Adult Traumatic Brachial Plexus Injuries Adult traumatic brachial plexus injuries are devastating life-altering injuries occurring with increasing frequency. Evaluation includes a detailed physical examination and radiologic and electrodiagnostic studies. Critical concepts in surgical management include knowledge of injury patterns, timing of surgery, prioritization in restoration of function, and management of patient expectations. Options for treatment include neurolysis, nerve grafting, or nerve transfers and should be generally performed within 6 months of injury. The use of free functioning muscle transfers can improve function both in the acute and late setting. Modern patient-specific management can often permit consistent restoration of elbow flexion and shoulder stability with the potential of prehension of the hand. Understanding the basic concepts of management of this injury is essential for all orthopaedic surgeons who treat trauma patients.

Tardy Ulnar Nerve Palsy Tardy ulnar nerve palsy is a chronic clinical condition characterized by a delayed onset ulnar neuropathy after an injury to the elbow. Typically, tardy ulnar nerve palsy occurs as a consequence of nonunion of pediatric lateral condyle fractures at the elbow, which eventually lead to a cubitus valgus deformity. While the child grows, the deformity worsens and the ulnar nerve is gradually stretched until classic symptoms of ulnar nerve neuropathy appear. Other childhood elbow trauma has also been associated with tardy ulnar nerve palsy, including supracondylar fractures resulting in cubitus varus, fractures of the medial condyle and of the olecranon, as well as radial head or Monteggia fractures/dislocation, with or without deformity. The clinical assessment includes obtaining a complete history, physical examination, nerve conduction tests, and elbow imaging studies. Treatment consists of ulnar nerve decompression, with or without corrective osteotomy, with overall successful results usually achieved.

The Role of Intraoperative Navigation in Orthopaedic Surgery An orthopaedic surgeon's knowledge of anatomical landmarks is crucial, but other modalities supplement this by providing guidance and feedback to a surgeon. Advances in imaging have enabled three-dimensional visualization of the surgical field and patient anatomy, whereas advances in computer technology have allowed for real-time tracking of instruments and implants. Together, these innovations have given rise to intraoperative navigation systems. The authors review these advances in intraoperative navigation across orthopaedic subspecialties, focusing on the most recent evidence on patient outcomes and complications, the associated learning curve, and the effects on operative time, radiation exposure, and cost. In spine surgery, navigated pedicle screw placement may increase accuracy and safety, especially valuable when treating complex deformities. Improved accuracy of pelvic and peri-articular tumor resection and percutaneous fixation of acetabular and femoral neck fractures has also been achieved using navigation. Early applications in arthroscopy have included surface-based registration for tunnel positioning for anterior cruciate ligament reconstruction and osteochondroplasty for femoro-acetabular impingement. Navigated arthroplasty techniques have addressed knee gap balancing and mechanical axis restoration as well as acetabular cup and glenoid baseplate positioning. Among these orthopaedic subspecialties, significant variation is found in the clinical relevance and dedication to research of navigation techniques.

Use of Activity Trackers in Orthopaedics Activity trackers are relatively inexpensive, easily available, and widely used by consumers. There has been increased interest in healthcare practice and research to use activity tracker data. Continuous collection of health variables including step count, heart rate, and calorimetry provides researchers and clinicians data to monitor patients after an intervention and/or encourage physical activity. The purpose of this article is to review the current use of activity trackers in orthopaedics and discuss potential applications in clinical research.

Modern Implant Options for the Treatment of Distal Femur Fractures Distal femur fractures occur in a periarticular fracture pattern and disproportionately afflict an aging population. Although the goals of treatment have not changed, the emergence of new surgical techniques and devices has recently been developed and refined to treat this challenging fracture pattern. Treatment options include open reduction and internal fixation with periarticular locking plates, intramedullary nails, or distal femur replacement. Despite rapid adoption, these modern solutions display a concerning complication rate, specifically from nonunion and malunion. The indications for each of these treatment strategies are not well defined and are the subject of current debate. As with the use of any orthopaedic implant, the knowledge of the strengths and weaknesses of each construct is paramount to successful treatment of these fractures. Recently, as the understanding of the biomechanics of distal femur fracture healing has improved, the literature has demonstrated clinical and theoretical improvements in the outcomes after distal femur fracture repair.

Proximal Radius Fractures in Children Fractures of the proximal radius represent 5% to 10% of all elbow fractures in children. These fractures have many treatment options and have a high risk of complication, particularly loss of forearm rotation. Nonsurgical management of minimally displaced radial neck fractures produces excellent results in most patients. For displaced fractures, numerous methods of closed and percutaneous reduction have been proposed, whereas open reduction has been associated with particularly poor outcome. Many additional factors, including fracture angulation, patient age, associated injury, articular involvement, and internal fixation, may lead to worse outcomes. Because the literature is limited to retrospective case series, few studies provide high-level evidence to guide the treatment of pediatric proximal radius fractures; however, certain management principles have been established that are reviewed here.

Outcomes After Hemiarthroplasty of the Elbow for the Management of Posttraumatic Arthritis: Minimum 2-Year Follow-up Background: Hemiarthroplasty (HA) of the elbow represents an alternative to total elbow arthroplasty (TEA) without the associated activity restrictions. This study reviews our experience with distal humerus HA with minimum 2-year follow-up. Methods: Between 2002 and 2012, 16 elbows underwent HA for posttraumatic arthritis of the elbow. Patients were followed for a minimum of 2 years or until revision surgery. Outcome measures included pre- and postoperative Mayo Elbow Performance Scores (MEPSs), complications, and revisions. Results: Mean age at arthroplasty was 45 years, and follow-up averaged 51 months. All patients had previously undergone one or more surgical procedures at the elbow (average of 1.5 procedures). At follow-up, five had undergone additional surgery; two were revised to TEA. In surviving implants, the range of motion at follow-up was markedly improved from preoperative motion. The MEPS for the remaining HA included five excellent results, three good results, five fair results, and one poor result. Discussion: Elbow HA is an option for young or active patients with end-stage elbow posttraumatic arthritis who are unwilling to accept activity limitations. However, high rates of revision surgery and revision to TEA occur after HA for posttraumatic osteoarthritis of the elbow. Only 57% of patients with surviving implants had a good to excellent MEPS, although improvement in the range of motion was predictable.

Utilization and Real-world Effectiveness of Tranexamic Use in Shoulder Arthroplasty: A Population-based Study Introduction: Tranexamic acid (TXA) is increasingly used to reduce blood loss in lower extremity arthroplasty, but limited data exist for its effectiveness in patients undergoing shoulder arthroplasty. We aimed to use national data to assess the frequency of use and effectiveness of TXA in patients undergoing shoulder arthroplasty. Methods: Using national claims data from patients undergoing shoulder arthroplasty (Premier Healthcare; 2010 to 2016; n = 82,512; 429 hospitals), we categorized patients according to whether they received perioperative TXA. Multilevel multivariable regression models measured associations between TXA and blood transfusion risk, combined complications (including thromboembolic events, acute renal failure, cerebral infarction, and acute myocardial infarction), and length and cost of hospitalization. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported. Results: Overall, TXA was used in 12.8% (n = 10,582) of patients with a strong increasing trend. After adjustment for relevant covariates, TXA use (compared with no TXA use) was associated with a 36% decrease in transfusion risk (OR, 0.64; 95% CI, 0.52 to 0.77; P < 0.05) and a 35% decreased risk for combined complications (OR, 0.65; 95% CI, 0.50 to 0.83; P < 0.05). Moreover, TXA use was associated with 6.2% shorter hospital stay (95% CI, −8.0% to −4.4%; P < 0.05), whereas no difference was observed with the cost of hospitalization. Conclusion: In this first large-scale study assessing TXA use and effectiveness in patients undergoing shoulder arthroplasty, we found that although TXA utilization is still low, it is associated with a marked decrease in transfusion risk with no increases in complication risk. Effects on the length and cost of hospitalization appeared minor. Future studies should assess whether higher volumes of TXA utilization would translate into more gains on the length and cost of hospitalization. Level of Evidence: Level III

A Dedicated Fracture Reduction Room: A Cost-Effective Alternative to the Operating Room Introduction: Charges, procedural efficiency, return to activity, and complications after closed treatment of fractures performed in an operating room (OR) versus closed reduction in a dedicated fracture reduction room (FRR) were compared. Methods: Patients with closed fractures of the forearm who underwent closed reduction in the year before (OR), and after implementation of the FRR, were retrospectively reviewed. Charges, American Society of Anesthesiologists class, sex, age, length of follow-up, prior reduction, fracture location/displacement, time from injury to procedure, procedural time, time to return to activity, and complications were recorded. Results: Eighteen patients met the inclusion criteria in the FRR group (13 men, 5 women), and 22 in the OR group (18 men, 4 women). No notable differences in age, sex, follow-up, American Society of Anesthesiologists class, fracture location/displacement, incidence of prior reduction, or time to return to activity were observed. Two (9.5%) complications occurred in the FRR group versus 7 (32%) in the OR group, P > 0.05. No anesthesia complications were present. Patients treated in the FRR incurred charges of $5,299 ± $1,289 versus $10,455 ± $2,290 in the OR, P < 0.001. Total time of visit in the FRR was ∼30% less than the OR, P < 0.001. No notable delay in treatment was observed. Discussion: In the era of finite resources and value-based care, implementation of a FRR resulted in safe, cost-effective, and increased procedural efficiency.