Volume 29-4, Winter 2020

Feature Article

Dysfunction of the Lateral Branch of the Superficial Radial Nerve Associated with Radial Collateral Ligament Injuries of the Thumb Metacarpophalangeal Joint: A Case Series with Cadaveric Dissections - Robert G. Thompson, MD; Sravan C. Dhulipala, MD; and Gary M. Lourie, MD

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The lateral branch of the superficial radial nerve (SRN) may undergo a neuropraxic stretch injury following radial collateral ligament (RCL) injury to the thumb metacarpophalangeal joint. This case series presents seven athletes who sustained a previously undescribed injury pattern combining dysfunction of the lateral branch of the SRN associated with RCL injury. Successful stabilization of the joint as well as relief of pain was obtained with surgical repair of the RCL, neurolysis and wrapping of the nerve with a tissue engineered allograft product, and, when necessary, excision of a post-traumatic osteophyte. Diagnostic workup along with surgical treatment is presented. Additionally, cadaveric dissections confirmed the course of this nerve, proximity to surrounding structures, and its innervation of the MP capsule. (Journal of Surgical Orthopaedic Advances 29(4):195–198, 2020)

Key words: radial collateral ligament, lateral branch of superfi cial radial nerve, thumb metacarpophalangeal joint

Technical Tips and Pearls

Combined Total Talus Replacement and Total Ankle Arthroplasty - Lorena Bejarano-Pineda, MD; James K. DeOrio, MD; and Selene G. Parekh, MD, MBA

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Avascular necrosis (AVN) of the talus remains a clinical challenge with suboptimal outcomes after treatment. In cases of extensive disease, the insuffi cient blood supply leads to a high rate of complications including non-union after surgical treatment. This, in conjunction with the development of premature adjacent arthritis represents a challenge for the treating surgeon. Nowadays, total ankle arthroplasty is a reasonable option for the treatment of end-stage ankle arthritis with improved short- and long-term outcomes. We present a technique for patients with end-stage ankle arthritis associated to extensive talar osteonecrosis, and patients with prior total ankle replacement and talar component collapse due to AVN. This technique provides a more anatomic treatment for patients with severely defi cient bone stock due to talar necrosis with ankle arthritis or failed ankle replacement. Nonetheless, evaluation of the outcomes at long-term is needed. (Journal of Surgical Orthopaedic Advances 29(4):244–248, 2020) Key words: ankle arthritis, avascular necrosis talus, talar bone loss, talus replacement, ankle replacement

Technical Trick: The Trochanteric Hook Plate in Treatment of B1 Periprosthetic Femur Fractures - Suman Medda, MD; Tyler Snoap, MD; Holly T. Pilson, MD; Jason J. Halvorson, MD; and Eben A. Carroll, MD

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Vancouver B1 periprosthetic fractures undergoing operative fixation remain difficult to treat due to a short proximal segment that offers limited options for fixation. The trochanteric hook plate addresses this issue by maximizing proximal purchase and utilizing the entire lateral surface area of the greater trochanter. A surgical technique that prioritizes proximal fixation and adheres to basic principles resulted in all fractures healing in a small case series. (Journal of Surgical Orthopaedic Advances 29(4):199–201, 2020)

Key words: periprosthetic fracture, trochanteric hook plate, Vancouver B1 fracture, femur fracture

Noise Exposure and Risk of Noise Induced Hearing Loss to the Adult Reconstruction Surgeon: Recommendations for Prevention and Monitoring - Kelli S. Baum, DO; Anna E. Nichols, AuD; Michael E. Seem, MD; T. David Luo, MD; Dainnya Busbin, CIH; Maxwell K. Langfitt, MD1; and John S. Shields, MD

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Goal of the study was to determine the average noise exposure to the orthopaedic surgeon performing hip and knee arthroplasty and the benefit of customized hearing protection. Data from dosimeters (3MTM Edge 4) worn by three adult reconstruction orthopedic surgeons for a total of 27 operative day recordings was analyzed using 3MTM Detection Management Software (product version 2.7.152.0). Westone TRU custom hearing protection was used with different filters according to noise reduction rating (NRR). The overall average decibel level was 80.64 dB (73.6-87.2 dB, +/- 4.18). The peak decibel level averaged 103.66 dB (97.30-110.30, +/-3.02). The authors subjective trial of custom hearing protection determined the NRR 10 and 15 filters were most effective at noise reduction with adequate ability to communicate effectively. Our study demonstrates that the daily exposure to the total joint surgeon exceeds safe levels. (Journal of Surgical Orthopaedic Advances 29(4):202–204, 2020)

Key words: noise; arthroplasty; hearing loss

The Role of Body Mass Index in Perioperative Complications Among Patients Undergoing Total Knee Arthroplasty - Rolanda A. Willacy, MD; Olubode A. Olufajo, MD, MPH; Caldon J. Esdaille, BS; Hamza M. Raja, BS; and Robert H. Wilson, MD

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Obesity is a modifiable risk factor that causes mechanical forces to be exerted within the joints, further contributing to the debilitating effects of osteoarthritis. Total Knee Arthroplasty (TKA) can have a profound impact on patients with osteoarthritis, providing them with increased quality of life, improved function, reduction of pain, while simultaneously preventing the development of additional comorbidities. Although there is inconclusive evidence that increased body mass index (BMI) is linked to increased perioperative complications among TKA patients, recent studies suggest this association exists. The aim of this study is to provide conclusive data on the effects of BMI on perioperative complications in TKA using the national riskadjusted database, ACS-NSQIP. Our study demonstrated that there was a correlation between increased BMI and perioperative outcomes, particularly with surgical site infections, renal, and respiratory complications. (Journal of Surgical Orthopaedic Advances 29(4):205–208, 2020)

Key words: body mass index (BMI), total knee arthroplasty (TKA), obesity, comorbidities, perioperative outcomes

Cerclage Cable Tensioning of Intraoperative Hip Arthroplasty Proximal Femoral Fractures: A Cadaveric Model - Joshua D. Namm, MD; David Kaimrajh, MS; Edward Milne, BS; Ronald W. Lindsey, MD; and Loren Latta, PhD, PE

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Cerclage fixation following intraoperative fracture of the proximal femur during total hip arthroplasty (THA) carries a risk of compromising the femoral blood supply. Thus, we sought to determine the minimum cerclage cable tension required to restore the stability of a cementless femoral stem. Cementless femoral prostheses were implanted in seven proximal femoral cadaver specimens, and a periprosthetic fracture was simulated in the medial cortex. A single cerclage cable was placed just above the lesser trochanter and tensioned and tested at increasing intervals. The implant’s torsional stability was determined in the intact bone, prior to fixation, and at each level of cable tension. We found that a single cerclage cable placed above the lesser trochanter can significantly improve, but not fully restore, torsional stability following intraoperative periprosthetic femur fracture during THA. The optimal position for a single cerclage cable appears to be above the lesser trochanter. (Journal of Surgical Orthopaedic Advances 29(4):209–211, 2020)

Key words: total hip arthroplasty, periprosthetic fracture, cerclage, fracture fixation, total hip arthroplasty (THA) complications

Factor Associated with Successful Closed Reduction of Glenohumeral Fracture Dislocation - Shane Tipton, MD; Fiesky Alejandro Nunez, Jr., MD, PhD; Karanpreet Dhaliwal, MS; Matthew Duffin, MD; Ian AlKhafaji, MD; and Michael T. Freehill, MD

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The literature is scarce regarding the safety or efficacy of closed reduction attempts of acute glenohumeral fracture dislocations. The objective of this study was to assess the safety and success rate of attempted closed reduction of proximal humerus fracture dislocations. A retrospective review was performed on all proximal humerus fracture dislocations seen at one institution from 2011-2015 in order to evaluate for clinical scenarios with greater failure rates of glenohumeral fracture dislocation joint reductions by closed manipulation. The results indicate that, in general, reduction attempts are safe, but that success rates are inversely proportional to fracture severity. (Journal of Surgical Orthopaedic Advances 29(4):212–215, 2020)

Key words: proximal humerus fracture, dislocation, reduction, trauma

Lower Extremity Total Joint Arthroplasty Has Minimal Effect on Golf Handicap - Matthew L. Brown, MD; Blair S. Ashley, MD; Steven N. Copp, MD; and Kace A. Ezzet, MD

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Although the vast majority of arthroplasty surgeons allow patients to return to participation in golf following total knee arthroplasty (TKA) and total hip arthroplasty (THA), there is relatively little published data regarding how TKA or THA affects a patient’s golfing ability. The purpose of this study was to determine how golfers’ handicaps change following TKA and THA. We mailed a questionnaire to patients who had underwent primary TKA or THA at our institution and asked whether they played golf and for their golf handicap information network (GHIN) number. We then obtained handicap data for each patient that provided a GHIN number. Handicap increased 0.9 strokes 1 year following THA; however, this difference was not statistically significant (p = 0.20). Handicap increased 0.3 strokes 1 year following TKA; however, this difference was not statistically significant (p = 0.29). Our study demonstrates that despite improved implants, surgical techniques, and rehabilitation protocols that golf handicap does not change significantly following lower extremity total joint arthroplasty (TJA). (Journal of Surgical Orthopaedic Advances 29(4):216–218, 2020)

Key words: total hip arthroplasty, total knee arthroplasty, golf, handicap, functional outcomes

The Outcomes of Surgically Treated Distal Tibia Salter-Harris Type III and IV Fractures - Rahul Gupta, BS; Zachary Winthrop, MD; and William Hennrikus, MD

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Current literature suggests that distal tibia Salter-Harris Type III and IV fractures with > 2 mm of displacement should be treated surgically to minimize growth arrest. The objective of the current study is to determine, in Salter-Harris Type III and IV distal tibia fractures, if gap displacements < 2 mm post-surgery are associated with fracture union, if step-off s > 2 mm post-surgery are associated with osteoarthritis, and to determine how often growth disturbances are observed in surgically-treated patients. A retrospective case series review of fourteen patients with displaced distal tibia Salter-Harris Type III and IV fractures was performed. The patients were evaluated using Kärrholm’s method of clinical evaluation. The current study demonstrated that surgical reduction to < 2 mm gap displacement results in fracture union in all cases, reduction to < 2 mm does not result in osteoarthritis in any cases, and only 8% of patients demonstrated a growth disturbance with surgical intervention. (Journal of Surgical Orthopaedic Advances 29(4):219–224, 2020)

Key words: distal tibia fracture, Salter-Harris fracture, surgical reduction, gap displacement, step-off , growth disturbance

Spinal Anesthetic Type and Independent Risk Factors for Postoperative Urinary Retention Following Total Joint Arthroplasty - Andrew W. Kuhn, MD; Jonathan R. Lynch, MD; Carolyn G. Ahlers, BS; and
Gregory G. Polkowski, MD, MSc

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While risk factors for postoperative urinary retention (POUR) after total joint arthroplasty (TJA) have been identified, its association with type of spinal anesthetic has not yet been thoroughly investigated. Patients undergoing primary TJA between 2013–2018 were reviewed. From August 2013 to March 2016 bupivacaine was primarily given and from March 2016 through August 2018, most, although not all, received mepivacaine. Patient demographics as well as intraoperative data were recorded. One-thousand and fifty-four patients were included. POUR rates were not significantly different between groups (5.5% vs 6.1%, p = 0.675). Those who received mepivacaine had a significantly shorter length of stay (LOS) (1 vs. 2 days, p < 0.001). However, spinal anesthetic type was not significantly associated with either POUR or LOS after controlling for between-group differences. Older age (odds ratio [OR] 1.024 [95% confidence interval {CI}:1.000–1.049]; p = 0.049) and a history of benign prostatic hyperplasia or urinary incontinence/retention (OR 2.155 [95% CI:1.114–4.168]; p = 0.023) were confirmed as independent risk factors for POUR. (Journal of Surgical Orthopaedic Advances 29(4):225–229, 2020)

Key words: spinal anesthesia, total joint arthroplasty, urinary retention, risk

Identification of Microsurgical Suture Needles in the Hand Using Plain Radiographs - Francis Bustos, MD; Nathan S. Lanham, MD; Noah J. Orfield, PhD; Peter J. Apel, MD, PhD; and Cay M. Mierisch, MD

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Our objective is to determine if radiographs are adequate for identification of retained microsurgical needles. Four microsurgical needles ranging from 3.8 mm to 6.5 mm in length and 50 μ to 130 μ in diameter were affixed to an anthropomorphic phantom limb. Portable radiograph images were then obtained and viewed by a group of 20 subjects comprised of attending radiologists, attending orthopaedic surgeons, orthopaedic surgery residents and operating room nurses. For all subjects, 3.35 out of 4 needles were identified in a mean 4.7 minutes. Radiologists identified all four needles and needed the least amount of time (mean 2.3 minutes). Orthopaedic surgery attendings identified a mean 3.5 of 4 needles while orthopaedic surgery residents and operating room nurses identified a mean 3 of 4 needles. Identification of microsurgical needles is possible using digital radiographs but requires 2–5 minutes of searching the image and adjusting the windows. (Journal of Surgical Orthopaedic Advances 29(4):230–233, 2020)

Key words: microneedles, radiographs, retained surgical instruments, microsurgical needles

Outcomes for Pauwels’ Osteotomy in Nonunions of Displaced Femoral Neck Stress Fractures: A Case
Series - Wei Wei Wu, MD; Ryan Christopher Myers, MD; and Kevin Matthew Kuhn, MD

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Femoral neck stress fractures (FNSF) are rare injuries and have shown poor results after displacement, including nonunion and osteonecrosis (ON). The goal of this study was to retrospectively evaluate a series of patients who underwent a valgus producing intertrochanteric osteotomy for FNSF nonunion and assess the degree of Pauwels’ correction, ON rate, and return to duty. Current functional outcomes were prospectively obtained via a telephone script. Six patients underwent Pauwels’ osteotomy for FNSF nonunion, and all went onto bony union. Three of the six patients progressed onto ON, with two patients requiring a total hip arthroplasty due to life-limiting symptoms. Pauwels’ osteotomy is a reliable salvage procedure for FNSF nonunions. (Journal of Surgical Orthopaedic Advances 29(4):234–239, 2020)

Key words: femoral neck stress fractures, nonunions, Pauwel’s osteotomy, valgus intertrochanteric osteotomy

Opioid Prescribing Guidelines for Arthroscopic Partial Meniscectomy Based on Patient-reported  Opioid Consumption - Justin Turcotte, PhD, MBA; Samuel Taylor, BS; Andrew Palsgrove, BS; Jeffrey Gelfand MD; Benjamin Petre, MD; and Daniel Redziniak, MD

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The purpose of our study was to determine the optimum number of opioid pills and morphine milligram equivalents (MME) required to treat postoperative pain following arthroscopic partial meniscectomy. A retrospective cohort study of 77 patients undergoing arthroscopic partial meniscectomy between January, 2017 and May, 2019 was conducted. Of patients, 19.48% took no opioids following surgery. Patients were prescribed 84.34 ± 49.54 MME on average and took 28.23 ± 40.99 MME. This equated to an average of 16.52 ± 8.85 narcotic pills prescribed and 4.90 ± 6.26 pills taken. Of 77 patients, 66 (85.7%) took less than 10 total pills, and 57 (74.0%) took 5 or fewer. Patients undergoing arthroscopic partial meniscectomy are commonly overprescribed opioids postoperatively. On average, patients consumed just under fi ve narcotic pills, less than one-third of the number prescribed. A standard prescription of 5 opioid pills or 25 MME is recommended for patients undergoing arthroscopic partial meniscectomy. (Journal of Surgical Orthopaedic Advances 29(4):240–243, 2020)

Key words: meniscus, meniscectomy, opioid, narcotics, pain

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