Purpose: Untreated episodes of shoulder instability can
have major consequences on athletic careers. Operative
shoulder stabilization reduces the rate of recurrent instability and allows for high rates of return to sport (RTS).
Basketball players who experience an episode of instability
have high rates of recurrence, though little is known about
postoperative player performance. The purpose of this study
was to identify the impact of shoulder instability and surgical
stabilization on player performance and career lengths in
the National Basketball Association (NBA).
Methods: NBA players who had episodes of shoulder
instability between 1994-2014 were identified using the
NBA Injury Surveillance and Analytics Database. Players
were stratified according to operative versus nonoperative
treatment of shoulder instability. Two demographic- and
performance-matched controls were chosen for each test
subject. Univariate analyses were used to compare pre- and
postoperative player performance metrics. Survival analysis
was used to assess the effect of shoulder surgery on postoperative career lengths.
Results: Fifty athletes were identified, 46 (92.0%) returned to play in the NBA. Compared to controls, there
was no significant difference in postoperative performance
according to either 1- or 3-year averages. Survival analysis demonstrated no significant difference in postoperative
career lengths between athletes with a history of shoulder
surgery for instability and matched controls.
Conclusion: NBA players return to professional basketball in high numbers following orthopedic surgery for
shoulder instability. Shoulder instability may not be a
career-altering event, as there are highly effective methods
of shoulder stabilization available to athletes.
Open Surgical Management of Chronic Exertional Compartment Syndrome of the Leg
Utkarsh Anil, BS, Amos Z. Dai, BS, Hien Pham, MD, Jordan Werner, MD, Eric J. Strauss, MD, and Laith M. Jazrawi, MD
Purpose: The purpose of this study is to present one institution’s experience managing chronic exertional compartment syndrome (CECS) and to identify patient and surgical
characteristics associated with better outcomes following
open surgical management of CECS with specific emphasis
on return to sports.
Methods: Fifteen patients (10 male, 5 female) who underwent open fasciotomy for CECS with a minimum of 1-year
follow-up were included. Chart review was performed to
obtain patient demographics, medical and surgical history,
presenting symptomatology, and surgical details of fasciotomy. Outcomes were assessed using follow-up questionnaires
that consisted of Tegner Activity Scale, EuroQol-5D (EQ5D) index score, EQ-5D rating scale, symptom resolution,
patient satisfaction, and return to sports.
Results: The mean patient age at the time of surgery was
28.1 years (range: 17 to 49 years). At mean follow-up of 2.7
years (range: 1.0 to 5.1 years), five patients reported complete resolution of symptoms, eight reported improvement
(but not resolution) of symptoms, one reported no change
in symptoms, and one reported worsening of symptoms. The
mean Tegner Activity Score was 6.7 (range: 1 to 9) prior
to injury and 4.7 (range: 1 to 9) postoperatively. Patients
with any preoperative symptoms at rest had significantly
lower Tegner before score (4.0 vs. 7.1, p = 0.036) and EQ5D rating (50.0 vs. 83.5, p = 0.04) compared to those that
only experienced symptoms with activity. Patients that had
prior surgery, including fasciotomy, had significantly lower
EQ-5D rating than patients with no history of prior lower
extremity surgery (56.7 vs. 84.6, p = 0.045). Although 10
(66%) patients were able to return to sports, only four (27%)
of them were able to return to their prior level of sport. The
overall satisfaction rate was 87%.
Conclusion: Although open surgical fasciotomy for treatment of chronic exertional compartment syndrome leads to
high rates of symptom improvement or resolution, fewer
patients are able to return to their prior level of sports. Presence of symptoms at rest, presence of bilateral symptoms,
and history of prior lower extremity surgery all portend
worse outcomes.
Total Hip Arthroplasty for Secondary Causes of Arthritis An Increase in Time and Money
Vinay K. Aggarwal, MD, Yu Min Suh, MS, Lorraine Hutzler, MPA, Leon Moscona, MD, and Pablo Castañeda, MD
Background: Total hip arthroplasty (THA) is a frequently
performed, highly successful orthopedic procedure. Although primary osteoarthritis (PA) is the most common
reason for (THA), there are several secondary conditions
that lead to degenerative hip disease that are successfully
treated with THA. The purpose of this study was to examine
the incidence of these secondary causes of arthritis (SA)
leading to THA and to compare the relative surgical costs,
operating times, and hospital length of stay (LOS) for THA
done for PA versus SA.
Methods: Electronic medical records from 836 continuous
patients undergoing primary THA over a 2-year period were
reviewed at a single high-volume joint arthroplasty center.
Data obtained included age, sex, laterality, diagnosis leading to THA, surgical costs based on hospital fees, operating
room time, and hospital LOS. Using operative reports, office
visit notes, and radiology reports or images, patients were
categorized into PA or SA groupings. PA was defined as
osteoarthritis of no other known etiology, whereas SA was
defined when a known underlying diagnosis led to degenerative joint disease of the hip. SA included hip dysplasia,
post-traumatic arthritis (PTA), avascular necrosis (AVN),
inflammatory arthropathy, Perthes disease, and slipped
capital femoral epiphysis (SCFE). Means and proportions of
the variables from both groups were analyzed and compared
using t-tests and chi-squared tests where applicable.
Results: There were 599 patients in the PA group and 237
patients in the SA group. The SA group was significantly
younger than the PA group (54.4 years versus 64.0 years;
p = 0.0001). The SA cohort had significantly higher mean
surgical costs ($29,662 versus $27,078; p = 0.0005), operating room times (189 minutes versus 179 minutes; p =
0.0042), and LOS (4.2 days versus 3.9 days; p = 0.0312).
Within the SA group, the hip dysplasia subgrouping had
the lowest cost and operating room time, whereas the PTA
subgrouping had the highest cost and operating room time.
Conclusions: More than a quarter of primary THAs are
performed due to secondary arthritis, most commonly due
to hip dysplasia. Cases of THA due to secondary arthritis
are associated with significantly increased hospital costs,
operating time, and postoperative length of stay compared
to THA’s performed for primary osteoarthritis. Patients
with post-traumatic hip arthritis may contribute the highest
economic burden and present the most complex cases for
arthroplasty surgeons.
Clinical Outcomes of Open Subpectoral Biceps Tenodesis with Cortical Button Fixation
Samuel L. Baron, BS, Steven Shamah, BA, Alan W. McGee, MD, Michael J. Alaia, MD, Andrew J. Feldman, MD, and Laith M. Jazrawi, MD
Background: Open subpectoral biceps tenodesis (OSBT)
with cortical button fixation can deliver acceptable results
for long head of the biceps (LHB) pathology with the benefit
of smaller bone tunnel diameter and a potential reduced risk
of postoperative humeral shaft fracture. However, functional
outcomes and complications of a button-only technique with
a small diameter tunnel in the subpectoral region have not
been studied sufficiently.
Purpose: We sought to determine whether OSBT with
cortical button fixation results in significant functional
improvements from preoperative to final follow-up. The
secondary purpose was to determine whether there is a
lower risk of major postoperative complications.
Methods: A retrospective review of patients who underwent OSBT with cortical button fixation at one institution
was conducted with objective measurements and clinical
outcomes collected with a minimum of 2 years of follow-up.
Surgical data was collected for analysis. Objective measures
obtained at follow-up included physical exam, strength
testing using a handheld dynamometer, and Long-Head of
the Biceps score. Clinical outcomes were measured using
the following validated questionnaires preoperatively and
postoperatively: American Shoulder and Elbow Surgeons
score (ASES), Disabilities of the Arm, Shoulder and Hand
score (DASH), and Oxford Shoulder Score (OSS).
Results: Sixty-one patients with mean age of 53.1 ±
10.1 years at the time of surgery were enrolled in the study.
Mean follow-up time was 42.4 ± 16.9 months (range: 24 to
64 months). The postoperative LHB score was 95.5 ± 6.1
(range: 77 to 100). All functional outcome measures (ASES,
DASH, and OSS) demonstrated statistically significant improvements at final follow-up (p < 0.05 for each). At total
of 92.5% of patients stated they would have the procedure
again if necessary. Mean elbow flexion strength on the
operative side measured 98.7% ± 15.9% (range: 74.1% to
142.3%) of the contralateral arm. The mean LHB tendon
diameter was 5.7 ± 0.8 mm and mean tunnel diameter was
5.9 ± 0.7 mm. There were no cases of intraoperative or
postoperative fracture, infection, or Popeye deformity noted
during the follow-up period.
Conclusion: Subpectoral biceps tenodesis with cortical
button fixation is a safe and effective surgical treatment
option to relieve pain and restore function.
Poor Access to Opioid Addiction Care for Total Joint Arthroplasty Patients
Kelly I. Suchman, BS, Meredith Bartelstein, MD, Madeline Smith, BS, Nicole Zubizarreta, MPH, Mitchell C. Weiser, MD, MEng, and Calin S. Moucha, MD
Introduction: The United States is experiencing an opioid
epidemic, and orthopedists prescribe a large proportion of
these drugs. Patients often become dependent on painkillers and face barriers to treatment. Given that many joint
arthroplasty patients are enrolled in Medicare, we aimed to
examine the ease of orthopedic patients with various insurance types to access addiction and pain specialists.
Methods: Using three web-based directories, we identified addiction specialists within a 5-mile radius of our
hospital. We contacted these practices and inquired as to
whether they treated addiction, types of insurance they accepted, and appointment availability.
Results: We identified 190 addiction and pain management specialists and were able to reach 134/190 (70.5%).
Nine (6.7%) of the 134 reachable physicians accepted
Medicare or Medicaid, which is nine (4.7%) of the 190
physicians initially located. The average wait time to an
appointment was 4.2 days, and a significant difference in
wait time existed across insurance types (p = 0.0284).
Discussion: Orthopedic patients face many barriers to
receiving treatment for painkiller addiction. Wait time to
see an addiction specialist also varied based on insurance
type. Online directories may not be useful for certain patient
populations to identify physicians. Orthopedic surgeons
should partner with addiction and pain specialists to help
alleviate the barriers that patients face
Accuracy of Closed Reduction of Pediatric Supracondylar Humerus Fractures Is Training in Pediatric Orthopedic Surgery Necessary?
Kenneth A. Egol, MD, Surya Mundluru, MD, Christina Escalante, MD, Randy M. Cohn, MD,
David S. Feldman, MD, and Norman Y. Otsuka, MD
Background: Supracondylar humerus fractures account
for two thirds of all hospitalizations for elbow injuries in
children. A prevailing assumption exists regarding whether
treatment quality varies by surgeon training background.
This study compares radiographic outcomes of pediatric supracondylar humerus fractures treated by fellowship trained
pediatric orthopedists (PO) and non-pediatric orthopedists
(adult traumatologists, AT) with regard specifically to ability
to obtain and maintain an operative closed reduction.
Methods: We retrospectively reviewed all pediatric patients between 2007 and 2013 operatively treated for closed
extension-type supracondylar humerus fractures. Inclusion
criteria included skeletally immature patients with Gartland
classification type II and III fractures. Eighty-five cases were
included with 37 fractures treated by four fellowship trained
adult traumatologists at a level I trauma center and 48 fractures treated by five fellowship trained pediatric orthopedists
at a tertiary referral center. Radiographs were analyzed for
Baumann’s angle and shaft-condylar angle, then statistical
comparisons were performed to compare preoperative and
postoperative measurements.
Results: There was no difference in age, gender, laterality,
fracture classification, use of medial pins, or neurovascular
injuries between PO and AT (p > 0.05). Change in Baumann’s angle (p = 0.61) or shaft-condylar angle (p = 0.87)
did not differ between PO and AT. There was no significant
difference in operative and postoperative Baumann’s angle
(p = 0.18 and p = 0.59, respectively) and shaft-condylar
angle measurements (p = 0.05 and p = 0.09, respectively)
between PO and AT. There was no difference in loss of
reduction between the two groups (p = 0.64).
Conclusions: Radiographic analysis of supracondylar
humerus fractures showed no significant difference in
alignment or loss of reduction when treated by pediatric orthopedists compared to non-pediatric orthopedists. Though
it seems that the trend is to send pediatric fracture care to
tertiary referral centers it may not be necessary for simple
fracture management
Short-Term Clinical Outcomes of High Tibial Osteotomy with the iBalance HTO System
Kamali A. Thompson, BS, MBA, Christon N. Darden, MS, Anna Katsman, MD, Michael J. Alaia, MD, Eric J. Strauss, MD, and Laith M. Jazrawi, MD
Purpose: High tibial osteotomy (HTO) is an invaluable
tool in the treatment of a variety of conditions in active
patients with varus malalignment of the knee. The polyetheretherketone (PEEK) iBalance HTO system has been
designed to make the osteotomy safer, more reproducible,
and avoid metal hardware related complications. The purpose of this study was to evaluate short-term outcomes in
patients who underwent an open wedge high tibial osteotomy
with the iBalance HTO system.
Methods: We identified patientswho underwent HTO using
iBalance with a minimum of 2-year follow-up. Medical records
were reviewed for demographics, Workers Compensation and
no-fault insurance claims, history of smoking, concomitant
procedures, degree of correction, and complications. Patient
outcomes using Knee injury and Osteoarthritis Outcome Score
(KOOS) and visual analog scale (VAS) were recorded before
undergoing HTO and compared with those recorded after a
2-year follow-up. Statistical analysis was performed using
paired sample t-tests with p < 0.05 considered significant.
Results: Twenty-three patients with mean age of 44.9 (±
8.48) were identified. The mean correction angle was 9.9°
(range: 5° to 15°). Sixteen patients underwent a concomitant
procedure. The average follow-up was 2 years (range: 2 to
3.5 years). Six patients reported a positive history of smoking. The mean preoperative KOOS scores of symptoms, pain,
activities of daily living (ADL), sport, and quality of life were
14 (± 18.5), 53.1 (± 14.8), 69.1 (± 21.7), 29.2 (± 22.0), and
30.0 (± 20.0), respectively. The mean preoperative VAS score
was 5.5 (± 2.5). At follow-up, the mean scores of symptoms,
pain, ADL, sport, and quality of life all improved to 67.53
(± 24.9), 68.06 (± 23.4), 75.74 (± 25.3), 45.91 (± 36.1), and
43.47 (± 33.4), respectively. The mean VAS at follow-up was
1.9 (± 2.1). There was a significant increase (p < 0.05) in
all KOOS categories, except ADL. Additionally, there was
a statistical difference between smoking and change in ADL
score. Former smokers demonstrated an average decrease
of 10.3 points, increasing their disability, and nonsmokers
increased 15.3 points on the KOOS ADL scale, decreasing
their disability. There were three complications (DVT, cellulitis, and serosanguinous drainage) within a month after
the procedure. There were three complications, including a
revision HTO, pes anserine bursitis, and lateral hamstring
tendinitis, within the 2-year follow up including one revision
after 1 year. Five patients went on to total knee arthroplasty
at an average of 3 years (range: 1 to 5 years).
Conclusion: This study suggests that the iBalance medial opening wedge HTO system implant can be used with
comparable outcomes to traditional methods, however the
conversion rate to total knee arthroplasty may be higher
than previously reported. This appears to be unrelated to
implant choice and likely related to extended indications for
the procedure in younger patients refusing knee arthroplasty.
The iBalance medial opening wedge HTO system has shown
to be safe, removing many of the complications existing with
other osteotomy implant options. Our findings highlight the
importance of additional studies in order to investigate the
risk factors causing progression from HTO to TKA.
Improved HCAHPS Scores with a Same Day Discharge Program for Total Hip Arthroplasty
Jacob Ziegler, MD, Ameer Elbuluk, MD, Ran Schwarzkopf, MD, MSc, and William J. Long, MD, FRCSC
Background: Total hip arthroplasty is increasingly being
performed as a same day procedure. Additionally, greater
emphasis is being placed on patient satisfaction surveys
such as the Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS)® Survey. This study aims
to assess if patients who undergo THA through a same day
discharge program respond with higher HCAHPS scores.
Methods: Patients undergoing THA through our same day
surgery (SDD) program at our institution from January 1,
2015, to September 2016 and completed HCAHPS surveys
were compared to a cohort of patients who underwent THA
as a standard inpatient and completed the HCAHPS survey
during the same period. Electronic medical records were
reviewed to obtain demographic data and improvement in
validated patient reported outcomes measures.
Results: Patientsin our SDD program were significantly
more likely to rate the hospital as “top box” on eight of 11
HCAHPS domains. The remaining three domains that did
not reach statistical significance all showed a trend toward
increased likelihood of rating the hospital in the “top box”
level. For willingness to recommend, 91% of SDD patients
vs. 77% of non-SDD patients (p = 0.045) rated our hospital
as “top box.” We had no significant difference between the
groups in change from pre- to postoperative EQ-5D score or
Hip Disability and Osteoarthritis Outcomes Score (HOOS).
Conclusion: A same day surgery program can significantly improve patient satisfaction with THA as measured
by the HCAHPS survey
A Novel Method to Prevent Terminal Appositional Overgrowth Following Pediatric Below Knee Amputations A Case Series and Review of the Literature
Alan T. Blank, MD, MS, Timothy J. Luchetti, MD, Daniel M. Lerman, MD, Khanin Iamthanaporn, MD, Bhasanan Sukanthanak, MD, and R. Lor Randall, MD, FACS
The terminal overgrowth of the tibia following pediatric
transtibial amputation is a common problem leading to
pain, disability, and repeat surgical procedures. We present
three patients who underwent transtibial amputation due to
sarcoma of the lower extremity followed by compress osseointegration prosthesis fixation. The minimum follow-up was
1 year. The average age of patients was 10.8 years. There
were no complications that required surgical revision. To
date, there has been no evidence of terminal appositional
overgrowth in this series. The application of an end-cap
implant utilizing compressive osseointegration fixation can
prevent terminal bone overgrowth in pediatric transtibial
amputations
Non-Hodgkin Lymphoma with Synovial Involvement of the Knee
Brandon Kim, Bruce Raphael, MD, Cynthia Liu, MD, PhD, and Brian D. Golden, MD
Musculoskeletal involvement occurs in approximately 25%
of patients diagnosed with non-Hodgkin lymphoma (NHL).
Skeletal involvement is typically secondary, with primary
lymphoma of the bone being much rarer. We describe a case
in which a 52-year-old man initially presented features suggestive of Lyme arthritis in his left knee. A synovial biopsy
performed as part of a synovectomy procedure revealed a
proliferative synovium with dense lymphoplasmacytic B cell
infiltrate, suggestive of NHL. An inguinal lymph node biopsy
was also performed but did not produce results pathologically similar to those of the left knee synovial biopsy.
A Specialized Orthosis for Suppressing Bony Destruction from Multiple Myeloma and to Enhance Healing of a Pathologic Fracture in an Appendicular Lesion
Ernest C. Chisena, MD, MS, Yudell Edelstein, MD, and Robert S. Chisena, PhD
Appendicular metastasis from multiple myeloma (MM)
frequently presents with a pathologic fracture. In this case
report, a patient with a long history of MM and an associated
pathologic fracture was treated using a specialized brace.
This orthosis uses a deforming element to asymmetrically
increase the soft tissue pressure around the pathologic fracture. The patient experienced rapid pain relief and bony
healing without surgical intervention.
Articles
Effect of Shoulder Stabilization on Career Length and Performance in National Basketball Association Athletes
Benjamin Kester, MD, Shalen Kouk, MD, Shobhit V. Minhas, MD, Frederick M. Azar, MD, and Joseph Bosco, MD
Purpose: Untreated episodes of shoulder instability can
have major consequences on athletic careers. Operative
shoulder stabilization reduces the rate of recurrent instability and allows for high rates of return to sport (RTS).
Basketball players who experience an episode of instability
have high rates of recurrence, though little is known about
postoperative player performance. The purpose of this study
was to identify the impact of shoulder instability and surgical
stabilization on player performance and career lengths in
the National Basketball Association (NBA).
Methods: NBA players who had episodes of shoulder
instability between 1994-2014 were identified using the
NBA Injury Surveillance and Analytics Database. Players
were stratified according to operative versus nonoperative
treatment of shoulder instability. Two demographic- and
performance-matched controls were chosen for each test
subject. Univariate analyses were used to compare pre- and
postoperative player performance metrics. Survival analysis
was used to assess the effect of shoulder surgery on postoperative career lengths.
Results: Fifty athletes were identified, 46 (92.0%) returned to play in the NBA. Compared to controls, there
was no significant difference in postoperative performance
according to either 1- or 3-year averages. Survival analysis demonstrated no significant difference in postoperative
career lengths between athletes with a history of shoulder
surgery for instability and matched controls.
Conclusion: NBA players return to professional basketball in high numbers following orthopedic surgery for
shoulder instability. Shoulder instability may not be a
career-altering event, as there are highly effective methods
of shoulder stabilization available to athletes.
Open Surgical Management of Chronic Exertional Compartment Syndrome of the Leg
Utkarsh Anil, BS, Amos Z. Dai, BS, Hien Pham, MD, Jordan Werner, MD, Eric J. Strauss, MD, and Laith M. Jazrawi, MD
Purpose: The purpose of this study is to present one institution’s experience managing chronic exertional compartment syndrome (CECS) and to identify patient and surgical
characteristics associated with better outcomes following
open surgical management of CECS with specific emphasis
on return to sports.
Methods: Fifteen patients (10 male, 5 female) who underwent open fasciotomy for CECS with a minimum of 1-year
follow-up were included. Chart review was performed to
obtain patient demographics, medical and surgical history,
presenting symptomatology, and surgical details of fasciotomy. Outcomes were assessed using follow-up questionnaires
that consisted of Tegner Activity Scale, EuroQol-5D (EQ5D) index score, EQ-5D rating scale, symptom resolution,
patient satisfaction, and return to sports.
Results: The mean patient age at the time of surgery was
28.1 years (range: 17 to 49 years). At mean follow-up of 2.7
years (range: 1.0 to 5.1 years), five patients reported complete resolution of symptoms, eight reported improvement
(but not resolution) of symptoms, one reported no change
in symptoms, and one reported worsening of symptoms. The
mean Tegner Activity Score was 6.7 (range: 1 to 9) prior
to injury and 4.7 (range: 1 to 9) postoperatively. Patients
with any preoperative symptoms at rest had significantly
lower Tegner before score (4.0 vs. 7.1, p = 0.036) and EQ5D rating (50.0 vs. 83.5, p = 0.04) compared to those that
only experienced symptoms with activity. Patients that had
prior surgery, including fasciotomy, had significantly lower
EQ-5D rating than patients with no history of prior lower
extremity surgery (56.7 vs. 84.6, p = 0.045). Although 10
(66%) patients were able to return to sports, only four (27%)
of them were able to return to their prior level of sport. The
overall satisfaction rate was 87%.
Conclusion: Although open surgical fasciotomy for treatment of chronic exertional compartment syndrome leads to
high rates of symptom improvement or resolution, fewer
patients are able to return to their prior level of sports. Presence of symptoms at rest, presence of bilateral symptoms,
and history of prior lower extremity surgery all portend
worse outcomes.
Total Hip Arthroplasty for Secondary Causes of Arthritis An Increase in Time and Money
Vinay K. Aggarwal, MD, Yu Min Suh, MS, Lorraine Hutzler, MPA, Leon Moscona, MD, and Pablo Castañeda, MD
Background: Total hip arthroplasty (THA) is a frequently
performed, highly successful orthopedic procedure. Although primary osteoarthritis (PA) is the most common
reason for (THA), there are several secondary conditions
that lead to degenerative hip disease that are successfully
treated with THA. The purpose of this study was to examine
the incidence of these secondary causes of arthritis (SA)
leading to THA and to compare the relative surgical costs,
operating times, and hospital length of stay (LOS) for THA
done for PA versus SA.
Methods: Electronic medical records from 836 continuous
patients undergoing primary THA over a 2-year period were
reviewed at a single high-volume joint arthroplasty center.
Data obtained included age, sex, laterality, diagnosis leading to THA, surgical costs based on hospital fees, operating
room time, and hospital LOS. Using operative reports, office
visit notes, and radiology reports or images, patients were
categorized into PA or SA groupings. PA was defined as
osteoarthritis of no other known etiology, whereas SA was
defined when a known underlying diagnosis led to degenerative joint disease of the hip. SA included hip dysplasia,
post-traumatic arthritis (PTA), avascular necrosis (AVN),
inflammatory arthropathy, Perthes disease, and slipped
capital femoral epiphysis (SCFE). Means and proportions of
the variables from both groups were analyzed and compared
using t-tests and chi-squared tests where applicable.
Results: There were 599 patients in the PA group and 237
patients in the SA group. The SA group was significantly
younger than the PA group (54.4 years versus 64.0 years;
p = 0.0001). The SA cohort had significantly higher mean
surgical costs ($29,662 versus $27,078; p = 0.0005), operating room times (189 minutes versus 179 minutes; p =
0.0042), and LOS (4.2 days versus 3.9 days; p = 0.0312).
Within the SA group, the hip dysplasia subgrouping had
the lowest cost and operating room time, whereas the PTA
subgrouping had the highest cost and operating room time.
Conclusions: More than a quarter of primary THAs are
performed due to secondary arthritis, most commonly due
to hip dysplasia. Cases of THA due to secondary arthritis
are associated with significantly increased hospital costs,
operating time, and postoperative length of stay compared
to THA’s performed for primary osteoarthritis. Patients
with post-traumatic hip arthritis may contribute the highest
economic burden and present the most complex cases for
arthroplasty surgeons.
Clinical Outcomes of Open Subpectoral Biceps Tenodesis with Cortical Button Fixation
Samuel L. Baron, BS, Steven Shamah, BA, Alan W. McGee, MD, Michael J. Alaia, MD, Andrew J. Feldman, MD, and Laith M. Jazrawi, MD
Background: Open subpectoral biceps tenodesis (OSBT)
with cortical button fixation can deliver acceptable results
for long head of the biceps (LHB) pathology with the benefit
of smaller bone tunnel diameter and a potential reduced risk
of postoperative humeral shaft fracture. However, functional
outcomes and complications of a button-only technique with
a small diameter tunnel in the subpectoral region have not
been studied sufficiently.
Purpose: We sought to determine whether OSBT with
cortical button fixation results in significant functional
improvements from preoperative to final follow-up. The
secondary purpose was to determine whether there is a
lower risk of major postoperative complications.
Methods: A retrospective review of patients who underwent OSBT with cortical button fixation at one institution
was conducted with objective measurements and clinical
outcomes collected with a minimum of 2 years of follow-up.
Surgical data was collected for analysis. Objective measures
obtained at follow-up included physical exam, strength
testing using a handheld dynamometer, and Long-Head of
the Biceps score. Clinical outcomes were measured using
the following validated questionnaires preoperatively and
postoperatively: American Shoulder and Elbow Surgeons
score (ASES), Disabilities of the Arm, Shoulder and Hand
score (DASH), and Oxford Shoulder Score (OSS).
Results: Sixty-one patients with mean age of 53.1 ±
10.1 years at the time of surgery were enrolled in the study.
Mean follow-up time was 42.4 ± 16.9 months (range: 24 to
64 months). The postoperative LHB score was 95.5 ± 6.1
(range: 77 to 100). All functional outcome measures (ASES,
DASH, and OSS) demonstrated statistically significant improvements at final follow-up (p < 0.05 for each). At total
of 92.5% of patients stated they would have the procedure
again if necessary. Mean elbow flexion strength on the
operative side measured 98.7% ± 15.9% (range: 74.1% to
142.3%) of the contralateral arm. The mean LHB tendon
diameter was 5.7 ± 0.8 mm and mean tunnel diameter was
5.9 ± 0.7 mm. There were no cases of intraoperative or
postoperative fracture, infection, or Popeye deformity noted
during the follow-up period.
Conclusion: Subpectoral biceps tenodesis with cortical
button fixation is a safe and effective surgical treatment
option to relieve pain and restore function.
Poor Access to Opioid Addiction Care for Total Joint Arthroplasty Patients
Kelly I. Suchman, BS, Meredith Bartelstein, MD, Madeline Smith, BS, Nicole Zubizarreta, MPH, Mitchell C. Weiser, MD, MEng, and Calin S. Moucha, MD
Introduction: The United States is experiencing an opioid
epidemic, and orthopedists prescribe a large proportion of
these drugs. Patients often become dependent on painkillers and face barriers to treatment. Given that many joint
arthroplasty patients are enrolled in Medicare, we aimed to
examine the ease of orthopedic patients with various insurance types to access addiction and pain specialists.
Methods: Using three web-based directories, we identified addiction specialists within a 5-mile radius of our
hospital. We contacted these practices and inquired as to
whether they treated addiction, types of insurance they accepted, and appointment availability.
Results: We identified 190 addiction and pain management specialists and were able to reach 134/190 (70.5%).
Nine (6.7%) of the 134 reachable physicians accepted
Medicare or Medicaid, which is nine (4.7%) of the 190
physicians initially located. The average wait time to an
appointment was 4.2 days, and a significant difference in
wait time existed across insurance types (p = 0.0284).
Discussion: Orthopedic patients face many barriers to
receiving treatment for painkiller addiction. Wait time to
see an addiction specialist also varied based on insurance
type. Online directories may not be useful for certain patient
populations to identify physicians. Orthopedic surgeons
should partner with addiction and pain specialists to help
alleviate the barriers that patients face
Accuracy of Closed Reduction of Pediatric Supracondylar Humerus Fractures Is Training in Pediatric Orthopedic Surgery Necessary?
Kenneth A. Egol, MD, Surya Mundluru, MD, Christina Escalante, MD, Randy M. Cohn, MD,
David S. Feldman, MD, and Norman Y. Otsuka, MD
Background: Supracondylar humerus fractures account
for two thirds of all hospitalizations for elbow injuries in
children. A prevailing assumption exists regarding whether
treatment quality varies by surgeon training background.
This study compares radiographic outcomes of pediatric supracondylar humerus fractures treated by fellowship trained
pediatric orthopedists (PO) and non-pediatric orthopedists
(adult traumatologists, AT) with regard specifically to ability
to obtain and maintain an operative closed reduction.
Methods: We retrospectively reviewed all pediatric patients between 2007 and 2013 operatively treated for closed
extension-type supracondylar humerus fractures. Inclusion
criteria included skeletally immature patients with Gartland
classification type II and III fractures. Eighty-five cases were
included with 37 fractures treated by four fellowship trained
adult traumatologists at a level I trauma center and 48 fractures treated by five fellowship trained pediatric orthopedists
at a tertiary referral center. Radiographs were analyzed for
Baumann’s angle and shaft-condylar angle, then statistical
comparisons were performed to compare preoperative and
postoperative measurements.
Results: There was no difference in age, gender, laterality,
fracture classification, use of medial pins, or neurovascular
injuries between PO and AT (p > 0.05). Change in Baumann’s angle (p = 0.61) or shaft-condylar angle (p = 0.87)
did not differ between PO and AT. There was no significant
difference in operative and postoperative Baumann’s angle
(p = 0.18 and p = 0.59, respectively) and shaft-condylar
angle measurements (p = 0.05 and p = 0.09, respectively)
between PO and AT. There was no difference in loss of
reduction between the two groups (p = 0.64).
Conclusions: Radiographic analysis of supracondylar
humerus fractures showed no significant difference in
alignment or loss of reduction when treated by pediatric orthopedists compared to non-pediatric orthopedists. Though
it seems that the trend is to send pediatric fracture care to
tertiary referral centers it may not be necessary for simple
fracture management
Short-Term Clinical Outcomes of High Tibial Osteotomy with the iBalance HTO System
Kamali A. Thompson, BS, MBA, Christon N. Darden, MS, Anna Katsman, MD, Michael J. Alaia, MD, Eric J. Strauss, MD, and Laith M. Jazrawi, MD
Purpose: High tibial osteotomy (HTO) is an invaluable
tool in the treatment of a variety of conditions in active
patients with varus malalignment of the knee. The polyetheretherketone (PEEK) iBalance HTO system has been
designed to make the osteotomy safer, more reproducible,
and avoid metal hardware related complications. The purpose of this study was to evaluate short-term outcomes in
patients who underwent an open wedge high tibial osteotomy
with the iBalance HTO system.
Methods: We identified patientswho underwent HTO using
iBalance with a minimum of 2-year follow-up. Medical records
were reviewed for demographics, Workers Compensation and
no-fault insurance claims, history of smoking, concomitant
procedures, degree of correction, and complications. Patient
outcomes using Knee injury and Osteoarthritis Outcome Score
(KOOS) and visual analog scale (VAS) were recorded before
undergoing HTO and compared with those recorded after a
2-year follow-up. Statistical analysis was performed using
paired sample t-tests with p < 0.05 considered significant.
Results: Twenty-three patients with mean age of 44.9 (±
8.48) were identified. The mean correction angle was 9.9°
(range: 5° to 15°). Sixteen patients underwent a concomitant
procedure. The average follow-up was 2 years (range: 2 to
3.5 years). Six patients reported a positive history of smoking. The mean preoperative KOOS scores of symptoms, pain,
activities of daily living (ADL), sport, and quality of life were
14 (± 18.5), 53.1 (± 14.8), 69.1 (± 21.7), 29.2 (± 22.0), and
30.0 (± 20.0), respectively. The mean preoperative VAS score
was 5.5 (± 2.5). At follow-up, the mean scores of symptoms,
pain, ADL, sport, and quality of life all improved to 67.53
(± 24.9), 68.06 (± 23.4), 75.74 (± 25.3), 45.91 (± 36.1), and
43.47 (± 33.4), respectively. The mean VAS at follow-up was
1.9 (± 2.1). There was a significant increase (p < 0.05) in
all KOOS categories, except ADL. Additionally, there was
a statistical difference between smoking and change in ADL
score. Former smokers demonstrated an average decrease
of 10.3 points, increasing their disability, and nonsmokers
increased 15.3 points on the KOOS ADL scale, decreasing
their disability. There were three complications (DVT, cellulitis, and serosanguinous drainage) within a month after
the procedure. There were three complications, including a
revision HTO, pes anserine bursitis, and lateral hamstring
tendinitis, within the 2-year follow up including one revision
after 1 year. Five patients went on to total knee arthroplasty
at an average of 3 years (range: 1 to 5 years).
Conclusion: This study suggests that the iBalance medial opening wedge HTO system implant can be used with
comparable outcomes to traditional methods, however the
conversion rate to total knee arthroplasty may be higher
than previously reported. This appears to be unrelated to
implant choice and likely related to extended indications for
the procedure in younger patients refusing knee arthroplasty.
The iBalance medial opening wedge HTO system has shown
to be safe, removing many of the complications existing with
other osteotomy implant options. Our findings highlight the
importance of additional studies in order to investigate the
risk factors causing progression from HTO to TKA.
Improved HCAHPS Scores with a Same Day Discharge Program for Total Hip Arthroplasty
Jacob Ziegler, MD, Ameer Elbuluk, MD, Ran Schwarzkopf, MD, MSc, and William J. Long, MD, FRCSC
Background: Total hip arthroplasty is increasingly being
performed as a same day procedure. Additionally, greater
emphasis is being placed on patient satisfaction surveys
such as the Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS)® Survey. This study aims
to assess if patients who undergo THA through a same day
discharge program respond with higher HCAHPS scores.
Methods: Patients undergoing THA through our same day
surgery (SDD) program at our institution from January 1,
2015, to September 2016 and completed HCAHPS surveys
were compared to a cohort of patients who underwent THA
as a standard inpatient and completed the HCAHPS survey
during the same period. Electronic medical records were
reviewed to obtain demographic data and improvement in
validated patient reported outcomes measures.
Results: Patientsin our SDD program were significantly
more likely to rate the hospital as “top box” on eight of 11
HCAHPS domains. The remaining three domains that did
not reach statistical significance all showed a trend toward
increased likelihood of rating the hospital in the “top box”
level. For willingness to recommend, 91% of SDD patients
vs. 77% of non-SDD patients (p = 0.045) rated our hospital
as “top box.” We had no significant difference between the
groups in change from pre- to postoperative EQ-5D score or
Hip Disability and Osteoarthritis Outcomes Score (HOOS).
Conclusion: A same day surgery program can significantly improve patient satisfaction with THA as measured
by the HCAHPS survey
A Novel Method to Prevent Terminal Appositional Overgrowth Following Pediatric Below Knee Amputations A Case Series and Review of the Literature
Alan T. Blank, MD, MS, Timothy J. Luchetti, MD, Daniel M. Lerman, MD, Khanin Iamthanaporn, MD, Bhasanan Sukanthanak, MD, and R. Lor Randall, MD, FACS
The terminal overgrowth of the tibia following pediatric
transtibial amputation is a common problem leading to
pain, disability, and repeat surgical procedures. We present
three patients who underwent transtibial amputation due to
sarcoma of the lower extremity followed by compress osseointegration prosthesis fixation. The minimum follow-up was
1 year. The average age of patients was 10.8 years. There
were no complications that required surgical revision. To
date, there has been no evidence of terminal appositional
overgrowth in this series. The application of an end-cap
implant utilizing compressive osseointegration fixation can
prevent terminal bone overgrowth in pediatric transtibial
amputations
Non-Hodgkin Lymphoma with Synovial Involvement of the Knee
Brandon Kim, Bruce Raphael, MD, Cynthia Liu, MD, PhD, and Brian D. Golden, MD
Musculoskeletal involvement occurs in approximately 25%
of patients diagnosed with non-Hodgkin lymphoma (NHL).
Skeletal involvement is typically secondary, with primary
lymphoma of the bone being much rarer. We describe a case
in which a 52-year-old man initially presented features suggestive of Lyme arthritis in his left knee. A synovial biopsy
performed as part of a synovectomy procedure revealed a
proliferative synovium with dense lymphoplasmacytic B cell
infiltrate, suggestive of NHL. An inguinal lymph node biopsy
was also performed but did not produce results pathologically similar to those of the left knee synovial biopsy.
A Specialized Orthosis for Suppressing Bony Destruction from Multiple Myeloma and to Enhance Healing of a Pathologic Fracture in an Appendicular Lesion
Ernest C. Chisena, MD, MS, Yudell Edelstein, MD, and Robert S. Chisena, PhD
Appendicular metastasis from multiple myeloma (MM)
frequently presents with a pathologic fracture. In this case
report, a patient with a long history of MM and an associated
pathologic fracture was treated using a specialized brace.
This orthosis uses a deforming element to asymmetrically
increase the soft tissue pressure around the pathologic fracture. The patient experienced rapid pain relief and bony
healing without surgical intervention.