Total Knee Arthroplasty Outcomes in Patients with Medicare, Medicare Advantage, and Commercial Insurance.

As more commercial insurance companies adopt a bundled reimbursement model, similar to the Comprehensive Care for Joint Replacement (CJR) algorithm for Medicare beneficiaries, accurate risk adjustment of patient-reported outcomes (PROs) is critical to ensure success. With this movement toward bundled reimbursement, it is unknown if a formula adjusting for similar risks in the Medicare population could be applied to PROs in commercially insured and Medicare Advantage populations undergoing total knee arthroplasty (TKA). This study was performed to compare PROs after TKA in these insurance groups after adjusting for proposed risks. Demographics and clinical data were abstracted from medical records of 302 patients who underwent TKA performed by a single surgeon at a university-based orthopaedic practice during 2013 to 2017. Differences in PROs between commercially insured, Medicare Advantage, and Medicare patients during the 6 months following surgery were evaluated while controlling for demographics, clinical data, and baseline PRO scores. Medicare and Medicare Advantage patients were older (p < 0.001) and had more comorbidities (p = 0.001) than commercial patients. During the first 3 months following TKA, patients in all three groups experienced similar rates of recovery. At 6 months after surgery, outcomes began to diverge by insurance group. Medicare patients reported significantly less ability to perform activities of daily living (78.6 vs. 63.2; p = 0.001), worse physical function (39.6 vs. 44.9; p = 0.003), and more pain interference (57.9 vs. 52.4; p = 0.018) at day 180 than commercially insured patients. There were no statistically significant differences between Medicare Advantage patients and either commercially insured or Medicare patients. Therefore, commercial insurance companies that intend to apply a risk-adjusted equation similar to the CJR algorithm to commercial populations should be cautioned since the postoperative outcomes in this investigation differed after adjusting for the same risk factors that have been proposed for inclusion in the CJR algorithm. Nonetheless, further studies should be performed to ensure that companies participating in bundled reimbursement models have a positive influence on comprehensive health care for patients and providers. This is a level III, retrospective prognostic study.

Right Ring Finger Volar Mass in a 14-Year-Old Boy.

A trigger digit is relatively uncommon in adolescents and often has a different etiology in that age group vs adults. In the pediatric population, trigger digits frequently arise from a variety of underlying anatomic situations, including thickening of the flexor digitorum superficialis or flexor digitorum profundus tendons, an abnormal relationship between the flexor digitorum superficialis and flexor digitorum profundus tendons, a proximal flexor digitorum superficialis decussation, or constriction of the pulleys. In addition, underlying conditions such as mucopolysaccharidosis, juvenile rheumatoid arthritis, Ehlers-Danlos syndrome, and central nervous system disorders such as delayed motor development have been associated with triggering. Less commonly, triggering secondary to intratendinous or peritendinous calcifications or granulations has been described, which is what occurred in the current case. This report describes a case of tenosynovitis with psammomatous calcification treated with excision of the mass from the flexor digitorum superficialis tendon and release of both the A1 and palmar aponeurosis pulleys in an adolescent patient. [Orthopedics. 2017; 40(5):e918-e920.].

Gunshot-associated Fractures in Children and Adolescents Treated at Two Level 1 Pediatric Trauma Centers.

INTRODUCTION: Gunshot injuries are a potentially significant cause of morbidity and mortality in the pediatric population. The objective of this study was to evaluate the epidemiology, fracture locations, associated injuries, types of treatment, and complications of gunshot-associated fractures in children and adolescents treated at two level 1 trauma centers. METHODS: The clinical and radiographic records of all children and adolescents who had a gunshot-associated fracture treated at 1 of 2 level 1 pediatric trauma centers between January, 2005, and April, 2013, were reviewed. The following characteristics were recorded: patient age and sex, type of weapon, fracture location, presence of neurovascular injury or other associated injuries, antibiotic treatment, method of stabilization, duration of hospital stay, complications, and need for subsequent procedures. RESULTS: Forty-nine patients with 58 fractures were identified; 9 patients had multiple fractures. The 41 males and 8 females had an average age of 12.2 years (range, 1 to 18 y). The tibia and femur were the most common sites of fracture (19% each), followed by the small bones of foot (4%) and the fibula (4%). Most of the fractures (71%) were treated nonoperatively. Nearly half (47%) of the patients had additional injuries, including abdominal or genitourinary injuries, neuropraxia or nerve injuries, and vascular injuries. Two patients (4%) developed infections (1 superficial and 1 deep) that required multiple irrigation and debridement procedures. Three patients developed compartment syndrome, and 4 patients had vascular injuries requiring repair. Nearly a third of patients (35%) had fractures or complications that required additional operative procedures. CONCLUSIONS: This large retrospective study highlights the significant morbidity of fractures caused by gunshots. Although the overall infection rate was low and most of these fractures were successfully treated nonoperatively, many of the patients required an additional operative procedure and nearly half had additional nonorthopaedic injuries. This emphasizes the necessity of coordination among emergency, general surgeons, intensivist, and orthopaedic surgical teams. LEVEL OF EVIDENCE: Level IV­retrospective case series.

Correlation of Pelvic and Spinal Parameters in Adult Deformity Patients With Neutral Sagittal Balance.

STUDY DESIGN: Retrospective measurement of spinal and pelvic parameters in adult spinal deformity patients. OBJECTIVE: To correlate spinal and pelvic parameters in adult spinal deformity patients who were in neutral spinal balance. SUMMARY AND BACKGROUND DATA: It is believed that sagittal spinal balance is influenced by both spinal and pelvic parameters, which are closely interrelated as manifested by the reciprocal changes seen when any of the interrelationships was altered. New parameters including proximal thoracic slope (PTS), proximal thoracic tilt, thoracic apical tilt, and coxo-spinal angle (CSA) were studied and correlated with previously studied spinal and pelvic parameters. METHODS: One thousand patients who had undergone standing scoliosis views from 2007 to 2010 were screened. A total of 70 patients, 29 with a diagnosis of degenerative scoliosis and 41 with the diagnosis of adult idiopathic scoliosis, were analyzed for various spinal and spinopelvic parameters. Linear regression analysis was performed. RESULTS: Thoracic kyphosis (TK) plus sacral slope (SS) had as strong a correlation with lumbar lordosis (LL) (r = 0.871; p < .000) as with pelvic incidence. The ratio LL / (TK + SS) yielded a constant ratio of 0.74 for the balanced spine. Pelvic incidence ± 9 = LL. Lumbar lordosis × 0.74 = TK. Coxo-spinal angle correlated with TK (r = 0.404; p = .000) and CSA / TK yielded a constant ratio in balanced spines. Proximal thoracic slope and thoracic apical tilt strongly correlated with TK (R = 0.793; p = 0.000). Proximal thoracic slope allows introduction of the spinal equation, PTS + LL = SS + TK, which is based on the geometric principle that when measuring angles between 2 horizontal parallel lines the sum of the angles in opposite directions is equal. CONCLUSION: The spinal equation may predict ideal spinal and pelvic parameters that may aid in preventing complications such as proximal junctional failure.

Assessment of a multibeam Fizeau wedge interferometer for Doppler wind lidar.

The Fabry-Perot interferometer is the standard instrument for the direct detection Doppler lidar measurement of atmospheric wind speeds. The multibeam Fizeau wedge has some practical advantages over the Fabry-Perot, such as the linear fringe pattern, and is evaluated for this application. The optimal Fizeau must have a resolving power of 10(6) or more. As the multibeam Fizeau wedge is pushed to such high resolving power, the interference fringes of the device become complicated by asymmetry and secondary maxima. A simple condition for the interferometer plate reflectance, optical gap, and wedge angle reveals whether a set of parameters will yield simple, Airy-like fringes or complex Fizeau fringes. Tilting of the Fizeau wedge improves the fringe shape and permits an extension of the regime of Airy-like fringes to higher resolving power. Sufficient resolving power for the wind lidar application is shown to be possible with a large-gap, low-finesse multibeam Fizeau wedge. Liabilities of the multibeam Fizeau wedge in the wind lidar application include a smaller acceptance solid angle and calibration sensitivity to localized deviations of the plates from the ideal.