Clinical and radiological septic joint analysis of spontaneous sternoclavicular joint infections: achieving the best outcomes-a systems engineering approach

OBJECTIVES

Spontaneous sternoclavicular joint infection (SSCJI) is a rare and poorly understood disease process. This study aims to identify factors guiding effective management strategies for SSCJI by using data mining.

METHODS

An Institutional Review Board-approved retrospective review of patients from 2 large hospitals (2010-2022) was conducted. SSCJI is defined as a joint infection without direct trauma or radiation, direct instrumentation or contiguous spread. An interdisciplinary team consisting of thoracic surgeons, radiologists, infectious disease specialists, orthopaedic surgeons, hospital information experts and systems engineers selected relevant variables. Small set data mining algorithms, utilizing systems engineering, were employed to assess the impact of variables on patient outcomes.

RESULTS

A total of 73 variables were chosen and 54 analysed against 11 different outcomes. Forty-seven patients [mean age 51 (22-82); 77% male] met criteria. Among them, 34 underwent early joint surgical resection (<14 days), 5 patients received delayed surgical intervention (>14 days) and 8 had antibiotic-only management. The antibiotic-only group had comparable outcomes. Indicators of poor outcomes were soft tissue fluid >4.5 cm, previous SSCJI, moderate/significant bony fragments, HgbA1c >13.9% and moderate/significant bony sclerosis.

CONCLUSIONS

This study suggests that targeted antibiotic-only therapy should be considered initially for SSCJI cases while concurrently managing comorbidities. Patients displaying indicators of poor outcomes or no symptomatic improvement after antibiotic-only therapy should be considered for surgical joint resection.

Time to surgery and outcomes following open reduction and internal fixation of both-bone forearm fractures

PURPOSE

To determine the effect of time to surgery on outcomes following open reduction and internal fixation (ORIF) of both-bone forearm fractures (BBFFs).

METHODS

Ninety-nine patients who underwent ORIF of BBFFs in a single academic medical center over a 16-year time period were retrospectively reviewed. Demographic and clinical data including age, sex, current smoking status, time from injury to surgery (tsurg), presence of open injury, polytrauma status, and complications were obtained. Radiographs of the affected extremity were reviewed for fracture morphology, reduction quality, and time to union (or presence of nonunion). In addition to descriptive statistics, Chi-square and Wilcoxon-Mann-Whitney tests were used to compare categorical and interval, respectively, with a significance level of 0.05.

RESULTS

A tsurg > 48 h was associated with increased rate of delayed unions (tsurg < 48 h: 25% vs tsurg > 48 h: 59%, p = 0.03), but not complications (tsurg < 48 h: 44% vs tsurg > 48 h: 47%, p = 0.79). Open BBFFs were not associated with increased rates of delayed unions (closed: 16% vs open: 19%, p = 0.77) or complications (closed: 42% vs open: 53%, p = 0.29). A trend toward increased time to union with tsurg > 48 h was also seen, but did not reach significance (tsurg < 48 h: 13.5 weeks vs tsurg > 48 h: 15.7 weeks, p = 0.11).

CONCLUSION

A tsurg > 48 h is associated with an increased rate of delayed union, but not complications, after ORIF of BBFFs.

LEVEL OF EVIDENCE

Therapeutic Level III (Retrospective Cohort).

Complications in Hand Surgery During Early Independent Practice: A Single Surgeon's 5-Year Experience

BACKGROUND

The objective of this study was to understand the frequency and types of complications, and the associated postoperative outcomes within the first 5 years of practice after hand and upper extremity surgery fellowship.

METHODS

This was a retrospective observational study of all patients seen and surgically treated by a single surgeon at a single institution from August 2014 to September 2019. This corresponded to the first 5 years of practice after fellowship. Data collected included patient demographics, perioperative data, complication type, and outcome of the complication (better/same/worse than preoperative status). Complications were classified using the Clavien-Dindo system and a unique, self-derived system.

RESULTS

In total, 3301 surgeries were performed during the first 5 years of practice. The overall complication rate was 7.9% (261 complications from 239 patients). The 30-day complication rate was 5.2% (171/3301). Eleven (4.2%) of the 261 complications occurred intraoperatively. The total number of complications significantly declined during the first 5 years of practice as follows: 74, 71, 46, 37, and 33 (P = .010, R2 = .92). Hand and wrist were the most frequent anatomic locations involved and bone pathology was the predominant indication.

CONCLUSION

The overall surgical complication rate for hand and upper extremity surgery was 7.9%, with a 30-day complication rate of 5.2% (171/3301). The rate of complications after fellowship declined over the first 5 years of independent practice. Superficial infections were the most common complication. More than 90% of patients ultimately improved after addressing the complication.

LEVEL OF EVIDENCE

IV.

Treatment Patterns for Distal Radius Fractures Before and After Appropriate Use Criteria Adoption

BACKGROUND

The purpose of this study was to determine agreement with the American Academy of Orthopaedic Surgery Appropriate Use Criteria (AUC) for distal radius fractures (DRFs), before and after their adoption, and secondarily determine predictors of operative management.

METHODS

A single-institution retrospective cohort study comparing patients treated either nonoperatively (115 patients) or operatively (767 patients) for DRFs between May 1, 2008, and May 1, 2018, by 8 hand surgeons was performed. Data included demographics, injury characteristics, DRF radiographic measurements, treatment rendered, and their appropriateness according to the AUC. Statistical testing used the Fisher and χ2 tests, t test, and multiple variable logistic regression, with a significance level of .05.

RESULTS

Overall, there was a significant increase in AUC agreement for operatively treated DRFs (82.7%-89.3%, P = .01), but no difference in agreement for nonoperatively treated DRFs (12.5%-10.7%, P = .77). Age <80 years, AO classes other than B, intra-articular displacement >1 mm, radial inclination <18°, high-energy mechanism of injury, and greater than 1 week to treatment were independent predictors of operative treatment. The area under the curve for the validated regression model using the aforementioned predictors was 0.82.

CONCLUSION

Agreement with AUC for DRFs increased after its adoption for operatively treated, but not for nonoperatively treated, fractures. In addition, a predictive model for operative treatment was developed and validated. Future studies may benefit from further model refinement and testing in other patient cohorts.

Total Wrist Fusion with an Intramedullary Device: A Single-Institution Series with a Minimum of One Year Follow-Up

Objective  The primary purpose of this study was to evaluate the functional and surgical outcomes of total wrist fusion (TWF) following the use of a locked intramedullary nail (IMN). Methods  A single institution study was performed, which entailed in-person reexamination of 18 patients ( n  = 19 wrists), out of 35 eligible patients, who underwent TWF with an IMN from 2010 to 2017. For each patient, demographic, preoperative diagnosis, physical examination, wrist radiograph, and outcome questionnaire data were obtained. The questionnaires included the visual analog scale (VAS), quick disabilities of the arm, shoulder, and hand (QuickDASH), and Mayo Wrist Score assessments. In addition, complication and reoperation data for all TWFs with an IMN during the 2010 to 2017 period (35 patients, n _I  = 38 wrists) were noted. Results  In the 18 patients, age was 47.6 ± 13.9 years, 12 (63.2%) were female, and median follow-up was 150 weeks (range: 74-294). The VAS score was 0 ± 0 in 5 of 19 wrists with rheumatoid arthritis (RA) and 1.82 ± 2.78 in 14 of 19 wrists without RA. It was found that 21 of 38 wrists (55.3%) had an implant-related complication and 5 wrists (13%) underwent a reoperation due to the implant itself. Conclusions  To date, no sufficient data are present demonstrating a clear advantage of an IMN over dorsal plating for TWF at intermediate-term follow-up. Surgeons should be knowledgeable of the several potential complications of this IMN prior to its use for TWF. Level of Evidence  This is a Level IV, therapeutic study.

Two-stage TKA for tuberculosis septic arthritis of the knee masquerading as pigmented villonodular synovitis: A case report

A 25-year-old female presented with left knee pain following arthroscopic synovectomy for presumed pigmented villonodular synovitis (PVNS). Radiographs and magnetic resonance imaging demonstrated tricompartmental arthritic changes. She underwent a two-stage procedure first involving antibiotic spacer implantation, followed 1 week later by spacer removal and definitive total knee arthroplasty (TKA) once initial intraoperative culture results were negative. Subsequent cultures confirmed tuberculosis septic arthritis. Repeat evaluation 1 year postoperatively showed no complications and patient satisfaction with left knee function. This is a unique case report in the United States describing 1-year outcomes following staged TKA for tuberculosis septic arthritis masquerading as PVNS.

Utility of 45S5 Bioactive Glass As Bone Graft Substitute for Cavitary Defects in Pediatric Bone Tumors: A Preliminary Study

BACKGROUND

Bioactive glass has become an increasingly used treatment of cavitary bone defects in a number of orthopaedic applications. The purpose of this study was to evaluate the clinical and radiographic outcomes of bioactive glass used for benign cavitary pediatric bone tumors. A specific focus was on radiographic filling of defects and occurrence of complications by tumor class.

METHODS

A single institution retrospective study was performed, which entailed review of the clinical and radiographic data of 21 patients who underwent surgical curettage and grafting of benign or low-grade malignant bone tumors from 2018 to 2020. In all the cases, 45S5 bioactive glass (Fibergraft; Prosidyan, New Providence, NJ) was used to fill the bone defects. For each patient, data on demographic, preoperative diagnosis, defect size, time to mobilization, radiographic filling grade, pain, and complications were obtained. The Wilcoxon-Mann-Whitney test and Kaplan-Meier survival analysis were used for comparisons between tumor classes.

RESULTS

In the 21 patients, 11 bone tumors were latent or active (class 1) and 10 were aggressive (class 2). The mean age was 13.0±3.7 years, 6 (28.6%) were female, and the median and interquartile range for initial tumor size were 18.8 (5.8 to 50.6) cm 3 . Tumors that were class 2 had significantly more complications with bioactive glass use compared with class 1 tumors [0 vs. 1 (0 to 1), P =0.040]. The time of persistent fill grade 1 or 2 defects up to final follow-up was less in class 1 versus class 2 lesions ( P =0.048).

CONCLUSIONS

Bioactive glass agents have utility for treating a broad variety of pediatric bone tumors after curettage. However, focusing these agents' use in treating latent or active subtypes of bone tumors may be ideal in minimizing complications and time to higher fill grade.

LEVEL OF EVIDENCE

Level III - Therapeutic.

Risk factors for postoperative blood transfusion after shoulder arthroplasty

Purpose

To identify the effect of surgical indication, patient factors, and perioperative characteristics on transfusion after shoulder arthroplasty (SA).

Methods

Shoulder arthroplasties for osteoarthritis (OA) (N = 47), rotator cuff arthropathy (RCA) (N = 50), fracture (N = 76), revision (N = 66), and periprosthetic joint infection (PJI) (N = 35) performed at a single institution during a 6-year period were included. All other indications were excluded. Patient-based and surgical risk factors, including surgical indication, for postoperative allogeneic red blood cell transfusion were assessed with multivariate logistic regression analysis.

Results

A total of 274 SAs were included; transfusions were performed in 2% (2/97) of primary SAs for OA or RCA. Increased transfusion rates occurred in PJI (23%, p = 0.0006) and fracture (18%, p = 0.0018) cases. The mean preoperative hemoglobin (Hgb) was 12.2 ± 2.2 with PJI, 12.0 ± 2.1 with fracture, and 13.3 ± 1.6 g/dL for all other SAs. Independent risk factors for transfusion included lower preoperative hemoglobin (p < 0.001), PJI indication (p = 0.008), and fracture indication (p = 0.02), with no difference for fracture greater or less than 4 weeks old (p = 0.53).

Conclusion

Risk factors for allogeneic red blood cell transfusion after SA were low preoperative hemoglobin and procedures for PJI or fracture.Level of Evidence: Level III, retrospective case-control study.

Role of Dynamic Stabilizers of the Elbow in Radiocapitellar Joint Alignment: A Prospective In Vivo Study

PURPOSE

To investigate the effect of dynamic stabilizers of the elbow on radiocapitellar joint alignment, before and after the administration of regional anesthesia.

METHODS

At a single institution, 14 patients were prospectively enrolled in a study using a within-subjects control design. Before performing a supraclavicular regional block, 10 fluoroscopic images (1 anteroposterior and 9 lateral views) of the elbow were obtained for each patient. The lateral images were obtained with the forearm in maximal supination, neutral rotation, and maximal pronation, and these forearm positions were repeated for 3 elbow positions: (1) full extension; (2) flexion to 90°, with 0° of shoulder internal rotation; and (3) flexion to 90°, with 90° of shoulder internal rotation. After obtaining the 10 initial images, a block was performed to achieve less than 3/5 motor strength of the imaged extremity, followed by obtaining the same 10 images in each patient. Radiocapitellar ratio, defined as the minimal distance between the right bisector of the radial head and the center of the capitellum divided by the diameter of the capitellum, was measured in each image.

RESULTS

The 14 patients had a mean age of 47.8 ± 15.7 years, and 10 (71.4%) patients were women. A difference between radiocapitellar ratios measured before and after the regional block administration was observed for all lateral images (-1.0% ± 7.2% to -2.2% ± 8.0%), although this difference was less than the minimum clinically important difference.

CONCLUSIONS

Paralysis of the dynamic stabilizers of the elbow produces a difference in the radiocapitellar joint alignment, but this did not reach the minimum clinically important difference.

CLINICAL RELEVANCE

Paralysis of the dynamic stabilizers of the elbow via a supraclavicular nerve block produces no clinically relevant effect on the radiocapitellar alignment of uninjured elbows.

Factors Associated With Elevated Inflammatory Markers Prior to Shoulder Arthroplasty

Background: Preoperative erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) ranges for several shoulder arthroplasty indications are not well understood. Purpose: We sought to compare preoperative ESR and CRP values for a variety of shoulder arthroplasty indications and evaluate risk factors for elevated preoperative ESR and CRP values. Methods: We conducted a retrospective cohort study of shoulder arthroplasty cases performed at a single academic medical institution from 2013 to 2018. Preoperative ESR and CRP values for 235 shoulder arthroplasties with various indications were recorded. Independent risk factors for elevated values (CRP > 10.0 mg/L and ESR > 30.0 mm/h) were determined via multiple variable logistic regression. Results: Patients undergoing shoulder arthroplasty for osteoarthritis had an ESR (mean ± SD) of 22.6 ± 17.8, with 29.8% of patients elevated, and a CRP of 6.5 ± 6.4, with 25.5% of patients elevated. Arthroplasty for acute fracture and prosthetic joint infection (PJI) had higher preoperative ESR and CRP values. Multivariate analysis identified several predictors of elevated ESR, including infection, acute fracture, diabetes, and female sex. It also identified predictors of elevated CRP, including infection, acute fracture, and younger age. Conclusions: Preoperative ESR and CRP values may be elevated in 25% to 30% of patients undergoing primary shoulder arthroplasty. Arthroplasty for both acute fracture and PJI, along with several other patient factors, was associated with elevated preoperative ESR and CRP. Thus, routine collection of ESR and CRP preoperatively may not be of benefit, as elevated values are common. Further study is warranted.

The effect of patient factors on opioid use after anatomic and reverse shoulder arthroplasty

Background

Prolonged opioid use can lead to suboptimal outcomes after total shoulder arthroplasty (TSA), and thus, reduced consumption is desirable. Our primary aims were to determine if differences in total morphine equivalent doses existed owing to (1) age less than or greater than 65 years, (2) sex, and (3) TSA type - reverse or anatomic total shoulder arthroplasty. We also characterized potential risk factors for (1) visiting another provider for pain, (2) pain control 6 weeks postoperatively, and (3) needing an opioid refill.

Methods

A retrospective cohort study of 100 patients who underwent TSA (reverse total shoulder arthroplasty N ₁ = 50; anatomic total shoulder arthroplasty N ₂ = 50) between 1 July 2018 and 31 December 2018 was performed. Demographics, perioperative treatments, and postoperative opioid prescriptions were recorded. Primary hypotheses were evaluated with Wilcoxon-Mann-Whitney testing. Univariate and multivariate analyses assessed potential risk factors for the 3 outcomes of interest. Results were given in adjusted odds ratios (aORs), 95% confidence intervals (CIs), and P values.

Results

There was a difference (P = .009) in total morphine equivalent doses used (in 5-milligram oxycodone tablets) between patients who were younger than 65 years of age (median: 83 tablets, interquartile range: 62-140) and those who were older than 65 years of age (median: 65 tablets, interquartile range: 52-90). Unemployment (aOR = 4.68, CI: 1.5-14.2, P = .006) and age less than 65 years (aOR = 4.18, CI: 1.6-11.2, P = .004) were independent risk factors for inadequate pain control 6 weeks postoperatively. Two independent risk factors for needing an opiate prescription refill after discharge were unemployment (aOR = 4.56, CI: 1.5-13.8, P = .007) and preoperative opiate use (aOR = 3.95, CI: 1.4-11.0, P = .009).

Conclusion

After TSA, morphine equivalent dose usage is higher for patients younger than 65 years of age, and several risk factors exist for requiring a refill and having inadequate pain control 6 weeks postoperatively. Prospective studies using these data to guide interventions may be beneficial.

Delayed Presentation of Seymour Fractures: A Single Institution Experience and Management Recommendations

Background: Seymour fractures in children are prone to complications without prompt and appropriate treatment. This study investigated outcomes of Seymour fractures with delayed presentations; specifically, if deep infection predisposed to operative treatment, if antibiotic administration improved fracture healing, and if oral clindamycin had fewer treatment failures than oral cephalexin. Methods: A single-institution retrospective cohort study was performed of patients with delayed Seymour fracture presentations (defined as greater than 24 hours post-injury) between 2009 and 2017. Data collected included demographics, time to presentation, infection on presentation, operative treatment, antibiotic use and duration, fracture union, and complications. Statistical testing used logistic regression and Fisher's exact test, with results reported as P-values (P), odds ratios (ORs), and 95% confidence intervals (CIs). Results: There were 73 patients with delayed Seymour fracture presentations, with mean age of 11.1 years (standard deviation: 2.9), with 56 (77%) males, and median time to presentation of 7 days (interquartile range: 3-17). Deep infection on presentation was a risk factor for operative intervention (OR = 34.4, P = .0001, CI, 5.5-217.2). Antibiotic administration protected against the development of a nonunion or delayed union (OR = 0.11, P = .008, CI, 0.021-0.57). Time to antibiotics did not protect against nonunion or delayed union (OR = 0.77, P = .306, CI, 0.37-1.3). Clindamycin had fewer treatment failures than cephalexin (P = .039). Conclusions: Deep infection is a risk factor for operative treatment of Seymour fractures with delayed presentations. Clindamycin is a better antibiotic choice for Seymour fractures that present in delayed fashion.

Outcomes following Distal Radius Fractures with Preexisting Ulnocarpal Abutment

Background  Due to the commonality of distal radius fractures (DRFs), the potential impact of ulnocarpal abutment (UA) on patient outcomes is significant, whether it developed after or prior to injury. It is, therefore, important to consider whether preexisting UA has any impact on outcomes after an acute DRF. Questions/Purpose  The aims of this study were to determine if differences were present in (1) pain at final follow-up, (2) complications, and (3) unintended operations in patients with DRFs and either without or with preexisting radiographic UA. Methods  A single institution retrospective cohort study comparing patients treated either nonoperatively (43 patients) or operatively (473 patients) for DRFs between 5/1/2008 to 5/1/2018 was performed. Data included demographics, prior wrist pain or surgery, ulnar variance, select treatment data, and presence of pain, complication, or unintended operation by final follow-up. Statistical testing used Fisher's exact test and chi-squared test, with a significance level of 0.05. Results  The prevalence of preexisting UA was 14.0 and 15.6% in the nonoperatively- and operatively treated groups, respectively. In nonoperatively treated patients without or with UA, no differences in pain (37.8 vs. 33.3%, p  = 1.00) or complications were seen (13.5 vs. 50.0%, p  = 0.07). A higher unintended operation rate for nonoperatively treated DRFs with UA, compared with those without, UA was seen (5.4 vs. 50.0%, p  = 0.01). No differences in pain, complications, or unintended operations were seen between those without and with UA in the operatively treated group. Conclusion  Preexisting UA is not associated with pain, complications, or unintended operations after operative treatment of DRFs. Prospective studies further evaluating outcomes in nonoperatively treated DRFs with UA may be beneficial.

The Effect of Patient and Surgical Factors on Opioid Prescription Requests Following Arthroscopic Rotator Cuff Repair

Purpose

To determine whether differences in total morphine equivalent doses (MEDs) prescribed after arthroscopic rotator cuff repair (RCR) existed because of age younger than or older than 55 years and sex and to characterize potential risk factors for needing an opioid medication refill, visiting a provider other than the surgeon (either in the emergency department or ambulatory settings), and postoperative pain control requiring opioids approximately 6 weeks from the date of surgery.

Methods

A retrospective cohort study of 100 patients who underwent arthroscopic RCR between July 1, 2018, to November 30, 2018, in a single institution was performed. Data including demographics, perioperative treatments, and postoperative opioid prescriptions were recorded. Our primary hypotheses were evaluated with the Wilcoxon-Mann-Whitney test. Univariate and multivariate analyses assessed potential risk factors for the 3 outcomes of interest. Results were given in adjusted odds ratios (aORs), 95% confidence intervals (CIs), and P values.

Results

There was a difference (P = .038) in total MEDs used (in 5 mg oxycodone tablets) between males (median 56 tablets; interquartile range, 50-98 tablets) and females (median 78 tablets; interquartile range, 56-116 tablets). Age younger than 55 years was a risk factor for seeking an opioid refill (OR = 2.51; CI, 1.11-5.66; P = .026). A significant risk factor for visiting another provider was preoperative opiate use (OR = 15.0; CI, 1.79-125.8; P = .013). Age younger than than 55 years (aOR = 2.51; CI, 1.01-6.02; P = .047), body mass index (aOR = 1.08; CI, 1.01-1.17; P = .046), and shorter surgical duration (aOR = 0.97; CI, 0.95-0.99, P =.007) were independent predictive factors for requiring opioids for pain control 6 weeks after surgery.

Conclusions

After arthroscopic RCR, MED prescription is higher for females than males. The risk factors for requesting opioid prescription refill for pain control 6 weeks after surgery were age younger than 55 years and shorter surgical duration.

Level of Evidence

Level III, retrospective comparative study.

An Update on Loss to Follow-up After Upper Extremity Surgery: Survey of Patient Responses

Background: Incomplete patient follow-up is a common problem after hand and upper extremity (HUE) surgery and is influenced by many demographic factors. The aims of this investigation are to determine patient-stated factors for lack of follow-up, identify potential interventions, and measure satisfaction following operations. Methods: A prospective survey sampling of 173 of 655 patients lost to follow-up after HUE operations in a single institution between June 2014 and July 2015 was performed. Demographic variables collected included age, sex, distance to clinic, insurance payor, and length of time to last follow-up visit. Survey responses regarding reasons for insufficient follow-up, future recommendations, and overall satisfaction were recorded. Statistical results were reported as P values, odds ratios (ORs), and 95% confidence intervals (CIs). Results: More than half (65.3%) of 173 patients erroneously thought that they had completed follow-up, with private insurance being the only risk factor (OR = 2.45, P = .010, 95% CI = 1.24-4.85). Other common reasons for insufficient follow-up included not placing the appointment into a personal calendar (7%), excessive costs (6%), and transportation (5%). Approximately half (51%) of 55 patients aware that they had missed follow-up stated that no intervention would have helped. Median patient satisfaction with their operation was 10/10 (interquartile range = 8-10). Conclusions: Most patients lost to follow-up after HUE operations were not aware that they had a follow-up appointment, but were nevertheless satisfied with treatment. Interventions targeted to patients who erroneously thought they had followed up may be the most beneficial.

The financial burden of musculoskeletal firearm injuries in children with and without concomitant intra-cavitary injuries

BACKGROUND

Musculoskeletal pediatric firearm injuries are a clinically significant and expensive public health problem in the United States. In this retrospective cohort analysis, we sought to characterize musculoskeletal firearm injuries in children and to describe the financial burden associated with these injuries.

METHODS

This study is a single center, retrospective review. Patients were identified from January 2002 - December 2015 from an institutional database using ICD-9 codes pertaining to firearm injury. Inclusion criteria were: 1) age < 18 years at injury; 2) firearm injury to an extremity, spine, or pelvis; and 3) patient received orthopedic evaluation and/or treatment. 140 patients with 142 distinct orthopedic injuries meeting inclusion criteria were analyzed (N = 142). Primary measures were demographic and situational data including intent, length of stay, follow-up, and complications; and financial outcomes including charges, costs, and net revenues.

RESULTS

Median age was 15.3 years [IQR: 13.3, 16.4], 84% were male, and 52% were African American. 59% of the firearm injuries were of violent intent. 32% of patients were privately insured, 61% were publicly insured, and 6% were uninsured. Median length of stay was 2 days [0, 4], with 73% of patients being admitted. 43% of patients required additional hospitalizations, emergency room visits, and/or outpatient surgeries, and 93% of patients had outpatient follow-up. 42% of patients experience an injury-related or long-term orthopedic complication. Total charges for the cohort were $11.4 million, with $3.7 million in costs and $45,042 in net revenues. In the multivariable analysis, more surgeries predicted higher charges, and more secondary encounters predicted higher costs and net revenues. Only privately-insured patients had a positive median net revenue.

CONCLUSIONS

Children who sustain musculoskeletal injuries from firearms experience high rates of orthopedic complications. Institutional costs to manage these preventable injuries are excessive. Policy makers should continue to pursue measures to reduce gun violence and improve gun safety in the pediatric population.

LEVEL OF EVIDENCE

Level III, economic/decision.

High prevalence of outpatient falls following elective shoulder arthroplasty

BACKGROUND

This study characterized the prevalence and risk factors of inpatient and outpatient postoperative falls in patients undergoing elective shoulder arthroplasty.

METHODS

A retrospective chart review of 198 patients undergoing anatomic or reverse total shoulder arthroplasty or hemiarthroplasties at one institution between 2015 and 2017 was reviewed to determine the prevalence of inpatient and outpatient falls up to 90 days after discharge. Univariate and multivariate analyses were conducted to assess potential risk factors for postoperative falls including demographics, indication for surgery, surgical procedure, medical history, length of hospital stay, perioperative hemoglobin, need for transfusion, and discharge disposition.

RESULTS

There were 23 falls in 22 patients within a 90-day postoperative period. The inpatient fall rate was 1.0% (2 of 198). The outpatient fall rate was 10.6% (21 of 198). Outpatient falls resulted in emergency department evaluation in 23.8% of cases (5 of 21), readmission in 19.0% (4 of 21), injury to an anatomic site other than the shoulder in 19.0% (4 of 21), and injury at the surgical site (eg, periprosthetic humeral fracture) in 4.8% (1 of 21). No significant risk factors were identified for inpatient falls. Independent risk factors for an outpatient fall were female sex (adjusted odds ratio [aOR] = 4.79; 95% confidence interval [CI]: 1.32, 17.4; P = .007), increased length of hospital stay (aOR = 1.23; 95% CI: 1.04, 1.45; P = .02), and history of a movement disorder (aOR = 7.20; 95% CI: 1.22, 42.6; P = .03).

CONCLUSION

A high outpatient fall rate of 10.6% within 90 days after discharge raises the concern that falls after shoulder arthroplasty are significantly higher than previously reported.

Use of Standardized Letters of Recommendation for Orthopaedic Surgery Residency Applications: A Single-Institution Retrospective Review

BACKGROUND

Standardized letters of recommendation (SLORs) were introduced to provide a more objective method of evaluating applicants for orthopaedic surgery residency positions. We sought to establish whether there exists an association between the SLOR summative rank statement (SRS), which is a question that asks the letter-writing authors where they would rank a student relative to other applicants, and success in matching into orthopaedic surgery residency.

METHODS

We reviewed 858 applications to an orthopaedic surgery residency program from 2017 to 2018. Data on 9 assessment categories, SRSs, and written comments in the SLORs were extracted. The match success of applicants was determined by an internet search algorithm. Logistic regression was used to evaluate the association between the SRSs and match success. The Spearman correlation was performed between the SRSs and other variables.

RESULTS

Only 60% of all LORs were SLORs. With 24% of the SLORs, a supplemental letter was used. Median percentile rank ranged from 90% to 100% for the 9 categories in the SLORs. Recommendations of "high rank" or higher were found in 88% of the SRSs. The mean of the SLOR SRSs was associated with match success.

CONCLUSIONS

The mean of the SLOR SRSs was associated with match success. However, the SLOR is not uniformly used. Future efforts should be devoted to improving question design and validity in order to better discriminate among applicants, increase adherence to the rating scale, and quantify the strength of the written comments in the SLOR.

Evaluation of an Incorporated Superior Capsular Reconstruction Graft: A Case Report

CASE

A 66-year-old man presented with 2 years of atraumatic right shoulder pain and difficulty with overhead activities. Radiographs and magnetic resonance imaging demonstrated Hamada stage I changes and a massive irreparable rotator cuff tear involving the supraspinatus and infraspinatus. He underwent superior capsular reconstruction with acellular human dermal matrix (SCR with ADM) allograft. Diagnostic arthroscopy and humeral avulsion of the glenohumeral ligament repair 1 year postoperatively showed that the SCR appeared intact and vascularized.

CONCLUSIONS

This is the first study to confirm visually that SCR with ADM allograft is well-vascularized and intact 1 year post-operatively.

Integrated treatment of a lumbar vertebral hemangioma with spinal stenosis and radiculopathy: A case report and a review of the literature

We describe a comprehensive, multidisciplinary treatment approach for lumbar vertebral hemangiomas (VHs) with spinal stenosis and radiculopathy. A 59-year-old female presented with 1 year of pain predominantly in the lower back, with pain in the left buttock and proximal left anterior thigh as well and magnetic resonance imaging of the lumbar spine demonstrated lumbar scoliosis and an L3 vertebral lesion suspicious for hemangioma. A computed tomography guided biopsy was done, which supported the diagnosis. Definitive treatment entailed preoperative angiography and embolization, followed by L3 laminectomy, right L3 pedicle resection, partial L3 corpectomy, L3 vertebral cement augmentation, and L1 to L5 instrumented fusion. By 1-year postoperatively, the patient reported no radicular pain and only mild groin pain attributed to left hip degenerative joint disease. Radiographs 1-year postoperatively confirmed the stability of the instrumented posterior fusion and a magnetic resonance imaging with and without contrast confirmed no VH recurrence. A comprehensive and multidisciplinary approach for the treatment of VHs with neurological symptoms or signs is presented. This approach is recommended to maximize lesion removal, ensure biomechanical stability, and minimize recurrence.

Utility of Postoperative Radiographs for Pediatric Scoliosis: Association Between History and Physical Examination Findings and Radiographic Findings

BACKGROUND

Postoperative radiographs are routinely obtained following surgery for the correction of scoliosis in pediatric patients. The purpose of this study was to comprehensively evaluate the utility of obtaining routine postoperative radiographs in the management of these patients.

METHODS

A total of 1969 clinic notes and corresponding radiographs regarding 451 consecutive patients with scoliosis (age range, ten to eighteen years) who had surgical correction over a ten-year period at a single institution were retrospectively reviewed. Curve etiology, preoperative curve characteristics, and surgical procedures performed were recorded. All postoperative clinic notes and radiographs were reviewed for abnormalities and changes in treatment course. It was then determined whether clinical signs and symptoms and/or abnormal radiographic findings led to a change in treatment course, which was defined as a therapeutic intervention or further diagnostic testing.

RESULTS

Of the 451 patients in this study (average age [and standard deviation], 14.7 ± 2.4 years), 72.5% had adolescent idiopathic scoliosis, 23.3% had neuromuscular scoliosis, and 4.2% had other underlying causes of scoliosis. A change in treatment course occurred in the cases of forty-two patients, all of whom had symptomatic findings on postoperative history and physical examination and only fifteen of whom had supportive abnormal findings on postoperative radiographs. Curve etiology and surgical procedures performed had no impact on radiographic utility. A significant increase in utility was seen for radiographs obtained at visits one year or more following surgery compared with those obtained at visits less than one year following surgery (1.7% compared with 0.3%, p = 0.001). The overall sensitivity, specificity, positive predictive value, and negative predictive value of routine postoperative radiographs in guiding treatment course were 35.7%, 98.1%, 28.8%, and 98.6%, respectively.

CONCLUSIONS

Routine radiographs provide low utility in guiding the course of treatment for asymptomatic pediatric patients following surgery for scoliosis. The results of this study suggest that patient or caregiver complaints, comorbidities, and clinical suspicion should be considered before obtaining radiographs at postoperative visits in order to minimize radiation exposure in pediatric patients and reduce medical costs without compromising care.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Tachycardia-induced early afterdepolarizations: insights into potential ionic mechanisms from computer simulations

Although early afterdepolarizations (EADs) are classically thought to occur at slow heart rates, mounting evidence suggests that EADs may also occur at rapid heart rates produced by tachyarrhythmias, due to Ca overload of the sarcoplasmic reticulum (SR) leading to spontaneous SR Ca release. We hypothesized that the mechanism of tachycardia-induced EADs depends on the spatial and temporal morphology of spontaneous SR Ca release, and tested this hypothesis in computer simulations using a ventricular action potential mathematical model. Using two previously suggested spontaneous release morphologies, we found two distinct tachycardia-induced EAD mechanisms: one mechanistically similar to bradycardia-induced EADs, the other to delayed afterdepolarizations (DADs).