Volume 24-1, Spring 2015

This study investigates an alternative approach for steroid injection into the carpal canal through a palmar site and its exposure of vital wrist structures to potential injury. The Rankin’s zone entry site is more distally located than conventional sites. This cadaveric study investigated 28 wrists from 26 cadavers. Red latex dye was injected as a localizing aid. Layered dissections were performed to localize the needle tip with respect to vital wrist structures. Calipers measured the distance from the needle to nerves. Twenty-three of the 28 injections using this approach demonstrated dye solely within the carpal tunnel. One median nerve was punctured. The mean distance from the median nerve was 5.76 š 2.9 mm and 18.27 š 5.27 mm from the palmar cutaneous branch. This study suggests that the Rankin’s zone approach might be utilized with diminished frequency of neural puncture. (Journal of Surgical Orthopaedic Advances 24(1):1–4, 2015) Key words: cadaveric study, conservative treatment, early carpal tunnel syndrome, nerve injury, palmar injection site, percutaneous, topical steroids

Using radiographs of a cross section of patients, measurements of phalanges were done to aid in surgical planning for distal interphalangeal joint (DIPJ) arthrodesis using a headless compression screw. Measurements were performed of the distal and middle phalanx of all fingers and the proximal and distal phalanx of the thumb. Three independent reviewers measured 50 patients. The average measurements (in mm) of anteroposterior (AP) dimensions were as follows: for the thumb P1 and P2: 5.7 and 5.5, lateral 4.2 and 3.5; for the index P2 and P3 AP: 4.2 and 3.3, lateral 2.1 and 1.8; for the long P2 and P3 AP: 4.5 and 3.5, lateral 2.2 and 1.8; for the ring P2 and P3 AP: 4.3 and 3.1, lateral 1.8 and 1.7; and for the small P2 and P3 AP: 3.7 and 2.2, lateral 1.8 and 1.5. Careful surgical planning by measuring the involved digit and knowledge of screw size is paramount to avoid complications from DIPJ arthrodesis with a compression screw. (Journal of Surgical Orthopaedic Advances 24(1):5–11, 2015) Key words: arthrodesis, distal interphalangeal joint (DIPJ), headless compression screw, morphometric

This retrospective study examined the early outcomes of healthy weight and severely obese subjects who underwent minimally invasive (MI) fusion and decompression surgery for degenerative lumbar disease at one to two spinal levels. A single surgeon (D.A.) operated on all subjects. Subjects were categorized based on body mass index [normal (18.5–24.9 kg/m2) or severely obese (over 35 kg/m2)]. Surgical data included blood loss, hospital length of stay, narcotic use, discharge disposition, and postoperative infection. Data were compared using Levene’s test for equality of variances, t test for equality of means, Pearson chi-square test, and Cramer’s V correlation test (˛  .05 for all). SPSS software was utilized for all tests. Significant differences between the groups included blood loss, hospital length of stay, and early narcotic use. In the early postoperative setting, healthy weight subjects went home sooner and lost less blood, but needed more narcotic prescriptions filled than their obese counterparts. The use of MI spinal surgery in the severely obese population provides manageable issues for the patient and no significant complications when compared with the healthy weight population, indicating that it is a good alternative for obese patients. (Journal of Surgical Orthopaedic Advances 24(1):12–17, 2015) Key words: body mass index, decompression, fusion, minimally invasive surgery, spine

The objective of this study was to compare intramedullary (IM) nail and IM screw fixation for reattachment of the proximal ulna. Preserved elbow anatomy served as the primary outcome and was defined as the distance between the coronoid process and the olecranon. A retrospective cohort study of 31 patients treated with IM fixation of the proximal ulna was performed. Radiographs were used to compare displacement distances between the coronoid process and the olecranon, with average follow-up of approximately 5 months. IM nail fixation corresponded to a mean displacement of 0.65 mm between the olecranon and coronoid process, versus 0.23 mm for IM screw fixation. No patients were identified with loss of reduction of bone fragments. Both IM fixation techniques maintained the functional anatomy of the elbow. Minimal displacement of bone fragments and no identified loss of reduction suggest that both techniques could be reasonable alternatives to more traditional approaches. (Journal of Surgical Orthopaedic Advances 24(1):18–21, 2015) Key words: elbow, intramedullary, olecranon, osteotomy, ulna

The purpose of this study is to evaluate the documentation of acute compartment syndrome (ACS) in combat casualties in an effort to identify potential areas for improvement. Medical records of U.S. service members wounded during the current conflicts in Afghanistan and Iraq who underwent fasciotomies were reviewed. Key descriptors including signs and symptoms of ACS were recorded. Injury severity scores andmuscle excision at the time of fasciotomy were also included for analysis. Of 134 patients who met inclusion criteria, documentation was inadequate overall in 65 patients (49%). Fourteen (10%) had muscle excised at the time of fasciotomy, but this was not associated with a higher rate of inadequate documentation. This study demonstrates the need for improved awareness and documentation of impending compartment syndrome in the austere setting to improve the continuity of care during the medical evacuation process. (Journal of Surgical Orthopaedic Advances 24(1):22–26, 2015) Key words: combat, extremity, fasciotomy, performance improvement, quality assurance

Periarticular infiltration analgesia when used as a component of multimodal analgesia regimen has been shown to provide excellent pain relief after major joint replacement surgery. Recently, a liposomal formulation of bupivacaine (Exparel) has been approved for administration into the surgical site to produce postsurgical analgesia. It is a sustained release preparation of bupivacaine that has been shown to provide pain relief for up to 72 hours with a single local administration. Because the success of infiltration technique depends on systematic, extensive, meticulous tissue injection before surgical wound closure, a group convened to address the best practice for periarticular injection techniques for hip and knee replacement surgery. This article provides recommendations for optimal solution for injection (i.e., drug combinations or ‘‘cocktail’’ and total volume) as well as detailed description (including illustrations) of the infiltration technique for primary, revision, and unicompartmental knee arthroplasty and primary and revision hip arthroplasty using various surgical approaches. (Journal of Surgical Orthopaedic Advances 24(1):27–35, 2015) Key words: hip arthroplasty, knee arthroplasty, liposomal bupivacaine, pain management, periarticular infiltration

This study sought to determine the optimal treatment setting (emergency department vs. operating room) for the initial incision and drainage of acute suppurative finger infections. A search of hospital medical records over a 5-year period identified 152 cases. In 108 cases (71%), a single drainage successfully resolved infection; 44 cases (29%) required multiple drainage procedures. Treatment setting did not decrease the risk for multiple procedures. Seventy-six cases (57%) of community-acquired methicillinresistant Staphylococcus aureus (CA-MRSA) were identified. Bivariate analysis identified CA-MRSA infection as a significant, independent risk factor for multiple procedures. Obtaining initial cultures correlated with a decreased need for multiple procedures. In conclusion, initial surgical drainage in the emergency department is a safe alternative to the operating room. However, patients with CAMRSA infection have an increased risk for persistent infection requiring multiple procedures. Prompt organism identification and appropriate antibiotics following surgical drainage remain most crucial for the successful treatment of finger infections. (Journal of Surgical Orthopaedic Advances 24(1):36–41, 2015) Key words: debridement, finger infection, incision and drainage, MRSA

Acetate templating for total hip arthroplasty (THA) is cumbersome and inaccurate. High cost hampers mainstream use of digital templating despite ease of use and accuracy. The aim of this study was to validate a low-cost digital THA templating system. Low-cost digital templating software was created using C# programming language. On the basis of power calculations, three surgeons templated 20 consecutive anteroposterior pelvis X-rays using this software against an industry standard. Intraclass correlation coefficient for both systems was approximately .90 for component size and femoral neck cut position. Bland–Altman plots demonstrated that both systems predicted actual implant size with similar accuracy. Interrater reliability was not significantly different between the two systems. This low-cost digital THA templating system is up to 12-fold lower in cost than currently available software with similar accuracy. (Journal of Surgical Orthopaedic Advances 24(1):42–46, 2015) Key words: digital templating system, templating, total hip arthroplasty

Postoperative stiffness is a relatively uncommon issue in total knee arthroplasty (TKA). However, it can be a debilitating complication when it occurs. Manipulation under anesthesia (MUA) is commonly used as the primary treatment modality following failed physiotherapy. The Advance medial pivot knee (Wright Medical Technology) was created in an effort to prevent stiffness postoperatively and increase range of motion. The Evolution medial pivot knee is a second-generation design that builds on the technology of the Advance knee. This article presents a retrospective review of prospectively collected data on 881 primary medial pivot knees (592 Advance knees, 289 Evolution knees). It was theorized that the design changes made to the Evolution knees might contribute toward reducing the need for MUA. It was found that the Evolution knees required significantly fewer manipulations under anesthesia (p D .036). The design modifications made to the Evolution knees may have contributed to the lower rate of MUA. (Journal of Surgical Orthopaedic Advances 24(1):47–50, 2015) Key words: knee manipulation, knee stiffness, manipulation under anesthesia, range of motion

Recent failure mechanisms seen with metal-on-metal (MOM) total hip arthroplasty (THA) include a spectrum of inflammatory and immune-mediated reactions of lymphocyte predominance. Frozen section (FS) analysis has been used to evaluate joints for acute inflammation indicative of infection. However, the impact of the inflammatory response to metal debris on FS analysis is unknown and the usefulness of FS analysis in failed MOM THA has not been reported. This study investigated the impact of intraoperative FS analysis in evaluating the possibility of infection in 30 patients undergoing revision of a failed MOM THA. The authors’ experience suggests that FS has acceptable specificity (96.6%) for infection in revision MOM surgery, although one false positive was noted in this series and the addition of FS did not provide obvious diagnostic utility. The authors believe that FS should be used selectively (if at all) in conjunction with other studies to avoid misdiagnosis in failed MOM THA. (Journal of Surgical Orthopaedic Advances 24(1):51–56, 2015) Key words: frozen section, infection, metal-on-metal, revision total hip arthroplasty

Computed tomography (CT) has become an increasingly popular and powerful tool for clinicians managing trauma patients with life-threatening injuries, but the ramifications of increasing radiation burden on individual patients are not insignificant. This study examines a continuous series of 337 patients less than 40 years old admitted to a level 1 trauma center during a 4-month period. Primary outcome measures included number of scans; effective dose of radiation from radiographs and CT scans, respectively; and total effective dose from both sources over patients’ hospital stays. Several variables, including hospital length of stay, initial Glasgow Coma Scale score, and Injury Severity Score, correlated with greater radiation exposure. Blunt trauma victims were more prone to higher doses than those with penetrating or combined penetrating and blunt trauma. Location and mechanism of injury were also found to correlate with radiation exposure. Trauma patients as a group are exposed to high levels of radiation from X-rays and CT scans, and CT scans contribute a very high proportion (91.3% š 11.7%) of that radiation. Certain subgroups of patients are at a particularly high risk of exposure, and greater attention to cumulative radiation dose should be paid to patients with the above mentioned risk factors. (Journal of Surgical Orthopaedic Advances 24(1):57–63, 2015) Key words: computed tomography, quantifying radiation, radiation exposure, trauma evaluation, trauma imaging

Musculoskeletal ultrasound (MSK-US) is a quick and effective imaging tool that can be utilized by orthopaedic surgeons to identify common musculoskeletal pathology such as ankle tendinopathy. This study evaluated the ability of 15 orthopaedic surgery residents to identify and measure ankle tendons after attending a multimedia tutorial on MSK-US. Afterwards, proficiency of usage was assessed by identification and quantification of three ankle tendons (Achilles, tibialis posterior, and flexor hallucis longus) in a cadaver limb. Resident comfort level and plan for future use were also assessed. After completing the tutorial, accuracy measuring the Achilles, tibialis posterior, and flexor hallucis longus tendons was 94.8%, 90.2%, and 90.1%, respectively. Resident comfort level improved from a level of 2.3 before the tutorial to 6.8 afterwards. Seventy-one percent of residents plan to use ultrasound in clinical practice. These results show that orthopaedic surgery residents can identify and assess tendon size via MSK-US with sufficient accuracy after a multimedia tutorial. (Journal of Surgical Orthopaedic Advances 24(1):64–68, 2015) Key words: musculoskeletal ultrasound, tendon disorders

This study determined in a prospective manner if arthroscopic shoulder capsular release can decrease the duration of adhesive capsulitis symptoms when compared with a nonoperative home therapy program. Patients randomized to the operative group underwent arthroscopic capsular release and manipulation of the shoulder. Immediately after surgery they began the same stretching program as the nonoperative group, which consisted of terminal range of motion low-grade stretches twice daily for at least 15 minutes per session for 3 months. Twenty-six patients granted consent for the study (final analyses included 10 operative and 7 nonoperative). There were no statistical differences between the groups regarding gender, age (operative mean age, 51.5 š 11.1 years; nonoperative mean age, 52.0 š 6.8 years) or treatment outcome. This prospective, randomized study, which compared arthroscopic capsular release to a gentle home stretching program, demonstrated both treatment options to be effective treatment modalities. (Journal of Surgical Orthopaedic Advances 24(1):69–74, 2015) Key words: adhesive capsulitis, physical therapy, shoulder, surgery

Reconstruction of chronic rupture and resection of chronic tendinosis of the Achilles tendon can be challenging when there is insufficient tendon for repair. This article describes the demographics, diagnosis, surgical technique, and results of a series of patients having Achilles allograft reconstruction of the Achilles tendon. A retrospective chart review identified patients who required Achilles reconstruction. Between 2006 and 2013, 78 patients had surgical repair for Achilles rupture or resection of tendinosis. Eight patients required use of Achilles tendon allograft with calcaneal block. In all patients, there was insufficient viable tendon to repair by direct reattachment. The postdebridement gap was greater than 5 cm. All patients had good function at last follow-up. This series of patients undergoing Achilles allograft reconstruction technique demonstrated promising results and suggests that allograft reconstruction is a reasonable solution. (Journal of Surgical Orthopaedic Advances 24(1):75–78, 2015) Key words: Achilles rupture, Achilles tendinosis, chronic Achilles

Lisfranc ligament and joint injuries are relatively uncommon but can result from a variety of low- and highimpact trauma. Up to 20% of Lisfranc fracture–dislocations are misdiagnosed or missed during the initial evaluation. Timely and accurate diagnosis of the injury and early anatomical reduction and stabilization of the Lisfranc joint are crucial to avoid long-term sequelae and functional impairment. Magnetic resonance imaging (MRI) is a sensitive and specific imaging modality and should be considered in injuries with equivocal physical and radiographic findings. In this article, the mechanism and the classification of the Lisfranc joint and ligament injuries are outlined, and imaging findings of different modalities are discussed with the emphasis on MRI. (Journal of Surgical Orthopaedic Advances 24(1):79–82, 2015) Key words: joint, ligament, Lisfranc, tarsometatarsal