Volume 26-3, Fall 2017

Burnout and Stress in Medicine in the 21st Century: Catastrophe or Opportunity? - Cormac A. O’Donovan, MD, FRCPI

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Burnout and stress occur in all aspects of life and are considered by many to be increasing in our modern-day culture. These have been studied most often in relation to the workplace and are prevalent in all occupations. As a result, growing numbers of people are consulting physicians for stress-related complaints. Patients may look to their doctors as role models in their quest to obtain optimal physical and mental health. However, the prevalence of burnout in physicians is increasing at a much greater rate than in all other professional groups (1). Anecdotal evidence from social media attributes the issue of burnout to simply being involved in the practice of medicine, rather than premorbid psychiatric dysfunction. Whatever the cause, physicians have rates of depression and other related psychiatric disorders equal or greater to those outside the profession (2). Accurate estimates are difficult to ascertain, since physicians are concerned that acknowledging their situation may prevent them from practicing medicine. This intentional underreporting is in part validated by analyses of several confidential surveys of thousands of physicians, with rates of issues such as substance abuse disorders up to 15% (3).

A Retrospective Comparative Analysis of the Use of Implantable Bone Stimulators in Nonunions - J. Ryan Martin, MD; George Vestermark, MD; Brian Mullis, MD; and Jeffrey Anglen, MDM

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This study details the use of implantable bone stimulators in the setting of nonunion. A retrospective comparative analysis was used to evaluate the efficacy of implantable bone stimulators in achieving union in the setting of atrophic or oligotrophic nonunion by two fellowship-trained orthopaedic trauma surgeons. Initially, 72 patients underwent surgical intervention for nonunion. Twenty-one patients had an implantable bone stimulator placed at the time of nonunion surgery. Thirty-eight patients had a minimum of 1-year follow-up. An implantable bone stimulator was used in 13 patients and 25 patients did not have a bone stimulator. The use of implantable bone stimulators was found to be significantly associated with increased union rates (p = .042). (Journal of Surgical Orthopaedic Advances 26(3):128–133, 2017) Key words: bone stimulators, electrical stimulation, nonunion

Influence of Body Mass Index on Clinical Outcomes in Reverse Total Shoulder Arthroplasty - J. Michael Wiater, MD; Shannon Carpenter, MD; Denise M. Koueiter, MS; David Marcantonio, MD; and Brett P. Wiater, MD

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The purpose of this study was to compare reverse total shoulder arthroplasty (RTSA) outcomes in normal weight, overweight, and obese patients. A RTSA outcomes registry was reviewed for rotator cuff-deficient patients with a minimum 2-year follow-up. Fractures, rheumatoid arthritis, and revisions were excluded. Based on World Health Organization body mass index (BMI) classification, there were 29 normal weight, 50 overweight, and 51 obese patients. All groups demonstrated significant improvements from preoperative to most recent follow-up in function scores, pain, and forward elevation. Obese and overweight groups had significantly worse preoperative rotation than the normal weight group. Postoperatively, there was no significant difference in absolute values or degree of improvement of rotation between groups. There was no significant difference in the incidence of radiographic or clinical complications between groups. Results of this study suggest that BMI has little influence on outcomes or risk of complication following RTSA. Longer-term studies are needed to determine if these results are maintained. (Journal of Surgical Orthopaedic Advances 26(3):134–142, 2017) Key words: body mass index, cuff tear arthropathy, obesity, retrospective comparative study, reverse total shoulder arthroplasty, rotator cuff deficiency

Do Routine Radiographs Obtained at Initial Outpatient Postoperative Visit Change Management? - Eric Grenier, MD, DPT; Dave Tennent, MD; Jean Patzkowski, MD; Joseph Hsu, MD; and Anthony Johnson, MD

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Routine postoperative radiographs are commonly obtained at the initial postoperative visit. The purpose of this study was to demonstrate the clinical utility of routine postoperative radiographs and quantify the radiation exposure and cost to the health care system. All orthopaedic surgeries performed during 2007 at a level I trauma center were retrospectively analyzed. Surgical procedures that were likely to require follow-up radiographs were included. Analysis demonstrated 878 procedures with 471 procedures (54%) receiving initial postoperative radiographs. Routine radiographs were performed in 455 (96.6%) procedures with 4/455 (0.879%) resulting in a change in management. Nonroutine radiographs were performed in 16 (3.40%) procedures with 2/16 (12.5%) triggering a change in management. Subjects receiving radiographs at the initial postoperative visit obtained a mean of 2.54 radiographs per procedure with a mean exposure of 0.199 mSv with a median cost of $29.98 per radiographic series in 2013 Medicare reimbursement dollars. (Journal of Surgical Orthopaedic Advances 26(3):143–147, 2017) Key words: cost utility, postoperative, radiographs

Predictors of Acute Ischemic Stroke After Total Knee Arthroplasty - Mariano E. Menendez, MD; Eric M. Greber, MD; Charles S. Schumacher, MD; and C. Lowry Barnes, MD

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Although acute ischemic stroke (AIS) is a feared medical complication after total knee arthroplasty (TKA), little is known about its incidence and risk factors. The purpose of this retrospective populationbased study using the Nationwide Inpatient Sample (2008–2011) was to determine the incidence and predictors of AIS following TKA. The rate of perioperative AIS was 0.08%. Patients undergoing bilateral TKA were almost three times more likely to develop AIS compared with unilateral TKA patients. The age group with the highest odds of AIS was ⪚85 years. Sex and race and ethnicity were not independently associated with AIS. The comorbidity with the highest risk for AIS was history of stroke, followed by cardiac valvular disease, peripheral vascular disease, atrial fibrillation, complicated diabetes, coagulopathy, and ischemic heart disease. The data in this article might prove useful for preoperative counseling and decision making, resource allocation, and implementation of strategies to minimize the occurrence of AIS after TKA. (Journal of Surgical Orthopaedic Advances 26(3):148–153, 2017) Key words: complications, Nationwide Inpatient Sample, risk, stroke, total knee arthroplasty

Efficacy of Arthroscopic Teaching Methods: A Prospective Randomized Controlled Study - Luke Robinson, MD; Jonathon Spanyer, MD; Zachary Yenna, MD; Patrick Burchell, BS; Andrew Garber, MD; and John Riehl, MD

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Arthroscopic education research recently has been focused on the use of skills labs to facilitate resident education and objective measure development to gauge technical skill. This study evaluates the effectiveness of three different teaching methods. Medical students were randomized into three groups. The first group received only classroom-based lecture. The second group received the same lecture and 28 minutes of lab-based hands-off arthroscopy instruction using a cadaver and arthroscopy setup. The final group received the same lecture and 7 minutes of hands-on arthroscopy instruction in the lab on a cadaver knee. The arthroscopic knee exam that followed simulated a diagnostic knee exam and subjects were measured on task completion and by the number of look downs. The number of look downs and the number of tasks completed did not achieve statistical significance between groups. Posttest survey results revealed that the hands-on group placed significantly more value on their educational experience as compared with the other two groups. (Journal of Surgical Orthopaedic Advances 26(3):154–159, 2017) Key words: arthroscopic education, arthroscopic skills, arthroscopy, hands-on training, residency education, teaching curriculum

Reduction Loss After Distal Radius Fracture Fixation With Locked Volar Plates - Michael M. Vosbikian, MD; Constantinos Ketonis, MD, PhD; Ronald Huang, MD; James A. Costanzo, MD; and Asif M. Ilyas, MD

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Distal radius fractures are among the most common injuries in the upper extremity. While many studies have looked at the maintenance of reduction with volar locking plates, there is a paucity of literature comparing the ability of different plates to maintain reduction over time. This study reviews the ability of various plates to maintain radiographic reduction at union after distal radius fracture treatment. Loss of some aspect of fracture reduction was routinely observed following locked volar plating regardless of implant. However, choice of implant did have a significant impact on final radiographic alignment, particularly with respect to volar tilt and ulnar variance. Yet, selecting between a fixed angle versus a variable angle was not found to make a difference in maintaining reduction. The authors recommend that surgeons take these findings into consideration when selecting a volar locking plate. (Journal of Surgical Orthopaedic Advances 26(3):160–165, 2017) Key words: distal radius fracture, loss of reduction, volar locking plate

A Novel Technique Utilizing a Vastus Lateralis Anchor in Treatment of Chronic Patellar Dislocation After Total Knee Arthroplasty - Allison Mayfield, MD; Vamsi Singaraju, MD; Afshin A. Anoushiravani, MD; Zain Sayeed, MS, MHA; Jamal K. Saleh, BSc; and Khaled J. Saleh, MD, MSc, FRCS(C),
MHCM, CPE

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Extensor mechanism complications involving the patella frequently result in total knee arthroplasty (TKA) failure. Postoperative patellar dislocation may be caused by soft tissue imbalance, improper sizing, and position of the prosthesis. This report describes a case of revision TKA requiring several rounds of soft tissue releases in an effort to treat the patient’s chronic patellar dislocation. In the process, a novel surgical approach was developed for the surgical management of refractory chronic patellar dislocations. Postoperative follow-up at 1, 2, 6, 12, and 24 months indicated no complaints of patellar subluxation or dislocation. Plain films also demonstrated no effusion, fracture, or patellar dislocation on sunrise, anteroposterior, and lateral views. This novel anatomic repositioning of the vastus lateralis around the quadriceps tendon converted a pathologic lateralizing force into a medial stabilizer. On follow-up evaluations, successful patellar tracking without dislocation has been demonstrated. (Journal of Surgical Orthopaedic Advances 26(3):166–172, 2017) Key words: extensor mechanism complications, novel surgical technique, patellar maltracking, revision total knee arthroplasty, total knee arthroplasty, vastus lateralis release

Vascularized Medial Femoral Condyle Graft for Manubrium Nonunion: Case Report and Review of the Literature - William R. Aibinder, MD; Michael E. Torchia, MD; Allen T. Bishop, MD; and Alexander Y. Shin, MD

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Fractures of the sternum are rare. Persistent nonunions, however, can lead to chronic pain and significant functional limitations. The vascularized medial femoral condyle is a versatile tool in the surgeon’s armamentarium. Traditionally, it has been used as a thin corticoperiosteal graft in the treatment of nonunion of tubular bones. Its use as a structural corticocancellous graft has also been expanding. This report presents a case of a patient with a recalcitrant symptomatic nonunion of the manubrium treated with the unique combined corticoperiosteal and corticocancellous vascularized bone graft from the medial femoral condyle and reviews the literature concerning these uncommon nonunions. (Journal of Surgical Orthopaedic Advances 26(3):173–179, 2017) Key words: corticocancellous structural graft, manubrial fracture, manubrial nonunion, medial femoral condyle, vascularized bone graft

Two Patients and Two Knee Cysts - Hale Ersoy, MD, and Stephen J. Pomeranz, MD

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Differential diagnosis of a cystic lesion adjacent to menisci can be a challenge even when the case presents as seemingly straightforward. To ‘‘tell the story’’ as accurately as possible, the radiologist must be familiar with the natural history of these lesions as well as distinctive imaging features and must take all relevant factors into consideration, such as patient’s age, activity level, and surgical history. This article presents two cases to illustrate how imaging features affect the report and management plan. (Journal of Surgical Orthopaedic Advances 26(3):180–182, 2017) Key words: capsulosynovial cyst, ganglion, knee MRI, parameniscal pseudocyst

Distal Radius Skyline View: How to Prevent Dorsal Cortical Penetration - Benjamin C. Taylor, MD; Andy R. Malarkey, DO; Ryan L. Eschbaugh, DO; and John Gentile, DO

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Volar locked plating has become a standard treatment for operative stabilization of distal radius fractures. It is assumed that volar plating portends a low risk of extensor tendon irritation and rupture, especially when compared with dorsal plating constructs; however, extensor tendon tenosynovitis and rupture is a well-described complication after volar plating of the distal radius. Dorsal cortical penetration of screws may go unnoticed with traditional intraoperative fluoroscopic techniques and may contribute to extensor tendon irritation. This article presents the authors’ experience with an additional fluoroscopic dorsal tangential radiograph helping the surgeon ascertain dorsal screw prominence following volar plate fixation. (Journal of Surgical Orthopaedic Advances 26(3):183–186, 2017) Key words: distal radius fracture, dorsal cortex, dorsal cortical view, extensor tendon irritation, skyline view

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