Infections After Open Fractures in Pediatric Patients: A Review of 288 Open Fractures - Derek Kelly, MD; Benjamin Sheffer, MD; Robert Elrod, MD; Lauren Piana; Naveen Pattisapu, MD; Vikki Nolan, MD; David Spence, MD; and Jeffrey Sawyer, MD

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We reviewed pediatric open fractures treated at a large Level 1 children’s trauma center to determine the rate of infection after open fractures, potential risk factors for infection, and the rate of infection caused by antibiotic-resistant organisms. A retrospective review identified 288 open fractures in children 1 to 17 years of age. Post-traumatic infections developed in 24 (8.3%) open fractures. There was no significant association between the development of infection and mechanism of injury (p = 0.33), time to surgical debridement (p = 0.93), or type of empiric antibiotic given (p = 0.66). Infection occurred more frequently in overweight and obese patients (odds ratio = 2.22; 95% confidence interval: 0.93, 5.46, p = 0.07). There was one infection (4.2%) caused by methicillin-resistant staphylococcus aureus (MRSA). The most commonly identified organisms on culture were methicillin-sensitive staphylococcus aureus (n = 3) and pseudomonas (n = 3). Obesity is a significant risk factor for the development of infection after an open fracture in the pediatric population. (Journal of Surgical Orthopaedic Advances 31(2):073–075, 2022)

Key words: open fracture, pediatric patients, risk factors, infecting organism, obesity, treatment

The 50 Most Cited Papers Concerning Open Fractures - Paul R. Allegra, MD; Ramakanth R. Yakkanti, MD; Dylan N. Greif, BA; Sohil S. Desai, BA; Joseph S. Geller, MD; and Amiethab Aiyer, MD

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The purpose of this study is to identify and evaluate the top 50 most cited papers regarding open fractures. The ISI Web of Knowledge database was used to conduct a search query during May 2020 for articles pertaining to open fractures. The query used multiple Boolean operative combinations. The Boolean operative combination that yielded the largest search result was: “open fracture” OR “compound fracture” OR “gustilo” or “gustilo anderson” or “tscherne” or “oestern”. Articles were sorted from highest to lowest number of total citations. Articles were refined to include peer-reviewed original articles, review papers, or editorials. Articles were then screened by title and abstract to confirm they pertained to open fractures. This review provides an analysis of the most influential published literature and recent trends with regards to the treatment and management of open fractures. This data can assist physicians in their search for impactful literature. (Journal of Surgical Orthopaedic Advances 31(2):076–085, 2022)

Key words: open fractures, top 50, infection, traumas

Impact of an Opioid Stewardship Initiative Involving Early Conversion to Oral Narcotics in Postoperative Orthopaedic Patients - Jacklyn Downey, PharmD; John D. Adams Jr, MD; Stephanie Tanner, MS; Li He; and Michael Wagner, PharmD

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The objective of this study was to determine if the implementation of an opioid stewardship initiative involving early conversion to oral opioids improves outcomes in postoperative orthopaedic patients. This single-center retrospective chart review compared adult patients undergoing lower extremity orthopaedic procedures during a specified six-month time period. The primary outcome was total opioid utilization in morphine milligram equivalence (MME) at 48-hours post-surgery. Four hundred ninety-five patients were included in the study, 233 in the intervention group and 262 in the pre-intervention group. The average pain scores at 12, 24 and 48 hours postoperatively were similar among the two groups. After a multivariate linear regression was performed, a 22.9 MME reduction was estimated in the post-implementation group compared to the pre-implementation group (p = 0.003). Based on these results, it appears that converting from intravenous to oral narcotics 24-hours post-orthopaedic surgery reduces total mean MMEs while providing similar pain control. (Journal of Surgical Orthopaedic Advances 31(2):086–089, 2022)

Key words: morphine milligram equivalence, opioid stewardship, oral narcotics, orthopaedic surgery, pain scores

Program Directors’ Perception of the Role of Personal Statements in the Orthopaedic Surgery Residency Selection Process - Laith K. Hasan, BBA; Lara L. Cohen, MPH; Caroline J. Granger, BS; Allison L. Boden, MD; Symone M. Brown, MPH; Amiethab Aiyer, MD; and Mary K. Mulcahey, MD

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The purpose of this study was (1) to determine how much emphasis is placed on the Personal Statement (PS) by program directors (PDs) and (2) to gain a better understanding of what factors within the PS are considered most important to PDs. An anonymous survey was distributed to PDs at allopathic orthopaedic residency programs in the United States using Survey Monkey (San Mateo, CA). Survey responses were received from 51 of 152 (34%) PDs. Forty-five (88.2%) identified as male, five (9.8%) identified as female, and one (1.9%) chose not to disclose. PDs reported the PS was of average importance, with an average score of 2.82 (range,1–4). Although the PS is still given consideration as part of the overall orthopaedic surgery residency application process, it does not play a major role in determining which applicants will be invited for an interview or how they will be ranked. (Journal of Surgical Orthopaedic Advances 31(2):090–095, 2022)

Key words: program director, personal statement, residency, application

Frozen Shoulder Manipulation with the FEAR Technique: A Retrospective Case Series with Minimum Two-Year Follow-up - Zachary K. Pharr, MD; Eric N. Bowman, MD, MPH; Baylor E. Blickenstaff, MD; Adam K. Hubler, MD; Tyler J. Brolin, MD; Thomas W. Throckmorton, MD; and Frederick M. Azar, MD

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Conservative treatment of adhesive capsulitis fails in up to 30% of patients. Manipulation under anesthesia (MUA) has been shown to be safe and effective, although complications (iatrogenic fracture, glenohumeral dislocation, rotator cuff tears, nerve injuries) have been reported. This study details a novel technique, FEAR (Forward elevation, Extension, Adduction/abduction, and internal and external Rotation), and its results. Medical records review identified 100 patients with a diagnosis of adhesive capsulitis who had at least 6 weeks of physical therapy, with or without corticosteroid injection, with persistence of pain and loss of motion loss. An Institutional Review Board approved phone survey obtained Single Assessment Numeric Evaluation (SANE) scores, visual analog scale (VAS) scores, functional scores, and range of motion, with 43 available for survey. At average 5-year follow-up, 81% had excellent (≥ 90) scores and 77% were pain-free. Patients with diabetes and male patients had significantly lower SANE scores at follow-up. (Journal of Surgical Orthopaedic Advances 31(2):096–099, 2022)

Key Words: adhesive capsulitis, frozen shoulder, manipulation under anesthesia, FEAR technique, outcomes, patient characteristics

The Relationship Between Preoperative Opioid Use and Adverse Events Following Total Knee Arthroplasty - Charles D. Qin, MD; Lohith Vatti, MD; Mia M. Qin, MD; Cody S. Lee, MD; and Aravind Athiviraham, MD

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This study aims to compare perioperative events following total knee arthroplasty (TKA) amongst various degrees of preoperative opioid use. In total, 84,569 patients undergoing TKA were identified from a Humana Claims Dataset, and stratified by their preoperative opioid use based on number of prescriptions filled within 6 months of surgery (naïve 0 [50,561]; sporadic 1 [12,411]; chronic 2 or greater [21,687]). Outcomes of interest included Center for Medicare and Medicaid Services (CMS)-reportable complications, need for postoperative supplemental oxygen, 90-day readmission, and hospital length of stay. Complication rates (9.8% vs 8.9% vs 12.6%; p < 0.01), need for supplemental oxygen (3.0% vs 3.1% vs 5.3%; p = 0.03), mean length of stay (2.1 vs 2.8 vs 3.5; p < 0.01), and 90-day readmission (9.7% vs 10.8% vs 16.4%; p < 0.01) significantly differed amongst groups. On logistic regression, only the chronic opioid use group was associated with significantly increased likelihood of complications, need for supplemental oxygen, and readmission. (Journal of Surgical Orthopaedic Advances 31(2):100–103, 2022)

Key words: total knee arthroplasty, TKA, opioids, complications, readmission

Fracture Severity Based on Neer Classification Does Not Predict Short-term Complications Following Reverse Shoulder Arthroplasty - Barrie S. Sugarman, MD1; Jeffrey A. O’Donnell, MD; Elshaday S. Belay, MD; Daniel Goltz, MD, MBA; Richard Danilkowicz, MD; Mark Gage, MD; Christopher S. Klifto, MD; and Oke A. Anakwenze, MD

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Proximal humerus fractures (PHF) are common in elderly and osteoporotic patients, and these fractures are often described using the Neer classification. As reverse shoulder arthroplasty (RSA) for PHF becomes more common, it is helpful to identify the utility of Neer classification in predicting postoperative outcomes for patients undergoing RSA. The medical records of patients undergoing primary RSA for PHF at a single academic institution from 2013–2019 were identified using medical billing codes. A multivariable logistic regression analysis identified independent factors associated with all cause 90-day readmissions, reoperation, and length of stay (LOS) greater than three days. Fifty-five patients (average age of 72.3 ± 8.6 years) were included. No statistically significant differences among two-, three-, and four-part fractures with regard to LOS, discharge location, 90- day readmission, revision surgery, postoperative dislocation, or deep infection were detected. These findings suggest that Neer classification for PHF is not predictive of short-term complications after RSA. (Journal of Surgical Orthopaedic Advances 31(2):104–108, 2022)

Key words: Neer Classification, reverse shoulder arthroplasty, proximal humerus fracture, postoperative outcomes

High-Fidelity Orthopaedic Surgical Skills Models and Resident Performance in the Surgical Treatment of Tibial Plateau Fractures - Joshua Kotler, MD, MC, USN; Jennifer Sanville, MS; Joy Greer, MD, MC, USN; and Christopher Smith, MD, MC, USN

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The purpose of this study was to quantify the impact of low-fidelity simulation on resident surgical skills education. Fourteen orthopaedic surgery residents (PGY-1 through PGY-5) were separated into two, training-level-matched cohorts – an untrained control cohort (UCC) and a low-fidelity Sawbones training cohort (SAW). Together, both cohorts received didactic instruction on the soft-tissue approach, intra-operative reduction, internal-fixation, and surgical wound closure of Schatzker II tibial plateau fractures. The SAW cohort first rehearsed open-reduction, internal-fixation on radiopaque Sawbones models (Pacific Research Laboratories Inc. Vashon, WA). Both cohorts were then evaluated while performing the same procedure on high- fidelity cadaveric models (Rimasys GmbH Cologne, Germany). Surgical skill and knowledge were assessed using the objective structured assessment of technical skills (OSATS) tool, a written exam, and an after-action survey. There were no significant differences in OSATS scores or written exam scores between the two cohorts. A near-linear positive relationship (R2 = 0.9737) existed between training year and average overall OSATS score. All residents expressed a preference for surgical skills training with high-fidelity cadaveric models. The results of this study fail to demonstrate a training advantage of low-fidelity Sawbones models when surgical skill is measured on high-fidelity cadaveric models. Despite this, residents across both cohorts qualitatively felt the high-fidelity models offered a better educational opportunity for surgical practice than did the low-fidelity Sawbones models. (Journal of Surgical Orthopaedic Advances 31(2):109–112, 2022)

Key words: resident education, graduate medical education, healthcare simulation, surgical simulation, surgical skills, sawbones, tibial plateau

Prophylactic Radiotherapy for Prevention of Heterotopic Ossification After Periacetabular Fractures: A Review of Efficacy and Associated Conditions - Joseph S. Geller, MD; Paul R. Allegra, MD; Crystal S. Seldon, MD; Benjamin O. Spieler, MD; Lara L. Cohen, MPH; Spencer W. Barnhill, MD; Samuel R. Huntley, MD MPH; Stuart Samuels, MD PhD; Lora Wang, MD; Derek Isrow, MD, PhD; Alberto De La Zerda, PhD; Aaron H. Wolfson, MD; Giselle Hernandez, MD; Fernando E. Vilella, MD and Raphael L. Yechieli, MD

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Prophylactic radiotherapy (XRT) is a commonly used treatment to decrease heterotopic ossification (HO) in patients with traumatic hip injuries. We conducted a retrospective review of patients at risk for HO who underwent XRT. Of the patients reviewed, 27.3% developed radiographic HO, 11.2% developed symptoms, and 2.0% required resection surgery. Patients were divided into primary (n = 71) and secondary prophylaxis (n = 27) cohorts. In the primary group, 25.0% developed radiographic HO, 5.6% developed symptoms, and 0 required surgery. In the secondary cohort, 33.3% of patients developed new radiographic HO, and 25.9% were symptomatic: four had a Brooker score of 3, and three had a score of 4 (p = 0.03), and 7.4% required surgical resection. (Journal of Surgical Orthopaedic Advances 31(2):113–118, 2022)

Key words: heterotopic ossification, radiation therapy, prophylaxis, acetabular fracture

Evaluation of Rotator Cuff Augmentation of Proximal Humerus Fracture Fixation - Yaser El-Gazzar, MD; Edward Davis, PhD; Tim R. Beals, DO; and Fred Flandry, MD

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Proximal humerus fractures represent one of the most common fractures in the elderly, and are increasingly treated with surgical fixation. Suture augmentation attaching the rotator cuff to the plate has been advocated to combat varus collapse and other associated complications. The objective of this study was to evaluate the contribution of rotator cuff augmentation to stability of proximal humerus fracture fixation. Twelve shoulder specimens from six cadavers underwent simulated two-part and three- part proximal humerus fractures. Matched specimens from the same cadaver were randomized to suture augmentation with locking plate fixation vs. locking plate fixation alone. Greater tuberosity fragment displacement was recorded during cyclic rotational strain of the glenohumeral joint. Greater tuberosity displacement in the two-part fracture model trended towards greater motion without suture augmentation, but did not reach statistical significance (0.032 + 0.012 mm vs. 0.213 + 0.109 mm, p = 0.130). In the three-part fracture model, there was a statistically significant decrease in fracture displacement in the presence of suture augmentation (0.068 + 0.025 mm vs. 2.392 + 0.373 mm, p < 0.001). No specimens demonstrated premature failure during cyclic loading. Suture augmentation of locking plate fixation of three-part proximal humerus fractures results in decreased fracture displacement than locked plating alone, during rotational stresses simulating in vivo rotator cuff deformation forces. (Journal of Surgical Orthopaedic Advances 31(2):119–122, 2022)

Key words: proximal humerus, locking plate, locked plate, suture augmentation, rotator cuff augmentation

Pectoralis Major Tendon Reconstruction: A Systematic Review - Phillip R. Schneider, MD; Michael D. Eckhoff, MD; Logan R. Koehler, MD; Loc-Uyen Vo, MD, MPH; and John C. Dunn, MD

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Pectoralis major tendon injuries are an uncommon injury. They can be treated with primary repair, however, when the tendon becomes retracted it necessitates tendon reconstruction. We performed a systematic review to evaluate patient characteristics, surgical techniques, and outcomes associated with pectoralis major reconstruction. A review was performed for studies published between 1990 and 2019. Peer-reviewed studies with a minimum 1-year follow-up were included. Return to activity, range of motion, complications, and functional outcome scores were primary outcomes. Fourteen primary studies with 88 total patients met inclusion criteria. All patients were male with the average age of 34.6 years-old. Hamstring autograft represented the most frequently used graft type (35). Functional outcomes demonstrated good to excellent results in the majority of patients. Pectoralis major tendon reconstruction is a viable option for tears not amenable to primary repair. We found good to excellent outcomes, and 94.2% return to sport for patients undergoing reconstruction. (Journal of Surgical Orthopaedic Advances 31(2):123–126, 2022)

Key words: pectoralis major reconstruction, pectoralis major rupture, allograft, autograft

Overlapping Surgery for Distal Radius Fractures: Is It Safe? - Jeffrey Klott, MD; Randall T. Loder, MD; and Brian Mullis, MD

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Patients who underwent distal radius fracture (open reduction and internal fixation [ORIF]) at a Level 1 trauma center deemed “overlapping” (greater than 30 minutes overlap) were compared against consecutive cases. Unplanned return to surgery within 1 year was the primary outcome. Sixty-two patients were included in the overlapping group and 37 in the consecutive group. There was no difference in unplanned return to surgery 1 year following procedure with three cases (5%) in the overlapping group and one case (3%) in the consecutive group. There was a significant difference (p = 0.02) in procedure time between the overlapping group (151 + 54 minutes) and nonoverlapping group (126 + 35 minutes). There was no difference in infection, readmission, nonunion, malunion, deep infection, or superficial infection between groups. Based on a post-hoc power analysis with p < 0.05 and power at 80%, 2,691 patients would be needed to determine if there is truly no difference between groups. (Journal of Surgical Orthopaedic Advances 31(2):127–130, 2022)

Key words: distal radius, graduated responsibility, overlapping surgery, resident supervision, graduate medical education

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