In meeting the increasing demands for total knee arthroplasty, can we achieve high levels of quality care in a small community hospital? A mixed-methods study.

Purpose: Small community hospitals (SCHs) help meet the demand for total knee arthroplasty (TKA). This mixed-methods study compares outcomes and analyses of environmental differences following TKA at a SCH and a tertiary care hospital (TCH). Methods: Quantitative: A retrospective review of 352 propensity-matched primary TKA procedures at both a SCH and a TCH, based on age, body mass index, and American Society of Anesthesiologists class, was completed. Groups were compared by length of stay (LOS), 90-day emergency department visits, 90-day readmissions, reoperations, and mortality. Qualitative: Based on the Theoretical Domains Framework, seven prospective semistructured interviews were performed. Interview transcripts were coded and belief statements were generated and summarized by two reviewers. Discrepancies were resolved by a third reviewer. Results: Quantitative: The average LOS for the SCH was significantly shorter than that for the TCH (2.0 ± 0.2 vs. 3.6 ± 2.7 days; p < 0.001), a difference that persisted following a subgroup analysis of ASA I/II patients (2.0 ± 0.2 vs. 3.2 ± 2.2; p < 0.001). There were no significant differences in other outcomes. Qualitative: The main themes that revolved around a higher case load for physiotherapy at the TCH resulted in patients waiting longer to be mobilized after surgery. Patient disposition also affected their discharge rates. Conclusion: Given the increasing demand for TKA, the SCH represents a viable option to increase capacity, while reducing LOS. Future directions to reduce LOS include addressing social barriers to discharge and patient prioritization for assessment by allied health services. When TKA is performed by the same set of surgeons, the SCH provides quality care with a shorter LOS and comparable with urban hospitals, and this can be attributed to the differences in resource utilization in the two hospital settings.

Periprosthetic Supracondylar Femoral Fractures Above a Total Knee Replacement: An Updated Compatibility and Technique Guide for Fixation With a Retrograde Intramedullary Nail.

BACKGROUND: Multiple studies have described retrograde nailing as a treatment of periprosthetic supracondylar femoral fractures (OTA/AO type 33A-C) above total knee replacements (TKRs). It is often difficult to discern which TKRs will be compatible with intramedullary nailing because the femoral component design and intercondylar distance is highly variable among total knee designs. The goal of our study is 3-fold: (1) Review and update previous work of intercondylar distances of all currently available prostheses in the United States. (2) Review retrograde nails currently on the market and associated driving end to nail shaft diameter mismatch and opening reamer sizing. (3) Review technical tricks for executing a retrograde femoral nail for the treatment of periprosthetic supracondylar femur fractures. METHODS: Data for the intercondylar distance of the femoral components, diameter of retrograde nails and reamers, and notch compatibility were gathered. RESULTS: The results were compiled and recorded. A "technical tricks" section was included that highlights reduction and fixation techniques. CONCLUSIONS: This update further empowers surgeons to use all the tools available when treating periprosthetic femur fractures and allows efficient identification of the compatibility of different TKR designs with various intramedullary nails. LEVEL OF EVIDENCE: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

A reliable method of determining glenohumeral offset in anatomic total shoulder arthroplasty.

BACKGROUND: Glenohumeral offset (GHO) may change from the preoperative state after anatomic total shoulder arthroplasty (TSA), and has been identified as a factor that may affect shoulder mechanics, strength, and function. The primary objective was (1) to establish a reliable method of measuring GHO with standardized computed tomography (CT) imaging planes and (2) to determine whether an association exists between GHO and functional outcomes in TSA. METHODS: Thirty-seven patients underwent TSA for glenohumeral osteoarthritis. Preoperative and postoperative CT scans were reformatted along standardized measurement planes for the glenoid and humerus separately. Inter-rater and intrarater reliability was determined for 3 methods to measure humeral offset and 2 methods to measure glenoid offset. Univariate regression analysis was used to determine the association between GHO and functional outcomes including the Constant score and strength. RESULTS: Of all methods tested, the highest preoperative and postoperative inter-rater reliability was r = 0.84 and r = 0.8, and r = 0.7 and r = 0.8 for humeral and glenoid offset, respectively. Intrarater reliability was >0.94. There was a mean increase of 4.3 mm (standard deviation, 4.6; range, -10.6 to 10.8) in combined GHO from preoperative to postoperative time points. No associations were observed between change in offset and functional or strength scores. DISCUSSION: A reliable approach to measure prearthroplasty and postarthroplasty GHO with CT plane standardization has been described. A net increase in GHO was observed after TSA. No associations were found between change in offset after TSA and functional scores or strength up to 2 years postoperatively.

The Effect of Varying Tension of a Suture Button Construct in Fixation of the Tibiofibular Syndesmosis-Evaluation Using Stress Computed Tomography.

BACKGROUND/PURPOSE: There have been no studies assessing the optimal biomechanical tension of suture button constructs. The purpose of this study was to assess optimal tensioning of suture button fixation and its ability to maintain reduction under loaded conditions using a stress computed tomography (CT) model. METHODS: Ten cadaveric lower limbs disarticulated at the knee were used. The limbs were placed in a modified ankle load frame that allowed for the application of sustained torsional axial or combined torsional/axial loads. The syndesmosis and the deep deltoid ligaments complex were sectioned and the limbs were randomized to receive a suture button construct tightened at 4, 8, or 12 kg. The specimens were loaded under the 3 loading scenarios with CT scans performed after each and at the conclusion of testing. Multiple measurements of translation and rotation were compared with baseline CT scan taken before sectioning. RESULTS: Significant lateral (maximum 5.26 mm) and posterior translation (maximum 6.42 mm) and external rotation (maximum 11.71 degrees) was noted with the 4 kg repair. Significant translation was also seen with both the 8 and the 12 kg repairs; however, the incidence was less than with the 4 kg repair. Significant overcompression (ML = 1.69 mm, B = 2.69 mm) was noted with the 12 kg repair and also with the 8 kg repair (B = 2.01 mm). CONCLUSION: Suture button constructs must be appropriately tensioned to maintain reduction and re-approximate the degree of physiological motion at the distal tibiofibular joint. These constructs also demonstrate overcompression of the syndesmosis; however, the clinical effect of this remains to be determined.

Use of the supercapsular percutaneously assisted total hip approach for femoral neck fractures: surgical technique and case series.

BACKGROUND: Femoral neck fractures are common injuries in the geriatric population associated with high morbidity and mortality rates. Studies have shown outcomes can be positively influenced by early postoperative mobilization. The supercapsular percutaneously assisted total hip (SuperPath) surgical technique has been shown to lead to early mobilization for osteoarthritic total hip replacement patients and as such has the potential to provide similar benefits in fracture patients. This manuscript provides a detailed description of this technique using hemiarthroplasty to treat femoral neck fractures and presents the first case series of this application. METHODS: Seventeen patients with femoral neck fractures managed with this technique at two separate institutions were reviewed. In an attempt to minimize blood loss and enhance early mobilization, hemiarthroplasty utilizing the SuperPath technique was performed. The authors noticed decreased blood loss, operative time, and postoperative narcotic usage when compared to their previous experiences using traditional techniques. CONCLUSIONS: Early mobilization following femoral neck fractures has been shown to decrease mortality and morbidity. There is little existing literature on the use of tissue-sparing surgical techniques for this application, and none details the use of the SuperPath technique for it. The described case reports suggest the technique is a viable option for bipolar hemiarthroplasty to treat femoral neck fractures. Appropriately designed future studies are needed to confirm findings and definitively compare outcomes to traditional approaches.

Comparison of pedicle subtraction and Smith-Petersen osteotomies in correcting thoracic kyphosis when closed with a central hook-rod construct.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: To demonstrate the effectiveness of hook-rod constructs in closing thoracic osteotomies safely and effectively. SUMMARY OF BACKGROUND DATA: The outcomes of hook-rod instrumentation in osteotomies for the correction of kyphosis at the lumbar region of the spine have been described. Little literature exists on the outcomes at the thoracic level. METHODS: The radiographs and clinical scores of 38 patients who underwent pedicle subtraction osteotomy or Smith-Petersen osteotomy in the thoracic spine with the osteotomies closed using a central rod were retrospectively reviewed. Measurements included osteotomy angle, thoracic kyphosis (T2-T12), and maximum kyphosis. Perioperative and long-term complications were reviewed. RESULTS: Thirty-eight patients underwent thoracic level osteotomies. There were 8 males and 30 females with a mean age of 51.9 years (range, 18-76 yr) at the time of surgery. The mean construct length was 13.2 levels (4-25). Kyphosis correction was equal in the 2 groups. In the pedicle subtraction osteotomy group, a mean of 24.7° (4°-47°) correction was obtained through the osteotomies compared with 24.0° (9°-65°) in the Smith-Petersen osteotomy group. Correction per osteotomy was 23.7° (4°-47°) in the pedicle subtraction osteotomy group compared with 11.8° (2.8°-46.0°) in the Smith-Petersen osteotomy group. No difference in the amount of correction achieved at the different regions of the thoracic spine was observed with either type of osteotomy with central rod closure. CONCLUSION: Central hook-rod constructs provide a safe and effective means of closing thoracic osteotomies and result in good correction of rigid sagittal plane deformities. LEVEL OF EVIDENCE: 4.

The use of fusion mass screws in revision spinal deformity surgery.

STUDY DESIGN: To report the use of a posterior based 'fusion mass screw' (FMS) as a primary or salvage fixation point in a revision spinal deformity following a previous posterior spinal fusion (PSF). Our experience of this technique in a case report and the clinical and radiological results are reported. OBJECTIVES: To describe the technique and uses of the FMS as a primary/salvage fixation point in osteotomies in previously arthrodesed spinal deformity surgery. Obtaining fixation points to correct and stabilize a spinal deformity with coronal and sagittal imbalance in a previously arthrodesed spine during revision surgery can be challenging. Several alternate pedicle fixation techniques and laminar screw techniques have been described in the literature. However, there is no description of these techniques in the presence of a spinal fusion with distorted anatomy. A pedicle screw placed coronally across a thick posterior fusion mass can provide an alternate method of fixation in these cases with complex anatomy. METHODS: Two cases of complex spinal deformity and corrective spinal osteotomies using fusion mass screws (FMSs) placed coronally across the posterior fusion mass are described. The first case is an 8-year-old patient with Marfan's syndrome who developed a crank shaft phenomenon and severe thoracolumbar kyphoscoliosis following a previous PSF. The second case is a 53-year-old patient with coronal imbalance following PSF as a child using Harrington instrumentation who developed distal degeneration with stenosis in her remaining mobile segments. Both patients underwent vertebral column resection and osteotomy closure plus stabilisation using FMS. The clinical and radiological results and technique for insertion of the FMS are described. CONCLUSION: In this report, we present a novel method of using posterior FMSs to achieve fixation and correction in cases of revision deformity surgery with difficult anatomy. While we feel pedicle screws are the gold standard in deformity correction, knowledge of alternatives such as the FMS can allow surgeons to achieve stable constructs when faced with challenging situations.

Learning surgically oriented anatomy in a student-run extracurricular club: an education through recreation initiative.

Didactic and laboratory anatomical education have seen significant reductions in the medical school curriculum due, in part, to the current shift from basic science to more clinically based teaching in North American medical schools. In order to increase medical student exposure to anatomy, with clinical applicability, a student-run initiative called surgically oriented anatomy prosectors (SOAP) club was created within the extracurricular program at the Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Canada. SOAP invites surgeons and residents from various surgical specialties to demonstrate, on a cadaver, a surgical procedure of their choosing. During the demonstration, the anatomy, as it relates to the surgical procedure, is discussed. The students then break into smaller groups to examine the relevant anatomy on the cadavers, during which time the discussion is broadened. The group continues the conversation in a social environment with refreshments. SOAP is one of the most popular extracurricular clubs with 65% of first and second year medical students registered as members. The high demand for SOAP, along with the positive participant feedback, may be due to its utilization of the principle of education through recreation, which seeks to provide opportunities for learning seamlessly throughout all facets of life. It also demonstrates the desire, amongst certain medical students, to learn applied anatomy, particularly within a surgical context.

Upper instrumented vertebral fractures in long lumbar fusions: what are the associated risk factors?

STUDY DESIGN: A retrospective comparative study. OBJECTIVE: To investigate the risk factors associated with upper instrumented vertebral (UIV) fractures in adult lumbar deformity. SUMMARY OF BACKGROUND DATA: Long segment lumbar fusions may lead to junctional failures. The purpose of this study was to determine factors associated with junctional failures. METHODS: Twenty-seven consecutive patients from 2001 to 2008 with minimum 4 levels fused, lower instrumented vertebra (LIV) of L5 or S1, upper instrumented vertebra of T10 or distal, and no previous surgery proximal to the instrumentation were retrospectively reviewed. We describe the UIV angle, the sagittal angle of the upper instrumented vertebra with the horizontal. Patients were divided into 3 groups: group 1, 7 patients with UIV fractures; group 2, 6 patients with other proximal failures; and group 3, 14 patients with no proximal complications. RESULTS: The mean number of levels fused was 5.7 (4-7), 5.2 (4-8), and 6.2 (4-8); mean age was 64.1, 61.8, and 64.1, and mean body mass index was 33.5, 30.0, and 31.6 for groups 1, 2, and 3, respectively (P > 0.05). Osteotomies were performed in 5 of 7 in group 1, 1 of 6 in group 2, and 5 of 14 in group 3. Mean follow-up was 26.3 months. The average intraoperative UIV angle (UIV0) and immediate postoperative UIV angle (UIV1) were 18.6°/15.4° for group 1, 5.7°/5.3° for group 2, and 10.3°/7.1° for group 3 (P < 0.05). Surgical revision rates were higher in group 1 (71%) compared with groups 2 (50%) and 3 (43%). Eight of 11 (73%) patients with upper instrumented vertebra of L1 or L2 had either UIV fracture or other proximal failure compared with 5 of 16 (31%) in patients with upper instrumented vertebra of T10, T11, or T12. CONCLUSION: Our series of long lumbar fusions had a high long-term complication and revision rate. A high UIV angle on intraoperative lateral radiograph was strongly associated with UIV fractures. UIVs of L1 or L2 had a higher rate of adjacent segment or UIV failure.