Louis C. Grandizio

Levels of evidence have increased for musculoskeletal trauma questions on the orthopaedic in-training examination.

OBJECTIVE The purpose of this study was to determine if the levels of evidence for primary journal articles used as references for musculoskeletal trauma questions on the Orthopaedic In-Training Examination (OITE) have increased over a 15-year period. DESIGN Basic science article. SETTING Geisinger Medical Center (Danville, PA), tertiary referral center. PARTICIPANTS All 329 questions in the musculoskeletal trauma content domain on the OITE from 1995 to 1997 and 2010 to 2012 were reviewed. Baseline characteristics for each question and each reference were recorded. References were categorized as a textbook, a journal review article, an instructional course lecture, or a primary journal article. For each primary journal article, the level of evidence for the article was determined in accordance with the American Academy of Orthopaedic Surgeons Levels of Evidence Guidelines. RESULTS The level of evidence used for primary journal articles demonstrated a statistically significant increase from 1995 to 1997 to 2010 to 2012. Overall, 27% of primary journal articles cited on the 1995 to 1997 OITEs were level I, II, or III studies, increasing to 43% during the 2010 to 2012 period (p = 0.04). The Buckwalter classification for the OITE questions changed significantly between the 2 periods, with questions from 2010 to 2012 including more T1 questions (25% vs 39%) and fewer T3 questions (46% vs 39%, p = 0.016). The Journal of Bone and Joint Surgery and the Journal of Orthopaedic Trauma were the most frequently cited journals overall. CONCLUSIONS The levels of evidence for primary journal articles cited on the OITE for questions within the musculoskeletal trauma content domain have increased between 1995 and 2012. Our analysis can be used as a guide to help examinees prepare for musculoskeletal trauma questions on the OITE and as an aid in core curriculum development.

Distal biceps brachii tendon rupture resulting in acute compartment syndrome.

Distal biceps brachii tendon rupture is an uncommon injury. Compartment syndrome of the upper arm is rarely described in the literature. The diagnosis of upper arm compartment syndrome requires a high index of suspicion, and emergent surgical treatment with fasciotomy in the acute setting is necessary to avoid devastating neurovascular complications. This article reports a case of acute compartment syndrome of the anterior compartment of the upper arm after a complete rupture of the distal biceps brachii tendon. A healthy 45-year-old man presented with increasing arm pain; paresthesia in the lateral antebrachial cutaneous nerve distribution; and a tense, swollen anterior compartment of his upper arm. Side port catheter absolute pressure measurement was 83 mm Hg with a diastolic blood pressure of 92 mm Hg. The patient underwent an emergent fasciotomy and was found to have a complete rupture of his distal biceps brachii tendon. He subsequently underwent distal biceps tendon repair and delayed primary closure of his incision. Postoperatively, his paresthesia improved and he has no neurological deficit. There is a paucity of case reports describing compartment syndrome after rupture of either the proximal or distal end of the biceps brachii tendon, and none of the reports describe compartment syndrome of the upper arm after rupture of the distal biceps tendon. This article highlights an unusual complication of an uncommon injury and reviews diagnostic and treatment principles for the management of acute compartment syndrome of the upper arm.

The Use of Residual Collagenase for Single Digits With Multiple-Joint Dupuytren Contractures

PURPOSE Standard 0.58 mg (0.25 mL) collagenase Clostridium histolyticum (CCH) preparations result in unused CCH that is often discarded. Our purpose was to assess the results on Dupuytren contractures affecting both the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints in the same digit utilizing an injection containing the maximum CCH volume that can be withdrawn from a single vial. METHODS A consecutive series of patients with MCP and PIP cords in the same digit received a single treatment with 2 injections totaling 0.30 mL distributed between the MCP and the PIP cords and underwent manipulation approximately 24 hours later. Reduction in contracture, clinical success, and complications were assessed 30 days after manipulation. RESULTS Thirty-one patients (34 digits) had a mean preinjection flexion contracture of 50° at the MCP joint and 53° at the PIP joint. Clinical success (reduction in joint contracture to 0°-5° of full extension 30-days postmanipulation) was noted in 65% of MCP cords and 38% of PIP joint cords. We had a 24% incidence of skin tears, which correlated with the degree of preinjection contracture. CONCLUSIONS For Dupuytren contractures involving the MCP and PIP joints in the same digit, distributing the maximum amount of CCH that can be withdrawn from a single vial provides efficacy at both joints that is similar to that reported in previously published series, with a comparable complication rate. Utilizing excess CCH typically discarded may provide cost savings. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Sagittal band, boutonniere, and pulley injuries in the athlete

Purpose of reviewWhile hand injuries occur frequently in the athletic population, sagittal band ruptures, boutonniere deformities, and pulley ruptures are infrequently encountered. These injuries represent diagnostic challenges and can result in significant impairment. Early recognition with appropriate treatment is necessary to maximize recovery and minimize return to athletic competition. This review will focus on the underlying mechanism, pathophysiology of injury, diagnosis, and treatment of each of these injuries.Recent findingsWith respect to sagittal band ruptures, boutonniere deformities, and pulley ruptures, the recent literature has been limited in scope. For sagittal band injuries, current efforts have focused on alternative techniques for sagittal band reconstruction. Little progress has been made in recent years with respect to boutonniere injuries in the athletic population; prevention of fixed deformities remains the backbone of treatment. The exact contribution from individual and combined pulley injuries in the creation of bowstringing remains controversial. Recent anatomical studies have failed to definitively answer the question of what degree of rupture is necessary to create symptomatic bowstringing. Favorable outcomes, with respect to both preventing bowstringing and returning to full athletic participation, have been newly reported following pulley reconstruction in rock climbers.SummaryDue to the infrequent nature of sagittal band ruptures, boutonniere deformities, and pulley ruptures, current treatment is mostly guided by historically established methods, limited case series, and case reports. Nonsurgical treatment remains the mainstay for most injuries and, if employed early, often precludes the need for surgery. Further anatomical and clinical research, including outcome studies, is necessary in guiding treatment algorithms.

Analysis of Orthopedic Resident Ability to Apply Levels of Evidence Criteria to Scientific Articles

OBJECTIVE In the era of evidence-based medicine, understanding study design and levels of evidence (LoE) criteria is an important component of resident education and aids practicing surgeons in making informed clinical decisions. The purpose of this study is to analyze the ability of orthopedic residents to accurately determine LoE criteria for published articles compared with medical students. DESIGN Basic science article. SETTING Geisinger Medical Center (Danville, PA), tertiary referral center. PARTICIPANTS Overall, 25 U.S. orthopedic residents and 15 4th year medical students interviewing for a residency position in orthopedic surgery voluntarily participated and provided baseline demographic information. A total of 15 articles from the American Volume of Journal of Bone and Joint Surgery were identified. Study participants were provided with the article title, the abstract, and the complete methods section. The assigned LoE designation was withheld and access to the LoE criteria used by Journal of Bone and Joint Surgery was provided. Each participant was assigned a study type and LoE designation for each article. RESULTS There were more correct responses regarding the article type (67%) than for LoE designation (39%). For LoE, the intraclass correlation coefficient was 0.30. The percentage of correct responses for article type and LoE increased with more years of training (p = 0.005 and p = 0.002). Although residents had a higher proportion of correct LoE responses overall than medical students, this difference did not reach statistical significance (42% vs. 35%, p = 0.07). CONCLUSIONS Although improvements in accurately determining both article type and LoE were seen among residents with increasing years of training, residents were unable to demonstrate a statistically significant improvement for determining LoE or article type when compared with medical students. Strategies to improve resident understanding of LoE guidelines need to be incorporated into orthopedic residencies, especially when considering the increased emphasis on evidence-based medicine.

Levels of Evidence for Foot and Ankle Questions on the Orthopaedic In-Training Examination: 15-Year Trends

BACKGROUND The foot and ankle (FA) content domain is a component of the orthopaedic in-training examination (OITE). Levels of evidence (LoE) have been infrequently studied on the OITE. The purpose of this study is to determine if LoE for primary journal articles referenced for FA questions increased over a 15-year period. We also aim to determine if reference characteristics and question taxonomy have changed during this period. METHODS All 132 questions and 261 references in the FA content domain from 1995 to 1997 and from 2010 to 2012 were included. We defined the characteristics of each reference and taxonomy of each question. Every primary journal article was assigned a LoE based on American Academy of Orthopaedic Surgeons (AAOS) guidelines. RESULTS Foot & Ankle International (FAI) was the most frequently cited journal. The change in the distribution of the Buckwalter classifications was statistically significant (p = 0.0286) with an increase in the number of clinical management questions. There were more level I studies on the 2010 to 2012 OITE (p = 0.0478) 6/54 (11%) of questions on the 2010 to 2012 OITE cited level I or II evidence compared with 3/78 (4%) on the 1995 to 1997 examinations (p = 0.1035). CONCLUSIONS There is a trend toward improved LoE for journal articles within the FA content domain on the OITE over a 15-year period, particularly when analyzing the increase in level I studies. FAI is the most frequently cited journal and questions increasingly test clinical management concepts. CLINICAL RELEVANCE Our results can be used to help improve resident self-study and suggest that reviewing recent FAI articles may aid OITE preparation. LEVEL OF EVIDENCE Basic Science.

Levels of Evidence for Hand Questions on the Orthopaedic In-Training Examination

Background: Although analyses of the Orthopaedic In-Training Examination (OITE) subspecialty content domains have been performed, few studies have analyzed the levels of evidence (LoEs) for journal articles used as references to create OITE questions. We present an analysis of reference characteristics and question taxonomy for the hand surgery content domain on the OITE. We aim to determine whether level of evidence (LoE) for hand surgery questions have increased over a 15-year period. Methods: All questions and references in the hand surgery content domain on the OITE from 1995-1997 and 2010-2012 were reviewed. The taxonomic classification was determined for each question. Publication characteristics were defined for each reference, and each primary journal article was assigned a LoE. Results: A total of 129 questions containing 222 references met inclusion criteria: 76 questions from 1995-1997 and 53 from 2010-2012. The Journal of Hand Surgery American and European Volumes, Journal of Bone and Joint Surgery American and British Volumes, and the Journal of the American Academy of Orthopaedic Surgeons were the most frequently cited journals overall. Recent examinations were more likely to have Buckwalter T3 complex clinical management questions. There was a statically significant increase in the LoE used to create hand questions on the 2010-2012 compared with the 1995-1997 OITE. Conclusions: Primary journal articles cited on the hand surgery content domain of the OITE frequently included recent publications from both general and subspecialty journals. More recent examination questions appear to test clinical management scenarios. LoE for hand questions has increased over a 15-year period. Our results can be used as a guide to help prepare orthopedic residents for the OITE.

Orthopaedic trauma in the Anabaptist community: epidemiology and hospital charges

ABSTRACT This study aims to define the epidemiology of orthopaedic trauma in the rural Anabaptist community and analyze the hospital charges associated with their treatment. The authors performed a retrospective review of 79 Amish and 40 Mennonite patients who had been seen in their rural level I trauma center emergency department for an orthopaedic injury from January 2006 to May 2013. Data collection included baseline demographics, injury mechanism and severity, injury complex, operative interventions, outcomes, and hospital charges. Amish and Mennonite groups were similar except for a higher percentage of males in the Mennonite group. For Amish patients, occupational injuries (52%) and buggy accidents (16%) accounted for the highest percentage of admissions. Eighty-seven percent sustained at least one fracture, most commonly of the hand (11%). Amish patients were statistically more likely to sustain fractures of the spine, and Mennonite patients were more likely to sustain fractures of the foot and femur. Over half of patients required surgery (58%). Total hospital charges did not differ based between the groups. Amish patients completed outpatient follow-up less frequently than Mennonite patients. Anabaptist patients are at risk for a variety of orthopaedic injuries related to their unique lifestyle and vocations. Socioreligious beliefs must be taken into consideration when educating these patients regarding postinjury care, as attendance at outpatient follow-up is low. Understanding the types of injuries that these patients sustain can help create strategies to prevent costly transportation and agricultural accidents within the Anabaptist community.

The Management of Persistent and Recurrent Cubital Tunnel Syndrome

Cubital tunnel syndrome (CuTS) is the second most common compressive neuropathy in the upper extremity. There are considerable diagnostic and therapeutic challenges associated with treating patients after a failed primary procedure for CuTS. Distinguishing cases of recurrence versus persistence and identifying concomitant pathology can guide treatment. Conditions that mimic CuTS must be carefully ruled out and coexisting dysfunction of the medial antebrachial cutaneous nerve needs to be addressed. Results of revision procedures are not as reliable as primary procedures for CuTS; however, improvements in pain and paresthesias are noted in approximately 75% of patients. Nerve wraps represent a promising adjuvant treatment option, but long-term outcome data are lacking. External neurolysis and anterior transposition after failed CuTS procedures are supported by case series; multicenter, prospective randomized trials are needed to guide treatment further and improve outcomes.

Incidence and Reason for Readmission and Unscheduled Health Care Contact After Distal Radius Fracture

Background: Understanding risk factors for readmission may help decrease the rate of these costly events. The purpose of this study is to define the incidence of 30-day readmission and unscheduled health care contact (UHC) after distal radius fracture (DRF). In addition, we aim to define risk factors for readmission and UHC. Methods: A retrospective review of patients who sustained a DRF at our trauma center was performed. We recorded baseline demographics, fracture characteristics, and treatment. Any UHC or readmission (including emergency department [ED] visits) was documented. Reasons for readmission and UHC were stratified by cause. We utilized a case-control design comparing patients readmitted within 30 days after DRF versus those who were not, as well as patients with and without UHC. Results: About 353 patients were identified. The 30-day incidence of readmission after DRF was 7% with 2% of patients readmitted for reasons related to their fracture. Twenty percent of patients had UHC within 30 days, most frequently due to pain. Patients with anxiety or depression and those with open fractures were more likely to be readmitted. Patients with UHC were younger, more likely to have depression or anxiety, and more likely to have undergone operative treatment. Conclusions: For patients sustaining DRF, we report a 30-day readmission rate of 7% with 20% of patients having UHC. Patients with depression or anxiety were more likely to be both readmitted and have UHC. Identifying risk factors for readmission during initial presentation may help reduce readmissions. Improving pain relief strategies early may aid in decreasing the burden of UHC.