Acute Complications in Total Wrist Arthroplasty: A National Surgical Quality Improvement Program Review.

Background The study sought to assess the patient-based variables, surgical risk factors, and postoperative conditions associated with readmission after total wrist arthroplasty (TWA). Materials and Methods All patients undergoing TWA were identified from the National Surgical Quality Improvement Program dataset from 2005 to 2016. Patient demographics, medical comorbidities, surgical characteristics, and outcomes were examined to isolate predictors for readmission within 30 days postoperatively. Results A total of 57 patients were identified to have undergone TWA. The average patients were 62.3 (13.8) years old, female (57.7%), and most were treated in the outpatient setting (67.3%). Comorbid conditions included smoking (17.3%), diabetes (15.4%), and chronic steroid therapy (15.4%). No complications were identified in the 30-day postoperative period. There was a trend for increasing utilization of TWA over the years included. Conclusion TWA is a safe procedure with low complication rates in the acute postoperative period. Increasing utilization is likely a result of improved outcomes and cost-effectiveness of TWA. Level of Evidence This is a Level II, prognostic study.

Comparing clinician use of three ankle fracture classifications.

PURPOSE: This study evaluated the accuracy and interrater reliability of US Army physician assistants (PAs) in identifying ankle fracture patterns using existing classification schemes. METHODS: Twenty-eight PAs reviewed criteria for stability, Danis-Weber, and Lauge-Hansen ankle fracture classification systems. Participants reviewed 45 ankle radiographs and independently rated each radiograph using these classification schemes. RESULTS: Participants were able to successfully identify ankle fracture stability in 82.1% of cases (95% CI, 77.6, 86.6) with established criteria. Using the Danis-Weber classification, accurate classification was achieved in 77.8% of cases (95% CI, 72.8, 82.7). The Lauge-Hansen classification system was least reliable, with accuracy of 54.5% (95% CI, 46, 63). CONCLUSION: Referring PAs can reliably discern unstable ankle fractures in more than 80% of cases. Lauge-Hansen classification was significantly less accurate than the Danis-Weber system or criteria for stability. Good communication between orthopedic surgeons and PAs and an emphasis on PA orthopedic education can improve patient care.

Anteromedializing Tibial Tubercle Osteotomy for Patellofemoral Instability: Occupational and Functional Outcomes in U.S. Military Service Members.

This article sought to determine rates for return to work, pain relief, and recurrent patellofemoral instability for military service members undergoing tibial tubercle osteotomy (TTO) for persistent lateral patellar subluxation or dislocation. Patient demographic and surgical variables were isolated from the medical records of active duty service members with at least 2 years of postoperative follow-up, and correlated with return to work, pain improvement, recurrent patellofemoral instability, and perioperative complications. There were 51 service members (58 primary TTOs) with an average follow-up of 3.3 (range, 2.0-6.7) years. Service members had an average of 2.8 (1-12) instability events preoperatively. At a minimum of 2 years postoperatively, 41 (80%) military service members returned to full active duty service. Among the 58 TTOs, there was a 46% improvement in the patient-reported visual analog score from 4.1 to 2.2 (p < 0001). The postoperative recurrent instability rates were patellar dislocation (5.1%) and patellar subluxation (15.5%). Concomitant proximal realignment was performed in 48% of cases, which did not affect return to service, postoperative patellar instability events, or pain improvement (p > 0.05). The overall complication rate was 10%. Postoperative tibial fractures occurred in 6.9% of TTOs. At short- to mid-term follow-up, 80% of service members undergoing TTO for patellofemoral instability returned to military duty with significant improvement in pain scores and a moderate perioperative complication and postoperative instability rate. This study is a level IV therapeutic case series.

Epidemiology of Posterior Glenohumeral Instability in a Young Athletic Population.

BACKGROUND: While several studies have observed the incidence of posterior glenohumeral instability in selected populations, there are no data from large-scale population-based studies with corresponding athletic exposure data to calculate incidence rates (IRs) and associated risk factors. PURPOSE: To determine risk factors for posterior glenohumeral instability within the physically active population at the United States Military Academy. STUDY DESIGN: Descriptive epidemiology study. METHODS: A longitudinal cohort study was performed over a 6-year period from 2006 to 2012 at the United States Military Academy utilizing the Cadet Illness and Injury Tracking System. Exposure data were collected from daily attendance data documented for every practice and game at the intramural, club, or varsity sport level. The primary outcomes calculated were the IRs of posterior glenohumeral joint instability per 1000 person-years at risk and per 1000 athlete-exposures. IR ratios and confidence intervals were calculated between male and female cadets and between intercollegiate and intramural athletes. RESULTS: Between 2006 and 2012, there were 1348 shoulder injuries in total, with 633 instability events. During the study period, 113 posterior shoulder instability injuries (17.9% of instability events) and 26,408 person-years at risk were documented, for an overall IR of 4.28 per 1000 person-years. The overall IR of posterior instability was 0.08 per 1000 athlete exposures. In male athletes, 105 sustained a posterior shoulder instability event, for an IR of 4.67 per 1000 person-years. Female athletes were less likely to sustain a posterior instability event, accounting for only 8 events, for an IR of 2.04 per 1000 person-years. A total of 6670 athletes were at risk for posterior shoulder instability injury during the study period. A total of 55 injuries were documented, for an IR of 8.25 per 1000 person-years. Intercollegiate wrestlers had the highest IR: 34.15 per 1000 person-years. The sport with the highest injury rate among intramural sports was football, at 2.79 per 1000 person-years. Three athletes had a history of a posterior shoulder dislocation, while no significant difference was found for subluxation versus pain as the presenting symptom. Of the 113 posterior shoulder instability injuries, 77.0% required surgical stabilization. All injuries associated with weight lifting required surgical stabilization. CONCLUSION: Among athletes, intercollegiate athletes are at an increased risk of posterior glenohumeral instability when compared with intramural athletes. Intercollegiate athletes and weight lifters demonstrate a high likelihood of requiring surgical treatment as compared with intramural athletes.

Medialized Clavicular Bone Tunnel Position Predicts Failure After Anatomic Coracoclavicular Ligament Reconstruction in Young, Active Male Patients.

BACKGROUND: Recent radiographic data have suggested that medialized conoid tunnel placement greater than 25% of absolute clavicular length is correlated with early failure after anatomic coracoclavicular ligament reconstructions. A comparison with a larger active duty military cohort of clinical and radiographic outcomes can serve as a basis for standardizing surgical technique. PURPOSE: To establish the ideal radiographic tunnel position for anatomic coracoclavicular ligament reconstruction and to elucidate variables associated with early loss of reduction and ability to return to active-duty military service. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review of the military's electronic medical record between the years 2000 and 2013 was performed. All anatomic coracoclavicular reconstructions at a single institution were included for analysis, and nonanatomic or revision reconstructions were excluded. Radiographic failure was defined as 6 mm of superior clavicle displacement on immediate postoperative films. RESULTS: A cohort of 38 patients underwent 39 anatomic coracoclavicular reconstructions. Average follow-up time was 26 months (range, 1.2-92 months). A total of 20 radiographic failures were identified, with an average conoid tunnel ratio of 0.27. When conoid tunnel ratios were compared with a reference ratio of 0.20 to 0.25, increased risk of failure was statistically significant with lateralization greater than 0.20 (P = .018; odds ratio [OR] = 40 [95% CI, 1.05-999.06]) or with medialization of 0.251 to 0.30 (P = .002; OR = 39 [95% CI, 1.58-944.36]) or greater than 0.30 (P = .029; OR = 21 [95% CI, 0.77-562.15]). Medialization of the trapezoid position greater than 0.16 (vs a range of 0.13-0.16) was also found to be significant for failure (P < .023; OR = 8 [95% CI, 1.33-48.18]). However, these significant findings did not correlate with symptoms or ability to return to duty (P > .05). CONCLUSION: The optimal technique for treating acromioclavicular separations has yet to be determined. Recently, anatomic coracoclavicular reconstruction has demonstrated biomechanical superiority to previously described methods. The findings of optimal tunnel positioning in anatomic reconstructions from this large active-duty military cohort can assist preoperative planning to reduce failure rates when treating these difficult injuries.