Total joint arthroplasty surgery: does day of surgery matter?

Length of stay (LOS) after total joint arthroplasty (TJA) impacts the expense to the hospital. Our purpose was to evaluate the impact that day of surgery has on postoperative LOS. 547 patients who had a primary TJA at two tertiary care hospitals were identified retrospectively. TJA patients admitted on day of surgery and who had primary elective surgery were included in our sample. Patients were subdivided into one of four groups: those who had operations on Monday, Tuesday, Thursday, and Friday respectively. Patients who had surgery on Thursday and Friday had significantly longer LOS when compared to Monday and Tuesday. This variation in LOS between the groups may be due to inconsistencies in weekend functionality, less experienced part-time staffing, and inaccessibility of rehabilitation personnel.

Biomechanical Evaluation of Standard Versus Extended Proximal Fixation Olecranon Plates for Fixation of Olecranon Fractures.

Background: Small olecranon fractures present a significant challenge for fixation, which has resulted in development of plates with proximal extension. Olecranon-specific plates with proximal extensions are widely thought to offer superior fixation of small proximal fragments but have distinct disadvantages: larger dissection, increased hardware prominence, and the increased possibility of impingement. Previous biomechanical studies of olecranon fracture fixation have compared methods of fracture fixation, but to date there have been no studies defining olecranon plate fixation strength for standard versus extended olecranon plates. The purpose of this study is to evaluate the biomechanical utility of the extended plate for treatment of olecranon fractures. Methods: Sixteen matched pairs of fresh-frozen human cadaveric elbows were used. Of the 16, 8 matched pairs received a transverse osteotomy including 25% and 8 including 50% of the articular surface on the proximal fragment. One elbow from each pair was randomly assigned to a standard-length plate, and the other elbow in the pair received the extended-length plate, for fixation of the fracture. The ulnae were cyclically loaded and subsequently loaded to failure, with ultimate load, number of cycles, and gap formation recorded. Results: There was no statistically significant difference between the standard and extended fixation plates in simple transverse fractures at either 25% or 50% from the proximal most portion of the articular surface of the olecranon. Conclusion: Standard fixation plates are sufficient for the fixation of small transverse fractures, but caution should be utilized particularly with comminution and nontransverse fracture patterns.

Functional Outcomes of 24-Hour Thumb Immobilization in Healthy Volunteers: Prospective Comparative Study.

Background Immobilization is often needed for the treatment of wrist and hand injuries. The current best method of immobilization for several types of injuries has yet to be elucidated with little being reported on the functional differences of each type of immobilization. Purpose The purpose of this study is to compare the functional outcome between healthy young volunteers with a 24-hour short arm cast (SAC) versus thumb spica cast (TSC) immobilization. Methods A total of 50 healthy volunteers completed a baseline typing assessment and a Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity functional scoring assessment. Participants in group 1 were randomly initially assigned to a TSC of their dominant hand followed by an SAC, whereas participants in group 2 were randomly initially assigned to a TSC of their nondominant hand followed by an SAC. The volunteers completed the typing assessment and PROMIS assessment at the end of the 24-hour casting period. Results A total of 50 participants were enrolled in the study with 25 in group 1 and 25 in group 2. There was a 24.3-point difference between the average PROMIS score for participants with SAC compared with participants with TSC (93 vs. 68.7; p = 0.0001). There was a significant difference between the typing speed and accuracy of participants with SAC compared with participants with TSC ( p = 0.0001). Conclusion There is a significant difference in functionality of a TSC immobilization versus an SAC immobilization according to the PROMIS functional outcome score and typing speed in a 24-hour casting period. SAC immobilization should be considered to have a possible similar effect in pathologic conditions instead of TSC immobilization given these findings even though a 24-hour period is not enough to provide adequate long-term conclusions. Level of Evidence I, prospective comparative study.

Assessment of the Accuracy of Online Information Regarding Trigger Finger.

BACKGROUND: Review of the recent literature suggests substantial use of the Internet by patients seeking health care information despite questionable accuracy and readability of information presented on some websites. The purpose of our study was to assess the accuracy, quality, and readability of online information regarding trigger finger. METHODS: Three terms ("trigger finger", "stenosing tenosynovitis", and "finger locking") were used to query three Internet search engines to evaluate websites regarding information about trigger finger. Three hand surgery fellows independently assessed website accuracy and quality using standardized scoring criteria. The Fleisch-Kincaid reading grade level score was used to assess website readability. Website authorship and commercial association were also noted. RESULTS: Sixty-nine unique websites were assessed. Internet information obtained using the search term "stenosing tenosynovitis" was written at a significantly higher reading level than information found using "finger locking" or "trigger finger". Website quality and accuracy were both significantly better in websites authored by physicians compared to websites authored by non-physicians. However, website accuracy was significantly poorer in websites featuring commercial association. Additionally, websites presenting information written below the 8(th) grade reading level demonstrated poorer accuracy. CONCLUSIONS: Search term has a significant effect on the readability of online information regarding trigger finger. Despite the terminology used in searches, most websites are largely inaccurate and may not be easily understandable by the general population. This demonstrates a substantial barrier to accessing accurate health care information and may impact patient outcomes. Hand surgeons should direct patients towards websites presenting accurate information with easily readable content.

Factors Affecting Hand Surgeon Operating Room Turnover Time.

Background: The purpose of this study was to determine the factors that affect hand surgeon operating room (OR) turnover time. We hypothesized that surgeon presence in the OR, decreased American Society of Anesthesiologists (ASA) class, smaller case type, and earlier case time, as well as other factors, decreased OR turnover time. Methods: A total of 685 hand surgery cases performed by 5 attending hand surgeons between September 2013 and December 2014 were identified. Turnover time, patient comorbidities (ASA class), surgeon, prior OR surgical procedure, current OR surgical procedure, location of the surgery (ambulatory surgical center [ASC] vs orthopedic specialty hospital [OSH]), time of surgery, and order of OR cases were recorded. The effect of surgeon routine variables, OR case factors, and patient health status on OR turnover was analyzed. Results: Turnover time was significantly shorter in cases where the surgeon remained in the OR during turnover (27.5 minutes vs 30.4 minutes) and when the surgeon incentivized OR staff (24 minutes vs 29 minutes). The ASC was found to have shorter turnover times than the OSH (27.9 minutes vs 36.4 minutes). In addition, ASA class, type of prior OR procedure, type of current OR procedure, and case order all significantly affected turnover time. Comparison of OR turnover time among the 5 surgeons revealed a statistically significant difference at the OSH but not at the ASC. Conclusion: OR turnover time is significantly affected by surgeon routine, location of surgery, patient ASA class, procedure type, and case order. Interestingly, the effect of hand surgeon routine on OR turnover time may be amplified at an academic OSH versus an ASC.

Perilunate Dislocations and Fracture Dislocations.

Perilunate dislocations and fracture dislocations are the result of an axial load with hyperextension and ulnar deviation of the wrist, combined with intercarpal supination. Prompt treatment injuries is essential. There is a high rate of missed or incorrect diagnosis. In the past, closed management was recommended. These methods proved to be ineffective. Current research and data show better results with anatomic restoration of carpal alignment and direct ligament repair. A combined dorsal and volar approach is preferred. This article reviews the current literature and discusses the surgical techniques to restore carpal alignment and repair the scapholunate interosseous ligament.

Open carpal tunnel release with use of a nasal turbinate speculum.

Incomplete release of the transverse carpal ligament (TCL) and median nerve injury are complications of carpal tunnel release (CTR). In this article, we describe a modified mini-open release using a fine nasal turbinate speculum to aid in the proximal release with direct visualization of the proximal limb of the TCL and the distal volar forearm fascia (DVFF). The technique begins with a 2.5-cm palmar longitudinal incision, and standard distal release of the TCL is completed. A fine nasal turbinate speculum is inserted into the plane above the proximal limb of the TCL and the DVFF. A long-handle scalpel is used to incise the TCL and the DVFF under direct visualization. We retrospectively analyzed a cohort of 101 consecutive CTR cases (63 right, 38 left). Carpal tunnel syndrome symptoms were relieved in all patients with a high degree of satisfaction. This modified mini-open technique provides surgeons with a reproducible and inexpensive method to ensure a safe proximal release of the TCL.

Clinical outcomes following collagenase injections compared to fasciectomy in the treatment of Dupuytren's contracture.

INTRODUCTION: The aim of this study is to compare the efficacy of collagenase injections with that of fasciectomy in the treatment of Dupuytren's contracture. METHODS: This is a case-control retrospective study. We reviewed the electronic medical records from January 2009 through January 2013, identifying 142 consecutive patients who underwent either fasciectomy or collagenase injection. Exclusion criteria for both groups were age <18 years, pregnant women, and arthroplasty or arthrodesis of the treated joint. Follow-up data beyond 1-year duration was available for 117 of the patients: 44 patients who had undergone fasciectomy, and 73 patients who had received collagenase injection. The primary outcome measure in this study was resolution of joint contracture to 0-5° deficit of full extension. Data was analyzed using two-sample t tests for continuous data and chi-square test for categorical data. A significant P value was set at <0.05. RESULTS: At the latest follow-up, significantly more joints treated with fasciectomy met the primary outcome measure. Metacarpophalangeal (MP) joints responded better than the proximal interphalangeal (PIP) joints for both treatments. At the latest follow-up (14.2 months for collagenase, 16.3 months for fasciectomy), 46 % of MP joints treated with collagenase and 68 % of MP joints treated with fasciectomy maintained resolution of joint contracture. Sub-analysis of the affected joints based on the severity of initial contracture demonstrated that MP and PIP joints with contractures <45° responded better than more severely contracted joints (>45°). CONCLUSIONS: Fasciectomy yields a greater mean magnitude of correction for digital contractures at the latest follow-up when compared to collagenase. Both treatments were more effective for treatment of MP joint contracture compared to PIP joint contracture. LEVEL OF EVIDENCE: Level III, therapeutic.