Volume 26-1, Spring 2017

The objective of this study was to examine the risk to the sciatic nerve and femoral artery during open passage of cerclage wires and to evaluate the safest techniques. After a standard lateral approach, cerclage passes along the femur were made in cadaveric specimens. Distance to the sciatic nerve and femoral artery was recorded. Careful technique resulted in an increase in distance to the sciatic nerve and femoral artery. There was an increase in the distance to the femoral artery with passes in an anterior to posterior direction. There was decreased distance to structures proximally and distally. There was a trend toward increased safety with smaller passers. Open cerclage wiring of the femur is safest if proper technique is used, care is taken at the proximal and distal ends of the femur, passes are made in an anterior to posterior direction, and the smallest cerclage passer that can be passed is utilized. (Journal of Surgical Orthopaedic Advances 26(1):1–6, 2017) Key words: anatomy, artery, cerclage, femur, fracture, sciatic

Multiple methods for surgical fixation of distal radius fractures exist, including percutaneous pinning with Kirschner wires and open reduction volar plating. Despite increased costs, the hypothesis of this study was that open reduction and volar plating does not provide improved outcomes over wire fixation. Following Transparent Reporting of Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a meta-analysis of randomized controlled trials was conducted comparing these two methods with regard to clinical outcomes, radiographic parameters, and complications. Seven trials with a total of 858 patients were included. Plating was not favored over pinning with regard to clinical outcomes and radiographic parameters. Pinning was associated with a higher superficial infection risk compared with plating, though the risk of repeat surgery was not different. It was concluded that Kirschner wire fixation, which may be associated with lower costs, is associated with similar clinical and radiographic outcomes when compared with volar plate fixation, although wire fixation is associated with higher superficial infection risk. (Journal of Surgical Orthopaedic Advances 26(1):7–17, 2017) Key words: distal radius, internal fixation, Kirschner wire, meta-analysis, percutaneous, pin, plate

A systematic review of the literature was performed to compare complications of endoscopic and open carpal tunnel release. Techniques were further subdivided into traditional open, limited open, singleportal endoscopic, and two-portal endoscopic. This study also compared incidence of complications in each group based on chronological periods of data collection. The study found that endoscopic release has a higher incidence of transient nerve injury. There was also an increased incidence of superficial palmar arch injuries in the endoscopic group in the 1960–1990 time period as compared with the 1991–2000 and 2001–2012 periods. No difference was found in scar complications between open and endoscopic groups. While vascular injuries have decreased over time, the rate of nerve injuries has not changed since the introduction of endoscopic release. This higher incidence of transient nerve injury and lack of increased skin complications should be weighed when deciding between open and endoscopic techniques. (Journal of Surgical Orthopaedic Advances 26(1):18–24, 2017)

Ambulatory surgery centers are the preferred setting for many procedures formerly performed in a hospital setting. This study sought to determine whether outpatient total elbow arthroplasty (TEA) is as safe as inpatient TEA. A retrospective analysis was performed of inpatient (IP) versus outpatient (OP) TEA by a single surgeon over a period of 18 years. Demographic, social, and comorbidity measures as well as complication rates were analyzed and stratified by IP or OP status. Bivariate comparison showed increased prevalence of coronary artery disease in the OP group (32% vs. 7%) and increased age in the IP group (68 years vs. 58 years). All other demographic, social, and comorbidity factors were comparable between the IP and OP groups, although more infections were seen in the IP group. The surgeons’ initial learning curve occurred mostly within the IP group. Most important, no difference in complication rate was observed between the IP and OP groups. (Journal of Surgical Orthopaedic Advances 26(1):25–28, 2017) Key words: ambulatory, arthroplasty, complication, elbow, outpatient

Cannulated screws are widely used for the treatment of slipped capital femoral epiphysis; however, the optimal choice and number of implants have not been clearly defined. Studies have shown that two screws are biomechanically superior to a single screw in load-to-failure testing, but the fatigue performance of different screw designs has not been investigated. This study compared the fatigue characteristics of fully and partially threaded cannulated screws. Partially and fully threaded 7.3-mm screws were subjected to cyclic loading on a custom testing fixture. Screws were tested in three-point bending, with a force between 20 N and 780 N applied at 10 Hz. Cycles to failure were recorded, as well as force and displacement data. Partially threaded screws had statistically higher cycles to failure than fully threaded screws (p = .001). Partially threaded screws demonstrated higher cycles to failure when subjected to loading, suggesting greater resistance to fatigue failure under similar clinical conditions. (Journal of Surgical Orthopaedic Advances 26(1):29–32, 2017) Key words: fatigue failure, SCFE, screw fixation, slipped capital femoral epiphysis

There are no data-supported recommendations on how proximal is too proximal for retrograde nailing (RGN). At six level 1 trauma centers, patients with femur fractures within the proximal one-third of the femur treated with RGN were included. This article describes a proximal segment capture ratio (PSCR) and nail segment capture ratio to evaluate RGN of proximal fractures. The study included 107 patients. The average follow-up was 44 weeks. There were two nonunions and three malunions. There was no significant difference between PSCR of 0.3 or less and need for secondary procedures or time to full weight bearing (p > .05). In this study, a smaller (< 0.3) PSCR was not associated with an increased number of complications. A higher Orthopaedic Trauma Association classification was predictive of malunion and increased time to union. These data demonstrate that retrograde nailing is safe and effective for the treatment of supraisthmal femur fractures. (Journal of Surgical Orthopaedic Advances 26(1):33–39, 2017) Key words: femur fracture, femur malunion, proximal femur, retrograde intramedullary nail

A retrospective review was performed of all shoulder arthroplasties with patients grouped on the basis of transfusion protocol time period. Group 1 had transfusions if postoperative hematocrit was <30. Group 2 had transfusions based on symptomatic anemia. Bivariate analysis of transfusion factors and multivariate analysis of significant bivariate factors were performed. Protocol change decreased transfusion rates from 16% (group 1, 153 arthroplasties) to 8%(group 2, 149 arthroplasties). Reverse shoulder arthroplasty (RTSA) transfusion rate decreased dramatically (from 24% to 5%). Transfusion rates after total shoulder arthroplasty (TSA) were low (4%) and after revision arthroplasty were high (21% C 27%) in both groups. Age, gender, heart disease, preoperative hematocrit, diagnosis, and estimated blood loss (EBL) were risk factors on bivariate analysis. Failed arthroplasty and fracture diagnoses carried high transfusion rates (25% C 28%). Logistic regression showed that low preoperative hematocrit, increased EBL, revision arthroplasty, and heart disease were transfusion risk factors. Protocol based on symptomatic anemia results in low transfusion rates after primary TSA and RTSA. (Journal of Surgical Orthopaedic Advances 26(1):40–47, 2017) Key words: blood transfusion, revision shoulder arthroplasty, shoulder arthroplasty, symptomatic anemia, transfusion protocol

This study investigated whether current Medicare reimbursements for orthopaedic trauma procedures correlate with complications. A total of 18,510 patients representing 33 orthopaedic trauma procedures from 2005 to 2011 were studied. Adverse events and Medicare payments for each orthopaedic trauma procedure were collected. Linear regressions determined correlations between complications and Medicare payments for orthopaedic trauma procedures. A weak correlation between Medicare payments and complications was found for all procedures (r = .399, p = .021). A 1.0% increase in complications was associated with a payment increase of only $100. There were no correlations between complications and reimbursements for upper extremity (p = .878) and lower extremity (p = .713) procedures. A strong correlation (r = .808, p = .015) existed for hip and pelvic fractures, but a 1.1% increase in hip and pelvic complications correlated with only an increase of $100 in reimbursements. This study is the first to show that Medicare payments are not strongly correlated with complications, therefore demonstrating the potential risks of a bundled payment system for orthopaedic trauma surgeons. (Journal of Surgical Orthopaedic Advances 26(1):48–53, 2017) Key words: bundled payment, Medicare, reimbursement, risk

Milwaukee shoulder syndrome (MSS) is a rare, rapidly destructive arthropathy associated with calcium hydroxyapatite crystal deposition. This condition is a combination of rotator cuff tear, osteoarthritic changes, noninflammatory joint effusion containing crystals, synovial hyperplasia, cartilage and subchondral bone destruction, and multiple osteochondral loose bodies. This article discusses pathophysiology, clinical presentation, differential considerations, and magnetic resonance imaging findings of MSS. (Journal of Surgical Orthopaedic Advances 26(1):54–57, 2017) Key words: apatite-associated destructive arthritis, calcium pyrophosphate crystals, HADD, hydroxyapatite crystal, Milwaukee shoulder syndrome, MRI

Posteriorly based osteochondral lesions of the talus (OCLTs) are relatively rare, and when they are symptomatic and not amenable to traditional arthroscopic treatment techniques, they may require osteochondral graft transfer procedures, such as the osteochondral autograft transfer system (OATS) procedure. Historically described osteotomies to gain perpendicular access to these OCLTs, while excellent techniques, present many possible postoperative morbidities. This technical tip describes the use of a prone position midline Achilles tendon-splitting approach, a well-described approach to the posterior ankle and hindfoot, to perform osteochondral autograft transfer without need for any malleolar osteotomies. At 12 months postoperatively, the patient reported a pain visual analog score of 1.0 (75% improvement) and demonstrated an American Orthopaedic Foot and Ankle Society ankle and hindfoot score of 90 (38% improvement). At 24 months postoperatively, the patient had near complete resolution of ankle pain and had returned to normal recreational physical activities. (Journal of Surgical Orthopaedic Advances 26(1):58–64, 2017) Key words: Achilles tendon, approach, osteochondral lesion, posterior, split, talus