Lisocabtagene maraleucel for treatment of relapsed and refractory primary mediastinal large B-cell lymphoma in an adolescent patient.

The safety and efficacy of CAR T-cell therapy are unknown in pediatric and adolescent patients with relapsed or refractory primary mediastinal large B-cell lymphoma (R/R PMBCL) which is associated with dismal prognosis. Here, we present a case report of a 16-year-old patient with R/R PMBCL treated with lisocabtagene maraleucel including correlative studies. Patient achieved complete response at 6 months without cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome. She only experienced mild cytopenias, requiring filgrastim once. This report highlights the safety and efficacy of lisocabtagene maraleucel in this population, warranting prospective studies to improve clinical outcomes.

Metacarpal Shortening with Intramedullary Screw Fixation: A Cadaveric Study.

Background Intramedullary screw fixation is a commonly used technique for the management of metacarpal fractures. However, compression across the fracture site can lead to unintentional shortening of the metacarpal. Questions/Purposes Our aim was to evaluate the risk of overshortening with differing intramedullary device designs for fixation of metacarpals. Methods The small finger metacarpal of nine fresh-frozen cadavers were included. A metacarpal neck fracture was simulated with a 5-mm osteotomy. Three different intramedullary screw designs were compared. Each screw was placed in a retrograde fashion into the intramedullary canal and the amount of shortening measured. Screws were reversed and the number of reverse turns with the screwdriver needed to release overshortening were measured. Results The average shortening at the osteotomy site was 2.5 mm. The mean shortening was 80%, 58%, and 12% for the partially threaded screw, fully threaded screw, and threaded nail, respectively. The mean differences of the distance shortened were statistically significant for the threaded nail compared with the partially and fully threaded screws. The partially threaded screw had the most shortening, while the threaded nail provided the least amount of shortening. When the screws were reversed, the screws did not disengage until the screw was fully removed from the osteotomy site. Conclusion The fully threaded nail demonstrates less shortening and possibly minimizes overshortening of fractures compared with partially threaded and fully threaded screw designs. Overshortening cannot be corrected by unscrewing the screw unless completely removed from the distal fragment. Clinical Relevance Orthopaedic surgeons may select intermedullary screws based on the design that is suited for the particular metacarpal fracture pattern.

Are Orthopedic Fellowship Programs Giving Out Too Many Interviews? A Retrospective Analysis Suggests They Are.

Background: The orthopedic surgery fellowship match process is associated with substantial stress and expense, yet the optimal number of interviews for fellowships to offer has not been evaluated. Purpose: We sought to evaluate the number of orthopedic surgery fellowship interviews given and construct a model to determine the appropriate number of interviews to offer based on specialty and program size. Methods: We conducted a retrospective study of 6 orthopedic fellowship specialties; data were obtained from San Francisco Match and covered the 5-year period from 2014 to 2018. The orthopedic fellowship subspecialties included adult reconstruction/oncology, foot and ankle, pediatrics, spine, sports medicine, and trauma. We excluded shoulder and elbow (less than 5 years of data) and hand and upper extremity (alternative matching process). Parameters included number of programs, number of spots per program, number of ranked applicants per program (mean ± SD), and difference in number of interviews offered and ranked applicants per program (mean ± SD). Multiple regression analysis was used to create an equation for determining the optimal number of interviews for the programs. Results: Of 1377 orthopedic fellowship programs analyzed, 1370 (99.50%) conducted interviews beyond the number of ranked applicants. Programs ranked an overall mean of 20.10 ± 10.17 applicants with an overall mean of 11.60 ± 8.62 additional interviews offered. Sports medicine had the highest mean ranked applicants (23.21 ± 9.77) and pediatrics had the lowest mean ranked applicants (15.74 ± 7.76). The most additional interviews were given in adult reconstruction (14.80 ± 9.92) and the least were given in pediatrics (8.32 ± 7.17). The predictive equation was reported as Y = ß1x1 + ß2x2 (Y = ranked applicants, x1 = spots open, and x2 = last rank). Conclusion: Programs in 6 orthopedic subspecialties in the fellowship match process appear to consistently offer more interviews than necessary. We have developed a model to help programs predict the optimal number of fellowship applicants to interview. Future studies need to validate the model, especially with anticipated increases of the virtual interview format.

Comparative Cost Analysis of Single-use Sterile versus Reprocessed Distal Radius Volar Plate Sets.

Background: With the rise in distal radius fracture (DRF) incidence and treatment through open reduction internal fixation, there are increasing concerns in the current medical cost containment climate. To help reduce costs, manufacturers are introducing sterile packed kits. The purpose of this study is to compare the costs of the single use kit (SK) against conventional reprocessed DRF surgical sets (RS). Methods: A four-year retrospective review at three surgical centers was performed to determine a company's RS average sterilization and processing costs. RS instrumentation cost was estimated by straight-line depreciation from the original purchase price. RS implant costs were calculated from the list price. SK list cost was obtained from the same company. Incidence of surgical delays was estimated by a survey of 23 hand surgeons and cost of delays was obtained from surgical center reports. Sensitivity analysis on delay frequency was performed to assess a range of overall costs. Results: OR delays were estimated at one out of 100 cases, with an average cost of $11 per case. For RS, average instruments, implants, and sterilization costs per case was $47, $2882, and $39. The total RS cost of $2,978 and the SK was $1,667 with a difference of $1,313 per case. Conclusion: RS was found to cost $1,313 more per case than the SK in an ambulatory surgical setting and potentially more cost effective. Ultimately, pricing is highly variable at each center based on negotiated and contractual pricing.

Surveying the Use and Perceptions of Wrist Arthroscopy Among Upper Extremity Surgeons.

This study describes current trends in the skill acquisition and practice patterns for wrist arthroscopy among upper extremity surgeons. A survey was sent to the membership of the American Association for Hand Surgery (AAHS). A total of 104 responses were available for analysis. Of those respondents who did not use wrist arthroscopy, lack of educational training was cited as the most common reason. Of those who did use arthroscopy, fellowship training was credited as the primary source. However, most of those who completed an instructional course felt immediately able to perform arthroscopy. Triangular fibrocartilage complex tears were recorded as the most common indication. Surgeons frequently evaluated the midcarpal joint, but did not frequently use arthroscopy for distal radio-ulnar joint or carpometacarpal joint pathology. Ultimately, this highlights an area of improvement for residency and fellowship education. [Orthopedics. 2022;45(5):310-313.].

Does Undergoing Outpatient Hand Surgery Lead to Prolonged Opioid Use? A Comparison of Surgical and Nonsurgical Patients.

BACKGROUND: Orthopedic surgical patients in general have been found to be at higher risk for developing opioid dependence in the postoperative period. However, there is conflicting evidence in the literature whether opioid exposure after hand surgery leads to prolonged use. In the absence of a nonoperative control group, it is not clear whether prolonged opioid use in hand surgical patients is related to undergoing a surgical intervention. The purpose of our study to compare opioid prescription fulfillment patterns in surgical and nonoperative patients in a hand surgery practice. METHODS: We retrospectively compared 320 patients that underwent elbow, wrist, and hand surgery procedures with 741 nonoperative patients treated by 2 hand surgeons. The Pennsylvania Drug Monitoring Program (PDMP), a mandatory statewide database, was used to evaluate the primary outcomes of filling more than one opioid prescription and filling opioid prescriptions beyond 6 months of the index surgery or clinic visit. Bivariate and multivariable logistic regression analysis was performed using the following variables: surgery, prior benzodiazepine use, and prior opioid use. RESULTS: There was no difference in prior opioid use (15.2% vs 16.9%, P = .51) or prior benzodiazepine (10.4% vs 8.4%, P = .33) use between the nonoperative and operative groups. Patients that underwent surgery had a higher incidence of filling more than one opioid prescription (20.9% vs 8.8%, P < .001). However, continued opioid use was not statistically different between nonoperative and operative patients (2.8% vs 5%, P = .08). Bivariate analysis demonstrated that prior opioids (odds ratio [OR] = 12.94, P < .001) and prior benzodiazepines (OR = 1.95, P < .001) were significant independent risk factors for prolonged opioid use. Multivariable analysis demonstrated prior opioid use to be the only independent risk factor for prolonged opioid use (OR = 12.58, P < .001). CONCLUSION: Undergoing outpatient hand surgery do not appear to be an independent risk factor for filling opioid prescriptions beyond 6 months. Significant risk factors for prolonged opioid use include prior use of controlled substances, particularly prior opioid use.

Evaluation of the Incidence and Etiology of Unplanned Return to Operating Room Following Open Reduction Internal Fixation of Distal Radius Fractures.

BACKGROUND: Distal radius fractures (DRF) are the most common upper extremity fractures in adults. The purpose of this study was to determine the incidence, causes, and independent predictors for unplanned return to the operating room (URTO) in a single institution within 90 days following distal radius open reduction internal fixation (ORIF). METHODS: A retrospective study of 2933 consecutive patients from January 2015 to December 2019 who underwent distal radius ORIF was undertaken. Patients who returned to the operating room within 90 days of the index procedure were identified. Patients with planned return to the operating room for staged procedures were excluded, yielding a patient cohort of those with URTO. Demographic data, causes for reoperation, and final Quick Disabilities of the Arm, Shoulder and Hand DASH (QuickDASH) scores were collected. RESULTS: Overall, 45 patients had URTO (1.5%) occurring a mean of 44 (6-89) days from the index procedure. Reasons for reoperation included nerve complications (n = 14), loss of fixation (n = 11), hardware complications (n = 9), wound complications (n = 7), and tendon complications (n = 4). Neurologic reasons for return included carpal tunnel release (n = 13) and ulnar nerve decompression (n = 1). QuickDASH scores were higher for URTO compared with control cohort at the final follow-up (33 [range: 0-91] vs 14 [range: 0-100], P < .01). CONCLUSIONS: Mechanical hardware failure and neurologic symptoms were the most common reasons for URTO after distal fracture ORIF.

Radiographic Incidence and Functional Outcomes of Distal Radius Fractures Undergoing Volar Plate Fixation With Concomitant Scapholunate Widening: A Prospective Analysis.

Background: Scapholunate (SL) ligament injuries can occur concomitantly with distal radius fractures (DRFs), and the management of acute SL injury in the setting of DRFs remains controversial. The purpose of the study is to identify the radiographic incidence of SL widening in DRF treated with volar plate fixation and to determine the functional outcomes of DRF with concomitant radiographic SL-widening. Methods: One hundred and seventeen patients with DRFs, with and without radiographic SL-widening, and treated with volar locked plating, were prospectively enrolled. No SL ligament repairs or reconstructions were performed in any cases. Patients with DRFs with radiographic criteria for SL widening were compared to those without. Patients were evaluated at 3 months and 1 year postoperatively with Quick Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation (PRWE) questionnaires. Results: Thirty-one patients (26.5%) were found to have radiographic evidence of SL widening. Patients with concomitant SL widening had less wrist extension at 3 months (52.4 degrees vs 60.8, P = .034) and at 1 year (64.5 degrees vs 71.8, P = .023). The group with SL widening had greater articular step off at 3 months (0.33 vs 0.06, P = .042), but no difference at 1 year (0.11 vs 0.05, P = .348). There were no differences in wrist flexion, supination, pronation, volar tilt, radial inclination, radial height, ulnar variance, PRWE scores, and Quick Dash scores at 3 months and 1 year. Conclusions: Radiographic SL-widening is a common finding associated with DRFs undergoing surgical repair. There are similar clinical outcomes between those with untreated SL widening compared to those without an SL widening at 1-year postoperatively.

Effects of Upper Extremity Elevation on Intra-Cast Pressure and Digital Perfusion in a Fiberglass Short-Arm Cast Model.

The goal of this study was to determine the relationship of digital artery pressure to arm position and forearm skin surface pressure using a short-arm cast experimental setup, to ascertain the safest position for the injured casted upper extremity. A total of 27 volunteers were placed in bilateral short-arm fiber-glass casts with an empty 50-mL bladder bag under the cast and attached to a pressure transducer. Digital systolic pressure (Pdig), and skin surface pressure under the cast (Pskin) were assessed in 4 positions. Measurements were taken with and without 50 mL air in the bladder bag. A total of 54 forearms were evaluated. Both arm position and Pskin had a significant effect on Pdig (P<.001 for both), with increasing elevation leading to a decrease in Pdig (r=-0.50). The effect size of position on Pdig was large, whereas that of Pskin was small (partial eta-squared=0.371 and 0.028, respectively). Linear regression analysis of Pskin and Pdig with air in the neutral position yielded a moderate negative relationship with body mass index (r=-0.64, P<.001 for Pskin; r=0.49, P<.001 for Pdig) and wrist circumference (r=-0.66, P<.001 for Pskin; r=0.52, P<.001 for Pdig), without significant association with forearm length. For volunteers with short-arm fiberglass casts, increasing arm elevation had a large effect size on digital arterial pressure, whereas 50 mL simulated swelling had only a small effect size. Decreasing body mass index and forearm circumference correlated with increased skin surface pressure and decreased digital arterial pressure. These findings show that aggressive elevation of the injured limb may not be as desirable as previously believed. [Orthopedics. 2021;44(4):e487-e492.].

Geometric deep learning enables 3D kinematic profiling across species and environments.

Comprehensive descriptions of animal behavior require precise three-dimensional (3D) measurements of whole-body movements. Although two-dimensional approaches can track visible landmarks in restrictive environments, performance drops in freely moving animals, due to occlusions and appearance changes. Therefore, we designed DANNCE to robustly track anatomical landmarks in 3D across species and behaviors. DANNCE uses projective geometry to construct inputs to a convolutional neural network that leverages learned 3D geometric reasoning. We trained and benchmarked DANNCE using a dataset of nearly seven million frames that relates color videos and rodent 3D poses. In rats and mice, DANNCE robustly tracked dozens of landmarks on the head, trunk, and limbs of freely moving animals in naturalistic settings. We extended DANNCE to datasets from rat pups, marmosets, and chickadees, and demonstrate quantitative profiling of behavioral lineage during development.

Continuous Whole-Body 3D Kinematic Recordings across the Rodent Behavioral Repertoire.

In mammalian animal models, high-resolution kinematic tracking is restricted to brief sessions in constrained environments, limiting our ability to probe naturalistic behaviors and their neural underpinnings. To address this, we developed CAPTURE (Continuous Appendicular and Postural Tracking Using Retroreflector Embedding), a behavioral monitoring system that combines motion capture and deep learning to continuously track the 3D kinematics of a rat's head, trunk, and limbs for week-long timescales in freely behaving animals. CAPTURE realizes 10- to 100-fold gains in precision and robustness compared with existing convolutional network approaches to behavioral tracking. We demonstrate CAPTURE's ability to comprehensively profile the kinematics and sequential organization of natural rodent behavior, its variation across individuals, and its perturbation by drugs and disease, including identifying perseverative grooming states in a rat model of fragile X syndrome. CAPTURE significantly expands the range of behaviors and contexts that can be quantitatively investigated, opening the door to a new understanding of natural behavior and its neural basis.

What is the clinical impact of positive cultures at the time of primary total shoulder arthroplasty?

BACKGROUND: Cultures taken at the time of primary shoulder arthroplasty are commonly positive for Cutibacterium acnes. Despite our limited understanding of the clinical implication of deep tissue inoculation from dermal colonization, significant efforts have been made to decolonize the shoulder prior to surgery. The purpose of this study is to determine differences in clinical outcomes based on culture positivity at the time of primary shoulder arthroplasty. METHODS: A series of 134 patients who underwent primary anatomic or reverse total shoulder arthroplasty and had intraoperative cultures obtained via a standard protocol were included. In each case, 5 tissue samples were collected and processed in a single laboratory for culture on aerobic and anaerobic media for 13 days. Minimum 2-year functional outcomes scores (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES] and Single Assessment Numeric Evaluation [SANE]) and reoperation data were analyzed. RESULTS: Forty-two (31.3%) patients had positive cultures (30 C acnes and 21 with at least 2 positive cultures) at the time of surgery. There was no statistically significant difference in postoperative functional outcome scores (ASES: 82.5 vs. 81.9; P = .89, SANE: 79.5 vs. 82.1; P = .54) between culture-positive and culture-negative cohorts. There were no cases of infection. Two patients (4.8%; 2/42) with positive cultures required reoperation compared with 4 patients (5.6%; 4/71) without positive cultures. CONCLUSION: The apparent colonization by nonvirulent organisms in patients undergoing primary shoulder arthroplasty does not appear to have a clinically significant effect on functional outcomes or need for repeat surgery in the short term.

Preoperative Sedative Use and Other Risk Factors for Continued Narcotic Use After Total Knee Arthroplasty: A Comprehensive Analysis of a Mandatory Database.

Opioids are used for pain control after total knee arthroplasty (TKA) and carry risk for abuse. Mandatory statewide databases have been created to monitor their use. The goal of this study was to identify patient risk factors for prolonged opioid use after TKA. The authors retrospectively reviewed a consecutive series of 676 primary TKA procedures performed between January 2017 and July 2017. Information on fulfillment of narcotic, sedative, benzodiazepine, and stimulant prescriptions was obtained from the Pennsylvania State Controlled Substance Monitoring website 6 months before and 1 year after the procedure. Bivariate and multivariate analyses were used to identify risk factors for the need for a second prescription and opioid use for longer than 6 months. Of this cohort, 30.3% used preoperative opioids, 60.5% filled a second opioid prescription, and 11.8% continued opioid use for longer than 6 months. Patients who had opioid use before the index procedure had more than 3-fold (odds ratio [OR], 3.29; P<.001) increased odds of filling a second opioid prescription and 8-fold (OR, 8.05; P<.001) increased odds of postoperative opioid use for longer than 6 months. Multivariate analysis was used to identify independent risk factors for requiring a second prescription, including discharge to a rehabilitation facility (OR, 2.77), bilateral procedures (OR, 1.88), preoperative narcotic use (OR, 1.70), and younger age (OR, 0.95). Independent risk factors for narcotic use for longer than 6 months included preoperative sedative (OR, 3.30) or narcotic use (OR, 1.49). This study identified several risk factors associated with prolonged narcotic use after TKA, including preoperative sedative use, and determined their relative weight. [Orthopedics. 2021;44(1):e50-e54.].

Dorsal Bridge Plating versus External Fixation for Distal Radius Fractures.

Background External fixation and dorsal bridge plating are wrist spanning fixation options for distal radius fractures; however, their comparative effectiveness is not well understood. A meta-analysis was conducted to compare the clinical outcomes between these two techniques. Materials and Methods A PubMed database query of all distal radius fracture cases managed with spanning external fixation or dorsal bridge plating was performed. A total of 28 articles met inclusion criteria, yielding 895 patients for data extraction and comparative analysis. Results Dorsal bridge plating demonstrated lower rates of infection (2 vs. 10%, p = 0.05) and complex regional pain syndrome (1 vs. 4%, p = 0.04) but higher rates of hardware failure (4 vs. 1%, p = 0.026). Bridge plating also demonstrated higher rates of excellent/good ratings under the Gartland and Werley outcome score (91 vs. 83%, p = 0.016). There was no significant difference in DASH (Disability of the Arm, Shoulder, and Wrist) scores, radiographic parameters, or unplanned reoperations between the two spanning fixation options. Conclusion Bridge plating and external fixation both appear to be comparable for spanning fixation constructs for distal radius fractures, but with bridge plating having a potentially lower complication profile.

Understanding Opioid Use After Total Hip Arthroplasty: A Comprehensive Analysis of a Mandatory Prescription Drug Monitoring Program.

INTRODUCTION: Opioids remain the most prescribed medication after total hip arthroplasty (THA) despite the potential for abuse and adverse effects. Given the high rates of opioid abuse and potential adverse effects, the reporting of controlled substances is now mandatory in many statewide databases. This study aimed to use a mandatory statewide database to analyze opioid prescription patterns in postoperative THA patients and identify independent risk factors for those patients who need a second prescription and/or require prolonged use (>6 months). METHODS: We retrospectively reviewed a consecutive series of 619 primary THAs. Demographic and comorbidity information were collected for all patients. Narcotic prescription data (converted to morphine milligram equivalents) as well as prescription data for sedatives, benzodiazepines, and stimulants were collected from the State's Controlled Substance Monitoring websites 6 months before and 9 months after the index procedure. Bivariate and multivariate analyses were done for second prescription and continued use. RESULTS: Of the 619 patients who underwent THA, 34.9% (216/619) used preoperative opioids, 36.2% (224/619) filled a second opioid prescription, and 10.5% (65/619) had continued use past 6 months. Patients with preoperative opioids were at an approximately 4-fold increased odds of requiring a second script and 12 times odds of continued opioid use. In the multivariate analysis, independent risk factors for requiring a second prescription, in descending order of magnitude, included the use of any sedative or sleep aid prescription and preoperative narcotic use. Independent risk factors for continued narcotic use longer than 6 months after THA included preoperative narcotic use and increased length of stay. DISCUSSION: Several risk factors and their relative weight have been identified for continued narcotic consumption after THA. It is important for surgeons to consider these predisposing factors preoperatively during the informed consent process and for managing postoperative pain expectations.

A Comparison of 6 Diagnostic Tests for Carpal Tunnel Syndrome Using Latent Class Analysis.

Background: Nerve conduction studies (NCS), ultrasonography (US), Carpal Tunnel Syndrome 6 (CTS-6), Wainner, Lo, and Kamath are clinical diagnostic tools that can be used to diagnose carpal tunnel syndrome (CTS). Latent class analysis (LCA) is a proven statistical technique that can be used to evaluate diagnostic tests in a lack of a reference standard. Given that there is no accepted reference standard, we elected to perform an LCA to evaluate the 6 clinical diagnostic tests. Methods: One hundred eighty-seven wrists were prospectively evaluated by a board-certified hand surgeon using US, the CTS-6, Wainner, Lo, and Kamath. The NCS were performed by an electrophysiologist according to the standards of the American Association of Neuromuscular & Electrodiagnostic Medicine. The LCA was performed to evaluate individual performance and pairwise combinations of the tests. Results: The NCS demonstrated the highest estimated sensitivity of 97%, and the Wainner had the highest estimated specificity of 97%. Alternatively, the Lo had the lowest estimated sensitivity (36%), and NCS had the lowest estimated specificity (40%). When evaluating pairwise combinations, positive US and NCS demonstrated the highest overall sensitivity at 86%, and negative US and NCS had a specificity of 83%. Conclusions: There is no perfect clinical diagnostic test, with the 6 clinical diagnostic tests having differing sensitivities and specificities. Pairwise combinations of the test can be used to complement one another.

Do we really need to order magnetic resonance imaging? Shoulder surgeon ultrasound practice patterns and beliefs.

BACKGROUND: Despite significant benefits, many orthopedic surgeons are hesitant to incorporate diagnostic ultrasound into their practice. This may be because of a lack of comfort, knowledge, and/or training. The purpose of this study was to analyze practice patterns regarding the use of shoulder ultrasound by orthopedic surgeons to diagnose rotator cuff tears. MATERIALS AND METHODS: We conducted a survey of the members of the American Shoulder and Elbow Surgeons (ASES) regarding their use of ultrasound. A systematic review of the literature on the use of ultrasound in the shoulder by orthopedic surgeons was also performed. RESULTS: Of the members of ASES responding to the survey, 55% are using ultrasound for diagnostic purposes in the shoulder. The leading reason for not using ultrasound as the sole imaging modality prior to performing rotator cuff repair was lack of confidence in the ability to determine the reparability of the tear (83%). Our systematic review showed that for an orthopedic surgeon diagnosing a full-thickness rotator cuff tear, the mean sensitivity was 92% and mean specificity was 89%. CONCLUSIONS: Many ASES surgeons are not using ultrasound in the shoulder despite its many potential benefits over magnetic resonance imaging. This is because of a lack of confidence in the ability to quantify fatty infiltration, muscle atrophy, and the level of retraction medial to the acromion. Our systematic review showed that orthopedic surgeons can be accurate in the diagnosis of full-thickness rotator cuff tears. Future research should focus on defining parameters of shoulder ultrasound associated with rotator cuff tendon reparability. Educating surgeons on ultrasound technique, cost, and evidence may be a promising strategy to enhance the value in musculoskeletal care delivery.

Self-Directed Home Exercises vs Outpatient Physical Therapy After Total Knee Arthroplasty: Value and Outcomes Following a Protocol Change.

BACKGROUND: The need for outpatient physical therapy (OPPT) has been questioned following primary total knee arthroplasty (TKA). Recent studies have suggested that similar outcomes may be possible with self-directed home exercise programs (HEP) compared to OPPT, which can be costly to both the patient and healthcare system. The aim of the present study is to compare the safety, efficacy, and health economics of formal OPPT with self-directed home exercises after TKA following a protocol change. METHODS: A single-surgeon, retrospective study of 520 consecutive patients undergoing primary unilateral TKA from 2016 to 2018 was performed. All 251 TKAs performed in 2016 were routinely prescribed OPPT, while all 269 TKAs in 2017 completed a self-directed HEP alone for 2 weeks. At their 2-week visit, OPPT was prescribed if patients had less than 90° range of motion or per patient request. Financial data of postdischarge costs were collected for all patients. Multivariate logistic regression evaluated for variables associated with failure of the HEP program. RESULTS: Overall, 65.8% (177/269) of patients in the HEP group did not require OPPT. There was no significant difference in percentage of patients whose range of motion was less than 90° at 2-week follow-up between OPPT and HEP (14% vs 11.9%, P = .467). Between OPPT and HEP, there were no differences in manipulation under anesthesia (3.2% vs 3%, P = .883). On average, patients who received OPPT incurred an increase in average cost of $1340.87 and $1893.42 for Medicare and private insurer patients, respectively. We did not identify any significant risk factors for failing HEP. CONCLUSION: Comparable outcomes were demonstrated between patients receiving HEP compared to OPPT with a substantial cost saving. While a portion of patients still require formal OPPT, the majority do not. Surgeons should consider an initial trial of HEP with close follow-up in order to limit unnecessary costs associated with OPPT.

The diagnostic clinical value of thumb metacarpal grind, pressure-shear, flexion, and extension tests for carpometacarpal osteoarthritis.

STUDY DESIGN: Clinical measurement. INTRODUCTION: Common provocative maneuvers to differentiate thumb carpometacarpal (CMC) osteoarthritis from other sources of pain are the grind, metacarpal (MC) flexion, and MC extension tests. A maneuver known as the pressure-shear test is described here. PURPOSE OF THE STUDY: To compare the diagnostic value of the grind, metacarpal flexion, metacarpal extension, and pressure-shear tests for CMC osteoarthritis of the thumb. METHODS: The diagnostic accuracy of each test was compared in 127 thumbs from 104 patients. Sensitivity, specificity, and predictive values of each test were calculated. In a secondary analysis, polychoric correlation coefficients were used to assess the correlation of each test with severity defined by Eaton-Littler stage. RESULTS: The overall diagnostic accuracy of the thumb MC grind, pressure-shear, flexion, and extension tests were 70%, 98%, 47%, and 55%, respectively. The sensitivities were 64%, 99%, 36%, and 46%, respectively, and specificities were 100%, 95%, 100%, and 100%, respectively. For the diagnosis of Thumb CMC arthritis, the MC pressure-shear test was superior overall in terms of overall diagnostic accuracy and sensitivity, while having comparable specificity to the other maneuvers. CONCLUSION: The pressure-shear test was found to be superior to the commonly used grind maneuver and the provocative maneuvers of MC flexion and extension tests to confirm diagnosis of CMC osteoarthritis.

A Novel Technique for Correcting Radial Length and Translation in Distal Radius Fractures.

We describe a novel technique in correcting distal radius fractures deformed with significant shortening or coronal plane translation in both the acute or chronic setting. The technique involves using a modified push-pull device to assist the surgeon in correcting length and/or translation of the articular block without the use additional hardware outside of the volar plate.