Lakshmanan Sivasundaram

Preoperative risk factors for discharge to a postacute care facility after shoulder arthroplasty

BACKGROUND Shoulder arthroplasty procedures are becoming increasingly prevalent in the United States due to expanding indications and an aging population. Most patients are discharged home, but a subset of patients is discharged to a postacute care (PAC) facility. The purpose of this study was to identify the risk factors for discharge to a PAC facility after shoulder arthroplasty. METHODS The Nationwide Inpatient Sample discharge records from 2011 to 2012 were analyzed for patients who underwent a total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RTSA). Patient and hospital characteristics were identified. Univariate and multivariate analysis were used to determine the statistically significant risk factors for discharge to a PAC facility while controlling for covariates. RESULTS In 2011 and 2012, 103,798 patients underwent shoulder arthroplasty procedures: 58,937 TSAs and 44,893 RTSAs were identified. RTSA patients were 1.3 times as likely to be discharged to a PAC facility as TSA patients (P = .001). Medicare patients were 2 times as likely to be discharged to a PAC facility than those with private insurance (P < .001). In addition, women and patients presenting with a fracture, older age, or an increasing number of medical comorbidities were more likely to be discharged to a PAC facility (P < .001). CONCLUSION The risk factors identified in our study can be used to stratify patients at high risk for postoperative discharge to PAC, allowing for greater improvement in overall care and the facilitation of postoperative discharge planning.

Surgical Approach and Anesthetic Modality for Carpal Tunnel Release A Nationwide Database Study With Health Care Cost Implications

Background: Carpal tunnel release (CTR) is commonly performed for carpal tunnel syndrome once conservative treatment has failed. Operative technique and anesthetic modality vary by surgeon preference and patient factors. However, CTR practices and anesthetic trends have, to date, not been described on a nationwide scale in the United States. Methods: The PearlDiver Patient Records Database was used to search Current Procedural Terminology codes for elective CTR from 2007 to 2011. Anesthetic modality (eg, general and regional anesthesia vs local anesthesia) and surgical approach (eg, endoscopic vs open) were recorded for this patient population. Cost analysis, patient demographics, regional variation, and annual changes in CTR surgery were evaluated. Results: We identified 86 687 patients who underwent carpal tunnel surgery during this 5-year time period. In this patient sample, 80.5% of CTR procedures were performed using general or regional anesthesia, compared with 19.5% of procedures performed using local anesthesia; 83.9% of all CTR were performed in an open fashion, and 16.1% were performed using an endoscopic technique. Endoscopic surgery was on average

Effect of Insurance on Rates of Total Ankle Arthroplasty Versus Arthrodesis for Tibiotalar Osteoarthritis

794 more expensive than open surgery, and general or regional anesthesia was

Utility of Postoperative Imaging in Radial Shaft Fractures.

654 more costly than local anesthesia. Conclusions: In the United States, open CTR under local anesthesia is the most cost-effective way to perform a CTR. However, only a small fraction of elective CTR procedures are performed with this technique, representing a potential area for significant health care cost savings. In addition, regional and age variations exist in procedure and anesthetic type utilized.

Predictive Factors of Neurovascular and Tendon Injuries Following Dog Bites to the Upper Extremity

Background: Several studies have examined the effect of insurance on the management of various orthopedic conditions. The purpose of our study was to assess the effect of insurance and other demographic factors on the operative management of tibiotalar osteoarthritis. Methods: The National Inpatient Sample (NIS) database was used to identify patients who underwent a total ankle arthroplasty (TAA) or tibiotalar arthrodesis (TTA) for tibiotalar osteoarthritis. Insurance status was identified for each patient, and the proportions of each insurance type were computed for each operative modality. A multivariate analysis was performed to account for confounding variables to isolate the effect of insurance type on operative treatment. Results: From 2007 to 2012, a total of 10 010 patients (35.6%) were identified who underwent a total ankle replacement (TAR) procedure and 18 094 patients (64.4%%) who underwent TTA for tibiotalar osteoarthritis. Patients receiving a TAR were older (65.8 vs 64.2, P < .001), more likely to be female (54% vs 51%, P < .001), and had fewer comorbidities (4.2 vs 4.5, P < .001) than patients who underwent a TTA. After controlling for baseline differences, patients with Medicare (odds ratio [OR] 3.00, P < .001), and private insurance (OR 3.19, P < .001) were approximately 3 times more likely to undergo TAR than patients with Medicaid. Conclusions: Patients with tibiotalar osteoarthritis were more likely to receive a TAR procedure if they had Medicare or private insurance compared with patients who had Medicaid. Further research should be done to better understand the drivers of this phenomenon if equitable care is to be achieved. Level of Evidence: Level II, prognostic study.

Diffusion restriction in a non-enhancing metastatic brain tumor treated with bevacizumab — recurrent tumor or atypical necrosis? ☆ ☆☆

Background: Postoperatively, radial shaft fractures are often followed clinically with serial radiographs to assess for fracture healing. Currently, there is no standard of care regarding postoperative imaging for these injuries. The purpose of this study is to determine whether imaging influences management decisions. Methods: Patients who presented to a level I trauma center between 2009 and 2014 with an operatively treated radial shaft fracture were retrospectively screened for inclusion in our study. Patients with ipsilateral ulna or radius fractures, or with inadequate imaging or inadequate follow-up, were excluded. Four blinded, board-certified, orthopedic surgeons reviewed the postoperative films twice for each patient and stated whether the imaging would influence management decisions. Images were separated into 3 groups based on time from surgery: 0 to 4 weeks, 4 to 8 weeks, and greater than 8 weeks. The number of times imaging influenced these hypothetical management decisions was recorded. Interobserver and intraobserver agreements were calculated using Fleiss’s and Cohen’s kappa coefficients, respectively. Results: One hundred eighteen patients underwent operative fixation for an isolated radial shaft fracture, of whom 38 met inclusion criteria. Imaging from 0 to 4 weeks, 4 to 8 weeks, and greater than 8 weeks postoperatively resulted in a change of management in 0%, 32%, and 16% of patients, respectively. After 4 weeks, changes were primarily for immobilization and activity-level modification. Intraobserver and interobserver agreement kappa coefficients were 0.761 and 0.563, respectively. Conclusions: Films obtained within 4 weeks of surgery for radial shaft fractures are unlikely to change postoperative management and may not be warranted during routine postoperative follow-up.

Functional Outcomes of Type V Acromioclavicular Injuries With Nonsurgical Treatment.

Background: Dog bite injuries to the upper extremity can result in traumatic neurovascular and musculotendinous damage. Currently, there are no clear guidelines dictating which patients may benefit from early operative exploration. The purpose of this study was to identify clinical variables that were predictive of abnormal intraoperative findings in patients who sustained an upper extremity dog bite injury. Methods: All patients who presented to a level I trauma center between 2007 and 2015 with an upper extremity dog bite injury who underwent subsequent surgical exploration were retrospectively screened for inclusion in our study. Patients with inadequate documentation or preexisting neurovascular or motor deficits were excluded. Abnormalities on physical exam and injuries encountered during surgical exploration were recorded for each patient. Contingency tables were constructed comparing normal and abnormal nerve, tendon, and vascular physical exam findings with intact or disrupted neurovascular and musculotendinous structures identified during surgical exploration. Results: Between 2007 and 2014, 117 patients sustained a dog bite injury to the upper extremity, of which 39 underwent subsequent surgical exploration and were included in our analysis. Sixty-nine percent of patients with neuropraxia on exam had intraoperative nerve damage. Seventy-seven percent of patients with an abnormal tendon exam had intraoperative musculotendinous damage. One hundred percent of patients with an abnormal vascular physical exam had intraoperative arterial injury. Conclusions: To date, there are no clear guidelines on what clinical criteria indicate the need for operative exploration and possible repair of neurovascular structures in upper extremity dog bite injuries. In our study, nerve, tendon, and vascular abnormalities noted on physical exam were strongly predictive of discovering neurovascular and musculotendinous damage during surgical exploration.

Database studies: an increasing trend in the United States orthopaedic literature

A 38-year-old female with metastatic brain cancer developed non-enhancing, diffusion restricted lesions following bevacizumab treatment. From our review of the literature, this is the first reported case of this type of lesion. Clinicians should be wary of these lesions, as they can represent either tumor progression or necrosis/effects of chronic hypoxia from anti-angiogenic therapy. Further investigation is necessary to determine the biological mechanism and clinical significance of this type of imaging appearance.

Partial semitendinosus tendon tear in a young athlete: a case report and review of the distal semitendinosus anatomy

Introduction: This study investigated nonsurgical management of type V acromioclavicular (AC) injuries to determine functional outcomes and to attempt to identify factors associated with positive results.Methods: In a retrospective chart review, patients with radiographic and clinical evidence of type V AC injuries per the Rockwood classification were included in the study. Patients treated nonsurgically for ≥6 months were considered eligible for analysis. Functional outcomes were assessed using Disabilities of the Arm, Shoulder, and Hand (DASH) and American Shoulder and Elbow Surgeons (ASES) scores.Results: Twenty-two patients with a mean age of 42.2 ± 12.8 years were included in the study. The average coracoclavicular distance at the time of presentation was 26.3 mm (+199%). Mean DASH and ASES scores were 27.8 ± 17.7 and 62.8 ± 17.1, respectively, at an average of 34 months from the time of injury. Patients with normal DASH (⩽10) and ASES (>92) scores were younger than those with abnormal scores. At final assessment, 77% of the patients were currently working, with nine patients performing manual labor.Conclusion: Following nonsurgical management of type V AC injuries, most patients are able to return to work but have limited functional outcome scores. A small subset of patients with type V AC injuries can achieve normal functional outcomes with nonsurgical management.Level of Evidence: Level IV, Case Series

Predicting adverse events, length of stay, and discharge disposition following shoulder arthroplasty: a comparison of the Elixhauser Comorbidity Measure and Charlson Comorbidity Index

Background:There has been a recent increase in the number of orthopaedic publications using large-scale databases. The purpose of this study was to examine current database publication trends in the United States orthopaedic literature. In addition, we briefly discuss the strengths and limitations of the most utilized databases. Methods:PubMed was queried, and all abstracts and text were screened by two authors to insure that they reported on an orthopaedic topic using database findings. Studies from international databases, single-center databases, specialty-specific registries, and review articles were excluded. Annual and subspecialty trends were analyzed using Spearman correlation. Significance was set at P<0.05. Results:Our initial search yielded 1080 articles, of which 306 met inclusion criteria. There was a significant increase in the number of database studies published from 2004 to 2014, and an almost two-fold increase in the number of published studies from 2013 to 2014. The Journal of Bone and Joint Surgery, Spine (Phila Pa 1976), and Clinical Orthopaedics and Related Research had the most database publications over the period examined. Spine, joints, and sports subspecialties published the most database studies. Conclusions:There has been a large increase in the number of database studies published in United States orthopaedic literature, with the most dramatic increase observed between 2013 and 2014. Understanding the general strengths and limitations of these databases, as well as the differences between the various types of databases, is essential to fully understand this medium of orthopaedic research.