Volume 29-2, Summer 2020

Polyethylene wear and osteolysis has long been an issue with the survivorship of total hip arthroplasty. The purpose of this study was to assess the survivorship after isolated liner exchange with the use of the RingLoc acetabular cup. A query of our practice registry revealed 106 patients (112 hips) with a single cementless titanium plasma sprayed acetabular component (RingLoc, Zimmer Biomet, Warsaw, IN), who underwent acetabular liner exchange for treatment of polyethylene wear between January 2001 and March 2015. Eighty patients (85 hips) met inclusion criteria. Clinical outcomes were assessed with the Harris hip score and radiographic evaluation was performed. The mean follow-up after liner exchange was 6 years (range, 2–15.7 years). Harris hip scores improved from 70.9 (range, 28–100) preoperatively to 79 (range, 29–100) at most recent evaluation (p < 0.001). Subsequent surgery was required in 11 patients (11 hips, 13%). Components were revised in 7 hips (8.2%). One acetabular revision was performed for aseptic loosening and four for instability (4.7%). One metal-polyethylene sandwich liner was revised for metal hypersensitivity. One patient underwent two-staged exchange for infection. In our early to mid-term experience with the RingLoc acetabular cup, isolated liner exchange for treatment of polyethylene wear yielded 98.8% acetabular survival for aseptic loosening at up to 15 years. (Journal of Surgical Orthopaedic Advances 29(2):59–64, 2020) Key words: acetabular, liner, exchange, aseptic, loosening

The objective of this study was to describe examples and review the literature of distal humerus fracture reconstruction in the setting of severe bone loss. Four individuals (ages 19–59 years) were treated with either fibular strut allograft or fresh frozen osteochondral allograft in the setting of unreconstructable periarticular bone loss. The radiographs were evaluated for evidence of union. Pain and degrees of range of motion were reported when available. The follow-up period ranged from 3 to 42 months. While additional surgery was often needed, union was ultimately obtained in each case. Normal range of motion was not obtained, but two of the four patients were near normal upon union. Two of the four patients were pain free, and the other two had mild pain. All were limited in their activities, even after union. This case series describes satisfactory results with the use of allograft in this difficult clinical problem. (Journal of Surgical Orthopaedic Advances 29(2):65–72, 2020) Key words: humerus, reconstruction, allograft

Arthrofibrosis of the knee continues to challenge Orthopaedic surgeons. With a wide etiology, lack of knee motion can be debilitating. Its surgical management has several complications. The purpose of this study is to describe a modification of previously described techniques to aid in the management of knee arthrofibrosis. Arthroscopic vastus elevation in conjunction with adjuvant hemostatic agents allows for a controlled quadriceps elevation in the setting of arthrofibrosis. In addition to a thorough intra-articular lysis of adhesions, this appears to improve motion, while minimizing postoperative complications. Minimized postoperative complications include extensor lag, skin necrosis, and bleeding complications. (Journal of Surgical Orthopaedic Advances 29(2):117–120, 2020) Keywords: arthroscopic, arthrofibrosis, elevation, lysis, knee stiffness

Infections associated with external fixation are thought to be related to the fixator construct, the length of time a fixator is on the limb and the injury severity score (ISS). Patients who had temporary external fixation applied for lower extremity fractures were included. Charts were reviewed for prevalence of infection, loss of reduction or other external fixator modification. Other variables were length of time the fixator was applied and the length of hospitalization. Seventy-five patients with 80 fractures met our study criteria. Of 80 fractures, 23 (28.8%) were associated with infection at the fracture site. Average time to conversion from external fixation to definitive fixation was 13.23 ± 19.8 for infected fractures and 20.03 ± 17.08 (p = 0.137) for those without infection. We did not find that the length of time a fixator was applied was associated with an increased infection rate of the fracture site, the pin sites or other regions. (Journal of Surgical Orthopaedic Advances 29(2):73–76, 2020) Keywords: external fixation, long bone fractures, surgical site infection, Injury Severity Score (ISS)

This study assessed damage to the gluteus medius tendon insertion when performing trochanteric nailing with either a reconstruction nail or a cephalomedullary nail. Ten cadavers were randomized to receive proximal reaming for either a reconstruction nail or cephalomedullary nail; the contralateral hip served as an internal control. One specimen was found to have a displaced femoral neck fracture and was excluded from data analysis. Reconstruction nailing led to tendon damage in 4 of 9 hips, compared to 8 of 9 with hip fracture nailing (p = 0.29). In the reconstruction nail group, the average amount of tendon damaged was 3% (range 0–10%), while in the hip fracture nail group, the average was 15% (range 0–20.3%) (p = 0.0003). Open reaming for placement of a reconstruction nail caused less gluteus medius tendon damage when compared to open reaming for placement of a hip fracture nail. (Journal of Surgical Orthopaedic Advances 29(2):77–80, 2020) Key words: hip abductors, reconstruction nail, cephalomedullary nail

The role of intramedullary (IM) fi xation of displaced mid-shaft clavicle fractures in adolescents has not been described. This study analyzes characteristics and outcomes of IM fi xation in adolescent clavicle fractures. Patients < 18 years with acute, midshaft clavicle fractures treated with IM clavicle pins between March 2007 and August 2013 were reviewed. Outcomes of interest were activity level, fracture patt ern, time to union, return to sports and complications. Twenty-nine patients (14.8 years (range 11.4–17.9)) underwent IM pin fi xation for a displaced, mid-shaft clavicle fracture, including 7 (24.1%) that were multi-fragmentary (length unstable). Complete displacement (> 100%) occurred in 27/29 (93.1%), with average preoperative shortening length of 18 mm. Union occurred in 100% of patients, at a mean duration of 8 weeks. Among student-athletes (25/29, 86.2%), average return to sport was at 18 weeks post-injury. IM pinning off ers stable fi xation of clavicle fractures in the active adolescent population. (Journal of Surgical Orthopaedic Advances 29(2):81–87, 2020) Keywords: clavicle fracture, fracture fi xation, intramedullary, adolescent, athlete, trauma

Postoperative analgesia remains an important area of research in orthopaedics. There remains a lack of information on the complex interplay between opioid utilization postoperatively, pain and patient satisfaction. This study aims to describe the relationship between opioid utilization, postoperative pain, and patient satisfaction following outpatient orthopaedic surgery in a multispecialty orthopaedic practice. As a part of an ongoing quality control project at our institution patients were instructed to monitor utilization of postoperative opioids. The results of a convenience sample of 139 patients representing a 53% response rate among eligible patients that completed the survey following outpatient orthopaedic surgery are reported. Among patients undergoing outpatient orthopaedic surgery, there was no clinically signifi cant association between opioid utilization and patient satisfaction. This association appeared largely independent of the patient’s actual pain. While lower pain scores were associated with increasing patient satisfaction, this appeared to be independent of opioid utilization. (Journal of Surgical Orthopaedic Advances 29(2):88–93, 2020) Keywords: analgesics, opioid, ambulatory surgical procedures, patient satisfaction, quality improvement

We sought to prospectively determine the effi cacy of a noninvasive hemoglobin measurement system compared to a traditional blood draw in patients undergoing total joint arthroplasty. One hundred consecutive patients had their hemoglobin level measured by blood draw and the noninvasive device, simultaneously. Results were analyzed for the entire group and further stratifi ed based on race and perfusion index measured by the device. The fi nancial implications and patient satisfaction were compared. Hemoglobin measurements in the entire group and the two sub-groups were similar between the noninvasive device and the traditional blood draw. The noninvasive system was preferred by 100% of patients. Additionally, cost savings per patient using the noninvasive system was $16.50. This correlated to an 86% savings per case over the standard blood draw. The noninvasive hemoglobin monitoring system off ers comparable measurements to a standard blood draw, while improving patient satisfaction and lowering costs. (Journal of Surgical Orthopaedic Advances 29(2):94–98, 2020) Keywords: arthroplasty, total joint, hemoglobin, noninvasive, cost savings

Every year over 330,000 people are hospitalized for hip fractures in the US. Of those patients, approximately 4–5% of patients with hip fractures present with a concomitant upper extremity fracture. Upper extremity (UE) fractures account for an estimated 2 million fractures a year. The number of hip fractures is projected to double by 2050. There is evidence that the presence of a concomitant upper extremity fracture results in an increased hospital length of stay (LOS), lower functional capacity upon discharge and higher mortality rates than seen with hip fractures in isolation. Additionally, hip fractures pose a signifi cant economic burden and are expected to increase to over $62 billion in 2040. As such, hip fractures are a public health crisis. This study seeks to evaluate the diff erences in perioperative outcomes between nonoperative and operative management of humeral diaphyseal fractures in patients with concomitant hip fractures. (Journal of Surgical Orthopaedic Advances 29(2):99–102, 2020) Keywords: hip fractures, concomitant, upper extremity, mortality, hospital length of stay (LOS), surgical management

Smokers who undergo total joint arthroplasty (TJA) face increased rates of medical and surgical complications that can be reduced by preoperative smoking cessation. We investigated the long-term durability of preoperative smoking cessation among TJA patients. Twenty-seven TJA patients who were identifi ed as having an active history of smoking at the preoperative appointment before TJA consented to telephone survey about their perioperative and current smoking status. Average time from operation to survey was 3.7 years. Of the 27 patients, 21 (77.8%) were identifi ed as having quit smoking prior to surgery. Of these 21 patients, 10 (47.6%) self-reported continued abstinence from smoking at the time of survey. Our cessation rate was signifi cantly lower than reported long-term smoking cessation rates with standard therapies (p < 0.001). Our results suggest that preoperative counseling and a requirement for smoking-cessation prior to elective TJA may have long-term durability that exceeds that of popular reported methods. (Journal of Surgical Orthopaedic Advances 29(2):103–105, 2020) Keywords: smoking cessation, total joint arthroplasty, quality improvement, hip, knee

There are diff erent frameworks to describe how people make decisions. One framework, maximization, is an approach where individuals approach choices with a goal of fi nding the “best” possible alternative. We sought to determine the relationship between maximization and patient reported disability in patients with hand problems. We performed a cross-sectional study of 119 patients who presented to a hand surgery clinic. Patients completed a questionnaire that included sociodemographics, QuickDASH, Decisional Confl ict Scale, Pain Catastrophizing Scale, Patient Health Questionnaire, Health Anxiety Inventory and General Self-Effi cacy. Maximization did not correlate with subjective disability in patients with hand problems. Depression, pain catastrophizing and a diagnosis of upper extremity fracture had the greatest independent association with disability. In patients presenting for an initial hand surgery consultation, maximization was not associated with variation in patient reported disability or symptoms of psychosocial disease. Alternative factors infl uencing patient decision-making and outcomes should be explored. (Journal of Surgical Orthopaedic Advances 29(2):106–111, 2020) Keywords: hand surgery, maximization personality, patient reported outcomes, quality

Litt le is known about the epidemiology of orthopaedic conditions among the uninsured. This is a descriptive study of 107 patients presenting with 140 orthopaedic conditions for care at the student-run free clinic, the Shade Tree Clinic. Patients were 50.0 (± 13.0) years old with a BMI of 32.9 (± 8.60). About half were female (58.9%), of Spanish origin/Hispanic or Latino descent (50.9%), immigrants (48.3%), and non-English speaking (44.9%). Most presented with chronic (75.5%) conditions of the knee (24.3%), hand (16.4%) and spine (13.6%). While knee osteoarthritis was the most common diagnosis made (18.7%), there were 38 (35.5%) unique diagnoses with only a single occurrence. Most conditions were initially treated nonoperatively (82.9%). There was an average of 1.92 (± 1.44) visits per condition, and 74.0% of conditions had reported improvement or resolution. Though further study is needed, providing free comprehensive patient-centered orthopaedic care to uninsured individuals in a low-cost sett ing may prove cost-eff ective. (Journal of Surgical Orthopaedic Advances 29(2):112–116, 2020) Keywords: orthopaedic, uninsured, healthcare, cost-eff ectiveness, free clinic