Entrapment Neuropathies of the Shoulder.

Entrapment neuropathies of the shoulder most commonly involve the suprascapular or axillary nerves, and they primarily affect the younger, athletic patient population. The extremes of shoulder mobility required for competitive overhead athletes, particularly in the position of abduction and external rotation, place this cohort at particular risk. Anatomically, the suprascapular nerve is most prone to entrapment at the level of the suprascapular or spinoglenoid notch; the axillary nerve is most prone to entrapment as it traverses the confines of the quadrilateral space.Radiographs should be ordered as a primary imaging study to evaluate for obvious pathology occurring along the course of the nerves or for pathology predisposing the patient to nerve injury. Magnetic resonance imaging plays a role in not only identifying any mass-compressing lesion along the course of the nerve, but also in identifying muscle signal changes typical for denervation and/or fatty atrophy in the distribution of the involved nerve.

Predictive value of magnetic resonance imaging in outcomes of nonsurgical treatment of lateral epicondylitis.

BACKGROUND: The diagnosis of lateral epicondylitis is typically made on the basis of clinical history and examination. However, magnetic resonance imaging (MRI) is often used to supplement evaluation of the patient with a painful elbow and can identify extensor carpi radialis brevis (ECRB) tendon tears. The objective of this study was to determine if ECRB tear size on MRI could be used as a prognostic indicator for patients with recalcitrant lateral epicondylitis and partial ECRB tears. METHODS: Forty-one patients with recalcitrant lateral epicondylitis and a partial ECRB tear on MRI were identified (22 men and 19 women; age: 49 ± 8 years; height: 165 ± 36 mm; weight: 73 ± 18 kg). Patients were divided into two groups based on whether they underwent surgery or not. Nonsurgical treatment was evaluated by the Disabilities of the Arm, Shoulder, and Hand questionnaire, and surgery was considered a failure of nonsurgical treatment. Nonsurgical treatment was variable and included a mixture of physical therapy, rest, injection therapy, and splinting. RESULTS: Of the 41 patients, 5 patients opted for immediate surgery and 36 patients were treated nonsurgically. Of those 36 patients, 11 patients had symptom relief, 19 patients had subsequent surgery, and 6 patients chose not to have surgery despite continued symptoms. Tear size on MRI did not differ significantly between the patients who had symptom relief with nonsurgical treatment and the other patients (7.7 ± 4.3 mm vs. 9.7 ± 2.5 mm, P = .07). DISCUSSION: Only 11 of 41 patients (27%) with recalcitrant lateral epicondylitis and ECRB tear had symptom relief with nonsurgical treatment. However, ECRB tendon defect size on MRI did not predict success or failure of nonsurgical treatment.

Higher Hospital Costs Do Not Result in Lower Readmission Rates Following Total Joint Arthroplasty.

INTRODUCTION: Hip and knee arthroplasty are high volume, clinically successful, but costly orthopedic surgical procedures. There is significant variation in volume, outcomes, and cost at various hospitals. METHODS: Using the Statewide Planning and Research Cooperative System (SPARCS) database to determine readmission rates and the New York State Department of Health (NYSDoH) hospital cost transparency database to obtain costs, we reviewed this data for hip and knee replacements to determine if there was a relationship between volume of procedures performed and cost or readmission rates. RESULTS: The readmission rate increased with increasing cost for facilities performing total knee arthroplasty (p = 0.02). Readmission rate did not change significantly with volume of procedures performed. Similarly, the readmission rate increased with increasing cost for facilities performing total hip arthroplasty but did not change significantly with respect to volume (p < 0.01). CONCLUSION: Spending more money to perform total hip and knee arthroplasty in New York State does not ensure lower readmission rates. Readmission rates vary independent of volume of procedures performed. Total hip and knee arthroplasty are two of the most successful and commonly performed orthopedic surgical procedures. Outcome investigations demonstrate reliable pain relief and consistently good or excellent functional outcomes.1-3 However, there is significant variability in both cost and quality of these procedures, resulting in a wide difference in their value. Porter defines value as outcomes divided by cost.4 One metric that reflects both the cost as well as the quality of care is the unplanned readmission rate. Whether readmission occurs as a result of thromboembolic disease, surgical site infection, or cardiopulmonary complications in the postoperative period, it represents a deterioration of outcome at a significant cost burden to the treating institution. The New York State Department of Health's Statewide Planning and Research Cooperative System (SPARCS) database was established in 1979. Licensed hospitals in the state are mandated to report data on all discharges, including inpatient and outpatient surgery procedures and emergency department admissions.5 On December 5, 2013, the New York State Department of Health made hospital-specific average costs for over 300 diagnosis-related groups (DRGs) available publicly on its website.6 Among the selected DRGs were total hip (301) and total knee (302) arthroplasty. The purpose of this study was to determine if there was a relationship between quality (as indicated by readmission rate) and either volume of procedures performed or cost of performing those procedures.

Meniscal Root Tears Evaluation and Management.

The management of meniscal root injuries has changed as biomechanical studies have demonstrated the importance of meniscal integrity in load distribution across the knee joint. Meniscal injury causes altered joint mechanics, which is postulated to be related to the onset of arthrosis. Arthroscopic meniscal root repair has been shown to restore more normal joint mechanics and is considered a treatment option in the appropriately indicated patient. Short- and midterm clinical results of meniscal root repair are promising, but long-term results are yet to be established. Herein, we review meniscal root injuries and repairs with respect to their anatomy, biomechanics, clinical diagnosis, treatment indications, operative techniques, potential complications, postoperative management, and clinical outcomes.

Evaluation, Treatment, and Outcomes of Meniscal Root Tears: A Critical Analysis Review.

Meniscal root tears or avulsions compromise the biomechanical function of the menisci to a greater extent than simple meniscal tears do. As such, if left untreated, root injuries render the menisci incapable of properly distributing axial load and resisting rotation and translation. The clinical diagnosis of meniscal root abnormalities may be difficult as the signs and symptoms typically associated with meniscal body injuries, such as mechanical locking and catching, may not be present in patients with root injury and there may not be a history of an acute traumatic event. Treating practitioners need to have a high suspicion for meniscal root abnormalities in patients presenting with joint line tenderness and pain with deep flexion activities. Magnetic resonance imaging (MRI) signs indicative of meniscal root abnormality include a radial tear of the meniscal root (on axial imaging), a vertical linear defect in the meniscal root (truncation sign on coronal imaging), meniscal extrusion >3 mm outside the peripheral margin of the joint (on coronal imaging), and increased signal within the meniscal root (ghost sign on sagittal sequences). Two main approaches for meniscal root repair have evolved. One approach involves the use of a transtibial pullout technique, and the other involves the use of a suture anchor repair. The goal of both approaches is to restore an anatomical attachment of the meniscal root to bone that is capable of converting axial weight-bearing loads into hoop stresses. In a recent systematic review of meniscal root repairs, healing (partial and complete) was reported to have occurred in 96% of cases, with all studies demonstrating improvements in terms of subjective and functional scores at a mean of 30.2 months postoperatively.

Outcomes of anterior cruciate ligament reconstruction in patients older than 50 years of age.

BACKGROUND: Anterior cruciate ligament reconstruction (ACLR) has traditionally been reserved for young patients with functional instability. As the aging population continues to grow and embrace a more active lifestyle, it is important to determine if favorable outcomes of ACLR can be achieved in older adults. METHODS: Patients greater than 50 years of age undergoing ACLR between January 2001 and September 2006 were identified. Charts were retrospectively reviewed for clinical, pathologic, and radiographic findings. Prospective data was collected at follow-up, including Lysholm Knee Score, Tegner Activity Level Score, International Knee Documentation Committee (IKDC) Subjective Knee Form Score, and Knee Injury and Osteoarthritis Outcome Score (KOOS). Anteroposterior (AP) instability was assessed with use of a KT-2000 arthrometer (MEDmetric, San Diego, CA). RESULTS: Forty-seven patients underwent ACLR with 32 (16 males and 16 females) available at a mean follow-up of 5.0 years (range: 2.2 to 9.0 years). The mean age at the time of operation was 58.4 years (range: 51 to 65 years). At time of final follow-up, the mean side-to-side difference measured by KT-2000 was 1.2 ± 1.3 mm (range: 0 to 4.5 mm). Mean postoperative subjective IKDC score was 80.1 (range: 33 to 100) and Lysholm score was 86.7 (range: 45 to 95). There was no change in Tegner score from pre-injury (range: 0 to 3) to postoperative (range: 0 to 3). Twelve patients (38%) underwent subsequent knee surgery. All patients were satisfied with the final outcome of their ACLR surgery. Only patellofemoral Outerbridge cartilage grade was associated with worse outcome. CONCLUSION: ACLR provides symptomatic relief and restoration of function for patients greater than 50 years of age. ACLR should be considered in active older patients with subjective functional instability.

Hospital-acquired conditions after orthopedic surgery do not affect patient satisfaction scores.

INTRODUCTION: The purpose of this study was to determine whether development of a hospital-acquired condition (HAC) affected responses to Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey questions. HCAHPS is a national, standardized satisfaction survey. Patient responses form, in part, the basis for Medicare reimbursement to hospitals via the value-based purchasing system established by the Patient Protection and Affordable Care Act of 2010. We hypothesized that patients who developed an HAC would be less satisfied with their care. METHODS: We randomly distributed the HCAHPS survey, a validated, standardized measure of patient satisfaction, to 6,056 patients discharged from our institution for any orthopedic admission over a 2-year period. All patients who develop HACs are logged by our hospital quality assurance monitoring system. We reviewed the HCAHPS database, identified completed surveys associated with patients who had developed an HAC, and compared satisfaction scores between patients with HACs and patients without HACs. Survey scores were normalized to a 100-point scale. Univariate analysis was performed for two global ratings, and six specific satisfaction categories. Subgroup analysis was performed for surgical site infections (SSIs) and venous thromboembolic disease (VTE). RESULTS: A total of 2,876 controls and 159 HAC cases were identified from completed surveys. The cases and controls were similar in terms of race, however, the HAC group contained significantly more women (p < .001). Patients in the HAC group also were, on average, significantly older, with a mean age of 66.84 versus 58.65 (p < .001). There was no difference in satisfaction scores in patients' mean rating of communication by nurses (p = .81), communication by doctors (p = .31), communication about medications (p = .69), pain control (p = .66), the cleanliness of the hospital environment (p = .54), and the quietness of the hospital (p = .589). The mean normalized score for overall satisfaction was 93.99 (out of 100) for controls and 94.84 for HAC cases (p = .61). The mean normalized score for overall willingness to recommend the hospital to others was 90.22 for controls and 90.65 for HAC cases (p = .77). There was no statistically significant difference in satisfaction for patients with SSI versus VTE versus all other HACs (p > .05). DISCUSSION: Performance on HCAHPS is an area that demands hospital attention both to provide patient-centered care and to maximize revenue. Development of an HAC was not associated with decreased satisfaction scores in a population of orthopedic surgery patients at a private, university-affiliated specialty center. The lack of any statistically significant difference in patient satisfaction may be attributable to patient satisfaction with care in response to complications, the decreased sensitivity inherent to using a general satisfaction survey, or a homogeneity among orthopedic surgery patients and their expectations of care.

Functional outcomes and patient satisfaction after fasciotomy for chronic exertional compartment syndrome.

BACKGROUND: Patients with chronic exertional compartment syndrome who have failed nonoperative treatment are evaluated with pre-exertion and postexertion compartment pressure testing and may be treated with fasciotomy. Failure rates of up to 20% have been reported and may be related to factors such as age, sex, postexertion compartment pressures, compartment(s) released, and duration of symptoms. HYPOTHESIS: Higher preoperative postexertion compartment pressures are correlated with higher success and patient satisfaction rates after fasciotomy. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: From 1999 to 2008, patients with clinical symptoms of chronic exertional compartment syndrome with failed nonoperative management underwent standardized pre-exertion and postexertion compartment pressure measurements. Patients were then offered continued nonoperative treatment or referral to an orthopaedic surgeon for compartment release. Patients with a minimum 2-year follow-up were given a telephone questionnaire describing their pretreatment and posttreatment conditions including quality and duration of symptoms, analog pain scale, symptomatic and functional responses to treatment, and satisfaction with treatment. Medical records and operative reports were reviewed. RESULTS: The mean follow-up period for the nonoperative treatment group (n = 27) was 5.6 years (range, 2.1-10.6) and for the operative group (n = 73) was 5.2 years (range, 2.0-11.3). The operative group had a higher success rate (81%) compared with the nonoperative group (41%) (P < .001), and the operative group had a higher patient satisfaction rate (81%) compared with the nonoperative group (56%) (P = .011). There was no significant correlation between compartment pressures and patient outcomes. Patients with combined anterior and lateral compartment releases had an increased failure rate compared with isolated anterior release (31% vs. 0%, respectively; P = .035). Surgical patients who were post-college had a lower satisfaction rate (66%) compared with high school (89%) and college patients (94%) (P = .017). CONCLUSION: High school and college patients (age <23 years) and isolated anterior compartment release (compared with anterior/lateral release) were factors associated with improved subjective function and satisfaction after fasciotomy. We recommend the avoidance of lateral release unless symptoms or postexertion compartment pressures are clearly indicative of lateral compartment involvement.

Meniscal allograft transplantation.

PURPOSE: Meniscal allograft transplantation (MAT) has become an accepted treatment option for patients undergoing meniscectomy with recalcitrant pain in the corresponding compartment. Whether MAT can oppose cartilage degeneration is unclear. Our purpose was to perform a systematic review of available literature to answer the following: (1) Does MAT prevent advancing chondrosis? (2) Who is the ideal candidate for MAT? (3) What is the survival time for allograft in a stable knee? (4) Can MAT be successful when performed with concomitant procedures? (5) Is there an outcome difference between medial and lateral meniscal allograft transplants? (6) What is the expected function of a knee that has undergone MAT? METHODS: Two authors performed a systematic review of the literature pertaining to MAT. Included in the review are studies with at least 2 years' follow-up, studies with validated outcome measures, and studies in which the allograft meniscal horns were secured with bony fixation. RESULTS: We identified 14 clinical articles that satisfied our inclusion and exclusion criteria. Thirteen of the articles provided Level IV evidence, and one article provided Level III evidence. CONCLUSIONS: MAT can result in alleviation of knee pain, improvement in knee function, and good patient satisfaction if performed in the optimal candidate. Improvements in both objective and subjective outcome measures were shown in relatively young patients without significant chondromalacia who underwent concomitant procedures for cartilage defects, limb malalignment, and/or knee instability. We detected no significant difference in outcomes when comparing medial and lateral meniscal allograft transplants. We detected no significant difference when comparing isolated MAT with MAT performed with concomitant procedures. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Irreducible anterior and posterior dislocation of the shoulder due to incarceration of the biceps tendon.

Mechanical obstacles may infrequently impede closed reduction of anterior shoulder dislocation. Imaging techniques such as arthrography, computed tomography (CT) and magnetic resonance imaging (MRI) complement conventional radiography by allowing identification of obstacles to reduction. We present a case of irreducible anterior glenohumeral dislocation resulting from an initial anterior dislocation, converted to a posterior dislocation with an attempt at reduction, then converted back to anterior dislocation with a second reduction attempt. Soft tissue obstacles to shoulder reduction should be suspected when plain films do not identify a bony fragment as the culprit. CT and MRI are useful for identifying the cause of irreducibility and for operative planning.