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Background: Supracondylar humerus (SCH) fractures are one of the most common pediatric orthopaedic injuries. Described using the Wilkins modification of the Gartland Classification system, current practice guidelines give moderate evidence for closed reduction and percutaneous pinning of type 2 and 3 injuries, but little evidence exists regarding the appropriate surgical setting for fixation. The goal of this study was to evaluate the perioperative complication profile of type 3 fractures with maintained metaphyseal contact and determine their suitability for outpatient surgery. Methods: Skeletally immature patients with type 2 and 3 SCH fractures treated at a single, Level-1 trauma institution from March 2019 to January 2000 were retrospectively reviewed. A total of 1126 subjects were identified. Open, concomitant injuries, incomplete physical examination, initial neurovascular compromise, flexion-type fractures, ecchymosis, skin compromise, and those managed nonoperatively were excluded. Type 3 fractures were categorized as either "3M" versus type "3" ("M" denoting metaphyseal bony contact). Demographic data, neurovascular changes, and postoperative complications were collected. Categorical variables were evaluated using χ 2 or Fisher exact tests, and continuous variables analyzed using analysis of variance, with significance defined as a P-value < 0.05. Results: A total of 485 patients (189 type 2, 164 type 3M, 132 type 3) met inclusion criteria. Sex and length of stay did not differ among groups. The incidence of neurovascular change between initial presentation and surgical fixation was significantly greater for type 3 fractures compared with other groups (P = 0.02). No child in the 3M group had preoperative neurovascular examination changes, compared with 3 patients with type 3 injuries. When directly compared with the 3M group, type 3 fractures had a higher incidence of neurovascular examination changes that trended towards significance (P = 0.08). There was no difference in postoperative complication rate between groups (P = 0.61). Conclusions:Our findings demonstrate that Gartland type 3 SCH fractures lacking metaphyseal bony contact, compared with types 3M and 2, are more likely to experience neurovascular examination changes between initial presentation and definitive surgical fixation. Type 3M fractures clinically behaved like type 2 injuries and, accordingly, could be considered for treatment on an outpatient basis.

Hip preservation and peri-trochanteric procedures are becoming more commonplace for the arthroplasty surgeon. Understanding the reimbursement for these procedures remains a challenge for those looking to expand this portion of their practice. In order to financially maximize the surgeon’s efforts, we present recommendations for hip preservation procedural coding.

Tobacco exposure negatively affects bone mineral density and early osseointegration of surgical implants. We sought to determine if elevated nicotine and/or cotinine levels prior to primary total hip arthroplasty (THA) are associated with early femoral component subsidence. We hypothesize that tobacco users will have higher rates of readmission/reoperation and increased radiographic subsidence. We conducted an institutional review of 75 patients (average age = 52.9 years; 55% females; body mass index = 31.3) who underwent THA from April 2017 to January 2018. Immediate postoperative radiographs were compared with those obtained at 2 to 6 weeks postoperatively to determine early femoral component subsidence. Of the 75 patients, 10 (13.3%) had early radiographic femoral component subsidence ≥ 2 mm. In this group, preoperative nicotine levels were significantly elevated (7.2 vs. 1.5ng/mL; p = 0.04), whereas preoperative cotinine levels did not statistically differ (108.3 vs. 33.8 ng/mL; p = 0.45). A significantly greater magnitude of subsidence was seen in those with elevated preoperative nicotine levels compared with those with normal levels (1.7 vs. 0.5 mm; p = 0.04). The mean time to radiographic follow-up was 2.6 weeks. Surgical approach, implant type, categorical variables, and patient readmission were not associated with ≥ 2 mm of early subsidence. There was a single reoperation for periprosthetic fracture, but none was related to instability from subsidence. Early femoral component subsidence was more prevalent in patients with elevated preoperative nicotine levels. Rates of readmission/reoperation at 90 days did not differ between those with and without elevated tobacco markers. Clinically relevant thresholds of preoperative nicotine and/or cotinine values are needed to better delineate appropriate surgical candidates to achieve optimal surgical outcomes.

Background: Multiple enchondromas in the pediatric hand is a relatively rare occurrence and the literature regarding its incidence and treatment is sparse. Within this rare subset of patients, we identified a unique cohort in which lesions are confined to multiple bones in a single ray or adjacent rays within a single nerve distribution. We review the clinical and pathologic characteristics and describe the indications for and outcomes of treatment in this unique subset of patients as well as offer conjectures about its occurrence. Methods: Institutional review board (IRB)-approved retrospective multicenter study between 2010 and 2018 identified subjects with isolated multiple enchondromas and minimum 2-year follow-up. Data analyzed included demographics, lesion quantification and localization, symptoms and/or fracture(s), treatment of lesion(s), complications, recurrence, and presence of malignant transformation. Results Ten patients were evaluated with average age at presentation of 9 years (range: 4 to 16) and mean clinical follow-up of 6 years (range: 2.8 to 8.6). Five subjects had multiple ray involvement in a single nerve distribution and 5 had single ray involvement with an average of 4 lesions noted per subject (range: 2 to 8). All children in the study had histopathologic-proven enchondromas and underwent operative curettage±bone grafting. Indications for surgical intervention included persistent pain, multiple prior pathologic fractures, impending fracture and deformity. During the study period three subjects experienced pathologic fracture treated successfully with immobilization. Recurrence was noted in 40% at an average of 105 weeks postoperatively (range: 24 to 260) and appears higher than that reported in the literature. No case of malignant transformation was observed during the study period. Conclusions: A rare subset of pediatric patients with multiple enchondromas of the hand is described with lesions limited to a single ray or single nerve distribution. Further awareness of this unique subset of patients may increase our understanding of the disease and improve patient outcomes. Level of Evidence: Level IV—therapeutic (case series).