Radial Head Arthroplasty for Fracture: Implant Survivorship and Outcomes at Mean Follow-up of 8 Years.

PURPOSE: The purpose of this study was to evaluate implant survivorship and clinical outcomes following radial head arthroplasty for fracture at long-term follow-ups. METHODS: A retrospective analysis was conducted on adult patients who underwent primary uncemented radial head arthroplasty for radial head or neck fractures between 2012 and 2015. Medical records were reviewed to collect information regarding demographics, injury characteristics, reoperations, and revisions requiring implant removal. A bivariate analysis was conducted to identify potential risk factors for reoperation. A Kaplan-Meier curve was created to determine implant survival rates. Eligible patients were contacted to confirm any reoperations and obtain Quick Disability of the Arm, Shoulder, and Hand scores at long-term follow-ups. RESULTS: A total of 89 patients were eligible for analysis and assessed at a mean of 97 months after surgery (range, 81-128). Reoperation rate was 16% (14 of 89 patients), including 5% of patients requiring implant removal or revision. However, 93% of reoperations occurred within the first 12 months of the index surgery. Fracture dislocations of the elbow had a higher rate of reoperation. A Kaplan-Meier curve demonstrated an implant survival rate of 96% at 10-year follow-up. Of the patients who responded, the mean Quick Disability of the Arm, Shoulder, and Hand score was 8.7 ± 10.3, with none requiring additional reoperations or revisions. There were otherwise similar outcome scores among patients requiring reoperation versus those who did not. CONCLUSIONS: Although radial head arthroplasty for fractures has a high potential for reoperation within the first year, survival rates with uncemented implants remain high at 10 years, and patients report excellent Quick Disability of the Arm, Shoulder, and Hand scores at long-term follow-ups, despite any need for reoperation. Fractures with associated elbow dislocation may be at a higher risk for reoperation, and it is important to provide this prognostic information to patients who are likely to require arthroplasty for more extensive injuries. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Characterization of Opioid Prescribing Tendencies Among Orthopaedic Surgeons: A National Perspective.

There has been increasing pressure on healthcare providers to exhibit restraint when prescribing opioids for pain control. However, data that characterizes the differences between orthopaedic providers and their accompanying prescription rates is not well developed. This study accessed Medicare Provider Utilization and Payment Data from 2015 to collect the number of prescriptions for opioid-based medications administered by orthopaedic surgeons across the country. A total of 19,410 orthopaedic providers were identified as opioid prescribers from the 2015 Medicare Part D Database. Providers averaged an opioid prescription every 10.9 days, with 94.7% of prescribers (18,387) having written more than 10 opioid prescriptions. Regionally, the Southern United States had the highest percentage of providers prescribing an opioid greater than 10 times at 96.4%. Female orthopaedic surgeons prescribed just over half the number of scripts that male surgeons did (79.4 vs. 154.2, p < 0.001). (Journal of Surgical Orthopaedic Advances 32(3):199-201, 2023).

Epithelioid sarcoma: half a century later.

Background and objectives: Epithelioid sarcoma (ES) is an aggressive malignancy scarcely reported on due to its rarity. This study is a review of its traits and features of prognosis and survival by analyzing both the literature and a national cancer database.Methods: Data were acquired from both the Survival, Epidemiology, and End Results database and literature. 1, 5, and 10-year Disease Specific Survival rates and hazard ratios (HR) were determined. Data were split into pre-2000 (<2000) and post-2000 (>2000) groups. Overall survival, recurrence, and metastasis rates were obtained.Results: Ninety hundred and ninety eight and 992 cases of ES were identified from the database and literature, respectively. Age, anatomical site, grade, TNM staging, treatment modality and year of diagnosis were demonstrated to be independent predictors of survival. Overall 5- and 10-year survival were 60.4% and 50.2%, respectively. Overall recurrence and metastasis rates were 63.4% and 40.3%. Using cases diagnosed prior to 2000 as reference, those diagnosed after 2000 had a worse prognosis (HR: 1.55).Conclusions: We report using the largest cohort of ES to date. Despite ES's often dismal prognosis, there are factors associated with better outcomes. A worsening survival over the years warrants further investigation into this sarcoma.

Four-Corner Arthrodesis Versus Proximal Row Carpectomy for Scapholunate Advanced Collapse: A Systematic Literature Review and Meta-analysis.

BACKGROUND: Scapholunate advanced collapse (SLAC) of the wrist is one of the most common patterns of degenerative arthritis in the wrist. Surgical intervention is warranted for individuals with symptomatic SLAC and degenerative disease that affects the radioscaphoid joint. The most popular options for motion-preserving reconstruction and treatment of this disease include 4-corner arthrodesis and proximal row carpectomy. The purpose of this article was to conduct a systematic literature review and meta-analysis to identify any differences in the clinical outcomes of 4-corner arthrodesis and proximal row carpectomy for the treatment of SLAC. METHODS: An electronic literature search of PubMed, Embase, OVID, and the Cochrane Library was conducted to identify studies evaluating the clinical outcomes of 4-corner arthrodesis versus proximal row carpectomy for the treatment of SLAC. Primary outcome measures included flexion/extension range of motion, grip strength, and level of pain. RESULTS: Eight studies encompassing 311 patients met the inclusion criteria for the meta-analysis. Our meta-analysis indicated that when compared with 4-corner arthrodesis, patients who underwent proximal row carpectomy had statistically significantly increased flexion/extension range of motion by 6.2 degrees, significantly increased grip strength by 1.52%, and reduced level of pain by 0.3. CONCLUSIONS: This study demonstrated that in comparative studies, there was a statistical difference favoring proximal row carpectomy to 4-corner arthrodesis for the treatment of SLAC. Although these differences were statistically significant, they remain very small and lack clinical relevance. This study further supports that both of these treatment options are equivalent for the treatment of this disease. Although not clinically significant, compared with 4-corner arthrodesis, patients treated with proximal row carpectomy had increased range of motion, increased grip strength, and decreased pain. Limitations to these findings are the small number of studies available and the increased heterogeneity between the studies. Further studies need to be conducted to confirm these findings.

Risk factors of venous thromboembolism in patients with benign and malignant musculoskeletal tumors: a dual database analysis.

PURPOSE: Venous thromboembolism (VTE) is a potentially life-threatening condition associated with both orthopaedic surgery and tumour growth. In this study, we identify risk factors associated with VTE in patients with musculoskeletal tumours using two national datasets. METHODS: The ACS-NSQIP and NIS databases were queried for patients undergoing surgery with a diagnosis of benign or malignant musculoskeletal tumours. Chi-square and binary logistic regression analyses were used to determine risk factors for VTE. RESULTS: The incidence of VTE was 2% in both databases. Patients with malignant tumours, those with tumours of the pelvis, sacrum, or coccyx, obesity, arrhythmias, paralysis, metastatic disease, coagulopathy, and recent weight loss were at increased risk for VTE. In patients with benign tumours, those who were African American, those with tumours of the pelvis, sacrum, or coccyx, diabetes, anaemia, and coagulopathy were at increased risk of VTE. CONCLUSIONS: Patients with malignant or benign lesion are at greater risk of VTE if they are age 30 and over, of the African American population, or with tumors of the pelvis/sacrum/coccyx, or any of the following comorbidities: pulmonary disease, paralysis, other neurological disorders, or coagulopathy.

Effect of Mitomycin C on Recurrence of Ganglion Cysts in the Foot and Ankle.

Ganglion cysts are among the most common benign soft tissue masses. Although surgery has been shown to be effective, ∼12% to 42% of cases with long-term follow-up have been reported to recur. The purpose of this study was to determine the impact of the topical application of mitomycin C used as an adjuvant to surgery on recurrence rate of ganglion cysts. A retrospective analysis was done on all patients surgically treated by 1 surgeon for ganglion cysts. The primary end point was local recurrence after the procedure, determined clinically and by ultrasound. Secondary outcomes included wound complication rate, adverse effects, and overall patient satisfaction. A total of 98 consecutive patients were included in this study and assigned to a study group in a nonrandomized manner. The control group (n = 52) consisted of patients who underwent surgical resection only. The study group (n = 46) consisted of patients who underwent surgical resection with application of topical mitomycin C. No patients were lost to follow-up. Of the 52 patients in the control group, 13 (25.0%) had recurrence of the ganglion cyst. In contrast, in the experimental study group, 2 patients (4.3%) had a recurrence. There was no difference in superficial wound infections between the 2 groups. In this study, we found that the use of topical mitomycin C as an adjuvant to surgical resection significantly reduced the recurrence rate. Wound infection and overall nonrecurrence complication rates were similar to those of other studies.

Is Insurance Status Associated with the Likelihood of Operative Treatment of Clavicle Fractures?

BACKGROUND: Most closed clavicle fractures are treated nonoperatively. Research during the past decade has reported differences in the treatment of clavicle fractures based on insurance status in the US and may highlight unmet needs in a vulnerable population, particularly because new data show that surgery may lead to improved outcomes in select populations. Large-scale, national data are needed to better inform this debate. QUESTIONS/PURPOSES: (1) Does the likelihood of operative fixation of closed clavicle fractures vary among patients with different types of insurance? (2) What demographic and socioeconomic factors are associated with the likelihood of clavicle fracture surgery? (3) Has the proportion of operative fixation of clavicle fractures changed over time? METHODS: A retrospective analysis of the Nationwide Inpatient Sample 2001-2013 database was performed. This database is the largest publicly available all-payer inpatient database in the US that provides pertinent socioeconomic data on a nationwide scale. Data were queried for patients with closed clavicle fractures using International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes, and surgery was determined using ICD-9 procedural codes. A total of 252,109 patients were included in the final analysis after 158,619 patients were excluded because of missing demographic or insurance data, ambiguous fracture location, or age younger than 19 years. Of the 252,109 included patients, 21,638 (9%) underwent surgical fixation of clavicle fractures. A chi-square analysis was performed to determine variables to be included in a multivariable analysis. A binary logistic regression analysis was used to examine demographic and other important variables, with a significance level of p < 0.01. Poisson's regression and a t-test were used to analyze trends over time. Results were recorded as odds ratios (OR) and incidence rate ratios. RESULTS: After controlling for demographic and potentially relevant variables, such as the median income and fracture location, we found that patients with Medicare, Medicaid, and no insurance had a lower likelihood of undergoing operative fixation of clavicle fractures than did those with private insurance. Patients without insurance were the least likely to undergo surgery (OR, 0.63; 95% CI, 0.60-0.66; p < 0.001), followed by those with Medicare (OR, 0.73; 95% CI, 0.70-0.78; p < 0.001) and those with Medicaid (OR, 0.74; 95% CI, 0.69-0.78; p < 0.001). Women, black, and Hispanic patients were also less likely to undergo surgery than men and white patients (OR, 0.95; p = 0.003; OR = 0.67; p < 0.001; and OR = 0.82; p < 0.001, respectively) There was an increase in the overall proportion of patients undergoing surgery, from 5% in 2001 to 11% in 2013 (incidence rate ratio, 2.99; p < 0.001). CONCLUSIONS: We believe that the greater use of surgery among adult patients with clavicle fractures who have private insurance than among those with nonprivate or no insurance-as well as among men and white patients compared with women and patients of color-may be a manifestation of important health care disparities in the inpatient population. This may be owing to variable access to care or a difference in the likelihood that a surgeon will offer surgery based on a patient's insurance status. Because operative fixation of closed clavicle fractures increases in the adult population, future research should elucidate conscious and subconscious motivations of patients and surgeons to better inform the discussion of health care disparities in orthopaedics. LEVEL OF EVIDENCE: Level III, therapeutic study.

Can Navigation-assisted Surgery Help Achieve Negative Margins in Resection of Pelvic and Sacral Tumors?

BACKGROUND: Navigation-assisted resection has been proposed as a useful adjunct to resection of malignant tumors in difficult anatomic sites such as the pelvis and sacrum where it is difficult to achieve tumor-free margins. Most of these studies are case reports or small case series, but these reports have been extremely promising. Very few reports, however, have documented benefits of navigation-assisted resection in series of pelvic and sacral primary tumors. Because this technology may add time and expense to the surgical procedure, it is important to determine whether navigation provides any such benefits or simply adds cost and time to an already complex procedure. QUESTIONS/PURPOSES: (1) What proportion of pelvic and sacral bone sarcoma resections utilizing a computer-assisted resection technique achieves negative margins? (2) What are the oncologic outcomes associated with computer-assisted resection of pelvic and sacral bone sarcomas? (3) What complications are associated with navigation-assisted resection? METHODS: Between 2009 and 2015 we performed 24 navigation-assisted resections of primary tumors of the pelvis or sacrum. Of those, four were lost to followup after the 2-year postoperative visit. In one patient, however, there was a failure of navigation as a result of inadequate imaging, so nonnavigated resection was performed; the remaining 23 were accounted for and were studied here at a mean of 27 months after surgery (range, 12-52 months). During this period, we performed navigation-assisted resections in all patients presenting with a pelvis or sacral tumor; there was no selection process. No patients were treated for primary tumors in these locations without navigation during this time with the exception of the single patient in whom the navigation system failed. We retrospectively evaluated the records of these 23 patients and evaluated the margin status of these resections. We calculated the proportion of patients with local recurrence, development of metastases, and overall survival at an average 27-month followup (range, 12-52 months). We queried a longitudinally maintained surgical database for any complications and noted which, if any, could have been directly related to the use of the navigation-assisted technique. RESULTS: In our series, 21 of 23 patients had a negative margin resection. In all patients the bone margin was negative, but two with sacral resections had positive soft tissue margins. Six of 23 patients experienced local recurrence within the study period. Three patients died during the study period. Seventeen patients demonstrated no evidence of disease at last recorded followup. We noted three intraoperative complications: one dural tear, one iliac vein laceration, and one bladder injury. Eight patients out of 23 had wound complications resulting in operative débridement. Two patients in the series developed transient postoperative femoral nerve palsy, which we believe were caused by stretch of the femoral nerve secondary to the placement of the reference array in the pubic ramus. CONCLUSIONS: Navigation-assisted resection of pelvic and sacral tumors resulted in a high likelihood of negative margin resection in this series, and we observed relatively few complications related specifically to the navigation. We have no comparison group without navigation, and future studies should indeed compare navigated with nonnavigated resection approaches in these anatomic locations. We did identify a potential navigation-related complication of femoral nerve palsy in this series and suggest careful placement and observation of the reference array during the operative procedure to lessen the likelihood of this previously unreported complication. We suggest it is worthwhile to consider the use of navigation-assisted surgery in resection of tumors of the pelvis and sacrum, but further study will be needed to determine its precise impact, if any, on local recurrence and other oncologic outcomes. LEVEL OF EVIDENCE: Level IV, therapeutic study.

A Mobile-Based Surgical Simulation Application: A Comparative Analysis of Efficacy Using a Carpal Tunnel Release Module.

PURPOSE: The utilization of surgical simulation continues to grow in medical training. The TouchSurgery application (app) is a new interactive virtual reality smartphone- or tablet-based app that offers a step-by-step tutorial and simulation for the execution of various operations. The purpose of this study was to compare the efficacy of the app versus traditional teaching modalities utilizing the "Carpal Tunnel Surgery" module. We hypothesized that users of the app would score higher than those using the traditional education medium indicating higher understanding of the steps of surgery. METHODS: A total of 100 medical students were recruited to participate. The control group (n = 50) consisted of students learning about carpal tunnel release surgery using a video lecture utilizing slides. The study group (n = 50) consisted of students learning the procedure through the app. The content covered was identical in both groups but delivered through the different mediums. Outcome measures included comparison of test scores and overall app satisfaction. RESULTS: Test scores in the study group (89.3%) using the app were significantly higher than those in the control group (75.6%). Students in the study group rated the overall content validity, quality of graphics, ease of use, and usefulness to surgery preparation as very high (4.8 of 5). CONCLUSIONS: Students utilizing the app performed better on a standardized test examining the steps of a carpal tunnel release than those using a traditional teaching modality. The study findings lend support for the use of the app for medical students to prepare for and learn the steps for various surgical procedures. CLINICAL RELEVANCE: This study provides useful information on surgical simulation, which can be utilized to educate trainees for new procedures.

Posterior Interosseous Neuropathy Related to a Loose Distal Biceps Cortical Button: A Case Series.

Posterior interosseous nerve (PIN) injury is an uncommon yet debilitating complication following distal bicep tendon repair. There are case reports of acute intraoperative PIN injury related to retractor placement, drill trajectory, and nerve incarceration. We report three cases of delayed PIN neuropathy in the setting of a loose cortical button. All patients had resolution of their pain with removal of the cortical button and decompression of the radial tunnel. The purpose of this case series is to: 1) highlight the possibility of a loose cortical bicep button as the cause of proximal forearm pain and PIN neuropathy in the early or late postoperative timeframe; and 2) emphasize the importance of proper surgical technique and use of intraoperative fluoroscopy to assure the cortical button is well-fixed and flush with the radial shaft. .

Is surgical indication in multiple myeloma a poor prognosis sign? SEER database analysis.

AIM: This study aims to investigate demographic data, survival rates, and the relationship of these rates with surgery in a large case series including multiple myeloma (MM) patients. METHOD: MM cases were analyzed retrospectively using the latest version of the SEER database published in April 2020. This version covers January 1975 to December 2017. Patients were classified according to gender, age, and race/ethnicity. Tumors were classified according to their localization, grade, year of diagnosis, and follow-up results. RESULTS: There were 60,239 patients diagnosed with Plasma Cell Myeloma. While 670 patients (1.2%) were operated on, 43,976 patients (76.7%) did not indicate operation, and 12,670 patients (22.1%) could not be operated on despite the recommendation. The mean survival was 62 months in those without an indication for surgery, and 42 months in patients with an indication but could not be operated on, and the difference was significant (p = 0.001). The mean survival was 58 months in the operated patients, and 42 months in the patients who could not be operated on despite the indication, and the difference was significant (p = 0.001). There was no difference between those who did not indicate surgery and those who were operated on with an indication (p = 0.243). CONCLUSION: In multiple myeloma, the best prognosis is in the group of patients who received medical treatments without any indication for operation, while an indication for operation indicates a worse prognosis. A worse prognosis should be expected in patients who do not accept the operation or who cannot be operated on compared to the operated patients.

Which Pre-Operative, Modifiable Risk Factors are Most Predictive of Complications in orthopedic Upper Extremity Surgery?

Objectives: Identification of modifiable comorbid conditions in the preoperative period is important in optimizing outcomes. We evaluate the association between such risk factors and postoperative outcomes after upper extremity surgery using a national database. Methods: The National Surgical Quality Improvement Program (NSQIP) 2006-2016 database was used to identify patients undergoing an upper extremity principle surgical procedure using CPT codes. Modifiable risk factors were defined as smoking status, use of alcohol, obesity, recent loss of >10% body weight, malnutrition, and anemia. Outcomes included discharge destination, major complications, bleeding complications, unplanned re-operation, sepsis, and prolonged length of stay. Chi square and multivariable logistic regressions were used to identify significant predictors of outcomes. Significance was defined as P<0.01. Results: After applying exclusion criteria, 53,780 patients were included in the final analysis. Preoperative malnutrition was significantly associated with non-routine discharge (OR=4.75), major complications (OR=7.27), bleeding complications (OR=7.43), unplanned re-operation (OR=2.44), sepsis (OR=10.22), and prolonged length of stay (OR=5.27). Anemia was associated with non-routine discharge (OR=2.67), bleeding complications (OR=13.27), and prolonged length of stay (OR=3.26). In patients who had a weight loss of greater than 10%, there was an increase of non-routine discharge (OR=2.77), major complications (OR=2.93), and sepsis (OR=3.7). Smoking, alcohol use, and obesity were not associated with these complications. Conclusion: Behavioral risk factors (smoking, alcohol use, and obesity) were not associated with increased complication rates. Malnutrition, weight loss, and anemia were associated with an increase in postoperative complication rates in patients undergoing upper limb orthopaedic procedures and should be addressed prior to surgery, suggesting nutrition labs should be part of the initial blood work.

Cephalomedullary Nailing has a Higher Reoperation Rate Compared to Sliding Hip Screw Fixation in the Treatment of Intertrochanteric Femur Fractures: A Systematic Literature Review and Meta-analysis.

Objectives: Intertrochanteric hip fractures are a common orthopaedic injury in the United States. Complications of surgical treatment include nonunion, lag screw cutout, implant failure, post-operative pain, risk of refracture or reoperation, and infection. The purpose of this study was to compare the rate of complications of sliding hip screw fixation (SHS) compared to cephalomedullary nailing (CMN) for the treatment of closed intertrochanteric femur fractures in adult patients. Methods: PubMed, CINAHL, and Cochrane Library databases were searched for studies comparing SHS to CMN in the treatment of closed intertrochanteric femur fractures in adults. Data were compiled to observe the rate of nonunion, cutout failure, infection, refracture, perioperative blood loss, reoperation, postoperative pain, pulmonary embolism/deep venous thrombosis (DVT), length of hospital stay, and mortality. Results: Seventeen studies were included comprising 1,500 patients treated with SHS and 1,890 patients treated with CMN. Treatment of intertrochanteric femur fractures with SHS demonstrated significantly fewer refractures and reoperations. There was no significant difference in other variables between SHS and CMN treated groups. Conclusion: This meta-analysis shows that the only notable difference in outcomes is patients treated with CMN have a higher rate of refracture and reoperation. With new advances in the development of both CMNs and SHS, further studies will be required to see if these differences persist in the coming years.

Comparison of Treatment Options for Chronic Scapholunate Interosseous Ligament (SLIL): A Systematic Literature Review and Meta-Analysis.

Background: The scapholunate interosseous ligament (SLIL) is an important contributor to wrist stability and functionality. SLIL injury is debilitating and therefore many surgical techniques have been proposed, but the optimal treatment modality remains debated.This meta-analysis reviews the available literature comparing surgical techniques used in the treatment of chronic SLIL to determine the best approach. Methods: An electronic search of the literature was conducted to identify all randomized controlled trials and cohort studies published before January 2019 that evaluated clinical outcomes of capsulodesis reconstruction, the modified Brunelli technique, and the reduction and association of the scaphoid and lunate (RASL) procedure for treatment of chronic SLIL. A chi-square analysis was performed to identify possible differences between each technique for several outcome measures. Results: A total 20 studies encompassing 409 patients met inclusion criteria. Average age among patients was 36.7 years, and 68.2% of patients were male. Reductions in visual analog scale pain scale; Disabilities of Arm, Shoulder, and Hand (DASH) scores; and increases in grip strength and range of motion were observed for all techniques. Capsulodesis was superior to the modified Brunelli technique regarding preserved range of motion. Conclusions: No significant differences were observed among any of the techniques for pain, DASH score, and grip strength outcomes. Capsulodesis, modified Brunelli, and RASL surgical techniques for the treatment of chronic SLIL injuries may all be seen as reliable methods of treatment of chronic SLIL injuries. While future trials directly comparing these methods are needed, this study suggests there is no superiority of one technique over another.

Hand Tumors: An Individual Surgeon's Retrospective Review.

Background: Tumors of the hand are encountered frequently and represent a variety of pathologic diagnoses, both benign and malignant. Even within a single pathologic type, presentation can vary. This study reviews hand tumors encountered by an individual surgeon and described presenting features to better aid in clinical decision making. Methods: A retrospective chart review of patients presenting with a hand tumor between January 2005 and December 2017 from an individual surgeon's perspective was performed. Pertinent data were extracted by researchers and statistical analysis was completed with GraphPad Prism (GraphPad Software, Inc). Results: A total of 101 patients aged 14 months to 87 years (mean age, 40.52 years) were included. Within this patient group, soft tissue tumors accounted for 97%, malignant neoplasm 2%, and bone tumors 1%. Ganglion cysts were most common (54.5%) followed by hemangiomas (9.9%), giant cell tumors (6.9%), granulomas (5.9%), and fibromas (5%). A total of 54.5% of patients reported pain and 43.5% reported decreased range of motion (ROM). Conclusions: In this patient cohort, ganglion cyst was the most common tumor type and presented with pain and deficits in ROM. This is contrary to the asymptomatic presentation of such cases in the literature. Other common tumors were hemangiomas, giant cell tumors, granulomas, and fibromas. Malignant tumors were rare, as expected, and both cases presented without pain or tenderness.

Association of Bacterial Etiology With Rates of Reoperation in Patients With Septic Tenosynovitis of the Hand.

Background: The anatomy of the hand makes it uniquely sensitive to complications after bacterial infection. The causative organism has been implicated as a predictor of complications after surgery. We hypothesize that bacterial etiology is associated with different operation and reoperation rates in patients with flexor tenosynovitis. Methods: The Nationwide Inpatient Sample 2001-2013 database was queried for cases of tenosynovitis by using International Classification of Diseases, 9th Revision (ICD-9) diagnostic codes 727.04 and 727.05. The pathogen cultured was also identified with ICD-9 codes, and surgical intervention was determined using ICD-9 procedural codes. χ2 analysis and logistic regression were used to determine predictors of outcomes. Outcomes included initial surgery and the need for additional surgery, which was defined as records having ICD-9 procedural codes repeated for the same patient. Results: A total of 17,476 cases were included. The most common bacterial etiology was methicillin-sensitive Staphylococcus aureus followed by Streptococcus species. Infections with gram-positive organisms, including methicillin-sensitive and methicillin-resistant S aureus, unspecified Staphylococcus, and Streptococcus species were significantly associated with higher rates of initial surgery for tenosynovitis. Patients receiving Medicaid and Hispanic patients had a statistically significant lower likelihood of surgery. Higher rates of reoperation were reported in patients aged 30 to 50 years, 51 to 60 years, 61 to 79 years, and ≥80 years; other factors associated with higher reoperation rates were Streptococcus and Staphylococcus infections and use of Medicare. Conclusions: The data show that cultures of Streptococcus and certain species of Staphylococcus in patients with septic tenosynovitis are predictive of operation and reoperation rates. Patients with these infectious etiologies may have more severe presentations that warrant operative intervention. This data may allow for more informed decision-making in the preoperative period.

Intramedullary Nailing Versus Plate Fixation for Humeral Shaft Fractures: A Systematic Review and Meta-Analysis.

Background: The two techniques most utilized in the surgical treatment of humeral shaft fractures are open reduction internal fixation (ORIF) and intramedullary nailing (IMN). Although there have been multiple comparative clinical studies comparing outcomes for these two treatments, studies have not suggested one approach to be superior to the other. The purpose of this study is to perform a systematic literature review and meta-analysis of studies that evaluated the treatment of humeral shaft fractures with either ORIF or intramedullary nail. Methods: We conducted this meta-analysis utilizing stricter inclusion and broader exclusion criteria to examine these two common approaches. We examined those articles which have compared first-time, closed fractures of the humeral diaphysis in adults in fracture patterns that could be treated equivalently by intramedullary nail or plate fixation. The primary outcome of interest was nonunion, and studies that did not report nonunion rates were excluded. Results: There were a total of 1,926 abstracts reviewed and a total of three articles were included in the final analysis after screening. There was no significant difference in the incidence of nonunion between plating (2/111, 1.8%) and nailing (4/104, 3.9%) (P>0.05). The mean difference in average time to union for plated fractures and nailed fractures was 1.11 weeks (95% CI 0.82 to 1.40) which was statistically significant (P<0.05). There was a significant difference in the incidence of radial nerve palsy (12/111, 10.8%) for plating compared to nailing (0/104, 0%) (P=0.0004). There was no difference in incidence of post-operative infection between the two groups intramedullary nailing (P>0.05). Conclusion: The results of this analysis demonstrate an increased risk of iatrogenic radial nerve injury, and a significantly shorter time to union when treating humeral shaft fractures with plating as compared to intramedullary nailing. There was no difference in the rates of nonunion or delayed union. Based on the evidence, both plating and nailing can achieve a similar treatment effect on humeral shaft fractures.

Intraoperative Nerve Conduction Studies During Open Carpal Tunnel Release: A Pilot Study.

Background: Operative management of carpal tunnel syndrome (CTS) involves release of the transverse carpal ligament (TCL) and often the volar antebrachial fascia (VAF). Evidence of a difference between TCL and TCL+VAF release is limited. We conducted a pilot study to measure changes of intraoperative nerve conduction velocity (NCV) after CTS surgery and compared outcomes of variable degrees of decompression. Methods: Patients aged 18 to 65 years diagnosed with idiopathic CTS that failed to respond to conservative management were included in this study. Patients were excluded if they had prior surgical release, diabetes, acute CTS, trauma, or cervical spine radiculopathy. Outcomes included motor and sensory amplitude and latency. Electrodes were placed on the skin intraoperatively along the abductor pollicis brevis, index finger, and forearm. Outcome data were recorded at baseline, after TCL release, and after TCL+VAF release. Data were compared using a single-tail t test. Results: A total of 10 patients were included in this study. There were no significant changes in mean motor or sensory amplitude and latency from baseline to TCL release, TCL to VAF release, or from baseline to TCL+VAF release measured intraoperatively. Conclusions: This pilot study shows there is no immediate detectable difference in NCV following release of TCL or TCL+VAF. This suggests that NCV may not be useful for assessing intraoperative improvement. We highlight the need for future research in the form of case-control studies to determine the utility of intraoperative NCV. These studies should be conducted with larger numbers of patients and involve multiple hand specialists.

Cemented-augmented fixation of metastatic humeral lesions without segmental bone loss results in reliable outcomes.

Background: Treatment of metastatic lesions to the humerus is dependent on patient's pain, lesion size and location, and post-operative functional goals. Surgical options include plate or nail fixation [open reduction internal fixation (ORIF)], or endoprosthetic replacement (EPR), with cement augmentation. The objective of this study was to perform a single institution retrospective analysis of outcomes by method of reconstruction, tumor volume, and pathologic diagnosis. Methods: The records of 229 consecutive patients treated surgically for appendicular metastatic disease from 2005-2018 at our musculoskeletal oncology center were retrospectively reviewed following institutional review board (IRB) approval. Indications for surgical treatment at the humerus included patients who presented with impending and displaced pathologic fractures. Results: Sixty patients (34 male, 26 female) with a mean age of 62.9±12.2 were identified who were treated surgically at the proximal (n=21), diaphyseal (n=29), or distal (n=10) humerus. Forty-nine (82%) patients presented with displaced pathologic fractures. The remaining eleven patients had a mean Mirels score of 9.5. There was no difference in overall complication rate between EPR or ORIF [4/36 (11%) versus 2/24 (8%); P=0.725]. Mean Musculoskeletal Tumor Society (MSTS) scores were 83% for both EPR and ORIF, with no differences in subgroup analyses at the proximal, diaphyseal, or distal humerus. Patients with cortical destruction on anterior posterior (AP) and lateral imaging were at increased risk for mechanical failure [2/6 (33%) versus 0/18 (0%), P=0.015]. Conclusions: In conclusion, when pathologic pattern permits, cement-augmented fixation allows for stabilization of pathologic bone, while minimizing risk of soft-tissue detachment, while EPR resulted in similar outcomes in patients with more extensive bone destruction. Increased tumor volume was associated with lower MSTS scores.

Clavicle fractures: Associated trauma and morbidity.

BACKGROUND: Clavicle fractures are frequently associated with trauma to regions beyond the immediate zone of injury. In order to provide surgeons with information on injury prevalence to prevent delays in diagnosis and management, we describe the epidemiology of concomitant injuries in patients with clavicle fractures and identify differences between those with open and closed fractures. Methods:The Nationwide Inpatient Sample (NIS) 2001-2013 database was queried for adult patients discharged with a diagnosis of a clavicle fracture using ICD-9 codes. A "common" injury was defined as prevalence ≥4.0% in our study population. We analyzed data for injury locations associated with open vs. closed clavicle fractures with chi square and independent samples t-tests. RESULTS: A total of 41,1612 patients were included in our study population. The majority of patients had closed clavicle fractures (98.2%). The most common concomitant fracture was that of the rib, followed by the spine. The most common non-vascular, non-nervous injury was a hemo/pneumothorax followed by a lung, bronchus, or diaphragm injury. Fractures of the humerus, rib, scapula, pelvis, tibia or fibula, and facial bones as well as concussion, pneumo/hemothorax, other pulmonary, and splenic injuries were more common in patients with open clavicle fractures. Patients with open clavicle fractures were, on average, 11.8 years younger than those with closed fractures. CONCLUSION: There is a significant association between clavicle fractures and concussion, splenic, and thoracic injuries, as well as increased rate of complications with open fractures. Clinicians may use this information to perform risk assessments prevent delays in diagnosis.