Postural stability is a known risk factor for musculoskeletal injury although the impact of sex on postural stability is not well understood. This systematic review evaluated 24 studies that reported on postural stability. Findings regarding the impact of sex on postural stability were mixed, with some studies reporting male superiority, others reporting female superiority, and still others demonstrating no significant difference.

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Aim: The purpose of this systematic review is to present the evidence examining concussion and subsequent lower extremity injury (LEI) risk, and to provide a clinically relevant interpretation of the existing literature for sports medicine clinicians. We hypothesize that there is sufficient high-quality evidence providing an association between concussion and subsequent LEI risk. Background: In active individuals who have suffered a concussion, even after acute symptoms resolve, the long-term consequences and cognitive deficits that persist remain a pervasive topic of study in sports medicine research. As more studies indicate a risk of secondary injury following a concussion, specifically a risk of LEI, a review of the literature is necessary to bring the latest research into discussion. Review Results: Of the 459 studies reviewed for eligibility, 10 articles were accepted for systematic review and graded for quality. Overall, eight of the ten studies meeting the inclusion criteria demonstrated an association between concussion and LEI. The risk of LEI following a concussion ranged in studies with odds ratios ranging from 1.72 to 2.48, hazards ratios ranging from 1.47 to 4.07, and the incident rate ratio ranging from 1.97 to 2.02 in athletes who had acquired a concussion versus those who did not. Conclusion: Taken together, there is enough evidence of sufficient quality to determine that there is an association between concussion and the subsequent risk of acquiring a lower-extremity injury. This systematic review suggests care should be taken in future studies to assess the contributing factors that may predispose an individual to lower extremity injuries following a concussion. Clinical Significance: Concussions and the subsequent risk of LEI remain a growing concern for sports medicine providers. Our study suggests that there is a need to further investigate the mechanistic processes that may be predisposing an individual to subsequent lower extremity injuries following a concussion, and if this risk can be reduced with appropriate postconcussion care.

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Background: For patients undergoing lumbar fusion, a variety of interbody arthrodesis techniques and devices exist, but few studies have evaluated the effect of cage geometry on radiographic outcomes. Thus, the purpose of this study is to compare the performance of expandable lordotic posterior lumbar interbody fusion (ePLIF) cages to lordotic anterior lumbar interbody fusion (ALIF) cages and to compare the early radiographic outcomes of different cage designs through review of the available literature. Materials and Methods: This is a retrospective case–control study, including 31 ePLIF and 36 ALIF levels, for the treatment of lumbar radiculopathy. Three-dimensional computed tomography scans were used to measure disc height, interbody angle, and foraminal height, both pre- and postoperatively. Implant geometry and positioning were then correlated with radiographic outcomes. The available ALIF and PLIF literature was then analyzed to determine the radiographic outcomes for each surgical technique based on cage geometry. Results: ePLIF cages increased foraminal height (P < 0.001), which was comparable to lordotic ALIF cages (P < 0.001). ePLIF and ALIF provided similar restoration of disc height; however, ALIF cages provided a significant increase in interbody angle (P < 0.001). Across the available literature, ALIF correlated with greater changes in interbody angle relative to PLIF regardless of cage geometry (lordotic vs. nonlordotic), while PLIF trended toward greater restoration of foraminal height. Conclusion: ePLIF cages are able to restore foraminal and disc height comparable to ALIF cages. However, lordotic ALIF cages should be utilized if sagittal restoration is a priority. Future studies are necessary to further explore the value of different implant design options. Level of Evidence: Level III. Clinical Relevance: Patients with abnormal sagittal balance should undergo a lordotic ALIF procedure. Patients who are sagittally balanced, however, can achieve fusion and decompression with either ALIF or ePLIF.

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It is estimated that 10,000–20,000 new cases of osteonecrosis of the femoral head (ONFH) are diagnosed annually in the United States. Left untreated, this disease results in progressive collapse of the femoral head and destruction of the hip joint, resulting in the need for total hip arthroplasty (THA). However, in younger patients with ONFH, initial treatment with THA is not a practical option because these patients typically outlive the life of their implant, and thus may require multiple revision operations. Therefore, a variety of nonarthroplasty treatments for ONFH have been developed to slow the progression of disease and prolong the time that a person can go before requiring THA. These nonarthroplasty treatments are grouped into three general categories: Pharmacologic, nonpharmacologic/nonoperative, and operative. However, there is no consensus as to the optimal nonarthroplasty management of ONFH. This article provides a review of the literature regarding nonarthroplasty management of ONFH.

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Background: Bone marrow stimulation (BMS) has proven to be the standard treatment for small osteochondral lesions of the talus (OLTs). It has been theorized that bone marrow aspirate concentration (BMAC) has the potential to enhance cartilage repair stimulated by BMS. The aim of this study was to prospectively compare the effect of BMS with BMAC versus BMS alone on patient-reported outcomes after the treatment of OLTs. Methods: This is a single-institution, randomized prospective study. Patients over the age of 18 with OLTs who were proceeding with BMS were included in the study. Patients with multiple OLTs and follow-up period of <1 year were excluded from the study. Patients were randomized to receive BMS alone or BMS with BMAC. Patient-reported outcome scores, including the visual analog scale pain, Short Musculoskeletal Function Assessment, Short Form-36, and Foot and Ankle Disability Index, were compared between the two cohorts. Results: Nine patients were evaluated in the study. Six patients were in the BMS with BMAC group, and three patients were in the BMS alone group. Average final follow-up was >2 years for both groups. Both groups showed improvements in patient-reported outcome scores from preoperatively to final follow-up. There were no significant differences in final outcome scores or changes in outcome scores from preoperatively to final follow-up between the two groups. Conclusion: Our study found that both BMS alone and BMS with BMAC treatments are effective in improving pain and functional outcomes in patients with OLTs. There were no significant differences between the two modalities of treatment. This is a pilot study and a larger randomized trial is needed to make definitive conclusions.

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Aim: The identification of sport- and gender-specific, prospective, and modifiable risk factors contributing to noncontact anterior cruciate ligament (ACL) injury is limited. This lack of information leaves clinicians at a loss in practicing evidence-based injury prevention. The purpose of this study is to describe the methods by which a female soccer player suffering from a noncontact ACL injury was compared to the rest of her team to identify modifiable strength and flexibility deficits possibly contributing to the injury. Materials and Methods: Twenty-two individuals were recruited from a Division I, female soccer team (age = 19.3 ± 1.2 years). All testing was completed 2 months before competitive play. Strength was assessed for ankle inversion/eversion and dorsiflexion (AIS/AES, ADS), knee flexion/extension (KFS/KES), hip abduction/adduction (HABS/HADS), and hip internal/external rotation (HIS/HES). Agonist/antagonist ratios were also calculated. Flexibility was assessed for active ankle dorsiflexion (DF), weight-bearing ankle DF mobility, hamstring flexibility with passive hip flexion (PHF), and active knee extension. The ACL case's strength and flexibility variables were compared to team averages for the dominant leg (affected side) using one-sample t-tests and Wilcoxon signed-rank tests. Results: The ACL case's injury was the result of a planting and cutting motion. The ACL case displayed significantly lower ADS (−7.84% of body weight), AIS (−7.41%), AES (−6.58%), KFS (−5.39%), HABS (−3.14%), HES (−2.84%), and a significantly lower HABS-to-HADS ratio (−0.12) compared to team averages. The ACL case also displayed significantly lower PHF (−16.89°) and higher DF (+1.85°). Conclusions: Several plausible strength and flexibility deficits were identified that could have played a role in the ACL case's injury. Clinical Significance: The methods and instrumentation used to identify deficits in the ACL case were inexpensive and clinic-friendly.

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Context: Despite Achilles rupture posing a potentially career-threatening injury to professional athletes, limited sports medicine research has been conducted to investigate how to improve the ability of players to return to sport after sustaining the injury. Objective: The main objective of the study is to aggregate the current literature on professional athlete return to play after Achilles tendon rupture in an attempt to identify the current strengths and gaps in knowledge. Materials and Methods: A PubMed literature reviews was performed using the terms “Achilles”and/or “elite,” “professional,” “return,” “sport,” “national basketball association”, “national football league,” “major league baseball,” “major league soccer,” “national hockey league,” “injury” to identify articles of interest. Only studies involving professional athletes in the major United States football, soccer, basketball, baseball, and hockey leagues as well as European Soccer Leagues who sustained a torn or ruptured Achilles tendon were included. Data Sources: PubMed literature search utilizing the key words, “Achilles” and/or “elite,” “professional,” “return,” “sport,” “national basketball association,” “national football league,” “major league baseball,” “Major League Soccer (MLS),” “national hockey league,” “injury.” Study Selection: Studies found using the keywords above were considered for inclusion. Individual case studies, injuries other than tear or rupture, and studies with unclear methodology were excluded. Nine studies met inclusion criteria. Study Design: This study is a review of published literature. Level of Evidence-IV: IV. Data Extraction: Data were taken directly from the included studies and aggregated. The quality and validity of the data is limited by the collection methodology of each individual study included. Results: Overall return-to-play percentage of 67.1% across all included studies with a total of 322 included participants. Soccer athletes were found to have the highest return percentage at 70.8% and baseball with the lowest at 55.6%. The average age of the players returning to play across all studies was 28.9 years, with football players comprising the youngest group at 27.5 years and baseball the oldest at 31.4 years. Conclusions: A lack of reliable data has made the study of professional athlete Achilles rupture and return to play a difficult endeavor. Despite the limitations, studies have shown that over 30% of players do not return to their respective sports, with no statistically significant correlation to age or position played. More research is needed to determine how specific injury patterns, rehabilitation protocols, and functional testing plays into the athletes' ability to return to play.

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Background: As the demands of patients and the health-care reimbursement system continue to change rapidly, hospitals and surgeons are adopting new methods of delivering high-quality care at a lower cost. To this end, the use of a daily, dedicated orthopedic trauma room has been increasing in popularity. Our institution, a major Level I academic trauma center, however, has been a late adopter, only starting a dedicated orthopedic trauma room on November 1, 2013. The purpose of this retrospective data review was to assess the clinical (intensive care unit [ICU] length of stay [LOS] and hospital LOS) and financial outcomes of a dedicated trauma room. Design: This is a retrospective analysis of pre- and post-intervention measures of patient outcomes and financial performance using archival data from a trauma registry linked to cost, charge, and payment records. Methods: Our trauma registry was used to identify admission of patients requiring surgery for orthopedic injuries involving the lower extremity from the hip to the ankle for 11 months preceding the adoption of a daily trauma room (pre) and 11 months following its implementation (post). We compared pre- and post-hospital LOS and ICU LOS, while controlling for the effect of race, age, gender, Injury Severity Score (ISS), and type of insurance. There were 243 eligible patients identified for the “post” group and 258 in the “pre” group. Results: We found no statistically significant difference between the groups in mean age, ISS, or in distribution of patient sex or race. The estimated mean LOS (controlling for patient characteristics) was 8.35 days in the “pre” group and 7.79 days in the “post” group. This represented a statistically significant reduction (P < 0.0223) in overall LOS by more than a half-day per admission. Moreover, the mean estimated number of days in the ICU (for patients with any ICU use) decreased from 8.18 in the “pre” period to 5.94, a 2.24-day reduction (P < 0.0001) in the months following the adoption of the trauma room. This improvement in LOS and ICU use was not reflected in the observed difference between the pre- and post-time period in mean hospital charges (P = 0.5524), hospital cost (P = 0.5590), hospital payments (P = 0.8350), provider charges (P = 0.1985), or provider payments (P = 0.6388). However, the reductions in mean LOS and ICU used were estimated to free up 680.4 bed days, which would allow an additional 109.1 admissions per year, resulting in $1,299,498 estimated additional revenue to the hospital. Conclusions: These findings represent a significant improvement over the previous system and have implications for overall patient outcomes and also financial outcomes. Other studies have suggested that decreased total hospital and ICU stay have both been associated with overall better patient outcomes. Furthermore, the decreased LOS, especially in the ICU, frees scarce capacity in an institution experiencing a chronic shortage of available ICU beds. Our study illustrates the importance of capturing both resource use (such as bed days) and cost when evaluating the effect of process improvements in large hospitals. Costs and revenue measures alone may not capture the true economic benefits of process improvements in institutions where resources that are freed up by one service may be used by other service lines.

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Background: Femoral head osteonecrosis (FHO) is a debilitating condition. Free vascularized fibular grafting (FVFG) has good survivorship, however patients are at risk for reoperation. AIM and Objectives: This study compares patient characteristics, hip pathology, and surgical intervention in patients with FHO. We hypothesized that patients with FHO who underwent FVFG would demonstrate less severe degeneration of hip chondral surfaces compared to patients who did not. Materials and Methods: A database of 1,481 hip arthroscopies performed by a single surgeon was queried. Inclusion criteria included history of FHO. Patients with a previous hip surgery were excluded. Non-FVFG patients served as a control. Demographics, presentation, physical examination, imaging, intraoperative pathology, and procedures performed were compared. Cartilage degeneration was quantified with chondromalacia severity index (CMI). The Hip Outcome Score- Activity of Daily Living (HOS-ADL), -Sports Subscale (HOS-SS), and modified Hip Harris Score (mHHS) were calculated. Results: Sixteen patients had a history of FHO. Six (37.5%) previously underwent FVFG. Both groups had similar demographics, clinical presentation, preoperative range of motion, and radiographic findings (P>0.05). Arthroscopy identified similar chondral lesion Outerbridge grade and size for the acetabulum and femoral head (P>0.05). Compared with controls, FVFG patients had greater CMI of the acetabulum (844.7±501.3 vs. 345.8±433.3; P=0.018) and similar CMI of the femoral head (408. ±187.7 vs. 1461.0±1493.6; P=0.289). Microfracture of the acetabulum and ligamentum teres debridement were performed preferentially in patients with a history of FVFG compared with controls. Of the six previous FVFG patients, two converted to total hip arthroplasty, two completed patient reported outcomes, and two were lost to follow-up. Conclusion: Patients with previous FVFG for FHO are at an increased risk of chondral damage to the acetabulum and demonstrated more advanced chondral degeneration compared with controls. Level of Evidence: III; Retrospective cohort study

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Background: Open fractures often require additional procedures for timely definitive soft-tissue coverage. Delayed coverage is associated with poor outcomes. Thus, we sought to (1) define the incidence and severity of open fractures presenting to our institution, (2) identify soft-tissue coverage methods, and (3) determine the incidence of postoperative complications. Materials and Methods: Patients were identified in our institutional registry through the International Classification of Diseases (ICD)-9 and ICD-10 codes specific for open long-bone and extremity fractures. Descriptive statistics were performed on demographics, injury mechanism, and fracture type (Gustilo–Anderson classification). Fractures requiring coverage (Type IIIB/C), surgical methods, and duration until coverage (mean days ± standard deviation) were recorded. Postoperative complications were also identified. Results: From 2012 to 2017, 243 patients were treated for open long-bone fractures. Blunt trauma accounted for 76.9% (n = 187) of the injuries. Grade III tibia fractures represented the highest incidence (n = 74, 30.4%). Of the IIIB/C injuries, the most common coverage methods were split-thickness skin grafting (n = 24, 32.4%) occurring 16.2 ± 11.5 (range: 3–40) days following injury and rotational flap coverage (n = 22, 29.7%). IIIB/C injuries were complicated by nonunion (n = 11, 14.9%), infection (n = 12, 16.2%), amputation (n = 21, 28.4%), and wound breakdown (n = 7, 9.5%). Conclusions: High-grade open fractures treated without timely definitive coverage can result in complications. Multiple specialties may be required to manage these patients, and it may be beneficial for orthopedic surgeons to obtain skills in skin grafting and rotational muscle flap coverage to decrease time to definitive wound closure.

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Background: Radiographic measurements defining anterior acetabular coverage show variability in the literature. A reliable radiographic measure to evaluate anterior acetabular coverage following the Bernese Periacetabular Osteotomy during the nonweight bearing healing phase would be helpful to evaluate the quality of reduction. Questions/Purposes: (1) To compare a new radiographic means to measure the Anterior Center Edge Angle (ACEA) on the iliac oblique (IO) Judet view with the ACEA on False Profile (FP) view with respect to intra-and inter-observer reliability and (2) To describe the utility of the Judet views as an alternative approach monitor postosteotomy healing. Methods: We defined and validated ACEA measurements for the FP and IO Judet View for 11 post-surgical periacetabular osteotomy (PAO) patients. Intraclass correlation coefficients with 95% confidence intervals were calculated for intra- and inter-observer reliability, Bland Altman plot was created, and paired t-tests were performed between the two sample measurements. Results: The intra-observer reliability for ACEA measurements was 0.987 and 0.983 for the FP and IO Judet views, respectively. The inter-observer reliability correlation coefficients were 0.978 and 0.934 for the FP and IO Judet views, respectively. When comparing measurements between the two surgeons, the mean standard deviation (SDV) for the FP group was within ± 2.5° for all observations. For the IO Judet group, the SDV was within ± 3.5°. Conclusion: This study demonstrates a new method of measuring the ACEA utilizing the IO Judet view for nonweight bearing postoperative PAO patients. The results of this study suggest that FP view is no longer necessary postoperatively for this population. Level of Evidence: III, diagnostic study.

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Introduction: Sharp injuries continue to pose a significant safety issue in the clinical setting with 385,000 injuries occurring annually among the United States health-care workers. In the operating room (OR), a majority of the needlestick injuries are due to frequent passing of contaminated needles. Operative Armour™ is a novel arm guard enabling surgeons to independently self-secure and self-dispose needles. We hypothesized that the use of Operative Armour™ as compared to the standard technique of sequentially passed needles would reduce the number of sutures passes. Methods: A 12 cm incision was made through an anterior and posterior approach to the ankle in three cadavers. In Group A (standard technique), 2-0 vicryl suture was used. In Group B (Operative Armour™), 2-0 vicryl suture packs, containing five sutures, were used. Three participants completed three trials for each group. Outcomes included wound closure time and the number of dropped and passed needles. Results: Wound closure time for Group A was 16:35 ± 0.2 min and 16:33 ± 0.1 min for Group B (P > 0.05). No needles were dropped in either group. Suture passes averaged 52 ± 8.9 in Group A compared to 5.3 ± 0.7 in Group B (P < 0.05). There were 24 needle handoffs in Group A, while in Group B, only three suture packs were passed. Conclusions: Use of the Operative Armour™compared to the standard technique demonstrated a statistically significant decreased number of suture passes but no change in total closure time. Given the large reduction in suture passes, the use of the Operative Armour™ could lead to a significant reduction in the number of needlesticks in the OR during wound closure. Clinical Significance: Compared to current standard techniques, the use of Operative Armour™ could increase safety in the OR by decreasing the number of suture passes. By reducing the demands on the surgical technician, this device could also decrease OR turnaround time and enhance overall efficiency.

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Purpose of Study: The purpose of this study was to evaluate the incidence of dislocations, infections, revisions, and other medical and surgical complications in patients with Parkinson's disease (PD), who undergo total hip arthroplasty (THA) compared to a control group without PD. Materials and Methods: Medicare patient data from 2005 to 2011 were retrospectively reviewed using the PearlDiver Technologies software (West Conshohocken, Pennsylvania, USA). Administrative coding and Boolean language were used to identify 6587 patients with PD diagnosed prior to THA and compared to a cohort containing all Medicare patients with a THA between 2005 and 2011 without any history of PD (767,991 patients). Statistical analysis was used to compare the number of patients with common comorbidities and medical and surgical complications. Systematical review of the literature on PD and THA was also performed. Results: Patients with PD had a higher rate of medical complications, including pneumonia, urinary tract infection, and sepsis at 30 days postoperatively. At 90 days and final follow-up, they had a higher rate of postoperative complications including dislocation, prosthetic joint infection, and risk of revision. Conclusion: PD is a progressive neurodegenerative disorder that affects the musculoskeletal system, and patients with PD often require surgical intervention for hip pain from a fracture, post-traumatic arthritis, or osteoarthritis. This study demonstrates the increased risk for several postoperative complications in patients with PD undergoing THA. It highlights the importance of an individualized risk-benefit analysis and multidisciplinary management before proceeding with arthroplasty for patients with PD.

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Introduction: The potential benefit of human mesenchymal stem cells has received increasing attention in a wide variety of biomedical fields. The management of delayed union and non-union poses as a challenge to many orthopaedic surgeons. Bone marrow contains osteoprogenitor cells capable of forming bone. Aims and Objectives: To observe the functional outcome, evaluate complications and assess the factors influencing results of bone marrow injection in long bone fractures which are in delayed union and non-union. Methodology: We conducted prospective follow up study in orthopaedic department at tertiary care hospital over a period of two years. 30 patients with delayed or non-union of long bone fractures were included in the study About 20-50 ml of bone marrow was aspirated from single or both posterior iliac crests and injected into the recipient site under radiological control. Clinically patients were assessed and cortical bridging on AP and lateral X-rays was noted. Results: In our study sex, age, state of union, initial treatment given before BMA, site of fracture, type of fracture, amount of bone marrow aspirate etc did not have any significant association with the final outcome after bone marrow injection. Also we did not get any significant complications. Conclusion: Bone marrow injection from iliac crest (posterior) is safe, effective treatment method for delayed and non-union of long bone fractures without any significant complications.

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Aim: The aim of the study is to examine the relationship between musculoskeletal injury and time within an athletic event and to propose that these injuries may be fatigue-related. Background: Musculoskeletal injuries impede athletic performance. The identification of risk factors is essential to reducing injury. Materials and Methods: We searched PubMed, Embase, SPORTDiscus, and CINAHL and performed manual reference checks. Included articles reported the timing of acute musculoskeletal injury in a single athletic event; 23 articles were selected for multireviewer assessment of quality and levels of evidence. Results: Eighty-seven percent of studies found a higher incidence of injury in later stages of play (second half or later in the second half) and 60% found this to be significant. All but two articles suggested that injury trends were related to fatigue development. Conclusion: Based on our review, a connection between the development of musculoskeletal injury and duration of play supports the concept that fatigue is a risk factor for injury. Clinical Significance: A greater understanding of the correlation between fatigue and musculoskeletal injury is essential to designing injury prevention programs that will decrease the onset of musculoskeletal injury in athletes. Ultimately, preventative strategies that reduce injury risk will lead to superior health and performance in athletes during athletic careers and later in life.

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Aim: Complication rates for total elbow arthroplasty (TEA) have not been well studied. The aim of this study was to analyze its utilization rate, the use of perioperative packed red blood cell transfusions, overall rates of surgical complications, and any association of perioperative transfusions with short-term postoperative medical and long-term surgical complications. Materials and Methods: We queried a large Medicare Standard Analytic Files database from 2005 to 2014 to identify index surgery, perioperative blood transfusions, and postoperative complications. Incidence, odds ratios (ORs), 95% confidence intervals, and P values were calculated for 30-day, 90-day, and 2-year postoperative complications. Results: We identified a total of 7480 primary TEA procedures with a minimum of 2-year follow-up. 577 of these patients received perioperative blood transfusion, whereas 2058 age- and gender-matched controls did not. The transfusion cohort had statistically significantly higher rates of 30-day medical complications such as anemia (OR, 7.54), acute kidney injury (OR, 5.55), sepsis (OR, 4.97), myocardial infarction (OR, 3.36), respiratory failure (OR, 3.17), heart failure (OR, 2.56), pneumonia (OR, 2.46), and urinary tract infection (OR, 2.19). They also had higher rates of infection-related surgical complications within 90 days such as periprosthetic infection (OR, 3.36) and cellulitis/seroma (OR, 2.12) and more blood transfusions (OR, 2.59), which remained significantly elevated at 2 years after surgery. Conclusions: Patients requiring perioperative transfusions after surgery have higher rates of complications. Clinical Significance: Surgeons should preoperatively mitigate transfusion risk and preemptively counsel patients during admission and discharge. Further evidence is needed to determine whether perioperative transfusion is a marker of overall poor health or whether transfusion has an immunomodulatory effect that increases complication risk.

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Aim: Following upper brachial plexus injury, one of the primary goals of reconstruction is reinnervation of elbow flexion (EF). Various reconstruction methods have been described including ulnar nerve fascicle and/or median nerve fascicle transfer to the musculocutaneous biceps brachii motor branch and/or the brachialis motor branch. However, there is no study that analyzes the efficacy of one set of transfers to another. We aim to determine if there are improved outcomes with the ulnar nerve transfer to biceps branch and median nerve transfer to brachialis branch (UBB/MBr, Group 1) compared to ulnar nerve transfer to brachialis and median nerve transfer to biceps branch (UBr/MBB, Group 2). Methods: We performed a retrospective analysis of 12 patients who sustained C5–C6 ± C7 brachial plexus injuries and underwent nerve transfers for EF reconstruction. All clinical and electromyographic (EMG) data were captured for an average follow-up time of 35 months. Data were analyzed using a generalized estimating equation model (P < 0.05). Results: Seven and five patients were included in Groups 1 and 2, respectively. At 6 months, Group 2 achieved a greater Medical Research Council score of global elbow function 4 versus 1.5 (P < 0.05), biceps strength 3.67 versus 2.13 (P < 0.05), and brachialis strength 3.5 versus 2.5 (P < 0.05). The brachialis EMG recruitment pattern also demonstrated improved results in Group 2 as compared to Group 1 at 12, 24, and 36 months (P < 0.05). Conclusion: These findings indicate that UBr/MBB nerve transfer confers significantly faster recovery of global EF, biceps, and brachialis strength at 6 months. Although differences in strength equalized by 24 months, EMG data demonstrated increased muscle nerve potential in Group 2 at 12 months and beyond. Clinical Significance: The median nerve fascicle transfer to the biceps branch and ulnar nerve fascicle transfer to brachialis branch appear to have advantages in EF function.

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Background Context: Local temperature change and thermal injury from electrosurgical instruments may be a source of complications in anterior lumbar interbody fusion (ALIF). Purpose: To determine if use of a low-thermal injury electrosurgical device affected changes in tissue temperature, depth of thermal injury, and incidence of electrical coaptations (arcs) in a cadaveric model of ALIF, compared to traditional electrosurgery. Study Design/Setting: Basic research study. Methods: Fiber optic temperature sensors were positioned percutaneously at the iliac artery, iliolumbar vein, sympathetic plexus, psoas muscle, illac vein, and aorta of four fresh, room temperature, cadaveric lumbar spine specimens. Traditional electrosurgery (ES) or a low thermal injury device (LTD) was used to perform a standard ALIF dissection. Change in tissue temperature at each anatomic point and the number of electrosurgical arcs to nearby retractors were recorded. Tissue samples at the temperature-monitoring points were harvested for histological analysis and measurement of depth of acute thermal injury. Results: Compared to electrosurgery, use of the LTD resulted in a meaningful and statistically significant reduction in temperature change at all anatomic measurement points except the aorta, and an overall 52% decrease in mean depth of thermal injury (0.14 ± 0.86 mm vs. 0.29 ± 0.17 mm, respectively; P = 0.0003). There were 95% fewer electrical arcs between LTD and retractors compared to ES (1 vs. 18 events; P = 0.0002). Conclusions: In a cadaveric model of ALIF, use of a low-thermal-injury electrosurgical device reduced local temperature change, depth of thermal injury, and the number of electrosurgical arcs compared to traditional electrosurgery.

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Malpositioned pedicle screws can lead to motor and sensory deficits in the effected level. Traditional intraoperative techniques to avoid a malpositioned pedicle screw include manual palpation of the screw tract, intraoperative imaging (XR, Fluro, and computed tomography), and neuromonitoring. This case report discusses an arthroscopic application of a novel endoscopic camera. This new direct visualization technique answers the intraoperative question of a pedicle screw breach. A 57-year-old male presented to our outpatient clinic for continued left S1 radiculopathy after multiple previous spinal surgeries. His presenting construct was a L4-S1 pedicle screw instrumented posterior spinal fusion with an anterior lumbar interbody fusion interbody at L5-S1 and a TLIF at L4-5 with complete laminectomies of L4-S1. He had failed >12 months of nonoperative treatment for his continued left S1 radiculopathy. He underwent a left S1 hardware removal with arthroscopic intra peculiar evaluation and decompression. Informed consent was obtained from the patient before writing this case report. At 3 months postoperation, the patient demonstrated full resolution of his left S1 radiculopathy, and his strength was rehabilitated back to 5/5. His paresthesia remained in the left S1 dermatome. This case report adds an off-the-shelf intraoperative technique for directly visualizing a pedicle screw breach, evaluating the continuity of the affected nerve, and gives the option to decompress bony fragments which may be a source of continued pain if not removed. The purposed endoscopic breach classification system allows for future studies to give prognostic information about nerve recovery potential based on the amount of breach encountered endoscopically.

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Fillet flaps are useful for reconstructing large soft-tissue defects, especially in cases where the surgeon has available spare body parts that would otherwise be discarded. The use of free forearm fillet flaps to reconstruct large chest wall defects arising from traumatic extremity amputation or malignant tumor excision has been previously described. This report represents the first case of a free forearm fillet flap used to reconstruct an extensive chest wall defect after forequarter amputation and excision of a malignant peripheral nerve sheath tumor involving the brachial plexus.

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