Volume 27-2, Summer 2018

Use of 360° Feedback to Develop Physician Leaders in Orthopaedic Surgery - Paul J. Gregory, PhD; David Ring, MD2; Harry Rubash, MD; and Larry Harmon, PhD

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Twelve service chiefs participated in 360° feedback surveys and coaching as part of a departmental leadership development activity. Changes in the means of both composite survey scores and individual behavioral item scores over time were evaluated with paired t tests. Agreement between self-rating and rating of others was evaluated with unpaired t tests. There was a nonsignificant change in overall behavioral performance (composite scores) for the physician leaders (n D 12) from baseline [mean (M) D 68.7, standard deviation (SD) D 16.9] to 1-year follow-up (M D 73.1, SD D 11.4), but the performance of four of the leaders with the lowest scores improved substantially. There was a significant improvement in ‘‘identifies mistakes respectfully’’ when comparing baseline to 1-year follow-up. Ten behaviors were identified as improvement opportunities and nine behaviors were identified as behavioral strengths at baseline. Surgeon leaders were in agreement with others’ ratings on 68% of behaviors, underestimated 20% of behaviors, and overestimated 13% of behaviors. (Journal of Surgical Orthopaedic Advances 27(2):85–91, 2018) Key words: 360° feedback, interpersonal and communication skills, leadership effectiveness, multisource feedback, orthopaedic leaders, PULSE 360, self–other agreement

Analysis of References Used in Orthopaedic Self-Assessment Exams - Sean P. Moroze, MD; Andrew S. Murtha, MD; Jessica C. Rivera, MD; and Chad A. Krueger, MD

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Orthopaedic surgery board certification and maintenance of certification requires success on standardized tests and ongoing continuing medical education. This study aims to identify the most impactful resources for preparation for and maintenance of board certification. Questions included in the Orthopaedic Self-Assessment Exams (SAEs) from 2009 to 2014 were examined with the type and age of reference materials cited for each question. There were 4479 total citations. There were 289 journals and 95 textbooks identified. The Journal of Bone and Joint Surgery (15% of citations), Journal of the American Academy of Orthopaedic Surgeons (11%), and Clinical Orthopaedic and Related Research (6%) were the most frequently cited journals. The average age of cited articles was 8.2 years. These data demonstrate that certain orthopaedic journals are consistently the most commonly cited references for SAEs and could also be expected to be the highest yield references for knowledge acquisition and exam preparation. (Journal of Surgical Orthopaedic Advances 27(2):92–97, 2018) Key words: ABOS Part I, maintenance of certification, OITE, self-assessment exam

Interest in Orthopedic Surgery Residency: A Google Trends Analysis - Tochukwu C. Ikpeze, MS, and Addisu Mesfin, MD

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Google Trends, a powerful online search tool, was used to evaluate the association between the United States applicant pool for orthopedic surgery residency and Internet queries for orthopedic residency and orthopedic salary. From 2006 to 2015, searches for orthopedic salary and orthopedic residency were conducted by Google Trends. Data from the National Residency Match Program (NRMP) in the same time period was plotted and subsequently compared to the Google Trends results. From 2006 to 2015, Google Trends demonstrated an increase in orthopedic residency queries with the largest increase between 2008 and 2010. Orthopedic salary searches increased over the study period, with the sharpest increase from 2008 to 2009. NRMP demonstrated an increase over the study period in U.S. medical school orthopedic surgery applicants and positions filled. The Google Trends analysis mirrored the data from the NRMP, suggesting that online search tools could be of important predictive value for medical students’ interest in orthopedic surgery residency. (Journal of Surgical Orthopaedic Advances 27(2):98–101, 2018) Key words: Google Trends, medical student, orthopedic residency, orthopedic salary

Marginal Skin Flap Advancement: A Technique to Optimize the Skin Graft Interface Following Tumor Resections - Wayne A. Chen, MD, and William G. Ward, MD

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Split-thickness skin graft (STSG) for soft tissue defects is often required following tumor resections. There is often a step-off with subcutaneous adipose tissue along the defect margins. This review of 20 years of experience was performed to determine the success of marginal skin flap advancement, a simple surgical technique addressing this issue. Seventy-one cases were identified that underwent sarcoma resection and this technique. Marginal skin flap advancement decreased the defect size from 217 š 162 cm2 to 128 š 101 cm2 (p < .001). STSG was successfully applied in 69 cases (97%) with a mean 96% take of the skin graft. Although 29 cases (41%) had wound healing complications of any nature, only 11 (15%) required a secondary operation. Marginal skin flap advancement, in conjunction with vacuum-assisted closure therapy, decreases the defect surface area requiring STSG by 41% and provides an excellent reconstructive option for soft tissue defects following sarcoma resections. (Journal of Surgical Orthopaedic Advances 27(2):102–108, 2018) Key words: sarcoma, soft tissue reconstruction, split-thickness skin graft, vacuum-assisted closure, wound healing

How Often Are Protocols Followed at Level I Trauma Centers? - Richard W. Nicolay, MD; Akhil A. Tawari, MD; Harish Kempegowda, MD; Michael Suk, MD; and Brian Mullis, MD

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This study analyzes adherence to an evidence-based protocol established at two level I trauma centers to determine its effect on clinical decision making. The centers’ trauma databases were retrospectively studied and 51 patients with long bone fractures were identified who required revascularization and orthopaedic intervention and survived long enough to receive an index intervention. An arterial shunt was the protocol’s first step; the preprotocol rate of shunting was 9.5%, while the postprotocol rate of shunting was 3.3%. The protocol’s next step was external fixation; among the cases managed without a shunt, external fixation was the index intervention in 63.2% of the preprotocol cases and 31.0% of the postprotocol cases. Definitive vascular surgery was routinely performed before external fixation in 28.6% of the preprotocol cases and 56.7% of the postprotocol cases. This study demonstrates that this evidence-based protocol had no effect on the management of patients with combined orthopaedic and vascular injuries. Protocols should never supersede clinical judgment, but poor protocol adherence may represent a need for trauma centers to routinely review their protocols’ compliance and efficacy. (Journal of Surgical Orthopaedic Advances 27(2):109–112, 2018) Key words: ACS, adherence, American College of Surgeons, arterial, clinical practice guideline, compliance, level I, long bone, open fracture, protocol, shunt, trauma center, type IIIC open fracture, vascular injury

Predictors of Acute Complications Following Traumatic Upper Extremity Amputation - Tuesday F. Fisher, MD; Nicholas A. Kusnezov, MD; Julia A. Bader, PhD; and James A. Blair, MD

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Current literature is deficient in its description of acute complications following major traumatic upper extremity amputations (UEAs). This study sought to identify acute complications following major UEAs by the 2009–2012 National Trauma Databank to extract demographics, comorbidities, concomitant injuries, and surgical characteristics for major traumatic UEA patients. Multivariate analyses identified significant predictors of mortality and major systemic complications. Major traumatic upper extremity amputations were identified in 1190 patients. Major systemic complications occurred in 13% of patients and most often involved pulmonary (7.4%) or renal (4.7%) systems. Overall in-hospital mortality rate was 11%. Male sex, prehospital systolic blood pressure less than 90, Injury Severity Score > 16, and initial Glasgow Coma Scale > 8 were risk factors for complications or in-hospital mortality. Acute replantation was performed in 0.12%. Systemic complications following major traumatic UEA typically affect the pulmonary system. Injury or patient-dependent factors did not influence acute treatment with revision amputation versus replantation. (Journal of Surgical Orthopaedic Advances 27(2):113–118, 2018) Key words: polytrauma, replantation, systemic complications, upper extremity amputation

Hip and Knee Arthroplasty Outcomes After Abdominal Organ Transplantation - Neil L. Duplantier, MD; Amy E. Rivere, MD; Ari J. Cohen, MD ; and George F. Chimento, MD

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This case control study retrospectively compares patients who underwent solid organ transplantation and total joint replacement with a control group that only underwent joint replacement. The study compares 42 transplant patients who underwent liver or kidney transplantation and total hip arthroplasty (THA) or total knee arthroplasty (TKA) to a matched group of 42 nontransplant patients who underwent only THA or TKA. The transplant cohort had significantly more complications (18) than the nontransplant cohort (7) (p D .022). Renal transplant patients had 6.75 times higher odds (95% CI, 1.318–34.565) of experiencing a complication compared with liver transplant patients. The average time between transplant and joint replacement was 2 š 4.9 years. Transplant patients undergoing joint arthroplasty at an average of 2 years posttransplant are at higher risk for complications than a matched cohort of patients undergoing only joint arthroplasty, with renal transplant patients being more at risk for complications than liver transplant patients. (Journal of Surgical Orthopaedic Advances 27(2):119–124, 2018) Key words: arthroplasty, hip, kidney, knee, liver, transplant

Functional Outcomes of Isolated Gastrocnemius Recession - Cory Messerschmidt, MD; Anuj Netto, MD; William R. Barfield, PhD; Christopher Gross, MD; and William McKibbin, MD

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The effects of gastrocnemius recession on strength and function are underreported. This prospective study reports strength and functional effects after isolated gastrocnemius recession. Patients (n D 20) underwent an isolated gastrocnemius recession for foot and ankle conditions with associated gastrocnemius or gastrocnemius–soleus contracture. Eight patients prospectively underwent range of motion (ROM) and Biodex testing preoperatively and at 3 and 6 months postoperatively. Foot Function Index (FFI) assessed functional outcomes. Repeated measures analysis of variance with Bonferroni post hoc testing compared variables across three time intervals. Control and operative sides were compared with t tests. Mean patient age was 61.1 š 13.3 years. Significant improvement in FFI was observed at 3 and 6 months (p D .001). Ankle dorsiflexion improved 11° between preoperative and 6-month postoperative intervals (p D .018). No differences were observed in Biodex testing. Results demonstrate improved ROM and FFI of the gastrocnemius recession between preoperative and 6-month postoperative intervals for isolated gastrocnemius and gastrocnemius–soleus contracture. (Journal of Surgical Orthopaedic Advances 27(2):125–130, 2018) Key words: equinus contracture, gastrocnemius contracture, gastrocnemius recession, Strayer procedure

Self-Citation Does Not Appear to Artificially Inflate Orthopaedic Journal Ranking - Michael P. Hawkinson, MD; Chad A. Krueger, MD; and John Carroll, BS

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Until recently the impact factor has been considered the tool of choice among the many available for evaluating the relative prestige of journals. However, the inclusion of self-citations in its calculation has led some to question its validity. The SCImago Journal Rank is a relatively new rating system that excludes self-citation. This study analyzed the top 30 orthopaedic journals to determine which journals had higher self-citation rates and if those rates had any correlation with their impact factors and SCImago Journal Ranks. The study verified that self-citing was more common in specialty journals compared with general orthopaedic journals (p D .002). The results demonstrate a more positive correlation between self-citation and SCImago Journal Rank than impact factor. This finding suggests that the impact factor’s inclusion of self-citations should not be thought to artificially inflate the impact factor of the subspecialty journals that most commonly cite their own work. (Journal of Surgical Orthopaedic Advances 27(2):131–135, 2018) Key words: impact factor, orthopaedics, SCImago Journal Rank, self-citation

Effectiveness of Thrombin–Collagen and Autologous Platelet-Rich Plasma in Total Hip Arthroplasty Hemostasis: A Prospective, Randomized, Controlled Trial - Eric N. Bowman, MD, MPH; Michael P. McCabe, MD; and Kevin B. Cleveland, MD

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Bovine derived thrombin–collagen combined with autologous platelet-rich plasma (PRP) has shown promise as a topical, surgical hemostatic agent. The purpose of this study was to determine the effect of thrombin–collagen–PRP on perioperative blood loss in total hip arthroplasty (THA). A prospective, single-blinded, randomized, controlled study comparing thrombin–collagen–PRP use to standard treatment was performed. All patients undergoing elective primary THA for osteoarthritis by a single physician at a single institution were included. Thirty-nine patients were enrolled. There was no significant difference in estimated total blood loss or blood transfusions received. There was no significant difference in operative blood loss, drain output, daily postoperative hematocrit, change in hematocrit, or length of stay. There is insufficient evidence to support the routine use of a topical thrombin–collagen–autologous PRP hemostatic agent in primary total hip arthroplasty. (Journal of Surgical Orthopaedic Advances 27(2):136–141, 2018) Key words: collagen, hemostasis, platelet-rich plasma, PRP, thrombin, total hip arthroplasty

Immobilization Versus Observation in Children With Toddler’s Fractures: A Retrospective Review - Lauren C. Leffler, MD; Stephanie L. Tanner, MS; and Michael L. Beckish, MD

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While long leg casts have been historically recommended for immobilization of toddler’s fractures, short leg casts are often used by treating physicians. Others question whether any immobilization is necessary because of the internal stability provided by the thickened periosteum of pediatric bones. The purpose of this study is to review the results of toddler’s fractures treated with long leg casts, short leg casts, or without immobilization. Eighty-five patients were included in a retrospective review of nondisplaced spiral or oblique tibial shaft fractures in children under 6 years old from 2007 to 2012. Treatments included long leg casts (19), short leg casts (59), and no immobilization (7). Average time to ambulation was 15.5 days. There were 11 casting complications. Only one patient, in a short leg cast, had measurable displacement or angulation. There were no complications reported in the nonimmobilized group. The results suggest that toddler’s fractures can be effectively treated with short leg casts or without immobilization. (Journal of Surgical Orthopaedic Advances 27(2):142–147, 2018) Key words: immobilization, return to ambulation, tibial shaft fracture, toddler’s fracture

Risk of Opioid-Related Adverse Events After Primary and Revision Total Knee Arthroplasty - Jeff Gonzales, MD, MA; Scott T. Lovald, PhD; Edmund C. Lau, MS; and Kevin L. Ong, PhD

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Postoperative analgesia after primary total knee arthroplasty (TKA) and revision knee arthroplasty (RKA) can be reliant on the use of opioids and may lead to opioid-related adverse events (ORAEs). This study evaluated the risk of ORAEs following TKA and RKA using the 5% Medicare claims (2010–2013) database. There were 41,702 TKA and 3817 RKA patients who met the inclusion criteria. At 90 days, respiratory complications were the most common complication (TKA: 6.12%; RKA: 8.01%), followed by postoperative nausea and vomiting (TKA: 2.86%; RKA: 3.95%), and urinary retention complications (TKA: 2.79%; RKA: 3.20%). For TKA, risk factors for respiratory complications included older age, lower socioeconomic status, more comorbidities, obesity, chronic obstructive pulmonary disease, white race, and patients in the Midwest and West (vs. South) (p 002). The average Medicare payment for treating complications within 90 days of a TKA was $6206 and $6222 following RKA. Awareness risks for ORAEs in select patients can assist in developing a multimodal postoperative pain control and patient education protocols. (Journal of Surgical Orthopaedic Advances 27(2):148–154, 2018) Key words: adverse event, opioid, pain, revision knee arthroplasty, total knee arthroplasty

Wound Closure With Acute Dermatotraction - James W. Barnes, MD; Garth Sherman, BS; and Jonathan Dubin, MD

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Many described techniques take advantage of the viscoelasticity of the human integument to assist in primary closure of fasciotomy wounds. A retrospective chart review was performed on eight patients with a total of 17 incisions who underwent fasciotomy for acute compartment syndrome. Wounds were closed with delayed primary closure (DPC). Patients were males with a mean age of 40 years (range, 21–64). Fasciotomy mean wound length and width at attempted closure was 16.1 š 6 cm and 6.3 š 2 cm, respectively. Mean time to closure after fasciotomy was 3.9 days (range, 2–8). All wounds healed, at a mean of 18.3 š 2.6 days. Patients were followed for a mean of 21 weeks (range, 3–52). The described novel sequential suturing technique can achieve closure with low risk of major complications; 100% wound healing was achieved. When used judiciously, the technique presented can achieve reliable results in selected fasciotomy wound healing. (Journal of Surgical Orthopaedic Advances 27(2):155–159, 2018) Key words: acute wounds, compartment syndrome, delayed primary closure, dermatotraction, fasciotomy closure

Coronal Plane Deformity Correction in Distal Radius Fracture Fixation With the Volar Locking Plate - Arun Aneja, MD, PhD; T. David Luo, MD; Eric B. Lerche, DO; Jason J. Halvorson, MD; and Eben A. Carroll, MD

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The goal of treatment for distal radius fractures is anatomic articular reduction and restoration of coronal and sagittal plane alignment, rotation, and angulation of the metadiaphyseal component of these fractures. This article presents a reproducible technique for restoring coronal plane alignment of the metadiaphyseal component of the fracture using an indirect reduction maneuver leveraging the volar locking plate as an indirect reduction aid. After applying an appropriately sized volar locking plate, the first screw is placed in the center of the shaft of the plate. Next, the distal row of subarticular locking screws is placed to neutralize a reduced articular surface. The shaft screw is subsequently loosened, and two Freer elevators are used to rotate the plate, indirectly translating the distal articular block and achieving improved coronal plane alignment. Last, the remaining diaphyseal screws are applied to appropriately neutralize the fracture. (Journal of Surgical Orthopaedic Advances 27(2):160–163, 2018) Key words: coronal deformity, distal radius, fracture, locking plate, technique, volar

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