Septic Mycobacterium Avium Intracellulare Extensor Tenosynovitis of the Wrist.

Mycobacterium avium intracellulare (MAI) infections of the hand, wrist, and upper extremity are rare, but potentially devastating atypical mycobacterial infections that can affect tendon, bone, and other soft tissues of the musculoskeletal system. We present an immunocompromised patient presenting with acute swelling and pain in the dorsum of the hand and wrist that underwent a wrist extensor tenosynovectomy with intraoperative cultures revealing infection with MAI. The patient developed severe progression of the infection with osteomyelitis of the distal forearm and carpal bones, multiple subsequent extensor tendon ruptures, and dorsal skin necrosis. The infection was eradicated with a combination of surgical treatment and antibiotic therapy. The case is discussed in context of the prior scant literature of infectious tenosynovitis of the hand, wrist, and upper extremity caused by MAI. This case report and literature review outline recommendations for diagnosis and effective treatment of MAI.

Radially Based Extensor Retinacular Sling Reconstruction for Extensor Carpi Ulnaris Subsheath Injuries.

Purpose: Extensor carpi ulnaris (ECU) subsheath injuries result in ulnar-sided wrist pain and often present concurrently with intrinsic ECU pathology and ulnocarpal compartment injuries. There is a lack of surgical outcome data despite the variety of described ECU subsheath pathologies and reconstructive strategies. Methods: We retrospectively reviewed our hand-center experience of 33 patients who prospectively underwent radially based extensor retinacular sling ECU subsheath reconstruction by 4 hand surgery-fellowship-trained surgeons between April 2010 and April 2021. Preoperative clinical and magnetic resonance imaging findings, along with intraoperative findings, were cataloged. Statistical analysis was conducted via a 2-tailed paired t test. Results: The median age at the time of surgery was 44 years (range, 18-63 years). Twenty (60.6%) patients underwent reconstruction on their dominant wrist. The median time between symptom onset and surgery was 6.5 months (range, 4 days-16.1 years). Eight (18%) patients were collegiate-level or professional athletes. Ten (30.3%) patients had frank ECU snapping on the preoperative examination with no recurrence or apprehension on the postoperative examination. All 33 patients underwent a preoperative magnetic resonance imaging. Fifteen (45.4%) patients had intrinsic ECU tendinopathy, 19 (57.6%) patients had ECU tenosynovitis, 18 (54.5%) patients had triangular fibrocartilage complex tears, 20 (60.6%) patients had ulnocarpal synovitis, and 2 (6.1%) patients had lunotriquetral interosseous ligament tears. The mean postoperative pain on a visual analog scale was 0.39 ± 0.55. Grip strength, wrist flexion-extension, and pronosupination arcs (P < .05) showed excellent recovery after surgery. The mean time to unrestricted return to sports was 97.3 ± 19.7 days for the athletes in this study. There were no major complications. Conclusions: Radially based extensor retinacular sling ECU subsheath reconstruction resulted in satisfactory improvements in range of motion and grip strength. Although the mean improvements in these parameters were statistically significant, the clinical significance of these postoperative improvements remains to be defined. Type of study/level of evidence: Therapeutic, Level IV.

Radially Based Extensor Retinacular Sling Reconstruction for Extensor Carpi Ulnaris Subsheath Injuries in Elite Athletes.

BACKGROUND: Extensor carpi ulnaris (ECU) subsheath injuries are an increasingly recognized cause of ulnar-sided wrist pain in elite athletes. There is a lack of surgical outcome data in elite athletes, and unique considerations exist for these patients. METHODS: We performed a retrospective review of our hand center experience of 14 elite professional or collegiate athletes who prospectively underwent radially based extensor retinacular sling ECU subsheath reconstruction by 3 hand surgery-fellowship-trained surgeons between April 2011 and April 2021. Clinical, magnetic resonance imaging (MRI), and intraoperative findings were cataloged. Subgroup analyses of elite hockey players and acute subsheath injuries were also conducted. Statistical analysis was performed via a 2-tailed paired t test. RESULTS: Mean age at the time of surgery was 21.3 years (range, 18-34). Mean time from symptom onset to surgery was 102.1 ± 110.7 days. All 14 patients underwent preoperative MRI. Five patients (35.7%) had intrinsic ECU tendinopathy, 9 patients (64.3%) had ECU tenosynovitis, 6 patients (42.9%) had triangular fibrocartilage complex tears, and 9 patients (64.3%) had ulnocarpal synovitis. Mean postoperative pain on a Visual Analog Scale was 0.25 ± 0.43. Grip strength (P = .001), wrist flexion-extension (P = .037), and pronosupination arcs (P = .093) showed excellent recovery postoperatively. Mean time to unrestricted return to sports was 92.5 ± 21.0 days. There were no complications. Subgroup analyses found similar functional improvement and characterized injury patterns. CONCLUSIONS: Overall, our findings suggest surgical management of ECU subsheath injuries is a viable option in both acute and chronic settings in elite athletes and may be favorable compared with nonoperative management.

Risk Factors for Skin Tears Following Collagenase Clostridium histolyticum to Treat Dupuytren Contractures.

PURPOSE: Skin tears are an unpleasant complication that may occur after collagenase Clostridium histolyticum (CCH) administration to treat Dupuytren contractures of the fingers. The purpose of this study was to determine risk factors for the development of this complication. METHODS: Over a 6-year period, patients with a measurable metacarpophalangeal or proximal interphalangeal joint Dupuytren contracture and a palpable cord treated with CCH were prospectively observed. Patients were assessed for the development of skin tears immediately on the day of manipulation as well 30 days or more after manipulation. RESULTS: A total of 117 patients (174 cords) met inclusion criteria. There was a 25.6% incidence of skin tears (30 of 117 patients; 33 skin tears). Multivariable regression analysis revealed that patients with a combined digital flexion contracture (total combined metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joint contracture) of 75° and greater and those treated with 2 simultaneous doses of CCH in the same hand were more likely to sustain a tear. All skin tears healed with nonsurgical management at short-term follow-up. CONCLUSIONS: Although a relatively minor complication, skin tears are not well-tolerated by all patients and may change the postinjection course of orthosis use, wound care, and manual activity. Based on these results, patients with digital contractures 75° or greater and those treated with 2 simultaneous doses of CCH in the same hand may be counseled that they have a higher likelihood of developing a skin tear during manipulation. Pretreatment education may reduce anxiety experienced by patients who otherwise unexpectedly develop a skin tear at the time of manipulation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Ulnar Nerve Complications After Ulnar Collateral Ligament Reconstruction of the Elbow: A Systematic Review.

BACKGROUND: While ulnar collateral ligament reconstruction (UCLR) of the elbow is an increasingly commonly performed procedure with excellent results reported in the published literature, less attention has been paid to specifically on the characterization of postoperative ulnar nerve complications, and it is unclear what operative strategies may influence the likelihood of these complications. PURPOSE: The purpose of this study is to examine the prevalence and type of ulnar nerve complications after UCLR of the elbow based on the entirety of previously published outcomes in the English literature. In addition, this study examined how the rate of ulnar nerve complications varied as a function of surgical exposures, graft fixation techniques, and ulnar nerve management strategies. STUDY DESIGN: Systematic review and meta-analysis. METHODS: A systematic review of the literature was completed using the MEDLINE, PubMed, and Ovid databases. UCLR case series that contained complications data were included. Ulnar neuropathy was defined as any symptoms or objective sensory and/or motor deficit(s) after surgery, including resolved transient symptoms. Meta-analysis of the pooled data was completed. RESULTS: Seventeen articles (n = 1518 cases) met the inclusion criteria, all retrospective cohort studies. The mean prevalence of postoperative ulnar neuropathy was 12.0% overall after any UCLR procedure at a mean follow-up of 3.3 years, and 0.8% of cases required reoperation to address ulnar neuropathy. There were no cases of intraoperative ulnar nerve injury reported. The surgical approach associated with the highest rate of neuropathy was detachment of flexor pronator mass (FPM) (21.9%) versus muscle retraction (15.9%) and muscle splitting (3.9%). The fixation technique associated with the highest rate of neuropathy was the modified Jobe (16.9%) versus DANE TJ (9.1%), figure-of-8 (9.0%), interference screw (5.0%), docking technique (3.3%), hybrid suture anchor-bone tunnel (2.9%), and modified docking (2.5%). Concomitant ulnar nerve transposition was associated with a higher neuropathy rate (16.1%) compared with no handling of the ulnar nerve (3.9%). Among cases with concomitant transposition performed, submuscular transposition resulted in a higher rate of reoperation for ulnar neuropathy (12.7%) compared with subcutaneous transposition (0.0%). CONCLUSION: Despite a perception that UCLR has minimal morbidity, a review of all published literature revealed that 12.0% of UCLR surgeries result in postoperative ulnar nerve complications. UCLR techniques associated with the highest rates of neuropathy were detachment of the FPM, modified Jobe fixation, and concomitant ulnar nerve transposition, although it remains unclear whether there is a causal relationship between these factors and subsequent development of postoperative ulnar neuropathy due to limitations in the current body of published literature.

Pyrolytic Carbon Arthroplasty versus Suspensionplasty for Trapezial-Metacarpal Arthritis.

Purpose This study aims to compare outcomes after pyrolytic carbon implant hemiarthroplasty (PH) versus Thompson suspensionplasty (TS) for trapezial-metacarpal (TM) arthritis. Patients and Methods There were 87 arthritic TM joints in 71 patients treated with PH (n = 47 joints, 37 patients) or TS (n = 40 joints, 34 patients). Patients had significantly longer follow-up in the TS group (86.9 months, 25th-75th percentile = 55.6-103.8) versus the PH group (38.4 months, 25th-75th percentile = 23.2-65.8, p < 0.001). Results PH patients maintained higher final grip strength (p = 0.03) and apposition pinch strength (p = 0.01) compared with TS patients. Nelson scores were significantly higher among patients undergoing PH (mean = 50.4, standard deviation [SD] = 24.5) compared with TS (mean = 36.8, SD = 12.5, p < 0.01). There was a significantly higher proportion of complications (p < 0.01), reoperations (p < 0.01), and joint revision surgery (p < 0.01) in patients undergoing PH compared with TS. Controlling for age and sex, there was a 72.8% lower risk of complications (p = 0.02), 87.7% lower risk of reoperations (p = 0.01), and 87.2% lower risk of joint revision surgery (p < 0.01) among patients undergoing TS compared with PH. There was a shorter time to first complication (p < 0.01), reoperation (p < 0.02), and joint revision (p < 0.01) in those undergoing PH compared with TS. Conclusion Both cohorts exhibited functional range of motion and pinch and grip strengths postoperatively, and those undergoing PH began with and maintained higher grip and pinch strength at final follow-up. Those undergoing PH had significantly increased risk of complications, reoperations, and joint revision surgery. Most complications in patients undergoing PH were related to suspected development of scaphotrapezotrapezoidal (STT) arthritis postoperatively. We thus recommend careful evaluation of possible STT arthritis when considering PH arthroplasty. Level of Evidence Level III.

Extensor Carpi Ulnaris Subsheath Reconstruction.

Acute extensor carpi ulnaris (ECU) subsheath injury and chronic subsheath insufficiency may result in symptomatic ECU instability at the level of the distal ulna osseous sulcus. Associated ulnocarpal (ie, triangular fibrocartilage complex) and ECU intrinsic tendinopathic changes may accompany subsheath pathologies and require concomitant treatment. Surgical treatment is indicated in refractory cases despite nonoperative treatment and may consist of repair of the torn edge of the ECU subsheath or, more frequently, reconstruction utilizing a radially based extensor retinacular sling. An ECU subsheath reconstructive technique is detailed.

Extensor Pollicis Longus Rupture after Mini TightRope Suspensionplasty.

Background Arthritis of the first carpometacarpal (CMC) joint has been surgically treated in multiple ways with varying levels of success as measured by subjective and objective measures. Trapeziectomy with numerous variations in suspensionplasty comprises one of the more commonly used surgical procedures. Recently, the Mini TightRope apparatus has been utilized as a new method for achieving suspensionplasty, and as such lacks significant review of use and safety in the literature. Case Description An extensor pollicis longus (EPL) rupture following a trapeziectomy and Mini TightRope suspensionplasty for CMC arthritis of the thumb is presented. The patient successfully underwent an extensor indicis proprius (EIP) to EPL transfer to treat this complication. Literature Review There is well-established documentation of injury to the extensor tendons from orthopedic hardware such as volar locking plates. Regarding use of the Mini TightRope apparatus, guidelines for placement of the suture button include caution to place the button away from the EPL tendon to minimize the chance of tendon irritation. Additionally, FiberWire sutures, a component of the apparatus, have been shown to demonstrate soft tissue reactions with adjacent inflammatory response. Published reports on adverse events utilizing this device have been limited to case reports including an index metacarpal fracture. Clinical Relevance The aim of this case report was to cite an occurrence of EPL rupture following its use and discuss the possibilities of its direct contribution.

Intra-articular Fractures of the Sigmoid Notch of the Distal Radius: Analysis of Progression to Distal Radial Ulnar Joint Arthritis and Impact on Upper Extremity Function in Surgically Treated Fractures.

Background Studies have established an increased risk of radiocarpal joint posttraumatic arthritis in patients with displaced intra-articular fractures of the distal radius, although this phenomenon has yet to be evaluated in the distal radioulnar joint (DRUJ). Purpose We hypothesized that patients with displaced intra-articular fractures of the sigmoid notch would have a higher prevalence of DRUJ arthritis and greater upper extremity dysfunction after operative treatment of distal radius fractures compared with fractures without sigmoid notch involvement. We also hypothesized that the degree of sigmoid notch incongruity would be correlated with the grade of DRUJ arthritis and the severity of upper extremity dysfunction. Patients and Methods A retrospective review was conducted on surgically treated patients with distal radius fractures with pre- and/or postoperative computed tomography (CT) scans. Patients were divided into groups based on presence or absence of fracture extension into the sigmoid notch. Within the sigmoid notch group, postoperative CT scans were used to measure sigmoid notch fracture step-off and diastasis (mm), as well as volar or dorsal DRUJ subluxation (%). Patients were administered Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires and radiographs were obtained to grade DRUJ arthritis using the Kellgren-Lawrence (KL) radiographic criteria. Results Thirty-three patients were included (19 with sigmoid notch involvement and 14 without) with an average radiographic follow-up of 6.3 years (range: 3.5-10.1 years). DASH scores were available for all patients, and radiographic follow-up was available in 24 patients (73%). A trend toward higher grade of DRUJ arthritis and poorer average DASH was found in those with sigmoid notch involvement, but was not statistically different. In the sigmoid notch group there were poorer DASH scores in patients with coronal step-off > 1.0-mm (p < 0.05). There were no significant correlations between sigmoid notch step-off, diastasis or DRUJ subluxation and either KL grade of arthritis or DASH scores. Conclusion Fractures involving the sigmoid notch did not appear to have a greater prevalence of DRUJ posttraumatic arthritis in operatively treated patients at greater than 6 years of follow-up. Postoperative sigmoid notch step-off, diastasis or DRUJ subluxation had a minimal effect on upper extremity function, but fractures with a coronal step-off of > 1.0-mm exhibited higher levels of upper extremity dysfunction. Level of Evidence Prognostic, Level III-Case control.

Prosthetic Arthroplasty Versus Arthrodesis for Osteoarthritis and Posttraumatic Arthritis of the Index Finger Proximal Interphalangeal Joint.

PURPOSE: To compare outcomes of prosthetic arthroplasty versus arthrodesis to treat index finger proximal interphalangeal (PIP) joint arthritis. METHODS: Patients with osteoarthritis or posttraumatic arthritis of index finger PIP joints were evaluated. Digit range of motion, grip and pinch strength, patient-rated pain and satisfaction scores, Michigan Hand Questionnaire scores, and complications were recorded. RESULTS: A total of 79 finger PIP joints were followed for a median of 67 months overall (72 months for arthroplasty and 8 months for the arthrodesis group). Sixty-five were treated with arthroplasty and 14 with arthrodesis. Patients undergoing arthroplasty experienced no significant postoperative change in PIP joint range of motion whereas all preoperative PIP joint motion was eliminated after arthrodesis. Patients undergoing arthroplasty experienced significant postoperative improvement in opposition pinch. In contrast, patients undergoing arthrodesis experienced significant improvement in both opposition and apposition pinch. There were no differences in pain relief, satisfaction, or Michigan Hand Questionnaire scores between treatment groups. Patients undergoing arthroplasty had a significantly greater mean number of complications per year and mean number of complications in the first year postoperatively. There was a 4.3 times increased risk of complication in patients undergoing arthroplasty versus arthrodesis, and Kaplan-Meier analysis revealed a shorter time to first complication among patients undergoing arthroplasty. CONCLUSIONS: The decision for prosthetic arthroplasty versus arthrodesis in the index finger of patients with osteoarthritis or posttraumatic arthritis must be made with patient goals in mind and in light of greater risk of complications associated with arthroplasty.

Tenosynovitis of the wrist and thumb and carpal tunnel syndrome caused by Histoplasma capsulatum: case report and review of the literature.

A patient presenting with acute carpal tunnel syndrome and swelling and pain in the wrist and thumb is presented. An open carpal tunnel release and tenosynovectomy were performed with biopsy specimen revealing infection with Histoplasma capsulatum. The case is discussed in context of the prior scant literature of tenosynovitis of the wrist and hand caused by histoplasmosis.

Safety of open suprapectoral and subpectoral biceps tenodesis: an anatomic assessment of risk for neurologic injury.

BACKGROUND: Surgical techniques for proximal biceps tenodesis that include penetration of the posterior humeral cortex for fixation may pose risk to the surrounding neurovascular structures. HYPOTHESIS: The risk of neurologic injury with techniques that involve penetration of the posterior humeral cortex for fixation in proximal biceps tenodesis will increase as the tenodesis site moves proximally from the subpectoral to the suprapectoral location. METHODS: Proximal biceps tenodesis was performed on 10 cadaveric upper extremities with 3 separate techniques. The proximity of the hardware to the relevant neurovascular structures was measured. The distances between the tenodesis site and the relevant neurovascular structures were measured. RESULTS: The guide pin was in direct contact with the axillary nerve in 20% of the suprapectoral tenodeses. The distance between the axillary nerve and the tenodesis site was 10.5 ± 5.5 mm for the suprapectoral location, 36.7 ± 11.2 mm in the subpectoral scenario, and 24.1 ± 11.2 mm in the 30° cephalad scenario (P = .003). The distance between the radial nerve and the anterior tenodesis site was 41.3 ± 9.3 mm for the suprapectoral location and 48.0 ± 10.7 mm for the subpectoral location. The distance of the musculocutaneous nerve from the tenodesis site was 28.4 ± 9.2 mm for the suprapectoral location and 37.4 ± 11.2 mm for the subpectoral location. CONCLUSION: In a cadaveric model of open biceps tenodesis, penetration of the posterior humeral cortex at the suprapectoral location results in proximity to the axillary nerve and should be avoided. Subpectoral bicortical button fixation drilled perpendicular to the axis of the humerus was a uniformly safe location with respect to the axillary nerve.

Is there an association between chronicity of patellar instability and patellofemoral cartilage lesions? An arthroscopic assessment of chondral injury.

The purpose of this study was to investigate the association between chronicity of patellar instability on the prevalence, grade, and location of chondral lesions in patients with recurrent patellar instability. Patellofemoral chondral status was documented and graded according to the Outerbridge classification in 38 patients who underwent arthroscopic examination at the time of a medial patellofemoral ligament reconstruction procedure. Chondral lesions of any location were observed in 63.2% of patients. Patellar and trochlear lesions were observed in 57.9 and 13.2% of patients, respectively. There was a significantly higher duration of patellar instability in patients with a trochlear lesion versus those without a trochlear lesion (p < 0.01), and in patients with combined patellar and trochlear lesions versus those without both patellar and trochlear lesions (p < 0.01). There was a significant correlation between chronicity of patellar instability and Outerbridge grade of trochlear chondral injury (p = 0.01). Chi-squared analysis revealed that chronicity of patellar instability greater than 5 years was significantly associated with the likelihood of trochlear lesions (p < 0.05). We conclude that patients with increasing chronicity of patellar instability may have a higher likelihood of and higher grade of patellofemoral chondral injuries, specifically for trochlear lesions.

A percutaneous technique to treat unstable dorsal fracture-dislocations of the proximal interphalangeal joint.

PURPOSE: Unstable dorsal fracture-dislocations of the proximal interphalangeal (PIP) joint are complex injuries that are difficult to treat and usually require operative fixation. There are a number of surgical techniques for treating these injuries but none has emerged as superior. The purposes of this study were to describe a simple percutaneous technique to treat unstable dorsal fracture-dislocations of the PIP joint and to report short-term postoperative results. METHODS: We treated 6 patients with unstable dorsal fracture-dislocations of the PIP joint with the technique of closed reduction, percutaneous fracture reduction, and pinning via a volar approach and also with dorsal block pinning. We collected information on postoperative stability, range of motion at the PIP and distal interphalangeal joints, and radiographic outcomes. We also administered the Disabilities of the Arm, Shoulder, and Hand and visual analog pain scale questionnaires. RESULTS: At a mean follow-up of 18 months (range, 6-57 mo), there were no subluxation or dislocation events. The mean range of motion was from 4° of extension to 93° of flexion at the PIP joint and from 1° of extension to 73° of flexion at the distal interphalangeal joint. Radiographic analysis revealed a concentric reduction and union in all cases. The mean Disabilities of the Arm, Shoulder, and Hand score was 8 and the mean visual analog pain score was 1.4 out of 10. There were no minor or major complications. CONCLUSIONS: This percutaneous technique reliably restored stability to the PIP joint, allowed for concentric reduction of the joint, and produced excellent radiographic and clinical outcomes. The postoperative management course with this technique is critical to the outcome.

Elbow arthroscopy: setup, portal placement, and simple procedures.

Elbow arthroscopy has become an accepted treatment for numerous elbow conditions, including loose bodies, lateral epicondylitis, contractures, painful osteophytes, synovitis, osteochondritis dissecans, synovial plica, and osteoarthritis. It is absolutely necessary that the treating surgeon have complete knowledge of elbow anatomy. Three options exist for patient positioning: supine, prone, and lateral decubitus. Standard arthroscopic probes, grasping forceps, punches, and motorized shavers and burrs are used in the procedure. Retractors are essential for visualizing, exposing, and protecting nerves. Specially designed capsular biters can be used to develop a plane between the capsule and the surrounding soft tissues to facilitate capsulotomy and capsulectomy. Among elbow arthroscopists, the sequence of portal placement varies; however, there is little variation in the exact location of portal placement because of neurovascular constraints. Loose body removal and extensor carpi radialis brevis release for lateral epicondylitis are common procedures suitable for the beginning arthroscopist. For beginning and advanced procedures, the surgeon's skill and competence must be at a level consistent with the procedure to avoid complications.

Elbow arthroscopy: capitellar osteochondritis dissecans and radiocapitellar plica.

The combination of excessive radiocapitellar compressive forces and the limited vascularity of the capitellum are responsible for the development of osteochondritis dissecans. Repetitive compressive forces are generated by throwing or racket swinging motions or from constant axial compressive loads on the elbow, which are common in athletes such as gymnasts. Symptoms include activity-associated pain and stiffness. Physical examination findings show tenderness over the radiocapitellar joint and, commonly, loss of extension. Plain radiographs may show flattening and sclerosis of the capitellum, lucencies, and possibly intra-articular loose bodies. MRI can detect bone edema early in the disease process and further delineate the extent of the injury. The management of osteochondritis dissecans lesions is primarily based on the demands of the patient, the size and location of the lesion, and the status and stability of the overlying cartilage. Possible treatments include transarticular drilling; removing detached fragments or loose bodies, followed by drilling; and mosaicplasty. Radiocapitellar plica can cause chondromalacic changes on the radial head and capitellum, with symptoms including painful clicking and effusions. Arthroscopic plica resection is indicated when nonsurgical treatment fails.

Pharmacologic reversal of warfarin-associated coagulopathy in geriatric patients with hip fractures: a retrospective study of thromboembolic events, postoperative complications, and time to surgery.

PURPOSE: Patients with acute hip fractures who are on maintenance warfarin for anticoagulation present a significant challenge and their management remains controversial. The purpose of this study was to assess thromboembolic and systemic complications associated with pharmacological reversal of warfarin-associated coagulopathy in a population of geriatric patients with hip fractures. METHODS: This retrospective cohort study identified patients with operative hip fractures on oral warfarin therapy who had an international normalized ratio (INR) >1.50 on admission (N = 93) approximately over a 13-year span. The control group consisted of patients whose warfarin was held upon admission without further intervention preoperatively (n = 23). The treatment group consisted of patients who underwent pharmacologic reversal of elevated INR with vitamin K and/or fresh frozen plasma (FFP) in addition to holding warfarin (n = 70). Primary outcomes included thromboembolic and other complications as well as mortality within 3 months of presentation. Time to surgery was a secondary outcome. RESULTS: The 3-month mortality rate was 4% in the pharmacological intervention group and 17% in the watch-and-wait group; this difference trended toward statistical significance (P = .06). There were no significant differences in the likelihoods of other thromboembolic or nonthromboembolic complications between groups. While the difference in mean time to surgery was not significantly different overall between groups, this difference was significant in a subgroup of patients with higher baseline INRs (n = 46, INR >2.17), with a mean difference of 4.0 fewer days until surgery in the pharmacological intervention group (P < .01). CONCLUSIONS: Pharmacological reversal of warfarin-associated coagulopathy with a combination of vitamin K and FFP appears to be a safe way to optimize patients for operative fixation of hip fractures and is associated with a shorter delay to surgery in patients with more elevated INRs preoperatively. LEVEL OF EVIDENCE: retrospective cohort study (level III).

The rising incidence of acromioplasty.

BACKGROUND: Acromioplasty is considered a technically simple procedure but has become controversial with regard to its indications and therapeutic value. METHODS: Two complementary databases were used to ascertain the frequency of acromioplasty over a recent span of time. In Part A, the New York Statewide Planning and Research Cooperative System (SPARCS) ambulatory surgery database was searched from 1996 to 2006 to identify all ambulatory surgery acromioplasties as well as all orthopaedic ambulatory surgery procedures. In Part B, the American Board of Orthopaedic Surgery (ABOS) database was searched from 1999 to 2008 to identify all arthroscopic acromioplasties as well as all orthopaedic procedures. RESULTS: Part A revealed that in 1996 there were 5571 acromioplasties in New York State, representing a population incidence of 30.0 per 100,000. In 2006 there were 19,743 acromioplasties, representing a population incidence of 101.9 per 100,000. Over these eleven years, the volume of acromioplasties increased by 254.4%, compared with only a 78.3% increase in the volume of all orthopaedic ambulatory surgery procedures. In 2006, as compared with 1996, patients were 2.4 times more likely to have an acromioplasty compared with all other orthopaedic ambulatory procedures (p < 0.0001). Part B revealed that, in 1999, a mean of 2.6 arthroscopic acromioplasties were reported per candidate for Board certification. In 2008 a mean of 6.3 arthroscopic acromioplasties per candidate were reported. Over these ten years, the mean number of arthroscopic acromioplasties reported increased by 142.3%, compared with only a 13.0% increase in the mean number of all orthopaedic surgery procedures. In 2008, as compared with 1999, candidates were 2.2 times more likely to report an arthroscopic acromioplasty compared with all other orthopaedic procedures (p < 0.0001). CONCLUSIONS: There has been a substantial increase in the overall volume and the population-based incidence of acromioplasties in recent years on both the state and national levels in the United States. The reasons for this increase have yet to be determined and are likely multifactorial, with patient-based, surgeon-based, and systems-based factors all playing a role.