31-1 TOC

Infection and Mortality Rate in Hepatitis C and Cirrhotic Patients Undergoing Hip and Knee Replacement - Zachary C. Lum, DO; Eric G. Kim, DO; Trevor J. Shelton, MD; and John P. Meehan, MD

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Liver disease carries significant risk in total joint arthroplasty (TJA). The authors sought to investigate the complications in hepatitis C virus (HCV) and cirrhosis patients after TJA. PRISMA guidelines extracted ten studies and meta-analytic analysis was performed. Five hundred and twenty-seven patients with liver disease underwent TJA. The complication rate was 38.9%, with 8% infection at 57 months. Cirrhotic patients had higher complication and infection rates compared to HCV patients (p < 0.001, p < 0.039, respectively). Mortality in cirrhosis patients was 17.8% at 36 months. Studies suggested Child Pugh Class A patients had significantly lower complications than Class B or C. One study revealed lower MELD (Model for End-Stage Liver Disease) scores &lt; 10 carry a low mortality risk of 9.8% compared with 32% mortality if MELD score 10 or above. Cirrhosis has significant infection and mortality risk in total hip and knee arthroplasty. Surgeons can risk stratify these patients by MELD score and Child Pugh Class. (Journal of Surgical Orthopaedic Advances 31(1):001–006, 2022) Key words: cirrhosis, hepatitis C virus (HCV), liver disease, complications, infection, mortality, total hip arthroplasty (THA), total knee arthroplasty (TKA)

The Incidence of Subsequent Cervical Spine Surgery after Cervical Disc Arthroplasty, a Minimum Two-year Follow-up - Alexander M. Satin, MD; Dean Perfetti, MD, MPH; Deepak Kaji, BS; Jesse Galina, BS; Aaron Atlas, DO, MS; Austen Katz, MD; Jeff S. Silber, MD; and David A. Essig, MD

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To identify the risk factors and incidence of subsequent cervical spine surgery in patients undergoing primary cervical disc arthroplasty (CDA). We analyzed the 2005–2015 NYS SPARCS database. Patients were longitudinally followed to determine the incidence of re-operation. Univariate and Multivariate analyses were used to identify demographic risk factors. Eight-hundred and thirty-five CDA patients had a cervical spine re-operation rate of 7.5%; 4.4% re-operation rate at two-year follow-up. The most common cervical re-operation was a primary anterior cervical discectomy and fusion (ACDF) (76.2%). Patients who underwent re-operation were more likely to be younger (p = 0.034) and female (p = 0.007). Logistic regression analysis found only female sex to have increased odds of re-operation (odds ration = 2.10, 95% confidence interval 1.21-3.63). There was a 4.4% rate of subsequent cervical spine surgery following CDA at 2 years and a 7.5% rate of subsequent cervical spine surgery. The most common cervical spine procedure following CDA was ACDF. Female sex was the only patient demographic factor to significantly influence the odds of cervical spine re-operation. (Journal of Surgical Orthopaedic Advances 31(1):007–011, 2022)

Key words: cervical disc arthroplasty, re-operation, cervical spine, risk factors, cervical disc degeneration, ACDF, revision

Intramedullary Nailing of Humerus Fractures Using an Implant System with Internal Distal Locking and Avoiding Distal Incisions: Operative and Clinical Outcomes - Anthony Lam, DO; Benjamin W. Hoyt, MD; Anthony Allsbrook, DO; and Romney Andersen, MD

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There is limited evidence to guide implant selection for humeral shaft fractures. The objective of this study was to evaluate operative differences, early outcomes, and complications associated with use of an intramedullary nailing (IMN) system without distal interlock screws and compare this to a standard humeral nailing system. We evaluated 49 consecutive patients who underwent IMN for humeral shaft fracture between 2015–2018. Patients were grouped based on implant; Stryker T2 Nail (n = 37), or ODI Talon DistalFix (n = 12), which achieves distal interference with an endocortical barb mechanism. Operative time using the T2 nail was significantly longer than DistalFix nails (90 vs. 64 minutes, p < 0.05). With the numbers available, there was no significant difference in estimated blood loss for both systems (114 vs. 97 ml, respectively; p = 0.6). Neurologic complications occurred in eight versus one patient in the T2 and DistalFix cohort, respectively. These findings may support increased shifts to implant systems that bypass distal interlocking systems for cost savings and patient/surgeon safety. (Journal of Surgical Orthopaedic Advances 31(1):012–016, 2022)

Key words: humeral shaft fracture, intermedullary nail, interlock, bar bed nail, operative efficiency

Preoperative Quadratus Lumborum Block Reduces Initial Postoperative Opioid Consumption Following Hip Arthroscopy: A Retrospective Analysis - Sylvia H. Wilson, MD; Renuka M. George, MD; Dulaney A. Wilson, PhD; Caitlyn Risley, BS; and Shane K. Woolf, MD

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Compare postoperative opioid consumption following hip arthroscopy in patients who received a preoperative, lateral quadratus lumborum block versus those who did not. Patients were retrospectively identified. The primary outcome was postoperative opioid consumption (IV morphine milligram equivalents) in patients with and without a block. Comparisons between groups were conducted with Chi-square tests and Fisher Exact Tests where appropriate. Continuous data were compared with twosided t-tests and Wilcoxon rank-sum tests. Data were collected on 100 patients. Mean (95% confidence interval) postoperative opioid consumption was reduced in patients with a quadratus lumborum block compared to those without a block (6.6 [5.2 – 8.1] vs 11.8 [10.2 – 13.4]; p &lt; 0.0001; respectively). Eleven percent of patients with a preoperative quadratus lumborum block did not consume any opioids in the post anesthesia care unit. Opioid consumption in the immediate postoperative period was significantly reduced in patients that received a preoperative quadratus lumborum block. Level of Evidence: Level III – Retrospective Cohort Study. (Journal of Surgical Orthopaedic Advances 31(1):017–021, 2022)

Key words: analgesia, arthroscopy, hip, nerve block, pain management

Arthroscopic Case Volumes Among Orthopaedic Surgery Residents and Orthopaedic Sports Medicine Fellows: An Analysis of ACGME Case Log Data - Bejan Alvandi, MD; Matthew Hartwell, MD; Bennet Butler, MD; Daniel Johnson, MD; Robert A. Christian, MD, MBA; Joshua Castle; and Vehniah Tjong, MD

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Arthroscopic procedures are used to treat a multitude of disorders, but they can be technically demanding. These procedures are a fundamental aspect of orthopaedic surgery residency and surgical sports medicine fellowship. The goal of this study was to analyze the variability in arthroscopic case experience to better understand the disparities between various training programs and the opportunity for increased surgical case volume of an orthopaedic sports medicine fellowship. Resident and fellow case log reports were gathered from the Accreditation Council for Graduate Medical Education. Fellows reported 286% more arthroscopic cases in one year of fellowship than residents reported in five years of residency (554 cases vs. 193 cases, p Impact of Certificate of Need on Lumbar Discectomy Reimbursement and Utilization 0.0001). Fellows also performed 770% more arthroscopic hip procedures than residents (57 cases vs. 7 cases, p < 0.0001). There is a significant difference in arthroscopic case volume between residents and fellows. An orthopaedic sports medicine fellowship dramatically increases the arthroscopic experience of trainees. (Journal of Surgical Orthopaedic Advances 31(1):022–025, 2022)

Key words: orthopaedic surgery, arthroscopic surgery, sports medicine fellowship, residency, case volume, ACGME

Impact of Certificate of Need on Lumbar Discectomy Reimbursement and Utilization - Chason Ziino, MD; Abiram Bala, MD; Shay Warren, MD; and Ivan Cheng, MD

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The Certificate of Need (CON) program was established to respond to increasing healthcare costs; however, its impact on spine surgery trends is not well understood. The purpose of this study was to evaluate the impact of CON status on utilization of single-level lumbar discectomy. A combined Medicare and private payor database was used to identify single-level lumbar discectomies performed from 2007 to 2015. Utilization and reimbursement trends were compared using the compound annual growth rate (CAGR) with reimbursement adjusted by the consumer price index. In total, 30,617 lumbar discectomies were analyzed. Procedure utilization increased across all settings. CAGR was highest in the outpatient CON group (19.7%) and lowest in the inpatient non-CON group (0.5%). Reimbursement increased in the outpatient setting (CAGR: 1.2% CON, 1.0% non- CON), but decreased in the inpatient sett ing (CAGR: -6.1% CON, -5.5% non-CON). These trends are important to consider in a value-based healthcare environment. (Journal of Surgical Orthopaedic Advances 31(1):026–029, 2022)

Key words: certificate-of-need, lumbar discectomy, cost, government regulation

Opioid Knowledge and Prescribing Preferences of Orthopaedic Surgery Residents Before and After an Educational Intervention - Pankti P. Acharya, MPH; Brianna Fram, MD; Ryan A. Hoff man, MD; Dana Cruz, MD; and Asif M. Ilyas, MD, MBA

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Orthopaedic surgeons are among the highest prescribers of opioids. This study explores the effect of an educational intervention on orthopaedic surgery residents’ opioid knowledge and prescribing practices. Orthopaedic residents were surveyed at three urban academic institutions. A pre-survey was administered to residents prior to an educational lecture and case-based session. This included background on the opioid epidemic, multimodal analgesia, opioid consumption in common orthopaedic procedures, and state laws regulating prescribing. Following this intervention, residents were given a post-survey to complete. There was a significant increase in resident confidence concerning their opioid prescribing training (p = 0.03) and their knowledge of alternative pain management therapies (p = 0.03). This was accompanied by an objective improvement in knowledge of state prescribing laws and of metrics regarding the opioid epidemic. Hypothetical opioid pills prescribed after common orthopaedic procedures decreased between the pre- and post-tests. The educational session significantly improved orthopaedic surgery residents’ knowledge about opioids and prescribing habits. Formal resident education on opioid knowledge and evidence-based prescribing strategies is an area of potential improvement to combat the opioid crisis. (Journal of Surgical Orthopaedic Advances 31(1):030–033, 2022)

Key words: opioid, resident, education, counseling

Analyzing the Orthopaedic Surgery Personal Statement: Do Residency Applicants See Value in Its Use? - Caroline J. Granger, BS; Lara L. Cohen, MPH; Allison L. Boden, MD; Laith K. Hasan, BBA; Mary K. Mulcahey, MD; and Amiethab A. Aiyer, MD

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Orthopaedic surgery is one of the most competitive specialties in the residency match. The personal statement (PS) is one component of the application. The significance of the PS to orthopaedic surgery residency applicants is unknown. This study evaluates applicant perceptions of the PS. Applicants to two separate United States orthopaedic residency programs for the 2019– 2020 cycle were invited to participate. Survey was distributed via email. Twenty-one percent (204/978) of applicants completed the survey. Most were men (157/204, 77%), and most (125/204, 61%) spent up to 15 hours writing their PS. Many [79.4% (162/204)] believed the PS should continue to be included in the application. Women always edited their PS, while 7.0% (11/ 157) of men did not use any editors. Applicants believe the PS is valuable. The PS is time consuming but allows applicants to communicate details that otherwise may not be included in their application. (Journal of Surgical Orthopaedic Advances 31(1):034–041, 2022)

Key words: orthopaedic education, orthopaedic residency, residency match

Resident Selection: An Orthopaedic Program Director Survey - Alexis B. Sandler, BA; John P. Scanaliato, MD; Dawn M. LaPorte, MD; Leon Nesti, MD, PhD; and John C. Dunn, MD

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As the competitiveness of orthopaedic surgery residency increases, we sought to determine whether program and Program Director (PD) characteristics influence candidate selection. This novel 19-question survey reviews PDs’ opinions and practices in resident selection. Response rate was 31% (63/203). Performance during orthopaedic rotations, United States Medical Licensing Examination (USMLE) scores, and clerkship honors were the top three ranked criteria, with USMLE scores used to screen candidates for interviews (70%) and rotations (43%). PDs practicing < 10 years felt USMLE scores reflect resident quality, while those practicing >10 years felt they reflect ability to pass the American Board of Orthopaedic Surgery exam. Most (81%) accept applicants with low scores. PDs > 66 years old emphasized academic honors and Dean’s letters, PDs 46–55 emphasized conscientiousness, and PDs practicing >21 years emphasized dexterity. PD demographics such as age, time in practice, and geographic location affect how they approach candidate selection. (Journal of Surgical Orthopaedic Advances 31(1):042– 047, 2022)

Key words: resident selection, orthopaedic resident selection, program director survey, residency application, USMLE Step 1, grit

Determining the Impact of the COVID-19 Pandemic on Hand Surgery Fellowship Education - Joseph A. Weiner, MD; Peter R. Swiatek, MD; Daniel J. Johnson, MD; Erik B. Gerlach, MD; Cody Goedderz, BS; Bennet A. Butler, MD; Chirag M. Shah, MD; and David M. Kalainov, MD, MBA

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The purpose of this study is to report the impact of COVID-19 on hand surgery fellow learning and preparedness for practice. A multi-dimensional questionnaire was distributed to current hand fellows and fellowship directors across the United States. Survey questions included fellowship location, institutional response, impact on practice, education and job search. Thirty-two hand surgery fellows and 14 fellowship directors completed the survey. Of fellows, 59% reported a greater than 75% decrease in case volume. Mean hours worked per week per fellow decreased by 52%. All fellowship directors and 94% of fellows did not expect COVID-19 to impact their ability to graduate, and nearly all fellows felt prepared to start practice after fellowship training. However, many fellows expressed concern about job opportunities. The work hours and exposure of hand surgery fellows to elective surgical cases have been adversely impacted by COVID-19. Nevertheless, current hand fellows feel prepared to enter practice. (Journal of Surgical Orthopaedic Advances 31(1):048–052, 2022)

Key words: COVID-19, coronavirus, hand surgery, fellowship training, education

Operative Outcomes for Accessory Navicular in Adolescents - Ally A. Yang, BS; William L. Hennrikus MD; and Ellius Kwok, MS

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The purpose of this study is to report the operative outcomes in a consecutive series of adolescent patients with symptomatic accessory navicular (AN). A retrospective review was conducted. Patient characteristics, operative techniques, and outcomes were recorded. Radiographs were used to identify the type of AN, skeletal maturity, and presence of concurrent pesplanus. Twenty-two patients and 24 feet were studied. All 22 patients had an excision of the AN, and 19 patients had an additional reefing of the tibialis posterior tendon. At final follow up, 22 cases reported no pain, one had minimal pain, and one reported no change in pain. Symptomatic AN is more common in females. Surgery technique was not correlated with postoperative pain. Surgery eliminated pain in 91% of patients and can be safely performed in athletes with high rate of return to their previous athletic performance. (Journal of Surgical Orthopaedic Advances 31(1):053–055, 2022)

Key words: accessory navicular bone, foot diseases, adolescent, athletes, flatfoot

Favorable Radiographic and Early Postoperative Results with the Inguinal Crease Direct Anterior Total Hip Arthroplasty - Bradford S. Waddell, MD; Jesse A. Raszewski, DO, MBS; Kwesi G. Dawson-Amoah, MD; Imraan A. Khan, BS; and Edwin P. Su, MD

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We report the results, scar appearance, and patient satisfaction of a direct anterior approach total hip arthroplasty performed through an oblique inguinal incision. Patients were separated into direct anterior THA (n = 29) or an oblique inguinal incision anterior approach (n = 41). Clinical and radiographic data was compared, scar appearance was assessed by the Vancouver Scar Scale (VSS), and satisfaction was assessed by a simple questionnaire. Harris Hip Scores significantly improved in each group (1.8×10-8) and improved similarly between groups (p ≥ 0.35). The VSS score was lower in the inguinal incision versus the standard incision group (0.68 [range 0–3] vs. 1.56 [range 0–4], p = 0.015). Scar satisfaction was higher in the inguinal incision group with 87% compared to only 32% in the standard approach. The inguinal incision approach was safe, offered similar postoperative results, and resulted in improved patient scar satisfaction compared to the standard anterior approach by using an incision that more closely resembled normal anatomy. (Journal of Surgical Orthopaedic Advances 31(1):056–060, 2022)

Key words: anterior approach, inguinal incision, minimally invasive, total hip replacement

Treatment of Chronic Proximal Hamstring Tendinopathy with Surgical Debridement and Suture Anchor Repair - Sean Fitzpatrick, MD; Robert A. Magnussen, MD MPH; Benjamin Léger-St-Jean, MD, FRCSC; Zylyftar Gorica, MD; W. Kelton Vasileff, MD; and Christopher C. Kaeding, MD

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We evaluated outcomes following surgical debridement and suture anchor repair of chronic proximal hamstring tendinopathy without sciatic nerve decompression. Chart review identified eight patients (one bilateral) who met study requirements. All eight patients were available for follow-up at a mean of 6.7 years and none underwent re-operation on the index hip during the follow-up period. Seven patients completed patient-reported outcome scores. The mean LEFS score was 81.1, and the mean SANE score was 74.9. The mean Marx activity score was 2.8, and the mean Custom Marx score was 23.3. Pain relief was excellent. The mean numeric pain score at rest was 0.6, while the mean numeric pain score with activity was 4.0. Treatment of chronic, recalcitrant proximal hamstring tendinopathy with surgical debridement and suture anchor repair without exploration of the sciatic nerve results in excellent pain relief, good function, and low re-operation risk. (Journal of Surgical Orthopaedic Advances 31(1):061–064, 2022)

Key words: proximal hamstring, tendinopathy, debridement, repair

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