Preliminary Experience with Conservative Sharp Wound Debridement by Nurses in the Outpatient Management of Diabetic Foot Ulcers: Safety, Efficacy, and Economic Analysis.

Background: Treatment of diabetes costs the United States an estimated $245 billion annually; one-third of which is related to the treatment of diabetic foot ulcers (DFUs). We present a safe, efficacious, and economically prudent model for the outpatient treatment of uncomplicated DFUs. Methods: 77 patients (mean age = 54 years, range 31 to 83) with uncomplicated DFUs prospectively enrolled from September 2008 through February 2012. All patients received an initial sharp debridement by one of two orthopaedic foot and ankle fellowship trained surgeons. Ulcer dressings, offloading devices, and debridement procedures were standardized. Patients were evaluated every two weeks by research nurses who utilized a clinical management algorithm and performed conservative sharp wound debridement (CSWD). Results: Average time to clinical healing was 6.0 weeks. There were no complications of CSWD performed by nurses. The sensitivity for the timely identification of wound deterioration was 100%, specificity = 86.49%, PPV = 68.75% and NPV = 100% with an overall accuracy of 89.58%. The estimated cost savings in this model by having nurses perform CSWD was $223.26 per encounter, which, when extrapolated to national estimates, amounts to $1.56 billion to $2.49 billion in potential annual savings across six to ten-week treatment periods, respectively. Conclusion: CSWD of DFUs by nurses in a vertically integrated multidisciplinary team is a safe, effective, and fiscally responsible clinical practice. This clinical model on a national scale could result in significant healthcare savings. Surgeons and other licensed independent practitioners would have more time for evaluating and treating more complex and operative patients; nurses would be practicing closer to the full extent of their education and training as allowed in most states.Level of Evidence: III.

Biomechanical comparison of a proximal humeral locking plate using two methods of head fixation.

HYPOTHESIS: Locking plates have emerged as the implant of choice for stabilization of proximal humeral fractures. The biomechanical properties of a locked plating system using smooth pegs vs threaded screws for fixation of the humeral head were compared to test the hypothesis that there would be no biomechanical difference between pegs and threaded screws. MATERIALS AND METHODS: Sixteen pairs of fresh frozen cadaveric humeri were randomized to have a surgical neck gap osteotomy stabilized with a locked plate using threaded screws (n=8) or smooth pegs (n=8). The intact contralateral humerus served as a control. Each specimen was tested with simultaneous cyclic axial compression (40 Nm) and torsion (both +/-2 Nm and +/-5 Nm) for 6000 cycles. All specimens were loaded to failure. Interfragmentary motion and load-displacement curves were analyzed to identify differences between the groups. Our data were then compared to previously published forces across the glenohumeral joint to provide evidence based recommendations for postoperative use of the shoulder. RESULTS: There was a statistically significant difference between test specimens and their paired control (P < .001) in cyclic testing and load to failure. Differences between the smooth pegs and threaded screws were not statistically significant. DISCUSSION: There is no biomechanical difference between locked smooth pegs and locked threaded screws for proximal fragment fixation in an unstable 2-part proximal humeral fracture model. CONCLUSION: Our study contributes to the published evidence evaluating forces across the glenohumeral joint and suggests that early use of the affected extremity for simple activities of daily living may be safe. Use of the arm for assisted ambulation requiring a crutch, cane, walker, or wheelchair should be determined on a case-by-case basis.

Predicting transfusion in shoulder arthroplasty.

BACKGROUND: This study was conducted to evaluate the incidence of transfusion in shoulder arthroplasty, determine clinical factors associated with increased risk for transfusion, and develop an algorithm to assist the surgeon in preoperative planning with regards to blood management. MATERIAL AND METHODS: The study had 2 phases: (1) development of a clinical prediction rule for transfusion using 280 procedures and (2) a validation study of the algorithm applied to 109 new patients. Phase 1 consisted of a retrospective record review of 280 consecutive shoulder arthroplasties to determine risk factors for transfusion. Phase 1 also identified a preoperative hemoglobin level of less than 12.5 g/dL as predictive of the need for blood transfusion. This cutoff was prospectively applied to 109 patients undergoing shoulder arthroplasty in phase 2. RESULTS: The transfusion rate for phase 1 was 19.6%. Preoperative hemoglobin level (P < .001), age (P= .003), and the number of comorbid conditions (P = .005) were statistically significant risk factors. Patients with a preoperative hemoglobin level of less than 12.5 g/dL have a 4-fold increased risk of requiring a blood transfusion. In phase 2, the cutoff of less than 12.5 g/dL yielded a sensitivity of 88%, specificity of 78%, and positive and negative likelihood ratios of 4.0 and 0.15, respectively. CONCLUSION: Preoperative hemoglobin level, age, and number of comorbid conditions are all predictive of transfusion in shoulder arthroplasty. Tailoring blood ordering based on a preoperative hemoglobin level of 12.5 g/dL is safe and effective. LEVEL OF EVIDENCE: Prognostic study, level 2.