Operative treatment of Mason Type III radial head fractures - A comparative analysis using PROMIS.

Objectives: The purpose of this study is to evaluate the outcomes of operatively treated Mason Type III radial head fractures. Additionally, this project seeks to assess efficacy of PROMIS in evaluating post-operative outcomes for this patient population. Methods: A total of 143 patients who underwent operative treated Mason Type III radial head fractures were analyzed retrospectively. PROMIS physical function (PF), PROMIS upper extremity (UE), PROMIS pain interference (PI), demographic variables, and range of motion were collected and analyzed over 12-month follow-up. Results: Radial head arthroplasty (RHA) was performed on 89 patients, open reduction and internal fixation (ORIF) was performed on 47 patients, and radial head excision was performed on 7 patients. Among the RHA patients, PROMIS PF, PI and UE demonstrated a change of -1.33 (p < 0.05), -1.48 (p < 0.05), and 2.23 (p < 0.05) respectively from injury to 12-months. Among the ORIF patients, PROMIS PF, PI and UE demonstrated a change of 3.22 (p < 0.05), -1.56 (p < 0.05), and 2.09 (p < 0.05) respectively from injury to 12-months. At the pre-operative and 12-month visits, the RHA group demonstrated lower PROMIS PF scores 34.75 vs 38.02 (p < 0.05) and 33.42 vs 41.24 (p < 0.05) respectively. Ther was no difference in PROMIS PI, UE, or elbow range of motion between the two groups at 6- or 12-month follow-up (p > 0.05). Conclusion: Comparing the RHA and ORIF groups, there was no difference in PROMIS PI or UE scores nor was there a clinically significant improvement at the 6- or 12-month mark. The ORIF group demonstrated improved PROMIS PF at all follow-up periods and did show a clinically significant improvement. Patient Acceptable Symptom State (PASS) correlated only with PROMIS UE at 6- and 12- months for both groups.

An Analysis of Patient-Reported Outcomes Measurement Information System (PROMIS) in Non-operative Posterolateral Elbow Dislocations.

INTRODUCTION: The purpose of our study is to analyze the outcomes of traumatic posterolateral elbow dislocations using patient-reported outcomes measurement information system (PROMIS). We hypothesized that physical function (PF) and upper extremity (UE) scores in PROMIS will significantly improve over six months of follow-up and correlate with a positive change in the patient-acceptable symptom state (PASS). METHODS: This is a seven-year retrospective study of 165 consecutive adult patients with traumatic posterolateral elbow dislocations. Demographic information, PROMIS PF, PROMIS UE, PROMIS pain interference (PI), PROMIS depression, and PASS were recorded over six months of follow-up. RESULTS: At the time of injury, mean PROMIS scores were PF 41.24 (SD 11.16), UE 34.27 (SD 11.87), PI 60.44 (SD 8.07), and depression 49.82 (SD 10.42). At six months, the mean PROMIS scores were PF 39.71 (SD 9.71), UE 33.95 (SD 9.09), PI 57.35 (SD 8.59), and depression 51.43 (SD 10.62). The overall six-month changes in PROMIS scores were PF -1.53, UE -0.32, PI -3.09, and depression +1.61. At the 6-month follow-up, 41.7% responded positively on the PASS, which correlated only with PROMIS PI. CONCLUSIONS: Among patients who improved from negative to positive response on PASS, the PROMIS PF, UE, and depression scores did not significantly improve. Only PROMIS PI correlated with PASS at the six-month follow-up; PROMIS PI significantly improved among simple posterolateral elbow dislocation patients at both short-term and long-term follow-up points. PROMIS PF, UE, and depression did not significantly differ between time of injury and short-term and long-term follow-up points.

Non-operative Treatment of Mason Type I Radial Head Fractures: A Comparative Analysis Using Patient-Reported Outcomes Measurement Information System (PROMIS).

OBJECTIVES: The purpose of this study is to compare the outcomes of Mason type I radial head fractures. This information will help to provide physicians with a critical decision-making tool when considering non-operative intervention and evaluate Patient-Reported Outcomes Measurement Information System (PROMIS) as a potentially valuable measure to track outcomes. METHODS: We retrospectively identified 527 patients undergoing non-operative intervention. Demographic information, physical exam measurements, patient acceptable symptom state (PASS), and PROMIS Upper Extremity (UE), Physical Function (PF), and Pain Interference (PI) scores were analyzed over 12 months. RESULTS: At the initial outpatient post-injury visit (within one week of injury), the average PROMIS PF, UE, PI, and Depression were 42.04 (SD: 6.3), 35.31 (SD: 7.3), 59.18 (SD: 9.2), and 48.68 (SD: 6.8), respectively. The average change in PROMIS PF, UE, PI, and Depression scores from the time of injury to six weeks were -0.23 (p=0.7), 1.43 (p=0.03), -2.1 (p=0.01), and -0.99 (p=0.1). The average change in PROMIS PF, UE, PI, and Depression scores from the time of injury to six months was -0.56 (p=0.56), 1.84 (p<0.001), -1.84 (p<0.001), and -0.13 (p=0.68). Among patients initially reporting "not acceptable" on PASS and reporting "acceptable" at the six-month visit, the average PROMIS PF, UE, PI, and Depression scores were 42.14, 38.91, 56.91, and 47.51 respectively. This represents an average difference of 1.11 (p=0.07), 2.82 (p<0.01), -1.19 (p=0.04), and -1.7 (p=0.01) respectively. CONCLUSION: PROMIS UE and PI significantly improved among Mason I radial head fractures treated non-operatively at both six-week and six-month follow-up points but did not meet the mean clinically important difference (MCID) PROMIS PF did not significantly differ between the time of injury, six-week or six-month follow-up points. Only PROMIS UE correlated with PASS at six-week and six-month follow-up. Among patients who improved from negative to positive responses on PASS, PROMIS UE, and PI significantly improved.

Carpometacarpal Joint Pathology in the Thumb and Hand: Evaluation and Management of Difficult Conditions.

Thumb carpometacarpal arthroplasty with complete trapeziectomy with or without suspensionplasty, ligament reconstruction, and/or tendon interposition is largely considered equivalent techniques in providing pain relief and improving function for patients with thumb carpometacarpal arthritis. In cases of continued pain, instability, and dysfunction following an index surgery, one must first identify the cause of failure. Any options for revision surgery depend on addressing the specific cause of persistent symptoms with awareness of available options. Most of the patients undergoing revision surgeries can achieve good to fair outcomes.

Endoscopic Versus Open Carpal Tunnel Surgery: Risk Factors and Rates of Revision Surgery.

PURPOSE: The purpose of our study was to compare the 1-year revision surgery rates and outcomes of open versus endoscopic carpal tunnel release. Our hypothesis was that, compared to open release, endoscopic carpal tunnel release was an independent risk factor for revision surgery within 1-year. METHODS: This was a retrospective cohort study of 4338 patients undergoing isolated endoscopic or open carpal tunnel release. Demographic data, medical comorbidities, surgical approach, need for revision surgery, hand dominance, history of prior injection, and Patient Reported Outcomes Measurement Information System upper extremity (UE), pain interference (PI) and physical function scores were analyzed. Multivariable analysis was used to identify the risk factors for revision surgery within one year of the index procedure. RESULTS: In total, 3280 patients (76%) underwent open and 1058 (24%) underwent endoscopic carpal tunnel release. Within one year of the index procedure, 45 patients required revision carpal tunnel release. The average time to revision was 143 days. The rate of revision carpal tunnel release in the open group was 0.71% compared to 2.08% in the endoscopic group. Multivariable analysis demonstrated that endoscopic surgery, male sex, cubital tunnel syndrome, tobacco use, and diabetes were associated independently with revision surgery. CONCLUSIONS: In this study, we found that endoscopic carpal tunnel release was associated independently with a 2.96 times greater likelihood of requiring revision carpal tunnel release within one year, compared to open carpal tunnel release. Male sex, concurrent cubital tunnel syndrome, tobacco use, and diabetes also were associated independently with greater risk of needing revision carpal tunnel release within one year. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

The Role of Dual-Mobility Components in Total Hip Arthroplasty.

➤: Dual mobility (DM) refers to a now widely available option for total hip articulation. DM implants feature a small inner head, a hard bearing, that connects via a taper fit onto the femoral trunnion. This head freely rotates but is encased inside a larger, outer polyethylene head that articulates with a smooth acetabular component. ➤: DM acetabular components are available in the form of a monoblock shell or as a liner that is impacted into a modular shell, providing a metal articulation for the polyethylene outer head. ➤: DM is designed to increase hip stability by providing the arthroplasty construct with a higher jump distance, head-to-neck ratio, and range of motion prior to impingement. ➤: The use of DM in total hip arthroplasty continues to increase in the United States for both primary and revision arthroplasty. Surgeons should be aware of the potential benefits and pitfalls. ➤: Long-term data are lacking, especially for modular DM implants. Points of concern include a potential for accelerated polyethylene wear, intraprosthetic dislocation, and modular backside fretting corrosion.

Risk Factors for Infections Following Open Reduction and Internal Fixation for Distal Radius Fractures An Analysis of the Medicare Claims Database.

Bulletin of the Hospital for Joint Diseases 2022;80(2):228-33228 Mahmood B, Golub IJ, Ashraf AM, Ng MK, Vakharia RM, Choueka J. Risk factors for infections following open reduction and internal fixation for distal radius fractures: an analysis of the medicare claims database. Bull Hosp Jt Dis. 2022;80(2):228-33. Abstract Background: Infections following open reduction and internal fixation (ORIF) of distal radius fractures (DRFs) are associated with worse outcomes and increasing health care costs. The purpose of this study was to utilize a nationwide administrative claims database to compare patient demo- graphics of patients who did and did not develop infections and identify patient-related risk factors for postoperative infections. METHODS: Using the PearlDiver database, the 100% Medicare Files from 2005 to 2014 were queried. Patients undergoing ORIF for DRF were identified using Current Procedural Terminology (CPT) codes. Inclusion for the study group consisted of patients who developed infection within 90 days after the procedure and were identified us- ing CPT and International Classification of Disease, Ninth Revision (ICD-9) codes. Multivariable binomial logistic regression analyses were performed to calculate the odds (OR) of certain patient comorbidities and their association with infection following ORIF of DRFs. A p-value less than 0.002 was considered statistically significant after Bonfer- roni correction. RESULTS: The query yielded 132,650 patients within the study, 456 who developed surgical site infections (SSI) and 132,194 who did not. Surgical site infections were more commonly found in certain demographics, such as patients under the age of 65 (26.75 vs. 14.73%) and in males (20.83 vs. 14.15%). Multivariate regression analysis further highlighted that certain comorbidities increased odds for infections within 90-days following ORIF for distal radius fractures and those included: morbid obesity (OR: 2.06, p < 0.0001), depression (OR: 1.92, p = 0.0002), and pathologic weight loss (OR: 1.49, p = 0.001). CONCLUSION: The study found statistically significant dif- ferences between patients who developed and did not develop infection. These findings may help orthopedic surgeons to educate certain high-risk patients of the potential complica- tions that may occur following surgery.

Comparing early and mid-term outcomes between robotic-arm assisted and manual total hip arthroplasty: a systematic review.

The projected increase in utilization rates of total hip arthroplasty (THA) has created an emphasis on novel technologies that can aid providers in maintaining historically positive outcomes. Widespread utilization of robotic assisted THA (RA-THA) is contingent upon achieving favorable outcomes compared to its traditional manual counterpart (mTHA). Therefore, the purpose of our systematic review was to compare RA-THA and mTHA in terms of the following: (1) functional outcomes and (2) complication rates. The PubMed, Embase, and Cochrane library databases were searched for articles published October 1994 and May 2021 comparing functional outcomes and complication rates between RA-THA and mTHA cohorts. When three or more studies evaluated certain PROMs and complications, a pooled analysis utilizing Mantel-Haenszel (M-H) models was conducted utilizing data from final follow-up. Our final analysis included 18 studies which reported on a total of 2811 patients [RA-THA: n = 1194 (42.48%); mTHA: n = 1617 (57.52%)]. No significant differences were demonstrated for a majority of pooled analyses and when segregating by robotic system. Only WOMAC scores were significantly lower among RA-THA patients (p = 0.0006). For outcomes without sufficient data for a pooled analysis, there were no significant differences reported among included studies. The growing utilization of RA-THA motivates comparisons to its manual counterpart. Collectively, we found comparable functional outcomes and complication profiles between RA-THA and mTHA cohorts. More randomized controlled trials of higher quality and larger sample sizes are necessary to further strengthen these findings.

Increasing the Educational Value of the Orthopaedic Subinternship: The Design and Implementation of a Fourth-Year Medical Student Curriculum.

INTRODUCTION: Most orthopaedic subinternships function as month-long interviews. These rotations remain relatively unstructured and lack standardization, and their overall educational value has been called into question. The goals of this educational initiative were to create a structured subinternship curriculum for orthopaedic applicants and to shift the focus of the subinternship from a month-long interview to an organized educational experience. METHODS: After review of knowledge and skills expected for early orthopaedic residency under the structure of the Accreditation Council for Graduate Medical Education Milestones, a curriculum dedicated to orthopaedic subinternships was created. Students who completed the curriculum filled out anonymous Likert scale evaluations (rating their comfort/knowledge from 0 to 10 before and after their rotation) and answered open-ended qualitative questions. RESULTS: Forty-six subinterns participated in the program over 3 years. Four weekly learning modules were designed and taught by orthopaedic residents, with faculty oversight of content and structure. Each monthly rotation began with an orthopaedic surgical skills laboratory and concluded with a case-based oral presentation. Weeks two and three covered different milestone-based topics and included didactic and skills development. Data analysis revealed that students reported notable improvement in knowledge and familiarity with each of the topics. The greatest improvements were in tibia intramedullary nailing and applying a tension band to an olecranon fracture. When asked which surgical skills station was the most helpful, 70% chose lag screw insertion and basic plating techniques. All students felt that creating their case presentation was productive. CONCLUSION: This educational initiative resulted in the successful design and implementation of a milestone-based orthopaedic surgery subinternship curriculum. The program was well received by students, contributed to learning and competency, and provided teaching opportunities for residents. The format and content of this subinternship curriculum can easily be adapted to regional and national teaching programs.

Clinical utilization of species-specific immunoassays for identification of Staphylococcus aureus and Streptococcus agalactiae in orthopedic infections.

Staphylococcus aureus and Streptococcus agalactiae (Group B streptococcus, GBS) are common causes of deep musculoskeletal infections (MSKI) and result in significant patient morbidity and cost to the healthcare system. One of the major challenges with MSKI is the lack of faithful diagnostics to correctly identify the primary pathogen, as standard culture-based assays are prone to false positives in the case of polymicrobial infections, and false negatives due to limitations in sample acquisition and antibiotic use before presentation. To improve upon our current diagnostic methods for MSKI, we developed a multiplex immunoassay for antigen-specific IgGs in serum (Luminex), and medium enriched for newly synthesized antibodies (MENSA) for anti-S. aureus and GBS generated from cultured peripheral blood mononuclear cells (PBMCs) of orthopedic infection patients undergoing surgical treatment. Samples were obtained from 110 MSKI patients: 80 diabetic foot ulcer, 21 periprosthetic joint infection, 5 septic arthritis, 2 spine, 1 hand, and 1 fracture-related infection (FRI). Anti-S. aureus and anti-GBS antibody titers were compared to culture results to assess their concordance in identifying the pathogens. Immunoassay, particularly MENSA, showed high diagnostic potential for monomicrobial S. aureus and GBS orthopedic infections (AUC > 0.95). MENSA also demonstrated diagnostic potential for GBS polymicrobial orthopedic infection and for GBS DFU (AUC > 0.83 for both). Serum showed high diagnostic potential for S. aureus PJI (AUC > 0.95). Taken together, these findings support the development of species-specific immunoassays for the identification of causal pathogens in active MSKI, especially in conjunction with standard culture.

Duration of antibiotics for penetrating spine trauma: a systematic review.

Penetrating trauma to the spine with resultant spinal and paraspinal infection represents a potentially devastating injury for which there is little consensus regarding management. The duration, route and type of antibiotics required to prevent infections such as epidural abscess, vertebral osteomyelitis, and discitis is remain controversial. Several studies support standard prophylactic antimicrobial treatment for 48 hours following penetrating spinal trauma while others demonstrate that extended therapy for one week or greater is necessary to reduce risk of infection. However, there is no established protocol or consensus for management. Our systematic review aims to determine the ideal duration of antibiotics following penetrating spine trauma. Three databases (PubMed, SCOPUS, and Ovid) were queried using the following keywords: penetrating spine trauma, spine infection, spine trauma antibiotics. Nine articles were found to meet the inclusion criteria for this systematic review. The majority of studies included in final analysis discussed penetrating spinal trauma in the form of gunshot wounds. 459 patients were included in total across all studies and 21 patients developed spinal or paraspinal infection (4.58%). Five studies demonstrated an infection rate below 5% with antibiotic therapy for 5 days or longer while 2 more recent studies demonstrated a similar infection rate in their cohort with only 48 hours of antimicrobial prophylaxis. Our systematic review finds a low rate of paraspinal and spinal infections following penetrating spine trauma. As all studies included are retrospective in nature, no definitive recommendations can be made regarding duration of therapy. Forty-eight hours of antimicrobial prophylaxis may be sufficient for most patients except for those with trans-colonic injuries as these are associated with a greater contamination and risk for spinal infection.

Opioid Use Disorder Is Associated with an Increased Risk of Infection after Total Joint Arthroplasty: A Large Database Study.

BACKGROUND: Recent studies have shown that patients with opioid use disorder have impaired immunity. However, few studies with large patient populations have evaluated the risks of surgical site infection (SSI) and prosthetic joint infection (PJI) with opioid use disorder after total joint arthroplasty (TJA), and there is a lack of evidence for revision TJA in particular. QUESTIONS/PURPOSES: Are patients with opioid use disorder who undergo (1) primary THA, (2) primary TKA, (3) revision THA, or (4) revision TKA at a higher risk of experiencing SSIs 90 days after surgery or PJIs 2 years after surgery than those who do not have opioid use disorder? METHODS: All primary and revision TJAs performed between 2005 and 2014 were identified from the Medicare Analytical Files of the PearlDiver Supercomputer using ICD-9 codes. This database is one of the largest nationwide databases; it comprehensively and longitudinally tracks patients based on all insurance claims rather than particular hospital visits, and has a low error rate (estimated at 1.3%). Boolean command operators were used to form a study group of patients with a history of opioid use disorder before surgery. ICD-9 diagnosis codes 304.00 to 304.02 and 305.50 to 305.52 were used to identify patients with opioid use disorder. Study group patients were matched 1:1 to control participants without opioid use disorder undergoing TJA, according to age, sex, and comorbidity burden (Elixhauser comorbidity index [ECI]). The ECI is comprised of 31 different comorbidities and can be used for large administrative databases. The query yielded a study population of 54,332 patients: 14,944 undergoing primary THA (opioid use disorder: n = 7472), 23,680 undergoing primary TKA (opioid use disorder: n = 11,840), 8116 undergoing revision THA (opioid use disorder: n = 4058), and 7592 undergoing revision TKA (opioid use disorder: n = 3796). The primary outcomes analyzed were SSI at 90 days and PJI at 2 years postoperatively, which were identified with ICD-9 codes. Logistic regression analyses were performed to calculate the risk that an infection would develop in a patient with opioid use disorder compared with the matched control patients without opioid use disorder. RESULTS: Patients with opioid use disorder undergoing primary THA had an increased risk of SSI at 90 days (OR 1.85 [95% CI 1.51 to 2.25]; p < 0.001) and PJI at 2 years (OR 1.66 [95% CI 1.42 to 1.93]; p < 0.001). Compared with matched controls, opioid use disorder patients undergoing primary TKA had an increased risk of SSI at 90 days (OR 1.72 [95% CI 1.46 to 2.02]; p < 0.001) and PJI at 2 years (OR 1.31 [95% CI 1.16 to 1.47]; p < 0.001). Similarly, for revision THAs, there was an increase in 90-day SSIs (OR 1.89 [95% CI 1.53 to 2.32]; p < 0.001) and 2-year PJIs (OR 4.24 [95% CI 3.67 to 4.89]; p < 0.001). The same held for revision TKAs for 90-day SSIs (OR 1.88 [95% CI 1.53 to 2.29]; p < 0.001) and 2-year PJIs (OR 4.94 [95% CI 4.24 to 5.76]; p < 0.001). CONCLUSIONS: After accounting for age, sex, and comorbidity burden, these results revealed that patients with opioid use disorder undergoing TJA were at increased risk of having SSIs and PJIs. Based on these findings, healthcare systems and/or administrators should recognize the increased associated PJI and SSI risks in patients with opioid use disorder and enact clinical policies that reflect these associated risks. Additionally, these findings should encourage surgeons to pursue multidisciplinary approaches to help patients reduce their opioid consumption before their arthroplasty procedure. LEVEL OF EVIDENCE: Level III, therapeutic study.

What Are Risk Factors for Infection after Primary or Revision Total Joint Arthroplasty in Patients Older Than 80 Years?

BACKGROUND: Patients older than 80 years of age form an increasing proportion of the patient population undergoing total joint arthroplasty (TJA). With increasing life expectancy and the success of TJA, orthopaedic surgeons are more likely to operate on patients older than 80 years than ever before. Given that most other studies focus on younger populations, only evaluate primary TJA, or limit patient populations to institutional or regional data, we felt a large-database, nationwide analysis of this demographic cohort was warranted, and we wished to consider both primary and revision TJA. QUESTIONS/PURPOSES: In this study, we sought to investigate the risk factors for surgical site infections (SSIs) at 90 days and periprosthetic joint infections (PJIs) at 2 years after surgery in patients aged 80 years and older undergoing (1) primary and (2) revision lower extremity TJA. METHODS: All patients aged 80 years or older who underwent primary or revision TJA between 2005 and 2014 were identified using the Medicare Analytical Files of the PearlDiver Supercomputer using ICD-9 codes. This database is unique in that it is one of the largest nationwide databases, and so it provides a large enough sample size of patients 80 years or older. Additionally, this database provides comprehensive and longitudinal patient data tracking, and a low error rate. Our final cohort consisted of 503,241 patients (TKA: n = 275,717; THA: n = 162,489; revision TKA: n = 28,779; revision THA: n = 36,256). Multivariate logistic regression models were constructed to evaluate the association of risk factors on the incidences of 90-day SSI and 2-year PJI. Variables such as sex, diabetes, BMI, and congestive heart failure, were included in the multivariate regression models. Several high-risk comorbidities as identified by the Charlson and Elixhauser comorbidity indices were selected to construct the models. We performed a Bonferroni-adjusted correction to account for the fact that multiple statistical comparisons were made, with a p value < 0.002 being considered statistically significant. RESULTS: For primary TKA patients, an increased risk of 90-day SSIs was associated with male sex (OR 1.28 [95% CI 1.25 to 1.52]; p < 0.001), BMI greater than 25 k/m (p < 0.001), and other comorbidities. For primary THA patients, an increased risk of 90-day SSIs was associated with patients with obesity (BMI 30-39 kg/m; OR 1.91 [95% CI 1.60 to 2.26]; p < 0.001) and those with morbid obesity (BMI 40-70 kg/m; OR 2.58 [95% CI 1.95 to 3.36]; p < 0.001). For revision TKA patients, an increased risk of SSI was associated with iron-deficiency anemia (OR 1.82 [95% CI 1.37 to 2.28]; p < 0.001). For revision THA patients, electrolyte imbalance (OR 1.48 [95% CI 1.23 to 1.79]; p < 0.001) and iron-deficiency anemia (OR 1.63 [95% CI 1.35 to 1.99]; p < 0.001) were associated with an increased risk of 90-day SSI. Similar associations were noted for PJI in each cohort. CONCLUSIONS: These findings show that in this population, male sex, obesity, hypertension, iron-deficiency anemia, among other high-risk comorbidities are associated with a higher risk of SSIs and PJIs. Based on these findings, orthopaedic surgeons should actively engage in comanagement strategies with internists and other specialists to address modifiable risk factors through practices such as weight management programs, blood pressure reduction, and electrolyte balancing. Furthermore, this data should encourage healthcare systems and policy makers to recognize that this patient demographic is at increased risks for PJI or SSI, and these risks must be considered when negotiating payment bundles. LEVEL OF EVIDENCE: Level III, therapeutic study.

The transition of total elbow arthroplasty into the outpatient theater.

BACKGROUND: Outpatient total joint arthroplasty is increasing in frequency as reimbursement models change. Potential benefits include same-day surgery for patients and decreased exposure to nosocomial pathogens. This study aims to determine if total elbow arthroplasty (TEA) is also trending toward an outpatient setting, and if there is any impact on complication rates as a result. METHODS: A retrospective chart review of the American College of Surgeons National Surgical Quality Improvement Program was performed. Specifically, the database was queried for all patients with CPT code 24363 from 2010-2017. The percentage of TEAs performed each year as an outpatient was trended from 2010-2017. Additionally, the complication rate between the inpatient and outpatient cohorts was compared. RESULTS: A total of 524 TEAs were analyzed. Of these, 111 procedures (21.2%) were performed as an outpatient. There was a statistically significant increase in the percentage of outpatient TEAs from 2010-2017 (P = .0016). In 2010, 2.4% of TEAs were outpatient, compared with 34.5% in 2017. The total complication rate trended toward being lower in the outpatient group, but this difference was not statistically significant (P = .08). CONCLUSIONS: There is a significant trend toward TEA being performed as an outpatient procedure, with more than one-third currently being performed in this manner. In our study, there was no difference in the complication rate between inpatient and outpatient TEAs; in fact, outpatient TEAs trended toward having a lower complication rate than inpatient TEAs. Taken together, the outpatient setting comprises an ever-increasing segment of TEA without an increase in morbidity to patients.

Subchondral insufficiency fractures of the femoral head: systematic review of diagnosis, treatment and outcomes.

Subchondral insufficiency fractures of the femoral head (SIFFH) are a cause of femoral head collapse leading to degenerative hip disease. SIFFH is often mistaken for osteonecrosis given similar clinical and radiographic features. These similarities often lead to missed or delayed diagnosis which can often delay or change management. The purpose of this article is to systematically review the spectrum of demographics, diagnostic and treatment options, including hip preservation in young patient populations. A systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. All related peer-reviewed publications from January 1999 to January 2019 were reviewed using the following databases: Medline, EMBASE, Scopus and Web of Science. The systematic review identified 54 articles, encompassing 482 patients (504 hips) diagnosed with SIFFH. One hundred and seventy-six (35%) males and 306 (63%) females were included, with a mean age of 53.6 ± 17.5 years and mean body mass index of 23.4 ± 4.0 kg/m2. Mean follow-up was 23.4 ± 15.9 months. Treatment decisions were 256 (55%) non-operative, 157 (34%) total hip arthroplasty (THA), 24 (5%) transtrochanteric anterior rotational osteotomy, 9 (2%) hip arthroscopy, 7 (2%) hip resurfacing, 3 (1%) bone grafting, 3 (1%) hemiarthroplasty and 1 (1%) tantalum rod insertion. Overall, 35% of SIFFH hips were converted to THA at latest follow-up. A majority of SIFFH patients had symptom resolution with non-operative management. Failure most often resulted in THA. In younger patients, hip preservation techniques have shown promising early results and should be considered as an alternative.

Does Hypothyroidism Increase Complications, Lengths of Stay, Readmissions, and Costs Following Primary 1- to 2-Level Lumbar Fusion?

STUDY DESIGN: Level III-retrospective review. OBJECTIVE: To evaluate the impact of hypothyroidism in patients undergoing 1- to 2-level lumbar fusion (1-2LF). SUMMARY OF BACKGROUND DATA: Hypothyroidism is a common cause of morbidity and mortality following surgery. Studies have demonstrated the effects of hypothyroidism following orthopedic surgery, but not 1-2LF. MATERIALS AND METHODS: Patients undergoing 1-2LF with hypothyroidism were identified within the Medicare population, and served as the study group. Study group patients were randomly matched to controls in a 1:5 ratio by age, sex, and medical comorbidities. Primary outcomes analyzed included in-hospital lengths of stay (LOS), 90-day readmission rates, 90-day medical complications, and costs of care. Pearson χ tests were used to compare patient demographics. Logistic regression analyses were used to calculate odds ratios (OR) for medical complications and readmissions. Welch t test was used to test for significance in cost between the cohorts. An α value <0.002 was considered statistically significant. RESULTS: The query yielded 417,483 patients who underwent 1-2LF with (n=69,584) and without (n=347,899) hypothyroidism. Hypothyroid patients had significantly longer in-hospital LOS (8 vs. 4 d; P<0.0001) compared with controls. In addition, study group patients had significantly higher incidence and odds of 90-day readmissions (20.22% vs. 17.62%; OR, 1.18; P<0.0001) and 90-day medical complications (6.38% vs. 1.89%; OR, 3.53; P<0.0001) compared with controls. Study group patients had higher day of surgery costs ($97,304.01 vs. $95,168.35; P=0.014) and 90-day costs of care ($113,514.15 vs. $108,860.60; P=0.0001) compared with controls. CONCLUSIONS: After adjusting for age, sex, and medical comorbidities, the study demonstrates patients who have hypothyroidism have longer in-hospital LOS and higher rates of readmissions, complications, and costs. The study is vital as it can allow orthopedic surgeons to adequately counsel and educate these patients of the potential complications that may occur following their procedure.

Carpal Fractures Other than Scaphoid in the Athlete.

Carpal fractures of bones other than the scaphoid occur at a much lower rate than scaphoid fractures. The close relationship between the carpus, intrinsic and extrinsic wrist ligaments, and wrist kinematics makes a thorough history, clinical examination, and interpretation of imaging for carpal malalignment essential. Carpal malalignment should be addressed with reduction and fixation. Nondisplaced fractures are often treated nonoperatively and displaced intraarticular fractures are almost always treatment operatively. The physician should keep in mind the athlete's specific goals and needs. Treatment must be individualized. Options for early return to play should be discussed when possible.

Reevaluation of the Scaphoid Fracture: What Is the Current Best Evidence?

Scaphoid fractures are common and notorious for their troublesome healing. The aim of this review is to reevaluate the current best evidence for the diagnosis, classification, and treatment of scaphoid fractures and nonunions. MRI and CT are used to establish a "definitive diagnosis" with comparable diagnostic accuracy although neither is 100% specific. Current classifications cannot reliably predict union or outcomes; hence, a descriptive analysis of fracture location, type, and extent of displacement remains most useful. Treatment of a nondisplaced scaphoid waist fracture remains an individualized decision based on shared decision-making. Open reduction and internal fixation may be preferred when fracture displacement exceeds 1 mm, and the fracture is irreducible by closed or percutaneous means. For unstable nonunions with carpal instability, either non-vascularized cancellous graft with stable internal fixation or corticocancellous wedge grafts will provide a high rate of union and restoration of carpal alignment. For nonunions characterized with osteonecrosis of the proximal pole, vascularized bone grafting can achieve a higher rate of union.

Overcoming the Axillary Nerve Blind Spot Through the Deltopectoral and Axillary Approaches: A Cadaveric Study.

PURPOSE: The aim of this study was to evaluate the feasibility of exploring the axillary nerve (AN) at the 6 o'clock position (blind spot) using the deltopectoral approach, with the interval lateral to the conjoint tendon (CJT) or combined with the axillary approach. METHODS: Four ANs were dissected combining the deltopectoral approach-medial to the CJ (A), the deltopectoral approach-lateral to the CJT (B) and the axillary approach (C) in 3 sequences: A-B-C, B-A-C, and C-B-A. After the first approach was completed, the proximal and distal margins were marked. Additional exposure with the second and third approaches and the 6 o'clock position were also marked. Then, the AN was excised and the amount of exposed nerve with the 3 approaches was measured. RESULTS: The deltopectoral approach-medial to the conjoint tendon did not allow exposure of the AN at the 6 o'clock position. Six o'clock position exposure was accomplished using the lateral interval of the deltopectoral and the axillary approaches. A deltopectoral approach lateral to the CJT allowed exploration of the AN at the blind spot, but not the terminal branches. The axillary approach was able to expose the AN at the 6 o'clock position, the terminal branches, but not the nerve-muscle junction. Combining the 3 approaches exposed 81% to 94% of the total length of the AN. CONCLUSIONS: The deltopectoral approach allowed visualization of the AN at the 6 o'clock position when explored lateral to the CJT. The axillary approach allowed visualization of the terminal branches of the AN and the 6 o'clock position of the glenoid. CLINICAL RELEVANCE: The deltopectoral approach lateral to the conjoint tendon allows the surgeon to assess continuity of the AN at the 6-o'clock position and to perform a neurolysis. If nerve repair, nerve grafting, or nerve transfer is attempted, a combination of the 3 approaches could be used.

Cadaveric Evaluation of Myelinated Nerve Fiber Count in the Nerve to the Gracilis Muscle in Relation to Use as a Free Functional Muscle Transfer for Elbow Flexion.

BACKGROUND: Optimizing axon count is essential for successful nerve transfer surgery, and a donor-to-recipient axon count ratio greater than 0.7:1 has been associated with improved outcomes. A gracilis free functioning muscle transfer (FFMT) is an option to restore elbow flexion, but its axon count has not been evaluated. Our aim was to quantify the axon count of the nerve to the gracilis muscle. METHODS: The nerve to the gracilis was dissected in 10 fresh frozen adult cadaveric hindquarter specimens (four females and six males). The length of the nerve to the gracilis was measured and a biopsy taken. A validated histologic preparation technique was utilized, and axons were counted. The mean length and axon counts were calculated. RESULTS: The average axon count in the nerve to the gracilis was 818 (range = 684-1,000, standard deviation [SD] = 116). The average length was 98 mm (range = 81-115 mm, SD = 13 mm). CONCLUSION: Our study found the average axon count in the nerve to the gracilis was 818. Prior literature suggests axon count ratio greater than 0.7:1 is associated with better clinical outcomes. Using data from prior studies, the spinal accessory, three intercostal, and two intercostal nerves are all sufficient for the transfer to the nerve to the gracilis with donor to recipient ratios of 1.7:1, 1.3:1, and 0.9:1, respectively.