Influence of Level 1 Evidence on Management of Clavicle and Distal Humerus Fractures: A Nationwide Comparative Study of Records From 2005 to 2014.

The purpose of this study was to examine alterations in national trends managing midshaft clavicle fractures (MCF) and intra-articular distal humerus fractures (DHF) surrounding recent level 1 publications. A retrospective review of the PearlDiver supercomputer for DHF and MCF was performed. Using age limits defined in the original level 1 studies, total use and annual use rates were examined. Nonoperative management and open reduction and internal fixation (ORIF) were reviewed for MCF. ORIF and total elbow arthroplasty (TEA) were reviewed for DHF. A query yielded 4929 MCF and 106,535 DHF patients. A significant increase in ORIF use for MCF following the publication of the level 1 study (p = .002) and a strong, positive correlation (p = .007) were evident. Annual TEA (p = .515) use for DHF was not observed. (Journal of Surgical Orthopaedic Advances 27(3):219-225, 2018).

Cost of Treatment for Proximal Humerus Fractures: An Acute and 90-Day Cost Evaluation.

The purpose of this study was to examine the 90-day costs of three common surgical treatments for proximal humerus fractures and compare the costs associated with the initial day and subsequent 89 days of care. This was conducted through a retrospective review of a national database examining patients who suffered proximal humerus fractures. Patients were stratified by type of surgical procedure performed, hemiarthroplasty (HA), reverse shoulder arthroplasty (RSA), and open reduction and internal fixation (ORIF). RSA was the most costly procedure for the same-day and 90-day costs (p < 0.001). Mean initial day reimbursement costs were significantly different among treatment groups, with the highest costs seen with RSA ($16,151), followed by HA ($9,348), and ORIF ($6,745). Subsequent 89-day reimbursement costs were not significantly different for RSA, HA, and ORIF (p = 0.112). The 90-day costs for the surgical treatment of proximal humerus fractures are driven by the initial day costs. RSA was associated with the highest cost, followed by HA and ORIF.

Speed of recovery after arthroscopic rotator cuff repair.

BACKGROUND: The purpose of this study was to delineate the time taken to achieve maximum improvement (plateau of recovery) and the degree of recovery observed at various time points (speed of recovery) for pain and function after arthroscopic rotator cuff repair. METHODS: An institutional shoulder surgery registry query identified 627 patients who underwent arthroscopic rotator cuff repair between 2006 and 2015. Measured range of motion, patient satisfaction, and patient-reported outcome measures were analyzed for preoperative, 3-month, 6-month, 1-year, and 2-year intervals. Subgroup analysis was performed on the basis of tear size by retraction grade and number of anchors used. RESULTS: As an entire group, the plateau of maximum recovery for pain, function, and motion occurred at 1 year. Satisfaction with surgery was >96% at all time points. At 3 months, 74% of improvement in pain and 45% to 58% of functional improvement were realized. However, only 22% of elevation improvement was achieved (P < .001). At 6 months, 89% of improvement in pain, 81% to 88% of functional improvement, and 78% of elevation improvement were achieved (P < .001). Larger tears had a slower speed of recovery for Single Assessment Numeric Evaluation scores, forward elevation, and external rotation. Smaller tears had higher motion and functional scores across all time points. Tear size did not influence pain levels. CONCLUSION: The plateau of maximum recovery after rotator cuff repair occurred at 1 year with high satisfaction rates at all time points. At 3 months, approximately 75% of pain relief and 50% of functional recovery can be expected. Larger tears have a slower speed of recovery.

E-mail reminders improve completion rates of patient-reported outcome measures.

BACKGROUND: Patient-reported outcome measures (PROMs) have become increasingly important in assessing clinical outcomes. However, acquisition of data at routine time intervals can be challenging. The ability of e-mail reminders to save follow-up intervals when office visits are missed is unknown. MATERIALS AND METHODS: A retrospective review of a consecutive series of 186 shoulder surgical patients who underwent surgery between October 2, 2012, and July 2, 2013, was conducted. Simple Shoulder Test and 12-Item Short Form Health Survey scores were completed at preoperative visits using office-based tablet surveys. Patients were observed for completeness of PROMs at expected routine follow-up of 1 year and 2 years. When office visits were missed, e-mail reminders with links to online surveys were sent to patients without further incentives. Improvement in data acquisition achieved using e-mail reminders when patient follow-up was missed was assessed. The influence of the procedure performed was further analyzed to determine whether patients treated with different surgical procedures would be more compliant with PROM completion. RESULTS: Use of e-mail reminders significantly increased the number of patients for whom complete follow-up data were obtained. Compared with tablet surveys completed during office visits alone, the addition of e-mail reminders increased the collection of complete PROM data (both 1- and 2-year follow-up) by 25.8% (P < .001). Similar findings were observed for total shoulder arthroplasty and arthroscopic rotator cuff repair patients (increased by 25.7% and 34.4%, respectively; P < .001). CONCLUSION: E-mail reminders serve as a mechanism to increase the completeness of follow-up data in the absence of in-office patient evaluation.

Treatment of Periprosthetic Humerus Fractures With Open Reduction and Internal Fixation.

Periprosthetic humerus fractures are relatively uncommon occurrence that can be difficult to manage nonoperatively. Locking plate technology has enhanced the surgical management of these fractures. However, adequate fixation around the stem remains of some concern. We describe an osteosynthesis technique using a locking plate utilizing eccentrically placed screw holes to place "skive screws" in the proximal end of the plate to achieve fixation around the stem of the implant. A clinical series of 5 consecutive patients treated with this technique is presented with an average follow-up of 29 months (range, 12-48). Two additional patients had less than 1-year follow-up. All patients demonstrated fracture healing. Functional outcomes were limited with only 1 patient achieving forward elevation above 90 degree, and the average American Shoulder and Elbow Surgeons Function score was 28. Pain relief was nearly uniform with an average visual analog scale pain score of 0.5.

Reverse shoulder prosthesis in the treatment of locked anterior shoulders: a comparison with classic reverse shoulder indications.

BACKGROUND: Locked anterior shoulder (LAS) with static instability and anterior glenoid bone loss is challenging in the elderly population. Reverse shoulder arthroplasty (RSA) has been employed in treating these patients. No study has compared RSA for LAS with classically indicated RSA. METHODS: A retrospective case-control study of patients treated with RSA for LAS with glenoid bone loss and static instability was performed using matched controls treated with primary RSA for classic indications. Twenty-four cases and 48 controls were evaluated. Average follow-up was 25.5 months, and median age was 76 years. Motion, outcome assessments, and postoperative radiographs were compared. RESULTS: Preoperatively, LAS had significantly less rotation and lower baseline outcome scores. Glenoid bone grafting was more common (P = .05) in the control group (26%) than in the LAS group (6.3%). Larger glenospheres were used more often (P = .001) in the LAS group (75%) than in the control group (29%). Both groups demonstrated significant improvements in pain, function, and outcome scores. Postoperatively, the control group had significantly better elevation and functional outcome scores. With the exception of flexion and Simple Shoulder Test score, effectiveness of treatment was similar between groups. Postoperative acromion stress fractures were seen in 21% of LAS patients and 9% of controls (P = .023) with a predominance of type 3 fractures in LAS. Two LAS patients remained dislocated. CONCLUSION: Patients with LAS treated with RSA can anticipate improvements in pain and function by use of larger glenospheres, often without the need for glenoid bone grafting. Worse postoperative motion and function and a higher incidence of acromion stress fracture may be expected.

Trends in total elbow arthroplasty in the Medicare population: a nationwide study of records from 2005 to 2012.

BACKGROUND: Utilization of total elbow arthroplasty (TEA) has reportedly increased in recent years. Since the introduction of disease-modifying antirheumatic drugs, there has been a reported decline in its use among rheumatoid patients; yet, the shift in indications for TEA remains unclear. This study evaluated trends in TEA utilization from 2005 to 2012 by analyzing the most common indications within the population of Medicare patients. METHODS: We performed a retrospective review of a comprehensive Medicare patient population database using the PearlDiver supercomputer (Warsaw, IN, USA) for TEA utilization in rheumatoid arthritis (RA), osteoarthritis (OA), distal humerus fracture (DHF), post-traumatic arthritis (PTA), and distal humerus nonunion (DHNU). Total reported incidence of office visits and TEA utilization for each indication was reviewed. RESULTS: Utilization of TEA remained unchanged (P = .9530) despite a growing Medicare population (P = .0201). There was a significant decline in annual TEA utilization for RA (P = .002) and DHNU (P = .003). No significant change was found in TEA use for DHF, OA, and PTA. A significant increase was noted in total visits coded for OA, RA, and DHNU (P < .001). A significant, strong negative correlation was found for office visit coding and TEA use in RA (r = -0.850; P = .008) and DHNU (r = -0.902; P = .002). CONCLUSION: From 2005 to 2012, utilization rates of TEA in the Medicare population remained constant. Despite increases in office visits, TEA use for RA and DHNU has declined, likely secondary to improved medical management with disease-modifying antirheumatic drugs and the surgeon's comfort with improved fracture fixation options.

Operatively treated type IV tibial tubercle apophyseal fractures.

BACKGROUND: Displaced tibial tubercle apophyseal fractures in children and adolescents are typically treated with closed reduction or open reduction with anterior to posterior screw fixation. Since the original classification by Watson-Jones and Ogden, an important variant with a posterior metaphyseal fracture line (type IV) was later described. However, there has been a lack of information regarding type IV tibial tubercle apophyseal fractures and its implications for surgical fixation. METHODS: Twenty-four type IV tibial tubercle fractures in 23 children and adolescents were reviewed. Operative reports and clinic records were used to identify the patient demographics, fracture type, and clinical results. Available imaging was also used to characterize these fractures. Minimum follow-up was 2 years. RESULTS: Type IV fractures accounted for 18.5% (24/130) of all tibial tubercle apophyseal fractures. Three type IV fractures were identified that had an additional epiphyseal split. These were categorized as type IV-B, whereas the rest were considered type IV-A. There were 19 males and 4 females (average age, 14.8 y; range, 11.8 to 16 y). The most common mechanism was an eccentric quadriceps contraction during basketball. Three patients were initially treated with closed reduction and casting and were noted to have loss of reduction. All patients were treated definitively with open reduction and internal fixation or percutaneous screw placement. In addition to AP compression screws, 4 patients required supplemental plate fixation to stabilize the proximal tibia. Major complications included 1 compartment syndrome and 1 large DVT. All fractures healed and there were no growth disturbances. CONCLUSIONS: Type IV tibial tubercle apophyseal fractures are an important variant that requires careful assessment to ensure adequate stabilization of the proximal tibia when surgery is warranted. LEVEL OF EVIDENCE: IV (prognostic case series).