Geriatric proximal humerus fracture operative management: a Truven Health Analytics database study (2015-2020).

BACKGROUND: The purpose of this study is to assess the trends in operative management of geriatric (≥65 years) proximal humerus fractures during a 6-year period (2015-2020) within an insurance claims database. METHODS: This retrospective database cohort study used data gathered from the 2015-2020 IBM Truven MarketScan Commercial and IBM Truven MarketScan Medicare Supplemental databases. The International Statistical Classification of Disease and Related Health Problems, Tenth Revision, data was correlated to the Current Procedural Terminology code for shoulder arthroplasty (proximal humeral prosthetic replacement: 23616, shoulder hemiarthroplasty [HA]: 23470, reverse total shoulder arthroplasty [rTSA]: 23472) or open reduction internal fixation (ORIF; open treatment of proximal humerus fracture with internal fixation: 23615, open treatment of proximal humerus fracture-dislocation with internal fixation: 23680). We investigated the number of proximal humerus fracture operative cases per year, percentage arthroplasty used per year, rTSA and HA per year, hospital cost information, as well as percentage arthroplasty per US geographic region. RESULTS: A total of 8057 operative proximal humerus fractures cases were identified in 7697 patients aged >65 years, with 0.45% (360 of 8057) being bilateral. There was a 40.8% decrease in the rate of operative management of proximal humerus fractures between the first half (2015-2017, 1687.3 ± 146.6) and the second half of the study period (2018-2020, 998.3 ± 258.7). Arthroplasty accounted for 78.7% of all surgeries, 91% of those being rTSA. The total number of cases of rTSA and ORIF performed decreased per year (P = .01). The downward trend of percentage ORIF per year approached significance (P = .054). Arthroplasty was a more expensive option of payment for total case by almost $850.00 (P = .001). There was a larger percentage of arthroplasty performed in the Northeast and North Central US geographic regions. CONCLUSION: Despite the rise of both the elderly population and related geriatric proximal humerus fractures, they were less operatively represented in this insurance claims database across the 6-year period. There may be a trend to use less ORIF when addressing these fractures. Although it incurred a higher in-hospital cost, arthroplasty was being performed at a higher percentage in the Northeast and North Central regions of the United States.

Reamer irrigator aspirator (RIA) reduces risk of fat embolism in bilateral pediatric femur shaft fractures: a case report.

A 14-year-old male patient was successfully treated with the reamer irrigator aspirator for femur intramedullary rod preparation after sustaining right and left closed femur fractures because of an all-terrain vehicle accident. In patients already categorized as high risk for fat embolism syndrome, such as those with bilateral femur fractures, reaming both femora greatly increases the likelihood of this complication. The reamer irrigator aspirator provides an effective tool that potentially mitigates the risk of fat embolism syndrome in pediatric patients with this type of orthopedic trauma.

The Perfect Circle Technique Shows Poor Inter-rater Reliability in Measuring Anterior Glenoid Bone Loss on Magnetic Resonance Imaging.

Purpose: To evaluate the reliability of the perfect circle methodology for measurement of glenoid bone loss in patients with anterior glenohumeral instability. Methods: We performed a chart review of retrospectively collected patients who underwent isolated arthroscopic anterior labral repair between January 1 and June 30, 2021, using our institution's electronic medical records. The inclusion criteria included isolated anterior shoulder instability with anterior labral repair and corroborated tears on magnetic resonance imaging. A total of 9 raters, either sports or shoulder and elbow fellowship-trained orthopaedic surgeons, each evaluated the affected shoulder magnetic resonance imaging scans twice, with a minimum of 2 weeks between measurements. Measurements followed the "perfect circle" technique and included projected anterior-to-posterior glenoid diameter, amount of posterior bone loss, and percentage of posterior bone loss. Intrarater reliability and inter-rater reliability were then determined by calculating intraclass correlation coefficients (ICCs). Results: Ten consecutive patients meeting the selection criteria were chosen for inclusion in this analysis. Average estimated bone loss for the cohort was 2.45 mm, and the mean estimated glenoid diameter of the involved shoulder was 28.82 mm. The average percentage of bone loss measured 8.54%. The ICC for interobserver reliability was 0.55 for the perfect circle diameter and 0.17 for the anterior bone loss measurement (poorly to moderately reliable). The ICC for intraobserver reliability was 0.69 for the perfect circle diameter and 0.71 for anterior bone loss (moderately reliable). Conclusions: The perfect circle technique for estimating anterior glenoid bone loss on magnetic resonance imaging was found to have moderate intrarater reliability; however, reliability between observers was found to be moderate to poor. Level of Evidence: Level IV, diagnostic case series.

Acute Simple Elbow Dislocations in the United States: An Epidemiological Analysis of Trends Including COVID-19.

Background Elbows are one of the most frequently dislocated large joints; however, there is limited epidemiological data, especially during the coronavirus disease 2019 (COVID-19) pandemic. This study characterizes elbow dislocations presenting to Emergency Departments (EDs) over the last decade. Methods This study is a cross-sectional, descriptive, epidemiologic analysis of isolated elbow dislocations presenting to EDs from 2011-2020 using the National Electronic Injury Surveillance System (NEISS) database. Patients under 10, those with radial head subluxation, and those with complex fractures were excluded. Data on incidence ratios, patient demographics, mechanisms of injury, and incident locales were analyzed. Results Approximately 83,996 simple, primary elbow dislocations occurred from 2011-2020 (n=2,328), generating an incidence of 2.98/100,000 person-years. Incidence was higher among males (3.26 versus 2.69/100,000 person-years). Dislocations peaked in patients aged 10-19, with higher rates in males (11.12 versus 5.31/100,000 person-years; injury rate ratio 2.09, CI=2.05-2.14, p<0.001). Rates of elbow dislocations decreased with age in males (age 20-29=11.12, age >80=0.63/100,000) but increased in females over 40 (age 40-49=1.59, age 70-79=2.83/100,000). Athletic activities accounted for 55% of dislocations (n=45,902), with 15% from football and 14% from wrestling. The fewest annual dislocations occurred during COVID-19 (n=6440). Injuries occurring at schools and during contact and indoor sports decreased, while those from soccer increased. Conclusions Elbow dislocations are common, with trends of decreasing incidence with age among men and increasing incidence in women over 40. COVID-19 impacted sports-related and epidemiologic injury patterns. Ultimately, understanding population-level risks for elbow dislocations enables orthopaedic surgeons to predict injury trends and conceive educational preventative measures.

The Perfect-Circle Technique Demonstrates Poor Inter-Rater Reliability in Measuring Posterior Glenoid Bone Loss on Magnetic Resonance Imaging.

Purpose: To evaluate the reliability of the "perfect-circle" methodology for measurement of glenoid bone loss with magnetic resonance imaging (MRI) in patients with posterior glenohumeral instability. Methods: A prospective chart review was performed on patients who underwent isolated arthroscopic posterior labral repairs in our institution's electronic medical records between January 1, 2021, and June 30, 2021. Inclusion criteria included isolated posterior shoulder instability with posterior labral repair and corroborated tears on MRI. A total of 9 raters, either sports or shoulder and elbow fellowship-trained orthopaedic surgeons, each evaluated the affected shoulder MRI scans twice, at over 2 weeks apart. Measurements followed the "perfect-circle" technique and included projected anterior-to-posterior (AP) glenoid diameter, amount of posterior bone loss, and percentage of posterior bone loss. Results: Ten consecutive patients between the ages of 17 and 46 years with diagnosed posterior glenohumeral instability were selected. The average age was 28 ± 10 years, and 60% of patients were male. The patient's dominant arm was affected in 40%, and 50% of cases involved the right shoulder. The average glenoid diameter was 29.62 ± 3.69 mm, and the average measured bone loss was 2.8 ± 1.74 mm. The average percent posterior glenoid bone loss was 9.41 ± 5.78%. The inter-rater reliability was poor for the AP diameter and for the posterior glenoid bone loss with intraclass correlation coefficients at 0.30 (0.12-0.62) and 0.22 (0.07-0.54) respectively. The intrarater reliability was poor for AP diameter and moderate for posterior glenoid bone loss, with intraclass correlation coefficients at 0.41 (0.22-0.57) and 0.50 (0.33-0.64), respectively. Conclusions: Using the "perfect-circle" technique for evaluating posterior glenohumeral bone loss has poor-to-moderate inter- and intrarater reliability from MRI. Level of Evidence: Level IV, prospective diagnostic study.

Operative challenges of intramedullary nailing for subtrochanteric blastic pathological femur fracture: a case report.

Prostate adenocarcinoma metastasizes to bone and forms fragile blastic lesions, which can present as dense obstacles intraoperatively. There are limited reports on the challenges surgeons face when operating through these lesions. A 60-year-old male with a pathologic subtrochanteric femur fracture in the presence of blastic lesions was successfully treated with intramedullary (IM) fixation. Pathologic fractures from blastic bone lesions are expected to increase in prevalence as survivability improves for metastatic prostate cancer. Orthopedic surgeons, when performing IM fixation for these fractures, should be prepared to utilize accessory equipment and should adopt creative techniques for reduction and fixation.

Tibial Bone Transport With a Single Implant All-Internal Bone Transport Nail.

SUMMARY: A single implant all-internal magnet-driven bone transport nail (BTN-NuVasive Specialized Orthopaedics Inc) has recently been introduced as a treatment method for segmental tibial bone defects. This innovation provides promise in the management of segmental bone defects because it negates numerous complications associated with circular external fixation and the need for multiple implants when considering hybrid plate-assisted bone segment transport constructs. Given the novelty of the BTN, description of the surgical application and patient outcome measures are scarce in the current literature. To date, we have treated 4 patients with an average age of 27 years (range 19-44 years) using the BTN for segmental tibial defects ranging from 50 to 128 mm. We have accumulated data over an average follow-up of 18.07 months (range 12.96-25.13 months), demonstrating good patient tolerance of the device. Three patients successfully completed their treatment course with a calculated average bone healing index of 41.4 days/cm (range 31.41-54.82 days/cm). One patient was noted to experience an asymptomatic docking site nonunion requiring subsequent surgery for nonunion repair. Implant-associated complications included symptomatic implant, axial malalignment, docking site nonunion, and external remote control technical malfunction. Injury-related complications were encountered and noted to include: superficial infection, wound dehiscence, peroneal tendonitis, and joint rigidity. In this study, the authors present a case series using this implant to date and discuss our experiences with the BTN with reference to clinical indications, tibial bone preparation, BTN implantation, transport protocol, docking site procedure, and clinical/radiographic outcomes.

Correction of Cubitus Varus Using Computer-Assisted Hexapod Multiplanar External Fixators: A Report of 3 Cases.

CASE: Three male patients, 8-, 13-, and 18-year-old, all developed posttraumatic cubitus varus elbow deformity after distal humerus supracondylar fractures. Each underwent a distal humerus osteotomy with application of a hexapod external fixator to gradually correct the deformity. CONCLUSION: In patients with cubitus varus malunion, the stability of the hexapod external fixation, percutaneous nature of the osteotomy, and availability of running a residual computer-assisted program provides a consistent technique for deformity correction.

Unroofing osteotomy for dissociated tibial intramedullary magnetic rod during implant removal: a case report.

The PRECICE® intramedullary rod (NuVasive, San Diego, CA) utilizes multiple telescopic components to magnetically drive limb lengthening. These devices are routinely explanted after desired growth correction is met. To the author's knowledge, this is the first description of an osteotomy assisted extraction of a disassociated tibial magnetic lengthening rod. A 17-year-old girl with fibular hemimelia and resolved left tibial length discrepancy after successful surgical lengthening underwent a complex implant removal approximately seven years after regenerate consolidation. During implant removal, the telescopic portion of the rod remained lodged in the tibial medullary canal and a subsequent unroofing osteotomy of the tibia was performed. Tibial limb length discrepancies are oftentimes corrected with complex implants comprised of multiple fragile components that are routinely explanted. During the unfortunate event of a telescopic intramedullary rod dissociation, an unroofing osteotomy can be successfully performed to removal all implant components.

Ten-Year Trends in Level of Evidence in Hand Surgery.

BACKGROUND: The purposes of this study were to analyze the trends in Oxford level of evidence (LOE), LOE of most-cited articles, and association between LOE and journal impact factor (IF) and SCImago Journal Rank (SJR) over a 10-year period (2009-2018) in 3 prominent hand surgery journals, specifically HAND, Journal of Hand Surgery (American Volume) (JHS), and Journal of Hand Surgery (European Volume) (JHSE). METHODS: All articles published from 2009 to 2018 in HAND, JHS, and JHSE were reviewed for assigned or available LOE. Data were pooled and analyzed for trends in LOE; relationship among IF, SJR, and LOE; and citation density. RESULTS: A total of 3921 total publications were tabulated from 2009 to 2018, with the majority of studies being level V (1700, 43%) and fewer studies being level I (146, 4%). Over the 10-year study period, there was no significant change in frequency of level I studies for any journal. HAND trended significantly toward higher LOE, JHS trended toward higher LOE, and JHSE trended toward decreased LOE without significance. Among all journals, the annual number of articles and the average LOE were independent significant predictors of IF and SJR. Statistically significant correlations were found between citation density and LOE for JHS and HAND. CONCLUSIONS: Higher quality evidence is becoming more prevalent in the hand surgery literature over the past 10 years. Annual articles, average LOE, and level I and II and level IV articles were significant predictors of increasing IF and SJR.

Treatment patterns of ABOS part II candidates: A decline of operative management among geriatric proximal humerus fractures over the decade (2010-2020).

BACKGROUND: The purpose of this study was to assess trends in ABOS part II candidate's operative management of geriatric (≥65 years) proximal humerus fractures over the 2010-2020 decade. METHODS: This retrospective database cohort study utilized the American Board of Orthopaedic Surgery (ABOS) database for candidates taking Part II of their boards. Surgical coding was reviewed and the ICD10 data was correlated to the CPT code for shoulder arthroplasty or open reduction internal fixation. We investigated the number of proximal humerus fracture operative cases per year, the percent arthroplasty used per year, the stratification of percent arthroplasty per orthopaedic fellowship subspecialty and geographic region. RESULTS: A total of 2,409 operative cases for proximal humerus fractures in patients 65 years of age and older were submitted by 1,420 ABOS candidates. There was a 37% reduction in operatively managed proximal humerus fractures among ABOS part II candidates between the first half of the decade (2010-2015, 263.2 +/- 13.4) and the second half of the decade (2016-2020, 166 +/- 31.2; p<.05). There also was a downward trend with a 53% reduction in percent treated with arthroplasty as compared to ORIF during those same windows (2010-2015, 34.4 +/-11.7) and (2016-2020, 16.2 +/- 6.4; p<.5). Partitioned by single fellowship training, Shoulder and Elbow (S&E) surgeons performed the highest percent arthroplasty at 25.2%, followed by Sports at 23.1% and the lowest percent arthroplasty was Trauma at 11.7%. The Southeast United States had the lowest percentage arthroplasty at 15.8% as compared to the Midwest (23.8%) and Northeast (25.8%). CONCLUSION: Despite the rapid growth of both the elderly population and related geriatric proximal humerus fractures, ABOS candidates are treating less with surgery. There has been approximately a 37% decrease in the total number of operatively treated proximal humerus fractures between the first and second half 2010-2020 decade. When operative treatment is performed, there is a trend towards ORIF over an arthroplasty. Trauma fellowship trained surgeons are less likely to perform an arthroplasty as compared to other subspecialties. The Southeast region is least likely to perform an arthroplasty as compared to the Midwest or Northeast.

Nerve Reconstruction Using Processed Nerve Allograft in the U.S. Military.

BACKGROUND: Processed nerve allograft (PNA) is an alternative to autograft for the reconstruction of peripheral nerves. We hypothesize that peripheral nerve repair with PNA in a military population will have a low rate of meaningful recovery (M ≥ 3) because of the frequency of blasting mechanisms and large zones of injury. METHODS: A retrospective review of the military Registry of Avance Nerve Graft Evaluating Utilization and Outcomes for the Reconstruction of Peripheral Nerve Discontinuities database was conducted at the Walter Reed Peripheral Nerve Consortium. All adult active duty military patients who underwent any peripheral nerve repair with PNA for complete nerve injuries augmented with PNA visit were included. Motor strength and sensory function were reported as a consensus from the multidisciplinary Peripheral Nerve Consortium. Motor and sensory testing was conducted in accordance with the British Medical Research Council. RESULTS: A total of 23 service members with 25 nerve injuries (3 sensory and 22 mixed motor/sensory) underwent reconstruction with PNA. The average age was 30 years and the majority were male (96%). The most common injury was to the sciatic nerve (28%) from a complex mechanism (gunshot, blast, compression, and avulsion). The average defect was 77 mm. Twenty-four percent of patients achieved a meaningful motor recovery. Longer follow-up was correlated with improved postoperative motor function (r = 0.49 and P = .03). CONCLUSIONS: The military population had complex injuries with large nerve gaps. Despite the low rate of meaningful recovery (27.3%), large gaps in motor and mixed motor/sensory nerves are difficult to treat, and further research is needed to determine if autograft would achieve superior results. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level III.

Novel Utilization of Anterior Intrapelvic (Stoppa) Approach for Periacetabular Ganz Osteotomy: A Report of 2 Cases.

CASE: The Ganz periacetabular osteotomy (PAO) is widely used to correct developmental hip dysplasia in the adolescent and young adult population. The aim of this case study was to examine the novel utility and safety of Stoppa approach for the Ganz PAO in a 15-year-old girl and 25-year-old man. The Stoppa approach is traditionally used for acetabular fractures, and its use for a Ganz PAO is relatively novel. CONCLUSION: The Stoppa approach allows surgeons to successfully perform the Ganz PAO while simultaneously providing direct visualization for all osteotomies and vital structures.

Epidemiology and Long-Term Outcomes of Wrist Sprains in Military Academy Cadets.

BACKGROUND: The American Society for Surgery of the Hand advises patients that symptoms after wrist sprains resolve in 6 weeks and that recovery is usually excellent; however, there is scant supporting evidence for this reassurance. PURPOSE: To describe the epidemiology and report long-term outcomes of wrist sprains. STUDY DESIGN: Descriptive epidemiology study. METHODS: The US Department of Defense Military Health System Management Analysis and Reporting Tool was queried for wrist sprain International Classification of Diseases, Ninth Revision, codes between 2005 and 2008 among US Military Academy cadets. The electronic medical records were reviewed to obtain demographic information, mechanism of injury, and patient characteristics. A telephone survey was conducted to collect Single Assessment Numeric Evaluation (SANE) score, the shortened version of Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, and ability to return to full military duty. RESULTS: Of the 90 patients identified, 49 patients (50 wrists) met the final inclusion criteria. The mean patient age was 21 years, the majority were male (86%), and most sprains occurred during athletics (65%) and military activities (20%). Most patients (61%) had radiographs taken after index wrist sprain, and few (14%) underwent magnetic resonance imaging (MRI). After a mean follow-up of 10.4 years, most patients (78%) had no further wrist injury. The average SANE and QuickDASH scores were 88 and 7.5, respectively. Two patients (4%) ultimately were treated with surgical repair. Most patients (96%) were on an upper extremity profile, limiting military duty for a median of 14 days. All patients ultimately returned to full military duty. CONCLUSION: Patients with a wrist sprain diagnosis were followed for an average of 10 years. Although the majority (96%) of patients required a median of 14 days with limited upper extremity function, MRI is rarely indicated in the acute setting and most patients will never have another wrist injury and can expect excellent wrist recovery outcomes.

Alleviation of Pain After Femur and Tibia Shaft Fractures Using Nothing Stronger Than Codeine and Tramadol.

OBJECTIVE: To determine whether using nothing stronger than codeine and tramadol provides adequate pain alleviation in people recovering from fixation of a fracture of the femur or tibia shaft. DESIGN: Retrospective case series. SETTING: Level 1 trauma center in the United States. PATIENTS: All adult patients from October 2016 to October 2018 with femur (OTA/AO 32) and tibial (OTA/AO 42) shaft fractures who were treated surgically were included. A nurse counseled patients on safe and effective alleviation of pain. Charts were reviewed for pain medication prescribed, noting utilization of schedule II opioid medications. MAIN OUTCOME MEASURES: Frequency of schedule II pain medication prescription on discharge or during follow-up, emergency department presentation for pain, or readmission for pain. RESULTS: One hundred fifty patients with 162 fractures were treated for femoral (N = 73 fractures) or tibial (N = 89 fractures) shaft fractures. Sixty patients (40%) were multiple injured patients. Thirteen (8.7%) patients were discharged with hydrocodone, oxycodone, or fentanyl. Of the remaining patients with adequate follow-up (N = 109), 6.4% requested hydrocodone, oxycodone, or fentanyl after discharge. There was 1 patient presentation to the emergency department for pain, and there were no pain-related readmissions. CONCLUSIONS: Alleviation of pain can be achieved in most patients with femoral and tibial shaft fractures, including multiply injured patients, with one-on-one patient support and by using nothing stronger than codeine and tramadol. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.