Background: Each Orthopaedic In-Training Examination (OITE) question references one or more journal articles or textbook sections as the evidence-based origin of its “pre- ferred response.” Previous studies identified the number of references to the top sources but not the number of questions covered by these top sources. The current study analyzes the question yield, time lag from publication, and sequential benefit—in terms of OITE questions covered—of the most referenced sources in order to provide residents and educa- tors strategies for developing an efficient reading program. Methods: We analyzed all OITE references from 2002 to 2009 and identified 1. The most referenced journals, text- books, authors, and journal articles; 2. The question yield of the top journals; 3. The time lag from article publication to OITE reference; and 4. The additional question benefit of the top sources when added sequentially. We repeated the analysis considering only journal articles published within 5 years of each respective OITE. Results: The most referenced journals were the The Journal of Bone and Joint Surgery, American Edition (JBJS-Am), Clinical Orthopaedics and Related Research (CORR), and the The Journal of the American Academy of Orthopaedic Surgeons (JAAOS). JBJS-Am accounted for 14% of all references and was referenced on 24% of questions; CORR and JAAOS each contributed 6% of references and were referenced on 11% of questions. The average time from article publication to OITE reference was 8.1 years (median: 6 years, mode: 2 years). The top 29 authors were referenced on 15% of OITE questions. The two most-referenced articles were each referenced 7 times in 8 years. Regarding question yield, 18% of published JAAOS articles were referenced on an OITE, as opposed to 7% of JBJS-Am articles and 2% of CORR articles. Considering articles published within 5 years of an OITE, the number of questions referencing JBJS-Am decreased from 24% to 10%. The sequential benefit of adding JAAOS and CORR during the 5 years was an additional 8% of total questions. Conclusions: When developing a reading curriculum, educators and residents should be aware of the question yield, reading efficiency, and time lag to publication of the most common OITE reference sources.

Ice hockey is a fast paced sport with unique injury potential. A covering physician must be prepared to acutely manage injuries to the face, neck, and chest that are not common in orthopedic practice. Injuries about the face seen in ice hockey include facial fractures, lacerations, and eye and dental injuries. Neck trauma can result in lacerations and neurologic injury. Commotio cordis and sudden cardiac death are potentially fatal conditions seen in ice hockey. This review details the appropriate acute management of these conditions for the physician covering an ice hockey game. Knowledge of these conditions and appropriate rink-side management can be potentially life-saving.

Background: Numerous studies have reported on post- operative infection following spinal arthrodesis for spinal deformity. The incidence of infection associated with spinal surgery overall ranges from less than 1% to 15%. Certain factors may increase the risk of surgical site infection (SSI) in patients who undergo surgical treatment for spinal defor- mities. These include a diagnosis of neuromuscular disease, use of surgical drain or lack thereof, patient comorbidities, increased blood transfusions, and an allergic inflamma - tory response to the use of instrumentation. Many of these studies, however, have been limited by small numbers and confounded by multiple surgeons and hospitals. Purpose: The purpose of this study was to determine the rate of spinal wound infection following spinal deformity surgery in a single surgeon’s practice and to identify risk factors for infection, particularly those related to type of deformity and surgical procedures performed. Study Design: This is a retrospective review of prospec- tively collected data from a single surgeon. Only spinal deformity patients’ records were reviewed. Methods: We reviewed 941 spinal deformity operative procedures (806 patients, 584 females, 222 males) done by a single surgeon from 1999 to 2009. Outcome measures were superficial wound infection, deep wound infection, possible infection, and no infection. The following variables were as- sessed: gender, age, height, weight, body mass index (BMI), primary diagnosis, associated comorbidities, prior spinal surgeries, surgical approach, type and number of procedures performed, radiographic measurements, operative data (including operative time), and complications. A one-way ANOVA and Turkey post-hoc analysis was used. Results: The average age was 22.3 years (range 1.8 to 82 years). There were 13 deep wound infections (1.4%) and 17 incidences of superficial wound infection (1.8%), for an overall infection rate of 3.2%. The following variables were found to be independent predictors of deep infection: neu- romuscular scoliosis (odd ratio (O.R. 9.2) and Lenke 3 or 4 curve types in adolescent idiopathic scoliosis patients (O.R. 7.4). Kyphosis (O.R. 4.38), combined approach (O.R. 0.81), total number of levels fused (O.R. 1.16), and Lenke 3 or 4 curve types in AIS (O.R. 4.54) were independent predictors of superficial infection. Lastly, logistic regression identi- fied the following as predictors of any infection: BMI (O.R. 1.11), total number of comorbidities (O.R. 1.24), osteotomy procedure (O.R. 3.14), number of levels fused (O.R. 1.13), and Lenke 3 or 4 curve types (O.R. 1.67). Conclusion: Age, BMI, number of levels, Lenke 3-4 curves, osteotomy, and number of comorbidities were found to be predictors of any infection. Of these, only Lenke 3-4 and neuromuscular comorbidity was correlated with deep infection.

Background: Shoulder arthroplasty provides predictable pain relief and functional improvement of the shoulder for glenohumeral disease. With recent emphasis on health eco- nomic planning and rising patient expectation, physicians are encouraged to adopt more evidence-based strategies for decision-making. In the context of shoulder arthroplasty, surgeon preference and bias may play a large role in the choice of the procedure performed. The purpose of this study is to objectively examine the perceived differences and similarities, from the surgeon’s perspective, between total shoulder arthroplasty (TSA) and hemiarthroplasty anticipated outcomes. Methods: We conducted a web-based survey that asked surgeons to weigh the relative values of these procedures in relation to one another. Within the survey, there were nu- merous variables in which the surgeon was asked to choose the preferred surgical outcome. Ninety-eight surgeons re- sponded to the survey. The average age was 51.7 years. Results: Surgeons in our study chose pain relief and improved ROM as a more likely outcome in TSA than any level of complication and as a more likely out-come than improved strength compared to hemiarthroplasty. These results emphasized the perception amongst the polled sur- geons that TSA is a preferred treatment option for patients who expect a high level of pain relief and ROM even at the expense of a decreased strength. Conclusion: This study is a first step in the construction of a patient oriented model for treatment decisions. With this information, we may be better able to tailor our patients’ needs and wishes to the procedures that most predictably result in the outcomes they desire.

Study Design: A retrospective review of 74 consecutive, surgical patients with neuromuscular scoliosis (NMS). Objective: This study evaluates the distribution of hos- pital and operating room costs incurred during surgical correction of NMS. Background Data: Recent studies have demonstrated that surgical treatment improves both medical outcomes and the quality of life in patients with progressive NMS. Characterization of the costs incurred at the time of surgery and hospitalization will facilitate the identification of op - portunities for cost reduction. Methods: Demographic data collected included gender, age, preoperative height, weight, and BMI. Major coronal curvatures and T5-T12 kyphosis were assessed from ra- diographs. Construct type and number of screws, hooks, and wires implanted were recorded. Surgical costs were calculated based on cost of surgical correction, hospital stay, and postoperative care. Results: Mean age was 15.8 ± 7.3 years; 57% were male. Comorbidities included cerebral palsy (28%) and familial dysautonomia (14%). The mean preoperative major curve magnitude was 60°; minor curve magnitude was 33°. Posterior approach (76%) and pedicle screws (75%) were predominantly utilized. The average length of hospitalization was 8 days (range: 3 to 47). There were six major complica- tions (8%). The total surgical cost was $50,096 ± $23,998. The highest individual cost was for implants ($13,916; 24% of total costs). The second highest was inpatient room and ICU costs ($12,483; 22%); bone grafts were the third ($6,398; 11%). Increased major and minor structural curve, increased total (A/P) levels fused, and increased length of hospital stay predicted an increase in total cost. Conclusions: Major contributors to cost in NMS surgery are implants, inpatient room and ICU costs, and bone grafts. Independent predictors of higher cost are the degree of major and minor structural curve, total number of A/P levels fused, and length of hospital stay. These conclusions provide insight into costs associated with care for a medically fragile and challenging patient population.

Purpose: The purpose of this study is to validate a re- verse shoulder computer impingement model and quantify the impact of implant position on scapular impingement by comparing it to that of a radiographic analysis of 256 patients who received the same prosthesis and were followed postoperatively for an average of 22.2 months. Methods: A geometric computer analysis quantified an - terior and posterior scapular impingement as the humerus was internally and externally rotated at varying levels of abduction and adduction relative to a fixed scapula at de - fined glenoid implant positions. These impingement results were compared to radiographic study of 256 patients who were analyzed for notching, glenoid baseplate position, and glenosphere overhang. Results: The computer model predicted no impingement at 0° humeral abduction in the scapular plane for the 38 mm, 42 mm, and 46 mm devices when the glenoid baseplate cage peg is positioned 18.6 mm, 20.4 mm, and 22.7 mm from the inferior glenoid rim (of the reamed glenoid) or when glenosphere overhang of 4.6 mm, 4.7 mm, and 4.5 mm was obtained with each size glenosphere, respectively. When compared to the radiographic analysis, the computer model correctly predicted impingement based upon glenoid base- plate position in 18 of 26 patients with scapular notching and based upon glenosphere overhang in 15 of 26 patients with scapular notching. Conclusions: Reverse shoulder implant positioning plays an important role in scapular notching. The results of this study demonstrate that the computer impingement model can effectively predict impingement based upon implant positioning in a majority of patients who developed scapular notching clinically. This computer analysis provides guid- ance to surgeons on implant positions that reduce scapular notching, a well-documented complication of reverse shoul- der arthroplasty.

Purpose: This study quantifies the ability of humeral retroversion, glenoid tilt, bone graft, and varying prosthesis design parameters to restore anatomic muscle length and deltoid wrapping with reverse shoulder arthroplasty. Methods: A computer model simulated abduction and internal and external rotation for a normal shoulder, the RSP reverse shoulder, the Equinoxe reverse shoulder, and the Grammont reverse shoulder when implanted using various implantation methods. The length of eight different muscles and the deltoid wrapping angle were quantified to evaluate the ability of each implantation method and design to restore anatomic muscle tensioning. Results: Each reverse shoulder shifted the center of rota- tion medially and inferiorly relative to the normal shoulder and caused a corresponding shift in the position of the humerus. Each reverse shoulder elongated each head of the deltoid and shortened the internal and external rotators relative to the normal shoulder. The surgical techniques and prosthesis designs, which resulted in a more lateral humeral position, were associated with more deltoid wrapping and better tensioning of the anterior and posterior shoulder muscles. Conclusions: Muscle tensioning and deltoid wrapping can be substantially altered by surgical implantation meth- ods using the Grammont reverse shoulder. However, the results of this study demonstrate that more anatomic muscle tensioning and improved deltoid wrapping are achieved using alternative prosthesis designs that better restore the lateral position of the humerus.

A 65-year-old female presented with history of a fall on an outstretched hand 2 months back and with complaints of pain, limitation of movement of right elbow, and inability to carry out her daily routine activities. On examination, there was swelling and tenderness at the elbow, three point relation was altered, had fixed flexion deformity of 50° with range of motion from 50° to 60°. Radiographs showed ne- glected old unreduced posterior elbow dislocation, fractures of radial head, and coronoid process. Patient was treated with total elbow replacement using 3rd generation sloppy hinged elbow prosthesis. At 3 weeks, range of motion was from 30° to 120°. At 6 weeks follow-up, patient was able to do her routine activities independently with ROM of 20° to 140° and minimum pain.

Iatrogenic vascular injury during hip fracture surgery is a rare complication, with infrequent reports of injury during the procedure of cepahalo-medullary nailing. We describe a case report of injury to the superior gluteal artery which occurred during insertion of a nail for prophylactic fixation of an incomplete femur fracture secondary to alendronate use. We describe the anatomy of the arterial branches, the postoperative course, and the management strategy and hope this will increase awareness of these rare injuries.

Insufficiency fractures present a significant problem in pa - tients with osteoporosis. We report a case of bilateral iliac wing insufficiency fracture following low energy injury in an 87-year-old osteoporotic woman occurring 2 weeks after primary total hip arthroplasty. There are only a few reports of insufficiency fractures involving the ilium in the literature, and diagnosis has proven challenging, as radiographs are often negative at symptom onset. Magnetic resonance or radionuclide imaging is generally necessary for definitive diagnosis. This case highlights the importance of careful perioperative management of patients with osteoporosis.

Background: Each Orthopaedic In-Training Examination (OITE) question references one or more journal articles or textbook sections as the evidence-based origin of its “pre- ferred response.” Previous studies identified the number of references to the top sources but not the number of questions covered by these top sources. The current study analyzes the question yield, time lag from publication, and sequential benefit—in terms of OITE questions covered—of the most referenced sources in order to provide residents and educa- tors strategies for developing an efficient reading program. Methods: We analyzed all OITE references from 2002 to 2009 and identified 1. The most referenced journals, text- books, authors, and journal articles; 2. The question yield of the top journals; 3. The time lag from article publication to OITE reference; and 4. The additional question benefit of the top sources when added sequentially. We repeated the analysis considering only journal articles published within 5 years of each respective OITE. Results: The most referenced journals were the The Journal of Bone and Joint Surgery, American Edition (JBJS-Am), Clinical Orthopaedics and Related Research (CORR), and the The Journal of the American Academy of Orthopaedic Surgeons (JAAOS). JBJS-Am accounted for 14% of all references and was referenced on 24% of questions; CORR and JAAOS each contributed 6% of references and were referenced on 11% of questions. The average time from article publication to OITE reference was 8.1 years (median: 6 years, mode: 2 years). The top 29 authors were referenced on 15% of OITE questions. The two most-referenced articles were each referenced 7 times in 8 years. Regarding question yield, 18% of published JAAOS articles were referenced on an OITE, as opposed to 7% of JBJS-Am articles and 2% of CORR articles. Considering articles published within 5 years of an OITE, the number of questions referencing JBJS-Am decreased from 24% to 10%. The sequential benefit of adding JAAOS and CORR during the 5 years was an additional 8% of total questions. Conclusions: When developing a reading curriculum, educators and residents should be aware of the question yield, reading efficiency, and time lag to publication of the most common OITE reference sources.

Ice hockey is a fast paced sport with unique injury potential. A covering physician must be prepared to acutely manage injuries to the face, neck, and chest that are not common in orthopedic practice. Injuries about the face seen in ice hockey include facial fractures, lacerations, and eye and dental injuries. Neck trauma can result in lacerations and neurologic injury. Commotio cordis and sudden cardiac death are potentially fatal conditions seen in ice hockey. This review details the appropriate acute management of these conditions for the physician covering an ice hockey game. Knowledge of these conditions and appropriate rink-side management can be potentially life-saving.

Background: Numerous studies have reported on post- operative infection following spinal arthrodesis for spinal deformity. The incidence of infection associated with spinal surgery overall ranges from less than 1% to 15%. Certain factors may increase the risk of surgical site infection (SSI) in patients who undergo surgical treatment for spinal defor- mities. These include a diagnosis of neuromuscular disease, use of surgical drain or lack thereof, patient comorbidities, increased blood transfusions, and an allergic inflamma - tory response to the use of instrumentation. Many of these studies, however, have been limited by small numbers and confounded by multiple surgeons and hospitals. Purpose: The purpose of this study was to determine the rate of spinal wound infection following spinal deformity surgery in a single surgeon’s practice and to identify risk factors for infection, particularly those related to type of deformity and surgical procedures performed. Study Design: This is a retrospective review of prospec- tively collected data from a single surgeon. Only spinal deformity patients’ records were reviewed. Methods: We reviewed 941 spinal deformity operative procedures (806 patients, 584 females, 222 males) done by a single surgeon from 1999 to 2009. Outcome measures were superficial wound infection, deep wound infection, possible infection, and no infection. The following variables were as- sessed: gender, age, height, weight, body mass index (BMI), primary diagnosis, associated comorbidities, prior spinal surgeries, surgical approach, type and number of procedures performed, radiographic measurements, operative data (including operative time), and complications. A one-way ANOVA and Turkey post-hoc analysis was used. Results: The average age was 22.3 years (range 1.8 to 82 years). There were 13 deep wound infections (1.4%) and 17 incidences of superficial wound infection (1.8%), for an overall infection rate of 3.2%. The following variables were found to be independent predictors of deep infection: neu- romuscular scoliosis (odd ratio (O.R. 9.2) and Lenke 3 or 4 curve types in adolescent idiopathic scoliosis patients (O.R. 7.4). Kyphosis (O.R. 4.38), combined approach (O.R. 0.81), total number of levels fused (O.R. 1.16), and Lenke 3 or 4 curve types in AIS (O.R. 4.54) were independent predictors of superficial infection. Lastly, logistic regression identi- fied the following as predictors of any infection: BMI (O.R. 1.11), total number of comorbidities (O.R. 1.24), osteotomy procedure (O.R. 3.14), number of levels fused (O.R. 1.13), and Lenke 3 or 4 curve types (O.R. 1.67). Conclusion: Age, BMI, number of levels, Lenke 3-4 curves, osteotomy, and number of comorbidities were found to be predictors of any infection. Of these, only Lenke 3-4 and neuromuscular comorbidity was correlated with deep infection.

Background: Shoulder arthroplasty provides predictable pain relief and functional improvement of the shoulder for glenohumeral disease. With recent emphasis on health eco- nomic planning and rising patient expectation, physicians are encouraged to adopt more evidence-based strategies for decision-making. In the context of shoulder arthroplasty, surgeon preference and bias may play a large role in the choice of the procedure performed. The purpose of this study is to objectively examine the perceived differences and similarities, from the surgeon’s perspective, between total shoulder arthroplasty (TSA) and hemiarthroplasty anticipated outcomes. Methods: We conducted a web-based survey that asked surgeons to weigh the relative values of these procedures in relation to one another. Within the survey, there were nu- merous variables in which the surgeon was asked to choose the preferred surgical outcome. Ninety-eight surgeons re- sponded to the survey. The average age was 51.7 years. Results: Surgeons in our study chose pain relief and improved ROM as a more likely outcome in TSA than any level of complication and as a more likely out-come than improved strength compared to hemiarthroplasty. These results emphasized the perception amongst the polled sur- geons that TSA is a preferred treatment option for patients who expect a high level of pain relief and ROM even at the expense of a decreased strength. Conclusion: This study is a first step in the construction of a patient oriented model for treatment decisions. With this information, we may be better able to tailor our patients’ needs and wishes to the procedures that most predictably result in the outcomes they desire.

Study Design: A retrospective review of 74 consecutive, surgical patients with neuromuscular scoliosis (NMS). Objective: This study evaluates the distribution of hos- pital and operating room costs incurred during surgical correction of NMS. Background Data: Recent studies have demonstrated that surgical treatment improves both medical outcomes and the quality of life in patients with progressive NMS. Characterization of the costs incurred at the time of surgery and hospitalization will facilitate the identification of op - portunities for cost reduction. Methods: Demographic data collected included gender, age, preoperative height, weight, and BMI. Major coronal curvatures and T5-T12 kyphosis were assessed from ra- diographs. Construct type and number of screws, hooks, and wires implanted were recorded. Surgical costs were calculated based on cost of surgical correction, hospital stay, and postoperative care. Results: Mean age was 15.8 ± 7.3 years; 57% were male. Comorbidities included cerebral palsy (28%) and familial dysautonomia (14%). The mean preoperative major curve magnitude was 60°; minor curve magnitude was 33°. Posterior approach (76%) and pedicle screws (75%) were predominantly utilized. The average length of hospitalization was 8 days (range: 3 to 47). There were six major complica- tions (8%). The total surgical cost was $50,096 ± $23,998. The highest individual cost was for implants ($13,916; 24% of total costs). The second highest was inpatient room and ICU costs ($12,483; 22%); bone grafts were the third ($6,398; 11%). Increased major and minor structural curve, increased total (A/P) levels fused, and increased length of hospital stay predicted an increase in total cost. Conclusions: Major contributors to cost in NMS surgery are implants, inpatient room and ICU costs, and bone grafts. Independent predictors of higher cost are the degree of major and minor structural curve, total number of A/P levels fused, and length of hospital stay. These conclusions provide insight into costs associated with care for a medically fragile and challenging patient population.

Purpose: The purpose of this study is to validate a re- verse shoulder computer impingement model and quantify the impact of implant position on scapular impingement by comparing it to that of a radiographic analysis of 256 patients who received the same prosthesis and were followed postoperatively for an average of 22.2 months. Methods: A geometric computer analysis quantified an - terior and posterior scapular impingement as the humerus was internally and externally rotated at varying levels of abduction and adduction relative to a fixed scapula at de - fined glenoid implant positions. These impingement results were compared to radiographic study of 256 patients who were analyzed for notching, glenoid baseplate position, and glenosphere overhang. Results: The computer model predicted no impingement at 0° humeral abduction in the scapular plane for the 38 mm, 42 mm, and 46 mm devices when the glenoid baseplate cage peg is positioned 18.6 mm, 20.4 mm, and 22.7 mm from the inferior glenoid rim (of the reamed glenoid) or when glenosphere overhang of 4.6 mm, 4.7 mm, and 4.5 mm was obtained with each size glenosphere, respectively. When compared to the radiographic analysis, the computer model correctly predicted impingement based upon glenoid base- plate position in 18 of 26 patients with scapular notching and based upon glenosphere overhang in 15 of 26 patients with scapular notching. Conclusions: Reverse shoulder implant positioning plays an important role in scapular notching. The results of this study demonstrate that the computer impingement model can effectively predict impingement based upon implant positioning in a majority of patients who developed scapular notching clinically. This computer analysis provides guid- ance to surgeons on implant positions that reduce scapular notching, a well-documented complication of reverse shoul- der arthroplasty.

Purpose: This study quantifies the ability of humeral retroversion, glenoid tilt, bone graft, and varying prosthesis design parameters to restore anatomic muscle length and deltoid wrapping with reverse shoulder arthroplasty. Methods: A computer model simulated abduction and internal and external rotation for a normal shoulder, the RSP reverse shoulder, the Equinoxe reverse shoulder, and the Grammont reverse shoulder when implanted using various implantation methods. The length of eight different muscles and the deltoid wrapping angle were quantified to evaluate the ability of each implantation method and design to restore anatomic muscle tensioning. Results: Each reverse shoulder shifted the center of rota- tion medially and inferiorly relative to the normal shoulder and caused a corresponding shift in the position of the humerus. Each reverse shoulder elongated each head of the deltoid and shortened the internal and external rotators relative to the normal shoulder. The surgical techniques and prosthesis designs, which resulted in a more lateral humeral position, were associated with more deltoid wrapping and better tensioning of the anterior and posterior shoulder muscles. Conclusions: Muscle tensioning and deltoid wrapping can be substantially altered by surgical implantation meth- ods using the Grammont reverse shoulder. However, the results of this study demonstrate that more anatomic muscle tensioning and improved deltoid wrapping are achieved using alternative prosthesis designs that better restore the lateral position of the humerus.

A 65-year-old female presented with history of a fall on an outstretched hand 2 months back and with complaints of pain, limitation of movement of right elbow, and inability to carry out her daily routine activities. On examination, there was swelling and tenderness at the elbow, three point relation was altered, had fixed flexion deformity of 50° with range of motion from 50° to 60°. Radiographs showed ne- glected old unreduced posterior elbow dislocation, fractures of radial head, and coronoid process. Patient was treated with total elbow replacement using 3rd generation sloppy hinged elbow prosthesis. At 3 weeks, range of motion was from 30° to 120°. At 6 weeks follow-up, patient was able to do her routine activities independently with ROM of 20° to 140° and minimum pain.

Iatrogenic vascular injury during hip fracture surgery is a rare complication, with infrequent reports of injury during the procedure of cepahalo-medullary nailing. We describe a case report of injury to the superior gluteal artery which occurred during insertion of a nail for prophylactic fixation of an incomplete femur fracture secondary to alendronate use. We describe the anatomy of the arterial branches, the postoperative course, and the management strategy and hope this will increase awareness of these rare injuries.

Insufficiency fractures present a significant problem in pa - tients with osteoporosis. We report a case of bilateral iliac wing insufficiency fracture following low energy injury in an 87-year-old osteoporotic woman occurring 2 weeks after primary total hip arthroplasty. There are only a few reports of insufficiency fractures involving the ilium in the literature, and diagnosis has proven challenging, as radiographs are often negative at symptom onset. Magnetic resonance or radionuclide imaging is generally necessary for definitive diagnosis. This case highlights the importance of careful perioperative management of patients with osteoporosis.