Publications by authors named "Shaw Aaron"

59 Publications

Predicting adjacent infections in pediatric septic arthritis: Do predictive criteria extrapolate across geographic regions?: Predicting Periarticular Infection in the Southeast.

J Orthop 2021 Nov-Dec;28:53-57. Epub 2021 Nov 9.

Dwight D. Eisenhower Army Medical Center, Augusta, GA, USA.

Purpose: This study aims to assess previously determined predictive criteria for presence of adjacent infection in septic arthritis within a Southeastern United States (US) pediatric population.

Results: The sensitivity, specificity, positive predictive value, and negative predictive value of the Rosenfeld criteria were: 91.7%, 22.7%, 39.3%, and 83.3%, respectively. The patients with periarticular infection were more likely to have positive blood cultures than those with isolated septic arthritis. There was no difference in likelihood of secondary surgical intervention.

Conclusions: Previously defined criteria to predict adjacent infection in pediatric septic arthritis did not demonstrate external validity in a Southeastern US pediatric population.
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http://dx.doi.org/10.1016/j.jor.2021.11.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8603010PMC
November 2021

Volar DRUJ Instability After Midshaft Both-Bone Forearm Fracture in a Toddler: A Case Report.

JBJS Case Connect 2021 11 17;11(4). Epub 2021 Nov 17.

Department of Orthopaedic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia.

Case: A 2.5-year-old male child presented to the clinic for evaluation of left wrist popping. Ten months earlier, he sustained a closed left both-bone forearm fracture (BBFF) treated with reduction and casting. His clinical course was complicated by redisplacement requiring secondary manipulation and casting before osseous union. His parents reported wrist popping with active motion in the setting of a 20° apex volar malunion of the midshaft radius. He has been treated with observation and monitoring of deformity remodeling.

Conclusion: Distal radioulnar joint instability is a potential complication of malunited BBFF, even in a pediatric population. Residual deformity, especially in the radius, should prompt clinical follow-ups after osseous union to assess functional recovery and deformity remodeling.
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http://dx.doi.org/10.2106/JBJS.CC.21.00578DOI Listing
November 2021

Anterior Glenoid Reconstruction With Distal Tibial Allograft: Biomechanical Impact of Fixation and Presence of a Retained Lateral Cortex.

Orthop J Sports Med 2021 Nov 9;9(11):23259671211050435. Epub 2021 Nov 9.

Steadman Philippon Research Institute, Vail, Colorado, USA.

Background: Glenoid reconstruction with distal tibial allograft (DTA) is a known surgical option for treating recurrent glenohumeral instability with anterior glenoid bone loss; however, biomechanical analysis has yet to determine how graft variability and fixation options alter the torque of screw insertion and load to failure.

Hypothesis: It was hypothesized that retention of the lateral cortex of the DTA graft and the presence of a washer with the screw will significantly increase the maximum screw placement torque as well as the load to failure.

Study Design: Controlled laboratory study.

Methods: Whole, fresh distal tibias were used to harvest 28 DTA grafts, half of which had the lateral cortex removed and half of which had the lateral cortex intact. The grafts were secured to polyurethane solid foam blocks with a 2-mm epoxy laminate to simulate a glenoid with an intact posterior glenoid cortex. Grafts underwent fixation with 4.0-mm cannulated drills, and screws and washers were used for half of each group of grafts while screws alone were used for the other half, creating 4 equal groups of 7 samples each. A digital torque-measuring screwdriver recorded peak torque for screw insertion. Constructs were then tested in compression with a uniaxial materials testing system and loaded in displacement control at 100 mm/min until at least 3 mm of displacement occurred. Ultimate load was defined as the load sustained at clinical failure.

Results: The use of a washer significantly improved the ultimate torque that could be applied to the screws (+cortex and +washer = 12.42 N·m [SE, 0.82]; -cortex and +washer = 10.54 N·m [SE, 0.59]) ( < .0001), whereas the presence of the native bone cortex did not have a significant effect (+cortex and -washer = 7.83 N·m [SE, 0.40]; -cortex and -washer = 8.03 N·m [SE, 0.56]) ( = .181).

Conclusion: In a hybrid construct of fresh cadaveric DTA grafts secured to a foam block glenoid model, the addition of washers was more effective than the retention of the lateral distal tibial cortex for both load to failure and peak torque during screw insertion.

Clinical Relevance: This biomechanical study is relevant to the surgeon when choosing a graft and selecting fixation options during glenoid reconstruction with a DTA graft.
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http://dx.doi.org/10.1177/23259671211050435DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8581783PMC
November 2021

Too Loud for Comfort: A Simulated Evaluation of Cast Saw Noise.

J Pediatr Orthop 2021 Nov-Dec 01;41(10):e889-e893

Department of Orthopaedic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA.

Background: Orthopaedic cast saws are an integral component to a pediatric orthopaedic practice but can also be associated with patient anxiety and noise exposure for patient. Although previous studies have deemed the noise generation from orthopaedic cast saws to be within safe occupational exposure levels, no study to date has compared the noise generation from a cast saw used in various exam room settings.

Methods: A simulated fiberglass cast model was used. Noise generation was assessed using calibrated sound level meters with measurements performed at 18 inches, 36 inches, and 6 ft measured from the cast saw. Measurements were performed in 1 of 2 clinical settings: (1) an open bay setting and (2) an enclosed exam room. In the enclosed exam room, the 6-foot measurement was performed behind the closed exam door. An orthopaedic cast saw with built-in vacuum was used to continuously cut the fiberglass model for 1 minute with measurements of peak and mean sound generation, recorded in decibels (dB), a logarithmic scale. Three measurements were recorded at each distance. Between group comparisons were performed with statistical significance set at P=0.05.

Results: Baseline sound levels were similar between cohorts with progressive decreases in mean sound with increasing distance from the saw. Mean sound levels were significantly higher in the enclosed room setting at 18 inches (92.8 dB, 95% confidence interval (CI): 91.72-93.88 vs. 90.6 dB, 95% CI: 89.91-91.29; P=0.043] and 36 inches (90.3 dB, 95% CI: 89.9-90.7 vs. 86.0 dB, 95% CI: 85.18-86.82; P=0.017). At 6-ft distance, however, the enclosed room demonstrated a 13.8-fold sound reduction compared with the open bay (72.0 dB, 95% CI: 71.59-72.4 vs. 83.4 dB, 83.14-83.72; P<0.001).

Conclusion: By closing the exam door, a 13-fold reduction in noise exposure can be achieved for adjacent patients and personnel. Consideration should be given for using orthopaedic cast saws in an enclosed exam room to prevent unnecessary noise exposure with hearing protection of cast saw operators and treated patients.

Clinical Relevance: Orthopaedic cast removal.
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http://dx.doi.org/10.1097/BPO.0000000000001941DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8508722PMC
October 2021

Parachute-Induced Pectoralis Major Tears in Military Servicemembers: What Is the Functional Recovery?

Orthop J Sports Med 2021 Jun 16;9(6):23259671211014494. Epub 2021 Jun 16.

Department of Orthopaedic Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia, USA.

Background: Although the most common injury mechanism for pectoralis major (PM) tears is an eccentric loading mechanism typically caused by bench pressing, within the military, there is a unique injury mechanism associated with airborne operations. The results of operative repair for these parachute-induced PM tears have not been previously reported.

Purpose/hypothesis: To assess the functional outcomes in military servicemembers undergoing operative repair of parachute-induced PM tears. We hypothesized that functional recovery would be impaired with delayed surgical intervention.

Study Design: Cohort study; Level of evidence, 3.

Methods: Included were active duty military servicemembers who underwent operative repair for PM tears caused by a parachute-induced mechanism. Charts were reviewed to identify characteristic, injury, and surgical variables. Patients completed the functional outcome assessment with the Disabilities of the Arm, Shoulder and Hand (DASH) and the American Shoulder and Elbow Surgeons (ASES) questionnaires. Outcomes were compared between patients treated within 6 weeks of injury and those treated beyond 6 weeks.

Results: Of the 68 identified PM tears, 25 were the result of parachute-induced mechanisms. A total of 13 patients consented and completed the functional outcome assessment. The mean patient age was 30.6 ± 6.4 years, and the mean follow-up period was 5.46 ± 1.26 years. Ten patients underwent repair within 6 weeks of injury, and the remaining 3 patients underwent repair at a mean of 338 days after injury (95% CI, -42.8 to 718.8 days), a significant difference between groups ( = .006). All 13 patients were able to return to military duties at a mean of 6 months from injury. Patients treated within 6 weeks of injury had significantly higher functional outcomes (DASH score, 6.17 vs 26.67; = .018; ASES score, 85.97 vs 49.5; = .008), with greater strength performance compared with preinjury (bench press, 90.58% vs 38.95%; = .0057; push-ups, 81.9% vs 23.8%; = .023) compared with patients treated beyond 6 weeks of injury.

Conclusion: Operative repair of parachute-induced PM tears within 6 weeks of injury provided a superior functional and strength recovery when compared with delayed surgical repair. Acute repair should be recommended for military servicemembers who experience this unique injury mechanism.
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http://dx.doi.org/10.1177/23259671211014494DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8212380PMC
June 2021

Primary Medial Patellofemoral Ligament Reconstruction in Military Servicemembers: Can We Reliably Restore Preinjury Function and Stability?

Orthop J Sports Med 2021 Jun 11;9(6):23259671211013334. Epub 2021 Jun 11.

Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA.

Background: Medial patellofemoral ligament (MPFL) reconstruction for patellar instability is a commonly performed procedure with a reported high rate of return to preinjury activity. However, no previous study has assessed the functional outcomes of military servicemembers undergoing MPFL reconstruction.

Hypothesis: Primary MPFL reconstruction confers patellar stability, but with limited return to preinjury function and ability to maintain unrestricted military active duty status.

Study Design: Case series; Level of evidence, 4.

Methods: Using the Management Analysis and Reporting Tool database, we conducted a retrospective review of active duty servicemembers throughout the US Department of Defense Health System who underwent primary MPFL reconstruction between 2012 and 2015. Demographic variables were recorded as well as ability to return to impact activities-defined as running, jumping, rucking with a load >40 pounds (18 kg), and returning to airborne operations-and to remain on active duty status. The rates of recurrent instability and the need for subsequent surgeries were identified and assessed for statistical significance using uni- and multivariate analyses. Patients were evaluated for a minimum of 2 years postoperatively.

Results: Of the 213 patients who underwent primary MPFL reconstruction, including 34 with concomitant tibial tubercle osteotomy, 19 (8.9%) patients developed recurrent instability. The presence of bilateral patellar instability was associated with higher recurrence rate. Patients with bilateral instability comprised 47.3% of those with recurrence but only 24.9% of patients without recurrence ( = .019). Impact activity restrictions were present in 57.6% of patients (n = 121), with 86 patients (52.1%) undergoing medical separation from the military. Patients who were prescribed activity restriction before surgery were significantly more likely to have postoperative activity restrictions (64.5%; = .019), and junior enlisted servicemembers were more likely to be medically separated from service postoperatively than higher ranking senior enlisted members or officers.

Conclusion: Only 42.4% of US military servicemembers undergoing primary MPFL reconstruction were able to return to unrestricted impact activity after surgery. Bilateral instability negatively affected return to impact activities. Military servicemembers, particularly junior enlisted members, should be counseled on this poor prognosis for a full return to unrestricted activity postoperatively.
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http://dx.doi.org/10.1177/23259671211013334DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8202279PMC
June 2021

Application of a Halo Fixator for the Treatment of Pediatric Spinal Deformity.

JBJS Essent Surg Tech 2021 Jan-Mar;11(1). Epub 2021 Feb 17.

Children's Healthcare of Atlanta, Atlanta, Georgia.

Background: In spine surgery, the halo fixator was initially utilized to stabilize cervical fusions in patients with poliomyelitis. More recently, the indications for halo fixation have evolved to include stabilization and definitive treatment for upper cervical spine injuries (Jefferson fractures, atlanto-occipital dissociations, odontoid fractures, etc.), treatment of atlantoaxial rotatory subluxation, stabilization of long cervical fusions, and preoperative traction. In the realm of pediatric spinal deformity, halo fixation has proved to be a valuable resource for severe or neglected spinal deformities. In this video article, we demonstrate the application of a halo fixator in a pediatric patient with severe scoliosis.

Description: The procedure includes appropriate pin placement in the safe zones of the skull performed under either general anesthesia or local anesthesia. Pins are secured to a halo frame that is sized to be 2 cm larger than the circumference of the skull and are tightened according to age-specific torque guidelines.

Alternatives: Alternative treatments vary from cervical spine immobilization to definitive surgical treatment in the spine, or even spinal osteotomies, depending on the underlying spinal pathology.

Rationale: The halo fixator works by limiting motion of the cervical spine in flexion, extension, and axial rotation. The halo is also able to control and correct translational injuries of the cervical spine. In the setting of spinal deformity, the halo fixator can also be utilized to overcome the effects of gravity and lengthen the spine.

Expected Outcomes: For spinal deformities, the halo fixator can be expected to lengthen the spine and increase deformity flexibility prior to definitive surgical treatment in the spine or growth-friendly spinal instrumentation.

Important Tips: Correct identification of safe zones for pin placement is vital to correct pin placement.For pediatric patients, it is important to obtain fixation with a minimum of 6 to 8 pins.Pins should be tightened with use of a torque-limiting wrench, up to no more than 1 in/lb (55.9 mm/kg) per year of age, up to a maximum of 8 in/lb (447.9 mm/kg).Applied traction should be a maximum of 50% of the body weight of the patient.Neurovascular examination is vital following application of weight.
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http://dx.doi.org/10.2106/JBJS.ST.20.00005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8189602PMC
February 2021

Comparative cost-utility analysis of postoperative discharge pathways following posterior spinal fusion for scoliosis in non-ambulatory cerebral palsy patients.

Spine Deform 2021 11 18;9(6):1659-1667. Epub 2021 May 18.

Department of Pediatric Orthopaedic Surgery, Children's Healthcare of Atlanta, Scottish Rite Campus, 5445 Meridian Mark Rd Suite 250, Atlanta, GA, USA.

Purpose: Accelerated postoperative discharge (AD) pathways have demonstrated numerous benefits for patients with adolescent idiopathic scoliosis undergoing PSF. Although early evidence supports the application of AD pathways over more traditional discharge (TD) approaches for patients with neuromuscular scoliosis, the economic impact of these pathways has not been investigated.

Methods: A decision-analysis model was constructed using a hypothetical 15-year-old male with non-ambulatory CP with a 65-degree thoracolumbar scoliosis and pelvic obliquity undergoing operative treatment with PSF from T2-pelvis with pedicle screw fixation. The literature was reviewed to estimate costs, probabilities, and quality-adjusted life years (QALYs)) for identified complication profiles for discharge pathways. QALYs were constructed using age-matched values for US population average, applying a CP diagnosis corrective value. A probabilistic sensitivity analysis was performed using a second-order Monte Carlo simulations. Incremental cost-utility ratio and incremental net monetary benefit (NMB) were calculated. One-way sensitivity analyses were performed by selective variable variation.

Results: AD pathway resulted in an average cost and effectiveness of $67,069 and 15.4 QALYs compared with $81,312 and 15.4 QALYs for TD. AD resulted in a 2.1% greater NMB with a cost-effectiveness ratio of $4361/QALY compared with $5290/QALY in the TD. The cost-effectiveness of TD was inversely sensitive to implant cost variation while the AD maintained effectiveness despite cost variations.

Conclusion: This cost-utility analysis demonstrated that the implementation of an AD pathway following PSF for non-ambulatory CP scoliosis is economically more effective, providing a 17.5% cost reduction with enhanced value of care evidenced by a 2.1% greater NMB over a TD pathway. The cost-effectiveness of the AD was maintained despite implant cost variations.
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http://dx.doi.org/10.1007/s43390-021-00362-yDOI Listing
November 2021

5 ns electric pulses induce Ca-dependent exocytotic release of catecholamine from adrenal chromaffin cells.

Bioelectrochemistry 2021 Aug 27;140:107830. Epub 2021 Apr 27.

Department of Pharmacology, University of Nevada, Reno School of Medicine, 1664 N. Virginia St., Reno, NV 89557, USA.

Previously we reported that adrenal chromaffin cells exposed to a 5 ns, 5 MV/m pulse release the catecholamines norepinephrine (NE) and epinephrine (EPI) in a Ca-dependent manner. Here we determined that NE and EPI release increased with pulse number (one versus five and ten pulses at 1 Hz), established that release occurs by exocytosis, and characterized the exocytotic response in real-time. Evidence of an exocytotic mechanism was the appearance of dopamine-β-hydroxylase on the plasma membrane, and the demonstration by total internal reflection fluorescence microscopy studies that a train of five or ten pulses at 1 Hz triggered the release of the fluorescent dye acridine orange from secretory granules. Release events were Ca-dependent, longer-lived relative to those evoked by nicotinic receptor stimulation, and occurred with a delay of several seconds despite an immediate rise in Ca. In complementary studies, cells labeled with the plasma membrane fluorescent dye FM 1-43 and exposed to a train of ten pulses at 1 Hz underwent Ca-dependent increases in FM 1-43 fluorescence indicative of granule fusion with the plasma membrane due to exocytosis. These results demonstrate the effectiveness of ultrashort electric pulses for stimulating catecholamine release, signifying their promise as a novel electrostimulation modality for neurosecretion.
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http://dx.doi.org/10.1016/j.bioelechem.2021.107830DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8187336PMC
August 2021

Post-operative radiculitis following one or two level anterior lumbar surgery with or without posterior instrumentation.

J Orthop 2021 May-Jun;25:45-52. Epub 2021 Apr 2.

Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia.

The purpose of this study was to define risk factors for non-compression radiculitis following anterior lumbar surgery with or without posterior instrumentation and to define a time to resolution. In this study, we followed 58 consecutive patients who had anterior lumbar surgery with or without posterior instrumentation. We identified those with and without post-operative radiculitis. There as a 36.5% rate of postoperative radiculitis. We found that there was a moderate to strong correlation with height change and radiculitis ( = 0.044). Additionally patients treated with rh-BMP2 had a higher risk of developing symptoms. In all of the patients who developed postoperative radiculitis, symptoms resolved by 3 months. In conclusion 36.5% of patients developed post operative radiculitis. This was associated with the use of rh-BMP2, as well as increasing disc height through surgery. All symptoms resolved by 3 months posoperatively.
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http://dx.doi.org/10.1016/j.jor.2021.03.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8065250PMC
April 2021

In-hospital opioid usage following posterior spinal fusion for adolescent idiopathic scoliosis: Does methadone offer an advantage when used with an ERAS pathway?

Spine Deform 2021 07 18;9(4):1021-1027. Epub 2021 Mar 18.

Department of Pediatric Orthopaedic Surgery, Children's Healthcare of Atlanta, Scottish Rite Campus, Atlanta, GA, USA.

Purpose: Intraoperative methadone has been shown to decrease opioid medication requirement following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). No study to date has investigated the effect of methadone on opioid medication requirement when used in conjunction with an enhanced recovery after surgery (ERAS) protocol following PSF.

Methods: A retrospective cohort study was performed at a single, tertiary care pediatric hospital. Patients with AIS undergoing PSF were consecutively given a single intra-operative methadone dose and matched 1:2 to a AIS control group without methadone. Patients were matched for age, curve magnitude, levels fused, blood loss, and operating time. All children followed a standard ERAS protocol with methadone being the only change in the post-operative regimen. In-hospital data for opioid and non-opioid medication use, surgical, and patient variables were recorded and compared between cohorts.

Results: Twenty-six patients received methadone (average 15.1 ± 1.9 years) and were matched with 52 control patients without methadone (average 14.7 ± 2.2 years). There were no significant differences in total opioid usage at any time-interval prior to hospital discharge or in cumulative opioid usage. Additionally, patients had a similar VAS pain level at discharge (methadone: 4.0 ± 2.3 vs control: 3.8 ± 1.9; P = 0.572). Total opioid usage was correlated with LOS. There were no opioid-related medication complications in either cohort.

Conclusion: There was no decrease of in-hospital opioid usage when methadone was used with an ERAS protocol. Total opioid usage is correlated with hospital LOS following PSF.
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http://dx.doi.org/10.1007/s43390-021-00288-5DOI Listing
July 2021

Making Use of Your Assets: Clinical Use of EOD Radiography in the Forward-Deployed Setting.

J Spec Oper Med 2021 ;21(1):87-89

Ultrasonography is currently the primary means of imaging for forward surgical teams/forward resuscitative surgical teams (FSTs/FRSTs). As FSTs/FRSTs are pushed farther forward into more austere environments, access to other imaging modalities may be limited, potentially affecting resources. On a recent deployment, the 126th FRST was able to use radiography equipment from a co-located explosive ordnance disposal (EOD) team to assist in the diagnosis and treatment of medical and surgical patients, thereby saving time and resources. We provide three case examples in which using EOD radiography assisted in clinical decision making. Although the safety profile has not been assessed for clinical use in humans, EOD radiography can be a useful technique to aid in time-sensitive decision making in resource-constrained operational areas.
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March 2021

Current Variation in Joint Aspiration Practice for the Evaluation of Pediatric Septic Arthritis.

J Am Acad Orthop Surg Glob Res Rev 2020 09;4(9):e20.00133

Children's Healthcare of Atlanta, Department of Pediatric Orthopaedic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA.

Introduction: Pediatric septic arthritis (SA) is a condition that can be associated with significant morbidity. Although previous research has been on predictive care pathways, scrutiny of the literature continues to reveal wide differences in the patient evaluation and management. The purpose of this study was to define the differences in joint aspiration for the evaluation of pediatric SA across pediatric tertiary care institutions in the United States.

Methods: Surgeons from 18 pediatric tertiary care centers across the United States were surveyed on current institutional practices regarding joint aspiration, laboratory studies, MRI usage, and treatment timing in the evaluation for SA. Responses were recorded by institution and analyzed to generate descriptive statistics.

Results: Responses were received from all institutions asked to participate. Overall, joint specific practice variation exists regarding the person completing the aspiration, where the aspiration is performed, utilization of image guidance, and the utilization of anesthesia. Additional areas of variation included the method and calculation of cell count and the routine use of MRI.

Discussion: Significant practice variations exist across pediatric tertiary care centers for the evaluation of pediatric SA. Using these data, future prospective studies can be used to unify institutional practices to minimize practice variation and ultimately improve the care delivery to pediatric patients presenting with SA.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-20-00133DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7469993PMC
September 2020

Magnetic Resonance Imaging of Pectoralis Major Injuries in an Active Duty Military Cohort: Mechanism Affects Tear Location.

Orthop J Sports Med 2020 Jun 10;8(6):2325967120925019. Epub 2020 Jun 10.

Department of Orthopaedic Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia, USA.

Background: Pectoralis major (PM) tendon tears are common injuries in athletic patient populations, where operative repair is largely recommended for maximum functional recovery. The repair varies in difficulty and technique based on the location of the tear within the muscle-tendon unit. Magnetic resonance imagining (MRI) has been reported to be sensitive and specific for identifying the tear location, but the effect of injury mechanism on tear pattern has not been previously investigated.

Purpose: To examine PM tears in a military patient population and assess the effect of injury mechanism (weightlifting vs high-energy trauma) on the tear pattern and accuracy of MRI interpretation.

Study Design: Cohort study; Level of evidence, 3.

Methods: Active duty military servicemembers undergoing operative repair of PM tendon tears with corresponding preoperative MRIs from 2 medical centers were identified. Two musculoskeletal fellowship-trained radiologists reviewed imaging studies, reporting the location of the tear within the muscle-tendon unit and the severity of the tear (sternal head vs clavicular head vs both). Radiographic findings were compared against intraoperative findings. Mechanism of injury and timing from injury to imaging and surgery were assessed to determine whether they affected the accuracy of MRI interpretations.

Results: A total of 72 patients were included (mean ± SD age, 33.7 ± 7.0 years; 100% male). Mechanisms of injury consisted of 46 weightlifting injuries and 26 high-energy injuries. Interrater reliability was poor for tear location (kappa, 0.162; = .003) but substantial for extent of tear (kappa, 0.637; < .0001). MRI had a 51.3% sensitivity and 63.6% specificity for identifying complete tears. MRI had a sensitivity of 73.9% and specificity of 72.2% for avulsion injuries and sensitivity of 75% and specificity of 79.3% for musculotendinous injuries. Mechanism of injury had no effect on extent of the tear but did affect the location of the tear, with a higher rate of avulsion injuries in the high-energy mechanism cohort (81% vs 40%; = .02).

Conclusion: The mechanism of injury was found to significantly affect the location of tendon tears. A higher rate of avulsion injuries was found in high-energy injuries than weightlifting injuries. MRI appeared to be less sensitive and specific than previous reports for traumatic PM tendon injuries.
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http://dx.doi.org/10.1177/2325967120925019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7288815PMC
June 2020

Are precontoured cobalt-chromium spinal rods mechanically superior to manually contoured rods?

Spine Deform 2020 10 18;8(5):871-877. Epub 2020 May 18.

Department of Pediatric Orthopedic Surgery, Children's Healthcare of Atlanta, Scottish Rite Campus, Atlanta, GA, USA.

Study Design: Laboratory based study.

Objective: To compare reduction force and plastic deformation of cobalt-chromium (Co-Cr) spinal rods using a rigid, thoracolumbar spinal deformity model. Pre-contoured spinal rods are growing in their utilization for spinal deformity. Although there are theoretical advantages to pre-contouring rods, no previous studies have compared pre-contoured and manually contoured rods for their ability to maintain sagittal contour and resist mechanical load.

Methods: A spinal deformity model was utilized, simulating a rigid, thoracolumbar spinal deformity fixated with pedicle screws. Roll-formed pre-contoured and manually contoured 5.5 mm and 6.0 mm Co-Cr rods were reduced to the model with a load cell attached to the apical screw to measure corrective force. Rods remained reduced in the model for 20 min and change in contour was assessed to characterize plastic deformation.

Results: Twenty-four rods were tested with six rods per group (Table 1). The load to reduction was significantly lower in the 5.5 mm rods compared to the 6.0 mm rods (95% CI -254.0 to -61.42; p = 0.008). Although there was no difference in the corrective forces for manual and pre-contoured 5.5 mm rods (p = 0.722), the 6.0 mm rod produced significantly less corrective force compared to the manually contoured 6.0 mm rods (95% CI -134.42 to -5.317; p = 0.039). Additionally, rod contour for the manual group showed significantly less plastic deformation than the pre-contoured group in both 5.5 mm and 6.0 mm rods (5.5 mm: 57.1% vs. 61.6%, p = 0.006; 6.0 mm: 54.3% vs. 62.28%, p = 0.003).

Conclusions: Roll formed, pre-contoured Co-Cr rods demonstrated significantly greater plastic deformation when compared with manually contoured rods of the same diameter. Furthermore, 6.0 mm pre-contoured rods required significantly lower load for rod reduction, the equivalent of 15 lb-force. Post-manufacturing, roll-formed pre-contouring of larger diameter Co-Cr may impair the rods mechanical properties.
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http://dx.doi.org/10.1007/s43390-020-00133-1DOI Listing
October 2020

Guided growth for the Treatment of Infantile Blount's disease: Is it a viable option?

J Orthop 2020 Jul-Aug;20:41-45. Epub 2020 Jan 10.

Department of Orthopaedic Surgery, Children's Hospital of Georgia at Augusta University, Augusta, GA, USA.

Introduction: Guided growth with temporary hemiepiphysiodesis has gained interest as a less invasive means for the treatment of coronal plane lower extremity deformities as well as leg length discrepancies. Its application to infantile Blount's disease has been less reported. The object of this study was to identify predictive factors of guided growth for treatment of infantile Blount's.

Methods: A retrospective review was performed of children undergoing guided growth for the treatment of infantile Blount's disease over an eight-year period. Inclusion criteria included treatment with THE for infantile Blount's disease. Clinical information, preoperative Langenskiold classification, and intra-operative and post-operative data. Preoperative variables were used to identify risk factors for speed of correction and the need for subsequent surgery.

Results: A total of 11 patients, 17 extremities, meeting inclusionary criteria. Preoperatively, 7 extremities were classified as Langenskiold stage ≥3, with 12 being classified as stage ≤2. Overall, the Drennan's angle improved from 18.3° to 0.3° by final follow-up at an average of 4.31 years. Eight extremities demonstrated deformity recurrence/persistence (stage ≤2:33% vs stage ≥3: 100%), requiring 24 reoperations. Children with Langenskiold stage ≥3 demonstrated a significantly higher rate of reoperation.

Conclusion: Guided growth is a viable treatment option for Infantile Blount's disease presenting with Langenskiold stage ≤2 disease at treatment initiation. The treatment course can expect a 33% rate of recurrent deformity, treated successfully with repeat THE. No child stage ≤2 required corrective osteotomy. Caution should be used when considering guided growth for children presenting with Langenskiold stage ≥3.
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http://dx.doi.org/10.1016/j.jor.2020.01.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7000423PMC
January 2020

Use of electrocautery does not diminish the transmission rate of compared to a scalpel blade.

J Orthop 2020 May-Jun;19:162-165. Epub 2019 Nov 27.

Department of Orthopaedics, Augusta University Medical Center, Augusta, GA, USA.

Many methods are used during shoulder surgery to prevent wound contamination with , but there are no accepted standards for prevention. Some surgeons use an electrosurgical instrument instead of a scalpel blade during open shoulder surgery in an effort to prevent deep tissue contamination with . We sought to compare the transference rate of between a scalpel blade at room temperature and an electrosurgical blade heated to 41°C (temperature of electrosurgical blade after standard deltopectoral approach). In our model, using a scalpel blade versus a heated electrosurgical blade resulted in no difference in pathogen transference.
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http://dx.doi.org/10.1016/j.jor.2019.11.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6997636PMC
November 2019

Diagnosis and Management of Common Conditions of the Pediatric Spine.

Instr Course Lect 2020 ;69:349-362

Back pain and spinal deformity in the pediatric and adolescent patient population are common reasons for presentation to the orthopaedic surgeon, and although most conditions are benign and self-limiting, a standardized approach to the history and physical examination can identify concerning signs and symptoms as well as aid in determining the final diagnosis and a recommended treatment plan. The most common and concerning etiologies of back pain and spinal deformity will be reviewed, along with nonsurgical and surgical management of these conditions.
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February 2020

Magnetic Resonance Imaging Correlates With Computed Tomography for Glenoid Version Calculation Despite Lack of Visibility of Medial Scapula.

Arthroscopy 2020 01;36(1):99-105

Steadmon Phillipon Research Institute, Vail, Colorado, U.S.A.

Purpose: To assess the accuracy of measuring glenoid version on magnetic resonance imaging (MRI) in the presence of varying amounts of the medial scapula body as compared with the gold standard of glenoid version measured on computed tomography (CT) imaging, including the entire scapula in a cohort of young patients with shoulder instability and without glenohumeral arthritis.

Methods: A retrospective review was performed on instability patients with preoperative MRI and CT imaging. Measurements of available scapular width and glenoid version were performed using the Cobb angle method to measure the angle between the plane of the glenoid fossa to Friedman's line on axial images. Intra- and interrater reliability analysis was performed using intraclass correlation coefficients to assess agreement between MRI and CT measurements. Paired t tests were used to compare measurement differences between MRI and CT.

Results: Thirty-two patients with both MRI and CT scans were assessed. Intra- and inter-rater assessment revealed strong agreement for scapular width measurement. For glenoid version measurement, intra-rater agreement was excellent and inter-rater agreement was moderate on CT and good on MRI. The mean available scapular body width was 24.7 mm longer on CT as compared with MRI (95% confidence interval 17.5-31.9, P < .0001; 109.8 ± 8.2 mm vs 85.1 ± 16.9 mm, respectively), with MRI having an average of 78.2% (±17.6%) of the CT scapular width shown on CT. No significant difference in glenoid version was found between MRI and CT (95% confidence interval -0.87 to 1.75, P = .499; MRI -2.57° vs CT -2.13°).

Conclusion: MRI provided significantly shorter available scapular widths when compared with CT imaging in a cohort of patients with glenohumeral instability and without arthritis. However, this failed to produce a significant difference of ≥5° in measured glenoid version compared with CT measurements when 75% (8 cm) of the scapular width was present on MRI. Measuring glenoid version on MRI does not appear to be significantly affected when the entirety of the medial border of the scapula is not included in the imaging field.

Level Of Evidence: Level III; study of diagnostic test.
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http://dx.doi.org/10.1016/j.arthro.2019.07.030DOI Listing
January 2020

Exploring Penicillin G as an Intrawound Antibiotic Powder for Prevention of Postoperative Shoulder Infections: Does It Exhibit In Vitro Chondrotoxicity?

J Orthop Res 2020 04 22;38(4):726-730. Epub 2019 Nov 22.

Department of Orthopaedic Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia.

Cutibacterium acnes (C. acnes) is a significant insidious pathogen for postoperative infections in shoulder surgery. Studies have demonstrated that certain topical antibiotic powders used have the potential for chondrotoxicity. Benzylpenicillin, commonly referred to as Penicillin G (Pen G) has the lowest minimum inhibitory concentration (MIC) for C. acnes. There is no research regarding the topical application of Pen G during shoulder surgery, nor has its chondrocyte toxicity been previously investigated. This study sought to characterize the in vitro chondrocyte toxicity of Pen G. Culture-derived bovine chondrocytes were exposed to serial Pen G concentrations and compared with a positive and negative control. A negative control of growth medium and positive control of 1% Triton solution. The chondrocyte viability was assessed via spectrophotometer absorbance. The treatment groups were analyzed using one-way repeated measures analysis of variance and Pearson's correlation analysis. The chondrocyte viability was significantly higher for all Pen G concentrations as compared with the positive control (p < 0.001). All concentrations of Pen G exhibited continued chondrocyte metabolic activity over time. Analysis of variance, independent of time, demonstrated no significant decrease in chondrocyte viability for Pen G concentrations ≤6.25 mg/ml, as compared with the negative control (p > 0.05). Pen G demonstrated a significant negative correlation with its concentration and absorbance (r = 0.371, p < 0.001), however, concentrations ≤6.25 mg/ml did not demonstrate a significant decrease in chondrocyte viability (p = 0.063). Pen G in concentrations appropriate for C. acnes is not significantly chondrotoxic and may be safe for intrawound application. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:726-730, 2020.
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http://dx.doi.org/10.1002/jor.24524DOI Listing
April 2020

Salvage Treatment Options for Painful Hip Dislocations in Nonambulatory Cerebral Palsy Patients.

J Am Acad Orthop Surg 2020 May;28(9):363-375

From the Department of Orthopaedic Surgery (Dr. Shaw), Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA, the Department of Orthopaedic Surgery (Dr. Shaw and Dr. Cearley), Children's Hospital of Georgia at Augusta University, Augusta, GA, and the Department of Orthopaedic Surgery (Dr. Hire), General Leonard Wood Army Community Hospital, Fort Leonard Wood, MO.

Hip dislocation is a common occurrence in nonambulatory patients with cerebral palsy, occurring in up to 70% of patients. However, only 15% to 57% of chronic dislocations progress to become painful. In these patients, several salvage treatment options are available, including proximal femoral resection, subtrochanteric valgus osteotomy, hip arthrodesis, and prosthetic arthroplasty. Of the options, proximal femoral resection, subtrochanteric osteotomy, and prosthetic arthroplasty have been shown to provide reliable pain relief with improved sitting balance, with no evidence of one technique being superior to another. However, each technique has unique aspects to its postoperative care and potential complication profile that requires thorough understanding and communication with parents/caregivers when considering surgical intervention.
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http://dx.doi.org/10.5435/JAAOS-D-19-00349DOI Listing
May 2020

Demographics and Distal Tibial Dimensions of Suitable Distal Tibial Allografts for Glenoid Reconstruction.

Arthroscopy 2019 10 13;35(10):2788-2794. Epub 2019 Sep 13.

Steadman Philippon Research Institute, Vail, Colorado, U.S.A.

Purpose: To evaluate whether characteristics such as age, height, weight, sex, or body mass index affected the distal tibial dimensions and radius of curvature (ROC) of a potential donor for anterior glenoid augmentation.

Methods: A retrospective review of magnetic resonance imaging of ankles without bony trauma was performed, and the anteroposterior (AP) and medial-lateral (ML) distances and ROC of the tibial plafond articular surface were measured. Demographic characteristics, including age, sex, height, weight, and body mass index, were recorded.

Results: A total of 141 imaging studies were included (73 men and 68 women; average age, 38.2 ± 12.65 years). All potential specimens accommodated harvest of a 10 × 22-mm distal tibial allograft bone block. Men had greater ML (42.74 cm [95% confidence interval (CI), 42.09-43.39 cm] vs 38.01 cm [95% CI, 37.30-38.72 cm]; P < .001) and AP (38.16 cm [95% CI, 37.47-38.85 cm] vs 34.57 cm [95% CI, 33.97-35.17 cm]; P < .001) dimensions. Significant moderately positive correlations were found for AP dimensions with height (r = 0.584, P < .001) and weight (r = 0.383, P < .001) and for ML dimensions with height (r = 0.711, P < .001) and weight (r = 0.467, P < .001). ROC was positively correlated with height (r = 0.509, P < .001) and weight (r = 0.294, P < .001). Patient age was not related to either the AP or ML distal tibial dimensions or ROC.

Conclusions: After magnetic resonance imaging analysis, all potential donors permitted harvest of a standard-sized distal tibial allograft irrespective of sex or common anthropometric measures, and 85.8% showed distal tibial morphology acceptable for glenoid augmentation. AP and ML graft dimensions and ROC correlated significantly with height and weight.

Level Of Evidence: Level II, diagnostic study.
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http://dx.doi.org/10.1016/j.arthro.2019.05.019DOI Listing
October 2019

Fundamental principles of rehabilitation and musculoskeletal tissue healing.

Vet Surg 2020 Jan 4;49(1):22-32. Epub 2019 Jul 4.

Department of Small Animal Surgery, University of Zurich, Zurich, Switzerland.

Objective: To review fundamental principles of tissue healing and physical rehabilitation as they apply to dogs recovering from cranial cruciate ligament (CCL) surgery.

Study Design: Invited Review.

Sample Population: None.

Methods: A multidisciplinary group of specialists in small animal surgery, rehabilitation/sports medicine, and human physical and occupational therapy reviewed the currently available evidence for rehabilitation post-CCL surgery. Because current evidence is limited, this group proposes guidelines for rehabilitation after CCL surgery based on the fundamental principles of tissue healing and physical therapy.

Results: This Review proposes four fundamental principles of small animal physical rehabilitation based on the foundations of tissue healing and patient-centric and goal-oriented therapy. Postoperative rehabilitation programs should be designed such that patient progress is based on individual assessment according to the degree of tissue healing, strength, and achievement of functional goals. Therapists must fully understand phases of tissue healing, reassess the patient frequently, and use clinical reasoning skills to progress treatment appropriately for the individual patient.

Conclusion: Until more robust evidence is available to guide treatment protocols, fundamental principles of rehabilitation should ideally be adhered to when providing rehabilitation, including after CCL surgery.

Clinical Significance: While this Review specifically addresses post-CCL surgery rehabilitation, these fundamental principles should be applied broadly to animals enrolled in rehabilitation programs.
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http://dx.doi.org/10.1111/vsu.13270DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6973127PMC
January 2020

Outcomes After Fresh Osteochondral Allograft Transplantation for Medium to Large Chondral Defects of the Knee.

Orthop J Sports Med 2019 Mar 19;7(3):2325967119832299. Epub 2019 Mar 19.

Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA.

Background: Articular cartilage defects of the knee can significantly impair function among young, high-demand patients. There are several techniques for chondral restoration, including osteochondral allograft transplantation (OCA), that may alleviate pain and re-create the native anatomy. However, clinical outcomes among athletic cohorts are limited.

Purpose: To evaluate the efficacy and functional outcomes of OCA for medium to large osteochondral defects of the knee in physically active United States military servicemembers.

Study Design: Case series; Level of evidence, 4.

Methods: A military health care database was queried to identify all OCA procedures performed between January 2009 and March 2013. Inclusion criteria were army personnel with a minimum of 2 years' follow-up. Exclusion criteria included incomplete follow-up, inaccurate coding, and nonmilitary status. Variables of interest included sex, age, lesion location, grade and size of the lesion, body mass index, tobacco use, preoperative and postoperative visual analog scale (VAS) scores for pain, and presence of perioperative complications. Overall failure was defined as the inability to return to preoperative functional activities because of persistent knee complaints (clinical failure) or a revision cartilage procedure or arthroplasty (surgical failure).

Results: A total of 61 patients (52 male; mean age, 31.7 years) were identified, with a mean 46.2-month follow-up. The mean VAS pain score improved from 4.10 ± 2.17 preoperatively to 2.68 ± 2.73 postoperatively ( < .0009), and only 6 (9.8%) required a subsequent revision chondral procedure. Overall, 39 patients (63.9%) were able to return to a level of activity that allowed for the completion of military duties. Risk factors for clinical failure were preoperative body mass index, preoperative pain as measured on the VAS, and moderate to severe postoperative pain on the VAS. The risk factor for surgical failure was the presence of a complication. Risk factors for overall failure were the presence of a complication and moderate to severe postoperative pain on the VAS.

Conclusion: OCA provided moderate success in retaining active-duty army servicemembers. Approximately two-thirds of patients undergoing OCA were able to return to their preinjury occupational activity, while approximately 57% of patients returned to prior levels without a subsequent revision chondral procedure or arthroplasty.
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http://dx.doi.org/10.1177/2325967119832299DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6429660PMC
March 2019

Late acetabular dysplasia after successful treatment for developmental dysplasia of the hip using the Pavlik method: A systematic literature review.

J Orthop 2019 Jan-Feb;16(1):5-10. Epub 2018 Dec 4.

Department of Pediatric Orthopaedic Surgery, Children's Healthcare of Atlanta, Scottish Rite Campus, Atlanta, GA, USA.

The Pavlik method is the most common method used for treatment of developmental dysplasia of the hip (DDH). Late acetabular dysplasia despite successful treatment, however, has had varied reporting. A systematic review was performed, investigating the long-term outcomes of DDH treated with the Pavlik method. Seventeen studies met inclusionary criteria, including 6029 hips treated with an average of 5.29 years follow-up. Radiographic evidence of late dysplasia was present in 280 hips, with 109 hips requiring additional surgery. A specified treatment algorithm had significantly decreased rates of radiographic dysplasia (3.8% vs 17.6%, p = 0.004).

Level Of Evidence: IV.
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http://dx.doi.org/10.1016/j.jor.2018.11.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6354705PMC
December 2018

Test yourself: question: "painless right leg swelling".

Skeletal Radiol 2019 08;48(8):1311-1312

Children's Healthcare of Atlanta, Scottish Rite Campus, Atlanta, GA, USA.

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http://dx.doi.org/10.1007/s00256-019-3147-1DOI Listing
August 2019

Test Yourself: Question: "Painless right leg swelling".

Skeletal Radiol 2019 08;48(8):1275-1277

Dwight D. Eisenhower Army Medical Center, Department of Orthopaedic Surgery, 300 East Hospital Road, Fort Gordon, GA, 30905, USA.

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http://dx.doi.org/10.1007/s00256-019-3146-2DOI Listing
August 2019
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