Anatomic variations of the deltoid muscle insertion: a cadaveric study.

Background: The deltoid is a trisegmented muscle with anterior, middle, and posterior components. While the clinical relevance of the presence of anatomic variations of the deltoid origin and insertion continues to be debated, the architecture of the deltoid muscle is more complex than initially believed. This study aimed to evaluate the gross anatomy of the deltoid muscle insertion by qualitatively and quantitatively characterizing the insertion and location of the deltoid muscle's anterior, middle, and posterior components. This information is valuable to surgeons as it raises awareness of potential variants that could be encountered during surgery, promotes mindfulness of neurovascular proximities, and reduces the likelihood of confusion between adjacent muscle fibers. Methods: Eight nonpaired, fresh-frozen clavicle-to-fingertip cadaveric shoulders were acquired for the study (6 left, 2 right). The average age of the cadavers was 79.5 years (range: 64-92). The standard deltopectoral approach was carried out on all specimens. The planes dividing the anterior, middle, and posterior deltoid were identified and marked. Once complete exposure had been achieved, digital calipers were used to record the size of the deltoid insertion. The specimens were qualitatively assessed to characterize the style of insertion they demonstrated. Results: The average length of the deltoid insertion was 39.45 ± 9.33 mm (n = 8). Six of the eight shoulders demonstrated an insertion style previously characterized in the literature. The remaining two shoulders highlighted an insertion pattern not previously described. Conclusion: The current study demonstrates a novel insertion pattern for the deltoid muscle that has not been previously characterized. This "step-off" insertion pattern shows that the anterior, middle, and posterior tendons are inserted superior-medial, directly on, and inferior-lateral to the deltoid tuberosity and was found in 2/8 of our cadaveric specimens.

Immediate Weight-bearing Through Walker or Crutches After Surgical Fixation of Clavicle Fractures in Patients With Lower Extremity Fractures: A Retrospective Cohort Study.

OBJECTIVES: To assess the safety of immediate upper extremity weight-bearing as tolerated (WBAT) rehabilitation protocol after clavicle fracture open reduction internal fixation (ORIF). DESIGN: Retrospective cohort study. SETTING: Three Level 1 trauma centers. PATIENTS SELECTION CRITERIA: Patients older than 18 years who had ORIF of mid-shaft clavicle fractures and lower extremity fractures who were allowed immediate WBAT on their affected upper extremity through use of a walker or crutches were included. All clavicles were fixed with either precontoured clavicular plates or locking compression plates. Included patients were those who had clinical/radiographic follow-up until fracture union, nonunion, or construct failure. OUTCOME MEASURES AND COMPARISONS: WBAT patients were matched in a one-to-one fashion to a cohort with isolated clavicle fractures who were treated non-weight-bearing (NWB) postoperatively on their affected upper extremity. Matching was done based on age, sex, and temporality of fixation. After matching, treatment and control groups were compared to determine differences in possible confounding variables that could influence the primary outcome, including patient demographics, fracture classification, cortices of fixation, and construct type. All patients were assessed to verify conformity with weight-bearing recommendation. Primary outcome was early hardware failure (HWF) with or without revision surgery. Secondary outcomes included postoperative infections and union of fracture. RESULTS: Thirty-nine patients were included in the WBAT cohort; there were no significant differences with the matched NWB cohort based on patient demographics. Both the WBAT and the NWB cohorts had 2.5% chance of acute HWF that required surgical intervention ( P = 1.0). Additionally, there was no difference in overall HWF ( P = 0.49). All patients despite weight-bearing status including those who required revision ORIF for acute HWF had union of their fracture ( P = 1.0). CONCLUSIONS: Our data would support that immediate weight-bearing after clavicle fracture fixation in patients with concomitant lower extremity trauma does not lead to an increase in HWF or impact ultimate union. This challenges the dogma of prolonged postoperative weight-bearing restrictions and allow for earlier rehabilitation. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Prospective Clinical Trial Comparing Denervation With Suspension Arthroplasty for Treatment of Carpometacarpal Arthritis of the Thumb.

PURPOSE: Trapeziectomy with suspensionplasty is the most popular treatment for thumb carpometacarpal arthritis. However, carpometacarpal denervation has recently shown promise as an alternative treatment option. This study was designed to compare functional outcomes, pain reduction, and quality of life between denervation and suspension arthroplasty in patients treated for thumb carpometacarpal osteoarthritis. METHODS: We conducted a prospective clinical trial between June 2020 and December 2021. Preoperative and postoperative evaluations were conducted on patients, including the evaluation of functional outcomes via the Michigan Hand Outcomes Questionnaire, pain with the visual analog score, quality of life with the EuroQol-5D, and the evaluation of time to return to function. Outcomes and complications were compared between patients undergoing denervation versus arthroplasty. RESULTS: Forty-eight patients were included in the study, 34 of whom underwent denervation and 14 underwent suspension arthroplasty of the thumb carpometacarpal joint. Patients in the denervation group were younger, with an average age of 59 years compared with 67 years in the arthroplasty group. All other patient characteristics were similar. Pain reduction, functional outcomes, and quality of life scores showed equal improvement in both groups. Denervation patients had a reduced time to return to function (3.3 weeks vs 4.5 months in the arthroplasty group). CONCLUSIONS: Carpometacarpal denervation appears to provide similar short-term outcomes as suspension arthroplasty for the treatment of thumb carpometacarpal arthritis. Treatment with denervation may offer a quicker return to function. The long-term outcomes of denervation remain unknown. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Physician Professional Fees Are Declining and Inpatient and Outpatient Facility Fees Are Increasing for Orthopaedic Procedures in the United States.

PURPOSE: To examine the trends in physician professional fees and inpatient and outpatient facility fees in orthopaedic surgery in the United States. METHODS: Physician professional fees and inpatient and outpatient facility fees were tracked from 2008 to 2021 for the most common orthopaedic procedures in each orthopaedic subspecialty. Using common procedure codes for physician and outpatient procedures and Medicare severity diagnosis related group codes for inpatient procedures, the Medicare Physician Fee Schedules were used to obtain the national payment amounts for physician professional fees and inpatient and outpatient facility fees. Trends in fees were tracked over time after adjustment for inflation. RESULTS: From 2008 to 2021, physician professional fees decreased by an average of 20%, whereas inpatient facility fees increased by 15%, and outpatient facility fees increased by 72%. The orthopaedic subspecialty with the largest decrease in physician professional fees was oncology, with an average decrease of 23.5%, followed by general orthopaedics (23.1%), and sports medicine (22.8%). The largest increase in outpatient facility fees was seen in the subspecialties of general orthopaedics (149.8%), spine (130.1%), and trauma (123.0%). CONCLUSIONS: Over the past 13 years, physician professional fees for the most common orthopaedic procedures have declined while inpatient and outpatient facility fees have increased. Understanding these changes is important to the practice of orthopaedic surgery in the United States. LEVEL OF EVIDENCE: IV, economic.

Targeted Muscle Reinnervation Does Not Increase the Risk of Postsurgical Complication or Overall Cost.

Background: Targeted muscle reinnervation (TMR) has shown promise in reducing postsurgical limb pain in amputees. However, there has been little evidence on the increased risk of complications and cost as compared with traditional amputations. This study was designed to assess the rate of complications and healthcare costs between those treated with TMR and traditional amputations. Methods: Patients undergoing amputation were selected from the PearlDiver Mariner dataset and categorized into one of two treatment groups depending on the use of TMR versus traditional amputation. Rates of postsurgical complications and overall healthcare costs were compared between the two groups, while controlling for differences in patient demographics and comorbidities. Results: One hundred sixteen TMR procedures and 76,412 traditional amputations were included in the study. The rate of complications did not differ between groups, with a complication rate of 77% in the TMR and 87% in the traditional amputation groups. Overall healthcare costs also did not differ 1 year after surgery, with an average cost of $32,632 in the TMR group and $36,219 in the traditional amputation group. Conclusions: Amputees experience high rates of postsurgical complications, morbidity, and mortality. However, there is no increased risk of complications or cost with the use of TMR. TMR has the potential benefits of reducing overall postsurgical pain and reestablishing activities of daily living. Although TMR is more expensive up front, it may reduce the overall healthcare costs by reducing the need for subsequent care. Further work is needed in large, randomized trials to examine these findings.

Development of a Risk Stratification Scoring System to Predict General Surgical Complications for Patients Undergoing Foot and Ankle Surgery.

Preventing postoperative complications is crucial for patients, surgeons, and health care facilities. We developed a risk stratification scoring system to optimize postoperative outcomes for patients undergoing foot and ankle surgery. A total of 35,580 patients who underwent foot and ankle procedures from 2005 to 2017 were identified as part of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). To assess the risk of a postoperative complication, we identified several independent risk factors associated with 30-day postoperative complications, then proceeded to develop a point-based risk scoring system. To validate our scoring system, we used it on a cohort of patients from the database who underwent foot and ankle surgery. Risk factors that correlated with postoperative complications included tobacco abuse, age (≥65 years), diabetes mellitus, hypertension, elevated creatinine level (≥1.3 mg/dL), hypoalbuminemia (<3.5 g/dL), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hyponatremia (<135 mEq/L), and anemia (hematocrit value, men <42%; women <38%). Point scores for each factor were: anemia, +10; hypoalbuminemia, +9; elevated creatinine level, +6; CHF, +4; diabetes mellitus, +3; hyponatremia, +3; COPD, +2; hypertension, +2; age, +1; and tobacco abuse, +1. For the validation cohort, we stratified patients according to risk as low (0-20 points), medium (21-30 points), and high (≥31 points) risk. In terms of having a postoperative complication, compared with low-risk patients, patients who were at medium risk had an odds ratio of 4.7 (95% CI, 2.8-7.9) and those at high risk had an odds ratio of 8.3 (95% CI, 4.8-14.5). [Orthopedics. 2022;45(3):139-144.].

Chemoselective catalytic conversion of glycerol as a biorenewable source to valuable commodity chemicals.

New opportunities for the conversion of glycerol into value-added chemicals have emerged in recent years as a result of glycerol's unique structure, properties, bioavailability, and renewability. Glycerol is currently produced in large amounts during the transesterification of fatty acids into biodiesel and as such represents a useful by-product. This paper provides a comprehensive review and critical analysis on the different reaction pathways for catalytic conversion of glycerol into commodity chemicals, including selective oxidation, selective hydrogenolysis, selective dehydration, pyrolysis and gasification, steam reforming, thermal reduction into syngas, selective transesterification, selective etherification, oligomerization and polymerization, and conversion of glycerol into glycerol carbonate.