Volume 25-3, Fall 2016

Patients who have undergone a lower extremity amputation may develop an unstable soft tissue envelope of the amputation stump. This envelope may result in pain that prohibits prosthetic use or may become chronically infected. Providing stable soft tissue coverage at the amputation site may provide relief from pain and cure of infection. Additionally, a stable amputation soft tissue envelope may assist with the ability of that patient to maintain his or her existing level of ambulation, overall sense of wellness, and ability to maintain social integration. Salvage of a lower extremity amputation level may significantly improve a patient’s overall quality of life. Attempts to salvage an amputation level that is plagued by unstable wounds, pain, or infection are warranted in those patients who have the physiologic reserves to undergo salvage of their amputation level. This article presents an approach to the salvage of lower extremity amputations utilizing both local tissue rearrangements and free tissue transfer techniques. (Journal of Surgical Orthopaedic Advances 25(3):137–148, 2016) Key words: Key words: amputation level, free flaps, lower extremity, salvage, tissue transfers

The purpose of this article is to report midterm follow-up of operatively treated calcaneus fractures. All patients with a calcaneus fracture, treated with open reduction and internal fixation (ORIF) using the extensile lateral approach, were identified. Functional outcomes were assessed using the American Orthopaedic Foot and Ankle Society’s (AOFAS) ankle–hindfoot assessment, SF-36, and a questionnaire. There were 20 patients (25 fractures): 16 males and four females. The average age was 42 years (range, 16–73 years) and the mean follow-up time was 40 months (range, 13–73 months). The mean AOFAS score was 67.8 (SD = 19.3) and the mean SF-36 score was 55.7 (SD = 26.3). Patients in an motor vehicle accident had more associated injuries. Statistically significantly worse AOFAS scores were noted in patients with ORIF > 21 days after their injury (p = .047). Many lifestyle alterations were found to be present, including change in work, participation in recreational activities, footwear, and use of ambulatory assistive devices. (Journal of Surgical Orthopaedic Advances 25(3):149–156, 2016) Key words: American Orthopaedic Foot and Ankle Society’s (AOFAS) ankle–hindfoot assessment, calcaneus fracture, open reduction and internal fixation (ORIF); Short Form-36 (SF-36) health survey

This study describes a new surgical technique to transfer the tibial tubercle, explains the rationale for its development, and reports the results of initial biomechanical testing. The design goals were to create a tibial tubercle osteotomy that would provide equivalent or better initial fixation compared with traditional techniques, yet would be more flexible, reproducible, accurate, less invasive, and safer. The results of the biomechanical analysis suggest that initial fixation with this novel tubercle transfer technique is as strong as traditional Elmslie–Trillat and anteromedialization procedures. (Journal of Surgical Orthopaedic Advances 25(3):157–164, 2016) Key words: anteromedialization, osteotomy, patella tracking, Q angle, tibial tubercle, trochlear groove

This study sought to identify the 50 most-cited articles in the literature pertaining to the surgical treatment of the hip, which has not yet been done to the authors’ knowledge. In December 2014, an all-years search of the Thompson Institute for Scientific Information Web of Science was conducted for the term ‘‘hip.’’ Articles were sorted from most to least cited. Citations per article ranged from 3176 to 372. The majority of the articles were clinical in nature (64%) and hip arthroplasty was the predominant focus (70%). Eight different journals were included. The majority of the articles were published since the 1990s. Sixty-two percent of the articles originated from U.S. institutions. Only 12% of the articles were level I or II evidence with the majority being level IV evidence (44%). This study highlights the paucity of high-quality evidence, and further well-designed studies are needed to guide the future direction of hip surgery. (Journal of Surgical Orthopaedic Advances 25(3):165–171, 2016) Key words: fifty most-cited; hip, orthopaedics; most-cited articles; top articles; top-cited

Postoperative surgical wound infections are a significant cause of morbidity in orthopaedic surgical cases. To date, there has been no large, single-institution study evaluating orthopaedic surgical wound infection rates and their correlation with seasonality. The hypothesis of this study was that there would be more infections in the warmer months of the year. A retrospective review of all orthopaedic surgery cases at the authors’ institution from 1992 to 2012 was performed of all patients with postoperative wound infections. Patients were placed into two groups on the basis of the date of initial surgical fixation: those occurring in warm months (May–September) and those occurring in cold months (October–April). From July 2010 to June 2012, there was not a statistically significant increase in total infection rate during the months of May to September compared with the months of October to April (0.8% and 0.6%, respectively; p = .131). The hypothesis was rejected: there was no significant increase in postoperative infections during the warmer months. Although previous studies have demonstrated such an increase, the results of this study, which were from a much larger cohort, disagree. (Journal of Surgical Orthopaedic Advances 25(3):172–175, 2016) Key words: infection, orthopaedic, postoperative, seasonal, wound

The purpose of this study was to evaluate for ulnar nerve instability following incrementally widened in situ decompression. A standard release of the ulnar nerve was performed in 16 cadaveric elbows, extending from 7cm distal to the medial epicondyle, and then released proximally for a total of 10 cm in 2-cm increments. Eight of the 16 elbows (50%) displayed subluxation of the ulnar nerve following complete in situ decompression. The rate of subluxation was found to increase with increasing length of proximal decompression. The greatest increase in rate of subluxation was seen beyond 4 cm proximal to the medial epicondyle. Cubital tunnel release should be limited to decompression of only the cubital tunnel if clinical and electrodiagnostic studies indicate that the cubital tunnel is the source of compression. (Journal of Surgical Orthopaedic Advances 25(3):176–179, 2016) Key words: cubital tunnel, epicondylectomy, in situ decompression, subluxation, transposition

physical examination. The purpose of this report was to assess the value of gait analysis in documenting recovery quantitatively. A professional football player underwent gait analysis before and after surgery for a peroneal intraneural ganglion cyst causing a left-sided foot drop. Surface electromyography (SEMG) recording from surface electrodes and motion parameter acquisition from a computerized motion capture system consisting of 10 infrared cameras were performed simultaneously. A comparison between SEMG recordings before and after surgery showed a progression from disorganized activation in the left tibialis anterior and peroneus longus muscles to temporally appropriate activation for the phase of the gait cycle. Kinematic analysis of ankle motion planes showed resolution from a complete foot drop preoperatively to phase-appropriate dorsiflexion postoperatively. Gait analysis with dynamic SEMG and motion capture complements physical examination when assessing postoperative recovery in athletes. (Journal of Surgical Orthopaedic Advances 25(3):180–186, 2016) Key words: athlete, gait analysis, intraneural ganglion cyst

The technological innovation of magnetic resonance imaging (MRI) is ongoing and necessitates recurring reevaluation of appropriateness standards. As evidenced by current standards, T1 data sets provide an essential role to musculoskeletal imaging. According to a recent survey, T1 data sets are increasingly underutilized. This article discusses common and less commonly recognized T1 data set utility. It is suggested that a single non-fat-suppressed T1 data set (in any plane) continues to be standard in routine MRI musculoskeletal imaging. (Journal of Surgical Orthopaedic Advances 25(3):187–194, 2016) Key words: ACR appropriateness standards, fatty degeneration, hemorrhage, infection, marrow, musculoskeletal MRI, pseudoscar, spatial resolution, T1 data sets, therapeutic decision making, tumor

significant risk of complications. Reducing time of surgery, limiting incisions, and minimizing unnecessary surgical exposure are paramount in reducing complications. This article describes the use of a singlestage, single-surgical approach operation for the correction of neuromuscular hip dysplasia. The operation consists of a modified anterolateral approach to the hip joint (modified Watson-Jones approach) to perform a varus derotational proximal femur osteotomy, hinged acetabuloplasty, and soft tissue releases.. (Journal of Surgical Orthopaedic Advances 25(3):195–197, 2016) Key words: cerebral palsy, femoral corrective osteotomy, neuromuscular hip dysplasia, San Diego acetabuloplasty