Heterotopic Ossification Prophylaxis in Acetabular Fracture Surgery: A Systematic Review - Colin K. Cantrell, MD; Erik B. Gerlach, MD; Gregory H. Versteeg, MD; Michael D. Stover, MD; and Bennet A. Butler, MD

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Heterotopic ossification (HO) following acetabular fracture surgery is relatively common. The purpose of this study was to perform a systematic review of the literature regarding HO rates following acetabular surgery and the effectiveness of the various prophylactic measures taken to prevent its occurrence. A search of PubMed, MEDLINE, and Cochrane Database of Systematic Reviews was performed using the search terms (“Acetabular” OR “Acetabulum”) AND (“Heterotopic Ossification” OR “HO” OR “Ectopic Ossification”). Inclusion criteria included articles published in English reporting on HO in acetabular fracture surgery. Descriptive statistics were calculated with categorical data presented as frequency with percentages and continuous data as means. Standard weighted means were calculated for all parameters. Sixty-six articles were included in this study with a total of 5,028 patients. HO was identified in 1,511 (30%) of fractures. Indomethacin (27%) and radiation therapy (24%) demonstrated decreased rates of HO formation versus no prophylaxis (36%). In particular, rates of severe HO formation were substantially decreased with radiation therapy (3%) and indomethacin (7%) compared to no prophylaxis (18%). Indomethacin and radiation therapy both appear to decrease HO formation and severity without substantially increasing surgical morbidity. (Journal of Surgical Orthopaedic Advances 32(4):217–224, 2023)

Key words: heterotopic ossification (HO), acetabular fracture, heterotopic ossification, prophylaxis

Orthopaedic Injuries from All-Terrain Vehicles: An Epidemiological Account and Review of Legislation - Alexis Sandler, MD1; John Dunn, MD; Adam Adler, MD; Austin Fares, MD; and John Scanaliato, MD

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All-terrain vehicles (ATVs) are an ongoing source of orthopaedic trauma in the United States. The National Electronic Injury Surveillance System (NEISS) database was queried for ATV-related extremity trauma from 2010 to 2019. An estimated 31,979 ATV-related injuries present to emergency departments annually without significant variability between years. Patients were predominantly white (63.5%), male (72.2%), and aged 18 – 44 (49.9%). Injury sites frequently included the shoulder (24%), wrist (12.8%), and ankle (11.2%). Fractures were most common followed by strains and sprains. Only 15.5% of injuries occurred on public land. Alcohol use was rarely implicated. Orthopaedic surgeons should be aware that rates of ATV-related musculoskeletal injuries have not changed significantly over the last ten years despite legislative efforts to improve ATV safety. Additionally, safety laws are inconsistent across the US, and many apply to the use of ATVs on public land when a minority of injuries occur on non-public land. (Journal of Surgical Orthopaedic Advances 32(4):225–231, 2023)

Key words: all-terrain vehicles (ATV), trauma, epidemiology

Mortality Rate Increase in Elderly Patients With Hip Fractures Presenting During the COVID-19 Pandemic to a Hospital in the United States Epicenter: Minimum 30-day Follow Up Comparative Study - Nicholas C. Danford, MD, MA; Liana J. Tedesco, MD; Cesar D. Lopez, BS; Emma R. Berube, BA; Shawn M. Simmons, BA; John T. Heffernan, MD; and Charles M. Jobin, MD

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The purpose of this study was to compare mortality and complication rates among geriatric patients who sustained a hip fracture before the coronavirus disease (COVID-19) pandemic began to those who presented during the peak of the pandemic. Patients greater than or equal to 50 years of age who presented with a diagnosis of hip fracture from March 16, 2020 to May 1, 2020 were compared with a historical control group who presented between December 1, 2019 and January 16, 2020. Minimum follow up was 30 days. The primary outcome was a 30-day mortality rate. Thirty-day mortality was significantly different between groups, with no deaths of 24 patients in the pre-COVID-19 cohort versus six deaths of 23 patients (26.1%) in the COVID-19 cohort (chi-squared test, p-value = 0.02). The study concluded that the COVID-19 pandemic increased mortality risk for geriatric hip fracture patients. (Journal of Surgical Orthopaedic Advances 32(4):232-237, 2023)

Key words: hip fracture mortality, COVID-19, patient outcomes, acute hip fracture, postoperative complications, geriatric hip fracture

Circumventing Acute Compartment Syndrome: Outcomes from a Cadaver-based Course in Fasciotomy Procedural Skills - Christopher H. Renninger, MD; Christopher S. Smith, MD; Jennifer A. Sanville; Mark W. Bowyer, MD; and Pamela B. Andreatta, PhD

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Acute compartment syndrome (ACS) represents a surgical emergency requiring effective, complete fasciotomy. The purpose of this study is to evaluate cadaver-based training on the ability of practicing general surgeons to effectively perform upper extremity, thigh, and leg fasciotomies. One hundred seventeen general surgeons underwent a 2-day, cadaver-based course with formative and summative assessments based on validated scoring tools. Overall performance and critical item scores were recorded and compared utilizing analysis of variance with repeated measures and eta-squared values to evaluate effect size. For all three procedures, post-training scores were significantly improved when compared with pre-training scores (p < 0.001). Mean pre-training score for lower leg fasciotomy met the standard for competent performance of the procedure (total score > 80), whereas neither thigh nor upper extremity performance scores met this standard before training. This 2-day, cadaver-based course improves the ability of practicing general surgeons to effectively and independently perform upper extremity, thigh, and lower leg fasciotomies. (Journal of Surgical Orthopaedic Advances 32(4):238-241, 2023)

Key words: fasciotomy, assessment, education

Repair of Chronic Patellar Tendon Rupture With Extensor Mechanism Allograft Augmentation - LDCR Hicks C. Manson, MC, USN; W. Michael Pullen, MD; Robert O. Boatwright, MD; and Patrick W. Joyner, MD

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The purpose of this study was to evaluate the effectiveness of our novel chronic patellar tendon repair with allograft augmentation in an active-duty military population. From 2014 to 2018, five patients with chronic patellar tendon ruptures were treated with a primary repair of the patellar tendon augmented with Achilles tendon allograft. All patients were followed for 12 months, and their range of motion, Lysholm scores, and straight leg raise ability were assessed. Additionally, their return to active military duty was followed. All patients were managed with tendon reapproximation and Achilles allograft augmentation. Lysholm scores improved in all patients from an average of 35 to 87 postoperatively. No patients demonstrated postoperative extensor lag, and patients regained an average flexion of 130 degrees. All patients returned to active military duty. We presented a safe and effective technique to manage chronic patellar tendon ruptures that produced good outcomes. (Journal of Surgical Orthopaedic Advances 32(3):242-245, 2023)

Key words: patellar tendon, primary repair, chronic, allograft, augmentation, military

Outcomes Following Intramedullary Nailing of Select Periarticular Distal Tibia Fractures - Anokha A. Padubidri, MD; Anthony T. Sorkin, MD; Andrew Gudeman, MD; Roman M. Natoli, MD, PhD; and Greg E. Gaski, MD

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Intramedullary nailing (IMN) of periarticular distal tibia fractures may offer advantages compared to plating. This study aims to report on the outcomes of select periarticular distal tibia fractures treated with IMN. Patients over 17 years of age that underwent IMN for extraarticular distal tibia fractures (Osteosynthesefragen/Orthopaedic Trauma Association [AO/OTA] 43-A), partial articular with associated segmental shaft component (43-B), and simple intraarticular (43-C1/2) at a Level I Trauma Center were included. The primary outcome was physical function (PF) and pain interference (PI) assessed via Patient- Reported Outcomes Measurement Information System (PROMIS). Secondary outcomes included reoperation, nonunion, infection, and malalignment. Eighty-four patients with > 12 months follow up were included. Mean PROMIS PI and PF scores were 55.5 and 45.0, respectively. The rate of nonunion and deep infection each were 8%. Eighty-four percent of patients achieved normal alignment. There were no differences detected in clinical outcomes between patients with intraarticular injuries compared with those with extraarticular fractures. Satisfactory clinical, radiographic, and patient-reported outcomes can be expected following treatment of extraarticular and simple intraarticular distal tibia fractures with IMN. (Journal of Surgical Orthopaedic Advances 32(4):246-251, 2023)

Key words: fracture, distal tibia, intramedullary nail, PROMIS, AO/OTA 43C

Machine Learning to Predict Discharge Destination After Total Knee Arthroplasty and Total Hip Arthroplasty - Gregory J. Booth, MD; Jacob Cole, MD; Phil Geiger, MD; George C. Balazs, MD; Scott Hughey, MD; Natalie Nepa, MD; and Ashton Goldman, MD

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Discharge destination impacts costs and perioperative planning for primary total knee (TKA) or hip arthroplasty (THA). The purpose of this study was to create a tool to predict discharge destination in contemporary patients. Models were developed using more than 400,000 patients from the National Surgical Quality Improvement Program database. Models were compared with a previously published model using area under the receiver operating characteristic curve (AUC) and decision curve analysis (DCA). AUC on patients with TKA was 0.729 (95% confidence interval [CI]: 0.719 to 0.738) and 0.688 (95% CI: 0.678 to 0.697) using the new and previous models, respectively. AUC on patients with THA was 0.768 (95% CI: 0.758 to 0.778) and 0.726 (95% CI: 0.714 to 0.737) using the new and previous models, respectively. DCA showed substantially improved net clinical benefit. The new models were integrated into a web-based application. This tool enhances clinical decision making for predicting discharge destination following primary TKA and THA. (Journal of Surgical Orthopaedic Advances 32(4):252- 258, 2023)

Key words: total knee arthroplasty, total hip arthroplasty, machine learning, artificial intelligence, clinical risk prediction

Comparison of Lateral Versus Medial Entry Femoral Traction Pin Complication Rates - T. David Luo, MD; S. Hanif Hussaini, MD; Nicholas A. Andring, MD; Erin A. Kelly, MD; Eben A. Carroll, MD; and Jason J. Halvorson, MD

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Distal femoral skeletal traction is a common procedure for the stabilization of fractures of the pelvis, acetabulum, and femur following trauma. Femoral traction pins are traditionally inserted via medial-to-lateral (MTL) entry to accurately direct the pin away from the medial neurovascular bundle. Alternatively, cadaveric studies have demonstrated low risk to the neurovascular bundle using a lateral-to-medial (LTM) approach. The purpose of this study was to compare the incidence of complications of LTM and MTL femoral traction pin placement at a single institution. This was a retrospective review of patients from the orthopaedic consult registry at a academic Level I Trauma Center. We identified 233 LTM femoral traction pin procedures in 231 patients and 29 MTL pin procedures in 29 patients. The two pin placement techniques were compared with respect to complications, specifically the incidence of neurovascular injury, cellulitis, septic arthritis, osteomyelitis, and heterotopic ossification after femoral traction pin placement. Two complications were reported. One patient developed heterotopic ossification along the pin tract after LTM traction pin placement. Another patient developed septic arthritis after LTM pin placement, likely a!ributable to retrograde intramedullary nailing of his open femur fracture rather than his traction pin. There were no reports of neurovascular injury, cellulitis, or osteomyelitis associated with pin placement. The complication rate was 0.9% for LTM group and 0.0% for MTL group (p = 0.616). LTM femoral traction pin placement is a safe procedure with a similarly low complication rate compared with traditional MTL placement when the limb is positioned in neutral alignment. (Journal of Surgical Orthopaedic Advances 32(4):259-262, 2023)

Key words: traction pin, complications, trauma, femur fracture

Transitioning to Outpatient Shoulder Arthroplasty: Safety, Efficiency, and Cost in a Diverse Payer Mix - Daniel E. Goltz, MD, MBA; Jay M. Levin, MD, MBA; John R. Wickman, MD, MBA; Jeffrey A. O’Donnell, MD; Barrie S. Sugarman, BS; Colleen M. Wixted, BS; Jocelyn R. Wittstein, MD; and Tally E. Lassiter, Jr., MD, MHA

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Outpatient shoulder arthroplasty presents potential clinical benefits but also risk without perioperative optimization. Length of stay depends largely on surgeon preferences, and a large single-surgeon cohort may provide insight into optimal strategies and costs for outpatient shoulder arthroplasty. A single-surgeon cohort of 472 anatomic and reverse shoulder arthroplasties performed between 2017 and 2020 was retrospectively reviewed. Cases were stratified by those who did or did not undergo same-day discharge. The 90-day readmission, discharge to post-acute care, cost, and 45 patient/case factors were examined. Two hundred fifty (53%) underwent same-day discharge, with the proportion of outpatient cases increasing over time to nearly 80%, with no significant difference in 90-day readmissions. Revision cases often underwent same-day discharge, whereas fractures were typically admi"ed. The cost was significantly higher for inpatients, with implants accounting for 52%. Surgeons may safely transition a substantial proportion of shoulder arthroplasties to same-day discharge with some reassurance regarding cost savings and 90-day readmissions. (Journal of Surgical Orthopaedic Advances 32(4):263-269, 2023)

Key words: anatomic total shoulder arthroplasty, reverse total shoulder arthroplasty, readmission, outpatient, same-day discharge, cost

Radiographic Prediction of Soft Tissue Injury Associated With Tibial Plateau Fractures: The Direction of Articular Depression Matters - Matthew P. Lunati, MD; Jesse Seilern und Aspang, MD; J’Lynn L. Baker, BS; Jacob M. Wilson, MD; and Thomas J. Moore, Jr., MD

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This investigation aimed to evaluate the impact of coronal articular fragment displacement of Schatzker type II tibial plateau fractures on concomitant soft tissue knee injuries. One hundred consecutively treated patients were included. Depression depth and coronal articular fragment displacement were measured radiographically, and medial collateral ligament (MCL) and lateral meniscus (LM) injury, and pain and range of motion (ROM) on final follow up, were recorded. Multivariable regression was then performed. Coronal articular fragment displacement was medially and laterally hinged in 74% and 26% of patients, respectively. MCL injuries were significantly higher in the lateral hinge group (odds ratio [OR]: 3.25; confidence interval [CI]: 1.07 to 9.84; p = 0.03). No difference was found in LM injury incidence and amount of articular depression between groups. At final follow-up, average pain and ROM was similar between groups. Findings demonstrate a significant correlation between laterally hinged articular depression in Schatzker II tibial plateau fractures and concomitant MCL injury. (Journal of Surgical Orthopaedic Advances 32(4):270-275, 2023)

Key words: tibial plateau, articular depression, Schatzker II, medial collateral ligament, lateral meniscus

Modified Saha Procedure for Chronic Paralytic Shoulder After Reverse Shoulder Arthroplasty Complicated With Brachial Plexus Injury - Rachel Bordelon, MS; Amy Trammell, MD; and Zhongyu Li, MD, PhD

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Nerve injuries after reverse total shoulder arthroplasty (rTSA) are rare, and fortunately, most patients recover without long- term sequelae. However, irreversible deltoid paralysis due to brachial plexus or axillary nerve injury is devastating, as the deltoid is the main force of movement of the humerus after rTSA. Denervation of the deltoid results in weakness in abduction, forward flexion, and elevation, as well as varying degrees of chronic pain and shoulder instability. Treatment options for chronic deltoid denervation after axillary nerve or brachial plexus injuries are limited, since nerve repair, graft, or transfer procedures are ineffective. Trapezius tendon transfers, including the Saha technique, have been used to treat chronic deltoid weakness in native shoulders. Here, the authors present a modified Saha technique to improve shoulder motion and stability in patients with chronic deltoid paralysis following rTSA. (Journal of Surgical Orthopaedic Advances 32(4):276-280, 2023)

Key words: Saha procedure, trapezius transfer, reverse shoulder arthroplasty, deltoid dysfunction, brachial plexus injury, axillary nerve injury

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