Christopher J. Dy

Complications After Flexor Tendon Repair: A Systematic Review and Meta-Analysis

PURPOSE Although outcomes after flexor tendon repair have reportedly improved with modern treatment, complications are common. The purpose of this study was to determine the incidence of these complications and the potential contributory factors within the published literature. METHODS We performed a systematic review of the available literature to identify publications in which patients with flexor tendon ruptures were surgically treated. We extracted demographics, zone of injury, core suture technique (only modified Kessler or a combination of techniques), use of epitendinous suture, and date of publication (before or after January 1, 2000). We excluded articles if they did not report information on reoperation, rupture, or adhesions. We used unadjusted pooled meta-analysis to report the incidence of complications, and meta-regression to describe the potential contributory factors for each complication while controlling for age, gender, and zone of injury. RESULTS Unadjusted meta-analysis revealed rates of re-operation of 6%, rupture of 4%, and adhesions of 4%. Meta-regression analysis of 29 studies showed that core suture technique or use of an epitendinous suture does not influence rupture. However, the presence of an epitendinous suture decreases re-operation by 84%. Adhesion development is 57% lower when the modified Kessler technique is used. The incidence of complications did not vary with publication date. CONCLUSIONS The published literature supports use of the modified Kessler repair technique with an epitendinous suture to minimize complications. Although complication rates are low, our data suggest that there has been no definitive improvement in reported complications before and after 2000.

An Economic Evaluation of a Systems-Based Strategy to Expedite Surgical Treatment of Hip Fractures

BACKGROUND A recent systematic review has indicated that mortality within the first year after hip fracture repair increases significantly if the time from hospital admission to surgery exceeds forty-eight hours. Further investigation has shown that avoidable, systems-based factors contribute substantially to delay in surgery. In this study, an economic evaluation was conducted to determine the cost-effectiveness of a hypothetical scenario in which resources are allocated to expedite surgery so that it is performed within forty-eight hours after admission. METHODS We created a decision tree to tabulate incremental cost and quality-adjusted life years in order to evaluate the cost-effectiveness of two potential strategies. Several factors, including personnel cost, patient volume, percentage of patients receiving surgical treatment within forty-eight hours, and mortality associated with delayed surgery, were considered. One strategy focused solely on expediting preoperative evaluation by employing personnel to conduct the necessary diagnostic tests and a hospitalist physician to conduct the medical evaluation outside of regular hours. The second strategy added an on-call team (nurse, surgical technologist, and anesthesiologist) to staff an operating room outside of regular hours. RESULTS The evaluation-focused strategy was cost-effective, with an incremental cost-effectiveness ratio of

Risk Factors for Revision Within 10 Years of Total Knee Arthroplasty

2318 per quality-adjusted life year, and became cost-saving (a dominant therapeutic approach) if =93% of patients underwent expedited surgery, the hourly cost of retaining a diagnostic technologist on call was <

In-Hospital Patient Falls After Total Joint Arthroplasty Incidence, Demographics, and Risk Factors in the United States

20.80, or <15% of the hospitalists salary was funded by the strategy. The second strategy, which added an on-call surgical team, was also cost-effective, with an incremental cost-effectiveness ratio of

The medical orthopaedic trauma service: an innovative multidisciplinary team model that decreases in-hospital complications in patients with hip fractures.

43,153 per quality-adjusted life year. Sensitivity analysis revealed that this strategy remained cost-effective if the odds ratio of one-year mortality associated with delayed surgery was >1.28, =88% of patients underwent early surgery, or =339.9 patients with a hip fracture were treated annually. CONCLUSIONS The results of our study suggest that systems-based solutions to minimize operative delay, such as a dedicated on-call support team, can be cost-effective. Additionally, an evaluation-focused intervention can be cost-saving, depending on its success rate and associated personnel cost.

Internet search term affects the quality and accuracy of online information about developmental hip dysplasia.

BackgroundAn in-depth understanding of risk factors for revision TKA is needed to minimize the burden of revision surgery. Previous studies indicate that hospital and community characteristics may influence outcomes after TKA, but a detailed investigation in a diverse population is warranted to identify opportunities for quality improvement.Questions/purposesWe asked: (1) What is the frequency of revision TKA within 10 years of primary arthroplasty? (2) Which patient demographic factors are associated with revision within 10 years of TKA? (3) Which community and institutional characteristics are associated with revision within 10 years of TKA?MethodsWe identified 301,955 patients who underwent primary TKAs in New York or California from 1997 to 2005 from statewide databases. Identifier codes were used to determine whether they underwent revision TKA. Patient, community, and hospital characteristics were analyzed using multivariable regression modeling to determine predictors for revision.ResultsThe frequency of revision was 4.0% at 5 years after the index arthroplasty and 8.9% at 9-years. Patients between 50 and 75 years old had a lower risk of revision than patients younger than 50 years (hazard ratio [HR], 0.47; 95% CI, 0.44, 0.50). Black patients were at increased risk for needing revision surgery (HR, 1.39; 95% CI, 1.29, 1.49) after adjustment for insurance type, poverty level, and education. Women (HR, 0.82; 95% CI, 0.79, 0.86) and Medicare recipients (HR, 0.82; 95% CI, 0.79, 0.86) were less likely to undergo revision surgery, whereas those from the most educated (HR, 1.09; 95% CI, 1.02, 1.16) and the poorest communities (HR, 1.08; 95% CI, 1.01, 1.15) had modest increases in risk of revision. Mid-volume hospitals (200–400 annual cases) had a reduction of early revision (HR, 0.91; 95% CI, 0.83, 0.99) compared with those performing less than 200 cases annually, whereas higher-volume hospitals (greater than 400 cases) showed little effect compared with low-volume hospitals.ConclusionsPatient, community, and institutional characteristics affect the risk for revision within 10 years of index TKA. These data can be used to develop process improvement and implant surveillance strategies among high-risk patients.Level of EvidenceLevel III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Long term safety, efficacy, and patient acceptability of hyaluronic acid injection in patients with painful osteoarthritis of the knee.

In-hospital falls (IFs) increase morbidity, cost, and may result in litigation. We analyzed the Nationwide Inpatient Sample to quantify the incidence of IFs in patients who underwent hip and knee arthroplasty and to define trends, patients demographics, risk factors, complications, and hospital cost. Patients operated on between 1998 and 2007 were identified and grouped depending on the presence of a diagnosis of IF. Of those, 0.85% had an IF, representing 2.1 falls per 1000 inpatient days. The incidence of IF increased from 0.4% to 1.3% during the study period. Independent risk factors included revision surgery, advanced age, male sex, minority race, and the presence of comorbidities. Patients having IF had a longer hospital stay and were less likely to be discharged to their primary residence. In-hospital mortality, complications, and cost were higher in patients sustaining IF. Given the associated morbidity, mortality, and increased cost, resources should be allocated to minimize the risk of IF in this population.

Does the Quality, Accuracy, and Readability of Information about Lateral Epicondylitis on the Internet Vary with the Search Term Used?

Objectives: The purpose of the study is to evaluate the influence of a multidisciplinary model of care on the incidence of postoperative complications after a hip fracture. Design: Retrospective cohort series. Setting: Level I trauma center. Patients/Participants: Three hundred six patients with pertrochanteric femur fracture (OTA classification: 31-B1, 31-B2, 31-B3, 31-A1, 31-A2, 31-B3, 32-A1, and 32-A2). Intervention: A multidisciplinary, collaborative model of perioperative care: the Medical Orthopaedic Trauma Service (MOTS). Main Outcome Measures: Incidence of in-patient complications, length of in-patient hospitalization, readmission rate after hospital discharge, and postdischarge mortality at 90 days and 1 year. Results: Although there was no change in length of hospitalization, there was a significantly decreased overall incidence of in-patient complications and a decreased incidences of new-onset urinary tract infection and arrhythmias in the MOTS cohort. These differences persisted after controlling for age, comorbidity, gender, ethnicity, type of fracture, and number of days from admission to surgery with a logistic regression model. Subgroup analysis of patients with an American Society of Anesthesiologists physical status classification of 1 or 2 revealed a significantly decreased 90 day readmission rate with the MOTS model, but this did not persist in a regression model (P = 0.07). Conclusions: A multidisciplinary, collaborative model of care for patients with hip fractures decreases the incidence of postoperative in-patient complications and may influence hospital readmission rates. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk factors for early revision after total hip arthroplasty.

Background: The recent emphasis on shared decision-making has increased the role of the Internet as a readily accessible medical reference source for patients and families. However, the lack of professional review creates concern over the quality, accuracy, and readability of medical information available to patients on the Internet. Methods: Three Internet search engines (Google, Yahoo, and Bing) were evaluated prospectively using 3 difference search terms of varying sophistication (“congenital hip dislocation,” “developmental dysplasia of the hip,” and “hip dysplasia in children”). Sixty-three unique Web sites were evaluated by each of 3 surgeons (2 fellowship-trained pediatric orthopaedic attendings and 1 orthopaedic chief resident) for quality and accuracy using a set of scoring criteria based on the AAOS/POSNA patient education Web site. The readability (literacy grade level) of each Web site was assessed using the Fleisch-Kincaid score. Results: There were significant differences noted in quality, accuracy, and readability of information depending on the search term used. The search term “developmental dysplasia of the hip” provided higher quality and accuracy compared with the search term “congenital hip dislocation.” Of the 63 total Web sites, 1 (1.6%) was below the sixth grade reading level recommended by the NIH for health education materials and 8 (12.7%) Web sites were below the average American reading level (eighth grade). Conclusions: The quality and accuracy of information available on the Internet regarding developmental hip dysplasia significantly varied with the search term used. Patients seeking information about DDH on the Internet may not understand the materials found because nearly all of the Web sites are written at a level above that recommended for publically distributed health information. Clinical Relevance: Physicians should advise their patients to search for information using the term “developmental dysplasia of the hip” or, better yet, should refer patients to Web sites that they have personally reviewed for content and clarity. Orthopaedic surgeons, professional societies, and search engines should undertake efforts to ensure that patients have access to information about DDH that is both accurate and easily understandable.

Meta-analysis of re-operation, nonunion, and infection after open reduction and internal fixation of patella fractures.

The increasing prevalence of painful knee osteoarthritis has created an additional demand for pharmacologic management to prevent or delay surgical management. Viscosupplementation, via intraarticular injection of hyaluronic acid (HA), aims to restore the favorable milieu present in the nonarthritic joint. The safety profile of intraarticular HA injections for painful knee osteoarthritis is well established, with the most common adverse effect being a self-limited reaction at the injection site. Although acceptance of the early literature has been limited by publication bias and poor study quality, more recent and rigorous meta-analysis suggests that intraarticular HA injection is superior to placebo injection for pain relief and matches, if not surpasses, the effect size of other nonoperative treatments, such as nonsteroidal anti-inflammatory medication. Intraarticular HA injection is effective in providing temporary pain relief in patients with painful knee osteoarthritis. Future investigations should focus on optimizing the composition and administration of HA agents to provide prolonged relief of painful osteoarthritis in the knee and other joints.