Volume 26-2, Summer 2017

Axillary Intraneural Ganglion Cysts - Kartik G. Krishnan, MD, PhD; Nikhil K. Prasad, MB, ChB; Kimberly K. Amrami, MD; Paul J. Kurtin, MD; and Robert J. Spinner, MD

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Aside from affecting the stability of the glenohumeral joint, tears in the joint capsule can give rise to extraneural (paralabral) and, very rarely, intraneural ganglion cysts. This report presents the first two cases of axillary intraneural ganglion cysts in the literature with magnetic resonance imaging. Both cases were incidentally noted to have coexisting lesions (lymphadenopathy from an undifferentiated malignancy and suprascapular nerve entrapment, respectively). This report reinforces the applicability of the articular theory for intraneural ganglion cysts at a novel site. (Journal of Surgical Orthopaedic Advances 26(2):69–74, 2017) Key words: arthroscopy, axillary nerve, intraneural ganglion cyst, labral tear

Reverse Total Shoulder Arthroplasty for Complex Three- and Four-Part Proximal Humerus Fractures in Elderly Patients: A Review - George F. Lebus V, MD; Hassan R. Mir, MD, MBA; and Brandon D. Bushnell, MD, MBA

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Complex proximal humerus fractures in elderly patients represent a difficult problem for orthopaedic surgeons. Classically, treatment methods have included nonoperative management, open reduction and internal fixation, and hemiarthroplasty. Outcomes of nonoperative management for these complex fractures have been poor, and results of traditional operative techniques are variable at best. Over the past several years, reverse total shoulder arthroplasty (RTSA) has been increasingly employed in these injuries with encouraging results. RTSA may represent a valuable treatment option for select patients. This article reviews the existing data on RTSA in the treatment of complex proximal humerus fractures in the elderly population as well as the authors’ experience with this technique. (Journal of Surgical Orthopaedic Advances 26(2):75–80, 2017) Key words: proximal humerus fracture, reverse total shoulder arthroplasty

Insurance-Mandated Stay Prolongs Hospitalization Following Total Shoulder Arthroplasty - Krysten M. Bell, MD; Mark E. Mildren, MD; Montri D. Wongworawat, MD; Torrey Parry, MD; Christopher M. Jobe, MD; and Wesley P. Phipatanakul, MD

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Medicare currently requires a 3-night hospitalization for a patient to be considered for skilled nursing facility (SNF) placement. The purpose of this study was to analyze the relationship between length of stay and (a) insurance status and (b) readmission rates in Medicare-age patients undergoing primary total shoulder arthroplasty. A retrospective review of 251 primary consecutive total shoulder arthroplasty cases was performed. In patients discharged to SNF, Medicare insurance was associated with a significantly longer hospital stay (p < .001) compared with patients with private insurance. Readmission rates for Medicare and private insurance patients were similar at 30 and 90 days after surgery (p = 1.000). Ninety-five percent of Medicare patients discharged to SNF had a prolonged hospital stay primarily to fulfill the 3-night requirement. These findings call into question the necessity of the current 3-night inpatient hospitalization requirement for facility placement following total shoulder arthroplasty. (Journal of Surgical Orthopaedic Advances 26(2):81–85, 2017) Key words: hospital readmission, length of stay, shoulder arthroplasty, 3-night rule, value-based health care

Damage Control Plating in Open Tibial Shaft Fractures: A Cheaper and Equally Effective Alternative to Spanning External Fixation - Paul S. Whiting, MD; Phillip M. Mitchell, MD; Aaron M. Perdue, MD; Arnold J. Silverberg, BS; Sarah E. Greenberg, BA; Rachel V. Thakore, BS;
Vasanth Sathiyakumar, BA; Hassan R. Mir, MD, MBA; William T. Obremskey, MD, MMHC, MPH; and Manish K. Sethi, MD

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The purpose of this study was to evaluate damage control plating (DCP) as an alternative to external fixation (EF) in the provisional stabilization of open tibial shaft fractures. Through retrospective analysis, the study found 445 patients who underwent operative fixation for tibial shaft fractures from 2008 to 2012. Twenty patients received DCP or EF before intramedullary nailing with a minimum follow-up of 3 months. Charts and radiographs were reviewed for postoperative complications. Hospital charges were reviewed for implant costs. Nine patients (45%) with DCP and 11 patients (55%) with EF were analyzed. There was no significant difference in the complication rates. The mean implant cost of DCP was $1028, whereas mean EF construct cost was $4204. Therefore, DCP resulted in significant cost savings with no difference in complication rates, making it a valuable alternative to EF for the provisional stabilization of open tibial shaft fractures. (Journal of Surgical Orthopaedic Advances 26(2):86–93, 2017) Key words: damage control plating, external fixation, open tibia fracture

A Process Improvement Evaluation of Sequential Compression Device Compliance and Effects of Provider Intervention - Jason A. Beachler, MD; Chad A. Krueger, MD; and Anthony E. Johnson, MD

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This process improvement study sought to evaluate the compliance in orthopaedic patients with sequential compression devices and to monitor any improvement in compliance following an educational intervention. All non–intensive care unit orthopaedic primary patients were evaluated at random times and their compliance with sequential compression devices was monitored and recorded. Following a 2-week period of data collection, an educational flyer was displayed in every patient’s room and nursing staff held an in-service training event focusing on the importance of sequential compression device use in the surgical patient. Patients were then monitored, again at random, and compliance was recorded. With the addition of a simple flyer and a single in-service on the importance of mechanical compression in the surgical patient, a significant improvement in compliance was documented at the authors’ institution from 28% to 59% (p < .0001). (Journal of Surgical Orthopaedic Advances 26(2):94–97, 2017) Key words: compliance; mechanical prophylaxis, venous thromboembolism

Intercondylar Fractures of the Distal Humerus in Patients Younger Than 20 Years: Capsulectomy Results - W. Andrew Eglseder, MD, and Ebrahim Paryavi, MD, MPH

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Few reports in the literature have been dedicated to young patients with distal fractures of the humerus, and few have addressed subsequent indications to improve range of motion (ROM). This article is a retrospective review of the elbow flexion–extension ROM in 31 patients (age, 12–19 years) who had been treated with open reduction and internal fixation of intercondylar fractures of the distal humerus at a level I trauma center from 1991 through 2013. The ROM of patients who underwent capsulectomy was compared with that of those who did not. Main outcome measures were ROM in degrees and need for capsulectomy. Nine (29%) of the 31 patients had elected to undergo capsulectomy. Eleven did not require capsulectomy. The final flexion–extension arc was improved by 31° compared with the precapsulectomy ROM but did not attain the ROM of those who did not undergo capsulectomy. (Journal of Surgical Orthopaedic Advances 26(2):98–101, 2017) Key words: capsulectomy, intercondylar fracture of distal humerus, range of motion

Fluoroscopic Exposure With Use of Mini-C-Arm During Routine Hand Surgery: A Prospective Comparison of Hand Versus Eye Radiation Dosage - Mark L. Wang, MD, PhD; C. Edward Hoffler, MD, PhD; Asif M. Ilyas, MD; Pedro K. Beredjiklian, MD; and Charles F. Leinberry, MD

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Radiation exposure with use of intraoperative fluoroscopy is a potential orthopedic occupational risk factor. The purpose of this study was to perform a prospective comparison of hand versus eye radiation exposure associated with mini-C-arm utilization and to test the hypothesis that routine mini-C-arm does not yield hand or eye dosages exceeding current recommended levels. Over a 12-month period, hand and eye radiation exposure was prospectively measured in a single board-certified hand surgeon using mini-C-arm fluoroscopy. Twenty-five cases were performed utilizing mini-C-arm fluoroscopy. Average monthly hand radiation dosage (45.81±14.49 mrem) was significantly higher (p = .01) than eye radiation dosage ( Key words: cataracts, eye radiation, fluoroscopy, hand radiation, mini-C-arm, radiation exposure

Pin Malposition in External Fixator Stabilization of Combat-Related Pelvic Fractures - Mark P. Coseo, MD; Dustin J. Schuett, DO; Kevin M. Kuhn, MD; and Joseph Bellamy, MD

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The purpose of this study was to compare the accuracy of pin placement in patients with unstable pelvic fractures undergoing either iliac crest or supra-acetabular external fixation. A retrospective review was performed of computed tomography (CT) scans and injury characteristics for all patients presenting to a North Atlantic Treaty Organization Medical Treatment Facility with data entered into the Department of Defense Trauma Registry from January 2008 to October 2013 who underwent pelvic external fixation for unstable pelvic ring injuries. Thirty-two patients were analyzed. Sixteen patients underwent damage control iliac crest-based and 16 patients underwent supra-acetabular-based external fixation. There was no significant difference in patient characteristics at presentation between the two groups. Pin malposition rate on CT scan was 50/64 (78.1%) for the iliac crest group and 3/32 (9.4%) for the supraacetabular group. Pinmalpositionwas correlatedwith increasing Injury Severity Score, Abbreviated Injury Scale (AIS) head score, and AIS face score. The review concluded that iliac crest-based external fixation has a significantly higher rate of pin malposition than supra-acetabular-based external fixation. (Journal of Surgical Orthopaedic Advances 26(2):106–110, 2017) Key words: external fixation, iliac crest,musculoskeletal trauma, pelvic fracture, supra-acetabular, war trauma

Scapulothoracic Joint Dysfunction - Joseph Ugorji, DO, and Stephen J. Pomeranz, MD

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Scapulothoracic derangements are often overlooked and hidden within the clinical fog created by complex back, shoulder, and rib symptoms. This study reviewed 200 magnetic resonance imaging and computed tomography studies dedicated for scapular imaging between January 2010 and May 2016. This article discusses scapulothoracic pathologies and imaging findings. (Journal of Surgical Orthopaedic Advances 26(2):111–115, 2017) Key words: baseball, lower infraserratus bursa, scapular dyskinesia, scapulothoracic bursitis, scapulothoracic crepitus, scapulothoracic joint, snapping scapula syndrome, subserratus bursa, throwing athlete, trapezoid bursa, upper infraserratus bursa

First Ray Elevation Osteotomy for Cavovarus Foot: Dorsal Oblique Wedge Osteotomy - Pablo Wagner, MD; Diego Zanolli, MD; Andres Keller, MD; Cristian Ortiz, MD; Ximena Ahumada, MD; Patricia Paz, MD1; Beat Hintermann, MD; and Emilio Wagner, MD

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This article presents a new technique that allows a controlled and stable correcting osteotomy of the first metatarsal for cavovarus deformity. The preoperative planning and the surgical technique are described. (Journal of Surgical Orthopaedic Advances 26(2):116–119, 2017) Key words: cavovarus, elevation, foot, osteotomy, treatment

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