Michael B. Gottschalk

Subpectoral Biceps Tenodesis for the Treatment of Type II and IV Superior Labral Anterior and Posterior Lesions

Background: Surgical repair remains the gold standard for most type II and type IV superior labral anterior and posterior (SLAP) lesions that fail nonoperative management. However, most recently, there have been data demonstrating unacceptably high failure rates with primary repair of type II SLAP lesions. Biceps tenodesis may offer an acceptable, if not better, alternative to primary repair of SLAP lesions. Hypothesis: Subpectoral biceps tenodesis provides satisfactory, reproducible outcomes for the treatment of type II and type IV SLAP lesions. Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent subpectoral biceps tenodesis and labral debridement for type II and type IV SLAP lesions by a single board-certified shoulder surgeon from 2006 to 2012 were evaluated. Exclusion criteria included those patients who underwent biceps tenodesis with an associated rotator cuff repair, anterior labral repair, or posterior labral repair. Outcome measures included the visual analog scale (VAS) for pain, the American Shoulder and Elbow Surgeons (ASES) score, and demographic data. Results: Between 2006 and 2012, a total of 36 subpectoral biceps tenodesis procedures were performed in 33 patients for type II or IV SLAP lesions. Twenty-six patients with 29 shoulder surgeries were available for follow-up. The average age was 46.7 years, with 16 male and 10 female patients participating in the study. The average follow-up was 40.17 months. There was a significant improvement in ASES and VAS scores: 48.1 and 6.4 preoperatively compared with 87.5 and 1.5 postoperatively, respectively (P < .001). There was no significant difference based on SLAP lesion type, patient age, or patient sex. Of 29 shoulders, 26 (89.66%) were able to return to the previous level of activity. Conclusion: This study adds to the evolving literature supporting biceps tenodesis as a viable treatment for type II and IV SLAP lesions. Patient age had no effect on the outcomes. Based on these results, biceps tenodesis is a safe, effective, and technically straightforward alternative to primary SLAP repair in patients with type II and IV SLAP tears.

Posterior Shoulder Instability: Does Glenoid Retroversion Predict Recurrence and Contralateral Instability?

PURPOSE To determine whether glenoid retroversion is a predictor of posterior shoulder instability, contralateral instability, or recurrent instability in patients with traumatic, contact-related posterior shoulder instability. METHODS Patients who underwent shoulder stabilization by 2 senior orthopaedic sport surgeons were identified retrospectively. Patients with a connective tissue disorder, multidirectional instability, or non-trauma-induced pathology were excluded. Patients with a glenoid lesion involving greater than 25% of the glenoid or an engaging humeral lesion were also excluded. Thus patients with a traumatic injury and a magnetic resonance imaging scan available for review were included. Magnetic resonance imaging scans were reviewed, and glenoid version was measured using the glenoid vault method. Charts were reviewed for epidemiologic data, recurrent instability requiring reoperation, evidence of glenoid/humeral bone lesions, and contralateral shoulder instability requiring surgery. Both recurrence and contralateral injury were defined based on having repeat surgery. RESULTS We identified 143 patients who met the inclusion criteria. Twenty-eight patients had posterior instability, whereas 115 patients had anterior instability. Patients with posterior instability had significantly more glenoid retroversion than patients with anterior instability (-15.4° ± 5.14° v -12.1° ± 6.9°; P < .016). Patients with retroversion of more than -16° showed a higher incidence of contralateral injuries (P < .036). However, no difference in postsurgical recurrent instability was noted. CONCLUSIONS Our data show that patients with posterior instability have a higher incidence of having a retroverted glenoid. Patients with increased retroversion showed increased posterior contralateral instability. Furthermore, patients with posterior instability and no humeral bone lesions may be more likely to incur contralateral injuries than those with humeral lesions. These data suggest that glenoid version and concomitant injury patterns may be used to help physicians counsel patients on their future risks of contralateral injury. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Surgical training using three-dimensional simulation in placement of cervical lateral mass screws: a blinded randomized control trial

BACKGROUND CONTEXT The skills and knowledge that residents have to master has increased, yet the amount of hours that the residents are allowed to work has been reduced. There is a strong need to improve training techniques to compensate for these changes. One approach is to use simulation-training methods to shorten the learning curve for surgeons in training. PURPOSE To analyze the effect of surgical training using three-dimensional (3D) simulation on the placement of lateral mass screws in the cervical spine on either cadavers or sawbones. STUDY DESIGN A blinded randomized control study. METHODS Fifteen orthopedic residents, postgraduate year (PGY) 1 to 6, were asked to simulate Magerl lateral mass screw trajectories from C3-C7 on cadavers using a navigated drill guide, but with no feedback as to the actual trajectory within the bone (Baseline 1). This was repeated to determine baseline accuracy (Baseline 2). They were then randomized into three groups: Group 1, control, did not receive any training, whereas Groups 2 and 3 received 3D navigational feedback as to the intended drill trajectory on sawbones and cadavers, respectively. All three groups then performed final simulated drilling (final test). All 3D images were deidentified and reviewed by a blinded single fellowship-trained orthopedic spine surgeon. Each image/screw was measured for the starting site, caudad/cephalad angle, and medial/lateral angle to determine trajectory accuracy. RESULTS The aggregate mean difference from a perfect screw was compiled for each session for each group. A negative difference shows improvement, whereas a positive difference shows regression. The difference between final test and Baseline 1 in the control group was 2.4°, suggesting regression. In contrast, the differences for groups sawbone and cadaver were -8.2° and -7.2°, respectively, suggesting improvement. When comparing the difference in aggregate sum angle for the sawbones and cadaver groups with the control group, the difference was statistically significant (p<.0001). CONCLUSIONS Training with 3D navigation significantly improved the ability of orthopedic residents to properly drill simulated lateral mass screws. As such, training with 3D navigation may be a useful adjunct in resident surgical education.

Humeral Shaft Fracture Fixation: Incidence Rates and Complications as Reported by American Board of Orthopaedic Surgery Part II Candidates.

BACKGROUND Despite extensive research regarding patient outcomes after operative fixation of humeral shaft fractures by means of open reduction and internal fixation (ORIF) or intramedullary nailing (IMN), no current consensus exists regarding the optimal surgical treatment. The objective of this study was to compare IMN and plate fixation (ORIF) of humeral shaft fractures by using the American Board of Orthopaedic Surgery (ABOS) Part II operative database to analyze incidence rates, changes in management trends over time, early complications, and factors affecting the management choice. METHODS The ABOS database is a collection of surgical cases that are self-reported by orthopaedic candidates approved for admission to the ABOS oral examination. The database was searched for records from 2004 to 2013 for humeral shaft surgical cases as indicated by Current Procedural Terminology (CPT) codes 24515 (open reduction internal fixation) and 24516 (insertion of intramedullary nail) pertaining to humeral shaft fractures. The geographic region and fellowship training of the candidates; the year of surgery, diagnosis code, age, and sex of the patients; and the surgeon-reported complications were analyzed. RESULTS The search identified 3,430 surgically treated humeral shaft fractures that were reported to the ABOS database from 2004 to 2013. A significant decline in IMN use was seen from 2004 (42.9%) to 2013 (21.2%, p < 0.001). The IMN cohort had lower complication rates pertaining to both infections (1.5% compared with 3.0% for ORIF, p = 0.007) and nerve palsies (3.1% compared with 7.8%, p < 0.001). No significant difference was seen in the rate of nonunion (1.3% for IMN compared with 1.6% for ORIF, p = 0.63), although follow-up may be too short to demonstrate a difference. The IMN cohort did have significantly higher mortality (4.9% compared with 0.7% for ORIF, p < 0.001). Subset analysis demonstrated that the IMN cohort had significantly more pathologic fractures (26.8% compared with 1.5% of the fractures treated with ORIF, p < 0.001). CONCLUSIONS Although the overall incidence of fixation of humeral shaft fractures was unchanged from 2004 to 2013, there was a significant shift from IMN to ORIF using plate fixation during this time period. Possible reasons for this shift in treatment to ORIF include the potential impact of recent publications highlighting complications of IMN and increased surgeon attention to cost containment. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Decreased infection rates following total joint arthroplasty in a large county run teaching hospital: a single surgeon's experience and possible solution.

Total joint arthroplasty is a common orthopaedic procedure producing valuable improvements in patients quality of life. A dreaded complication of this procedure is deep seated, periprosthetic infection. This complication can lead to multiple reoperations and upwards of

Carpal Coalitions and Metacarpal Synostoses A Review

100,000 of increased cost burden. At one 900 bed county run teaching hospital, with a historically high infection rate in total joints, the total joint service was closed and restarted using a new protocol, dropping infection rates from 12.9% to 1.9% (P = 0.007).

Effect of a Dedicated Orthopaedic Advanced Practice Provider in a Level I Trauma Center: Analysis of Length of Stay and Cost.

Background: Carpal coalition and metacarpal synostosis are uncommon congenital anomalies of the carpus and hand. Methods: A comprehensive review of the literature was performed to help guide surgical and non-surgical treatment of carpal coalition and metacarpal synostosis. Results: The embryology, epidemiology, medical and surgical management, and associated outcomes are detailed. Conclusions: Most patients with these disorders will likely benefit from conservative measures. Surgery should be considered in patients with pain and limitations in wrist and hand function.

Factors Affecting Hand Surgeon Operating Room Turnover Time

Objectives: The objective of this study is to analyze the effect of an orthopaedic trauma advanced practice provider on length of stay (LOS) and cost in a level I trauma center. The hypothesis of this study is that the addition of a single full-time nurse practitioner (NP) to the orthopaedic trauma team at a level I Trauma center would decrease overall LOS and hospital cost. Methods: A retrospective chart review of all patients discharged from the orthopaedic surgery service 1 year before the addition of a NP (pre-NP) and 1 year after the hiring of a NP (post-NP) were reviewed. Chart review included age, gender, LOS, discharge destination, intravenous antibiotic use, wound VAC therapy, admission location, and length of time to surgery. Statistical analysis was performed using the Wilcoxon/Kruskal–Wallis test. Results: The hiring of a NP yielded a statistically significant decrease in the LOS across the following patient subgroups: patients transferred from the trauma service (13.56 compared with 7.02 days, P < 0.001), patients aged 60 years and older (7.34 compared with 5.04 days, P = 0.037), patients discharged to a rehabilitation facility (10.84 compared with 8.31 days, P = 0.002), and patients discharged on antibiotics/wound VAC therapy (15.16 compared with 11.24 days, P = 0.017). Length of time to surgery was also decreased (1.48 compared with 1.31 days, P = 0.37). Conclusions: The addition of a dedicated orthopaedic trauma advanced practice provider at a county level I trauma center resulted in a statistically significant decrease in LOS and thus reduced indirect costs to the hospital. Level of Evidence: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Early Complications Following Osteosynthesis of Distal Radius Fractures: A Comparison of Geriatric and Nongeriatric Cohorts

Background: The purpose of this study was to determine the factors that affect hand surgeon operating room (OR) turnover time. We hypothesized that surgeon presence in the OR, decreased American Society of Anesthesiologists (ASA) class, smaller case type, and earlier case time, as well as other factors, decreased OR turnover time. Methods: A total of 685 hand surgery cases performed by 5 attending hand surgeons between September 2013 and December 2014 were identified. Turnover time, patient comorbidities (ASA class), surgeon, prior OR surgical procedure, current OR surgical procedure, location of the surgery (ambulatory surgical center [ASC] vs orthopedic specialty hospital [OSH]), time of surgery, and order of OR cases were recorded. The effect of surgeon routine variables, OR case factors, and patient health status on OR turnover was analyzed. Results: Turnover time was significantly shorter in cases where the surgeon remained in the OR during turnover (27.5 minutes vs 30.4 minutes) and when the surgeon incentivized OR staff (24 minutes vs 29 minutes). The ASC was found to have shorter turnover times than the OSH (27.9 minutes vs 36.4 minutes). In addition, ASA class, type of prior OR procedure, type of current OR procedure, and case order all significantly affected turnover time. Comparison of OR turnover time among the 5 surgeons revealed a statistically significant difference at the OSH but not at the ASC. Conclusion: OR turnover time is significantly affected by surgeon routine, location of surgery, patient ASA class, procedure type, and case order. Interestingly, the effect of hand surgeon routine on OR turnover time may be amplified at an academic OSH versus an ASC.

National Trends in Carpal Tunnel Release and Hand Fracture Procedures Performed During Orthopaedic Residency: An Analysis of ACGME Case Logs

Background: Distal radius fractures (DRFs) are common geriatric fractures with the overall incidence expected to increase as the population continues to age. The purpose of this investigation was to compare the short-term complication rates in geriatric versus nongeriatric cohorts following osteosynthesis of DRFs. Methods: The American Board of Orthopaedic Surgery (ABOS) part II database was queried for adult DRF cases performed from 2007 to 2013. Current Procedural Terminology codes were used to identify cases treated via osteosynthesis. Patient demographic information and reported complication data were analyzed. Comparisons between geriatric (age ≥65 years) and nongeriatric (age <65 years) patients were performed. Results: From 2007 to 2013, a total of 9867 adult DRFs were treated via osteosynthesis by ABOS part II candidates. Geriatric patients comprised 28% of the study cohort. Mean age of the geriatric and nongeriatric cohorts was 74 ± 7 and 46 ± 13 years, respectively. There was a greater proportion of female patients (P < .001) in the geriatric cohort as compared with the nongeriatric cohort. The geriatric cohort demonstrated higher rates of anesthetic complications (P = .021), iatrogenic bone fracture (P = .021), implant failure (P = .031), loss of reduction (P = .001), unspecified medical complications (P = .007), and death (P = .017) than the nongeriatric cohort. The geriatric cohort also showed lower rates of nerve palsy (P = .028) when compared with the nongeriatric cohort, though no differences in rates of secondary surgery were noted between the two cohorts. Conclusion: Increased rates of complications related to poor bone quality and poor health status may be expected among geriatric patients following osteosynthesis of DRFs. However, geriatric and nongeriatric patients have similarly low rates of secondary surgery. Future studies are needed to delineate the economic, functional, and societal impact of geriatric DRFs treated via osteosynthesis.