Volume 27-4, Winter 2018

Posterior Fibula of Pes Cavus: Real or Artifact? Answer Based on Cross-Sectional Imaging - Sean C. Peden, MD; John C. Tanner III, MD; and Arthur Manoli II, MD

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Cavus foot deformity is an often overlooked source of pathology. In the cavus foot, the fibula is often noted to be posterior on lateral radiographs. The objective of the study was to determine with threedimensional imaging if the fibula is truly posterior or just artifact. Using physical examination, patients with cavus were selected and compared to controls. An established technique to determine fibular position on computed tomography and magnetic resonance imaging was used to compare the study group to controls. Thirty-six cavus feet were compared to 36 controls. The average cavus fibula was noted to be 72% more posterior than the fibula of control patients and the difference in axial malleolar index was significant between the groups. This study shows that the cavus fibula is truly more posterior in patients with high arches. (Journal of Surgical Orthopaedic Advances 27(4):255–260, 2018) Key words: axial malleolar index (AMI), fibula, peek-a-boo heel sign, pes cavus

Ascorbic Acid and Its Clinical Role in Orthopaedic Surgery - Tianyi David Luo, MD; Anthony J. Marois, MD; Thomas L. Smith, PhD; Jeffrey S. Willey, PhD; and Cynthia L. Emory, MD

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Ascorbic acid (vitamin C) is an essential micronutrient with evidence supporting its role in bone formation, tissue repair, and collagen production. Its clinical importance to the field of orthopaedic surgery has yet to be fully defined. Several observational studies have shown improved bone density and reduced hip fracture risk with supplementation. Its effect on bone fracture and soft tissue injury has been promising in animal models, but is not adequately studied in human trials. Results have been mixed concerning its role in chondroprotection and osteoarthritis treatment. Evidence suggesting reduced incidence of complex regional pain syndrome following distal radius fracture when treated with adjuvant ascorbic acid has prompted much debate but has received an endorsement of moderate support from the American Academy of Orthopaedic Surgeons. Given its potential benefits, low cost, and safety profile, ascorbic acid supplementation warrants consideration by orthopaedic surgeons in the treatment of a variety of musculoskeletal injuries (Journal of Surgical Orthopaedic Advances 27(4):261–268, 2018) Key words: ascorbic acid, bone health, cartilage, complex regional pain syndrome, fracture healing, ligaments, osteoarthritis, osteoblast differentiation, tendons, vitamin C

Opioid Prescribing in the Pediatric Orthopaedic Trauma Population - Robert T. Simril III, BS; Brian P. Scannell, MD; Meghan K. Wally, MSPH;
Michael H. LeFlore, BS; Rachel B. Seymour, PhD; Joseph R. Hsu, MD; and the PRIMUM Group

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The purpose of this article is to describe opioid prescribing patterns for children with orthopaedic injuries. A retrospective chart review was conducted on pediatric orthopaedic trauma patients (n = 124) who were discharged from the hospital or emergency department or had a clinic visit during a 1-month period. Patient demographics, prescription specifics, injury details, and fracture fixation information were collected. Results show that most children received opioids after injury (82.3%). While children undergoing operative fixation typically received opioids, only 39.5% with closed reduction did. Hydrocodone–acetaminophen accounted for 93% of prescriptions, but adolescents were more likely to receive other drugs. There was a significant trend of increasing daily dosage with increased age; 36.73% of adolescents received > 50 morphine milligram equivalents per day. Children with orthopaedic injuries are typically prescribed opioids; older children more commonly receive higher dosages. Further study is needed to define prescribing trends across facility and specialty types to aid in development of standardized prescribing guidelines. (Journal of Surgical Orthopaedic Advances 27(4):269–273, 2018) Key words: opioids, orthopaedic trauma, pain, pediatrics

Comparison of Hand Drills for the Insertion of Skeletal Traction Pins - Cameron A. Roth, MD, MHS; Stefan Turkula, MD; David A. Fuller, MD; and Kenneth W. Graf, MD

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Skeletal traction pins are inserted as part of emergent stabilization of lower extremity fractures. The purpose of this study is to compare two drill options: a reusable store-bought drill and a single-use, sterilely packaged drill. The reusable drill and disposable drill were compared by having volunteers insert traction pins within a foam bone, fully encased, knee joint model using both systems. The two drill types were evaluated on three measures: user satisfaction, time required for insertion of the pins, and cost. The disposable drill received a statistically significant higher user satisfaction score and a statistically significant faster time to pin insertion. The per-use cost of the disposable system was found to be higher. For skeletal traction pin insertion, the disposable, single-use drill was found to be superior to the reusable drill in user satisfaction and time required for traction pin insertion. Institutional cost analysis favors the disposable system because of the more predicable charge capture, while the per-use cost of the disposable system remains higher. (Journal of Surgical Orthopaedic Advances 27(4):274–276, 2018) Key words: cost analysis, damage control orthopaedics, skeletal traction, traction pins, trauma, user satisfaction

Impact of Fluoroscopically Guided Bone Biopsy on Antibiotic Management of Osteomyelitis in the Lower Extremity - Joseph G. Mammarappallil, MD, PhD; Thorsten M. Seyler, MD, PhD; Leon Lenchik, MD; Scott D. Wuertzer, MD; and Johannes F. Plate, MD, PhD

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This study evaluated the impact of fluoroscopically guided percutaneous bone biopsy on altering antibiotic regimens in lower extremity osteomyelitis. Eighty-eight patients who received fluoroscopically guided bone biopsies were identified. There was bacterial growth in 28% of bone biopsies overall. The rate of positive culture was decreased in patients started on empiric antibiotics before biopsy (23%) compare with patients without empiric antibiotics (44%). Antibiotic regimens were changed in 24% of patients overall in response to culture data. The majority of positive biopsy cultures (76%) but minority of negative biopsy cultures (3%) resulted in a change to antibiotic regimens. The impact of percutaneous bone biopsy on antibiotic management of adult patients with osteomyelitis diagnosed by magnetic resonance imaging is modest and is decreased in patients previously started on antibiotics. Despite its modest impact, bone biopsy results can provide useful information in antibiotic management, especially when positive (Journal of Surgical Orthopaedic Advances 27(4):277–280, 2018) Key words: fluoroscopy, IR guided, musculoskeletal MRI, osteomyelitis, percutaneous bone biopsy

Comparison of Microbial Count on Various Surfaces in Operating Rooms at Different Times of the Day - Graysen Petersen-Fitts, MD; Andrew Gambone, MD; Alexandria Sherwood, BS; James Whaley, MD; Danielle L. Katz, MPH; Diego J. L. Lima, MD; and Vani Sabesan, MD

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The purpose of this study was to determine the degree of microbial contamination of surfaces in the operating room (OR) and to understand the relationship between time and location of contamination. Five OR surfaces were sampled at two time points on three consecutive Mondays and Thursdays. Each sample was cultured on a blood agar plate and introduced to a liquid nutrient broth. The most sterile surface was the OR lights with only one positive growth sample at each time. At both times, the most commonly contaminated surface was the staff keyboard. Coagulase-negative staphylococcus was the most common isolated species. Contamination rate of OR surfaces was not affected by time of day or day of the week. Simple cleaning and daily decontamination of staff keyboards can significantly reduce bacterial burdens and should be of primary importance to optimize OR sterility. (Journal of Surgical Orthopaedic Advances 27(4):281–285, 2018) Key words: bacteria, contamination, operating room, time of day

Excess Readmission-Based Penalty: Is Arthroplasty Different From the Other Outcomes? - Raj N. Manickam, MS; Stavros G. Memtsoudis, MD, PhD; Yi Mu, PhD; Jeehyoung Kim, MD; Abhijit V. Kshirsagar, MD, MPH; and Heejung Bang, PhD

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Whether factors not under a hospital’s control affect readmissions remains intensely debated in the context of the Centers for Medicare & Medicaid Services’ Hospital Readmission Reduction Program. This study aimed to evaluate the potential effects of poverty, race, and hospital volume on excess readmissions, with >3000 hospitals participating in ‘‘Hospital Compare.’’ Correlations between excess readmission ratios for five eligible outcomes (including hip and knee arthroplasty) were assessed with the three area and hospital-level factors: poverty, race (percent of black population), and hospital volume (number of discharges). Correlation coefficients of the ratios with race were approximately r = 0.2, consistently larger than those with poverty (r = 0–0.1), and those with volume were r = 0 to –0.5. Hip and knee arthroplasty had unique findings: null correlation with poverty (r ≈ 0), largest variability, and strong monotonicity with volume (r ≈ –0.5). The percent of Hispanic population showed negligible correlations in secondary analysis. Penalty assessment and hospital profiling should consider areas with high percentages of black population and a small volume of hospitals and providers of hip and knee surgery. (Journal of Surgical Orthopaedic Advances 27(4):286–293, 2018) Key words: black, CMS, hip, Hospital Readmission Reduction Program, knee

Insulin-Dependent Diabetes Is an Independent Risk Factor for Complications and Readmissions After Total Joint Replacements - Udai S. Sibia, MD, MBA; Adam S. Weltz, MD; James H. MacDonald, MD; and Paul J. King, MD

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This study examined the risk for postoperative complications, reoperations, and readmissions for patients with insulin-dependent diabetes mellitus (IDDM), patients with non-insulin-dependent diabetes mellitus (NIDDM), and patients without diabetes undergoing total joint replacements (TJRs). The American College of Surgeons National Surgical Quality Improvement Program database was queried for all primary TJRs in 2015. The study identified 78,744 TJRs (84.1% nondiabetic patients, 12.0% NIDDM, and 3.9% IDDM). Multiple logistic regression models identified IDDM as an independent risk factor for increased blood loss, myocardial infarctions, pneumonia, renal insufficiency, urinary tract infections, and readmissions when compared with both NIDDM and nondiabetics. Risk for wound complications and reoperations were comparable between all three groups. IDDM increases the risk for medical complications and readmissions after TJRs. Physicians must counsel patients on the increased risks associated with IDDM before elective surgery and provide appropriate medical support for these patients. (Journal of Surgical Orthopaedic Advances 27(4):294–298, 2018) Key words: American College of Surgeons National Surgical Quality Improvement Program (ACSNSQIP), insulin-dependent diabetes mellitus, total joint replacements

Treatment of Pediatric Osteoid Osteomas Not Amenable to Radiofrequency Ablation: A Retrospective Review of Surgical Outcomes - Thomas Sanders, MD; Doris E. Wenger, MD; Ali Ashraf, MD; Amy L. McIntosh, MD; Anthony A. Stans, MD; William J. Shaughnessy, MD; Andre J. van Wijnen, PhD; and A. Noelle Larson, MD

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The purpose of this study is to describe the surgical treatment of osteoid osteomas in a pediatric cohort of patients who were found not to be candidates for percutaneous ablative therapies. Medical records for 29 pediatric patients who were treated surgically for osteoid osteomas were reviewed. Reasons for surgical management included diagnostic uncertainty or lesions that were in close proximity to an articular surface or neurovascular structure. Twenty-eight patients experienced complete symptom resolution. Surgical treatment may still be indicated in a select group of osteoid osteoma patients who are not candidates for percutaneous treatment. (Journal of Surgical Orthopaedic Advances 27(4):299–302, 2018) Key words: osteoid osteoma, pediatric, radiofrequency ablation, recurrence

Does Traction Decrease the Need for Open Reduction in Femoral Shaft Fractures Treated Within 24 Hours? - Michael R. Koerner, MD; Lindsay E. Young, MD; Ashley Daniel, MD; Stephanie L. Tanner, MS; Brett Crist, MD; Thomas M. Schaller, MD; Kyle J. Jeray, MD; Michael S. Sridhar, MD; and John D. Adams, Jr., MD

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This study evaluates whether preoperative skeletal traction reduces the need for open reduction in femoral shaft fractures treated with intramedullary nailing (IMN) within 24 hours. A retrospective review was conducted of femoral shaft fractures undergoing IMN within 1 day of admission. Primary outcome was an open reduction at the time of IMN. Secondary outcomes were blood loss and transfusion requirements. One hundred eighty-four patients were analyzed, 106 in the knee immobilizer group and 78 in the skeletal traction group. Skeletal traction did not reduce the need for an open reduction. The knee immobilizer group required open reduction in 13% (14/106) compared with 14% (11/78) in the skeletal traction group, which was not significant (p = .89). Blood loss and transfusion rates were similar between groups. Skeletal traction does not appear to reduce the need for open reduction at the time of IMN for femoral shaft fractures treated within 1 day of admission. (Journal of Surgical Orthopaedic Advances 27(4):303–306, 2018) Key words: femur fracture, intramedullary nail, knee immobilizer, skeletal traction, temporary stabilization

What Factors Influence Compliance With Sequential Compression Devices in an Orthopaedic Unit: A Quality Assurance Observational Study - Avionna L. Baldwin, BS; Sean J. McMahon, MBA; and Addisu Mesfin, MD

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The purpose of this study was to determine the compliance rate with sequential suppression devices (SCDs) of patients admitted to an orthopaedic unit of a level I trauma center. A quality assurance observational study was conducted over a 4-week period (June/July 2015). Three observations were performed per 24-hour period (0700, 1300, 1900 hours). ‘‘Full SCD compliance’’ was defined as the SCD ordered, on and functioning properly at the time of observation. Of the 1356 observations in 109 patients, 434 (32%) were fully compliant with SCD prophylaxis. SCD compliance in trauma patients was higher (21%) as compared with elective surgical patients (10%) (p < .0001). Morning observations had the highest compliance rate (38.3%), whereas the afternoon (23.5%) and evening observations (33.1%) had less compliance rates (p < .0001). There was a significantly higher compliance rate on weekdays (33.9%) as compared with weekends (28%) (p < .03). The overall low compliance level (32%) indicates compliance challenges and not the modality of the prophylaxis as the cause (Journal of Surgical Orthopaedic Advances 27(4):307–311, 2018) Key words: compression device, compliance, DVT, DVT prophylaxis, orthopaedic surgery, PE, SCD, sequential compression device

Return to Duty in Military Members Following Surgical Treatment of Incomplete Femoral Neck Fractures - LT Clare E. Griffis, MD; LT Vanna Rocchi, DO; LCDR Grant Cochran, MD; and CDR Kevin M. Kuhn, MD

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The purpose of this study was to determine whether active duty military members treated surgically for incomplete femoral neck stress fractures (FNSFs) return to duty. A retrospective review of 53 patients was evaluated to determine the rate of return to duty (RTD) related to sex, branch of service, side of fracture, and signs of femoroacetabular impingement (FAI). Signs of FAI were measured and compared to RTD. Sixty-seven percent of the sample population did not return to duty. Eighty-three percent of Marine Corps members did not return to duty and 18% of Navy active duty members did not return to duty. This finding was statistically significant (p < .001). Average follow-up was 25 months. Surgical fixation of FNSFs does not seem to affect the ability to return to active duty; however, it did prevent progression to complete or displaced fracture in all of the study patients. (Journal of Surgical Orthopaedic Advances 27(4):312–316, 2018) Key words: femoral neck stress fractures, femoroacetabular impingement, functional outcomes, hip/pelvis/thigh, military members, surgical fixation

Patient Attitudes Toward Local Anesthesia With or Without Sedation for Minor Hand Procedures - Seth H. Bowman, MD; Taylor A. Horst, MD; Kyle P. Kokko, MD, PhD; William Barfield, PhD; and Eric Angermeier, MD

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The purpose of this study was to assess patient preferences in this population with respect to anesthesia for minor hand procedures. This prospective cohort study assessed 183 patients undergoing minor hand surgery to determine their preferences for local-only anesthesia with or without sedation and the reasons for their choices. Fifty-six percent of patients preferred local anesthesia with sedation, 43% preferred local-only anesthesia, and 2% had no preference. Caucasian patients were 2.7 times more likely to choose local-only anesthesia. Other than race, no other demographics showed statistical significance with respect to anesthesia preference. Patients with a prior history of local-only anesthesia were half as likely to choose it again for future surgeries. Use of an IV and awareness of procedure were the most consistent factors affecting patient decisions. Nearly half of the patients preferred local-only anesthesia. Further prospective studies evaluating outcomes and patient satisfaction with these two types of anesthesia are necessary. (Journal of Surgical Orthopaedic Advances 27(4):317–320, 2018) Key words: anesthesia, carpal tunnel, hand, preferences, trigger finger

Effect of Facility on Operative Costs of Total Ankle Arthroplasties - Christopher E. Gross, MD; Daniel Scott, MD, MBA; Richard C. Mather III, MD; and James A. Nunley II, MD

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Cost containment and bundled payments are becoming increasingly important in health care. The purpose of this study was to investigate if ambulatory surgery centers (ASCs) can deliver lower cost care and to identify sources of those cost savings in total ankle replacement (TAR). A cost identification analysis of primary TAR was performed at a single academic medical center. Multiple costs and time measures were taken from 730 consecutive patients over 5 years at either an inpatient facility or ASC. The relationships between total cost and operative time and multiple variables were examined, using multivariate analysis and regression modeling. The mean operative cost over 4 years was significantly greater at the inpatient facility than at the outpatient facility. Significant cost drivers of this difference were inpatient, physical and occupational therapy, pharmacy, and operating room costs. The most significant predictor of cost was facility type. This study supports the use of ASC facilities to achieve efficient resource use in the operative treatment of total ankle arthroplasties (Journal of Surgical Orthopaedic Advances 27(4):321–324, 2018) Key words: ambulatory surgery center, ankle arthroplasty, cost

Location of the Popliteal Artery in Knee Extension on Magnetic Resonance Imaging - Matt Simons, MD; Nicholas Schraut, MD; Vincent Moretti, MD; Greg Klazura, MD; Donald Chuang, MD; Amit Parekh, MD; and Mark Gonzalez, MD, PhD

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The goal of this study was to define the course of the popliteal artery (PA) and determine any variability among different patient demographics; by identifying risk factors for injury, surgeons can decrease patient morbidity and mortality. Ninety-four adult magnetic resonance imaging studies of the knee were reviewed. In extension, the artery is at most 7.87 mm posterior and 4.83 mm lateral to the midline below the tibial plateau. Proximally, the artery is more anterior and midline. With increasing body mass indexes, the artery is more posterior at any level. At the femur, 1 cm above the distal articular surface, the artery was more posterior in younger patients; 1 cm below the joint line, it was more posterior in elder patients. Attention should be given during total knee arthroplasty, revision surgery, lateral meniscal repair, posterior cruciate ligament reconstruction, high tibial osteotomy, and fixation of tibial tubercle fractures. Proximally, the PA is more anterior and midline, placing it at significant risk during these procedures. (Journal of Surgical Orthopaedic Advances 27(4):325–328, 2018) Key words: arthroplasty, knee, location, MRI, popliteal artery

Distal Femoral Flexion Closing Wedge Osteotomy for Treatment of Failed Chronic Distal Femoral Extension Osteotomy in a Patient With Poliomyelitis - Eitan Ingall, BS; Osama Elattar, MD; Emily J. Curry, BA; and Xinning Li, MD

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The goal of orthopaedic treatment in chronic poliomyelitis is to address the functional impairments resulting from muscular imbalances and bony deformities. The most common knee deformity is a flexion contracture seen in the sagittal plane. Inappropriate or overcorrections of these deformities can have devastating long-term consequences. Revision surgery presents the surgeon with a complex and challenging case with very sparse published literature on revision techniques and osteotomy options. This report describes the successful use of a posterior closing wedge flexion osteotomy with plate fixation to correct a hyperextension deformity caused by a failed or overcorrected extension osteotomy in a 40-year-old man. In this patient, this flexion osteotomy led to complete deformity correction, resolution of symptoms, functional improvement, and return to work without restrictions. (Journal of Surgical Orthopaedic Advances 27(4):329–334, 2018) Key words: distal femoral flexion closing wedge osteotomy, failed distal femoral extension osteotomy, poliomyelitis

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