The Epidemiology of Upper Extremity Fractures in the United States, 2009.

BACKGROUND: No single epidemiological study of upper extremity fractures exists in the United States using data from all payers. Current epidemiological estimates are based on case series, foreign databases, or Medicare data, which are not representative of the entire US population. The objective of this project was to accurately describe the incidence of fractures of the upper extremity in a representative sample of the US population. METHODS: Using International Classification of Disease, Ninth Edition codes for patient visits reported in the 2009 State Emergency Department Database and the State Inpatient Database, available from the Healthcare Cost and Utilization Project, and 2010 US Census data, we calculated the annual incidence rates per 10,000 persons of upper extremity fractures of all patients, regardless of age or payer type. This was done using a representative national sample from 8 states: Arizona, California, Iowa, Maryland, Massachusetts, New Jersey, and Vermont. RESULTS: Overall, in this population of over 87 million Americans, there were 590,193 fractures of the upper extremity, yielding an annual incidence of 67.6 fractures per 10,000 persons. Distal radius and ulna fractures were the most common upper extremity fractures (16.2 fractures per 10,000 persons), followed by hand fractures (phalangeal and metacarpal fractures; 12.5 and 8.4 per 10,000, respectively), proximal humerus fractures (6.0 per 10,000), and clavicle fractures (5.8 per 10,000). The most common type of fracture for all age groups was distal radius fractures, except in the 18- to 34-year-old group, in which metacarpal and phalangeal fractures were more common (16.1 and 12.5 per 10,000, respectively) and the 35- to 49-year-old group, in which phalangeal fractures were most common (11.5 per 10,000). The incidence of distal radius fractures was bimodal, with the highest rates in the under 18 and over 65 age groups (30.18 and 25.42 per 10,000, respectively) with lower rates in the middle age groups. The most common type of fracture for males was phalangeal fractures (11.5 per 10,000), and distal radius and ulna fractures were the most common type for females (11.8 per 10,000). Interestingly, phalangeal and metacarpal fractures varied by socioeconomic status (SES), which decreased with increasing SES. No other fracture type varied by SES. CONCLUSIONS: Epidemiological studies are necessary for research, clinical applications, and public health and health policy initiatives. This study reports national estimates of upper extremity fractures with subgroup analysis.

Lumbar disc herniation in the Spine Patient Outcomes Research Trial: does educational attainment impact outcome?

STUDY DESIGN: Randomized trial with concurrent observational cohort. A total of 1171 patients were divided into subgroups by educational attainment: high school or less, some college, and college degree or above. OBJECTIVE: To assess the influence of education level on outcomes for treatment of lumbar disc herniation. SUMMARY OF BACKGROUND DATA: Educational attainment has been demonstrated to have an inverse relationship with pain perception, comorbidities, and mortality. METHODS: The Spine Patient Outcomes Research Trial enrolled surgical candidates (imaging-confirmed disc herniation with at least 6 weeks of persistent signs and symptoms of radiculopathy) from 13 multidisciplinary spine clinics in 11 US states. Treatments were standard open discectomy versus nonoperative treatment. Outcomes were changes from baseline for 36-Item Short Form Health Survey (SF-36), bodily pain (BP), and physical function (PF) scales and the modified Oswestry Disability Index (ODI) at 6 weeks, 3 months, 6 months, and yearly through 4 years. RESULTS: Substantial improvement was seen in all patient cohorts. Surgical outcomes did not differ by level of education. For nonoperative outcomes, however, higher levels of education were associated with significantly greater overall improvement over 4 years in BP (P = 0.007), PF (P = 0.001), and ODI (P = 0.003). At 4 years a "dose-response" type relationship was shown for BP (high school or less = 25.5, some college = 31, and college graduate or above = 36.3, P = 0.004) and results were similar for PF and ODI. The success of nonoperative treatment in the more educated cohort resulted in an attenuation of the relative benefit of surgery. CONCLUSION: Patients with higher educational attainment demonstrated significantly greater improvement with nonoperative treatment while educational attainment was not associated with surgical outcomes.

United States' trends and regional variations in lumbar spine surgery: 1992-2003.

STUDY DESIGN: Repeated cross-sectional analysis using national Medicare data from the Dartmouth Atlas Project. OBJECTIVE: To describe recent trends and geographic variation in population-based rates of lumbar fusion spine surgery. SUMMARY OF BACKGROUND DATA: Lumbar fusion rates have increased dramatically during the 1980s and even more so in the 1990s. The most rapid increase appeared to follow the approval of a new surgical implant device. METHODS: Medicare claims and enrollment data were used to calculate age, sex, and race-adjusted rates of lumbar laminectomy/discectomy and lumbar fusion for fee-for-service Medicare beneficiaries over age 65 in each of the 306 US Hospital Referral Regions between 1992 and 2003. RESULTS: Lumbar fusion rates have increased steadily since 1992 (0.3 per 1000 enrollees in 1992 to 1.1 per 1000 enrollees in 2003). Regional rates of lumbar discectomy, laminectomy, and fusion in 1992-1993 were highly correlated to rates of discectomy, laminectomy (R2 = 0.44), and fusion (R2 = 0.28) in 2002-2003. There was a nearly 8-fold variation in regional rates of lumbar discectomy and laminectomy in 2002 and 2003. In the case of lumbar fusion, there was nearly a 20-fold range in rates among Medicare enrollees in 2002 and 2003. This represents the largest coefficient of variation seen with any surgical procedure. Medicare spending for inpatient back surgery more than doubled over the decade. Spending for lumbar fusion increased more than 500%, from 75 million dollars to 482 million dollars. In 1992, lumbar fusion represented 14% of total spending for back surgery; by 2003, lumbar fusion accounted for 47% of spending. CONCLUSIONS: The rate of specific procedures within a region or "surgical signature" is remarkably stable over time. However, there has been a marked increase in rates of fusion, and a coincident shift and increase in cost. Rates of back surgery were not correlated with the per-capita supply of orthopedic and neurosurgeons.

Complications of cemented long-stem hip arthroplasties in metastatic bone disease.

UNLABELLED: It is controversial whether a cemented long-stem femoral arthroplasty is a safe surgical option for patients with meta-static bone disease of the hip. Cemented long stems increase the risk of embolic cascades and may cause subsequent cardiopulmonary complications, particularly in patients with metastatic disease. We retrospectively reviewed results of 29 long-stem cemented femoral arthroplasties in 27 patients in which surgical techniques that minimized intramedullary debris and canal pressurization were used. The surgical techniques minimized intraoperative cement-related emboli with aggressive medullary lavage, intraoperative canal suctioning during cementation, use of early low-viscosity polymethylmethacrylate, and slow, controlled insertion of the long-stem prosthesis. Cement-associated hypotension occurred in four (14%) patients, sympathomimetics were administered in nine (31%) patients, and a worsening mental status occurred postoperatively in one (3%) patient. There were no cement-associated desaturation events, cardiac arrests, or intraoperative deaths. No patients required prolonged intubation, and there were no postoperative cardiopulmonary events. Cemented long-stem femoral arthroplasty is a safe procedure for patients with high-risk metastatic disease. Increased awareness of cement-related cardiopulmonary pathophysiology, and modifying conventional surgical techniques can minimize cement-associated complications. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Case reports: fibrosarcoma metastatic to the sciatic nerve.

Fibrosarcoma that metastasizes to the central nervous system has been documented in the literature. However, we know of no recorded case of spread to a major peripheral nerve. We report a unique occurrence of fibrosarcoma with metastatic involvement of the sciatic nerve, and a review of the literature.