Andrew Jawa

Predictors of Success on the American Board of Orthopaedic Surgery Examination

Predictors of success of orthopaedic residents on the American Board of Orthopaedic Surgery (ABOS) examination are controversial. We therefore evaluated numerous variables that may suggest or predict candidate performance on the ABOS examination. We reviewed files of 161 residents (all graduates) from one residency program distributed into two study groups based on whether they passed or failed their first attempt on the ABOS Part I or Part II examination from 1991 through 2005. Predictors of success/failure on the ABOS I included the mean percentile score on the Orthopaedic In-Training Examination (OITE) (Years 2 through 4), the percentile OITE score in the last year of training, US Medical Licensing Examination (USMLE) score, Dean’s letter, election to Alpha Omega Alpha (AOA), and number of honors in selected third-year clerkships. All but the USMLE score predicted passing the ABOS Part II examination. These data suggest there are objective predictors of residents’ performance on the ABOS Part I and Part II examinations.

Prosthesis of Antibiotic-Loaded Acrylic Cement (PROSTALAC) Use for the Treatment of Infection After Shoulder Arthroplasty

BACKGROUNDnThere are limited data on Prosthesis of Antibiotic-Loaded Acrylic Cement (PROSTALAC) use for the treatment of infection following shoulder arthroplasty. We performed a retrospective review of our experience with the PROSTALAC in terms of infection eradication, complications, and outcomes.nnnMETHODSnTwenty-eight patients with an infection at the site of a shoulder arthroplasty who were managed with the PROSTALAC were followed until eradication of the infection and maximum functional improvement. The average duration of follow-up was 27.6 months (range, twelve to sixty-nine months). In twenty-five of the twenty-eight patients, the PROSTALAC was created with antibiotic-impregnated cement, a standard humeral head mold, and a scaffold with either a one-third tubular plate or a 3.5-mm reconstruction plate. Three PROSTALAC implants had no scaffold.nnnRESULTSnAlthough all patients benefited from the use of the PROSTALAC, there were nine complications in eight patients (29%), with six additional unplanned surgical procedures being performed in this group. One patient had a dislocation, three had a fracture of the PROSTALAC, and five had recurrent infections requiring debridement and revision PROSTALAC placement. All fractures were associated with use of the semitubular plate. Twelve patients (43%), including two with revision PROSTALAC implants, were satisfied with pain relief and function and declined a second-stage procedure. With the exclusion of two patients who had a revision PROSTALAC implant, sixteen patients (57%) had a second-stage procedure; the procedures included ten reverse shoulder arthroplasties, three hemiarthroplasties, two total shoulder arthroplasties, and one resection arthroplasty. At the time of the latest follow-up, the average forward elevation of the shoulder was 77° (range, 30° to 130°). Fifteen patients had no or mild pain, eight patients had moderate pain, and five had severe pain. Patients with reverse total shoulder arthroplasties did not have improved function compared with the other cohorts.nnnCONCLUSIONSnThe use of the PROSTALAC for the treatment of infection following shoulder arthroplasty is beneficial. Infection was initially eradicated in twenty-three (82%) of twenty-eight patients, more than half of our patients had mild or no pain, and 43% of patients declined a second-stage procedure because of acceptable function and pain relief. Conversely, five of twenty-eight patients had severe pain and five patients had persistent infection requiring additional surgery. The use of the reverse total shoulder arthroplasty did not appear to improve outcomes.

Risk Factors for Fracture Mobility Six Weeks After Initiation of Brace Treatment of Mid-Diaphyseal Humeral Fractures

BACKGROUNDnRecent studies have identified specific subsets of diaphyseal humeral fractures for which functional bracing is less effective. The present study tested the hypothesis that a gap between fracture fragments may be a risk factor (after accounting for other potential risk factors) for fracture instability six weeks after functional bracing of humeral shaft fractures.nnnMETHODSnWe retrospectively identified seventy-nine adult patients (forty-six men, thirty-three women; forty-two fractures on the right side, thirty-seven fractures on the left), each with an acute, closed, AO type-A2 (oblique, ≥30°) or type-A3 (transverse, <30°) mid-diaphyseal humeral shaft fracture treated nonoperatively at three different level-I trauma centers from June 2004 to August 2011. The gap between the fracture fragments was measured on the first radiographs made after the affected upper extremity was placed in a brace.nnnRESULTSnSixty-three patients (80%) had documented healing of the fracture. Sixteen patients (20%) had motion at the fracture site and a persistent fracture line shown on radiographs six weeks or more after injury. In multivariable analysis, each millimeter of gap between the main fragments with the patient wearing the brace (odds ratio [OR] = 1.4, 95% confidence interval [CI] = 1.1 to 1.7), smoking (OR = 5.8, 95% CI = 1.4 to 25), and female sex (OR = 5.3, 95% CI = 1.2 to 23) increased the risk of fracture instability six weeks after injury (R2 = 0.38, area under the receiver operating characteristic [ROC] curve = 0.81).nnnCONCLUSIONSnThe magnitude of the gap between the fracture fragments is an independent risk factor for fracture instability and the lack of a bridging callus six weeks after a diaphyseal humeral fracture.

Predicting alignment after closed reduction and casting of distal radius fractures.

PURPOSEnWe sought to independently validate the McQueen equation and LaFontaines criteria as predictors of instability in a large series of distal radius fractures treated nonsurgically. In addition, we hypothesized that restoring the volar cortical integrity (ie, volar hook) would be another factor that would independently predict the maintenance of a closed reduction in a cast.nnnMETHODSnWe screened 546 consecutive distal radius fractures with 168 meeting all inclusion criteria. Dorsal tilt, radial height, radial inclination, ulnar variance, and carpal malalignment were measured on initial postreduction and final radiographs. A univariate analysis evaluated the predictability of the McQueen equation, Lafontaines criteria, and volar hook on each radiographic parameter. A multivariate analysis was performed using the significant results from the univariate analysis.nnnRESULTSnIn the univariate analysis, the McQueen formula, the number of Lafontaine criteria, and age all correlated with radial height, radial inclination, and ulnar variance. In the multivariate analysis, age correlated with the most radiographic factors including radial height, radial inclination, ulnar variance, and carpal alignment at healing. Volar hook correlated with dorsal tilt and carpal alignment at healing, and dorsal comminution correlated with dorsal tilt.nnnCONCLUSIONSnIn the nonsurgical treatment of distal radius fractures, we were able to validate the McQueen equation and Lafontaines criteria in predicting the final radial height and inclination and final ulnar variance. Neither method was predictive of final dorsal tilt or carpal malalignment. However, restoring volar cortical continuity by hooking the volar cortex in the initial reduction proved to be the strongest predictor of final volar tilt, the change in volar tilt, and carpal malalignment at union.nnnTYPE OF STUDY/LEVEL OF EVIDENCEnTherapeutic III.

Injury patterns and outcomes of open fractures of the proximal ulna do not differ from closed fractures.

BackgroundThe incidence and injury patterns of open fractures of the proximal ulna are poorly elucidated and little evidence exists to guide management.Questions/purposesThe purpose of this study was to compare the (1) bony injury patterns; (2) range of motion (ROM) and frequency of union; and (3) postoperative complications between open and closed fractures of the proximal ulna.MethodsSeventy-nine consecutive open fractures of the proximal ulna were identified. After excluding fracture-dislocations, penetrating injuries, and pediatric injuries, 60 were compared in a retrospective case-control study with an age- and sex-matched group of 91 closed fractures to compare the bony injury patterns based on radiographic review. In a subset of 39 open and 39 closed fractures with sufficient followup, chart and radiographic review was performed by someone other than the operating surgeon to compare differences in final ROM, union, and postoperative complication rates at a minimum followup of 3 months (mean, 22 and 15 months; range, 3–86 months and 3–51 months for open and closed fractures, respectively). A total of 12% of the fractures were open (79 of 671) at the three study centers, and the majority of fractures were intraarticular (45 of 60 [75%]) with Gustilo-Anderson Type I and II wounds (54 of 60 [90%]).ResultsOverall, open fractures of the proximal ulna overall did not have more complex bony injury patterns, but there were more anterior olecranon fracture-dislocations among the open fracture group (nine of 60 [15%] versus two of 91 [2%]; p = 0.004) and more posterior olecranon fracture-dislocations in the closed fracture group (31 of 91 [34%] versus seven of 60 [12%]; p = 0.002). Final ROM was not different in both groups and all fractures healed. There was no difference in wound infection rate but a higher secondary procedure rate among open fractures of the proximal ulna (39% versus 23%, p = 0.014).ConclusionsIn contrast to open fractures of the distal humerus, open fractures of the proximal ulna present with mild soft tissue injuries and do not have more complex bony injury patterns than closed fractures. Our findings suggest that open fractures of the proximal ulna are the result of tension failure of the skin secondary to the limited soft tissue envelope around the proximal ulna. Open fractures of the proximal ulna should be regarded as relatively mild injuries that are not different in severity and prognosis compared with closed fractures.Level of EvidenceLevel III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence

Face and thigh swelling in a 6-year-old girl.

Learning ObjevtivesUpon completion of this study, the reader should be able: recall the differences in clinical presentation between B-cell lymphoma and T-cell lymphomas,describe the basis of immunohistochemical differentiation between B-cell lymphoma and other lymphoproliferative diseases,identify the appropriate staging studies and appropriate refferal to other medical specialties when indicated.

Lateralized Center of Rotation and Lower Neck-Shaft Angle Are Associated With Lower Rates of Scapular Notching and Heterotopic Ossification and Improved Pain for Reverse Shoulder Arthroplasty at 1 Year.

Heterotopic ossification and scapular notching are common following reverse total shoulder arthroplasty. Compared with the original Grammont-style prosthesis with a medialized center of rotation (COR) and a 155° neck-shaft angle, lateralization of COR and reduction of neck-shaft angle have been associated with decreased incidence of scapular notching. The authors hypothesized that these design features may also be effective in reducing heterotopic ossification after reverse total shoulder arthroplasty. Ninety-seven consecutive patients who underwent reverse total shoulder arthroplasty performed by a single surgeon were included in the study. Forty-eight patients received a Grammont-style prosthesis, and 49 received a prosthesis with either 6 mm or 10 mm of lateral COR offset and a 135° neck-shaft angle. Radiographs at 1-year follow-up were reviewed by 2 surgeons for notching and heterotopic ossification. Patient-reported outcome scores and range of motion were also compared between the groups. More patients in the Grammont-style group showed scapular notching (Grammont, 35.4%; lateral COR, 12.2%; P=.018) and heterotopic ossification (Grammont, 47.9%; lateral COR, 22.4%; P=.009). The lateralized COR group reported lower pain on the visual analog scale (Grammont mean, 1.1; lateral COR mean, 0.5; P=.01) and trended toward better American Shoulder and Elbow Surgeons scores (Grammont mean, 77.2; lateral COR mean, 83.4; P=.05). However, range of motion was similar between the 2 groups. Compared with the Grammont-style prosthesis, the lateralized COR prosthesis with a decreased neck-shaft angle resulted in a lower incidence of both scapular notching and heterotopic ossification as well as better pain scores and a trend toward improved function at 1 year after reverse total shoulder arthroplasty. [Orthopedics. 2018; 41(4):230-236.].

High pain intensity after total shoulder arthroplasty

BACKGROUNDnAs reimbursement becomes increasingly tied to quality and patient experience, there is growing interest in alleviation of postoperative pain combined with optimal opioid stewardship. We characterized predictors of severe inpatient pain after elective total shoulder arthroplasty and evaluated its association with opioid use, operative time, hospital length of stay, discharge disposition, and cost.nnnMETHODSnWe identified 415 patients undergoing elective primary total shoulder arthroplasty between 2016 and 2017 from our registry. Severe postoperative pain was defined as peak pain intensityu2009≥75th percentile. Multivariable logistic regression modeling was used to determine preoperative characteristics associated with severe pain, including demographics, emotional health, comorbidities, and American Shoulder and Elbow Surgeons score. Opioid consumption was expressed as oral morphine equivalents (OMEs). Costs were calculated using time-driven activity-based costing.nnnRESULTSnIn decreasing order of magnitude, the predictors of severe postoperative pain were greater number of self-reported allergies, preoperative chronic opioid use, lower American Shoulder and Elbow Surgeons score, and depression. Patients reporting severe pain took more opioids (202 vs. 84u2009mg OMEs), stayed longer in the hospital (2.9 vs. 2.0 days), used postacute inpatient rehabilitation services more frequently (28% vs. 10%), and were more likely to be high-cost patients (23% vs. 5%; all Pu2009<u2009.001), but they did not have longer operations (166 vs. 165 minutes, Pu2009=u2009.86).nnnCONCLUSIONSnEfforts to address psychological and social determinants of health might do as much or more than technical improvements to alleviate pain, limit opioid use, and contain costs after shoulder arthroplasty. These findings are important in the redesign of care pathways and bundling initiatives.

Distal humerus fractures

BE is a 65-year-old woman who is brought to the Emergency Department complaining of severe arm pain after a fall from a standing height. On primary survey, she has a GCS of 15, a patent airway and is hemodynamically stable. On secondary survey, she has an obviously deformed right elbow. Her past medical history is unremarkable. She takes no medications and has no allergies.

Enlarging thigh mass in a 13-month-old boy

A 13-month-old boy presented with a history of a slowly enlarging mass of his proximal anteromedial right thigh that was noticed shortly after birth. He was born after an uncomplicated 40-week gestation by spontaneous vaginal delivery with a weight of 3062 g. He was healthy and gaining weight appropriately. The mass enlarged in proportion to his growth, it was not related to any history of trauma, and it did not appear to be tender. On physical examination, the child was a healthy appearing 13-month-old boy. A soft 5 x 4-cm mass was palpable deep to the fascia of the anteromedial area of his right thigh. There were no associated skin changes. The neurovascular bundle was palpable superiorly and anteriorly to the mass while his pulses distally were palpable and symmetric. The ROM and strength at his hips and knees were normal and testing did not elicit any pain. Magnetic resonance imaging scans obtained 3 days before referral to the authors’ institution were reviewed with the preliminary diagnosis of sarcoma (Figs 1–5). Based on the history, physical examination, and imaging studies, what is the differential diagnosis? SECTION III REGULAR AND SPECIAL FEATURES