Tranexamic Acid in Shoulder and Knee Arthroscopy - Daniel J. Song, MD; Emily R. McDermott, MD; Brian F. Grogan, MD; David J. Tennent, MD; and Justin J. Ernat, MD, MHA

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The role of tranexamic acid (TXA) in orthopaedic surgery is expanding. It has been shown to decreased blood loss in orthopaedic trauma, total joint arthroplasty, and spine surgery. Although significant blood loss with arthroscopic surgery is rare, the use of TXA in these procedures has been advocated to help with intraoperative visualization and decreased postoperative swelling and hemarthrosis. TXA in shoulder arthroscopy may improve visual clarity, decrease the amount of fluid used during arthroscopy, and decrease postoperative pain. Although several studies have shown TXA in shoulder and knee arthroscopy may decrease early pain, swelling, and hemarthrosis, others have shown no difference in short- or long-term outcomes when compared with placebo. Although there is a low reported rate of complications after TXA use in shoulder and knee arthroscopy, TXA may be chondrotoxic in high concentrations. Further investigation is warranted, but TXA may have some early benefits in arthroscopic shoulder and knee surgeries. (Journal of Surgical Orthopaedic Advances 33(3):131-134, 2024)

Key words: tranexamic acid, TXA, arthroscopy, shoulder arthroscopy, knee arthroscopy

Adolescent Compressive Epiphysitis of the Spine: A Diagnosis for Adolescent Back Pain - Alexander H. Jinnah, MD, PhD; Rosser McCallie, MD; Georges A. Abdelahad, BS; Alejandro Marquez-Lara, MD, PhD; Michael S. Hughes, MD; and John Frino, MD

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Adolescent back pain is a difficult problem to diagnose owing to the variability in diagnoses that can stem from this symptom. It may be due to simple myalgias or something as complex as a neoplastic or infectious process, and the consequences of missing the later are detrimental. The authors theorize that the increased forces seen in the lower back owing to posture in conjunction with the increase in smartphone usage over the last decade and heavy backpack use have led to an increased prevalence of a phenomenon of adolescent compressive epiphysitis of the spine (ACES). In this article, the authors describe ACES as a diagnosis for nonspecific low back pain in adolescents and reiterate the red flag symptoms associated with adolescent back pain that warrant further workup. Furthermore, they describe their treatment algorithm for these patients. (Journal of Surgical Orthopaedic Advances 33(3):135-137, 2024)

Key words: adolescent, back pain, spine

Risk Factors for Postoperative Deep Venous Thrombosis and Pulmonary Embolism Following Primary Total Hip Arthroplasty and Primary Total Knee Arthroplasty - Catherine Raquel, BS; Michael Zebold, BS; Michael Foy, BS; Anshum Sood, MD; and Mark Gonzalez, MD, PhD

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Pulmonary embolism (PE) and deep vein thrombosis (DVT) are common postoperative complications. This study retrospectively analyzes preoperative a!ributes as risk factors for DVT or PE following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Preoperative transfusion, age 65+, dyspnea with moderate exertion, body mass index (BMI) 24.9+ were independent risk factors for PE following THA. Cardiac comorbidities were related with reduced risk. Bleeding disorder, operative time > 110 minutes, perioperative transfusion, age 65+, dyspnea at rest, and BMI < 18.5 were independent risk factors for DVT following THA. Perioperative transfusion, age 57+, dyspnea at rest and with moderate exertion, and BMI 24.9+ were independent risk factors for PE following TKA. Smoking status was related to reduced risk. Perioperative transfusion, age 65+, dyspnea with moderate exertion, and male sex were independent risk factors for DVT following TKA. Cardiac comorbidities were related with reduced risk. Identifying risk factors helps prevent DVT and PE after THA or TKA. (Journal of Surgical Orthopaedic Advances 33(3):138-142, 2024)

Key words: total hip arthroplasty, total knee arthroplasty, pulmonary embolism, deep vein thrombosis, venous thromboembolism, risk factors

Efficacy of Liposomal Bupivacaine Versus a Traditional Local Anesthetic in Periarticular Injections During Total Hip Arthroplasty: A Systematic Review and Meta-analysis - Samantha Harrer, BA; Michael Yayac, MD; Gregory R. Toci, BS; Eric Levicoff, MD; P. Maxwell Courtney, MD; Andrew M. Star, MD; and Arjun Saxena, MD, MBA

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Periarticular injections (PAI) are a common component to multimodal regimens in total hip arthroplasty (THA), although the efficacy of adding liposomal bupivacaine (LB) remains unclear. A meta-analysis of total knee arthroplasty did not find LB superior, but a similar study has not been performed in THA. The purpose of this study was to compare opioid consumption, pain scores, and length of stay between PAIs with LB and traditional PAIs in THA. Eleven included studies showed LB to have minor decreases in opioid consumption and length of stay. No clinically significant benefits were achieved in pain control based on minimal clinically important difference thresholds. There is not adequate evidence to suggest that the increased cost of LB merits its utilization over traditional PAI in THA. The variability in the study designs, as well as results, calls for more consistent randomized clinical trials to ascertain the true efficacy of LB. (Journal of Surgical Orthopaedic Advances 33(3):143-153, 2024)

Key words: liposomal bupivacaine, periarticular injection, total hip arthroplasty, local anesthetic, multimodal analgesia

Time and State Opioid Legislation Have Reduced Opioid Filling in Elective Shoulder Surgery - Daniel J. Cunningham, MD, MHSc; Jay Levin, MD, MBA; Jeffrey O’Donnell, MD; Joshua Helmkamp, MD; Oke Anakwenze, MD, MBA; Tally Lassiter, MD, MHA; Mark J. Gage, MD; and Christopher S. Klifto, MD

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Opioid-limiting legislation has been enacted in response to the opioid epidemic in the United States. However, the impact of this legislation on perioperative opioid prescribing in elective shoulder surgery is not well understood. This is an observational review of 90-day perioperative opioid-prescription filling by patients undergoing shoulder surgery using a national insurance database (n = 231,634 patients) between 2010 and 2019. Statistics evaluated the impact of the year and opioid-limiting legislation on first prescription and cumulative 90-day opioid filling. Initial and cumulative opioid-prescription volume decreased significantly from 2010 to 2019 (49 to 44.4 initial oxycodone 5-mg equivalents, 132.8 to 72.3 cumulative oxycodone 5-mg equivalents; all p < 0.001). States with opioid-limiting legislation had larger reductions in initial and cumulative opioid- prescription filling over similar time frames (p < 0.001). Perioperative opioid prescribing has decreased significantly in shoulder surgery with time and state legislation. Individual prescribers and state and national legislators should continue to seek ways to reduce opioid overprescribing. (Journal of Surgical Orthopaedic Advances 33(3):152-157, 2024)

Key words: shoulder surgery, opioid, legislation

Patient Language Does Not Impact Need for Manipulation Following Total Knee Arthroplasty - David M. Ramsden, MD; Nicholas R. Pagani, MD; Jordan A. Santiago, BA; Mariano E. Menendez, MD; Michael D. Baratz, MD; and Matthew J. Salzler, MD

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Socioeconomic factors have been associated with an increased need for manipulation under anesthesia (MUA) following total knee arthroplasty (TKA). The purpose of this study was to compare the rate of MUA and range of motion (ROM) following primary TKA in English and non-English-speaking patients. The authors conducted a retrospective cohort study of all primary TKAs performed at their institution between 2010 and 2017. A total of 1,099 English-speaking and 163 non-English-speaking patients were included. There was no significant difference in rate of MUA (3.5 vs. 4.9%, p = 0.392) or postoperative ROM (102.2 vs. 100°, p = 0.142) between English and non-English-speaking patients. Younger age (p = 0.001) and female sex (p = 0.005), but not patient language, were associated with need for MUA. Patient language does not appear to impact the rate of MUA or ROM following TKA. (Journal of Surgical Orthopaedic Advances 33(3):158-161, 2024)

Key words: total knee arthroplasty, stiffness, manipulation, language, demographics

Enhanced Recovery Pathway Reduced Opioid Use and Pain Scores in Elective Spine Surgery - Logan A. Reed, MD; Kevin Luque-Sanchez, MD; Alexander Mihas, MD; Eli B. Levitt, MD; Roland T. Short, MD; Christopher A. Godlewski, MD; and Steven M. Theiss, MD

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The purpose of this study was to determine if implementation of an enhanced recovery pathway (ERP) for elective spine surgery reduced opioid use and pain scores in elective spine surgery. A historical cohort study of 171 patients undergoing elective spine procedures between 2017 and 2021 was performed. The primary outcomes were opioid use and average daily pain scores. A group of 92 patients received the novel ERP (2019 – 2021) in comparison to a historical control group of 79 patients without the ERP (2017 – 2019). On postoperative days 1 to 3, the ERP group received 36% (p < 0.001), 36% (p < 0.001), and 37% (p = 0.005) less milligram morphine equivalents, respectively. On postoperative days 1 to 3, the ERP group pain scores were 1.5 (p < 0.001), 1.0 (p = 0.003), and 1.1 (p = 0.004) points lower, respectively. Length of stay was similar (4.3 vs. 4.5 days, p = 0.693). Adoption of this ERP protocol was associated with clinically significant reduced opioid consumption and pain scores in elective spine surgery. (Journ al of Surgical Orthopaedic Advances 33(3):162-167, 2024)

Key words: enhanced recovery after surgery, ketamine, narcotics, opioids, pain management, perioperative care, spine

Outcomes of Total Hip Arthroplasty With and Without a History of Hip Arthroscopy - Laura A. Stock, MS; Andrea H. Johnson, MSN, CRNP; Jane C. Brennan, MS; Justin J. Turcotte, PhD, MBA; Benjamin M. Petre, MD; and Paul J. King, MD

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Studies have shown increased risk for dislocation, loosening, and revision in patients undergoing total hip arthroplasty (THA) after hip arthroscopy (HA). The authors examined differences in presentation and outcomes between patients who underwent THA with and without prior HA from 2016 to 2021. Twenty-one HA to THA patients were matched on age, sex, race, body mass index (BMI), American Society of Anesthesiology (ASA) score, and comorbidities to 100 THA controls. Univariate analysis was used to determine differences between groups. HA patients were more likely to have Kellgren-Lawrence (KL) grades of 2 or 3, whereas those with no HA were more likely to present with 3 or 4. HA to THA patients had 1.2 mm more joint space than THA patients. Time to THA from first orthopaedic visit was 16 months longer for patients with HA. Postoperatively, there were no significant differences. This suggests THA can be an effective intervention for failed HA. (Journal of Surgical Orthopaedic Advances 33(3):168-170, 2024)

Key words: hip arthroscopy, HA, total hip arthroplasty, THA, Kellgren-Lawrence grade, KL grade, osteoarthritis

The Fate of Orthopaedic Surgery Applicants from Medical Schools Without an Orthopaedic Surgery Residency - Joshua R. Eskew, MD; Jonathan J. Light, MS; Amelia J. Weingart, MD; Jacob R. Jackowski, MD; Natalie M. Marenghi, MD; and Lisa Cannada, MD

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The purpose of this study was to analyze and assess students from medical schools without a home orthopaedic residency program when applying for a residency position in orthopaedic surgery in terms of metrics utilized by program directors in the Match. An anonymous survey consisting of 23 questions was distributed to graduates of six different medical schools without a home orthopaedic residency program who successfully matched into orthopaedic residency over the past 6 years. Forty- three total responses were received. The number of honors achieved in the junior clerkship phase, mean United States Medical Licensing Examination (USMLE) step 1 and step 2 clinical knowledge (CK) exam scores, number of away rotations, and number of orthopaedic research publications in surgery and total publications overall at the time of application were determined. Graduates of medical schools without a home orthopaedic residency program who successfully matched performed at a higher level across all metrics compared with national match data and the orthopaedic literature. (Journal of Surgical Orthopaedic Advances 33(3):172-177, 2024)

Key words: orthopaedic surgery, residency application, orphan medical schools, audition, match

Civilian Ballistic Distal Femur Intraarticular Fracture Patterns - Colin Cantrell, MD; Gregory Versteeg, MD; Haley Smith, MD; Daniel Johnson, MD; Erik Gerlach, MD; Michael Stover, MD; and Bennet Butler, MD

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The purpose of this study was to assess the rate and pattern of intraarticular extension of ballistic distal femur fractures. The authors examined all ballistic distal femur fractures that presented to their hospital between 2015 and 2019. The authors excluded direct condylar injuries and patients of whom a computed tomography (CT) scan was not obtained. The authors classified the rate of intraarticular extension and the pattern of that extension. Sixty-three fractures met inclusion in this study. Of these, 19 (30%) extended intraarticular, whereas the remaining 44 did not. Ninety-five percent of the fractures in the intraarticular group contained a sagital fracture, whereas only 26% contained a fracture in the coronal plane. Ballistic distal femur fractures have a lower rate of intraarticular extension than blunt fractures. There are predictable patterns of joint involvement with ballistic injuries that warrant different treatment strategies. The authors propose a new classification system to further classify these unique fractures. (Journal of Surgical Orthopaedic Advances 33(3):178-180, 2024)

Key words: ballistic, distal femur fracture, fracture patterns

Impact of Tourniquet Use During Intramedullary Tibial Nailing on Clinical Outcomes - Lindsay Luce, MD; William Barfield, PhD; Charles Cody White, MD; Weston McDonald, BS; Kristoff Reid, MD; and Langdon Hartsock, MD

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The objective of this retrospective study was to investigate the impact of tourniquet use during intramedullary tibial nailing on clinical outcomes at a regional Level I Trauma Center. One hundred ninety-four patients with intramedullary tibial fixation over a 5-year period at a single institution were studied following Institutional Review Board (IRB) approval. Patients were stratified into 81 polytrauma patients and 113 patients with isolated tibial shaft injuries. Patients were then stratified within these two groups according to whether or not a tourniquet was used intraoperatively (including during reaming). Postoperative narcotic use, length of stay, operating room (OR) time, tourniquet time, estimated blood loss, units of blood utilized, infection rate, and age were the outcome variables. No significant differences were found for any outcome measure (p ≥ 0.05), including age, narcotic use, OR time, postoperative inpatient days, estimated blood loss, and units of blood used between tourniquet and nontourniquet patients. Statistically significant differences were found between isolated and nonisolated fracture patients for postanesthesia care unit (PACU) morphine dose equivalents (MDEs), with isolated tibia fracture patients requiring more MDEs (13.80 vs. 9.92 units; p = 0.025). Nonisolated tibia patients had more inpatient days (14.88 vs. 3.16 days; p = 0.001), greater estimated blood loss (252.44 vs. 128.07 mL; p = 0.001), and more units of blood (5.07 vs. 2.29 units; p = 0.017). Thermal necrosis of the tibia was not seen in any patient within any group. Tourniquet use did not significantly affect clinical outcomes. This provides surgeons with updated data on the impact of tourniquet use on clinical outcomes given the modernization of techniques for tibial intramedullary nailing. There were statistically significant differences between isolated tibia fractures and polytrauma patients for postoperative length of stay, estimated blood loss, and units of blood; however, this was unrelated to tourniquet use and would be expected for polytraumatic patients who commonly have a longer postoperative recovery. (Journal of Surgical Orthopaedic Advances 33(3):181-183, 2024)

Key words: tourniquet, tibia nailing, patient outcomes

Comparing Severity of Knee Arthritis at an Urban Center by Insurance Type Prior to Total Knee Arthroplasty - Salvador G. Ayala, BS; Abhishek Deshpande, MD; Michael J. Patetta, MD; Julio C. Castillo Tafur, MD; Ye Lin, MD; Diego Barragan Echenique, MD; and Mark H. Gonzalez, MD, PhD

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This study compares radiographic osteoarthritis severity prior with total knee arthroplasty (TKA) by payer type. Five hundred and three primary TKAs were included. Preoperative radiographs were scored by Ahlback, Kellgren-Lawrence (KL), and International Knee Documentation Commi!ee (IKDC) classifications. Osteoarthritis severity by age and insurance type (private, Medicare, and Medicaid) were compared using Mann Whitney U and Kruskal-Wallis testing. Three hundred and two (60%) subjects were under 65 years old, and 201 (40%) were 65 years and older. Younger subjects had no differences in radiographic severity in KL (p = 0.268), Ahlback (p = 1), or IKDC (p = 0.948) classification by insurance. Older subjects also had no differences in osteoarthritis severity for KL (p = 0.282), Ahlback (p = 0.354), or IKDC (p = 0.735) classifications by insurance. Three osteoarthritis classification systems found no difference in preoperative radiographic changes by payor type, suggesting that, in the study’s population, there is no delay in appropriate surgical treatment by payer. Future studies should compare preoperative clinical symptoms. (Journal of Surgical Orthopaedic Advances 33(3):184-188, 2024)

Key words: payer type, osteoarthritis severity, total knee arthroplasty

Cemented Versus Cementless Primary Total Knee Arthroplasty in Obese Patients: A Systematic Review - Jordan G. Tropf, MD; Timothy P. Murphy, MD; Emily Shohfi, MLIS, AHIP; John P. Cody, MD; and Robert W. Tracey, MD

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Total knee arthroplasty (TKA) in obese patients (body mass index [BMI] > 30) is associated with increased complications. There is a renewed interest in cementless fixation in obese patients. However, the ideal method of TKA fixation in obese patients remains unclear. The literature was systematically reviewed to evaluate survivorship and functional outcomes of cemented versus cementless TKAs performed in obese patients. Complications, revision rates, and patient-reported functional outcomes were examined in studies comparing cemented and cementless fixation methods. Five articles met inclusion criteria to be included in the review. The cementless cohort had lower revision rates in two included studies but no difference in the three other studies examined. Functional outcomes were inconsistently reported. Overlap of patient cohorts and heterogeneity in reporting of functional outcomes precluded a pooled metaanalysis. Cementless TKA may have lower revision rates and be"er functional outcomes in obese patients, but paucity of data and inconsistency in reporting of functional outcomes prevents definitive conclusions. (Journal of Surgical Orthopaedic Advances 33(3):189-195, 2024)

Key words: total knee arthroplasty, TKA, cemented total knee arthroplasty, cementless total knee arthroplasty, obesity

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