An evaluation of fusion status following lumbar fusion surgery utilizing multi-planar computed tomography.

PURPOSE: To report the rate of fusion in a sample of patients undergoing lumbar fusion surgery and assess interrater reliability of computed tomography (CT)-based parameters for the assessment of fusion. METHODS: All adult patients who underwent lumbar fusion surgery from 2017 to 2021 were retrospectively identified. Patient demographics and surgical characteristics were collected through chart review of the electronic medical records. CT scans were reviewed independently by two attending spine surgeons and two spine fellows. Fusion was defined as evidence of bone bridging in any one of (1) posterolateral gutters, (2) facets, or (3) interbody (when applicable) on any CT views. Evidence of screw haloing was indicative of nonunion. Interrater reliability was determined using cohen's kappa. Afterwards, a consensus agreement for each component of fusion was reached between participants. RESULTS: The overall fusion rate among all procedures was 63/69 (91.3%). Overall 22/25 (88.0%) TLIF, 16/19 (84.2%) PLDF, 3/3 (100%) LLIF, and 22/22 (100%) circumferential fusions experienced a successful fusion. Interrater reliability was good for interbody fusion (k = 0.734) and moderate for all other measures (k = 0.561 for posterolateral fusion; k = 0.471 for facet fusion; k = 0.458 for screw haloing). Overall, interrater reliability as to whether a patient had a fusion or nonunion was moderate (k = 0.510). CONCLUSION: There was only moderate interrater reliability across most radiographic measures used in assessing lumbar fusion status. Reliability was highest when evaluating the presence of interbody fusion. The majority of fusions occurred across the facet joints.

Values derived from patient reported outcomes in spine surgery: a systematic review of the minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state.

PURPOSE: While patient reported outcome measures (PROMs) define value in spine surgery, several values such as minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) help guide the interpretation of PROMs and identify thresholds of clinical significance. Significant variation exists in reported values and their calculation, so the primary objective of this study was to systematically review the spine surgery literature for metrics of clinical significance derived from PROMs. METHODS: We conducted a query of PubMed/MEDLINE and Scopus databases from inception to January 1, 2023, for studies that derived quantitative metrics (e.g., SCB, MCID, PASS) from PROMs in the setting of spine surgery with minimum 1-year follow-up. Details regarding the specific PROMs were collected including which PROM was measured, whether anchor- or distribution-based methods were utilized, the specific calculations, and the recommended value for a given PROM based on all evaluated calculations. RESULTS: Thirty-seven studies of 21,780 patients were included. The most commonly evaluated PROM-derived value was the MCID (n = 28), followed by PASS (n = 6) and SCB (n = 4). Twenty-one studies only utilized anchor-based calculations, 15 utilized both anchor-based and distribution-based methods, and one only utilized distribution-based calculations. The most commonly evaluated legacy PROMs were the Oswestry Disability Index (ODI) (N = 11, MCID range 4-20) and visual analog scale back pain (N = 5, MCID range 0.5-4.6). All 10 studies that derived SCB or PASS utilized the receiver operating characteristic methods. Among the six studies deriving a PASS value, four only evaluated ODI, identifying PASS ranging from 5 to 22. CONCLUSION: While calculated measures of clinical significance such as MCID, PASS, and SCB exist, significant heterogeneity exists in the current literature. Current shortcomings include a wide variability of reported value thresholds across the literature, and limited applicability to more heterogenous patient populations than the targeted cohorts included in published investigations. Continued investigations that apply these methods to heterogenous, large-scale populations can help increase generalizability and validity of these measures. LEVEL OF EVIDENCE: III.

The severity of preoperative anemia escalates risk of poor short-term outcomes after lumbar spine fusion.

OBJECTIVE: To evaluate how preoperative anemia severity affects 90-day outcomes of spinal fusion surgery. METHODS: A retrospective cohort study was conducted on adult lumbar fusion patients at a tertiary medical center. Patients were classified by World Health Organization anemia severity definitions for comparisons. Multivariate regression models were created to control for confounding variables, for all primary outcomes of transfusion requirements, non-home discharge, readmissions, complications, and length of stay. RESULTS: A total of 2582 patients were included: 2.7% with moderate-severe anemia, 11.0% with mild anemia, and 86.3% without anemia. Moderate-severe patients had the longest hospital stay (5.03 days vs 4.14 and 3.59 days, p < 0.001) and highest risk of transfusion (52.2% vs 13.0% vs 2.69%, p < 0.001), non-home discharge (39.1% vs 27.8% vs 15.4%, p < 0.001), readmission (7.25% vs 5.99% vs 3.36%, p = 0.023), and complications (13.0% vs 9.51% vs 6.20%, p = 0.012). On multivariable logistic regression, both patients with mild and moderate-severe anemia had an increased risk of transfusion (OR: 37.3, p < 0.001; OR: 5.25, p < 0.001, respectively) and non-home discharge (OR: 2.00, p = 0.021; OR: 1.71, p = 0.001, respectively) compared to patients without anemia. Anemia severity was not independently associated with complications or 90-day readmission. On multivariable linear regression, mild anemia (ß: 0.37, p = 0.001) and moderate-severe anemia (ß: 1.07, p < 0.001) were independently associated with length of hospital stay. CONCLUSION: Patients with moderate-severe preoperative anemia are at increased risk for longer length of stay, transfusions, and non-home discharge. Improved optimization of preoperative anemia may significantly reduce healthcare utilization, and surgeons should consider these risks in preoperative planning. LEVEL OF EVIDENCE: III.

Does Surgery Improve Healing After Isolated Diaphyseal Ulna Fractures?

PURPOSE: Isolated diaphyseal ulna fractures can be treated nonsurgically or with open reduction and internal fixation (ORIF). It is unclear whether ORIF provides quicker and/or more predictable healing. The purpose of this study was to compare the healing characteristics of isolated diaphyseal ulna fractures after surgical and nonsurgical treatment. METHODS: All patients treated for an isolated diaphyseal (distal- or middle-third) ulna fracture between 2010 and 2018, with a minimum of 3 months of follow-up, were identified. Electronic medical records were reviewed to record patient demographics, assess the treatments used, and compare outcomes. We determined healing and nonunion rates, complications, reoperations, and final radiographic fracture alignment. RESULTS: Ninety-five patients were included with a median follow-up of 20 weeks. Of these, 56 patients were treated nonsurgically and 39 patients were treated with ORIF. At the time of the final follow-up, 51 of the 56 (91.1%) nonsurgically treated fractures had healed and 38 of the 39 (97.4%) surgically managed fractures had healed. There were 5 nonunions after nonsurgical treatment (8.9%) and 1 nonunion after ORIF (2.6%). Eleven patients (19.6%) treated nonsurgically required conversion to ORIF, whereas 4 patients (10.3%) treated with ORIF required reoperation. Middle-third fractures treated nonsurgically had a higher rate of nonunion (30.8%) compared with distal-third fractures treated nonsurgically (2.3%). CONCLUSIONS: The healing characteristics of isolated ulnar shaft fractures do not appear to differ substantially between surgical and nonsurgical treatment. However, nearly 20% of the patients treated nonsurgically may require eventual ORIF. Distal-third fractures may be at a higher risk of conversion to ORIF, and middle-third fractures may be at a higher risk of nonunion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Wound Dehiscence Following Cubital Tunnel Surgery.

PURPOSE: Cubital tunnel syndrome is the second most common upper-extremity compressive neuropathy, and persistent symptoms can necessitate operative treatment. Surgical options include simple decompression and ulnar nerve transposition. The cause of wound dehiscence after surgery is not well known, and the factors leading to the development of these complications have not been previously described. METHODS: Patients undergoing ulnar nerve surgery from January 1, 2016, to December 31, 2019, were retrospectively evaluated for the development of wound dehiscence within 3 months of surgery. There were 295 patients identified who underwent transposition and 1,106 patients who underwent simple decompression. Patient demographics and past medical history were collected to evaluate the risk factors for the development of wound dehiscence. RESULTS: The overall rate of wound dehiscence following surgery was 2.5%. In the simple decompression group, the rate of wound dehiscence was 2.7% (30/1,106), which occurred a mean of 21 days (range, 2-57 days) following surgery. In the transposition group, the rate of wound dehiscence was 1.7% (5/295), which occurred a mean of 20 days (range, 12-32 days) following surgery. The difference in rates of dehiscence between the decompression and transposition groups was not significant. Five patients in the simple decompression group and 1 patient in the transposition group required a secondary surgery for closure of the wound. Age, body mass index, smoking status, and medical comorbidities were not found to contribute to the development of wound dehiscence. CONCLUSIONS: Wound dehiscence can occur following both simple decompression and transposition, even after postoperative evaluation demonstrates a healed wound. Surgeons should be aware of this possibility and specifically counsel patients about remaining cautious with, and protective of, their wound for several weeks after surgery. Dehiscence may be related to suboptimal vascularity in the soft tissue envelope in the posteromedial elbow. When it occurs, dehiscence can generally be treated by allowing healing by secondary intention. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

A Rare Presentation of Extensor Pollicis Longus Tendon Rupture After Nondisplaced Scaphoid Fracture.

Extensor pollicis longus tendon rupture is a reported complication after nondisplaced distal radius fractures. These are thought to occur secondary to mechanical irritation or compromised blood supply. We present a case of extensor pollicis longus rupture after a healed nondisplaced scaphoid fracture, which may have involved a similar attritional process. We are unaware of any prior reports of extensor pollicis longus rupture after this type of injury.

The Financial Implications of Telehealth Visits Within a Hand and Wrist Surgery Clinical Practice During the COVID-19 Pandemic.

PURPOSE: Telehealth use is likely to increase as a result of practice changes during the COVID-19 pandemic, although the overall picture surrounding the billing, coding, and continued insurance coverage of these visits remains uncertain. The purpose of this study was to identify potential financial implications of continued telehealth use in hand and wrist surgery clinical practice. METHODS: Two hundred telehealth visits were randomly selected and matched 1:1 based on primary diagnosis code to in-person visits. Medical and billing records were reviewed to compare visit complexities, total visit charges, work relative value units (wRVUs), and approved insurance reimbursement. Postoperative visits and visits with radiographic evaluation were excluded. RESULTS: Level 4 visits were more common with in-person encounters compared to telehealth (11% vs 2%, respectively), and level 1 and 2 visits were more common with telehealth compared to in-person encounters (14% vs 6%, respectively). Twenty-seven in-person visits (13%) had at least 1 additional procedure code billed. The mean total visit charge was 26% less in telehealth compared to in-person. Based on the primary procedure code alone, the sum of wRVUs was 15.1 points less in the telehealth cohort compared to in-person (per visit average, 1.1 [telehealth] vs 1.2 [in-person]). The 28 additional services provided during in-person visits accounted for an added 20.7 wRVUs. Unpaid claims were more common among telehealth encounters (8% [telehealth] vs 3% [in-person]). CONCLUSIONS: Higher complexity visits and visits with additional procedural codes billed were more common with in-person visits. This led to a lower number of total wRVUs and lower total visit charges among the included telehealth visits compared to the matched in-person controls. CLINICAL RELEVANCE: It is important to understand and consider the long-term financial impact of telehealth implementation. Practices must develop strategies to incorporate radiographic evaluation into telehealth visits and effectively stratify those patients that may require procedural interventions for in-person visits. Understanding the economic implications of this changing care delivery paradigm, providers can continue to provide telehealth services while protecting the financial sustainability of hand surgery practices.

A Subpopulation of Amygdala Neurons Mediates the Affective Component of Itch.

Itch consists of both sensory and affective components. For chronic itch patients, the affective component of itch affects both quality of life (leading to psychological comorbidities) and disease prognosis (by promoting scratching of itchy skin). We found that acute itch stimuli, such as histamine, induced anxiety-like behavior and increased activity (c-Fos expression) in the amygdala in adult male C57BL/6 mice. Itch stimuli also increased activity in projection areas to the amygdala, suggesting that these regions form a circuit for affective itch processing. Electrophysiological characterization of histamine-responsive amygdala neurons showed that this population was active on a behaviorally relevant timescale and partially overlapped with pain signaling. Selective optogenetic activation of histamine-responsive amygdala neurons in adult male and female Fos:CreERT2;R26Ai14 mice using the Targeted Recombination in Active Populations system enhanced both scratching and anxiety-like behavior. These results highlight the importance of itch-responsive amygdala neurons in modulating itch-related affect and behavior.SIGNIFICANCE STATEMENT The sensation of itch includes an affective component that leads to stress and anxiety in chronic itch patients. We investigated the neuronal basis of affective itch in mice, with a focus on the amygdala, the key brain region for the generation of anxiety. A subpopulation of amygdala neurons responded to itch stimuli such as histamine. Optogenetic activation of histamine-responsive amygdala neurons affected both scratching and anxiety-like behavior. Therefore, this population appears to be important for mediating the affective component of itch.

An evaluation of Alberta retina health service delivery in an office setting: a cross-sectional survey of patient experience.

BACKGROUND: Retina sub-specialists provide much of the retina related eye care across Canada. In the province of Alberta, 18 retina sub-specialists work across six different offices. The purpose of this study was to assess the quality of care provided by Alberta retina sub-specialists in an office setting by administering a patient satisfaction survey. The results of this survey were provided to the same retina specialists to promote improvements in patient-centered health care delivery. METHODS: A cross sectional patient satisfaction survey was performed using a thirty-part questionnaire developed in collaboration with the Physician Learning Program at the University of Alberta. The survey was modelled after other similar patient satisfaction surveys used in other areas of medicine. Patients from ten of the eighteen retina practices in Alberta participated in this survey. Topics of the survey included pre-appointment experience, physician-patient interactions and quality, comments/ feedback and patient demographics. RESULTS: 214 randomly sampled patients completed the survey from three geographically separate office locations in Calgary and Edmonton. 90% of patients responded that their retina sub-specialist listened adequately and provided quality care in a timely manner. Patients felt that there could be improvements to accessibility to the clinic and reduced wait times, as well as in the pre-operative consent process. Including a more complete explanation of the procedure as well as the potential risks and benefits. Only 51% of patients felt that the risks of a potential surgery had been adequately explained to them. There was a statistically significant association found between overall satisfaction and lower wait times, understanding of procedural risks and time with, listening to and involving the patient in care. There were no correlations found with other demographics such as ethnicity, sex, distance traveled or age. CONCLUSIONS: This patient satisfaction survey provided valuable patient care feedback to the retina sub-specialists of Alberta. The survey results will assist this group to improve the consent process and thereby improve patient centered health care delivery. We would recommend the distribution of this survey or other similar patient satisfaction questionnaire by retina sub-specialists to their patients to improve patient centered care in their clinics.

Clinically significant subscapularis failure after anatomic shoulder arthroplasty: is it worth repairing?

BACKGROUND: Symptomatic subscapularis (SC) failure after anatomic total shoulder arthroplasty (TSA) is difficult to treat. The purpose of this study was to determine the outcomes of reoperation for SC failure. METHODS: All patients undergoing reoperation for SC failure after TSA were identified from a single-institution database. Patients underwent either revision SC repair or revision to reverse shoulder arthroplasty. At a minimum of 1 year after reoperation, complications, reoperations, and functional outcomes were collected. RESULTS: Patients who initially underwent SC repair were significantly younger than patients who underwent revision to reverse shoulder arthroplasty (mean age, 59.3 years vs. 70.3 years; P = .004), had a better comorbidity profile (mean Charlson Comorbidity Index, 2.2 vs. 3.6; P = .04), and had a more acute presentation (mean time between injury and surgery, 9.1 weeks vs. 28.5 weeks; P = .03). Patients who underwent SC repair also had a significantly higher reoperation rate (52.9% vs. 0.0%, P = .01). At final follow-up, functional outcomes scores and patient satisfaction rates were not significantly different between treatment groups. DISCUSSION: Decision making on how to treat patients with SC failure following TSA remains challenging and should be individualized to the patient's age, level of activity, comorbidities, timing and mechanism of SC failure, and functional expectations.

Sports and Recreation-Related Wrist Fractures: An Epidemiological Study.

Background Wrist fractures have increased over the past several decades. The objective of this study was to identify all-cause and sports-related incidence rates of wrist fractures presenting to emergency departments (EDs) in the United States (U.S.) from 2013 to 2022. A secondary aim of the study was to identify if wrist fractures significantly decreased during 2020. Methodology The National Electronic Injury Surveillance System database was queried to identify the number of wrist fractures presenting to U.S. EDs from 2013 to 2022. Incidence rates in 100,000 person-years were calculated by sport, age, sex, and year. Results From 2013 to 2022, there were 2,027,131 wrist fractures evaluated at U.S. EDs. Injuries peaked in the 10-14-year-old age group, followed by the 5-9 and 85+-year-old age groups. In total, 1,096,598 were sustained during sports and recreation. Cycling, playgrounds, and skateboarding were the leading sports and recreation-related activities. Sports-related wrist fractures followed a unimodal distribution peaking in the 10-14-year-old age group. Females sustained 52% of wrist fractures overall but only 39% of sports-related wrist fractures. All-terrain vehicle and skateboarding-related wrist fractures significantly increased over the study period. Playground and soccer-related wrist fractures significantly decreased in 2020. Conclusions All-cause wrist fractures presenting to U.S. EDs significantly increased from 2013 to 2022 though sports-related wrist fractures did not. Pediatric males and elderly females are most at risk for wrist fractures overall while sports-related wrist fractures predominate in the pediatric population. Youth sports and recreation officials should be aware of the risks to mitigate the incidence of sports-related wrist fractures.

Which North American spine society disc herniation morphology descriptors are most associated with improvements in clinical outcomes after microdiscectomy?

Background: The North American Spine Society (NASS) assembled the first ever comprehensive naming system for describing lumbar disc disease, including lumbar disc herniation. The objectives of this study were (1) to determine which NASS descriptors are most predictive of independent patient-reported outcomes after microdiscectomy and (2) to identify the inter-rater reliability of each NASS descriptor. Methods: Adult patients (≥18 years) who underwent a lumbar microdiscectomy from 2014-2021 were retrospectively identified. Patient-reported outcome measures (PROMs) were collected at preoperative, 3-month, and 1-year postoperative time points. Lumbar disc herniations were evaluated and classified on preoperative MRI using the NASS lumbar disc nomenclature specific to disc herniation. Results: About 213 microdiscectomy patients were included in the final analysis. Herniation descriptors exhibiting the greatest reliability included sequestration status (κ=0.83), axial disc herniation area (κ=0.83), and laterality (κ=0.83). The descriptor with the lowest inter-rater reliability was direction of migration (κ=0.53). At 3 months, a sequestered herniation was associated with lower odds of achieving the minimal clinically important difference (MCID) for ODI (p=.004) and MCS (p=.032). At 12 months, a similar trend was observed for Oswestry Disability Index (ODI) MCID achievement (p=.001). At 3 months, a herniation with larger axial area was a predictor of MCID achievement in ODI (p=.004) and the mental component summary (MCS) (p=.009). Neither association persisted at 12 months; however, larger axial disc herniation area was able to predict MCID achievement in the Visual Analogue Scale (VAS) leg (p=.031) at 12 months. Conclusions: The utility of the NASS nomenclature system in predicting postoperative outcomes after microdiscectomy has yet to be studied. We showed that sequestration status and disc area are both reliable and able to predict the odds of achieving MCID in certain clinical outcomes at 3 months and 12 months after surgery. Hence, preoperative imaging analysis of lumbar disc herniations may be useful in accurately setting patient expectations.

Does Operative Level Impact Dysphagia Severity After Anterior Cervical Discectomy and Fusion?: A Multicenter Prospective Analysis.

STUDY DESIGN: Prospective multicenter cohort study. OBJECTIVE: To explore the association between operative level and postoperative dysphagia after anterior cervical discectomy and fusion (ACDF). BACKGROUND: Dysphagia is common after ACDF and has several risk factors, including soft tissue edema. The degree of prevertebral soft tissue edema varies based on the operative cervical level. However, the operative level has not been evaluated as a source of postoperative dysphagia. PATIENTS AND METHODS: Adult patients undergoing elective ACDF were prospectively enrolled at 3 academic centers. Dysphagia was assessed using the Bazaz Questionnaire, Dysphagia Short Questionnaire, and Eating Assessment Tool-10 (EAT-10) preoperatively and at 2, 6, 12, and 24 weeks postoperatively. Patients were grouped based on the inclusion of specific surgical levels in the fusion construct. Multivariable regression analyses were performed to evaluate the independent effects of the number of surgical levels and the inclusion of each particular level on dysphagia symptoms. RESULTS: A total of 130 patients were included. Overall, 24 (18.5%) patients had persistent postoperative dysphagia at 24 weeks and these patients were older, female, and less likely to drink alcohol. There was no difference in operative duration or dexamethasone administration. Patients with persistent dysphagia were significantly more likely to have C4-C5 included in the fusion construct (62.5% vs . 34.9%, P = 0.024) but there were no differences based on the inclusion of other levels. On multivariable regression, the inclusion of C3-C4 or C6-C7 was associated with more severe EAT-10 (ß: 9.56, P = 0.016 and ß: 8.15, P = 0.040) and Dysphagia Short Questionnaire (ß: 4.44, P = 0.023 and (ß: 4.27, P = 0.030) at 6 weeks. At 12 weeks, C3-C4 fusion was also independently associated with more severe dysphagia (EAT-10 ß: 4.74, P = 0.024). CONCLUSION: The location of prevertebral soft tissue swelling may impact the duration and severity of patient-reported dysphagia outcomes at up to 24 weeks postoperatively. In particular, the inclusion of C3-C4 and C4-C5 into the fusion may be associated with dysphagia severity.

Radiology Reports Do Not Accurately Portray the Severity of Cervical Neural Foraminal Stenosis.

STUDY DESIGN: Retrospective study. OBJECTIVE: (1) To compare cervical magnetic resonance imaging (MRI) radiology reports to a validated grading system for cervical foraminal stenosis (FS) and (2) to evaluate whether the severity of cervical neural FS on MRI correlates to motor weakness or patient-reported outcomes. BACKGROUND: Radiology reports of cervical spine MRI are often reviewed to assess the degree of neural FS. However, research looking at the association between these reports and objective MRI findings, as well as clinical symptoms, is lacking. PATIENTS AND METHODS: We retrospectively identified all adult patients undergoing primary 1 or 2-level anterior cervical discectomy and fusion at a single academic center for an indication of cervical radiculopathy. Preoperative MRI was assessed for neural FS severity using the grading system described by Kim and colleagues for each level of fusion, as well as adjacent levels. Neural FS severity was recorded from diagnostic radiologist MRI reports. Motor weakness was defined as an examination grade <4/5 on the final preoperative encounter. Regression analysis was conducted to evaluate whether the degree of FS by either classification was related to patient-reported outcome measure severity. RESULTS: A total of 283 patients were included in the study, and 998 total levels were assessed. There were significant differences between the MRI grading system and the assessment by radio-logists ( P < 0.001). In levels with moderate stenosis, 28.9% were classified as having no stenosis by radiology. In levels with severe stenosis, 29.7% were classified as having mild-moderate stenosis or less. Motor weakness was found similarly often in levels of moderate or severe stenosis (6.9% and 9.2%, respectively). On regression analysis, no associations were found between baseline patient-reported outcome measures and stenosis severity assessed by radiologists or MRI grading systems. CONCLUSION: Radiology reports on the severity of cervical neural FS are not consistent with a validated MRI grading system. These radiology reports underestimated the severity of neural foraminal compression and may be inappropriate when used for clinical decision-making. LEVEL OF EVIDENCE: Level III.

Surgical Treatment of Shoulder Infection Following Rotator Cuff Repair.

Background: Deep infection after rotator cuff repair (RCR) can cause significant morbidity and healthcare burden. Outcomes of surgical treatment of infection following RCR are limited. This study aimed to assess the clinical course and outcomes related to surgical management of deep infection following RCR. Methods: Patients treated with debridement for infection after RCR at a single institution were included. Postoperative deep infection included the following criteria: persistent drainage more than five days from index surgery, development of a sinus tract to the joint, ≥ 2 positive cultures at the time of revision surgery with the same bacteria, or presence of purulence. Functional outcomes (ASES, SANE, SF-12) were assessed at a minimum of 1-year post-debridement. Results: Twenty-three patients were included and analyzed at mean six years post-debridement. All were free of infection at the final follow-up. The average age was 55 years; fifteen (65.2%) had infection after primary RCR and eight (34.8%) after revision RCR. Twelve (52.2%) patients required a repeat debridement prior to eradicating infection for an average of 1.9 surgeries before clearance of infection. Statistically significant predictors of need for a repeat debridement included initial open RCR (P = .02), open debridement (P = .002) and infection requiring IV antibiotics (P = .014). Postoperative ASES, SANE, SF-12M, SF-12P, and satisfaction scores were 71.7±25.7, 67.0±28.1, 55.5±6.5, 38.4±14.3 and 3.7±1.3, respectively. Conclusion: Deep infection after RCR can be treated with open or arthroscopic debridement. However, more than 50% of patients may require multiple debridements. Final functional results after infection control following RCR are satisfactory. However, chronic infection predicts worse functional outcomes.

Functional Outcomes of Flexor Tendon Repair in the Fingers: A Comparison of Wide-Awake Local Anesthesia No Tourniquet Versus Traditional Anesthesia.

BACKGROUND: Flexor tendon lacerations in the fingers are challenging injuries that can be repaired using the wide-awake local anesthesia no tourniquet (WALANT) technique or under traditional anesthesia (TA). The purpose of our study was to compare the functional outcomes and complication rates of patients undergoing flexor tendon repair under WALANT versus TA. METHODS: All patients who underwent a primary flexor tendon repair in zone I and II without tendon graft for closed avulsions or open lacerations between 2015 and 2019 were identified. Electronic medical records were reviewed to record and compare patient demographics, range of motion, functional outcomes, complications, and reoperations. RESULTS: Sixty-five zone I (N = 21) or II (N = 44) flexor tendon repairs were included in the final analysis: 23 WALANT and 42 TA. There were no statistical differences in mean age, length of follow-up, proportion of injured digits, or zone of injury between the groups. The final Quick Disabilities of the Arm, Shoulder, and Hand score in the WALANT group was 17.2 (SD: 14.4) versus 23.3 (SD: 18.5) in the TA group. There were no statistical differences between the groups with any final range of motion (ROM) parameters, grip strength, or Visual Analog Scale pain scores at the final follow-up. The WALANT group was found to have a slightly higher reoperation rate (26.1% vs 7.1%; P = .034) than the TA group. CONCLUSIONS: This study represents one of the first clinical studies reporting outcomes of flexor tendon repairs performed under WALANT. Overall, we found no difference in rupture rates, ROM, and functional outcomes following zone I and II flexor tendon repairs when performed under WALANT versus TA.

Outcomes After Surgically Managed Oblique Extra-Articular Proximal Phalanx Fractures: A Comparison of Closed-Reduction Percutaneous Pinning and Open-Reduction Internal Fixation With Lag Screws.

BACKGROUND: Long oblique extra-articular proximal phalanx fractures are common orthopedic injuries. When unstable and without substantial comminution, treatment options include closed-reduction percutaneous pinning (CRPP) and open-reduction internal fixation using lag screws (ORIF-screws). The aims of this study are primarily to compare the functional outcomes and complication rates between these techniques and secondarily to assess potential factors affecting outcomes after surgery. METHODS: All patients with long oblique extra-articular proximal phalanx fractures treated surgically within a single orthopedic institution from 2010 to 2017 were identified. Outcome measures and complications were assessed at the final follow-up. RESULTS: Sixty patients were included in the study with a mean time to the final follow-up of 41 weeks (range: 12-164 weeks). Thirty-four patients (57%) were treated with CRPP and 26 patients (43%) with ORIF-screws. The mean Disabilities of the Arm, Shoulder, and Hand score across both fixation types was 8 (range: 0-43) and did not differ significantly between the 2 groups. Mean proximal interphalangeal extension at the final follow-up was 9° short of full extension after CRPP and 13° short of full extension after ORIF-screws. The rates of flexion contracture and extensor lag were 15% and 41% in the CRPP group compared with 12% and 68% in the ORIF-screws group. Reoperation rates and complication rates did not differ significantly between fixation strategies. CONCLUSIONS: Acceptable outcomes can be achieved after surgical fixation of long oblique extra-articular proximal phalanx fractures using both CRPP and ORIF-screws. Extensor lag may be more common after ORIF-screws.

Does decompression adjacent to arthrodesis in the lumbar spine predispose patients to adjacent segment degeneration and disease: A retrospective analysis.

Background: The treatment for multi-level spinal stenosis in the setting of single-level instability is a common operative scenario for surgeons who treat degenerative lumbar spine pathology. However, there is conflicting evidence regarding the inclusion of adjacent "stable" levels in the arthrodesis construct because of the potential for iatrogenic instability placed on those segments with decompressive laminectomy alone. This study aims to determine whether decompression adjacent to arthrodesis in the lumbar spine is a risk factor for adjacent segment disease (AS Disease). Methods: A retrospective analysis identified consecutive patients over a three-year period who underwent single-level posterolateral lumbar fusion (PLF) in the setting of single or multi-level spinal stenosis. Patients were required to have a minimum of two-year follow-up. AS Disease was defined as the development of new radicular symptoms referable to a motion segment adjacent to the lumbar arthrodesis construct. The incidence of AS Disease and reoperation rates were compared between cohorts. Results: 133 patients met the inclusion criteria with an average follow-up of 54 months. Fifty-four patients had a PLF with adjacent segment decompression, and 79 underwent a single-segment decompression and PLF. 24.1% (13/54) of patients who had a PLF with adjacent level decompression developed AS Disease resulting in a 5.5% (3/54) reoperation rate. 15.2% (12/79) of patients who did not receive an adjacent level decompression developed AS Disease resulting in a reoperation rate of 7.5% (6/79). There was neither a significantly higher rate of AS Disease (p = 0.26) nor reoperation (p = 0.74) between the cohorts. Conclusions: Decompression adjacent to single-level PLF was not associated with an increased rate of AS Disease relative to single-level decompression and PLF.

Evaluating Dysphagia Duration and Severity After ACDF in Patients With Underlying Dysphagia - A Prospective, Multicenter Study.

STUDY DESIGN: Prospective Cohort Study. OBJECTIVES: The purpose of this study was to prospectively evaluate the impact of preoperative dysphagia on the postoperative incidence and severity of dysphagia in patients undergoing ACDF at multiple institutions. METHODS: After IRB approval, patients over 18 years of age who underwent an elective ACDF for degenerative conditions were prospectively enrolled at two academic centers from 2018 to 2021. Preoperative dysphagia was self-reported by patients through a pre-operative questionnaire on a binary basis. Patients completed dysphagia surveys (Bazaz, Dysphagia Short Questionnaire, 10-item Eating Assessment Tool) to assess dysphagia severity during their preoperative visit, and these dysphagia surveys were repeated immediately postoperatively, at two weeks and again at six, 12, and 24 weeks postoperatively. Patients were stratified into three subgroups based on dysphagia status preoperatively and immediately postoperatively and compared using ANOVA tests or Kruskal-Wallis tests for continuous variables and Pearson chi-square analysis or Fisher's Exact test for categorical variables. RESULTS: A total of 168 patients (23 with preoperative dysphagia, 145 without preoperative dysphagia) met study criteria and were enrolled in the study. Patients with preoperative dysphagia had less frequent alcohol consumption (23.8% vs 53.7%, P = .0210), and higher rates of dysphagia at 2-weeks (77.8% vs 38.7%, P = .004) and 24-weeks (43.8% vs 14.8%, P = .010) postoperatively. These patients also had higher severity scores for dysphagia on the Bazaz (P = .001), DSQ (P = .012), EAT10 (P = .022) questionnaires at the 2-week follow-up period, higher DSQ scores (P = .036) at the 6-week follow-up period, higher EAT-10 scores (P = .009) at the 12-week follow-up period, and higher Bazaz (P = .001), DSQ (P = .002), and EAT-10 (P = .005) scores at the 24-week follow-up period. There were no differences in demographic, medical history, surgical variables, rates of ENT consultation, length of stay, or other in-hospital events between groups. CONCLUSIONS: Patients undergoing ACDF who had preoperative dysphagia have prolonged postoperative dysphagia and greater dysphagia severity. Surgeons should be aware of the risk of prolonged dysphagia severity that may persist past 24 weeks after surgery when discussing clinical decisions with patients.

The Five-Year Growth of an Orthopedic Urgent Care Center: Identifying Patient and Center Trends.

INTRODUCTION: With emergency department utilization rising at a dramatic rate, orthopedic urgent care centers (oUCCs) have become increasingly popular. The financial viability and basic advantages of oUCCs have been described in the literature, but little is known about the characteristics of patients treated and the diagnoses encountered. The purpose of this study is to report and evaluate the patients and diagnoses that are most commonly seen in an oUCC so that future care may be better tailored to the needs of the patients seeking these services. MATERIALS AND METHODS: All patients seen at a single suburban oUCC in its first and fifth years of operation (2014 and 2019) were identified. The medical records were reviewed to assess patient demographics, diagnoses encountered, and services rendered. The clinical courses of patients treated were also reviewed to identify those who underwent eventual surgery for their presenting complaint. RESULTS: A total of 24,756 patient visits occurred during the study period, and the number of visits nearly doubled between the first and fifth years (8,301 in 2014 and 16,455 in 2019). The most common diagnoses encountered were lower leg pain, back pain, and foot/ankle pain. Radiographs were obtained in 17,236 visits (70%), most commonly of the knee, elbow, foot, or ankle. A total of 1,334 patients (5.4%) underwent eventual surgery for their presenting complaint - defined as a surgical conversion. Of all the orthopedic subspecialties, sports medicine had the highest rate of surgical conversion (29% of all conversions). The surgical conversion rate increased slightly from year one (4.7%) to year five (5.8%). CONCLUSIONS: OUCCs are an effective means of expanding access to care for patients and increasing the volume of an orthopedic practice. Continued monitoring of the types of patients seen within oUCCs will further optimize care delivery.