Complications in Olecranon Fracture Surgery: A Comparison of Tension Band Vs. Plate Osteosynthesis.

Background: The purpose of this study is to compare the incidence of complications associated with tension band wiring (TBW) versus plate osteosynthesis (POS) in the treatment of olecranon fractures. Methods: We performed a retrospective cohort study of operatively treated adult olecranon fractures from an integrated healthcare system by multiple surgeons from January 2008 to December 2011. Patients were divided into two cohorts: fractures fixed using the tension band technique and fractures fixed using plate osteosynthesis. The study was limited to the Orthopedic Trauma Association classification of olecranon fracture type 21-B1, with subtypes 1-3. Outcome measures were loss of fracture fixation requiring revision, postoperative infection, stiffness requiring surgery, and symptomatic hardware removal (HWR). Univariate and multivariable logistic regressions were performed to test the associations between the type of internal fixation and outcomes. Results: A total of 321 olecranon fractures were included (median age: 61 years old, 57 % female); 153 participants were treated with TBW, and 168 patients with POS. There was one failure in the TBW group and two in the POS group (P=0.62). There were no significant differences in the infection rates (TBW 5%, POS 9%, P=0.20) and no reoperations for stiffness. The HWR occurred significantly more often in TBW (29%) than in POS (14%) (OR=0.39, P=0.001). The association between POS and decreased HWR remained highly significant (OR=0.40, P=0.003) after adjusting for clinical variables. Conclusion: In this large study comparing POS and TBW for 21-B1 olecranon fractures, no difference in fixation failure, infection, or postoperative stiffness was noted. A significantly greater risk of symptomatic hardware occurred in TBW. These findings may assist surgeons and patients in considering the risks and benefits of TBW and POS as treatment options for displaced olecranon fractures.

Radial head arthroplasty: a descriptive study of 970 patients in an integrated health care system.

BACKGROUND: Radial head arthroplasty (RHA) is commonly performed for isolated comminuted radial head fractures and in conjunction with traumatic elbow instability. However, there is a paucity of literature directly describing the characteristics and outcomes of patients who undergo RHA in a community-based setting. We describe a cohort of 970 RHA performed in the California regions of a US integrated health care system over a 9-year period. Patient demographics, implant selection, 90-day acute postoperative events, and cumulative reoperation/revision rates are included. METHODS: Patients aged ≥18 years who underwent primary RHA were identified (2009-2017). Patient characteristics and demographics, including age, body mass index, gender, diabetes status, American Society of Anesthesiologists (ASA) classification, primary diagnosis, and concomitant procedures were described. Crude cumulative revision and reoperation probabilities were calculated as 1 minus the Kaplan-Meier estimator, with follow-up time calculated as the time from the index RHA to revision/reoperation date for those with the outcome of interest and time from index RHA to censoring date (eg, date of death, health care termination, study end date [March 31, 2018]) for those without the outcome. Ninety-day postoperative incidence of emergency department (ED) visit, readmission, and mortality was calculated as the number of patients with the event of interest over the number of patients at risk. RESULTS: A total of 970 patients underwent primary unilateral RHA by 205 surgeons during the study period. Annual procedure volume increased from 53 procedures in 2009 to 157 procedures in 2017. More patients were female, without diabetes, and had an ASA classification of 1 or 2. Fracture was the predominant indication for RHA (98.4%) and more than half (54.3%) had concomitant procedures performed. Most implants were press fit (63.2%) over loose fit, and >90% were monopolar. Three-year cumulative revision and reoperation probabilities following RHA were 6.5% (95% confidence interval [CI] = 5.0%-8.5%) and 8.2% (95% CI = 6.5%-10.3%), respectively. Revisions and reoperations tended to occur within the first postoperative year. Of the 970 RHA patients, 83 (8.5%) had a 90-day ED visit, 58 (6.0%) had a 90-day readmission, and 1 (0.1%) died within a 90-day postoperative period. CONCLUSION: This large cohort of RHA patients provides information about the practice of RHA at large and in the community. Surgeons are performing more RHA over time and choosing press fit stems more often. Revisions and reoperations tended to occur early. Readmission and ED visits were low but not negligible, with pain being the most common reason for ED visit.

Total Elbow Arthroplasty: A Descriptive Analysis of 170 Patients From a United States Integrated Health Care System.

PURPOSE: Total elbow arthroplasty (TEA) can be used, with varying degrees of success, for the treatment of rheumatoid arthritis, osteoarthritis, and distal humerus fractures and their sequelae in elderly patients. Some of the largest studies of TEA have included data from more than 20 years ago and may not reflect the current practice of TEA. We sought to describe a modern cohort of patients who underwent TEA in a United States integrated health care system. METHODS: All patients aged 18 years and older who underwent primary unilateral TEA from January 1, 2009, through March 31, 2018, were identified to conduct a descriptive study. The patients' characteristics and demographics, including age, body mass index, sex, diabetes status, American Society of Anesthesiologists classification, and surgical indication, were recorded. The crude cumulative revision probability as well as the 90-day postoperative incidence rate of emergency department visit, readmission, and mortality was calculated. RESULTS: A total of 170 patients met our inclusion criteria. The annual procedure volume nearly doubled, from 11 procedures in 2009 to 21 procedures in 2017. The most common indication for TEA was fracture (40.6%), followed by rheumatoid arthritis (36.5%). At 4-year follow up, the crude cumulative revision probability was 9.8% (95% confidence interval, 5.6%-16.9%). Of the 170 patients who underwent TEA, 43 (25.3%) experienced a 90-day emergency department visit, 24 (14.1%) experienced a 90-day readmission, and 2 (1.2%) died within 90 days postoperatively. CONCLUSIONS: This cohort of patients who underwent TEA using modern implants showed a notable increase in the volume of TEA over the study period, with more TEAs performed for trauma. The incidence of readmission and emergency department visits following TEA were high in this study. Further studies are needed to better define the current practice of TEA in the community at large. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Unplanned emergency department or urgent care visits after outpatient rotator cuff repair: potential for avoidance.

BACKGROUND: With the cost of health care rising, the potential to avoid costs from an unplanned return to the emergency department (ED) or urgent care center (UC) after elective outpatient rotator cuff repair (RCR) has been discussed but not extensively assessed. METHODS: Outpatient RCR procedures were queried in a closed health care system, and all unplanned ED and UC visits within 7 days of procedures were collected and compared with other typical outpatient orthopedic procedures (knee arthroscopy, carpal tunnel release, and anterior cruciate ligament reconstruction). Avoidable diagnoses (ADs) for the unplanned visits were defined in advance as visits for (1) constipation, (2) nausea or vomiting, (3) pain, and (4) urinary retention. Final tallies of all visits versus visits with ADs were compared. RESULTS: From June 2015 to May 2016, 1306 outpatient RCRs were performed (729 male and 577 female patients; average age, 60 years). Of the patients, 90 returned for ED or UC visits (6.9%), with 34 for ADs (2.6%). Pain was the most common AD. However, when RCR was compared with other case types, ED or UC visits for urinary retention were significantly more common (P = .007), whereas there was no significant difference with the other ADs. The 1306 RCRs led to a greater proportion of ED or UC visits than the combined 5825 other cases studied (P < .001). DISCUSSION AND CONCLUSIONS: Unplanned ED visits within 7 days of outpatient RCR are measurable and in many cases, such as ED or UC visits for pain, are avoidable. Visits for urinary retention are seen more commonly after RCR. Outpatient RCR led to more unplanned ED and UC visits than other common outpatient orthopedic surgical procedures.

Kirschner wire infections in pediatric orthopaedic surgery.

BACKGROUND: Few studies have described the presentation, bacteriology, risk factors, and complications of Kirschner wire infections in pediatrics. The purpose of this study is to describe these factors to better understand, prevent, and treat infectious complications of smooth wires. METHODS: A retrospective review was performed to identify all patients (birth to 16 y) who were hospitalized for Kirschner wire infection from 1995 to 2012. Presentation, hospital course, bacteriology, outcomes, and complications were recorded. A management algorithm was developed from the experience. RESULTS: Kirschner wire infections were present in 12 patients: 5 supracondylar fractures, 3 lateral humeral condylar fractures, a distal tibia physeal fracture, a great toe open fracture, a distal radius fracture, and an elective osteotomy for hallux valgus. The patients presented with cellulitis in 3 cases, soft-tissue abscess in 4 cases, osteomyelitis in 4 cases, and 1 case of toxic shock syndrome. A history of missed appointments or wet dressing was present in 60% of cases. Reoperation was required in 5 patients with abscess, septic arthritis, or osteomyelitis. Methicillin-sensitive Staphylococcus aureus (MSSA) was the most common pathogen followed by Pseudomonas aeruginosa. Methicillin-resistant S. aureus was not seen. Complications were present in 5 patients and included: loss of range of motion, joint destruction, wound breakdown, catheter migration, and toxic shock syndrome. CONCLUSIONS: Infected Kirschner wires are rare and may be maintained in a nonunited bone if the infection is superficial. Infections in this series commonly had a history of missed appointments and wet dressings, which suggests that improved postoperative education may reduce the risk. Osteomyelitis was often preceded by pin-site drainage and failed oral antibiotic therapy. MSSA and Pseudomonas were most commonly cultured and should be considered when empiric antibiotic therapy is necessary. LEVEL OF EVIDENCE: Prognostic level IV.

The impact of residency and fellowship training on the practice of microsurgery by members of the american society for surgery of the hand.

PURPOSE: The purpose of this study was to assess the microsurgical training background of current members of the American Society for Surgery of the Hand (ASSH) and then determine the impact that prior training had on current microsurgical practice. METHODS: A 174-item anonymous Web-based survey was sent to all active ASSH members. Items addressed prior residency and fellowship training, practice setting, and training, comfort, and practice of specific microsurgical procedures. Data were analyzed using frequency tables, cross-tabulations, χ tests, and other established statistical methods. RESULTS: Surveys were received from 377 of 2019 ASSH members (18.7% response rate). Residency training was in orthopedics (n=249, 66.9%), plastic surgery (n=56, 15.1%), or general surgery (n=55, 14.8%). Fellowship training was in orthopedic (n=242, 65.1%), combined (n=65, 17.5%), and plastic surgery (n=15, 4%) programs. Microsurgical procedures involving nerves were performed by 96.6% of surgeons (n=337), with no significant differences between surgeons trained in plastic surgery versus orthopedic surgery residencies, and no differences between those who had completed orthopedic versus combined fellowships. Of the surgeons completing the survey, 56.1% (n=208) performed general microvascular procedures, 50% (n=179) performed replantations, and 30.6% (n=113) performed free flaps. Hand surgeons who completed plastic surgery residencies were more likely to perform general microvascular procedures, replantations, and free flaps than surgeons trained in orthopedic residencies. When comparing training in orthopedic and combined fellowships, there was no difference in performance of replantations, free flaps, general microvascular surgery, or microsurgical procedures involving nerves. CONCLUSIONS: Training backgrounds have a substantial impact on current microsurgical practice, with residency having the most significant effect. Specifically, hand surgeons trained in plastic surgery residency programs are more likely to perform replantations, free tissue transfer, and general microvascular surgery than those who completed orthopedic residencies. Fellowship training background does not significantly affect microsurgical practice.

The history and evolution of hand transplantation.

Hand transplantation has proven itself to be a viable treatment option for upper extremity reconstruction. It has grown through advancements in several critical areas: microsurgery, transplant immunology, and hand surgery. The field has also benefited from a global effort with active transplant centers in 3 different continents. The early struggles and breakthroughs of hand transplantation's past have shaped and formed its current state. This article traces the events of the modern era of hand transplantation.

Classification and treatment of proximal humerus fractures: inter-observer reliability and agreement across imaging modalities and experience.

SUMMARY: Proximal humerus fractures (PHF) are common injuries, but previous studies have documented poor inter-observer reliability in fracture classification. This disparity has been attributed to multiple variables including poor imaging studies and inadequate surgeon experience. The purpose of this study is to evaluate whether inter-observer agreement can be improved with the application of multiple imaging modalities including X-ray, CT, and 3D CT reconstructions, stratified by physician experience, for both classification and treatment of PHFs. METHODS: Inter-observer agreement was measured for classification and treatment of PHFs. A total of sixteen fractures were imaged by plain X-ray (scapular AP and lateral), CT scan, and 3D CT reconstruction, yielding 48 randomized image sets. The observers consisted of 16 orthopaedic surgeons (4 upper extremity specialists, 4 general orthopedists, 4 senior residents, 4 junior residents), who were asked to classify each image set using the Neer system, and recommend treatment from four pre-selected choices. The results were evaluated by kappa reliability coefficients for inter-observer agreement between all imaging modalities and sub-divided by: fracture type and observer experience. RESULTS: All kappa values ranged from "slight" to "moderate" (k = .03 to .57) agreement. For overall classification and treatment, no advanced imaging modality had significantly higher scores than X-ray. However, when sub-divided by experience, 3D reconstruction and CT scan both had significantly higher agreement on classification than X-ray, among upper extremity specialists. Agreement on treatment among upper extremity specialists was best with CT scan. No other experience sub-division had significantly different kappa scores. When sub-divided by fracture type, CT scan and 3D reconstruction had higher scores than X-ray for classification only in 4-part fractures. Agreement on treatment of 4 part fractures was best with CT scan. No other fracture type sub-division had significantly different kappa scores. CONCLUSIONS: Although 3D reconstruction showed a slight improvement in the inter-observer agreement for fracture classification among specialized upper extremity surgeons compared to all imaging modalities, fracture types, and surgeon experience; overall all imaging modalities continue to yield low inter-observer agreement for both classification and treatment regardless of physician experience.

Microsurgery of the upper extremity.

In the past 50 years, hand surgeons have made considerable contributions to microsurgery. The unique demands of complex upper extremity care have driven many of the technical and scientific advances of this discipline, including functional muscle transfers, nerve transfers, and composite tissue allotransplantation. The purpose of this article was to review the current applications of microsurgery to the upper extremity.

Head-shaft angle measurement in children with cerebral palsy.

BACKGROUND: It has been observed in children with cerebral palsy (CP) that the femoral head rests in a valgus position as compared to the proximal neck and/or shaft. The purpose of this study was to compare the head-shaft angle (HSA) as a measure of femoral head valgus in children with CP (group 1) with a subset of children with CP who have more significant hip subluxation (group 2, as demonstrated by the need for surgery to correct the deformity), with age-matched (group 3) and historical controls. METHODS: There were a total of 39 patients (70 hips), 15 patients in group 1, 10 in group 2, and 14 in group 3. The HSA was measured as described by Southwick (Southwick WO. Osteotomy of the lesser trochanter for slipped capital femoral epiphysis. J Bone Joint Surg Am. 1967;49A:803-835). Interrater and intrarater reliabilities and the variation of these measures with rotation were assessed. RESULTS: The mean HSA in group 1 was 160.8 degrees; group 2, 170.3 degrees; group 3, 152.5 degrees; and historical control, 146.7 degrees. The difference was statistically significant between groups 1 and 2 and between both CP groups and the control groups. Intrarater and interrater reliabilities were found to be low, and variation with rotation was found to be minimal. CONCLUSIONS: This study demonstrates that HSA is greater in children with CP than in typically developing children and that this is more pronounced in children with CP who are at risk for eventual subluxation. Evaluation of the HSA may be prudent in children with CP.