Depression and Non-modifiable Patient Factors Associated with Patient Satisfaction in an Academic Orthopaedic Outpatient Clinic: Is it More Than a Provider Issue?

BACKGROUND: Patient satisfaction surveys play an increasingly important role in United States healthcare policy and serve as a marker of provided physician services. In attempts to improve the patient's clinical experience, focus is often placed on components of the healthcare system such as provider interaction and other experiential factors. Patient factors are often written off as "non-modifiable"; however, by identifying and understanding these risk factors for dissatisfaction, another area for improvement and intervention becomes available. QUESTIONS/PURPOSES: (1) Do patients in the orthopaedic clinic with a preexisting diagnosis of depression report lower satisfaction scores than those without a preexisting diagnosis of depression? (2) What other non-modifiable patient factors influence patient-reported satisfaction? METHODS: We reviewed Press Ganey Survey scores, which assess patient experiential satisfaction with a single clinical encounter, from 3044 clinic visits (2527 patients) in adult reconstructive, sports, and general orthopaedic clinics at a single academic medical center between November 2010 and May 2017, during which time approximately 19,000 encounters occurred. Multiple patient factors including patient age, gender, race, health insurance status, number of previous clinic visits with their physician, BMI, and a diagnosis of depression were recorded. Patient satisfaction was operationalized as a binary outcome as satisfied or less satisfied, and a multiple logistic regression analysis was used to estimate the odds of being satisfied. RESULTS: After adjusting for all other covariates in the model, we found that patients with a diagnosis of depression were less likely to be satisfied than patients without this diagnosis (odds ratio 0.749 [95% confidence interval, 0.600-0.940]; p = 0.01). Medicare-insured patients were more likely to be satisfied than non-Medicare patients (OR 1.257 [95% CI, 1.020-1.549]; p = 0.03), patients in the sports medicine clinic were more likely to be satisfied than those seen in the general orthopaedic clinic (OR 1.397 [95% CI, 1.096-1.775]; p = 0.007), and established patients were more likely to be satisfied than new patients (OR 0.763 [95% CI, 0.646-0.902]; p = 0.002). CONCLUSIONS: Given the association of depression with lower satisfaction with a single visit at the orthopaedic clinic, providers should screen for depression and address the issue during the outpatient encounter. The impact of such comprehensive care or subsequent treatment of depression on improving patient-reported satisfaction offers areas of future study. LEVEL OF EVIDENCE: Level III, therapeutic study.

Three osteochondritis dissecans lesions in one knee: a case report.

BACKGROUND: Osteochondritis dissecans (OCD) has been defined as a localized process in which a focus of subchondral bone and adjacent articular cartilage separates from the surrounding bone. With the knee being the most common location for OCD development and the propensity for this lesion to be found in those who participate in sports, a repetitive microtrauma hypothesis for its cause has gained favor. However, the cause of OCD remains controversial, as does the most appropriate treatment for the varying degrees of OCD lesions. CASE DESCRIPTION: We present a unique case of three OCD lesions in one knee. The patient was a young, athletic boy who developed three separate OCD lesions in his right knee over the course of 4 years. Temporally, the OCD lesions developed first in the lateral femoral condyle, then in the medial femoral condyle, and finally in the trochlea. LITERATURE REVIEW: Our literature review yielded a few reports of bicondylar OCD lesions. We identified no previous reports of three separate OCD lesions found in a single joint. PURPOSES AND CLINICAL RELEVANCE: This report illustrates how a uniquely affected knee with three OCD lesions was treated in three different ways with resolution of symptoms. Each of the OCD lesions was evaluated individually and treatment for each based on the severity of the lesion from the physical examination, imaging studies, and arthroscopic findings.

Epidemiology of Pediatric Gymnastics Injuries Reported in US Emergency Departments: Sex- and Age-Based Injury Patterns.

Background: Despite increasing participation rates in youth gymnastics, the majority of epidemiologic literature focuses on older elite athletes or stratifies athletes by level of competition. Hypothesis: The authors hypothesized that sex- and age-based patterns in youth gymnastics-related injuries exist, which are otherwise overlooked in an unstratified population. Study Design: Descriptive epidemiology study. Methods: Publicly available injury data from the National Electronic Injury Surveillance System were collected on pediatric gymnastics injuries presenting to emergency departments in the United States. Participation data from the National Sporting Goods Association were used to calculate national injury incidence rates in 7- to 11-year-olds (childhood) and 12- to 17-year-olds (adolescence) from January 1, 2012, to December 31, 2018. Z tests were conducted for the comparison of injury rates between girls and boys within each age group and for overall injury rate across age groups. Results: Girls participated in gymnastics at a frequency 6.5 times that of boys in childhood and 13.5 times that of boys in adolescence. An estimated 72,542 youth gymnastics-related injuries were reported in US emergency departments each year. A large proportion (61.3%) occurred in childhood, with female predominance in both age groups. Overall, there was no difference in weighted annual injury rate (injuries per 100,000 athlete-days per year) by age group (6.9 [childhood] vs 8.8 [adolescence]; P = .19) or sex (7.4 [girls] vs 8.1 [boys]; P = .65). In adolescence, boys were more likely than girls to experience injury (16.47 vs 8.2; P = .003). Wrist and lower arm fractures were more common in childhood than adolescence (1.07 vs 0.43; P = .002) and specifically in girls (childhood vs adolescence, 1.06 vs 0.37; P = .001). Ankle injuries and concussions were more common in adolescence vs childhood (P = .01 and .0002). Conclusion: Upper extremity injuries predominated among childhood gymnasts, particularly girls. In adolescence, girls and boys experienced increases in concussions and foot and ankle injuries. Although representing a lower overall number of training gymnasts as compared with girls, adolescent boys experience a higher rate of injuries overall.

Osteochondral Allograft for Unsalvageable Osteochondritis Dissecans in the Skeletally Immature Knee.

BACKGROUND: While an excellent option for osteochondral defects in the adult knee, fresh osteochondral allograft (FOCA) in the skeletally immature adolescent knee has been infrequently studied. PURPOSE: To compare radiographic and patient-reported outcomes (PROs) in skeletally mature and immature adolescents after FOCA in the knee for treatment of unsalvageable osteochondritis dissecans (OCD). STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Included were 34 patients (37 knees) who underwent size-matched FOCA of the knee for unsalvageable OCD lesions. All patients were aged ≤19 years and had a minimum of 12 months of follow-up. Patient characteristics, lesion characteristics, reoperations, and PROs were evaluated and compared between patients with open physes (skeletally immature; n = 20) and those with closed physes (skeletally mature; n = 17). Graft failure was defined as the need for revision osteochondral grafting. Postoperative radiographs were analyzed at 1 year and the final follow-up for graft incorporation and classified as A (complete), B (≥50% healed), or C (<50% healed). RESULTS: The mean patient age was 15.4 years (range, 9.6-17.6 years), and the mean follow-up was 2.1 years (range, 1-5.3 years). The mean graft size was 5.0 cm2 and did not differ significantly between the study groups. Patients with open physes were younger (14.7 vs 16.2 years; P = .002) and more commonly male (80% vs 35%; P = .008). At the 1-year follow-up, 85% of immature patients and 82% of mature patients had radiographic healing grades of A or B. Patients with open physes were more likely to achieve complete radiographic union at 1 year (65% vs 15%; P = .007) and demonstrated better Knee injury and Osteoarthritis Outcome Score (KOOS) Daily Living (96.8 vs 88.5; P = .04) and KOOS Quality of Life (87.0 vs 56.8; P = .01) at the final follow-up. Complications were no different in either group, and graft failure occurred in only 1 skeletally mature patient with a trochlear lesion. CONCLUSION: FOCA treatment for unsalvageable OCD in the young knee may be expected to yield excellent early results. Despite the presence of open physes and immature epiphyseal osteochondral anatomy, equivalent or improved healing and PRO scores compared with those of skeletally mature patients may be expected.

The Insidious Effects of Childhood Obesity on Orthopedic Injuries and Deformities.

The current childhood obesity epidemic, affecting approximately 20% of American children and adolescents, is accompanied by unique orthopedic manifestations. The growing musculoskeletal system is susceptible to the endocrine effects of obesity, resulting in decreased bone mass and quality. As a result, obese children are at increased risk of musculoskeletal injury, fracture, and lower extremity deformities. The efficacy of nonoperative treatment such as casting or bracing may be limited by body habitus and surgical treatment is accompanied by increased risk of perioperative complications.

Vertical shear pelvic ring injuries: do transsacral screws prevent fixation failure?

OBJECTIVES: To determine the frequency of fixation failure after transsacral-transiliac (TS) screw fixation of vertical shear (VS) pelvic ring injuries (OTA/AO 61C1) and to describe the mechanism of failure of TS screws. DESIGN: Retrospective cohort study. SETTING: Level 1 academic trauma center. PATIENTS/PARTICIPANTS: Twenty skeletally mature patients with unilateral, displaced, unequivocal VS injuries were identified between May 1, 2009 and April 31, 2016. Mean age was 31 years and mean follow-up was 14 months. Twelve had sacroiliac dislocations (61C1.2) and eight had vertical sacral fractures (61C1.3). INTERVENTION: Operative treatment with at least one TS screw. MAIN OUTCOME MEASUREMENTS: Radiographic failure, defined as a change of >1 cm of combined displacement of the posterior pelvis compared with the intraoperative position on inlet and outlet radiographs. RESULTS: Radiographic failure occurred in 4 of 8 (50%) vertical sacral fractures. Posterior fixation was comprised of a single TS screw in 3 of these 4 failures. The dominant mechanism of screw failure was bending. All of these failures occurred early in the postoperative period. No fixation failures occurred among the sacroiliac dislocations. There were no deep infections or nonunions. CONCLUSIONS: This is the first study to describe the mechanism of failure of TS screws in a clinical setting after VS pelvic injuries. We caution surgeons from relying on single TS screw fixation for vertically unstable sacral fractures. Close radiographic monitoring in the first few weeks after surgery is advised. LEVEL OF EVIDENCE: Level IV.

Flexible Fixation in Foot and Ankle Surgery.

Flexible fixation has been described and utilized in various aspects of foot and ankle surgery over the past several decades. In regards to ankle surgery, flexible fixation devices have been used for stabilization of the ankle syndesmosis and augmentation of lateral collateral ankle ligament repair. In the foot, flexible fixation devices have been incorporated into hallux valgus or varus correction, Lisfranc injury repair, and more recently spring ligament repair augmentation. This article reviews the various applications for flexible fixation in foot and ankle surgery, as well as evidence-based literature on surgical applications and clinical outcomes.

Tranexamic acid administration for anatomic and reverse total shoulder arthroplasty: a systematic review and meta-analysis.

BACKGROUND: Tranexamic acid (TXA) has been shown to reduce perioperative blood loss and risk of blood transfusion. Evidence establishing its efficacy in total shoulder arthroplasty (TSA) is limited. The current study evaluated the effect of TXA on perioperative blood loss and transfusion risk after TSA. METHODS: A systematic review and meta-analysis of TXA administration for TSA was performed, and 6 studies with a total of 680 patients were found. Data on change in hemoglobin, drain output, total blood loss, and transfusion were extracted. Meta-analysis was performed with stratification into reverse and anatomic TSA subgroups. RESULTS: TXA administration was associated with decreased change in hemoglobin (-0.63 g/dL; 95% CI, -0.87 to -0.39 g/dL; P < .00001), drain output (-112.05 mL; 95% CI, -182.29 to -41.81 mL; P < .0001), and total blood loss (-231.87 mL; 95% CI, -334.23 to -129.48 mL; P < .00001) after reverse TSA. There was a trend toward reduction in transfusion rate after reverse TSA (-4%; 95% CI, -8% to 0%; P = .06). TXA administration was associated with reduced drain output after anatomic TSA (-123.07 mL; 95% CI, -163.93 to -82.20 mL; P < 0.00001). TXA administration was not associated with decreased transfusion rate after anatomic TSA. Data to evaluate the effect of TXA on change in hemoglobin and total blood loss after anatomic TSA were insufficient. CONCLUSIONS: Routine administration of TXA reduces perioperative blood loss and may reduce the risk of transfusion after reverse TSA. Future studies are needed to further characterize its effect on the risk of transfusion after reverse TSA and efficacy in anatomic TSA.

Diagnostic Accuracy of the Scapular Retraction Test in Assessing the Status of the Rotator Cuff.

BACKGROUND: Currently, clinical physical examination maneuvers alone provide variable reliability in diagnosing full-thickness rotator cuff tears (RCTs). PURPOSE: To assess the diagnostic accuracy of the scapular retraction test (SRT) to predict full-thickness RCTs. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: A total of 331 patients were prospectively evaluated in this cohort study. SRT was performed to assess the status of the rotator cuff. A positive SRT indicates an intact rotator cuff, and a negative SRT indicates a full-thickness RCT. Magnetic resonance imaging (MRI) was used as the gold standard. The examiner was blinded to the results until completing the physical examination. Statistical analysis was performed to assess the sensitivity, specificity, accuracy, positive and negative predictive values, and positive and negative likelihood ratios of the SRT. RESULTS: The prevalence of full-thickness RCTs diagnosed on MRI was 54.4% (180 of 331). Among the 180 patients with an MRI-confirmed full-thickness RCT, the SRT was negative for 147. Of 150 patients with an intact rotator cuff by MRI, 122 had a positive SRT. In diagnosing full-thickness RCTs, the SRT had a sensitivity of 81.7% (95% CI, 77.2%-85.4%), specificity of 80.8% (95% CI, 75.5%-85.3%), and accuracy 81.3%. The positive predictive value was 83.5% (95% CI, 78.9%-87.4%); the negative predictive value, 78.7% (95% CI, 73.5%-83.1%); the positive likelihood ratio, 4.3 (95% CI, 3.1-5.8); the negative likelihood ratio, 0.23 (95% CI, 0.17-0.30); and the diagnostic odds ratio, 18.7 (95% CI, 10.4-34.0). CONCLUSION: The results of this diagnostic study indicate that the SRT can accurately be used to clinically assess the status of the rotator cuff. This physical examination maneuver was found to be accurate, sensitive, and specific in diagnosing full-thickness RCTs. Additionally, our results indicate that it is equally as accurate to predict an intact rotator cuff tendon. Providing an accurate, reliable, and reproducible physical examination test will allow clinicians to diagnosis the integrity of the rotator cuff and will help guide treatment recommendations.

Foot Deformities in Hajdu-Cheney Syndrome: A Rare Case Report and Review of the Literature.

INTRODUCTION: Hajdu-Cheney syndrome (HCS) is a rare autosomal dominant disease characterized by acroosteolysis, wormian skull bones with persistent skull sutures, premature loss of teeth, micrognathia, short stature, hypermobility of the joints, neurologic manifestations such as basilar invagination with subsequent paresthesia, hearing loss, and speech alterations, and osteoporosis with tendency to pathologic fractures of long bones and vertebrae as well as painful hands and feet. Very few cases have been earlier reported in the literature. CASE REPORT: We report a case of a 50-year-old female with bilateral foot deformities as a manifestation of the rare genetic disorder HCS. Surgical management of the left foot consisted of Morton's neuroma excision and Weil osteotomy with proximal interphalangeal joint resection and Kirschner wire fixation of the second and third metatarsophalangeal (MTP) joints. Recurrent subluxation of the left second MTP joint was observed at 5-week follow-up. The right foot was treated similarly 7weeks after the initial operation. The post-operative course of the right foot was complicated by bone resorption and nonunion of the second and third metatarsal Weil osteotomies. CONCLUSION: Management of complex foot deformities associated with HCS can be challenging and have not previously been described in the literature. Underlying bone and connective tissue abnormalities intrinsic to the syndrome may increase the risk of recurrence after surgical correction. Consideration should be given to such post-operative complications when treating foot deformities in a patient with HCS.

Overuse Injuries of the Pediatric and Adolescent Throwing Athlete.

In the hypercompetitive environment of year round youth baseball, arm pain is commonplace. Although much research has been done about injuries in the overhead throwing athlete, the emphasis has been on the more elite levels, where athletes have reached full development. The anatomy of the skeletally immature athlete, including open physeal plates and increased tissue laxity, raises unique issues in the presentation and treatment of repetitive throwing injuries of the elbow and shoulder. With a focus on "little leaguers," this discussion evaluates five of the most common elbow and shoulder injuries-Little Leaguer's elbow, ulnar collateral ligament sprain or tear, osteochondritis dissecans/Panner's disease, Little Leaguer's shoulder, and multidirectional instability. In the developmentally distinct pediatric athlete, pathogenesis, diagnosis, and treatment may differ from that established for adults. Offering early diagnosis and treatment appropriate to a child's level of development will enable youth to not only continue to play sports but to also maintain full functionality as active adults.