Cost-benefit analysis of routine pathology examination in primary shoulder arthroplasty.

BACKGROUND: The annual number of shoulder arthroplasty procedures is continuing to increase. Specimens from shoulder arthroplasty cases are routinely sent for pathologic examination. This study sought to evaluate the clinical utility and associated costs of routine pathologic examination of tissue removed during primary shoulder arthroplasty cases and to determine cost-effectiveness of this practice. METHODS: This is a retrospective review of primary shoulder arthroplasty cases. Patients whose humeral head was sent for routine pathologic examination were included. Cases were determined to have concordant, discrepant, or discordant diagnoses based on preoperative/postoperative diagnosis and pathology diagnosis. Costs were estimated in 2015 U.S. dollars, and cost-effectiveness was determined by the cost per discrepant diagnosis and cost per discordant diagnosis. RESULTS: We identified 714 cases of primary shoulder arthroplasty in 646 patients who met inclusion criteria. The prevalence of concordant diagnoses was 94.1%, the prevalence of discrepant diagnoses was 5.9%, and no cases had discordant diagnoses. There were 172 cases that had biceps tendon specimens sent for pathology examination, and none led to a change in patient care. Total estimated costs were $77,309.34 in 2015 U.S. dollars. Cost per discrepant diagnosis for humeral head specimens was $1424.09, and cost per discordant diagnosis is at least $59,811.78. DISCUSSION/CONCLUSION: Primary shoulder arthroplasty has a high rate of concordant diagnosis. Discrepant diagnoses were 5.9% in our study, and there were no discordant diagnoses. This study showed limited clinical utility in routinely sending specimens from primary shoulder arthroplasty cases for pathology examination, and calculation using a traditional life-year value of $50,000 showed that the standard for cost-effectiveness is not met.

Thumb Metacarpophalangeal Joint Ulnar Collateral Ligament Injuries: Management and Biomechanical Evaluation.

First described in 1955 as "gamekeeper's thumb," injuries to the ulnar collateral ligament (UCL) of the thumb metacarpophalangeal joint are common and can cause pain and instability, especially during key pinch and grasp. Although primarily diagnosed on physical examination, stress radiographs, ultrasonography, and magnetic resonance imaging can be used to diagnose UCL injuries and distinguish partial from complete tears. If complete rupture occurs, the adductor aponeurosis can become interposed between the retracted UCL stump and its insertion on the proximal phalanx, known as a "Stener lesion." When instability persists after a trial of nonsurgical management or in the setting of complete rupture, there are various methods of repair or reconstruction. Biomechanically, there are no treatments of repair or reconstruction using native tissues that provide equivalent strength to the preinjured ligament. Recently, suture tape augmentation has been used for the repair or reconstruction with excellent short-term results and earlier return to function, although there is a paucity of literature on longer term outcomes. The various methods of surgical treatment yield excellent outcomes with a low incidence of complications.

Two Parallel Headless Compression Screws for Scaphoid Fractures: Radiographic Analysis and Preliminary Outcome.

BACKGROUND: Despite surgical fixation, the scaphoid nonunion rate remains at 3% to 5%. Recent biomechanical studies have demonstrated increased stability with 2-screw constructs. The objective of our study is to determine the preliminary union rate and anatomic feasibility of 2-screw surgical fixation for scaphoid fractures. METHODS: This study is a retrospective case series of 25 patients (average age 32 years) with scaphoid fractures treated with 2 parallel headless compression screws (HCS). Postoperative evaluation included Mayo Wrist Score (MWS), range of motion, time to union, and return to activity. Bivariate analysis for gender and Pearson correlation coefficient for body size (height, weight, and body mass index) was conducted against radiographically measured scaphoid width, screw lengths, and the distance between the 2 screws. RESULTS: All fractures healed with an average time to union of 9.9 weeks (median 7.6 weeks; range: 4.1-28.3). The mean MWS was 93.3 (range: 55-100), with 3 complications (12%), one of which affected the outcome of the surgery. The bivariate analysis demonstrated that the female gender was associated with significantly smaller scaphoid width (P = .004) but a similar distance between the 2 screws (P = .281). The distance between the 2 screws and the body size demonstrated a weak-to-no correlation. CONCLUSIONS: The 2-screw construct for scaphoid fracture achieved a favorable union rate and clinical outcome. Gender was the only variable significantly associated with scaphoid width and screw length. The distance between the screws was constant regardless of gender and body size, indicating that the technique for parallel screw placement can remain consistent. TYPE OF STUDY: Therapeutic. LEVEL OF EVIDENCE: Level IV.

Surgical Approach and Internal Fixation Techniques for Intra-Articular Distal Humerus Fracture With Coronal Shear Capitellar Fracture.

Intra-articular distal humerus fractures with an associated coronal shear capitellar fragment present a challenge for stable internal fixation. Adequate visualization and fixation of the capitellar shear fragment are difficult to achieve with conventional exposures, including the olecranon osteotomy. The capitellar fragment often translates anterior and proximally and is challenging to visualize with intact soft tissue attachments from a posterior approach. We describe a surgical exposure that releases the lateral ulnar collateral ligament in addition to an olecranon osteotomy to allow complete visualization of the entire articular surface. In contrast to an isolated capitellar fracture, the column stability and the posterior cortex are frequently disrupted with distal humerus fractures. Depending on the comminution of the posterior cortex, a supplemental posterolateral plate or headless compression screws can provide fixation to the coronal fracture plane. The lateral ulnar collateral ligament is repaired at the conclusion of fracture stabilization through a bone tunnel or to the plate to restore lateral stability. Despite the release of the ligament and additional soft tissue stripping, there were no cases of elbow instability or avascular necrosis in our case series of 9 patients.

Anomalous Courses of the Palmar Cutaneous Branch of the Median Nerve in Relation to the Flexor Carpi Radialis Tendon for ORIF of Distal Radius Fractures.

Background: The purpose of this study was to prospectively document the incidence of variations in the course of palmar cutaneous branch of the median nerve (PCBMN) that may increase the risk of injury to the nerve during the flexor carpi radialis (FCR) approach. We hypothesize that the incidence of anomalous branching of the PCBMN around the FCR sheath will be approximately 5%. Methods: All cases that met inclusion criteria between November 2013 and March 2018 were included. The operating surgeon made the final decision for operative intervention using the FCR approach. Each surgeon performed the standard FCR approach to the distal radius. The branching location from the median nerve, the relationship to the FCR sheath, and the course of the PCBMN were recorded. Results: In total, 101 distal radius fractures were included. The average branching point of PCBMN was 5.2 cm from the distal wrist crease (range = 3.3-9.0). There were 26 anomalous branching patterns of PCBMN. Nineteen (18.8%) crossed volar, dorsal, or ran within the FCR sheath. Six PCBMN were found within the FCR sheath, 1 penetrated the FCR sheath, 6 crossed volar to the FCR sheath, and 6 were dorsal to the FCR tendon sheath. When comparing the branching patterns of the PCBMN from the median nerve, 4 branched from the volar aspect, 2 branched from the dorsal aspect, and 1 branched from the ulnar aspect of the median nerve. Conclusions: Variation in the course of the PCBMN relative to the FCR sheath is more than previously thought and can be expected in approximately 18.8% of patients.

Long-Term Follow-up of Capsular Interposition Arthroplasty for Hallux Rigidus.

BACKGROUND: Capsular interposition arthroplasty is a joint- and motion-sparing procedure that has been shown as an effective alternative to fusion. This study aimed to evaluate patient function and satisfaction after long-term follow-up. METHODS: Sixty-four patients were treated with capsular interposition arthroplasty for hallux rigidus by the senior author performed between February 1998 and July 2011. Twenty-two patients could not be reached for follow-up and were thus excluded from the analysis. Therefore, 42 remaining patients were evaluated using the visual analog scale (VAS), Foot Function Index (FFI), Short Form 12 (SF-12), and patient satisfaction scores. The mean follow-up was 11.3 (range, 4-16) years. RESULTS: The mean VAS for pain was 7.9 preoperatively and 1.8 postoperatively ( P = .003). The mean preoperative SF-12 physical score was 42.0 vs 64.2 postoperatively ( P = .02). The mean preoperative SF-12 mental score was 50.7, while the postoperative SF-12 mental score was 54.6 ( P = .01). The total FFI score also significantly improved, with a preoperative value of 98.3 and a postoperative mean score of 49.6 ( P = .001). The mean patient satisfaction score was 7.4 of 10. Overall, 39 of 42 patients (92.9%) stated they would have the surgery again. Four of the 42 patients (9.5%) required conversion to hallux metatarsophalangeal fusion at a mean of 6.1 years after the index procedure secondary to pain, but no other complications were reported. CONCLUSION: Capsular interposition arthroplasty was a safe and effective treatment for severe hallux rigidus. These longer term results demonstrate a high level of patient satisfaction. LEVEL OF EVIDENCE: Level IV, retrospective case series.

A review of the diagnosis and treatment of atlantoaxial dislocations.

Study Design Literature review. Objective Atlantoaxial dislocation (AAD) is a rare and potentially fatal disturbance to the normal occipital-cervical anatomy that affects some populations disproportionately, which may cause permanent neurologic deficits or sagittal deformity if not treated in a timely and appropriate manner. Currently, there is a lack of consensus among surgeons on the best approach to diagnose, characterize, and treat this condition. The objective of this review is to provide a comprehensive review of the literature to identify timely and effective diagnostic techniques and treatment modalities of AAD. Methods This review examined all articles published concerning "atlantoaxial dislocation" or "atlantoaxial subluxation" on the PubMed database. We included 112 articles published between 1966 and 2014. Results Results of these studies are summarized primarily as defining AAD, the normal anatomy, etiology of dislocation, clinical presentation, diagnostic techniques, classification, and recommendations for timely treatment modalities. Conclusions The Wang Classification System provides a practical means to diagnose and treat AAD. However, future research is required to identify the most salient intervention component or combination of components that lead to the best outcomes.