Feature Article: Operative vs. Nonoperative Treatment of Isolated Humeral Shaft Fractures: A Prospective Cohort Study - Lisa K. Cannada, MD; Lauren Nelson, MD; Paul Tornetta, III, MD; Robert Hymes, MD; Clifford B. Jones, MD; William Obremskey, MD MPH; Eben Carroll, MD; Brian Mullis, MD; Michael Tucker, MD; David Teague, MD; Andrew Marcantonio, DO; Robert Ostrum, MD; Michael Del Core, MD; Heidi Israel, PhD

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The purpose was to compare plate and screw fixation (open reduction internal fixation [ORIF]) and functional bracing (FB) of isolated humeral shaft fractures with treatment and patient-based outcomes. We performed a prospective trial of ORIF v. FB at 12 centers. Surgeons counseled patients on treatment options and a patient centered decision was made. We enrolled 179 patients, of which 6-month data was analyzed for 102 (39 female; 63 male). Forty-five were treated with ORIF and 57 with FB. We found no difference in the disability of the arm, shoulder and hand (DASH) score, visual analogue score (VAS) or elbow range of motion (ROM) at 6 months. However, 11% of the FB group developed nonunion. Complications in the ORIF group included a 2% infection and nonunion rate and 13% iatrogenic radial nerve dysfunction (RND). ORIF can be expected to result in higher union rates with the inherent risks of infection and RND. Finally, at 6 months, both groups demonstrated higher DASH scores than population norms, indicating a lack of full recovery. (Journal of Surgical Orthopaedic Advances 30(2):067–072, 2021)

Key words: humeral shaft fractures, plate fixation, functional brace, nonunion, DASH score

Feature Article: Is There a Critical Radiographic Angle That Portends Poor Functional Outcome Scores in Nonoperative Treatment of Isolated Humeral Shaft Fractures? - Brian W. Hill, MD; Lisa K. Cannada, MD; Lauren Nelson, MD; Paul Tornetta, III, MD; Robert Hymes, MD; Clifford B. Jones, MD; William Obremskey, MD, MPH; Eben Carroll, MD; Brian Mullis, MD; Michael Tucker, MD; David Teague, MD; Andrew Marcantonio, DO; Robert Ostrum, MD; Michael Del Core, MD; Heidi Israel, PhD

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Acknowledgements: Sarah Dawson, RN; Molly Moore; Martha B. Holden; Valda Frizzell; Lolita Ramsey; Andres Rodriguez; Janet Wells; John Garfi ; Chad Helgeson; and Holly Tyler-Paris Pilson. This study represents a collaboration of the Southeast Fracture Consortium (SEFS) and the Orthopaedic Trauma Research Consortium (OTRC). Our purpose was to evaluate radiographic alignment of nonoperatively treated humerus fractures and determine if there is a critical angle associated with worse outcomes. All patients with humeral shaft fractures that were prospectively followed as part of a larger multicenter trial were reviewed. These patients were selected for nonoperative management based on shared decision making. There were 80 patients that healed with adequate data. The receiver operating characteristic (ROC) had best fit with a sagittal radiographic angle of 10° (AUC: 0.731) and coronal angle of 15° (AUC: 0.580) at 1-year follow-up. We found increased or worse disabilities of the arm, shoulder and hand (DASH) scores with > 10° sagittal alignment or > 15° of coronal alignment. Poor DASH scores were observed at angles lower than previously accepted for nonoperative treatment. These findings are useful in decision making and patient guidance. (Journal of Surgical Orthopaedic Advances 30(2):073–077, 2021)

Key Words: humeral shaft fractures, malunion, functional brace, nonunion, DASH score

Anatomic Considerations Regarding the Placement of a Retrograde Intramedullary Fibular Screw - Suman Medda, MD; Amy P. Trammell, MD; and Robert D. Teasdall, MD

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The purpose of this study was to identify the ideal start site for a retrograde intramedullary fibular cortical screw based on its relationship to the surrounding soft tissue structures and to assess for damage to the surrounding soft tissue structures caused during placement of the screw. Four fresh frozen cadavers underwent fluoroscopic placement of a 3.5 mm cortical screw utilizing a standardized protocol. No damage to the peroneal tendons were noted in any cadaver with the foot in an inverted and plantarflexed position. The closest structure to the center of the screw head was the anterior talofibular ligament anteriorly (3.33 mm range: 3–4 mm) and the calcaneofibular ligament posteriorly (2.66 mm, range: 2–3 mm). Two screws violated the malleolar fossa medially and were noted to impinge on the lateral process of the talus. The ideal start site for a 3.5 mm intramedullary fibular screw is at the midline on the lateral radiograph and 3.0 mm lateral to the malleolar fossa on the AP radiograph. This avoids damage to the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) and prevents impingement on the lateral process of the talus. (Journal of Surgical Orthopaedic Advances 30(2):078–081, 2021)

Key words: fibular screw, intramedullary fibular implant, peroneal tendons, fibula fracture

No Increase in Instability with Obturator Externus Release in Direct Anterior Approach - Marc Hungerford, MD; Thomas Hendricks, MD; Philip Neubauer, MD; and Ashlie Boner, BS

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Use of the direct anterior approach in total hip arthroplasty is becoming increasingly common. Complications associated with this approach pertain to proximal femoral exposure. Selective capsular and tendinous releases improve exposure intraoperatively. Release of obturator externus has been avoided to prevent postoperative instability. A retrospective casecontrol review of consecutive patients who underwent direct anterior approach was performed. Demographic information, sequence of releases performed, dislocations that occurred postoperatively, and revision total hip arthroplasties (THAs) were recorded. Overall dislocation rate was 0.6% (2/340). Obturator externus release was performed in 169 cases (49.7%). Both groups with and without release experienced a single dislocation event (p = 1.0). Overall revision rate was also 0.6% (2/340). One dislocation underwent revision for instability. Selective release of obturator externus after other releases have failed to improve proximal femoral exposure does not result in an increased rate of postoperative hip instability in direct anterior approach THA. (Journal of Surgical Orthopaedic Advances 30(2):082–084, 2021)

Key words: direct anterior, obturator externus, dislocation

Opioid Prescribing Patterns and Patient Satisfaction with Care - MAJ Nathan S. Lanham, MD; CPT Kyle Bockelman, DO; CPT Michael J. Elsenbeck, MD; LTC Brendan J. McCriskin, MD; MAJ (P) Scott H. Robinson, MD; MAJ James N. Foster, MD, MAJ (ret) Jacob C.L Rumley, DO

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We sought to examine the relationship between opioid prescribing patterns and patient reported satisfaction with care. Opioid prescribing was characterized in terms of morphine equivalent daily dosing (MEDD), total morphine equivalent dosing (TMED), and total number of opioid prescriptions. A total of 1,666 opioid prescriptions were written for a TMED of 379,660 and a median MEDD of 204 (interquartile range [IQR] 195–269) from 2017–2019. Two hundred and forty-four patient satisfaction surveys were obtained for review and comparison. During the study period, 2,358 cases were performed, and no statistically significant differences were found with respect to case distribution among orthopaedic surgeons at our institution. High patient satisfaction, defined as achieving a 100 on a 0-to-100 scale, was found to have no association with MEDD (odds ratio = 0.968; 95% confidence interval [CI], 0.925–1.014), TMED (odds ratio = 1.00; 95% CI, 1.00–1.01), or total number of opioid prescriptions (odds ratio = 1.003; 95% CI, 0.905–1.112). (Journal of Surgical Orthopaedic Advances 30(2):085–089, 2021)

Key words: opioid crisis, patient satisfaction, army, morphine equivalent daily dosing, total morphine equivalent dosing

The Impact of Certificate of Need Status on the Utilization and Reimbursement of Open and Endoscopic Carpal Tunnel Release - Sahitya K. Denduluri, MD; Allison Roe, MD; Abiram Bala, MD; Nathaniel Fogel, MD; Chason Ziino, MD; and Robin N. Kamal, MD

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A certificate of need (CON) permits a healthcare organization to build new facilities only if significant medical needs exist. Many states have implemented CON programs to prevent procedure overutilization and price inflation. We hypothesized that there are no differences in reimbursement or utilization for open and endoscopic carpal tunnel release (CTR) when comparing states with and without CON programs. We queried a private-payer database to identify open and endoscopic CTRs performed between 2007 and 2015. In total, 82,689 CTRs were identified: 70,160 open, 12,529 endoscopic. Reimbursement increased for open procedures (compound annual growth rate [CAGR] 1.0% CON, 1.4% non-CON) but only marginally increased or decreased in the endoscopic group (CAGR -0.8% CON, 0.2% non-CON). Utilization increased across all settings, and was highest in the endoscopic CON group (CAGR 17.9%). Least growth was seen in the open non-CON group (CAGR 10.0%). Overall, CON programs may not actually decrease CTR spending or utilization. (Journal of Surgical Orthopaedic Advances 30(2):090–092, 2021)

Key words: certificate of need, carpal tunnel release, open, endoscopic, utilization, reimbursement

Orthopaedists Versus Radiologists: A Prospective Comparison of Radiographic Interpretation Between Orthopaedists and Radiologists at a Level I Trauma Center - Griffin Biedron, MD; Reuben Macias, MD; Isaac Fernandez, MD; Nicholas Kusnezov, MD; John C. Dunn, MD; and James H. Nelson, MD

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The purpose of this investigation was to evaluate the difference in response time, accuracy of radiographic interpretation, and frequency of changes in clinical management necessary after inaccurate reads when comparing orthopaedic and radiology providers. Data including provider response time, accuracy of radiographic interpretation and the frequency of changes in clinical management necessary after imaging reads was collected over a continuous two-month period at a Level I Trauma Center. A total of 188 orthopedic injuries involving imaging were included. Orthopedic providers responded 203.2 minutes sooner than radiology providers. Accuracy of radiographic interpretation of the orthopaedic and radiology providers was 100% and 91%, respectively. Frequency of changes in clinical management after inaccurate interpretation of imaging by the orthopaedic and radiology provider was 0% and 7.6%, respectively. Based on our study, orthopaedic providers are significantly faster, more accurate, and make fewer mistakes affecting patient care while interpreting images of orthopaedic injuries than our radiology colleagues. (Journal of Surgical Orthopaedic Advances 30(2):093–096, 2021)

Key words: orthopaedics, radiology, radiographic interpretation, skeletal radiographs

Readability Level of English and Spanish Orthopaedic Patient Education Materials English and Spanish Patient Education - Michael J. Patetta, MD; Kristina M. Pond, BS; Elizabeth M. Tennant, MD; Anshum Sood, MD; and Mark H. Gonzalez, MD, PhD

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There are 16 million Hispanic people in the United States who rely on Spanish as their only effective method of communication. However, there is a scarcity of literature evaluating if patient education resources in Spanish meet the average American reading level or National Institute of Health (NIH) and American Medical Association (AMA) grade-level recommendations, especially in the field of orthopaedics. Representative orthopaedic search terms were input into Google and ten articles pertaining to patient education were selected. Videos, scientific journals, and surgical technique guides were excluded. Articles were then digitally analyzed and compared. Mean United States grade level equivalent was 11.26 ± 2.23 for English articles and 10.55 ± 1.45 for Spanish articles. English orthopaedic materials featured a significantly more difficult grade level (p < 0.01) than equivalent Spanish works. Spanish orthopaedic materials generated in the United States featured significantly lower (p < 0.01) readability scores than those written outside the United States. Our study demonstrated both English and Spanish materials were written at a high school level. Spanish materials were written at more appropriate grade-levels than their English counterparts. (Journal of Surgical Orthopaedic Advances 30(2):096–100, 2021)

Key word: patient education, orthopaedics, racial and ethnic disparities, patient outcome

Legislation Only Limiting Opioid Prescription Length Has Minimal Impact on Prescribing in Orthopaedic Trauma - Daniel J. Cunningham, MD, MHSc; Micaela L. LaRose, BA; Isabel F. DeLaura, BS; Gloria X. Zhang, BS; Christopher S. Klifto, MD and Mark J. Gage, MD

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This study evaluates the efficacy of North Carolina’s Strengthen Opioid Misuse Prevention (STOP) Act in reducing the volume and rate of 90-day perioperative opioid prescribing to patients ages 18 and older after orthopaedic trauma surgery. Patients undergoing fracture surgery from January 2017 to June 2017 (pre-STOP) were compared with patients undergoing fracture surgery from January 2018 to June 2018 (post-STOP). Adjusted analyses demonstrated that patients undergoing surgery after the STOP Act (n = 730) were prescribed significantly lower volume of opioids in the discharge to 2-week time frame and at the first postoperative prescription (7.3 and 5.8 fewer oxycodone, respectively). Otherwise, there were no significant differences between the two cohorts in adjusted volume or rates of 90-day opioid prescribing. The STOP act has had only a minor impact on early post-discharge opioid prescribing in patients undergoing fracture surgery. These findings question the efficacy of this type of legislation in combating opioid overprescribing in orthopaedic trauma. (Journal of Surgical Orthopaedic Advances 30(2):101–107, 2021)

Key words: opioid prescribing, Strengthen Opioid Misuse Prevention (STOP) Act, orthopaedic trauma surgery

Visual Estimation of Length by Orthopaedic Surgeons: How Accurate Are Lengths Estimated in Digital Images Compared to In-Person Estimations? - S. Craig Morris, MD; Joshua N. Speirs, MD; Christopher K. Heinrich, BS; and M. Daniel Wongworawat, MD

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Orthopaedic surgeons are frequently required to make estimations, often without the use of measuring tools, including the lengths of wounds, incisions, bone fragments, and soft tissue defects. To evaluate the accuracy of these estimations, simulated wounds of randomized lengths were drawn on a healthy volunteer. Resident and attending physicians estimated the length of each wound via digital photograph and subsequently in person. Comparison of digital photograph versus in-person estimation was completed with paired t-test. The accuracy of estimation by experience level was assessed using Spearman rank. Accuracy was higher with in-person measurement compared with digital photographs, but overall low in both settings. There was no correlation between better accuracy and more experience in either setting. In order to properly guide treatment decisions and document physical exam findings, a ruler should be used rather than visual estimation alone. Likewise, clinical photographs used for patient care should always include a ruler. (Journal of Surgical Orthopaedic Advances 30(2):108–111, 2021)

Key words: visual estimations, digital images, estimation, wound length, open fracture

Bringing Physical Exam Skills Back from the Dead - James Ross Bailey, MD; David C. Tapscott, MD; Norman Y. Otsuka, MD; Kyle T. Boden, MD; Robert M. Becker, BS; Tom E. Kwasigroch, MD; and Brian D. Johnston, PhD

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Physical examination education begins early for medical learners. A hindrance to physical exam competency is lack of exposure to pathology in standardized patient settings. This research focuses on improving medical education through the utilization of cadavers that have undergone a soft-embalming technique: the Thiel method. Three scenarios were created in four Thiel cadavers: anterior cruciate ligament (ACL) tear, posterior cruciate ligament (PCL) tear, and sham incision. Students were asked to diagnose ACL tears using the Lachman exam. A total of 54 learners participated in the study. Post-surveys indicated most learners: (1) prefer to use standardized patients (SPs) and soft-embalmed cadavers in their physical examination courses, (2) increased their confi dence in performing the Lachman exam on real patients, and (3) enhanced their Lachman technique. SPs ultimately cannot volitionally reproduce the physical exam findings of ACL deficiency. Consequently, learners cannot accurately identify positive versus negative examination findings. Thiel-embalmed cadavers are a valuable resource for physical examination education. (Journal of Surgical Orthopaedic Advances 30(2):112–115, 2021)

Key words: soft-embalmed cadavers, physical exam, interprofessional training, Lachman exam

Wartime Military Orthopaedics - Michael D. Eckhoff MD; Richard L. Purcell MD; Justin D. Orr MD; Leon J. Nesti MD PHD; Benjamin K. Potter MD; and John C. Dunn MD

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Military orthopaedic surgeons are faced with hardship and decreased morale. Surgeons have frequent deployments and practice ineffi ciencies resulting in poor retention rates. The purpose of this analysis is to report demographics and factors eff ecting military retention. A survey was sent to all members of the Society of Military Orthopedic Surgeons. The survey obtained demographic information, as well as factors aff ecting retention and termination of service. Data was compared between subset groups within the total respondent population. Of active-duty personnel, 38.5% plan on staying in the military until retirement. Most surgeons entered into the military due to a desire to serve their country, while most people leave service due to higher pay as a civilian. A minority of military orthopaedic surgeons achieve military retirement; however, increased pay, increased control over practice, and decreased frequency of deployments are factors that could improve retention rates. (Journal of Surgical Orthopaedic Advances 30(2):116–119, 2021)

Keywords: military, orthopaedics, retention, combat

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