The Rates of Nonunion and Malunion in Lower Extremity Fractures: Experience in South Carolina Over 17 years - Dane N. Daley, MD; Phillip A. Westbrook, MD; William R. Barfield, PhD, FACSM; Anbesaw Selassie, DrPH, FACE; and Langdon A. Hartsock, MD, FACS

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Our purpose was to determine the rates of lower extremity nonunion and malunion over 17 years in South Carolina. Our hypothesis was that malunions and nonunions decreased over time due to improved access to trauma centers and improved orthopaedic surgical training. The South Carolina Department of Budget and Control Hospital Discharge Database was queried between 1998–2014 and yielded a total of 4,994 malunions and 16,454 nonunions. Malunions increased from 1.2% (1998) to 1.8% (2010); nonunions increased from 4.0% (1999) to 5.8% (2011). Older age and gender were predictive of malunion and nonunion. This study identified females as having a higher odds ratio for malunion or nonunion; higher nonunion rates in worker’s compensation or government payer status; and older age as incurring greater risks for sustaining fractures or developing a malunion or nonunion. There was increased prevalence of nonunion and malunion despite improved access to trauma centers and trained orthopaedic trauma surgeons. (Journal of Surgical Orthopaedic Advances 29(3):129–134, 2020)

Key words: fracture, nonunion, malunion, lower extremity, trauma, South Carolina

Gunshot Wounds to the Hip: Doomed to Failure? - Yiyi Zhang, BS; Breydan Wright, BS; Peter D’Amore, MD; Cody Hightower, MD; Thomas Stang, MD; Heidi Israel, PhD; Michael Tucker, MD; Robert Zura, MD; and Lisa K. Cannada, MD

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The purpose is to evaluate hip fractures due to gunshot wounds (GSW) to the hip, which are treated surgically, and the complications. Patients who sustained a low velocity GSW with fracture to the femoral head/neck and intertrochanteric/ peritrochantric region at three Level 1 Trauma Centers were eligible. There were 69 patients (63 males–91%), with an average age of 29 (18–60). Nine patients had orthopaedic surgical site infections. There were 6 nonunions, 4 patients with hardware failure, 2 cases of avascular necrosis (AVN), 3 patients with post traumatic arthritis (PTA) and 20 patients with heterotopic ossification (HO). There was no significant difference found regarding fracture site or type of fixation with regards to complications. This represents the largest study of surgically treated GSW to the hip. Of patients studied, 61% sustained additional GSW. These injuries are not benign; the main complications being infection and heterotopic ossification. (Journal of Surgical Orthopaedic Advances 29(3):135–140, 2020)

Key words: low-velocity gunshot wound, hip fracture, surgical fixation, debridement, complication

Infantile Tibia Vara (Blount Disease) with Iatrogenic Changes Causing Residual Tibial Deformities - Geovanny Oleas-Santillán, MD, MS; Faaiza K. Kazmi, MD; Mihir M. Thacker, MD; H. Theodore Harcke, MD; Harry Lawall III, CPO; and J. Richard Bowen, MD

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Treatment of infantile tibia vara or Blount disease (ITV/BD) in patients < 3 years old and Langenskiold stages I-III consists of orthosis and, in relapsing cases, proximal tibial osteotomy and/or proximal tibial guided growth laterally with a tension band plate. Our aim was to evaluate the results of treatments in a consecutive group. After Institutional Review Board approval, data from 2002 to 2018 were collected. Thirty-nine knees (average age 22.4 months) with ITV/BD were treated with orthoses, and 10 knees failed. Six knees showed hyperintense T2-weighted signal in the medial proximal tibial epiphyseal cartilage on magnetic resonance imaging. Three of six knees with tibial osteotomy failed and underwent guided growth. Tibial plateau slopes were abnormal medially from the ITV/BD and laterally from the guided growth (triangular physis and depressed plateau deformities) because of factors such as orthotic treatment, tibial osteotomy, magnetic resonance imaging “physis severity score,” and guided growth. (Journal of Surgical Orthopaedic Advances 29(3):141–148, 2020)

Key words: Blount disease, infantile tibia vara, magnetic resonance imaging, orthosis, tibial osteotomy, guided growth, tibia plateau deformity

Current Biopsy Methods for Primary Musculoskeletal Lymphoma: A Retrospective Multicenter Review - Matthew T. Wallace, MD, MBA; Alex Sin, MD; Frank J. Frassica, MD; and Albert J. Aboulafia, MD, MBA

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Primary musculoskeletal lymphoma often requires multiple biopsies for tissue confirmation. This challenge is understood by specialists but has not been specifically quantified. One-hundred-eighteen biopsies performed in 100 cases of primary musculoskeletal lymphoma was performed. Demographics, tumor location and the method and performer of biopsy were recorded. Pearson chi-square and analysis of variance (ANOVA) statistics were used to compare rates of diagnostic yield, time to diagnosis and the presence of crush artifact based on method of biopsy, imaging, performer and tumor location. Diagnostic yield of initial biopsy is 82%. Open biopsy is associated with a higher yield compared to percutaneous techniques (p = 0.005). Biopsies performed by the treating surgeon had a higher yield compared to other practitioners (p = 0.035). Musculoskeletal lymphomas are a greater diagnostic challenge compared to other lesions. A higher index of suspicion and more aggressive sampling procedure may be necessary to establish this diagnosis. (Journal of Surgical Orthopaedic Advances 29(3):149–153, 2020)

Key words: lymphoma, biopsy, oncology

High Energy Midfoot Fracture-Dislocations: Does Staged Treatment with External Fixation Help? - John Arvesen, MD; Zachary Burnett, MD; Ashleigh N. Bush; Heidi Israel, PhD; Brian Mullis, MD; and Lisa K. Cannada, MD

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This study analyzes the outcomes of patients treated for high energy midfoot injuries with temporary stabilization (TS) prior to definitive operative fixation compared to a control group (C) treated initially with splint only. Three Level 1 trauma centers reduced and temporized high energy Lisfranc injuries. A matched control group was compared with the intervention group. Clinical parameters, complications and need for additional surgery were evaluated. There were 15 patients in group C and 29 patients with temporary stabilization (TS). Both the TS and C groups demonstrated no significant difference in the number of additional operations, infection rate, incidence of deep vein thrombosis (DVT), nonunion and need for orthotics postoperatively (p > 0.05). Staged treatment of high energy Lisfranc injuries in the TS group led to a delay in definitive fixation or arthrodesis while having a similar minimal complication rate relative to the controls. This is a Level III, Retrospective Case Control Study. (Journal of Surgical Orthopaedic Advances 29(3):154–158, 2020)

Key words: Lisfranc fracture, midfoot fracture, tarsometatarsal fracture-dislocation, external fixation

The Effect of Diabetes Mellitus on Revision Discectomy After Single-level Lumbar Discectomy - Eric J. Smith, MD; Bradley P. Inkrott, MD; Jerry Y. Du, MD; Chang-Yeon Kim, MD; Uri M. Ahn, MD; and Nicholas U. Ahn, MD

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Diabetes currently affects over 25 million Americans, with the elderly carrying much of the disease burden. It’s well known that diabetes increases the risk of surgical complications, but few studies have analyzed its effects on reoperation rates after singlelevel lumbar discectomy. Data was obtained using the commercially available Explorys software, which houses de-identified data for several healthcare systems. A database search was conducted to fi nd all patients who’d undergone a lumbar discectomy. Scoliosis, spondylolisthesis, smoking history and obesity were excluded as possible confounding variables, after which 31,210 patients remained. Of them, 950 were found to have undergone a revision discectomy within 2 years. Those with diabetes were found to have a relative risk of 1.29 for revision discectomy compared to those who did not, 95% confidence interval (95% CI) 1.10–1.52, p < 0.002. These findings contribute to the importance of modifiable risk factor assessment preoperatively and their effects on surgical complications. (Journal of Surgical Orthopaedic Advances 29(3):159–161, 2020)

Key words: revision, discectomy, diabetes mellitus, Explorys, herniated disc, reoperation, modifiable risk factor

Urinary Tract Infection After Total Hip Arthroplasty: A Retrospective Cohort Study - Paull C. Gossett, MD; Brian E. Schwartz, MD; Donald P. Chuang, MD; Hristo I. Piponov, MD; and Mark H. Gonzalez, MD

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Perioperative urinary tract infections (UTI) are a relatively common occurrence after total hip arthroplasty (THA). The purpose of this study was to assess demographics, outcomes and trends in the development of UTI’s after THA using the National Hospital Discharge Survey (NHDS). All patients undergoing THA were divided based on whether or not they developed a UTI, and data regarding demographics, outcome and complications were gathered and analyzed. No significant trend in rate of UTI after THA was found. Patients who developed a UTI were more likely to be female, have more comorbidities and receive a transfusion. They had a longer hospitalization, lower rate of discharge directly home and an increased rate of discharge to a rehabilitation facility. Orthopaedists should identify those patients at increased risk who according to this study appear to be older, female patients with multiple co-morbidities who received a blood transfusion. (Journal of Surgical Orthopaedic Advances 29(3):162–164, 2020)

Key words: urinary tract infection (UTI), total hip arthroplasty, outcomes, National Hospital Discharge Survey (NHDS) Database

The Relationship Between Cigarette Smoking and the Prevalence, Frequency and Severity of Back Pain - Carolyn R. Postol, DO; David J. Kusin, MD;  Charles C. Yu, MD; Jerry Y. Du, MD; Chang Y. Kim, MD; Adam J. Schell, MD; Uri M. Ahn, MD; and Nicholas U. Ahn, MD

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The purpose of this study was to examine the relationship between smoking and back pain in a cross-sectional analysis. Using the Osteoarthritis Initiative database, a multi-center, longitudinal, observational cohort study with 4796 participants, we examined the prevalence of back pain and of limitations in activity due to back pain, as well as the frequency and severity of back pain in participants who were current smokers compared to those who had never smoked. Data was evaluated using binary and ordinal logistic regression analyses. An increase in prevalence, frequency and severity of back pain was strongly associated with smoking. This demonstrates a relationship between smoking and back pain; however, further studies are needed to evaluate causation. (Journal of Surgical Orthopaedic Advances 29(3):165–168, 2020)

Key words: back pain, smoking, osteoarthritis, tobacco, intervertebral disc degeneration, degenerative disc disease

Scapholunate Ligament: Comparing the Native Strength of the Ligament to an All-suture  Anchor Construct - Laura W. Lewallen, MD; Carson F.  Woodbury, MPhil; Adam Margalit, MD; Hannah C. Langdell, MD;  Stephen M. Belkoff , PhD; and John V. Ingari, MD

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Our aim was to compare the tensile strength of the native scapholunate ligament (SLL) with that of an all-suture anchor construct in a cadaveric model. The scaphoid and lunate were isolated, preserving all segments of the SLL. Using a servohydraulic testing machine, we increased the load until peak load-to-failure of the native SLL was reached in nine specimens (mean ± standard deviation, 273 ± 132 N). Using the same specimens, two JuggerKnot 1.4-mm suture anchors (Zimmer Biomet) were placed into the lunate and tensioned through transosseous tunnels in the scaphoid. Sutures were tied over the radial nonarticular aspect of the scaphoid. Load-to-failure testing was repeated. The mean peak load-to-failure for the all-suture anchor constructs was 172 ± 59 N versus 231 ± 117 N for the native group (p = 0.157). This represents approximately 75% of the native ligament strength. (Journal of Surgical Orthopaedic Advances 29(3):169–172, 2020)

Key words: all-suture anchor construct, scapholunate ligament injury, scapholunate ligament reconstruction, scapholunate ligament strength

Non-displaced Femoral Neck Stress Fractures in Young Adults: 7-Year Outcomes of Prophylactic Fixation Versus Nonoperative Treatment - Ryan C. Myers, MD; Grant K. Cochran, MD; Jacob E. Waldron, DO; Clarence E. Steele, MD; Bradley K. Deafenbaugh, MD; and Kevin M. Kuhn, MD

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Retrospectively compare outcomes of prophylactic fixation to nonoperative treatment of incomplete or non-displaced femoral neck stress fractures (FNSF) in young adults. Outcomes of 82 patients (mean age 21.7 years) who were diagnosed with incomplete or non-displaced FNSFs from 2002 to 2015 were compared. Forty-one underwent prophylactic fixation; the remaining were treated without surgery. Fracture characteristics and complications were recorded. Pain scores, modified Harris Hip Scores (mHHS), and Hip Outcome Scores (HOS) were obtained and compared. The average fracture line in the operative group was 67% of the femoral neck width versus 18% in the nonoperative group (p < 0.001). There was no difference in outcome scores between the two groups. Prophylactic fixation of high-risk non-displaced FNSFs resulted in similar outcome scores to non-operative management of lower-risk variants at an average of 7.3 years follow up. No patient in either group progressed to a displaced femoral neck stress fracture. (Journal of Surgical Orthopaedic Advances 29(3):173–176, 2020)

Key words: femoral neck stress fracture, non-displaced, Harris Hip Score, Hip Outcome Score

Healing of Pathologic Humeral Fractures in Patients with Metastatic Disease: Consideration for Operative Fixation in Patients - Sandesh S. Rao, MD; Jad M. El Abiad, MD; Varun Puvanesarajah, MD; Micheal Raad, MD; Carol D. Morris, MD, MS; Jonathan A. Forsberg, MD, PhD; and Adam S. Levin, MD

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We compared short-term outcomes after operative versus nonoperative treatment of pathologic humeral fractures. We hypothesized that patients who underwent operative fixation would heal faster and have better pain control. A retrospective review was conducted of 25 patients who underwent operative fixation and 6 who received nonoperative treatment from 2005– 2017. Operative patients healed significantly earlier than nonoperative patients (p = 0.02). At 16-week follow-up, radiographs showed evidence of healing in 24 of 25 operatively treated patients and 2 of 6 nonoperatively treated patients (p < 0.01). Pain improved during the inpatient stay in 24 of 25 operatively treated patients and none of the nonoperatively treated patients (p < 0.01). All operatively treated patients returned to self-reported baseline motor function by final follow-up, whereas none of the nonoperatively treated patients returned to baseline (p = 0.01). Operative treatment was associated with earlier healing, pain control and return to function compared with nonoperative treatment of pathologic humeral fractures. Level of Evidence: 3. (Journal of Surgical Orthopaedic Advances 29(3):177–181, 2020)

Key words: fracture fixation, functional outcomes, intramedullary nail fixation, open reduction and internal fixation, operative treatment, pathologic humeral fracture

The Evolving Role of the Orthopaedic Surgeon in Combat Zones and Austere Deployed Locations Since the 2012 Troop Drawdown - Mark Slabaugh, MD; Daniel Kopolovich, MD; Richard J. Robbins, MD; and Francois Trappey, MD

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The purpose of this study was to evaluate the operative experience of orthopaedic surgeons in the various deployment locations since 2012. We also evaluated the implications of humanitarian surgical care and the impact of deployment on an orthopaedic practice. An emailed survey was sent to orthopaedic surgeons deployed after 2012. The survey was 48 questions. Most cases in Iraq, Afghanistan and Syria were emergent traumas. In other locations, however, most cases were elective/non-emergent cases. Of surgeons surveyed, 44% performed less than 10 cases during their deployment, and 50% considered humanitarian surgery part of their mission. Six weeks was needed to prepare for deployment, and 4.4 weeks to re-build a practice. Disparity exists in surgical case volume and types of cases performed by orthopaedic surgeons that is dependent on deployed location. This dichotomy in operative experience places surgeons deployed to such locations at risk of losing surgical skills. (Journal of Surgical Orthopaedic Advances 29(3):182–186, 2020)

Key words: deployment, military medicine, humanitarian surgical care (HSC)

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