Volume 27-3, Fall 2018

Evaluation of Biofilms on Explanted Shoulder Prostheses Using Functional Biofilm Assay and Scanning Electron Microscopy - Wesley Frevert, MD; Thomas W. Wright, MD; Kevin W. Farmer, MD; Qingping Yang, MS; Aimee M. Struk, MEd, ATC; and Greg Schultz, PhD

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Successfully treating shoulder arthroplasty infection requires diagnosis and bacterial identification. Higher incidence of infection with low-virulence bacteria makes this challenging. This study evaluates shoulder prostheses for infection using sonication and a functional biofilm assay. Nineteen patients undergoing revision shoulder arthroplasty were followed prospectively. Periprosthetic tissue and prosthetic components were obtained during the revision and evaluated with a functional biofilm assay. Results were compared with conventional cultures and laboratory results. Hardware samples were analyzed with scanning electron microscopy. Six of the 19 cases demonstrated growth on the biofilm assay. Three of these had positive conventional culture results and metMusculoskeletal Infection Society (MSIS) criteria for infection. Two other cases met MSIS criteria but demonstrated negative assay and conventional culture results. Of the six cases with positive assay results, three demonstrated evidence of biofilm on scanning electron microscopy. The biofilm assay identifies infections not recognized by traditional culture or MSIS criteria. (Journal of Surgical Orthopaedic Advances 27(3):171–177, 2018) Key words: biofilm, functional biofilm assay, prosthetic infection, shoulder arthroplasty, shoulder prostheses, sonication

Beyond Mirels: Factors Influencing Surgical Outcome of Metastasis to the Extremities in the Modern Era - Elizabeth Scott, MD; Mitchell R. Klement, MD; Brian E. Brigman, MD, PhD; and William C. Eward, MD, DVM

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Mirels scoring system for determining prophylactic stabilization need of skeletal metastases includes a limited number of variables and does not differentiate between procedure types. This study sought to identify additional variables associated with surgical failure, radiographic disease progression, and patient survival. A retrospective review was performed of patients from January 2004 to 2014 who underwent surgical treatment of skeletal metastases of the extremities, were >18 years of age, and had adequate radiographic surveillance. Eighty-nine metastatic bone lesions in 77 patients were included. Mirels score >8 (p = .015) and tumor origin (p = .008) were associated with surgical failure, which was 16.8%. Male gender (p < .001) and use of bone cement (p = .019) were associated with radiographic progression, 43.8% overall. Antiresorptive medications usage (p = .02) was associated with survival. The study concluded that tumor origin may be highly important when considering surgical treatment for metastatic bone disease and antiresorptive medications should be used postoperatively, given an association with survival. (Journal of Surgical Orthopaedic Advances 27(3):178–186, 2018) Key words: complications, extremity metastasis, metastatic disease, Mirels criteria, patient survival, surgery

Player Performance After Returning From a Concussion in the National Football League: A Pilot Study - Scott L. Zuckerman, MD, MPH; Andrew W. Kuhn, BA; Weston Gentry, BS; Andrew Ghaly, BA; Romil D. Patel, BS; Aaron M. Yengo-Kahn, MD; Zachary Y. Kerr, PhD, MPH; and Gary S. Solomon, PhD

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This study aimed to determine if gameplay performance in the National Football League (NFL) is adversely affected after returning to play from a sport-related concussion (SRC). Players who sustained a SRC between the 2007–2008 and 2013–2014 seasons were identified. Concussed players were matched to nonconcussed control players in a 2:1 (control–case) fashion by position, season, experience, age, body mass index, and time missed. Gameplay statistics were recorded for the three games before and after returning from SRC. When compared with the control group, the majority of NFL players did not demonstrate any performance-based deficits on returning to play after SRC. However, concussed quarterbacks (QBs) displayed a reduced QB rating compared with controls. These results indicate that performance immediately following return from SRC may be adversely affected in certain populations and circumstances, though the overwhelming majority of players showed no decline in performance. (Journal of Surgical Orthopaedic Advances 27(3):187–197, 2018) Key words: athletic performance, concussion, football, National Football League, professional sports, return to play

Are Cardiac Complications Associated With Other Adverse Events? A Look at 56,000 Orthopaedic Trauma Patients - Mahesh Yarlagadda, MSPH; Michelle Shen, BA; Abenezer Abraham, MHS; Idine Mousavi; and Manish K. Sethi, MD

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The purpose of this study was to identify those complications for which patients with adverse cardiac events are at risk within the 30-day postoperative period following treatment oforthopaedic trauma cases. This was a retrospective cohort study of orthopaedic trauma patients in the United States between 2006 and 2013. A total of 56,336 patients meeting any one of 89 CPT codes in the American College of Surgeons National Surgical Quality Improvement Program database were used. The main outcome measure was myocardial infarction or cardiac arrest within the 30-day postoperative period. Patients experiencing adverse cardiac events were at a significantly higher risk to have also developed deep surgical site infection, pneumonia, the need for reintubation, pulmonary emboli, a failure to wean off of ventilation, chronic and acute renal failure, urinary tract infection, stroke, deep venous thrombosis, sepsis, and shock. Cardiac complications in orthopaedic trauma patients are relatively uncommon (1.3%); however, cardiac complications are associated with greater risks of other complications, including pneumonia, stroke, and urinary tract infection. (Journal of Surgical Orthopaedic Advances 27(3):198–202, 2018) Key words: adverse events, cardiac, complications, orthopaedic surgery, risk factors, trauma

Management of Femoral Defects Greater Than 5 cm Following Open Femur Fractures: A 12-Year Retrospective Review - Basem Attum, MD; Diana G. Douleh, BS; Paul S. Whiting, MD; Ashley C. Dodd, BS; Michelle S. Shen, BA; Nikita Lakomkin, BSc; William T. Obremskey, MD, MPH, MMHC; and Manish K. Sethi, MD

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This study sought to evaluate the outcomes of patients with osseous defects exceeding 5 cm following open femur fractures. Size of the osseous defect, method of internal fixation (plate vs. intramedullary nail), patient demographics, medical comorbidities, and surgical complications were collected. Twentyseven of the 832 open femur fracture patients had osseous defects exceeding 5 cm. Mean osseous defect size was 8 cm, and each patient had an average of four operations including initial debridement. Average time from injury to bone grafting was 123.7 days. The overall complication rate was 48.1% (n = 13). The most common complications were infection (26.0%, n = 7) and nonunion (41.0%, n = 11). Smoking, diabetes, ASA score, and defect size did not independently increase the risk of a complication. Management of open femur fractures with osseous defects greater than 5 cm is associated with high complication rate, driven primarily by infection and nonunion. (Journal of Surgical Orthopaedic Advances 27(3):203–208, 2018) Key words: large femoral defect, postoperative complication, risk factors

Multilevel Lumbar Fusion Is a Risk Factor for Lower Return to Work Rates Among Workers’ Compensation Subjects With Degenerative Disc Disease - Joshua T. Anderson, MD1; Erik Y. Tye, BA2; Arnold R. Haas, BS, BA3; Rick Percy, PhD3; Stephen T. Woods, MD3; Uri M. Ahn, MD4; and Nicholas U. Ahn, MD5

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Discogenic fusion is associated with variable outcomes, especially if multiple levels are fused. This study sought to determine the impact of fused levels on return to work (RTW) status in a workers’ compensation (WC) setting. Nine hundred thirty-seven subjects were selected for study. The primary outcome was the ability to RTW within 2 years following fusion and to sustain this level for greater than 6 months. Many secondary outcomes were collected. A multivariate logistic regression model was used to determine the impact of multilevel fusion on RTW status. Of the multilevel fusion group, 21.7% met the RTW criteria versus 28.1% of the single-level fusion group (p < .028). Multilevel fusion was a negative predictor of RTW status (p < .041; OR 0.71). Additional negative predictors included prolonged time out of work, male gender, chronic opioid analgesia, and legal representation. Multilevel fusion led to poor clinical outcomes while overall RTW rates were low, which suggests a limited role of discogenic fusion within the WC setting. (Journal of Surgical Orthopaedic Advances 27(3):209–218, 2018) Key words: clinical outcomes, discogenic fusion, lumbar spine, multilevel surgery, return to work, workers’ compensation

Influence of Level 1 Evidence on Management of Clavicle and Distal Humerus Fractures: A Nationwide Comparative Study of Records From 2005 to 2014 - Jennifer Kurowicki, MD; Jacob J. Triplet, DO; Samuel Rosas, MD; Tsun yee Law, MD; Timothy Niedzielak, DO; Enesi Momoh, MD; and Jonathan C. Levy, MD

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The purpose of this study was to examine alterations in national trends managing midshaft clavicle fractures (MCF) and intra-articular distal humerus fractures (DHF) surrounding recent level 1 publications. A retrospective review of the PearlDiver supercomputer for DHF and MCF was performed. Using age limits defined in the original level 1 studies, total use and annual use rates were examined. Nonoperative management and open reduction and internal fixation (ORIF) were reviewed for MCF. ORIF and total elbow arthroplasty (TEA) were reviewed for DHF. A query yielded 4929 MCF and 106,535 DHF patients. A significant increase in ORIF use for MCF following the publication of the level 1 study (p = .002) and a strong, positive correlation (p = .007) were evident. Annual TEA (p = .515) use for DHF was not observed. (Journal of Surgical Orthopaedic Advances 27(3):219–225, 2018) Key words: clavicle fracture, distal humerus fracture, nonoperative treatment, open reduction and internal fixation, PearlDiver, total elbow arthroplasty

Early-Stage Chronic Kidney Disease and Hip Fracture Mortality - Nicholas B. Frisch, MD, MBA; Nolan Wessell, MD; Toufic R. Jildeh, MD; Alexander Greenstein, MD; and S. Trent Guthrie, MD

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Chronic kidney disease (CKD) is a documented risk factor for hip fracture mortality. CKD represents a spectrum of disease and there is no clear evidence differentiating the risk between patients with early versus end-stage CKD. The purpose of this study was to explore the relationship between the stages of CKD and mortality following operative treatment of hip fractures. Four hundred ninety-eight patients were analyzed; 81 were identified as having CKD. This study followed overall patient mortality at 90 days and at 1 year postoperatively. Patients with CKD had higher mortality at both 90 days and 1 year compared with those without CKD (hazard ratio 1.69 and 1.84, respectively). In a subgroup analysis to determine the effect of CKD stage, only stage 3 CKD was associated with increased mortality. The orthopaedic surgeon can play a key role in identifying at-risk patients and help to facilitate additional management. (Journal of Surgical Orthopaedic Advances 27(3):226–230, 2018) Key words: chronic kidney disease, hip fracture, intertrochanteric fracture, mortality

Opioid Prescriptions After Total Joint Arthroplasty - Udai S. Sibia, MD, MBA; Abigail E. Mandelblatt; G. Caleb Alexander, MD, MS; Paul J. King, MD; and James H. MacDonald, MD

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Prescription opioids are commonly prescribed for pain relief after total joint arthroplasty (TJA), yet little is known about the quantity of opioids prescribed after surgery. This study retrospectively reviewed a consecutive series of 1000 TJAs from April 2014 through September 2015. Postoperative opioid prescriptions were quantified using standardized morphine milligram equivalents (MME). Eighty-four percent of total knee arthroplasty (TKA) and 77% of total hip arthroplasty (THA) patients were opioid na¨ıve. The median opioid volume of the first prescription for those undergoing TKA was greater than for those undergoing THA (600 vs. 450 MME), as was the proportion of individuals requiring one or more refills (48% vs. 32%). The total volume of opioids after TKA was also higher than for total hip replacement (870 vs. 525 MME). Patients who were not opioid na¨ıve were prescribed substantially more opioids than their counterparts after TKA (mean 1593 vs. 1064 MME, p < .001) and THA (mean 1031 vs. 663 MME, p < .001). Decreasing opioid use before surgery may decrease total volume of opioid prescriptions after TJA. (Journal of Surgical Orthopaedic Advances 27(3):231–236, 2018) Key words: opioids, total hip arthroplasty, total knee arthroplasty

Remodeling of the Calcaneocuboid Joint in the Acquired Flatfoot - Arthur Manoli II, MD

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There has been debate recently as to whether the lateral column is actually short in the acquired flatfoot. Doubters argue that it is not possible for the lateral column to change in length and actually shorten, especially in the acquired type. In this series of 21 consecutive patients operated on for an acquired flatfoot, the calcaneocuboid joint (CC) had remodeled in all, resulting in the calcaneal side being short, facing laterally and dorsally. These findings give evidence to the rationale for performing a lateral column lengthening (LCL) proximal to the CC joint to treat the acquired flatfoot. When performing a LCL, one should attempt to restore length to the calcaneal side of the joint and to redirect it medially and plantarward. (Journal of Surgical Orthopaedic Advances 27(3):237–245, 2018) Key words: acquired flatfoot, bone remodeling, calcaneocuboid joint, flatfoot, lateral column lengthening, posterior tibial tendon insufficiency

The ‘‘Well-Cap’’ Technique: Screw Insertion for Pelvic Nutrient Foramen Hemostasis - Brendan R. Southam, MD; Frank R. Avilucea, MD; Amanda J. Schroeder, MD; Ryan P. Finnan, MD; and Michael T. Archdeacon, MD, MSE

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Several approaches to the pelvis and acetabulum involve subperiosteal dissection of the iliacus from the internal iliac fossa.Typically bleeding is encountered from the nutrient foramen located near the sacroiliac joint. Bone wax and electrocautery have traditionally been used to achieve hemostasis from this foramen but produce inconsistent results.The authors of this technical tip describe a novel technique of inserting a cortical screw directly into the foramen tocontrol osseous hemorrhage.This technique has been consistently effective at achieving hemostasis in cases of refractory bleeding and has produced no complications. (Journal of Surgical Orthopaedic Advances 27(3):246–250, 2018) Key words: bone wax, cortical screw, hemostasis, iliac nutrient foramen, osseous bleeding

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