The Use of Patient-Specific Implants for the Treatment of Upper Extremity Fractures.

In this article, we discuss the use of three-dimensional (3-D) printed patient-specific implants in the management of upper extremity fractures. Traditional fracture fixation methods involve the use of standard-sized implants, which may not adequately address the needs of every patient, particularly those who have complications related to fracture nonunion or malunion and those who have significant bone loss. The benefits and limitations of this technology are also discussed, along with considerations for implementation in clinical practice. Overall, the use of 3-D printed patient-specific implants holds promise for improving the accuracy and efficacy of upper extremity fracture management.

Early Outcomes of Combined Total Ankle Total Talus Replacement Using a 3D-Printed Talus Component With Hindfoot Arthrodesis.

Late-stage talar avascular necrosis (AVN) results in devascularization of the talus with osteonecrosis and subchondral collapse. A combined total ankle and total talus replacement (TATTR) with hindfoot arthrodesis may be utilized for end-stage talar AVN with tibiotalar and hindfoot joint arthritis. The purpose of this study is to evaluate the short-term outcomes of combined TATTR with hindfoot arthrodesis. Patients who underwent a combined TATTR or TTR with a hindfoot arthrodesis (subtalar with or without talonavicular arthrodesis) from 2016 to 2020 were retrospectively reviewed. Patient demographics, comorbidities, and surgical data were collected. Outcomes included the Visual Analog Scale (VAS) scores, range of motion, radiographic parameters, union rates, and complications. A total of 18 patients were reviewed. Nine patients were included with an average of 19.4 months follow-up. Significant postoperative improvements were observed in VAS scores (P < .001), ankle plantarflexion (P = .04), talocalcaneal height (P = .03), and tibiotalar alignment (P = .02). All patients achieved a successful union of their subtalar and talonavicular joints arthrodesis. There was one reoperation for a persistent varus ankle deformity. This is the first study to evaluate the clinical outcomes, radiographic outcomes, and union rate in combined TATTR with hindfoot arthrodesis. The early results demonstrated significant clinical improvement with 100% hindfoot union rate and no prosthetic failure.Level of Evidence: IV.

Ulnar Resection Length: A Risk Factor for Nonunion in Ulnar Shortening Osteotomy.

BACKGROUND: Nonunion rates following ulnar shortening osteotomy (USO) are reported up to 18% with few known risk factors. While resection length is variable in practice, little is known about the prognostic implications on healing. The purpose of this study was to evaluate whether longer resection lengths increased the odds of nonunion. METHODS: A retrospective review was performed on patients who underwent an elective USO at a single institution over a 6-year period. Demographic, social, comorbidity, and surgical data were reviewed. Ulnar resection length was obtained from operative notes and dichotomized into smaller (<5.5 mm) and larger (≥5.5 mm) groups. The primary outcome was the rate of nonunion. Univariate analyses and a multivariable logistic regression model were used to assess for significant predictors of nonunion. RESULTS: A total of 87 patients were included with a mean age of 45 years. Patient comorbidities included 12.6% with diabetes, 29.9% with an American Society of Anesthesiologists score of ≥ 3, 5.8% reporting current tobacco use, and 29.9% reporting former tobacco use. There were 55 patients (63.2%) with resection lengths < 5.5 mm and 32 patients (36.8%) with ≥ 5.5 mm resections. Multivariable analysis identified longer resection length (≥5.5 mm) and current tobacco use as independent risk factors for nonunion. Patients with a resection length of ≥ 5.5 mm had 20.2 times greater odds of nonunion compared with patients with smaller resections, and current smokers had 72.2 times greater odds of nonunion compared with nonsmokers. CONCLUSION: Longer ulnar resection length (≥5.5 mm) significantly increases the risk of nonunion following USO.

Influence of medical comorbidity and surgical indication on total elbow arthroplasty cost of care.

BACKGROUND: Movement toward providing value-based musculoskeletal care requires understanding the cost associated with surgical care as well as the drivers of these costs. The aim of this study was to investigate the effect of common medical comorbidities and specific total elbow arthroplasty (TEA) indications on reimbursement costs throughout the 90-day TEA episode of care. The secondary aim was to identify the drivers of these costs. METHODS: Administrative health claims for patients who underwent orthopedic intervention between 2010 and 2020 were queried using specific disease classification and procedural terminology codes from a commercially available national database of 53 million patients. Patients with commercial insurance were divided into various cohorts determined by different surgical indications and medical comorbidities. The reimbursement costs of the surgical encounter, 89-day postoperative period, and total 90-day period in each cohort were evaluated. The cost drivers for the 89-day postoperative period were also determined. Analyses were performed using descriptive statistics and the Kruskal-Wallis test for comparison. RESULTS: A total of 378 patients who underwent TEA were identified. The mean reimbursement cost of the surgical encounter ($13,393 ± $8314) did not differ significantly based on patient factors. The mean reimbursement cost of the 89-day postoperative period ($4232 ± $2343) differed significantly when stratified by surgical indication (P < .0001) or by medical comorbidity (P < .0001). The indication of rheumatoid arthritis ($4864 ± $1136) and the comorbidity of chronic kidney disease ($5873 ± $1165) had the most expensive postoperative period. In addition, the total 90-day reimbursement cost ($16,982 ± $4132) differed significantly when stratified by surgical indication (P = .00083) or by medical comorbidity (P < .0001), with the indication of acute fracture ($18,870 ± $3971) and the comorbidity of chronic pulmonary disease ($19,194 ± $3829) showing the highest total 90-day cost. Inpatient costs related to readmissions represented 38% of the total reimbursement cost. The overall readmission rate was 5.0%, and the mean readmission cost was $16,296. CONCLUSION: TEA reimbursements are significantly influenced by surgical indications and medical comorbidities during the postoperative period and the total 90-day episode of care. As the United States transitions to delivering value-based health care, the need for surgeons and policy makers to understand treatment costs associated with different patient-level factors will expand.

Endoscopic Proximal Hamstring Repair Is Safe and Efficacious With High Patient Satisfaction at a Minimum of 2-Year Follow-Up.

PURPOSE: To evaluate the short-term outcomes of endoscopic proximal hamstring repair including clinical outcomes, patient-reported outcomes, and complications. METHODS: A retrospective analysis was performed on consecutive patients who underwent endoscopic proximal hamstring repair from 2013-2018 by a senior sports medicine orthopaedic surgeon. Demographic, operative, clinical data, complications, and patient-reported outcomes were collected and analyzed including the International Hip Outcome Tool-12 (iHOT-12), Single Assessment Numeric Evaluation (SANE), modified Harris Hip Score (mHHS), and the Hip Outcome Score activities of daily living scale (HOS-ADL). RESULTS: Thirty patients were included with a minimum 24.0- and average 44.0-month follow-up. The average age was 52.0 years (standard deviation [SD], 14.2), and 80.0% (n = 24) were women. Most patients presented with a history of refractory insertional tendinosis (83.3%, n = 25) and an average of 34.0 months of symptoms prior to surgical intervention. Two-year patient-reported outcomes were clinically acceptable with a postoperative iHOT-12 of 81.9 (SD, 21.1), SANE 78.8% (SD, 20.0), mHHS 89.6 (SD 13.4), and HOS-ADLs 87.2% function (SD, 15.9). Nine patients (30%) had available preoperative iHOT-12 scores. Among these patients, the mean increase in iHOT-12 was 46.3 (P = .0005; n = 9). Eighty percent (n = 24) of patients achieved the iHOT-12 patient acceptability symptomatic state. Complications (3%) included 1 atraumatic rerupture. Four patients participated in an organized sport and 18 in recreational sport with a return to play of 100% and 72.2%, respectively. All patients returned to work. Some 76.7% (n = 23) of patients reported return to their baseline level of physical activity, and 73.3% (n=22) of patients reported complete resolution of pain at last follow-up. There was a 90.0% (n=27) satisfaction rate. CONCLUSIONS: Short-term follow-up for endoscopic proximal hamstring repair shows high patient satisfaction (90.0%) and clinically significant patient-reported outcomes with minimal residual pain and a low complication rate (3%). LEVEL OF EVIDENCE: IV, retrospective case series.

The Intrarater and Inter-rater Reliability of Radiographic Evaluation of the Posterior Tibial Slope in Pediatric Patients.

BACKGROUND: In young athletes, an association exists between an increased posterior tibial slope (PTS) and the risk of primary anterior cruciate ligament (ACL) injury, ACL graft rupture, contralateral ACL injury, and inferior patient reported outcomes after ACL reconstruction. In spite of this, there is no consensus on the optimal measurement method for PTS in pediatric patients. The purpose of this study was to evaluate the reliability of previously described radiographic PTS measurement techniques. METHODS: A retrospective review was performed on 130 patients with uninjured knees between the ages of 6 and 18 years. The medial PTS was measured on lateral knee radiographs by four blinded reviewers using three previously described methods: the anterior tibial cortex (ATC), posterior tibial cortex (PTC), and the proximal tibia anatomic axis (PTAA). The radiographs were graded by each reviewer twice, performed 2 weeks apart. The intrarater and inter-rater reliability were assessed using the intraclass correlation coefficient (ICC). Subgroup analyses were then performed stratifying by patient age and sex. RESULTS: The mean PTS were significantly different based on measurement method: 12.5 degrees [confidence interval (CI): 12.2-12.9 degrees] for ATC, 7.6 degrees (CI: 7.3-7.9 degrees) for PTC, and 9.3 degrees (CI: 9.0-9.6 degrees) for PTAA (P<0.0001). Measures of intrarater reliability was excellent among all reviewers across all 3 methods of measuring the PTS with a mean ICC of 0.87 (range: 0.82 to 0.92) for ATC, 0.83 (range: 0.82 to 0.87) for PTC, and 0.88 (range: 0.79 to 0.92) for PTAA. The inter-rater reliability was good with a mean ICC of 0.69 (range: 0.62 to 0.83) for the ATC, 0.63 (range: 0.52 to 0.83) for the PTC, and 0.62 (range: 0.37 to 0.84) for the PTAA. Using PTAA referencing, the PTS was greater for older patients: 9.9 degrees (CI: 7.7-9.4 degrees) vs 8.5 degrees (CI: 9.2-10.7 degrees) (P=0.0157) and unaffected by sex: 9.5 degrees (CI: 8.8-10.1 degrees) for females and 9.0 degrees (CI: 8.0-10.0) for males (P=0.4199). There were no major differences in intrarater or inter-rater reliability based on age or sex. CONCLUSIONS: While the absolute PTS value varies by measurement technique, all methods demonstrated an intrarater reliability of 0.83 to 0.88 and inter-rater reliability of 0.61 to 0.69. However, this study highlights the need to identify PTS metrics in children with increased inter-rater reliability. LEVEL OF EVIDENCE: IV, Case series.

Risk of suprascapular nerve injury during glenoid baseplate fixation for reverse total shoulder arthroplasty: a cadaveric study.

BACKGROUND: Reverse total shoulder arthroplasty (rTSA) is an effective treatment for patients with advanced rotator cuff arthropathy. During implantation of the glenoid baseplate, screws are inserted through the glenoid face into the scapular body to achieve adequate fixation. Placement of peripheral baseplate screws in the superior and posterior glenoid may increase the risk of injury to the suprascapular nerve (SSN). The purpose of this cadaveric study was to evaluate the risk of SSN injury with placement of baseplate screws in the superior and posterior direction. METHODS: Twelve cadaveric shoulders were implanted with glenoid baseplates. A bicortical 44-mm screw was placed in both the superior and posterior glenoid baseplate screw holes. Following implantation, the SSN was dissected and visualized through a posterior shoulder approach. The distance from the tip of the screws to the SSN and the distance from the screw's scapular exiting hole to the SSN was recorded. Average distances were calculated for each measurement. RESULTS: The superior screw contacted the SSN in 8 of the 12 specimens (66%). For the superior screw, the average distance from the exiting point in the scapula to the SSN was 9.2 ± 6.3 mm, with the shortest distance being 3.9 mm. The posterior screw contacted the SSN in 6 of 12 specimens (50%). For the posterior screw, the average distance from the exiting point to the SSN was 8.9 ± 3.8 mm, with the shortest distance to the nerve being 2.2 mm. CONCLUSION: Placement of the superior and posterior screws in the glenoid baseplate during rTSA risks injury to the SSN. The safe zone for superior- and posterior-directed baseplate screw is <2 mm from its exiting point on the scapula. Therefore, precise measurements of screw lengths in this area is important in avoiding injury to the SSN.

Rotator cuff to deltoid and pectoralis tendon to anatomic neck distances: methods for anatomic restoration of humeral height and tuberosity position in proximal humerus fractures for operative fixation and arthroplasty.

INTRODUCTION: Proper anatomic tuberosity reduction and restoration of humeral height during surgical treatment of proximal humerus fractures leads to fewer complications and better outcomes. In the presence of significant displacement and comminution in proximal humerus fractures, the assessment of the correct tuberosity position and humeral height can be challenging. The goal of this cadaveric study was to provide new and useful measurements for intraoperative guidance of proper tuberosity position and humeral height when treating proximal humerus fractures with open reduction internal fixation, anatomic hemiarthroplasty, or reverse total shoulder arthroplasty. METHODS: A total of 28 cadaveric shoulders were dissected with a deltopectoral approach. The distance between the insertion of the supraspinatus tendon and the superior aspect of the deltoid tendon was measured (cuff to deltoid distance [CDD]). Secondly, the distance between the superior aspects of the pectoralis major tendon to the medial aspect of the anatomic neck (PND) was measured. Further, we sought to determine if these measurements would correlate to patient height and differ between gender. RESULTS: The average age of the donors was 65.3 years (64% male). The CDD and PND were 87.6 ± 10.6 and 16.6 ± 6.9 mm, respectively (mean ± standard deviation). There were no differences between females and males for the CDD (86.9 ± 9.4 vs. 87.2 ± 15.2 mm, P = .96) and PND (16.3 ± 9.1 vs. 17.1 ± 5.9 mm, P = .76). There was no correlation between the cadaver height and CDD (R2 = 0.1) and PND (R2 = 0.3). DISCUSSION: In this study, we describe 2 new measurement tools that can readily be applied intraoperatively during surgical treatment of proximal humerus fractures to aid in tuberosity reduction and humeral height assessment. These measurements were found to be independent of patient height and gender and can be used as a reference tool for most patients.

Systematic Review of Subtalar Distraction Arthrodesis for the Treatment of Subtalar Arthritis.

BACKGROUND: Subtalar distraction arthrodesis (SDA) was developed as a means of treating the symptoms of subtalar arthritis. Despite almost 30 years of research in this field, many controversies still exist regarding SDA. The objective of this study was to present an overview of outcomes following SDA, focusing on surgical technique as well as clinical and radiographic results. METHODS: MEDLINE and EMBASE were queried and data abstraction was performed by 2 independent reviewers. Inclusion criteria for the articles were (1) English language, (2) peer-reviewed clinical studies with evidence levels I to IV, (3) with at least 5 patients, and (4) reporting clinical and/or radiographic outcomes of SDA. RESULTS: Twenty-five studies matched the inclusion criteria (2 Level III and 23 Level IV studies) including 492 feet in 467 patients. The most common indication for SDA was late complications of calcaneus fractures. Many different operative techniques have been described, and there is no proven superiority of one method over the other. The most commonly reported complications were nonunion, hardware prominence, wound complications, and sural neuralgia. All studies showed both radiographic and clinical improvement at the last follow-up visit compared with the preoperative evaluation. Pooled results (12 studies, 237 patients) demonstrated improved American Orthopaedic Foot & Ankle Society ankle-hindfoot scores with a weighted average of 33 points of improvement. CONCLUSION: SDA provides good clinical results at short-term and midterm follow-up, with improvement in ankle function as well as acceptable complication and failure rates. Higher quality studies are necessary to better assess outcomes between different operative techniques. LEVEL OF EVIDENCE: Level III.

Neurocranial shape variation among Tarascan populations: Evidence for varying degrees in artificially modified crania in pre-Hispanic West Mexico (1200-1400 AD).

INTRODUCTION: Along the Mesoamerican western margin, the Zacapu basin has yielded a large number of human remains demonstrating usage of artificial cranial modification (ACM). However, at the onset of the Middle Postclassic (1200-1400 AD) only few individuals still exhibit clear signs of ACM. Some authors have suggested that, rather than disappearing entirely, ACM may have become less visible anatomically, making it difficult to identify based on simple visual analyses. Here, we used 3D geometric morphometric methods to investigate the extent to which ACM persisted during the Postclassic in this region. MATERIALS AND METHODS: We measured the 3D vault's shape changes in a sample of surface-scanned human crania: 55 individuals from the Postclassic Zacapu basin and a control group of 31 individuals from a Huichol Mexican Indian sample and a French medieval series from La Granède. We used a principal component analysis to explore the shape variation within the sample and employed the neighbor joining method to identify morphological groups. Finally, we quantified each individual's asymmetry. RESULTS: We identified three groups displaying shape features diverging from those of the control group. The first group is characterized by marked fronto-obelionic ACM, whereas the other two show mild forms of ACM. The individuals in all three groups display moderate to high degrees of asymmetry compared to the control group. DISCUSSION: The marked fronto-obelionic modification is clear evidence of a specific ACM technique. The two types of mild ACM most likely result from different techniques but their moderate degree of modification brings into question the intentions behind their production.

Priorities of Care Among Older Adults in the Emergency Department: A Cross-sectional Study.

OBJECTIVES: Emergency departments (EDs) are an increasingly important site of care for older adults, but little is known about the priorities of emergency care in this population. We sought to describe and rank priorities of care among older adults receiving care in the ED. METHODS: We conducted a cross-sectional study of cognitively intact patients aged 65 years and older receiving care in two U.S. EDs. Participants provided up to three open-ended responses to a single question asking what would make their ED visit successful, useful, or valuable. A literature review and patient responses were used to generate priority categories and larger metacategories. Each response was then assigned to one of the categories by independent reviewers. We report the percentage of patients identifying a priority in each category and metacategory and the relative weight of each category based on the frequency and order of priorities provided by patients. RESULTS: A total of 185 participants provided 351 priorities. Twenty-four categories and seven metacategories were identified. Sixty-two percent (N = 114) of participants reported at least one priority in the "evaluation, treatment, and outcomes" metacategory. Of these, the most common priorities included treatment of the medical problem (n = 37, 20%), accurate diagnosis (n = 36, 19%), competent staff and provider (n = 28, 15%), and desirable health outcome (n = 24, 13%). The second and third most common metacategories were "timely care" (n = 67, 36%), and "service" (n = 38, 21%). Nineteen patients (10%) expressed a desire to be discharged; one patient (1%) expressed a desire for admission. The ranking of weighted priorities were identical to the unweighted rank order by frequency. CONCLUSIONS: Among a sample of cognitively intact older ED patients, the most common priorities were related to the accuracy and efficiency of the medical evaluation. These priorities should be considered by those attempting to improve the emergency care of older adults.

Pain, distress, and anticipated recovery for older versus younger emergency department patients after motor vehicle collision.

BACKGROUND: Motor vehicle collisions (MVCs) are the second most common injury mechanism resulting in emergency department (ED) visits by older adults. MVCs result in substantial pain and psychological distress among younger individuals, but little is known about the occurrence of these symptoms in older individuals. We describe the frequency of and characteristics associated with pain, distress, and anticipated time for physical and emotional recovery for older adults presenting to the ED after MVC in comparison to younger adults. METHODS: In-person interviews were conducted for adults presenting to one of eight EDs after MVC without an obvious fracture or injury requiring admission as part of two prospective studies. Pain severity was assessed using a 0-10 verbal scale. Distress was assessed using the Peritraumatic Distress Inventory (range 0-52). Patients were asked to estimate their expected time for physical and emotional recovery; these responses were dichotomized to <30 or ≥30 days. ED pain and distress and associations between patient and collision characteristics and ED pain and distress were examined for patients age 65 years and older and patients age 18 to 64. RESULTS: Older (n = 96) and younger (n = 943) adults had the same mean pain scores (5.5, SD 2.5 vs. 5.5, SD 2.4). Distress scores were lower in older than in younger adults (15.5, SD 9 vs. 19.2, SD 10). A higher percentage of older adults than younger adults had an anticipated time to physical recovery ≥30 days (41%, 95% confidence interval [CI] 28%-55% vs. 11%, 95% CI 9%-13%). Similarly, older adults were more likely to have an anticipated time for emotional recovery ≥30 days (45%, 95% CI 35%-55% vs. 17%, 95% CI 15%-20%). Older adults were less likely than younger adults to have moderate or severe neck pain (score ≥4) (25%, 95% CI 23% to 41% vs. 54%, 95% CI 48% to 60%) or back pain (31%, 95% CI 23% to 46% vs. 56%, 95% CI 51 to 62%) but more likely to have moderate or severe chest pain (42%, 95% CI 32% to 50% vs. 20%, 95% CI 16 to 23%). Pre-MVC depressive symptoms and pain catastrophizing were positively associated with pain and distress in both older and younger adults. CONCLUSIONS: In our cohort, older adults who presented to the ED after MVC experienced similar pain severity as younger patients and less distress but were more likely to estimate their times for physical and emotional recovery to be 30 days or more. Increased emergency provider awareness of acute pain and distress symptoms among older patients experiencing MVC may improve outcomes for these patients.

Prevalence of nonmedical problems among older adults presenting to the emergency department.

OBJECTIVES: Health outcomes among older emergency department (ED) patients may be influenced by physical, economic, and psychological problems not routinely identified during the ED visit. The objective of this study was to characterize such problems among older adults presenting to the ED. METHODS: This was a prevalence study with enrollment during 4-hour periods randomly selected between 9 a.m. and 9 p.m. on random days of the week over a period of 8 weeks at an academic ED in the southeast United States. Participants were noninstitutionalized, cognitively intact adults aged 65 years or older without life-threatening illness or injury. Consenting patients were asked about the frequency of 10 prespecified problems during the past year. RESULTS: Patients (N = 138) were non-Hispanic white (69%) and female (57%) and almost all had primary providers (95%) and health insurance (98%). Forty percent reported their overall health as fair (21%) or poor (19%). Hazardous drinking habits were reported by 10% of patients. The prevalence of problems occurring either "sometimes" or "often" in the past year were pain (60%), difficulty walking (47%), lack of money (32%), isolation and loneliness (14%), lack of transportation (12%), difficulty scheduling a doctor's appointment (4%), difficulty getting prescriptions filled (4%), and lack of dental care (6%). Nine patients (7%) reported experiencing physical or psychological abuse at some point in the past year. Females, minorities, and individuals living in urban areas reported higher rates of most problems. CONCLUSIONS: Nonmedical problems are common among cognitively intact, independent living, non-critically ill older patients presenting to an ED in the southeast United States.