Volume 25-2, Summer 2016

Presentation and Management of Venomous Snakebites: Should All Patients Be Transferred to a Tertiary Referral Hospital? - Val H. Irion, MD; James Barnes, MS; Brooke E. E. Montgomery, MPH, PhD; Larry J. Suva, PhD; and Corey O. Montgomery, MD

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Venomous snakebites may be difficult to manage because of the varied clinical presentations that may lead to uncertainty regarding the most appropriate medical and surgical management. Frequently, snakebite victims are referred from smaller rural hospitals to larger tertiary centers offering more specialized services and care. A retrospective chart review was performed using medical records from both adult and pediatric hospitals in a rural state over a 7-year period (January 2004 to January 2011) to investigate the utility of intensive care and specialized medical services offered at tertiary referral centers. The results demonstrated that presentation of venomous snakebites is the same in adults and children as well as the management. The results also demonstrated that the use of supportive care and antivenin alone was successful in the management of the vast majority of snakebites. Most snakebite victims recovered with nonsurgical care; thus surgical intervention is rarely warranted. These findings demonstrate that snakebite victims may not need referral to a tertiary center, if the primary local hospital has supportive care capacity and familiarity with antivenin usage. (Journal of Surgical Orthopaedic Advances 25(2):69–73, 2016) Key words: antivenin, snakebites, venomous

Intrusion Characteristics of Three Bone Cements for Tibial Component of Total Knee Arthroplasty in a Cadaveric Bone Model - Justin K. Walden, MD; Alexander C. M. Chong, MSAE, MSME; Nam L. Dinh, MD; Scott Adrian, BS; Robert Cusick, MD; and Paul H. Wooley, PhD

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The purpose of this study was to evaluate and compare the intrusion characteristics of Simplex-HV to Simplex-P and Palacos-R in cadaveric proximal tibial bone. Eighteen fresh-frozen cadaver proximal tibiae were examined with standard arthroplasty tibial cuts. Each tibia was randomly assigned to receive one of the three bone cements for use with finger packing technique. Sagittal sections were prepared and analyzed using digital photography and stereoscopic micrographs to evaluate cement intrusion characteristics. The cement penetration depth was measured from the tibial bone cut surface, which did not include the cement thickness under the tibial base plate. Significant differences were detected in the bone cement penetration between the three cements. Penetration was increased using the Simplex-HV (average, 2.7 mm; range, 2.0–3.0 mm) compared with Simplex-P (average, 2.2 mm) and Palacos-R (average, 1.8 mm). These depths approximate to 3.7, 3.2, and 2.8 mm of total cement penetration, respectively. The data suggest that high-viscosity bone cement may provide good fixation of the tibial component of a total knee arthroplasty when using the finger packing technique. (Journal of Surgical Orthopaedic Advances 25(2):74–79, 2016) Key words: bone cement, cement penetration, intrusion characteristics, tibial component fixation, total knee arthroplasty

Computed Tomography-Based Software Safely Guides Anterograde Percutaneous Anterior and Posterior Column Acetabular Screws - Soham Banerjee, MD; Adam J. Starr, MD; and Rahul Banerjee, MD

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The objective of this study was to develop three-dimensional (3-D) modeling software to generate the optimal individualized starting points and pathways for anterior and posterior column screws. In this cross-sectional study, 95 consecutive patients from a level I trauma center with noncontrast pelvis computed tomography (CT) images without displaced acetabular fractures were studied. A Javabased program was designed that generated a 3-D graph of pelvic bones and a list was compiled of every potential anterograde anterior and posterior column screw that exited distal to the acetabulum, eliminating screws that did not safely remain within the cortex. The longest safe screw pathway for each patient was determined for both 6.5-mm and 7.3-mm diameter screws. The program was able to identify safe screw pathways for the vast majority of patients (>96%). The study also found that males tolerated significantly longer screws in the anterior column (p < .05), but there was no posterior column difference regarding sex. (Journal of Surgical Orthopaedic Advances 25(2):80–85, 2016) Key words: acetabulum, computer-assisted surgery, percutaneous screw, three-dimensional modeling

Southern Orthopaedic Association Abstract Publication Rate - Mark Adam Tait, MD; Cara Petrus, BS; and C. Lowry Barnes, MD

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The purpose of this study was to determine the publication rate ofmanuscripts presented at the Southern Orthopaedic Association’s (SOA) annual meetings. An extensive literature search was performed using Google Scholar and PubMed search engines and all accepted abstracts (posters or podium presentations) presented at an SOA annual meeting from 2005 to 2011 were evaluated. A total of 568 abstracts were presented at SOA meetings between 2005 and 2011. Of these, 234 (41%) were published in the peer-reviewed literature. The publication rate was 66% in 2005 and 28% in 2010. The average time from presentation to peer-reviewed publication was 1.6 ± 0.24 years (range, 2 years in 2006 to 1 year in 2011). The SOA publication rate was comparable with other major orthopaedic conference publication rates, yet more than half of all abstracts remain unpublished. SOA attendees should be aware that approximately 40% of all accepted presentations will go unpublished. (Journal of Surgical Orthopaedic Advances 25(2):86–88, 2016) Key words: Southern Orthopaedic Association, publication rates

Military Orthopaedic Trauma Registry: Quality Data Now Available - Jessica C. Rivera, MD; Renee M. Greer, RN; Joseph C. Wenke, PhD; James R. Ficke, MD; and Anthony E. Johnson, MD

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The Military Orthopaedic Trauma Registry (MOTR) orginally began as part of the Department of Defense Trauma Registry (DoDTR) and became a live registry in 2013. As a quality improvement process, this study examined MOTR data for 20 female amputees compared with DoDTR data. The DoDTR provided diagnosis and procedure codes as a list but no details. The MOTR provided additional data, including specific limb, fracture classifications, and associated injuries per limb. The MOTR allowed for construction of a treatment time line for each limb, including number and timing of debridements, antibiotics, and implant types. Orthopaedic-specific complications were also coded more frequently in the MOTR and clearly identified with a specific injury and treatment. During initial quality control checks, the MOTR provides a greater volume and granularity of detail for orthopaedic-specific injury and treatment information, indicating that the MOTR is on track to provide a valuable repository for data-driven orthopaedic management of combat injury. (Journal of Surgical Orthopaedic Advances 25(2):89–92, 2016) Key words: amputations, combat injury, quality assurance, registry data, registry development

Balance Assessment in Sports-Related Concussion: Evaluating Test–Retest Reliability of the Equilibrate System - Mitchell J. Odom, BS; Young M. Lee, BSPH; Scott L. Zuckerman, MD; Rachel P. Apple, MD; Theodore Germanos, BS; Gary S. Solomon, PhD; and Allen K. Sills, MD

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This study evaluated the test–retest reliability of a novel computer-based, portable balance assessment tool, the Equilibrate System (ES), used to diagnose sports-related concussion. Twenty-seven students participated in ES testing consisting of three sessions over 4 weeks. The modified Balance Error Scoring System was performed. For each participant, test–retest reliability was established using the intraclass correlation coefficient (ICC). The ES test–retest reliability from baseline to week 2 produced an ICC value of 0.495 (95% CI, 0.123–0.745). Week 2 testing produced ICC values of 0.602 (95% CI, 0.279–0.803) and 0.610 (95% CI, 0.299–0.804), respectively. All other single measures test–retest reliability values produced poor ICC values. Same-day ES testing showed fair to good test–retest reliability while interweek measures displayed poor to fair test–retest reliability. Testing conditions should be controlle when using computerized balance assessment methods. ES testing should only be used as a part of a comprehensive assessment. (Journal of Surgical Orthopaedic Advances 25(2):93–98, 2016) Keywords: balance, BESS, concussion, modified balance assessment scoring system, postural stability, sports

Effect of Malnutrition and Morbid Obesity on Complication Rates Following Primary Total Joint Arthroplasty - P. Maxwell Courtney, MD; Joshua C. Rozell, MD; Christopher M. Melnic, MD; Neil P. Sheth, MD; and Charles L. Nelson, MD

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The purpose of this study is to identify any association between malnutrition and morbid obesity and determine if either independently increases complications following primary total joint arthroplasty (TJA). The study retrospectively reviewed a series of 670 patients who underwent primary TJA at a single institution. Patients were categorized as malnourished if their preoperative serum albumin was 40 kg/m2. Of the 670 patients in the study, 83 patients were malnourished (12.4%), while 125 patients (18.7%) were morbidly obese. Morbidly obese patients were more likely to be malnourished than nonmorbidly obese patients (19% vs. 11%, p = .010). Malnutrition is an independent risk factor for complications [adjusted odds ratio (OR) 3.00, 95% confidence interval (CI) 1.56–5.75]. Morbid obesity was not independently associated with a significant increase (adjusted OR 1.82, 95% CI 0.70–4.71). Preoperative screening with serum albumin, particularly in morbidly obese patients, can identify at-risk patients for complications. (Journal of Surgical Orthopaedic Advances 25(2):99–104, 2016) Key words: complications, malnutrition, morbid obesity, total hip arthroplasty, total knee arthroplasty

American Society of Anesthesiologists Score as a Predictive Tool to Optimize Blood Ordering for Intraoperative Transfusion in Orthopaedic Trauma Cases - Vasanth Sathiyakumar, BA; Dagoberto Estevez-Ordonez, BS; Rachel V. Thakore, BS; Young M. Lee, BS; Jesse M. Ehrenfeld, MD, MPH; William T. Obremskey, MD, MPH, MMHC; and Manish K. Sethi, MD

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The objective of this study was to determine the clinical factors that are predictors for intraoperative transfusion in orthopaedic trauma patients. A retrospective chart review of patients admitted to a level I trauma center with isolated fractures was conducted. Variables such as gender, height, weight, body mass index, American Society of Anesthesiologists (ASA) classification, and medical comorbidities were assessed to determine likelihood of blood transfusion. A total of 1819 patients with isolated fractures were identified. ASA class was strongly associated with patients receiving intraoperative blood transfusion. For example, compared with patients with an ASA class I, patients with an ASA class IV were 14.71 times more likely to receive transfusion. Patients’ ASA class is correlated with the need for intraoperative blood transfusion in patients undergoing orthopaedic surgery for isolated fractures. Institutional or departmental maximum surgical blood order schedule algorithms could use patients’ preoperative ASA class to determine whether blood transfusion will be necessary during procedures. (Journal of Surgical Orthopaedic Advances 25(2):105–109, 2016) Key words: ASA score, blood transfusion

Occupational Impact of Multilevel Cervical Disease Treated With Hybrid Cervical Disc Arthroplasty in Active Duty Military Population - Andrew Cleveland, MD; Josh Herzog, MD; and Pedro Caram, MD

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This article evaluates the techniques, results, and complications of hybrid cervical disc arthroplasty in a high-demand military population. Emphasis is on the occupational impact and return to duty outcomes. This article is a case series with prospective follow-up of 30 hybrid cervical disc arthroplasty patients from the authors’ institution. Average follow-up was 16.1 months. Average patient age was 39.7 years. Noncommissioned officer was the most common military rank. Cervical disc arthroplasty at C5/6 with fusion at C6/7 was the most common procedure (21/30). All classifications of military occupational specialty were represented. A total of 24/30 (80%) patients returned to duty (RTD) and 24/24 (100%) of RTD patients reported relief (postoperative improvement) compared with 4/6 (66.7%) medical evaluation board patients. Average RTD time was 15.6 weeks. All RTD patients maintained their preoperative military occupational specialty. Hybrid cervical disc arthroplasty has the potential to provide relief and return military patients to preoperative active duty status. (Journal of Surgical Orthopaedic Advances 25(2):110–113, 2016) Key words: arthroplasty, cervical, military, radiculopathy, spondylosis

Arthroscopic Release of Adhesive Capsulitis of the Shoulder Complicated With Shoulder Dislocation and Brachial Plexus Injury - Fiesky A. Nunez, Jr., MD; Anastasios Papadonikolakis, MD; and Zhongyu Li, MD, PhD

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The incidence of brachial plexus injury after shoulder dislocation or arthroscopic shoulder surgery is low. Complex regional pain syndrome (CRPS) is an uncommon but painful condition that can develop after nerve injury. Historically, CRPS has been difficult to treat and therapeutic efforts are sometimes limited to ameliorating symptoms. However, if a dystrophic focus can be identified, the condition can be addressed with surgical exploration for potential neurolysis or nerve repair. The present article reports on a case of type II CRPS that developed in the postoperative setting of arthroscopic shoulder surgery complicated with simple shoulder dislocation. (Journal of Surgical Orthopaedic Advances 25(2):114–116, 2016) Key words: adhesive capsulitis, brachial plexus injury, causalgia, complex regional pain syndrome, nerve injury, shoulder dislocation

Complex Regional Pain Syndrome - Hale Ersoy, MD; and Stephen J. Pomeranz, MD

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Complex regional pain syndrome (CRPS) is a neurological disorder producing peripheral neurogenic inflammatory process in hands and feet distal to injury, which may lead to severe disability. Symptoms are often out of proportion to the initiating event and not limited to a single peripheral nerve. There is no gold standard in diagnosis of this entity, and a multidisciplinary approach is necessary for proper diagnosis. Magnetic resonance imaging (MRI) is one of the most useful diagnostic modalities in early stages of CRPS (when clinical diagnosis is most difficult), the most desirable time to diagnose this disorder to expedite treatment and improve function. This article discusses MRI findings of CRPS, particularly in the early phase, and differential considerations. (Journal of Surgical Orthopaedic Advances 25(2):117–120, 2016) Key words: bone marrow edema, complex regional pain syndrome, magnetic resonance imaging, MRI, overuse, reflex sympathetic dystrophy

Obtaining Volar Tilt in Distal Radius Fixation: Use of a Screw as a Proximal Post - B. Collier Watson, DO; Benjamin C. Taylor, MD; Adam Madsen, DO; Freddie D. Persinger, DO; and Andy R. Malarkey, DO

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Volar plating of distal radius fractures was introduced as a means to circumvent some of the issues with dorsal-based plating but has been shown not to be a complete panacea, as other advantages and challenges have subsequently been discovered. Careful attention and proper technique must be utilized to restore and maintain volar tilt. This study reports a technique of using a locking screw as a proximal peg to reliably obtain the volar tilt in a simple fashion. (Journal of Surgical Orthopaedic Advances 25(2):121–125, 2016) Key words: distal radius fracture, proximal peg, reduction technique, volar plating

Ponseti Casting Technique: Using the Flags - Anil Agarwal, MS; Abbas Shaharyar, MS; Anubrat Kumar, MS; and Mohd Shafi Bhat, MS

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Ponseti casts for congenital clubfoot are generally removed in the clinics by soaking and unwrapping them. It is often difficult to find the plaster bandage edge for unwrapping it. The use of flags at cast ends can ease this problem. (Journal of Surgical Orthopaedic Advances 25(2):126–127, 2016) Key words: cast, clubfoot, congenital talipes equinovarus, plaster of paris, Ponseti method

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