Volume 26-4, Winter 2017

Evolution of Health Literacy Research in Orthopaedics and Other Medical Specialties - Kristie Hadden, PhD

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Research has linked patient outcomes to health literacy in many areas of medicine and health over the past three decades. Early research focused on the readability of medical materials that were accessed by patients, followed by association studies establishing health literacy as a contributor to health outcomes, and finally interventions to improve those outcomes identified. Scientific exploration of how the field of orthopaedics can and should address health literacy can be accelerated if investigators follow the path that has been established through the evolution of health literacy in general over the past 30 years. Given that there have been studies on the readability of patient educational materials in orthopaedics, this agenda appears to be underway. Future research in orthopaedics and health literacy should focus on identifying specific outcomes in orthopaedics that are associated with health literacy that could be improved through future, targeted interventions. (Journal of Surgical Orthopaedic Advances 26(4):191–192, 2017) Key words: health literacy, orthopaedics

Evaluating Nonoperative Treatments for Adhesive Capsulitis - Ryan C. Xiao, BS; Joseph P. DeAngelis, MD, MBA; Christopher C. Smith, MD; and Arun J. Ramappa, MD

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Patients commonly present with shoulder complaints to the primary care and orthopaedic setting. The differential includes rotator cuff tears, subacromial impingement, osteoarthritis, and adhesive capsulitis, also known as frozen shoulder. Despite the prevalence of adhesive capsulitis, it is commonly misdiagnosed and management remains unclear. This article reviews the presentation of adhesive capsulitis, presents an overview of the pathophysiology of this poorly understood disease, and evaluates nonoperative treatment options for adhesive capsulitis. (Journal of Surgical Orthopaedic Advances 26(4):193–199, 2017) Key words: adhesive capsulitis, corticosteroid, frozen shoulder, injection, periarthritis, physical therapy

Outcomes of Below-the-Knee Amputations for Chronic Lower Extremity Pain - Shannon Alejandro, MD; Robert D. Teasdall, MD; Martha Holden, AA, AAS; Beth Paterson Smith, PhD; Gregory B. Russell, PhD; and Aaron Scoff, MD

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The study evaluated the physical,mental, and functional outcomes following below-the-knee amputation (BKA) for management of chronic, debilitating lower extremity pain. The hypothesis was that patients who undergo a BKA to alleviate chronic pain achieve a greater level of function, experience decreased pain, and benefit from improved health-related quality of life. Patients who received a BKA attended an orthopaedic clinic and completed questionnaires examining their overall health, functional status, mental health, and pain. Thirty-seven patients were identified as eligible for study participation; 15 agreed to participate. Although most participants continued to experience pain in their residual limb after BKA, they reported their pain decreased to a manageable level. Participants experienced a statistically significant improvement in their perceived physical health. The authors believe a BKA for chronic pain is a reasonable treatment option for patients who continue to experience lower extremity pain after failed medical and surgical management of chronic pain. (Journal of Surgical Orthopaedic Advances 26(4):200–205, 2017) Key words: Below-the-knee amputation, chronic pain, lower extremity, outcomes, trauma

Predictability of Lower Extremity Peripheral Nervous Anatomy - Austin Fares, BS; Nicholas Kusnezov, MD; John C. Dunn, MD; Heather Balsiger, MS; James Showery, BS; Mark Hsiao, MD; and Justin Orr, MD

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Lower extremity nervous anatomy is highly variable. This study sought to determine relationships of lower extremity peripheral nerves to anatomic landmarks. Sixteen well-preserved lower extremities were dissected. The distance from each nerve point of interest to relevant landmarks was measured in standardized fashion. The sciatic nerve divided on average 26.0% ± 5% of the distance from the superior aspect of the fibula to the greater trochanter proximal to the knee joint line [Pearson correlation coefficient (PCC) = 0.764]. The superficial peroneal nerve pierced the crural fascia at an average of 28.0% ± 6% of the fibular length proximal to the lateral malleolus (PCC = 0.718). The deep peroneal nerve emerged between the tibialis anterior and extensor hallucis longus on average 2.7% ± 0.4% of the fibular length proximal to the tibiotalar joint line (PCC = 0.530). While there was substantial variability in the course of lower extremity peripheral nerves, the study found strong correlation with femur and fibula length within each specimen. (Journal of Surgical Orthopaedic Advances 26(4):206–210, 2017) Key words: common peroneal, deep peroneal, lower extremity, nervous anatomy, sciatic, superficial peroneal

Return of Quadriceps Strength After Primary Total Knee Arthroplasty With Single-Radius Knee System: Five-Year Follow-up - Alexander Fokin, MD, PhD, and David Heekin, MD, FACS

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Preoperative quadriceps muscle strength (isometric peak torque) was expectedly lower on the total knee arthroplasty side in comparison with the unaffected contralateral side and it was further reduced after surgery. This reduction continued for up to 6 months postoperatively. After 6 months, muscle strengths exceeded preoperative values and continued to increase for the following 2 years. From 2 to 5 years postoperatively, there was a tendency for decline; however, the quadriceps muscle strength still exceeded preoperative values. On the nonoperative side, the increase in muscle strength was detected 1 year after surgery and it was still noticeable at 5 years. Contralateral side improvement can be explained by the increased mobility of the patients. Knee Society Scores and function scores were significantly increased at 3 months after surgery and were significantly greater than preoperative values 5 years after surgery. SF-12 (physical score) exceeded preoperative values at 3 months and this increase was observed continuously over the 5-year follow-up. (Journal of Surgical Orthopaedic Advances 26(4):211–215, 2017) Key words: quadriceps muscle strength, single-radius knee system, total knee arthroplasty

Blood Transfusion After Primary Total Hip Arthroplasty: National Trends and Perioperative Outcomes - Cory W. Helder, BS; Brian E. Schwartz, MD; Michael Redondo, BS; Hristo I. Piponov, MD; and Mark H. Gonzalez, MD, PhD

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The purpose of this study was to quantify the changes in transfusion rates, both allogeneic blood transfusion (ALBT) and autogenic blood transfusion (ATBT) on a national scale, and determine patient factors associated with transfusions. The National Hospital Discharge Survey was evaluated between 2001 and 2010 for primary total hip arthroplasty (THA) patients and categorized on the basis of transfusion necessity, type, and comorbidity burden. A logistic regression comparison of ALBT, ATBT, and nontransfused patients was performed with respect to patient demographics and in-hospital complications. The proportion of patients requiring any transfusion decreased from an average rate of 22.8% between 2001 and 2005 to 21.2% between 2006 and 2010 (p = .01). ATBT rates decreased (r = –.99) from 11.0% in 2001 to 2.8% in 2010. ALBT rates increased (r = .66) from 14% in 2001 to 16.6% in 2010. The number of patients requiring a blood transfusion after THA decreased in the United States with a trend shifting from ATBT to ALBT. (Journal of Surgical Orthopaedic Advances 26(4):216–222, 2017) Key words: allogeneic transfusion, autologous transfusion, THA, total hip arthroplasty, transfusion

Smartphone-Based Goniometry Accuracy in Clinical Scenarios - Bradford S. Waddell, MD; Neil L. Duplantier, MD; Qingyang Luo, BS, MS; Mark S. Meyer, MD; and Scott F. M. Duncan, MD

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This study compared two popular iPhone-based goniometer applications to the gold standard universal goniometer for the measurement of the hip and knee joints in scenarios mimicking the normal pace of an orthopaedic clinical practice.Three physicians measured hip and knee joint angles 35 times with one of three goniometers: universal 12-inch goniometer, DrGoniometer (iPhone-5 based), and SimpleGoniometer (iPhone-5 based). Data wwere analyzed using Pearson correlation coefficient calculations. Average knee angles measured with the universal goniometer, DrGoniometer, and SimpleGoniometer measured 83.46°, 85.23°, and 80.39°, respectively. The smartphone-based goniometers had moderate agreement with the universal goniometer in the knee (r > .322). Average hip angles measured with the universal goniometer, DrGoniometer, and SimpleGoniometer measured 62.34°, 60.87°, and 59.34°, respectively. The smartphone-based goniometers had moderate agreement with the universal goniometer in the hip (r > .168). Smartphone-based goniometers gave accurate, with weak to moderate correlation, measurements for the knee and hip. (Journal of Surgical Orthopaedic Advances 26(4):223–226, 2017) Key words: goniometer, hip, knee, smartphone

Predictors of Carpal Tunnel Release After Open Distal Radius Fracture - Jaehon M. Kim, MD; Mitchel B. Harris, MD; David Zurakowski, PhD; Wanjun Liu, MD; Jesse B. Jupiter, MD; Joung Heon Kim, BS; and Mark S. Vrahas, MD

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The purpose of this investigation was to determine the incidence and identify the predictors of carpal tunnel release (CTR) after open fractures of the distal radius (DRF). Patients with clinical symptoms of persistent median nerve neuropathy that required CTR were analyzed for risk factors. One hundred thirty-nine open DRFs (107 grade I, 23 grade II, 9 grade III) met the inclusion criteria. The incidence of CTR was 13.7% in all open DRFs (19 out of 139). Multivariable logistic regression analysis identified four predictors: male sex [odds ratio (OR) = 8.8, p = .001], type III Gustilo and Anderson grade (OR = 6.2, p = .04), OTA fracture type C (OR = 3.8, p = .03), and the application of external fixation (OR = 14.0, p = .02). The probability of CTR, determined by preoperative variables, was 80% with three factors present and 2% with no risk factors. High-risk patients may be identified who may benefit from closer perioperative surveillance and possibly carpal tunnel release. (Journal of Surgical Orthopaedic Advances 26(4):227–232, 2017) Key words: carpal tunnel release, complications, distal radius fractures, median nerve compression, open fracture

Intramedullary Bone Graft Harvest Using Reamer-Irrigator-Aspirator System: A Case Series - Brian Waterman, MD; Shaunette Davey, DO; Enes Kanlic, MD; and Amr Abdelgawad, MD

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Autogenous iliac crest bone grating has been the gold standard. Recently, intramedullary bone graft harvest using a reamer-irrigator-aspirator (RIA) had been gaining more interest among orthopedic surgeons. Twenty-four RIA bone graft harvesting procedures in 23 consecutive patients with nonunions were included. The mean age was 37.8 years. Rates of perioperative complications, secondary surgical procedures, and union were assessed for all patients. At mean 10.1 months follow-up, three donor site complications occurred (12.5%), including two fractures (8.3%). Eighteen patients (78%) progressed to radiographic union, three (13%) were lost for follow-up, and two (9%) failed to achieve union. Mean reamer size was 13.7 mm (mode, 14.0 mm), producing an average volume of 39.4 mL (range, 15–90 mL) bone graft. While RIA bone grafting results in predictably high rates of union, patients should be counseled extensively about fracture risk. Tibial RIA may be less optimal as a primary source of bone grafting. (Journal of Surgical Orthopaedic Advances 26(4):233–238, 2017) Key words: bone graft, iatrogenic complication, intramedullary, nonunion, open fracture, reamerirrigator- aspirator, RIA, tibia fracture

Risk of Obtaining Routine Cultures During Presumed Aseptic Orthopaedic Procedures - MAJ Matthew A. Napierala, MD; MAJ Jaime L. Bellamy, DO; COL Clinton K. Murray, MD; CPT Richard K. Hurley, Jr., MD; Joseph C. Wenke, PhD; and Joseph R. Hsu, MD

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Treating patients with antibiotics that are selected based on routine cultures obtained from presumed aseptic orthopaedic procedures may lead to an increased risk of antibiotic-related complications without reducing the rate of late deep infection. Routine cultures obtained from 60 of 169 procedures resulted in 23 (38.3%) positive and 37 (61.7%) negative results. Twenty-two patients (13.5%) developed late infections. Seven of 14 patients with positive cultures, who were treated with antibiotics, developed a late infection, while two of nine patients with routine cultures, who received no antibiotic treatment, developed a late infection. Six of 37 patients with negative cultures and seven of 109 patients with no cultures developed a late infection. In patients who developed late deep infection, the microorganism isolated on routine culture only corresponded to the microorganism causing late infection 55.5% of the time. Of all patients treated with antibiotics, seven (29%) experienced an antibiotic-related complication (p = .01). (Journal of Surgical Orthopaedic Advances 26(4):239–245, 2017) Key words: antibiotic-related complications, aseptic, orthopaedic procedures, routine cultures

Radiation Exposure to the Orthopaedic Surgeon and Efficacy of a Novel Radiation Attenuation Product - Emily M. Mayekar, MD; Aysel Bayrak, BS; Smiresh Shah, MD; and Alfonso Mejia, MD, MPH

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The purpose of this study was to examine the intraoperative radiation dosage to different body parts and to determine the effectiveness of a new lightweight radiation-attenuating fabric (XPF) versus lead, the current standard. For 51 cases involving fluoroscopy, one attending orthopaedic surgeon wore a set of three dosimeters at various locations. Per each set of three, one dosimeter was shielded with a swatch of XPF, one was placed underneath the lead apron, and one was left exposed. The total dose of radiation was tabulated per body site and the percent attenuation was calculated for both XPF and lead. There was no statistically significant difference in the percent of radiation attenuation by lead and XPF (p = .47). The use of XPF produced 57.83% reduction in weight compared with lead when adjusting for total surface body area. XPF can be used for operating room personnel and patients, providing effective protection from radiation. (Journal of Surgical Orthopaedic Advances 26(4):246–249, 2017) Key words: ALARA, C-arm, fluoroscopy, lead, radiation, XPF

Patient Satisfaction After Bilateral Thumb Carpometacarpal Osteoarthritis Surgery - Arnold B. Alqueza, MD; Sigrid Fostvedt, MD; W. Emerson Floyd, MS; and Jesse B. Jupiter, MD

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This study seeks to determine whether patients with bilateral thumb carpometacarpal osteoarthritis were sufficiently satisfied with their surgeries to choose to undergo surgery again. The null hypothesis is that patients are dissatisfied with the results of the first surgery. Out of 46 living patients meeting enrollment criteria, 41 were enrolled and evaluated using the Disabilities of the Arm, Shoulder and Hand (DASH) score and the Enneking musculoskeletal score. The average DASH score was 17.37. The average Enneking musculoskeletal score was 88.21. Of 41 patients, one expressed unwillingness to undergo the next procedure, three indicated that they would reluctantly do surgery again, and four were satisfied. The remaining 33 subjects were enthused with their functional result, expressing willingness to undergo the procedure again. At an average follow-up of 44.9 months, most patients are satisfied with bilateral thumb carpometacarpal surgery for osteoarthritis. Consent for the contralateral surgery implies that the outcome of the first surgery was sufficiently acceptable to seek surgery on the contralateral thumb. (Journal of Surgical Orthopaedic Advances 26(4):250–256, 2017) Key words: carpometacarpal osteoarthritis, patient satisfaction, surgical outcomes, thumb osteoarthritis

Implementation of a Service-Specific Template Integrating Objective Structured Clinical Examination and Accreditation Council for Graduate Medical Education Milestones: One Institution’s Experience David J. Ruta, MD; Mark S. Morris, MD; Matthew T. Pigott, MD; J. Sybil Biermann, MD; Todd A. Irwin, MD; and James R. Holmes, MD

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The Accreditation Council for Graduate Medical Education (ACGME) orthopaedic milestones require detailed, frequent resident evaluations. This institution desired a cost-effective objective structured clinical examination (OSCE) to facilitate these evaluations. Data were collected as a prospective, uncontrolled observational study. The OSCE was completed by residents entering and exiting the foot and ankle rotation during postgraduate years 2 and 4. Physician assistants functioned as standardized patients. Statistical analyses were performed using paired and independent t tests. The OSCE was implemented using reliable, low-cost modalities and has facilitated milestones evaluations. Preliminary data show 4th-year residents performed higher in prerotation global assessment with a standardized patient and written exam (p < .03). Second-year residents showed improvement in the written exam on rotation completion (p = .03). Using this methodology, institutions may establish similar cost-effective OSCEs as feasible evaluative solutions to satisfy milestone requirements. The authors believe this tool may be modified for any specialty. (Journal of Surgical Orthopaedic Advances 26(4):257–261, 2017) Key words: ACGME milestones, competency, OSCE; objective structured clinical examination, OSCE, resident evaluation

Return to Duty Following a Tibial Tubercle Osteotomy CPT - Tony Locrotando, DO; CPT K. Aaron Shaw, DO; CPT Jeremy M. Jacobs, MD; and LTC(Ret) John A. Bojescul, MD

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Anterior knee pain is a common complaint among military members, with a negative impact on operational readiness. A tibial tubercle osteotomy is one treatment option for select etiologies of anterior knee pain and has been reported to result in high rates of return to activity. A retrospective review of active duty service members undergoing a tibial tubercle osteotomy at a single army medical center was performed. Thirteen active duty service members were identified as undergoing a tibial tubercle osteotomy. Nine patients remained on active duty at 1 year following surgery. After 24 months, only four service members remained on active duty, while seven were medically retired. Seventy-five percent of patients who underwent concomitant cartilaginous procedure underwent a medical discharge. A small subset of active duty military personnel who underwent a tibial tubercle osteotomy was able to remain on active duty, but concomitant cartilaginous procedures did not appear to be compatible with retention on active duty because of the high physical demands placed on soldiers. (Journal of Surgical Orthopaedic Advances 26(4):262–265, 2017) Key words: active duty, knee pain, military, patellofemoral, tibial tubercle osteotomy

Plantar Fibromatosis and Other Fibroblastic and Fibrohistiocytic Soft Tissue Tumors of the Foot - Hale Ersoy, MD, and Stephen J. Pomeranz, MD

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Plantar fibromatosis, also known as Ledderhose’s disease, is a benign fibroblastic disorder of plantar aponeurosis, more specifically the medial side of the foot arch. Magnetic resonance imaging (MRI) has an important role in the diagnosis, staging, and determining the deep extension found in advanced, aggressive forms of plantar fibromatosis, thereby guiding appropriate clinical and surgical management. This case report aims to provide radiologists and clinicians with simple guidelines for the differential diagnosis of the fibroblastic and fibrohistiocytic soft tissue tumors of the foot with the emphasis on the MRI findings. (Journal of Surgical Orthopaedic Advances 26(4):266–270, 2017) Key words: desmoplastic fibromatosis, fibroma of tendon sheath, Ledderhose’s disease, MRI, nodular fasciitis, plantar fibromatosis, proliferative fasciitis

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