JSOA Online https://www.jsoaonline.com Journal of Surgical Orthopaedic Advances Thu, 08 Oct 2020 05:32:55 +0000 en-US hourly 1 https://www.jsoaonline.com/wp-content/uploads/2020/06/cropped-Siteicon-3-32x32.png JSOA Online https://www.jsoaonline.com 32 32 Volume 29-3, Fall 2020 https://www.jsoaonline.com/volume-29-3-fall-2020/ Wed, 07 Oct 2020 17:45:59 +0000 https://www.jsoaonline.com/?p=4519 Read more ›]]>
  • Table of Contents - 29-3
  • How Do We Restart Elective Orthopaedic Services Responsibly?
  • A Message to the Orthopaedic Family
  • The Rates of Nonunion and Malunion in Lower Extremity Fractures: Experience in South Carolina Over 17 years - Dane N. Daley, MD; Phillip A. Westbrook, MD; William R. Barfield, PhD, FACSM; Anbesaw Selassie, DrPH, FACE; and Langdon A. Hartsock, MD, FACS

    Abstract | Download Purchase

    Our purpose was to determine the rates of lower extremity nonunion and malunion over 17 years in South Carolina. Our hypothesis was that malunions and nonunions decreased over time due to improved access to trauma centers and improved orthopaedic surgical training. The South Carolina Department of Budget and Control Hospital Discharge Database was queried between 1998–2014 and yielded a total of 4,994 malunions and 16,454 nonunions. Malunions increased from 1.2% (1998) to 1.8% (2010); nonunions increased from 4.0% (1999) to 5.8% (2011). Older age and gender were predictive of malunion and nonunion. This study identified females as having a higher odds ratio for malunion or nonunion; higher nonunion rates in worker’s compensation or government payer status; and older age as incurring greater risks for sustaining fractures or developing a malunion or nonunion. There was increased prevalence of nonunion and malunion despite improved access to trauma centers and trained orthopaedic trauma surgeons. (Journal of Surgical Orthopaedic Advances 29(3):129–134, 2020)

    Key words: fracture, nonunion, malunion, lower extremity, trauma, South Carolina

    Gunshot Wounds to the Hip: Doomed to Failure? - Yiyi Zhang, BS; Breydan Wright, BS; Peter D’Amore, MD; Cody Hightower, MD; Thomas Stang, MD; Heidi Israel, PhD; Michael Tucker, MD; Robert Zura, MD; and Lisa K. Cannada, MD

    Abstract | Download | Purchase

    The purpose is to evaluate hip fractures due to gunshot wounds (GSW) to the hip, which are treated surgically, and the complications. Patients who sustained a low velocity GSW with fracture to the femoral head/neck and intertrochanteric/ peritrochantric region at three Level 1 Trauma Centers were eligible. There were 69 patients (63 males–91%), with an average age of 29 (18–60). Nine patients had orthopaedic surgical site infections. There were 6 nonunions, 4 patients with hardware failure, 2 cases of avascular necrosis (AVN), 3 patients with post traumatic arthritis (PTA) and 20 patients with heterotopic ossification (HO). There was no significant difference found regarding fracture site or type of fixation with regards to complications. This represents the largest study of surgically treated GSW to the hip. Of patients studied, 61% sustained additional GSW. These injuries are not benign; the main complications being infection and heterotopic ossification. (Journal of Surgical Orthopaedic Advances 29(3):135–140, 2020)

    Key words: low-velocity gunshot wound, hip fracture, surgical fixation, debridement, complication

    Infantile Tibia Vara (Blount Disease) with Iatrogenic Changes Causing Residual Tibial Deformities - Geovanny Oleas-Santillán, MD, MS; Faaiza K. Kazmi, MD; Mihir M. Thacker, MD; H. Theodore Harcke, MD; Harry Lawall III, CPO; and J. Richard Bowen, MD

    Abstract | Download | Purchase

    Treatment of infantile tibia vara or Blount disease (ITV/BD) in patients < 3 years old and Langenskiold stages I-III consists of orthosis and, in relapsing cases, proximal tibial osteotomy and/or proximal tibial guided growth laterally with a tension band plate. Our aim was to evaluate the results of treatments in a consecutive group. After Institutional Review Board approval, data from 2002 to 2018 were collected. Thirty-nine knees (average age 22.4 months) with ITV/BD were treated with orthoses, and 10 knees failed. Six knees showed hyperintense T2-weighted signal in the medial proximal tibial epiphyseal cartilage on magnetic resonance imaging. Three of six knees with tibial osteotomy failed and underwent guided growth. Tibial plateau slopes were abnormal medially from the ITV/BD and laterally from the guided growth (triangular physis and depressed plateau deformities) because of factors such as orthotic treatment, tibial osteotomy, magnetic resonance imaging “physis severity score,” and guided growth. (Journal of Surgical Orthopaedic Advances 29(3):141–148, 2020)

    Key words: Blount disease, infantile tibia vara, magnetic resonance imaging, orthosis, tibial osteotomy, guided growth, tibia plateau deformity

    Current Biopsy Methods for Primary Musculoskeletal Lymphoma: A Retrospective Multicenter Review - Matthew T. Wallace, MD, MBA; Alex Sin, MD; Frank J. Frassica, MD; and Albert J. Aboulafia, MD, MBA

    Abstract | Download | Purchase

    Primary musculoskeletal lymphoma often requires multiple biopsies for tissue confirmation. This challenge is understood by specialists but has not been specifically quantified. One-hundred-eighteen biopsies performed in 100 cases of primary musculoskeletal lymphoma was performed. Demographics, tumor location and the method and performer of biopsy were recorded. Pearson chi-square and analysis of variance (ANOVA) statistics were used to compare rates of diagnostic yield, time to diagnosis and the presence of crush artifact based on method of biopsy, imaging, performer and tumor location. Diagnostic yield of initial biopsy is 82%. Open biopsy is associated with a higher yield compared to percutaneous techniques (p = 0.005). Biopsies performed by the treating surgeon had a higher yield compared to other practitioners (p = 0.035). Musculoskeletal lymphomas are a greater diagnostic challenge compared to other lesions. A higher index of suspicion and more aggressive sampling procedure may be necessary to establish this diagnosis. (Journal of Surgical Orthopaedic Advances 29(3):149–153, 2020)

    Key words: lymphoma, biopsy, oncology

    High Energy Midfoot Fracture-Dislocations: Does Staged Treatment with External Fixation Help? - John Arvesen, MD; Zachary Burnett, MD; Ashleigh N. Bush; Heidi Israel, PhD; Brian Mullis, MD; and Lisa K. Cannada, MD

    Abstract | Download | Purchase

    This study analyzes the outcomes of patients treated for high energy midfoot injuries with temporary stabilization (TS) prior to definitive operative fixation compared to a control group (C) treated initially with splint only. Three Level 1 trauma centers reduced and temporized high energy Lisfranc injuries. A matched control group was compared with the intervention group. Clinical parameters, complications and need for additional surgery were evaluated. There were 15 patients in group C and 29 patients with temporary stabilization (TS). Both the TS and C groups demonstrated no significant difference in the number of additional operations, infection rate, incidence of deep vein thrombosis (DVT), nonunion and need for orthotics postoperatively (p > 0.05). Staged treatment of high energy Lisfranc injuries in the TS group led to a delay in definitive fixation or arthrodesis while having a similar minimal complication rate relative to the controls. This is a Level III, Retrospective Case Control Study. (Journal of Surgical Orthopaedic Advances 29(3):154–158, 2020)

    Key words: Lisfranc fracture, midfoot fracture, tarsometatarsal fracture-dislocation, external fixation

    The Effect of Diabetes Mellitus on Revision Discectomy After Single-level Lumbar Discectomy - Eric J. Smith, MD; Bradley P. Inkrott, MD; Jerry Y. Du, MD; Chang-Yeon Kim, MD; Uri M. Ahn, MD; and Nicholas U. Ahn, MD

    Abstract | Download | Purchase

    Diabetes currently affects over 25 million Americans, with the elderly carrying much of the disease burden. It’s well known that diabetes increases the risk of surgical complications, but few studies have analyzed its effects on reoperation rates after singlelevel lumbar discectomy. Data was obtained using the commercially available Explorys software, which houses de-identified data for several healthcare systems. A database search was conducted to fi nd all patients who’d undergone a lumbar discectomy. Scoliosis, spondylolisthesis, smoking history and obesity were excluded as possible confounding variables, after which 31,210 patients remained. Of them, 950 were found to have undergone a revision discectomy within 2 years. Those with diabetes were found to have a relative risk of 1.29 for revision discectomy compared to those who did not, 95% confidence interval (95% CI) 1.10–1.52, p < 0.002. These findings contribute to the importance of modifiable risk factor assessment preoperatively and their effects on surgical complications. (Journal of Surgical Orthopaedic Advances 29(3):159–161, 2020)

    Key words: revision, discectomy, diabetes mellitus, Explorys, herniated disc, reoperation, modifiable risk factor

    Urinary Tract Infection After Total Hip Arthroplasty: A Retrospective Cohort Study - Paull C. Gossett, MD; Brian E. Schwartz, MD; Donald P. Chuang, MD; Hristo I. Piponov, MD; and Mark H. Gonzalez, MD

    Abstract | Download | Purchase

    Perioperative urinary tract infections (UTI) are a relatively common occurrence after total hip arthroplasty (THA). The purpose of this study was to assess demographics, outcomes and trends in the development of UTI’s after THA using the National Hospital Discharge Survey (NHDS). All patients undergoing THA were divided based on whether or not they developed a UTI, and data regarding demographics, outcome and complications were gathered and analyzed. No significant trend in rate of UTI after THA was found. Patients who developed a UTI were more likely to be female, have more comorbidities and receive a transfusion. They had a longer hospitalization, lower rate of discharge directly home and an increased rate of discharge to a rehabilitation facility. Orthopaedists should identify those patients at increased risk who according to this study appear to be older, female patients with multiple co-morbidities who received a blood transfusion. (Journal of Surgical Orthopaedic Advances 29(3):162–164, 2020)

    Key words: urinary tract infection (UTI), total hip arthroplasty, outcomes, National Hospital Discharge Survey (NHDS) Database

    The Relationship Between Cigarette Smoking and the Prevalence, Frequency and Severity of Back Pain - Carolyn R. Postol, DO; David J. Kusin, MD;  Charles C. Yu, MD; Jerry Y. Du, MD; Chang Y. Kim, MD; Adam J. Schell, MD; Uri M. Ahn, MD; and Nicholas U. Ahn, MD

    Abstract | Download | Purchase

    The purpose of this study was to examine the relationship between smoking and back pain in a cross-sectional analysis. Using the Osteoarthritis Initiative database, a multi-center, longitudinal, observational cohort study with 4796 participants, we examined the prevalence of back pain and of limitations in activity due to back pain, as well as the frequency and severity of back pain in participants who were current smokers compared to those who had never smoked. Data was evaluated using binary and ordinal logistic regression analyses. An increase in prevalence, frequency and severity of back pain was strongly associated with smoking. This demonstrates a relationship between smoking and back pain; however, further studies are needed to evaluate causation. (Journal of Surgical Orthopaedic Advances 29(3):165–168, 2020)

    Key words: back pain, smoking, osteoarthritis, tobacco, intervertebral disc degeneration, degenerative disc disease

    Scapholunate Ligament: Comparing the Native Strength of the Ligament to an All-suture  Anchor Construct - Laura W. Lewallen, MD; Carson F.  Woodbury, MPhil; Adam Margalit, MD; Hannah C. Langdell, MD;  Stephen M. Belkoff , PhD; and John V. Ingari, MD

    Abstract | Download | Purchase

    Our aim was to compare the tensile strength of the native scapholunate ligament (SLL) with that of an all-suture anchor construct in a cadaveric model. The scaphoid and lunate were isolated, preserving all segments of the SLL. Using a servohydraulic testing machine, we increased the load until peak load-to-failure of the native SLL was reached in nine specimens (mean ± standard deviation, 273 ± 132 N). Using the same specimens, two JuggerKnot 1.4-mm suture anchors (Zimmer Biomet) were placed into the lunate and tensioned through transosseous tunnels in the scaphoid. Sutures were tied over the radial nonarticular aspect of the scaphoid. Load-to-failure testing was repeated. The mean peak load-to-failure for the all-suture anchor constructs was 172 ± 59 N versus 231 ± 117 N for the native group (p = 0.157). This represents approximately 75% of the native ligament strength. (Journal of Surgical Orthopaedic Advances 29(3):169–172, 2020)

    Key words: all-suture anchor construct, scapholunate ligament injury, scapholunate ligament reconstruction, scapholunate ligament strength

    Non-displaced Femoral Neck Stress Fractures in Young Adults: 7-Year Outcomes of Prophylactic Fixation Versus Nonoperative Treatment - Ryan C. Myers, MD; Grant K. Cochran, MD; Jacob E. Waldron, DO; Clarence E. Steele, MD; Bradley K. Deafenbaugh, MD; and Kevin M. Kuhn, MD

    Abstract | Download | Purchase

    Retrospectively compare outcomes of prophylactic fixation to nonoperative treatment of incomplete or non-displaced femoral neck stress fractures (FNSF) in young adults. Outcomes of 82 patients (mean age 21.7 years) who were diagnosed with incomplete or non-displaced FNSFs from 2002 to 2015 were compared. Forty-one underwent prophylactic fixation; the remaining were treated without surgery. Fracture characteristics and complications were recorded. Pain scores, modified Harris Hip Scores (mHHS), and Hip Outcome Scores (HOS) were obtained and compared. The average fracture line in the operative group was 67% of the femoral neck width versus 18% in the nonoperative group (p < 0.001). There was no difference in outcome scores between the two groups. Prophylactic fixation of high-risk non-displaced FNSFs resulted in similar outcome scores to non-operative management of lower-risk variants at an average of 7.3 years follow up. No patient in either group progressed to a displaced femoral neck stress fracture. (Journal of Surgical Orthopaedic Advances 29(3):173–176, 2020)

    Key words: femoral neck stress fracture, non-displaced, Harris Hip Score, Hip Outcome Score

    Healing of Pathologic Humeral Fractures in Patients with Metastatic Disease: Consideration for Operative Fixation in Patients - Sandesh S. Rao, MD; Jad M. El Abiad, MD; Varun Puvanesarajah, MD; Micheal Raad, MD; Carol D. Morris, MD, MS; Jonathan A. Forsberg, MD, PhD; and Adam S. Levin, MD

    Abstract | Download | Purchase

    We compared short-term outcomes after operative versus nonoperative treatment of pathologic humeral fractures. We hypothesized that patients who underwent operative fixation would heal faster and have better pain control. A retrospective review was conducted of 25 patients who underwent operative fixation and 6 who received nonoperative treatment from 2005– 2017. Operative patients healed significantly earlier than nonoperative patients (p = 0.02). At 16-week follow-up, radiographs showed evidence of healing in 24 of 25 operatively treated patients and 2 of 6 nonoperatively treated patients (p < 0.01). Pain improved during the inpatient stay in 24 of 25 operatively treated patients and none of the nonoperatively treated patients (p < 0.01). All operatively treated patients returned to self-reported baseline motor function by final follow-up, whereas none of the nonoperatively treated patients returned to baseline (p = 0.01). Operative treatment was associated with earlier healing, pain control and return to function compared with nonoperative treatment of pathologic humeral fractures. Level of Evidence: 3. (Journal of Surgical Orthopaedic Advances 29(3):177–181, 2020)

    Key words: fracture fixation, functional outcomes, intramedullary nail fixation, open reduction and internal fixation, operative treatment, pathologic humeral fracture

    The Evolving Role of the Orthopaedic Surgeon in Combat Zones and Austere Deployed Locations Since the 2012 Troop Drawdown - Mark Slabaugh, MD; Daniel Kopolovich, MD; Richard J. Robbins, MD; and Francois Trappey, MD

    Abstract | Download | Purchase

    The purpose of this study was to evaluate the operative experience of orthopaedic surgeons in the various deployment locations since 2012. We also evaluated the implications of humanitarian surgical care and the impact of deployment on an orthopaedic practice. An emailed survey was sent to orthopaedic surgeons deployed after 2012. The survey was 48 questions. Most cases in Iraq, Afghanistan and Syria were emergent traumas. In other locations, however, most cases were elective/non-emergent cases. Of surgeons surveyed, 44% performed less than 10 cases during their deployment, and 50% considered humanitarian surgery part of their mission. Six weeks was needed to prepare for deployment, and 4.4 weeks to re-build a practice. Disparity exists in surgical case volume and types of cases performed by orthopaedic surgeons that is dependent on deployed location. This dichotomy in operative experience places surgeons deployed to such locations at risk of losing surgical skills. (Journal of Surgical Orthopaedic Advances 29(3):182–186, 2020)

    Key words: deployment, military medicine, humanitarian surgical care (HSC)

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  • Table of Contents
  • Isolated RingLoc Polyethylene Liner Revision for Treatment of Liner Wear - David A. Crawford, MD; Keith R. Berend, MD; Joanne B. Adams, BFA; and Adolph V. Lombardi, Jr., MD, FACS

    Abstract | Download | Purchase

    Polyethylene wear and osteolysis has long been an issue with the survivorship of total hip arthroplasty. The purpose of this study was to assess the survivorship after isolated liner exchange with the use of the RingLoc acetabular cup. A query of our practice registry revealed 106 patients (112 hips) with a single cementless titanium plasma sprayed acetabular component (RingLoc, Zimmer Biomet, Warsaw, IN), who underwent acetabular liner exchange for treatment of polyethylene wear between January 2001 and March 2015. Eighty patients (85 hips) met inclusion criteria. Clinical outcomes were assessed with the Harris hip score and radiographic evaluation was performed. The mean follow-up after liner exchange was 6 years (range, 2–15.7 years). Harris hip scores improved from 70.9 (range, 28–100) preoperatively to 79 (range, 29–100) at most recent evaluation (p < 0.001). Subsequent surgery was required in 11 patients (11 hips, 13%). Components were revised in 7 hips (8.2%). One acetabular revision was performed for aseptic loosening and four for instability (4.7%). One metal-polyethylene sandwich liner was revised for metal hypersensitivity. One patient underwent two-staged exchange for infection. In our early to mid-term experience with the RingLoc acetabular cup, isolated liner exchange for treatment of polyethylene wear yielded 98.8% acetabular survival for aseptic loosening at up to 15 years. (Journal of Surgical Orthopaedic Advances 29(2):59–64, 2020) Key words: acetabular, liner, exchange, aseptic, loosening

    Reconstruction of Distal Humerus Fractures with Severe Bone Loss: A Case Series and Review of the Literature - Shane Tipton, MD; Fiesky Alejandro Nunez Jr., MD, PhD; Fiesky Alejandro Nunez Vazquez Sr., MD; Jason J. Halvorson, MD; and Eben A. Carroll, MD

    Abstract | Download | Purchase

    The objective of this study was to describe examples and review the literature of distal humerus fracture reconstruction in the setting of severe bone loss. Four individuals (ages 19–59 years) were treated with either fibular strut allograft or fresh frozen osteochondral allograft in the setting of unreconstructable periarticular bone loss. The radiographs were evaluated for evidence of union. Pain and degrees of range of motion were reported when available. The follow-up period ranged from 3 to 42 months. While additional surgery was often needed, union was ultimately obtained in each case. Normal range of motion was not obtained, but two of the four patients were near normal upon union. Two of the four patients were pain free, and the other two had mild pain. All were limited in their activities, even after union. This case series describes satisfactory results with the use of allograft in this difficult clinical problem. (Journal of Surgical Orthopaedic Advances 29(2):65–72, 2020) Key words: humerus, reconstruction, allograft

    Arthroscopic Vastus Elevation (AVE) for Arthrofibrosis of the Knee: Surgical Technique and Literature Review - Saif U. Zaman, MD; Ikenna Nwachuku, MD; Rebecca Griffith, MD; Tina Wang, MD; and Hasan M. Syed, MD

    Abstract | Download | Purchase

    Arthrofibrosis of the knee continues to challenge Orthopaedic surgeons. With a wide etiology, lack of knee motion can be debilitating. Its surgical management has several complications. The purpose of this study is to describe a modification of previously described techniques to aid in the management of knee arthrofibrosis. Arthroscopic vastus elevation in conjunction with adjuvant hemostatic agents allows for a controlled quadriceps elevation in the setting of arthrofibrosis. In addition to a thorough intra-articular lysis of adhesions, this appears to improve motion, while minimizing postoperative complications. Minimized postoperative complications include extensor lag, skin necrosis, and bleeding complications. (Journal of Surgical Orthopaedic Advances 29(2):117–120, 2020) Keywords: arthroscopic, arthrofibrosis, elevation, lysis, knee stiffness

    Infections Associated with Temporary External Fixation - Mohamed Salar, MD and Paul J. Dougherty, MD, FAOA, FACS

    Abstract | Download | Purchase

    Infections associated with external fixation are thought to be related to the fixator construct, the length of time a fixator is on the limb and the injury severity score (ISS). Patients who had temporary external fixation applied for lower extremity fractures were included. Charts were reviewed for prevalence of infection, loss of reduction or other external fixator modification. Other variables were length of time the fixator was applied and the length of hospitalization. Seventy-five patients with 80 fractures met our study criteria. Of 80 fractures, 23 (28.8%) were associated with infection at the fracture site. Average time to conversion from external fixation to definitive fixation was 13.23 ± 19.8 for infected fractures and 20.03 ± 17.08 (p = 0.137) for those without infection. We did not find that the length of time a fixator was applied was associated with an increased infection rate of the fracture site, the pin sites or other regions. (Journal of Surgical Orthopaedic Advances 29(2):73–76, 2020) Keywords: external fixation, long bone fractures, surgical site infection, Injury Severity Score (ISS)

    Gluteus Medius Insertion Damage: A Comparison of Reconstruction and Hip Fracture Nails - Richard K. Hurley, Jr., MD; Andrew J. Sheean, MD; and Michael J. Beltran, MD

    Abstract | Download | Purchase

    This study assessed damage to the gluteus medius tendon insertion when performing trochanteric nailing with either a reconstruction nail or a cephalomedullary nail. Ten cadavers were randomized to receive proximal reaming for either a reconstruction nail or cephalomedullary nail; the contralateral hip served as an internal control. One specimen was found to have a displaced femoral neck fracture and was excluded from data analysis. Reconstruction nailing led to tendon damage in 4 of 9 hips, compared to 8 of 9 with hip fracture nailing (p = 0.29). In the reconstruction nail group, the average amount of tendon damaged was 3% (range 0–10%), while in the hip fracture nail group, the average was 15% (range 0–20.3%) (p = 0.0003). Open reaming for placement of a reconstruction nail caused less gluteus medius tendon damage when compared to open reaming for placement of a hip fracture nail. (Journal of Surgical Orthopaedic Advances 29(2):77–80, 2020) Key words: hip abductors, reconstruction nail, cephalomedullary nail

    Intramedullary Fixation for Displaced Clavicle Fractures in the Adolescent Athlete - Gabriella E. Ode, MD; Timothy B. Larson, MD; Patrick M. Connor, MD; James E. Fleischli, MD; and Donald F. D’Alessandro, MD

    Abstract | Download | Purchase

    The role of intramedullary (IM) fi xation of displaced mid-shaft clavicle fractures in adolescents has not been described. This study analyzes characteristics and outcomes of IM fi xation in adolescent clavicle fractures. Patients < 18 years with acute, midshaft clavicle fractures treated with IM clavicle pins between March 2007 and August 2013 were reviewed. Outcomes of interest were activity level, fracture patt ern, time to union, return to sports and complications. Twenty-nine patients (14.8 years (range 11.4–17.9)) underwent IM pin fi xation for a displaced, mid-shaft clavicle fracture, including 7 (24.1%) that were multi-fragmentary (length unstable). Complete displacement (> 100%) occurred in 27/29 (93.1%), with average preoperative shortening length of 18 mm. Union occurred in 100% of patients, at a mean duration of 8 weeks. Among student-athletes (25/29, 86.2%), average return to sport was at 18 weeks post-injury. IM pinning off ers stable fi xation of clavicle fractures in the active adolescent population. (Journal of Surgical Orthopaedic Advances 29(2):81–87, 2020) Keywords: clavicle fracture, fracture fi xation, intramedullary, adolescent, athlete, trauma

    The Association of Opioid Utilization and Patient Satisfaction Following Outpatient Orthopaedic Surgery: More May Not Be Better - Connor A. King, MD; David C. Landy, MD, PhD; John Curran, BBA; and Megan A. Conti Mica, MD

    Abstract | Download | Purchase

    Postoperative analgesia remains an important area of research in orthopaedics. There remains a lack of information on the complex interplay between opioid utilization postoperatively, pain and patient satisfaction. This study aims to describe the relationship between opioid utilization, postoperative pain, and patient satisfaction following outpatient orthopaedic surgery in a multispecialty orthopaedic practice. As a part of an ongoing quality control project at our institution patients were instructed to monitor utilization of postoperative opioids. The results of a convenience sample of 139 patients representing a 53% response rate among eligible patients that completed the survey following outpatient orthopaedic surgery are reported. Among patients undergoing outpatient orthopaedic surgery, there was no clinically signifi cant association between opioid utilization and patient satisfaction. This association appeared largely independent of the patient’s actual pain. While lower pain scores were associated with increasing patient satisfaction, this appeared to be independent of opioid utilization. (Journal of Surgical Orthopaedic Advances 29(2):88–93, 2020) Keywords: analgesics, opioid, ambulatory surgical procedures, patient satisfaction, quality improvement

    Prospective Evaluation of a Noninvasive Hemoglobin Measurement System in Total Joint Arthroplasty - Mike Casale, MD; Jesse A. Raszewski, DO, MBS; Alaa E. Mohammed, MPH, CME; Connor Ojard, MD; Nicholas L. Kolodychuk, MD; George Chimento, MD; Tyler Adams, BS; and Bradford S. Waddell, MD

    Abstract | Download | Purchase

    We sought to prospectively determine the effi cacy of a noninvasive hemoglobin measurement system compared to a traditional blood draw in patients undergoing total joint arthroplasty. One hundred consecutive patients had their hemoglobin level measured by blood draw and the noninvasive device, simultaneously. Results were analyzed for the entire group and further stratifi ed based on race and perfusion index measured by the device. The fi nancial implications and patient satisfaction were compared. Hemoglobin measurements in the entire group and the two sub-groups were similar between the noninvasive device and the traditional blood draw. The noninvasive system was preferred by 100% of patients. Additionally, cost savings per patient using the noninvasive system was $16.50. This correlated to an 86% savings per case over the standard blood draw. The noninvasive hemoglobin monitoring system off ers comparable measurements to a standard blood draw, while improving patient satisfaction and lowering costs. (Journal of Surgical Orthopaedic Advances 29(2):94–98, 2020) Keywords: arthroplasty, total joint, hemoglobin, noninvasive, cost savings

    30-Day Outcomes of Operative Versus Nonoperative Management for Humeral Diaphyseal Fractures in Patients with Concomitant Hip Fractures - Daniel Sutton, MD, MPH; Basilia Nwankwo, MD; Moses Adebayo, MD; Rolanda Willacy; Cina R. Karodeh; and Robert Wilson, MD

    Abstract | Download | Purchase

    Every year over 330,000 people are hospitalized for hip fractures in the US. Of those patients, approximately 4–5% of patients with hip fractures present with a concomitant upper extremity fracture. Upper extremity (UE) fractures account for an estimated 2 million fractures a year. The number of hip fractures is projected to double by 2050. There is evidence that the presence of a concomitant upper extremity fracture results in an increased hospital length of stay (LOS), lower functional capacity upon discharge and higher mortality rates than seen with hip fractures in isolation. Additionally, hip fractures pose a signifi cant economic burden and are expected to increase to over $62 billion in 2040. As such, hip fractures are a public health crisis. This study seeks to evaluate the diff erences in perioperative outcomes between nonoperative and operative management of humeral diaphyseal fractures in patients with concomitant hip fractures. (Journal of Surgical Orthopaedic Advances 29(2):99–102, 2020) Keywords: hip fractures, concomitant, upper extremity, mortality, hospital length of stay (LOS), surgical management

    Preoperative Smoking Cessation as a Durable Form of Long-Term Smoking Cessation - Jacob C. Balmer, BS; Ashley B. Anderson, MD; William R. Barfield, PhD; Vincent D. Pellegrini, MD; and Harry A. Demos, MD

    Abstract | Download | Purchase

    Smokers who undergo total joint arthroplasty (TJA) face increased rates of medical and surgical complications that can be reduced by preoperative smoking cessation. We investigated the long-term durability of preoperative smoking cessation among TJA patients. Twenty-seven TJA patients who were identifi ed as having an active history of smoking at the preoperative appointment before TJA consented to telephone survey about their perioperative and current smoking status. Average time from operation to survey was 3.7 years. Of the 27 patients, 21 (77.8%) were identifi ed as having quit smoking prior to surgery. Of these 21 patients, 10 (47.6%) self-reported continued abstinence from smoking at the time of survey. Our cessation rate was signifi cantly lower than reported long-term smoking cessation rates with standard therapies (p < 0.001). Our results suggest that preoperative counseling and a requirement for smoking-cessation prior to elective TJA may have long-term durability that exceeds that of popular reported methods. (Journal of Surgical Orthopaedic Advances 29(2):103–105, 2020) Keywords: smoking cessation, total joint arthroplasty, quality improvement, hip, knee

    Maximization Personality, Disability and Symptoms of Psychosocial Disease in Hand Surgery Patients - Jacob Gire, MD; Aaron Alokozai, BS; Nicole Sheikholeslami, MS; Sarah Lindsay, BS; Sara L. Eppler MPH; and Robin N. Kamal, MD

    Abstract | Download | Purchase

    There are diff erent frameworks to describe how people make decisions. One framework, maximization, is an approach where individuals approach choices with a goal of fi nding the “best” possible alternative. We sought to determine the relationship between maximization and patient reported disability in patients with hand problems. We performed a cross-sectional study of 119 patients who presented to a hand surgery clinic. Patients completed a questionnaire that included sociodemographics, QuickDASH, Decisional Confl ict Scale, Pain Catastrophizing Scale, Patient Health Questionnaire, Health Anxiety Inventory and General Self-Effi cacy. Maximization did not correlate with subjective disability in patients with hand problems. Depression, pain catastrophizing and a diagnosis of upper extremity fracture had the greatest independent association with disability. In patients presenting for an initial hand surgery consultation, maximization was not associated with variation in patient reported disability or symptoms of psychosocial disease. Alternative factors infl uencing patient decision-making and outcomes should be explored. (Journal of Surgical Orthopaedic Advances 29(2):106–111, 2020) Keywords: hand surgery, maximization personality, patient reported outcomes, quality

    Orthopaedic Conditions Among the Uninsured: Data from an American Student-Run Free Clinic - Andrew W. Kuhn, BA; Colby C. Wollenman, BS; Joseph T. Gibian, BS; Joshua R. Daryoush, BS; and James F. Fiechtl, MD, MMHC

    Abstract | Download | Purchase

    Litt le is known about the epidemiology of orthopaedic conditions among the uninsured. This is a descriptive study of 107 patients presenting with 140 orthopaedic conditions for care at the student-run free clinic, the Shade Tree Clinic. Patients were 50.0 (± 13.0) years old with a BMI of 32.9 (± 8.60). About half were female (58.9%), of Spanish origin/Hispanic or Latino descent (50.9%), immigrants (48.3%), and non-English speaking (44.9%). Most presented with chronic (75.5%) conditions of the knee (24.3%), hand (16.4%) and spine (13.6%). While knee osteoarthritis was the most common diagnosis made (18.7%), there were 38 (35.5%) unique diagnoses with only a single occurrence. Most conditions were initially treated nonoperatively (82.9%). There was an average of 1.92 (± 1.44) visits per condition, and 74.0% of conditions had reported improvement or resolution. Though further study is needed, providing free comprehensive patient-centered orthopaedic care to uninsured individuals in a low-cost sett ing may prove cost-eff ective. (Journal of Surgical Orthopaedic Advances 29(2):112–116, 2020) Keywords: orthopaedic, uninsured, healthcare, cost-eff ectiveness, free clinic

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    Volume 29-1, Spring 2020 https://www.jsoaonline.com/volume-29-1-spring-2020/ Mon, 23 Mar 2020 15:56:16 +0000 https://www.jsoaonline.com/?p=4368 Read more ›]]>
  • 29-1 Table of Contents
  • A Systematic Review of the Histological and Molecular Changes in the Subacromial Bursa in Rotator Cuff Disease - Ahmad Haj-Assaad; Rolanda Willacy; and Robert Wilson, MD

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    To evaluate the involvement of the subacromial bursa in the pathologic development of rotator cuff disease (RCD), a systematic review of the literature was undertaken to assess the cellular, biochemical and metabolic changes in the bursa. A systematic review was performed to identify all studies that reported histological and molecular changes in the subacromial bursa pertaining to RCD. The molecular biomarkers found to be altered in RCD included extracellular matrix enzymes, cytokines, growth factors and neuronal signals. Previous reports show an increase in IL-1, IL-6, TNFα, bone morphogenic proteins, substance P and vascular endothelial growth factor. All of these factors may contribute to the etiology and pathological changes in rotator cuff disease, but further study is needed to determine the specifi c role of the subacromial bursa in the pathophysiology of RCD. (Journal of Surgical Orthopaedic Advances 29(1):1-4, 2020) Key words: rotator cuff disease (RCD), bursitis, subacromial bursa, shoulder impingement, interleukins, COX enzyme, bone morphogenic proteins (BMPs), substance P, vascular endothelial growth factor (VEGF), biologic drugs, anti-metabolites

    Opioid Prescribing and Patient Satisfaction Scores Across Practice Types - Eric Secrist, MD; Meghan K. Wally, MSPH; Richard McKnight, MD; Robert Van Demark, MD; Rachel B. Seymour, PhD; Madhav Karunakar, MD; Joseph R. Hsu, MD; and PRIMUM Group (Michael Beuhler, MD; Michael Gibbs, MD; Christopher Griggs, MD; Steven Jarrett, PharmD; Daniel Leas, MD; Michael Runyon, MD; Animita Saha, MD; Bradley Watling, MD; and Stephen Wyatt, DO

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    US physicians prescribe opioids at a high rate relative to other countries. Of the US physicians surveyed, almost half report having prescribed an inappropriate opioid due to concerns about patient satisfaction scores. We investigated patterns in controlled substance prescribing practices, patient risk factors, and associated Press Ganey patient satisfaction scores at a sample of orthopaedic surgery and primary care clinics over a 6-month time period. Primary care practices had higher proportions of prescriptions, and patient risk profiles varied across sites. However, overall satisfaction was high, with little variation between sites (78.3 – 81.3%). Satisfaction with pain control was lower and more varied (67.1 – 78.0%). A total of 4,229 Press Ganey survey responses were received, including 7,232 comments, of which only 10 (0.1%) expressed frustration for not receiving opioids. Opioid prescriptions had minimal association with Press Ganey scores among varied practices and patient populations. Prescribers should prescribe opioids appropriately without fear that this will negatively impact their satisfaction scores. (Journal of Surgical Orthopaedic Advances 29(1):5-9, 2020) Key words: opioid, patient satisfaction, orthopaedic surgery, primary care

    The Effect of Obesity on Revision Discectomy After Single-level Lumbar Discectomy - Eric J. Smith, BS; Bradley P. Inkrott, MD; Chang-Yeon Kim, MD; Jerry Y. Du, MD; Uri M. Ahn, MD; and Nicholas U. Ahn, MD

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    The prevalence of obesity has been rising, creating a major public health concern. While several studies have shown obesity to increase the risk of surgical complications, few have analyzed its effects on reoperation, specifically after single-level lumbar discectomy. Data was obtained using the commercially available Explorys software that houses de-identified data for several major healthcare systems. A database search was used to find all patients who had undergone a lumbar discectomy. Scoliosis, spondylolisthesis, smoking history and depression were excluded as possible confounding variables, after which 25,960 patients remained. Of them, 690 were found to have undergone a revision discectomy within 2 years. Those who were obese were found to have a relative risk of 1.64 for revision discectomy compared to those who were non-obese, 95% confidence interval (95%CI) 1.32–2.03, p < 0.0001. These findings contribute to the importance of modifiable risk factor assessment preoperatively and their effects on surgical complications. (Journal of Surgical Orthopaedic Advances 29(1):10-12, 2020) Key words: revision, discectomy, obesity, Explorys, herniated disc, reoperation, risk factor

    Opioid Use Patterns After Total Joint Arthroplasty - Paul King, MD; Andrea Stone; Elizabeth Arentz; and James MacDonald, MD

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    The incidence of new persistent opioid use following elective total joint arthroplasty (TJA) hasn’t been well documented; with this study we aim to further characterize opioid use following TJA, specifically focusing on those patients still requiring opioid prescriptions 6 months postoperatively. Retrospective review of a consecutive series of 977 primary TJA performed from June 2016–May 2017. Opioid prescriptions verified in Surescripts database; 3.7% (29) opioid naïve patients and 18.0% (35) opioid non-naïve patients received fills at 6 months. Opioid naïve patients requiring fills at 6 months had more fills from 1-2 months onward. Opioid non-naïve patients requiring fills at 6 months had more preoperative fills than those that weren’t filling opioid prescriptions (5.49 vs. 2.52 fills). Most patients in this study ceased opioid use by 3 months postoperatively. More preoperative fills in the opioid non-naïve population and continuing to fill prescriptions after 2-3 months were associated with continued opioid use. (Journal of Surgical Orthopaedic Advances 29(1):13-17, 2020) Key words: opioid use; hip arthroplasty; knee arthroplasty; postoperative; opioid naïve; opioid non-naive

    Biomechanical Evaluation of a Minimally Invasive Fixation Method for Length Unstable Limb Injuries - Marc A. Egeland, MS; Timothy Vanderbilt, MD; Rewais Hanna, BS; Reuben Lufrano MD; Ray Vanderby, Jr., PhD; Dave Goodspeed, MD; and Matthew A. Halanski, MD

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    INFIX instrumentation has provided an alternative treatment option for anteriorly unstable pelvic injuries. In this study, we explore the biomechanical feasibility of using an INFIX construct in an unstable long-bone model and present a unique clinical case of its use. The external fixation, locked plate and spinal implant constructs (n = 5 each) were applied to lengthunstable fracture models and tested under various loads. Analysis of variance and pairwise T-tests were performed with levels of significance adjusted by Bonferroni correction to account for multiple comparisons. The biomechanical stiffness of the INFIX was found to be intermediate between the other two constructs in axial loading and torsion and was equivalent to one of the other constructs in sagittal and lateral bending. It was never the most compliant construct in any testing mode. This study and case report demonstrate the biomechanical feasibility of using INFIX to treat limb injuries. (Journal of Surgical Orthopaedic Advances 29(1):18-25, 2020) Keywords: femur fracture, pediatric, unstable, INFIX, external fixation, bridge plating

    A Systematic Review and Meta-analysis of Injury in Crossfit - Richard P. Gean; Robert D. Martin, MD; Michael Cassat, MD; and Simon C. Mears, MD, PhD

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    The present study aims to investigate the incidence and pattern of injury in Crossfit. This study used a database search of “Crossfit” AND “Injury” for systematic review and meta-analysis. Crossfit seems to be an effective exercise method to decrease weight and BMI while improving function. High intensity interval training improves blood pressure, body fat percentage, lung capacity and pancreas function. Articles meeting inclusion showed that shoulder, back and then knee injuries were the most commonly self-reported in surveys. Incidence of injury is similar to that of other common recreational sports. Some Crossfit movements and participant characteristics may lead to higher incidences of specific injuries and injuries overall. (Journal of Surgical Orthopaedic Advances 29(1):26-30, 2020) Key words: High-intensity interval training (HIIT), scaling, Olympic weightlifting, powerlifting

    Rotator Cuff Dysfunction After Anatomic Total-Shoulder Arthroplasty: Who Is at Risk? - Stephen T. Ikard, Jr., MD; Kevin W. Farmer, MD; Aimee M. Struk, MEd, ATC; Cynthia S. Garvan, PhD; Alexandra Gillespy Lorentsen, MD; and Thomas W. Wright, MD

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    We compare post-total shoulder arthroplasty (TSA) patients with suspected cuff dysfunction to a successful-TSA control group. Thirty-nine patients met suspected-cuff -dysfunction criteria. Forty matched controls were selected. Radiographic and functional outcomes and demographics were compared preoperatively and postoperatively. Humeral head height above the greater tuberosity and postoperative humeral head translations were significantly greater in the dysfunction group. The dysfunction group demonstrated a significant correlation between higher humeral heads and earlier postoperative dysfunction, significantly more glenoid radiolucencies, and significant deficits in active and passive forward elevation. External rotation did not diff er significantly until the final follow up. Functional scores differed significantly by 6 months, with the exception of the 1-year American Shoulder and Elbow Surgeons score. Post-TSA cuff dysfunction leads to worse functional scores, worse range of motion, and more glenoid radiolucencies. Proper patient selection and humeral head placement may prevent this. Early postoperative forward-elevation stiffness may portend dysfunction. (Journal of Surgical Orthopaedic Advances 29(1):31-35, 2020) Keywords: anatomic total shoulder arthroplasty, cuff dysfunction, functional scores, glenoid radiolucent lines, rotator cuff tear, stiffness

    Patient Age Is Inversely Associated with Injury Counts Caused by Motor Vehicle Crashes - Anna N. Miller, MD; Justin Tilan, MD; Alexandria Wellman; Jennifer Talton; Andrew Usoro, MD; Katherine Sun; Scott Wuertzer, MD; Leon Lenchik, MD; Joel Stitzel, MD; and Ashley Weaver, MD

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    Associations between age and fracture incidence, total number of fractures, and total number of injuries per occupant occurring in motor vehicle crashes were evaluated. An observational study of the Crash Injury Research and Engineering Network was conducted. Multivariable logistic regression and negative binomial models were used to relate age (20–64, 65+ years) to fracture incidence, total number of fractures per occupant, and total number of injuries, adjusting for sex and change in vehicle velocity (delta-v). Over 90% of occupants had at least one fracture for a total of 5,846 fracture injuries. The older age group experienced a 15% increase in the incidence of total injuries sustained compared to the younger group (Incident Rate Ratio = 1.15, 95% Confidence Interval = 1.08–1.23, p < 0.0001). Older patients should be considered for polytrauma evaluation even with a “lower energy” motor vehicle crash. (Journal of Surgical Orthopaedic Advances 29(1):36-39, 2020) Keywords: age, collision energy, delta-v, geriatric, motor vehicle collision, polytrauma

    Accuracy of the Spinal Pain Diagram Is Influenced by Patient Health Literacy in Completion of the Scoliosis Research Society-30 Questionnaire - Kristie Hadden, PhD; Jennifer Mei Gan, MBA; Spencer McClure; Richard E. McCarthy, MD; and David B. Bumpass, MD

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    The Scoliosis Research Society Questionnaire (SRS-30) was designed to measure health-related quality of life in scoliosis patients. Patients with low health literacy may need specific guidance when providing feedback on the SRS-30 so that reliable and valid results are collected for clinical decision making. The purpose of this research study was to investigate the health literacy demands of the Scoliosis Research Society Questionnaire (SRS-30) and to determine if health literacy best practices mitigate errors for patients with low health literacy. Readability assessment, focus groups and structured interviews were used. Results indicated that patients with low health literacy perceived health literacy best practices as helpful in completing the SRS-30 drawing. Additionally, patients with inadequate health literacy had a higher proportion of errors in pain location on the drawing (p = 0.0325) compared to patients with adequate health literacy. (Journal of Surgical Orthopaedic Advances 29(1):39- 42, 2020) Key words: health literacy, spine surgery, health-related quality of life, patient-reported outcomes, back pain

    The Dislocated Hip on CT Scan: An Argument for the Initial Pelvic Radiograph in Trauma Patients - John D. Adams, Jr., MD; Michael R. Koerner, MD; Catherine Long Williams, BS; Stephanie L. Tanner, MS; Michael S. Sridhar, MD; Thomas M. Schaller, MD; and Kyle J. Jeray, MD

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    This study evaluated the frequency in which a hip dislocation is first diagnosed by computed tomography (CT) scan. A retrospective review was conducted of orthopaedic trauma patients presenting with hip dislocation to a Level 1 trauma center over three years. We recorded whether the patient first received pelvic radiograph (PXR) or CT scan of the pelvis, if the patient underwent closed reduction of the hip prior to CT scan, and if repeat pelvis CT scan was done. Of 83 hip dislocations, 64 patients were sent to CT scanner dislocated; 19 patients first had PXR and underwent closed reduction of the hip prior to CT scan. By obtaining a PXR, reducing the hip prior to CT, the incidence of repeat CT scan decreased from 37% to 11% (p = 0.046). By diagnosing hip dislocation, reducing prior to CT scan, repeat scans can be reduced, thus decreasing cost and radiation exposure to patients. (Journal of Surgical Orthopaedic Advances 29(1):43-45, 2020) Keywords: hip dislocation, level 1 trauma, AP pelvis, pelvic x-ray, CT pelvis

    Reversed Palmaris Longus Muscle–A Normal Anatomic Variant: A Case Report - Kaitlyn Yoh, ATC; James Guille, MD; and Michael Thune, MD

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    The palmaris longus muscle is one of the most variable muscles in the human body. It has many anatomic variants, one of which is the reversed palmaris longus. In this specific variant, the tendinous origin and muscular insertion sites are reversed in the forearm. We report a case of a 15-year-old male with complaints of a mass in his right wrist; workup of the mass revealed a reversed palmaris longus muscle. (Journal of Surgical Orthopaedic Advances 29(1):46-47, 2020) Key words: reversed palmaris longus, palmaris longus, anatomic variant, forearm mass

    Recurrent Pain in a Patient with Bilateral Scaphotrapezial Coalition and Radiocarpal Arthritis - Arthur McDowell; Andrew Jeong; Rolanda Willacy and Robert Wilson, MD

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    Carpal coalition is an uncommon and rarely reported anomaly, characterized by the union of two or more carpal bones. It is usually found incidentally during radiographic evaluation for trauma or other unassociated pathology. While lunotriquetral and capitohamate coalitions are the most common forms of carpal coalition, there are very few reports of scaphotrapezial coalitions described in the literature. This a novel case report, in which we present a case of bilateral scaphotrapezial coalition in a patient with radiocarpal arthritis and persistent wrist pain. Furthermore, this case report discusses the classification systems and treatment options of this anomaly. (Journal of Surgical Orthopaedic Advances 29(1):48–49, 2020) Key words: scaphotrapezial coalition, anomaly, radiocarpal arthritis, Minnaar, arthrodesis

    Antegrade Screw Fixation of Medial Malleolus Fractures: A Technique Tip - Matthew W. Konigsberg, MD; and J. Turner Vosseller, MD

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    Ankle fractures are one of the most common orthopedic injuries and often include medial malleolus fractures. A number of techniques to repair medial malleolus fractures have been described. Depending on the exact fracture pattern, there are cases of medial malleolus fractures that are less amenable to standard fi xation strategies. We present an alternative strategy for fixing medial malleolus fractures, in which a screw is placed antegrade across the fracture line. (Journal of Surgical Orthopaedic Advances 29(1):50-52, 2020) Key words: trauma, medial malleolus fracture, ankle fracture, open reduction internal fixation

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  • Table of Contents
  • Cost Analysis and Bundled Care of Hip and Knee Replacement - James Kee, MD; Simon C. Mears, MD, PhD; Paul K. Edwards, MD; and C. Lowry Barnes, MD

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    Financial success in a bundled payment system requires knowledge of the costs of care throughout the period of risk. Understanding the significant cost-drivers of total joint arthroplasty (TJA) is crucial in this effort. This article inspects the basics of reimbursement under Medicare’s bundled care programs as well as some common investigative tools used in the literature to measure cost. Additionally, the effects of standardized enhanced recovery clinical pathways on costs are reviewed. Finally, drivers of implant costs and several proven measures for implant cost-reduction are evaluated. This review provides surgeons and hospitals successful measures to reduce the cost of TJA via enhanced recovery pathways and reduced implant pricing. (Journal of Surgical Orthopaedic Advances 28(4):241-249, 2019) Key words: arthroplasty, cost effectiveness, patient education, implant selection

    Predictive Accuracy of the ACS-NSQIP Surgical Risk Calculator for Pathologic Humerus Fracture Fixation - Zachary A. Mosher, MD; Eugene W. Brabston III, MD; Michael A. Ewing, MD; Martim C. Pinto, MD; Matthew C. Hess, MD; Nicole K. Behnke, MD; Gerald McGwin, PhD, MS; Brent A. Ponce, MD; and Joshua C. Patt, MD

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    Pathologic fractures are associated with poor outcomes. This article investigated the prevalence of underestimation of risk by the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Surgical Risk Calculator (SRC) in patients with pathologic humerus fractures. Two hundred seven (207) patients were identified and analyzed using the ACS-NSQIP SRC. Predicted and actual outcomes were then compared. Average hospitalization was 6 ± 10 days. Ten patients (5%) had a mild adverse event (AE), and 15 (7%) had a serious AE. The ACS-NSQIP SRC underestimated hospitalizations (p < 0.001), but not serious AE (p = 0.601), mild AE (p = 0.948), cardiac complications (p = 0.817), pneumonia (p = 0.713), surgical site infection (p = 0.692), urinary tract infection (p = 0.286), venous thromboembolism (p = 0.554), acute renal failure (p = 0.191), discharge to acute care facility (p = 0.865), readmission (p = 1.0), reoperation (0.956) or mortality (p = 0.872). Negative outcomes were limited in this cohort, and the SRC demonstrated acceptable accuracy. Future investigation of the calculator in other orthopaedic populations is warranted. (Journal of Surgical Orthopaedic Advances 28(4):250-256, 2019) Key words: pathologic fractures, humerus fractures, musculoskeletal oncology, ACS-NSQIP, ACS-NSQIP Surgical Risk Calculator

    Pediatric Patients with Spondylolysis Have High Rates of Vitamin-D Deficiency - Marielle A. Amoli, MD; Jeffrey R. Sawyer, MD; R. Tyler Ellis, MD; James Seymour, DO; David D. Spence, MD; Derek M. Kelly, MD; and William C. Warner, MD

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    The objective of this study was to document the 25-hydroxyvitamin D status of patients with a confirmed diagnosis of spondylolysis to determine if these patients have increased rates of vitamin D deficiency. After confirming the diagnosis of spondylolysis, patients were prospectively enrolled in this study. A total of 39 patients (30 male, 9 female) with a mean age of 14.9 years and a mean BMI of 22.9 had vitamin D levels drawn after imaging confirmed the diagnosis of spondylolysis. The mean 25-hydroxyvitamin D level was 26 ng/ml. Only 9 patients (23.1%) were considered to have normal vitamin D levels > 32 ng/ml. An additional 22 patients (56.4%) had insufficient values of 20 to 32 ng/ml, and 8 patients (20.5%) had vitamin D deficiency with values <20 ng/ml. Pediatric patients presenting with spondylolysis, regardless of race or age, have high rates of 25-hydroxyvitamin D deficiency. (Journal of Surgical Orthopaedic Advances 28(4):257-259, 2019) Key words: spondylolysis, vitamin D, deficiency, screening

    Rater Variation in Ultrasound Detection of Dorsal Cortex Screw Protrusion in Fixed-Angle Volar Plating of the Distal Radius - Kevin J. Leffers, MD; Joel I. Edionwe, MD; Caroline W. Stegink-Jansen, PhD; Daniel Jupiter, PhD; and Ronald W. Lindsey, MD

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    This study evaluates rater accuracy and variation for the purpose of using intraoperative ultrasound (US) imaging to detect dorsal screw protrusion during fixed-angle volar plating of distal radius fractures. Stabilizing volar plates and screws with varying lengths of dorsal protrusion were applied to 10 cadaver wrist pairs. After a brief training session, seven surgeons without prior ultrasound experience assessed screw protrusion on two separate occasions using a diagnostic ultrasound machine. Screw protrusions were visually confirmed after data collection was completed. Statistical analyses included percent agreement and Cohen’s kappa for accuracy and intra- and inter-rater reliability, sensitivity, specificity, and positive and negative predictive values. Only two out of seven raters met acceptable levels of accuracy and consistency. Our findings inform us that accuracy and consistency of ultrasound-guided detection of dorsal screw protrusion are negatively impacted by rater variation. Further investigations are needed to improve rater effectiveness. (Journal of Surgical Orthopaedic Advances 28(4):260-267, 2019) Key words: distal radius fractures, ultrasound imaging, screw protrusion, volar plating, diagnostic testing, measurement

    The Saline Load Test is Effective at Diagnosing Traumatic Arthrotomies of the Shoulder - Daniel Gittings, MD; Jonathan Dattilo, MD; George Fryhofer, MD; Anthony Martin, MD; Michael Hast, MD; and Samir Mehta, MD

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    The purpose of this study is to evaluate the fluid volume required for a saline load test to detect intra-articular involvement of the glenohumeral joint after penetrating trauma. A human cadaver study was conducted with 22 thawed, fresh-frozen forequarter amputations. A standard posterior shoulder portal was made with an 11-blade scalpel. A 19-gauge needle was inserted into the anterior portal site, and intra-articular position of both the blade and needle was confirmed with fluoroscopy. The blade was removed and normal saline was injected through the needle until extravasation of fluid was observed through the posterior portal. Injection volume required for extravasation was recorded. A logarithmic distribution of the volumes was then calculated in order to obtain estimated sensitivity ranges. Using a logarithmic distribution, 90%, 95% and 99% of simulated glenohumeral arthrotomies could be detected using injections of: 62 ml [41–96], 81 ml [50–133] and 136 ml [72–252], respectively. (Journal of Surgical Orthopaedic Advances 28(4):268-271, 2019) Key words: traumatic arthrotomy, shoulder, glenohumeral joint, saline load

    Smoking as a Risk Factor for Readmission in Arthroscopic Surgery: A Propensity Matched Analysis - Daniel J. Johnson, MD; Joshua P. Castle, BS; Matthew J. Hartwell, MD; Hayden Baker, BA; Ryan S. Selley, MD; Richard W. Nicolay, MD; and Vehniah K. Tjong, MD

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    The objective of this study was to perform a propensity matched analysis exploring smoking as a risk factor for readmission following hip, knee and shoulder arthroscopy. Patients undergoing knee, shoulder or hip arthroscopy between 2006-2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Patient’s smoking was analyzed for its effect on 30-day readmission using multivariate regression adjusting for demographics and comorbidities. A propensity matched analysis control identified 19,732 non-smokers to serve as the control group. The readmission rate for the non-smoking cohort was 0.9% and 1.3% in the smoking group (p = 0.01). In a multivariate analysis adjusting for baseline characteristics and medical comorbidities, smoking status was associated with increased risk readmission (Odds Ratio: 1.37 [95% Confidence Interval: 1.133–1.657] p = 0.0012). This study suggests that smoking increases chances of readmission in all arthroscopic surgery. (Journal of Surgical Orthopaedic Advances 28(4):272-276, 2019) Key words: arthroscopy, smoking, readmission

    Incidence of Periprosthetic Femur Fractures Utilizing the Posterior Approach with a Single Wedge Tapered Stem - Peter Formby, MD; Cierra S. Hong, BA; Sean Ryan, MD; Samuel Wellman, MD; Michael Bolognesi, MD

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    We sought to determine early periprosthetic femur fracture rate and stem-related failures in primary total hip arthroplasty (THA) performed through a posterior approach with a cementless wedge stem. We reviewed 818 primary THAs in 713 patients with a single wedge tapered titanium component. We used multivariate logistic regression to determine predisposing factors to stem failure. The mean radiographic follow up was 1.6 years. Overall there were eight perioperative femur fractures (0.98%). There were two intraoperative fractures (0.24%), six postoperative fractures (0.73%) and one case of stem subsidence (0.1%). There was a 0.49% rate of operative fractures occurring within 90 days of surgery. There were five stem revisions due to loosening or fracture (0.61%). When excluding infection, the ultimate stem retention rate at latest follow up was 99.3%. Multivariate logistic regression did not find age, sex, body mass index or American Society of Anesthesiologists (ASA) score significantly associated with periprosthetic fracture. (Journal of Surgical Orthopaedic Advances 28(4):277-280, 2019) Key words: periprosthetic femur fracture, posterior approach, wedge stem, taperloc, pressfit stem, femur fractures

    In Hospital Outcomes of Total Hip Arthroplasty in the Medicaid Population - Brian E. Schwartz, MD; Neal R. Shah, MD; Colin Woon, MD; Vincent Moretti, MD; Awais K. Hussain, MD, Amit Parekh, MD; Benjamin Goldberg, MD; Feroz Osmani, MD; Mark H. Gonzalez, MD, PhD

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    Total hip arthroplasty (THA) is one of the most common orthopaedic procedures. This study’s purpose was to evaluate national trends, patient demographics and hospital outcomes for Medicaid patients who underwent a primary THA. The National Hospital Discharge Survey (NHDS) database was queried for patients undergoing THA from 2001–2010. Patients were stratified into two groups based on insurance. We found from 2001–2005, Medicaid accounted for 2.38% of all THA performed, increasing insignificantly to 2.61% between 2006–2010. The Medicaid group was younger (50.3 vs. 65.6 years, p < 0.01). Length of stay was longer for the Medicaid group (4.6 vs. 4.0 days, p < 0.01). Medicaid patients were more likely to be discharged home (53.7% vs. 47.2%, p < 0.01) and less likely to be discharged to rehabilitation facilities (24.4% vs. 29.0%, p < 0.05). In conclusion, we discovered that the rate of Medicaid insurance in patients undergoing primary THA was stable through 2010, prior to the Affordable Care Act. We found Medicaid THA patients had longer length of stay, despite being a mean 15 years younger than the non-Medicaid cohort. Medicaid insurance status should be factored into risk adjustment models to avoid creating additional disincentive to treat the Medicaid population. (Journal of Surgical Orthopaedic Advances 28(4):281-284, 2019) Key words: total hip arthroplasty, Medicaid, insurance, NHDS, outcomes, morbidity, mortality, length

    New NCAA Bat Standard, BBCOR, is Associated with an Increased Incidence of Hamate Fractures - Ryan Nathe, MD; Tyler Nathe, MD; Trevor J. Shelton, MD, MS; and Robert M. Szabo, MD, MPH

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    Our institution saw four hamate fractures in the 2011 baseball season, the first season following implementation of new batting standards in collegiate baseball. The purpose of this paper was to identify whether the incidence of hamate fractures increased with the introduction of the new batting standard. Surveys sent to Division 1 collegiate baseball athletic trainers reported the number, mechanism, treatment and return to play of hamate fractures from 2008–2010 (old batting standards) and for the 2011 season. This study shows that there was more than a 200% increased risk of hamate fracture with implementation of the 2011 collegiate baseball batting standards. The most common injury mechanism was batting with the down hand (79%). We suggest that a national injury database be considered for collegiate athletics so that injury rates, risk factors and results of interventions could be studied to improve the health of our nations’ athletes. (Journal of Surgical Orthopaedic Advances 28(4):285-289, 2019) Key words: hamate fracture, bat standard, NCAA, baseball

    The Quality and Accuracy of Online Resources for Total and Reverse Shoulder Replacement - Emily J. Monroe, MD; Ryan S. Selley, MD; Mufaddal M. Gombera, MD; Rueben Nair, MD; Alexander Martusiewicz, MD; Robert A. Christian, MD; Guido Marra, MD; and Matthew D. Saltzman, MD

    Abstract | Download | Purchase

    Recent literature suggests that many online patient resources are poor in quality and lack important clinical information. The purpose of this study was to investigate the value of online resources available to patients considering shoulder arthroplasty. A total of 84 websites were discovered with the terms ‘‘total shoulder replacement’’ (TSR) and ‘‘reverse shoulder replacement’’ (RSR), they were reviewed and graded for quality and accuracy. Overall quality scores were low for TSR and RSR websites, 22.8/45 (95% confidence interval (CI): 19.9–25.6) and 24.2/45 (95% CI: 21.6–26.9), respectively. The authorship of a website significantly influenced the quality for both TSR (p = 0.013) and RSR (p = 0.048). When comparing search rank to quality scores, websites that appeared earlier demonstrated significantly higher quality scores, TSR (p = 0.017) and RSR (p = 0.018). Overall, most websites were accurate but provided incomplete information. Websites authored by professional societies have higher quality scores than websites authored by medical providers or commercial entities. (Journal of Surgical Orthopaedic Advances 28(4):290-294, 2019) Key words: total shoulder arthroplasty (TSA), reverse total shoulder arthroplasty (rTSA), online resources, quality, accuracy, patient information

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  • Table of Contents
  • Medial Patellofemoral Ligament Reconstruction Technique Utilizing Patellar Suture Anchors and a Peroneus Longus Tendon Allograft - Nathan A. Rimmke, MD; Robert A. Magnussen, MD, MPH; David C. Flanigan, MD

    Abstract | Download | Purchase

    The medial patellofemoral ligament (MPFL) is generally nonfunctional in cases of recurrent lateral patellar instability. While there are numerous techniques and graft choices, patellar fracture after MPFL reconstruction remains a rare but devastating complication, as tunnels drilled completely through the patella increase the risk of fracture. This article presents a technique of MPFL reconstruction utilizing patellar suture anchors and a peroneus longus tendon allograft that avoids the need to drill tunnels that completely traverse the patella. (Journal of Surgical Orthopaedic Advances 28(3):166–174, 2019) Key words: medial patellofemoral ligament, patellar fracture, patellar instability, suture anchors

    Orthopaedic Residency Training Structure: Implications on Quantity and Quality of Scholarship - John C. Dunn, MD; Nicholas Kusnezov, MD; Austin B. Fares, MD; E’stephan Garcia, MD; Brian R. Waterman, MD; Justin Orr, MD; and Mark Pallis, DO

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    The objective of this analysis was to compare the efficiency of scholarly activity withinmilitary orthopaedic training programs. The authors obtained the lists of abstracts accepted for presentation at the 2009 through 2014 Society of Military Orthopaedic Surgeons (SOMOS) annual meetings. Data were extracted for each individual presentation. Three primary groups were compared: a traditional program, a research program, and a hybrid program. The hybrid program produced the highest percentage of the presentations (28.6%). The traditional program contributed the most presentations (3.32) and publications (2.16) per resident and had the highest publication rate (87.7%) and the shortest time to publication (14.4 months). The research program published in the highest average impact journals (3.2). The addition of a research year does not improve the number of academic presentations or published papers but may improve the impact factor of the journals in which the projects are published. (Journal of Surgical Orthopaedic Advances 28(3):175–179, 2019) Key words: academic research, military, orthopaedic, residency training

    Trends and Characteristics of Highly Cited Articles in Proximal Humerus Fracture Research - Colin K. Cantrell, MD; Zachary A. Mosher, MD; Michael A. Ewing, MD; Samuel R. Huntley, MD; Martim C. Pinto, MD; Brent A. Ponce, MD; and Eugene W. Brabston III, MD

    Abstract | Download | Purchase

    As the treatment of proximal humerus fractures remains controversial in the literature, this study aims to identify highly cited articles and examine trends and characteristics. Scopus was used to identify the highest cited articles of proximal humerus fracture research. SPSS 23 was used for descriptive statistics and Pearson correlations for the relationship between citation count and density. Average citation count was 233 ± 164 with an annual citation density of 14 ± 7. Total citation count was associated with total citation density, 5-year citation count, and 5-year citation density. The Journal of Bone and Joint Surgery–American produced the most articles with 15 (30%). Thirty-five articles originated in Europe. The five most represented authors published three articles each. Finally, 13 (26%) papers appear in the American Shoulder and Elbow Surgeons Curriculum Guide. This study compiles a collection of articles investigating proximal humerus fractures for future review and demonstrates citation count to be an acceptable measure of an article’s contemporary academic influence. (Journal of Surgical Orthopaedic Advances 28(3):180–188, 2019) Key words: ASES Curriculum Guide, citation count, citation density, proximal humerus fracture

    Outcomes of Revision Arthroscopic Anterior Shoulder Stabilization in a Military Population: A Prospective Cohort Study - LCDR George C. Balazs, MD, MC, USN; MAJ Michael A. Donohue, MD, MC, USA; CPT Alaina M. Brelin, MD, MC, USA CPT Jared A. Wolfe, MD,MC, USA; CPT Patrick D. Grimm, MD, MC, USA; LT Theodora C. Dworak, MD, MC, USN1\; and CDR John-Paul H. Rue, MD, MC, USN

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    The purpose of the study was to determine the outcomes of revision arthroscopic anterior shoulder stabilization in a young, military population. The hypothesis was that this subgroup functions well in a high-demand environment without increased rates of failure. Patients were enrolled in an institutional database and followed prospectively. The primary outcomes were scores on the semiannual Physical Readiness Test (PRT), as compared to prior to reinjury. Secondary outcomes included the Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Simple Shoulder Test (SST), and Western Ontario Shoulder Instability Index (WOSI). Sixteen patients met inclusion. Mean age at revision was 20.9 years, and mean follow-up was 32.8 months (range, 12–60 months). Mean bone loss was 9%. Mean PRT score was similar to preinjury (86 vs. 87, p > .05), and mean push-ups showed a small decline (70.4 vs. 78.5, p > .05). Significant improvements were seen in SANE, SF-36 physical component, ASES, andWOSI scores. The results in this cohort suggest that revision arthroscopic stabilization is an acceptable treatment in high-demand military personnel. (Journal of Surgical Orthopaedic Advances 28(3):189–195, 2019) Key words: arthroscopic, Bankart, revision stabilization, shoulder

    Dreaded Ulnar Wrist Pain: Long-Term Results of Pisiformectomy for Painful Pisotriquetral Arthrosis - Maureen A. O’Shaughnessy, MD; Laura W. Lewallen, MD; Steven L. Moran, MD; and Marco Rizzo, MD

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    Pisiform pathology may be a source of ulnar-sided wrist pain. This study reviews the long-term outcomes of patients treated with pisiformectomy. A retrospective study approved by the institutional review board was performed over a 27-year period of patients undergoing pisiformectomy. Range of motion, grip strength, complications, and need for revision surgery were recorded. The series includes 61 wrists (60 patients) with an average age at surgery of 46 years. Two complications were noted (3%): a postoperative ulnar nerve palsy and symptomatic retained suture. At final follow-up, average flexion-extension arc was 81% (expressed as percent of contralateral), radioulnar deviation arc was 88%, and average grip strength was 89%. Pisiformectomy is a reliable, motion-preserving procedure with low complication rates for patients with chronic ulnar-sided wrist pain. In this series, 93% of patients did not require further procedures at an average of 8.2 years follow-up. (Journal of Surgical Orthopaedic Advances 28(3):196–200, 2019) Key words: chronic ulnar-sided wrist pain, pisiformectomy, pisotriquetral pain, ulnar-sided wrist pain, wrist

    Hip Range of Motion: Which Plane of Motion Is More Predictive of Lower Extremity Injury in Elite Soccer Players? A Prospective Study - Sarav S. Shah, MD; Edward J. Testa, MD; Isaac Gammal, MD; Joseph Sullivan, PT, OCS; Roger W. Gerland, MSPT, ATC; Jeffrey Goldstein, MD; Brian Sheridan, PT; Michael Mashura, MD; Aalok S. Shah, BS; Andrew Goodwillie, MD; and Randy M. Cohn, MD

    Abstract | Download | Purchase

    The objective of this study was to determine which plane of hip motion (rotational or sagittal) is more predictive of lower extremity (LE) injury in elite soccer players. A total of 69 athletes (43 professional and 26 collegiate) were examined (mean age, 22.6 years). Bilateral hip internal rotation (IR), external rotation, extension, and flexion measurements were taken along with the modified Thomas test during preseason physicals. There were 42 LE injuries (injury rate 3.74/1000 athlete exposures). Mean IR was 25.2◦ and 29.9◦ for injured versus noninjured extremities, respectively (p = .009). There was a significant association between decreased IR (categorized as IR < 28◦) and incidence of ipsilateral LE injury (p = .042). Extremities with IR < 28◦ were 2.81 times more likely to sustain a LE injury (95% CI, 1.15–6.84; p = .023). With a utilitarian focus, the current study has identified a measurement of decreased hip IR with potential for substantial clinical value in collegiate and professional soccer players. (Journal of Surgical Orthopaedic Advances 28(3):201–208, 2019) Key words: internal rotation, lower extremity injury, soccer, Thomas test

    Evaluating the Readability of Online Patient Education Materials Regarding Shoulder Surgery: How Do Medical Institution Web Sites Rate? -Anshum Sood, MD; Grant Duvall, MD; Varun Ayyaswami, BS; S. Ashfaq Hasan, MD, and Mohit N. Gilotra, MD

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    This study evaluated the readability of online patient education materials on shoulder surgery. Medical and nonmedical institution web sites were compared and it was hypothesized that medical institution materials are written at lower grade levels than nonmedical institution materials, because medical institutions understand physician-patient interactions. Eighty-six articles were scored according to 10 readability tests: cumulative combined average grade level was 12.5 ± 2.8 and average Flesch reading score was 43.5 ± 12.6 (college level). The average composite grade level readability for medical institution web sites was 13 ± 2, significantly higher than for nonmedical institution web sites (11.9 ± 2.1; p = .017). Patient education materials available online are written at a higher level than American Medical Association and National Institutes of Health guidelines. Medical institution articles are written at a statistically significant higher grade level than nonmedical institution articles, but the difference is small and both rate poorly compared with current standards. (Journal of Surgical Orthopaedic Advances 28(3):209–214, 2019)

    Gait and Functional Outcomes Between Cruciate-Retaining and Cruciate- Substituting Implants in Total Knee Arthroplasty: A Prospective, Randomized Study -Matthew L. Brown, MD; Christopher S. Wendt, MS; Thorsten M. Seyler, MD, PhD; Edward H. Ip, PhD; Judy L. Foxworth, PT, PhD, OCS; and Jason E. Lang, MD

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    Significant debate persists about posterior cruciate-retaining (CR) versus posterior cruciate-substituting (PS) implant design for total knee arthroplasty (TKA). This study sought to test the hypothesis that CR TKA will facilitate improved early functional outcomes in gait compared with PS TKA. Patients were randomized to either the CR or PS implant. Various patient-reported and surgeon-reported outcomes as well as gait analyses were obtained pre- and postoperatively. Patients undergoing PS TKA had higher University of California, Los Angeles activity scores at 12 months. No significant difference in spatiotemporal, kinematic, or kinetic parameters between groups was detected, but there was a trend toward quadriceps overuse gait pattern in the CR group. Patients undergoing TKA with a PS implant were more willing to engage in regular higher level physical activity. The CR implant may be a risk factor for quadriceps overuse gait pattern, while the PS implant may be protective against quadriceps overuse. (Journal of Surgical Orthopaedic Advances 28(3):215–223, 2019) Key words: gait analysis, kinematics, patient-reported outcomes, posterior-cruciate retaining, posterior cruciate-substituting, total knee arthroplasty

    Epidural Abscess in the Lumbar Spine: A Single Institution’s Experience With Nonsurgical and Surgical Management - Benjamin W. Berwick, MD, MS; T. David Luo, MD; Katherine W. Sun, MD; Rebecca A. Sharp, MD; John P. Birkedal, MD; and Tadhg J. O’Gara, MD

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    The purpose of this study was to compare patient factors and outcomes in conservatively and surgically treated patients with spinal epidural abscess (SEA). This was a single-center retrospective review of adult patients treated for SEA of the lumbar spine. Primary treatment outcome was readmission for recurrent abscess. Sixty-one patients met inclusion criteria: 59% male, mean age 56.9 years, and body mass index 30.8 kg/m2. Initially 47.5% of patients were treated with conservative measures and 52.5% were treated with surgery. In the conservative group, 31.0% failed treatment and underwent delayed surgery; 26.2% of the overall cohort was readmitted for SEA. Readmitted patients had a greater incidence of history of methicillin-resistant Staphylococcus aureus (p = .048), recurrent infections (p = .008), and recent sepsis and bacteremia (p = .005). Nearly one-third of patients failed initial conservative treatment and needed delayed surgery; however, no significant differences were found between the two treatment groups. Patients with a past history of infections may require more aggressive treatment and closer follow-up, because they are at higher risk for recurrence and readmission. (Journal of Surgical Orthopaedic Advances 28(3):224–231, 2019) Key words: central nervous system infection, conservative management, outcomes, spinal epidural abscess, spinal infection, surgical decompression

    Health Literacy Evaluation of Opioid Patient Education Materials for Orthopaedic Surgery - Latrina Y. Prince, EdD ; Simon C.Mears,MD, PhD; Jamie C. Watson, PhD; and Kristie B. Hadden, PhD

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    Increased opioid use in the United States has resulted in greater incidence of misuse. Orthopaedic patients are more likely to be prescribed opioids for pain. Low health literacy is related to opioid misuse; therefore, orthopaedic patient education tools on use of opioids must be easy to read, understand, and use for patients of all skill levels to be effective. This project aimed to review a broad array of opioid patient education tools and evaluate them from a health literacy perspective. Content evaluation revealed that not all tools expressed the same essential messaging. The mean readability score of the tools assessed was 9.5 grade; higher than the national and recommended 8th-grade reading level. Therefore, many opioid patient education tools may be difficult for patients to read and understand. Improvements in readability and other health literacy best practices are recommended to improve reading, comprehension, and use of opioid patient education tools. (Journal of Surgical Orthopaedic Advances 28(3):232–236, 2019)

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  • Table of Contents
  • Keeping Up With the Orthopaedic In-Training Examination: National Survey on Orthopaedic Residency Training in Practice Management - Matthew Varacallo, MD; Martin Herman, MD

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    The evolving health care environment warrants its physicians to be competent in basic practice management (PM) areas. A manifestation of this importance was reflected in the inaugural inclusion of a PM subsection on the 2017 Orthopaedic In-Training Examination. The purpose of this orthopaedic resident national survey study was to gain insight on the current state of formal residency education in PM. This study surveyed 500 orthopaedic residents nationwide in 2016. Resident participation was online, anonymous, and voluntary. Only complete survey responses were included, yielding a 49.2% (246/500) response rate. The majority of orthopaedic residents (72.4%, 178/246) reported no formal education in PM topics, and 86.2% (212/246) responded that they do not receive direct feedback on individual accuracy of Current Procedural Terminology (CPT) code case logging. Of the residents without formal education in PM, 87.1% (155/178) desire its implementation. The evolving health care system is becoming increasingly reliant on physicians to provide cost-effective, value-based health care to its patients. Consideration should be given to formally incorporating basic teaching elements on important PM topics at the residency training level. (Journal of Surgical Orthopaedic Advances 28(2):81–88, 2019) Key words: ACGME core competencies, CPT coding, documentation and coding, orthopaedic residency, residency curriculum, residency education

    A Legacy Revisited: Needle Holders - Anil Agarwal, MS (Orthopaedics); M. Arkesh, MS (Orthopaedics); Gourav Jandial, MS (Orthopaedics)

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    A needle holder is one of the crucial surgical instruments for surgeons. Its prime function is to steadily hold the needle while applying sutures, thus avoiding injury to the surrounding tissues and to the surgeon’s hand. Wide varieties of needle holders are available for use in orthopaedic practice. This review article briefly describes the biomechanics and other characteristics of some of the commonly used needle holders. The care aspects and wear features of needle holders are also discussed. A surgeon should be aware of the different types of needle holders, their special features, biomechanical properties, and specific uses as they are an important tool in the surgeon’s armamentarium. (Journal of Surgical Orthopaedic Advances 28(2):89–96, 2019) Key words: biomechanics,needle holder, wear

    Preoperative Risk Factor Score Predicts Malnutrition in Total Joint Arthroplasty Patients - Sarah Rudasill, BS; Daniel J. Gittings, MD; Nabil M. Elkassabany, MD; Jiabin Liu, MD, PhD; Charles L. Nelson, MD; Atul F. Kamath, MD

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    Malnutrition is a modifiable risk factor for poor outcomes in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). The purpose of this study is to highlight risk factors for hypoalbuminemia and develop a predictive model that identifies patients at risk for this condition before THA or TKA. The study retrospectively reviewed the National Surgical Quality Improvement Program database to analyze preoperative independent risk factors for a diagnosis of hypoalbuminemia in adult patients who underwent THA or TKA. These factors were used to create a preoperative risk model to predict hypoalbuminemia. Individuals with three or more risk factors in the seven-point model are predicted to have hypoalbuminemia in 20.4% of THA or 10.5% of TKA cases. Accurate identification of hypoalbuminemic patients may allow preoperative nutrition interventions to improve postoperative outcomes. (Journal of Surgical Orthopaedic Advances 28(2):97–103, 2019) Key words: albumin, hypoalbuminemia, malnutrition

    Generating Differential Ligamentotaxis Across the Radiocarpal Joint  - Gregory K. Faucher, MD; Brent G. Parks, MSc; Neal B. Zimmerman, MD

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    This study sought to determine if traction through the index or long finger metacarpal provided a selective distraction force through either the distal radius’ radial or ulnar column. In eight specimens, the radius was cut transversely 1 cm proximal to the Lister tubercle. Index and long finger metacarpals were cut and two-hole plates were fixed to metacarpals. Traction forces were alternately applied to index, then long finger metacarpals, sequentially through each metacarpal from 4.5N to 89N. Traction loading through the index finger metacarpal resulted in significantly more distraction force transmitted through the distal radius fragment’s radial column at all force intervals. Traction loading through long finger metacarpal resulted in significantly higher force transmission through distal radius’ ulnar column. In both cohorts, force transmission increased linearly in response to higher loads. Selective traction force of either the index or long finger metacarpal resulted in differential tensioning of the distal radius’ ulnar and radial columns. (Journal of Surgical Orthopaedic Advances 28(2):104–107, 2019) Key words: biomechanics, distal radius fracture, dorsal spanning plate, internal fixation, wrist

    Early to Midterm Clinical and Radiographic Survivorship of the All-Polyethylene Versus Modular Metal-Backed Tibia Component in Primary Total Knee Replacement -  Thomas Herschmiller, MD; Kendall E. Bradley, MD; Samuel S. Wellman, MD; David E. Attarian, MD

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    The purpose of this study was to compare the all-polyethylene tibial component with the modular metal-backed component in primary total knee arthroplasty. A retrospective review of 1064 patients recorded clinical failure, as determined by need for revision surgery, range of motion, and impending radiographic loosening, as evaluated by the presence of radiolucent lines. Mean follow-up was 1.2 and 3 years, respectively. Survival in the all-polyethylene group was 100%, with 95.5% (95% CI: 85.8–98.6) survival in the metal-backed component group at 4.3 years. Thin (<4 mm) radiolucent lines were present in one patient (0.7%) with an all-polyethylene implant and 24 (16.9%) patients with the metalbacked component (p < .001), while one (0.7%) and two (1.4%) patients had evidence of osteolysis, respectively (p = .621). While there were fewer radiolucent lines noted around the all-polyethylene implant on radiographs, the clinical implications of the finding are unknown. In this study population, the all-polyethylene tibial component appears appropriate. (Journal of Surgical Orthopaedic Advances 28(2):108–114, 2019) Key words: all-polyethylene, metal-backed, osteolysis, primary knee arthroplasty

    Radiographic Predictors of Screw Cutout for Intertrochanteric Fractures Treated With Cephalomedullary Nails - Nickolas J. Nahm, MD; Nicholas B. Frisch, MD, MBA; Wael Ghacham, MD; Clifford M. Les, DVM, PhD; Stuart T. Guthrie, MD; Michael A. Charters, MD, MS

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    The objective of this study was to determine the predictive value of tip-apex distance (TAD) and Parker’s ratio for screw cutout after treatment of intertrochanteric hip fractures with a long cephalomedullary nail. A total of 97 patients with AO/OTA 31-A1-A3 intertrochanteric fractures and a minimum follow-up of 8 weeks were included. Increased Parker’s ratio on the anteroposterior radiograph (OR = 1.386, p < .003) and lateral radiograph (OR = 1.138, p < .028) was significantly associated with screw cutout. In a multivariable regression analysis, only the Parker’s anteroposterior ratio was significantly associated with risk of screw cutout (OR = 1.393, p = .004), but TAD (OR = 0.977, p = .764) and Parker’s lateral ratio (OR 1.032, p = .710) were not independent predictors of cutout. The study concluded that Parker’s anteroposterior ratio is the most helpful measurement in predicting screw cutout. (Journal of Surgical Orthopaedic Advances 28(2):115–120, 2019) Key words: cephalomedullary nail, intertrochanteric fracture, screw cutout

    Adoption of Intramedullary Nail Fixation for Proximal Humerus Fractures: Assessment of Surgical Efficiency and Complications - Brent A. Ponce, MD; Johnathan F. Williams, MD; Shawna L. Watson, MD; Jorge L. Perez, MD; Parke W. Hudson, MD; Jonathan H. Scott, MD; Djuro Petkovic, MD; Christopher M. Jobe, MD; Patrick D. Rowan, MD; Wesley P. Phipatanakul, MD

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    Fixation of proximal humerus fractures (PHFs) with intramedullary (IM) nails potentially is a newer, less invasive technique. The purpose of this study was to report on the early adoption results of IM nail use for PHF. Retrospective chart reviews were performed on the first 60 patients treated with IM nails for acute PHFs by two shoulder surgeons. The first 15 patients treated by each surgeon were compared with the subsequent 15 patients. Surgical and fluoroscopic times, fracture type, union, and varus collapse were compared. The average operating time decreased (p = .002). Fluoroscopy time, radiographic alignment, union rate, complications, and reoperations were not influenced. Three- and four-part fractures had a higher complication rate than two-part fractures (53% vs. 20%). When considering implementing use of IM nails for treatment of PHFs, initial cases can have outcomes and complications similar to those performed with greater experience. IM nailing appears a good treatment option for two-part PHFs. (Journal of Surgical Orthopaedic Advances 28(2):121–126, 2019) Key words: dynamic fixation, humerus fracture, intramedullary nail, learning curve, shoulder, surgeon experience, trauma

    Diabetes and Total Joint Arthroplasty: Infection Risk May Not Be Predictable by Markers of Glycemic Control - Sean Ryan, MD; Marcus Dilallo, MD; Kevin McCoy, MD; Cindy Green, PhD; Thorsten Seyler, MD, PhD

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    With an increasing prevalence of diabetes, there is a need to risk stratify arthroplasty patients preoperatively and characterize postoperative infections. This study sought to determine if perioperative markers of diabetic control were associated with infection and to further characterize diabetic periprosthetic joint infections (PJI). A retrospective analysis of 506 diabetic patients and 900 nondiabetic patients who underwent primary total hip and knee arthroplasty was performed. In this cohort, an infection rate of 4.7% and 2.0% for diabetic and nondiabetic patients, respectively, was observed. There was no association between infection at 1 year and preoperative hemoglobin A1C or postoperative blood glucose; however, diabetic infections were significantly more likely to be deep (HR = 4.6; p < .001) and present >6 weeks postoperatively (HR = 8.0; p = .001). This study concluded that common markers of glycemic control are not predictive of the increased risk of diabetic PJI and alternative markers should be investigated. (Journal of Surgical Orthopaedic Advances 28(2):127–131, 2019) Key words: arthroplasty, diabetes, glucose, glycemic control, hemoglobin A1C, infection

    Isolated Subtalar Arthrodesis for Avascular Necrosis of the Talus - Travis J. Dekker, MD; Manuel J. Pellegrini, MD; Adam P. Schiff, MD; Mark E. Easley, MD; James K. DeOrio, MD; James A. Nunley, MD; Samuel B. Adams, MD

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    Isolated subtalar arthrodesis has been attempted in talar avascular necrosis (AVN) patients to preserve the tibiotalar joint and potential revascularization. This article reports the efficacy of isolated subtalar arthrodesis in the setting of AVN. A retrospective review of subtalar arthrodeses was performed on a cohort of 12 patients with talar AVN who underwent subtalar arthrodesis. The primary outcome was radiographic fusion with secondary outcomes of subsequent procedures, recurrent pain, and perioperative complications. Radiographic fusion of subtalar arthrodesis occurred in 12 of 12 patients. Five of six patients with traumatic etiology went on to have secondary procedures. One of six patients with atraumatic etiology underwent a secondary procedure for advancement of tibiotalar arthritis. In the setting of atraumatic talar AVN, this small cohort demonstrates that isolated subtalar arthrodesis is a safe and reliable procedure with high fusion rates and low need for secondary procedures. (Journal of Surgical Orthopaedic Advances 28(2):132–136, 2019) Key words: arthritis, avascular necrosis, outcome study, subtalar fusion, talus, trauma

    Early Stabilization of Femur Fractures in the Setting of Polytrauma Is Associated With Decreased Risk of Pulmonary Complications and Mortality - James A. Blair, MD; Nicholas Kusnezov, MD; Tuesday Fisher, MD; Gautham Prabhakar, MD; Julia O. Bader, PhD; Philip J. Belmont, MD

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    Timing of definitive fixation of femoral shaft fractures is a subject of continued controversy. The purpose of this study was to determine if early definitive fixation of femoral shaft fractures in the setting of polytrauma decreased the risk of pulmonary complications and mortality. The 2009–2012 National Sample Program of the National Trauma Data Bank was queried for all patients 18 to 65 years with Injury Severity Scores (ISS) >15 who underwent definitive fixation of femoral shaft fractures. Mortality, perioperative complications, and length of intensive care unit (ICU) and hospital stay were the primary outcome measures of interest. Following multivariate analyses, increased time to surgery was found to portend a statistically significant increased risk of acute respiratory distress syndrome(ARDS), mean ventilator time, length of ICU and hospital stay, and mortality. Earlier definitive fixation of femoral shaft fractures in the setting of polytrauma is associated with significantly decreased risk of ARDS, mean ventilator time, length of ICU and hospital stay, and mortality. (Journal of Surgical Orthopaedic Advances 28(2):137–143, 2019) Key words: early stabilization, femur fracture,mortality, polytrauma, pulmonary complications

    Musculoskeletal Health Literacy, Pain Catastrophization, and Sleep Quality: Effect on Functional Disability Scores - Peter C. Noback, BA; Mani Seetharaman, MD; Direk Tantigate, MD; Robert J. Strauch, MD; Melvin P. Rosenwasser, MD; J. Turner Vosseller, MD

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    Limited musculoskeletal health literacy, catastrophic pain thinking, and poor sleep quality may be associated with adverse long-term health outcomes, but are sparsely studied concomitantly in orthopedics. The purpose of this study was to assess how these factors influence baseline functional disability. Hand and wrist and foot and ankle patients presenting with a previously untreated complaint were enrolled and completed the Literacy in Musculoskeletal Problems questionnaire, Pain Catastrophization Scale (PCS), and Pittsburgh Sleep Quality Index (PSQI). Upper extremity patients completed the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and lower extremity patients completed the Foot and Ankle Outcome Score (FAOS) survey. DASH and FAOS scores were normalized to the same scale and termed ‘‘functional survey’’ (FS). Two hundred thirty-one patients (mean age 45.8 ± 16.8) were included in the analysis. PCS and PSQI were significantly correlated with FS score. The only other variables significantly correlated with FS score were insurance and diagnosis type. The variables PCS, PSQI, insurance, and diagnosis were entered into a multivariate analysis with FS score. All four variables significantly added to FS score in the model (R2 = .194, p < .001). Interventions that target both catastrophizing tendencies and sleep quality may independently improve functional outcomes. Further in-depth multifactorial research in this topic is critical to craft effective treatments with sustainable outcomes. (Journal of Surgical Orthopaedic Advances 28(2):144–149, 2019) Key words: functional outcomes, health literacy, orthopedics, pain catastrophization, sleep quality

    Acute Pectoralis Major Tears in Forward Deployed Active Duty U.S. Military Personnel: A Population at Risk? - MAJ Dane Salazar, MD; CAPT Irshad Shakir, MD; LT COL Keith Joe, MD; MAJ W. Stephen Choate, MD

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    The purpose of this study is to report on the causes of a series of acute pectoralis major tears in active duty deployed military personnel. Nine cases of acute pectoralis major tears evaluated at one expeditionary military treatment facility over a 4-month deployment cycle were analyzed. Nine male patients were diagnosed with tears: seven complete tears at the tendinous insertion, one complete tear at the musculotendinous junction, and one incomplete tear, with a mean age of 32 years (range, 23–52 years). All injuries occurred during bench press, with the dominant upper extremity involved 56% of the time. Injury occurred an average of 77 days into the tour (range, 3–198 days). Mean time from injury to surgical repair in the cohort was 18 days (range, 10–43 days). Combat-deployed active duty U.S. military personnel likely represent a high-risk population for this injury. Surgical repair is possible, but rarely advisable, in the deployed setting. (Journal of Surgical Orthopaedic Advances 28(2):150–157, 2019) Key words: active duty, military, pectoralis major tear, tendon repair, wartime injuries

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  • Table of Contents
  • Accuracy and Interobserver and Intraobserver Reliability of Ultrasound in the Early Diagnosis of Occult Scaphoid Fractures: Diagnostic Criteria and a Way of Interpretation - Michael-Alexander Malahias, MD, PhD; Vasileios S. Nikolaou, MD, PhD, MSc; Dimitrios Chytas, MD, PhD; Maria-Kyriaki Kaseta, MD, PhD; and George C. Babis, MD, PhD

    Abstracts | Download | Purchase

    The purpose of this study was to illustrate the usefulness of ultrasound in the early diagnosis of occult scaphoid fractures. Forty-eight patients with clinical symptoms of scaphoid fracture and negative initial X-rays were examined. All patients underwent ultrasonography in the emergency room (ER). After 14 days, a computed tomography (CT) scan was performed, which confirmed or not the initial suspicion of fracture. Twenty-two patients were found with subperiosteal hematoma, while six also had cortical discontinuity. The sensitivity of ultrasound in the diagnosis of occult scaphoid fractures was 90% and the specificity was 85.7%. The positive prognostic value was 81.8%. The authors support the use of the scaphoid ultrasound only under strict circumstances. If subperiosteal hematoma or cortical discontinuity is present, there is a high likelihood of scaphoid fracture. On the contrary, if the ultrasound is negative and symptoms persist, the patient will require a CT scan or magnetic resonance imaging for definitive diagnosis. (Journal of Surgical Orthopaedic Advances 28(1):1–9, 2019) Key words: cost-effectiveness, diagnosis, occult fractures, scaphoid fractures, subperiostal hematoma, ultrasound

    Trends and Characteristics of Highly Cited Articles in Shoulder Arthroplasty - Zachary A. Mosher, MD; Michael A. Ewing, MD; Parke W. Hudson, MD; Martim C. Pinto, MD; Eugene W. Brabston III, MD; and Brent A. Ponce, MD

    Abstracts | Download | Purchase

    Citation calculations measure academic influence. This study sought to analyze highly cited shoulder arthroplasty articles and determine the best measure to assess their impact. Scopus identified the 50 most cited articles, and each was analyzed for citation number, authors, institution, country of origin, and journal of publication. SPSS 23 was used for descriptive statistics, and a Pearson correlation coefficient assessed the relationship between citation measures. The results revealed an average citation count of 259 ± 108 and a citation density (citation count /years since publication) of 18 ± 10 annually. Most articles originated in the United States (31) and France (9). Twelve surgeons were included on three or more articles. Forty-one studies were clinically based. Finally, correlation was demonstrated between citation count and citation density (r = 0.486, p ¡ .001). In conclusion, this study revealed the trends of highly cited shoulder arthroplasty articles and found citation count and citation density to be acceptable measures of academic influence. (Journal of Surgical Orthopaedic Advances 28(1):10–17, 2019) Key words: citation count, citation density, citation trends, shoulder arthroplasty, most cited, publication trends, Scopus

    Comparison of Scapular Mechanics After Activity With and Without a Targeted Compression Garment - Andrew Golz, MD; Michael Conti Mica, MD; Dane Salazar, MD; Andrea Pellegrini, MD; and Pietro Tonino, MD

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    Muscle fatigue can result in scapular dyskinesis, which has been implicated in impingement, labral injury, and rotator cuff injury. This study evaluated the ability of a compression shirt to maintain scapular alignment after fatiguing of periscapular musculature. Subjects’ scapular movements were monitored before and after a periscapular muscle–fatiguing exercise program. In the anterior and posterior tilt and medial and lateral rotation dimensions, control and shirt subjects both exhibited differences between the prefatigue and postfatigue measurements throughout humeral elevation. In the retraction and protraction dimension, control subjects exhibited differences between prefatigue and postfatigue measurements for a large portion of elevation, while shirt subjects only had different measurements toward the extreme of shoulder flexion. Thus the shirt does not stabilize the scapula in the anterior and posterior tilt and medial and lateral rotation dimensions. In the retraction and protraction dimension, the shirt provides stability to the scapula and maintains prefatigue position. It is currently unclear if preserving one plane of scapular motion has clinical significance. (Journal of Surgical Orthopaedic Advances 28(1):18–23, 2019) Key words: biomechanics, injury prevention, scapular dyskinesis

    High-Energy Midfoot Fracture–Dislocations: Staged Treatment With an External Fixator - John E. Arvesen, MD; Zachary Burnett, MD; Heidi Israel, PhD; J. Tracy Watson, MD; and Lisa K. Cannada, MD

    Abstracts | Download | Purchase

    The purpose of this study was to analyze the clinical outcomes of patients treated for high-energy midfoot (Lisfranc) injuries with initial temporization of an external fixator before definitive fixation. A retrospective chart review at two level 1 trauma centers was completed. Clinical parameters including demographics and comorbidities were evaluated in addition to hospital and clinical data. Time to full weight bearing took an average of 4.4 months, and with the numbers available no significant difference (p > .05) was found between the open reduction and internal fixation (ORIF) group and the arthrodesis group in regard to length of stay, days from initial reduction with an external fixator to definitive fixation, time to full weight bearing, or return to work. Staged treatment of high-energy Lisfranc injuries with external fixation demonstrated minimal soft tissue complications similar to other series reported in the literature. Definitive stabilization with either ORIF or arthrodesis produced similar results in staged treatment of these injuries. (Journal of Surgical Orthopaedic Advances 28(1):24–30, 2019) Key words: external fixation, Lisfranc fracture, midfoot fracture, tarsometatarsal fracture–dislocation

    Survival of a Second-Generation Porous Plasma-Sprayed Acetabular Component at Minimum 15-Year Follow-up - David A. Crawford, MD; Keith R. Berend, MD; Joanne B. Adams, BFA; and Adolph V. Lombardi, Jr., MD, FACS

    Abstracts | Download | Purchase

    This study assessed the 15-year minimum outcomes of the RingLoc cup (Zimmer Biomet, Warsaw, Indiana), a second-generation cementless porous plasma-coated acetabular component. The study identified 2438 patients (2905 hips) who underwent total hip arthroplasty using the RingLoc acetabular component between 1992 and 2000. Fifteen-year minimum follow-up data were available on 431 consented patients (511 hips). Clinical outcomes included the Harris hip score. Follow-up radiographs, complications, and revisions were reviewed. Mean follow-up was 18.2 years (range, 15–24.7). Harris hip scores improved from 46.9 preoperatively to 79.3 postoperatively (p ¡ .001). Reoperation for any reason was performed in 141 hips (27.6%). Isolated liner exchange was performed in 96 hips (18.8%) and acetabular revisions were performed in 44 hips (8.6%). Acetabular survivorship at 15 years was 93.5% for all causes and 94.3% for aseptic revision. This study demonstrated excellent acetabular survivorship of the porous plasma-sprayed RingLoc cup at a minimum 15-year follow-up. (Journal of Surgical Orthopaedic Advances 28(1):31–34, 2019) Key words: acetabulum, cementless, porous, survivorship

    Misdiagnosis and Radial Tunnel Syndrome: Considering the Distal Biceps Tendon - Jacob M. Wilson, MD; Robert Runner, MD; Walter B. McClelland, Jr., MD; and Gary McGillivary, MD

    Abstracts | Download | Purchase

    Radial tunnel syndrome (RTS) has long been a difficult therapeutic and diagnostic entity for upper extremity surgeons. The presentation is vague and the diagnosis is typically one of exclusion. Multiple clinicalentitiesareknowntomimicRTS,butlittleattentionhasbeenpaidtothedistalbiceps.Experience suggests that insertional biceps tendonitis is a potential confounding diagnosis in suspected RTS and that magnetic resonance imaging (MRI) may be of diagnostic benefit in chronic cases before surgical intervention is undertaken. This study is a 13-patient case series. The included patients presented with proximal forearm pain and positive provocative maneuvers for RTS. All included patients were found to have distal biceps pathology on MRI evaluation. At final follow-up (average 6.9 years), all patients had resolution of symptoms with therapy aimed specifically at addressing the distal biceps tendon. A diagnosis of insertional biceps tendonitis could explain both the typical success with conservative treatment and the poor results from surgical intervention for RTS. (Journal of Surgical Orthopaedic Advances 28(1):35–40, 2019) Key words: conservative management, distal biceps, misdiagnosis, radial tunnel syndrome, tendonitis, therapy

    Shoulder Arthroplasty in Transplant Recipients: Complications and Mortality - Patrick K. Strotman, MD; Anai Kothari, MD; Paul Kuo, MD, MBA, FACS; Dane H. Salazar, MD; and Nickolas Garbis, MD

    Abstracts | Download | Purchase

    Given the increase in the incidence and survivability of those with solid organ transplantations in the UnitedStates,thepurposeofthisstudywastoidentifyinpatient,30-day,and90-dayoutcomesfollowing primary shoulder arthroplasty in transplant recipients. The Healthcare Cost and Utilization Project State Inpatient Databases identified patients who underwent shoulder arthroplasty after solid organ transplantation between January 2007 and December 2013. International Classification of Diseases, Ninth Revision, codes were used to define the primary composite outcome of death or postoperative complication. Logistic models with frequency weights were used to compare propensity-matched groups. Patients undergoing primary shoulder arthroplasty following solid organ transplant are at elevated risk of inpatient and 30-day and 90-day postoperative complications (respiratory, hemorrhage) and have longer length of stays compared with nontransplant patients. Transplant patients did not have an increased risk of surgical site infection or mortality at any time point (Journal of Surgical Orthopaedic Advances 28(1):41–47, 2019) Key words: complication, immunosuppression, infection, outcomes, shoulder arthroplasty, solid organ transplan

    Influence of Patient Activation, Pain Self-Efficacy, and Resilience on Pain Intensity and Magnitude of Limitations in Patients With Hip and Knee Arthritis - Tom J. Crijns, BSc; Tiffany C. Liu, MD; David Ring, MD, PhD; Kevin J. Bozic, MD, MBA; and Karl Koenig, MD, MS

    Abstracts | Download | Purchase

    Studying the relative impact of various measures of coping strategies can help determine which ones are most useful for patients with osteoarthritis (OA).This study prospectively enrolled 108 patients with hip or knee OA who were seeing an orthopedic surgeon before or after arthroplasty. Measures of coping strategies included the Patient Activation Measure (PAM), Pain Self-Efficacy Questionnaire (PSEQ-2), and the Brief Resilience Scale (BRS). The Hip Disability and Osteoarthritis Outcome Score, Junior (HOOS, JR), the Knee Injury and Osteoarthritis Outcome Score, Junior (KOOS, JR), and Numeric Rating Scale (NRS) were used to measure pain intensity. Pearson correlations measured the interrelationships of the outcome measures. The PSEQ-2 correlated significantly with the NRS, but the confidence intervals for the three instruments overlapped. The PAM and the PSEQ-2 correlated with the KOOS, JR. Only the PSEQ-2 was associated with variation in the NRS. The PAM, PSEQ-2, and BRS correlated with one another. While measures of self-efficacy, active involvement in care, and general resilience were correlated, the measure of pain self-efficacy had the strongest association with patient-reported outcomes. (Journal of Surgical Orthopaedic Advances 28(1):48–52, 2019) Key words: osteoarthritis, patient activation, patient-reported outcomes, resilience, self-efficacy

    Orthopaedic and Plastic Surgery Training Differences Manifested in the Analysis of Distal Radius Fracture Fixation - Logan R. Koehler, MD; Nicholas A. Kusnezov, MD; Justin D. Orr, MD; Mark Pallis, DO; and John C. Dunn, MD

    Abstracts | Download | Purchase

    All patients undergoing open reduction and internal fixation of a distal radius fracture (DRF) between the years 2010 and 2015 were isolated from the National Surgical Quality Improvement Program database. Patient demographics, respective surgical volume, outcome variables, and complications were extracted. The primary outcomes were surgical time, hospital length of stay, and unplanned reoperation. A total of 6691 patients were included in the study, the majority of whom were treated by orthopaedicsurgeons.Whiletherewerenosignificantdifferencesinbaselinedemographicsbetweenthe patients treated by orthopaedic and plastic surgeons, the overall operative time was significantly less for DRFsfixedbyorthopaedicsurgeons.Whiletherewasasignificantdifferenceforextra-articularfractures, this difference increased significantly for complex intra-articular fractures. Additionally, hospital length of stay was significantly shorter for patients treated by orthopaedic surgeons. To produce well-rounded, technically skilled surgeons, plastic surgery programs should incorporate fixation principles into their training programs. (Journal of Surgical Orthopaedic Advances 28(1):53–57, 2019) Key words: distal radius fracture, orthopaedic surgery, plastic surgery, residency training

    Multimodal Pain Management of Femoral Neck Fractures Treated With Hemiarthroplasty - Hank L. Hutchinson, MD; David J. Jaekel, PhD; Scott T. Lovald, PhD; Heather N. Watson, PhD; and Kevin L. Ong, PhD, PE

    Abstracts | Download | Purchase

    The purpose of this study was to evaluate a multimodal pain management program incorporating periarticular injections of liposomal bupivacaine after hemiarthroplasty treatment of femoral neck fractures. This retrospective study selected patients treated with periarticular injections of liposomal bupivacaine within the multimodal pain management program (LBUP) (n=100) and a control group of patients treated without local infiltration (n=78). Similar pain control was achieved between both groups from day 1 to day 4 postsurgery (min p= .392). Length of stay was significantly lower for LBUP patients (4.8 days vs. 5.7 days, p= .013), and LBUP patients were significantly more likely to be ambulatory at discharge (82% vs. 69%, p= .013). LBUP patients were also less likely to need the intensive care unit (4% vs. 14%, p= .027). The percentage of patients with at least one opioid-related adverse event was lower in the LBUP group (3% vs. 8%, p= .156) as was the 90-day mortality rate (2% vs. 8%, p= .069), but the differences were not statistically significant. (Journal of Surgical Orthopaedic Advances 28(1):58–62, 2019) Key words: hemiarthroplasty, hip fracture, liposomal bupivacaine, multimodal pain management

    Role of First Metacarpal Osteotomy in the Management of Basilar Thumb Arthritis - Maureen O’Shaughnessy, MD; Megan Conti Mica, MD; and Marco Rizzo, MD

    Abstracts | Download | Purchase

    This study reviews outcomes of patients undergoing Wilson extension osteotomy of the first metacarpal fortreatmentofcarpometacarpal(CMC)jointpainanddeformity.Thestudyreviewsvariedindicationsfor Wilsonosteotomyoutliningtechniqueandfunctionaloutcomes.Twelvepatients(11female,1male)with anaverageageatsurgeryof50(range,25–67)underwentosteotomyduringthestudyperiod.Diagnoses included seven patients with early degenerative changes of the CMC joint with painful subluxation or instability. The remaining patients had symptomatic adduction contracture in either end-stage arthritis (three) or following prior trapeziectomy (two). Average motion improved modestly among all groups with considerable improvement of metacarpophalangeal hyperextension in late deformity patients. Wilson osteotomy is a motion-preserving alternative procedure that may be indicated for patients with early CMC arthrosis and instability as well as for patients with adduction contractures in end-stage arthritis or posttrapeziectomy (Journal of Surgical Orthopaedic Advances 28(1):63–67, 2019) Key words: basilar thumb arthritis, corrective osteotomy, first metacarpal osteotomy, metacarpal osteotomy, Wilson extension osteotomy

    New Failure Mechanism of Acetabular Constrained Liner: A Case Report - John Wilkinson, MD; Paul K. Edwards, MD; Mathew Levine, MD; and C. Lowry Barnes, MD

    Abstracts | Download | Purchase

    Implant dislocation following total hip arthroplasty, particularly revision arthroplasty, remains a common postoperative complication. Constrained acetabular liners provide surgeons with an implant option that provides resistance to dislocation forces. These added forces, however, are transmitted to the implant materials and to the bone–implant interface, resulting in unique failure mechanisms. This case report presents two cases highlighting a previously unreported mechanism of failure of the Depuy Pinnacle ES constrained liner encountered during intraoperative implantation of the components (Journal of Surgical Orthopaedic Advances 28(1):68–73, 2019) Key words: constrained liner, cross-linked polyethylene, Depuy Pinnacle ES, failure, hip arthroplasty, polyethylene fracture

    A Modified "One-Stitch" Hamstring Tendon Suture Fixation Technique for Anterior Cruciate Ligament Graft Preparation - Joris A. Jansen, MD; Roderick S. M. Piekaar, MSc, MD; and Dirk P. Hogerzeil, MSc, MD

    Abstracts | Download | Purchase

    Hamstring tendon autografts are very often used for anterior cruciate ligament (ACL) reconstruction. After harvesting of the tendons, each end is most commonly fixed with a running whipstitch suture technique, which permits adequate handling and tensioning of the graft. This conventional technique, which uses multiple locking stitches running up and down the ends of both tendons, is time consuming and carries a risk for tendon damage and needle stick injuries. As a result of the conventional whipstitch technique, suture material is left behind within the tendon inside the tibial canal, which may lead to a local inflammatory response during resorption of the sutures. This article introduces a new technique involving a modified ‘‘one-stitch’’ hamstring tendon suture fixation technique. (Journal of Surgical Orthopaedic Advances 28(1):74–76, 2019) Key words: ACL graft, anterior cruciate ligament graft, hamstring tendon suture fixation technique, one-stitch hamstring tendon suture fixation technique, orthopedic surgery, surgical technique

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  • Table of Contents
  • Posterior Fibula of Pes Cavus: Real or Artifact? Answer Based on Cross-Sectional Imaging - Sean C. Peden, MD; John C. Tanner III, MD; and Arthur Manoli II, MD

    Abstracts | Download | Purchase

    Cavus foot deformity is an often overlooked source of pathology. In the cavus foot, the fibula is often noted to be posterior on lateral radiographs. The objective of the study was to determine with threedimensional imaging if the fibula is truly posterior or just artifact. Using physical examination, patients with cavus were selected and compared to controls. An established technique to determine fibular position on computed tomography and magnetic resonance imaging was used to compare the study group to controls. Thirty-six cavus feet were compared to 36 controls. The average cavus fibula was noted to be 72% more posterior than the fibula of control patients and the difference in axial malleolar index was significant between the groups. This study shows that the cavus fibula is truly more posterior in patients with high arches. (Journal of Surgical Orthopaedic Advances 27(4):255–260, 2018) Key words: axial malleolar index (AMI), fibula, peek-a-boo heel sign, pes cavus

    Ascorbic Acid and Its Clinical Role in Orthopaedic Surgery - Tianyi David Luo, MD; Anthony J. Marois, MD; Thomas L. Smith, PhD; Jeffrey S. Willey, PhD; and Cynthia L. Emory, MD

    Abstract | Download | Purchase

    Ascorbic acid (vitamin C) is an essential micronutrient with evidence supporting its role in bone formation, tissue repair, and collagen production. Its clinical importance to the field of orthopaedic surgery has yet to be fully defined. Several observational studies have shown improved bone density and reduced hip fracture risk with supplementation. Its effect on bone fracture and soft tissue injury has been promising in animal models, but is not adequately studied in human trials. Results have been mixed concerning its role in chondroprotection and osteoarthritis treatment. Evidence suggesting reduced incidence of complex regional pain syndrome following distal radius fracture when treated with adjuvant ascorbic acid has prompted much debate but has received an endorsement of moderate support from the American Academy of Orthopaedic Surgeons. Given its potential benefits, low cost, and safety profile, ascorbic acid supplementation warrants consideration by orthopaedic surgeons in the treatment of a variety of musculoskeletal injuries (Journal of Surgical Orthopaedic Advances 27(4):261–268, 2018) Key words: ascorbic acid, bone health, cartilage, complex regional pain syndrome, fracture healing, ligaments, osteoarthritis, osteoblast differentiation, tendons, vitamin C

    Opioid Prescribing in the Pediatric Orthopaedic Trauma Population - Robert T. Simril III, BS; Brian P. Scannell, MD; Meghan K. Wally, MSPH;
    Michael H. LeFlore, BS; Rachel B. Seymour, PhD; Joseph R. Hsu, MD; and the PRIMUM Group

    Abstract | Download | Purchase

    The purpose of this article is to describe opioid prescribing patterns for children with orthopaedic injuries. A retrospective chart review was conducted on pediatric orthopaedic trauma patients (n = 124) who were discharged from the hospital or emergency department or had a clinic visit during a 1-month period. Patient demographics, prescription specifics, injury details, and fracture fixation information were collected. Results show that most children received opioids after injury (82.3%). While children undergoing operative fixation typically received opioids, only 39.5% with closed reduction did. Hydrocodone–acetaminophen accounted for 93% of prescriptions, but adolescents were more likely to receive other drugs. There was a significant trend of increasing daily dosage with increased age; 36.73% of adolescents received > 50 morphine milligram equivalents per day. Children with orthopaedic injuries are typically prescribed opioids; older children more commonly receive higher dosages. Further study is needed to define prescribing trends across facility and specialty types to aid in development of standardized prescribing guidelines. (Journal of Surgical Orthopaedic Advances 27(4):269–273, 2018) Key words: opioids, orthopaedic trauma, pain, pediatrics

    Comparison of Hand Drills for the Insertion of Skeletal Traction Pins - Cameron A. Roth, MD, MHS; Stefan Turkula, MD; David A. Fuller, MD; and Kenneth W. Graf, MD

    Abstract | Download | Purchase

    Skeletal traction pins are inserted as part of emergent stabilization of lower extremity fractures. The purpose of this study is to compare two drill options: a reusable store-bought drill and a single-use, sterilely packaged drill. The reusable drill and disposable drill were compared by having volunteers insert traction pins within a foam bone, fully encased, knee joint model using both systems. The two drill types were evaluated on three measures: user satisfaction, time required for insertion of the pins, and cost. The disposable drill received a statistically significant higher user satisfaction score and a statistically significant faster time to pin insertion. The per-use cost of the disposable system was found to be higher. For skeletal traction pin insertion, the disposable, single-use drill was found to be superior to the reusable drill in user satisfaction and time required for traction pin insertion. Institutional cost analysis favors the disposable system because of the more predicable charge capture, while the per-use cost of the disposable system remains higher. (Journal of Surgical Orthopaedic Advances 27(4):274–276, 2018) Key words: cost analysis, damage control orthopaedics, skeletal traction, traction pins, trauma, user satisfaction

    Impact of Fluoroscopically Guided Bone Biopsy on Antibiotic Management of Osteomyelitis in the Lower Extremity - Joseph G. Mammarappallil, MD, PhD; Thorsten M. Seyler, MD, PhD; Leon Lenchik, MD; Scott D. Wuertzer, MD; and Johannes F. Plate, MD, PhD

    Abstract | Download | Purchase

    This study evaluated the impact of fluoroscopically guided percutaneous bone biopsy on altering antibiotic regimens in lower extremity osteomyelitis. Eighty-eight patients who received fluoroscopically guided bone biopsies were identified. There was bacterial growth in 28% of bone biopsies overall. The rate of positive culture was decreased in patients started on empiric antibiotics before biopsy (23%) compare with patients without empiric antibiotics (44%). Antibiotic regimens were changed in 24% of patients overall in response to culture data. The majority of positive biopsy cultures (76%) but minority of negative biopsy cultures (3%) resulted in a change to antibiotic regimens. The impact of percutaneous bone biopsy on antibiotic management of adult patients with osteomyelitis diagnosed by magnetic resonance imaging is modest and is decreased in patients previously started on antibiotics. Despite its modest impact, bone biopsy results can provide useful information in antibiotic management, especially when positive (Journal of Surgical Orthopaedic Advances 27(4):277–280, 2018) Key words: fluoroscopy, IR guided, musculoskeletal MRI, osteomyelitis, percutaneous bone biopsy

    Comparison of Microbial Count on Various Surfaces in Operating Rooms at Different Times of the Day - Graysen Petersen-Fitts, MD; Andrew Gambone, MD; Alexandria Sherwood, BS; James Whaley, MD; Danielle L. Katz, MPH; Diego J. L. Lima, MD; and Vani Sabesan, MD

    Abstract | Download | Purchase

    The purpose of this study was to determine the degree of microbial contamination of surfaces in the operating room (OR) and to understand the relationship between time and location of contamination. Five OR surfaces were sampled at two time points on three consecutive Mondays and Thursdays. Each sample was cultured on a blood agar plate and introduced to a liquid nutrient broth. The most sterile surface was the OR lights with only one positive growth sample at each time. At both times, the most commonly contaminated surface was the staff keyboard. Coagulase-negative staphylococcus was the most common isolated species. Contamination rate of OR surfaces was not affected by time of day or day of the week. Simple cleaning and daily decontamination of staff keyboards can significantly reduce bacterial burdens and should be of primary importance to optimize OR sterility. (Journal of Surgical Orthopaedic Advances 27(4):281–285, 2018) Key words: bacteria, contamination, operating room, time of day

    Excess Readmission-Based Penalty: Is Arthroplasty Different From the Other Outcomes? - Raj N. Manickam, MS; Stavros G. Memtsoudis, MD, PhD; Yi Mu, PhD; Jeehyoung Kim, MD; Abhijit V. Kshirsagar, MD, MPH; and Heejung Bang, PhD

    Abstract | Download | Purchase

    Whether factors not under a hospital’s control affect readmissions remains intensely debated in the context of the Centers for Medicare & Medicaid Services’ Hospital Readmission Reduction Program. This study aimed to evaluate the potential effects of poverty, race, and hospital volume on excess readmissions, with >3000 hospitals participating in ‘‘Hospital Compare.’’ Correlations between excess readmission ratios for five eligible outcomes (including hip and knee arthroplasty) were assessed with the three area and hospital-level factors: poverty, race (percent of black population), and hospital volume (number of discharges). Correlation coefficients of the ratios with race were approximately r = 0.2, consistently larger than those with poverty (r = 0–0.1), and those with volume were r = 0 to –0.5. Hip and knee arthroplasty had unique findings: null correlation with poverty (r ≈ 0), largest variability, and strong monotonicity with volume (r ≈ –0.5). The percent of Hispanic population showed negligible correlations in secondary analysis. Penalty assessment and hospital profiling should consider areas with high percentages of black population and a small volume of hospitals and providers of hip and knee surgery. (Journal of Surgical Orthopaedic Advances 27(4):286–293, 2018) Key words: black, CMS, hip, Hospital Readmission Reduction Program, knee

    Insulin-Dependent Diabetes Is an Independent Risk Factor for Complications and Readmissions After Total Joint Replacements - Udai S. Sibia, MD, MBA; Adam S. Weltz, MD; James H. MacDonald, MD; and Paul J. King, MD

    Abstract | Download | Purchase

    This study examined the risk for postoperative complications, reoperations, and readmissions for patients with insulin-dependent diabetes mellitus (IDDM), patients with non-insulin-dependent diabetes mellitus (NIDDM), and patients without diabetes undergoing total joint replacements (TJRs). The American College of Surgeons National Surgical Quality Improvement Program database was queried for all primary TJRs in 2015. The study identified 78,744 TJRs (84.1% nondiabetic patients, 12.0% NIDDM, and 3.9% IDDM). Multiple logistic regression models identified IDDM as an independent risk factor for increased blood loss, myocardial infarctions, pneumonia, renal insufficiency, urinary tract infections, and readmissions when compared with both NIDDM and nondiabetics. Risk for wound complications and reoperations were comparable between all three groups. IDDM increases the risk for medical complications and readmissions after TJRs. Physicians must counsel patients on the increased risks associated with IDDM before elective surgery and provide appropriate medical support for these patients. (Journal of Surgical Orthopaedic Advances 27(4):294–298, 2018) Key words: American College of Surgeons National Surgical Quality Improvement Program (ACSNSQIP), insulin-dependent diabetes mellitus, total joint replacements

    Treatment of Pediatric Osteoid Osteomas Not Amenable to Radiofrequency Ablation: A Retrospective Review of Surgical Outcomes - Thomas Sanders, MD; Doris E. Wenger, MD; Ali Ashraf, MD; Amy L. McIntosh, MD; Anthony A. Stans, MD; William J. Shaughnessy, MD; Andre J. van Wijnen, PhD; and A. Noelle Larson, MD

    Abstract | Download | Purchase

    The purpose of this study is to describe the surgical treatment of osteoid osteomas in a pediatric cohort of patients who were found not to be candidates for percutaneous ablative therapies. Medical records for 29 pediatric patients who were treated surgically for osteoid osteomas were reviewed. Reasons for surgical management included diagnostic uncertainty or lesions that were in close proximity to an articular surface or neurovascular structure. Twenty-eight patients experienced complete symptom resolution. Surgical treatment may still be indicated in a select group of osteoid osteoma patients who are not candidates for percutaneous treatment. (Journal of Surgical Orthopaedic Advances 27(4):299–302, 2018) Key words: osteoid osteoma, pediatric, radiofrequency ablation, recurrence

    Does Traction Decrease the Need for Open Reduction in Femoral Shaft Fractures Treated Within 24 Hours? - Michael R. Koerner, MD; Lindsay E. Young, MD; Ashley Daniel, MD; Stephanie L. Tanner, MS; Brett Crist, MD; Thomas M. Schaller, MD; Kyle J. Jeray, MD; Michael S. Sridhar, MD; and John D. Adams, Jr., MD

    Abstract | Download | Purchase

    This study evaluates whether preoperative skeletal traction reduces the need for open reduction in femoral shaft fractures treated with intramedullary nailing (IMN) within 24 hours. A retrospective review was conducted of femoral shaft fractures undergoing IMN within 1 day of admission. Primary outcome was an open reduction at the time of IMN. Secondary outcomes were blood loss and transfusion requirements. One hundred eighty-four patients were analyzed, 106 in the knee immobilizer group and 78 in the skeletal traction group. Skeletal traction did not reduce the need for an open reduction. The knee immobilizer group required open reduction in 13% (14/106) compared with 14% (11/78) in the skeletal traction group, which was not significant (p = .89). Blood loss and transfusion rates were similar between groups. Skeletal traction does not appear to reduce the need for open reduction at the time of IMN for femoral shaft fractures treated within 1 day of admission. (Journal of Surgical Orthopaedic Advances 27(4):303–306, 2018) Key words: femur fracture, intramedullary nail, knee immobilizer, skeletal traction, temporary stabilization

    What Factors Influence Compliance With Sequential Compression Devices in an Orthopaedic Unit: A Quality Assurance Observational Study - Avionna L. Baldwin, BS; Sean J. McMahon, MBA; and Addisu Mesfin, MD

    Abstract | Download | Purchase

    The purpose of this study was to determine the compliance rate with sequential suppression devices (SCDs) of patients admitted to an orthopaedic unit of a level I trauma center. A quality assurance observational study was conducted over a 4-week period (June/July 2015). Three observations were performed per 24-hour period (0700, 1300, 1900 hours). ‘‘Full SCD compliance’’ was defined as the SCD ordered, on and functioning properly at the time of observation. Of the 1356 observations in 109 patients, 434 (32%) were fully compliant with SCD prophylaxis. SCD compliance in trauma patients was higher (21%) as compared with elective surgical patients (10%) (p < .0001). Morning observations had the highest compliance rate (38.3%), whereas the afternoon (23.5%) and evening observations (33.1%) had less compliance rates (p < .0001). There was a significantly higher compliance rate on weekdays (33.9%) as compared with weekends (28%) (p < .03). The overall low compliance level (32%) indicates compliance challenges and not the modality of the prophylaxis as the cause (Journal of Surgical Orthopaedic Advances 27(4):307–311, 2018) Key words: compression device, compliance, DVT, DVT prophylaxis, orthopaedic surgery, PE, SCD, sequential compression device

    Return to Duty in Military Members Following Surgical Treatment of Incomplete Femoral Neck Fractures - LT Clare E. Griffis, MD; LT Vanna Rocchi, DO; LCDR Grant Cochran, MD; and CDR Kevin M. Kuhn, MD

    Abstract | Download | Purchase

    The purpose of this study was to determine whether active duty military members treated surgically for incomplete femoral neck stress fractures (FNSFs) return to duty. A retrospective review of 53 patients was evaluated to determine the rate of return to duty (RTD) related to sex, branch of service, side of fracture, and signs of femoroacetabular impingement (FAI). Signs of FAI were measured and compared to RTD. Sixty-seven percent of the sample population did not return to duty. Eighty-three percent of Marine Corps members did not return to duty and 18% of Navy active duty members did not return to duty. This finding was statistically significant (p < .001). Average follow-up was 25 months. Surgical fixation of FNSFs does not seem to affect the ability to return to active duty; however, it did prevent progression to complete or displaced fracture in all of the study patients. (Journal of Surgical Orthopaedic Advances 27(4):312–316, 2018) Key words: femoral neck stress fractures, femoroacetabular impingement, functional outcomes, hip/pelvis/thigh, military members, surgical fixation

    Patient Attitudes Toward Local Anesthesia With or Without Sedation for Minor Hand Procedures - Seth H. Bowman, MD; Taylor A. Horst, MD; Kyle P. Kokko, MD, PhD; William Barfield, PhD; and Eric Angermeier, MD

    Abstract | Download | Purchase

    The purpose of this study was to assess patient preferences in this population with respect to anesthesia for minor hand procedures. This prospective cohort study assessed 183 patients undergoing minor hand surgery to determine their preferences for local-only anesthesia with or without sedation and the reasons for their choices. Fifty-six percent of patients preferred local anesthesia with sedation, 43% preferred local-only anesthesia, and 2% had no preference. Caucasian patients were 2.7 times more likely to choose local-only anesthesia. Other than race, no other demographics showed statistical significance with respect to anesthesia preference. Patients with a prior history of local-only anesthesia were half as likely to choose it again for future surgeries. Use of an IV and awareness of procedure were the most consistent factors affecting patient decisions. Nearly half of the patients preferred local-only anesthesia. Further prospective studies evaluating outcomes and patient satisfaction with these two types of anesthesia are necessary. (Journal of Surgical Orthopaedic Advances 27(4):317–320, 2018) Key words: anesthesia, carpal tunnel, hand, preferences, trigger finger

    Effect of Facility on Operative Costs of Total Ankle Arthroplasties - Christopher E. Gross, MD; Daniel Scott, MD, MBA; Richard C. Mather III, MD; and James A. Nunley II, MD

    Abstract | Download | Purchase

    Cost containment and bundled payments are becoming increasingly important in health care. The purpose of this study was to investigate if ambulatory surgery centers (ASCs) can deliver lower cost care and to identify sources of those cost savings in total ankle replacement (TAR). A cost identification analysis of primary TAR was performed at a single academic medical center. Multiple costs and time measures were taken from 730 consecutive patients over 5 years at either an inpatient facility or ASC. The relationships between total cost and operative time and multiple variables were examined, using multivariate analysis and regression modeling. The mean operative cost over 4 years was significantly greater at the inpatient facility than at the outpatient facility. Significant cost drivers of this difference were inpatient, physical and occupational therapy, pharmacy, and operating room costs. The most significant predictor of cost was facility type. This study supports the use of ASC facilities to achieve efficient resource use in the operative treatment of total ankle arthroplasties (Journal of Surgical Orthopaedic Advances 27(4):321–324, 2018) Key words: ambulatory surgery center, ankle arthroplasty, cost

    Location of the Popliteal Artery in Knee Extension on Magnetic Resonance Imaging - Matt Simons, MD; Nicholas Schraut, MD; Vincent Moretti, MD; Greg Klazura, MD; Donald Chuang, MD; Amit Parekh, MD; and Mark Gonzalez, MD, PhD

    Abstract | Download | Purchase

    The goal of this study was to define the course of the popliteal artery (PA) and determine any variability among different patient demographics; by identifying risk factors for injury, surgeons can decrease patient morbidity and mortality. Ninety-four adult magnetic resonance imaging studies of the knee were reviewed. In extension, the artery is at most 7.87 mm posterior and 4.83 mm lateral to the midline below the tibial plateau. Proximally, the artery is more anterior and midline. With increasing body mass indexes, the artery is more posterior at any level. At the femur, 1 cm above the distal articular surface, the artery was more posterior in younger patients; 1 cm below the joint line, it was more posterior in elder patients. Attention should be given during total knee arthroplasty, revision surgery, lateral meniscal repair, posterior cruciate ligament reconstruction, high tibial osteotomy, and fixation of tibial tubercle fractures. Proximally, the PA is more anterior and midline, placing it at significant risk during these procedures. (Journal of Surgical Orthopaedic Advances 27(4):325–328, 2018) Key words: arthroplasty, knee, location, MRI, popliteal artery

    Distal Femoral Flexion Closing Wedge Osteotomy for Treatment of Failed Chronic Distal Femoral Extension Osteotomy in a Patient With Poliomyelitis - Eitan Ingall, BS; Osama Elattar, MD; Emily J. Curry, BA; and Xinning Li, MD

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    The goal of orthopaedic treatment in chronic poliomyelitis is to address the functional impairments resulting from muscular imbalances and bony deformities. The most common knee deformity is a flexion contracture seen in the sagittal plane. Inappropriate or overcorrections of these deformities can have devastating long-term consequences. Revision surgery presents the surgeon with a complex and challenging case with very sparse published literature on revision techniques and osteotomy options. This report describes the successful use of a posterior closing wedge flexion osteotomy with plate fixation to correct a hyperextension deformity caused by a failed or overcorrected extension osteotomy in a 40-year-old man. In this patient, this flexion osteotomy led to complete deformity correction, resolution of symptoms, functional improvement, and return to work without restrictions. (Journal of Surgical Orthopaedic Advances 27(4):329–334, 2018) Key words: distal femoral flexion closing wedge osteotomy, failed distal femoral extension osteotomy, poliomyelitis

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  • Table of Contents
  • Evaluation of Biofilms on Explanted Shoulder Prostheses Using Functional Biofilm Assay and Scanning Electron Microscopy - Wesley Frevert, MD; Thomas W. Wright, MD; Kevin W. Farmer, MD; Qingping Yang, MS; Aimee M. Struk, MEd, ATC; and Greg Schultz, PhD

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    Successfully treating shoulder arthroplasty infection requires diagnosis and bacterial identification. Higher incidence of infection with low-virulence bacteria makes this challenging. This study evaluates shoulder prostheses for infection using sonication and a functional biofilm assay. Nineteen patients undergoing revision shoulder arthroplasty were followed prospectively. Periprosthetic tissue and prosthetic components were obtained during the revision and evaluated with a functional biofilm assay. Results were compared with conventional cultures and laboratory results. Hardware samples were analyzed with scanning electron microscopy. Six of the 19 cases demonstrated growth on the biofilm assay. Three of these had positive conventional culture results and metMusculoskeletal Infection Society (MSIS) criteria for infection. Two other cases met MSIS criteria but demonstrated negative assay and conventional culture results. Of the six cases with positive assay results, three demonstrated evidence of biofilm on scanning electron microscopy. The biofilm assay identifies infections not recognized by traditional culture or MSIS criteria. (Journal of Surgical Orthopaedic Advances 27(3):171–177, 2018) Key words: biofilm, functional biofilm assay, prosthetic infection, shoulder arthroplasty, shoulder prostheses, sonication

    Beyond Mirels: Factors Influencing Surgical Outcome of Metastasis to the Extremities in the Modern Era - Elizabeth Scott, MD; Mitchell R. Klement, MD; Brian E. Brigman, MD, PhD; and William C. Eward, MD, DVM

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    Mirels scoring system for determining prophylactic stabilization need of skeletal metastases includes a limited number of variables and does not differentiate between procedure types. This study sought to identify additional variables associated with surgical failure, radiographic disease progression, and patient survival. A retrospective review was performed of patients from January 2004 to 2014 who underwent surgical treatment of skeletal metastases of the extremities, were >18 years of age, and had adequate radiographic surveillance. Eighty-nine metastatic bone lesions in 77 patients were included. Mirels score >8 (p = .015) and tumor origin (p = .008) were associated with surgical failure, which was 16.8%. Male gender (p < .001) and use of bone cement (p = .019) were associated with radiographic progression, 43.8% overall. Antiresorptive medications usage (p = .02) was associated with survival. The study concluded that tumor origin may be highly important when considering surgical treatment for metastatic bone disease and antiresorptive medications should be used postoperatively, given an association with survival. (Journal of Surgical Orthopaedic Advances 27(3):178–186, 2018) Key words: complications, extremity metastasis, metastatic disease, Mirels criteria, patient survival, surgery

    Player Performance After Returning From a Concussion in the National Football League: A Pilot Study - Scott L. Zuckerman, MD, MPH; Andrew W. Kuhn, BA; Weston Gentry, BS; Andrew Ghaly, BA; Romil D. Patel, BS; Aaron M. Yengo-Kahn, MD; Zachary Y. Kerr, PhD, MPH; and Gary S. Solomon, PhD

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    This study aimed to determine if gameplay performance in the National Football League (NFL) is adversely affected after returning to play from a sport-related concussion (SRC). Players who sustained a SRC between the 2007–2008 and 2013–2014 seasons were identified. Concussed players were matched to nonconcussed control players in a 2:1 (control–case) fashion by position, season, experience, age, body mass index, and time missed. Gameplay statistics were recorded for the three games before and after returning from SRC. When compared with the control group, the majority of NFL players did not demonstrate any performance-based deficits on returning to play after SRC. However, concussed quarterbacks (QBs) displayed a reduced QB rating compared with controls. These results indicate that performance immediately following return from SRC may be adversely affected in certain populations and circumstances, though the overwhelming majority of players showed no decline in performance. (Journal of Surgical Orthopaedic Advances 27(3):187–197, 2018) Key words: athletic performance, concussion, football, National Football League, professional sports, return to play

    Are Cardiac Complications Associated With Other Adverse Events? A Look at 56,000 Orthopaedic Trauma Patients - Mahesh Yarlagadda, MSPH; Michelle Shen, BA; Abenezer Abraham, MHS; Idine Mousavi; and Manish K. Sethi, MD

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    The purpose of this study was to identify those complications for which patients with adverse cardiac events are at risk within the 30-day postoperative period following treatment oforthopaedic trauma cases. This was a retrospective cohort study of orthopaedic trauma patients in the United States between 2006 and 2013. A total of 56,336 patients meeting any one of 89 CPT codes in the American College of Surgeons National Surgical Quality Improvement Program database were used. The main outcome measure was myocardial infarction or cardiac arrest within the 30-day postoperative period. Patients experiencing adverse cardiac events were at a significantly higher risk to have also developed deep surgical site infection, pneumonia, the need for reintubation, pulmonary emboli, a failure to wean off of ventilation, chronic and acute renal failure, urinary tract infection, stroke, deep venous thrombosis, sepsis, and shock. Cardiac complications in orthopaedic trauma patients are relatively uncommon (1.3%); however, cardiac complications are associated with greater risks of other complications, including pneumonia, stroke, and urinary tract infection. (Journal of Surgical Orthopaedic Advances 27(3):198–202, 2018) Key words: adverse events, cardiac, complications, orthopaedic surgery, risk factors, trauma

    Management of Femoral Defects Greater Than 5 cm Following Open Femur Fractures: A 12-Year Retrospective Review - Basem Attum, MD; Diana G. Douleh, BS; Paul S. Whiting, MD; Ashley C. Dodd, BS; Michelle S. Shen, BA; Nikita Lakomkin, BSc; William T. Obremskey, MD, MPH, MMHC; and Manish K. Sethi, MD

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    This study sought to evaluate the outcomes of patients with osseous defects exceeding 5 cm following open femur fractures. Size of the osseous defect, method of internal fixation (plate vs. intramedullary nail), patient demographics, medical comorbidities, and surgical complications were collected. Twentyseven of the 832 open femur fracture patients had osseous defects exceeding 5 cm. Mean osseous defect size was 8 cm, and each patient had an average of four operations including initial debridement. Average time from injury to bone grafting was 123.7 days. The overall complication rate was 48.1% (n = 13). The most common complications were infection (26.0%, n = 7) and nonunion (41.0%, n = 11). Smoking, diabetes, ASA score, and defect size did not independently increase the risk of a complication. Management of open femur fractures with osseous defects greater than 5 cm is associated with high complication rate, driven primarily by infection and nonunion. (Journal of Surgical Orthopaedic Advances 27(3):203–208, 2018) Key words: large femoral defect, postoperative complication, risk factors

    Multilevel Lumbar Fusion Is a Risk Factor for Lower Return to Work Rates Among Workers’ Compensation Subjects With Degenerative Disc Disease - Joshua T. Anderson, MD1; Erik Y. Tye, BA2; Arnold R. Haas, BS, BA3; Rick Percy, PhD3; Stephen T. Woods, MD3; Uri M. Ahn, MD4; and Nicholas U. Ahn, MD5

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    Discogenic fusion is associated with variable outcomes, especially if multiple levels are fused. This study sought to determine the impact of fused levels on return to work (RTW) status in a workers’ compensation (WC) setting. Nine hundred thirty-seven subjects were selected for study. The primary outcome was the ability to RTW within 2 years following fusion and to sustain this level for greater than 6 months. Many secondary outcomes were collected. A multivariate logistic regression model was used to determine the impact of multilevel fusion on RTW status. Of the multilevel fusion group, 21.7% met the RTW criteria versus 28.1% of the single-level fusion group (p < .028). Multilevel fusion was a negative predictor of RTW status (p < .041; OR 0.71). Additional negative predictors included prolonged time out of work, male gender, chronic opioid analgesia, and legal representation. Multilevel fusion led to poor clinical outcomes while overall RTW rates were low, which suggests a limited role of discogenic fusion within the WC setting. (Journal of Surgical Orthopaedic Advances 27(3):209–218, 2018) Key words: clinical outcomes, discogenic fusion, lumbar spine, multilevel surgery, return to work, workers’ compensation

    Influence of Level 1 Evidence on Management of Clavicle and Distal Humerus Fractures: A Nationwide Comparative Study of Records From 2005 to 2014 - Jennifer Kurowicki, MD; Jacob J. Triplet, DO; Samuel Rosas, MD; Tsun yee Law, MD; Timothy Niedzielak, DO; Enesi Momoh, MD; and Jonathan C. Levy, MD

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    The purpose of this study was to examine alterations in national trends managing midshaft clavicle fractures (MCF) and intra-articular distal humerus fractures (DHF) surrounding recent level 1 publications. A retrospective review of the PearlDiver supercomputer for DHF and MCF was performed. Using age limits defined in the original level 1 studies, total use and annual use rates were examined. Nonoperative management and open reduction and internal fixation (ORIF) were reviewed for MCF. ORIF and total elbow arthroplasty (TEA) were reviewed for DHF. A query yielded 4929 MCF and 106,535 DHF patients. A significant increase in ORIF use for MCF following the publication of the level 1 study (p = .002) and a strong, positive correlation (p = .007) were evident. Annual TEA (p = .515) use for DHF was not observed. (Journal of Surgical Orthopaedic Advances 27(3):219–225, 2018) Key words: clavicle fracture, distal humerus fracture, nonoperative treatment, open reduction and internal fixation, PearlDiver, total elbow arthroplasty

    Early-Stage Chronic Kidney Disease and Hip Fracture Mortality - Nicholas B. Frisch, MD, MBA; Nolan Wessell, MD; Toufic R. Jildeh, MD; Alexander Greenstein, MD; and S. Trent Guthrie, MD

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    Chronic kidney disease (CKD) is a documented risk factor for hip fracture mortality. CKD represents a spectrum of disease and there is no clear evidence differentiating the risk between patients with early versus end-stage CKD. The purpose of this study was to explore the relationship between the stages of CKD and mortality following operative treatment of hip fractures. Four hundred ninety-eight patients were analyzed; 81 were identified as having CKD. This study followed overall patient mortality at 90 days and at 1 year postoperatively. Patients with CKD had higher mortality at both 90 days and 1 year compared with those without CKD (hazard ratio 1.69 and 1.84, respectively). In a subgroup analysis to determine the effect of CKD stage, only stage 3 CKD was associated with increased mortality. The orthopaedic surgeon can play a key role in identifying at-risk patients and help to facilitate additional management. (Journal of Surgical Orthopaedic Advances 27(3):226–230, 2018) Key words: chronic kidney disease, hip fracture, intertrochanteric fracture, mortality

    Opioid Prescriptions After Total Joint Arthroplasty - Udai S. Sibia, MD, MBA; Abigail E. Mandelblatt; G. Caleb Alexander, MD, MS; Paul J. King, MD; and James H. MacDonald, MD

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    Prescription opioids are commonly prescribed for pain relief after total joint arthroplasty (TJA), yet little is known about the quantity of opioids prescribed after surgery. This study retrospectively reviewed a consecutive series of 1000 TJAs from April 2014 through September 2015. Postoperative opioid prescriptions were quantified using standardized morphine milligram equivalents (MME). Eighty-four percent of total knee arthroplasty (TKA) and 77% of total hip arthroplasty (THA) patients were opioid na¨ıve. The median opioid volume of the first prescription for those undergoing TKA was greater than for those undergoing THA (600 vs. 450 MME), as was the proportion of individuals requiring one or more refills (48% vs. 32%). The total volume of opioids after TKA was also higher than for total hip replacement (870 vs. 525 MME). Patients who were not opioid na¨ıve were prescribed substantially more opioids than their counterparts after TKA (mean 1593 vs. 1064 MME, p < .001) and THA (mean 1031 vs. 663 MME, p < .001). Decreasing opioid use before surgery may decrease total volume of opioid prescriptions after TJA. (Journal of Surgical Orthopaedic Advances 27(3):231–236, 2018) Key words: opioids, total hip arthroplasty, total knee arthroplasty

    Remodeling of the Calcaneocuboid Joint in the Acquired Flatfoot - Arthur Manoli II, MD

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    There has been debate recently as to whether the lateral column is actually short in the acquired flatfoot. Doubters argue that it is not possible for the lateral column to change in length and actually shorten, especially in the acquired type. In this series of 21 consecutive patients operated on for an acquired flatfoot, the calcaneocuboid joint (CC) had remodeled in all, resulting in the calcaneal side being short, facing laterally and dorsally. These findings give evidence to the rationale for performing a lateral column lengthening (LCL) proximal to the CC joint to treat the acquired flatfoot. When performing a LCL, one should attempt to restore length to the calcaneal side of the joint and to redirect it medially and plantarward. (Journal of Surgical Orthopaedic Advances 27(3):237–245, 2018) Key words: acquired flatfoot, bone remodeling, calcaneocuboid joint, flatfoot, lateral column lengthening, posterior tibial tendon insufficiency

    The ‘‘Well-Cap’’ Technique: Screw Insertion for Pelvic Nutrient Foramen Hemostasis - Brendan R. Southam, MD; Frank R. Avilucea, MD; Amanda J. Schroeder, MD; Ryan P. Finnan, MD; and Michael T. Archdeacon, MD, MSE

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    Several approaches to the pelvis and acetabulum involve subperiosteal dissection of the iliacus from the internal iliac fossa.Typically bleeding is encountered from the nutrient foramen located near the sacroiliac joint. Bone wax and electrocautery have traditionally been used to achieve hemostasis from this foramen but produce inconsistent results.The authors of this technical tip describe a novel technique of inserting a cortical screw directly into the foramen tocontrol osseous hemorrhage.This technique has been consistently effective at achieving hemostasis in cases of refractory bleeding and has produced no complications. (Journal of Surgical Orthopaedic Advances 27(3):246–250, 2018) Key words: bone wax, cortical screw, hemostasis, iliac nutrient foramen, osseous bleeding

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  • Table of Contents

  • Use of 360° Feedback to Develop Physician Leaders in Orthopaedic Surgery - Paul J. Gregory, PhD; David Ring, MD2; Harry Rubash, MD; and Larry Harmon, PhD

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    Twelve service chiefs participated in 360° feedback surveys and coaching as part of a departmental leadership development activity. Changes in the means of both composite survey scores and individual behavioral item scores over time were evaluated with paired t tests. Agreement between self-rating and rating of others was evaluated with unpaired t tests. There was a nonsignificant change in overall behavioral performance (composite scores) for the physician leaders (n D 12) from baseline [mean (M) D 68.7, standard deviation (SD) D 16.9] to 1-year follow-up (M D 73.1, SD D 11.4), but the performance of four of the leaders with the lowest scores improved substantially. There was a significant improvement in ‘‘identifies mistakes respectfully’’ when comparing baseline to 1-year follow-up. Ten behaviors were identified as improvement opportunities and nine behaviors were identified as behavioral strengths at baseline. Surgeon leaders were in agreement with others’ ratings on 68% of behaviors, underestimated 20% of behaviors, and overestimated 13% of behaviors. (Journal of Surgical Orthopaedic Advances 27(2):85–91, 2018) Key words: 360° feedback, interpersonal and communication skills, leadership effectiveness, multisource feedback, orthopaedic leaders, PULSE 360, self–other agreement

    Analysis of References Used in Orthopaedic Self-Assessment Exams - Sean P. Moroze, MD; Andrew S. Murtha, MD; Jessica C. Rivera, MD; and Chad A. Krueger, MD

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    Orthopaedic surgery board certification and maintenance of certification requires success on standardized tests and ongoing continuing medical education. This study aims to identify the most impactful resources for preparation for and maintenance of board certification. Questions included in the Orthopaedic Self-Assessment Exams (SAEs) from 2009 to 2014 were examined with the type and age of reference materials cited for each question. There were 4479 total citations. There were 289 journals and 95 textbooks identified. The Journal of Bone and Joint Surgery (15% of citations), Journal of the American Academy of Orthopaedic Surgeons (11%), and Clinical Orthopaedic and Related Research (6%) were the most frequently cited journals. The average age of cited articles was 8.2 years. These data demonstrate that certain orthopaedic journals are consistently the most commonly cited references for SAEs and could also be expected to be the highest yield references for knowledge acquisition and exam preparation. (Journal of Surgical Orthopaedic Advances 27(2):92–97, 2018) Key words: ABOS Part I, maintenance of certification, OITE, self-assessment exam

    Interest in Orthopedic Surgery Residency: A Google Trends Analysis - Tochukwu C. Ikpeze, MS, and Addisu Mesfin, MD

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    Google Trends, a powerful online search tool, was used to evaluate the association between the United States applicant pool for orthopedic surgery residency and Internet queries for orthopedic residency and orthopedic salary. From 2006 to 2015, searches for orthopedic salary and orthopedic residency were conducted by Google Trends. Data from the National Residency Match Program (NRMP) in the same time period was plotted and subsequently compared to the Google Trends results. From 2006 to 2015, Google Trends demonstrated an increase in orthopedic residency queries with the largest increase between 2008 and 2010. Orthopedic salary searches increased over the study period, with the sharpest increase from 2008 to 2009. NRMP demonstrated an increase over the study period in U.S. medical school orthopedic surgery applicants and positions filled. The Google Trends analysis mirrored the data from the NRMP, suggesting that online search tools could be of important predictive value for medical students’ interest in orthopedic surgery residency. (Journal of Surgical Orthopaedic Advances 27(2):98–101, 2018) Key words: Google Trends, medical student, orthopedic residency, orthopedic salary

    Marginal Skin Flap Advancement: A Technique to Optimize the Skin Graft Interface Following Tumor Resections - Wayne A. Chen, MD, and William G. Ward, MD

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    Split-thickness skin graft (STSG) for soft tissue defects is often required following tumor resections. There is often a step-off with subcutaneous adipose tissue along the defect margins. This review of 20 years of experience was performed to determine the success of marginal skin flap advancement, a simple surgical technique addressing this issue. Seventy-one cases were identified that underwent sarcoma resection and this technique. Marginal skin flap advancement decreased the defect size from 217 š 162 cm2 to 128 š 101 cm2 (p < .001). STSG was successfully applied in 69 cases (97%) with a mean 96% take of the skin graft. Although 29 cases (41%) had wound healing complications of any nature, only 11 (15%) required a secondary operation. Marginal skin flap advancement, in conjunction with vacuum-assisted closure therapy, decreases the defect surface area requiring STSG by 41% and provides an excellent reconstructive option for soft tissue defects following sarcoma resections. (Journal of Surgical Orthopaedic Advances 27(2):102–108, 2018) Key words: sarcoma, soft tissue reconstruction, split-thickness skin graft, vacuum-assisted closure, wound healing

    How Often Are Protocols Followed at Level I Trauma Centers? - Richard W. Nicolay, MD; Akhil A. Tawari, MD; Harish Kempegowda, MD; Michael Suk, MD; and Brian Mullis, MD

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    This study analyzes adherence to an evidence-based protocol established at two level I trauma centers to determine its effect on clinical decision making. The centers’ trauma databases were retrospectively studied and 51 patients with long bone fractures were identified who required revascularization and orthopaedic intervention and survived long enough to receive an index intervention. An arterial shunt was the protocol’s first step; the preprotocol rate of shunting was 9.5%, while the postprotocol rate of shunting was 3.3%. The protocol’s next step was external fixation; among the cases managed without a shunt, external fixation was the index intervention in 63.2% of the preprotocol cases and 31.0% of the postprotocol cases. Definitive vascular surgery was routinely performed before external fixation in 28.6% of the preprotocol cases and 56.7% of the postprotocol cases. This study demonstrates that this evidence-based protocol had no effect on the management of patients with combined orthopaedic and vascular injuries. Protocols should never supersede clinical judgment, but poor protocol adherence may represent a need for trauma centers to routinely review their protocols’ compliance and efficacy. (Journal of Surgical Orthopaedic Advances 27(2):109–112, 2018) Key words: ACS, adherence, American College of Surgeons, arterial, clinical practice guideline, compliance, level I, long bone, open fracture, protocol, shunt, trauma center, type IIIC open fracture, vascular injury

    Predictors of Acute Complications Following Traumatic Upper Extremity Amputation - Tuesday F. Fisher, MD; Nicholas A. Kusnezov, MD; Julia A. Bader, PhD; and James A. Blair, MD

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    Current literature is deficient in its description of acute complications following major traumatic upper extremity amputations (UEAs). This study sought to identify acute complications following major UEAs by the 2009–2012 National Trauma Databank to extract demographics, comorbidities, concomitant injuries, and surgical characteristics for major traumatic UEA patients. Multivariate analyses identified significant predictors of mortality and major systemic complications. Major traumatic upper extremity amputations were identified in 1190 patients. Major systemic complications occurred in 13% of patients and most often involved pulmonary (7.4%) or renal (4.7%) systems. Overall in-hospital mortality rate was 11%. Male sex, prehospital systolic blood pressure less than 90, Injury Severity Score > 16, and initial Glasgow Coma Scale > 8 were risk factors for complications or in-hospital mortality. Acute replantation was performed in 0.12%. Systemic complications following major traumatic UEA typically affect the pulmonary system. Injury or patient-dependent factors did not influence acute treatment with revision amputation versus replantation. (Journal of Surgical Orthopaedic Advances 27(2):113–118, 2018) Key words: polytrauma, replantation, systemic complications, upper extremity amputation

    Hip and Knee Arthroplasty Outcomes After Abdominal Organ Transplantation - Neil L. Duplantier, MD; Amy E. Rivere, MD; Ari J. Cohen, MD ; and George F. Chimento, MD

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    This case control study retrospectively compares patients who underwent solid organ transplantation and total joint replacement with a control group that only underwent joint replacement. The study compares 42 transplant patients who underwent liver or kidney transplantation and total hip arthroplasty (THA) or total knee arthroplasty (TKA) to a matched group of 42 nontransplant patients who underwent only THA or TKA. The transplant cohort had significantly more complications (18) than the nontransplant cohort (7) (p D .022). Renal transplant patients had 6.75 times higher odds (95% CI, 1.318–34.565) of experiencing a complication compared with liver transplant patients. The average time between transplant and joint replacement was 2 š 4.9 years. Transplant patients undergoing joint arthroplasty at an average of 2 years posttransplant are at higher risk for complications than a matched cohort of patients undergoing only joint arthroplasty, with renal transplant patients being more at risk for complications than liver transplant patients. (Journal of Surgical Orthopaedic Advances 27(2):119–124, 2018) Key words: arthroplasty, hip, kidney, knee, liver, transplant

    Functional Outcomes of Isolated Gastrocnemius Recession - Cory Messerschmidt, MD; Anuj Netto, MD; William R. Barfield, PhD; Christopher Gross, MD; and William McKibbin, MD

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    The effects of gastrocnemius recession on strength and function are underreported. This prospective study reports strength and functional effects after isolated gastrocnemius recession. Patients (n D 20) underwent an isolated gastrocnemius recession for foot and ankle conditions with associated gastrocnemius or gastrocnemius–soleus contracture. Eight patients prospectively underwent range of motion (ROM) and Biodex testing preoperatively and at 3 and 6 months postoperatively. Foot Function Index (FFI) assessed functional outcomes. Repeated measures analysis of variance with Bonferroni post hoc testing compared variables across three time intervals. Control and operative sides were compared with t tests. Mean patient age was 61.1 š 13.3 years. Significant improvement in FFI was observed at 3 and 6 months (p D .001). Ankle dorsiflexion improved 11° between preoperative and 6-month postoperative intervals (p D .018). No differences were observed in Biodex testing. Results demonstrate improved ROM and FFI of the gastrocnemius recession between preoperative and 6-month postoperative intervals for isolated gastrocnemius and gastrocnemius–soleus contracture. (Journal of Surgical Orthopaedic Advances 27(2):125–130, 2018) Key words: equinus contracture, gastrocnemius contracture, gastrocnemius recession, Strayer procedure

    Self-Citation Does Not Appear to Artificially Inflate Orthopaedic Journal Ranking - Michael P. Hawkinson, MD; Chad A. Krueger, MD; and John J.  Carroll, MD

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    Until recently the impact factor has been considered the tool of choice among the many available for evaluating the relative prestige of journals. However, the inclusion of self-citations in its calculation has led some to question its validity. The SCImago Journal Rank is a relatively new rating system that excludes self-citation. This study analyzed the top 30 orthopaedic journals to determine which journals had higher self-citation rates and if those rates had any correlation with their impact factors and SCImago Journal Ranks. The study verified that self-citing was more common in specialty journals compared with general orthopaedic journals (p D .002). The results demonstrate a more positive correlation between self-citation and SCImago Journal Rank than impact factor. This finding suggests that the impact factor’s inclusion of self-citations should not be thought to artificially inflate the impact factor of the subspecialty journals that most commonly cite their own work. (Journal of Surgical Orthopaedic Advances 27(2):131–135, 2018) Key words: impact factor, orthopaedics, SCImago Journal Rank, self-citation

    Effectiveness of Thrombin–Collagen and Autologous Platelet-Rich Plasma in Total Hip Arthroplasty Hemostasis: A Prospective, Randomized, Controlled Trial - Eric N. Bowman, MD, MPH; Michael P. McCabe, MD; and Kevin B. Cleveland, MD

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    Bovine derived thrombin–collagen combined with autologous platelet-rich plasma (PRP) has shown promise as a topical, surgical hemostatic agent. The purpose of this study was to determine the effect of thrombin–collagen–PRP on perioperative blood loss in total hip arthroplasty (THA). A prospective, single-blinded, randomized, controlled study comparing thrombin–collagen–PRP use to standard treatment was performed. All patients undergoing elective primary THA for osteoarthritis by a single physician at a single institution were included. Thirty-nine patients were enrolled. There was no significant difference in estimated total blood loss or blood transfusions received. There was no significant difference in operative blood loss, drain output, daily postoperative hematocrit, change in hematocrit, or length of stay. There is insufficient evidence to support the routine use of a topical thrombin–collagen–autologous PRP hemostatic agent in primary total hip arthroplasty. (Journal of Surgical Orthopaedic Advances 27(2):136–141, 2018) Key words: collagen, hemostasis, platelet-rich plasma, PRP, thrombin, total hip arthroplasty

    Immobilization Versus Observation in Children With Toddler’s Fractures: A Retrospective Review - Lauren C. Leffler, MD; Stephanie L. Tanner, MS; and Michael L. Beckish, MD

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    While long leg casts have been historically recommended for immobilization of toddler’s fractures, short leg casts are often used by treating physicians. Others question whether any immobilization is necessary because of the internal stability provided by the thickened periosteum of pediatric bones. The purpose of this study is to review the results of toddler’s fractures treated with long leg casts, short leg casts, or without immobilization. Eighty-five patients were included in a retrospective review of nondisplaced spiral or oblique tibial shaft fractures in children under 6 years old from 2007 to 2012. Treatments included long leg casts (19), short leg casts (59), and no immobilization (7). Average time to ambulation was 15.5 days. There were 11 casting complications. Only one patient, in a short leg cast, had measurable displacement or angulation. There were no complications reported in the nonimmobilized group. The results suggest that toddler’s fractures can be effectively treated with short leg casts or without immobilization. (Journal of Surgical Orthopaedic Advances 27(2):142–147, 2018) Key words: immobilization, return to ambulation, tibial shaft fracture, toddler’s fracture

    Risk of Opioid-Related Adverse Events After Primary and Revision Total Knee Arthroplasty - Jeff Gonzales, MD, MA; Scott T. Lovald, PhD; Edmund C. Lau, MS; and Kevin L. Ong, PhD

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    Postoperative analgesia after primary total knee arthroplasty (TKA) and revision knee arthroplasty (RKA) can be reliant on the use of opioids and may lead to opioid-related adverse events (ORAEs). This study evaluated the risk of ORAEs following TKA and RKA using the 5% Medicare claims (2010–2013) database. There were 41,702 TKA and 3817 RKA patients who met the inclusion criteria. At 90 days, respiratory complications were the most common complication (TKA: 6.12%; RKA: 8.01%), followed by postoperative nausea and vomiting (TKA: 2.86%; RKA: 3.95%), and urinary retention complications (TKA: 2.79%; RKA: 3.20%). For TKA, risk factors for respiratory complications included older age, lower socioeconomic status, more comorbidities, obesity, chronic obstructive pulmonary disease, white race, and patients in the Midwest and West (vs. South) (p 002). The average Medicare payment for treating complications within 90 days of a TKA was $6206 and $6222 following RKA. Awareness risks for ORAEs in select patients can assist in developing a multimodal postoperative pain control and patient education protocols. (Journal of Surgical Orthopaedic Advances 27(2):148–154, 2018) Key words: adverse event, opioid, pain, revision knee arthroplasty, total knee arthroplasty

    Wound Closure With Acute Dermatotraction - James W. Barnes, MD; Garth Sherman, BS; and Jonathan Dubin, MD

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    Many described techniques take advantage of the viscoelasticity of the human integument to assist in primary closure of fasciotomy wounds. A retrospective chart review was performed on eight patients with a total of 17 incisions who underwent fasciotomy for acute compartment syndrome. Wounds were closed with delayed primary closure (DPC). Patients were males with a mean age of 40 years (range, 21–64). Fasciotomy mean wound length and width at attempted closure was 16.1 š 6 cm and 6.3 š 2 cm, respectively. Mean time to closure after fasciotomy was 3.9 days (range, 2–8). All wounds healed, at a mean of 18.3 š 2.6 days. Patients were followed for a mean of 21 weeks (range, 3–52). The described novel sequential suturing technique can achieve closure with low risk of major complications; 100% wound healing was achieved. When used judiciously, the technique presented can achieve reliable results in selected fasciotomy wound healing. (Journal of Surgical Orthopaedic Advances 27(2):155–159, 2018) Key words: acute wounds, compartment syndrome, delayed primary closure, dermatotraction, fasciotomy closure

    Coronal Plane Deformity Correction in Distal Radius Fracture Fixation With the Volar Locking Plate - Arun Aneja, MD, PhD; T. David Luo, MD; Eric B. Lerche, DO; Jason J. Halvorson, MD; and Eben A. Carroll, MD

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    The goal of treatment for distal radius fractures is anatomic articular reduction and restoration of coronal and sagittal plane alignment, rotation, and angulation of the metadiaphyseal component of these fractures. This article presents a reproducible technique for restoring coronal plane alignment of the metadiaphyseal component of the fracture using an indirect reduction maneuver leveraging the volar locking plate as an indirect reduction aid. After applying an appropriately sized volar locking plate, the first screw is placed in the center of the shaft of the plate. Next, the distal row of subarticular locking screws is placed to neutralize a reduced articular surface. The shaft screw is subsequently loosened, and two Freer elevators are used to rotate the plate, indirectly translating the distal articular block and achieving improved coronal plane alignment. Last, the remaining diaphyseal screws are applied to appropriately neutralize the fracture. (Journal of Surgical Orthopaedic Advances 27(2):160–163, 2018) Key words: coronal deformity, distal radius, fracture, locking plate, technique, volar

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