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   Table of Contents - Current issue
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January-December 2019
Volume 9 | Issue 1
Page Nos. 0-68

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SPECIALTY PIECES  

Letter from the Editors p. 0
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Letter from the Chairman p. 0
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The 67th Annual Meeting of the Piedmont Orthopedic Society p. 0
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Bassett Faculty Teaching Award p. 0
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Emily Berend Adult Reconstruction Symposium 2019 Update p. 0
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Duke Resident Awards p. 0
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Parekh Indo-US Foot and Ankle Meeting p. 0
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Chief Autobiographies p. 0
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ORIGINAL ARTICLES Top

Bone marrow stimulation plus bone marrow aspirate concentrate versus bone marrow stimulation alone in the treatment of osteochondral lesions of the talus: A prospective study p. 1
Christine Park, John R Steele, Samuel B Adams
DOI:10.4103/DORJ.DORJ_5_19  
Background: Bone marrow stimulation (BMS) has proven to be the standard treatment for small osteochondral lesions of the talus (OLTs). It has been theorized that bone marrow aspirate concentration (BMAC) has the potential to enhance cartilage repair stimulated by BMS. The aim of this study was to prospectively compare the effect of BMS with BMAC versus BMS alone on patient-reported outcomes after the treatment of OLTs. Methods: This is a single-institution, randomized prospective study. Patients over the age of 18 with OLTs who were proceeding with BMS were included in the study. Patients with multiple OLTs and follow-up period of <1 year were excluded from the study. Patients were randomized to receive BMS alone or BMS with BMAC. Patient-reported outcome scores, including the visual analog scale pain, Short Musculoskeletal Function Assessment, Short Form-36, and Foot and Ankle Disability Index, were compared between the two cohorts. Results: Nine patients were evaluated in the study. Six patients were in the BMS with BMAC group, and three patients were in the BMS alone group. Average final follow-up was >2 years for both groups. Both groups showed improvements in patient-reported outcome scores from preoperatively to final follow-up. There were no significant differences in final outcome scores or changes in outcome scores from preoperatively to final follow-up between the two groups. Conclusion: Our study found that both BMS alone and BMS with BMAC treatments are effective in improving pain and functional outcomes in patients with OLTs. There were no significant differences between the two modalities of treatment. This is a pilot study and a larger randomized trial is needed to make definitive conclusions.
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An analysis of musculoskeletal variables, comparative to team norms, leading to an anterior cruciate ligament rupture in a female soccer player Highly accessed article p. 6
Caleb D Johnson, Mallory S Faherty, Michelle S Varnell, Mita Lovalekar, Valerie J Williams, Jennifer Csonka, Karl Salesi, Timothy C Sell
DOI:10.4103/DORJ.DORJ_2_19  
Aim: The identification of sport- and gender-specific, prospective, and modifiable risk factors contributing to noncontact anterior cruciate ligament (ACL) injury is limited. This lack of information leaves clinicians at a loss in practicing evidence-based injury prevention. The purpose of this study is to describe the methods by which a female soccer player suffering from a noncontact ACL injury was compared to the rest of her team to identify modifiable strength and flexibility deficits possibly contributing to the injury. Materials and Methods: Twenty-two individuals were recruited from a Division I, female soccer team (age = 19.3 ± 1.2 years). All testing was completed 2 months before competitive play. Strength was assessed for ankle inversion/eversion and dorsiflexion (AIS/AES, ADS), knee flexion/extension (KFS/KES), hip abduction/adduction (HABS/HADS), and hip internal/external rotation (HIS/HES). Agonist/antagonist ratios were also calculated. Flexibility was assessed for active ankle dorsiflexion (DF), weight-bearing ankle DF mobility, hamstring flexibility with passive hip flexion (PHF), and active knee extension. The ACL case's strength and flexibility variables were compared to team averages for the dominant leg (affected side) using one-sample t-tests and Wilcoxon signed-rank tests. Results: The ACL case's injury was the result of a planting and cutting motion. The ACL case displayed significantly lower ADS (−7.84% of body weight), AIS (−7.41%), AES (−6.58%), KFS (−5.39%), HABS (−3.14%), HES (−2.84%), and a significantly lower HABS-to-HADS ratio (−0.12) compared to team averages. The ACL case also displayed significantly lower PHF (−16.89°) and higher DF (+1.85°). Conclusions: Several plausible strength and flexibility deficits were identified that could have played a role in the ACL case's injury. Clinical Significance: The methods and instrumentation used to identify deficits in the ACL case were inexpensive and clinic-friendly.
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Anterior versus posterior lumbar interbody fusion: Does cage geometry matter more than surgical approach? Highly accessed article p. 15
Sean P Ryan, Rachel Nash, Nyle Larson, Anthony A Catanzano, Brian L Dial, Bethany Harpole, Andrew J Pugely, Sergio A Mendoza-Lattes
DOI:10.4103/DORJ.DORJ_3_19  
Background: For patients undergoing lumbar fusion, a variety of interbody arthrodesis techniques and devices exist, but few studies have evaluated the effect of cage geometry on radiographic outcomes. Thus, the purpose of this study is to compare the performance of expandable lordotic posterior lumbar interbody fusion (ePLIF) cages to lordotic anterior lumbar interbody fusion (ALIF) cages and to compare the early radiographic outcomes of different cage designs through review of the available literature. Materials and Methods: This is a retrospective case–control study, including 31 ePLIF and 36 ALIF levels, for the treatment of lumbar radiculopathy. Three-dimensional computed tomography scans were used to measure disc height, interbody angle, and foraminal height, both pre- and postoperatively. Implant geometry and positioning were then correlated with radiographic outcomes. The available ALIF and PLIF literature was then analyzed to determine the radiographic outcomes for each surgical technique based on cage geometry. Results: ePLIF cages increased foraminal height (P < 0.001), which was comparable to lordotic ALIF cages (P < 0.001). ePLIF and ALIF provided similar restoration of disc height; however, ALIF cages provided a significant increase in interbody angle (P < 0.001). Across the available literature, ALIF correlated with greater changes in interbody angle relative to PLIF regardless of cage geometry (lordotic vs. nonlordotic), while PLIF trended toward greater restoration of foraminal height. Conclusion: ePLIF cages are able to restore foraminal and disc height comparable to ALIF cages. However, lordotic ALIF cages should be utilized if sagittal restoration is a priority. Future studies are necessary to further explore the value of different implant design options. Level of Evidence: Level III. Clinical Relevance: Patients with abnormal sagittal balance should undergo a lordotic ALIF procedure. Patients who are sagittally balanced, however, can achieve fusion and decompression with either ALIF or ePLIF.
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Achilles rupture and return to sport in professional athletes p. 26
Richard M Danilkowicz, Nathan L Grimm, Annunziato Amendola
DOI:10.4103/DORJ.DORJ_1_19  
Context: Despite Achilles rupture posing a potentially career-threatening injury to professional athletes, limited sports medicine research has been conducted to investigate how to improve the ability of players to return to sport after sustaining the injury. Objective: The main objective of the study is to aggregate the current literature on professional athlete return to play after Achilles tendon rupture in an attempt to identify the current strengths and gaps in knowledge. Materials and Methods: A PubMed literature reviews was performed using the terms “Achilles”and/or “elite,” “professional,” “return,” “sport,” “national basketball association”, “national football league,” “major league baseball,” “major league soccer,” “national hockey league,” “injury” to identify articles of interest. Only studies involving professional athletes in the major United States football, soccer, basketball, baseball, and hockey leagues as well as European Soccer Leagues who sustained a torn or ruptured Achilles tendon were included. Data Sources: PubMed literature search utilizing the key words, “Achilles” and/or “elite,” “professional,” “return,” “sport,” “national basketball association,” “national football league,” “major league baseball,” “Major League Soccer (MLS),” “national hockey league,” “injury.” Study Selection: Studies found using the keywords above were considered for inclusion. Individual case studies, injuries other than tear or rupture, and studies with unclear methodology were excluded. Nine studies met inclusion criteria. Study Design: This study is a review of published literature. Level of Evidence-IV: IV. Data Extraction: Data were taken directly from the included studies and aggregated. The quality and validity of the data is limited by the collection methodology of each individual study included. Results: Overall return-to-play percentage of 67.1% across all included studies with a total of 322 included participants. Soccer athletes were found to have the highest return percentage at 70.8% and baseball with the lowest at 55.6%. The average age of the players returning to play across all studies was 28.9 years, with football players comprising the youngest group at 27.5 years and baseball the oldest at 31.4 years. Conclusions: A lack of reliable data has made the study of professional athlete Achilles rupture and return to play a difficult endeavor. Despite the limitations, studies have shown that over 30% of players do not return to their respective sports, with no statistically significant correlation to age or position played. More research is needed to determine how specific injury patterns, rehabilitation protocols, and functional testing plays into the athletes' ability to return to play.
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Institutional delay in wound coverage increases postoperative complications in patients with traumatic open fractures p. 30
Alyssa D Althoff, Russell A Reeves, India S Robinson, William R Barfield, Langdon A Hartsock
DOI:10.4103/DORJ.DORJ_6_19  
Background: Open fractures often require additional procedures for timely definitive soft-tissue coverage. Delayed coverage is associated with poor outcomes. Thus, we sought to (1) define the incidence and severity of open fractures presenting to our institution, (2) identify soft-tissue coverage methods, and (3) determine the incidence of postoperative complications. Materials and Methods: Patients were identified in our institutional registry through the International Classification of Diseases (ICD)-9 and ICD-10 codes specific for open long-bone and extremity fractures. Descriptive statistics were performed on demographics, injury mechanism, and fracture type (Gustilo–Anderson classification). Fractures requiring coverage (Type IIIB/C), surgical methods, and duration until coverage (mean days ± standard deviation) were recorded. Postoperative complications were also identified. Results: From 2012 to 2017, 243 patients were treated for open long-bone fractures. Blunt trauma accounted for 76.9% (n = 187) of the injuries. Grade III tibia fractures represented the highest incidence (n = 74, 30.4%). Of the IIIB/C injuries, the most common coverage methods were split-thickness skin grafting (n = 24, 32.4%) occurring 16.2 ± 11.5 (range: 3–40) days following injury and rotational flap coverage (n = 22, 29.7%). IIIB/C injuries were complicated by nonunion (n = 11, 14.9%), infection (n = 12, 16.2%), amputation (n = 21, 28.4%), and wound breakdown (n = 7, 9.5%). Conclusions: High-grade open fractures treated without timely definitive coverage can result in complications. Multiple specialties may be required to manage these patients, and it may be beneficial for orthopedic surgeons to obtain skills in skin grafting and rotational muscle flap coverage to decrease time to definitive wound closure.
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Timing of musculoskeletal injuries during a single athletic event: A systematic review p. 35
Hannah Palmer, Timothy Sell, Carolyn Killelea, Katelyn Allison, Leila Ledbetter
DOI:10.4103/DORJ.DORJ_9_19  
Aim: The aim of the study is to examine the relationship between musculoskeletal injury and time within an athletic event and to propose that these injuries may be fatigue-related. Background: Musculoskeletal injuries impede athletic performance. The identification of risk factors is essential to reducing injury. Materials and Methods: We searched PubMed, Embase, SPORTDiscus, and CINAHL and performed manual reference checks. Included articles reported the timing of acute musculoskeletal injury in a single athletic event; 23 articles were selected for multireviewer assessment of quality and levels of evidence. Results: Eighty-seven percent of studies found a higher incidence of injury in later stages of play (second half or later in the second half) and 60% found this to be significant. All but two articles suggested that injury trends were related to fatigue development. Conclusion: Based on our review, a connection between the development of musculoskeletal injury and duration of play supports the concept that fatigue is a risk factor for injury. Clinical Significance: A greater understanding of the correlation between fatigue and musculoskeletal injury is essential to designing injury prevention programs that will decrease the onset of musculoskeletal injury in athletes. Ultimately, preventative strategies that reduce injury risk will lead to superior health and performance in athletes during athletic careers and later in life.
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Perioperative blood transfusions and complication rates in total elbow arthroplasty p. 43
Swara Bajpai, Cary S Politzer, Abiram Bala, Grant E Garrigues
DOI:10.4103/DORJ.DORJ_4_19  
Aim: Complication rates for total elbow arthroplasty (TEA) have not been well studied. The aim of this study was to analyze its utilization rate, the use of perioperative packed red blood cell transfusions, overall rates of surgical complications, and any association of perioperative transfusions with short-term postoperative medical and long-term surgical complications. Materials and Methods: We queried a large Medicare Standard Analytic Files database from 2005 to 2014 to identify index surgery, perioperative blood transfusions, and postoperative complications. Incidence, odds ratios (ORs), 95% confidence intervals, and P values were calculated for 30-day, 90-day, and 2-year postoperative complications. Results: We identified a total of 7480 primary TEA procedures with a minimum of 2-year follow-up. 577 of these patients received perioperative blood transfusion, whereas 2058 age- and gender-matched controls did not. The transfusion cohort had statistically significantly higher rates of 30-day medical complications such as anemia (OR, 7.54), acute kidney injury (OR, 5.55), sepsis (OR, 4.97), myocardial infarction (OR, 3.36), respiratory failure (OR, 3.17), heart failure (OR, 2.56), pneumonia (OR, 2.46), and urinary tract infection (OR, 2.19). They also had higher rates of infection-related surgical complications within 90 days such as periprosthetic infection (OR, 3.36) and cellulitis/seroma (OR, 2.12) and more blood transfusions (OR, 2.59), which remained significantly elevated at 2 years after surgery. Conclusions: Patients requiring perioperative transfusions after surgery have higher rates of complications. Clinical Significance: Surgeons should preoperatively mitigate transfusion risk and preemptively counsel patients during admission and discharge. Further evidence is needed to determine whether perioperative transfusion is a marker of overall poor health or whether transfusion has an immunomodulatory effect that increases complication risk.
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Reducing needlestick injuries in the operating room: Efficacy of wound closure with operative Armour™ as compared with traditional methods p. 51
Sneha Rao, Eliana Saltzman, Daniel Scott, Sandra Au, Selene Parekh
DOI:10.4103/DORJ.DORJ_7_19  
Introduction: Sharp injuries continue to pose a significant safety issue in the clinical setting with 385,000 injuries occurring annually among the United States health-care workers. In the operating room (OR), a majority of the needlestick injuries are due to frequent passing of contaminated needles. Operative Armour™ is a novel arm guard enabling surgeons to independently self-secure and self-dispose needles. We hypothesized that the use of Operative Armour™ as compared to the standard technique of sequentially passed needles would reduce the number of sutures passes. Methods: A 12 cm incision was made through an anterior and posterior approach to the ankle in three cadavers. In Group A (standard technique), 2-0 vicryl suture was used. In Group B (Operative Armour™), 2-0 vicryl suture packs, containing five sutures, were used. Three participants completed three trials for each group. Outcomes included wound closure time and the number of dropped and passed needles. Results: Wound closure time for Group A was 16:35 ± 0.2 min and 16:33 ± 0.1 min for Group B (P > 0.05). No needles were dropped in either group. Suture passes averaged 52 ± 8.9 in Group A compared to 5.3 ± 0.7 in Group B (P < 0.05). There were 24 needle handoffs in Group A, while in Group B, only three suture packs were passed. Conclusions: Use of the Operative Armour™compared to the standard technique demonstrated a statistically significant decreased number of suture passes but no change in total closure time. Given the large reduction in suture passes, the use of the Operative Armour™ could lead to a significant reduction in the number of needlesticks in the OR during wound closure. Clinical Significance: Compared to current standard techniques, the use of Operative Armour™ could increase safety in the OR by decreasing the number of suture passes. By reducing the demands on the surgical technician, this device could also decrease OR turnaround time and enhance overall efficiency.
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Optimal nerve transfer for elbow flexion restoration in brachial plexus injuries: An analysis of postoperative recovery p. 55
Eliana B Saltzman, Natalia Fullerton, Joseph T Nguyen, Joseph H Feinberg, Steve K Lee, Scott W Wolfe
DOI:10.4103/DORJ.DORJ_8_19  
Aim: Following upper brachial plexus injury, one of the primary goals of reconstruction is reinnervation of elbow flexion (EF). Various reconstruction methods have been described including ulnar nerve fascicle and/or median nerve fascicle transfer to the musculocutaneous biceps brachii motor branch and/or the brachialis motor branch. However, there is no study that analyzes the efficacy of one set of transfers to another. We aim to determine if there are improved outcomes with the ulnar nerve transfer to biceps branch and median nerve transfer to brachialis branch (UBB/MBr, Group 1) compared to ulnar nerve transfer to brachialis and median nerve transfer to biceps branch (UBr/MBB, Group 2). Methods: We performed a retrospective analysis of 12 patients who sustained C5–C6 ± C7 brachial plexus injuries and underwent nerve transfers for EF reconstruction. All clinical and electromyographic (EMG) data were captured for an average follow-up time of 35 months. Data were analyzed using a generalized estimating equation model (P < 0.05). Results: Seven and five patients were included in Groups 1 and 2, respectively. At 6 months, Group 2 achieved a greater Medical Research Council score of global elbow function 4 versus 1.5 (P < 0.05), biceps strength 3.67 versus 2.13 (P < 0.05), and brachialis strength 3.5 versus 2.5 (P < 0.05). The brachialis EMG recruitment pattern also demonstrated improved results in Group 2 as compared to Group 1 at 12, 24, and 36 months (P < 0.05). Conclusion: These findings indicate that UBr/MBB nerve transfer confers significantly faster recovery of global EF, biceps, and brachialis strength at 6 months. Although differences in strength equalized by 24 months, EMG data demonstrated increased muscle nerve potential in Group 2 at 12 months and beyond. Clinical Significance: The median nerve fascicle transfer to the biceps branch and ulnar nerve fascicle transfer to brachialis branch appear to have advantages in EF function.
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Total hip arthroplasty in patients with Parkinson's disease p. 60
Colin T Penrose, Abiram Bala, Travis J Dekker, Thorsten M Seyler, Timmothy R Randell, Cynthia L Green, Samuel S Wellman, Michael P Bolognesi
DOI:10.4103/DORJ.DORJ_10_19  
Purpose of Study: The purpose of this study was to evaluate the incidence of dislocations, infections, revisions, and other medical and surgical complications in patients with Parkinson's disease (PD), who undergo total hip arthroplasty (THA) compared to a control group without PD. Materials and Methods: Medicare patient data from 2005 to 2011 were retrospectively reviewed using the PearlDiver Technologies software (West Conshohocken, Pennsylvania, USA). Administrative coding and Boolean language were used to identify 6587 patients with PD diagnosed prior to THA and compared to a cohort containing all Medicare patients with a THA between 2005 and 2011 without any history of PD (767,991 patients). Statistical analysis was used to compare the number of patients with common comorbidities and medical and surgical complications. Systematical review of the literature on PD and THA was also performed. Results: Patients with PD had a higher rate of medical complications, including pneumonia, urinary tract infection, and sepsis at 30 days postoperatively. At 90 days and final follow-up, they had a higher rate of postoperative complications including dislocation, prosthetic joint infection, and risk of revision. Conclusion: PD is a progressive neurodegenerative disorder that affects the musculoskeletal system, and patients with PD often require surgical intervention for hip pain from a fracture, post-traumatic arthritis, or osteoarthritis. This study demonstrates the increased risk for several postoperative complications in patients with PD undergoing THA. It highlights the importance of an individualized risk-benefit analysis and multidisciplinary management before proceeding with arthroplasty for patients with PD.
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