2021 Campbell Orthopaedic Journal Volume 7 by CampbellFoundation

2021

Campbell Orthopaedic Journal Volume 7

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Volume 7, May 2021

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A JOINT PUBLICATION OF

Campbell Clinic Orthopaedics • The Campbell Foundation University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering EDITORIAL BOARD

Editor-in-Chief S. Terry Canale, M.D.

Editorial Advisor Kay Daugherty, BS

Editorial Support Staff Linda Jones, BA

• Margaret Knack, RN, BSN, MS • Jenny Koltnow, BS, MEd Jennifer Strain, BA, MBA • Rebecca Williams

TABLE OF CONTENTS Letter from the Editor-in-Chief

Tributes

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S. Terry Canale, MD

Campbell Clinic Mission/Vision

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Resident Training Today and Tomorrow

Dedicated Lectureship Series

Report from Alumni

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Randy Davidson, MD

Campbell Foundation: Celebrating 75 Years

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CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

Built strong

T H E N AT I O N ’ S T O P O R T H O PA E D I C E X P E R T S

• Accel Performance and Wellness

• Orthopaedic Trauma

• Back, Neck, and Spine Care

• Pediatric Orthopaedics

• Elbow Care

• Physical Medicine & Rehabilitation

• Endoscopic Spine Surgery

• Regenerative Medicine

• Foot and Ankle Care

• Shoulder Care

• Hand and Wrist Care

• Sports Medicine

• Knee Injury Care

• Total joint Replacement

• Orthopaedic Oncology

• Youth Hip Preservation

Official sports medicine provider

New Germantown building located at 7887 Wolf River Blvd.

901-759-3100 | CampbellClinic.com

Class of 2021 Resident Research Office-Based Percutaneous Fasciotomy for Dupuytren Contracture

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Chambers JS • Pate T • Calandruccio JH

Patient-Related Risk Factors Predict Outcomes After Arthroscopic Rotator Cuff Repair

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Cline JT • Falkner DA • Brolin TJ • Smith R • Azar FM • Throckmorton TW

A Biomechanical Investigation of Shape Memory Staples

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Duncan PP • Bettin CC • Reagan JT • DiAngelo DJ • Johnson PJ

Single Dose Antibiotic Regimens in Total Shoulder Arthroplasty are Safe in the Outpatient Surgery Setting

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Fryberger CT • Throckmorton TW • Oh SR • Wan JY • Azar FM • Brolin TJ

Frequency of and Risk Factors for Postoperative Urinary Retention (POUR) after Total Hip Arthroplasty: Study of 409 Arthroplasties

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Mathew MJ • Mihalko WM • Ragsdale T • Pharr ZK • Rider CM • Toy PC

Effect of Deltoid Volume on Range of Motion and Patient-Reported Outcomes Following Reverse Total Shoulder Arthroplasty in Rotator Cuff -Intact and Rotator Cuff -Deficient Conditions

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McClatchy SG • Heise GM • Mihalko WM • Azar FM • Smith RA • Witte DH • Stanfill JG • Throckmorton TW • Brolin TJ

The Importance of Surgeon Judgment in Obtaining Early Magnetic Resonance Imaging to Prevent Delays in Care for Acute Subacromial Injury

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Stevens TT • Hartline JT • Brolin TJ • Bernhold DL • Dibaba DT • Azar FM • Throckmorton TW

Closed Reductions of Pediatric Wrist, Forearm, and Elbow Fractures in a Free-Standing Ambulatory Surgery Center is a Safe and Cost-effective Alternative to the Emergency Department

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Strickland CD • Neel RT • Porter E • Sheffer BW • Kelly DM

The Year in Review: 2020 Publications

Staff Composite

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CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

Campbell Clinic Staff Research Racial and Ethnic Disparities in Utilization of Total Knee Arthroplasty Among Older Women

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Cavanaugh A • Rauh MJ • Thompson CA • Alcarez J • Mihalko WM • Bird CE • Eaton CB • Rosal MC • Li W Shadyab AH • Gilmer T • LaCroix AZ

Patient and Procedural Factors Predict Operating Room Time Intervals in Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis: A Retrospective Cohort Study

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Hartline JT • Nolan VG • Kelly DM • Sheffer BW • Spence DD • Pereiras L • Warner Jr. WC • Sawyer JR

The Effect of Subscapularis Management Technique on Outcomes and Complication Rates Following Reverse Total Shoulder Arthroplasty

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Hartline JT • Brolin TJ • Wan JY • Dibaba DT • Azar FM • Throckmorton TW

Prophylaxis for Pediatric Venous Thromboembolism: Current Status and Changes Across Pediatric Orthopaedic Society of North America from 2011

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Murphy RF • Williams D • Hogue GD • Epps H • Chambers HG • Shore BJ • Spence DD

Outpatient Hip Safety in an Ambulatory Surgery Center Is Independent of Approach

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Pharr ZK • Rider CM • Bell JW • Wilde JH • Westbrooks TJ • Toy PC

Effect of Intrawound Vancomycin Powder on Postoperative Drain Output in Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

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Richardson SM • Hundman CN • Smith RA • Sawyer JR • Kelly DM • Spence DD • Sheffer BW • Warner Jr WC

Hunger Games: Impact of Fasting Guidelines for Orthopedic Procedure Sedation in the Pediatric Emergency Department

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Stewart RJ • Strickland CD • Sawyer JR • Kumar P • Gungor B • Longjohn M • Kelly DM • Kink RJ

Campbell Club in Memorium

2021 Orthopaedic Fellows

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Current Orthopaedic Residents

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CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

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Letter from the Editor-in-Chief

S. Terry Canale, MD

Department Chair, Emeritus UT-Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering University of Tennessee Health Science Center As many of the obstacles from the last year remain, I hope this letter finds you healthy and safe, and beginning to return to the activities you love. Even with all the demands of the pandemic, we remain focused on research; after all, it is the foundation of knowledge. Therefore, I share with you this seventh volume of the Campbell Orthopaedic Journal, highlighting some of our original orthopaedic research. It has been sent to the more than 600 distinguished alumni of our educational programs, every orthopaedic chair and program director in the country, medical schools nationwide, and donors and friends of the Campbell Foundation. Highlighted in this edition are eight articles resulting from the senior projects of our 2021 Graduating Resident Class, exceptional surgeons who will continue their training in a fellowship program in their chosen orthopaedic subspecialty. In addition, we’ve included a sample of the publications and presentations made by our staff, residents and fellows nationally and internationally, supplied in seven original and review articles. Residency Program Director Derek Kelly, MD, Pediatric Orthopaedic Specialist, and Assistant Director Clayton Bettin, MD, offer a closer look at the many ways our Residency has adapted and thrived through the last year and sustains excellence. The year 2021 marks the 75th anniversary of the Campbell Foundation. We look forward to honoring Dr. Campbell’s legacy and celebrating our shared history later this year. Please enjoy this edition of the Journal. We invite you to keep us informed of your work, accomplishments and opportunities to work together, and together, continue to advance orthopaedic medicine.

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

TRIBUTES

S. TERRY CANALE, MD It is with humble appreciation and admiration that we dedicate the seventh edition of Campbell’s Orthopaedic Journal to Editor-in-Chief, Dr. S. Terry Canale. Dr. Canale takes great pride in this position and works tirelessly to continue to improve “the COJ.” Dr. Canale is also the former Editor of Campbell’s Operative Orthopaedics and deeply committed to orthopaedic research and education. He has played a vital role in Campbell’s long-standing commitment to world-wide orthopaedic education and made it a priority to ensure that each publication provides valuable and up-to-date information. His enthusiasm for this work will continue to influence and inspire every publication and paper which bear his name.

KAY C. DAUGHERTY It is with equal appreciation and regard that we dedicate this edition to Kay C. Daugherty, who has played a pivotal role in seven editions of Campbell’s Orthopaedic Journal and has served as the managing editor of the last nine editions of Campbell’s Operative Orthopaedics. Over the last 42 years, she has faithfully and tirelessly edited, reshaped, and overseen all aspects of publications from manuscript preparation to proofing. She has a profound talent to put ideas and disjointed words into comprehensible text, ensuring that each revision maintains the gold standard in readability. Each publication is a testament to her dedication to excellence in writing and education. A favorite quote of Mrs. Daugherty to one of our late authors was, “I’ll make a deal. I won’t operate if you won’t punctuate.” We are grateful for her many years of continual service to the Campbell Foundation and for the publications yet to come.

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

TRIBUTES

GEORGE HERNANDEZ We are deeply grateful to George Hernandez who served as CEO of the Campbell Clinic and Executive Director of the Campbell Foundation from 2010-2020. When George began his career as CFO at the Campbell Clinic in 1995, revenues were $30 million and by 2019 they exceeded $300 million. During his time as CEO, he guided the Clinic through the enormous task of building a state-of-the-art center in Germantown that opened in 2019, enhancing patient care and access with an ambulatory surgery center, expanded physical therapy, and the ACCEL Performance and Wellness Center. Under George’s leadership, the Campbell Foundation also experienced tremendous growth. Research activity increased tenfold, with more than 150 active studies in the last year alone. An explosion of publications included the introduction of the Campbell Orthopaedic Journal and Current Orthopaedic Practice. Resident training was enriched by the Molly Shumate Scholarship, which was introduced in 2012 to provide residents valuable training through international medical trips. In 2018 the Center for Excellence for Cerebral Palsy Care and Research at Le Bonheur Children’s Hospital opened, servicing families throughout the Mid-South area. Thanks to George’s dedication and vision, the Foundation’s work continues to reach around the globe. During the unprecedented 2020 year, George’s steady hand led the way through the Covid crisis, with both the Clinic and the Foundation emerging stronger than ever. For this and his other accomplishments, we are indebted.

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

Campbell Clinic Mission

The mission of the Campbell Clinic is to provide unsurpassed patient care while being recognized as a leader in teaching and research in the profession of orthopaedic surgery.

Campbell Clinic Vision Statement

Another century of world-class orthopaedic care restoring function and quality of life.

Campbell Clinic Core Values Excellence We aim to exceed expectations by providing an exceptional patient experience through accessible & efficient quality care, a comfortable and safe environment, and effective communication. Integrity We embrace, expect, and exhibit honesty, accountability and professionalism toward patients, each other, and outside partners. Compassion We commit to cultivating an environment of compassion for each patient and family member through sensitivity, sincerity, and empathy.

Innovation We commit to delivering innovative technologies, products, and services through our rich orthopaedic heritage and a strong research foundation. Commitment We commit to each other, to excellent patient care, to education, to innovation and research, to community service, and to orthopaedic leadership. Legacy We will do what is right for the Campbell Clinic, our patients, and our employees. Unity Everything we do, we do together.

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

THE CAMPBELL WAY

Resident Training Today and Tomorrow For nearly 100 years, the Campbell Clinic has trained orthopaedic surgeons who practice throughout the United States and around the world. The University of Tennessee–Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering residency works with the Campbell Foundation to run this top-tier accredited fiveyear program for 40 residents. This program sets residents up for success as surgeons, researchers, educators and leaders. Derek M. Kelly, MD

Clayton C. Bettin, MD

Alumni include presidents of the American Academy of Orthopaedic Surgeons (AAOS), directors of the American Board of Orthopaedic Surgery (ABOS), presidents of the American Orthopaedic Association (AOA), and numerous presidents of subspecialty societies, making Campbell one of the best represented private practices in the country. We reached out to Derek M. Kelly, MD, Pediatric Orthopaedics Specialist and Residency Program Director, and Clayton C. Bettin, MD, FAAOS and Assistant Program Director, to discuss the state of the residency. With support from Renee Poe, MS, Program Coordinator, this powerhouse team led the program through COVID-19 and upholds the gold standard first set by Dr. Campbell. How has the COVID-19 pandemic challenged the residency program? Dr. Kelly: Like so many other industries, we had to move much of our formal teaching and research online. We facilitated an entirely virtual resident recruitment and selection process, going from 800 applicants to 90 interviews to 8 future orthopaedic surgeons and giving applicants a virtual experience with our program and community. We launched CampbellResidency.org. Thanks to Zoom and Microsoft Teams (and great staff ), we’ve sustained teaching and research schedules.

Renee Poe, MS

Dr. Bettin: COVID has presented unique challenges, but it has made us an even stronger organization. We have developed hybrid online learning environments for our resident educational sessions, as well as for all of our subspecialty meetings. Our residents have been exposed to telemedicine and have learned valuable lessons in how to apply this to their own practices in the future.

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

What makes the Campbell Residency so special? Dr. Bettin: This residency is the most well-rounded educational training program in the country. We offer learning opportunities in all subspecialties of orthopaedics in a variety of settings, ranging from Level 1 trauma centers to private practice surgery centers. We cover hospitals in all of the major health systems in Memphis and our own state-of-the-art facilities. We attract doctors seeking hands-on experience and a terrific research infrastructure. In addition, our residents are some of the few in the country who receive training in the business of orthopaedics, making them better prepared to enter the workforce. How do the orthopaedic residents serve the community and patients while completing their training? Dr. Kelly: Our residents engage with the community through our treatment of all orthopaedic patients at Le Bonheur Children’s Hospital, Baptist Children’s Hospital, Regional One Health, and Methodist University Hospital, regardless of a patient's ability to pay for care. Residents are also engaged in projects such as Soles4Souls, international mission work to underserved countries and serving local athletes through school partnerships and outreach. How does the Campbell Orthopaedic Surgery Residency program make Campbell Clinic stronger?

all the teaching faculty on our toes! We must constantly strive for excellence to match their energy and enthusiasm. We also remain at the forefront of medical knowledge to ensure they receive the most current information and learn the newest techniques. The residents also extend our reach and care to more patients, particularly those who are uninsured and under-insured seen at our partner hospitals. To you, what is most exciting/promising about medical education in, say, 2–4 years? Dr. Bettin: I am excited for the continued integration of online learning and communication to our practice. We have an ability to engage with residency alumni across the country through online platforms during our specialty conferences and connect with colleagues and alumni in new ways. Dr. Kelly: I am most excited about the changing demographics of the orthopaedic surgery resident. Now in the U.S., medical school classes are over 50% women. Orthopaedic surgery has traditionally been a white male-dominated specialty. As our field gains more diverse professionals and perspectives, our specialty will advance in many ways. Our challenge at Campbell Clinic will be to attract and recruit diverse resident applicants at a rate equal to or greater than the rest of the nation. As access to education and advancement expands, the orthopaedic world will enjoy even more diversity of thought and leadership. This is exciting and promising.

Dr. Bettin: The creativity and inquisitive nature of these conscientious, intelligent residents keeps

Every day, patients in need of care and compassion see Campbell-trained physicians. Whether suffering debilitating pain or struggling to walk, patients’ needs are met and well-being restored. Your investment is important to serving patients worldwide and training generations of physicians in “the Campbell way.”

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

DEDICATED LECTURESHIP SERIES Alvin J. Ingram Memorial Lecture The year, Campbell Foundation’s annual Alvin Ingram, MD Each the Campbell Foundation proudly hostsJ.a Distinguished Memorial in Lecture was in memory of former Campbell Professor memory of ainitiated fine surgeon. The annual Alvin J. Ingram, Clinic Chief ofLecture Staff and Chairman Alvin J.Campbell Ingram, MD Memorial was Department initiated in memory of former MD through a gift from members of his family, to Clinic Chief of Staff and Department Chairman Alvin J. Ingram,honor M.D., his commitment to education. Dr. Ingram was a graduate of through a gift from members of his family, to honor his commitment our residency program and a world authority on the treatment to education. Dr. Ingram was a graduate of our residency project, of polio. and was a world authority on the treatment of polio. Alvin J. Ingram, MD

The series highlights achievementsininsurgeon surgeon education, The lecture Lecture highlights achievements education and features a Keynote Address by a Distinguished Professor, foland features a Keynote address by a Distinguished Professor and lowed by presentations from the Campbell Foundation graduating presentations from the Campbell Foundation graduating residents. residents. Beginning in 2014, of under the director guidance of course director In 2014, under the guidance course Derek M. Kelly, MD, Derek M. Kelly, M.D., the Ingram Lecture was expanded considerably the Lecture expanded with lectures by our Distinguished Professor, and included only Panel. lectures by our Distinguished Professor, faculfaculty and annot Expert ty and the residents, but also an Expert Panel and technical exhibits. TheThe Ingram Lecture is open to the public,virtually with continuing education Ingram Lecture is now offered and open to the credits for physicians and other allied health for professionals. public, available with continuing education credits available physicians and Ingram other allied health professionals. The Ingram Lecture The Lecture regularly attracts an audience of more regularly than 150 attracts more than 150 surgeons, engineers, scientists, others surgeons, engineers, scientists, and others dedicated to and excellence dedicated to excellence in orthopaedics. in orthopaedics.

2021 Alvin J. Ingram, MD Memorial Lecture Visiting Series May 21, Professorship 2021 Distinguished Professor: Xavier A. Duralde, M.D. Felix H.American “Buddy”Shoulder Savoie &III,Elbow MD Surgeons • VP, • Atlanta Braves Team Physician Ray J. Haddad Professor of Clinical Orthopaedics, • Peachtree Orthopedics, Shoulder Surgeon Chief of the Division of Sports Medicine, Tulane School of Medicine •Director, Chief ofTulane Orthopaedic Line, InstituteService of Sports Medicine Piedmont Hospital, Atlanta, GA Dr.• Felix H. “Buddy” Savoie is Surgery, an internationally-recognized expert Professor of Orthopaedic in the areasUniversity of Shoulder andof Elbow Surgery and Sports Medicine. Emory School Medicine Dr. Savoie came to the Tulane University School of Medicine in 2007 following Hurricane Katrina topractices lead as Professor of Clinical Xavier A. Duralde, MD, currently at Peachtree OrthoOrthopaedics, Chief of the Division of Sports Medicine, and Director paedics in Atlanta, GA and serves as the Vice President of the Amerof the Tulane Institute of Sports Medicine. he was named ican Shoulder and Elbow Surgeons (ASES).InDr.2015, Duralde earned his Chairman of the Department of Orthopaedics, and in 2016, he was A.B. from Harvard University in 1979 and his M.D. from Columbia named theCollege Ray J. Haddad Professor of Orthopaedics. University of Physicians and Surgeons in 1983. He remained at Columbia University for his orthopaedic training and fellowship in An established, well-known leader and sought-out speaker in shoulder and elbow surgery. Orthopaedics, Shoulder & Elbow Surgery, and Arthroscopy, Dr. Dr. Duralde served 2nd his country as a major in the United States Air Savoie is the current Vice President of the American Academy Force from 1988 to 1992. While in the Air Force,ofhethe served as chief of Orthopaedic Surgeons, former President Arthroscopy Association of North America (AANA), and President of the • • •

Felix H. “Buddy” Savoie III, MD

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

MD Memorial Lecture was initiated in memory of former Campbell MD Memorial initiated in memoryAlvin of former Campbell Clinic Chief of Lecture Staff andwas Department Chairman J. Ingram, M.D., Clinic Chief of Staff and Department Chairman Alvin J. Ingram, M.D., through a gift from members family, to commitment Orthopaedic Learning Center. He has served on the Boards of ofhis Directors ofhonor many his societies including through a gift from members of family, to his commitment Orthopaedic Learning Center. He has on Ingram the Boards of Directors ofhonor many societies including education. Dr. was a his graduate of our residency project, AANA and Services the International ofserved Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine of Surgical and ChiefSociety ofto the Department of Orthopedics to education. Dr. Ingram was a graduate of our residency project, AANA and the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine of Surgical Services and Chief ofof the Department of Orthopedics and was aatworld authority on the treatment of polio. (ISAKOS), he has hundreds published peer-reviewed articles. at the 20thand Tactical Fighter Wing Hospital RAF Upper Heyford, and was a world authority on the treatment of polio. (ISAKOS), and he has hundreds of published peer-reviewed articles. at the 20th Tactical Fighter Wing Hospital at RAF Upper Heyford, Oxfordshire, England. The lecture series highlights achievements in surgeon education, Alvin J. Ingram, MD Louisiana State University School of Medicine in New Orleans, he completed his A graduate of the Oxfordshire, England. The lecture series highlights achievements in surgeon education, and features aSchool Keynote Address byinaNew Distinguished Professor, fol- his J. Ingram, MDbeen Dr.Alvin Duralde named Castle Connolly Top Doctor for A graduate of has the Louisiana State University of Medicine Orleans, he completed internship and residency at the University of Mississippi Medical Center in Jackson. In addition, and features a Keynote Address by a Distinguished Professor, fol- he Dr. Duralde has been named Castle Connolly Top Doctor for lowed by presentations from the Campbell Foundation graduating internship and residency at the University of Mississippi Medical Center in Jackson. In addition, he 2020 and Top Orthopedic Surgeon in Atlanta from 2010 2020 completed multiple fellowships inlowed sportsbymedicine and arthroscopy at the Medical Collegegraduating of Wisconsin presentations from the Campbell Foundation 2020 and Top Orthopedic Surgeon in Atlanta from 2010 2020 residents. Beginning in 2014, under the guidance of course director completed multiple fellowships in sports medicine and arthroscopy at the Medical College of Wisconsin by both Connolly Atlanta Magazine. and the Castle Mayo Clinic; an and AO International Fellowship at D. F. Harder, Basil, Switzerland; at Orthopaedic residents. Beginning in 2014, under the guidance of course director by both Castle Connolly and Atlanta Magazine. Derek M. Kelly, M.D., the Ingram Lecture was expanded considerably and the Mayo Clinic; an AO International Fellowship at D. F. Harder, Basil, Switzerland; at Orthopaedic Research of Richmond, Virginia; and at Fowler Kennedy Sports Medicine, London, Ontario. As an active member of Peachtree volunteer Derek M.Orthopedics’ Kelly,not M.D., Ingram Lecture was expanded considerably and onlythe lectures our Distinguished Professor, faculResearch of Richmond, Virginia; and included at Fowler Kennedy Sports by Medicine, London, Ontario. As Dr. an Duralde active member of annually Peachtree Orthopedics’ volunteer team, visits Haiti to off er his services at the and included not only lectures by our Distinguished Professor, faculty andLecture theoffresidents, but also an Panel and technical team, Duralde visits Haiti annually to er Distinguished his atProfessor, theExpert Dr. As theDr. 2021 Alvin J. Ingram Memorial Savoie discussedexhibits. “Throwing Hospital Albert Schweitzer and outlying clinics. Heservices has authored ty and the residents, but also an Expert Panel and technical exhibits. The He Ingram Lecture is open to the continuing As the 2021 Alvin J. Ingram Memorial Lecture Distinguished Professor, Dr.with Savoie “Throwing Hospital Albert Schweitzer and outlying clinics. He has authored Shoulder,” with a focus on athletes. addressed the causes andpublic, conditions thatdiscussed lead toeducation injuries and many publications regarding the shoulder, including The Ingram Lecture isprimary open torethe public, with continuing education credits available for physicians and other allied health professionals. Shoulder,” with a focus on athletes. He addressed the causes conditions that lead to injuries and many publications regarding the shoulder, including primary rethe treatments andbook therapies that enable athletes tophysicians return to and play.other His decades-long experience with search papers and chapters. Dr. Duralde is regularly invited credits available for allied health professionals. the treatments and therapies that enable athletes toregularly return toattracts play.travel His experience The Lecture an decades-long audience of more than 150with search papers and book chapters. Dr.Ingram Duralde is regularly invited athletes—many, including professional and college athletes, who to New Orleans to seek to speak nationally and internationally on various subjects of the The Ingram Lecture regularly attracts an audience of more than 150 out athletes—many, including professional and college athletes, who travel to New Orleans to seek out surgeons, engineers, scientists, and others dedicated to excellence his care—demonstrated his extraordinary expertise in meeting to speak nationally and internationally on various subjects of thepatients’ needs and delivering optimal shoulder. surgeons, engineers, scientists, and others dedicated to excellence his care—demonstrated his extraordinary expertise in meeting patients’ needs and delivering optimal in orthopaedics. outcomes. to “coaching” sports parents, more than 100 virtual participants shoulder. From innovative techniques in orthopaedics. outcomes. From innovative techniques to “coaching” more than 100 virtual participants As a 2021 Campbell Foundation Visiting Professorsports Seriesparents, speaker, Dr. Duralde’s presentation was greatly benefited from his wise insight and counsel. As a 2021 Campbell Foundation Visiting Professor Series speaker, Dr. Duralde’s presentation greatly benefited from his wise insight and counsel. entitled “Throwing Shoulder - Shoulder Pain in Baseball Players” capitalizing on his expertise and was deentitled “Throwing Shoulder - Shoulder Pain in Baseball Players” capitalizing on his expertise and decades-long relationship with amateur and professional athletes. Visiting Professorship Series cades-long relationship with amateur and professional athletes. Visiting Professorship Series 2021 Visiting Professorship Series In addition, Dr. Duralde partnered withA. Campbell Clinic Orthopaedics, Xavier Duralde, M.D. 2021 Visiting Professorship Series Accel Performance Center and Xavier A. Duralde, MD In addition, Dr. Duralde partnered with Campbell Clinic Orthopaedics, Performance and Xavier A. Duralde, M.D. the Campbell Foundation to offer the “Training &MD Injury Prevention forSurgeons theAccel Throwing Athlete”Center workshop, Xavier A. Duralde, • VP, American Shoulder & Elbow the Campbell to offer “Training & and Injury Prevention for thecoaches. ThrowingDr.Athlete” workshop, sponsored byFoundation Zimmer Biomet, tothe athletes their parents and Duralde and col•local VP, American Shoulder & Elbow Surgeons •local Atlanta Braves Team Physician • VP,to American Shoulder & their Elbow Surgeons sponsored by Zimmer Biomet, athletes and parents and coaches. Dr. Duralde and and colleagues discussed why and howAmerican to establish a great training regime, proper throwing mechanics • Atlanta Braves Team Physician •• VP, Shoulder & Elbow Surgeons Former Braves Lead Orthopaedist • Atlanta Peachtree Shoulder Surgeon leagues discussed why andmatter!). how to establish aOrthopedics, great training regime, proper throwing mechanics and pitch counts (and why they •• Former Atlanta Braves Lead Orthopaedist • Peachtree Orthopedics, Shoulder Surgeon Peachtree Orthopedics, Shoulder Surgeon pitch counts (and why they matter!). • Chief of Orthopaedic Service Line, •• Peachtree Surgeon We are grateful for this opportunity toOrthopedics, educate ourShoulder surgeons and help Hospital, our local Atlanta, athletesGA train safely Chief•ofChief Orthopaedic Service Line, Piedmont of Orthopaedic Service Line, Piedmont Hospital, Atlanta, GA We are grateful for this opportunity to educate our surgeons and help our local athletes train safely • Chief of Orthopaedic Service Line, Piedmont Hospital, Atlanta, GA and avoid injury. • Professor of Orthopaedic Surgery, Piedmont Hospital, Atlanta, GA • Professor of Orthopaedic Surgery, and avoid injury. • Professor of Orthopaedic Emory• University School ofSurgery, Medicine Professor of Orthopaedic Emory University School ofSurgery, Medicine Emory University School of Medicine Xavier A. Duralde, MD Emory University School of Medicine Xavier A. Duralde, MD Xavier A. Duralde, MD, currently practices at Atlanta from 2010 - 2020 by both Castle Connolly Xavier A. Duralde, MD, currently practices at Peachtree OrthofromMagazine. 2010 - 2020 both Castle Connolly Xavier A. Orthopedics Duralde, MD, currently at Atlanta and Atlanta Heby is Peachtree an active member of Peachtree in Atlanta, GApractices andA.serves Xavier Duralde, MD, currently practices at Orthopaedics inShoulder Atlanta, andAtlanta serves as the ViceHe President ofteam, themember Amerand Magazine. is an active of Peachtree in the Atlanta, GA and serves GA Peachtree Orthopedics’ volunteer visiting as the ViceOrthopedics President of American paedics in Atlanta, GA and serves as the Vice President of the American Shoulder and Elbow Surgeons (ASES). Dr. Duralde earned his Peachtree volunteer team, visiting as ViceSurgeons President(ASES). of the Dr. American Shoulder Haiti Surgeons each Orthopedics’ year(ASES). to serve the Hospital Albert andthe Elbow Duralde earned ican Shoulder and Elbow Dr.M.D. Duralde earned his A.B. from Harvard University in 1979 and his from Columbia and Elbow Surgeons (ASES). Dr. Duralde earned Haiti each year to serve the Hospital Albert Schweitzer and outlying clinics. He has authored his A.B. from Harvard University in 1979 and his MD A.B. from Harvard University in 1979 and his M.D. from Columbia and outlying clinics. He authored his A.B. from Harvard University in 1979 his MD ofSchweitzer University College Physiciansofand Surgeons in 1983. He remained from Columbia University College of and Physicians hundreds published articles and ishas a sought-out University College of Physicians and Surgeons in 1983. He remained from Columbia University College of Physicians hundreds of published articles and is a sought-out at Columbia University for hisfor orthopaedic training and fellowship in speaker his expertise. and Surgeons in 1983. He remained at Columbia at Columbia University for hisfor orthopaedic training and fellowship in speaker his expertise. and Surgeons in 1983. He remained at Columbia shoulder and elbow surgery. University for his orthopaedic training and shoulder and elbow University his orthopaedic training and surgery. 2021 Campbell Foundation Visiting Professor fellowship infor shoulder and elbow surgery. Dr. Duralde servedAshisa country as a major in the United States Air As a country 2021 Campbell Foundation Visiting Professor fellowship in shoulder and elbow surgery. Dr. Duralde served his as a major in the United States Airwas Series speaker, Dr. Duralde’s presentation Force from 1988 to 1992. While in the Air Force, he served as chief Series speaker, Dr. Duralde’s presentation from 1988 While in the AirShoulder Force, he- served as chief Dr. Duralde served as a major inForce the United Statesto 1992. entitled “Throwing Shoulder Painwas in Dr. Duralde served as a major in the United States entitled “Throwing Shoulder Shoulder Pain in Air Force from 1988 to 1992. While in the Air Baseball Players” capitalizing on his expertise Players” relationship capitalizing with on his expertise Air Force from 1988 to of 1992. While in the and Air Baseball and decades-long amateur and Force, he served as Chief Surgical Services CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021 18 and decades-long relationship with amateur and Force, he served as Chief of Surgical Services and professional athletes. In addition, Dr. Duralde Chief ofCAMPBELL the Department of Orthopaedics at the7, 2021 ORTHOPAEDIC JOURNAL • VOLUME 18 professional athletes. In addition, Dr. Duralde Chief of the Department of Orthopaedics at the 20th Tactical Fighter Wing Hospital at RAF Upper partnered with the Campbell Foundation to offer with the Campbell Foundation to offer 20th Tactical Fighter Wing Hospital at RAF Upper partnered Heyford, Oxfordshire, England. the “Training & Injury Prevention for the Throwing Heyford, Oxfordshire, England. the “Training & Injury Prevention for the Throwing Athlete” workshop, sponsored by Zimmer Biomet, workshop, by and Zimmer Biomet, Dr. Duralde has been named Castle Connolly Top Athlete” to local athletes andsponsored their parents coaches. Dr. Duralde has been named Castle Connolly Top Doctor for 2020 and Top Orthopaedic Surgeon in to local athletes and their parents and coaches. Doctor for 2020 and Top Orthopaedic Surgeon in CAMPBELL CAMPBELL ORTHOPAEDIC ORTHOPAEDIC JOURNAL JOURNAL •• VOLUME VOLUME 7, 7, 2021 2021 CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

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Community Healthcare Outreach Volume 32 • Number 3 • May/June 2021

Volume 32 • Number 3 • May/June 2021

Residents Trained

www.c-orthopaedicpractice.com

Current

Current Orthopaedic Practice

Orthopaedic Practice

Orthopaedic Research

A REVIEW AND RESEARCH JOURNAL IN THIS ISSUE: • Special Focus: Total Joint Arthroplasty • Rate of Periprosthetic Joint Infections and Hospital Influence • Perception of Care During a Pandemic

• Lateral Humeral Condylar Fractures in Children • Chondroblastoma of the Femoral Neck • Holding Traction During CT • Orthopaedic Considerations During COVID-19

Thank you to our generous Campbell alumni for standing with us during a challenging year.

pp 223–318

You made an impact!

Return to the Legendary The Peabody Memphis Saturday Evening Gala & Awards

Ingram Memorial Lecture, Scientific Sessions & CMEs Special Spouse Outings

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

Alumni Update

Randy Davidson, MD Campbell Club President Dear Campbell Alumni, When I was writing this letter to you this time last year, the pandemic had just begun, and we were unaware that our lives would be disrupted for months to come. I hope you, your family, and your practice weathered the storm unscathed. As we begin to emerge from our socially distanced world, I encourage you to reconnect - with your fellow alumni, with your subspecialty colleagues, and with Campbell staff, residents, and fellows. There are several upcoming opportunities, so please make every attempt to join in. Please mark your calendar to reconvene and reconnect at these events: Ingram Lecture: I hope you were able to login and participate virtually in the 2021 Ingram Lecture. Next year at Triennial, Ingram Lecture will constitute the Friday morning scientific session. This is an excellent opportunity for you to mentor and learn from our residents. Ingram Lecture 2022 will take place on Friday morning, April 22nd. Footprints in Motion: Footprints in Motion is the signature fundraiser for the Campbell Foundation, and the disco-themed event is planned for Saturday, October 30, 2021, at Shelby Farms FedEx Event Center. Put on your disco shoes and dance the night away with Campbell staff and Foundation community partners and supporters. Campbell Club Triennial 2022: The 25th Triennial celebration, marks the 75th anniversary of the Campbell Foundation! It will take place April 21-24, 2022. We will return to the historic Peabody Hotel, with social events planned throughout the weekend - from spouse outings to the black tie gala on Saturday night. Be sure to make your hotel reservation in the Willis C. Campbell Club room block by calling 901-529-4000. Thank you for your continued support of the Campbell Foundation, sustaining its mission of resident education, orthopaedic research, and community healthcare. Your gifts are vital to the research and education highlighted throughout the Campbell Orthopaedic Journal. I look forward to reconnecting with you soon. Respectfully, Randy Davidson, MD ‘90 Campbell Club President

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

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Campbell Foundation:

Celebrating 75 Years Orthopaedic excellence takes many forms. As the Campbell Foundation has grown and evolved, so has our ability to produce superior research, educate future surgeons and ensure excellent patient care. This charitable powerhouse focuses on:

Education Education and training are at the heart of the Campbell Foundation mission. The Foundation sustains one of the most sought-after residency programs in the United States, educating forty surgeons in a five-year residency and training them in “the Campbell way.” Each year, six sub-specialty Fellows actively engage in patient care, research and outreach. Perhaps best known for producing Campbell’s Operative Orthopaedics, the “bible” of orthopaedic medicine since 1939, the Foundation supports a robust publication program, with more than 150 publications, presentations and posters produced and distributed to practitioners worldwide in the last year alone. 22

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

In addition, training events, including the Alvin J. Ingram Memorial Virtual Lecture and James Beaty Visiting Professorship, offer indepth continuing medical education experiences for residents, staff and partners across the globe.

Research Campbell Foundation staff administer and facilitate more than 140 clinical studies each year, demonstrating Campbell’s unwavering commitment to innovation and patient well-being. Each subspecialty has teams that engage in multi-center clinical studies, sponsored clinical research and physician-initiated studies to examine everything from treatments to pain management systems. Research activities also engage Campbell residents and fellows, medical students and industry and academic partners, further fostering collaboration and driving future innovation. Results are shared with the world through presentations and posters at academic conferences, publications and industry outreach.

Community Impact The Campbell Foundation ensures orthopaedic care is available to everyone. Partnerships with healthcare partners, including Regional One Medical Center and Le Bonheur Children’s Hospital, ensures children, veterans and the underserved can access excellent orthopaedic care. Each year, community clinics support uninsured and under-insured individuals who depend on charitable clinics for care. The desire to serve extends to annual medical mission trips, where Campbell surgeons and residents provide care and training to high need communities in developing countries. Compassion drove the creation of the Center of Excellence for Cerebral Palsy Care & Research at Le Bonheur Children’s Hospital in 2018, where hundreds of CP patients now have a “one-stop shop” for multidisciplinary, comprehensive care and treatment. The year 2021 marks the 75th Anniversary of the Campbell Foundation. Thanks to countless partners and friends, the excellence, innovation and education defining our last 75 years will set the course for the next 75. This year, we celebrate you, our partners and investors, and all things Campbell.

To learn more, visit Campbell-Foundation.org.

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

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CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

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CLASS OF 2021 RESIDENT RESEARCH

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

J. Stephen Chambers, MD1 Taylor Pate, MD2 James H. Calandruccio, MD1 1

University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering Memphis, Tennessee Eastern Virginia Medical School Norfolk, Virginia

Oﬃce-Based Percutaneous Fasciotomy for Dupuytren Contracture Dupuytren disease is a chronic progressive disorder that affects connective tissue in various areas and can cause functional issues when significant contractures develop in the palmar and digital fascia. The disease has an autosomal dominant inheritance pattern with variable penetrance, with family history cited as a strong predictor of the disease. The disease is most commonly diagnosed in Caucasian men, with increasing prevalence in men older than 65. Dupuytren disease often is tolerated for many years before the patient presents for evaluation when skin tightness and contour changes progress to form nodules, typically on the palmar aspect of the hand. These nodules produce tension in pretendinous and other cords of the palm and fingers resulting in joint flexion contractures. The contractures occur most often on the ring and small fingers with the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints most commonly affected. Treatment usually is begun for patients when the contractures are significant enough to interfere with daily activities. Primary treatment goals are to completely straighten the affected ray(s) while reducing the risk of recurrence and avoiding complications. Treatments options are of 2 general types: minimally invasive and open surgical procedures. Minimally invasive procedures include percutaneous needle fasciotomy (PNF), cordotomy, and enzymatic fasciotomy. These options typically are more cost-effective, but have higher rates of recurrence compared with open procedures. Open surgical procedures have higher complication rates but lower rates of recurrence and often are preferred as a second line of treatment.

Corresponding Author James H. Calandruccio, MD 1400 S. Germantown Road Germantown, TN 38138 P: 901-759-3210 F: 901-759-3195 jcalandruccio@campbellclinic.com

Although fasciotomy was described more than 200 years ago, it was seldom used until French rheumatologists described fasciotomy with a percutaneous needle technique (PNF). The technique gained more widespread acceptance after the report by Foucher and colleagues. In 2003, a series of 100 patients treated with PNF resulted in few complications, reoperation rate of 24%, and recurrence at 3-year follow-up of 58%. More recent studies have shown that 79% of patients retain a straight joint after 2 years, but recurrence of the contracture(s) remains frequent, regardless of treatment method. Pess and colleagues reported a recurrence rate of 48% in 1,013 fingers followed for a median of 3 years. In their randomized controlled trial, van Rijssen and colleagues found a recurrence rate of 22% with PNF compared with 5% with limited fasciectomy. Because it is a simple procedure with few complications, PNF can be done repeatedly if necessary. The effectiveness of treatment of Dupuytren contractures can be subjectively assessed using patient-reported outcome measures (PROM). Quick Disabilities of Arm, Shoulder, and Hand (QuickDASH) is a commonly used PROM in upper extremity research including Dupuytren disease. It consists of 11 questions that focus on severity of symptoms and This article reproduced with permission from Orthopedic Clinics of North America. Chambers JS, Pate T, Calandruccio JH. Office-Based Percutaneous Fasciotomy for Dupuytren Contracture. 2020 Jul;51(3):369-372. doi: 10.1016/m.ocl.2020.02.008. Epub 2020 Apr 1.

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

Fig. 1: (A) A #15 scalpel blade is placed between the skin, parallel to the underlying cord. (B) The finger is extended to deliver the taut cord to the blade, which is then directed perpendicular to the cord. The knife is gently pushed against the underlying cord with the finger held in forceful extension. (C) The scalpel is removed and force-ful extension is used to get as much correction as possible.

difficulty in completing specific tasks. The QuickDASH score has 2 additional modules, work and sports/art, which focus on the patient’s disability while playing a sport/musical instrument or at work. There is limited evaluation of these additional modules in patients with Dupuytren disease. Percutaneous office-based cordotomy is an effective treatment for Dupuytren contracture; however, given that the cords are divided rather than excised, recurrence is frequent. There have been many different definitions of recurrence causing inconsistencies among studies and data, with rates ranging from 2% to 86%. In 2017, Kan and colleagues as part of the Dupuytren’s Delphi group, addressed this problem with an expert consensus of recurrence as “an increase in extension deficit of 20 at 1 year compared to at 6 weeks post-procedure.” Identifying risk factors associated with recurrence of contracture is important because this information may change treatment plans. Degreef and De Smet, in a study of more than 300 patients, showed that rates of recurrence are high for patients younger than 50 years and those with Ledderhose disease, family history, and male sex. The variable penetrance of the disease plays a confounding role in identifying specific risk factors. Effectiveness of treatment also can be assessed from a patient’s perspective using PROM. Budd and colleagues showed an improvement in QuickDASH Score from 15.1 before procedure to 8.0 afterward at a mean of 110 days. The QuickDASH survey has 2 additional modules that focus on the ability to work (Work Module Score or WMS) and to play a musical instrument/sport (Sport Module Score or SMS). MacDermid and colleagues studied up-

per extremity conditions and showed a reduction in QuickDASH score of 15 points or more to appreciate a change in function; their study, however, did not include Dupuytren disease. The correlation between improvement of contracture and patient-reported outcomes after treatment for Dupuytren disease has been shown to be weak or nonexistent. Budd and colleagues showed that the change in QuickDASH score and change in extension deficit did not correlate. Post-procedure patient satisfaction also contributes to the patient’s perceived function of the digit(s). Most patients are satisfied with the outcomes of the procedure at 1 year. Patient satisfaction outcomes following fasciotomy and collagenase treatment showed rates of 84% at an average of 10 months and 73% at 3-year follow-up. Complication rates are low after percutaneous fasciotomy. Pess and colleagues reviewed more than 1000 percutaneous releases and found skin tear to be the most common complication, occurring in only 3.4%; nerve laceration occurred in 0.1%. Skin ruptures have been reported in from 5% to 38% of patients. Nerve injuries (<0.5%) and tendon injuries (<0.05%) are rare.

Percutaneous Fasciectomy Technique •

Under sterile conditions, 3.0 mL of 1% lidocaine without epinephrine is injected into the skin and subcutaneous tissues proximal to the intended site of cord division.

•

A #15 scalpel blade is placed between the skin, parallel to the underlying cord (Fig. 1A).

•

The finger is extended to deliver the taut cord to the blade,

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

which is then directed perpendicular to the cord (Fig. 1B). •

The knife is gently pushed against the underlying cord with the finger held in forceful extension. The cord tissue when being divided yields a palpable gritty sensation and usually produces a predictable audible pop when the cord gives way.

•

The scalpel is removed and forceful extension is used to obtain as much correction as possible (Fig. 1C).

•

Occasionally additional sites along the cord are released, sometimes using a 25-gauge needle mounted on a syringe.

After the procedure, a soft dressing is applied and patients are instructed to begin range of motion exercises immediately. The soft dressing is removed the day after the procedure, and wound healing monitored daily for closure and home-based range-ofmotion exercises are continued.

Outcomes In 52 patients (65 digits) followed prospectively from the time of the office-based procedure to 1-year follow-up, the rate

of recurrence was 33%. The average metacarpophalangeal joint correction in active extension was from 39.6 to 9.3 (P = .001), and passive extension correction was from 25.4 to 3.6 of hyperextension (P = .001). The average QuickDASH score decreased by 8, the WMS score by 12, and the SMS score by 9 compared with preoperative scores, and these decreases were statically significant. The improvement in patient-reported outcomes (WMS and SMS) did correlate at 6 weeks and 1 year with active extension improvement. Also, SMS at 1 year correlated with passive extension improvement. On average, the wound closed by 7 days and pain resolved by day 2. The average highest pain score was 2.3 on a scale of 10. None of patients who had the procedure sustained a sensory deficit. At 1 year, 82% of patients were satisfied with the outcome of their procedure, and 87% considered the procedure worth having done. A much shorter recovery time with this officebased procedure is appealing and is useful in patients with welldefined cords, especially with MP joint contractures.

REFERENCES 1.

Eaton C. Dupuytren disease. In: Wolfe SW, Hotchkiss RN, Pederson WC, et al, editors. Green’s operative hand surgery. 7th edition. Philadelphia: Elsevier; 2017. p. 128–51.

2. Leafblad ND, Wagner E, Wanderman NR, et al. Outcomes and direct costs of needle aponeurotomy, collagenase injection, and fasciectomy in the treatment of Dupuytren contracture. J Hand Surg Am 2019;44:919–27. 3. Chen NC, Srinivasan RC, Shauver MJ, et al. A systematic review of outcomes of fasciotomy, aponeurotomy, and collagenase treatments for Dupuytren’s contracture. Hand (N Y) 2011;6:250–5. 4. Elliot D. The early history of contracture of the palmar fascia. Part 1: the origin of the disease: the curse of the MacCrimmons: the hand of benediction: Cline’s contracture. J Hand Surg Br 1988; 13:246–53. 5. Foucher G, Medina J, Navarro R. Percutaneous needle aponeurotomy: complications and results. J Hand Surg Br 2003;28:427–31. 6. StrÖmberg J, Ibsen-Sorensen A, Fridden J. Comparison of treatment outcome after collagenase and needle fasciotomy for dupuytren contracture: a randomized, single-blinded, clinical trial with a 1- year follow-up. J Hand Surg Am 2016;41: 873–80. 7.

Pess GM, Pess RM, Pess RA. Results of needle aponeurotomy for Dupuytren contracture in over 1,000 fingers. J Hand Surg Am 2012;37:651–6.

8. van Rijssen AL, ter Linden H, Werker PM. Five-year results of a randomized clinical trial on treatment in Dupuytren’s disease: percutaneous needle fasciotomy versus limited fasciectomy. Plast Reconstr Surg 2012;129:469–77. 9. Beaton DE, Wright JG, Katz JN, et al. Development of the QuickDASH: comparison of three item-reduction approaches. J Bone Joint Surg Am 2005;87:1038–46. 10. Kan HJ, Verrijp FW, Huisstede DM, et al. The consequences of different definitions for recurrence of Dupuytren’s disease. J Plast Reconstr Aesthet Surg 2013;66:95–103. 11. Kan HJ, Verrijp FW, Jouvis SER, et al. Recurrence of Dupuytren’s contracture: a consensus-based definition. PLoS One 2017;12:e0164849.

12. Degreef I, De Smet L. Risk factors in Dupuytren’s diathesis: is recurrence after surgery predictable? Acta Orthop Belg 2011;77:27–32. 13. Budd HR, Larson D, Chojnowski A, et al. The Quick-DASH score: a patientreported outcome measure for Dupuytren’s surgery. J Hand Ther 2011;24:15–20. 14. MacDermid JC, Richards RS, Donner A, et al. Responsiveness of the short form36, disability of the arm, shoulder, and hand questionnaire, patient-rated wrist evaluation, and physical impairment measurements in evaluation recovery after a distal radius fracture. J Hand Surg Am 2000;25: 330–40. 15. Degreef I, Vererfve PB, De Smet L. Effect of severity of Dupuytren contracture on disability. Scand J Plast Reconstr 2009;43:41–2. 16. Engstrand C, Boren L, Liedberg GM. Evaluation of activity limitation and digital extension in Dupuytren’s contracture three months after fasciec-tomy and hand therapy interventions. J Hand Ther 2009;22:21–6. 17. Jerosch-Herold C, Shepstone L, Chojnowski A, et al. Severity of contracture and self-reported disability in patients with Dupuytren’s contracture referred for surgery. J Hand Ther 2011;24:6–10. 18. Zyluk A, Jagielski W. The effect of the severity of Dupuytren’s contracture on the function of the hand before and after surgery. J Hand Surg Eur 2007;32:326–9. 19. Scherman P, Jenmalm P, Dahlin LB. One-year results of needle fasctiotomy and collagenase injec-tion in treatment of Dupuytren’s contracture: a two-centre prospective randomized clinical trial. J Hand Surg Eur 2016;41:577–82. 20. StrÖmberg J, Ibsen-Sorensen A, Fridden J. Percutaneous needle fasciotomy versus collagenase treatment for Dupuytren contracture: a randomized controlled trial with two-year follow-up. J Bone Joint Surg Am 2018;100:1079–86. 21. Zhou C, Hovius SE, Slijper HP, et al. Predictors of patient satisfaction with hand function after fasciectomy for Dupuytren’s contracture. Plast Reconstr Surg 2016;138:649–55. 22. Bradley J, Warwick D. Patient satisfaction with collagenase. J Hand Surg Am 2016;41:689–97. 23. Krefter C, Marks M, Hensler S, et al. Complica-tions after treating Dupuytren’s disease. A systematic literature review. Hand Surg Rehabil 2017;36:322–9.

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J. STEPHEN CHAMBERS, MD Hometown: McDonough, Georgia Undergraduate Institution: Georgia Institute of Technology Medical School: Mercer University School of Medicine-Savannah Dr. Chambers has a younger brother and is the first in his family to choose medicine as a career. When asked why he chose medicine as a career: I chose a career in medicine because the human body is the world’s best machine, and I wanted to learn more about it. And why he chose orthopaedics as a specialty: The ability to restore a patient’s function is what I find truly special, and I believe orthopaedics best fosters this. Plans After Campbell: Dr. Chambers will complete a Hand/Upper Extremity Fellowship at University of Pittsburgh Medical Center. Dr. Chambers adds: Thank you to my fellow classmates. These past five years have been unforgettable, and I couldn’t have done it without your support. Thank you to all the Campbell Clinic faculty and the staff (especially Karen and Tonya) for the countless hours of education and support you provided. Thank you, Dr. Cal, for introducing me to the best subspecialty. I am grateful for my experience here and proud to call myself a Campbell Clinic graduate.

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

Joseph T. Cline, MD1 Dima Falkner, MS2 Tyler Brolin, MD1 Richard Smith, PhD1 Frederick Azar, MD1 Thomas W. Throckmorton, MD1 1

University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering Memphis, Tennessee

University of Tennessee Health Science Center College of Medicine Memphis, Tennessee

Patient-Related Risk Factors Predict Outcomes After Arthroscopic Rotator Cuﬀ Repair Background/Hypothesis Several factors are known to impact outcomes of arthroscopic rotator cuff repair; however, little is known about patient-specific, potentially modifiable risk factors that may be of significance. Based on prior study of the early post-operative effects of these factors, we hypothesized that certain preoperative patient characteristics would have an impact on pain and functional outcomes at a minimum of 2 years follow-up after primary arthroscopic rotator cuff repair.

Methods After Institutional Review Board (IRB) approval, records review identified 75 primary arthroscopic rotator cuff repairs with at least 2 years (2.2-6.5 years) of clinical follow-up done at our institution by a single shoulder and elbow trained surgeon. Based on previous studies of short-term outcomes, we included pre-operative tobacco use, opioid use, alcohol use, disability claims, mood disorders (depression/anxiety), worker’s compensation claims, and obesity as patient-specific variables. Outcomes measures included visual analog (VAS) pain scores, American Shoulder and Elbow Surgeons (ASES) scores, Single Assessment Numeric Evaluation (SANE) scores, range of motion (ROM) and strength at a minimum of 2 years follow up. Risk factor analysis was performed using Student t-tests and ANOVA with p<0.05 considered statistically significant.

Results Of the variables studied, preoperative smoking was a significant predictor of pain at most recent follow-up (VAS 4.5 vs 1.3, p=0.009). Smoking patients also had worse ASES (62.4 vs 84.0, p=0.004) and SANE (63.0 vs 83.4, p=0.011) scores at most recent follow-up. Preoperative opioid use also trended toward worse pain (VAS 2.6 vs 1.3, p=0.06) and ASES (74.1 vs 84.9 p= 0.074) scores at minimum 2-year follow-up, with no significant difference in SANE (76.1 vs 82.8, p=0.27). However, alcohol use, disability claims, mood disorders, worker’s compensation claims, and obesity were not associated with significantly inferior pain scores or functional outcomes at most recent follow-up (all p>0.05). There were no statistically significant differences noted regarding ROM or strength for any of the risk factors studied.

Conclusions Corresponding Author Thomas W. Throckmorton, MD 1400 S. Germantown Road Germantown, TN 38138 P: 901-759-3110 F: 901-759-3195 tthrockmorton@campbellclinic.com

Pre-operative smoking and opioid use were both associated with increased pain and inferior function at a minimum of 2 years following primary arthroscopic rotator cuff repair. Moreover, these represent potentially modifiable risk factors that can be addressed before operative intervention to optimize outcomes and maximize value. Alcohol use, disability claims, mood disorders, worker’s compensation claims, and obesity were not associated with worse pain or functional scores at a minimum of 2 years follow-up in this study.

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JOSEPH T. CLINE, MD Hometown: Raleigh, North Carolina Undergraduate Institution: Davidson College Medical School: University of North Carolina School of Medicine Dr. Cline is an only child, and his decision to choose medicine as a career came naturally - his father is a general surgeon, and his mother is a dermatologist. Dr. Cline met his wife, Meg, at Davidson College where he was fortunate enough to have the apartment below hers. They were married in 2018 and have one son - Robert Tucker Cline, who was born on April 7, 2021. Meg is the Director of Summer Programming at Lausanne Collegiate School. When asked why he chose medicine as a career: I grew up around medicine with both my parents being doctors. I always enjoyed meeting their patients out in the community and having them go out of their way to tell me how one of my parents had helped them in some way. I knew I wanted a career where I could have a similar impact on people’s lives. And why he chose orthopaedics as a specialty: Orthopaedics allows us to make a tangible, often immediate, difference in our patients’ lives. I loved the idea that I could help a patient struggling with a debilitating problem to not only get out of pain, but go back to being active and enjoying their life. Plans After Campbell: Dr. Cline will complete an Adult Reconstruction Fellowship at Rush University in Chicago. Dr. Cline adds: Honestly, it’s impossible to name everyone deserving of thanks. The Campbell Clinic has many unique features that make it such an amazing place to train, but I think the people we get the privilege of learning from and with stand apart the most. From the trauma and pediatric staff who see us through the busy summer nights on call to the joints staff who helped guide me on my chosen career path, I’m incredibly grateful for everyone here.

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Parker P. Duncan, MD1 Clayton C. Bettin, MD1 James T. Reagan, MD2 Denis J. DiAngelo, PhD1 PJ Johnson, BS1 1

University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering Memphis, Tennessee

Tennessee Orthopaedic Clinics Knoxville, Tennessee

A Biomechanical Investigation of Shape Memory Staples Purpose The use of shape memory alloys, specifically nitinol staples, has gained popularity in orthopedic osteosynthesis applications secondary to their inherent simplicity and ease of use as well as their biomechanical compressive ability. The key objectives of this pilot study were to determine the effect on staple leg and bridge length and unicortical versus bicortical fixation on compression, bending stiffness, and torsional rigidity as well as to investigate how staple position and construct configuration would altered these values.

Methods Transverse osteotomies were made using a sagittal saw in identical bicortical sawbones blocks to simulate an osteosynthesis site. This site was fixed with a single staple of varying bridge and leg length with unicortical or bicortical purchase. Tekscan sensors were used to determine compressive force before and after cyclic loading with a four-point bender and biaxial mechanical testing frame to determine bending stiffness and torsional rigidity of each construct. Also tested were anatomic sawbones 1st metatarsal and metacarpal models which were fixed with different staple products and constructs from multiple different manufacturers including: orthogonal and parallel placed two staple constructs, multiple four-leg staples, and a staple plate.

Results This study is currently underway at the UTHSC Orthopedic Biomechanics Lab (DiAngelo). All materials have been obtained, but await final protocol testing prior to formal testing runs.

Conclusions We hypothesize that staples placed with bicortical technique, perpendicular to a potential osteosynthesis site will produce the most compression, bending stiffness, and torsional rigidity. Also, we hypothesize that orthogonally placed staples will produce the most bending stiffness and torsional rigidity among staple constructs with each producing similar compressive ability.

Corresponding Author Clayton C. Bettin, MD 1211 Union Avenue, Suite 500 Memphis, TN 38104 P: 901-759-5422 F: 901-435-5639 cbettin@campbellclinic.com

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PARKER P. DUNCAN, MD Hometown: Johnson City, TN Undergraduate Institution: University of Memphis Medical School: University of Tennessee Health Science Center College of Medicine Dr. Duncan is the oldest of three children. He follows in the footsteps of his father, an orthopaedic spine surgeon, in choosing a career in medicine. Dr. Duncan met his wife August at the University of Memphis, and they were married in 2014. August is an Executive Assistant and recently earned her MHA. When asked why he chose medicine as a career: Growing up, I enjoyed science (biology and chemistry) and enjoyed studying physiology and anatomy. I shadowed my dad and his partners as well for job experience, and seeing the good they could do for their patients through medicine was inspiring to me to pursue a career in it. And why he chose orthopaedics as a specialty: In medical school, my favorite subject was gross anatomy, and I really enjoyed working in the gross lab. I spent four semesters teaching anatomy to other med students as a tutor throughout med school. Orthopaedics is all about anatomy, so naturally it was a fit for me, as I knew I would go into surgery. Plans After Campbell: Dr. Duncan will complete a Foot and Ankle Fellowship at Steadman Clinic in Vail, Colorado. Dr. Duncan adds: Thank you to all of my staff for allowing me to take care of your patients. Thank you, as well, for your time and resources that make our training at Campbell Clinic the best orthopaedic training in the world.

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Charles Fryberger, MD1 Thomas W. Throckmorton, MD1 SaeRam Oh, BS2 Jim Wan, PhD3 Frederick M. Azar, MD1 Tyler J. Brolin, MD1 1

University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering Memphis, Tennessee

University of Tennessee Health Science Center College of Medicine Memphis, Tennessee

University of Tennessee Health Science Center Department of Biostatistics and Epidemiology Research Department Memphis, Tennessee

Single Dose Antibiotic Regimens in Total Shoulder Arthroplasty are Safe in the Outpatient Surgery Setting Background As the healthcare environment continues to evolve, government and regulatory organizations continue to place increasing emphasis on the delivery of safe, high-quality, cost-effective, and efficient healthcare. This has led to a shift toward shorter hospital stays and increased utilization of the outpatient setting for total joint arthroplasty. Shoulder arthroplasty is a valuable procedure in the treatment of end-stage shoulder condition, and the demand for total shoulder arthroplasty (TSA) continues to increase. Recent literature supports outpatient shoulder arthroplasty as a safe alternative to the traditional inpatient setting in appropriately selected patients. One potential drawback to outpatient TSA is the inability to administer 24 hours of intravenous (IV) prophylactic antibiotics to prevent prosthetic joint injection (PJI) as generally, patients are sent home on the same day of surgery.

Methods An institutional database query was used to identify patients who underwent either primary anatomic (aTSA) or reverse total shoulder arthroplasty (rTSA) between the years of 2009 to 2019. Patient candidacy for outpatient TSA was based on each patient’s overall health status, adequacy of social support, and patient preference. A multidisciplinary team comprised of physical therapy, anesthesiology and orthopaedic surgery evaluated the patient preoperatively for candidacy of outpatient TSA. Of the total 1,022 patients identified, 896 received 24hr of perioperative IV antibiotics while in the traditional inpatient setting and 126 patients received a single dose of preoperative IV antibiotics (single) prior to undergoing an outpatient TSA at an ambulatory surgery center. Outcomes measured include overall infection and revision rates. Infection rate was further subcategorized into superficial versus deep infection. Additionally, the timing of infection was subcategorized as early, with the diagnosis made within first three months after the procedure, or late, with the diagnosis made after three months.

Results

Corresponding Author Tyler J. Brolin, MD 1458 W. Poplar Avenue, Suite 100 Collierville, TN 38017 P: 901-759-5522 F: 901-759-3195 tbrolin@campbellclinic.com

The 896 patients who received 24hr of IV antibiotics had an average age of 67.6±9.9 years (age range of 22-90). The average age of the 129 patients who received a single dose of antibiotics was 57.3±7.7 years (range of 33 to 79). The 24hr groups was on average 10.3 years older (p<0.001) than the single dose cohort. The patients in the 24hr group were more likely to undergo rTSA (61.5% vs 29.4%; p=<0.0001), more likely to have diabetes (23.0% vs 10.3%; p=0.001), and hypertension (69.3% vs 47.6%, p=<0.0001). The patients in the single dose group were more likely to have undergone previous non-arthroplasty shoulder surgery on the operative side (23.8% vs 16.5%; p=0.04). Employment status (p=<0.0001) and indication for procedure (p=0.001) varied significantly between the two groups. The patients in single dose group were more likely to be employed and patients in the 24hr group were more likely to be retired (employed single: 73.8% vs 24hr: 24.4%, retired single: 14.3% vs 24hr: 57.1%, unemployed single: 11.9% vs 24hr: 18.5%).

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Average length of follow-up was 23.0±21.0 months for the 24hr group and 17.8±15.6 months for the single dose group. There was no significant difference in overall infection rate (24hr: 1.5% vs single: 1.6%, p=0.71) or revision rate (24hr: 4.6% vs single: 3.2%, p=0.47). Rate of superficial (24hr: 0.2% vs single: 0%) or deep infection (24hr: 1.2%, single: 1.6%, p=0.73), timing of infection (24hr: <3months=0.6%, >3months=0.9% vs single dose: <3months=0%, >3months=1.6%, p=0.53), and revision for infection (24hr: 1.1% vs single: 0.8%) versus non-infectious indications (24hr: 4.6% vs single: 3.2%, p=0.92) were not statistically significant.

Discussion The goal of this study was to compare infection rates of single dose antibiotic prophylaxis in an ambulatory setting versus 24hr

IV antibiotic prophylaxis in an inpatient setting in patients undergoing TSA. To our knowledge, this is the first study to report such antibiotic regimens in TSA. This study is the largest to date comparing single dose and 24hr antibiotic regimens in TSA. Our data revealed no significant difference in infection rates between 24hr IV inpatient antibiotic regimens and single dose ambulatory antibiotic regimens, most notably within the first 3 post-operative months. There were no statistically significant differences in post-operative infection or revision rate seen between the two groups. Ultimately, this study suggests that a single dose of IV antibiotic prophylaxis protocols can be safely used in patients undergoing TSA in an ambulatory center.

CHARLES T. FRYBERGER, III, MD Hometown: Huntsville, Alabama Undergraduate Institution: Auburn University Medical School: University of Alabama School of Medicine Dr. Fryberger is the oldest of three children and is the first in his family to pursue a medical career. Dr. Fryberger met his wife Emily in college, and they were married in 2013. Emily is a full-time mom to their two children two-year-old Colton, and four-month-old Landon. When asked why he chose medicine as a career: There is no better way to combine science, critical thinking and helping people. And why he chose orthopaedics as a specialty: I love that the majority of patients get better and want to get better. I love the mechanical nature of many of the surgeries and the immediate gratification they provide. I can’t imagine doing anything else. Plans After Campbell: Dr. Fryberger will complete a Sports Medicine Fellowship at American Sports Medicine Institute in Birmingham, AL. Dr. Fryberger adds: Thank you to Drs. Azar, Throckmorton, Brolin, Bernholt, Miller, and Phillips for allowing me to learn from you and your patients. Thank you for mentoring me throughout residency.

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Matthew J. Mathew, MD1 William M. Mihalko, MD, PhD1 Tyler Ragsdale, MD2 Zachary Pharr, MD1 Carson Rider, MD1 Patrick C. Toy, MD1 1

University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering Memphis, Tennessee Washington University St. Louis, Missouri

Frequency of and Risk Factors for Postoperative Urinary Retention (POUR) after Total Hip Arthroplasty: Study of 409 Arthroplasties Background Total joint arthroplasty has seen a practice shift in the past few years as more surgeons begin to perform total hip and total knee arthroplasties in the Ambulatory Surgery Center (ASC). One reasons for delay in discharge to home is postoperative urinary retention (POUR). In this study, we defined POUR as the inability to urinate that required either intermittent catheterization or indwelling catheterization following total joint arthroplasty surgery.

Methods and Results Following Institutional Review Board (IRB) approval, a retrospective record review was conducted of 409 total hip arthroplasties (357 patients) done in an ASC with a direct anterior approach. Among these patients, POUR occurred in two patients (0.5%); one patient was treated with a straight catheter inserted in the postoperative anesthesia care unit (PACU) and was able to void with control, and one patient ultimately required an indwelling catheter before discharge. Factors associated with POUR included older age, amount of time spent in the ASC, and intraoperatively albumin volume administered. The two patients who developed POUR had an average body mass index (BMI) of 26.85, average age of 60 years, average albumin volume administered of 750 milliliters, average surgical time of 1.09 hours, average operative time of 1.73 hours, and average time spent in the ASC of 20.04 hours. No significant differences were found in BMI, preoperative hematocrit, estimated blood loss, surgical time, or operating time. No significant associations were found with gender, race, coronary artery disease, hyperlipidemia, congestive heart failure, hypertension, diabetes mellitus, obstructive sleep apnea, presence of a mood disorder, renal disease, alcohol use, current or history of tobacco use, laterality, American Society Anesthesiologist (ASA) score, type of anesthesia, anti-emetics given in the PACU, Bethanechol given in the PACU, or opiates given in the PACU.

Conclusions Corresponding Author

Our results suggest that POUR is an infrequent occurrence and can be safely managed when it does occur.

Patrick C. Toy, MD 1458 W. Poplar Avenue, Suite 100 Collierville, TN 38017 P: 901-759-5537 F: 901-435-5653 ptoy@campbellclinic.com

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MATT “JEJO” MATHEW, MD Hometown: Olathe, Kansas Undergraduate Institution: University of Kansas Medical School: University of Kansas School of Medicine Dr. Mathew is the youngest of three brothers, and is the first in his family to pursue a medical career. When asked why he chose medicine as a career: Despite fulfilling the stereotype of working with computers my entire life, I fell in love with medicine after shadowing a few physicians during high school. Watching them develop lasting relationships with their patients and ultimately seeing the progress patients made during their hospital stay or after surgery was something that I wanted to be a part of. And why he chose orthopaedics as a specialty: I had an ACL reconstruction on my right knee during college (I was, what you would call, an elite athlete back then). After that, I ended up shadowing my orthopaedic surgeon who did my surgery and saw first hand the rapport he developed with patients and loved every minute of doing surgical cases with him. It was after that point that I knew I belonged in the operating room and ultimately loved being involved in the preoperative, intraoperative, and postoperative aspects of patient care. Plans After Campbell: Dr. Mathew will be pursuing an Adult Reconstruction Fellowship at the NorthShore Orthopaedic Institute in Chicago. Dr. Mathew adds: Thank you to all of the Joints faculty (Guyton, Harkess, Ford, Crockarell, and Mihalko) for mentoring me all these years and showing me that joint replacements actively made the biggest difference in patients’ lives. Thank you to all of the Trauma staff at the Med (Weinlein, Rudloff, Beebe, Whittle and Cosgrove) for continuing to support us on the trauma rotation. I have continued to tell residents at other institutions that we have the best trauma experience in the country, and my experience has been well representative of that. Lastly, a big thank you to “The Oﬃce” downtown for sponsoring my weekends during the five years of residency.

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S. Gray McClatchy, MD1 Griﬃn M. Heise, BS2 William M. Mihalko, MD, PhD1 Frederick M. Azar, MD1 Richard A. Smith, PhD1 Dexter H. Witte, MD3 John G. Stanﬁll, MD3 Thomas W. Throckmorton, MD1 Tyler J. Brolin, MD1 1

University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering Memphis, Tennessee

University of Tennessee Health Science Center College of Medicine Memphis, Tennessee

Mid-South Imaging and Therapeutics Memphis, Tennessee

Effect of Deltoid Volume on Range of Motion and Patient-Reported Outcomes Following Reverse Total Shoulder Arthroplasty in Rotator Cuff-Intact and Rotator Cuff-Deficient Conditions Background Deltoid muscle function is paramount to the success of reverse total shoulder arthroplasty (RTSA). The purpose of this study was to investigate the role of deltoid volume on shoulder range of motion and patient-reported outcomes following RTSA in rotator cuff-intact and rotator cuff-deficient conditions.

Methods Retrospective review of records identified 107 patients who met inclusion criteria. The rotator cuff (RC) integrity was evaluated by two musculoskeletal-trained radiologists. Volumetric deltoid measurements were calculated from preoperative CT or MRI scans. Satisfactory outcomes were defined as forward elevation (FE) of at least 135 degrees, external rotation of at least 35 degrees, and scores of at least 70 on the American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numerical Evaluation (SANE) patient-reported outcomes.

Results Mean total deltoid muscle volume was significantly higher in patients with satisfactory FE (57.8 cm³ ± 18.1 cm³) versus unsatisfactory FE (48.6 cm³ ± 19.5 cm³) (p = 0.013). When separated by RC integrity, total deltoid volume was significantly higher (p = 0.030) in patients who achieved satisfactory FE in the RC-deficient group but not the RC-intact group (p = 0.533).

Discussion Preoperative deltoid volume directly correlated with achieving satisfactory FE after RTSA in RC-deficient conditions and may be one factor in determining the ability to achieve satisfactory outcomes in the RC-deficient patient. Corresponding Author Tyler J. Brolin, MD 1458 W. Poplar Avenue, Suite 100 Collierville, TN 38017 P: 901-759-5522 F: 901-435-5713 tbrolin@campbellclinic.com

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S. GRAY MCCLATCHY, MD Hometown: Memphis, Tennessee Undergraduate Institution: Mississippi State University Medical School: University of Arkansas for Medical Sciences Dr. McClatchy is the middle child, with an older and a younger sister. He is the first in his family to choose medicine as a career. Dr. McClatchy and his wife Katie were introduced by a friend while he was in med school and she was about to begin pharmacy school, and they were married in 2018. Katie is a pharmacist at Sam’s Club. When asked why he chose medicine as a career: I’ve always loved science and engineering and understanding how and why different parts work together. Medicine combined those interests with personal interaction and the ability to impact the lives of others in a meaningful way on a daily basis. And why he chose orthopaedics as a specialty: I like that orthopaedics generally involves specific problems with abstract solutions. It offers the ability to greatly improve the quality of life for a wide variety of patients by restoring function and relieving pain. Plans After Campbell: Dr. McClatchy will complete a Sports Medicine Fellowship at Mississippi Sports Medicine and Orthopaedic Center in Jackson, Mississippi. Dr. McClatchy adds: I’m grateful for the opportunity to train at Campbell Clinic for the past five years. It has been an honor to learn from such giants in the field. They set a great example and have taught us much more than just orthopaedics. Their patience and commitment to teaching and developing residents into better people and surgeons is what makes Campbell Clinic such a special place. Finally, I want to thank my fellow residents for their friendship and support throughout residency. I feel honored to have trained alongside the best.

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Trenton T. Stevens, MD1 Jacob T. Hartline, MD2 Tyler J. Brolin, MD1 David L. Bernholt, MD1 Daniel T. Dibaba, PhD MPH3 Frederick M. Azar, MD1 Thomas W. Throckmorton, MD1 1

University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering Memphis, Tennessee

University of Maryland, College of Medicine Orthopaedic Department Baltimore, Maryland

Tennessee Clinical and Transitional Science Institute University of Tennessee Health Science Center Memphis, Tennessee

The Importance of Surgeon Judgment in Obtaining Early Magnetic Resonance Imaging to Prevent Delays in Care for Acute Subacromial Injury INTRODUCTION Shoulder pain accounts for up to one-third of orthopaedic complaints in the United States. Payors often dictate a minimum duration of conservative treatment for patients with shoulder pain emanating from the subacromial space before authorizing advanced imaging studies. This study evaluated the role of initial assessment by an orthopaedic surgeon to identify potential surgical lesions benefitting from early imaging in the setting of acute subacromial injury. We compared 1) the incidence of full and partial-thickness rotator cuff tears between patients undergoing acute magnetic resonance imaging (MRI) and those initially managed conservatively, and 2) the time between initial treatment and surgery for those with surgical lesions in each group.

METHODS A retrospective analysis identified patients between the age of 18 and 65 who presented to an outpatient orthopaedic clinic between 2015 and 2018 with the initial diagnosis of subacromial injury that began within 3 months from presentation. These initial diagnoses included partial or full-thickness rotator cuff tear, subacromial bursitis, rotator cuff strain, and subacromial impingement. All patients were initially evaluated by a board certified orthopaedic surgeon. Patients with fractures, those receiving prior physical therapy, MRI, other advanced imaging, or other targeted treatments such as corticosteroid and/or biologic injections were excluded. The study group included patients who had an acute MRI ordered at their initial visit after being judged by the treating physician as having a high likelihood of a surgical lesion. The control group of remaining patients were treated conservatively without obtaining an acute MRI. Data abstracted from the electronic medical record included an MRI order at initial or subsequent visits, duration of time to MRI completion, surgical intervention, and duration from initial visit to surgery. When obtained, MRIs were reviewed to determine the presence of full-thickness or high-grade partial thickness rotator cuff tears. Dependent sample t-test compared the patient characteristics between the control group and the acute MRI group. Analysis of variance and simple and multivariate linear regression were used to evaluate the amount of time to MRI and to surgery based on injury type.

RESULTS Corresponding Author Thomas W. Throckmorton, MD 1400 S. Germantown Road Germantown, TN 38138 P: 901-759-3110 F: 901-759-3195 tthrockmorton@campbellclinic.com

A total of 367 patients were included in the retrospective analysis; 298 had initial conservative treatment, while 69 had an MRI ordered at their initial visit. In the MRI-first group, 32 patients (46.4%) had surgery at an average time of 85 days from presentation compared to 38 patients (12.8%) in the conservatively treated group at an average time of 140 days from presentation (p=0.019). The average time to scan for the MRI-first group was 20 days compared to 89 days in the conservatively treated cohort (p<0.001). After a trial of conservative therapy, 84 of the 298 (28.1%) patients had an MRI subsequently completed. Review of MRI scans revealed that 41/69 (59.4%) patients who had an MRI ordered at the initial visit had a full-thickness rotator cuff tear and 8/69 (11.6%) had a partial-thickness tear. Of the patients in whom initial conservative treatment failed,

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33/84 scans (39.3%) revealed a full-thickness tear and 17/84 (20.2%) a partial thickness tear. Chi square analysis demonstrated a significant difference in the presence of a full-thickness rotator cuff tear with MRI ordered at first visit, 59.4%, versus diagnosis of full-thickness tear after trial of conservative treatment, 39.3% (p=0.020).

DISCUSSION A minimal period of non-operative treatment often is dictated by payors for patients presenting with suspected acute subacromial injury; however, these data suggest that acute MRI is warranted in patients who are judged by a board-certified orthopaedic

surgeon to have a potential surgical lesion. Specifically, almost 60% of patients who had acute MRIs had a full-thickness rotator cuff tear, significantly more than patients treated non-operatively upon initial evaluation. Further, patients who first have a trial of conservative treatment for suspected acute subacromial injury experience a significant delay both to MRI and surgical intervention, if indicated. Because delays in surgical treatment of rotator cuff tears have been shown to have compromised functional outcomes, we conclude surgeon judgment is an important factor in the decision to obtain MRI in the setting of acute subacromial injury to prevent these delays in care.

TRENTON T. STEVENS, MD Hometown: Johnson City, Tennessee Undergraduate Institution: University of North Carolina - Chapel Hill Medical School: University of Tennessee Health Science Center College of Medicine Dr. Stevens is the middle child, with an older sister and a younger brother. He is the first in his family to pursue a career in medicine. Dr. Stevens met his wife Jeanne-Marie, a CRNA, at college in Chapel Hill. They were married in 2019, and their daughter Eleanor Louise will be one year old in June. When asked why he chose medicine as a career: I pursued a career in medicine for reasons too many to list, but primarily for the challenge of staying ahead in a continually evolving complex field, the ability to take care of patients both healthy and severely traumatized, and the opportunity to use my education and training to positively impact patients on a daily basis. And why he chose orthopaedics as a specialty: I chose orthopaedics after my rotation in the emergency department when I witnessed trauma admits with severe injuries and the amount of planning, expertise, passion and commitment by the trauma team and staff to successfully care for and treat these patients. Plans After Campbell: Dr. Stevens will complete an Orthopaedic Trauma Fellowship at Hospital for Special Surgery in New York. Dr. Stevens adds: I would like to thank all of the Campbell Clinic faculty and staff for their dedication and commitment to resident training and education. I am exceptionally thankful for the mentorship of Dr. Rudloff, Dr. Weinlein and Dr. Beebe. I aspire to carry on the same passion they have for orthopaedic trauma and education throughout my own career. I am beyond grateful for the companionship and support of my fellow residents, before and after me, who push me to be a better person and physician. CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

Carson D. Strickland, MD1 Robert Neel, BS2 Evan Porter, MD1 Benjamin W. Sheﬀer, MD1 Derek M. Kelly, MD1 1

University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering Memphis, Tennessee

2 University of Tennessee Health Science Center College of Medicine Memphis, Tennessee

Closed Reductions of Pediatric Wrist, Forearm, and Elbow Fractures in a Free-Standing Ambulatory Surgery Center is a Safe and Cost-eﬀective Alternative to the Emergency Department Background Pediatric extremity fractures and dislocations have historically been treated on the day of presentation to the pediatric emergency department (PED). As the use of ambulatory surgery centers (ASCs) has increased, so has delayed treatment of these injuries in an outpatient setting.

Objectives The goal of this study was to examine clinical and radiographic outcomes, as well as length of stay, in the treatment of pediatric upper extremity fractures below the elbow in the pediatric ED, hospital ASC (hASC), and a free-standing ASC (fASC).

Methods A retrospective chart review identified pediatric patients who had closed manipulation and immobilization of upper extremity injuries distal to the elbow from October 2013, to December 2018. We specifically looked at 3 venues of care: a level 1 PED, a hASC, and a fASC. There were 95 and 99 patients in the hASC and fASC cohorts, respectively. To match these numbers, the first 99 patients in the PED group were considered. The primary outcomes were length of visit, length of sedation, time from admission to procedure, time from initial presentation to reduction in the outpatient groups, post-procedure radiographic parameters of angulation and change in angulation, procedural complications, need for remanipulation, and need for conversion to open treatment.

Results

Corresponding Author Derek M. Kelly, MD 1458 W. Poplar Avenue, Suite 100 Collierville, TN 38017 P: 901-759-5552 F; 901-435-5654 dkelly@campbellclinic.com

There was a significant difference in the length of visit between all groups, with the fASC being about 80 and 73 minutes shorter compared to the PED and hASC groups, respectively (p<0.05). There was no significant difference amongst the groups for length of sedation. On average, patients waited approximately 193 minutes prior to reduction in the PED compared to 83 minutes at the fASC and 143 minutes at the hASC, which was significant (p<0.05). Pre- and post- radiographic fracture angulation and displacement were similar for the groups. There were no procedural complications for any of the groups, and there was no significant difference in the rates of remanipulation and conversion to open treatment.

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CARSON D. STRICKLAND, MD Hometown: Columbus, Georgia Undergraduate Institution: University of Georgia Medical School: Mercer University School of Medicine Dr. Strickland is the older of two children, and his sibling Chandler is a NICU nurse in Athens, Georgia. Dr. Strickland is the first MD in his family. Dr. Strickland and his wife Klaire became best friends after college and were married in 2013. Klaire is an insurance claims analyst who works remotely from home while also taking care of their two children - five-year-old Mary Jennings, and twoand-a-half-year-old Collins. When asked why he chose medicine as a career: Growing up, I was interested in science and athletics. Though I enjoyed playing sports, I realized pretty early on that professional athletics weren't in the cards for me. The opportunity to take care of athletes and sports injuries seemed like a nice consolation to playing in the big leagues, and this is what initially attracted me to medicine, and especially, orthopaedics. And why he chose orthopaedics as a specialty: Ultimately, I was blessed to have many mentors who helped me learn that there was much more to orthopaedics than being on the sidelines on Friday night. We are able to provide pain relief, deformity correction, and improvement in functioning in a generally quick manner. There is nothing more rewarding than seeing someone you’ve treated return to an active lifestyle or be able to walk with a plantigrade foot. Plans After Campbell: Dr. Strickland will complete a Foot and Ankle Fellowship at OrthoCarolina in Charlotte, North Carolina, and will then join the staff at Mid-Tennessee Bone and Joint Clinic in Columbia, Tennessee. Dr. Strickland adds: To the Campbell Clinic staff: I sincerely thank you for your patience, wisdom, and teaching that you have imparted on me. I have learned so much about orthopaedics and how to run a private practice from each of you, but also about life and the art of medicine. It has been an honor to train here under your guidance, and I am forever grateful for my time here. I would like to thank the trauma staff for teaching me how to operate and take care of the vast majority of traumatic orthopaedic injuries I will encounter in practice. Lastly, I would like to give a special thanks to the foot and ankle staff for your mentorship and helping me become a foot and ankle surgeon. I have learned so many different techniques and philosophies from each of you, and my practice will bear aspects from each of yours. I am excited for next year, but I feel like I have already had the best foot and ankle training in the country. To the residents: It has been a pleasure working with of all you, and I cherish the friendships and memories we have made over the past five years. Best of luck to everyone still going through the process. It gets better. To my parents: Thank you for your unwavering support and always putting your children before yourselves. I would not be here today without all the sacrifices you have made for me. To my wife, Klaire: You are the glue that holds our family together, and you have been the real MVP during this long and arduous process. You deserve just as much credit as I do for completing residency. Thank you for your love and support in helping me realize my goals. I love you. CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

2020 PUBLICATIONS Despite the challenges encountered in 2020, the commitment of Campbell Clinic and Campbell Foundation to improving patient outcomes and quality of life through evidence-based clinical research remains strong. There are over 160 active research projects being conducted by our Surgeons, Residents, and Fellows in collaboration with Foundation staff. The following is a list of publications from our researchers in 2020.

FOOT AND ANKLE • Rider CM, Olinger CR, Szatkowski JP, Richardson DR. "LockedLateral" Calcaneal Fracture-Dislocation Treated with Primary Subtalar Fusion: A Case Report. JBJS Case Connect. 2020 JanMar;10(1):30467. PMID: 32044781 • Ruta D, Ellis RT, Grear BJ, Richardson DR, Murphy GA. Headless Compression Screw Fixation of Jones Fractures: A Clinical and Radiographic Comparison Study. Curr Orthop Prac; 31(5), Sept/Oct 2020, pp. 429-436 • Stevens TT, Hartline JT, Inojo T, Grear BJ, Richardson DR, Murphy GA, Bettin CC. Race and Insurance Status Predict Which Patients Receive Orthopaedic Surgeon-prescribed Foot Orthotics. Publication pending-Foot & Ankle International • Ruta DJ, Parker D. Jones Fracture Management in Athletes. Orthop Clin North Am. 2020 Oct;51(4):541-553. doi: 10.1016/j. ocl.2020.06.010. Epub 2020 Aug 12. PMID: 32950224

GENERAL • Chen AF, Dulai SK, Grewal R, Kelly DM, Lee M, Leucht P, Mir H. The 2019 American-British-Canadian (ABC) Traveling Fellowship. J Bone Joint Surg Am. 2020 Jan2;102(1):e1. doi:10.2106/ JBJS.19,01000. No abstract available. PMID: 31596817 • Kelly DM, Sawyer JR, Lane JC, Gilber Sr, Frick S. From the Ground Up: Building a Pediatric Orthopedic Clinical Research Program. J of the Ped Orthop Soc of N Am. Nov 2020;2(3) • Li J, Wang L, Guo S, Xie N, Yao L, Cao Y, Day SW, Howard SC, Graff JC, Gu T, Ji J, Gu W, Sun D. The Data Set for Patient Information Based Algorithm to Predict Mortality Cause by COVID-19. Data Brief. 2020 Apr 24:105619. doi: 10.1016/j. dib.2020.105619. Online ahead of print. PMID: 32337324 • Lichstein PM, He JK, Estok D, Prather JC, Dyer GS, Ponce BA, Throckmorton TW (Collaborative Orthopaedic Educational Research Group). What Is the Prevalence of Burnout, Depression, and Substance Use Among Orthopaedic Surgery Residents and What Are the Risk Factors? A Collaborative Orthopaedic Educational Research Group Survey Study. Clin Orthop Relat Res. 22 May 2020. 478:1709-1718

• Martin BD, Kelly DM, Nolan VG, Matthews A, Flournory J, Kim H. Does Participation in a Multicenter Study Group Affect Physician Treatment Preference? A Survey of Participants. Curr Orthop Prac. 31(6):565-570. November/December 2020. doi: 10.1097/BCO.0000000000000937 • Mosher ZA, Mathew MJ, Mihalko WM. Prevention and Treatment of Orthopaedic Infections: Present and Future. Publication pending-ASTM STP1630 • Wang L, Li J, Guo S, Xie N, Yao L, Cao Y, Day SW, Howard SC, Graff JC, Gu T, Ji J, Gu W, Sun D. Real-time Estimation and Prediction of Mortality Caused By COVID-19 with Patient Information Based Algorithm. Sci Total Environ. 2020 Jul 20;727:138394. doi: 10.1016/j.scitotenv.2020.138394. Epub 2020 Apr 8. PMID: 32334207 • Wright RW, Armstrong AD, Azar FM, Bendnar MS, Carpenter JE, Evans JB, Flynn JM, Garvin KL, Jacobs JJ, Kang JD, Luncy DW, Menico GA, Murray PM, Nelson CL, Peabody T, Porter SE, Roberson JR, Saltzman CL, Sebastianelli WJ, Taitsman LA, Van Heest AE, Martin DF. The American Board of Orthopaedic Surgery Response to COVID-19. J Am Acad Orthop Surg. 2020 Jun1;28(11):e465-3468. doi: 10.5435/JAAOS-D-20-00392. PMID: 32324709

HAND • Chambers J, Pate T, Calandruccio JH. Office-Based Percutaneous Fasciotomy for Dupuytren Contracture. Orthop Clin North Am. 2020 Jul;51(3):369-372. doi:10.1016/j.ocl.2020.02.008. Epub 2020 Apr 16. PMID: 32498955 • Fournier MN, Cline JT, Seal A, Smith RA, Throckmorton TW, Mauck BM. Operative Distal Radial Fractures: A Comparison of Time to Surgery After Evaluation by Surgical and Nonsurgical Providers in a Walk-in Clinic. Orthop Clin North Am. 2020 Apr;51(2);235-239. doi: 10.1016/j.ocl.2019.11.006. PMID: 32138861 • Mauck BM, Kelly DM, Sheffer BW, Rambo A, Calandruccio JH. Gymnast's Wrist. Orthop Cln North Am. 2020 Oct;51(4):394497. doi: 10.1016/j.ocl.2020.06.012. Epub 2020 Aug 13. PMID: 32950218 • Phillips SG. An Evidence-Based Review of Overuse Wrist Injuries in Athletes. Orthop Clin North Am. 2020 Oct;51(4):499-509. doi: 10.1016/j.ocl.2020.06.007. PMID 32950219. Review

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

JOINT REPLACEMENT • Arnholt BC, Lowell JA, Perkins MR, Mihalko WM, Kurtz SM. Postmortem Retrieval Analysis of Metallosis and Periprosthetic Tissue Metal Concentrations in Total Knee Arthroplasty. J Arthroplasty. 2020 Feb;35(2):569-578. PMID: 31699531 • Calkins TE, Culvern C, Nam D, Gerlinger TL, Levine BR, Sporer SM, Della Valle CJ. Dilute Betadine Lavage Reduces the Risk of Acute Postoperative Periprosthetic Joint Infection in Aseptic Revision Total Knee and Hip Arthroplasty: A Randomized Controlled Trial. J Arthroplasty. 2020 Feb;35(2): 538-543. PMID: 31575448 • Calkins TE, Hannon CP, Fillingham YA, Culver CC, Berger Ra, Della Valle CJ. Fixed-bearing Medial Unicompartmental Knee Arthroplasty in Patients Younger Than 55 Years of Age at 4-19 Years of Follow-up: A Concise Follow-up of a Previous Report. J Arthroplasty. 2020 Sept 28;S0883-5403(20)31053-6. doi: 10.1016/j.arth.2020.09.042. PMID: 33051122 • Calkins TE, Hannon CP, Nam D, Gerlinger TL, Sporer SM, Della Valle CJ. Who is Prescribing Opioids Preoperatively? A Survey of New Patients Presenting to Tertiary Care Adult Reconstruction Clinics. J Am Acad Orthop Surg. 2020 Apr 1;38(7):301-307. doi: 10.5435/JAAOS-D-19-00602. PMID: 31977344 • Cavanaugh AM, Rauh MJ, Thompson CA, Alcaraz J, Mihalko WM, Bird CD, Corbie-Smith G, Rosal MC, Li W Shadyab AH, Gilmer T, LaCroix AZ. Racial and Ethnic Disparities in Physical Function Before and After Total Knee Arthroplasty in Women in the United States. JAMA Netw Open. 2020 May1;3(5):e204937. doi: 10.1001/jamanetworkopen.2020.4937. PMID: 32412635 • Chambers S, Kerkhof A, Tidwell L, Smith R, Mihalko WM. Topical Tranexamic Acid is Effective in Cementless Total Knee Arthroplasty. Orthop Clin North Am. 2020 Jan;51(1):7-11. doi: 10.1016/j.ocl.2019.08.002. PMID: 31739881 • Crockarell JR, Harkess JW, Guyton JL, Ford MC, Kerkhof A, Mihalko WM. Cryoneurolysis Prior to Total Knee Arthroplasty in Patients With Severe Osteoarthritis For Reduction of Postoperative Pain and Opioid Use in a Single-Center Randomized Controlled Trial. J Arthroplasty. 2020 Nov 14; S0883-5403(20)31204-3. doi: 10.1016/j.arth.2020.22.013. PMID: 33279353-Journal of Arthroplasty • Ford MF, Walters JD, Mulligan RP, Dabov GD, Mihalko WM, Mascioli AA, Throckmorton TW. Safety and Cost-effectiveness of Outpatient Unicompartmental Knee Arthroplasty in the Ambulatory Surgery Center: A Matched Cohort Study. Orthop Clin North Am. 2020 Jan; 51(1):1-5. doi: 10.1016/j.ocl.2019.08.01 Epub 2019 Oct 21. Review. PMID: 31739873 • Frisch NB, Keating TC, Calkins TE, Culvern CN, Della Valle CJ. Conversion Total Knee Arthroplasty: Prior Fracture or Osteotomy Around the Knee Leads to Increased Resource Utilization. J Arthroplasty. 2020 Dec;35(12):3563-3568. doi: 10.1016/j. arth.2020.06.050. Epub 2020 Jun 23. PMID: 32665156

• Grupp TM, Schilling C, Schwiesau J, Pfaff A, Altermann B, Mihalko WM. Tibial Implant Fixation Behavior in Total Knee Arthroplasty - A Study with Five Different Bone Cements. J Arthroplasty. 2020 Feb;35(2):579-587. PMID: 31653466 • Heise G, Black C, Smith RA, Morrow B, Mihalko WM. In Vitro Effects of Macrophages on Orthopaedic Implant Alloys and Local Release of Metal Ions. Bone Joint J. 2020 Jul;102-B(7_ Supple_B):116-121. doi: 10.1302/0301-62OX.102B7.BJJ-2019-1556. R1. PMID: 32600200 • Mascioli AA, Shaw ML, Boykin S, Mahadeva P, Wilder JH, Bell JW, Dabov GD, Toy PC. Total Knee Arthroplasty in Freestanding Ambulatory Surgery Centers: 5-Year Retrospective Chart Review of 90-Day Postsurgical Outcomes and Health Care Resource Utilization. J Am Acad Orthop Surg. 2021 Jan 13. doi: 10.5435/ JAAOS-D-20-00934. Online ahead of print. PMID: 33443387 • McClatchy SG, Rider CM, Mihalko WM, Pharr ZK, Toy PC. Defining Outpatient Hip and Knee Arthroplasty: A Systematic Review. J Am Acad Orthop Surg. 2020 Sep 9. doi: 10.5435/ JAAOS-D-19-00636. Online ahead of print. PMID: 32925385 • Miller KC, Morrow BR, Sorrels JH, Arnholt CM, Mihalko WM. Electrocautery-Induced Damage of Total Knee Implants: Not All Bearing Surfaces are the Same. J of Arthroplasty. Sept. 26, 2020. https://doi.org/10.1016/j.arth.2020.09.044 • Mihalko WM, Haider H, Kurtz S, Marcolongo M, Urish K. New Materials for Hip and Knee Joint Replacement: What's Hip and What's in Kneed? J Orthop Res. 2020 Jul;38(7):1436-1444. doi: 10.1002/jor.24750. Epub 2020 May 28. PMID: 32437026 • Mihalko WM, Urish K. Optimal Designs and Surgical Technique for Hip and Knee Joint Replacement: The Best is Yet to Come! J Orthop Res. 2020 Oct 1. doi: 10.1002/jor.24873. Online ahead of print. PMID: 33002224 • Parvizi J, Gehrke T, Krueger CA, Chisari E, Citak M, Van Onsem S, Walter WL, International Consensus Group and Research Committee of AAHKS (Mihalko WM). Current Concepts Review Resuming Elective Orthopaedic Surgery During the COVID-19 Pandemic. JBJS. May 2020. doi: 10.2106/JBJS.20.00844 • Perkins MR, Arnholt Cm, MacDonald DW, Kurtz SM, Mihalko WM. Retrieval Analysis of Cruciate-Retaining and PosteriorStabilized Total Knee Arthroplasty and Correlations to Laxity and Wear. J Arthroplasty. 2020 Aug;35(8):2249-2253. doi: 10.1016/j. arth.2020.03.027. Epub 2020 Mar 21. PMID: 32279944 • Pharr ZK, Rider C, Toy PC. Outpatient Hip Safety in an Ambulatory Surgery Center is Independent of Approach. J Arthroplasty. 2020 Jul 31:S0883-5403(2)30861-5. doi: 10.1016/j. arth.2020.07.068. PMID: 32826145 • Richey PA, Johnson KC, Neiber RH, Bahnson JL, Singhal K, Coday M, Thomas F, Lew CE, Mihalko WM, Look AHEAD Research Group. Association of the Intensive Lifestyle Intervention with Total Knee Replacement in the Look AHEAD

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

HYDROLYZED COLLAGEN IN THE OPERATING ROOM CellerateRX® Surgical aids in the management of surgical wounds. When applied to a surgical wound, the hydrolyzed collagen is ready to aid in the natural wound healing process.

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PEDIATRICS • Brown DW, Iorio TJ, Mosher ZA, Beaty, JH, Warner WC, Sawyer JR, Spence DD, Sheffer BW, Kelly DM. Intra-observer and Interobserver Reliability of the Peritubercle Lucency Sign in Slipped Capital Femoral Epiphysis. 2020 Dec15; Publish ahead of print. doi: 10.1097/BPO.0000000000001733. PMID: 33332871 • Ellis HB, Li Y, Bae DS, Kalish LA, Wilson PL, Pennock AT, Nepple JJ, Willimon Sc, Spence DD, Pandya NK; FACTS Study Group, Kocher MS, Edmonds EW, Farley FA, Gordon JE, Kelly DM, Busch MT, Sabatini CS, Heyword BE. Descriptive Epidemiology of Adolescent Clavicle Fractures: Results from the FACTS (Function after Adolescent Clavicle Trauma and Surgery) Prospective, Multicenter Cohort Study. Orthop J Sports Med. 2020 May 29;8(5):2325967120921344 • Fournier MN, Neel R, Spence DD, Sawyer JR, Sheffer BW, Kelly DM. Initial Evaluation by a Non-Surgeon Provider Does Not Delay the Surgical Care of Pediatric Forearm and Elbow Trauma in a Walk-In Orthopaedic Clinic. Cureus 12(5):e8139. doi:10.7759/ cureus.8139. PMID: 32550059 • Fournier MN, Sinclair MR, Zheng ET, Spiegel DA, Johnson AL, Shaw AS, Riccio AI, Elliott ME, Bae DS, Sawyer JR. The Frequency of Mediastinal Injury in Acute Posterior Sternoclavicular Dislocations: A Multicenter Study. J Pediatr Orthop. Nov/Dec 2020;40(10):e927-e931. doi: 10.1097/BPO.0000000000001649. PMID: 32804865 • Jasty NM, FACTS Study Group (Spence DD), Heyworth BE. Evaluation and Management of Mid-Shaft Clavicle Fractures in Adolescents. JPOSNA, Nov. 2020;2(3):1-13 • Koehler RJ, Shore BJ, Hedequest D, Heyworth BE, May C, Miller PE, Rademacher ES, Sanborn RM, Murphy JS, Roseman A, Stoneback JW, Trizno AA, Goldstein RY, Harris L, Nielsen E, Talwar D, Denning JR, Saaed N, Kutz B, Laine JC, Naas M, Truong WH, Rotando M, Spence DD, Brighton BK, Churchill C, Janicki JA, King K, Wild J, Beebe AC, Crouse S, Rough T, Rowan M, Singh S, Davis-Juarez A, Gould A, Hughes O, Rickert KD, Upasani VV, Blumberg TJ, Bompadre V, Lindberg AW, Miller ML, Hill JF, Peoples H, Rosenfeld SB, Turner R, Copley LA, Lindsay EA, Ramo BA, Tareen N, Winberly RL, Li GY, Sessel J, Johnson ME, Johnson S, Moore-Lotridge SN, Shelton J, Baldwin KD, Schoenecker JG. Children’s Orthopaedic Trauma and Infection Consortium for Evidence Based Study (CORTICES) Group. Defining the volume of consultations for musculoskeletal infection encountered by pediatric orthopaedic services in the United States. PLoS One. 2020 Jun 4;15(6):e0234055. doi: 10.1371/journal.pone.0234055. Erratum in: PLoS One. 2020 Aug 13;15(8):e0237942. PMID: 32497101

• Laine JC, Novotny SA, Tis JE, Sankar WN, Martin BD, Kelly DM, Gilbert SR, Shah H, Joseph B, Kim HKW; International Perthes Study Group. Demographics and Clinical Presentation of EarlyStage Legg-Calve-Perthes Disease: A Prospective, Multicenter, International Study. J Am Acad Ortho Surg. 2020 Aug 27. doi: 10.5435/JAAOS-D-19-00379. PMID: 32868700 • Matsumoto H, Hyman JE, Shah HH, Sankar WN, Laine JC, Mehlman CT, Schrader T, Kelly DM, Rosenfeld SB, Janicki JA, Thacker MM, Trupia E, Mcquire MF, Kim HKW; International Perthes Study Group. Validation of Pediatric Self-Report PatientReported Outcomes Measurement Information System (PROMIS) Measures in Different Stages of Legg-Calve-Perthes Disease. J Pediatr Orthop. 2020 May/Jun;40(5):235-249. doi: 10.1097/ BPO.0000000000001423. PMID: 31318732 • Mo AZ, Miller PE, Glotzbecker MP, Li Y, Fletcher ND, Upasani W, Riccio Al, Kresko MT, Krengel WF, Spence DD, Garg S, Hedequist DJ. The Reliability of AOSpine Thoracolumbar Classification System in Children: Results of a Multicenter Study. J Pediatr Orthop. 2020 May/Jun;40(5):e352-e356. doi: 10.1097/ BPO.0000000000001521. PMID: 32032218 • Murphy RF, Barﬁeld WR, Emans JB, Akbarnia B, Thompson G, Sponseller P, Skaggs D, Marks D, Smith JR, Flynn J, Presson A, Sawyer JR, Johnston C. Minimum 5-Year Follow-up on Graduates of Growing Spine Surgery for Early Onset Scoliosis. J Pediatr Orthop. 2020 Nov/Dec 2020;40(10):e942-e946. doi: 10.1097/ BPO.0000000000001646. PMID: 32773654 • Murphy RF, Barﬁeld WR, St. Hilaire T, Smith JT, Emans JB, Samdani A, Garg S, Sawyer JR, Pahys JM; Children's Spine Study Group. Prospectively Collected Surgeon Indications for Discontinuation of a Lengthening Program for Early-onset Scoliosis. Spine Deform. 2020 Feb;8(1):129-133. Epub 2020 Jan 24. PMID: 31981149 • Murphy RF, Williams D, Hogue GD, Spence DD, Epps H, Chambers HG, Shore BJ, Prophylaxis for Pediatric Venous Thromboembolism: Current Status and Changes Across Pediatric Orthopaedic Society of North America from 2011. J Am Acad Orthop Surg. 2020 May 1;28(9):388-394. doi: 10.5435/ JAAOS-D-D-19-00578. PMID: 32011545 • Nelson KL, Locke LL, Rhodes LM, Mabry WA, Sawyer JR, Warner WC, Jones T, Spence DD, Kelly DM. Evaluation of Outcomes Before and After Implementation of a Standardized Postoperative Care Pathway in Pediatric Posterior Spinal Fusion Patients. Orthopaedic Nursing, 2020 Jul/Aug;39(4):257-263. doi:10.1097/NOR.0000000000000678. PMID: 32701784 • Richardson SM, Dove JH, Beaty JH, Sheffer BW, Spence DD, Warner WC Jr, Sawyer JR, Kelly DM. Flexible Intramedullary Nailing of Femoral Shaft Fractures: Closed Versus Open Reduction. J Pediatr Orthop B. Sept 2020, Vol 29, No 5, P472-477. doi: 10.1097/BPB.0000000000000685. PMID: 31651747

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

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• Roye BD, Marciano G, Matsumoto H, Fields MW, Campbell M, White KK, Sawyer JR, Smith JT, Luhmann S, Sturm P, Sponseller P, Vitale MG, Growing Spine Study Group, Children's Spine Study Group. Is Rod Diameter Associated with the Rate of Rod Fracture I Patients Treated With Magnetically Controlled Growing Rods? Spine Deform. 2020 Dec;8(6):13751384. doi: 10.1007/s43390-020-00161-x. Epub 2020 Jun 19. PMID: 32562099 • Serrano R, Mir HR, Sagi HC, Horwitz DS, Ketz JP, Kistler BJ, Quade JH, Beebe MJ, Au BK, Sanders R, Shah AR. Modern Results of Functional Bracing of Humeral Shaft Fractures: A Multicenter Retrospective Analysis. J Orthop Trauma. 2020 Apr;34(4):206-209. doi: 10.1097/BOT.0000000000001666. PMID: 31923040 • Sheffer BW, Kelly DM, Spence DD, Walker KL, Westbrooks TJ, Palm PH, Nolan VG, Sawyer JR. Can Pediatric Orthopaedic Surgery Be Done Safety In a Freestanding Ambulatory Surgery Center? Review of 3780 Cases. J Pediatr Orthop. 2020 Aug 25. doi: 10.1097/BPO.0000000000001670. PMID: 32852367 • Sheffer BW, Villarreal ED, Ochsner MG 3rd, Sawyer JR, Spence DD, Kelly DM. Concurrent Ipsilateral Tibial Shaft and Distal Tibial Fractures in Pediatric Patients: Risk Factors, Frequency, and Risk of Missed Diagnosis. J Pediatr Orthop. 2020 Jan;40(1):e1-e5. doi:10.1097/BPO/.0000000000001384. PMID: 30969196 • Stewart RJ, Strickland CD, Sawyer JR, Kumar P, Gungor B, Longjohn M, Kelly DM, Kink RJ. Hunger Games: Impact of Fasting Guidelines for Orthopaedic Procedural Sedation in the Pediatric Emergency Department. 2020 Dec 12:S07364679(20)31086-6.doi: 10.1016/j.jemermed.2020.10.038. PMID: 33323292 • Villarreal ED, Wrenn JO, Sheffer BW, Sawyer JR, Spence DD, Kelly DM. Do Patient-specific of Fracture-specific Factors Predict the Development of Acute Compartment Syndrome After Pediatric Tibial Shaft Fractures? J Pediatr Orthop. 2020 Mar;40(3):e193-e197. doi: 10.1097/BPO.0000000000001410. [Epub ahead of print]. PMID: 31157755 • Wu JC, Daley E, Koueiter DM, Lilly R, Vara AD, Settecerri JJ. Operating Room Intervention Rates After Orthopaedic Residentreduced Pediatric Both-Bone Forearm Fractures Relative to the Academic Calendar. J Pediatr Orthop. 2020 May/Jun;40(5):228234. doi: 10.1097/BPO.0000000000001441. PMID: 31425402

PHYSICAL MEDICINE • Martinez SF. A Challenge for All. Phys Med Rehabil Clin N Am. 2020 Feb;31(1):xiii. doi: 10.1016/j.pmr.2019.11.002. PMID: 31760997 (SFM) • Martinez SF. There is Room for Improvement. Phys Med Rehabil Clin N Am. 2020 Nov;31(4):xiii-xiv. doi: 10.1016/j.pmr.2020.08.006. PMID: 32981588

SHOULDER AND ELBOW • Acott TR, Azar FM, Smith RA, Mihlako WM, Throckmorton TW, Brolin TJ. A Quantitative Analysis of Deltoid Lengthening and Deltoid-related Complications After Reverse Total Shoulder Arthroplasty: A Retrospective Case-control Study. Curr Orthop Prac. March/April 2020; 31(2):126-132. doi:10.1177/175857322092506 • Brolin TJ, Cox RM, Horneff JG, Namdari S, Abboud JA, Nicholson K, Ramsey ML. Humeral-sided Radiographic Changes Following Reverse Total Shoulder Arthroplasty. Archives of Bone and Joint Surgery. 2020 Jan;8(1):50-57. doi:10.22038/ abjs.2019.26065. PMID: 32090146 • Chan WW, Brolin TJ, Thakar O, Patel MS, Sholder DS, Abboud JA, Getz CL. Concomitant Rotator Cuff Repair and Instability Surgery Provide Good Patient-reported Functional Outcomes in Patients Aged 40 Years or Older With Shoulder Dislocation. JSES Int. 2020 Sep 17;4(4):792-796. doi: 10.1016/j.jseint.2020.08.006. eCollection 2020 Dec. PMID: 33345217 • DelBello S, Dopico P, Mihalko WM, Brolin TJ, Azar FM, Throckmorton TW. First Place Award: A Quantitative Analysis of the Effect of Glenoid Bone Volume on Baseplate Failure in Reverse Total Shoulder Arthroplasty in Patients with Inflammatory Arthritis: A Retrospective Case Control Study. Current Orthop Practice. 31(4):327-329. July/August 2020. • Feldman JJ, Azar FM, Brolin TJ, Duquin T, Throckmorton. Results of Reconstruction of Proximal Humeral Bone Loss With a Reverse Total Shoulder Prosthesis Using a Modular Endoprosthetic Reconstruction System: A Case Series. Curr Orthop Prac. 31(5):483-488, September/October 2020. doi: 10.1097/ BCO.0000000000000901 • Hartline JT, Brolin TJ, Wan JY, Dibaba DT, Azar FM, Throckmorton TW. The Effect of Subscapularis Management Technique on Outcomes and Complication Rates Following Reverse Total Shoulder Arthroplasty. Seminars in Arthroplasty: JSES; 30(1) May 2020: 42-49 • Hopkins C, Mulligan R, Azar FM, Brolin TJ, Throckmorton TW. Computed Tomography and Magnetic Resonance Imaging are Similarly Reliable in the Assessment of Glenohumeral Arthritis and Glenoid Version. Publication pending in Archives Bone & Joint Surgery • Littleton TW, Throckmorton TW, Toy PC, Mihalko WM, Mascioli AA. A Matched-Cohort Study Comparing Outpatient Total Knee Arthroplasty in an Ambulatory Surgery Center With Inpatient Total Knee Arthroplasty in a Hospital. Curr Orthop Prac: September/October 2020; 31(5):474-478. doi: 10.1097/ BCO.0000000000000911 • McClatchy SG, Azar FM, Smith RA, Mihalko WM, Throckmorton TW, Brolin TJ. Effect of Deltoid Volume on Range of Motion and Patient-Reported Outcomes Following Reverse Total

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

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Shoulder Arthroplasty in Rotator Cuff-Intact and Rotator CuffDeficient Conditions. May 14, 2020. https://doi.org/10.1177 /1758573220925046 • Moore R, Azar FM, Brolin TJ, Throckmorton TW. Outcomes Following Primary Reverse Total Shoulder Arthroplasty in Patients With Comorbid Anxiety and Depressive Disorders: A Retrospective Cohort Study. Publication pending-Current Orthopaedic Practice • Mosher ZA, Ewing MA, Collins CS, Young PG, Brabston EW, Momaya AM, Tashjian RZ, Ponce BA. Usage Trends of Patientreported Outcome Measures in Shoulder Literature. J Am Acad Orthop Surg. 2020 Sept1;28(17):e774-e781. PMID: 31663915 • Power I, Throckmorton TW, Smith RA, Azar FM, Brolin TJ. Pulmonary Comorbidities are Associated with Increased major Complication Rates Following Indwelling Interscalene Nerve Catheters for Shoulder Arthroplasty. Orthop Clin North Am; 2020 Oct;51(4):527-532. doi: 10.1016/j.ocl.2020.06.008. Epub 2020 Aug 12. PMID: 32950222. Review • Rider CM, Fournier MN, Thompson KM, Azar FM, Brolin TJ, Throckmorton TW. Firearms Can be Safety Used Following Shoulder Arthroplasty. Seminars in Arthroplasty:JSES. 12 Dec 2020. https://doi.org/10.1053/j.sart.2020.22.008 • Walters JD, George LW 2nd, Walsh RN, Wan JY, Brolin TJ, Azar FM, Throckmorton, Effect of Current and Former Tobacco Use on Outcomes After Primary Reverse Total Shoulder Arthroplasty. J Shoulder Elbow Surg. 2020 Feb;29(2):244251. doi: 10.1016/j.jse.2019.05.045 [Epub ahead of print]. PMID 31427230 • Walters JD, Walsh RN, Smith RA, Brolin TJ, Azar FM, Throckmorton TW. Bundled Payment Plans Are Associated With Significant Cost Savings for Ambulatory Outpatient Total Shoulder Arthroplasty. J Am Acad Orthop Surg. 2020 Oct 1;28(19):795-801. doi: 10.5435/JAAOS-D-19-0014. PMID: 31834035

SPINE • Olinger CR, Gardocki JR. Deep Venous Thrombosis and Pulmonary Embolism After Minimally Invasive Transforaminal Lumbar Interbody Fusion: Report fo 2 Cases in 315 Procedures. Orthop Clin North Am. 2020 Jul;51(3):423-425. doi: 10.1016/j. ocl.2020.02.006. Epub 2020 Mar 19. PMID: 32498960

SPORTS • Azar FM. Global Perspectives in Orthopedic Care. Orthop Clin North Am. 2020 Apr;51(2):xv-xvi. doi: 10.1016/m.ocl.2020.01.001. PMID: 32138867 • Azar FM. Minimally Invasive Surgery: Is Less More? Orthop Clin North Am. 2020 Jul;51(3):xiii-xiv. doi: 10.1016/j.ocl.2020.04.001. Epub 2020 May 5. PMID: 32498961 • Azar FM. Preface Orthop Clin North Am. 2020 Oct:51(4):xv-xvi. doi: 10.1016/j.ocl.2020.07.002. Epub 2020 Aug 1. PMID: 32950225

• Azar FM. Reconstruction. Orthop Clin North Am. 2020 Jan;51(1):xv-xvi. doi: 10.1016/j.ocl.2019.10.001. PMID: 31739885 • Bernholt DL, DePhillipo NN, Crawford MD, Aman ZS, Grantham WJ, LaPrade RF. Incidence of Displaced Posterolateral Tibial Plateau and Lateral Femoral Condyle Impaction Fractures in the Setting of Primary Anterior Cruciate Ligament Tear. Am J Sports Med. 2020 Mar;48(3):545-553. doi: 10.1177/0363546519895239. Epub 2020 Jan 9. PMID: 31917606 • Bernholt DL, DePhillipo NN, Grantham WJ, Aman ZS, Crawford MD, Kennedy MI, LaPrade RF. Morphological variants of posterolateral tibial plateau impaction fractures in the setting of primary ACL tear. Am J Sports Med. 2020 Feb;48(2):318-325. doi: 10.1177/0363546519893709. Epub 2020 Jan 3. PMID: 31899869 • Bernholt DL, Dornan GJ, DePhillipo NN, Aman ZS, Kennedy MI, LaPrade RF. High-Grade Posterolateral Tibial Plateau Impaction Fractures in the Setting of a Primary Anterior Cruciate Ligament Tear Are Correlated With an Increased Preoperative Pivot Shift and Inferior Postoperative Outcomes After Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2020 Jul;48(9):2185-2194. doi: 10.1177/0363546520932912. PMID: 32667268 • Bernholt DL, Rosenberg SI, Brady AW, Storaci HW, Viola RW, Hackett TR. Quantitative and Qualitative Analyses of the Lateral Ligamentous Complex and Extensor Tendon Origins of the Elbow: An Anatomic Study. Orthop J Sports Med. 2020 Oct 29;8(10):2325967120961373. doi: 10.1177/2325967120961373. eCollection 2020 Oct. PMID: 33195726 • Bernholt DL, Lacheta L, Millett PJ. The Bony Bankart: Clinical and Technical Considerations. Sports Med Arthrosc Rev. 2020 Dec;28(4):146-152. doi:10.1097/JSA.0000000000000286. PMID: 33156229 • Bernholt DL, Smith MV; Ulnar Collateral Ligament Injury in the Elbow: Current Trends for Treatment. Annals of Joint: Emerging Trends in Elbow Injury, Pathology and Treatment. Accepted 31 December 2019; Published: 15 April 2020. doi: 10.21037/ aoj.2020.01.02 • Pharr ZK, Mascioli AA, Dickerson AB, Throckmorton TW, Azar FM. Cyclops Lesions After ACL Reconstruction: Bone-Tenon-Bone Autograph Compared to Hamstring Autograph. Curr Orthop Prac. January/February 2020; 31(1):36-40 • Smith PJ, Azar FM. Knee Dislocations in the Morbidly Obese Patient. Sports Med Arthrosc Rev. 2020 Sep:28(3):110-115. PMID: 32740463 • Tasaki A, Nozaki T, Morita W, Kobayashi D, Phillips BB, Kiamura N. The Relationship Between High-signal Intensity Changes in the Glenohumeral Joint Capsule on MRI and Clinical Shoulder Symptoms. Asia Pac J Sports Med Arthrosc Rehabil Technol. 2020 Jul 31;22:27-33. doi: 10.1016/j.asmart.2020.06.006. PMID: 32802748

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

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Summary of Indications for Use for DUROLANE: is indicated for the treatment of pain in osteoarthritis (OA) of the knee in patients who have failed to respond adequately to conservative non-pharmacological therapy or simple analgesics, e.g. acetaminophen. Do not inject DUROLANE in patients with knee joint infections, skin diseases, or other infections in the area of the injection site. Do not administer to patients with known hypersensitivity or allergy to sodium hyaluronate preparations. Risks can include transient pain or swelling at the injection site. DUROLANE has not been tested in pregnant or lactating women, or children. Full prescribing information can be found in product labeling, at www.DUROLANE.com, or by contacting Bioventus Customer Service at 800-836-4080. Summary of Indications for Use for GELSYN-3: is indicated for the treatment of pain in osteoarthritis (OA) of the knee in patients who have failed to respond adequately to conservative non-pharmacologic therapy and simple analgesics (e.g., acetaminophen). Do not administer to patients with known hypersensitivity (allergy) to sodium hyaluronate preparations. Do not inject GELSYN-3 into the knees of patients having knee joint infections or skin diseases or infections in the area of the injection site. GELSYN-3 is not approved for pregnant or nursing women, or children. Risks can include general knee pain, warmth and redness or pain at the injection site. Full prescribing information can be found in product labeling, at www.GELSYN3.com or by contacting Customer Service at 800-836-4080. Summary of Indications for Use for SUPARTZ FX: is indicated for treatment of pain in osteoarthritis (OA) of the knee in patients who have failed to respond adequately to conservative non-pharmacologic therapy and simple analgesics, e.g., acetaminophen. You should not use SUPARTZ FX if you have infections or skin diseases at the injection site or allergies to poultry products. SUPARTZ FX is not approved for pregnant or nursing women, or children. Risks can include general knee pain, warmth and redness or pain at the injection site. Full prescribing information can be found at www.SupartzFX.com or by contacting Customer Service at 800-836-4080. Bioventus, the Bioventus logo and DUROLANE are registered trademarks of Bioventus LLC. GELSYN-3 is a trademark of Bioventus LLC. SUPARTZ FX is a trademark of Seikagaku Corp. SMK-002498 4/18 ©2018 Bioventus LLC

TRANSLATIONAL • Chu Y, Gao Y, Yang Y, Liu Y, Guo N, Wang L, Huang W, Wu L, Sun D, Gu W. B-Catenin Mediates Fluoride-induced Aberrant Osteoblasts Activity and Osteogenesis. Environ Pollut. 2020 Oct:265(Pt A):11473. doi: 10.1016/j.envpol.2020:114734. PMID: 32806408 • Lin L, Jiao Y, Luo XG, Zhang JZ, Yin HL, Ma L, Chen BR, Kelly DM, Gu WK, Chen H. Modified Technique of Advanced Cored Decompression for Treatment of Femoral Head Osteonecrosis. World J Clin Cases. 2020 July 6;8(13):2749-2757. doi:10.12998/ wjcc.v8.i13.2749. PMID: 32742985 • Lui W, Jiao Y, Tian C, Hasty K, Song L, Kelly DM, Chen H, Gu W, Liu S. Gene Expression Profiling Studies Using Microarray in Osteoarthritis: Genes in Common and Different and Conditions. Arch Immunol Ther Exp 2020 Sep 10;68(5):28. doi: 10.1007/ s00005-020-00592-4. PMID: 32914280 • Ma L, Qiang J, Yin H, Lin L, Jiao Y, Ma C, Li X, Dong L, Cui J, Wei D, Sharma AM, Schwartz DL, Gu W, Chen H. Low-kilovolt x-ray Intraoperative Radiotherapy for pT3 Locally Advanced Colon Cancer: a Single-institution Retrospective Analysis. World J Surg Oncol. 2020 Jun 17;18(1):132. doi: 10.1186/s12957-020-01903-x. PMID: 32552838

TRAUMA • Beckmann J, Haller JM, Beebe M, Ali A, Presson A, Stuart A, Sagi HC, Kubiak E. Validated Radiographic Scoring System for Lateral Compression Type 1 (LC-1) Pelvis Fractures. J Orthop Trauma. 2020 Feb;34(2):70-76. PMID: 31524667 • Montgomery T, Pearson J, Agarwal A, Olinger C, Tobey D, Beebe M, McGwin G, Cichos K, Ghanem E, Spitler C, Dubose C, Quade J. Thrombin Hemostatic Matrix Reduces Heterotopic Ossification in Acetabular Fractures Fixed via the Kocher-

Langenbeck Approach. J Orthop Trauma. 2020 Sep;34(9):451-454. doi: 10.1097/BOT.0000000000001783. PMID: 32815830

BOOK CHAPTERS • Beebe MJ. Fractures of Acetabulum and Pelvis, in Azar FM, Beaty JH, Canale ST (eds): Campbell's Operative Orthopaedics, ed 14. Philadelphia, PA: Elsevier, 2020 • Beebe MJ. Campbell ST: Ankle Fractures, in Ricci W, Mehta S, (eds): Orthopaedic Knowledge Update: Trauma, ed 6. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins, 2020 • Ford MC, Clohisy JC. Pelvic Osteotomies for Hip Dysplasia. In Surgery of the Hip, 2nd edition. Berry DJ, Lieberman J (eds). Elsevier, 2020 • Heck RK, Toy PC. Proximal Tibial Resection and Reconstruction. In AAOS Orthopaedic Knowledge Update: Musculoskeletal Tumors 4. Biermann JS et al (ed.), American Academy of Orthopaedic Surgeons, Wolters-Kluwer, 2020 • Kramer D, Kelly DM. Orthopaedic Examination of the Pediatric Patient: Chest, Shoulder, and Upper Arm. In Ken Noonan, Min Kocher, eds. Physical Examination for Pediatric and Adolescent Musculoskeletal Disorders: A Media-enhanced Guide for Diagnosis and Next Steps. Wolters Kluwer, 2020 • Mihalko WM, Mont M. (eds.) Primary Total Knee Arthroplasty by Kenneth A. Krackow, MD. Second Edition. 2020 Elsevier Inc. • Mihalko WM, Olinger CR. Metal Hypersensitivity to Implant Alloys, In Handbook of Spine Technology, Springer, 2020 • Richardson DR, Shapiro S. Morton Neuroma and Revision Morton Neuroma Excision or Endoscopic Decompression. Operative Techniques in Orthopaedic Surgery. Lippincott Williams & Wilkins, 2020

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

Frederick M. Azar, MD

Nahum M. Beard, MD

James H. Beaty, MD

Michael J. Beebe, MD

David L. Bernholt, MD

Clayton C. Bettin, MD

John R. Crockarell, MD

Gregory D. Dabov, MD

Dee Dockery, MD

Marcus C. Ford, MD

Benjamin J. Grear, MD

James L. Guyton, MD

Benjamin M. Mauck, MD

Marc J. Mihalko, MD

William M. Mihalko, MD, PhD

Robert M. Miller, MD

G. Andrew Murphy, MD

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Henry L. Sherman, MD

David D. Spence, MD

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Kirk M. Thompson, MD

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CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

Campbell Clinic STAFF RESEARCH

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

Alyson Cavanaugh, MPH1 Mitchell J. Rauh, PhD2,3 Caroline A. Thompson, PhD3 John Alcaraz, PhD3 William M. Mihalko, MD, PhD4 Chloe E. Bird, PhD5 Charles B. Eaton, MD, MS6 Milagros C. Rosal, MS, PhD7 Wenjun Li, PhD8 Aladdin H. Shadyab, PhD9 Todd Gilmer, PhD9 Andrea Z. LaCroix, PhD9 1

San Diego State University/ University of California San Diego Joint Doctoral Program in Public Health

Doctor of Physical Therapy Program San Diego State University San Diego, California

Graduate School of Public Health, San Diego State University, San Diego, California

University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering Memphis, Tennessee

Health Care Division, RAND Santa Monica, California

Department of Family Medicine at Warren Alpert Medical School and Department of Epidemiology at School of Public Health at Brown University, Providence, Rhode Island

⁷ Department of Population and Quantitative Sciences University of Massachusetts Medical School 8

Department of Medicine University of Massachusetts Medical School Worcester, Massachusetts Department of Family Medicine and Public Health, University of California San Diego, California

Corresponding Author Alyson M. Cavanaugh, DPT, PhD Joint Doctoral Program in Public Health San Diego State University/ University of California, San Diego 9500 Gilman Dr, Mail Code 0725C La Jolla, CA 92093 alcavana@ucsd.edu

Racial and Ethnic Disparities in Utilization of Total Knee Arthroplasty Among Older Women ABSTRACT Importance Although racial/ethnic differences in functional outcomes after total knee arthroplasty (TKA) exist, whether such differences are associated with differences in presurgical physical function (PF) has not been thoroughly investigated.

Objective To examine trajectories of PF by race/ethnicity before and after TKA among older women.

Design, Setting, And Participants This cohort study was conducted among the prospective Women’s Health Initiative with linked Medicare claims data. A total of 10,325 community-dwelling women throughout the United States with Medicare fee-for-service underwent primary TKA between October 1, 1993, and December 31, 2014, and were followed up through March 31, 2017.

Exposures Race/ethnicity comparisons between Hispanic or Latina women, non-Hispanic black or African American women, and non-Hispanic white women (hereafter referred to as Hispanic, black, and white women, respectively).

Main Outcomes And Measures Physical functioning scale scores and self-reported activity limitations with walking 1 block, walking several blocks, and climbing 1 flight of stairs were measured by the RAND 36-Item Health Survey during the decade before and after TKA, with a median of 9 PF measurements collected per participant over time.

Results In total, 9528 white women (mean [SD] age at surgery, 74.6 [5.5] years), 622 black women (mean [SD] age at surgery, 73.1 [5.3] years), and 175 Hispanic women (mean [SD] age at surgery, 73.1 [5.2] years) underwent TKA. During the decade prior to TKA, black women had lower PF scores than white women (mean difference, −5.8 [95% CI, −8.0 to −3.6]) and higher odds of experiencing difficulty walking a single block (5 years before TKA: odds ratio, 1.86 [95% CI, 1.57-2.21]), walking multiple blocks (odds ratio, 2.14 [95% CI, 1.83-2.50]), and climbing 1 flight of stairs (odds ratio, 1.81 [95% CI, 1.55-2.12]). After TKA, black women continued to have lower PF scores throughout the decade (mean difference 1 year after TKA, −7.8 [95% CI, −10.8 to −4.9]). After adjusting for preoperative PF scores, PF scores after TKA were attenuated (mean difference 1 year after TKA, −3.0 This open access article was reproduced from Cavanaugh A, Rauh MJ, Thompson CA, et al: Racial and ethnic disparities in utilization of total knee arthroplasty among older women, JAMA Netw Open 2020; May 1 30(5):e204937 under creative commons license. Please refer to original publication for supplementary tables and figures. CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

[95% CI, −5.3 to −0.7]), with no statistically significant differences in long-term follow-up. Hispanic women had similar PF scores to white women during the pre-TKA and post-TKA periods.

Conclusions And Relevance This study suggests that black women had significantly poorer

INTRODUCTION

Racial/ethnic disparities in total knee arthroplasty (TKA) are well documented.1-3 Less studied, but equally important, are the racial/ethnic disparities in outcomes after TKA.4 Current evidence suggests that racial/ethnic minority groups experience lower satisfaction, higher postoperative pain, more residual joint stiffness, and poorer physical function (PF) after joint arthroplasty.4 Preoperative PF is associated with function after TKA.5,6 Limited evidence is currently available regarding the association of preoperative PF and racial disparities in functional outcomes. However, poorer PF among black and Hispanic patients undergoing TKA have been reported.7-10 Little is known regarding the onset and progression of functional limitations prior to TKA. A longer duration of living with limited mobility could be associated with further deterioration in muscle strength, restrictions in joint range of motion, and altered pain pathways.11-13 Thus, both the level of PF at the time of surgery and the duration of PF limitations may be important factors associated with functional outcomes after TKA. The purpose of this study was to use prospectively collected data from a large cohort of community-dwelling older women to assess functional status trajectories by race/ethnicity during the decades leading to and following TKA.

PF than white women during the decades before and after TKA. Poorer PF after surgery was associated with poorer preoperative PF. Reducing disparities in post-TKA functional outcomes should target maintenance of function preoperatively in the early stages of arthritic disease and/or reduction of delays to receiving TKA once need arises.

Women were followed up until September 2005, and surviving women were then invited to participate in subsequent extension studies from 2005 to the present. Written informed consent was obtained from each participant. Procedures were approved by the institutional review boards at all participating institutions. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. Figure 1: Study Inclusion Flowchart

METHODS Participants This prospective cohort study used data from the Women’s Health Initiative (WHI), which included 2 major parts: clinical trials and an observational study. The design of the WHI is described in detail elsewhere.14,15 In brief, the WHI enrolled 161,808 postmenopausal community-dwelling women at 40 US clinical centers between October 1, 1993, and December 31, 1998. 60

ESRD indicates end-stage renal disease; FFS, fee for service; and TKA, total knee arthroplasty.

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

Medicare fee-for-service (FFS) claims data have been linked to 145,753 consenting WHI participants. Those who self-identified as non-Hispanic white, non-Hispanic black, or Hispanic or Latina and had Medicare data available were included in this study (Figure 1). Medicare Part A FFS claims were used to identify women who underwent a first TKA from the time of WHI enrollment through December 31, 2014, using the International Classification of Diseases, Ninth Revision primary procedure code 81.54. Because the focus was on PF trajectories from time of first TKA, women with prior TKA were excluded. Self-report of joint replacement, other than hip replacement, or a documented procedure code of 81.54 in FFS claims prior to WHI enrollment were used to identify prior TKA. Women without continuous FFS coverage from the time of WHI enrollment or the time of Medicare enrollment until the time of TKA were excluded for lack of surgical history information.

Measures The RAND 36-Item Health Survey (RAND-36) PF scale was used to measure PF.16 This composite score (range, 0-100, where 0 indicates maximal disability and 100 indicates no limitations) includes 10 survey questions regarding self-perceived difficulty in specific functional activities. Women’s Health Initiative clinical trial participants completed this questionnaire at the screening visit, at 1-year follow-up year 1, and at the end of study, with a 25% subsample completing additional surveys at 3, 6, and 9 years. Surveys were administered to observational study participants at baseline and year 3. Surveys were administered annually to all extension study participants beginning in 2005, and this study included measurements collected through 2017. Three items of the RAND-36 questionnaire were also analyzed as binary outcomes to determine specific activity limitations prior to TKA. If a woman responded that her health limited her either “a little” or “a lot” in climbing 1 flight of stairs, walking 1 block, or walking several blocks, she was classified as having an activity limitation with the corresponding functional task. Demographic information was collected through questionnaires administered at the WHI baseline. Race/ethnicity was categorized according to self-identified racial or ethnic group and was limited to the responses of non-Hispanic white, non-Hispanic black

or African American, or Hispanic or Latina (referred to hereafter as white, black, and Hispanic, respectively). Self-reported family annual income at baseline (classified as <$20 000, $20 000 to <$50 000, and $50 000) and highest educational level (classified as less than a high school diploma or General Educational Development certificate, high school diploma or General Educational Development certificate, some college or associate degree, and Baccalaureate degree or higher) were used to assess socioeconomic status (SES). Neighborhood SES (NSES), a computed variable based on 2000 census tract-level data on poverty, educational level, and other SES variables within the geographical region, was also included as a measure of SES.17,18 Neighborhood SES values range from 0 to 100, with higher values representing more affluent census tracts. Body mass index (BMI) was measured at baseline using height and weight collected by trained assessors using a wall-mounted stadiometer to the nearest 0.1 cm and a balance beam scale to the nearest 0.1 kg. Body mass index was calculated as weight in kilograms divided by height in meters squared and categorized according to World Health Organization cutpoints (underweight, <18.5; healthy weight, 18.5 to <25; overweight, 25 to <30; obese I, 30 to <35; obese II, 35 to <40; obese III, ≥ 40).19 Marital status, living arrangement, depressive symptoms, and physical activity were determined using the data collection point prior to and most recent to TKA. Marital status was dichotomized (yes or no) according to the response of being currently married or in an intimate relationship. Living arrangement was dichotomized (yes or no) based on whether the participant lived alone. Presence of depressive symptoms was determined using the 8-item scale for depressive disorders by Burnam et al,20 which combines 6 questions from the short form of the Center for Epidemiological Studies Depression Scale and 2 items from the Diagnostic Interview Schedule, with a score range of 0 to 1 (where 0 indicates lowest probability of having a depressive disorder and 1 indicates highest probability). A cutoff of 0.06 was used to determine the presence of depressive symptoms.21 Time spent in moderate to vigorous physical activity was based on self-reported frequency and duration of activities of various intensities. Moderate to vigorous physical activity was classi-

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

Table 1: Demographic and Health Characteristics of Study Participants by Race/Ethnicity Participants, No. (%)a Characteristic Age at surgery, mean (SD), y

White

Black

Hispanic or Latina

74.6 (5.5)

73.1 (5.3)

73.1 (5.2)

2085 (21.9)

144 (23.2)

22 (15.8)

Region Midwest Northeast

2671 (28.0)

98 (15.8)

90 (51.4)

South

3070 (32.2) 3

35 (53.9)

54 (30.9)

West

702 (17.9)

45 (7.2)

Married, yes

6519 (68.8)

335 (54.1)

112 (65.1)

Live alone, yes

2628 (29.8)

200 (35.8)

36 (24.7)

Underweight or normal weight (<25)

1815 (19.2)

31 (5.0)

Overweight (25 to <30)

3323 (35.2)

67 (27.1)

48 (27.8)

BMI

Obese I (30 to <35)

2473 (26.2)

198 (32.1)

58 (33.5)

II or III (≥35)

1831 (19.4)

220 (35.7)

48 (27.8)

0.61 (0.35-0.92)

0.65 (0.41-0.99)

0.55 (0.35-0.96)

3786 (39.8)

295 (47.6)

90 (52.0)

1 to <150

3147 (33.1)

209 (33.7)

42 (24.3)

>150

2578 (27.1)

116 (18.7)

41 (23.7)

897 (9.4)

74 (12.0)

35 (20.6)

Multimorbidity score (CMS-HCC), median (IQR) Moderate to strenuous physical activity, min/wk None

Depressive symptoms, yes Educational level <High school

248 (2.6)

52 (8.4)

28 (16.2)

High school

1698 (17.9)

89 (14.4)

31 (17.9)

Some college

3569 (37.6)

225 (36.3)

70 (40.5)

College graduate

3977 (41.9)

254 (41.0)

44 (25.4)

Family income, $ <20 000

939 (10.5)

126 (21.6)

40 (24.7)

20 000 to <50 000

4136 (46.1)

262 (44.9)

69 (42.6)

≥50 000

3897 (43.4)

195 (33.5)

53 (32.7)

77.3 (7.0)

65.8 (11.4)

70.2 (10.5)

Neighborhood SES, mean (SD)

Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); CMS-HCC, Centers for Medicare & Medicaid Services Hierarchical Conditions Categories; IQR, interquartile range; SES, socioeconomic status. a

Presentation of data is

fied as greater than or equal to 150 minutes per week, 1 minute per week to less than 150 minutes per week, or none. Medicare FFS claims were used to determine age at TKA and multimorbidity scores. Multimorbidity scores were calculated using the Centers for Medicare & Medicaid Services Hierarchical Conditions Categories risk adjustment, with scores lower than 1.0 indicating rela62

tively healthier individuals. Medicare claims from hospital inpatient and outpatient treatment and physician claims starting 1 year prior to the date of surgery were included to calculate dichotomous values for the 70 Hierarchical Conditions Categories conditions included in the Centers for Medicare & Medicaid Services Hierarchical Conditions Categories risk score.22,23

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

Figure 2: Unadjusted Mean Physical Function Before and After Total Knee Arthroplasty (TKA) by Race/Ethnicity

Error bars indicate 95% CIs.

Statistical Analysis Assessment of Pre-TKA Functional Status and Temporal Changes Physical function 1 year prior to surgery for each participant was estimated using generalized linear mixed modeling. Physical function scores from the 10-year period prior to date of surgery were included in the modeling to estimate PF 1 year prior to surgery. With the use of multiple imputations, missing PF measurements for intervals of less than 1 year, 1 to less than 2 years, 2 to less than 5 years, and 5 to 10 years prior to TKA were imputed. Multiple imputation using chained equations was performed with variables of PF, age, time of PF collection, quadratic time, and cubic time and auxiliary variables of baseline PF, time from baseline PF to TKA, and multimorbidity. Twenty-five imputed data sets were created. Generalized linear mixed modeling was then performed using the imputed data sets. Unstructured covariance was used to obtain robust estimates, after comparing Akaike information criterion statistics of models fit with unstructured, autoregressive, and Toeplitz structures. Generalized linear mixed modeling included age, a cubic spline with 5 knots for time, and random intercepts to account for differences in PF measurements at the individual level. Results were averaged among the imputed data sets,24 and individual PF measurements 1 year prior to

TKA was used as a variable for subsequent modeling. Physical function trajectories over time by race/ ethnicity were modeled using generalized estimating equations (GEEs) in the preoperative and postoperative periods. Preoperative PF was modeled for a period of 10 years prior to surgery. Race/ethnicity and age at TKA were independent variables in the GEE models. Quadratic and cubic time variables were included to allow for nonlinear changes in PF over time. Interaction terms for time and race/ethnicity were included to allow for differing rates of change in PF by race/ethnicity. Interactions were retained in the model if the Wald test statistic was significant at P < .10. Because differences in PF between racial/ethnic groups before and after TKA would be compared, women without both pre-TKA and post-TKA PF measurements were excluded from the PF GEE models. To examine whether race/ ethnicity associations with preoperative PF varied by SES, the variables NSES, income, and educational level were stratified at their median values, and interaction terms for each were added into 3 separate GEE models. An autoregressive working correlation structure was used for all GEE models. Activity limitations by race/ethnicity in the decade before TKA were assessed using 3 GEE models with binary outcomes of difficulty walking 1 block, difficulty walking several blocks, and difficulty climbing 1 flight of stairs. Race/ethnicity, time, and interactions of race/

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Table 2: Estimated Mean Physical Function Scores and Odds of Activity Limitations at Selected Points Prior to TKA, Women’s Health Initiative, 1993-2017 Speciﬁc activity limitations, AOR (95% CI)b Walking Physical function, estimated 1 Block mean (95% CI)a

Several blocks

Climbing a ﬂight of stairs

Black

53.6 (51.5-55.8)

1.86 (1.57-2.21)

1.91 (1.60-2.28)

1.55 (1.29-1.85)

Hispanic

56.7 (53.2-60.2)

1.06 (0.75-1.49)

1.29 (0.92-1.80)

1.67 (1.21-2.31)

White

59.5 (58.9-60.0)

1 [Reference]

Black

59.1 (56.9-61.2)

1.86 (1.57-2.21)

1.96 (1.67-2.31)

1.61 (1.36-1.90)

Hispanic

62.2 (58.7-65.6)

1.06 (0.75-1.49)

1.27 (0.94-1.73)

1.66 (1.23-2.23)

White

64.9 (64.3-65.5)

1 [Reference]

Black

67.1 (65.0-69.3)

1.86 (1.57-2.21)

2.14 (1.83-2.50)

1.81 (1.55-2.12)

Hispanic

70.2 (66.7-73.7)

1.06 (0.75-1.49)

1.22 (0.90-1.66)

1.61 (1.20-2.17)

White

72.9 (72.4-73.5)

1 [Reference]

Black

73.9 (71.7-76.1)

1.86 (1.57-2.21)

2.48 (1.94-3.17)

2.20 (1.72-2.82)

Hispanic

77.0 (73.5-80.5)

1.06 (0.75-1.49)

1.15 (0.68-1.93)

1.55 (0.96-2.49)

White

79.7 (79.0-80.4)

1 [Reference]

Time prior to TKA 1 Year

2 Years

5 Years

10 Years

Abbreviations: AOR, adjusted odds ratio; TKA, total knee arthroplasty. Physical function scores correspond to RAND 36-Item Health Survey physical functioning scale. Mean physical function scores estimated through general estimating equations that included the following covariates: age at TKA and linear, quadratic, and cubic time. Mean values correspond to model fit for an age of 74 years at TKA. b Activity limitations correspond to self-reported difficulty in performing the specific item of the RAND 36-Item Health Survey. Adjusted odds ratios determined through general estimating equations that included age at TKA and linear, quadratic, and cubic time. Time by race/ethnicity interaction term additionally included in models for walking several blocks and climbing a flight of stairs. a

ethnicity and time were included using the same method as described for the PF GEE models. Estimated probabilities of experiencing difficulties in the 3 activity limitations were determined during a 10-year interval prior to surgery. Assessment of Post-TKA Functional Status and Temporal Changes Unadjusted mean values of PF both before and after TKA were calculated at annual increments for each racial/ethnic group and included all available PF scores collected within 364 days of the start of the year. For example, year 1 after TKA included PF scores collected at day 365 through day 729. Scores collected during the first postoperative year were not included because of an assumed temporary decline during 64

the initial postoperative recovery period.25 Generalized estimating equation modeling in the postoperative decade used PF measurements collected from 365 days after TKA through year 10 and applied the same method as described for the preTKA period. To evaluate whether preoperative PF was associated with racial/ethnic differences in postoperative PF, participants’ estimated 1-year preoperative PF scores as determined by generalized linear mixed modeling were included as an independent variable in the postoperative PF GEE model. Specific time periods of 1 and 2 years, 5 years, and 10 years from TKA were selected to examine disparities in short-term, midterm, and long-term outcomes, respectively. Because of the large number of women without post-TKA PF measures, a sensitivity analysis using

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Figure 2: Physical Function in the Decade After Total Knee Arthroplasty (TKA) Without or With Adjustment for Preoperative Function

A, Physical function estimates from model fit for age 74 years at time of TKA, adjusted for age. B, Physical function estimates from model fit for age 74 years at TKA and preoperative RAND 36-Item Health Survey physical functioning scale score of 60, adjusted for age and preoperative physical function at 1 year prior to TKA. Error bars indicate 95% CIs.

censoring weighting was performed. The inverse of the estimated probability of remaining in the study26 (having available post-TKA PF measures) was used to determine individual weights for pre-TKA and postTKA PF GEE models. Probabilities of remaining in the study were estimated by logistic regression using factors of baseline PF and BMI, 1-year pre-TKA PF, age at TKA, race/ethnicity, multimorbidity, depression, moderate to vigorous physical activity, income, educational level, NSES, and region. Confidence intervals were determined based on a bootstrap distribution with 500 resampling iterations. All P values were from 2-sided tests and results were deemed statistically significant at P < .05. All analyses were performed using SAS, version 9.4 (SAS Institute Inc).

RESULTS

Overall, 10 325 women from the WHI who underwent primary TKA were included, with 9528 (92.3%) self-identifying as white, 622 (6.0%) as black, and 175 (1.7%) as Hispanic (Table 1). The mean (SD) age at TKA was 74.6 (5.5) years for white women, 73.1 (5.2) years for Hispanic women, and 73.1 (5.3) years for black women. Compared with white women, black and Hispanic women were less likely to be married, had lower income, lower educational attainment, lower NSES,

higher BMI, and lower participation in moderate to vigorous physical activity. Black women had higher multimorbidity scores, whereas Hispanic women had lower multimorbidity scores, compared with white women.

PF Before TKA All racial/ethnic groups had declining PF during the decade before TKA, with some functional improvements after TKA (Figure 2). Black women had significantly lower PF scores than white women during the 10-year preoperative period after adjusting for age (mean difference, −5.8 [95%CI, −8.0 to –3.6]). Hispanic women also had slightly lower preoperative PF scores than white women, but this difference was not statistically significant. The odds of experiencing specific activity limitations (walking 1 block, walking several blocks, or climbing 1 flight of stairs) increased in the years approaching surgery for all racial/ethnic groups (eFigure 1 in the Supplement). Although black women had higher odds of experiencing activity limitations during the entire preoperative period compared with white women (difficulty walking a single block at 5 years prior to TKA: odds ratio [OR], 1.86 [95% CI, 1.572.21]; difficulty walking multiple blocks: OR, 2.14 [95% CI, 1.83-2.50]; difficulty climbing a flight of stairs: OR, 1.81 [95% CI, 1.55-2.12]), white women experienced higher rates of developing limitations in walking sev-

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eral blocks and climbing stairs in the immediate years preceding TKA compared with black women (Table 2). Hispanic and white women were similarly likely to experience walking limitations, but Hispanic women had 67% higher odds of difficulty with climbing a flight of stairs during the year prior to TKA compared with white women (OR, 1.67 [95% CI, 1.21-2.31]). Differences in pre-TKA PF between black and white women were more pronounced among women with SES characteristics below median levels compared with those with higher SES levels.

PF After TKA Black women had significantly lower PF scores during the decade after TKA compared with white women (Figure 3). At 1 year after TKA, black women had age-adjusted mean PF scores 7.8 points lower than white women (95% CI, −10.8 to −4.9), representing a widening of the gap noted preoperatively (1-year pre-TKA mean difference, −5.8 [95% CI, −8.0 to −3.6]). However, this racial difference in post-TKA PF narrowed over time (10-year post-TKA mean difference, −3.3 [95% CI, −7.1 to 0.4]) because black women, on average, experienced a more gradual decline in function compared with white women (race/ethnicity by time interaction P = .06). Hispanic women showed similar mean PF scores compared with white women during the 10-year postoperative period. Adjustment for 1-year preoperative PF attenuated the racial/ethnic differences in postoperative PF (Figure 3). After adjustment for preoperative PF, black women still had significantly lower PF at 1 and 2 years after TKA (1-year post-TKA mean difference, −3.0 [95% CI, 5.3 to −0.7]; 2-year post-TKA mean difference, −2.5 [95% CI, −4.5 to −0.4]), but no significant differences persisted between any racial/ethnic groups after year 2. After adjustment for pre-TKA function, black women had a significantly slower overall rate of decline in PF than white women during the decade after TKA.

Sensitivity Analyses Women with characteristics of poorer health (higher BMI, multimorbidity, and depression) were more likely to have missing post-TKA PF scores, and there was a statistically significant difference in censoring by race/ethnicity (eTable 2 in the Supplement). The inverse probability of censoring weighting resulted in a strengthening of the association between PF and 66

race/ethnicity during the post-TKA decade.

DISCUSSION

In a population of community-dwelling older women who underwent TKA, black women had significantly poorer PF scores than white women during the decade before TKA, which persisted during the decade after TKA. After adjustment for preoperative PF, black women had lower PF scores than their white counterparts for the first 2 years after surgery but then had similar PF scores during the remaining years of follow-up. Hispanic and white women had similar preoperative and postoperative PF scores. The TKA procedure is considered an effective treatment for adults with end-stage knee arthritis and is associated with reduced pain and improved function. However, our findings are consistent with the growing body of evidence that suggests that older black adults do not have the same post-TKA functional outcomes as older white adults.4 Although Hispanic ethnicity has been less studied with regard to TKA, our results are congruent with 2 other reports that Hispanic ethnicity was not significantly associated with PF outcomes.7,27 Several studies investigating the potential causes of racial/ethnic disparities in post-TKA outcomes have focused on minority groups’ disproportionately higher use of low-volume surgeons or institutions28,29 and higher rates of perioperative and postoperative complications, including the development of arthrofibrosis.30-32 Others have focused on racial/ethnic differences in rehabilitation pathways or postoperative care.33,34 However, while preoperative PF is known to be associated with postoperative PF,5,6 to date, only few reports have addressed how preoperative PF may be associated with these functional outcome disparities. Kamath et al35 performed a retrospective analysis of patients undergoing TKA and reported that African American patients had significantly lower PF scores 2 years after TKA, which was associated with patient self-report of longer delays from onset of symptoms to presentation at the orthopedist office. Lavernia et al7 reported that non-Hispanic African American patients had worse functional scores postoperatively than white patients, even after adjusting for worse preoperative functional scores. Both studies used data from surgical institutions where pre-TKA PF and symptom reporting were measured at the patient’s first orthopedist office visit.7,35 Our findings, using a community-dwelling cohort,

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add important and novel information by illustrating the severity of activity limitations and PF impairment, which was present earlier and for a longer duration among black women. Although a gap in function persisted in short-term follow-up, even after adjustment for preoperative function, it is promising to recognize that mid-term and long-term outcomes were similar between race/ethnicity groups after accounting for differences in preoperative PF. The longer duration of PF impairment among black women is of concern because of the cyclic association with reduction in physical activity, weight gain, and further restrictions in mobility,36 all of which are associated with poorer outcomes after TKA.5 In addition to poorer PF, black women in this study had higher BMI and lower physical activity before TKA. Although we were unable to measure temporal changes in weight and physical activity prior to TKA because of the timing of data collection for these measures, previous WHI studies have reported that higher BMI and lower physical activity measured at baseline were associated with late-life mobility limitations after TKA, independent of race/ethnicity.37,38 Preserving mobility and preventing further functional decline among black women may ultimately need to include strategies such as weight management, promotion of physical activity, or targeted interventions aimed at functional mobility, such as physical therapy. Uptake of evidence-based treatments for arthritis may help slow declines in mobility due to painful joints. However, black adults with arthritis have been shown to be less likely to receive medical or pharmaceutical treatments for pain39,40 and are less likely to receive physical therapy services.41 Ultimately, identifying black adults with arthritis earlier in the disease process and increasing referrals for and uptake of evidence-based treatments aimed at preserving functional mobility may help reduce the observed disparities both before and after TKA. Reducing delays to surgery, once the clinical need for TKA arises and conservative treatments become ineffective, may help improve the prognosis postoperatively. In our study, white women who underwent TKA were more likely to develop mobility limitations in the years immediately preceding TKA, whereas black women lived with these mobility limitations several years longer. Similarly, Kamath et al35 reported that black women who underwent TKA reported, on aver-

age, an additional 20 months of delay from time of onset of disability until time of surgical consultation compared with other racial/ethnic groups. The reasons for delayed surgical intervention likely include differences in health care seeking, referral patterns, and medical access. Although all women in this study had Medicare insurance, fewer economic resources to cover copayments, deductibles, and lost wages may be associated with postponing medical care and/or surgical intervention.42-44 In our study, women with fewer financial resources experienced poorer PF during the decade prior to TKA, yet the racial/ethnic disparities in preoperative PF were wider in this group than among women with greater SES resources. Mistrust of medical professionals and misconceptions about the benefits and risks of TKA are prevalent among older black adults and have been associated with the underuse of TKA among this group.45-47 These same factors may play a role in deferral and thus delayed receipt of TKA. In addition, differences between racial/ethnic groups in social responsibilities and resources could be associated with decisions to undergo TKA. Black women were less likely to be married and more likely to live alone; thus, postsurgical care concerns may have led to an initial hesitation to undergo TKA. In addition to economic, cultural, and social factors that may be associated with the timeliness of patients’ decisions to undergo TKA, clinician factors including implicit bias may be associated with referrals, recommendations, and timeliness of surgical treatment. Emerging research suggests that, despite the presence of clinicians’ implicit biases, race/ethnicity does not appear to be associated with physicians’ recommendations for TKA.48,49 However, a more thorough understanding of the association of clinician biases with recommendations, patient-clinician communication, and referrals and processes of care from primary to specialist care may elucidate why patients of minority race/ethnicity present at the time of surgery with more advanced disability.7,50 Ultimately, reducing delays to surgical intervention once clinical need arises may reduce the observed disparities after TKA.

Strengths and Limitations Our study has several limitations. This study population was limited to women with Medicare FFS coverage; therefore, findings may not be generalizable to managed-care beneficiaries, men, or younger popu-

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lations. The number of younger adults receiving TKA has increased over the years,51 yet disparities in the use of TKA and outcomes among adults younger than 65 years follow distinct trends from older adult populations.52,53 However, older women still remain the demographic group most likely to receive TKA,54 and given women’s longevity and the likelihood of living alone in older age,55 the examination of PF in this large cohort of aging women remains highly valuable. The findings for the Hispanic group should be interpreted with caution because of the large variability in PF, likely associated with the smaller sample size as well as the probable heterogeneity within this group. The RAND-36 is a generic, patient-reported measure and not a knee-specific or arthritis-specific tool nor a performance-based measure. Nevertheless, the PF scale of the RAND-36 provides a global view of self-perceived mobility required for daily living and has been widely used in studying outcomes after joint arthroplasty.56 Our sensitivity analysis using censoring weights demonstrated that our main findings regarding post-TKA PF are likely biased toward the null because of loss to follow-up and may in fact be an underestimation of the true disparities between racial/ethnic groups. Finally, health policy changes subsequent to the timing of the TKA procedure dates for this study may have been associated with health care use and outcomes, particularly with respect to expanded access for adults prior to or approaching Medicare eligibility. Although it is beyond the scope of this study, these findings may serve as an essential baseline for evaluating the association of the Patient Protection and Affordable Care Act and other

policy changes with racial/ethnic differences in treatments and outcomes after TKA. Balancing these limitations were several key strengths. The Medicare-WHI linked data allowed an investigation of PF from a large, diverse population of women throughout the United States using prospectively collected individual-level measurements that would not be available from medical Medicare claims data alone. Patterns in PF were examined over an extended time period, including the preoperative decade, which likely included several years prior to the first encounter with specialist care.

CONCLUSIONS

In this study, black women had poorer PF after TKA compared with white women. The disparity in postTKA PF was associated with disparities in PF preoperatively. Efforts to reduce the racial/ethnic gap in postoperative function should be aimed at maintaining functional mobility among black women with arthritis and at reducing delays to surgery once need arises. Investigation into the determinants of delayed use of TKA among black women warrants further attention. Additional research is also merited to understand the greater diversity in experiences and TKA outcomes among Hispanic women. Finally, it is possible that as surgical techniques and prostheses, clinical practice guidelines, and health care policies change, disparities in PF may also change, supporting the importance of continued examination of outcomes by race/ethnicity going forward.

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43. Dunlop DD, Manheim LM, Song J, et al. Age and racial/ethnic disparities in arthritis-related hip and knee surgeries. Med Care. 2008;46(2):200-208. doi:10.1097/MLR.0b013e31815cecd8

51. Singh JA. Epidemiology of knee and hip arthroplasty: a systematic review. Open Orthop J. 2011;5(1):80-85. doi:10.2174/1874325001105010080

44. Hanchate AD, Zhang Y, Felson DT, Ash AS. Exploring the determinants of racial and ethnic disparities in total knee arthroplasty: health insurance, income, and assets. Med Care. 2008;46(5):481-488. doi:10.1097/MLR. 0b013e3181621e9c 45. Blum MA, Ibrahim SA. Race/ethnicity and use of elective joint replacement in the management of end-stage knee/hip osteoarthritis: a review of the literature. Clin Geriatr Med. 2012;28(3):521-532. doi:10.1016/j.cger.2012. 05.002

52. McCalden RW, Robert CE, Howard JL, Naudie DD, McAuley JP, MacDonald SJ. Comparison of outcomes and survivorship between patients of different age groups following TKA. J Arthroplasty. 2013;28(8)(suppl):83-86. doi:10.1016/j. arth.2013.03.034 53. Chen J, Rizzo JA, Parasuraman S, Gunnarsson C. Racial disparities in receiving total hip/knee replacement surgery: the effect of hospital admission sources. J Health Care Poor Underserved. 2013;24(1):135-151. doi:10.1353/hpu.2013.0026

46. Shahid H, Singh JA. Racial/ethnic disparity in rates and outcomes of total joint arthroplasty. Curr Rheumatol Rep. 2016;18(4):20. doi:10.1007/s11926-016-0570-3

54. Maradit Kremers H, Larson DR, Crowson CS, et al. Prevalence of total hip and knee replacement in the United States. J Bone Joint Surg Am. 2015;97(17):13861397. doi:10.2106/JBJS.N.01141

47. Ibrahim SA. Racial and ethnic disparities in hip and knee joint replacement: a review of research in the Veterans Affairs Health Care System. J Am Acad Orthop Surg. 2007;15(suppl 1):S87-S94. doi:10.5435/00124635-200700001-00019

55. US Department of Health and Human Services. A profile of older Americans: 2016. Accessed September 13, 2019. https://www.giaging.org/documents/A_ Profile_of_Older_Americans__2016.pdf

48. Ang DC, James G, Stump TE. Clinical appropriateness and not race predicted referral for joint arthroplasty. Arthritis Rheum. 2009;61(12):1677-1685. doi:10.1002/ art.24944

56. Jauregui JJ, Banerjee S, Cherian JJ, Elmallah RDK, Mont MA. Rating systems to assess the outcomes after total knee arthroplasty. Surg Technol Int. 2015;26:289294. https://www.ncbi.nlm.nih.gov/pubmed/26055022.

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

Jacob T. Hartline MD1 Vikki G. Nolan DSc MPH2 Derek M. Kelly MD3,4 Benjamin W. Sheﬀer MD3,4 David D. Spence MD3,4 Liliana Pereiras MD4 William C. Warner Jr. MD3,4 Jeﬀrey R. Sawyer MD3,4 1

University of Maryland College of Medicine Orthopaedic Department Baltimore, Maryland

University of Memphis School of Public Health Division of Epidemiology and Biostatistics Memphis, Tennessee

University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering Memphis, Tennessee

Department of Anesthesiology Le Bonheur Children’s Hospital Memphis, Tennessee

Patient and Procedural Factors Predict Operating Room Time Intervals in Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis: A Retrospective Cohort Study Background Charges for surgical treatment of adolescent idiopathic scoliosis have steadily increased, with an estimated 10% of these charges attributed to operating room block time alone. Maximizing operating room efficiency should be a priority. The objective of this study was to examine the effect of patient- and procedure-specific factors on operating rooom time intervals.

Methods Records of consecutive posterior spinal fusions (PSF) done in a high-volume children’s spine center over a 2-year period were reviewed, and multiple perioperative and intraoperative time intervals were recorded. Predictors of preparation time, surgery time, and total operating room time were identified using generalized linear models with backward selection. Predictors investigated included body mass index (BMI), age, gender, race, curve magnitude, scoliosis etiology, number of levels fused and screws placed, and whether or not osteotomy was performed.

Results Chart review identified 140 posterior spinal fusions. Predictors of increased total operating room time included body mass index (51.7-minute increase in obese patients; P<0.001, osteotomy performed (16.4-minute increase; P=0.001), and number of levels fused (8.9-minute increase for each level, P<0.003). Predictors of surgery time were similar. BMI was a significant predictor of variability in preparation time, with obese patients requiring 9.8 mins more of preparation time than normal weight patients P=0.003) Scoliosis etiology and curve magnitude did not significantly affect any of the times studied.

Corresponding Author Derek M. Kelly MD 1211 Union Avenue, Suite 510 Memphis TN 38104 P: 901-759-3270 F: 901-759-3278 dkelly@campbellclinic.com

INTRODUCTION

Recently there has been an increased focus on operating room (OR) efficiency. Various studies have shown that OR costs account for 40% to 60% of total hospital costs,1,2 and these costs continue to increase. Charges for surgical treatment of adolescent idiopathic scoliosis were reported to have tripled between 1997 and 2012, with an estimated 10% of these charges attributed to OR block time alone.3,4 Furthermore, increased time in the OR has been linked to increased complication rates and worse outcomes.5-8 Because increased time spent in the OR leads to increased CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

Figure 1: Operating room time intervals.

Total Room Time

Prep Time

In-room

Block

Surgery Time

financial burden and worse patient outcomes, maximizing OR efficiency should be a priority. The surgeon and anesthesiologist have been shown to have a significant effect on various OR time intervals.9-11 Across multiple surgical specialties, various factors, including call models, surgery centers, team training sessions, and familiarity, also have been shown to have an effect on OR efficiency.12-15 Obesity has typically been associated with increases in operative times, while other patient-related factors have not been implicated or studied as frequently.10,16-18 It has been suggested that identification of patient and procedural factors affecting OR time may improve scheduling.19 The aim of this study was to identify patient characteristics and factors specific to pediatric posterior spinal fusion (PSF) that predict time in the OR. To our knowledge, only one study in the field of pediatric orthopaedics has looked at similar factors.10 This study builds on those findings by looking at a larger population and at various operative time intervals. We hypothesized that patient-specific and procedure-specific factors would predict OR time. Identification of these factors can contribute to improving OR efficiency through preoperative planning and OR scheduling.

MATERIALS AND METHODS Ethical Review and Study Design This retrospective cohort study was approved by the institutional review board of (approval #12-02101XP) prior to data collection and statistical analysis. Patient informed consent was waived by the ethical review board. 72

Surgery End

Surgery Start

Outroom

Data Collection A retrospective chart review of the years 2014 to 2017 identified patients under the age of 21 with spinal deformity who had PSF of seven or more levels based on CPT codes 22843 and 22844. All patients included had surgery performed by a fellowship-trained, board-certified pediatric orthopaedic surgeon and had complete medical records. Patients were excluded if they included a neurosurgeon assisting, two attending surgeons participating, insertion or revision of a rib or spine-based growth-friendly device, revision of any spinal implants, or extension of a previous fusion. Patients with a scoliosis etiology other than idiopathic as well as those who did not have a spinal block were excluded because these were found to have a more complex and heterogenous OR course. At the time of this review, intrathecal duramorph was routinely administered by the attending anesthesiologist prior to skin incision. For consistency, only patients who received this injection were included in this review.

Intraoperative Factors Neuro-monitoring with transcranial motor-evoked potentials and somatosensory-evoked potentials was used in each case. Navigation was not used in any case; pedicle screws were placed using a combination of intraoperative fluoroscopy and anatomical landmarks. Osteotomies, when used, were only those of the posterior column, (e.g., Ponte osteotomy). No multiple-column osteotomies, such as pedicle subtraction osteotomies, or vertebral column resections were included in this study. A well-trained subset of the total OR personnel and anesthesia personnel at our institu-

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tion routinely participate in scoliosis surgeries. Personnel factors at our institution, and how each relates to the chosen time intervals, have been previously studied and published.

Time Intervals Time intervals were chosen based on previous studies looking at time in the OR and on time points available in our perioperative nursing records (Figure 1).9,14,20,21,22 Preparation time included administration of anesthetic, intubation, standard line placement, spinal block, patient positioning, and skin preparation. Surgery time began at the first skin incision and ended with the application of the dressing.

Patient and Procedural Factors Patient factors recorded were body mass index (BMI), age at surgery, gender, ethnicity, location of major curve, and Cobb angle of major curve. Because raw BMI scores have little meaning in children without putting the score in the context of age and gender, the percentile BMI was used as recommended by the CDC (https://www.cdc.gov/ obesity/childhood/defining.html). Overweight was defined as ≥ 85th percentile and <95th percentile for height and weight, and obese was defined as greater than 95th percentile. Procedural factors recorded were number of levels fused, number of screws used, and number of osteotomies performed. The surgeon has been shown to significantly predict variability in the studied time intervals in PSF and was therefore recorded to control for this factor in the model.9.10

Statistical Analysis Categorical variables are presented as frequency and percent of those non-missing, and continuous variables are presented as mean and standard deviation. Sample size calculation was not completed, as all patients meeting inclusion criteria between 2014 and 2017 were studied. To determine predictors of each OR interval, generalized linear regression was used. Backwards selection of variables based on the Akaike Information Criterion (AIC) rather than statistical significance was used to identify the final model. This method was chosen because the AIC identifies the subset of variables that best fit these data and avoids overfitting the model. All analyses were done using PROC GLMSELECT in SAS Software, Version 9.4 (SAS Institute Inc., Cary, NC, USA).

Table 1: Subject Characteristics N = 140 n (%) Gender Male

43 (30.7)

Female

97(69.3)

Race White

83 (59.7)

Black

52 (37.4)

Other

4 (2.9)

Age Mean (std)

14.2 (2.0)

BMI Normal

98 (70.5)

Overweight

15 (10.8)

Obese

26 (18.7)

Major curve Mean (std)

61.4 (12.4)

Curve Location R Thoracic

104 (80.6)

L Thoracic

4 (3.1)

R Thoracolumbar/lumbar

10 (7.8)

L Thoracolumbar/lumbar

11 (8.5)

Osteotomy Yes

21(15)

Screws Mean (std)

18.1 (3.1)

Fusion levels Mean (std)

11.8 (1.9)

Surgeon Surg1

22 (15.8)

Surg2

21 (15.1)

Surg3

59 (42.5)

Surg4

37 (26.6)

RESULTS Overall Results Of 208 PSFs identified, 140 met inclusion criteria. The average age of patients was 14.2 years (std=2.0). Sixty-nine percent of patients were female, 60% were of white race, 30% were overweight or obese, and 81% had a right thoracic curve, with the average Cobb angle measuring 61.4 degrees (Table 1). An average of 18.1 screws were used and an average of 11.8 levels were

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fused. Osteotomy was performed in 21 patients (15%), with an average of 3.6 levels of osteotomy performed in each patient.

Surgeon Eﬀect Surgeon effect was found to predict variability at all three time intervals. This factor was retained in the models to allow analysis of patient and personnel factors while controlling for surgeon effect.

Preparation Time (Entry into OR to Start of Surgery) BMI was a significant predictor of variability, with obese patients requiring 9.8 minutes more of preparation time than normal weight patients (95% CI [3.3, 16.3]; P=0.003).

Surgery Time (Surgery Start to Surgery End) BMI was a significant predictor of variability, with an increase of 42.4 minutes in surgery time in obese patients compared to normal weight patients (95% CI [24.2, 60.5]; P=<0.001). Osteotomy significantly increased surgery time by 14.9 minutes per each level of osteotomy performed (95% CI [7.8, 22.0]; P=<0.0001) The number of fusion levels significantly predicted an increase of 9.6 minutes with each additional level (95% CI [4.3, 14.9]; P=<0.001). The number of screws used significantly predicted an increase of 5.4 minutes with each additional screw (95% CI [2.0, 8.9]; P=0.003).

Total Room Time (Entry into OR to Exit from OR) BMI was a significant predictor of variability, with an increase of 51.7 minutes in surgery time in obese patients compared to normal weight patients (95% CI [31.4, 71.9]; P=<0.001). The number of fusion levels significantly predicted an increase of 8.9 minutes for each additional level (95% CI [3.2, 14.7]; P=0.003) and the number of screws significantly predicted an increase of 6.0 minutes for each additional screw (95% CI [2.2, 9.8]; P=0.002). Finally, the use of osteotomy increased total room time by 16.4 minutes per each level of osteotomy performed (95% CI [8.51, 24.3]; P<0.001). Age at surgery, gender, Cobb angle of major curve, and ethnicity did not predict variation at any time interval (P>0.05). There were no significant differences in age, Cobb angle of major curve, or osteotomy between male and female patients (P>0.05). 74

DISCUSSION

The results of this study suggest that both patient-specific and procedure-specific factors predict significant variation at multiple operative time intervals during PSF in a pediatric population. Once in the OR, the time before the first incision was best predicted by BMI. Between the first incision and closing, BMI again was a significant predictor of time, along with osteotomy, number of screws used, and the number of fusion levels. These same factors significantly predicted total OR time. Age, gender, and ethnicity did not predict variation in any time interval. Of the patient characteristics that predicted variations in time, BMI was the most pervasive factor with the largest effect size. Obese patients were found to add around 10 additional minutes to preparation time and roughly 40 minutes to surgery time—increases of approximately 10% and 13%, respectively. This finding is consistent with other studies that showed BMI to be predictive of surgery time.16,17 Although some studies have found no significant connection, including another study on pediatric PSF, no studies to our knowledge have shown obese patients to have shorter operative times.10,18 Overall, the results of this study add to previous findings that prolonged operative time should be expected in procedures involving obese patients; however, the effect of obesity on OR time specifically during pediatric PSF needs to be further studied because of conflicting data. We did not find gender to be a predictor of OR time, which differs from previous studies showing males to have longer surgery times.10,23 This finding has been attributed to stiffer curves, greater curve magnitudes, and older age at surgery in males.23,24 The male patients in our study did present at an older age than female patients, but did not differ in curve magnitude, number of fusion levels, or osteotomy. This may suggest that the difference in gender seen in previous studies might be attributed to factors other than older age. Further study is needed to elucidate these factors. Finally, curve location did not predict variation in any of the studied time intervals. This finding, however, is limited by the discrepancy in sample sizes, four left thoracic curves compared 104 right thoracic curves. Missing data for curve location also contributed to sample size issues (Table 1). Of the procedure-specific factors, osteotomy use

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was the most pervasive, increasing surgery and total room time. Heller et al.10 found that the use of osteotomy increases surgery time by 13%. Our findings confirm the significant effect of osteotomies on OR time and further break this down into number of osteotomies performed, with each level of osteotomy adding 14.9 minutes to surgery time and 16.4 minutes to total room time. We found that additional screws increased surgery time and total room time. Although we also found that additional fusion levels predicted increased surgery and total room time, Heller et al.10 found only the number of screws to be significant predictors. Taken as a whole, the number of fusion levels likely predict OR times but may not be as consistent predictors as the addition of an osteotomy and increased number of screws. Finally, although Heller et al.10 found that each additional degree of the Cobb angle of the major curve increased surgery time, we did not find the Cobb angle to be predictive of any time interval. This suggests larger Cobb angles may be associated with more time in the OR but may not be as strong a predictor as osteotomy and increased number of screws. The results of this study can be used to improve OR efficiency through improving scheduling efficiency. Variability in procedure times leads to delayed start times, increased overtime costs, and underutilization when cases run unexpectedly short. It has been shown that surgeons are at least as good as certain commercial scheduling software at predicting case durations;25,26 however, variation is still present, with anywhere from a third to a half of cases being significantly overestimated or underestimated.25,27 A previous study showed that anesthesiologists significantly affect start times and surgeons have a significant effect on time after entering the OR.28 Promising work has already shown that creating models using factors identified as affecting variability leads to better estimates of case durations, and multiple studies have suggested that identification of patient and procedure factors, specifically, may lead to further improvement.19,26,29,30 The findings of this study, in combination with previous

work elucidating other factors, could be incorporated into a model that would improve scheduling and OR efficiency in pediatric spinal fusions. Specific to this study, surgeons and hospital systems attempting to complete two AIS PSF cases in the same room on the same day might choose to consider patient weight, planned osteotomies, and number of fusion levels when scheduling the cases.

Limitations and Future Study Perspectives One of the main limitations of this study is that the relatively small sample sizes of patients with rarer curve locations make it difficult to parse out significant differences that may exist. Furthermore, all procedures were performed at a single institution and may reflect its specific culture and framework. However, many of the factors and time points in this study are common to most institutions, making the results easily generalizable. Larger studies that include rarer curve locations would help to determine if these predict longer surgery times. Gender and age differences also require future investigation in regard to their effects on surgery time. The effect of obesity on OR times specifically during pediatric PSF would benefit from further study to corroborate the findings in this study.

CONCLUSIONS

Patient- and procedure-specific factors predict significant variation in OR times for pediatric PSF. BMI was a significant predictor of increased time in the OR. Osteotomy, number of screws used, and the number of fusion levels also were significant factors in predicting OR times. Age, gender, and ethnicity did not predict variation at any time interval. The results of this study suggest that OR efficiency can be improved through appropriate scheduling, as patient weight, planned osteotomies, and number of fusion levels should be taken into consideration when scheduling back-to-back surgeries.

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2. McCarthy IM, Hostin RA, Ames CP, et al. Total hospital costs of surgical treatment for adult spinal deformity: an extended follow-up study. Spine J 2014; 14:23262333. 3. Kamerlink JR, Quirno M, Auerbach JD, et al. Hospital cost analysis of adolescent idiopathic scoliosis correction surgery in 125 consecutive cases. J Bone Joint Surg Am 2010;92:1097-1104. 4. Vigneswaran HT, Grabel ZJ, Eberson CP, et al. Surgical treatment of adolescent idiopathic scoliosis in the United States from 1997 to 2012: an analysis of 20,346 patients. J Neurosurg Pediatr 2015;16:322-328. 5. Bech-Larsen SJ, Lalla M, Thorup JM. The influence of age, duration of symptoms and duration of operation on outcome after appendicitis in children. Dan Med J 2013;60:A4678. 6. Kim BD, Hsu WK, De Oliveira GS, et al. Operative duration as an independent risk factor for postoperative complications in single-level lumbar fusion: an analysis of 4588 surgical cases. Spine (Phila Pa 1976) 2014;39:510-520. 7.

Procter LD, Davenport DL, Bernard AC, et al. General surgical operative duration is associated with increased risk-adjusted infectious complication rates and length of hospital stay. J Am Coll Surg 2010;210:60-65.e1-2.

8. Scott CF Jr. Length of operation and morbidity: is there a relationships? Plast Reconstr Surg 1982;69:1017-1021. 9. Hartline J, Nolan V, Kelly DM, et al. Operating room personnel determine efficiency of pediatric spinal fusions for scoliosis. Spine Deformity 2019;7:702-708. 10. Heller A, Melvani R, Thome A, et al. Predictors of variability in the length of surgery of posterior instrumented arthrodesis in patients with adolescent idiopathic scoliosis. J Pediatr Orthop B 2016;25:258-262.

16. Bobin L, Maciolek-Blewniewska G, Malinowski A. [Operating time of laparoscopically assisted vaginal hysterectomy (LAVH)--the causative factors and the course of the postoperative period]. Ginekol Pol 2007;78:204-209. 17. Gadinsky NE, Manuel JB, Lyman S, et al. Increased operating room time in patients with obesity during primary total knee arthroplasty: conflicts for scheduling. J Arthroplasty 2012;27:1171-1176. 18. Kanazawa T, Ohta Y, Goutsu K, et al. [Significant factors affecting the operation time for benign parotid tumor]. Nihon Jiblinkoka Gakkai Kaiho 2008;111:481-485. 19. Bravo F, Levi R, Ferrari LR, et al. The nature and sources of variability in pediatric surgical case duration. Paediatr Anaesth 2015;25:999-1006. 20. Beaulé PE, Frombach AA, Ryu JJ. Working toward benchmarks in orthopedic OR efficiency for joint replacement surgery in an academic centre. Can J Surg 2015;58:408-413. 21. Rymaruk S, Buch K. How is time used within the orthopaedic trauma theatre? J Perioper Pract 2015;25:188-191. 22. Wasaterlain AS, Tran AA, Trang C, et al. Can we improve workflows in the OR? A comparison of quality perceptions and preoperative efficiency across institutions in spine surgery. Bull Hosp Jt Dis 2015;73:46-53 23. Sucato DJ, Hedequist D, Karol LA. Operative correction of adolescent idiopathic scoliosis in male patients. A radiographic and functional outcome comparison with female patients. J Bone Joint Surg Am 2004;86A:2005–2014. 24. Marks M, Petcharaporn M, Betz RR, et al. Outcomes of surgical treatment in male versus female adolescent idiopathic scoliosis patients. Spine (Phila Pa 1976) 2007;32:544-549. 25. Pandit JJ, Carey A. Estimating the duration of common elective operations: implications for operating list management. Anaesthesia 2006; 61:768-776.

11. Strum DP, Sampson AR, May JH, et al. Surgeon and type of anesthesia predict variability in surgical procedure times. Anesthesiology 2000;92:1454-1466.

26. Wright IH, Kooperberg C, Bonar BA, et al. Statistical modeling to predict elective surgery time. Comparison with a computer scheduling system and surgeonprovided estimates. Anesthesiology 1996;85:1235-1245.

12. Awad SS, Fagan SP, Bellows C, et al. Bridging the communication gap in the operating room with medical team training. Am J Surg 2005;190:770-774.

27. Laskin DM. Abubaker AO, Strauss RA. Accuracy of predicting the duration of a surgical operation. J Oral Maxillofac Surg 2013;71:446-447.

13. Beebe AC, Arnott L, Klamar JE, et al. Utilization of orthopaedic trauma surgical time: an evaluation of three different models at a Level I pediatric trauma center. Orthop Surg 2015;7:333-337.

28. Hartline J, Nolan VD, Kelly DM, et al. Operating room personnel determine efficiency of pediatric spinal fusions for scoliosis. Spine Deformity 2019; 7(5):702708.

14. Kadhim M, Gans I, Baldwin K, et al. Do surgical times and efficiency differ between inpatient and ambulatory surgery centers that are both hospital owned? J Pediatr Orthop 2016;36:423-428.

29. Kayis E, Wang H, Patel M, et al. Improving prediction of surgery duration using operational and temporal factors. AMIA Ann Symp Proc 2012;456-462.

15. Maruthappu M, Duclos A, Zhou CD, et al. The impact of team familiarity and surgical experience on operative efficiency: a retrospective analysis. J R Soc Med 2016;109:147-153.

30. Stepaniak PS, Heij C, Mannaerts GH, et al. Modeling procedure and surgical times for current procedural terminology-anesthesia-surgeon combinations and evaluation in terms of case-duration prediction and operating room efficiency: a multicenter study. Anesth Analg 2009;109:1232-1245.

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Jacob T. Hartline, MD1 Tyler J. Brolin, MD2 Jim Y. Wan, PhD3 Daniel T. Dibaba, PhD4 Frederick M. Azar, MD2 Thomas W. Throckmorton, MD2 1

University of Maryland Medical System Baltimore, Maryland

University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering Memphis, Tennessee

University of Tennessee Health Science Center Department of Preventative Medicine Memphis, Tennessee

University of Tennessee Health Science Center, Tennessee Clinical and Translational Science Institute Memphis, Tennessee

The Eﬀect of Subscapularis Management Technique on Outcomes and Complication Rates Following Reverse Total Shoulder Arthroplasty ABSTRACT Background

Repair of the subscapularis tendon following rTSA has been shown to decrease postoperative dislocations in some studies, but the effect of repair on other outcomes has not been defined. We proposed to assess differences in postoperative pain, function, range of motion, strength, complications, and reoperations after three types of management of the subscapularis tendon—primary repair (tendon-to-tendon), transosseous repair, and no repair—at a minimum of two years of follow-up after rTSA.

Methods Review of an institutional database identified patients with primary rTSA treated by a single surgeon using the same operative technique and implant (medial glenoid with lateral humeral implant) except for subscapularis repair (tendon-to-tendon repair, trans-osseous repair, no repair). Patients with revision rTSA, anatomic TSA, hemiarthroplasty, or surgery for proximal humeral fracture, nonunion, or malunion were excluded.

Results Of 210 patients meeting inclusion criteria, 82 (39%) had primary tendon repair of the subscapularis (PTR), 88 (41.9%) had transosseous repair (TOR), and 40 (19%) did not have the subscapularis repaired (NR). Of all demographics and comorbidities measured, the only significant differences among treatments groups were in gender (54.9% female in PTR, 43.2%in TOR, and 72.5% in NR, p = 0.008) and subscapularis status before surgery (89% intact in PTR, 80.7% in TOR, and 38.5% in NR, p < 0.001). There were significantly more patients in the NR group whose operative indication was massive rotator cuff tear compared to the TO and PR groups. Similarly, there were significantly more patients whose operative indication was primary osteoarthritis in the TR group over the PR group, and the PR group over the NR group. There were no significant differences in complication rates (11% PTR, 13.6% TOR, 15% NR, p = 0.79) or reoperation rates (PTR 2.4%, TOR 2.3%, NR 5.0%, p = 0.66) or associations between subscapularis management technique and reoperation or complication rates.

Conclusion Corresponding Author Thomas W. Throckmorton, MD 1400 S. Germantown Road Germantown, TN 38138 P: 901-759-3110 F: 901-759-3195 tthrockmorton@campbellclinic.com

Subscapularis management technique in rTSA did not affect complication or reoperation rates, and the procedure led to improvements in pain, function, range of motion, and strength in all three treatment groups. Repair of the subscapularis, regardless of technique, led to greater improvements in pain compared to no repair, although this may be partially attributable to better preoperative subscapularis status in the repair groups. Both repair techniques led to equal improvements in all measured outcomes, with the exception of primary tendon repair producing more improvement in ER strength compared to transosseous repair.

Level of evidence Level III; Case Control Study CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

Robert F. Murphy, MD1 David Williams, MD2 Grant D. Hogue, MD3 Howard Epps, MD5 Henry G. Chambers, MD6 Benjamin J. Shore, MD7 David D. Spence, MD4 1

Orthopaedics and Physical Medicine Medical University of South Carolina Charleston, SC

The Institutional Centers for Clinical and Translational Studies Boston Children's Hospital Boston, Massachusetts

The Department of Orthopaedic Surgery University of Texas Health Science Center in San Antonio San Antonio, Texas

The Campbell Clinic Memphis, Tennessee

The Texas Children’s Hospital Houston, Texas

The Rady Children’s Hospital San Diego, California

The Department of Orthopaedic Surgery Boston Children’s Hospital Boston, Massachusetts

This abstract was reproduced with permission from the Journal of the American Academy of Orthopaedic Surgeons: Murphy RF, Williams D, Hogue GD, Spence DD, et al: Prophylaxis for Pediatric Venous Thromboembolism: Current Status and Changes Across Pediatric Orthopaedic Society of North America from 2011, J Am Acad Orthop Surg 2020 May1; 28(9):388-394.

Corresponding Author David D. Spence, MD 1400 S. Germantown Road Germantown, TN 38138 P: 901-759-3226 F: 901-759-3195 tthrockmorton@campbellclinic.com

Prophylaxis for Pediatric Venous Thromboembolism: Current Status and Changes Across Pediatric Orthopaedic Society of North America from 2011 Introduction Pediatric venous thromboembolism (VTE) is a concern for orthopaedic surgeons. We sought to query the Pediatric Orthopaedic Society of North America (POSNA) members on current VTE prophylaxis practice and compare those results with those of a previous survey (2011).

Methods A 35-question survey was emailed to all active and candidate POSNA members. The survey consisted of questions on personal and practice demographics; knowledge and implementation of various VTE prophylaxis protocols, mechanical and chemical VTE prophylaxis agents, and risk factors; and utilization of scenarios VTE prophylaxis agents for various clinical scenarios. One- and two-way frequency tables were constructed comparing results from the current survey and those of the 2011 survey.

Results Two hundred thirty-nine surveys were completed (18% respondent rate), with most respondents from an academic/university practice reporting one or two partners (>60%). Half were in practice >15 years, and >90% reported an almost exclusive pediatric practice. One-third of the respondents reported familiarity with their institution-defined VTE prophylaxis protocol, and 20% were aware of an institutionally driven age at which all patients receive VTE prophylaxis. The most frequently recognized risk factors to guide VTE prophylaxis were oral contraceptive use, positive family history, and obesity. Respondents indicated a similar frequency of use of a VTE prophylaxis agent (either mechanical or chemical) for spinal fusion, hip reconstruction, and trauma (60% to 65%), with lower frequency for neuromuscular surgery (34%) (P < 0.001). One hundred thirty-seven respondents had a patient sustain a deep vein thrombosis, and 66 had a patient sustain a pulmonary embolism. Compared with responses from 2011, only 20 more respondents reported familiarity with their institution VTE prophylaxis protocol (75 versus 55). In 2018, aspirin was used more frequently than in 2011 (52% versus 19%; P<0.0001) and enoxaparin was used less frequently (20% versus 41%; P < 0.0001).

Discussion Over the past 7 years since the first POSNA survey on VTE prophylaxis, most POSNA members are still unaware of their institution specific VTE prophylaxis protocol. Most respondents agree that either mechanical or chemical VTE prophylaxis should be used for spinal fusion, hip reconstruction, and trauma. The use of aspirin as an agent of chemical VTE prophylaxis has increased since 2011.

Level of Evidence Level IV. Type of evidence: therapeutic

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

Zachary K. Pharr, MD1 Carson M. Rider, MD2 Jack W. Bell, BS3 James H. Wilde, BS3 Timothy J. Westbrooks, BS4 Patrick C. Toy, MD1 1

University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering Memphis, Tennessee

Foot Ankle Fellowship Hospital for Special Surgery New York, New York

University of Tennessee Health Science Center College of Medicine Memphis, Tennessee

Orthopaedic Surgery University of Kentucky Lexington, Kentucky

Outpatient Hip Safety in an Ambulatory Surgery Center Is Independent of Approach ABSTRACT Background There are few data comparing the direct anterior approach (DAA) and posterior approach (PA) for total hip arthroplasty (THA) in the outpatient setting. The purpose of this study is to compare 90-day complications between the 2 approaches. We hypothesized that they would be equally safe and effective.

Methods Retrospective review identified 432 THAs (346 DAA, 86 PA) performed at a single ambulatory surgery center (ASC). Outcomes compared included demographics, comorbidities, preoperative and discharge pain scores (visual analog scale [VAS]), overall time spent in the ASC, overnight stay, emergency room visits, admission, reoperation, and complications within a 90-day period.

Results There were no differences in mean preoperative VAS (DAA 4.7, PA 4.5), mean discharge VAS (DAA 0.8, PA 0.7), overall time spent in the ASC (DAA 9.0 hours, PA 9.3 hours), total number of overnight stays (DAA 0.9%, PA 1.2%), emergency room visits (DAA 1.7%, PA 1.2%), admissions (DAA 1.4%, PA 1.2%), reoperations (DAA 1.4%, PA 1.2%), or complications (DAA 3.5%, PA 2.3%).

Conclusion There were no differences in the safety outcomes, and overall there were few complications in the 90-day period, regardless of the surgeon’s preferred approach. This study indicates both DAA and PA are equally safe for THA in the outpatient setting, and the choice of surgical approach should be based on patient and surgeon preference.

Corresponding Author Patrick C. Toy, MD 1458 W. Poplar Avenue, Suite 100 Collierville, TN 38017 P: 901-759-5537 F: 901-435-5653 ptoy@campbellclinic.com

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

Spencer M. Richardson, BA1 Chloe Hundman, BS1 Richard A. Smith, PhD2 Jeﬀrey R. Sawyer, MD2,3 Derek M. Kelly, MD2,3 David D. Spence, MD2,3 Benjamin W. Sheﬀer, MD2,3 William C. Warner Jr, MD2,3 1

College of Medicine University of Tennessee Health Science Center Memphis, Tennessee

University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering Memphis, Tennessee

Le Bonheur Children's Hospital Memphis, Tennessee

Eﬀect of Intrawound Vancomycin Powder on Postoperative Drain Output in Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis Background Increased postoperative drain output after posterior spinal fusion (PSF) has been associated with increased risk of infection, but there is little information on the risk factors for increased postoperative drainage in patients with subcutaneous drains. We hypothesized that intrawound vancomycin powder is a risk factor for increased postoperative drainage.

Methods Record review identified 375 patients with PSF for adolescent idiopathic scoliosis. Patient demographics and intraoperative data were gathered from the operative report, anesthesia records, and intra-operative nursing records. Drain output was recorded for every post-operative day until the drain was removed.

Results The use of vancomycin powder was not associated with increased drainage and patients who received intrawound vancomycin powder had decreased postoperative drainage when compared to untreated patients (414.10 ± 370.91 mL and 622.78 ± 517.46; p≤0.001). Subfascial drains had higher drain output than suprafascial drains. Postoperative drainage from subfascial drains was positively correlated to estimated blood loss, volume of cell saver returned, units of thrombin administered, number of vertebrae fused, units of fresh frozen plasma, and units of red blood cells transfused. Only the number of vertebrae fused and volume of red blood cells transfused intraoperatively were significantly correlated with drain output in suprafascial drains.

Conclusions The use of vancomycin powder was not associated with increased drainage, and patients who received intrawound vancomycin powder had decreased postoperative drainage when compared to untreated patients. Vancomycin powder was associated with decreased drainage in subfascial drains, but not suprafascial drains.

Level of evidence Corresponding Author Benjamin W. Sheffer, MD 7545 Airways Boulevard Southaven, Mississippi 38671 P: 901-759-3225 F: 901-435-5789 bsheffer@campbellclinic.com

Level III, retrospective comparative cohort study

INTRODUCTION The reported incidence of surgical site infections (SSIs) after correction of adolescent idiopathic scoliosis (AIS) ranges from 0.5% to 3%, with a much higher prevalence after correction of non-idiopathic scoliosis1–4. Prevention of SSIs after correction of scoliosis is an important because

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

of significant cost and morbidity associated with multiple debridements, implant removal, and prolonged hospital stays. Practices such as the placement of subcutaneous drains5,6 and use of intrawound topical vancomycin powder7–9 have been proposed as possible mechanisms to lower SSI risk in pediatric spinal surgery, but their use varies among surgeons, with no universally accepted criteria for their use in the treatment of AIS.10–12 Although little information exists in the literature regarding risk factors for increased postoperative drainage after posterior spinal fusion (PSF) in AIS surgery, increased drainage has been suggested to increase the risk of delayed infection.5 Investigations of the use of postoperative drains in PSF for AIS have shown that patients with drains placed deep to the closed fascial layers are more likely to require transfusions postoperatively than those with suprafascial drains.6,12,13 The volume of drainage is, therefore, thought to increase with deep drains because the greatest amount of bleeding occurs in this location and subfascial drains may not allow adequate wound tamponade. Tranexamic acid (TXA) is known to decrease the rate of postoperative bleeding in patients undergoing PSF for AIS.15 The effect of vancomycin powder on postoperative drain output has not been examined in patients with PSF for AIS. Studies of vancomycin powder use in adult spinal surgery have reported similar durations of postoperative drainage in untreated patients and those treated with vancomycin powder, but the total volume drained in these studies was not reported.16,17 Seroma formation has been reported to occur in 4.4% of adult patients with hip arthroplasty and intrawound vancomycin powder,18 but is less frequent in adult spinal surgery (0.28%).19,20 We hypothesized that intrawound vancomycin powder would be associated with increased postoperative drainage.

weight(kg)/height(m2). Data on attending surgeon, number of vertebrae fused, number of osteotomies, estimated blood loss, volume of cell saver used, position of drain, units of fresh frozen plasma, units of blood, use of vancomycin powder in allograft, units of thrombin, and milligrams of TXA were gathered from the operative report, anesthesia records, and intra-operative nursing records. Drain output was recorded for every post-operative day until the drain was removed. Follow-up data included seroma or hematoma formation. Categorical variables were compared with chisquared tests and continuous measurements were compared with t-tests. Significance was determined at p-values <0.05.

RESULTS

Of 631 patients identified, 256 were excluded because of diagnoses other than AIS, leaving 375 patients with AIS treated with PSF. Patients were excluded if they had juvenile idiopathic scoliosis with onset at less than 10 years of age, scoliosis due to a neuromuscular disease, congenital scoliosis, a history of thoracic surgery, intraspinal lesions such as syringomyelia, Chiari malformation or tethered cord, Scheuermann kyphosis, intraspinal tumors, a history of spinal trauma, or prior spinal surgery. Five patients were excluded for inadequate recording of drain output. Of the 375 patients in the study, 74% (277) were female, and 67% (252) had intrawound vancomycin powder. Subfascial drains were used in 182 patients (49%), suprafascial drains in 174 (46%), and both subfascial and suprafascial drains in 4 (1.1%). Records of 15 patients did not include drain location. All surgeries were performed

Figure 1

MATERIALS AND METHODS

Approval was obtained from the authors’ Institutional Review Board, and a list was generated of all patients who had PSF from March, 2008, to May, 2018. Only patients with AIS treated with SPF were included in the study. The patients’ age, sex, weight, and height were gathered from the electronic medical record and body mass index (BMI) was calculated with the equation CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

Figure 2

Figure 3

by 5 pediatric fellowship-trained surgeons at one institution. Subfascial drains had significantly higher drainage than suprafascial drains (Figure 1). The estimated blood loss, volume of cell saver returned, units of thrombin administered, number of vertebrae fused, volume of fresh frozen plasma, and units of red blood cells transfused intraoperatively were positively correlated with total drain output in patients with subfascial drains (Table 1). Total drain output in patients with suprafascial drains was positively correlated with only the number of vertebrae fused and units of red blood cells transfused intraoperatively (Table 2). Tranexamic acid (TXA) was negatively correlated with postoperative drainage in both drain positions (Table 1 and Table 2). A chi-square test of independence showed no sig-

nificant association between intrawound vancomycin powder and hematoma/seroma formation, X2 (1, N = 375) = 0.82, p = 0.37). The frequency of hematoma or seroma formation was 2.4% (3 patients) in untreated patients and 1.2% (3 patients) in those treated with vancomycin powder. Patients with subfascial drains had more frequent hematoma/seroma formation (2.7%, 5 patients) than patients with suprafascial drains (0.57%, 1 patient), X2 (1, N = 356) = 2.5, p = .11). Mean drain output was significantly lower in patients who received vancomycin powder compared to patients not treated with intrawound vancomycin (Figure 2). Patients who received TXA had significantly less drain output than those who did not receive TXA (Figure 3). Patients who did not receive TXA and were treated with intrawound vancomycin powder had a lower mean drain output (490.31 ± 362.39 mL) than those not treated with vancomycin powder (646.12 ± 529.00 mL), but this did not reach statistical significance (p=0.111). The use of vancomycin powder in patients with subfascial drains who did not receive

Table 1: Factors Correlated With Postoperative Drainage in Patients with Subfascial Drains (n=182) Correlation Coeﬃcient

p-value

Age

0.062

0.409

Estimated blood loss

0.397

<0.001

Volume of cellsaver returned

0.404

<0.001

Units thrombin

0.313

<0.001

Body mass index

0.051

0.492

Number of vertebrae fused

0.318

<0.001

Number of osteotomies

0.083

0.268

Units of fresh frozen plasma

0.153

0.039

Units of red blood cells transfused

0.211

0.004

-0.286

<0.001

Tranexamic acid

Figure 4

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

Table 2: Factors Correlated With Postoperative Drainage in Patients with Subfascial Drains (n=182) Correlation Coeﬃcient

p-value

Age

0.005

0.949

Estimated blood loss

0.131

0.084

Volume of cellsaver returned

0.129

0.068

Units thrombin

0.086

0.265

Body mass index

0.004

0.963

Number of vertebrae fused

0.215

0.004

Number of osteotomies

-0.011

0.887

Units of fresh frozen plasma

0.036

0.639

Units of red blood cells transfused

0.184

0.015

Tranexamic acid

-0.264

<0.001

TXA was associated with decreased postoperative drainage (Figure 4); however, patients with suprafascial drains who were not treated with TXA did not show a difference in drain output between vancomycin powder treatments (Table 3).

DISCUSSION

Intrawound vancomycin powder and placement of subcutaneous drains are common after PSF in AIS surgery.10,11 The benefits and risk of these interventions continue to be debated in the literature. The potential interaction between intrawound vancomycin powder and volume of drainage has not previously been described in PSF for AIS. This study hypothesized that intrawound vancomycin powder would increase the volume of postoperative drainage after PSF in AIS patients. We found, however, that the use of vancomycin powder was not associated with increased drainage and patients who received intrawound vancomycin powder had decreased postoperative drainage com-

pared to untreated patients (Figure 2). Subfascial drains had higher drain output than suprafascial drains, as has previously been suggested (Figure 1).12,13 A recent review found that total postoperative drain volume was positively correlated with the volume of cell saver returned, units of packed red blood cells (RBCs) transfused, and the number of Ponte osteotomies.14 Our study differs from this review because only 1.1% of our patients had both subfascial and suprafascial drains placed compared to 72% in their review. We also report a much lower rate of Ponte osteotomies (9.9% compared to 76%). The number of Ponte osteotomies was not correlated with postoperative drainage in patients with subfascial or suprafascial drains (Table 1 and Table 2). Postoperative drainage from subfascial drains was found to be positively correlated with estimated blood loss, volume of cell saver returned, units of thrombin administered, units of fresh frozen plasma, and units of RBC transfused (Table 1). Only the number of vertebrae fused and volume of RBC transfused intraoperatively were significantly correlated with drain output in suprafascial drains (Table 2). Vancomycin powder was associated with decreased drainage in subfascial drains, but not suprafascial drains (Table 3). We found no difference in seroma/hematoma formation between treatment groups. Previous reports of seroma formation after the use of vancomycin powder may represent postoperative infections that are culture-negative because of high levels of vancomycin powder, as has been suggested by previous authors.20 Limitations of this study are its retrospective nature that did not allow for carefully managed control groups. The use of tranexamic acid (TXA) is known to decrease postoperative bleeding after PSF in AIS surgery and began to be used at our institution around the same time as intrawound vancomycin powder.15 Thus, we divided patients into subfascial and supra-

Table 3: Postoperative Drain Output after Treatment with Intrawound Vancomycin Powder in Patients Who did not Receive Tranexamic Acid Drain Location Subfascial

Suprafascial

Use of Vancomycin powder

Postoperative Drain Volume (mL)

p-value

Yes

771.69 ± 308.86

0.003

1088.77 ± 510.61

Yes

314.35 ± 283.04

340.58 ± 275.16

0.714

*Equal variances not assumed.

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

fascial drain groups and examined those who had received vancomycin powder but had not been treated with TXA. Those with subfascial drains treated with vancomycin powder showed a significant decrease in postoperative drainage compared those without (Figure 3). There was no difference in patients with suprafascial drains (Table 3).

Our study failed to find an association between intrawound vancomycin powder and increased postoperative drain output in patients undergoing PSF for AIS. Surprisingly, intrawound vancomycin was associated with decreased drain output.

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Reames DL, Smith JS, Fu KMG, et al. Complications in the surgical treatment of 19,360 cases of pediatric scoliosis: a review of the Scoliosis Research Society Morbidity and Mortality database. Spine (Phil Pa 1976). 2011;36:1484–1491. doi: 10.1097/BRS.0b013e3181f3a326.

2. Mackenzie WGS, Matsumoto H, Williaks BA, et al. Surgical site infection following spinal instrumentation for scoliosis: a multicenter analysis of rates, risk factors, and pathogens. J Bone Joint Surg Am. 2013; 95:800–806. doi: 10.2106/ JBJS.L.00010. 3. Rihn JA, Lee JY, Ward WT. Infection after the surgical treatment of adolescent idiopathic scoliosis: evaluation of the diagnosis, treatment, and impact on clinical outcomes. Spine (Phil Pa 1976). 2008; 33:289–294. doi: 10.1097/ BRS.0b013e318162016e 4. Cahill PJ, Warnick DE, Lee MJ, et al. Infection after spinal fusion for pediatric spinal deformity: thirty years of experience at a single institution. Spine (Phil Pa 1976). 2010; 35:1211–1217. doi: 10.1097/BRS.0b013e3181c212d1. 5. Ho C, Sucato DJ, Richards BS. Risk factors for the development of delayed infections following posterior spinal fusion and instrumentation in adolescent idiopathic scoliosis patients. Spine (Phil Pa 1976). 2007;32:2272–2277. doi: 10.1097/BRS.0b013e31814b1c0b. 6. Blank J, Flynn JM, Bronson W, et al. The use of postoperative subcutaneous closed suction drainage after posterior spinal fusion in adolescents with idiopathic scoliosis. J. Spinal Disord Tech. 2003; 16:508–512. doi: 10.1097/00024720200312000-00004. 7.

Thompson GH, Poe-Kochert C, Hardesty CK, et al. Does vancomycin powder decrease surgical site infections in growing spine surgery? A preliminary study. J Bone Joint Surg Am. 2018; 100:466– 471. doi: 10.2106/JBJS.17.00459.

11. Glotzbecker MP, Vitale MG, Shea KG, et al; POSNA Committee on the Quality, Safety, Value Initiative (QSVI). Surgeon practices regarding infection prevention for pediatric spinal surgery. J Pediatr Orthop.2013; 33:694–699. doi: 10.1097/ BPO.0b013e31829241b8. 12. Diab M, Smucny M, Dormans JP, et al. Use and outcomes of wound drain in spinal fusion for adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2012; 37:966–973. doi: 10.1097/BRS.0b013e31823bbf0b. 13. Ovadia D, Drexler M, Kramer M, et al. Closed wound subfascial suction drainage in posterior fusion surgery for adolescent idiopathic scoliosis: a prospective randomized control study. Spine (Phila Pa 1976). 2019; 44:377–383. doi: 10.1097/ BRS.0000000000002892. 14. Choi D, Vives MJ, Shah H, et al. Do postoperative drain volumes correlate with intraoperative blood loss and postoperative transfusion requirements in posterior spinal fusion for adolescent idiopathic scoliosis? J Pediatr Orthop B. 2019; 28:368373. doi: 10.1097/BPB.0000000000000568. 15. Goobie SM, Zurakowski D, Glotzbecker MP, et al. Tranexamic acid is efficacious at decreasing the rate of blood loss in adolescent scoliosis surgery: a randomized placebo-controlled trial. J Bone Joint Surg Am. 2018; 100:2024–2032. doi: 10.2106/JBJS.18.00314. 16. Hida T, Ando K, Kobayashi K, et al. Intrawound vancomycin powder as the prophylaxis of surgical site infection after invasive spine surgery with a high risk of infection. Nagoya J Med Sci. 2017; 79:545–550. doi: 10.18999/nagjms.79.4.545. 17. Kim HS, Lee SG, Kim WK, et al. Prophylactic intrawound application of vancomycin powder in instrumented spinal fusion surgery. Korean J Spine. 2013; 10:121–125. doi: 10.14245/kjs.2013.10.3.121.

8. Gans I, Dormans JP, Spiegel DA, et al. Adjunctive vancomycin powder in pediatric spine surgery is safe. Spine (Phil Pa 1976). 2013; 38:1703–1707. doi: 10.1097/BRS.0b013e31829e05d3.

18. Dial BL, Lampley AJ, Green CL, et al. Intrawound vancomycin powder in primary total hip arthroplasty increases rate of sterile wound omplications. Hip Pelvis. 2018; 30:37–44. doi: 10.5371/hp.2018.30.1.37.

9. Armaghani SJ, Menge TJ, Lovejoy SA, et al. Safety of topical vancomycin for pediatric spinal deformity: nontoxic serum levels with supratherapeutic drain levels. Spine (Phil Pa 1976). 2014; 39:1683–1687. doi: 10.1097/ BRS.0000000000000465.

19. Van Hal M, Lee J, Laudermilch D, et al. Vancomycin powder regimen for prevention of surgical site infection in complex spine surgeries. Clin Spine Surg. 2017; 30:E1062–E1065. doi: 10.1097/BSD.0000000000000516.

10. Vitale MG, Riedel MD, Glotzbecker MP, et al. Building consensus: development of a Best Practice Guideline (BPG) for surgical site infection (SSI) prevention in high-risk pediatric spine surgery. J Pediatr Orthop. 2013; 33:471–478. doi: 10.1097/ BPO.0b013e3182840de2.

20. Ghobrial GM, Cadotte DW, Williams K, et al. Complications from the use of intrawound vancomycin in lumbar spinal surgery: a systematic review. Neurosurg Focus. 2015; 39: E11. doi: 10.3171/2015.7.FOCUS15258.

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

Robert J. Stewart, MD1 Carson D. Strickland, MD2 Jeﬀrey R. Sawyer, MD3 Padam Kumar, BS4 Busra Gungor, BS4 Mindy Longjohn, MD, MPH5 Derek M. Kelly, MD3 Rudy J. Kink MD6 1

Le Bonheur Children's Hospital Memphis, Tennessee.

Le Bonheur Children's Hospital Memphis, Tennessee Department of Orthopaedic Surgery and Biomedical Engineering University of Tennessee-Campbell Clinic Memphis, Tennessee.

University of Tennessee Health Science Center College of Medicine Memphis, Tennessee.

Le Bonheur Children's Hospital Memphis, Tennessee Department of Pediatrics University of Tennessee Health Science Center Memphis, Tennessee.

Le Bonheur Children's Hospital Memphis, Tennessee Department of Emergency Medicine University of Tennessee Health Science Center College of Medicine Memphis, Tennessee

Hunger Games: Impact of Fasting Guidelines for Orthopedic Procedure Sedation in the Pediatric Emergency Department Background Fasting guidelines for pediatric procedural sedation have historically been controversial. Recent literature suggests that there is no difference in adverse events regardless of fasting status.

Objectives The goal of this study was to examine adverse outcomes and departmental efficiency when fasting guidelines are not considered during pediatric emergency department (PED) sedation for orthopedic interventions.

Methods Retrospective chart review identified 2674 patients who presented to a level I PED and required procedural sedation for orthopedic injuries between February 2011 and July 2018. This was a level III, retrospective cohort study. Patients were categorized into the following groups: already within American Society of Anesthesiologists (ASA) fasting guidelines on presentation to the PED (n = 671 [25%]), had procedural sedation not within the ASA guidelines (n = 555 [21%]), and had procedural sedation after fasting in the PED to meet ASA guidelines (n = 1448 [54%]). Primary outcomes were length of stay, time from admission to start of sedation, length of sedation, time from end of sedation to discharge, and adverse events.

Discussion There was a significant difference in the length of stay and time from admission to sedation—both approximately 80 min longer in those with procedural sedation after fasting in the PED to meet ASA guidelines (p < 0.001). There was no significant difference among groups in length of sedation or time to discharge after sedation. Adverse events were uncommon, with only 55 total adverse events (0.02%). Vomiting during the recovery phase was the most common (n = 17 [0.006%]). Other notable adverse events included nine hypoxic events (0.003%) and five seizures (0.002%). There was no significant difference in adverse events among the groups.

Conclusions Corresponding Author Rudy J. Kink, MD Department of Pediatrics University of Tennessee Health Science Center 50 N. Dunlap, Room 461R Memphis, TN 38103

Length of stay in the PED was significantly longer if ASA fasting guidelines were followed for children requiring sedation for orthopedic procedures. This is a substantial delay in a busy PED where beds and resources are at a premium. Although providing similar care with equivalent outcomes, the value of spending less time in the PED is evident. Overall, adverse events related to sedation are rare and not related to fasting guidelines.

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

FOR PATIENTS WITH OSTEOARTHRITIS KNEE PAIN

GO WITH A HYALURONIC ACID

DESIGNED FOR

PERFORMANCE

1,2*

GIVE THEM EUFLEXXA FOR LONG-LASTING PAIN RELIEF3† *In a well-controlled, 12-week, pivotal clinical trial, the primary endpoint measured noninferiority in safety and effectiveness between EUFLEXXA and Synvisc in 321 patients with confirmed OA of the knee. †In a 26-week, multicenter, randomized, double-blind trial, the primary endpoint measured efficacy between EUFLEXXA and saline in 588 patients with confirmed OA of the knee.

INDICATION EUFLEXXA® [1% sodium hyaluronate] is indicated for the treatment of pain in osteoarthritis [OA] of the knee in patients who have failed to respond adequately to conservative nonpharmacologic therapy and simple analgesics [eg, acetaminophen]. IMPORTANT SAFETY INFORMATION EUFLEXXA is contraindicated in patients who have a known hypersensitivity to hyaluronate preparations or who have knee joint infections, infections, or skin disease in the area of the injection site. EUFLEXXA should not be administered through a needle previously used with medical solutions containing benzalkonium chloride. Do not use skin disinfectants for skin preparation that contain quaternary ammonium salts. Do not inject intravascularly due to potential for systemic adverse events. The safety and effectiveness of injection in conjunction with other intra-articular injectables, or into joints other than the knee have not been studied. Remove any joint effusion prior to injecting. Transient pain or swelling of the injected joint may occur after intra-articular injection with EUFLEXXA. The most common adverse events related to EUFLEXXA injections reported in 12- and 26-week clinical studies were arthralgia, back pain, pain in extremity, musculoskeletal pain, and joint swelling. In an open-label extension of the 26-week clinical study with repeat series of injections, the most common adverse events related to EUFLEXXA at Week 52 were arthralgia and joint swelling.

BRIEF SUMMARY Please consult package insert for full Prescribing Information. INDICATION EUFLEXXA® (1% sodium hyaluronate) is indicated for the treatment of pain in osteoarthritis (OA) of the knee in patients who have failed to respond adequately to conservative non-pharmacologic therapy and simple analgesics (e.g., acetaminophen). CONTRAINDICATIONS • Do not use EUFLEXXA® to treat patients who have a known hypersensitivity to hyaluronan preparations. • Do not use EUFLEXXA® to treat patients with knee joint infections, infections or skin disease in the area of the injection site. WARNINGS • Mixing of quaternary ammonium salts such as benzalkonium chloride with hyaluronan solutions results in formation of a precipitate. EUFLEXXA® should not be administered through a needle previously used with medical solutions containing benzalkonium chloride. Do not use disinfectants for skin preparation that contain quaternary ammonium salts. • Do not inject intravascularly because intravascular injection may cause systemic adverse events. PRECAUTIONS General • Patients having repeated exposure to EUFLEXXA® have the potential for an immune response; however, this has not been assessed in humans. • Safety and effectiveness of injection in conjunction with other intra-articular injectables, or into joints other than the knee has not been established. • Remove any joint effusion before injecting. • Transient pain or swelling of the injected joint may occur after intra-articular injection with EUFLEXXA®. • Do not use after expiration date. • Protect from light. • Do not re-use—dispose of the syringe after use. • Do not use if the blister package is opened or damaged. Information for Patients • Transient pain and/or swelling of the injected joint may occur after intra-articular injection of EUFLEXXA®. • As with any invasive joint procedure, it is recommended that the patient avoid any strenuous activities or prolonged (i.e., more than 1 hour) weight-bearing activities such as jogging or tennis within 48 hours following intra-articular injection. • The safety of repeated treatment cycles of EUFLEXXA® has been established up to 1 year. Use in Specific Populations • Pregnancy: The safety and effectiveness of EUFLEXXA® have not been established in pregnant women. • Nursing Mothers: It is not known if EUFLEXXA® is excreted in human milk. The safety and effectiveness of EUFLEXXA® have not been established in lactating women. • Children: The safety and effectiveness of EUFLEXXA® have not been demonstrated in children. ADVERSE REACTIONS Adverse event information regarding the use of EUFLEXXA® as a treatment for pain in OA of the knee was available from two sources; a 12 week multicenter clinical trial conducted in Germany, and a 26 week multicenter trial conducted in the U.S. Report Device-Related Adverse Events The most common adverse events related to EUFLEXXA® injections reported in the clinical studies are arthralgia, back pain, pain in extremity, musculoskeletal pain and joint swelling. Potential Adverse Events Potential adverse events that may occur in association with intra-articular injections are arthralgia, joint swelling, joint effusion, injection site pain and arthritis. 12 Week Multicenter Clinical Study In a prospective randomized, double blinded, active control (commercially available hyaluronan product) study conducted at 10 centers. Three hundred twenty-one patients were randomized into groups of equal size to receive either EUFLEXXA® (n=160) or the active control (n=161). A total of 119 patients reported 196 adverse events; this number represents 54 (33.8%) of the EUFLEXXA® group and 65 (44.4%) of the active control group. There were no deaths reported during the study. Incidences of each event were similar for both groups, except for knee joint effusion, which was reported by 9 patients in the active control group and one patient in the EUFLEXXA® treatment group. A total of 160 patients received 478 injections of EUFLEXXA®. There were 27 reported adverse events considered to be related to EUFLEXXA® injections: arthralgia – 11 (6.9%); back pain – 1 (0.63%); blood pressure increase – 3 (1.88%); joint effusion – 1 (0.63%); joint swelling – 3 (1.88%); nausea – 1 (0.63%); paresthesia – 2 (1.25%); feeling of sickness of injection – 3 (1.88%); skin irritation – 1 (0.63%); tenderness in study knee – 1 (0.63%). Four adverse events were reported for the EUFLEXXA® group that the relationship to treatment was considered to be unknown: fatigue – 3 (1.88%); nausea – 1 (0.63%). 26 Week Multicenter Study In a multicenter, randomized, double-blind trial evaluating the efficacy and safety of EUFLEXXA® as compared with saline, in subjects with chronic osteoarthritis of the knee followed by an open labeled safety extension study. The intervention consisted of three (3) weekly injections of study device into the target knee, with scheduled follow-up evaluations during the 26 weeks following the first injection. In the extension phase subjects received three (3) weekly injections of EUFLEXXA® into the target knee with follow-up evaluation up to 52 weeks. Twenty-three serious TEAEs were reported in 19 (3.2%) subjects during the study: 10 (3.4%) subjects in the EUFLEXXA® group and 9 (3.1%) subjects in the saline group. One of these events was considered related to the study device (increased redness of the left knee joint in the EUFLEXXA® group). Eight (1.4%) subjects had 9 TEAEs leading to discontinuation: 3 (1.0%) subjects in the EUFLEXXA® group and 5 (1.7%) subjects in the saline group. Twelve (2.8%) subjects reported 20 TEAEs during the extension phase. Six of these subjects had received EUFLEXXA® during the core study. None of these serious TEAEs was considered related to the study device, and all resolved. Two (0.5%) subjects has TEAEs leading to discontinuation from the study, one of whom received EUFLEXXA® during the core study; both subjects had events that were considered unrelated to study device. This product is not made with natural rubber latex. See EUFLEXXA® DIRECTIONS FOR USE For more information, go to www.euflexxa.com. To report SUSPECTED ADVERSE REACTIONS, contact FERRING PHARMACEUTICALS Inc. at 1-888-FERRING (1-888-337-7464) or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. Rx only MANUFACTURED FOR:

Please see Brief Summary of full Prescribing Information on adjacent column. REFERENCES: 1. EUFLEXXA [package insert]. Parsippany, NJ: Ferring Pharmaceuticals Inc. 2. Kirchner M, Marshall D. A double-blind randomized controlled trial comparing alternate forms of high molecular weight hyaluronan for the treatment of osteoarthritis of the knee. Osteoarthritis Cartilage. 2006;14(2):154-162. 3. Altman RD, Rosen JE, Bloch DA, et al. A double-blind, randomized, saline-controlled study of the efficacy and safety of EUFLEXXA for treatment of painful osteoarthritis of the knee, with an open-label safety extension (the FLEXX Trial). Semin Arthritis Rheum. 2009;39(1):l-9.

PROTECT YOUR PATIENTS

Comprehensive Post-Operative Amputation Care

REMOVABLE RIGID DRESSINGS (RRD) RRDs protect the surgical site from bumps and falls. Decades of published evidence shows that RRDs: • Expedite healing, reduce pain and promote earlier ambulation • Control edema and prevent contractures • Allow for visual inspection of the leg at any time

AMPUSHIELD® Below Knee and Above Knee RRD Limb Protectors • Indicated for most transtibial and transfemoral amputation patients • Gentle on the surgical site • Flexible protocols for fitting and dressings • Measured and fit the same day for most patients BK AmpuShield

As the nation’s leading provider of orthotic and prosthetic solutions, Hanger Clinic has the expertise to empower your patients achieve their potential. * REFERENCES • Churilov I, Churilov L, Murphy. Do rigid dressing reduce the time from amputation to prosthetic fitting? A systematic review and meta-analysis. Ann Vasc Surg. 2014 Oct;28(7):1801-8. • Geertzen J et al. Dutch evidence-based guidelines for amputation and prosthetics for the lower extremity: Amputation surgery and postoperative management. Part 1. Prosthet Orthot Int. 2015 Oct;39(5):351-60. • Highsmith JM et al. Prosthetic interventions for people with transtibial amputation: Systematic review and meta-analysis of high-quality prospective literature and systematic review: J Rehabil Res Dev. 2016;52(2):157-84. • Nawijn SE, H van der Linde, CH Emmelot and CJ Hofstad. Stump management after transtibial amputation: A systematic review. Prosthet Orthot Int. 2005;29(1):13-26.

AK AmpuShield

• Wu Y, Keagy RD, Krick, Stratigos JS, Betts HB. An innovative removable rigid dressing technique for below-the-knee amputation. J Bone Joint Surg Am 1979; 61:724-9.

Interested in fitting your next amputation patient with AmpuShield?

CAMPBELL CLUB IN MEMORIAM

LISH E D

4 9 1

CA M

FOUND L L E AT B P

Kermit W. Fox, MD Isaac L. George, MD Marvin M. Gibson, MD Gary Giles, MD A. Lee Gordon, III, MD Harry R. Gossling, MD John T. Gray, MD Basil Griffin, MD Herbert Alfred Hamel, MD Joe Frank Hamilton, Jr., MD Joe Frank Hamilton, Sr., MD Richard M. Harkness, MD Benjamin L. Hawkins, MD David N. Hawkins, MD C. Leon Hay, MD Don Henard, MD Edward D. Henderson, MD Malcolm E. Heppenstall, MD George B. Higley, Sr., MD Kenneth C. Hill, MD John T. Hocker, MD Frank C. Hodges, MD Royce Hobby, MD John M. Hundley, MD Wiley C. Hutchins, MD Alvin J. Ingram, MD E.R. ‘Rickey’ Innis, MD Otis E. James, Jr., MD Leland H. Johnson, Jr., MD David S. Johnston, MD Orville N. Jones, MD Dan Klinar, MD Robert A. Knight, MD Timothy H. Krahn, MD F. E. Linder, MD Stanley Lipinski, MD Wayne B. Lockwood, MD John F. Lovejoy, MD William L. Lovett, MD Harry A. Luscher, MD Athey R. Lutz, MD Michael Lynch, MD H. B. Macey, MD Paul H. Martin, MD Juan A. Mayne, MD James M. McBride, MD Frank O. McGhee, MD C. C. McReynolds, MD I. S. McReynolds, MD Walter C. Metz, MD

Lee W. Milford, MD T. Rothrock Miller, MD Alfred F. Miller, MD William L. Minear, MD J. M. Mitchell, MD Joseph Mitchell, MD J. M. Mitchner, MD James D. Moore, MD Larry B. Morrison, MD James S. Mulhollan, MD John T. Murphy, MD Vernon Nickel, MD Arthur Osborne, MD W. Martin Payne, MD Samuel B. Prevo, MD George D. Purvis, MD R. Beverly Ray, MD Thomas A. Richardson, MD S. L. Robbins, MD R. C. Robertson, MD R. C. Rountree, MD Fred P. Sage, MD Stanley Schwartz, MD T. David Sisk, MD W. H. Sisler, MD Donald Slocum, MD Hugh Smith, MD J. Spencer Speed, MD William B. Stanton, MD Marcus J. Stewart, MD Bruce Stivers, MD Mario M. Stone, MD Henry Thomas Stratton, MD Ernest J. Tarnow, MD Ethan O. Todd, MD Robert E. Tooms, MD Phillip C. Trout, MD Thomas C. Turner MD Fredrico Van Domselaar, MD Keith D. VandenBrink, MD Isaac L. Van Zandt, MD John A. Vann, MD R. H. Walker, Jr., MD Thomas L. Waring, MD Gilbert G. Whitmer, MD James H. Wiley, MD Harold Williamson, MD Frank D. Wilson, MD Frederick C. Workmon, MD B. T. Wright, MD

N IO

Alfons Altenberg, MD Lewis D. Anderson, MD Robin Arena, MD Borden Bachynski, MD Troy Bagwell, MD James Barnett, MD Robert Basist, MD Henry Beck, MD Reginald V. Bennett, MD Dan R. Bigelow, MD Thomas H. Blake, Sr., MD W. Griffin Bland, MD Michael Bluhm, MD Harrison O. Bourkard, MD Robert L. Bourland, MD William J. Bourland, MD Harold B. Boyd, MD David M. Bratton, MD Hanes H. Brindley, Sr., MD Robert G. Brashear, MD Charles E. Brighton, MD Louis P. Britt, MD Joseph C. Burd, MD John G. Caden, MD Rocco A. Calandruccio, MD Willis C. Campbell, MD Dan Carlisle, MD Peter G. Carnesale, MD Charles O. Carothers, MD Charles A. Carraway, MD Paul A. Caviale, MD Tom Phillip Coker, MD Romulo E. Colindres, MD Harry Collins, MD Francis V. Costello, MD John M. Crates, MD P. Thurman Crawford, MD A. Hoyt Crenshaw, Sr., MD Henry I. Cross, MD Jere M. Disney, MD Daniel B. Eck, MD Thomas S. Eddleman, MD Allen S. Edmonson, MD J. Kendall Ethridge, MD E.W. Ewart, MD W. McDaniel Ewing, MD Edward L. Farrar, MD M. Craig Ferrell, MD Bryan Fleming, MD Dale E. Fox, MD

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

Know more. Cut less. Know how some things are simply better together? Like the knowledge that comes from a CT-based plan that captures each patient’s unique anatomy, and Mako’s AccuStop™ haptic technology, which helps you use this knowledge to precisely and accurately cut what you’ve planned.1,2,3 So you know more and cut less.4,5,6,7*

That’s Mako. SmartRobotics™.

Visit makosmartrobotics.com to learn more. * For the Mako Total Knee application, “cut less” refers to less soft tissue damage and greater bone preservation as compared to manual surgery.5,6 For the Mako Total Hip and Partial Knee applications, “cut less” refers to greater bone preservation as compared to manual surgery.4,7 1. Anthony I, Bell SW, Blyth M, Jones B et al. Improved accuracy of component positioning with robotic-assisted unicompartmental knee arthroplasty. J Bone Joint Surg Am. 2016;98-A(8):627-35. 2. Illgen, R, Bukowski, B, Abiola, R, Anderson, P, Chughtai, M, Khlopas, A, Mont, M. Robotic-assisted total hip arthroplasty: Outcomes at minimum two year follow up. Surgical Technology International. 2017 July 25; 30:365-372. 3. Mahoney O, Kinsey T, Mont M, Hozack W, Orozco F, Chen A. Can computer generated 3D bone models improve the accuracy of total knee component placement compared to manual instrumentation: a prospective multi-center evaluation? International Society for Technology in Arthroplasty 32nd Annual Congress. Toronto, Canada. October 2-5, 2019. 4. Suarez-Ahedo, C; Gui, C; Martin, T; Chandrasekaran, S; Domb, B. Robotic arm assisted total hip arthoplasty results in smaller acetabular cup size in relation to the femoral head size: A Matched-Pair Controlled Study. Hip Int. 2017; 27 (2): 147-152. 5. Haddad, F.S, et al. Iatrogenic Bone and Soft Tissue Trauma in Robotic-Arm Assisted Total Knee Arthroplasty Compared With Conventional Jig-Based Total Knee Arthroplasty: A Prospective Cohort Study and Validation of a New Classification System. J Arthroplasty. 2018 Aug;33(8):2496-2501. Epub 2018 Mar 27. 6. Hozack, W, Chen, A, Khlopas, A, Mahoney, O, Mont, M, Murray, T, Orozco, F, Higuera Rueda, C, Stearns, K. Multicenter Analysis of Outcomes after Robotic-Arm Assisted Total Knee Arthroplasty. American Academy of Orthopedic Surgeons Annual Meeting. Las Vegas, NV. March 12-16, 2019. 7. Banks, Scott A, PhD. Haptic Robotics Enable a Systems Approach to Design of a Minimally Invasive Modular Knee Arthroplasty. Am J Orthop. 2009;38(2 suppl):23-27. February 2009. A surgeon must always rely on his or her own professional clinical judgment when deciding whether to use a particular product when treating a particular patient. Stryker does not dispense medical advice and recommends that surgeons be trained in the use of any particular product before using it in surgery. The information presented is intended to demonstrate the breadth of Stryker’s product offerings. A surgeon must always refer to the package insert, product label and/or instructions for use before using any of Stryker’s products. Products may not be available in all markets because product availability is subject to the regulatory and/or medical practices in individual markets. Please contact your sales representative if you have questions about the availability of products in your area. Stryker Corporation or its divisions or other corporate affiliated entities own, use or have applied for the following trademarks or service marks: AccuStop, Mako, SmartRobotics, Stryker. All other trademarks are trademarks of their respective owners or holders. MKOSYM-AD-9_22370 Copyright © 2019 Stryker

2021 ORTHOPAEDIC FELLOWS TIMOTHY J. ASHWORTH, MD  TRAUMA FELLOW Hometown: Boise, Idaho Undergraduate Institution: Brigham Young University Medical School: Case Western Reserve University Orthopaedic Residency: University of North Carolina Dr. Ashworth is the oldest of seven brothers, and is the first in his family to pursue a medical career. Dr. Ashworth and his wife Candilyn met on a ropes course in the Utah mountains, and were married in 2009. Candilyn is a pianist and stay-at-home mom. They have three children - Max (10 years old), Jake (7 years old), and Bradley (one year old). When asked why he chose medicine as a career: I wanted a challenging profession where I could help people. And why he chose orthopaedics as a specialty: My undergrad was in mechanical engineering and it was a perfect fit to be able to continue using those skills and principles. I also liked the hands-on nature of the job. Research Activities: Dr. Ashworth prepared study design for a collaborative study with Brigham Young University evaluating the resiliency of a novel antimicrobial carbon nanotube coating on an orthopaedic implant and is working on a retrospective chart review study correlating the incidence of certain complications following surgical fixation of tibial pilon fractures with pre-existing patient characteristics. Plans After Campbell: Dr. Ashworth will be joining an orthopaedic trauma practice in Fort Wayne, Indiana. Dr. Ashworth adds: Thank you to Drs. Weinlein, Rudloff, Beebe and Cosgrove for all the fantastic training, and to all the residents who help to make the fellow experience here second to none!

AARON M. BAESSLER, MD  SPORTS MEDICINE FELLOW Hometown: Bartlett, Illinois Undergraduate Institution: University of Illinois at Urbana-Champaign Medical School: Chicago Medical School at Rosalind Franklin University Orthopaedic Residency: Indiana University School of Medicine Dr. Baessler is the youngest of three brothers, and is the first in his family to pursue a medical career. Dr. Baessler met his wife Lindsey on Tinder, and they were married in 2019. Lindsey is an RN. When asked why he chose medicine as a career: It seemed like the right thing to do. And why he chose orthopaedics as a specialty: “Medicine” wasn’t the right thing to do. I liked fixing things. Nothing is more complex than the musculoskeletal system, and it needs to be fixed at some point in nearly every human’s lifetime. Research Activities: Dr. Baessler prepared five manuscripts, all under review, for submission to peer-reviewed journals, and led the design on two new study protocols currently in progress. He assisted with data collection on three studies in progress and worked with residents, medical students, and Foundation staff to assist in study procedure implementation. Dr. Baessler also met with statistics resources to aid in data analysis of research project data. Plans After Campbell: Dr. Baessler will be joining a shoulder/sports practice in Indianapolis. Dr. Baessler adds: Thank you for having me here. Best year I’ve had - I have no doubt that fellowship has prepared me. The residents are well-trained and exceptional. The staff I’ve worked with are the best I’ve come across. Campbell Clinic has a reputation that is unrivaled, and I’ve seen it first hand.

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

2021 ORTHOPAEDIC FELLOWS TRAVIS A. DOERING, MD

 HAND FELLOW

Hometown: Branchburg, New Jersey Undergraduate Institution: Amherst College Medical School: Donald and Barbara Zucker School of Medicine Orthopaedic Residency: Northwell Health Dr. Doering is the older of two children, and is the first in his family to pursue a medical career. When asked why he chose medicine as a career: I chose to practice medicine to avoid staring at a computer screen all day. And why he chose orthopaedics as a specialty: I chose a career in orthopaedics so that I could use power tools and make people better. Research Activities: Dr. Doering prepared a study protocol for a randomized clinical trial evaluating a treatment modality for improving outcomes of distal biceps repair. He led the preparation and publication of a two review article in a peer review journal. Plans After Campbell: Dr. Doering will be in private practice in Austin, Texas. Dr. Doering adds: I would like to extend my deepest thanks and appreciation to Drs. Calandruccio, Mauck, Thompson, Weller and Jobe for teaching me the art and craft of hand surgery.

BENJAMIN B. LINDSEY, MD  FOOT & ANKLE FELLOW Hometown: Norfolk, Virginia Undergraduate Institution: University of Virginia Medical School: Medical College of Virginia Orthopaedic Residency: University of Michigan Dr. Lindsey is the older of two children, and is the first in his family to pursue a medical career. Dr. Lindsey met his wife Felicia, a social worker, while visiting UNC-Chapel Hill. They have a daughter, Lydia, who is one year old. When asked why he chose medicine as a career: I chose medicine due to a passion for science and a desire to tangibly apply that passion. And why he chose orthopaedics as a specialty: I chose orthopaedics due to both enjoyment of the technical aspects of orthopaedic surgery and a desire to improve patients’ functional abilities. Research Activities: Dr. Lindsey has taken the lead on a research project evaluating the intra- and inter-reliability of CPT coding by foot and ankle surgeons. He is also working on a systematic review evaluating mid-term outcomes of total talus replacements and a technique video for distraction subtalar arthrodesis through a posterior approach. He completed a technique article on percutaneous fixation of 5th metatarsal base fractures and presented an abstract on return to play following turf toe injuries at AOFAS at Home. Plans After Campbell: Dr. Lindsey will join OrthoSC in Myrtle Beach, South Carolina. Dr. Lindsey adds: I have been amazed at how friendly, talented, and helpful the residents and faculty are at the Campbell Clinic. Additionally, the support staff has been incredible. I am very appreciative for everyone’s help and support throughout the year, and am grateful for the experience I’ve had.

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

2021 ORTHOPAEDIC FELLOWS ANNA L. RAMBO, MD  PEDIATRIC FELLOW Hometown: Birmingham, Alabama Undergraduate Institution: Rhodes College Medical School: University of Mississippi Medical Center Orthopaedic Residency: University of South Alabama Dr. Rambo is the second of four children, and followed in the footsteps of her mother, a pulmonologist, to pursue a medical career. Dr. Rambo met her husband Lee, a civil engineer, while in residency in Mobile, Alabama. They are the proud parents of two large dogs - Ava and Bella When asked why she chose medicine as a career: I felt that medicine would be the only career with my personality that I would be able to have any type of positive impact in my community. I am also very similar to my mother and admired her for being a critical care physician. And why she chose orthopaedics as a specialty: I was initially drawn to orthopaedics because I liked the immediate correction and satisfaction that could be achieved through orthopaedic surgery, particularly in trauma and scoliosis cases. Research Activities: Dr. Rambo collaborated on research studies prior to beginning her fellowship with plans to continue the partnership in her practice. She has four manuscripts that have published in peer-reviewed journals and one currently under review. Dr. Rambo has worked on study design of two new projects and is currently supervising two research studies. Plans After Campbell: Dr. Rambo will join Nemours Children’s Hospital in Jacksonville, Florida, where there are two Campbell Clinic pediatric orthopaedic fellows. Dr. Rambo adds: I am so grateful to all my mentors at Campbell Clinic for giving me the opportunity to train here. I have had the best year so far of my training and think it is the best fellowship I could have asked for. I have learned so much and created so many good memories. I hope I make my mentors proud after I graduate.

SHUMAILA SARFANI, MD  FOOT & ANKLE FELLOW Hometown: San Antonio, Texas Undergraduate Institution: Rice University Medical School: Mayo Medical School Orthopaedic Residency: Vanderbilt University Dr. Sarfani is the older of two children, and is the first in her family to pursue a career in medicine. When asked why she chose medicine as a career: I loved my anatomy courses. And why she chose orthopaedics as a specialty: I appreciated being able to see pathology and make people consistently better. Research Activities: Dr. Sarfani has composed a manuscript concerning antibiotic use among foot and ankle surgeons of patients who are allergic to penicillin in conjunction with an allergist and our F&A surgeons; an outline for the manuscript has been accepted by a peer-reviewed journal. She led meetings with stats for analysis in conjunction with a medical student and has taken the lead on communication with our collaborative study site to evaluate mid-term outcomes of total ankle arthroplasty. Dr. Sarfani is also assisting with data collection on both the CPT and PED CAT research studies. Plans After Campbell: Dr. Sarfani will be in private practice in San Antonio, Texas. Dr. Sarfani adds: I can’t thank the foot and ankle staff enough for how much time they spent in clinic, in the OR, and just in general to teach me, let me operate, talk me through life decisions, and answer my million and one questions. I have learned so much from each of you and sincerely just had a lot of fun every day working with y’all. It is going to be hard to leave.

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

Aquamantys™ bipolar sealers may enable a surgeon to perform tourniquet-free total knee arthroplasty and direct anterior total hip arthroplasty

EASIER. BETTER.* FASTER. Advanced hemostatic sealing in orthopedic procedures Aquamantys™ 6.0 Bipolar Sealer

Aquamantys™ bipolar sealers combine radiofrequency energy with saline to produce high-integrity hemostatic sealing of soft tissue and bone in orthopedic procedures. Operating at almost 200° C less than traditional electrosurgery, Aquamantys™ devices produce nearly negligible smoke and have an increased depth of effect with less surface coagulum and char.1-3

Aquamantys™ MBS Malleable Bipolar Sealer

*Compared to traditional electrosurgery. Easier: Procyk S. The Transcollation: Short Hospitals Stay and Accelerated Recovery in Total Hip and Knee Arthroplasties Using a Radiofrequency Bipolar Sealer - an Innovative Approach in the Conceptualization of the Surgical Gesture. Natl Acad of Surg 2015:15(2):87-97 Better: Data on file. Report 81-10-5683. And Marulanda GA, Ragland PS, Seyler TM, Mont MA. Reductions in blood loss with use of a bipolar sealer for hemostasis in primary total knee arthroplasty. Surg Technol Int. 2005;14:281-286. Faster: Clement RC, Kamath AF, Derman PB, et al. Bipolar sealing in revision total hip arthroplasty for infection: efficacy and cost analysis. J Arthroplasty 2012;27(7):1376-1381. 1. Geller DA, Tsung A, Maheshwari V et al. Hepatic resection in 170 patients using saline-cooled radiofrequency coagulation. HPB 2005; 7:208-213. 2. Data on file. Report 81-10-5683. 3. Data on file. Report 81-10-5753. Rx only. Refer to product instruction manual/package insert for instructions, warnings, precautions and contraindications. © 2020 Medtronic. All rights reserved. Medtronic, Medtronic logo and Further, Together are trademarks of Medtronic. All other brands are trademarks of a Medtronic company. UC202103720 EN

Current Orthopaedic Residents INTERNS

CLINICAL YEAR 2

Andrew J. Couture, MD

Tyler E. Calkins, MD

Undergraduate: University of Central Arkansas Medical School: University of Arkansas for Medical Sciences College of Medicine

Undergraduate: West Virginia University Medical School: West Virginia University School of Medicine

Nolan D. Farrell, MD

David W. Cooper, MD

Undergraduate: The Ohio State University Medical School: Ohio State University College of Medicine

Undergraduate: Tusculum College Medical School: East Tennessee State University James H. Quillen College of Medicine

Andrew D. Gailey, MD

Zachary R. Diltz, MD

Undergraduate: Tulane University Medical School: University of North Carolina at Chapel Hill School of Medicine

Undergraduate: The University of Alabama Medical School: Ohio State University College of Medicine

Brenton R. Jennewine, MD

Ilya M. Gutman, MD

Undergraduate: Case Western Reserve University Medical School: University of Virginia School of Medicine

Undergraduate: The University of Alabama Medical School: University of Alabama School of Medicine

Andrew D. Nahr, MD

Claire E. Hays, MD

Undergraduate: Newman University Medical School: University of Kansas School of Medicine

Undergraduate: Louisiana State University Medical School: Louisiana State University School of Medicine

Evan R. Porter, MD

W. Colby Skinner, MD

Undergraduate: Drury University Medical School: Geisinger Commonwealth School of Medicine

Undergraduate: University of Georgia Medical School: Medical College of Georgia at Augusta University

Eric J. West, MD

Carson J. Smith, MD

Undergraduate: Lafayette College Medical School: The Brody School of Medicine at East Carolina University

Undergraduate: University of Miami Medical School: USF Health Morsani College of Medicine

Jacob T. Zalewski, MD

Clayton W. Wing, MD

Undergraduate: Sewanee: The University of the South Medical School: East Tennessee State University James H. Quillen College of Medicine

Undergraduate: University of Georgia Medical School: Medical College of Georgia at Augusta University

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

MORE THAN

8 MILLION ADULT PATIENTS HAVE RECEIVED EXPAREL SINCE 2012

Learn more at EXPAREL.com

Reference: Data on file. 6450. Parsippany, NJ: Pacira Pharmaceuticals Inc.; February 2021.

For full Prescribing Information, please visit www.EXPAREL.com or call 1-855-793-9727.

04/21

Current Orthopaedic Residents CLINICAL YEAR 3

CLINICAL YEAR 4

Seth R. Cope, MD

Nathaniel B. Alexander, MD

Undergraduate: Brigham Young University Medical School: University of Texas School of Medicine at San Antonio

Undergraduate: University of Arkansas Medical School: University of Arkansas for Medical Sciences College of Medicine

Austin Hardaway, MD

Stephanie N. Chen, MD

Undergraduate: The University of Alabama Medical School: University of Tennessee Health Science Center College of Medicine

Undergraduate: Case Western Reserve University Medical School: University of Toledo College of Medicine

Hayden S. Holbrook, MD

Travis B. Eason, MD

Undergraduate: Wake Forest University Medical School: Wake Forest School of Medicine

Undergraduate: North Carolina State University Medical School: Brody School of Medicine at East Carolina University

Caleb A. Jones, MD

Richard A. Hillesheim, MD

Undergraduate: Tyler Junior College Medical School: University of Texas School of Medicine at San Antonio

Undergraduate: Washington University in St. Louis Medical School: Sidney Kimmel Medical College at Thomas Jefferson University

Anthony J. Marois, MD Undergraduate: Wake Forest University Medical School: Wake Forest School of Medicine

Zachary A. Mosher, MD Undergraduate: Auburn University Medical School: University of Alabama School of Medicine – Huntsville

Austin B. Murphy, MD Undergraduate: Samford University Medical School: University of Alabama School of Medicine

David L. Parker, MD Undergraduate: Brigham Young University Medical School: University of North Dakota School of Medicine and Health Sciences

Daniel J. Smigielski, MD Undergraduate: University of Alabama Medical School: University of Tennessee Health Science Center College of Medicine

Eric D. Villereal, MD Undergraduate: University of Mississippi Medical School: University of Tennessee Health Science Center College of Medicine

Naveen Pattisapu, MD Undergraduate: University of Texas at Austin Medical School: Baylor College of Medicine

Devon Tobey, MD Undergraduate: University of Georgia Medical School: Mercer University School of Medicine

CAMPBELL ORTHOPAEDIC JOURNAL • VOLUME 7, 2021

MAZOR™ ROBOTIC GUIDANCE

PREDICTABILITY. PRECISION. VISIBILITY. medtronic.com/mazorandmidas

INDICATIONS: The Mazor X™ system is indicated for precise positioning of surgical instruments or spinal implants during general spinal surgery. It may be used in either open or minimally invasive or percutaneous procedures. Spinal implants are limited for use in certain disease states and spinal procedures, The Stealth-Midas™ system and The Midas Rex™ Attachments and Dissecting Tools for Mazor™ system are indicated for the incision/cutting, drilling, burring, and removal of hard tissue and bone in open and minimally invasive spine procedures. For instruments and implant-specific indications, contraindications, warnings, precautions, and other medical information please see the package inserts for the respective product(s). An electronic version of the package insert may be found at www.medtronic.com/manuals. © 2021 Medtronic. All Rights Reserved. Medtronic, Medtronic logo and Further, Together are trademarks of Medtronic. All other brands are trademarks of a Medtronic company. 826 Coal Creek Circle, Louisville, CO 80027 USA UC202119612 EN

Current

Orthopaedic Practice A REVIEW AND RESEARCH JOURNAL Current Orthopaedic Practice (COP) is a bi-monthly, peer-reviewed, general orthopaedic journal that publishes original clinical and basic science research, systematic reviews, meta-analyses, technical innovations, case reports, point/counterpoint, and orthopaedic pathology. Editors Dr. Andrew Crenshaw Jr. and Dr. John Crockarell invite all orthopaedic staff and residents to submit original papers to COP:

https://www.editorialmanager.com/cop/Default.aspx Associate Special Focus Editors: Robert Heck, MD (UT-Campbell Clinic) Michael Huo, MD (UT Southwestern) Sheldon Lin, MD (UMDNJ) Anand Murthi, MD (University of Maryland) Samir Mehta, MD (PennMedicine) Derek Papp, MD (John Hopkins University) Benjamin Sheffer, MD (UT-Campbell Clinic) Norfleet Thompson, MD (UT- Campbell Clinic)

Visit the COP website at: https://journals.lww.com/c-orthopaedicpractice/pages/default.aspx

2021 Campbell Orthopaedic Journal Volume 7

Articles from 2021 Campbell Orthopaedic Journal Volume 7