High failure rate of 2-stage revision for the infected total elbow arthroplasty: a single institution's experience

BACKGROUND

Despite 2-stage revision being a common treatment for elbow prosthetic joint infection (PJI), failure rates are high. The purpose of this study was to report on a single institution's experience with 2-stage revisions for elbow PJI and determine risk factors for failed eradication of infection. The secondary purpose was to determine risk factors for needing allograft bone at the second stage of revision in the setting of compromised bone stock.

METHODS

We retrospectively analyzed all 2-stage revision total elbow arthroplasties (TEAs) performed for infection at a single institution between 2006 and 2020. Data collected included demographics and treatment course prior to, during, and after 2-stage revision. Radiographs obtained after explantation and operative reports were reviewed to evaluate for partial component retention and incomplete cement removal. The primary outcome was failed eradication of infection, defined as the need for repeat surgery to treat infection after the second-stage revision. The secondary outcome was the use of allograft for compromised bone stock during the second-stage revision. Risk factors for both outcomes were determined.

RESULTS

Nineteen patients were included. Seven patients (37%) had either the humeral or ulnar component retained during the first stage, and 10 (53%) had incomplete removal of cement in either the humerus or ulna. Nine patients (47%) had allograft strut used during reimplantation and reconstruction. Nine patients (47%) failed to eradicate the infection after 2-stage revision. Demographic data were similar between the repeat-infection and nonrepeat-infection groups. Six patients (60%) with retained cement failed compared with 3 patients (33%) with full cement removal (P = .370). Two patients (29%) with a retained component failed compared to 7 patients (58%) with full component removal (P = .350). Allograft was used less frequently when a well-fixed component or cement was retained, with no patients with a retained component needing allograft compared to 9 with complete component removal (P = .003). Three patients (30%) with retained cement needed allograft, compared with 6 patients (67%) who had complete cement removal (P = .179).

CONCLUSION

Nearly half of the patients failed to eradicate infection after 2-stage revision. The data did not demonstrate a clear association between retained cement or implants and risk of recurrent infection. Allograft was used less frequently when a component and cement were retained, possibly serving as a proxy for decreased bone loss during the first stage of revision. Therefore, the unclear benefit of removing well-fixed components and cement need to be carefully considered as it likely leads to compromised bone stock that complicates the second stage of revision.

Reverse Shoulder Arthroplasty to Treat Proximal Humerus Fracture Sequelae: A Review

While several proximal humerus fractures treated nonsurgically reach satisfactory outcomes, some become symptomatic malunions or nonunions with pain and dysfunction. When joint-preserving options such as malunion or nonunion repair are not optimal because of poor remaining bone stock or glenohumeral arthritis, shoulder arthroplasty is a good option. Because of the semiconstrained design of reverse shoulder arthroplasty, it is effective at improving function when there is notable bony deformity or a torn rotator cuff. Clinical studies have demonstrated reliable outcomes, and a classification system exists that is helpful for predicting prognosis and complications. By understanding the associated pearls and pitfalls and with careful management of the tuberosities, reverse shoulder arthroplasty is a powerful tool for managing proximal humerus fracture sequelae.

Surprise Billing in Elective Shoulder Surgery and Its Effect on Patient Satisfaction

Patients often receive multiple bills following surgery, which may come as a surprise to them if they are not appropriately informed or educated prior to surgery. The purpose of this study was to identify whether surprise billing occurs following shoulder rotator cuff repair and its effect on patient satisfaction. The study surveyed adult patients who underwent elective rotator cuff repair from January 2020 to October 2021. Patients were asked if they received unexpected bills after their surgery, as well as about details regarding those bills. Additionally, patients were asked about their medical insurance carrier, knowledge of the billing process prior to surgery, and how they felt the process could be improved. Finally, patients were asked how these bills and the overall billing process affected their surgical satisfaction. Of the 158 responses, 25% of the patients stated they received at least one surprise bill following their rotator cuff surgery, with 57% of these bills being greater than $1000. Patients who received surprise bills reported being significantly less satisfied with their surgery (P<.001) and felt their billing experience affected their surgical satisfaction (64% vs 9%, P<.001). One in 4 patients undergoing elective rotator cuff repair received a surprise bill following surgery. These bills were monetarily substantial and significantly affected surgical satisfaction. Although surgeons may be unable to limit the amount of bills patients receive postoperatively, increased communication and education regarding the perioperative billing process may prove to be beneficial for both patient satisfaction and the physician-patient relationship. [Orthopedics. 2024;47(2):123-127.].

Effect of vitamin E-enhanced highly cross-linked polyethylene on wear rate and particle debris in anatomic total shoulder arthroplasty: a biomechanical comparison to ultrahigh-molecular-weight polyethylene

BACKGROUND

Particle-induced osteolysis resulting from polyethylene wear remains a source of implant failure in anatomic total shoulder designs. Modern polyethylene components are irradiated in an oxygen-free environment to induce cross-linking, but reducing the resulting free radicals with melting or heat annealing can compromise the component's mechanical properties. Vitamin E has been introduced as an adjuvant to thermal treatments. Anatomic shoulder arthroplasty models with a ceramic head component have demonstrated that vitamin E-enhanced polyethylene show improved wear compared with highly cross-linked polyethylene (HXLPE). This study aimed to assess the biomechanical wear properties and particle size characteristics of a novel vitamin E-enhanced highly cross-linked polyethylene (VEXPE) glenoid compared to a conventional ultrahigh-molecular-weight polyethylene (UHMWPE) glenoid against a cobalt chromium molybdenum (CoCrMo) head component.

METHODS

Biomechanical wear testing was performed to compare the VEXPE glenoid to UHMWPE glenoid with regard to pristine polyethylene wear and abrasive endurance against a polished CoCrMo alloy humeral head in an anatomic shoulder wear-simulation model. Cumulative mass loss (milligrams) was recorded, and wear rate calculated (milligrams per megacycle [Mc]). Under pristine wear conditions, particle analysis was performed, and functional biologic activity (FBA) was calculated to estimate particle debris osteolytic potential. In addition, 95% confidence intervals for all testing conditions were calculated.

RESULTS

The average pristine wear rate was statistically significantly lower for the VEXPE glenoid compared with the HXLPE glenoid (0.81 ± 0.64 mg/Mc vs. 7.00 ± 0.45 mg/Mc) (P < .05). Under abrasive wear conditions, the VEXPE glenoid had a statistically significant lower average wear rate compared with the UHMWPE glenoid comparator device (18.93 ± 5.80 mg/Mc vs. 40.47 ± 2.63 mg/Mc) (P < .05). The VEXPE glenoid demonstrated a statistically significant improvement in FBA compared with the HXLPE glenoid (0.21 ± 0.21 vs. 1.54 ± 0.49 (P < .05).

CONCLUSIONS

A new anatomic glenoid component with VEXPE demonstrated significantly improved pristine and abrasive wear properties with lower osteolytic particle debris potential compared with a conventional UHMWPE glenoid component. Vitamin E-enhanced polyethylene shows early promise in shoulder arthroplasty components. Long-term clinical and radiographic investigation needs to be performed to verify if these biomechanical wear properties translate to diminished long-term wear, osteolysis, and loosening.

Elliptical Humeral Head Implants in Anatomic Total Shoulder Arthroplasty

Humeral implants for anatomic total shoulder arthroplasty and hemiarthroplasty have typically used spherical humeral heads that have a uniform diameter and radius of curvature. However, the native humeral head has a more elliptical morphology, which has spurred interest in nonspherical implant designs. Cadaveric studies indicate that the native humeral head diameter is 10% longer in the superior-inferior plane than the anterior-posterior plane and has a radius of curvature that is approximately 8% greater. An elliptical implant that more closely replicates native anatomy may allow for more accurate coverage of the humeral resection surface with less implant overhang and risk of overstuffing. Biomechanical evidence suggests that an elliptical implant yields glenohumeral kinematics that mimic the native joint, and early clinical results are promising. As clinical research continues to emerge, it will become clearer whether encouraging cadaveric, biomechanical, and early clinical data translates to meaningful sustained improvements in patient outcomes.

The Incidence of Symptomatic Mediastinal Compromise Following Medial Clavicle Fractures

Medial clavicle fractures pose a concern for mediastinal compromise because of their proximity to the sternoclavicular joint. However, the true incidence of this complication is unknown. The purpose of this study was to evaluate fracture configuration and determine the incidence of mediastinal compromise following medial clavicle fractures. A retrospective analysis of all patients treated for isolated medial one-third clavicle fractures at a single institution was performed. Patient demographics, the mechanism of injury, complications, and treatment were recorded. The fracture pattern and orientation were determined from a review of injury radiographs and computed tomography scans. The incidence of subsequent mediastinal compromise was then identified via a chart review. One hundred five patients were included for analysis. Twenty-two patients (20.8%) had computed tomography scans for review. The average age was 56 years, with 53% of patients being male. Sixty-eight percent of patients reported a high-energy mechanism of injury. No patients demonstrated evidence of mediastinal compression on physical examination. No patients required hospitalization for complications secondary to mediastinal compromise. Ninety percent (n=94) of patients were treated nonoperatively. Forty-three percent of fractures were nondisplaced. The remaining fractures demonstrated anterior or superior displacement of the lateral fragment, with a 0% incidence of posterior displacement. The most common indication for surgery was fracture displacement (n=10). A classification of medial clavicle fractures was developed using data from our cohort and a literature review. Medial clavicle fractures rarely demonstrate posterior displacement. Despite fracture proximity, mediastinal injury is exceedingly uncommon. [Orthopedics. 202X;XX(X):xx-xx.].

Factors Associated with Functional Improvement After Posteriorly Augmented Total Shoulder Arthroplasty

BACKGROUND

Posteriorly augmented glenoid components in anatomic total shoulder arthroplasty (TSA) address posterior glenoid bone loss with inconsistent results. The purpose of this study is to identify pre- and postoperative factors that impact range of motion and function after augmented TSA in patients with B2 or B3 glenoid morphology.

METHODS

A retrospective review was performed of all patients who underwent TSA with a step type augment by a single surgeon between 2009 and 2018. Patients with a Walch type B2 or B3 glenoid were included. Outcomes included forward elevation (FE), external rotation (ER), internal rotation (IR), Single Assessment Numeric Evaluation (SANE), and Visual Analog Scale for pain (VAS). Preoperative imaging was reviewed to assess glenoid retroversion and posterior humeral head subluxation relative to the scapular body and mid-glenoid face. Postoperative measurements included glenoid retroversion, subluxation relative to the scapular body, subluxation relative to the central glenoid peg, and center-peg osteolysis. Measurements were performed by investigators blinded to range of motion and functional outcome scores.

RESULTS

Fifty patients (mean age, 68.1 + 8.0) with a mean follow-up of 42.0 months (Range, 24-106 months) were included. Glenoid morphology included 41 B2 and 9 B3 glenoids. One patient had center-peg osteolysis and one patient had glenoid component loosening. The average preoperative FE, ER, and IR was 110°, 21°, and S1, respectively. The average postoperative FE, ER, and IR was 155°, 42°, and L1, respectively. The mean postoperative VAS score was 0.5 + 0.8 and mean SANE score was 94.5 + 5.6. Patients with B3 glenoids were associated with better postoperative internal rotation compared to B2 glenoids (T10 vs L1, p=0.024), with no other differences in range of motion between the glenoid types. Preoperative glenoid retroversion did not significantly impact postoperative range of motion. Postoperative glenoid component retroversion and residual posterior subluxation relative to the scapular body or glenoid face did not correlate with range of motion in any plane. However, posterior subluxation relative to the glenoid face was moderately associated with lower SANE scores (r= -0.448, p=0.006).

CONCLUSION

Patients achieved excellent functional outcomes and pain improvement after TSA with an augmented glenoid component. Postoperative range of motion and function had no clinically important associations with pre- or postoperative glenoid retroversion or humeral head subluxation in our cohort of posteriorly augmented total shoulder arthroplasties except for worse functional scores with increased humeral head subluxation in relation to the glenoid surface.

Return to driving following anatomic and reverse shoulder arthroplasty: a comparative analysis

BACKGROUND

The currently recommended time to return to driving following shoulder arthroplasty is controversial. The purpose of this study was to determine patient-specific factors associated with early return to driving after anatomic (aTSA) and reverse total shoulder arthroplasty (RTSA).

METHODS

All patients aged >18 years undergoing primary aTSA or RTSA at a single institution over a 3-year period were retrospectively identified. Patients were emailed a questionnaire to determine time to postoperative return to driving and frequency of driving prior to and following surgery. Patients who did not drive prior to surgery or did not complete the questionnaire were excluded from analysis. Multivariate analysis was used to determine patient-specific factors associated with early return to driving (within 2 weeks following surgery) and delayed return (>6 weeks following surgery).

RESULTS

Four hundred six patients were included for analysis (aTSA = 214, RTSA = 192). Patients undergoing aTSA were significantly younger (68 vs. 74 years) and drove more frequently both pre- and postoperatively than the RTSA cohort. One hundred percent of patients returned to driving postoperatively. Patients undergoing aTSA more commonly demonstrated earlier return to driving than RTSA patients (34% vs. 20%). Factors associated with increased odds of early return to driving included male sex (aTSA) and compliance with surgeon instruction (aTSA). Decreased odds of early return was associated with waiting to drive until cessation of sling use (RTSA), older age (RTSA), and increased body mass index (RTSA). The presence of surgical complications (aTSA) and prolonged use of narcotics (RTSA) were associated with return to driving >6 weeks following surgery. No difference in the rate of motor vehicle accidents was found between patients returning to driving <2 vs. >2 weeks postoperatively.

CONCLUSION

Patients undergoing aTSA return to driving sooner than those undergoing RTSA. Early return to driving appears to be influenced by patient sex, age, BMI, narcotic and sling use, and compliance with surgeon instruction, but does not appear to result in a high incidence of postoperative MVA.

Biomechanical comparison of elbow stability constructs

BACKGROUND

Despite surgical stabilization of complex elbow trauma, additional fixation to maintain joint congruity and stability may be required. Multiple biomechanical constructs include a static external fixator (SEF), a hinged external fixator (HEF), an internal joint stabilizer (IJS), and a hinged elbow orthosis (HEO). The optimal adjunct fixation to surgical reduction is yet to be determined.

METHODS

Eight matched cadaveric upper extremities were tested in a biomechanical model. Anteroposterior stress radiographs were obtained of the elbow in full supination at 0° and 45° of elbow flexion with the weight of the hand serving as a varus load as the baseline. A 360° capsuloligamentous soft-tissue release was performed around the elbow. The biomechanical constructs were applied in the same sequential order: SEF, HEF, IJS, and HEO. For each construct, 0 kg (0-lb) and 2.3 kg (5-lb) of weight were applied to the distal arm. At both weights, radiographs were obtained with the elbow at 0° and 45° of flexion, with subsequent measurement of displacement, congruence at the ulnohumeral joint, and the ulnohumeral opening angle. Statistical analysis was performed to quantify the strength and stability of each construct.

RESULTS

Compared with the control group at 0° with and without 2.3 kg (5-lb) of varus force and at 45° with and without 2.3 kg (5-lb) of varus force, no difference was noted in the medial ulnohumeral joint space, lateral ulnohumeral joint space, or ulnohumeral opening angle between the SEF, HEF, and IJS. The gap change after exertion of a 2.3-kg (5-lb) force between the control condition and application of each construct demonstrated no difference between the SEF, HEF, and IJS. Comparison among destabilized elbows showed no significant difference between the SEF, HEF, and IJS. The HEO catastrophically failed in each position at 0 kg (0-lb) of weight.

CONCLUSION

The SEF, HEF, and IJS are neither superior nor inferior at maintaining elbow congruity with the weight of the arm and 2.3 kg (5-lb) of varus stress. The HEO did not provide additional stability to the unstable elbow.

The Opioid Risk Tool: Can This Validated Tool Predict Post-Operative Opioid Dependence Following Arthroscopic Rotator Cuff Repair?

BACKGROUND

Numerous attempts have been made to decrease the incidence of opioid dependence after orthopedic surgeries. However, no effective means of preoperative risk stratification currently exists. The purpose of this study was to determine the ability of the Opioid Risk Tool (ORT) to predict the rate of opioid dependence 2 years after arthroscopic rotator cuff repair (ARCR).

METHODS

We prospectively evaluated all patients undergoing primary ARCR at a single institution over a 1.5 year period with a minimum of 2-year follow-up. All patients completed the ORT prior to surgery and were stratified into Low, Moderate, and High risk categories. The primary outcome was postoperative opioid dependence, defined as receiving a minimum of 6 opioid prescriptions within 2 years following surgery. Secondary outcomes included the total number of morphine milligram equivalents prescribed, total number of opioid prescriptions filled, and total number of opioid pills prescribed during this time interval. All outcome variables were compared amongst Low, Moderate, and High risk groups. Assessment of a statistical correlation between each outcome variable and individual numerical ORT scores (1-9) was performed.

RESULTS

A total of 137 patients were included for analysis. No statistically significant difference was noted in any primary or secondary outcome variable when compared between Low, Moderate, and High risk groups. The total cohort demonstrated a 19% rate of post-operative opioid dependence. No correlation was identified between any outcome variable and individual numerical ORT scores. A greater rate of dependence and quantity of opioids prescribed was noted amongst patients with a history of prior opioid use.

CONCLUSION

The ORT was not predictive of the risk of opioid dependence or quantity of opioids prescribed after ARCR. Attention should be focused on alternative means of identification and management of patients at risk for opioid dependence after orthopedic procedures, including those with a history of prior opioid use.

Opioid-Free Arthroscopic Rotator Cuff Repair

Rotator cuff repair is known to cause significant pain, and therefore opioids are often prescribed postoperatively. The United States is currently experiencing an opioid epidemic, and prescription opioids are considered a gateway drug to opioid abuse and addiction. Orthopedic surgeons are looking for alternative means to control pain. The purpose of this study was to evaluate the efficacy of an opioid-free postoperative pain protocol in patients following an arthroscopic rotator cuff repair. A prospective study of 36 consecutive patients was performed. Patient demographics, prior narcotic consumption, past medical history, and visual analog scale (VAS) pain score were collected. All patients received an opioid-free postoperative pain protocol, including education, premedication, interscalene nerve blockade, and intraoperative injection, and were discharged with ketorolac, zolpidem, and acetaminophen. A sealed envelope containing an oxycodone prescription was also received at discharge. Patients were instructed only to fill the oxycodone prescription if they had uncontrolled pain. The primary outcomes were filling of the oxycodone prescription and use. Secondary outcomes were VAS pain scores and patient satisfaction scores. Sixty-seven percent of patients successfully completed opioid-free arthroscopic rotator cuff repair. Patients who did not use oxycodone had lower pain scores overall when comparing each postoperative day. By the first postoperative visit, patients who did not take oxycodone also demonstrated higher satisfaction with their pain management. This study demonstrates that with appropriate multimodal pain management, the majority of willing patients can undergo rotator cuff repair without use of opioids. [Orthopedics. 2021;44(2):e301-e305.].

The Effect of State Legislation on Opioid Prescriptions Following Arthroscopic Rotator Cuff Repair

New Jersey State Law, P.L. 2017 Chapter 28 22, C.24:21-15.2, passed in February 2017, is the most restrictive opioid legislation passed thus far in the United States. This study evaluated the effects of this legislation on the postoperative opioid prescriptions of patients undergoing arthroscopic rotator cuff repair (RCR). Opioid prescriptions were compared following arthroscopic RCR before and after implementation of the new law using the New Jersey Prescription Monitoring Program Aware Drug Database. A consecutive cohort of patients who underwent RCR during a 6-month period prior to the legislation was compared with a consecutive cohort of patients who underwent RCR during a 6-month period after the law went into effect. The primary outcome measure was prescribed postoperative milligram morphine equivalents (MME) and number of pills prescribed. There were 265 patients in the pre-law cohort and 198 patients in the post-law cohort. In the pre-law cohort, there was a median of 1250 MME (interquartile range [IQR], 900-1800 MME) and a median of 100 pills (IQR, 60-175 pills) prescribed postoperatively. In the post-law cohort, a median of 900 MME (IQR, 550-1050 MME) and a median of 60 pills (IQR, 60-90 pills) were prescribed postoperatively. A comparison of pre-law and post-law data for MME and number of pills prescribed was statistically significant (P<.001). The median opioid consumption MME and number of pills prescribed following RCR decreased significantly following the implementation of the New Jersey state law. Findings of this study indicate state regulations may play a role in reducing narcotic consumption following RCR. [Orthopedics. 2021;44(1):e80-e84.].

Revision total elbow arthroplasty failure rates: the impact of primary arthroplasty failure etiology on subsequent revisions

BACKGROUND

The number of primary total elbow arthroplasties (TEAs) performed is increasing annually, necessitating a rise in the number of revision procedures. No studies exist to illustrate reliable indications for revision arthroplasty. The purpose of this study was to determine the impact of the etiology of primary TEA failure on the failure rate of revision surgery.

METHODS

We retrospectively analyzed the patient charts of all revision TEAs performed at a single institution between 2006 and 2016. The primary outcome was revision failure, defined as the need for a second revision surgical procedure. Patients were organized into cohorts by etiology of primary implant failure. Failure rates, time to second revision, and average number of additional revisions were compared among cohorts.

RESULTS

A total of 46 patients with a mean age of 62.7 years and minimum 2-year follow-up were included. The etiologies of failure identified were infection (n = 20), aseptic loosening (n = 17), periprosthetic fracture (n = 6), and bushing wear (n = 3). All noninfectious etiologies were grouped into an additional cohort. Patients who underwent revision for infection demonstrated a significantly greater failure rate and greater number of additional revisions per patient than those with aseptic loosening, those with periprosthetic fracture, and the noninfectious group, as well as a shorter time to failure than the noninfectious group.

CONCLUSION

Patients in whom primary TEA fails because of infection are more likely to experience revision failure and require a greater number of subsequent operations than patients with other etiologies of primary TEA failure. These data question the efficacy of revision surgery in the treatment of infected TEAs.

The Effectiveness of Aspirin for Venous Thromboembolism Prophylaxis for Patients Undergoing Arthroscopic Rotator Cuff Repair

Venous thromboembolic disease (VTED) is a rare complication following arthroscopic rotator cuff repair (RCR). The American Academy of Orthopaedic Surgeons and the American College of Chest Physicians have no prophylaxis guidelines specific to shoulder arthroscopy, yet many surgeons prescribe aspirin following RCR. The purpose of this study was to evaluate the effectiveness of aspirin and mechanical prophylaxis compared with mechanical prophylaxis alone in preventing VTED following RCR. A total of 914 patients underwent RCR between January 2010 and January 2015. A retrospective case-control study was performed. The control group (n=484) consisted of patients treated with compression boots and early mobilization. The study group (n=430) used compression boots, early mobilization, and 81 mg/d of aspirin. The primary outcome was symptomatic VTED, including deep venous thrombosis (DVT) and pulmonary embolism (PE). A total of 7 VTED events occurred during the study period: 6 DVTs and 1 PE; 1 patient experienced both DVT and PE. The percentage of patients with VTED, DVT, and PE was 0.66%, 0.66%, and 0.11%, respectively. There was no significant difference for DVT or PE between the 2 groups. The incidence of DVT and PE was 0.62% and 0.00%, respectively, for the control group (no aspirin) and 0.70% and 0.23%, respectively, for the study group (aspirin). Aspirin does not lead to a clinically significant reduction in either DVT or PE rate in patients undergoing RCR. The authors conclude that the use of mechanical prophylaxis and early mobilization is a sufficient method of VTED prophylaxis in this low-risk population. [Orthopedics. 2019; 42(2):e187-e192.].

The Effect of Price on Surgeons' Choice of Implants: A Randomized Controlled Survey

PURPOSE

Surgical costs are under scrutiny and surgeons are being held increasingly responsible for cost containment. In some instances, implants are the largest component of total procedure cost, yet previous studies reveal that surgeons' knowledge of implant prices is poor. Our study aims to (1) understand drivers behind implant selection and (2) assess whether educating surgeons about implant costs affects implant selection.

METHODS

We surveyed 226 orthopedic surgeons across 6 continents. The survey presented 8 clinical cases of upper extremity fractures with history, radiographs, and implant options. Surgeons were randomized to receive either a version with each implant's average selling price ("price-aware" group), or a version without prices ("price-naïve" group). Surgeons selected a surgical implant and ranked factors affecting implant choice. Descriptive statistics and univariate, multivariable, and subgroup analyses were performed.

RESULTS

For cases offering implants within the same class (eg, volar locking plates), price-awareness reduced implant cost by 9% to 11%. When offered different models of distal radius volar locking plates, 25% of price-naïve surgeons selected the most expensive plate compared with only 7% of price-aware surgeons. For cases offering different classes of implants (eg, plate vs external fixator), there was no difference in implant choice between price-aware and price-naïve surgeons. Familiarity with the implant was the most common reason for choosing an implant in both groups (35% vs 46%). Price-aware surgeons were more likely to rank cost as a factor (29% vs 21%).

CONCLUSIONS

Price awareness significantly influences surgeons' choice of a specific model within the same implant class. Merely including prices with a list of implants leads surgeons to select less expensive implants. This implies that an untapped opportunity exists to reduce surgical expenditures simply by enhancing surgeons' cost awareness.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic/Decision Analyses I.

Effect of Humeral Component Version on Outcomes in Reverse Shoulder Arthroplasty

Although reverse shoulder arthroplasty provides excellent clinical results in appropriately selected patients, loss of external and internal rotation may occur. Component selection, design, and placement affect postoperative results. Recent studies considered the effect of humeral component version on functional results. The current study investigated whether humeral stem retroversion affects the outcomes of reverse shoulder arthroplasty with a retrospective review of a multisurgeon, industry-sponsored, prospectively gathered database of a single reverse shoulder arthroplasty implant. All patients had at least 2-year follow-up. Clinical outcomes, including American Shoulder and Elbow Surgeons score, visual analog scale pain score, Short Form-12 Mental and Physical Component scores, range of motion, and internal rotation function, were compared between patients with humeral retroversion of 10° or less (group A) and those with humeral retroversion of 20° or greater (group B). Radiographic outcomes were compared. The analysis included 64 patients (group A, 29 patients; group B, 35 patients). No clinical or statistically significant difference was found in American Shoulder and Elbow Surgeons scores. Both groups showed statistical and clinical improvement vs preoperative scores, with group A averaging 77.8 and group B averaging 79.2 at final follow-up. No differences were found between groups in range of motion or ability to perform tasks that require shoulder internal rotation. Patients can expect good clinical improvement after reverse shoulder arthroplasty. No difference was found in clinical or radiologic outcomes based on humeral component retroversion. Despite the theoretical increase in external rotation when the humeral component is placed closer to native retroversion, the results did not show this effect. [Orthopedics. 2017; 40(3):179-186.].

Surgical Cost Disclosure May Reduce Operating Room Expenditures

Health care expenditures are rising in the United States. Recent policy changes are attempting to reduce spending through the development of value-based payment systems that rely heavily on cost transparency. This study was conducted to investigate whether cost disclosure influences surgeons to reduce operating room expenditures. Beginning in 2012, surgeon scorecards were distributed at a regional health care system. The scorecard reported the actual direct supply cost per case for a specific procedure and compared each surgeon's data with those of other surgeons in the same subspecialty. Rotator cuff repair was chosen for analysis. Actual direct supply cost per case was calculated quarterly and collected over a 2-year period. Surgeons were given a questionnaire to determine their interest in the scorecard. Actual direct supply cost per rotator cuff repair procedure decreased by $269 during the study period. A strong correlation (R²=0.77) between introduction of the scorecards and cost containment was observed. During the study period, a total of $39,831 was saved. Of the surgeons who were queried, 89% were interested in the scorecard and 56% altered their practice as a result. Disclosure of surgical costs may be an effective way to control operating room spending. The findings suggest that providing physicians with knowledge about their surgical charges can alter per-case expenditures. [Orthopedics. 2017; 40(2):e269-e274.].

Comparison of implant cost and surgical time in arthroscopic transosseous and transosseous equivalent rotator cuff repair

BACKGROUND

We investigated the cost savings associated with arthroscopic transosseous (anchorless) double-row rotator cuff repair compared with double-row anchored (transosseous-equivalent [TOE]) repair.

METHODS

All patients undergoing double-row arthroscopic rotator cuff repair from 2009 to 2012 by a single surgeon were eligible for inclusion. The study included 2 consecutive series of patients undergoing anchorless or TOE repair. Excluded from the study were revision repairs, subscapularis repairs, patients with poor tendon quality or excursion requiring medialized repair, and partial repairs. Rotator cuff implant costs (paid by the institution) and surgical times were compared between the 2 groups, controlling for rotator cuff tear size and additional procedures performed.

RESULTS

The study included 344 patients, 178 with TOE repairs and 166 with anchorless repairs. Average implant cost for TOE repairs was $1014.10 ($813.00 for small, $946.67 for medium, $1104.56 for large, and $1507.29 for massive tears). This was significantly more expensive compared with anchorless repairs, which averaged $678.05 ($659.75 for small, $671.39 for medium, $695.55 for large, and $716.00 for massive tears). Average total operative time in TOE and anchorless groups was not significantly different (99 vs. 98 minutes). There was larger (although not statistically significant) case time variation in the TOE group.

CONCLUSIONS

Compared with TOE repair, anchorless rotator cuff repair provides substantial implant-related cost savings, with no significant differences in surgical time for medium and large rotator cuff tears. Case time for TOE repair varied more with extremes in tear size.

Accuracy of Athletic Trainer and Physician Diagnoses in Sports Medicine

It is standard practice in high school athletic programs for certified athletic trainers to evaluate and treat injured student athletes. In some cases, a trainer refers an athlete to a physician for definitive medical management. This study was conducted to determine the rate of agreement between athletic trainers and physicians regarding assessment of injuries in student athletes. All high school athletes who were injured between 2010 and 2012 at 5 regional high schools were included in a research database. All patients who were referred for physician evaluation and treatment were identified and included in this analysis. A total of 286 incidents met the inclusion criteria. A total of 263 (92%) of the athletic trainer assessments and physician diagnoses were in agreement. In the 23 cases of disagreement, fractures and sprains were the most common injuries. Kappa analysis showed the highest interrater agreement in injuries classified as dislocations and concussions and the lowest interrater agreement in meniscal/labral injuries and fractures. In the absence of a confirmed diagnosis, agreement among health care providers can be used to infer accuracy. According to this principle, as agreement between athletic trainers and physicians improves, there is a greater likelihood of arriving at the correct assessment and treatment plan. Athletic trainers are highly skilled professionals who are well trained in the evaluation of athletic injuries. The current study showed that additional training in identifying fractures may be beneficial to athletic trainers and the athletes they treat. [Orthopedics. 2016; 39(5):e944-e949.].

Displaced Proximal Humerus Fractures in Older Patients: Shoulder Surgeons Versus Traumatologists

Proximal humerus fractures are relatively common, with treatment dependent on fracture-specific, patient-specific, and surgeon-specific factors. This study sought to identify preferences among shoulder specialists and orthopedic traumatologists in the treatment of proximal humerus fractures. An anonymous Internet survey of fellowship-trained shoulder surgeons and traumatologists was conducted with radiographs and select computed tomography images of 15 unique displaced proximal humerus fractures. Participants were asked to classify each case according to Neer criteria and choose management from a list of options. Groups were analyzed using chi-square test for independence, paired t test, and Fleiss' kappa within and between each group. Among shoulder surgeons, there were a total of 19 cases selected for nonoperative management, 204 cases selected for open reduction and internal fixation (ORIF), and 122 cases selected for arthroplasty. Among traumatologists, there were 44 cases selected for nonoperative management, 234 for ORIF, and 67 for arthroplasty. Fleiss' kappa for intraobserver agreement on treatment choice was 0.26 for shoulder surgeons and 0.18 for traumatologists, and chi-square test for independence was significant between the 2 groups (P<.001). Paired t test of the average treatment proportions was significant for nonoperative management and arthroplasty (P=.003) but not significant for differences in rates of ORIF. These results confirm poor consistency in Neer classification among surgeons and suggest that shoulder surgeons were more likely to consider arthroplasty for treatment and that traumatologists were more likely to use ORIF or to manage patients nonoperatively. These variations in care may translate to differences in outcome and cost. [Orthopedics. 2016; 39(3):e509-e513.].

Prospective Evaluation of Sleep Disturbances After Total Knee Arthroplasty

Sleep disturbance after total knee arthroplasty (TKA) has not been studied 6 months after surgery. A prospective study was conducted on 34 primary, unilateral TKA patients preoperatively until 6 months postoperatively. Sleep quality was measured using the Pittsburgh Sleep Quality Index and Epworth Sleepiness Scale. Pain was measured on a visual analog scale. Sleep quality worsened from baseline during the first 6 weeks postoperatively (P = .03), but improved at 3 and 6 months (P = .003). Pain scores decreased from baseline over all time points, and there was no correlation between sleep quality and pain. The Epworth Sleepiness Scale did not change over time. This study can be used to counsel TKA patients to expect initial sleep disturbances that improve by 3 months.

Arthroscopic Transosseous and Transosseous-Equivalent Rotator Cuff Repair: An Analysis of Cost, Operative Time, and Clinical Outcomes

The incidence of arthroscopic rotator cuff repair (RCR) continues to rise. Given the changing healthcare climate, it is becoming increasingly important to critically evaluate current practice and attempt to make modifications that decrease costs without compromising patient outcomes. We conducted a study of the costs associated with arthroscopic anchorless (transosseous [TO]) RCR and those associated with the more commonly performed anchor-based TO-equivalent (TOE) method to determine whether there are any cost savings with the TO-RCR method. Twenty-one consecutive patients who underwent arthroscopic TO-RCR were prospectively enrolled in the study and matched on tear size and concomitant procedures with patients who underwent arthroscopic TOE-RCR. The groups' implant costs and operative times were obtained and compared. Outcome measures, including scores on the VAS (visual analog scale) for pain, the SANE (Single Assessment Numeric Evaluation), and the SST (Simple Shoulder Test), recorded at 3, 6, and >12 months after surgery, were compared between the TO and TOE groups. Mean implant cost was $946.91 less for the TO group than the TOE group-a significant difference. Mean operative time was not significantly different between the TO and TOE groups. There was significant improvement on all outcomes measures (VAS, SANE, SST) at >12 months, and this improvement was not significantly different between the groups. Arthroscopic TO-RCR provides significant cost savings over TOE-RCR with no significant difference in operative time or short-term outcomes.

Thromboelastography predictive of death in trauma patients

OBJECTIVES

To determine if thromboelastography (TEG) is predictive of patient outcomes following traumatic injury.

METHODS

A retrospective review of 131 patients with pelvic trauma admitted to a Level II trauma center was conducted over four years from 1 January 2009 to 31 December 2012. Patients were identified retrospectively from a prospectively collected database of acute pelvic trauma (n = 372). Eligible patients were identified from billing/coding data as having fractures of the acetabulum, iliac wing or sacral alae. Patients with incomplete TEG data were excluded (n = 241), as were patients with pathological fractures. TEG clotting variables and traditional clotting variables were recorded.

RESULTS

Evaluation of TEG data revealed 41 patients with abnormal clotting times (TEG R). TEG R > 6 was an independent risk factor for death (OR, 16; 95%CI 5.4-53; P = 0.0001). The death rate was 52% in patients with TEG R values ≥6 (n = 13/25). There was no significant association between traditional clotting markers and death rate.

CONCLUSIONS

TEG reaction time value, representing the time of initial clot formation, was the only hematologic marker predictive of mortality in patients with pelvic trauma. Delay in reaction time was associated with a significantly increased death rate, independent of injury severity. The death rate association was not observed with traditional markers of clotting. Future prospective studies may be warranted to determine the presentation and significance of TEG abnormalities when resuscitating patients with orthopaedic trauma.

Epidemiology of Aquatic and Recreational Water Sport Injuries: A Case-Control Analysis

The purposes of the current investigation are to evaluate the epidemiology of water sport injuries at a coastal tertiary trauma center and to determine the association of these activities with spinal column injury and to determine whether aquatic trauma injuries differ significantly from those that occur terrestrially. A retrospective review of a consecutive series of 105 patients with aquatic-based mechanisms of injury admitted to a Level II trauma center over a 3-year period, as well as a matched control cohort with terrestrial-based mechanisms of injury, was conducted. Patients were treated at a Level II trauma center from January 1, 2008, to December 31, 2010. All patients received a full trauma work-up on arrival. Patients were identified retrospectively from a prospectively collected database (N=5298). Eligible patients were identified from billing/coding data as having mechanisms of injury related to an aquatic setting. Patients were evaluated using standard trauma protocols. Spinal column and cord injury occurrence and differences between groups were reviewed. Personal watercrafts accounted for the majority of injuries (n=39). Cervical (33.3%), closed-head (25.7%), and thoracolumbar (21.9%) injuries accounted for the majority of injury types. The cervical spinal column and the spinal cord were at an increased risk of injury in the aquatic injury cohort (P<.0001). The current data show the high incidence of spinal column and cord injuries in this patient population relative to controls. Practitioners who care for trauma patients near an aquatic environment should be aware of the high prevalence of these injuries, with proper spinal cord preservation protocols in place to optimize outcome.

Venous air embolism: an under-recognized and potentially catastrophic complication in orthopaedic surgery

INTRODUCTION

Venous air embolism (VAE) is the entry of air or other medical gases into the central venous system, producing an air embolism to the right heart or pulmonary artery. VAE is a largely iatrogenic complication with potentially devastating sequelae that can occur in a variety of surgical procedures.

METHOD

Within orthopaedics, VAE has been associated with both open and arthroscopic surgeries with the patient in a variety of positions (ie, prone, supine, sitting). These articles, as well as reports of VAE in other surgical settings outside of orthopaedics, are examined.

CONCLUSION

Diagnosis of VAE requires a high index of suspicion, as clinical presentation ranges from completely asymptomatic to fatal cardiopulmonary collapse. The vigilant surgeon should carefully watch for air entry at the operative site and the astute anesthesiologist must closely monitor end-tidal CO2 (ETCO2). Prevention of VAE is of paramount importance, as management is largely supportive and aimed at inhibiting further air ingress.

The prevalence of articular cartilage changes in the knee joint in patients undergoing arthroscopy for meniscal pathology

PURPOSE

The purposes of this study were to evaluate the prevalence of articular cartilage changes in the knee joint and to analyze predictive factors for these changes in patients undergoing arthroscopy for meniscal pathology.

METHODS

Between March 2005 and June 2009, 1,010 patients underwent arthroscopic meniscectomy or meniscal repair by the senior author. During surgery, a precise diagram was used to carefully note the presence, location, size, and Outerbridge grade of changes to the articular surfaces of the knee joint. The prevalence of articular cartilage changes was calculated for 6 age groups: younger than 20 years, 20 to 29 years, 30 to 39 years, 40 to 49 years, 50 to 59 years, and 60 years or older. Demographic data including gender, ethnicity, smoking status, and body mass index (BMI) were acquired from patient charts.

RESULTS

Overall, 48% of patients showed changes to the medial compartment, 25% to the lateral compartment, and 45% to the patellofemoral compartment. Eighty-five percent of patients aged 50 to 59 years and 86% of patients aged 60 years or older showed articular cartilage changes to at least 1 knee compartment. In contrast, only 13% of patients aged younger than 20 years and 32% of patients aged 20 to 29 years showed changes to at least 1 compartment. A significant relation was found between age and the development of articular cartilage changes in each of the 3 compartments (P < .0001). BMI was also significantly related to articular cartilage changes in the medial and patellofemoral compartments (P < .0001) but not the lateral compartment (P = .08).

CONCLUSIONS

This study shows a high prevalence of articular cartilage damage as defined by the Outerbridge classification in patients undergoing arthroscopic surgery for meniscal pathology. Risk factors that correlate with articular cartilage damage include increasing age, elevated BMI, medial compartment pathology, and knee contractures.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Hemiarthroplasty versus reverse total shoulder arthroplasty for acute proximal humerus fractures in elderly patients

Proximal humerus fractures are the third most common fracture in elderly patients. Hemiarthroplasty has been the treatment of choice in patients with bone quality and fracture patterns not amenable to open reduction and internal fixation. Reverse total shoulder arthroplasty is a newer option that appears to be less dependent on tuberosity healing than hemiarthroplasty. The authors hypothesized that reverse total shoulder arthroplasty provides improved functional outcomes compared with hemiarthroplasty for fractures in elderly patients.A retrospective review was performed of all patients treated with arthroplasty for acute proximal humerus fractures in an orthopedic practice using a Current Procedural Terminology code search, patient charts, and radiographs. Validated outcome scores were used to assess satisfaction, function, and general well-being. Twenty-three patients were treated for acute proximal humerus fractures (11 reverse total shoulder arthroplasties and 12 hemiarthroplasties). Three patients were lost to follow-up, and 6 patients were deceased. Mean follow-up was 3.6 years (range, 1.3-8 years). Reverse total shoulder arthroplasty outperformed hemiarthroplasty with regard to forward flexion, American Shoulder and Elbow Society score, University of Pennsylvania shoulder score, and Single Assessment Numerical Evaluation score.Reverse total shoulder arthroplasty is a reliable option for acute, proximal humerus fractures that are not amenable to closed treatment or reconstruction in elderly patients. Improved functional outcomes when compared with hemiarthroplasty must be balanced against the increased cost and limited life expectancy of patients with this injury.

Chronic ankle pain secondary to talus partitus: two case reports

Level of Evidence: V, Expert Opinion

Therapeutic approaches for survivors of disaster

Common psychiatric responses to disasters include depression, PTSD, generalized anxiety disorder, substance-abuse disorder, and somatization disorder. These symptom complexes may arise because of the various types of trauma experienced, including terror or horror, bereavement, and disruption of lifestyle. Because different types of disaster produce different patterns of trauma, clinical response should address the special characteristics of those affected. Traumatized individuals are typically resistant to seeking treatment, so treatment must be taken to the survivors, at locations within their communities. Most helpful is to train and support mental health workers from the affected communities. Interventions in groups have been found to be effective to promote catharsis, support, and a sense of identification with the group. Special groups to be considered include children, injured victims, people with pre-existing psychiatric histories, and relief workers.

Cost-effectiveness of television, radio, and print media programs for public mental health education

Mass media campaigns to influence public attitudes and behaviors in the area of mental health must consider cost-effectiveness, which is based on actual costs, the number of people reached (exposures), and the impact of the program on the individual. Cost per exposure is a critical factor. The authors review their experience in developing media programs in several broadcast formats and in print. Their experience suggests that an effective television production has a very high per-exposure cost and that radio is a more cost-effective way to present health messages. Radio programs also have the advantage of reaching people in their homes or cars or at work. Brief segments may be particularly cost-effective because they can be can be inserted between programs during prime-time hours. Print media--newspapers, magazines, and newsletters--can be cost-effective if magazine or newspaper space is free, but newsletters can be costly due to fixed postage costs. One advantage of print is that it can be reread, clipped out, copied, and passed on.

Dopamine blocking activity of clomipramine in patients with obsessive-compulsive disorder

While many data suggest that Obsessive-Compulsive Disorder (OCD) is an illness accompanied by dysregulation of the serotonergic system, interesting clinical evidence and animal studies also suggest possible dysregulation of the dopaminergic (DA) system. In order to determine whether clomipramine (CMI), an antiobsessional agent, is capable of altering DA function, we performed a neuroleptic radioreceptor assay (NRRA) on plasma samples from OCD patients before and after treatment in a double-blind, placebo controlled trial of CMI. CMI produced mild but significant DA D-2 receptor binding activity in an in vitro assay. The degree of dopamine binding activity did not correlate with clinical response to clomipramine. Because it has been suggested that another drug with antiobsessional efficacy, fluoxetine, may also have dopamine blocking properties, it may be speculated that antidopaminergic activity in combination with serotonergic effects is involved in antiobsessional activity of effective agents for some patients.

Panic and phobic disorders in patients with obsessive compulsive disorder

Obsessive compulsive disorder shares numerous clinical features with other anxiety disorders. To study the relationship between OCD and other anxiety disorders, the authors administered the Structured Clinical Interview for DSM-III to 36 OCD patients. Thirty-nine percent (14) of patients reported a lifetime history of panic attacks, and 14% (5) met DSM-III-R criteria for panic disorder at the time of interview. Fourteen percent (5) met criteria for social phobias, and 19% (7) met criteria for simple phobias. Eighteen patients were treated with clomipramine in doses of at least 100 mg/day for 3 months. Patients with a history of other anxiety disorders responded significantly better to clomipramine.

Toxicity resulting from lithium augmentation of antidepressant treatment in elderly patients

Lithium augmentation of antidepressant treatment is a commonly used strategy for treatment-resistant cases of depression. Two cases are described in which significant neurotoxicity developed in elderly patients despite therapeutic doses of antidepressant and lithium.

Clomipramine: an antiobsessional tricyclic antidepressant

The chemistry, pharmacology, pharmacokinetics, adverse effects, and dosage of clomipramine hydrochloride are described, and clinical studies of the use of clomipramine in treating obsessive-compulsive disorder (OCD), other psychiatric conditions, and chronic pain are reviewed. Clomipramine hydrochloride, a tricyclic antidepressant, is a potent inhibitor of serotonin reuptake and may affect dopaminergic neurotransmission, suppress rapid eye movement sleep, produce changes in electrocardiograms, and elevate plasma prolactin. The drug is well absorbed from the gastrointestinal tract and undergoes extensive first-pass metabolism. Peak plasma concentrations occur three to four hours after a 150-mg oral dose. The mean elimination half-life is 39 hours. Some 66% of a dose is excreted in the urine, the remainder being eliminated in the feces. In clinical trials, clomipramine was significantly more effective than placebo, clorgiline, amitriptyline, imipramine, and doxepin in ameliorating the symptoms of OCD. Initial effects are seen at four weeks; improvement may continue for up to 18 weeks. Clomipramine may also be effective in treating panic attacks, phobias, depression, and chronic pain. The most common adverse effects of clomipramine are anticholinergic; others include nausea, seizures, and sexual difficulties. Interactions between clomipramine and barbiturates, haloperidol, monoamine oxidase inhibitors, and cigarette smoking have been documented. The usual initial adult dosage is 25-50 mg/day, titrated gradually to 250 mg/day if necessary. Clomipramine hydrochloride is a welcome new agent for the treatment of obsessive-compulsive disorder. Although its adverse-effect profile is like that of other tricyclic antidepressants, sexual dysfunction and seizures may be more frequent with this agent and limit its use.

Failure of topical prostaglandin inhibitors to improve wound healing following deep partial-thickness burns

The present study was designed to determine the efficacy of topical inhibitors of prostaglandins on wound healing. Two uniform deep partial-thickness burns were inflicted on mirror-image areas of guinea pig backs by an aluminum template heated to 75 degrees C and applied for 10 seconds. Indomethacin was tested extensively in a wide range of concentrations in groups of six or more animals each. The healing rates measured at 21 days postburn showed that topical indomethacin at each concentration tested was not effective for improving wound healing. In fact, the treated sites were consistently worse than the control sites. Moreover, the drug adversely affected the healing process proportional to the concentration and was associated with death, which was related to perforations of the GI tract. Also, the India ink filling in the dermal microcirculation was no better in the experimental wounds than in the controls. The evaluations for hair growth were definitely in favor of the controls. The other tested inhibitors, ibuprofen, flurbiprofen, tolmetin, zomepirac, piroxicam, and dipyridamole, also failed to show any benefit.