Six-Week Radiographic Follow-up Does Not Change Management for Nonoperatively Treated Extraarticular Metacarpal Shaft Fractures

BACKGROUND

Metacarpal fractures are common and account for over 30% of all hand fractures. Previous literature has shown similar outcomes between operative and nonoperative management of metacarpal shaft fractures. There is little information regarding the natural history of conservatively managed metacarpal shaft fractures and changes in management based on follow-up radiographs.

METHODS

A retrospective chart review was performed on all patients who presented to a single institution with an extraarticular metacarpal shaft or base fracture between 2015 and 2019.

RESULTS

Thirty-one patients with 37 metacarpal fractures were included for review: average age 41 years, male 48%, right hand dominant 91%, and average follow-up duration 7.3 weeks. At follow-up, a change of 2.4° in angulation (P = .0005) and a change in shortening of 0.1 mm (P = .0386) were noted over the 6-week time interval. No fractures had malrotation at presentation, and none developed malrotation during the follow-up period.

CONCLUSIONS

Recent systematic reviews and meta-analysis have suggested that metacarpal fractures treated nonoperatively had similar outcomes to surgical fixation at 12 months of follow-up. We found that extraarticular metacarpal shaft fractures that do not meet operative indications at the initial visit should be expected to heal reliably with minimal change in angulation and shortening over time. The transition to removable brace or no brace at the 2-week follow-up is likely sufficient, and additional follow-up is not necessary and will reduce cost.

LEVEL OF EVIDENCE

Level III.

Interscalene Block Versus Periarticular Liposomal Bupivacaine for Pain Control Following Reverse Shoulder Arthroplasty: A Randomized Trial

BACKGROUND

Interscalene nerve blocks and local anesthetic infiltration are two methods commonly used in multimodal analgesia regimens for shoulder arthroplasty. Liposomal bupivacaine is a novel anesthetic that can be detected more than 24 hours following local administration. Studies comparing liposomal bupivacaine with conventional analgesic methods have found mixed results regarding pain and narcotic consumption, and there is little information available regarding patient satisfaction and the role of psychosocial variables.

METHODS

This is a randomized study of 76 adult patients undergoing reverse shoulder arthroplasty who were assigned to receive a preoperative interscalene nerve block with ropivacaine (BLOCK=38) or an intra-operative periarticular injection of liposomal bupivacaine (LOCAL=38). The primary outcomes were narcotic consumption (MEq, morphine equivalents), visual analog scale (VAS) pain scores, and satisfaction (0-10). The secondary outcomes were the effect of patient group preference (BLOCK vs LOCAL) and psychosocial variables (Pain Catastrophizing Scale, Brief Resilience Scale) on satisfaction. Length of stay, pain related phone calls, pain related readmissions, and the number of narcotic refills were tracked from the day of surgery through the first postoperative appointment, which was routinely 7-14 days following surgery.

RESULTS

Intraoperative and day 0 narcotic consumption was lower in the BLOCK group by 17.3 and 21.6 MEq (p < 0.001, p = 0.035) with no differences on day 1 or 2. There was no difference in VAS pain scores, length of stay, pain related phone calls, pain related readmissions, or the number of narcotic refills. Patient satisfaction was higher in the BLOCK group [8.3 vs. 6.8, p = 0.017]. Pain catastrophizing, resilience, and patient group preference did not have any significant relationship with patient satisfaction.

CONCLUSION

Patients undergoing reverse shoulder arthroplasty have higher satisfaction with a conventional interscalene block compared to a periarticular injection of liposomal bupivacaine. There were no clinically important differences in narcotic consumption, VAS pain scores, length of stay, pain related phone calls, pain related readmissions, or the number of narcotic refills. The Pain Catastrophizing Scale, Brief Resilience Scale, and patient preferences did not have any relationship with patient satisfaction.

Defining massive rotator cuff tears: a Delphi consensus study

BACKGROUND

A standard definition for massive rotator cuff tears (MRCTs) has not been identified. The purpose of this study is to use the modified Delphi technique to determine a practical, consensus definition for MRCTs.

METHODS

This study is based on responses from 20 experts who participated in 4 rounds of surveys to determine a consensus definition for MRCT. Consensus was achieved when at least 70% of survey responders rated an item at least a 4 on a 5-point scale. A set of core characteristics was drafted based on literature review and then refined to achieve a consensus MRCT definition.

RESULTS

The following core characteristics reached consensus in the first round: tear size, number of tendons torn, and degree of medial retraction. Magnetic resonance imaging (MRI) and intraoperative findings reached consensus as the modalities of diagnosis. The second round determined that tear size should be measured as a relative value. An initial definition for MRCT was proposed in the third round: retraction of tendon(s) to the glenoid rim and/or a tear with ≥67% greater tuberosity exposure (65% approval). A modified definition was proposed that specified that degree of retraction should be measured in the coronal or axial plane and that the amount of greater tuberosity exposure should be measured in the sagittal plane (90% approval).

CONCLUSIONS

This study determined with 90% agreement that MRCT should be defined as retraction of tendon(s) to the glenoid rim in either the coronal or axial plane and/or a tear with ≥67% of the greater tuberosity exposed measured in the sagittal plane. The measurement can be performed either with MRI or intraoperatively.

Treatments of Choice for Isolated, Full-Thickness Tears of the Posterior Cruciate Ligament: A Nationwide Survey of Orthopaedic Surgeons

The ideal treatment for isolated, full-thickness tears of the posterior cruciate ligament (PCL) is uncertain. The purpose of this study was to determine how the majority of orthopaedic surgeons treat isolated, full-thickness tears of the PCL. In July 2017, a 17-question multiple-choice survey regarding the treatment of isolated, full-thickness tears of the PCL was emailed to 3,500 orthopaedic sports medicine surgeons with membership in the American Orthopaedic Society for Sports Medicine. Responders answered multiple-choice questions related to indications, technique, graft choice, bracing, and weight-bearing status following reconstruction. Answer choices were then analyzed against surgeon-specific variables. The survey was completed by 663 orthopaedic surgeons. Of the responders, 93% were fellowship trained in sports medicine with an average practice duration of 13 years. The total number of PCLs reconstructed per surgeon was low, 11.6. On average, surgeons estimate they reconstruct the PCL in only 22% of patients with full-thickness tears. The two most common surgical indications were functional limitations and failure of physical therapy. The reconstruction of choice involves a transtibial approach (63%) with a single bundle (87%) allograft (83%) of the Achilles tendon (51%). The postoperative brace is typically locked in extension (66%), and weight-bearing is delayed for 3.8 weeks. Of the surgeons with the fewest years of experience, 39% use all-inside, 89% use allograft, and 24% use dynamic bracing. Compared with surgeons with the most years of experience, only 16% use all-inside (p < 0.01), 57% use allograft (p < 0.01), and 11% use dynamic bracing (p = 0.01). Isolated, full-thickness tears of the PCL are rare injuries that are infrequently reconstructed. The most common indications for reconstruction are functional limitations and failure of conservative management. Most surgeons' treatment of choice for reconstruction involves a transtibial approach with a single bundle Achilles allograft and a postoperative brace locked in extension. On average, weight-bearing is prolonged for 3.8 weeks. The all-inside technique, allograft, and dynamic bracing are becoming more popular.

Evaluating Glenohumeral Osteoarthritis: The Relative Impact of Patient Age, Activity Level, Symptoms, and Kellgren-Lawrence Grade on Treatment

BACKGROUND

It is not always clear how to treat glenohumeral osteoarthritis, particularly in young patients. The goals of this study were to 1) quantify how patient age, activity level, symptoms, and radiographic findings impact the decision-making of shoulder specialists and 2) evaluate the observer reliability of the Kellgren-Lawrence (KL) grading system for primary osteoarthritis of the shoulder.

METHODS

Twenty-six shoulder surgeons were each sent 54 simulated patient cases. Each patient had a different combination of age, symptoms, activity level, and radiographs. Responders graded the radiographs and chose a treatment (non-operative, arthroscopy, hemiarthroplasty, or total shoulder arthroplasty). Spearman correlations and chi square tests were used to assess the relationship between factors and treatments. Sub-analysis was performed on surgical cases. An intra-class correlation (ICC) was used to assess observer agreement.

RESULTS

The significant correlations (P<0.01) were: symptoms [0.46], KL grade [0.44], and age [0.11]. In the sub-analysis of operative cases, the significant correlations were: KL grade [0.64], age [0.39], and activity level [-0.10]. The chi square analysis was significant (P<0.01) for all factors, but the practical significance of activity level was minimal. The ICCs were [inter](intra): KL [0.79] (0.84), patient management [0.54].

CONCLUSION

When evaluating glenohumeral osteoarthritis, patient symptoms and KL grade are the factors most strongly associated with treatment. In operative cases, the factors most strongly associated with the choice of operation were the patient's KL grade and age. Additionally, the KL classification demonstrated excellent observer reliability. However, there was only moderate agreement among shoulder specialists regarding treatment, indicating that this remains a controversial topic.

Poor Readability of AOSSM Patient Education Resources and Opportunities for Improvement

Background

Appropriate education on the disease processes associated with orthopaedic pathology can affect patient expectations and functional outcome.

Hypothesis

Patient education resources from the American Orthopaedic Society for Sports Medicine (AOSSM) are too complex for comprehension by the average orthopaedic patient.

Study Design

Cross-sectional study.

Methods

Patient education resources provided by the AOSSM were analyzed with software that provided 10 readability scores as well as opportunities for improving readability. The readability scores were compared with the recommended eighth-grade reading level.

Results

A total of 39 patient education resources were identified and evaluated. The mean ± SD reading grade-level scores were as follows: Coleman-Liau Index, 12.5 ± 1.11; New Dale-Chall Readability Formula, 10.9 ± 1.37; Flesch-Kincaid Grade Level, 9.9 ± 1.06; FORCAST Readability Formula, 11.4 ± 0.51; Fry Readability Formula, 12.8 ± 2.79; Gunning Fog Index, 11.9 ± 1.37; Raygor Readability Index, 13.1 ± 2.37; Simple Measure of Gobbledygook, 12.3 ± 0.90; Automated Readability Index, 11.2 ± 1.18; and New Automated Readability Index, 10.6 ± 1.27. After averaging the reading grade-level scores, only 1 patient education resource was found to be written at an 8th- to 9th-grade level, and 14 (36%) were written above a 12th-grade level. All scores were significantly different from the eighth-grade level (P < .0065). The percentage of complex words and long words were 19.6% ± 2.67% and 41.4% ± 3.18%, respectively.

Conclusion

Patient education resources provided by the AOSSM are at a significantly higher reading level than recommended. Simple changes can drastically improve these scores to increase health literacy and possibly outcome.

Proximal Humerus Fractures: Evaluation and Management in the Elderly Patient

Introduction:

Proximal humerus fractures are common in the elderly. The evaluation and management of these injuries is often controversial. The purpose of this study is to review recent evidence and provide updated recommendations for treating proximal humerus fractures in the elderly.

Methods:

A literature review of peer-reviewed publications related to the evaluation and management of proximal humerus fractures in the elderly was performed. There was a focus on randomized controlled trials and systematic reviews published within the last 5 years.

Results:

The incidence of proximal humerus fractures is increasing. It is a common osteoporotic fracture. Bone density is a predictor of reduction quality and can be readily assessed with anteroposterior views of the shoulder. Social independence is a predictor of outcome, whereas age is not. Many fractures are minimally displaced and respond acceptably to nonoperative management. Displaced and severe fractures are most frequently treated operatively with intramedullary nails, locking plates, percutaneous techniques, or arthroplasty.

Discussion:

Evidence from randomized controlled trials and systematic reviews is insufficient to recommend a treatment; however, most techniques have acceptable or good outcomes. Evaluation should include an assessment of the patient’s bone quality, social independence, and surgical risk factors. With internal fixation, special attention should be paid to medial comminution, varus angulation, and restoration of the calcar. With arthroplasty, attention should be paid to anatomic restoration of the tuberosities and proper placement of the prosthesis.

Conclusion:

A majority of minimally displaced fractures can be treated conservatively with early physical therapy. Treatment for displaced fractures should consider the patient’s level of independence, bone quality, and surgical risk factors. Fixation with percutaneous techniques, intramedullary nails, locking plates, and arthroplasty are all acceptable treatment options. There is no clear evidence-based treatment of choice, and the surgeon should consider their comfort level with various procedures during the decision-making process.

How Informative are the Plastic Surgery Residency Websites to Prospective Applicants?

OBJECTIVE

To evaluate the comprehensiveness of plastic surgery program websites.

DESIGN

American Medical Association interactive database was accessed for the list of integrated plastic surgery programs, in June 2015. Since then, 67 plastic surgery program websites were accessed and searched for the presence or absence of 31 criteria, which were further grouped into 5 categories: First, program contact information; second, training and research; third, program setup; fourth, benefits and facilities; and fifth, information for applicants. Programs were categorized based on US census bureau designated regions, and number of residency positions available. One-way ANOVA test was used for comparison.

RESULTS

Only 25% (17) program website had information available on more than two-thirds (21 or more of 31) of the criteria. The 3 least factors commonly available by program websites were: operative log (10%), contract (10%), and information on night float (25%). The 3 most commonly available factors included: coordinator information (92%), number of residents (92%), and comprehensive faculty list (88%). Less than 50% of the programs provided information regarding fellowship opportunities, active and previous research projects, and operative logs. There was no difference in amount of information on program websites when analyzed for program size or program geographic location.

CONCLUSION

Programs should consider revising their websites to include aforementioned 31 criteria. This would make applicants and potential resident physicians better informed of the programs before the interview process such that they would be more likely to apply to only those programs that match their specific aspirations.