Volume 24-2, Summer 2015

The literature suggests that high-volume hip and knee surgeons have better patient outcomes. Therefore, clearly defining a high-volume or a low-volume surgeon is important. The definition of high-volume has been quite arbitrary, and numbers such as 50 surgeries per year have been used to define high-volume. The objective of this study was to show that, on the basis of data contained in the National Inpatient Sample database, using the quartile approach will quantify the increasing number of surgeries required per year to remain a high-volume joint surgeon. Using quartiles may provide a more consistent way to define what is meant by a low- or high-volume surgeon in the United States, and a clear definition of quartiles will aid future studies seeking to determine whether outcomes can be correlated with quartiles. (Journal of Surgical Orthopaedic Advances 24(2):87–90, 2015)

Most orthopaedic surgeons are unfamiliar with proton therapy or the difference between proton radiation and photon (X-ray) radiation. After they perform a total hip replacement or metallic hip implant, their patient cannot have proton therapy for prostate cancer because the protons must pass exclusively through the hips and are blocked by metal. Proton therapy is a sophisticated and expensive technology with growing demand and limited supply. In proton therapy, heavy protons are accelerated to almost the speed of light in a synchrotron (particle accelerator) down a magnetic beam the length of a football field to radiate cancers. Proton therapy is a remarkably safe and effective treatment for prostate cancer, the most common cancer in men, although treatment superiority has yet to be proved in randomized studies. There are currently only 10 proton centers in the United States.. (Journal of Surgical Orthopaedic Advances 24(2):91–98, 2015) Key words: Bragg peak, particle accelerator, prostate cancer, proton radiation, proton therapy, protons, synchrotron

Concerns remain about total hip arthroplasty (THA) performed in very young patients, especially those with complex medical history such as allogeneic bone marrow transplantation (ABMT). This study retrospectively reviews the perioperative courses and functional outcomes of ABMT patients <21 years old undergoing primary uncemented THA. Nine THAs were performed in five ABMT patients at an average age of 19.7 years. The interval between ABMT and THA was 73.0 months with clinical follow-up of 25.8 months. Harris Hip Scores (HHS) increased dramatically from preoperatively 44.5 (range, 31.1–53.4) to postoperatively 85.2 (range, 72.0–96.0) and all patients subjectively reported a good (four hips) to excellent (five hips) overall outcome. There was one reoperation for periprosthetic fracture fixation but there were no infections or revisions performed. Despite the history of severe hematopoietic conditions requiring ABMT, these very young patients do appear to have improved pain and function following primary THA with short-term follow-up. (Journal of Surgical Orthopaedic
Advances 24(2):99–104, 2015) Key words: allogeneic bone marrow transplantation, femoral head osteonecrosis, hematopoietic stem cell transplantation, hip arthroplasty, hip dysplasia

Pathology affecting the long head of the biceps tendon and its insertion is a frequent cause of shoulder pain in the active duty military population. The purpose of this investigation was to evaluate functional outcomes of subpectoral biceps tenodesis in an active duty population. A retrospective case series of 22 service members who underwent biceps tenodesis was performed and Shoulder Pain and Disability Indexes (SPADI) and Disabilities of the Arm, Shoulder and Hand (DASH) scores were obtained preoperatively and at 6 months. Additionally, a review of each subject’s physical profile was performed 6 months after surgery to determine continued physical limitations and one’s ability to deploy. There was a statistically significant improvement in SPADI and DASH scores comparing preoperative versus postoperative outcomes. Although five subjects (22%) continued to have a restriction to performing push-ups on the Army Physical Fitness Test, all were deemed deployable from a physical standpoint. The results of this review suggest that active duty personnel undergoing biceps tenodesis have significant functional improvement at 6 months. Additionally, very few have long-term physical limitations or deployment restrictions. (Journal of Surgical Orthopaedic Advances 24(2):105–110, 2015) Key words: biceps tendon, military, shoulder arthroscopy, SLAP tear, subpectoral, tenodesis

Postsurgical evaluation of osteochondral allograft transplant surgery (OATS) of the distal femur most commonly utilizes radiographs or magnetic resonance imaging. This article proposes the utilization of computed tomography (CT) arthrography as an additional option, which allows clear assessment of articular congruity and osseous integration. A retrospective review was performed of 18 patients who underwent an OATS for distal femoral chondral lesions and obtained CT arthrograms postoperatively. CT arthrograms were evaluated for osseous integration and articular congruity. The average age and follow-up were 30.9 years and 4.3 years, respectively. Only 60% of patients were able to remain in the military postoperatively. The articular cartilage was smooth in eight (44.4%); complete bony integration was noted in eight (44.4%) patients. Neither articular congruity nor bony integration was associated with duty status at final follow-up. Although it allows excellent evaluation, similar to other modalities, CT arthrogram does not appear predictive of functional outcome. (Journal of Surgical Orthopaedic Advances 24(2):111–114, 2015) Key words: allograft, arthrogram, cartilage, computed tomography, femur, osteochondral transplant

There is a known bleeding risk with administration of the antiplatelet drug clopidogrel, but in certain patients the likelihood of thrombosis is too high to cease its administration perioperatively. The risks of performing total joint arthroplasty in this population are unknown. An inpatient pharmacy database query identified seven patients who underwent eight hip or knee arthroplasties from 2007 to 2009 without perioperative interruption in clopidogrel administration. Bleeding-related events were recorded, including one inpatient death, one reoperation for infection, two 30-day readmissions, two antibiotic prescriptions for the incision, and blood transfusion administration during seven of eight admissions. The majority of bleeding-related events occurred following knee arthroplasty. Uninterrupted perioperative clopidogrel administration was associated with a high risk of bleeding-related events following total joint arthroplasty, particularly of the knee. Consideration should be given to delaying total joint arthroplasty until clopidogrel can safely be held in the perioperative period. (Journal of Surgical Orthopaedic Advances 24(2):115–119, 2015) Key words: arthroplasty, bleeding, clopidogrel, hip, knee

Factors associated with successful selection in U.S. Army orthopaedic surgical programs are unreported. The current analysis includes survey data from all Army orthopaedic surgery residency program directors (PDs) to determine these factors. PDs at all Army orthopaedic surgery residency programs were provided 17 factors historically considered critical to successful selection and asked to rank order the factors as well as assign a level of importance to each. Results were collated and overallmean rankings are provided. PDs unanimously expressed that performance during the on-site orthopaedic surgery rotation at the individual program director’s institution was most important. Respondents overwhelmingly reported that Steps 1 and 2 licensing exam scores were next most important, respectively. Survey data demonstrated that little importance was placed on letters of recommendation and personal statements. PDs made no discriminations based on allopathic or osteopathic degrees. The most important factors for Army orthopaedic surgery residency selection were clerkship performance at the individual PD’s institution and licensing examination score performance. Army PDs consider both USMLE and COMLEX results, because Army programs have a higher percentage of successful osteopathic applicants. (Journal of Surgical Orthopaedic Advances 24(2):120–124, 2015) Key words: Army, COMLEX, match, orthopaedic surgery, residency, USMLE

This survey investigated patients’ return to driving after rotator cuff surgery, to determine whether pain, weakness, sling use, and narcotics correlate with self-assessed safety and maneuvering. Fifty-four patients (80.6% of those eligible) were surveyed 4 months after surgery. Return to driving ranged widely from same day to 4 months, with two not driving at 4 months; 12% reported narcotics use and 33% reported sling use. Drivers reporting weakness were more likely to feel unsafe (p D .02) and more likely to report difficulty maneuvering (p < .01). Drivers reporting pain were more likely to feel unsafe (p < .01) and more likely to report difficulty maneuvering their vehicle (p < .01). Patient-reported return to driving does not correspond to perceived safety; pain and weakness correspond with feeling unsafe and difficulty maneuvering. Although subjective, clinicians may find these self-assessments predictive when counseling patients on return to driving. (Journal of Surgical Orthopaedic Advances 24(2):125–129, 2015) Key words: arthroscopic rotator cuff repair, narcotic use in driving, patient-reported recovery, predictors of safe driving, return to driving, rotator cuff surgery

Fracture stability can be challenging for osteoporotic individuals. The end screw of nonlocked plates is subjected to the greatest loading and is typically the site of construct failure. To enhance fixation, the end screw can be angled away from the fracture. The current study biomechanically evaluated screws angled the other direction: toward the fracture using 3.5-mm dynamic compression plates in an osteoporotic bone model. Three different plate lengths (6-, 8-, 12-hole) were tested in three-point bending with an oblique, perpendicular, or reverse oblique end screw. The peak load for loss of screw fixation for the reverse oblique end screw constructs was significantly less than the other screw orientations for all plate lengths. The 12-hole peak load, energy, and displacement magnitudes for all three screw orientations were significantly greater than all 6- and 8-hole constructs. The use of a reverse oblique end screw is inferior to both perpendicular and oblique end screws. (Journal of Surgical Orthopaedic Advances 24(2):130–136, 2015) Key words: fracture, osteoporosis, plate, screw angle

Revision total knee arthroplasty (TKA) often requires long diaphyseal supporting stems. Pain at the end of the cemented revision stem has been reported, but no study has been published regarding the incidence in cementless revision TKA. This study reviewed 120 cementless revision TKAs with a diaphyseal slotted stem to compare the incidence of stem pain to that in a control cohort of 100 primary TKA patients with a metaphyseal stem. In the revision cohort, 20 out of 120 patients reported pain at the end of their stem on the tibia, but no patient reported thigh pain. In the primary TKA cohort, seven out of 100 patients reported pain below the tibial stem. No correlation between stem length or stem fit was found. This study found that more than 16% of patients may have pain at the end of their press-fit revision TKA stem, and this complication should be explained to patients before their revision TKA surgery. (Journal of Surgical Orthopaedic Advances 24(2):137–139, 2015) Key words: arthroplasty, knee, outcome, pain, revision, stem

This case study reviews the pathophysiology of scapholunate advanced collapse (SLAC), which is the most common etiology of degenerative arthritis in the wrist. The scapholunate ligament serves a critical role in stability of the carpus. Disruption of the scapholunate ligament, its sequela, and the magnetic resonance imaging evaluation are discussed, with review of the defining features of this disease and its progression. (Journal of Surgical Orthopaedic Advances 24(2):140–143, 2015) Key words: MRI, review, scapholunate advanced collapse, wrist

Core decompression with free vascularized fibular grafting is an effective hip preservation treatment for osteonecrosis of the femoral head. This procedure has traditionally utilized a single Kirschner wire to secure the fibular strut within the femoral neck. While this method has proven effective, migration of the Kirschner wire remains the most common recipient site complication. Additionally the presence of the Kirschner wire traversing the intramedullary canal can also complicate future hip arthroplasty. Therefore, this article describes a simple graft fixation technique utilizing a buttress plate that obviates migration problems. Ten patients are presented with at least 6 months of follow-up who have been treated with this technique without complications. This fixation method is simple and eliminates a major potential complication and allows for easier conversion to total hip arthroplasty. (Journal of Surgical Orthopaedic Advances 24(2):144–146, 2015) Key words: avascular necrosis, free vascularized fibular graft, FVFG, osteonecrosis

Safe percutaneous placement of iliosacral screws remains a challenge given the close proximity to neurovascular structures. Because of the concerns with safe placement, surgeons have explored the use of three-dimensional fluoroscopy and intraoperative computed tomography–guided screw placement with success; however, these intraoperative aids are not readily available and, in some cases, are cost prohibitive. The authors present a surgical technique that varies from the standard technique for placement of percutaneous iliosacral screws by utilizing the lateral sacral view at the start of the procedure to identify the appropriate starting point and trajectory lines, which aid in obtaining fluoroscopic imaging and guiding pin advancement. Use of this technique has resulted in the safe placement (no cortical breach) of 97.5% of iliosacral screws. (Journal of Surgical Orthopaedic Advances 24(2):147–150, 2015) Key words: iliosacral screw, pelvic fracture, posterior pelvic fixation, SI screw