Ameya V. Save

Driving Reaction Times in Patients With Foot and Ankle Pathology Before and After Image-Guided Injection Pain Relief Without Improved Function

Background: Foot and ankle pathology is common in the driving population. Local anesthetic steroid injections are frequent ambulatory treatments. Brake reaction time (BRT) has validated importance in motor vehicle safety. There are no prior studies examining the effect of foot and ankle pathology and injection treatment on the safe operation of motor vehicles. We studied BRT in patients with foot and ankle musculoskeletal disease before and after image-guided injection treatment. Methods: A total of 37 participants were enrolled. Image-guided injections of local anesthetic and steroid were placed into the pathological anatomical location of the right or left foot and ankles. A driving reaction timer was used to measure BRTs before and after injection. Patients suffering right “driving” and left “nondriving” pathology as well as a healthy control group were studied. Results: All patients reported >90% pain relief postinjection. All injections were confirmed to be accurate by imaging. Post hoc Bonferonni analysis demonstrated significant difference between the healthy group and the right-sided injection group (P = .008). Mean BRT for healthy controls was 0.57 ± 0.11 s. Patients suffering right foot and ankle disease displayed surprisingly high BRTs (0.80 ± 0.23 s preinjection and 0.78 ± 0.16 s postinjection, P > .99). Left nondriving foot and ankle pathology presented a driving hazard as well (BRT of 0.75 ± 0.12 s preinjection and 0.77 ± 0.12 s postinjection, P > .99). Injections relieved pain but did not significantly alter BRT (P > .99 for all). Conclusion: Patients suffering chronic foot and ankle pathology involving either the driving or nondriving side have impaired BRTs. This preexisting driving impairment has not previously been reported and exceeds recommended cutoff safety values in the United States. Despite symptom improvement, there was no statistically significant change in BRT following image-guided injection in either foot and ankle. Levels of Evidence: Therapeutic, Level II: Prospective Comparative Study

Low-intensity pulsed ultrasound treatment for scaphoid fracture nonunions in adolescents.

Background Treatment of scaphoid nonunion is challenging, leading clinicians to pursue innovation in surgical technique and adjunctive therapies to improve union rates. Purpose The purpose of this study was to investigate the use of low-intensity pulsed ultrasound as an adjunctive treatment modality following surgical treatment of scaphoid nonunion in adolescent patients, for whom this therapy has not yet been FDA-approved. Patients and Methods We performed a retrospective review of adolescent patients with scaphoid nonunion treated surgically followed by adjunctive low-intensity pulsed ultrasound therapy. All patients underwent 20 minutes of daily ultrasound therapy postoperatively until there was evidence of bony healing, based on both clinical and radiographic criteria. Final healing was confirmed by > 50% bone bridging on CT scan. Results Thirteen of fourteen (93%) patients healed at a mean interval of 113 days (range 61-217 days). There were no surgical or postoperative complications. One patient developed heterotopic bone formation about the scaphoid. Conclusions Our study suggests that low-intensity pulsed ultrasound therapy can safely be utilized as an adjunctive modality in adolescents to augment scaphoid healing following surgical intervention. Level of Evidence Level IV, Case series.

Dorsal spanning plate fixation for distal radius fractures.

In polytrauma patients, the presence of a multifragmentary distal radius fracture poses a challenge with respect to early mobilization. Dorsal spanning plate fixation is an alternative choice for these patients for providing definitive operative fixation of the distal radius fracture and for providing a construct to allow weight-bearing through the injured wrist for rehabilitative purposes. In this article, we describe the operative technique to place a dorsal spanning plate and provide a retrospective review of outcomes in polytrauma patients.

Scaphoid interfragmentary motions due to simulated transverse fracture and volar wedge osteotomy

BACKGROUND Our goal was to determine 3-dimensional interfragmentary motions due to simulated transverse fracture and volar wedge osteotomy of the scaphoid during physiologic flexion-extension of a cadaveric wrist model. METHODS The model consisted of a cadaveric wrist (n = 8) from the metacarpals through the distal radius and ulna with load applied through the major flexor-extensor tendons. Flexibility tests in flexion-extension were performed in the following 3 test conditions: intact and following transverse fracture and wedge osteotomy of the scaphoid. Scaphoid interfragmentary motions were measured using optoelectronic motion tracking markers. Average peak scaphoid interfragmentary motions due to transverse fracture and wedge osteotomy were statistically compared (P<0.05) to intact. FINDINGS The accuracy of our computed interfragmentary motions was ± 0.24 mm for translation and ± 0.54° for rotation. Average peak interfragmentary motions due to fracture ranged between 0.9 mm to 1.9 mm for translation and 5.3° to 10.8° for rotation. Significant increases in interfragmentary motions were observed in volar/dorsal translations and flexion/extension due to transverse fracture and in separation and rotations in all 3 motion planes due to wedge osteotomy. INTERPRETATION Comparison of our results with data from previous in vitro and in vivo biomechanical studies indicates a wide range of peak interfragmentary rotations due to scaphoid fracture, from 4.6° up to 30°, with peak interfragmentary translations on the order of several millimeters. Significant interfragmentary motions, indicating clinical instability, likely occur due to physiologic flexion-extension of the wrist in those with transverse scaphoid fracture with or without volar bone loss.

Access of Patients With Lumbar Disc Herniations to Spine Surgeons: The Effect of Insurance Type Under the Affordable Care Act

Study Design. Prospective cohort study. Objective. To determine the effects of insurance type (Medicaid vs. a specific private insurance) on patient access to spine surgeons for lumbar disc herniation as measured by (A) acceptance of insurance, (B) need for a referral, and (C) wait time for appointment. Summary of Background Data. Limited studies have been conducted to examine the issue of patient access to spine surgeons based on different insurance types (Medicaid vs. a specific private insurance), especially in relation to the Medicaid expansion that resulted from the Affordable Care Act. Methods. Appointment success rates, the need for a referral, and waiting periods were compared between Medicaid and a specific private insurance for patients needing an evaluation for a herniated lumbar disc. The waiting period was studied in the context of comparing states that have expanded Medicaid eligibility to ones that have not, and the surgical training of the spine surgeon (orthopaedic surgeons vs. neurosurgeons). Results. Appointment success rate for patients seeking access to lumbar spine care was significantly higher for patients with BlueCross insurance (95.0%) versus patients with Medicaid insurance (0.8%) (P <0.001). The need for referrals was significantly higher for patients with Medicaid insurance (93.3%) versus patients with BlueCross insurance (4.2%) (P <0.001). Among BlueCross patients, wait times were longer in Medicaid-expanded states. However, the same trend was not seen among patients with Medicaid insurance. Conclusion. Patients with Medicaid were less successful at scheduling an appointment and faced more barriers to care, such as the need for a referral, compared with the private insurance studied. In the states with expanded Medicaid, wait times for appointments were longer for BlueCross patients, but were not longer for patients with Medicaid insurance. Overall, this study suggests that increased coverage resulting from Medicaid expansion does not necessarily equate to increased access to care. Level of Evidence: 2

The Influence of Medical Insurance on Patient Access to Orthopaedic Surgery Sports Medicine Appointments Under the Affordable Care Act

Background: The goal of the Patient Protection and Affordable Care Act (PPACA) was to expand patient access to health care. Since the rollout of the PPACA, Medicaid patients have demonstrated difficulty obtaining appointments in some specialty care settings. Purpose: To assess the effect of insurance type (Medicaid and private) on patient access to orthopaedic surgery sports medicine specialists for a semiurgent evaluation of a likely operative bucket-handle meniscus tear. The study was designed to determine whether disparities in access exist since the PPACA rollout. Study Design: Cohort study; Level of evidence, 2. Methods: The design was to call 180 orthopaedic surgery sports medicine specialists in 6 representative states (California, Ohio, New York, Florida, Texas, and North Carolina) between June 2015 and December 2015. An appointment was requested for the caller’s fictitious 25-year-old-brother who had suffered a bucket-handle meniscus tear. Each office was called twice to assess the ease of obtaining an appointment: once for patients with Medicaid and once for patients with private insurance. For each call, data pertaining to whether an appointment was given, wait times, and barriers to receiving an appointment were recorded. Results: A total of 177 surgeons were called within the study period. Overall, 27.1% of offices scheduled an appointment for a patient with Medicaid, compared with 91.2% (P < .0001) for a patient with private insurance. Medicaid patients were significantly more likely to be denied an appointment due to lack of referral compared with private patients (40.2% vs 3.7%, P < .0001), and Medicaid patients were more likely to experience longer wait times for an appointment (15 vs 12 days, P < .029). No significant differences were found in patients’ access to orthopaedic surgery sports medicine specialists between Medicaid-expanded and -nonexpanded states. Medicaid reimbursement for knee arthroscopy with meniscus repair was not significantly correlated with appointment success rate or patient waiting periods. Conclusion: Despite the passage of the PPACA, patients with Medicaid have reduced access to care. In addition, patients with Medicaid confront more barriers to receiving appointments than patients with private insurance and wait longer for an appointment.

Of 20,376 Lumbar Discectomies, 2.6% of Patients Readmitted within 30 Days: Surgical Site Infection, Pain, and Thromboembolic Events are the Most Common Reasons for Readmission.

Study Design. A retrospective cohort study of prospectively collected data. Objective. As an initial effort to address readmissions after lumbar discectomy, reasons for hospital readmission are identified and discussed. Summary of Background Data. Lumbar discectomy is a commonly performed procedure. The Affordable Care Act codifies penalties for hospital readmissions. New quality-based reimbursements tied to readmissions call for a better understanding of the causes of readmission after procedures such as lumbar discectomy. Methods. Lumbar discectomies performed in 2012 to 2014 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patient demographics, surgical variables, and reasons for readmissions within 30 days were recorded. Pearson chi square was used to compare rates of demographics and surgical variables between readmitted and nonreadmitted patients. Multivariate regression was used to identify risk factors for readmission. Results. Of 20,376 lumbar discectomies, 533 patients (2.62%) were readmitted within 30 days of surgery. The most common reasons for readmission were surgical site infections (n = 130, 0.64% of all discectomies, 24.4% of all readmissions), followed by pain issues (n = 89, 0.44%, 16.7%), and thromboembolic events (43, 0.21%, 8.1%). Overall time to readmission was 13.0 ± 8.0 days (mean ± standard deviation). Factors most associated with readmission after lumbar discectomy were higher American Society of Anesthesiologists class (relative risk = 1.49, P < 0.001) and prolonged operative time (relative risk = 1.41, P = 0.002). Conclusion. Surgical site infection, postoperative pain, and thromboembolic events were the most common reasons for readmission after lumbar discectomy. These findings identify potential areas for quality improvement initiatives. Level of Evidence: 3

The Use of Soft Tissue Expanders Prior to Total Ankle Arthroplasty.

Soft tissue coverage and tension-free closure can often be challenging in patients with ankle arthropathy being considered for total ankle arthroplasty. We present 2 patients with severe posttraumatic ankle arthropathy who underwent placement of a soft tissue expander to assist with soft tissue coverage prior to total ankle arthroplasty. Levels of Evidence: Level IV