Volume 29-1, Spring 2020

To evaluate the involvement of the subacromial bursa in the pathologic development of rotator cuff disease (RCD), a systematic review of the literature was undertaken to assess the cellular, biochemical and metabolic changes in the bursa. A systematic review was performed to identify all studies that reported histological and molecular changes in the subacromial bursa pertaining to RCD. The molecular biomarkers found to be altered in RCD included extracellular matrix enzymes, cytokines, growth factors and neuronal signals. Previous reports show an increase in IL-1, IL-6, TNFα, bone morphogenic proteins, substance P and vascular endothelial growth factor. All of these factors may contribute to the etiology and pathological changes in rotator cuff disease, but further study is needed to determine the specifi c role of the subacromial bursa in the pathophysiology of RCD. (Journal of Surgical Orthopaedic Advances 29(1):1-4, 2020) Key words: rotator cuff disease (RCD), bursitis, subacromial bursa, shoulder impingement, interleukins, COX enzyme, bone morphogenic proteins (BMPs), substance P, vascular endothelial growth factor (VEGF), biologic drugs, anti-metabolites

US physicians prescribe opioids at a high rate relative to other countries. Of the US physicians surveyed, almost half report having prescribed an inappropriate opioid due to concerns about patient satisfaction scores. We investigated patterns in controlled substance prescribing practices, patient risk factors, and associated Press Ganey patient satisfaction scores at a sample of orthopaedic surgery and primary care clinics over a 6-month time period. Primary care practices had higher proportions of prescriptions, and patient risk profiles varied across sites. However, overall satisfaction was high, with little variation between sites (78.3 – 81.3%). Satisfaction with pain control was lower and more varied (67.1 – 78.0%). A total of 4,229 Press Ganey survey responses were received, including 7,232 comments, of which only 10 (0.1%) expressed frustration for not receiving opioids. Opioid prescriptions had minimal association with Press Ganey scores among varied practices and patient populations. Prescribers should prescribe opioids appropriately without fear that this will negatively impact their satisfaction scores. (Journal of Surgical Orthopaedic Advances 29(1):5-9, 2020) Key words: opioid, patient satisfaction, orthopaedic surgery, primary care

The prevalence of obesity has been rising, creating a major public health concern. While several studies have shown obesity to increase the risk of surgical complications, few have analyzed its effects on reoperation, specifically after single-level lumbar discectomy. Data was obtained using the commercially available Explorys software that houses de-identified data for several major healthcare systems. A database search was used to find all patients who had undergone a lumbar discectomy. Scoliosis, spondylolisthesis, smoking history and depression were excluded as possible confounding variables, after which 25,960 patients remained. Of them, 690 were found to have undergone a revision discectomy within 2 years. Those who were obese were found to have a relative risk of 1.64 for revision discectomy compared to those who were non-obese, 95% confidence interval (95%CI) 1.32–2.03, p < 0.0001. These findings contribute to the importance of modifiable risk factor assessment preoperatively and their effects on surgical complications. (Journal of Surgical Orthopaedic Advances 29(1):10-12, 2020) Key words: revision, discectomy, obesity, Explorys, herniated disc, reoperation, risk factor

The incidence of new persistent opioid use following elective total joint arthroplasty (TJA) hasn’t been well documented; with this study we aim to further characterize opioid use following TJA, specifically focusing on those patients still requiring opioid prescriptions 6 months postoperatively. Retrospective review of a consecutive series of 977 primary TJA performed from June 2016–May 2017. Opioid prescriptions verified in Surescripts database; 3.7% (29) opioid naïve patients and 18.0% (35) opioid non-naïve patients received fills at 6 months. Opioid naïve patients requiring fills at 6 months had more fills from 1-2 months onward. Opioid non-naïve patients requiring fills at 6 months had more preoperative fills than those that weren’t filling opioid prescriptions (5.49 vs. 2.52 fills). Most patients in this study ceased opioid use by 3 months postoperatively. More preoperative fills in the opioid non-naïve population and continuing to fill prescriptions after 2-3 months were associated with continued opioid use. (Journal of Surgical Orthopaedic Advances 29(1):13-17, 2020) Key words: opioid use; hip arthroplasty; knee arthroplasty; postoperative; opioid naïve; opioid non-naive

INFIX instrumentation has provided an alternative treatment option for anteriorly unstable pelvic injuries. In this study, we explore the biomechanical feasibility of using an INFIX construct in an unstable long-bone model and present a unique clinical case of its use. The external fixation, locked plate and spinal implant constructs (n = 5 each) were applied to lengthunstable fracture models and tested under various loads. Analysis of variance and pairwise T-tests were performed with levels of significance adjusted by Bonferroni correction to account for multiple comparisons. The biomechanical stiffness of the INFIX was found to be intermediate between the other two constructs in axial loading and torsion and was equivalent to one of the other constructs in sagittal and lateral bending. It was never the most compliant construct in any testing mode. This study and case report demonstrate the biomechanical feasibility of using INFIX to treat limb injuries. (Journal of Surgical Orthopaedic Advances 29(1):18-25, 2020) Keywords: femur fracture, pediatric, unstable, INFIX, external fixation, bridge plating

The present study aims to investigate the incidence and pattern of injury in Crossfit. This study used a database search of “Crossfit” AND “Injury” for systematic review and meta-analysis. Crossfit seems to be an effective exercise method to decrease weight and BMI while improving function. High intensity interval training improves blood pressure, body fat percentage, lung capacity and pancreas function. Articles meeting inclusion showed that shoulder, back and then knee injuries were the most commonly self-reported in surveys. Incidence of injury is similar to that of other common recreational sports. Some Crossfit movements and participant characteristics may lead to higher incidences of specific injuries and injuries overall. (Journal of Surgical Orthopaedic Advances 29(1):26-30, 2020) Key words: High-intensity interval training (HIIT), scaling, Olympic weightlifting, powerlifting

We compare post-total shoulder arthroplasty (TSA) patients with suspected cuff dysfunction to a successful-TSA control group. Thirty-nine patients met suspected-cuff -dysfunction criteria. Forty matched controls were selected. Radiographic and functional outcomes and demographics were compared preoperatively and postoperatively. Humeral head height above the greater tuberosity and postoperative humeral head translations were significantly greater in the dysfunction group. The dysfunction group demonstrated a significant correlation between higher humeral heads and earlier postoperative dysfunction, significantly more glenoid radiolucencies, and significant deficits in active and passive forward elevation. External rotation did not diff er significantly until the final follow up. Functional scores differed significantly by 6 months, with the exception of the 1-year American Shoulder and Elbow Surgeons score. Post-TSA cuff dysfunction leads to worse functional scores, worse range of motion, and more glenoid radiolucencies. Proper patient selection and humeral head placement may prevent this. Early postoperative forward-elevation stiffness may portend dysfunction. (Journal of Surgical Orthopaedic Advances 29(1):31-35, 2020) Keywords: anatomic total shoulder arthroplasty, cuff dysfunction, functional scores, glenoid radiolucent lines, rotator cuff tear, stiffness

Associations between age and fracture incidence, total number of fractures, and total number of injuries per occupant occurring in motor vehicle crashes were evaluated. An observational study of the Crash Injury Research and Engineering Network was conducted. Multivariable logistic regression and negative binomial models were used to relate age (20–64, 65+ years) to fracture incidence, total number of fractures per occupant, and total number of injuries, adjusting for sex and change in vehicle velocity (delta-v). Over 90% of occupants had at least one fracture for a total of 5,846 fracture injuries. The older age group experienced a 15% increase in the incidence of total injuries sustained compared to the younger group (Incident Rate Ratio = 1.15, 95% Confidence Interval = 1.08–1.23, p < 0.0001). Older patients should be considered for polytrauma evaluation even with a “lower energy” motor vehicle crash. (Journal of Surgical Orthopaedic Advances 29(1):36-39, 2020) Keywords: age, collision energy, delta-v, geriatric, motor vehicle collision, polytrauma

The Scoliosis Research Society Questionnaire (SRS-30) was designed to measure health-related quality of life in scoliosis patients. Patients with low health literacy may need specific guidance when providing feedback on the SRS-30 so that reliable and valid results are collected for clinical decision making. The purpose of this research study was to investigate the health literacy demands of the Scoliosis Research Society Questionnaire (SRS-30) and to determine if health literacy best practices mitigate errors for patients with low health literacy. Readability assessment, focus groups and structured interviews were used. Results indicated that patients with low health literacy perceived health literacy best practices as helpful in completing the SRS-30 drawing. Additionally, patients with inadequate health literacy had a higher proportion of errors in pain location on the drawing (p = 0.0325) compared to patients with adequate health literacy. (Journal of Surgical Orthopaedic Advances 29(1):39- 42, 2020) Key words: health literacy, spine surgery, health-related quality of life, patient-reported outcomes, back pain

This study evaluated the frequency in which a hip dislocation is first diagnosed by computed tomography (CT) scan. A retrospective review was conducted of orthopaedic trauma patients presenting with hip dislocation to a Level 1 trauma center over three years. We recorded whether the patient first received pelvic radiograph (PXR) or CT scan of the pelvis, if the patient underwent closed reduction of the hip prior to CT scan, and if repeat pelvis CT scan was done. Of 83 hip dislocations, 64 patients were sent to CT scanner dislocated; 19 patients first had PXR and underwent closed reduction of the hip prior to CT scan. By obtaining a PXR, reducing the hip prior to CT, the incidence of repeat CT scan decreased from 37% to 11% (p = 0.046). By diagnosing hip dislocation, reducing prior to CT scan, repeat scans can be reduced, thus decreasing cost and radiation exposure to patients. (Journal of Surgical Orthopaedic Advances 29(1):43-45, 2020) Keywords: hip dislocation, level 1 trauma, AP pelvis, pelvic x-ray, CT pelvis

The palmaris longus muscle is one of the most variable muscles in the human body. It has many anatomic variants, one of which is the reversed palmaris longus. In this specific variant, the tendinous origin and muscular insertion sites are reversed in the forearm. We report a case of a 15-year-old male with complaints of a mass in his right wrist; workup of the mass revealed a reversed palmaris longus muscle. (Journal of Surgical Orthopaedic Advances 29(1):46-47, 2020) Key words: reversed palmaris longus, palmaris longus, anatomic variant, forearm mass

Carpal coalition is an uncommon and rarely reported anomaly, characterized by the union of two or more carpal bones. It is usually found incidentally during radiographic evaluation for trauma or other unassociated pathology. While lunotriquetral and capitohamate coalitions are the most common forms of carpal coalition, there are very few reports of scaphotrapezial coalitions described in the literature. This a novel case report, in which we present a case of bilateral scaphotrapezial coalition in a patient with radiocarpal arthritis and persistent wrist pain. Furthermore, this case report discusses the classification systems and treatment options of this anomaly. (Journal of Surgical Orthopaedic Advances 29(1):48–49, 2020) Key words: scaphotrapezial coalition, anomaly, radiocarpal arthritis, Minnaar, arthrodesis

Ankle fractures are one of the most common orthopedic injuries and often include medial malleolus fractures. A number of techniques to repair medial malleolus fractures have been described. Depending on the exact fracture pattern, there are cases of medial malleolus fractures that are less amenable to standard fi xation strategies. We present an alternative strategy for fixing medial malleolus fractures, in which a screw is placed antegrade across the fracture line. (Journal of Surgical Orthopaedic Advances 29(1):50-52, 2020) Key words: trauma, medial malleolus fracture, ankle fracture, open reduction internal fixation