Feature Article: Prospective Randomized Study Evaluating the Effects of Preoperative Opioid Counseling on Postoperative Opioid Use After Outpatient Lower Extremity Orthopaedic Surgery - Taylor Paskey; Sage Vincent; Elizabeth Critchlow; Erica Mann; Talia Chapman, MD; Christopher Aland, MD; Christopher Dodson, MD; William Emper, MD; Kevin B. Freedman, MD; David Pedowitz, MD; and Asif M. Ilyas, MD

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The objective of this study was to investigate the effect of standardized preoperative opioid counseling on postoperative opioid consumption for patients undergoing outpatient lower extremity orthopaedic surgery. Participating patients undergoing elective outpatient lower extremity orthopaedic surgery were randomized to either receive preoperative opioid counseling or not receive counseling (control group). Counseling was delivered via a five-minute pre-recorded standardized video preoperatively. Postoperatively, patients in both groups were queried for their postoperative pain experience, opioid consumption, non-opioid medication consumption, and any adverse effects related to their pain management experience. A total of 107 patients were studied, with 45 in the counseling group and 62 in the control group. Patients that received preoperative opioid counseling consumed on average 6.5 opioid pills postoperatively; the control group consumed 12.4 opioid pills (p = 0.008). Preoperative opioid counseling resulted in a statistically significant reduction in postoperative opioid consumption after outpatient lower extremity orthopaedic surgery. (Journal of Surgical Orthopaedic Advances 30(1):002–006, 2021)

Key words: opioid, narcotics, counseling

Feature Article: Role of Depression in Total Knee Arthroplasty: A Retrospective Analysis of Perioperative Outcomes in Patients in the United States - Donald Chuang, MD; Sapan Shah, MD; Hristo Piponov, MD; Olivia Wang, MD; Michael Redondo, MD; Diego Barragan Echenique, MD;  Nickolas Boroda, MD; Feroz A. Osmani, MD; and Mark H. Gonzalez, MD, PhD

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We evaluate the patient demographics, perioperative outcomes, in-hospital complications, and assess recent national trends in clinically depressed and non-depressed patients undergoing primary total knee arthroplasty (TKA). Using the National Hospital Discharge Survey from 2001 and 2010, patients undergoing primary TKA in the United States were identified based upon the diagnosis of depression. Differences in gender, patient-demographics, comorbidities, complications, length of stay, and discharge disposition were analyzed. A total of 32,761 TKA patients were identified, consisting of 1,880 patients with a diagnosis of depression and 30,881 patients without. The depression group had an average age significantly younger than the non-depression cohort (p < 0.01). The depression group contained a significantly greater percentage of females when compared to the non-depression group. The non-depression group had a significantly greater percentage of African-Americans (p < 0.01), and a significantly smaller percentage of Caucasians (p < 0.01). Our findings contribute to the literature on the role of depression on perioperative outcomes of TKA. (Journal of Surgical Orthopaedic Advances 30(1):007–009, 2021)

Key words: depression, total knee arthroplasty, psychiatric conditions

Particulated Juvenile Articular Cartilage Allograft for Treatment of Chondral Defects of the Knee: Short-Term Survivorship with Functional Outcomes - Brian R. Waterman, MD, MAJ MC USA; Scott M. Waterman, MD; Brendan McCriskin, MD, MAJ MC USA; Edward C. Beck, MD, MPH; and Richard M. Graves, MD

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While basic science research confirms the robust biological profile of juvenile chondrocytes, the clinical outcomes after particulated juvenile cartilage allograft transplantation are not well established. A retrospective analysis of active duty servicemembers undergoing surgical treatment with particulated juvenile articular cartilage allograft transplantation for chondral defects of the knee from two military treatment facilities was completed. Demographic variables, operative details, activity limitations, and medical discharges were obtained. A total of 29 patients with 36 treated chondral defects were isolated at an average follow-up of 16.2 months. The cohort was comprised of male service members in the Army with mean age of 33.1 years. Location of chondral lesion included the patellofemoral articulation (patella 39%, trochlea 31%, bipolar lesions 8%) and condyles (31%). Offloading or realignment osteotomy procedures were performed in 7 patients (23%). Of all patients, 14 servicemembers (48%) underwent knee-related medical discharge, and one patient underwent conversion to total knee arthroplasty. In this small patient cohort, particulated juvenile cartilage allograft transplantation for chondral defects of the knee did not reliably restore military servicemembers to full military function. At least one in two patients had persisting knee pain after chondral restoration procedure. (Journal of Surgical Orthopaedic Advances 30(1):010–013, 2021)

Key words: chondral defects, minced juvenile articular cartilage, cartilage transplantation, return to duty, knee pain

Geographic Variation in Physician Payments from Private Insurers for Commonly Performed Inpatient Orthopaedic Surgeries in the United States - Majd Marrache, MD; Suraj Dhanjani, BS; Andrew B. Harris, BS; Varun Puvanesarajah, MD; Micheal Raad, MD; Olivia Petrusky, BS; Uma Srikumaran, MD; and Amit Jain, MD

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We investigated geographic variation in percentage of private insurance payments to United States physicians for commonly performed orthopaedic procedures. We queried a private administrative claims database for patients who underwent inpatient total knee arthroplasty (TKA), total hip arthroplasty (THA), single-level anterior cervical discectomy and fusion (ACDF), and posterior lumbar fusion (PLF) from 2010 to 2017. Percentage of total payments to physician (PPP) was calculated by dividing physician payments by total payments. Analysis of variance was used to determine geographic differences in PPP. A total of 542,530 patients were included, mean age was 55 ± 8. PPP significantly varied between states for all four procedures (p < 0.001); Colorado and Alabama had the lowest and highest PPP, respectively. There was a significant annual decrease in PPP across all regions in all procedures. There was significant variation in percentage of total payments to physicians across geographic regions in the United States for TKA, THA, ACDF and PLF. (Journal of Surgical Orthopaedic Advances 30(1):014–019, 2021)

Key words: geographic variation, percentage of total physician payments, private insurance, health economics research, cost effectiveness.

Are All Hardware Removals Equal? - Jesse M. Galina, BS; Vishal Sarwahi, MD; Aaron M. Atlas, BS; Sayyida S. Hasan, BS; Terry D. Amaral, MD; Yungtai Lo, PhD; and Lior Shabtai, MD

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The objective of this study is to report operative time and associated complications of six types of implants and to determine if surgeons are adequately compensated. Hardware removals were analyzed from 2014–2019. Implants were flexible nails, intramedullary rigid nails, long plates, screw(s), single guided-growth plates, and multiple guided-growth plates. Patient demographics, operative time, blood loss, complications, and relative value units (RVU)/min were collected. RVU/min was used to maximize rate. In total, 392 patients were analyzed. Long plate removals took significantly longer than screw removal, therefore RVU/min was significantly lower (p < 0.001). Long plate removals also took significantly longer, and RVU/min was significantly lower compared to guided-growth plate removal (p < 0.001). Intramedullary nails took significantly longer compared to flexible nails, nearly double the RVU/min (p = 0.02). The results from this study indicate that the RVU/ minute for these six diff erent types of implant removals are not equal. Surgeons can use this data to set up their schedule to ensure maximum utilization. (Journal of Surgical Orthopaedic Advances 30(1):020–023, 2021)

Key words: implant removal, operative time, relative value unit, productivity, value-based care

Are Comorbidities Affecting Rotator Cuff Repair Outcomes? A Retrospective Review of Postoperative Costs and Complications - Alexander T. Bradley, MD; Ye Lin, BS; Kiera A. Kingston, MD; Jason L. Koh, MD; Michael J. Lee, MD; and Lewis Shi, MD

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Our study examines the effect of comorbidities on rotator cuff repair (RCR) postoperative costs and complication rates. A retrospective review of patients receiving RCRs from 2008-2016 using the PearlDiver database was performed. We evaluated the effect of major comorbidities on postoperative costs and complications within one year of surgery. In total, 8,747 patients underwent RCR. Patients with no comorbidities had a 6-month and 12-month postoperative cost of $3,534 and $3,853, respectively. Patients with one comorbidity had 6-month postoperative costs ranging from $2,623 to $3,466 and 1-year postoperative costs ranging from $2,992 to $5,906. Patients with 3+ comorbidities receiving arthroscopic RCR had the highest complication rates at 1-, 3- and 6-month intervals (11.8%, 19.7% and 26.8%, respectively) compared to those with no comorbidities (8.1% [p = 0.139], 12.7% [p = 0.022] and 15.9% [p = 0.001], respectively). Patients with isolated comorbidities likely require similar healthcare utilization to those without, but patients with 3+ comorbidities risk greater complications and higher post-operative costs. (Journal of Surgical Orthopaedic Advances 30(1):024–029, 2021)

Key words: rotator cuff repair, postoperative costs

An Applicant’s Residency Program Region May Influence Where They Complete Fellowship - Chad A. Krueger, MD; Jonathan R. Helms, MD; Anthony J. Bell, MD; Heidi Israel, PhD, MD; Lisa K. Cannada, MD

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The primary goal of this study was to determine if an applicant’s geographic region of residency was associated with where they matched for fellowship. San Francisco Match (SF Match) provided results regarding applicant data and match results from 2014–2018 for orthopaedic subspecialties except hand and shoulder and elbow. Residency programs were divided into five regions: (Northeast [NE], Southeast [SE], Midwest [MW], Southwest [SW] and West [W]). The MW region had the fewest number of fellowship positions per applicant (0.62), the W region had the most (1.7). Applicants from each region were significantly (p < 0.0001) more likely to complete fellowship in the same region where they completed residency, and there were significant (p < 0.05) differences between regions for specific subspecialties. There are imbalances in terms of the number of applicants and specific fellowship spots available in each region. This imbalance seems important considering the strong associations found between the region in which an applicant completes residency and fellowship. Level of Evidence: Level 3. (Journal of Surgical Orthopaedic Advances 30(1):030–035, 2021)

Key words: fellowship, match, orthopaedic residency, orthopaedic match

Flexor Tendon Repair with Adjunctive Botulinum Toxin Administration: A Systematic Review - Christopher J. Alberts, DO; Justin D. Orr, MD; Leon J. Nesti, MD, PhD; and John C. Dunn, MD

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Chemical denervation with Botulinum toxin has been proposed as an augment therapy to flexor tendon repairs to decrease complications including adhesions and re-rupture. We compiled and analyzed the results and complications for chemical denervation with Botulinum toxin in augmentation of flexor tendon repairs. Reviewed studies were from 1990–2018 and contained a minimum 3-month follow-up. A total of 26 patients were included in this review. All patients were reported to have excellent or good outcomes by the Strickland or Kleinert criteria. Complications were present in 9.3% of fingers including one with a flexion contracture, one with postoperative swelling, one with bowstringing, one with residual hypesthesia and first web contracture. Only one patient required re-operation. There were no cases of re-rupture or adhesions reported. All complications were unrelated to the use of Botulinum toxin. We conclude that Botulinum toxin therapy is a safe and efficacious augmentation to flexor tendon repair. (Journal of Surgical Orthopaedic Advances 30(1):036–039, 2021)

Key words: flexor tendon repair, botulinum, chemprotection, bioprotection

Webril-only Soft Spica Cast for Pediatric Femoral Fractures: A Preliminary Study - Achraf Jardaly, BS; Matthew Hess, MD; Michael Conklin, MD; and Shawn Gilbert, MD

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We report using a spica cast created with cotton padding and Ace wrap without a rigid component for femur fracture in infants. Outcomes and complications of this soft spica cast were retrospectively compared with other treatments. There were 43 children younger than 6 months (43 diaphyseal fractures) included in the study. Treatment was a Pavlik harness (26 patients), a hard spica cast (8), or a soft spica cast (9) for an average of 3 weeks. All fractures demonstrated healing with similar final angulation and shortening. Hard spica casts caused the most complications. As for material costs, the soft spica is the least costly method ($2 per cast versus $87–$107 for Pavlik harness and $150 for hard spica). In conclusion, soft spica casts are as effective as other treatment options for femoral shaft fractures in young children. These casts are advantageous since they are easier to apply, easier to manage, and have a lower cost. (Journal of Surgical Orthopaedic Advances 30(1):040–043, 2021)

Key words: femur fractures, children, spica cast, Pavlik harness, orthopaedics

Bilateral Nerve Involvement in Lipomatosis of Nerve - Tomas Marek, MD; Kimberly K. Amrami, MD; Robert J. Spinner, MD; and Mark A. Mahan, MD

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Lipomatosis of nerve (LN) is an intriguing pathological entity defined by the abundance of fibro-adipose tissue within the epineurium, a pathognomonic magnetic resonance imaging (MRI), and frequently associated nerve-territory overgrowth. A recent systematic review showed that the majority of cases are unilateral and predominately involve the median nerve. We reviewed bilateral cases of LN to further understand this pathology. We conducted a review of the literature and our institutional databases. The cases from the literature were sorted into three groups – bilaterally confirmed LN (n = 9), unilaterally confirmed, opposite side probable LN (n = 4), and probable bilateral LN (n = 10). Review of our institutional databases identified one case: a 47-year-old man. MRI revealed LN of the brachial plexus bilaterally. To our knowledge, this is the first reported case of brachial plexus LN occurring bilaterally. More research is necessary on this topic to further understand the genetic background of this entity, particularly in relationship to the overgrowth. (Journal of Surgical Orthopaedic Advances 30(1):044–049, 2021)

Key words: lipomatosis of nerve, brachial plexus, bilateral, fibrolipomatous hamartoma

Three-dimensional Computed Tomography Posterior Iliac Oblique Images Enhance Preoperative Planning for Acetabular Fracture Surgery - Matthew P. Sullivan, MD; Zachary L. Telgheder, MD; and Conor P. Kleweno, MD

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The advent of computed tomography and development of three-dimensional (3-D) reconstructions has allowed for profound advances in the understanding of complex acetabular fractures. The authors sought to determine the impact of 3-D reconstructions on understanding of the morphology of these injuries. A survey of 20 fellowship-trained orthopaedic trauma surgeons was undertaken to assess the utility of these reconstructions on understanding three complex posterior acetabulum fractures. Respondents noted significantly better understanding of posterior wall and transverse-posterior wall fracture patterns compared to a posterior column-posterior wall pattern when utilizing two-dimensional imaging only. The respondent’s understanding of all three patterns was improved with the addition of 3-D reconstructions. With regards to individual images, posterior iliac oblique reconstructions obtained at 36-degree and 54-degree from posterior were reported to be most helpful in improving understanding of fracture morphology. Three-dimensional reconstructions of posterior acetabular fractures are effective in enhancing understanding of fracture morphology. (Journal of Surgical Orthopaedic Advances 30(1):050–054, 2021)

Key words: acetabulum, computed tomography, three-dimensional, fracture, trauma

Intramedullary Nail Fixation of Intra-articular and Extra-articular Proximal Tibia Fractures - Anokha Padubidri, MD; Anthony T. Sorkin, MD; Andrew Gudeman, MD; Roman M. Natoli, MD, PhD; and Greg E. Gaski, MD

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Recent studies suggest advantages to intramedullary nailing (IMN) of extra-articular proximal tibia fractures compared to plating. To our knowledge, no studies have evaluated IMN treatment of proximal tibia fractures with simple articular extension. We sought to compare rate of reoperation, malalignment, and patient-reported outcomes in patients with intra-articular versus extra-articular proximal tibia fractures treated via IMN. This retrospective cohort study compared patients that underwent IMN of extra-articular proximal tibia fractures (AO/OTA 41A2 and A3; n = 33) to simple intra-articular fractures (AO/OTA 41C1 and C2; n = 20) with minimum 12-month follow-up. With the numbers available, no significant differences were detected between the extra- and intra-articular groups for unplanned reoperation (9/33 vs. 2/20, p = 0.18), infection (4/33 vs. 1/20, p = 0.64), nonunion (4/33 vs. 2/20, p > 0.99), or malunion (5/30 vs. 3/19, p > 0.99). IMN of simple intra-articular proximal tibial fractures is a reasonable treatment strategy that may be desirable in certain clinical situations. (Journal of Surgical Orthopaedic Advances 30(1):055–060, 2021)

Key words: fracture, tibia plateau, proximal tibia, intramedullary nail; PROMIS, AO/OTA 41C

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