Direct and indirect costs associated with nonoperative treatment for shoulder instability: an observational study in 132 patients.

BACKGROUND: Shoulder instability is associated with decreased functioning. The associated costs could be substantial and interesting to clinicians, researchers, and policy makers. This prospective observational study aims to (1) estimate productivity losses and healthcare expenses following the nonoperative treatment of shoulder instability and (2) identify patient characteristics that influence societal costs. METHODS: One hundred and thirty-two patients completed a questionnaire regarding production losses and healthcare utilization following consecutive episodes of shoulder instability. Productivity losses were calculated using the friction cost approach. Healthcare utilization was evaluated using standard costs. analysis of variance test was used to assess which patient characteristics are related to productivity losses and healthcare expenses. Societal costs were assessed using multilevel analyses. Bootstrapping was used to estimate statistical uncertainty. RESULTS: Mean productivity losses are €1469, €881, and €728 and mean healthcare expenses are €3759, €3267, and €2424 per patient per dislocation for the first, second, and third dislocation. Productivity losses decrease significantly after the second (mean difference €-1969, 95%CI= -3680 to -939) and third (mean difference €-2298, 95%CI= -4092 to -1288) compared to the first dislocation. CONCLUSIONS: Nonoperative treatment of shoulder instability has substantial societal costs. LEVEL OF EVIDENCE: III, economic analysis.

Quantitative 3-dimensional Computerized Tomography Modeling of Isolated Greater Tuberosity Fractures with and without Shoulder Dislocation.

BACKGROUND: The aim of this study was to assess differences in fracture morphology and displacement between isolated greater tuberosity (GT) fractures (i.e. fractures of the greater tuberosity without other fractures of the proximal humerus) with and without shoulder dislocation utilizing quantitative 3-dimensional CT imaging. METHODS: Thirty-four CT-scans of isolated greater tuberosity fractures were measured with 3-dimensional modeling. Twenty patients (59%) had concomitant dislocation of the shoulder that was reduced prior to CT-scanning. We measured: degree and direction of GT displacement, size of the main fracture fragment, the number of fracture fragments, and overlap of the GT fracture fragment over the intact proximal humerus. RESULTS: We found: (1) more overlap -over the intact humerus- in patients without concomitant shoulder dislocation as compared to those with shoulder dislocation (P=0.03), (2) there was a trend towards greater magnitude of displacement between those without (mean 19mm) and those with (mean 11mm) a concomitant shoulder dislocation (P=0.07), and (3) fractures were comparable in direction of displacement (P=0.50) and size of the fracture fragment (P=0.53). CONCLUSION: We found substantial variation in degree and direction of displacement of GT fracture fragments. Variation in degree of overlap and displacement is partially explained by concomitant shoulder dislocation.

Melone's Concept Revisited: 3D Quantification of Fragment Displacement.

We applied quantitative 3D computed tomography to 50 complete articular AO type C fractures of the distal radius and tested the null hypothesis that fracture fragments can be divided according to Melone's concept (radial styloid and volar and dorsal lunate facet fragments) and that each fragment has similar (1) displacement and (2) articular surface area. Thirty-eight fractures fit the Melone distribution of fragments. Radial styloid fragments were most displaced, and volar lunate fragments were least displaced. Volar lunate fragments had the largest articular surface area. While these findings confirm Melone's concepts, the finding that volar lunate fragments are relatively large and dorsal lunate fragments relatively small suggests that alignment of the volar lunate fragment with the radial styloid may be the key element of treatment and the dorsal lunate fragment may not routinely benefit from specific reduction and fixation.

Progression of Heterotopic Ossification around the Elbow after Trauma.

BACKGROUND: This study addresses the null hypothesis that there is no expansion of heterotopic ossification (HO) in the elbow beyond what can be seen early on. METHODS: The area of HO was measured on lateral radiographs of 38 consecutive patients that had operative treatment of HO between 2000 and 2013. Measurements from radiographs obtained between 3 to 7 weeks were compared to measurements from radiographs made 3 months or more after injury. RESULTS: There was no significant difference between the average area of HO on the first (median 2.8 square centimeters, Q1: 1.5, Q3: 5.1) and later radiographs (median of 2.8 square centimeters, Q1: 1.4, Q3: 5.0) (P = 0.99). CONCLUSION: According to our results the area of HO does not expand beyond what can be seen early in the disease process.

Quantitative three-dimensional computed tomography analysis of glenoid fracture patterns according to the AO/OTA classification.

HYPOTHESIS/BACKGROUND: This study measures the characteristics of glenoid fractures to determine if the AO Foundation and Orthopaedic Trauma Association (AO/OTA) classification captures the most common fracture patterns. The primary null hypothesis was that surface area and degree of fragmentation do not differ among the different fracture types. Secondarily, we tested if there was a relationship between high- vs. low-energy trauma and fracture classification. METHODS: Three-dimensional models were created for a consecutive series of 53 fractures. The fracture classifications, the number of fragments, and the fragmented articular surface area were related to the type of injury. The difference of articular surface size and number of fragments among classification groups was analyzed with the Kruskal-Wallis test. RESULTS: There is a significant difference in fractured articular surface area among classification groups. Compared with transverse and multifragmented fractures, both anterior and posterior fractures involved significantly less of the articular surface area. High-energy trauma is associated with transverse and multifragmented fractures in 93% of the cases. It is associated with a greater number of fracture fragments and fracture of a larger percentage of the glenoid surface area, with a mean fractured surface of 60% for high-energy fractures and 25% for low-energy injuries. DISCUSSION/CONCLUSION: Quantitative 3-dimensional CT analysis confirms that the current AO/OTA classification adequately characterizes and discriminates glenoid fracture patterns. The classification groups are related to the fragmented articular surface area and the number of fragments. Also, the mechanism of injury is related to the classification group, which supports the clinical relevance of the classification.

What Is the Radiographic Prevalence of Incidental Kienböck Disease?

BACKGROUND: Kienböck disease is characterized by osteonecrosis of the lunate. Not all patients with radiographic evidence of the disease experience symptoms bothersome enough to consult a doctor. Little research has been performed on the prevalence of Kienböck disease, and the prevalence in the asymptomatic population is unclear. Knowledge of the natural course of the disease and how often patients are not bothered by the symptoms is important, because it might influence the decision as to whether disease-modifying treatment would be beneficial. QUESTIONS/PURPOSES: (1) What is the prevalence of incidental and symptomatic Kienböck disease? (2) What are the factors associated with incidental and symptomatic Kienböck disease? (3) Are there differences in Lichtman stage distribution between incidentally discovered and symptomatic Kienböck disease? METHODS: We retrospectively searched radiology reports of all MRI scans, CT scans, and radiographs that included the wrists of 51,071 patients obtained over an 11-year period at one institution to screen for Kienböck disease and avascular necrosis of the lunate. Corresponding MR images, CT scans, or radiographs were reviewed by an orthopaedic hand surgeon to confirm the presence of Kienböck disease when the report was inconclusive. The medical record was reviewed to determine whether the radiographic Kienböck disease was incidental. Prevalences were calculated for both symptomatic and incidental Kienböck disease. Additionally, we assessed the association of age, sex, and race with incidental and symptomatic Kienböck disease as well as the radiographic severity according to the Lichtman classification and calculated odds ratios. RESULTS: We identified 51 cases (0.10%) of incidental Kienböck disease and 87 cases (0.17%) of symptomatic Kienböck disease out of 51,071 patients. Patients with incidental Kienböck were older (mean, 54 years; SD, 17; mean difference, -6.1; 95% confidence interval [CI], -11 to -0.96; p = 0.020) and patients with symptomatic Kienböck disease were younger (mean, 43 years; SD, 14; mean difference, 5.1; 95% CI, 1.2-9.0; p = 0.010) compared with the group of patients without Kienböck disease (mean, 48 years; SD, 19). Lunate collapse (Lichtman Stages III and IV) was seen in nine of 51 patients (18%) with incidental Kienböck disease and in 44 of 87 patients (51%) with symptomatic Kienböck disease (odds ratio, 0.21; 95% CI, 0.086-0.51; p < 0.001). Our study did not identify any other factors associated with Kienböck disease. CONCLUSIONS: We found that Kienböck disease is diagnosed on radiographs in a notable number of asymptomatic patients and that asymptomatic patients are more likely to have precollapse stages of the disease. This suggests that symptoms and disability do not correlate with pathophysiology, progression, or activity. Patients and surgeons benefit from awareness that symptoms are not a good indicator of the severity or prognosis of pathophysiology and that lunate osteonecrosis can exist with no or insufficient symptoms. This is important when considering treatment, because we cannot distinguish active disease at risk of collapse that could merit disease-modifying treatment from disease that will not progress. LEVEL OF EVIDENCE: Level III, prognostic study.

Quantitative 3-dimensional CT analyses of fractures of the middle phalanx base.

BACKGROUND: Quantitative 3-dimensional computed tomography (3DCT) analyses can provide a more detailed understanding of fracture morphology. For fracture-dislocation of the proximal interphalangeal joint, the extent of fragmentation of the volar lip of the middle phalanx-a factor that might influence treatment-is not always apparent from radiographs. We hypothesized that there is no correlation between number of fracture fragments and the percentage of articular surface area involved in intra-articular fractures of the base of the middle phalanx using quantitative 3DCT analyses. METHODS: We used 13 computed tomography scans with a slice thickness of 1.25 mm or less to create 3-dimensional models of 15 intra-articular fractures of the base of the middle phalanx in 13 patients. We resized 3-dimensional models of a non-fractured middle phalanx of the same hand to fit the fractured middle phalanx in order to approximate the size and shape of the fractured middle phalanx in its pre-injury state. We created a heatmap to demonstrate the location of the fractured articular surface. RESULTS: With the number of scans available, we did not find a significant correlation between the percentage of articular surface area involved and the number of fracture fragments. The median percentage of articular surface area involved was 46 % (range, 21-90 %). The heatmap demonstrated that the radio-volar side of the articular surface seems to be more involved than the ulnar-volar side in intra-articular fractures of the base of the middle phalanx. CONCLUSION: Quantitative 3DCT analysis of fracture fragments provides useful information that could facilitate surgery and analysis of complex fractures of the base of the middle phalanx. LEVEL OF EVIDENCE: IV, Basic Science Study, Anatomic Study, Imaging.

[Scapula alata following a gunshot injury]. / Scapula alata na een schotverwonding.

BACKGROUND: The clinical condition "winged scapula" (scapula alata) is frequently not recognized as such. The accompanying symptoms are often attributed to more frequently occurring shoulder disorders, which can lead to unnecessary surgical procedures. CASE DESCRIPTION: A 41-year-old man was shot during a robbery 3 years ago, resulting in a complete paraplegia from the fourth thoracic vertebra downwards. Within a year of the attack, during rehabilitation towards wheelchair use, he developed pain around his right shoulder. He also had diminished strength when extending his right arm and problems with trunk balance. These symptoms were long thought to be caused by shoulder overuse during wheelchair use, but turned out to be a consequence of injury to the long thoracic nerve. CONCLUSION: Shoulder symptoms due to scapula alata can be caused be a penetrating wound leading to nerve injury. The treatment of patients with a scapula alata calls for a multidisciplinary approach.

Does verbal and nonverbal communication of pain correlate with disability?

BACKGROUND: Illness (symptoms and disability) consistently correlates more with coping strategies and symptoms of depression than with pathophysiology or impairment. OBJECTIVE: This study tested the primary null hypothesis that there is no correlation between verbal and nonverbal communication of pain (pain behavior) and upper extremity-specific disability in patients with hand and upper extremity illness. METHODS: A total of 139 new and followed up adult patients completed the QuickDASH, an ordinal rating of pain, and 4 Patient-Reported Outcomes Measurement Information System (PROMIS) Computer Adaptive Testing instruments: (1) PROMIS pain behavior, (2) PROMIS pain interference (measuring the degree to which pain interferes with achieving ones physical goals), (3) PROMIS physical function, and (4) PROMIS depression. RESULTS: Factors associated with a higher QuickDASH score in bivariate analysis included a higher PROMIS pain behavior score, not working, being separated/divorced or widowed, having sought treatment before, having other pain conditions, a higher PROMIS pain interference score, a higher PROMIS depression score, and lower education level. The final multivariable model of factors associated with QuickDASH included PROMIS pain interference, having other pain conditions, and being separated/divorced or widowed, and it explained 64% of the variability. CONCLUSION: PROMIS pain behavior (verbal and nonverbal communication of pain) correlates with upper extremity disability, but PROMIS pain interference (the degree to which pain interferes with activity) is a more important factor. LEVEL OF EVIDENCE: Level IV, cross-sectional study.

Estimation of base of middle phalanx size using anatomical landmarks.

PURPOSE: To determine whether there is a measurable and reproducible relationship between the articular surface size of the middle phalanx base and the size of the middle phalanx head and proximal phalanx length of the same finger. METHODS: Size of the articular surface of the middle phalanx base, size of the middle phalanx head, and proximal phalanx length were measured in 84 lateral radiographs by 3 observers. RESULTS: The ratio of articular surface size of the middle phalanx base to the proximal phalanx length of the same finger was 0.17. The ratio of articular surface size of the middle phalanx base to the size of the middle phalanx head of the same finger was 1.34. The intraclass correlation (ICC) among 3 raters was 0.99 for proximal phalanx length and 0.88 for size of the middle phalanx head. CONCLUSIONS: Knowledge of this relationship and ratios allow for accurate estimation of the percentage of articular surface involvement in a fracture of the middle phalanx base. The ICC was highest for measuring proximal phalanx length, making it the most reliable measurement for estimation of the articular surface size. CLINICAL RELEVANCE: This quantitative estimate may be useful for clinical research and is applicable to patient care.