Prevalence of asymptomatic TFCC tears on MRI: A systematic review.

BACKGROUND: Recent studies show a high prevalence of triangular fibrocartilage complex (TFCC) tears in asymptomatic wrists. While a TFCC tear may be identified when evaluating ulnar sided wrist pain, this could be incidental and not the true cause of pain. The purpose of this review was to (1) examine the frequency of which TFCC tears are diagnosed on MRI in asymptomatic versus symptomatic wrists and (2) determine whether rates of asymptomatic TFCC tears are higher in two important subgroups commonly at risk for this pathology: elderly patients and high-impact athletes. METHODS: Articles of level IV or higher evidence were selected from PubMed, Ovid MEDLINE, and Cochrane Central Register of Controlled Trials Database to compare patient demographics, study parameters, and clinical outcomes. RESULTS: Seven studies met inclusion criteria with a total of 501 wrists (205 symptomatic and 296 asymptomatic). All studies included asymptomatic patients with wrist MR imaging and included information on the structural integrity of the TFCC. Variability in outcome measures reported across studies prevented the conduction of a meta-analysis. CONCLUSIONS: TFCC abnormalities are present in patients of all ages, symptomatology, and levels of involvement in high-impact sports. Although, there are differences in tear and abnormality prevalence when comparing these three factors, the difference was not significant. Given these findings, using MRI to assess ulnar-sided wrist pain should be fortified with clinical suspicion, physical exam, and physician judgment.

The Primary Cost Drivers of Outpatient Distal Radius Fracture Fixation: A Cost-Minimalization Analysis of 15,379 Cases.

Background Distal radius fractures are the most common fracture of the upper extremity. While some distal radius fractures can be managed with closed reduction and immobilization, operative treatment is the standard of care, with open reduction internal fixation (ORIF) as a predominant operative method. Questions/Purpose To investigate how patient and surgical characteristics affect the overall costs of internal fixation of distal radius fractures in adults. Patients and Methods The 2014 State Ambulatory Surgery and Services Databases for six states were used to identify cases and surgical characteristics of distal radius fracture ORIF in adult patients. Results Surgical variables that significantly increased cost were postoperative admission within 30 days, regional anesthesia, simultaneous endoscopic carpal tunnel release, and increasing operating room time. Conclusion Substantial contributors to total cost are postoperative hospital admission within 30 days of surgery, use of regional anesthesia, simultaneous endoscopic carpal tunnel release, and longer operative time. Level of Evidence Level III, retrospective cohort study.

Postoperative Rehabilitation to Improve Outcomes After Cervical Spine Fusion for Degenerative Cervical Spondylosis: A Systematic Review.

Postoperative rehabilitation has recently been identified as a high-priority research topic for improving surgical outcomes for degenerative cervical spondylosis (DCS). However, there remains no consensus on specific rehabilitation strategies. Thus, the objective of this study was to evaluate the effectiveness of postoperative rehabilitation strategies for short-term and long-term outcomes after cervical spine fusion for DCS. A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines using the PubMed, Scopus, and Ovid Medline databases. All level I-IV therapeutic studies in the English language investigating the outcomes of postoperative rehabilitation strategies after cervical spine fusion for DCS were included. Nine studies with 895 patients with DCS (747 anterior-only fusion, 55 patients with posterior-only fusion, 93 patients with physiotherapy alone) were included in this analysis, with 446 (49.8%) patients receiving physiotherapy alone or standard postoperative therapy and 449 (50.2%) patients receiving standard postoperative therapy with additional intervention or augmentation. These interventions included pulsed electromagnetic field (PEMF) stimulation, telephone-supported home exercise program (HEP), early cervical spine stabilizer training, structured postoperative therapy, and a postoperative cervical collar. One level II study demonstrated that PEMF led to increased fusion rates at six months postoperatively compared to standard therapy alone, one level II study demonstrated that postoperative cervical therapy in addition to standard therapy was better than standard therapy alone in the improvement of neck pain intensity, one level IV study demonstrated home exercise therapy led to an improvement in neck pain, arm pain, and disability, and six level II studies reported no difference in clinical outcome measures between augmented or targeted therapy and standard postoperative therapy for DCS. In conclusion, there is moderate evidence to suggest that there is no significant difference in clinical and surgical outcomes between standard postoperative therapy and augmented or targeted postoperative therapy for cervical fusion in the setting of cervical spondylosis. However, there is some evidence to support that certain therapeutic modalities, such as PEMF stimulation, may lead to improved fusion rates, clinical outcomes, and patient satisfaction when compared to standard postoperative therapy protocols. There is no evidence to support a difference in effectiveness with different types of postoperative rehabilitation strategies between anterior and posterior fusions for DCS.

Extensor Carpi Ulnaris Instability: A Comprehensive Review of Pathology and Operative Techniques.

The extensor carpi ulnaris (ECU) is primarily responsible for extension and ulnar deviation at the wrist. Secondary to repetitive loading of, or acute trauma to the flexed, supinated and ulnarly deviated wrist, the ECU tendon can be a common source of ulnar-sided wrist pain. Common pathology includes ECU tendinopathy, tenosynovitis, tendon instability, and tendon rupture. Extensor carpi ulnaris pathology commonly occurs in athletes and patients with inflammatory arthritis. Given the multitude of available methods to treat ECU tendon pathology, the aim of our study was to outline operative management of ECU tendon pathology, with emphasis on reviewing techniques for addressing ECU instability. We acknowledge a continuing debate between anatomical and nonanatomical techniques for ECU subsheath reconstruction. However, use of a portion of the extensor retinaculum for nonanatomical reconstruction is commonly used and demonstrates successful outcomes. Future comparative studies on ECU fixation are required to increase data on patient outcomes, to further define and standardize these techniques.

Anterior Column Realignment Using an Anterior-To-Psoas Approach: A Radiographic-Anatomic Feasibility Study at L1-L5.

STUDY DESIGN: Cross-sectional radioanatomic study. OBJECTIVE: To determine the feasibility of performing an anterior column realignment (ACR) using an anterior-to-psoas (ATP) approach at L1-L5. METHODS: Axial magnetic resonance images (MRI) of the L1-L5 disc levels obtained at a single institution were obtained and analyzed. The feasibility of performing an ACR was assessed using a combination of the size of the left oblique corridor (OC), the psoas morphology using the modified Moro classification, and the anterior disc edge to great vessel distance. RESULTS: Three hundred MRI studies obtained from 300 patients were included. All patients had a measurable left OC at the L1-L4 levels. Twenty patients (6.7%) had no measurable OC at the L4-L5 level. According to the modified Moro's classification, a high-rising psoas was seen in 4 patients (1.3%) at the L3-L4 level and 57 patients (19.0%) at the L4-L5 level. An ALL release was considered high risk due to no measurable space between the anterior disc edge and the great vessels in 54 patients (18.0%) at the L1-L2 level, 39 patients (13.0%) at the L2-L3 level, 119 patients (39.7%) at the L3-L4 level, and 226 patients (75.3%) at the L4-L5 level. CONCLUSION: ACR using an ATP approach is the most radioanatomically feasible at L2-L3. The L4-L5 level has the highest risk with regards to both the ATP approach and the ALL release for an ACR due to high rates of unmeasurable left OC and space between the anterior disc edge and the great vessels.

Anterior versus posterior spinal fusion for Lenke type 5 adolescent idiopathic scoliosis: a systematic review and meta-analysis of comparative studies.

PURPOSE: To review and compare clinical and radiologic outcomes between anterior spinal fusion (ASF) and posterior spinal fusion (PSF) for the treatment of Lenke type 5 adolescent idiopathic scoliosis (AIS). METHODS: A systematic review was performed according to Preferred reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. All level I-III evidence studies investigating the clinical and radiologic outcomes of ASF and PSF for the treatment of Lenke type 5 AIS were included. RESULTS: Nine studies (285 ASF patients, 298 PSF patients) were included. ASF was associated with a significantly lower number of levels fused compared with PSF (p < 0.01) with similar immediate and long-term coronal deformity correction (p = 0.16; p = 0.12, respectively). PSF achieved a better correction of thoracic hypokyphosis in one study and lumbar hypolordosis in three studies. PSF was associated with a significant shorter length of stay (LOS) compared with ASF (p < 0.01). One long-term study demonstrated a significantly higher rate of proximal junctional kyphosis (PJK) with PSF compared with ASF. There were no significant differences in major complication or re-operation rates. CONCLUSION: For the treatment of Lenke type 5 AIS, there is moderate evidence to suggest that ASF requires a lower number of instrumented levels to achieve similar immediate and long-term coronal deformity correction compared with PSF. There is some evidence to suggest that PSF may achieve better thoracic and lumbar sagittal deformity correction compared with ASF. There is some evidence to suggest a higher incidence of PJK at long-term follow-up with PSF compared with ASF. ASF is associated with a longer post-operative LOS compared with PSF.

Prior shoulder surgery and rheumatoid arthritis increase early risk of infection after primary reverse total shoulder arthroplasty.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) has become an increasingly popular surgery for patients with rotator cuff arthropathy, unreconstructible proximal humeral fracture, and end-stage glenohumeral arthritis. The increased annual volume of RTSAs has resulted in more postoperative complications and revision rates between 3.3% and 10.1%. Postoperative infection is one of the most common complications requiring revision surgery after primary RTSA. This study assesses patient-specific risk factors for development of early infection after primary RTSA in a single high-volume shoulder arthroplasty institution. METHODS: From 2014 to 2019, 902 consecutive primary RTSAs were performed for surgical treatment of rotator cuff arthropathy, glenohumeral arthritis, inflammatory arthropathy, and/or dislocation. Excluding proximal humeral or scapula fractures, 756 cases met the inclusion criteria and had a minimum of 3-month follow-up. All surgeries were performed using the same surgical technique and received similar antibiotic prophylaxis. Age, patient demographics, medical history, smoking history, and prior ipsilateral shoulder treatment and/or surgery were recorded. Multivariable logistic regression analysis was used to determine risk factors associated with development of postoperative shoulder infection. RESULTS: Thirty-five patients did not meet minimum follow-up criteria and were lost to follow-up. Overall, of 721, 22 patients (3%) developed a postoperative ipsilateral shoulder infection. Previous nonarthroplasty surgery and history of rheumatoid arthritis were significantly associated with the development of postoperative shoulder infection. Amongst 196 patients who had previous nonarthroplasty shoulder surgery, there were 12 postoperative shoulder infections (6%) compared with those without previous shoulder surgery (10 of 525, 2%) (P = .003). Among 58 patients with rheumatoid arthritis, there were 5 postoperative shoulder infections (9%) compared with patients without rheumatoid arthritis (17 of 663, 3%) (P = .010). Patient age, gender, smoking status, history of diabetes mellitus, history of cancer/immunosuppression, and prior cortisone injection did not demonstrate significant associations with the development of postoperative infection. CONCLUSION: Prior nonarthroplasty shoulder surgery and/or rheumatoid arthritis are independently associated with the development of postoperative infection after primary RTSA. Patients who demonstrate these risk factors should be appropriately evaluated and preoperatively counseled before undergoing primary RTSA. Strong consideration should be given to avoid minimally invasive nonarthroplasty surgery as a temporizing measure to delay definitive RTSA.