Infection Rate and Risk Factor Analysis in an Orthopaedic Ambulatory Surgical Center - Daniel L. Edmonston, BS, and Guy D. Foulkes, MD

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Surgical site infections (SSI) are a costly problem. The purpose of this study was to determine the rate of infection and identify patient and technical risk factors for SSI in an orthopaedic ambulatory surgical center. Over 11,000 consecutive orthopaedic surgeries over 5 years were reviewed for SSI as well as demographic, medical, and surgical risk factors. Nearly 400 noninfected patients served as statistical controls. The overall infection rate was 0.33%, which compares favorably to previous studies of outpatient surgery and appears to be substantially lower than SSI rates previously reported for inpatient orthopaedic surgery. Male sex, smoking, and diabetes demonstrated significantly higher risk for infection. Surgery time and duration of anesthesia administration were also associated statistically with SSI. A history of cancer, hypertension, or thyroid problems were all associated with higher but statistically insignificant risk of SSI. Patient age and number of past surgeries were equal in the SSI and control groups. (Journal of Surgical Orthopaedic Advances 19(3):174–176, 2010) Key words: ambulatory surgery, infection rate, orthopaedic, outpatient, surgical site infection

Utility of Magnetic Resonance Imaging Obtained Before Evaluation by the Hand Surgeon - Curtis M. Henn, MD, Arnold-Peter Weiss, MD, and Edward Akelman, MD

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The objective of this study was to assess prospectively the utility of magnetic resonance imaging (MRI) obtained before evaluation by a hand surgeon. Over a 4-week period, the hand surgeon documented the type of imaging used in each encounter, which prereferral MRIs were useful, and if he agreed with the radiologist’s interpretation. Of 396 consecutive patients, 14 (4%) presented with an MRI. Of those MRIs, 10 were found to be useful. The hand surgeons agreed with the radiologist’s interpretation on 13 of the 14. Eleven patients presented with only an MRI, and 10 of those were helpful. In contrast, none (0 of 3) of the MRIs of patients who presented with both radiographs and an MRI were useful (p D .01). These results suggest that previous retrospective studies may be confounded by recall bias. The data support the selective ordering of MRIs by referring physicians; however, ordering more than one imaging modality is less likely to be helpful. (Journal of Surgical Orthopaedic Advances 19(3):159–161, 2010) Key words: hand, imaging, MRI, prereferral

Clinical Observations on Surgical Details of Resection of Heterotopic Ossification at the Hip in Traumatic Brain-Injured Adult - P. Koulouvaris, MD, PhD

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Heterotopic ossification (HO) complicated with neurovascular bundle can be a very challenging operation. Preoperative planning before any HO resection is imperative. Plans to reconstruct nerve or artery should be in place. A case study is presented that involved a large bone mass of HO in hip joint which enclosed the sciatic nerve. Preoperative planning, microsurgical techniques, and equipment necessary for this complicated surgical procedure are reviewed. (Journal of Surgical Orthopaedic Advances 19(3):177–180, 2010) Key words: heterotopic ossification, preoperative planning, surgical technique

Beta-Blocker Prophylaxis for Total Knee Arthroplasty Patients: A Case Series - Kathryn A. Heim, MD, Mark P. Lachiewicz, MD, Elizabeth S. Soileau, BSN

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Cardiac complications are an infrequent yet undesirable cause of morbidity and mortality following total knee arthroplasty. Perioperative prophylaxis with beta-blocker medication has been shown to reduce in-hospital cardiac deaths in noncardiac surgical patients. This study evaluated the safety and in-hospital cardiac complications of a consecutive cohort of 267 total knee arthroplasties in patients who followed a perioperative beta-blocker prophylaxis institutional protocol. The patients were categorized into three groups: A, already on a beta-blocker; B, beta-blocker prescribed by orthopaedic surgeon; and C, not given the medication. The 90-day mortality and in-hospital cardiac complications were evaluated. Of the patients who had 267 procedures, 203 (76%) received beta-blocker prophylaxis perioperatively: 110 (41.2%) were already on the medication preoperatively, 93 (34.8%) were prescribed the medication by the surgeon, and 64 (24%) did not receive this medication. There were no deaths within the first 90 days. There were two nonfatal myocardial infarctions (0.7%) and six other cardiac complications (2.2%).With a beta-blocker prophylaxis protocol implemented by one surgeon, 76% of total knee arthroplasty patients were given the medication and it was prescribed in 34.8% by the orthopaedic surgeon. In-hospital cardiac complications were low. (Journal of Surgical Orthopaedic Advances 19(3):162–165, 2010) Key words: beta-blocker prophylaxis, postoperative complications, total knee arthroplasty

Effectiveness of the Cavus Foot Orthosis - Matteo LoPiccolo, MD, Margaret Chilvers, MD, Brian Graham, CPed, and Arthur Manoli II, MD

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This study investigated the use of a custom cavus foot orthosis (CFO) in the treatment of ankle instability and pain associated with the subtle cavus foot, a common pathological foot alignment in the United States population. Patients referred by a single orthopedic foot and ankle surgeon to a single pedorthotist for a CFO over a 2-year period were eligible. Pain score pre-and postorthosis and number of instability events pre- and postorthosis were retrospectively evaluated. Ninety-three of 174 eligible patients participated. Average age was 48 years (range, 20–75) and patients suffered a variety of foot pathologies. Average pre-CFO pain score was 7.22 (0 no pain, 10 worst pain). Post-CFO pain score average was 2.41 (p < .0005). Ninety-two percent of patients reporting ankle instability as a problem experienced a decrease in the frequency of instability events post-CFO. The custom cavus foot orthosis is effective at relieving pain and reducing ankle instability in the patient with the subtle cavus foot alignment. (Journal of Surgical Orthopaedic Advances 19(3):166–169, 2010) Key words: ankle instability, cavus, orthotic, peroneal tendons, stress fracture

Traumatic Closed Transection of the Triceps Brachii: A Case Report - Maria Kyriaki A. Kaseta, MD, Robin M. Queen, PhD, and Claude T. Moorman III, MD

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There are only a few reports about intramuscular injury to the triceps brachii, offering the surgeon limited clinical options and estimates of prognosis. This is a case report of a patient with a traumatic closed tear of his triceps brachii who was treated surgically. This report presents the initial surgical management and data throughout 64 months of follow-up, during which time the patient showed continual, gradual improvement in function with no functional limitations. (Journal of Surgical Orthopaedic Advances 19(3):149–152, 2010) Key words: closed transection, surgical intervention, triceps

Noninstrumented Facet Fusion in Patients Undergoing Lumbar Laminectomy for Degenerative Spondylolisthesis - Dhruv B. Pateder, MD, and Edward Benzel, MD

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The purpose of this retrospective study was to evaluate the radiographic and clinical efficacy of uninstrumented facet fusion in elderly patients undergoing lumbar laminectomy for spinal stenosis due to a single-level degenerative spondylolisthesis. Several studies have clearly demonstrated the beneficial effects of concomitant spinal fusion with laminectomy in degenerative spondylolisthesis. Controversy, however, persists regarding the virtues of fusion in this patient population.This study included 62 patients with a single-level grade I or II degenerative spondylolisthesis who underwent laminectomy and uninstrumented facet fusion for unremitting symptoms of spinal stenosis. Group 1 (39 patients) had a fixed degenerative spondylolisthesis with no measurable translation on flexion/extension radiographs, while group 2 (23 patients) had a mobile degenerative spondylolisthesis with preoperative translation. Postoperatively, the 62 listhetic levels were analyzed for radiographic signs of instability on flexion/extension radiographs for a minimum of 24 months. Clinical outcome was assessed in each patient at the time of final follow-up. In group 1 (patients with no preoperative translation), 64% of the index listhetic facet fusion levels had 2 mm of motion on postoperative flexion/extension radiographs, while the other 36% had >2 mm to 15 mm of motion. Ninety-six percent of patients with 2 mm of postoperative motion were ‘‘much better’’ after surgery, whereas only 50% of patients with >10 mm of postoperative motion had similar results. Similar trends were also observed in group 2 with 52% of levels having 2 mm motion and patient ‘‘much better’’ outcomes being observed with less motion postoperatively. The overall postoperative radiographic stabilization rate and improved patient outcomes were higher in group 1 than in group 2. In patients undergoing laminectomy for a grade I or II fixed or mobile degenerative spondylolisthesis, concomitant facet fusion decreases motion and stabilizes the spine via a bony fusion or a stable pseudarthrosis. In general, patients with less motion on postoperative flexion/extension radiographs had a better clinical outcome than those with more motion. (Journal of Surgical Orthopaedic Advances 19(3):153–158, 2010) Key words: degenerative, facet, fusion, lumbar, spondylolisthesis, stenosis

The Effect of Footwear on Preoperative Gait Mechanics in a Group of Total Ankle Replacement Patients - Robin M. Queen, PhD, and James A. Nunley, MD

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Debate exists within the current clinical literature as to whether patients should be tested barefoot or in shoes either before or following surgical interventions. The objective of this study was to determine the effect of shod versus barefoot walking on spatiotemporal gait parameters before total ankle arthroplasty (TAA). Twenty patients who were scheduled for TAA were asked to walk four trials in shoes and four barefoot trials over a GaitRite mat while spatiotemporal variables were recorded. A series of repeated measures analysis of variance were performed to determine significant differences. Step length, stride length, double support time, and walking velocity were significantly increased in the shod condition. However, step width, swing time, and support time were significantly decreased in the shod condition. The results of this study indicate the importance of testing clinical populations barefoot in order to more accurately assess gait pathology. (Journal of Surgical Orthopaedic Advances 19(3):170–173, 2010) Key words: clinical evaluation, footwear comparison, walking

A Complex Cyst Characterized Into Its Individual Components: A Shared Pathogenesis From the Superior Tibiofibular Joint - Robert J. Spinner, MD, Marie-Noelle

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In a patient with a peroneal neuropathy, magnetic resonance imaging (MRI) allowed characterization of a complex para-articular cyst into three different types of cysts, all derived from the superior tibiofibular joint: 1) an intraneural cyst extending along the articular branch to the common peroneal nerve; an interconnected intraneural component extending within the extensor digitorum muscle neural branch, penetrating the fascia of the anterior compartment, and reaching the subcutaneous tissues; 2) an intraosseous cyst isolated to the fibular head and neck, and 3) an extraneural cyst heading toward the tibial nerve and vessels. Joint resection and articular branch disconnection led to excellent functional recovery; an MRI confirmed no cyst recurrence. This case illustrates that different types of cysts can derive from a single joint of origin and extend in various locations and that the articular (synovial) theory is versatile for demonstrating a joint connection, even in unusual appearing combinations of cysts. (Journal of Surgical Orthopaedic Advances 19(3):143–148, 2010) Key words: articular (synovial) theory, ganglion, intraneural cyst, synovial cyst

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