High Resolution MRI Confirms Torsional Injury as Mechanism for Combined Ankle and Common Fibular (Peroneal) Nerve Injuries - Rohin Singh, BS; Kimberly K. Amrami, MD; and Robert J. Spinner, MD

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Common fibular nerve (CFN) injury due to ankle fracture is an underreported complication. The authors have proposed that torsional injury to the ankle can be translated along the interosseous membrane (IOM), producing tension on the CFN at the fibular neck. A 23-year-old woman presented to our clinic for left foot drop. Three months prior, the patient sustained a fall with left ankle inversion injury while running. She was diagnosed with a minor ankle fracture and placed in an orthopaedic boot. Unfortunately, her swelling worsened and one week later the patient was diagnosed with foot drop, which was further corroborated with EMG studies showing severe CFN injury localizing to the fibular neck. Because of the lack of recovery, she underwent decompression of the CFN. She experienced immediate symptomatic relief. High resolution imaging in this case supports our previous mechanism for indirect trauma to the ankle resulting in CFN injury. (Journal of Surgical Orthopaedic Advances 33(1):053-055, 2024)

Key words: peroneal nerve, interosseous membrane, common fibular nerve, peripheral nerve, foot drop

Surgical Scissors: The Core Surgical Instrument - Anil Agarwal; Ankit Jain; Ankur Upadhyay; and Nitish Deo

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Surgical scissors form an essential part of both basic and specialty surgical sets. Their prime function is to cut tissues. They are also used for blunt dissection/development of tissue planes and piercing tissues. A wide variety of scissors are available for use in practice. This review article briefly describes common surgical scissors in orthopaedic use. The basic construct, biomechanics, types, their identification, specific uses, and care aspects are also discussed. A surgeon should be aware of the different types of scissors, their biomechanical features, and specific uses, as they are an important tool in his/her armamentarium. (Journal of Surgical Orthopaedic Advances 33(1):001-004, 2024)

Key words: scissors, biomechanics, wear

Patient-Related Risk Factors Predict Outcomes After Arthroscopic Rotator Cuff Repair - Joseph Cline, MD; Dmitri Falkner, BS; Tyler Brolin, MD; Richard Smith, PhD; Frederick Azar, MD; and Thomas Throckmorton, MD

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The objective of this study was to determine if preoperative patient characteristics have an effect on pain and function after primary arthroscopic rotator cuff repair. Seventy-five arthroscopic primary rotator cuff repairs with at least 2 years of follow-up were identified. Studied variables were preoperative tobacco, opioid, and alcohol use; obesity; mood disorders; disability claim; and Workers’ Compensation status. Outcome measures included visual analog pain scores, American Shoulder and Elbow Surgeons (ASES) scores, Single Assessment Numeric Evaluation (SANE) scores, range of motion, and strength. Preoperative smoking was significantly associated with worse pain (p = 0.009), ASES (p = 0.004), and SANE (p = 0.011) scores. Opioid use showed no statistically significant difference in pain or functional scores. Alcohol use did predict improved ASES scores at long-term follow-up (p = 0.046). The other variables were not associated with inferior outcomes. Smoking and preoperative opioid use represent modifiable risk factors that can be corrected before surgery to optimize outcomes. (Journal of Surgical Orthopaedic Advances 33(1):005-009, 2024)

Key words: rotator cuff repair, outcomes, preoperative risk factors, pain score, tobacco use

Incidence of Urinary Retention Following Posterior Spinal Fusion for Adolescent and Pediatric Scoliosis at a Single Academic Center: Is There a Role for Prophylactic Tamsulosin? - Georges Abdelahad, MD; Alejandro Marquez-Lara, MD, PhD; Kathleen Marsh, MD; Alexander Jinnah, MD; and John Frino, MD

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The purpose of this study is to be!er characterize patient- and surgery-specific parameters associated with postoperative urinary retention (POUR) and assess the impact of prophylactic Tamsulosin following posterior spinal fusion (PSF) for the management of scoliosis in pediatric and adolescent patients. All patients who underwent PSF for surgical correction of adolescent idiopathic scoliosis (AIS) and neuromuscular scoliosis (NMS) between 2015 and 2019 were retrospectively reviewed. Patients were stratified based on whether they received prophylactic Tamsulosin. Overall, POUR was reported in 3.7% (n = 10) of all patients in the study, although Tamsulosin was associated with a lower rate of POUR, and this did not reach statistical significance. Longer fusion constructs were identified as a risk factor for POUR and could help surgeons counsel families prior to surgery. This is the first study to assess the rate of POUR on AIS and NMS patients following PSF without epidural analgesia. (Journal of Surgical Orthopaedic Advances 33(1):010-013, 2024)

Key words: adolescent idiopathic scoliosis, neuromuscular scoliosis, urinary retention, length of stay, posterior spinal fusion

Major Metropolitan Area COVID-19 – Positive Patients Undergoing Emergency and Elective Orthopaedic Surgeries: A Case-matched Control Study - Allison JoAnna Lewis, BS, RT(R), ARRT; Lisa K. Cannada, MD, FAAOS, FAOA; and Paulvalery Roulette, MD

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The SARS-CoV-2 pandemic affected surgical management in Orthopaedics. This study explores the effect of COVID-19–positive patients on time to surgery from admission, total time spent in preoperative preparation, costs of orthopaedic care, and inpatient days in COVID-19–positive patients. The authors’ case-matched study was based on the surgeon, procedure type, and patient demographics. The authors reviewed 58 cases, 23 males and 35 females. The results for the COVID-19–positive and – negative groups are time to admission (362.9; 388.4), time in preparation (127.8; 122.3), inpatient days to surgery (0.2; 0.2), and orthopaedic cost ($81,938; $86,352). With available numbers, no significant difference could be detected for inpatient days until surgery, any associated time to surgery, or orthopaedic costs for operating on COVID-19–positive patients during the pandemic. Perceived increased time and cost of care of COVID-19–positive patients were not proven in this study. (Journal of Surgical Orthopaedic Advances 33(1):014-016, 2024)

Key words: COVID-19, orthopaedics

Preoperative Dehydration Is an Underrecognized Modifiable Risk Factor in Total Hip Arthroplasty - Brandon E. Lung, MD; Matthew Kim, BA; Kylie Callan, BS; Maddison McLellan, BA; Edward D. Wang, MD; William McMaster, MD; Steven Yang, MD; and David H. So, MD

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Dehydration is an overlooked modifiable risk factor that should be optimized prior to elective total hip arthroplasty (THA) to reduce postoperative complications and inpatient costs. All primary THA from 2005 – 2019 were queried from the National Surgical Quality Improvement Program database, and patients were compared based on dehydration status: blood urea nitrogen (BUN): creatinine ratio (Cr) (BUN/Cr) < 20 (nondehydrated), 20 ≤ BUN/Cr ≤ 25 (moderately dehydrated), 25 < BUN/ Cr (severely dehydrated). A subgroup analysis involving only elderly patients > 65 years and normalized gender-adjusted Cr values was also performed. The analysis included 212,452 patients who underwent THA. Adjusted multivariate logistic regression analysis showed that the severely dehydrated cohort had a greater risk of overall complications, postoperative anemia requiring transfusion, nonhome discharge, and increased length of stay (all p < 0.01). Among the elderly, dehydrated patients had a greater risk of postoperative transfusion, cardiac complications, and nonhome discharge (all p < 0.01). BUN/Cr > 20 is an important preoperative diagnostic tool to identify at-risk dehydrated patients. Providers should optimize dehydration to prevent complications, decrease costs, and improve discharge planning. (Journal of Surgical Orthopaedic Advances 33(1):017-025, 2024)

Key words: hip arthroplasty, postoperative complications, dehydration status, BUN/Cr ratio, ACS NSQIP

Fluoroscopy and Radiographs for Detecting Retained Surgical Needles in the Hand - David Woodard, MD; Ian Ridge, MD; Allie Blackburn, MD; S. Craig Morris, MD; Montri Daniel Wongworawat, MD; and Jason Solomon, MD

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When a surgical needle is lost, the protocol is to explore the surgical field and to obtain a plain radiograph if the needle cannot be located. The size of the needle that can be detected with imaging is debated. Plain-film radiographs, C-arm, and mini C-arm fluoroscopy imaging was obtained of a cadaveric hand with retained needle of varying lengths (suture sizes 4-0 – 10-0). The authors performed analyses to determine the sensitivity and specificity of the imaging modalities. There were no differences in diagnostic area under the receiver operating characteristic curve between the three modalities. For plain film, optimal cutoff for needle size was 5.2 mm (sensitivity 0.87, specificity 0.75), for C-arm 6.8 mm (sensitivity 0.84, specificity 0.87), and for mini C-arm 5.9 mm (sensitivity 0.82, specificity 0.86). In the hand, the use of C-arm fluoroscopy is as sensitive as plain-film radiography at detecting retained needles greater than 5.9 mm. (Journal of Surgical Orthopaedic Advances 33(1):026-028, 2024)

Key words: retained needle, retained surgical instrument, microvascular surgery, fluoroscopy, radiographs

Adolescent Idiopathic Scoliosis: Increased Body Mass Associated with Decreased Bracing Outcomes - Adam Margalit, MD; Krishna V. Suresh, MD; Daniel Badin, MD; R. Jay Lee, MD; and Paul D. Sponseller, MD, MBA

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Bracing reduces the need for surgical intervention in patients with adolescent idiopathic scoliosis (AIS). However, bracing outcomes with variable body mass index (BMI) are understudied. The authors sought to determine the association of BMI with bracing outcomes. The authors performed a retrospective cohort study of 104 patients presenting with AIS. Initial Risser score, hours of bracing per day, BMI percentile, and curve magnitude pre- and postbracing were collected. There was no detectable difference between years of brace wear or primary curve magnitude at time of presentation between both groups. Overall, 29% (25/87) of underweight/normal weight patients and 59% (10/17) of overweight/obese patients had curves ≥ 45 degrees at the end of bracing (p = 0.016). Odds of having a curve ≥ 45 degrees after bracing were 3.5 (95% confidence interval: 1.2 to 10.3, p = 0.021) times higher for overweight/obese patients compared with underweight/normal weight patients. Increased overlying adipose tissue may reduce the corrective forces required to straighten the spine. (Journal of Surgical Orthopaedic Advances 33(1):029-032, 2024)

Key words: adolescent idiopathic scoliosis, bracing, obesity, body mass index, pediatric orthopaedics

Who Benefits From Manipulation Under Anesthesia Following Total Knee Arthroplasty? - Matthew L. Brown, MD; Kenneth M. Vaz, MD; Julie C. McCauley, MPH; Laura May, RN; and Clifford W. Colwell, Jr., MD

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Arthrofibrosis is a multifactorial process that results in decreased knee range of motion (ROM). Manipulation under anesthesia (MUA) is commonly regarded as the preferred initial treatment of arthrofibrosis following total knee arthroplasty (TKA). There have been no well-controlled studies demonstrating that MUA effectively increases ROM in patients who develop arthrofibrosis after TKA when compared with routine care. The purpose of this study was to determine whether MUA had any advantage over routine care in the treatment of patients who developed arthrofibrosis following TKA. The authors identified patients who underwent primary TKA at the authors’ institution between 2010 and 2014 and had flexion ≤ 100 degrees at early follow- up. Knees were grouped based on how the arthrofibrosis was treated: those who underwent MUA and those who received routine care. Knee flexion was captured preoperatively (prior to TKA), at early follow-up (prior to MUA or routine care), and at 1-year follow up. Flexion change from early follow-up to 1 year was calculated. The average flexion at 1-year follow-up was not significantly different between the two groups (106.1 ± 11.7 degrees in the routine care group versus 106.3 ± 12.8 degrees in the MUA group). The MUA group had a greater proportion of patients with flexion gains > 20 degrees at final follow-up when compared with patients who underwent routine care (56% vs. 8%, p < 0.0001). This study demonstrates that patients with decreased ROM at early follow-up after primary TKA can expect greater ROM increase at 1-year follow-up if they undergo MUA compared with patients who undergo routine care. (Journal of Surgical Orthopaedic Advances 33(1):033-036, 2024)

Key words: total knee arthroplasty, restricted range of motion, arthrofibrosis, manipulation under anesthesia

Indirect Coronal Reduction Technique Using a Volar Locking Plate in Distal Radius Fractures: A Case Series - Nicholas Andring, MD; T. David Luo, MD, PhD; Suman Medda, MD; Kelly Stumpff, MD; and Eben Carroll, MD

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This is a retrospective case series of patients with distal radius fractures treated with an indirect coronal reduction technique previously described by the senior author using volar locking plates. Seventeen distal radius fractures underwent treatment at a Level I Trauma Center and were retrospectively reviewed for anatomic alignment, surgical complications, and wrist range of motion in the global period. Near-anatomic restoration was achieved with the average radial inclination, radial height, and volar tilt measured as 23.2 ± 3.9 degrees, 11.8 ± 2.1 degrees, and 8.5 ± 5.4 degrees, respectively. Average coronal translation was 2.8 ± 2.7 mm. Postoperative wrist motion on average was within the normal ranges for pronation, supination, wrist flexion, and wrist extension at an average of 36 weeks follow-up. There were no complications related to surgical technique or implant. This case series demonstrates the reliability for coronal reduction with a volar locking plate technique without complications. (Journal of Surgical Orthopaedic Advances 33(1):037-040, 2024)

Key words: distal radius fracture, volar locking plate, distal radial-ulnar joint, trauma, coronal reduction

The Perceived Value of Same-Sex or Same-Race Mentors and Role Models in Academic Medicine - Kryls Ong Sitco Domalaon, MD, USAF, MC; Lydia Jeannette Henderson, BA; Soo Kyoung Kim, MD; Holly Leshikar, MD, MPH; Sandra L. Taylor, PhD; Yueju Li, MS; and Robert M. Szabo, MD, MPH

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This study aims to describe the perception of need for same-sex and same-race mentorship and role models at evolving stages of a medical career and to explore whether these differences affect career choices within the field of medicine. A total of 326 medical students, 309 resident physicians, and 200 faculty a"ending physicians at the University of California, Davis School of Medicine completed an online survey focused on their perceived value of same-sex and same-race mentorship throughout their stages of medical training and practice. The top three factors influencing specialty choice were lifestyle, time commitment, and supportive department. Although most respondents did not believe same-sex or same-race mentors or role models influenced their specialty choice, there were significant differences in the perceived importance and value of gender or race concordance between male versus female and white versus nonwhite populations. (Journal of Surgical Orthopaedic Advances 33(1):041- 048, 2024)

Key words: mentor, role model, diversity, underrepresented groups, academic medicine, specialty choice

Proximal Femur Guided Growth: A Systematic Review - Joshua C. Tadlock, MD; Michael D. Eckhoff, MD; Hunter R. Graver, MD; Tyler H. Doty, BS; Tyler C. Nicholson, MD; and EStephan J. Garcia, MD

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Children with cerebral palsy (CP) and those with avascular necosis (AVN) after treatment of developmental hip dysplasia (DDH) are at risk of developing coxa valga. Proximal femur guided growth is a minimally invasive option to correct this deformity. A systematic review of articles that described treatment of coxa valga with proximal femur guided growth (PFGG) and reporting on primary radiographic outcomes, demographic variables, surgical variables and complications. One hundred and seventy-nine hips underwent PFGG (117 with CP and 62 with lateral overgrowth). Average age at surgery was 8.1 years; average follow-up was 52.5 months. Migration percentage improved from 11.2% (p < 0.0001). Neck-shaft angle improved by 11.9° (p < 0.0001). The most common complication was screw growth out of the physis (30% of cases). PFGG can correct coxa valga, improve radiographic parameters, and in children with CP prevent further subluxation. This technique modulates proximal femur growth, induces changes to the acetabulum and can correct valgus deformity. Evidence Level III. (Journal of Surgical Orthopaedic Advances 32(4):049-052, 2024)

Key words: coxa valga, guided growth, neuromuscular hip dysplasia, pediatrics, epiphysiodesis

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