Femoral head collapse after hip intra-articular corticosteroid injection: An institutional response to improve practice and increase patient safety.

INTRODUCTION: Femoral head collapse (FHC) is a rarely reported complication of hip intra-articular corticosteroid injection (IACSI). Upon observing a high rate of FHC after hip IACSI, we sought to (1) describe how we addressed the problem through a systematic evaluation of clinical data and institutional care practices followed by process improvement efforts; and (2) report our results. METHODS: Patients receiving hip IACSI during a 27-month period underwent retrospective review to determine the rate of FHC and to identify associated patient factors or practice shortfalls. Findings led to institution-wide interventions: (1) to improve patient/provider awareness of this association; and (2) to develop/implement practice guidelines. Rates of FHC after hip IACSI and practice patterns among providers before and after intervention were compared. RESULTS: Initial FHC rate after hip IACSI was 20.4%. Patient-related factors included body mass index (p = 0.025), history of cancer therapy (p = 0.012), Vitamin D level (p = 0.030), and multiple injections (p = 0.004). Volume/dose of injectate and post-injection surveillance methods varied widely. Quality improvement (QI) intervention resulted in fewer treatment referrals (from 851 to 436), fewer repeat injections (mean = 1.61 to 1.37; p = 0.0006), and a 5% lower FHC rate (p = 0.1292). Variation in practice patterns persisted, so a systems-based Clinical Pathway was established. DISCUSSION: When a high rate of FHC after hip IACSI was found to be associated with certain patient and practice factors, introduction of education materials and treatment guidelines decreased number of referrals, number of injections per patient, and FHC rate. In the absence of the systems-based Pathway, the type, dose, and volume of injectate and post-procedure follow-up remained variable.

Risk of surgical site infection after carpal tunnel release performed in an operating room versus a clinic-based procedure room within a Veterans Affairs medical center.

BACKGROUND: Carpal tunnel release (CTR) is increasingly performed in a clinic-based procedure room (PR) environment, which is less restrictive than traditional operating rooms (ORs). It is unknown if there is an impact on surgical site infection (SSI) rates. METHODS: Records of patients who underwent clean, elective CTR from October 2014 to April 2017 at a single site were identified using Current Procedural Terminology codes and charts reviewed using National Healthcare Safety Network SSI criteria. Procedure type and patient characteristics were assessed with multivariate logistic regression and costs compared using administrative data. RESULTS: A total of 312 procedures were included: 221 in OR and 91 in PR. SSI rate, including revisions, was 2.88% (nonrevision rate was 2.30%). Unadjusted SSI rate was 3.2% in OR and 2.2% in PR (P = .64). After adjusting for underlying risk factors, procedure setting was not associated with risk of SSI (P = .53; odds ratio, 0.43; 95% confidence interval, 0.03-5.94). Revision CTR was a predictor of SSI (P = .02; odds ratio, 28.21; 95% confidence interval, 1.84-434.57). The mean total cost of CTR in the OR was $4,254.21 and PR was $416.93. CONCLUSIONS: There was no significant difference in SSI rates for CTR performed in OR and PR environments. CTRs performed in a PR led to a 10-fold cost savings. Based on our findings of PRs as both safe and cost-effective, we recommend that more facilities explore the use of PRs for CTR.

A Comparison of Four-Year Health Outcomes following Combat Amputation and Limb Salvage.

Little research has described the long-term health outcomes of patients who had combat-related amputations or leg-threatening injuries. We conducted retrospective analysis of Department of Defense and Department of Veterans Affairs health data for lower extremity combat-injured patients with (1) unilateral amputation within 90 days postinjury (early amputation, n = 440), (2) unilateral amputation more than 90 days postinjury (late amputation, n = 78), or (3) leg-threatening injuries without amputation (limb salvage, n = 107). Patient medical records were analyzed for four years postinjury. After adjusting for group differences, early amputation was generally associated with a lower or similar prevalence for adverse physical and psychological diagnoses (e.g., pain, osteoarthritis, posttraumatic stress disorder) versus late amputation and/or limb salvage. By contrast, early amputation was associated with an increased likelihood of osteoporosis during the first year postinjury. The prevalence of posttraumatic stress disorder increased for all patient groups over four years postinjury, particularly in the second year. The different clinical outcomes among combat extremity injured patients treated with early amputation, late amputation, or limb salvage highlight their different healthcare requirements. These findings can inform and optimize the specific treatment pathways that address the physical and psychological healthcare needs of such patients over time.

Glasgow Coma Scale scores, early opioids, and 4-year psychological outcomes among combat amputees.

Morphine and fentanyl are frequently used for analgesia after trauma, but there is debate over the advantages and disadvantages of these opioids. Among combat amputees, intravenous (IV) morphine (vs IV fentanyl) after injury was associated with reduced likelihood of posttraumatic stress disorder (PTSD). The previous results were based on military health diagnoses over 2 yr postinjury. The present study followed psychological diagnoses of patients with amputation for 4 yr using military and Department of Veterans Affairs health data. In-theater combat casualty records (n = 145) documented Glasgow Coma Scale (GCS) scores and/or morphine, fentanyl, or no opioid treatment within hours of injury. We found that (1) GCS scores were not significantly associated with PTSD; (2) longitudinal modeling using four (yearly) time points showed significantly reduced odds of PTSD for patients treated with morphine (vs fentanyl) across years (adjusted odds ratio = 0.40; 95% confidence interval = 0.17­0.94); (3) reduced PTSD prevalence for morphine (vs IV fentanyl; morphine = 25%, fentanyl = 59%, p < 0.05) was significant, specifically among patients with traumatic brain injury during the first 2 yr postinjury; and (4) PTSD prevalence, but not other disorders (e.g., mood), increased between year 1 (PTSD = 18%) and years 2 through 4 postinjury (PTSD range = 30%­32%).

Glasgow Coma Scores, early opioids, and posttraumatic stress disorder among combat amputees.

A recent study found that combat amputees had a reduced prevalence of posttraumatic stress disorder (PTSD) compared with nonamputees with serious extremity injuries. We hypothesized that an extended period of impaired consciousness or early treatment with morphine could prevent consolidation of traumatic memory and the development of PTSD. To examine this hypothesis, we retrospectively reviewed 258 combat casualty records from the Iraq or Afghanistan conflicts from 2001-2008 in the Expeditionary Medical Encounter Database, including medications and Glasgow Coma Scale (GCS) scores recorded at in-theater facilities within hours of the index injury. All patients sustained amputations from injuries. Psychological diagnoses were extracted from medical records for 24 months postinjury. None of 20 patients (0%) with GCS scores of 12 or lower had PTSD compared to 20% of patients with GCS scores of 12 or greater who did have PTSD. For patients with traumatic brain injury, those treated with intravenous morphine within hours of injury had a significantly lower prevalence of PTSD (6.3%) and mood disorders (15.6%) compared to patients treated with fentanyl only (prevalence of PTSD = 41.2%, prevalence of mood disorder = 47.1%). GCS scores and morphine and fentanyl treatments were not significantly associated with adjustment, anxiety, or substance abuse disorders.

Incidence of knee sepsis after ACL reconstruction at one institution: the impact of a clinical pathway.

BACKGROUND: After experiencing an unusually high incidence of knee sepsis after anterior cruciate ligament (ACL) reconstruction, we sought to (1) describe how we resolved this problem through temporary discontinuation of the procedure, formation of a multidisciplinary ACL Task Force, systematic investigation of clinical data and institutional care practices, and development and implementation of an evidence-based ACL Clinical Pathway (the Pathway); and (2) report our findings and results. METHODS: From 1999 through 2008, thirty-seven cases of knee sepsis after ACL reconstruction were recorded at our institution. In 2008 (yearly incidence, 4.4%), ACL reconstructions were temporarily suspended and a Task Force was assembled to (1) identify infection risk factors or epidemiological links among cases, (2) inspect environment and processes for possible infection sources, and (3) update existing perioperative practices according to current evidence-based guidelines to reduce surgical site infection risk. These actions led to the development of the Pathway for patients and providers. The rates of knee sepsis before and after the Pathway was implemented were compared. RESULTS: There was no consistent risk factor or epidemiologic link among the cases of knee sepsis other than the time and place of the ACL reconstruction. Process review identified shortfalls in decontamination and sterilization of some surgical equipment. Perioperative care practices review revealed wide interprovider variation. Pathway implementation reduced the rate of knee sepsis after ACL reconstruction from 1.96% (twenty-four cases after 1226 ACL reconstructions performed from 2002 to 2008) to 0% (zero cases after 500 ACL reconstructions performed from 2008 to 2011); the difference was significant (p = 0.003). CONCLUSIONS: When a Task Force investigation suggested that knee sepsis after ACL reconstruction was a multifactorial problem, we implemented and standardized evidence-based perioperative care practices via the institution-wide Pathway, which significantly improved the quality and consistency of care for patients undergoing ACL reconstruction, as well evidenced by the elimination of knee sepsis.

Short-term physical and mental health outcomes for combat amputee and nonamputee extremity injury patients.

OBJECTIVES: The present study: (1) reports the early physical health complications, mental health outcomes, and outpatient health care utilization of patients with serious extremity injuries sustained during the Iraq or Afghanistan wars and (2) compares clinical outcomes between amputee and nonamputee extremity injury groups. METHOD: This was a retrospective review of clinical records in military health databases for patients injured in the Iraq and Afghanistan wars. Health outcomes of amputee (n = 382, injured 2001-2005) and nonamputee patients (n = 274, injured 2001-2007) with serious extremity injuries (abbreviated injury score ≥ 3) were followed up to 24 months post injury. This study was performed at Naval Health Research Center, San Diego. RESULTS: Amputee and nonamputee groups had similar injury severity scores. Amputees had nearly double the risk of certain adverse complications (infections, anemia, septicemia, and thromboembolic disease), but other complications (osteomyelitis and nonhealing wound) were similar between the 2 groups. Amputees had significantly greater odds of certain mental health disorders including mood, sleep, pain, and postconcussion syndrome. However, amputees had significantly reduced odds of posttraumatic stress disorder compared with nonamputees. Amputees used various outpatient clinics significantly more than nonamputees. CONCLUSIONS: Patients with serious combat extremity injuries showed high rates of adverse health outcomes in the short term. Amputees had higher rates of many but not all clinically important physical and mental health outcomes compared to nonamputees. These results are important for military orthopaedic surgeons and allied providers who care for and counsel these patients and clinicians and researchers who seek to understand and improve health outcomes in patients with extremity war injuries. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Healthcare delivery aboard US Navy hospital ships following earthquake disasters: implications for future disaster relief missions.

OBJECTIVE: Since 2004, the US Navy has provided ship-borne medical assistance during three earthquake disasters. Because Navy ship deployment for disaster relief (DR) is a recent development, formal guidelines for equipping and staffing medical operations do not yet exist. The goal of this study was to inform operational planning and resource allocation for future earthquake DR missions by 1) reporting the type and volume of patient presentations, medical staff, and surgical services and 2) providing a comparative analysis of the current medical and surgical capabilities of a hospital ship and a casualty receiving and treatment ship (CRTS). DESIGN: The following three earthquake DR operations were reviewed retrospectively: 1) USNS Mercy to Indonesia in 2004, 2) USNS Mercy to Indonesia in 2005, and 3) USNS Comfort/USS Bataan to Haiti in 2010. (The USS Bataan was a CRTS.) Mission records and surgical logs were analyzed. Descriptive and statistical analysis was performed. Comparative analysis of hospital ship and CRTS platforms was made based on firsthand observations. RESULTS: For the three missions, 986 patient encounters were documented. Of 1,204 diagnoses, 80 percent were disaster-related injuries, more than half of which were extremity trauma. Aboard hospital ships, healthcare staff provided advanced (Echelon III) care for disaster-related injuries and various nondisaster-related conditions. Aboard the CRTS, staff provided basic (Echelon II) care for disaster-related injuries. CONCLUSIONS: Our data indicate that musculoskeletal extremity injuries in sex- and age-diverse populations comprised the majority of clinical diagnoses. Current capabilities and surgical staffing of hospital ships and CRTS platforms influenced their respective DR operations, including the volume and types of surgical care delivered.

Total knee arthroplasty in a patient with pseudopseudohypoparathyroidism.

Pseudopseudohypoparathyroidism (PPH) is a rare genetic disorder characterized by multiple musculoskeletal anomalies and normal serum calcium, phosphate, and parathyroid hormone levels. Although the musculoskeletal manifestations of PPH are well known, little has been reported on the management of orthopedic problems. We report a case of total knee arthroplasty (TKA) performed in a patient with PPH. To our knowledge, this case is not only unique to the arthroplasty literature but is the first report of its kind. This report illustrates the unique pathoanatomy of PPH, the medical and surgical management required, and a previously unreported musculoskeletal abnormality associated with PPH: synovial osteochondromatosis of the knee. Common musculoskeletal anomalies associated with PPH include shortening/bowing of long bones; shortening of metacarpals, metatarsals, and/or phalanges; exostoses; calcification/ossification of subcutaneous and/or periarticular soft tissues; a thickened calvarium; microcephaly; bony coalitions of the hand; vertebral column abnormalities; cubitus valgus; radius/ulna curvus; coxa vara; coxa valga; and genu valgum. This case is the first to report an association of synovial osteochondromatosis with PPH. Because synovial osteochondromatosis and PPH share a common disorder of soft tissue calcification/ossification, as well as abnormal bone formation, this clinical finding does not seem merely coincidental.

Prepatellar septic bursitis: a case report of skin necrosis associated with open bursectomy.

Patients with prepatellar septic bursitis are typically successfully managed nonoperatively with rest, compression, immobilization, aspiration, and antibiotics. Rarely, surgical excision of the bursa may be required for recalcitrant cases. Prepatellar bursectomy, however, has been associated with considerable risk of surgical-site morbidity. Although skin necrosis is frequently cited as a complication of open bursectomy, there is limited information in the medical literature on the etiology and management of this rare but serious complication.

Case report: reconstruction of a recalcitrant scapular neck nonunion and literature review.

We present the first reported treatment failure of a reconstructed scapula body that proceeded to nonunion. This is a unique case report of an otherwise healthy patient who underwent open reduction and internal fixation of a scapula fracture nonunion, which is very rare. Failure of internal fixation in this application has not been reported, and, to our knowledge, this is only the fifth case report of a scapula body nonunion that was reconstructed. Of 159 reported cases of open reduction and internal fixation for treatment of scapula neck and body fractures (with or without intraarticular glenoid fractures), there is not one reported case of a nonunion. Our case is described in detail, including the method of surgical reconstruction, and a review of the literature regarding surgical treatment of scapula nonunions after nonoperative treatment also is presented.

Prolonged femoral external fixation after natural disaster: successful late conversion to intramedullary nail aboard the USNS Mercy hospital ship.

After the 9.0 magnitude earthquake and tsunami of December 26, 2004, orthopaedic injuries were a major healthcare problem in parts of South East Asia. We report our late encounter with an Indonesian patient treated acutely with external fixation of a femur fracture. We describe our procedure for conversion of prolonged external fixation (59 days) to an intramedullary nail (IMN) aboard the USNS Mercy and provide two-year follow-up. A review of current literature on conversion of femoral external fixation to IMN is included. This report highlights the potential pitfalls of external fixation of femur fractures in an austere post-natural disaster environment where orthopaedic follow-up care may be delayed or nonexistent.

Activity level in young patients with primary total hip arthroplasty: a 5-year minimum follow-up.

Increased activity level after total hip arthroplasty (THA) is considered a risk factor for early prosthetic failure in young patients. Forty-one primary total hip arthroplasties in 34 patients were evaluated. Walking activity was measured using a pedometer to record gait cycles. Patients completed a University of California, Los Angeles (UCLA) activity questionnaire. Linear wear rates were measured. Mean ages at surgery and final follow-up were 42 and 50.3 years, respectively (mean gait cycles per year, 1.2 million; mean UCLA score, 6; mean linear wear, 0.16 mm/y). Increased body mass index and age correlated with decreased gait cycles per year. Patients with systemic disease were less active than patients with localized hip conditions. Femoral head diameter was a predictor of linear wear. The average gait cycles per year and wear rate for this population do not appear accelerated relative to average values reported in older populations.

Reconstruction of a ruptured patellar tendon with achilles tendon allograft following total knee arthroplasty.

BACKGROUND: Rupture of the patellar tendon after total knee arthroplasty is a rare and debilitating complication. Proper surgical management of this condition remains controversial. The purpose of this study was to review the results of reconstruction of a ruptured patellar tendon with an Achilles tendon allograft following total knee arthroplasty. METHODS: We reviewed our experience with the use of a fresh-frozen Achilles tendon allograft with an attached calcaneal bone graft to restore extensor function in nine patients with patellar tendon rupture following total knee arthroplasty (five primary and four revision). All patients were examined clinically and radiographically at an average of twenty-eight months. RESULTS: The average knee and functional scores improved from 26 and 14 points, respectively, before the surgery to 81 and 53 points after the surgery. The average extensor lag decreased from 44 degrees preoperatively to 3 degrees postoperatively, and the average range of motion of the knee increased from 88 degrees to 107 degrees. Two grafts failed in the early postoperative period. Both were repaired successfully. Radiographs showed an average proximal patellar migration of 17.8 mm, which did not appear to affect extensor function. CONCLUSIONS: This short-term follow-up study showed that once an Achilles allograft has healed, it can serve as a reliable reconstruction of a ruptured patellar tendon following total knee arthroplasty. This technique may be particularly suited for patients in whom the extensor mechanism was compromised by multiple prior operations. Continued follow-up is necessary to determine the long-term durability of these results.