Medial Patellofemoral Ligament Reconstruction Technique Utilizing Patellar Suture Anchors and a Peroneus Longus Tendon Allograft - Nathan A. Rimmke, MD; Robert A. Magnussen, MD, MPH; David C. Flanigan, MD

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The medial patellofemoral ligament (MPFL) is generally nonfunctional in cases of recurrent lateral patellar instability. While there are numerous techniques and graft choices, patellar fracture after MPFL reconstruction remains a rare but devastating complication, as tunnels drilled completely through the patella increase the risk of fracture. This article presents a technique of MPFL reconstruction utilizing patellar suture anchors and a peroneus longus tendon allograft that avoids the need to drill tunnels that completely traverse the patella. (Journal of Surgical Orthopaedic Advances 28(3):166–174, 2019) Key words: medial patellofemoral ligament, patellar fracture, patellar instability, suture anchors

Orthopaedic Residency Training Structure: Implications on Quantity and Quality of Scholarship - John C. Dunn, MD; Nicholas Kusnezov, MD; Austin B. Fares, MD; E’stephan Garcia, MD; Brian R. Waterman, MD; Justin Orr, MD; and Mark Pallis, DO

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The objective of this analysis was to compare the efficiency of scholarly activity withinmilitary orthopaedic training programs. The authors obtained the lists of abstracts accepted for presentation at the 2009 through 2014 Society of Military Orthopaedic Surgeons (SOMOS) annual meetings. Data were extracted for each individual presentation. Three primary groups were compared: a traditional program, a research program, and a hybrid program. The hybrid program produced the highest percentage of the presentations (28.6%). The traditional program contributed the most presentations (3.32) and publications (2.16) per resident and had the highest publication rate (87.7%) and the shortest time to publication (14.4 months). The research program published in the highest average impact journals (3.2). The addition of a research year does not improve the number of academic presentations or published papers but may improve the impact factor of the journals in which the projects are published. (Journal of Surgical Orthopaedic Advances 28(3):175–179, 2019) Key words: academic research, military, orthopaedic, residency training

Trends and Characteristics of Highly Cited Articles in Proximal Humerus Fracture Research - Colin K. Cantrell, MD; Zachary A. Mosher, MD; Michael A. Ewing, MD; Samuel R. Huntley, MD; Martim C. Pinto, MD; Brent A. Ponce, MD; and Eugene W. Brabston III, MD

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As the treatment of proximal humerus fractures remains controversial in the literature, this study aims to identify highly cited articles and examine trends and characteristics. Scopus was used to identify the highest cited articles of proximal humerus fracture research. SPSS 23 was used for descriptive statistics and Pearson correlations for the relationship between citation count and density. Average citation count was 233 ± 164 with an annual citation density of 14 ± 7. Total citation count was associated with total citation density, 5-year citation count, and 5-year citation density. The Journal of Bone and Joint Surgery–American produced the most articles with 15 (30%). Thirty-five articles originated in Europe. The five most represented authors published three articles each. Finally, 13 (26%) papers appear in the American Shoulder and Elbow Surgeons Curriculum Guide. This study compiles a collection of articles investigating proximal humerus fractures for future review and demonstrates citation count to be an acceptable measure of an article’s contemporary academic influence. (Journal of Surgical Orthopaedic Advances 28(3):180–188, 2019) Key words: ASES Curriculum Guide, citation count, citation density, proximal humerus fracture

Outcomes of Revision Arthroscopic Anterior Shoulder Stabilization in a Military Population: A Prospective Cohort Study - LCDR George C. Balazs, MD, MC, USN; MAJ Michael A. Donohue, MD, MC, USA; CPT Alaina M. Brelin, MD, MC, USA CPT Jared A. Wolfe, MD,MC, USA; CPT Patrick D. Grimm, MD, MC, USA; LT Theodora C. Dworak, MD, MC, USN1\; and CDR John-Paul H. Rue, MD, MC, USN

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The purpose of the study was to determine the outcomes of revision arthroscopic anterior shoulder stabilization in a young, military population. The hypothesis was that this subgroup functions well in a high-demand environment without increased rates of failure. Patients were enrolled in an institutional database and followed prospectively. The primary outcomes were scores on the semiannual Physical Readiness Test (PRT), as compared to prior to reinjury. Secondary outcomes included the Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Simple Shoulder Test (SST), and Western Ontario Shoulder Instability Index (WOSI). Sixteen patients met inclusion. Mean age at revision was 20.9 years, and mean follow-up was 32.8 months (range, 12–60 months). Mean bone loss was 9%. Mean PRT score was similar to preinjury (86 vs. 87, p > .05), and mean push-ups showed a small decline (70.4 vs. 78.5, p > .05). Significant improvements were seen in SANE, SF-36 physical component, ASES, andWOSI scores. The results in this cohort suggest that revision arthroscopic stabilization is an acceptable treatment in high-demand military personnel. (Journal of Surgical Orthopaedic Advances 28(3):189–195, 2019) Key words: arthroscopic, Bankart, revision stabilization, shoulder

Dreaded Ulnar Wrist Pain: Long-Term Results of Pisiformectomy for Painful Pisotriquetral Arthrosis - Maureen A. O’Shaughnessy, MD; Laura W. Lewallen, MD; Steven L. Moran, MD; and Marco Rizzo, MD

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Pisiform pathology may be a source of ulnar-sided wrist pain. This study reviews the long-term outcomes of patients treated with pisiformectomy. A retrospective study approved by the institutional review board was performed over a 27-year period of patients undergoing pisiformectomy. Range of motion, grip strength, complications, and need for revision surgery were recorded. The series includes 61 wrists (60 patients) with an average age at surgery of 46 years. Two complications were noted (3%): a postoperative ulnar nerve palsy and symptomatic retained suture. At final follow-up, average flexion-extension arc was 81% (expressed as percent of contralateral), radioulnar deviation arc was 88%, and average grip strength was 89%. Pisiformectomy is a reliable, motion-preserving procedure with low complication rates for patients with chronic ulnar-sided wrist pain. In this series, 93% of patients did not require further procedures at an average of 8.2 years follow-up. (Journal of Surgical Orthopaedic Advances 28(3):196–200, 2019) Key words: chronic ulnar-sided wrist pain, pisiformectomy, pisotriquetral pain, ulnar-sided wrist pain, wrist

Hip Range of Motion: Which Plane of Motion Is More Predictive of Lower Extremity Injury in Elite Soccer Players? A Prospective Study - Sarav S. Shah, MD; Edward J. Testa, MD; Isaac Gammal, MD; Joseph Sullivan, PT, OCS; Roger W. Gerland, MSPT, ATC; Jeffrey Goldstein, MD; Brian Sheridan, PT; Michael Mashura, MD; Aalok S. Shah, BS; Andrew Goodwillie, MD; and Randy M. Cohn, MD

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The objective of this study was to determine which plane of hip motion (rotational or sagittal) is more predictive of lower extremity (LE) injury in elite soccer players. A total of 69 athletes (43 professional and 26 collegiate) were examined (mean age, 22.6 years). Bilateral hip internal rotation (IR), external rotation, extension, and flexion measurements were taken along with the modified Thomas test during preseason physicals. There were 42 LE injuries (injury rate 3.74/1000 athlete exposures). Mean IR was 25.2◦ and 29.9◦ for injured versus noninjured extremities, respectively (p = .009). There was a significant association between decreased IR (categorized as IR < 28◦) and incidence of ipsilateral LE injury (p = .042). Extremities with IR < 28◦ were 2.81 times more likely to sustain a LE injury (95% CI, 1.15–6.84; p = .023). With a utilitarian focus, the current study has identified a measurement of decreased hip IR with potential for substantial clinical value in collegiate and professional soccer players. (Journal of Surgical Orthopaedic Advances 28(3):201–208, 2019) Key words: internal rotation, lower extremity injury, soccer, Thomas test

Evaluating the Readability of Online Patient Education Materials Regarding Shoulder Surgery: How Do Medical Institution Web Sites Rate? -Anshum Sood, MD; Grant Duvall, MD; Varun Ayyaswami, BS; S. Ashfaq Hasan, MD, and Mohit N. Gilotra, MD

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This study evaluated the readability of online patient education materials on shoulder surgery. Medical and nonmedical institution web sites were compared and it was hypothesized that medical institution materials are written at lower grade levels than nonmedical institution materials, because medical institutions understand physician-patient interactions. Eighty-six articles were scored according to 10 readability tests: cumulative combined average grade level was 12.5 ± 2.8 and average Flesch reading score was 43.5 ± 12.6 (college level). The average composite grade level readability for medical institution web sites was 13 ± 2, significantly higher than for nonmedical institution web sites (11.9 ± 2.1; p = .017). Patient education materials available online are written at a higher level than American Medical Association and National Institutes of Health guidelines. Medical institution articles are written at a statistically significant higher grade level than nonmedical institution articles, but the difference is small and both rate poorly compared with current standards. (Journal of Surgical Orthopaedic Advances 28(3):209–214, 2019)

Gait and Functional Outcomes Between Cruciate-Retaining and Cruciate- Substituting Implants in Total Knee Arthroplasty: A Prospective, Randomized Study -Matthew L. Brown, MD; Christopher S. Wendt, MS; Thorsten M. Seyler, MD, PhD; Edward H. Ip, PhD; Judy L. Foxworth, PT, PhD, OCS; and Jason E. Lang, MD

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Significant debate persists about posterior cruciate-retaining (CR) versus posterior cruciate-substituting (PS) implant design for total knee arthroplasty (TKA). This study sought to test the hypothesis that CR TKA will facilitate improved early functional outcomes in gait compared with PS TKA. Patients were randomized to either the CR or PS implant. Various patient-reported and surgeon-reported outcomes as well as gait analyses were obtained pre- and postoperatively. Patients undergoing PS TKA had higher University of California, Los Angeles activity scores at 12 months. No significant difference in spatiotemporal, kinematic, or kinetic parameters between groups was detected, but there was a trend toward quadriceps overuse gait pattern in the CR group. Patients undergoing TKA with a PS implant were more willing to engage in regular higher level physical activity. The CR implant may be a risk factor for quadriceps overuse gait pattern, while the PS implant may be protective against quadriceps overuse. (Journal of Surgical Orthopaedic Advances 28(3):215–223, 2019) Key words: gait analysis, kinematics, patient-reported outcomes, posterior-cruciate retaining, posterior cruciate-substituting, total knee arthroplasty

Epidural Abscess in the Lumbar Spine: A Single Institution’s Experience With Nonsurgical and Surgical Management - Benjamin W. Berwick, MD, MS; T. David Luo, MD; Katherine W. Sun, MD; Rebecca A. Sharp, MD; John P. Birkedal, MD; and Tadhg J. O’Gara, MD

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The purpose of this study was to compare patient factors and outcomes in conservatively and surgically treated patients with spinal epidural abscess (SEA). This was a single-center retrospective review of adult patients treated for SEA of the lumbar spine. Primary treatment outcome was readmission for recurrent abscess. Sixty-one patients met inclusion criteria: 59% male, mean age 56.9 years, and body mass index 30.8 kg/m2. Initially 47.5% of patients were treated with conservative measures and 52.5% were treated with surgery. In the conservative group, 31.0% failed treatment and underwent delayed surgery; 26.2% of the overall cohort was readmitted for SEA. Readmitted patients had a greater incidence of history of methicillin-resistant Staphylococcus aureus (p = .048), recurrent infections (p = .008), and recent sepsis and bacteremia (p = .005). Nearly one-third of patients failed initial conservative treatment and needed delayed surgery; however, no significant differences were found between the two treatment groups. Patients with a past history of infections may require more aggressive treatment and closer follow-up, because they are at higher risk for recurrence and readmission. (Journal of Surgical Orthopaedic Advances 28(3):224–231, 2019) Key words: central nervous system infection, conservative management, outcomes, spinal epidural abscess, spinal infection, surgical decompression

Health Literacy Evaluation of Opioid Patient Education Materials for Orthopaedic Surgery - Latrina Y. Prince, EdD ; Simon C.Mears,MD, PhD; Jamie C. Watson, PhD; and Kristie B. Hadden, PhD

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Increased opioid use in the United States has resulted in greater incidence of misuse. Orthopaedic patients are more likely to be prescribed opioids for pain. Low health literacy is related to opioid misuse; therefore, orthopaedic patient education tools on use of opioids must be easy to read, understand, and use for patients of all skill levels to be effective. This project aimed to review a broad array of opioid patient education tools and evaluate them from a health literacy perspective. Content evaluation revealed that not all tools expressed the same essential messaging. The mean readability score of the tools assessed was 9.5 grade; higher than the national and recommended 8th-grade reading level. Therefore, many opioid patient education tools may be difficult for patients to read and understand. Improvements in readability and other health literacy best practices are recommended to improve reading, comprehension, and use of opioid patient education tools. (Journal of Surgical Orthopaedic Advances 28(3):232–236, 2019)

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