Volume 30-3, Fall 2021

Quality Improvement Tools in Total Joint Arthroplasty: A Systematic Review - Henry V. Bonner, BS; James R. Jones, BS; Alexandra M. Arguello, MD; Jun Kit He, MD; Brent A. Ponce, MD; Amit M. Momaya, MD; Elie S. Ghanem MD; and Eugene W. Brabston, MD

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Systems review and quality improvement (QI) is a significant need within orthopaedic surgery. The focus of this paper is to systematically review QI principles utilized in total joint arthroplasty to determine most successful QI tools. A systematic search on MEDLINE/Pubmed, Embase, Cochrane Library and other sources was conducted from September 1991 through October 2018. The three primary improved outcomes from each article were recorded along with the date, author and subspecialty. Thirty-four eligible studies related to joint arthroplasty were identified for inclusion in the systematic review. The most common outcomes that were improved in these publications were: length of stay (LOS), cost, medication management, and patient education. Lean, clinical care pathways (CCP), plan-do-check-act (PDCA), and shared decision-making improved those metrics. Four metrics were found that were consistently improved by certain quality improvement tools: LOS, cost, medication management, and patient education. Further research is warranted to continue to build a framework for quality improvement in orthopaedic surgery. (Journal of Surgical Orthopaedic Advances 30(3):125–130, 2021)

Key words: quality improvement, process optimization, arthroplasty, clinical care pathways (CCP), plan-do-check-act (PDCA), lean

Economic Impact of Unused Surgical Instruments in an Orthopaedic Surgery Department at an Academic Medical Center: A Prospective Cross-sectional Study - Stephanie S. Shim, MD; Nicholas C. Danford, MD; Margaret L. Wright, MD; Laura A. Vogel Abernathie, MD; Jun S. Kim, MD; R. Kumar Kadiyala, MD, PhD; and J. Turner Vosseller, MD

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Orthopaedic surgical trays contain unused instruments, but we do not know which specific instruments go unused nor do we know the savings from eliminating them from a given tray. This was a single-site, observational study conducted at an academic medical center. The primary outcome was type of unused instruments and percentage of instruments used in two commonly used surgical trays. The secondary outcome was cost savings in United States dollars (USD) that could be attained by eliminating these instruments. In the first tray, five instruments (10.6%) were unused in any of 37 observed cases. In the second tray, nineteen instruments (19.6%) were unused in 37 observed cases. The total annual savings from replacement cost analysis and reprocessing cost analysis was $6,597.00 USD. Unused instruments are common in surgical trays. Eliminating unused instruments can result in immediate cost savings. (Journal of Surgical Orthopaedic Advances 30(3):131–135, 2021)

Key words: cost analysis, savings, surgical tray, efficiency, instrument

Return to Sport After Nonoperative Management of Medial Ulnar Collateral Ligament Injuries About the Elbow in Non-throwing Athletes - Ian A. Mullikin, MD; Richard Robins, MD; Jonathan Jackson, MD; and Mark Slabaugh, MD

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There is a paucity of literature published on management of acute medial ulnar collateral ligament injuries in the non-throwing athlete and when these athletes may expect to safely return to sport. Non-overhead throwing athletes that sustained medial ulnar collateral ligament (MUCL) injuries treated conservatively with brace immobilization and therapy can successfully return to sport in a relatively short duration. A radiographic query of Magnetic Resonance Images (MRIs) was performed to identify patients sustaining elbow MUCL injury. Only those participating as intercollegiate athletes were included. Medical charts and documents were reviewed to determine time away from sport and rehabilitation protocol. A total of 17 patient-athletes were identified as having sustained MUCL injuries that met inclusion criteria. There was a 100% return to sport rate, averaging 5 weeks from date of injury. Non-overhead throwing athletes competing at the intercollegiate level who sustained acute MUCL injury were effectively treated nonoperatively. (Journal of Surgical Orthopaedic Advances 30(3):136–139, 2021)

Key words: medial ulnar collateral ligament (MUCL), college athletes, nonoperative, return to sport, non-throwing

The Orthopaedic Traumatologist and the Peritrochanteric Hip Fracture–Does Experience Matter? - Paul Tornetta III, MD; Alex DeHaan, MD; Derek Hinds, MD; and T. William Axelrad, MD, PhD\

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The purpose of this study was to review our protocol of sliding hip screws for stable and cephallomedullary devices for unstable peritrochanteric fractures to evaluate the correctness of the decisions made based on complication rates and on shortening of the fractures as well as financial implications. Over a five-year period, two orthopaedic traumatologists followed a protocol utilizing a sliding hip screw (SHS) for all fractures that were deemed stable and a cephallomedullary nail for unstable fractures. Injury radiographs were then re-reviewed by a blinded observer to classify each fracture pattern as stable or unstable based on the Evansclassifi cation. Of 121 patients, 62 were classified as stable and 59 unstable. The tip apex distance averaged 16 mm with 2/61 (3.3%) > 25mm for plates and 22 mm with 6/60 (10%) > 25mm for intermedullary (IM) nails. Two partial cutouts occurred, both in the SHS group. Minimal shortening and deformity were noted for each group. A stability-based protocol utilizing sliding hip screws for stable and IM nails for unstable peritrochanteric hip fractures based on the judgment of experienced surgeons is valid and reasonable, resulting in significant savings compared to using IM nails for all cases ($104,898 in this series). (Journal of Surgical Orthopaedic Advances 30(3):140–143, 2021)

Key words: hip fracture, peritrochanteric hip fracture, trauma, experience, sliding hip screws, cephallomedullary devices, Evans classification

Preoperative Diagnosis of Depression Leads to Increased Opioid Tablets Taken After Total Hip Arthroplasty: A Prospective Study - Gregory Kurkis, MD; Jacob M. Wilson, MD; Albert T. Anastasio MD; Kevin X. Farley, BS; and Thomas L. Bradbury, MD

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Balancing postoperative analgesia with minimizing opioid consumption remains a challenge. We aim to document trends in opioid consumption for patients undergoing total hip arthroplasty (THA) and hypothesize that preoperative patient education will decrease postoperative opioid consumption. This is a prospective study of patients undergoing elective primary THA. Preoperatively, patients completed a survey regarding opioid-use history, surgical history, and pain tolerance. Patients were randomized to receive preoperative education on opioid use or no formal education. Six weeks postoperatively, patients completed a questionnaire regarding opioid use, disposal, and pain control. Ninety-five patients were included. Preoperative education was not associated with taking fewer narcotic medications (p = 0.790) and did not significantly alter disposal practices (p = 0.255). Depression was correlated with increased opioid use (mean difference 24 tabs, p = 0.001) and linked to longer duration of opioid use postoperatively (20.3 +/- 15.6 versus 7.2 +/- 7.3 days, p < 0.001). History of prior surgical procedure was associated with fewer narcotics taken (mean difference 26 tabs, p = 0.01). Depression is correlated with increased opioid use. Preoperative education did not affect opioid use or disposal frequency. (Journal of Surgical Orthopaedic Advances 30(3):144–149, 2021)

Key words: total hip arthroplasty, opioid, education, pain control, depression, narcotic

Are Orthopaedic Surgery Residency Applicants Making an Impact? A Bibliometric Evaluation of Applicants - Martin Collier, MD, MC, USN and Cory Janney, MD, MC, USN

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Orthopaedic surgery is one of the most competitive surgical specialties in the United States. No investigation has focused on the impact of research productivity and reputation on matching in this applicant pool. A retrospective investigation evaluating publications was conducted on residency applicants to the department of orthopaedic surgery of a single institution in 2019. Predictors of successful matching in orthopaedic surgery were analyzed. Of 519 candidates, 314 (60.5%) reported publications on their applications at the time of submission. The mean impact factor of reported publications was 3.6 (95% CI 0–11.8) and did not differ between candidates who did (3.4 [95% confidence interval [CI] 0–12.2]) and did not (3.4 [95%CI 0–8.0]) match, (p = 0.90). An applicant’s participation in research, number of publications, publications in higher impact journals, or misrepresentation of their publications had no effect on successful orthopaedic residency match. (Journal of Surgical Orthopaedic Advances 30(3):150–155, 2021)

Key words: orthopaedic surgery, research involvement, medical education, successful match, United States Medical Licensing Examination (USMLE)

WALANT Hand Surgery: Do the AORN Guidelines Apply? - Alba Avoricani, BA; Qurratul-Ain Dar, BS; Kenneth H. Levy; and Steven M. Koehler, MD

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This study evaluates current guidelines for patients receiving local anesthesia, set forth by the Association of Perioperative Nurses (AORN), within the context of hand surgery. The study reviewed 217 patients and 265 operations performed under wide-awake local anesthesia no tourniquet (WALANT) technique in an outpatient procedure room with minor field sterility. Only the surgeon, one resident, and one circulating nurse were present. All surgical complications were documented, including any infection at postoperative follow-ups. One female patient developed a deep surgical site infection (SSI) following repair of her flexor digitorum superficialis and flexor digitorum profundus, which resolved after irrigation/debridement. We report 0% intraprocedural complication, 0% superficial SSI, and 0.37% deep SSI (n = 1) incidence across this cohort. Most institutions require two nurses present for local anesthesia, but our low complication and infection incidence suggest a single circulating nurse present during WALANT hand surgeries may improve nurse staffing, drive greater turnover efficiency, and reduce costs. (Journal of Surgical Orthopaedic Advances 30(3):156–160, 2021)

Key words: Association of PeriOperative Registered Nurses (AORN), field sterility, hand, local anesthesia systemic toxicity, surgical site infection, wide-awake local anesthesia no tourniquet (WALANT)

Effects of Fellowship Training on Pediatric Anterior Cruciate Ligament Reconstruction Techniques and Outcomes - Erik J. Stapleton DO, MS; Jesse Galina, BS; Colin J. Burgess, DO; Aaron Atlas, DO, MS; Randy M. Cohn, MD; Terry Amaral, MD; Yungtai Lo, PhD; Michael J. Sayegh, MD; Sayyida Hasan, MD; and Jon-Paul DiMauro MD

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The purpose of this study is to examine differences in pediatric anterior cruciate ligament reconstruction (ACLR) between surgeons with either pediatric or sports medicine fellowship training. Patients were divided into two groups, those performed by either a pediatric or sports medicine fellowship-trained surgeon. One hundred and forty-one patients were identified: 91 (64.5%) by pediatric trained surgeons and 50 (35.4%) by sports medicine trained surgeons. Patients that had ACLR by a pediatric trained surgeon were younger (p = 0.02), had larger body mass index (BMI) (p = 0.027), and more likely to have government assisted insurance (p = 0.006). Pediatric trained surgeons had longer procedure time (p < 0.001), used smaller graft sizes (p = 0.016), used soft tissue grafts (p < 0.001) and used butt on fixation at both the femur and tibia (p < 0.001). There were no differences regarding meniscus surgery, surgical technique (transphyseal versus physeal sparing), arthrofibrosis, graft failure, and intraoperative complications (p > 0.05). This study shows favorable and comparable results after ACLRs with either pediatric or sports medicine fellowship training. (Journal of Surgical Orthopaedic Advances 30(3):161–165, 2021)

Key words: anterior cruciate ligament (ACL), reconstruction, bone graft, outcomes, fellowship, pediatric

Characterizing Particle Evacuation in the Setting of Positive-pressure Body Exhaust Suit Using a Novel Gloving Technique - Kevin Sagers, DO; John S. Shields, MD; David C. Pollock, MD; Maxwell K. Langfitt, MD; and Steven K. Nishiyama, DO, PhD

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The sterility of the gown-glove interface during total joint arthroplasty is a key factor in preventing contamination of the surgical field. To compare the potential of gown-glove interface contamination with a novel gloving technique versus standard gloving technique. We performed a study quantifying potential gown-glove interface contamination using two different gloving techniques. A 5 μm fluorescent powder simulated potential bacterial contamination. Each group gowned and gloved each hand using a modified technique versus traditional technique. Ultraviolet light was used to measure contamination at the gown-glove interface after performing a simulated surgery. The modified gloving technique did not statistically reduce the contamination at the gown-glove interface compared to the traditional gloving technique (p = 0.27). Despite using a gloving technique recently described as decreasing contamination, we noted contamination at the interface after performing a simulated surgery with a positive pressure exhaust suit. Further study is needed. (Journal of Surgical Orthopaedic Advances 30(3):166–169, 2021)

Key words: surgical gloving, complications/infection, total joint arthroplasty, surgical contamination

Postoperative Outcomes of Patients Undergoing Fasciotomy for Exercise Induced Compartment Syndrome: A Case Series - Justin Turcotte, PhD, MBA; Natalia Gonzales; and Christina Morganti, MD

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Exercise induced compartment syndrome (EICS) is a rare source of pain in athletes that can significantly limit their ability to compete and train. We evaluated a series of patients undergoing open fasciotomy for EICS of the leg in our institution. Twenty-five patients were followed for an average of 3.2 ± 1.5 years postoperatively. Sixteen patients underwent bilateral fasciotomies (64%), with four patients (16%) receiving two compartment and 21 (84%) receiving four compartment release. A significant reduction in intra-compartmental pressure, measured intraoperatively by hand-held manometry, was observed in all treated compartments. Surgical success, defined as the absence of revision surgery within the study time-period, was achieved in 19 patients (76.0%). Postoperative wound complications occurred in six patients (24.0%). Twenty-four of 25 patients (96.0%) achieved confirmed return to function within the study period. Our case series confirms the efficacy of open fasciotomy for the treatment of EICS. Patients should be followed closely after fasciotomy, and further research is necessary to improve surgical techniques and rehabilitation to decrease postoperative complications. (Journal of Surgical Orthopaedic Advances 30(3):170–172, 2021)

Key words: exercise induced compartment syndrome, fasciotomy, sports medicine

C-arm Drape Perforation During Primary Anterior Hip Arthroplasty - Sarah Jane DeWeese and Frederick Thane DeWeese, MD

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Violation of the sterile fi eld due to tears or perforations in the C-arm drape during primary anterior hip arthroplasty could lead to an increased risk of infection. Deep prosthetic infection is a catastrophic complication of hip arthroplasty. The incidence of C-arm drape perforation during primary anterior hip arthroplasty is unknown. We sought to determine the incidence of C-arm drape perforation during primary anterior hip arthroplasty. The integrity of the C-arm drape was checked with a novel leak test after 36 primary anterior hip arthroplasties. One or more C-arm drape perforations were found intraoperatively or during testing of drapes used for four of thirty-six (11%) procedures. An additional drape leaked at its end seam and ruptured at this seam during testing. Quality testing of this seam may need further evaluation. No infections or wound complications were found at an average follow-up of 9 months. (Journal of Surgical Orthopaedic Advances 30(3):173–175, 2021)

Key words: C-arm, drape, perforation, anterior, primary, hip, arthroplasty

Comparison of Self-reported Versus Actual Height and Weight in the Orthopaedic Population - Nicholas Kolodychuk, MD; Alexander Habashy, MD; Michael Casale, MD; George Chimento, MD; William F. Sherman, MD, MBA; and Bradford S. Waddell, MD

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The purpose of our study was to determine the accuracy of orthopaedic patient’s reported height, weight, and body mass index (BMI). We hypothesized that patient’s age, sex and/or BMI may affect their accuracy. We performed a prospective, observational study in the setting of our orthopaedic clinic. Differences between self-reported and actual values were calculated. Patients were categorized based on their age (< 65 vs. ≥ 65), sex, and actual BMI (<30 vs. >30). Student t-test and chi-square test were used to compare groups. Our study included 329 patients. Patients were more likely to underestimate weight (p < 0.001) and overestimate height (p = 0.007). Comparing patients with a BMI < 30 and > 30, height overestimation (0cm vs. 1.14cm, p = 0.004) and weight underestimation (0.09kg vs. 1.29kg, p = 0.02) discrepancies were greater in the BMI > 30 group. Patients, particularly with a BMI >30 kg/m2, over-estimate their height and under-estimate their weight. (Journal of Surgical Orthopaedic Advances 30(3):176–180, 2021)

Key words: total joint arthroplasty, total knee arthroplasty, total hip arthroplasty, practice management, body mass index, patient reported data

Epiphysiodesis for Leg Length Discrepancy: A Cost Analysis of Drill Versus Screw Technique - Lara L. Cohen, MPH; Benjamin J. Shore, MD, MPH, FRCSC; Patricia E. Miller, MS; Michael J. Troy, BS; Susan T. Mahan, MD, MPH; James R. Kasser, MD; Samantha A. Spencer, MD; Daniel J. Hedequist, MD; Benton E. Heyworth, MD; and Michael P. Glotzbecker, MD

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Research has demonstrated similar efficacy of drill epiphysiodesis and percutaneous epiphysiodesis using transphyseal screws for the management of adolescent leg length discrepancy. A cost analysis was performed to determine which procedure is more cost-effective. Patients seen for epiphysiodesis of the distal femur and/or proximal tibia and fibula between 2004 and 2017 were reviewed. A decision analysis model was used to compare costs. Two hundred thirty-five patients who underwent either drill (155/235, 66%) or screw (80/235, 34%) epiphysiodesis were analyzed with an average age at initial procedure of 13 years (range, 8.4 to 16.7 years). There was no significant difference in average initial procedure cost or total cost of all procedures across treatment groups (n = 184). The cost difference between drill and screw epiphysiodesis is minimal. In order for screw epiphysiodesis to be cost-favored, there would need to be a significant decrease in its cost or complication rate. (Journal of Surgical Orthopaedic Advances 30(3):181–184, 2021)

Key words: leg length discrepancy, cost effectiveness, cost analysis, orthopaedic surgery, pediatric orthopaedics

The Impact of Smoking in Workers’ Compensation Patients Receiving Spinal Cord Stimulation - Bryan O. Ren, BS; Jeffrey A. O’Donnell, MD; Joshua T. Anderson, MD; Arnold R. Haas, BS, BA; Rick Percy, PhD; Stephen T. Woods, MD; Uri M. Ahn, MD; and Nicholas U. Ahn, MD

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The objective of this study was to determine the impact of smoking on clinical outcomes in workers’ compensation (WC) patients receiving spinal cord stimulation (SCS). One hundred and ninety-six patients from the Ohio Bureau of Workers’ Compensation were identified who received SCS with implantation occurring between 2007–2012. Patients were divided into smokers (n = 120) and nonsmokers (n = 76). Population characteristics before and after implantation were analyzed between the two groups. A multivariate logistic regression was run to determine predictors of return to work (RTW) status. Our regression determined smoking (p = 0.006; odds ratio [OR] = 0.260) and body mass index (p = 0.036; OR = 0.905) to be negative predictors of RTW status. After implantation, smokers were less likely to RTW after 6 months and had higher pain scores after 6 and 12 months. Both smokers and nonsmokers had significance reductions in opioid use after SCS implantation. (Journal of Surgical Orthopaedic Advances 30(3):185–189, 2021)

Key words: spinal cord stimulation, smoking, tobacco, workers’ compensation, return to work

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