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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

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    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

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    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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    Volume 28-2, Summer 2019 https://www.jsoaonline.com/volume-28-2-summer-2019/ Mon, 29 Jul 2019 05:56:00 +0000 https://www.jsoaonline.com/?p=4137 Read more ›]]>
  • 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

    Abstracts | Download | Purchase

    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

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    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

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    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

    Abstract | Download Subscribers only | Purchase

    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

    ]]>
    Volume 27-1, Spring 2018 https://www.jsoaonline.com/volume-27-1-spring-2018/ Tue, 08 May 2018 14:19:44 +0000 https://www.jsoaonline.com/?p=3723 Read more ›]]> Musculoskeletal Manifestations of Amyloidosis: A Focused Review - Thomas X. Nguyen, MD; Abbas Naqvi, MD; Terry L. Thompson, MD; and Robert H. Wilson, MD
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    Amyloidosis is a poorly understood condition that can wreak havoc on numerous systems within the human body. In addition, this disease can present in multiple forms which each have their own unique physiology and subsequent effects. However, while the literature on the etiology and effect of amyloidosis on various organ systems is numerous, few have highlighted the musculoskeletal manifestations of this devastating disease. This review focuses on the recent research on amyloid deposition in the musculoskeletal system. Additionally, risk factors, classification, differential diagnoses, indications for biopsy, and manifestations of amyloidosis in the musculoskeletal system as well as in other tissues are discussed. Furthermore, the surgical and nonsurgical approaches to treatment are covered. (Journal of Surgical Orthopaedic Advances 27(1):1–5, 2018) Key words: amyloid light chain (AL) amyloidosis, amyloidoma, beta 2-microglobulin (Aβ2M) amyloidosis, musculoskeletal manifestations, transthyretin (ATTR) amyloidosis, systemic amyloid A (AA) amyloidosis

    Midterm Follow-up of Divergent Peg Glenoid Components in Total Shoulder Arthroplasty - Thomas W. Wright, MD; Tony L. Bryant, MD; Christopher G. Stevens, MD; Brett C. Bentley, MD; and Kevin W. Farmer, MD

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    Glenoid component aseptic loosening is the most common source of total shoulder arthroplasty (TSA) revision. Divergent pegged glenoids may improve fixation. Thirty-four patients underwent divergent peg TSA. Data were reviewed for component loosening. Failure was defined as the need for revision after loosening. The last postoperative radiographs were graded on a Lazarus glenoid lucency scale. Mean follow-up was 5.6 years š 2.44 (range, 2–10 years). Radiolucency around one or fewer pegs was noted in 14/20 patients. Six glenoids had complete radiolucency around two pegs; one shoulder had gross loosening. No secondary surgery was performed. Improvements were seen in active elevation and internal rotation. The mean Shoulder Pain and Disability Index (SPADI) score decreased by 48.1 points (p D .039). Shoulder elevation, internal rotation, and SPADI scores significantly improved at final follow-up. No patients underwent revision for glenoid loosening. There were, however, a significant number of patients with radiolucency around two pegs. (Journal of Surgical Orthopaedic Advances 27(1):6–9, 2018) Key words: divergent peg, glenoid component, loosening, revision, total shoulder arthroplasty

    Behavioral Economics and Physician Board Meetings: Opportunity Cost, Regret, and Their Mitigation in Orthopaedic Surgery - Brent J. Sinicrope, MD; Craig S. Roberts, MD, MBA; and Lyle Sussman, PhD

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    Health care is a business. Health care providers must become familiar with terms such as opportunity costs, the potential loss or gain when one choice is made in lieu of another. The purpose of this study was to calculate the opportunity cost of two orthopaedic surgery society board meetings and discuss these in the context of behavioral economics and regret. A literature search was conducted to determine an orthopaedic surgeon’s average yearly salary, hours worked per week, and weeks worked per year. The details of two orthopaedic surgery professional society meetings that one senior author (CSR) attended were used to calculate opportunity cost. Although the true benefits are multifactorial and difficult to objectively quantify, awareness of the cost–benefit ratio can help guide time and resource management to maximize the return on investment while minimizing buyer’s remorse and perhaps influence the media by which medical meetings are held in the future. (Journal of Surgical Orthopaedic Advances 27(1):10–13, 2018) Key words: behavioral economics, buyer’s regret, opportunity cost

    Surgical Complications Associated With Atypical Femur Fractures Attributed to Bisphosphonate Use - Douglas S. Schultz, MD; Henry M. Gass IV, MD; William R. Barfield, PhD; Harry A. Demos, MD; and Langdon A. Hartsock, MD

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    Complications of atypical femur fractures (AFFs) are common. AFFs often receive the same treatment as other femoral fractures; however, there appears to be a higher rate of adverse outcomes. Nine patients sustained a total of 13 AFFs, had documented bisphosphonate use before fracture, and had surgery between 2006 and 2012. Complications included continued pain, surgical revision, nonunion, malunion, deformity, or heterotopic ossification. The overall complication rate was 33.3%, with four of the 12 surgeries performed at this institution resulting in one nonunion and three minor complications. None of the primary fixations required revision. There was a higher complication rate for AFFs when compared with non-bisphosphonate-related intramedullary nail femur fracture fixations. This cohort demonstrated a lower rate of major complications compared to the literature. Using a reamed, statically locked nail, halting bisphosphonate medication, and allowing early weight bearing is a safe and efficacious method to treat atypical femur fractures. (Journal of Surgical Orthopaedic Advances 27(1):14–20, 2018) Key words: atypical femur fracture, bisphosphonate medication

    Direct Anterior Approach Has Lower Deep Infection Frequency Than Less Invasive Direct Lateral Approach in Primary Total Hip Arthroplasty - Sean A. Sutphen, DO; Keith R. Berend, MD; Michael J. Morris, MD; and Adolph V. Lombardi, Jr., MD, FACS

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    Debate continues over the direct anterior (DA) approach. The purpose of this study is to compare the frequency of deep infection between a DA approach and a less invasive direct lateral (LIDL) approach in a large consecutive series of primary total hip arthroplasty (THA). The authors identified 5702 primary THAs performed between 2007 and 2014. DA approach was used in 3540 hips and LIDL in 2162. Patient records were reviewed. Statistical analysis of reoperation, infection- or wound-related complication, and deep infection was performed. During the 8-year follow-up period, there were 98 reoperations in the DA group (2.8%) and 77 in the LIDL group (3.6%; p D .09 NS). Wound- or infection-related reoperation occurred in 32 DA THAs (0.9%) versus 36 LIDL THAs (1.7%; p D .01). Deep infection occurred in 7 DA THAs (0.2%) versus 21 LIDL THAs (0.97%; p < .0001). The risk of deep infection was statistically lower in the DA approach. (Journal of Surgical Orthopaedic Advances 27(1):21–24, 2018) Key words: direct anterior approach, infection, surgical technique, total hip arthroplasty

    Lumbar Discography Is Associated With Poor Return to Work Status Following Lumbar Fusion Surgery in a Workers’ Compensation Setting - Joshua T. Anderson, BS; Jeffrey A. O’Donnell, BS; Arnold R. Haas, BS, BA; Rick Percy, PhD; Stephen T. Woods, MD; Uri M. Ahn, MD; and Nicholas U. Ahn, MD

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    Lumbar discography (LD) is used to guide surgical decision making in patients with degenerative disc disease (DDD). Its safety and diagnostic accuracy are under contention. This study evaluates LD’s efficacy within the workers’ compensation (WC) population. Multivariate logistic regression analysis was used to determine the impact that undergoing LD before lumbar fusion for DDD had on return to work (RTW) rates among 1407 WC subjects. Discography was negatively associated with RTW status (p D .042; OR 0.76); 22.2% (142/641) of LD subjects met the RTW criteria, compared with 29.6% (227/766) of controls. Additional preoperative risk factors included psychological comorbidity (p < .001; OR 0.34), age greater than 50 (p < .005; OR 0.64), male gender (p < .037; OR 0.75), chronic opioid use (p < .001; OR 0.53), legal representation (p < .034; OR 0.72), and fusion technique (p < .043). LD subjects used postoperative narcotics for an average of 123 additional days (p < .001). This raises concerns regarding the utility of discography in the WC population. (Journal of Surgical Orthopaedic Advances 27(1):25–32, 2018) Key words: degenerative disk disease, low back pain, lumbar discography, lumbar fusion, return to work, workers' compensation

    Cervicothoracic Pedicle Morphometry: Using an Osteological Collection to Characterize Trends in Pedicle Size - Mhamad Faour, MD1; Charles C. Yu, MD; Navkirat Bajwa, MD; Jason O. Toy, MS; Uri M. Ahn, MD; and Nicholas U. Ahn, MD

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    Pedicle screws are a common treatment option for spinal instability. Despite their popularity, pedicle screws carry the risk of transpedicular violation with subsequent neural and vascular damage. This study measured the pedicle dimensions of 500 dry specimens in an osteological collection. The data provide the orthopedic spine surgeon with an accurate measure of pedicle morphometry in light of previously limited and contradictory results. The study demonstrates that pedicle height at the cervicothoracic junction tends to increase with body height, particularly for females. Additionally, T1 pedicle width is smaller for females than males and, for males, tends to decrease with increasing body weight. These results are valuable to the spine surgeon because they suggest that taller patients may afford a larger margin for error in the vertical plane. However, they also demonstrate that heavier patients do not have wider pedicles and thus cannot be assumed to tolerate or require larger-diameter screws. (Journal of Surgical Orthopaedic Advances 27(1):33–38, 2018) Key words: cervical pedicle, femoral head, fusion, instrumentation, morphometry, pedicle dimensions, pedicle height, pedicle screw, pedicle size, pedicle width, screw fixation, thoracic pedicle

    Pectoralis Major Tendon Insertion Anatomy and Description of a Novel Anatomic Reference - CPT Joseph H. Dannenbaum, MD; LT Michael D. Eckhoff, BS; MAJ Joseph W. Galvin, DO; CPT Betsey K. Bean, DO; MAJ David J. Wilson, MD; and COL(Ret) Edward D. Arrington, MD

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    Pectoralis major rupture is an uncommon injury often treated surgically, requiring anatomic knowledge of the tendon insertion. This study defines the pectoralis major tendon insertion footprint and a novel anatomic relationship. Twelve cadaver shoulders were evaluated and measured using a standard surgical ruler to demonstrate the normal anatomic footprint. Measurements were taken from the anterior medial margin of the articular surface of the humeral head to the superior margin of the pectoralis major insertion and its relation to the latissimus dorsi tendon insertion. The average length and width of the pectoralis major insertion were 73.3 š 10.0 mm and 3.3 š 0.54 mm, respectively, consistent with previous publications. On average, the superior margin of the pectoralis tendon was within 1 mm of the latissimus dorsi insertion and 41.2 š 9.27 mm from the articular margin. These points form a new anatomic reference of the latissimus dorsi, providing an intraoperative reference point when performing pectoralis major muscle tendon repair. (Journal of Surgical Orthopaedic Advances 27(1):39–41, 2018) Key words: anatomic insertion, pectoralis major, pectoralis major repair, pectoralis major rupture

    Effects of Accreditation Council for Graduate Medical Education Duty Hour Regulations on Clinical Preparedness of First-Year Orthopaedic Attendings: A Survey of Senior Orthopaedic Surgeons - Steven T. DiSegna, MD; Timothy D. Kelley, MD; Deborah M. DeMarco, MD; and Abhay R. Patel, MD

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    It is unclear how the Accreditation Council for Graduate Medical Education (ACGME) resident duty hour restriction has affected attending orthopaedic surgeons in their first year of practice. The purpose of this study was to compare the clinical preparedness of first-year orthopaedic attending surgeons who trained with ACGME duty hour regulations versus those trained without regulations. Senior orthopaedic surgeons with greater than 10 years of experience were surveyed and results indicate that first-year attendings who trained with ACGME duty hour regulations required more supervision reviewing cases preoperatively, required more assistance completing operative cases, had inferior technical skills, had more major operative complications, had poorer physical exam skills, and delivered an inferior quality of care. Private attendings were most critical. In the postregulatory era, residency programs must optimize the resident’s time to ensure competency on graduation. Strategies include increasing midlevel staff, focusing on competencies outlined by ACGME milestones, and increasing the role of simulation. (Journal of Surgical Orthopaedic Advances 27(1):42–46, 2018) Key words: ACGME, duty hour regulation, orthopaedic surgery residency

    Incidence and Risk Factors for Reoperation Following Meniscal Repair in a Military Population - CPT Alaina M. Brelin, MD; CPT Michael A. Donohue, MD; LCDR George C. Balazs, MD; LCDR Lance E. LeClere, MD; CDR John-Paul H. Rue, MD; and MAJ Jonathan F. Dickens, MD

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    The purpose of this study is to determine the reoperation rate following meniscal repair and the associated risk factors. The Military Health System Data Repository was queried for active duty patients between January 2009 and December 2012 undergoing meniscal repair by Current Procedural Terminology code (29882, 29883, and 27403). This cohort was then screened for subsequent procedures following the index procedure. Risk factors for reoperation were calculated using a Cox proportional hazard analysis. A total of 3259 primary meniscal repairs were identified over the study period, of which 1423 (43.7%) were performed in conjunction with anterior cruciate ligament (ACL) reconstruction. The reoperation rate was 13.6%, occurring at a median of 1.1 years following the index procedure. Marine Corps service, younger age (<35), enlisted or cadet rank, and junior rank status were identified as significant risk factors for requiring reoperation. Isolated repairs were significantly more likely to require a secondary procedure than those with concomitant ACL reconstruction. Meniscal repairs performed in the military demonstrate similar reoperation rates as published literature despite increased occupational demands. (Journal of Surgical Orthopaedic Advances 27(1):47–51, 2018) Key words: failure, meniscus repair, meniscus tear, military, reoperation

    Smartphone Photography as a Tool to Measure Knee Range of Motion - Megan Conti Mica, MD; Eric R. Wagner, MD; and Alexander Y. Shin, MD

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    The objective of this study was to validate measuring knee range of motion (ROM) from smartphone photography. Thirty-two participants (64 knees) obtained smartphone photographs of knee flexion and extension. Surgeons obtained the same photographs and goniometric measurement of ROM. ROM was measured using Adobe Photoshop. Goniometer versus digital measurements, participant versus surgeon photographs, and interobserver measurements were analyzed. The average difference in goniometer and digital photograph measurements was 5°. The interclass correlation was .642(L) and .656(R). The Bland–Altman plots demonstrated that 29/32 digital measurements were within the 95% confidence interval (CI). Participants’ versus researchers’ photographs averaged a 2° difference. The interclass correlation was .924(L) and .91(R). Bland–Altman plots demonstrated that 31/32 measurements were within the 95% CI. Interobserver reliability averaged a ROM difference of 5°. The concordance coefficients were .647(L) and .723(R). Bland–Altman plots demonstrated that 30 of 32 digital measurements were within the 95% CI. Measuring knee ROM using smartphone digital photography is valid and reliable. (Journal of Surgical Orthopaedic Advances 27(1):52–57, 2018) Key words: digital photography, knee range of motion, smartphone

    Pediatric Orthopaedic Consults From Chiropractic Care - Andy B. Awwad, BS; William L. Hennrikus, MD; and Douglas G. Armstrong, MD

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    Alternative medicine in pediatrics is expanding, with chiropractic now a common choice for families seeking alternative medical care. Currently, there is sparse information in the literature exploring the role of chiropractic in orthopaedic pathology. The objective of this case series is to present pediatric patients who received treatment from chiropractors and orthopaedic physicians as well as to review the respective existing research. Data collected included chiropractic diagnosis, orthopaedic diagnosis, imaging studies, treatments, and complications. Twenty-three patients were studied. Scoliosis, LeggCalve-Perthes disease, developmental dysplasia of the hip, cerebral palsy, skeletal dysplasia, and slipped´ capital femoral epiphysis were diagnoses included. Children had multiple sessions of chiropractic for management of these conditions. The parents’ perception for chiropractic was positive in every case. Delayed referral, misdiagnosis, adverse events from manipulative therapy, and ineffective treatments were observed in the present study. More research is indicated to validate chiropractic in children with orthopaedic pathology. (Journal of Surgical Orthopaedic Advances 27(1):58–63, 2018) Key words: chiropractic, hip dysplasia, manipulative therapy, pediatric orthopaedic, Perthes, scoliosis

    Hip Fracture Mortality: Differences Between Intertrochanteric and Femoral Neck Fractures - Nicholas B. Frisch, MD, MBA; Nolan Wessell, MD; Michael Charters, MD; Alexander Greenstein, BS; Jonathan Shaw, BS; Edward Peterson, PhD; and S. Trent Guthrie, MD

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    The purpose of this study was to identify the specific risk factors that affect mortality in patients with hip fractures and differentiate mortality-associated factors between intertrochanteric (IT) and femoral neck (FN) fractures. A total of 1538 consecutive patients with hip fractures were treated at the authors’ institution between January 2005 and October 2013. Ultimately 858 IT and 479 FN fracture patients were included on the basis of age >60 years with an isolated hip fracture. Mortality rate at 90 days was 12.1% for IT and 9.6% for FN fractures. In both IT and FN fractures, variables associated with mortality risk include increased age, greater days to surgery, male gender, decreased body mass index, and increased American Society of Anesthesiologists score. When evaluated independently, the presence of cardiac arrhythmia and chronic kidney disease was strongly associated with greater mortality risk in FN fracture patients. The presence of chronic kidney disease and hypertension correlated with decreased mortality risk among FN fracture patients. (Journal of Surgical Orthopaedic Advances 27(1):64–71, 2018) Key words: femoral neck, hip fractures, intertrochanteric, mortality

    Readability of Patient Educational Materials for Total Hip and Knee Arthroplasty -  Asa W. Shnaekel, MD, MPH; Kristie B. Hadden, PhD; Tina D. Moore, EdD; Latrina Y. Prince, EdD; and C. Lowry Barnes, MD

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    This study aimed to evaluate patient education materials that are focused on total hip arthroplasty (THA) and total knee arthroplasty (TKA) using health literacy best practices and plain language principles as frameworks. Readability assessments were conducted on a sample of nine patient education documents that are commonly given to THA and TKA surgery patients. Mean readability scores were compared across the sample. The mean readability grade level for the nine arthroplasty educational documents analyzed in this study was 11th grade (10.5). The mean readability ranged from 9th to 12th grade. The documents in this study were written at levels that exceed recommendations by health literacy experts. Health literacy best practices and plain language principles were suggested to reduce the demands on patients so that the documents are easier to understand. Incorporating health literacy best practices into patient education materials for THA and TKA can contribute to improved communication with patients that is necessary for patient understanding and satisfaction. (Journal of Surgical Orthopaedic Advances 27(1):72–76, 2018) Key words: health literacy, hip arthroplasty, knee arthroplasty, patient education, readability

    Friction Syndromes of the Knee: The Iliotibial Band and Anterior Fat Pads - Robert D. Wissman, MD, and Stephen J. Pomeranz, MD

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    As participation in sporting activities increases among the general population, the incidence of overuse injuries continues to rise. Friction syndromes of the knee are common and are often clinically diagnosed without the need for imaging. However, clinical symptoms may overlap with other joint abnormalities, and physical examination may be limited in individuals with excessive pain. Magnetic resonance imaging has remained the modality of choice for the evaluation of internal derangements of the joints and is a useful aid in the diagnosis of friction syndrome of the knee. This case report provides clinicians with an understanding of the most common friction syndromes of the knee joint as well as their imaging findings. (Journal of Surgical Orthopaedic Advances 27(1):77–80, 2018) Key words: fat pad, friction syndrome, iliotibial band syndrome, knee, magnetic resonance imaging

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    Volume 26-4, Winter 2017 https://www.jsoaonline.com/volume-26-4-winter-2017/ Mon, 12 Feb 2018 06:55:58 +0000 https://www.jsoaonline.com/?p=3658 Read more ›]]>
  • Table of Contents
  • Evolution of Health Literacy Research in Orthopaedics and Other Medical Specialties - Kristie Hadden, PhD

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    Research has linked patient outcomes to health literacy in many areas of medicine and health over the past three decades. Early research focused on the readability of medical materials that were accessed by patients, followed by association studies establishing health literacy as a contributor to health outcomes, and finally interventions to improve those outcomes identified. Scientific exploration of how the field of orthopaedics can and should address health literacy can be accelerated if investigators follow the path that has been established through the evolution of health literacy in general over the past 30 years. Given that there have been studies on the readability of patient educational materials in orthopaedics, this agenda appears to be underway. Future research in orthopaedics and health literacy should focus on identifying specific outcomes in orthopaedics that are associated with health literacy that could be improved through future, targeted interventions. (Journal of Surgical Orthopaedic Advances 26(4):191–192, 2017) Key words: health literacy, orthopaedics

    Evaluating Nonoperative Treatments for Adhesive Capsulitis - Ryan C. Xiao, BS; Joseph P. DeAngelis, MD, MBA; Christopher C. Smith, MD; and Arun J. Ramappa, MD

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    Patients commonly present with shoulder complaints to the primary care and orthopaedic setting. The differential includes rotator cuff tears, subacromial impingement, osteoarthritis, and adhesive capsulitis, also known as frozen shoulder. Despite the prevalence of adhesive capsulitis, it is commonly misdiagnosed and management remains unclear. This article reviews the presentation of adhesive capsulitis, presents an overview of the pathophysiology of this poorly understood disease, and evaluates nonoperative treatment options for adhesive capsulitis. (Journal of Surgical Orthopaedic Advances 26(4):193–199, 2017) Key words: adhesive capsulitis, corticosteroid, frozen shoulder, injection, periarthritis, physical therapy

    Outcomes of Below-the-Knee Amputations for Chronic Lower Extremity Pain - Shannon Alejandro, MD; Robert D. Teasdall, MD; Martha Holden, AA, AAS; Beth Paterson Smith, PhD; Gregory B. Russell, PhD; and Aaron Scoff, MD

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    The study evaluated the physical,mental, and functional outcomes following below-the-knee amputation (BKA) for management of chronic, debilitating lower extremity pain. The hypothesis was that patients who undergo a BKA to alleviate chronic pain achieve a greater level of function, experience decreased pain, and benefit from improved health-related quality of life. Patients who received a BKA attended an orthopaedic clinic and completed questionnaires examining their overall health, functional status, mental health, and pain. Thirty-seven patients were identified as eligible for study participation; 15 agreed to participate. Although most participants continued to experience pain in their residual limb after BKA, they reported their pain decreased to a manageable level. Participants experienced a statistically significant improvement in their perceived physical health. The authors believe a BKA for chronic pain is a reasonable treatment option for patients who continue to experience lower extremity pain after failed medical and surgical management of chronic pain. (Journal of Surgical Orthopaedic Advances 26(4):200–205, 2017) Key words: Below-the-knee amputation, chronic pain, lower extremity, outcomes, trauma

    Predictability of Lower Extremity Peripheral Nervous Anatomy - Austin Fares, BS; Nicholas Kusnezov, MD; John C. Dunn, MD; Heather Balsiger, MS; James Showery, BS; Mark Hsiao, MD; and Justin Orr, MD

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    Lower extremity nervous anatomy is highly variable. This study sought to determine relationships of lower extremity peripheral nerves to anatomic landmarks. Sixteen well-preserved lower extremities were dissected. The distance from each nerve point of interest to relevant landmarks was measured in standardized fashion. The sciatic nerve divided on average 26.0% ± 5% of the distance from the superior aspect of the fibula to the greater trochanter proximal to the knee joint line [Pearson correlation coefficient (PCC) = 0.764]. The superficial peroneal nerve pierced the crural fascia at an average of 28.0% ± 6% of the fibular length proximal to the lateral malleolus (PCC = 0.718). The deep peroneal nerve emerged between the tibialis anterior and extensor hallucis longus on average 2.7% ± 0.4% of the fibular length proximal to the tibiotalar joint line (PCC = 0.530). While there was substantial variability in the course of lower extremity peripheral nerves, the study found strong correlation with femur and fibula length within each specimen. (Journal of Surgical Orthopaedic Advances 26(4):206–210, 2017) Key words: common peroneal, deep peroneal, lower extremity, nervous anatomy, sciatic, superficial peroneal

    Return of Quadriceps Strength After Primary Total Knee Arthroplasty With Single-Radius Knee System: Five-Year Follow-up - Alexander Fokin, MD, PhD, and David Heekin, MD, FACS

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    Preoperative quadriceps muscle strength (isometric peak torque) was expectedly lower on the total knee arthroplasty side in comparison with the unaffected contralateral side and it was further reduced after surgery. This reduction continued for up to 6 months postoperatively. After 6 months, muscle strengths exceeded preoperative values and continued to increase for the following 2 years. From 2 to 5 years postoperatively, there was a tendency for decline; however, the quadriceps muscle strength still exceeded preoperative values. On the nonoperative side, the increase in muscle strength was detected 1 year after surgery and it was still noticeable at 5 years. Contralateral side improvement can be explained by the increased mobility of the patients. Knee Society Scores and function scores were significantly increased at 3 months after surgery and were significantly greater than preoperative values 5 years after surgery. SF-12 (physical score) exceeded preoperative values at 3 months and this increase was observed continuously over the 5-year follow-up. (Journal of Surgical Orthopaedic Advances 26(4):211–215, 2017) Key words: quadriceps muscle strength, single-radius knee system, total knee arthroplasty

    Blood Transfusion After Primary Total Hip Arthroplasty: National Trends and Perioperative Outcomes - Cory W. Helder, BS; Brian E. Schwartz, MD; Michael Redondo, BS; Hristo I. Piponov, MD; and Mark H. Gonzalez, MD, PhD

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    The purpose of this study was to quantify the changes in transfusion rates, both allogeneic blood transfusion (ALBT) and autogenic blood transfusion (ATBT) on a national scale, and determine patient factors associated with transfusions. The National Hospital Discharge Survey was evaluated between 2001 and 2010 for primary total hip arthroplasty (THA) patients and categorized on the basis of transfusion necessity, type, and comorbidity burden. A logistic regression comparison of ALBT, ATBT, and nontransfused patients was performed with respect to patient demographics and in-hospital complications. The proportion of patients requiring any transfusion decreased from an average rate of 22.8% between 2001 and 2005 to 21.2% between 2006 and 2010 (p = .01). ATBT rates decreased (r = –.99) from 11.0% in 2001 to 2.8% in 2010. ALBT rates increased (r = .66) from 14% in 2001 to 16.6% in 2010. The number of patients requiring a blood transfusion after THA decreased in the United States with a trend shifting from ATBT to ALBT. (Journal of Surgical Orthopaedic Advances 26(4):216–222, 2017) Key words: allogeneic transfusion, autologous transfusion, THA, total hip arthroplasty, transfusion

    Smartphone-Based Goniometry Accuracy in Clinical Scenarios - Bradford S. Waddell, MD; Neil L. Duplantier, MD; Qingyang Luo, BS, MS; Mark S. Meyer, MD; and Scott F. M. Duncan, MD

    Abstract | Download Subscribers only | Purchase

    This study compared two popular iPhone-based goniometer applications to the gold standard universal goniometer for the measurement of the hip and knee joints in scenarios mimicking the normal pace of an orthopaedic clinical practice.Three physicians measured hip and knee joint angles 35 times with one of three goniometers: universal 12-inch goniometer, DrGoniometer (iPhone-5 based), and SimpleGoniometer (iPhone-5 based). Data wwere analyzed using Pearson correlation coefficient calculations. Average knee angles measured with the universal goniometer, DrGoniometer, and SimpleGoniometer measured 83.46°, 85.23°, and 80.39°, respectively. The smartphone-based goniometers had moderate agreement with the universal goniometer in the knee (r > .322). Average hip angles measured with the universal goniometer, DrGoniometer, and SimpleGoniometer measured 62.34°, 60.87°, and 59.34°, respectively. The smartphone-based goniometers had moderate agreement with the universal goniometer in the hip (r > .168). Smartphone-based goniometers gave accurate, with weak to moderate correlation, measurements for the knee and hip. (Journal of Surgical Orthopaedic Advances 26(4):223–226, 2017) Key words: goniometer, hip, knee, smartphone

    Predictors of Carpal Tunnel Release After Open Distal Radius Fracture - Jaehon M. Kim, MD; Mitchel B. Harris, MD; David Zurakowski, PhD; Wanjun Liu, MD; Jesse B. Jupiter, MD; Joung Heon Kim, BS; and Mark S. Vrahas, MD

    Abstract | Download Subscribers only | Purchase

    The purpose of this investigation was to determine the incidence and identify the predictors of carpal tunnel release (CTR) after open fractures of the distal radius (DRF). Patients with clinical symptoms of persistent median nerve neuropathy that required CTR were analyzed for risk factors. One hundred thirty-nine open DRFs (107 grade I, 23 grade II, 9 grade III) met the inclusion criteria. The incidence of CTR was 13.7% in all open DRFs (19 out of 139). Multivariable logistic regression analysis identified four predictors: male sex [odds ratio (OR) = 8.8, p = .001], type III Gustilo and Anderson grade (OR = 6.2, p = .04), OTA fracture type C (OR = 3.8, p = .03), and the application of external fixation (OR = 14.0, p = .02). The probability of CTR, determined by preoperative variables, was 80% with three factors present and 2% with no risk factors. High-risk patients may be identified who may benefit from closer perioperative surveillance and possibly carpal tunnel release. (Journal of Surgical Orthopaedic Advances 26(4):227–232, 2017) Key words: carpal tunnel release, complications, distal radius fractures, median nerve compression, open fracture

    Intramedullary Bone Graft Harvest Using Reamer-Irrigator-Aspirator System: A Case Series - Brian Waterman, MD; Shaunette Davey, DO; Enes Kanlic, MD; and Amr Abdelgawad, MD

    Abstract | Download Subscribers only | Purchase

    Autogenous iliac crest bone grating has been the gold standard. Recently, intramedullary bone graft harvest using a reamer-irrigator-aspirator (RIA) had been gaining more interest among orthopedic surgeons. Twenty-four RIA bone graft harvesting procedures in 23 consecutive patients with nonunions were included. The mean age was 37.8 years. Rates of perioperative complications, secondary surgical procedures, and union were assessed for all patients. At mean 10.1 months follow-up, three donor site complications occurred (12.5%), including two fractures (8.3%). Eighteen patients (78%) progressed to radiographic union, three (13%) were lost for follow-up, and two (9%) failed to achieve union. Mean reamer size was 13.7 mm (mode, 14.0 mm), producing an average volume of 39.4 mL (range, 15–90 mL) bone graft. While RIA bone grafting results in predictably high rates of union, patients should be counseled extensively about fracture risk. Tibial RIA may be less optimal as a primary source of bone grafting. (Journal of Surgical Orthopaedic Advances 26(4):233–238, 2017) Key words: bone graft, iatrogenic complication, intramedullary, nonunion, open fracture, reamerirrigator- aspirator, RIA, tibia fracture

    Risk of Obtaining Routine Cultures During Presumed Aseptic Orthopaedic Procedures - MAJ Matthew A. Napierala, MD; MAJ Jaime L. Bellamy, DO; COL Clinton K. Murray, MD; CPT Richard K. Hurley, Jr., MD; Joseph C. Wenke, PhD; and Joseph R. Hsu, MD

    Abstract | Download Subscribers only | Purchase

    Treating patients with antibiotics that are selected based on routine cultures obtained from presumed aseptic orthopaedic procedures may lead to an increased risk of antibiotic-related complications without reducing the rate of late deep infection. Routine cultures obtained from 60 of 169 procedures resulted in 23 (38.3%) positive and 37 (61.7%) negative results. Twenty-two patients (13.5%) developed late infections. Seven of 14 patients with positive cultures, who were treated with antibiotics, developed a late infection, while two of nine patients with routine cultures, who received no antibiotic treatment, developed a late infection. Six of 37 patients with negative cultures and seven of 109 patients with no cultures developed a late infection. In patients who developed late deep infection, the microorganism isolated on routine culture only corresponded to the microorganism causing late infection 55.5% of the time. Of all patients treated with antibiotics, seven (29%) experienced an antibiotic-related complication (p = .01). (Journal of Surgical Orthopaedic Advances 26(4):239–245, 2017) Key words: antibiotic-related complications, aseptic, orthopaedic procedures, routine cultures

    Radiation Exposure to the Orthopaedic Surgeon and Efficacy of a Novel Radiation Attenuation Product - Emily M. Mayekar, MD; Aysel Bayrak, BS; Smiresh Shah, MD; and Alfonso Mejia, MD, MPH

    Abstract | Download Subscribers only | Purchase

    The purpose of this study was to examine the intraoperative radiation dosage to different body parts and to determine the effectiveness of a new lightweight radiation-attenuating fabric (XPF) versus lead, the current standard. For 51 cases involving fluoroscopy, one attending orthopaedic surgeon wore a set of three dosimeters at various locations. Per each set of three, one dosimeter was shielded with a swatch of XPF, one was placed underneath the lead apron, and one was left exposed. The total dose of radiation was tabulated per body site and the percent attenuation was calculated for both XPF and lead. There was no statistically significant difference in the percent of radiation attenuation by lead and XPF (p = .47). The use of XPF produced 57.83% reduction in weight compared with lead when adjusting for total surface body area. XPF can be used for operating room personnel and patients, providing effective protection from radiation. (Journal of Surgical Orthopaedic Advances 26(4):246–249, 2017) Key words: ALARA, C-arm, fluoroscopy, lead, radiation, XPF

    Patient Satisfaction After Bilateral Thumb Carpometacarpal Osteoarthritis Surgery - Arnold B. Alqueza, MD; Sigrid Fostvedt, MD; W. Emerson Floyd, MS; and Jesse B. Jupiter, MD

    Abstract | Download Subscribers only | Purchase

    This study seeks to determine whether patients with bilateral thumb carpometacarpal osteoarthritis were sufficiently satisfied with their surgeries to choose to undergo surgery again. The null hypothesis is that patients are dissatisfied with the results of the first surgery. Out of 46 living patients meeting enrollment criteria, 41 were enrolled and evaluated using the Disabilities of the Arm, Shoulder and Hand (DASH) score and the Enneking musculoskeletal score. The average DASH score was 17.37. The average Enneking musculoskeletal score was 88.21. Of 41 patients, one expressed unwillingness to undergo the next procedure, three indicated that they would reluctantly do surgery again, and four were satisfied. The remaining 33 subjects were enthused with their functional result, expressing willingness to undergo the procedure again. At an average follow-up of 44.9 months, most patients are satisfied with bilateral thumb carpometacarpal surgery for osteoarthritis. Consent for the contralateral surgery implies that the outcome of the first surgery was sufficiently acceptable to seek surgery on the contralateral thumb. (Journal of Surgical Orthopaedic Advances 26(4):250–256, 2017) Key words: carpometacarpal osteoarthritis, patient satisfaction, surgical outcomes, thumb osteoarthritis

    Implementation of a Service-Specific Template Integrating Objective Structured Clinical Examination and Accreditation Council for Graduate Medical Education Milestones: One Institution’s Experience David J. Ruta, MD; Mark S. Morris, MD; Matthew T. Pigott, MD; J. Sybil Biermann, MD; Todd A. Irwin, MD; and James R. Holmes, MD

    Abstract | Download Subscribers only | Purchase

    The Accreditation Council for Graduate Medical Education (ACGME) orthopaedic milestones require detailed, frequent resident evaluations. This institution desired a cost-effective objective structured clinical examination (OSCE) to facilitate these evaluations. Data were collected as a prospective, uncontrolled observational study. The OSCE was completed by residents entering and exiting the foot and ankle rotation during postgraduate years 2 and 4. Physician assistants functioned as standardized patients. Statistical analyses were performed using paired and independent t tests. The OSCE was implemented using reliable, low-cost modalities and has facilitated milestones evaluations. Preliminary data show 4th-year residents performed higher in prerotation global assessment with a standardized patient and written exam (p < .03). Second-year residents showed improvement in the written exam on rotation completion (p = .03). Using this methodology, institutions may establish similar cost-effective OSCEs as feasible evaluative solutions to satisfy milestone requirements. The authors believe this tool may be modified for any specialty. (Journal of Surgical Orthopaedic Advances 26(4):257–261, 2017) Key words: ACGME milestones, competency, OSCE; objective structured clinical examination, OSCE, resident evaluation

    Return to Duty Following a Tibial Tubercle Osteotomy CPT - Tony Locrotando, DO; CPT K. Aaron Shaw, DO; CPT Jeremy M. Jacobs, MD; and LTC(Ret) John A. Bojescul, MD

    Abstract | Download Subscribers only | Purchase

    Anterior knee pain is a common complaint among military members, with a negative impact on operational readiness. A tibial tubercle osteotomy is one treatment option for select etiologies of anterior knee pain and has been reported to result in high rates of return to activity. A retrospective review of active duty service members undergoing a tibial tubercle osteotomy at a single army medical center was performed. Thirteen active duty service members were identified as undergoing a tibial tubercle osteotomy. Nine patients remained on active duty at 1 year following surgery. After 24 months, only four service members remained on active duty, while seven were medically retired. Seventy-five percent of patients who underwent concomitant cartilaginous procedure underwent a medical discharge. A small subset of active duty military personnel who underwent a tibial tubercle osteotomy was able to remain on active duty, but concomitant cartilaginous procedures did not appear to be compatible with retention on active duty because of the high physical demands placed on soldiers. (Journal of Surgical Orthopaedic Advances 26(4):262–265, 2017) Key words: active duty, knee pain, military, patellofemoral, tibial tubercle osteotomy

    Plantar Fibromatosis and Other Fibroblastic and Fibrohistiocytic Soft Tissue Tumors of the Foot - Hale Ersoy, MD, and Stephen J. Pomeranz, MD

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    Plantar fibromatosis, also known as Ledderhose’s disease, is a benign fibroblastic disorder of plantar aponeurosis, more specifically the medial side of the foot arch. Magnetic resonance imaging (MRI) has an important role in the diagnosis, staging, and determining the deep extension found in advanced, aggressive forms of plantar fibromatosis, thereby guiding appropriate clinical and surgical management. This case report aims to provide radiologists and clinicians with simple guidelines for the differential diagnosis of the fibroblastic and fibrohistiocytic soft tissue tumors of the foot with the emphasis on the MRI findings. (Journal of Surgical Orthopaedic Advances 26(4):266–270, 2017) Key words: desmoplastic fibromatosis, fibroma of tendon sheath, Ledderhose’s disease, MRI, nodular fasciitis, plantar fibromatosis, proliferative fasciitis

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  • Table of Contents
  • Burnout and Stress in Medicine in the 21st Century: Catastrophe or Opportunity? - Cormac A. O’Donovan, MD, FRCPI

    Abstract | Download Subscribers only | Purchase

    Burnout and stress occur in all aspects of life and are considered by many to be increasing in our modern-day culture. These have been studied most often in relation to the workplace and are prevalent in all occupations. As a result, growing numbers of people are consulting physicians for stress-related complaints. Patients may look to their doctors as role models in their quest to obtain optimal physical and mental health. However, the prevalence of burnout in physicians is increasing at a much greater rate than in all other professional groups (1). Anecdotal evidence from social media attributes the issue of burnout to simply being involved in the practice of medicine, rather than premorbid psychiatric dysfunction. Whatever the cause, physicians have rates of depression and other related psychiatric disorders equal or greater to those outside the profession (2). Accurate estimates are difficult to ascertain, since physicians are concerned that acknowledging their situation may prevent them from practicing medicine. This intentional underreporting is in part validated by analyses of several confidential surveys of thousands of physicians, with rates of issues such as substance abuse disorders up to 15% (3).

    A Retrospective Comparative Analysis of the Use of Implantable Bone Stimulators in Nonunions - J. Ryan Martin, MD; George Vestermark, MD; Brian Mullis, MD; and Jeffrey Anglen, MDM

    Abstract | Download Subscribers only | Purchase

    This study details the use of implantable bone stimulators in the setting of nonunion. A retrospective comparative analysis was used to evaluate the efficacy of implantable bone stimulators in achieving union in the setting of atrophic or oligotrophic nonunion by two fellowship-trained orthopaedic trauma surgeons. Initially, 72 patients underwent surgical intervention for nonunion. Twenty-one patients had an implantable bone stimulator placed at the time of nonunion surgery. Thirty-eight patients had a minimum of 1-year follow-up. An implantable bone stimulator was used in 13 patients and 25 patients did not have a bone stimulator. The use of implantable bone stimulators was found to be significantly associated with increased union rates (p = .042). (Journal of Surgical Orthopaedic Advances 26(3):128–133, 2017) Key words: bone stimulators, electrical stimulation, nonunion

    Influence of Body Mass Index on Clinical Outcomes in Reverse Total Shoulder Arthroplasty - J. Michael Wiater, MD; Shannon Carpenter, MD; Denise M. Koueiter, MS; David Marcantonio, MD; and Brett P. Wiater, MD

    Abstract | Download Subscribers only | Purchase

    The purpose of this study was to compare reverse total shoulder arthroplasty (RTSA) outcomes in normal weight, overweight, and obese patients. A RTSA outcomes registry was reviewed for rotator cuff-deficient patients with a minimum 2-year follow-up. Fractures, rheumatoid arthritis, and revisions were excluded. Based on World Health Organization body mass index (BMI) classification, there were 29 normal weight, 50 overweight, and 51 obese patients. All groups demonstrated significant improvements from preoperative to most recent follow-up in function scores, pain, and forward elevation. Obese and overweight groups had significantly worse preoperative rotation than the normal weight group. Postoperatively, there was no significant difference in absolute values or degree of improvement of rotation between groups. There was no significant difference in the incidence of radiographic or clinical complications between groups. Results of this study suggest that BMI has little influence on outcomes or risk of complication following RTSA. Longer-term studies are needed to determine if these results are maintained. (Journal of Surgical Orthopaedic Advances 26(3):134–142, 2017) Key words: body mass index, cuff tear arthropathy, obesity, retrospective comparative study, reverse total shoulder arthroplasty, rotator cuff deficiency

    Do Routine Radiographs Obtained at Initial Outpatient Postoperative Visit Change Management? - Eric Grenier, MD, DPT; Dave Tennent, MD; Jean Patzkowski, MD; Joseph Hsu, MD; and Anthony Johnson, MD

    Abstract | Download Subscribers only | Purchase

    Routine postoperative radiographs are commonly obtained at the initial postoperative visit. The purpose of this study was to demonstrate the clinical utility of routine postoperative radiographs and quantify the radiation exposure and cost to the health care system. All orthopaedic surgeries performed during 2007 at a level I trauma center were retrospectively analyzed. Surgical procedures that were likely to require follow-up radiographs were included. Analysis demonstrated 878 procedures with 471 procedures (54%) receiving initial postoperative radiographs. Routine radiographs were performed in 455 (96.6%) procedures with 4/455 (0.879%) resulting in a change in management. Nonroutine radiographs were performed in 16 (3.40%) procedures with 2/16 (12.5%) triggering a change in management. Subjects receiving radiographs at the initial postoperative visit obtained a mean of 2.54 radiographs per procedure with a mean exposure of 0.199 mSv with a median cost of $29.98 per radiographic series in 2013 Medicare reimbursement dollars. (Journal of Surgical Orthopaedic Advances 26(3):143–147, 2017) Key words: cost utility, postoperative, radiographs

    Predictors of Acute Ischemic Stroke After Total Knee Arthroplasty - Mariano E. Menendez, MD; Eric M. Greber, MD; Charles S. Schumacher, MD; and C. Lowry Barnes, MD

    Abstract | Download Subscribers only | Purchase

    Although acute ischemic stroke (AIS) is a feared medical complication after total knee arthroplasty (TKA), little is known about its incidence and risk factors. The purpose of this retrospective populationbased study using the Nationwide Inpatient Sample (2008–2011) was to determine the incidence and predictors of AIS following TKA. The rate of perioperative AIS was 0.08%. Patients undergoing bilateral TKA were almost three times more likely to develop AIS compared with unilateral TKA patients. The age group with the highest odds of AIS was ⪚85 years. Sex and race and ethnicity were not independently associated with AIS. The comorbidity with the highest risk for AIS was history of stroke, followed by cardiac valvular disease, peripheral vascular disease, atrial fibrillation, complicated diabetes, coagulopathy, and ischemic heart disease. The data in this article might prove useful for preoperative counseling and decision making, resource allocation, and implementation of strategies to minimize the occurrence of AIS after TKA. (Journal of Surgical Orthopaedic Advances 26(3):148–153, 2017) Key words: complications, Nationwide Inpatient Sample, risk, stroke, total knee arthroplasty

    Efficacy of Arthroscopic Teaching Methods: A Prospective Randomized Controlled Study - Luke Robinson, MD; Jonathon Spanyer, MD; Zachary Yenna, MD; Patrick Burchell, BS; Andrew Garber, MD; and John Riehl, MD

    Abstract | Download Subscribers only | Purchase

    Arthroscopic education research recently has been focused on the use of skills labs to facilitate resident education and objective measure development to gauge technical skill. This study evaluates the effectiveness of three different teaching methods. Medical students were randomized into three groups. The first group received only classroom-based lecture. The second group received the same lecture and 28 minutes of lab-based hands-off arthroscopy instruction using a cadaver and arthroscopy setup. The final group received the same lecture and 7 minutes of hands-on arthroscopy instruction in the lab on a cadaver knee. The arthroscopic knee exam that followed simulated a diagnostic knee exam and subjects were measured on task completion and by the number of look downs. The number of look downs and the number of tasks completed did not achieve statistical significance between groups. Posttest survey results revealed that the hands-on group placed significantly more value on their educational experience as compared with the other two groups. (Journal of Surgical Orthopaedic Advances 26(3):154–159, 2017) Key words: arthroscopic education, arthroscopic skills, arthroscopy, hands-on training, residency education, teaching curriculum

    Reduction Loss After Distal Radius Fracture Fixation With Locked Volar Plates - Michael M. Vosbikian, MD; Constantinos Ketonis, MD, PhD; Ronald Huang, MD; James A. Costanzo, MD; and Asif M. Ilyas, MD

    Abstract | Download Subscribers only | Purchase

    Distal radius fractures are among the most common injuries in the upper extremity. While many studies have looked at the maintenance of reduction with volar locking plates, there is a paucity of literature comparing the ability of different plates to maintain reduction over time. This study reviews the ability of various plates to maintain radiographic reduction at union after distal radius fracture treatment. Loss of some aspect of fracture reduction was routinely observed following locked volar plating regardless of implant. However, choice of implant did have a significant impact on final radiographic alignment, particularly with respect to volar tilt and ulnar variance. Yet, selecting between a fixed angle versus a variable angle was not found to make a difference in maintaining reduction. The authors recommend that surgeons take these findings into consideration when selecting a volar locking plate. (Journal of Surgical Orthopaedic Advances 26(3):160–165, 2017) Key words: distal radius fracture, loss of reduction, volar locking plate

    A Novel Technique Utilizing a Vastus Lateralis Anchor in Treatment of Chronic Patellar Dislocation After Total Knee Arthroplasty - Allison Mayfield, MD; Vamsi Singaraju, MD; Afshin A. Anoushiravani, MD; Zain Sayeed, MS, MHA; Jamal K. Saleh, BSc; and Khaled J. Saleh, MD, MSc, FRCS(C),
    MHCM, CPE

    Abstract | Download Subscribers only | Purchase

    Extensor mechanism complications involving the patella frequently result in total knee arthroplasty (TKA) failure. Postoperative patellar dislocation may be caused by soft tissue imbalance, improper sizing, and position of the prosthesis. This report describes a case of revision TKA requiring several rounds of soft tissue releases in an effort to treat the patient’s chronic patellar dislocation. In the process, a novel surgical approach was developed for the surgical management of refractory chronic patellar dislocations. Postoperative follow-up at 1, 2, 6, 12, and 24 months indicated no complaints of patellar subluxation or dislocation. Plain films also demonstrated no effusion, fracture, or patellar dislocation on sunrise, anteroposterior, and lateral views. This novel anatomic repositioning of the vastus lateralis around the quadriceps tendon converted a pathologic lateralizing force into a medial stabilizer. On follow-up evaluations, successful patellar tracking without dislocation has been demonstrated. (Journal of Surgical Orthopaedic Advances 26(3):166–172, 2017) Key words: extensor mechanism complications, novel surgical technique, patellar maltracking, revision total knee arthroplasty, total knee arthroplasty, vastus lateralis release

    Vascularized Medial Femoral Condyle Graft for Manubrium Nonunion: Case Report and Review of the Literature - William R. Aibinder, MD; Michael E. Torchia, MD; Allen T. Bishop, MD; and Alexander Y. Shin, MD

    Abstract | Download Subscribers only | Purchase

    Fractures of the sternum are rare. Persistent nonunions, however, can lead to chronic pain and significant functional limitations. The vascularized medial femoral condyle is a versatile tool in the surgeon’s armamentarium. Traditionally, it has been used as a thin corticoperiosteal graft in the treatment of nonunion of tubular bones. Its use as a structural corticocancellous graft has also been expanding. This report presents a case of a patient with a recalcitrant symptomatic nonunion of the manubrium treated with the unique combined corticoperiosteal and corticocancellous vascularized bone graft from the medial femoral condyle and reviews the literature concerning these uncommon nonunions. (Journal of Surgical Orthopaedic Advances 26(3):173–179, 2017) Key words: corticocancellous structural graft, manubrial fracture, manubrial nonunion, medial femoral condyle, vascularized bone graft

    Two Patients and Two Knee Cysts - Hale Ersoy, MD, and Stephen J. Pomeranz, MD

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    Differential diagnosis of a cystic lesion adjacent to menisci can be a challenge even when the case presents as seemingly straightforward. To ‘‘tell the story’’ as accurately as possible, the radiologist must be familiar with the natural history of these lesions as well as distinctive imaging features and must take all relevant factors into consideration, such as patient’s age, activity level, and surgical history. This article presents two cases to illustrate how imaging features affect the report and management plan. (Journal of Surgical Orthopaedic Advances 26(3):180–182, 2017) Key words: capsulosynovial cyst, ganglion, knee MRI, parameniscal pseudocyst

    Distal Radius Skyline View: How to Prevent Dorsal Cortical Penetration - Benjamin C. Taylor, MD; Andy R. Malarkey, DO; Ryan L. Eschbaugh, DO; and John Gentile, DO

    Abstract | Download Subscribers only | Purchase

    Volar locked plating has become a standard treatment for operative stabilization of distal radius fractures. It is assumed that volar plating portends a low risk of extensor tendon irritation and rupture, especially when compared with dorsal plating constructs; however, extensor tendon tenosynovitis and rupture is a well-described complication after volar plating of the distal radius. Dorsal cortical penetration of screws may go unnoticed with traditional intraoperative fluoroscopic techniques and may contribute to extensor tendon irritation. This article presents the authors’ experience with an additional fluoroscopic dorsal tangential radiograph helping the surgeon ascertain dorsal screw prominence following volar plate fixation. (Journal of Surgical Orthopaedic Advances 26(3):183–186, 2017) Key words: distal radius fracture, dorsal cortex, dorsal cortical view, extensor tendon irritation, skyline view

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  • Table of Contents
  • Axillary Intraneural Ganglion Cysts - Kartik G. Krishnan, MD, PhD; Nikhil K. Prasad, MB, ChB; Kimberly K. Amrami, MD; Paul J. Kurtin, MD; and Robert J. Spinner, MD

    Abstract | Download Subscribers only | Purchase

    Aside from affecting the stability of the glenohumeral joint, tears in the joint capsule can give rise to extraneural (paralabral) and, very rarely, intraneural ganglion cysts. This report presents the first two cases of axillary intraneural ganglion cysts in the literature with magnetic resonance imaging. Both cases were incidentally noted to have coexisting lesions (lymphadenopathy from an undifferentiated malignancy and suprascapular nerve entrapment, respectively). This report reinforces the applicability of the articular theory for intraneural ganglion cysts at a novel site. (Journal of Surgical Orthopaedic Advances 26(2):69–74, 2017) Key words: arthroscopy, axillary nerve, intraneural ganglion cyst, labral tear

    Reverse Total Shoulder Arthroplasty for Complex Three- and Four-Part Proximal Humerus Fractures in Elderly Patients: A Review - George F. Lebus V, MD; Hassan R. Mir, MD, MBA; and Brandon D. Bushnell, MD, MBA

    Abstract | Download Subscribers only | Purchase

    Complex proximal humerus fractures in elderly patients represent a difficult problem for orthopaedic surgeons. Classically, treatment methods have included nonoperative management, open reduction and internal fixation, and hemiarthroplasty. Outcomes of nonoperative management for these complex fractures have been poor, and results of traditional operative techniques are variable at best. Over the past several years, reverse total shoulder arthroplasty (RTSA) has been increasingly employed in these injuries with encouraging results. RTSA may represent a valuable treatment option for select patients. This article reviews the existing data on RTSA in the treatment of complex proximal humerus fractures in the elderly population as well as the authors’ experience with this technique. (Journal of Surgical Orthopaedic Advances 26(2):75–80, 2017) Key words: proximal humerus fracture, reverse total shoulder arthroplasty

    Insurance-Mandated Stay Prolongs Hospitalization Following Total Shoulder Arthroplasty - Krysten M. Bell, MD; Mark E. Mildren, MD; Montri D. Wongworawat, MD; Torrey Parry, MD; Christopher M. Jobe, MD; and Wesley P. Phipatanakul, MD

    Abstract | Download Subscribers only | Purchase

    Medicare currently requires a 3-night hospitalization for a patient to be considered for skilled nursing facility (SNF) placement. The purpose of this study was to analyze the relationship between length of stay and (a) insurance status and (b) readmission rates in Medicare-age patients undergoing primary total shoulder arthroplasty. A retrospective review of 251 primary consecutive total shoulder arthroplasty cases was performed. In patients discharged to SNF, Medicare insurance was associated with a significantly longer hospital stay (p < .001) compared with patients with private insurance. Readmission rates for Medicare and private insurance patients were similar at 30 and 90 days after surgery (p = 1.000). Ninety-five percent of Medicare patients discharged to SNF had a prolonged hospital stay primarily to fulfill the 3-night requirement. These findings call into question the necessity of the current 3-night inpatient hospitalization requirement for facility placement following total shoulder arthroplasty. (Journal of Surgical Orthopaedic Advances 26(2):81–85, 2017) Key words: hospital readmission, length of stay, shoulder arthroplasty, 3-night rule, value-based health care

    Damage Control Plating in Open Tibial Shaft Fractures: A Cheaper and Equally Effective Alternative to Spanning External Fixation - Paul S. Whiting, MD; Phillip M. Mitchell, MD; Aaron M. Perdue, MD; Arnold J. Silverberg, BS; Sarah E. Greenberg, BA; Rachel V. Thakore, BS;
    Vasanth Sathiyakumar, BA; Hassan R. Mir, MD, MBA; William T. Obremskey, MD, MMHC, MPH; and Manish K. Sethi, MD

    Abstract | Download Subscribers only | Purchase

    The purpose of this study was to evaluate damage control plating (DCP) as an alternative to external fixation (EF) in the provisional stabilization of open tibial shaft fractures. Through retrospective analysis, the study found 445 patients who underwent operative fixation for tibial shaft fractures from 2008 to 2012. Twenty patients received DCP or EF before intramedullary nailing with a minimum follow-up of 3 months. Charts and radiographs were reviewed for postoperative complications. Hospital charges were reviewed for implant costs. Nine patients (45%) with DCP and 11 patients (55%) with EF were analyzed. There was no significant difference in the complication rates. The mean implant cost of DCP was $1028, whereas mean EF construct cost was $4204. Therefore, DCP resulted in significant cost savings with no difference in complication rates, making it a valuable alternative to EF for the provisional stabilization of open tibial shaft fractures. (Journal of Surgical Orthopaedic Advances 26(2):86–93, 2017) Key words: damage control plating, external fixation, open tibia fracture

    A Process Improvement Evaluation of Sequential Compression Device Compliance and Effects of Provider Intervention - Jason A. Beachler, MD; Chad A. Krueger, MD; and Anthony E. Johnson, MD

    Abstract | Download Subscribers only | Purchase

    This process improvement study sought to evaluate the compliance in orthopaedic patients with sequential compression devices and to monitor any improvement in compliance following an educational intervention. All non–intensive care unit orthopaedic primary patients were evaluated at random times and their compliance with sequential compression devices was monitored and recorded. Following a 2-week period of data collection, an educational flyer was displayed in every patient’s room and nursing staff held an in-service training event focusing on the importance of sequential compression device use in the surgical patient. Patients were then monitored, again at random, and compliance was recorded. With the addition of a simple flyer and a single in-service on the importance of mechanical compression in the surgical patient, a significant improvement in compliance was documented at the authors’ institution from 28% to 59% (p < .0001). (Journal of Surgical Orthopaedic Advances 26(2):94–97, 2017) Key words: compliance; mechanical prophylaxis, venous thromboembolism

    Intercondylar Fractures of the Distal Humerus in Patients Younger Than 20 Years: Capsulectomy Results - W. Andrew Eglseder, MD, and Ebrahim Paryavi, MD, MPH

    Abstract | Download Subscribers only | Purchase

    Few reports in the literature have been dedicated to young patients with distal fractures of the humerus, and few have addressed subsequent indications to improve range of motion (ROM). This article is a retrospective review of the elbow flexion–extension ROM in 31 patients (age, 12–19 years) who had been treated with open reduction and internal fixation of intercondylar fractures of the distal humerus at a level I trauma center from 1991 through 2013. The ROM of patients who underwent capsulectomy was compared with that of those who did not. Main outcome measures were ROM in degrees and need for capsulectomy. Nine (29%) of the 31 patients had elected to undergo capsulectomy. Eleven did not require capsulectomy. The final flexion–extension arc was improved by 31° compared with the precapsulectomy ROM but did not attain the ROM of those who did not undergo capsulectomy. (Journal of Surgical Orthopaedic Advances 26(2):98–101, 2017) Key words: capsulectomy, intercondylar fracture of distal humerus, range of motion

    Fluoroscopic Exposure With Use of Mini-C-Arm During Routine Hand Surgery: A Prospective Comparison of Hand Versus Eye Radiation Dosage - Mark L. Wang, MD, PhD; C. Edward Hoffler, MD, PhD; Asif M. Ilyas, MD; Pedro K. Beredjiklian, MD; and Charles F. Leinberry, MD

    Abstract | Download Subscribers only | Purchase

    Radiation exposure with use of intraoperative fluoroscopy is a potential orthopedic occupational risk factor. The purpose of this study was to perform a prospective comparison of hand versus eye radiation exposure associated with mini-C-arm utilization and to test the hypothesis that routine mini-C-arm does not yield hand or eye dosages exceeding current recommended levels. Over a 12-month period, hand and eye radiation exposure was prospectively measured in a single board-certified hand surgeon using mini-C-arm fluoroscopy. Twenty-five cases were performed utilizing mini-C-arm fluoroscopy. Average monthly hand radiation dosage (45.81±14.49 mrem) was significantly higher (p = .01) than eye radiation dosage ( Key words: cataracts, eye radiation, fluoroscopy, hand radiation, mini-C-arm, radiation exposure

    Pin Malposition in External Fixator Stabilization of Combat-Related Pelvic Fractures - Mark P. Coseo, MD; Dustin J. Schuett, DO; Kevin M. Kuhn, MD; and Joseph Bellamy, MD

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    The purpose of this study was to compare the accuracy of pin placement in patients with unstable pelvic fractures undergoing either iliac crest or supra-acetabular external fixation. A retrospective review was performed of computed tomography (CT) scans and injury characteristics for all patients presenting to a North Atlantic Treaty Organization Medical Treatment Facility with data entered into the Department of Defense Trauma Registry from January 2008 to October 2013 who underwent pelvic external fixation for unstable pelvic ring injuries. Thirty-two patients were analyzed. Sixteen patients underwent damage control iliac crest-based and 16 patients underwent supra-acetabular-based external fixation. There was no significant difference in patient characteristics at presentation between the two groups. Pin malposition rate on CT scan was 50/64 (78.1%) for the iliac crest group and 3/32 (9.4%) for the supraacetabular group. Pinmalpositionwas correlatedwith increasing Injury Severity Score, Abbreviated Injury Scale (AIS) head score, and AIS face score. The review concluded that iliac crest-based external fixation has a significantly higher rate of pin malposition than supra-acetabular-based external fixation. (Journal of Surgical Orthopaedic Advances 26(2):106–110, 2017) Key words: external fixation, iliac crest,musculoskeletal trauma, pelvic fracture, supra-acetabular, war trauma

    Scapulothoracic Joint Dysfunction - Joseph Ugorji, DO, and Stephen J. Pomeranz, MD

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    Scapulothoracic derangements are often overlooked and hidden within the clinical fog created by complex back, shoulder, and rib symptoms. This study reviewed 200 magnetic resonance imaging and computed tomography studies dedicated for scapular imaging between January 2010 and May 2016. This article discusses scapulothoracic pathologies and imaging findings. (Journal of Surgical Orthopaedic Advances 26(2):111–115, 2017) Key words: baseball, lower infraserratus bursa, scapular dyskinesia, scapulothoracic bursitis, scapulothoracic crepitus, scapulothoracic joint, snapping scapula syndrome, subserratus bursa, throwing athlete, trapezoid bursa, upper infraserratus bursa

    First Ray Elevation Osteotomy for Cavovarus Foot: Dorsal Oblique Wedge Osteotomy - Pablo Wagner, MD; Diego Zanolli, MD; Andres Keller, MD; Cristian Ortiz, MD; Ximena Ahumada, MD; Patricia Paz, MD1; Beat Hintermann, MD; and Emilio Wagner, MD

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    This article presents a new technique that allows a controlled and stable correcting osteotomy of the first metatarsal for cavovarus deformity. The preoperative planning and the surgical technique are described. (Journal of Surgical Orthopaedic Advances 26(2):116–119, 2017) Key words: cavovarus, elevation, foot, osteotomy, treatment

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