Rapid return to function and stability with dual mobility components cemented into an acetabular reconstructive cage for large osseous defects in the setting of periacetabular metastatic disease.

BACKGROUND AND OBJECTIVES: Large acetabular defects secondary to metastatic disease frequently require extensive acetabular reconstruction. Techniques of acetabular reconstruction have been described, but no consensus for the management of these defects has been reached so far. We present our technique and patient outcomes for acetabular reconstruction by cementing a dual mobility cup into an acetabular cage. METHODS: We reviewed 152 total hip arthroplasties and identified 19 patients with periacetabular metastatic disease and large defects who required acetabular reconstruction utilizing a dual mobility cup cemented into an acetabular reconstructive cage. The following outcomes were evaluated: pain relief, functional improvement, postoperative complications. RESULTS: Mean follow-up was 3 years, with 13 of the 19 patients eligible for 2-year follow-up. Patients reported a significant improvement in both pain and functional outcomes. There were no dislocations or signs of loosening. Two patients developed postoperative infections. One patient required hemipelvectomy 16 months postop due to recurrence of metastatic disease. CONCLUSIONS: Cementing a dual mobility cup into an acetabular cage provides a highly stable and durable option for patients with periacetabular metastatic disease and large defects. Patients are able to return to immediate full weight bearing with significant improvement in both function and pain at 2 years.

Predictors of discharge to an inpatient rehabilitation facility after a single-level posterior spinal fusion procedure.

PURPOSE: To determine perioperative characteristics of patients undergoing single-level spinal fusion surgery that could help predict discharge to an inpatient rehabilitation facility (IRF). METHODS: Demographic, peri- and postoperative characteristics were reviewed for 107 patients who underwent single-level spinal fusion surgery at a high-volume level I trauma center between January 2011 and December 2013. The relationships between discharge to IRF and gender, age, body mass index (BMI), Charlson Comorbidity Index (CCI), insurance provider, length of stay (LOS), intra- and postoperative outcomes and readmission rates in patients undergoing single-level spinal fusion surgery were analyzed using unpaired and paired t testing. RESULTS: 21.5 % (n = 23) of patients were discharged to an IRF. By using unpaired and paired t tests, it was determined that age, BMI, CCI, LOS and insurance provider were all correlated with a higher probability of being discharged to an IRF. Additionally, a logistic regression model demonstrated a correlation between lower CCI and discharge to an IRF. CONCLUSIONS: Statistically significant differences were seen regarding age, BMI, CCI, LOS and insurance provider when determining the necessity of a patient being discharged to an IRF. These characteristics can be used to begin the process of setting up discharge disposition preoperatively rather than postoperatively. There were no perioperative characteristics that were statistically significant in determining discharge disposition; therefore, physicians can utilize these preoperative demographics in deciding and organizing discharge before the day of surgery, which can diminish LOS and lead to substantial health system savings.

Pain Management following Open Reduction and Internal Fixation of Distal Radius Fractures.

Background Distal radius fractures (DRF) are commonly treated with open reduction and internal fixation (ORIF). Few studies address perioperative and postoperative pain control for this procedure. Questions/Purpose We attempt to demonstrate efficacy of pain management modalities during the perioperative and acute postoperative period after ORIF. Specifically, does the type of perioperative anesthesia used during fixation of DRF affect pain control postoperatively? Does the quantity of narcotic pain medication prescribed or type of pain medication given postoperatively affect pain management? Methods We retrospectively reviewed 294 adult (≥18 years old) patients who underwent outpatient ORIF of acute DRF between December 2012 and December 2014. All procedures were performed with a standard volar plating technique through a flexor carpi radialis approach. Patient demographics, fracture laterality, severity of fracture, type of operative anesthesia, and details regarding postoperative oral pain medications were recorded. We reviewed the number and timing of patient phone calls regarding postoperative pain and refills of pain prescriptions. Results Two-hundred ninety-four patients (average age 48.7 years) were included. One-hundred twenty-two injuries were right-sided (41.5%), 168 were left-sided (57.1%), and four were bilateral (1.4%). One-hundred fifty-one patients (51.4%) received regional anesthesia prior to surgery. Average number of narcotics tablets prescribed was 58. There were 66 patients who called the orthopaedic patient hotline regarding pain-control issues at a median of 7.0 days postoperatively. One-hundred twenty-nine (43.9%) patients required refills of narcotic pain medication postoperatively. There was no significant difference in the number of calls or refills given with regard to the type of anesthesia used or postoperative pain regimen prescribed. Conclusions More than one-fifth of patients who underwent ORIF experienced pain severe enough to call our institution's orthopaedic hotline to ask for help at a median of 7 days after fixation. Clinical Relevance Our study demonstrates poor pain control regardless of intraoperative anesthesia or utilization of varying postoperative pain regimens.

Early Postoperative Improvement in Sleep and Pain After Carpal Tunnel Release.

Background: Carpal tunnel syndrome (CTS) is the most common compressive neuropathy of the upper extremity. We sought to assess the subjective improvement in preoperative symptoms related to CTS, particularly those affecting sleep, and describe opioid consumption postoperatively. Methods: All patients undergoing primary carpal tunnel release (CTR) for electromyographically proven CTS were studied prospectively. All procedures were performed by hand surgery fellowship-trained adult orthopedic and plastic surgeons in the outpatient setting. Patients underwent either endoscopic or open CTR from June 2017 to December 2017. Outcomes assessed were pre- and postoperative Quick Disabilities of Arm, Shoulder and Hand (QuickDASH), visual analog scale (VAS), and Pittsburgh Sleep Quality Index (PSQI) scores as well as postoperative pain control. Results: Sixty-one patients were enrolled. At 2 weeks, all showed significant (P < .05) improvement in QuickDASH scores. At 6 weeks, 40 patients were available for follow-up. When compared with preoperative scores, QuickDASH (51 vs 24.5; P < .05), VAS (6.7 vs 2.9; P < .05), and PSQI (10.4 vs 6.4; P < .05) scores continued to improve when compared with preoperative scores. At 2-week follow-up, 39 patients responded to the question, "How soon after your carpal tunnel surgery did you notice an improvement in your sleep?" Seventeen patients (43.6%) reported they had improvement in sleep within 24 hours, 12 patients (30.8%) reported improvement between 2 and 3 days postoperatively, 8 patients (20.5%) reported improvement between 4 and 5 days postoperatively, and 2 patients (5.1%) reported improvement between 6 and 7 days postoperatively. Conclusions: The present study demonstrates rapid and sustained improvement in sleep quality and function following CTR.

A Survey of Fellowship-Trained Upper Extremity Surgeons on Treatment of Lateral Epicondylitis.

Background: The aim of the study is to investigate current management strategies for lateral epicondylitis by fellowship-trained upper extremity surgeons. Methods: A 17-question survey of treatment approaches and outcomes related to lateral epicondylitis was sent to 3354 surgeons using the American Society for Surgery of the Hand and American Shoulder and Elbow Surgeons member databases. Results: Six hundred twelve upper extremity surgeons completed the survey. The 6 most frequently prescribed nonoperative treatments for lateral epicondylitis were home exercise program/stretching (81%), nonsteroidal anti-inflammatory drugs (75%), steroid injection (71%), counterforce bracing (68%), formal physical therapy (65%), and wrist brace (47%). Less commonly performed nonoperative treatment measures included platelet-rich plasma injection (16%), Tenex procedure (6%), and iontophoresis (2%). Conclusions: There is a lack of consensus in the literature for the management of lateral epicondylitis, which is reflected by individual variation in clinical treatment among the experts. Future prospective randomized control studies are needed to establish evidence-based practice standards for this common diagnosis.

Smoking is Associated With 1-year Suboptimal Patient-reported Outcomes After 2-level Anterior Cervical Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To study the impact of smoking on patient-reported outcomes after primary 2-level anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: Previous studies have found suboptimal outcomes after multilevel ACDF in smoking patients. There is contrasting evidence on the negative effects of smoking in single-level ACDF, while there are no specific reports in 2-level ACDF. Adding knowledge of smoking's impact on patient-reported outcomes (PRO) will help in tailored patient counseling and preoperative education. METHODS: Patients 18 years of age or older at a single academic institution who underwent 2-level ACDF to treat cervical radiculopathy and/or myelopathy between September 2013 and September 2015 were included. PRO was studied using the neck disability index (NDI) preoperatively, and at 3, 6, 12 months. χ test for qualitative variables, and one-way analysis of variance (ANOVA) and unpaired t test for quantitative variables were used for statistical analysis. RESULTS: A total of 61 patients, of which 23 (37.7%) were classified as smokers were included. Demographic and clinical profile of patients was similar both groups. Preoperatively, smokers had a mean NDI of 62.8±12.7 with a 17.5%, 18.7%, and 27.7% decrease at 3, 6, and 12-months, respectively. Nonsmokers had a mean preoperative NDI of 45.9±15.3, with a 36.4%, 61.2% and 65.4% decrease at 3, 6, and 12-months, respectively. Despite higher baseline NDI in smokers, improvement in NDI reached significance at 3-months in nonsmokers. In smokers, the improvement in NDI was slower and reached significance at 12-months. The radiographic fusion status at latest follow-up was similar in smokers and nonsmokers (P=0.67). CONCLUSIONS: Smokers had lower improvements in NDI scores compared to nonsmokers after a 2-level ACDF. Preoperative counseling before 2-level ACDF should include education about risks of inferior clinical outcomes in smokers independent of fusion status.

Clinical Outcomes of Single-Level Anterior Cervical Discectomy and Fusion.

BACKGROUND: The purpose of the present study was to determine the differences in health outcomes between patients with cervical spondylosis who underwent single-level anterior cervical discectomy and fusion (ACDF) and patients with cervical spondylosis who did not undergo an ACDF fusion (non-ACDF). The hypothesis of the study was that patients undergoing single-level fusion have a lower risk of downstream cardiovascular disease and depression. METHODS: The Medicare 5% sample was used to identify patients who received a diagnosis of spondylosis during 2005-2012. All spondylosis patients were separated into nonoperative and operative groups. Differences in new disease diagnoses, age, sex, and Charlson Comorbidity Index (CCI) scores were recorded. RESULTS: The relative risk (RR) of heart failure was lower in the ACDF group after 3 years (RR = 0.6719; P < .05), 5 years (RR = 0.8477; P = 1.17), and 7 years (RR = 0.7709; P = 1.625). The RR of depression was higher in the ACDF group at 1 year (RR = 2.5008), 3 years (RR = 1.4473), 5 years (RR = 2.2625), and 7 years (RR = 2.2257; P < .05 for all). Mean CCI score of patients before undergoing ACDF was 10 (SD, 9.20), whereas the mean score after surgery was 8 (SD, 7.84; P < .05), and the score for non-ACDF patients remained unchanged at a CCI of 10 (SD, 9.00; P < .05). CONCLUSIONS: The results demonstrate the patients in the ACDF cohort have an increased RR of depression but a decreased risk of cardiovascular disease. Further research may be needed to delineate why the ACDF procedure potentially benefits a patient for heart disease but may stress a patient's social/economic supports during the recovery process, thus leading to higher depression rates for patients undergoing ACDF.

Surgeon Preference, Influence, and Treatment of Thumb Carpometacarpal Arthritis.

BACKGROUND: The purpose of this study was to evaluate current surgical practice patterns, the factors that influence these patterns, and overall trends in the treatment of thumb carpometacarpal osteoarthritis. METHODS: An online survey containing 14 questions was sent to all active members of the American Society for Surgery of the Hand. Information on demographics and treatments was collected. Results were anonymously uploaded to an online spreadsheet. RESULTS: A total of 823 responses were recorded. Trapeziectomy with ligament reconstruction and tendon interposition (LRTI) using whole flexor carpi radialis was the most popular technique at 37.44%. In all, 26.38% of surgeons with fewer than 5 years of experience utilize trapeziectomy with suture suspension (bone anchor based or tendon based); 55.76% choose a particular procedure because of "Personal Clinical Experience" over "Current Evidence" and "Training." In addition, 24.17% of surgeons who have been practicing for longer than 5 years have changed procedures in the last 5 years. In the United States, 97.2% of hand surgeons prescribe either oxycodone or hydrocodone postoperatively compared with just 23.75% of international hand surgeons. CONCLUSIONS: The results show that trapeziectomy with LRTI remains the most popular treatment of choice. The use of trapeziectomy with suture suspension is on the rise, particularly in younger surgeons. International hand surgeons rely more on current evidence, utilize less postoperative therapy and opioid medications, and change procedures more often than US hand surgeons.

Polytrauma Patients With Associated Spine Fractures: An Assessment of Surgical Intervention on Patient Outcome.

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: To examine perioperative characteristics among polytraumatized patients with operative, unstable spine fractures with and without concomitant operative long bone injuries. SUMMARY OF BACKGROUND DATA: Treatment of polytrauma patients has delicate and time-sensitive protocols to ensure successful recovery. The literature defines standards for vertebral injury and surgical intervention. DATA: Severely polytraumatized patients with an Injury Severity Score (ISS)≥15 were divided according to those with operative spine fractures with operative long bone fractures (OSFLBF) and those with operative spine fractures alone (OSFA). METHODS: Patients were compared by sex, age, mechanism of injury (MOI), ISS, location of injuries, time spent inpatient before procedure(s), total time in the operating room, type of procedure(s) performed, estimated operative blood loss, complications, length of stay (LOS), and time to discharge. RESULTS: In a 12-year period, >600 patients were admitted to our level I trauma center with polytrauma and unstable spine fracture. Twelve had sustained operative unstable spine injuries and 21 had unstable spine injuries with a long bone injury requiring operative stabilization. Significant differences in ISS, LOS, MOI, region of vertebral injury, or total operating room time between the 2 groups were not observed. Differences were seen concerning average blood loss during surgery and time spent inpatient before entering the operating room. OSFLBF patients were discharged at a faster rate after 20 days compared with OSFSA patients. CONCLUSIONS: No differences in ISS, LOS, MOI, region of vertebral injury or vertebral procedure, or total operating room time were observed. Blood loss was more substantial in the OSFLBF group, but it spent fewer days in the hospital preoperatively. Despite a nonstatistical difference in LOS, a larger proportion of OSFA patients remained in the hospital after being inpatient for >20 days, reducing the risk for iatrogenic complication in that group compared with OSFA. LEVEL OF EVIDENCE: III, retrospective comparative.

The Morel-Lavallée lesion revisited: management in spinopelvic dissociation.

BACKGROUND CONTEXT: The Morel-Lavallée lesion occurs from a compression and shear force that usually separates the skin and subcutaneous tissue from the underlying muscular fascia. A dead space is created that becomes filled with blood, liquefied fat, and lymphatic fluid from the shearing of vasculature and lymphatics. If not treated appropriately, these lesions can become infected, cause tissue necrosis, or form chronic seromas. PURPOSE: To review appropriate identification and treatment of Morel-Lavallée lesions in spinopelvic dissociation patients. STUDY DESIGN: Uncontrolled case series. METHODS: Retrospective review of medical records. No funding was received in support of this study. The authors report no conflicts of interest. RESULTS: We present four cases of patients with traumatic spinopelvic dissociation. All had concomitant lumbosacral Morel-Lavallée lesions. All four trauma patients suffered traumatic spinopelvic dissociation with concomitant lumbosacral Morel-Lavallée lesions. Appropriate treatment included irrigation and debridement, drainage, antibiotics, and vacuum-assisted wound closure. CONCLUSIONS: Our series reflects an association of Morel-Lavallée lesion in spinopelvic dissociation trauma patients. Possibly, the rotatory injury that occurs at the spinopelvic junction creates a shear force to form the Morel-Lavallée lesion. When presented with a spinopelvic dissociation patient, one should be prepared to treat a Morel-Lavallée lesion.

Adjacent segment disease.

EDUCATIONAL OBJECTIVES As a result of reading this article, physicians should be able to: 1. Understand the forces that predispose adjacent cervical segments to degeneration. 2. Understand the challenges of radiographic evaluation in the diagnosis of cervical and lumbar adjacent segment disease. 3. Describe the changes in biomechanical forces applied to adjacent segments of lumbar vertebrae with fusion. 4. Know the risk factors for adjacent segment disease in spinal fusion. Adjacent segment disease (ASD) is a broad term encompassing many complications of spinal fusion, including listhesis, instability, herniated nucleus pulposus, stenosis, hypertrophic facet arthritis, scoliosis, and vertebral compression fracture. The area of the cervical spine where most fusions occur (C3-C7) is adjacent to a highly mobile upper cervical region, and this contributes to the biomechanical stress put on the adjacent cervical segments postfusion. Studies have shown that after fusion surgery, there is increased load on adjacent segments. Definitive treatment of ASD is a topic of continuing research, but in general, treatment choices are dictated by patient age and degree of debilitation. Investigators have also studied the risk factors associated with spinal fusion that may predispose certain patients to ASD postfusion, and these data are invaluable for properly counseling patients considering spinal fusion surgery. Biomechanical studies have confirmed the added stress on adjacent segments in the cervical and lumbar spine. The diagnosis of cervical ASD is complicated given the imprecise correlation of radiographic and clinical findings. Although radiological and clinical diagnoses do not always correlate, radiographs and clinical examination dictate how a patient with prolonged pain is treated. Options for both cervical and lumbar spine ASD include fusion and/or decompression. Current studies are encouraging regarding the adoption of arthroplasty in spinal surgery, but more long-term data are required for full adoption of arthroplasty as the standard of care for prevention of ASD.

Cost estimates of biologic implants among orthopedic surgeons.

The use and development of biologic implants such as autogenous bone grafts and bone morphogenetic proteins (BMPs) remain on the rise in orthopedic surgery. Apart from the differences in efficacies seen between the different methods, there is also a difference in the cost associated with each. We generated a questionnaire inquiring about current use of osteobiologics and cost perceptions, and distributed it to 30 orthopedic surgeons. When answers were compared to operating room pricing data from each institution, surgeons grossly over and underestimated the costs associated with each of the osteobiologics in the questionnaire. More than 25% of those questioned did not know the cost of the osteobiologics they had used in the last 3 months. Furthermore, none of the participating institutions had a committee with physician participation concerning the use of these techniques. As the use and cost of osteobiologics by orthopedic surgeons continues to increase, so should the importance of educating those surgeons on the financial outcomes so as to assuage extraneous and unnecessary economic ramifications.