Short-term Complications for Proximal Humerus Fracture Surgery Have Decreased: An Analysis of the National Surgical Quality Improvement Program Database

BACKGROUND

Multiple surgical treatments exist for proximal humerus fractures (PHFs), but current practice patterns and short-term complication profiles remain poorly understood. This is in part due to changes in treatment paradigms over the past decade. A more thorough understanding of the evolution in management over this time as well as an appreciation of the preoperative factors associated with both the chosen surgical modality and short-term complications will help inform future surgical considerations.

QUESTIONS/PURPOSES

In this study, we sought to: (1) characterize trends in the surgical management of PHFs over time, including usage rates of various surgical modalities and changes in complication rates; (2) identify preoperative variables associated with the selection of surgical modality; and (3) assess the independent covariates of acute 30-day complications, including demographic variables, injury characteristics, and treatment type.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was queried using Current Procedural Terminology and ICD-9 and ICD-10 codes to identify individuals with PHF undergoing open reduction and internal fixation (ORIF), hemiarthroplasty (HA), or reverse total shoulder arthroplasty (RTSA) from 2007 to 2018. The NSQIP database was utilized because of its collection of detailed preoperative demographic information and large repository of clinically derived data, which is felt to be more accurate than claims or administrative data. In total, 5889 patients with PHFs met the inclusion criteria. Patients 17 years or older were included. Patients with isolated greater tuberosity, humeral shaft, and distal humerus fractures; nonunions; malunions; and those undergoing revision procedures were excluded. A Cochran-Armitage test was used to evaluate surgical trends over time. Multivariable logistic regression models were created to identify covariates associated with surgical modality and complications. Although complications were either classified as major or minor, specific complications were also individually analyzed to avoid potentially misleading conclusions associated with pooling.

RESULTS

The proportion of patients with PHFs undergoing RTSA (4% in 2007 and 34% in 2018; p < 0.001) and ORIF (46% in 2007 and 57% in 2018; p < 0.001) increased over time, and the proportion of those undergoing HA (50% in 2007 and 9% in 2018; p < 0.001) decreased. Across each surgical modality, minor complication rates decreased over time (RTSA: 10% in 2018; p < 0.001; ORIF: 5% in 2018; p = 0.01; and HA: 6% in 2018; p = 0.01). After controlling for confounding variables like diabetes, chronic obstructive pulmonary disease, congestive heart failure, dialysis, and preoperative blood transfusion, the following factors were independently associated with an increased odds of a patient undergoing RTSA rather than HA: older age, higher BMI, independent functional status, and smoking. The following factors were independently associated with a decreased odds of a patient undergoing ORIF rather than RTSA and HA: older age, higher BMI, higher American Society of Anesthesiologists (ASA) classification, smoking, steroid/immunosuppressant use, as well as three- and four-part fractures. After controlling for age, ASA classification, functional status, and preoperative blood transfusion, we also found that in the latter part of the study period, arthroplasty (RTSA and HA) was no longer independently associated with 30-day major or minor complications compared with ORIF.

CONCLUSION

The increasing utilization of RTSA and decreasing short-term complication rates for fixation and arthroplasty alike represent a substantial change compared even with recent historic norms in the management of proximal humerus fractures. Quantifying demographics, injury characteristics, and comorbidities associated with both the choice of surgical modality and complications serves as the groundwork for decision support tools, which can inform patients and surgeons of the probability of a particular surgical modality being chosen and the risk of complications, based on national benchmarks. Future studies should investigate longer term complication rates, as many differences between the approaches being compared might occur beyond the perioperative period and our study had no means to address questions about complications beyond that period, but obviously those must be considered when choosing a treatment for patients with these injuries. Future work might also investigate the mechanisms behind the decreasing rates of short-term complications.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Effects of Parathyroidectomy on Normocalcemic Primary Hyperparathyroidism and the Role of Intraoperative PTH Measurement

BACKGROUND

Normocalcemic primary hyperparathyroidism (NCpHPT) and normohormonal primary hyperparathyroidism (NHpHPT) are recently recognized variants of primary hyperparathyroidism. Current guidelines for the management hyperparathyroidism recognize NCpHPT as one of the areas that are recommended for more research due to limited available data.

METHODS

A retrospective review of patients who had parathyroidectomy between 2014 and 2019. We excluded patients with multiple endocrine neoplasia syndromes and secondary and tertiary hyperparathyroidism. Included patients were classified based on the biochemical profile into classic or normocalcemic hyperparathyroidism group. Collected data included demographics, preoperative localizing imaging, intraoperative parathyroid hormone levels, and postoperative cure rates.

RESULTS

261 patients were included: 160 patients in the classic and 101 patients in the normocalcemic group. Patients in the normocalcemic group had significantly more negative sestamibi scans (n = 58 [8.2%] vs 78 [51.3%], P = <.01), smaller parathyroid glands (mean weight 436.0 ± 593.0 vs 742.4 ± 1109.0 mg, P = .02), higher parathyroid hyperplasia rates (n = 51 [50.5%] vs 69 [43.1%]), and significantly higher intraoperative parathyroid hormone at 10 minutes (78.1 ± 194.6 vs 43.9 ± 62.4 1, P = .04). Positive predictive value of both intraoperative parathyroid hormone and cure rate was lower in the normocalcemic group (84.2% vs 95.7%) and (80.5% vs 95%), respectively.

CONCLUSION

Normocalcemic hyperparathyroidism is a challenging disease. Surgeons should be aware of the lower cure rate in this group, interpret intraoperative parathyroid hormone with caution, and have a lower threshold for bilateral neck exploration and 4 glands visualization.

Recurrent Osteomyelitis Requiring Surgical Management Secondary to Nail-Biting: A Case Report

CASE

Onychophagia, or nail-biting, is a common habit seen in both children and adults. Harmful effects include oral exposure to a variety of pathogens and concomitant damage to dentition and fingers. This report focuses on the most severe reported case of recurrent osteomyelitis of the bilateral hands with destructive changes secondary to onychophagia.

CONCLUSION

Successful treatment relies on a multidisciplinary approach which in this case included surgical management and counseling on cessation, with referrals to other providers to address underlying psychiatric and/or psychologic conditions that may predispose to this compulsion.

Medial Ulnar Collateral Ligament Repair With Internal Brace Augmentation: Results in 40 Consecutive Patients

Background:

Medial ulnar collateral ligament (MUCL) repair has been proven to be effective in nonprofessional overhead-throwing athletes, with faster and higher rates of return to play (RTP) than the more traditional Tommy John reconstruction. Biomechanical studies and clinical data suggest that MUCL repair augmented with a collagen-coated internal brace may be an effective treatment option in this patient population.

Purpose:

To evaluate the functional outcomes of young nonprofessional athletes who underwent MUCL repair with internal brace augmentation for medial elbow instability. The hypothesis was that these patients will have high rates of RTP and improved functional outcomes.

Study Design:

Case series; Level of evidence, 4.

Methods:

Nonprofessional overhead athletes treated with MUCL repair with internal brace augmentation between 2015 and 2017 were prospectively evaluated for a minimum of 1 year. Preoperatively, all patients had evidence of medial elbow pain caused by MUCL insufficiency, as confirmed by signal changes on magnetic resonance imaging and valgus instability on arthroscopic examination. These findings did not allow them to participate in their chosen sport or profession, and each patient had failed nonoperative treatment. Postoperative outcomes were evaluated using the Overhead Athlete Shoulder and Elbow Score of the Kerlan-Jobe Orthopaedic Clinic. Complications were recorded and detailed.

Results:

A total of 40 nonprofessional overhead athletes were included in this study (35 men and 5 women; mean age, 17.8 years [range, 14-28 years]). The mean follow-up time was 23.8 months (range, 12-44 months). The mean postoperative Kerlan-Jobe Orthopaedic Clinic score was 92.6 (range, 64-100). Overall, 37 athletes (92.5%) returned to play or profession at the same level or higher at a mean time of 6.9 months (range, 2-12 months). Three patients did not RTP: 1 was limited by a concomitant medical diagnosis, and the other 2 chose not to resume athletics after the procedure but remained symptom free.

Conclusion:

In the nonprofessional athlete, primary MUCL repair with internal brace augmentation is a viable alternative to traditional repair techniques or reconstruction, allowing for a rapid RTP and promising functional outcomes.

Abstract P3008: Beta Adrenergic Receptor Activation Causes Endothelial Glycocalyx Degradation

The endothelial glycocalyx is a proteoglycan and glycoprotein matrix that coats the luminal surface of endothelial cells. It is an important component of the permeability barrier function of endothelial cells, including in the glomerular capillaries. Furthermore, it is a sensor of shear stress, and in vessels treated with enzymes to remove the glycocalyx do not exhibit flow-mediated vasodilation. Sparse previous studies have implicated a reduced glycocalyx thickness in hypertensive patients, but the causative signaling mechanisms have not been investigated. We and others have found that the endothelial glycocalyx can be studied in cultured endothelial cells if the medium contains significant soluble protein. We hypothesized that elevated catecholamines cause shedding of the endothelial glycocalyx in vitro . We cultured human umbilical vein endothelial cells (HUVECs) in M200 medium supplemented with 1% bovine serum albumin to permit development of a glycocalyx. We exposed these cells to concentrations of epinephrine, norepinephrine, phenylephrine, or isoproterenol from 0.01 to 10 μM for 30 minutes. We then imaged the glycocalyx using fluorescently labelled wheat germ agglutinin. We found that norepinephrine, epinephrine, and isoproterenol all caused a significant decrease in the endothelial glycocalyx staining intensity (5.82 ± 0.28 vs. 4.82 ± 0.21, 6.82 ± 0.28 vs. 5.09 ± 0.25, 7.46 ± 0.33 vs. 6.51 ± 0.28, at 1 μM, 1 μM, and 0.1 μM, respectively). However, phenylephrine caused an increase in glycocalyx staining intensity (6.27 ± 0.25 vs. 7.72 ± 0.32 at 1 μM). These results suggest that catecholamines acutely cause degradation of the glycocalyx in endothelial cells, but only when β adrenergic receptors are involved, since phenylephrine actually acted to increase glycocalyx. Future work will be needed to investigate the pathophysiological role of the reduced glycocalyx in hypertension. Furthermore, in vivo experiments are needed to determine whether these results are applicable to endothelial cells in the complex environment of intact blood vessels. Future work will also investigate the signaling mechanisms leading from adrenergic receptor activation to enzymatic degradation of the glycocalyx.

Gender disparities are present in academic rank and leadership positions despite overall equivalence in research productivity indices among senior members of American Head and Neck Society (AHNS) Fellowship Faculty

BACKGROUND

This study aims to examine potential disparities in scholarly performance based on sex, academic rank, leadership positions, and regional distribution of faculty in accredited Head and Neck Surgery fellowships in the United States.

METHODS

Online faculty listings for 37 accredited fellowships were organized according to academic rank, leadership position, sex, and institutional location. Academic productivity was measured with three bibliometric indices: h-index, m-index, and the weighted relative citation ratio.

RESULTS

A total of 732 faculty members were included, of which 153 (21%) were female. Fifty-eight males (89.2%) held leadership positions, compared to seven females (10.8%). There was no significant difference in overall productivity between male and female senior faculty. There were regional differences in productivity by sex.

CONCLUSIONS

Females are underrepresented in senior faculty and within three common leadership positions, although scholarly productivity for male and female senior faculty and for those in leadership positions is similar.

Efficacy of Medical Students as Stop the Bleed Participants and Instructors

OBJECTIVE

The Stop the Bleed (STB) program trains lay rescuers to identify and control life-threatening bleeding. Recently, medical students were allowed to become coinstructors. The aim of this study was to assess the efficacy of medical student course participation as both learners and instructors. No previous study to date has provided a critical objective assessment of medical student learners and educators of STB courses.

STUDY DESIGN

Participants anonymously self-reported pre- and postcourse confidence in 6 major skill areas using a 5-point Likert scale. At the end of the course, students' ability to perform STB skills was assessed using an internally validated 15-point objective assessment tool.

SETTING

Two US medical schools (Tulane University School of Medicine and Louisiana State University in New Orleans) which represent private and state institutions, respectively.

PARTICIPANTS

A total of 423 medical students were enrolled in the course. A pilot group of medical students volunteered to be instructors and their ability to effectively teach the course was objectively assessed.

RESULTS

Overall precourse confidence was highest in holding pressure on a wound and lowest in identification of severe active bleeding. Postcourse participant confidence increased significantly in all 6 core areas, including confidence to teach hemorrhage control skills to others. Objective assessment of medical students by STB instructors found 72.4% of medical students achieving perfect scores on their skill proficiency assessments. An assessment of 48 medical student instructors found that all students were able to proficiently serve as instructors.

CONCLUSIONS

This study demonstrates that medical students can effectively master STB skills and can also serve as competent course instructors. Future program development should focus on continued training of medical students and their involvement as instructors to help increase the availability of STB courses.