Adjunctive Dorsal Spanning Plate Fixation in the Stabilization of Perilunate Dislocations.

PURPOSE: To compare the biomechanical properties of adjunctive dorsal spanning plate (DSP) fixation with traditional K-wire fixation of perilunate dislocations in a cadaveric model. METHODS: Fourteen fresh-frozen cadaveric wrists underwent simulated perilunate injury. The specimens were randomly allocated to either K-wire fixation versus K-wire and DSP fixation. Scapholunate (SL) ligament repair was performed in all specimens. The constructs were tested using a robot cyclically and to failure. Fluoroscopic images were obtained of the specimens prior to simulated injury, after fixation, after 10 and 100 loading cycles, and at construct failure. Differences in carpal alignment parameters (SL interval, SL angle, lunotriquetral interval, and capitolunate angle) and load to failure were recorded. RESULTS: There were no statistically significant differences between the two group's carpal alignment parameters after fixation. Specimens fixated with K-wires and DSP required significantly higher loads to achieve construct failure. The only significant difference between the two groups' carpal alignment parameters was SL interval change at failure. CONCLUSIONS: Compared with K-wire fixation alone, adjunctive DSP fixation resulted in significantly increased loads to failure and decreased change in SL interval at the time of failure. CLINICAL RELEVANCE: Adjunctive DSP may be a useful technique in the polytraumatized patient in whom providing back a weight-bearing extremity may be advantageous in the rehabilitation process.

Efficacy of Ultrasound Shear Wave Elastography in the Diagnosis of Salivary Gland Tumors.

PURPOSE: Diagnostic accuracy of fine-needle aspiration cytology (FNAC) to discriminate between the target condition and health in the evaluation of salivary gland tumors is not perfected yet and thus, false-negative results are possible. The purpose of the present study was to measure and compare the diagnostic accuracy of FNAC performed with conventional B-mode ultrasound and ultrasound with shear wave elastography (SWE) FNAC navigation. METHODS: The investigators implemented a single-blind randomized study (sealed envelope method). The study population was composed of all patients presenting for evaluation and management of suspected benign or malignant tumors of the major salivary glands between July 2013 and December 2020. The involvement of SWE navigation was the primary predictor variable affecting FNA targeting. The method involved analysis of redistribution of SWE values within the affected gland expressed in kilopascals (kPa) and the four-point ES1 (soft tissue) to ES4 (stiff) scoring. The primary outcome variable was the success in obtaining diagnostic tissue resulting in a histologically confirmed FNAC diagnosis and coded as yes/no. Age and sex of the patients and topographical locations of lesions were covariates. Descriptive and bivariate statistics were computed and the P value was set at .05. RESULTS: The sample included 132 subjects (male/female 59/73; mean age 54 ± 11 years; 144 tumors). SWE + Group (n = 66) consisted of patients presurgically diagnosed with salivary tumors SWE-guided FNAC and SWE- Group (n = 66) was diagnosed with tumors by conventional ultrasound-(B-mode)-guided FNAC. The SWE-guided FNAC statistically significantly reduced the incidence of false-negative results (n = 0; P = .001) and nondiagnostic cases (n = 3 SWE FNAC vs n = 7 B-mode US FNAC; P = .04). For SWE + Group, the FNAC diagnosis was confirmed by postsurgical histology in 95.5% with 91.0% sensitivity (confidence interval [CI] 0.62 to 0.97) and 84.4% specificity (CI 0.58 to 0.96). For SWE- Group, 81.8% confirmation was obtained (P = .05) with 82.3% sensitivity (CI 0.54 to 0.90) and 74.0% specificity. CONCLUSION: SWE can increase success in obtaining diagnostic tissue when used for FNAC navigation purposes. We suggest combining both SWE and standard B-mode ultrasonography methods when the FNAC procedure is performed.

An Assessment of Upper-Extremity Surgical Technique Videos and Their Relationship With Procedural Learning Theory.

PURPOSE: Our purpose was to ascertain how well award-winning and highly viewed upper-extremity surgical videos meet the needs of users and adhere to procedural learning theory. We hypothesized that upper-extremity videos hosted on academic society websites meet user needs better than upper-extremity videos hosted on a commercial website. METHODS: Twenty-five upper-extremity videos were evaluated by 3 reviewers. A standardized scoring sheet was used to assess each video's content, production quality, and adequacy. Video lengths were compared. The inclusion frequencies of specific content categories, the adequacy of content, and meeting certain production standards, all of which assess consistency with procedural learning theory, were reported, stratified by video host. Associations between the video host and video content, production quality, and adequacy were assessed. RESULTS: The median lengths of academically hosted and commercially hosted videos were similar. Regardless of the video host, no video contained information in all content categories. Sixty percent of the scored categories were present in less than 75% of evaluated videos. Academically hosted videos contained scored content more frequently than commercially hosted videos in 68.4% of categories. There were significant associations between academic hosts and inclusion of a case presentation, surgical indications, outcomes literature, a preoperative examination, follow-up visit intervals, and alternative surgical techniques. Overall, academically hosted videos had a higher percentage of adequate content categories compared with commercially hosted videos. CONCLUSIONS: Videos on academic websites more consistently meet users' content needs and production expectations, as informed by procedural learning theory, while having higher rates of adequate content compared with videos on commercial websites. CLINICAL RELEVANCE: While academically hosted videos appear to more consistently adhere to the tenets of procedural learning theory, opportunity exists for video creators to more consistently apply procedural learning theory, allowing for the creation of even more educationally beneficial online surgical videos.

Reverse Hemi-Hamate Autograft for Volar Proximal Interphalangeal Joint Fracture-Dislocations.

Volar proximal interphalangeal joint fracture-dislocations are rare injuries. Treatment is challenging when they are not identified acutely, with poor outcomes reported. We report a surgical technique to treat chronic volar proximal interphalangeal joint fracture-dislocations: a reverse hemi-hamate autograft.

Automating Patient-Reported Outcome Measures Following Hand Surgery.

PURPOSE: The purpose of this study was to assess the overall response rate of patients receiving electronic patient-reported outcome measures (ePROMs) following hand surgery and to determine the patient characteristics associated with responding. METHODS: A Health Insurance Portability and Accountability Act-compliant, web-based system was developed to automatically distribute ePROMs to patients undergoing hand surgery at five institutions with 22 surgeons. Patients who were at least 18 years old were eligible. The PROMs used were the visual analog scale (VAS) for pain and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH). After surgery, ePROMs along with a satisfaction questionnaire were electronically sent three, six, 12, 24, and 52 weeks after surgery. RESULTS: A total of 6458 patients were eligible. Of these, 80% were enrolled voluntarily. Among these, 70% completed ePROMs for at least one postoperative time point, whereas 30% did not complete any. Among responders, 28% completed all five time points, whereas 72% completed four or fewer time points. Incomplete responders were more likely to be insured by workers' compensation when compared to complete responders. Incomplete responders exhibited higher baseline QuickDASH scores and similar baseline VAS compared to complete responders. During the follow-up, incomplete responders demonstrated worse VAS and QuickDASH scores at all time points. Finally, in comparison with complete responders, incomplete responders were less likely to be satisfied with their surgery at all time points. CONCLUSIONS: This study demonstrates that automated email-based ePROM systems may be an effective method for survey distribution. Particularly for simple, outpatient surgeries, this study illustrates the potential for clinical use of the data obtained from these systems. CLINICAL RELEVANCE: Patient-reported outcome measures continue to have an expanding role in health care with the rise of valued-based systems. Electronic PROMs are a relatively unexplored medium that may offer a viable alternative to more effectively collecting these valuable patient metrics.

Short-Term Patient Outcomes after Placement of an Internal Joint Stabilizer for Terrible Triad Injuries: A Multicenter Study.

PURPOSE: The purpose of this study was to assess the functional and patient-reported outcomes after the use of the internal joint stabilizer (IJS) for unstable terrible triad injuries. Specifically, we sought to determine our complication rate and the impact of complications on patient outcomes. METHODS: We identified all patients who had an IJS placed as a supplemental fixation for a terrible triad injury at two urban, level 1 academic medical centers. We reviewed these patients' charts for demographic information, complication profiles, postoperative range of motion (ROM), and pain-level data. We also collected the QuickDASH and Patient-Rated Elbow Evaluation (PREE) scores. Descriptive statistics were reported. Final visit data were compared between patients who returned to the OR for a complication and those who did not. RESULTS: From 2018 to 2020, 29 patients had an IJS placed for a terrible triad injury. The median final follow-up was 6.3 months after surgery (IQR: 6.2 months). There were 38 complications in 19 patients (65.5%) that required 12 patients to return to the OR (41.3%) for procedures beyond simple IJS removal. There were no significant differences in the ROM between patients who returned to the OR for a complication and those who did not. QuickDASH and PREE scores were greater (indicating more disability) in patients who had a complication that required a secondary surgical procedure. CONCLUSIONS: Patients who receive an IJS incur a high rate of complications. When patients sustain complications that require secondary surgeries, their ultimate functional outcome scores worsen. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Casting Position for Distal Radius Fractures Changes Radiocarpal Joint Forces: A Cadaveric Study.

PURPOSE: Nonsurgical distal radius fracture treatment requires immobilization and classical teaching suggests varying cast positions. We investigated the effect of cast position on the force and pressure experienced by the articular cartilage in the scaphoid and lunate fossae. METHODS: Ten fresh-frozen cadaveric specimens were used. A standardized extra-articular distal radius fracture was made. Force sensors were affixed to the articular cartilage of the scaphoid and lunate fossae. Baseline data were obtained. Specimens were then placed into a short arm cast with the wrist either neutrally aligned or flexed and ulnarly deviated (FUD). Specimens had a standard load applied, and a force profile was obtained. The cast was removed and the other cast type was placed and measurements were repeated. Overall force and pressure values were compared between baseline data and the 2 cast types. Additionally, differences in volar and dorsal scaphoid and lunate fossa forces and pressures were compared pairwise within the 2 cast types. The relative force and pressure values across cast types were also compared. RESULTS: Both cast types significantly reduced the median force and pressure experienced by the radiocarpal joint compared with no cast. In the FUD cast, the volar and dorsal lunate fossa experienced significantly greater force, and the dorsal lunate fossa experienced significantly greater pressure compared with the dorsal scaphoid fossa. There were no differences for any fossae in the neutral cast. When comparing between casts, the volar lunate fossa experienced a significantly greater relative force in the FUD cast compared with the neutral cast. CONCLUSIONS: Casting a distal radius fracture decreases the forces and pressures in the radiocarpal joint. Placing the wrist in a FUD position results in greater forces and pressures on the lunate fossa compared with the scaphoid fossa. CLINICAL RELEVANCE: When immobilization is needed, we advocate for the placement of patients in a relatively neutral short-arm cast with minimal FUD to avoid this increased pressure.

Experience Level Influences Users' Interactions With and Expectations For Online Surgical Videos: A Mixed-Methods Study.

PURPOSE: Upper-extremity surgeons and trainees widely use online surgical videos, and the use of these videos can assist with procedural learning. The purpose of this study was to characterize online video use and understand the role videos play in the learning process of orthopedic residents and practicing surgeons. We hypothesized that the use of surgical videos and video content desired among orthopedic learners differs based on their experience level. METHODS: Four focus groups were conducted to discuss online surgical videos and their role in the learning process of orthopedic learners. Participants were separated based on their experience level. Three reviewers qualitatively analyzed the transcripts of the focus groups using constant comparative methods to identify overarching themes and categories. Findings regarding the participants' desires for video content and production quality were translated into a survey. The survey results were analyzed to assess their associations with experience level. RESULTS: The focus group analysis helped identify 4 overarching themes that reflected users' interactions with videos: prewatching experience, choosing a video, video use, and video design, with the users' comments differing based on their experience level. The survey results showed that the median ideal length for a video was 10 minutes and that all users, regardless of their experience level, ranked showing the surgical procedure as the most important part of a video. Junior residents more frequently desired background information and a written outline of surgical steps, whereas more senior learners placed greater emphasis on advanced surgical decision-making and the use of particular implants/devices. CONCLUSIONS: Experience level influences users' interactions with videos, including how they are chosen and used, and their expectations in terms of content and production. CLINICAL RELEVANCE: Video creators should specify their targeted audience's experience level and adjust content to meet users' needs. Our results can provide video creators and hosts a checklist for appropriate content and production standards.

Comparison of machine learning techniques to predict unplanned readmission following total shoulder arthroplasty.

BACKGROUND: Machine learning (ML) techniques have been shown to successfully predict postoperative complications for high-volume orthopedic procedures such as hip and knee arthroplasty and to stratify patients for risk-adjusted bundled payments. The latter has not been done for more heterogeneous, lower-volume procedures such as total shoulder arthroplasty (TSA) with equally limited discussion around strategies to optimize the predictive ability of ML algorithms. The purpose of this study was to (1) assess which of 5 ML algorithms best predicts 30-day readmission, (2) test select ML strategies to optimize the algorithms, and (3) report on which patient variables contribute most to risk prediction in TSA across algorithms. METHODS: We identified 9043 patients in the American College of Surgeons National Surgical Quality Improvement Database who underwent primary TSA between 2011 and 2015. Predictors included demographics, comorbidities, laboratory data, and intraoperative variables. The outcome of interest was 30-day unplanned readmission. Five ML algorithms-support-vector machine (SVM), logistic regression, random forest (RF), an adaptive boosting algorithm, and neural network-were trained on the derivation cohort (2011-2014 TSA patients) to predict 30-day unplanned readmission rates. After training, weights for each respective model were fixed and the classifiers were evaluated on the 2015 TSA cohort to simulate a prospective evaluation. C-statistic and f1 scores were used to assess the performance of each classifier. After evaluation, features were removed independently to assess which features most affected classifier performance. RESULTS: The derivation and validation cohorts comprised 5857 and 3186 primary TSA patients, respectively, with similar demographics, comorbidities, and 30-day unplanned readmission rates (2.9% vs. 2.7%). Of the ML algorithms, SVM performed the worst with a c-statistic of 0.54 and an f1-score of 0.07, whereas the random-forest classifier performed the best with the highest c-statistic of 0.74 and an f1-score of 0.18. In addition, SVM was most sensitive to loss of single features, whereas the performance of RF did not dramatically decrease after loss of single features. Within the trained RF classifier, 5 variables achieved weights >0.5 in descending order: high bilirubin (>1.9 mg/dL), age >65, race, chronic obstructive pulmonary disease, and American Society of Anesthesiologists' scores ≥3. In our validation cohort, we observed a 2.7% readmission rate. From this cohort, using the RF classifier we were then able to identify 436 high-risk patients with a predicted risk score >0.6, of whom 36 were readmitted (readmission rate of 8.2%). CONCLUSION: Predictive analytics algorithms can achieve acceptable prediction of unplanned readmission for TSA with the RF classifier outperforming other common algorithms.

Superior Capsule Reconstruction for Irreparable Rotator Cuff Tears: A Systematic Review.

PURPOSE: To evaluate the preliminary clinical outcomes and complications of superior capsule reconstruction (SCR) for irreparable rotator cuff tears. METHODS: A systematic review of PubMed, MEDLINE, EMBASE, and Cochrane databases was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies reporting clinical outcomes of irreparable rotator cuff tears managed by SCR were included. Clinical outcome analyses of pre- and postoperative range of motion, American Shoulder and Elbow Surgeons scores, visual analog scale pain scores, and acromiohumeral intervals (AHIs) were performed and reported as range or frequency. RESULTS: Five studies (285 patients, 291 shoulders) of level III-IV evidence were included, with a weighted mean (± standard deviation) follow-up of 27.7 ± 17.3 months. Forward flexion improved from 91°-130° preoperatively to 147°-160° postoperatively, external rotation from 26°-41° to 41°-45°, and internal rotation from L4-L1 to L1. American Shoulder and Elbow Surgeons scores increased from 36-52.2 to 77.5-92, and visual analog scale pain scores decreased from 4.0-6.3 to 0.4-1.7. Radiographically, AHIs with acellular dermal allograft ranged from 4.5 to 7.1 mm preoperatively, improving to 7.6-10.8 mm immediately postoperation before decreasing to 6.7-9.7 mm by final follow-up. Complication and graft failure rates were 17.2% and 11.7%, respectively. CONCLUSIONS: Preliminary results of SCR show consistent improvement in shoulder functionality and pain reduction. However, a decrease in postoperative AHIs indicates dermal allograft elongation and persistent superior migration of the humerus, potentially contributing to later graft failure. Studies with longer follow-up will be essential to evaluate the long-term utility of SCR in the treatment of irreparable rotator cuff tears. LEVEL OF EVIDENCE: Level IV, systematic review of level III-IV studies.

Comparative strength of elbow splint designs: a new splint design as a stronger alternative to posterior splints.

BACKGROUND: Musculoskeletal injuries of the upper extremity are frequently treated with temporary external immobilization. Traditionally, long arm posterior splints have been used to limit flexion/extension of the elbow. However, long arm posterior splints have been observed to fail clinically, necessitating a stronger alternative. In this study, we assessed the biomechanical strength of the long arm posterior splint compared with a new spiral splint design. METHODS: One male and one female participant were placed 10 times in long arm posterior splints and 10 times in spiral splints. Both splint types were subjected to a downward mechanical load of 39.2 N (4 kg) and assessed for a change in both flexion/extension and pronation/supination. RESULTS: There was no significant difference in starting position or starting flexion/extension between the 2 splint designs. Posterior splints allowed significantly greater initial pronation/supination compared with spiral splints. Both splint groups had significant increases in flexion/extension and pronation/supination compared with their starting ranges of motion. There was no significant difference in the change in pronation/supination between the 2 splint groups. Finally, posterior splints allowed a significantly greater change in flexion/extension compared with spiral splints. CONCLUSION: Spiral splints offered less initial pronation/supination than long arm posterior splints. Furthermore, spiral splints are able to resist flexion/extension of the elbow after application of a downward mechanical load better than posterior splints, thus suggesting spiral splints are mechanically superior to long arm posterior splints.

Is Wikipedia a complete and accurate source for musculoskeletal anatomy?

PURPOSE: Wikipedia is a popular online encyclopedia generating over 5.4 billion visits per month, and it is also a common resource for the general public and professionals for medical information. The goal of this study is to determine the accuracy and completeness of Wikipedia as a resource for musculoskeletal anatomy. METHODS: The origin, insertion, innervation, and function of all muscles of the upper and lower extremities as detailed on Wikipedia was compared to the available corresponding information in Grant's Atlas of Anatomy (14th edition). Entries were scored for both accuracy and completeness. Descriptive statistics were calculated and associations between and within entries for accuracy and completeness were assessed by McNemar's tests. Information on Wikipedia's references was also collected. RESULTS: Overall, data on Wikipedia was 97.6% complete and 98.8% accurate when compared to Grant's Atlas of Anatomy. 78.6% of all entries were fully complete and accurate, with 15.3% of entries containing one error and 6.1% containing two errors. There were no associations between or within entries' accuracy and completeness. Only 62% of references from Wikipedia included were from academic sources. CONCLUSIONS: Musculoskeletal anatomy entries on Wikipedia are imperfect; they have inaccurate and missing information. Furthermore, a considerable proportion of references cited in entries are from poorly identified sources. While Wikipedia is an easily accessible resource for a large number of people and much of the anatomic information is appropriate, it cannot be considered to be an equivalent resource when compared to anatomic texts.

Comparative Morbidity of Cubital Tunnel Surgeries: A Prospective Cohort Study.

PURPOSE: Randomized controlled trials have not identified a superior surgical approach to cubital tunnel syndrome surgery. This study evaluates the early morbidity of open in situ decompression and transposition. METHODS: This prospective cohort study enrolled 125 adult patients indicated for cubital tunnel surgery at a tertiary institution. Exclusion criteria included preoperative use of narcotics and concurrent elbow procedures. In situ decompressions (n = 47) and ulnar nerve transpositions (n = 78) were performed. Data were collected by independent clinicians at 3 postoperative intervals: 1 to 3 weeks, 4 to 8 weeks, and longer than 8 weeks. Postoperative data quantified surgical morbidity: visual analog scale (0-10) surgical site pain, narcotic consumption, patient-reported disability (Levine-Katz, Patient-Reported Elbow Evaluation [PREE] scores). Olecranon paresthesia and wound complications (hematoma, drainage, infection) were recorded. RESULTS: No preoperative differences in age, sex, or the presence of pain existed between the surgical groups. Surgical site pain was not significantly different at any time. Following transposition, a significantly greater percentage of patients were using narcotics at 4 to 8 weeks after surgery and the average total morphine equivalents consumed per patient was significantly greater. Both Levine-Katz and PREE scores indicated greater disability at 1 to 3 and 4 to 8 weeks after transposition, but this significant difference resolved by final follow-up. Olecranon paresthesias occurred after both procedures but were significantly less frequent at 4 to 8 weeks and longer than 8 weeks after decompression. Twelve hematomas occurred following transposition (15%) with 1 requiring operative debridement and 5 hematomas resolved with nonsurgical treatment after in situ decompression (11%). CONCLUSIONS: Ulnar nerve transposition imparts greater surgical morbidity than decompression with greater narcotic consumption, more patient-reported disability up to 8 weeks after surgery, and more persistent olecranon paresthesia. However, most differences in surgical morbidity are transient with resolution after 8 weeks following surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Perioperative Celecoxib and Postoperative Opioid Use in Hand Surgery: A Prospective Cohort Study.

PURPOSE: Prescription opioid abuse is an epidemic in the United States; multimodal analgesia has been suggested as a potential solution to decrease postoperative opioid use. The primary aim of this study was to determine the effect of perioperative celecoxib on opioid intake. Secondary goals were to determine whether perioperative administration of celecoxib decreased postoperative patient-reported pain and whether patient demographic characteristics could predict postoperative pain and opioid intake. METHODS: This prospective cohort study enrolled patients undergoing mass excision or carpal tunnel, trigger finger, or de Quervain release by 1 of 3 fellowship-trained hand surgeons. Patients in the experimental group were given 200 mg celecoxib tablets taken twice a day starting the day before surgery and continued for 5 days after surgery. Both groups received hydrocodone-acetaminophen tablets 5 mg/325 mg as needed after surgery. After surgery, patients completed daily opioid consumption and pain logs for 7 days and underwent a pill count. Outcomes included morphine milligram equivalents (MME) consumed and postoperative pain. RESULTS: A total of 123 patients were enrolled: 68 control patients and 54 celecoxib patients. Fifty (74%) and 37 (69%) patients, respectively, completed the study. Overall, the median number of MMEs consumed was 25 (range, 0-330). During the first postoperative week, patients in the celecoxib and control groups were similar with respect to postoperative pain experienced (median visual analog scale score, 2.0 vs 1.4, respectively) and amount of opioid taken (median MMEs = 30 vs 20, respectively). CONCLUSIONS: Patients taking perioperative celecoxib had similar postoperative pain and opioid intake compared with patients not prescribed celecoxib in the study. Regardless of study group, 4 to 10 hydrocodone tablets were sufficient to control postoperative pain for most patients undergoing soft tissue ambulatory hand surgery. This may be the result of the limited duration and mild nature of pain after outpatient elective hand surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

The (in)stability of 21st century orthopedic patient contact information and its implications on clinical research: A cross-sectional study.

BACKGROUND: In clinical research, minimizing patients lost to follow-up is essential for data validity. Researchers can employ better methodology to prevent patient loss. We examined how orthopedic surgery patients' contact information changes over time to optimize data collection for long-term outcomes research. METHODS: Patients presenting to orthopedic outpatient clinics completed questionnaires regarding methods of contact: home phone, cell phone, mailing address, and e-mail address. They reported currently available methods of contact, if they changed in the past 5 and 10 years, and when they changed. Differences in the rates of change among methods were assessed via Fisher's exact tests. Whether participants changed any of their contact information in the past 5 and 10 years was determined via multivariate modeling, controlling for demographic variables. RESULTS: Among 152 patients, 51% changed at least one form of contact information within 5 years, and 66% changed at least one form within 10 years. The rate of change for each contact method was similar over 5 (15%-28%) and 10 years (26%-41%). One patient changed all four methods of contact within the past 5 years and seven within the past 10 years. Females and younger patients were more likely to change some type of contact information. CONCLUSION: The type of contact information least likely to change over 5-10 years is influenced by demographic factors such as sex and age, with females and younger participants more likely to change some aspect of their contact information. Collecting all contact methods appears necessary to minimize patients lost to follow-up, especially as technological norms evolve.

Discharge Disposition After Joint Replacement and the Potential for Cost Savings: Effect of Hospital Policies and Surgeons.

BACKGROUND: Up to 55% of total joint arthroplasty costs come from post-acute care, with large variability dependent on a patient's discharge location. At our institution, we identified a group of surgeons using a preoperative discharge planning protocol emphasizing the merits of home discharge. We hypothesized that using the protocol would increase patients' odds for discharge home. METHODS: Administrative data from 14,315 total hip and knee arthroplasties performed over a 3-year period were retrospectively analyzed to determine predictors of patient discharge location. Bayesian hierarchical logistic regression modeling was used to account for the complex multilevel structure within the data as we considered patient-, surgeon-, and hospital-level predictors. A simplified case-control data structure with logistic regression analysis was also used to better understand the impact of the preoperative discharge planning protocol. RESULTS: A variety of patient- and surgeon-level variables are predictive of patients being discharged home after total joint arthroplasty including a patient's length of stay, age, illness severity, and insurance, as well as surgeon's affiliation. In the case-control data, patients exposed to the rapid recovery protocol had 45% increased odds of being discharged home compared to patients not exposed to the protocol. CONCLUSIONS: Although patient factors are known to play a role in predicting postdischarge destination, this analysis describes additional surgeon- and hospital-level factors that predict discharge location. Exogenous factors based on how surgeons and hospital staff practice and interact with patients may impact the postdischarge decision-making process and provide a cost savings opportunity.

Pediatric proximal phalanx fractures: outcomes and complications after the surgical treatment of displaced fractures.

BACKGROUND: The outcomes literature on proximal phalanx fractures in children is sparse. The purpose of this study is to report the complications and outcomes of displaced proximal phalanx fractures after treatment with closed reduction and percutaneous pinning (CRPP). METHODS: A retrospective chart review identified 105 patients treated with CRPP of displaced proximal phalanx fractures. Specific complications were recorded for all patients. Thirty-one of these patients returned >1 year after surgery for assessment including visual analogue scales (VAS) of pain level, functional ability, and esthetics. Objective measurements included range of motion, grip and pinch strength, and finger deformity. Radiographs were taken to assess deformity. RESULTS: Five of the 105 patients (4.8%) had a complication including infection, pin site complication, or malunion. Of the entire group, 36 had stiffness and 31 ultimately underwent hand therapy to regain motion. Subcondylar fractures were associated with a greater likelihood of stiffness. In the 31 patients returning for assessment, the median VAS score was 0 for pain (none), function (full), and esthetics (perfect). Range of motion, grip, and pinch strength were equivalent to the contralateral side. Seven of the 31 patients (22.6%) had a measureable coronal plane deviation averaging 5 degrees (range, 3 to 13 degrees) on radiographs. Deviation was associated with subcondylar fractures and a worse esthetic VAS. Deviation was not associated with worse outcomes overall. CONCLUSIONS: Pediatric patients with a displaced proximal phalanx fracture treated with CRPP have an initial notable complication rate related to stiffness; subcondylar proximal phalanx fractures are more commonly affected. At >1-year follow-up, patients had full motion, no pain, and were happy with both function and appearance despite minor deformity in some. These complication data may help better inform patients and families before surgical intervention. LEVEL OF EVIDENCE: Level IV-therapeutic.

Blood glucose levels in diabetic patients following corticosteroid injections into the hand and wrist.

PURPOSE: To quantify diabetic patients' change in blood glucose levels after corticosteroid injection for common hand diseases and to assess which patient-level risk factors may predict an increase in blood glucose levels. METHODS: Patients were recruited for this case-crossover study in the clinic of fellowship-trained hand surgeons at a tertiary care center. Patients with diabetes mellitus type 1 or 2, who received a corticosteroid injection, recorded the morning fasting blood glucose levels for 14 days after the injection. Fasting glucose levels on days 1 to 7 after injection qualified as case data; levels on days 10 to 14 provided control data. A mixed model with a priori contrasts was used to compare postinjection blood glucose levels with baseline levels. We used a linear regression model to determine patient predictors of a postinjection rise in blood glucose levels. RESULTS: Of 67 patients recruited for the study returned, 40 (60%) completed blood glucose logs. There was a significant increase in fasting blood glucose levels after injection limited to postinjection days 1 and 2. Among patient risk factors in the linear regression model, type 1 diabetes and use of insulin each predicted a postinjection increase in blood glucose levels from baseline, whereas higher glycated hemoglobin levels did not predict increases. CONCLUSIONS: Corticosteroid injections in the hand transiently increase blood glucose levels in diabetic patients. Patients with type 1 diabetes and insulin-dependent diabetics are more likely to experience this transient rise in blood glucose levels. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Performance characteristics of the verbal QuickDASH.

PURPOSE: To quantify the performance of the verbally administered Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire by assessing its replication of self-administered scores, its test-retest reliability, and its rate of scorable completion compared with its self-administered, written administration. METHODS: Fifty patients presenting for initial visits to a hand clinic were enrolled regardless of diagnosis. All patients completed a written and a verbal QuickDASH 1 day apart (25 patients written first; 25 patients verbal first). Intraclass correlation coefficients quantified the verbal questionnaire's ability to reproduce written scores. Participants verbally completed the questionnaire a final time, 5 months later, to assess test-retest reliability. To quantify the usability of survey data, we compared percentages of scorable surveys between written and verbally administered QuickDASH questionnaires in this study and in prior studies within our division. RESULTS: The intraclass correlation coefficient between the 2 QuickDASH administration types for the entire sample was 0.91. Across all participants, there was a minimal change in mean score from a patient's written QuickDASH to that patient's first verbal QuickDASH score. Scoring consistency between QuickDASH administrations was similar for each administration sequence (phone followed by written vs. written followed by phone) and by diagnosis. Test-retest reliability between the 2 verbal administrations demonstrated good reliability and a minimal difference between scores. In this study, no written or verbal surveys were incomplete. Reviewing our practice, 17% of 258 written questionnaires produced unscorable data compared with 0% of 239 verbally administered surveys. CONCLUSIONS: Our results indicate that verbal administration of the QuickDASH replicates clinically relevant scores of the written QuickDASH, has good test-retest performance, and may minimize unusable data. These data allow researchers greater flexibility in gathering patient outcome data in both retrospective and prospective studies. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.