Elbow Evaluation Via Telephone and Video Visit.

Background Elbow conditions and pathology are commonly seen in the outpatient clinic. Telephone and video visits can allow for expeditious assessment of elbow complaints, without the added challenges of commuting for a clinic-based evaluation. In the setting of a pandemic, the benefits of telemedicine are apparent, but the time and effort saved from being able to remotely evaluate musculoskeletal conditions are also useful in a non-pandemic situation. In this modern era of telemedicine, protocols need to be developed to provide guidance for a remote elbow evaluation. As with all musculoskeletal conditions, the history about the elbow complaint allows the clinician to develop a differential diagnosis, which is either supported or refuted based on physical examination and diagnostic studies. Appropriate questions asked over a telephone call can provide answers that lead the clinician to a specific diagnosis and treatment plan. Furthermore, responses to these same questions can be further supported by a video assessment of the affected elbow, which may provide additional evidence to support a diagnosis and plan of care. Aims To outline possible questions, responses, and video examination techniques to aid the clinician in elbow examinations conducted via telemedicine. Methods We have created a pathway for step-by-step evaluation to help physicians direct their patients through the typical elements of a thorough elbow examination via telehealth. Results We have created tables of questions, answers, and instructions to help guide the physician through different aspects of a telehealth elbow examination. We have also included a glossary of descriptive images that demonstrate each maneuver.  Conclusion This article provides a structured guide to efficiently extracting clinically relevant information during telemedicine examinations of the elbow.

Which Factors Predict 30-Day Readmission After Total Hip and Knee Replacement Surgery?

Background The Centers for Medicare and Medicaid Services enacted the Hospital Readmissions Reduction Program to impose penalties for diagnoses with high readmission rates. Despite several elective orthopedic procedures being included in this program, readmission rates have not declined, and associated costs have reached critical levels for total knee and total hip arthroplasty. Readmissions drastically impact patient outcomes. There are many known contributors to patient readmission rates, including infection, pain, and hematomas. However, evidence is inconclusive regarding other aspects, such as demographics, insurance, and discharge disposition. The purpose of this manuscript is to 1) measure hospital readmission rates for total knee and total hip arthroplasty, 2) evaluate the causes of readmissions, and 3) provide a predictive profile of risk factors associated with hospital readmissions. Methods Patients who underwent total knee or total hip arthroplasty were identified through a retrospective database review. An electronic chart review extracted data concerning patient demographics, comorbidities, surgical information, 30-day outcomes, and reasons for 30-day readmissions. Continuous and categorical variables were assessed with the Wilcoxon rank-sum test and the Chi-square test, respectively. Results A total of 6,065 patients were included, with 269 (4.4%) having at least one surgery-related 30-day readmission. No differences in readmission were noted with age, sex, or ethnicity; however, differences were found in weight and body mass index. Statistically significant comorbidities were heart failure, chronic obstructive pulmonary disease, dialysis, and alcohol use or abuse. Conclusion Our research indicated that surgery type, length of stay, and heart failure most significantly impacted 30-day readmission rates. By assessing readmission rates, we can take steps to optimize care for non-elective surgeries that will improve patient outcomes and cost-effectiveness.

Bullous Disseminated Herpes Zoster: An Atypical Presentation.

Herpes zoster is an infection resulting from the reactivation of dormant varicella zoster virus (VZV) in a posterior dorsal root ganglion. It affects 50% of immunocompromised patients and, when the viral infection persists, it can lead to a process known as disseminated varicella zoster virus (dVZV). Here we discuss a case of a bullous presentation of VZV with a rapid evolution of disseminated herpes zoster in an immunocompromised patient. Maintaining a broad differential diagnosis is necessary for early diagnosis and treatment of atypical presentations of herpes zoster, which is imperative to avoid increasing morbidity and mortality.

Disseminated herpes zoster with cauda equina symptoms.

Herpes zoster is a common infection resulting from the reactivation of dormant varicella zoster virus in a posterior dorsal root ganglion. The typical dermatomal involvement includes the thoracic region, followed by the face and the cervical and lumbosacral regions, with 1% having disseminated disease. We present a rare case of an immunocompetent 85-year-old man presenting with herpes zoster at the L3-S2 dermatomes, that evolved to disseminated varicella zoster virus (dVZV), with radiologically and laboratory-confirmed lumbosacral plexopathy manifesting with cauda equina syndrome. Here we also discuss the diagnosis and complications of dVZV as well as treatment strategy. By maintaining a high degree of clinical suspicion and initiating early treatment, high-quality patient care and good outcomes are able to be achieved in cases like this.