dartmouth orthopaedic journal 2014; vol...

3

Dartmouth Orthopaedic Journal 2014; Vol I

Rowan J. Michael MD and Dipak B. Ramkumar MDInternational Orthopaedics at Dartmouth 61

Ana Mata-Fink MDA Tribute to Dr. Philip Bernini and Dr. Thomas Shirreffs 62

Wayne M. Moschetti MD MSOrthopaedic Teaching Awards 64

Charles F. Carr MDFreddie Fu Award 64

Charity A. Jacobs MDDHMC Courage to Teach Award 65

Dipak R. Ramkumar MDNew Faculty 66Welcome to the incoming Orthopaedic Interns 67Graduating Residents 68Update on Recent Graduates 69Faculty 70Associate Providers 73Alumni of the Dartmouth Orthopaedic Surgery Resi-dency Program 74

DOJo Staff

The Dartmouth Orthopaedic Journal is a resident-run, peer-reviewed publication that aims to increase Dartmouth’s

contribution to orthopaedic knowledge and foster camaraderie among Dartmouth Orthopaedic residents, staff and alumni.

Chairman, Department of OrthopaedicsSohail K. Mirza, MD, MPH

Residency Program DirectorCharles F. Carr, MD

EditorsBrendan T. Higgins, MD MS

Timothy J. Lin, MD MS

Faculty AdvisorsJohn-Erik Bell, MD MS

Robert V. Cantu, MD MS

ReviewersJames B. Ames, MD MSJohn-Erik Bell, MD MS

Robert V. Cantu, MD MSMarcus P. Coe, MD MS

Kevin W. Dwyer, MD MSBrendan T. Higgins, MD MS

Karl M. Koenig, MD MSTimothy J. Lin, MD MS

Wayne E. Moschetti, MD MSMatthew E. Oetgen, MD

Adam M. Pearson, MD MS

Administrative StaffLinda S. Eickhoff

Special thanks to Dr. Bob Porter and Dr. Pete Hall

CONTENTS

Letter From The Editors 4Brendan T. Higgins MD MS and Timothy J. Lin MD MS

Chairman’s Update 5Sohail K. Mirza MD MPH

Program Director’s Update 7Charles F. Carr, MD

How do video decision aids affect patients considering total joint arthroplasty for symptomatic hip or knee osteoarthritis? 8

Wayne Moschetti1 MD MS, Jared Conley2 MPH, Garrett Davis1 MD MBA MS, Kevin F. Spratt3 PhD, Stephen R. Kantor1 MD, Ivan Tomek1,4 MD FRCSC

Predicting electrodiagnostic study results in CTS 15Erik R. Bergquist1 MD, Jeffrey A. Cohen1 MD, Kevin F. Spratt2 PhD, Lance G. Warhold1 MD

Establishment of a Designated Transfer Center Im-proves Care of Orthopaedic Trauma Patients 21

Eugene W. Brabston2 MD, John E. Bell1 MD MS, Robert V. Cantu1 MD MS

Comparison of Two Fusionless Scoliosis Surgery Methods in the Treatment of Progressive Adolescent Idiopathic Scoliosis: A Preliminary Study 25

John T. Braun MDPatient Education and Compliance with Deep Vein Thrombosis Prophylaxis after Discharge from Total Joint Replacement 34

Brooks Crowe BA, Reema Vaze BA, Andrew Banos MD, James Slover MD MS

Intramedullary Screw Fixation of Transverse Olecra-non Fractures 41

Alexander R. Orem MD MS and Robert V. Cantu MD MSCase Report 44Femoral artery occlusion after total hip Arthroplasty through the direct anterior approach: A case report 44

Wayne Moschetti MD MS, Spencer Amundsen MDTotal Knee Arthroplasty in a Patient with an Ipsilateral Transtibial Amputation: A Case Report and Surgical Technique for Addressing a Short Residual Tibia 47

Joshua M. Murphy MD, Scott M. Sporer MDA History of the Dartmouth Hitchcock Medical Center Orthopaedic Residency Training Program 52

Charles F. Carr MDLevel V Evidence 56

Timothy J. Lin MDDevelopment of a Surgical Skills Curriculum for DHMC Orthopedic Surgery Residents 60

Letter From The EditorsBrendan T. Higgins MD MS and Timothy J. Lin MD MS

Dear Alumni and Friends of Dartmouth Orthopaedics,

Welcome to the inaugural issue of the Dartmouth Ortho-paedic Journal. This is the first issue of what will be an annual, resident-run, faculty-supervised, peer-reviewed publication. Our goal for this journal is twofold. First, to increase Dart-mouth’s contribution to orthopaedic knowledge, and second, to develop greater camaraderie, esprit de corps and national network among Dartmouth Orthopaedic residents, staff and alumni. To that end, I’d like to give you a brief update on two recent advancements in the Orthopaedics Department at Dartmouth: implementation of our “GreenCare” pathway and opening of the Center for Surgical Innovation (CSI).

Our department believes that quality can be defined and measured, that benchmarks matter, that clinical practice must be science-based, and that patient-interests have priority over clinician preferences. Nearly a hundred years ago, an ortho-pedic surgeon in Boston named Ernest Amory Codman ad-vocated “The End Result Idea”: “The common sense notion that every hospital should follow every patient it treats, long enough to determine whether or not the treatment has been successful, and then to inquire, ‘If not, why not?’ with a view to preventing similar failures in the future.” In 1996, James N. Weinstein, a spine surgeon at Dartmouth at the time and now our CEO and President, expanded Codman’s idea to include measuring patient reported outcomes during routine care in The Spine Center, and established the nation’s first Center for Shared Decision Making to help patients make more informed choices.

The Dartmouth GreenCare program further enhances these innovations by using information technology to support patient centered, evidence-based decisions. We have worked hard over the past 5 years to re-design our care delivery process-es to adjust to the changes we see and the direction we anticipate in the healthcare environment. We have moved to team-based care rather than solo surgeon practice, standardizing things as much as possible using clinical evidence and trustworthy guidelines, and integrating formal shared decision making and patient reported measurements into the care process (Figure 1). The scale of change was very difficult for our surgeons and staff, but results have been encouraging at each implemen-tation phase so far (Fig ure 2). We have called this model of clinical practice “GreenCare.”

Codman’s End Result Hospital in Boston was a financial

failure in 1918, seven years after it opened. We are seeing that Codman’s End Result Idea, when implemented with a team-based care approach, electronic health records, patient-fo-cused information technology, and thoughtful operations engineering, can serve as the core business model for contin-uously improving outcomes and remaining financially sus-tainable. Our early results show GreenCare improves patient experience and outcomes, and reduces costs.

Chairman’s UpdateSohail K. Mirza MD MPH

Figure 1. Goals of the GreenCare Program

Figure 2. Design and implementation timeline for GreenCare

6


Secondly, we are proud to announce the opening of the Center for Surgical Innovation, a one-of-a-kind research facil-ity dedicated to improving surgical procedures and developing new surgical technologies to improve patient outcomes (Fig-ure 3). CSI is a collaborative investment by Dartmouth-Hitch-cock Medical Center, Geisel School of Medicine, Thayer School of Engineering, and grant funding from the National Institutes of Health.

Surgeons are too often limited by what they cannot see. At Dartmouth, that constraint will soon be removed, with MRI and CT machines that can move in and out of operating rooms. For surgeries in which a few millimeters means the difference between restoring physical ability or causing per-manent disability, or between curing cancer and missing a bit of tumor that may grow back, 3-D imaging during surgery is priceless. CSI will allow surgeons and engineers to innovate like never before, rapidly developing, testing, and validating new surgical tools and techniques, with the goal of achieving better, safer, and, over the longer term, less-costly care for pa-tients everywhere. I encourage you to visit the CSI website at

http://med.dartmouth-hitchcock.org/csi.html.

These are just two examples of how Dartmouth Ortho-paedics continues to innovate patient care, improve value, outcomes research and resident education. In summary, I am happy to report that the status of the DHMC Orthopaedic De-partment is strong and continuously improving. We welcome our graduate residents to come back and visit at any time!

Sincerely,Sohail K. Mirza, MD MPHChair, Department of OrthopaedicsMay 16, 2014

Figure 3. Schematic of the Center for Surgical Innovation

I am also extremely happy to report that the state of your orthopaedic residency program is excellent. The program un-derwent an accreditation site review last year by the Orthopae-dic Residency Review Committee and received a full ACGME accreditation with no citations and the maximum ten year cycle for a re-evaluation. The board certification rate for all of our graduating residents over 57 years remains 100%. Our graduates continue to enter the most competitive fellowship programs in all the subspecialty areas and nearly 20% have continued on in an academic setting.

Thanks to you all for being a part of our success and pride.

Sincerely,Charles F. Carr, MDDHMC Orthopaedic Residency Program Director

Alumni and Friends of Dartmouth Orthopaedics,

Greetings and welcome to the inaugural issue of the Dart-mouth Orthopaedic Journal. I congratulate Dr. John-Erik Bell and the first two resident editors, Drs. Tim Lin and Brendan Higgins, on all of their hard work and effort in completing this initial publication. The first issue always seems to be the most difficult to finish.

Since many of you who receive this may have had little con-tact with the program over the past two decades, included in this Journal is A History of the Dartmouth Hitchcock Medical Center Orthopaedic Residency Training Program which was written to give you a historical update on our program from our inception to our most recent developments. The changes in orthopaedic surgery training and in the DHMC program have been profound. Much of the credit for the program’s structure, foundation and personality go to my predecessors – Drs. Staples, Hall, Bernini and Murphy. Thanks to their work and efforts we continue to attract the best resident applicants in the country to DHMC.

Program Director’s UpdateCharles F. Carr MD

ABSTRACTIntroduction: Video decision aids (DAs) summarizing current evi-

dence-based practices are adjuncts to communication between provider and patient, and useful when a preference-sensitive decision is being made, such as consideration of arthroplasty for severe hip and knee osteoarthritis.

Methods: 123 patients (80 knees, 43 hips), mean age 63 years, with

symptomatic hip and knee osteoarthritis, were enrolled prospectively to evaluate the value of a video DA. Patients completed a questionnaire before and after viewing the DA, answering questions related to patient knowledge, treatment preference, personal values, decision readiness, and preferred role in treatment decision making.

Results: Approximately 80% of the patients reported that the DA

prepared them to discuss their values related to the treatment decisions, but concordance between treatment choice and im-portance of symptom relief and wishing to avoid surgery were not changed in either cohort. Decision readiness significantly improved after viewing the DA in both knee and hip patients. The majority of patients reported a treatment preference prior to seeing the DA and demonstrated no significant treatment preference shift after viewing the video (p=0.28). Pre- to post-DA concordance between treatment choice and importance of symptom relief (r=0.09 vs. r=0.39 p=0.28) and wishing to avoid surgery (r=.-0.54 vs. r=-0.49, p=0.76) were not im-proved. After viewing the DA, basic knowledge about joint replacement improved in both knee (59% vs. 77%, p<0.0001)

and hip arthritis groups (71% vs. 81%, p=.028). Knowledge re-garding complication risk improved in those with hip arthritis (73% vs. 94 %, p<.0001), but not in those with knee arthritis (68% vs. 69%, p=.54).

Conclusions: Video DAs improved decision readiness and basic knowl-

edge in patients with hip and knee osteoarthritis. However, viewing a DA did not lead to greater concordance between patient values and treatment choices. Patients with an initial treatment preference were not likely to change their prefer-ence, while those who were unsure about their treatment pref-erence were more likely to report a preference after watching the video.

Level of Evidence:Level II

INTRODUCTIONShared medical decision making (SDM) empowers pa-

tients to make better quality health decisions by presenting evidence-based treatment options, clarifying values, and al-lowing patients to have more meaningful discussions with their care providers. SDM is poised to play a greater role in the healthcare of patients in the United States, including those with symptomatic hip and knee osteoarthritis (OA). It is felt that participating in SDM increases a patient’s knowledge of their condition and the risks associated with available treat-ment options, thus improving the quality of the decision.1 Much of the SDM literature has involved the utility of decision aids on patients’ knowledge of options and outcomes regard-ing non-orthopaedic disease.2-7 Less is understood about the role of SDM on individuals undergoing total joint arthroplas-ty (TJA). New federal and state legislation has emphasized patient-centered care, and participating health systems will be incentivized if they include SDM in their care pathways. Integral to most SDM processes are decision aids (DAs), of-ten video-based, that review treatment-related knowledge and personal values, which may lead to choosing one option over the other. DAs are felt to be especially helpful in prefer-ence-sensitive decisions like treatment of osteoarthritis where there are multiple potential options that have differing bene-fits, risks, and tradeoffs. In those cases DAs have been shown to increase patient involvement in decision making, leading to

1. Dartmouth-Hitchcock Medical Center, Lebanon NH 2. Case Western Medical School, Cleveland, OH3. Dartmouth Medical School, Hanover NH 4. The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon NH

Corresponding Author: Wayne Moschetti, MD, MSE-mail: [email protected]

DISCLOSURE: None of the authors received payments or services, either directly or indirectly, from a third party in support of any aspect of this work. The complete disclosures of potential conflicts of interest submitted by au-thors is available upon request through correspondence with the DOJo office.

How do video decision aids affect patients considering total joint arthroplasty for symptomatic hip or knee

osteoarthritis?Wayne Moschetti1 MD MS, Jared Conley2 MPH, Garrett Davis1 MD MBA MS, Kevin F. Spratt3

PhD, Stephen R. Kantor1 MD, Ivan Tomek1,4 MD FRCSC

9


value-based decisions about treatment.8

Patients with pain and/or disability secondary to hip or knee OA face numerous treatment options, both surgical and non-operative, each of which is associated with varying de-grees of potential risk and benefit. The treatment decision may be made more complicated by the waxing and waning nature of osteoarthritis symptoms. Furthermore, patients’ pre-opera-tive expectations of joint replacement surgery are variable and may be unrealistically high or low, with expectations that are sometimes dramatically misaligned with reality.9,10 Current population demographics and recent utilization trends sug-gest that demand for TJA surgery is growing, with an estimat-ed 4.5 million annual procedures costing Medicare $50 billion dollars by the year 2030.11,12 Evidence suggests that SDM in musculoskeletal surgery can improve knowledge, adjust un-realistic expectations, and elicit vlues about benefits desired and the degree of acceptable risks.13 Yet there is relatively little information regarding how decision aids and shared decision making affect patients with osteoarthritis who are considering TJA.14 There are also many patients limited by severe osteo-arthritis who choose not to pursue the potential benefits of arthroplasty surgery because of their perceived understanding of the potential risks and benefits. There are seemingly perfect candidates for TJA who choose not to undergo the procedure and it is believed that a lack of understandable, quality infor-mation is one of the main factors influencing their decision making.15,16 To date, much of the SDM literature has focused on the effect of DA’s on patients’ knowledge of options and outcomes, most commonly in association with conditions such as benign prostate disease, ischemic heart disease, hor-mone therapy, and treatment options for breast cancer includ-ing lumpectomy versus mastectomy.2-7 Less well understood is the role and potential benefit of SDM on individuals con-sidering TJA.

The purpose of the current study was to prospectively ex-amine the impact of a video DA on patients with symptom-atic hip or knee OA who were failing medical management and were seeking assessment and advice from an orthopae-dic surgeon specializing in hip and knee arthroplasty. The primary outcome measures of this study were related to the decision-making process and decision quality, rather than condition-specific outcomes or health-related quality-of-life outcomes. In particular, the study sought to answer the ques-tion of whether a video DA for hip and knee OA improved pa-tient decision quality, as defined by the International Patient Decision Aid Standards (IPDAS) collaboration.17 This includ-

ed measures of whether the DA improved treatment-related general knowledge, accuracy of risk perceptions, congruence between patient values and the chosen treatment option, the effect of the DA on decision readiness, the perceived useful-ness of the DA, and the patients preferred role in decision making.

METHODSThe study protocol was approved by the institutional re-

view board at the study institution. A prospective, observa-tional cohort clinical trial was conducted, consisting of a study population of patients 40-80 years of age with symptomatic hip or knee OA and no prior history of knee arthroplasty surgery. All patients were either self-referred or had been referred by their primary care provider to one of two, arthroplasty-fellow-ship trained, Orthopaedic surgeons (SRK, IMT), for opinion and treatment recommendations.

The study site is an academic medical center, where pa-tient-reported outcomes collection and shared medical deci-sion making have been integrated into clinical care pathways, including hip and knee osteoarthritis. Patients with moderate to severe osteoarthrosis of the hip or knee were referred to receive a video DA at the institution’s Center for Shared De-cision Making. The patients completed pre-video SDM ques-tionnaires assessing treatment preference, preferred role in decision making, osteoarthritis and complication knowledge scores, as well as their decision readiness. All participants viewed a 50 minute-long video decision aid (Health Dialog Inc., Boston, MA) about hip or knee osteoarthritis and com-pleted a post-video questionnaire. The pre- and post-survey results were then compared in an effort to better understand the impact the video had on patients with hip and knee osteo-arthritis.

Potential study patients were pre-screened by a research coordinator who previewed the upcoming clinic schedules of the two co-investigators (SRK, IMT), and identified individ-uals who had (1) a presenting complaint of symptomatic hip or knee osteoarthritis and (2) were meeting with the ortho-paedic surgeon for the very first time. Immediately after the clinic visit, if the orthopaedic surgeon agreed that the patient was a candidate for TJA, enrollment in the study was offered. Complete inclusion and exclusion criteria appear in Table 1. If the patient accepted the offer to enroll, the research coor-dinator explained the study methodology, the study consent was signed, and the patients were provided with the pre-video

Table 1: Inclusion and exclusion criteria for SDM study participation.Inclusion Criteria

Exclusion Criteria

10


questionnaire. Patients were asked to complete the first part of the questionnaire, then watch the video DA, and finally to complete the second set of survey questions. The data from the pre and post-video questionnaires were then entered into a secure database for statistical analysis.

Statistical Analysis

Bowker’s Symmetry was used to compute a p-value as it compares two categorical responses and tests the null-hypoth-esis that the responses on the pre-video questionnaire did not differ from the responses on the post-video questionnaire.

Source of Funding

No external or internal funds were received in the conduct of this report. The authors of this study have no related disclo-sures or conflicts of interest to report.

RESULTS

Group Demographics

One hundred and twenty three patients, 80 with knee OA (61% female) and 43 with hip OA (47% female) were re-

cruited into the study. The mean age in both groups was 63 years.

Treatment Preference

One hundred and eighteen patients (78 knees, 40 hips) reported their treatment preference. A majority reported a treatment preference prior to seeing the video and this group demonstrated no significant treatment preference shift after viewing the video, (85% knee patients p=0.28; 88% hip pa-tients p=0.81; Table 2, Figure 1).

Of those unsure before the video, 67% (8 of 12) in the knee cohort and 40% (2 of 5) in the hip cohort had a treatment pref-erence after the video. After watching the video, 9% (7 of 78) with knee OA and 13% (5 of 40) with hip OA remained un-sure about their treatment decision. The majority of patients in this cohort were leaning towards surgery prior to viewing the video and the overall number of patients choosing surgery after watching the video increased in both groups, though this was not statistically significant (p>0.2). Interestingly, despite pre- to post-video preference shifts, the overall distributions of pre- and post-video treatment preferences were quite sim-ilar.

Role in Decision Making

One hundred and nineteen patients reported on their role in decision making. In the hip cohort, females preferred the shared decision-making process include both themselves and their physician more so than men (70% vs. 30%, p < .012), who more of the time preferred being the sole decision maker (Table 3). Overall, 60.5% of patients wished to be the sole decision maker while knowing their doctors opinion, while 39.5% of patients felt the decision should be shared between them and their physician.

Knowledge

Five questions were used to assess patient knowledge Figure 1: Treatment preference shift before and after viewing a decision aid on total joint arthroplasty

Table 2: Patient Treatment Preference Before and After Viewing the Video# of patients Before Decision Aid (%) After Decision Aid (%)

Hip Osteoarthritis 40 §

Non-operative 3 (8%) 2 (5%)

Not Sure 5 (13%) 5 (13%)

Surgery 32 (80%) 33 (82%)

Knee Osteoarthritis 78 ¥

Non-operative 7 (9%) 11 (14%)

Not Sure 12 (15%) 7 (9%)

Surgery 59 (76%) 60 (77%)§ Hip group with missing data on 3 patients¥ Knee group with missing data on 2 patients

11


regarding pain, expected implant survival, post-operative re-covery, and complications. In the knee cohort, basic knowl-edge improved after the video (59% vs. 77%, p<.0001); howev-er a slight improvement in complication risk knowledge was not statistically significant, (68% vs. 69%, p=.54). In the hip cohort, both basic knowledge and knowledge about complica-tions improved after viewing the video, (71% vs. 81%, p<.028) and (73% vs. 94 %, p<.0001), respectively (Table 4).

Values

When asked about their values, 80% (63 of 79) of those with knee arthritis and 79% (31 of 39) of those with hip ar-thritis reported that the video prepared them to discuss their values. Patient values and their concordance with treatment preference were quantified by asking participants how im-portant it was for them to obtain relief from their pain and how important it was for them to avoid surgery on 10-point Likert scales. Although 80% of knee patients reported that the video prepared them to discuss their values, pre- to post-vid-eo concordance between treatment choice and both impor-tance of symptom relief (r=.26 vs. r=.40 p=0.20) and wishing to avoid surgery (r=-0.47 vs. r=-0.57, p=0.83) were not im-proved. In the hip cohort, despite 79% of patients reporting that the video prepared them to discuss their values, pre- to post-video concordance between treatment choice and both importance of symptom relief (r=0.09 vs. r=0.39 p=0.28) and wishing to avoid surgery (r=-0.54 vs. r=-0.49, p=0.76) were not improved.

Decision Readiness

Decision readiness in both cohorts improved after watching the video. Post-video decision readiness in those with knee OA was significantly improved as 50% of patients reported greater decision readiness after viewing the video compared to 6.6% of patients reporting lower decision read-iness (p < .001). In those with hip OA, 83% of patients re-ported greater decision readiness after viewing the video com-pared to 18% of patients reporting lower decision readiness (p < .001).

Evaluation of the Decision Aid

In all, 72% of patients stated they would “definitely recom-mend” the DA to other patients, while another 21% said they would “probably recommend” the DA.

DISCUSSIONDespite the increased emphasis on patient involvement in

medical decision making, there is little evidence in the medical literature related to SDM or the use of patient DAs in Ortho-paedic surgery specifically. An opinion survey demonstrated that orthopaedic surgeons in the United Kingdom were gen-erally positive about the use of patient DAs for joint replace-ment surgery, with 79% responding that DAs were a good or excellent idea.18 DAs were not typically used in daily practice, though. In a recent review of the literature, Slover et. al. (2011) determined that there were limited studies suggesting that DAs enhance decision-making and that conclusions about the use of these aids in orthopaedic clinical practice could not be made.14 It was suggested that further research examining the

Table 3: Effects of Video Decision Aid on Patients’ Preferred Role in Shared-decision MakingHip Cohort Knee Cohort

Who should make decision? Male(n = 23)

Female(n = 17)

Male(n=31)

Female(n=48)

Total

My doctor and I should both make the decision

7 12 11 17 47 (39.5%)

Mainly I should make the decision, while knowing my doctor’s opinion

16 5 20 31 72 (60.5%)

Table 4: Effects of Video Decision Aid on Patients’ Knowledge Regarding Hip and Knee Osteoarthritis# of patients Before Decision Aid After Decision Aid P value

Hip Osteoarthritis 43

Basic Knowledge (%) 71 81 <0.028

Complication Knowledge (%)

73 94 <0.001

Knee Osteoarthritis 80

Basic Knowledge (%) 59 77 <0.001

Complication Knowledge (%)

68 69 >0.2

12


best type, timing, and content of decision aids that will lead to maximum patient involvement and knowledge gains, with minimal clinical workflow disruptions, is needed.

The major finding of this study is that hip and knee osteo-arthritis patients found the video DA to be helpful, and felt that viewing the DA improved their preparedness to make a decision about possible treatment options. There was no evi-dence that viewing a DA either reduced or increased the rate of hip or knee replacement surgery in the current study pop-ulation. In fact, the majority of patients who had made a deci-sion about treatment before viewing a DA stuck to that treat-ment choice even after viewing the DA video. This finding is similar to those reported in a recent musculoskeletal clinical trial concerning spine surgery where patients with specific lumbar spine disorders who watched an evidence-based DA formed and/or strengthened their treatment preferences in a balanced way that did not appear biased toward or away from surgery.19 In this study the video DA did appear to help some of the undecided patients make a decision about treatment. It also appears that a video DA strengthens the convictions of those patients who have already made a treatment decision. After viewing the DA, treatment decision readiness improved in both hip and knee patient cohorts, with the majority of pa-tients reporting greater decision readiness after viewing the DA.

In all, 72% of patients stated they would “definitely recom-mend” the DA to other patients, while another 21% said they would “probably recommend” the DA. About 80% of patients reported that the DA prepared them to discuss treatment op-tions with their provider. This should diminish the concerns that some Orthopaedic surgeons have about whether a DA would be helpful to, and accepted by, their patient population. Vieeeevewing a DA did help those OA patients decide on a treatment who were undecided about a treatment course after meeting with their Orthopaedic surgeon.

Some patients who had a treatment preference prior to the video became unsure after viewing the DA. In the hip OA pa-tients, despite 2 of the 5 unsure patients choosing a treatment preference after the video, 2 patients who had a preference be-came unsure; thus, there was no significant effect of viewing a decision aid on the total number of undecided patients. While 12 of 78 knee patients were unsure of treatment prior to view-ing the DA, only 7 were undecided afterwards.

This study demonstrated that a video DA improved the general knowledge of disease and treatment options for hip and knee arthritis patients who were seeking Orthopaedic opinion for possible surgery. While general knowledge im-proved in both hip and knee groups, only the hip DA group demonstrated significant improvement in complication-re-lated knowledge related to the decision. This shortcoming is important, given that the International Patient Decision Aid Standards (IPDAS) group has identified the improvement of

general knowledge and complication knowledge as two im-portant goals of DAs.17 Previous studies from the orthopaedic spine literature have suggested that video DAs are successful in improving patient knowledge and that they may enhance involvement in clinical decisions.20 Perhaps one of the great-est incentives to adopt DA use by Orthopaedic surgeons would be the fact that DAs strengthen the informed consent process, by reviewing evidence based knowledge and improv-ing patient understanding of the benefits and risks of surgical versus non-operative treatment. The fact that the DA used in this study was not successful in improving knee-related com-plication knowledge suggests that either the information pre-sented in the video, or the questions used to assess knowledge, might need to be reviewed.

Patient values as they relate to preference-sensitive deci-sions such as total hip or knee replacement are important to consider. Preference-sensitive decisions are those where there is more than one feasible treatment option, and the risks, ben-efits, and outcomes vary considerably between the potential options. Patient values relevant to severe hip or knee OA have often been distilled down to the “desire to avoid surgery” and “desire to alleviate pain” as was the case in this study. The premise is that if a patient expresses the desire to avoid sur-gery, they should ultimately choose non-operative treatment modalities. Conversely, a patient whose main goal is to allevi-ate pain should select arthroplasty surgery, which is more ef-fective in pain relief in the cases of severe hip or knee OA than other treatment options. This matching of values to treatment choice has been described as “concordance”, and in the shared decision making literature it is considered to be the hallmark of a high quality healthcare decision. Thus, a non-concordant decision would be one in which a patient whose stated values were to avoid surgery eventually ended up seeking operative management, or vice versa.

In the current study, there was no evidence that DAs im-proved concordance between values and treatment choice in hip and knee OA patients. While approximately 80% of pa-tients reported that the video prepared them to discuss their values, the relationship between treatment choice and both importance of symptom relief and wishing to avoid surgery was not concordant. While some may consider this to be a failure of DAs, an alternative explanation is that the currently accepted definition of concordance may be overly simplistic when it comes to evaluating the quality of OA treatment de-cisions. While many patients may initially express the strong desire to avoid surgery, the relative ineffectiveness of non-op-erative modalities for severe hip and knee OA may push many patients towards a surgical treatment choice. It has been pre-viously suggested that the desire to obtain pain relief was the most important factor identified by patients who chose sur-gery instead of non-operative management.21 It may be that pain relief is such a strong motivator for arthroplasty that after reviewing the DA, even those patients who initially wanted to

13


avoid surgery will choose operative management.

In some clinical trials, decision aids have been shown to decrease the rates of major surgery by 20% to 40%.22 In spine surgery, for example, patients with intervertebral disc herniation who viewed a video DA were more likely to switch from surgical to non-operative treatment. 23 The use of SDM and video DAs in a cohort of patients considering TJA might therefore be expected to drive down the utilization of surgery. In fact, this may be one of the unspoken fears of Orthopaedic surgeons and health systems regarding SDM. Interestingly, af-ter viewing the DA, the overall number of patients preferring surgery as a treatment option demonstrated no statistically significant change. This observation is contradictory to some evidence which has suggested that SDM may hold the key to reducing rates of costly, elective surgery1,2,6,24. A potential ex-planation for why video DAs failed to reduce patient enthusi-asm for surgery is that there is significant asymmetry in the known outcomes of non-operative versus operative treatment for severe hip and knee OA. The video DA reports an overall satisfaction with non-operative modalities of approximate-ly 40%, while surgical modalities have patient satisfaction of 85% to 90%. It may not be surprising, therefore, that pa-tients tend to gravitate towards the more successful treatment option. Even the risk of acute perioperative complications, which has been estimated at 2%, does not seem to be enough to discourage patients from pursuing arthroplasty treatment.

In this study, women seemed to prefer sharing the deci-sion making process with their physician, compared to men who preferred to be the sole decision maker. This suggests gender, in addition to patient values and goals may play a large role in determining how patients arrive at treatment decisions for severe hip and knee OA.

There are several potential limitations to this study. All patients recruited to this study had been referred to an or-thopaedic surgeon, suggesting they had time to contemplate TJA prior to viewing the video DA. It may be that hip and knee OA patients should be exposed to DAs much earlier in the disease process. Another limitation was the assumption that each patient watched the video in its entirety and completed the questionnaire appropriately after the video was complete. This study only looked at a video DA and did not consider the influence of other sources of information patients common-ly use before deciding on surgery. The questions used were written in accordance with the best known data available on gathering these types of outcome measures and the validity of substantiating some of these values could potentially be called into question.

Information on the timing and effect of SDM on patient preference and treatment decision continues to expand and further study into this aspect of SDM is needed. In patients with symptomatic hip and knee OA, a video DA improved basic knowledge and improved complication knowledge in

patients with hip OA. Improved preparedness to discuss their values and decision readiness did not translate into greater concordance between patients’ values and treatment choices. Patients with an initial treatment preference were not likely to change their preference while those who werre unsure about their treatment preference were more likely to report a pref-erence after watching the video. Ultimately, the total number of people choosing surgery did not change after viewing the decision aid.

REFERENCES

1. O’Connor AM, Rostom A, Fiset V, et al. Decision aids for patients facing health treatment or screening decisions: systematic review. BMJ. Sep 18 1999;319(7212):731-734.2. Bernstein SJ, Skarupski KA, Grayson CE, Starling MR, Bates ER, Eagle KA. A randomized controlled trial of information-giving to patients referred for coronary angiography: effects on outcomes of care. Health Expect. Jun 1998;1(1):50-61.3. Lerman C, Biesecker B, Benkendorf JL, et al. Controlled trial of pretest education approaches to enhance informed decision-making for BRCA1 gene testing. J Natl Cancer Inst. Jan 15 1997;89(2):148-157.4. O’Connor AM, Tugwell P, Wells GA, et al. Randomized trial of a portable, self-administered decision aid for postmenopausal women considering long-term preventive hormone therapy. Med Decis Mak-ing. Jul-Sep 1998;18(3):295-303.5. Rothert ML, Holmes-Rovner M, Rovner D, et al. An educational intervention as decision support for menopausal women. Res Nurs Health. Oct 1997;20(5):377-387.6. Street RL, Jr., Voigt B, Geyer C, Jr., Manning T, Swanson GP. Increasing patient involvement in choosing treatment for early breast cancer. Cancer. Dec 1 1995;76(11):2275-2285.7. Barry MJ, Cherkin DC, Chang YC, Fowler FJ, S S. A randomized trial of a multimedia shared decision-making program for men facing a treatment decision for benign prostatic hyperplasia. Disease Man-agement and Clinical Outcomes. 1997;1:5–14.8. O’Connor AM, Bennett CL, Stacey D, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2009(3):CD001431.9. Mancuso CA, Jout J, Salvati EA, Sculco TP. Fulfillment of patients’ expectations for total hip arthroplasty. J Bone Joint Surg Am. Sep 2009;91(9):2073-2078.10. Mancuso CA, Sculco TP, Wickiewicz TL, et al. Patients’ expecta-tions of knee surgery. J Bone Joint Surg Am. Jul 2001;83-A(7):1005-1012.11. Wilson NA, Schneller ES, Montgomery K, Bozic KJ. Hip and knee implants: current trends and policy considerations. Health Aff (Millwood). Nov-Dec 2008;27(6):1587-1598.12. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of pri-mary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. Apr 2007;89(4):780-785.13. Weinstein JN, Clay K, Morgan TS. Informed patient choice: patient-centered valuing of surgical risks and benefits. Health Aff (Millwood). May-Jun 2007;26(3):726-730.14. Slover J, Shue J, Koenig K. Shared Decision-making in Ortho-paedic Surgery. Clin Orthop Relat Res. Nov 5 2011.15. Ballantyne PJ, Gignac MA, Hawker GA. A patient-centered perspective on surgery avoidance for hip or knee arthritis: lessons for the future. Arthritis Rheum. Feb 15 2007;57(1):27-34.16. Clark JP, Hudak PL, Hawker GA, et al. The moving target: a qualitative study of elderly patients’ decision-making regarding total joint replacement surgery. J Bone Joint Surg Am. Jul 2004;86-A(7):1366-1374.

14


21. Bozzuto L KS, Clay C, Kantor S, Tomek I. Hip and Knee Os-teoarthritis: Shared Decision Making and Factors affecting Patient Treatment Choice. AAOS Annual Meeting Paper Presentations. 2011.22. O’Connor AM, Stacey D, Rovner D, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2001(3):CD001431.23. Deyo RA, Cherkin DC, Weinstein J, Howe J, Ciol M, Mulley AG, Jr. Involving patients in clinical decisions: impact of an interactive vid-eo program on use of back surgery. Med Care. Sep 2000;38(9):959-969.24. Morgan M. A randomized trial of the ischemic heart disease shared decision making program: an evaluation of a decision aid [Master’s thesis]. Toronto:University of Toronto. 1997.

17. O’Connor AM, Bennett C, Stacey D, et al. Do patient decision aids meet effectiveness criteria of the international patient decision aid standards collaboration? A systematic review and meta-analysis. Med Decis Making. Sep-Oct 2007;27(5):554-574.18. Adam JA, Khaw FM, Thomson RG, Gregg PJ, Llewellyn-Thomas HA. Patient decision aids in joint replacement surgery: a literature review and an opinion survey of consultant orthopaedic surgeons. Ann R Coll Surg Engl. Apr 2008;90(3):198-207.19. Lurie JD, Spratt KF, Blood EA, Tosteson TD, Tosteson AN, Wein-stein JN. Effects of viewing an evidence-based video decision aid on patients’ treatment preferences for spine surgery. Spine (Phila Pa 1976). Aug 15 2011;36(18):1501-1504.20. Phelan EA, Deyo RA, Cherkin DC, et al. Helping patients decide about back surgery: a randomized trial of an interactive video pro-gram. Spine (Phila Pa 1976). Jan 15 2001;26(2):206-211;discussion 212.

ABSTRACT: Introduction: Carpal tunnel syndrome is the most common compressive

neuropathy in the United States and has a significant financial burden on the health care system. The diagnosis is based upon history, physical exam and electrodiagnostic studies. The pur-pose of this study was to determine if patient demographics and medical comorbidities could be used in the clinic to aid in the diagnosis of carpal tunnel syndrome (CTS) by predict-ing the results of electrodiagnostic studies (EDS) in patients diagnosed with carpal tunnel syndrome based on history and physical exam.

Methods:A retrospective chart review of consecutive patients re-

ferred for EDS with the presumed diagnosis of CTS based on history and physical exam was performed to identify charac-teristics that could predict a positive or negative EDS. Two Orthopaedic surgeons independently evaluated each chart and resolved differences by consensus. Patient profiles includ-ing demographics and medical comorbidities were recorded. Chi-squared test was used to identify significance differences for each variable and binary regression was used to evaluate prediction of CTS status.

Results:Three hundred thirty-four of the 431 (77%) patients re-

viewed had positive EDS. Predictors for positive EDS include age greater than or equal to 50 years, male sex, retired, dia-betes, negative smoking status, and cardiac or renal/urinary medical comorbidities. Negative predictors for a positive EDS include unemployment and psychiatric medical comorbidi-ties. Binary regression of EDS status on all nine positive pre-dictors simultaneously indicated that patient age great than or equal to 50 years, male sex, cardiac comorbidity, and negative smoking status remained significant predictors for a positive EDS.

Discussion: Demographics and comorbidities can be used to identify-

ing patients with a high likelihood of a positive or negative EDS in patients with a positive history and physical exam. This knowledge can help physicians diagnose CTS upon initial evaluation of a patient.

Level of Evidence:Level II

INTRODUCTION:Carpal tunnel syndrome (CTS) is the most common com-

pressive neuropathy in the United States. The prevalence is believed to be approximately 3.7% in the United States.1 There are approximately 400,000-500,000 surgeries performed per year in the US for CTS with an estimated economic impact of $2 billion annually.2 Multiple associations of CTS with patient demographics and comorbidities, such as age, female sex, smoking, diabetes, and thyroid disorder have been report-ed.3,4,5,6,7

Several provocative tests assist in diagnosing CTS but no one test is definitively diagnostic. The sensitivity and speci-ficity of Phalen’s test range from 0.46 – 0.80 and 0.51 – 0.91, Tinel’s sign 0.28 - 0.73 and 0.44 - 0.95, Median nerve compres-sion test 0.04 - 0.79 and 0.25 – 0.96, respectively. Combining these tests is believed to increase both the sensitivity and spec-ificity.8,9,10,11,12,13 2-point discrimination and threshold sensory measurements using Semmes-Weinstein monofilament or vibrometry has a sensitivity of 0.91 and specificity of 0.8 for detecting CTS.14 Steroid injection can be used diagnostically, since therapeutically it has been found to improve 70% of pa-tients with CTS at two weeks in a double blinded randomized controlled trial.15

Electrodiagnostic studies (EDS), the combination of elec-tromyography and nerve conduction studies, are performed regularly to assist in diagnosis of CTS. Practice Parameters produced by the American Academy of Neurology, American Association of Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation give a sensi-tivity ranging from 0.04 - 0.85 and specificity of 0.52 – 0.99 for a number of different electrodiagnostic tests for carpal tunnel syndrome.16

In patients suspected to have CTS based on their history

Predicting electrodiagnostic study results in CTSErik R. Bergquist1 MD, Jeffrey A. Cohen1 MD, Kevin F. Spratt2 PhD, Lance G. Warhold1 MD

1. Dartmouth-Hitchcock Medical Center, Lebanon NH 2. Geisel School of Medicine at Dartmouth

Corresponding Author: Erik R. Bergquist, MDE-mail: [email protected]


16


and physical exam, it was hypothesized that patient demo-graphics and medical comorbidities (medical condition or disease process) could be examined independently and simul-taneously to determine those that best predict the chance of a patient having a positive or negative based on EDS evalua-tion. The ability to predict CTS status based on EDS results can assist physicians in making the diagnosis of carpal tunnel syndrome upon initial evaluation and determine the next step in treatment. We performed a retrospective cohort study to determine if demographics and medical comorbidities could predict EDS results in patients with a diagnosis of CTS based on history and physical exam.

MATERIALS AND METHODS:

Study Design and Cohort Identification

Institutional Review Board approval was obtained for this study. A cohort of consecutive patients was identified by re-viewing the clinic schedules for the providers in the Depart-ment of Neurology at our institution that performed EDSs for CTS in accordance with the recommendations of the Amer-ican Academy of Orthopaedic Surgeons (AAOS) Clinical Practice (CPG).17 Schedules were reviewed from November 2008 through August 2011.

All patients over this period were included if their refer-ring diagnosis was CTS or median nerve compression at the wrist and excluded if their referring diagnosis was hand pain, hand numbness, finger numbness, or anything other than CTS/median nerve compression at the wrist. If a patient had multiple visits for the diagnosis of CTS, the patient was en-tered into the study only once with the EDS from the initial visit used.

Data from clinic notes and the hospital information system were abstracted by two evaluators and entered independently into a REDCap electronic data capture.18 REDCap (Research Electronic Data Capture) is a secure, web-based application designed to support data capture for research studies, provid-ing: 1) an intuitive interface for validated data entry; 2) audit trails for tracking data manipulation and export procedures; 3) automated export procedures for seamless data downloads to common statistical packages; and 4) procedures for import-ing data from external sources.

Chart Review Protocol

After receiving internal review board approval, patient demographic, medical comorbidity, and EDS result data were recorded. Medical comorbidities as reported by the patients were defined as persistent medical issues affecting the patient at the time of the EDS. The double data entry comparison tools built into the software was used to identify discrepancies in data entry that were then clarified by the two evaluators by returning to the source data and resolving each discrep-

ancy. Variables extracted were based on previously reported predictors of CTS in the literature. 3,19,20,21,22,23 These included: patient age and sex; specific medical comorbidities of active smoking, diabetes, and thyroid disorder; profession; workers compensation status; referring provider type; total number of medical comorbidities; and specific medial comorbidities re-corded on a health system basis: cardiac, pulmonary, gastro-enterological, renal/urinary, rheumatologic, musculoskeletal, neurologic, endocrine, psychiatric, reproductive, hematolog-ic/oncologic, dermatologic, and eyes/ears/nose/throat.

EDS protocol

EDSs were performed in accordance with the standards set by the American Association of Electrodiagnostic Medi-cine, American Academy of Neurology, and the American Academy of Physical Medicine and Rehabilitation (Appendix A).16 The values used in regards to an abnormal EDS are those set as the institutional standard for our institution (Appendix B).

Data Analysis

Data analyses described the overall sample and evaluated for differences in patient demographics and comorbidities rel-ative to CTS status. Chi-square tests for categorical variables and analysis of variance (ANOVA) for continuous variables were used to evaluate the association of each variable with CTS status with type I error set at 0.05. Unadjusted and adjusted relative risks (URR and ARR) associated with significant pre-dictors identified in the preliminary chi-square and ANOVA results were evaluated with generalized regression using the GLIMMIX procedure that specified a binary distribution with a log link and specifying patient id as a random effect.

Source of Funding:

No external or internal funds were received in the conduct of this report. The authors of this study have no disclosures or conflicts of interest to report.

RESULTS: Four-hundred forty-nine consecutive patient visits to the

Department of Neurology at our institution for an EDS to rule in CTS between November 2008 and August 2011 were iden-tified. Four-hundred thirty-one (96%) met study inclusion/exclusion criteria. Of the 18 patients excluded, 17 were repeat referrals and one patient did not have an adequate medical history for collection of patient demographics and medical comorbidities.

Patient demographics and medical comorbidities are summarized in Table 1. Overall, 334 of the 431 (77%) patients presumed to have CTS were had positive EDS for CTS. Nine demographics/comorbidities were associated with (p < 0.05)

17


Table 1. Patient Demographics / Medical Comorbidities and EDS Result

N Overalln = 431

CTS+n = 334

CTS-n = 97 p Value

Age in years: Mean (SD) 431 55.4 (14.5) 58.0 (15.2) 46.4 (12.8) <0.001

>=50 272 63.1% 70.1% 39.2% <0.001

<50 159 36.9% 29.9% 60.8% <0.001

Gender <0.001

% Male 154 35.7% 42.2% 13.4% <0.001

% Female 277 64.3% 57.8% 86.6% <0.001

Tobacco Use %Smoking 82 19.0% 15.3% 32.0% 0.001

Working status 0.001

Working - Active 157 36.4% 35.3% 40.2% 0.064

Working - Sedentary 93 21.6% 20.7% 24.7% 0.075

Not Working - Retired 103 23.9% 28.4% 8.3% <0.001

Not Working - Student 5 1.2% 1.2% 1.0% 0.408

Not Working - Unemployed 58 13.5% 11.4% 20.6% 0.010

Unknown 15 3.5% 3.0% 5.2% 0.136

Referring provider type 0.504

PCP 171 39.7% 39.8% 39.2%

Neurosurgeon 4 0.9% 1.2% 0.0%

Orthopeadic Surgeon 103 23.9% 22.8% 27.8%

Plastic Surgeon 110 25.5% 27.0% 20.6%

Neurologist 22 5.1% 4.8% 6.2%

Rheumatologist 11 2.6% 2.7% 2.1%

Other 10 2.3% 1.8% 4.1%

Medical comorbidities

Mean No. of comorbidities (SD) 431 4.50 (2.8) 4.6 (2.9) 4.0 (2.6) 0.068

cardiac comorbidities % Yes 266 61.7% 66.8% 44.3% <0.001

pulmonary comorbidities % Yes 104 24.1% 22.4% 26.8% 0.484

GI comorbidities % Yes 153 35.5% 33.2% 43.3% 0.068

renal/urinary comorbidities % Yes 63 14.6% 16.5% 8.3% 0.044

rheumatologic comorbidities % Yes 66 15.3% 15.9% 13.4% 0.553

musculoskeletal comorbidities % Yes 206 47.8% 49.4% 42.3% 0.216

neurologic comorbidities % Yes 101 23.4% 21.6% 29.9% 0.088

endocrine comorbidities % Yes 138 32.0% 32.6% 29.9% 0.611

psychiatric comorbidities % Yes 159 36.9% 32.6% 51.6% 0.001

reproductive comorbidities % Yes 68 15.8% 15.6% 16.5% 0.826

heme/onc comorbidities % Yes 55 12.8% 14.1% 8.3% 0.130

dermatologic comorbidities % Yes 65 15.1% 16.8% 9.3% 0.070

EENT comorbidities % Yes 70 16.2% 17.7% 11.3% 0.137

Diabetes %Yes 69 16.0% 18.0% 9.3% 0.040

Thyroid Disease %Yes 69 16.0% 15.6% 17.5% 0.644

Workers compensation 27 6.3% 6.0% 7.2% 0.660

18


CTS. Patients who had clinical evidence of CTS and posi-tive EDS were more likely to be 50 years of age or older, male, retired, diabetic, or report comorbidities involving cardiac or renal/urinary systems. Patients who had clinical evidence of CTS but paradoxically had negative EDS were more likely to be unemployed, be a smoker, or report a psychiatric comor-bidity. Table 2 classifies the variables relative to their relation-ship with the EDS result.

Univariate binary regression results for each of the nine demographics/comorbidities related to the EDS results pro-vides both the unadjusted relative risks (URR) and the adjust-ed relative risks (ARR) associated with each predictor and for the overall model (Table 2). Multi-variable binary regression analysis demonstrated significant (p < 0.05) ARRs for four of the nine predictive demographics/comorbidities. These in-clude age greater than or equal to 50, male sex, presence of cardiac comorbidities, and lack of smoking, Table 3. Model sensitivity and specificity were both 0.72 with positive predic-tive value (PPV) of 0.90, and negative predictive value (NPV) of 0.43.

DISCUSSION: Patient demographics and comorbidities can predict the

results of EDS in patients believed to have CTS based on his-tory and physical exam. Multi-variable analysis indicate the demographics/comorbidities that best predict the results of a patient’s EDS for CTS include a patient’s age, sex, presence of a cardiac comorbidity, and smoking status.

History and physical exam predicted CTS on EDS in this study at rates similar to those already published.8,9,10,11,12,13,14 CTS was also associated with increasing age,1,11,19,24,25 diabe-tes,3,26 cardiac comorbidities,23 renal/urinary comorbidities,27 and retired working status11,28 on univariate analysis.

This research agrees with the reported literature, finding a greater incidence of females referred with presumptive CTS as well as females who had a positive EDS.1,19 Despite this fact, when sex was analyzed for rates of CTS with EDS in relation

to their relative populations in the cohort, male gender was more predictive of a positive EDS. This could suggest that fe-males may be more likely to seek treatment earlier in the dis-ease process than males when their EDS are not yet positive.

Studies have provided mixed results regarding the rela-tionship of tobacco use and CTS.3,29,30 This study found tobac-co use to be associated with negative EDS for CTS. This does not negate the role of smoking in vascular disease, nerve inju-ry, and carpal tunnel syndrome, but instead suggests an over-powering presence of smoking use as a surrogate for other fac-tor(s) in these patients leading to a negative EDS. Psychiatric medical comorbidities have not previously been found to have an association with CTS.31 Although, patients with CTS and psychiatric medical comorbidities report more intense symp-toms.32 This study found psychiatric medical comorbidities to be associated with a negative EDS. This negative associa-tion may be due to a hypersensitive state where patients seek medical attention before their EDS meet the threshold for a diagnosis of CTS. Finally, employment status has been asso-ciated with CTS.22 Although this study did not examine em-ployment versus unemployment, it did compare patients who reported to be “unemployed” vs. other work status (working, retired, student). Unemployed status was predictive of a neg-ative EDS. This, in association with the other predictors of a negative EDS (younger age, smoking, and psychiatric med-ical comorbidities) presents a psychosocial/socioeconomic component to those patients with a history and physical exam consistent with CTS but paradoxical negative EDS.

Demographics and medical comorbidities previous-ly associated with CTS but not found to be associated with CTS, either positive or negative, include thyroid disorder, rheumatologic medical comorbidities, and workers compen-sation.3,21,33 When thyroid disorder is treated, EDS for CTS have been found to normalize.20 It is possible the patients in this study had their thyroid disorder well managed, as they required a referral to have their EDS and were consumers of healthcare. There is a clear correlation between synovial pro-liferative rheumatologic diseases such as rheumatoid arthritis and CTS.34 Other rheumatologic diseases such as fibromyal-gia do not have these correlations. It is possible that patients with these other rheumatologic comorbidities diluted the number of patients with synovial proliferative rheumatologic diseases thus finding no correlation between rheumatologic comorbidities and CTS. This study found no statistically sig-nificant association between worker compensation claims and EDS results for CTS. Thus, workers compensation does not play a role in diagnosis of CTS.

This study did not find a significant difference in the rates of predicting CTS with EDS between the different types of referring physicians. This could suggest that the cohort was without subgroups that could skew the data based upon a sin-gle type of provider (Ex. Primary care physician) referring a disproportionate number of patients in the cohort using ei-

Table 2. Predictors of CTS on EDSPositive Negative Not predictive

Age >= 50 Tobacco use Other medical comorbidities

Male sex Psychiatric comorbidities

Thyroid disease

Diabetes Unemployed Number of medial comorbidities

Cardiac comorbidities

Referring provider type

Renal/urinary comorbidities

Workers compensation

Retired

19


ther a better or worse clinical acumen.

This was a retrospective cohort study and this design comes with known limitations. The greatest limitation is the accuracy of the referral diagnosis. The history and physical exam that lead to that diagnosis was not available for many patients, as the referral came from outside the institution per-forming the EDS. The rate of positive EDS was consistent with the literature. Additionally, the accuracy and completeness of the data in the medical record limits the quality of the conclu-sions. To minimize this limitation, two independent review-ers performed double data entry. Discrepancies may also exist between the interpretations of which medical system a medi-cal comorbidity should be attributed or the strenuous nature of a profession. The two independent reviewers agreed upon these interpretations but their judgment may differ from that of the medical body. The patients in this study come from a rural portion of New England and may not be generalizable to other regions. Finally, this study provides data for patients believed to have CTS based on history and physical exam. It does not provide information on patients with an equivocal diagnosis of CTS.

Patient demographics and medical comorbidities were identified that can be used in the clinic to predict the results of EDS and thereby assist in the diagnosis of CTS upon initial evaluation. This knowledge can help physicians better treat their patients.

REFERENCES

1. Papanicolaou GD, McCabe SJ, Firrell J. The prevalence and char-acteristics of nerve compression symptoms in the general population. J Hand Surg. 2001;26(3):460–466.2. Palmer DH, Hanrahan LP. Social and economic costs of carpal tunnel surgery. Instr Course Lect. 1995;44:167–172.3. Karpitskaya Y, Novak CB, Mackinnon SE. Prevalence of smoking, obesity, diabetes mellitus, and thyroid disease in patients with carpal tunnel syndrome. Ann Plast Surg. 2002;48(3):269–273.4. Ablove RH, Ablove TS. Prevalence of carpal tunnel syndrome in pregnant women. WMJ. 2009;108(4):194–196.5. Goodman CM, Steadman AK, Meade RA, et al. Comparison of carpal canal pressure in paraplegic and nonparaplegic subjects: clini-cal implications. Plast Reconstr Surg. 2001;107(6):1464–14716. Andersen JH, Thomsen JF, Overgaard E, et al. Computer use and carpal tunnel syndrome: a 1-year follow-up study. JAMA. 2003;289(22):2963–2969. 7. Franklin GM, Haug J, Heyer N, Checkoway H, Peck N. Occupa-tional carpal tunnel syndrome in Washington State, 1984-1988. Am J Public Health. 1991;81(6):741–746.8. Gomes I, Becker J, Ehlers JA, Nora DB. Prediction of the neuro-physiological diagnosis of carpal tunnel syndrome from the demo-graphic and clinical data. Clin Neurophysiol 2006;117(5):964–971.9. de Krom MC, Knipschild PG, Kester AD, Spaans F. Efficacy of provocative tests for diagnosis of carpal tunnel syndrome. Lancet. 1990;335(8686):393–395. 10. Raudino F. Tethered median nerve stress test in the diagnosis of carpal tunnel syndrome. Electromyogr Clin Neurophysiol. 40(1):57–60. 11. Katz JN, Larson MG, Sabra A, et al. The carpal tunnel syndrome: diagnostic utility of the history and physical examination findings. Ann Intern Med. 1990;112(5):321–327.12. Fertl E, Wöber C, Zeitlhofer J. The serial use of two provocative tests in the clinical diagnosis of carpal tunel syndrome. Acta Neurol Scand. 1998;98(5):328–332.13. Kaul MP, Pagel KJ, Wheatley MJ, Dryden JD. Carpal compres-sion test and pressure provocative test in veterans with median-distri-

Table 3. Multiple Variable Analysis Using the 9 Predictors Found on Univariate AnalysisUnivariate Regression Results Multiple Regression Results

Variable Contrast URR 95% CI c*** p < ARR 95% CI c*** p <

Full Model* PV+ ref (1 - PV-)** 1.57 1.37-1.82 0.78 0.0001

Age >=50 ref < 50 1.367 1.20-1.56 0.65 0.0001 1.179 1.03-1.35 0.78 0.0160

Sex Male ref Female

1.314 1.19-1.44 0.64 0.0001 1.254 1.12-1.40 0.0001

No tobacco use Yes ref No 1.304 1.08-1.45 0.58 0.003 1.181 1.01-1.39 0.0310

Retired Yes ref No 1.265 1.15-1.39 0.60 0.0001 1.033 0.90-1.18 0.6300

Unemployed Yes ref No 0.826 0.68-1.01 0.55 0.0206 0.917 0.77-1.09 0.3200

Diabetes Yes ref No 1.149 1.03-1.29 0.54 0.0440 1.042 0.90-1.20 0.5600

Cardiac Yes ref No 1.246 1.10-1.41 0.61 0.0001 1.133 1.01-1.28 0.0490

Renal/urinary Yes ref No 1.151 0.91-1.14 0.54 0.0490 1.035 0.90-1.19 0.6500

Psychiatric Yes ref No 0.829 0.73-0.94 0.59 0.0008 1.104 0.80-1.02 0.0910* Full model included all 9 variables** PV+ ref (1 -PV-) = (the likelihood of CTS + given that the model predicts CTS+ or Positive Predictive Value) / (the likelihood of CTS+ given that the model predicts CTS- or 1 - Negative Predictive Value)*** c is the area under the ROC curve (plotting Sensitivity (y) against 1-Specificity (x)

20


in-hospital carpal tunnel syndrome in the general population and possible associations with marital status. BMC Public Health. 2008;8:374.25. Atroshi I, Gummesson C, Johnsson R, et al. Prevalence of carpal tunnel syndrome in a general population. JAMA. 1999;282(2):153–158.26. Chammas M, Bousquet P, Renard E, et al. Dupuytren’s disease, carpal tunnel syndrome, trigger finger, and diabetes mellitus. J Hand Surg. 1995;20(1):109–114.27. Halter SK, DeLisa JA, Stolov WC, Scardapane D, Sherrard DJ. Carpal tunnel syndrome in chronic renal dialysis patients. Arch Phys Med Rehabil. 1981;62(5):197–201.28. Lo J. Community-based referrals for electrodiagnostic studies in patients with possible carpal tunnel syndrome: What is the diagno-sis? Arch Phys Med Rehabil. 2002;83(5):598–603. 29. Geoghegan JM, Clark DI, Bainbridge LC, Smith C, Hub-bard R. Risk factors in carpal tunnel syndrome. J Hand Surg Br. 2004;29(4):315–320.30. Nathan PA, Keniston RC, Lockwood RS, Meadows KD. Tobacco, caffeine, alcohol, and carpal tunnel syndrome in American industry. A cross-sectional study of 1464 workers. J Occup Environ Med. 1996;38(3):290–298.31. Chan L, Turner JA, Comstock BA, et al. The relationship between electrodiagnostic findings and patient symptoms and function in car-pal tunnel syndrome. Arch Phys Med Rehabil. 2007;88(1):19–24.32. Hobby JL, Venkatesh R, Motkur P. The effect of psycholog-ical disturbance on symptoms, self-reported disability and sur-gical outcome in carpal tunnel syndrome. J Bone Joint Surg Br. 2005;87(2):196–200.33. Szabo RM. Carpal tunnel syndrome as a repetitive motion disor-der. Clin Orthop Relat Res. 1998;(351):78–89.34. Dorwart BB. Carpal tunnel syndrome: a review. Semin Arthritis Rheum. 1984;14(2):134–140.

bution paresthesias. Muscle Nerve. 2001;24(1):107–111.14. Gellman H, Gelberman RH, Tan AM, Botte MJ. Carpal tunnel syndrome. An evaluation of the provocative diagnostic tests. J Bone Joint Surg Am. 1986;68(5):735–737.15. Armstrong T, Devor W, Borschel L, Contreras R. Intracarpal steroid injection is safe and effective for short-term management of carpal tunnel syndrome. Muscle Nerve. 2004;29(1):82–88.16. Jablecki CK, Andary MT, Floeter MK, et al. Practice parameter: Electrodiagnostic studies in carpal tunnel syndrome. Report of the American Association of Electrodiagnostic Medicine, American Acad-emy of Neurology, and the American Academy of Physical Medicine and Rehabilitation. Neurol. 2002;58(11):1589–1592.17. Keith MW, Masear V, Amadio PC, et al. Treatment of carpal tun-nel syndrome. J Am Acad Orthop Surg. 2009;17(6):397–405. 18. Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–381.19. Hobby JL, Venkatesh R, Motkur P. The effect of age and gender upon symptoms and surgical outcomes in carpal tunnel syndrome. J Hand Surg Br. 2005;30(6):599–604. 20. Palumbo CF, Szabo RM, Olmsted SL. The effects of hypothy-roidism and thyroid replacement on the development of carpal tunnel syndrome. J Hand Surg. 2000;25(4):734–739.21. Cranford CS, Ho JY, Kalainov DM, Hartigan BJ. Carpal tunnel syndrome. J Am Acad Orthop Surg. 2007;15(9):537–548.22. Roquelaure Y, Ha C, Pelier-Cady M-C, et al. Work increases the incidence of carpal tunnel syndrome in the general population. Muscle Nerve. 2008;37(4):477–482.23. Shiri R, Heliövaara M, Moilanen L, et al. Associations of cardio-vascular risk factors, carotid intima-media thickness and manifest atherosclerotic vascular disease with carpal tunnel syndrome. BMC Musculoskelet Disord. 2011;12:80.24. Mattioli S, Baldasseroni A, Curti S, et al. Incidence rates of

Establishment of a designated transfer center improves care of orthopaedic trauma patients

Eugene W. Brabston2 MD, John E. Bell1 MD MS, Robert V. Cantu1 MD MS

1. Dartmouth-Hitchcock Medical Center, Lebanon NH 2. New York-Presbyterian Hospital, Columbia University, NYC

Corresponding Author: Robert V. Cantu, MD, MSE-mail: [email protected]


ABSTRACT: IntroductionThis study aims to evaluate what impact the establishment

of a “Transfer Center” has on the transfer process from the perspective of the referring Emergency Department (ED) phy-sician.

MethodsPaper surveys were mailed to all ED directors in NH and

VT to assess their perception of a newly established Transfer Center at a Level I trauma center on patient care and on the transfer process.

Results19 out of 38 (50%) of surveys were returned. 59% of re-

spondents said the Transfer Center improved the process of transferring patients while 35% said it made no difference. Despite overall improvement, 33% said the process is still ei-ther “very” or “somewhat” frustrating.

DiscussionEstablishing a dedicated Transfer Center can improve com-

munication and facilitate the transfer of patients to tertiary care hospitals.

Level of EvidenceIV

INTRODUCTIONRecent years have seen what some describe as a “crisis”

in the availability of orthopaedic surgeons to provide trauma care.1-5 In a previous study conducted by this group, ED pro-viders in NH and VT were surveyed regarding their experi-ence with their orthopaedic call coverage.6 The transfer of or-

thopaedic trauma patients was also examined. Approximately 29% of survey respondents stated that it was often easier to have an orthopaedic trauma patient transferred to a Level I trauma center than have the on-call staff evaluate the patient. An equal number of respondents, however, felt the transfer process was “very frustrating.”

In an effort to facilitate the process of transferring patients, a designated Transfer Center was established at a northern New England Level I trauma center. The Transfer Center in-cludes a triage secretary who is available 24 hours per day. The triage secretary receives the incoming transfer request call and contacts the appropriate accepting service(s). A conference call with all of the parties is then recorded with the triage secretary acting as facilitator. Prior to the establishment of the Transfer Center, incoming requests for transfer did not follow any set pattern. Sometimes the calls went through the hospital op-erator, other times through the ED physician, and sometimes through department answering services. This study sought to see, from the ED physicians’ perspective, what impact the Transfer Center has had on the transfer process.

METHODSInstitutional Review Board approval was obtained prior

to commencing this survey. Self-addressed anonymous enve-lopes were mailed to each of the 38 Emergency Department directors in Northern New England. The survey assessed the ED director’s perception of transferring orthopaedic trauma patients to a regional Level I trauma center both before and after the institution of the Transfer Center. Statistical analysis utilizing Fisher’s exact test was used to compare responses to previous responses published by the group. An open-ended response section was placed at the end of the survey to solicit recommendations for improvement as well as allow for a gen-eral assessment of the “Transfer Center”.

Source of Funding


RESULTS

22


19 out of 38 surveys (50% response rate) were returned. Of the respondents 50% had completed Emergency Medicine residency training, 30% Family Practice, and 20% Internal Medicine. The majority (90%) had been an ED physician for more than 10 years. Almost all respondents (95%) were aware the accepting facility had a designated Transfer Center. In ad-dressing the overall premise of the study, 59% of respondents treplied that the Transfer Center has made the transfer of or-thopaedic trauma patients easier, while 35% of respondents stated that it made no difference (Figure 1.) Despite the over-all improvement, 33% stated that the process was still either “very” or “sometimes” frustrating (Figure 2.)

Of the respondents, 83% stated that speaking with the or-thopaedic surgeon/resident improved quality of care and as-sisted with the transfer process, while 12% stated that it made no difference. Interestingly, 67% stated that they would rath-er speak with the attending orthopaedic surgeon, 11% would prefer to speak with the emergency medicine attending staff, and only 6% would prefer to speak with the resident on call.

Regarding the transparency of bed availability at the ac-cepting facility, 71% of respondents stated that the Transfer Center had improved the knowledge of available beds for a patient requiring an inpatient stay. Approximately 18% of re-spondents stated that it had not improved the process.

Following the institution of the Transfer Center, the trans-fer of the orthopaedic trauma patient took 16-30 minutes in 56% of responses and only 5-15 minutes for 31% of responses. The process took greater than one hour in 13% of responses. The majority of responses (76%) preferred to have the patient transferred via the Transfer Center as opposed to the ED (6%).

Although not directly related to the transfer center, the survey also assessed the availability of the accepting facility to view radiographs prior to transfer of the patient. 57% of respondents felt that the accepting facility being able to view radiographs prior to transfer was “always beneficial” to the transfer process with 35% stating that it was “sometimes ben-eficial” (Figure 3.)

Responses to the open-ended questions were general-ly positive in regard to the function of the Transfer Center. “The Transfer Center has enhanced communication and bed availability determination.” Several responses echoed similar sentiments, however there were some replies that voiced frus-tration with the transfer process. “To some degree, it slows the process on our end because I have to speak to more people.” The time being on hold and waiting for paged residents and staff was surmised as a reason for the time delay in one re-sponse. The writer offered, “other transfer centers work this out in the background and call us back rather than have us hold throughout the entire process.”

Figure 2. General frustration level by referring ED provider on transfer of patient to DHMC after implementation of Transfer Center

Figure 1. ED Provider satisfaction with communication after imple-mentation of the Transfer Center

Figure 3. Effect of viewing radiographs prior to transfer of patient.

Figures 1-3 demonstrate responses to the following questions:

1. How would you rank your access to speaking with the orthopaedic surgeon or resident through the Transfer center?

2. How frustrating is it to transfer a patient to DHMC after the Trans-fer Center?

3. Do you feel that having the ability for the orthopaedic team to view x-rays prior to transfer through a shared digital imaging has been beneficial to the transfer process for the patient?

23


DISCUSSIONPrior studies have examined on-call coverage and the

function of a transfer center from the viewpoint of the ac-cepting facility.7-8 Esposito et al. concluded the problems with the transfer of patients are due to a “reticence and functional inability on the part of individual providers and institutions to care for trauma patients.” Between 2000 and 2006, Rudkin et al. found orthopaedic call coverage to have become more “problematic”. The increasing difficulties in coverage oc-curred despite increased reimbursement for on-call coverage (35% receiving payments up from 21% in 2000).

Our study is unique in that it looks at the impact of a trans-fer center from the perspective of the referring ED physician. The survey results show most ED directors feel the transfer center has improved the process, with less time involved and fewer phone calls needed to arrange transfer. For a busy ED physician this means more time can be spent seeing new pa-tients.

Southard et al. studied the impact of a transfer center on interhospital referrals.9 In this case the transfer center was staffed by ED physicians and the initial phase of the process was determining the appropriateness of transfer. The num-ber of transfers to the center increased from 1,532 requests for transfer to 2,082 requests after the “transfer center” was established. Of the transferred patients, 90% either met the Emergency Medical Treatment and Labor Act (EMTALA) cri-teria or tertiary center criteria for transfer. The other 10% were deemed “convenience” transfers. The authors concluded, “en-hancements to the acute medical center transfer center cou-pled with the faculty education and partnership with a senior clinical administrator worked to ensure appropriate transfers and a stable payer mix.”

The transfer of complex trauma patients to regional Level I trauma centers has been demonstrated to reduce mortality.10-12 The ability to transfer patients efficiently is an important fac-tor. When Menchine et al. examined the timeliness of trans-fer, they found approximately 44% of orthopaedic transfers to a higher level of care facility took more than 3 hours to coor-dinate and locate an accepting facility.13 A report released by the Joint Commission on Accreditation of Healthcare Organi-zations (JCAHO) stated that over half of all hospital sentinel events involving death or permanent disability resulting from delays in treatment occur in EDs.14 In the same study, ap-proximately 21% of ED patient deaths or permanent injuries were directly attributed to delays in treatment due to shortag-es of specialist physicians. In our survey, the majority (87%) of calls for transfer took less than 30 minutes. Furthermore, the number of facilities contacted prior to transfer has decreased pointing to an improved process. The study did not assess the actual time of transfer of patients.

Our survey assessed the utility of being able to review

radiographic images prior to the transfer of a patient. Most respondents found the pre-transfer review of images to be beneficial to the transfer process as well as the overall care of the patient. Due to the growing use of electronic medical re-cords, it is the hope of this group that shared viewing of imag-ing could prompt an immediate transfer for patients needing acute care and also prevent patients from the time and effort of an unnecessary transfer.

Most respondents stated that being able to speak with ei-ther a resident or attending staff has improved the quality of care and improved the transfer process. Although the majority of respondents stated that they would rather discuss the case with an attending orthopaedic physician over having a dis-cussion with the orthopaedic resident, most did not feel the current practice hindered the adequacy of care for the ortho-paedic patient.

There are several weaknesses to our study. The study, by design, is open to bias as it looks at the transfer center through the lens of the transferring ED provider. A second deficiency in this paper is the response rate. An attempt was made at tar-geting the ED staff that had the best perception of the process. Only 50% of the 38 surveys were returned. This response rate, however, correlates with another study that was sent to ED directors.7 (7) In this study,43% of surveys were returned from the ED directors in their 2000 study and 51% in their 2006 study.

Although our study shows some advantages to a designat-ed Transfer Center, it also points to areas of further improve-ment. This was perhaps most clear in the response to the open ended questions. One respondent offered valuable insight into placing a caller on hold while assisting with the transfer pro-cess. “Other transfer centers work this out in the background and call us back rather than have us hold throughout the en-tire process.” This was noted to consume time during a busy ED shift.

REFERENCES

1. Vanlandingham BD, et al. On Call Specialist Coverage in U.S. Emergency Departments. ACEP Survey of Emergency Department Directors. American College of Emergency Physicians. 20062. Bosse, Michael J., et al., “Access to Emergent Musculoskeletal Care: Resuscitating Orthopaedic Emergency Department Coverage,” Journal of Bone and Joint Surgery, Vol. 88A(6):1385-94.3. Cryer HM 3rd. The future of trauma care: at the crossroads. J Trauma 2005;58: 425-36.4. Crichlow RJ, Zeni A, et al. Appropriateness of patient transfer with associated orthopaedic injuries to a Level I Trauma Center. J Orthop Trauma. 2010 Jun;24(6):331-5.5. Rotondo MF, Esposito TJ, Reilly PM et al. The position of the Eastern Association for the Surgery of Trauma on the future of trau-ma surgery. J Trauma. 2005;59: 77-96. Cantu RV, Bell JE, et al. How Do Emergency Department Physi-cians Rate Their Orthopaedic On-Call Coverage? JOT: January 2012 - Volume 26 - Issue 1 - pp 54-56

24


11. Mullins RJ, Veum-Stone J, Helfand M, et al. Outcome of hospital-ized injured patients after institution of a trauma system in an urban area. JAMA 1994;271:1919–1924.12. Papa L, Langland-Orban B, Kallenborn C, et al. Assessing ef-fectiveness of a mature trauma system: association of trauma center presence with lower injury mortality rate. J Trauma 2006;61:261–266.13. Menchine MD, Baraff LJ. On call specialists and higher level of care transfers in California. Acad Emerg Med. 2008;15(4):329-36. 14. The Joint Commission. Sentinel Event Alert, No. 26. The Joint Commission, 2002. Delays in Treatment. Available at: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_26.htm.

7. Esposito TJ, Crandall M. Socioeconomic Factors, Medicolegal Issues, and Trauma Patient Transfer Trends: Is There a Connection? The Journal of Trauma: Injury, Infection, and Critical Care 2006;61(6): 1380-1388.8. Rudkin et al. The worsening of ED on-call coverage in California: 6-year trend. Am J Emerg Med. 2009;27(7):785-91.9. Southard PA, Hedges JR, Hunter JG, Ungerleider RM. Impact of a transfer center on interhospital referrals and transfers to a tertiary care center. Acad Emerg Med 2005;12(7):653-7.10. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evalu-ation of the effect of trauma-center care on mortality. N Engl J Med. 2006;354: 366–378

Comparison of Two Fusionless Scoliosis Surgery Methods in the Treatment of Progressive

Adolescent Idiopathic Scoliosis: A Preliminary Study

John T. Braun MDABSTRACT

SummaryInitial correction and subsequent control of progression

were evaluated in 9 adolescent idiopathic scoliosis (AIS) pa-tients treated with one of two methods of fusionless scoliosis surgery (FSS): vertebral stapling versus ligament tethering. Ligament tethering demonstrated significantly greater initial correction and subsequent control of curve progression than stapling. Ligament tethering, unlike bracing or fusion sur-gery, allows significant scoliosis correction without sacrificing growth, motion and function of the spine.

IntroductionFusionless scoliosis surgery (FSS) is a novel treatment op-

tion for AIS patients not amenable to brace treatment and at high risk (>90%) for progression to fusion surgery. Though two FSS methods, vertebral stapling and ligament tether-ing, have demonstrated effectiveness in controlling AIS pro-gression, these have never been compared clinically in well matched groups with similar indications.

MethodsRetrospective study of 9 consecutive AIS patients (average

age 12+11) treated with stapling versus tethering for thoracic curves >30° (average 35.6°) in the setting of skeletal immatu-rity (average Risser 0 to 1). Risk of progression was assessed using 3 methods (Lonstein, Sanders, ScoliScore). All patients had >90% risk of progression to fusion surgery by at least 2 of the 3 methods. Cobb angles pre-op, post-op and final were compared.

ResultsNine well matched female patients with 14 curves under-

went endoscopic FSS: 4 had stapling of 6 curves and 5 had tethering of 8 curves. Stapled curves were initially correct-ed from 34.5° pre-op to 31.3° post-op but subsequent curve

control was poor with progression over 22 months to 44.5°. Tethered curves initially corrected from 36.6° pre-op to 21.4° post-op with good control over 14.4 months with additional correction to 17.8°. Ligament tethering demonstrated signifi-cantly greater initial correction (p=.001) and subsequent con-trol of curve progression (p=.002) when compared to verte-bral stapling. No significant complications were encountered; however, 1 stapled patient required fusion for a progressive curve to 55°.

ConclusionBoth initial correction and subsequent control of curve

progression are important in the fusionless treatment of AIS. In this preliminary study, it appears that ligament tethering provides greater initial correction and subsequent control of AIS curve progression than vertebral stapling.

Level of Evidence:III

INTRODUCTIONFusionless scoliosis surgery is a novel treatment option

for idiopathic scoliosis that offers perceived advantages over the current standard forms of treatment. When compared to bracing, fusion surgery or other nonfusion options (for exam-ple, growing rods or the vertical, expandable, prosthetic titani-um rib, VEPTR, Synthes Spine, West Chester, PA), fusionless scoliosis surgery offers the potential for significant deformity correction via a single, minimally invasive intervention that preserves the growth, motion and function of the spine.

Over the past decade or so, fusionless scoliosis surgery has been referred to by many names – endoscopic vertebral sta-pling, anterior ligament tethering, convex scoliosis tethering, mechanical modulation of spinal growth and internal bracing of spinal deformity. However, regardless of the descriptive term used, or even the device employed, the goal of all fusion-less scoliosis surgery is the same. That is, to harness the sco-liosis child’s inherent spinal growth and redirect it to achieve correction, rather than progression, of the spinal deformity.

Implant choices in anterior fusionless scoliosis surgery es-sentially fall into two categories, staples and ligament tethers. Though extensive pre-clinical testing of both types of devic-es has demonstrated their safety and efficacy in experimental

1. Dartmouth-Hitchcock Medical Center, Lebanon NH

Corresponding Author: John T. Braun, MDE-mail: [email protected]


26


models,1-9 human studies have been limited to the retrospec-tive analysis of a single implant type.10-13 The current study compares fusionless scoliosis surgery treatment using two different implant types – a shape memory alloy staple (SMA Staple, Medtronic, Memphis, TN) versus a vertebral screw and ligament tether construct (Dynesys Dynamic Stabilization System, Zimmer Spine, Warsaw, IN) – in two well matched idiopathic scoliosis patient groups with similar indications for surgery. It should be noted that neither implant type in this study enjoys FDA approval for the fusionless treatment of idiopathic scoliosis in children, thus, both were used in an off-label manner in this study.

METHODSUnder an Institutional Review Board approved study pro-

tocol, a retrospective analysis was performed on 9 consecu-tive female patients treated for progressive idiopathic scoliosis with fusionless scoliosis surgery over a one year period from November 2009 to October 2010. Fusionless scoliosis surgery was contemplated as a treatment option in these 9 patients when 5 criteria were met:

1. The idiopathic scoliosis curve progressed to 30° or greater in the setting of significant skeletal immaturity and was highly likely (90% estimated risk or greater) to progress beyond 40° to a “surgical curve” (a high likelihood of progression was es-tablished if at least 2 of 3 methods of risk assessment suggested

a 90% or greater risk – these included 2 standard radiographic methods, described by Lonstein and Carlson14 and by Sand-ers,15 and prognostic genetic testing using ScoliScore, Axial Biotech, Salt Lake City, UT).16,17 (Figure 1)2. The child was not amenable to brace treatment due to 1 or more factors including a clear refusal on the part of the child or family to embark on brace treatment (6 patients); a refusal on the part of the child and family due to a medical co-morbidity such as ADHD or claustrophobia (1 patient); or non-compliance (2 patients). 3. The child and family participated in an extensive program of self education that included the use of printed and web ma-terials as well as patient contacts and they understand both standard and novel treatment options for idiopathic scoliosis.4. The child and family demonstrated a reasonable under-standing of the FDA status of fusionless scoliosis surgery de-vices.5. The child and family unanimously agreed with the treat-ment plan.

Of the 9 patients who underwent fusionless scoliosis sur-gery, the first 4 underwent stapling of 6 curves. All 4 had thoracic curves that were treated with stapling. Two of the 4 had single thoracic curves while the other 2 had additional secondary lumbar curves measuring 25° or greater that were also treated. The second 5 patients underwent ligament teth-

TABLE I. Demographic, Curve, and Skeletal Maturity Characteristics of Staple vs. Tether PatientsAge Sex Pre-op

Curve(s)Pre-opRisser

TR Sanders SS Rx Post-op FinalCurve(s)

FinalRisser

F/U

Staple Patients

12+11 F 35°T30°L

0 Closed 3 140 Staple T, L

36°T15°L

55°T28°L

3 20 mo (PSF)

14+3 F 35°T 1 Closed 3 166 Staple T

28°T 38°T 4 18 mo.

13+4 F 35°T26°L

0 Closing 3 NA Staple T, L

30°T10°L

40°T20°L

4 24 mo.

13+3 F 33°T 0 Closed 3 186 Staple T

31°T 45°T 4 24 mo.

TetherPatients

12+9 F 32°T34°L

1 Closed 3 NA Tether T,L

20°T0°L

23°T-8°L

4 20 mo.

15+3 F 37°T 2 Closed 3 74 Tether T

20°T 16°T 4 20 mo.

9+6 F 38°T29°L

0 Open NA NA Tether T,L

26°T-3°L

13°T-1°L

0 16 mo.

14+3 F 41°TL19°L

3 Closed 5 120 Tether TL, L

21°TL-2°L

18°TL-5°L

4 11 mo.

12+6 F 35°T 0 Closed 3 NA Tether T

20°T 19°T 1 5 mo.

27


ering of 8 curves. All 5 had thoracic curves that were treat-ed with ligament tethering. Two of the 5 had single thoracic curves; two had primary thoracic curves with secondary lum-bar curves that were also treated; and 1 had a primary lumbar curve with a secondary thoracic curve, both of which were treated. No patient underwent treatment of a single lumbar curve.

Thoracic curves were treated endoscopically using the same standard anterior approach for both stapling and liga-ment tethering.18 Prior to positioning, general endotrachial anesthesia was induced using a double lumen endotrachial tube. Standard SSEP and MEP spinal cord monitoring were used in all cases. As all thoracic curves in this study were right sided, the patients were placed in a left lateral decubitus po-sition on the operating table (radiolucent OSI flat top table) to allow access to the right thorax. Appropriate padding was applied to all bony prominences across the torso as well as the upper and lower extremities. The patient was then taped in place to minimize any potential for movement during sur-gery. Care was taken to assure that the axilla and groin were free of pressure prior to prepping and draping. Fluoroscopic images were then used to guide the placement of 3 to 4 small oblique incisions or portals equally spaced along the right posterior axillary line. After entry into the chest, first distally, then proximally, the lung was deflated and then both the lung and diaphragm appropriately retracted to allow visualization of the right thoracic spine. A marking fluoroscopic image was used to assure that the appropriate levels were addressed. The pleura was then split vertically on the right across the desired levels using electrocautery. In patients undergoing vertebral stapling the segmental vessels were preserved. However, in those patients undergoing ligament tethering the segmental

vessels were ligated with a harmonic scapel.

Implantation of proportional SMA staples was accom-plished at all appropriate levels once a second marking film was obtained fluoroscopically to confirm that the appropriate levels were addressed. Staples cooled in a sterile ice bath were implanted across the disc spaces after pilot holes were created using the appropriate size trial. Two staples were placed an-terolaterally at all levels of the curve with 3 staples at 1 or 2 of the apical segments. Automatic deployment or crimping of the staples occurred within a few minutes as they warmed to body temperature.

Implantation of vertebral body screws in preparation for ligament tethering was performed after creation of a trial hole with a pedicle probe starting in the middle of the right lateral vertebral cortex and extending to the left lateral cortex. Ap-propriate screw length was estimated fluoroscopically and en-doscopically. Bicortical screw purchase was preferred. Screw placement proceeded in a distal to proximal fashion with subsequent tensioning of the ligament in a proximal to distal fashion. (Figure 2) Tensioning of the ligament to correct the deformity was guided at each disc level by fluoroscopy.

At the completion of implantation of either staples or a ligament tether, final fluoroscopic images were taken and the chest prepared for closure. A small 20 French chest tube was placed and removed on post-operative day 1. Patients were mobilized post-operatively in a standard manner as tolerat-ed without a brace. Activity restrictions included minimal bending, lifting or twisting for 6 weeks and no athletics for 12 weeks with gradual return to full activity after 12 weeks.

For patients undergoing additional treatment of a lumbar

Figure 1. Risk of progression was estimated using two radiographic methods and one genetic method: 1. Lonstein and Carlson (Risser sign); 2. Sanders (left hand film); and 3. ScoliScore. In this example, the child has a 33 degree progressive adolescent idiopathic scoliosis with an estimated risk of progression of 90%,100% and 80%, respectively, using these three methods.

1. 2. 3.

28


curve under the same anesthetic, a mini-open, lateral retro-peritoneal approach was used.18 As all lumbar curves in this study were left-sided, the patients were repositioned in a right

lateral decubitus position on the same operating table for this portion of the procedure. The approaches were similar for both stapling and ligament tethering and the implanta-tion similar to that performed in the thoracic spine. How-ever, all lumbar levels treated with stapling employed only 2 staples. For the 1 patient with a lumbar curve spanning the diaphragm, the single lateral incision was placed more prox-imally to allow access to the thoracolumbar junction above and below the diaphragm. Ligament tethering was accom-plished in this patient without takedown of the diaphragm by tunneling the ligament under the diaphragm, along the spine, just posterior to the crus. Due to the exposure of the left tho-racic cavity, a second chest tube was required on the left at the completion of the procedure. The post-operative protocol was similar for patients who underwent treatment of a lumbar curve in addition to treatment of a thoracic curve.

Pre-operative, post-operative and final follow-up plain radiographs in the posterior-anterior and lateral planes were used to determine the magnitude of the deformity and the gross integrity of the implants throughout the study. Progres-sion of deformity was defined as an increase in curve magni-tude of 5° or greater as measured with the Cobb method.19 All staples and screws that demonstrated evidence of loosening, including radiolucency, drift, or backout, were noted. Statis-tical analyses were performed on all of the radiographic data with the use of standard t tests, with a level of significance defined as a p value (alpha) of <0.05.

Figure 3: This child is a 13+3 year old girl with a progressive adoles-cent idiopathic scoliosis involving a single right thoracic curve measuring 33 degrees in the setting of relative skeletal imma-turity with a Risser sign of 0, a Sanders grade of 3 and a ScoliScore of 186. The curve corrected 2 degrees after an anteri-or endoscopic stapling procedure but then pro-gressed 13 degrees over the next 24 months.

Figure 2: An endoscopic view of the proximal portion of a tether-ing construct after tensioning of the ligament and securing of the set screws. The vertebral screws are implanted on the right side of the spine spanning T6 (top) to T9 (bottom). The distal implants are not visualized in this view. The posterior ribs are evident on the left and the deflated lung on the right.

29


Source of Funding


RESULTSNine consecutive female patients with 14 idiopathic scoli-

osis curves (9 thoracic, 5 lumbar) were treated with fusionless scoliosis surgery during the 1 year study period. The aver-age age at the time of surgery was 12+11 years (range 9+6 to 15+3). The average skeletal maturity was Riser 0.8 (range 0 to 3), with open triradiate cartilages in only 1 patient. The aver-age Sanders’ stage was 2.9 (range 0 to 5). Five of the 9 patients were eligible, early in their evaluation, for prognostic genetic testing using ScoliScore, with an average score of 137.2 (range 74 to 186) on a scale of 1 to 200.

The first group of 4 patients treated in this series under-went stapling of 6 curves (2 single thoracic curves and 2 pri-mary thoracic curves, both with secondary lumbar curves).

The average age in this group was 13+5 (range 12+11 to 14+3). The average skeletal maturity was Risser 0.2 (range 0 to 1), with closed triradiate cartilages in all patients. The average Sanders’ stage was 3 (range 3 only) and the average ScoliScore was 164 (range 140 to 186 in 3 patients).

The average thoracic curve in this stapling group was ini-tially corrected from 34.5° (range 33° to 35°) pre-operatively to 31.5° (range 28° to 36°) post-operatively for a correction of 3.0°. Over an average follow-up of 22 months (range 18 to 24 months) subsequent thoracic curve control was poor, with an average progression of 13.0° to 44.5° (range 38° to 55°). (Fig-ure 3) The average skeletal maturity at study completion was Risser 3.8 (range 3 to 4). One patient’s stapled thoracic curve progressed from 35° pre-operatively to 55° at 20 months, de-spite stability of a stapled lumbar curve in the 30° range. This patient underwent a standard posterior instrumented fusion from T2-L2 at 20 months for significant curve progression in the setting of relative skeletal maturity (Risser 3).

Stapled lumbar curves remained relatively stable when

37º 20º

15+3 pre-op R=2, S=3 SS=74

15+3 post-op

16+11 20mo R=4

16º

Figure 4. This child is a 15+3 year old girl with a progressive adolescent idiopathic scoliosis involving a single right thoracic curve measuring 37 degrees in the setting of relative skeletal immaturity with a Risser sign of 2, a Sanders grade of 3 and a ScoliScore of 74. The curve corrected 17 degrees after an anterior endoscopic tethering procedure and an additional 4 degrees of correction over the next 20 months.

30


treated, but 1 of 2 untreated curves progressed. As a thresh-old of 25° was established for stapling of secondary lumbar curves, two curves measuring 28° on average (range 26° to 30°) were stapled and remained stable at 24° (range 20° to 28°) over 22 months. Of two untreated lumbar curves measuring 17° on average (range 17° only), 1 progressed to 29° while the other remained stable at 17° over the same time period.

In the sagittal plane, the average pre-operative thoracic kyphosis of 30.3° (range 17° to 42°) increased in the stapling group over 22 months to 36.8° (range 24° to 53°). The aver-age pre-operative lumbar lordosis of 63.5° (range 50° to 76°) remained stable at 61.8° (range 53° to 77°) for over the same period. In the subgroup of 2 patients with stapled lumbar curves, the average pre-operative measurement of 63° (range 50° to 76°) remained stable at 65° (range 53° to 77°) at 22 months.

The second group of 5 patients treated in this series un-derwent ligament tethering of 8 curves (2 single thoracic curves; 2 primary thoracic curves, both with secondary lum-bar curves; and 1 primary lumbar curve with a secondary tho-racic curve). The average age in this group was 13+10 (range 9+6 to 15+3). The average skeletal maturity was Risser 1.2 (range 0 to 3), with open triradiate cartilages in 1 patient. The average Sanders’ stage was 2.8 (range 0 to 5) and the average ScoliScore was 97 (range 74 to 120 in 2 patients).

The average thoracic curve in this ligament tethering group was initially corrected from 36.6° (range 32° to 41°) pre-operatively to 21.4° (range 20° to 25°) post-operatively for a correction of 15.2°. The average skeletal maturity at study completion was Risser 2.6 (range 0 to 4). When compared to the initial correction with stapling (3.2°), the initial correc-tion achieved by ligamentous tethering (15.2°) was significant (p=0.001). Over an average follow-up of 14.4 months (range 5 to 20 months) curve control was good, with additional cor-rection to 17.8° (range 13° to 23°). When compared to subse-quent loss of correction with stapling (13.0° progression), the subsequent correction with ligament tethering (3.6° correc-tion) was significant (p=0.002). (Figure 4)

Lumbar curves not only remained stable in this ligament tethering group, but untreated curves tended to correct and treated curves to overcorrect. Though a threshold of 25° was again used to guide treatment of secondary lumbar curves, an exception was made for a 19° left lumbar curve, below a 41° right thoracic curve, associated with a large right trunk shift of nearly 5 cm. Three lumbar curves measuring 27.3° on av-erage (range 19° to 34°) initially corrected to -1.7° (range 0° to -3°) with ligament tethering then subsequently overcorrected to -4.7° (range -1° to -8°) over 14.4 months. Two untreated lumbar curves measuring 22° on average (range 21° to 23°) remained stable at 13.5° on average (range 13° to 14°).

In the sagittal plane, the average pre-operative thoracic

kyphosis of 25° (range 11° to 42°) remained stable in this liga-ment tethering group at 26.4° (range 5° to 48°) at 14.4 months. The average pre-operative lumbar lordosis of 54.8° (range 47° to 60°) remained stable at 55.8° (range 50° to 70°) over the same period. The average pre-operative lumbar lordosis of 52.3° (range 47° to 60°), in the subgroup of 3 patients with tethered lumbar curves, also remained stable at 50.3° (range 50° to 51°) over 14.4 months.

No significant complications were encountered intra-op-eratively or post-operatively in either the stapling or ligament tethering group. However, the first stapling patient treated in this series required reinsertion of her chest tube on post-op-erative day one for reaccumulation of a pneumothorax. This resolved uneventfully. Estimated blood loss was 161cc on average for all 9 patients, with no significant difference be-tween the stapled (175cc) and ligament tether (150cc) groups. There was a difference, however, in EBL between single tho-racic curves treated endoscopically (100cc) and double curves treated with both an endoscopic thoracic procedure and a mini-open lumbar procedure (210cc). The length of stay was 4 days on average (range 2 to 6 days) for all 9 patients, with no significant difference between stapled (4.2 days) and ligament tether (3.8 days) groups. A difference was noted, however, in length of stay between patients treated for a single thorac-ic curve (3 days) and those treated for thoracic and lumbar curves (4.8 days).

With respect to implant integrity over time, 2 patients in the stapling group demonstrated partial backout of a single thoracic staple, but in each case, the staple remained in a func-tional position. A single patient demonstrated evidence of a broken lumbar staple without backout or dislodgement. Two patients in the tethering group demonstrated slight drift of the proximal thoracic screw, at the T5 and T6 levels, without loss of correction or evidence of lucency or backout.

DISCUSSIONIn this preliminary study of 9 well-matched female idio-

pathic scoliosis patients who underwent fusionless scoliosis surgery for similar indications, the data demonstrated liga-ment tethering to be superior to vertebral stapling in initial curve correction and subsequent control of curve progression over time. While vertebral stapling initially corrected thorac-ic curves 3.0°, this effect was lost over time, with subsequent progression of 13.0° over the study period. All 4 patients in the vertebral stapling group demonstrated progression of their thoracic curves past 40°, with 1 of 4 eventually undergoing a posterior instrumented fusion for a curve that reached 55°. In contrast, ligament tethering initially corrected thoracic curves 15.2°, with an additional correction of 3.6° over time. All 5 patients in the ligament tethering group demonstrated good control of their thoracic curves, with all curves measuring less than 25° at study completion.

31


The data on lumbar curve control are more difficult to in-terpret as some curves were stable while others progressed, corrected or overcorrected. The likely dependence of lumbar curve behavior on thoracic curve behavior is a potential con-founder as is the fact that an arbitrary threshold of 25° was established for treatment of a secondary lumbar curve (with only one exception). This resulted in treated and untreated lumbar curves of various magnitudes adjacent to thoracic curves that progressed or corrected. In the vertebral stapling group, where all thoracic curves progressed, 2 stapled and 1 untreated secondary lumbar curves remained stable while 1 untreated lumbar curve progressed. In the ligament tether-ing group, where all thoracic curves corrected, 2 untreated secondary lumbar curves corrected while 3 tethered lumbar curves mildly overcorrected. The data suggest that the 25° threshold for treatment of a secondary lumbar curve could be adjusted up or down depending on the implant type used to treat the thoracic curve. For ligament tethering cases, in which good control of the thoracic curve is likely, consider-ation should be given to raising the threshold for tethering of secondary lumbar curves. Conversely, for vertebral stapling cases, where thoracic curve control may be less optimal, con-sideration should be given to lowering the threshold for sta-pling a secondary lumbar curve.

Though the sagittal plane parameters of thoracic kyphosis and lumbar lordosis are always a concern when treating spinal deformities with instrumentation, changes in these regions of the spine were not significant during this study overall and no significant differences were noted between groups. Though the pre-operative thoracic kyphosis was slightly greater than would be expected for the typically hypokyphotic idiopathic scoliosis patient population at 30.3°, the kyphogenic vertebral stapling and ligament tethering only increased this kyphosis to 36.8° over the study period. Lumbar lordosis was relatively stable in the 60° range throughout the study period, with little difference between treated and untreated, stapled and teth-ered, curves.

Though the above data are preliminary, the results are supported by a previous study in an experimental scoliosis model in which we demonstrated greater curve control with ligament tethering versus vertebral stapling.2 In the experi-mental scoliosis model, curves measuring 77.3° on average pre-operatively progressed to 94.3° despite vertebral stapling over a 12 to 16 week observation period. Curves of a sim-ilar magnitude, measuring 73.4° on average pre-operatively, were better controlled after ligament tethering with modest correction to 69.9° over the same period. The limitations of this experimental model study included the use of fusionless scoliosis surgery implants in extremely severe, perhaps, even malignant curves, and the use of a single staple per disc level.

It is speculated that several implant related factors con-tributed to the greater control of scoliosis progression in the ligament tethering versus vertebral stapling groups. These im-

plant related factors, including specific device characteristics and requirements for implantation, highlight 4 areas in which these implants are distinguished: 1) strength of initial fixation; 2) modularity; 3) rigidity or flexibility; and 4) integrity over time.

With respect to the strength of initial fixation, it should be noted that implant testing was not performed in this study. However, a previous study by our group demonstrated a sig-nificant difference in initial pullout strength between a shape memory alloy staple (100N) and a unicortical screw device or bone anchor (495N).2 In the current study, it is likely that the threaded, bicortical screw, measuring 6.0 to 6.5mm in diam-eter and 25 to 40mm in length, provided significantly greater initial fixation to bone than the smooth, unicortical staple tine, measuring less than 4mm in diameter and less than 15mm in length.

While greater initial fixation and, perhaps, improved me-chanical advantage are important, the value only becomes ap-parent when these attributes can be exploited for deformity correction. The highly modular or adjustable ligament teth-er construct allowed for significant active curve correction at each disc level through tensioning of the ligament across each pair of well fixed, mechanically advantageous, bicortical verte-bral screws. The minimally modular shape memory alloy sta-ple allowed for some crimping of the staple with deployment, but the small, unicortical tine provided little if any active cor-rection of deformity. Methods were employed to overcome the limitations of the staple in achieving active correction, in-cluding optimal patient positioning on the operating table and corrective manual maneuvers during implantation, but these were unsatisfactory in achieving significant curve correction.

The significant active correction achieved in the ligament tethering group not only improved spinal alignment but like-ly increased the chances for additional passive correction of deformity over time with growth. Like scoliosis progression, passive deformity correction after vertebral stapling or lig-ament tethering, is also governed by the Hueter-Volkmann law.3,6,20-24 This law describes a vicious cycle of progression in scoliosis initiated by a spinal asymmetry and propagated by a force and growth differential from concavity to convexity. The initial asymmetry results in excessive forces on the vertebral growth plates that alter vertebral growth, with excessive con-cave compression inhibiting growth and excessive convex ten-sion stimulating growth. This growth differential from con-cave to convex leads to progressive vertebral wedging which only exacerbates the force differential, furthers asymmetric growth and increases the overall deformity.

Passive correction of scoliosis is achieved by reversing or redirecting the vicious cycle described by Hueter-Volkmann. The ligament tethering group demonstrated some passive cor-rection over time likely due to decreased exuberant growth on the convexity of the curve and increased growth on the concav-

32


ity of the curve. It is likely that the improved force differential in the actively corrected ligament tether patients allowed for some passive correction over time. With little change in this force differential in the stapled group, no passive correction was demonstrated. In a previous study using an experimental model, our group demonstrated a relationship between active and passive curve correction in which the amount of passive correction achieved with growth was directly related to the amount of initial active correction achieved at the time of sur-gery.25

The flexibility of the ligament tether construct may also have contributed to passive curve correction over time due to dynamic loading of the vertebral growth plates. Though we did not measure the flexibility of the implants in this study, our group has analyzed the biomechanics of multiple different fu-sionless implant strategies in the past.26 In comparing 2 staple and 3 staple constructs to various screw ligament constructs, an almost 30% difference in spinal motion was demonstrated – the 2 and 3 staples constructs being the most rigid and the ligament tether constructs being the most flexible. Though dynamism of a device after implantation can only be inferred, a flexible device is more likely to be dynamic than a rigid de-vice. In a separate well-controlled experimental model com-paring static and dynamic asymmetric loading across a single immature rat tail vertebra, a 50% greater change in angulation due to growth modulation was demonstrated using dynamic versus static loading.27 If, indeed, the flexible ligament con-struct in the present study resulted in dynamic loading, this might explain some of the improved curve control, as evi-denced by passive curve correction, over the more rigid and, perhaps, static, loading scenario that resulted from stapling.

And finally, the integrity of the implants over time was likely related to their ability to control curve progression. Though we have demonstrated a significant rate of halo for-mation around staple tines in an experimental model,2 and Betz10-12 has confirmed these findings in his studies of children with idiopathic scoliosis, we did not find significant halo for-mation in this study. We did note staple backout in 2 patients and 1 broken staple, but other than these staple integrity was reasonable. Integrity of the screws was good, perhaps relat-ed to the size of the implant, the bicortical purchase across the vertebra and they hydroxyappetite coating on the screw. Some protection of implant integrity may also have been af-forded by the flexible ligament tether dissipating, more than a staple, the high peak forces generated with spinal motion. Nevertheless, 2 patients demonstrated a mild change in the position of the most proximal thoracic screw over time, sug-gesting some drift in the implant but no loss of correction or evidence of lucency. Loss of implant integrity was likely not a significant factor in this study.

The limitations of this study are not insignificant in that it is a retrospective analysis of a small number of patients treat-ed with 2 different fusionless scoliosis surgery implants. Un-

fortunately, due to regulatory restrictions, prospective studies involving the off label use of implants or devices is prohibited without formal FDA approval. Further, follow-up on these patients was relatively short, with full 2 year follow-up in only 2 of 9 patients. However, 7 of 9 patients had at least 1 year follow-up and the majority had achieved a definitive outcome (skeletal maturity, defined as Risser 4, in 6 of 9, and a posterior instrumented fusion in a single additional patient). Despite these limitations, this preliminary study does provide signifi-cant insights into the safety and efficacy of 2 fusionless scoli-osis surgery treatment strategies in 2 well-matched groups of patients with similar indications. Further study, however, is warranted.

RefeRences:

1. Braun JT, Akyuz E, Ogilvie JW: The use of animal models in fusionless scoliosis investigations. Spine (Phila Pa 1976) 2005;30(17 Suppl):S35-S45.2. Braun JT, Akyuz E, Ogilvie JW, Bachus KN: The efficacy and integrity of shape memory alloy staples and bone anchors with liga-ment tethers in the fusionless treatment of experimental scoliosis. J Bone Joint Surg Am 2005;87(9):2038-2051.3. Braun JT, Hines JL, Akyuz E, Vallera C, Ogilvie JW: Relative versus absolute modulation of growth in the fusionless treatment of experimental scoliosis. Spine (Phila Pa 1976) 2006;31(16):1776-1782.4. Braun JT, Ogilvie JW, Akyuz E, Brodke DS, Bachus KN: Fusion-less scoliosis correction using a shape memory alloy staple in the anterior thoracic spine of the immature goat. Spine (Phila Pa 1976) 2004;29(18):1980-1989.5. Hunt KJ, Braun JT, Christensen BA. The effect of two clinically relevant fusionless scoliosis implant strategies on the health of the intervertebral disc: analysis in an immature goat model. Spine (Phila Pa 1976). Feb 15;35(4):371-377.6. Braun JT, Hoffman M, Akyuz E, Ogilvie JW, Brodke DS, Bachus KN. Mechanical modulation of vertebral growth in the fusionless treatment of progressive scoliosis in an experimental model. Spine (Phila Pa 1976). May 20 2006;31(12):1314-1320.7. Braun JT, Akyuz E, Udall H, Ogilvie JW, Brodke DS, Bachus KN. Three-dimensional analysis of 2 fusionless scoliosis treatments: a flexible ligament tether versus a rigid-shape memory alloy staple. Spine (Phila Pa 1976). Feb 1 2006;31(3):262-268.8. Newton PO, Faro FD, Farnsworth CL, et al: Multilevel spinal growth modulation with an anterolateral flexible tether in an immature bovine model. Spine (Phila Pa 1976) 2005;30(23):2608-2613.9. Wall EJ, Bylski-Austrow DI, Kolata RJ, Crawford AH: Endoscopic mechanical spinal hemiepiphysiodesis modifies spine growth. Spine (Phila Pa 1976) 2005;30(10):1148-1153.10. Betz RR, D’Andrea LP, Mulcahey MJ, Chafetz RS: Vertebral body stapling procedure for the treatment of scoliosis in the growing child. Clin Orthop Relat Res. 2005;434:55-60.11. Betz RR, Kim J, D’Andrea LP, Mulcahey MJ, Balsara RK, Clements DH: An innovative technique of vertebral body stapling for the treatment of patients with adolescent idiopathic scolio-sis: A feasibility, safety, and utility study. Spine (Phila Pa 1976) 2003;28(20):S255-S265.12. Betz RR, Ranade A, Samdani AF, et al. Vertebral body stapling: A fusionless treatment option for a growing child with moderate idio-pathic scoliosis. Spine (Phila Pa 1976) 2010;35(2):169-176.13. Crawford CH III, Lenke LG. Growth modulation by means of an-terior tethering resulting in progressive correction of juvenile idiopath-ic scoliosis: a case report. J Bone Joint Surg Am 2010:92(1):202-209.14. Lonstein JE, Carlson JM: The prediction of curve progression in

33


untreated idiopathic scoliosis during growth. J Bone Joint Surg Am 1984:66(7):1061-1071.15. Sanders JO, Khoury JG, Kishan S, et al: Predicting scoliosis progression from skeletal maturity: a simplified classification during adolescence. J Bone Joint Surg Am 2008:90(3):540-553.16. Ward K, Ogilvie JW, Singleton MV, Chettier R, Engler G, Nelson LM. Validation of DNA-based prognostic testing to predict spinal curve progression in adolescent idiopathic scoliosis. Spine (Phila Pa 1976). Dec 1;35(25):E1455-1464.17. Braun JT, Lavelle WF, Ogilvie JW: The impact of genetics re-search on adolescent idiopathic scoliosis, in Newton PO, O’Brien MF, Shufflebarger HL, Betz RR, Dickson RA, Harms J, eds: Idiopathic Scoliosis: The Harms Study Group Treatment Guide. New York, NY, Thieme, 2010, pp 408-415. 18. Braun JT: “Fusionless Scoliosis Surgery.” In Advanced Re-construction Spine. American Academy of Orthopaedic Surgeons Publications, Rosemont, IL 2011.19. Cobb JR: Outline for the study of scoliosis. Instr Course Lecture. 1948;5:261-275.20. Hueter C: Anatomische studien an den extremitutengelenken neugeborener und erwachsener. Arch Pathol Anat. 1862;25:572-599.21. Mente PL, Aronsson DD, Stokes IA, Iatridis JC: Mechanical mod-ulation of growth for the correction of vertebral wedge deformities. J Orthop Res. 1999;17:518-524.

22. Stokes IA, Spence H, Aronsson DD, Kilmer N. Mechanical modu-lation of vertebral body growth. Implications for scoliosis progression. Spine (Phila Pa 1976).1996:21:1162-1167.23. Volkmann R, Verletzungen und krankenheiten der bewegungsor-gane. In: Billroth T, editor. Handbuch der allgemeinen und speciellen chirurgie Bd II Teil II. Stuttgart: Ferdinard Enke; 1882.24. Braun JT, Hunt KJ, Sorenson S, Ogilvie JW. “Can Fusionless Scoliosis Surgery Reverse the Hueter-Volkmann Effect?” Forty-sec-ond Annual Meeting of the Scoliosis Research Society, Edinburgh, Scotland, UK, September 5-8, 2007.25. Braun JT, Hunt KJ, Sorenson S, Ogilvie JW. “Active and Passive Tethering Effects of Four Clinically Relevant Fusionless Scoliosis Implant Strategies.” Forty-second Annual Meeting of the Scoliosis Research Society, Edinburgh, Scotland, UK, September 5-8, 2007.26. Braun JT, Akyuz E, Bachus K. “Biomechanical Evaluation of Seven Different Fusionless Scoliosis Surgery Treatment Strategies.” Poster presentation at the Thirteenth International Meeting on Ad-vanced Spine Techniques, Athens, Greece, July 2006.27. Akyuz E, Braun JT, Brown N, Bachus K. Static Versus Dynamic Loading in the Mechanical Modulation of Vertebral Growth. Spine. 31(25):E952-E958, 2006.

Patient Education and Compliance with Deep Vein Thrombosis Prophylaxis after Discharge from Total Joint

ReplacementBrooks Crowe BA, Reema Vaze BA, Andrew Banos MD, James Slover MD MS

1. NYU Hospital for Joint Diseases, NYC

Corresponding Author: Brooks Crowe, BAE-mail: [email protected]


ABSTRACTObjectivesPatients undergoing total joint arthroplasty are at high risk

for postoperative thromboembolic disease. A course of anti-coagulation prophylaxis following surgery has been shown to lower the risk of thromboembolic disease. The primary objec-tive of this study is to determine the degree of compliance with prophylaxis and the presence of possible barriers to compli-ance for patients receiving outpatient prophylaxis after prima-ry hip and knee arthroplasty. We also hope to assess quality of training and education prior to discharge for patients receiv-ing outpatient prophylaxis following arthroplasty.

Methods:A total of 150 patients who had undergone primary total

hip or knee arthroplasty with one of fourteen surgeons at our institution were surveyed over a five-month period by tele-phone, one to two months following surgery. Patients were grouped according to method of prophylaxis administration, either oral or by injection.

Results:Out of 150 patients surveyed, 136 were included in the

data analysis. 74 were prescribed injectable anticoagulation while 62 used oral prophylaxis. 8 patients from the injection group (10.8%) and 11 from the oral group (17.7%) reported missing one or more doses. Of these 136 patients, 113 (83.1%) were able to recall the reason for taking prophylaxis. Howev-er, 22 patients (29.7%) were unable to recall the name of their prescribed injection medication and 8 patients (12.9%) were unable to recall the name of their prescribed oral medication. The mean copayment amount for injections was $173 (median $100) compared with $53 (median $20) for oral medication. Overall, 93.4% of all patients believed taking the medication as instructed was either important or very important.

Conclusion: Venous thromboembolism (VTE) remains the most com-

mon complication following hip and knee replacement and the clinical consequences can be significant. 10.8% and 17.7% of injection and oral patients respectively missed one or more doses of prophylaxis. Given the concern for VTE after ma-jor orthopedic surgery, efforts to maximize appropriate pre-scribing, patient education, and compliance should be made. Specific efforts towards patient education and awareness re-garding post-operative VTE prophylaxis at home may help improve compliance further, which may improve outcomes by reducing the VTE events associated with these procedures.

Level of Evidence: IV

INTRODUCTION:Patients undergoing total joint arthroplasty are at high

risk for postoperative venous thromboembolic (VTE) disease. Consequently, anticoagulation prophylaxis with either oral or injectable medications is recommended postoperatively.1 The most recent guidelines from the American College of Chest Physicians recommends prophylaxis for a minimum of 10 to 14 days following total knee or hip arthroplasty with a sug-gested duration of up to 35 days postoperatively.2 However, questions still remain in regards to patients’ knowledge of and compliance with their prescribed outpatient regimen.3 While many studies have attempted to evaluate effectiveness of pro-phylaxis at preventing VTE, less attention has been devoted to gauging patient compliance with their outpatient treatment.

The demand for total joint arthroplasty (TJA) has been steadily increasing in recent years and is projected to acceler-ate as the population ages. It is estimated that approximately 650,000 total knee arthroplasty (TKA) and 250,000 total hip arthroplasty (THA) procedures occurred in the United States during 2010 and these figures are expected to rise dramatically to reach 3.48 million total knee replacements and 572,000 total hip replacements by 2030.4 Given the large volume of arthro-plasty procedures that occur each year, it is vital to ensure ad-equate attention is given to prophylaxis treatment to not only reduce morbidity and mortality, but also to help control the burden of rising health care costs.

In prior studies that show data on compliance, practical

35


issues related to obtaining the medication following discharge were not closely examined as the medication was given as part of the study protocol.5 In recent years, more emphasis has been placed on properly educating patients about the risks of VTE disease following major orthopedic surgery and the im-portance of ensuring adequate prophylaxis.6,7 The goal of this study was to determine the compliance of patients with either oral or injectable anticoagulation prophylaxis and to ascertain the presence of any barriers to compliance that may have af-fected the successful completion of an outpatient prophylaxis course. Additionally, we hoped to evaluate the effectiveness of inpatient hospital instruction in preparing patients for their self-administered outpatient regimen. By surveying patients about these issues, we hoped to gain a clearer understanding of knowledge and compliance for routine patients after dis-charge.

METHODS:Patients who underwent total knee or hip arthroplasty

over a five-month period in 2012 and received outpatient VTE prophylaxis were surveyed by phone one to two months fol-lowing surgery. The potential study group was identified from a population of consecutive patients from fourteen different

surgeons at our institution. Patients who did not receive any form of prophylaxis treatment or completed their entire pro-phylactic course while in inpatient rehabilitation were exclud-ed from our analysis. Patients who spent a short duration of time in inpatient rehab but completed their prophylaxis on an outpatient basis were included for analysis. A baseline questionnaire was designed by our research team to evalu-ate patient experience regarding medications with a specific focus on education, access, and compliance. We attempted to contact approximately 260 patients in order to achieve 150 completed surveys from patients all of whom were prescribed outpatient VTE prophylaxis. However, only 136 patients were included in the final analysis. The fourteen patients who only took their medication while in an inpatient facility were ex-cluded.

The questionnaire was designed to gauge patient under-standing of the importance of outpatient prophylaxis treat-ment (Appendix A). It included questions regarding under-standing of reasons for taking the medication, method of education, cost of treatment, and compliance. The question-naire also assisted in grouping patients into two categories based on the type of prophylaxis administered. Those patients receiving injections were asked additional questions related to

Table 1. Patient Demographics, Knowledge of Regimen and Prophylaxis DsurationOral: N=62 Injection: N=74

ProcedureTotal Hip Arthroplasty 32 42

Total Knee Arthroplasty 30 32

Gender 42

Male 24 22

Female 38 52

Age: Average (Range) 63.8 (26-86) 60.9 (22-85)

Race/EthnicityCaucasian 45 57

African American 11 13

Spanish/Hispanic 2 2

Other 4 2

% Knew Name of Drug 87.1 70.3

% Knew Reason for Taking Medication 85.5 81.1

Length of Prophylactic Regimen:<10 Days 6.5% 5.4%

10-21 Days 9.7% 35.1%

21-30 Days 54.8% 52.7%

1-2 Months 17.7% 5.4%

>2 Months 9.7% 1.4%

Unknown 1.6% 0

36


previous experience with self-injections, difficulty performing injections, and pain rating. No outside funding was obtained for this study and exempt status for this study was granted by our Institutional Review Board.

A major component of our study was to investigate barriers that affected the respective prophylactic treatment. Patients were surveyed regarding differences in associated costs and medication schedules for injectable prophylaxis ver-sus those taking oral prophylaxis. Other factors such as diffi-culty in obtaining as well as remembering to take the medica-tion were assessed. Descriptive statistics were used to analyze the data.

Source of Funding

No external or internal funds were received in the conduct

of this report. The authors of this study have no disclosures or conflicts of interest to report.

RESULTS: Of 136 patients included in our analysis, 74 were pre-

scribed injectable anticoagulation while 62 used oral prophy-laxis. As indicated in Table 1, 29.7% (N=22) and 12.9% (N=8) of patients taking injectable and oral prophylaxis respectively were unable to recall the name of the medication prescribed, while 83.1% (N=113) of all patients were aware of the reason for taking the medication. When asked about the importance of taking medication as scheduled, 93% (N=127) believed tak-ing the medication as instructed was either very important or important (Table 2).

From the 74 members of the injection group, 62 per-

Table 2. Patient Opinion, Barriers to Treatment and AdherenceOral (N=62) Injection (N=74)

Opinion of Taking Medication as Instruction:Somewhat Important 1.6% 1.4%

Important 19.4% 14.9%

Very Important 74.2% 78.4%

N/A 4.8% 5.4%

Difficulty Obtaining Medication*Mean (Standard Deviation) 1.5 (1.7) 1.5 (1.9)

Copayment:Cannot Recall 13.1% 13.5%

No Copayment 9.8% 25.7%

Copayment of Unknown Amount 32.8% 24.3%

Average (median) of Dollar Amounts $54 ($20) $173 ($100)

Average Copayment Impact on obtaining Medication#

1.0 1.4

Difficulty Remembering to take MedicationNot Difficult 90.3% 90.4%

Somewhat Difficult 8.1% 9.6%

Difficult 1.6% 0

Number of Missed DosesStopped Early 0 2.7%

None 80.6% 86.5%

One or More 17.7% 10.8%

Unknown 1.6% 0

*Rated on a scale of 1-10 with 1 indicating “non difficult” and 10 indicating “very difficult”#Rated on a scale of 1-10 with 1 indicating “no impact” and 10 indicating “large burden”

37


formed self-injections with a mean prior experience of 3.5 rated on a scale of 1-10 (Table 3) with 1 indicating “no prior experience” and 10 meaning “very experienced.” The majority of self-injection patients (79%, N=49) were trained by a nurse at the bedside typically for one session while 11.3% (N=7) were already experienced in giving self-injections. Patients rated their level of preparedness to perform self-injections upon discharge at an average of 8.8 with 10 representing “very prepared” and 1 indicating “not prepared.” On a scale of 1-10 with 1 representing “not difficult” and 10 representing “very difficult,” the average difficulty for performing injections was 2.0. The average rating for the pain associated with the injec-tion was 2.5 with 1 representing “no pain” and 10 indicating “very painful.”

In regards to possible barriers to compliance, among the 92 patients who reported being responsible for a copayment, 27 oral and 27 injection patients recalled the specific dollar amount (Table 2). The injection group paid a mean of $173 (median $100), and the oral group had a mean of $54 (median $20). Most patients in the study reported no difficulty in ob-

taining the medication and little impact of cost on obtaining the medication as scheduled rated on a scale of 1-10 with 10 repre-senting extreme difficulty.

Overall, 53.7% (N=73) of all patients took the prophylactic regimen for a period of 21-30 days compared to 23.5% (N=32) who took the medication for 10-21 days with variations in pro-phylaxis length influenced by pa-tient characteristics and varying surgeon preferences (Table 1). Approximately 90% of patients responded that it was not difficult to remember to take each dose. Of oral and injection patients, 80.6% (N=50) and 86.5% (N=64) respectively reported taking each dose as scheduled.

DISCUSSION:Considerable effort has been

directed towards determining the effectiveness of various forms of VTE prophylaxis following elective hip and knee arthroplas-ty. The rate of deep vein throm-bosis following surgery may be as high as 45-57% following THA and 40-84% following TKA without adequate prophylaxis.8

Table 3. Data Specific to Injection Group Only – prior experience, education, difficulty, and preparednessSelf-Injection 83.8%

Non self-injection 16.2%

Prior Experience with Self-Injections*:Mean (Standard Deviation) 3.5 (3.7)

Person Providing EducationNurse at Bedside 79.0%

Other 8.1%

No One 1.6%

No Education Required 11.3%

Patient Observed Performing InjectionYes 75.8%

No 17.7%

Unkown 3.2%

Prior Experience 3.2%

Difficulty Performing Injection#:Mean (Standard Deviation) 2.0 (1.7)

Preparedness to Perform Injection at Discharge^Mean (Standard Deviation) 8.8 (2.2)

Pain on Injection@

Mean (Standard Deviation) 2.5 (2.0)

*Rated on a scalte of 1-10 with 1 indicating “no experience” and 10 indicating “very experienced”#Rated on a scale of 1-10 with 1 indicating “not difficult” and 10 indicating “very difficult”^Rated on a scale of 1-10 with 1 indicating “not prepared” and 10 indicating “very prepared”@Rated on a scale of 1-10 with 1 indicating “no pain” and 10 indicating “very painful”

Furthermore, postoperative mortality rates due to pulmonary embolism following THA can be as high as 3-6% without ad-equate prophylaxis and venous thromboembolism is the most common cause of emergency re-hospitalization following these procedures.8 Risk of VTE following arthroplasty sur-gery can be reduced with appropriate prophylaxis9,1,10 with minimal effects on the risk of major bleeding events.10,11 It is critical that patients be prescribed prophylaxis and are com-pliant following THA or TKA to help lower risk of VTE relat-ed complications.

While many studies have evaluated the effectiveness of different pharmacologic agents, few have investigated compli-ance with prescribed regimens under regular outpatient cir-cumstances. Given that patients are now routinely discharged within a few days after surgery, determining typical levels of compliance in the days and weeks after discharge is important as strong adherence is necessary for proper VTE prevention.

The administration of prophylaxis can be with oral or in-jectable medication. It has been shown that compliance of or-

38


thopedic surgeons with prescribing prophylaxis in accordance with the American College of Chest Physicians recommended dose, timing, and duration was lower in the United States than in other countries for both THA (47% vs. 62%, respectively) and TKA patients (61% vs. 69%, respectively).12 However, this is only the first step, as appropriate patient education and compliance is also important.

In our study, 79% of the patients that were prescribed injectable prophylaxis received education by a nurse at their bedside. For comparison, a study in 2008 found 18.7% of hos-pitalized non-orthopedic patients had no knowledge of either DVT or PE, and of the patients who had heard of either DVT or PE, 22.6% and 51.6% respectively could not provide any accurate information about the condition.13 Of the 136 pa-tients we surveyed, 93% believed that taking the medication was important or very important, however only 83.1% were

able to recall the reason for taking the prescribed medication. Moreover, many patients responded that they believed taking the medication was important because their surgeon said it was. However, 22 patients (29.7%) using injections and 8 pa-tients (12.9%) using oral medication were unable to recall the name of their medication. Still, many of the patients who were unable to spontaneously recall the names of their medication were able to identify the prescribed regimen when prompted with a list of common choices.

Given that patients now typically spend only a few days as an inpatient after surgery, emphasis on education regarding signs and symptoms of VTE can help improve early detection and intervention since clots are more likely to occur after dis-charge. In a study reviewing VTE incidence among 14,875 patients undergoing arthroplasty, Warwick et al found a mean time to VTE of 21.5 days and 9.7 days following total hip and

Appendix A. Prophylaxis Survey Study Data Collection Form

39


by telephone to participate, not all patients were successfully reached and not all agreed to participate. Thus, a selection bias may be present in our study population. Additionally, since all information in our study was obtained only from the patients and was not independently verified in the medical record, a recall bias may be present. Some patients also had home nurses or other assistance with care after surgery, which may have had an influence on adherence. Those patients who had undergone prior orthopaedic surgery may have been more knowledgeable about prophylaxis from past experience.

The study has several important strengths. We recruited a total of 150 patients and included 136 in the final analysis, which created a diverse patient population in age, race and gender. While other multicenter studies contained larger study groups to analyze efficacy of prophylaxis, our study fo-cused on compliance and was larger than similar studies de-signed specifically to evaluate compliance. Participants sur-veyed were identified from among fourteen surgeons at our institution, which minimized selection bias and created a di-verse population to evaluate possible barriers and compliance.

CONCLUSION:VTE remains the most common complication following

hip and knee replacement and the clinical consequences can be significant. Given the major concern for VTE disease af-ter major orthopedic surgery, efforts to maximize appropri-ate prescribing, patient education and compliance should be made. Specific efforts towards patient education and aware-ness regarding post-operative VTE prophylaxis at home may help increase compliance further, which may improve out-comes by reducing the VTE events associated with these pro-cedures.

REFERENCES

1. Colwell CW, Froimson MI, Mont MA, Ritter MA, Trousdale RT, Buehler KC, et al. Thrombosis Prevention after Total Hip Arthroplasty - a Prospective, Randomized Trial Comparing a Mobile Compression Device with Low-Molecular-Weight Heparin. JBJS. 2010; 92-A(3): 527-535.2. Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ. Executive Summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141(2 suppl.): 7S-47S.3. Sadideen H, O’Callaghan JM, Navidi M, Sayegh M. Educating surgical patients to reduce the risk of venous thromboembolism: an audit of an effective strategy. JRSM Short Rep. 2011; 2(12): 97.4. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of Primary and Revision Hip and Knee Arthroplasty in the United States from 2005 to 2030. JBJS. 2007; 89(4): 780-785.5. Vallano A, Arnau JM, Miralda GP, Bartoli, JP. Use of venous thrombopropyhlaxis and adherence to guideline recommendations: a cross-sectional study. Thrombosis Journal. 2004; 2(3): 1-7.6. Sadideen H, O’Callaghan JM, Navidi M, Sayegh M. Educating surgical patients to reduce the risk of venous thromboembolism: an

knee arthroplasty respectively. The events occurred after the median time to discharge for 75% of THA and 57% of TKA patients.14 This demonstrates the importance of patient com-pliance beyond the first few days in the hospital. A 2005 study examining compliance found that after specific education and instruction for the 51 study participants, 98% of patients were aware of the reason for enoxaparin administration on follow up interview.15 The observed compliance with enoxaparin among the forty participants assessed in this study showed 55% with complete compliance and 37.5% with partial com-pliance defined as missing no more than one dose in first sev-en days and one dose in the next fourteen days.

A multicenter study in 2010 included 1315 patients for analysis to quantify nonadherence with outpatient use of low molecular weight heparin following major orthopedic sur-gery. Definite or probable nonadherence occurred in 19.8% of patients and non-adherent patients typically missed between 38% and 53% of their outpatient doses.16 Watts et al. found that among 34 evaluated patients 85% of patients achieved a 90% compliance rate or better with six weeks of daily fondaparinux injections following knee or hip arthroplasty.17 A study in 2012 examining compliance with oral prophylaxis for 56 patients following total hip replacement revealed that 98.1% of dabigatran doses were taken correctly.18 A study of 68 patients undergoing lower limb arthroplasty found 95.5% of patients achieved full compliance with a 10 day prophylaxis course of LMWH.19

These studies reveal rates of compliance with VTE pro-phylaxis upwards of 80%. However, in some studies address-ing compliance, patients were included in the study at the beginning of therapy. We attempted to avoid this possible bias by recruiting patients after the conclusion of their ther-apy window. Out of the 150 patients surveyed in our study, 136 were included in the data analysis with 74 using injectable anticoagulation and 62 using oral prophylaxis. Eight patients from the injection group (10.8%) and 11 from the oral group (17.7%) reported missing at least one dose. We found that 83.8% of our surveyed patients reported full compliance hav-ing missed no doses which is consistent with other studies. Our compliance values differ somewhat from some studies that either provided the medication for patients or looked at shorter durations of prophylaxis. In addition, our study group was larger than several other studies designed to look specifi-cally at compliance. For our patients that had missed a dose, the most common reasons given were that they had forgot or because did not have access to their medication. While some patients did report varying degrees of burden related to med-ication costs, most reported little to no difficulty obtaining medication with regards to cost. These findings seem to indi-cate that cost did not in fact play a significant role in compli-ance for this patient population.

Despite attempts to reduce possible bias in our study, there were still some limitations. Given that we recruited patients

40


boembolism (VTE) Prevention Among Hospitalized Patients. Journal of Vascular Nursing. 2008; 26(4): 109-116.14. Warwick D, Friedman RJ, Agnelli G, Gil-Garay E, Johnson K, Fitzgerald G, Turibio FM. Insufficient Duration of Venous Thrombo-embolism Prophylaxis after Total Hip or Knee Replacement when Compared with the Time Course of Thromboembolic Events. JBJS. 2007; 89-B(6): 799-807.15. Colwell CW Jr., Pulido P, Hardwick ME, Morris BA. Patient Compliance with Outpatient Prophylaxis: An Observational Study. Orthopedics. 2005; 28(2): 143-147.16. Wilke T, Moock J, Muller S, Pfannkuche M, Kurth A. Nonad-herence in Outpatient Thrombosis Prophylaxis with Low Molecular Weight Heparins after Major Orthopaedic Surgery. Clinical Orthopae-dics and Related Research. 2010; 468(9): 2437-2453.17. Watts AC, Howie CR, Simpson AH. Assessment of a Self-admin-istration Protocol for Extended Subcutaneous Thromboprophylaxis in Lower Limb Arthroplasty. JBJS. 2006; 88-B(1): 107-110.18. Lebel B, Melherbe M, Gouzy S, Parienti JJ, Dutheil JJ, Barrellier MT, Vielpeau C. Oral Thromboprophylaxis Following Total Hip Re-placement: the Issue of Compliance. Orthopaedics & Traumatology: Surgery & Research. 2012; 98: 186-192.19. Rajkumar S, Tavares S. Patient Compliance with Deep Vein Thrombosis Prophylaxis Following Lower Limb Arthroplasty Surgery. The Online Journal of Clinical Audits. 2010; 2(2): 2-10.ee

audit of an effective strategy. J R Soc Med Sh Rep. 2011;2(12):97.7. Vallano A, Arnau JM, Miralda GP, Pérez-Bartolí J. Use of venous thromboprophylaxis and adherence to guideline recommendations: a cross-sectional study. Thrombosis Journal. 2004; 2: 3.8. Friedman RJ. Extended Thromboprophylaxis after Hip or Knee Replacement. Orthopedics. 2003; 26(2 - supplement): 225-30.9. Planes A, Vochelle N, Darmon J-Y, Fagola M, Bellaud M, Huet Yann. Risk of deep-venous thrombosis after hospital discharge in patients having undergone total hip replacement: double-blind randomised comparison of enoxaparin versus placebo. Lancet. 1996; 348: 224-228.10. Eikelboom JW, Quinlan DJ, Douketis JD. Extended-duration prophylaxis against venous thromboembolism after total hip or knee replacement: a meta-analysis of the randomised trials. Lancet. 2001; 358: 9-15.11. Geerts WH, Heit JA, Clagett GP, Pineo GF, Colwell CW, Ander-son FA, et al. Prevention of Venous Thromboembolism. Chest. 2001; 119:132S–175S.12. Friedman RJ, Gallus AS, Cushner FD, Fitzgerald G, Anderson FA Jr. Physcian Compliance with Guidelines for Deep-Vein Throm-bosis Prevention in Total Hip and Knee Arthroplasty. Current Medical Research and Opinion. 2008; 24(1): 87-97.13. Le Sage S, McGee M, Emed JD. Knowledge of Venous Throm-

length, resulting in mismatch between the diameters of the screw and the canal.3 A technique is presented here that has allowed our team to consistently and accurately measure the length of an intramedullary screw to provide stable fixation for transverse olecranon fractures.

SURGICAL TECHNIQUEThe patient is placed in a lateral decubitus position with

the affected arm draped over a bump (Figure 2). A standard posterior approach is made to the proximal ulna and the frac-ture is exposed in the usual fashion. A 2.5mm drill is used to create opposing drill holes approximately two to three centi-meters distal to the fracture on the radial and ulnar sides of the ulna (Figure 3). Two tenaculum clamps are then placed on each side of the ulna with one tong in the drill hole and the second tong on the proximal fracture fragment. The frac-ture is then reduced and the clamps are tightened to hold the reduction (Figure 4). The guide wire for a 7.3mm screw is then placed through the proximal tip of the ulna, driven across

Intramedullary Screw Fixation of Transverse Olecranon Fractures

Alexander R. Orem MD MS and Robert V. Cantu MD MS

ABSTRACTMultiple options exist for fixation of transverse olecranon

fractures. Intramedullary (IM) screw fixation has the advan-tage of minimizing prominent hardware thereby decreasing the need for secondary surgery. Maintaining fracture reduc-tion while placing the screw and determining proper screw length can present a challenge. We describe a technique that addresses these issues by using an intramedullary tap to accu-rately and consistently measure the appropriate length for an intramedullary screw.

Level of Evidence:V

INTRODUCTIONDisplaced olecranon fractures in active patients do best

with open reduction and internal fixation with primary goals of articular restoration, stable fixation and early range of mo-tion.1 For transverse, intra-articular, two-part fractures (Fig-ure 1), the tension band technique has been described as a method of fixation.2 Multiple authors have referred to this technique as the “gold standard.”3,4 This method of fixation is not without issues, however, including a rate of revision surgery for symptomatic hardware removal approaching 65-90%.4-6 In addition, irritation of the proximal radioulnar joint by prominent k-wires and damage to neurovascular structures have both been described.7

Placement of an intramedullary implant for fixation has the advantage of minimal prominent hardware and may re-duce the need for revision surgery.8 Biomechanical studies on fixation of olecranon fractures with intramedullary screws have shown inconsistent results when compared to other olec-ranon fixation constructs.3 One study concluded the inconsis-tent results were due to difficulty determining the appropriate

1. Dartmouth Hitchcock Medical Center, Lebanon, NH

Corresponding Author: Alexander R. Orem, MD, MSE-mail: [email protected]


Figure 1. Transverse, intraarticular olecranon Fractures

42


with the figure-of-eight wire had the greatest energy to failure when tested by rapid loading. In a similar cadaver study Fyfe et al. compared five techniques of fixation and found “incon-sistent” results with the IM cancellous screw.3 The authors used the same size (6.0mm) and length (90mm) screw on all specimens. They concluded the inconsistent results were due to the lack of “correlation between the size of the screw thread and the diameter of the medullary cavity.” Our technique ad-dresses this problem by using the tap to directly measure the intramedullary distance needed to consistently obtain suffi-cient screw purchase. This typically occurs as the tap advanc-es from the metaphyseal to the more narrow diaphyseal region of the proximal ulna. Morphologic study of the canal diam-eter and shape of the proximal ulna have found the smallest diameter to range from 3.5mm-7mm in the anterior-posteri-or dimension and 3-6mm in the medial-lateral dimension.10 Therefore a 7.3mm screw should achieve purchase in even the largest canal diameters. For some younger patients with narrower intramedullary canals a cannulated screw of smaller diameter might be considered.

In addition, the use of two tenaculum clamps is helpful both to obtain reduction of the fracture and to maintain it as the screw is tightened. Typically the screw achieves solid pur-chase and the clamps are needed to prevent rotation of the proximal fragment. The drill holes used to place the clamps can then be used to pass a suture for figure-of-eight fixation to supplement the screw fixation. Carofino et al. has shown that a non-absorbable suture (FiberWire) provides similar fixation strength to a metal tension wire.11 The suture is typically less noticeteeeable to the patient provided the knot is placed to the

the fracture fragment and then down the intramedullary canal using C-arm guidance to ensure an intramedullary trajectory on orthogonal views. A cannulated drill is used to open the intramedullary canal across the fracture. Next the cannulated tap is used to prepare the canal for screw placement. The total length of the tap is first measured. The tap is then advanced carefully by hand until it begins to experience solid resistance in the canal, at which point advancement is stopped. The length of the tap remaining external to the bone is measured (Figure 5), and this is subtracted from the total length of the tap, giving an accurate measurement of the length of the in-ternal portion of the tap. This is the length chosen for the 7.3mm cannulated intramedullary screw. The screw is then placed over the wire and both the reduction and rotational alignment are held with the tenaculum clamps as the screw is tightened. Once the screw is in position the clamps are re-moved (Figure 6 & 7). At this point there is the option to add a figure-of-eight tension band suture through the drill holes and under the triceps tendon, to provide additional compres-sive force to the fracture. A posterior splint is placed until the first post-operative visit at 10-14 days at which time gentle elbow motion is begun.

DISCUSSIONStudies looking at the fixation strength of olecranon frac-

tures with intramedullary screws have shown varied results. Murphy et al. used a cadaver model with a transverse osteot-omy in the semilunar notch and compared a figure-of-eight wire, a cancellous screw, a screw plus a wire, and an AO ten-sion band construct.9 Their study found the cancellous screw

Figure 2. The olecranon is approached through a standard posterior approach Post operative X-ray of intramedullary olecranon screw

Figure 3. A 2.5mm drill bit is used to create two opposing holes in the ulna distal to the fracture line.

Figure 4. Two tenaculum clamps are placed in the drill holes and are used to reduce and hold the proximal fragment

43


6. Macko D, Szabo RM. Complications of tension-band wiring of olecranon fractures. The Journal of Bone & Joint Surgery. 1985;67(9):1396-1401.7. Catalano LW, 3rd, Crivello K, Lafer MP, Chia B, Barron OA, Glickel SZ. Potential dangers of tension band wiring of olecranon fractures: an anatomic study. J Hand Surg [Am]. Oct 2011;36(10):1659-1662.8. Argintar E, Cohen M, Eglseder A, Edwards S. Clinical results of olecranon fractures treated with multiplanar locked intramedullary nailing. J Orthop Trauma. Mar 2013;27(3):140-144.9. MURPHY DF, GREENE WB, GILBERT JA, DAMERON TBJ. Displaced Olecranon Fractures in Adults: Biomechani-cal Analysis of Fixation Methods. Clinical Orthopaedics and Related Research. 1987;224:210-214.10. Akpinar F, Aydinlioglu A, Tosunand N, Tuncay I. Morphologic evaluation of the ulna. Acta Orthopaedica. 2003;74(4):415-419.11. Carofino BC, Santangelo SA, Kabadi M, Mazzocca AD, Browner BD. Olecranon Fractures Repaired With FiberWire or Metal Wire Tension Banding: A Biomechanical Compar-ison. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2007;23(9):964-970.

side of the ulna and not directly posterior.

SUMMARYIn this paper we have presented a technique to allow for

intramedullary fixation of olecranon fractures by consistently and accurately measuring the distance from the proximal cor-tex to the point in the intramedullary canal where a 7.3mm cannulated screw will find secure purchase and allow stable compression across the fracture. The intramedullary screw technique has been shown in previous research to have ade-quate biomechanical stability when the implant has sufficient osseous purchase and may also avoid the major pitfalls of tension-band techniques, most notably the need for revision surgery for symptomatic prominent hardware and the dan-ger to anterior neurovascular structures caused by prominent k-wires through the anterior ulnar cortex.

REFERENCES

1. Cabanella M, Morrey B. Fractures of the Proximal Ulna and Olecranon. 2nd ed. Philadelphia: WB Saunders; 1993.2. Wolfgang G, Burke F, Bush D, et al. Surgical Treatment of displaced olecranon fractures by tension band wiring tech-nique. Clin Orthop. 1987;224:192-204.3. Fyfe I, Mossad M, Holdsworth B. Methods of Fixation of Olecranon Fractures. J Bone Joint Surg Br. 1985;67-B(3):367-372.4. Chalidis BE, Sachinis NC, Samoladas EP, Dimitriou CG, Pournaras JD. Is tension band wiring technique the “gold standard” for the treatment of olecranon fractures? A long term functional outcome study. Journal of Orthopaedic Sur-gery and Research. 2008;3.5. Rommens PM, Kuchle R, Schneider RU, Reuter M. Olec-ranon fractures in adults: factors influencing outcome. Injury. 2004;35(11):1149-1157.

Figures 6-7. Post operative X-ray of intramedullary olecranon screwFigure 5. Once the tap is advanced to the point at which solid resistance is felt, the external portion is mea-sured and subtracted from the total length to determine the length of the implant.

with peripheral vascular disease the risk of occlusion or em-bolization is increased8 and the risk to intra-pelvic vascular structures secondary to acetabular screw placement are well described7. To our knowledge, no previous report describing a femoral artery injury resulting in a pulseless limb with the use of the direct anterior approach for total hip arthroplasty has been published and we believe this represents an important original observation. Approval from the subject of the case re-port was obtained prior to its submission. Institutional Review Board Approval was not required for this case report.

Source of Funding


PRESENTATION OF THE CASE:A 73-year-old woman with hypertension, hypothyroidism,

osteopenia and right hip pain from severe degenerative osteo-arthritis, which was refractory to conservative management presented to an outside facility within our referral area and underwent a total hip arthroplasty through a direct anterior approach.

The procedure was carried out under spinal anesthesia. The patient was positioned supine on a HANA® table (MIZUHO OSI Union City, CA) with the feet placed in well-padded boots. A padded perineal post and the independent leg ad-justment function of this table allows for controlled intra-op-erative rotation, traction and hyperextension of the limbs. An anterior skin incision was carried down to the tensor fascia lata, which was sharply divided. Blunt digital dissection en-sued around the tensor down to the capsule. The circumflex vessels were coagulated with electrocautery. Manual traction was applied during the case to allow for hip dislocation and femoral broaching with the leg hyperextended and adducted. A Zimmer Press-Fit M/L Taper stem with a 36mm head was used on the femoral side with a 50mm Press-Fit trabecular metal cup and a standard polyethylene liner (Zimmer, Inc, Warsaw IN) on the acetabular side (Figure 1). There were no apparent intra-operative complications. The patient was taken to the recovery room where adequate capillary refill and nor-mal limb appearance in the operative extremity were noted.

Case Report

Femoral artery occlusion after total hip Arthroplasty through the direct anterior approach: A case report

Wayne Moschetti MD MS, Spencer Amundsen MD

1. Dartmouth Hitchcock Medical Center, Lebanon, NH

Corresponding Author: Wayne Moschetti, MD, MSE-mail: [email protected]


ABSTRACT: Iatrogenic vascular injury during primary total hip arthro-

plasty is an uncommon but serious complication. The direct anterior approach for THA has experienced a resurgence in popularity due to the muscle sparing nature of the procedure, yet difficulties with exposure and a steep learning curve to per-form the procedure are risk factors for complications. This case report describes a femoral artery injury during this ap-proach leading to a dysvascular limb. It emphasizes the impor-tance of rapid identification of any potential vascular insult. Immediate vascular surgery consultation and intervention when vascular compromise is suspected is highlighted.

Level of EvidenceV

INTRODUCTION:Total hip arthroplasty (THA) is a successful procedure in

restoring function in patients with severely symptomatic hip osteoarthritis who have failed conservative non-operative management1. Despite the success of this procedure there is continual focus on refining the operative technique to fur-ther improve patient outcomes and minimize complications. There are several commonly used surgical approaches with varying complication risks2,3. Over the past decade the direct anterior approach has been reintroduced in the United States and has become popular with surgeons and patients. Push from patients and institutions are driving surgeons to abandon other approaches and use this approach despite little evidence supporting its superiority. Exposure and positioning of the leg with this approach can be difficult and a learning curve associ-ated with case volume has been identified4.

Vascular injuries are uncommon but potentially devastat-ing complications after total hip arthroplasty5,6. In patients

45


and a large burden of thrombus. The arteriotomy was closed with a bovine pericardial patch. Four compartment fascioto-mies were performed in the right lower extremity to prevent reperfusion compartment syndrome. At the end of the pro-cedure posterior tibial and dorsalis pedal doppler signals had returned.

Post operatively the patient was anticoagulated with sub-cutaneous heparin 5000 units three times daily for three days after which she was transitioned to Coumadin. She began physical therapy the day after the surgery and was allowed to weight bear as tolerated. The fasciotomy sites were found to have healthy viable muscle with minimal edema on post-op-erative day three and were closed primarily. The patient was discharged to a rehabilitation facility on post-operative day able to ambulate a few steps with an assistive device.

At her two week follow up from the vascular repair she was ambulating without difficulty, her ankle/brachial systol-ic pressure index was one, and there was no significant low-er extremity arterial occlusive disease identified. There was persistent diminished sensation over the foot globally but this improved by 4 months.

DISCUSSION: Iatrogenic vascular injury after Orthopaedic surgery

Approximately six hours after surgery on the hospital ward the patient began complaining of increasing right foot pain. On clinical examination her foot was cool to touch, slightly mottled with a bluish hue. Dorsalis pedis and posterior tibial artery pulses were non-palpable and no doppler signal could be identified. This prompted emergent transfer to our facility for vascular surgery evaluation.

Upon arrival approximately 9 hours later, she had absent right femoral, popliteal, dorsalis pedis, and posterior tibial pulses both by palpation and doppler evaluation. Her report-ed normal post-operative motor exam had changed now with no ankle or foot voluntary movement. She demonstrated de-creased sensation to light touch up to the level of her mid-calf. The Vascular Surgery team emergently evaluated her, subcutaneous heparin was started, and she was taken to the operating room expeditiously. An aortogram demonstrated stagnant flow to the right common femoral artery consistent with thrombosis and occlusion (Figure 2). The common fem-oral artery was then exposed via a longitudinal cutdown and hematoma was noted in the soft tissues. No femoral pulse was palpable. A transverse intimal rupture within the common femoral artery causing vessel thrombosis with proximal mi-gration was found at the time of surgery and repaired primar-ily after local direct thrombectomy. Subsequently, a balloon thrombectomy of the superficial femoral, popliteal, and tib-ial arteries was performed due to insufficient back bleeding

Figure 1. Post-operative pelvis x-ray after a right total hip Arthroplasty through the direct anterior approach with no apparent intra-operative compli-cations

Figure 2. Aortogram demonstrating lack of blood flow through the right common femoral artery (arrow) with pronounced iliac collaterals consistent with common femoral artery occlusion

46


CONCLUSION Vascular injuries are uncommon but potentially devas-

tating complications after total hip Arthroplasty. Iatrogenic vascular injury with the use of the direct anterior approach to the hip for total hip Arthroplasty poses a risk to the neigh-boring femoral artery. The specific cause of injury to the common femoral artery in this case is unknown but one must be cognizant of appropriate retractor placement, identifying the appropriate intermuscular plane, and the amount of trac-tion placed on the operative leg. Diligence in comparing the pre-operative to post-operative neurovascular exam is crucial in the rapid identification of a vascular problem and emergent vascular surgery consultation and intervention in the setting of a vascular insult can dramatically improve outcomes and limit catastrophic complications.

REFERENCES:

1. Ethgen O, Bruyere O, Richy F, Dardennes C, Reginster JY. Health-related quality of life in total hip and total knee arthroplasty. A qualitative and systematic review of the literature. J Bone Joint Surg Am 2004;86-A:963-74.2. Jolles BM, Bogoch ER. Posterior versus lateral surgical approach for total hip arthroplasty in adults with osteoarthritis. Cochrane Data-base Syst Rev 2006;3:CD003828.3. Masonis JL, Bourne RB. Surgical approach, abductor function, and total hip arthroplasty dislocation. Clin Orthop Relat Res 2002:46-53.4. Masonis J, Thompson C, Odum S. Safe and accurate: learning the direct anterior total hip arthroplasty. Orthopedics 2008;31.5. Wilson JS, Miranda A, Johnson BL, Shames ML, Back MR, Bandyk DF. Vascular injuries associated with elective orthopedic procedures. Ann Vasc Surg 2003;17:641-4.6. Rossi G, Mavrogenis A, Angelini A, Rimondi E, Battaglia M, Ruggi-eri P. Vascular complications in orthopaedic surgery. J Long Term Eff Med Implants 2011;21:127-37.7. Wasielewski RC, Cooperstein LA, Kruger MP, Rubash HE. Ace-tabular anatomy and the transacetabular fixation of screws in total hip arthroplasty. J Bone Joint Surg Am 1990;72:501-8.8. Barrack RL, Butler RA. Avoidance and management of neurovas-cular injuries in total hip arthroplasty. Instr Course Lect 2003;52:267-74.9. Jewett BA, Collis DK. High complication rate with anterior total hip arthroplasties on a fracture table. Clin Orthop Relat Res 2011;469:503-7.10. Chimento GF, Pavone V, Sharrock N, Kahn B, Cahill J, Sculco TP. Minimally invasive total hip arthroplasty: a prospective random-ized study. J Arthroplasty 2005;20:139-44.11. Matta JM, Shahrdar C, Ferguson T. Single-incision anterior ap-proach for total hip arthroplasty on an orthopaedic table. Clin Orthop Relat Res 2005;441:115-24.12. Sculco TP, Boettner F. Minimally invasive total hip arthroplasty: the posterior approach. Instr Course Lect 2006;55:205-14.13. Siguier T, Siguier M, Brumpt B. Mini-incision anterior approach does not increase dislocation rate: a study of 1037 total hip replace-ments. Clin Orthop Relat Res 2004:164-73.14. Barton C, Kim PR. Complications of the direct anterior approach for total hip arthroplasty. Orthop Clin North Am 2009;40:371-5.15. Woolson ST, Pouliot MA, Huddleston JI. Primary total hip arthro-plasty using an anterior approach and a fracture table: short-term results from a community hospital. J Arthroplasty 2009;24:999-1005.16. Carrillo EH, Spain DA, Miller FB, Richardson JD. Femoral vessel

is a rare but potentially devastating complication. As with other newly adopted procedures, the risk of complications are greatest in the earlier stages of the learning curve and this holds true for the direct anterior approach for total hip arthro-plasty4,9. Proponents of this approach believe that by spar-ing the posterior and lateral musculature during the surgical dissection, patients may be afforded a quicker recovery with fewer functional limitations and a lower dislocation risk10-13. Despite the successful use of this approach for total hip arthroplasty10-12 there has been notable emphasis placed on the potential for higher complication rates14,15. A review of 800 primary THAs performed through a direct anterior approach with 1.8 years of follow up described trochanteric fractures, femoral perforations, and wound complications as being common with this approach9. There was one vascular injury reported in this series resulting from a drain that punc-tured a superficial varicose vein.

To our knowledge this case represents the first de-scribed common femoral artery injury resulting in a dysvas-cular limb using the direct anterior approach for THA and is an important original observation. The exact cause of the vas-cular injury in this case can only be speculated and the close proximity to the femoral neurovascular bundle with this ap-proach needs to be respected. With placement of a retractor over the anterior column of the acetabulum care must be tak-en to stay beneath the muscle belly of the rectus femoris as the neurovascular bundle lies on the opposite side of this struc-ture. When considering all Orthopaedic surgeries the major-ity of vascular injuries occur in total knee (67%) and total hip (19%) arthroplasties. Unless brisk bleeding is noted after an intra-operative laceration of a vessel, most injuries are discov-ered post-operatively with as many as 25% being noted after 24 hours5. This emphasizes the overwhelming importance of performing serial post-operative neurovascular examinations and the early recognition of any change in comparison to the pre-operative exam. The neurovascular exam should be fol-lowed beyond the initial 24 hours and if any discrepancy in the exam is noted suspicion for a vascular injury should be raised with the appropriate work up ensuing.

Identifying a vascular injury promptly and proceeding with expeditious vascular surgery consultation and interven-tion was imperative for success in the case described. A femo-ral artery injury unrecognized and left untreated can result in an amputation rate approximately 50% while early diagnosis and intervention can lower that rate to near 9%16,17. This case highlights the importance of respecting the close prox-imity of the femoral vessels and to a degree the neighboring femoral nerve to the proximal femur. Caution must be tak-en when considering the direct anterior approach when per-forming low volumes of total hip Arthroplasty as it is techni-cally demanding and has a documented learning curve where the risk of complications are higher4,9.

Total Knee Arthroplasty in a Patient with an Ipsilateral Transtibial Amputation: A Case Report and Surgical

Technique for Addressing a Short Residual TibiaJoshua M. Murphy MD, Scott M. Sporer MD

ABSTRACT:The presence of knee arthrosis in the setting of ipsilateral

transtibial amputation is uncommon. Therefore, there have been limited reports regarding total knee arthroplasty (TKA) in this patient population. We present the case of a 44-year old man with symptomatic knee arthrosis and ipsilateral transtibi-al amputation with a residual tibia measuring 4.7 cm in length treated with TKA. Our surgical technique is presented and in-volved the use of Steinman Pins in the residual tibia for control of the limb along with intra-operative fluoroscopy to verify correct tibia cutting guide placement. This technique has not been previously described and is an efficient, inexpensive and reproducible technique for addressing TKA in patients with ipsilateral transtibial amputation.

INTRODUCTIONTotal knee arthroplasty (TKA) is accepted as a highly suc-

cessful operation. Alignment of the implanted components is critical to the biomechanics of the limb and to the survival of the implants.1 Patients with transtibial amputations and ip-silateral knee arthrosis present a unique challenge to the sur-gical technique as it relates to proper component alignment. The lack of an ipsilateral ankle and foot makes identification of anatomic landmarks used for limb and component align-ment difficult. Standard extramedullary alignment guides rely on recreating the mechanical axis of the tibia with the distal alignment target being the center of the ankle. Additionally, the lack of a foot limits the tactile control of the limb distal to the knee, which creates surgical technical challenges.

There are very few published reports concerning TKA in patients with ipsilateral transtibial amputation. Three such case reports were identified in a pubmed literature search. In

2000, Pasquina and Dahl reported excellent results and unlim-ited ambulation in a 73-year old patient with a transtibial am-putation treated with TKA.2 In 2003, Crawford and Coleman reported good results in a 75 year old female who underwent TKA in the setting of an ipsilateral transtibial amputation.3 In 2008, Konstantakos et al published a novel technique for ad-dressing tibial alignment in a patient with a BKA. At 8 year follow-up the patient maintained a good result.4

The current case describes a unique surgical technique for addressing limb control and limb alignment in the setting of an extremely short residual tibia after transtibial amputation.

CASE REPORTThe patient is a 44-year old man who presented to the clin-

ic of the senior author (S.M.S.) for expert opinion regarding surgical management of symptomatic knee arthrosis in the setting of an ipsilateral transtibial amputation. The patient was involved in a severe motorcycle accident seven years pri-or to presentation to our clinic. His left lower extremity was severely injured and he underwent multiple operations in an attempt at limb salvage ultimately resulting is an extremely proximal transtibial amputation. After a prolonged hospi-talization the patient eventually functioned well for several years. He was pain free and ambulated with the aid of a pros-thetic leg (patella-tendon-bearing with a silicone lined sock-et extending to supracondylar fit, standard prosthetic shank and foot attached). He subsequently developed symptomatic post-traumatic knee arthritis. Non-operative treatment in-cluding non-steroidal anti-inflammatory drugs, corticosteroid injections, and viscosupplementation injections initially pro-vided the patient with relief but progressively failed to provide symptomatic relief. The referring surgeon counseled the pa-tient regarding transfemoral amputation as surgical treatment given the extremely proximal below knee amputation. Prior to proceeding with transfemoral amputation the patient was referred to our clinic for second opinion and consideration of total knee arthroplasty.

The patient had no other medical problems. He was five feet eleven inches in height and weighed 260 pounds. On exam, his extensor mechanism was intact with full active ex-tension was without flexion contracture. He maintained ac-tive flexion of the knee with flexion greater than 120 degrees

1. Ruch University Medical Center, Chicago, IL

Corresponding Author: Scott M. Sporer, MDE-mail: [email protected]


48


joint space narrowing and osteophyte formation. His residual tibia measured 4.7 cm in length.

The referring surgeon had exhausted non-operative op-tions for this patient. The patient was indicated for TKA, how-ever, he presented unique technical challenges with increased peri-operative risk, most notably continued pain after TKA, potential issues with prosthetic fit and comfort, and rehabil-itative efforts. Prior to the development of symptomatic ar-throsis the patient had ambulated and functioned pain free with a prosthetic limb. Although transfemoral amputation was an option for treating his symptomatic arthrosis in the presence of his short residual tibia, our opinion was that the patient would be higher functioning with less energy expen-diture during ambulation if he retained his knee. Given these considerations, the patient was offered a TKA ipsilateral to his transtibial amputation with the understanding that com-plication or unsatisfactory pain relief could potentially lead to transfemoral amputation. After discussion of these factors and consideration of the benefits and risks of transfemoral amputation versus TKA, the patient elected to proceed with TKA.

SURGICAL TECHNIQUECombined spinal anesthesia with IV sedation was uti-

lized, a tourniquet was applied to the patient’s thigh, and the limb was draped and prepared for surgery in a sterile fashion (Figure 3). We performed a longitudinal incision in line with the medial aspect of the tibial tubercle extending proximally. A medial arthrotomy was used to access the knee. Steinman pins were placed in the tibia directed anterior medial to poste-rior lateral and anterior lateral to posterior medial (Figure 4) and utilized to control the residual tibia. The femur was cut in 5 degrees of valgus alignment using a standard intramedullary alignment guide. Nine millimeters of bone was resected from the medial femoral condyle. A gap balancing technique was employed in order to obtain appropriate coronal alignment of the tibia cutting guide. Laminar spreaders were placed medially and laterally in the tibiofemoral space with the knee in extension, and then the tibia cutting guide was positioned such that the collateral ligaments would be under equal ten-sion. Biplanar fluoroscopy was utilized to ensure proper tibia cutting guide with approximately 5 degrees of posterior slope (Figures 5 and 6). An angel wing was placed in the cutting guide slot in order to project the angle of the planned tibia resection on lateral fluoroscopy image thus estimating the planned posterior slope. After tibial resection was completed the posterior cruciate ligament was examined and found to be intact and functional. We decided to proceed with a cru-ciate retaining knee prosthesis. The femur was then sized in 3 degrees of external rotation, followed by anterior, posterior and chamfer cuts. The tibia was sized with rotation based on the medial and middle third of the tibial tubercle. A trial tibial tray was provisionally pinned. The patella was recessed

although exact flexion arc could not be measured secondary to the extremely proximal nature of his residual limb. His collateral ligaments appeared to be intact although his short residual limb did not provide a significant lever arm for varus and valgus stress maneuvers of the knee joint. His traumat-ic and surgical incisions were all healed and without physical exam findings of infection. His radiographs (Figures 1 and 2) demonstrated tricompartmental arthrosis with significant

Figure 1. Pre-operative standing AP radiograph of the bilateral knees. The residual tibia measures 4.7 cm.

Figure 2. Pre-operative standing lateral radiograph of the left knee.

49


and the tibia was drilled and punched for a four-pegged tib-ial component. Simplex P bone cement with tobramycin was used to cement the tibial, femoral, and patellar components in place (Zimmer, Nexgen CR Flex, Fixed Bearing). Once the cement had polymerized, the final 10-millimeter insert was placed. The Steinman pins were removed from the tibia, an

and a patella trial placed. A 10-millimeter trial cruciate re-taining tibial insert was placed. The knee was taken through full range of motion utilizing the previously placed Steinman pins to control the tibia. The knee was ligamentously stable when varus and valgus stresses were applied, was able to reach full extension, and the patella tracked centrally without lat-eral subluxation or tilt. The trial components were removed

Figure 3. Intra-operative photograph of the knee prior to incision.

Figure 4. Intra-operative view after medial arthrotomy and inser-tion of Steinman Pins into the residual tibia.

Figure 5. Intra-operative AP fluoroscopy view demonstrating posi-tion of the tibial cutting guide.

Figure 6. Intra-operative lateral fluoroscopy view demonstrating position of the tibial cutting. Note a saw blade was placed in the cutting slot to verify correct tibial posterior slope prior to making tibial cut.

50


therapy. The patient mobilized immediately with Aspirin 325 milligrams twice daily for deep venous thrombosis prophylax-is. The patient was discharged to home on post-operative day four with no complications or events.

The patient was evaluated at 13 days post-op in the out-patient clinic and staples were removed from the operative incision site. The patient’s weight bearing on the residual limb was progressed to as tolerated with use of his prosthetic leg as tolerated. At 10 weeks post-operatively no wound compli-cations had been encountered and the patient continued to progress with utilization of his prosthetic limb.

DISCUSSIONKnee osteoarthrosis ipsilateral to a transtibial amputation

is uncommon. It has been previously reported that arthritis is more common in the contralateral limb.5-7 Previous reports have demonstrated successful outcomes for TKA in patients with ipsilateral BKA.2-4 A more recent publication reported good results in a patient with bilateral congenital amputations undergoing bilateral TKA for osteoarthrosis.8 Based on the available reports we felt that TKA was a reasonable surgical option for the patient presented in our report.

The current patient presented a unique challenge even for patients with ipsilateral transtibial amputation. This patient had a severely shortened residual tibia measuring 4.7 cm in length, which is substantially shorter than those previously reported. The cases previously referenced had residual tibia lengths measuring 17 cm, 12.5 cm, and 17 cm.2,3,4,9

Crawford and Coleman described the use of a sterile poly-styrene box intra-operatively in order to maintain knee flexion while intramedullary tibial alignment rod was used to align the tibial cutting guide.3 Konstantakos et al’s report described the construction of a modified prosthesis that was sterilized and brought into the operative field and then used as a distal landmark for an extramedullary alignment guide.4 We faced significant limitations with respect to these techniques sec-ondary to the extremely shortened residual tibia. By placing Steinman pins in the patient’s residual tibia we were able to ex-tend the lever arm and gain control of the tibia. With the use of intra-operative fluoroscopy and gap balancing technique, the tibia cutting guide was positioned in order to ensure equal collateral ligamentous tension and thus tibial alignment. We chose a four pegged tibial component as the remaining tibial bone was unlikely to support and completely contain a keeled tibia base plate. Post-operative radiographs are shown in Fig-ures 7 and 8.

In summary, we have presented an inexpensive and time efficient technique for aligning a TKA in a patient with an ip-silateral BKA. By allowing collateral ligamentous tension to guide the proximal tibia coronal resection and utilizing flu-oroscopy to guide posterior tibial slope, this method can be

intra-articular drain was placed and a layered closure was per-formed. The patient was recovered in the post-operative anes-thesia care unit and admitted for standard post-operative care.

Post-operative activity modifications included non-weight-bearing on the residual limb with free active range of motion as tolerated. No bracing or splinting was utilized post-opera-tively. The shortened residual tibia limited the passive range of motion rehabilitation that could be performed with physical

Figure 7. Post-operative standing AP radiograph of the bilateral knees taken on POD#13.

Figure 8. Post-operative standing lateral radiograph of the left knee taken on POD#13.

51


5. Burke MJ, Roman V, Wright V. Bone and joint changes in lower limb amputees. Ann Rheum Dis. 1978;37(3):252-254.6. Nolan L, Lees A. The functional demands on the intact limb during walking for active trans-femoral and trans-tibial amputees. Prosthet Orthot Int. 2000;24(2):117-125.7. Norvell DC, Czerniecki JM, Reiber GE, Maynard C, Pecoraro JA, Weiss NS. The prevalence of knee pain and symptomatic knee osteoarthritis among veteran traumatic amputees and nonamputees. Arch Phys Med Rehabil. 2005;86(3):487-493.8. Dudhniwala AG, Singh S, Morgan-Jones R. Bilateral total knee replacement in a congenital amputee with bilateral fibular deficien-cy. Knee. 2011 Dec;18(6):488-90. doi: 10.1016/j.knee.2010.08.013. Epub 2010 Sep 21.9. Karam MD, Willey M, Shurr DG. Total knee replacement in pa-tients with below-knee amputation. Iowa Orthop J. 2010;30:150-2.

reproduced without requiring additional instruments. Unlike previous reported techniques3,4 for addressing the intra-oper-ative challenges of performing TKA with an ipsilateral BKA, this technique is not limited by a shortened residual tibia from a proximal transtibial amputation.

REFERENCES:

1. Ritter M, Faris P, Keating E, Meding J. Postoper- ative alignment of total knee replacement. Its effect on survival. Clin Orthop Relat Res. 1994 Feb;(299):153-6.2. Pasquina PF, Dahl E. Total knee replacement in an amputee pa-tient: a case report. Arch Phys Med Rehabil. 2000 Jun;81(6):824-6.3. Crawford JR, Coleman N. Total knee arthroplasty in a below-knee amputee. J Arthroplasty. 2003 Aug;18(5):662-5.4. Konstantakos EK, Finnan RP, Krishnamurthy AB. Eight-year follow-up of total knee arthroplasty in a patient with an ipsilater-al below-knee amputation. Am J Orthop (Belle Mead NJ). 2008 Oct;37(10):528-30.

The roots of the Dartmouth Hitchcock Medical Center (DHMC) orthopaedic residency training program date back to its founding father, Dr. O. Sherwin Staples, (Figure 1) who came to Mary Hitchcock Memorial Hospital (MHMH) in 1946 from Harvard/Massachusetts General Hospital. He was the first orthopaedic surgeon in the state of New Hampshire and was joined shortly thereafter by Dr. Stuart Russell from Michigan State University in 1948. The final two “founding” orthopaedists were Dr. Robert Shoemaker from the University of Pennsylvania in 1955 and Dr. Leland Hall from the Univer-sity of Minnesota in 1963.

Dr. Staples’ application to the American Board of Ortho-

paedic Surgery (ABOS) for a residency training program be-gan in 1949. He was unsuccessful in his first two attempts. Ultimately, the ABOS approved a residency training program at Mary Hitchcock Memorial Hospital in 1957 as long as pe-diatric orthopaedics was taught elsewhere. The first resident, Dr. Robert Orth, started his three-year orthopaedic residency in 1957, spending the first year at MHMH, the second year at the White River Junction VA Hospital and the third year at the Newington Children’s Hospital in Connecticut. The residency training continued as a three-year program (preceded by two years of general surgery) with one resident per year until 1970. Drs. Roger Hansen and Howard Black (Figure 2) were the first residents to be admitted as a pair. This same year, the residen-

A History of the Dartmouth Hitchcock Medical Center Orthopaedic Residency Training Program

Charles F. Carr MD

Figure 1. Dr. Staples at bedside; 1946.

53


cy program director position was handed from Dr. Staples to Dr. Hall (Figure 3) who accepted reluctantly. The landmark procedure of the first total hip replacement at MHMH was performed in April of 1971. One year later, the first total knee replacement was performed. Two longstanding members of the section of orthopaedics, Drs. Michael Mayor and Robert Porter arrived to increase the number of attending physicians to five.

The next significant change to the residency program oc-curred in 1980 when the length of rotations at the VA Hospi-tal and Newington Children’s Hospital were shortened to six months each. This allowed for four residents to always be at MHMH while the other two were offsite. 1984 saw perhaps the most significant change that has occurred in orthopaedic training when the ABOS increased the required years of de-

over the previous fifteen years. After thirty-three years of the fifty-seven year history of the Dartmouth-Hitchcock Residen-cy Training Program, there had been forty-four residents who had started and completed the program.

October 5, 1991 was a historical day for Dartmouth-Hitch-cock Medical Center as the entire institution moved from the 100 year old campus in Hanover to a new million square foot complex, four miles away in Lebanon (Figure 4). The Spine Center at DHMC opened in 1997 and created an innovative, comprehensive, multispecialty approach to the care of spine patients. The development was under the guidance of Dr. James Weinstein who had joined the clinical staff of DHMC orthopaedics in 1996 after completing a master’s degree at the Center for Evaluative Clinical Sciences (CECS) at Dartmouth Medical School. This program would soon become a core ele-

Figure 2. Orthopaedic surgery residents; 1970-1971.

Figure 3. Dr. Hall at bedside; 1967.

voted orthopaedic surgery training from three to four. The final three-year ortho-paedic class and the first four-year orthopaedic class of residents were selected to begin training in 1984. By 1986, Dr. Hall turned over the reins of the resi-dency program to Dr. Phil Bernini who stayed in this position until 1988 when he assumed the chairmanship of the section. Dr. Jim Mur-phy assumed the position of program director at that time. By 1990, the attending staff members had swelled to eight with the additions of Drs. Shirreffs, Bernini, Murphy, Nutting, and Carr

54


thopaedics, was introduced. Several years prior to this change (1994), the section had made the decision to join the National Residency Match Program, selecting residents directly out of medical school, making Dartmouth one of the last programs in the country to make this change. 1998 also was a year of change in leadership of the residency program, as Dr. Jim Murphy stepped down to pursue other administrative duties and Dr. Charlie Carr took on the challenges of residency pro-gram director. The Spine Patient Outcomes Research Trial (SPORT), a multicenter study based out of DHMC, designed to address the need for high-quality, prospectively collected data on the operative and non-operative treatment of spinal conditions began in 1999. This project allowed for the initi-ation of many research projects by our orthopaedic residents and brought DHMC orthopaedics national and international recognition. In 2001, our program added a third resident po-sition. The approval of the “extra” resident was coupled with our new Orthopaedic Physician Leadership Training Program at Dartmouth and completion of a sixth year, obtaining a mas-ter’s degree at the CECS focusing on evidence based medicine and health care policy. The first resident admitted to the new program was in 2001. The chairmanship of the section of or-thopaedics changed hands in 2002. Dr. Phil Bernini stepped down from the position after serving for fifteen years. Dr. James Weinstein assumed the role as section chair in July 2002

ment of the Dartmouth Orthopaedic Training Program. Our first residents to start and complete the CECS program (Fig-ure 5) and receive their master’s degrees during their five-year residency were Drs. Scott Sporer and Randall Schultz in 2001 and 2002.

1998 saw a change in the PGY-1 intern year made by the ABOS. A mandate to complete month long rotations on vari-ous subspecialty services, including up to three months in or-

Figure 6. Dr. James N. Weinstein replaces Dr. Jack Wennberg as Di-rector of CECS in 2007

Figure 4. Dartmouth Hitchcock Medical Center shortly after the move.

55


educational program is robust with conferences held every morning including a two year cycle didactic core curriculum taught by faculty, grand rounds with visiting lecturers, indi-cations conference, pathology conference, research update conference, anatomy prosections and other various confer-ences throughout the year. The most recent educational offer-ing demonstrating the transition to an earlier, more focused experience in orthopaedics provided to our PGY-1 residents is a bio-skills course. PGY-1 residents are provided a weekly hands-on surgical simulation experience using simulators, or-thopaedic surgical equipment with sawbones, and cadavers to perform surgical approaches. (Figure 8)

The history and evolution of the orthopaedic training program at DHMC has “mirrored” several other preeminent programs across the country. We feel we deserve to be includ-ed amongst the best orthopaedic residency programs as the products of our training (many of you) are proof of that.

admitted with four residents per class graduated in 2009 and 2010. The department’s most recent change in leadership also occurred in 2009 when Dr. Weinstein (Figure 6) took over the role as Director of The Dartmouth Institute relinquishing the role of Orthopaedic Department chairman to Dr. Sohail Mir-za, who had arrived from the University of Washington in the previous year as the inaugural vice-chair of the department.

Over the past twelve years the Dartmouth Orthopaedic Residency Program has flourished under the leadership of Drs. Weinstein and Mirza. They have championed academic and educational pursuits allowing the program to innovate in many areas. (Figure 7) Presently, our twenty two residents (20 on clinical rotations and two in the TDI) rotate through six subspecialty teams at DHMC, spend three months in ortho-paedic oncology at Beth-Israel Deaconness Medical Center in Boston with Dr. Mark Gebhardt, rotate through a three month block in pediatric orthopaedics at Children’s Hospital in Bos-ton, and complete a recently “renewed” rotation in general orthopaedics at the White River Junction VA Hospital. Our

Figure 8. Bioskills Lab in Simulation Center.

and his first accomplishment was to successfully gain institutional acceptance for orthopaedic sur-gery to become its own depart-ment. He also led a restructur-ing of the new department and residency program into clinical and academic programs that were subspecialty team-based.

As our department contin-ued to grow, so did our residency program, which added a fourth resident per year in 2004. We chose to offer two positions as a five-year clinical tract and the two other positions as a six-year clinical + CECS experience tract. Through an NIH educational grant we have been able to main-tain funding for two residents per year in the masters degree pro-gram given through the renamed Dartmouth Institute for Health Policy and Clinical Practice (TDI). The first group of trainees

the Dartmouth Orthopaedic Department into what it has be-come today, though his humility prevents him from taking such credit. Seeing Dr. Hall’s potential and ability, Dr. Staples soon “pushed” Dr. Hall into the position of residency direc-tor. Dr. Hall describes the first resident he worked with as a “hard-working boy,” and he ensured this would remain the character of the department. Taking call each Friday night, every third weekend, and another day per week, Dr. Hall saw his practice grow along with the volume of patients seeking care in the department, and as a result the department slowly grew. A second resident was soon added, as were other pillars of Dartmouth Orthopaedics, Dr. Mayor in 1971 and Dr. Porter in 1972.

All in all, Dr. Hall trained 52 residents in his tenure as head of the department, many of whom stayed on as staff. The first such resident was Dr. Philip Bernini, who retired from oper-ating this year. Dr. Hall dismisses the idea that he was crucial to resident learning: “the residency essentially ran itself -there were not much didactics, but the residents were a group of go-getters.” However, his closest peers dismiss such a falsity.

Dr. Hall’s practice spanned what he describes as the “glory times in medicine. There were no quotas and time with pa-tients was unlimited.” Total hip arthroplasty began to rise in popularity in the early 1970’s in the US. The hospital, seeing the early success of this new procedure, sent Dr. Hall to En-gland where he spent a week with Sir John Charnley to learn the technique. When he returned, his luggage included six acetabular components and six femoral components that he would soon implant in patients. From there “the first year was gangbusters,” recalls Dr. Hall. Total knee arthroplasty’s rise ensued, and soon arthroplasty made up a significant portion of Dr. Hall’s practice.

He finished operating and taking call in 1995, then retired from Dartmouth Hitchcock in 2002. He’s had some time to re-flect on a successful career since then. Dr. Hall led a balanced life, and looked for this trait in those he hired as residents and staff. He would often ski two afternoons a week at the Dart-mouth Skiway, learned woodworking and spent time making and fixing furniture, and with the help of his lovely wife, Mau-reen, grew a family of four children during and after residency. He did admit that Mrs. Hall deserves all the credit for raising their kids. When asked what advice he would give to young orthopaedic surgeons the answer came more in what was not said than what was, as his confident humility is enviable. Dr. Hall attributes much of his own success to those around him, and said having Dr. Staples to learn from early in his practice was invaluable. While he understands some prefer indepen-

Level V EvidenceTimothy J. Lin MD

Dr. Hall

Dr. Peter Wesley Hall was born on November 2nd, 1928, in Forest Grove, Oregon, 15 miles west of Portland. He traveled to the Midwest for his rotating internship at Minneapolis Gen-eral Hospital, where he was exposed to one-month rotations in different services, including Orthopaedics, OB/Gyn, and Neu-rosurgery. Due to a delay in pursuing a stint in the Air Force, Dr. Hall spent one year in general practice after his internship back in Oregon. Though he requested Europe as a destination, high demand forced him to Korea where he spent a year as a flight surgeon in 1956. On the Kunsan air force base on the western coast of South Korea Dr. Hall practiced general med-icine and performed physicals for recruits. He left the service and returned to Salem, OR, where he chose the direction of his future career, but not before he met his future wife, Mau-reen, on the ski slopes in Turin, NY. He soon would return to Minneapolis General Hospital for five years of orthopaedics residency, and graduated in 1962.

Mary Hitchcock Memorial hospital beckoned from the east coast, after one of its three orthopaedic attendings had recently left for Rochester, NY. The two remaining surgeons, Dr. Russell and Dr. Staples, were growing a young Orthopae-dic department, that was not in existence several years prior. They looked to the Midwest where they found the future of the department. Dr. Hall moved nearly 1,400 miles across the country to settle in the Upper Valley area of NH, and joined the nascent Dartmouth Orthopaedics department.

Dr. Hall has fond and unwavering memories of his new surroundings, such as the bygone basement of Mary Hitch-cock hospital, built in 1892, connected by tunnels made of stone, or the natural beauty of the mountains and the valley, whose charm has never let him leave. He also remembers his first month on the job. Dr. Hall recalls that Hitchcock was the “only thing close to a tertiary care center between Burlington and Boston at the time.” Left alone with his partners away at a conference, Dr. Hall cared for 26 tibial fractures in January of 1963, most of which were the result of skiing accidents. He soon learned to enjoy trauma patients, many falling victim to the diverse outdoor recreational activities the twin-states of Vermont and New Hampshire offer. What he loved most about trauma was having enough time with patients to devel-op a bond while often seeing the final result of their treatment in a short period of time.

By all accounts Dr. Hall is a pleasant, humorous, caring, and dedicated individual. There is no doubt that he poured significant amounts of time and energy into helping to mold

57


air force as a flight surgeon, on a tactical air base in Glasgow, Montana, and helped in the operating room when needed. He enjoyed taking care of “the jocks with orthopaedic problems” and enjoyed the simplicity of dealing with one body region at a time, confirming his choice of Orthopaedics. In the Air Force for two years, more than learning medicine, Dr. Por-ter learned much in his late twenties as he flew on supersonic fighter jets and B-52’s, dealt with nuclear weaponry, and sim-ulated bomb runs in Guam.

Dr. Porter recalls the lack of fellowships upon finishing his orthopaedic residency, and decided to go into academic practice at Syracuse University. A desire for more patient care, less academics, and a rural landscape led Dr. Porter to look into Dartmouth Hitchcock medical center. A ski trip to Stowe with his daughter added more attraction, and Dr. Porter made the transition to DHMC after a transition year at the Universi-ty of Sheffield in Yorkshire, England. Prior to returning state-side Dr. Porter received some specialty training on the Spina Bifida team, and also refined his English accent, which he was able to fake well. He arrived at DHMC in 1972 and stayed there for a successful career.

Tinted by grueling winters from 1972-1977 and a share of call only fit for a junior attending, Dr. Porter’s first few years at DHMC were no cakewalk. Working with Drs. Hall, Russell, and Staples, as well as a slightly more junior attending, Dr. Mayor, Dr. Porter soon established himself as a valuable ad-dition to the Dartmouth Orthopaedic department. Not only treating one another, these founding fathers of Dartmouth Orthopaedics cared for each other’s children and formed a tight-knit group that has since grown in size, with no sacrifice of camaraderie. Dr. Porter fondly speaks of barbeques, staff versus resident volleyball games, and basketball contests, de-spite one such match that saw his chin meet a resident’s elbow, leaving him unable to open his mouth or talk.

Dr. Porter recalls Dr. Russell mentoring him as he became involved with the NH Board of Registration in Medicine. Seeking a side of medicine beyond orthopaedics, he became involved in licensure and discipline, and saw this as an oppor-tunity to help colleagues through tough times. He then joined the Federation of State Medical Boards, was on the nation-al board of directors, and helped institute the standardized patient program in all ACGME accredited medical schools. While Dr. Porter found these activities rewarding, he strong-ly advocates “following one’s bliss” rather than rushing to get involved. While running hearings for the NH Board of Med-icine, Dr. Porter observed that misguided aspirations, such as using financial reward as motivation, didn’t often pay off.

The theme of mentorship was clear in speaking with Dr. Porter. He has undying gratitude for those mentors that shaped his career, and was appreciative of the opportunity to give back to young physicians as a mentor himself. Today, he enjoys returning to Hanover for “Golf Day” and the Chief

dent practice, he suggests that continually learning techniques and tips from partners makes you a better surgeon. He also placed emphasis on spending time with family, and preventing oneself from becoming enveloped by the narrow blanket of a demanding career. When choosing residents and partners he thought would be successful, he “looked for people with broad interests outside of medicine” and was notorious for being untrusting of the match in favor of gut instinct. While none would question Dr. Hall’s surgical abilities, it is the culture, now engrained in the Dartmouth Orthopaedic Community, of hard work, dedication to patients and colleagues, and a sense of duty to one’s family that will remain his lasting legacy.

Dr. Porter

Dr. Robert E. Porter was born and raised in small-town Wisconsin to two educators. His father was a teacher and his mother was a music professor at Beloit, a small liberal arts college. Athletics helped shape Dr. Porter’s childhood, from soccer in grade school to becoming a 7-Letter athlete in high school, excelling in football, basketball, and track, as a pole-vaulter. At age 17 Dr. Porter was honored with a scholarship from the MIT club in Chicago, which afforded him a summer at MIT to study engineering. He remembers being dropped off by his mother at a Cambridge YMCA, left to manage alone in a new, big city, prior to returning to the Midwest to attend Beloit. There he majored in biology and minored in history, but MIT left him with a continued interest in engineering. Under the guidance of a classmate’s father, the chair of the biology department, who was an important men-tor, Dr. Porter became interested in medicine and orthopae-dics. Glimpses into the medical field cultivated his early love of medicine. As an orderly in a local hospital he remembers emptying bedpans and performing other menial tasks, while “peeking in on surgeries as much as possible.”

Having graduated from Beloit College in 1901, and then Johns Hopkins Medical School, Dr. Porter’s grandfather was a physician from the old school – he delivered his grandson, performed tonsillectomies, and set broken bones. In his grandfather’s footsteps and along with five other Beloit class-mates, Dr. Porter attended medical school at the University of Chicago. Looking back he asserts that medicine is a calling, not a second choice. He remembers reading books about be-ing a doctor during high school and college and marveling at the opportunity to bring satisfaction and happiness to pa-tients by taking care of their problems and returning them to functional lives. It’s with the passion of a brand new medical student that Dr. Porter speaks of a profession from which he retired several years ago.

While internal medicine seemed to be his initial choice of specialty, delivering babies in the inner city later piqued a brief interest in Obstetrics. Ultimately he felt orthopaedics matched best with his personality and skills, and he was off to begin a surgical internship at Iowa. He spent some time in the

58


Resident roast and graduation each June, to meet new resi-dents and catch up with former colleagues, and derives the most satisfaction from seeing former residents returning as attendings. He also recently returned to a track meet at Beloit College where he volunteered, managing the pole vault pit.

Backing up his words with his actions, Dr. Porter echoes Dr. Hall in encouraging today’s residents and young attend-ings to strive for a balance of life and career. Far from the jad-ed calls of clichéd, surly surgeons wishing a House-of-God-like misery upon all new interns, Dr. Porter urges us to fight the internal demands we place on ourselves in order to strike such a balance. He emphasized family as most important, and cautions that he never regrets the instances he chose to spend time with his family, rather than work.

Evidenced by the strong sense of mentorship permeating the department, the varied interests of the staff and residents, and the relationship we have with Dartmouth athletics that Dr. Porter established, his life and career provide us with a hard act to follow.

One of the major criticisms of surgical skills laboratories for surgical training has been a paucity of objective criteria for evaluating performance. It has proven even harder to correlate this performance in a lab setting to performance in the op-erating room. In order to tackle this deficit, several research projects are underway in order to develop objective scoring systems of performance on some of the simulated tasks. Addi-tionally, the use of video-assisted feedback with Google Glass® is also being explored to bridge the gap between performance in the simulation lab and the operating room.

In the changing environment of orthopedic residency ed-ucation it seems as though simulation training will play an increasingly important role. With the development of a struc-tured surgical skills curriculum and several research projects relating to objectively measuring performance on simulated tasks, we are excited to be at the forefront of a new paradigm in surgical training.

REFERENCES

1. Atesok K, Mabrey JD, Jazrawi LM, Egol KA: Surgical simulation in orthopedic skills training. J AM Acad Orthop Surg 2012;20(7):410-4222. Karam MD, Pedowitz RA, Mevis H, Marsh JL: Surgical skills labo-ratories in orthopaedic surgery residency training: Results of a survey. J Bone Joint Surg Am3. Karam MD, Westerlind B, Anderson DD, Marsh JL: Development of an orthopedic surgical skills curriculum for post-graduate year one resident learners – the University of Iowa experience. Iowa Orthope-dic J 2013;33:178-84.4. Yehyawi, Karam MD, Brown TD, Anderson DD: A simulation trainer for complex articular fracture surgery. J Bone Joint Surg Am 2013 Jul 3:95(13)

Development of a Surgical Skills Curriculum for DHMC Orthopedic Surgery Residents

Rowan J. Michael MD and Dipak B. Ramkumar MD

Over the past several years, surgical simulation has come to the forefront of residency education. The original model of surgical residency developed by William Halsted was based on an apprenticeship pattern. With greater restrictions on resi-dent work hours, an emphasis on improving operating room efficiency and an increasing complexity of surgical cases, reli-ance on pure apprenticeship within the operating room may no longer be feasible.

Simulation training has proven invaluable in the areas of flight and military training. In these settings pilots are able to practice in a controlled environment so that they are comfort-able landing in an unexpected emergent situation. Within gen-eral surgery, simulation trainers have also been used for some time and have successfully been shown to improve perfor-mance within the operating room. Most orthopedic surgery training programs have been slow to adopt a formal surgical skills curriculum as a part of residency education; however, interest in them has grown. A recent survey demonstrated that 80% of orthopedic residency program directors and 86% of residents believed a laboratory based surgical skills curric-ulum should be a part of orthopedic residency training. The ABOS mandated development of a surgical skills curriculum for PGY-1 interns starting in 2012.

This year, under the mentorship of Dr. Marcus Coe and Dr. Charles Carr, the PGY-1 class completed the first dedicated orthopedic surgical skills program at Dartmouth-Hitchcock. The curriculum was largely based on the ABOS Surgical Skills Modules for PGY-1 residents, the University of Toronto Com-petency Based Curriculum workshop and the The ACGME Orthopaedic Milestone’s Project. This curriculum included topics essential to the core orthopedic fund of knowledge for junior residents, such as traction pin placement, compartment syndrome diagnosis and treatment (using a unique Sawbones model developed for this purpose) basic arthroscopy skills, casting/splinting and sterile operating room technique.

Additionally, the PGY-1 class participated in an eight-week anatomy curriculum, aimed to teach commonly utilized orthopedic surgical approaches on cadavers. Most of these sessions were lead by the PGY-1 class with appropriate faculty supervision and support. The sessions were held once weekly, for a three-hour period, during protected resident education block time, free from clinical responsibilities.

that it will disrupt the education of the local Orthopaedic res-idents.

Although unable to travel with Dr. Nutting and Dr. Sparks to Haiti, Dartmouth Orthopaedic residents have become more involved in international work. Ana Mata-Fink, PGY4, spent 2 weeks in Managua, Nicaragua in June 2013 with Orthopaedics Overseas. Orthopaedics Overseas is based on an education and sustainability model, sending volunteers to established sites repeatedly. While in Nicaragua, Ana worked with the res-idents at Hospital Lenin Fonseca (the public trauma hospital in Managua) in the OR and in the clinic. She reviewed trauma and ED care and studied techniques with the residents.

Katie Fuchs, PGY3, will be going to Nieva, Columbia for 1 week in June with Heal the Children. She will be joining Dr. Snyder and the pediatric orthopaedic fellows from Boston Children’s Hospital. She plans to establish a DDH education program to teach new swaddling techniques to the local com-munity. Katie will also work in the operating room with Dr. Snyder and Dr. Fajardo to bring operative orthopaedic care to Nieva.

International Orthopaedics at DartmouthAna Mata-Fink MD

There has been a growing interest in international work among residents in the Department of Orthopaedic Surgery, following the lead of John Nutting, MD and Michael Sparks, MD.

Since 2011, Dr. Nutting and Dr. Sparks have been travel-ing yearly to Haiti with Partners in Health. They have been to Cange and Hinche, performing urgent surgeries and train-ing two local residents. Most recently in February 2014, Dr. Nutting went to Mirebalais, where there is a new clinic, oper-ative, inpatient, and emergency treatment facility. While the facilities are new and there is a large case mix, there remains inadequate orthopaedic coverage and equipment issues, such as no functional C-arm and insufficient inventory. With the new facility, the hope is that the focus can now be transferred to orthopaedic training and education.

Dr. Nutting has also become involved with designing a new operative facility at L’Hospital de St. Boniface in Fond des Blancs, Haiti. As this site is constructed, there is a possibility that residents from Dartmouth will be able to travel with Dr. Nutting to Haiti. Currently, Partners in Health does not allow American residents to travel to Haiti with them out of concern

by example. His skillset went far beyond arthroplasty and he was recognized as an expert in multiple conditions including hemophilia, myelomeningocele, coccydynia and the treatment of spine conditions. His leadership roles spanned far beyond the department including roles in the New Hampshire Medi-cal Society, New Hampshire Bar Association, American Board of Orthopaedic Surgery, AOA and Dartmouth Hitchcock. Be-yond orthopaedics, Dr. Bernini’s love for art and culture makes him a true renaissance man.

Dr. Shirreffs graduated from Colgate University with a Bachelor of Arts prior to attending medical school at Case Western Reserve University in Cleveland, Ohio, not far from his birthplace of Columbus. He later finished his residency at Case Western after completing his internship at the University of Washington in Seattle. Before joining Dartmouth Hitch-cock as an Assistant Professor, Dr. Shirreffs served his country in the United States Navy at the National Naval Medical Cen-ter in Bethesda, Maryland. After completing his military ser-vice he joined the staff at Dartmouth and had a diverse Ortho-paedic practice with interests ranging from spine surgery and pediatric disorders to disorders of the foot and ankle. Towards the end of his career Dr. Shirreffs saw his practice morph into one dedicated to treating osteoarthritis of the knee and he per-formed thousands of knee replacements.

Anyone who has worked with Dr. Bernini in clinic knows that no stone is left unturned when he takes a medical history, which is performed with the bedside manner of Sir William Osler. He is also one of the few orthopaedic surgeons who still carry a stethoscope in his white coat. He does this partly on principle, making sure his residents remember that they are physicians first and foremost, and not solely technicians. The truth of the matter is that Dr. Bernini treats his stethoscope with the same regard as any other tool, and as with any other tool, he did not hesitate to use it. He knew the act of placing one’s hands on a patient was, at times, more important than the surgery itself and took great pride in taking care of his pa-tients regardless of the aliment.

Dr. Shirreffs was a true general orthopaedic surgeon for much of his career. He treated a multitude of orthopaedic problems while in the Navy and this continued once in prac-tice. Whether he was performing a complex foot surgery or a Laterjet procedure at the VA, he was always a pleasure to work with. As his career matured Dr. Shirreffs commonly found himself on the opposite side of the operating table from Dr. Bernini during simultaneous, bilateral total knee replace-ments. These cases were intimidating to the junior resident who was trying to follow each and every step, but an absolute

It is with great honor and privilege that I have the oppor-tunity to pay tribute to the careers of doctors Philip Bernini and Thomas Shirreffs. Combined they have dedicated almost eight decades to patient care and resident education, training multiple generations of current and future orthopaedic sur-geons under the Dartmouth banner. This year they will both retire from Dartmouth-Hitchcock’s operating rooms, leaving an enormous legacy behind.

These men each have left a mark on the Dartmouth Hitchcock Department of Orthopaedics that will echo for years to come. On an individual level each man will be remembered for the many ways he has impacted orthopaedic care, not only on the local level, but also in the region as a whole. They have set the highest standard of patient care, exemplifying the Dart-mouth Hitchcock mission by providing every patient the best care, in the right place, at the right time, every time. Trainees have been taught that being a good doctor is paramount and that taking a medical history encompasses more than just in-quiring about a painful arthritic joint. On a daily basis the “art” of medicine was taught by example with great precision.

Dr. Bernini and Dr. Shirreffs have both been predominant forces in the Arthroplasty division at Dartmouth Hitchcock Medical Center (DHMC). Between the two, they’ve replaced greater than ten thousand joints, which is an impressive feat. The joint replacements performed were in grateful and pro-foundly loyal patients (regardless of how long they may have had to wait to be seen). Some expressed their thanks through tears of joy, while others offered jugs of homemade maple syr-up. What many of these patients and those that have worked alongside them may not have realized is how distinguished a career each of these two men had beyond joint replacement.

After obtaining a degree in Psychology from Fordham University in his hometown, New York City, Dr. Bernini trav-eled to Philadelphia where he completed medical school at Jefferson Medical College. He then moved north to the Up-per Valley and began his internship in general surgery at Dart-mouth Hitchcock. After completing a second year of general surgery training, as was required at the time, he began his or-thopaedic residency at Dartmouth and ended it at Newing-ton Children’s hospital in Connecticut after spending a year learning pediatric orthopaedics. After residency he completed a yearlong spine fellowship at the University of Pennsylvania’s Pennsylvania Hospital. Upon completion of fellowship he re-turned to Dartmouth as an Assistant professor. Over his 35 year career on staff at DHMC he was promoted to Associate Professor and later to Full Professor. Dr. Bernini spent rough-ly 13 years as Chairman of the department where he truly led

A Tribute to Dr. Philip Bernini and Dr. Thomas ShirreffsWayne M. Moschetti MD MS

62


program. As a former trainee of theirs, I find it hard to believe the day has come for these two men to hand in their gloves, but I count myself among the lucky to have been able to learn from them, because despite their physical absence from the operating rooms their legacy will continue in all those they have trained.

Dr. Moschetti trained under Dr. Bernini and Dr. Shirreffs from 2008-2013 and graduated from the Dartmouth Orthopae-dic Surgery residency in 2013.

delight for the senior resident - who typically had the honor of being on the left side of the table with Dr. Shirreffs. In the midst of the chaos, Dr. Shirreffs would provide valuable in-sight on the technical aspects of balancing a total knee. As the wound was being closed, you would be lucky to hear stories from his days in training. One would learn about the times when he carried resterilizable needles on his belt buckle for drawing his own daily labs, which he then reviewed under the microscope, himself, something unimaginable to current res-idents. He also shared many stories from his military days, when he served in the Navy and flew in military aircraft. His non-medical advice and insight was just as useful, such as how to develop your sons into collegiate and professional hockey players. The truth is, whatever the topic of conversation, it was always a joy to be working with such a humble man who had such an acclaimed career.

Dr. Bernini and Dr. Shirreffs have each had an impact on orthopaedic care in New Hampshire and beyond. Their dedication to patient care and resident education is unparal-leled, and they have set a strong precedent for this training

Orthopaedic Teaching AwardsCharles F. Carr MD

The Dartmouth Orthopaedic Surgery Training Program has long been considered one of the premiere teaching pro-grams at Dartmouth-Hitchcock Medical Center. That distinc-tion is brought about by committed faculty and residents who deserve to be recognized for their tireless efforts. As such, it seemed well overdue that our best educators should be hon-ored with an annual award. 2013 marked the first year of both a faculty and resident teaching awards determined by a vote of the residents for each award. The faculty award has been named in honor of our most notable, devoted educator over the past half century and is called “The Philip M. Bernini Fac-ulty Teaching Award.” It is given from the orthopaedic resi-

dents to a faculty member for excellence in teaching and men-toring. Appropriately, the first recipient of the award as voted upon by the residents was Dr. Phil Bernini.

The resident teacher award can be given to any level res-ident and is awarded by the residents to the “Outstanding Resident Teacher of the Year.” The inaugural recipient of the award was one of our chief residents, Dr. Wayne Moschetti. Dr. Moschetti is completing an arthroplasty fellowship at the Brigham and Women’s Hospital in Boston and will be return-ing to DHMC in the fall to join our attending staff. Congratu-lations to our first 2 honorees.

Freddie Fu AwardCharity A. Jacobs MD

****

year, the award recipient is announced at the Annual Program Directors’ Retreat. This year, Dr. Charlie Carr from the De-partment of Orthopaedic Surgery was recognized for his con-tributions.

Dr. Carr has served as program director for the orthopae-dic surgery residency program for more than fourteen years. His tenure has been instrumental in developing a training pro-gram that is nationally recognized as one of the best. One res-ident nomination specifically appreciated Dr. Carr’s mentor-ship by stating, “Dr. Carr motivates me to be a better person, husband, father, and physician.” Both current residents and alumni have all experienced Dr. Carr’s commitment to excel-lence in education and we are all thankful to have benefited from his mentorship. Congratulations, Dr. Carr!

DHMC Courage to Teach AwardDipak R. Ramkumar MD

Program directors routinely handle multiple challenges while administering a residency or fellowship program. In 2005, Dartmouth-Hitchcock Medical Center established the “Courage to Teach Award”, a prestigious recognition bestowed upon a program director who finds innovative ways to teach residents to provide high quality patient care, learn research techniques, model professionalism and regularly champion the academic ethos of a program. Nominations are solicited from all current residents and fellows at Dartmouth-Hitch-cock, with the goal of recognizing one program director who demonstrates effectiveness and dedication in teaching, elicits excitement surrounding education, functions as a strong role model, demonstrates behaviors that are value-based and high-ly principled and incorporates a sense of their authentic self as well as a sense of humor while directing their program. Each

New Faculty

Marcus Coe joined the orthopaedics department in 2013. Dr. Coe graduated from Dartmouth College with a degree in English and Creative Writing in 2000. He taught English and coached swimming and baseball at a boarding school for two years prior to obtaining his MD at Yale. Dr. Coe completed his residency in orthopaedic surgery at Dartmouth Hitchcock in 2012, during which time he received an MS in Health Care Leadership from The Dartmouth Institute. Dr. Coe completed a fellowship in foot and ankle reconstruction at the University of British Columbia in 2013. Dr. Coe practices at Dartmouth Hitchcock and the White River Junction VA hospital. He specializes in general orthopaedics and foot and ankle recon-struction. He has an interest in residency education and runs the intern surgical skills course throughout the year.

Eric Henderson joined the Department of Orthopaedic Surgery in late 2012. He graduated from the University of Florida with a degree in English. He attended medical school at the University of South Florida where he also performed residency. He completed a musculoskeletal oncology fellow-ship at Massachusetts General Hospital in 2011, after which he spent a brief time in Italy at the Rizzoli Institute. Dr. Hender-son practices at Dartmouth-Hitchcock and the White River Junction VA Hospital. He specializes in orthopaedic oncology and general orthopaedics.

In 2013 the Dartmouth Orthopaedic Department was for-tunate to welcome Dr. Michelle Prince to the staff. This is a return to New England for Dr. Prince; she grew up in Maine where she graduated from Gould Academy. She remained in Maine at Bowdoin College before transferring to Smith Col-lege in western MA where she graduated cum laude. After working in labs in Boston and Los Angeles, Dr. Prince attend-ed Stritch School of Medicine of Loyola University, Illinois. She completed her residency in Orthopaedic Surgery at the University of Massachusetts Medical Center in Worcester, MA and was the recipient of the Dr. John J. Monahan award. She then moved to Georgia for a pediatric orthopaedic fellowship. Dr. Prince comes to New Hampshire from a private practice in Austin, Texas and Locum Tenens in Springfield, Illinois.

Clinically Dr. Prince’s interests include pediatric trauma and volunteerism. She served with Medecins Sans Frontières in Nigeria and is a trained US disaster responder. She is a mem-ber of several professional committees including the POSNA, the AAOS, and the Scoliosis Research Society.

Dr. Prince is married and has a two-year-old daughter and a newborn son.

MARCUS P. COE, MD, MS

ERIC R. HENDERSON, MD

MICHELLE M. PRINCE, MD

Welcome to the incoming Orthopaedic Interns

Daniel Austin grew up in Mechanicsburg, Pennsylvania. He majored in Biology at Williams College where he was a member of theTrack and Field Team. After graduation, Dan continued to pursue his passion for the discus throw and had the opportunity to compete in the 2008 Olympic Trials.

Before entering medical school, Dan worked as a fly fish-ing guide in Colorado and as a middle school science teacher in New York City as part of Teach for America. He attended medical school at the University of Pennsylvania. In his free time, Dan enjoys spending time outdoors with his wife, Juli-anne, and chocolate labrador, Mousse.

Matt DeWolf is from Pittsfield, MA. He went to Boston University for his undergraduate education and the Universi-ty of Massachusetts Medical School. His interests are working out, hiking, and he has completed 2 Tough Mudder races. He also enjoys cooking, traveling, and spending time with family and friends.

Kelly Esposito is from Wilmington, North Carolina. She grew up playing soccer and running cross country and plays the flute. She also worked as an ocean lifeguard for three sum-mers in Carolina Beach, North Carolina.

Kelly attended the University of North Carolina at Chapel Hill, where she majored in journalism and biology and stud-ied abroad for a semester in Puebla, Mexico. She played on the varsity soccer team for two years, which won an NCAA Division I National Championship her sophomore year. She continued on to medical school at UNC and also completed an MBA at UNC’s Kenan-Flagler Business School, making her a Triple Tar Heel. In her free time, she enjoys sports, the out-doors, cooking and traveling.

Samuel Kunkel is originally from Cincinnati, OH. He completed his undergraduate degree at the University of Chi-cago, and returned to Cincinnati to obtain a masters degree in physiology as well has his medical doctorate at the University of Cincinnati. Sam competed in wrestling during his youth and was a member of the varsity wrestling team at the Uni-versity of Chicago. His current interests outside of medicine include outdoor activities such as hiking and mountain biking, and he has an avid interest in history.

DANIEL C. AUSTIN, MD, MEd KELLY R. ESPOSITO, MD, MBA

MATTHEW C. DeWOLF, MD SAMUEL T. KUNKEL, MD, MS

Graduating Residents

SARA C. GRAVES, MD, MS

R. BRAD WASHBURN, MD

ADEWALE O. ADENIRAN, MD

GARRETT C. DAVIS, MD, MBA, MS

Dr. Graves graduated from Smith College and the Dart-mouth 12-college exchange program with a Bachelor of Arts in Biochemistry. She received a Doctorate of Medicine from the University of Southern California’s Keck School of Medicine. During residency, she received a Master’s of Science Degree from the Dartmouth Institute for Health Policy and Clinical Practice. After graduation, she will complete a one year Trauma fellowship at the University of Minnesota’s Regions Hospital in St. Paul, MN.

Dr. Adeniran graduated from The Jacksonville University with a Bachelor of Science in Biochemistry. He then attended Washington University in St. Louis School of Medicine where he served as class president, built lasting friendships and received his MD. After graduation, he looks forward to completing a fel-lowship in Spine Surgery at Texas Back Institute in Plano, TX.

Dr. Davis graduated from Brigham Young University with a BS in General Management. He obtained his MD from Dart-mouth Medical School. While earning his medical degree he also obtained his MBA from the Tuck School of Business at Dart-mouth. During his residency at Dartmouth -Hitchcock, he ob-tained an MS from The Dartmouth Institute for Health Policy and Clinical Practice. After graduation, he is planning to com-plete a one-year fellowship in Adult Reconstructive Surgery at the Rothman Institute at Thomas Jefferson University in Phila-

Dr. Washburn graduated from Wake Forest University with a Bachelors degree in Economics. After spending several years as a fly-fishing guide in Montana and as an innkeeper with his family in North Carolina, he obtained his MD from the Univer-sity of North Carolina at Chapel Hill. Following graduation, Dr. Washburn will complete a one year fellowship in Sports Medicine and Shoulder Reconstruction at the Steadman-Hawkins Clinic in Greenville, SC with Dr. Richard Hawkins.

Update on Recent Graduates

Dr Brabston graduated from Grove City College with a de-gree in philosophy and pre-medical studies. Following grad-uation, he worked as an admissions counselor for his alma mater before returning to Alabama to complete his Doctorate of Medicine. He continued his orthopaedic training at Dart-mouth Hitchcock Medical Center followed by a fellowship in Shoulder, Elbow and Sports Medicine at Columbia Presbyteri-an Medical Center in New York City. Upon completion of his fellowship, he will return to his home state with an academic appointment at the University of Alabama at Birmingham.

Jennie completed her undergraduate studies at Yale Uni-versity and did her medical training at University of Penn-sylvania. After graduating from the Dartmouth Orthopaedic Surgery residency in 2013, she returned to New Haven, where she is currently finishing a fellowship in Shoulder and Elbow Surgery at Yale New Haven Hospital. She plans to work in New England upon finishing her fellowship this summer.

Dr. Dwyer graduated from the College of the Holy Cross in Worcester, MA and received his medical degree from Tufts University. He finished his orthopaedic surgery residency at Dartmouth Hitchcock Medical Center in 2013. He joined Connecticut Valley Orthopaedics after graduation and he is practicing general orthopaedics in a small critical access hospital in Springfield Vermont. He has been working to build a general orthopaedic practice focusing on arthroplasty(shoulder, hip, and knee), arthroscopy(shoulder and knee), and fracture care. He has also been enjorying more free time with his wife and three children.

Dr. Moschetti graduated from the University of New Hampshire magna cum laude with a BA in Political Science. After working in healthcare technology in New York City he obtained his MD from Boston University School of Medicine where he graduated magna cum laude. While completing his residency at Dartmouth-Hitchcock, he obtained a Masters of Science from The Dartmouth Institute for Health Policy and Clinical Practice. He is currently completing a one-year fel-lowship in Adult Reconstructive Surgery at the Brigham and Women’s hospital in Boston, MA. After fellowship he plans to pursue an academic appointment and return to Dartmouth with an interest in primary knee and hip arthroplasty with an emphasis on the direct anterior approach, revision hip and knee arthroplasty, periprosthetic fracture management, and periprosthetic infections.

KEVIN W. DWYER, MD, MS WAYNE M. MOSCHETTI, MD, MS

E. WILL BRABSTON, MD JENNIE V. GARVER, MD

Faculty

William A. AbduSpine

James B. AmesSports

John-Erik BellShoulder & Elbow

Philip M. BerniniArthroplasty

John T. BraunPediatric Spine

Robert V. CantuTrauma

Charles F. CarrSports

Marcus P. CoeFoot & Ankle

Roland G. HazardSpine

Faculty

Paul J. HechtFoot & Ankle

James D. HeckmanGeneral Orthopaedics

Eric R. HendersonOrthopaedic Oncology

Stephen R. KantorArthroplasty

Kristine A. KarlsonSports Medicine

Karl M. KoenigArthroplasty

Franklin Lynch Jr.General Orthopaedics

William E. MinsingerGeneral Orthopaedics

Sohail K. MirzaSpine

Chair of Orthopaedics

John T. NuttingShoulder & Elbow

Adam M. PearsonSpine

Michelle M. PrincePediatrics

Dilip K. SenguptaSpine

Thomas G. ShirreffsArthroplasty

Michael B. SparksLower Extremity

Ivan M. TomekArthroplasty

Lance G. WarholdHand

James N. WeinsteinSpine

Faculty

Associate Providers

Mitchel B. Harris, MD1985-1989

1990William A. Abdu, MD1986-1990

Christopher N. Walton, MD1986-1990

1991W. Kevin Olehnik, MD1987-1991Lance G. Warhold, MD1987-1991

1992Gregg J. Fasulo, MD1988-1992

Carol J. Pelmas, MD1988-1992

1993Jonathan E. Fuller, MD1989-1993

John T. Gorczyca, MD1989-1993

1994Geoffrey M. McCullen, MD1990-1994

Peter G. Noordsij, MD1990-1994

1995Michael B. Sparks, MD1991-1995

James M. Hartford, MD1991-1995

1996Diane C. Riley, MD1992-1996

Jim A. Youssef, MD1992-1996

1997Charles A. Hope, MD1993-1997

Thomas M. Mitchell, MD1993-1997

1973H. Roger Hansen, MD 1970-1973

Howard M. Black, Jr., MD1970-1973

1974Edward Bradley, MD1971-1974

Preston R. Clark, MD(Deceased)1971-1974

1975Bradford A. Stephens, MD1972-1975

Thomas E. Clarke, MD1972-1975

1976Kenneth C. Spengler, Jr., MD1973-1976

Sterling E. Doster, MD1973-1976

1977Edward W. King, MD1974-1977

1978Philip M. Bernini, MD1975-1978

John W. Lyons, MD1975-1978

1979James M. Perry, MD(Deceased)1976-1979

Thomas S. Eagan, MD1976-1979

1980James J. O’Connor, MD(Deceased)1977-1980

Jeffrey A. Metheny, MD1977-1980

Alumni of the Dartmouth Orthopaedic Surgery Residency Program

1961Robert H. Orth, MD(Deceased)1958-1961

1962Keith D. Woolpert, MD1959-1962

1963Walter N. Garger, MD1960-1963

1964George M. Hazel, MD1961-1964

1965Francis P. Saunders, MD1962-1965

1966Richard J. Hastings, MD1963-1966

1967Richard A. McArthur, MD1964-1967

1968Stephen R. Shaffer, MD1965-1968

1969Thomas M. Malloy, MD1966-1969

1970Kenneth W. Gregg, MD1967-1970

1971Richard L. Withington, MD1968-1971

1972David W. Moore, MD1969-1972

1981J. Michael Whitaker, MD1978-1981

Franklin Lynch, MD1978-1981

1982Derrik F. Woodbury, MD1979-1982

1983Thomas M. Barton, MD1980-1983

Deborah R. Fabian, MD1980-1983

1984James M. Murphy, MD1981-1984

Philippe S. Cote, MD1981-1984

1985Gary C. Bessette, MD1982-1985

John T. Nutting, MD1982-1985

1986James L. Telfer, MD1983-1986

Edward N. Powell, MD1983-1986

1987Charles F. Carr, MD1984-1987

Samuel S. Scott, MD1984-1987

1988Joseph Sirois, MD1984-1988

G. Raymond Payne, MD1984-1988

1989R. Mark Caulkins, MD1985-1989

74


1998Bertrand P. Kaper, MD1994-1998

Michael R. Yorgason, MD1994-1998

1999Dirk Asherman, MD1994-1999

2000John F. Parker, MD1995-2000

David G. Goss, MD1995-2000

2001Jeffrey W. Wiley, MD1996-2001

Thomas L. Martin, MD1996-2001

2002Scott Sporer, MD (5 year TDI)1997-2002

Gregory Sassmannshausen, MD1997-2002

2003Randall Schultz, MD (5 year TDI)1998-2003

Ronald Michalak, MD (5 year TDI)1998-2003

2004Andrew Myrtue, MD1999-2004

2005Elizabeth Weber, MD1999-2005

Eric Marsh, MD (5 year TDI)2000-2005

Jorge Brito, MD2000-2005

2006James D. Slover, MD (5 year TDI)2001-2006

Michael Hoffman, MD (5 year TDI)2001-2006

2007Brian Aros, MD (6 year TDI)2001-2007

Jason Fanuele, MD2002-2007

2008Kane Anderson, MD (6 year TDI)2002-2008

Justin Cummins, MD (6 year TDI)2002-2008

Dan Bullock, MD2003-2008

2009Karl Koenig, MD (6 year TDI)2003-2009

Jamie Genuario, MD (6 year TDI)2003-2009

Brian Leung, MD2004-2009

2010Jamie Ames, MD (6 year TDI)2004-2010

Adam Pearson, MD (6 year TDI)2004-2010

Xan Courville, MD (6 year TDI)2004-2010

Anthony Albert, MD2005-2010

Joseph Signorelli, MD2005-2010

Wayne McGough, MD2005-2010

2011Patrick Olson, MD (6 year TDI)2005-2011

Ryan Pizinger, MD2006-2011

2012Greg Ford, MD (6 year – all clinical)2006-2012

Ryan Donegan, MD (6 year TDI)2006-2012

Marcus Coe, MD (6 year TDI)2006-2012

Erik Bergquist, MD2007-2012

Scott Faucett, MD2007-2012

2013Kevin Dwyer, MD (6 year TDI)2007-2013

Wayne Moschetti, MD (6 year TDI)2007-2013

Jennie Garver, MD2008-2013

Eugene “Will” Brabston, MD2008-2013

2014Sara Graves, MD (6 year TDI)2008-2014

Garrett Davis, MD (6 year TDI)2008-2014

Richard “Brad” Washburn, MD2009-2014

Adewale Adeniran, MD2009-2014

Dartmouth Orthopaedic Journal Submission Guidelines

SUBMISSION GUIDELINES, DARTMOUTH ORTHOPAEDIC JOURNAL, 2014Any original article relevant to orthopaedic surgery, orthopaedic science or the teaching of either will be considered for publi-

cation in The Dartmouth Orthopaedic Journal. Additionally, we encourage submissions of editorials and/or essays pertaining to orthopaedics and the history of orthopaedics. Submissions are encouraged from alumni, visitors to the department, residents, and friends of Dartmouth-Hitchcock Medical Center Department of Orthopaedics. The first edition of the journal will be published in June 2014, and annually thereafter.

General Guidelines

1. Articles are accepted only for exclusive publication in The Dartmouth Orthopaedic Journal. Previously published articles are not accepted. Published articles and illustrations become the property of The Dartmouth Orthopaedic Journal. Publication does not constitute official endorsement of opinions presented in articles.

2. If the Editor(s) of The Dartmouth Orthopaedic Journal request additional data forming the basis for the work, the authors will make the data available for examination in a timely fashion.

3. In the preparation of a manuscript, authors should, in general, follow the recommendations in “Uniform Requirements for Manuscripts Submitted to Biomedical Journals: Writing and Editing for Biomedical Publication” by the International Commit-tee of Medical Journal Editors (www.icmje.org).

4. All clinical trials submitted for consideration (i.e., any clinical study in which patients are randomized into two treatment groups OR are followed prospectively to compare two different treatments) must have been registered in a public trials registry such as www.clinicaltrials.gov.

5. All manuscripts dealing with the study of human subjects must include a statement that the subjects gave informed consent to participate in the study and that the study has been approved by an institutional review board or a similar committee. All studies should be carried out in accordance with the World Medical Association Declaration of Helsinki, as presented in The Journal of Bone and Joint Surgery (1997;79-A:1089-98). Patient confidentiality must be protected according to the U.S. Health Insurance Portability and Accountability Act (HIPAA).

6. All manuscripts dealing with experimental results in animals must include a statement that the study has been approved by an animal utilization study committee.

7. Manuscripts are evaluated by the editorial staff of The Dartmouth Orthopaedic Journal and are sent to consultant review-ers. On occasion, reviewers may have a conflict of interest or a competing interest with regard to the subject matter of a manuscript. Such conflicts are disclosed to the Editor(s) - who have no known conflicts of interest or competing interests, and who make the final decision regarding acceptance or rejection of all manuscripts.

Preparation of manuscripts:

Manuscripts must be typewritten and double spaced using wide margins and submitted as a Microsoft Word file. They should not exceed 4000 words excluding references and figure legends. Write out numbers under 10 except percentages, degrees or num-bers expressed as decimals. Direct quotations should include the exact page number on which they appeared in the book or arti-cle. All measurements should be given in SI metric units. Use only standard abbreviations. Avoid abbreviations in the title of the manuscript. The spelled-out abbreviation followed by the abbreviation in parenthesis should be used on first mention unless the

76


abbreviation is a standard unit of measurement.

Items Required for Submission

1. Title Page: List the title of the manuscript and the authors’ names in the order in which they should appear. Provide each author’s highest academic degree, name of the department(s) and institution(s) where the work should be attributed and a complete mailing address for each author. Clearly designate the corresponding author and his/her telephone number and e-mail address.

2. Abstract: no more than 350 words, consisting of five paragraphs, with the headings Introduction (which states the pri-mary research question), Methods, Results, Discussion and Level of Evidence (for clinical articles) or Clinical Relevance (for basic-science articles).

3. Manuscript: in “IMRAD format”

a. Introduction: State the problem that led to the study, including a concise review of only the relevant literature. State your hypothesis and the purpose of the study. It is preferable that this be done in the form of a research question that describes the setting of the study, the population or sample studied, and the primary outcome measure.

b. Materials and Methods: Describe the study design in detail using standard methodologic terms, such as retrospective or prospective cohort study, prospective randomized trial, case-control study, cross-sectional study, etc.

i. Reports of randomized controlled trials (RCTs) should follow the twenty-five-item checklist developed by the CONSORT Group (www.consort-statement.org), and include, with the submission of the article, a copy of that checklist and a flow diagram. Please note that this flow diagram must appear as a manuscript figure (typ-ically in the Figure 1 position).

ii. Submissions reporting cohort, case-control and cross-sectional studies should conform to the format suggested by the STROBE panel (http://www.strobe-statement.org).

iii. Reporting of systematic reviews and meta-analyses should conform to the PRISMA (Preferred Report-ing Items for Systematic Reviews and Meta-Analyses) Statement criteria. These are available at http://www.pris-ma-statement.org/. Meta-analyses must include a description of how data were pooled and the details of any sensitivity analyses that were performed.

iv. Reporting of all study designs should include information about the sample including how it was assem-bled and how inclusions and exclusions were identified. State how the sample size was determined. Justification for complex statistical strategies, including those involving any kind of modeling approach, should be described in detail. It is especially important to identify any assumptions about the data that are implicit to the statistical strategy. P values are required to support any statement indicating a significant difference. We encourage the use of validated outcome instruments wherever possible. Novel measurement scales should be used only if existing scales are deemed insufficient in some way to the needs of the study.

c. Source of Funding: Sources of funding must be be disclosed – these include grants, equipment, drugs, and/or other support that facilitated conduct of the work described in the article or the writing of the article itself. If no outside support was obtained this should be clearly stated.

d. Results: Provide a detailed report on the data obtained during the study. Give numeric results not only as derivatives (for example, percentages) but also as the absolute numbers from which the derivatives were calculated, and specify the statistical significance attached to them, if any. Avoid nontechnical uses of technical terms in statistics, such as “random” (which implies a randomizing device), “normal,” “significant,” “correlations,” and “sample.”

e. Discussion: Be succinct. What does your study show? Is your hypothesis affirmed or refuted? Discuss the importance of this article with regard to the current relevant literature; a complete literature review is unnecessary. Analyze your data and discuss their strengths, their weaknesses, and the limitations of the study.

77


4. Tables: must be labeled individually and submitted as separate electronic files. Tables should be submitted in their orig-inal file format (Word or Excel) and not as graphics files. Number tables consecutively in the order of their first citation in the text and supply a title for each. Titles in tables should be short but self-explanatory, containing information that allows readers to understand the table’s content without having to go back to the text. Be sure that each table is cited in the text. Give each column a short or an abbreviated heading. Authors should place explanatory matter in footnotes, not in the heading. Explain all nonstan-dard abbreviations in footnotes. Identify statistical measures of variation in standard deviation.

5. Figures: must be submitted electronically as either .tiff or .jpg file. (Special illustrations and photographs may be ex-empted from this electronic requirement and should be mailed to the address below.) Figures should be numbered consecutively according to the order in which they have been cited in the text. All images must have resolution of 300 pixels per inch (ppi). Web page images are to be avoided. Set digital cameras to their highest quality (ppi) setting for photographs. When submitting an illustration that has appeared elsewhere, give full information about previous publication and credit to be given, and state whether or not permission to reproduce it has been obtained. Color illustrations may not be used unless it is the opinion of the journal that they convey information not available in black and white.

6. Legends for Tables & Figures: should be listed separately in order of appearance and single-spaced.

7. Bibliography: must list references in order of their use, and be double-spaced. References must be presented in the text by superscript numbers using JBJS style and should follow the standards summarized in the International Committee of Medical Journal Editors (ICMJE) Recommendations for the Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals:

8. Cover Letter (optional)

9. Acknowledgment (optional) If included, it must be attached as a separate file, not included in the text of the manuscript.

Follow-on Items required: these will be provided if manuscript accepted for publication

1. Dartmouth Orthopaedic Journal – Assignment of Copyright and Author Agreement: must be signed by all authors. The form must reference the manuscript title. Completed (signed) forms should be scanned and submitted via email in PDF for-mat.

2. ICMJE Conflict of Interest Disclosure: This form must be completed electronically with use of Adobe Acrobat or Reader and submitted via email in PDF format. The form must reference the manuscript title and corresponding author. This statement has no bearing on the editorial decision to publish a manuscript. No article will be published until the completed conflict of inter-est form has been incorporated into the record kept on that manuscript in The Dartmouth Orthopaedic Journal office. A summary of the statements selected by the author or authors will be printed with the published article.

3. IRB Approval (if applicable): A copy of the letter granting approval from the institutional review board or the animal utilization study committee is required.

Send electronic copies of all items to Ross McEntarfer, MD ([email protected]) or Patrick Dickerson, MD ([email protected]). For questions pertaining to these instructions please contact us at:

Ross McEntarfer, MD Patrick Dickerson, MD John-Erik Bell, MDRoss.A.McEntarfer @hitchcock.org [email protected] [email protected] Medical Ctr Dartmouth-Hitchcock Medical Ctr Dartmouth-Hitchcock Medical CtrOne Medical Center Drive One Medical Center Drive One Medical Center DriveLebanon, NH 03756 Lebanon, NH 03756 Lebanon, NH 03756(603) 650-7590 (603) 650-7590 (603) 650-8494

78


dartmouth orthopaedic journal 2014; vol...

Documents