Increasing severity of preoperative anemia is associated with higher postoperative medical and surgical complications after primary shoulder arthroplasty.

BACKGROUND: Anemia is a major cause of morbidity worldwide and compounds numerous medical conditions. Studies have found associations between anemia and both medical and surgical complications after shoulder arthroplasty (SA); however, most of these studies have used commercially available national databases with limited information on outcomes and typically short-term follow-up. Our study sought to evaluate the midterm outcomes of primary SA at a single institution when stratified by the degree of preoperative anemia. METHODS: Between 2000 and 2020, 5231 primary SA (477 hemiarthroplasties, 2091 anatomic total SA, and 2335 reverse SA) with preoperative hematocrit values available and a minimum follow-up of 2 years were collected from a single-institution joint registry database. The severity of anemia was subclassified as no anemia (hematocrit >39% for males, >36% for females; n = 4194 [80.2%]), mild anemia (hematocrit 33%-39% for males, 33%-36% for females; n = 742 [14.2%]), and moderate-to-severe anemia (hematocrit <33% for both males and females; n = 295 [5.6%]). The mean follow-up time for the entire cohort was 5.9 years (range, 2-22 years). Medical and surgical complications, reoperations, revisions, and implant survivorship were assessed. RESULTS: SA with moderate-to-severe anemia had the highest rate of nonfatal and nontransfusion medical complications (5.1%) relative to the nonanemic (1.2%; P < .001) and mild anemic groups (1.5%; P < .001). Similarly, SA with moderate-to-severe anemia had the highest rate of surgical complications (19.3%) compared with mild anemia (14.3%; P = .044) and no anemia (11.6%; P < .001). Postoperative transfusion was most frequent in the moderate-to-severe anemia cohort (40.3%) compared with the mild anemia (14.2%; P < .001) and nonanemic groups (2.5%; P < .001). Furthermore, SA who received postoperative transfusions had a higher risk of nonfatal medical complications (8.2% vs. 1.0%; P < .001), 90-day mortality (1.5% vs. 0.03%; P = .001), and surgical complications (19.5% vs. 12.0%; P < .001) when compared with those without transfusion. CONCLUSIONS: Moderate-to-severe anemia (hematocrit <33% for both males and females) was identified in approximately 5.6% of patients who underwent SA at a single institution and was associated with increased medical and surgical complications. Patients who received postoperative transfusions presented elevated rates of medical complications, 90-day mortality, and surgical complications. Health care teams should be aware of these risks in order to provide more individualized medical optimization and postoperative monitoring.

Metacarpophalangeal Joint Pyrocarbon Arthroplasty for Osteoarthritis: An Analysis of 44 Arthroplasties.

PURPOSE: The objective of this study was to analyze postoperative outcomes in a group of patients who underwent metacarpophalangeal (MCP) arthroplasty using a pyrocarbon prosthesis for noninflammatory arthritis. METHODS: An analysis of 44 MCP joint arthroplasties in 30 patients with >2 years of follow-up over a 12-year period was reviewed. The mean age was 63 years. The primary operative indication was pain and stiffness from osteoarthritis refractory to nonsurgical management. RESULTS: At a mean follow-up of 6 ± 3 years, 8 (18%) joints underwent reoperation, including 5 (11%) that underwent revision arthroplasty. The 2- and 5-year rates for survival free of revision arthroplasty were 95% and 93%, respectively. One (2%) operation was complicated by intraoperative fracture. Postoperative complications occurred in 8 (18%) fingers and included ligament/tendon rupture (n = 3) and instability (n = 2). There was significant postoperative improvement in pain levels, MCP arc of motion, pinch strength, and grip strength. At a mean 5 years of radiographic follow-up, 7% had progressive implant instability because of grade 3 or greater loosening. No joints experienced implant instability from progressive subsidence. CONCLUSIONS: Metacarpophalangeal arthroplasty using a pyrocarbon implant for osteoarthritis demonstrates an 7% revision rate at 5 years after surgery. Complications lead to reoperation in 1 of 5 arthroplasties. Radiographic evidence of implant instability was uncommon. Overall, patients experienced predictable pain relief and improvements in their range of motion and pinch strength. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Arthrodesis as Salvage for Failed Metacarpophalangeal Arthroplasty.

BACKGROUND: Surgical management of failed metacarpophalangeal (MCP) arthroplasties includes revision arthroplasty and arthrodesis. The purpose of this study was to review the indications and outcomes of arthrodesis as a salvage procedure for failed MCP arthroplasties. METHODS: This was a retrospective cohort study of all patients undergoing salvage MCP arthrodesis at a single institution from 1990 to 2020. Patient charts were reviewed for patient demographics, indication for salvage, surgical technique, revision rate, and time to radiographic union. Patient-reported outcomes, including the Michigan Hand Outcomes Questionnaire and an MCP-specific questionnaire detailing pain, functional, appearance, and patient satisfaction, were also collected. RESULTS: Eleven digits in 9 patients (6 women, 3 men, median age of 66) with median 36-month follow-up were included. The majority (91%) of patients also had concomitant soft tissue deformities, including joint contractures, extension lag, and collateral ligament insufficiency. The overall revision rate following arthrodesis was 45% with 3 digits requiring one revision each, and 2 digits undergoing 3 revisions. The overall union rate was 91% with median time to union of 4 months from most recent arthrodesis. Patient-reported outcomes obtained from 4 patients demonstrated improvements in pain and function. CONCLUSION: Despite a high revision rate of 45%, salvage MCP arthrodesis following arthroplasty has a high eventual union rate of 91% and is associated with improved pain and function based on 4 patients' experiences. Arthrodesis as a salvage procedure for failed MCP arthroplasties should be considered in patients with persistent joint instability and functionally limiting soft tissue deformities.

Follow up care for adults with diabetes treated for severe hypoglycemia by emergency medical Services, 2013-2019.

AIMS: To capture the types and content of healthcare encounters following severe hypoglycemia requiring emergency medical services (EMS) and to correlate their features with subsequent risk of severe hypoglycemia. METHODS: A retrospective cohort was obtained by linking data from a multi-state health system and an advanced life support ambulance service. This identified 1977 EMS calls by 1028 adults with diabetes experiencing hypoglycemia between 1/1/2013-12/31/2019. We evaluated the healthcare engagement over the following 7 days to identify rates of discussion of hypoglycemia, change of diabetes medications, glucagon prescribing, and referral for diabetes. RESULTS: Rates of hypoglycemia discussion increased with escalating levels of care, from 11.5 % after EMS calls without emergency department (ED) transport or outpatient clinical encounters to 98 % among hospitalized patients with outpatient follow-up. EMS transport and outpatient follow-up were associated with significantly higher odds of discussion of hypoglycemia (OR 60 and OR 22.1, respectively). Interventions were not impacted by previous severe hypoglycemia within 30 days. Prescription of glucagon was rare among all patients. CONCLUSIONS: Interventions to prevent recurrent hypoglycemia increase with escalating levels of care but remain inadequate and inconsistent with clinical guidelines. Greater attention is needed to ensure timely diabetes-related follow-up and treatment modification for patients experiencing severe hypoglycemia.

Primary Arthrodesis of Non-thumb Metacarpophalangeal Joints of the Hand: Clinical and Patient-Reported Outcomes.

BACKGROUND: Metacarpophalangeal (MCP) joint arthritis is common secondary to a variety of inflammatory, degenerative, and traumatic causes. Although MCP arthroplasty is more common for the second to fifth digits, primary arthrodesis can be used for high-demand patients with arthritis or unsalvageable fractures of the MCP joint. There has been limited recent studies on the outcomes of these patients. METHODS: A retrospective review of 38 fingers in 27 patients with primary arthrodesis from 1990 to 2020 was conducted. The major outcomes were complications, reoperations, radiographic union, and time to union. Patient-reported outcomes including the Michigan Hand Outcomes Questionnaire and a questionnaire specific to the operative MCP joint were collected. RESULTS: Rate of radiographic union was 84% including revisions. The average time to union was 3.6 months. Rates of complications, reoperation, and amputation were 26%, 16%, and 7%, respectively. Arthrodesis as part of emergent trauma reconstruction was significantly more likely to result in reoperation (50% vs 7%) and complication (63% vs 17%) than chronic arthritis. Patient-reported outcomes were fair to good with improvement in pain (79%), function (66%), and appearance (40%). Sixty-six percent (66%) of patients were satisfied with their surgery, and 73% would repeat the surgery. CONCLUSION: Arthrodesis for unsalvageable MCP fractures was associated with higher rates of reoperation and complication than inflammatory or degenerative arthritis. Excluding emergent trauma, MCP fusion was reliable with a reoperation rate of 7% and a modest complication rate of 17%. Patients rated reasonable levels of satisfaction and willingness to repeat the procedure despite complications.

Surgical Management of Swan Neck Deformity Following Mallet Finger Injury: A Review of 25 Patients Over 20 Years.

INTRODUCTION: Swan neck deformity develops as a sequela of chronic mallet finger. Surgical management can include soft tissue reconstruction or distal interphalangeal joint (DIPJ) fusion. Studies examining the incidence and management of posttraumatic swan neck deformity following mallet fracture are limited. METHODS: A retrospective, single-institution review of patients undergoing surgical management of swan neck deformity following a traumatic mallet finger from 2000 to 2021 was performed. Patients with preexisting rheumatoid arthritis were excluded. Injury, preoperative clinical, and surgical characteristics were recorded along with postoperative outcomes and complications. RESULTS: Twenty-five patients were identified who had surgical intervention for swan neck deformity. Sixty-four percent of mallet fingers were chronic. Median time to development of mallet finger was 2 months. Twelve (48%) mallet fingers were Doyle class I, 6 (24%) were class III, and 7 (28%) were class IVB. Forty percent of injuries failed nonoperative splinting trials. Sixteen (64%) underwent primary DIPJ arthrodesis, 8 (32%) underwent DIPJ pinning, and 1 underwent open reduction and internal fixation of mallet fracture. The complication rate was 50% overall, and 33% of surgeries experienced major complications. The overall reoperation rate was 33%. Proximal interphalangeal joint hyperextension improved by 11° on average. Median follow-up was 61.2 months. CONCLUSIONS: The development of symptomatic swan neck deformity following traumatic mallet finger injury is rare. All patients warrant an attempt at nonsurgical management. Attempts at surgical correction had a high rate of complications, and DIPJ fusion appeared to provide the most reliable solution.

Chronic Q fever presenting as bilateral extensor tenosynovitis: a case report and review of the literature.

Musculoskeletal manifestations of Coxiella burnetii are rare. We describe an elderly, immunosuppressed male with bilateral Coxiella burnetii extensor tenosynovitis treated with incision and debridement and chronic doxycycline and hydroxychloroquine. Additionally, disease etiology, risk factors, pertinent features of the history, testing modalities, and treatment strategies of musculoskeletal Q fever are reviewed.

Systematic approach to diagnosing suspected Creutzfeldt-Jakob disease.

Evaluation of rapidly progressive dementia (RPD) is usually challenging. In most cases, patients progress to dementia in weeks to months, and the differential diagnosis is broad. In this case, a woman in her 60s presented with a 1-month history of episodic vertigo, cognitive decline, ataxia and myoclonus. Cerebrospinal fluid total tau was markedly elevated, which was helpful in establishing the diagnosis and discussing prognosis/end-of-life measures with the patient's family. This case summarises a stepwise diagnostic approach for patients with RPD and highlights recent literature on biomarkers of Creutzfeldt-Jakob disease and autoimmune encephalitis.