Charges for Distal Radius Fracture Fixation Are Affected by Fracture Pattern, Location of Service, and Anesthesia Type

BACKGROUND

This study sought to characterize charges associated with operative treatment of distal radius fractures and identify sources of variation contributing to overall cost.

METHODS

A retrospective study was performed using the New York Statewide Planning and Research Cooperative System database from 2009-2017. Outpatient claims were identified using the International Classification of Diseases-9/10-Clinical Modification diagnosis codes for distal radius fixation surgery. A multivariable mixed model regression was performed to identify variables contributing to total charges of the claim, including patient demographics, anesthesia method, surgery location (ambulatory surgery center [ASC] versus a hospital outpatient department [HOPD], operation time, insurance type, Charlson Comorbidity Index, and billed procedure codes.

RESULTS

A total of 9029 claims were included, finding older age, private primary insurance, surgery performed in a HOPD, and use of local anesthesia (vs general or regional) associated with increased total charges. There was no difference between gender, race, or ethnicity. Additionally, open reduction and internal fixation (ORIF), increased operative time/fracture complexity, and use of perioperative medications contributed significantly to overall costs.

CONCLUSIONS

Charges for distal radius fracture surgery performed in a HOPD were 28.3% higher than compared to an ASC, and cases with local anesthesia had higher billed claims compared to regional or general anesthesia. Furthermore, charges for percutaneous fixation were 54.6% lower than ORIF of extraarticular fracture, and claims had substantial geographic variation. These findings may be used by providers and payers to help improve value of distal radius fracture care.

LEVEL OF EVIDENCE

Level III.

Implant Charge Differences Between Distal Radius Fixation Constructs (CPT 25607, 25608, and 25609)

BACKGROUND

Implants are a significant contributor to health care costs. We hypothesized that extra-articular fracture patterns would have a lower implant charge than intra-articular fractures and aimed to determine risk factors for increased cost.

METHODS

In total, 163 patients undergoing outpatient distal radius fracture fixation at 2 hospitals were retrospectively reviewed stratified by Current Procedural Terminology codes. Implants and associated charges were noted, as were sex, age, insurance status, surgeon specialty, and location. Bivariate and multivariable regression were used to determine associations.

RESULTS

Total implant charges were significantly lower for 25607 (extraarticular, $3,348) than 25608 (2-part intraarticular, $3,859) and 25609 (3+ part intraarticular, $3,991). In addition, intra-articular fractures had higher charges for distal screws/pegs and bone graft. Charge was lower when surgery was performed at a trauma center. There was no charge difference associated with insurance status, age, sex, hand surgery specialty, or fellow status. Substantial intersurgeon variation existed in all fracture types.

CONCLUSION

Distal radius fractures may represent a good model for examining implant costs. Extra-articular fractures had lower implant charges than intra-articular fractures. These data may be used to help construct pricing for distal radius fracture bundles and potential cost savings.

Implicit and Explicit Factors That Influence Surgeons' Decision-Making for Distal Radius Fractures in Older Patients

PURPOSE

The purpose of this study was to evaluate factors that influence surgeons' decision-making in the treatment of distal radius fractures in older patients.

METHODS

Fourteen clinical vignettes of a 72-year-old patient with a distal radius fracture were sent to 185 orthopedic hand and/or trauma surgeons. The surgeons were surveyed regarding the demographic/practice details, treatment decision (surgical or nonsurgical), and factors that influenced management, including the Charlson Comorbidity Index, functional status, radiographic appearance, and handedness. Multivariable regression analyses were used to assess the effect of both surgeon-described (explicit) and given clinical (implicit) factors on the treatment decision and to evaluate for discrepancies.

RESULTS

Sixty-six surgeons completed the survey, and 7 surgeons completed 10-13 vignettes. Surgeons made the explicit determination to pursue nonsurgical treatment based on the presence of comorbidities (odds ratio [OR], 0.02 for surgery; 95% confidence interval [CI], 0.01-0.05), but the observation of the underlying clinical data suggested that the recommendation for surgical treatment was instead based on a higher functional status (OR, 3.54/increase in functional status; 95% CI, 2.52-4.98). Those employed by hospitals/health systems were significantly less likely to recommend surgery than those in private practice (OR, 0.42; 95% CI, 0.23-0.79) CONCLUSIONS: This study demonstrates that the presence of comorbidities, functional status, and practice setting has a significant impact on a surgeon's decision to treat distal radius fractures in older patients. The discrepancy between the surgeon-described factors and underlying clinical data demonstrates cognitive bias.

CLINICAL RELEVANCE

Surgeons should be aware of cognitive biases in clinical reasoning and should work through consequential patient decisions using an analytical framework that attempts to reconcile all available clinical data.

Unanticipated Admission Following Outpatient Ligament Reconstruction and Tendon Interposition: An Analysis of 3966 Cases

Background: Hand surgeons in the United States commonly perform ligament reconstruction and tendon interposition (LRTI) to address debilitating thumb carpometacarpal arthritis. The objective of this investigation was to examine the characteristics that place patients at risk for unanticipated inpatient admission after a planned outpatient LRTI. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) datasets from years 2009 to 2016 were used to identify patients with a primary Current Procedural Terminology code for LRTI (25445, 25447). Only outpatient, nonemergent, and elective procedures were considered. Univariable and multivariable regression were used to determine risk factors and postoperative complications associated with increased likelihood of unanticipated admission, defined as length of initial hospital stay greater than 0 days. Statistical significance was set at P < .05. Results: Of 3966 patients who underwent outpatient LRTI, 134 (3.4%) had unplanned admission. On multivariable regression, age ≥ 65 years (odds ratio [OR] = 1.50), white race (OR = 4.44), and chronic steroid use (OR = 2.42) were significant predictors of unplanned admission. History of smoking, obesity, hypertension, diabetes, American Society of Anesthesiologists classification, and anesthesia method were not associated with admission. Patients who had unplanned admission had increased rate of reoperation (2.5% vs 0.3%) compared with nonadmitted patients. There was no difference in rate of postoperative infection, deep vein thrombosis, wound dehiscence, or 30-day mortality. Conclusions: Age ≥ 65 years, chronic steroid use, and white race were significant predictors of unplanned admission following LRTI. Identifying patients with these characteristics will be critical in risk adjusting the anticipated cost of the episode of care in outpatient LRTI.

Pediatric Digit Replantation Following Traumatic Amputation: Nationwide Analysis of Patient Selection, Outcomes, and Cost

Background: Indications for replantation following traumatic digit amputations are more liberal in the pediatric population than in adults, but delineation of patient selection within pediatrics and their outcomes have yet to be elucidated. This study uses a national pediatric database to evaluate patient characteristics and injury patterns involved in replantation and their outcomes. Methods: The Healthcare Cost and Utilization Project Kid's Inpatient Database was queried for traumatic amputations of the thumb and finger from 2000 to 2012. Participants were separated into those who underwent replantation and those who underwent amputation. Patients undergoing replantation were further divided into those requiring revision amputation and/or microvascular revision. Patient age, sex, insurance, digit(s) affected, charges, length of stay, and complications were extracted for each patient. Results: Traumatic digit amputations occurred in 3090 patients, with 1950 (63.1%) undergoing revision amputation and 1140 (36.9%) undergoing replantation. Younger patients, those with thumb injuries, females, and those covered under private insurance were significantly more likely to undergo replantation. Cost, length of stay, and in-hospital complications were significantly greater in replantation patients than in those who had undergone amputation. Following replantation, 237 patients (20.8%) underwent revision amputation and 209 (18.3%) underwent vascular revision, after which 58 required revision amputation. Risk of revision following replantation involved older patients, males, and procedures done recently. Conclusions: Pediatric patients who underwent replantation were significantly younger, female, had thumb injuries, and were covered by private insurance. Our findings demonstrate that in addition to injury factors, demographics play a significant role in the decision for finger replantation and its outcomes.

Seasonal Trends in Traumatic Digit Amputations: Experience of a Level І and a Level ІІ Hospital in a Northeastern State

Background: Traumatic digit amputations are common hand injuries in the United States. The primary aim of our study was to describe the relationship between season and mechanisms of amputation. Methods: The Emergency Department and Orthopaedic Surgery Billing Department databases of our level І institution in the Northeast were reviewed to identify patients with a traumatic digit amputation between January 2010 and December 2015. Inclusion criteria were defined as any patient presenting with a partial or complete amputation through Verdan zone I or II. All patient information was entered into a secure database, including date of injury, demographic information, digits amputated, mechanism of injury (crush, laceration, avulsion, bite, blast, saw, snow blower, or lawn mower), and Verdan zones of amputation. In addition to descriptive statistics, Fisher exact and χ² tests were used to compare the incidence of these traumatic digit amputation mechanisms between seasons. Results: For this 6-year period, an average of 24 patients presented each season for treatment of a traumatic digit amputation. Of all seasons, spring had the highest proportion of lawn mower amputations (62.5%; P < .0001), summer had the highest proportion of blast amputations (75.0%; P = .011), and winter had the highest proportion of snow blower amputations (90.9%; P < .0001). All other traumatic digit amputation mechanisms had no significant seasonal variation in incidence (P > .30). Conclusions: Given that certain traumatic digit amputation mechanisms occur predictably during certain seasons, seasonal public education has the potential to prevent these debilitating injuries.

Effect of Hospital Characteristics on Performance of Pediatric Digit Replantation in the United States

Introduction  Utilize a national pediatric database to assess whether hospital characteristics such as location, teaching status, ownership, or size impact the performance of pediatric digit replantation following traumatic digit amputation in the United States. Materials and Methods  The Kid's Inpatient Database (KID) was used to query pediatric traumatic digit amputations between 2000 and 2012. Ownership (private and public), teaching status (teaching and non-teaching), location (urban and rural), hospital type (general and children's), and size (large and small-medium) characteristics were evaluated. Replantations were then divided into those that required subsequent revision replantation or amputation. Fisher's exact tests and multivariable logistic regressions were performed with p <0.05 considered statistically significant. Results  Overall, 1,015 pediatric patients were included for the digit replantation cohort. Hospitals that were privately owned, general, large, urban, or teaching had a significantly greater number of replantations than small-medium, rural, non-teaching, public, or children's hospitals. Privately owned (odds ratio [OR]: 1.80; 95% confidence interval [CI]: 1.06-3.06; p  = 0.03) and urban (OR: 2.29; 95% CI: 1.41-3.73; p  = 0.005) hospitals were significantly more likely to perform replantation. Urban (OR: 4.02; 95% CI: 1.90-8.47; p  = 0.0003) and teaching (OR: 2.11; 95% CI: 1.17-3.83; p  = 0.014) hospitals were significantly more likely to perform a revision procedure following primary replantation. Conclusion  Private and urban hospitals were significantly more likely to perform replantation, but urban and teaching hospitals carried a greater number of revision procedures following replantation. Despite risk of requiring revision, the treatment of pediatric digit amputations in private, urban, and teaching centers provide the greatest likelihood for an attempt at replantation in the pediatric population. The study shows Level of Evidence III.

Four-Corner Arthrodesis versus Proximal Row Carpectomy: Risk Factors and Complications Associated with Prolonged Postoperative Opioid Use

Introduction This article compares opioid use patterns following four-corner arthrodesis (FCA) and proximal row carpectomy (PRC) and identifies risk factors and complications associated with prolonged opioid consumption.

Materials and Methods The PearlDiver Research Program was used to identify patients undergoing primary FCA (Current Procedural Terminology [CPT] codes 25820, 25825) or PRC (CPT 25215) from 2007 to 2017. Patient demographics, comorbidities, perioperative opioid use, and postoperative complications were assessed. Opioids were identified through generic drug codes while complications were defined by International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modification codes. Multivariable logistic regressions were performed with p < 0.05 considered statistically significant.

Results A total of 888 patients underwent FCA and 835 underwent PRC. Three months postoperatively, more FCA patients (18.0%) continued to use opioids than PRC patients (14.7%) (p = 0.033). Preoperative opioid use was the strongest risk factor for prolonged opioid use for both FCA (odds ratio [OR]: 4.91; p < 0.001) and PRC (OR: 6.33; p < 0.001). Prolonged opioid use was associated with an increased risk of implant complications (OR: 4.96; p < 0.001) and conversion to total wrist arthrodesis (OR: 3.55; p < 0.001) following FCA.

Conclusion Prolonged postoperative opioid use is more frequent in patients undergoing FCA than PRC. Understanding the prevalence, risk factors, and complications associated with prolonged postoperative opioid use after these procedures may help physicians counsel patients and implement opioid minimization strategies preoperatively.

Cost-Effectiveness of Initial Revision Digit Amputation Performed in the Emergency Department Versus the Operating Room

Background: The objective of this study was to determine the comparative cost-effectiveness of performing initial revision finger amputation in the emergency department (ED) versus in the operating room (OR) accounting for need for unplanned secondary revision in the OR. Methods: We retrospectively examined patients presenting to the ED with traumatic finger and thumb amputations from January 2010 to December 2015. Only those treated with primarily revision amputation were included. Following initial management, the need for unplanned reoperation was assessed and associated with setting of initial management. A sensitivity analysis was used to determine the cost-effectiveness threshold for initial management in the ED versus the OR. Results: Five hundred thirty-seven patients had 677 fingertip amputations, of whom 91 digits were initially primarily revised in the OR, and 586 digits were primarily revised in the ED. Following initial revision, 91 digits required unplanned secondary revision. The unplanned secondary revision rates were similar between settings: 13.7% digits from the ED and 12.1% of digits from the OR (P = .57). When accounting for direct costs, an incidence of unplanned revision above 77.0% after initial revision fingertip amputation in the ED would make initial revision fingertip amputation in the OR cost-effective. Therefore, based on the unplanned secondary revision rate, initial management in the ED is more cost-effective than in the OR. Conclusions: There is no significant difference in the incidence of unplanned/secondary revision of fingertip amputation rate after the initial procedure was performed in the ED versus the OR.

Efficacy and Cost-effectiveness of Topical Vancomycin Powder in Primary Cementless Total Hip Arthroplasty

Topical vancomycin has been shown to effectively reduce infections after spinal surgery while remaining safe and cost-effective; however, there are few studies evaluating topical vancomycin in total hip arthroplasty. The authors hypothesized that the incidence of periprosthetic joint infection would decrease with the use of topical vancomycin in total hip arthroplasty and that topical vancomycin would be cost-effective. A retrospective patient chart review was performed to evaluate consecutive primary cementless total hip arthroplasties performed in the authors' hospital system between April 2015 and December 2016. Demographic data were collected. Periprosthetic joint infection was defined by Musculoskeletal Infection Society criteria. Statistical analysis included t test, Fisher's exact test, and logistic regression. The costs of vancomycin and postoperative infection were used to determine the absolute risk reduction (1/number needed to treat) threshold needed for topical vancomycin to be cost-effective. In this study, 309 patients (55.7%) undergoing total hip arthroplasty were treated with topical vancomycin, and 246 patients (44.3%) did not receive treatment. There were 2 infections in the vancomycin group (0.6% incidence), and 4 in the no vancomycin group (1.6% incidence). There was no statistical difference in infection rate between the 2 cohorts (P=.414). The absolute risk reduction was 0.98%, and the number needed to treat with topical vancomycin was 102 patients to prevent 1 periprosthetic joint infection. Topical vancomycin ($12 per vial) resulted in an expected cost savings of $904 per patient. Topical vancomycin is inexpensive and cost-effective. Although not statistically significant, the topical vancomycin group had a 60% lower incidence of infection. Further research regarding appropriate prophylactic topical and intravenous antibiotic use is needed prior to widespread adoption. [Orthopedics. 2019; 42(5):e430-e436.].

Shoulder and elbow injuries in NCAA football players, 2009-2010 through 2013-2014

Background: Although football is one of the most popular collegiate sports, the epidemiology of and risk factors for shoulder and elbow injuries in this population not been recently described. We aimed to characterize this incidence in National Collegiate Athletic Association (NCAA) football players, determine risk factors, and establish outcomes after injury. Methods: All shoulder and elbow injuries in men's football occurring during the 2009-2010 through 2013-2014 academic years were retrospectively identified in the NCAA Injury Surveillance Program database. The injury incidence per 10,000 athletic exposures (AEs) was calculated overall, and by different risk factors. In addition to descriptive statistics, risk factors were compared using injury risk-ratios, and outcomes were compared using injury proportion ratios. Results: NCAA football players sustained 1,187 shoulder and elbow injuries in 899,225 AEs (incidence: 13.20/10,000 AE), most commonly acromioclavicular separation (29.9%), anterior shoulder subluxation (9.0%), shoulder contusion (9.0%), and rotator cuff tear/sprain (8.0%). Together, shoulder instability comprised 28.1% of injuries. Injuries were split evenly between offense (43.5%) and defense (45.9%), and a tackling mechanism caused 37.7%, with 30.3% coming from blocking. The incidence was eight times higher in competition than practice (62.9/10,000 vs 7.9/10,000AE, p < 0.001). Surgery was performed for 9.9% of injuries, and most commonly for all types of shoulder instability (56.8% of surgeries). Injuries were season-ending in 5.2% of players. The likelihood of an injury being season-ending was 2.9 times greater for recurrent injuries than a new injury (p < 0.001); 86.1% of all injuries were new. Conclusions: Shoulder and elbow injuries to NCAA football players can be severe. Competition had an eight times higher incidence than did practice. Tackling and blocking were the most common mechanisms, while AC separation and shoulder instability were the most common injuries. This epidemiology may help players, coaches, trainers, and governing bodies target injury-prevention programs and assess improvement over time.

Acute Carpal Tunnel Syndrome in Inpatients With Operative Distal Radius Fracture

Acute carpal tunnel syndrome (CTS) may occur concomitantly with distal radius fracture (DRF) and is often managed with carpal tunnel release (CTR). Carpal tunnel syndrome may also develop postoperatively after DRF fixation. The authors sought to determine the rate of CTS with DRF, prophylactic CTR, and postoperative development of CTS. Furthermore, they also sought to identify predictors of these. The Nationwide Inpatient Sample database was queried (2002 to 2014) to identify adult inpatients undergoing surgical fixation of DRFs. They were segregated by the presence of CTS and further stratified by the timing of CTR in relation to DRF fixation. Those with a CTS diagnosis undergoing CTR on the same day as or prior to DRF fixation were classified as having CTS concomitantly. Patients undergoing CTR without a CTS diagnosis were considered prophylactically released. Carpal tunnel releases on any day after fracture fixation were considered complications. The authors identified 275,052 inpatients who had fixation of DRFs. Of these, 11,816 patients (4.3%) had CTS concomitantly. A total of 530 patients developed CTS after their DRF fixation (0.3%). Of those without CTS, 4420 patients (1.6%) underwent prophylactic CTR. Male sex, age younger than 50 years, and polytrauma status were associated with concomitant CTS and prophylactic CTR. Age younger than 50 years and polytrauma status were associated with postoperative development of CTS. The authors identified the rate of concomitant CTS, prophylactic CTR, and CTS developing postoperatively in inpatients undergoing DRF fixation. As early recognition and treatment optimizes outcomes after acute CTS, these data draw attention to the high rate of CTS and may be useful to surgeons treating patients with DRFs. [Orthopedics. 2019; 42(4):227-234.].

The Trapezium Dislocation: Case Presentation, Review of the Literature, Radiographic Analysis, Proposed Classification, and Treatment

BACKGROUND

Trapezium dislocations are rare injuries.

METHODS

A PubMed search of the term "trapezium dislocation" was conducted. Publications reporting a complete trapezium dislocation were included in the review.

RESULTS

The PubMed search resulted in 168 results. Fourteen publications reporting on 16 complete trapezium dislocations met inclusion criteria. A case of delayed diagnosis of a trapezium dislocation is presented. The literature is reviewed for pertinent clinically relevant information with respect to trapezium dislocations. A systematic method for radiographic analysis of trapezium dislocations and classification are described, and a treatment algorithm is presented.

CONCLUSIONS

Trapezium dislocations are infrequent injuries with few cases reported in the literature. Given the rarity of this injury, diagnosis and appropriate treatment may be delayed due to difficulty in recognition. Using the described method of radiographic analysis, delayed diagnosis may be avoided with implementation of timely treatment.

Assessment of a Geriatric Hip Fracture Program: Analysis of Harmful Adverse Events Using the Global Trigger Tool

BACKGROUND

The purpose of this study was to assess the impact of adding a geriatric comanagement program to the care of geriatric patients with a hip fracture at our hospital. The Institute for Healthcare Improvement (IHI) Global Trigger Tool (GTT) was used to follow the frequency and severity of adverse events occurring in hospitalized patients and to examine the effectiveness of a comanagement program (the Geriatric Hip Fracture Program [GHFP]).

METHODS

Data were collected for patients treated for a hip fracture from 2010 to 2014, which was 1 year prior to (October 2010 to September 2011) and 2 years after the implementation of the GHFP, and were grouped into 3-month intervals for analysis. The patients treated prior to the implementation of the GHFP were compared with those treated following the implementation of the program. The frequency and severity of adverse events were collected using the GTT.

RESULTS

There were 75.9 patients with an adverse event and 160.7 adverse events per 100 admissions. After the institution of the GHFP, there was a significant decrease in the number of patients with adverse events and the number of adverse events per 100 admissions over time. The rate of adverse events decreased by 12% per year when acute blood loss anemia was excluded. Similarly, the number of adverse events (excluding blood loss anemia) decreased significantly over time, from 128.7 per 100 admissions before the GHFP to 34.2 in the last quarter. Multivariable analysis (excluding acute blood loss anemia) demonstrated a trend toward a decreased likelihood of a patient experiencing an adverse event after the institution of the GHFP as well as a trend toward a decrease in the number of adverse events per patient. The length of the hospital stay was significantly shorter after the implementation of the GHFP.

CONCLUSIONS

The implementation of the GHFP reduced the number of adverse events over time. Increasing age and the Carlson Comorbidity Index (CCI) were predictors of adverse events, while only age was a predictor of readmissions and CCI was a predictor of death in our study. The implementation of the GHFP has played an important role at our institution in quantifying the decrease in adverse events over a 2-year period, and we believe that it is essential for improving care of geriatric patients with a hip fracture.

LEVEL OF EVIDENCE

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

Epidemiology of Elbow Ulnar Collateral Ligament Injuries in Throwing Versus Contact Athletes of the National Collegiate Athletic Association: Analysis of the 2009-2010 to 2013-2014 Seasons

Background:

The management and outcomes of elbow ulnar collateral ligament (UCL) injuries in throwing athletes have been well investigated. However, less is known regarding the management, severity, and outcomes of such injuries in contact athletes.

Purpose:

To compare the incidence, severity, and outcomes of elbow UCL injuries between throwing and contact athletes in collegiate sports.

Study Design:

Descriptive epidemiology study.

Methods:

Elbow UCL injuries were queried from the National Collegiate Athletic Association (NCAA) Injury Surveillance Program between the seasons of 2009-2010 and 2013-2014 in 25 varsity sports. The rates and distribution of injuries by mechanism, participation restriction time, and outcomes (eg, season-ending injury, surgery) were examined. A severe injury was defined as loss of ≥21 days from participation, a season-ending injury, or requiring a surgical intervention. The injury frequency, incidence per 10,000 athlete-exposures (AEs), and injury proportion ratio comparing throwing and contact athletes were calculated with 95% CIs.

Results:

Over the course of 5 seasons, 109 UCL injuries were recorded, for an overall injury rate of 0.29 per 10,000 AEs. Of these injuries, 83 (76.1%) were a result of contact and 26 (23.9%) from throwing. Men’s wrestling (1.78 per 10,000 AEs) and men’s baseball (1.12 per 10,000 AEs) sustained the highest injury rates. A larger proportion of throwing (n = 8; 36.4%) compared with contact (n = –7; 9.1%) (P < 0.01) injuries results in >21 days of time loss. Additionally, more throwing-related UCL injuries required surgery (n = 2; 11.1%) compared with contact-related injuries (n = 1; 1.3%) (P < 0.01). As a result, throwing athletes demonstrated a significantly higher proportion of severe injuries than contact athletes (injury proportion ratio, 4.62 [95% CI, 1.72-12.40]).

Conclusion:

The evaluation of athletes in 25 collegiate varsity sports across 5 seasons found over 3 times more elbow UCL injuries in contact versus throwing athletes. However, the number of severe injuries in throwing athletes was significantly higher than in contact athletes. These findings demonstrate that although elbow UCL injuries are prone to occur in both contact and throwing athletes, their prevention, management, and outcomes must be framed on a sport-by-sport basis.

Treatment of femoral neck fractures in patients 45-64 years of age

INTRODUCTION

Young patients with femoral neck fractures are optimally treated with reduction and stable fixation, while patients over the age of sixty-five are often treated with arthroplasty. This study analyzes in-hospital outcomes associated with total hip arthroplasty, hip hemiarthroplasty and internal fixation for treatment of femoral neck fractures in patients aged 45-64.

METHODS

Records of patients between the ages of 45-64, from 2002 to 2014, sustaining femoral neck fractures and treated with internal fixation, hip hemiarthroplasty or total hip arthroplasty were obtained from the Nationwide Inpatient Sample (NIS). Examined variables were age, sex and Charlson Comorbidity Index (CCI). Outcome measures included hospital length of stay (LOS), complications, and inpatient hospitalization charge.

RESULTS

From 2002-2014 74,678 femoral neck fractures were available for analysis. THA use increased from 5.3% of operatively managed fractures in 2002 to 22.3% of operatively managed fractures in 2014 (p < 0.0001). Patients undergoing THA had higher hospital cost, higher in hospital complication rates and longer length of stay than patients undergoing internal fixation (p < 0.0001). The in-hospital mortality for patients undergoing a hip hemiarthroplasty was higher (1.2%) than either total hip arthroplasty (0.2%) or internal fixation (0.5%) (P = 0.007).

CONCLUSION

This study demonstrates that the use of total hip arthroplasty in treatment of femoral neck fractures in patients from the age of 45-64 increased 4.2-fold over the study period. This treatment is associated with increased hospital cost, length of stay and complications. Additionally, as age increased in our study population, there was a stepwise increase in the use of arthroplasty, and it appears that hemiarthroplasty is being used with a different patient population.

Evaluation, Management, and Outcomes of Lunate and Perilunate Dislocations

Lunate and perilunate dislocations are potentially devastating injuries that are often unrecognized at initial evaluation. Prompt recognition and treatment is necessary to prevent adverse sequelae, including median nerve dysfunction, carpal instability, posttraumatic arthritis, reduced functionality, and avascular necrosis. In patients who are surgical candidates, operative intervention is warranted to restore carpal kinematics and provide optimal outcomes. [Orthopedics. 2019; 42(1):e1-e6.].

Efficacy of a radial-based thumb metacarpophalangeal-stabilizing orthosis for protecting the thumb metacarpophalangeal joint ulnar collateral ligament

STUDY DESIGN

Basic research (biomechanics).

INTRODUCTION

The high degree of motion that occurs at the thumb metacarpophalangeal (MCP) joint must be taken into account when immobilizing a partially torn or repaired thumb ulnar collateral ligament.

PURPOSE OF THE STUDY

To determine the efficacy of a radial-based thumb MCP-stabilizing orthosis in resisting abduction across the thumb ulnar collateral ligament.

METHODS

Ten fresh cadaveric hands were mounted to a custom board. An anteroposterior radiograph of the thumb was obtained with a 2 N preload valgus force applied to the thumb, and the angle between the Kirschner wires was measured as a baseline. Subsequently, 20, 40, 60, 80, and 100 N valgus forces were applied 15 mm distal to the MCP joint. Anteroposterior radiographs of the thumb were obtained after each force was applied. The angle of displacement between the wires was measured and compared with the baseline angle. The angles were measured with an imaging processing tool. A custom radial-based thumb MCP-stabilizing orthosis was fashioned for each cadaveric thumb by a certified hand therapist. The aforementioned loading protocol was then repeated.

RESULTS

The radial-based thumb MCP-stabilizing orthosis significantly reduced mean abduction angles at each applied load.

DISCUSSION

We found that our orthosis, despite being hand-based and leaving the thumb IP and CMC joints free, significantly reduced mean abduction angles at each applied load.

CONCLUSIONS

This investigation provides objective evidence that our radial-based thumb MCP-stabilizing orthosis effectively reduces the degree of abduction that occurs at the thumb MCP joint up to at least 100 N.

LEVEL OF EVIDENCE

n/a (cadaveric).

The expanding use of total elbow arthroplasty for distal humerus fractures: a retrospective database analysis of 56,379 inpatients from 2002-2014

OBJECTIVES

Distal humerus fractures are challenging to treat, with significant morbidity. Precontoured distal humerus locking plates and total elbow arthroplasty implants have become available in the past 15 years, potentially offering the promise of improved outcomes. However, national data regarding the usage of and in-hospital complications associated with these implants is scarce. Therefore, we aimed to determine if the incidence of inpatients with distal humerus fractures treated with arthroplasty or open reduction and internal fixation (ORIF) changed over time. Secondarily, we sought to determine what demographic factors were associated with arthroplasty versus fixation and compare inpatient outcomes.

METHODS

Inpatients over 50 years old with operatively treated closed distal humerus fractures were identified between 2002 and 2014 in the Nationwide Inpatient Sample, a nationally representative, all-payer database. Patient demographic factors were associated with treatment type. Outcomes examined included complications, mortality, length-of-stay, and charges; multivariable logistic regression compared associations with treatment.

RESULTS

Of 56,379 inpatients undergoing surgery, the proportion undergoing arthroplasty rose 2.3-fold from 4.8% to 10.9% from 2002 to 2014 (OR 1.039/year [95% CI [1.016-1.062]). Annual patient volume remained similar. Arthroplasty patients were older than those undergoing fixation (75.5 vs. 71.0 years, p < 0.001), more likely to be female (83.1% vs. 75.4%, p < 0.001), and less likely to be treated at a rural hospital (OR 0.601, 95% CI 0.445-0.812, p < 0.001). There was no significant difference in comorbidities. Arthroplasty patients had similar inpatient medical complication (7.1% vs. 7.8%, OR 0.998, p = 0.988) and mortality rates (0.38% vs. 0.94%, OR 0.426, p = 0.102), a decreased length of stay (by 0.3 days, p = 0.032), but increased hospital charges (by $12,033, p < 0.001).

CONCLUSIONS

For inpatients over 50 years old with operatively-treated distal humerus fractures, use of elbow arthroplasty has expanded, albeit with increased cost. Further studies may help to delineate the long-term costs and benefits, as well as which patients may benefit from each type of implant.

LEVEL OF EVIDENCE

Level III, Therapeutic Study.

Epidemiology of Upper Extremity Soccer Injuries Among High School- and College-Aged Players in the United States: An Analysis of the 1999-2016 NEISS Database

BACKGROUND:

Although lower extremity injuries are more common than upper extremity injuries in high school- and college-aged soccer players, upper extremity injuries may be equally severe. The epidemiology of upper extremity injuries is poorly characterized in this population.

HYPOTHESIS:

Upper extremity injuries are an important contributor to soccer-related morbidity among high school- and college-aged players.

STUDY DESIGN:

Descriptive epidemiology study.

LEVEL OF EVIDENCE:

Level 3.

METHODS:

The National Electronic Injury Surveillance System (NEISS) is a nationally representative sample of 100 hospital emergency departments (EDs). Each record contains demographic and injury information. Records from 1999 to 2016 were analyzed, including patients between the ages of 14 and 23 years with a soccer-related injury sustained at school or during an athletic event.

RESULTS:

A total of 1,299,008 high school- or college-aged patients presented to the ED for a soccer-related injury from 1999 to 2016, of which 20.4% were in the upper extremity. Patients were predominantly male (58.0%) and high school-aged (81.4%). Males constituted a greater proportion of upper extremity injuries when compared with other injury locations (63.5% male for upper extremity). Upper extremity injuries were more likely to be fractures (43.7% vs 13.9%) and dislocations (7.1% vs 3.4%) and less likely to be strains/sprains (27.8% vs 56.6%). Males suffered more shoulder dislocations (81.8% males among patients with shoulder dislocation vs 57.8% among those with other injuries), finger dislocations (72.0% vs 58.0%), upper arm fractures (74.9% vs 57.6%), and forearm fractures (68.3% vs 57.3%).

CONCLUSION:

Upper extremity injuries are frequent in high school- and college-aged soccer players presenting to the ED. Efforts to reduce soccer-related injuries should include strategies targeting the upper extremity, perhaps reducing the incidence of high-energy falls.

CLINICAL RELEVANCE:

Efforts to reduce soccer-related injuries should include strategies targeting upper extremity injuries, particularly among males and college-aged players.

Shoulder and elbow injuries in soccer goalkeepers versus field players in the National Collegiate Athletic Association, 2009-2010 through 2013-2014

OBJECTIVES

Examination of the incidence of shoulder and elbow injuries in the collegiate soccer player population is limited, as is comparison between goalkeepers and field players. We hypothesized that goalkeepers would have a higher incidence of shoulder and elbow injuries than field players. Furthermore, we sought to determine the incidence of shoulder and elbow injuries among National Collegiate Athletic Association (NCAA) soccer players, and to determine injury risk factors.

METHODS

The NCAA Injury Surveillance Program database was analyzed for injuries to NCAA men's and women's soccer players during the 2009-2010 through 2013-2014 academic years. The incidence of injury was calculated per 10,000 athletic exposures (AE) for goalkeepers versus field players, activity, and injury characteristics, and compared using univariate analysis and risk-ratios to determine injury risk factors.

RESULTS

While the overall incidence of shoulder and elbow injuries in soccer players was 2.7/10,000AE [95% CI 2.62-2.78], the incidence among goalkeepers was 4.6-fold higher (8.3 vs. 1.8/10,000AE, p < 0.0001). Goalkeepers had significantly higher incidences of injury in practice (21.3-fold) and in the preseason (16.1-fold) than field players. Women goalkeepers were disproportionately affected, with injury incidences 7.7-fold higher than women field players, and 1.9-fold higher than male goalkeepers. Acromioclavicular joint injuries, rotator cuff tears/sprains, and elbow and shoulder instability constituted the majority of the goalkeeper injuries.

CONCLUSIONS

Shoulder and elbow injuries in NCAA soccer players are significantly more common in goalkeepers than field players. Incidence varies widely by position and injury, with a number of associated risk factors. Soccer players sustaining these injuries, along with their coaches and medical providers, may benefit from this injury data to best manage expectations and outcomes. Soccer governing bodies may use this to track injury incidence and response to preventative measures.

Epidemiology of shoulder and elbow injuries in National Collegiate Athletic Association wrestlers, 2009-2010 through 2013-2014

OBJECTIVES

Examination of the incidence of shoulder and elbow injuries in the collegiate wrestling population is limited. Therefore, we sought to determine the incidence of shoulder and elbow injuries in wrestlers competing in the National Collegiate Athletic Association (NCAA), and investigate the risk factors involved.

METHODS

All shoulder and elbow injuries in wrestlers from the 2009-2010 through 2013-2014 academic years in the NCAA Injury Surveillance Program database were extracted. The incidence of different injuries, sports, activity, time-in-game, competition status, and injury characteristics was recorded. Risk-ratios were calculated to determine risk factors for injury.

RESULTS

Collegiate wrestlers had an incidence of 21.59 shoulder and elbow injuries per 10,000 athletic exposures (AEs). The most frequent injury types included elbow ulnar collateral ligament tears, shoulder impingement, and acromioclavicular joint sprains, although there was significant variability. Freshman collegiate wrestlers suffered a significantly higher percentage of shoulder and elbow injuries than more senior athletes, signifying an association between experience and injury risk. There was a 4-fold higher incidence of injury during competition. Injuries were significantly more likely to occur later in the match, with a 2.5-fold increased risk compared with early. While 26.8% of wrestlers were out of play for at least 14 days, only 5.9% of all injuries required surgery. Lastly, Division I collegiate wrestlers had the highest overall injury rate.

CONCLUSIONS

Collegiate wrestlers have a high incidence of shoulder and elbow injury, with specific risk factors identified here. This at-risk patient population should be monitored closely for signs of fatigue, which may leave them susceptible to injury. Further prospective investigation of wrestling injuries with a special attention to injury prevention in higher risk athletes are needed to further validate these findings.

Characteristics of Operative Shoulder Injuries in the National Collegiate Athletic Association, 2009-2010 Through 2013-2014

Background:

Injuries to the upper extremity among collegiate athletes are reported to account for approximately 20% of all injuries; however, little is known about the proportion of these injuries that require surgery.

Purpose/Hypothesis:

The purpose of this study was to examine all shoulder injuries that required a surgical intervention and were recorded in the National Collegiate Athletic Association (NCAA) Injury Surveillance Program (ISP). We hypothesized that contact would be the mechanism causing injuries most at risk for needing surgery and that dislocations would be the injuries most likely to require an operative intervention.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

Injury surveillance data between 2009-2010 and 2013-2014 for operative collegiate shoulder injuries and their associated sport exposures were analyzed.

Results:

A total of 185 operative shoulder injuries occurred over 3,739,004 athlete-exposures (AEs), for an overall incidence of 0.49 per 10,000 AEs. The sports with the highest incidence of operative injuries were men’s football (1.31/10,000 AEs), men’s wrestling (1.14/10,000 AEs), men’s ice hockey (0.60/10,000 AEs), women’s gymnastics (0.44/10,000 AEs), and men’s swimming (0.41/10,000 AEs). Men were significantly more likely than women to sustain operative injuries for all sports combined. Of the injuries that required surgical treatment, superior labrum from anterior to posterior (SLAP) tears (46.4%), other non-SLAP glenoid labrum tears (46.2%), anterior shoulder dislocations (33.3%), and posterior shoulder dislocations (30.0%) were seen most often. There was no significant difference in injury proportion ratios (IPRs) for injuries requiring surgery when comparing contact versus noncontact mechanisms of injury (IPR, 1.0 [95% CI, 0.6-1.6]). The incidence of operative injuries sustained during competition was significantly higher compared with during practice.

Conclusion:

The sports with the highest incidence of operative shoulder injuries were men’s football, men’s wrestling, men’s ice hockey, and women’s gymnastics. Operative shoulder injuries were more likely to occur during competition. SLAP tears, other non-SLAP glenoid labrum tears, and anterior shoulder dislocations had the highest incidence of requiring surgery. Athletes sustaining these injuries, along with their coaches and medical providers, may benefit from identifying collegiate sport participants who are at highest risk for sustaining an operative injury. This may assist in planning medical care and setting expectations, which may be critical to a young athlete’s career.

Season-Ending Shoulder Injuries in the National Collegiate Athletic Association: Data From the NCAA Injury Surveillance Program, 2009-2010 Through 2013-2014

BACKGROUND

Examination of the incidence of shoulder season-ending injury (SEI) in the collegiate athlete population is limited.

PURPOSE

To determine the incidence of shoulder SEI in the National Collegiate Athletic Association (NCAA) and to investigate the risk factors for a shoulder injury ending an athlete's season.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

All shoulder injuries from the NCAA Injury Surveillance Program database for the years 2009-2010 to 2013-2014 were extracted, and SEI status was noted. The incidences of SEI and non-SEI were calculated for athlete, activity, and injury characteristics and compared via univariable analysis and risk ratios to determine risk factors for an injury being season ending.

RESULTS

Shoulder injuries were season ending in 4.3% of cases. The overall incidence of shoulder SEI was 0.31 per 10,000 athlete exposures (AEs), as opposed to 7.25 per 10,000 AEs for all shoulder injuries. Shoulder instability constituted 49.1% of SEI, with an incidence of 0.15 per 10,000 AEs, while fractures had the highest rate of being season ending (41.9%). Men's wrestling had the highest incidence of shoulder SEI (1.65 per 10,000 AEs), while men's soccer had the highest proportion of shoulder injuries that ended a season (14.6%). Overall, men had a 6.3-fold higher incidence of SEI than women and a 2.4-fold increased likelihood that an injury would be season ending.

CONCLUSION

Injury to the shoulder of an NCAA athlete, while somewhat infrequent, can have significant implications on time lost from play. Incidence of these injuries varies widely by sport and injury, with a number of associated risk factors. Athletes sustaining potentially season-ending shoulder injuries, with their coaches and medical providers, may benefit from these data to best manage expectations and outcomes.

Epidemiology of Elbow Ulnar Collateral Ligament Injuries Among Baseball Players: National Collegiate Athletic Association Injury Surveillance Program, 2009-2010 Through 2013-2014

BACKGROUND

Injuries to the ulnar collateral ligament (UCL) of the elbow are of major concern in baseball; however, the epidemiology of these injuries among National Collegiate Athletic Association (NCAA) athletes is poorly described.

PURPOSE

To determine the incidence of UCL injuries in NCAA baseball and investigate the risk factors involved.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

All UCL injuries for academic years 2009-2010 through 2013-2014 were extracted from the NCAA Injury Surveillance Program database. The incidence was calculated for different positions, activity, time in game, competition status, and injury characteristics and compared via injury risk ratios to determine risk factors for injury occurrence. The NCAA provides sampling weights based on division and year. For all other injury characteristic analysis, unweighted data were used.

RESULTS

Over the course of the 2009-2010 to 2013-2014, 20 UCL injuries were reported in the NCAA Injury Surveillance Program over 177,992 athletic exposures (AEs) for an overall incidence of 1.12 per 10,000 AEs (95% CI, 0.63-1.62). Eighty-five percent occurred during throwing, and 100% were new injuries. Of the injuries sustained during games, 28.6% occurred early (warm-up through third inning) and 71.4% late (fourth inning or later), with a risk ratio of 1.3 for late-game injuries (95% CI, 0.24-6.44). Of those injured, 45.0% were able to return to play by the next season, while the remainder were out for at least 7 days. Injury was season ending for 15% of athletes (0.17 per 10,000 AEs), and 15% of athletes required surgery.

CONCLUSION

UCL injury is a potentially season-ending, even career-ending, injury among NCAA baseball players. Additionally, while more injuries occurred later in games, the current study revealed no significant difference in injury rates with respect to time in game. Last, the authors found a higher reported rate of extensive time away from sport after UCL injury than previously published studies on this patient population.

Assessment of 30-day mortality and complication rates associated with extended deep vein thrombosis prophylaxis following hip fracture surgery

BACKGROUND

DVT is a common complication following lower extremity surgery, occurring in up to 60% of patients undergoing hip fracture surgery without postoperative anticoagulation. The risk of fatal PE continues well-beyond two weeks postoperatively, thus extended DVT prophylaxis beyond 14 days may be warranted. This investigation sought to examine the association between prescription of extended DVT prophylaxis and 30-day postoperative complications following hip fracture surgery.

METHODS

This study utilized the ACS NSQIP Hip Fracture Procedure Targeted dataset, a newly available set of patient variables for 2016. The outcome measures were death, occurrence of any postoperative complication, complication subtype, readmission or reoperation within 30-days postoperatively, and length of stay. The primary independent variable was medical DVT prophylaxis continued 28-days postoperatively ("extended DVT prophylaxis"). The control group contains both patients receiving no prophylaxis and those receiving short-duration prophylaxis. Multivariate stepwise logistic regression was employed to control for potential demographic, comorbidity, and procedural/medical confounding factors.

RESULTS

In total, 7533 surgically treated hip fracture patients treated in 2016 were analyzed. Overall, 57.8% of patients (n = 4354) were prescribed extended DVT prophylaxis. On bivariate analysis, prescription of extended DVT prophylaxis was associated with significantly lower incidence of death (7.7% without vs. 2.7% with, p < 0.0001) and stroke/CVA (1.4% vs. 0.6%, p = 0.0016). In multivariate analysis, prescription of extended DVT prophylaxis was significantly associated with lower odds of death (OR 0.33, p < 0.0001), stroke/CVA (OR 0.44, p = 0.0010), and acute kidney injury (AKI) (OR 0.31, p = 0.0010).

CONCLUSIONS

This retrospective cohort study of the 2016 ACS NSQIP found that hip fracture surgery patients prescribed ≥28 days of postoperative DVT prophylaxis exhibited 67% lower odds of death and significantly lower rates of AKI and stroke/CVA as compared to those prescribed short-duration prophylaxis. Given the retrospective and uncontrolled nature of this analysis, these results should be interpreted with caution, and additional prospective randomized controlled trials examining the association between extended DVT prophylaxis and postoperative outcomes are warranted. If these observations accurately reflect real-world experience, these data suggest that ≥28 days of DVT prophylaxis following hip fracture surgery should be strongly considered for patients without explicit contraindications.

Unanticipated Admission Following Outpatient Rotator Cuff Repair: An Analysis of 18,061 Cases

The objective of this investigation was to examine the characteristics that place patients at risk for unanticipated inpatient admission after outpatient arthroscopic rotator cuff repair. This retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program data sets from years 2012 to 2015. Patients were included in the study based on the presence of a primary Current Procedural Terminology code for rotator cuff repair (23410, 23412, 23420, and 29827). Only outpatient, nonemergent, and elective procedures performed on patients with American Society of Anesthesiologists classification of 4 or less were considered. The primary outcome variable was admission after outpatient surgery (defined as length of initial hospital stay >0). This study examined risk factors for unanticipated admission following rotator cuff repair, finding that age of 65 years or older, female sex, hypertension, body mass index of 35 kg/m² or greater, American Society of Anesthesiologists classification of 2 or greater, and open surgical technique were significant predictors of admission, whereas monitored anesthesia care and regional anesthesia were associated with decreased odds of admission. Identifying patients with these characteristics will be critical in risk adjusting the anticipated cost of the episode of care in outpatient rotator cuff repair. [Orthopedics. 2018; 41(3):164-168.].

Thirty-Day Reoperation and/or Admission After Elective Hand Surgery in Adults: A 10-Year Review

PURPOSE

Whereas acute complications following elective hand surgery have been assumed to be rare, the incidence of 30-day unplanned reoperation and/or admission for the most common elective procedures has not been well described. Our goal was to calculate the incidence and identify the risk factors associated with these complications in a busy academic practice.

METHODS

Our institution's quality assurance database was examined retrospectively for unplanned reoperations and/or admissions within 30 days in adults undergoing elective procedures with 2 senior attending surgeons from February 2006 to January 2016. Each event was categorized by causative factor and charts were reviewed to establish risk factors and cultured organisms. Our billing database was examined for the concomitant procedural volume.

RESULTS

In our cohort of 18,081 surgeries (57.6% carpal tunnel or trigger digit releases), 27 patients had an unplanned reoperation and/or admission within 30 days (0.15% total incidence; including carpal tunnel release, 0.10%; trigger digit release, 0.09%; major wrist surgery, 0.74%) including 17 infections (0.09%). These were unevenly distributed over time after surgery with 29.6% occurring within 7 days, 59.2% in 8 to 14 days, 11.1% in 15 to 21 days, and none between 22 and 30 days.

CONCLUSIONS

Reoperations and/or unplanned admission within 30 days after elective hand surgery are infrequent (15 per 10,000 cases) and are most commonly related to infections (63.0%). More invasive surgeries are associated with a higher incidence than simpler procedures, and these complications are most likely to occur within 3 weeks after surgery. These data in elective patients do not cover certain clinically relevant outcomes, such as chronic pain or limited function, and may not be generalizable to all practices.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Elbow Dislocation and Subluxation Injuries in the National Collegiate Athletic Association, 2009-2010 Through 2013-2014

Background

Examination of the incidence of elbow dislocation and subluxation injuries in the collegiate athlete population is limited.

Purpose

To determine the incidence of elbow dislocation and subluxation injuries in the National Collegiate Athletic Association (NCAA) and investigate the risk factors involved.

Study Design

Descriptive epidemiology study.

Methods

All elbow subluxation and dislocation injuries from the 2009-2010 through 2013-2014 academic years in the NCAA Injury Surveillance Program database were extracted. The incidence was calculated for different injuries, sports, activity, time in game, competition status, and injury characteristics. Such differences were compared by use of risk ratios to determine risk factors for injury.

Results

The overall incidence of elbow instability injuries was 0.04 per 10,000 athlete-exposures (AEs). Elbow dislocations were more common, with 553 injuries (82.2%, 0.03/10,000 AEs), while elbow subluxations were the minority, with 119 injuries (17.8%, 0.01/10,000 AEs). Men's wrestling had the highest incidence of elbow instability (1.08/10,000 AEs), more than women's gymnastics (0.74), men's football (0.11), and women's volleyball (0.06). All injuries occurred via a contact mechanism, and 99.2% were new injuries. Sixty-nine percent of injuries kept athletes sidelined for more than 2 weeks. Injuries were 3 times more likely to occur in competition (0.08/10,000 AEs) than practice (0.03/10,000 AEs). Injuries sustained during competition were 1.4 times more likely to occur early in the match than late.

Conclusion

Elbow instability injuries are an infrequent but serious source of disability for select NCAA athletes, with a number of associated risk factors. Athletes sustaining these injuries, along with their coaches and medical providers, may benefit from these return-to-play data to best manage expectations and outcomes.

Polymicrobial pyogenic flexor tenosynovitis of the index finger and first ray resulting from autophagia

Pyogenic flexor tenosynovitis (PFT) is a well known infectious condition of the hand, involving the inoculation of the flexor tendon sheath with microorganisms. Many cases have been reported, common causes including direct inoculation by a puncture wound and deep lacerations extending into the flexor tendon sheath. In this report, we present a case of a 50 year old female with PFT resulting from autophagia (consuming one's own body parts, in our case, fingers) successfully treated with irrigation and debridement, amputation of the index finger at the metacarpophalangeal joint and antibiotic therapy.

Coronal Hamate Fracture Associated With Carpometacarpal Dislocations of All of the Fingers: Review of the Literature and Case Report

BACKGROUND

Dislocation of all 5 carpometacarpal (CMC) joints of a single hand is a rare injury.

METHODS

The literature regarding CMC fracture-dislocations was reviewed and a case was presented.

RESULTS

The relevant literature was consolidated to clinically relevant categories including 'Clinical Presentation and Diagnosis,' 'Management of CMC Fracture Dislocation and Hamate Fractures,' and 'Outcomes.'

CONCLUSIONS

The mechanism associated with this injury is often high energy that causes multiple simultaneous life- or limb-threatening injuries that could distract the examiner from identifying this injury. The case we present involves an axial dislocation of the carpus that resulted in dorsal dislocations of all CMC joints, dislocation of the hamate-capitate articulation, as well as fractures of the first metacarpal and the hamate.

Hypersensitivity to Orthopedic Implants: A Review of the Literature

Awareness of rare etiologies for implant failure is becoming increasingly important. In addition to the overall increase in joint arthroplasties, revision surgeries are projected to increase dramatically in the coming years, with volume increasing up to seven-fold between 2005 and 2030. The literature regarding the relationship between metal allergy and implant failure is controversial. It has proven difficult to determine whether sensitization is a cause or a consequence of implant failure. Testing patients with functional implants is not a clinically useful approach, as the rate of hypersensitivity is higher in implant recipients than in the general population, regardless of the status of the implant. As a result of the ineffectiveness of preoperative patch testing for predicting adverse outcomes, as well as the high cost of implementing such patch testing as standard procedure, most orthopedists and dermatologists agree that an alternative prosthesis should only be considered for patients with a history of allergy to a metal in the standard implant. In patients with a failed implant requiring revision surgery, hypersensitivity to an implant component should be considered in the differential diagnosis. Because a metal allergy to implant components is currently not commonly considered in the differential for joint failure in the orthopedic literature, there should be improved communication and collaboration between orthopedists and dermatologists when evaluating joint replacement patients with a presentation suggestive of allergy.

Crush Injuries of the Hand

Crush injuries of the hand are a rare but devastating phenomenon, with historically poor outcomes. A compressive force, usually caused by a high-energy mechanism such as a motor vehicle or industrial accident, crushes and transiently increases the pressures within the hand. This force acts on the incompressible blood in the vasculature and leads to a dramatic rise in tissue pressures and damage to multiple tissue types, including bones, blood vessels, nerves, and soft tissues. A wide zone of injury results from a delayed inflammatory reaction involving the zone bordering the crushed cells, which may initially belie the severity of the injury. As such, these injuries go on to produce tremendous inflammation and swelling, potentially followed by compartment syndrome or other vascular damage, infection, neurological injury, and tissue necrosis. Crush injuries with minimal skin disruptions can be particularly challenging to accurately diagnose and manage. This paper provides a review of the initial evaluation of hand crush injuries as well as short- and long-term management strategies.

Evaluation of the symbol digit modalities test (SDMT) and MS neuropsychological screening questionnaire (MSNQ) in natalizumab-treated MS patients over 48 weeks

BACKGROUND AND OBJECTIVES

Brief cognitive tests to monitor cognitive impairment in patients with multiple sclerosis (MS) are needed.

METHODS

Performance on monthly administrations of the Symbol Digit Modalities Test (SDMT) and the MS Neuropsychological Questionnaire (MSNQ) was assessed in 660 patients with MS in 21 countries (109 sites) for 48 weeks in an open-label, safety-extension study of natalizumab.

RESULTS

At baseline, the cohort's mean age was 40.1 years, 67.6% were female and the median Expanded Disability Status Scale score was 2.5. Test-retest correlations were high for both SDMT (range 0.89 for weeks 0-4 to 0.96 for weeks 44-48) and MSNQ (0.82 for weeks 0-4 to 0.93 for weeks 44-48). There were no statistically significant effects of geographic region. While SDMT scores improved by 15 points over 48 weeks (p < 0.0001), incremental monthly changes were small (effect size d < 0.3). Similar results were obtained on the MSNQ except that scores moved downward, suggesting fewer cognitive complaints over 48 weeks (p < 0.0001), but again the incremental monthly changes were small (d <-0.2).

CONCLUSIONS

These results replicate earlier work in a smaller cohort treated with conventional disease-modifying therapy, and support the reliability of the SDMT and MSNQ as potential screening for monitoring tools for cognition over time.

Rapid disease course in African Americans with multiple sclerosis

OBJECTIVE

To investigate utility of a Multiple Sclerosis Severity Scale (MSSS)-based classification system for comparing African American (AA) and white American (WA) multiple sclerosis (MS) subpopulations in the New York State Multiple Sclerosis Consortium (NYSMSC) database. MSSS is a frequency-rank algorithm relating MS disability to disease duration in a large, untreated reference population. Design/

METHODS

Distributions of patients in 6 MSSS-based severity grades were calculated for AA and WA registrants.

RESULTS

There were 419 AA and 5,809 WA patients in the NYSMSC, who had EDSS recorded during years 1-30 since symptom onset. Median EDSS was not different in AA and WA (3.5 vs 3.0, p = 0.60), whereas median MSSS in AA was higher than in WA (6.0 vs 4.8, p = 0.001). AA patients were overrepresented in the 2 most severe grades (41.5% vs 29.3% for WA) and underrepresented in the 2 lowest grades (23.4% vs 35.4%; p < 0.001). In multivariable analysis (ordered logistic and median regression), MSSS for AA remained significantly higher than in WA after adjusting for age, gender, disease duration, disease type distribution, and treatment with disease-modifying therapies.

CONCLUSIONS

The 6-tiered MSSS grading system is a powerful tool for comparing rate of disease progression in subpopulations of interest. MSSS-based analysis demonstrates that African ancestry is a risk factor for a more rapidly disabling disease course.

Continuous long-term immunomodulatory therapy in relapsing multiple sclerosis: results from the 15-year analysis of the US prospective open-label study of glatiramer acetate

The ongoing US Glatiramer Acetate (GA) Trial is the longest evaluation of continuous immunomodulatory therapy in relapsing-remitting multiple sclerosis (RRMS). The objective of this study was to evaluate up to 15 years of GA as a sole disease-modifying therapy. Two hundred and thirty-two patients received at least one GA dose since study initiation in 1991 (mITT cohort), and 100 (43%, Ongoing cohort) continued as of February 2008. Patients were evaluated every 6 months using the Expanded Disability Status Scale (EDSS). Mean GA exposures were 8.6 +/- 5.2, 4.81 +/- 3.69, and 13.6 +/- 1.3 years and mean disease durations were 17, 13, and 22 years for mITT, Withdrawn and Ongoing cohorts, respectively. For Ongoing patients, annual relapse rates (ARRs) maintained a decline from 1.12 +/- 0.82 at baseline to 0.25 +/- 0.34 per year; 57% had stable/improved EDSS scores (change < or = 0.5 points); 65% had not transitioned to secondary progressive multiple sclerosis (SPMS); 38%, 18%, and 3% reached EDSS 4, 6, and 8. For all patients on GA therapy (the mITT cohort), ARRs declined from 1.18 +/- 0.82 to 0.43 +/- 0.58 per year; 54% had stable/improved EDSS scores; 75% had not transitioned to SPMS; 39%, 23%, and 5% reached EDSS 4, 6, and 8. In conclusion, multiple sclerosis patients with mean disease duration of 22 years administering GA for up to 15 years had reduced relapse rates, and decreased disability progression and transition to SPMS. There were no long-term safety issues.

GLANCE: results of a phase 2, randomized, double-blind, placebo-controlled study

OBJECTIVE

To evaluate the safety and tolerability of natalizumab when added to glatiramer acetate (GA) in patients with relapsing multiple sclerosis. The primary outcome assessed whether this combination would increase the rate of development of new active lesions on cranial MRI scans vs GA alone.

METHODS

This phase 2, randomized, double-blind, placebo-controlled study included patients aged 19 to 55 years who were treated with GA for at least 1 year before randomization and experienced at least one relapse during the previous year. Patients received IV natalizumab 300 mg (n = 55) or placebo (n = 55) once every 4 weeks plus GA 20 mg subcutaneously once daily for < or = 20 weeks.

RESULTS

The mean rate of development of new active lesions was 0.03 with combination therapy vs 0.11 with GA alone (p = 0.031). Combination therapy resulted in lower mean numbers of new gadolinium-enhancing lesions (0.6 vs 2.3 for GA alone, p = 0.020) and new/newly enlarging T2-hyperintense lesions (0.5 vs 1.3, p = 0.029). The incidence of infection and infusion reactions was similar in both groups; no hypersensitivity reactions were observed. One serious adverse event occurred with combination therapy (elective hip surgery). With the exception of an increase in anti-natalizumab antibodies with combination therapy, laboratory data were consistent with previous clinical studies of natalizumab alone.

CONCLUSION

The combination of natalizumab and glatiramer acetate seemed safe and well tolerated during 6 months of therapy.

Dose comparison trial of sustained-release fampridine in multiple sclerosis

OBJECTIVE

To examine the efficacy and safety of three different doses of sustained-release fampridine in people with multiple sclerosis (MS).

METHOD

This multicenter, randomized, double-blind, placebo-controlled, parallel-group study recruited 206 participants at 24 centers in the United States and Canada. After a single-blind, 2-week placebo run-in, participants were randomly assigned to receive fampridine (10, 15, or 20 mg twice daily) or placebo for 15 weeks. The primary efficacy variable was percent change in walking speed based on the timed 25-foot walk.

RESULTS

Trends for increased walking speed were consistent across dose groups vs placebo, but not significant, on the prospective analysis. An increase from baseline in lower extremity strength during the 12-week stable-dose period was seen in the groups receiving 10- and 15-mg doses, compared with placebo (p = 0.018 and 0.003). There were no significant changes in other secondary assessments. Post hoc analysis revealed subsets of participants in each dose group with walking speeds during the treatment period that were consistently faster than during the nontreatment period. There were significantly more "consistent responders" in the drug-treated groups than in the placebo group (36.7% compared with 8.5%). Consistent responders showed significantly greater improvement in self-assessed ambulation on the 12-Item MS Walking Scale than did nonresponders. Fampridine was generally well tolerated. Severe and serious adverse events were more frequent at the highest dose.

CONCLUSIONS

This phase 2 study suggests that a subgroup of patients, when treated with fampridine, experiences a clinically relevant improvement in walking ability, which is sustained for at least 14 weeks.

Avonex Combination Trial in relapsing—remitting MS: rationale, design and baseline data

Objective To review the rationale, design and baseline data of the Avonex Combination Trial (ACT), an investigator-run study of intramuscular interferon beta-1a (IM IFNβ-1a) combined with methotrexate (MTX) and/or IV methylprednisolone (IVMP) in relapsing—remitting multiple sclerosis (RRMS) patients with continued disease activity on IM IFNβ-1a monotherapy.

Methods Eligibility criteria included RRMS, Expanded Disability Status Scale score 0—5.5, and ≥1 relapse or gadolinium-enhancing MRI lesion in the prior year while on IM IFNβ-1a monotherapy. Subjects continued IFNβ-1a 30 mcg IM weekly and were randomized in a 2 × 2 factorial design to adjunctive weekly placebo or MTX 20 mg PO, with or without IVMP 1000 mg/day for three days every other month. ACT was industry-supported, and collaboratively designed and governed by an Investigator Steering Committee with independent Advisory and Data Safety Monitoring Committees. Study operations, MRI analysis and aggregated data were managed by the Cleveland Clinic MS Academic Coordinating Center.

Results In total 313 subjects were enrolled with clinical and MRI characteristics typical of RRMS. Most subjects (86.9%) qualified with a clinical relapse, with or without an enhancing MRI lesion, in the preceding year. At baseline, 21.4% had enhancing lesions, and 5.1% had anti-IFNβ neutralizing antibodies. ACT's management and operational structures functioned well.

Conclusion This study provides an innovative model for academic—industry collaborative MS research and will enhance understanding of the utility of combination therapy for RRMS patients with continued disease activity on an established first-line treatment. Multiple Sclerosis 2008; 14: 370—382. http://msj.sagepub.com

Randomized, double-blind, dose-comparison study of glatiramer acetate in relapsing-remitting MS

OBJECTIVE

To evaluate the safety, tolerability, and efficacy of glatiramer acetate (GA) 40 mg daily vs the approved 20-mg formulation in relapsing-remitting multiple sclerosis.

METHODS

Eligibility criteria included clinically definite multiple sclerosis, Expanded Disability Status Scale score 0 to 5.0, no previous use of GA, at least one relapse in the previous year, and 1 to 15 gadolinium-enhancing (GdE) lesions on a screening MRI. MRI was repeated at months 3, 7, 8, and 9, and neurologic examinations were performed at baseline and months 3, 6, and 9.

RESULTS

Of 229 subjects screened, 90 were randomly assigned to GA 20 mg (n = 44) or 40 mg (n = 46). The groups were well matched at baseline for demographic, clinical, and MRI characteristics. The primary efficacy endpoint, total number of GdE lesions at months 7, 8, and 9, showed a trend favoring the 40-mg group (38% relative reduction, p = 0.0898). A difference between the two dose groups emerged as early as month 3 (52% reduction; p = 0.0051). There was a trend favoring the 40-mg group for relapse rate with benefit on proportion of relapse-free subjects (p = 0.0183) and time to first relapse (p = 0.0367). GA 40 mg was well tolerated, with an overall safety profile similar to that of 20 mg. Some features of injection site reactions and immediate postinjection reactions were more common and severe with the higher dose.

CONCLUSIONS

Glatiramer acetate (GA) 40 mg was safe and well tolerated. The overall efficacy results suggested that a 40-mg dose of GA may be more effective than the currently approved 20-mg daily dose in reducing MRI activity and clinical relapses.

Fampridine-SR in multiple sclerosis: a randomized, double-blind, placebo-controlled, dose-ranging study

Objective To determine the safety of sustained-release 4-aminopyridine in subjects with mutiple sclerosis (MS) and to examine dose-related efficacy up to 40 mg twice daily.

Method Multicenter, randomized, double-blind, placebo-controlled, study. Following a 4-week baseline peroid, subjects were randomly assigned to receive Fampridine-SR (n=25, doses from 10 to 40 mg twice daily, increasing in 5 mg increments weekly) or placebo (n=11). A battery of assessments was performed weekly, including the MS Functional Composite (MSFC), fatigue questionnaires, and lower extremity manual muscle testing.

Results The most common adverse events were dizziness, insomnia, paresthesia, asthenia, nausea, headache, and tremor. Five subjects were discontinued from Fampridine-SR because of adverse events at doses greater than 25 mg, and these included convulsions in two subjects at doses of 30 and 35 mg twice daily. Improvement were seen in lower extremity muscle strength (prospective analysis) and walking speed (post-hoc analysis) in the Fampridine-SR group compared to placebo (unadjusted p-values of 0.01 and 0.03, respectively). There were no significant differences in other MSFC measure or fatigue scores.

Conclusions Future studies should employ doses up to 20 mg twice daily with lower extremity strength and walking speed as potential outcome measures. Multiple Sclerosis 2007; 13: 357-368. http://msj.sagepub.com

An open-label safety and drug interaction study of natalizumab (Antegren) in combination with interferon-beta (Avonex) in patients with multiple sclerosis

In this open-label drug-interaction trial, we studied 38 patients with relapsing-remitting multiple sclerosis (MS) who received 3.0 or 6.0 mg/kg of natalizumab as a single intravenous (i.v.) infusion during stable treatment with intramuscular (i.m.) interferon beta-1a 30 microg (IFNbeta-1a; Avonex). To assess the pharmacokinetic (PK) interaction of natalizumab and IFNbeta-1a, serum concentration-time data for both agents were collected and analysed. Biologic response markers of IFNbeta-1a activity, beta2-microglobulin and neopterin, were also assessed to determine effects of natalizumab on IFNbeta-1a pharmacodynamics (PD). Further, safety and immunogenicity were evaluated. The combination of drug therapies was well tolerated. Although natalizumab serum concentrations (and corresponding PK exposure measures) appeared to be somewhat elevated in the presence of IFNbeta-1a, when compared to the same dose (6.0 mg/kg) administered alone in a concurrent comparator study, the differences were generally small and unlikely to be clinically relevant. In general, natalizumab had no apparent clinically relevant effects on the PK or PD properties of IFNbeta-1a. The presence of antibodies to IFNbeta-1a and natalizumab was relatively low. Overall, the study provided safety, immunogenicity, PK and PD data to support a combination strategy for the use of natalizumab and IFNbeta-1a in the treatment of patients with relapsing-remitting MS. A large clinical study is currently in progress to evaluate the efficacy and long-term safety of this combination drug therapy.

Glatiramer acetate (Copaxone): comparison of continuous versus delayed therapy in a six-year organized multiple sclerosis trial

The aim of this study was to assess the long-term safety and efficacy of glatiramer acetate (GA) for patients with multiple sclerosis (MS) who received active treatment versus those on placebo for approximately 30 months (24-35 months) before receiving GA during a six-year organized, prospective open label study. Entry required two relapses in the previous two years and an Expanded Disability Status Scale (EDSS) score of 0-5. Patients (251) were equally randomized to daily subcutaneous GA, 20 mg, or to placebo. After approximately 30 months, 208 patients continued in an open label study: 101 continued on GA and 107 switched from placebo to active drug. Groups were well matched at randomization and entry to the open label study. Patients always on GA showed a steady decline in relapses: a mean of 1.5 per year at entry, a mean of 0.42 over the entire six years (95% CI = 0.34-0.51), a 72% reduction (P = 0.0001). They averaged a relapse every four + years (yearly rate 0.23 in year six) and 26/101 remain relapse free. Patients did less well if on placebo for 30 months, but relapses then declined, and by year six the rates were similar. Of patients always on GA, 69% showed neurological improvement of > or = 1 EDSS steps or remained stable compared with 57% if GA treatment was delayed. Of relapse-free patients always on GA over six years, only three of 26 (11%) were worse by > or = 1 EDSS steps, whereas nine of 21 (43%) in the placebo/active group were worse (P < 0.03). Disability, measured every six months, showed that the group of patients always on GA was relatively stable over the six years, while the group who received placebo for the first two-and-a-half years did significantly less well. Daily injections of GA were well tolerated. This longest ever organized MS treatment trial shows that delaying therapy with GA increases the risk of neurologic disability, reinforcing the rationale for using GA as a first-line treatment early in the course of relapsing-remitting MS.

Multiple sclerosis characteristics in African American patients in the New York State Multiple Sclerosis Consortium

The objective of this study was to determine the clinical characteristics of multiple sclerosis (MS) in African American (AA) patients in the New York State Multiple Sclerosis Consortium (NYSMSC) patient registry. The NYSMSC is a group of 18 MS centers throughout New York State organized to prospectively assess clinical characteristics of MS patients. AAs comprise 6% (329) of the total NYSMSC registrants (5602). Demographics, disease course, therapy, and socioeconomic status were compared in AA registrants versus nonAfrican Americans (NAA). There was an increased female preponderance and a significantly younger age at diagnosis in the AA group. AA patients were more likely to have greater disability with increased disease duration. No differences were seen in types of MS and use of disease modifying therapies. Our findings suggest a racial influence in MS. Further genetic studies that consider race differences are warranted to elucidate mechanisms of disease susceptibility.

Benefit of interferon beta-1a on MSFC progression in secondary progressive MS

BACKGROUND

Interferon beta-1a (IFNbeta-1a, Avonex) is efficacious in relapsing forms of MS. Studies of other IFNbeta preparations in secondary progressive MS (SPMS) yielded conflicting results. This study was undertaken to determine whether IFNbeta-1a slowed disease progression in SP-MS.

METHODS

A total of 436 subjects with SPMS and Expanded Disability Status Scale (EDSS) score 3.5 to 6.5 were randomized to receive IFNbeta-1a (60 micro g) or placebo by weekly intramuscular injection for 2 years. The primary outcome measure, used for the first time in a large-scale MS trial, was baseline to month 24 change in the MS Functional Composite (MSFC), comprising quantitative tests of ambulation (Timed 25-Foot Walk), arm function (Nine-Hole Peg Test [9HPT]), and cognition (Paced Auditory Serial Addition Test [PASAT]).

RESULTS

Median MSFC Z-score change was reduced 40.4% in IFNbeta-1a subjects (-0.096 vs -0.161 in placebo subjects, p = 0.033), an effect driven mainly by the 9HPT and PASAT. There was no discernible benefit on the EDSS, which in this range principally reflects walking ability. IFNbeta-1a subjects had 33% fewer relapses (p = 0.008). There was significant benefit on eight of 11 MS Quality of Life Inventory subscales. New or enlarging T2-hyperintense brain MRI lesions and gadolinium-enhancing lesions were reduced at months 12 and 24 (both p < 0.001). IFNbeta-1a was well tolerated by the majority of subjects. Neutralizing antibodies developed in 3.3% of IFNbeta-1a-treated subjects.

CONCLUSIONS

IFNbeta-1a demonstrated benefit on MSFC progression, relapses, quality of life, and MRI activity in SPMS.