Reducing the Syndesmosis Under Direct Vision: Where Should I Look?

OBJECTIVES: To compare the quality of syndesmotic reduction obtained using the incisura versus the ankle articular surface as the visual cue. Secondarily, we evaluated the difference in the anterior to posterior depth of the fibula to the tibia at the joint level and the fibula to the incisura 1 cm above the joint. METHODS: Seven surgeons reduced disrupted syndesmoses of 10 cadaveric ankles using either the anterolateral articular surface of the distal tibia to the anteromedial fibular articular surface or the location of the fibula within the incisura as a visual reference. Malreductions in translation were measured in millimeter from the anatomical position of the fibula. The anterior to posterior distances of the tibia and fibula were also measured at both levels to determine the differences in their depths. RESULTS: The translational reduction was within 2 mm in 93% (0.7 ± 0.7 mm) of reductions using the articular surface as a reference compared with 80% (1.2 ± 1.0 mm) using the incisura as a reference (P = 0.0001). All surgeons' reductions were better using the joint articular surface as the visual reference. The difference in the fibular and the tibial depth was smaller at the level of the articular surface versus the incisura (2.1 mm vs. 5.9 mm; P = 0.0002). CONCLUSIONS: The articular surface is a significantly more accurate visual landmark for translational reduction of the syndesmosis. This is potentially explained by the larger differences in the fibula and tibial depth at the incisura versus the articular surface.

Regional Variations of Medicare Physician Payments for Hand Surgery Procedures in the United States.

BACKGROUND: Medicare reimbursement is known to exhibit geographic variation for inpatient orthopedic procedures. This study determined whether US geographic variations also exist for commonly performed hand surgeries. METHODS: Using the Medicare Provider Utilization and Payment Data (2012-2013) from Centers for Medicare & Medicaid Services, we analyzed regional physician charges/payments for common outpatient hand surgeries. RESULTS: The most commonly performed procedures in the United States were open carpal tunnel release (n = 21 944), trigger finger release (n = 15 345), endoscopic carpal tunnel release (n = 7106), and basal joint arthroplasty/ligament reconstruction and tendon interposition (n = 2408). A range of average Medicare physician reimbursements existed based on geographic region for basal joint arthroplasty ($669-$571), endoscopic carpal tunnel release ($400-$317), open carpal tunnel release ($325-$261), and trigger finger release ($215-$167). The latter three exhibited statistically significant variation across geographic regions with regard to both charges and physician reimbursement. However, the overall percentage physician reimbursement (70%-79%) to charges was similar across all geographic regions. CONCLUSIONS: In conclusion, further research is warranted to determine why regional or geographic variations in physician payments exist in the United States for commonly performed hand surgeries.

In-Patient Trends and Complications After Total Ankle Arthroplasty in the United States.

The number of total ankle arthroplasties (TAAs) performed annually in the United States has increased. The purpose of this study was to evaluate the in-patient demographics, complications, and readmission rates of patients after TAA at academic medical centers in the United States. The University HealthSystems Consortium administrative database was searched for patients who underwent TAA in 2007 to 2011. A descriptive analysis of demographics was performed, followed by a similar analysis of clinical benchmarks, including hospital length of stay, hospital direct cost, in-hospital mortality, and 30-day readmission rates. The study included 2340 adult patients with a mean age of 62 years (47% men and 53% women) who underwent TAA. The majority of patients were Caucasian (2073; 88.5%). Average hospital length of stay was 2.2±1.26 days. Average total direct cost for the hospital was $16,212±7000 per case, with 49.7% of patients having private insurance. In-hospital mortality was less than 1%, and overall complications were 1.4%. Complications after discharge included deep venous thrombosis (2.3%), reoperation (0.7%), and infection (3.2%). A readmission rate of 2.7% within the first 30 days from the time of discharge occurred. Total ankle arthroplasty in the United States is a relatively safe procedure with low overall complication rates. Patients who are male, have a history of community-acquired pneumonia, and have a larger number of preoperative comorbidities had a significant increased risk of developing 1 complication within 30 days of surgery.

Urine matrix metalloproteinases (MMPs) as biomarkers for the progression of fracture healing.

Whilst the majority of fractures heal normally, it is estimated that ∼10% of fractures exhibit some level of delayed or impaired healing. Although radiography is the primary diagnostic tool to assess the progression of fracture healing, radiographic features only qualitatively correlate with tissue level increases in mineral content and do not quantitatively measure underlying biological processes that are associated with the progression of healing. Specific metaloproteinases have been shown to be essential to processes of both angiogenesis and mineralised cartilage resorption and bone remodelling at different phases of fracture healing. The aim of this study was to determine the potential of using a simple urine based assay of the activity of two MMPs as a means of assessing the biological progression of fracture healing through the endochondral phase of healing. Using a standard mid-diaphyseal murine model of femoral fracture, MMP9 and MMP13 proteins and enzymatic activity levels were quantified in the urine of mice across the time-course of fracture healing and compared to the mRNA and protein expression profiles in the calluses. Both urinary MMP9 and MMP13 protein and enzymatic activity levels, assessed by Western blot, zymogram and specific MMP fluorometric substrate assays, corresponded to mRNA expression and immunohistologic assays of the proteins within callus tissues. These studies suggest that urinary levels of MMP9 and MMP13 may have potential as metabolic markers to monitor the progression of fracture healing.