Preoperative Electrodiagnostic Study Findings Differ Between Patients With Double-crush Syndrome and Carpal Tunnel Syndrome: A Propensity Matched Analysis.

INTRODUCTION: Double-crush syndrome (DCS) represents a condition that involves peripheral nerve compression in combination with spinal nerve root impingement. The purpose of this study was to compare electrodiagnostic study (EDS) results in patients undergoing carpal tunnel release (CTR) for carpal tunnel syndrome with those undergoing both CTR and anterior cervical diskectomy and fusion for DCS. METHODS: Patients receiving an isolated CTR were compared with those undergoing CTR and anterior cervical diskectomy and fusion within two years of CTR. The latter group was defined as our DCS cohort. Electrodiagnostic study results were collected which included sensory and motor nerve conduction data as well as electromyogram (EMG) findings. All electrodiagnostic studies were done before CTR in both sets of patients. RESULTS: Fifty-four patients with DCS and 137 CTR-only patients were included. Patients with DCS were found to have decreased sensory onset latency (3.51 vs 4.01; P = 0.015) and peak latency (4.25 vs 5.17; P = 0.004) compared with the CTR-only patients. Patients with DCS had slower wrist motor velocity (30.5 vs 47.7; P = 0.012), decreased elbow motor latency (9.62 vs 10.6; P = 0.015), and faster elbow motor velocity (56.0 vs 49.4; P = 0.031). EMG results showed that patients with DCS were more likely to have positive findings in the biceps (31.9% vs 1.96%; P < 0.001) and triceps (24.4% vs 2.97%; P < 0.001), but not abductor pollicis brevis (APB) (45.7% vs 37.9%; P = 0.459). CONCLUSION: We identified changes on EDS between patients with and without DCS. In patients with DCS, sensory nerve studies showed shorter peak and onset latency than in CTR-only patients. Interestingly, DCS and CTR-only patients had different patterns of wrist and elbow motor nerve conduction. Providers observing positive EMG findings proximal to the APB should raise their suspicion for possible cervical radiculopathy and when present with carpal tunnel syndrome-like symptoms, should also consider DCS in their diagnostic differential.

A quality and readability comparison of artificial intelligence and popular health website education materials for common hand surgery procedures.

INTRODUCTION: ChatGPT and its application in producing patient education materials for orthopedic hand disorders has not been extensively studied. This study evaluated the quality and readability of educational information pertaining to common hand surgeries from patient education websites and information produced by ChatGPT. METHODS: Patient education information for four hand surgeries (carpal tunnel release, trigger finger release, Dupuytren's contracture, and ganglion cyst surgery) was extracted from ChatGPT (at a scientific and fourth-grade reading level), WebMD, and Mayo Clinic. In a blinded and randomized fashion, five fellowship-trained orthopaedic hand surgeons evaluated the quality of information using a modified DISCERN criteria. Readability and reading grade level were assessed using Flesch Reading Ease (FRE) and Flesch-Kincaid Grade Level (FKGL) equations. RESULTS: The Mayo Clinic website scored higher in terms of quality for carpal tunnel release information (p = 0.004). WebMD scored higher for Dupuytren's contracture release (p < 0.001), ganglion cyst surgery (p = 0.003), and overall quality (p < 0.001). ChatGPT - 4th Grade Reading Level, ChatGPT - Scientific Reading Level, WebMD, and Mayo Clinic written materials on average exceeded recommended reading grade levels (4th-6th grade) by at least four grade levels (10th, 14th, 13th, and 11th grade, respectively). CONCLUSIONS: ChatGPT provides inferior education materials compared to patient-friendly websites. When prompted to provide more easily read materials, ChatGPT generates less robust information compared to patient-friendly websites and does not adequately simplify the educational information. ChatGPT has potential to improve the quality and readability of patient education materials but currently, patient-friendly websites provide superior quality at similar reading comprehension levels.

A Novel Classification of Intraoperative Ulnar Nerve Instability to Aid Transposition Surgery.

HYPOTHESIS: The purpose of this study was to compare inter-and intraobserver agreement of a novel intraoperative subluxation classification for patients undergoing ulnar nerve surgery at the elbow. We hypothesize there will be strong inter- and intraobserver agreement of the four-category classification system and reviewers will have substantial confidence while reviewing the classification system. METHODS: Four blinded fellowship-trained orthopedic hand surgeons reviewed 25 videos in total on two separate viewings, 21 days apart. Variables collected were ulnar subluxation classification (A, B, C or D) and a confidence metric. Subsequent to primary data collection, classification grading was stratified into A/B or C/D subgroups for further analysis. Cohen's kappa scores were used to evaluate all variables collected in this study. The interpretation of kappa scores included ≤0.0 as no agreement, 0.01-0.20 as none to slight, 0.21-0.40 as fair, 0.41-0.60 as moderate, 0.61-0.80 as substantial, and 0.81-1.0 as almost perfect agreement. RESULTS: Interobserver agreement of subluxation classification as a four-category scale demonstrated a moderate agreement on first viewing, second viewing, and when both viewings were combined (kappa=0.51, 0.51, and 0.51 respectively). Seventy-five percent (3 out of 4) of reviewers had moderate intraobserver agreement for ulnar nerve subluxation classification while one reviewer had substantial intraobserver classification (kappa= 0.72). Overall, there was high confidence in 65% of classification scores in the second round of viewing, which improved from 58% in the first viewing round. When ulnar subluxation classification selections were regrouped into classes A/B or C/D, 100% of reviewers had substantial interobserver (kappa=0.74 - 0.75) and substantial to almost perfect intraobserver (kappa=0.71 to 0.91) agreement. CONCLUSIONS: The four-category classification was reproducible within and between reviewers. Agreement appeared to increase when simplifying the classification to two categories, which may provide guidance to surgical decision making. The validation of a reproducible classification scheme for intraoperative ulnar subluxation may aid with decision making and further postoperative outcomes research.

Electrodiagnostic Severity Does Not Predict Short to Mid-term Outcomes of Cubital Tunnel Release Surgery.

HYPOTHESIS: This study aimed to explore the prognostic value of electrodiagnostic studies (EDS) to clarify their utility in clinical practice prior to cubital tunnel release surgery as well as identify patient factors associated with patient-reported functional improvement after surgery. Our hypothesis is that patients with severe preoperative findings on EDS will tend to experience less functional improvement after surgery given the extent of ulnar nerve compressive injury. METHODS: Patients with cubital tunnel syndrome and preoperative electrodiagnostic data treated from 2012-2022 with cubital tunnel release were assessed regarding demographic information, preoperative physical exam findings, EDS findings, postoperative complications, and patient-reported outcomes. Short to mid-term qDASH scores were collected for all patients for further evaluation of preoperative EDS data. Patients were grouped into those who had met the MCID in delta qDASH at short to mid-term follow-up and those that did not. EDS data included sensory nerve onset latency, peak latency, amplitude, conduction velocity as well as motor nerve latency, velocity, and amplitude. Electromyogram (EMG) studies were also reviewed which included data pertaining to fibrillations, presence of abnormal fasciculation, positive sharp waves, variation in insertional activity, motor unit activity, duration of activity, and presence of increasing polymorphisms. RESULTS: Of the 257 patients included, 160 (62.0%) were found to meet the MCID for short to mid-term qDASH scores. There were no significant differences between patients who did or did not meet the MCID regarding baseline demographics, comorbidities, preoperative exam findings, and operative technique. Patients who met MCID tended to have lower complication (3.80% vs 7.20%; p=0.248) and revision (0.60% vs 4.10%; p=0.069) rates but these findings were not statistically significant. The cubital tunnel severity as determined by the EDS was similar between cohorts (14.1% vs. 14.3%, p=0.498). Analysis of EMG testing showed there were no significant differences in preoperative, short to mid-term qDASH, or delta short to mid-term qDASH scores for patients with or without abnormal EMG findings. Multivariate regression suggested that only age (p=0.003) was associated with larger delta qDASH scores (Table 7). CONCLUSION: Patient-reported preoperative disease severity may predict the expected postoperative change in ulnar nerve functional improvement and EDS may not have prognostic value for patients undergoing cubital tunnel decompression. Therefore, physicians may suggest surgical treatment without positive EDS findings and still expect postoperative improvement in functional outcomes.

Evaluation of perioperative care and drivers of cost in geriatric thoracolumbar trauma.

Introduction: As the population of elderly patients continues to rise, the number of these individuals presenting with thoracolumbar trauma is expected to increase. Research question: To investigate thoracolumbar fusion outcomes for patients with vertebral fractures as stratified by decade. Secondarily, we examined the variability of cost across age groups by identifying drivers of cost of care. Materials and methods: We queried the United States Nationwide Inpatient Sample(NIS) for adult patients undergoing spinal fusion for thoracolumbar fractures between 2012 and 2017. Patients were stratified by decade 60-69(sexagenarians), 70-79(septuagenarians) and 80-89(octogenarians). Bivariable analysis followed by multivariable regression was performed to assess independent predictors of length of stay(LOS), hospital cost, and discharge disposition. Results: A total of 2767 patients were included, of which 46%(N = 1268) were sexagenarians, 36% septuagenarians and 18%(N = 502) octogenarians. Septuagenarians and octogenarians had shorter LOS compared to sexagenarians(ß = -0.88 days; p = 0.012) and(ß = -1.78; p < 0.001), respectively. LOS was reduced with posterior approach(-2.46 days[95% CI: 3.73-1.19]; p < 0.001), while Hispanic patients had longer LOS(+1.97 [95% CI: 0.81-3.13]; p < 0.001). Septuagenarians had lower total charges $12,185.70(p = 0.040), while the decrease in charges in octogenarians was more significant, with a decrease of $26,016.30(p < 0.001) as compared to sexagenarians. Posterior approach was associated with a decrease of $24,337.90 in total charges(p = 0.026). Septuagenarians and octogenarians had 1.72 higher odds(p < 0.001) and 4.16 higher odds(p < 0.001), respectively, of discharge to a skilled nursing facility. Discussion and conclusions: Healthcare utilization in geriatric thoracolumbar trauma is complex. Cost reductions in the acute hospital setting may be offset by unaccounted costs after discharge. Further research into this phenomenon and observed racial/ethnic disparities must be pursued.

Triceps Tendon Reattachment Using Mini Plates and Screws After Failure of Olecranon Avulsion Fracture Fixation in Osteoporotic Bone: A Case Report.

This is a case report of an 85-year-old woman with osteopenia who underwent olecranon avulsion fracture repair with supplemental triceps tendon repair following a fall on an outstretched arm. The initial procedure failed due to osteoporotic bone quality and an atraumatic disruption of the olecranon fracture fixation. The patient subsequently underwent further surgical intervention with an olecranon avulsion fracture excision and a novel triceps tendon repair technique using plate augmentation and fiber tape. Surgeons may consider this novel approach as an initial treatment for elderly patients with osteopenia or osteoporosis undergoing olecranon avulsion fracture fixation, to prevent the failure and consequent revision surgery.

Pickleball- and Paddleball-Related Injuries in the Lower Extremity: Description, Treatment Options, and Return to Play.

Background Pickleball and paddleball are the fastest-growing sports in the United States. However, there are limited studies on the types of lower extremity injuries and treatment options in an outpatient clinic setting. Hypothesis/purpose This study reports the incidence rate, treatments, and return-to-play (RTP) outcomes for patients presenting to a single orthopedic outpatient center with pickleball- and paddleball-related lower extremity injuries. Study design This study is a retrospective case series, with level IV evidence. Methods A database search of our multispecialty electronic medical record (EMR) system from 2015 to 2023 identified 166 patients with outpatient pickleball- and paddleball-related lower extremity injuries. The retrospective data were reviewed for patient demographics, injury type, mechanism of injury, surgical or non-surgical treatment, and return-to-play recommendations. Results We observed that the majority of the patients with pickleball- and paddleball-related injuries in the lower extremities were over 60 years of age, with more males. Additionally, most injuries encountered were ankle sprain/strain from a twisting mechanism, which was treated non-surgically. Additionally, a significant number of patients suffered an Achilles tendon rupture (12.0%), which was treated surgically with an Achilles tendon repair (88.1%), accounting for the most common surgical treatment performed in this study. Of the 166 patients who were seen and treated, 68 (40.9%) returned to play, and 93 (56.3%) were lost to follow-up. Conclusion Most of these injuries were seen in the older population and caused by a sprain or strain due to sudden changes in direction, which were treated non-surgically. The most common surgical treatment was an Achilles tendon repair due to an Achilles tendon rupture. Although a relatively good number of patients were cleared to return to play, some patients were lost to follow-up. Meanwhile, some patients were advised to stop playing pickleball or paddleball due to the severity of their injuries. As this sport continues to rise in popularity and with the incidence rate of lower extremity injuries increasing over time, orthopedic surgeons should be aware of the types of injuries, treatment options, and outcomes, as well as ways to advise patients on prevention. Therefore, further research on the standard treatments and outcomes of pickleball- and paddleball-related injuries in the lower extremities is encouraged.

Reimbursement of Lumbar Fusion at an Orthopaedic Specialty Hospital Versus Tertiary Referral Center.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: To explore the differences in Medicare reimbursement for lumbar fusion performed at an orthopaedic specialty hospital (OSH) and a tertiary referral center and to elucidate drivers of Medicare reimbursement differences. SUMMARY OF BACKGROUND DATA: To provide more cost-efficient care, appropriately selected patients are increasingly being transitioned to OSHs for lumbar fusion procedures. There are no studies directly comparing reimbursement of lumbar fusion between tertiary referral centers (TRC) and OSHs. METHODS: Reimbursement data for a tertiary referral center and an orthopaedic specialty hospital were compiled through the Centers for Medicare and Medicaid Services. Any patient with lumbar fusions between January 2014 and December 2018 were identified. OSH patients were matched to TRC patients by demographic and surgical variables. Outcomes analyzed were reimbursement data, procedure data, 90-day complications and readmissions, operating room times, and length of stay (LOS). RESULTS: A total of 114 patients were included in the final cohort. The tertiary referral center had higher post-trigger ($13,554 vs. $8,541, P<0.001) and total episode ($49,973 vs. $43,512, P<0.010) reimbursements. Lumbar fusion performed at an OSH was predictive of shorter OR time (ß=0.77, P<0.001), shorter procedure time (ß=0.71, P<0.001), and shorter LOS (ß=0.53, P<0.001). There were no significant differences in complications (9.21% vs. 15.8%, P=0.353) or readmission rates (3.95% vs. 7.89%, P=0.374) between the 2 hospitals; however, our study is underpowered for complications and readmissions. CONCLUSION: Lumbar fusion performed at an OSH, compared with a tertiary referral center, is associated with significant Medicare cost savings, shorter perioperative times, decreased LOS, and decreased utilization of post-acute resources. LEVEL OF EVIDENCE: 3.

Clinical Outcomes Following Open Olecranon Bursa Excision for Septic and Aseptic Olecranon Bursitis: An Observational Study.

Background and objective Olecranon bursitis (aseptic or septic) is caused by inflammation in the bursal tissue. While it is typically managed with conservative measures, refractory cases may indicate surgical intervention. There is currently limited research about outcomes following bursal excision for both septic and aseptic etiologies. In light of this, the purpose of this study was to determine if patients experienced improvement following surgical olecranon bursa excision and to compare outcomes between septic and aseptic forms. Materials and methods A retrospective review was performed involving patients who underwent olecranon bursa excision from 2014 to 2021. Demographic data, patient characteristics, surgical data, and outcome-related data were collected from the medical records. Patients were classified into subgroups based on the type of olecranon bursitis (septic or aseptic). Preoperative and one-year postoperative 12-item short-form survey (SF-12) results and range of motion (ROM) outcomes were evaluated for the entire cohort as well as the subgroups. Results We included 61 patients in our study and found significant improvement in the Physical Component Scale 12 (PCS-12) score for all patients (42.0 vs. 45.5, p=0.010) following surgery. However, based on subgroup analysis, the aseptic group improved in PCS-12 following surgery (41.5 vs. 46.8, p<0.001), but the septic group did not (43.6 vs. 40.5, p=0.277). No improvements were found in the Mental Component Scale 12 (MCS-12) scores following surgery in either group. Eighteen of the 61 patients experienced postoperative complications (29.5%), but only 6.5% required a second surgical procedure. Specifically, 14 of the 18 complications occurred in the aseptic group while two septic and two aseptic patients required additional surgeries. Elbow ROM did not change significantly after surgery but more patients were found to have full ROM postoperatively (83.0% to 91.8%, p=0.228). Conclusion Our findings suggest that patients with refractory olecranon bursitis, particularly if aseptic, tend to gain significant physical health benefits from open bursectomy.

Implementation of a Post-Encounter Telephone Call at a Student-Run Free Clinic to Promote Preventive Medicine and Early Clinical Education.

The goals of this study were to determine the completion rates of patient order forms at the Cooper Rowan Clinic, a student-run free clinic, and to implement the use of a post-encounter phone call to improve completion rates, preventive medicine, and medical student clinical involvement. 151 patients completed a pre-intervention questionnaire before their visit. The questionnaire collected information regarding successfully completed order forms. First-year students were trained to perform phone calls and called their patients for five months. 205 patients then completed a post-intervention questionnaire. Dependent variables included completion rates for laboratory studies, specialty referrals, imaging studies and miscellaneous tests. Chi-squared tests were performed. Although the completion rates for laboratory testing (pre = 73.7% vs post = 81.1%), referrals (pre = 50.0% vs post = 65.1%) and imaging studies (pre = 60.9% vs post = 71.7%) increased, the results were not statistically significant. The completion rate of miscellaneous testing (pre = 41.7% vs post = 100.0%) increased following the implementation and was statistically significant. When patients were stratified to those who received a phone call, completion rates of referrals (73.0%), laboratory testing (86.1%), imaging studies (80.5%), and miscellaneous studies (100.0%) substantially increased. Although not statistically significant except for miscellaneous studies, there was an overall increase in completion in all categories. Further evidence to suggest that phone calls improved order completion was the substantial increase in completion rates in patients who received a call. The implementation improves completion of orders which could enhance preventive measures within the clinic. Additionally, it provides an opportunity for earlier student clinical exposure through direct patient contact.