Incidence of Vitamin D Deficiency in Foot and Ankle Arthrodesis Nonunions.

Background Vitamin D has been found to be crucial in musculoskeletal health. The role of vitamin D levels in orthopedic patients has become a growing area of interest given its negative impact on fracture healing which can contribute to the development of nonunion following surgery. We sought to investigate the incidence of hypovitaminosis D in a cohort of patients who experienced a nonunion following a foot and ankle arthrodesis procedure. Methodology Patients who underwent a major elective foot and ankle arthrodesis procedure and developed a nonunion were given the opportunity to obtain serum vitamin D levels. All vitamin D levels were reported from percutaneous venous blood samples and compared to our institution's range of accepted normal values (25-80 ng/mL). Results A total of 13 patients who developed a nonunion agreed to have a vitamin D level obtained, and 11 of 13 patients had a low vitamin D level (average = 14.6 ng/mL, range = 9-24 ng/mL). Five patients underwent revision arthrodesis after normalization of vitamin D levels, and four out of five patients went on to successful union. Conclusions Hypovitaminosis D may be a modifiable risk factor for nonunion following a major foot and ankle arthrodesis procedure. Orthopedic surgeons should consider vitamin D screening and supplementation in patients undergoing elective arthrodesis procedures.

Orthopaedic Trauma Never Sleeps: Resource Allocation Even During a Non-trauma Crisis.

This study aimed to describe hospital resource utilization of an orthopaedic trauma service and the injury epidemiology during the 2019-2020 coronavirus pandemic to help plan future non-trauma crises. A retrospective chart review was performed on adult patients > 18 years of age who presented to our Level I Trauma Center for musculoskeletal trauma from March 30, 2020 to May 8, 2020 (stay-at-home order) and from March 30, 2019 to May 8, 2019 (comparison group). There were 182 patient encounters and 274 fractures in the 2020 stay-at-home period, and there were 210 patient encounters and 337 fractures in the 2019 control group. There was no statistical difference found comparing the proportion of patient encounters in the stay-at-home period to the control period (p > 0.05). The similar volume of consultations and surgeries justifies maintenance of standard resource allocation. (Journal of Surgical Orthopaedic Advances 32(2):102-106, 2023).

Surgeons' Recommendations for Return to Work After Carpal Tunnel Release.

BACKGROUND: Recommendations and expectations regarding return to work (RTW) after carpal tunnel release (CTR) are often inconsistent. The study aim was to describe preferences of American Society for Surgery of the Hand (ASSH) members for perioperative management of patients following CTR, emphasizing surgeon preference regarding RTW. METHODS: A survey was sent to all ASSH members with active e-mail addresses. The primary outcome was the recommended time frame for patients to RTW full duty. Secondarily, associated factors with RTW were evaluated. RESULTS: In total, 4109 e-mail surveys were sent with 632 responses (15%). The highest proportion of respondents perform >100 CTRs per year (43.2%), have been practicing for >20 years (38.1%), and perform CTR using standard, open approach at outpatient surgery centers. The primary surgeon made recommendations about RTW in 99.5% of cases. For desk-based duties, the median recommended RTW time was 3 days; for duties requiring repetitive, light lifting of <10 lbs, the median recommended RTW time was 10 days; and for heavy manual duties, the median recommended RTW time was 30 days after CTR, according to the respondents. The 3 factors considered most influential for RTW were type of work, employer support, and financial considerations. CONCLUSIONS: Our study demonstrates consistency among ASSH members in the perioperative management of CTR patients. The most important factors affecting RTW were type of work performed, employer support, and financial considerations. This study provides a meaningful foundation to manage expectations and guide patients, medical providers, and employers on the amount of time likely to be missed from work after CTR.

Impact of Timing of Targeted Muscle Reinnervation on Pain and Opioid Intake Following Major Limb Amputation.

BACKGROUND: Targeted muscle reinnervation (TMR) has been shown to play an important role in managing neuromas. However, the impact of the timing of TMR on pain visual analogue scale (VAS) scores or patient opioid use has not been thoroughly explored. We hypothesized that TMR performed acutely would lead to lower VAS scores and decreased opioid intake. METHODS: Prospectively collected data from an amputation registry at a single institution were utilized to identify patients who underwent TMR. Acute TMR was defined as TMR performed within 1 month of the major limb amputation. Primary outcomes included VAS pain scores and patient-reported opioid consumption. RESULTS: In all, 25 patients (26 limbs) were identified in the acute group, and 18 patients (18 limbs) were identified in the delayed group. At intermediate follow-up (between 4 and 8 months postoperatively) and at final follow-up, the average pain VAS score in the delayed TMR group was significantly higher than that in the acute group (5.2 vs. 1.9 at intermediate P = .01 and 6.2 vs. 1.9 at final P = .002). In all, 84% of the amputees overall were not consuming opioid medications at the time of final follow-up (79% acute, 88% delayed, P = .72). There were no statistically significant differences in opioid consumption between the acute and delayed group at intermediate follow-up (P = .35) or at final follow-up (P = .68). CONCLUSIONS: TMR is an effective procedure to reduce pain following major limb amputation. Patients with TMR performed acutely had significantly lower VAS pain scores at both intermediate and final follow-up than patients with TMR performed in a delayed setting. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

The Prevalence of Depression and PTSD in Adults With Surgically Managed Traumatic Upper-Extremity Amputations.

BACKGROUND: Upper-extremity limb loss has been associated with serious psychological sequelae. Despite advancements in surgical procedures and prostheses for upper limb amputees, it is critical to recognize the psychosocial component of these patients' care. Although the role of psychological factors in outcomes is increasingly acknowledged, little is known about the prevalence of depression and post-traumatic stress disorder (PTSD) in the civilian population after traumatic upper-extremity amputation. METHODS: In this retrospective observational single-center study, adult patients evaluated for traumatic upper limb amputations from 2016 to 2019 completed the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, Visual Analogue Scale, the Center for Epidemiologic Studies Depression Scale, and the Primary Care PTSD Screen during visits. All data underwent descriptive statistical analysis. RESULTS: Thirty-nine adult patients treated for upper-extremity traumatic amputation completed patient-reported outcomes (PROs) questionnaires. The median final follow-up time for our cohort was 17 months from amputation. Twenty patients (51%) screened positive for depression and 27 (69%) for PTSD during follow-up. The median time from amputation to first positive screening was 6.5 months for depression and 10 months for PTSD. The physical component score of Veterans RAND 12-Item Health Survey (VR-12) was significantly worse for patients with depression. The Median DASH and mental component score of VR-12 were significantly worse for patients with PTSD. CONCLUSION: Upper-extremity limb loss has a significant impact on mental health, which in turn affects PROs. The high prevalence of depression and PTSD in traumatic upper-extremity amputees underscores the necessity for screening and multidisciplinary treatment.

Age and socioeconomic status affect access to telemedicine at an urban level 1 trauma center.

OBJECTIVES: Despite clinical and economic advantages, routine utilization of telemedicine remains uncommon. The purpose of this study was to examine potential disparities in access and utilization of telehealth services during the rapid transition to virtual clinic during the coronavirus pandemic. DESIGN: Retrospective chart review. SETTING: Outpatient visits (in-person, telephone, virtual-Doxy.me) over a 7-week period at a Level I Trauma Center orthopaedic clinic. INTERVENTION: Virtual visits utilizing the Doxy.me platform. MAIN OUTCOME MEASURES: Accessing at least 1 virtual visit ("Virtual") or having telephone or in-person visits only ("No virtual"). METHODS: All outpatient visits (in-person, telephone, virtual) during a 7-week period were tracked. At the end of the 7-week period, the electronic medical record was queried for each of the 641 patients who had a visit during this period for the following variables: gender, ethnicity, race, age, payer source, home zip code. Data were analyzed for both the total number of visits (n = 785) and the total number of unique patients (n = 641). Patients were identified as accessing at least 1 virtual visit ("Virtual") or having telephone or in-person visits only ("No virtual"). RESULTS: Weekly totals demonstrated a rapid increase from 0 to greater than 50% virtual visits by the third week of quarantine with sustained high rates of virtual visits throughout the study period. Hispanic and Black/African American patients were able to access virtual care at similar rates to White/Caucasian patients. Patients of ages 65 to 74 and 75+ accessed virtual care at lower rates than patients ≤64 (P = .003). No difference was found in rates of virtual care between payer sources. A statistically significant difference was found between patients from different zip codes (P = .028). CONCLUSION: A rapid transition to virtual clinic can be performed at a level 1 trauma center, and high rates of virtual visits can be maintained. However, disparities in access exist and need to be addressed.

Sternoclavicular Septic Arthritis Caused by Cutibacterium acnes in a Previously Healthy 13-Year-Old Male: A Case Report.

CASE: A 13-year-old boy presented with 3 weeks of atraumatic left-sided sternoclavicular (SC) joint pain, swelling, and decreased range of motion. After imaging and laboratory workup, he underwent operative irrigation, debridement, and antibiotic therapy with complete resolution of his symptoms. Surgical cultures were consistent with SC septic arthritis. CONCLUSION: The management of septic arthritis in pediatric patients remains varied. Here, we present the only report of SC septic arthritis due to Cutibacterium acnes in a healthy pediatric patient. Given the similar clinical findings of pain and swelling to affected bones and joints, differentiating SC septic arthritis from other conditions within the clinical spectrum of chronic nonbacterial osteomyelitis remains challenging. Clinicians should maintain a high index of suspicion when patients present with pain and swelling over the SC joint.

Is postoperative glucose variability associated with adverse outcomes following shoulder arthroplasty?

BACKGROUND: Postoperative infection after shoulder arthroplasty is a devastating complication. Multiple patient risk factors have been associated with postoperative infection, including increased body mass index and diabetes. Although the association between preoperative glucose control and infection has been established, little is known about the effect of perioperative glycemic control on outcomes following shoulder arthroplasty. The purpose of this study was to investigate the association between postoperative glycemic variability and short-term complications after total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA). METHODS: A retrospective study was performed at a large, single-specialty center from January 2015 to December 2018. Patients were included if they underwent primary TSA or RTSA with a minimum of 90 days' follow-up and had a minimum of 1 serum glucose value obtained per day of the hospital stay or had ≥3 measurements obtained during the hospital admission period. The primary outcome variable was postoperative infection per accepted definitions of surgical-site infection or periprosthetic joint infection. Secondary outcome variables included stiffness, periprosthetic fracture, periprosthetic dislocation, and reoperation. RESULTS: In total, 1074 TSAs or RTSAs (in 1032 patients) met the eligibility criteria. The mean patient age was 69.9 ± 8.4 years, and 40.3% of patients had a preoperative diagnosis of diabetes mellitus. Of the patients, 670 (62%) had a calculable coefficient of variation. A younger patient age (median, 65 years [interquartile range (IQR), 13.5 years] vs. 71 years [IQR, 11.0 years]; P = .02) and a preoperative diagnosis of diabetes mellitus (P = .01) showed statistically significant associations with postoperative infection. The first in-hospital glucose measurement beyond the reference tertile of 70-140 mg/dL showed a statistically significant association with postoperative infection, with a median of 128.0 mg/dL (IQR, 43 mg/dL) vs. 167.5 mg/dL (IQR, 37.0 mg/dL; P = .01), whereas the second and third glucose measurements showed no association with postoperative infection. We found no associations between the coefficient of variation and reoperations or complications including surgical-site infection, periprosthetic joint infection, death, postoperative infection, periprosthetic fracture, or stiffness. CONCLUSION: We found an association between a preoperative diagnosis of diabetes mellitus and postoperative infection following shoulder arthroplasty. We also found that an elevated first glucose measurement is associated with the development of postoperative infection. In-hospital glycemic control, as well as preoperative glycemic control and optimization, may be beneficial for reducing postoperative infections following shoulder arthroplasty.

Factors Associated with Patient-Initiated Telephone Calls After Spine Surgery.

BACKGROUND: Telephone calls play a significant role in the follow-up care of postoperative patients. However, further data are needed to identify the determinants of patient-initiated telephone calls after surgery because these factors may also highlight potential areas of improvement in patient satisfaction and during the hospital discharge process. Therefore, the goal of this study is to determine the number of postoperative patient telephone calls within 14 days after surgery and establish the factors associated with patient-initiated calls and reasons for calling. METHODS: A retrospective chart review of all spine surgeries performed at our institution from January 1, 2014, through January 2, 2015, was completed. Patient demographics, perioperative and operative variables, and telephone encounter data were collected. The primary outcome was a patient-initiated telephone call within 14 days after surgery. Secondary outcomes included reporting and analyzing the reasons for patient phone calls, analyzing which procedures were associated with the most telephone calls, and conducting a multivariate analysis to determine independent risk factors for patient calls. RESULTS: Of the 488 patients who underwent surgical procedures, 222 patients (45.7%) made a telephone call within 14 days after surgery. There were 61 patients (27.48%) who called regarding pain control and 54 patients (23.87%) who called with bathing/dressing/wound questions. Other common categories include the following: other (21.17%), medication problems (15.77%), weight-bearing status/activity restrictions (5.14%), fever (3.15%), bowel management (1.35%), work notes (1.35%), and anticoagulation questions (0.45%). Factors associated with a telephone call within 14 days postoperatively included increased body mass index (P = 0.031), lower number of comorbidities (P = 0.043), telephone call within 2 weeks prior to surgery (P = 0.027), American Society of Anesthesiologists (ASA) score of 2 (P = 0.036), discharge disposition to home (P = 0.003), and elective procedure (P = 0.006). Multivariate analysis revealed that fusion procedures (odds ratio [OR], 2.16; 95% confidence interval [CI], 1.05-4.45; P = 0.037) and ASA score of 3-4 (OR, 0.55; 95% CI, 0.31-0.96, P = 0.036) were independently associated with increased and decreased propensity, respectively, toward making a phone call within 2 weeks. CONCLUSIONS: Postoperative patient-initiated telephone calls within 14 days after spine surgery are very common, occurring after almost one half of all procedures. By evaluating such determinants, patient care can be improved by better addressing patient needs during and prior to discharge to prevent potential unnecessary postoperative calls and improve patient satisfaction.