Gradual distal fibula lengthening (DFL), in conjunction with other procedures, was used to correct ankle valgus and short fibulae in three pediatric patients with multiple hereditary exostoses (MHE). The average amount of DFL was 15 mm with a mean follow-up of 2.9 years. Final radiographs showed that all three patients had a stable ankle mortise without evidence of talar tilt or widening. In conclusion, gradual DFL has the advantage of restoring anatomy in cases of ankle valgus due to short fibulae and MHE, and may be performed in conjunction with other procedures.

Background: Digital templating systems have been promoted due to their ability to reduce costs, facilitate preoperative planning, and maintain surgical accuracy. The implementation of a templating system at a large institution is complicated and has not been fully described. Purpose: We aim to explain the requisite collaboration between orthopaedic surgery, radiology, and information technology needed to implement a successful orthopaedic templating system at a large institution. Methods: A search of the PubMed database was performed to provide a comprehensive review of digital templating. Furthermore, we offer the organizational and technical details needed to implement an institutional templating system. Results: We have provided a strategic plan to describe the collaboration between orthopaedic surgery, musculoskeletal radiology, and information technology required for a successful templating system. Conclusions: The transition to digital templating requires planning, training, and communication between multiple disciplines. Digital templating systems have the potential to foster preoperative planning, improve trainee education, and reduce departmental costs. Clinical Significance: Preoperative digital templating is a means to reduce the risk of intraoperative fracture, decrease overall surgical time, and plan for implant size prior to surgery.

Background: Though previous studies have shown improved outcomes associated with higher volume surgeons and hospitals, this may not be replicated in ASDS due to case complexity variation. We hypothesized that high-volume surgeons perform more complex surgeries. Therefore, we defined an Operative Complexity Index (OCI), specifically for the National Inpatient Samples (NIS) data, which provides information on in-hospital postoperative complications, to assess rates of adult spine deformity surgery (ASDS) cases as they relate to surgeon and hospital operative volume. Methods: The 2001 to 2010 NIS was queried for patients greater than 21 years of age with in-hospital stays, including a spine arthrodesis for a diagnosis of scoliosis. Surgeon and hospital identifiers were used to allocate records into volume quartiles by number of surgeries per year. The OCI was devised considering the number of fusion levels, surgical approach, revision status, and use of osteotomy. The index was validated using blood-loss-related diagnostic and procedural codes. One-way ANOVA assessed continuous measures. Chi-square assessed categorical measures. Results: 141,357 ASDS cases met the inclusion criteria. High-volume surgeons performed a higher rate of longfusions (> 8 levels), revision surgeries, and surgeries requiring osteotomy. The OCI showed weak, but significant, correlation with blood loss values: acute blood loss anemia (r = 0.21) and treatment with blood products (r = 0.12) (p < 0.001). High OCI also was also associated with increased length of stay (r = 0.27) and total charges (r = 0.41) (p < 0.001). Conclusions: The operative complexity index (OCI) for ASDS increases with high-volume surgeons and centers, indicating it can be useful to adjust for surgical invasiveness in the NIS database. Operative complexity must be considered when evaluating patient safety and quality indices among hospitals and surgeons.

Paget’s disease of the bone is a chronic osteopathy that leads to structural weakness, hypervascularity, and bone deformities. Rapid bone turnover in patients with Paget’s disease may affect outcomes following total hip arthroplasty (THA). Most literature on THA in the setting of Paget’s disease is limited to isolated case reports or case series documenting a single institution experience. By completing a comprehensive analysis of the available cases, this study aims to investigate the outcomes and complications of THA in patients with Paget’s disease.

Early physical activity has been proven to accelerate functional recovery after total hip replacement (THR). Weightbearing intolerance secondary to postoperative pain inhibits participation in physical therapy and limits the achievement of functional independence. Neuromuscular electrical stimulation (NMES) has been shown to improve pain and accelerate recovery. This study focused on the effects of NMES on weightbearing pain. The primary objective of this study was to compare the efficacy of NMES versus placebo in the reduction of pain and the use of opiate medications in the treatment of patients during weightbearing exercises after THR. A secondary objective was to assess the use of NMES during weightbearing exercise and its effects on function, hospital length of stay, and disposition planning. This was a randomized, doubleblinded, placebo-controlled study performed with subjects obtained from an outpatient orthopaedic service. Subject underwent elective THR. The NMES device was provided to all subjects; active and a control group were assigned different intensity levels of stimulation. Twenty-nine subjects participated in the study: 15 in the active and 14 in the control group. Data, including pain assessment, opiates use, function, hospital length of stay in days, and disposition was recorded and analyzed. Both control and active groups showed no significant difference on the pain visual analog scale at various postoperative time intervals, length of inpatient hospital stay, and days on opiate medications.

We identified 168,247 total hip and total knee arthroplasties performed in New York State between 2010 and 2012 to examine the evidence for increased geographical and institutional centralization of these procedures. We measured the increased growth of high volume institutions as compared to lower volume hospitals in New York State. We found a high proportion of total arthroplasties already performed in the dozen biggest hospitals in New York back in 2010 and a significant higher growth of these high volume, “centers of excellence,” hospitals when compared to low volume hospitals.

Background: The incidence of distal femoral periprosthetic fractures associated with total knee arthroplasty (TKA) has been reported as 0.3% to 2.5%. This study examined the incidence of distal femoral periprosthetic fractures at one hospital over a 16-year period. We hypothesized that the incidence of these fractures would be lowered after the introduction of lugged femoral implants and insertion of a distal femoral intramedullary bone graft during TKA. Methods: From 1994 to 2010, 4,943 primary TKAs were performed. Following these TKA operations, 21 distal femoral fractures occurred. The surgical technique and implant design changed during this interval. Lugged femoral implants were introduced in 2000. Intramedullary bone grafting of the distal femoral intramedullary guide hole was introduced in 2002. Results: The incidence of distal femoral periprosthetic fracture in this series of 4,943 TKA operations was 0.42% (21/4943). Six fractures occurred in 1,236 knees with femoral implants without femoral fixation lugs (0.49%). Fifteen fractures occurred in 3,707 knees with femoral implants with femoral fixation lugs (0.40%). Eight fractures occurred in 1,653 knees that did not have intramedullary bone grafts (0.48%). Thirteen fractures occurred in 3,290 knees that had intramedullary bone grafts (0.40%). Two fractures occurred in 417 knees with lugged femoral implants and no bone graft (0.48%). Conclusions: In this series, there was no significant difference in the incidence of distal femoral periprosthetic fractures associated with adding fixation lugs to the femoral implant and filling the femoral intramedullary hole with bone graft.

Purpose: The purpose of this study was to investigate the early complications associated with the dorsal approach to the proximal radius. This approach, also called the Thompson approach, is used relatively infrequently for the treatment of forearm fractures. It is primarily reserved for proximal one-third radius fractures where a volar plate may not be placed sufficiently proximal for adequate fixation. Methods: A retrospective chart review was performed on forearm fractures performed at our institution. Over a period from January 2008 to May 2014 a total of 120 patients underwent fixation for radius shaft fractures either isolated or associated with ulna fractures; of these 120 patients, 11 were found to have utilized the Thompson approach to the proximal radius. Demographic data was collected, along with fracture pattern, and associated complications in the first 2 weeks after surgery. Results: The average age of the patients was 31 years (range: 20 to 46 years). Ten patients were male and one was female. The mean follow-up time was 15 weeks (range: 1 to 52 weeks). The stated indication for the dorsal approach was a proximal location of the radius fracture in 10 cases and presence of dorsal open wounds in one patient. In all cases, the posterior interosseous nerve was identified and protected. The average distance from the fracture to the radial head articular surface was 72 mm (range: 34 mm to 132 mm). Four fractures were open, and seven were closed injuries. There were two postoperative posterior interosseous nerve palsies, along with one compartment syndrome requiring fasciotomy. There were no wound complications. There was an overall complication rate of 27%. Conclusion: Postoperative posterior interosseous nerve palsy was the most common complication in this series, occurring in 18% of the patients in spite of identification and protection of the nerve throughout the procedure. High vigilance for compartment syndrome must also be maintained after fixation of any forearm fracture, as it occurred in 1 of 11 patients in this study.

Introduction: This study aimed to develop a tool to quantify risk of inpatient mortality among geriatric and middleaged trauma patients. This study sought to demonstrate the ability of the novel risk score in the early identification of high risk trauma patients for resource-sparing interventions, including referral to palliative medicine. Materials and Methods: This retrospective cohort study utilized data from a single level 1 trauma center. Regression analysis was used to create a novel risk of inpatient mortality score. A total of 2,387 low energy and 1,201 high-energy middle-aged (range: 55 to 64 years of age) and geriatric (65 years of age or odler) trauma patients comprised the study cohort. Model validation was performed using 37,474 lowenergy and 97,034 high-energy patients from the National Trauma Databank (NTDB). Potential hospital cost reduction was calculated for early referral of high risk trauma patients to palliative medicine services in comparison to no palliative medicine referral. Results: Factors predictive of inpatient mortality among the study and validation patient cohorts included; age, Glasgow Coma Scale, and Abbreviated Injury Scale for the head and neck and chest. Within the validation cohort, the novel mortality risk score demonstrated greater predictive capacity than existing trauma scores [STTGMALE-AUROC: 0.83 vs. TRISS 0.80, (p < 0.01), STTGMAHE-AUROC: 0.86 vs. TRISS 0.85, (p < 0.01)]. Our model demonstrated early palliative medicine evaluation could produce $1,083,082 in net hospital savings per year. Conclusion: This novel risk score for older trauma patients has shown fidelity in prediction of inpatient mortality; in the study and validation cohorts. This tool may be used for early intervention in the care of patients at high risk of mortality and resource expenditure.

The low incidence of intraneural ganglion makes it difficult to diagnose and treat before it becomes serious nerve damage. This case describes a 69-year-old female, who suffered from the right drop foot and was diagnosed as a peroneal intraneural ganglion. Resection of the mass relieved the pain; however, motor function was not recovered. Early diagnosis and nerve decompression are essential for the peroneal intraneural ganglion before critical nerve symptoms

A 39-year-old man presented to orthopaedic care with a painful, fully locked knee. Workup revealed free intraarticular nodules, which were subsequently arthroscopically removed and identified to be synovial hemangioma. To the investigators’ knowledge, this is the second reported case of synovial hemangioma presenting as a painful, definitively locked knee. Synovial hemangioma should be considered in the differential diagnosis of knee pain, particularly after more common diagnoses have been ruled out. Efficient and appropriate diagnosis and treatment may result in favorable patient outcomes and avoid long-term disability and dysfunction.

A 67-year-old man presented to orthopaedic care with a painful knee. Workup was consistent with septic arthritis of a native knee, and the patient underwent operative treatment. Cultures from the operating room were speciated to Staphylococcus lugdunensis. To the investigators’ knowledge, this is the first reported S. lugdunensis infection in a peripheral joint in the absence of an orthopaedic prosthesis. Although traditionally associated with infectious endocarditis, S. lugdunensis has been identified as a causative agent in many organ systems, including orthopaedic infections. This case report emphasizes the importance of familiarity with this emerging pathogen in the treatment of a septic joint.

The Latarjet procedure involves the transfer of the coracoid process with its soft tissue attachments, thereby providing both bony and soft tissue articular reinforcement for glenohumeral stabilization. Most studies show positive outcomes with this procedure and complications at rates as low as 1%, predominately secondary to technical error. We present a case of recurrent anterior instability after two attempts at soft tissue stabilization (arthroscopic labral repair followed by open inferior capsular shift) in which an open Latarjet procedure was performed followed by subsequent revision secondary to coracoid autograft fracture. The case presented specifically highlights the need to appropriately identify the “bony margins” of the coracoid prior to drilling to make certain that drill holes are not eccentrically placed.

Gradual distal fibula lengthening (DFL), in conjunction with other procedures, was used to correct ankle valgus and short fibulae in three pediatric patients with multiple hereditary exostoses (MHE). The average amount of DFL was 15 mm with a mean follow-up of 2.9 years. Final radiographs showed that all three patients had a stable ankle mortise without evidence of talar tilt or widening. In conclusion, gradual DFL has the advantage of restoring anatomy in cases of ankle valgus due to short fibulae and MHE, and may be performed in conjunction with other procedures.

Background: Digital templating systems have been promoted due to their ability to reduce costs, facilitate preoperative planning, and maintain surgical accuracy. The implementation of a templating system at a large institution is complicated and has not been fully described. Purpose: We aim to explain the requisite collaboration between orthopaedic surgery, radiology, and information technology needed to implement a successful orthopaedic templating system at a large institution. Methods: A search of the PubMed database was performed to provide a comprehensive review of digital templating. Furthermore, we offer the organizational and technical details needed to implement an institutional templating system. Results: We have provided a strategic plan to describe the collaboration between orthopaedic surgery, musculoskeletal radiology, and information technology required for a successful templating system. Conclusions: The transition to digital templating requires planning, training, and communication between multiple disciplines. Digital templating systems have the potential to foster preoperative planning, improve trainee education, and reduce departmental costs. Clinical Significance: Preoperative digital templating is a means to reduce the risk of intraoperative fracture, decrease overall surgical time, and plan for implant size prior to surgery.

Background: Though previous studies have shown improved outcomes associated with higher volume surgeons and hospitals, this may not be replicated in ASDS due to case complexity variation. We hypothesized that high-volume surgeons perform more complex surgeries. Therefore, we defined an Operative Complexity Index (OCI), specifically for the National Inpatient Samples (NIS) data, which provides information on in-hospital postoperative complications, to assess rates of adult spine deformity surgery (ASDS) cases as they relate to surgeon and hospital operative volume. Methods: The 2001 to 2010 NIS was queried for patients greater than 21 years of age with in-hospital stays, including a spine arthrodesis for a diagnosis of scoliosis. Surgeon and hospital identifiers were used to allocate records into volume quartiles by number of surgeries per year. The OCI was devised considering the number of fusion levels, surgical approach, revision status, and use of osteotomy. The index was validated using blood-loss-related diagnostic and procedural codes. One-way ANOVA assessed continuous measures. Chi-square assessed categorical measures. Results: 141,357 ASDS cases met the inclusion criteria. High-volume surgeons performed a higher rate of longfusions (> 8 levels), revision surgeries, and surgeries requiring osteotomy. The OCI showed weak, but significant, correlation with blood loss values: acute blood loss anemia (r = 0.21) and treatment with blood products (r = 0.12) (p < 0.001). High OCI also was also associated with increased length of stay (r = 0.27) and total charges (r = 0.41) (p < 0.001). Conclusions: The operative complexity index (OCI) for ASDS increases with high-volume surgeons and centers, indicating it can be useful to adjust for surgical invasiveness in the NIS database. Operative complexity must be considered when evaluating patient safety and quality indices among hospitals and surgeons.

Paget’s disease of the bone is a chronic osteopathy that leads to structural weakness, hypervascularity, and bone deformities. Rapid bone turnover in patients with Paget’s disease may affect outcomes following total hip arthroplasty (THA). Most literature on THA in the setting of Paget’s disease is limited to isolated case reports or case series documenting a single institution experience. By completing a comprehensive analysis of the available cases, this study aims to investigate the outcomes and complications of THA in patients with Paget’s disease.

Early physical activity has been proven to accelerate functional recovery after total hip replacement (THR). Weightbearing intolerance secondary to postoperative pain inhibits participation in physical therapy and limits the achievement of functional independence. Neuromuscular electrical stimulation (NMES) has been shown to improve pain and accelerate recovery. This study focused on the effects of NMES on weightbearing pain. The primary objective of this study was to compare the efficacy of NMES versus placebo in the reduction of pain and the use of opiate medications in the treatment of patients during weightbearing exercises after THR. A secondary objective was to assess the use of NMES during weightbearing exercise and its effects on function, hospital length of stay, and disposition planning. This was a randomized, doubleblinded, placebo-controlled study performed with subjects obtained from an outpatient orthopaedic service. Subject underwent elective THR. The NMES device was provided to all subjects; active and a control group were assigned different intensity levels of stimulation. Twenty-nine subjects participated in the study: 15 in the active and 14 in the control group. Data, including pain assessment, opiates use, function, hospital length of stay in days, and disposition was recorded and analyzed. Both control and active groups showed no significant difference on the pain visual analog scale at various postoperative time intervals, length of inpatient hospital stay, and days on opiate medications.

We identified 168,247 total hip and total knee arthroplasties performed in New York State between 2010 and 2012 to examine the evidence for increased geographical and institutional centralization of these procedures. We measured the increased growth of high volume institutions as compared to lower volume hospitals in New York State. We found a high proportion of total arthroplasties already performed in the dozen biggest hospitals in New York back in 2010 and a significant higher growth of these high volume, “centers of excellence,” hospitals when compared to low volume hospitals.

Background: The incidence of distal femoral periprosthetic fractures associated with total knee arthroplasty (TKA) has been reported as 0.3% to 2.5%. This study examined the incidence of distal femoral periprosthetic fractures at one hospital over a 16-year period. We hypothesized that the incidence of these fractures would be lowered after the introduction of lugged femoral implants and insertion of a distal femoral intramedullary bone graft during TKA. Methods: From 1994 to 2010, 4,943 primary TKAs were performed. Following these TKA operations, 21 distal femoral fractures occurred. The surgical technique and implant design changed during this interval. Lugged femoral implants were introduced in 2000. Intramedullary bone grafting of the distal femoral intramedullary guide hole was introduced in 2002. Results: The incidence of distal femoral periprosthetic fracture in this series of 4,943 TKA operations was 0.42% (21/4943). Six fractures occurred in 1,236 knees with femoral implants without femoral fixation lugs (0.49%). Fifteen fractures occurred in 3,707 knees with femoral implants with femoral fixation lugs (0.40%). Eight fractures occurred in 1,653 knees that did not have intramedullary bone grafts (0.48%). Thirteen fractures occurred in 3,290 knees that had intramedullary bone grafts (0.40%). Two fractures occurred in 417 knees with lugged femoral implants and no bone graft (0.48%). Conclusions: In this series, there was no significant difference in the incidence of distal femoral periprosthetic fractures associated with adding fixation lugs to the femoral implant and filling the femoral intramedullary hole with bone graft.

Purpose: The purpose of this study was to investigate the early complications associated with the dorsal approach to the proximal radius. This approach, also called the Thompson approach, is used relatively infrequently for the treatment of forearm fractures. It is primarily reserved for proximal one-third radius fractures where a volar plate may not be placed sufficiently proximal for adequate fixation. Methods: A retrospective chart review was performed on forearm fractures performed at our institution. Over a period from January 2008 to May 2014 a total of 120 patients underwent fixation for radius shaft fractures either isolated or associated with ulna fractures; of these 120 patients, 11 were found to have utilized the Thompson approach to the proximal radius. Demographic data was collected, along with fracture pattern, and associated complications in the first 2 weeks after surgery. Results: The average age of the patients was 31 years (range: 20 to 46 years). Ten patients were male and one was female. The mean follow-up time was 15 weeks (range: 1 to 52 weeks). The stated indication for the dorsal approach was a proximal location of the radius fracture in 10 cases and presence of dorsal open wounds in one patient. In all cases, the posterior interosseous nerve was identified and protected. The average distance from the fracture to the radial head articular surface was 72 mm (range: 34 mm to 132 mm). Four fractures were open, and seven were closed injuries. There were two postoperative posterior interosseous nerve palsies, along with one compartment syndrome requiring fasciotomy. There were no wound complications. There was an overall complication rate of 27%. Conclusion: Postoperative posterior interosseous nerve palsy was the most common complication in this series, occurring in 18% of the patients in spite of identification and protection of the nerve throughout the procedure. High vigilance for compartment syndrome must also be maintained after fixation of any forearm fracture, as it occurred in 1 of 11 patients in this study.

Introduction: This study aimed to develop a tool to quantify risk of inpatient mortality among geriatric and middleaged trauma patients. This study sought to demonstrate the ability of the novel risk score in the early identification of high risk trauma patients for resource-sparing interventions, including referral to palliative medicine. Materials and Methods: This retrospective cohort study utilized data from a single level 1 trauma center. Regression analysis was used to create a novel risk of inpatient mortality score. A total of 2,387 low energy and 1,201 high-energy middle-aged (range: 55 to 64 years of age) and geriatric (65 years of age or odler) trauma patients comprised the study cohort. Model validation was performed using 37,474 lowenergy and 97,034 high-energy patients from the National Trauma Databank (NTDB). Potential hospital cost reduction was calculated for early referral of high risk trauma patients to palliative medicine services in comparison to no palliative medicine referral. Results: Factors predictive of inpatient mortality among the study and validation patient cohorts included; age, Glasgow Coma Scale, and Abbreviated Injury Scale for the head and neck and chest. Within the validation cohort, the novel mortality risk score demonstrated greater predictive capacity than existing trauma scores [STTGMALE-AUROC: 0.83 vs. TRISS 0.80, (p < 0.01), STTGMAHE-AUROC: 0.86 vs. TRISS 0.85, (p < 0.01)]. Our model demonstrated early palliative medicine evaluation could produce $1,083,082 in net hospital savings per year. Conclusion: This novel risk score for older trauma patients has shown fidelity in prediction of inpatient mortality; in the study and validation cohorts. This tool may be used for early intervention in the care of patients at high risk of mortality and resource expenditure.

The low incidence of intraneural ganglion makes it difficult to diagnose and treat before it becomes serious nerve damage. This case describes a 69-year-old female, who suffered from the right drop foot and was diagnosed as a peroneal intraneural ganglion. Resection of the mass relieved the pain; however, motor function was not recovered. Early diagnosis and nerve decompression are essential for the peroneal intraneural ganglion before critical nerve symptoms

A 39-year-old man presented to orthopaedic care with a painful, fully locked knee. Workup revealed free intraarticular nodules, which were subsequently arthroscopically removed and identified to be synovial hemangioma. To the investigators’ knowledge, this is the second reported case of synovial hemangioma presenting as a painful, definitively locked knee. Synovial hemangioma should be considered in the differential diagnosis of knee pain, particularly after more common diagnoses have been ruled out. Efficient and appropriate diagnosis and treatment may result in favorable patient outcomes and avoid long-term disability and dysfunction.

A 67-year-old man presented to orthopaedic care with a painful knee. Workup was consistent with septic arthritis of a native knee, and the patient underwent operative treatment. Cultures from the operating room were speciated to Staphylococcus lugdunensis. To the investigators’ knowledge, this is the first reported S. lugdunensis infection in a peripheral joint in the absence of an orthopaedic prosthesis. Although traditionally associated with infectious endocarditis, S. lugdunensis has been identified as a causative agent in many organ systems, including orthopaedic infections. This case report emphasizes the importance of familiarity with this emerging pathogen in the treatment of a septic joint.

The Latarjet procedure involves the transfer of the coracoid process with its soft tissue attachments, thereby providing both bony and soft tissue articular reinforcement for glenohumeral stabilization. Most studies show positive outcomes with this procedure and complications at rates as low as 1%, predominately secondary to technical error. We present a case of recurrent anterior instability after two attempts at soft tissue stabilization (arthroscopic labral repair followed by open inferior capsular shift) in which an open Latarjet procedure was performed followed by subsequent revision secondary to coracoid autograft fracture. The case presented specifically highlights the need to appropriately identify the “bony margins” of the coracoid prior to drilling to make certain that drill holes are not eccentrically placed.