- 32-2 Table of Contents [PDF]
Sub-chondroplasty Reduces Pain, Improves Function and Delays the Conversion to Arthroplasty in Patients with Advanced Knee Osteoarthritis: A Stratified Meta-analysis and Quality Assessment - Mariana Roldan, BS; Mohamed E. Awad, MD, MBA; Trey D. VanAken, MBA; Wael Saasouh, MD; Padmavathi Patel, MD; Gamal Mostafa, MD; and Khaled J. Saleh, MD, MSc, FRCS(C), MHCH, CPE
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There is an ongoing interest in alternatives to total knee arthroplasty, as a means to delay inevitable replacement. A possible, minimally invasive, alternative is a sub-chondroplasty, involving interosseous injection of bone substitute materials such as calcium phosphate (CaPo4), platelet-rich plasma (PRP), bone marrow aspirate concentrate (BMAC) or Injectable demineralized bone matrix (iDBM) into the subchondral bone. Eleven clinical trials were found, investigating the effectiveness of sub-chondroplasties performed using CaPo4, PRP, BMAC, and iDBM. A non-stratified and stratified meta-analysis of the included studies were conducted to test for confounding variables across the trials. Non-stratified analysis, regardless of injectable type, revealed a significant improvement in the average Visual Analog Scale (VAS) score and postoperative Knee Injury and Osteoarthritis Outcome Score (KOOS) in patients post sub-chondroplasty, as compared to baseline. This analysis demonstrates that the sub-chondroplasty procedure reduces pain, improves function, and has lower risk of conversion to arthroplasty. (Journal of Surgical Orthopaedic Advances 32(2):065–074, 2023)
Key words: sub-chondroplasty, osteoarthritis, bone marrow lesion, bone marrow edema, calcium phosphate, platelet rich plasma, bone marrow aspirate concentrate, injectable demineralized bone matrix
Early Clinical Results Following Repair of Gluteal Tendon Tears - Trevor Smith, MS; Michael Matthews; Kenneth D. Weeks, MD; Susan M. Odum, PhD; and Bradley S. Ellison, MD
Gluteal tendinopathy is a common source of impairment in adults due to degenerative changes in the gluteus medius tendon. We identified patients with gluteal tendinopathy who underwent surgery with a minimum six-month follow up. Radiographs, magnetic resonance images, demographic data, Hip Outcome Score (HOS), Veterans Rand 12-item health survey (VR-12), and a patient survey were reviewed. The cohort consisted of seventeen complete tears and thirty-one partial tears of the gluteal medius tendon (n = 48). Of patients, 72.9% reported satisfaction with surgery and noted 95.5% improvement in symptoms. Patients with partial tears demonstrated 90.0% improvement, while patients with complete tears noted 85% (p = 0.983). The median percent improvement for satisfied patients was 95.00 (85–100) and was significantly different from non-satisfied patients (p < 0.0001). Surgical repair resulted in higher HOS, activities of daily living (ADL), and HOS Sports scores. The majority of patients were satisfied with surgical treatment at follow up, noting near complete resolution in preoperative symptoms. (Journal of Surgical Orthopaedic Advances 32(2):075–082, 2023)
Key words: gluteus medius, reconstruction, clinical improvement
Availability of Consumer Prices for Arthroscopic Meniscus Surgery - Toufic R. Jildeh, MD; Patrick Buckley, MD; Muhammad J. Abbas, MD; Noel O. Akioyamen, MD; Leena Abbas, BS; James Calvin Montgomery, BS; and Kelechi R. Okoroha, MD
The purpose is to examine the availability of consumer pricing information for arthroscopic meniscal surgery in the United States. Secondary objectives were comparing the price of meniscal repair to meniscectomy and regional pricing differences. Orthopaedic sports medicine clinics were sorted by state and randomly selected from American Orthopaedic Society for Sports Medicine’s online directory. Following standardized script, each clinic was called a maximum of three times to obtain pricing information for meniscal surgery. A total of 1,008 distinct orthopaedic sport medicine practices were contacted. Six (6%) clinics were able to provide complete bundle pricing, and 183 (18.2%) clinics were able to provide physician-only fees for either meniscectomy or meniscal repair. Physician-only fees and bundle pricing were significantly less for meniscal repairs as compared to meniscectomies. There were no geographic regional differences in pricing for physician-only fees. There is a paucity of information regarding price transparency for arthroscopic meniscal surgery. (Journal of Surgical Orthopaedic Advances 32(2):083–087, 2023)
Key words: meniscus surgery, healthcare economics, pricing availability, meniscectomy, meniscal repair
Pediatric Upper Extremity Trauma Secondary to All-terrain Vehicle Use - Derek B. Asserson, MD; Steven F. Shannon, MD; Todd A. Milbrandt, MD; and Alexander Y. Shin, MD
All-terrain vehicles (ATVs) have become popular with respect to recreational activities. Multiple orthopaedic and pediatric organizations currently recommend limiting use of ATVs to older age groups of children with supervision. These recommendations have not generally been adhered to, resulting in a disproportionate number of pediatric orthopaedic trauma, specifically of the upper extremities. A retrospective review of patients 18-years-old and younger who presented to a single, Level I Trauma Center with ATV-related upper extremity trauma between 1996 and 2006 was undertaken to determine the impact of ATV use on the upper extremities of children. A total of 65 patients were identified with an average age of 12.3. Only 29.2% wore helmets and 73.8% were drivers. The hand and elbow were the most common injury sites in patients under age 12, elbow for those between ages 12 and 16, and wrist for those over age 16 (p = 0.031). Fractures/Dislocations were the most common injury in all age groups (p = 0.0077). The most performed surgical procedure was open reduction internal fixation of fractures, and patients required an average of 4.8 total operations. Patients who had non-isolated upper extremity injuries were associated with longer hospital stays (p = 0.011) but not ICU stays (p = 0.10). In order to reduce pediatric upper extremity injuries from ATVs, restrictions must be more stringent and safety education made a priority. (Journal of Surgical Orthopaedic Advances 32(2):088–091, 2023)
Key word: upper extremity, pediatric, ATVs, regulations
Posterior Capsule Reconstruction with Polypropylene Mesh After Total Hip Arthroplasty - James M. Rizkalla, MD; Brian P. Gladnick, MD; Tolulope F. Obafemi, MD; Kurt J. Kitziger, MD; Paul C. Peters, Jr., MD; and Richard D. Schubert, MD
Instability remains a challenge after total hip arthroplasty (THA). We have previously utilized a monofilament polypropylene mesh to reconstruct the posterior capsule for unstable THA. This study identified 24 hips that underwent mesh reconstruction of the posterior capsule for instability. Survivorship was 70.8% at mean 6.5 years (range 6 weeks–20.1 years). Six patients underwent re-operation, and one patient had the mesh removed. Of eight hips, five (62.5%) with a history of prior revision re-dislocated, while only 2/16 hips (12.5%) with no previous revision history re-dislocated (p = 0.02). Posterior capsule reconstruction with polypropylene mesh has reasonable mid-term survivorship in this challenging population. (Journal of Surgical Orthopaedic Advances 32(2):092–096, 2023)
Key words: total hip arthroplasty, dislocation, posterior capsule reconstruction, polypropylene mesh, survivorship
A Physician-led Care Redesign Blunts Predictors of Length of Stay After Total Hip and Knee Arthroplasty - Arnold J. Silverberg, MD; Hari K. Parvataneni, MD; Hernan A. Prieto, MD; Justin T. Deen; Terrie Vasilopoulos, PhD; MaryBeth Horodyski, EdD; and Chancellor F. Gray, MD
We questioned to what extent traditional predictors of care team burden (via increased length of stay [LOS] after total joint arthroplasty [TJA]) were able to be mitigated through alteration of the care pathway. The impact on LOS of traditional patient risk factors, as well as encounter variables, were analyzed for a consecutive set of patients undergoing surgery before and after a physician-initiated arthroplasty care pathway redesign. We analyzed the impact of these variables on LOS, discharge disposition, and 90-day readmission; separate analyses were performed pre- and post-redesign for LOS. Several patient factors (Risk Assessment and Prediction Tool, body mass index, age, insurance type, smoking) predicted longer LOS in the pre-redesign cohort; post-redesign, only ambulation on the day of surgery and anticoagulation type were predictive. The redesign also lessened the aggregate impact of the patient-specific risk factors, resulting in reduced variation in LOS. Physician leadership of care pathways can reduce the impact of factors that have portended longer LOS, thereby reducing variability in LOS and costs for disparate patient populations while driving improvements in value-based care indices. (Journal of Surgical Orthopaedic Advances 32(2):097–101, 2023)
Key words: length of stay (LOS), value-based care, care pathway redesign, postoperative mobilization, health policy, Comprehensive Care for Joint Replacement Model (CJR)
Orthopaedic Trauma Never Sleeps: Resource Allocation Even During a Non-trauma Crisis - Risa Reid, MD; Tamar Roomian, MS, MPH; Madhav Karunakar, MD; Samuel Posey, MD; Alexander Hysong, MD; Rachel B. Seymour, PhD; Joseph R. Hsu, MD; and Evidence-based Musculoskeletal Injury and Trauma Collaborative (EMIT)
This study aimed to describe hospital resource utilization of an orthopaedic trauma service and the injury epidemiology during the 2019–2020 coronavirus pandemic to help plan future non-trauma crises. A retrospective chart review was performed on adult patients > 18 years of age who presented to our Level I Trauma Center for musculoskeletal trauma from March 30, 2020 to May 8, 2020 (stay-at-home order) and from March 30, 2019 to May 8, 2019 (comparison group). There were 182 patient encounters and 274 fractures in the 2020 stay-at-home period, and there were 210 patient encounters and 337 fractures in the 2019 control group. There was no statistical difference found comparing the proportion of patient encounters in the stay- at-home period to the control period (p > 0.05). The similar volume of consultations and surgeries justifies maintenance of standard resource allocation. (Journal of Surgical Orthopaedic Advances 32(2):102–106, 2023)
Key words: Coronavirus pandemic, orthopaedic trauma epidemiology, resource utilization
Increased Duration and Frequency of Lateral C-Arm Draping Does Not Increase Contamination Rates - Erin K. Haggerty, MD; Harin B. Parikh, MD; Zachary A. Rockov, MD; David M. Hampton, MD; Milton T.M. Little, MD; Charles N. Moon, MD; and Carol A. Lin, MD, MA
This study sought to quantify the rate of culture-positive drape contamination with varying degrees of drape manipulation for intra-operative fluoroscopic imaging. In this prospective cohort study, 30 patients with operatively closed lower extremity fractures were evaluated. The clip-drape technique was employed to cover the emitter. Swab samples were collected for bacterial growth. A t-test was applied for statistical comparison. Three of 30 cases (10% of operations) showed evidence of contamination. There was no statistically significant difference between duration of drape use or the amount of drape manipulations. None of the 30 patients in this study developed surgical site infection 90-days post-surgery. The clip drape technique for lateral fluoroscopy appears to be effective in maintaining surgical field sterility. Moreover, the number of drape manipulations and length of time the drape was in use was not related to drape contamination. Level of Evidence: Therapeutic Level II. (Journal of Surgical Orthopaedic Advances 32(2):107–110, 2023)
Key words: draping, C-arm, C-armor, intraoperative fluoroscopy, clip-drape technique
No Increased Risk of Aseptic Loosening with Tourniquetless Cemented Total Knee Arthroplasty - Michael Merz, MD; Anil Thomas, MD; Carl Talmo, MD; and Sumon Nandi, MD MBA
Our study examined whether risk of revision for aseptic loosening following cemented total knee arthroplasty (TKA) is (1) increased with tourniquetless surgery and (2) affected by patient characteristics or surgical factors. Primary cemented TKAs from 2005–2012 with 2-year follow up were analyzed (n = 5,508 with tourniquet; n=101 without). Revision for aseptic loosening was compared between TKA performed with and without a tourniquet. Patient characteristics were recorded. At mean 4.8- year follow up, risk of aseptic loosening was similar between TKA performed with or without a tourniquet (p = 0.3151). Aseptic loosening was more likely in men (p = 0.0018) and patients younger than 50 (p < 0.0001). No difference was observed between cruciate-retaining and posterior-stabilized implants (p = 0.1250). With the numbers available for study, we did not observe an increased risk of aseptic loosening with tourniquetless cemented primary TKA. Patients younger than 50, particularly men, should be counselled on the increased risk of TKA revision for aseptic loosening. (Journal of Surgical Orthopaedic Advances 32(2):111–113, 2023)
Key words: tourniquet, aseptic loosening, cemented total knee arthroplasty, revision total knee arthroplasty
The Role of Body Mass Index and Hypoalbuminemia on Postoperative Outcomes in Patients Undergoing Total Knee Arthroplasty - Alexis Gaskin, MD; Rolanda Willacy, MD; Regan Burgess; Kyra Caldwell; Olubode A. Olufajo, MD; and Shelton McKenzie, MD
Obesity and malnutrition are modifiable risk factors associated with increased postoperative complications following total knee arthroplasty (TKA). Obesity is paradoxically associated with malnutrition. Previous studies have only evaluated the impact of body mass index (BMI) and hypoalbuminemia separately in relation to postoperative TKA outcomes and have attempted to compare the impact of these modifiable risk factors. Our study seeks to establish if increased BMI and decreased albumin levels have a compounding effect on postoperative outcomes. A retrospective analysis was conducted using the 2011–2014 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) dataset. This study reaffirmed that increased BMI and low albumin levels are associated with increased postoperative complications following TKA. Moreover, this study demonstrated that they do not have a compounding effect, but rather only help predict outcomes when analyzed individually. (Journal of Surgical Orthopaedic Advances 32(2) 114–117, 2023)
Key word: body mass index (BMI), total knee arthroplasty, obesity, hypoalbuminemia, postoperative outcomes
Evaluation of Mid-term Outcomes Following Shoulder Hemiarthroplasty for Avascular Necrosis of the Humeral Head in Patients 40 Years and Younger - Matthew L. Hrin, BA; Edward C. Beck, MD, MPH; Evan M. Miller, MD; Alex S. Weimer, BS; Colin M. Robbins, BA; Hunter Matthews, MD, Michael T. Freehill, MD, Christopher J. Tuohy, MD; Ethan R. Wiesler, MD; Benjamin R. Graves, MD; and Brian R. Waterman, MD
In order to evaluate postoperative function and failure rates among younger patients undergoing hemiarthroplasty for humeral head avascular necrosis (AVN), data from patients < 40 years treated between December 2008 – January 2018 was retrospectively analyzed. Pain was assessed preoperatively and at final follow up using a visual analogue scale (VAS). The American Shoulder and Elbow Surgeons (ASES) standardized assessment, single assessment numeric evaluation (SANE) score, and patient satisfaction were assessed at final follow up, as well as surgical revision rates. In total, eight shoulders were included in the final analysis, with a follow up of 6.6 + 3.6 years. Analysis indicated a statistical improvement in VAS pain (p = 0.001), while comparison of postoperative function between surgical and non-surgical limbs did not demonstrate statistical differences in SANE or ASES averages (p > 0.05). At final follow up, 25% of patients expressed dissatisfaction; however, there were no cases of revision surgery. In conclusion, younger patients undergoing hemiarthroplasty for humeral head AVN experienced pain improvement and no revisions at short-to-mid-term follow up, but one-in-four indicated dissatisfaction. Level of evidence: IV, case series. (Journal of Surgical Orthopaedic Advances 32(2):118–121, 2023)
Key words: avascular necrosis of humeral head, outcomes, young patients, hemiarthroplasty, shoulder arthroplasty
Static Non-articulating Knee Spacers Are Associated with a High Degree of Morbidity in Challenging Clinical Scenarios - Emanuel C. Haug, MD; Jeremy T. Hines, MD; Benjamin Dalkin, BA; Patrick J. Dunne, BA; Wendy M. Novicoff, PhD; Lucian C. Warth, MD; R. Michael Meneghini, MD; and James A. Browne, MD
The morbidity associated with the use of static non-articulating knee spacers for the treatment of periprosthetic joint infection (PJI) in challenging clinical scenarios has not been well described. From 2011–2019, 63 molded block static spacers were utilized at two academic institutions for the treatment of PJI with associated severe soft tissue compromise (59%), collateral ligament deficiency (49%), extensor mechanism compromise (48%), or type 3 bone defects (44%). Complications and outcomes were assessed. Complications with the use of static spacers were common and included further bone loss (46%), spacer migration (16%), extensor mechanism compromise (16%), cast or related soft tissue injuries (16%), fracture (13%), and spacer breakage (3%). Ultimately, 22% of patients underwent amputation. Patient variables such as age and body mass index were not associated with outcomes. Static knee spacers are associated with substantial morbidity in challenging clinical scenarios and alternatives may need to be considered. (Journal of Surgical Orthopaedic Advances 32(2):122–126, 2023)
Key words: total knee arthroplasty, static antibiotic spacers, periprosthetic joint infection, complications
Pediatric Hip Spica Casting: Casting Technique Guide with Procedural Tips - Catherine Mackey MD; Zachary T. Sharfman, MS, MD; Daniel H. Wiznia, MD; and Melinda S. Sharkey, MD
The purpose of this technical note is to outline our preferred methods of pediatric hip spica casting, not only to assist with placement of the cast, but to provide tips for improved waterproofing and decreased skin complications. At our institution, pediatric spica casts are placed to treat a variety of hip and femur conditions. This step-by-step guide was developed using the experience of our authors. In our experience, following this technique has resulted in successful spica cast placement. Specifically, our use of duct tape as a means of waterproofing the casts has decreased urine and fecal soilage of the cast padding and allowed smoothing over sharp cast edges, thus reducing skin complications. In summary, the pediatric spica cast is a valuable tool for the pediatric orthopaedist. With adequate preparation, the right equipment, and the following technique, these historically tedious casts can be placed safely and efficiently. (Journal of Surgical Orthopaedic Advances 32(2): 127–129, 2023)
Key words: spica cast, waterproof, technique
A Novel Technique for Obtaining Neutral Entrance Angle During Suprapatellar Nailing of Tibial Shaft Fractures - Julianne M. Forlizzi, MD; Daniel C. Mascarenhas, MD; Matthew H. Nasra, MBS; and Carlos A. Sagebien, MD
Fractures of the tibial shaft are often treated with intramedullary nailing. Despite advances of implants and surgical techniques such as suprapatellar nailing, certain fracture patterns can still pose challenges in obtaining adequate fracture reductions. Difficulty obtaining a proper starting position with a neutral entrance angle can be difficult with the suprapatellar technique. Use of a cannulated awl can improve the ease and accuracy of attaining the correct start point and facilitate treatment of these complex fractures. Our purpose was to describe the novel use of a curved, cannulated awl to improve the ease and accuracy of obtaining the correct starting point and neutral entrance angle in suprapatellar nailing of tibial shaft fractures. Using this curved, cannulated awl is a novel technique that surgeons can employ to obtain a correct starting point and neutral entrance angle more easily when treating tibial shaft fractures with suprapatellar nailing. (Journal of Surgical Orthopaedic Advances 32(2):130–132, 2023)
Key words: tibial shaft fracture, suprapatellar, intramedullary nail, technique