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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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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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: 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: 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: 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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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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