 94 ACDF procedures. Single-level ACDF was performed in 61 patients and multilevel ACDF was performed in 15 patients. CO construct was used in 13 ACDFs and CP construct used in 81 ACDFs. Mean radiological followup was 8.5 months (SD: 6.3; range: 3-24). Cage subsidence rate was greater in CO group compared to CP group (CO 54% (n=7), 95% CI: 29-77%; CP 19% (n=15), 95% CI 12-28% (x2 p=0.01)). There was no significant difference in fusion rates between CO and CP groups. One patient underwent revision surgery for cage subsidence. Age, indication for surgery, number of levels treated, cage size, cage lordosis, and progression to fusion were not significantly associated with cage subsidence. Conclusion:Incidence of cage subsidence was greater when Tritanium cages were used for ACDF surgery as cage-only constructs compared to cageplate constructs. Correlation of these results with patient-reported outcomes would be valuable. Level of Evidence:III.
Background:A 74-year-old female with a history of polycythemia vera on ruxolitinib and type two diabetes mellitus presented with a left calcaneal Coccidioides immitis and methicillin sensitive Staphylococcus aureus Brodie's abscess in the setting of pulmonary coccidioidomycosis. Patient underwent surgical debridement of the abscess with amphotericin mixed cementing of the calcaneal defect and long-term oral posaconazole leading to abscess and sinus tract resolution. Conclusion:Calcaneal Brodie's abscess is a rare osseous manifestation of disseminated Coc-cidiomycosis requiring surgical debridement and coordinated care with infectious disease. Early recognition, debridement, filling of the abscess void, and prolonged antifungals are paramount in treatment. Level of Evidence:V.
Background:Locking plates (LP) are commonly used to treat distal femur fracture. Far cortical locking (FCL) screws are designed to increase axial motion at the fracture site resulting in more callus formation in animal study. In our previous study, progress to healing was assessed. There were statistically significant differences in modified RUST score postoperatively with higher scores in the FCL group. However, the amount of callus formed was not quantitatively measured. The purpose of this study is to quantitatively assess the medial callus area (mm2) and changes in callus area over time in radiographs of distal femur fractures treated with FCL as compared to traditional locking plate constructs. Methods:A retrospective review of medical records conducted to identify patients with distal femur fractures. Medial callus area from AP radiographs was quantified from 6-, 12- and 24-week postop radiographs using OrthoRead software. Medial callus areas were compared between FCL construct fixation and traditional LP. Results:After applying inclusion and exclusion criteria, 69 patients with 70 total fractures were included for analysis. There were no significant differences between FCL (n=42) and LP (n=28) in demographic data or rates of complications (18%), fixation failures (10%), union (90%), or revision (10%) (all p>0.05). Medial callus areas did not significantly differ after adjustment for multiple comparisons between FCL vs. LP at 6 (195.2 mm2 (0.0-2007.1) vs. 200.7 mm2 (0.0-1137.0), p=0.982) or 12 (372.1 mm2 (0.0-2241.9) vs. 298.1 mm2 (0.0-1959.9), p=0.727) weeks postop. While between group differences were significant at 24 weeks postop (FCL:455.7 mm2 (30.4-2388.2) vs. LP:287.8 mm2 (0.0-1514.7), p=0.023) statistically significant differences were not sustained following adjustment for multiple comparisons (p=0.069). Larger medial callus was formed as duration from surgery increased to 24 weeks in the FCL as compared to the LP group in analyses limited to titanium implants ((FCL:455.7 mm2 (30.4-2388.2) vs. LP: 259.25 mm2 (0.001514.70), p=0.039). Conclusion:In this study, there is increased callus generated in FCL vs LP constructs at 24 weeks postoperatively (p=0.02). This is in accordance with previous animal models. However clinical advantages of this increased callus were not identified in the study. Because of the study limitations and potential confounders, prospective studies are necessary to further assess whether there is a clinically relevant healing advantage of FCL over standard LP constructs. Level of Evidence:III.
Background:Cephalomedullary nails (CMNs) are commonly used for femoral fracture fixation; however, operative times may vary based on patient-specific factors. Characterizing the influence of these factors provides important context for understanding the variability in procedure time. This study aimed to evaluate the relationship between patient demographics and operative time in CMN fixation for both long and short nail cohorts. Methods:A retrospective review of femoral CMN cases was performed, excluding bilateral procedures. Patient demographics, including BMI, sex, and age, as well as procedure time, were collected. Procedure time was compared between short and long cohorts, and associations between procedure time and demographic variables were evaluated using nonparametric statistical methods. Results:744 CMN cases (421 long and 323 short) were evaluated. Procedure time was greater for long CMNs (median: 104 min, IQR: 81-133 min) compared to short (median: 62 min, IQR: 51-76 min, p<0.001). In short CMNs, obese individuals (median: 66 min, IQR: 58-86 min) had longer procedure times than overweight (median: 59 min, IQR: 49-73 min, p=0.028), and normal weight individuals (median: 61 min, IQR: 49-73 min, p=0.011). In long CMNs, obese individuals (median: 112 min, IQR: 89-148 min) had longer procedure times compared to normal weight patients (median: 97 min, IQR: 79-128 min, p=0.005), and men (median: 108 min, IQR: 88137 min) had longer procedure times than women (median: 98 min, IQR: 78-128 min, p=0.002). Conclusion:Procedure time for CMN fixation was influenced by BMI, sex, and age. Obesity consistently contributed to increased procedure time independent of nail length. Sex and age demonstrated smaller, nail-specific associations with operative duration. Patient demographic factors should be considered when interpreting variability in operative time for CMN fixation. Level of Evidence:III.
Background:Cemented implants have long been considered the benchmark for total knee arthroplasty (TKA). With advances in highly porous metal technology, cementless TKA implants have shown promising short to medium term radiographic survivorship. While early data on cementless TKA is promising, many surgeons have concerns with transitioning a portion or majority of their patient population to cementless design. Our study aims to evaluate if there is an increase in revisions for surgeons in their first 100 cementless total knee arthroplasties. Methods:Retrospective review of the first 100 cementless total knee arthroplasties performed by two adult reconstruction surgeons, with minimum one year follow-up. Patient charts were reviewed for any evidence of complication or re-operation within one year from their surgical date. Patients were separated into 5 groups: operations 1 to 20, 21 to 40, 41 to 60, 61 to 80, and 81 to 100. All radiographs were reviewed for any signs of failure or loosening. Results:200 patients were reviewed in total, including the first 100 consecutive cementless total knee arthroplasties from each surgeon. There were no revisions at one year for patients in group 1. Group 2 had 1 revision. Group 3 had 1 revision followed by group 4 which had 4 revisions and group 5 in which 3 patients underwent revision TKA. There was no statistically significant difference between groups (p 0.16). There was no statistically significant difference in patient age (p 0.054) or BMI (p 0.114) for patients undergoing revision TKA. Kaplan-Meier did not show any difference between groups at one year follow-up. Conclusion:Transitioning from all cemented to cementless TKAs did not show an increase in complications leading to revision TKA, and there was no discernable 'learning curve' incorporating cementless TKAs into practice. Level of Evidence:III.
Background:Despite their association with high morbidity and mortality rates, limited data is available regarding subsequent fracture after femoral shaft fragility fractures. Specifically, two clinically important questions remain unanswered: (1) What is the cumulative incidence of proximal peri-implant femur fractures following femoral shaft fragility fractures? (2) Is fixation protecting the proximal femur associated with a lower cumulative incidence of proximal peri-implant femur fracture compared to when the proximal femur is not protected? Methods:A multi-center retrospective cohort study was conducted at four level 1 trauma centers. Patients aged 50 years or older treated with reduction and fixation of a low energy femoral shaft fracture between 2005 to 2024 were included in this review.Cases were categorized by whether fixation protected the proximal femur. Descriptive statistics were reported, and Kaplan Meier survival analyses assessed associations of patient, injury and treatment characteristics with the main outcome of cumulative incidence of proximal peri-implant fracture. Statistical significance was considered for p < 0.05. Results:There were 245 patients with a median age of 75 years old and interquartile range (IQR) 65 to 83, 192 (78.4%) women, and median Charlson Comorbidity Index 4 (IQR 3 to 6). Assessment via the AO/OTA classification revealed 193 32A, 34 32B, and 18 32C fractures. The overall rate of subsequent proximal femur fracture was less with fixation that protected the proximal femur (0/119, 0%) than without (6/126, 4.8%), p = 0.030. Without fixation protecting the proximal femur, the cumulative incidence of proximal femur fracture climbed to 6.9% within 10 months of femoral shaft fracture and was significantly greater than a sustained 0% incidence when fixation protected the proximal femur, log-rank p = 0.015. Proximal femur fracture was not associated with age, sex, comorbidity burden or AO/OTA classification (p > 0.05 for all). Conclusion:Without fixation protecting the proximal femur, approximately 1 in 15 patients treated for a femoral shaft fracture sustained a proximal femur fracture within 10 months of fixation of their shaft fracture. Protecting the proximal femur reduces the cumulative incidence of proximal peri-implant femur fracture and should be considered when possible. Level of Evidence:III.
Background:Effusion is a frequent finding after anterior cruciate ligament (ACL) injury and reconstruction, but the reliability of its quantification on routine [non-contrast] magnetic resonance imaging (MRI) is not established. This study sought to evaluate the intra-rater and inter-rater reliability of volumetric quantitative measurements (VQM) of knee effusion volumes (EV) using axial proton density-weighted, fat-suppressed (PD-FS) sequences after ACL injury and reconstruction. Methods:Twenty deidentified MRIs (10 ACL-injured knees and 10 uninjured knees) were randomly selected from a prospective observational cohort of participants aged 15-35 years. Two independent raters analyzed EV using a custom MATLAB protocol. Intra- and inter-rater reliability was assessed using intraclass correlation coefficients (ICC3,1) with minimal detectable changes calculated. Measurement agreement was assessed using Bland-Altman plots. Results:Mean EV were higher in the injured compared to uninjured knees (11.88±8.14 mL vs 2.03±0.76 mL). Volumetric effusion measurements demonstrated excellent intra-rater (ICC3,1=0.993, 95% CI: 0.981-0.997, p<0.001) and inter-rater reliability (ICC3,1=0.974, 95% CI: 0.907-0.991, p<0.001). The minimal detectable change was 0.145 mL for intra-rater measurements and 0.504 mL for inter-rater measurements. Bland-Altman plots revealed no systematic bias between raters, although variability increased with larger volumes (>8 mL). Conclusion:VQM using standard axial PD-FS MRI sequences demonstrate excellent reliability across raters. Restricting segmentation to the anterior compartment aligns with clinical assessment (e.g., sweep tests), though it does not capture whole-joint eflusion. This semi-automated approach may provide a relevant biomarker for monitoring EV in ACL research and rehabilitation trials. Level of Evidence:III.
Background:Gluteus maximus tendon transfer has been described as a salvage treatment option for irreparable abductor tendon tears. Current literature has demonstrated favorable short term outcomes, yet strength and gait abnormalities persist. The purpose of this study was to evaluate the impact of gluteus maximus tendon transfer on patient reported outcomes (PROs) over two consecutive time points and determine the prevalence of concomitant lumbosacral pathology. Methods:A retrospective review of 17 patients who underwent gluteus maximus transfer for irreparable abductor insufficiency was performed. The mean age was 71 years (range, 61 to 83), and 88% (15/17) were women. Clinical outcomes were obtained from follow-up visits, and modified Harris Hip Scores (mHHS) and Visual Analog Scale (VAS) pain scores were obtained at 24.9 ± 8.4 months (range, 13 to 42) and 47.1 ± 9.4 months (range, 31 to 65) postoperatively. Results:Mean mHHS (46.3 vs. 66.1, P<0.01), VAS at rest (3.1 vs. 0.9, P<0.01), and VAS with activity (5.9 vs. 1.9, P<0.01) improved between preoperative and 24.9 months postoperatively. Between 24.9 months and 47.1 months, mean mHHS (66.1 vs. 53.7, P<0.01) and VAS with activity (1.9 vs. 4.4, P<0.01) declined, and there was no difference in VAS at rest (0.9 vs. 2.1, P=0.09). Compared to the preoperative state, there was maintained improvement in mHHS (46.3 vs. 53.7, P=0.03) but no difference in VAS scores. Lumbar spine pathology or lumbar spine instrumentation was present in 76% (13/17) of patients. Conclusion:Patients undergoing gluteus maximus transfer for irreparable abductor deficiency demonstrate improved PROs at 2 years postop-eratively. These improvements persist to a variable degree at 4 years. There was a high prevalence of associated lumbar spine pathology suggesting a key etiologic factor explaining why these patients exhibit severe fatty degeneration of the abductor musculature while preserving gluteus maximus function. Level of Evidence:IV.
Background:Novel hemostatic agents, such as oxidized regenerated cellulose (ORC) have grown in popularity. The aim of this systematic review and meta-analysis is to evaluate the efficacy of ORC for intraoperative and postoperative blood loss in total joint arthroplasty (TJA). Methods:A search was conducted across seven databases. Titles and abstracts were screened for eligibility for inclusion criteria. Full texts were screened and included if they met eligibility criteria. Demographics and results of the studies were extracted. Meta-analysis was conducted to evaluate outcomes. Results:Eleven studies met inclusion criteria. One case report study did report a hypersensitivity reaction, however, the remaining studies showed no additional complications from the use of ORC. Five studies reported equivalent rates of blood transfusion, with one study finding that ORC led to lower rates of blood transfusions. Nine studies were included for meta-analysis. Total blood loss (Cohen's d: -0.42, CI: -0.66-0.19, p<0.001) and intraoperative blood loss (Cohen's d: -0.33, CI: -0.51-0.14, p<0.001) were significantly lower in the ORC cohort compared to using no ORC. The ORC cohort also had significantly lower hemoglobin drop on postoperative day 1, however, publication bias was present in association with this finding. There was no significant difference between the ORC cohort and the no ORC cohort for postoperative day 7 hemoglobin (Cohen's d: 1.13, CI: -0.15- 2.42, p=0.08), postoperative day 1 C-Reactive Protein (CRP) (Cohen's d: 0.09, CI: -0.10- 0.29, p=0.36), and postoperative day 7 CRP (Cohen's d: 0.04, CI: -0.50- 0.58, p=0.88).. Conclusion:ORC may help to reduce total blood loss and intraoperative blood loss in TJA, however, it does not appear to have sustained effects over the following week, nor does it appear to lower transfusion rates with the current available evidence. ORC has been shown to be safe, with CRP levels remaining constant postoperatively, and only one case report showing a self-limited hypersensitivity reaction (local rash). ORC may be a useful adjunct to help reduce blood loss for TJA, however, it is not currently clear if its usage leads to significant improvements in clinical outcomes. Level of Evidence:IV.
Background:Transverse patella fractures requiring surgical fixation are typically treated with a tension band construct using metal wire. This technique is associated with high rates of complications and reoperation. Alternative fixation technique utilizing non-absorbable suture materials have been introduced. This biomechanical study aims to compare the stability of two tension band constructs, both utilizing headed cannulated lag screws, with either suture tape or traditional metal wire under cyclic load conditions, simulating repetitive physiological stress. Methods:Six matched pairs of fresh frozen cadaveric knees were obtained for testing. A standardized transverse patellar osteotomy (AO/OTA 34C1.1) was created in each to simulate a simple transverse patella fracture. Each pair was repaired using a tension band construct with headed cannulated screws, randomized to fixation with either suture tape or metal wire. All specimens underwent cyclic loading from 0 to 90 knee flexion at a frequency of 0.2 Hz for up to 1000 cycles. Two displacement transducers were used to measure real-time fracture gap displacement during testing from the start of testing and until clinical fixation failure. Clinical failure is defined as fracture gap displacement > 3 mm. Results:Clinical failure occurred in 5 of 6 specimens (83%) in the suture tape group, with a mean of 296±433 cycles. In the metal wire group, 4 of 6 specimens (67%) experienced clinical failure, with a mean of 421±461 cycles. There was no statistically significant difference in cycles to failure between the two groups (p=0.29). Kaplan-Meier survival analysis demonstrated a 500-cycle survival rate of 33% (95% CI: 0%-71%) for both groups. Conclusion:Both constructs may be considered viable options for the surgical treatment of simple transverse patella fractures. Level of Evidence:V.
