Publications by authors named "James Genuario"

18 Publications

  • Page 1 of 1

Return-to-Play Outcomes in Professional Baseball Players After Nonoperative Treatment of Incomplete Medial Ulnar Collateral Ligament Injuries: A Long-Term Follow-up Study.

Am J Sports Med 2021 04 15;49(5):1137-1144. Epub 2021 Mar 15.

UCHealth Steadman Hawkins Clinic-Denver, Englewood, Colorado, USA.

Background: Medial ulnar collateral ligament (UCL) injuries are common among baseball players. There is sparse literature on long-term results after nonoperative treatment of UCL injuries in professional baseball players.

Purpose: The primary purpose was to assess long-term follow-up on reinjury rates, performance metrics, rate of return to the same level of play or higher (RTP), and ability to advance to the next level of play in professional baseball players after nonoperative treatment of incomplete UCL injuries. The secondary aim was to perform a matched-pair comparison between pitchers treated nonoperatively and a control group without a history of UCL injuries.

Study Design: Cohort study; Level of evidence, 3.

Methods: Twenty-eight professional baseball players (18 pitchers, 10 position players) treated nonoperatively were identified from a previous retrospective review of a single professional baseball organization between 2006 and 2011. UCL reinjury rates and player performance metrics were evaluated at long-term (minimum, 9 years) follow-up. Rates of RTP were calculated. A matched-pair comparison was made between the pitchers treated nonoperatively and pitchers without a history of UCL injuries.

Results: Overall, 27 players (17 pitchers, 10 position players) were available for long-term follow-up at a mean follow-up of 12 years (SD, 2 years). The overall rate of RTP was 85% (23/27), with the rate of RTP being 82% (14/17) in pitchers and 90% (9/10) in position players. Of the 23 players who did RTP, 18 (78%) reached a higher level of play and 5 (21.7%) stayed at the same level. Of the 9 position players who did RTP, the median number of seasons played after injury was 4.5 (interquartile range, 3.3). Of the 14 pitchers who did RTP, the mean number of seasons played after injury was 5.8 (SD, 3.8). In the matched-pair analysis, no significant differences were observed in any performance metrics (P > .05). The overall reinjury rate was 11.1% (3/27), with no players requiring UCL reconstruction.

Conclusion: There was a high rate of RTP for professional baseball players treated nonoperatively for incomplete UCL injuries. Compared with a matched cohort with no history of UCL injury, professional baseball pitchers treated nonoperatively had similar performance metrics. Reinjury rates were low, and no player had reinjury requiring UCL reconstruction. Nonoperative treatment of incomplete UCL injuries in professional baseball players, specifically pitchers, is a viable treatment option in the long term.
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http://dx.doi.org/10.1177/0363546521996706DOI Listing
April 2021

Distal Adductor Longus Avulsion: A Technique for Successful Repair.

Arthrosc Tech 2019 Jun 23;8(6):e617-e622. Epub 2019 May 23.

Department of Orthopedic Surgery and Radiology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, U.S.A.

Strains of the adductor muscle are common among athletes, but avulsion at its insertion is rare. Likewise, the diagnosis and management of distal ruptures of the adductors are infrequently reported in the literature. Presented here are the common presenting clinical findings of chronic distal adductor longus tendon ruptures and a description of how these can be successfully treated with a previously undescribed surgical technique. Preoperative and postoperative magnetic resonance imaging can be compared for verification of successful surgical repair. Also reviewed are common sports and mechanisms that elicit this injury pattern, adductor longus muscle function, relevant surgical anatomy, and treatment strategies.
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http://dx.doi.org/10.1016/j.eats.2019.02.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6624124PMC
June 2019

Open Repair of Acute Proximal Adductor Magnus Avulsion.

Arthrosc Tech 2019 Jan 24;8(1):e75-e80. Epub 2018 Dec 24.

Steadman Hawkins Clinic-Denver, Greenwood Village, Colorado, U.S.A.

Hip adduction is accomplished through coordinated effort of the adductor magnus, brevis, and longus and the obturator externus and pectineus muscles. Each of these muscles may be injured at its proximal or distal insertion or in its midsubstance. The incidence of injuries to the adductor complex is difficult to determine in sport because of players' underreporting and playing through minor strains. The most commonly injured adductor muscle is the adductor longus muscle. The injury most frequently occurs at the proximal or distal musculotendinous junction, but several case reports of origin and insertional ruptures of the adductor longus exist in the literature. Successful outcomes have been obtained with both operative and nonoperative approaches in these cases. Reports of isolated proximal avulsion of the adductor magnus are less common. This article describes our surgical technique for management of a rare acute proximal adductor magnus avulsion.
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http://dx.doi.org/10.1016/j.eats.2018.09.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6408720PMC
January 2019

Surgical Technique for Release of Anterior Interval Scarring of the Knee After Anterior Cruciate Ligament Reconstruction.

Arthrosc Tech 2018 Sep 6;7(9):e887-e891. Epub 2018 Aug 6.

Steadman Hawkins Clinic Denver, Department of Orthopedic Surgery, University of Colorado School of Medicine, Denver, Colorado, U.S.A.

Postoperative scarring is a known complication after arthroscopic anterior ligament reconstruction of the knee. The anterior interval of the knee has been previously identified as a common location for anterior scar formation. The anterior interval is defined as the space between the infrapatellar fat pad and the anterior border of the tibia. Patients with anterior interval scarring often present with lack of terminal knee extension, anterior knee pain, decreased patellar mobility, and quadriceps atrophy. The goal of this paper is to describe the technique for anterior interval release of the knee.
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http://dx.doi.org/10.1016/j.eats.2018.04.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6153305PMC
September 2018

Thromboembolic Events After Arthroscopic Knee Surgery: Increased Risk at High Elevation.

Arthroscopy 2016 11 16;32(11):2350-2354. Epub 2016 Jun 16.

Steadman-Hawkins Clinic-Denver, Greenwood Village, Colorado, U.S.A.

Purpose: To evaluate the incidence of thromboembolic events in patients undergoing arthroscopic surgery of the knee in centers located at elevations near sea level and compare those rates with the patients undergoing the same operations in centers at high elevation.

Methods: A retrospective review was conducted using a database of a major health care system with surgery centers located throughout the United States. More than 115 centers located in 15 different states were analyzed for any reported thromboembolic events including deep vein thromboses and pulmonary embolism (PE) in patients who had undergone knee arthroscopy over a 2-year period. The centers located at elevations lower than 1,000 ft were considered sea level centers. Centers located at elevations above 4,000 ft were considered high-elevation centers. Centers located between 1,000 ft and 4,000 ft elevation were excluded.

Results: A total of 35,877 patients underwent a knee arthroscopy at a low-elevation center and 10,181 patients underwent a knee arthroscopy at a high-elevation center between 2011 and 2012. During that same time period, 45 total venous thromboembolic events (VTEs) including 12 PEs occurred at centers considered low elevation, whereas 50 VTEs including 4 PEs occurred at centers considered high elevation. The incidence of VTE at low-elevation centers was 0.13%. The incidence of VTE at high-elevation centers was 0.49%. The difference was statistically significant, P < .0001. The relative risk of developing a VTE was 3.8 times higher at high elevation. There was no difference in PE incidence between high- and low-elevation centers (0.04% vs 0.03%, respectively; P = .78).

Conclusions: Patients undergoing arthroscopic procedures of the knee in centers at high elevation are at 3.8 times higher risk of developing a VTE than those undergoing the same procedures in centers at low elevations. There was no observed increased risk of PE.

Level Of Evidence: Level III, retrospective comparative study.
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http://dx.doi.org/10.1016/j.arthro.2016.04.008DOI Listing
November 2016

Return-to-Play Outcomes in Professional Baseball Players After Medial Ulnar Collateral Ligament Injuries: Comparison of Operative Versus Nonoperative Treatment Based on Magnetic Resonance Imaging Findings.

Am J Sports Med 2016 Mar 13;44(3):723-8. Epub 2016 Jan 13.

Steadman Hawkins Clinic-Denver, Greenwood Village, Colorado, USA.

Background: The medial ulnar collateral ligament (UCL) is the primary static stabilizer to valgus stress of the elbow. Injuries to the UCL are common in baseball pitchers. In the 1970s, reconstructive surgery was developed. Return-to-play (RTP) rates of 67% to 95% after reconstruction have been reported. There is a paucity of published studies among professional baseball players reporting RTP with nonoperative treatment.

Purpose: To identify professional baseball players' ability to RTP after the nonoperative treatment of UCL injuries based on the magnetic resonance imaging (MRI) grade.

Study Design: Case series; Level of evidence, 4.

Methods: A review of elbow injuries among a professional baseball organization from 2006 to 2011 was performed. MRI was performed on all players. Forty-three UCL injuries were diagnosed. Treatment included rehabilitation, surgery, or both. Rates of RTP and return to the same level of play or higher (RTSP) were calculated and correlated with the MRI grade, location of injury, and player position. MRI grading was as follows: I, intact ligament with or without edema; IIA, partial tear; IIB, chronic healed injury; and III, complete tear.

Results: Forty-three UCL injuries in 43 players were diagnosed. Eight had complete tears (grade III), were treated operatively with UCL reconstruction, and had an RTP rate of 75% and RTSP rate of 63% (5/8 returned to the same level and 1 to a lower level). All 8 were pitchers. The remaining 35 players had incomplete injuries (4 grade I, 8 grade IIA, and 23 grade IIB), consisting of 24 pitchers and 11 positional players. Of these 35 players, 1 underwent surgery without attempted rehabilitation, 3 initiated rehabilitation until MRI was performed and then underwent surgery, and 3 underwent surgery after failed rehabilitation. The 7 players who underwent UCL reconstruction surgery had an RTP rate of 100% and RTSP rate of 86% (6/7 returned to the same level and 1 to a lower level). The remaining 28 with nonoperative treatment had both RTP and RTSP rates of 93% (26/28 returned to the same level and 0 to a lower level). Of these, 10 were positional players with an RTSP rate of 90%, and 18 were pitchers with an RTSP rate of 94%. Of all players with incomplete UCL injuries who completed nonoperative rehabilitative treatment (n = 31), 26 had a successful RTSP (84%).

Conclusion: Incomplete UCL injuries in professional baseball players can be successfully treated nonoperatively in the majority of cases. Pitchers are more likely to have complete tears leading to surgery. MRI grading of UCL injuries can help predict RTP and the need for surgery.
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http://dx.doi.org/10.1177/0363546515621756DOI Listing
March 2016

Can Robot-Assisted Unicompartmental Knee Arthroplasty Be Cost-Effective? A Markov Decision Analysis.

J Arthroplasty 2016 Apr 26;31(4):759-65. Epub 2015 Oct 26.

Steadman-Hawkins Clinic, Denver, Colorado.

Background: Unicompartmental knee arthroplasty (UKA) is a treatment option for single-compartment knee osteoarthritis. Robotic assistance may improve survival rates of UKA, but the cost-effectiveness of robot-assisted UKA is unknown. The purpose of this study was to delineate the revision rate, hospital volume, and robotic system costs for which this technology would be cost-effective.

Methods: We created a Markov decision analysis to evaluate the costs, outcomes, and incremental cost-effectiveness of robot-assisted UKA in 64-year-old patients with end-stage unicompartmental knee osteoarthritis.

Results: Robot-assisted UKA was more costly than traditional UKA, but offered a slightly better outcome with 0.06 additional quality-adjusted life-years at an incremental cost of $47,180 per quality-adjusted life-years, given a case volume of 100 cases annually. The system was cost-effective when case volume exceeded 94 cases per year, 2-year failure rates were below 1.2%, and total system costs were <$1.426 million.

Conclusion: Robot-assisted UKA is cost-effective compared with traditional UKA when annual case volume exceeds 94 cases per year. It is not cost-effective at low-volume or medium-volume arthroplasty centers.
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http://dx.doi.org/10.1016/j.arth.2015.10.018DOI Listing
April 2016

Functional improvement after humeral shaft nonunion in a patient with glenohumeral ankylosis.

Am J Orthop (Belle Mead NJ) 2013 Dec;42(12):561-5

Bluegrass Orthopaedics and Hand Care, Lexington, KY.

Functionally limiting heterotopic ossification about the shoulder represents an uncommon clinical entity, which has been most commonly reported as a consequence of prolonged immobilization in intensive care unit patients. Severe cases may result in complete glenohumeral ankylosis, with resultant upper extremity motion through the scapulothoracic joint, and significant functional consequences. We report the case of a 72-year-old male with spontaneous glenohumeral ankylosis who suffered a humeral shaft fracture with resultant painless nonunion. Motion through the nonunion site caused significant subjective functional improvements, increased range of motion, and the ability to complete his activities of daily living. Patients with limited shoulder range of motion may be at higher risk for humeral fractures and nonunion. These patients, however, may experience improved function due to increased upper extremity range of motion through the nonunion site.
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December 2013

National Football League athletes' return to play after surgical reattachment of complete proximal hamstring ruptures.

Am J Orthop (Belle Mead NJ) 2013 Jun;42(6):E38-41

UT-Houston, Department of Orthopaedics, Houston, TX 77030, USA.

Although hamstring strains are common among professional football players, proximal tendon avulsions are relatively rare. Surgical repair is recommended, but there is no evidence on professional football players return to play (RTP). We hypothesized that surgical reattachment of complete proximal hamstring ruptures in these athletes would enable successful RTP. Ten proximal hamstring avulsions were identified in 10 National Football League (NFL) players between 1990 and 2008. Participating team physicians retrospectively reviewed each player's training room and clinical records, operative notes, and imaging studies. The ruptures were identified and confirmed with magnetic resonance imaging. Of the 10 injuries, 9 had palpable defects. Each of the ruptures was managed with surgical fixation within 10 days of injury. All of the players reported full return of strength and attempted to resume play at the beginning of the following season, with 9 of the 10 actually returning to play. However, despite having no limitations related to the surgical repair, only 5 of the 10 athletes played in more than 1 game. Most NFL players who undergo acute surgical repair of complete proximal hamstring ruptures are able to RTP, but results are mixed regarding long-term participation. This finding may indicate that this injury is a marker for elite-level physical deterioration.
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June 2013

Quadriceps tendon injuries in national football league players.

Am J Sports Med 2013 Aug 4;41(8):1841-6. Epub 2013 Jun 4.

Steadman Hawkins Clinic-Denver, 8200 East Belleview Avenue, #615, Greenwood Village, CO 80111, USA.

Background: Distal quadriceps tendon tears are uncommon injuries that typically occur in patients older than 40 years of age, and they have a guarded prognosis. Predisposing factors, prodromal findings, mechanisms of injury, treatment guidelines, and recovery expectations are not well described in high-level athletes.

Hypothesis: Professional American football players with an isolated tear of the quadriceps tendon treated with timely surgical repair will return to their sport.

Study Design: Case series; Level of evidence, 4.

Methods: Fourteen unilateral distal quadriceps tendon tears were identified in National Football League (NFL) players from 1994 to 2004. Team physicians retrospectively reviewed training room and clinic records, operative notes, and imaging studies for each of these players. Data on each player were analyzed to identify variables predicting return to play. A successful outcome was defined as returning to play in regular-season NFL games.

Results: Eccentric contraction of the quadriceps was the most common mechanism of injury, occurring in 10 players. Only 1 player had antecedent ipsilateral extensor mechanism symptoms. Eleven players had a complete rupture of the quadriceps tendon, and 3 had partial tears. There were no associated knee injuries. All ruptures were treated with surgical repair, 1 of which was delayed after failure of nonoperative treatment. Fifty percent of players returned to play in regular-season NFL games. There was a trend toward earlier draft status for those who returned to play compared with those who did not (draft round, 3.1 ± 2.5 vs. 6.0 ± 2.9, respectively; P = .073). For those who returned to play, the average number of games after injury was 40.9 (range, 12-92).

Conclusion: Quadriceps tendon tears are rare in professional American football players, and they usually occur from eccentric load on the extensor mechanism. Prodromal symptoms and predisposing factors are usually absent. Even with timely surgical repair, there is a low rate of return to play in regular-season games. There is a trend toward early draft rounds for those who successfully return to play.
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http://dx.doi.org/10.1177/0363546513490655DOI Listing
August 2013

The cost-effectiveness of single-row compared with double-row arthroscopic rotator cuff repair.

J Bone Joint Surg Am 2012 Aug;94(15):1369-77

The Steadman Hawkins Clinic-Denver, CO 80124, USA.

Background: Interest in double-row techniques for arthroscopic rotator cuff repair has increased over the last several years, presumably because of a combination of literature demonstrating superior biomechanical characteristics and recent improvements in instrumentation and technique. As a result of the increasing focus on value-based health-care delivery, orthopaedic surgeons must understand the cost implications of this practice. The purpose of this study was to examine the cost-effectiveness of double-row arthroscopic rotator cuff repair compared with traditional single-row repair.

Methods: A decision-analytic model was constructed to assess the cost-effectiveness of double-row arthroscopic rotator cuff repair compared with single-row repair on the basis of the cost per quality-adjusted life year gained. Two cohorts of patients (one with a tear of <3 cm and the other with a tear of ≥3 cm) were evaluated. Probabilities for retear and persistent symptoms, health utilities for the particular health states, and the direct costs for rotator cuff repair were derived from the orthopaedic literature and institutional data.

Results: The incremental cost-effectiveness ratio for double-row compared with single-row arthroscopic rotator cuff repair was $571,500 for rotator cuff tears of <3 cm and $460,200 for rotator cuff tears of ≥3 cm. The rate of radiographic or symptomatic retear alone did not influence cost-effectiveness results. If the increase in the cost of double-row repair was less than $287 for small or moderate tears and less than $352 for large or massive tears compared with the cost of single-row repair, then double-row repair would represent a cost-effective surgical alternative.

Conclusions: On the basis of currently available data, double-row rotator cuff repair is not cost-effective for any size rotator cuff tears. However, variability in the values for costs and probability of retear can have a profound effect on the results of the model and may create an environment in which double-row repair becomes the more cost-effective surgical option. The identification of the threshold values in this study may help surgeons to determine the most cost-effective treatment.
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http://dx.doi.org/10.2106/JBJS.J.01876DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7002075PMC
August 2012

A cost-effectiveness analysis comparing 3 anterior cruciate ligament graft types: bone-patellar tendon-bone autograft, hamstring autograft, and allograft.

Am J Sports Med 2012 Feb 15;40(2):307-14. Epub 2011 Nov 15.

Steadman Hawkins Clinic Denver, Greenwood Village, Colorado, USA.

Background: Anterior cruciate ligament (ACL) reconstruction, despite being one of the most common surgical interventions, is also one of the least agreed upon surgeries when it comes to optimum graft choice. Three graft choices stand among the most widely used in this procedure: (1) bone-patellar tendon-bone autograft (BPTB), (2) quadruple hamstring tendon autograft (HS), and (3) allograft.

Hypothesis: Bone-patellar tendon-bone ACL reconstruction is the most cost-effective method of ACL reconstruction.

Study Design: Economic and decision analysis; Level of evidence, 2.

Methods: A simplified decision tree model was created with theoretical patients assigned equally to 1 of 3 ACL reconstruction cohorts based on graft type. These treatment arms were further divided into outcome arms based on probabilities from the literature. The terminal outcomes were assigned a health state/utility score and a societal cost. Utilities were calculated from real clinic patients via the time trade-off questionnaire. Costs were literature based. An incremental cost-effectiveness ratio of $50 000/quality-adjusted life year (QALY) was used as the threshold for cost-effectiveness.

Results: Hamstring tendon autograft was the least costly ($5375/surgery) and most effective (0.912) graft choice, dominating both BPTB and allograft reconstructions. Allograft was both the most costly and least effective strategy for the average patient undergoing ACL reconstruction. However, if baseline costs of BPTB could be reduced (by $500) or the effectiveness increased (anterior knee pain <15% or postoperative instability <7%), then BPTB became an incrementally cost-effective choice. In addition, if the effectiveness of HS could be reduced (instability >29% or revision rates >7%), then BPTB also became incrementally cost-effective.

Conclusions: This model suggests that hamstring autograft ACL reconstruction is the most cost-effective method of surgery for the average patient with ACL deficiency. However, specific clinical scenarios that change postoperative probabilities of the different complications may sway surgeons to choose either allografts or BPTB. Cost-effectiveness analysis is not intended to replace individual clinician judgment but rather is intended to examine both the effectiveness and costs associated with theoretical groups undergoing specific multifactorial decisions.
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http://dx.doi.org/10.1177/0363546511426088DOI Listing
February 2012

Patellar tendon ruptures in National Football League players.

Am J Sports Med 2011 Nov 2;39(11):2436-40. Epub 2011 Aug 2.

Steadman Hawkins Clinic–Denver, 8200 East Belleview Avenue #615, Greenwood Village, CO 80111, USA.

Background: Although knee injuries are common among professional football players, ruptures of the patellar tendon are relatively rare. Predisposing factors, mechanisms of injury, treatment guidelines, and recovery expectations are not well established in high-level athletes.

Hypothesis: Professional football players with isolated rupture of the patellar tendon treated with timely surgical repair will return to their sport.

Study Design: Case series; Level of evidence, 4.

Methods: Twenty-four ruptures of the patellar tendon in 22 National Football League (NFL) players were identified from 1994 through 2004. Team physicians retrospectively reviewed training room and clinic records, operative notes, and imaging studies for each of these players. Player game statistics and draft status were analyzed to identify return to play predictors. A successful outcome was defined as participating in 1 regular-season NFL game.

Results: Eleven of the 24 injuries had antecedent symptoms. The most common mechanism of injury was an eccentric overload to a contracting extensor mechanism. Physical examination demonstrated a palpable defect in all players. Twenty-two were complete ruptures, and 2 were partial injuries. Three of the 24 cases had a concomitant anterior cruciate ligament (ACL) injury. In 19 of the 24 injuries, the player returned to participate in at least 1 game in the NFL. Players who returned were drafted, on average, in the fourth round, while those who failed to return to play were drafted, on average, in the sixth round. Of those players who returned to play, the average number of games played was 45.4, with a range of 1 to 142 games.

Conclusion: Patellar tendon ruptures can occur in otherwise healthy professional football players without antecedent symptoms or predisposing factors. The most common mechanism of injury is eccentric overload. Close attention should be paid to stability examination of the knee given the not uncommon occurrence of concomitant ACL injury. Although this is usually a season-ending injury when it occurs in isolation, acute surgical repair generally produces good functional results and allows for return to play the following season. Players chosen earlier in the draft are more likely to return to play.
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http://dx.doi.org/10.1177/0363546511417083DOI Listing
November 2011

Precision of lumbar intervertebral measurements: does a computer-assisted technique improve reliability?

Spine (Phila Pa 1976) 2011 Apr;36(7):572-80

Department of Orthopaedic Surgery, Dartmouth-Hitchcock Metical Center, Lebanon, NH 03756, USA.

Study Design: Comparison of intra- and interobserver reliability of digitized manual and computer-assisted intervertebral motion measurements and classification of "instability."

Objective: To determine if computer-assisted measurement of lumbar intervertebral motion on flexion-extension radiographs improves reliability compared with digitized manual measurements.

Summary Of Background Data: Many studies have questioned the reliability of manual intervertebral measurements, although few have compared the reliability of computer-assisted and manual measurements on lumbar flexion-extension radiographs.

Methods: Intervertebral rotation, anterior-posterior (AP) translation, and change in anterior and posterior disc height were measured with a digitized manual technique by three physicians and by three other observers using computer-assisted quantitative motion analysis (QMA) software. Each observer measured 30 sets of digital flexion-extension radiographs (L1-S1) twice. Shrout-Fleiss intraclass correlation coefficients for intra- and interobserver reliabilities were computed. The stability of each level was also classified (instability defined as >4 mm AP translation or 10° rotation), and the intra- and interobserver reliabilities of the two methods were compared using adjusted percent agreement (APA).

Results: Intraobserver reliability intraclass correlation coefficients were substantially higher for the QMA technique THAN the digitized manual technique across all measurements: rotation 0.997 versus 0.870, AP translation 0.959 versus 0.557, change in anterior disc height 0.962 versus 0.770, and change in posterior disc height 0.951 versus 0.283. The same pattern was observed for interobserver reliability (rotation 0.962 vs. 0.693, AP translation 0.862 vs. 0.151, change in anterior disc height 0.862 vs. 0.373, and change in posterior disc height 0.730 vs. 0.300). The QMA technique was also more reliable for the classification of "instability." Intraobserver APAs ranged from 87 to 97% for QMA versus 60% to 73% for digitized manual measurements, while interobserver APAs ranged from 91% to 96% for QMA versus 57% to 63% for digitized manual measurements.

Conclusion: The use of QMA software substantially improved the reliability of lumbar intervertebral measurements and the classification of instability based on flexion-extension radiographs.
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http://dx.doi.org/10.1097/BRS.0b013e3181e11c13DOI Listing
April 2011

Is prophylactic fixation a cost-effective method to prevent a future contralateral fragility hip fracture?

J Orthop Trauma 2010 Feb;24(2):65-74

Dartmouth-Hitchcock Medical Center, Department of Orthopaedic Surgery, Lebanon, New Hampshire 03756, USA.

Objective: : A previous hip fracture more than doubles the risk of a contralateral hip fracture. Pharmacologic and environmental interventions to prevent hip fracture have documented poor compliance. The purpose of this study was to examine the cost-effectiveness of prophylactic fixation of the uninjured hip to prevent contralateral hip fracture.

Methods: : A Markov state-transition model was used to evaluate the cost and quality-adjusted life-years (QALYs) for unilateral fixation of hip fracture alone (including internal fixation or arthroplasty) compared with unilateral fixation and contralateral prophylactic hip fixation performed at the time of hip fracture or unilateral fixation and bilateral hip pad protection. Prophylactic fixation involved placement of a cephalomedullary nail in the uninjured hip and was initially assumed to have a relative risk of a contralateral fracture of 1%. Health states included good health, surgery-related complications requiring a second operation (infection, osteonecrosis, nonunion, and malunion), fracture of the uninjured hip, and death. The primary outcome measure was the incremental cost-effectiveness ratio estimated as cost per QALY gained in 2006 US dollars with incremental cost-effectiveness ratios below $50,000 per QALY gained considered cost-effective. Sensitivity analyses evaluated the impact of patient age, annual mortality and complication rates, intervention effectiveness, utilities, and costs on the value of prophylactic fixation.

Results: : In the baseline analysis, in a 79-year-old woman, prophylactic fixation was not found to be cost-effective (incremental cost-effectiveness ratio = $142,795/QALY). However, prophylactic fixation was found to be a cost-effective method to prevent contralateral hip fracture in: 1) women 71 to 75 years old who had 30% greater relative risk for a contralateral fracture; and 2) women younger than age 70 years. Cost-effectiveness was greater when the additional costs of prophylaxis were less than $6000. However, for most analyses, the success of prophylactic fixation was highly sensitive to the effectiveness and the relative morbidity and mortality of the additional procedure.

Conclusion: : Prophylactic fixation with a cephalomedullary nail was not found to be cost-effective for the average older woman who sustained a hip fracture. However, it may be appropriate for select patient populations. The study supports the need for basic science and clinical trials investigating the effectiveness of prophylactic fixation for patient populations at higher lifetime risk for contralateral hip fracture.
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http://dx.doi.org/10.1097/BOT.0b013e3181b01dceDOI Listing
February 2010

Does hospital surgical volume affect in-hospital outcomes in surgically treated pelvic and acetabular fractures?

Bull NYU Hosp Jt Dis 2008 ;66(4):282-9

Department of Orthopaedic Surgery, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA.

A retrospective evaluation was done to determine the relationship between hospital volume and in-hospital mortality, complications, and length of stay in patients with operatively treated fractures of the pelvis or acetabulum. Patients were divided into three groups based on hospital volume. High volume centers had higher percentages of patients with one or more comorbidities, but who were less severely injured. Mortality rates were highest in small volume centers. Moderate volume centers had the lowest odds of death. Complication rates were similar between small and high volume hospitals. Length of stay was shortest in high volume centers. In-hospital outcomes associated with surgical fixation of the pelvis, acetabulum, or both were not uniformly associated with hospital volume.
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February 2009

Current issues in health policy: a primer for the orthopaedic surgeon.

J Am Acad Orthop Surg 2007 Feb;15(2):76-86

Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10461, USA.

Political, social, and economic forces occupy an increasingly larger role in health care. It is essential that orthopaedic surgeons become familiar with the ever-changing landscape within which they practice. Greater comprehension of the current issues in health policy will enable practitioners to appreciate these issues and understand the importance of the involvement of the AAOS in the political process. Five topics in particular will continue to have a great impact on the practice of orthopaedic surgery: the flawed Medicare payment formula, implementation of a pay-for-performance program, the creation of gainsharing agreements between hospitals and physicians, the medical liability crisis, and the importance of advocacy with the political action committee of the AAOS.
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http://dx.doi.org/10.5435/00124635-200702000-00002DOI Listing
February 2007

Nonsurgical treatment of closed mallet finger fractures.

J Hand Surg Am 2005 May;30(3):580-6

Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.

Purpose: Surgical repair of closed mallet finger fractures has been favored for displaced injuries involving more than one third of the articular surface and for injuries with palmar subluxation of the distal phalanx. This study analyzed the results of nonsurgical treatment for closed and displaced mallet finger fractures with greater than one-third articular surface damage, comparing cases with and without concomitant terminal joint subluxation.

Methods: Twenty-two closed mallet finger fractures in 21 patients who were treated nonsurgically and involving more than one third of the articular surface were reviewed retrospectively. The patients were treated by continuous extension splinting of the distal interphalangeal joint for a mean of 5.5 weeks. The average patient age at the time of injury was 35.2 years, with a mean delay to treatment of 21 days. Nine cases showed a reduced distal interphalangeal joint at presentation (type IB) and 13 cases showed palmar subluxation of the distal phalanx (type IIB). Complications from splinting were limited to 2 cases of transient skin irritation. All patients returned for new finger radiographs and completed a survey to assess pain, function, and satisfaction at an average of 24.5 months after injury.

Results: Patients expressed negligible pain, minimal difficulties with activities of daily living and work, relatively high satisfaction with finger function and treatment outcome, but only marginal satisfaction with finger appearance. The differences between type IB and type IIB cases were not significant. The resultant terminal joint extensor lag improved in both groups. Moderate and large joint prominences, swan-neck deformities, and moderate arthritis were seen more commonly in type IIB cases but the differences between groups were not significant.

Conclusions: This study supports the rationale for nonsurgical treatment of closed and displaced mallet finger fractures with greater than one-third articular surface involvement. Pain likely will be negligible and patient satisfaction with finger function and treatment outcome is projected to be relatively high at 2-year follow-up evaluation. A dorsal joint prominence, terminal joint extensor lag, swan-neck deformity, and degenerative joint changes, however, may develop, particularly in cases with palmar subluxation of the distal phalanx.
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http://dx.doi.org/10.1016/j.jhsa.2005.02.010DOI Listing
May 2005
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