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Objectives: Although uncommon, arthrofibrosis following anterior cruciate ligament reconstruction (ACLR) is considered to be a significant and disabling complication for a young, athletic population. In this study, we aimed to determine: (1) the prevalence of manipulation under anesthesia (MUA) for treatment of arthrofibrosis following ACLR (2) whether anticoagulant use following ACLR is associated with an increased risk of MUA. We anticipate that postoperative use of anticoagulants will be associated with an increased risk of subsequent MUA. Methods: A retrospective cohort study was conducted using data collected from the Humana insurance database using the PearlDiver Patient Records Database from 2007-2017. Subjects were identified using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes. Patients were initially identified by ACL sprain or tear diagnosis utilizing ICD codes. Patients who underwent a concomitant MCL, PCL or LCL repair or reconstruction were excluded from this analysis. Patients who underwent MUA within one year of ACLR were then identified. Patient demographic characteristics including age, sex, and Charlson Comorbidity Index (CCI) were recorded. In addition, previously identified risk factors for knee stiffness were collected, including history of diabetes mellitus and obesity. Lastly, the time between ACL tear and surgery and ACL reconstruction to MUA were collected and categorized into 2 groups: (1) <4 weeks and (2) >4 weeks. Anticoagulants included in this analysis were warfarin, aspirin, low-molecular-weight heparin, direct factor Xa inhibitors and fondaparinux. Patient demographics, comorbidities, timing to surgery, concomitant meniscal repair, and postoperative complications were analyzed with a logistic multivariate analysis to determine adjusted associations of risk factors of arthrofibrosis. A p-value of < 0.05 was used as the cutoff for statistical significance. Results: There were 7,798 patients who met the inclusion criteria for this analysis. 115 (1.5%) patients received a subsequent MUA within one-year, while 7,683 (98.5%) patients did not. Among patients who underwent ACLR, 234 (3.0%) patients were on anticoagulants postoperatively. Patients who were on anticoagulants following ACLR were more likely to require an MUA (OR: 4.626; 95% CI: 2.462-8.093; p<0.001; Table 1). Other risk factors for MUA are listed in Table 1. Conclusion: The key finding of this study was that the use of anticoagulants is associated with increased rates of MUA following ACLR. One potential mechanism for the effect of anticoagulants may be the increased risk of postoperative hematoma. Recurrent hematoma has been suggested as a risk factor for arthrofibrosis requiring MUA following ACLR due to increased vascular micro-permeability that anticoagulants can produce. The presence of blood products in the joint may stimulate the accumulation of inflammatory mediators and subsequent fibrosis, as it is well-established that unresolved inflammation can initiate and propagate scar tissue formation. In conclusion, arthrofibrosis after ACLR is associated with postoperative use of thromboprophylaxis. Healthcare providers should be cognizant of this risk when considering anticoagulant usage in this patient population.

Background Pisiform dislocations are an extremely rare injury. There are reports in the literature of isolated dislocations, but to our knowledge there are no reports of distal radius fractures with associated pisiform dislocations. Methods and Results We present two cases of isolated pisiform dislocation and distal radius fracture in the adult population. Both patients were managed conservatively with closed reduction in both the distal radius and pisiform, and subsequently achieved good pain relief and progressive return of wrist function. Conclusion For adult patients with distal radius fractures and an associated pisiform dislocation, successful closed reduction and immobilization can result in symptomatic improvement and return of function.

Cement intravasation occurs in hemiarthroplasty when pressurization of cement through the medullary canal backflows through the nutrient vessels. This case report describes a 70-year-old woman who underwent hip hemiarthroplasty for a displaced left femoral neck fracture. Postoperative radiographs demonstrated radio-opacity consistent with local cement intravasation. A Doppler ultrasound study subsequently revealed a mobile thrombus at the confluence of the femoral and profunda femoris veins, as well as a nonmobile thrombus within the profunda femoris vein. The more proximal thrombus was determined to be cement that had intravasated during the index operation. The cement likely impeded venous flow, ultimately leading to the development of deep vein thrombosis just distal to the site of cement occlusion.