Monkey Bar-Associated Pediatric Fractures: A National Epidemiologic Study of Emergency Department Visits.

INTRODUCTION: Emergency department (ED) visits because of pediatric fractures are not only burdensome for patients and their families but also result in an increased healthcare expenditure. Almost half of all children experience at least one fracture by the age of 15. Many fractures occur in playgrounds, with monkey bars and other climbing apparatuses noted as frequent mechanisms of injury. Our purpose was to identify the pattern of injury and the population sustaining monkey bar-associated fractures. METHODS: We queried the National Electronic Injury Surveillance System database for all monkey bar-associated injuries in patients aged 0 to 18 years from January 1, 2009, to December 31, 2019. We described demographic data, patient disposition from the ED, fracture pattern, and injury setting using unweighted and weighted estimates. Weighted results that more closely reflect national estimates were calculated. RESULTS: During the study period, 30,920 (862,595 weighted) monkey bar-associated injuries presented to EDs; 16,410 (53.1%) (weighted injuries: 408,722 [47.4%]) were fracture injuries. The average age of kids sustaining fractures was 6.5 years, with most injuries (66.4%) occurring in kids between 6 and 12 years. A higher percentage of male patients presented to the ED with fractures compared with female patients (53% versus 47%). Upper extremity fractures were most common, 382,672 (94%) with forearm fractures constituting the majority (156,691 [38%]). Most children were treated and released (354,323 [87%]), with only 35,227 children (9%) being admitted for treatment. Places of recreation/sports were the most common setting of fractures (148,039 [36%]), followed by schools (159,784 [39%]). A notable association was observed between year and ethnicity and between month period and injury setting. CONCLUSION: Monkey bar-associated injuries are a major cause of upper extremity fractures in children, with most injuries occurring in recreational areas or schools. Young elementary school children are at the highest risk of injury. ED visits because of monkey bar-associated fractures have increased over the study period, and these injuries continue to be a major cause of fractures in children. Additional measures should be installed to decrease these preventable fractures among children, with schools as a potential starting point.

Benchmarking cytology support for ROSE during endoscopic and bronchoscopic procedures.

INTRODUCTION: There has been an increase in endoscopic and bronchoscopic biopsies as minimally invasive methods to obtain specimens from gastrointestinal (GI) or pancreatobiliary lesions and thoracic or mediastinal lesions, respectively. As hospitals undertake more of these procedures, it is important to consider the staffing implications that this has on cytopathology laboratories with respect to support for rapid on-site evaluation (ROSE). MATERIALS AND METHODS: Volume and time data from endoscopic ultrasound and bronchoscopic procedures (including endobronchial ultrasound-guided transbronchial needle aspirations and small biopsies with touch preparation) in the GI suite, bronchoscopy suite, or operating room were reviewed for 2 months at 2 different medical centers with ROSE services provided by cytologists or fellows physically present at the procedure and cytopathologists located remotely using telecytology. Statistical analysis was performed to investigate significant trends based on the location of the biopsies and other factors. RESULTS: A total of 16 proceduralists performed 159 procedures and submitted 276 different specimens during 16 total weeks at 2 institutions. The total ROSE time for the on-site personnel to cover these procedures was 109.3 hours (bronchoscopy, 62.3 hours [57%]; GI, 29.8 hours [27%]; OR, 17.2 hours [16%]), which represents an average of 0.69 hour (41.4 minutes) per procedure or 0.40 hour (24.0 minutes) per part, with the shortest procedure times per sample recorded during bronchoscopy. When stratified by practice volume for individual proceduralists, the average time per specimen sample submitted was shorter for proceduralists with high volume practices and was most pronounced during bronchoscopy procedures. CONCLUSIONS: Endoscopic and bronchoscopic procedures account for an increasing amount of the ROSE time for the cytology team. On average, each ROSE procedure takes 0.69 hour (41.4 minutes) or approximately 0.40 hour (24.0 minutes) per specimen, with shorter time requirements for specimens obtained in bronchoscopy procedures and for operators with high volume practices for endobronchial ultrasound-guided transbronchial needle aspirations. This provides important benchmarking data to calculate staffing needs for cytology to provide ROSE support for different proceduralists.

Association of Demographic Characteristics and Laboratory Values in Diabetic Foot Infections Leading to Lower-Extremity Amputation.

BACKGROUND: Lower-extremity amputations are a common complication of poorly controlled diabetes and contribute to significant morbidity and mortality in diabetic patients. We sought to determine whether objective data points obtained on presentation or hospital admission, including white blood cell (WBC) count, hemoglobin A1c (HbA1c), C-reactive protein (CRP), and descriptive patient demographics allow for the ability to predict optimal amputation levels and outcomes of lower-extremity amputation in the diabetic population. METHODS: A retrospective analysis of 162 patients was performed evaluating laboratory and descriptive values on hospital presentation for lower-extremity infection during a 16-year period. Occurrence of multiple amputations and level of amputation were assessed against laboratory values to determine whether these objective values would provide clinicians with a better understanding of amputations in the diabetic patient. RESULTS: The mean patient age was 60.6 years. A significantly higher percentage of patients who underwent amputations through the tibia and fibula or of the foot midtarsal were male compared with patients who underwent amputations of the thigh through femur. Patients who had amputations through the tibia and fibula had a significantly higher WBC count compared with patients who had a transmetatarsal amputation (P = .03). There was no significant difference in type or quantity of amputations when analyzing HbA1c and CRP levels. CONCLUSIONS: An admission WBC count may be used as a predictor of lower-extremity amputation level and outcomes in diabetic infections. Although a statistically significant difference was not found for CRP or HbA1c levels between amputation procedures and number of procedures performed, these values remain useful in managing lower-extremity infections in diabetic patients.

Trends in the Utilization of Computed Tomography in Operative Treatment of Distal Radius Fractures.

Purpose: To identify patient, surgeon, and injury characteristics associated with preoperative computed tomography (CT) scan utilization for operative distal radius fractures (DRF). In addition, we aimed to determine if preoperative CT was associated with treatment methods other than isolated volar-locked plating (VLP). Methods: We retrospectively reviewed all operatively treated adult DRFs within our health care system from 2016 to 2020. Baseline demographics, injury, treatment characteristics, and the fellowship training of the 44 included surgeons were recorded. We compared cases with and without a preoperative CT, and an adjusted logistic regression model was generated to determine the odds of having a preoperative CT. Results: A total of 1,204 operatively treated DRFs performed by 44 surgeons were included. CT utilization increased during the study period. Intra-articular fractures accounted for 76% of cases, and preoperative CT scans were ordered in 243 of 1240 cases (20%). Overall, isolated VLP was used in 83% of cases. Cases with a preoperative CT were more likely to be treated with an alternative method of fixation (such as dorsal plating). The adjusted logistic regression model demonstrated that male sex (OR 1.62; 95% CI: 1.16, 2.26), intra-articular fractures (OR 3.11; 95% CI: 1.87, 5.81), and associated fractures (OR 2.69; 95% CI: 1.82, 3.98) had a significantly increased odds of having a preoperative CT. Fellowship training was not associated with increased CT utilization overall, but hand surgeons were more likely to use a CT in Orthopaedic Trauma Association-C3 fractures. Conclusions: Patient and injury characteristics are associated with CT utilization in operative DRFs. Preoperative CTs are associated with alternative fixation approaches, as cases with a CT were more likely to use fixation methods other than isolated VLP. The costs and benefits of CT scans must be carefully weighed against whether this modality adds value or improves outcomes in treating DRFs. Level of evidence: Prognostic II.

An analysis of cost and complications for patients sustaining a second, contralateral hip fracture within 1 year.

INTRODUCTION: Hip fractures are an increasingly common occurrence among the aging population. With increased life expectancy and advancements in medicine, patients sustaining a hip fracture are at an increasing risk of sustaining a contralateral hip fracture. Efforts are being made to better understand the environment of these hip fractures so that secondary prevention clinics and guidelines can be made to help prevent recurrent osteoporotic hip fractures. The estimated incidence of a contralateral hip fracture varies from 2 to 10% and is reportedly associated with a higher incidence of complications. Previous studies evaluating contralateral hip fractures compared a single cohort of patients sustaining a second hip fracture with patients who sustained only one hip fracture. We aimed to investigate the overall complications and associated costs as it relates to a patients first hip fracture and contrast this to the same patient's contralateral, second hip fractures. METHODS: We performed a retrospective review of all patients in our health systems electronic database who were found to have surgically treated hip fractures between January 2004 and July 2019. Patients with surgically treated hip fractures (CPT Codes: 27235, 27236, 27245, 27244), who sustained a second contralateral hip fracture were included. Medical complications within 30 days of either procedure (such as pneumonia, UTI, altered mental status and others), length of stay, orthopedic complications (such as wound complications, infection, hardware failure, nonunion), type of implants, costs, comorbidities, and ASA Class as well as Mortality were reviewed. RESULTS: A total of 4,870 hip fractures were identified during the study period where 137 (2.8%) patients sustained a second hip fracture, and 47 (0.9%) of which were sustained within the first year after their index hip fracture. There was no statistical difference in length of stay (p = 0.68), medical (p>0.99) or orthopedic complications (p>0.99) between patients first and second hip fractures. There was an increased incidence of cognitive impairment with the second hip fracture (P = 0.0002). For patients that underwent operative treatment of a second hip fracture, the total cost of care was higher for the second surgery (mean difference 757. 38 USD) however the difference wasn't statistically significant (p = 0.31). The overall 1-year mortality rate was 14.9 percent. CONCLUSIONS: Our study demonstrates there is no statistical difference between the first and second surgery regarding length of stay, medical or orthopedic complications and cost.

Physician Perspectives on Telemedicine at an Integrated Health System During the COVID-19 Pandemic.

Introduction: The use of telemedicine (TM) for patient care greatly increased during the COVID pandemic. This study presents data from a single health system regarding physician's perspectives on TM, which could ultimately determine how it is used in the future. Methods: A questionnaire was distributed to physicians throughout the health system. Physicians were divided based on the standard level of patient interaction in each specialty, as well as practice locations and years in practice. Physician perspectives were categorized by their opinions on different aspects of telehealth visits. Results: Of 1,794 physicians, 379 (20.7%) responded to the survey. Psychiatrists used TM significantly more than other groups and project the most future use. Surgeons were least likely to incorporate TM in the future. Ability to perform a physical examination via TM differed significantly by specialty and practice environment, but not by years in practice. Frequency of being able to complete a treatment plan via TM differed significantly by specialty, but not by years in practice or practice environment. Overall, 76.3% of physicians reported feeling "satisfied" with performing TM visits. Satisfaction with TM varied significantly by specialty and practice environment, but not by years in practice. There were no significant differences regarding physician expectations on reimbursement or billing for TM visits based on specialty, age, or practice environment. Conclusions: Discrepancies exist among physicians with respect to their satisfaction and expected future use of TM. Consensus may be difficult to reach regarding reimbursement for these visits, and further work is needed to clarify the optimal practice setting for TM.

Results of single-incision distal biceps tendon repair for early-career upper-extremity surgeons.

Background: The purpose of this investigation was to assess surgical outcomes after distal biceps tendon (DBT) repair for upper-extremity surgeons at the beginning of their careers, immediately following fellowship training. We aimed to determine if procedure times, complication rates, and clinical outcomes differed during the learning curve period for these early-career surgeons. Methods: All cases of DBT repairs performed by 2 fellowship-trained surgeons from the start of their careers were included. Demographic data as well as operative times, complication rates, and patient reported outcomes were retrospectively collected. A cumulative sum chart (CUSUM) analysis was performed for the learning curve for both operative times and complication rate. This analysis continuously compares performance of an outcome to a predefined target level. Results: A total of 78 DBT repairs performed by the two surgeons were included. In the CUSUM analysis of operative time for surgeon 1 and 2, both demonstrated a learning curve until case 4. In CUSUM analysis for complication rates, neither surgeon 1 nor surgeon 2 performed significantly worse than the target value and learning curve ranged from 14 to 21 cases. Mean Disabilities of Arm, Shoulder, and Hand score (QuickDASH) (10.65 ± 5.81) and the pain visual analog scale scores (1.13 ± 2.04) were comparable to previously reported literature. Conclusions: These data suggest that a learning curve between 4 and 20 cases exists with respect to operative times and complication rates for DBT repairs for fellowship-trained upper-extremity surgeons at the start of clinical practice. Early-career surgeons appear to have acceptable clinical results and complications relative to previously published series irrespective of their learning stage.

Median Nerve and Carpal Tunnel Morphology Before and After Endoscopic Carpal Tunnel Release: A 6-Year Follow-up Study.

BACKGROUND: Our purpose was to describe structural and morphological features of the median nerve and carpal tunnel on magnetic resonance imaging (MRI) studies obtained before, immediately after, 6 weeks after, and 6 years after endoscopic carpal tunnel release (ECTR). METHODS: In this prospective cohort study, 9 patients with a diagnosis of carpal tunnel syndrome (CTS) underwent ECTR. Standardized MRI studies were obtained before ECTR, immediately after ECTR, and 6 weeks and 6 years after surgery. Structural and morphological features of the median nerve and carpal tunnel were measured and assessed for each study with comparisons made between each time point. RESULTS: All 9 patients had complete symptom resolution postoperatively. On the immediate postoperative MRI, there was a discrete gap in the transverse carpal ligament in all patients. There was retinacular regrowth noted at 6 weeks in all cases. The median nerve cross-sectional area and the anterior-posterior dimension of the carpal tunnel at the level of the hamate increased immediately after surgery and these changes were maintained at 6 years. CONCLUSIONS: We defined structural and morphological changes on MRI for the median nerve and carpal tunnel in patients with continued symptom resolution 6 years after ECTR. Changes in median nerve and carpal tunnel morphology that occur immediately after surgery remain unchanged at mid-term follow-up in asymptomatic patients. Established imaging criteria for CTS may not apply to postoperative patients. Magnetic resonance imaging appears to be of limited clinical utility in the workup of persistent or recurrent CTS.

The Impact of Smoking on Delayed Osseous Union After Arthrodesis Procedures in the Hand and Wrist.

PURPOSE: The purpose of this study was to evaluate the relationship between smoking and delayed radiographic union after hand and wrist arthrodesis procedures. We hypothesized that smoking would be associated with a higher rate of delayed union. METHODS: All cases of hand or wrist arthrodesis procedures in patients aged ≥18 years from 2006 to 2020 were identified. Cases were included if they had >90 days of radiographic follow-up or evidence of union before 90 days. Baseline demographics were recorded for each case including smoking status at the time of surgery. Complications were recorded and all postoperative radiographs were reviewed to assess for evidence of delayed union (defined as lack of osseous union by 90 days after surgery). We compared active smokers and nonsmokers and performed a logistic regression analysis to estimate the odds of experiencing a delayed radiographic union. RESULTS: A total of 309 arthrodesis cases were included and 24% were active smokers. Overall, radiographic evidence of a delayed union was found in 17% of cases. Smokers were significantly more likely to have a delayed union compared with nonsmokers (27% vs 14%). Results of the adjusted logistic regression analysis demonstrated that there was a significantly increased odds of experiencing a delayed union for patients who were active smokers compared with nonsmokers (odds ratio, 2.20; 95% confidence interval, 1.09-4.43). In addition, the rate of symptomatic nonunion requiring reoperation was higher in smokers (15%) compared with nonsmokers (6%). CONCLUSIONS: Smoking was associated with increased odds of delayed radiographic union in patients undergoing hand and wrist arthrodesis procedures. Patients should be counseled appropriately on the risks of smoking on bone healing and encouraged to abstain from nicotine use in the perioperative period. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Trends in the Management of Fifth Metacarpal Neck Fractures.

PURPOSE: To describe management trends of fifth metacarpal neck (5MCN) fractures within a large health care system. We aimed to define patient and surgeon factors associated with nonsurgical versus surgical treatment, as well as to identify factors associated with receiving care only in the emergency department (ED). METHODS: We identified all 5MCN fractures within our system for the years 2012-2020 and recorded baseline demographics for cases. Injury, treatment, and fracture characteristics were all recorded. For fractures treated nonsurgically, we determined the type of immobilization used (if any) and recorded whether patients were seen only in the ED or received subsequent outpatient follow-up. Demographic comparisons were made between groups, and adjusted logistic regression models were generated to predict the odds of having a surgical 5MCN fracture or being seen in the ED only. RESULTS: There were 611 5MCN fractures over an 8-year period, of which 10% were treated surgically. During the first half of the study period, 8% of isolated cases were treated surgically compared with 7% of cases in the second half. Soft dressings were increasingly used. There were no nonsurgically managed cases that underwent subsequent surgical procedures for symptomatic nonunion or malunion. Twenty-one percent of patients were seen only in the ED. Fracture angulation, associated injuries, insurance status, and treatment by a hand surgeon were all significantly associated with an increased likelihood of surgery. CONCLUSIONS: Of the 611 5MCN fractures identified, 90% were treated nonsurgically. Patient and surgeon factors were associated with increased odds of surgery. Of patients who sought care for 5MCN injuries, >20% received no follow-up care outside of the ED. These data can be used to assess future changes in management trends and suggest that nonunion and symptomatic malunions are uncommon occurrences. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Patient physiology influences the MRI-based vertebral bone quality score.

BACKGROUND CONTEXT: Osteoporosis is a critical issue affecting postmenopausal women and the aging population. A novel magnetic resonance imaging (MRI)-based vertebral bone quality (VBQ) score has been proposed as a method to identify poor bone quality and predict fragility fractures. The diagnostic accuracy of this tool is not well understood. PURPOSE: To examine the ability of VBQ to predict osteoporosis and osteopenia, its correlation with dual-energy x-ray absorptiometry (DEXA), and the influence of patient-specific factors upon the score. STUDY DESIGN: Retrospective cohort study. PATIENT SAMPLE: Patients over the age of 18 with a DEXA scan and noncontrast, T1-weighted MRI of the lumbar spine completed within a 2-year period. OUTCOME MEASURES: Area-under-curve (AUC) values of the VBQ score predicting osteopenia and osteoporosis when controlling for patient characteristics. METHODS: Patients with noncontrast, T1-weighted MRIs of the lumbar spine and DEXA scans completed within a 2-year time frame were retrospectively reviewed. Patient demographics and medical risk factors for osteoporosis were identified and compared. VBQ scores were measured by two trained researchers and interrater reliability was calculated. Patients were separated into three groups defined by lowest DEXA T-score: Healthy Bone, Osteopenia, and Osteoporosis. analysis of variance, Kruskal-Wallis test, chi-square, t tests, Mann-Whitney U tests, and multivariate linear regression were performed to examine the relationship between patient characteristics, DEXA t-scores, and VBQ scores. Receiver operating characteristic analysis and AUC values were generated for the prediction of osteopenia and osteoporosis. RESULTS: A total of 156 patients were included for analysis. Sufficient inter-rater reliability was determined for VBQ measures (intraclass correlation coefficient: 0.81). Most patients were female (83%), postmenopausal (81%), and had hyperlipidemia (64%). Patients with hyperlipidemia and healthy bone density by DEXA had elevated baseline VBQ scores (p<.001) reflective of values seen in osteopenia and osteoporosis. The AUC of the VBQ score predicting osteopenia and osteoporosis changed to be more concordant with DEXA results after controlling for hyperlipidemia (AUC=0.72, 0.70 vs. AUC=0.88, 0.89; p<.001). Sub-analysis of hyperlipidemia subtypes revealed that elevated high-density lipoprotein is associated with elevated VBQ scores. CONCLUSIONS: Hyperlipidemia increased the MRI-based VBQ score in our healthy bone population. The high signal intensities resembled values seen in osteopenia and osteoporosis, suggesting that physiologic variables which impact bone composition may influence the VBQ score. Specifically, elevated high-density lipoprotein may contribute to this. The microarchitectural changes and the clinical implications of these factors need further exploration.

The effect of low preoperative platelet count on adverse outcomes following lumbar microdiscectomy.

Background: Low preoperative platelet count, or thrombocytopenia, has previously been associated with increased complications in elective spine surgeries. No other study has investigated the effects of abnormal coagulation profiles on postoperative outcomes specific to lumbar microdiscectomy (MLD) using a propensity matched cohort. Methods: Patient data was retrospectively retrieved from the National Surgical Quality Improvement Program database using Current Procedural Terminology (CPT) code 63030 to isolate patients who solely underwent MLD. Data was collected from 2010 to 2019 and included preoperative, perioperative, and 30-day postoperative variables. Patients were grouped into four platelet categories for ANOVA analysis and pairwise comparisons: Severe Thrombocytopenia (≤100), Thrombocytopenia (101-150), Moderate (151-199), and Normal (200-450). Variables that were significant in the univariate analysis were used in the multivariate analysis to determine the likelihood of experiencing adverse postoperative events - unplanned return to the operating room and surgical site infection. A propensity matched analysis was performed to control for confounding variables. Results: A total of 64,747 patients were identified within the 10-year period. The results of the multivariate analysis and the propensity matched analysis showed no significant differences in low preoperative platelet count as an independent predictor of experiencing a return to the operating room or surgical site infection. Furthermore, patients who had diabetes, history of smoking, or had emergency cases were associated with a high likelihood of experiencing these negative adverse events. Conclusion: Thrombocytopenia does not appear to independently predict return to the operating room or postoperative infection following MLD. Proper preoperative management strategies should be implemented to monitor comorbidity burden which would otherwise influence adverse outcomes in patients with thrombocytopenia undergoing MLD.

Distal Biceps Tendon Rupture Videos on YouTube: An Analysis of Video Content and Quality.

Purpose: Our purpose was to analyze the content and quality of YouTube videos related to distal biceps tendon (DBT) ruptures and repair. We aimed to compare differences between academic and nonacademic video sources. Methods: The most popular YouTube videos related to DBT injuries were compiled and analyzed according to source. Viewing characteristics were determined for each video. Video content and quality were assessed by 2 reviewers and analyzed according to the Journal of the American Medical Association benchmark criteria, DISCERN criteria, and a Distal Biceps Content Score. Cohen's kappa was used to measure interrater reliability. Results: A total of 59 DBT YouTube videos were included. The intraclass correlation coefficients ranged from moderate to excellent for the content scores. The mean DISCERN score was 29, and no videos were rated as either "good" or "excellent" for content quality. With the exception of the mean Journal of the American Medical Association criteria score (1.5 vs 0.5), videos from academic sources did not demonstrate significantly higher levels of content quality. Only 4/59 videos (7%) discussed the natural history of nonsurgically treated DBT ruptures. Of the 32 videos that discussed surgical techniques, only 3/32 (9%) had a preference for 2-incision techniques. No videos discussed the association between spontaneous DBT ruptures and cardiac amyloidosis. Conclusions: The overall content, quality, and reliability of DBT videos on YouTube are poor. Videos from academic sources do not provide higher-quality information than videos from nonacademic sources. Videos related to operative treatment of DBT ruptures more frequently discuss single-incision techniques. Clinical relevance: Social media videos can function as direct-to-consumer marketing materials, and surgeons should be prepared to address misconceptions regarding the management of DBT tears. Patients are increasingly seeking health information online, and surgeons should direct patients toward more reliable and vetted sources of information.

The Reliability of the CTS-6 for Examiners With Varying Levels of Clinical Experience.

PURPOSE: To assess the interrater reliability of the CTS-6 for examiners with varying levels of clinical expertise. We also aimed to analyze this instrument's sensitivity (Sn) and specificity (Sp), using the CTS-6 score obtained by a hand surgeon as a reference standard. METHODS: Three examining groups consisting of medical students, occupational hand therapists, and hand surgeons examined a consecutive series of patients in an academic upper-extremity clinic. A total of 3 examiners (1 from each group) recorded a CTS-6 score for each patient. The examiners were blinded to the scores from the other groups. The interrater reliability was determined between the groups with respect to the diagnosis of CTS and the individual CTS-6 components. Sn and Sp were calculated for each of the groups using the CTS-6 obtained by the hand surgeons as the reference standard. RESULTS: Two hundred seven patients were included. For the diagnosis of CTS (CTS-6 score of 12 or greater as determined by a hand surgeon), there was substantial agreement between the 3 groups (Fleiss kappa 0.73; 95% CI [0.65 -0.82]; P < .05). For individual CTS-6 components, the agreement between the groups was highest for assessing subjective numbness and lowest for assessing a Tinel sign (Fleiss kappa of 0.77 and 0.49, respectively). The Sn/Sp for diagnosing CTS was 87%/91% for the medical student group and 81%/95% for the occupational hand therapist group. CONCLUSIONS: The CTS-6 can be reliably used as a screening and diagnostic tool for CTS by clinicians with a variety of experience levels and without specific fellowship training in upper-extremity surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic I.

Evaluation of a Comprehensive Telemedicine Pathway for Carpal Tunnel Syndrome: A Comparison of Virtual and In-Person Assessments.

PURPOSE: We evaluated a comprehensive telemedicine pathway for carpal tunnel syndrome (CTS). Our primary aim was to compare telemedicine and in-person administration of the six item CTS-6 instrument (CTS-6) in patients undergoing carpal tunnel release (CTR) and to determine whether surgical plans determined via telemedicine were altered by in-person assessments. We additionally aimed to assess agreement between telemedicine and in-person examinations. METHODS: In this prospective investigation, patients referred to a hand surgeon for evaluation of CTS were offered a telemedicine pathway. A modified, virtual CTS-6 was administered during the telemedicine consultation and a virtual exam was performed. Patients indicated for CTR were evaluated in person on the day of surgery. Agreement between the telemedicine and in-person CTS-6 and exam findings was determined. Patients were evaluated via telemedicine postoperatively to determine satisfaction with the program and assess surgical complications. RESULTS: A total of 32 cases were included. The mean CTS-6 score administered via telemedicine was 17.7, compared with 16.8 in person; this difference was not statistically significant. There were no cases indicated for CTR during the telemedicine visit that had a subsequent change in management based on the in-person evaluation. Agreement was lowest for the sensory assessment (63%). The Phalen and Durkan compression tests demonstrated high levels of agreement (97% and 94%, respectively). Satisfaction was high for patients in the telemedicine CTS pathway. CONCLUSIONS: Overall agreement between telemedicine and in-person administration of the CTS-6 is high for patients with CTS. In patients indicated for CTR via telemedicine, an in-person examination does not appear to alter management. The telemedicine examination of hand sensation demonstrates lower levels of agreement with the in-person assessment. Telemedicine can serve as an alternative to conventional, in-person clinic visits for the diagnosis and postoperative management of uncomplicated, primary CTS. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

An analysis of body weight changes after shoulder arthroplasty.

BACKGROUND: To determine if there are postoperative weight changes for patients undergoing primary shoulder arthroplasty (SA). In addition, we aimed to determine if glycemic control (hemoglobin A1C levels) change postoperatively for patients undergoing SA. METHODS: All patients 18 years of age or older who had undergone primary SA over a 12-year period were analyzed. Patients were excluded if they did not have a preoperative body mass index or if they had less than 1-year follow-up. Baseline demographics were recorded for all patients and comparisons were made between the obese and nonobese groups. Clinically meaningful weight loss was defined as a ≥ 5% reduction in body weight postoperatively. RESULTS: A total of 469 patients met inclusion criteria. Of them, 65% of patients were obese, and the mean preoperative body mass index for all patients was 33. With a mean follow-up of 40 months, 70% of patients demonstrated clinically significant weight loss. Compared with patients without obesity, patients with obesity lost significantly more weight (10 vs. 6 kg) and demonstrated significantly greater postoperative body mass index reductions (4 vs. 2). Overall, 72% of patients with obesity demonstrated clinically meaningful postoperative weight loss of ≥5% body weight. Patients with obesity who lost weight also saw a decrease in their postoperative hemoglobin A1C: for every 10 pounds of weight loss, A1C decreased by 0.08 units. CONCLUSIONS: In our series, 72% of patients with obesity undergoing primary SA achieved clinically meaningful weight loss, with a mean follow-up of more than 3 years. Patients who lose weight after SA additionally demonstrate improved glycemic control. Surgeons and patients should balance the association between postoperative weight loss after SA with the potential increased risks of operative complications, particularly for severely obese patients.