RESUMEN
BACKGROUND: Two popular systems for classifying rheumatoid arthritis affecting the elbow are the Larsen and Sharp schemes. To our knowledge, no study has investigated the reliability of these 2 systems. We compared the intraobserver and interobserver agreement of the 2 systems to determine whether one is more reliable than the other. METHODS: The radiographs of 45 patients diagnosed with rheumatoid arthritis affecting the elbow were evaluated. Anteroposterior and lateral radiographs were deidentified and distributed to 6 evaluators (4 fellowship-trained upper extremity surgeons and 2 orthopedic trainees). Each evaluator graded all 45 radiographs according to the Larsen and Sharp scoring methods on 2 occasions, at least 2 weeks apart. RESULTS: Overall intraobserver reliability was 0.93 (95% confidence interval [CI], 0.90-0.95) for the Larsen system and 0.92 (95% CI, 0.86-0.96) for the Sharp classification, both indicating substantial agreement. Overall interobserver reliability was 0.70 (95% CI, 0.60-0.80) for the Larsen classification and 0.68 (95% CI, 0.54-0.81) for the Sharp system, both indicating good agreement. There were no significant differences in the intraobserver or interobserver reliability of the systems overall and no significant differences in reliability between attending surgeons and trainees for either classification system. CONCLUSION: The Larsen and Sharp systems both show substantial intraobserver reliability and good interobserver agreement for the radiographic classification of rheumatoid arthritis affecting the elbow. Differences in training level did not result in substantial variances in reliability for either system. We conclude that both systems can be reliably used to evaluate rheumatoid arthritis of the elbow by observers of varying training levels.
Asunto(s)
Artritis Reumatoide/clasificación , Articulación del Codo , Artritis Reumatoide/diagnóstico por imagen , Humanos , Variaciones Dependientes del Observador , Radiografía , Reproducibilidad de los ResultadosRESUMEN
HYPOTHESIS AND BACKGROUND: The severity of elbow arthritis is one of many factors that surgeons must evaluate when considering treatment options for a given patient. Elbow surgeons have historically used the Broberg and Morrey (BM) and Hastings and Rettig (HR) classification systems to radiographically stage the severity of post-traumatic arthritis (PTA) and primary osteoarthritis (OA). We proposed to compare the intraobserver and interobserver reliability between systems for patients with either PTA or OA. METHODS: The radiographs of 45 patients were evaluated at least 2 weeks apart by 6 evaluators of different levels of training. Intraobserver and interobserver reliability were calculated by Spearman correlation coefficients with 95% confidence intervals. Agreement was considered almost perfect for coefficients >0.80 and substantial for coefficients of 0.61 to 0.80. RESULTS: In patients with both PTA and OA, intraobserver reliability and interobserver reliability were substantial, with no difference between classification systems. There were no significant differences in intraobserver or interobserver reliability between attending physicians and trainees for either classification system (all P > .10). The presence of fracture implants did not affect reliability in the BM system but did substantially worsen reliability in the HR system (intraobserver P = .04 and interobserver P = .001). CONCLUSIONS: The BM and HR classifications both showed substantial intraobserver and interobserver reliability for PTA and OA. Training level differences did not affect reliability for either system. Both trainees and fellowship-trained surgeons may easily and reliably apply each classification system to the evaluation of primary elbow OA and PTA, although the HR system was less reliable in the presence of fracture implants.
Asunto(s)
Lesiones de Codo , Articulación del Codo/diagnóstico por imagen , Fracturas Intraarticulares/complicaciones , Osteoartritis/clasificación , Osteoartritis/diagnóstico por imagen , Competencia Clínica , Articulación del Codo/cirugía , Humanos , Fracturas Intraarticulares/diagnóstico por imagen , Fracturas Intraarticulares/cirugía , Variaciones Dependientes del Observador , Osteoartritis/etiología , Radiografía , Reproducibilidad de los Resultados , Índice de Severidad de la EnfermedadRESUMEN
PURPOSE: To test the reliability of the Mayo Elbow Performance Score (MEPS) and compare it with a validated outcomes instrument, the American Shoulder and Elbow Surgeons (ASES) score. METHODS: A total of 42 patients with the chief problem of elbow dysfunction formed the study cohort. Patients with an immediate surgical indication or treatment at the index visit were excluded. The others completed an MEPS questionnaire; at a second visit 2 to 3 weeks later, they completed another MEPS questionnaire and were evaluated with the ASES elbow assessment. Reliability and accuracy were calculated using 2-tailed Pearson correlation coefficients with 95% confidence intervals. Pearson coefficients greater than 0.8 indicated strong agreement. RESULTS: The average MEPS score at the initial visit was 58. At the second visit, the average MEPS score was 69 and the average ASES score was 78. The Pearson coefficient for MEPS scores at the 2 time points averaged 0.82, and between the MEPS and ASES scores averaged 0.83. Both coefficients indicated strong agreement. CONCLUSIONS: The MEPS has strong reliability when assessed at different times and when compared with a validated elbow outcomes instrument. Differences in compared scores of approximately 10 points indicate some patient improvement between time points; however, 95% confidence intervals, standard deviations, and ranges were essentially equivalent between and among tests, indicating similar accuracy. CLINICAL RELEVANCE: The MEPS is a reliable outcomes instrument for clinical studies of elbow function that is used to assess nonsurgical treatment.
Asunto(s)
Evaluación de la Discapacidad , Articulación del Codo/fisiopatología , Artropatías/fisiopatología , Adulto , Anciano , Femenino , Humanos , Artropatías/terapia , Masculino , Persona de Mediana Edad , Psicometría , Reproducibilidad de los Resultados , Encuestas y CuestionariosRESUMEN
Pediatric foot polydactyly presents in a wide variety of deformities from single extra digits attached only by a narrow soft-tissue connection to complex central foot duplications with tarsal bone duplication. The goal of surgical reconstruction is a stable, mobile, pain-free foot with five cosmetically appealing toes that allows for normal footwear and painless ambulation. This review covers the incidence, genetics and embryology, classification, presentation and natural history, physical examination, radiographic assessment, and surgical intervention for all types of foot polydactyly.
Asunto(s)
Deformidades Congénitas del Pie , Polidactilia , Niño , Pie , Deformidades Congénitas del Pie/diagnóstico , Deformidades Congénitas del Pie/cirugía , Humanos , Polidactilia/epidemiología , Polidactilia/cirugía , Dedos del Pie , CaminataRESUMEN
Distal radial fractures are associated with good outcomes; however, although they occur at low rates, complications can significantly impair treatment success. Therefore, the treating surgeon should be aware of potential complications associated with each treatment type and how to best prevent them. Although certain patient-specific and fracture-specific factors may increase the risk of adverse outcomes, most are nonmodifiable risk factors at the time of presentation, so it is imperative that every effort is made to mitigate these risk factors to prevent long-term morbidity. Patients should be well-informed about these complications and potential symptoms so that they can be addressed expeditiously.
Asunto(s)
Fijación de Fractura/efectos adversos , Complicaciones Posoperatorias , Fracturas del Radio/cirugía , Humanos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Radio (Anatomía)/diagnóstico por imagen , Radio (Anatomía)/fisiopatología , Factores de RiesgoRESUMEN
The field of hand surgery continues to evolve in new and exciting directions. Advances in diagnosis and management for common complaints and complex injuries allow higher-level care, while still being cognizant of the cost of health care delivery. Indications and protocols for past paradigm shifts, such as volar locked plating for distal radial fractures, continue to be honed, and the outcomes seen for modern flexor tendon repairs are impressive. Open questions remain, but promising results for scaphoid nonunion surgery and peripheral nerve reconstruction with processed allograft will continue to shed light on these unsolved problems.
Asunto(s)
Traumatismos de la Mano/cirugía , Procedimientos Ortopédicos/métodos , Traumatismos de la Muñeca/cirugía , Analgésicos Opioides/administración & dosificación , Evaluación de la Discapacidad , Humanos , Dolor Postoperatorio/tratamiento farmacológicoRESUMEN
To determine if orthopedic surgeons are more efficient than nonsurgical providers at care of operative injuries in walk-in clinics, patients in a walk-in clinic for evaluation of acute injury who subsequently had surgical treatment of isolated distal radial fracture were compared based on whether the initial visit was with a surgical or nonsurgical provider. Initial evaluation in a walk-in orthopedic clinic setting versus a conventional hand surgeon's clinic was associated with longer delay between initial evaluation and surgical treatment, but this difference may not be significant. Evaluation by a nonsurgical provider was not associated with increased duration to definitive treatment.
Asunto(s)
Fracturas del Radio/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Atención Ambulatoria , Instituciones de Atención Ambulatoria , Femenino , Fijación Interna de Fracturas , Curación de Fractura , Humanos , Masculino , Persona de Mediana Edad , Fracturas del Radio/terapia , Tiempo de Tratamiento , Adulto JovenRESUMEN
Distal radius fractures are one of the most commonly treated fractures in the United States. The highest rates are seen among the elderly, second only to hip fractures. With the increasing aging population these numbers are projected to continue to increase. Distal radius fractures include a spectrum of injury patterns encountered by general practitioners and orthopedists alike. This evidence-based review of distal radius fractures incorporates current and available literature on the diagnosis, management, and treatment of fractures of the distal radius.
Asunto(s)
Fijación Interna de Fracturas/métodos , Fijación Interna de Fracturas/rehabilitación , Fracturas del Radio/cirugía , Traumatismos de la Muñeca/cirugía , Factores de Edad , Anciano , Medicina Basada en la Evidencia , Femenino , Curación de Fractura/fisiología , Humanos , Incidencia , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Radiografía/métodos , Fracturas del Radio/diagnóstico por imagen , Recuperación de la Función , Medición de Riesgo , Factores Sexuales , Traumatismos de la Muñeca/diagnóstico por imagen , Traumatismos de la Muñeca/epidemiologíaRESUMEN
The cost of carpal tunnel release (CTR) surgery can be decreased and patient satisfaction increased by a few relatively simple changes. Although cost estimates vary in the literature, most investigators agree that open CTR costs less than endoscopic CTR, and the clinic procedure room or ambulatory surgery center is cheaper than the ambulatory surgery center, which is less than the hospital. Patient satisfaction can be increased by making office visits more patient-centered and improving the quality of dialogue between the surgeon and patient.
Asunto(s)
Síndrome del Túnel Carpiano/cirugía , Costos de la Atención en Salud , Procedimientos Ortopédicos/economía , Evaluación de Resultado en la Atención de Salud/economía , Satisfacción del Paciente , Síndrome del Túnel Carpiano/economía , Humanos , Procedimientos Ortopédicos/normasRESUMEN
The olecranon process, coronoid process, and greater sigmoid notch are important components of the complex proximal ulna. Along with providing bony stability to the ulnohumeral joint, the proximal ulna serves as the attachment site of many important muscles and ligaments that impart soft tissue stability to the elbow joint. Management of proximal ulnar fractures continues to evolve as advances in imaging and anatomic and biomechanical studies have led to improvements in available implants; however, controversies remain, as shown in the current relevant literature.
Asunto(s)
Fijación Interna de Fracturas/métodos , Olécranon/lesiones , Fracturas del Cúbito/cirugía , Humanos , Olécranon/cirugíaRESUMEN
Hand injuries account for up to 15% of sports injuries and are common in contact sports and in sports with a high risk of falling. Appropriate management requires knowledge of the type of injury, demands of the sport and position, competitive level of the athlete, future athletic demands and expectations, and the role of rehabilitation and protective splints for return to play. Management of the athlete requires aggressive and expedient diagnostic intervention and treatment. This article describes ligamentous injuries to the thumb, including thumb carpometacarpal dislocations, thumb metacarpophalangeal dislocations, collateral ligament injuries and interphalangeal dislocations, their evaluation, treatment and outcomes.
Asunto(s)
Atletas , Traumatismos en Atletas/epidemiología , Ligamentos Colaterales/lesiones , Traumatismos de la Mano/epidemiología , Articulación Metacarpofalángica/lesiones , Pulgar/lesiones , Humanos , Incidencia , Estados Unidos/epidemiologíaRESUMEN
Biceps tenodesis is typically performed through an open anterior incision. Even when an arthroscopic rotator cuff repair is performed, an open procedure is typically performed to address the biceps rupture or subluxation. Recently, there has been great interest in performing this procedure arthroscopically. Techniques have included using an interference screw or 2 suture anchors through an anterior cannula. If the biceps is partially ruptured or subluxated and the proximal end is still visible in the joint, a biceps tenodesis can be performed using standard arthroscopic techniques and suture anchors. The senior author (K.D.N.) developed the subclavian portal in 1997 for arthroscopic repair of rotator cuff tears using a pointed suture grasper. This portal is located 1 to 2 cm medial to the acromioclavicular joint line, directly above and slightly medial to the coracoid. It provides an optimal angle for suture anchor placement directly through the anterior supraspinatus or coracohumeral ligament and into the humeral head at the edge of the articular cartilage. Anchors inserted through the subclavian portal reproduce the 45 degrees Deadman's angle, which was described for placing anchors during rotator cuff repair. Using a burr or shaver through the lateral portal, the articular and bony surface under the biceps tendon and just proximal to the bicipital groove are abraded. Suture anchors are inserted through the subclavian portal, then through the biceps tendon, and into the bone. Sutures are retrieved and tied through the lateral cannula if there is a tear of the supraspinatus. If the supraspinatus is intact, the sutures can be tied intra-articularly through the anterior cannula. Release of the biceps is not performed until the repair is accomplished, which prevents the tendon from retracting down the bicipital groove. The anatomy of the subclavian portal is reviewed and the technique of the arthroscopic biceps tenodesis is presented. Preliminary results of 11 cases with average follow-up of 24 months are presented. Ninety-one percent of the cases had good/excellent results. Adhesive capsulitis occurred in 1 Workers' Compensation patient, which resulted in a fair outcome.
Asunto(s)
Brazo/cirugía , Artroscopía/métodos , Técnicas de Sutura , Tendones/cirugía , Adulto , Anciano , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Cuidados Posoperatorios , Tendinopatía/cirugíaRESUMEN
To determine if there are significant differences in outcomes and costs between tension-band and locking-plate fixation of transverse olecranon fractures in adults, we retrospectively compared functional outcomes, complications, and costs in 2 cohorts of displaced transverse olecranon fractures. These cohorts (10 patients each) were matched on age and length of follow-up. There were no significant differences between the groups in range of motion, functional scores, or arthrosis. There were no infections or nonunions in either group. There was no significant difference in rate of implant removal or symptomatic implants, though a trend was found toward a higher rate of both with tension bands. Operative time was significantly (P = .025) less for tension-band than locking-plate fixation (55 vs 85 minutes). In the tension-band group, charges were significantly less for implant, index procedure, and overall operative charges including reoperations ($6598.36 vs $14,333.46; P = .001). If all tension bands and no locking plates had been removed, tension-band fixation still would have cost significantly less ($7307.31 vs $14,160.26; P = .0005).
Asunto(s)
Placas Óseas , Hilos Ortopédicos , Fijación de Fractura/instrumentación , Olécranon/lesiones , Fracturas del Cúbito/cirugía , Placas Óseas/economía , Hilos Ortopédicos/economía , Femenino , Fijación de Fractura/economía , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Reoperación , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Shoulder arthroscopy and the introduction of suture anchors has provided the surgeon with the ability to repair rotator cuff tears through minimal incisions. Rotator cuff repair involves the use of several portals, such as the posterior portal, the anterior portal, the anterior superior portal, the anterior inferior portal, and the Neviaser portal. The authors have developed 2 additional portals, the new Subclavian portal and the modified Neviaser portal, to improve the safety and efficacy of rotator cuff repair and solve a number of problems associated with traditional repair techniques. The subclavian portal is located directly below the clavicle, 1 to 2 cm from the acromioclavicular joint, and instruments are aimed medial to lateral. The modified Neviaser portal changes the angle of insertion of the Neviaser portal. Instruments are aimed 20 degrees from the horizontal plane and 45 degrees anterior, directly at the suture anchor. Repair techniques using each portal were reviewed. Twenty cadaveric shoulders were dissected for each portal and the anatomy from each portal was documented. The cadaveric dissections showed that this portal passes greater than 6 cm from the brachial plexus, musculocutaneous nerve, and subclavian artery and vein, and 4.7 cm from the cephalic vein. The modified Neviaser portal was shown to be safer than the Neviaser portal because it passes on top of the supraspinatous muscle, thereby protecting the suprascapular nerve. These portals provide an optimal angle of approach to the rotator cuff tendon and suture anchor as well as improved safety and efficacy in the repair of rotator cuff tears.
Asunto(s)
Artroscopía/métodos , Manguito de los Rotadores/cirugía , Anciano , Antropometría , Femenino , Humanos , Masculino , Seguridad , Técnicas de Sutura/instrumentaciónRESUMEN
Superior labrum anterior posterior (SLAP) repair using suture anchors requires successful passing of sutures through the labrum. The optimal angle for passing a penetrating suture retriever is perpendicular to the superior labrum. The Neviaser (superior-medial) portal, without a cannula, is ideally suited for this procedure. The authors demonstrate their technique and review the anatomy of this portal. The Neviaser portal is illustrated as an important working portal and not merely for inflow or outflow. The authors demonstrate that this is a safe and easy technique for SLAP repair.