Primary Total Knee and Total Hip Arthroplasty in the Rural Patient - David A. Forgas, MD; Sowmyanarayanan Thuppal, MD, PhD; Steven L. Scaife, MS; Anthony Sleiman, BA; and Youssef El Bitar, MD - David A. Forgas, MD; Sowmyanarayanan Thuppal, MD, PhD; Steven L. Scaife, MS; Anthony Sleiman, BA; and Youssef El Bitar, MD

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Rural patients have poorer health indicators, including higher risk of developing osteoarthritis. The objective of this study is to compare rural patients undergoing primary total joint arthroplasty (TJA) at rural hospitals with those undergoing primary TJA at urban hospitals with regards to demographics, comorbidities, and complications and to determine the preferred location of care for rural patients. Data from the Healthcare Cost and Utilization Project National Inpatient Sample between 2016 and 2018 were analyzed. Demographics, comorbidities, inpatient complications, hospital length of stay, inpatient mortality, and discharge disposition were compared between rural patients who underwent TJA at rural hospitals and urban hospitals. Rural patients undergoing primary TJA in rural hospitals were more likely to be women, to be treated in the South, to have Medicaid payer status, to have dementia, diabetes mellitus, lung disease, and postoperative pulmonary complications, and to have a longer hospital length of stay. Those patients were also less likely to have baseline obesity, heart disease, kidney disease, liver disease, cancer, postoperative infection, and cardiovascular complications, and were less likely to be discharged home. Rural patients undergoing primary TJA tend to pursue surgery in their rural hospital when their comorbidity profile is manageable. These patients get their surgery performed in an urban setting when they have the means for travel and cost, and when their comorbidity profile is more complicated, requiring more specialized care, Rural patients are choosing to undergo their primary TJA in urban hospitals as opposed to their local rural hospitals. (Journal of Surgical Orthopaedic Advances 33(2):061–067, 2024)

Key words: rural patient, total joint arthroplasty, total joint arthroplasty utilization, patient demographics, hospital demographics

Victor McKusick: Father of Medical Genetics and His Impact on Orthopaedics - Majd Marrache, MD; and Paul D. Sponseller, MD

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Victor McKusick, an iconic figure in medicine and considered the founding father of medical genetics, lived an exemplary life bound to inspire others. As a geneticist, McKusick was heavily involved in the Human Genome Project and the development of the widely used Online Mendelian Inheritance in Man. As a researcher and prolific writer, he published more than 700 research articles, reviews, and books. McKusick educated and inspired thousands of students, doctors, and scientists while performing landmark studies in hereditary disorders and skeletal dysplasias. This brief history describes the life of Dr. Victor McKusick and his tremendous impact on orthopaedic surgery. (Journal of Surgical Orthopaedic Advances 33(2):068-071, 2024)

Key words: McKusick, genetics, orthopaedics, Victor McKusick, skeletal dysplasia

Posttraumatic Arthritis Is More Common in Patients Undergoing Total Knee Arthroplasty Before Age 50 - LCDR Aaron A. Olsen, DO, MC, USN; LT Jonathan K. Kallevang, DO, MC, USN; CDR George C. Balazs, MD, MC, USN; and LCDR Ashton H. Goldman, MD, MC, USN

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Primary total knee arthroplasty (TKA) in patients under 50 is becoming more common. The goal of this study was to identify the diagnoses and predisposing factors for TKA prior to age 50. The Military Data Repository was queried for patients undergoing TKA prior to age 50. The cohort was matched to older patients. A total of 1,504 patients underwent manual record review for demographics, prior knee surgery, and indication for TKA. Primary osteoarthritis was the most common indication in both cohorts. Pos! raumatic osteoarthritis was more common in patients who underwent TKA before age 50 (28%) compared with patients 50 and older (7%; p < 0.001). Patients who underwent TKA before age 50 were more likely to have previous anterior cruciate ligament injury, or any previous ipsilateral knee surgery (p < 0.001). These data suggest an association between prior knee injury and age at time of TKA. (Journal of Surgical Orthopaedic Advances 33(2):072-076, 2024)

Key words: posttraumatic arthritis, total knee arthroplasty, ACL reconstruction, young TKA

Recent Trends in Concomitant Distal Clavicle Excision During Rotator Cuff Repair - Matthew J. Partan, DO; John M. Tarazi, MD; Peter B. White, DO, MS; Cesar Iturriaga, DO; and Randy M. Cohn, MD

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The purpose of this study is to evaluate trends in distal clavicle excision (DCE) in association with arthroscopic rotator cuff repair (RCR) from 2010 to 2019. The National Surgical Quality Improvement Program database was queried to identify all patients who underwent arthroscopic RCR from January 1, 2010 to December 31, 2019, and was further subdivided into procedure type: (1) isolated RCR; and (2) RCR with arthroscopic or open DCE. The proportion of each surgery type, by year and within groups, was calculated. The Cochran-Armitage test for trend was used to analyze yearly proportions of RCR with concomitant DCE. In a sample size of 19,163 patients, the proportion of RCR with DCE decreased from 51.2% to 40.8% (r = −0.830; p = 0.003). Although the results of this study suggest that surgeons are performing fewer DCEs in the setting of RCR, many DCEs are still being done. (Journal of Surgical Orthopaedic Advances 33(2):077-079, 2024)

Key words: rotator cuff repair, distal clavicle excision, trends

Superficial Branch of the Radial Nerve Versus Sural Nerve Grafting After Traumatic Adult Brachial Plexus Injury - Andres A. Maldonado, MD, PhD; Eric R. Wagner, MD; Morad Askari, MD; Robert J. Spinner, MD; Allen T. Bishop, MD; and Alexander Y. Shin, MD

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The purpose of this study was to compare two sources of nerve graft for brachial plexus reconstruction: the denervated superficial branch of the radial nerve (SBRN) and the sural nerve. Ninety-seven patients who underwent brachial plexus reconstruction with denervated SBRN nerve (24 patients with 24 grafts) or with sural nerve grafting (73 patients with 83 nerve grafts) were included. The two groups were compared with respect to postoperative muscle reinnervation, disabilities of the arm, shoulder, and hand (DASH) scores. In the SBRN group, only four (17%) of the nerve grafts provided grade III or higher muscle function. In the sural nerve group, 31 (37%) of the nerve grafts provided grade III or higher muscle function. Smoking had a negative impact on muscle recovery. Denervated SBRN grafts are associated with inferior outcomes when compared with sural nerve grafts in the treatment of traumatic adult brachial plexus injuries. (Journal of Surgical Orthopaedic Advances 33(2):080-083, 2024)

Key words: superficial branch radial nerve, grafting, brachial plexus

Assessment of Prophylactic Antibiotic Coverage in Culture-positive Traumatic Open Fractures - Rachel LaBianca Toler, PharmD; Susan E. Hamblin, PharmD; Lauren E. Mangan, PharmD; J. Myles Keck, PharmD; Austin Ing, PharmD; Matthew Felbinger, PharmD; Cory Collinge, MD; and Bradley M. Dennis, MD

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Guidelines provide varying recommendations for the prophylactic antimicrobial treatment of open fractures. This single-center, retrospective cohort study was conducted to determine how well an institutional prophylactic antibiotic protocol covered pathogens associated with open fractures. The authors included adult trauma patients with one or more open fractures and a positive culture from the site of the open fracture, and compared outcomes between patients who were covered by prophylactic antibiotics with patients not covered by prophylactic antibiotics. Of 957 patients evaluated, 75 were included, with 40 patients (53%) covered by the prophylactic antibiotics received. Multidrug-resistant pathogens were isolated in 23 (58%) patients covered versus 26 (74%) patients not covered (p = 0.128). The median time to positive culture was less in patients not covered by initial antibiotics compared with those who were covered (30.2 vs. 102.1 days; p = 0.003). Over half of the patients developed cultures with pathogens that were covered by their initial antibiotic prophylaxis. (Journal of Surgical Orthopaedic Advances 33(2):084-087, 2024)

Key words: prophylactic antibiotics, antibiotics, open fracture, infection, multidrug-resistant, trauma

Isolated Lateral Plating for Bicondylar Tibial Plateau Fractures: Factors Influencing Decision Making - Mandip Singh, MD; Mikel Headford, DO; Krishna Vangipuram Suresh, MD; and Thomas Revak, DO

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Lateral plating alone has been postulated as an alternative for fixation of bicondylar tibial plateau fractures in attempts to limit morbidity associated with dual plating. Characterization of fracture patterns that may facilitate lateral plating alone for bicondylar tibial plateau fractures is not well established. The authors analyzed radiographic and clinical outcomes of isolated lateral plating in patients with at least 6 months of follow-up. Of 56 patients identified, 37 (66%) had 41 AO Foundation (AO)/ Orthopaedic Trauma Association (OTA) C1/C2 fractures with 19 (34%) presenting with 41 C3 fractures. Mean posteromedial articular fracture angle (PMAFA) was 69.9 degrees, with an average of 1.3 medial articular fragments. Only 16 patients (28%) had a PMAFA under 45 degrees. There were no cases of nonunion, and five patients (8.9%) developed wound infection during follow-up. Four patients (7.1%) experienced malreduction over three degrees, and eight patients (14.3%) experienced change in alignment over the follow-up duration, indicating some risk of inadequate fixation with this technique. (Journal of Surgical Orthopaedic Advances 33(2):088-092, 2024)

Key words: bicondylar tibial plateau, isolated lateral plating, postoperative outcomes, decision making, case series

Angina Pectoris Is Associated with Cervical Disc Disease: A Cross-Sectional, Population-Based Study Using the Medicare Expenditure Panel Survey (MEPS) - Peter Ahorukomeye, BS; Jerry Du, MD; Amit K. Bhandutia, MD; Charles C. Yu, MD; Douglas S. Weinberg, MD; and Nicholas U. Ahn, MD

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Atherosclerotic disease in the vessels that supply the cervical spine may lead to degenerative disease. In angina pectoris (AP), atherosclerotic disease leads to coronary vessel occlusion and resulting symptoms. This study aims to determine the relationship between AP and neck pain. Analysis was focused on respondents who had a history of cervical pain disorders, adjusting for demographic, education, and mental health confounders. A total of 30,461 participated in the survey. Of 1,049 respondents, 21% reported neck pain. Mean age of the respondents was 62.6 ± 16.1 years. Nonwhite race, current everyday smokers, lower family income, hypertension, and diabetes had higher prevalence of neck pain (p < 0.05). On multivariate analysis, AP was associated with increased odds of neck pain (odds ratio [OR] = 1.42 [95% confidence interval (CI) 1.04 to 1.92], p = 0.026). AP was independently associated with 42% increased odds of having neck pain. Further study into the association of cardiovascular disease with degenerative disc disease pain should be performed. (Journal of Surgical Orthopaedic Advances 33(2):093- 096, 2024)

Key words: spine, cervical spine, degenerative cervical disease, angina pectoris

Reuse of Surgical Masks During the COVID-19 Shortage: Association with the Incidence of Surgical Site Infections - Zsombor T. Gal, BS; Ashley Y. Albano, BA; David C. Landy, MD, PhD; Arun Aneja, MD, PhD; and Arjun Srinath, MD, MPH

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The association between the reuse of surgical masks (SMs) for multiple procedures and rates of surgical site infections (SSIs) is unclear. Hence, the purpose of this study was to determine whether a policy mandating the reuse of SMs was associated with increased SSI incidence. It was hypothesized the rate of SSIs would be significantly greater during the postimplementation period compared with the preimplementation period. Retrospective chart review of patients who underwent orthopaedic and general surgery during the 60 days before and after policy implementation was performed. Focus was on consecutive procedures performed by the same surgeon on the same day. An assessment of SSI risk factors suggested the postimplementation group was at higher risk. However, the daily use of a single SM across multiple procedures was not associated with a clinically signifi cant increase in SSIs. Because future pandemics and public health crises may be accompanied by similar shortages, it may be possible to reuse masks in these situations without concern for increased SSI. (Journal of Surgical Orthopaedic Advances 33(2):097-102, 2024)

Key words: surgical site infections, surgical masks, surgical attire, COVID-19, PPE shortages

Smoking Is Independently Associated with Increased Pain Severity and Interference in Patients with Traumatic Spinal Cord Injury - Collin W. Blackburn, MD, MBA; Tyler J. Moon, MD; and Nicholas U. Ahn, MD

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Previous studies have shown a relationship between cigarette use and pain but never in the setting of traumatic spinal cord injury (TSCI). Therefore, the objectives of this study were to (1) determine whether smokers with TSCI experience increased pain compared with nonsmokers with TSCI and (2) determine whether smokers with TSCI experience worse functional outcomes than nonsmokers with TSCI. A retrospective analysis of the National Spinal Cord Injury Statistical Center database was performed. Pain severity, interference, and functional outcomes were compared between 514 nonsmokers and 124 smokers with American Spinal Injury Association (ASIA) C/D TSCI. Smokers reported higher scores for pain severity and interference compared with nonsmokers. These findings were significant on multivariable analysis. Smokers also reported higher rates of job loss compared with nonsmokers, but this finding was not significant on multivariable analysis. Smoking may be an independent risk factor for increased pain severity and interference in the setting of TSCI. (Journal of Surgical Orthopaedic Advances 33(2):103-107, 2024)

Key words: spine surgery, smoking, tobacco use, pain, pain severity, pain interference, spinal cord injury

Efficacy and Accuracy of Diagnosing Septic Arthritis: How Effective Are Current Methods for Timely Diagnosis of Septic Arthritis? - John G. Weeks, BS and Thomas J. Revak, DO

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The diagnosis of septic arthritis requires a reliance on ancillary tests, including synovial fluid white blood cell count (jWBC), percentage of polymorphonuclear leukocytes (%PMN), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). This study evaluated these tests to determine their diagnostic utility in suspected septic arthritis. A retrospective chart review was performed on patients admitted to an urban hospital who underwent arthrocentesis. The authors evaluated the jWBC, %PMN, ESR, and CRP with receiver operating characteristic (ROC) curve analyses. Two hundred sixty-fi ve patients met inclusion criteria. Sixty-three had a culture-positive aspirate. ROC curve analysis resulted in an area under the curve (AUC) of 0.80 for jWBC with cutoff point of 22,563 cells/mm3 and an AUC of 0.71 for %PMN with cutoff point of 90.5%. CRP and ESR had AUC values of 0.62 and 0.61, respectively. The culture-positive cohort had higher elevations in all assessed diagnostic tests. However, AUC data for ESR and CRP showed little diagnostic utility. Additionally, sensitivities and specifi cities of jWBC and %PMN were too low. Associated cutoff points would result in excessive unnecessary operative intervention. Further studies should incorporate synovial fluid biomarkers into the workup of a suspected septic joint. (Journal of Surgical Orthopaedic Advances 33(2):108-111, 2024)

Key words: septic arthritis, arthrocentesis, diagnostic testing, synovial fluid biomarkers

Robotic Arm-assisted Total Hip Arthroplasty Reduces Postoperative Trochanteric Bursitis and Changes in Hip Offset - Connor A. King, MD; Ye Joon Kim, MS; Alexander T. Bradley, MD; Kenneth S.  Chakour, MD; John M. Martell, MD; and Hue H. Luu, MD

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We investigated the effect of robotic assistance in a postoperative change in hip offset and the incidence of trochanteric bursitis among total hip arthroplasty (THA) patients. As part of a retrospective study of a consecutive series of patients over a 3-year period, 211 patients (102 traditional; 109 robotic) between 2013 and 2016 who underwent posterior-lateral THA were reviewed. Hip off set was measured on preoperative and postoperative anterior-posterior (AP) pelvis radiographs. The absolute change in total hip offset was higher in patients undergoing non-robotic THA than in patients undergoing robotic THA (5.98 ± 4.47 mm vs 4.33 ± 3.98 mm; p = 0.008). The rate of symptomatic trochanteric bursitis (p = 0.02) and cortisone injection was higher in non-robotic THA patients than in robotic THA patients (p = 0.002). Robotic arm-assisted THA is associated with a decreased postoperative change in hip off set, incidence of symptomatic trochanteric bursitis, and bursal steroid injections. (Journal of Surgical Orthopaedic Advances 32(4):112-116, 2023)

Key words: total hip arthroplasty (THA), trochanteric bursitis, off set, robotic arm-assisted

Preoperative Opioid Use Disorder Is Associated with Longer Length of Stay, Infection Rate, and Healthcare Expenditure Following Primary Shoulder Arthroplasty - Kevin Moattari, BS; Nicolás Valentino, BS; Adam M. Gordon, MD; Bhavya Sheth, MD; Charles Conway, MD; Afshin E. Razi, MD; and Jack Choueka, MD

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Recent research efforts have focused on the complications and outcomes associated with opioid use disorder (OUD). However, there is a lack of evidence on the associated risks respective to each primary shoulder arthroplasty procedure. After separating patients by total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) and matching to controls, our study demonstrated significant association with longer LOS in both groups, higher risk of SSI and PJI in the TSA group, PJI in the RSA group, and higher costs regardless of procedure. Eff orts to appropriately recognize OUD, optimize patients pre-operatively, and apply targeted surveillance postoperatively should be made. (Journal of Surgical Orthopaedic Advances 33(2):117-121, 2024)

Key words: total shoulder arthroplasty, reverse shoulder arthroplasty, opioid use disorder, peri-prosthetic joint infection

Effect of CURES Legislation on Narcotic Prescriptions After Soft-tissue Hand Surgery - Conor Spady, MD; Damien Cannon, MD; Montri Daniel Wongworawat, MD; David E Ruckle, MD; Rusheel Nayak, MD; and Brittany McPhee, BSc

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California’s Controlled Substance Utilization Review and Evaluation System (CURES) was mandated in 2018 to monitor and limit opiate prescriptions. This study evaluated the effects of this legislation on postoperative opioid prescriptions of patients undergoing soft tissue hand surgery. Patients receiving carpal tunnel release, trigger finger release, and ganglion excisions 18 months prior to and 18 months after CURES were selected. The primary outcome was milligram morphine equivalent (MME) prescribed at the surgical encounter and at first postoperative visit. There were 758 patients in the pre-CURES cohort and 701 patients in the post-CURES cohort. In the pre-CURES cohort, there was 116.9 ± 123.8 MME prescribed post op and 10.2 ± 70.8 at first follow-up, whereas post-CURES had 58.8 ± 68.4 MME and 1.1 ± 14.1 for post-op and first follow-up respectively. Findings of this study indicate state regulations may play a role in reducing narcotic consumption following soft tissue hand surgery. (Journal of Surgical Orthopaedic Advances 33(2):122-124, 2024)

Key words: hand surgery, CURES, opioid legislation, opioid control, orthopedic surgery, California

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