Electronic Health Records for Predicting Outcomes to Work-Related Musculoskeletal Disorders: A Scoping Review.

PURPOSE: Through electronic health records (EHRs), musculoskeletal (MSK) therapists such as chiropractors and physical therapists, as well as occupational medicine physicians could collect data on many variables that can be traditionally challenging to collect in managing work-related musculoskeletal disorders (WMSDs). The review's objectives were to explore the extent of research using EHRs in predicting outcomes of WMSDs by MSK therapists. METHOD: A systematic search was conducted in Medline, PubMed, CINAHL, and Embase. Grey literature was searched. 2156 unique papers were retrieved, of which 38 were included. Three themes were explored, the use of EHRs to predict outcomes to WMSDs, data sources for predicting outcomes to WMSDs, and adoption of standardised information for managing WMSDs. RESULTS: Predicting outcomes of all MSK disorders using EHRs has been researched in 6 studies, with only 3 focusing on MSK therapists and 4 addressing WMSDs. Similar to all secondary data source research, the challenges include data quality, missing data and unstructured data. There is not yet a standardised or minimum set of data that has been defined for MSK therapists to collect when managing WMSD. Further work based on existing frameworks is required to reduce the documentation burden and increase usability. CONCLUSION: The review outlines the limited research on using EHRs to predict outcomes of WMSDs. It highlights the need for EHR design to address data quality issues and develop a standardised data set in occupational healthcare that includes known factors that potentially predict outcomes to help regulators, research efforts, and practitioners make better informed clinical decisions.

The necessity of removal of third molars involved in mandibular fractures: A retrospective study.

This retrospective analysis aimed to investigate the necessity of removing the wisdom tooth in cases of angle fractures of the mandible. The study retrieved 595 mandible fractures from January 2006 to December 2021 through the Hospital Inpatient Enquiry System, of which 303 involved a fracture through the angle of the mandible, including the wisdom tooth socket. Of these, 203 (66.9%) underwent open reduction and internal fixation with retention of the third molar. The authors found that only four (2%) patients returned for the removal of plates and the retained third molar during the follow-up period. Therefore, the authors concluded that wisdom teeth removal should remain an exception during open reduction and internal fixation of mandibular angle fractures unless they hinder fracture reduction, pose a potential infection risk, or interfere with occlusal stability.

Assessing discards in an illegal small-scale fishery using fisher-led reporting.

About a third of all marine fish in the world are caught in Small-Scale Fisheries (SSF). SSF are increasingly recognised as essential for food security and livelihoods for vulnerable and economically fragile communities globally. Although individual SSF vessels are usually perceived as having little impact on the ecosystem, the cumulative impact of gear type and number of vessels may be substantial. Bottom trawling is a common fishing method that can greatly influence the marine ecosystem by damaging the seafloor and generating high levels of discards. However, appropriate sampling coverage using on-board observer programmes to collect these data from SSF are rare, as they are expensive and pose logistical constraints. A mobile App was used to assess whether self-reporting by fishers could provide reliable fine-scale information on fishing effort and discards over time in an illegal shrimp trawling fishery in northern Peru. Maps depicting the spatial distribution of trawling effort and the proportion of discards from observers and fishers were compared using the Similarity in Means (SIM) Index, which ranges from 0 when spatial patterns differ completely to 1 when spatial patterns are very similar. High levels of agreement between spatio-temporal patterns of effort (SIM Index = 0.81) and discards (0.96) were found between fisher and observer maps. Moreover, far greater spatial coverage was accomplished by fishers, suggesting that self-reporting via an App represents a useful approach to collect reliable fisheries data as an initial step for effective monitoring and management of these fisheries. Supplementary Information: The online version contains supplementary material available at 10.1007/s11160-022-09708-9.

Predictors of mortality following shoulder arthroplasty.

INTRODUCTION: This study aims to determine 30-day, 90-day and 1 year mortality following shoulder arthroplasty and identify predictors of mortality. MATERIALS AND METHODS: All shoulder arthroplasty cases performed at the host institution, between 2012 and 2018 were included. A review of patient records was completed to identify demographic data, Charlson comorbidity index, date of death and factors associated with mortality.Mortality analysis was undertaken using 1-Kaplan Meier estimates with 95% confidence intervals. Comparative analysis was performed for mortality following shoulder arthroplasty for elective vs. trauma and for primary vs. revision surgery. A multiple regression analysis was conducted to determine which factors were associated with increased mortality risk. RESULTS: 640 shoulder arthroplasty cases were performed in 566 patients. There were 44 deaths, 1 occurred within 90 days and 13 within 1 year. Trauma procedures had a hazard ratio of 5.3 (95% CI 1.9 to 15.0) for mortality compared to elective procedures (5 year survival trauma 78.6% (95% CI 60.7 to 89.0); elective 91.8% (95% CI 88.1 to 94.4). 1-year mortality was predicted by presence of malignancy, liver failure, cardiac failure, peptic ulcer, trauma surgery, revision surgery, intra-operative complication, transfusion and increased length of stay. DISCUSSION: 30-day, 90-day and 1-year mortality following shoulder arthroplasty were 0%, 0.16% and 2%; trauma procedures had a hazard ratio of 5.3 for 1-year mortality when compared to elective surgery. Malignancy, cardiac failure, liver failure, peptic ulcer and trauma surgery are associated with an increased risk of 1-year mortality.

Predictors of length of stay following shoulder arthroplasty in a high-volume UK centre.

INTRODUCTION: Shoulder arthroplasty rates are increasing in the UK. No data have been published from a UK centre on predictors of length of inpatient stay following shoulder arthroplasty. This study analyses the length of inpatient stay following shoulder arthroplasty in a high-volume UK centre and identifies predictors of prolonged inpatient stay. MATERIALS AND METHODS: All shoulder arthroplasty cases performed between 2012 and 2018 were identified. A review of case notes and electronic patient records was completed to identify demographic data, Charlson comorbidity score, length of inpatient stay and factors associated with length of stay. Multiple linear regression analysis was conducted to determine which factors were independently associated with length of inpatient stay. RESULTS: A total of 640 shoulder arthroplasty cases were performed in 566 patients. Median length of stay was two days. Length of stay was predicted by age, sex, chronic kidney disease, congestive cardiac failure, previous myocardial infarction, intraoperative complication and postoperative transfusion. DISCUSSION: Increasing age, female sex, chronic kidney disease, congestive cardiac failure, previous myocardial infarction, intraoperative complication and transfusion were independent predictors of increased length of stay. Strategies to reduce perioperative complication and transfusion, and to optimise renal and cardiac comorbidities may reduce overall length of stay for shoulder arthroplasty patients.

Aggressive Recurrence of Oral Squamous Cell Carcinoma in a patient with Fanconi's Anaemia (FA).

Fanconi's Anaemia is a rare autosomal recessive disease for which the incidence of head and neck cancer can be increased 700-fold1. We report a case of a 31-year old Caucasian male with FA who initially presented in July 2007 with oral squamous cell carcinoma for which he received radical surgery and radiotherapy. He was disease-free until August 2015 when he presented with an extremely aggressive recurrence.

Standard duplex criteria overestimate the degree of stenosis after eversion carotid endarterectomy.

OBJECTIVE: The eversion technique for carotid endarterectomy (eCEA) offers an alternative to longitudinal arteriotomy and patch closure (pCEA) for open carotid revascularization. In some reports, eCEA has been associated with a higher rate of >50% restenosis of the internal carotid when it is defined as peak systolic velocity (PSV) >125 cm/s by duplex imaging. Because the conformation of the carotid bifurcation may differ after eCEA compared with native carotid arteries, it was hypothesized that standard duplex criteria might not accurately reflect the presence of restenosis after eCEA. METHODS: In a case-control study, the outcomes of all patients undergoing carotid endarterectomy by one surgeon during the last 10 years were analyzed retrospectively, with a primary end point of PSV >125 cm/s. Duplex flow velocities were compared with luminal diameter measurements for any carotid computed tomography arteriography or magnetic resonance angiography study obtained within 2 months of duplex imaging, with the degree of stenosis calculated by the methodology used in the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST) as well as cross-sectional area (CSA) reduction. Simulations were generated and analyzed by computational model simulations of the eCEA and pCEA arteries. RESULTS: Eversion and longitudinal arteriotomy with patch techniques were used in 118 and 177 carotid arteries, respectively. Duplex follow-up was available in 90 eCEA arteries at a median of 16 (range, 2-136) months and in 150 pCEA arteries at a median of 41 (range, 3-115) months postoperatively. PSV >125 cm/s was present at some time during follow-up in 31% of eCEA and pCEA carotid arteries, each, and in the most recent duplex examination in 7% after eCEA and 21% after pCEA (P = .003), with no eCEA and two pCEA arteries occluding completely during follow-up (P = .29). In 19 carotid arteries with PSV >125 cm/s after angle correction (median, 160 cm/s; interquartile range, 146-432 cm/s) after eCEA that were subsequently examined by axial imaging, the mean percentage stenosis was 8% ± 11% by NASCET, 11% ± 5% by ECST, and 20% ± 9% by CSA criteria. For eight pCEA arteries with PSV >125 cm/s (median velocity, 148 cm/s; interquartile range, 139-242 cm/s), the corresponding NASCET, ECST, and CSA stenoses were 8% ± 35%, 26% ± 32%, and 25% ± 33%, respectively. NASCET internal carotid diameter reduction of at least 50% was noted by axial imaging after two of the eight pCEAs, and the PSV exceeded 200 cm/s in each case. CONCLUSIONS: The presence of hemodynamically significant carotid artery restenosis may be overestimated by standard duplex criteria after eCEA and perhaps after pCEA. Insufficient information currently exists to determine what PSV does correspond to hemodynamically significant restenosis.

The tricipital aponeurosis--a reliable soft tissue landmark for humeral plating.

This study aims to identify the relationship of the radial nerve as it descends across the humerus with reference to a reliable soft tissue landmark, the tricipital aponeurosis. Following cadaveric dissection of 10 adult humerii, the radial nerve was located as it crossed the lateral midsagittal point of the humeral diaphysis. A horizontal line was then subtended medially from this point to another line subtended vertically from the lateral border of the tricipital aponeurosis. The vertical distance from this intersection to the lateral apex of the aponeurosis was recorded in three positions (full flexion, 90° of flexion and full extension). The location of the radial nerve on the posterior aspect of the humeral diaphysis to the medial apex of the tricipital aponeurosis was also noted. In 90° of flexion the radial nerve at the lateral midsagittal point of the humerus was 0.9 mm proximal to the lateral apex of the tricipital aponeurosis. Flexion and extension of the elbow changed the interval to 16.3 mm (nerve proximal) in full flexion and 7.1 mm in full extension (nerve distal). On the posterior aspect of the humerus the radial nerve was 21.8 mm proximal to the medial aspect of the tricipital aponeurosis. The aponeurosis provides a reference point from which the nerve can be easily located on the lateral aspect of the humerus intraoperatively in a range of positions, whilst the medial apex provides a guide to the location of the nerve on the posterior aspect of the arm.

Reverse geometry shoulder replacement for proximal humeral metastases.

The management of skeletal metastases can be challenging for the orthopaedic surgeon. They represent a significant source of pain and disability for cancer patients, adding to the morbidity of their condition. Treatment is directed at the alleviation of symptoms and the restoration of function. Metastatic involvement of the proximal humerus can be especially debilitating, having the potential to cause severe pain and loss of function. We present a report of three such cases where reverse geometry proximal shoulder replacement was used to provide a pain free functional range of movement in patients with concomitant rotator cuff disease. In all cases, significant symptomatic relief was achieved postoperatively with preservation of upper limb function. No surgical complications were noted. It is our belief that this novel surgical strategy provides a valuable and effective option for the management of proximal humeral metastatic disease in the rotator cuff deficient patient.

The effect of ultrasound guided steroid injection on progression to surgery in thumb CMC arthritis.

Thumb carpometacarpal joint (CMCJ) osteoarthritis is a common complaint that produces pain and disability within the hand. This study aims to ascertain whether joint injection with local anaesthetic and steroid is of predicative value in disease progression in thumb carpometacarpal osteoarthritis. Forty-three patients were assessed at an average follow up of 24 months following ultrasound-guided injection. Fourteen patients (32%) progressed to surgery, at a mean interval of 8.6 months (range 4-14 months). There was a statistically significant correlation between those patients who had on-going pain following injection at one week and progression to surgery (p = 0.025) with an odds ratio of 3.14 and positive likelihood ratio of 2.1. Patients with thumb CMCJ osteoarthritis that does not respond favourably to injection at one week are likely to progress to surgery in the first year after the injection. This work offers a useful tool in predicting disease progression and patient counseling.

Contrast enhanced ultrasound (CEUS) reliably detects critical perfusion changes in compartmental muscle: a model in healthy volunteers.

PURPOSE: The purpose of this study was to assess the utility of contrast enhanced ultrasound (CEUS) in the differentiation between physiological and simulated pathophysiological lower limb muscle perfusion pressures in healthy volunteers. METHODS: The lower limb muscle perfusion pressures in eight healthy volunteers were assessed in the supine position (as a control) and then subsequently in an elevated position with a thigh tourniquet applied to induce venous stasis. An intravenous bolus injection of 2.5 ml contrast agent was given to create a perfusion signal, which was measured with a multiple-frequency probe. Semiquantitative analysis was performed using specific software to create a perfusion curve which allowed measurement of six parameters: the time to arrival (TTA) starting from bolus application (s); peak of signal intensity (%); time to peak (TTP) maximum (seconds); regional blood volume (RBV), regional blood flow (RBF), and mean transit time (MTT) in seconds. Statistical analysis was performed using the Mann-Whitney U test as a non-parametric test (IBM SPSS statistics, version 21, USA). RESULTS: The group of simulated hypoperfusion showed significant higher values for TTA (39.8 ± 5.1 s) (p = 0.028), TTP (43.8 ± 13.6 s) (p = 0.003), RBV (8,424 ± 5,405) (p = 0.028), and MTT (262 ± 90.6 s) (p = 0.005). In contrast, the parameter of regional blood flow (32.1 ± 10.9) was significantly lower (p = 0.038). The peak signal intensity (25.8 ± 8.2 %) was lower, but this was not significant (p = 0.083). CONCLUSIONS: CEUS provides a reliable non-invasive imaging modality for the assessment of lower limb muscle perfusion pressures. This may be of clinical use in the assessment of a developing compartment syndrome. Further clinical studies are required to further define its accuracy and reproducibility.

Enlarging neck masses in the elderly - Histological and surgical considerations.

INTRODUCTION: Anaplastic carcinoma of the thyroid is a rare but aggressive malignancy which can present with a rapidly enlarging neck mass or compressive sequelae of cough, dyspnoea, dysphagia and hoarseness. Treatment of such tumours is commonly palliative however they occasionally represent surgical challenges due to their rapid growth, diagnostic difficulty and locoregional spread. PRESENTATION OF CASE: A 75 year-old retired veterinary surgeon was referred with a 2 month history of a painless, enlarging neck mass. The patient denied any secondary compressive symptoms or general symptoms of malignancy. On examination a large right-sided neck mass measuring 7cm×5cm was appreciated which was fixed, hard and irregular with associated adenopathy. DISCUSSION: We discuss the diagnostic challenges posed by anaplastic carcinoma of the thyroid and the difficulties in selecting the appropriate intervention in this aggressive disease process. CONCLUSION: Anaplastic carcinoma of the thyroid is encountered infrequently in clinical practice and can generate diagnostic and therapeutic challenges.

Functional outcome following tibio-talar-calcaneal nailing for unstable osteoporotic ankle fractures.

INTRODUCTION: Fragility fractures of the ankle are increasing in incidence. Such fractures typically occur from low-energy injuries but lead to disproportionately high levels of morbidity. Ankle fractures in this age group are managed conservatively in plaster or by open reduction and internal fixation. Both modalities have shown high rates of failure in terms of delayed union or mal-union together with perioperative complications such as implant failure and wound breakdown. The optimal treatment of these patients remains controversial. OBJECTIVES: We aimed to review the functional outcome of patients with ankle fragility fractures primarily managed using a tibio-talar-calcaneal nail (TTC). METHODS: We retrospectively reviewed 31 consecutive patients primarily managed with a TCC nail for osteoporotic fragility fractures about the ankle. Data were collected via case notes, radiographic reviews and by clinical reviews at the outpatient clinic or a telephone follow-up. Information regarding patient characteristics, indication for operation, Arbeitsgemeinschaft für Osteosynthesefragen (AO) fracture classification, operative and postoperative complications, time to radiographic union and current clinical state including Olerud and Molander scores were recorded (as a measure of ankle function). RESULTS: Nine of 31 patients had died by the time of follow-up. Mean preoperative and postoperative Olerud and Molander scores were 56 and 45, respectively. There were no postoperative wound complications. Twenty-nine of 31 patients returned to the same level of mobility as pre-injury. There were three peri-prosthetic fractures managed successfully with nail removal and replacement or plaster cast. There were two nail failures, both in patients who mobilised using only a stick, which were managed by nail removal. Ten of 31 patients were not followed up radiographically due to either infirmity or death. Thirteen of 21 followed up radiographically had evidence of union and 8/21 had none. None, however, had clinical evidence of fracture nonunion. CONCLUSION: The TTC nail can successfully be used to manage fragility fractures about the ankle in the elderly. Much like fractured neck of femur patients, who also have a high rate of mortality, this allows immediate mobilisation with minimal risk of wound complications. However, careful assessment must be made of each patient's mobility, as there is a significant incidence of device failure in the more active patient.

The emergent assessment of supracondylar fractures of the paediatric humerus.

Supracondylar fractures of the distal humerus are a common and serious paediatric injury, often accompanied by neurovascular compromise. Accurate neurovascular evaluation of the injured limb is essential in order to guide emergent treatment. To assess whether trainees are proficient in the assessment and management of supracondylar fractures, performance was audited against objective standards drawn from the literature.

The cadaveric anatomy of the distal radius: implications for the use of volar plates.

INTRODUCTION: Fractures of the distal radius are common upper limb injuries, representing a substantial proportion of the trauma workload in orthopaedic units. With ever increasing advancements in implant technology, operative intervention is becoming more frequent. As growing numbers of surgeons are performing operative fixation of distal radial fractures, an accurate understanding of the relevant surgical anatomy is paramount. The flexor carpi radialis (FCR) tendon forms the cornerstone of the Henry approach to the volar cortex of the distal radius. A number of key neurovascular structures around the wrist are potentially at risk during this approach, especially when the FCR is mobilised and placed under retractors. METHODS: In order to clarify the safe margins of the FCR approach, ten fresh frozen human cadaver limbs were dissected. The location of the radial artery, the median nerve, the palmar cutaneous branch of the median nerve and the superficial branch nerve were measured with respect to the FCR tendon. Measurements were taken on a centre-to-centre basis in the coronal plane at the watershed level. In addition, the distances between the tendons of brachioradialis, abductor pollicis longus and flexor pollicis longus, and the radial artery and median nerve were measured to create a complete picture of the anatomy of the FCR approach to the distal radius. RESULTS: The structure most at risk was the palmar cutaneous branch of the median nerve. It was located on average 3.4mm from the FCR tendon. The radial artery and the main trunk of the median nerve were located 7.8mm and 8.9mm from the tendon. The superficial branch of the radial nerve was 24.4mm from the FCR tendon and 11.1mm from the brachioradialis tendon. CONCLUSIONS: Operative intervention is not without complication. We believe a more accurate understanding of the surgical anatomy is key to the prevention of neurovascular damage arising from the surgical management of distal radial fractures.

SU-E-T-583: Feasibility of Constraining Dose to the Nausea Center (area Postrema and Dorsal Vagal Complex) in IMRT Treatment Planning of the Head and Neck.

PURPOSE: Nausea and vomiting have been known to occur in patients undergoing external beam radiation treatments for head&neck cancers. We sought to determine the feasibility of limiting the dose delivered to the nausea center, area postrema (AP) and dorsal vagal complex (DVC), for these patients without compromising target coverage and critical organ doses. METHODS: In a retrospective study 23 oropharyngeal cancer patients were identified as being treated with definitive or adjuvant radiotherapy at Memorial Sloan Kettering Cancer Center. Patients were treated solely with external beam radiation using intensity modulated radiation therapy (IMRT). The nausea center was carefully contoured in the treatment CT with the assistance of a board certified neuroradiologist. The doses delivered to the nausea center were calculated for each plan delivered. Cases were replanned offline to determine the lowest achievable nausea center dose that does not compromise the overall PTV coverage or critical structures doses, these being brainstem, spinal cord, cochleas, and temporal lobes. RESULTS: Patients reporting higher nausea grade had median AP and DVC doses of 38.7Gy and 40.4Gy, respectively. Patients reporting higher vomiting grade had median AP and DVC doses of 39.5Gy and 44.7Gy, respectively. Replanning resulted in reduced dose to AP by an average of 18% and to the DVC by an average of 16% while maintaining adequate target coverage and doses to the critical organs the same or decreased by 1-4% . We aim to achieve a max dose of 36Gy to AP and 38Gy to DVC for these cases. CONCLUSIONS: It is feasible to limit the doses to the nausea center without compromising target coverage or critical organ limits for oropharyngeal cancer patients undergoing IMRT treatment. Clinical results indicating an association between radiation dose to the nausea center and development of nausea and/or vomiting can potentially be addressed by implementing this technique.

Intramedullary nailing for pathological fractures of the ulna.

Pathological lesions of long bones increase the morbidity of many common cancers. The orthopedic management of metastatic skeletal lesions can be challenging. The ultimate aim is to provide patients with a painless, functional limb. We present a report of two cases were a novel minimally invasive long bone nailing technique has been utilized to achieve skeletal stability and alleviation of symptoms.