Volume 25-1, Spring 2016

Hospital stays have been decreasing for hip and knee arthroplasty procedures. Short stay or outpatient procedures were first pioneered in hip replacement; however, short-stay knee replacement is now being routinely performed by some surgeons. Changes in pain control and mobilization have allowed for quicker discharge for knee replacement patients. Combined with specific pathways of care as well as changes in patient expectations and early mobilization, patients can now routinely go home the day after knee replacement. This review seeks to give the reader practical ways to facilitate rapid discharge after knee arthroplasty. (Journal of Surgical Orthopaedic Advances 25(1):2–7, 2016) Key words: knee arthroplasty, length of stay, short-stay surgery

Although biomechanical and clinical evidence exists regarding smaller compression screws, biomechanical data regarding the larger headless screws are not currently available. Headed and headless 6.5-mm cannulated compression screws were examined, with analysis of interfragmentary compression, insertion torque, and resistance of the construct to a shear force. No significant differences were seen between the maximum insertion torque of the headless or headed screws. Maximum and steady-state compression forces were also not significantly different between groups. Countersinking the headless model 2 mm led to a 77.01% decrease in steady-state compression levels. Shear testing did not reveal any significant differences in peak load at ultimate failure, specimen stiffness, or final block displacement, although a trend to increased peak load and stiffness was seen with the headless specimens. (Journal of Surgical Orthopaedic Advances 25(1):8–12, 2016) Key words: biomechanical, cannulated screws, headed, headless, 6.5 millimeter

The objective of this study was to compare complication rates and costs of staged columnar fixation (SCF) to external fixation for bicondylar tibial plateau fractures. Patients who received SCF or temporary external fixation across a 3-year period at a major level I trauma center underwent a retrospective chart review for associated complications. Fisher’s exact analysis was used to determine any statistical difference in complication rates between both groups. However, there was no significant difference in complication rates between the SCF and external fixator groups. Average medial plate costs for SCF were $2131 compared with an average external fixator cost of $4070 (p < .0001). Given that all patients with external fixation undergo eventual medial and lateral plating, savings with SCF include $4070 plus operative costs for removing the fixator. As our health care system focuses on cost-cutting efforts, orthopaedic trauma surgeons must explore cheaper and equally effective treatment alternatives. (Journal of Surgical Orthopaedic Advances 25(1):13–17, 2016) Key words: complications, external fixation, staged columnar fixation

The phenomenon of cartilage rim loading in defects exceeding the threshold diameter of 10 mm is well documented. Contoured defect fill off-loads the perimeter and counteracts further delamination and progression of defects. When biological procedures have failed, inlay arthroplasty follows these concepts. The human biological response to contouredmetallic surface implants has not been described. Four patients underwent non-implant-related, second-look arthroscopy following inlay arthroplasty for bi- (n D 3) and tricompartmental (n D 1) knee arthrosis without subchondral bone collapse. Arthroscopic probing of the implant–cartilage interface of nine prosthetic components did not show signs of implant–cartilage gap formation, loosening, or subsidence. The implant periphery was consistently covered by cartilage confluence leading to a reduction of the original defect size diameter. Femoral condyle cartilage flow appeared to have more hyaline characteristics. Trochlear cartilage flow showed greater histological variability and less organization with fibrocartilage and synovialized scar tissue. This review reconfirmed previous basic science results and demonstrated effective defect fill and rim off-loading with inlay arthroplasty. (Journal of Surgical Orthopaedic Advances 25(1):18–26, 2016) Key words: cartilage flow, cartilage rim stress, inlay arthroplasty

Both conventional and alternative medical therapies are used by patients to treat low back pain, a condition that affects approximately 33% of the U.S. population. Little is known about patients’ perceptions of conventional versus alternative therapies. Patients recruited from an orthopedic spine clinic completed surveys containing questions about their use of many conventional and alternative therapies. Patients rated perceived helpfulness, side effects, and their recommendation for each therapy. They also completed a questionnaire that detailed demographic information, stress, and pain. Questionnaires were completed by 166 patients. Conventional medications were used by 154 (95%) patients, most commonly acetaminophen and opioid derivatives. Alternative therapies were used by 159 (96%) patients, including therapeutic exercises, salves, supplements, and stress management techniques. Generally, patients reported that alternative therapies are more effective and have fewer side effects and would more likely recommend their use. These data can be used to counsel patients and guide future research. (Journal of Surgical Orthopaedic Advances 25(1):27–33, 2016) Key words: complementary and alternative medicine, low back pain, patient opinions

Two hundred thirty patients were prospectively enrolled in this study and completed various portions of the Short Form 36 and a study-specific questionnaire (visual analog scale 1 to 10, comprising three separate questionnaires) to evaluate quality of life and function in patients with Marfan syndrome. The greatest health concern was cardiac problems (high in 70% of patients), followed by spine issues and generalized fatigue (both high, in 53%). The most severe reported pain involved the back: 105 patients (46%) rated pain as 6 to 10 on the visual analog scale. Among the 72 patients who responded to work life questions, work hours were reduced because of treatment in 59 (82%) or directly because of Marfan syndrome in 29 (40%). Across all Short Form 36 domains, patients scored significantly lower than United States population norms (p < .05); physical health scores were considerably lower than mental health scores. (Journal of Surgical Orthopaedic Advances 25(1):34–40, 2016) Key words: health, Marfan syndrome, pain, questionnaire, SF-36

Illicit drug use among adults is increasing, but its associated risk following orthopaedic trauma remains largely unexplored. This study assessed the relationship of illicit drug use with inpatient adverse events, in-hospital mortality, prolonged length of stay, and nonroutine discharge. With the use of the Nationwide Inpatient Sample database, 7,118,720 orthopaedic trauma inpatients from 2002 to 2011 were identified and separated into illicit drug users (1.5%) and non-illicit drug users (98.5%). Multivariable regression modeling was used to determine the association between illicit drug use and each outcome variable. Illicit drug use was associated with higher odds of inpatient adverse events, but not greater likelihood of inpatient death. Illicit drug users were also more likely to experience prolonged hospital stay and nonroutine discharge. Prompt recognition and effective treatment interventions for orthopaedic trauma patients with a history of illicit drug use may improve inpatient outcomes. (Journal of Surgical Orthopaedic Advances 25(1):41–48, 2016) Key words: adverse events, drug use, fractures, mortality, orthopaedic trauma

The purpose of this study was to investigate operative costs and postoperative complication rates in relation to utilization of locking versus nonlocking implants in isolated, lower limb fractures. Seventyseven patients underwent plate fixation of isolated bicondylar tibial plateau, bimalleolar ankle, and trimalleolar ankle fractures at a large tertiary care center. Fixation with locking versus nonlocking implants was compared to incidence of postsurgical complications. Costs of these implants were directly compared. No significant correlation was found between locking versus nonlocking implants and incidence of complications. However, the cost of fixation with locking implants was significantly greater than nonlocking for all fractures. Utilization of more costly locking implants was not associated with reduced postoperative complications compared with nonlocking implants. More attention must be dedicated toward maximizing cost efficiency, since uniform usage of nonlocking implants has the potential to reduce surgical costs without compromising patient outcomes in isolated lower extremity fractures. (Journal of Surgical Orthopaedic Advances 25(1):49–53, 2016) Key words: isolated lower extremity fractures, locking implants, nonlocking implants

The posterior glenoid labrum has numerous surrounding structures and any of them can undergo derangement. It is prudent to consider the posterior glenoid labrum complex (PGLC) as a whole rather than simply the labral tissue in isolation when evaluating magnetic resonance imaging (MRI) of the shoulder. The PGLC contains the posterior capsulolabral junction, posterior capsule (posteroinferiorly , the posterior band of the inferior glenohumeral ligament), posterior chondro-osseous junction, posterior chondrolabral junction, posterior glenoid bone, posterior glenoid subchondral bone, posterior glenoid cartilage, posterior labrum, synovial fold (variably seen), and posterior glenoid periosteum (or periosteal sleeve). Noninvasive MRI techniques are the mainstay in evaluating PGLC injury with or without the use of intra-articular gadolinium contrast agents. When using the PGLC model, a spectrum of pathology can be stratified. (Journal of Surgical Orthopaedic Advances 25(1):54–57, 2016) Key words: capsulolabral junction, chondro-osseous junction, CT arthrogram, labral tear, MR arthrogram, periosteal sleeve, PGLC, PLIPSA, POLPSA, posterior glenohumeral instability, posterior glenoid labrum complex, shoulder arthrogram, SLAP 8

Calcaneal tuberosity fractures comprise only 1% to 2% of all calcaneal fractures. Treatment of these injuries has traditionally included open reduction and internal fixation with various means including lag screws, suture anchors, and K-wires. This article reports on a series of cases treated with excision of the tuberosity fragment with repair of the Achilles tendon supplemented by a flexor hallucis longus tendon transfer. (Journal of Surgical Orthopaedic Advances 25(1):58–63, 2016) Key words: Achilles, calcaneus, flexor hallucis longus, fracture, tendon transfer, tuberosity