Purpose Knee dislocations (KDs) are potentially devastating injuries, leading to loss of function or limb in often young patients. This retrospective database review aims to determine the relative incidence and risk factors for KDs presenting to North American Level I and II trauma centers. Methods The National Trauma Data Bank (NTDB) was retrospectively interrogated using ICD-9-CM codes to identify KDs between 2010 and 2014 to derive KD incidence. KDs were stratified by age, sex, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), drug and alcohol use, injury mechanism, open vs. closed KD, vascular injury and fracture. Each covariate was tested against different mechanisms of injury, using Chi-squared tests and risk adjusted analyses to derive risk factors for KD. The same calculations were done for secondary outcomes (vascular and neurological injuries, compartment syndrome, amputation, and mortality). Results A total of 6454 KDs met the inclusion criteria (18/10,000 admissions). KDs occurred most commonly amongst men, aged 20-39, with an ISS score 1-14 and following motor vehicle collision (MVC). A vascular investigation was performed in 29%, with injury documented in 15% of KDs and 10.8% receiving a vascular procedure. Associated fractures were observed in 41.4% of KDs. Open injuries in 13.6%. Neurological injury documented in 6.2%, compartment syndrome in 2.7%, amputation in 3.8% (> 50% had vascular injury) and 2.8% died. MVC was the most common mechanism of injury (p < 0.001), significantly more common in young, male patients, associated with higher ISS and lower GCS, especially when drugs or alcohol were involved (p < 0.0001). Being male, having a vascular injury or open KD were all risk factors for compartment syndrome, amputation and neurological injuries. Conclusions KDs are rare injuries, but their relative incidence may be increasing. Young, male patients involved in MVCs are risk factors for KDs and their associated injuries, such as neurological injuries, amputations and compartment syndrome. Vascular injury occurs at a frequency of around 15%. The findings of the current study may guide future research and help to inform clinicians on the expected rates of associated injuries in patients identified to have KD in a trauma center population. It informs regarding risk factors for KD, which may improve diagnosis rates of spontaneously reduced knee dislocations by increasing index of suspicion in high-risk patients and identifies specific links with impaired driving. Level of evidence IV.

Background: The optimum management of osteochondritis dissecans (OCD) of the capitellum is a widely debated subject. Purpose: To better understand the efficacy of different surgical modalities and nonoperative treatment of OCD as assessed by radiological and clinical outcomes and return to sports. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of all treatment studies published between January 1975 and June 2020 was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 76 clinical studies, including 1463 patients, were suitable for inclusion. Aggregate analysis and subgroup analysis of individual patient data were performed to compare the functional and radiographic outcomes between the various nonoperative and surgical treatment options for capitellar OCD. A unified grading system (UGS; grades 1-4) was developed from existing validated classification systems to allow a comparison of patients with similar-grade OCD lesions in different studies according to their treatment. Patient-level data were available for 352 patients. The primary outcome measures of interest were patient-reported functional outcome, range of motion (ROM), and return to sports after treatment. The influences of the capitellar physeal status, location of the lesion, and type of sports participation were also assessed. Each outcome measure was evaluated according to the grade of OCD and treatment method (debridement/microfracture, fragment fixation, osteochondral autograft transplantation [OATS], or nonoperative treatment). Results: No studies reported elbow scores or ROM for nonoperatively treated patients. All surgical modalities resulted in significantly increased postoperative ROM and elbow scores for stable (UGS grades 1 and 2) and unstable lesions (UGS grades 3 and 4). There was no significant difference in the magnitude of improvement or overall scores according to the type of surgery for stable or unstable lesions. Return to sports was superior with nonoperative treatment for stable lesions, whereas surgical treatment was superior for unstable lesions. Patients with an open capitellar physis had superior ROM for stable and unstable lesions, but there was no correlation with lesion location and the outcomes of OATS versus fragment fixation for high-grade lesions. Conclusion: Nonoperative treatment was similar in outcomes to surgical treatment for low-grade lesions, whereas surgical treatment was superior for higher grade lesions. There is currently insufficient evidence to support complex reconstructive techniques for high-grade lesions compared with microfracture/debridement alone.

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Bungee jumping is a recreational sport that is accepted to carry a level of risk. We present the case of a femoral fracture sustained during bungee jumping and examine the published literature on bungee jumping-related injuries. A previously well 31-year old female performed a 200ft bungee jump from a crane. The apparatus was performed as expected and documented on the bystander video footage. As the bungee-cord became taut for the second time, there was an audible crack with accompanying scream. A closed, neurovascularly-intact injury was sustained to her right thigh. Radiographs revealed a comminuted mid-diaphyseal spiral femoral fracture, which was treated with intra-medullary nail fixation the following day. Following loss of position with proximal fragment flexion, the intramedullary nail was revised with open reduction and cerclage wiring 6 weeks later. Progression to clinical and radiological union was uneventful. Fatalities in bungee jumping are generally secondary to trauma as a result of equipment malfunction, user error, or related to pre-existing co-morbidity2. As no records are kept on bungee jumping injuries in the UK, reliable statistics are not available regarding the relative risks of this sport. We conclude that incidence of bungee jumping injuries is likely to remain low, but consider that improved recording of bungee jumping-related injury data will allow providers to give customers a realistic quantification of risk before engaging in this sport.

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Aims: To assess outcomes of inpatient stay in patients referred to acute surgical unit from residential homes, comparing with non-institutional-ised patients with similar presenting complaints. Methods: 40 patients admitted from homes over six months were matched with following emergency surgical admission living independently aged >70. Data gathered via 'take' lists and discharge summaries. Results: Dementia was more prevalent in the residential care (45 vs. 28%), who also had more co-morbidities (4.4 vs. 2.6). Presenting complaints between groups were similar, abdominal pain and haematemesis being leading causes. Larger proportion of community residents underwent surgery during admission (28 vs. 5%) whilst greater proportion of residential care died during admission (15 vs. 2.5%). Residential care patients had a slightly longer average duration of stay in this study (5.5 vs 4.2 days). Conclusions: Whilst presenting with similar complaints, residential care patients are less often surgical candidates; fewer undergo surgery and a larger proportion die during admission. This supports value of geriatric liaison, particularly discharge planning, including in those patients palliative needs, as well as medical optimisation of co-morbidities when surgery is considered. Presented to the surgical and elderly care department: a new admission pathway for this group of patients was proposed to the trust, suggesting refferal via the geriatric team. Aim: In 2010 NCEPOD highlighted concerns over outcomes of elderly patients undergoing emergency surgery. This study aimed to investigate outcomes in nonagenarians undergoing emergency surgery and identify predictive risk factors for mortality and the impact on care requirements. Method: All nonagenarian patients who underwent emergency general surgery operations between June 2005 and June 2010 within one NHS Trust were retrospectively reviewed. Risk factors analysed included age, sex, ASA grade, clinical parameters, preoperative blood tests (including C-reactive protein (CRP)), preoperative care dependence, operation factors and surgeon factors. Kaplan-Meier survival analysis was performed using one year mortality rates. Results: Forty six patients (30 female) underwent surgery with an inpatient mortality of 32.6% and one year mortality of 54.3%. Patients undergoing major index surgery, a CRP > 100 or who required any form of preoperative social care had significantly reduced survival (P¼ 0.013, P<0.001 and p¼0.0024 respectively). Upon discharge 59.3 % of patient required no change in social care, 29.6% a temporary change and 11.1% a permanent change. Conclusion: Emergency surgery in the nonagenarian is feasible with little long term change in social care requirements. Predictors of mortality are CRP >100, requirement for social care preoperatively and major index surgery. Background: Acute appendicitis is commonly managed with laparoscopic appendicectomy. However, there is a perception that it takes longer than an open operation and may, therefore, impact on the efficiency of e...