Tourniquet Use for Short Hand Surgery Procedures Done Under Local Anesthesia Without Epinephrine.

PURPOSE: Wide-awake local anesthesia no tourniquet (WALANT) is an increasingly popular surgical technique. However, owing to surgeon preference, patient factors, or hospital guidelines, it may not be feasible to inject patients with solutions containing epinephrine the recommended 25 minutes prior to incision. The purpose of this study was to assess pain and patient experience after short hand surgeries done under local anesthesia using a tourniquet rather than epinephrine for hemostasis. METHODS: Ninety-six consecutive patients undergoing short hand procedures using only local anesthesia and a tourniquet (LA-T) were assessed before and after surgery. A high arm pneumatic tourniquet was used in 73 patients and a forearm pneumatic tourniquet was used in 23. All patients received a local, unbuffered plain lidocaine injection. No patients received sedation. Pain related to local anesthesia, pneumatic tourniquet, and the procedure was assessed using a visual analog scale (VAS). Patient experience was assessed using a study-specific questionnaire based on previous WALANT studies. Tourniquet times were recorded. RESULTS: Mean pain related to anesthetic injection was rated 3.9 out of 10. Mean tourniquet related pain was 2.9 out of 10 for high arm pneumatic tourniquets and 2.3 out of 10 for forearm pneumatic tourniquets. Patients rated their experience with LA-T favorably and 95 of 96 patients (99%) reported that they would choose LA-T again for an equivalent procedure. Mean tourniquet time was 9.6 minutes and only 1 patient had a tourniquet inflated for more than 20 minutes. Tourniquet times less than 10 minutes were associated with less pain than tourniquet times greater than 10 minutes (P < .05); however, both groups reported the tourniquet to be on average less painful than the local anesthetic injection. CONCLUSION: Short wide-awake procedures using a tourniquet are feasible and well accepted. Local anesthetic injection was reported to be more painful than pneumatic tourniquet use. Tourniquets for short wide-awake procedures can be used in settings in which preprocedure epinephrine injections are logistically difficult or based on surgeon preference. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The outcome of patients with cultured pathogens at time of nonunion surgery.

The purpose of this study is to evaluate incidence, preoperative laboratory markers, and outcomes of patients who positively cultured pathogens (PCP) at time of surgery for long bone fracture nonunion. Two-hundred and eighty-eight patients were enrolled in a trauma study on long bone nonunion. Two-hundred and sixteen of those 288 patients were cultured at the time of fracture nonunion surgery. Laboratory data were collected prior to intervention and infectious laboratory markers ordered on patients suspected for infection. Patients were followed for one year. Wound complications, antibiotic use, healing, function, and re-admission for further surgery were assessed. Cultures returned positive on 59 patients (representing 20.5% of the 288 patient cohort or 27.3% of the 216 patients cultured in the operative suite). More PCP's (47.5%; 28 of 59) developed wound complications, with greater mean antibiotic duration and more frequent returns to the OR averaging 1.3 procedures per patient. Twelve-month follow-up was obtained on 249 of the 288 (86.5%) and PCPs reported globally worse function. Patients who PCP at the time of operative management for long bone nonunion was a prognostic indicator of poorer long-term functional outcomes.

Does a Learning Curve Exist for the Surgical Treatment of Proximal Humerus Fractures?

BACKGROUND: The complication rate of locked plating for proximal humerus fractures remains stubbornly high. The purpose of this study was to determine if a learning curve exists with the operative treatment of proximal humerus fractures. METHODS: We prospectively followed 161 consecutive patients with proximal humerus fractures treated by a single surgeon with locked plates from 2005 to 2016. Radiographic data, functional outcomes, and complications from the surgeon's first 81 patients were compared to the subsequent 80 patients. RESULTS: There was no statistical difference in the rates of complications (p = 0.29) or screw penetration (p = 0.19). There were no differences in DASH scores (p = 0.64 to 0.79) or tip-apex distance (p = 0.40). Head shaft angles were slightly smaller in patients treated earlier in the surgeon's career (p = 0.02). DISCUSSION: While surgeon experience is certainly a favorable quality, there does not appear to be a significant "learning curve" in the treatment of proximal humerus fractures.

Socioeconomic Status Negatively Affects HCAHPS Scores in Orthopedic Patients The Results of 15,789 Patients at a Single Institution.

BACKGROUND: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a nationally reported survey of patients' perspectives of hospital care that is used for hospital comparison and reimbursement. Although the survey attempts to correct for many factors that may affect scoring, socioeconomic factors are not considered in score weighting. The purpose of this study was to analyze the effect of socioeconomic status on HCAHPS scores. PATIENTS AND METHODS: HCAHPS scores from 15,789 patients were collected. All patients were seen at a single academic medical center from 2010 to 2014, thus controlling for quality of care. HCAHPS Top Box scores were then compared to patient socioeconomic status based on the median income of the ZIP Code for each patient. RESULTS: Median income was negatively associated with patients' overall hospital rating (p < 0.001) and willingness to recommend hospital (p < 0.001). When controlling for the current adjustment factors (age, education, primary language, health status, and emergency admission), living in a ZIP Code with a median household income above $100,000 per year was independently associated with worse Top Box Scores for the categories of "Overall Hospital Rating" (p = 0.042), "Recommend Hospital" (p = 0.007), "Pain Management" (0.048), "Communication about Medicine" (p = 0.007), "Cleanliness of Hospital Environment" (p = 0.002), and "Quietness of Hospital Environment" (p < 0.001). CONCLUSION: Socioeconomic status independently affects HCAHPS scores. Patients living in ZIP Codes with lower median incomes generally rated hospitals better than patients with higher incomes. Therefore, treatment of a disproportionate number of low income patients cannot be cited as a pretext for poor HCAHPS scores.

Management of Pisotriquetral Instability.

Pisotriquetral instability is an often-overlooked condition that can lead to ulnar-sided wrist pain and dysfunction. Various case series and biomechanical studies have been published regarding the diagnosis and treatment of this condition. We review current methods for examining, diagnosing, and treating pisotriquetral instability.

Arthroscopic Cortical Button Stabilization of Isolated Acute Neer Type II Fractures of the Distal Clavicle.

Neer type II distal clavicle fractures are inherently unstable. The purpose of this study was to review the outcome of Neer type II distal clavicle fractures arthroscopically treated using a suspensory cortical button technique. Between 2008 and 2012, a total of 17 Neer type IIB fractures were managed operatively at the authors' institution. Functional outcomes were assessed using the pain score, the Disabilities of the Arm, Shoulder and Hand score, the Penn Shoulder Score, and the American Shoulder and Elbow Surgeons score. Radiographic union was also assessed. At a mean of 1 year, the mean pain score was 0.9±1.1, the mean Disabilities of the Arm, Shoulder and Hand score was 10.9±11.1, the mean Penn Shoulder Score was 90.3±7.9, and the mean American Shoulder and Elbow Surgeons score was 90.1±10.1. Radiographic union occurred in 14 patients. An all-arthroscopic surgical fixation of Neer type II distal clavicle fractures using a suspensory cortical button technique can result in a predictable outcome with a low complication rate. [Orthopedics. 2017; 40(6):e1050-e1054.].

Nature's wrath-The effect of weather on pain following orthopaedic trauma.

BACKGROUND: Despite frequent complaints by orthopaedic trauma patients, to our knowledge there is no data regarding weather's effect on pain and function following acute and chronic fracture. The aim of our study was to investigate the influence of daily weather conditions on patient reported pain and functional status. METHODS: We retrospectively examined prospectively collected data from 2369 separate outpatient visits of patients recovering from operative management of acute tibial plateau fractures, acute distal radius fractures, and chronic fracture nonunions. Pain and functional status were assessed using a visual analogue scale (VAS) and the DASH and SMFA functional indexes. For each visit date, the mean temperature, difference between mean temperature and expected temperature, dew point, mean humidity, amount of rain, amount of snow, and barometric pressure were recorded. Statistical analysis was run to search for associations between weather data and patient reported pain and function. RESULTS: Low barometric pressure was associated with increased pain across all patient visits (p=0.007) and for patients at 1-year follow-up only (p=0.005). At 1-year follow-up, high temperature (p=0.021) and high humidity (p=0.030) were also associated with increased pain. No significant association was noted between weather data and patient reported functional status at any follow-up interval. CONCLUSIONS: Patient complaints of weather influencing pain after orthopaedic trauma are valid. While pain in the immediate postoperative period is most likely dominated by incisional and soft tissue injuries, as time progresses barometric pressure, temperature, and humidity impact patient pain levels. Affirming and counseling that pain may vary based on changing weather conditions can help manage patient expectations and improve satisfaction.

Does Risk for Malnutrition in Patients Presenting With Fractures Predict Lower Quality Measures?

INTRODUCTION: The purpose of this study was to determine if nutritional screening could be used as a predictor for the development of complications and hospital readmissions. METHODS: A variation of the Malnutrition Universal Screening Tool (MUST) score was collected for all inpatients with orthopaedic trauma on admission to our hospital from 2009 to 2011. We retrospectively compared each patient's MUST score with the subsequent development of infection, venous thromboembolism, respiratory failure, ulceration, or readmission. Finally, a chart review was performed to collect comorbidity data and evaluate Charlson comorbidity indexes to estimate the overall health of each patient with an available MUST. RESULTS: Of the 796 consecutive patients in our total cohort, 57.7% (n = 459) were of normal nutritional status and 42.3% (n = 337) exhibited at least 1 sign of malnutrition. In patients with normal nutrition, 2.8% developed at least one of the specified complications, and we observed a complication-to-patient ratio of 0.033. In patients with signs of malnutrition, 8.0% developed at least 1 complication with a complication-to-patient ratio of 0.101. This difference was significant (P = 0.001). Multivariate regression analysis demonstrated that each additional point in a patient's nutrition score corresponded to a 49.5% increase in the odds of developing a complication when controlling for other factors (odds ratio = 1.495, confidence interval = 1.120-1.997, P = 0.006). Charlson comorbidity indexes were not significantly associated with total complications when MUST scores used were a covariant. DISCUSSION AND CONCLUSIONS: Patients treated for fractures and dislocations with any sign of malnutrition according to the MUST score were more than twice as likely to acquire some combination of infection, venous thromboembolism, respiratory failure, or other reason for readmission than those of normal nutritional status. Increasing levels of malnourishment corresponded with increasing risk for developing complications, whereas these complications were not necessarily associated with higher comorbidity. An assessment of a fracture patient's nutritional status should be considered a factor in evaluating risks related to fracture care. The MUST score is a predictive tool. These data have important implications for hospitals whose fiscal reimbursement is dependent on the maintenance of defined quality measures. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Sexual Function Is Impaired After Common Orthopaedic Nonpelvic Trauma.

OBJECTIVES: The purpose of this study was to investigate the prevalence and longitudinal improvement of patient reported sexual dysfunction after 5 common nonpelvic orthopaedic traumatic conditions. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Academic Medical Center. PATIENTS/PARTICIPANTS: The functional status of 1324 patients with acute proximal humerus fractures (n = 104), acute distal radius fractures (n = 396), acute tibial plateau fractures (n = 118), acute ankle fractures (n = 434), and chronic long bone fracture nonunions (n = 272) was prospectively assessed at baseline, 3, 6, and 12 months of posttreatment. Patient reported sexual dysfunction, acquired from validated functional outcomes surveys, was compared with overall patient reported functional outcome for each follow-up visit. Men and women were analyzed separately. RESULTS: Sexual dysfunction at the 3-month follow-up was reported in 31% of proximal humerus fracture patients, 32% of distal radius fracture patients, 47% of tibial plateau patients, 11% of ankle fracture patients, and 42% of long bone nonunions. By 1-year follow-up, greater than 80% of patients with all fracture types reported mild or no sexual dysfunction. Women reported a significantly higher degree of sexual dysfunction than men at 6 months (P = 0.003) and 12 months of follow-up (P = 0.031). CONCLUSIONS: After treatment of acute and chronic orthopaedic trauma conditions, a considerable number of patients experience sexual dysfunction, with women reporting more dysfunction than men. The results of this study should allow orthopaedic trauma surgeons to counsel patients regarding expectations of sexual function after traumatic orthopaedic conditions. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Sleep disturbance after fracture is related to emotional well-being rather than functional result.

OBJECTIVES: The aim of this study was to investigate the rate, longitudinal improvement, and risk factors of sleep disturbance after 4 common orthopaedic traumatic conditions. METHODS: The functional status of 1095 patients was prospectively assessed using validated questionnaires for patients with acute proximal humerus (n = 111), distal radius (n = 440), tibial plateau (n = 109), and ankle fractures (n = 435). Patient reported sleep difficulty was compared with the overall functional and emotional status of each patient at 3, 6, and 12 months after treatment. RESULTS: Sleep difficulty at 3-month follow-up was reported in 41% of patients with proximal humerus fracture, 25% of patients with distal radius fracture, 36% of patients with tibial plateau, and 19% of patients with ankle fracture. By 12-month follow-up, less than 20% of patients with all fracture types reported sleep difficulty. At 12-month follow-up, the SF-36 Mental Health category for patients with distal radius fractures (P = 0.001) and the Short Musculoskeletal Function Assessment Emotional category for patients with tibial plateau fractures (P = 0.024) and ankle fractures (P ≤ 0.001) were independent predictors of poor sleep, whereas the respective functional status categories were not. CONCLUSIONS: At 12-month follow-up, poor sleep was independently associated with poor emotional status but not associated with poor functional status. The mental health status of patients with sleep difficulty in the latter stages of fracture healing should be carefully assessed to provide the highest level of care. The results of this study should allow orthopaedic trauma surgeons to counsel patients regarding expectations of difficulty sleeping after acute fractures. LEVEL OF EVIDENCE: Prognostic level II. See Instructions for authors for a complete description of levels of evidence.

Minimally displaced radial head/neck fractures (Mason type-I, OTA types 21A2.2 and 21B2.1): are we "over treating" our patients?

OBJECTIVE: The purpose of this study was to investigate the nonoperative treatment strategies for Mason-Johnson type-I radial head fractures. DESIGN AND SETTING: Retrospective review of every patient with a closed radial head/neck fracture who presented to our tertiary care specialty institution in the past 2 years. PATIENTS/PARTICIPANTS: A search of ICD-9 code 813.05, closed fracture of the radial head/neck, in our electronic record system yielded 82 consecutive patients. MAIN OUTCOME MEASUREMENTS: Complications and treatment interventions were recorded. Demographic, radiographic, and physical examination data were collected for all patients treated nonoperatively and analyzed for association with recommendation for continued follow-up and radiographic assessment. RESULTS: Fifty-four patients (68%) had 56 nondisplaced or minimally displaced (<2 mm) radial head or neck fractures without an additional injury to the affected limb. All patients were treated nonoperatively, and no patient in this cohort developed a complication or had any medical or surgical intervention other than physical therapy. No radiographic or physical examination measure was significantly associated with recommendation for the second outpatient follow-up, third outpatient follow-up, or with the number of additional radiographs ordered beyond the initial examination. An average of 4.4 (SD, 3.3) additional x-rays were taken of each affected elbow after initial outpatient presentation. CONCLUSIONS: Orthopaedic surgeons are likely over treating patients with Mason-Johnson type-I radial head fractures by recommending frequent radiographic follow-up without modifying treatment, leading to unnecessary patient visits, radiation exposure, and increased costs. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Older age does not affect healing time and functional outcomes after fracture nonunion surgery.

INTRODUCTION: Elderly patients are at risk of fracture nonunion, given the potential setting of osteopenia, poorer fracture biology, and comorbid medical conditions. Risk factors predicting fracture nonunion may compromise the success of fracture nonunion surgery. The purpose of this study was to investigate the effect of patient age on clinical and functional outcome following long bone fracture nonunion surgery. MATERIALS AND METHODS: A retrospective analysis of prospectively collected data identified 288 patients (aged 18-91) who were indicated for long bone nonunion surgery. Two-hundred and seventy-two patients satisfied study inclusion criteria and analyses were performed comparing elderly patients aged ≥65 years (n = 48) with patients <65 years (n = 224) for postoperative wound complications, Short Musculoskeletal Functional Assessment (SMFA) functional status, healing, and surgical revision. Regression analyses were performed to look for associations between age, smoking status, and history of previous nonunion surgery with healing and functional outcome. Twelve-month follow-up was obtained on 91.5% (249 of 272) of patients. RESULTS: Despite demographic differences in the aged population, including a predominance of medical comorbidities (P < .01) and osteopenia (P = .02), there was no statistical differences in the healing rate of elderly patients (95.8% vs 95.1%, P = .6) or time to union (6.2 ± 4.1 months vs. 7.2 ± 6.6, P = .3). Rates of postoperative wound complications and surgical revision did not statistically differ. Elderly patients reported similar levels of function up to 12 months after surgery. Regression analyses failed to show any significant association between age and final union or time to union. There was a strong positive association between smoking and history of previous nonunion surgery with time to union. Age was associated (positively) with 12-month SMFA activity score. CONCLUSIONS: Smoking and failure of previous surgical intervention were associated with nonunion surgery outcomes. Patient's age at the time of surgery was not associated with achieving union. Advanced age was generally not associated with poorer nonunion surgery outcomes.

Do elderly patients fare worse following operative treatment of distal femur fractures using modern techniques?

BACKGROUND: The purpose of this study was to compare the functional outcomes and quality of life of older and younger patients with similarly treated distal femur fractures. METHODS: We conducted an assessment of 57 patients who sustained distal femur fractures (Orthopaedic Trauma Association Type 33B, C) and underwent surgical treatment at our academic medical center. Patients were divided into 2 groups for analysis: an elderly cohort of patients aged 65 or older and a comparison cohort of patients younger than age of 65. A retrospective review of demographics, preoperative ambulatory status, radiographic data, and physical examination data was collected from the medical records. Follow-up functional data were collected via telephone at a mean of 2.5 years (range 6 months-8 years) using a Short Musculoskeletal Functional Assessment (SMFA). All patients underwent standard operative treatment of either nail or plate fixation. RESULTS: There was no statistical difference in gender, fracture type, surgical technique, surgeon, or institution where the surgery was performed. The percentage of patients with healed fractures at 6-months follow-up was not significantly different between the cohorts. The elderly cohort had slightly worse knee range of motion at 3, 6, and 12 months postoperatively but there was not a statistically significant difference between the groups. The SMFA Daily Activity, Functional, and Bother indices were significantly worse in the older cohort (P < .01, P = .01, P = .02, respectively). However, there was no significant difference in the SMFA Emotional or Mobility indices. CONCLUSION: Despite lower quality of life and functional scores, this study suggests that relatively good clinical outcomes can be achieved with surgical fixation of distal femoral fractures in the elderly patients. Age should not be used as a determinate in deciding against operative treatment of distal femur fractures in the elderly patients.

Open reduction internal fixation for proximal humerus fractures indications, techniques, and pitfalls.

Proximal humerus fractures account for approximately 5% of all fractures. It is estimated that due to our aging population, orthopaedic surgeons will see a three-fold increase in proximal humerus fractures over the next 30 years. Internal fixation with locked plating is the current mainstay of treatment for functionally active patients who desire minimal loss of function. A thorough understanding of the indications, techniques, and drawbacks of treatment with internal fixation is essential to achieve the highest quality of patient care.

Outcomes After Fixation of Proximal Humerus (OTA Type 11) Fractures in the Elderly Patients Using Modern Techniques.

PURPOSE: To investigate the effects of age on the clinical, functional, and radiographic outcomes of patients with proximal humerus fractures treated operatively with locking plates. METHODS: Between February 2003 and July 2012, all patients who sustained a proximal humerus fracture who presented to our institution were enrolled into a database. Patients were followed up at 1, 6, 12, 26, and 52 weeks postoperatively with physical examination and radiographs. Validated functional outcomes scores were collected at 6 and 12 months. Complications were recorded as they occurred. Statistical analysis was conducted to assess for functional, physical, or radiographic differences between patients age younger than 65 and patients age 65 or older. RESULTS: Of the 147 consecutive patients treated operatively for a proximal humerus fracture, 115 (78%) patients with an average follow-up of 16 months met the inclusion criteria for this study. The young cohort (patients < 65) included 70 patients with an average age of 53, whereas the elderly cohort (patients ≥ 65) included 45 patients with an average age of 73. The older cohort had significantly more women (P = .04), but there was no statistical difference in fracture type between the age groups. There were no differences in the radiographic measures of screw penetration, humeral head height, and neck-shaft angle between the age groups. There were no differences in physical examination scores between the age groups. There were no significant differences in functional outcomes or complication rates between the age groups. CONCLUSION: Treating proximal humerus fractures operatively with locked plates can overcome the challenges of poor bone quality that often occur with increasing age. Age should not play a significant role in the decision-making process for treating proximal humerus fractures that would otherwise be indicated for surgical fixation.