Fellowship-trained Orthopaedic Surgeons Research Articles

The critical shoulder angle (CSA) in glenohumeral osteoarthritis: Does observer experience affect measurement reliability on plain radiographs?

BackgroundThe critical shoulder angle (CSA) has been associated with full-thickness rotator cuff tears both in the presence and absence of glenohumeral arthritis. It is unclear whether the CSA can be reliably measured from plain radiographs of concentric glenohumeral osteoarthritis amongst examiners at differing levels of training. MethodsWe retrospectively reviewed the radiographs of consecutive patients who underwent shoulder arthroplasty for glenohumeral osteoarthritis. The CSA was measured on a standardized AP scapular view at baseline and then 4 weeks later by fellowship-trained orthopaedic surgeons, a shoulder fellow and a senior orthopaedic resident. Grade of arthritis was categorized using the Samilson and Prieto method. The inter- and intra-observer reliability was then determined for all examiners, as well as for increasing severity of radiographic arthritis. The relationship between the CSA and grade of arthritis was assessed. ResultsThere were 166 included patients comprised of 104 females (63%) and 62 males (37%) with a mean age of 65.9 ± 10.4 years. The inter- and intra-observer reliability for measuring the CSA amongst all examiners was found to be excellent, with an intra-class coefficient (ICC) of >0.9 (p < 0.0001). The ICC remained excellent even amongst radiographs with more advanced arthritis. Furthermore, there was a weak, inverse relationship between the grade of arthritis and the CSA (r = −0.377, p < 0.005). ConclusionThe CSA can reliably be measured by examiners at varying levels of orthopaedic training, even with more advanced radiographic glenohumeral osteoarthritis. Level of evidence: Level III (Prognostic).

The Utilization of Physician Cell Phone Numbers by Patients in an Orthopaedic Surgery Practice.

IntroductionOrthopaedic surgeons choose to manage communication with their patients outside of official visits and interactions in a variety of ways, with some choosing to provide their personal cell phone number in order to provide patients with direct accessibility. The objective of this prospective study is to explore to what extent patients utilize the cell phone numbers of orthopaedic surgeons in the immediate period after it is provided to them.MethodsSeven fellowship-trained orthopaedic surgeons from five different subspecialties in a single private, multi-site group each provided his/her personal cell phone number to 30 consecutive patients. The surgeon’s phone number was written down on a business card, and the surgeons themselves provided the card to the patient. Phone calls and voice mail messages received in the 30 days following the patient receiving the phone number were recorded, and the reasons for these calls were categorized as being “appropriate” (e.g. acute postoperative issues, unclear instructions) or “inappropriate” (e.g. administrative issues, medication refills, advanced imaging-related inquires).ResultsTwo-hundred seven patients with an average age of 51.5 years were provided cell phone numbers. During the 30 days following administration of cell phone numbers to each patient, 21 patients (10.1%) made calls to their surgeons, for an average of 0.15 calls per patient. Six patients (2.9%) called their surgeons more than once. Seventeen calls (54.8%) were deemed appropriate, while 14 calls (45.2%) were inappropriate. Logistic regression analysis did not reveal patient age, sex, type of visit, or surgeon subspecialty to be independently associated with calling.ConclusionOur study has demonstrated a low rate of patient utilization of surgeon cell phone number when provided to them. If surgeons choose to provide their cell phone number to patients, we recommend specifying appropriate reasons to call in order to maximize the effectiveness of this communication method.

ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION IN ≤21 YEAR OLDS: PATELLAR VERSUS HAMSTRING TENDON AUTOGRAFTS

Background:Bone-patellar tendon-bone (BTB) and hamstring tendon (HS) are commonly used grafts for anterior cruciate ligament reconstruction (ACLR). The optimal graft choice for ACLR remains unclear. We evaluated clinical and self-reported outcomes of patients who underwent ACLR with use of a BTB autograft or double-bundle HS autograft/allograft-augmented HS autograft (HS hybrid).Hypothesis/Purpose:No significant differences in outcomes exist between graft choices.Methods:Retrospective review of prospectively collected data from patients aged ≤21 years who underwent primary ACLR with BTB or HS autograft/hybrid by one fellowship-trained orthopaedic surgeon and a minimum of 6 months follow-up. Demographics, injury characteristics, concomitant injuries, surgical and radiographic parameters were recorded. Clinical and patient self-reported outcomes (Tegner-Lysholm, pediIKDC, KOOSChild) were compared at 6-months, 1-year and latest follow-up.Results:A total of 109 subjects were included; 59 had a HS graft (55 HS autograft, 4 HS hybrid) and 50 a BTB autograft. Patients were between 13 and 21 years old at ACLR and had a follow-up of 1.5 ±1 year. Baseline comparison of demographic, injury and surgical parameters is presented in Table1.1.Graft rupture occurred in 10 patients (9.2%; 9 males and 1 female) at an average of 2 years after initial ACLR; 8 graft ruptures occurred in the HS group (13.6%, none in HS hybrids) and 2 in the BTB group (4%) (p=0.105). Parameters increasing the likelihood of a re-tear were older age at ACLR (HR: 2.348, p<0.005), a >1-year delay to surgery (HR: 4.105, p=0.048) and a concomitant chondral injury (HR: 5.476, p=0.038) (Cox proportional hazards model, Table1.2).Arthrofibrosis developed in 4 BTB patients (8%) at an average of 6 months after initial ACLR, but not in HS patients (p=0.041). At most recent follow-up, patellofemoral pain was present in 15 (28%) HS and 5 (10%) BTB patients (p=0.027) and a contralateral ACL tear had occurred in 4 patients (3.7%). No differences were seen between graft groups for knee range of motion, Lachman testing, leg raise, ligament stability and subjective scores - Tegner-Lysholm, pediIKDC, KOOSChild (p>0.05 for each comparison at 6-months, 1-year and most recent follow-up).Conclusion:In patients <21 years undergoing ACLR, BTB autograft lead to fewer graft ruptures, however, was associated with a higher rate of arthrofibrosis. Older age at surgery, a delay to surgery and chondral injuries increased the likelihood of re-tear. However, failure rates were low, and we observed no differences between graft types in terms of laxity and patient self-reported outcomes.Tables/Figures:Table 1.DemographicsHS, N=59BTB, N=50P-ValueGender, Female23 (39%)22 (44%) 0.697 Age at Surgery, years16.7 ± 1.6116.5 ± 1.33, 0.382 BMI25.2 ± 4.026.9 ± 5.3 0.146 Follow-up time, years1.84 ± 1.19, range 0.5-4.81.11 ± 0.70, range 0.5-4.21 <0.005 Injury Parameters Time Injury to Surgery, years0.41 ± 0.34, range 0.07-1.650.52 ± 0.52, range 0.09-2.520.477Laterality, Right33 (56%)25 (50%)0.568Meniscus tear, yes35 (59%)40 (80%) 0.024 Chondral Injury, yes22 (37%)16 (32%)0.687 Surgical Parameters Graft Size, mm8.6 ± 0.62, range 8-1010 ± 0.1, range 9.5-10 <0.005 Fem. Tunnel Diameter, mm8.6 ± 0.610 ± 0 <0.005 Femoral Tunnel Depth, mm29.9 ± 4.227.8 ± 1.2 0.014 Tibial Guide Angle, °55.2 ± 1.0, range 55-6058.1 ± 2.7, range 50-65 <0.005 Tibial Tunnel Diameter, mm8.6 ± 0.610 ± 0.1 <0.005 Meniscus surgery 0.050 None25 (42.4%)10 (20%) Meniscectomy12 (20.3%)15 (30%) Repair22 (37.3%)25 (50%) Chondroplasty, yes6 (10%)9 (18%) 0.274 Notchplasty, yes7 (12%)7 (14%) 0.782 Radiographic parameters Femoral Tunnel Angle, °34.6 ± 6.331.7 ± 8.3 0.064 Tibial Tunnel Angle, °64.8 ± 7.368.4 ± 7.3 0.011 PDFA, °87.3 ± 3.786.9 ± 4.20.582 Data are presented as Mean ± SD or N (%) Differences in demographic, injury, surgery and radiographic parameters between the two graft groups were compared using t-tests or Wilcoxon rank-sum tests for con.tinuous variables and chi-square or Fisher’s exact tests for categorical variables Table 2.Factors associated with time to graft ruptureDemographicsHazard Ratio95% CIP-valueGender, Male5.8880.728, 47.63 0.097 Age at Surgery, years2.3481.439, 3.831 <0.005 BMI0.9860.844, 1.153 0.863 Injury Parameters Time Injury to Surgery, ref within 0.5 years > 1 year4.1051.010,16.69 0.048 Meniscus tear, yes4.0290.499, 32.55 0.191 Chondral Injury, yes5.4761.102, 27.22 0.038 Surgical Parameters Graft type, reference HS0.9020.176, 4.629 0.902 Graft Size, mm1.2850.549, 3.007 0.563 Fem. Tunnel Diameter, mm1.2900.550, 3.022 0.558 Femoral Tunnel Depth, mm0.9750.824, 1.155 0.771 Tibial Guide Angle, °1.1760.791, 1.748 0.422 Tibial Tunnel Diameter, mm1.1010.497, 2.442 0.812 Meniscus surgery, reference none Meniscectomy5.3660.595, 48.41 0.134 Repair3.5900.397, 32.48 0.255 Chondroplasty, yes2.7660.300, 25.49 0.369 Notchplasty, yes0.5050.061, 4.152 0.525 Radiographic Parameters Femoral Tunnel Angle, °0.9640.865, 1.074 0.504 Tibial Tunnel Angle, °1.0820.980, 1.194 0.120 PDFA, °0.8710.723, 1.048 0.143 Cox proportional hazards models were used to examine associations of demographic, injury, surgery and radiographic factors with time to graft rupture.

Influence of First Metatarsophalangeal Joint Degenerative Changes on Functional Outcomes Following Hallux Valgus Correction

Category:Bunion; OtherIntroduction/Purpose:Previous studies have documented the prevalence of 1st metatarsophalangeal (MTP) joint arthritis in the setting of hallux valgus, with the articulation between the metatarsal head and the sesamoids being particularly vulnerable.However, little is known as to whether such degenerative changes of the metatarsal head-sesamoid articulation have any influence on postoperative functional and pain scores following hallux valgus correction. The purpose of this study is to determine the influence of degenerative changes of the 1st metatarsal head on outcomes at 2 years postoperatively.Methods:Patients who underwent correction of a hallux valgus deformity from 2016 to 2017 with 1 of 4 foot and ankle fellowship-trained orthopaedic surgeons were included in this study. Degenerative changes were classified using a novel grading system dividing the articular surface of the metatarsal head into 6 zones, with zones 1 through 4 representing the surface which articulates with the base of the proximal phalanx and zones 5 and 6 representing the plantar aspect of the metatarsal head.Cartilage loss in each zone was graded from 0-2, with a score of 0 representing the absence of arthritis, a score of 1 indicating fissures without exposed bone, and a score of 2 representing degenerative changes with exposed bone, for a maximum score of 12. Scoring was performed by the operating surgeon at the time of the index procedure by direct visualization. Photographic documentation of the metatarsal head was obtained in every case for secondary confirmation. At 2 years postoperatively, patients with intraoperative grading were contacted to complete the Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) and Sports subscales and Visual Analog Scale (VAS) for pain. Spearman’s correlations and one-way ANOVA were performed to determine if the degree of arthritis had any influence on outcomes.Results:Seventy-six patients (92.1% female) with both intraoperative arthritic grading and 2-year functional outcomes were included. At a mean of 24.6 (range, 23-28) months postoperatively, patients reported a mean (+- standard deviation) FAAM-ADL of 93.0 +- 11.9/100, FAAM-Sport of 84.8 +- 21.4/100, and VAS pain of 16.8 +- 22.2/100. Arthritis in zone 1 (r=0.345, p= 0.005) and zone 4 (r=0.249, p=0.044) was found to be positively correlated with FAAM-Sport scores. ANOVA analysis revealed those with a total arthritis grade of 0 or 2 or more in zones 1-4 had a significantly greater reduction in VAS pain scores (means of -36.5 and -48.1, respectively) than those with a grade of 1 (mean: +5.0) (p=0.005).Conclusion:We have demonstrated a significant influence of arthritis on 2-year functional outcomes following HV correction, with higher levels of degenerative changes in zones 1 and 4 generally associated with better functional outcomes. While this finding was unexpected, it demonstrates that those with arthritis may benefit more from surgical correction of HV. Furthermore, surgeon intraoperative evaluation of arthritis may allow for improved counseling of patients regarding expected postoperative functional improvement.

The outcome for surgical fixation of distal radial fractures in patients with idiopathic Parkinson\u2019s disease: a cohort study

IntroductionIdiopathic Parkinson’s disease (PD) is a progressive neurologic disorder causing postural instability and unsteady gait. These patients are at increased risk for fractures and have inferior outcomes after treatment. Several studies have evaluated the incidence and outcome of PD patients after hip fractures. However, there are limited studies assessing the outcome of upper extremity fractures in these patients. In this study, we evaluated the outcome of PD patients that received surgical intervention for distal radial fractures (DRF). We hypothesize that these patients have an inferior outcome after surgery in comparison with non-PD patients.MethodsBetween May 2005 and May 2017, we retrospectively reviewed all of the patients with DRF and subsequently underwent open reduction and internal fixation (ORIF) at a level 1 trauma center. All of the surgeries were performed by fellowship-trained orthopedic surgeons. The inclusion criteria include patients with a definitive diagnosis of PD, non-pathological DRF, and a minimum follow-up of 1 year or up until the time of treatment failure was noted. Each PD patient was matched for age and gender to 3 non-PD patients. The primary objective was to determine the failure rate after surgical fixation for DRF. The secondary outcomes include time to treatment failure, reoperation rate, readmission rate, length of hospital stay, and postoperative complications.ResultsA total of 88 patients were included in this study (23 PD, 65 non-PD patients). All underwent ORIF and received standard postoperative follow-ups. The overall treatment failure rate in PD was 39.1% vs. 4.6% in the non-PD group (p < 0.05). The time to treatment failure were 9.11 ± 3.86 weeks and 14.67 ± 5.8 weeks for PD and non-PD, respectively (p < 0.05). PD patients had a significantly higher rate of failure when k-wires and ESF were used (p < 0.05%), while loss of reduction was the most common mode of failure in PD (44.4%). The length of hospital stay for PD was 5.3 ± 4.69 days compared with 3.78 ± 0.96 days for non-PD (p = 0.01). There were 3 PD patients readmitted within 30 days after surgery, and 1 patient had pneumonia after the surgery.ConclusionThis study revealed that patients with PD have a high treatment failure rate despite surgical intervention for DRF. PD patients had a longer hospital stay and had a shorter time to treatment failure. In treating PD patients complicated with DRF, the surgeon must take into consideration the complex disease course of PD and the associated comorbidities such as osteoporosis, frail status, and frequent falls. Rehabilitation and disposition plans should be discussed in advance and longer hospital stays should be expected.Level of evidenceLevel IV, retrospective cohort study

Medial patellofemoral ligament reconstruction with allograft versus autograft tissue results in similar recurrent dislocation risk and patient-reported outcomes

To determine the rate of recurrent dislocation and patellar instability following medial patellofemoral ligament (MPFL) reconstruction with allograft or autograft tissue and compare patient-reported outcomes for patients undergoing allograft and autograft MPFL reconstruction. One hundred and fifteen MPFL reconstructions (78 allograft, 37 autograft) without concurrent bony procedures performed between 2008 and 2014 by four sports medicine fellowship-trained orthopedic surgeons at our center were identified. Patient demographics and surgical data were identified by chart review. Chart review and patient interviews were undertaken to identify recurrent patellar dislocations and as recurrent subjective patellofemoral instability. Recurrent dislocation and subjective instability risk were compared between the allograft and autograft groups. Eighty-seven patients (76%) with complete baseline data and minimum 1-year follow-up were contacted at a mean of 4.1years following isolated MPFL reconstruction, including 57 patient with allograft reconstructions and 30 with autograft reconstructions. No significant differences in patient sex, age at reconstruction, body mass index, or time to follow-up were noted between groups. Recurrent dislocation occurred in 2 patients in the allograft group (3.5%) and 1 patient in the autograft group (3.3%), (n.s.). Recurrent subjective instability occurred in 17 patients in the allograft group (28.9%) and 11 patients in the autograft group (36.7%), (n.s.). No significant differences in patient-reported outcomes were noted between groups. The use of either allograft or autograft tissue for MPFL reconstruction results in low (< 3%) risk of recurrent patellar dislocation. Risk of recurrent subjective instability is higher but is similar for both graft types. Surgeons can utilize either graft choice at their discretion without anticipating a significant impact of graft choice on patient outcomes. III.

Surgical Release of the Adductor Longus With or Without Sports Hernia Repair Is a Useful Treatment for Recalcitrant Groin Strains in the Elite Athlete.

Background:Chronic strain and/or tendinopathy of the adductor longus tendon can be a cause of long-standing groin pain in the elite athlete, resulting in significant time lost from competition. Accurate diagnosis and treatment can expedite return to play.Purpose/Hypothesis:To evaluate return to sport and performance in National Collegiate Athletic Association (NCAA) Division I football players and National Football League (NFL) players following adductor longus release with or without sports hernia repair. We hypothesized that adductor release will be an effective method of treatment for recalcitrant groin/adductor pain in these athletes.Study Design:Case series; Level of evidence, 4.Methods:A cohort study was performed of all NFL players and NCAA Division I college athletes who had undergone an adductor longus tendon release with or without sports hernia repair by 1 of 2 fellowship-trained orthopaedic surgeons between May 1999 and January 2013. All patients reported groin pain below the inguinal ligament and localized to their adductor longus. Symptoms lasted longer than 10 weeks and limited their ability to effectively perform during sport, as assessed by their coach and self-assessment. Questionnaires were given to all 26 patients to assess long-term surgical outcomes. A subgroup analysis was performed for NFL players, in which “performance scores” were calculated according to individual player statistics while playing. Scores obtained before the diagnosis of chronic adductor longus tendinopathy or strain were compared with those after surgery. Patients with prior abdominal or pelvic surgery, radiographic evidence of degenerative joint disease of the hip, labral tears or femoral acetabular impingement, prostatic or urinary tract disease, or nerve entrapment of the ilioinguinal, genitofemoral, or lateral femoral cutaneous nerves were excluded from the study.Results:A total of 32 athletes underwent an adductor longus tenotomy during the study period. Of these patients, 28 were college- or professional-level athletes who underwent an adductor longus tenotomy, with a mean ± SD follow-up time of 6.2 ± 4.2 years (range, 12-178 months). Of the 32 patients, 20 had a concomitant sports hernia repair in addition to an adductor longus tenotomy. Thirty-one patients (97%) were able to return to their previous sport, and 30 (94%) were able to return at their previous level of play. Thirty patients (94%) reported that they were satisfied with their decision to have surgery. No player complained of weakness or a decrease in running speed or power. Mean return to play was 12 weeks from date of surgery. In the subgroup analysis of 16 NFL players, there were no statistically significant differences for the pre- versus postoperative comparisons of the athlete performance scores (P = .74) and the percentage of the games started versus played (P = .46). After separation of players who had a concomitant hernia repair from players who did not, there was no statistically significant difference in performance scores or percentages of games started.Conclusion:In this study of elite athletes, adductor longus tenotomy with or without a concomitant sports hernia repair provided overall acceptable and excellent results. Athletes were able to return to their previous level of athletic competition and performance with consistent relief of groin pain. Return to play in an NFL game averaged 12 weeks following surgery.

The Influence of Lumbosacral Spine Pathology on Minimum 2-Year Outcome After Hip Arthroscopy: A Nested Case-Control Analysis

Background: Previous literature has examined the association between lumbosacral pathology and hip pathomechanics. However, the effect of lumbosacral pathologies and previous lumbosacral surgery on achieving meaningful outcomes after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) has yet to be studied conclusively. Purpose: To determine whether a history of lumbosacral spine pathology has an influence on achieving minimal clinically important differences (MCIDs) after hip arthroscopy for FAIS. Study Design: Cohort study; Level of evidence, 3. Methods: Patients undergoing hip arthroscopy for FAIS by a single, fellowship-trained orthopaedic surgeon between January 2012 and April 2017 with minimum 2-year follow-up were retrospectively reviewed. Patients with a history of lumbosacral spine pathology (eg, lumbosacral fusion, disc or vertebral pathology, or history of lumbosacral fractures) were matched 1:2 by age, body mass index, and sex to patients without spine pathology. Clinical outcomes including the Hip Outcome Score–activities of daily living subscale (HOS-ADL), HOS–sports subscale (HOS-SS), modified Harris Hip Score (mHHS), international Hip Outcome Tool–12 (iHOT-12), visual analog scale (VAS) pain, and VAS satisfaction were compared between the groups using an independent t test. The threshold of every outcome score for achieving MCID was calculated separately for each group and frequencies were compared. Results: A total of 83 of 108 eligible patients with lumbosacral pathology were identified and matched to 166 patients without any spine pathology. When compared with the non–spine pathology group, the lumbosacral pathology group had significantly lower 2-year postoperative outcome score averages across all reported outcome tools (all P < .001). There were significant differences in the proportion achieving the threshold for HOS-ADL (60.6% vs 80.0%; P = .004), HOS-SS (57.6% vs 82.1%; P < .001), mHHS (66.7% vs 81.7%; P = .025), and iHOT-12 (54.8% vs 87.6%; P < .001) scores for MCID when comparing the lumbosacral and nonlumbosacral pathology groups. Conclusion: Patients with a history of lumbosacral pathology achieved significantly lower short-term meaningful clinical outcomes after undergoing hip arthroscopy for FAIS when compared with patients without spine pathology. The present study findings have implications for preoperative patient screening, shared decision-making processes/expectation management, and rehabilitation strategies.

Surgical Trends in the Treatment of Supracondylar Humerus Fractures in Early Career Practice: An American Board of Orthopaedic Surgery (ABOS) Part-II Database Study.

Pediatric supracondylar humerus fractures are the most common elbow injury in children, accounting for 12% to 17% of all childhood fractures. A lack of information exists regarding complication rates on the basis of fellowship status and geography. The American Board of Orthopaedic Surgery (ABOS) Part-II database was used to identify candidates who performed either percutaneous or open treatment of humeral supracondylar or transcondylar fractures between 2002 and 2016 on patients aged 0 to 12 years. Candidates were categorized by fellowship training experience. Information analyzed included fellowship status, surgical procedure, complications, and geographic location of treatment. Data were analyzed utilizing the χ and Fischer exact tests and were considered significant if P≤0.05. A total of 9169 cases (mean, 5.36+2.27 y; range, 0 to 12) were identified between 2002 and 2016, 8615 of which were treated with closed reduction and percutaneous pinning, whereas 554 were treated with an open procedure. The 5 most common fellowships treating these fractures were listed as pediatrics (4106), sports medicine (1004), none (912), trauma (732), and hand/upper extremity (543). Pediatrics performed the highest number of open reduction and internal fixation (ORIF), however, reported the statistically lowest percentage of ORIF. A statistically significant difference was identified between surgical complication rates and fellowship specialties, with pediatrics having the lowest complication rate (7.0%), followed by no fellowship (8.2%), trauma (9.0%), sports medicine (9.8%), and hand/upper extremity (11.2%) (P<0.001). This significant difference was also present when analyzing closed reduction and percutaneous pinning alone (P=0.002), however, not with the analysis of ORIF. Early career pediatric fellowship-trained orthopaedic surgeons are more likely to treat pediatric supracondylar humerus fractures. Overall, although they treat more patients with ORIF than any other group, their percentage treated with ORIF is statistically the lowest. A significant difference in reported complication rates was found to be associated with specific fellowship training, with pediatric fellowship-trained surgeons having the fewest complications and foot/ankle fellowship-trained surgeons associated with the highest rate of reported surgical complications. Level III-retrospective cohort study.

Validation of a novel hip arthroscopy simulator: establishing construct validity.

Hip arthroscopy (HA) is technically demanding and associated with a prolonged learning curve. Recently, arthroscopic simulators have been developed to anatomically model various joints including the knee, shoulder and hip. The purpose of this study is to validate a novel HA simulator. Twenty trainees and one sports medicine fellowship-trained orthopaedic surgeon at a single academic institution were recruited to perform a diagnostic HA procedure using the VirtaMed ArthroS hip simulator. Trainee characteristics, including level of training, general arthroscopy experience and hip specific arthroscopy experience, were gathered via questionnaire. For the purpose of this study, participants were categorized as novice (<25), intermediate (25–74) or experienced (≥75) based on the number of prior arthroscopies performed. Various performance metrics, including composite score, time and camera path length were recorded for each attempt. Metrics were analyzed categorically using ANOVA tests with significance set to P < 0.05. Composite performance score in the novice cohort was 114.5 compared with 146.4 and 151.5 in the intermediate and experienced cohorts (P = 0.0019), respectively. Novice arthroscopists performed the simulated diagnostic arthroscopy procedure in an average time of 321 s compared with 202 s and 181 s in the intermediate and experienced cohorts (P < 0.002), respectively. Cartilage damage and simulator safety score did not differ significantly between groups (P = 0.775). Simulator composite score and procedure time showed strong correlation with year of training (r = 0.65 and −0.70, respectively) and number of arthroscopies performed (r = 0.65 and −0.72). The ArthroS hip simulator shows good construct validity and performance correlates highly with total number of arthroscopic cases reported during training.

Atypical Hip Pain in Femoroacetabular Impingement: A Comparison of Outcomes Based on Primary Hip Pain Location

Background: Patients with symptomatic femoroacetabular impingement (FAI) typically have anterior groin pain. However, a subset of these patients may have pain located laterally, posteriorly, or in a combination of locations around the hip. Purpose: To report and compare outcomes of hip arthroscopy for patients with FAI and atypical hip pain versus classic anterior groin pain. Study Design: Cohort study; Level of evidence, 2. Methods: Consecutive patients undergoing hip arthroscopy for FAI between August 2011 and March 2013 were identified. A total of 258 patients were identified as having symptomatic FAI based on clinical, radiographic, and advanced imaging diagnosis of FAI. Exclusion criteria included isolated thigh, knee, or low back pain. We also excluded patients with hip abductor pathology and trochanteric bursitis. Of the 226 patients ultimately included, 159 (70.4%) reported anterior groin pain, while 67 (29.6%) reported isolated lateral or posterior hip pain or a combination of locations. Patients were categorized into 4 groups: isolated anterior groin pain, lateral hip pain, posterior hip pain, and multiple primary hip pain locations (combined). These patients were followed prospectively with a minimum follow-up of 2 years. Patient characteristics, surgical characteristics, modified Harris Hip Score (mHHS), Non-arthritic Hip Score (NAHS), revision hip arthroscopy, and conversions to total hip arthroplasty (THA) were recorded. Results: All 226 patients were included at final follow-up. Hip arthroscopy was performed by a single sports medicine fellowship-trained orthopaedic surgeon. Preoperative patient characteristics and baseline functional outcome scores did not significantly differ among groups. All 4 groups showed statistically significant improvements in mHHS and NAHS from baseline to final follow-up of a mean 2.63 years (range, 2.01-3.23 years). Functional outcome scores and rates of revision hip arthroscopy or conversion to THA did not significantly differ between groups. Conclusion: Hip arthroscopy can effectively improve patient outcomes in atypical hip pain. A careful history and physical examination should identify this clinically meaningful subset of patients with FAI who can benefit from surgical intervention while identifying patients with concomitant posterior extra-articular hip or spine pathology that should be addressed appropriately.

Increased Radiographic Posterior Tibial Slope Is Associated With Subsequent Injury Following Revision Anterior Cruciate Ligament Reconstruction.

Background:Increased posterior tibial slope has been identified as a possible risk factor for injury to the anterior cruciate ligament (ACL) and has also been shown to be associated with ACL reconstruction graft failure. It is currently unknown whether increased posterior tibial slope is an additional risk factor for further injury in the context of revision ACL reconstruction.Purpose:To determine the relationship between posterior tibial slope and further ACL injury in patients who have already undergone revision ACL reconstruction.Study Design:Cohort study; Level of evidence, 3.Methods:A total of 330 eligible patients who had undergone revision ACL reconstruction between January 2007 and December 2015 were identified from a clinical database. The slope of the medial and lateral tibial plateaus was measured on perioperative lateral radiographs by 2 fellowship-trained orthopaedic surgeons using a digital software application. The number of subsequent ACL injuries (graft rupture or a contralateral injury to the native ACL) was determined at a minimum follow-up of 2 years (range, 2-8 years). Tibial slope measurements were compared between patients who sustained further ACL injury to either knee and those who did not.Results:There were 50 patients who sustained a third ACL injury: 24 of these injuries were to the knee that underwent revision ACL reconstruction, and 26 were to the contralateral knee. Medial and lateral slope values were significantly greater for the third-injury group compared with the no–third injury group (medial, 7.5° vs 6.3° [P = .01]; lateral, 13.6° vs 11.9° [P = .001]).Conclusion:Increased posterior tibial slope, as measured from lateral knee radiographs, was associated with increased risk of graft rupture and contralateral ACL injury after revision ACL reconstruction. This is consistent with the concept that increased posterior slope, particularly of the lateral tibial plateau, is an important risk factor for recurrent ACL injury.

Is There Value in Subspecialty Training? Comparison of Differences in Outcomes between Fellowship-Trained Orthopaedic Foot and Ankle Surgeons and All Other Orthopaedic Surgeons Using the American Board of Orthopaedic Surgery Database

Is There Value in Subspecialty Training? Comparison of Differences in Outcomes between Fellowship-Trained Orthopaedic Foot and Ankle Surgeons and All Other Orthopaedic Surgeons Using the American Board of Orthopaedic Surgery Database

Radiographic Predictors for Adverse Outcomes Following Surgical Correction of Hammertoe Deformity

Category:Lesser ToesIntroduction/Purpose:Hammertoe deformities are common, often painful deformities of the lesser foot and are known to severely affect physical function. When patients seek surgical management, x-ray imagining is utilized for diagnosis, evaluation for surgical candidacy, and selection of the operative technique. Postoperatively, radiographs are retaken to assess bone health, healing status, and alignment. Despite their frequent use, no previous data support particular X-ray findings as being indicative of clinical presentation nor surgical outcomes. The aim of this study is to identify specific radiographic parameters that are predictive of pain and function outcomes after surgical correction of hammertoe deformity.Methods:Prospectively collected data was reviewed on 116 patients who underwent hammertoe correctional surgery. Patient demographics, comorbidities, and postsurgical complications were recorded from their electronic medical records. Clinical outcomes were assessed utilizing preoperative and postoperative pain Visual Analogue Scale (VAS) and Short Form Health Survey Physical Component (SF-36 PCS) scores with 1-year follow-up. Radiographs were scored by a foot & ankle fellowship-trained orthopaedic surgeon to assess preoperative severity, postoperative joint fusion, and both pre- and postoperative joint instability. Data was examined using chi-squared, t-test, and ANOVA analyses.Results:Preoperatively, 14.7% of patients had a deformity classified radiographically as mild, 37.1% as moderate, and 48.3% as severe. X-rays prior to surgery showed that 65.5% had MTP joint instability, 9.5% had joint dislocation, and 18.1% had joint arthritis. Postoperatively, 78.5% had PIP joint fusion, 38.8% had MTP joint arthritis, and 17.2% had MTP joint instability. A significant association was found between postoperative MTP joint instability and a lower 1-year SF-36 PCS (p=0.0032). There were no associations found between the other radiographic findings and postoperative outcomes, and no parameters were associated with pain VAS scores.Conclusion:After undergoing surgical correction of hammertoe deformity, the postoperative radiographic finding of MTP joint instability was determined to be predictive of physical function. However, neither metatarsophalangeal joint arthritis nor PIP fusion were predictive of outcomes. This work informs foot and ankle specialists that proper joint alignment and stabilization is critical to ensuring success in hammertoe surgery.

The REVision Using Imaging to Guide Staging and Evaluation (REVISE) in ACL Reconstruction Classification.

Revision anterior cruciate ligament (ACL) procedures are increasing in incidence and possess markedly inferior clinical outcomes (76% satisfaction) and return-to-sports (57%) rates than their primary counterparts. Given their complexity, a universal language is required to identify and communicate the technical challenges faced with revision procedures and guide treatment strategies. The proposed REV: ision using I: maging to guide S: taging and E: valuation (REVISE) ACL (anterior cruciate ligament) Classification can serve as a foundation for this universal language that is feasible and practical with acceptable inter-rater agreement. A focus group of sports medicine fellowship-trained orthopaedic surgeons was assembled to develop a classification to assess femoral/tibial tunnel "usability" (placement, widening, overlap) and guide the revision reconstruction strategy (one-stage vs. two-stage) post-failed ACL reconstruction. Twelve board-certified sports medicine orthopaedic surgeons independently applied the classification to the de-identified computed tomographic (CT) scan data of 10 patients, randomly selected, who failed ACL reconstruction. An interclass correlation coefficient (ICC) was calculated (with 95% confidence intervals) to assess agreement among reviewers concerning the three major classifications of the proposed system. Across surgeons, and on an individual patient basis, there was high internal validity and observed agreement on treatment strategy (one-stage vs. two-stage revision). Reliability testing of the classification using CT scan data demonstrated an ICC (95% confidence interval) of 0.92 (0.80-0.98) suggesting "substantial" agreement between the surgeons across all patients for all elements of the classification. The proposed REVISE ACL Classification, which employs CT scan analysis to both identify technical issues and guide revision ACL treatment strategy (one- or two-stage), constitutes a feasible and practical system with high internal validity, high observed agreement, and substantial inter-rater agreement. Adoption of this classification, both clinically and in research, will help provide a universal language for orthopaedic surgeons to discuss these complex clinical presentations and help standardize an approach to diagnosis and treatment to improve patient outcomes. The Level of Evidence for this study is 3.

Early Practice Patterns of Hand Surgeons: An American Board of Orthopaedic Surgery Database Study

To investigate the variety of cases that are performed by newly graduated fellowship-trained orthopedic hand surgeons. All cases submitted by board-eligible orthopedic surgeons taking part II of their board examination between 2004 and 2013 were obtained from the database of the American Board of Orthopaedic Surgery (ABOS). Each case was then categorized based on the fellowship training of the treating surgeon and whether it was a hand surgery case. Each hand surgery case was then further categorized into 1 of the 8 surgical categories used by the ABOS to determine eligibility for the Subspecialty Certificate in Orthopaedic Surgery of the Hand (SCOSH). During our study period, 6,854 orthopedic surgeons submitted 858,146 cases to the ABOS. Fellowship-trained hand surgeons made up 13% of all surgeons, and 24% of all submitted cases were hand surgery cases. Based on the cases submitted, 44% of hand surgeons were not on track to become eligible for the SCOSH. The most common reason for not reaching eligibility was failure to meet the minimum requirements in 1 of either the congenital, the skin and wound problems, the contracture and joint stiffness, the microvascular, or the tumor categories. A large proportion of fellowship-trained orthopedic hand surgeons are not on track to meet the minimum eligibility requirements for the ABOS SCOSH during their part II case collections. Their case profile is not sufficiently diverse to be considered an active hand surgery practice for the purpose of SCOSH eligibility. This study highlights 1 possible reason why over one-third of young handsurgeons do not obtain their subspecialty certification.

P3. Perioperative immunonutrition in spine and total joint surgery

BACKGROUND CONTEXT In the current era of adding value to health care, modifiable risk factors have become a major focus. Quality and outcomes are now measured, reported, and tied to reimbursement. Recent studies in orthopedic surgery and spine surgery have shown nutritional status to be one of the most significant risk factors for post-operative complications. Our purpose for this study is to evaluate if perioperative nutritional support can reduce post-operative complications and improve outcomes in orthopedic and spine surgery patients. PURPOSE To evaluate if perioperative nutritional support with immunonutrition containing arginine, glutamine, omega 3 fatty acids, and nucleotides can reduce post-operative complications and improve outcomes in orthopedic and spine surgical patients. STUDY DESIGN/SETTING For a 12-month period from November 2016 to October 2017 we prospectively collected data for inpatient total joint replacements and spine surgeries occurring at two hospitals. Surgeries were performed by one of two fellowship trained Orthopedic spine surgeons. PATIENT SAMPLE A total of 125 patients were included. Patients were excluded from the study if they were receiving radiation, or chemotherapy, at the time of surgery or were non compliant with the nutritional protocol. Included patients were adults over the age of 18 undergoing elective spine or total joint replacement surgery OUTCOME MEASURES Postoperative complications, readmissions, reoperations were recorded. Number needed to treat and absolute risk reduction were calculated to evaluate results. METHODS Data were prospectively collected for inpatient total joint replacements and spine surgeries for 12 months beginning November 2016 and ending October 2017. All patients were followed a minimum of 90 days after surgery. The immunonutrition group was instructed to consume two 8 oz bottles of Ricochet Nutrition (Revive Medical, Brighton, MO USA) each day for 6 days before, and 6 days after, surgery. Outcome data was collected on reoperations, readmissions, and complications including: surgical site infections, Pneumonia, UTI, sepsis, and acute MI. RESULTS A total of 125 patients (62 in immunonutrition group and 63 in the control group) were included and no difference was found between the two groups regarding surgery type, comorbidities, sample size, and demographics. The control group had a total of 8 patients with complications after surgery: 1 pneumonia, 3 UTIs, 1 incisional hernia, and 2 deep surgical site infections. There was a total of 3 reoperations and 4 readmissions in the control group. The immunon trition group had no reoperations, no readmissions, and no complications. CONCLUSIONS Our study provides strong evidence that perioperative immunonutrition (containing Arginine, Glutamine, Omega 3 FAs and Nucleotides) reduces complications, reoperations and readmission for inpatient orthopedic and spine surgery patients.; Patient optimization prior to surgery should include optimizing nutritional status with immunonutrition. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

86. Rate of revision surgery following multilevel posterior cervical fusion at the cervicothoracic junction

BACKGROUND CONTEXT Recently the optimal caudal extent of multileval posterior cervical fusion in relation to the cervicothoracic junction has been debated in the literature. PURPOSE The purpose of this study is to compare the reoperation rate in patients who have had a posterior cervical laminectomy and fusion where the caudal extent of the fusion terminates cranial vs caudal to the cervicothoracic junction. The primary end point of this study is the reoperation rates within 1-year follow-up for each of the two groups. The secondary end points are comparisons of time to revision between the two groups and radiographic outcomes. STUDY DESIGN/SETTING Retrospective chart and radiographic review of patients at a single center between 9/1/2013 and 1/21/2016 who underwent multilevel posterior laminectomy and fusion with additional telephone follow-up to assess the presence of further surgical procedures. All surgeries were performed by one of two fellowship-trained orthopedic spine surgeons. Exclusion criteria included presence of trauma, tumor, or infection, and patients who had cervical surgery prior to posterior fusion. Preoperative, postoperative, and 1-year follow-up radiographs were assessed with C2-C7 SVA and lordosis. PATIENT SAMPLE Seventy-eight patients met inclusion criteria; 54 male and 24 female. Sixty-two patients had posterior constructs that terminated and C7 and 16 patients had constructs terminating from T1-T4. There was no significant difference in age, gender, diagnosis/reason for surgery, length of follow-up, or BMI. Average follow-up for both groups was 51 months. RESULTS There were a total of 13 revision surgeries in 12 patients whose constructs' caudal extent was C7 vs 2 revisions in patients whose caudal extent was in the thoracic spine. There was no significant difference in revision rate between the two groups. There was no difference in time to revision between the two groups. The median time to revision was 35 days and time to revision was widely distributed from 7 to 774 days. There was no difference in preoperative or postoperative cervical lordosis between the two groups. The C7 group had a lower preoperative SVA than the more caudal T1-4 group (39 vs 55) but no difference in postoperative SVA was detected (P value >.05). CONCLUSIONS It is likely that regional variations in the indications for revision surgery, variations in patient populations, and surgeon bias explain much of the differences seen in the current literature regarding where to end a multilevel posterior cervical fusion. Our study, along with others, suggests that similar revision rates and radiographic outcomes can be achieved with ending the fusion at C7 or extending it into the thoracic spine. Including the upper thoracic spine in the construct appears to be a reasonable option if there are concerns about bone quality, implant fixation in the lateral mass or pedicles of C7, tobacco use, or sagittal alignment issues. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Magnetic resonance imaging reproducibility for rotator cuff partial tears in patients up to 60\u2009years

BackgroundMagnetic resonance imaging (MRI) is the gold standard in diagnosing rotator cuff pathology; however, there is a lack of studies investigating the reliability agreement for supraspinatus partial-thickness tears among orthopaedic surgeons and musculoskeletal (MSK) radiologists.MethodsSixty digital MRI scans (1.5 Tesla) were reviewed by two orthopaedic shoulder surgeons, two MSK radiologists, two fellowship-trained shoulder surgeons, and two fellowship-trained orthopaedic surgeons at two distinct times. Thirty-two scans of partial-thickness tears and twenty-eight scans of the supraspinatus tendon with no tears were included. Supraspinatus tendonosis and tears, long head of the biceps pathology, acromial morphology, acromioclavicular joint pathology and muscle fatty infiltration were assessed and interpreted according to the Goutallier system. After a four-week interval, the evaluators were asked to review the same scans in a different random order. The statistical analyses for the intra- and interobserver agreement results were calculated using the kappa value and 95% confidence intervals.ResultsThe intraobserver agreement for supraspinatus tears was moderate among the MSK radiologists (k = 0.589; 95% CI, 0.446–0.732) and the orthopaedic shoulder surgeons (k = 0.509; 95% CI, 0.324–0.694) and was fair among the fellowship-trained shoulder surgeons (k = 0.27; 95% CI, 0.048–0.492) and the fellowship-trained orthopaedic surgeons (k = 0.372; 95% CI, 0.152–0.592). The overall intraobserver agreement was good (k = 0.627; 95% CI, 0.576–0.678). The intraobserver agreement was moderate for biceps tendonosis (k = 0.491), acromial morphology (k = 0.526), acromioclavicular joint arthrosis (k = 0.491) and muscle fatty infiltration (k = 0.505). The interobserver agreement results for supraspinatus tears were fair and poor among the evaluators: the MSK radiologists and the orthopaedic shoulder surgeons had the highest agreement (k = 0.245; 95% CI, 0.055–0.435).ConclusionsIn this sample of digital MRI scans, there was an overall good intraobserver agreement for supraspinatus partial tears; however, there were also poor and fair interobserver agreement results. The evaluators with higher levels of experience (the orthopaedic shoulder surgeons and the MSK radiologists) demonstrated better results than evaluators with lower levels of experience.

Bilateral magnetic resonance imaging findings in individuals with unilateral shoulder pain

Magnetic resonance imaging (MRI) is commonly used to diagnose structural abnormalities in the shoulder. However, subsequent findings may not be the source of symptoms. The aim of this study was to determine comparative MRI findings across both shoulders of individuals with unilateral shoulder symptoms. We prospectively evaluated 123 individuals from the community who had self-reported unilateral shoulder pain with no signs of adhesive capsulitis, no substantial range-of-motion deficit, no history of upper-limb fractures, no repeated shoulder dislocations, and no neck-related pain. Images in the coronal, sagittal, and axial planes with T1, T2, and proton density sequences were generated and independently and randomly interpreted by 2 examiners: a board-certified, fellowship-trained orthopedic shoulder surgeon and a musculoskeletal radiologist. Absolute and relative frequencies for each MRI finding were calculated and compared between symptomatic and asymptomatic shoulders. Agreement between the shoulder surgeon and the radiologist was also determined. Abnormal MRI findings were highly prevalent in both shoulders. Only the frequencies of full-thickness tears in the supraspinatus tendon and glenohumeral osteoarthritis were higher (approximately 10%) in the symptomatic shoulder according to the surgeon's findings. Agreement between the musculoskeletal radiologist and shoulder surgeon ranged from slight to moderate (0.00-0.51). Most abnormal MRI findings were not different in frequency between symptomatic and asymptomatic shoulders. Clinicians should be aware of the common anatomic findings on MRI when considering diagnostic and treatment planning.