The August 2024 Wrist & Hand Roundup³⁶⁰ looks at: Methotrexate shows potential in reducing pain for hand osteoarthritis with synovitis; Circumferential casting versus plaster splinting in adult distal radius fractures: the CAST study findings; Surgery shows superior long-term success for Dupuytren contracture compared to needle fasciotomy and collagenase injection; Evolving trends in surgical management of wrist arthritis: a decade-long national analysis; Mid-term outcomes of three commonly used surgical reconstructions for scapholunate instability; SLAC and SNAC: what is the evidence for treatment?; Steroids for trapeziometacarpal osteoarthritis?; When is it safe to return to driving after distal radius fracture fixation? A prospective study.

Aims

The present study aimed to investigate whether patients with inflammatory bowel disease (IBD) undergoing joint arthroplasty have a higher incidence of adverse outcomes than those without IBD.

Canada is second only to the United States worldwide in the number of opioid prescriptions per capita. Despite this, little is known about prescription patterns for patients undergoing total joint arthroplasty (TJA). The purpose of this study was to detail preoperative opioid use patterns and investigate the effect it has on perioperative quality outcomes in patients undergoing elective total hip and total knee arthroplasty surgery (THA and TKA). The study cohort was constructed from hospital Discharge Abstract Data (DAD) and National Ambulatory Care Reporting System (NACRS) data, using Canadian Classification of Health Intervention codes to select all primary THA and TKA procedures from 2017-2020 in Nova Scotia. Opioid use was defined as any prescription filled at discharge as identified in the Nova Scotia Drug Information System (DIS). Emergency Department (ED) and Family Doctor (FD) visits for pain were ascertained from Physician Claims data. Multivariate logistic regression was used to test for associations controlling for confounders. Chi-squared statistics at 95% confidence level used to test for statistical significance. In total, 14,819 TJA patients were analysed and 4306 patients (29.0%) had at least one opioid prescription in the year prior to surgery. Overall, there was no significant difference noted in preoperative opiate use between patients undergoing TKA vs THA (28.8% vs 29.4%). During the period 2017-2019 we observed a declining year-on-year trend in preoperative opiate use. Interestingly, this trend failed to continue into 2020, where preoperative opiate use was observed to increase by 15% and exceeded 2017 levels. Within the first 90 days of discharge, 22.9% of TKA and 20.9% of THA patients presented to the ED or their FD with pain related issues. Preoperative opiate use was found to be a statistically significant predictor for these presentations (TKA: odds ratio [OR], 1.45; 95% confidence interval [CI], 1.29 to 1.62; THA: OR, 1.46; 95% CI, 1.28 to 1.65). Preoperative opioid consumption in TJA remains high, and is independently associated with a higher risk of 90 day return to the FD or ED. The widespread dissemination of opioid reduction strategies introduced during the middle of the last decade may have reduced preoperative opiate utilisation. Access barriers and practice changes due to the COVID-19 pandemic may now have annulled this effect

Aims

The aim of this study was to identify the risk factors for adverse events following the surgical correction of cervical spinal deformities in adults.

Aims

Femoroacetabular impingement (FAI) describes abnormal bony contact of the proximal femur against the acetabulum. The term was first coined in 1999; however what is often overlooked is that descriptions of the morphology have existed in the literature for centuries. The aim of this paper is to delineate its origins and provide further clarity on FAI to shape future research.

The objective of this study was to quantify the burden of musculoskeletal disorders (MSDs) on the Ontario health care system. Specifically, we examined the magnitude and costs of MSD-associated ambulatory physician care and hospital service use, considering different physician types (e.g. primary care, rheumatologists, orthopaedic surgeons) and hospital settings (e.g. emergency department (ED), day surgery, inpatient hospitalizations). Administrative health data were analyzed for fiscal year 2013/14 for adults aged 18+ years (N=10,841,302). Data sources included: Ontario Health Insurance Plan Claims History Database, which captures data on in- and out-patient physician services, Canadian Institute for Health Information (CIHI) Discharge Abstract Database, which records diagnoses and procedures associated with all inpatient hospitalizations, and CIHI National Ambulatory Care Reporting System, which captures data on all emergency department (ED) and day surgery encounters. Services associated with MSDs were identified using the single three digit International Classification of Diseases (ICD) version 9 diagnosis code provided on each physician service claim for outpatient physician visits and the “most responsible” ICD-10 diagnosis code recorded for hospitalizations, ED visits and day surgeries. Patient visit rates and numbers of patients and visits were tabulated according to care setting, patient age and sex, and physician specialty. Direct medical costs were estimated by care setting. Data were examined for all MSDs combined as well as specific diagnostic groupings, including a comprehensive list of both trauma and non-trauma related conditions. Overall, 3.1 million adult Ontarians (28.5%) made 8 million outpatient physician visits associated with MSDs in 2013/14. These included 5.6 million primary care visits, nearly 15% of all adult primary care visits in the province. MSDs accounted for 560,000, 12.3%, of all adult ED visits. Patient visit rates to the ED for non-trauma spinal conditions were the highest of all MSDs at 1032 per 100,000 population, accounting for 23% of all MSD-related ED visits. Osteoarthritis had the highest rate of inpatient hospitalization of all MSDs at 340 per 100,000 population, accounting for 42% of all MSD-related admissions. Total costs for MSD-related care were $1.6 billion, with 12.6% of costs attributed to primary care, 9.2% to specialist care, 8.6% to ED care, and 61.2% of total costs associated with inpatient hospitalizations. Costs due to ‘arthritis and related conditions’ as a group accounted for 40.1% of total MSD costs ($966 million). Costs due to non-trauma related spinal conditions accounted for 10.5% ($168 million) of total MSD costs. All trauma-related conditions (spine and non-spine combined) were responsible for 39.4% ($627 million) of total MSD costs. MSD-related imaging costs for patients who made physician visits for MSDs were $169 million. Including these costs yields a total of $1.8 billion. MSDs place a significant and costly burden on the health care system. As the population ages, it will be essential that health system planning takes into account the large and escalating demand for MSD care, both in terms of health human resources planning and the implementation of more clinically and cost effective models of care, to reduce both the individual and population burden

Aims

Natural Language Processing (NLP) offers an automated method to extract data from unstructured free text fields for arthroplasty registry participation. Our objective was to investigate how accurately NLP can be used to extract structured clinical data from unstructured clinical notes when compared with manual data extraction.

Aims. Medical comorbidities are a critical factor in the decision-making process for operative management and risk-stratification. The Hierarchical Condition Categories (HCC) risk adjustment model is a powerful measure of illness severity for patients treated by surgeons. The HCC is utilized by Medicare to predict medical expenditure risk and to reimburse physicians accordingly. HCC weighs comorbidities differently to calculate risk. This study determines the prevalence of medical comorbidities and the average HCC score in Medicare patients being evaluated by neurosurgeons and orthopaedic surgeon, as well as a subset of academic spine surgeons within both specialities, in the USA. Methods. The Medicare Provider Utilization and Payment Database, which is based on data from the Centers for Medicare and Medicaid Services’ National Claims History Standard Analytic Files, was analyzed for this study. Every surgeon who submitted a valid Medicare Part B non-institutional claim during the 2013 calendar year was included in this study. This database was queried for medical comorbidities and HCC scores of each patient who had, at minimum, a single office visit with a surgeon. This data included 21,204 orthopaedic surgeons and 4,372 neurosurgeons across 54 states/territories in the USA. Results. Orthopaedic surgeons evaluated patients with a mean HCC of 1.21, while neurosurgeons evaluated patients with a mean HCC of 1.34 (p < 0.05). The rates of specific comorbidities in patients seen by orthopaedic surgeons/neurosurgeons is as follows: Ischemic heart disease (35%/39%), diabetes (31%/33%), depression (23%/31%), chronic kidney disease (19%/23%), and heart failure (17%/19%). Conclusion. Nationally, comorbidity rate and HCC value for these Medicare patients are higher than national averages for the US population, with ischemic heart disease being six-times higher, diabetes two-times higher, depression three- to four-times higher, chronic kidney disease three-times higher, and heart failure nine-times higher among patients evaluated by orthopaedic surgeons and neurosurgeons. Cite this article: Bone Joint Open 2020;1-6:257–260

Aims

The outcomes of total knee arthroplasty (TKA) depend on many factors. The impact of implant design on patient-reported outcomes is unknown. Our goal was to evaluate the patient-reported outcomes and satisfaction after primary TKA in patients with osteoarthritis undergoing primary TKA using five different brands of posterior-stabilized implant.

Informed consent is a very important part of surgical treatment. In this paper, we report a number of legal judgements in spinal surgery where there was no criticism of the surgical procedure itself. The fault that was identified was a failure to inform the patient of alternatives to, and material risks of, surgery, or overemphasizing the benefits of surgery. In one case, there was a promise that a specific surgeon was to perform the operation, which did not ensue. All of the faults in these cases were faults purely of the consenting process. In many cases, the surgeon claimed to have explained certain risks to the patient but was unable to provide proof of doing so. We propose a checklist that, if followed, would ensure that the surgeon would take their patients through the relevant matters but also, crucially, would act as strong evidence in any future court proceedings that the appropriate discussions had taken place. Although this article focuses on spinal surgery, the principles and messages are applicable to the whole of orthopaedic surgery.

Cite this article: Bone Joint J 2019;101-B:355–360.

Over the past two decades much has been written regarding pain and disability following whiplash injury. Several authors have reported on the relationship between insurance claims and whiplash-associated disorders. Our own experience of over 10-years suggests that fracture may be protective of whiplash injury following road traffic accident (RTA). We exported all ‘medical legal’ cases due to RTA from our EMR system and combined this with patient-reported outcome measures. 1,482 (57%) of all medicolegal cases are due to RTA: 26% ‘head-on’, 34% ‘side-impact’ and 40% ‘rear-ended’. Over half of the vehicles involved are subsequently written-off. While the mean BMI is 27.1, ¼ of this cohort has a BMI over 30 (obese). 163 (11%) patients report a fracture occurring as a result of RTA. Type of impact is significant for fracture (p < 0.05). 47% of RTA which result in fracture are due to ‘head-on’ collision; conversely only 21% are due to ‘rear-ended’ impacts. In 1,324 (89%) of RTA without fracture, patients are twice as likely to report whiplash injury as one of their top-3 sources of pain (p < 0.01). Gender is statistically significant for age (M 44.4, F 38.6, p < 0.05). While the BMI of this cohort is alarming, it is consistent with Irish obesity statistics. Type of impact, in particular ‘head-on’ collision (high kinetic energy event), is significant for fracture. Finally, we report that fracture is significantly protective (p < 0.01) of whiplash injury following RTA.

Use of large databases for orthopaedic research has increased exponentially. Each database represents unique patient populations and vary in methodology of data acquisition. The purpose of this study was to evaluate differences in reported demographics, comorbidities and complications following total hip arthroplasty (THA) amongst four commonly used databases. Patients who underwent primary THA during 2010–2012 were identified within National Surgical Quality Improvement Programs (NSQIP), Nationwide Inpatient Sample (NIS), Medicare Standard Analytic Files (MED) and Humana Claims Database (HAC). NSQIP definitions for comorbidities and surgical complications were queried in NIS, MED, and HAC using coding algorithms. Age, sex, comorbidities, inpatient and 30-day postoperative complications were compared (NIS has inpatient data only). Primary THAs from each database were 22,644 (HAC), 371,715 (MED), 188,779 (NIS) and 27,818 (NSQIP). Age and gender distribution were similar between databases. There was variability in the prevalence of comorbidities and complications depending upon the database and duration of post-operative follow-up. HAC and MED had twice the prevalence of COPD, coagulopathy and diabetes than NSQIP. NSQIP had more than twice the obesity than NIS. HAC had more than twice the rates of 30-day complications at all endpoints compared to NSQIP and more than twice the DVTs, strokes and deep infection as MED at 30-days post-op. Comparison of inpatient and 30-day complications rates demonstrated more than twice the amount of infections and DVTs are captured when analysis is extended from inpatient stay to 30-days post-op. Amongst databases commonly used in orthopaedic research, there is considerable variation in complication rates following THA depending upon the database. It will be important to consider these differences when critically evaluating database research. Additionally, with the advent of bundled payments, these differences must be considered in risk adjustment models

Litigation costs are significant and increasing annually within the National Health Service (NHS) in England.

The aim of this work was to evaluate the burden of successful litigation relating to hip surgery in England. Secondary measures looked at identifying the commonest causes of successful legal action.

A retrospective review was conducted on the National Health Service Litigation Authority (NHSLA) database. All successful claims related to hip surgery over a 10 year period from 2003–2013 were identified. A total of 798 claims were retrieved and analysed.

The total cost of successful claims to the NHS was £66.3 million. This compromised £59 million in damages and £7.3 million in NHS defence-related legal costs. The mean damages for settling a claim were £74,026 (range £197-£1.6million). The commonest cause of claim was post-operative pain with average damages paid in relation to this injury being £99,543. Nerve damage and intra-operative fractures were the next commonest cause of claim with average damages settled at £103,465.

Legal action in relation to hip surgery is a considerable source of cost to the NHS. The complexity of resolving these cases is reflected in the associated legal costs which represent a significant proportion of payouts. With improved understanding of factors instigating successful legal proceedings, physicians can recognise areas where practice and training need to be improved and steps can be taken to minimise complications leading to claims.

There are numerous examples in medicine where “eminence trumps evidence.” The direct anterior approach (DA) is no exception. Its meteoric rise has largely been driven by industry and surgeon promotion. This surgical approach continues to garner interest, but this interest is largely for marketing purposes, as emerging data would suggest a high risk, low reward operation. In addition, factors such as selection bias and impact bias, have substantially swayed peoples interest into making an inferior operation look better. There are several factors related to the direct anterior approach that should give us pause. Those include the surgeon learning curve, limited functional benefit and increased complications. There is no question the DA approach for total hip arthroplasty (THA) has a long and steep learning curve. The majority of studies would suggest at minimum, 50–100 cases before a surgeon is comfortable with this approach and some studies would suggest the technical difficulties of this approach remain an issue even with increasing experience. This proves difficult with an attempted rapid adoption of this technique by a surgeon who may perform less than 50 THAs per year but feel the need to offer this approach to their patients for marketing purposes. One of the many touted benefits of the DA approach is the perception of improved functional outcomes. Many of the early studies showed early improvement in gait, pain and mobility. However, these studies compared the DA approach to an anterolateral approach. Even when compared to the anterolateral approach, considered the most invasive and least muscle sparing, the benefits of the DA approach were only short term (6 weeks). The majority of retrospective studies, prospective randomised studies and meta-analyses comparing DA to a posterior approach show little, if any, benefit of one approach over another with regards to functional benefit. Another touted benefit includes a low or no dislocation risk associated with the posterior approach. On the contrary many studies have failed to demonstrate lower dislocation rates with the DA approach compared to a contemporary posterior approach. A recent registry study from the Michigan Arthroplasty Registry Quality Initiative (MARQI) showed equal dislocation rates between the DA and posterior approach. Concerns have also been raised regarding unique and more frequent complications with the DA approach compared to other surgical approaches for total hip arthroplasty. Unique complications such as ankle fractures and a high incidence of nerve injury, especially damage to the lateral femoral cutaneous nerve, have been reported. In addition, the data now clearly show a higher incidence of complications on the femoral side, including early loosening and periprosthetic fracture. As responsible surgeons, if we want to say the DA approach is different, then fine, we can say it's different. Claims of superiority of one approach over another have not been born our in the literature and in fact much of the data would suggest a high risk no reward operation for the DA approach compared to other surgical approaches for total hip arthroplasty

Aims

Patients with diabetes are at increased risk of wound complications after open reduction and internal fixation of unstable ankle fractures. A fibular nail avoids large surgical incisions and allows anatomical reduction of the mortise.