Andrew R. Tyser

Association Between Orthopaedic Outpatient Satisfaction and Non-Modifiable Patient Factors.

BACKGROUND Increasingly, patient satisfaction surveys are being utilized to evaluate hospital and physician performance. Despite this, little is known about factors associated with patient satisfaction. The objective of this study was to determine whether selected non-modifiable patient characteristics are associated with outpatient satisfaction scores. METHODS We reviewed patient satisfaction scores from 12,177 outpatient clinical encounters at an academic orthopaedic outpatient clinic between December 2010 and October 2013. Any adult patient who completed at least one patient satisfaction survey at any point during the study period was included in this study. Factors including age, sex, employment status, type of health insurance, zip code, and orthopaedic subspecialty were recorded. Patients were divided into more satisfied and less satisfied groups, and generalized estimating equation logistic regression analysis was performed to identify factors predictive of lower patient satisfaction. RESULTS Age was found to be strongly associated with patient satisfaction, with younger patients reporting less satisfaction; the adjusted odds ratio for the patient age of eighteen to twenty-nine years compared with the patient age of eighty years or older was 2.78 (95% confidence interval, 1.74 to 3.82) (p < 0.001). This relationship was maintained in a predictive model across all age groups, both sexes, all travel distances, and all orthopaedic subspecialties. Travel distance was also associated with patient satisfaction, with patients who live closer reporting less satisfaction compared with patients who live farther away; the adjusted odds ratio for a distance of less than fifty miles compared with a distance of fifty miles or more was 1.18 (95% confidence interval, 1.03 to 1.33) (p = 0.016). CONCLUSIONS The finding that non-modifiable patient factors such as age and geographic location affect patient satisfaction challenges the utility of comparing patient satisfaction between populations that differ significantly with regard to such characteristics. CLINICAL RELEVANCE A more complete knowledge of the factors that influence patient satisfaction may enable better insight into the interpretation of current patient satisfaction metrics and may allow physicians and hospitals to improve their delivery of care.

Examination of the PROMIS upper extremity item bank

STUDY DESIGN Clinical measurement. INTRODUCTION The psychometric properties of the PROMIS v1.2 UE item bank were tested on various samples prior to its release, but have not been fully evaluated among the orthopaedic population. PURPOSE OF THE STUDY This study assesses the performance of the UE item bank within the UE orthopaedic patient population. METHODS The UE item bank was administered to 1197 adult patients presenting to a tertiary orthopaedic clinic specializing in hand and UE conditions and was examined using traditional statistics and Rasch analysis. RESULTS The UE item bank fits a unidimensional model (outfit MNSQ range from 0.64 to 1.70) and has adequate reliabilities (person = 0.84; item = 0.82) and local independence (item residual correlations range from -0.37 to 0.34). Only one item exhibits gender differential item functioning. Most items target low levels of function. DISCUSSION The UE item bank is a useful clinical assessment tool. Additional items covering higher functions are needed to enhance validity. CONCLUSIONS Supplemental testing is recommended for patients at higher levels of function until more high function UE items are developed. LEVEL OF EVIDENCE 2c.

Psychometric properties of the Press Ganey® Outpatient Medical Practice Survey

BackgroundThe Press Ganey® Medical Practice Survey (“Press Ganey® survey”) is a patient-reported questionnaire commonly used to measure patient satisfaction with outpatient health care in the United States. Our objective was to evaluate the reliability and validity of the Press Ganey® survey in a single institution setting.MethodsWe analyzed surveys from 34,503 unique respondents seen by 624 providers from 47 specialties and 94 clinics at the University of Utah in 2013. The University of Utah is a health care system that provides primary through tertiary care for over 200 medical specialties. Surveys were administered online. The Press Ganey® survey consisted of 24 items organized into 6 scales: Access (4 items), Moving Through the Visit (2), Nurse Assistant (2), Care Provider (10), Personal Issues (4) and Overall Assessment (2). Missingness, ceiling and floor rates were summarized. Cronbach’s alpha was used to evaluate internal consistency reliability. Confirmatory factor analysis was used to assess convergent and discriminant validities.ResultsMissingness ranged from 0.8-11.4% across items. The ceiling rate was high at 29.3% for the total score, and ranged from 55.4 to 84.1% across items. Floor rates were 0.01% for the total score, and ranged from 0.1 to 2.1% across items. Internal consistency reliability ranged from 0.79 to 0.96, and item-scale correlations ranged from 0.49 to 0.9. Confirmatory factor analysis supported convergent and discriminant validities.ConclusionThe Press Ganey® survey demonstrated suitable psychometric properties for most metrics. However, the high ceiling rate can have a notable impact on quarterly percentile scores within our institution. Multi-institutional studies of the Press Ganey® survey are needed to inform administrative decision making and institution reimbursement decisions based on this survey.

A Scaphoid Stress Fracture in a Female Collegiate-Level Shot-Putter and Review of the Literature

Scaphoid stress fractures are rare injuries that have been described in young, high-level athletes who exhibit repetitive loading with the wrist in extension. We present a case of an occult scaphoid stress fracture in a 22-year-old female Division I collegiate shot-putter. She was successfully treated with immobilization in a thumb spica splint for 6 weeks. Loaded wrist extension activities can predispose certain high-level athletes to sustain scaphoid stress fractures, and a high index of suspicion in this patient population may aid prompt diagnosis and management of this rare injury.

The effect of aging on posterior intertransverse lumbar fusion: A New Zealand white rabbit model

Study Design: In vivo assessment of lumbar spinal fusion between a younger and older cohort of New Zealand white rabbits. Objective: Directly compare fusion within young and aged New Zealand white rabbits to establish an aged spinal fusion model translational research. Summary of Background Data: Prior studies have utilized skeletally mature young rabbits (6–12 mo old) that may not be appropriate as an analog for studying the aging human spine. Methods: Ten aged (>36 mo old) and 10 young (12 mo old) New Zealand white rabbits underwent a single-level, bilateral, L5–6 posterolateral intertransverse fusion using autogenous iliac crest bone graft. The animals were killed at 6 weeks postoperatively, and the specimens were then evaluated with quantitative microcomputerized tomography and manual palpation by 6 orthopedic surgeons. The fusions were graded as either fused or not fused by each examiner. The spines were then embedded in poly(methyl methacrylate) and cut into 2-mm-thick sections for histologic analysis. Results: A higher percentage of young rabbits were determined to be successfully fused through manual palpation testing compared with the aged rabbits. Micro-computed tomography (CT) analysis revealed a significantly greater fusion mass volume in the younger rabbits than in the older cohort. In addition, the fusion density of the younger rabbits was found to be significantly lower than that of the older rabbits when normalized to the bone density in the nonfused portion of the spine. Histologic analysis showed that the quality of the bone within the fusion mass was consistent between the young and old rabbits. A greater number of young animals had bilateral continuous bone graft compared with the aged animals. Conclusions: The aged (>36 mo) New Zealand white rabbit model appears to be a valid model to evaluate the effect of aging on lumbar fusion and has the potential to more accurately model conditions that are present in the older human spine.

Stiffness of Occipital-Cervical Constructs: Beam Theory

OBJECTIVE The purpose of this study is to show that stiffness of an occipital-cervical construct can be predicted based on rod geometry and material. MATERIALS AND METHODS Various rod-plate implants were tested as previously reported biomechanical studies of occipital-cervical fixation with the exception that no spine was used. A testing frame that holds paired contoured rods and plates to the same position as in the biomechanical testing protocol for occipital-cervical fixation was tested in the flexion-extension direction on a servo-hydraulic testing machine. Stiffness was determined from the plots of applied moment versus angular displacement. The occipital-cervical constructs were then modeled as a curved beam in pure bending in the sagittal plane to calculate the moment of inertia and theoretical stiffness. The Pearson correlation coefficient was used to assess the correlation of the experimental to the theoretical calculated stiffness. Product of inertia and material stiffness were determined for implants from previously published studies and the predicted rank order of this product was compared with the rank order of the observed biomechanical results in each study. RESULTS A strong correlation was observed between the experimental and theoretical stiffness (R2 = 0.85). A strong influence of the inertia was also found on the experimental construct stiffness (R2 = 0.77). In five of six previously published studies, the best experimental performance was predicted using simple mechanical calculations. CONCLUSION This study shows that both the theoretical stiffness and the calculated area moment of inertia are strongly correlated with the experimental stiffness of tested occipital-cervical fixation constructs.

Diagnostic Evaluation of Upper Extremity Masses and Tumors

The appropriate evaluation of hand and upper extremity masses is an important aspect of the care of orthopedic patients. Although most of these masses are benign, the orthopedic surgeon must have a high index of suspicion when assessing them because early diagnosis and treatment of aggressive or malignant masses may have a great effect on patient outcomes. This article provides an overview of benign and malignant osseous and soft tissue masses that orthopedic surgeons may encounter and a detailed algorithm for evaluating these masses. [Orthopedics. 2017; 40(5):e758-e764.].

Long-Term Outcome and Secondary Operations after Proximal Row Carpectomy or Four-Corner Arthrodesis

Abstract Background Proximal row carpectomy (PRC) and four‐corner arthrodesis (FCA) are common surgical procedures used to treat degenerative wrist conditions; however, complications and failures can occur. Purpose This study aimed to investigate and compare the long‐term rate of secondary surgeries including conversion to total wrist arthrodesis in patients who underwent PRC or FCA. Materials and Methods A retrospective chart review of all patients who underwent PRC or FCA in the past 20 years at a tertiary referral institution and associated Veterans Affairs (VA) hospital was performed. Patient demographics, comorbidities, surgical indications, and associated complications were tabulated. Patients were contacted via phone to obtain additional follow‐up information regarding any additional surgeries, 10‐point visual analog scale (VAS) for pain, quick Disabilities of the Arm, Shoulder, and Hand (quickDASH) scores, hand dominance, and occupational data. Results A total of 123 wrists made up the final dataset. Sixty‐two wrists treated with PRC and 61 wrists treated with FCA were reviewed at a mean follow‐up of 8.2 years. We did not find a significant difference in the rate of conversion to total wrist arthrodesis between the PRC (14.5%) and FCA (19.5%, p = 0.51) cohorts. Secondary operations were significantly greater in the FCA group (34.4%) compared with the PRC group (16.1%, p = 0.02). Females were 2.6 times more likely than males to undergo secondary operations when controlling for surgical procedure and smoking status (p = 0.04). We did not detect a significant difference in VAS pain or in quickDASH scores between the two groups (p = 0.35, 0.48, respectively). Conclusion PRC and FCA have comparable patient reported outcomes and wrist arthrodesis conversion rates at a mean follow‐up of 8.2 years. In contrast, the FCA patient group had a significantly higher rate of secondary operations, including those for nonunion, symptomatic hardware, and other implant‐related issues, when combined with wrist arthrodesis conversion. Level of Evidence Level IV, therapeutic study.

Unusual presentation of aneurysmal subarachnoid haemorrhage

Abstract The classic presentation of aneurysmal subarachnoid haemorrhage is sudden severe headache, associated with decreased level of consciousness. The authors present a most dramatic presentation of aneurysmal subarachnoid haemorrhage.

Mycobacterium avium complex olecranon bursitis resolves without antimicrobials or surgical intervention: A case report and review of the literature

Introduction Nontuberculous mycobacteria are an uncommon cause of septic olecranon bursitis, though cases have increasingly been described in both immunocompromised and immunocompetent hosts. Guidelines recommend a combination of surgical resection and antimicrobials for treatment. This case is the first reported case of nontuberculous mycobacterial olecranon bursitis that resolved without medical or surgical intervention. Case presentation A 67-year-old female developed a painless, fluctuant swelling of the olecranon bursa following blunt trauma to the elbow. Due to persistent bursal swelling, she underwent three separate therapeutic bursal aspirations, two involving intrabursal steroid injection. After the third aspiration, the bursa became erythematous and severely swollen, and bursal fluid grew Mycobacterium avium complex. Triple-drug antimycobacterial therapy was initiated, but discontinued abruptly due to a rash. Surgery was not performed. The patient was observed off antimicrobials, and gradually clinically improved with a compressive dressing. By 14 months after initial presentation, clinical exam revealed complete resolution of the previously erythematous bursal mass. Discussion This is the first reported case of nontuberculous mycobacterial olecranon bursitis managed successfully without surgery or antimicrobials. Musculoskeletal nontuberculous mycobacterial infections are challenging given the lack of clinical data about optimal duration and choice of antimicrobials or the role of surgery. Additionally, the potential toxicity and drug interactions of antimycobacterials are not insignificant and warrant close monitoring if treatment is pursued. Conclusion This case raises an important clinical question of whether close observation off antimicrobials is appropriate in select cases of immunocompetent patients with localized atypical mycobacterial disease of soft tissue and skeletal structures.