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Background It is common practice to order an immediate postoperative radiograph in the postanesthesia care unit (PACU) following reverse shoulder arthroplasty (RSA). However, with a growing emphasis on value-based care and cost-effectiveness, we question the necessity for immediate postoperative radiographs following uncomplicated, primary RSA. Methods From 2014-2020, patients undergoing primary RSA at a single institution by one of 3 surgeons were included in this cohort. Radiographs from the PACU and any clinic visit during the initial 3-month postoperative period were reviewed to determine if any radiographic findings from the PACU altered clinical care or decision making. Results A total of 157 patients were included in this study and 13 patients had abnormal findings during the initial 3-month postoperative period where the immediate postoperative radiograph provided clinical utility for decision making. In 9 of the 12 patients requiring revision surgery, the postoperative complication was instability. In those patients requiring revision surgery during the initial 3 months, the most common indication for primary surgery was proximal humerus nonunion. Immediate postoperative radiographs were read by the radiologist as normal/unremarkable for 100% of patients. The typical amount billed for the immediate postoperative radiograph was $544.00 per patient. Conclusion Based on our findings, we see utility for an intraoperative or immediate postoperative radiograph following uncomplicated, primary RSA, especially when done as a salvage procedure for indications such as proximal humerus nonunion. However, there is low utility for obtaining an immediate postoperative radiograph in the PACU when indications include osteoarthritis or rotator cuff tear arthropathy.

With the advent of endovascular technique and the emergence of vascular surgery as a separate branch distinct from general surgery, there is a decrease in exposure of open vascular technique to general surgery resident. Vascular access surgery is a vascular subspecialty area and not all residents get similar exposure during training, and this has implications if one becomes a vascular consultant in the future and have to undertake access surgery. There is no established protocol or duration, following which a surgical resident can be named as "trained" in vascular anastomosis. Our study tries to address the aforementioned problems; in particular the actual training that a general surgery resident needs in vascular access.To study and compare the outcomes of AV Fistula surgeries, created by "trained" general surgical residents and consultant.A single-institution retrospective cohort study comparing two groups of cohorts: trained residents (group A) and consultant (group B). Study has been done in accordance with the standards of ICMJE and registered with the Clinical Trial Registry of India. (CTRI/2021/12/038581).Out of 238 patients recruited, 157 underwent surgery in group 'A' (the trained residents performing arteriovenous fistula surgery) and 81 underwent surgery in group 'B' (by consultant of general surgery). Clinical maturation noted after 8 weeks was 83.4% (131/157) in group A and 90.1% (73/81) in group 'B'; (p = 0.113). The mean duration of surgery in group 'A' was 99.8 ± 18.2 min and group 'B' was 56.2 ± 10.4 min; (p value 0.0001).A structured training in vascular anastomosis provided to the newly recruited residents in general surgery for 6 months lead to outcomes that were comparable with the consultants.

INTRODUCTION Three-dimensional (3-D) CT volumetric filling ratio (VFR) is a better predictor of proximal humerus stress shielding after short-stem anatomic total shoulder arthroplasty (aTSA) than using plain radiographs. METHODS Forty-four patients with short-stem aTSAs, preoperative CT scans, and a minimum 3-year radiographic follow-up were included. Patients were divided into group A (stress shielding) and group B (no stress shielding) based on the radiographic analysis. Standard implant filling ratios were measured on plain radiographs. The 3-D VFR of the metaphyseal and diaphyseal segments of the aTSA stem was measured using MIMICS (Materialise). The area under a receiver operator characteristic curve was used to determine the predictive strength of the 3-D VFR method. RESULTS The average age and radiographic follow-up was 69 years and 44 months. Group A had 19 patients and statistically higher filling ratios using 3-D VFR method than group B, whereas no notable differences were found between the groups using standard techniques. The 3-D VFR had an area under a receiver operator characteristic curve of 92%, which supports it as a good predictor of stress shielding. CONCLUSIONS These methods enable early identification of patients at risk for stress shielding and can also be valuable in improving humeral stem designs. LEVEL OF EVIDENCE Level III. Case-control study.

Background The rate of vena cava (IVC) filter placement has increased over the past decade, especially in the orthopaedic trauma patient population. With the increasing use of IVC filters, radiologists and referring clinicians must be familiar with potential complications. Clinical Case This case report presents an 18-year-old polytraumatized patient who had an IVC filter placed and required T8-L2 posterior spinal fusion. At 4.5 years of follow-up, a computed tomography (CT) scan for painful spinal hardware incidentally found that the IVC filter had migrated into the L3 vertebral body. The patient eventually underwent removal of her spinal hardware, but the IVC filter migration was managed conservatively with routine surveillance. At 10 years follow-up, the patient continued to remain asymptomatic despite of filter penetration into the vertebral body. Conclusion This case demonstrates, long term follow-up for an asymptomatic patient with IVC migration and vertebral body penetration. This case may suggest that attempt at complex IR filter retrieval is not necessarily warranted in scenarios of strut penetration.

Background Perform computed tomography (CT) three-dimensional (3D) mapping analysis of the ipsilateral olecranon tip to determine its suitability as an autograft for unrepairable coronoid fractures. Methods CT was evaluated using Mimics 13.0 and 3-matic software (Materialise, Inc., Leuven, Belgium). Coronoid fracture fragment was measured from the medial sublime tubercle to the halfway point of the proximal radioulnar joint. Ipsilateral olecranon tip graft was measured at the equivalent height of the coronoid fragment and the angle of graft “cut” necessary to match the coronoid fragment was measured. The overall width of each graft site was measured in thirds and the congruity of surface geometry was measured by overlapping both fragments. The ipsilateral olecranon tip lateral facet which rotates to become the coronoid medial facet was also measured. Results The olecranon tip and coronoid fragments were similar in average maximum height and width. The average angle of graft cut needed to match the coronoid fragment was 86°. The average difference between the medial facet of the coronoid and lateral facet of the olecranon was Discussion The ipsilateral olecranon tip can be harvested through the same surgical incision and function as a local autograft during reconstruction of unrepairable coronoid fractures.

Case We report 2 cases of a spiral nerve variant that has only 1 previously reported description in the literature. A pretendinous cord was found to branch into a "Y" configuration, extending distally on both the radial and ulnar sides of the same digit, with the radial and ulnar digital nerves spiraling around each limb of the "Y cord". Conclusion Rare spiral nerve variants exist which place the digital neurovascular bundles (NVBs) at risk. Awareness of these variants and adherence to conservative surgical principles allow the surgeon to identify these scenarios intraoperatively and safely dissect the digital NVBs free of pathologic tissue.

Objectives: Determine the performance and return to play (RTP) outcomes for professional baseball players that undergo surgical treatment for thoracic outlet syndrome. Methods: All professional baseball players who underwent surgical treatment of TOS between 2010-2017 were identified using the major league baseball (MLB) HITS (Health and Injury Tracking System) database. Demographic and performance data (pre and post-surgery) for each player was recorded. Standard demographic and return to play outcomes were measured for all players and compared between different types of TOS and league status. Performance variables were analyzed for pitchers and compared to a 1:1 matched set of control pitchers. Results: Overall, 52 players underwent surgery for TOS of which 46 (88%) were pitchers. Neurogenic TOS was the most common and seen in 69% of players. Venous TOS was seen in 29% of players, and a single player had arterial TOS. Following TOS surgery, 79% of players returned to play at the same level (RTSP) and played at least 3 years after surgery. There was no differences in RTSP rate based on the type of TOS. There was no statistically significant difference in RTP and RTSP rates between major and minor league players. In pitchers only, there was a 76% RTSP, which was not different from the natural attrition of control pitchers (p=0.874). Following TOS surgery, pitchers saw a decline in several performance metrics, but not statistically different when compared to the control pitchers. This indicated that the decline in performance following TOS surgery was similar to the decline seen in healthy professional pitchers as they age. Conclusions: The most common type of TOS seen in professional baseball players is neurogenic. The RTSP rate following surgery for TOS in all professional baseball players is 79%. There was no statistically significant difference in ability to RTP based on the type of TOS or league status. Pitchers who underwent surgery for TOS had no significant difference in pitching performance metrics following surgery compared to matched controls. Overall, surgery for thoracic outlet syndrome can help prolong a professional baseball players career and help pitchers maintain their performance over time similar to their peers who have not had surgery for TOS. [Table: see text][Table: see text][Table: see text][Table: see text]

Background How shoulder injuries treated before the Major League Baseball (MLB) draft affect the player's performance over their career is unclear. The purpose of this study was to determine whether prior shoulder injuries were associated with a difference in the level of performance and advancement of MLB draftees. Methods Before entering the draft, 119 professional baseball players from 2004 to 2010 were treated for a shoulder injury (73% treated surgically) as an amateur. A 3:1 matched case-control was performed to players without prior shoulder injuries by age, position, round selected, and signing bonus. Follow-up data were collected in 2016, and professional advancement, disabled list time, and in-game performance statistics for pitchers were analyzed and compared. Results Players with a prior shoulder injury had a statistically higher chance to be assigned to the disabled list then controls (P = .03), but there was no difference in disabled list time or professional advancement. Pitchers with a prior shoulder injury pitched a statistically lower number of innings per game than controls (P = .04). All other in-game performance statistics were not statistically different. The type of treatment did not have any effect on future performance or advancement. Conclusions Professional baseball players treated for prior shoulder injuries at the amateur level were more likely to sustain future disability than their matched controls, but it did not affect professional advancement.

INTRODUCTION Three-dimensional (3-D) CT volumetric filling ratio (VFR) is a better predictor of proximal humerus stress shielding after short-stem anatomic total shoulder arthroplasty (aTSA) than using plain radiographs. METHODS Forty-four patients with short-stem aTSAs, preoperative CT scans, and a minimum 3-year radiographic follow-up were included. Patients were divided into group A (stress shielding) and group B (no stress shielding) based on the radiographic analysis. Standard implant filling ratios were measured on plain radiographs. The 3-D VFR of the metaphyseal and diaphyseal segments of the aTSA stem was measured using MIMICS (Materialise). The area under a receiver operator characteristic curve was used to determine the predictive strength of the 3-D VFR method. RESULTS The average age and radiographic follow-up was 69 years and 44 months. Group A had 19 patients and statistically higher filling ratios using 3-D VFR method than group B, whereas no notable differences were found between the groups using standard techniques. The 3-D VFR had an area under a receiver operator characteristic curve of 92%, which supports it as a good predictor of stress shielding. CONCLUSIONS These methods enable early identification of patients at risk for stress shielding and can also be valuable in improving humeral stem designs. LEVEL OF EVIDENCE Level III. Case-control study.

Background The present study aimed to determine anatomic references for the placement of five proximal humerus locking plates. Methods Five proximal humerus locking-plate systems were placed on six human shoulder cadavers. Plates were positioned by fluoroscopic confirmation so that the inferior oblique screw was within 5 mm of the inferomedial cortex. Plate position was measured using the superior border of the pectoralis major tendon (PMT) to the bottom of the first slotted or nonlocking hole and top of the plate to the top of the greater tuberosity. The distance from the PMT insertion to the top of the humeral head was measured as a control. Results There was consistency within each plating system for both the distance from the PMT insertion to the first hole and the top of the plate to the greater tuberosity: Synthes first-generation [mean (SD) 13.7 mm (3.1 mm); 10 mm (1.3) mm], Synthes second-generation [28.2 mm (2.2 mm); 18.5 mm (2.7 mm)], Biomet OptiLock® [25.5 mm (2.7 mm); 18.7 mm (2 mm)], Stryker AxSOS® [5 mm (2.8 mm); 12.3 mm (3.3 mm)] and Acumed Polarus® [9.5 mm (1.8 mm); 14.8 mm (1.6 mm)]. Conclusions The present study provides measurements that improve the accuracy of plate positioning for five plating systems.

Background: The aim of the study was to compare biomechanical strength, repair times, and repair values for zone II core flexor tendon repairs. Methods: A total of 75 fresh-frozen human cadaveric flexor tendons were harvested from the index through small finger and randomized into one of 5 repair groups: 4-stranded cross-stitch cruciate (4-0 polyester and 4-0 braided suture), 4-stranded double Pennington (2-0 knotless barbed suture), 4-stranded Pennington (4-0 double-stranded braided suture), and 6-stranded modified Lim-Tsai (4-0 looped braided suture). Repairs were measured in situ and their repair times were measured. Tendons were linearly loaded to failure and multiple biomechanical values were measured. The repair value was calculated based on operating room costs, repair times, and suture costs. Analysis of variance (ANOVA) and Tukey post hoc statistical analysis were used to compare repair data. Results: The braided cruciate was the strongest repair ( P > .05) but the slowest ( P > .05), and the 4-stranded Pennington using double-stranded suture was the fastest ( P > .05) to perform. The total repair value was the highest for braided cruciate ( P > .05) compared with all other repairs. Barbed suture did not outperform any repairs in any categories. Conclusions: The braided cruciate was the strongest of the tested flexor tendon repairs. The 2-mm gapping and maximum load to failure for this repair approached similar historical strength of other 6- and 8-stranded repairs. In this study, suture cost was negligible in the overall repair cost and should be not a determining factor in choosing a repair.

Background: Recent studies evaluating nonoperative treatment of elbow ulnar collateral ligament (UCL) injuries augmented with platelet-rich plasma (PRP) have shown promising results. To date, no comparative studies have been performed on professional baseball players who have undergone nonoperative treatment with or without PRP injections for UCL injuries. Hypothesis: Players who received PRP injections would have better outcomes than those who did not receive PRP. Study Design: Cohort study; Level of evidence, 3. Methods: The Major League Baseball (MLB) Health and Injury Tracking System identified 544 professional baseball players who were treated nonoperatively for elbow UCL injuries between 2011 and 2015. Of these, 133 received PRP injections (PRP group) before starting their nonoperative treatment program, and 411 did not (no-PRP group). Player outcomes and a Kaplan-Meier survival analysis were compared between groups. In addition, to reduce selection bias, a 1:1 matched comparison of the PRP group versus the no-PRP group was performed. Players were matched by age, position, throwing side, and league status: major (MLB) and minor (Minor League Baseball [MiLB]). A single radiologist with extensive experience in magnetic resonance imaging (MRI) interpretation of elbow injuries in elite athletes analyzed 243 MRI scans for which images were accessible for tear location and grade interpretation. Results: Nonoperative treatment of UCL injuries resulted in an overall 54% rate of return to play (RTP). Players who received PRP had a significantly longer delay in return to throwing ( P < .001) and RTP ( P = .012). The matched cohort analysis showed that MLB and MiLB pitchers in the no-PRP group had a significantly faster return to throwing ( P < .05) and the MiLB pitchers in the no-PRP group had a significantly faster RTP ( P = .045). The survival analysis did not reveal significant differences between groups over time. The use of PRP, MRI grade, and tear location were not statistically significant predictors for RTP or progression to surgery. Conclusion: In this retrospective matched comparison of MLB and MiLB pitchers and position players treated nonoperatively for a UCL tear, PRP did not improve RTP outcomes or ligament survivorship, although there was variability with respect to PRP preparations, injection protocols, time from injury to injection, and rehabilitation programs. MRI grade and tear location also did not significantly affect RTP outcomes or progression to surgery.

BACKGROUND The variation in the anatomic relationship between the coracoid and the clavicle affects the biomechanical stability of coracoclavicular ligament reconstruction (CCLR). METHODS Three-dimensional computed tomography reconstruction of 85 patients was analyzed. Anatomic landmarks were used to derive the coracoclavicular sagittal reconstruction angle (sRA). The lateral concave angle, which indicated the shape of the distal clavicle, and the offsets between the clavicle and coracoid were also measured. To investigate the biomechanical effects of the sRA on CCLR, 7 computed tomography scans with different sRAs were 3D printed. Two reconstructions, a single trans-coracoclavicular tunnel and a looped reconstruction technique, were performed sequentially. Models were cyclically loaded at 70 N in the anterior, posterior, and superior directions. RESULTS The mean sRA was 68° ± 9.3° (range, 47°-85°). The superoinferior offset between the clavicle and the coracoid and the lateral concave angle positively correlated with the sRA (r = 0.359 and 0.837, respectively; P ≤ .001), whereas the anteroposterior offset had a negative correlation (r = -0.925; P < .001). The sRA had a negative correlation with the anterior displacement of the clavicle (rho = -0.96; P < .001) and a positive correlation with the posterior displacement for both surgical techniques (rho = 1.0; P < .001). CONCLUSION The anatomic orientation of the native coracoclavicular ligaments is highly variable in the sagittal plane. Low sagittal angles can reduce anterior stability, whereas high sagittal angles can reduce posterior stability of CCLR.

To compare the biomechanical stability of 3 different coracoclavicular reconstruction techniques under rotational and vertical loading using a cadaveric model.In total, 12 cadaveric shoulders were used for testing. The native state was first tested then followed by 3 different reconstruction configurations using suture tapes and cortical buttons: coracoid loop (CL), single-bundle (SB), and double-bundle (DB). Superior displacement was measured by cycling an inferiorly directed force of 70 N to the scapula. The rotational stiffness of the scapula was determined by cycling the scapula in rotational displacement control between 15° of internal and external rotation. The rotational stiffness of the clavicle was determined by rotating the clavicle around its long axis 20° anteriorly and 30° posteriorly in rotational displacement control. All measurements were captured over 10 cycles at a rate of 200 Hz.Both the CL and SB techniques demonstrated significantly less internal scapular rotation stiffness. (intact: 19.70 ± 9.07 cNm/deg, CL: 3.70 ± 2.63 cNm/deg, SB:4.30 ± 2.66 cNm/deg, P.001) External scapular rotation stiffness was significantly decreased in all techniques (intact: 17.70 ± 4.43 cNm/deg, CL: 3.30 ± 1.37 cNm/deg, SB: 4.50 ± 1.56 cNm/deg, DB: 4.67 ± 1.99 cNm/deg, P.001). The CL and SB reconstructions were significantly less stiff with regards to posterior rotation of the clavicle (intact: 5.60 ± 1.80 cNm/deg, CL: 2.90 ± 1.10 cNm/deg, SB: 1.40 ± 0.65 cNm/deg, P.001). Anterior rotation stiffness of the clavicle was significantly lower in all of the reconstructions (intact: 6.95 ± 1.90 cNm/deg, CL: 3.08 ± 0.84 cNm/deg, SB: 3.64 ± 0.93 cNm/deg, DB: 4.48 ± 1.21 cNm/deg, P.001).None of the described techniques provided equivalent rotational stability in all planes compared with the native state. DB reconstruction presented stiffness characteristics closest to the native state under cyclic loading during internal scapular and posterior clavicular rotation.Additional procedures such as tendon grafting or acromioclavicular ligament reconstruction may be required to control rotational stability.

The Multifunctional Wheelchair is an automatic vehicle which reduces the user’s efforts and time while moving from one place to another. A wheelchair is a backbone of a disable person and it must be strong enough to sustain the loading of humans. So in present study a motorised wheelchair was designed in Catia and analysed by Ansys on the basis of vibration frequency. Two different materials were analyzed for result comparison to find out the best suited material, which can sustain the failure under vibration and external loading. From the result it was found that aluminium T6 6061 material has higher resonance frequency than Stainless steel- 304. Furthermore aluminium T6 6061 material made base frame was analyzed by static structural analysis with 80 kg of person load. The Simulation result shows that the design wheelchair can sustain the applied loading, because the value of maximum stress in base frame was less than yield strength of used aluminium T6 6061 material.

Objectives: In the setting of ulnar collateral ligament (UCL) injury, surgical reconstruction of the UCL is not always selected, as it leads to a prolonged recovery time and return to play rates between 67-95%. To date, there is limited data on outcomes following nonoperative treatment in this population. Orthobiologics, such as platelet-rich plasma (PRP), have recently been used as an adjunct therapy for standard nonoperative treatment including rest and physical therapy for UCL injuries. The objective of this study was to determine if the addition of PRP injections in professional baseball players with UCL injuries reduces recovery time, lowers the likelihood of surgery, and increases the return to play rate compared to traditional nonoperative treatment. Methods: The Health and Injury Tracking System (HITS) database was searched from 2011-2015 for Major and Minor league baseball players with Grade I, II or III UCL injuries. Standard demographic, injury, and return to play data was obtained for all players. MRI’s for 353 athletes were reviewed by a musculoskeletal radiologist and graded accordingly. Outcomes were compared between players who received PRP injections in addition to traditional nonoperative treatment (PRP group) and players who received traditional nonoperative treatment alone (No PRP group). Statistical analysis was performed using Student’s T-test and Chi-square for parametric data. Kaplan Meier’s analysis was used for estimating longevity of the treatment. Results: A total of 544 Major and Minor League Baseball players with UCL tears underwent an initial course of nonoperative treatment (active rest & rehabilitation) for their injury between 2011-2015. Of these, 133 underwent PRP injections plus rehab and 411 underwent rehab alone. There was a significantly higher proportion of Major League Baseball players in the PRP group compared to the No PRP group (25.6% vs 9.0%, PConclusion: Among Major and Minor League Baseball players who were treated nonoperatively for a UCL injury between 2011-2015, 24% underwent PRP injections prior to rehab. Compared to traditional nonoperative rehab alone program, players who received PRP injections experienced a significantly longer time before returning to throwing, which may be in part due to the delay between the injury date and PRP injection. PRP injections did not appear to have a significant effect on the likelihood of surgical intervention.

Multiple treatment options are available for patients who have peripheral nerve injuries with a gap. Decellular nerve allografts are one option and provide an extracellular scaffold for neuronal cells to migrate for axonal regrowth. Immunosuppression is not needed because improved nerve processing technologies have rendered decellular nerve allografts nonimmunogenic. These allografts have also shown promising results in both animal and human studies as an alternative repair option.

Introduction The use of a postoperative brace may be beneficial after open reduction and internal fixation of tibial plateau fractures. However, bracing has potential drawbacks related to cost, fitting, wound complications, and compliance. We hypothesized that no difference will be found between patients with and without bracing after open reduction and internal fixation of tibial plateau fractures. Methods In this prospective, comparative trial, patients were randomized to 6 weeks of bracing or no bracing after open reduction and internal fixation of tibial plateau fractures. Functional, subjective, and radiographic outcomes were recorded. Patients with an open physis, unstable ligamentous injuries, extensor mechanism disruption, and/or Results The 24 patients with bracing (average age, 50 ± 16 years; 14 women and 10 men) were compared with the 25 patients without bracing (average age, 51 ± 12 years [P = 0.74]; 9 women and 16 men). No statistically significant differences were found in most of the functional, subjective, and radiographic outcomes, including fracture characteristics, complications, postoperative range of motion, Medical Outcomes Study 36-Item Short Form scores, and union rates. In the nonbraced group, one patient had late joint collapse with valgus malalignment (>10°). Two wound complications occurred in the braced group and four wound complications occurred in the nonbraced group, but this difference was not statistically significant. Discussion Improvements in conventional and locking plate technology have allowed more reliable rigid internal fixation of tibial plateau fractures. However, the use of a brace for postoperative rehabilitation after open reduction and internal fixation of tibial plateau fractures continues to be debated. Conclusion Our prospective study showed no statistically significant difference between bracing and no bracing after open reduction and internal fixation of tibial plateau fractures in terms of functional, subjective, and radiographic outcomes. Level of evidence Therapeutic level II.

In modern society, Heart disease is the noteworthy reason for short life. Large population of people depends on the healthcare system so that they can get accurate result in less time. Large amount of data is produced and collected by the healthcare organization on the daily basis. To get intriguing knowledge, data innovation permits to extract the data through automization of processes. Weighted Association Rule is a type of data mining technique used to eliminate the manual task which also helps in extracting the data directly from the electronic records. This will help in decreasing the cost of services and also helps in saving lives. In this paper, we will find the rule to predict patient's risk of having coronary disease. Test results have shown that vast majority of the rules helps in the best prediction of coronary illness.

Subcutaneous emphysema after trauma should raise immediate suspicion for a necrotizing soft-tissue infection. However, there are certain circumstances in which subcutaneous emphysema is the result of a benign or noninfectious process. In the literature, subcutaneous emphysema has been reported secondary to high-pressure injection injuries, factitious self-injection of air and chemical substances in the extremities, elbow arthroscopy, air-sucking phenomenon from traumatic lacerations, and iatrogenic use of hydrogen peroxide in the face and extremities1-13. Surgical evaluation should be obtained for the assessment of subcutaneous emphysema so that, if necessary, immediate surgical intervention can be performed. We report a case of noninfectious subcutaneous emphysema of the upper extremity with an unusual cause. The patient was informed that data concerning the case would be submitted for publication, and she provided consent. A forty-six-year-old right-hand-dominant woman fell on some ice and landed on the left elbow, causing a 2-cm laceration over the olecranon process. The patient reported that she initially had managed the wound with intermittent hydrogen peroxide irrigation and gauze dressing. She was a medical assistant for a primary care physician who evaluated the wound at work approximately twelve hours after the initial injury. At that time, she had not experienced any symptoms in the upper extremity except for localized pain around the wound. She continued to work with a sterile dressing over the wound, but did not have the wound closed. Approximately twenty-four hours after the fall, she presented to our emergency room with the symptom of subjective pain (rated 5 of 10) in the entire upper extremity, especially with elbow range of motion. She also described a “crunchy” feeling in the forearm that had worsened over the course of the day and copious drainage from the laceration site. She denied numbness or tingling distally and any systemic symptoms …

Case: An eighteen-year-old polytrauma patient sustained multiple nonorthopaedic and orthopaedic injuries, including a closed femoral shaft fracture. She was started on extracorporeal membrane oxygenation (ECMO) for respiratory failure. After added resuscitation and stabilization, she underwent intramedullary nailing of the femoral fracture while on ECMO on the third day after the injury. She remained stable throughout the case and recovered after a prolonged hospital course. At the most recent clinical follow-up, she was walking without assistance and had union of the fracture. Conclusions: ECMO successfully stabilized and mitigated any potential pulmonary complications during intramedullary nailing of a femoral shaft fracture in an unstable patient with polytrauma.

Case: A 67-year-old woman who underwent a re-revision of a total hip arthroplasty with a cemented polyethylene liner fell 14 months after surgery. The patient had symptoms of pain and weakness; however, clinical, laboratory, and radiographic evaluation did not disclose fracture, infection, osteolysis, or component migration. Liner dissociation was suspected, and a double-contrast computed tomography (CT) arthrogram confirmed failure at the cement-liner interface. She underwent additional revision surgery and was doing well at the 3-year follow-up. Conclusion: Double-contrast CT arthrography confirmed failure at the cement-liner interface and is an effective diagnostic tool in identifying suspected dissociations of cemented polyethylene liners.

The purpose of this article is to discuss the indications and surgical techniques of "homemade" digital external fixators constructed from easily available and inexpensive hardware (K-wires and dental rubber bands).

The evolution in surgical technique and suture technology has provided an abundance of options for flexor tendon repairs. Multiple biomechanical studies have attempted to identify the best surgical technique based on suture properties, technical modifications, and repair configurations. However, the burgeoning amount of research on flexor tendon repairs has made it difficult to follow, and no gold standard has been determined for the optimal repair algorithm. Therefore, it seems that repairs are usually chosen based on a combination of familiarity from training, popularity, and technical difficulty. We will discuss the advantages, disadvantages, and technical aspects of some of the most common core flexor tendon repairs in the literature. We will also highlight the nomenclature carried through the years, drawings of the repairs referred to by that nomenclature, and the data that support those repairs.

Objectives: Evaluate the relationship of 1) MRI tear grade and 2) injury location with outcomes for non-operatively treated elbow ulnar collateral ligament (UCL) injuries in professional baseball players. Methods: 544 professional baseball players were identified from the MLB Health and Injury Tracking System (HITS) that were treated non-operatively for their UCL injuries from 2011-2015. Of these players, 237 MRI’s were directly available for review by an independent, expert musculoskeletal radiologist who evaluated the grade (Grade I -edema, II-partial tear, III-complete tear) and location of the tears (humeral, ulnar, both-sided). Player demographics and outcomes including return to throwing (RTT), return to play (RTP), failed non-operative treatment leading to UCL reconstruction (UCLR), and Kaplan-Meier survivorship analysis of the native UCL to re-injury or surgery based on MRI grade and tear location was measured. A multivariate analysis adjusting for age, MRI grade, tear location, and level of play (Major = MLB; Minor = MiLB) was also performed. Results: The average age of all players was 22.5 years, 90% played at the MiLB level, and 84% were pitchers. The radiologist’s MRI injury grade was distributed as follows: Grade I (36%), Grade II (49%), and Grade III (15%) injuries. The tear locations were distributed as follows: humeral (65%), ulnar (13%), and both-sided (22%). There were no statistically significant differences in RTT, RTP, and UCLR by grade or tear location. However, objectively, ulnar-sided tears had the lowest RTT (81%) and RTP (42%). The ulnar (58%) and both-sided (60%) tears also had an objectively higher rate of UCLR compared to humeral sided tears (51%, p=0.441). The survivorship analysis showed a consistent decline over time with increasing MRI grade. By location, humeral tears had the highest survivorship (1 yr = 51%; 2 yr = 44%). However, there was no statistically significant differences in survivorship for either grade or location. Multivariate analysis measured the likelihood of not returning to play as 3 times higher [95% CI: 1-9.3; p=0.044] for older players (>25) compared to younger players. The likelihood of having re-injury or UCLR after non-operative treatment failed was almost 6 times higher [95% CI: 1.5-21.7; p=0.012] for MLB players as opposed to MiLB players. MRI grade and tear location were not significantly predictive of returning to play, re-injury, or surgery. Conclusion: This is the largest study to evaluate the prognostic relationship of MRI injury grade and tear location with outcomes for non-operatively treated elbow UCL tears in professional baseball players. Lower MRI grade and humeral location were objectively associated with a higher RTT, higher RTP, lower UCLR, and higher survival compared to higher grade, and ulnar or both-sided tears. Older age (>25) had a significantly higher likelihood of not returning to play after non-operative treatment. Competing at the MLB level had a higher likelihood of re-injury or having UCLR. Based on this study, non-operative treatment of UCL injuries will likely be more successful in younger players, lower grade tears, and humeral-sided injuries.

Extensor tendon injuries of the hand and wrist in high-level athletes can cause a delay in return to play and permanently affect their performance. Given the inherent demand for a speedy and complete recovery, orthopedic surgeons must have an understanding of how to best direct an athlete's treatment for these injuries. The extensor anatomy is very intricate and a thorough understanding of the anatomy can help with both diagnosis and treatment. However, untreated or poorly managed injuries are at risk of leading to chronic deformities. We will discuss the diagnosis and management of the most common extensor tendon injuries and tendinopathies of the hand found in athletes: mallet fingers, swan-neck deformities, boutonniere deformities, central slip ruptures, sagittal band ruptures, intersection syndrome, extensor carpi ulnaris tendinitis, and extensor carpi ulnaris subluxation.

Most patients (>90%) will have continued or recurrent symptoms after primary cubital tunnel release. Those patients with severe preoperative findings are at a higher risk of failure. Failed primary surgery may be due to diagnostic, technical, or biologic factors. Revision surgical interventions can provide relief, but there is no consensus on what is the optimal technique. The options for revision surgery include simple neurolysis, neurolysis with subcutaneous transposition, and neurolysis with submuscular transposition. Autogenous (vein) and non-autogenous nerve wraps may be placed around the nerve to prevent cicatrix reformation.

Background Dysphagia is a known complication of pericardial effusions. Most cases of pericardial effusions are idiopathic, infectious, and neoplastic, but can also occur after cardiac procedures. Objective To report the case of a patient who developed dysphagia from a sub-acute pericardial effusion caused by the placement of an implantable cardioverter-defibrillator (ICD). Case Report A 62-year-old woman presented to the Emergency Department (ED) with a 2-day history of dysphagia. Imaging revealed a large pericardial effusion compressing the esophagus from the mid-thoracic level to the gastroesophageal junction. Ten days prior, a dual-chamber ICD with small-diameter active fixation leads was placed in the patient. There had been no apparent complications from the procedure, however, over this 10-day period she developed a sub-acute pericardial effusion from an incidental perforation during ICD lead placement that led to the extrinsic compression of the esophagus and her presenting symptom of dysphagia. The patient underwent pericardiocentesis for the pericardial effusion and she was discharged in stable condition. Conclusion This case report highlights the importance of recognizing a non-cardiac complaint such as dysphagia as the primary symptom of a critical cardiac condition. With an increase in cardiac procedures anticipated, clinicians should consider the possibility of a pericardial effusion as a cause of dysphagia, especially for those patients with recent cardiac procedures.

The aim of this analysis was to report a multidisciplinary series comparing choledochoceles to Todani Types I, II, IV, and V choledochal cysts.Choledochoceles have been classified as Todani Type III choledochal cysts. However, most surgical series of choledochal cysts have reported few choledochoceles because they are managed primarily by endoscopists.Surgical, endoscopic, and radiologic records were reviewed at the Riley Children's Hospital and the Indiana University Hospitals to identify patients with choledochal cysts. Patient demographics, presenting symptoms, radiologic studies, associated abnormalities, surgical and endoscopic procedures as well as outcomes were reviewed.A total of 146 patients with "choledochal cysts" including 45 children (31%) and 28 with choledochoceles (18%) were identified, which represents the largest Western series. Patients with choledochoceles were older (50.7 vs. 29.0 years, P0.05) and more likely to be male (43% vs. 19%, P0.05), to present with pancreatitis (48% vs. 24%, P0.05) rather than jaundice (11% vs. 30%, P0.05) or cholangitis (0% vs. 21%, P0.05), to have pancreas divisum (38% vs. 10%, P0.01), and to be managed with endoscopic therapy (79% vs. 17%, P0.01). Two patients with choledochoceles (7%) had pancreatic neoplasms.Patients with choledochoceles differ from patients with choledochal cysts with respect to age, gender, presentation, pancreatic ductal anatomy, and their management. The association between choledochoceles and pancreas divisum is a new observation. Therefore, we conclude that classifications of choledochal cysts should not include choledochoceles.

Posterior instability represents up to 10% of all cases of shoulder instability1. In athletes, posterior instability can result from a single traumatic injury, repetitive microtrauma, or, rarely, atraumatic instability. The demands on the athlete’s shoulder, especially in contact or overhead throwing sports, can be dramatic, and, as a result, the managing orthopaedic surgeon must understand the complexities of such an injury complex. Participation in contact sports may result in an increased risk for the development of traumatic posterior instability. In overhead athletes, posterior instability can result from repetitive microtrauma sustained from an early age, which can be further exacerbated with the increase in year-round play. ### Static Stabilizers The static stabilizers of the glenohumeral joint include the glenoid and the humeral head, the capsulolabral complex, the articular surface, and the glenohumeral ligaments. Anatomic alterations of the retroversion of the osseous and chondrolabral portions of the glenoid have been shown to be associated with posterior shoulder instability2. Cadaveric studies of …

y f t R t f d t o d d i p s w THE PATIENT A 52-year-old, healthy, right-handed woman presents to the emergency department with left wrist pain, swelling, and deformity after falling on her outstretched arm. Posteroanterior and lateral radiographs show a displaced, extra-articular distal radius fracture with 15° of dorsal angulation, 2 mm of radial shortening, no ulnar styloid fracture, and slight dorsal comminution. The fracture is reduced after a hematoma block, and a sugartong splint is applied. Postreduction radiographs show neutral alignment and 1 mm of shortening. She presents to your office 1 week later and strongly prefers nonsurgical treatment.

Cortical bone grafting is commonly required in the finger, hand, and carpus when managing bony trauma. A donor site that can provide a small or large amount of cortical bone graft that is easily accessible and within the same surgical field would be the ideal donor site. In high-energy injuries, a long cortical graft may be needed to reconstruct massive bony defects. In low-energy injuries such as scaphoid nonunions in which a wedge graft is needed, a reliable and easily accessible source of bone grafting would be beneficial. Although the traditional iliac bone grafting can be used, this option requires a separate sterile field to be prepared and may lead to donor site pain and morbidity. We propose an option that places the donor source close to the hand and wrist. The radial aspect of the distal radius metaphysis/diaphysis is superficial, which makes access and closure simpler than other alternatives. Furthermore, the technique only partly violates 1 of the 3 surfaces of the radius so that there is minimal weakening of the integrity of the bone and the likelihood of fracture is low. In this article, we describe the indications, contraindications, surgical technique, and postoperative management of the radial aspect of the distal radius metaphysis/diaphysis as a source of bone grafting.

Background Total elbow arthroplasty is successful in older, lower demand patients but not in the younger, more active individual with severe elbow arthritis. Interposition arthroplasty is an alternative for younger patients who hope to minimize the degree to which arm use is restricted. Interposition arthroplasty traditionally involves release of all ligaments and capsule. As a result, the postoperative care included the use of a hinged external fixator of the elbow to apply distraction and to permit motion during the early phases of healing. We describe a novel surgical technique without a hinged external fixator that allows secure fixation of the interposition graft through arthroscopic assistance and maintains the integrity of the medial collateral ligament with only a takedown and repair of the lateral collateral ligament complex. Methods A retrospective chart review was performed to analyze 4 patients with an average age of 57 years who underwent surgery between 2007 and 2011. The patients were also contacted to assess elbow-specific American Shoulder and Elbow Surgeons and Disabilities of the Arm, Shoulder, and Hand scores. Results The average follow-up was 3.6 years (range, 2.5-6 years), and 1 patient was converted to a total elbow arthroplasty after 2.5 years because of persistent pain. The remaining 3 patients have done well with regard to pain control, stability, and functional use of the operative extremity. There were no postoperative complications. Discussion On the basis of our small series of patients, an arthroscopically assisted elbow interposition arthroplasty without hinged external fixation can provide satisfactory medium-term outcomes as a salvage procedure for a difficult condition with limited options.

BackgroundAcute carpal tunnel syndrome (CTS) is a complication that can develop after distal radius fractures. Our hypothesis tested whether patient-reported outcomes after acute carpal tunnel release (CTR) performed in combination with distal radius fracture open reduction internal fixation (ORIF) are worse than patient-reported outcomes with only elective CTR as measured by the symptom severity and functional status scales of the Boston carpal tunnel questionnaire (BCTQ).MethodsA retrospective assessment identified 26 patients treated with acute CTR at the same time as distal radius ORIF, no history of pre-existing CTS or CTR, no other injuries, and >12 months follow-up. Sixteen of these patients (Group A) could be contacted and answered the BCTQ. Group A was age- and sex-matched to control patients (Group B) treated with only elective CTR. A case–control study was performed comparing outcomes of both groups.ResultsThe average age of patients was 51±15 years, with an average follow-up of Group A at 49±21 months versus Group B at 55±20 months. The mean symptom severity scale score for Group A was 1.4±0.4 and for Group B was 1.4±0.4. The mean functional status scale score for Group A was 1.4±0.5 and for Group B was 1.3±0.4. The mean total BCTQ score for Group Awas 26.5±7.5 and for Group B was 24.9±7.5. There were no statistical or clinically significant differences between Group A and Group B for symptom severity, functional status, and total BCTQ scores.ConclusionsPatients with acute CTR performed at the same time with distal radius ORIF do as well in the long-term as those patients with only elective CTR as measured by the BCTQ. Patients should expect similar recovery of subjective nerve function from acute median nerve dysfunction when CTR is performed with distal radius ORIF as patients with only elective CTR.

STUDY DESIGN Case report. OBJECTIVE To present the first reported case of using extracorporeal membrane oxygenation (ECMO) support in an emergent decompression and evacuation of a thoracic epidural abscess. SUMMARY OF BACKGROUND DATA Thoracic epidural abscesses with neurological deficits require surgical evaluation and intervention in most cases. We report a case of a 35-year-old patient with an acute onset of paraplegia diagnosed with a thoracic epidural abscess. The patient was emergently taken to the operating room and was unable to tolerate prone positioning secondary to cardiopulmonary collapse. ECMO was initiated for cardiopulmonary support to complete the case. METHODS Retrospective chart review of patient case. RESULTS The patient was stabilized with ECMO support and tolerated a T4-T8 laminectomy and decompression. The source of the patients abscess was hematogenous and at 6 months of clinical follow-up, the patient has no motor or sensory function of his bilateral lower extremities. CONCLUSION The use of ECMO support in adult spinal surgery has not been previously reported in the literature. Therefore we describe the first reported use of ECMO to maintain cardiopulmonary support in a patient unable to tolerate prone positioning during spine surgery. ECMO support can be a viable option in adult patients who need emergent spinal surgery but are unable to tolerate prone positioning secondary to cardiopulmonary complications.

Therapeutic hypothermia is an effective intervention for the postresuscitative care of patients who have sustained a cardiac arrest. There has been only 1 documented case of successful resuscitation of a pregnant patient and fetus with therapeutic hypothermia, with an abbreviated developmental follow-up of the child. A 33-year-old woman in her 20th week of pregnancy presented to our emergency department after experiencing a cardiac arrest. After successful resuscitation and a discussion with a multidisciplinary team about expected outcomes, the mother and fetus were successfully treated with therapeutic hypothermia, and a healthy baby was delivered 19 weeks later. The mother's cardiac and neurologic function was normal 36 months after the arrest, and the child has reached all growth and neurodevelopmental milestones. We present a case demonstrating excellent immediate and long-term maternal-fetal neurologic, cardiac, and developmental outcomes after the use of therapeutic hypothermia after cardiac arrest in a pregnant patient.

Both osteoporotic fractures and pleural effusions are frequently observed in medicine. However, rarely does one associate a hemorrhagic pleural effusion with a thoracic spinal fracture when the patient has not sustained massive trauma. In this paper, we discuss two cases where seemingly insignificant low-energy trauma precipitated massive haemothoraces in elderly patients with underlying osteoporosis, ultimately resulting in their immediate causes of death. This paper serves to remind health care professionals of the importance of using caution when moving elderly patients as well as to consider thoracic spinal fracture as a potential explanation for a hemorrhagic pleural effusion of undetermined etiology.

Cannabinoid hyperemesis is a syndrome characterized by severe nausea and hyperemesis associated with chronic marijuana abuse and marked by compulsive bathing habits, which temporarily alleviate symptoms. We describe the syndrome in 4 adult patients for whom extensive gastrointestinal evaluations failed to identify another clear cause. Cessation of marijuana use resulted in the alleviation of their symptoms. Because recreational and medical use of marijuana is increasing in the United States, this condition should be considered in many patients who present with cyclical vomiting.

BackgroundThe purpose of the present study was to demonstrate that post-operative morbidity (PM) associated with resections of hilar cholangiocarcinoma (HCCA) is associated with short- and long-term patient survival.MethodsBetween 1998 and 2008, 51 patients with a median age of 64 years underwent resection for HCCA at a single institution. Associations between survival and clinicopathologic factors, including peri- and post-operative variables, were studied using univariate and multivariate models.ResultsSeventy-six per cent of patients underwent major hepatectomy with resection of the extrahepatic bile ducts. The 30- and 90-day operative mortality was 10% and 12%. The overall incidence of PM was 69%, with 68% of all PM as major (Clavien grades III–V). No difference in operative blood loss or peri-operative transfusion rates was observed for patients with major vs. minor or no PM. Patients with major PM received adjuvant chemotherapy less frequently than patients with minor or no complications 29% vs. 52%, P= 0.15. The 1-, 3- and 5-year overall (OS) and disease-specific survival (DSS) rates for all patients were 65%, 36%, 29% and 77%, 46%, 35%, respectively. Using univariate and multivariate analysis, margin status (27% R1), nodal metastasis (35% N1) and major PM were associated with OS and DSS, P < 0.01. Major PM was an independent factor associated with decreased OS and DSS [hazard ratio (HR) = 3.6 and 2.8, respectively, P < 0.05]. The median DSS for patients with major PM was 14 months compared with 40 months for patients who experienced minor or no PM, P < 0.01.ConclusionExtensive operations for HCCA can produce substantial post-operative morbidity. In addition to causing early mortality, major post-operative complications are associated with decreased long-term cancer-specific survival after resection of HCCA.