Hand Surgery Fellowship Case Minimums: History and Design

In the 1960s, the American Society for Surgery of the Hand embarked on an endeavor to improve and standardize the educational experience in hand surgery. By the 1980s, numerous programs existed across the country with the Accreditation Council for Graduate Medical Education formally recognizing orthopedic surgery-based fellowships in 1985 and plastic surgery-based fellowships in 1986. In order to sit for what was then termed the Certificate of Additional Qualification examination, applicants had to demonstrate performance of a specific number of procedures while in practice. Borrowing from this theme, the Accreditation Council for Graduate Medical Education began to analyze programs according to the relative proportion of cases done by fellows at individual institutions compared to national trends. Beginning in 2019 and working collaboratively with the Accreditation Council for Graduate Medical Education, the Hand Fellowship Director's Association has since modified the methods by which programs are evaluated, pivoting away from comparative percentages to the establishment of case minimums. The development of this process has been iterative with the resultant outcome being an evaluation system that focuses on educational quality and technical proficiency over sheer numerical volume.

Evaluating Male Patients' Understanding of Osteoporosis Evaluation and Treatment Following a Distal Radius Fracture

PURPOSE

Current estimates suggest that 1-2 million men in the United States have osteoporosis, yet the majority of osteoporosis literature focuses on postmenopausal women. Our aim was to understand men's awareness and knowledge of osteoporosis and its treatment.

METHODS

Semistructured interviews were conducted with 20 male patients >50 years old who sustained a low-energy distal radius fracture. The goal was to ascertain patients' knowledge of osteoporosis, its management, and experience discussing osteoporosis with their primary care physicians (PCP).

RESULTS

Participants had little knowledge of osteoporosis or its treatment. Many participants regarded osteoporosis as a women's disease. Most participants expressed concern regarding receiving a diagnosis of osteoporosis. Several patients stated that they believe osteoporosis may have contributed to their fracture. Families, friends, or mass media served as the primary information source for participants, but few had good self-reported understanding of the disease itself. The majority of participants reported never having discussed osteoporosis with their PCPs although almost half had received a dual x-ray absorptiometry scan. Participants expressed general interest in being tested/screened and generally were willing to undergo treatment despite the perception that medication has serious side effects. One patient expressed concern that treatment side effects could be worse than having osteoporosis.

CONCLUSION

Critical knowledge gaps exist regarding osteoporosis diagnosis and treatment in at-risk male patients. Specifically, most patients were unaware they could be osteoporotic because of the perception of osteoporosis as a women's disease. Most patients had never discussed osteoporosis with their PCP.

CLINICAL RELEVANCE

Male patients remain relatively unaware of osteoporosis as a disease entity. Opportunity exists for prevention of future fragility fractures by improving communication between patients and physicians regarding osteoporosis screening in men following low-energy distal radius fractures.

Necrotizing Sweet Syndrome of the Hand and Forearm in the Immediate Postoperative Period: Case Report

Necrotizing soft tissue infection (NSTI) is a feared and potentially morbid postoperative complication requiring prompt surgical intervention. Cutaneous conditions that mimic NSTI have been reported and rarely occur in the postoperative period. Sweet syndrome, also known as acute febrile neutrophilic dermatosis, is a dermatologic condition characterized by fever, neutrophil-predominant leukocytosis, and painful skin lesions. Necrotizing Sweet syndrome (NSS) is an aggressive variant that causes a clinical appearance of localized skin necrosis and histologic evidence of necrotic foci extending to the deep aspects of the soft tissues and involving fascia and/or skeletal muscle. Necrotizing Sweet syndrome can be easily mistaken for NSTI. Contrary to infection, Sweet syndrome and NSS are worsened by surgical intervention due to the phenomenon of pathergy and readily respond to corticosteroid treatment. We present the case of a 54-year-old woman who developed NSS following an uncomplicated fasciectomy for Dupuytren disease.

Trends in Orthopedic Management of Distal Radius Fractures Among Medicare Beneficiaries From 2019 to 2020: A Claims Analysis

Purpose

Radius and ulna fractures are among the most common fractures. These fractures are managed through operative or nonsurgical treatment, with varying implications in terms of cost and functional outcome. There are few studies that robustly characterize the management of distal radius fractures (DRFs) in the United States during the COVID-19 pandemic. Furthermore, this has not been studied among the Medicare patient population, who are particularly vulnerable to fragility fractures and COVID-19. The purpose of this study is to analyze the services provided to Medicare beneficiaries both before and during the COVID-19 pandemic to determine how procedure volume was affected in this patient population.

Methods

We retrospectively analyzed services using the physician or supplier procedure summary data from the Centers for Medicare and Medicaid Services. All services provided by physicians between January 1, 2019, and December 31, 2020, were included. The data were stratified by US census region using insurance carrier number and pricing locality codes. We also compared data between states that maintained governors affiliated with the Democratic or Republican parties for the duration of the study.

Results

There was an overall decrease in claims regarding DRFs management from 2019 to 2020. There was a dramatic decline in procedure volume (-6.3% vs -12.9%). Of all distal radius related claims there was a relative increase in the proportion of operatively managed DRFs in 2020, from 50.2% to 52.0%. The Midwest saw the greatest decline in operatively managed DRFs, whereas the West experienced the smallest per-capita decline across all procedures. After separating the data by party affiliation, it was also found that operative and nonsurgical procedure volumes fell more sharply in states with Democratic governors.

Conclusions

This study shows a decrease in DRF procedural volume among Medicare beneficiaries. This data suggests that the operative and nonsurgical management of DRFs may have been affected by pandemic factors such as quarantine guidelines and supply chain or resource limitations. This may assist surgeons and health care systems in predicting how similar crises may affect operative volume.

Type of study/level of evidence

Therapeutic IV.

Do Surgeons Accurately Predict Level of Activity in Patients With Distal Radius Fractures?

PURPOSE

One factor influencing the management of distal radius fractures is the functional status of the patient. The purpose of this study was to assess the agreement between patient and surgeon assessments of patient activity level in patients sustaining a distal radius fracture.

METHODS

Ninety-seven patients were included, with a mean age of 58.5 years (range, 18-92 years). Patients completed the International Physical Activity Questionnaire, a validated survey that provides a score of low, moderate, or high activity levels. Treating surgeons provided an independent assessment using the same scale. Agreement between patient and surgeon assessments was evaluated using a weighted kappa-statistic, with a secondary analysis using logistic regression models to assess odds of surgical treatment.

RESULTS

Interrater agreement between surgeons and patients demonstrated only "fair" agreement, with a kappa-statistic of 0.33. Predictive models showed that surgeons accurately identified 73% of "high activity" patients but failed to correctly identify more than 41% of patients rated as "moderate activity" or "low activity." There was a correlation between surgical intervention and increasing physical activity status as assessed by the surgeon; however, the magnitude of this effect was unclear (odds ratio, 2.14; 95% confidence interval, 1.07-4.30). This relationship was no longer significant after adjusting for age, Charlson comorbidity index, and fracture class. There was no association between surgical intervention and physical activity status when using the status provided by the patient.

CONCLUSIONS

Surgeon assessment of patient activity level does not have strong agreement with patients' independent assessment. Surgeons are most accurate at identifying "high activity level" patients but lack the ability to identify "moderate activity level" or "low activity level" patients.

CLINICAL RELEVANCE

Recognition of surgeon assessment of patient activity level as flawed can stimulate improved dialog between patients and physicians, ultimately improving the shared decision-making process.

Self-Reported Physical Function and Grit Are Not Correlated in Patients Who Undergo Open Reduction Internal Fixation for Distal Radius Fractures

PURPOSE

"Grit" is defined as the perseverance and passion for long-term goals. Thus, grittier patients may have a better function after common hand procedures; however, this is not well-documented in the literature. Our purpose was to assess the correlation between grit and self-reported physical function among patients undergoing open reduction internal fixation (ORIF) for distal radius fractures (DRFs).

METHODS

Between 2017 and 2020, patients undergoing ORIF for DRFs were identified. They were asked to complete the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire before surgery and at 6 weeks, 3 months, and 1 year after surgery. The first 100 patients with at least 1-year follow-up also completed the 8-question GRIT Scale, a validated measure of passion and perseverance for long-term goals measured on a scale of 0 (least grit) to 5 (most grit). The correlation between the QuickDASH and GRIT Scale scores was calculated using Spearman rho (ρ).

RESULTS

The average GRIT Scale score was 4.0 (SD, 0.7), with a median of 4.1 (range, 1.6-5.0). The median QuickDASH scores at the preoperative, 6-week postoperative, 6-month postoperative, and 1-year postoperative time points were 80 (range, 7-100), 43 (range, 2-100), 20 (range, 0-100), and 5 (range, 0-89), respectively. No significant correlation was found between the GRIT Scale and QuickDASH scores at any time.

CONCLUSIONS

We found no correlation between self-reported physical function and GRIT levels in patients undergoing ORIF for DRFs, suggesting no correlation between grit and patient-reported outcomes in this context. Future studies are needed to investigate the influence of individual differences in character traits other than grit on patient outcomes, which may help better align resources where needed and further the ability to deliver individualized, quality health care.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Prospective Fellows' Appraisal of Hand Surgery Fellowships

PURPOSE

The nature and focus of hand surgery fellowships has been shown to vary. Compounding this issue is a paucity of information regarding the educational goals and desires of prospective fellows. The purpose of this study was to understand applicant motivation for pursuing a fellowship and the most important components of these fellowships.

METHODS

We performed an anonymous survey of all the candidates who applied for a hand surgery fellowship during the 2019-2020 academic year to establish general demographic information, preferences regarding fellowship size, and the importance of various educational and logistical components. We also recorded self-reported comfort level in treating pathologies encountered during a hand-focused subspecialty practice.

RESULTS

The most important motivation cited for pursuing a fellowship in hand surgery was the "complexity and variety of cases" (n = 55, 90%). The 5 most important desired components of a fellowship were the exposure to "bread and butter" hand surgery (n = 35, 57%), ability to take level 1 hand call (n = 26, 43%), exposure to complex wrist reconstruction (n = 26, 43%) or peripheral nerve surgery/transfers (n = 23, 38%), and soft tissue coverage including free flaps (n = 19, 31%). Further analysis revealed that the orthopedic surgery residents frequently rated exposure to level 1 call (n = 20, 45%) as 1 of their 3 most important characteristics, whereas the plastic/general surgery residents frequently ranked exposure to complex wrist reconstruction (n = 16, 38%) as 1 of their 3 most important characteristics. The components of a fellowship that received the fewest selections into an applicant's top 3 components were exposure to shoulder surgery (n = 1, 1.64%), education regarding practice building/billing (n = 2, 3.2%), and the ability to conduct research (n = 4, 6.5%).

CONCLUSIONS

Most applicants pursue a subspecialty training in hand surgery because of the field's variety and breadth of cases. The applicants prioritize exposure to "bread and butter" cases in conjunction with both complex soft tissue and microsurgical reconstruction.

CLINICAL RELEVANCE

Assisting hand fellowships in understanding what is most important to prospective fellows will allow for appropriate recruitment and development of the field of hand surgery in general.

The Association Between Depression and Antidepressant Use and Outcomes After Operative Treatment of Distal Radius Fractures at 1 Year

PURPOSE

Depression has been linked to inferior clinical outcomes among upper extremity patients. It often is challenging to distinguish the symptoms of depression, symptoms of injury, and the interaction between these 2 entities after a patient has been injured. We aimed to study the differences in clinical outcomes after surgical fixation of distal radius fractures between patients with and without a documented history and treatment for depression.

METHODS

All subjects with an isolated, acute distal radius fracture undergoing operative fixation in a 10-year period at a level 1 academic trauma center were screened. Baseline demographic data were collected, and psychiatric history and antidepressant use were recorded and verified with a pharmacy database. Quick Disability of the Arm, Shoulder and Hand (QuickDASH), range of motion, and grip strength were assessed at 12 months after surgery. Multivariable linear regression analysis was used to assess the association of depression with QuickDASH scores at 1 year after surgery.

RESULTS

A total of 211 patients were available for 1-year follow-up, 50 of whom were being treated actively for depression with medication at the time of injury and 161 were without a known diagnosis of, or treatment for, depression. Demographic and injury characteristics were similar between both groups. In a multivariable linear regression model controlling for age, sex, and a history of osteoporosis, active treatment for depression was associated with a slight mean increase in QuickDASH scores, 6.5 (1.3-11.8), 1 year after surgery.

CONCLUSIONS

This study demonstrates a small increase in QuickDASH scores between subjects with a confirmed diagnoses of depression compared with all others after surgical fixation of distal radius fracture at 1-year follow-up. We suggest that a history of depression may portend worse clinical outcomes, although other factors, such as underreporting of depression may influence results.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Predictors of Management of Distal Radius Fractures in Patients Aged >65 Years

BACKGROUND

Treatment of distal radius fractures (DRFs) in patients aged >65 years is controversial. The purpose of this study was to identify what patient and fracture characteristics may influence the decision to pursue surgical versus nonsurgical treatment in patients aged >65 years sustaining a DRF.

METHODS

We queried our institutional DRF database for patients aged >65 years who presented to a single academic, tertiary center hand clinic over a 5-year period. In all, 164 patients treated operatively were identified, and 162 patients treated nonoperatively during the same time period were selected for comparison (total N = 326). Demographic variables and fracture-specific variables were recorded. Patient and fracture characteristics between the groups were compared to determine which variables were associated with each treatment modality (operative or nonoperative).

RESULTS

The average age in our cohort was 72 (SD: 11) years, and 274 patients (67%) were women. The average Charlson Comorbidity Index (CCI) was 4.1 (SD: 2.1). The CCI is a validated tool that predicts 1-year mortality based on patient age and a list of 22 weighted comorbidities. Factors associated with operative treatment in our population were largely related to the severity of the injury and included increasing dorsal tilt (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.05-1.12; P < .001) and AO Classification type C fractures (OR, 5.42; 95% CI, 2.35-11.61; P < .001). Increasing CCI was the only factor independently associated with nonoperative management (OR, 0.84; 95% CI, 0.72-0.997; P = .046).

CONCLUSION

Fracture severity is a strong driver in the decision to pursue operative management in patients aged >65 years, whereas increasing CCI predicts nonoperative treatment.

Avascular Necrosis of Capitate and Other Uncommon Presentations of Carpal Avascular Necrosis

Outside of Preiser and Kienbock disease, avascular necrosis (AVN) of the remaining carpal bones is a rare cause of wrist pain and disability with a natural history that is incompletely understood. At present, much of the available clinical information exists in the form of isolated case reports or small case series. Although reported surgical treatment options are numerous, there is a dearth of comparative studies and long-term outcomes data with which to guide management.

Outcomes of Radial Head Fractures Treated With the "Tripod Technique"

PURPOSE

For fractures requiring operative fixation, the "tripod technique" using headless compression screws has recently been described as a less invasive alternative to open reduction and internal fixation with plate and screws. The purpose of this study was to evaluate the clinical and radiographic outcomes of the tripod technique for the treatment of radial head and neck fractures.

METHODS

We performed a retrospective chart review of all radial head and neck fractures treated with the tripod technique at our institution over a 10-year period. Patients with less than 6 months of follow-up were excluded. Outcomes were evaluated at the latest follow-up using range of motion measurements and the Quick Disabilities of the Arm, Shoulder and Hand questionnaire.

RESULTS

We evaluated 13 patients with a mean age of 48 years and average follow-up of 72 months (range, 21-153 months). All the patients achieved union by 12 weeks after surgery. The average postoperative Quick Disabilities of the Arm, Shoulder and Hand score was 5.9 (range, 0-23). The mean flexion was 139°, and the mean extension was -8°. There were no major postoperative complications. Five patients had minor complications. No patients required a reoperation.

CONCLUSIONS

The tripod technique is a useful alternative to the traditional method of plate and screw fixation for unstable radial head and neck fractures.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Longitudinal Changes in Serum Markers of Bone Metabolism and Bone Material Strength in Premenopausal Women with Distal Radial Fracture

BACKGROUND

Markers of bone metabolism (MBM) play an important role in fracture evaluation, and changes have been associated with increased fracture risk. The purpose of the present study was to describe changes in MBM in premenopausal women with distal radial fractures.

METHODS

Premenopausal women with distal radial fractures (n = 34) and without fractures (controls) (n = 39) were recruited. Serum MBM in patients with distal radial fractures were obtained at the time of the initial presentation, 6 weeks, and 3, 6, and 12 months. MBM included 25(OH) vitamin D, PTH, osteocalcin, P1NP, BSAP, CTX, sclerostin, DKK1, periostin, and TRAP5b. Areal bone mineral density (aBMD) was assessed with dual x-ray absorptiometry, and the bone material strength index (BMSi) was assessed with microindentation.

RESULTS

Most MBM reached peak levels at 6 weeks after the injury, including osteocalcin (+17.7%), sclerostin (+23.5%), and DKK1 (12.6%). Sclerostin was lower (-27.4%) and DKK1 was higher (+22.2%) at 1 year after the fracture. CTX declined below baseline levels at 6 and 12 months, whereas TRAP5b, BSAP, and periostin did not significantly change. At 12 months, sclerostin was lower (p = 0.003) and DKK1 was higher (p = 0.03) in the distal radial fracture group than in the control group. Greater fracture severity was associated with greater increases in P1NP and BSAP. aBMD and BMSi were not associated with fracture.

CONCLUSIONS

Distal radial fractures caused increases in several MBM, which typically peaked at 6 weeks after injury and gradually decreased over 6 months. Sclerostin and DKK1 remained below and above baseline at 1 year, respectively. Increasing fracture severity resulted in larger changes in MBM. aBMD and BMSi did not discriminate between patients with distal radial fractures and controls. Continued efforts to identify markers of skeletal fragility in young women are warranted to mitigate future fracture risk.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

"Age Is Just a Number": Distal Radius Fractures in Patients Over 75

Background: Management of distal radius fractures in patients over 65 is a topic of significant study, but there are variations within this group in terms of independence and activity level. This study compares the outcomes of operative distal radius fracture treatment in patients over 75 with those aged 65 to 74, to evaluate the effects of patient demand and advanced age on outcome. Methods: A retrospective review of a single-institution distal radius fracture database was performed. All patients over age 65 were evaluated for inclusion. Patient factors including activity, independence level, and quick disabilities of the arm, shoulder and hand (QuickDASH) score were recorded. Patients were selected for open reduction and internal fixation (ORIF) based on a discussion between the patient and the treating surgeon. Outcome measures including QuickDASH were recorded at 1-year post-injury. Patients aged 65 to 74 and 75 and over were compared to evaluate for demographic, functional, and outcome differences. Results: In all, 75 patients were included in the study. Fifty-one patients were aged 65 to 74, and 24 patients were aged over 75. The majority of patients rated themselves as "completely independent" and "active," the highest levels of each. There was no difference in QuickDASH scores between those patients who rated themselves as completely partially independent, or active versus moderately active. There was no statistically significant difference in QuickDASH or range of motion parameters at final follow-up. Conclusions: This study demonstrates that, in a group of patients with high levels of independence and activity, outcomes are similar in patients aged 65 to 74 and over 75 at 1 year following distal radius ORIF.

The Effect of an Electronic Prescribing Policy for Opioids on Physician Prescribing Patterns Following Common Upper Extremity Procedures

Purpose

We evaluated physician prescribing patterns before and after the implementation of a state-mandated opioid electronic prescribing (ePrescribing) program after 4 common outpatient hand surgeries. Specifically, we aimed to answer the following: (1) is there a change in the number of opioids prescribed after the institution of ePrescribing for carpal tunnel release (CTR), ganglion excision, distal radius fracture (DRF) open reduction internal fixation (ORIF), and carpometacarpal (CMC) arthroplasty and (2) what factors are associated with an increased number of tablets or total morphine milligram equivalents (MMEs) prescribed.

Methods

We retrospectively reviewed patients who underwent CTR, ganglion excision, DRF ORIF, or CMC arthroplasty and analyzed the number of tablets and MMEs prescribed before and after the policy implementation, as well as which factors were associated with an increased total number of opioid tablets and MMEs prescribed.

Results

A total of 428 patients were included. After policy implementation, there was a significant decrease in MMEs prescribed for ganglion excision (68 [SD, 45] vs 50 [SD, 60], P = .03) and CMC arthroplasty (283 [SD, 147] vs 217 [SD, 92], P < .01). There was also a significant decrease in the total number of tablets prescribed for ganglion excision (11 [SD, 5.7] vs 6.8 [SD, 8.0], P < .01), CMC arthroplasty (36 [SD, 13] vs 29 [SD, 12], P < .01), and DRF ORIF (31 [SD, 8.6] vs 28 [SD, 8.5], P = .04). The number of patients receiving any opioid prescription also significantly decreased following CTR (30% vs 51%, P = .03) and ganglion excision (11% vs 53%, P < .01).

Conclusions

The initiation of state-mandated ePrescribing was associated with a decreased number of opioids—both MMEs and tablets—prescribed after surgery by hand surgeons for a variety of common procedures. Furthermore, a greater percentage of patients received no opioid prescriptions after ePrescribing. These findings support the value of ePrescribing as a potential tool to further decrease excess opioid prescriptions.

Type of study/level of evidence

Therapeutic III.

Resistant fabric warming is a viable alternative to forced-air warming to prevent inadvertent perioperative hypothermia during hemiarthroplasty in the elderly

BACKGROUND

Surgical site infection (SSI) is associated with inadvertent perioperative hypothermia (IPH). This can be prevented by active patient warming. However, results from comparisons of warming techniques are conflicting. They are based mostly on elective surgery, are from small numbers of patients, and are dominated by the market leader, forced-air warming (FAW). Furthermore, the definition of hypothermia is debatable and systematic reviews of warming systems conclude that a stricter control of temperature is required to study the benefits of warming.

AIM

To analyse core temperatures in detail in a large subset of elderly patients who took part in a randomized trial of patient warming following hemiarthroplasty who had received constant zero-flux thermometry to record their temperature.

METHODS

Regression models with a fixed effect for warming group and covariates related to temperature were compared for 257 participants randomized to FAW or resistant fabric warming (RFW) from a prior clinical trial.

FINDINGS

Those in the RFW group were -0.08°C cooler and had a cumulative hypothermia score -1.87 lower than those in the FAW group. There was no difference in the proportion of hypothermic patients at either <36.5°C or <36.0°C.

CONCLUSIONS

This is the first study to provide accurate temperature measurements in patients undergoing a procedure predominantly under regional rather than general anaesthetic. It shows that RFW is a viable alternative to FAW for preventing IPH during hemiarthroplasty. Further studies are needed to measure the benefits of patient warming in terms of clinically important outcomes.

What Factors Are Associated with Increased Financial Burden and High Financial Worry For Patients Undergoing Common Hand Procedures?

BACKGROUND

Few studies have examined whether orthopaedic surgery, including hand surgery, is associated with patients' financial health. We sought to understand the level of financial burden and worry for patients undergoing two common hand procedures-carpal tunnel release and open reduction and internal fixation for a distal radius fracture-as well as to determine factors associated with a higher financial burden and worry.

QUESTIONS/PURPOSES

In patients undergoing operative treatment for isolated carpal tunnel syndrome with carpal tunnel release or open reduction and internal fixation for a distal radius fracture, we used validated financial burden and worry questionnaires to ask: (1) What percentage of patients report some level of financial burden, and what is the median financial burden composite score? (2) What percentage of patients report some level of financial worry, and what percentage of patients report a high level of financial worry? (3) When accounting for other assessed factors, what patient- and condition-related factors are associated with financial burden? (4) When accounting for other assessed factors, what patient- and condition-related factors are associated with high financial worry?

METHODS

In this cross-sectional survey study, a hand and upper extremity database at a single tertiary academic medical center was reviewed for patients 18 years or older undergoing operative treatment in our hand and upper extremity division for an isolated distal radius fracture between October 2017 and October 2019. We then selected all patients undergoing carpal tunnel release during the first half of that time period (given the frequency of carpal tunnel syndrome, a 1-year period was sufficient to ensure comparable patient groups). A total of 645 patients were identified (carpal tunnel release: 60% [384 of 645 patients]; open reduction and internal fixation for a distal radius fracture: 40% [261 of 645 patients). Of the patients who underwent carpal tunnel release, 6% (24 of 384) were excluded because of associated injuries. Of the patients undergoing open reduction and internal fixation for a distal radius fracture, 4% (10 of 261) were excluded because of associated injuries. All remaining 611 patients were approached. Thirty-six percent (223 of 611; carpal tunnel release: 36% [128 of 360]; open reduction and internal fixation: 38% [95 of 251]) of patients ultimately completed two validated financial health surveys: the financial burden composite and financial worry questionnaires. Descriptive statistics were calculated to report the percentage of patients who had some level of financial burden and worry. Further, the median financial burden composite score was determined. The percentage of patients who reported a high level of financial worry was calculated. A forward stepwise regression model approach was used; thus, variables with p values < 0.10 in bivariate analysis were included in the final regression analyses to determine which patient- and condition-related factors were associated with financial burden or high financial worry, accounting for all other measured variables.

RESULTS

The median financial burden composite score was 0 (range 0 [lowest possible financial burden] to 6 [highest possible financial burden]), and 13% of patients (30 of 223) reported a high level of financial worry. After controlling for potentially confounding variables like age, insurance type, and self-reported race, the number of dependents (regression coefficient 0.15 [95% CI 0.008 to 0.29]; p = 0.04) was associated with higher levels of financial burden, while retired employment status (regression coefficient -1.24 [95% CI -1.88 to -0.60]; p < 0.001) was associated with lower levels of financial burden. In addition, the number of dependents (odds ratio 1.77 [95% CI 1.21 to 2.61]; p = 0.004) and unable to work or disabled employment status (OR 3.76 [95% CI 1.25 to 11.28]; p = 0.02) were associated with increased odds of high financial worry.

CONCLUSION

A notable number of patients undergoing operative hand care for two common conditions reported some degree of financial burden and worry. Patients at higher risk of financial burden and/or worry may benefit from increased resources during their hand care journey, including social work consultation and financial counselors. This is especially true given the association between number of dependents and work status on financial burden and high financial worry. However, future research is needed to determine the return on investment of this resource utilization on patient clinical outcomes, overall quality of life, and well-being.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Orthopaedic Disaster Course: Preparing for the Worst/Best Moment in the Operating Room

Orthopaedic surgeons perform a variety of procedures where life-threatening or limb-threatening clinical scenarios or complications are relatively rare. Because these devastating complications and disaster presentations are infrequent, the occurrence can lead to concerns regarding training and preparedness. This chapter will provide a general knowledge base of common intraoperative disasters as well as life-threatening and/or limb-threatening conditions related to the upper extremity, pelvis, and lower extremity. Fundamental clinical and surgical management strategies are explored with respect to these conditions to provide a level of preparedness to help any orthopaedic surgeon control a potentially devastating complication or emergency.

Using the QuickDASH to Model Clinical Recovery Trajectory After Operative Management of Distal Radius Fracture

Purpose

There is a paucity of literature examining the trajectory of meaningful clinical improvement after distal radius fracture (DRF) fixation. We sought to answer the following questions: (1) When do patients meet the minimum clinically important difference (MCID) in the Quick-Disabilities in Arm, Shoulder, and Hand questionnaire (QuickDASH) score change after DRF fixation? (2) What gains in terms of number of MCIDs achieved (as measured by QuickDASH) do patients make as they recover from DRF fixation? (3) What patient and injury factors are characteristic of patients who meet or do not meet the average recovery trajectory?

Methods

We performed a retrospective review of an institutional database of DRF patients treated with operative fixation. The change in QuickDASH scores from before surgery to approximate follow-up intervals of 0 to 2 months, 3 to 6 months, and a minimum of 9 of 12 months was assessed, in which a delta of 14 reflected the MCID. The change in QuickDASH score from before surgery to each follow-up interval was divided by 14 to determine the number of MCIDs, representing appreciable clinical improvement. Patient characteristics were compared between those who did and did not reach average levels of clinical improvement.

Results

The study included 173 patients. Mean QuickDASH score before surgery was 74 (SD, 19; range, 0-100). After surgery, this improved to 50 (SD, 24; range, 0-100) by 0 to 2 months, 22 (SD, 22; range, 0-98) by 3 to 6 months, and 9.8 (SD, 15; range, 0-75) by a minimum of 9 to 12 months. Overall, 96% of patients reached the MCID by 1 year. Mean cumulative number of MCIDs achieved (ie, number of 14-point decreases in QuickDASH score) at each interval was 1.57, 3.64, and 4.43, respectively. Assuming 4.43 represents maximum average improvement at 1 year, patients achieved 35% (1.57 of 4.43) of recovery from 0 to 2 months after surgery and 82% (3.64 of 4.43) of recovery by 3 to 6 months after surgery. There appeared to be no difference in terms of age, sex, or body mass index with respect to these findings.

Conclusions

Overall, 96% of patients undergoing DRF fixation will achieve one QuickDASH MCID by 1 year after surgery. Patients achieved over 80% of total expected functional improvement by 3 to 6 months after surgery, which appeared to be irrespective of age, sex, or body mass index.

Type of study/level of evidence

Therapeutic IV.

Thumb Carpometacarpal Arthritis: Prognostic Indicators and Timing of Further Intervention Following Corticosteroid Injection

PURPOSE

Corticosteroid injections are commonly used to treat thumb carpometacarpal arthritis in adults. We aimed to define the timing of surgery following an initial corticosteroid injection and identify patient-specific factors that influence the likelihood of repeat injection or surgery.

METHODS

We performed a retrospective analysis of all patients who underwent a first-time corticosteroid injection for carpometacarpal arthritis between 2009 and 2017. Demographic information, radiographic classification, additional nonsurgical therapies, complications, and outcomes were collected. Primary outcomes were repeat injection and surgical reconstruction. Kaplan-Meier survival analysis was used to characterize the timing of surgical intervention and Cox regression modeling was used to identify predictors of subsequent intervention.

RESULTS

Two-hundred thirty-nine patients (average age, 62.9 years) were identified, of which 141 (59.0%) had a repeat injection and 90 (37.6%) underwent surgery. There were no patient-specific characteristics associated with repeat injection. Eaton stage III/IV arthritis at initial presentation, current smoking status, and prior ipsilateral hand surgery were associated with an increased likelihood of surgery. By Kaplan-Meier analyses, 87.7% of patients who presented with Eaton III/IV arthritis did not have surgery within a year and 66.7% of these patients did not have surgery within 5 years.

CONCLUSIONS

In this retrospective observational cohort study with 10-year follow-up from a 4-surgeon practice, advanced radiographic arthritis, current smoking status, and a history of ipsilateral hand surgery were patient-specific factors that predicted progression to surgery following injection. Of patients who presented with advanced radiographic arthritis, one-third underwent surgery within 5 years of initial injection. Although injection efficacy and causality cannot be inferred based on an observational longitudinal analysis, these data identify patient-specific factors that may have an impact on surgical decision-making and a potential timeframe for future intervention.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Challenging Dogma: Optimal Treatment of the "Fight Bite"

Background: The optimal treatment of human bites to the dorsal metacarpophalangeal region (ie, "fight bite") in the absence of gross purulence is controversial. Few studies have compared the outcomes of operative debridement with expectant wound care and oral antibiotics. Methods: We performed a retrospective chart review of all patients evaluated at a Level 1 trauma center over a 10-year period. We compared demographic and clinical characteristics of patients across treatment and outcome groups using the Fisher exact test. Logistic regression models were used to describe the relationships between the outcome and treatment variables. Results: We identified 115 patients with a mean age of 29 years. The mean follow-up was 51.8 days. Seventy-two (63%) patients were treated with antibiotics only. Thirty-two (28%) patients were treated with irrigation in the emergency department (ED) and expectant wound care. Eleven (9%) patients were treated with irrigation and debridement in the operating room. No demographic variables were found to correlate with the treatment selected. A 12% complication rate (major and minor) was observed. After adjusting for duration of follow-up and days to presentation, neither the treatment rendered nor the antibiotics selected influenced the rate of complications. Time to presentation >24 hours was the only variable associated with higher complication rate (P = .003). Conclusions: Not all fight bites require operative intervention. Irrigation in the ED with expectant wound care and oral antibiotics can be sufficient for patients presenting within 24 hours of injury in the absence of gross purulence.

Outcomes and Complications Following Volar and Dorsal Osteotomy for Symptomatic Distal Radius Malunions: A Comparative Study

PURPOSE

To compare patient-reported outcomes, functional outcomes, radiographic alignment, and complications of volar versus dorsal corrective osteotomies as the treatment for symptomatic distal radius malunions.

METHODS

We performed a retrospective review of all patients who underwent a distal radius corrective osteotomy with either a volar or dorsal approach and plating at 1 of 3 institutions between 2005 and 2017. Demographic data, type of surgical treatment, and radiographs were examined. Outcomes were Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) function scores and radius union scoring system as well as major and minor complications.

RESULTS

We included 53 cases (37 volar osteotomies and 16 dorsal osteotomies). Postoperative follow-up from the time of surgery to last QuickDASH score was 84.6 months (range, 12-169.4 months). Compared with the dorsal osteotomy group, the volar osteotomy group demonstrated a better postoperative flexion-extension arc (94.9° vs 72.9°, respectively), pronation-supination arc (146.2° vs 124.9°, respectively), and last QuickDASH scores (6.65 vs 12.87), respectively. Radiographically, there was no difference noted in radial height, radial inclination, or volar tilt in the immediate postoperative and last radiographs. There was a higher rate of complications in the dorsal osteotomy group (8 cases [50% of patients]) compared with the volar osteotomy group (7 cases [18.9% of patients]), including a higher rate of hardware removal.

CONCLUSIONS

For patients with symptomatic malunions of the distal radius, the volar and dorsal approaches both resulted in improvement in QuickDASH scores and range of motion. Volar plating resulted in slightly better QuickDASH scores and fewer complications compared with dorsal plating.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Evaluating Outcomes Following Open Fractures of the Distal Radius

PURPOSE

A paucity of evidence exists regarding the optimal treatment of open fractures of the distal radius. The purpose of this study was to compare short-term complication rates between various treatment options following open fractures of the distal radius.

METHODS

We performed a retrospective review of all open fractures of the distal radius at a single level 1 trauma center over a 10-year period. The primary outcome measure was the number of minor and major complications. Demographic and clinical characteristics of patients across treatment and outcome groups were compared and models were used to describe the relationships between outcome and treatment.

RESULTS

Ninety patients met the inclusion criteria for evaluation. An even distribution between high-energy (n = 45) and low-energy (n = 45) injuries was seen with 61 fractures Gustilo I (67%), 19 Gustilo II (22%), and 10 Gustilo III (11%). The majority of fractures were intra-articular (n = 48 AO type C vs n = 42 AO type A/B). Fractures were treated with immediate open reduction internal fixation (ORIF) in 67 cases (74%), external fixation in 12 (13%), initial external fixation followed by ORIF at a later time in 8 (9%), or closed reduction and percutaneous pinning in 3 (4%). We observed 33 complications (37%) of which 24 were major and 9 minor. Mechanism of injury and type of treatment were the only variables shown to correlate with an increased rate of complications.

CONCLUSIONS

We conclude that open fractures of the distal radius treated by immediate ORIF at the time of index debridement can result in satisfactory outcomes compared with other forms of treatment.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The Impact of Obesity and Smoking on Outcomes After Volar Plate Fixation of Distal Radius Fractures

PURPOSE

Distal radius fractures are common fractures of the upper extremity. Whereas surgical outcomes have been extensively investigated, the impact of risk factors such as body mass index (BMI) and smoking on patient outcomes has not been explored. We hypothesized that obesity and smoking would have a negative impact on the functional and radiographic outcomes of surgically treated patients with distal radius fractures.

METHODS

We performed a retrospective analysis of patients surgically treated for a distal radius fracture between 2006 and 2017 at 2 level 1 trauma centers. Patients were divided into obese (BMI ≥ 30) and nonobese (BMI < 30) groups according to the World Health Organization BMI Classification. Patients were also divided into current, former, and never smokers based on reported cigarette use. Primary outcomes included patient-reported outcome measures (Quick Disabilities of the Arm, Shoulder, and Hand [QuickDASH]), range of motion (ROM) arc (flexion-extension, pronation-supination), radiographic union (Radiographic Union Scoring System [RUSS] score), and change in radiographic alignment (radial height, radial inclination, volar tilt) between first and last follow-up. Multivariable models corrected for age, sex, comorbidities, fracture complexity, osteoporosis, and time to surgery.

RESULTS

Two hundred patients were identified, 39 with BMI of 30 or greater and 161 with BMI less than 30. Obese patients had more comorbidities but similar fracture types. At 3-month and 1-year follow-up, both groups achieved acceptable QuickDASH scores, close to those of the general population (21 vs 18, 14 vs 2, respectively). The 2 groups were similar in regard to motion, RUSS score, and alignment. There were 148 never smokers, 32 former smokers, and 20 current smokers. At 3 months, smokers demonstrated higher QuickDASH scores (42 vs 21-24) and a lower percentage of radiographically healed fractures (40% vs 69%-82%). At final follow-up, smokers reported small differences in patient-reported outcomes (QuickDASH 18 vs 9-13) whereas ROM, fracture healing, and complication rates were similar.

CONCLUSIONS

Both obese and nonobese patients can achieve excellent outcomes following surgical treatment of distal radius fracture with similar self-reported outcomes, motion, RUSS score, and alignment. Despite slower healing in the early postoperative period, smokers had similar QuickDASH scores, ROM, and union rates to past smokers and never smokers at final follow-up, with a similar complication profile.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Reducing Implant Infection in Orthopaedics (RIIiO): Results of a pilot study comparing the influence of forced air and resistive fabric warming technologies on postoperative infections following orthopaedic implant surgery

BACKGROUND

Active warming during surgery prevents perioperative hypothermia but the effectiveness and postoperative infection rates may differ between warming technologies.

AIM

To establish the recruitment and data management strategies needed for a full trial comparing postoperative infection rates associated with forced air warming (FAW) versus resistive fabric warming (RFW) in patients aged >65 years undergoing hemiarthroplasty following fractured neck of femur.

METHODS

Participants were randomized 1:1 in permuted blocks to FAW or RFW. Hypothermia was defined as a temperature of <36°C at the end of surgery. Primary outcomes were the number of participants recruited and the number with definitive deep surgical site infections.

FINDINGS

A total of 515 participants were randomized at six sites over a period of 18 months. Follow-up was completed for 70.1%. Thirty-seven participants were hypothermic (7.5% in the FAW group; 9.7% in the RFW group). The mean temperatures before anaesthesia and at the end of surgery were similar. For the primary clinical outcome, there were four deep surgical site infections in the FAW group and three in the RFW group. All participants who developed a postoperative infection had antibiotic prophylaxis, a cemented prosthesis, and were operated under laminar airflow; none was hypothermic. There were no serious adverse events related to warming.

CONCLUSION

Surgical site infections were identified in both groups. Progression from the pilot to the full trial is possible but will need to take account of the high attrition rate.

Management of Proximal Interphalangeal Joint Fracture Dislocations

Fracture dislocations of the proximal interphalangeal (PIP) joint of the finger are often caused by axial load applied to a flexed joint. The most common injury pattern is a dorsal fracture dislocation with a volar lip fracture of the middle phalanx. Damage to the soft-tissue stabilizers of the PIP joint contributes to the deformity seen with these fracture patterns. Unfortunately, these injuries are commonly written off and left untreated. A late-presenting PIP joint fracture dislocation has a poor chance of regaining normal range of motion. The provider must be suspicious of these injuries. Treatment options and algorithm are reviewed.

Open Distal Radius Fractures: Timing and Strategies for Surgical Management

Open distal radius fractures are rare injuries with few studies to guide treatment. Degree of soft tissue injury and contamination may be a primary consideration to dictate timing and operative intervention. Antibiotics should be started as early as possible and include a first-generation cephalosporin. Surgical fixation remains a matter of surgeon preference: although studies support the use of definitive internal fixation, many surgeons address contaminated injuries with external fixation. Although postoperative outcomes are similar to closed injuries for low-grade open distal radius fractures, high-grade injuries with more complex fracture patterns carry a high risk of complications, poor outcomes, and repeat surgical procedures.

Lunotriquetral Ligament Reconstruction Utilizing a Palmaris Longus Autograft

Injury to the lunotriquetral ligament can result in midcarpal instability, with resultant alterations in normal wrist kinematics and subsequent arthrosis. We performed a previously undescribed technique of lunotriquetral ligament reconstruction in two patients utilizing a palmaris longus tendon autograft. Average age at presentation was 24 years old with a mean follow up of 10 months. Average range of motion was 62.5° of flexion and 57.5° of extension. Total arc of motion was 83% of the contralateral uninvolved extremity. Average grip strength was 31 kg which was 91% of the contralateral extremity. Average Quick Disability of Arm, Shoulder and Hand score was 12.5 and Modern Activity Subjective Survey of 2007 was 1.5. No complications were noted.

Reversed Palmaris Longus Muscle Causing Volar Forearm Pain and Ulnar Nerve Paresthesia

A case of volar forearm pain associated with ulnar nerve paresthesia caused by a reversed palmaris longus muscle is described. The patient, an otherwise healthy 46-year-old male laborer, presented after a previous unsuccessful forearm fasciotomy for complaints of exercise exacerbated pain affecting the volar forearm associated with paresthesia in the ulnar nerve distribution. A second decompressive fasciotomy was performed revealing an anomalous "reversed" palmaris longus, with the muscle belly located distally. Resection of the anomalous muscle was performed with full relief of pain and sensory symptoms.

The Impact of Safety Regulations on the Incidence of Upper-Extremity Power Saw Injuries in the United States

PURPOSE

Over 50,000 power saw-related injuries occur annually in the United States. Numerous safety measures have been implemented to protect the users of these tools. This study was designed to determine which interventions, if any, have had a positive impact on the safety of the consumer or laborer.

METHODS

We queried the National Electronic Injury Surveillance System database for hand and upper-extremity injuries attributed to power saws from 1997 to 2014. Demographic information including age, sex, date of injury, device, location, body part involved, diagnosis, and disposition was recorded. We performed statistical analysis using interrupted time series analysis to evaluate the incidence of injury with respect to specific safety guidelines as well as temporal trends including patients' age.

RESULTS

An 18% increase in power saw-related injuries was noted from 1997 (44,877) to 2005 (75,037). From 2006 to 2015 an annual decrease of 5.8% was observed. This was correlated with regulations for power saw use by the Consumer Safety Product Commission (CPSC) and Underwriters Laboratories. Mean age of injured patients increased from 48.8 to 52.9 years whereas the proportion of subjects aged less than 50 years decreased from 52.8% to 41.9%. These trends were most pronounced after the 2006 CPSC regulations.

CONCLUSIONS

The incidence of power saw injuries increased from 1997 to 2005, with a subsequent decrease from 2006 to 2015. The guidelines for safer operation and improvements in equipment, mandated by the CPSC and Underwriters Laboratories, appeared to have been successful in precipitating a decrease in the incidence of power saw injuries to the upper extremity, particularly in the younger population.

CLINICAL RELEVANCE

The publication of safety regulations has been noted to have an association with a decreased incidence in power saw injuries. Based on this, clinicians should take an active role in their practice as well as in their professional societies to educate and counsel patients to prevent further injury.

Comparison of resistive heating and forced-air warming to prevent inadvertent perioperative hypothermia

BACKGROUND

Forced-air warming is a commonly used warming modality, which has been shown to reduce the incidence of inadvertent perioperative hypothermia (<36°C). The reusable resistive heating mattresses offer a potentially cheaper alternative, however, and one of the research recommendations from the National Institute for Health and Care Excellence was to evaluate such devices formally. We conducted a randomized single-blinded study comparing perioperative hypothermia in patients receiving resistive heating or forced-air warming.

METHODS

A total of 160 patients undergoing non-emergency surgery were recruited and randomly allocated to receive either forced-air warming (n=78) or resistive heating (n=82) in the perioperative period. Patient core temperatures were monitored after induction of anaesthesia until the end of surgery and in the recovery room. Our primary outcome measures included the final intraoperative temperature and incidence of hypothermia at the end of surgery.

RESULTS

There was a significantly higher rate of hypothermia at the end of surgery in the resistive heating group compared with the forced-air warming group (P=0.017). Final intraoperative temperatures were also significantly lower in the resistive heating group (35.9 compared with 36.1°C, P=0.029). Hypothermia at the end of surgery in both warming groups was common (36% forced air warming, 54% resistive heating).

CONCLUSION

Our results suggest that forced-air warming is more effective than resistive heating in preventing postoperative hypothermia.

CLINICAL TRIAL REGISTRATION

NCT01056991.

Can therapy dogs improve pain and satisfaction after total joint arthroplasty? A randomized controlled trial

BACKGROUND

The use of animals to augment traditional medical therapies was reported as early as the 9th century but to our knowledge has not been studied in an orthopaedic patient population. The purpose of this study was to evaluate the role of animal-assisted therapy using therapy dogs in the postoperative recovery of patients after THA and TKA.

QUESTIONS/PURPOSES

We asked: (1) Do therapy dogs have an effect on patients' perception of pain after total joint arthroplasty as measured by the VAS? (3) Do therapy dogs have an effect on patients' satisfaction with their hospital stay after total joint arthroplasty as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)?

METHODS

A randomized controlled trial of 72 patients undergoing primary unilateral THA or TKA was conducted. Patients were randomized to a 15-minute visitation with a therapy dog before physical therapy or standard postoperative physical therapy regimens. Both groups had similar demographic characteristics. Reduction in pain was assessed using the VAS after each physical therapy session, beginning on postoperative Day 1 and continuing for three consecutive sessions. To ascertain patient satisfaction, the proportion of patients selecting top-category ratings in each subsection of the HCAHPS was compared.

RESULTS

Patients in the treatment group had lower VAS scores after each physical therapy session with a final VAS score difference of 2.4 units (animal-assisted therapy VAS, 1.7; SD, 0.97 [95% CI, 1.4-2.0] versus control VAS, 4.1; SD, 0.97 [95% CI, 3.8-4.4], p<0.001) after the third physical therapy session. Patients in the treatment group had a higher proportion of top-box HCAHPS scores in the following fields: nursing communication (33 of 36, 92% [95% CI, 78%-98%] versus 69%, 25 of 36 [95% CI, 52%-84%], p=0.035; risk ratio, 1.3 [95% CI of risk ratio, 1.0-1.7]; risk difference, 23% [95% CI of risk difference, 5%-40%]), pain management (34 of 36, 94% [95% CI, 81%-99%], versus 26 of 36, 72% [95% CI, 55%-86%], p=0.024; risk ratio, 1.3 [95% CI of risk ratio, 1.1-1.6]; risk difference, 18% [95% CI of risk difference, 5%-39%]). The overall hospital rating also was greater in the treatment group (0-10 scale) (9.6; SD, 0.7 [95% CI, 9.3-9.8] versus 8.6, SD, 0.9 [95% CI, 8.3-8.9], p<0.001).

CONCLUSIONS

The use of therapy dogs has a positive effect on patients' pain level and satisfaction with hospital stay after total joint replacement. Surgeons are encouraged to inquire about the status of volunteer-based animal-assisted therapy programs in their hospital as this may provide a means to improve the immediate postoperative recovery for a select group of patients having total joint arthroplasty.

LEVEL OF EVIDENCE

Level II, randomized controlled study. See Instructions for Authors for a complete description of levels of evidence.

Distal radial fractures in older men. A missed opportunity?

BACKGROUND

Fractures of the distal aspect of the radius are common, yet little is known about this type of fracture among older men. The purpose of this study was to compare fracture characteristics, treatment, and osteoporosis evaluation among men and women who had sustained a distal radial fracture. We hypothesized that the men would have similar patterns of injury and lower rates of evaluation for osteoporosis.

METHODS

We retrospectively reviewed the medical records of ninety-five men and 344 women over the age of fifty years who were treated for a distal radial fracture at a single institution over a five-year period. We assessed whether the patients had received a dual x-ray absorptiometry (DXA) scan and osteoporosis treatment within six months following the injury. Multivariate analysis identified independent predictors of bone mineral density (BMD) testing and osteoporosis treatment.

RESULTS

Men had less severe fractures than women (a Type-C fracture rate of 20% for men compared with 40% for women; p = 0.014). While 184 (53%) of the women had a DXA scan after injury, only seventeen (18%) of the men were evaluated (p < 0.001). Among the patients who underwent DXA scan, nine men (9% of men overall) and sixty-five women (19% of women overall) had a diagnosis of osteoporosis (p = 0.01). Male sex was an independent predictor of failure to undergo BMD testing as well as receive subsequent treatment with calcium and vitamin D or bisphosphonates (p < 0.001).

CONCLUSIONS

Significantly fewer men received evaluation for osteoporosis following a distal radial fracture, with rates of evaluation unacceptably low according to published guidelines.

Acute idiopathic blue finger: case report

An acute blue finger is an uncommon but potentially serious finding with a heterogeneous etiology. A rare group of patients will present with acute, atraumatic, nonischemic blue fingers. The clinical course of these patients appears to be benign. We describe the presentation of an otherwise healthy 22-year-old woman with an acute idiopathic blue finger. We highlight the differential diagnoses and evaluation of this rare condition.

Myasthenic syndrome due to defects in rapsyn: Clinical and molecular findings in 39 patients

BACKGROUND

Pathogenic mutations in rapsyn result in endplate acetylcholine receptor (AChR) deficiency and are a common cause of postsynaptic congenital myasthenic syndromes.

METHODS

Clinical, electrophysiologic, pathologic, and molecular studies were done in 39 patients.

RESULTS

In all but one patient, the disease presented in the first 2 years of life. In 9 patients, the myasthenic symptoms included constant or episodic ophthalmoparesis, and 1 patient had a pure limb-girdle phenotype. More than one-half of the patients experienced intermittent exacerbations. Long-term follow-up was available in 25 patients after start of cholinergic therapy: 21 became stable or were improved and 2 of these became asymptomatic; 3 had a progressive course; and 1 died in infancy. In 7 patients who had endplate studies, the average counts of AChR per endplate and the synaptic response to ACh were less reduced than in patients harboring low AChR expressor mutations. Eight patients were homozygous and 23 heterozygous for the common p.N88K mutation. Six mutations, comprising 3 missense mutations, an in-frame deletion, a splice-site mutation, and a nonsense mutation, are novel. Homozygosity for p.N88K was associated with varying grades of severity. No genotype-phenotype correlations were observed except in 8 Near-Eastern patients homozygous for the promoter mutation (c.-38A>G), who had a mild course.

CONCLUSIONS

All but 1 patient presented early in life and most responded to cholinergic agonists. With early diagnosis and therapy, rapsyn deficiency has a benign course in most patients. There was no consistent phenotype-genotype correlation except for an E-box mutation associated with jaw deformities.

Characterization of cytokine-encapsulated controlled-release microsphere adjuvants

Controlled-release, injectable polymer microspheres provide a clinically feasible alternative to gene-modification for the local, sustained delivery of cytokines to tumors for cancer immunotherapy. Long-term release kinetics, bioactivity profiles, and stability of interleukin-2 (IL-2), interleukin-12 (IL-12), and granulocyte- macrophage colony-stimulating factor (GM-CSF)-encapsulated microspheres prepared by phase inversion nanoencapsulation (PIN) were evaluated. While all formulations released physiologically relevant quantities of cytokine for up to 30 days, the individual release kinetics were different. Recovery of specific activity after encapsulation was 40%, 60%, and 90%-that of pre-encapsulation levels for IL-2, GM-CSF and IL-12, respectively. Upon storage, the IL-12 microspheres rapidly lost activity, whereas IL-2 and GM-CSF microspheres remained stable for at least 9 weeks. These studies demonstrate that biochemical properties of microsphere formulations vary depending on the cytokine, and rigorous characterization of formulations is a prerequisite to in vivo testing.

Relationship between symptoms and disordered continence mechanisms in women with idiopathic faecal incontinence

BACKGROUND AND AIMS

Anal sphincter weakness and rectal sensory disturbances contribute to faecal incontinence (FI). Our aims were to investigate the relationship between symptoms, risk factors, and disordered anorectal and pelvic floor functions in FI.

METHODS

In 52 women with "idiopathic" FI and 21 age matched asymptomatic women, we assessed symptoms by standardised questionnaire, anal pressures by manometry, anal sphincter appearance by endoanal ultrasound and magnetic resonance imaging (MRI), pelvic floor motion by dynamic MRI, and rectal compliance and sensation by a barostat.

RESULTS

The prevalence of anal sphincter injury (by imaging), reduced anal resting pressure (35% of FI), and reduced squeeze pressures (73% of FI) was higher in FI compared with controls. Puborectalis atrophy (by MRI) was associated (p<0.05) with FI and with impaired anorectal motion during pelvic floor contraction. Volume and pressure thresholds for the desire to defecate were lower, indicating rectal hypersensitivity, in FI. The rectal volume at maximum tolerated pressure (that is, rectal capacity) was reduced in 25% of FI; this volume was associated with the symptom of urge FI (p<0.01) and rectal hypersensitivity (p = 0.02). A combination of predictors (age, body mass index, symptoms, obstetric history, and anal sphincter appearance) explained a substantial proportion of the interindividual variation in anal squeeze pressure (45%) and rectal capacity (35%).

CONCLUSIONS

Idiopathic FI in women is a multifactorial disorder resulting from one or more of the following: a disordered pelvic barrier (anal sphincters and puborectalis), or rectal capacity or sensation.

The prognostic value of pre-operative predicted forced vital capacity in corrective spinal surgery for Duchenne's muscular dystrophy

The majority of patients with Duchenne's muscular dystrophy require corrective spinal surgery for scoliosis to maintain seated balance and to slow the progression of respiratory compromise, thereby facilitating nursing and enhancing their quality of life. Traditionally patients with a pre-operative forced vital capacity (PFVC) of 30% or below predicted have been denied this surgery as it was thought that the incidence of postoperative complications was unacceptably high. We present data collected prospectively from 45 consecutive operations undertaken in our unit. These cases indicate that there is no clinically significant difference in operative and postoperative outcomes between patients with PFVC > 30% and < or =30%. However, the routine postoperative use of mask ventilation to facilitate early tracheal extubation is vital.

Interobserver variability in analysis of asbestos fibres and asbestos bodies in human lung tissue

Two different methods of quantifying asbestos fibre burden were assessed and the counts obtained were compared with semi-quantitative asbestos body counts in corresponding tissue sections. Comparison of the two methods found significantly different asbestos fibre counts between specimens. Each technique showed wide limits of agreement for reproducibility and interobserver variability as assessed by Bland-Altman plots, such that a repeated count could not necessarily be expected to lie within the same exposure category. Asbestos body counts in tissue sections were reproducible with good correlation between observers. Asbestos body and asbestos fibre counts showed correlation in some samples but not others. Counting of asbestos bodies is a valuable screening technique as the finding of asbestos bodies is accepted as a marker of significant asbestos exposure. When no asbestos bodies are identified asbestos fibres estimations may be useful in proving asbestos exposure. Different techniques are not interchangeable and each laboratory should establish a background range from unexposed individuals.

Magnetic resonance imaging of anatomic and dynamic defects of the pelvic floor in defecatory disorders

OBJECTIVE

Endoanal ultrasound identifies anal sphincter anatomy, and evacuation proctography visualizes pelvic floor motion during simulated defecation. These complementary techniques can evaluate obstructed defecation and fecal incontinence. Our aim was to develop a single, nonionizing, minimally invasive modality to image global pelvic floor anatomy and motion.

METHODS

We studied six patients with fecal incontinence and seven patients with obstructed defecation. The anal sphincters were imaged with an endoanal magnetic resonance imaging (MRI) coil and endoanal ultrasound (five patients). MR fluoroscopy acquired images every 1.4-2 s, using a modified real-time, T2-weighted, single-shot, fast-spin echo sequence, recording motion as patients squeezed pelvic floor muscles and expelled ultrasound gel; no contrast was added to other pelvic organs. Six patients also had scintigraphic defecography.

RESULTS

Endoanal ultrasound and MRI were comparable for imaging defects of the internal and external sphincters. Only MRI revealed puborectalis and/or external sphincter atrophy; four of these patients had fecal incontinence. MR fluoroscopy recorded pelvic floor contraction during squeeze and recorded relaxation during simulated defecation. Corresponding comparisons for angle change and perineal descent during defecation were not significant; only MRI, but not scintigraphy, identified excessive perineal descent in two patients.

CONCLUSIONS

Pelvic MRI is a promising single, comprehensive, nonradioactive modality to measure structural and functional pelvic floor disturbances in defecatory disorders. This method may provide insights into mechanisms of normal and disordered pelvic floor function in health and disease.

The effects of quality improvement interventions on inhospital mortality after acute myocardial infarction

OBJECTIVE

To evaluate the effects of quality improvement interventions on inhospital mortality after admission for acute myocardial infarction (AMI).

DESIGN

Before-and-after study (with concurrent controls) based on hospital discharge data from a routinely maintained, administrative database.

SETTING

All Queensland public hospitals, July 1991 - June 1999.

STUDY POPULATION

Patients with AMI admitted through the emergency department.

INTERVENTION

Development and promulgation of clinical practice guidelines at one hospital, combined with regular audit and feedback, commencing November 1995.

MAIN OUTCOME MEASURES

Inhospital mortality (adjusted for age, sex and comorbidities) for four-year periods before (1991-92 to 1994-95) and after (1995-96 to 1998-99) initiation of quality improvement interventions.

RESULTS

Before the intervention, the adjusted odds ratio (OR) for inhospital death at the intervention hospital was about the same as at other public hospitals (adjusted OR, 0.99; 95% CI, 0.80-1.24), but was more than 40% lower after the intervention (adjusted OR, 0.59; 95% Cl, 0.45-0.78). After the intervention, the risk of death at the intervention hospital was lower compared with hospitals with cardiologists as admitting practitioners (adjusted OR, 0.63; 95% CI, 0.48-0.83), with onsite revascularisation facilities (adjusted OR, 0.66; 95% CI, 0.49-0.88), and with large numbers (> or = 250 per year) of annual admissions of patients with AMI (adjusted OR, 0.72; 95% CI, 0.54-0.97).

CONCLUSIONS

Quality improvement interventions lower the risk of inhospital death in patients with AMI. Implementation of such interventions in all hospitals may confer a risk of death lower than that achieved by admitting all patients under the care of cardiologists, or to hospitals with revascularisation facilities or a high volume of admissions of patients with AMI.

Immunohistochemical analysis still has a limited role in the diagnosis of malignant mesothelioma. A study of thirteen antibodies

To identify the most accurate and useful panel to diagnose mesothelioma, we immunostained sections from 112 mesotheliomas, 18 adenocarcinomas, and 11 reactive pleural specimens with 13 antibodies. Positive results for mesotheliomas, adenocarcinomas, and reactive pleura, respectively, were CAM5.2, 111, 18, and 11; vimentin, 30, 3, and 3; HBME-1, 75, 10, and 8; thrombomodulin, 31, 2, and 2; calretinin, 43, 6, and 11; and CD44H, 68, 10, and 4. Positive results for adenocarcinoma markers in mesotheliomas and adenocarcinomas, respectively, were carcinoembryonic antigen, 1 and 15; LeuM1, 7 and 9; and Ber-EP4, 5 and 12. All reactive pleura were negative. Positive results for markers to help distinguish mesothelioma from reactive pleura in mesotheliomas, adenocarcinomas, and reactive pleura, respectively, were epithelial membrane antigen, 76, 17, and 6; p53, 78, 16, and 9; P-170 glycoprotein, 37, 4, and 2; and platelet-derived growth factor receptor beta, 31, 1, and 2. The differential diagnosis of mesothelioma from adenocarcinoma is based on negative markers. Individual mesothelial markers are of low sensitivity and specificity for mesothelioma. However, diagnostic accuracy is improved by the use of antibody panels. To date there are no antibodies that help distinguish mesothelioma from reactive pleura.