Publications by authors named "Gabriella Ode"

18 Publications

  • Page 1 of 1

Relationship between postoperative integrity of subscapularis tendon and functional outcome in reverse shoulder arthroplasty.

J Shoulder Elbow Surg 2021 Jun 30. Epub 2021 Jun 30.

Department of Orthopaedic Surgery, Prisma Health-Upstate, Greenville, SC, USA.

Hypothesis And Background: The role of the subscapularis in reverse shoulder arthroplasty (RSA) remains controversial. Studies have shown that subscapularis repair has no significant influence on the functional outcomes of patients. However, few studies have assessed the postoperative integrity of the subscapularis tendon after RSA. The aims of this study were to investigate the postoperative healing of the subscapularis after RSA via ultrasound and to evaluate the relationship between tendon integrity and functional outcomes. We hypothesized that subjects with a healed subscapularis after RSA would have higher Constant scores and better internal rotation (IR) than those without a healed subscapularis.

Methods: This was a retrospective review of all patients who underwent primary RSA with subscapularis tenotomy repair performed by a single surgeon with a minimum 2-year follow-up period. The inclusion criteria were (1) primary RSA and (2) complete intraoperative repair of the subscapularis tenotomy if the tendon was amenable to repair. The total Constant score and active and passive range of motion were measured preoperatively and at every postoperative visit. IR was further subcategorized into 3 functional types (type I, buttock or sacrum; type II, lumbar region; and type III, T12 or higher). The integrity of the subscapularis on ultrasound at 2 years was reported using the Sugaya classification. The correlation between subscapularis integrity and functional outcomes including functional IR was evaluated.

Results: A total of 86 patients (mean age, 73 ± 7.4 years; age range, 50-89 years) were evaluated. The mean postoperative Constant score for all patients significantly improved from 38 points to 72 points (P < .001) at last follow-up (mean, 3.3 years). There was significant improvement in all Constant score functional subscales and in terms of range of motion. The rate of sonographic healing of the subscapularis was 52.6%. There was no difference in Constant scores between "intact" and "failed" tendon repairs; however, intact tendons demonstrated significantly better IR with no difference in external rotation (P < .01).

Conclusion: The healing rate of the subscapularis following RSA was only 52.6%. IR function in patients with an intact subscapularis at 2 years after RSA was significantly better than in patients with failed or absent tendon repairs. Primary repair of reparable subscapularis tendons during RSA should be strongly considered.
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http://dx.doi.org/10.1016/j.jse.2021.05.024DOI Listing
June 2021

Perception of Racial and Intersectional Discrimination in the Workplace Is High Among Black Orthopaedic Surgeons: Results of a Survey of 274 Black Orthopaedic Surgeons in Practice.

J Am Acad Orthop Surg 2021 Jun 2. Epub 2021 Jun 2.

From the Department of Orthopaedic Surgery, Prisma Health-Upstate, Greenville, SC (Ode, Porter), the Department of Orthopedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, MS (Brooks), the Northside Hospital Orthopedic Institute, Atlanta, GA (Middleton), and the Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO (Carson).

Introduction: There are approximately 573 practicing Black orthopaedic surgeons in the United States, which represents 1.9% overall. The purpose of this study was to describe this underrepresented cohort within the field of orthopaedic surgery and to report their perception of occupational opportunity and workplace discrimination.

Methods: An anonymous survey was administered to 455 practicing orthopaedic surgeons who self-identify as Black. The 38-question electronic survey requested demographic and practice information and solicited perspectives on race and racial discrimination in current orthopaedic practices and general views regarding occupational opportunity and discrimination.

Results: The survey was completed by 274 Black orthopaedic surgeons (60%). Over 97% of respondents believe that Black orthopaedic surgeons in the United States face workplace discrimination. Most Black orthopaedic surgeons (94%) agreed that racial discrimination in the workplace is a problem but less than 20% agreed that the leaders of national orthopaedic organizations are trying sincerely to end it. Black female orthopaedic surgeons reported lower occupational opportunity and higher discrimination than Black male orthopaedic surgeons across all survey items.

Discussion: This study is the first to report on the workplace environment and the extent of discrimination experienced by Black surgeons, specifically Black orthopaedic surgeons in the United States. Most respondents, particularly female respondents, agreed that racial discrimination and diminished occupational opportunity are pervasive in the workplace and reported experiencing various racial microaggressions in practice.
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http://dx.doi.org/10.5435/JAAOS-D-20-01305DOI Listing
June 2021

The impact of Charlson and Elixhauser comorbidities on patient outcomes following shoulder arthroplasty.

Bone Joint J 2021 May;103-B(5):964-970

Sports Medicine Institute, Hospital for Special Surgery, New York, USA.

Aims: To investigate the impact of the Charlson and Elixhauser comorbidity indices on patient-reported outcomes measures (PROMs) following shoulder arthroplasty.

Methods: Patients undergoing total shoulder arthroplasty (TSA), reverse shoulder arthroplasty (RSA), or hemiarthroplasty (HA) from 2016 to 2018 were identified, along with the Charlson and Elixhauser comorbidities listed as their secondary diagnoses in the electronic medical records. Patients were matched to our institution's registry to obtain their PROMs, including shoulder-specific (American Shoulder and Elbow Society (ASES) and Shoulder Activity Scale (SAS)) and general health scales (12-Item Short Form Survey (SF-12) and Patient-Reported Outcomes Measurement Information System-Pain Interference). Linear regression models adjusting for age and sex were used to evaluate the association between increasing number of comorbidities and PROM scores. A total of 1,817 shoulder arthroplasties were performed: 1,017 (56%) TSA, 726 (40%) RSA, and 74 (4%) HA. The mean age was 67 years (SD 10), and 936 (52%) of the patients were female.

Results: The most common comorbidities were obesity (1,256, 69%) and hypertension (990, 55%). Patients with more comorbidities had lower ASES and SAS scores at baseline (p < 0.001). Elixhauser comorbidities continued to negatively impact ASES and SAS scores at one year (p = 0.002) and two-year follow-up (p = 0.002). Patients with more comorbidities reported greater pain interference on PROMIS at baseline (p = 0.007), but not at two years. Higher number of Charlson comorbidities were associated with lower scores on the SF-12 mental component at baseline (p < 0.001) and two years (p = 0.020). Higher number of Elixhauser comorbidities were associated with lower SF-12 physical component scores at baseline (p < 0.001) and two years (p = 0.004).

Conclusion: Higher number of comorbidities was associated with lower baseline scores and worse outcomes on both shoulder-specific and general health PROMs. The presence of specific comorbidities may be used during shared decision-making to manage expectations for patients undergoing shoulder arthroplasty. Cite this article:  2021;103-B(5):964-970.
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http://dx.doi.org/10.1302/0301-620X.103B5.BJJ-2020-1503.R1DOI Listing
May 2021

Current Concepts on Tissue Adhesive Use for Meniscal Repair-We Are Not There Yet: A Systematic Review of the Literature.

Am J Sports Med 2021 Apr 15:3635465211003613. Epub 2021 Apr 15.

Sports Medicine Institute, Hospital for Special Surgery, New York, USA.

Background: Tissue adhesives (TAs) represent a promising alternative or augmentation method to conventional tissue repair techniques. In sports medicine, TA use has been suggested and implemented in the treatment of meniscal tears. The aim of this review was to present and discuss the current evidence and base of knowledge regarding the clinical usage of TAs for meniscal repair.

Study Design: Systematic review; Level of evidence, 4.

Methods: A systematic literature search was performed using the PubMed, Embase, and Cochrane Library databases for studies reporting on clinical outcomes of TA usage for meniscal repair in humans in the English language published before January 2020.

Results: Ten studies were eligible for review and included 352 meniscal repairs: 94 (27%) were TA-based repairs and 258 (73%) were combined suture and TA repairs. Concomitant anterior cruciate ligament reconstruction was performed in 224 repairs (64%). All included studies utilized fibrin-based TA. Of the 10 studies, 9 were evidence level 4 (case series), and 8 reported on a cohort of ≤40 meniscal repairs. Rates of meniscal healing were evaluated in 9 of 10 studies, with repair failure seen in 39 repairs (11%).

Conclusion: The use of TAs, specifically fibrin-based TAs, for meniscal repair shows good results as either an augmentation or primary repair of various configurations of meniscal tears. However, this review reveals an absence of comparative high-quality evidence supporting the routine use of TAs for meniscal repair and emphasizes the lack of an ideal TA designed for that purpose. Further high-quality research, basic science and clinical, will facilitate the development of new materials and enable testing their suitability for use in meniscal repair.
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http://dx.doi.org/10.1177/03635465211003613DOI Listing
April 2021

Poor results after pyrocarbon interpositional shoulder arthroplasty.

J Shoulder Elbow Surg 2021 Mar 4. Epub 2021 Mar 4.

Institut Locomoteur de l'Ouest, CHP St Grégoire, St Grégoire, France. Electronic address:

Background: This study aimed to describe the clinical outcomes and complications of 10 cases of pyrocarbon interposition shoulder arthroplasty (PISA).

Methods: The clinical and radiographic records of 10 patients who underwent PISA using the InSpyre shoulder prosthesis (Tornier-Wright) between July 2012 and March 2017 were reviewed. The mean age at surgery was 55 years. Surgical indications included patients aged <60 years with Walch type B glenoid glenohumeral osteoarthritis (n = 7), avascular necrosis (AVN) of the humeral head (n = 1), or secondary severe glenohumeral osteoarthritis with axillary nerve dysfunction (n = 2). Outcomes of interest were postoperative complications and need for revision surgery, preoperative and postoperative patient-reported outcomes (Constant score [CS] and Subjective Shoulder Value [SSV]), and range of motion. The radiographic characteristics of the implants were evaluated.

Results: Among the 10 patients, 5 underwent revision to reverse shoulder arthroplasty during the study period owing to poor clinical outcomes based on the CS and SSV. All 5 revised patients had Walch type B glenoid morphology at the time of the index procedure. The mean time to revision surgery in this subset of patients was 60 months. The remaining 5 patients who did not undergo any revision procedure had significant improvement in mean CS and SSV from 30-65 points and 32%-87%, respectively, but at a shorter duration of follow-up of 35 months.

Conclusion: High clinical failure rate and poor results at mean 5-year follow-up were found in younger PISA patients with baseline Walch B glenohumeral osteoarthritis. We would caution against use of PISA in this challenging patient population. PISA yielded more favorable short-term outcomes in patients with humeral-sided deformity or severe secondary glenohumeral osteoarthritis with axillary nerve dysfunction; however, longevity of the implant in this population remains unclear.
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http://dx.doi.org/10.1016/j.jse.2021.01.032DOI Listing
March 2021

Comparing patient-reported outcome measures and physical examination for internal rotation in patients undergoing reverse shoulder arthroplasty: does surgery alter patients' perception of function?

J Shoulder Elbow Surg 2021 Jul 16;30(7S):S100-S108. Epub 2021 Feb 16.

Shoulder Service, Florida Orthopaedic Institute, Tampa, FL, USA; Department of Orthopedics and Sports Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA. Electronic address:

Background: The purpose of this study was to evaluate how patients treated with reverse shoulder arthroplasty (RSA) achieve internal rotation (IR) using video assessment and to compare this to patient-reported outcome measures (PROMs).

Methods: We reviewed 215 preoperative and 657 postoperative videos (3-78 months) for 215 patients who underwent primary RSA, performing IR using the modified vertebral level method. Their functional motion pattern was then grouped into 3 types: type I, could not reach behind their back; type II, able to reach to at least waist level, with assistance; and type III, able to reach to a minimum of waist level in an uninterrupted fashion. Patients completed functional questions (put on a coat, wash back, tuck in a shirt, and manage toileting) and a diagram of perceived IR. Patients' functional motion types were compared to PROM answers. Pre- and postoperative scores were also compared to assess the effect of surgery on patients' perception of IR function.

Results: Patients undergoing RSA will achieve IR in 3 distinct motion patterns. Analysis of self-reported IR indicated statistically significant difference between the 3 functional types of IR (P < .001). Patient-perceived IR was not significantly different between the 3 studied IR functional types (P = .076) in the analysis of preoperative measures but was significantly different in the postoperative setting (P < .001).

Conclusion: Patients attempt IR in 3 distinct functional motion patterns. The improvement of IR after RSA is measured better by patient questionnaires than by physical examination.
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http://dx.doi.org/10.1016/j.jse.2021.01.020DOI Listing
July 2021

The Arthroscopic Surgery Skill Evaluation Tool Global Rating Scale is a Valid and Reliable Adjunct Measure of Performance on a Virtual Reality Simulator for Hip Arthroscopy.

Arthroscopy 2021 06 2;37(6):1856-1866. Epub 2021 Feb 2.

Sports Medicine Institute, Hospital for Special Surgery, New York, New York, U.S.A.

Purpose: The purpose of this study is to further evaluate the construct validity and interobserver reliability of a hip arthroscopy virtual simulator using the Arthroscopic Surgery Skill Evaluation Tool (ASSET) global rating scale.

Methods: Thirty participants (23 male/7 female) completed a diagnostic arthroscopy and a loose body retrieval simulation on the VirtaMed Arthros Hip Simulator (Zurich, Switzerland) twice at a minimum of 1 week apart. Subjects consisted of 12 novices (medical students, postgraduate year [PGY] 1-2), 5 intermediate trainees (PGY3-4), 9 senior trainees (PGY5 and fellows), and 4 attending faculty. Simulator metrics were recorded and then compiled to generate a total simulator score (TSS). The loose body retrieval was graded using the ASSET scoring tool. Inter-rater and intrarater reliability for the ASSET for 2 blinded raters and construct validity of the ASSET and the TSS were calculated. Correlation between the TSS, ASSET and individual simulator metrics was determined.

Results: Prior simulation experience (P ≤ 0.01) correlated with higher TSS and higher ASSET, while video game experience correlated with higher TSS on the diagnostic module only (P = 0.004). There was a significant difference in ASSET score among all experience groups (P < 0.04). Novices had the lowest mean ASSET whereas experts had the highest mean ASSET with a difference of 17.4 points. Overall performance on the surgical module significantly correlated with the ASSET score (r = 0.444, P = 0.016). There was a significant positive correlation among higher ASSET and number of loose bodies retrieved, operation time, camera path and grasper path length, and percentage of cartilage injury. ASSET demonstrated excellent intrarater reliability and showed substantial or better inter-reliability in 8 of 9 domains.

Conclusion: The VirtaMed hip arthroscopy simulator demonstrated good construct validity and excellent reliability for simulator-based metrics and ASSET score. Use of both simulator metrics and ASSET offers a more comprehensive performance assessment on hip arthroscopy simulation than either measure alone.

Clinical Relevance: As virtual reality simulation for arthroscopy becomes more commonplace in orthopaedic training, evaluation of the most effective objective and subjective measures of performance is necessary to optimize simulation training.
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http://dx.doi.org/10.1016/j.arthro.2021.01.046DOI Listing
June 2021

Achieving a Diverse, Equitable, and Inclusive Environment for the Black Orthopaedic Surgeon: Part 1: Barriers to Successful Recruitment of Black Applicants.

J Bone Joint Surg Am 2021 Feb;103(3):e9

Department of Orthopedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson, Mississippi.

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http://dx.doi.org/10.2106/JBJS.20.01768DOI Listing
February 2021

Clinical characteristics and patient-reported outcomes of total shoulder arthroplasty after anterior stabilization: a retrospective matched control study.

J Shoulder Elbow Surg 2020 Jul;29(7S):S59-S66

The HSS Sports Medicine Institute, Hospital for Special Surgery, New York, NY, USA.

Background: Instability arthropathy is a known cause of glenohumeral osteoarthritis (OA) among patients with and without prior shoulder stabilization. This study aims to compare the clinical, radiographic, and patient-reported outcome measure (PROM) scores among total shoulder arthroplasty (TSA) patients with and without a history of shoulder stabilization.

Methods: A case-control study was performed comparing 20 patients with a history of anterior shoulder stabilization (11 open, 9 arthroscopic) who underwent TSA to a matched cohort of 20 TSA patients without a history of shoulder surgery (mean follow-up = 2.8 years). Patients were matched by sex, age, and baseline American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score within 10 points (mean age 59.6 ± 9.6 years). Patient characteristics, operative findings, and preoperative and postoperative radiographic characteristics for both groups were reported. Comparisons were made regarding PROM scores (ASES, 12-Item Short Form Health Survey (SF-12), Shoulder Activity Scale [SAS], numeric rating scale for pain) at baseline, 2 years, and 5 years and patient satisfaction at 2 years.

Results: Intraoperative findings of subscapularis scarring or attenuation was common among patients with prior anterior stabilization. The instability cohort did have a higher percentage of B2/B3 glenoid types than the OA cohort (45% vs. 15%), but this was not significantly different possibly because of the small sample size. At 2 years, both instability and OA groups reported significant improvement in pain, function, and activity level. There was no difference between groups on any PROMs or patient satisfaction level. At 5 years, instability patients had significantly lower scores on the ASES and the SF-12 PCS than the OA group.

Conclusion: There was notable alterations in both soft tissue and bony morphology among patients with prior anterior stabilization. After TSA, both instability and primary OA groups showed significant improvements at 2 years. However, PROMs for instability patients deteriorated at 5 years compared with the control group. Complex bony and soft tissue imbalances may contribute to more unpredictable long-term PROM scores. Thoughtful preoperative consideration of these factors should influence decision making regarding selection of TSA for management of OA in this complex patient cohort.
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http://dx.doi.org/10.1016/j.jse.2020.04.003DOI Listing
July 2020

Intramedullary Fixation for Displaced Clavicle Fractures in the Adolescent Athlete.

J Surg Orthop Adv 2020 ;29(2):81-87

OrthoCarolina Sports Medicine Center, Charlott e, North Carolina.

The role of intramedullary (IM) fixation of displaced mid-shaft clavicle fractures in adolescents has not been described. This study analyzes characteristics and outcomes of IM fixation in adolescent clavicle fractures. Patients < 18 years with acute, mid-shaft clavicle fractures treated with IM clavicle pins between March 2007 and August 2013 were reviewed. Outcomes of interest were activity level, fracture pattern, time to union, return to sports and complications. Twenty-nine patients (14.8 years (range 11.4-17.9)) underwent IM pin fixation for a displaced, mid-shaft clavicle fracture, including 7 (24.1%) that were multi-fragmentary (length unstable). Complete displacement (> 100%) occurred in 27/29 (93.1%), with average preoperative shortening length of 18 mm. Union occurred in 100% of patients, at a mean duration of 8 weeks. Among student-athletes (25/29, 86.2%), average return to sport was at 18 weeks post-injury. IM pinning offers stable fixation of clavicle fractures in the active adolescent population.(Journal of Surgical Orthopaedic Advances 29(2):81-87, 2020).
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November 2020

Ambulatory versus inpatient shoulder arthroplasty: a population-based analysis of trends, outcomes, and charges.

JSES Int 2020 Mar 3;4(1):127-132. Epub 2020 Jan 3.

OrthoCarolina Sports Medicine Center, Charlotte, NC, USA.

Background: The purpose of this study was to evaluate the clinical outcomes and cost of shoulder arthroplasty (SA) performed in ambulatory surgery centers (ASCs) compared with SA performed in hospital-based surgery settings.

Methods: The State Inpatient Databases and the State Ambulatory Surgery Databases were queried for patients undergoing primary or reverse SA between 2010 and 2014 in 5 states in either the inpatient (IP), hospital outpatient department (HOPD), or ASC setting. Outcomes included all-cause readmissions, emergency department visits within the 90-day postoperative period, and charges. Covariates included patient demographic data and procedure details. Risk factors for readmission were calculated using logistic regression analysis.

Results: We identified 795 ASC (2%), 183 HOPD (0.5%), 38,114 (97.5%) SA procedures. The outpatient cohort was overall younger and healthier with a lower percentage of diabetes (14.1% vs. 20.2%), cardiopulmonary disease (11.4% vs. 20.4%), and obesity (10.7% vs. 15.6%). The US state and obesity were factors significantly ( < .0001) associated with readmission. The median IP charge was $62,905 (range, $41,327-$87,881) vs. $37,395 (range, $21,976-$61,775) for combined outpatient cases. When outpatient SA was stratified into ASC and HOPD cases, the median charges were $31,790 for ASC cases vs. $55,990 for HOPD cases ( < .0001). After adjustment for multiple covariates, the charges for combined outpatient SA surgery were 40% lower than those for IP SA surgery ( < .0001).

Conclusion: As the current health care climate shifts toward lower-cost and higher-quality care, this study demonstrates that SAs performed in ASCs have a comparable safety profile to and significant financial advantage over SAs performed in the hospital-based setting.
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http://dx.doi.org/10.1016/j.jses.2019.10.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7075753PMC
March 2020

Obstacles Affecting the Implementation of the O-SCORE for Assessment of Orthopedic Surgical Skills Competency.

J Surg Educ 2019 May - Jun;76(3):881-892. Epub 2019 Feb 28.

Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, North Carolina. Electronic address:

Objectives: There is a need for meaningful and reliable measures of surgical competency in residency education. The goal of the current study is to incorporate the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) into the process of resident evaluation at our institution and to assess the feasibility and effectiveness of its use through a web-based platform.

Design: This is a feasibility study that prospectively assesses the implementation of a web-based O-SCORE at our institution. Over a 16-week period, 19 orthopedic surgery residents (PGY2-PGY5) participated in a quality improvement study, which involved collecting 2 feedback forms per week. Each form consisted of a resident form and a linked attending form. At the conclusion of the 16-week trial period, residents and faculty members were asked to complete a survey about their perceptions of the O-SCORE program.

Setting: An academic medical center.

Participants: The study included only residents in postgraduate training years (PGY) 2 through 5 (n = 20) and attendings (n = 37).

Results: During the 16-week study period, 608 resident surveys were requested for the 19 participating residents, of which 404 surveys (66.5%) were completed. Faculty completed 207 of 326 surveys for an overall compliance rate of 63.5%. The O-SCORE was able to significantly differentiate between all training years (p < 0.0001) with the exception of PGY3 residents when compared to PGY4 residents. Overall, residents and faculty found the program valuable and feasible. Resident and faculty perception of the value of the O-SCORE correlated with compliance rate of the O-SCORE surveys.

Conclusions: This study demonstrates that implementation of an immediate feedback program utilizing an electronic platform is achievable and offers reproducible construct validity. However, issues affecting compliance among both residents and faculty physicians must temper optimism for the program and should be systematically addressed to allow for successful implementation.
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http://dx.doi.org/10.1016/j.jsurg.2018.11.002DOI Listing
August 2020

Wrist Arthroscopy: Can We Gain Proficiency Through Knee Arthroscopy Simulation?

J Surg Educ 2018 Nov 3;75(6):1664-1672. Epub 2018 May 3.

OrthoCarolina Hand Center, Charlotte, North Carolina. Electronic address:

Objective: Wrist arthroscopy is a challenging discipline with limited training exposure during residency. The purpose of this study was to evaluate the effectiveness of virtual knee arthroscopy simulation training for gaining proficiency in wrist arthroscopy.

Design: Participants were recorded performing a cadaveric wrist arthroscopy simulation. The residents then practiced knee arthroscopy on a virtual reality simulator and repeated the wrist arthroscopy simulation. All videos were blinded prior to assessment. Proficiency was graded using the Arthroscopic Surgery Skill Evaluation Tool global rating scale. In addition, participants were asked to complete a survey assessing the value of the virtual reality knee arthroscopy simulator for wrist arthroscopy.

Setting: Orthopaedic Surgery Residency Program, Carolinas Medical Center, a large, public, nonprofit hospital located in Charlotte, North Carolina.

Participants: Orthopaedic residents at our center were asked to participate in the simulation training. Participation was voluntary and nonincentivized. All orthopaedic residents at our institution (N = 27) agreed to participate. In total, there were 10 Intern (PGY-0 and PGY-1), 10 Junior (PGY-2 and PGY-3), and 7 Senior (PGY-4 and PGY-5) residents. In addition, a fellowship-trained hand surgeon was recruited to participate in the study, performing the wrist arthoscopy simulation. Two additional fellowship-trained hand surgeons, for a total of 3, assessed the blinded videos.

Results: There was a trend toward better wrist Arthroscopic Surgery Skill Evaluation Tool scores by training level, although the difference was not statistically significant. Interns improved by an average of 1.8 points between baseline and postknee simulation tests. Junior and senior residents decreased by 1.6 and 5.0 points, respectively.

Conclusions: Knee arthroscopy simulation training did not objectively improve wrist arthroscopy proficiency among residents. A wrist-specific arthroscopy simulation program is needed if measurable competence through simulation is desired.
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http://dx.doi.org/10.1016/j.jsurg.2018.04.009DOI Listing
November 2018

MOPEDS: The high cost of cheap and poorly legislated transportation for negligent drivers.

Accid Anal Prev 2018 Aug 23;117:121-127. Epub 2018 Apr 23.

Carolinas HealthCare System, Charlotte, NC, United States.

Introduction: This study evaluates the impact of moped crashes in North Carolina, a state with lenient moped legislation by(1) describing the characteristics of moped crashes and (2) estimating the cost burden of moped-related injuries.

Methods: Health and public records of moped crash subjects treated at our hospital were reviewed. Direct costs were billed hospital charges. Indirect costs based on age and outcomes were calculated.

Results: Between 2008-2013, 368 subjects were involved in 373 moped crashes. 52% of drivers were intoxicated. 38% of drivers had prior DWIs and 26% had prior revoked licenses. Hospitalized subjects (n = 305) had a combined 2687 hospital days, 695 ICU days and 449 trips to the operating room for treatment of their injuries. Average hospital charges were $70,561 per subject. Total direct and indirect costs of moped injuries were over $26 million and $81 million respectively. Medicaid absorbed most of the direct cost ($13.7 M). Estimated direct cost of moped crashes across the state totaled $133 million.

Conclusion: Healthcare and financial ramifications of moped collisions are substantial. Laws governing moped drivers and stricter penalties for intoxicated drivers are needed.
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http://dx.doi.org/10.1016/j.aap.2018.03.023DOI Listing
August 2018

Cortical Button Fixation: A Better Patellar Tendon Repair?

Am J Sports Med 2016 Oct 7;44(10):2622-2628. Epub 2016 Jul 7.

Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA.

Background: Patellar tendon ruptures require surgical repair to optimize outcomes, but no consensus exists regarding the ideal repair technique. Cortical button fixation is a secure method for tendon repair that has not been studied in patellar tendons.

Hypothesis: Cortical button repair is biomechanically superior to the standard transpatellar repair and biomechanically equivalent to suture anchor repair.

Study Design: Controlled laboratory study.

Methods: Twenty-three fresh-frozen cadaveric knees were used to compare 3 techniques of patellar tendon repair after a simulated rupture at the inferior pole of the patella. Repairs were performed at 45° of flexion using a standard transpatellar suture repair (n = 7), polyetheretherketone (PEEK) suture anchor repair (n = 8), or cortical button repair (n = 8). All specimens were tested on a custom apparatus to simulate cyclic open kinetic chain quadriceps contraction from extension to 90 of flexion. Outcomes of gap formation up to 250 cycles, maximum load to failure, and mode of failure were evaluated.

Results: Cortical button repair had significantly less gap formation than anchor repair after 1 cycle (P < .001) and 20 cycles (P < .01) and significantly less gap formation than suture repair from 1 to 250 cycles (P < .05). Cortical button repair sustained significantly higher loads to failure than anchor repair and suture repair (P < .001). All suture repairs failed through the suture. Anchor repairs failed at the suture-anchor eyelet interface (n = 4) or by anchor pullout (n = 3). Cortical button repairs either failed through the suture (n = 5), secondary failure of the patellar tendon (n = 2), or subsidence of the button through the anterior cortex of the patella (n = 1).

Conclusion: Patellar tendon repair using cortical button fixation demonstrated mechanical advantages over suture repair and anchor repair in cadaveric specimens. Cortical button fixation showed less cyclic gap formation and withstood at least twice the load to failure of the construct.

Clinical Relevance: The biomechanical superiority of cortical button fixation may impart clinical advantages in accelerating postoperative rehabilitation.
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http://dx.doi.org/10.1177/0363546516651614DOI Listing
October 2016

Emergency tourniquets for civilians: Can military lessons in extremity hemorrhage be translated?

J Trauma Acute Care Surg 2015 Oct;79(4):586-91

From the Carolinas Healthcare System (G.O., R.S., M.J.B., J.R.H.), and Mecklenburg EMS Agency (J.S.), Charlotte, North Carolina.

Background: Among civilians, emergency tourniquet (TKT) use is infrequent because of concern for TKT-related complications. In large part because of positive reports from the military on emergency TKT use, all ambulances serving Mecklenburg County, which includes the city of Charlotte, North Carolina, were equipped with commercial TKTs in September 2012. This study compares the outcomes of emergency TKT use with conservative hemorrhage control in an urban civilian setting and evaluates outcomes related to appropriate TKT placement.

Methods: Emergency medical service and hospital records from September 2012 to November 2013 were reviewed. Injury characteristics, clinical interventions, outcomes, and TKT-related complications were reported, and appropriateness of TKT use was assessed. Primary analysis compared all TKT patients with non-TKT patients who received other hemorrhage control measures. Secondary analysis compared all appropriate TKT patients with those who had delayed/missed TKTs.

Results: Fifty-six patients met inclusion criteria (24 TKT, 32 non-TKT). Four patients died (three TKT, one non-TKT) (7.1%). There were no reported TKT-related complications. Of all the patients, 46.4% (16 of 56) demonstrated signs of shock in the prehospital or emergency department setting. Seventy-five percent (12 of 16) of the patients in shock had a vascular injury (p = 0.023). Of the non-TKT patients, 9.4% (3 of 32) should have received a TKT and were classified as "missed." One "missed" patient died in the emergency department. Among TKT patients, 62.5% (15 of 24) of TKTs were appropriate, 20.8% (5 of 24) were inappropriate, and 16.7% (4 of 24) were "delayed." Overall, there was a delayed/missed TKT rate of 12.5% (7 of 56). Patients with delayed/missed TKTs had higher incidences of shock (85.7% vs. 60%), inpatient admission (100% vs. 76.9%), and blood transfusions (71.4% vs. 40%).

Conclusion: The majority of TKTs were appropriately applied to civilians who had vascular injuries or required operative intervention for hemorrhage control. With appropriate indications, an emergency TKT is a valuable instrument for hemorrhage control in the civilian prehospital setting and has a low rate of associated complications.

Level Of Evidence: Therapeutic study, level IV.
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http://dx.doi.org/10.1097/TA.0000000000000815DOI Listing
October 2015

Effects of serial sectioning and repair of radial tears in the lateral meniscus.

Am J Sports Med 2012 Aug 11;40(8):1863-70. Epub 2012 Jul 11.

Rush University Medical Center, 720 North Larrabee Street, #1010, Chicago, IL 60654, USA.

Background: Radial transection of the peripheral fibers of the meniscus could render it nonfunctional; however, the biomechanical consequences of a complete lateral meniscal radial tear and repair in human specimens have not been elucidated.

Hypothesis: A complete radial tear will exhibit knee contact mechanics approaching those of total meniscectomy. Repair of complete radial tears will re-create normal load transmission across the joint.

Study Design: Controlled laboratory study.

Methods: Five matched pairs of fresh-frozen human cadaveric knees were tested in axial compression (800 N) at 2 knee flexion angles (0° and 60°). Six meniscal conditions were sequentially tested: (1) intact lateral meniscus; radial width tears of (2) 50%, (3) 75%, and (4) 100%; (5) meniscal repair; and (6) total meniscectomy. Repairs were pair matched and used either an inside-out or all-inside technique. Tekscan sensors measured tibiofemoral contact pressure, peak contact force, and contact area in the lateral meniscus and medial meniscus.

Results: Complete radial tears of the lateral meniscus produced significant increases in mean contact pressure (P = .0001) and decreased contact area (P < .0001) compared with the intact state. This effect was significantly less than that of total meniscectomy (P < .0023). Lesser degrees of radial tears were not significantly different from the intact state (P > .3619). Mean contact pressure after either repair technique was not significantly different from the intact state (P = .2595) or from each other (P = .4000). Meniscal repair produced an increase in contact area compared with a complete tear but was still significantly less than that of the intact meniscus (P < .0001). The medial compartment showed no significant difference between all testing conditions for 0° and 60° of flexion (P ≥ .0650).

Conclusion: A complete radial meniscal tear of the lateral meniscus has a detrimental effect on load transmission. Repair improved contact area and pressure. Contact pressures for repaired menisci were not significantly different from the intact state, but contact area was significantly different. Biomechanical performance of repair constructs was equivalent.

Clinical Relevance: Repair of complete radial tears improves joint mechanics, potentially decreasing the likelihood of cartilage degeneration.
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http://dx.doi.org/10.1177/0363546512453291DOI Listing
August 2012
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