Patient Satisfaction with Virtual Clinic Encounters: Analysis of Factors that Impact the Press Ganey Survey in the Hand Surgery Population.

Purpose: Our purpose was to identify patient characteristics and visit components that affect patient satisfaction with virtual new patient visits in an outpatient hand surgery clinic as measured by the Press Ganey Outpatient Medical Practice Survey (PGOMPS) total score (primary outcome) and provider subscore (secondary outcome). Methods: Adult patients evaluated through virtual new patient visits at a tertiary academic medical center between January 2020 and October 2020 who completed the PGOMPS for virtual visits were included. Data regarding demographics and visit characteristics were collected via chart review. Factors associated with satisfaction were identified using a Tobit regression model on the continuous score outcomes (Total Score and Provider Subscore) to account for substantial ceiling effects. Results: A total of 95 patients were included: 54% were men and the mean age was 54 ± 16 years. Mean area deprivation index was 32 ± 18, and the mean driving distance to the clinic was 97 ± 188 mi. Common diagnoses include compressive neuropathy (21%), hand arthritis (19%), hand mass (12%), and fracture/dislocation (11%). Treatment recommendations included small joint injection (20%), in-person evaluation (25%), surgery (36%), and splinting (20%). Multivariable Tobit regressions showed notable differences in satisfaction by the provider on the Total Score but not on the Provider Subscore. Other factors known to affect the PGOMPS scores for in-person visits were not notably associated with the Total or Provider Sub-Scores for virtual visits (area deprivation index, age, and offer of surgery or injection) other than the body mass index. Conclusions: Virtual clinic visit satisfaction was affected by the provider. Wait time strongly affects satisfaction with in-person visits but is not accounted for by the PGOMPS scoring system for virtual visits, which is a limitation of their survey. Further work is required to determine how to improve the patient experience with virtual visits. Type of study/level of evidence: Prognostic IV.

Application of Accepted Use Criteria for the Treatment of Developmental Dysplasia of the Hip Decreases the Number of Infants Treated With a Pavlik Harness.

BACKGROUND: This analysis examined how the application of the American Academy of Orthopedic Surgeons appropriate use criteria (AUC) for developmental dysplasia of the hip in infants would change treatment patterns and outcomes for Graf IIA hips at a single quaternary pediatric hospital. METHODS: After Institutional Review Board approval, patient medical records were reviewed and data were collected. Graf IIa hips were defined as alpha angle (AA) 50 to 59 degrees. AA and femoral head coverage (FHC) were measured from initial and 6-month ultrasounds and acetabular index (AI) was measured from radiographs at 6 months of age. Instability (positive Ortolani and Barlow tests) was noted. On the basis of the American Academy of Orthopedic Surgeons AUC for managing developmental dysplasia of the hip, hips were further categorized as normal (FHC ≥45%), borderline (FHC 35% to 44%), or dysplastic (FHC <35%). RESULTS: Overall, 13% (49/371) of Graf IIa hips (AA 50 to 59 degrees) were dysplastic (FHC <35%). Total 24% (89/371) were clinically unstable. Total 42% (37/89) of unstable Graf IIa hips were dysplastic. Only 4% of stable Graf IIa hips were dysplastic (12/282). Out of 371 Graf IIa hips, 256 were treated with Pavlik harness (n=250) or Rhino brace (n=6). Among stable, nondysplastic (SND) hips (those with normal and borderline FHC≥35%), 33% (52/158) were treated because of a more severe contralateral side. If the AUC had been applied, 67% (106/158) of SND Graf IIa hips would not have been treated. Among the n=162 hips that returned for a 6-month radiograph, there was no difference in AI in the 115 treated and 47 untreated SND hips (mean difference treatment vs. no treatment: -1.5, 95% CI, -3.1 to 0.2, P =0.0808). CONCLUSIONS: Using AUC recommendations, our center could reduce the number of SND Graf IIa hips we treat by 67%. Although 24% of Graf IIa hips were clinically unstable and 13% were dysplastic based on FHC, most Graf IIa hips had normal or borderline FHC per the AUC and may do well with observation and follow-up ultrasound at 12 weeks old. LEVEL OF EVIDENCE: Level III-diagnostic study.

Diagnosis of traumatic shoulder arthrotomies using saline load test with intra-articular pressure monitoring.

PURPOSE: The purpose of this study was to investigate the amount of saline required to identify a positive traumatic shoulder arthrotomy in a cadaveric model. In addition, intra-articular pressure monitoring was conducted to confirm needle placement and evaluate peak pressure curves prior to capsular failure. METHODS: We conducted a cadaveric study using thirty fresh-frozen upper extremities with maintained glenohumeral joint. A shoulder arthrotomy was made in the deltopectoral interval using a 4.4-mm trocar. The joint was loaded using an 18-gauge spinal needle inserted posteriorly and attached to a pressure monitoring system. Fluid was introduced at a uniform rate of 1 cc/sec until active extravasation was visualized from the anterior arthrotomy site. Statistical analysis included assessment of distribution, ANOVA and linear regression. RESULTS: A positive joint challenge was obtained in all specimens (n = 30) within a maximum of 59 ml of fluid (mean 28 ml, STD 15.4). Average intra-articular pressure at visualization (PAV) was 166.8 mmHg (min., 107; max., 268). In twelve specimens, peak pressures (PP) exceeded PAV, showing a corresponding fall in pressure prior to visualization (ΔPP-PAV = 16.5). To reach a sensitivity of 90% and 95% of arthrotomies, 50 and 58 ml of fluid had to be injected. CONCLUSION: Results demonstrated 58 ml of fluid was required to identify a majority of shoulder arthrotomies. Intra-articular pressure monitoring identified successful needle placement. Pressure curve analysis could identify capsular failure before fluid extravasation visualization which could enhance clinical identification and treatment of traumatic shoulder arthrotomies. LEVEL OF EVIDENCE: Level IV Diagnostic.

Twelve-week standard of care protocol longer than median time to normalization among IIc hips treated with Pavlik harness.

Best treatment protocols for infants with developmental dysplasia of the hip (DDH) are poorly defined. This study estimates the time to normalization among Graf IIc hips undergoing Pavlik harness treatment. Following institutional review board approval, patients referred for DDH evaluation at a pediatric institution between 2009 and 2018 (n = 1424 hips/712 patients) were identified. We isolated all Graf IIc hips that underwent Pavlik harness treatment (n = 132 hips/n = 106 patients). Demographic and outcome measures were collected. Normalization was defined as alpha angle greater than or equal to 60° and femoral head coverage greater than or equal to 50%. Kaplan-Meier and Cox proportional hazards regression analyses modeled time to normalization and identified factors associated with earlier normalization. Median time to normalization was 7.0 weeks. At 12 weeks standard treatment, 85.8% [95% confidence interval (CI): 80.2-91.9%] had normalized. Greater femoral head coverage [hazard ratio (HR) per 1% increase: 1.03; 95% CI: 1.01-1.05; P = 0.0068] and hip stability at treatment initiation (HR unstable vs. stable: 0.64; 95% CI: 0.44-0.93; P = 0.0192) were associated with longer time to normalization. Some patients may not need 12 weeks of Pavlik bracing, particularly those with stable presentation who normalize before week 12. Shorter treatment lengths offer benefit without sacrificing long-term outcomes. Findings reinforce growing evidence that femoral head coverage should be a more significant consideration during diagnosis and instability is a concerning finding on examination.

Tonnis Angle and Acetabular Retroversion Measurements in Asymptomatic Hips Are Predictive of Future Hip Pain: A Retrospective, Prognostic Clinical Study.

BACKGROUND: This study evaluated the prevalence of radiographic abnormalities potentially indicative of femoroacetabular impingement on AP pelvic radiographs in asymptomatic adolescents and young adults and aimed to determine whether the abnormalities were predictive of future hip pain. METHODS: AP pelvis images from scoliosis radiographs were obtained from patients 12 to 25 years of age free of any clinical hip/lower extremity symptoms between January 2006 and September 2009. The following radiographic abnormalities were collected: lateral center-edge angle of Wiberg >40° or <25°, Tönnis angle <0° or >10°, acetabular retroversion (crossover sign with a posterior wall sign), acetabular overcoverage (crossover sign without a posterior wall sign), and anterior offset alpha angle, calculated using alpha angle of Nötzli >50°. Patients were retrospectively followed (average 3.11 years) to identify those who subsequently developed hip pain. RESULTS: Of the 233 patients (466 hips) who were asymptomatic at the time of radiographic evaluation, at least one radiographic abnormality was present in 60% (281/466) of the hips. Within that group of hips (n = 281), 69% (195/281) of hips demonstrated a single abnormality, whereas 31% (86/281) of hips were associated with multiple abnormalities. Among all hips (n = 466), a lateral center-edge angle <25° or >40° was the most common radiographic abnormality, present in 27% (127/466) of hips. Anterior offset alpha angle and acetabular overcoverage were the most common abnormalities to present together, found in 5% (25/466) of hips. In the multivariable model, a decreasing Tönnis angle (hazard ratio per 1-degree decrease: 1.25, 95% confidence interval, 1.10-1.42, P = 0.0006) and the presence of acetabular retroversion (hazard ratio: 3.55, 95% confidence interval, 1.15-10.95, P = 0.0272) were predictive of the development of future hip pain. CONCLUSIONS: Our study demonstrates a high prevalence of radiographic abnormalities indicative of femoroacetabular impingement in asymptomatic adolescents and young adults. A decrease in Tönnis angle and the presence of acetabular retroversion were predictive of future hip pain.

Intramedullary Implant Choice and Cost in the Treatment of Pediatric Diaphyseal Forearm Fractures.

OBJECTIVES: To compare outcomes and costs between titanium elastic nails (TENs), stainless steel elastic nails (SENs), and Kirschner wires (K-wires) in the treatment of pediatric diaphyseal forearm fractures with intramedullary fixation. DESIGN: Retrospective cohort study. SETTING: Level 1 Pediatric Trauma Center. PATIENTS/PARTICIPANTS: A total of 100 patients (65 male and 35 female) younger than 18 years with diaphyseal forearm fractures treated with intramedullary fixation were included in the study. INTERVENTION: Patients received single or both bone intramedullary fixation with either TENs, SENs, or K-wires. MAIN OUTCOME MEASUREMENTS: Time to radiographic union, complication rate, surgical time, and average cost per implant. RESULTS: One hundred patients were included in the study. Thirty-one patients were treated with TENs, 30 with SENs, and 39 with K-wires. No significant difference in time to radiographic union, complication rate, or surgical time was found between the 3 types of fixation. Average time to union was 9.4 ± 5.4 weeks, and complication rate was 12.9% for TENs, 10.0% for SENs, and 12.8% for K-wires. There was a significant difference in cost per implant, with an average cost of $639, $172, and $24 for TENs, SENs, and K-wires, respectively (P < 0.001). CONCLUSIONS: This study demonstrates no difference between TENs, SENs, and K-wires in the treatment of pediatric diaphyseal forearm fractures with regards to outcome, time to union, surgical time, or complication rates. Given the significant cost difference between these implants, we recommend that surgeons consider modifying their implant selection to help mitigate cost. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Joint Preservation Techniques in Orthopaedic Surgery.

CONTEXT: With increasing life expectancy, there is growing demand for preservation of native articular cartilage to delay joint arthroplasties, especially in younger, active patients. Damage to the hyaline cartilage of a joint has a limited intrinsic capacity to heal. This can lead to accelerated degeneration of the joint and early-onset osteoarthritis. Treatment in the past was limited, however, and surgical treatment options continue to evolve that may allow restoration of the natural biology of the articular cartilage. This article reviews the most current literature with regard to indications, techniques, and outcomes of these restorative procedures. EVIDENCE ACQUISITION: MEDLINE and PubMed searches relevant to the topic were performed for articles published between 1995 and 2016. Older articles were used for historical reference. This paper places emphasis on evidence published within the past 5 years. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 4. RESULTS: Autologous chondrocyte implantation and osteochondral allografts (OCAs) for the treatment of articular cartilage injury allow restoration of hyaline cartilage to the joint surface, which is advantageous over options such as microfracture, which heal with less favorable fibrocartilage. Studies show that these techniques are useful for larger chondral defects where there is no alternative. Additionally, meniscal transplantation can be a valuable isolated or adjunctive procedure to prolong the health of the articular surface. CONCLUSION: Newer techniques such as autologous chondrocyte implantation and OCAs may safely produce encouraging outcomes in joint preservation.