Emergency dental treatment among patients waitlisted for the operating room.

This restrospective chart review examined dental emergencies among patients waitlisted for the operating room at an outpatient community dental clinic in a large academic medical center. Dental records of ASA I or II patients, who had dental restorations and/or extractions in the operating room between July 2015 to May 2019 were reviewed. Length of time the patient was waitlisted and number of emergency dental treatments (i.e., therapeutic pulpotomy or a dental extraction due to acute dental pain or infection) completed in the outpatient dental clinic during the wait period were collected. Data were dichotomized as <2 and ≥2 emergency treatments. Kruskal-Wallis test was used to compare the groups. Of 417 charts reviewed, 294 patients met the inclusion criteria. The average time on the waitlist was 228 days. The majority of patients (n = 222; 75.3%) had no emergency dental treatment while waitlisted. Those who had two or more emergency treatments (n = 34; 11.5%) were waitlisted longer than those who had fewer than two (n = 261; 88.5%) (p < 0.05). This study highlights the importance of early intervention (e.g., scheduled periodic follow-ups, interim caries arresting medication) and an ongoing discussion of possible alternatives while waitlisted. Future research identifying predictors of utilization of emergency services while waitlisted is warranted and may help identify those at increased risk of developing acute dental emergencies.

Boundary Conditions Matter-Impact of Test Setup on Inferred Construct Mechanics in Plated Distal Femur Osteotomies.

The mechanics of distal femur fracture fixation has been widely studied in bench tests that employ a variety of approaches for holding and constraining femurs to apply loads. No standard test methods have been adopted for these tests and the impact of test setup on inferred construct mechanics has not been reported. Accordingly, the purpose of this study was to use finite element models to compare the mechanical performance of a supracondylar osteotomy with lateral plating under conditions that replicate several common bench test methods. A literature review was used to define a parameterized virtual model of a plated distal femur osteotomy in axial compression loading with four boundary condition sets ranging from minimally to highly constrained. Axial stiffness, fracture gap closure, and transverse motion at the fracture line were recorded for a range of applied loads and bridge spans. The results showed that construct mechanical performance was highly sensitive to boundary conditions imposed by the mechanical test fixtures. Increasing the degrees of constraint, for example, by potting and rigidly clamping one or more ends of the specimen, caused up to a 25× increase in axial stiffness of the construct. Transverse motion and gap closure at the fracture line, which is an important driver of interfragmentary strain, was also largely influenced by the constraint test setup. These results suggest that caution should be used when comparing reported results between bench tests that use different fixtures and that standardization of testing methods is needed in this field.

Mallampati and Brodsky Classification and Children's Risk for Sleep Related Breathing Disorder.

OBJECTIVE: To evaluate associations between Mallampati and Brodsky classification and children's risk for sleep related breathing disorder (SRBD). STUDY DESIGN: This study recruited well-children 2-11 years old and legal guardians over 18 years from a community dental clinic. Modified Mallampati classification (IIV) and Brodsky grade (0-4) were classified by a single dentist. Guardians completed the validated 22-item pediatric sleep questionnaire (PSQ) to identify children at risk of SRBD. Associations between Mallampati and Brodsky classifications with risk for SRBD as defined by PSQ were determined by Chi-square, Kruskal-Wallis, and simple logistic regression models. RESULTS: Of 150 children included (M=5.9 years), 76 (51%) female, 108 (72%) Latino/Hispanic, 82 (55%) were classified as Mallampati class I or II, 68 (45%) class III or IV, 119 (79%) were identified as Brodsky grade 0, 1, or 2, and 31 (21%) grade 3 or 4. Children with Mallampati class III and IV and Brodsky grade 3 and 4 collectively had a 5.24-fold and 2.8-fold increase in SRBD risk per PSQ compared to children with class I and II and grade 1 and 2, respectively. CONCLUSION: Mallampati classification may be a quick, non-invasive screening tool to improve identification and timely intervention for children at risk of SRBD.

Imaging Modalities to Assess Fracture Healing.

PURPOSE OF REVIEW: This review discusses imaging modalities for fracture repair assessment, with an emphasis on pragmatic clinical and translational use, best practices for implementation, and challenges and opportunities for continuing research. RECENT FINDINGS: Semiquantitative radiographic union scoring remains the clinical gold standard, but has questionable reliability as a surrogate indicator of structural bone healing, particularly in early-stage, complex, or compromised healing scenarios. Alternatively, computed tomography (CT) scanning enables quantitative assessment of callus morphometry and mechanics through the use of patient-specific finite-element models. Dual-energy X-ray absorptiometry (DXA) scanning and radiostereometric analysis (RSA) are also quantitative, but technically challenging. Nonionizing magnetic resonance (MR) and ultrasound imaging are of high interest, but require development to enable quantification of 3D mineralized structures. Emerging image-based methods for quantitative assessment of bone healing may transform clinical research design by displacing binary outcomes classification (union/nonunion) and ultimately enhance clinical care by enabling early nonunion detection.

Tips and Tricks for Common, Yet Difficult Osteopenic Fractures in the Community.

Owing to advances in medicine, the number of elderly patients is growing, concurrently leading to an increasing incidence in osteopenic fractures that often require surgical management. Some of the most common anatomic areas include the proximal humerus, the distal humerus, femoral neck fractures, and periprosthetic fractures around a total knee arthroplasty (TKA). Here, surgical strategies for these challenging clinical scenarios are reviewed, offering poignant tips and tricks to avoid pitfalls and complications.

Lower Extremity Fractures: Tips and Tricks for Nails and Plates.

Lower extremity fractures, ranging from the proximal femur to the distal tibia, come in a variety of patterns and complexity. Treatment modalities typically consist of using plates and intramedullary nails; however, each has its advantages and disadvantages in each anatomic region. In this instructional course, salient points and nuances in setup and implant choice are reviewed. Furthermore, the essential tips and tricks to avoid pitfalls and achieve a desired clinical result are discussed.

Expanding the horizons of clinical applications of proximal humerus locking plates in the lower extremities: A technical note.

Pre-contoured anatomical locking plates were designed to address the clinical need of fixing small epiphyseal segments with a larger number of screws. Those plates match the contour and shape of a variety of bones allowing for optimal buttress properties. The aim of this manuscript is to highlight the benefits of applying proximal humerus locking plates in the fixation of lower extremity bones. Although designed for the proximal humerus, the low-profile plate shape and anatomic contour also provides versatile use in certain areas of the lower extremity. This technical narrative highlights the versatile and reliable use of this plate for other anatomical areas than the one to which it has been originally conceived.

Assessment of New York Primary Care Physicians' Knowledge, Attitudes, and Practices Related to Fluoride Varnish in an Urban Medical-Setting.

OBJECTIVE: To determine changes in knowledge, attitudes, and practices of primary care physicians (PCPs) regarding fluoride varnish (FV). STUDY DESIGN: Fifty-four PCPs at an urban medical center in New York completed a pre-intervention survey. A pediatric dental resident provided an hour-long educational lecture and a hands-on demonstration regarding FV application. Six months later, PCPs were sent a post-intervention survey via electronic mail. RESULTS: Fifty-four PCPs participated in the pre-survey and FV training and 48% completed the post-survey. Prior to the FV training, 57% of PCPs knew that FV application by medical practitioners was reimbursable for children under 6-years-old and 2% of PCPs were applying FV. Post FV training, 62% of PCPs reported applying FV. Pre and post survey, barriers to FV application was not enough hands-on training (43% to 15% respectively) and not enough time (50% to 85% respectively). CONCLUSIONS: Post FV training, PCPs' knowledge, attitudes and practices in regard to FV changed. Interprofessional education may be one approach to increasing FV application participation.

Emergency Utilization and Trends in a Community Dental Clinic in Northern Manhattan: A Retrospective Study.

Purpose: To evaluate utilization and trends associated with patients who presented with emergencies at a community dental clinic at Columbia University Medical Center, New York, NY. Study design: Data from deidentified dental records of patients aged 0-12 years old who presented as emergencies for oral and dental reasons for 2012, 2013, and 2014 were collected. Variables analyzed included demographic information, oral diagnosis, and current health status. Frequency distributions analysis, chi-square test and analysis of variance (ANOVA) test were performed using Stata 13.0. Results: There were 4,328 dental and oral-related emergencies with a mean age of 6-years-old. Approximately 50% were females, 71% were Hispanic, and 90% had Medicaid managed care. Most emergencies (49%) were caries-related, 41% were considered atraumatic in nature, and approximately 10% were traumatic. About 10% of patients presented with comorbidities and 37% were either first-time patients or patients that presented exclusively for emergencies. Acute tooth pain (45%) caused by dental caries was the most common chief complaint. The trends for emergency presentations showed a significant decrease (p<.001) between years 2012-2014 for caries-related visits and a significant increase (p<.001) between 2012-2013 and 2012-2014 for atraumatic visits. Conclusions: Caries-related dental diagnoses were more common than trauma-related diagnoses. The most common caries-related diagnosis was pulp necrosis for both primary and permanent dentitions while the most common traumarelated diagnosis was subluxation for the primary dentition and enamel-dentin fracture for the permanent dentition.

A simple method for bone graft insertion during Schatzker II and III plateau fixation.

Insertion of bone graft to fill metaphyseal defects and supply subchondral support when fixing Schatzker type II and III tibial plateau fractures can be difficult and tedious. Accurately directing the placement of bone graft through a small entry portal and against gravity can be challenging. Using a modified 3-mL syringe and bone tamps with application of the Seldinger technique can make this tedious task simple and more accurate.Level of evidence V.

Use of a stainless steel locking calcaneal plate for quadrilateral plate buttress in the treatment of acetabular fractures.

Operative fixation of acetabular fractures involving the quadrilateral surface presents a challenging clinical scenario. Classically, quadrilateral plate buttress was achieved via the use of a "seven" plate. More recently, the use of an anatomic, pre-contoured design has been gaining popularity due to its pre-contoured shape and larger footprint, allowing for a wider quadrilateral plate buttress. The current study presents using a stainless steel locking calcaneal plate to obtain similar surface area coverage as the modern pre-contoured quadrilateral plate, but at a lower cost.Level of evidence IV.

Maximizing outcomes in the treatment of radial head fractures.

The radial head plays a critical role in the stability of the elbow joint and its range of motion. Injuries may occur across a spectrum of severity, ranging from low energy non-displaced fractures to high energy comminuted fractures. Multiple classification systems exist to help characterize radial head fractures and their associated injuries, as well as to guide treatment strategies. Depending on the type of fracture, non-operative management may be possible if early range of motion is initiated. Other options include open reduction and internal fixation or excision followed by arthroplasty. A lateral approach is typically used for adequate surgical exposure. Controversy still remains regarding operative management of more severe fractures, but studies have shown good outcomes after radial head replacement for these fractures. We will review the current treatments available for radial head fractures, highlighting gaps in knowledge, as well as providing recommendations for the care of these injuries.Level of evidence: Level V.

Periprosthetic Fractures About the Hip and Knee: Contemporary Techniques for Internal Fixation and Revision.

The number of periprosthetic fractures is expected to increase given the growing number of elderly individuals who are living longer and advances in technology that allow for total hip and knee arthroplasty in younger patients. Evolving technologies in combination with a better understanding of required total hip and knee reconstruction has allowed for continued improvements in applied fixation strategies and patient outcomes. Current fixation and revision options have led to reliable, reproducible management of periprosthetic fractures about the hip and knee, including proximal femur and supracondylar femur fractures, which are common, and fractures about an acetabular component and between proximal and distal hip and knee prostheses, which are rare. Orthopaedic surgeons should understand the most contemporary techniques, strategies, and formulas for the successful management of periprosthetic fractures about the hip and knee.

Hip Arthroplasty for Fracture vs Elective Care: One Bundle Does Not Fit All.

BACKGROUND: To quantify how baseline differences in patients undergoing hip arthroplasty for fracture vs elective care potentially lead to significant differences in immediate health care outcomes and whether these differences affect feasibility of current bundled payment models. METHODS: New York Statewide Planning and Research Cooperative System database for the years 2000-2014. RESULTS: A total of 76,654 patients underwent total hip arthroplasty or hemiarthroplasty between 2010 and 2014; 82.8% of the sample was for elective care and 17.2% for fracture-related etiology. Fracture patients were significantly older, more likely to be female, Caucasian, reimbursed by Medicare, and receive general anesthesia. Comorbidity burden and postoperative complications were significantly higher in the fracture group, and hospital charges were significantly greater for fracture patients as compared with those of the elective cohort. CONCLUSION: Patients undergoing hip arthroplasty for fracture care are significantly older and have more medical comorbidities than patients treated on an elective basis, leading to more in-hospital complications, greater length of stay, increased hospital costs, and significantly more hospital readmissions. The present bundled payment system, even with the recent modification, still unfairly penalizes hospitals that manage fracture patients and has the potential to incentivize hospitals to defer providing definitive surgical management for these patients. Future amendments to the bundled payment system should consider further separating hip arthroplasty patients based on etiology and comorbidities, allowing for a more accurate reflection of these distinct patient groups.

The Interobserver and Intraobserver Reliability of the Sanders Classification Versus the Risser Stage.

BACKGROUND: Estimation of skeletal maturity, classically performed using Risser sign, plays a crucial role in the treatment of AIS. Recent data, however, has shown the simplified Tanner-Whitehouse (Sanders) classification, based on an anteriorposterior (AP) hand radiographs, to correlate more closely to the rapid growth phase and thus curve progression. This study evaluated the interobserver and intraobserver reliability of the Sanders and Risser classifications among clinicians at different levels of training. METHODS: Twenty AP scoliosis radiographs and 20 AP hand radiographs were randomized and distributed to 11 graders. The graders consisted of 3 orthopaedic residents, 3 spine fellows, 3 spine surgeons, and 1 radiologist. The graders were then asked to classify the radiographs according to the Sanders and Risser classifications. There were 3 rounds of grading, each done 3 weeks apart. The overall κ coefficient was then calculated for each system to evaluate the interobserver and intraobserver reliability. RESULTS: For all graders the average κ coefficient for the interobserver and intraobserver reliability of the Sanders classification was 0.54 and 0.62, respectively, and 0.46 and 0.49 for the Risser classification. With respect to spine attendings alone, the average κ coefficient for the interobserver and intraobserver reliability of Sanders classification was 0.72 and 0.77, respectively, and 0.46 and 0.67 for the Risser classification. CONCLUSIONS: Our study demonstrated that the Sanders classification had moderate reliability with respect to physicians at various levels of training and had good reliability with respect to attending spine surgeons. Interestingly, the Risser staging was found to have less interobserver and intraobserver reliability overall. The Sanders classification is a reliable and reproducible system and should be in the armamentarium of surgeons who treat adolescent idiopathic scoliosis. LEVEL OF EVIDENCE: Level III.

Staged Treatment of Infected Tibiotalar Fusion Using a Combination Antibiotic Spacer and Antibiotic-Coated Intramedullary Nail.

Pilon fractures are notoriously difficult injuries to treat. The current published data on salvage procedures after failed pilon fractures includes both total ankle arthroplasty (TAA) and tibiotalar fusion, each with its own specific indications. However, no acceptable treatment algorithm addressing the complications of these limb salvage procedures is available. We present the case of a 23-year-old patient, who sustained a complex pilon fracture after a motor vehicle accident. The patient was referred to our institution after an initial fixation attempt, followed by subsequent failed TAA, which was complicated by an infected fusion attempt. We describe a staged treatment approach to clearing the infection and obtaining the final fusion goals.

Characteristics and Associated Comorbidities of Pediatric Dental Patients Treated under General Anesthesia.

OBJECTIVE: To describe characteristics and identify common comorbidities of children receiving dental treatment under general anesthesia at Children's Hospital of New York-Presbyterian. STUDY DESIGN: Electronic medical records of all children that received dental treatment under general anesthesia through the Division of Pediatric Dentistry from 2012-2014 were reviewed. Data describing patient characteristics (age, sex, race/ethnicity, insurance carrier, and American Society of Anesthesiologists physical status classification system), medical history, and justification for treatment were collected. Descriptive statistics, including frequencies, percentages and t-tests, were calculated. RESULTS: A total of 298 electronic medical records were reviewed, of which 50 records were excluded due to missing information. Of the 248 electronic medical records included, the average age was 5-years-old and 58% were male. The most common reason for dental treatment under general anesthesia was extent and severity of dental disease (53%), followed by significant medical history (47%) and behavior/pre-cooperative age (39%). Those who were ASA III or IV were older (6.6-years) (p<.001). Common medical comorbidities appear evenly distributed: autism (12%), cardiac anomalies (14%), developmental delay (14%), genetic syndromes/chromosomal disorders (13%), and neurological disorders (12%). Younger age groups (1 to 2 years and 3 to 5 years) had a high percentage of hospitalizations due to the extent and severity of the dental disease (83%) and behavior (77%) (p<0.001). CONCLUSIONS: No single comorbidity was seen more often than others in this patient population. The range of medical conditions in this population may be a reflection of the range of pediatric specialty services at Children's Hospital of NewYork-Presbyterian.

Dental Findings and Functional Prosthesis use in Child with Hypohidrotic Ectodermal Dysplasia: A Case Report.

Fabrication of maxillary and mandibular esthetic functional prostheses in a 5-year-old female patient with ectodermal dysplasia is reported. This report presents, clinically and radiographically, the orofacial manifestations of a child diagnosed with hypohidrotic ectodermal dysplasia, along with the construction of removable prosthetic devices.

Steinmann pin augmentation versus locking plate constructs.

BACKGROUND: Aggressive bone neoplasms, such as giant cell tumors, often affect the proximal tibia warranting bony resection via curettage leaving behind massive defects that require extensive reconstruction. Reconstruction is usually accomplished with poly(methyl methacrylate) (PMMA) packing supplemented with an internal fixation construct. The purpose of this study is to compare Steinmann pin augmentation to locking plate constructs to determine which offers the stiffer reconstruction option. MATERIALS AND METHODS: Large defects were created below the lateral condyle of fresh frozen tibias. The defects extended for an average of 35 mm beneath the lateral plateau in the frontal plane, and from the anterior to posterior cortex in the sagittal plane. Distally the defect extended for an average of 35 mm to the metadiaphyseal junction. In the Pin group, the tibias were reconstructed with three 4-mm diameter Steinmann pins placed in the medullary canal and PMMA packing. In the Plate group, the tibias were reconstructed with a 6-hole 3.5-mm LCP Proximal locking plate fixed to the proximal-lateral tibia utilizing seven 3.5-mm screws and PMMA packing. The tibias were tested for stiffness on a MTS machine by applying up to 400 N to the tibial plateau in force control at 5 N/s. Fatigue properties were tested by applying a haversine loading waveform between 200 N and 1,200 N at 3 Hz simulating walking upstairs/downstairs. RESULTS: Locking plate constructs (801.8 ± 78 N/mm) had greater (p = 0.041) stiffness than tibial constructs fixed with Steinmann pins (646.5 ± 206.3 N/mm). CONCLUSIONS: Permanent deformation was similar between the Pin and Plate group; however, two tibia from the Pin group exhibited displacements >5 mm which we considered failure. LEVEL OF EVIDENCE: n/a.

Prognostic Value of the Radiologic Appearance of the Navicular Ossification Center in Congenital Talipes Equinovarus.

Congenital talipes equinovarus (CTEV), more commonly known as clubfoot, is a deformity of the foot that is not well understood. The tarsal navicular is at the center of the disease process and exhibits abnormal development and delayed ossification. However, its role in the pathologic process is not clear. The aim of the present study was to better understand the role of the tarsal navicular in CTEV by correlating the presence of the navicular ossification center and relapse of clubfoot deformity after surgical treatment. The medical records and radiographs of 34 patients (41 feet) with surgically treated CTEV were reviewed for the presence of the navicular ossification center and the lateral talocalcaneal angles. Of the 41 feet, 17 (41.46%) did not have the tarsal navicular ossification center present before surgery, and 24 (58.54%) did have the ossification center present. The talocalcaneal angles were similar between those with and without the navicular ossification center present. No significant difference was found in the incidence of relapse between the nonossified navicular group (17.6%) and the ossified navicular group (16.7%; p = .63). The presence of the navicular ossification center before surgery does not appear to have prognostic value for the relapse of CTEV after surgical intervention.