Crosswalk between the PROMIS physical function CAT and PROMIS upper extremity CAT v1.2 in a hand surgery population.

BACKGROUND: There is no gold standard patient-reported outcome measure (PROM) in hand surgery. As a result, a diverse array of PROM instruments have been utilized across centers over time. Lack of score interchangeability limits the ability to compare or conglomerate scores when new instruments are introduced. Our aim was to develop a linkage for the PROMIS UE CAT v1.2 and PROMIS PF CAT scores and develop crosswalk tables for interconversion between these PROMs. METHODS: Retrospective review was conducted to identify adult (≥ 18y) patients seen by orthopaedic hand surgeons at a single academic tertiary care hospital who had completed PROMIS UE CAT v1.2 and PROMIS PF CAT score at the same visit. For those with multiple visits, only one randomly selected visit was included in the analyses. Pearson's correlation was calculated to determine the linear relationship between the scores. Linkage from PF to UE was performed utilizing several commonly utilized equating models (identity, mean, linear, equipercentile and circle-arc methods). The performance of the models was assessed using intraclass correlation (ICC) between observed PROMIS UE CAT v1.2 and estimated PROMIS UE CAT v1.2 scores generated using the model as well as Root Mean Square Error (RMSE). The model chosen as the 'best' was further assessed for population invariance using root expected mean squared difference (REMSD) where < 0.08 were considered good. RESULTS: Of 10,081 included patients, mean age was 48.3 (SD = 17.0), and 54% were female (5,477/10,081). Mean UE CAT v1.2 and PF CAT scores were 37 (SD = 9.8) and 46 (SD = 10.0), respectively. There was a strong correlation between the scores (Pearson correlation r = 0.70). All methods performed acceptably (ICC ≥ 0.66 and RMSE < = 7.52 for all). The equipercentile method had the highest ICC (ICC = 0.70 (95% CI 0.69-0.71)) while the mean and circle arc methods had the lowest RMSE. The circle arc method is the most reliable with the smallest standard error and has satisfactory population invariance across age group (REMSD 0.065) and sex (REMSD 0.036). CONCLUSIONS: Crosswalk tables to be used for bidirectional conversion between scores were created. LEVEL OF EVIDENCE: III.

CRP Predicts the Need to Escalate Care After Initial Debridement for Musculoskeletal Infection.

BACKGROUND: Musculoskeletal infections (MSKIs) are a major cause of morbidity in the pediatric population and account for nearly 1 in every 10 consultations with a pediatric orthopaedic provider at a tertiary care center. To prevent or deescalate the risk of adverse medical and musculoskeletal outcomes, timely medical intervention in the form of antibiotics and potential surgical debridement is required. While there have been numerous studies indicating the value of laboratory testing during the initial workup of a child with MSKI, few studies to date have examined the utility of longitudinal assessment of laboratory measures in the acute setting to monitor the efficacy of antibiotic therapy and/or surgical intervention. The purpose of this investigation was to retrospectively determine whether measuring changes in the inflammatory response could indicate the need for escalated care. Specifically, this study examined the hypothesis that serial measurements of C-reactive protein (CRP), immediately preoperatively and 2 days after surgical debridement, could predict the need for medical (change in antibiotics) or surgical (additional debridement) escalation. METHODS: Retrospective review of pediatric patients undergoing operative debridement for the treatment of MSKI between September 2009 and December 2015 from whom laboratory data (CRP) was obtained preoperatively and at postoperative day (POD) 2. Patient demographics, the need for escalated care, and patient outcomes were evaluated. RESULTS: Across 135 pediatric patients, preoperative CRP values >90 mg/L and a positive change in CRP at POD2 effectively predicted the need for escalation of care after initial surgical debridement (Area under the Receiver Operator Curve: 0.883). For each 10-unit increase in preoperative CRP or postoperative change in CRP, there was a 21% or 22% increased risk of needing escalated care, respectively. Stratification by preoperative CRP >90 mg/L and change in CRP postoperatively likewise correlated with increased rates of disseminated disease, percent tissue culture positivity, length of stay, and rate of adverse outcomes. CONCLUSIONS: This study demonstrates the utility of serial CRP to assess the need for escalated care in patients being treated for MSKI. As serial CRP measurements become standard of practice in the acute setting, future prospective studies are needed to optimize the timing of CRP reassessment during inpatient hospitalization to prognosticate patient outcomes, weighing both improvements of patient care and clinical burden. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Tibial Plateau Fractures Complicated by Compartment Syndrome Are Associated With a 3 Times Higher Cost of Care.

OBJECTIVES: To determine the impact of acute compartment syndrome (ACS) and identify cost drivers of 1-year total treatment costs for operative tibial plateau fractures. DESIGN: Retrospective review. SETTING: Level 1 trauma center. PATIENTS: 337 patients with tibial plateau fractures, 24 of which were complicated by ACS. OUTCOMES: The primary outcome was total treatment cost over the first year for operatively treated tibial plateau fractures. The secondary objective was to use regression analysis to identify significant cost drivers. RESULTS: The diagnosis of ACS was associated with 2.85 times higher total treatment cost ( P < 0.001). ACS demonstrated increased total treatment cost when controlling for polytrauma ( P < 0.001) and postoperative infection ( P < 0.001). Regression analysis identified 5 variables significantly associated with total cost of care: body mass index, injury severity score, ACS, staged external fixation, and locking fixation ( P < 0.001; R 2 = 0.57). The diagnosis of ACS had the largest impact on total cost with a 3.5× greater impact on cost compared with the next highest variable, staged external fixation. CONCLUSIONS: Tibial plateau fractures complicated by ACS are associated with 2.85 times higher treatment costs over a 1-year period. There were 5 significant variables identified by regression analysis with ACS having the highest impact on total treatment. Together, these 5 factors account for 57% of treatment cost variability. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Reformatting of Computed Tomography Scans Parallel to the S1 End Plate Increases Visualization of Trans Sacral Pathway in the First Sacral Segment, Especially With Dysmorphism.

OBJECTIVE: To determine whether reformatted computed tomography (CT) scans would increase surgeons' confidence in placing a trans sacral (TS) screw in the first sacral segment. SETTING: Level 1 trauma center. DESIGN: A retrospective cohort study. PATIENTS/PARTICIPANTS: There were 50 patients with uninjured pelvises who were reviewed by 9 orthopaedic trauma fellowship-trained surgeons and 5 orthopaedic residents. MAIN OUTCOME MEASUREMENTS: The overall percentage of surgeons who believe it was safe to place a TS screw in the first sacral segment with standard (axial cuts perpendicular to the scanner gantry) versus reformatted (parallel to the S1 end plate) CT scans. RESULTS: Overall, 58% of patients were believed to have a safe corridor in traditional cut axial CT scans, whereas 68% were believed to have a safe corridor on reformatted CT scans ( P < 0.001). When grouped by dysplasia, those without sacral dysplasia (n = 28) had a safe corridor 93% of the time on traditional scans and 93% of the time with reformatted CT scans ( P = 0.87). However, of those who had dysplasia (n = 22), only 12% were believed to have a safe corridor on original scans compared with 35% on reformatted scans ( P < 0.001). CONCLUSIONS: CT scan reformatting parallel to the S1 superior end plate increases the likelihood of identifying a safe corridor for a TS screw, especially in patients with evidence of sacral dysplasia. The authors would recommend the routine use of reformatting CT scans in this manner to provide a better understanding of the upper sacral segment osseous fixation pathways.

Occupational Hazards to the Joint Replacement Surgeon: Radiation Exposure.

BACKGROUND: Intraoperative fluoroscopy is an essential tool to assist orthopedic surgeons in accurately and safely implanting hardware. In arthroplasty cases, its use is on the rise with the increasing popularity of the direct anterior (DA) approach for THA. However, exposure of ionizing radiation poses a potential health risk to surgeons. While the benefits of intraoperative fluoroscopy in DA THA is becoming clearer, and are well-described in the literature, the potential health dangers associated with career-long cumulative radiation exposure are rarely discussed. METHODS: In this article, we review the available literature to discuss radiation safety in orthopedics with a focus on total joint arthroplasty. We present the basic science of radiation, discuss the amount of radiation exposure in orthopedic surgery, and review the potential health risks associated with long-term exposure. CONCLUSION: Overall, the radiation dose exposure to arthroplasty surgeons is low and within recommendations for occupation exposure limits. However, due to the stochastic health impacts of ionizing radiation, there is no threshold dose below which radiation exposure is truly safe. Therefore, it is imperative that surgeons practice proper fluoroscopy safety habits, such as wearing proper protective equipment, minimizing fluoroscopy time and magnification, and maximizing distance from the radiation source to minimize the life-long cumulative radiation exposure and associated health risks.

The Heterogeneity of Pediatric Knee Infections: A Retrospective Analysis.

BACKGROUND: Musculoskeletal infection is a major cause of morbidity in the pediatric population. Despite the canonical teaching that an irritable joint and signs of infection likely represent an infected joint space, recent evidence in the pediatric hip has demonstrated that alternative diagnoses are equally or more likely and that combinations of pathologies are common. The knee is the second most commonly infected joint in children, yet there remains a paucity of available data regarding the epidemiology and workup of the infected pediatric knee. The authors hypothesize that there is heterogeneity of pathologies, including combinations of pathologies, that presents as a potentially infected knee in a child. The authors aim to show the utility of magnetic resonance imaging and epidemiologic and laboratory markers in the workup of these patients. METHODS: A retrospective review of all consults made to the pediatric orthopaedic surgery team at a single tertiary care center from September 2009 through December 2015 regarding a concern for potential knee infection was performed. Excluded from the study were patients with penetrating trauma, postoperative infection, open fracture, no C-reactive protein (CRP) within 24 hours of admission, sickle cell disease, an immunocompromised state, or chronic osteomyelitis. RESULTS: A total of 120 patients were analyzed in this study. There was marked variability in pathologies. Patients with isolated osteomyelitis or osteomyelitis+septic arthritis were older, had an increased admission CRP, were more likely to be infected with Staphylococcus aureus, required an increased duration of antibiotics, and had an increased incidence of musculoskeletal complications than patients with isolated septic arthritis. CONCLUSIONS: When considering a child with an irritable knee, a heterogeneity of potential underlying pathologies and combinations of pathologies are possible. Importantly, the age of the patient and CRP can guide a clinician when considering further workup. Older patients with a higher admission CRP value warrant an immediate magnetic resonance imaging, as they are likely to have osteomyelitis, which was associated with worse outcomes when compared with patients with isolated septic arthritis. LEVEL OF EVIDENCE: Level III-retrospective research study.

Orthopaedic Conditions Among the Uninsured: Data from an American Student-Run Free Clinic.

Little is known about the epidemiology of orthopaedic conditions among the uninsured. This is a descriptive study of 107 patients presenting with 140 orthopaedic conditions for care at the student-run free clinic, the Shade Tree Clinic. Patients were 50.0 (± 13.0) years old with a BMI of 32.9 (± 8.60). About half were female (58.9%), of Spanish origin/Hispanic or Latino descent (50.9%), immigrants (48.3%), and non-English speaking (44.9%). Most presented with chronic (75.5%) conditions of the knee (24.3%), hand (16.4%) and spine (13.6%). While knee osteoarthritis was the most common diagnosis made (18.7%), there were 38 (35.5%) unique diagnoses with only a single occurrence. Most conditions were initially treated nonoperatively (82.9%). There was an average of 1.92 (± 1.44) visits per condition, and 74.0% of conditions had reported improvement or resolution. Though further study is needed, providing free comprehensive patient-centered orthopaedic care to uninsured individuals in a low-cost setting may prove cost-effective. (Journal of Surgical Orthopaedic Advances 29(2):112-116, 2020).