Vertical shear pelvic ring injuries: do transsacral screws prevent fixation failure?

OBJECTIVES: To determine the frequency of fixation failure after transsacral-transiliac (TS) screw fixation of vertical shear (VS) pelvic ring injuries (OTA/AO 61C1) and to describe the mechanism of failure of TS screws. DESIGN: Retrospective cohort study. SETTING: Level 1 academic trauma center. PATIENTS/PARTICIPANTS: Twenty skeletally mature patients with unilateral, displaced, unequivocal VS injuries were identified between May 1, 2009 and April 31, 2016. Mean age was 31 years and mean follow-up was 14 months. Twelve had sacroiliac dislocations (61C1.2) and eight had vertical sacral fractures (61C1.3). INTERVENTION: Operative treatment with at least one TS screw. MAIN OUTCOME MEASUREMENTS: Radiographic failure, defined as a change of >1 cm of combined displacement of the posterior pelvis compared with the intraoperative position on inlet and outlet radiographs. RESULTS: Radiographic failure occurred in 4 of 8 (50%) vertical sacral fractures. Posterior fixation was comprised of a single TS screw in 3 of these 4 failures. The dominant mechanism of screw failure was bending. All of these failures occurred early in the postoperative period. No fixation failures occurred among the sacroiliac dislocations. There were no deep infections or nonunions. CONCLUSIONS: This is the first study to describe the mechanism of failure of TS screws in a clinical setting after VS pelvic injuries. We caution surgeons from relying on single TS screw fixation for vertically unstable sacral fractures. Close radiographic monitoring in the first few weeks after surgery is advised. LEVEL OF EVIDENCE: Level IV.

Depression and Non-modifiable Patient Factors Associated with Patient Satisfaction in an Academic Orthopaedic Outpatient Clinic: Is it More Than a Provider Issue?

BACKGROUND: Patient satisfaction surveys play an increasingly important role in United States healthcare policy and serve as a marker of provided physician services. In attempts to improve the patient's clinical experience, focus is often placed on components of the healthcare system such as provider interaction and other experiential factors. Patient factors are often written off as "non-modifiable"; however, by identifying and understanding these risk factors for dissatisfaction, another area for improvement and intervention becomes available. QUESTIONS/PURPOSES: (1) Do patients in the orthopaedic clinic with a preexisting diagnosis of depression report lower satisfaction scores than those without a preexisting diagnosis of depression? (2) What other non-modifiable patient factors influence patient-reported satisfaction? METHODS: We reviewed Press Ganey Survey scores, which assess patient experiential satisfaction with a single clinical encounter, from 3044 clinic visits (2527 patients) in adult reconstructive, sports, and general orthopaedic clinics at a single academic medical center between November 2010 and May 2017, during which time approximately 19,000 encounters occurred. Multiple patient factors including patient age, gender, race, health insurance status, number of previous clinic visits with their physician, BMI, and a diagnosis of depression were recorded. Patient satisfaction was operationalized as a binary outcome as satisfied or less satisfied, and a multiple logistic regression analysis was used to estimate the odds of being satisfied. RESULTS: After adjusting for all other covariates in the model, we found that patients with a diagnosis of depression were less likely to be satisfied than patients without this diagnosis (odds ratio 0.749 [95% confidence interval, 0.600-0.940]; p = 0.01). Medicare-insured patients were more likely to be satisfied than non-Medicare patients (OR 1.257 [95% CI, 1.020-1.549]; p = 0.03), patients in the sports medicine clinic were more likely to be satisfied than those seen in the general orthopaedic clinic (OR 1.397 [95% CI, 1.096-1.775]; p = 0.007), and established patients were more likely to be satisfied than new patients (OR 0.763 [95% CI, 0.646-0.902]; p = 0.002). CONCLUSIONS: Given the association of depression with lower satisfaction with a single visit at the orthopaedic clinic, providers should screen for depression and address the issue during the outpatient encounter. The impact of such comprehensive care or subsequent treatment of depression on improving patient-reported satisfaction offers areas of future study. LEVEL OF EVIDENCE: Level III, therapeutic study.

Diagnostic Accuracy of the Scapular Retraction Test in Assessing the Status of the Rotator Cuff.

BACKGROUND: Currently, clinical physical examination maneuvers alone provide variable reliability in diagnosing full-thickness rotator cuff tears (RCTs). PURPOSE: To assess the diagnostic accuracy of the scapular retraction test (SRT) to predict full-thickness RCTs. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: A total of 331 patients were prospectively evaluated in this cohort study. SRT was performed to assess the status of the rotator cuff. A positive SRT indicates an intact rotator cuff, and a negative SRT indicates a full-thickness RCT. Magnetic resonance imaging (MRI) was used as the gold standard. The examiner was blinded to the results until completing the physical examination. Statistical analysis was performed to assess the sensitivity, specificity, accuracy, positive and negative predictive values, and positive and negative likelihood ratios of the SRT. RESULTS: The prevalence of full-thickness RCTs diagnosed on MRI was 54.4% (180 of 331). Among the 180 patients with an MRI-confirmed full-thickness RCT, the SRT was negative for 147. Of 150 patients with an intact rotator cuff by MRI, 122 had a positive SRT. In diagnosing full-thickness RCTs, the SRT had a sensitivity of 81.7% (95% CI, 77.2%-85.4%), specificity of 80.8% (95% CI, 75.5%-85.3%), and accuracy 81.3%. The positive predictive value was 83.5% (95% CI, 78.9%-87.4%); the negative predictive value, 78.7% (95% CI, 73.5%-83.1%); the positive likelihood ratio, 4.3 (95% CI, 3.1-5.8); the negative likelihood ratio, 0.23 (95% CI, 0.17-0.30); and the diagnostic odds ratio, 18.7 (95% CI, 10.4-34.0). CONCLUSION: The results of this diagnostic study indicate that the SRT can accurately be used to clinically assess the status of the rotator cuff. This physical examination maneuver was found to be accurate, sensitive, and specific in diagnosing full-thickness RCTs. Additionally, our results indicate that it is equally as accurate to predict an intact rotator cuff tendon. Providing an accurate, reliable, and reproducible physical examination test will allow clinicians to diagnosis the integrity of the rotator cuff and will help guide treatment recommendations.

Foot Deformities in Hajdu-Cheney Syndrome: A Rare Case Report and Review of the Literature.

INTRODUCTION: Hajdu-Cheney syndrome (HCS) is a rare autosomal dominant disease characterized by acroosteolysis, wormian skull bones with persistent skull sutures, premature loss of teeth, micrognathia, short stature, hypermobility of the joints, neurologic manifestations such as basilar invagination with subsequent paresthesia, hearing loss, and speech alterations, and osteoporosis with tendency to pathologic fractures of long bones and vertebrae as well as painful hands and feet. Very few cases have been earlier reported in the literature. CASE REPORT: We report a case of a 50-year-old female with bilateral foot deformities as a manifestation of the rare genetic disorder HCS. Surgical management of the left foot consisted of Morton's neuroma excision and Weil osteotomy with proximal interphalangeal joint resection and Kirschner wire fixation of the second and third metatarsophalangeal (MTP) joints. Recurrent subluxation of the left second MTP joint was observed at 5-week follow-up. The right foot was treated similarly 7weeks after the initial operation. The post-operative course of the right foot was complicated by bone resorption and nonunion of the second and third metatarsal Weil osteotomies. CONCLUSION: Management of complex foot deformities associated with HCS can be challenging and have not previously been described in the literature. Underlying bone and connective tissue abnormalities intrinsic to the syndrome may increase the risk of recurrence after surgical correction. Consideration should be given to such post-operative complications when treating foot deformities in a patient with HCS.

Overuse Injuries of the Pediatric and Adolescent Throwing Athlete.

In the hypercompetitive environment of year round youth baseball, arm pain is commonplace. Although much research has been done about injuries in the overhead throwing athlete, the emphasis has been on the more elite levels, where athletes have reached full development. The anatomy of the skeletally immature athlete, including open physeal plates and increased tissue laxity, raises unique issues in the presentation and treatment of repetitive throwing injuries of the elbow and shoulder. With a focus on "little leaguers," this discussion evaluates five of the most common elbow and shoulder injuries-Little Leaguer's elbow, ulnar collateral ligament sprain or tear, osteochondritis dissecans/Panner's disease, Little Leaguer's shoulder, and multidirectional instability. In the developmentally distinct pediatric athlete, pathogenesis, diagnosis, and treatment may differ from that established for adults. Offering early diagnosis and treatment appropriate to a child's level of development will enable youth to not only continue to play sports but to also maintain full functionality as active adults.