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Postoperative Inpatient Conversions Following Ambulatory Orthopedic Surgery

Gonzalez, Matthew; Ganta, Abhishek; Sapienza, Anthony
BACKGROUND:Despite the recent trend toward outpatient orthopedic surgical procedures, there are patients who incur unanticipated conversions to inpatient status either immediately following ambulatory surgery or within days to weeks via presentation to the emergency department. The purpose of this study was to examine characteristics, co-morbidities, and causes of admissions in these populations in order to help identify factors for which strategies can be developed in order to minimize unanticipated admissions and medical costs. METHODS:Using a major academic medical center's bill-ing department's database, 95 outpatients were identified who were immediately converted into inpatient status and another 84 outpatients who were admitted within 30 days of surgery. The reasons for admission, length of procedure, length of admission, ASA score, comorbidities, and insur-ance type were assessed. RESULTS:For the patients who were converted to inpa-tient status postoperatively, pain accounted for 57% of conversions. Hypertension was the most commonly seen comorbidity (44%). In patients admitted within 30 days of ambulatory surgery, infection (25%) was the most common cause of admission. Smoking (46.4%) represented the most common comorbidity in this cohort. CONCLUSIONS:The majority of immediate inpatient con-versions were due to pain, emphasizing the need to optimize perioperative analgesia and provide impactful patient education regarding postoperative pain expectations. For patients admitted within 30 days of surgery, infection represented the majority of readmissions, and smoking was the most common comorbidity. While, some infections may be unavoidable, this stresses the importance of medical and social factor optimization prior to surgery. Addressing these factors leading to unanticipated admissions can have a profound effect on health care expenditures and patient outcomes.
PMID: 33207147
ISSN: 2328-5273
CID: 4672822

Tourniquet Use for Short Hand Surgery Procedures Done Under Local Anesthesia Without Epinephrine

Shulman, Brandon S; Rettig, Michael; Yang, S Steven; Sapienza, Anthony; Bosco, Joseph; Paksima, Nader
PURPOSE/OBJECTIVE:Wide-awake local anesthesia no tourniquet (WALANT) is an increasingly popular surgical technique. However, owing to surgeon preference, patient factors, or hospital guidelines, it may not be feasible to inject patients with solutions containing epinephrine the recommended 25 minutes prior to incision. The purpose of this study was to assess pain and patient experience after short hand surgeries done under local anesthesia using a tourniquet rather than epinephrine for hemostasis. METHODS:Ninety-six consecutive patients undergoing short hand procedures using only local anesthesia and a tourniquet (LA-T) were assessed before and after surgery. A high arm pneumatic tourniquet was used in 73 patients and a forearm pneumatic tourniquet was used in 23. All patients received a local, unbuffered plain lidocaine injection. No patients received sedation. Pain related to local anesthesia, pneumatic tourniquet, and the procedure was assessed using a visual analog scale (VAS). Patient experience was assessed using a study-specific questionnaire based on previous WALANT studies. Tourniquet times were recorded. RESULTS:Mean pain related to anesthetic injection was rated 3.9 out of 10. Mean tourniquet related pain was 2.9 out of 10 for high arm pneumatic tourniquets and 2.3 out of 10 for forearm pneumatic tourniquets. Patients rated their experience with LA-T favorably and 95 of 96 patients (99%) reported that they would choose LA-T again for an equivalent procedure. Mean tourniquet time was 9.6 minutes and only 1 patient had a tourniquet inflated for more than 20 minutes. Tourniquet times less than 10 minutes were associated with less pain than tourniquet times greater than 10 minutes (P < .05); however, both groups reported the tourniquet to be on average less painful than the local anesthetic injection. CONCLUSION/CONCLUSIONS:Short wide-awake procedures using a tourniquet are feasible and well accepted. Local anesthetic injection was reported to be more painful than pneumatic tourniquet use. Tourniquets for short wide-awake procedures can be used in settings in which preprocedure epinephrine injections are logistically difficult or based on surgeon preference. TYPE OF STUDY/LEVEL OF EVIDENCE/METHODS:Therapeutic IV.
PMID: 31924434
ISSN: 1531-6564
CID: 4257802

Musculoskeletal Injuries in Yoga

Klifto, Christopher S; Bookman, Jared S; Kaplan, Daniel J; Dold, Andrew P; Jazrawi, Laith M; Sapienza, Anthony
While yoga has been widely studied for its benefits to many health conditions, little research has been performed on the nature of musculoskeletal injuries occurring during yoga practice. Yoga is considered to be generally safe, however, injury can occur in nearly any part of the body-especially the neck, shoulders, lumbar spine, hamstrings, and knees. As broad interest in yoga grows, so will the number of patients presenting with yoga-related injuries. In this literature review, the prevalence, types of injuries, forms of yoga related with injury, specific poses (asanas) associated with injury, and preventive measures are discussed in order to familiarize practitioners with yoga-related injuries.
PMID: 31513523
ISSN: 2328-5273
CID: 4088332

Bone Graft Options in Upper-Extremity Surgery

Klifto, Christopher S; Gandi, Sapan D; Sapienza, Anthony
Bone grafting in the upper extremity is an important consideration in patients with injuries or conditions resulting in missing bone stock. A variety of indications can necessitate bone grafting in the upper extremity, including fractures with acute bone loss, nonunions, malunions, bony lesions, and bone loss after osteomyelitis. Selecting the appropriate bone graft option for the specific consideration is important to ensure optimal patient outcomes. Considerations such as donor site morbidity and the amount and characteristics of bone graft needed all weigh in the decision making regarding which type of bone graft to use. This article reviews the options available for bone grafting in the upper extremity.
PMID: 29980395
ISSN: 1531-6564
CID: 3186282

Assessment of Pronator Quadratus Repair Integrity Using Dynamic Ultrasonography Following Volar Plate Fixation for Distal Radius Fractures

Hinds, Richard M; Montero-Lopez, Nicole; Brock, Kenneth; Adler, Ronald; Sapienza, Anthony; Capo, John T; Paksima, Nader
BACKGROUND:Previous work evaluating the pronator quadratus (PQ) muscle following volar plate fixation (VPF) of distal radius fractures (DRF) suggests that PQ repair often fails in the postoperative period. The purpose of this investigation was to assess PQ repair integrity following VPF of DRF using dynamic musculoskeletal ultrasonography. METHODS:Twenty adult patients who underwent VPF of DRF with repair of the PQ with a minimum follow-up of 3 months underwent bilateral dynamic wrist ultrasonography. The integrity of the PQ repair, wrist range of motion (ROM) and strength, and functional outcome scores were assessed. RESULTS:Mean patient age at the time of surgery was 59 ± 14 years, and 50% underwent VPF of their dominant wrist. Patients were evaluated at a mean 9 ± 4 months after VPF. All patients had an intact PQ repair. The volar plate was completely covered by the PQ in 55% of patients and was associated with a larger PQ when compared to patients with an incompletely covered volar plate ( P = .026). The flexor pollicis longus tendon was in contact with the volar plate in 20% of patients, with those patients demonstrating a trend toward significantly increased wrist flexion ( P = .053). No difference in ROM, strength, or outcome scores was noted among wrists with completely or incompletely covered volar plates. CONCLUSIONS:The PQ demonstrates substantial durability after repair following VPF. Wrist ROM, strength, and functional outcomes are similar in wrists in which the volar plate is completely or incompletely covered by the repaired PQ.
PMID: 30003811
ISSN: 1558-9455
CID: 3192682

Scaphoid Nonunions

Klifto, Christopher; Ramme, Austin; Sapienza, Anthony; Paksima, Nader
Scaphoid nonunions are challenging injuries to manage and the optimal treatment algorithm continues to be debated. Most scaphoid fractures heal when appropriately treated; however, when nonunions occur, they require acute treatment to prevent future complications like scaphoid nonunion advanced collapse. Acute nonunion treatment technique depends on nonunion location, vascular status of the proximal pole, fracture malalignment, and pre-existing evidence of arthrosis. Bone grafting and vascular grafts are common in nonunion management. Chronic nonunions that have progressed to scaphoid nonunion advanced collapse often require a salvage procedure such as four corner fusions, proximal row carpectomy, or wrist fusion. Herein, we review the current literature regarding scaphoid nonunions with regards to their anatomy, natural history, classification, diagnostic imaging, surgical management, and clinical outcomes.
PMID: 29537954
ISSN: 2328-5273
CID: 2992792

Scaphoid Healing Necessary for Unrestricted Activity: A Biomechanical Cadaver Model

Guss, Michael S; Mitgang, Joshua T; Sapienza, Anthony
PURPOSE/OBJECTIVE:To determine if scaphoid fractures with bridging bone of 50% of their width treated with a centrally placed screw will restore biomechanical integrity equivalent to that of the intact scaphoid. METHODS:Twenty-four fresh cadaver scaphoids were used. Six were left intact to serve as the control group. Six were osteotomized 50% of their width and made up the osteotomy without screw group. Six were included in the 50% osteotomy plus compression screw group. The remaining 6 were to be treated with an osteotomy of 25% or 75% with a screw, based upon the results of the 50% osteotomy with screw group. Biomechanical testing was performed using an Instron testing machine, with a load applied to the scaphoid's distal pole. Load to failure and stiffness were measured. RESULTS:Intact scaphoids had an average load to failure of 610.0 N. The average load to failure of the 50% osteotomy group without a screw was 272.0 N and with a screw was 666.3 N. There was no significant difference in load to failure between the 50% osteotomy plus screw and the intact scaphoid. The 75% osteotomy plus screw was found to have a load to failure of 174.0 N, significantly lower than the intact scaphoid. The 50% osteotomy plus screw had a significantly higher stiffness than the intact scaphoid control. CONCLUSIONS:A 50% intact scaphoid with a centrally placed screw showed similar load to failure and significantly higher stiffness than the intact scaphoid when tested in cantilever bending. CLINICAL RELEVANCE/CONCLUSIONS:This study demonstrates that patients with scaphoid waist fractures who undergo surgery with a compression screw may be able to return to unrestricted activity with 50% partial healing.
PMID: 29122424
ISSN: 1531-6564
CID: 2908522

Flexor Tendon Injuries

Klifto, Christopher S; Capo, John T; Sapienza, Anthony; Yang, S Steven; Paksima, Nader
Flexor tendon injuries of the hand are uncommon, and they are among the most challenging orthopaedic injuries to manage. Proper management is essential to ensure optimal outcomes. Consistent, successful management of flexor tendon injuries relies on understanding the anatomy, characteristics and repair of tendons in the different zones, potential complications, rehabilitation protocols, recent advances in treatment, and future directions, including tissue engineering and biologic modification of the repair site.
PMID: 29303923
ISSN: 1940-5480
CID: 2899522

Management of Pisotriquetral Instability

Shulman, Brandon S; Rettig, Michael; Sapienza, Anthony
Pisotriquetral instability is an often-overlooked condition that can lead to ulnar-sided wrist pain and dysfunction. Various case series and biomechanical studies have been published regarding the diagnosis and treatment of this condition. We review current methods for examining, diagnosing, and treating pisotriquetral instability.
PMID: 29169722
ISSN: 1531-6564
CID: 2898732

The Relationships Between Surface Measurements and Underlying Tendon Autograft Length for Upper Extremity Reconstructive Surgery

Milone, Michael T; Starecki, Mikael; Ayalon, Omri; Aversano, Michael W; Sapienza, Anthony
PURPOSE: The availability of tendon grafts is an important consideration for successful upper extremity reconstructive surgery, including flexor or extensor tendon reconstructions, tendon transfers, and ligament reconstructions. Graft selection is based on availability, expendability, ease of harvest, and length. Given variations in patient height and extremity length, existing average values may provide suboptimal insight into actual tendon lengths available. The purpose of this study is, therefore, to pursue a method of estimating available donor tendon lengths based on easily measured anatomical surface landmarks. METHODS: Thirty cadaveric upper and lower extremity limbs were dissected and the length of commonly harvested tendon grafts including the palmaris longus, extensor indicis proprius, extensor digiti minimi, plantaris, and second long toe extensor was measured. Surface forearm length (from finger tip to cubital fossa) and surface fibular length (from lateral malleolus to fibular head) were also measured. Correlations between surface measurements and underlying tendon lengths were analyzed, and linear models were generated that predicted tendon length as a function of surface measurements. RESULTS: Surface measurements were correlated with underlying tendon length (R = 0.46 - 0.66). Linear models could predict tendon lengths based on surface measurements (P < .05). A ratio of donor tendon length compared with the limb segment measured was established for each tendon and can be applied to estimate donor tendon length. For the upper extremity tendons, the multipliers for the palmaris longus, extensor indicis proprius, and extensor digiti minimi were 0.51, 0.20, and 0.18, respectively. Lower extremity tendon ratios for the plantaris and extensor digitorum longus were 0.69 and 0.60, respectively. CONCLUSIONS: Although length of available donor tendon can be a limiting variable at the time of surgery, surgeons may be better able to estimate underlying tendon lengths using easily obtained superficial measurements. CLINICAL RELEVANCE: Information obtained from these cadaveric measurements may aid in preoperative planning in hand and upper extremity surgery.
PMID: 28606434
ISSN: 1531-6564
CID: 2617792