Justin T. Newman

A New Minimally Invasive Technique for Large Volume Bone Graft Harvest for Treatment of Fracture Nonunions

Autologous Reamer-Irrigator-Aspirator bone grafting represents a safe and efficient procedure to treat fracture nonunions of long bones.

Posttraumatic Stress Disorder and Depression Negatively Impact General Health Status After Hand Injury

PURPOSE To estimate the prevalence of posttraumatic stress disorder (PTSD) and depression among hand-injured patients and assess the impact of these disorders on general health status. METHODS A total of 106 adult hand-injured patients (40 women, 66 men) with a mean age of 42 years (range, 18-79 years) participated. Patients with a chronic mental illness or cognitive impairment were excluded. Psychological status was assessed using the Revised Civilian Mississippi Scale for PTSD and the Beck Depression Inventory. General health status was evaluated with the Short Form-36 health survey (SF-36). We obtained demographics and injury characteristics from the patient medical records. RESULTS Prominent mechanisms of injury included a fall (n = 38), traffic-related injuries (n = 14), machine versus operator (n = 8), gunshot wounds (n = 6), and assault (n = 6). Using the screening questionnaires, 32 persons qualified for PTSD and 19 for depression. Sixteen patients met the criteria for both PTSD and depression. The association between PTSD and depression was significant (p < .01). Patients with PTSD had significantly lower scores than those who did not endorse items consistent with PTSD or depression on the SF-36 subscales of role-emotional (p < .01), body pain (p = .013), social function (p = .028), and mental health (p < .01). We found no significant differences between groups for the subscales of role-physical (p = .289), general health (p = .147), vitality (p = .496), and physical functioning (p = .476). Patients who had concurrent PTSD and depression had significantly lower scores than patients who had neither PTSD nor depression on all subscales (p < .05 for all) except role-physical (p = .135). We found significant negative correlations between Beck Depression Inventory scores and all of the SF-36 subscales (p < .05 for all). CONCLUSIONS In this study, nearly one third of hand-injured patients met diagnostic criteria for PTSD, depression, or both, according to the thresholds of the instruments used to measure these psychological aspects of illness. PTSD and depression had a negative effect on general health status after hand injury. It may be important to consider psychological status when caring for patients with hand injuries.

Factors Predictive of Concomitant Injuries Among Children and Adolescents Undergoing Anterior Cruciate Ligament Surgery

Background: The timing of treatment for pediatric anterior cruciate ligament (ACL) injuries remains controversial. The risks of delaying reconstruction and the differences between age groups are poorly defined. Purpose: To investigate factors that contribute to the prevalence and severity of concomitant chondral and meniscal injuries among patients aged 14 to 19 years versus those aged ≤14 years at the time of ACL reconstruction. The hypothesis was that concomitant injuries would be more prevalent in older versus younger subjects. Also, a delay in surgery would be predictive of the presence and severity of concomitant knee injuries requiring additional operative procedures. Study Methods: Cohort study; Level of evidence, 3. Methods: All subjects who underwent primary ACL reconstruction at a single tertiary pediatric hospital between 2005 and 2012 were retrospectively reviewed. The location, severity, and treatment of all concomitant knee injuries were recorded. Chi-square tests were used to compare the prevalence of chondral and meniscal injuries in the older (age, 14-19 years; n = 165) versus younger (age, ≤14 years; n = 66) cohorts. A multivariable logistic regression analysis was used to identify factors related to the presence of a concomitant injury that required additional treatment. Kaplan-Meier analyses were used to explore the relation between time to surgery and meniscal injury severity. Results: There was a significant relationship between time to surgery and the development of an irreparable meniscal injury (P < .05 for all) in both the younger and older groups. Time to surgery correlated with severity of chondral injury in the younger cohort (P = .0343) but not in the older cohort (P = .8877). In the younger cohort, only a delay in surgery >3 months (odds ratio [OR] = 4.8; 95% CI, 1.7-14.4; P = .0027) was significantly predictive of the presence of an injury that required additional operative procedures. In the older patients, a return to activity before surgery (OR = 3.8; 95% CI, 1.52-11.9; P = .0034) and obesity (OR = 2.5; 95% CI, 1.1-7.4; P = .0381) were significantly predictive of an injury that required additional operative procedures. Conclusion: Compared with younger subjects, the prevalence of concomitant knee injuries as well as the need for additional operative procedures was greater among older subjects. A delay to surgery correlated with increased severity of injury among both older and younger populations. A delay in surgery >3 months was the strongest predictor of the development of a concomitant injury in the younger cohort. A return to activity and obesity were significantly related to the presence of a concomitant knee injury in the older cohort.

Revision Hip Arthroscopy A Matched-Cohort Study Comparing Revision to Primary Arthroscopy Patients

Background: As the number of hip arthroscopic surgeries being performed increases, so too does the prevalence of revision hip arthroscopic surgery. Hypothesis/Purpose: The purpose of this study was to compare outcomes in patients requiring revision hip arthroscopic surgery to patients undergoing primary hip arthroscopic surgery. The hypothesis was that patients undergoing revisions would demonstrate similar outcomes to those undergoing primary hip arthroscopic surgery. Study Design: Cohort study; Level of evidence, 2. Methods: Included in the study were patients undergoing revision hip arthroscopic surgery who did not have a history of prior open hip surgery. Each patient in the revision cohort was matched with 2 patients undergoing primary hip arthroscopic surgery. Preoperatively and at a minimum follow-up of 2 years, outcome scores were collected, including the Hip Outcome Score–Activities of Daily Living subscale (HOS-ADL), which was the primary outcome variable; modified Harris hip score (mHHS); Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC); Hip Outcome Score–Sports subscale (HOS-Sports); and the 12-Item Short Form Health Survey (SF12). At follow-up, scores from the Tegner activity scale and patient self-reported satisfaction with surgical outcome were also collected. Results: A total of 246 patients in the revision cohort were matched with 492 patients in the primary cohort. In the revision cohort, 183 patients had 1 prior surgery, 45 had 2 surgeries, and 18 had ≥3 prior surgeries. Subsequent hip arthroscopic surgery was reported in 39 of 492 (8%) patients in the primary cohort and 5 of 246 (2%) patients in the revision cohort (P = .001). Subsequent surgery was reported in 50 of 492 (10%) patients in the primary cohort and 15 of 246 (6%) patients in the revision cohort (P = .07). Both groups saw significant improvement in outcome scores from preoperation to follow-up. The HOS-ADL was lower in the revision cohort preoperatively (65 vs 70) and postoperatively (79 vs 87) (P = .001). This was also seen in the HOS-Sports, WOMAC, and SF12 physical component scores. Patients who had 1 prior hip arthroscopic procedure had higher postoperative mHHS (81 vs 75) compared with patients with >1 hip arthroscopic procedure; however, there was no difference in postoperative mHHS between the single-revision cohort and the primary cohort. In the revision group, patients whose HOS-ADL improved ≥10 points had greater joint space. Patients with greater improvement were more likely to have had a previous labral tear that was not repaired and to require capsular plication at revision. Conclusion: Patients who underwent revision hip arthroscopic surgery had significant improvement in outcome scores but did have lower scores compared with patients with primary hip arthroscopies. Patients with ≥2 revisions had lower outcomes. Improvement in the revision cohort was seen in patients with increased joint space, no prior labral repair, and capsular plication at revision.

Modality of wound closure after total knee replacement: are staples as safe as sutures? A retrospective study of 181 patients

BackgroundSurgical site wound closure plays a vital role in post-operative success. This effect is magnified in regard to commonly performed elective procedures such as total knee arthroplasty. The use of either sutures or staples for skin re-approximation remains a contested subject, which may have a significant impact on both patient safety and surgical outcome. The literature remains divided on this topic.MethodsTwo cohorts of patients at a level one trauma and regional referral center were reviewed. Cohorts consisted of consecutive total knee arthroplasties performed by two surgeons who achieved surgical wound re-approximation by either staples or absorbable subcuticular sutures. Outcome variables included time of surgery, wound dehiscence, surgical site infection per Center for Disease Control criteria and repeat procedures for debridement and re-closure.Results181 patients qualified for study inclusion. Staples were employed in 82 cases (45.3% of total) and sutures in 99 cases (54.7%). The staples group had no complications while the sutures group had 9 (9.1%). These consisted of: 4 infections (2 superficial, one deep, one organ/space); three patients required re-suturing for dehiscence; one allergic type reaction to suture material; and one gout flare resulting in dehiscence. The mean surgical time with sutures was 122.3 minutes (sd = 33.4) and with staples was 114 minutes (sd = 24.4).ConclusionThis study demonstrated significantly fewer complications with staple use than with suture use. While all complications found in this study cannot be directly attributed to skin re-approximation method, the need for further prospective, randomized trials is established.

Return to Elite Level of Play and Performance in Professional Golfers After Arthroscopic Hip Surgery

Background: Hip conditions, such as femoroacetabular impingement and labral injury, can cause pain and limit the ability to play sports at a professional level. Purpose: To evaluate performance metrics of professional golfers prior to arthroscopic hip surgery and after surgery. Study Design: Case series; Level of evidence, 4. Methods: This study included professional golfers who underwent arthroscopic hip surgery. Primary outcome variables were greens in regulation and driving distance. Metrics were recorded for 2 years prior to arthroscopic hip surgery and 1, 2, and 5 years after arthroscopy. Results: A consecutive cohort of 20 male professional golfers (27 hips) from 2000 to 2011 underwent arthroscopic hip surgery by a single surgeon. All players were on the PGA Tour with a mean age of 38 years (range, 26-54 years). Eleven hips had labral repair and 16 had labral debridements. Four hips required microfracture of a chondral lesion. All players returned to play at a mean of 4.7 months (range, 1 month to 2 years). The mean number of years played after surgery was 5.72. There was no significant difference between preoperative and postoperative greens in regulation (P = .227). The mean distance per golf drive was significantly longer at 1 and 2 years postoperative compared with prior to surgery (P < .01), and driving distance at 5 years was also longer than preoperative (P = .008). Conclusion: Arthroscopic management of chondrolabral dysfunction due to femoroacetabular impingement in the professional golfer allowed the golfer to return to the same skill level prior to surgery. Mean driving distance was found to increase after arthroscopy, demonstrating not only a return but also an improvement in driving performance from prior level of play.

Efficacy of composite allograft and demineralized bone matrix graft in treating tibial plateau fractures with bone loss

Tibial plateau fractures with bone loss or significant comminution require grafting and stable fixation. We hypothesized a standardized protocol of internal fixation augmented with a mixture of demineralized bone matrix and corticocancellous allograft chips would result in high healing rates with minimal subsidence. Union was achieved in all 36 patients available for follow-up by a mean of 4.4 months. Mean range of motion was 2 degrees to 120 degrees. One patient developed osteomyelitis. Subsidence ranging from 2.5 to 5.7 mm occurred in 4 patients (11%). This treatment method provides sufficient structural integrity with a high union rate and a low complication rate.

Hip arthroscopy for the management of trauma: a literature review

The first descriptions of the use of hip arthroscopy for traumatic injuries were presented in 1980. One paper described arthroscopy for the removal of a bullet fragment while others reported using hip arthroscopy to remove fragments following total hip arthroplasty. With the application of traction and modification of arthroscopic instruments, hip arthroscopy has become a useful tool in treating trauma to the hip. Most of the literature describes traumatic hip dislocation. Several studies have documented the successful use of arthroscopy for removal of loose bodies, but it has also been used to treat labral tears, chondral defects and acetabular rim fractures. Complications reported include fluid extravasation, the lowering of the patients body temperature using cool saline irrigation and further injury due to unrecognized concomitant pathology.

Outcomes After Revision Hip Arthroscopic Surgery in Adolescent Patients Compared With a Matched Cohort Undergoing Primary Arthroscopic Surgery

Background: The incidence of hip arthroscopic surgery is increasing in the young athlete. This has also led to increased numbers of revision hip arthroscopic surgery. Hypothesis/Purpose: The purpose of this study was to describe the outcomes after revision hip arthroscopic surgery in patients ≤18 years of age in comparison to a matched cohort of patients undergoing primary hip arthroscopic surgery. Our hypothesis was that patients undergoing revision hip arthroscopic surgery would demonstrate similar outcomes to those patients undergoing primary hip arthroscopic surgery. Study Design: Cohort study; Level of evidence, 3. Methods: Patients were included in the study if they underwent revision hip arthroscopic surgery by a single surgeon and did not undergo prior open hip surgery. Each patient in the revision hip arthroscopic surgery cohort was matched with 2 patients undergoing primary hip arthroscopic surgery from the same institution. Cohorts were matched by age, sex, and year of surgery. Preoperatively and at a minimum follow-up of 2 years, outcome scores were collected. The primary outcome measure was the Hip Outcome Score for activities of daily living scale (HOS-ADL), a self-reported validated outcome instrument, in addition to the HOS for sports scale (HOS-Sport), modified Harris Hip Score (mHHS), and 12-Item Short Form Health Survey Physical Component Summary (SF-12 PCS). Results: Forty-two patients were included in the revision group and were matched with 84 patients in the primary group. The mean age in both groups was 16 years (range, 14-18 years). All female patients in the study were ≥14 years of age, and all male patients were ≥16 years of age. In patients undergoing revision, 13 underwent 1 prior surgical procedure, 22 underwent 2 prior surgical procedures, and 7 underwent ≥3 prior surgical procedures. The mean time from last surgery to revision was 18.7 months (range, 4.7-74 months). Eleven patients (26%) had prior femoroacetabular impingement treated, which required osteoplasty or rim trimming at revision. Subsequent hip arthroscopic surgery was reported in 3 of 84 (4%) patients in the primary group and 6 of 42 (14%) patients in the revision group (P = .162). The mean follow-up in the revision group was 43 ± 17 months, and scores significantly improved (HOS-ADL: 59.6 to 77.6; HOS-Sport: 37.6 to 64.8; mHHS: 55.3 to 74.3; SF-12 PCS: 41.0 to 50.4; P < .05). The mean follow-up in the primary group was 45 ± 18 months, and all scores significantly improved (HOS-ADL: 65.8 to 87.4; HOS-Sport: 46.3 to 79.9; mHHS: 57.5 to 84.2; SF-12 PCS: 39.0 to 51.8; P < .05). At follow-up, there were no significant differences between the primary and revision groups for the HOS-ADL values (P = .051) and SF-12 PCS values (P = .846). Patients in the primary group had significantly higher HOS-Sport values (P = .008), mHHS values (P = .008), and patient satisfaction (P = .008). Patients who underwent 1 prior hip arthroscopic procedure had a higher mean postoperative mHHS value (79.5 vs 72, respectively), HOS-ADL value (91.2 vs 73.4, respectively), and HOS-Sport value (76 vs 60, respectively) (P < .05) compared with those who underwent more than 1 prior procedure. Median patient satisfaction was 9.0 (range, 2-10) in the primary group and 8.0 (range, 2-10) in the revision group. Conclusion: In conclusion, young patients who required revision hip arthroscopic surgery showed significant improvement in patient-reported outcome scores; however, final outcome scores in the revision group for sport activity, general health, and satisfaction were lower than those in the primary group. Patients who underwent 1 revision surgical procedure had higher outcome scores than patients who underwent more than 1 revision surgical procedure.

Delay to Reconstruction of the Adolescent Anterior Cruciate Ligament: The Socioeconomic Impact on Treatment

Background: A delay in pediatric and adolescent anterior cruciate ligament (ACL) reconstruction is associated with an increase in the number of concomitant meniscal and chondral injuries. Factors that contribute to this delay have not been well described. Hypothesis: Socioeconomic and demographic factors are related to ACL surgery timing. Study Methods: Cohort study; Level of evidence, 3. Methods: All subjects who underwent primary ACL reconstruction at a single tertiary pediatric hospital between 2005 and 2012 were retrospectively reviewed. Variables included concomitant knee injuries (cartilage or meniscus injuries requiring additional operative treatment) and chronologic, demographic, and socioeconomic factors. Multivariable Cox proportional-hazards analyses were used to identify factors related to ACL surgery timing. Results: The mean age of the 272 subjects was 15.2 ± 2.12 years. Time to surgery was significantly different among subjects who required multiple additional surgical procedures at time of ACL reconstruction (median, 3.3 months) compared with subjects with 1 (median, 2.0 months) or no additional injuries (median, 1.6 months). Subjects underwent ACL reconstruction significantly sooner if they were older at the time of injury (hazard ratio [HR], 1.2 per 1 year; 95% CI, 1.1-1.2; P < .0001) or were covered by a commercial insurance plan (HR, 2.0; 95% CI, 1.6-2.6; P < .0001). Median time to ACL surgery was 1.5 months (95% CI, 1.3-1.7) for subjects with commercial insurance plans compared with 3.0 months (95% CI, 2.3-3.3) for subjects with noncommercial insurance coverage. Conclusion: The risk of delayed ACL surgery was significantly higher among pediatric and adolescent subjects who were less affluent, who were covered by a noncommercial insurance plan, and who were younger. This study also confirms previous studies that have reported an association between a delay in ACL surgery and the presence of additional knee injuries requiring operative treatment, accentuating the importance of timely care. Clinical Relevance: Access to care is a current area of research interest and health policy formation. Information in this arena drives 2 important aspects of health: most immediately, care provided to patients, and over a broader scope, the policy that directs health care. The orthopaedic surgeon should be aware of the association between socioeconomic and demographic factors and ACL surgery timing to optimize outcomes.