A 17-Year Experience in Hand and Digit Replantation at an Academic Center.

BACKGROUND RESULTS: of replantation surgery following upper extremity traumatic amputation are extensively described in the literature, with success rates varying from 57 to 100 percent. The purpose of this study was to evaluate replantation success rate at a Level I trauma center over a 17-year period and to assess definable factors contributing to these results. METHODS: A retrospective review of all digit and hand replantations at a Level I trauma center was performed using CPT codes from 2001 through 2018. Descriptive analyses, Mann-Whitney test, Kruskal-Wallis test, and logistic regressions were used. Significance was defined as p ≤ 0.05. RESULTS: Analysis consisted of 76 patients with 101 amputated parts (93 digits and eight hands). Fifty-six single digit amputations (30 percent success rate), 37 multidigit injuries (22 percent digit success rate), and eight hand amputations (50 percent success rate) were attempted. The overall success rate was 25 of 76 patients (33 percent) and 29 of 101 parts (29 percent). The most common mechanism of injury was laceration (n = 56), followed by crush (n = 30), and avulsion (n = 11), with repair of laceration-type injuries having the greatest success rate (36 percent). CONCLUSIONS: The authors report a lower success rate of hand and digit replantation than previously described in the literature. Whole hand and thumb replantations resulted in the highest survival rate in our series. Laceration mechanism showed a higher success rate than crush or avulsion-type injuries. The authors' modest results highlight the importance of effective internal auditing of low-volume replantation centers such as their own. Quality improvement measures are proposed for higher future success in replantation surgery at the authors' institution. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Patient Perception of Pain Control (Not Opiate Amount) Affects Hospital Consumer Assessment of Healthcare Providers and Systems and Press Ganey Satisfaction Scores After Orthopaedic Trauma.

INTRODUCTION: Opiate abuse is a public health issue linked to prescribing. Prescribing increased partly in response to adopting pain as the fifth vital sign. Assessing pain control on patient satisfaction surveys, including government-mandated Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and optional private surveys (Press Ganey) administered on hospital discharge, may contribute. This study evaluates whether opiate amounts affect orthopaedic trauma patient perception of pain control and overall hospital rating on HCAHPS and Press Ganey surveys. METHODS: Consecutive adult patients >18 years surgically treated for isolated fractures (UE = upper extremity, LE = lower extremity, and PA = pelvis/acetabulum) at a level 1 trauma center between January 1, 2014, and December 31, 2016, were retrospectively analyzed. Hospital charts, HCAHPS, and Press Ganey data were reviewed; patients without survey responses were excluded. Data included comorbidities, psychiatric history, substance use, injury type, and surgery. Analysis included Spearman's rho for correlations, Wilcoxon rank-sum and Kruskal-Wallis for continuous variables, and adjusted ordinal regression to estimate association between opioid prescribing and patient ratings. RESULTS: One hundred fifty-two total patients (UE 29, LE 112, and PA 11) with mean age of 57 years and median length of stay 3 days were included. Adjusted models showed longer duration outpatient prescriptions were associated with lower rating on how often inpatient pain was controlled (P = 0.002), lower total MME inpatient was associated with higher ratings (HCAHPS P = 0.015; Press Ganey, P = 0.03), lower average daily MME inpatient was associated with lower ratings (HCAHPS P = 0.008; Press Ganey, P = 0.037), and shorter outpatient prescription duration was associated with lower ratings (P = 0.008). Patient perception of pain control was strongly associated with overall HCAHPS (P < 0.05) and Press Ganey (P < 0.001) ratings. DISCUSSION: Inpatient and outpatient opiate amounts and duration demonstrated some associations with overall scores. However, patients' pain control perception seems to have the strongest relationship with hospital rating. Counseling and multimodal pain control may lead to strong satisfaction scores without needing high opiates after orthopaedic trauma.

Anatomic vs. reverse shoulder arthroplasty for the treatment of Walch B2 glenoid morphology: a systematic review and meta-analysis.

Background: Walch B2 glenoid morphology with glenohumeral osteoarthritis is a difficult degenerative pattern to manage for shoulder surgeons. Anatomic total shoulder arthroplasty (TSA) in combination with eccentric reaming or bone grafting are the traditional methods of treatment. Newer approaches such as TSA with posteriorly augmented glenoid components and reverse shoulder arthroplasty (RSA) may offer better stability for the posteriorly subluxated biconcave B2 wear pattern. The aim of this systematic review is to compare mid-term surgical and functional outcomes of Walch B2 glenoids without significant rotator cuff pathology treated with TSA and RSA. Methods: The review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines by searching the MEDLINE (PubMed) and Embase (Elsevier) databases. Inclusion criteria were clinical studies that evaluated the outcomes and complications of TSA or RSA in the setting of B2 glenoid morphology without significant rotator cuff pathology. Data relevant to TSA and RSA surgical outcomes were extracted and compiled, and outcomes were compared. A meta-analysis of proportions of complication and revision rates among TSA and RSA groups was performed. Results: Overall, 16 articles were included with 414 TSAs and 78 RSAs. The average follow-up duration was 54.1 ± 14.8 months for patients undergoing TSA and 44.8 ± 10.1 months for patients undergoing RSA. The TSA group was further subdivided based on the use of eccentric reaming (135 TSAs), an augmented glenoid component (84 TSAs), or bone grafting (11 TSAs) or was unspecified (184 TSAs). Overall, patients undergoing TSA and RSA demonstrated mean improvements of 50.1 ± 8.5° and 64.7 ± 5.2° in active flexion, 58.5 ± 10.3° and 68.9 ± not reported° in active abduction, and 31.3 ± 5.7° and 29.0 ± 10.2° in active external rotation, respectively. In regard to functional outcome scores, patients undergoing TSA and RSA showed mean Constant score improvements of 38.8 ± 5.3 and 46.6 ± 3.1 points and American Shoulder and Elbow Surgeons score improvements of 48.2 ± 1.0 and 49.2 ± 25.3 points, respectively. Results of the meta-analysis with mid-term follow-up data demonstrated pooled complication rates of 9% (95% confidence interval [CI], 1%-22%) for TSA and 6% (95% CI, 0%-28%) for RSA and pooled revision rates of 2% (95% CI, 0%-8%) for TSA and 1% (95% CI, 0%-15%) for RSA. Conclusion: In the setting of Walch B2 glenoid morphology, TSA with eccentric reaming or an augmented component yields comparable outcomes to RSA. Based on the patient's age, activity level, and expectations, both TSA and RSA can be considered a reasonable option to treat Walch B2 glenoid morphology.