Radiographic Evaluation of Elbow Fractures.

Fractures and dislocations of the elbow are a common cause of emergency department visits each year. Radiography remains the bedrock of an initial injury assessment, and recognition of distinctive injury patterns based on fracture location, morphology, and severity, guides optimal clinical decision-making. This article reviews basic elbow anatomy, frequently seen fractures and injury patterns, and highlights how these findings influence surgical planning and patient management.

Comorbidity effects on shoulder arthroplasty costs analysis of a nationwide private payer insurance data set.

BACKGROUND: The purpose of this study was to evaluate the effect of common medical comorbidities on the reimbursements of different shoulder arthroplasty procedures. METHODS: We conducted a retrospective query of a single private payer insurance claims database using PearlDiver (Warsaw, IN, USA) from 2010 to 2014. Our search included the Current Procedural Terminology codes and International Classification of Diseases, Ninth Revision codes for total shoulder arthroplasty (TSA), hemiarthroplasty, and reverse shoulder arthroplasty (RSA). Medical comorbidities were also searched for through International Classification of Diseases codes. The comorbidities selected for analysis were obesity, morbid obesity, hypertension, smoking, diabetes mellitus, hyperlipidemia, atrial fibrillation, chronic obstructive pulmonary disease, cirrhosis, depression, and chronic kidney disease (excluding end-stage renal disease). The reimbursement charges of the day of surgery, 90-day global period, and 90-day period excluding the initial surgical day of each comorbidity were analyzed and compared. Statistical analysis was conducted through analyses of variance or Kruskal-Wallis test. RESULTS: Comorbidities did not have a significant effect on same-day reimbursements but instead caused a significant effect on the subsequent 89-day (interval) and 90-day reimbursements in the TSA and RSA cohorts. For TSA and RSA, the highest reimbursement costs during the 90-day period after surgery were seen with the diagnosis of hepatitis C, followed by atrial fibrillation and later chronic obstructive pulmonary disease. For hemiarthroplasty, the same was true in the following order: hepatitis C, cirrhosis, and atrial fibrillation. CONCLUSION: Shoulder arthroplasty reimbursements are significantly affected by comorbidities at time intervals following the initial surgical day.

Trends in surgical management of proximal humeral fractures in the Medicare population: a nationwide study of records from 2009 to 2012.

BACKGROUND: Surgical management of proximal humeral fractures has reportedly increased in recent years. Much of this growth relates to a growing elderly population, together with the introduction of modern implants, such as locking plates and, recently, introduction of reverse shoulder arthroplasty (RSA). This study evaluated trends in surgical management of proximal humeral fractures from 2009 to 2012 by analyzing the use of hemiarthroplasty (HA), RSA, and osteosynthesis (open reduction with internal fixation [ORIF]) within the Medicare patient population. METHODS: We retrospectively reviewed a comprehensive Medicare patient population database within the PearlDiver supercomputer (Warsaw, IN, USA) for proximal humeral fractures treated with HA, RSA, or ORIF. Total use, annual utilization rates, age, and gender were investigated. RESULTS: Within the study period, 32,150 proximal humeral fractures were treated operatively, with no significant change in annual volume (P = .119). The percentage of fractures treated surgically decreased significantly from 16.2% to 13.9% (P < .001). The utilization rate decreased significantly for HA from 52% to 39% (P < .001), increased significantly for RSA from 11% to 28% (P < .001), and did not change significantly for ORIF (P = .164). The utilization rate of RSA nearly tripled for patients older than 65 years (11% to 29%) and doubled for patients younger than 65 (6% to 12%). CONCLUSION: From 2009 to 2012, utilization rates of ORIF remained fairly constant. HA remains the most commonly used surgical treatment for proximal humeral fractures in the Medicare population, but its use has declined significantly. This decline has been offset by a corresponding increase in RSA.

Radiographic appearance of displaced lesser tuberosity osteotomy: a case series.

BACKGROUND: Lesser tuberosity osteotomy has become a popular method of subscapularis management during total shoulder arthroplasty with high healing rates and reliable functional recovery. One major advantage of this technique is the ability to monitor healing using routing radiographs. Recognition of displacement of the lesser tuberosity may provide a unique opportunity for revision repair before the tuberosity becomes irreversibly retracted. METHODS: A series of four patients were identified with a displaced lesser tuberosity osteotomy following total shoulder arthroplasty. Radiographs from these patients were reviewed to identify the optimal radiograph for detecting displacement. RESULTS: In each of the four cases, the displaced lesser tuberosity osteotomy was not seen on the axillary radiograph. A true AP radiograph consistently provided the only clear view of the displaced osteotomy. CT or MRI was used to confirm displacement of the lesser tuberosity osteotomy. In each case, displacement of the lesser tuberosity resulted from either a traumatic event, or from patient non-compliance with post-operative restrictions. DISCUSSION/CONCLUSION: This is the first report that characterizes the radiographic appearance of failure of the lesser tuberosity osteotomy technique. Displacement of lesser tuberosity osteotomy following shoulder arthroplasty is best observed using a true AP radiograph.

Morbid obesity and 1-year costs after elbow dislocation.

BACKGROUND: Morbid obesity has been linked with serious associated injuries following dislocations of the knee. While similar devastating injuries have been observed following elbow dislocations in the obese, no study to date has characterized the financial impact of elbow dislocations in the morbidly obese population. PURPOSE: The purpose of this study is to determine the impact of morbid obesity on 1-year costs related to elbow dislocation. METHODS: A retrospective query of the Medicare Standard Analytic Files database was performed for patients sustaining elbow dislocation from 2005 to 2014. 1-year reimbursement costs from the initial open or closed reduction procedures were compared for morbidly obese (BMI ≥ 40 kg/m2) patients versus those without morbid obesity (BMI < 40 kg/m2). Cohorts were matched based on age and gender. Total reimbursement costs associated with a diagnosis of elbow dislocation and/or reduction were analyzed. RESULTS: We identified 182 morbidly obese patients and 422 patients without morbid obesity who underwent open or closed reduction for elbow dislocation. 102 patients with 1-year cost data remained in each cohort after matching. Mean 1-year reimbursement costs related to elbow dislocation were significantly greater in morbidly obese patients ($6227.43 vs $4225.71, p = 0.006). CONCLUSION: 1-year costs related to elbow dislocation are significantly higher in morbidly obese patients. The increased costs likely reflect the complexity of managing dislocations in the obese population. Difficulties maintaining closed reduction, longer and more challenging surgeries with a higher likelihood on intra- and post-operative complications, and a higher risk of peri-operative medical complications may all contribute to these increased costs.

Cost of Treatment for Proximal Humerus Fractures: An Acute and 90-Day Cost Evaluation.

The purpose of this study was to examine the 90-day costs of three common surgical treatments for proximal humerus fractures and compare the costs associated with the initial day and subsequent 89 days of care. This was conducted through a retrospective review of a national database examining patients who suffered proximal humerus fractures. Patients were stratified by type of surgical procedure performed, hemiarthroplasty (HA), reverse shoulder arthroplasty (RSA), and open reduction and internal fixation (ORIF). RSA was the most costly procedure for the same-day and 90-day costs (p < 0.001). Mean initial day reimbursement costs were significantly different among treatment groups, with the highest costs seen with RSA ($16,151), followed by HA ($9,348), and ORIF ($6,745). Subsequent 89-day reimbursement costs were not significantly different for RSA, HA, and ORIF (p = 0.112). The 90-day costs for the surgical treatment of proximal humerus fractures are driven by the initial day costs. RSA was associated with the highest cost, followed by HA and ORIF.

An alternative method of osteosynthesis for distal humeral shaft fractures.

Treatment of extra-articular distal humerus shaft fractures with plating techniques is often difficult, as traditional centrally located posterior plates often encroach on the olecranon fossa, limiting distal osseous fixation. The use of a modified Synthes Lateral Tibial Head Buttress Plate (Synthes, Paoli, PA) allows for a centrally placed posterior plating of the humeral shaft that angles anatomically along the lateral column to treat far distal humeral shaft fractures. Fifteen patients treated in this manner were followed to radiographic and clinical union. There were no cases of instrumentation failure or loss of reduction.

Proximal humeral nonunions treated with fixed-angle locked plating and an intramedullary strut allograft.

OBJECTIVE: To determine if the use of a fixed-angle locked plate plus an intramedullary allograft in the treatment of proximal humeral nonunions resulted in improved union. DESIGN: Retrospective clinical analysis of patients' medical charts and radiographs. SETTING: Clinical practice of senior authors. PATIENTS/PARTICIPANTS: Eighteen patients who presented to the senior authors' clinic between 2001 and 2007 with clinical and radiographic evidence of symptomatic proximal humeral nonunions that were treated with the described method were included for analysis. Patients with severe humeral head bone loss, avascular necrosis, evidence of arthrosis, and less than 12-month clinical follow-up were excluded. INTERVENTION: All patients with a symptomatic viable nonunion of the proximal humerus were treated with a fixed-angle locked plate and an intramedullary cortical allograft. MAIN OUTCOME MEASUREMENT: Patients were followed until radiographic union was achieved, with this being the principle determinant of a successful outcome. RESULTS: Radiographic union was achieved in 17 of 18 patients (94%). The average follow-up was 26.5 months (range 12-49 months). The average time from surgery to radiographic union was 5.4 months (range 2.5-8.8 months). There was 1 failure of fixation, and 2 patients developed transient neurologic sequelae. Range of motion measurements obtained from the most recent clinical follow-up were 115 degrees (range 20-180 degrees) active forward elevation, 37 degrees (range 0-70 degrees) passive external rotation, and active internal rotation was to the 10th thoracic vertebrae. American Shoulder and Elbow Surgeon scores improved from a level of 40 preoperatively to 81 postoperatively, and visual analog scale scores improved from 6.7 to 1.5. CONCLUSION: Intramedullary strut allograft insertion combined with fixed-angle plating is an effective technique for treating viable nonunions of the proximal humerus and was successful in achieving union in 94% of our patients.