Understanding Variations in the Management of Displaced Distal Radius Fractures With Satisfactory Reduction.

BACKGROUND: The American Academy of Orthopaedic Surgeons has set forth Clinical Practice Guidelines (CPGs) to help guide management of closed, displaced distal radius fractures (DRFs). There still exists variation in practice regarding operative vs nonoperative decision-making. This study aims to identify which factors influence the decision to treat DRFs not indicated for surgery by the CPGs after initial closed reduction. METHODS: Fifteen sets of DRFs and clinical vignettes were distributed via email to over 75 orthopedic residency programs, Orthopaedic Trauma Association, and New York Society for Surgery of the Hand membership. A Qualtrics survey collected respondent demographics, choice of treatment, and rationale. RESULTS: Responses were received from 106 surgeons and resident trainees. The odds of selecting operative management for fractures with 5 or more radiographic instability signs versus 3 or 4 was 3.11 (P < .05). Age over 65, higher patient activity level, and dominant-hand injury were associated with greater odds of operative management (3.4, 30.28, and 2.54, respectively). In addition, surgeons with more years in practice and high-volume surgeons had greater odds of selecting operative management (2.43 and 2.11, respectively). CONCLUSIONS: Assessment of instability at the time of injury, patient age and activity level, as well as surgeon volume and time in practice independently affect the decision to manage well-reduced DRF with surgical or nonsurgical treatment. The source of heterogeneity in the treatment of these fractures is borne at least in part from a lack of formal direction on the importance of prereduction instability from the CPGs.

Acute Exertional Bilateral Thigh Compartment Syndrome in a Patient with Rhabdomyolysis After Spin Class: A Case Report.

CASE: A healthy 24-year-old woman developed rhabdomyolysis and acute bilateral thigh compartment syndrome after 10 minutes of spin class. She was successfully managed with early recognition, aggressive fluid resuscitation, and prompt bilateral surgical decompressive fasciotomy. CONCLUSION: Rhabdomyolysis with acute compartment syndrome is a rare but devastating combination of conditions. A high suspicion for rhabdomyolysis and progression to acute compartment syndrome is warranted for any patient presenting with increasing pain even with a limited history of trauma or exertion. Early recognition and medical and surgical treatment are paramount to preventing permanent damage.

Mycobacterium Immunogenum Flexor Tenosynovitis: A Case Report.

Background Nontuberculous mycobacterial (NTM) flexor tenosynovitis represents a rare but potentially devastating manifestation of upper extremity infection. We present a novel case of NTM flexor tenosynovitis in which Mycobacter iumimmunogenum was found to be the causative agent. Case Description The patient presented with pain and insidiously progressive swelling and required multiple operative interventions and a complex antimicrobial regimen based on susceptibility profiles. Specifically, our patient was managed with three debridements and empiric antimicrobial agents based on inherent macrolide sensitivity, with later conversion to a complex antimicrobial regimen tailored to sensitivity. Literature Review The diagnosis and management of NTM tenosynovitis arechallenging because of low suspicion, nonspecific presentation, and cumbersome laboratory identification techniques. M. immunogenum was only characterized in the past two decades, and, to our knowledge, this is the first reported case of the pathogen causing a musculoskeletal infection. Clinical Relevance We present this case primarily because of the novelty of the organism and to demonstrate the recalcitrant nature of the infection. Due to the extensive resistant patterns of M. immunogenum , management requires complex antimicrobial preparations and almost certainly needs multispecialty collaboration between orthopaedic surgery and infectious diseases.

Race, Gender, and Residency: a Survey of Trainee Experience.

BACKGROUND: Racial minority and female trainees undergo residency attrition at significantly higher rates than their counterparts. We hypothesize that racial minority, and female trainees will report significantly different training experiences from non-minority and male trainees, respectively. Further, we hypothesize that thoughts of withdrawal and summative description of residency experience will be significantly impacted by access to mentorship and feelings of isolation. METHODS: A link to a Qualtrics survey was sent to program officials from all residency programs registered with the ACGME to be distributed to their trainees. It was live from June through August of 2019 and collected data about respondent's demographics and posed questions addressing some of the key elements of the residency experience. RESULTS: Minority trainees reported lower scores for ease of execution of orders placed compared to non-minority trainees 2.12 vs. 2.28 (p = 0.030). Females reported more frequently being mistaken for staff at lower training levels and more frequently feeling overwhelmed than male trainees, 3.29 vs. 1.64 (p < 0.001) and 3.57 vs. 3.16 (p < 0.001). Racial minority and female trainees had numerical but nonsignificant differences in scores for access to mentorship and feelings of isolation compared to non-minority, and male trainees, respectively. Trainees who had thoughts of withdrawal reported less access to mentorship (3.12 vs. 3.88 p < 0.001) and more feelings of isolation (2.22 vs. 1.68 p < 0.001). Trainees reporting more positive experiences had greater access to mentorship and lower feelings of isolation than those who reported a neutral or negative experience, 3.89 vs. 3.14 vs. 2.79 (p < 0.001) and 1.60 vs. 2.21 vs. 2.82 (p < 0.001), respectively. Greater access to mentorship and more frequent family contact both significantly decreased feelings of isolation p < 0.001 and p = 0.035. CONCLUSION: Minority status and female gender impact some of the key elements of the residency experience, manifesting as decreased respect afforded to these trainees. Thoughts of withdrawal and overall residency experience are significantly impacted by access to mentorship and feelings of isolation during residency. Attention should be paid to ensuring that high risk trainees have adequate access to mentorship, making deliberate efforts to cultivate a sense of community and camaraderie among residents, and emphasizing the value of diversity and inclusion.

A Series of Nontuberculous Mycobacterial Flexor Tenosynovitis Infections and Cost of Treatment.

Background Nontuberculous mycobacteria (NTM) are rare but potentially devastating causes of musculoskeletal infection and impairment in immunocompetent patients. Purpose Given the sparse body of literature surrounding these infections, we describe a series of patients with and the cost of treatment of upper extremity NTM infections. Patients and Methods In a retrospective review of seven patients with NTM infections of the upper extremity treated at a university hospital from 2010 to 2019, we assessed patient demographics, exposures, infection characteristics, management course, outcomes, and costs of treatment. Results Insidious pain and swelling were the most common clinical manifestation of infection. Despite coupled surgical and medical management, recurrence was common. Two patients required amputation, and three others had lasting functional deficits. The most common pathogen was Mycobacterium avium complex (5 of 7). The estimated median charge related to management was $85,126 with a range from $8,361 to $1,66,229. Conclusions The treatment of NTM infections is complex and expensive. Diagnosis is usually delayed, which further complicates the management of these patients who often suffer from lasting debilitation. Due to its potentially devastating course, NTM infection should be considered and tested for whenever flexor tenosynovitis is suspected. Regardless of initial presentation, our experience suggests that a protocol of serial surgical debridement immediately after tissue diagnosis is necessary for optimal outcomes. Furthermore, NTM infections require collaboration with infectious disease colleagues to guide antimicrobial regimens based on susceptibility testing and therapeutic drug monitoring for the recommended 6 to 12 months of therapy after the final operative debridement. Level of Evidence This is a Level IV, case series study.

Does Arthroscopic Repair of Femoroacetabular Impingement Pathology Affect Clinical Outcomes after Ipsilateral Total Hip Arthroplasty?

PURPOSE: Arthroscopy for repair of femoroacetabular impingement (FAI) and related conditions is technically challenging, but remains the preferred approach for management of these hip pathologies. The incidence of this procedure has increased steadily for the past few years, but little is known about its potential long-term effects on future interventions. The purpose of this study was to evaluate whether prior arthroscopic correction of FAI pathology impacts postoperative complication rates in patients receiving subsequent ipsilateral total hip arthroplasty (THA) on a national scale. MATERIALS AND METHODS: A commercially available national database - PearlDiver Patients Records Database - identified primary THA patients from 2005 to 2014. Patients who had prior arthroscopic FAI repair (post arthroscopy group) were separated from those who did not (native hip group). Prior FAI repair was examined as a risk factor for complications following THA and a multivariable logistic regression analysis was applied to identify risk factors for complications following THA. RESULTS: A total of 11,061 patients met all inclusion and exclusion criteria; 10,951 in the native hip group and 110 in the post arthroscopy group. Prior FAI repair was not significantly associated with higher rates of 90-day readmission (P=0.585), aseptic dislocation/revision within 3 years (P=0.409), surgical site infection within 3 years (P=0.796), or hip stiffness within 3 years (P=0.977) after THA. CONCLUSION: Arthroscopic FAI repair is not an independent risk factor for complications following subsequent ipsilateral THA (level of evidence: III).

Opioids and Spinal Cord Stimulators: Pre- and Postoperative Opioid Use Patterns and Predictors of Prolonged Postoperative Opioid Use.

OBJECTIVE: The aim of the study was to compare trends and differences in preoperative and prolonged postoperative opioid use following spinal cord stimulator (SCS) implantation and to determine factors associated with prolonged postoperative opioid use. METHODS: A database of private-payer insurance records was queried to identify patients who underwent a primary paddle lead SCS placement via a laminectomy (CPT-C3655) from 2008-2015. Our resulting cohort was stratified into those with prolonged postoperative opioid use, opioid use between 3- and 6-month postoperation, and those without. Multivariate logistic regression was used to determine the effect preoperative opioid use and other factors of interest had on prolonged postoperative opioid use. Subgroup analysis was performed on preoperative opioid users to further quantify the effect of differing magnitudes of preoperative opioid use. RESULTS: A total of 2,374 patients who underwent SCS placement were identified. Of all patients, 1,890 patients (79.6%) were identified as having prolonged narcotic use. Annual rates of preoperative (p = 0.023) and prolonged postoperative narcotic use (p < 0.001) decreased over the study period. Significant independent predictors of prolonged postoperative opioid use were age < 65 years (odds ratio [OR], 1.52; p = 0.004), male sex (OR, 1.33; p = 0.037), preoperative anxiolytic (OR, 1.55; p = 0.004) and muscle relaxant (OR, 1.42; p = 0.033), and narcotic use (OR, 15.04; p < 0.001). Increased number of preoperative narcotic prescriptions correlated with increased odds of prolonged postoperative use. CONCLUSION: Patients with greater number of preoperative opioid prescriptions may not attain the same benefit from SCSs as patients with less opioid use. The most significant predictor of prolonged narcotic use was preoperative opioid use.

Demographic Trends in Paddle Lead Spinal Cord Stimulator Placement: Private Insurance and Medicare Beneficiaries.

OBJECTIVE: Although spinal cord stimulators (SCS) continue to gain acceptance as a viable nonpharmacologic option for the treatment of chronic back pain, recent trends are not well established. The aim of this study was to evaluate recent overall demographic and regional trends in paddle lead SCS placement and to determine if differences in trends exist between private-payer and Medicare beneficiaries. METHODS: A retrospective review of Medicare and private-payer insurance records from 2007-2014 was performed to identify patients who underwent a primary paddle lead SCS placement via a laminectomy (CPT-63655). Each study cohort was queried to determine the annual rate of SCS placements and demographic characteristics. Yearly SCS implantation rates within the study cohorts were adjusted per 100,000 beneficiaries. A chi-square analysis was used to compare changes in annual rates. RESULTS: A total of 31,352 Medicare and 2,935 private-payer patients were identified from 2007 to 2014. Paddle lead SCS placements ranged from 5.9 to 17.5 (p<0.001), 1.9 to 5.9 (p<0.001), and 5.2 to 14.5 (p<0.001) placements per 100,000 Medicare, private-payer, and overall beneficiaries respectively from 2007 to 2014. SCS placements peaked in 2013 with 19.6, 7.1, and 16.8 placements per 100,000 Medicare, private-payer, and overall patients. CONCLUSION: There was an overall increase in the annual rate of SCS placements from 2007 to 2014. Paddle lead SCS placements peaked in 2013 for Medicare, private-payer, and overall beneficiaries. The highest incidence of implantation was in the Southern region of the United States and among females. Yearly adjusted rates of SCSs were higher among Medicare patients at all time points.