Keeping Up With the Orthopaedic In-Training Examination: National Survey on Orthopaedic Residency Training in Practice Management - Matthew Varacallo, MD; Martin Herman, MD

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The evolving health care environment warrants its physicians to be competent in basic practice management (PM) areas. A manifestation of this importance was reflected in the inaugural inclusion of a PM subsection on the 2017 Orthopaedic In-Training Examination. The purpose of this orthopaedic resident national survey study was to gain insight on the current state of formal residency education in PM. This study surveyed 500 orthopaedic residents nationwide in 2016. Resident participation was online, anonymous, and voluntary. Only complete survey responses were included, yielding a 49.2% (246/500) response rate. The majority of orthopaedic residents (72.4%, 178/246) reported no formal education in PM topics, and 86.2% (212/246) responded that they do not receive direct feedback on individual accuracy of Current Procedural Terminology (CPT) code case logging. Of the residents without formal education in PM, 87.1% (155/178) desire its implementation. The evolving health care system is becoming increasingly reliant on physicians to provide cost-effective, value-based health care to its patients. Consideration should be given to formally incorporating basic teaching elements on important PM topics at the residency training level. (Journal of Surgical Orthopaedic Advances 28(2):81–88, 2019) Key words: ACGME core competencies, CPT coding, documentation and coding, orthopaedic residency, residency curriculum, residency education

A Legacy Revisited: Needle Holders - Anil Agarwal, MS (Orthopaedics); M. Arkesh, MS (Orthopaedics); Gourav Jandial, MS (Orthopaedics)

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A needle holder is one of the crucial surgical instruments for surgeons. Its prime function is to steadily hold the needle while applying sutures, thus avoiding injury to the surrounding tissues and to the surgeon’s hand. Wide varieties of needle holders are available for use in orthopaedic practice. This review article briefly describes the biomechanics and other characteristics of some of the commonly used needle holders. The care aspects and wear features of needle holders are also discussed. A surgeon should be aware of the different types of needle holders, their special features, biomechanical properties, and specific uses as they are an important tool in the surgeon’s armamentarium. (Journal of Surgical Orthopaedic Advances 28(2):89–96, 2019) Key words: biomechanics,needle holder, wear

Preoperative Risk Factor Score Predicts Malnutrition in Total Joint Arthroplasty Patients - Sarah Rudasill, BS; Daniel J. Gittings, MD; Nabil M. Elkassabany, MD; Jiabin Liu, MD, PhD; Charles L. Nelson, MD; Atul F. Kamath, MD

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Malnutrition is a modifiable risk factor for poor outcomes in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). The purpose of this study is to highlight risk factors for hypoalbuminemia and develop a predictive model that identifies patients at risk for this condition before THA or TKA. The study retrospectively reviewed the National Surgical Quality Improvement Program database to analyze preoperative independent risk factors for a diagnosis of hypoalbuminemia in adult patients who underwent THA or TKA. These factors were used to create a preoperative risk model to predict hypoalbuminemia. Individuals with three or more risk factors in the seven-point model are predicted to have hypoalbuminemia in 20.4% of THA or 10.5% of TKA cases. Accurate identification of hypoalbuminemic patients may allow preoperative nutrition interventions to improve postoperative outcomes. (Journal of Surgical Orthopaedic Advances 28(2):97–103, 2019) Key words: albumin, hypoalbuminemia, malnutrition

Generating Differential Ligamentotaxis Across the Radiocarpal Joint  - Gregory K. Faucher, MD; Brent G. Parks, MSc; Neal B. Zimmerman, MD

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This study sought to determine if traction through the index or long finger metacarpal provided a selective distraction force through either the distal radius’ radial or ulnar column. In eight specimens, the radius was cut transversely 1 cm proximal to the Lister tubercle. Index and long finger metacarpals were cut and two-hole plates were fixed to metacarpals. Traction forces were alternately applied to index, then long finger metacarpals, sequentially through each metacarpal from 4.5N to 89N. Traction loading through the index finger metacarpal resulted in significantly more distraction force transmitted through the distal radius fragment’s radial column at all force intervals. Traction loading through long finger metacarpal resulted in significantly higher force transmission through distal radius’ ulnar column. In both cohorts, force transmission increased linearly in response to higher loads. Selective traction force of either the index or long finger metacarpal resulted in differential tensioning of the distal radius’ ulnar and radial columns. (Journal of Surgical Orthopaedic Advances 28(2):104–107, 2019) Key words: biomechanics, distal radius fracture, dorsal spanning plate, internal fixation, wrist

Early to Midterm Clinical and Radiographic Survivorship of the All-Polyethylene Versus Modular Metal-Backed Tibia Component in Primary Total Knee Replacement -  Thomas Herschmiller, MD; Kendall E. Bradley, MD; Samuel S. Wellman, MD; David E. Attarian, MD

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The purpose of this study was to compare the all-polyethylene tibial component with the modular metal-backed component in primary total knee arthroplasty. A retrospective review of 1064 patients recorded clinical failure, as determined by need for revision surgery, range of motion, and impending radiographic loosening, as evaluated by the presence of radiolucent lines. Mean follow-up was 1.2 and 3 years, respectively. Survival in the all-polyethylene group was 100%, with 95.5% (95% CI: 85.8–98.6) survival in the metal-backed component group at 4.3 years. Thin (<4 mm) radiolucent lines were present in one patient (0.7%) with an all-polyethylene implant and 24 (16.9%) patients with the metalbacked component (p < .001), while one (0.7%) and two (1.4%) patients had evidence of osteolysis, respectively (p = .621). While there were fewer radiolucent lines noted around the all-polyethylene implant on radiographs, the clinical implications of the finding are unknown. In this study population, the all-polyethylene tibial component appears appropriate. (Journal of Surgical Orthopaedic Advances 28(2):108–114, 2019) Key words: all-polyethylene, metal-backed, osteolysis, primary knee arthroplasty

Radiographic Predictors of Screw Cutout for Intertrochanteric Fractures Treated With Cephalomedullary Nails - Nickolas J. Nahm, MD; Nicholas B. Frisch, MD, MBA; Wael Ghacham, MD; Clifford M. Les, DVM, PhD; Stuart T. Guthrie, MD; Michael A. Charters, MD, MS

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The objective of this study was to determine the predictive value of tip-apex distance (TAD) and Parker’s ratio for screw cutout after treatment of intertrochanteric hip fractures with a long cephalomedullary nail. A total of 97 patients with AO/OTA 31-A1-A3 intertrochanteric fractures and a minimum follow-up of 8 weeks were included. Increased Parker’s ratio on the anteroposterior radiograph (OR = 1.386, p < .003) and lateral radiograph (OR = 1.138, p < .028) was significantly associated with screw cutout. In a multivariable regression analysis, only the Parker’s anteroposterior ratio was significantly associated with risk of screw cutout (OR = 1.393, p = .004), but TAD (OR = 0.977, p = .764) and Parker’s lateral ratio (OR 1.032, p = .710) were not independent predictors of cutout. The study concluded that Parker’s anteroposterior ratio is the most helpful measurement in predicting screw cutout. (Journal of Surgical Orthopaedic Advances 28(2):115–120, 2019) Key words: cephalomedullary nail, intertrochanteric fracture, screw cutout

Adoption of Intramedullary Nail Fixation for Proximal Humerus Fractures: Assessment of Surgical Efficiency and Complications - Brent A. Ponce, MD; Johnathan F. Williams, MD; Shawna L. Watson, MD; Jorge L. Perez, MD; Parke W. Hudson, MD; Jonathan H. Scott, MD; Djuro Petkovic, MD; Christopher M. Jobe, MD; Patrick D. Rowan, MD; Wesley P. Phipatanakul, MD

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Fixation of proximal humerus fractures (PHFs) with intramedullary (IM) nails potentially is a newer, less invasive technique. The purpose of this study was to report on the early adoption results of IM nail use for PHF. Retrospective chart reviews were performed on the first 60 patients treated with IM nails for acute PHFs by two shoulder surgeons. The first 15 patients treated by each surgeon were compared with the subsequent 15 patients. Surgical and fluoroscopic times, fracture type, union, and varus collapse were compared. The average operating time decreased (p = .002). Fluoroscopy time, radiographic alignment, union rate, complications, and reoperations were not influenced. Three- and four-part fractures had a higher complication rate than two-part fractures (53% vs. 20%). When considering implementing use of IM nails for treatment of PHFs, initial cases can have outcomes and complications similar to those performed with greater experience. IM nailing appears a good treatment option for two-part PHFs. (Journal of Surgical Orthopaedic Advances 28(2):121–126, 2019) Key words: dynamic fixation, humerus fracture, intramedullary nail, learning curve, shoulder, surgeon experience, trauma

Diabetes and Total Joint Arthroplasty: Infection Risk May Not Be Predictable by Markers of Glycemic Control - Sean Ryan, MD; Marcus Dilallo, MD; Kevin McCoy, MD; Cindy Green, PhD; Thorsten Seyler, MD, PhD

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With an increasing prevalence of diabetes, there is a need to risk stratify arthroplasty patients preoperatively and characterize postoperative infections. This study sought to determine if perioperative markers of diabetic control were associated with infection and to further characterize diabetic periprosthetic joint infections (PJI). A retrospective analysis of 506 diabetic patients and 900 nondiabetic patients who underwent primary total hip and knee arthroplasty was performed. In this cohort, an infection rate of 4.7% and 2.0% for diabetic and nondiabetic patients, respectively, was observed. There was no association between infection at 1 year and preoperative hemoglobin A1C or postoperative blood glucose; however, diabetic infections were significantly more likely to be deep (HR = 4.6; p < .001) and present >6 weeks postoperatively (HR = 8.0; p = .001). This study concluded that common markers of glycemic control are not predictive of the increased risk of diabetic PJI and alternative markers should be investigated. (Journal of Surgical Orthopaedic Advances 28(2):127–131, 2019) Key words: arthroplasty, diabetes, glucose, glycemic control, hemoglobin A1C, infection

Isolated Subtalar Arthrodesis for Avascular Necrosis of the Talus - Travis J. Dekker, MD; Manuel J. Pellegrini, MD; Adam P. Schiff, MD; Mark E. Easley, MD; James K. DeOrio, MD; James A. Nunley, MD; Samuel B. Adams, MD

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Isolated subtalar arthrodesis has been attempted in talar avascular necrosis (AVN) patients to preserve the tibiotalar joint and potential revascularization. This article reports the efficacy of isolated subtalar arthrodesis in the setting of AVN. A retrospective review of subtalar arthrodeses was performed on a cohort of 12 patients with talar AVN who underwent subtalar arthrodesis. The primary outcome was radiographic fusion with secondary outcomes of subsequent procedures, recurrent pain, and perioperative complications. Radiographic fusion of subtalar arthrodesis occurred in 12 of 12 patients. Five of six patients with traumatic etiology went on to have secondary procedures. One of six patients with atraumatic etiology underwent a secondary procedure for advancement of tibiotalar arthritis. In the setting of atraumatic talar AVN, this small cohort demonstrates that isolated subtalar arthrodesis is a safe and reliable procedure with high fusion rates and low need for secondary procedures. (Journal of Surgical Orthopaedic Advances 28(2):132–136, 2019) Key words: arthritis, avascular necrosis, outcome study, subtalar fusion, talus, trauma

Early Stabilization of Femur Fractures in the Setting of Polytrauma Is Associated With Decreased Risk of Pulmonary Complications and Mortality - James A. Blair, MD; Nicholas Kusnezov, MD; Tuesday Fisher, MD; Gautham Prabhakar, MD; Julia O. Bader, PhD; Philip J. Belmont, MD

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Timing of definitive fixation of femoral shaft fractures is a subject of continued controversy. The purpose of this study was to determine if early definitive fixation of femoral shaft fractures in the setting of polytrauma decreased the risk of pulmonary complications and mortality. The 2009–2012 National Sample Program of the National Trauma Data Bank was queried for all patients 18 to 65 years with Injury Severity Scores (ISS) >15 who underwent definitive fixation of femoral shaft fractures. Mortality, perioperative complications, and length of intensive care unit (ICU) and hospital stay were the primary outcome measures of interest. Following multivariate analyses, increased time to surgery was found to portend a statistically significant increased risk of acute respiratory distress syndrome(ARDS), mean ventilator time, length of ICU and hospital stay, and mortality. Earlier definitive fixation of femoral shaft fractures in the setting of polytrauma is associated with significantly decreased risk of ARDS, mean ventilator time, length of ICU and hospital stay, and mortality. (Journal of Surgical Orthopaedic Advances 28(2):137–143, 2019) Key words: early stabilization, femur fracture,mortality, polytrauma, pulmonary complications

Musculoskeletal Health Literacy, Pain Catastrophization, and Sleep Quality: Effect on Functional Disability Scores - Peter C. Noback, BA; Mani Seetharaman, MD; Direk Tantigate, MD; Robert J. Strauch, MD; Melvin P. Rosenwasser, MD; J. Turner Vosseller, MD

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Limited musculoskeletal health literacy, catastrophic pain thinking, and poor sleep quality may be associated with adverse long-term health outcomes, but are sparsely studied concomitantly in orthopedics. The purpose of this study was to assess how these factors influence baseline functional disability. Hand and wrist and foot and ankle patients presenting with a previously untreated complaint were enrolled and completed the Literacy in Musculoskeletal Problems questionnaire, Pain Catastrophization Scale (PCS), and Pittsburgh Sleep Quality Index (PSQI). Upper extremity patients completed the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and lower extremity patients completed the Foot and Ankle Outcome Score (FAOS) survey. DASH and FAOS scores were normalized to the same scale and termed ‘‘functional survey’’ (FS). Two hundred thirty-one patients (mean age 45.8 ± 16.8) were included in the analysis. PCS and PSQI were significantly correlated with FS score. The only other variables significantly correlated with FS score were insurance and diagnosis type. The variables PCS, PSQI, insurance, and diagnosis were entered into a multivariate analysis with FS score. All four variables significantly added to FS score in the model (R2 = .194, p < .001). Interventions that target both catastrophizing tendencies and sleep quality may independently improve functional outcomes. Further in-depth multifactorial research in this topic is critical to craft effective treatments with sustainable outcomes. (Journal of Surgical Orthopaedic Advances 28(2):144–149, 2019) Key words: functional outcomes, health literacy, orthopedics, pain catastrophization, sleep quality

Acute Pectoralis Major Tears in Forward Deployed Active Duty U.S. Military Personnel: A Population at Risk? - MAJ Dane Salazar, MD; CAPT Irshad Shakir, MD; LT COL Keith Joe, MD; MAJ W. Stephen Choate, MD

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The purpose of this study is to report on the causes of a series of acute pectoralis major tears in active duty deployed military personnel. Nine cases of acute pectoralis major tears evaluated at one expeditionary military treatment facility over a 4-month deployment cycle were analyzed. Nine male patients were diagnosed with tears: seven complete tears at the tendinous insertion, one complete tear at the musculotendinous junction, and one incomplete tear, with a mean age of 32 years (range, 23–52 years). All injuries occurred during bench press, with the dominant upper extremity involved 56% of the time. Injury occurred an average of 77 days into the tour (range, 3–198 days). Mean time from injury to surgical repair in the cohort was 18 days (range, 10–43 days). Combat-deployed active duty U.S. military personnel likely represent a high-risk population for this injury. Surgical repair is possible, but rarely advisable, in the deployed setting. (Journal of Surgical Orthopaedic Advances 28(2):150–157, 2019) Key words: active duty, military, pectoralis major tear, tendon repair, wartime injuries

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