Presentation and Management of the Pediatric Trigger Finger: A Multicenter Retrospective Cohort Study.

PURPOSE: Pediatric trigger finger (PTF) is an acquired condition that is uncommon and anatomically complex. Currently, the literature is characterized by a small number of retrospective case series with limited sample sizes. This investigation sought to evaluate the presentation, management, and treatment outcomes of PTF in a large, multicenter cohort. METHODS: A retrospective review of pediatric patients with a diagnosis of PTF between 2009 and 2020 was performed at three tertiary referral hospitals. Patient demographics, PTF characteristics, treatment strategies, and outcomes were abstracted from the electronic medical records. Patients and families also were contacted by telephone to assess the downstream persistence or recurrence of triggering symptoms. RESULTS: In total, 321 patients with 449 PTFs were included at a mean follow-up of 3.9 ± 4.0 years. There were approximately equal numbers of boys and girls, and the mean age of symptom onset was 5.4 ± 5.1 years. The middle (34.7%) and index (11.6%) fingers were the most and least commonly affected digits, respectively. Overall, PTFs managed operatively achieved significantly higher rates of complete resolution compared with PTFs managed nonsurgically (97.1% vs 30.0%). Seventy-five percent of PTFs that achieved complete resolution with nonsurgical management did so within 6 months, and approximately 90% did so within 12 months. Patients with multidigit involvement, higher Quinnell grade at presentation, or palpable nodularity were significantly more likely to undergo surgery. There was no significant difference in the rate of complete resolution between splinted versus not splinted PTFs or across operative techniques. CONCLUSIONS: Only 30% of the PTFs managed nonsurgically achieved complete resolution. Splinting did not improve resolution rates in children treated nonsurgically. In contrast, surgical intervention has a high likelihood of restoring motion and function of the affected digit. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The synergistic effect of preoperative opioid use and many associated preoperative predictors of poor outcome in the trauma patient population.

OBJECTIVE: The purpose of this study is to investigate if preoperative opioid use is associated with other predictors of poor outcome and the effect of these factors on complications. We hypothesized that preoperative opioid use (POU) is associated with increased rates of postoperative complications. DESIGN: Retrospective case control study. SETTING: Academic level-1 trauma center. PATIENTS/PARTICIPANTS: Patients with long bone, lower extremity fractures requiring operative fixation. INTERVENTION: N/A. MAIN OUTCOME MEASURES: Postoperative hospital admissions, emergency room (ER) visits, and reoperations. RESULTS: 399 patients (opioid naïve [ON] 80.2%, Age 38, 95% CI 35.9-39.6) were reviewed. Patients who had POU were older (P = 0.004), had higher BMI (P = 0.03), proportion of females (P < 0.001), tobacco use (P < 0.001), proportion of American Society of Anesthesiologist (ASA) class ≥ 3 (P < 0.001), and rates of substance use disorder (SUD) (P < 0.001). POU was associated with prolonged opiate use at 6 months (60.8%), 1 year (43.0%), higher rates of postoperative readmissions (18.1%), ER visits (17.2%), reoperations (17.5%), and complications (Odds Ratio [OR]: 2.4, P < 0.01). The risk of complication increased synergistically with the addition of other predictors: less than a high school education (OR: 4.6, P = 0.001); ASA class ≥3 (OR: 5.6, P < 0.001). All three factors combined also increased risk of complication synergistically (OR: 9.1, P = 0.003). CONCLUSIONS: Our study demonstrates that many predictors of poor outcome frequently accompany POU. POU combined with many of these predictors synergistically increases the risk of complication. Outcomes-based payment models should reflect this expected rate of readmissions, ER visits and complications in this group. Patients with POU should be targeted with multi-disciplinary interventions aimed to modify these risk factors.

Joint Fluid Proteome after Anterior Cruciate Ligament Rupture Reflects an Acute Posttraumatic Inflammatory and Chondrodegenerative State.

OBJECTIVE: The purpose of this study was to evaluate changes in the synovial fluid proteome following acute anterior cruciate ligament (ACL) injury. DESIGN: This study represents a secondary analysis of synovial fluid samples collected from the placebo group of a previous randomized trial. Arthrocentesis was performed twice on 6 patients with an isolated acute ACL tear at a mean of 6 and 14 days postinjury. Synovial fluid was analyzed by a highly multiplexed assay of 1129 proteins (SOMAscan version 3, SomaLogic, Inc., Boulder, CO). Pathway analysis using DAVID was performed; genes included met 3 criteria: significant change between the 2 study time points using a paired t test, significant change between the 2 study time points using a Mann-Whitney nonparametric test, and significant Benjamini post hoc analysis. RESULTS: Fifteen analytes demonstrated significant increases between time points. Five of the 15 have been previously associated with the onset and/or severity of rheumatoid arthritis, including apoliopoprotein E and isoform E3, vascular cell adhesion protein 1, interleukin-34, and cell surface glycoprotein CD200 receptor 1. Chondrodegenerative enzymes and products of cartilage degeneration all increased over time following injury: MMP-1 (P = 0.08, standardized response mean [SRM] = 1.00), MMP-3 (P = 0.05, SRM = 0.90), ADAM12 (P = 0.03, SRM = 1.31), aggrecan (P = 0.08, SRM = 1.13), and CTX-II (P = 0.07, SRM = 0.56). Notable pathways that were differentially expressed following injury were the cytokine-cytokine receptor interaction and osteoclast differentiation pathways. CONCLUSIONS: The proteomic results and pathway analysis demonstrated a pattern of cartilage degeneration, not only consistent with previous findings but also changes consistent with an inflammatory arthritogenic process post-ACL injury.

Isolated Small Finger Distal Interphalangeal Joint Dupuytren's Contracture.

Dupuytren's contracture is a disease involving abnormal myofibroblast proliferation and collagen deposition leading to the formation of pathologic cords in the hand. Given that Dupuytren's contractures rarely extend to the distal interphalangeal joint (DIP), affecting only 5% of patients, there are few cases reported in the literature. Collagenase injection is a frequently used option for minimally invasive treatment of Dupuytren's disease with greater than a 20-degree joint contracture. Unfortunately, there is limited research on the effectiveness of these injections in isolated DIP joint deformities. We present a case of a 61-year-old right hand-dominant male with a 2-year history of isolated right small finger Dupuytren's contracture at the DIP joint who achieved significant improvement after collagenase injection.

Greater Rates of Acute Kidney Injury in African American Total Knee Arthroplasty Patients.

BACKGROUND: This retrospective study compared the change in serum creatinine between African American and Caucasian total knee arthroplasty (TKA) patients. The authors hypothesized that African Americans would demonstrate significantly greater change, and that a significantly greater proportion would demonstrate creatinine changes consistent with acute kidney injury (AKI). METHODS: Primary TKAs performed at a single institution between July 2011 and June 2016 were identified: 1035 primary TKAs met inclusion and exclusion criteria (110 African American, 925 Caucasian, excluding Hispanic and Asian patients). None were excluded based on gender, age, body mass index, preoperative diagnosis, or comorbidities. All patients had preoperative and postoperative creatinine levels available in the electronic medical records. Each patient received the same preop and postop protocol for nonsteroidal anti-inflammatory drug use along with other drugs administered including anesthesia. All patients received 1 g of intravenous vancomycin with some patients additionally receiving 1 g of vancomycin powder administered locally at the end of surgery. All patients were controlled for fluid intake and blood loss, along with no patient receiving a transfusion or intravenous contrast. Patient demographics and preoperative/postoperative serum creatinine were recorded and then analyzed for presence of AKI (≥0.3 mg/dL). Preoperative/postoperative serum creatinine concentrations were compared between African American and Caucasian patients using 2 × 2 repeated measures analysis of variance. Prevalence of patients in each group demonstrating AKI was calculated using Fisher's exact test. RESULTS: African American patients had significantly greater serum creatinine preoperatively (1.00 ± 0.26 vs 0.90 ± 0.22, P < .001) and a significantly greater increase postoperatively (0.10 vs 0.03, P < .001). A significantly greater number of African American patients demonstrated AKI (10.9% vs 5.1%, P = .03). Furthermore, a significantly greater number of African American patients stayed in the hospital an additional 2 or more days for renal issues (2.7% vs 0.4%, P = .03). CONCLUSION: Altered renal function was significantly more common in African American TKA patients. Future studies are necessary to determine if tailoring anti-inflammatories, perioperative medications, and preoperative comorbidities reduce the risk of renal injury and/or a longer hospital stay for this subset of patients.

The Hidden Cost of Commercial Antibiotic-Loaded Bone Cement: A Systematic Review of Clinical Results and Cost Implications Following Total Knee Arthroplasty.

BACKGROUND: The purpose of this systematic review is to compare deep prosthetic joint infections (PJIs) between total knee arthroplasty (TKA) patients treated with either antibiotic-loaded bone cement (ALBC) or plain bone cement, and to explore the potential cost implications of commonly used bone cement regimens. We hypothesized that ALBC would not substantially reduce PJIs and would thereby present an unnecessary cost to the healthcare system. METHODS: Using the PRISMA guidelines, we reviewed articles through May 2017 involving primary TKA patients with both ALBC cohort and plain bone cement cohort. A meta-analysis was performed comparing the prevalence of deep infections between cohorts. A cost comparison for a hypothetical setting with an annual volume of 1000 TKAs was performed to compare 3 commonly used cement regimens: 2 bags of ALBC used during each case, 1 bag of ALBC with 1 bag of plain cement, and 2 bags of plain cement. Pricing at our institution is $215/bag for commercial ALBC and $60/bag for plain cement. RESULTS: Eight articles were included with a total of 34,664 patients. ALBC did not reduce the PJI (ALBC = 93/8189, 1.1% vs plain = 251/26,475, 0.9%; P = .09). The estimated costs for the 3 bone cement regimens per 1000 primary TKAs were as follows: 2 bags of ALBC = $430,000/y, 1 bag of ALBC +1 bag of plain cement = $275,000/y, and 2 bags of plain cement = $120,000/y. CONCLUSION: ALBC did not reduce the prevalence of PJI suggesting that ALBC may be an unnecessary cost to the healthcare system. Hospital systems that perform 1000 TKAs/y could save between $155,000 and $310,000/y by switching to plain cement.

Patient Complaints Emphasize Non-Technical Aspects of Care at a Tertiary Referral Hospital.

BACKGROUND: Patient concerns represent opportunities for improvement in orthopaedic care. This study's objective is to identify the nature and prevalence of unsolicited patient complaints regarding orthopaedic care at a tertiary referral hospital. The primary null hypothesis that there are no demographic factors associated with complaint types was tested. Secondarily we determined if the overall complaint number and types differed by year. METHODS: Complaints to the hospital ombudsperson by orthopaedic patients between January 1997 and June 2013 were reviewed. All 1118 complaints were categorized: access and availability, humaneness and disrespect, communication, expectations of care and treatment, distrust, billing and research. RESULTS: Patients between 40 and 60 years of age filed the most complaints in all categories except distrust (more common in patients over age 80) and research. Women were slightly more likely to address access and availability, humaneness, disrespect, and billing compared to men. The overall number of complaints peaked in 1999. The most common issue was access and availability followed by communication, and humaneness/disrespect. CONCLUSION: Half of concerns voiced by patients addressed interpersonal issues. The largest category was related to access and availability. Quality improvement efforts can address technology to improve access and availability as well as empathy and communication strategies.

The factors influencing the decision making of operative treatment for proximal humeral fractures.

BACKGROUND: The factors influencing the decision making of operative treatment for fractures of the proximal humerus are debated. We hypothesized that there is no difference in treatment recommendations between surgeons shown radiographs alone and those shown radiographs and patient information. Secondarily, we addressed (1) factors associated with a recommendation for operative treatment, (2) factors associated with recommendation for arthroplasty, (3) concordance with the recommendations of the treating surgeons, and (4) factors affecting the inter-rater reliability of treatment recommendations. METHODS: A total of 238 surgeons of the Science of Variation Group rated 40 radiographs of patients with proximal humerus fractures. Participants were randomized to receive information about the patient and mechanism of injury. The response variables included the choice of treatment (operative vs nonoperative) and the percentage of matches with the actual treatment. RESULTS: Participants who received patient information recommended operative treatment less than those who received no information. The patient information that had the greatest influence on treatment recommendations included age (55%) and fracture mechanism (32%). The only other factor associated with a recommendation for operative treatment was region of practice. There was no significant difference between participants who were and were not provided with information regarding agreement with the actual treatment (operative vs nonoperative) provided by the treating surgeon. CONCLUSION: Patient information-older age in particular-is associated with a higher likelihood of recommending nonoperative treatment than radiographs alone. Clinical information did not improve agreement of the Science of Variation Group with the actual treatment or the generally poor interobserver agreement on treatment recommendations.

Disability in patients with trapeziometacarpal joint arthrosis: incidental versus presenting diagnosis.

PURPOSE: To test the hypothesis that there is no difference in trapeziometacarpal (TMC) joint arthrosis-related symptoms and disability between patients seeking treatment for symptoms of TMC arthrosis and those with incidental TMC joint arthrosis. METHODS: We compared 64 patients presenting for care of TMC joint arthrosis with 64 with incidental TMC joint arthrosis. For both groups, the diagnosis was based on crepitation on examination. Bivariate and multivariate analyses assessed factors associated with symptoms and disability related to TMC joint arthrosis. RESULTS: In bivariate analysis, patients presenting for care of TMC joint arthrosis had significantly more symptoms and disability from TMC joint arthrosis than those with incidental TMC joint arthrosis. The best multivariate linear regression model for fewer TMC joint arthrosis-related symptoms and disability included patients with incidental TMC joint arthrosis, male sex, no other painful conditions, less catastrophic thinking, and fewer depressive symptoms and explained 74% of the variability. Having incidental TMC joint arthrosis (25%) and more adaptive coping strategies (less catastrophic thinking; 5%) were the most important contributors to fewer symptoms and less disability. CONCLUSIONS: Future studies are merited to determine whether training in better coping strategies (eg, less catastrophic thinking and fewer depressive symptoms) can decrease symptoms and disability in patients with TMC joint arthrosis. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic III.

The influence of patients' participation in research on their satisfaction.

PURPOSE: To determine if there was a difference between patients participating in research and those who did not regarding their satisfaction with the medical encounter and their physician. METHODS: We prospectively randomized 128 patients to either complete 20 minutes of questionnaires (participate in research) or not. After the visit, all patients rated their satisfaction with their visit and satisfaction with the doctor on an 11-point ordinal satisfaction scales, with 0 being not at all satisfied and 10 being completely satisfied. Average satisfaction scores were analyzed in relation to demographics, questionnaires, and involvement in research. RESULTS: There were no significant differences between patients that did and did not participate in research for satisfaction with the medical encounter or satisfaction with the treating physician. Satisfaction was not associated with marital status, work status, or diagnosis. There was a significant correlation between greater satisfaction and both less education and lower self-efficacy. There was no significant correlation between patient satisfaction and magnitude of disability, pain intensity, or health anxiety. CONCLUSIONS: This study demonstrated that patients' participation in research can coexist with patient satisfaction. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic I.

Does rewording MRI reports improve patient understanding and emotional response to a clinical report?

BACKGROUND: Diagnostic MRI reports can be distressing for patients with limited health literacy. Humans tend to prepare for the worst particularly when we are in pain, and words like "tear" can make us feel damaged and in need of repair. Research on words used in provider-patient interactions have shown an affect on response to treatment and coping strategies, but the literature on this remains relatively sparse. QUESTIONS/PURPOSES: The aim of this observational cross-sectional study is to determine whether rewording of MRI reports in understandable, more dispassionate language will result in better patient ratings of emotional response, satisfaction, usefulness, and understanding. Furthermore, we wanted to find out which type of report patients would choose to receive. METHODS: One hundred patients visiting an orthopaedic hand and upper extremity outpatient office for reasons unrelated to the presented MRI report were enrolled. Four MRI reports, concerning upper extremity conditions, were reworded to an eighth-grade reading level and with the use of neutral descriptive words and the most optimistic interpretations based on current best evidence. After reading each report, emotional response was measured using the Self Assessment Manikin (SAM). Subjects also completed questions about satisfaction, usefulness, and understanding of the report. RESULTS: According to the results of the SAM questionnaire, the reworded MRI reports resulted in significantly higher pleasure and dominance scores and lower arousal scores. The mean satisfaction, usefulness, and understanding scores of the reworded report were significantly higher compared with the original reports. Seventy percent of the patients preferred the reworded reports over the original reports. CONCLUSIONS: Emotional response, satisfaction, usefulness, and understanding were all superior in MRI reports reworded for lower reading level and optimal emotional content and optimism. Given that patients increasingly have access to their medical records and diagnostic reports, attention to health literacy and psychologic aspects of the report may help optimize health and patient satisfaction.

Surgeon confidence in an outpatient setting.

BACKGROUND: We have the impression that provider uncertainty arises from either nonspecific pathology or disproportionate symptoms and disability, both of which correlate with symptoms of depression, heightened illness concern, and low patient self-efficacy. This study tested the primary null hypothesis that there is no correlation between provider confidence and patient self-efficacy. METHODS: Eighty-five patients visiting an orthopedic hand and upper extremity surgeon completed the Pain Self-Efficacy Questionnaire (PSEQ). The surgeon's confidence in the diagnosis, optimal treatment, expected outcome, and the anticipated satisfaction of the patient and the referring doctor were measured with five questions rated on 5-point Likert scales (Physician Confidence Scale). RESULTS: Overall physician confidence was high and there was no correlation between the PSEQ score and the Physician Confidence Scale. Provider confidence was significantly lower for nonspecific diagnoses, but there was no significant difference between the mean PSEQ for the 72 patients with a specific diagnosis and the 12 patients with nonspecific diagnoses. CONCLUSIONS: Physician confidence did not relate with self-efficacy in this study. LEVEL OF EVIDENCE: Prognostic, level II.

Evolution of Pseudomonas aeruginosa type III secretion in cystic fibrosis: a paradigm of chronic infection.

Pseudomonas aeruginosa (PA) from acute and chronic (eg, cystic fibrosis (CF)) infections differ in several respects, but they can worsen prognosis in each context. Factors that facilitate conversion from an acute to chronic phenotype are poorly understood. T3 secretion proteins are virulence factors associated with poorer outcomes in acute infections, but little is known about their role in CF. We wished to characterize T3 secretion in CF PA isolates and to examine its role in clinical outcomes. A total of 114 CF subjects were divided into 3 cohorts: 1st infected individuals, CI children, and adults. Serial respiratory cultures were analyzed for T3 secretion. Serial spirometry and exacerbation data were collected prospectively. In 1st infection, 45.2% +/- 9.1% of PA isolates secreted T3 proteins compared with 29.1% +/- 4.2% and 11.5% +/- 3.0% in CI children and CI adults, respectively (P < 0.001). An inverse correlation was observed between duration of PA infection and percent T3 positive isolates (r = -0.32, P < 0.001). Overall, no association was observed between T3 secretion and pulmonary outcomes, but in the subgroup of subjects who had at least 1 T3 positive organism, T3 secretion was inversely correlated with the forced expiratory volume in 1 s (FEV(1)) decline (r = -0.35, P = 0.02). In 1st infection, 82% of cultures grew either all or no T3-positive organisms. In these patients, T3 secretion was associated with a greater risk of subsequent PA isolation (P < 0.001). In CF, PA T3 secretion decreases with residence time in lung, may predict FEV(1) decline in patients who have detectable T3 organisms, and may facilitate persistence after 1st infection.

Pseudomonas aeruginosa induces localized immunosuppression during pneumonia.

Hospital-acquired bacterial pneumonia is a common and serious complication of modern medical care. Many aspects of such infections remain unclear, including the mechanisms by which invading pathogens resist clearance by the innate immune response and the tendency of the infections to be polymicrobial. Here, we used a mouse model of infection to show that Pseudomonas aeruginosa, a leading cause of hospital-acquired pneumonia, interferes with the ability of recruited phagocytic cells to eradicate bacteria from the lung. Early in infection, phagocytic cells, predominantly neutrophils, are recruited to the lungs but are incapacitated when they enter the airways by the P. aeruginosa toxin ExoU. The resulting paucity of functioning phagocytes allows P. aeruginosa to persist within the lungs and results in local immunosuppression that facilitates superinfection with less-pathogenic bacteria. Together, our results provide explanations for previous reports linking ExoU-secreting P. aeruginosa with more severe pulmonary infections and for the tendency of hospital-acquired pneumonia to be polymicrobial.