Elbow Arthritis.

Elbow arthritis is an uncommon condition that can cause debilitating pain, stiffness, or instability. The most common etiologies include rheumatoid arthritis, posttraumatic arthritis, and primary osteoarthritis. Treatment begins with nonsurgical modalities, including activity modification, anti-inflammatories, hand therapy, and corticosteroids. Operative intervention may be considered once nonsurgical management has failed. Surgical treatment depends on the underlying etiology, chief complaint, patient age, and functional demand. Advances in technology, especially arthroscopic techniques, have expanded the treatment options available to surgeons. The goals of treatment include pain relief and restoration of functional range of motion. The purpose of this article is to review the pertinent soft tissue and osseous anatomy, discuss the etiologies, review the principles of diagnosis and evaluation, and finally, study the treatment options for elbow arthritis.

Risk Factors and Reasons for Emergency Department Visits Within 30 Days of Elective Hand Surgery: An Analysis of 3,261 Patients.

Background: The frequency of hand and elbow surgeries occurring in outpatient and elective settings is on the rise. Emergency department (ED) visits in the postoperative period are increasingly used as quality measures for surgical care. The aim of this study is to determine the number of postoperative ED visits, the primary reason for these visits, and to identify risk factors associated with these visits. Methods: We examined all elective hand and elbow procedures performed at two hospitals within a single healthcare network between 2008 and 2017. A total of 3,261 patients met the study criteria. Descriptive statistics were calculated for our population, followed by univariate and multivariate analyses, to identify risk and protective factors associated with ED visits in the first 30 days after surgery. Results: Eighty-seven of 3,261 patients presented to the ED within 30 days of their operation (2.7%). The most common reasons for ED visits were related to pain (28.7%), swelling (26.4%), and concerns for infection (20.7%). Univariate analysis indicated history of drug use, number of procedures, smoking history, and serum albumin <3.5 mg/dL as risk factors for returns to the ED. Multivariate analysis identified history of drug use, number of procedures, and serum albumin <3.5 mg/dL as independent risk factors. Smoking history failed to achieve statistical significance as an independent risk factor. Both univariate and multivariate analyses identified age >60 years as protective for postoperative ED visits. Conclusions: ED visits within the first 30 days after elective hand surgery are relatively common, despite remarkably low complication rates among these procedures. This information may help to improve risk stratification in these patients, and to aid in the development of enhanced postoperative follow-up strategies to reduce unnecessary utilization of emergency medical services. Level of Evidence: Level III (Therapeutic).

Effect of Smoking on Short-term Postoperative Complications After Elective Upper Extremity Surgery.

Background: There is a paucity of literature exploring the impact of smoking on short-term complications, readmissions, and reoperations after elective upper extremity surgery using a large multicenter national database. We hypothesized that smokers will have an increased rate of complications, readmissions, and reoperations compared with a cohort of nonsmokers undergoing elective upper extremity surgery. Methods: Patient data were collected from the American College of Surgeons National Surgical Quality Improvement Program database between the years 2012 and 2017. Patients were included if they underwent elective surgery of the upper extremity using 338 predetermined Current Procedural Terminology codes. The data collected were divided into patient demographics, comorbidities, perioperative variables, and 30-day complications. Current smoking status was defined as smoking within 1 year prior to surgery. The incidence of surgical complications, reoperations, and readmissions was compared between the 2 cohorts using multivariable regression analysis. Results: Of the 107 943 patients undergoing elective surgeries of the upper extremity, 73 806 met the inclusion criteria. Of these, 57 986 (78.6%) were nonsmokers in the year prior to surgery, and 15 820 (21.4%) were current smokers. Between these groups, current smokers were younger (P < .001), more often men (P < .001), had lower body mass index (P < .001), and more often underwent procedures that involved bone manipulation (P < .001). Multivariate regression analysis defined current smoking as significantly associated with overall surgical site complications, superficial surgical site infections, deep surgical site infections, reoperation, and readmission. Conclusion: Current smoking was significantly associated with an increase in all surgical site complications, readmissions, and reoperations after elective upper extremity surgery. Surgeons should consider smoking a modifiable risk factor for postoperative complications and appropriately counsel patients on outcomes and complications given the elective nature of upper extremity surgery.

Effect of Diabetes and Hemoglobin A1c on Complications Following Elective Hand Surgery.

Background: Limited research exists investigating the association between diabetes and glycemic control on complications following elective hand surgery. The goal of this research was to assess the incidence of complications within 30 days of elective hand surgery in a large population of diabetic patients compared to a population of non-diabetics. Furthermore, we sought to examine the relationship of glycemic control, as measured by HbA1c, and postoperative complications. Methods: We performed a retrospective review of electronic medical records at our institution of all patients who underwent elective hand, forearm, or elbow surgery from the dates of January 1st, 2008 to December 31st, 2017. Patients were categorized as diabetic or non-diabetic and most recent HbA1c was documented. Multivariable analysis was employed to compare the incidence of surgical complications within 30 days between the diabetics and non-diabetic populations, adjusting for baseline patient characteristics. Results: A total of 3,261 patients met the inclusion criteria. There were 646 (20%) diabetic patients and 2,615 (80%) non-diabetic patients. No difference was found in the overall rate of complications between the cohort of diabetic and non-diabetic patients. Additionally, statistical analysis found no difference in the complication rate between insulin and non-insulin controlled diabetics. Rates of complications were stratified based on HbA1c level and statistical analysis found no increased risk of complications with increased hemoglobin A1c value. Conclusions: In our present study we were not able to demonstrate any significant difference in the 30 day complication rates between and non-diabetics undergoing elective hand surgery. This study attempted to aid in risk stratification of diabetic patients by evaluating preoperative glycemic indices in the form of HbA1c.

Glenohumeral arthrodesis.

Glenohumeral arthrodesis is a salvage procedure indicated for brachial plexus palsy, refractory instability, humeral and/or glenoid bone loss, deltoid and rotator cuff insufficiency, and chronic infections. The aim is to provide a painless, stable shoulder that is positioned to maximize function. Scapulothoracic motion as well as motion of the elbow and hand deliver satisfactory function in most patients. Intra-articular, extra-articular, and more commonly, combined techniques involving glenohumeral and humeroacromial fusion, have been described. More recently, authors have reported arthroscopic assisted techniques for shoulder arthrodesis with promising results as well as less complicated conversion from shoulder arthrodesis to reverse total shoulder arthroplasty. Despite advances in materials and techniques, glenohumeral arthrodesis continues to be associated with complication rates as high as 43%. A thorough understanding of the indications, contraindications, outcomes, and complications is paramount to improving patient results. Glenohumeral arthrodesis is a safe and effective procedure for the appropriate indications. The high frequency of complications mandates a frank preoperative discussion to ensure that each patient understands the magnitude of the procedure, its risks, possible complications, and expected outcome.

Systematic review and network meta-analysis of subscapularis management techniques in anatomic total shoulder arthroplasty.

BACKGROUND: Controversy exists regarding the optimal subscapularis management technique in patients undergoing anatomic total shoulder arthroplasty. The purpose of this study was to compare clinical, radiographic, and functional outcomes between subscapularis tenotomy (ST), lesser tuberosity osteotomy (LTO), and subscapularis peel (SP) techniques. METHODS: We performed a level III systematic review and network meta-analysis comparing ST, LTO, and SP in patients undergoing anatomic total shoulder arthroplasty. Our primary collection endpoints included range of motion, subscapularis function, subscapularis healing, functional patient-reported outcomes, complications, and revision surgery. Data were pooled and network meta-analysis was performed owing to the comparison of 3 groups. RESULTS: Eight studies met our inclusion criteria for meta-analysis. There was no difference in sex or primary diagnosis between the 3 cohorts. No significant difference was found in postoperative external rotation or forward flexion between the groups. Meta-analysis found the SP cohort to have significantly greater internal rotation strength than the ST cohort. The belly-press test results were negative most commonly in the LTO group, and there was a significant difference compared with the ST or SP group (P < .0001). The weighted-mean healing rate for the LTO site was 98.9% on radiographic imaging. There was a significantly higher ultrasound healing rate in the LTO cohort than in the ST and SP cohorts. All groups had good postoperative patient-reported outcome scores (average American Shoulder and Elbow Surgeons score range, 78.6-87) and a relatively low rate of complications (3%). CONCLUSION: This network meta-analysis demonstrates that the LTO group has superior healing and postoperative subscapularis-specific physical examination test results compared with the ST and SP groups. However, no difference in postoperative range of motion was found between the groups, and all techniques demonstrated good functional patient-reported outcomes, with a low rate of postoperative complications. These findings provide evidence-based support that ST, SP, and LTO all demonstrate similar outcomes; therefore, selection should be based on surgeon experience and comfort.

Clinical and Radiographic Outcomes of Femoral Head Fractures Associated with Traumatic Hip Dislocations.

BACKGROUND: Femoral head fractures are an uncommon but severe injury. These high-energy injuries typically occur in association with traumatic hip dislocations. Initial treatment includes urgent concentric reduction; however, controversy exists regarding specific fracture management. The well-known complications of avascular necrosis (AVN), posttraumatic arthritis (PTA), and heterotrophic ossification can leave patients with a significant functional loss of their affected hip. The purpose of this study is to evaluate the clinical and radiographic outcomes of femoral head fractures. METHODS: A retrospective review was performed at our institution assessing all patients who presented from 2007 to 2015 with a femoral head fracture associated with a hip dislocation and at least 6 months of clinical and radiographic follow-up. Twenty-two patients met our inclusion criteria. There were 15 males and 7 females with an average age of 36 years (range: 17-55). The average follow-up time was 18 months (range: 6-102). Fractures were classified according to the Pipkin classification. The Thompson and Epstein score was used to determine functional outcomes. RESULTS: There were five, Pipkin I, 3 Pipkin II, 0 Pipkin III, and 14 Pipkin IV, femoral head fractures. Sixteen patients were successfully closed reduced in the emergency department (ED) and six patients required open reduction after failed reduction in the ED. Four patients (18%) were successfully treated with closed reduction alone and 18 patients (82%) required operative intervention. Of those undergoing operative intervention, one patient underwent excision of the femoral head fragment, seven underwent open reduction internal fixation (ORIF) of the femoral head, nine underwent ORIF of the acetabulum, and one underwent ORIF of the femoral head and the acetabulum. Nine patients (41%) had an uneventful postoperative course. Two patients (9%) developed AVN, both requiring total hip arthroplasty (THA). Five patients (23%) developed PTA, two eventually requiring a THA. Two patients (9%) had sciatic nerve palsy. One patient (5%) developed a postoperative infection and four patients (18%) developed heterotrophic ossification (HO), none requiring operative treatment. Two patients (9%) had persistent anterolateral (AL) thigh numbness. Overall functional results were excellent in six patients (27%), good in six (27%), fair in seven (32%), and poor in three patients (14%). Four patients (18%) required a THA. CONCLUSION: Femoral head fractures are a rare injury with well-known complications. Early diagnosis and concentric reduction are the prerequisites for successful treatment. This study adds to the growing literature on femoral head fractures associated with hip dislocations in efforts to define treatment plans and to guide patient expectations. HOW TO CITE THIS ARTICLE: Del Core MA, Gross B, Ahn J, et al. Clinical and Radiographic Outcomes of Femoral Head Fractures Associated with Traumatic Hip Dislocations. Strategies Trauma Limb Reconstr 2019;14(1):6-10.

Gender Differences on SF-36 Patient-Reported Outcomes of Diabetic Foot Disease.

The primary aim of this study was to evaluate the impact of gender on health-related quality of life (HRQOL) using a generic (Short Form-36 [SF-36]) and region-specific (Foot and Ankle Ability Measure [FAAM]) health measurement tool among a matched cohort of male and female patients with diabetes-related foot complications. The HRQOL of 240 patients with diabetic foot disease was measured using the SF-36 and the FAAM surveys. A total of 120 male patients were matched with 120 female patients with the same primary diagnosis, age, type, and duration of diabetes and insulin use. The SF-36 physical component summary (PCS) and mental component summary (MCS) scores were calculated using orthogonal and oblique rotation methods. The median age of the respondents was 54 years (interquartile range = 46-61). No differences in patient characteristics were found between genders. Among the SF-36 subscales, women reported significantly worse physical function ( P = .014) and bodily pain ( P = .021) scores with a trending decrease in general health score ( P = .067). Subsequently, women had worse orthogonal ( P = .009) and oblique PCS scores ( P = .036) than men. However, orthogonal ( P = .427) or oblique ( P = .140) MCS scores did not differ between groups. No significant differences in FAAM scores with respect to gender were appreciated. Our findings suggest that in patients with diabetic foot disease, women tend to report lower physical HRQOL compared with men. In efforts to increase compliance, providers should recognize the impact of gender on patients' perceptions of foot-related complications of diabetes. This knowledge may improve outcomes by adapting more individualized and gender-specific approaches to patients.

Scoring Mental Health Quality of Life With the SF-36 in Patients With and Without Diabetes Foot Complications.

The aim of this study was to examine if using orthogonal and oblique factor analysis detect changes in health-related quality of life differently in diabetic patients on the Short Form-36 (SF-36) survey. A total of 155 patients had diabetic foot complications (DFC), and 145 patients had no DFCs. The SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were calculated using scoring coefficients determined by orthogonal and oblique rotation principle component analyses of the subscales. The DFC group had lower orthogonal ( P < .00001) and oblique PCS scores ( P < .00001). However, despite lower Mental Health subscale scores in the patients with DFCs, orthogonal MCS scores ( P = .156) did not differ. In contrast, the oblique MCS scores reflected the difference in the Mental Health subscale ( P = .0005). Orthogonal and oblique PCS scores did not differ significantly. However, orthogonal MCS scores were significantly higher than oblique MCS scores in those with DFCs ( P = .0004) and without DFCs ( P = .005). The shorter, 12-item SF-12 survey demonstrated similar results. Poorer physical function leads to higher orthogonal MCS scores than if determined by oblique scoring coefficients since Physical Function, Bodily Pain, and General Health are weighted more negatively in orthogonal coefficients when calculating the MCS score. Oblique scoring coefficients may address this issue, but further study is necessary to confirm whether oblique MCS scores accurately represent the mental health of patients with diabetic foot disease.

Functional Outcomes After Operative Treatment of Calcaneal Fractures: Midterm Review.

The purpose of this article is to report midterm follow-up of operatively treated calcaneus fractures. All patients with a calcaneus fracture, treated with open reduction and internal fixation (ORIF) using the extensile lateral approach, were identified. Functional outcomes were assessed using the American Orthopaedic Foot and Ankle Society's (AOFAS) ankle-hindfoot assessment, SF-36, and a questionnaire. There were 20 patients (25 fractures): 16 males and four females. The average age was 42 years (range, 16-73 years) and the mean follow-up time was 40 months (range, 13-73 months). The mean AOFAS score was 67.8 (SD = 19.3) and the mean SF-36 score was 55.7 (SD = 26.3). Patients in an motor vehicle accident had more associated injuries. Statistically significantly worse AOFAS scores were noted in patients with ORIF > 21 days after their injury (p = .047). Many lifestyle alterations were found to be present, including change in work, participation in recreational activities, footwear, and use of ambulatory assistive devices.