The Iowa orthopaedic journal最新文献

Background: 30-day readmission is an important quality metric evaluated following primary total joint arthroplasty (TJA) that has implications for hospital performance and reimbursement. Differences in how 30-day readmissions are defined between Centers for Medicare and Medicaid Services (CMS) and other quality improvement programs (i.e., National Surgical Quality Improvement Program [NSQIP]) may create discordance in published 30-day readmission rates. The purpose of this study was to evaluate 30-day readmission rates following primary TJA using two different temporal definitions.

Methods: Patients undergoing primary total hip and primary total knee arthroplasty at a single academic institution from 2015-2020 were identified via common procedural terminology (CPT) codes in the electronic medical record (EMR) and institutional NSQIP data. Readmissions that occurred within 30 days of surgery (consistent with definition of 30-day readmission in NSQIP) and readmissions that occurred within 30 days of hospital discharge (consistent with definition of 30-day readmission from CMS) were identified. Rates of 30-day readmission and the prevalence of readmission during immortal time were calculated.

Results: In total, 4,202 primary TJA were included. The mean hospital length of stay (LOS) was 1.79 days. 91% of patients were discharged to home. 30-day readmission rate using the CMS definition was 3.1% (130/4,202). 30-day readmission rate using the NSQIP definition was 2.7% (113/4,202). Eight readmissions captured by the CMS definition (6.1%) occurred during immortal time.

Conclusion: Differences in temporal definitions of 30-day readmission following primary TJA between CMS and NSQIP results in discordant rates of 30-day readmission. Level of Evidence: III.

Background: Core curricula do not include courses on how to find employment after hand fellowships. Little data exists in literature regarding job selection in hand surgery. This study's purpose was to provide information to future hand surgeons on ways of finding a job that meets their expectations and to elucidate factors that should be considered before deciding on a hand practice.

Methods: A web-based survey asked hand fellows and fellowship applicants how they were searching for employment, the kind of practice they sought, expectations about hours, call, salary, possible niches, and importance of location, research, and passive income. A second survey was sent to hand surgeons. Statistical analysis determined how fellow expectations differed from reality.

Results: Prospective hand surgeons completed 96 of 270 (36%) surveys and hand surgeons completed 63/107 (59%). Most prospective hand surgeons utilize word of mouth, mentors/faculty to search for employment, whereas most surgeons received connections through residency, friends/ family, or cold calling. The niches that prospective hand surgeons planned to bring to their practice differed from those of practicing surgeons. Expectations of call matched those of practicing hand surgeons, with most expecting to work 50 to 60 hours per week. For prospective surgeons, location and passive income were important but research was less so. Most hand surgeons have passive income and indicated low research participation.

Conclusion: Minimal training in job selection has been cited as a reason for changing jobs. The applicants' and fellows' expectations on call, work hours, passive income, and research were similar to hand surgeons, but the niches they hoped to fill differed, perhaps indicating those may not be possible in actual practice. This study provides perspective on what practice as a hand surgeon is like and things to consider when job searching. Level of Evidence: IV.

Background: Dislocation remains a common complication following total hip arthroplasty (THA). Previous literature has shown that the femoral head-to-neck ratio is essential in hip motion, function, and stability. While large femoral heads and dual mobility bearings have been developed to improve stability, it remains unknown if the ratio between femoral head size to acetabular cup size also plays a role in stability. This study aimed to investigate if the relationship between the femoral head size and the acetabular cup size factors into the risk of hip dislocation.

Methods: 3155 patients who underwent primary THA for the indication of osteoarthritis between 2016 and 2019 were identified. Patient demographic, radiographic, implant and procedural data were analyzed. The primary outcome was determining head-to-cup ratios calculated by dividing the femoral head size by the acetabular cup size. Head-to-cup ratios were then compared in patients who suffered a dislocation after THA to those who did not. Univariate and logistic regression was conducted to determine additional dependent variables for hip dislocation.

Results: Patients in this study had an average age of 64 ± 11 years. Females comprised 51% of the cohort, and BMI was 29.2 ± 5.2. A total of thirty-six (1.1%) patients sustained a dislocation at a median of 51 days following surgery. The dislocation cohort was similar to the non-dislocation cohort in age, gender, BMI, CCI, and ASA scores. The head-to-cup ratio was also identical between the dislocation (0.64 ± 0.05 mm) and non-dislocation (0.64 ± 0.05 mm) patients, P=0.317. Logistic regression adjusting for age, sex, BMI, and surgical approach demonstrated that the head-to-cup ratio was not associated with an increased risk of dislocation (p=0.728).

Conclusion: Head-to-cup ratio was not found to be predictive of dislocation. Hip dislocation is complex and multifactorial, and it is difficult to isolate specific risks, such as the head-to-cup ratio analyzed in our study. Further investigation is needed to define groups benefiting from specialized implants such as large-diameter or dual mobility heads and the optimal head-to-cup size ratio. Level of Evidence: III.

Tarsal tunnel syndrome (TTS) refers to compression of the posterior tibial nerve as it traverses the tarsal tunnel in the ankle. First described by Keck and Lam in 1962, TTS is an underdiagnosed cause of heel pain and foot dysfunction.^1,2 The tarsal tunnel contains the tibial nerve, posterior tibial artery, and tendons of the tibialis posterior, flexor digitorum longus, and flexor hallucis longus muscles. Compression of the tibial nerve within this tunnel leads to pain, numbness, tingling, and weakness along its distribution. The clinical presentation of TTS can vary due to the numerous etiologies and range of structures involved. Symptoms may develop insidiously over months to years or have a traumatic onset. Lack of definitive clinical tests or imaging often delays diagnosis, which contributes to poor patient outcomes and treatment success. In severe or long-standing cases, permanent nerve damage may occur if left untreated. TTS deserves increased recognition given its potential to significantly impact mobility and quality of life. This review provides a comprehensive overview of the anatomy, etiology, diagnosis, and management of TTS. Optimal strategies to diagnose and treat this condition based on available evidence are discussed to improve patient outcomes and limit disability. Early diagnosis and intervention are key to avoiding permanent nerve injury and maximizing the benefits of treatment, whether conservative or surgical.

Background: Recognizing ACL injuries on the field and in the office can be very challenging in awake and apprehensive patients. Despite high specificity, many published "pivot-shift" techniques have limited acceptance mainly because of unsatisfactory sensitivity. We describe in detail, four specific modifications and provide a critical review of our clinical experiences to empower the new user's readiness to master a novel screening procedure for ACL disruption.

Methods: 18 cadavers assessed instability kinematics of the novel technique. Clinical Exam Study Part II-A (ACL Disrupted): 208 awake, hemarthrosis patients with MRI evidence of ACL deficiency underwent 363 examinations by 41 examiners. Clinical Exam Study Part II-B: (ACL Intact) 47 consecutive posttraumatic hemarthrosis patients with intact ACLs underwent 76 examinations by 30 examiners.

Results: Cadaveric study confirmed patterns of coupled, anterior translation-internal rotation pathologic laxity at 25.6±8.2 degrees flexion. Clinically, the novel test yielded sensitivity of 94.7% and Specificity of 97.3%. Potentially perplexing situations included: MRI availability; pain and anxiety-related traumatic hemarthrosis, protective hamstring antagonism and examiners experience.

Conclusion: When the examiner and patient agree on a feeling of instability, the Albright-Losee Test maximizes ability to establish ACL status in the awake patient to the point that the sensitivity is even greater than the Lachman Test. Armed with background knowledge of our experiences confirms that, despite of impact of various challenging factors, the Positive Predictive Value 98.8% 95% CI (95.5%-99.7%) that a torn ACL exists in face of a positive exam confirms its value for sports medicine providers to master. Level of Evidence: II.

Background: The orthopaedic surgery residency match is becoming increasingly more competitive with a disproportionate number of applicants to positions. As the residency application process has become more competitive, applicants have resorted to applying broadly to improve their chance of a successful match. Preference signaling was implemented for orthopaedic surgery for the 2022-2023 match cycle which allowed applicants to "signal" 30 programs of their choosing.

Methods: The purpose of this study was to assess the impact of preference signaling on orthopaedic surgery applicant experiences and outcomes in the 2023 residency application cycle and match. An anonymous electronically based survey study developed using Research Electronic Data Capture (REDCap) was send to 895 applicants to a single orthopedic residency program. 148 applicants filled out some portion of the survey for a 16.5% response rate.

Results: 51% of applicants applied to 61-100 programs. Applicants received more interview offers from programs they signaled compared to programs they did not signal. 50% of applicants responded that the number of allotted signals was "just right", with more applicants responding that the number of signals allotted was "too many" rather than "too few". 62% of applicants agreed that signaling increased his/her chances of receiving an interview offer at a signaled program, 66% were satisfied with the results of the match, and 50% thought signaling had a positive impact on the application process.

Conclusion: Overall, preference signaling was well received by applicants and may help to connect applicants with residency programs they are specifically interested in. Level of Evidence: III.

Background: Female athletes are at increased risk for anterior cruciate ligament (ACL) injuries. The influence of hormonal variation on female ACL injury risk remains ill-defined. Recent data suggests that the collagen-degrading menstrual hormone relaxin may cyclically impact female ACL tissue quality. This review aims to identify any correlation between menstrual relaxin peaks and rates of female ACL injury.

Methods: A systematic review was performed, utilizing the MEDLINE, EMBASE, and CINAHL databases. Included studies had to directly address relaxin/female ACL interactions. The primary outcome variable was relaxin proteolysis of the ACL, at cellular, tissue, joint, and whole-organism levels. The secondary outcome variable was any discussed method of moderating relaxin levels, and the clinical results if available.

Results: AllThe numerous relaxin receptors on female ACLs upregulate local collagenolysis and suppress local collagen production. Peak serum relaxin concentrations (SRC) occur during menstrual cycle days 21-24; a time phase associated with greater risk of ACL injury. Oral contraceptives (OCPs) reduce SRC, with a potential ACLprotective effect.

Conclusion: A reasonable correlative and plausible causative relationship exists between peak relaxin levels and increased risk of ACL injury in females, and further investigation is warranted. Level of Evidence: III.