kelly day journal 2014

EMORY UNIVERSITY SCHOOL OF MEDICINE

Department of Orthopaedics

The Kelly Society

Orthopaedic Journal

2014

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TABLE OF CONTENTS

Letter from the Chairman .......................................................... 2

2014 Kelly Society Visiting Professor ........................................ 3

Letter from Kelly Society President ........................................... 4

Kelly Day Agenda ..................................................................... 5

PGY5 Class .............................................................................. 8

PGY5 Bios, Manuscripts & Abstracts .................................. 9-58

James Black, MD ............................................................................. 9

Mihir Desai, MD ............................................................................. 22

Michael Gottschalk, MD ................................................................. 31

Mark Magill, MD ............................................................................. 43

Ravi Patel, MD ............................................................................... 56

PGY 1-4 Residency Classes ................................................... 59 Manuscripts PGY3’s ............................................................... 60 Manuscripts PGY1’s ............................................................... 89 Emory Orthopaedics Surgical Faculty ................................... 114 Publications (2013-14) .......................................................... 115

Meeting Presentations (2013-14) .......................................... 120

Honors & Awards (2013-14).................................................. 121

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LETTER FROM THE CHAIRMAN

James R. Roberson, MD

Welcome to the Annual Robert P. Kelly Resident Research Day. The program showcases the culmination of a tremendous amount of thought, planning and effort. I anticipate seeing several of these projects in our published literature. Congratulations to the researchers. I am excited about the re-energizing of the Kelly Society under the leadership of Drs. Kercher and Jarrett. Alumni support is a vital component of a successful department and I look forward to increasing alumni involvement. We have been fortunate to have a long tradition of the most respected leaders in our field serve as the annual Kelly Visiting Professor. This year is no exception. Dr. William Levine’s contributions to surgical education, innovation and leadership in our most important organizations are indeed impressive. On behalf of our faculty and residents I would like to thank Dr. Levine for taking time from a busy schedule to honor us with his presence. I would also like to recognize Dr. Thomas Whitesides, previous Department Chair and Professor Emeritus. Dr. Whitesides was selected to receive the Arnall Patz Lifetime Achievement Award from the School of Medicine. This award honors distinguished alumni from Emory School of Medicine who displayed extraordinary leadership and accomplishment in the field of medicine at the national or international level. Congratulations Tom, on this well deserved recognition for a long career. Finally I am grateful to the many people who put a great deal of time and effort into organizing this event.

James R. Roberson, M.D.

James Roberson, MD Robert P. Kelly Professor and Chairman, Department of Orthopaedic Surgery Emory University School of Medicine Board of Directors of the American Board of Orthopaedic Surgery

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2014 KELLY SOCIETY VISITING PROFESSOR

William N. Levine, MD

Professor of Clinical Orthopaedic Surgery, Columbia University Vice Chairman of Education, Department of Orthopaedic Surgery Director, Sports Medicine Department of Orthopaedic Surgery Associate Director, Center for Shoulder, Elbow & Sports Medicine Residency Program Director, Orthopaedic Surgery, Columbia University Medical Center

William N. Levine, MD is a renowned specialist in arthroscopic and open shoulder, elbow, and knee surgery and sports medicine. He is Vice Chairman of the Department of Orthopaedic Surgery and serves as its Residency Director and Fellowship Director. He is the Chief of the Shoulder Service and the Co-Director of the Center for Shoulder, Elbow and Sports Medicine. Dr. Levine is the Head Team Physician for Columbia University, responsible for providing care for its 31 intercollegiate athletic teams. He is the recipient of the prestigious American Shoulder and Elbow Surgeon’s Traveling Fellowship. Dr. Levine was recently named to the Board of Directors of the American Board of Orthopaedic Surgery - the governing body which oversees licensure and training of orthopaedic surgeons.

Dr. Levine has given over 200 scientific presentations both here and abroad, has published more than 125 peer-reviewed articles and 50 book chapters, and has edited 5 textbooks. Additionally, he serves as the Deputy Editor of the Journal of the American Academy of Orthopaedic Surgeons (JAAOS). He has served on the Board of Directors of the AOSSM and is currently on the Executive Committee of the American Orthopaedic Association (AOA) – the oldest and one of the most prestigious Orthopaedic organizations.

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LETTER FROM THE 2014 KELLY SOCIETY PRESIDENT

James Kercher, MD

I am honored to be writing this on behalf of the Kelly Society. I feel privileged to have received training and clinical experience from the Emory Program, as I know most of you do who have walked the same path. I believe that with this privilege comes obligation. We have an obligation to support our program so that it will continue to remain strong and improve opportunities for those who follow.

As we embrace the challenges that face us in the future of healthcare, I would like take this opportunity to add one more item to your list. I challenge each one of you to make 2014 the year we engage in the Kelly Society. Our first step is to re-ignite membership. To do this, we need help gathering contact information as well as graduation dates for you and your classmates. Once we have re-established the membership, we will be organizing events and resources for the benefit of the group.

We have already seen the benefits of the monthly emails, as former classmates have been able to use the e-blast as a way to reach out to each other. As the Kelly Society membership grows, we will be able to offer a more exciting event schedule, potentially including some destination events. Members will also be able to access our online directory that is currently being constructed.

I am excited about what’s to come with the Kelly Society and hope you are too. Please feel free to contact me with ideas, suggestions and questions. Thank you for your commitment. Sincerely, James Kercher, MD

James Kercher, MD Orthopaedic Surgeon Sports Medicine Peachtree Orthopaedic Clinic Atlanta, Georgia

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2014 KELLY DAY AGENDA

7:00 AM Registration & Breakfast

7:45 AM Welcoming Remarks: James Roberson, MD

Session I

8:00 AM Subpectoral Biceps Tenodesis for the Treatment of Type II and IV SLAP Lesions Michael Gottschalk, MD PGY-5

8:10 AM The Effect of Contouring on Fatigue Resistance of Reconstruction Plates Mark Magill, MD PGY-5

8:20 AM Factors Involved in Return to High Level Division 1 Football Following ACL Reconstruction Jimmy Daruwalla, MD PGY-1

8:30 AM Discussion 8:40 AM Alumnus Presentation: Handling the Subscapularis in Shoulder Arthroplasty

Claudius Jarrett, MD Alumni, Class of 2010

8:50 AM Case Presentation: Adolescent ACL Deficient Knee Ravi Patel, MD PGY-5

Panel Discussion John Xerogeanes, MD, Kyle Hammond, MD, Dane Todd, MD

Session II 9:05 AM Arthroscopic Repair of Triangular Fibrocartilage Complex Tears: A Biomechanical

Comparison of a Knotless Suture Anchor and the Traditional Outside Mihir Desai, MD PGY-5

9:15 AM Analysis of Length of Stay and Cost-Effectiveness before and after the Addition of a dedicated Orthopaedic Mid-Level Provider in a Level I Trauma Center

Elise Hiza, MD PGY-3 9:25 AM Long-term Results of Extensor Mechanism Reconstruction Using Achilles Tendon

Allograft after Knee Arthroplasty Brent Wise, MD PGY-3 9:35 AM Discussion 9:50 AM Alumnus Presentation: Surgical management of patellofemoral instability

James Kercher, MD Alumni, Class of 2007

Friday, June 6, 2014

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10:00 AM Case Presentation: Proximal Humerus Fracture: Has Surgical Intervention Gone Too Far Kyle Sweeney, MD PGY-3

Panel Discussion: William Levine, MD, Gary McGillivary, MD, Thomas Moore, MD

10:15 AM BREAK 10:30 AM Introduction of 2014 Kelly Visiting Professor William Levine James Roberson, MD 2014 Kelly Visiting Professor Lecture

History of Shoulder Arthroplasty – Where are we in 2014? William Levine, MD

11:30 AM Lunch Presentation | Volume to Value: Our Response to the Affordable Care Act

Herschel Beker, MD, MHCDS, Alumni, Class of 1986

12:30 PM Introduction of Reunion Class 2004 James Kercher, MD, President of Kelly Society

Session III 12:40 PM Value of a Saturday Dedicated Orthopaedic Trauma Operating Room

Robert Runner, MD PGY-1

12:50 PM Height, Weight and Age Predict Quadriceps Tendon Length and Thickness in Skeletally Immature Patients Dane Todd, MD PGY-3

1:00 PM The Treatment of Refractory Equinus of the Foot and Ankle Following Trauma with Circular Ring External Fixation James Black, MD, PGY-5

1:10 PM Discussion 1:20 PM Alumnus Presentation: Clinical Outcomes of Combined RTSA with Modified L’Episcopo

Transfer Walter McClelland, MD Alumni, Class of 2010 1:30 PM Case Presentation: Hemicap/Posterior Bankart Ashton Mansour, MD, PGY3

Panel Discussion: William Levine, MD, Spero Karas, MD, Claude Jarrett, MD

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Session IV: Post Graduate Orthopaedic Training in 2014

1:45 PM New Horizons in Orthopaedic Resident Education Rashard Dacus, MD, Alumni Class of 2006, Director University of Virginia Orthopaedic Residency Program

2:30 PM 80-hour work week rules – How did we get there and are we better off for it? William Levine, MD 3:00 PM Culturally competent care for the Orthopaedic surgeon Rajiv Rajani, MD, Alumni Class of 2010 3:30 PM Panel Discussion: James Roberson, MD, William Levine, MD, Thomas Bradbury, MD, Rashard Dacus, MD 3:45 PM The Future of Kelly Society James Kercher, MD, President of Kelly Society 4:00 PM Closing Remarks James Roberson, MD and Thomas Bradbury, MD

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2013 – 2014 Orthopaedics Residents

PGY5

James Black, MD Administrative Chief

Fellowship Match: Washington University St. Louis, MO Trauma Surgery Fellowship

Medical School: Emory University School of Medicine

Hometown: Atlanta, GA

Mihir Desai, MD Administrative Chief

Fellowship Match: Duke University Durham, NC Hand and Microvascular Fellowship

Medical School: Georgetown University School of Medicine

Hometown: Roanoke, VA

Michael Gottschalk, MD

Fellowship Match: New York University Hospital of Joint Disease New York, NY Hand and Upper Extremity Fellowship

Medical School: University of Texas Medical School at San Antonio

Hometown: San Antonio, TX

Mark Magill, MD

Fellowship Match: OrthoCarolina Foot & Ankle Institute Charlotte, NC Foot and Ankle Fellowship

Medical School: Vanderbilt University School of Medicine

Hometown: Topeka, KS

Ravi Patel, MD

Fellowship Match: Harvard Medical School Boston, MA Spine Surgery Fellowship

Medical School: Jefferson Medical College of Thomas Jefferson University

Hometown: Philadelphia, PA

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James Black, MD PGY-5

Administrative Chief Resident

UPCOMING FELLOWSHIP TRAINING

Trauma Surgery Fellowship

Washington University

St. Louis, MO

EDUCATION

Emory University School of Medicine, Atlanta, GA

Doctor of Medicine, May 2009

Middlebury College, Middlebury, VT

Bachelor of Arts, Economics, May 2004

HONORS AND LEADERSHIP

Administrative Chief Resident, Orthopaedic Surgery Residency 2013-2014 1st Prize Resident Research American College of Surgeons, 2013 Georgia Committee on Trauma 3rd Prize Resident Research, Georgia Orthopaedic Society 2012 Class Representative, Program Evaluation Committee 2010 - present Residency Education Committee 2010 - present Residency Research Committee 2010 - present

PUBLICATIONS

Black J, Moore T, Yonz M, Barnes W, Bellaire L. Ballistic Fractures of the Lower Extremities: A Review of Soft Tissue Complications From a Level I Trauma Center. Manuscript in development.

Black J, Moore T. The treatment of severe post traumatic equinus contracture of the ankle using an adjustable multiplane external fixator: our report of four cases. Manuscript in development.

Kercher J, Xerogeanes J, Tannenbaum A, Al-Hakim R, Black J, Zhao J, Green J. ACL Reconstruction in the Skeletally Immature: An Anatomic Study Utilizing 3-D Reconstructions. Journal of Pediatric Orthopaedics, March 2008.

BOOK CHAPTERS

“Lower Extremity Amputations.” Black J, Oskouei S, Fleming L. Medical Management of the Surgical Patient: A Textbook of Perioperative Medicine, 5th edition. Cambridge University Press, 2013.

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PRESENTATIONS

Ballistic Fractures of the Lower Extremities: A Review of Soft Tissue Complications From a Level I Trauma Center. Black J, Moore T, Yonz M, Barnes W, Bellaire L. Georgia Society of the American College of Surgeons, Atlanta, GA Podium Presentation: August 24, 2013 Georgia Committee on Trauma, Macon, GA Podium Presentation: August 9, 2013 Southern Orthopaedic Association, 30th Annual Meeting, Palm Beach, FL Podium Presentation: July 18, 2013 American Academy of Orthopaedic Surgeons, 59th Annual Meeting, Chicago, IL Podium Presentation: March 2, 2013 Georgia Orthopaedic Society Annual Meeting, Sea Island, GA Podium Presentation: September 28, 2012 Emory University, Robert P. Kelly Society Meeting, Atlanta, GA Podium Presentation: June 9, 2012 Anterior Cruciate Ligament Reconstruction in the Skeletally Immature: An Anatomic Study Utilizing 3-D Reconstructions. Kercher J, Xerogeanes J, Tannenbaum A, Black J, Al-Hakim R, Zhao J, Green J. Southern Orthopaedic Association, 25th Annual Meeting, Hot Springs, VA Podium Presentation: June 14, 2008

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The treatment of severe post traumatic equinus

contracture of the ankle using an adjustable multiplane

external fixator.

James C. Black, MD and Thomas J. Moore, MD

Emory University Department of Orthopaedics, Atlanta GA Grady Memorial Hospital, Atlanta GA

ABSTRACT

Purpose of the study: To report on four cases of severe, recalcitrant equinus contracture of the ankle successfully treated with soft tissue distraction through the use of an adjustable ring external fixator and provide a description of our technique.

Methods and Results: Between 2012 and 2014, we treated three patients with four cases of severe post-traumatic equinus contracture using a distraction method through an adjustable ring fixator. All three patients had resistant equinus contractures as the result of traumatic injuries or compartment syndrome. The procedure included application of the adjustable fixator and variations of achilles tendon lengthening and gastrocnemius recession as indicated. Successful correction to a plantigrade foot was achieved in all cases with average treatment duration of 73 days. Two complications were observed requiring revision surgery. Follow up has ranged from one to eleven months with no recurrence. Conclusion: The use of an adjustable circular ring fixator can provide a safe and accurate method of correcting difficult equinus contractures of the ankle in the trauma patient.

Introduction

Equinus contractures of the ankle can be common sequelae of lower extremity trauma and pose a challenging problem for the treating orthopaedic surgeon. Equinus deformities are defined by the lack of dorsiflexion of the ankle beyond neutral with the subtalar joint in the neutral position and the knee extended. This creates a state of insufficient ankle dorsiflexion to perform normal gait. Although equinus deformities of the ankle after trauma have been well recognized, there is no consensus on the ideal management.1,2,3

Equinocavovarus foot deformities are well documented among adult and pediatric populations with neuromuscular disorders, neglected clubfeet and burns, and the treatment options range from serial casting, tendon transfers and releases, osteotomies, and fusions.2,4 However, the trauma patient with an equinus contracture is often complicated with compromised soft tissues, scarring of the achilles and other injuries which preclude invasive correction attempts and reconstruction. The orthopaedic literature is scant on this trauma population, compromised of only a limited number of reviews and case studies on the utilization of an Ilizarov-type hinged, external fixation device or the Taylor Spatial Frame (Smith and Nephew, Memphis TN) for gradual correction of the deformity.5,6,7,8 In the late 1980s’ and early 1990’s, the Ilizarov technique for deformity correction was increasingly being investigated in the United States. Several studies demonstrated successful lower extremity deformity correction utilizing these frames.1,2 Additionally, reports on treatment of equinus deformity after burns using the Ilizarov

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frame were presented with promising results.9 However, the Ilizarov frame was limited by the steep learning curve and common complications which prevented widespread use.

In a recent abstract from the Bone and Joint Journal Proceedings supplement, Lahoti et al reported on five cases of severe post traumatic equinus contracture which were successfully treated using the Taylor Spatial frame for gradual correction.8 All five patients underwent tendoachilles lengthening, ankle and subtalar capsulotomy and gradual correction using a two-ring Taylor Spatial frame with no recurrence of the deformity with 3 month to five year follow up.

In our study, we report on the technique and outcome of four cases of recalcitrant equinus deformity in three patients with soft tissue compromise seen at our facility between 2012 and 2014 utilizing tendoachilles lengthening and correction using the Taylor Spatial Frame.

Methods

Between 2012 and 2014, three patients were identified with four cases of severe equinus deformity. Indications for our technique included symptoms such as deformity greater than 45 degrees, inability to ambulate, and soft tissue compromise preventing open, invasive release and reconstruction. The surgeries where completed at a single institution by a single surgeon. The study population included two females and one male with a mean age of 33. The first patient sustained an open achilles laceration treated at an outside institution which was complicated with soft tissue loss and achilles scarring. The second patient developed an equinus contracture due to acute lower extremity ischemia after aortofemoral bypass surgery and resultant compartment syndrome. The third patient had bilateral equinus deformities after sustaining massive full body burns from a motor vehicle accident. All patients were informed of the procedure risks and potential benefits as well as the option for continued conservative management, but they wished to proceed with deformity correction using a Taylor Spatial frame with the goal of obtaining a plantigrade foot for ambulation.

Surgical Technique

A thorough preoperative assessment and complete radiographs of the foot, ankle and leg are necessary for surgical planning. The Taylor Spatial frame construct is preliminarily templated on printed imaging to ensure the proper intraoperative positioning of the components.

Under general anesthesia, the patient is positioned supine on an operating room table with a bump until the hip of the affected side. A tourniquet is applied but not routinely elevated unless necessary. The lower extremity is then prepped and draped in the usual sterile manner.

After initial evaluation under anesthesia, the need for achilles lengthening is determined. Each patient receives consideration for percutaneous tendoachilles lengthening, Strayer-type gastrocnemius release and posterior capsular releases to provide the initial correction. The type of lengthening is determined by the extent of posterior soft tissue compromise, in an attempt to minimize the trauma to local tissue while gaining maximal soft tissue correction.

Utilizing the Taylor Spatial Frame, a hinged fixator construct is built to allow for gradual correction (Figure 1). A circular ring is positioned over the distal tibia and three 6-mm partially threaded half pins are inserted into the tibia in a minimum of two distinct planes. These pins are then secured to the circular ring using rancho cubes of the necessary size. Next, a “U” plate is positioned around the foot, maintaining the angle of equinus. The “U” plate is secured using trans calcaneal partially threaded 5-mm pins placed into the posterior calcaneus from both medial and lateral, while protecting the neurovascular structures. Those pins are secured to the “U” plate utilizing rancho cubes. Alternatively, multiple 1.5-mm olive wires can be placed

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in a trans calcaneal fashion and secured to the plate with appropriate tension. Lastly, one or two 1.5-mm wires are placed medial to lateral to capture the metatarsals and secure the forefoot to the construct. These wires are tensioned to a recommended 70 kg. All components are tightened and six articulated struts are placed along the rings in the designated locations. The struts are then tightened to hold the correction obtained by the prior soft tissue and achilles releases. Fluoroscopy is used throughout the procedure to confirm proper placement of the threaded pin and smooth wires.

Postoperative orthogonal radiographs of the leg, ankle and foot are imperative to allow for proper correction measurements. Using the Taylor Spatial Frame software, the postoperative radiographs provide the initial measurements to calculate the residual correction. Within the software program, we utilize a proximal reference fragment, input the parameters and identify the at-risk structures. A prescription is calculated using a maximum correction of 1-mm per day, which provides the initial deformity, the strut adjustment instruction, and final deformity correction graphic within the timeline. Adjustments can be made throughout the correction process as necessary. Of note, if the deformity contains a hindfoot varus component, this should be corrected first before the equinus to prevent the development of a rocker bottom foot deformity or subluxation of the talus.

Postoperatively, the patient will remain non-weightbearing with crutches until correction of the deformity is complete. Initially, weekly follow up visits are necessary to ensure the patient is accurately adjusting the struts per the prescription. Later in the process, clinic visits can revolve around the necessary strut changes which can be completely quickly in the clinic setting. After the deformity has corrected, we prefer to remove the frame in the operating room and place the patient in a short leg splint. After two weeks, the splint is removed and the patient begins protected weight bearing in a walking boot. Many patients have associated, pre-existing extremity neurologic dysfunction and may require a permanent orthosis for ambulation.

Case Studies

Case 1

A 35 year old female presented after sustaining a large, full thickness achilles laceration in another state, approximately 18 months prior to our evaluation. The details regarding her prior treatments where unknown, but as a result, she had developed an 80 degree fixed equinus contracture with severe scarring around her achilles tendon and posterior ankle This deformity prevented ambulation and she wished to pursue surgical intervention.

In the operating room, she underwent gastrocnemius release, percutaneous tendoachilles lengthening and posterior capsule release with application of the Taylor Spatial Frame. Her deformity was corrected to 40 degrees intraoperatively with these releases. Three weeks after the index procedure, she presented to clinic with severe pain in her leg after sustaining a fall at home. Radiographs obtained demonstrated a fracture through her tibia at the site of the proximal half pin. She was admitted to clinic and underwent revision surgery the following day. The revision involved removal of the pin at the fracture site, the addition of a second stacked ring above the level of the fracture and placement of new tibial, partial threaded half pins. The new construct was fixed across the fracture site to allow for fracture healing, while maintaining the ability to correct the deformity. She spent another two months in the frame and gained full correction of her equinus to a plantigrade foot and the tibial fracture healed. Correction was obtained over 83 days (11 weeks) in the frame. After frame removal, she was placed in a short leg cast for an additional month, followed by progressive weight bearing in a walking boot. At her last follow up, 11 months after frame removal, she had maintained her correction and was walking unassisted. (Figures 2-5).

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Case 2

A 41 year old female with presented to us as a consult from our vascular surgery colleagues. She had recently undergone bilateral aortofemoral bypass for severe aortoiliac occlusive disease. Her surgery was complicated by immediate ischemia of her left lower extremity, necessitating the need for revision bypass. Subsequently, she developed an acute compartment syndrome of her left lower extremity and underwent multiple surgical procedures after the compartment release which included eventual split-thickness skin grafting to her lower extremity.

On initial consultation, she was found to have a 90 degree fixed equinus contracture of her left ankle, which was painful and preventing ambulation. Her prior fasciotomies and skin grafts had healed and the vascular surgeons approved of a less-invasive surgical intervention to attempt correction of the equinus. She underwent a percutaneous tendoachilles lengthening and Taylor Spatial frame placement. Six weeks into the correction, her trans metatarsal pin was bending and causing talar shift. The decision was made for a revision, and she returned to the operating room for revision of her metatarsal olive wires which corrected her talar tilt and allowed for continued correction.

After a total of 127 days (18 weeks), full correction was obtained of her equinus deformity resulting in a plantigrade foot allowing for ambulation with an ankle foot orthosis. The correction was maintained at the most recent, two month follow up. (Figures 6.7).

Case 3

This is a 24 year old male who was involved in a motor vehicle collision and sustained severe, full thickness burns throughout his body. He had a long, complicated hospital course while an inpatient with our trauma burns service. Nine months after his initial injury, he presented to us with bilateral 90 degree fixed equinus contractures and had received prior forefoot amputations by the trauma surgeons. Overall, he had recovered well from his burns and other traumatic injuries, and he wished to undergo correction of his bilateral deformities.

Initial correction was performed on the left ankle after percutaneous tendoachilles lengthening and frame placement in the operating room. There were no complications or reoperations during the correction period and after 50 days (7 weeks) full correction was obtained. The frame was removed from the left ankle in the operating room and a new frame was placed on the right ankle for correction of his contralateral extremity. After 31 days (4 weeks), full correction was obtained of the right ankle. The most recent postoperative follow up demonstrated full correction of the bilateral ankle equinus contractures, allowing for ambulation. He has since moved out of state, so recent radiographs are absent. However, he has communicated that he believes his correction has been maintained and he is able to bear weight fully and ambulate independently. (Figures 8-10).

Discussion

Patients with post traumatic equinus deformity of the ankle pose a difficult challenge for the treating orthopaedic surgeon. With the increase in successful limb salvage procedures, the cases of residual equinus deformities are on the rise. Additionally, the associated soft tissue contractures, scars and soft tissue compromise surrounding these injuries can prevent the traditional, invasive reconstructive procedures. There is increasing clinical evidence demonstrating successful correction of these equinus deformities using a variety of achilles lengthening procedures, capsular releases, and gradual correction using a hinged external fixation device.

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Our study demonstrates the successful correction of four cases of severe, equinus deformity after three distinct traumatic events: direct injury, compartment syndrome and burns. Utilization of the Taylor Spatial Frame provided complete correction of the equinus deformity and provided these patients with a plantigrade foot and the ability to resume ambulation. Wukich and Dial described a very similar surgical technique in 2006.6 However, they did not publish the results of their cases. Shu et al reported on a technique involving a hinged Ilizarov fixator with achilles lengthening and reversed sural fasciocutaneous island flap transfer for post traumatic equinus contractures with concomitant unstable scar or ulcer of the heel.7 They demonstrated good results in six of seven patients with excellent gait normalization. Lahoti et al recently reported on five successful cases after gradual correction with a Taylor Spatial Frame with no recurrence after follow up ranging from three months to five years.8 Their procedure included tendoachilles lengthening, ankle and subtalar capsulotomy, and application of the Taylor Spatial Frame.

Although our results demonstrate successful treatment of the equinus contractures, the procedure is far from benign. While this procedure is advocated as a less-invasive technique to account for concomitant soft tissue compromise, there are clear risks to the procedure. Two out of four cases required revision surgery. One case sustained a fracture of the tibia through the site of a half pin requiring a revision construct and longer total treatment time. A second patient developed talar shift and metatarsal pin bending requiring revision. Both of these cases resulted in successful outcomes, but the possible complications of this procedure are real and need to be taken into account before proceeding with the index procedure.

Additionally, our case studies are limited by virtue of their methodology. Formal outcome measures were not studied beyond radiographic measurements and clinical evaluation. Additionally, our follow up times are short. Our most recent case of bilateral contracture correction after burns, only recently completed treatment in the past few months so further follow up is needed. Overall, these cases are not common, which creates difficulty in developing a more thorough study. However, future research should be directed towards formal outcome measures and longer follow up to build stronger literature supporting our methods.

Our proposed treatment algorithm for post traumatic equinus contracture correction has shown to be a reliable solution for the problematic equinus contracture in patients who are unable to undergo more aggressive surgical reconstruction procedures. Our results mimic those published in previous case studies, and only further strengthen the literature which supports the use of this technique. Reserved for the cases of recalcitrant, post traumatic equinus deformity, the use of a hinged external fixation device, such as the Taylor Spatial Frame, is an important tool in the orthopaedic trauma surgeon’s arsenal for treatment of these complex cases.

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Figures

Figure 1

Reproduced from: Wukich DK, Dial D. Equinovarus deformity correction with the Taylor Spatial Frame. Oper Tech Orthop. 2006;16:18-22.

Figure 2

Case 1: Preoperative deformity, 80 degrees

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Figure 3

Case 1: Fracture through proximal tibial pin, requiring revision

Figure 4

Case 1: Photograph showing the revision construct with additional static proximal ring to span tibia fracture

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Figure 5

Case 1: Postoperative radiograph demonstrating the healing tibia fracture and full equinus correction

Figure 6

Case 2: Preoperative deformity, 90 degrees

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Figure 7

Case 2: Postoperative correction

Figure 8

Case 3: Preoperative deformity, 90 degrees, bilateral ankles

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Figure 9

Case 3: Intraoperative radiograph demonstrating complete correction of right ankle

Figure 10

Case 3: Pre- and postoperative photographs of left ankle

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References

1. Grill F, Franke J. The Ilizarov distractor for the correction of relapsed or neglected clubfoot. J Bone Joint Surg Am. 1987;69B;593.

2. Oganesyan OV, Istomina IS, Kuzmin VI. Treatment of equinocavovarus deformity in adults with the use of a hinged distraction apparatus. J Bone Joint Surg Am. 1996;78:546-556.

3. Tsuchiya H, Sakurakichi K, Uehara K, et al. Gradual closed correction of equinus contracture using the Ilizarov apparatus. J Orthop Sci. 2003;8:802-806.

4. Nomura I, Watanabe K, Matsubara H, Nishida H, Shirai T, Tsuchiya H. Correction of a severe poliomyelitic equinocavovarus foot using an adjustable external fixation frame. J Foot Ankle Surg. 2014;53:235-238.

5. Melvin JS, Dahners LE. A technique for correction of equinus contracture using a wire fixator and elastic tension. J Orthop Trauma. 2006;20:138-142.

6. Wukich DK, Dial D. Equinovarus deformity correction with the Taylor Spatial Frame. Oper Tech Orthop. 2006;16:18-22.

7. Shu H, Ma B, Kan S, Wang H, Shao H, Watson JT. Treatment of posttraumatic equinus deformity and concomitant soft tissue defects of the heel. J Trauma. 2011;71:1699-1704.

8. Lahoti O, Willmott H, Abhishetty N. Correction of post traumatic equinus contracture of ankle using Taylor Spatial Frame. Bone Joint Proceedings. 2013;95:Supp 7.

9. Calhoun JH, Evans EB, Herndon DN. Techniques for the management of burn contractures with the Ilizarov fixator. Clin Orthop Relat Res. 1992;280:117-124.

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Mihir Desai, MD PGY-5

Administrative Chief Resident


Hand and Microvascular Fellowship

Duke University

Durham, NC

EDUCATION

Georgetown University, Washington, DC

Doctor of Medicine, Graduated Cum Laude, May 2009

Davidson College, Davidson, NC

Bachelor of Science, Psychology, May 2004

HONORS AND AWARDS

Administrative Chief Resident, Orthopaedic Surgery Residency 2013-2014

Thomas E. Whitesides, MD Resident Research Award 2013 Georgia Orthopaedic Society Annual Meeting, Sea Island, GA

Repair of the Peripheral Triangular Fibrocartilage Complex: A Biomechanical Comparison Between a Knotless Suture Anchor Repair and the Traditional Outside – in Repair. Desai MJ

OREF Resident Research Award - Southern Orthopaedic Association 2013 Annual Meeting, Palm Beach, FL

Repair of the Peripheral Triangular Fibrocartilage Complex: A Biomechanical Comparison Between a Knotless Suture Anchor Repair and the Traditional Outside – in Repair. Desai MJ

Outstanding PGY-2 Award Recipient - Emory University 2011 Department of Orthopaedics

The Joshua Pletka, MD Award – Georgetown University School of Medicine 2009 Awarded to the former Georgetown Master’s of Physiology and biophysics graduate with the highest academic achievement during medical school

The Donald M. Kerwin, MD Award – Georgetown University 2009 School of MedicineDepartment of Pathology’s award given for outstanding academic performance

Department of Orthopaedic Surgery Senior Medical Student Award 2009 Georgetown University School of Medicine

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PUBLICATIONS:

Compartment syndrome of the upper arm and forearm. Desai MJ, Shuler MS, Seiler JG. Tech

Orthop 2012;27: 30-37.

Tendon transfers for radial, median, and ulnar nerve palsy. Seiler JG, Desai MJ, Payne SH. J

Am Acad Orthop Surg 2013;21:65-684.

Arthroscopic repair of triangular fibrocartilage complex tears: a biomechanical comparison of a

knotless suture anchor and the traditional outside – in repairs. Desai MJ, Hutton, WC, Jarrett

CD. J Hand Surg [AM] 2013;38:2193-2197.

BOOK CHAPTERS:

Biologics For Spinal Fusion (Chapter 49). In: Shen Fh Ed. The Cervical Spine (In Press) Park DK, Desai MJ, Yoon ST

Flexor Tendon Repair And Reconstruction (Chapter 7). In: Wolfe, Sw Ed. Green’s Operative Hand Surgery – 7th Edition (In Process) Seiler JG, Desai MJ

ACTIVE RESEARCH: Factors Affecting Spanning – Knee External Fixator Stiffness: A Biomechanical Study. Desai MJ, Reisman W, Fechter C, Lin A, Hutton WC. Manuscript Submitted for Publication Medicaid Patients with Adolescent Idiopathic Scoliosis Present with Larger Curves and Wait Longer for Surgery than Privately Insured Patients. Fletcher ND, Bruce RW, Desai MJ. Manuscript Submitted for Publication

PRESENTATIONS:

*Presenter

Trapeziometacarpal Joint Anatomy and Non-operative Treatment of TM arthritis. Seiler JG, Desai MJ American Society for Surgery of the Hand Annual Meeting, Las vegas, NV, 2011 Reconstruction of Brachial Plexus injuries using Nerve Transfers. Desai MJ

Georgia Society for Surgery of the Hand Annual Meeting, Sea Island, GA, 2011 Dupuytren’s Disease – Treatment Options, Prognosis, and Complications: An EBM review. Seiler JG, Desai MJ American Society for Surgery of the Hand Annual Meeting, Chicago, IL, 2012 Tendon Transfers for Median Nerve Palsy. Seiler JG, Desai MJ American Society for Surgery of the Hand Annual Meeting, Chicago, IL, 2012 Factors Affecting Spanning - Knee External Fixator Stiffness: A Biomechanical Study. Desai MJ Atlanta Trauma Symposium, Atlanta, GA, 2013*

24

Factors Affecting Spanning - Knee External Fixator Stiffness: A Biomechanical Study. Desai MJ Southern Orthopaedic Association Annual Meeting, Palm Beach, FL, 2013* Repair of the Peripheral Triangular Fibrocartilage Complex: A Biomechanical Comparison Between a Knotless Suture Anchor Repair and the Traditional Outside – in Repair. Desai MJ Southern Orthopaedic Association Annual Meeting, Palm Beach, FL, 2013* Repair of the Peripheral Triangular Fibrocartilage Complex: A Biomechanical Comparison Between a Knotless Suture Anchor Repair and the Traditional Outside – in Repair. Desai MJ Georgia Orthopaedic Society Annual Meeting, Sea Island, GA, 2013* Repair of the Peripheral Triangular Fibrocartilage Complex: A Biomechanical Comparison Between a Knotless Suture Anchor Repair and the Traditional Outside – in Repair. Desai MJ Eastern Orthopaedic Association, Miami, FL, 2013 – Podium Presentation Repair of the Peripheral Triangular Fibrocartilage Complex: A Biomechanical Comparison Between a Knotless Suture Anchor Repair and the Traditional Outside – in Repair. Desai MJ American Society for Surgery of the Hand Annual Meeting, San Francisco, CA, 2013* Tendon Transfers for Median Nerve Palsy. Seiler JG, Desai MJ American Society for Surgery of the Hand Annual Meeting, San Francisco, CA, 2013 Children with Medicaid Requiring Spinal Fusion for Scoliosis Present with Larger Curves and Wait Longer for Surgery than Patient’s with Private Insurance. Lazarus D, Desai MJ, Fletcher N, Bruce R. POSNA/AAOS International Pediatric Orthopaedic Symposium, Lake Buena Vista, FL, 2013 Repair of the Peripheral Triangular Fibrocartilage Complex: A Biomechanical Comparison Between a Knotless Suture Anchor Repair and the Traditional Outside – in Repair. Desai MJ American Association for Hand Surgery, Honolulu, HI, 2014 – Podium Presentation*

25

Arthroscopic Repair of Triangular Fibrocartilage Tears: A

Biomechanical Comparison of a Knotless Suture Anchor

and the Traditional Outside-In Repairs

Mihir J. Desai, MD, William C. Hutton, DSc, Claudius D. Jarrett, MD Purpose To compare the biomechanical strength of a knotless suture anchor repair and the traditional outside-in repair of peripheral triangular fibrocartilage complex (TFCC) tears in a cadaveric model.

Methods We dissected the distal ulna and TFCC from 6 matched cadaveric wrist pairs and made iatrogenic complete peripheral TFCC tears in each wrist. In 6 wrists, the TFCC tears were repaired using the standard outside-in technique using 2 2-0 polydioxane sutures placed in a vertical mattress fashion. In the other 6 wrists, we repaired the TFCC tears using mini- pushlock suture anchors to the fovea. The strength of the repairs was then determined using a materials testing machine with the load placed across the repair site. We loaded the repairs until a gap of 2 mm formed across the repair site, and then subsequently loaded them to failure. Thus, for each repair we obtained the load at 2-mm gap formation, load to failure, and mode of failure.

Results At the 2-mm gap formation, the suture anchor repairs were statistically stronger than the outside-in repairs. For load to failure, the suture anchor repairs were also statistically stronger than the outside-in repairs. Failure in both techniques occurred most commonly as suture pull-out from the soft tissues.

Conclusions The all-arthroscopic suture anchor TFCC repair was biomechanically stronger than an outside-in repair.

Clinical relevance The suture anchor technique allows for repair of both the superficial and deep layers of the articular disk directly to bone, restoring the native TFCC anatomy. By being knotless, the suture anchor repair avoids irritation to the surrounding soft tissues by suture knots. (J Hand Surg 2013;38A:2193e2197. Copyright © 2013 by the American Society for Surgery of the Hand. All rights reserved.)

Key words Repair, suture anchor, triangular fibrocartilage complex tears, wrist.

The triangular fibrocartilage complex

(TFCC) is an important stabilizer of the distal radioulnar joint. It also acts as a cushion for load transfers across the distal ulnae carpus articulation.1 The critical stabilizing component of the TFCC inserts directly into the ulna either deep into the fovea (ligamentum subcruentum) or at the base of the styloid. Palmer and Werner1 classified TFCC injuries based on the location and chronicity of the tear. Acute peripheral tears (type IB) tend to be the most amenable to surgical repair in patients

From the Department of Orthopaedic Surgery, Emory University School of Medicine; and the Veterans Affairs Medical Center, Atlanta, GA. Received for publication June 5, 2013; accepted in revised form August 6, 2013. Support was received from Arthrex (Naples, FL). Corresponding author: Mihir J. Desai, MD, Emory Orthopaedics and Spine Center, 59 Executive Park South, Atlanta, GA 30329; e-mail: [email protected] 0363-5023/13/38A11-0016$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2013.08.097

© 2013 ASSH r Published by Elsevier, Inc. All rights reserved. r 2193

mailto:[email protected]

http://dx.doi.org/10.1016/j.jhsa.2013.08.097

26 JHS r Vol 38A, November 2013

FIGURE 1: The TFCC with the distal ulna. A The hash sign shows the distal ulna articular surface, the asterisk shows the TFCC, and the double asterisk shows the extensor carpi ulnaris subsheath with tendon. B Polyester fiber tape is looped through the repair. The articular disk is to the right. Simulated TFCC tear after knotless suture anchor repair is positioned for testing. C Simulated TFCC tear after outside-in repair loaded to failure. D The specimen is seen after testing with suture pullout from the soft tissues. The asterisk denotes the articular disc. Polydioxane sutures have pulled from the disc and the soft tissue repair.

who fail conservative treatment.2,3 Furthermore, operative treatment may be elected in a special subset of patients, such as athletes. Several open and arthroscopic techniques for the repair of peripheral tears have been described.4 Current arthroscopic repairs are either inside-out, outside-in, or all-arthroscopic.5e8

Inside-out and outside-in repair techniques rely mostly on soft tissue fixation of the superficial TFCC fibers. A prolonged period of above-elbow immobilization is then required. In addition, both techniques place patients at risk for pain resulting from prominent subcutaneous suture knots, skin problems, nerve or tendon injury, and even septic arthritis.9e12

Several all-arthroscopic peripheral TFCC repairs have been described using techniques largely borrowed from meniscal repairs in the knee.7,11 These techniques also rely on soft tissue fixation and tend to require a protracted period of immobilization.

27

Specimen Load to 2-mm Gap Load to Formation, N Failure, N

Outside-in repair

1 2 62

2 1 62

3 2 49

4 3 55

5 1 50

6 2 48

Knotless

suture

anchor

repair

1

2

3

4

5

6

JHS r Vol 38A, November 2013

Recently, suture anchors have been used to allow all- arthroscopic repairs with the potential benefits of providing an improved anatomic, biologic, and mechanical repair.13,14 The purpose of this biomechanical study, using a cadaveric model, was to compare a knotless suture anchor repair with the traditional outside-in repair. We hypothesized that the suture anchor fixation would be stronger than the traditional outside-in soft tissue repair.

MATERIALS AND METHODS

We used 6 matched pairs of fresh-frozen cadaveric wrists in this study. All specimens were evaluated and found to be free of any prior wrist pathology. The distal ulna and TFCC were dissected from each wrist (Fig. 1A), and complete Palmer IB peripheral TFCC tears were created in all of the specimens using a scalpel. One wrist in each pair was randomly assigned to the control group and underwent an outside-in TFCC repair. This was done using two 2-0 polydioxane (PDS; Ethicon, Somerville, NJ) sutures placed in a vertical mattress fashion, as described by Whipple and Geissler.14 The contralateral wrist in each pair was assigned to the experimental group and received a suture anchor repair. This was done using 2-0 fiber wire and mini-pushlock suture anchors (Arthrex, Naples, FL) to the fovea, as described by Geissler.15

We then mounted each repaired specimen mounted onto a Mini Bionix materials testing machine (Eden Prairie, MN) with polyester fiber tape (Ethicon) placed across the repaired tear (Fig. 1B). This testing model was similar to the one used by Yao.9 We then determined the strength of the repair by applying a load across the repaired peripheral TFCC tear. The vector of pull was perpendicular to the repair (Fig. 1C). Each repair was loaded until a gap of 2 mm formed across the repair site, when the load was noted. The specimen was then loaded to failure, when the load was again noted. Failure was defined as suture pullout, knot failure, or tissue failure. Thus, for each repair we obtained the load at 2-mm gap formation, load to failure, and mode of failure. We compared load at 2-mm gap formation and load to failure for each repair using the Wilcoxon signed- rank test; P ::; .05 was considered significant.

RESULTS

Table 1 shows the load to 2-mm gap formation and load to failure for each specimen. At 2 mm gap formation, the loads to failure for the suture anchor repairs (10 ± 3 N) were statistically stronger than for the outside-in repairs (2 ± 1 N; P < .05). For load to failure, the suture anchor repairs (73 ± 3 N) were also statistically stronger than the outside-in repairs (54 ± 6 N; P < .05).

TABLE 1. Results for Load to 2-mm Gap Formation and Load to Failure for Each Specimen Repaired With Traditional Outside-In Technique and With Knotless Suture Anchor Technique


The most common mode of failure was suture pullout. In 5 specimens from the suture anchor group, sutures pulled out from the radial aspect of the TFCC repair. Of the 3 specimens from the outside-in group where the suture pulled out, 2 were from the radial aspect of the TFCC repair and 1 was from radial and capsular aspect of the repair (Fig. 1D). The knots failed in 2 specimens from the outside-in group. Soft tissue failure occurred in 1 specimen from each group.

DISCUSSION

This experiment showed that suture anchor repairs were stronger than outside-in repairs at both 2-mm gap formation and load to failure. Failure in both techniques

occurred most commonly as suture pullout from the soft tissues.

Injury to the TFCC can result in long-term pain and disability.2 Although symptomatic tears may be treated conservatively with cast immobilization, some require surgical repair to meet patients’ functional and recreational demands. Palmer type IB tears tend to be the most amenable to surgical repair because of the vascular and structural anatomy of the TFCC.16,17 Several open and arthroscopically assisted techniques have been described to repair these tears.7e20 Most authors advocate 6 to 8 weeks of above-elbow postoperative immobilization after repair.11,12,18

Open repairs of the peripheral TFCC require larger incisions, with associated patient morbidity. Visualization of the injured structures is often difficult with open repair techniques. Arthroscopic management of these injuries offers smaller incisions, less soft tissue dissection, earlier patient recovery, and better visualization of the injured tissue.8

Several arthroscopic techniques have been described. Whipple and Geissler initially described the outside-in technique using 2-0 monofilament suture to repair the injured peripheral TFCC tear to the floor of the sixth extensor compartment. Zachee et al19 described another technique using a pair of sutures introduced into the joint by a needle and pulled out of the joint using forceps. A knot is tied into the sutures and drawn back into the joint. The other ends of the sutures are then sutured subcutaneously with each other.

De Araujo et al20 and Skie et al21 described inside- out techniques. Araujo et al discussed the technique of using a Tuohy needle to bring 2 stitches as a mattress suture into the TFCC. Skie et al used various angled, zone-specific cannulas to bring the sutures from the inside to the outside of the wrist.

Both inside-out and outside-in techniques have disadvantages and complications.9e12 Both techniques require an additional incision to tie the sutures. Sutures tied to the floor of the sixth extensor compartment may irritate the extensor carpi ulnaris tendon. Monofilament sutures often require many throws for secure repair, and these bulky knots may irritate the overlying skin because of their superficial location. The ulnar nerve and artery and the dorsal sensory branch of the ulnar nerve are also at risk during repair. There are also reports of septic arthritis with these techniques when sutures are tied over a button placed on the skin.7,9e12

All-arthroscopic techniques were developed to avoid the sequelae of the inside-out or outside-in repair techniques. Bohringer et al8 described an all-arthroscopic soft tissue repair using a Meniscus Fastener Fixation System (Mitek, Westwood, MA) to repair the torn TFCC to the dorsal capsule. Yao7 described a similar technique using the FasT-Fix


meniscal repair system (Smith and Nephew, Andover, MA) to create a soft tissue repair. Chou et al13 described the use of suture anchors with an arthroscopically assisted mini-open technique in the treatment of Palmer type 1B injuries. In 8 patients, they found results comparable to those obtained using other techniques. Geissler15 described an all-arthroscopic technique using mini push-lock suture anchors and 2-0 fiber wire (Arthrex). He showed that this technique allowed repair of both the superficial and deep layers of the TFCC to the fovea, facilitating ligament to bone healing while limiting the complications associated with the outside-in and inside-out techniques. Specifically, this technique avoids an incision over the extensor carpi ulnaris tendon and requires no potentially irritating suture knots. However, the dorsal sensory branch of the ulnar nerve is still at risk with the 6R wrist arthroscopy portal. The results of our study showed that suture anchor repairs were stronger than outside-in repairs at both 2-mm gap formation and load to failure. Yao9 compared the FasT-Fix technique with the traditional outside-in repair with the same testing model that we employed for this study. He reported loads to failure of 3.7 and 2.4 N for the FasT-Fix and traditional outside-in groups, respectively. Failure was not defined, but the reported load to failure was similar to our reported load to 2-mm gap formation (2 N) for the outside-in technique. In addition, our reported load to 2-mm gap formation from the suture anchor repair group (10 N) was higher than the reported load to failure for the FasT-Fix soft tissue repair.

In a retrospective study of 14 patients treated with the FasT-Fix technique at a mean follow-up of 16 months, Yao22 reported full range of motion for all patients and an average return to work or full activity at 5 months. He also reported that 93% of patients achieved excellent subjective outcomes, based on Quick Disabilities of the Arm, Shoulder, and Hand and Patient-Related Wrist Evaluation questionnaires. Following his previous biomechanical data and the favorable clinical results, the author recommended the protocol of a short arm orthosis for 2 weeks, followed by a short arm cast for an additional 2 weeks. Patients are allowed to begin range of motion at 4 weeks.

There are limitations to this study. The applied force across the repaired TFCC in this biomechanical study did not completely replicate a true clinical environment. However, previous studies have implemented similar cadaveric testing models with some correlation to clinical results.9,22 Long-term clinical studies are necessary to advocate the routine use of suture anchors in repairing peripheral TFCC tears. Furthermore, not all peripheral TFCC tears are foveal detachments, and in these cases a soft tissue repair would adequately repair the injured structures.

Clinical studies are necessary to determine whether a stronger repair would allow a patient to begin early motion and avoid the possible sequelae of lost time from work and deconditioning resulting from extended above elbow immobilization.


REFERENCES

1. Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist—Anatomy and function. J Hand Surg Am. 1981;6(2):153e162.

2. Palmer AK. Triangular fibrocartilage complex lesions: a classifica tion. J Hand Surg Am. 1989;14(4):594e606. 3. Palmer AK. Triangular fibrocartilage disorders: injury patterns and treatment. Arthroscopy. 1990;6(2):125e132. 4. Kovachevich R, Elhassan BT. Arthroscopic and open repair of the TFCC. Hand Clin. 2010;26(4):485e494. 5. Shih J, Lee H, Tan C. Early isolated triangular fibrocartilage complex tears: management by arthroscopic

repair. J Trauma. 2002;53(5):922e927. 6. Bednar JH, Osterman AL. The role of arthroscopy in the treatment of traumatic triangular fibrocartilage injuries.

Hand Clin. 1994;10(4):605e614. 7. Yao J, Dantuluri P, Osterman AL. A novel technique of all-inside triangular fibrocartilage complex repair.

Arthroscopy. 2007;23(12):1357e1361. 8. Bohringer G, Schadel-Hopfner M, Petermann J, et al. A method for all-inside arthroscopic repair of Palmer 1B

triangular fibrocartilage complex tears. Arthroscopy. 2002;18(2):211e213. 9. Yao J. All-arthroscopic triangular fibrocartilage complex repair: safety and biomechanical comparison with a

traditional outside-in technique in cadavers. J Hand Surg Am. 2009;34(4):671e676. 10. Waterman SW, Slade D, Masini BD, et al. Safety analysis of all-inside arthroscopic repair of peripheral

triangular fibrocartilage complex. Arthroscopy. 2010;26(11):1474e1477. 11. Yao J, Lee AT. All-arthroscopic repair of Palmer 1B triangular fibrocartilage complex tears using the FasT-

Fix device. J Hand Surg Am. 2011;36(5):836e842. 12. Conca M, Conca R, Pria AD. Preliminary experience of fully arthroscopic repair of triangular fibrocartilage

complex lesions. Arthroscopy. 2004;20(7):79e82. 13. Chou KH, Sarris IK, Sotereanos DG. Suture anchor repair of ulnar-sided triangular fibrocartilage complex

tears. J Hand Surg Br. 2003;28(6):546e550. 14. Whipple T, Geissler W. Arthroscopic management of wrist triangular fibrocartilage complex injuries in the

athlete. Orthopedics. 1993;16(9):1061e1067. 15. Geissler W. Arthroscopic knotless peripheral triangular fibrocartilage repair. J Hand Surg Am.

2012;37(2):350e355. 16. Bednar M, Arnoczky S, Weiland A. The microvasculature of the triangular fibrocartilage complex: its clinical

significance. J Hand Surg Am. 1991;16(6):1101e1105. 17. Thiru-Pathi R, Ferlic D, Clayton M, McClure D. Arterial anatomy of the triangular fibrocartilage of the wrist and

its surgical significance. J Hand Surg Am. 1986;11(2):258e263. 18. Papapetropoulos PA, Ruch DS. Repair of arthroscopic triangular fibrocartilage complex tears in athletes.

Hand Clin. 2009;25(3):389e394. 19. Zachee B, De Smet L, Fabry G. Arthroscopic suturing of TFCC lesions. Arthroscopy. 1993;9(2):242e243. 20. De Araujo W, Poehling GG, Kuzma GR. New Tuohy needle technique for triangular fibrocartilage complex

repair: preliminary studies. Arthroscopy. 1996;12(6):699e703. 21. Skie MC, Mekhail AO, Deitrich DR, et al. Operative technique for inside-out repair of the triangular

fibrocartilage complex. J Hand Surg Am. 1997;22(5):814e817. 22. Yao J. Repair of the peripheral triangular fibrocartilage complex tears using Fast-Fix. Hand Clin. 2011;27(3):237e242.

31

Michael Gottschalk, MD PGY-5


Hand and Upper Extremity Fellowship New York University - Hospital of Joint Disease New York, NY

EDUCATION

University of Health Science Center San Antonio (UTHSCSA)


University of Texas at Austin

Bachelor of Business Administration, Business Honors,

Finance, May 2005

HONORS AND AWARDS

2nd Place Resident Research Award Georgia Orthopaedic Society Sept 2013 Resident Traveling Award Southern Orthopaedic Association July 2013 1st Place Emory Senior Research Day - Kelly Day (Dr. Garfin) June 2013 1st Place Emory Senior Research Day - Kelly Day (Dr. Herring) June 2012 Cervical Spine Research Society Resident/Fellow Award/Grant June 2011 Texas State Board of Education - Celebration of Excellence Award May 2001 University Interscholastic Scholar Award May 2001 AP Scholar with Distinction May 2001 Valedictorian Scholarship (Highest Ranking Graduate to attend Public School) May 2001 Colorado School of Mines Award (Full College Scholarship offered) May 2000

PUBLICATIONS

Gottschalk M, Johnson J, Mitchell P, Sadlack C. Decreased Infection Rates Following Total Joint Arthroplasty in a Large County Run Teaching Hospital: A Single Surgeon's Experience and Possible Solution. Journal of Arthroplasty. -accepted to JOA, awaiting publication date

Mitchell P, Gottschalk M, Butts G, Xerogeanes J. SSI: A Comparison Between Multispecialty

and Single Specialty Outpatient Facilities. Journal of Orthopedics (2013)

http://dx.doi.org/10.1016/j.jor.2013.07.005

BOOK CHAPTERS

Moore T, Gottschalk M. Hip Fractures. Medical Management of the Surgical Patient. In Press

ACTIVE RESEARCH

Gottschalk M, Yoon S, Park D, Rhee J, Mitchell P. Surgical Training Using 3-Dimensional Real Time Navigation in Placement of Cervical Lateral Mass Screws -Manuscript submitted to The Spine Journal -CSRS Grant -Podium Presentation scheduled 12/2014 at CSRS Annual Meeting

32

Gottschalk M, Karas S, East M, Labib S, Xerogeanes J. Effect of Patient Positioning on the Incidence of Postoperative Infections in Anterior Cruciate Ligament Reconstruction -Manuscript submitted to Journal of Arthroscopy

Gottschalk M, Bellaire L, Moore T. Effective Radiation Dose in Level I Trauma Patients: The Effect of CT Scans -Manuscript submitted to Journal of Southern Orthopaedics

Gottschalk M, Karas S, Burdette R, Ghattas T. Subpectoral Biceps Tenodesis for the Treatment of Type II and Type IV Slap Lesions

-Manuscript submitted to American Journal of Sports Medicine, possible acceptance pending revision

-Accepted at AANA as podium presentation 2014 Annual Meeting -Accepted as poster presentation AOA meeting 2014 -Accepted as podium presentation at AOSSM annual meeting 2014

Gottschalk M, Boden S, Heller J, Rhee J, Yoon S. A Direct Comparison of Transforaminal Lumbar Interbody Fusion versus Posterolateral Fusion for Degenerative Spondylolisthesis -Final data gathering, manuscript phase -Accepted as E Poster LSRS 2014 Meeting

Chokshi F, Gottschalk M, Refai D, Bass D. Retrospective CT Assessment of Transforaminal Lumbar Interbody Fusion (TLIF): Radiological Evolution by Hounsfield Units and Correlation with Clinical Outcomes. -Data gathering

Gottschalk M, Todd D, Darruwalla J, Xerogeanes J, Karas S. Glenoid Version: A Predictor of Shoulder Instability in the Contact Athlete -Awaiting submission to Journal of Arthroscopy

PRESENTATIONS

Gottschalk M, Johnson J, Mitchell P, Sadlack C. Surgical Site Infection (SSI) Following Total Joint Arthroplasty in a Large Urban Teaching Hospital: A Possible Solution -Podium Presentation, Emory University Kelly Day June 2012 -1st Place Emory Senior Resident Research Day (Awarded by Dr. Tony Herring)

Mitchell P, Gottschalk M, Butts G, Xerogeanes J. SSI: A Comparison Between Multispecialty and Single Specialty Outpatient Facilities -Podium Presentation Southern Orthopaedic Association July 2013 -Resident Travelling Award Southern Orthopaedic Association -Podium Presentation Georgia Orthopaedic Society September 2013 -2nd Place Resident Research Award Georgia Orthopaedic Society

Gottschalk M, Bellaire L, Moore T, Adekunle A. Effective Radiation Dose in Level I Trauma Patients: The Effect of CT Scans. -Podium Presentation, Emory University Kelly Day June 2013 -1st Place Emory Senior Resident Research Day (Awarded by Dr. Steve Garfin) -Podium Presentation, Southern Orthopaedic Association July 2013

Gottschalk M, Karas S, Burdette R, Ghattas T. Subpectoral Biceps Tenodesis for the Treatment of Type II and Type IV Slap Lesions

-Accepted Podium Presentation AANA and AOSSM; AOA Poster Presentation Annual Meetings 2014 -Podium Presentation, North American Traveling Fellows (NATF) Emory Symposium October 2013

33

Subpectoral Biceps Tenodesis for the Treatment of Type II

and IV SLAP Lesions

Michael B Gottschalk, MD1, Spero G Karas, MD,2 Timothy N Ghattas, MD,3 Rachel Burdette, ATC, OTC4

1. Resident, PGY -5 Department of Orthopaedic Surgery Emory University School of Medicine Atlanta, GA 2. Senior Author, Associate Professor of Orthopaedic Surgery Director of Orthopaedic Sports Fellowship Head Team Physician Atlanta Falcons Department of Orthopaedic Surgery Emory University School of Medicine Atlanta, GA 3. Emory Orthopaedic Sports Fellow Department of Orthopaedic Surgery Emory University School of Medicine Atlanta, GA 4. Emory Athletic Training Fellow Department of Orthopaedic Surgery Emory University School of Medicine Atlanta, GA

Abstract

Background: Surgical repair remains the gold standard for most Type II and Type IV SLAP lesions that fail conservative management6, 34. However, most recently there are data demonstrating unacceptably high failure rates with primary repair of Type II SLAP lesions6, 34. Biceps tenodesis may offer an acceptable, if not better, alternative to primary repair of SLAP lesions 6, 34, 43, 44. Our study attempts to add to the paucity of knowledge regarding biceps tenodesis for the management of SLAP tears. Hypothesis: Subpectoral biceps tenodesis provides satisfactory, reproducible outcomes for the treatment of Type II and Type IV SLAP lesions. Study Design: Prospective Case Series Methods Patients who underwent subpectoral biceps tenodesis for Type II and Type IV SLAP lesions by a single board certified shoulder surgeon from 2006-2012 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 Visual Analog Scale (VAS) for pain, American Shoulder and Elbow Surgeons Scores (ASES), and demographic data. Results: Between 2006-2012, 36 subpectoral biceps tenodesis were performed in 33 patients for Type II or Type IV SLAP lesions. Twenty-six patients with 29 shoulder surgeries were available for follow up. Average age was 46.7 years old with 16 males and 10 females participating in the study. Average follow up was 40.17 months. There was a significant improvement in ASES and VAS scores: 48.1 and 6.4 preoperatively compared to 87.5 and

34

1.5 post-operatively (p < .001). There was no significant difference based on SLAP lesion type, age, or gender. 26 of 29 shoulders (89.65%) were able to return to their previous level of activity. Conclusion: Our 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. Key Terms: Biceps Tenodesis, SLAP tear, outcomes, arthroscopy What is known about the subject: SLAP repair outcomes vary widely in the literature with more recent studies demonstrating significant failure rates in patients 36-50 years old6, 17, 34. What this study adds to existing knowledge: To date, only one study compares biceps tenodesis to SLAP repair for Type II SLAP lesions6. This study would corroborate the results of others for Type II SLAP lesions and include new outcomes data for Type IV SLAP lesions. Our study also suggests that the outcomes of biceps tenodesis, unlike SLAP repair, appear to be

independent of patient age.

Introduction

Injuries to the superior glenoid labrum-biceps anchor complex were initially recognized

by Andrews, et al in 19852. In 1990, Snyder and colleagues coined the term “SLAP” lesions for

Superior Labral Anterior and Posterior tear of the glenoid labrum and created a classification

system with four distinct subtypes40. Morgan, et al further divided Type II SLAP lesions in to

three separate entities29. For the purpose of this paper, a full description of SLAP lesions and

their classification can be found in the original manuscripts29, 40.

The overall incidence of SLAP lesions has been widely reported in the literature and

has ranged from 6% to 29 %24, 27, 39. The individual incidence of the various SLAP lesions has

also been reported with Type II lesions being the most common, ranging from 21-55%, and

Type IV lesions being the least common, ranging from 4%-15% 24, 27, 39, 40. Studies have

demonstrated that isolated SLAP lesions are uncommon and that SLAP lesions are often

accompanied by concomitant shoulder pathology24, 35. Documented associated pathologies

have included Bankart lesions (15-22%), full thickness rotator cuff tears (11-15%), partial

thickness rotator cuff tears (26-29%), acromioclavicular (AC) joint arthritis (11-15%), and

glenohumeral chondral injury (10-15%)24, 27, 39, 40.

The mechanism of injury for SLAP lesions has varied widely in the literature. Most

injuries can be divided into acute traumatic injuries and overuse injuries25. Specific injury

mechanisms include a fall on a flexed abducted arm, traction injury, recurrent instability

episodes, and repetitive overhead use in athletes27, 38-40. Because of the high incidence of

SLAP lesions in the overhead athlete, several prevailing theories have been described to

explain the pathophysiology of SLAP lesions and the ensuing shoulder ailments in this specific

subset. These include the "peel back mechanism" described by Burkhart, et al and the

"posterior superior glenoid impingement model" described by Walch and Jobe4, 8, 21, 42.

Despite an abundance of evidence-based literature over the last three decades, the etiology

of SLAP lesions remain ambiguous.

35

Although the mechanism of injury for SLAP lesions remains debatable, the ensuing

shoulder disability has been widely established. Studies suggest that most patients present

with pain, mechanical symptoms, instability, loss of range of motion, or inability to perform at

their previous athletic level27, 39. Despite these significant functional impairments, diagnosis of

isolated SLAP lesions has historically been difficult. This has been attributed to several

reasons such as the high incidence of other associated shoulder pathology, poor

sensitivity/specificity of clinical exam tests, and difficulties with the interpretation of advanced

imaging11, 24, 30. The advent of magnetic resonance arthrography and improved physical

examination techniques has enhanced the ability of clinicians to diagnose these entities in

isolation3, 5, 23.

For the previously mentioned reasons, the reported results of SLAP repairs have been

inconsistent. Successful outcomes for repair of Type II SLAP lesions have been reported in

anywhere from 65% to 94% of patients1, 7, 10, 22, 35. Return to sports has been less

encouraging, with results ranging from 20% to 87%. Not surprisingly, patients with overhead

sports demands (throwing or racquet sports) have among the worst results20, 22. Some studies

have also implicated age as a risk factor for failure of repair and ultimately worse return to play

activity6, 34. Despite these recent reports, SLAP repairs in this subset of patients continue to

increase43, 44.

To our knowledge, only one study has investigated biceps tenodesis as a primary and

salvage operation for Type II SLAP lesions6. Due to the discrepancy of reported outcomes for

primary repair of SLAP lesions, it was the objective of this study to evaluate subpectoral

biceps tenodesis as a technique for the treatment of Type II and Type IV SLAP lesions.

Materials and Methods

Institutional review board approval was obtained for this study. From 2006 to the

present, all patients undergoing shoulder surgery by a single, board certified, fellowship

trained shoulder surgeon were prospectively entered into the surgeon’s pre-operative data

base. From this group, patients who underwent biceps tenodesis for isolated Type II or Type

IV SLAP lesions were identified using Current Procedural Terminology (CPT) codes (CPT

code 23430). Inclusion criteria included patients with Type II or Type IV SLAP lesions that

were greater than 18 years of age. Patients who had impingement-type disorders, isolated

intra articular chondral defects, acromioclavicular (AC) joint osteoarthritis, partial rotator cuff

tears or recurrence of a previous SLAP repair were also included. Exclusion criteria included

those patients with Type II or Type IV SLAP lesions who underwent biceps tenodesis with

rotator cuff repair, Bankart repair, or any other type of labral repair (i.e. significant intra-

articular pathology). Patients with global degenerative changes (involving both the humeral

head and the glenoid) were also excluded.

A single, board certified orthopedic shoulder surgeon performed all procedures, and

operative technique was standardized for all patients. From the beach chair position, a

diagnostic arthroscopy was performed on all patients. The superior labrum was evaluated via

probe from the anterior portal. Biceps tenotomy was performed with a bipolar radiofrequency

probe (Arthrocare Sports Medicine, Austin, Texas). The remaining superior labrum was

debrided using an arthroscopic shaver to remove loose fragments back to a stable smooth

surface. To perform the bicep tenodesis, the surgical bed was placed in Trendelenberg

position to orient the patient in a more supine position. The arm was slightly abducted and

36

placed on a padded Mayo stand and the axilla re-prepped to ensure sterility. The pectoralis

tendon was palpated in the anterior axillary fold and an incision made just inferior to the

palpated tendon. Blunt dissection was carried out deep to the pectoralis musculotendinous

junction and the pectoralis tendon was retracted superolaterally using a blunt Homan

retractor. Medially, another blunt Homan retractor was utilized to retract the short flexors of

the elbow. The biceps was localized and excised from its sheath using a right angle clamp. A

Fiberloop (Arthrex Inc Naples, Florida) whipstitch was utilized to secure the biceps. The

proximal portion of the biceps was excised. Thereafter, an eight-millimeter drill hole was drilled

at the base of the biceps groove and a Bio-Tenodesis Screw (Arthrex Inc Naples, Florida) was

used for fixation. Wounds were irrigated and closed in layers. (See Video 1)

Following subpectoral biceps tenodesis all patients received a standardized

rehabilitation protocol. The protocol is divided in to three phases. Phase one (weeks 1-3)

required immobilization in a sling for three weeks, passive elbow range of motion, and active

shoulder range of motion. Phase two (weeks 4-8) added gentle isometric biceps exercises

and a rotator cuff strengthening program. Phase three (weeks 9-16) involved a progressive

strengthening and functional rehabilitation. Patients were released at four to five months

postoperatively. Overhead athletes completed a staged, sport specific interval program prior

to returning to play.

Outcome measures included Visual Analog Scale (VAS) pain and American Shoulder

and Elbow Surgeons (ASES) scores. All patients were prospectively enrolled in the surgeon’s

database pre-operatively, and had previously completed VAS and ASES outcome measures.

Post-operatively, patients were contacted via telephone and interviews were conducted based

on consent from the patient. Post-operative VAS and ASES scores were obtained and

patients were asked about their return to sport or their ability to return to previous activities.

Patients' activities were rated from one to three with one being “high demand” and three being

“low demand”. Age, gender, date of surgery, VAS, ASES, activity, activity level, type of SLAP

lesion, and complications were all recorded and analyzed.

A department-designated statistician performed statistical analysis. Mean and

standard deviations were calculated for continuous variables. Wilcoxon Rank Sum Test,

Mixed Model, Adjusted Model, and Covariance analysis were performed when applicable. A p

value of < 0.05 was used to define statistical significance.

Results

36 subpectoral biceps tenodesis procedures (in 33 patients) for isolated Type II or

Type IV SLAP lesions were prospectively enrolled into the database. All patients were

followed for a minimum of 5 months postoperatively, and 26 patients (29 tenodesis

procedures) were available for follow up at an average of 40.17 months (range 16-80 months)

post-operatively (80% follow-up). 19 patients had Type II SLAP lesions and 10 had Type IV

SLAP lesions. There were 16 males and 10 females with a mean age of 46.7 years (range 19

- 63 years) (Table 1).

Subpectoral biceps tenodesis resulted in significant improvement in ASES scores from

an average of 48.1 (range 32-68) pre-operatively to an average of 87.5 (range 46.7-100.0)

post-operatively (p < .001). VAS scores also decreased significantly from 6.4 (range 4-10)

pre-operatively to 1.5 (range 0 - 8) post-operatively (p< .001) (Table 2). There was no

significant difference noted based on SLAP lesion type, age, activity level, or gender (Table

37

3). 26 of 29 patients (89.65%) were able to return to their pre-injury level of activity. These

activities included softball, weightlifting, golf, tennis, volleyball, snow skiing, equestrian

activities, racquetball, and boxing. The three patients that were unable to return to their pre-

injury sporting activities included one softball player, one cricket bowler, and a gymnast. The

gymnast underwent bicep tenodesis for a failed SLAP repair, and also incurred a foot fracture

that limited her competitive career.

There were four complications (11%) in our series. One patient incurred a brachial

plexus neurapraxia that was determined to result from the pre-operative interscalene

anesthetic. Another patient suffered a traumatic rupture of the biceps tenodesis after a fall

one week postoperatively. Two patients developed wound erythema postoperatively that

raised a concern for perioperative infection. Both of these resolved with oral antibiotics and

no additional procedures were required. Specifically, no patients complained of instability or

mechanical symptoms as a result of their biceps tenodesis.

Discussion

Recent reports have revealed an alarming increase in the incidence of surgery for the

repair of SLAP lesions43, 44. However, SLAP repair outcomes have varied widely in the

literature, and there remains doubt regarding the efficacy of SLAP repairs, especially in middle

aged patients 6, 17, 34, 43, 44. This can likely be explained due to the variety of techniques used

for repair, multiple concomitant pathologies addressed at the time of surgery, patients' activity

levels, and the age of the patient. Several studies have shown good to excellent success with

SLAP repairs for Type II lesions, while others have shown poor results in certain patient

subsets7, 9, 18, 20, 22, 25, 35. Due to the low incidence of isolated Type IV SLAP lesions, limited

outcomes data is available for review.

The aim of our study was to evaluate the effectiveness of biceps tenodesis in a

prospectively enrolled group of patients with Type II and IV SLAP lesions. We noted

significant improvements in pain, ASES scores, and return to previous level of activity in our

cohort of patients. The study has numerous strengths, including a prospectively enrolled

patient set, a narrow list of concomitant pathologies, and a single surgeon performing all the

procedures. Also, all procedures were performed with a highly standardized surgical

technique and postoperative rehabilitation protocol. However, our study also has several

limitations. Because the procedures were limited to those performed by a single surgeon, a

relatively small number of patients were available for follow up. Furthermore, because of the

wide spectrum of patients treated in the surgeon’s practice, there were several concomitant

pathologies treated at the time of the procedures. However, previous authors have evaluated

the effect of addressing associated pathology at the time of SLAP repair, with minimal clinical

impact on patient outcomes7, 10, 14, 15, 35.

Several surgical methods have been employed for SLAP repair with varying success

rates. The use of staples, transosseous sutures, bioabsorbable implants, suture anchors, and

biceps tenodesis have previously been described9, 16, 20, 25, 26, 33, 37. Biomechanical studies

have proven that suture anchors offer a secure construct for SLAP repair, while interference

screw fixation provides an excellent method for biceps tenodesis13, 28, 32. Functional and self

reported outcomes have also favored suture anchors over bioabsorbable tacks with outcomes

ranging from 87-94% and 70-88%, respectively7, 9, 10, 25, 29. In summary, the current literature

does not support insufficient fixation as a source of failed SLAP repair.

38

SLAP repairs for high demand patients, specifically overhead athletes, have

demonstrated wide variability in outcomes, with return to play percentages ranging from 20-

87%6. Several factors may affect this discrepancy in outcomes4, 7, 9, 10, 18, 20, 22, 25, 29-31, 33, 35, 37.

The biceps tendon has been implicated in failure of primary SLAP repair due to its theorized

role as a persistent force on the repair2. Patient age is another commonly suggested factor in

failed SLAP repairs. Recent literature has demonstrated that older patients may have a higher

propensity toward clinical failure of their SLAP repair, with specific age cutoffs ranging from

36-50 years of age 1, 6, 17, 25, 31, 34. The intrinsic vascular properties of the superior osseous

glenoid may also play a role in failed repair, as previous studies have demonstrated

decreased vascularity in the superior osseous glenoid and the superior labral complex12, 19. It

is important to note that our study revealed no significant link between patient age and

surgical outcomes. We postulate that the biceps tenodesis eliminates the pull of the biceps as

a contributing factor to repair failure and does not require healing at the relative avascular

zone of the superior glenoid. Finally, although the biceps has been identified as an

intraarticular stabilizer of the glenohumeral joint36, 41, we noted no incidence of glenohumeral

instability postoperatively. Other authors have also demonstrated no cases of glenohumeral

instability after biceps tenodesis for the management of SLAP lesions6.

In conclusion, the results of this study would indicate that subpectoral biceps tenodesis

is an acceptable alternative to primary SLAP repair, and may provide the surgeon distinct

advantages in the management of SLAP lesions. The procedure is safe, reproducible, and

eliminates the requirement of direct tissue healing in a relatively avascular zone. Furthermore,

in our limited patient sample, patient age did not appear to be a significant factor in clinical

outcomes. Of course, as with any new surgical concept, enthusiasm for the procedure must

be tempered with additional study in a larger set of patients undergoing longer follow up.

39

Table 1: Demographic, Outcome, and Frequency Data

Demographic, Outcome, and Frequency Data

Demographic Data P Value

N=26 Average Age 46.70

Age Range 19-63

Male 16

Female 10

Average Follow Up 40.17

Range of Follow Up 16-80

Outcomes

N=29 Average Pre Op ASES 48.10 0.001

Range of Pre Op ASES 32-68

Average Post Op ASES 87.50

Range of Post Op ASES 46.7-100

Average Pre Op VAS 6.40 0.001

Range of Pre Op VAS 4-10

Average Post Op VAS 1.50

Range of Post Op VAS 0-8

Type of Lesions

N=29 Type II SLAP Lesions 19

Type IV SLAP Lesions 10

Associated Lesions/Surgery

N=29 Buford Complex 1

Glenohumeral Changes 5

AC Joint Arthritis 14

Impingment/Subacromial Decompression 26

Partial Rotator Cuff Tear 10

Adhesive Capsulitis 3

Prior SLAP Repair 3

Table 2: Outcomes for All SLAP Lesions

Outcomes for All SLAP Lesions

Pre Post P-Value

VAS 6.0 (4-10) 1.5(0-8) <.001

ASES 48.1(32-68) 87.5(46-100) <.001

40

Table 3: Comparison of Type II and IV SLAP Lesions

Comparison of Type II and IV SLAP Lesions

II IV

Male 12 7

Female 7 3

Age 48 46

Pre VAS 6.37 6.56

Post VAS 1.47 1.5

Pre ASES 48.16 48

Post ASES 86.67 89

Buford 1 0

Glenohumeral Changes 3 2

AC Joint Arthirtis 9 5

Impingement/SAD 17 9

Partial RCT 7 3

Adhesive Capsulitis 2 1

Prior SLAP Lesion 2 1

41

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43

Mark Magill, MD PGY-5


Foot and Ankle Fellowship

OrthoCarolina Foot & Ankle Institute

Charlotte, NC

EDUCATION

Vanderbilt University School of Medicine, Nashville, TN


Saint Louis University, St. Louis, MO

Bachelor of Science in Biomedical Engineering, June

2005

HONORS AND AWARDS

McKnight Scholarship

McMannis Educational Trust Fund Scholarship

Scott Scholarship

Jacobson Scholarship

David Hitt Williams Memorial Scholarship

PUBLICATIONS

Labib SA, Magill M. “Revision Total Ankle Replacement.” edited by James DeOrio and Selene

Parekh. Total Ankle Replacement: An Operative Manual, 2013 Orthopedics

Richards JE, Magill M, Tressler MA, Shuler FD, Kregor PJ, Obremskey WT; Southern Fracture Consortium. “External Fixation versus ORIF of Distal Intra-articular Tibia Fractures.” Orthopedics, 2012 Roy, M.E., Whiteside L.A., Magill M.E., Katerberg B.J., “Reduced Wear of Cross-linked UHMWPE Using Magnesia-stabilized Zirconia Femoral Heads in a Hip Simulator.” Clinical Orthopaedics and Related Research, 2011

ACTIVE RESEARCH

Labib SA, Magill M. “Ankle Arthroscopy in Fracture Care.” Techniques in Foot and Ankle

Surgery, Submitted 2014

Lin, Angela, MS; Fechter, Chelsea; Magill, Mark, MD; Wipf, Felix; Moore, Thomas, MD; Guldberg, Robert E., PhD. “The Effect of Contouring on Fatigue Resistance of Reconstruction Plates” Journal of Orthopaedic Trauma. Submitted 2013

44

Mark Magill MD, Jaron Sullivan MD, John Xerogeanes MD, Annunziato Amendola MD. “Acute exercise induced compartment syndrome while walking” Orthopedics, Submitted 2012

Magill, M. E. and Obremskey, William T. “Time to Initiation of Antibiotic Prophylaxis in Open Fractures.” Practice guideline recommendation. Orthopaedic Trauma Association. Submitted Magill, M. E. and Obremskey, William T. “Time to Debridement of Open Fractures.” Practice guideline recommendation. Orthopaedic Trauma Association. Submitted

PRESENTATIONS

Roy, M.E., Magill M.E., Whiteside L.A., Katerberg B.J., Steiger J.A. “The Influence of Roughness on the Wettability of Retrieved Cobalt-Chromium and Zirconia Femoral Heads” Society for Biomaterials. April 18-21, 2007

Roy, M.E., Whiteside L.A., Katerberg B.J., Magill M.E., Steiger J.A. “Diamond-Like Carbon Coatings to Enhance Bearing Surfaces in Joint Arthroplasty.” Orthopedic Research Society. February 11-14, 2007

45

The Effect of Contouring on Fatigue Resistance of

Reconstruction Plates

Angela Lin, MS1,2, Chelsea Fechter3, Mark Magill, MD4, Felix Wipf5, Thomas Moore, MD6, Robert Guldberg, PhD7

Institutions:

1. George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, GA, USA

2. Parker H. Petit Institute for Bioengineering & Bioscience, Georgia Institute of Technology, Atlanta, GA, USA

3. Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA

4. Department of Orthopaedics – Trauma, Emory University School of Medicine, Atlanta, GA, USA

5. Stryker Trauma AG, Selzach, Switzerland

+ Corresponding author: Robert E. Guldberg, PhD, 315 Ferst Dr. NW, Atlanta, GA 30332; tel: +14048946589; fax: +14048942291; email: [email protected] Conflicts of Interest and Source of Funding:

Stryker Trauma AG provided funding and materials for this study.

Previous Presentation: This work was presented as a poster at the 59th

Annual Meeting of the Orthopaedic Research Society, January 2013, in San Antonio, Texas.

Acknowledgements: Authors would like to thank Michel Vallotton and Claudia Beimel from Stryker for their expertise in experimental protocol development and statistical analysis, respectively, and John Heflin, MD, from Emory University Medical School for advising during experimental concept development.

Abstract

Objectives: To assess whether contouring affects fatigue resistance for three types of 7-hole

fixation plates (Stryker BFS Reconstruction, MPS Straight, and MPS Flex Plates).

Methods: Plates were contoured using a bench-top plate bender to ±20° either 0, 3, 6, or 9

times (n=5 per group) and tested in the straight 0° configuration. Preliminary yield strength

was assessed for one control plate of each type to define cyclic fatigue protocols. Plates

underwent cyclic 4-point bending in an incremental stepwise staircase approach (one step =

100,000 cycles, 10Hz, between 10-100% of designated maximum load) until failure was

reached. Plate failure was defined as brittle fracture or plastic deformation (10° permanent

bend at 10N, assessed between steps). Moment – cycle product (MCP) was computed as the

summation of maximum moment x number of cycles and used as a measure of fatigue

resistance.

mailto:[email protected]

46

Results: No significant differences in MCP were detected between groups for BFS

Reconstruction Plates. For MPS Straight Plates, significantly lower MCP was required to bring

Group C plates (9x) to failure compared to Control plates (p = 0.023). For MPS Flex Plates,

Group A plates (3x) required significantly higher MCP to failure than Control (p = 0.031) and

Group C plates (p = 0.032).

Conclusions: This work suggests that clinicians should avoid repeatedly contouring non-

annealed Stryker MPS Straight Plates while annealed Stryker BFS Reconstruction Plates or

MPS Flex Plates would not be negatively affected with high contouring repetitions.

Key Words: pelvic, fracture fixation, internal fixator, stainless steel, bone plates, contouring, cyclic fatigue resistance

Introduction: Pelvic fractures often occur due to high-energy trauma such as those experienced in

motor vehicle accidents, auto-pedestrian collisions, falls from a height, or crush injuries. In

these polytrauma scenarios, significant morbidity and mortality may occur depending on the

fracture configuration and severity of the combined injuries1, 2. Additionally, even those pelvic

fractures at lower risk for mortality may result in significant pain, deformities, and disability if

not treated properly. Significant pelvic fractures have been linked to long term disability, poor

functional outcomes, abnormal gait, urological complications, sexual dysfunction, and

neurological deficiencies3-5. Over the past two decades, advances in operative techniques and

implants and the realization of the systemic benefits of early mobilization have resulted in

better outcomes for pelvic fracture patients2, 6.

Post-operative care for pelvic fracture patients involves intense physical and

occupational therapy, especially during the immediate 6-12 week post-operative protected

weight bearing period. Patients are mobilized early to avoid the known morbidity of prolonged

recumbency7. Typical post-operative protocols include range of motion (ROM) exercises on

the affected operative hip as tolerated and exercises involving hip abductor, quadriceps, and

hamstring strengthening. Even non-weight bearing exercises used in neuromuscular re-

education impart loads and bending moments that are transmitted to the pelvis. For example,

joint reaction forces across the hip are approximately 2.5 times body weight (BW) when lifting

both hips off of a hospital bed, 1.5 times body weight with ipsilateral straight leg raises. In

addition comparable forces are experienced by the injured hip during contralateral hip leg

raises8, 9. When patients perform seated active exercises of the hip and knee, the forces

across the hip are equivalent to slow walking. During non-weight bearing activity, the hip

usually experiences less than one times body weight across the hip. Forces of up to 8.7 times

body weight can occur across the hip with stumbling onto the affected extremity8, 9. A recent

study reported an implant failure rate of 43% at a median of 12 months following pelvic

reconstruction, which was higher than the 12-31% previously reported in literature10. Clearly,

for pelvic fractures experiencing loads of these magnitudes during rehabilitation, proper

restoration of pelvic ring stability with implants able to withstand cyclic loading is necessary for

preventing reinjury or implant failure.

Many intraoperative challenges exist in providing the necessary stabilization.

Visualization of pelvic fractures can be difficult due to the large muscles that span the pelvis,

especially the hip abductors, and indirect reduction is often necessary. High variance in

47

individual pelvic sizes and differences due to gender make pre-contoured plates impractical.

The plates used in pelvic reconstructions are initially straight but malleable to allow contouring

in multiple planes to match individual patient anatomy. Several contouring repetitions are often

necessary to achieve proper fit, particularly for inexperienced surgeons. Though plate integrity

following contouring has been questioned, no studies to date have assessed the effects of

multiple contouring on mechanical properties of fixation plates.

Studies regarding stability of pelvic and long bone fixations have largely been

conducted on model systems. In these models, single or multiple fixation plate constructs

were assembled to stabilize fractures created on synthetic or cadaver long bones11-23 or

pelves24-32. While these studies provided relevant model-specific assessments of stability and

failure mechanisms in systems involving plates that were not contoured, no studies quantified

mechanical properties of fixation systems involving contoured plates.

Evaluating mechanical properties of the plates themselves is one direct method for

assessing changes that may lead to increased construct failure rate. The American Society for

Testing and Materials (ASTM) standard F382-99 specifies test methods to assess mechanical

characteristics important to the in vivo performance of bone plates33. F382-99 has been

recognized by the Food and Drug Administration (FDA) as a standard that applies to metallic

bone plates for orthopaedic use and affects several medical device regulation processes

(including 510(k), PMA, IDE; Recognition Number 11-240)34. Static 4-point bending test

methods from F382-99 have been utilized to compare plate strength and stiffness for various

types of long bone fixation plates35. Another recent study generated finite element (FE)

models to predict the stress distributions experienced by distal tibial fixation plates and

validated using static 4-point bending tests36. Though empirical mechanical assessment was

limited, the models included clinically relevant contour deformations at the ends of the plates.

Results indicated that Ti-6Al-4V alloy plates should not be used if large deformation

contouring was required while 316L stainless steel plates would maintain mechanical integrity

after large deformations.

Fatigue represents the accumulation of damage incurred by a material when it is

subjected to repetitive cyclic loading at stress magnitudes lower than that required to cause

failure in a single cycle37, 38. Fracture due to fatigue develops through the initiation of

microscopic cracks followed by gradual propagation through the implant. The study of fatigue

properties in metal components dates back to the 1800s39, 40, but the application to medical

device design is clearly of fundamental importance today41, 42 - particularly for orthopaedic

devices implanted in weight bearing fracture repair sites11, 13, 17, 19, 22, 43-46.

This study focused on assessing whether plate fatigue properties, which would be

more consistent with immediate post-operative low weight and high repetition exercises and

not unexpected falls or acute instances of extreme loading, would be negatively affected

through contouring and recontouring. Specifically, the objectives were to quantify changes in

fatigue resistance due to contouring for three types of fixation plates. The hypothesis was that

contouring with a standard bench-top plate bender would decrease plate fatigue resistance as

a function of the number of bending repetitions.

48

Materials and Methods:

Plates and Contouring

Three types of 7-hole Stryker plates were used (provided by Stryker Trauma AG, Selzach,

Switzerland, n=22 each type, 66 total plates; Figure 1): Basic Fragment Set (BFS) 4.5mm

Reconstruction Plate (REF 432207, annealed, length = 110mm), Matta Pelvic System (MPS)

Straight Plate (REF 425707, length 106.5mm), Matta Pelvic System (MPS) Flex Plate (REF

425757, annealed, length = 82.5mm). The number of contouring repetitions for each of the 4

groups were as follows: Control = 0x (no contouring), A = 3x, B = 6x, C = 9x (n=5 each group).

Contouring was performed on the middle hole with a standard bench-top plate bender to +20°

then -20° as 1x repetition. After the final repetition, the plate was returned to the 0° straight

configuration.

Preliminary 4-point Bending Tests

ASTM F382-99(Reapproved 2008)ε1, Standard Specification and Test Method for Metallic

Bone Plates, was used as a guideline for apparatus setup and fatigue test performance33.

Plates were oriented in the fixture with the bone interface (concave) side facing upwards. For

BFS Reconstruction Plates and MPS Straight Plates of the same length, outer and inner span

widths were 80mm and 32mm, respectively; for MPS Flex Plates, span widths were 60mm

and 24mm (Table 1). For one control plate of each type, preliminary static 4-point bending

was performed (MTS 858 Mini Bionix II, Figure 1) at a constant displacement control rate of

0.1 mm/s to determine bending moment at yield (My) using the 0.2% yield offset method. For

subsequent stepwise cyclic loading, step increments of 10% of the minimum of these three My

values was used.

Cyclic Fatigue Testing (4-point Bending)

Plates were subjected to cyclic loads in a stepwise staircase approach. At each step, 100,000

cycles in 4-point bending were applied at 10Hz between 10-100% of the maximum load

designated for that step. Load corresponding to 10% of the predetermined minimum My was

used as the incremental increase between steps for all samples (12.5N for BFS

Reconstruction and MPS Straight Plates; 17N for MPS Flex Plates, Table 1). To estimate

failure load levels, preliminary cyclic fatigue testing was performed on a control plate of each

type beginning at 20% of the load corresponding to My and increasing stepwise as described

until failure occurred. Based on these results, subsequent plates were cyclically tested

beginning at an initial maximum load such that failure criteria would be reached in ≤8 steps

(~24 hrs). See Table 1 for initial maximum load levels for each plate type.

Assessment of Cyclic Fatigue Resistance

For each step endured until the failure point, the maximum moment of that step was multiplied

by the number of cycles in that step, and these values were summed to compute a total

moment – cycle product (MCP) to failure. This parameter was used as a measure of cyclic

fatigue resistance similar to the moment cycle integral metric used in Schmidt, et al. for testing

locking fixation plates17.

49

Failure Criteria

Failure was defined as plate fracture due to cyclic loading or plastic deformation resulting in

10° permanent bending of the plate (empirically determined to be equivalent to 1.95mm

crosshead displacement) at low load (10N). Between each step, the plate was loaded to 10N,

and crosshead displacement was measured to determine whether the deformation criterion

was reached.

Statistics

For each plate type, MCP was compared between groups using 2-tailed Mann-Whitney U test

with Monte Carlo p-value (95% confidence interval, 10,000 samples) in SPSS Statistics V20

(IBM).

Results:

For each plate, mode of failure was indicated as reaching either brittle fracture or plastic

deformation criteria. Table 2 lists these instances for each plate type and group. Additionally,

Table 2 shows average cycles to failure, average failure load level (Ffail), average failure

moment (Mfail), and average MCP. The MCP values were selected as the most appropriate

parameter for assessing differences in cyclic fatigue resistance as this parameter included

considerations for geometry and total cycles endured whereas cycles to failure, failure load

levels, and bending moments at failure did not represent the combination of these factors as

completely. Boxplots were generated to depict MCP median values, 1st and 3rd quartiles, and

minimum and maximum values (Figure 2).

BFS Reconstruction Plates (432207)

There was no contouring group within the BFS Reconstruction Plates that exhibited failure

due to only one mode (Table 2). No differences in MCP were observed between groups

(Figure 2A).

MPS Straight Plates (425707)

Plates from all contouring groups failed due to brittle fracture, which was not the case for BFS

Reconstruction or MPS Flex Plates (Table 2). Group C plates (9x contoured) required

significantly lower MCP to fail than Control plates (p = 0.023) (Figure 2B).

MPS Flex Plates (425757)

Plates in the Control group all failed due to plastic deformation while plates in the C group (9x

contoured) all failed due to brittle fracture (Table 2). Group A plates exhibited higher MCP

compared to Control (p = 0.031) and C (p = 0.032) plates (Figure 2C).

Discussion:

This work represents the first biomechanics study to assess fatigue properties of

fracture fixation plates that have been contoured prior to testing. Biomechanical evaluations of

various standard plating systems for pelvic fracture fixation exist and provide invaluable data

for recognizing the importance of appropriate fixation and developing appropriate systems to

achieve stability24-26, 30, 31, 47. However, effects of the common practice of intraoperative plate

50

contouring on mechanical integrity have been analyzed retrospectively with radiographs48 but

not biomechanically quantified.

Annealing is a material treatment involving heating a substance to above its upper

critical temperature, maintaining this temperature, and cooling slowly to room temperature in

air. This process may allow metals and alloys to possess greater structural homogeneity and

ductility. For stainless steel and titanium alloy plates used in bone fracture fixation, annealing

will facilitate contouring because of increased ductility. For traumatic injury sites requiring

absolute stability and therefore greater resistance against immediate loading, a softer

annealed plate may not be appropriate. However, as this study showed, non-annealed plates

with lower ductility may withstand less fatigue loading after multiple contouring.

The annealed plates (BFS Reconstruction and MPS Flex Plates) used in this study

demonstrated good fatigue resistance properties. BFS Reconstruction Plates exhibited no

differences in MCP to failure across groups, indicating no effect on fatigue resistance when

plates were contoured up to 9x. No differences between control and 6x or 9x contoured plates

were observed for MPS Flex Plates, indicating no deleterious effects of high contouring

repetitions. Additionally, an increase in the ability of MPS Flex Plates to withstand cyclic

fatigue loading after 3x contouring was seen. This may be attributed to strain hardening, or a

strengthening of a material through repeated plastic deformation, with lower numbers of

contours.

Non-annealed MPS Straight Plates contoured 9x experienced lower MCP prior to

failure, indicating a significantly detrimental effect of contouring. When combined with

observations that all non-annealed MPS Straight Plates failed via brittle fracture, this

suggested that 9 or more contouring repetitions should be avoided in the clinical setting.

Although no significant differences in MCP were detected between Control and 3x or 6x

contoured plates, larger sample sizes may have allowed differences in fatigue resistance to be

detected between these groups.

One potential limitation of this study was that contouring only included single plane

bending. In the clinic, plates often undergo contouring along multiple planes, therefore

contouring performed here may not have produced clinically equivalent post-contouring

states. However, the contouring protocol was considered aggressive as it involved bending

repetitions of large (±20°) deformations in a localized position at the center of the plates.

Additionally, plates underwent high frequency and high volume cycling, and average cyclic

failure loads were above 80% of initially determined yield loads for each plate type. Fatigue

crack propagation rates have been shown to accelerate in biomedical alloy materials when

tested at high stress amplitudes in saline solution compared to tests performed in air44. This

further supports that tests were performed at adequately high cyclic loading magnitudes, as

plates in this study were tested in air.

Though the testing results do not provide insight on the effects of contouring on acute

plate failure as in the case of an accidental fall, the work suggests that clinicians should avoid

repeatedly contouring non-annealed Stryker MPS Straight Plates while annealed Stryker BFS

Reconstruction Plates or MPS Flex Plates would not be negatively affected with high

contouring repetitions. Potential future work includes a follow-up study to assess static 4-point

bending strength of these and other plates used in pelvic fracture fixation procedures.

Intraoperative contouring occurs frequently in the treatment of pelvic fractures. Unlike

long bone fractures where there is direct visualization of the bone during the contouring

51

process, pelvic fractures require indirect contouring due to low visibility associated with the

pelvis and surrounding musculature. Clinical solutions to avoid excess intraoperative

contouring include using precontoured plates or preoperatively contouring plates on a

standard anatomic model. However, the considerable anatomic variance of individual pelvic

anatomies makes these techniques non-ideal. Techniques utilizing CT imaging to generate 3D

models for the purpose of designing patient-specific plate shapes have been developed49-51,

but these capabilities are costly, not widely available, and may be excessively time consuming

for trauma situations. Completely eliminating intraoperative indirect contouring of fixation

plates may not be possible. As such, this study provides clinicians with guidelines for

intraoperative contouring of pelvic plates and resultant fatigue resistance.

Table 1. Plate characteristics and cyclic fatigue starting load levels and step increments. Lo = outer span width, Li = inner span width for 4-point bending test fixture.

Plate type

Annealed?

Length / hole

spacing (mm)

Lo

(mm)

Li

(mm)

Start F

level (N)

Load step

increment

(N)

BFS Reconstruction Y 110 / 16 80 32 300 12.5

MPS Straight N 106.5 / 16 80 32 200 12.5

MPS Flex Y 82.5 / 12 60 24 153 17

52

Table 2. Cyclic fatigue data for plate types and groups. Number of plates that failed due to either brittle fracture or plastic deformation are indicated (total n=5 per group). Average cycles to failure, failure load level (Ffail), failure moment (Mfail), and moment-cycle product (MCP) are shown as mean ± standard error.

Plate type

Group

Brittle

fracture

failure

Plastic

def.

failure

Avg

cycles to

failure

Avg Ffail

(N)

Avg Mfail

(N-mm)

Avg MCP

(N-mm)

BFS

Reconstruction

Control

4/5

1/5 497600 ±

30535

358 ±

3.1

4290 ±

37 1.94x10

9 ±

1.31x108

A (3x)

2/5

3/5 448800 ±

37803

350 ±

4.0

4200 ±

47

1.74x109

±

1.56x108

B (6x)

2/5

3/5 478000 ±

24160

355 ±

3.1

4260 ±

37 1.86x10

9 ±

1.03x108

C (9x)

3/5

2/5 429200 ±

85320

348 ±

12.1

4170 ±

145 1.67x10

9 ±

3.42x108

MPS Straight

Control

5/5

0/5 538200 ±

55203

260 ±

7.3

3120 ±

87

1.48x109

±

1.73x108

A (3x)

5/5

0/5 425400 ±

37214

245 ±

5.2

2942 ±

62 1.11x10

9 ±

1.11x108

B (6x)

5/5

0/5 423200 ±

28798

248 ±

4.7

2970 ±

56 1.12x10

9 ±

8.58x107

C (9x)

5/5

0/5 364600 ±

5741 238 ±

0

2850 ± 0 9.49x10

8 ±

1.64x107

MPS Flex

Control

0/5

5/5 632000 ±

50465

252 ±

9.9

2264 ±

89 1.14x10

9 ±

1.15x108

A (3x)

3/5

2/5 812000 ±

25938

282 ±

4.2

2540 ±

37 1.56x10

9 ±

6.55x107

B (6x)

1/5

4/5 726600 ±

43271

272 ±

5.4

2448 ±

48 1.36x10

9 ±

1.07x108

C (9x)

5/5

0/5 717200 ±

18985

269 ±

7.6

2417 ±

31 1.33x10

9 ±

4.54x107

53

Figure legends: Figure 1. Representative pictures of BFS Reconstruction, MPS Straight, and MPS Flex Plates with no contouring and before fatigue testing; 4-point bending test setup on MTS 858 Mini Bionix II (cyclic loads applied as shown, F; inner and outer span lengths Li and Lo, respectively).

Figure 2. Boxplots depict median moment-cycle product (MCP) values, 1st and 3rd quartiles, whiskers indicate maximum and minimum values (n=5 for each group). (A) BFS Reconstruction Plates: no significant differences in MCP between groups. (B) MPS Straight Plates: Group C (9x) exhibited significantly lower MCP to failure than Controls (* p=0.023). (C) MPS Flex Plates: Group A (3x) exhibited significantly higher MCP to failure than Control ($ p=0.031) and Group C (9x) († p=0.032).

54

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http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfstandards/detail.cfm?standard__identification_no=30351

http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfstandards/detail.cfm?standard__identification_no=30351

http://www.scientific.net/AMR.602-604.1181

56

Ravi Patel, MD PGY-5:


Spine Surgery Fellowship Harvard Medical School Boston, MA

EDUCATION

Jefferson Medical College, Philadelphia, PA


Pennsylvania State University, State College, PA

Bachelor of Science, May 2005

HONORS AND AWARDS

Alpha Omega Alpha Honors Society 2008

Hobart Amory Hare Honors Society 2007

Cum Laude Graduate Jefferson Medical College 2009

PUBLICATIONS

Complications associated with single-level transforaminal lumbar interbody fusion. Rihn JA, Patel RR, Makda J, Hong J, Anderson DG, Vaccaro AR, Hilibrand AS, Albert TJ. Spine J. 2009 Aug;9(8):623-9. Epub 2009 May 30. PMID: 19482519

The use of RhBMP-2 in single-level transforaminal lumbar interbody fusion: a clinical and radiographic analysis. Rihn JA, Makda J, Hong J, Patel RR, Hilibrand AS, Anderson DG, Vaccaro AR, Albert TJ. Eur Spine J. 2009 Nov;18(11):1629-36. Epub 2009 May 28 PMID:19475434

Coccydynia. Patel RR, Appannagari A, Whang PG.Curr Rev Musculoskelet Med. 2008 Dec;1(3-4):223-6. PMID: 19468909

Percutaneous vertebral compression fracture management with polyethylene mesh-contained morcelized allograft bone. Kerr SM, Liechty B, Patel RR, Harrop JS. Curr Rev Musculoskelet Med. 2008 Jun;1(2):84-7 PMID: 19468877

Thromboprophylaxis in spinal trauma surgery: consensus among spine trauma surgeons. Ploumis A, Ponnappan RK, Bessey JT, Patel RR, Vaccaro AR. Spine J. 2009 Jul;9(7):530-6. Epub 2009 Feb 28 PMID: 19251486

Biomechanical evaluation and comparison of polyetheretherketone rod system to traditional titanium rod fixation. Ponnappan RK, Serhan H, Zarda B, Patel RR, Albert T, Vaccaro AR Spine J. 2009 Mar;9(3):263-7. Epub 2008 Oct 1 PMID: 18838341

57

Thromboprophylaxis in patients with acute spinal injuries: an evidence-based analysis. Ploumis A, Ponnappan RK, Maltenfort MG, Patel RR, Bessey JT, Albert TJ, Harrop JS, Fisher CG, Bono CM, Vaccaro AR. J Bone Joint Surg Am. 2009 Nov;91(11):2568-76. Review PMID: 19884429

Total Joint Arthroplasty in Patients with Obstructive Sleep Apnea: Strategies for Reduction of Perioperative Complications. Cashman J, Bican O, Patel RR, Jacovides C, Dalsey C, Parvizi J. Surg Technol Int. 2012 Dec 1;XXI:261-26 PMID: 22505000

Patel RR, Albert TJ, Rihn JA. Cost Effectiveness, QALYs, and Incremental Cost Effectiveness Ratios. Accepted for publication in Seminars in Spine Surgery

BOOK CHAPTERS

Silber JS, Dagly K, Brown Z, Patel A, Patel R, Vaccaro AR. (2006). How the Disc Degenerates. In RJ Davis and FP Girari (ed.) Nucleus Arthroplasty in Spinal Care: Fundamentals (pp3-9). Wayne, PA: RRY Publications

Rihn JA, Anderson DT, Patel R, Albert, TJ. C1-2 Fixation: Lateral Mass/Pars Screw-Rod Fixation. In Patel VV, Brown C, Burder E (ed.) Spine Trauma: Surgical Techniques (pp 144-155). New York, New York: Springer Publishing Company

Patel R, Rihn JA, Ponnapan RK, Albert TJ. Surgical indications for Lumbar Degenerative Disease. In Shapiro IM, Risbud MV (ed.) The Intervertebral Disc (pp 213-225. New York, New York: Springer Publishing Company

PRESENTATIONS

Patel RR Cervical Spine Chordoma: Pathology and Clinical Manifestations. Ninth Annual Symposium of Pathology Honors Society Thomas Jefferson University Hospital 2007 Dooris A, Vaccaro AR, Serhan H, Albert TJ, Ponnappan RK, Patel R, Zarda B. Mechanical Testing of PEEK Rods for Use in Lumbar Fusion Constructs. Orthopaedic Research Society: 55th Annual Meeting Las Vegas, NV 2009 Bican O, Parvizi J, Patel RR, Dalsey C, Hozack WJ, Rothman RH. Total Joint Arthroplasty in Patients with Obstructive Sleep Apnea: The Importance of Post-operative Diligence. Oral Presentation. Eastern Orthopaedics Association: 40th Annual Meeting Paradise Island, Bahamas 2009 [Winner Resident/Fellow Travel Grant]

58

Utility of Postoperative Radiographs after Transforaminal

Lumbar Interbody Fusion with Posterior Instrumentation

Dolan, RS, Ravi R. Patel, MD, Simpson AK, Rhee JM

Study Design: retrospective clinical and radiographic review

Objective: To evaluate the utility of plain radiographic surveillance after Transforaminal Lumbar Interbody Fusion (TLIF) and determine to what extent radiographic findings affect postoperative decision making.

Summary of Background Data: Routine radiographic surveillance is routinely performed

after lumbar fusion surgery despite its cost and limited evidence of efficacy. This is of

particular interest given the recent focus on increasing healthcare costs. Lumbar interbody

fusions are being performed with increasing frequency from numerous approaches;

nonetheless, there are no evidence-based guidelines for postoperative radiographic

evaluation of patients after these procedures.

Methods: Three hundred and thirty consecutive patients who underwent TLIF from 2002 to 2008 were reviewed. Exclusion criteria were less than 6 months of follow-up, the use of a routine CT scan in an asymptomatic patient, prior lumbar surgery, and age less than 18 years. For the 167 qualifying patients, 524 radiographs were evaluated for abnormalities and 352 clinical notes were reviewed for any changes in clinical management.

Results: The 167 patients were followed for an average 8.7 months before CT scan or reaching a maximum of 24 months. No radiographic abnormalities in asymptomatic patients led to a change in management. There was no single instance of change in treatment course based on radiographic evidence alone in the absence of symptoms. Six patients (3.6%) experienced worsening clinical symptoms which prompted advanced imaging (MRI/CT). Three patients underwent irrigation and debridement for wound infection concerns (1.8%).

Conclusion: Routine postoperative radiographical surveillance has minimal value for asymptomatic patients after Transforaminal Lumbar Interbody Fusion.

59

2013-2014 Orthopaedics Residents

PGY4 – PGY1

PG

Y -

4

Gregory Faucher University of Florida College of Medicine Hometown: Jacksonville, FL

Ramsey C. Kinney Emory University School of Medicine Hometown: Chino Valley, AZ

David E. Lazarus University of Tennessee Health Science Center College of Medicine Hometown: Nashville, TN

Michael Smith Harvard Medical School Hometown: Birmingham, AL

Patterson Owings Medical College of Virginia Hometown: Atlanta, GA

PG

Y -

3

Elise Hiza University of Colorado, Denver School of Medicine Hometown: Olney Springs, CO

Ashton Mansour Louisiana State University School of Medicine Hometown: Alexandria, LA

Kyle Sweeny Vanderbilt University School of Medicine Hometown: Portage, IN

Dane Todd Emory University School of Medicine Hometown: Lincoln, NE

Brent Wise University of Florida School of Medicine Hometown: Harrisburg, PA

PG

Y -

2

Timothy Borden

Baylor University Hometown: Fr. Myers, FL

Charles Daly Medical University of South Carolina Hometown: Charleston, SC

Eli Garrard University of Texas – Houston Hometown: Katy, TX

Joel Huleatt Brown University Hometown: Vail, CO

Bryan Simon University of South Alabama Hometown: Fairhope, AL

PG

Y -

1

Laura Bellaire Emory University Hometown: Atlanta, GA

William Carpenter University of Texas-San Antonio Hometown: Waco, TX

Jimmy Daruwalla Emory University Hometown: Rockville, MD

Anuj Patel University of South Alabama Hometown: Gadsden, AL

Robert Runner Emory University Hometown: Atlanta, GA

60

Manuscripts: PGY3’s

Analysis of Length of Stay and Cost-Effectiveness Before

and After the Addition of a Dedicated Orthopaedic Mid-

Level Provider in a Level I Trauma Center

Elise A. Hiza, MD; Erica Umpierrez, BA; Patricia Bush, MS; William Reisman, MD Grady Memorial Hospital, Emory University Department of Orthopaedics; Atlanta, Georgia ABSTRACT

Given the changing face of healthcare, it is imperative to evaluate both the patient-centered approach and the cost-effectiveness of our current practices. We hypothesized that the addition of a single full-time nurse practitioner (NP) to the Orthopaedic Trauma team at a busy, Level I Trauma, teaching hospital would decrease overall length of stay (LOS). A decrease in length of stay would also likely be associated with lower cost of care for the hospital and patient while continuing to provide a high standard of care. A retrospective chart review of all patients discharged from the Orthopaedic surgery service one year prior to the addition of a nurse practitioner (Pre-NP) and one year after the hiring of a nurse practitioner (Post-NP) yielded a statistically significant decrease in the length of stay for the following sub-groups of patients: patients transferred from the trauma service to the orthopedic service by 6.54 days (from 13.56 to 7.02 days; p<0.0001), patients aged 60 years old and greater by 2.30 days (from 7.34 to 5.04 days; p=0.0369), patients discharged to a rehab facility by 2.53 days (from 10.84 to 8.31 days; p=0.0024) and patients discharged on antibiotics/wound-vac therapy by 3.92 days (from 15.16 to 11.24 days; p=0.0171). Length of time to surgery was also decreased by 0.25 days (from 1.26 to 1.01 days, p=0.0201).

Although not statistically significant, a decrease in stay was also noted in the entire group of patients discharged from the orthopedic service (including those transferred from other services) by 1.11 days (from 6.02 to 4.91 days; p=0.1441), patients admitted and discharged from orthopedic service excluding those transferred from other services by 0.89 days (from 5.58 to 4.69 days; p=0.2677), patients of age less than 60 years old by 1.04 days (from 5.79 to 4.75 days; p=0.2101), patients discharged home by 0.78 days (from 5.12 to 4.33 days; p=0.7350), patients admitted through the emergency department by 0.95 days (from 6.23 to 5.28 days; p=5.28164), patients admitted for elective surgery by 1.13 days (from 5.36 to 4.24 days; p=0.2782), and patients discharged to jail by 2.74 days (from 8.84 to 6.10 days; p=0.8582). The average cost of a hospital bed at our facility is, on average, $2000 per twenty-four hour time period. The significant decrease in length of stay after the addition of a mid-level provider leads to significant cost savings for the institution, patient, and payers. INTRODUCTION

To our knowledge, there have been no studies evaluating the effectiveness of a mid-level provider and his/her impact on length-of-stay in an orthopaedic in-patient setting. Recent resident work-hour restrictions, as well as healthcare reform and the current medicolegal system have prompted many institutions to employ physician extenders to assist with patient care.(7) Improved communication and access to providers has been shown to improve patient satisfaction scores.(5,6,7) Christmas et. al. showed that the addition of two mid-level providers on a general trauma service was beneficial in decreasing patient length of stay and resident work-hours,(3,5) but cost and mortality remained the same.(1,2)

61

In 2012, a single nurse practitioner was added to the orthopaedic surgery team at a busy, Level I County Trauma Hospital. Duties of the nurse practitioner included assisting with daily floor work such as arrangement of social service needs, discharge planning, and paperwork. Moreover, the nurse practitioner acted as a liaison to improve communication between resident/attending physicians and their patients. This included daily multidisciplinary meetings to discuss all patients on the orthopaedic service with physical therapists, nurse case managers, and social workers. In our experience, it has proven difficult for residents and attending surgeons to be both in the operating room and performing routine work on the wards. Time and time again, discharges have been delayed due to the inability of an operating resident/attending to sign discharge paperwork or make social service arrangements in a timely fashion due to his/her responsibilities in the operating room.

Studies have also shown that the severity of patient’s psychosocial problems is a predictor of length of stay. (4) From our experience, these patients typically require more involvement from social services throughout their hospitalization. Thus, we believe that better communication between the orthopaedic and social services teams via a mid-level provider will be beneficial in diminishing length of stay.

It is our hypothesis that the addition of a dedicated orthopedic mid-level provider to our busy Level I trauma institution will not only improve length-of-stay, but is also cost-effective to the institution and patients themselves. MATERIALS AND METHODS

This is a retrospective chart review. All patients discharged from the orthopedic service at Grady Memorial Hospital from January 1, 2011-December 31, 2011 (one year prior to addition of a dedicated nurse practitioner to the orthopaedic service, or Pre-NP) and March 1, 2012-February 29, 2012 (one year after addition of a nurse practitioner, or Post-NP) were included in the study. A two month gap between data collection periods was allowed for training of the nurse practitioner in her duties and hospital policies. Patients who were treated operatively, non-operatively, or who were transferred from other services to the orthopaedic service that were then discharged from the orthopaedic team were included. Exclusion criteria included patients admitted to other services for which Orthopaedics acted as a consulting team. A thorough chart review was performed for each subject and stored in a Microsoft Excel spreadsheet. Specific data points that were collected included patient age, gender, date of admission, date of discharge, length of stay (days), patient’s discharge destination (home, rehab facility or jail), whether they were discharged on IV antibiotics or wound-vac therapy, admission through the Emergency Room, elective surgery admission, length of time to surgery and whether they were transferred to the orthopedic service from a different service. Discharge destination was classified as either home, to a rehabilitation facility or to jail. Acute, sub-acute, skilled nursing facilities and personal care homes for the homeless were all classified as being discharged to a rehabilitation facility and treated as an entity separate from patients who were discharged to jail or to their home.

There were no significant changes in the faculty at Grady Memorial Hospital during the time periods for which data was collected.

Clearance from the Emory Institutional Review Board and the Grady Research Oversight Committee was granted prior to the commencement of the study. Personal health information was de-identified prior to data analysis in accordance with IRB regulations. Strict patient confidentiality was maintained throughout the research process.

Statistical analysis was performed utilizing the Wilcoxson/Kruskal-Wallis one way analysis of variance given that our variables were continuous, non-parametric and were not normally distributed. Wilcoxson/Kruskal-Wallis analysis of variance was utilized to analyze the variables of length of stay in the Pre-NP and Post-NP subcategories of all patients discharged from the orthopaedic service, only patients admitted to and discharged from the orthopaedic service (excluding transfers from other services), patients transferred from

62

another service to the orthopaedic service, patients discharged to rehab facilities, patients discharged home, patients discharged to jail, patients discharged home on IV Antibiotics and/or with a wound-vac device, patients discharged age 60 and greater, patients discharged age 59 and less, patients admitted for elective surgery, and patients admitted through the emergency department. Length of time to surgery was also analyzed by the Wilcoxson/Kruskal-Wallis test. Statistical significance was set a p value of <0.05. RESULTS

Retrospective chart review of all patients discharged from the orthopedic service yielded a total of 713 patients in the Pre-NP group and 871 patients in the Post-NP group. Analysis of all patients discharged from the Orthopaedic service revealed an overall decrease in the mean length of stay from 6.02 days in the Pre-NP group to 4.91 days in the Post-NP group (95% CI 5.52-6.51 and 4.61-5.21 respectively). This was not statistically significant (p=0.1441). Patients who were transferred from the trauma service were then excluded from the analysis, taking into account only those who were admitted and discharged from the orthopaedic team. This yielded 674/713 (94.53%) and 790/871 (90.70%) patients in the Pre-NP and Post-NP groups respectively. The mean length of stay for patients admitted and discharged from the orthopedic service excluding transfers decreased by 0.89 days (from 5.58 to 4.69 days) in the Pre-NP group compared with the Post-NP group, which was not statistically significant. Patients who were transferred from the trauma service to the orthopedic service and subsequently discharged from the orthopedic service where then analyzed. There were 39/713 (5.47%) and 81/871 (9.30%) patients transferred from the trauma service to the orthopedic service. The length of stay in this subgroup was decreased by 6.54 days (from 13.56 to 7.02 days; p<0.0001).

Patients were further categorized into three subsets to determine whether there was a difference in LOS based on patients discharged to home, patients discharged to a rehabilitation facility or patients discharged to jail. There were 588/713 (82.47%) and 720/871 (82.22%) patients discharged home, 95/713 (13.32%) and 122/871 (14.01%) patients discharged to rehab, and 25/713 (3.5%) and 19/871 (2.18%) patients discharged to jail in the Pre-NP and Post-NP groups respectively (Table 2). Length of stay was also decreased by 0.78 days (from 5.11 to 4.33 days) in the subgroup of patients discharged home (p=0.8582) and by 2.73 days (from 8.84 to 6.12 days) in the subgroup discharged to jail (p=0.7350). The decrease in length of stay was not statistically significant in either of these groups. There was a significant decrease in the mean length of stay of patients who were discharged to a rehab facility by 2.63 days (from 10.84 to 8.31 days; p=0.0024).

Breaking down patients into subgroups by age showed that there were 105/713 (14.72%) and 172/871 (19.74%) patients of age greater than 60 in the Pre-NP and Post-NP group and 608/713 (85.27%) and 699/871 (80.25%) of patients age less than 60 in the Pre-NP and Post-NP groups respectively. Length of stay in patients greater than 60 years old was decreased by 1.80 days (from 7.24 to 5.54 days; p=0.0369). In the subgroups of patients of age less than 60 years old length of stay was decreased by 1.03 days (from 5.79 to 4.75 days; p=0.2101).

Again, length of stay was decreased by 0.95 days (from 6.23 to 5.28 days) in patients who were admitted through the ER in the Pre-NP group (539/713, 76.6%) and Post-NP group (561/871, 64.41%), but was not found to be statistically significant (p=5.28164). LOS in patients admitted for elective surgery (174/713, 24.40%; and 310/871, 35.59% in the Pre-NP and Post-NP groups respectively) was decreased by 1.11 days (from 5.36 to 4.24 days), which was not statistically significant (p=0.2782).

Furthermore, there were 73/713 (10.24%) and 61/871 (9.0%) patients who were discharged with IV antibiotics or a wound-vac in the Pre-NP and Post-NP groups. Length of stay was significantly decreased by 3.92 days (from 15.17 to 11.26 days; p=0.0171) in these groups.

63

Length of time to surgery in the Pre-NP group and Post-NP group was also determined to be statistically significant. There were 660/719 (91.79%) and 789/871 (90.59%) patients admitted that underwent a surgical intervention. Length of time to surgery was decreased by 0.25 days (from 1.26 to 1.01 days, p=0.0201).

Total

Number

of

Patients

Pre-NP

Total

Number

of

Patients

Post-NP

Percentage

of Total

Patients

Pre-NP

Percentage of Total

Patients Post-NP

All

Discharged

from Ortho

Service

713 871 100% 100%

Discharged

from Ortho

Excluding

Transfers

674 790 94.53% 90.70%

Transferred from Other Service 39 81 5.47% 9.30%

Discharged to Home 588 720 82.47% 82.66%

Discharged to Rehab Facility 95 122 13.32% 14.01%

Discharged to Jail 25 19 3.50% 2.18%

Age >60 105 172 14.72% 19.74%

Age <60 608 699 85.27% 80.25%

Discharged on IV Antibiotics/WV 73 61 10.24% 7.00%

ER Admit 539 561 76.6% 64.41%

Elective Admit 174 310 24.40% 35.59%

Time to Surgery 660 789 91.79% 90.59%

Table 1: Number of patients in subcategories and percentage of patients of subcategories as related to total number of patients in the Pre-NP and Post-NP groups.

64

Number

of

Patients

Mean

LOS

(days)

Difference

in Mean

LOS

(days)

Standard

Deviation

Lower

95% CI

Upper

95% CI

p-value

All Pre-NP 713 6.02104 1.1083 6.74232 5.5253 6.5168 0.1441

All Post-NP 871 4.91274 4.53053 4.6114 5.2140

Ortho Pre-NP 674 5.58457 0.88837 6.22697 5.1136 6.0555 0.2677

Ortho Post-

NP

790 4.69620 4.30066 4.3958 4.9966

Transfer Pre-

NP

39 13.5641 6.5394* 10.1613 10.270 16.858 <0.0001*

Transfer Post-

NP

81 7.0247 5.9853 5.701 8.348

Home Pre-NP 588 5.11735 0.77985 5.70676 4.6551 5.5796 0.7350

Home Post-

NP

720 4.33750 3.78618 4.0605 4.6145

Rehab Pre-

NP

95 10.8421 2.629* 7.92292 9.2281 12.456 0.0024*

Rehab Post-

NP

122 8.2131 6.69924 7.0123 9.414

Jail Pre-NP 25 8.8400 2.73474 13.4805 3.2755 14.404 0.8582

Jail Post-NP 19 6.10526 4.5570 3.9089 8.302

Age >60 Pre-

NP

105 7.34286 1.80216* 6.46712 6.0913 8.5944 0.0369*

Age >60 Post-

NP

172 5.54070 4.77978 4.8213 6.2501

Age <60 Pre-

NP

608 5.79276 1.03453 6.76773 5.2537 6.3318 0.2101

Age <60 Post-

NP

699 4.75823 4.45708 4.4272 5.0892

Antibiotics/WV

Pre-NP

73 15.1656 3.9197* 10.9367 13.010 18.113 0.0171*

Antibiotics/WV

Post-NP

61 11.2459 6.3996 9.607 12.885

ER Admit Pre-

NP

539 6.2337 0.95206 7.05904 5.6365 6.8310 0.5969

ER Admit 561 5.28164 4.87807 4.8771 5.6862

65

DISCUSSION

Today’s medicolegal system requires that physicians and physician extenders

complete increasing amounts of paperwork, pre-certifications, and approvals. In academic

medicine, the responsibilities of rounding, charting, paperwork and communication with multi-

disciplinary teams often fall in the hands of the resident physicians. The implementation of

the 80-hour work week has made it even more difficult for residents to complete necessary

paperwork and fulfill operative and clinical duties in the allotted time frame, all while continuing

their education and providing exceptional patient care. At our institution, social workers work

weekdays from 9 a.m. to 5 p.m., and the physical therapy staff is limited on weekends to only

0

2

4

6

8

10

12

14

16

Len

gth

of

Stay

(d

ays)

*p-value < 0.05

Mean LOS in Pre- and Post-NP Periods

Pre- NP

Post-NP

Post-NP

Elective Admit

Pre-NP

174 5.36207 1.11691 5.61696 4.5216 6.2025 0.2782

Elective Admit

Post-NP

310 4.24516 3.73792 3.8274 4.6629

Time to

Surgery

660 1.26212 0.24945* 2.48994 1.0718 1.4524 0.0201*

Time to

Surgery

789 1.01267 1.99615 0.8732 1.1522

Table 2: Statistical analysis of mean length of stay in subgroups as calculated by the Wilcoxson/Kruskal-Wallis one way analysis of variance. (* designates statistically significant reduction in LOS).

66

seeing patients who are immediately post-operative. We found that the best time to

communicate with ancillary staff coincided with our resident physicians’ peak operative hours.

As a result, communication related to the planning of social services, discharges, and physical

therapy and discharge orders themselves were often delayed while the resident attempted to

complete their operative duties. The decision to add a full-time nurse practitioner was made in

an attempt to improve the patients’ hospital experience, improve access to a provider during

operative hours, and improve communication amongst multidisciplinary teams. The NP was

available by pager at all times, from 7 am until 4 pm, Monday through Friday. Duties were

restricted to caring for patients on the wards and their immediate needs. We hypothesized

that easier access to a provider and daily multidisciplinary meetings with the NP would also

decrease the mean length of stay while providing residents with the opportunity to focus on

clinical and operative responsibilities.

Analysis of the mean length of stay one year prior to the addition of a NP and one year

after the addition of a NP at a Level 1 trauma, county teaching hospital showed a significant

decrease in length of stay for patients discharged to rehabilitation centers, patients greater

than the age of 60, patients transferred from the trauma service to the orthopedic service prior

to discharge, and patients who were discharged on IV antibiotics or wound-vac therapy. Given

that these subgroups of patients require more paperwork, communication with

multidisciplinary teams, discharge planning, and follow up, it is likely that the reduction in

length of stay is largely attributed to the addition of a nurse practitioner.

The length of time to surgery was also decreased by 0.25 days after the addition of a

nurse practitioner. This was statistically but likely not clinically significant and unlikely a factor

in decreasing over-all length of stay.

We can identify no major faculty or system changes in the orthopaedic service during

the pre-NP and post-NP periods that could have led to confounding in our results. Our faculty

and staff remained stable in the Pre-NP and Post-NP periods, and electronic medical records

utilizing the EPIC system had been in place for over one year prior to the commencement of

our study. A prior study showed that a dedicated Saturday, orthopaedic operating room

reduced length of stay of orthopaedic patients with operative femur or tibia fractures from 14

to 11 days. (8) However, this was implemented prior to the pre-NP period and therefore does

not cause concern for confounding.

Our hospital serves a large indigent and homeless population with limited access to

transportation and medical care in general. The addition of a nurse practitioner has allowed

the orthopedic team to implement a pathway through which patients undergoing initial

temporary stabilization of fractures can be discharged and followed-up for definitive fixation

without the need to be seen in clinic prior to re-operation. The pathway also connects patients

with the resources needed to obtain their county-approved health care benefits. Prior to the

addition of the staff and resources necessary to complete this pathway, patients were kept in-

house until their definitive fixation. The implementation of this pathway has greatly improved

patient access to care and likely added to the global decrease in length of stay seen across all

subgroups, even if not statistically significant.

Finally, reducing LOS in the in-patient hospital setting is becoming increasingly

important from a financial standpoint. As we shift away from fee-for-service reimbursements

and towards business models based on bundled payments, efficiency and cost-effectiveness

becomes crucial. Traditionally, a hospital bed at Grady Memorial Hospital costs, on average,

67

$2000 for a 24-hour time period. If this is true, it can be assumed that a decrease in LOS

provides a significant financial benefit to the hospital and the payer. A cost-analysis of each

subgroup of patients that showed a statistically significant decrease in length of stay was

performed. Among the subgroup of patients discharged to rehab, we observed an average

decrease in LOS of 2.63 days from the Pre-NP to Post-NP period. With 122 patients in the

Post-NP subgroup and an average hospital bed cost of $2000/day, a cost savings of

$641,476/year can be deduced. A similar cost-analysis yielded a savings of $1,059,480/year

in the subgroup of patients transferred to orthopaedics from another service, $790,240/year in

patients over age 60, and $478,240/year in patients discharged on IV antibiotics or wound-vac

therapy. Because many of these patients are included in more than one subgroup, the cost-

benefit analysis is not additive, but nonetheless significant.

In the future, we would like to further analyze length of stay data based on injury type,

injury severity score, type of surgery, insurance status, patients having more than one

surgery, and length of time to surgery in patients admitted through the emergency department.

SUMMARY

The addition of a nurse practitioner has significantly decreased mean length of stay by

6.54 days in patients transferred from another service (from 13.56 to 7.02 days; p<0.0001),

2.63 days in patients transferred to a rehab facility (from 10.84 to 8.31 days; p=0.0024), 3.92

days in patients discharged on IV antibiotics or home wound-vac therapy (from 15.17 to 11.26

days; p=0.0171), and 1.7 days in patients discharged who were over the age of 60 (from 5.79

to 4.75 days; p=0.2101). Length of time to surgery was also decreased by 0.25 days (from

1.26 to 1.01 days, p=0.0201).

These values are all both clinically and statistically significant and can lead to

significant cost savings for the payer and the hospital. They also support the hiring and

maintenance of a physician extender to an orthopedic team at an academic, Level I trauma

county hospital and should serve as a model on which to base future orthopedic practices.

ACKNOWLEDGEMENTS

We would like to thank Kirk Easley and Neeta Shenvi for their assistance with

statistical analysis, Patricia Bush for her assistance in obtaining Grady ROC and IRB

approval, Chadrick Anderson and Jeffrey Baccam for their assistance in obtaining medical

records, and Michael B. Gottschalk for his assistance with this paper.

68

REFERENCES 1. Christmas AB; Physician extenders impact trauma systems. Journal of Trauma. 2005

May 58(5):917-20. 2. Haan, JP; Discharge Rounds in the 80 hour workweek: Importance in the trauma

nurse practitioner. Journal of Trauma. 2007 August; 63(2): 339 3. Huynh, TT; An initiative by mid-level providers to conduct tertiary surveys at a Level I

trauma center. Journal of Trauma. 2010, May 1052-1058. 4. Lechman, C; Hospital length of stay: Social work services as an important factor.

Social Work Health Care. 2009; 48(5): 495-504 5. Moher, D; Effects of a medial team coordinator on length of hospital stay. 1992

August 1, 147(3):287. 6. Nyberg, S; Midlevel providers in the level one trauma service: Experience at Wesley

Medical Center. Journal of Trauma. 2007; July 128-34. 7. Pezzi, C; The present and future of physician extenders in general surgery training

programs: one response to the 80-hour work week. Journal of American College of Surgeons. 2009 April 208(4):597-91

8. Runner, R; The Value of a Saturday Dedicated Orthopedic Trauma Operating Room. In pre-publication review.

69

Height, Weight, and Age Predict Quadriceps Tendon Length

and Thickness in Skeletally Immature Patients

Dane Todd MD, Alexander Ghasem BS, John Xerogeanes MD Objectives: As anterior cruciate ligament (ACL) reconstruction becomes more common in skeletally immature patients, several new reconstruction techniques and grafts have been described. Quadriceps tendon autografts have been used with success in adults and are becoming a popular graft option in pediatric patients due to size, decreased donor site morbidity, ease of harvest, and favorable biomechanical characteristics. However, little is known about the length and thickness of the quadriceps tendon in pediatric patients. The purpose of this study was to determine whether quadriceps tendon length and thickness follows a predictable pattern of development based on height, weight, age, and body mass index (BMI) in skeletally immature patients. Methods: After recording the height, weight, age, and gender of each participant, ultrasound measurements of bilateral quadriceps tendons of one hundred fifty one children between 4 and 16 years old were performed. Using ultrasound machines with 10-12 megahertz (MHz) transducers and extended view technology, a single technician sonographically measured tendon length and thickness. Patients were placed supine with a styrofoam roller behind the popliteal fossa for standardization of leg positioning. The quadriceps tendon was then visualized at its patellar insertion and traced proximally to the musculotendinous junction of the rectus femoris. The extended view function was then used to visualize and measure the entire length of the tendon from the most distal point of the rectus to the superior pole of the patella. The probe was then rotated medially to obtain a sagital view of the quadriceps tendon, and tendon thickness was measured 3 centimeters (cm) proximal to the superior pole of the patella. Results:

Average quadriceps tendon length and thickness were 6.87 1.49cm and 0.37 0.12cm respectively. Tendon length averaged 3.89cm at 4 years and 7.98cm at 16 years of age while thickness averaged 0.24cm at 4 years and 0.40cm at 16 years of age. There was no significant difference in tendon length or thickness between males and females (p=0.97), nor was there a difference in length or thickness between right and left legs (p=0.6). Tendon length and thickness increased significantly with age (p<0.01). Additionally both tendon length and thickness varied significantly based upon weight and height (p<0.01). Tendon thickness and length showed a strong correlation with BMI, however, this did not reach statistical significance (p=0.06 and p=0.053). Conclusions: The quadriceps tendon is of sufficient length and thickness to be used as an autograft for pediatric patients in nearly all age groups. The size of the graft is also highly predictable using the age, height, and weight of the patient. Graft length and thickness can also be easily confirmed using ultrasound. Thus, given the quadriceps tendon's size, favorable biomechanical characteristics, minimal donor site morbidity, and post ACL reconstruction functional outcomes, it is a viable, and predictable, autograft for pediatric patients.

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Introduction Anterior cruciate ligament injury and reconstruction is becoming more common among skeletally immature patients. This increase is secondary to increased participation in cutting and pivoting sports, improved physical examination skills, and increased use of magnetic resonance imaging (MRI)[1-6]. Historical management of ACL injuries in patients with open physes involved activity modification, bracing, and strengthening until skeletal maturity[7-11]. However, studies have shown that chronic instability in skeletally immature patients leads to increased incidence of meniscal injury, cartilage damage, and osteoarthritis [12-16]. As a result many surgeons are leaning toward early operative reconstruction of ACL injuries in patients with open physes. Several ACL reconstructive techniques have been utilized with success in skeletally immature patients using a variety of materials, including hamstring, tensor fascia lata and allograft tissue[17-21]. There are pros and cons to each of the tissues in use. Harvest morbidity of the hamstring and tensor fascia lata graft are not insignificant and include, pain, weakness, numbness and deformity[22-24]. Allograft reconstruction avoids graft site morbidity and demonstrates quicker postoperative recovery with less pain than autograft reconstruction. However, allograft reconstruction has inferior outcomes in the pediatric population with up to four times higher rupture rate than autograft reconstruction [25, 26]. Allograft use also remains controversial in children due to potential risk of disease transmission [27]. Autologous hamstring graft length and diameter are difficult to predict as they do not correlate with anthropomorphic measurements and are difficult to accurately measure using MRI [28-30]. This is problematic in younger patients in varying stages of growth and development especially given evidence that in adults hamstring autografts smaller than 8mm in diameter have a higher failure rate [31]. In the adult population, the all soft tissue quadriceps tendon autograft has been utilized with success. The quadriceps tendon has been shown to result in similar outcomes of the other commonly used grafts. The International Knee Documentation Committee (IKDC) and Lysholm scores as well as Lachman and pivot-shift testing are similar to the hamstring and bone-patella tendon-bone autografts[32]. Furthermore, the all soft tissue quadriceps tendon autograft has been shown to result in less anterior knee pain and kneeling pain when compared to patellar tendon autograft as well as a decreased incidence of anterior knee numbness[32-35]. Muscle strength following quadriceps tendon autograft is similar to that of hamstring and patella tendon autografts[36, 37]. Additionally, to our knowledge there have been no reported post-operative ruptures of the remaining quadriceps tendon.

Because of the minimal graft harvest morbidity and satisfactory adult clinical outcomes, there has been increased interest in utilizing the quadriceps tendon as an autograft in skeletally immature patients. To date there have been no specific studies of quadriceps tendon size in pediatric patients. O'Brien et al. utilized MRI scans to compare quadriceps muscle and tendon dimensions in adults and children. They found that while the quadriceps total volume and physiological cross-sectional area were greater in adults, the proportion of each muscle head to total quadriceps volume was similar in adults and children [38]. These findings suggest that the fascicle, muscle, and tendon lengthen proportionally during growth. Thus it may be possible to predict the changes that will occur as patients age and it may be appropriate to treat children as 'small-scale adults' with respect to quadriceps tendon development [38]. The purpose of this study was to determine whether quadriceps tendon length and thickness showed a predictable correlation with height, weight, and age in skeletally immature patients.

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Materials and Methods After receiving institutional review board approval, pediatric patients with no history of lower extremity surgery, pathology of the quadriceps tendon, diagnosed leg length discrepancy, diagnosis of short stature, or history of growth hormone use were enrolled with parental or guardian consent and assent from children over 6 years of age. A total of 151 participants between 4 and 16 years old were enrolled. Each participant's height, weight, gender, and age were recorded and ultrasound imaging was used to measure the length and thickness of their bilateral quadriceps tendons. All measurements were conducted by a single technician in order to standardize data collection and maximize measurement precision [39]. Patients were placed supine with a styrofoam roller behind the popliteal fossa for standardization of leg positioning. The superior pole of the patella was palpated and an ultrasound machine with a 10-12MHz transducer with extended view technology was used to visualize the quadriceps tendon at its patellar insertion. The tendon was traced proximally to the musculotendinous junction of the rectus femoris and the extended view function was utilized to visualize the entire quadriceps tendon. Tendon length was measured from the distal aspect of the rectus femoris to its proximal attachment on the patella[40]. The ultrasound probe was then rotated medially to obtain a saggital view of the tendon and tendon thickness was measured 3cm proximal to the superior pole of the patella. This process was then repeated on the patient's other leg. Statistical Methods A kernel density estimate showed that the data followed a normal distribution and suggested that the data for tendon length and thickness by gender was symmetric. As such we utilized parametric approaches to regression modeling. For each measurement linear and quadratic regression equations were calculated for each sex to model the effect of age and a p-value was calculated for the difference between sexes. A mixed effects model was performed to determine the within-child variance between right and left leg. Because this model showed that there was no significant leg effect a both legs mixed model was created to predict tendon length and thickness for a new subject given age, weight, height, or body mass index (BMI). A p value of less than 0.05 was considered significant. Results A total of 151 subjects were enrolled in the study, 76 males and 75 females. The average age of males and females were 10 and 11 years respectively, ranging from 5 to 16 years in males and 4 to 16 years in females. A total of 298 quadriceps tendons were measured as four subjects chose to have only their right leg measured due to time constraints. The means and ranges are given in Table 1 for height, weight, BMI, tendon length, and tendon thickness for each age group. Tendon length did not vary between males and females (p=0.97), however, tendon length changed significantly with age using both linear (p<0.01) and quadratic regression analysis (p=0.012). The shortest tendon length was 2.81cm in a single 4 year old. However, outside of this age group there were no other subjects with tendon lengths measuring less than 4.26cm and the average length for all other age groups was greater than 5.3cm. The longest quadriceps tendon was 12.64cm in a single 12 year old subject with the longest average length being 7.98cm in 16 year old patients. Among all participants, the average quadriceps tendon length was 6.87cm +/- 1.49cm. Quadriceps tendon thickness changed significantly with age based on linear (p<0.0001) and quadratic (p=0.0007) regression, however, there was no significant difference in quadriceps tendon thickness between males and females. The smallest tendon thickness

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was 1.1mm in a single 5 year old with the smallest average tendon thickness measuring 2.4mm in 4 and 5 year olds. The largest tendon thickness was 7.1mm in a 13 year old and the largest average tendon thickness was 4.9mm in the 13 year old age group. Overall quadriceps tendon thickness averaged 3.7mm +/- 1.2mm among all participants. Regression modeling demonstrated that tendon length and thickness changed significantly with age, weight, and height (p<0.01). Tendon length and thickness had positive linear and negative quadratic regression equations for age and weight indicating that length and thickness initially increase as the children age, but eventually plateau. Tendon length and thickness also increased linearly with height. And although tendon length and thickness had strong linear correlations with BMI (p values of 0.06 and 0.053 respectively) these changes were not statistically significant. In addition to linear and quadratic regression analyses a mixed-effects model was used to determine 95% Prediction Intervals (PI) for tendon length and thickness based on the subject's age, height, weight, or BMI. Because the within child variance between right and left leg was not statistically significant (p=0.6) and because there was no difference in tendon thickness or length based on gender, neither leg effect nor gender were included in the model for predicting tendon length and thickness. The 95% PI for all variables can be found in Figures 1a to 8b. While the linear and quadratic regression analyses were not statistically significant for BMI, a 95% PI was calculated for tendon length and thickness using BMI for comparative purposes. Discussion As orthopaedic surgeons have moved toward early operative intervention for ACL injuries in pediatric patients several physeal sparing, partial transphyseal, and transepiphyseal reconstruction techniques have been described and utilized with success [18, 20, 21, 41-44]. Graft selection remains largely technique and surgeon dependent, however, the majority of ACL reconstructions continue to be quadruple hamstring or patella tendon autografts[32]. While the quadriceps tendon has not been utilized for ACL reconstruction as frequently as hamstring and patella tendon autografts, several intermediate term studies have shown that there is no difference in IKDC and Lysholm scores, knee range of motion, or stability when comparing hamstring, patella tendon, and quadriceps tendon autografts[35, 36, 45, 46]. Furthermore, several studies found quadriceps tendon autografts to have significantly less anterior knee pain, kneeling pain, and anterior knee numbness than patellar tendon autograft[35, 45, 46]. And while Kim et al found that patients had quadriceps muscle weakness following both quadriceps tendon-bone and bone patella tendon bone autografts, other studies have found that all soft tissue quadriceps tendon harvest had little to no effect on quadriceps strength [46, 47]. Additionally, the all soft tissue quadriceps tendon autograft has been utilized with success in skeletally immature patients [48]. Autograft selection for ACL reconstruction must take into account patient age, activity level, and harvest site morbidity. The size of the potential autograft is also important as the length, thickness, and volume of the graft are essential to ensuring a good outcome. Despite its frequent use, hamstring autograft size is widely variable and unpredictable using preoperative imaging [49]. Patellar tendon graft volume is much more predictable than the hamstring tendon and a recent study by Xerogeanes et al. demonstrated that the quadriceps tendon produced a highly predictable graft in terms of length, thickness and volume. The quadriceps tendon also produced a graft with almost twice the intra-articular volume than that from patella tendon [35, 49-52]. Recent studies in our lab also showed that a matched width quadriceps tendon graft had an ultimate load 28% higher than a patella tendon from the same specimen. The quadriceps tendon also had a Young's Modulus which was similar to the native ACL while that of the patella tendon was significantly higher (ORS ABSTRACT). Adams et al. also found that the residual post harvest quadriceps tendon had an ultimate load to

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failure 21% greater than that of the intact patellar tendon and 66% greater than that of a post harvest patellar tendon [47]. While variations in quadriceps tendon anatomy exist, it is described as a three layer arrangement of the rectus femoris superficially, vastus medialis and lateralis in the intermediate layer, and the vastus intermedius deep [53]. The quadriceps tendon is also composed of large and small diameter collagen fibrils in a bimodal distribution similar to that of the native ACL [36, 54]. Staeubli et al. assessed quadriceps tendon length and thickness in adults using cadaveric dissections, cryosections, and Magnetic Resonance Arthrography (MRA) [55]. They found that the MRA measurements compared favorably to the gross anatomy and cryosections, with an average length of 49mm in women and 50mm in males [55]. Our study showed average tendon lengths between 7 and 8cm among the 10 to 15 year old age groups. These values are similar to a recent MRI study by our group which demonstrated that the quadriceps tendon length is directly proportional to a patient's height and had an average length of 73mm in females and 81mm in males [52]. The difference in quadriceps tendon length between these studies is related to measurement technique. While both studies measured from the proximal pole of the patella, Staeubli et al. measured to the proximal aspect of the suprapatellar pouch whereas Xerogeanes et al. measured to the distal aspect of the rectus femoris muscle belly, which is more representative of the portion of quadriceps tendon available for autograft harvest. Staeubli et al. also found that the thickness of the quadriceps tendon at the base of the patella was similar to previously published results by Schweitzer, showing a mean thickness of 8mm at the superior pole of the patella in men and just under 8mm in women [55, 56]. Xerogeanes et al. similarly demonstrated an average thickness of 7.37mm at a point 3cm proximal to the superior pole of the patella [52]. The quadriceps tendon thickness in our study was considerably lower than Staeubli and Xerogeanes' results with the largest average thickness being 4.9mm in the 13 year old age group. While this finding deserves further review and evaluation it may be related to measurement technique since the Xerogeanes et al. study included patients as young as 17 years old and the smallest thickness in their study was 6.29mm[52]. Regardless, the average quadriceps tendon thickness in this study was 3.6mm or greater among age groups 8 to 15. This thickness is comparable to that of the adult patella tendon and thus sufficient for use as an ACL autograft[52]. The length and diameter of the graft needed for ACL reconstruction is dependent upon reconstruction technique, size of the patient, and surgeon preference. The intra-articular tendon length of the adult ACL is between 2 and 4cm with an average of 3.2cm and has been shown to be dependent on the height of the patient [57-59]. The amount of tendon left in the tibial and femoral tunnels is dependent on surgeon preference and fixation technique and ranges from as little as 5mm to filling the entire tunnel. Thus graft lengths between 6 and 7cm are sufficient for most adults. Based on the fact that the ACL increases in length with increases in height, shorter graft lengths between 4 and 5cm would likely be sufficient for smaller children, especially when using a physeal sparing technique with suspensory fixation. Previous studies from our laboratory showed that an 8mm diameter, physeal sparing, femoral epiphyseal tunnel can be predictably placed in patients 6 years of age and older [44]. While it would be unlikely that we would choose a graft of this size in a smaller patient, data from our current study demonstrates that a graft at or near this diameter is possible from young patients. While we prefer to use physeal sparing techniques in the skeletally immature population, if a surgeon chooses to cross the physes animal studies have shown that physeal arrest is unlikely until a threshold of 7% of the physeal volume is removed [60, 61]. Additionally, a prior study from our laboratory showed that an 8mm transphyseal tunnel removed less than 3% of physeal volume [62]. While most surgeons would not use an 8mm graft in small children, this number is discussed secondary to it being defined as a prognostic factor in graft failure in the adult population.

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While our results demonstrate that the pediatric quadriceps tendon is of sufficient length and thickness to use as an autograft for ACL reconstruction, the most interesting finding of our study is the ease with which a quadriceps tendon autograft size can be predicted. Because there was no difference in quadriceps tendon length or thickness between males and females patient gender can be eliminated as a variable affecting tendon size. Our study also demonstrated that the quadriceps tendon length and thickness increased linearly with age and weight before plateauing while tendon length and thickness increased linearly with height but did not plateau. These findings allowed us to create 95% predictive intervals to estimate quadriceps tendon length and thickness based on a patient's height, weight, or age (Figures 1a to 8b). Tendon length and thickness also correlated strongly with BMI (p = 0.053 and 0.06 respectively) but did not reach statistical significance. To our knowledge this is the first study to identify a correlation between quadriceps tendon length and thickness and BMI, however, prior studies have noted a correlation between BMI and semitendinosus and gracilis tendon graft length and diameter [49]. Thus, easily measurable patient variables can be used to preoperatively estimate graft length and thickness. Comparison to anatomic dissection would have been preferred, however, obtaining an appropriate number of pediatric quadriceps tendons would be problematic for obvious reasons. While MRI technology provides good visualization of the quadriceps tendon, it is cost-prohibitive and time consuming. CT scans are easier to obtain, less costly, and can be used to make soft tissue measurements, however the radiation exposure to patients is unacceptable. Ultrasonography (US) has been utilized in prior studies of the quadriceps muscle and tendon, resulting in measurements between 1.9 and 8.9% smaller than CT scan measurements with intra and inter-experimenter reliability ranging from 0.6 to 2.7% [63]. US has also been compared to MRI in the measurement of the vastus lateralis, with intra class correlation values between 0.905 and 0.999. Furthermore, US has been compared to MRI using anatomical phantoms which determined that US images were as accurate as MRI in measuring length and thickness[40, 64, 65]. US is noninvasive, cost effective, fast, reliable, and its measurements compare to those obtained by CT and MRI. Thus, it is a viable tool for assessing the length and thickness of the pediatric quadriceps tendon. There are several limitations to this study. First, our measurements and predictions are based on chronological rather than physiological age. Second, the number of subjects in each age group and the distribution of males and females in each age group were variable. This was especially true for the four year old subjects of which there were no males and only 6 females. Drawing specific conclusions from the numbers at this young age range would not be advisable, however, it is unlikely that there are any ACL reconstructions being performed in this age group. Third, it would have been preferable to compare our ultrasound measurements to MRI measurements. However, this would have been cost prohibitive and may not have provided any significant additional information based on several prior studies indicating that ultrasound and MRI were equivalent for measuring length and thickness [40, 64, 65]. Finally, while our study included 151 subjects, enrolling more participants would better define the significance of BMI with regard to quadriceps tendon length and thickness. However, it should be noted that BMI did have a very strong correlation with tendon length and thickness (p=0.053 and 0.06 respectively) and age, height, and weight had statistically significant relationships with both tendon length and thickness (p<0.05). ACL reconstruction in the pediatric patient represents a unique challenge technically,

as well as in selecting an autograft for reconstruction. Our study shows that the quadriceps

tendon is of sufficient length and thickness to be used as an autograft for pediatric patients.

The size of the graft is also highly predictable asheight, weight, and age can be used to

reliably predict potential autograft size. Furthermore, non-invasive and cost effective

ultrasound can be used to confirm potential graft size. Thus, given the quadriceps tendon's

75

size, strength, minimal donor site morbidity, post ACL reconstruction functional outcomes, and

predictability it is a viable autograft for pediatric patients.

Table 1 - Means and Ranges of Subject Height, Weight, BMI, and Tendon Dimensions

Age Number Mean Height (cm)

Mean Weight (kg)

Mean Tendon Length (cm)

Mean Tendon Thickness (cm)

4 6 106.67 (97-114) 24.00 (15-32)

3.89 (2.81-5.50)

0.24 (0.18-0.32)

5 24 111.42 (101-122)

21.67 (18-27)

5.32 (4.28-6.82)

0.24 (0.11-0.53)

6 14 120.43 (104-137)

23.57 (20-31)

5.98 (4.42-7.44)

0.28 (0.13-0.49)

7 20 129.50 (121-147)

32.00 (23-48)

5.87 (4.38-7.12)

0.32 (0.22-0.46)

8 31 133.87 (114-157)

34.29 (19-57)

6.27 (4.8-8.73)

0.36 (0.16-0.56)

9 19 135.16 (124-152)

34.42 (28-39)

6.49 (5.19-7.48)

0.36 (0.17-0.54)

10 18 145.44 (127-163)

38.89 (28-63)

7.96 (5.67-9.83)

0.37 (0.30-0.55)

11 28 149.04 (134-165)

41.57 (24-65)

6.98 (4.82-8.94)

0.40 (0.22-0.58)

12 28 155.71 (117-183)

58.00 (32-95)

7.49 (4.26-12.64)

0.39 (0.23-0.52)

13 34 165.47 (142-183)

60.24 (43-87)

7.49 (4.68-8.73)

0.49 (0.27-0.71)

14 26 162.08 (142-183)

55.62 (45-78)

7.29 (4.74-9.27)

0.39 (0.23-0.67)

15 26 163.38 (135-183)

55.15 (34-73)

7.47 (5.36-10.21)

0.40 (0.23-0.60)

16 24 172.75 (165-186)

64.58 (51-84)

7.98 (5.72-11.24)

0.40 (0.26-0.62)

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Table 2 - Predictive Equations with p values for Tendon Length Note - Predictive equations do not contain the quadratic term if the quadratic term was not statistically significant. BMI predictive equation is included for comparison purposes even though it was not statistically significant

Patient Variable (X)

Predictive Equation p-value Linear Term p-value Quadratic Term

Age Y = 2.210 + 0.7064X - 0.0229X2

0.0002 0.012

Weight Y = 3.3787 + 0.1168X -0.00075X2

0.02617 0.005

Height Y = 1.5252 + 0.03645X 0.03645 0.09

BMI Y = 4.92 + 0.0972X 0.053 0.30

Table 3 - Predictive Equations with p values for Tendon Thickness Note - Predictive equations do not contain the quadratic term if the quadratic term was not statistically significant. BMI predictive equation is included for comparison purposes even though it was not statistically significant

Patient Variable (X)

Predictive Equation p-value Linear Term p-value Quadratic Term

Age Y = -0.0189 + 0.0655X -0.00245X2

<0.0001 0.0007

Weight Y = 0.0968 + 0.0098X -0.000070X2

<0.0001 0.005

Height Y = -0.057 + 0.0029X <0.0001 0.09

BMI Y = 0.2992 + 0.003627X 0.06 n/a

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Figures 1a and 1b - Predictive Model of Tendon Length Based on Patient Age

Figures 2a and 2b - Predictive Model of Tendon Length Based on Patient Weight

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Figures 3a and 3b - Predictive Model of Tendon Length Based on Patient Height

Figures 4a and 4b - Predictive Model of Tendon Length Based on Patient BMI

79

Figures 5a and 5b - Predictive Model of Tendon Thickness Based on Patient Age

Figures 6a and 6b - Predictive Model of Tendon Thickness Based on Patient Weight

80

Figures 7a and 7b - Predictive Model of Tendon Thickness Based on Patient Height

Figures 8a and 8b - Predictive Model of Tendon Length Based on Patient BMI

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Figure 9 - Quadriceps Tendon Ultrasound Length Measurement

Figure 10 - Quadriceps Tendon Ultrasound Thickness Measurement 3cm Proximal to Superior Pole of Patella

Quadriceps Tendon Length

Rectus Femoris

Superior Pole Patella

Quadriceps Tendon

82

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skeletally immature prepubescent children and adolescents. Surgical technique. J Bone Joint Surg Am, 2006. 88 Suppl 1 Pt 2: p. 283-93.

44. Xerogeanes, J.W., K.E. Hammond, and D.C. Todd, Anatomic landmarks utilized for physeal-sparing, anatomic anterior cruciate ligament reconstruction: an MRI-based study. J Bone Joint Surg Am, 2012. 94(3): p. 268-76.

45. Geib, T.M., et al., Anterior cruciate ligament reconstruction using quadriceps tendon autograft: intermediate-term outcome. Arthroscopy, 2009. 25(12): p. 1408-14.

46. Kim, S.J., P. Kumar, and K.S. Oh, Anterior cruciate ligament reconstruction: autogenous quadriceps tendon-bone compared with bone-patellar tendon-bone grafts at 2-year follow-up. Arthroscopy, 2009. 25(2): p. 137-44.

47. Adams, D.J., A.D. Mazzocca, and J.P. Fulkerson, Residual strength of the quadriceps versus patellar tendon after harvesting a central free tendon graft. Arthroscopy, 2006. 22(1): p. 76-9.

48. Kohl, S., et al., Mid-term results of transphyseal anterior cruciate ligament reconstruction in children and adolescents. Knee, 2014. 21(1): p. 80-5.

49. Xie, G., X. Huangfu, and J. Zhao, Prediction of the graft size of 4-stranded semitendinosus tendon and 4-stranded gracilis tendon for anterior cruciate ligament reconstruction: a Chinese Han patient study. Am J Sports Med, 2012. 40(5): p. 1161-6.

50. Goldblatt, J.P., et al., Reconstruction of the anterior cruciate ligament: meta-analysis of patellar tendon versus hamstring tendon autograft. Arthroscopy, 2005. 21(7): p. 791-803.

51. Pichler, W., et al., Differences in length and cross-section of semitendinosus and gracilis tendons and their effect on anterior cruciate ligament reconstruction: a cadaver study. J Bone Joint Surg Br, 2008. 90(4): p. 516-9.

52. Xerogeanes, J.W., et al., Anatomic and morphological evaluation of the quadriceps tendon using 3-dimensional magnetic resonance imaging reconstruction: applications for anterior cruciate ligament autograft choice and procurement. Am J Sports Med, 2013. 41(10): p. 2392-9.

53. Waligora, A.C., N.A. Johanson, and B.E. Hirsch, Clinical anatomy of the quadriceps femoris and extensor apparatus of the knee. Clin Orthop Relat Res, 2009. 467(12): p. 3297-306.

54. Baek, G.H., et al., Quantitative analysis of collagen fibrils of human cruciate and meniscofemoral ligaments. Clin Orthop Relat Res, 1998(357): p. 205-11.

55. Staeubli, H.U., et al., Quantification of intact quadriceps tendon, quadriceps tendon insertion, and suprapatellar fat pad: MR arthrography, anatomy, and cryosections in the sagittal plane. AJR Am J Roentgenol, 1999. 173(3): p. 691-8.

56. Schweitzer, M.E., D.G. Mitchell, and S.M. Ehrlich, The patellar tendon: thickening, internal signal buckling, and other MR variants. Skeletal Radiol, 1993. 22(6): p. 411-6.

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57. Amis, A.A. and G.P. Dawkins, Functional anatomy of the anterior cruciate ligament. Fibre bundle actions related to ligament replacements and injuries. J Bone Joint Surg Br, 1991. 73(2): p. 260-7.

58. Duthon, V.B., et al., Anatomy of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc, 2006. 14(3): p. 204-13.

59. Brown, J.A., et al., Avoiding allograft length mismatch during anterior cruciate ligament reconstruction: patient height as an indicator of appropriate graft length. Am J Sports Med, 2007. 35(6): p. 986-9.

60. Makela, E.A., et al., The effect of trauma to the lower femoral epiphyseal plate. An experimental study in rabbits. J Bone Joint Surg Br, 1988. 70(2): p. 187-91.

61. Janarv, P.M., B. Wikstrom, and G. Hirsch, The influence of transphyseal drilling and tendon grafting on bone growth: an experimental study in the rabbit. J Pediatr Orthop, 1998. 18(2): p. 149-54.

62. Kercher, J., et al., Anterior cruciate ligament reconstruction in the skeletally immature: an anatomical study utilizing 3-dimensional magnetic resonance imaging reconstructions. J Pediatr Orthop, 2009. 29(2):

p. 124-9. 63. Noorkoiv, M., K. Nosaka, and A.J. Blazevich, Assessment of quadriceps muscle cross-sectional area by

ultrasound extended-field-of-view imaging. Eur J Appl Physiol, 2010. 109(4): p. 631-9. 64. Reeves, N.D., C.N. Maganaris, and M.V. Narici, Ultrasonographic assessment of human skeletal muscle

size. Eur J Appl Physiol, 2004. 91(1): p. 116-8. 65. Ahtiainen, J.P., et al., Panoramic ultrasonography is a valid method to measure changes in skeletal

muscle cross-sectional area. Eur J Appl Physiol, 2010. 108(2): p. 273-9.

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Long-term Results of Extensor Mechanism Reconstruction

Using Achilles Tendon Allograft after Knee Arthroplasty

Brent Wise, MD, Thomas Bradbury, MD, James Roberson, MD, Gregory Erens, MD ABSTRACT: Background: Disruption of the extensor mechanism after total knee arthroplasty is an infrequent but devastating complication. Limited published data exists to guide physicians to the optimal treatment and provide insight into the long-term outcomes. This study presents long-term results of extensor mechanism reconstruction using Achilles tendon allograft following patellar and quadriceps tendon rupture after TKA. Methods: Patients who underwent reconstruction of their knee extensor mechanism using Achilles tendon allograft following TKA between January 2003 and January 2012 were identified. Sixteen patients with 17 reconstructions were enrolled. The 17 reconstructions consisted of 10 patellar tendon and 7 quadriceps tendon ruptures. All patients underwent evaluation at an average of 46 months. Ten patients, with a minimum of two years follow up, were followed to an average of 65 months. Nine of these 10 completed an SF-36 form.

Results: The average extensor lag was 6.6 and average range of motion was 105.1. Of the patients with a minimum follow up of 2 years and an average follow up of 65 months, the

average extensor lag and range of motion was 8.4 and 107.9, respectively, with strength maintained at 4/5. The quadriceps tendon reconstructions had an average extensor lag and

range of motion of 2.9 and 103, respectively. Five patients died during the follow up period with 4 of those being in the quad tendon group. All but one of the patients were below the mean for age-matched controls on the SF-36. Conclusion: This study demonstrates that Achilles tendon reconstruction is a reliable and durable treatment for patients who sustain not only patellar tendon ruptures, but also quadriceps tendon ruptures following TKA. This technique can predictably restore extensor mechanism function and strength while maintaining range of motion. Despite the success of this technique, the injury and procedure have a profound impact on overall function.

Background: Disruption of the extensor mechanism after or during total knee arthroplasty

(TKA) is an infrequent but devastating complication. Reported rates of incidence range from

0.1% to 2.5% with the most common cause being patellar tendon rupture though other causes

including quadriceps tendon rupture and patella fracture can occur (5, 9,11,19,23). Though

rare, extensor mechanism disruption after TKA leads to profound incapacity so repair must be

attempted if patient’s wish to return to their previous level of function with optimized mobility.

Surgical repair and reconstruction of the extensor mechanism presents many

challenges both to the surgeon as well as the patient. Reports of primary repair of the

extensor mechanism in these scenarios have shown poor results (12,19,20,23), and as such,

surgeons have focused on extensor mechanism reconstruction using allograft tissue to

improve surgical outcomes. Presently, reconstruction using allograft knee extensor

mechanisms (quadriceps tendon-patella- patellar tendon-tibial bone block) (2,4,5,14,21) and

Achilles tendon allografts (Achilles tendon-calcaneal bone block) (2,10) have shown the most

promise though there is limited published data available to help guide physicians to the

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optimal treatment and even less data to provide the surgeon and the patient with insight into

the long term functional results and overall impact on quality of life. In 2002, Crossett, et al.

presented a series of 9 cases of patella tendon reconstruction using Achilles tendon allograft

with favorable results, though the follow up period was short at an average of 28 months. In

2003, Barrack et al presented another series with short term follow-up but included a greater

number of cases (14 patients). This series, showed comparable short term results to previous

studies that used extensor mechanism composite allografts (13, 14, 21). However, the

midterm results of these patients were published in 2006 with 5 more patients included (total

of 19 patients) and the results showed less optimal results than previously reported (4,5, 10,

21) at a mean of 56 months. Of note, this series included patients who underwent

reconstruction of patellar tendon ruptures with both Achilles tendon allograft and complete

extensor mechanism composite allografts though the results of these two methods were not

directly compared. The purpose of this study was to present long term results of extensor

mechanism reconstruction using Achilles tendon allografts following both patellar and

quadriceps tendon rupture after TKA and compare these results to similar studies.

Methods: We identified patients who underwent reconstruction of their knee extensor

mechanism using fresh frozen Achilles tendon allograft with attached calcaneal bone block

following TKA at our institution between January 2003 and January 2012. Sixteen patients

with 17 extensor mechanism reconstructions were enrolled in the study group. These

included 5 males and 11 females with an average age at the time of surgery of 71 years

(range, 57-79 years) and average age at follow up of 74 years (range 57-85 years). The 17

reconstructions consisted of 10 patellar tendon and 7 quadriceps tendon ruptures. Prior to the

surgery, 4 patients required a wheelchair for mobility while the others required an assistive

device including canes, crutches, quad cane, or walkers. Three adult reconstruction

specialists using similar technique performed all of the surgeries with the majority performed

by the primary investigator (GE). The patients’ charts were retrospectively reviewed and

follow up appointments were arranged with those available for further clinical evaluation. This

study was approved by the institutional review board

All patients underwent clinical evaluation at an average of 46 months. Ten patients

with a minimum of two years follow up were followed clinically to an average of 65 months.

Clinical evaluation for all patients included range of motion measurements including extensor

lag and maximal flexion using a standard goniometer and quadriceps strength testing was

performed manually using the Oxford scale. Preoperative extensor lag and knee flexion were

recorded and compared to the most recent follow up. Nine of these 10 completed th Short

Form 36 (SF-36) patient reported outcomes survey.

The surgical technique used was adapted from that described in previously reported series

(10). After debriding the ruptured quadriceps or patellar tendon, a cortical window just medial

to the tubercle was made approximately 1 cm below the bony margin of the proximal tibia with

a dimensions of approximately 1.5 cm in width, 2.5 cm in length and 1 cm in depth using a

micro-sagittal saw. An Achilles tendon allograft with attached calcaneal bone block was then

fashioned to fit the defect and the bone block was then tamped into position. To secure the

bone block to the tubercle, a 4.5 mm drill hole was made through the bone block followed by a

3.2 mm drill hole placed through the posterior cortex of the tibia. A single 4.5 mm screw was

then placed with a washer to hold the bone block in position. In some instances, an 18 gauge

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cerclage wire was used to provide further fixation. The allograft was tensioned fully with the

knee in full extension and the Achilles allograft was repaired side-to-side with the medial soft

tissues and extensor mechanism using non-absorbable suture, both running and interrupted.

The suture was continued up to close the medial parapatellar incision. The remainder of the

allograft was then laid over the top of the quadriceps and, again, tensioned. Numerous

interrupted non-absorbable sutures were used to secure the allograft to the underlying tendon.

The patient was kept in full extension throughout the tensioning process. Post-operatively, the

patient’s were placed in a knee immobilizer at all times and made touch toe weight-bearing for

one month. During this time, no active straight leg raises or quad sets were allowed.

Results: The average extensor lag of the 17 reconstructions was 6.6 degrees and average

range of motion was 105.1 degrees (40.3 degrees and 105 degrees preoperatively). The

average extensor mechanism strength was 4.3/5. Of the 10 patients with a minimum follow up

of 2 years and an average follow up of 65 months, the average extensor lag and range of

motion was 8.4 degrees and 107.9 degrees, respectively, with quadriceps strength maintained

at 4/5. The 7 quadriceps tendon reconstructions had an average follow up of 2 ½ years with

average extensor lag and range of motion of 2.9 degrees and 103 degrees, respectively.

There was one wound complication treated with antibiotics alone, and there was 1 case of re-

rupture that occurred approximately 2 years post operatively. Five patients died during the

follow up period (within 5 years from date of surgery) with 4 of those being in the quad tendon

rupture group. All patients required an assistive device for ambulation and all but 1 of the

patients available to complete the SF-36 were below the mean for age-matched controls on

the physical component score.

Discussion/Conclusion:

This study demonstrates that Achilles tendon reconstruction is a reliable treatment for

patients who sustain not only patellar tendon ruptures, but also quadriceps tendon ruptures

following TKA. This technique can predictably restore extensor mechanism function and

strength while maintaining range of motion. The short term results in the published literature

as well as reported in this study are shown to persist at an average of greater than 5 years,

demonstrating durability of the repair technique. Despite the success in restoring the function

of the extensor mechanism, patients who undergo this procedure continue to have overall

function below the mean for their age and will likely require some assistive device for

ambulation. Patients should be counseled as such before proceeding with this reconstruction.

Furthermore, the 5-year all cause mortality following reconstruction in this study was 31%.

This is likely a result of not only the morbidity of the surgery and subsequent recovery, but

also of the underlying co-morbidities that may have predisposed the patients to tendon rupture

to begin.

References 1. Abril JC, Alvarez L, Vallejo JC. Patellar tendon avulsion after total knee arthroplasty: a new technique. J Arthroplasty. 1995;10:275–279. 2. Barrack RL, Stanley T, Butler AR. Treating extensor mechanism disruption after total knee arthroplasty. Clin Orthop Relat Res. 2003;416:98–104. 3. Bozic K, Busfield B, Ries M. Patella fractures and total knee arthroplasty. Techniques in Knee Surgery. 2005;4:55-61.

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4. Burnett RS, Berger RA, Della Valle CJ, Sporer SM, Jacobs JJ, Paprosky WG, Rosenberg AG. Extensor mechanism allograft reconstruction after total knee arthroplasty. J Bone Joint Surg Am. 2005;87(Suppl 1):175–194. 5. Burnett RS, Berger RA, Paprosky WG, Della Valle CJ, Jacobs JJ, Rosenberg AG. Extensor mechanism allograft reconstruction after total knee arthroplasty: a comparison of two techniques. J Bone Joint Surg Am. 2004;86:2694–2699. 6. Burnett RS, Butler RA, Barrack RL. Extensor mechanism allograft recostruction in TKA at a mean of 56 months. Clin Orthop Relat Res. 2006. 452: 159-165. 7. Burnett RS, Fornasier VL, Haydon CM, Wehrli BM, Whitewood CN, Bourne RB. Retrieval of a well-functioning extensor mechanism allograft from a total knee arthroplasty: clinical and histological findings. J Bone Joint Surg Br. 2004;86:986–990. 8. Burnett RS, Haydon CM, Rorabeck CH, Bourne RB. Patella resurfacing versus nonresurfacing in total knee arthroplasty: results of a randomized controlled clinical trial at a minimum of 10 years’ follow up. Clin Orthop Relat Res. 2004;428:12–25. 9. Cadambi A, Engh GA. Use of a semitendinosus tendon autogenous graft for rupture of the patellar ligament after total knee arthroplasty: a report of seven cases. J Bone Joint Surg Am. 1992;74:974–979. 10. Crossett LS, Sinha RK, Sechriest VF, Rubash HE. Reconstruction of a ruptured patellar tendon with achilles tendon allograft following total knee arthroplasty. J Bone Joint Surg Am. 2002;84:1354–1361. 11. Dobbs RE, Hanssen AD, Lewallen DG, Pagnano MW. Quadriceps tendon rupture after total knee arthroplasty: prevalence, complications, and outcomes. J Bone Joint Surg Am. 2005;87:37–45. 12. Doolittle KH 2nd, Turner RH. Patellofemoral problems following total knee arthroplasty. Orthop Rev. 1988;17:696–702. 13. Emerson RH Jr, Head WC, Malinin TI. Reconstruction of patellar tendon rupture after total knee arthroplasty with an extensor mechanism allograft. Clin Orthop Relat Res. 1990;260:154–161. 14. Emerson RH Jr, Head WC, Malinin TI. Extensor mechanism reconstruction with an allograft after total knee arthroplasty. Clin Orthop Relat Res. 1994;303:79–85. 15. Gitomirski ML, Finn HA. Medial gastrocnemius flap for reconstruction of knee extensor mechanism disruption after total knee replacement (TKR). Surg Technol Int. 2004;12:221–228. 16. Insall JN, DorrL D, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res. 1989;248:13–14. 17. Jaureguito JW, Dubois CM, Smith SR, Gottlieb LJ, Finn HA. Medial gastrocnemius transposition flap for the treatment of disruption of the extensor mechanism after total knee arthroplasty. J Bone Joint Surg Am. 1997;79:866–873. 18. Leopold SS, Greidanus N, Paprosky WG, Berger RA, Rosenberg AG. High rate of failure of allograft reconstruction of the extensor mechanism after total knee arthroplasty. J Bone Joint Surg Am. 1999;81:1574–1579. 19. Lynch AF, Rorabeck CH, Bourne RB. Extensor mechanism complications following total knee arthroplasty. J Arthroplasty. 1987; 2:135–140. 20. MacCollum MS 3rd, Karpman RR. Complications of the PCA anatomic patella. Orthopedics. 1989;12:1423–1428. 21. Nazarian DG, Booth RE Jr. Extensor mechanism allografts in total knee arthroplasty. Clin

Orthop Relat Res. 1999;367:123–129.21.

22. Parker DA, Dunbar MJ, Rorabeck CH. Extensor mechanism failure associated with total

knee arthroplasty: prevention and management. J Am Acad Orthop Surg. 2003;11:238–247.22. 23. Rand JA, Morrey BF, Bryan RS. Patellar tendon rupture after total knee arthroplasty. Clin Orthop Relat Res. 1989;244:233–238.

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Manuscripts: PGY1’s

Rates and Determinants of Return to Play After Anterior

Cruciate Ligament Reconstruction in Division 1 College

Football Athletes: A Study of the ACC, SEC, and PAC-12

Jimmy Daruwalla, MD and John Xerogeanes, MD Abstract Background: For competitive athletes, return to play (RTP) and return to pre-injury levels of performance after anterior cruciate ligament (ACL) reconstruction are the main goals of surgery. Although outcomes of ACL surgery are well studied, details on factors influencing RTP in elite college football players have not been thoroughly evaluated. We aim to determine the rate of RTP following ACL surgery amongst Division 1 college football athletes and examine variables that may affect these rates. Hypothesis: We hypothesize that the RTP rate in this cohort will be influenced by factors reflecting skill and accomplishment, i.e. those higher on the depth chart, on scholarship, and those later in their careers, will have higher RTP rates. We also predict that graft type and concomitant procedures may have an effect on RTP rates. Study Design: Retrospective case series. Methods: Athlete- and surgery-specific data on athletes from participating institutions in three major Division 1 college football conferences who had ACL reconstruction from 2004-2010 were collected. Statistical analyses were performed to determine RTP rate as a function of the variables, such as depth chart position, in the data collected. Results: 82% of our 184-player cohort, including 94% of starters, was able to RTP. Rates were greater amongst athletes higher on the depth chart (P = .004) and on scholarship (P = .008). Year of eligibility also affected RTP rates (P = .047), which increased from the redshirt and freshman year to the sophomore and junior years, but then decreased slightly into the senior and 5th-year senior seasons. The use of an autograft versus allograft was associated with RTP (P = .045). There was no significant difference (P = .18) between players who underwent an isolated ACL reconstruction versus those who underwent additional procedures. Conclusion: Over 80% of injured football players at the Division 1 level were able to RTP following ACL reconstruction. Factors representative of a player’s skill were associated with higher rates of RTP. Surgery-specific variables, in general, had no effect on RTP, except for the use of autograft.

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Key Terms: Return to Play, ACL Reconstruction, College Athletes, Football What is known about the subject: The rate of RTP after ACL reconstruction has been evaluated in the literature in a variety of recreational and competitive athlete populations. However, only a few studies have attempted to characterize which factors, such as certain demographic and surgery-specific variables, may affect rates of RTP. Only one study, to our knowledge, has specifically examined college football athletes, but this study included athletes across Divisions 1, 2, and 3, and only examined a relatively small number of athletes. What this study adds to existing knowledge: Our study is the first, to our knowledge, to exclusively examine Division 1 college football athletes, a population unique in both skill and playing circumstance. We thus believe a dedicated analysis of RTP after ACL reconstruction, a common and serious problem, is warranted in this cohort. Our study also provides data on factors that may modulate rates of RTP. We believe this information will allow clinicians caring for this group of athletes to better counsel their patients on expectations after surgery. Introduction

The anterior cruciate ligament plays an important role in preventing anterior translation

and rotation of the tibia with respect to the femur, and is frequently injured during sports

involving jumping, pivoting, and cutting maneuvers. With approximately 100,000 performed

per year in the USA,1 ACL reconstruction is a common orthopedic procedure, particularly in

athletes and patients involved in recreational sports. It is widely recommended that athletes

desiring to return to sports activities should undergo reconstructive surgery. For high-level

athletes, the ability to return to pre-injury levels of competitive play is of even greater

relevance and importance. Thus, information regarding return to play (RTP) after ACL surgery

is vital in order for physicians to be able to adequately council patients on realistic

expectations after surgery.

Although RTP outcomes have been studied in a variety of patient populations, detailed

data pertaining to certain specific athlete groups is still limited. Moreover, data on rates of RTP

and return to pre-injury levels of competition have varied widely with regard to type of sport,

level of play, and duration of follow up.19 A modest number of studies have examined various

demographic and surgery-related factors influencing RTP rates, though comprehensive data

is still lacking. Furthermore, most of these studies have either been large meta-analyses or

small studies of specific athlete populations, such as National Football Players.1,2,5,11,16

McCullough et al (2012) studied RTP in college football players, but included Division 1, 2,

and 3 athletes.12 Furthermore, only 26 total college athletes were included, and the study was

underpowered to analyze certain factors that may determine RTP rates. As such, there is

currently a lack of information on the rates of successful return to competition after ACL

reconstruction specifically in Division 1 college football athletes. Furthermore, certain factors

unique to this cohort that may potentially impact RTP rates, such as athletic scholarship

status, graduating from college or not, and year of college eligibility, have never been

evaluated in the literature.

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In the present study, we aimed to determine the rates of return to play after ACL

reconstruction amongst college football players by analyzing data from teams in three Division

1 FBS conferences. Furthermore, we hoped to identify specific factors related to a player’s

skill, such as depth chart position, scholarship status, and years of play, which may affect an

athlete’s successful return to play. Surgery-specific data, such as the type of ACL graft used

and the presence of concomitant procedures performed during surgery, were also analyzed to

determine their effect on RTP.

We hypothesized that rates of RTP amongst Division 1 college football players would

be higher than data previously reported in the literature for the general population. We

expected that players on scholarship, at higher depth chart positions, and with more years of

experience would be more likely to RTP and return to pre-injury levels of play than players

who were not on scholarship, were lower on the depth chart, and had fewer years of

experience. Furthermore, we postulated that graft choice and presence of concomitant injury

may have an effect on RTP rates.

Study Methods

Our study was a multi-institution, retrospective case series involving three Division 1

FBS conferences: the Southeastern Conference (SEC), Atlantic Coast Conference (ACC),

and Pacific 12 (Pac-12). After Institutional Review Board approval was granted by our

University, the orthopaedic staff or head team athletic trainer at institutions in all three

conferences were contacted individually to ask for their participation.

All institutions agreeing to participate were sent a data collection spreadsheet. Athlete-

specific data included age, year in school, position, scholarship status, and depth chart

position. We also requested specific information about each subject’s surgery, including

surgical method of ACL reconstruction (trans-tibial, two incision, or medial portal technique),

type of graft utilized, graft fixation method, and concomitant procedures performed. Finally,

data related to our outcome measures was collected: if the athlete returned to play, time to

return to play, depth chart position upon return, and whether the player eventually graduated

and/or continued to play after college. No identifiable patient information was asked for or

reported to the research team. Participating institutions were requested to report data on

all eligible athletes over a seven-year period from the 2004 to the 2010 seasons. The cut-off

was made at the 2010 season in order to allow athletes undergoing surgery during that

season at least one full year to achieve RTP status, as data was collected after the 2011

season.

For this study, inclusion criteria were any Division 1 college football athlete at

participating schools in the SEC, ACC, or PAC-12 who suffered an ACL injury and

subsequently underwent ACL reconstruction during the study period. Exclusion criteria

included any patient who left his institution before determination of RTP could be made, and

any patient who was never cleared to RTP for medical reasons unrelated to their knee injury.

Athletes who underwent ACL reconstruction late enough in their career (senior year without

adequate remaining eligibility) such that they never had an opportunity to RTP at the college

level were excluded as well. RTP was defined as achieving full, unrestricted participation in a

full-contact practice, scrimmage, or regular season game at any time after the date of surgery.

All players who went on to play at the professional level were considered to have returned to

play, even if they had not participated in additional college games after surgery. Depth chart

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position both before and after surgery was divided into three groups: starter, utilized player, or

rarely/never played. Once all data was collected from each institution, it was combined into a

master spreadsheet for analysis.

Statistical analysis was performed using SAS 9.3 software. Descriptive statistics were

run on all variables including preoperative, operative, postoperative, and RTP data. χ2

analysis and Fisher’s Exact tests were performed to identify any relationship between RTP

and our outcome measures, including scholarship status, depth chart position, and years of

playing experience.

Results

A total of 13 institutions chose to participate in this study: 5 from the ACC, 5 from the

PAC-12, and 3 from the SEC. From these conferences, data from 49 players from the ACC,

78 from the PAC-12, and 57 from the SEC were obtained, comprising a total of 184 athletes in

this study. We observed an overall RTP rate of 82% (151/184) in our cohort of college football

athletes from three Division 1 FBS conferences.

Player-Specific Data

When grouping athletes by depth chart position, we observed a significant (P = .004)

association between higher depth chart position and increasing rates of RTP. Starting players

returned at a 94.2% rate (65/69), utilized players returned at an 87.7% rate (50/57), and

players who rarely played before surgery returned to play 72.9% of the time (35/48). There

was no data available on depth chart position for 10 players.

Of those who were able to RTP, 87.5% (49/56) of starters were able to RTP as starters

after surgery. Of those who did not return to a starting role, 6 became utilized players and only

1 fell to a “rarely playing” position after surgery. Of utilized players, 53.5% (23/43) returned as

utilized players, while 27.9% (12/43) returned as starters and 18.6% (8/43) rarely played after

surgery. Overall, 81.4% (35/43) of utilized players were able to return at or above their pre-

injury level of play. Of the 29 players who rarely played before surgery and were able to RTP,

20 (68.9%) remained at the “rarely played” position, 6 (20.7) became utility players, and 3

(10.3%) rose to the starting position after RTP.

For players on an athletic football scholarship, we observed an 87.6% (127/145) RTP

rate. Those not on scholarship returned only 68.8% of the time (22/32), representing a

significant association (P = .008) between RTP and scholarship status. Scholarship status of 7

players was unknown. There was no statistically significant difference (P = .20) in RTP rates

between athletes who graduated college (85.6%) and those who did not (70%). However,

graduation data was obtained on only 100 total athletes, and just 10 of these players did not

graduate. In our cohort, 21.1% (27/184) of players went on to play professionally in the NFL.

By our definition, 100% of these athletes were able to RTP whether or not they participated in

another college game or practice after ACL reconstruction.

A statistically significant (P = .047) effect was observed when trending players’ years

of football experience to RTP rates. As demonstrated in Figure 1, rates of RTP increased from

the redshirt freshman year (33.3%) through the freshmen year (82.5%) and plateaued in the

sophomore (93.9%) and junior (88.6%) years. Beyond that, more veteran players in their

senior (72.8%) and 5th year senior (75%) seasons had lower RTP rates. Players who were

93

injured late in their last year of eligibility who did not have the potential to return to play due to

lack of time were excluded from analysis.

Surgery-Specific Data

Of the 182 players for whom graft information was obtained, 155 (85%) received an

autograft, and 27 (15%) received an allograft. Of the players who had autograft reconstruction,

140 were patella grafts and 15 were hamstring grafts. There were no reports of quad tendon

graft use. When comparing RTP rates amongst players who received a patella tendon

autograft versus those who received a hamstring autograft, we found no difference (P = .3206)

in RTP rates. However, we did observe a significant difference (P = .045) in RTP rates when

comparing players who received an autograft of any kind (84.5%) versus those who received

an allograft (68.9%).

Variation in graft selection was observed when we analyzed graft type and

reconstruction methods between the ACC, SEC, and PAC-12. While the patella tendon

autograft was the most popular graft choice within each conference, the PAC-12 and SEC did

show a propensity to utilize allograft tissue more than the ACC. 20.5% (16/78) of athletes in

the PAC-12 and 17.5% (10/57) in the SEC received an allograft, while only 2.1% (1/47) of

athletes in the ACC received an allograft. Of players who received an autograft, patella

utilization was most popular, and appeared to be similar between conferences: 86.9% (40/46)

in the ACC, 89.4% (42/47) in the SEC, and 93.5% (58/62) in PAC-12.

Data on other procedures that were performed concomitantly with ACL reconstruction

were collected for all of the 184 athletes studied. Specifically, we collected data on whether or

not each athlete underwent a medial and/or lateral menisectomy, medial and/or lateral

meniscal repair, MCL repair, LCL repair, PCL repair, microfracture, or chondroplasty. In our

cohort, 69% of players (127/184) underwent at least one of the above concomitant procedures

during ACL reconstruction. Cumulatively, no significant difference (P = .18) in RTP rates was

observed between players who underwent an isolated ACL reconstruction versus those who

underwent ACL reconstruction and a concomitant procedure. When analyzed individually,

none of the concomitant procedures demonstrated a statistically significant effect on RTP.

Similarly, we found no effect from the type of ACL reconstruction technique (P = .68) or type of

tibial (P = .66) or femoral (P = .73) fixation method on our players’ RTP rates.

Discussion

Outcome measures used to evaluate success following ACL reconstruction have often

utilized tools such as the IKDC, Lysholm, or Tegner score, the presence or absence of a

positive Lachman or pivot shift on exam, or the KT-1000 instrumented laxity value. These

tools provide meaningful data about how well ACL reconstructive surgery restores knee

function, mechanics and laxity. However, in some ways, the truest test of ACL reconstruction

is its ability to allow a high level athlete to successfully return to their previous sport at the

same level of performance. The present study is an attempt to evaluate ACL reconstruction in

Division 1 football athletes in this manner. By doing so, one is able to discern, to some

degree, the effect that ACL injury and reconstruction has on this specific athletic population.

Though we examined a number of surgery-specific variables that have been previously

evaluated in the literature, such as reconstruction technique, graft choice, and fixation

methods, our study also looked at several college athlete-specific variables and how they

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affected RTP following surgery. Issues such as scholarship status, depth chart position, and

year of eligibility may reflect more on a players’ innate ability or motivation, which may be

equally, if not more, important in determining their success at returning to the game at their

pre-injury level of play.

Our reported RTP was 82% for the group of players as a whole. This compares

favorably to the work of Shah et al (2010), who found that 63% of NFL players RTP following

ACL reconstruction,16 and the work of Carey et al (2006), who found a 79% RTP rate in

running backs and wide receivers in the NFL.7 A recent meta-analysis of 48 studies, which

included athletes of all levels and ages, also reported a pooled RTP rate of 82%, but sub-

group analysis only of athletes involved in competitive sports revealed a lower rate of RTP at

44%.1 Given the above previously published data, one might infer that RTP rates would

decrease linearly with increasing levels of competitive play. However, our results seem to

contradict this theory and may instead suggest that our reported rate is more dependent on a

unique set of factors and circumstances impacting RTP potential in this specific athlete

population.

Given the investment of time and effort, and the innate talent that is often necessary

for these athletes to reach these higher competitive levels, one may infer that talent and

motivation play a big role in RTP success. Our data on the effect of depth chart position on

RTP rates seem to support this theory: although players without starting roles still had a high

likelihood of RTP (80.9% combined rate for utilized and rarely played), they did not equal the

results of starting players (94.2%). One may look at this in the context of starters being more

talented to begin with so they return at a higher rate, and/or that starters are more motivated

to return, as they would have been more involved in play and would strive to attain that level

again.

This theory is further supported by our data on post-injury depth chart position in those

players who were able to RTP. 87.5% of starters were able to return to the same depth chart

position after RTP. Of the 7 players who did not, 6 became utilized players. With regards to

utilized players, 81% returned to the same depth chart position or higher, while only 19%

dropped to the “rarely played” category. Interestingly, 28% of athletes in the “utilized player”

category before injury were actually able to return as starters after surgery. Namdari et al

(2011) and Busfield et al (2009) demonstrated that most professional athletes are able to

return to pre-injury levels of performance after surgery.14,6 Our findings agree with this work,

but contrasts with data from a meta-analysis by Ardern et al (2011) and a study by Laboute et

al (2010) utilizing a mixed-sport cohort that found return to pre-injury levels to be lower (63-

65%).1,10 We believe this discrepancy stems from our cohort’s unique playing circumstances,

likely more similar to those of professional athletes than casual and recreational athletes. Our

findings on return to pre-injury level of play suggest that, while certainly a considerable

obstacle, undergoing ACL reconstruction does not necessarily portend a poor prognosis for

continuing to improve and excel in one’s collegiate career and beyond.

Scholarship athletes had a significantly higher (P = .008) RTP rate (87.6%) than those

not on scholarship (68.8%). If one assumes that scholarship athletes were deemed initially to

be more talented than those not offered football scholarships, one could again conclude that

increased ability or talent is a factor in RTP success. These results are in agreement with

previous studies on NFL athletes, which showed that earlier draft round and increasing years

of experience correlated positively with RTP after sports-related surgery.3,16

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Likewise, as playing through eligibility and graduating from college may be considered

another marker of dedication to football after injury, we expected players who graduated to

RTP at a higher rate than those who did not. While our data demonstrated a trend supporting

this hypothesis, the difference did not reach statistical significance. This is likely because we

only obtained data on 10 players who did not graduate, thereby limiting power for this

analysis.

Year of eligibility had a statistically significant (P = .047) effect on RTP, as we had

expected. Although, when stratifying RTP by year of eligibility (Figure 1), the trend was not the

positive linear relationship that we had hypothesized. RTP rates for players early in their

career (redshirt freshman and freshman) were lower than or at average compared to our

cohort as a whole, suggesting that early injury may be a barrier for career progression. A

substantial portion of these players may not have progressed in their football careers

regardless (i.e. they may have been cut from the team or dropped out voluntarily for other

reasons), though ACL injury and/or rehabilitation may still have been a salient factor in the

termination of these players’ careers. Once players were in their sophomore and junior years,

RTP rates were highest (94% and 89%, respectively). We theorize that players at this stage of

their careers had already proven their skill enough to remain on the team, and thus had more

incentive to RTP. Furthermore, the injury still occurred early enough such that each player

(especially the sophomores) could potentially make a full recover and continue playing for a

substantial period of time. RTP rates in the more veteran years returned at a lower than

average rate (73% and 75% in the senior and 5th year senior years, respectively). This may be

because these players realized they were at the end of their careers and, if not continuing on

to play professionally, may have been less willing to commit to the intensive rehabilitation

required to return to football.

The presence of concomitant knee procedures during ACL reconstruction did not

affect a player’s ability to RTP. This was true when analyzing the performance of concomitant

procedures in general and also when looking specifically at any of the nine individual

procedures that we had asked about in our data collection spreadsheet. Shah et al (2010)

also found no significant differences in RTP potential with respect to the number or type of

concomitant procedures performed.16 Although these findings suggest that ACL tears and

reconstructions are the limiting factor in an athlete’s recovery after complex knee injury, these

data should be interpreted with caution. A larger number of patients than ours is most likely

required to truly tease out the effect that each specific procedure has on the overall RTP rate

in athletes who undergo simultaneous surgical repair of multiple injuries in the same knee.

Interestingly, a level 3 study by Brophy et al (2009) demonstrated that a history of

menisectomy, but not ACL reconstruction, confers a deleterious effect on the longevity of an

NFL player’s career.4 While this study did not specifically assess RTP after surgery, it

demonstrates that more work is needed to elucidate the effects of ACL tears with and without

associated injuries on both short and long-term outcomes in competitive football players.

When analyzing surgery-specific factors pertaining to the ACL reconstruction, only the

choice between autograft and allograft had an impact on our rates of RTP, with autograft

superior. To our knowledge, our study is the first to compare the effect of allograft versus

autograft on RTP rates. While allograft use has been at times thought of as an attractive

alternative to autograft, there are certainly concerns raised by many authors relating to

increased failure rate with allograft use in the younger populations.17 Although most studies

96

claiming the inferiority of allograft cite specifically the need for re-operation from graft failure,9

and not the lower rate of immediate RTP, it is nevertheless interesting to consider our findings

in light of these previous reports. However, we must note that our study does not examine the

reason behind a failure to RTP, and thus no direct causal relationship between graft choice

and RTP can ultimately be concluded from our data.

While patellar tendon grafts were the most popularly utilized graft amongst all three

conferences, we found no difference in RTP rates between patellar tendon grafts and

hamstring tendon grafts in our cohort. This finding is consistent with the literature regarding

the impact of graft choice, which has largely shown to have no effect on ACL reconstruction

outcomes (though this topic remains controversial).8,13,15,18 Similarly, reconstruction technique

and type of tibia and femoral fixation did not impact RTP in our study. While the PAC-12 and

SEC utilized allograft more frequently than the ACC, we did not explore the rationale behind

graft choice.

While presenting novel and interesting findings that we believe will be clinically useful

for physicians caring for the elite college football athlete, our study has several limitations that

should be considered when interpreting our data. Foremost, this study is a retrospective case

series and thus may have several types of biases inherent to that study design. As a

multicenter study, there likely were variations in the data collection procedures used at each

institution. In addition to variation in data collection, there may also be differences in

rehabilitation protocols and training staff that may contribute to differences in RTP rates

between schools and conferences. Again, we also did not examine the reasons why a player

may not have returned to play. As previously demonstrated in college athletes, psychological

factors such as fear of re-injury are significant factors in a player’s decision to RTP.12 As such,

we cannot assume that a lack of RTP equates to surgical failure. It is also worth noting that

graft selection is largely based on surgeon preference and, as such, data on graft preferences

are inherently biased as only certain institutions participated in our study. Thus, data on these

preferences cannot be generalized to all institutions nor used to infer current preferences

amongst Division 1 college institutions as a whole.

Conclusions

In our cohort of 184 athletes from three major Division 1 FBS conferences, 82% of all

players, and 94% of starters, were able to RTP following ACL reconstruction. A large majority

were able to return at or above their pre-injury level of play. Having a starting position at the

time of injury and being on scholarship had a positive effect on RTP. Year of play was also

significantly associated with RTP, with sophomores and juniors having the highest rates.

Autograft reconstruction increased RTP levels compared to allograft use, while operative

technique, fixation method and concurrent procedures did not seem to affect RTP. While our

overall RTP rate was higher than that of most previously published data, the factors

significantly associated with RTP in our study, such as markers of player skill, were consistent

with preexisting data from similar athlete populations.

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Figure 1. Rate of RTP versus year of play. RTP rates increased over time to peak in the sophomore and junior years. Rates slightly decreased in the senior years. Interaction between RTP rates and year of play was statistically significant (P = 0.047). References

1. Ardern C, Webster K, Taylor N, Feller J. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med. 2011;45:596-608.

2. Bjordal J, Arnoy F, Hannestad B, Strand T. Epidemiology of anterior cruciate ligament injuries in soccer. Am J Sports Med. 1997;25(3):341-345.

3. Boublik M, Schlegel T, Koonce R, Genuario J, Lind C, Hamming D. Patellar tendon ruptures in National Football League players. Am J Sports Med. 2011;39(11):2436-2440.

4. Brophy RH, Gill CS, Lyman S, Barnes RP, Rodeo SA, Warren RF. Effect of anterior cruciate ligament reconstruction and menisectomy on length of career in National Football League athletes: a case control study. Am J Sports Med. 2009;37(11):2102-2107.

5. Brophy RH, Schmitz L, Wright RW, Dunn WR, Parker RD, Andrish JT, McCarty EC, Spindler KP. Return to play and future ACL injury risk after ACL reconstruction in soccer athletes form the multicenter orthopaedic outcomes network (MOON) group. Am J Sports Med. 2012;40(11):2517-2522.

6. Busfield BT, Kharrazi FD, Starkey C, Lombardo SJ, Seegmiller J. Performance outcomes of anterior cruciate ligament reconstruction in the national basketball association. Arthroscopy. 2009;25(8):825-830.

7. Carey JL, Huffman GR, Parekh SG, Sennett BJ. Outcomes of anterior cruciate ligament injuries to running backs and wide receivers in the National Football League. Am J Sports Med. 2006;34(12):1911-1917.

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

RedshirtFreshman

Freshman Sophomore Junior Senior 5th yearSenior

RTP Rate By Year Of Play

RTP Rate

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8. Goldblatt JP, Fitzsimmons SE, Balk E, Richmond JC. Reconstruction of the anterior cruciate ligament: meta-analysis of patellar tendon versus hamstring autograft. Arthroscopy. 2005;21(7):791-803.

9. Hettrich CM, Dunn WR, Reinke EK, MOON Group, Spindler KP. The rate of subsequent surgery and predictors after anterior cruciate ligament reconstruction: tw- and 6-year follow-up results from a multicenter cohort. Am J Sports Med. 2013;41(7):1534-1540.

10. Laboute E, Savalli L, Puig P, Trouve P, Sabot G, Monnier G, Dubroca B. Analysis of return to competition and repeat rupture for 298 anterior cruciate ligament reconstructions with patellar or hamstring tendon autograft in sportspeople. Ann Phys Rehabil Med. 2010;53(10):598-614.

11. Mascarenhas R, Tranovich MJ, Kropf EJ, Fu FH, Harner CD. Bone-patellar tendon-bone autograft versus hamstring autograft anterior cruciate ligament reconstruction in the young athlete: a retrospective matched analysis with 2-10 year follow up. Knee Surg Sports Traumatol Arthrosc. 2012;20:1520-1527.

12. McCullough KA, Phelps KD, Spindler KP, Matava MJ, Dunn WR, Parker RD, MOON group, Reinke E. Return to high school- and college-level football after anterior cruciate ligament reconstruction: A multicenter orthopaedic outcomes network (MOON) cohort study. Am J Sports Med. 2012;40(11):2523-2529.

13. Mohtadi NG, Chan DS, Dainty KN, Whelan DB. Patellar tendon versus hamstring tendon autograft for anterior cruciate ligament rupture in adults. Cochrane Database Syst Rev. 2011;9:CD5960.

14. Namdari S, Scott KB, Milby A, Baldwin K, Lee GC. Athletic performance after ACL reconstruction in the Women’s National Basketball Association. Phys Sportsmed. 2011;39(1):36-41.

15. Samuelsson K, Andersson D, Karlsson J. Treatment of anterior cruciate ligament injuries with special reference to graft type and surgical technique: an assessment of randomized controlled trials. Arthroscopy. 2009;25(10):1139-1174.

16. Shah V, Andrews J, Fleisig G, McMichael C, Lemak L. Return to play after anterior cruciate ligament reconstruction in national football league athletes. Am J Sports Med. 2010;38(11):2233-2239.

17. Singhal MC, Gardiner JR, Johnson DL. Failure of primary anterior cruciate ligament surgery using anterior tibialis allograft. Arthroscopy. 2007;23(5):469-75.

18. Spindler KP, Kuhn JE, Freedman KB, Matthews CE, Dittus RS, Harrell FE Jr. Anterior cruciate ligament reconstruction autograft choice: bone-tendon-bone versus hamstring: does it really matter? A systematic review. Am J Sports Med. 2004;32(8):1986-1995.

19. Warner S, Smith MV, Wright RW, Matava MJ, Brophy RH. Sport-specific outcomes after anterior cruciate ligament reconstruction. Arthroscopy. 2011;27(8):1129-1134.

99

The Value of a Saturday Dedicated Orthopaedic Trauma

Operating Room

Robert Runner BS α, Thomas Moore Jr. MD β, William Reisman, MD βγ α Emory University School of Medicine, Atlanta, GA β Emory University Department of Orthopaedics, Atlanta, GA γ Grady Memorial Hospital, Atlanta, GA Abstract

Hospital administrations constantly face cost-benefit decisions when balancing financial and patient care interests. These pressures are magnified at a large academic level 1 trauma center with recurring financial hardships like Grady Memorial Hospital. Providing quality care for patients in an efficient delivery model is imperative. One way to increase efficiency within the Orthopaedic Department is to clear cases by operating more often, which could potentially reduce costs by reducing patient length of stay (LOS).

Beginning November 1, 2010, the Orthopaedics and Anesthesia departments implemented a new policy to have a dedicated Saturday orthopaedic operating room to provide more continuous care for patients and efficiently work through a large caseload. The aim of this study is to assess the efficacy of this additional operative day by analyzing the primary outcomes of LOS and surgical waiting time. Trauma patients admitted with femur or tibia fractures one year prior to the implementation of this dedicated orthopaedic trauma OR were compared to patients admitted in the year after this policy change.

After the addition of a dedicated Saturday orthopaedic operating room, the overall LOS for all trauma patients admitted with femur or tibia fractures was significantly reduced by 2.7 days from a mean of 14.0 days to 11.3 days (p value 0.018). Additionally, there was a trend towards shorter waiting time to surgery (average reduction of 25.1 hours) for patients admitted on a Friday (48.6 hrs. vs. 23.5 hrs., p value 0.06). Furthermore, there was an increase in the number of cases performed on Saturdays by 59% (6.2% of the total caseload) while the originally disproportionally high number of cases on Mondays was appropriately reduced by 33% (6.7% of the total caseload). Overall, these findings support the continuation of a dedicated Saturday orthopaedic trauma OR and can provide the foundation for other departments with similar circumstances to negotiate for more operative time on weekends to improve efficiency.

Introduction

Given the current economic and political climate, it is important for hospital

administrations to analyze financial data and support cost reduction strategies in healthcare,

especially at a government funded hospital like Grady Memorial Hospital. Grady is a level 1

trauma center serving patients across Georgia and has faced significant financial strain in

recent years. Orthopaedic trauma accounts for a substantial portion of operations; therefore,

adjusting orthopaedic protocols or operating room (OR) scheduling can significantly impact

the overall cost that Grady and its patients incur. One major contributor to healthcare

spending is length of hospital stay (LOS) as it costs between $1,000 - 3,000 for each

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additional hospital day for an inpatient stay. System based changes that reduce length of stay

while maintaining quality of care can directly decrease healthcare costs and benefit both the

patient and the hospital.

Each orthopaedic trauma case requires significant resources. In addition to the

attending surgeon, at least one scrub nurse and a surgical assistant of a resident or surgical

nurse is needed for instrument delivery and patient manipulation. Additionally, a circulating

nurse, a dedicated radiographer, and an anesthesiologist are required.1 Due to the high

costs needed to staff a weekend OR, Grady did not have a dedicated orthopaedic trauma OR

on Saturdays until November 2010. Prior to this time, the most urgent cases that presented on

weekends were covered using ORs shared by all surgical specialties; however, some

orthopaedic surgeries were delayed until the beginning of the workweek as there were a

limited number of surgeons and operating support staff available on weekends. This study’s

hypothesis is that these delays in patient care impact healthcare costs, LOS and possibly

even patient morbidity.

Recent studies show that immediate surgical intervention represents one way to

reduce complications. One study performed at Grady and published in 2007 demonstrated

that femoral shaft fractures fixed using intramedullary nailing within 24 hours from

presentation to the emergency department (ED) had significantly lower LOS.2 The average

LOS for a patient with an isolated femoral shaft fracture was 3.9 days with 25% of patients

staying over 4 days. At that time, the average time from arrival to the hospital to surgery was

17.2 hours.2 Additionally, a systematic review specifically analyzing hip fractures published in

2009 concluded that early surgery within 48 hours of admission reduced hospital stay.3

Reductions in LOS associated with early intervention are further supported by the prospective

cohort study of hip fracture patients performed in 2004 by Orosz et. al. They found a

reduction in LOS and pain scores associated with early surgery, while mortality was not

affected.4 These studies of isolated fractures may not fully represent the caseload of an

orthopaedic trauma service which often cares for poly-trauma patients who require multiple

surgeries and co-management with the general surgery trauma service. Part of the

assessment of trauma patients is the injury severity score (ISS), a quantitative measure of the

significance of patient injuries. Isolated fractures of the femur or tibia correlate to an ISS of 4

and 9 respectively. Many patients seen at larger trauma centers have multiple injuries, higher

ISS, and longer hospital stays. There are many scoring mechanisms for assessing trauma

patient injuries including the Injury Severity Score (ISS), Trauma and Injury Severity Score

(TRISS), and ICD 9 Code Based Injury Severity Score (ICISS). The overall goal of these

scoring indices is to predict not only outcomes for patients but also resource utilization, LOS

and overall cost.5

As a large publically-funded level 1 trauma center serving the North Georgia and

Southeastern US population, Grady must adapt to efficiently work with its limited resources.

Prior to November 2010, there were only two active trauma operating suites on weekends.

One remained open for potential immediate general trauma surgery cases, while the other

was shared by subspecialty services like orthopaedics, urology, neurosurgery, and ENT.

Posted or scheduled orthopaedic cases could be delayed or even cancelled if other services

had a more immediate need for the OR. The backup of cases led to an overloaded surgical

schedule on Mondays in order to catch up from the weekend admissions. The Orthopaedics

Department began working with the hospital administration and was able to obtain a dedicated

101

orthopaedic trauma OR on Saturdays starting November 1, 2010. Since the implementation

of this policy, definitive analysis of the effect of this change has yet to be completed.

Examining the outcomes, like LOS and waiting time to surgery for patients admitted one year

pre- and post-policy change will be important. This analysis seeks to capture the effects of

this policy change and to determine if it should be continued at Grady. Additionally, this

analysis could serve as the foundation for other institutions that do not currently have

dedicated Saturday orthopaedic operating rooms to adopt this new policy.

Materials and Methods

This study is a retrospective chart review. Patients were identified by querying the

Grady Trauma Registry which stores data from all trauma patients who are evaluated in the

Grady emergency department. Eligible medical record numbers of patients were identified

who had a lower extremity fracture as documented by an ICD-9 code of femur or tibial shaft

fracture admitted to Grady Memorial Hospital from November 1, 2009 through October 31,

2011. 475 patients with femur or tibia fractures were identified as being admitted to the

hospital during this eligibility period. Of these 475 total patients, 167 were directly admitted to

the orthopaedic trauma team, while the other 308 were admitted to the general surgery

trauma team and had the orthopaedic team in consultation. Patients who had no operation

during their admission were excluded from the study. Patients who were misclassified as

having a femur or tibia fracture in the trauma database but on further chart review did not have

an operative femur or tibia fracture were excluded as well. Specific patient charts were

collected from the Grady Medical Records office over a period of 4 months using a

combination of paper charts and EPIC electronic medical record. A thorough chart review

was performed for each subject and data stored using Microsoft Excel. Specific data points

collected included: date of injury, date presented to emergency department, arrival time in

emergency department, date of surgery, surgical incision time, date of discharge, age, gender,

race, ISS, and mechanism of injury. Length of stay was calculated using the difference in the

date of arrival and date of discharge. Waiting time to surgery was calculated by determining

the length of time in hours from arrival in the emergency department to surgical incision time

as documented in anesthesia reports. There were no significant changes in number of faculty

caring for these patients during the analyzed two year period.

Strict patient confidentiality was maintained throughout the data collection process.

Ethical consideration and permission from the Emory Institutional Review Board (IRB) and

Grady Research Oversight Committee to perform this study was obtained prior to data

collection. Personal health information of subjects was de-identified in accordance with IRB

guidelines.

Statistical analysis: Kruskal-Wallis one way analysis of variance was used to analyze

the continuous variables as it is a non-parametric method and does not need the assumption

of a normal distribution of the outcomes as required by traditional student t-test. The Kruskal-

Wallis test was used to analyze the waiting time, LOS, ISS, and age. Two-tailed Fisher’s exact

test was used to analyze the categorical variables of race, day of the week of injury, and

mechanism of injury. Additionally Spearman’s rank correlation coefficients were calculated to

assess the nonparametric measures of statistical dependence between ISS and LOS. Further

analysis using Hoeffding Dependence coefficients was performed to test the non-linear

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correlation between ISS and LOS. To assess for a linear relationship between ISS and LOS,

linear fitting plots were obtained and R-square values calculated. Statistical significance was

set at p value < 0.05; r- square > 0.5 was set for an acceptable linear relationship. All the

analyses were performed with SAS 9.3 (SAS Institute Inc., Cary, NC; 2011).

Results

Based on this retrospective chart review of 475 patients with operative tibia or femur

fractures treated at Grady Memorial Hospital from November 1, 2009 to October 31, 2011, a

total of 20 patients were excluded from analysis. 4 of the 475 patient charts were unable to be

located by the medical records service. 6 patients in the pre group and 6 in the post group

were removed as they were treated with non-operative management. 4 patients were

misclassified as having a femur or tibia fracture in the original query from the Grady trauma

registry, when on full chart review these patients actually had a patella, calcaneus, or

metatarsal fracture; thus a total of 455 charts were analyzed.

As shown in Table 1, the demographic data of age and mechanism of injury were not

significantly different between the groups. The mean age was 37.8 and 38.8 for the pre- and

post-policy change groups respectively. Major mechanisms of injury included falls, gunshots,

motorcycle crash and motor vehicle crash and were not significantly different between the

groups. There was a significant difference in the racial distribution between the two groups (p

value <0.0001) with a larger portion of African-American patients admitted (55.2% vs. 71.5%)

in the post policy change group as compared to a relative decrease in Caucasian (34.3% vs.

21.5%) and Hispanic (7.1% vs. 0.9%).

In comparing the injury severity score between the pre and post groups, there was a

significant difference (p value 0.022) with a reduction in mean ISS from 12.1 to 10.6. In order

to determine if the reduced LOS in the post policy group could be accounted for by the

reduction in ISS, several methods were used to assess independence of these two variables.

First the collinearity of LOS and ISS using linear fitting plots (Figure 1) were calculated and

showed R- square values of 0.24 and 0.15 for the pre and post groups respectively; both were

below the standard 0.5 cutoff for acceptable linear relationship, indicating that a direct linear

relationship was unlikely between ISS and LOS. Additionally the Spearman Correlation

between ISS and LOS was calculated as 0.42, and the Hoeffding Dependence coefficient

between ISS and LOS was calculated as D=0.055. These nonparametric measures of

statistical dependence are used to evaluate if continuous variables such as ISS and LOS are

independent of one another. From these calculations, ISS and LOS do not directly show a

linear or nonlinear relationship between ISS and LOS. Thus, it appears the overall reduction in

LOS (as described below) between the two groups is not fully dependent on the difference in

ISS between the groups.

With respect to the distribution of the case load shown in Table 2, there was an

increase in the number of cases performed on Saturdays after the addition of the dedicated

Saturday orthopaedic trauma OR. Prior to the policy change, 10.5% of the total cases

(25/239) were completed on Saturday. After the new policy 16.7% of the total cases (36/216)

were performed on a Saturday. This is a relative 59% increase in the number of cases done

on Saturday (p-value 0.055) and corresponds to an absolute increase in the Saturday

caseload of 6.2% of the overall case load. Additionally, there was a trend towards a

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reduction in cases performed on Mondays with 20.1% (48/239) performed prior and 13.4%

(29/216) performed after the implementation of the Saturday OR (relative decrease of 33%, p

value 0.062). Although neither of the calculated p values was below 0.05, both display the

strong trend towards the change in case distribution. Additionally, the more balanced workload

is reflected in the overall comparison between the caseload distribution pre- and post-policy

change. This comparison trended towards a more even distribution (p value 0.09).

Additionally, overall LOS and LOS based on the day of the week the patient presented

to the ED were analyzed between the two groups. As seen in Table 3, the overall LOS was

significantly reduced by 2.7 days from average 14.0 days to 11.3 days (p value 0.018). The

most significant reductions in LOS between the groups were seen in the subset of patients

admitted on a Monday or Wednesday. The mean LOS for patients admitted on a Monday was

reduced from 20.5 days to 11.3 days (p value 0.011), while the LOS for patients admitted on a

Wednesday had a reduced mean LOS from 13.7 to 9.2 days (p value 0.088).

Another primary outcome analyzed was the waiting time to surgery, which was

calculated as the time between the patient’s arrival in the ED to surgical incision time. These

data are displayed in Table 4. Although there was no significant reduction in overall waiting

time after the extra OR day, there was a strong trend towards a reduction in the waiting time

for patients who presented on a Friday. Patients presenting on Friday had on average a 25.1

hour reduced waiting time (48.6 vs. 23.5 hours) after the addition of a dedicated Saturday

orthopaedic trauma OR (p value 0.060). There was no significant decrease in waiting time for

patients presenting on any other day of the week.

Discussion

Based on this retrospective chart review comparing patient data from one year prior to

the implementation of a dedicated Saturday orthopaedic trauma OR to one year after this

policy change, three major conclusions were observed. First, the overall length of stay was

reduced by a mean of 2.7 days in patients admitted after the implementation of the Saturday

dedicated orthopaedic trauma OR. This reduction from 14.0 days to 11.3 days was an

appropriate decrease and larger than the expected 1-2 day decrease in LOS from a single

additional OR day. From analysis of the subgroups based on date of admission, the majority

of the overall reduction in LOS was in patients admitted on Monday and Wednesday. Mean

LOS for patients admitted on a Monday was reduced from 20.5 days to 11.3 days, p value

0.011. Patients admitted on a Wednesday had mean LOS reduced from 13.7 to 9.2 days, p

value 0.088. Logically, the longer a patient stays in the hospital, the higher the cost of his or

her care, and sicker patients tend to remain in the hospital longer. These straightforward

conclusions have been proven specifically for trauma patients as prior studies have shown

increased cost associated with longer hospital stays and higher injury severity scores.6

Reducing the average LOS for patients is a major focus of hospital administrations as reduced

LOS is a surrogate for reducing the cost of patient care.

The business model of the hospital is to provide quality patient care while efficiently

treating and discharging patients. Given the changes occurring in the healthcare model with

the potential for a flat rate reimbursement for admission diagnosis, these efficiencies will be

critical in maintaining hospital solvency in the future. Policy changes that decrease LOS such

as this additional operative day could be part of the solution to reduce overall hospital costs.

104

Further microeconomic specific marginal cost-benefit analysis utilizing the confidential salaries

of the necessary OR personnel (attending orthopedist, anesthesiologist, scrub nurses,

circulator, radiographer) required to run the OR can be compared to the reduction in LOS and

estimated overall cost savings calculated based on each hospital system. Additionally,

assuming each procedure is profitable at baseline, the higher volume of cases being

performed should yield higher revenue for the hospital while also cutting costs by reducing

LOS. Overall this transition to a more factory-style or seven days per week operating schedule

may be necessary for the future of hospitals to remain profitable.

Prior data from Grady have shown a reduction in LOS for patients with isolated femoral

shaft fractures if they were treated with early fixation and surgery within 24 hours.2 The

subjects analyzed in our sample often had multiple injuries and higher injury severity scores

(overall average 11.4) than isolated femoral shaft fracture patients. Additionally our group of

patients had a longer average waiting time to surgery of 33.3 hours compared to the average

17.2 hours for isolated femur fracture patients. These factors help to explain why this study

has a higher overall mean LOS of 12.7 days as compared to Pendleton’s findings of 3.9 day

mean LOS for patients with isolated femoral shaft fractures. Additionally, patients with

isolated femur fractures are often immediately treated with a single surgery for definitive

fixation. Many of the patients in our sample required temporary external fixation followed by a

second surgery for definitive fixation during their inpatient stay that directly contributed to the

higher mean length of stay.

Both of the study populations in the Pendleton study and this study have similar

possible explanations for unnecessarily prolonged lengths of stay and therefore increased

hospital costs. One significant factor found by Pendleton et. al. was a delayed time to the first

physical therapy (PT) visit, greater than one day, which was found to contribute to a longer

LOS. Time to first PT visit was not specifically analyzed in our sample; however, many social,

medical and hospital delays can also contribute to a patient’s prolonged hospitalization. Some

social factors such as an unstable living situation, the inability to find transportation to and

from the hospital or even access to a pharmacy contribute to the need to keep some patients

admitted to the hospital. These social factors may be out of the physicians control; however,

some hospital system based factors that can be directly affected by physicians and

administrator should be adjusted to increase efficiency. One proposed solution to reducing

prolonged LOS for patients is to have ancillary services like physical therapy and social

services function in a greater capacity on weekends as well. Transition to a more continuous

delivery model for healthcare can help improve efficiency within the hospital system.

Additionally, providing appropriate pathways for prompt outpatient follow-up and outpatient

surgical scheduling for definitive fixation in appropriate cases can help directly reduce

inpatient length of stay and hospital costs. By achieving these goals through improved clinic

scheduling and dedicated outpatient facilities, limited resources can be utilized more

efficiently.

Damage control orthopaedics, which promotes temporary fixation over immediate

definitive fixation, has increased the use of temporizing external fixation devices. Many

patients, especially multi-trauma patients, are often too unstable for definitive treatment with

an intramedullary nail and require quick stabilization, followed by a staged surgery with a

subsequent procedure days to weeks later for definitive fixation.7 In other patients with open

105

fractures or severely damaged surrounding soft tissue, it may be more beneficial to delay

definitive fracture fixation to reduce the risk of infection.8 The use of delayed fixation could

contribute to longer a LOS in the poly-trauma patient. Another subset of patients exists who

require staged/delayed fixation for an isolated injury and have a stable social support. These

reliable patients can be sent home with a temporary external fixation device and return after 7-

10 days for outpatient surgery for definitive fixation. Thus with reliable follow-up and an

efficient outpatient surgery team, inpatient hospital LOS and costs can be reduced for this

subset of patients.

Additionally, the waiting time to surgery was decreased by an average 25.1 hours in

patients admitted on a Friday after the policy change. Before the orthopaedic department had

dedicated access to a Saturday OR, these “cold trauma” patients would often wait until

Monday or Tuesday of the next week for surgical fixation as emergent cases could bump them

from the shared Saturday schedule. Although the overall waiting time to surgery did not

change between the two groups, the isolated result of the decrease in waiting time for patients

admitted on Friday is significant since these patients are the most likely to benefit with the

Saturday OR being the next day.

It is surprising that this increased efficiency in moving Friday patients to surgery faster

did not also result in a shorter LOS for this subset of patients. Although they trended towards

a lower LOS after the policy change (11.4 days vs. 10.0 days), the calculated p value of 0.21

was not statistically significant. One explanation could be a delay in working with physical

therapy (PT). Often, there are delays in physical therapists seeing patients on weekends. The

time to first PT visit was not obtained during initial chart review to assess a delayed initiation

of PT on LOS for our patient group; however, future analysis would be beneficial in assessing

this variable.

There are many complications associated with long bone fracture fixation such as

acute respiratory distress syndrome, fat embolism syndrome and pneumonia given the

marrow infiltration into the blood during reaming of the canal. Although the debate in

orthopaedic trauma continues, there have been studies showing that early definitive

stabilization of femoral shaft fractures is associated with better outcomes, even in patients

with multiple injuries.9 Similar results are demonstrated by Brundage et. al., who showed that

although early fixation did not affect mortality, there was a reduction in complications and

hospital stay for patients with early fixation within 24 hours.10 Thus the goal of the

orthopaedics department and hospital staff should be early appropriate fixation in patients to

not only improve outcomes, but also decrease costs by reducing LOS.

Finally, this study shows how an additional weekend operative day allows for a more

even distribution of caseload within the work week. The 6.2% absolute increase and 59%

relative increase (p value 0.055) in the percentage of cases performed on Saturday was likely

due to specifically scheduling cases for that day in the dedicated orthopaedic trauma OR. The

chief residents, who schedule the cases, had additional operative time to schedule the “cold

trauma” cases, and these cases would no longer be cancelled for other service’s emergent or

urgent cases. This increase on Saturday was appropriately matched by a 6.7% absolute

decrease and 33% relative decrease in the percentage of cases performed on Mondays (p

value 0.062). This decrease caseload on Monday was a direct result of the ability to complete

cases on the previous Saturday. The overall redistribution of case load creates a steady

workflow. Prior to the extra operative day, the trauma team would frequently operate late into

106

Monday night trying to catch up on the weekend caseload. With the addition of the extra

Saturday operative day, these cases are completed sooner and do not overwhelm staff at the

start of the workweek. Additionally, residents are able to keep within the duty hour restrictions

as the staff that normally are present in-house on Saturday can accomplish cases and prevent

the backup of cases for Monday.

One of the limitations of this study is the significant difference in injury severity scores

between the pre and post policy groups. It would be expected that the patient population and

trauma admitted would not have significantly changed in the year before the Saturday OR and

the year following. However, the significantly lower ISS values (12.1 vs. 10.6, p value 0.022)

for the pre and post groups reflect a relatively less injured patient population for the post policy

group. Our analysis attempted to identify the effects of this potential confounding variable by

comparing ISS and LOS using linear modeling, Spearman Correlation and Hoeffding’s

Independence test. From the scatter plots give in Figure 1 and the calculated r-square values

for pre- and post-policy change of 0.24 and 0.15, no obvious linear relationship between LOS

and ISS was observed in these patients. The calculated Spearman Correlation coefficient of

0.42 and the Hoeffding Dependence coefficient of 0.055 showed that LOS may not fully

depend on ISS. From this analysis, the change in LOS following the Saturday OR policy was

unlikely to be fully due to the difference in ISS between the groups, thus the policy change

likely contributed to the reduction in LOS. Although it was not directly shown through our

statistical analysis, it is likely that the difference in ISS may have partially contributed to the

differences in observed LOS between the two groups. Previous studies have even shown a

moderately high correlation between hospital cost and ISS. This is appropriate as sicker

patients tend to require more invasive procedures, longer hospitalization and utilize more

hospital resources.6 Grady has no direct control over the severity of injuries in the population

that are seen in the ED; however, more public health related measures focused on motor

vehicle safety, fall prevention and reduction in gun related violence could reduce the overall

violence in the community and lead to a corresponding reduction in the average ISS of trauma

patients.

Another potential confounding influence could be the implementation of the electronic

medical record (EMR), EPIC, during the study time period. EPIC was instituted hospital-wide

in October 2010 which corresponded to the middle of our data collection. Although inpatient

use of EMR has been studied in internal medicine and family medicine showing decreased

rounding time and more time for interaction with patients, the specific effects of EMR have not

been well studied in surgical subspecialties and the effect of EMR on patient LOS has not

been fully investigated.11 As the learning curve to become efficient at EMR takes time, the

implementation of EMR likely did not significantly affect our subset of patients. During the

transition, inefficiencies in learning a new documentation system and glitches could have

slowed the initial workflow rather than immediately increasing efficiency early in EMR hospital-

wide implementation. Additionally, the improved efficiency of EMR probably has a more direct

benefit to general medicine specialties as surgical efficiency would be more directly correlated

with the operative time to complete cases. However, analysis of the effect of EMR on patient

outcome within surgical fields is a potential future project that was not within the scope of this

analysis.

One of the difficulties in this retrospective chart review is identifying the proper patient

population. Logically, the most improved patient population would be patients who were

107

admitted prior to the beginning of the Saturday dedicated orthopaedic trauma OR who were

delayed to surgery because this operative time was not available. This group of “cold trauma”

patients is interspersed with more emergent cases such as open fractures, compartment

syndrome and infectious flexor tenosynovitis. Given the nature of scheduling cases, these

emergent procedures were also performed in the Saturday dedicated orthopaedic trauma

room where they would have been performed in the shared trauma room prior to the

implementation of the policy. Thus the benefit of the dedicated orthopaedic trauma OR may

not have been fully captured in this sample as the “cold trauma” cases could be bumped by

emergent orthopaedic cases. We attempted to account for this weakness by isolating patients

with femur and tibia fractures; however, the most specific subgroup of patients would be very

difficult to isolate in a retrospective review given the dynamic and practical nature of case

scheduling. Of note, a separate sub-analysis (data not shown) was performed in patients in

this trauma population who were admitted directly to the orthopaedic service before and after

the Saturday dedicated orthopaedic trauma OR. We had initially anticipated these

orthopaedic patients would benefit the most from this policy change; however, there was no

significant difference in LOS or waiting time to surgery for patients directly admitted to the

orthopaedic service. The patient population that most benefits from the extra operative day is

difficult to capture in this retrospective chart review.

Although there was a significant difference in the racial distribution between the two

groups, it is unlikely to have contributed significantly to the primary outcomes of this study and

more likely is a random error or change in the patient population seen at Grady.

Finally, the future research projects that could stem from this analysis include the potential for

future surveys to obtain and interpret resident and attending satisfaction with this new policy of

the Saturday dedicated OR. These subjective survey results should be obtained both at this

institution and other centers that transition to the 6 day operative workweek. Although we were

unable to acquire such data for this analysis, more specific data on the confidential salaries of

the involved staff would be able to show the full cost savings of the implementation of this

policy.

Summary

In conclusion, this retrospective chart review of operative femur and tibial shaft

fractures admitted to Grady Memorial Hospital between November 1, 2009 and October 31,

2011, investigated the effects of the addition of a dedicated Saturday orthopaedic operating

room. The LOS overall for patients admitted after this policy change was significantly reduced

from a mean of 14.0 days to 11.3 days (p value 0.018). Also, the disproportionally high case

distribution on Monday observed prior to the Saturday OR was reduced and a larger

percentage of cases were performed on Saturday after the policy change. Furthermore, there

was a trend towards shorter waiting time to surgery for patients admitted on a Friday with an

average reduction in waiting time of 25.1 hours (48.6 hrs. vs. 23.5 hrs., p value 0.06). Overall,

these findings support the continuation of a dedicated Saturday orthopaedic trauma OR and

can provide the foundation for other departments with similar circumstances to negotiate for

more operative time on weekends as a potential way to increase efficiency, reduce patient

LOS and distribute the caseload more evenly.

108

Acknowledgements

We would like to acknowledge Patricia Bush for helping obtain approval from the Grady ROC;

Baohua Wu the Department of Orthopaedics statistician for helping perform the statistical

analysis; Sherika Kimbrough, Jennifer Wingo and the nurses who manage the Grady trauma

registry and queried the registry for patient information; and Earnestine Spearman at the

Grady Medical records department for pulling the paper charts for analysis. No direct funding

sources were contributed for this study. There are no conflicts of interest for any of the authors

or contributors.

References:

1. Association of Anaesthetists of Great Britain and Ireland, Griffiths R, Alper J, Beckingsale A, Goldhill D, Heyburn G, Holloway J, Leaper E, Parker M, Ridgway S, White S, Wiese M, Wilson I. Management of proximal femoral fractures 2011: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia. 2012 Jan;67(1):85-98. doi: 10.1111/j.1365-2044.2011.06957.x. PubMed PMID: 22150501.

2. Pendleton AM, Cannada LK, Guerrero-Bejarano M. Factors affecting length of stay after isolated femoral shaft fractures. J Trauma. 2007 Mar;62(3):697-700. PubMed PMID: 17414350.

3. Khan SK, Kalra S, Khanna A, Thiruvengada MM, Parker MJ. Timing of surgery for hip fractures: a systematic review of 52 published studies involving 291,413 patients. Injury. 2009 Jul;40(7):692-7. doi: 10.1016/j.injury.2009.01.010. Epub 2009 May 18. Review. PubMed PMID: 19450802.

4. Orosz GM, Magaziner J, Hannan EL, Morrison RS, Koval K, Gilbert M, McLaughlin M, Halm EA, Wang JJ, Litke A, Silberzweig SB, Siu AL. Association of timing of surgery for hip fracture and patient outcomes. JAMA. 2004 Apr 4;291(14):1738-43. PubMed PMID: 15082701; PubMed Central PMCID: PMC1454713.

5. Rutledge R, Osler T, Emery S, Kromhout-Schiro S. The end of the Injury Severity Score (ISS) and the Trauma and Injury Severity Score (TRISS): ICISS, an International Classification of Diseases, ninth revision-based prediction tool, outperforms both ISS and TRISS as predictors of trauma patient survival, hospital charges, and hospital length of stay. J Trauma. 1998 Jan;44(1):41-9. PubMed PMID: 9464748.

6. Dinh MM, McNamara K, Bein KJ, Roncal S, Barnes EH, McBride K, Byrne CM. Effect of the elderly and increasing injury severity on acute hospital resource utilization in a cohort of inner city trauma patients. ANZ J Surg. 2012 Aug 7. doi: 10.1111/j.1445- 2197.2012.06177.x. [Epub ahead of print] PubMed PMID: 22882734.

7. Nowotarski PJ, Turen CH, Brumback RJ, Scarboro JM. Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients. J Bone Joint Surg Am. 2000 Jun;82(6):781-8. PubMed PMID: 10859097.

8. Jenny JY, Jenny G, Kempf I. Infection after reamed intramedullary nailing of lower limb fractures. A review of 1,464 cases over 15 years. Acta Orthop Scand. 1994 Feb;65(1):94- 6. PubMed PMID: 8154294.

9. Nahm NJ, Como JJ, Wilber JH, Vallier HA. Early appropriate care: definitive stabilization of femoral fractures within 24 hours of injury is safe in most patients with multiple injuries. J Trauma. 2011 Jul;71(1):175-85. doi: 10.1097/TA.0b013e3181fc93a2. PubMed PMID: 21336198.

10. Brundage SI, McGhan R, Jurkovich GJ, Mack CD, Maier RV. Timing of femur fracture fixation: effect on outcome in patients with thoracic and head injuries. J Trauma. 2002 Feb;52(2):299-307. PubMed PMID: 11834992.

11. Kochendorfer KM, Morris LE, Kruse RL, Ge BG, Mehr DR. Attending and resident physician perceptions of an EMR-generated rounding report for adult inpatient services. Fam Med. 2010 May;42(5):343-9. PubMed PMID: 20461566

109

Table 1

Character

Overall (n=455) Pre (n=239) Post (n=216) p value

Age

Mean ± SD (N) 38.3 ± 15.4(455) 37.8 ± 15.5(239)

38.8 ± 15.2(216)

0.32

Race <0.0001*

Asian 21/453(4.6%) 8/239(3.3%) 13/214(6.1%)

Hispanic 19/453(4.2%) 17/239(7.1%) 2/214(0.9%)

African-American 285/453(62.9%) 132/239(55.2%)

153/214(71.5%)

Caucasian 128/453(28.3%) 82/239(34.3%) 46/214(21.5%)

ISS

Mean ± SD (N) 11.4 ± 7.4(455) 12.1 ± 7.7(239) 10.6 ± 7.0(216) 0.022*

Mechanism 0.24

Sports 3/455(0.7%) 0/239(0.0%) 3/216(1.4%)

Animal 2/455(0.4%) 1/239(0.4%) 1/216(0.5%)

ATV 3/455(0.7%) 2/239(0.8%) 1/216(0.5%)

Bicycle 5/455(1.1%) 3/239(1.3%) 2/216(0.9%)

Struck NOS 4/455(0.9%) 3/239(1.3%) 1/216(0.5%)

Motorcycle Crash 55/455(12.1%) 33/239(13.8%) 22/216(10.2%)

Pedestrian 64/455(14.1%) 34/239(14.2%) 30/216(13.9%)

Accident 10/455(2.2%) 5/239(2.1%) 5/216(2.3%)

Motor Vehicle Crash 123/455(27.0%) 73/239(30.5%) 50/216(23.1%)

Assault 14/455(3.1%) 8/239(3.3%) 6/216(2.8%)

GSW 76/455(16.7%) 38/239(15.9%) 38/216(17.6%)

Fall 96/455(21.1%) 39/239(16.3%) 57/216(26.4%)

Table 1. Demographic data. Age, Race, ISS and Mechanism of Injury for pre and post- policy change groups. There was no significant difference in the age of patients or mechanism of injury between the groups (p value 0.32 and 0.24 respectively). There was a significant difference in the race between the groups (p value <0.0001). There was a significant difference in the injury severity scores between the pre and post policy groups (p value 0.022)

110

Figure 1 Figure 1. The upper image is the scatterplot comparing ISS and LOS for patients prior to the implementation of the Saturday dedicated orthopaedic trauma OR. R-square = 0.24. The lower image is the scatterplot comparing ISS and LOS for patients after to the implementation of the Saturday dedicated orthopaedic trauma OR. R-square = 0.15. For both groups R-square < 0.5.

111

Table 2

Character

Overall (n=455) Pre (n=239) Post (n=216) p value

Day of the week 0.090*

Sunday 66/455(14.5%) 30/239(12.6%) 36/216(16.7%) 0.232

Monday 77/455(16.9%) 48/239(20.1%) 29/216(13.4%) 0.062*

Tuesday 65/455(14.3%) 34/239(14.2%) 31/216(14.4%) 1

Wednesday 73/455(16.0%) 44/239(18.4%) 29/216(13.4%) 0.161

Thursday 52/455(11.4%) 30/239(12.6%) 22/216(10.2%) 0.463

Friday 61/455(13.4%) 28/239(11.7%) 33/216(15.3%) 0.274

Saturday 61/455(13.4%) 25/239(10.5%) 36/216(16.7%) 0.055*

Table 2. Shows the number of lower extremity fracture operative cases performed on each day of the week both before and after the implementation of the Saturday dedicated orthopaedic trauma OR (pre and post). Overall the data trended towards a difference in the distribution of the case load between days of the week (p value 0.090). When comparing individual case load on Monday and Saturday, there was a trend towards a difference between groups with p values of 0.062 and 0.055 respectively.

112

Table 3 Length of Stay (days)

Characteristic

Overall

Pre

Post

p value

Any day of the week

Mean ± SD (N) 12.7 ± 18.4(455) 14.0 ± 20.9(239)

11.3 ± 15.0(216)

0.018*

Monday

Mean ± SD (N) 17.0 ± 29.5(77) 20.5 ± 34.1(48) 11.3 ± 18.8(29) 0.011*

Tuesday

Mean ± SD (N) 12.1 ± 14.7(65) 11.5 ± 15.7(34) 12.7 ± 13.7(31) 0.46

Wednesday

Mean ± SD (N) 11.9 ± 13.8(73) 13.7 ± 15.8(44) 9.2 ± 9.5(29) 0.088*

Thursday

Mean ± SD (N) 9.9 ± 12.3(52) 7.5 ± 4.7(30) 13.1 ± 17.9(22) 0.92

Friday

Mean ± SD (N) 10.6 ± 12.9(61) 11.4 ± 12.4(28) 10.0 ± 13.5(33) 0.21

Saturday

Mean ± SD (N) 11.2 ± 16.2(61) 11.4 ± 13.5(25) 11.1 ± 18.0(36) 0.84

Sunday

Mean ± SD (N) 14.8 ± 19.0(66) 17.9 ± 24.1(30) 12.2 ± 13.1(36) 0.26

Table 3. LOS data for all patients and for patients admitted on each day of the week. There was a significant difference in the overall length of stay between the pre and post policy groups (p value 0.018) with a reduced mean LOS from 14.0 days to 11.3 days. This reduced length of stay was most prominent in patients admitted on Monday or Wednesday (p values 0.011 and 0.088 respectively).

113

Table 4 Waiting Time to Surgery (hrs)

Characteristic

Overall

Pre

Post

p value

Any day of the week

Mean ± SD (N) 33.3 ± 57.7(455) 32.5 ± 53.0(239)

34.1 ± 62.6(216)

0.70

Monday

Mean ± SD (N) 32.9 ± 70.8(77) 32.6 ± 66.5(48) 33.3 ± 78.7(29) 0.44

Tuesday

Mean ± SD (N) 38.4 ± 63.3(65) 32.5 ± 42.2(34) 44.9 ± 80.6(31) 0.43

Wednesday

Mean ± SD (N) 30.3 ± 64.2(73) 26.2 ± 27.3(44) 36.4 ± 96.8(29) 0.43

Thursday

Mean ± SD (N) 28.9 ± 30.2(52) 32.8 ± 37.4(30) 23.7 ± 15.3(22) 0.78

Friday

Mean ± SD (N) 35.0 ± 69.1(61) 48.6 ± 93.1(28) 23.5 ± 36.8(33) 0.060*

Saturday

Mean ± SD (N) 28.2 ± 27.6(61) 25.1 ± 29.9(25) 30.3 ± 26.2(36) 0.24

Sunday

Mean ± SD (N) 38.6 ± 54.0(66) 32.6 ± 46.6(30) 43.6 ± 59.6(36) 0.18

Table 4. Waiting time to surgery data for all patients and for patients admitted on each day of the week. There was not a significant difference in the overall waiting time to surgery between the groups. However, there was a prominent trend towards a shorter waiting time in the subset of patients admitted on Friday with a reduced mean waiting time from 48.6hrs to 23.5hrs (p value 0.060).

114

Emory Orthopaedics Surgical Faculty

James R. Roberson, MD Professor & Chairman, Adult Reconstruction

Thomas L. Bradbury, MD Assistant Professor, Adult Reconstruction Director, Orthopaedics Residency Program

Scott D. Boden, MD Professor, Spine

John G. Heller, MD Baur Professor, Spine

Gerald Rodts, MD Professor, Spine

John ‘X’ Xerogeanes, MD Professor, Sports Medicine

Spero Karas, MD Associate Professor, Sports Medicine

Sameh (Sam) Labib, MD Associate Professor, Sports Medicine/Foot & Ankle

Thomas Moore, MD Associate Professor, Trauma

John Rhee, MD Associate Professor, Spine

George Wright, MD Associate Professor, Trauma/Hand & Upper Extremity

S. Tim Yoon, MD Associate Professor, Spine

Dheera Ananthakrishnan, MD Assistant Professor, Spine

Robert W. Bruce, Jr., MD Assistant Professor, Pediatrics

Greg Erens, MD Assistant Professor, Adult Reconstruction

Nicholas Fletcher, MD Assistant Professor, Pediatrics

Kyle Hammond, MD Assistant Professor, Sports Medicine

Claudius Jarrett, MD Assistant Professor, Hand & Upper Extremity

John Louis-Ugbo, MD Assistant Professor, Foot & Ankle

T. Scott Maughon, MD Assistant Professor, Sports Medicine

Gary McGillivary, MD Assistant Professor, Hand & Upper Extremity

David Monson, MD Assistant Professor, Musculoskeletal Oncology

Thomas Moore, Jr., MD Assistant Professor, Trauma

Shervin Oskouei, MD Assistant Professor, Musculoskeletal Oncology

Diane Payne, MD Assistant Professor, Trauma/Hand & Upper Extremity

Mathew Pombo, MD Assistant Professor, Sports Medicine

Daniel Refai, MD Assistant Professor, Spine

Nickolas Reimer, MD Assistant Professor, Musculoskeletal Oncology

William Reisman, MD Assistant Professor, Trauma

Christopher Sadlack, MD Assistant Professor, Adult Reconstruction

115

PUBLICATIONS & PRESENTATIONS

Peer-Reviewed Journals: 2013 – 2014

Boden SD. AOA 2013-2014 Presidential address: Failure to succeed?: AOA critical issues. J Bone Joint Surg Am. 2013 Dec 4;95(23):e1861-4 Sangadala S, Yoshioka K, Enyo Y, Liu Y, Titus L, Boden SD. Characterization of a unique motif in LIM mineralization protein-1 that interacts with junactivation-domain-binding protein 1. Mol Cell Biochem. 2014 Jan;385(1-2):145-57. Rodeo SA, Boden SD, Murray MM, Einhorn TA. 2011 AOA Symposium: Tissue Engineering and Tissue Regeneration: AOA critical issues. J Bone Joint Surg Am. 2013 Aug 7;95(15):e109. Bridwell KH, Anderson PA, Boden SD, Vaccaro AR, Wang JC. What's new in spine surgery. J Bone Joint Surg Am. 2013 Jun 19;95(12):1144-50. Park DK, Kim SS, Thakur N, Boden SD. Use of Recombinant Human Bone Morphogenetic Protein-2 With Local Bone Graft Instead of Iliac Crest Bone Graft in Posterolateral Lumbar Spine Arthrodesis. Spine (Phila Pa 1976). 2013 Mar 7. [Epub ahead of print] Wong E, Sangadala S, Boden SD, Yoshioka K, Hutton WC, Oliver C, Titus L. A novel low-molecular-weight compound enhances ectopic bone formation and fracture repair. J Bone Joint Surg Am. 2013 Mar 6;95(5):454-61. Fletcher ND, Larson AN, Glotzbecker MP, Shore BJ, Hydorn CR. A Critical Appraisal of the First-year Experience of 5 Pediatric Orthopaedic Surgeons. J Pediatr Orthop. 2014 Mar 1. [Epub ahead of print] PubMed PMID: 24590338. Larson AN, Garg S, Weller A, Fletcher ND, Schiller JR, Kwon M, Browne R, Copley LA, Ho CA. Operative Treatment of Type II Supracondylar Humerus Fractures: Does Time to Surgery Affect Complications? Pediatr Orthop. 2013 Nov 16. Weller A, Garg S, Larson AN, Fletcher ND, Schiller JR, Kwon M, Copley LA, Browne R, Ho CA. Management of the pediatric pulseless supracondylar humeral fracture: is vascular exploration necessary? J Bone Joint Surg Am. 2013 Nov 6;95(21):1906-12. Garg S, Weller A, Larson AN, Fletcher ND, Kwon M, Schiller J, Browne R, Copley L, Ho C. Clinical characteristics of severe supracondylar humerus fractures in children. J Pediatr Orthop. 2014 Jan;34(1):34-9. Crosby SN, Fletcher ND, Yap ER, Lee DH. The mechanical stability of extra-articular distal radius fractures with respect to the number of screws securing the distal fragment. J Hand Surg Am. 2013 Jun;38(6):1097-105. Heller JG, Raich AL, Dettori JR, Riew KD. Comparative Effectiveness of Different Types of Cervical Laminoplasty. Evid Based Spine Care J. 2013 Oct;4(2):105-115.

Riew KD, Raich AL, Dettori JR, Heller JG. Neck Pain Following Cervical Laminoplasty: Does Preservation of the C2 Muscle Attachments and/or C7 Matter? Evid Based Spine Care J. 2013 Apr;4(1):42-53.

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Peer-Reviewed Journals continued

Faucher GK, Golden ML 3rd, Sweeney KR, Hutton WC, Jarrett CD. Comparison of screw trajectory on stability of oblique scaphoid fractures: a mechanical study. J Hand Surg Am. 2014 Mar;39(3):430-5. Wang Z, Hutton WC, Yoon ST. Bone morphogenetic protein-7 antagonizes tumor necrosis factor-α-induced activation of nuclear factor κB and up-regulation of the ADAMTS, leading to decreased degradation of disc matrix macromolecules aggrecan and collagen II. Spine J. 2014 Mar 1;14(3):505-12. Wang Z, Weitzmann MN, Sangadala S, Hutton WC, Yoon ST. Link protein N-terminal peptide binds to bone morphogenetic protein (BMP) type II receptor and drives matrix protein expression in rabbit intervertebral disc cells. J Biol Chem. 2013 Sep 27;288(39):28243-53. Stauff MP, Freedman BA, Kim JH, Hamasaki T, Yoon ST, Hutton WC. The effect of pedicle screw redirection after lateral wall breach--a biomechanical study using human lumbar vertebrae. Spine J. 2014 Jan;14(1):98-103. Enyo Y, Yamada H, Hoon Kim J, Yoshida M, Hutton WC. Microendoscopic Lateral Decompression for Lumbar Foraminal Stenosis: A Biomechanical Study. J Spinal Disord Tech. 2013 Nov 5. [Epub ahead of print] PubMed PMID: 23563327. Yasen M, Fei Q, Hutton WC, Zhang J, Dong J, Jiang X, Zhang F. Changes of number of cells expressing proliferation and progenitor cell markers with age in rabbit intervertebral discs. Acta Biochim Biophys Sin (Shanghai). 2013 May;45(5):368-76. Wang Z, Hutton WC, Yoon ST. ISSLS Prize winner: Effect of link protein peptide on human intervertebral disc cells. Spine (Phila Pa 1976). 2013 Aug 1;38(17):1501-7. Okada M, Kim JH, Yoon ST, Hutton WC. Pulsed Electromagnetic Field (PEMF) plus BMP-2 upregulates intervertebral disc-cell matrix synthesis more than either BMP-2 alone or PEMF alone. J Spinal Disord Tech. 2013 Aug;26(6):E221-6. Ito Z, Higashino K, Kato S, Kim SS, Wong E, Yoshioka K, Hutton WC. Pedicle Screws Can be 4 Times Stronger Than Lateral Mass Screws for Insertion in the Midcervical Spine: A Biomechanical Study on Strength of Fixation. J Spinal Disord Tech. 2014 Apr;27(2):80-5 Okada M, Kim JH, Hutton WC, Yoon ST. Upregulation of intervertebral disc-cell matrix synthesis by pulsed electromagnetic field is mediated by bone morphogenetic proteins. J Spinal Disord Tech. 2013 May;26(3):167-73 Pappou IP, Schmidt CC, Jarrett CD, Steen BM, Frankle MA. AAOS appropriate use criteria: optimizing the management of full-thickness rotator cuff tears. J Am Acad Orthop Surg. 2013 Dec;21(12):772-5.

Desai MJ, Hutton WC, Jarrett CD. Arthroscopic repair of triangular fibrocartilage tears: a biomechanical comparison of a knotless suture anchor and the traditional outside-in repairs. J Hand Surg Am. 2013 Nov;38(11):2193-7. doi: Jarrett CD, Brown BT, Schmidt CC. Reverse shoulder arthroplasty. Orthop Clin North Am. 2013 Jul;44(3):389-408.

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Schmidt CC, Jarrett CD, Brown BT, DeGravelle M Jr, Sawardeker P, Weir DM, Latona CR, Miller MC. Effect of lesser tuberosity osteotomy size and repair construct during total shoulder arthroplasty. J Shoulder Elbow Surg. 2014 Jan;23(1):117-27. Schmidt CC, Jarrett CD, Brown BT. The distal biceps tendon. J Hand Surg Am. 2013 Apr;38(4):811-21; quiz 821. Rho M, Mautner K, Nichols JT, Kennedy DJ. Image-guided diagnostic injections with anesthetic versus magnetic resonance arthrograms for the diagnosis of suspected hip pain. PM R. 2013 Sep;5(9):795-800. Mautner K, Colberg RE, Malanga G, Borg-Stein JP, Harmon KG, Dharamsi AS, Chu S, Homer P. Outcomes after ultrasound-guided platelet-rich plasma injections for chronic tendinopathy: a multicenter, retrospective review. PM R. 2013 Mar;5(3):169-75. Monson DK, Vojdani S, Dean TJ, Louis-Ugbo J. Lateral ankle stabilization after distal fibular resection using a novel approach: a surgical technique. Clin Orthop Relat Res. 2014 Apr;472(4):1262-70. Fisher SB, Baxter KJ, Staley CA 3rd, Fisher KE, Monson DK, Murray DR, Oskouei SV, Weiss SW, Kooby DA, Maithel SK, Delman KA. The General Surgeon's quandary: atypical lipomatous tumor vs lipoma, who needs a surgical oncologist? J Am Coll Surg. 2013 Nov;217(5):881-8. Stuart LN, Gardner JM, Lauer SR, Monson DK, Parker DC, Edgar MA. Epithelioid sarcoma-like (pseudomyogenic) hemangioendothelioma, clinically mimicking dermatofibroma, diagnosed by skin biopsy in a 30-year-old man. J Cutan Pathol. 2013 Oct;40(10):909-13. Rowton M, Ramos P, Anderson DM, Rhee JM, Cunliffe HE, Rawls A. Regulation of mesenchymal-to-epithelial transition by PARAXIS during somitogenesis. Dev Dyn. 2013 Nov;242(11):1332-44. Shamji MF, Ames CP, Smith JS, Rhee JM, Chapman JR, Fehlings MG. Myelopathy and spinal deformity: relevance of spinal alignment in planning surgical intervention for degenerative cervical myelopathy. Spine (Phila Pa 1976). 2013 Oct 15;38(22 Suppl 1):S147-8. Lawrence BD, Shamji MF, Traynelis VC, Yoon ST, Rhee JM, Chapman JR, Brodke DS, Fehlings MG. Surgical management of degenerative cervical myelopathy: a consensus statement. Spine (Phila Pa 1976). 2013 Oct 15;38(22 Suppl 1):S171-2. Fehlings MG, Wilson JR, Yoon ST, Rhee JM, Shamji MF, Lawrence BD. Symptomatic progression of cervical myelopathy and the role of nonsurgical management: a consensus statement. Spine (Phila Pa 1976). 2013 Oct 15;38(22 Suppl 1):S19-20. Wilson JR, Fehlings MG, Kalsi-Ryan S, Shamji MF, Tetreault LA, Rhee JM, Chapman JR. Diagnosis, heritability, and outcome assessment in cervical myelopathy: a consensus statement. Spine (Phila Pa 1976). 2013 Oct 15;38(22 Suppl 1):S76-7. Rhee JM, Shamji MF, Erwin WM, Bransford RJ, Yoon ST, Smith JS, Kim HJ, Ely CG, Dettori JR, Patel AA, Kalsi-Ryan S. Nonoperative management of cervical myelopathy: a systematic review. Spine (Phila Pa 1976). 2013 Oct 15;38(22 Suppl 1):S55-67.

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Yoon ST, Hashimoto RE, Raich A, Shaffrey CI, Rhee JM, Riew KD. Outcomes after laminoplasty compared with laminectomy and fusion in patients with cervical myelopathy: a systematic review. Spine (Phila Pa 1976). 2013 Oct 15;38(22 Suppl 1):S183-94. Yoon ST, Raich A, Hashimoto RE, Riew KD, Shaffrey CI, Rhee JM, Tetreault LA, Skelly AC, Fehlings MG. Predictive factors affecting outcome after cervical laminoplasty. Spine (Phila Pa 1976). 2013 Oct 15;38(22 Suppl 1):S232-52. doi: Park DK, Rhee JM, Kim SS, Enyo Y, Yoshiok K. Do CT Scans Overestimate the Fusion Rate After Anterior Cervical Discectomy and Fusion? J Spinal Disord Tech. 2013 Nov 4. Park DK, Rhee JM, Wu B, Easley K. Factors related to choosing an academic career track among spine fellowship applicants. Spine (Phila Pa 1976). 2013 Mar 1;38(5):425-33. Pecha FQ, Xerogeanes JW, Karas SG, Himes ME, Mines BA. Comparison of the effect of medical assistants versus certified athletic trainers on patient volumes and revenue generation in a sports medicine practice. Sports Health. 2013 Jul;5(4):337-9. Mitchell P, Gottschalk M, Butts G, Xerogeanes J. Surgical site infection: A comparison of multispecialty and single specialty outpatient facilities. J Orthop. 2013 Sep 5;10(3):111-4. Xerogeanes JW, Mitchell PM, Karasev PA, Kolesov IA, Romine SE. Anatomic and morphological evaluation of the quadriceps tendon using 3-dimensional magnetic resonance imaging reconstruction: applications for anterior cruciate ligament autograft choice and procurement. Am J Sports Med. 2013 Oct;41(10):2392-9. doi: Fehlings MG, Barry S, Kopjar B, Yoon ST, Arnold P, Massicotte EM, Vaccaro A, Brodke DS, Shaffrey C, Smith JS, Woodard E, Banco RJ, Chapman J, Janssen M, Bono C, Sasso R, Dekutoski M, Gokaslan ZL. Anterior versus posterior surgical approaches to treat cervical spondylotic myelopathy: outcomes of the prospective multicenter AOSpine North America CSM study in 264 patients. Spine (Phila Pa 1976). 2013 Dec 15;38(26):2247-52.

Tetreault LA, Kopjar B, Vaccaro A, Yoon ST, Arnold PM, Massicotte EM, Fehlings MG. A clinical prediction model to determine outcomes in patients with cervical spondylotic myelopathy undergoing surgical treatment: data from the prospective, multi-center AOSpine North America study. J Bone Joint Surg Am. 2013 Sep 18;95(18):1659-66. Fehlings MG, Wilson JR, Kopjar B, Yoon ST, Arnold PM, Massicotte EM, Vaccaro AR, Brodke DS, Shaffrey CI, Smith JS, Woodard EJ, Banco RJ, Chapman JR, Janssen ME, Bono CM, Sasso RC, Dekutoski MB, Gokaslan ZL. Efficacy and safety of surgical decompression in patients with cervical spondylotic myelopathy: results of the AOSpine North America prospective multi-center study. J Bone Joint Surg Am. 2013 Sep 18;95(18):1651-8. Carragee EJ, Chu G, Rohatgi R, Hurwitz EL, Weiner BK, Yoon ST, Comer G, Kopjar B. Cancer risk after use of recombinant bone morphogenetic protein-2 for spinal arthrodesis. J Bone Joint Surg Am. 2013 Sep 4;95(17):1537-45.

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Arnold PM, Fehlings MG, Kopjar B, Yoon ST, Massicotte EM, Vaccaro AR, Brodke DS, Shaffrey CI, Smith JS, Woodard EJ, Banco RJ, Chapman JR, Janssen ME, Bono CM, Sasso RC, Dekutoski MB, Gokaslan ZL. Mild diabetes is not a contraindication for surgical decompression in cervical spondylotic myelopathy: results of the AOSpine North America multicenter prospective study (CSM). Spine J. 2014 Jan;14(1):65-72. Wang Z, Weitzmann MN, Sangadala S, Hutton WC, Yoon ST. Link protein N-terminal peptide binds to bone morphogenetic protein (BMP) type II receptor and drives matrix protein expression in rabbit intervertebral disc cells. J Biol Chem. 2013 Sep 27;288(39):28243-53. Vaccaro AR, Kepler CK, Kopjar B, Chapman J, Shaffrey C, Arnold P, Gokaslan Z, Brodke D, France J, Dekutoski M, Sasso R, Yoon ST, Bono C, Harrop J, Fehlings MG. Functional and quality-of-life outcomes in geriatric patients with type-II dens fracture. J Bone Joint Surg Am. 2013 Apr 17;95(8):729-35. Reisman WM, Shuler MS, Kinsey TL, Cole AL, Whitesides TE Jr., Davila MG, Smith EK, Moore TJ. Relationship between near infrared spectroscopy and intra-compartmental pressures. J Emerg Med Feb 2013 44(2)292-8 Aggarwal VK, Tischler EH, Lautenbach C, Willliams GR Jr, Abboud JA, Altena M, Bradbury TL, et al. Mitigation and education. J Arthroplasty 2014 Feb 29(2 Suppl)19-25 Beckworth WJ, Sood R, Katzer AF, Wu B. Anomalous location of the vertebral artery in relation to the neural foramen. Implications for cervical transforaminal epidural steroid injections. Pain Medicines 2013 Aug. 14(8)1119-25 Starr HM, Snoddy M, Hammond KE, Seiler JG 3rd. Flexor tendon repair rehabilitation protocols: a systemic review. J Hand Surg Am 2013 Sept 38(9)1712-7 Guild GN 3rd, Labib SA. Clinical outcomes in high flexion total knee arthroplasty were not superior to standard posterior stabilized total knee arthroplasty. A multicenter, prospective, randomized study. J Arthroplasty 2014 Mar 29(3)530-4 Labib SA, Raikin SM, Lau JT, Andeerson JG, SooHoo NF, Carette S, Pinney SJ. Joint preservation procedures for ankle arthritis. Foot and Ankle International 2013 34(7)1040-1047 Hernandez A, Gardner J, Parker D, Monson D, Edgar M. Chondroid syringoma (mixed tumor) with tyrosine crystals. 2013 June 40(6)527-9 Stuart LN, Gardner JM, Lauer SR, Monson DK, Parker DC, Edgar MA. Epithelioid sarcoma-like (pseudomyogenic) hemangioendothelioma, clinically mimicking dermatofibroma, diagnosed by skin biopsy in a 30-year-old man. J Cutan Pathol 2013 Oct 40(10)909-13 Datir A, Xing M, Kakarala A, Terk MR, Labib SA. Radiographic evaluation of INBONE total ankle arthroplasty: a retrospective analysis of 30 cases. Skeletal Radiology 2013 Dec 42(12)1693-701

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Meeting Presentations: 2013 – 2014

European Federation of Orthopaedic and Traumatology (Effort). Istanbul, Turkey. Microfracture versus osteochondral autologous transplantation for high-grade osteochondral lesions of the talus: a 10-year prospective comparative clinical experience. June 6, 2013. Sameh A. Labib, M.D. Datir A, Terk MR, Labib SA. Radiographic evaluation of the inbone ankle replacement. Poster Presentation. Society of Skeletal Radiology Annual Meeting, San Antonio, TX March 20, 2013 Labib SA, Switzer B. Osteochondral lesions of the talus (OLT): Techniques of osteochondral autologus transfer. DVD presentation. Mid-America Orthopaedic Association Meeting, Amelia Island, FL, April 17-21, 2013 Fisher SB, Baxter KJ, Staley CA, Monson DK, Murray DR, Oskouei SV, Weiss SW, Kooby DA, Maithel SK, Delman KA. “The General Surgeon’s Quandry: Atypical lipomatous tumor vs. lipoma. Who needs a surgical oncologist? Academic Surgical Congress, February 7, 2013. New Orleans, LA Dean T, Yim D, Monson D, Williams R. Percutaneous cryoablation: a novel method for rapid palliation for severely symptomatic osteoid osteoma Patients. World Conference for Inverventional Oncology. New York, NY, May 2013 Williams R, Yim D, Monson D, Dean T. First eighteen months experience with minimally invasive image-guide treatment of surgically persistent desmoid tumors. World Conference for Interventional Oncology. New York, NY, May 2013

Michael Smith (PGY-4), James Black (PGY-5) and Gregory Faucher (PGY-4) presented at the Southern Orthopaedic Association meeting

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HONORS & AWARDS 2013 – 2014

Listed as one of Atlanta’s Best Doctors by Atlanta Magazine

Scott Boden, M.D. Robert Bruce, M.D. Spero Karas, M.D. James Roberson, M.D. Gerald Rodts, M.D. John Xerogeanes, M.D.

International Society for the Study of the Lumbar Spine Prize Winner Paper Zili Wang, Ph.D. William Hutton, M.D. Tim Yoon, M.D. National offices Scott Boden, M.D., President American Orthopaedic Association

Tim Yoon, M.D., Secretary Elect, International Society of the Study of the Lumbar Spine Editorial

Tim Yoon, M.D. Issue Editor The Spine Journal. Special Issue on Biologics. March 2014 Millipub Membership Scott Boden, M.D. Residents

James Black (PGY-5) won first place for resident research at the Georgia Chapter of the American College of Surgeons/Georgia Committee on Trauma

Mihir Desai (PGY-5) won the SOA/OREF award at the Southern Orthopaedic Society Annual Meeting

Michael Gottschalk (PGY-5) won a SOA Resident Travel Grant Award

Elise Hiza (PGY-3) won first place for her research poster at the Atlanta Trauma Symposium on May 17, 2014 Robert Runner (PGY-1) won second place for resident research at the Georgia Chapter of the American College of Surgeons/Georgia Committee on Trauma

kelly day journal 2014

Documents

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kelly society president

emory school of medicine

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field of medicine

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