Age-Associated Functional Outcomes Following Hip Arthroscopy in Females Analysis with 5-Year Follow-Up
David A. Bloom, MD, Eoghan T. Hurley, MB, BAO, BCH, Babatunde Fariyike, MD, Berkcan
Akpinar, MD, Jonathan D. Haskel, MD, Steven A. Grapperhaus, BBA, and Thomas Youm, MD
Purpose: The purpose of this study was to evaluate out-
comes of hip arthroscopy for femoroacetabular impingement
(FAI) in female patients at 5-year follow-up. The working
hypothesis for this study was that increased age and body
mass index (BMI) would be associated with poor outcomes.
Methods: This study included all female patients 14
years and older who underwent primary hip arthroscopy for
FAI with 5-year patient-reported outcome scores. Patients
were separated into three age-based cohorts (< 30 years
old, 30 to 45 years old, and > 45 years old) for subsequent
statistical analysis. This analysis included a comparison of
patient demographic information, intraoperative pathology,
and functional outcome scores (modified Harris Hip Score
[mHHS] and nonarthritic hip score [NAHS]). Statistically
significant values were utilized in a regression-based analy-
sis to determine predictors of 5-year outcomes in female
patients. A p-value of < 0.05 was considered to be statisti-
cally significant.
Results: Overall, 97 patients met the inclusion criteria,
and there was no significant difference in patient demo-
graphics (other than age and BMI) or in intraoperative
pathologies identified. There were no significant difference
across the three groups for mHHS and NAHS at baseline (p
> 0.05). At baseline, there were no statistically significant
differences between groups for NAHS scores, however <
30-year-old and 30- to 45-year-old cohorts had superior
final NAHS scores relative to the > 45-year-old cohort
(p = 0.005). At 5-year follow-up, the NAHS scores were
significantly better for patients under 30 and 30 to 45 year
olds relative to patients over 45 (84.2 ± 15.1 vs. 86.7 ±
11.0 vs. 71.9 ± 26.8, respectively; p = 0.005). Overall, 88
patients (91%) met the minimal clinically important differ-
ence (MCID), and 60 patients (62%) achieved the patient
acceptable symptomatic state (PASS). Baseline mHHS and
BMI were shown to be statistically significant predictors of
achieving MCID at 5 years in multivariate analysis (p <
0.001).
Conclusion: The results of this study suggest that women
generally have good-to-excellent outcomes following hip ar-
throscopy, although females older than 45 may have inferior
outcomes relative to younger patients, and BMI and baseline
mHHS may be utilized to predict long-term improvement.
Return to Work and Sport Following Tibial Tubercle Anteromedialization
Matthew T. Kingery, MD, David A. Bloom, MD, Alexander Hoberman, MD, Brian Fliegel, MS, Michael J. Alaia, MD, Laith M. Jazrawi, MD, and Eric J. Strauss, MD
Background: Tibial tubercle anteromedialization (AMZ)
is a commonly performed procedure for patients with
patellofemoral instability or patellofemoral osteochondral
disease. While prior studies have demonstrated that this
form of osteotomy produces generally good outcomes, the
time needed for return to work and return to sport remains
unclear. This study aimed to determine the mean length of
time before return to work and the rate of return to sport
following AMZ.
Patients and Methods: Patients who had undergone AMZ
for either patellofemoral instability or isolated osteochon-
dral defect with a minimum follow-up time of 1 year were
identified. Patients less than 18 years of age were excluded.
Patients were asked to complete a series of patient reported
outcomes surveys including specific queries regarding their
return to work and return to athletic activity.
Results: A total of 109 patients were included in this
study. The majority were female (79 patients, 72.3%). The
mean age was 30.74 ± 9.90 years at the time of surgery.
The mean follow-up duration was 3.40 ± 1.97 years. Of the
109 patients, 104 (95.4%) had returned to work at the time
of follow-up. Mean time to return to work was 2.96 ± 3.33
months (range: 0.25 to 24 months). Of the 90 patients who
were involved in a sport or physical activity prior to injury,
64 patients (71.1%) had returned to sport at some level at the
time of most recent follow-up. Of those who had returned to
sport, mean time to return to sport was 9.21 ± 5.46 months
(range: 1 to 24 months).
Conclusions: At a minimum follow-up time of 1 year,
patients who underwent AMZ were found to have a return to
sport rate of 71% with a mean time of 9.21 months to return
to athletic activity. Over 95% of AMZ patients had returned
to work by 1 year after the procedure. Patients required an
average of 3 months to return to work, although those with
physically demanding jobs required slightly more time. Data
from the current study is useful in setting expectations for
patients undergoing tibial tubercle anteromedialization for
patellofemoral instability or patellofemoral osteochondral
disease.
Reconstruction of Chronic Triceps Brachii Tendon Rupture Using Semitendinosus Autograft Surgical Technique
Ludovico Panarella, MD, PhD, Monica Gasparini, MD, Franz Federico Sesti, MD, and Francesco Oliva, MD, PhD
Rupture of the triceps tendon is a rare event, and the care
could be often problematic for orthopedic surgeons. Cases of
triceps tendon re-rupture are even rarer. The stump is often
retracted, atrophic, and the tissue quality is poor. Several
surgical techniques have been reported. We present our surgi-
cal reconstruction using free semitendinosus (ST) autograft.
Clinical Outcomes of Total Hip Arthroplasty in Patients with Prior Periacetabular Osteotomy
Michael J. Moses, MD, David Novikov, BA, Tyler Luthringer, MD, Lazaros Poultsides, MD, and Jonathan M. Vigdorchik, MD
Background: Periacetabular osteotomy (PAO) has been
used as a treatment modality for development dysplasia
of the hip (DDH). Many patients will progress to total hip
arthroplasty (THA) following PAO. There is a discrepancy
in the literature regarding outcomes of THA after PAO.
Methods: A retrospective study was performed. Ten pa-
tients (12 hips) with prior PAO who progressed to THA with
at least 1-year follow-up after THA were identified. A control
group of patients matched for age, sex, and body mass index
(BMI) who underwent primary THA with minimum of 1-year
follow-up were included. Demographic and radiographic
parameters as well as clinical outcomes using the modified
Harris Hip Score (mHHS) were collected.
Results: The mean age at the time of THA was 36.2 ±
9.7 years for the PAO and 37.8 ± 9.1 years for the control
cohorts. There was no difference in the demographics be-
tween the groups. At mean follow-up time of 22.8 ± 10.7
months for the PAO group and 25 ± 13.8 months for the
control group, there was no significant difference in mHHS
following THA. There was significant improvement in mHHS
from preoperative to postoperative levels (p < 0.01).
Conclusion: Total hip arthroplasty is an effective means
to restore quality of life and function in patients who develop
osteoarthritis following PAO, with equivalent outcomes to
those undergoing primary THA.
Lack of Seasonal and Temporal Variability in Total Hip Arthroplasty Surgical Site Infections
Mackenzie A. Roof, BS, Lorraine Hutzler, MPA, Anna Stachel, PhD, MPH, Scott Friedlander, MPH, Michael Phillips, MD, and Joseph A. Bosco, III, MD
Background: Surgical site infections (SSIs) are a signifi-
cant cause of morbidity and mortality following total joint
arthroplasty (TJA). While many risk factors are known, the
seasonal and temporal associations of SSI are less under-
stood. Understanding the associations can help reduce SSI
rates.
Methods: We tracked rates of deep surgical site infec-
tions (dSSIs) following total hip arthroplasty (THA) at a
single large urban academic medical center from January
2009 through August 2018. Using a Poisson regression, we
determined the monthly and seasonal variability of dSSIs.
We also calculated the change in dSSI rate over the entire
9.67-year study period.
Results: In total, 15,703 THA cases between January
2009 and August 2018 were analyzed. There was no signifi-
cant difference in the dSSI rate following THA in fall, winter,
or spring as compared to summer. Similarly, there was no
significant difference in dSSIs in July as compared to other
months of the year. The average rate of dSSIs following THA
was 1.04 (SD, 0.90) per 100 patients. The dSSI rate following
THA decreased over the study period (r = 0.93, 95% CI:
0.84-1.03) but did not reach statistical significance.
Conclusion: This study demonstrated a non-significant,
albeit decreasing, rate of dSSIs following THA over the study
period. Contrary to previous reports, there was no difference
in the dSSI rate in the summer months as compared to other
seasons. The month of the year also does not appear to be a
significant risk factor for SSIs, calling into question previous
reports arguing for the importance of the “July effect.”
Assessing the Adequacy and Readability of Surgical Consents in Orthopedic Surgery
Emily M. Pflug, MD, Sebastian A. Giordano, BS, Lorraine Hutzler, MPA, Joseph A. Bosco, III, MD, Jordan Howard Green, MD, and Nader Paksima, DO, MPH
Background: Handwritten consent forms for medical
treatment are commonly used despite the associated risk of
documentation errors. We performed an internal audit of
handwritten surgical consent forms to assess the quality of
consenting practices within the department of hand surgery
at our orthopedic specialty hospital.
Methods: A sample of 1,800 charts was selected. Con-
sents were assessed for procedure type, physician details,
abbreviations, consistency, and legibility.
Results: A total of 1,309 charts met the inclusion crite-
ria. Two hundred and eight consents contained at least one
illegible word. The name of the consenting physician was
not listed or illegible on 114 forms. Medical abbreviations
were found on 1.8% of all included forms, and 19 consent
forms contained a crossed-out word or correction.
Conclusions: Although the majority of the handwrit-
ten consent forms were complete, accurate, and legible,
there were notable errors in the consenting process at our
institution. Documentation errors have medical and ethical
ramifications. Further research into consenting practices is
necessary to improve the quality of consent forms and the
process of informed consent.
The Clinician’s Guide to Differential Diagnosis of Non-Localized Musculoskeletal Pain A Primer on Musculoskeletal Medicine
Elisha Krasin, MD, Yaniv Warschawski, MD, and Amal Khoury, MD
Orthopedic surgeons may encounter patients with musculo-
skeletal complaints that are not localized to a specific joint
or anatomical area. The list of diagnoses that may cause
generalized pain originating from bones, muscles, fasciae,
and joints, including surrounding tissues like tendons,
ligaments, and bursae, is vast; starting with influenza or
fibromyalgia and ending with mycetism and ultra-rare he-
reditary disorders. A systematic multidisciplinary approach
is required. Many of these patients require referral to rheu-
matology, endocrinology, or other specialties but at least
a basic understanding of differential diagnosis is needed.
The purpose of this review is to comprehensively examine
the clinical presentation of various causes of generalized
musculoskeletal pain and create a mental framework to aid
the diagnostician in achieving the correct diagnosis in an
orderly and efficient manner.
Comparison of Three Suture Materials in Capsular Closure Closure Time and Wound Complications Following Knee Arthroplasty
Kavin Khatri, MS, DNB, FACS, R. K. Banga, MS, Neeraj Malhotra, MS, and Depak Bansal, MS
Background: Watertight capsular closure in knee arthro-
plasty is desirable in order to achieve a good functional
outcome. Barbed knotless sutures are being increasingly
used in wound closure following knee arthroplasty. The prior
studies have compared barbed sutures with either VICRYL® or
Ethibond for closure, while none had compared all the three in
a single setting in terms of closure time, needle stick injuries,
postoperative complications, and functional outcome.
Patients and Methods: One hundred and forty-three
subjects of unilateral knee arthroplasty were screened for
eligibility in the prospective randomized controlled trial.
One hundred and twenty patients fulfilled the inclusion
criteria and were randomized into three groups to undergo
capsular closure with barbed sutures, VICRYL, or Ethibond.
Results: The wound closure was fastest with barbed su-
tures followed by VICRYL and Ethibond (10.4 ± 4.1; 15.4 ±
4.7; 17.2 ± 3.8 minutes; p < 0.001). There were seven needle
stick injuries in the Ethibond group followed by three in the
VICRYL group and none in the barbed suture group. The
Knee Society Scores and wound related complications were
comparable in all the three groups.
Conclusion: Barbed suture, VICRYL, and Ethibond are
equally good in the capsular closure following knee arthro-
plasty. The faster wound closure time achieved may not be
clinically relevant in the short term.
Sex-Based Differences in Outcomes of Tibial Tubercle Anteromedialization
David A. Bloom, MD, Matthew Gonzalez, MD, Eoghan T. Hurley, MB, MBCH, Matthew T.
Kingery, MD, Cordelia W. Carter, MD, Laith M. Jazrawi, MD, and Eric J. Strauss, MD
Background: Previous research has demonstrated sex-
based differences in patient-reported outcomes of orthopedic
surgical procedures. The hypothesis of the current study was
that females would have inferior patient-reported outcomes
to their male peers following a tibial tubercle anteromedial-
ization (AMZ) procedure for both patellofemoral instability
and cartilage defects.
Methods: Patients who had undergone AMZ for isolated
osteochondral defect or patellofemoral instability with a
minimum follow-up time of 1 year were identified. They were
then asked to complete several patient-reported outcome
questionnaires that were then statistically analyzed.
Results: Overall, 109 patients were included in this study.
Seventy-nine patients (72.5%) were female with a mean
follow-up duration of 3.4 ± 2.0 years. Forty-seven females
had AMZ for patellar instability while 32 females had AMZ
for osteochondral defects. There were no statistically signifi-
cant differences between sexes with respect to concomitant
procedures performed, visual analog scale (VAS) pain score,
or patient reported outcome (PRO) scores at follow-up (p >
0.05). There was no statistically significant difference with
respect to outcomes between the sexes for AMZ overall and
when isolating the sexes based on indication.
Conclusion: This study demonstrates that female patients
undergoing AMZ have short-term clinical and functional
outcomes that are not significantly different to those reported
in males.
Indications for Conversion of Spinal into General Anesthesia During Total Joint Arthroplasty
Paul J. Tesoriero, MS, Chelsea S. Sicat, MS, Michael Collins, BS, James E. Feng, MD, David
L. Furgiuele, MD, William J. Long, MD, FRCSC, and Ran Schwarzkopf, MD, MSc
Introduction: Spinal anesthesia (SA) is the preferred
method of anesthesia at many centers for total joint arthro-
plasty (TJA). However, a small subset of patients fails SA,
necessitating a conversion to general anesthesia (GA). This
report assesses the patient characteristics associated with
failed SA.
Methods: A retrospective study was conducted on patients
who underwent SA during their primary TJA between Janu-
ary 2015 and December 2016 at our institution. A subset of
this group required a conversion from SA to GA. Anesthesia
reports were reviewed for the number of attempts at SA and
the documented reason for failure. The SA failure cohort was
then subdivided into failure categories based on the reasons
that had been provided.
Results: A total of 5,706 patients were included in this
study, 78 of which experienced SA failure. The number of
attempts was most strongly associated with SA failure, with
three attempts resulting in a five times increased failure
rate (OR = 4.73, p = 0.010) and four attempts resulting in
12 times increased failure rate compared to the no failure
cohort (OR = 12.3, p < 0.001). Greater than two attempts
occurred in 87.5% of the “technical failure” sub-group of
the SA failure cohort (p < 0.001). No difference was demon-
strated among the other patient characteristics, such as age,
sex, body mass index, race, American Society of Anesthesia
(ASA) score, and surgical time.
Conclusions: The results suggest that the major predic-
tor influencing spinal to general anesthesia conversion was
the number of attempts at SA, especially among technical
failure cases. Based on the results, it may be appropriate
for anesthesiologists to convert to GA after two failed spi-
nal attempts. Further studies are warranted to assess this
relationship for firm clinical recommendations.
The Cam-Post Dislocation in Posterior-Stabilized Total Knee Arthroplasty A Case Series
Jeffrey S. Chen, MD, Andrew S. Bi, MD, James D. Slover, MD, Scott E. Marwin, MD, and Ajit
J. Deshmukh, MD
Cam-post dislocations are a unique complication of total
knee arthroplasty (TKA) designs that utilize a cam-post
mechanism, representing an extreme form of deep flexion
instability. They are rare complications and are poorly
defined in the existing literature. The purpose of this case
study is to present a series of six cam-post dislocation
cases to improve understanding of this complication and its
mechanism, presentation, and available treatment options.
All patients experienced cam-post dislocations after a deep
flexion moment that were identified clinically and confirmed
radiographically. Affected implants included both primary
and revision components and all utilized a cam-post mecha-
nism. Three patients underwent revision surgery whereas
the remaining three were treated with closed reduction only.
Cam-post dislocations are rare complications of posterior-
stabilized TKA that should be understood and recognized
by adult reconstruction surgeons. Closed reduction may
be achieved with hyperflexion and anterior drawer or with
hyperextension, but these patients may ultimately require a
revision procedure.
ARTICLES
Age-Associated Functional Outcomes Following Hip Arthroscopy in Females Analysis with 5-Year Follow-Up
David A. Bloom, MD, Eoghan T. Hurley, MB, BAO, BCH, Babatunde Fariyike, MD, Berkcan
Akpinar, MD, Jonathan D. Haskel, MD, Steven A. Grapperhaus, BBA, and Thomas Youm, MD
Purpose: The purpose of this study was to evaluate out-
comes of hip arthroscopy for femoroacetabular impingement
(FAI) in female patients at 5-year follow-up. The working
hypothesis for this study was that increased age and body
mass index (BMI) would be associated with poor outcomes.
Methods: This study included all female patients 14
years and older who underwent primary hip arthroscopy for
FAI with 5-year patient-reported outcome scores. Patients
were separated into three age-based cohorts (< 30 years
old, 30 to 45 years old, and > 45 years old) for subsequent
statistical analysis. This analysis included a comparison of
patient demographic information, intraoperative pathology,
and functional outcome scores (modified Harris Hip Score
[mHHS] and nonarthritic hip score [NAHS]). Statistically
significant values were utilized in a regression-based analy-
sis to determine predictors of 5-year outcomes in female
patients. A p-value of < 0.05 was considered to be statisti-
cally significant.
Results: Overall, 97 patients met the inclusion criteria,
and there was no significant difference in patient demo-
graphics (other than age and BMI) or in intraoperative
pathologies identified. There were no significant difference
across the three groups for mHHS and NAHS at baseline (p
> 0.05). At baseline, there were no statistically significant
differences between groups for NAHS scores, however <
30-year-old and 30- to 45-year-old cohorts had superior
final NAHS scores relative to the > 45-year-old cohort
(p = 0.005). At 5-year follow-up, the NAHS scores were
significantly better for patients under 30 and 30 to 45 year
olds relative to patients over 45 (84.2 ± 15.1 vs. 86.7 ±
11.0 vs. 71.9 ± 26.8, respectively; p = 0.005). Overall, 88
patients (91%) met the minimal clinically important differ-
ence (MCID), and 60 patients (62%) achieved the patient
acceptable symptomatic state (PASS). Baseline mHHS and
BMI were shown to be statistically significant predictors of
achieving MCID at 5 years in multivariate analysis (p <
0.001).
Conclusion: The results of this study suggest that women
generally have good-to-excellent outcomes following hip ar-
throscopy, although females older than 45 may have inferior
outcomes relative to younger patients, and BMI and baseline
mHHS may be utilized to predict long-term improvement.
Return to Work and Sport Following Tibial Tubercle Anteromedialization
Matthew T. Kingery, MD, David A. Bloom, MD, Alexander Hoberman, MD, Brian Fliegel, MS, Michael J. Alaia, MD, Laith M. Jazrawi, MD, and Eric J. Strauss, MD
Background: Tibial tubercle anteromedialization (AMZ)
is a commonly performed procedure for patients with
patellofemoral instability or patellofemoral osteochondral
disease. While prior studies have demonstrated that this
form of osteotomy produces generally good outcomes, the
time needed for return to work and return to sport remains
unclear. This study aimed to determine the mean length of
time before return to work and the rate of return to sport
following AMZ.
Patients and Methods: Patients who had undergone AMZ
for either patellofemoral instability or isolated osteochon-
dral defect with a minimum follow-up time of 1 year were
identified. Patients less than 18 years of age were excluded.
Patients were asked to complete a series of patient reported
outcomes surveys including specific queries regarding their
return to work and return to athletic activity.
Results: A total of 109 patients were included in this
study. The majority were female (79 patients, 72.3%). The
mean age was 30.74 ± 9.90 years at the time of surgery.
The mean follow-up duration was 3.40 ± 1.97 years. Of the
109 patients, 104 (95.4%) had returned to work at the time
of follow-up. Mean time to return to work was 2.96 ± 3.33
months (range: 0.25 to 24 months). Of the 90 patients who
were involved in a sport or physical activity prior to injury,
64 patients (71.1%) had returned to sport at some level at the
time of most recent follow-up. Of those who had returned to
sport, mean time to return to sport was 9.21 ± 5.46 months
(range: 1 to 24 months).
Conclusions: At a minimum follow-up time of 1 year,
patients who underwent AMZ were found to have a return to
sport rate of 71% with a mean time of 9.21 months to return
to athletic activity. Over 95% of AMZ patients had returned
to work by 1 year after the procedure. Patients required an
average of 3 months to return to work, although those with
physically demanding jobs required slightly more time. Data
from the current study is useful in setting expectations for
patients undergoing tibial tubercle anteromedialization for
patellofemoral instability or patellofemoral osteochondral
disease.
Reconstruction of Chronic Triceps Brachii Tendon Rupture Using Semitendinosus Autograft Surgical Technique
Ludovico Panarella, MD, PhD, Monica Gasparini, MD, Franz Federico Sesti, MD, and Francesco Oliva, MD, PhD
Rupture of the triceps tendon is a rare event, and the care
could be often problematic for orthopedic surgeons. Cases of
triceps tendon re-rupture are even rarer. The stump is often
retracted, atrophic, and the tissue quality is poor. Several
surgical techniques have been reported. We present our surgi-
cal reconstruction using free semitendinosus (ST) autograft.
Clinical Outcomes of Total Hip Arthroplasty in Patients with Prior Periacetabular Osteotomy
Michael J. Moses, MD, David Novikov, BA, Tyler Luthringer, MD, Lazaros Poultsides, MD, and Jonathan M. Vigdorchik, MD
Background: Periacetabular osteotomy (PAO) has been
used as a treatment modality for development dysplasia
of the hip (DDH). Many patients will progress to total hip
arthroplasty (THA) following PAO. There is a discrepancy
in the literature regarding outcomes of THA after PAO.
Methods: A retrospective study was performed. Ten pa-
tients (12 hips) with prior PAO who progressed to THA with
at least 1-year follow-up after THA were identified. A control
group of patients matched for age, sex, and body mass index
(BMI) who underwent primary THA with minimum of 1-year
follow-up were included. Demographic and radiographic
parameters as well as clinical outcomes using the modified
Harris Hip Score (mHHS) were collected.
Results: The mean age at the time of THA was 36.2 ±
9.7 years for the PAO and 37.8 ± 9.1 years for the control
cohorts. There was no difference in the demographics be-
tween the groups. At mean follow-up time of 22.8 ± 10.7
months for the PAO group and 25 ± 13.8 months for the
control group, there was no significant difference in mHHS
following THA. There was significant improvement in mHHS
from preoperative to postoperative levels (p < 0.01).
Conclusion: Total hip arthroplasty is an effective means
to restore quality of life and function in patients who develop
osteoarthritis following PAO, with equivalent outcomes to
those undergoing primary THA.
Lack of Seasonal and Temporal Variability in Total Hip Arthroplasty Surgical Site Infections
Mackenzie A. Roof, BS, Lorraine Hutzler, MPA, Anna Stachel, PhD, MPH, Scott Friedlander, MPH, Michael Phillips, MD, and Joseph A. Bosco, III, MD
Background: Surgical site infections (SSIs) are a signifi-
cant cause of morbidity and mortality following total joint
arthroplasty (TJA). While many risk factors are known, the
seasonal and temporal associations of SSI are less under-
stood. Understanding the associations can help reduce SSI
rates.
Methods: We tracked rates of deep surgical site infec-
tions (dSSIs) following total hip arthroplasty (THA) at a
single large urban academic medical center from January
2009 through August 2018. Using a Poisson regression, we
determined the monthly and seasonal variability of dSSIs.
We also calculated the change in dSSI rate over the entire
9.67-year study period.
Results: In total, 15,703 THA cases between January
2009 and August 2018 were analyzed. There was no signifi-
cant difference in the dSSI rate following THA in fall, winter,
or spring as compared to summer. Similarly, there was no
significant difference in dSSIs in July as compared to other
months of the year. The average rate of dSSIs following THA
was 1.04 (SD, 0.90) per 100 patients. The dSSI rate following
THA decreased over the study period (r = 0.93, 95% CI:
0.84-1.03) but did not reach statistical significance.
Conclusion: This study demonstrated a non-significant,
albeit decreasing, rate of dSSIs following THA over the study
period. Contrary to previous reports, there was no difference
in the dSSI rate in the summer months as compared to other
seasons. The month of the year also does not appear to be a
significant risk factor for SSIs, calling into question previous
reports arguing for the importance of the “July effect.”
Assessing the Adequacy and Readability of Surgical Consents in Orthopedic Surgery
Emily M. Pflug, MD, Sebastian A. Giordano, BS, Lorraine Hutzler, MPA, Joseph A. Bosco, III, MD, Jordan Howard Green, MD, and Nader Paksima, DO, MPH
Background: Handwritten consent forms for medical
treatment are commonly used despite the associated risk of
documentation errors. We performed an internal audit of
handwritten surgical consent forms to assess the quality of
consenting practices within the department of hand surgery
at our orthopedic specialty hospital.
Methods: A sample of 1,800 charts was selected. Con-
sents were assessed for procedure type, physician details,
abbreviations, consistency, and legibility.
Results: A total of 1,309 charts met the inclusion crite-
ria. Two hundred and eight consents contained at least one
illegible word. The name of the consenting physician was
not listed or illegible on 114 forms. Medical abbreviations
were found on 1.8% of all included forms, and 19 consent
forms contained a crossed-out word or correction.
Conclusions: Although the majority of the handwrit-
ten consent forms were complete, accurate, and legible,
there were notable errors in the consenting process at our
institution. Documentation errors have medical and ethical
ramifications. Further research into consenting practices is
necessary to improve the quality of consent forms and the
process of informed consent.
The Clinician’s Guide to Differential Diagnosis of Non-Localized Musculoskeletal Pain A Primer on Musculoskeletal Medicine
Elisha Krasin, MD, Yaniv Warschawski, MD, and Amal Khoury, MD
Orthopedic surgeons may encounter patients with musculo-
skeletal complaints that are not localized to a specific joint
or anatomical area. The list of diagnoses that may cause
generalized pain originating from bones, muscles, fasciae,
and joints, including surrounding tissues like tendons,
ligaments, and bursae, is vast; starting with influenza or
fibromyalgia and ending with mycetism and ultra-rare he-
reditary disorders. A systematic multidisciplinary approach
is required. Many of these patients require referral to rheu-
matology, endocrinology, or other specialties but at least
a basic understanding of differential diagnosis is needed.
The purpose of this review is to comprehensively examine
the clinical presentation of various causes of generalized
musculoskeletal pain and create a mental framework to aid
the diagnostician in achieving the correct diagnosis in an
orderly and efficient manner.
Comparison of Three Suture Materials in Capsular Closure Closure Time and Wound Complications Following Knee Arthroplasty
Kavin Khatri, MS, DNB, FACS, R. K. Banga, MS, Neeraj Malhotra, MS, and Depak Bansal, MS
Background: Watertight capsular closure in knee arthro-
plasty is desirable in order to achieve a good functional
outcome. Barbed knotless sutures are being increasingly
used in wound closure following knee arthroplasty. The prior
studies have compared barbed sutures with either VICRYL® or
Ethibond for closure, while none had compared all the three in
a single setting in terms of closure time, needle stick injuries,
postoperative complications, and functional outcome.
Patients and Methods: One hundred and forty-three
subjects of unilateral knee arthroplasty were screened for
eligibility in the prospective randomized controlled trial.
One hundred and twenty patients fulfilled the inclusion
criteria and were randomized into three groups to undergo
capsular closure with barbed sutures, VICRYL, or Ethibond.
Results: The wound closure was fastest with barbed su-
tures followed by VICRYL and Ethibond (10.4 ± 4.1; 15.4 ±
4.7; 17.2 ± 3.8 minutes; p < 0.001). There were seven needle
stick injuries in the Ethibond group followed by three in the
VICRYL group and none in the barbed suture group. The
Knee Society Scores and wound related complications were
comparable in all the three groups.
Conclusion: Barbed suture, VICRYL, and Ethibond are
equally good in the capsular closure following knee arthro-
plasty. The faster wound closure time achieved may not be
clinically relevant in the short term.
Sex-Based Differences in Outcomes of Tibial Tubercle Anteromedialization
David A. Bloom, MD, Matthew Gonzalez, MD, Eoghan T. Hurley, MB, MBCH, Matthew T.
Kingery, MD, Cordelia W. Carter, MD, Laith M. Jazrawi, MD, and Eric J. Strauss, MD
Background: Previous research has demonstrated sex-
based differences in patient-reported outcomes of orthopedic
surgical procedures. The hypothesis of the current study was
that females would have inferior patient-reported outcomes
to their male peers following a tibial tubercle anteromedial-
ization (AMZ) procedure for both patellofemoral instability
and cartilage defects.
Methods: Patients who had undergone AMZ for isolated
osteochondral defect or patellofemoral instability with a
minimum follow-up time of 1 year were identified. They were
then asked to complete several patient-reported outcome
questionnaires that were then statistically analyzed.
Results: Overall, 109 patients were included in this study.
Seventy-nine patients (72.5%) were female with a mean
follow-up duration of 3.4 ± 2.0 years. Forty-seven females
had AMZ for patellar instability while 32 females had AMZ
for osteochondral defects. There were no statistically signifi-
cant differences between sexes with respect to concomitant
procedures performed, visual analog scale (VAS) pain score,
or patient reported outcome (PRO) scores at follow-up (p >
0.05). There was no statistically significant difference with
respect to outcomes between the sexes for AMZ overall and
when isolating the sexes based on indication.
Conclusion: This study demonstrates that female patients
undergoing AMZ have short-term clinical and functional
outcomes that are not significantly different to those reported
in males.
Indications for Conversion of Spinal into General Anesthesia During Total Joint Arthroplasty
Paul J. Tesoriero, MS, Chelsea S. Sicat, MS, Michael Collins, BS, James E. Feng, MD, David
L. Furgiuele, MD, William J. Long, MD, FRCSC, and Ran Schwarzkopf, MD, MSc
Introduction: Spinal anesthesia (SA) is the preferred
method of anesthesia at many centers for total joint arthro-
plasty (TJA). However, a small subset of patients fails SA,
necessitating a conversion to general anesthesia (GA). This
report assesses the patient characteristics associated with
failed SA.
Methods: A retrospective study was conducted on patients
who underwent SA during their primary TJA between Janu-
ary 2015 and December 2016 at our institution. A subset of
this group required a conversion from SA to GA. Anesthesia
reports were reviewed for the number of attempts at SA and
the documented reason for failure. The SA failure cohort was
then subdivided into failure categories based on the reasons
that had been provided.
Results: A total of 5,706 patients were included in this
study, 78 of which experienced SA failure. The number of
attempts was most strongly associated with SA failure, with
three attempts resulting in a five times increased failure
rate (OR = 4.73, p = 0.010) and four attempts resulting in
12 times increased failure rate compared to the no failure
cohort (OR = 12.3, p < 0.001). Greater than two attempts
occurred in 87.5% of the “technical failure” sub-group of
the SA failure cohort (p < 0.001). No difference was demon-
strated among the other patient characteristics, such as age,
sex, body mass index, race, American Society of Anesthesia
(ASA) score, and surgical time.
Conclusions: The results suggest that the major predic-
tor influencing spinal to general anesthesia conversion was
the number of attempts at SA, especially among technical
failure cases. Based on the results, it may be appropriate
for anesthesiologists to convert to GA after two failed spi-
nal attempts. Further studies are warranted to assess this
relationship for firm clinical recommendations.
The Cam-Post Dislocation in Posterior-Stabilized Total Knee Arthroplasty A Case Series
Jeffrey S. Chen, MD, Andrew S. Bi, MD, James D. Slover, MD, Scott E. Marwin, MD, and Ajit
J. Deshmukh, MD
Cam-post dislocations are a unique complication of total
knee arthroplasty (TKA) designs that utilize a cam-post
mechanism, representing an extreme form of deep flexion
instability. They are rare complications and are poorly
defined in the existing literature. The purpose of this case
study is to present a series of six cam-post dislocation
cases to improve understanding of this complication and its
mechanism, presentation, and available treatment options.
All patients experienced cam-post dislocations after a deep
flexion moment that were identified clinically and confirmed
radiographically. Affected implants included both primary
and revision components and all utilized a cam-post mecha-
nism. Three patients underwent revision surgery whereas
the remaining three were treated with closed reduction only.
Cam-post dislocations are rare complications of posterior-
stabilized TKA that should be understood and recognized
by adult reconstruction surgeons. Closed reduction may
be achieved with hyperflexion and anterior drawer or with
hyperextension, but these patients may ultimately require a
revision procedure.