Increased actual sling wear is associated with better early patient-reported and image-based outcomes after shoulder surgery.

BACKGROUND: Prior studies have failed to show differences in functional outcomes for patient-reported sling use after rotator cuff repair. Temperature-sensing devices are used to more accurately measure brace adherence. The purposes of this study were to quantify actual sling adherence and its predictors and to establish whether increased sling adherence is associated with improved functional and image-based outcomes. METHODS: We performed a prospective cohort study of 65 patients undergoing shoulder surgery requiring ≥4 weeks of postoperative sling use. Temperature-sensing devices were implanted in the slings to monitor sling adherence. Patient-reported sling adherence was determined from a questionnaire. Patients were considered 80% adherent if they wore the sling 16 h/d (112 h/week) when 20 h/d was prescribed. The primary outcomes were patient-reported and actual sling adherence, patient-reported outcomes (American Shoulder and Elbow Surgeons score and visual analog scale pain score) within 12 months postoperatively, and image-based failure based on ultrasound or radiography at 6 weeks and 1 year postoperatively. RESULTS: Patient-reported sling adherence was highly sensitive (82.8%), was poorly specific (28.6%), had low accuracy (53.1%), and was weakly correlated with actual sling adherence (r = 0.32, P = .009). On multivariable logistic regression analysis, male patients were 91% less likely than female patients to be adherent with sling use (odds ratio, 0.09; 95% confidence interval [CI], 0.02-0.42; P = .002). Additionally, obese and morbidly obese patients were 88% (95% CI, 0.02-0.84; P = .033) and 98% (95% CI, 0.002-0.27; P = .003), respectively, less likely than non-obese patients to adhere to sling wear postoperatively. After we controlled for surgical procedure, visual analog scale pain scores were significantly better at 6 weeks (ß = -1.47; 95% CI, -2.88 to -0.05; P = .04) and 3 months (ß = -1.68; 95% CI, -3.28 to -0.08; P = .04) if patients adhered to sling wear. A receiver operating characteristic curve showed that 13.6 hours and 15.4 hours of daily sling wear optimized image-based outcomes at 6 weeks (failure rate, 0% vs. 16%; P = .01) and 1 year (failure rate, 3% vs. 28%; P = .008) postoperatively, respectively. CONCLUSION: The results of this study demonstrate that patient-reported sling adherence is unreliable, adherence can be predicted by female sex and lower body mass index, and increased sling adherence is associated with improved early pain scores and image-based outcomes. These data can help inform future studies using postoperative sling protocols as patient-reported sling adherence is not an accurate method to assess sling use.

Hand size affects branching of the deep ulnar nerve and deep palmar arch.

PURPOSE: Understanding the anatomy of the deep neurovascular structures of the hand is essential in surgical planning. There is a lack of literature regarding hand size and its influence in branching variation and the distances between branches of various neurovascular structures. Our study quantifies the variation in branching distances of the deep ulnar nerve and deep palmar arch branches. METHODS: Twenty-five fresh-frozen cadaveric hands were dissected. Each branch of the deep ulnar nerve and deep palmar arch was identified. The distance from the most distal portion of the pisiform to the proximal aspect of the branch was measured. The relationship between the length of the third metacarpal and the distance of each branch from the pisiform was examined. RESULTS: There was no relationship between branching differences in the deep ulnar nerve and the length of the third metacarpal. There was a significant association between the length of the third metacarpal and the second, third, and fourth branches of the deep palmar arch (p < 0.05). CONCLUSIONS: Our study found a significant association between the branching distances of the second, third, and fourth branches of the deep palmar arch and hand size as measured by the length of the third metacarpal.

Risk Factors for Wound Complication following Primary Total Hip Arthroplasty.

This study assessed the National Surgical Quality Improvement Program (NSQIP), which provides data on 30-day post-operative complications from 500+ institutions, to identify risk factors for wound complications in patients undergoing primary total hip arthroplasty (THA). Patients undergoing primary THA between 2010-2017 were retrospectively reviewed. Patients experiencing post-operative wound complications were stratified based on pre-operative characteristics. Multivariate regression model was used to assess these characteristics as independent risk factors for post-operative complications. Of 119,096 patients undergoing primary THA, 1,264 (1.06%), 280 (0.2%), 622 (0.52%) and 139 (0.12%) experienced wound complications, deep surgical site infection, superficial surgical site infection, and wound dehiscence, respectively. Pre-operative transfusion (p < 0.0001), steroid use (p = 0.01), and obesity (p < 0.0001) were risk factors for wound dehiscence. Pre-operative transfusion (p < 0.0001), cardiac comorbidities (p = 0.02), and steroid use (p = 0.01) were risk factors for superficial surgical site infection. Assessment of the NSQIP identified modifiable risk factors for wound complications following primary THA, including pre-operative transfusion, steroid use, and obesity. (Journal of Surgical Orthopaedic Advances 31(4):242-247, 2022).

An accurate method of measuring shoulder sling compliance: a validation study.

BACKGROUND: The effect of postoperative shoulder sling compliance on surgical outcomes is unknown. The goal was to determine an accurate method to measure sling compliance. We compared volunteer recorded sling wear time with temperature-based sensors to monitor sling compliance. METHODS: Data loggers sutured at three locations measured heat generated in 15-minute intervals. Slings wearers logged sling wear to accurately cross-reference with temperature sensors. Secondary experiments analyzed whether surrounding ambient temperature can be discerned from actual sling wear. We created an algorithm to describe actual sling wear time as a function of heat recorded and calculated percent wear accuracy. RESULTS: The modified sling was worn for 172 h. The algorithm modeled sling on/off times by analyzing cutoff temperatures. Diagnostic accuracy was >99 % for the three locations, with no statistically significant differences among them. Compared with sling wear, ambient temperature took longer to reach critical temperature values determined by the algorithm, helping distinguish compliance from false positives. CONCLUSIONS: The described algorithm can effectively quantify shoulder sling wear time based on heat-generated sensor readings. False positives from ambient temperature are minimal. This measurement method could be used to study the relationship between postoperative sling use and functional outcomes after shoulder surgery.

Preoperative Risk Factors for Postoperative Urinary Tract Infection After Primary Total Hip and Knee Arthroplasties.

BACKGROUND: Establishing clear risk factors for complications such as urinary tract infection (UTI) after arthroplasty procedures helps guide clinical practice and provides more information to both surgeons and patients. This study aims to assess selected preoperative patient characteristics as risk factors for postoperative UTI after primary total hip and knee arthroplasties (THA and TKA). METHODS: This was a retrospective analysis using current procedural terminology codes to investigate the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database for patients who underwent THA or TKA from 2010 to 2017. Patients were classified for UTI by NSQIP guidelines. Patient samples with all possible covariates were included for multivariate logistic regression analysis and assessed for independent associations. RESULTS: In a cohort of 983 identified patients (983 of 119,096; 0.83%): ages 57+ years, preoperative red blood cell (RBC) transfusion, perioperative RBC transfusion, bleeding disorders, operative time 110+ minutes, preoperative steroid use, diabetes, pulmonary comorbidities, body mass index 30+ kg/m2 were independent risk factors for postoperative UTI after THA. In a cohort of 1503 identified patients (1503 of 189,327; 0.8%): ages 60+ years, preoperative RBC transfusion, perioperative RBC transfusion, anemia, platelets less than 150k, preoperative steroid use, diabetes, and body mass index 30+ kg/m2 were independent risk factors for postoperative UTI after TKA. Male sex was associated with a decreased risk of UTI in both THA and TKA. CONCLUSION: This study provides novel evidence on risk factors associated with the development of UTI after THA or TKA. Clinicians should be aware of risk factors in the manifestation of postoperative UTI after primary THA or TKA procedures.

Histological Assessment of Wallerian Degeneration of the Rat Tibial Nerve Following Crush and Transection Injuries.

BACKGROUND: Wallerian degeneration (WD) following peripheral nerve injury (PNI) is an area of growing focus for pharmacological developments. Clinically, WD presents challenges in achieving full functional recovery following PNI, as prolonged denervation of distal tissues for an extended period of time can irreversibly destabilize sensory and motor targets with secondary tissue atrophy. Our objective is to improve upon histological assessments of WD. METHODS: Conventional methods utilize a qualitative system simply describing the presence or absence of WD in nerve fibers. We propose a three-category assessment that allows more quantification: A fibers appear normal, B fibers have moderate WD (altered axoplasm), and C fibers have extensive WD (myelin figures). Analysis was by light microscopy (LM) on semithin sections stained with toluidine blue in three rat tibial nerve lesion models (crush, partial transection, and complete transection) at 5 days postop and 5 mm distal to the injury site. The LM criteria were verified at the ultrastructural level. This early outcome measure was compared with the loss of extensor postural thrust and the absence of muscle atrophy. RESULTS: The results showed good to excellent internal consistency among counters, demonstrating a significant difference between the crush and transection lesion models. A significant decrease in fiber density in the injured nerves due to inflammation/edema was observed. The growth cones of regenerating axons were evident in the crush lesion group. CONCLUSION: The ABC method of histological assessment is a consistent and reliable method that will be useful to quantify the effects of different interventions on the WD process.

Readability Level of English and Spanish Orthopaedic Patient Education Materials English and Spanish Patient Education.

There are 16 million Hispanic people in the United States who rely on Spanish as their only effective method of communication. However, there is a scarcity of literature evaluating if patient education resources in Spanish meet the average American reading level or National Institute of Health (NIH) and American Medical Association (AMA) grade-level recommendations, especially in the field of orthopaedics. Representative orthopaedic search terms were input into Google and ten articles pertaining to patient education were selected. Videos, scientific journals, and surgical technique guides were excluded. Articles were then digitally analyzed and compared. Mean United States grade level equivalent was 11.26 ± 2.23 for English articles and 10.55 ± 1.45 for Spanish articles. English orthopaedic materials featured a significantly more difficult grade level (p < 0.01) than equivalent Spanish works. Spanish orthopaedic materials generated in the United States featured significantly lower (p < 0.01) readability scores than those written outside the United States. Our study demonstrated both English and Spanish materials were written at a high school level. Spanish materials were written at more appropriate grade-levels than their English counterparts. (Journal of Surgical Orthopaedic Advances 30(2):096-100, 2021).

Biomechanical effects of superior capsular reconstruction in a rotator cuff-deficient shoulder: a cadaveric study.

BACKGROUND: Superior capsular reconstruction (SCR) has been gaining popularity as a treatment for irreparable rotator cuff tears (RCTs), especially in younger patients. This biomechanical study aimed to investigate how SCR affects functional abduction force, humeral head migration, and passive range of motion following an irreparable RCT. We hypothesized that SCR will restore these parameters to nearly intact shoulder levels. METHODS: Six fresh-frozen cadaveric shoulders were evaluated using a custom biomechanical testing apparatus. Each shoulder was taken through 3 conditions: (1) intact (control); (2) irreparable, complete supraspinatus (SS) tear; and (3) SCR. Functional abduction force, superior humeral head migration, and passive range of motion, including axial shoulder rotation, were measured in static condition at 0°, 30°, and 60° of glenohumeral abduction. Data were analyzed using the paired Student t test or Wilcoxon signed rank test, depending on the results of normality testing. RESULTS: The irreparable SS tear resulted in significantly lower functional abduction force at 30° of abduction (P = .01) and a trend toward a decrease (P = .17) at 60° compared with the intact configuration. SCR shoulders produced greater functional force at 0° compared with the tear configuration (P = .046). Humeral head migration was significantly increased by 4.4 and 3.0 mm at 0° and 30° of abduction, respectively, when comparing the intact vs. SS tear configurations (P = .001). SCR decreased superior migration down to levels of intact shoulders at 0° and 30° of abduction (P = .008 and P = .013, respectively) and was not significantly different from the intact configuration at any angle. SCR decreased passive shoulder extension compared with the tear configuration and increased abduction compared with the intact configuration (P = .007 and P = .03, respectively). The overall arc of axial rotation was not significantly different between SCR and the intact configuration at any angle. CONCLUSIONS: In the setting of an irreparable SS tear, SCR restores key biomechanical parameters of the shoulder to intact levels. SCR should be considered for qualifying patients with irreparable RCTs.

Benzoyl peroxide use transiently decreases Cutibacterium acnes load on the shoulder.

BACKGROUND: Cutibacterium acnes is the most common pathogen in shoulder prosthetic joint infections. Short-contact benzoyl peroxide (BPO) solutions effectively reduce C acnes loads on the shoulder preoperatively. It is unknown how long the effect of BPO lasts. We evaluated C acnes counts 1 week after BPO application. We hypothesized that BPO would decrease C acnes burden with a rebound after 1 week. METHODS: Screening of 102 healthy volunteers with no history of shoulder surgery or C acnes infection was performed to establish bacterial counts. Thirty-four participants were selected based on an established threshold. Each was given BPO 5% for 3 consecutive days of application on either the left or right shoulder as indicated by a random number generator. Deep sebaceous gland cultures were obtained with a detergent scrub technique before BPO application, after 3 days of use, and 1 week after BPO treatment commenced. RESULTS: The differences between the logarithmic reduction and the logarithmic rebound at the anterior, lateral, and posterior sites were statistically significant. Anteriorly, the average log reduction was -0.44 and the average log rebound was 0.69 (P = .003). Laterally, reduction was -0.64 and rebound was 0.74 (P = .003). Posteriorly, reduction was -0.63 and rebound was 0.78 (P = .008). At the axilla, reduction was -0.40 and rebound was 0.31 (P = .10). The differences in C acnes burden between pretreatment and 1-week counts at all sites were not statistically significant. CONCLUSION: A significant decrease in C acnes burden occurred after BPO application but was not permanent. Significant rebound occurred just 1 week later.

Beyond the dermis-high-risk invasive squamous cell carcinoma: a retrospective review.

OBJECTIVE: Most cutaneous squamous cell carcinomas (cSCC) are low risk and can be treated with simple excision or ablation. High-risk cSCC require invasive treatment, including radical surgery. We present our experience in treating invasive cSCC of the pelvis and extremities. METHOD: A retrospective review of the data of patients with invasive cSCC, indicated for surgery between 2014 and 2018, from a single institution was carried out. RESULTS: A total of 19 patients (nine men, 10 women) were included in the study. Mean age was 62 years; mean tumour size was 8.6cm). Of the 19 patients, five patients with paraplegia with cSCC arising from hard-to-heal ulcers died of infection or bleeding after surgery or systemic therapy. Also, nine patients with localised cSCC underwent margin-negative resection with or without radiation; one patient experienced disease relapse. Of the participants, two patients with previous transplants and multifocal aggressive cSCC underwent numerous resections but succumbed to disease, and two patients who presented with locally recurrent disease after previous positive margin resection and radiation underwent re-resection but developed recurrent disease. CONCLUSIONS: Prognosis for invasive cSCC largely depends on clinical setting. Tumours arising from ulcers in patients with paraplegia have a poor prognosis regardless of treatment. Invasive cSCC in transplant patients are often multifocal and often recur. Debulking procedures are associated with local recurrence despite radiation. Patients presenting with localised disease have a favourable prognosis with wide resection, flap coverage and adjuvant therapy.