Synthetic Mesh Reconstruction of Chronic, Native Quadriceps Tendon Disruptions following Failed Primary Repair.

CASE: Two patients presented with chronic knee extensor mechanism disruption after failed primary repairs. Both patients had minimal ambulatory knee function prior to surgical intervention and were treated with a synthetic mesh reconstruction of their extensor mechanism. Our technique has been modified from previously described techniques used in revision knee arthroplasty. At the one-year follow-up, both patients had improvement in their active range of motion and had returned to their previous activity. CONCLUSION: Synthetic mesh reconstruction of chronic extensor mechanism disruption is a viable technique that can be utilized as salvage for the persistently dysfunctional native knee.

Outcomes Following Revision for Mechanically Assisted Crevice Corrosion in a Single Femoral Design.

BACKGROUND: Mechanically assisted crevice corrosion (MACC) is a described complication following metal-on-polyethylene (MoP) total hip arthroplasty (THA). The literature regarding outcomes following revision for MACC suggests that complication rates are high. The purpose of this investigation is to add to this literature with the largest reported series to date. METHODS: This is a retrospective cohort study of 552 consecutive patients who underwent 621 MoP primary THAs. We identified patients who subsequently underwent revision THA for a diagnosis of MACC. All patients were implanted with the same implant combination (Accolade I stem/cobalt-chromium low friction ion treatment femoral head). Patient demographic, surgical, and laboratory data were collected. Follow-up was calculated from the revision surgery and Hip Disability and Osteoarthritis Outcome Score Joint Replacement and hip subjective values (HSV) were examined at final follow-up. Descriptive statistics were performed. RESULTS: The revision rate for MACC was 11.6% and mean time to revision was 6.6 (±2.4) years. Revised patients (n = 69) had a mean preoperative serum cobalt-chromium ratio of 3.5 (±2.4). There were 8 cases of gross trunnion failure. At mean 3.2 (±1.9) years following revision, the overall major complication rate was 11.6% with a 5.8% reoperation rate. At final follow-up, mean Hip Disability and Osteoarthritis Outcome Score Joint Replacement scores were 83.2 (±15.6) and mean hip subjective value was 77.6 (±17.4). Revision resulted in significant increases in both parameters (P < .001). CONCLUSION: The incidence of MACC in MoP THA is likely higher than previously reported, particularly for certain implant combinations. Revision surgery for MACC can achieve good outcomes but a high clinical suspicion with early detection and revision is likely key to success.

Utilization Patterns, Efficacy, and Complications of Venous Thromboembolism Prophylaxis Strategies in Revision Hip and Knee Arthroplasty as Reported by American Board of Orthopaedic Surgery Part II Candidates.

BACKGROUND: The optimum venous thromboembolism (VTE) prophylaxis strategy to minimize risk of VTE and bleeding complications following revision total hip and knee arthroplasty (rTHA/rTKA) is controversial. The purpose of this study is to describe current VTE prophylaxis patterns following revision arthroplasty procedures to determine efficacy, complication rates, and prescribing patterns for different prophylactic strategies. METHODS: The American Board of Orthopaedic Surgery Part II (oral) examination case list database was analyzed. Current Procedural Terminology codes for rTHA/rTKA were queried and geographic region, VTE prophylaxis strategy, and complications were obtained. Less aggressive prophylaxis patterns were defined if only aspirin and/or sequential compression devises were utilized. More aggressive VTE prophylaxis patterns were considered if any of low-molecular-weight heparin (enoxaparin), warfarin, rivaroxaban, fondaparinux, or other strategies were used. RESULTS: In total, 6387 revision arthroplasties were included. The national rate of less aggressive VTE prophylaxis strategies was 35.3% and more aggressive in 64.7%. Use of less aggressive prophylaxis strategy was significantly associated with patients having no complications (89.8% vs 81.9%, P < .001). Use of more aggressive prophylaxis patterns was associated with higher likelihood of mild thrombotic (1.2% vs 0.3%, P < .001), mild bleeding (1.7% vs 0.6%, P < .001), moderate thrombotic (2.6% vs 0.4%, P < .001), moderate bleeding (6.2% vs 4.0%, P < .001), severe bleeding events (4.4% vs 2.4%, P < .001), infections (6.4% vs 3.8%, P < .001), and death within 90 days (3.1% vs 1.3%, P < .001). There were no significant differences in rates of fatal pulmonary embolism (0.1% vs 0.04%, P = .474). Subgroup analysis of rTHA and rTKA patients showed similar results. CONCLUSION: The individual rationale for using a more aggressive VTE prophylaxis strategy was unknown; however, more aggressive strategies were associated with higher rates of bleeding and thrombotic complications. Less aggressive strategies were not associated with a higher rate of thrombosis. LEVEL OF EVIDENCE: Therapeutic Level III.

Preoperative Analgesia, Complications, and Resource Utilization After Total Hip Arthroplasty: Tramadol Is Associated With Less Risk Than Other Preoperative Opioid Medications.

BACKGROUND: Preoperative opioid use is known to be detrimental to outcomes after total hip arthroplasty (THA). This is concerning as multiple societies recommend tramadol for the management of arthritis. The purpose of this study was to determine if tramadol is associated with postoperative complications, increased resource utilization, and revision when compared with patients receiving nontramadol opioids (NTOs) and those who are opioid naive (ON). METHODS: This is a retrospective cohort study using the Truven MarketScan databases (Truven Health, Ann Arbor, MI). Adult patients undergoing primary THA were identified and divided into 4 cohorts based on preoperative opioid medications (ie, ON, tramadol-only [TO], or NTOs; ±tramadol). Demographics, comorbidities, and 90-day complications were collected and compared between cohorts. Revision rates were compared at 3 years. Univariate and multivariate analyses were performed. Finally, preoperative prescription patterns were trended during the study period. RESULTS: About 198,357 patients, including 18,694 TO and 106,768 ON, were identified. Compared with ON, TO patients had similar rates of complications and revision surgery (P > .05) but had slightly higher emergency department visits (odds ratio [OR], 1.06; 95% confidence interval [95% CI], 1.01-1.12; P = .027), readmissions (OR, 1.16; 95% CI, 1.09-1.22; P < .001), and nonhome discharges (OR, 1.07; 95% CI, 1.02-1.12; P = .010). TO patients had significantly lower odds of incurring most examined complications, including revision surgery, when compared with NTO (P < .05). From 2009 to 2018, the proportion of patients prescribed preoperative opioids decreased. CONCLUSION: Preoperative TO is associated with less postoperative risk than NTO use and is similar to opioid naivety. Fortunately, the number of patients receiving preoperative NTOs appears to be decreasing. Our results support tramadol as an appropriate pre-THA analgesic.

Quantifying the Backlog of Total Hip and Knee Arthroplasty Cases: Predicting the Impact of COVID-19.

BACKGROUND: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are two high-volume procedures that were delayed due to COVID-19. QUESTIONS/PURPOSES: To help strategize an effective return to elective orthopedic surgery, we aimed to quantify the volume of THA and TKA cases delayed across the USA and estimate the time required to care for these patients when non-urgent surgery resumes. METHODS: Population-level data was used to estimate monthly THA and TKA procedural volume from 2011 to 2017. Using linear regression, we used this data to project monthly procedural volumes for 2020 to 2023. Nine different permutations were modeled to account for variations in case delay rates (50%, 75%, 100%) and in resumption of non-urgent procedure timing. Two recovery pathways using the highest volume month as a surrogate for maximum operative capacity, and a second using the highest month + 20% were used to simulate a theoretical expansion of current capacity. RESULTS: The projected national volume of delayed cases was 155,293 (mid-March through April; 95% CI 142,004 to 168,580), 260,806 (through May; 95% CI 238,658 to 282,952), and 372,706 (through June; 95% CI 341,699 to 403,709). The best- and worst-case scenarios for delayed cases were 77,646 (95% CI 71,002 to 84,290) and 372,706 (95% CI 341,699 to 403,709), respectively. The projected catch-up time varied between 9 and nearly 35 months for the best- and worst-case scenarios. The addition of 20% increased productivity decreased this time to between 3.21 and 11.59 months. CONCLUSION: The COVID-19 pandemic has generated a significant backlog of THA and TKA procedures. Surgeons, administrators, and policymakers should account for these modeled estimates of case volume delays and projected demands.

Modifiability of Depression's Impact on Early Revision, Narcotic Usage, and Outcomes After Total Hip Arthroplasty: The Impact of Psychotherapy.

BACKGROUND: Depression is known to negatively influence functional recovery, patient satisfaction, narcotic requirements, implant survivorship, and perioperative resource utilization after total hip arthroplasty (THA). The degree to which this effect is modifiable is largely unknown, with mixed results on preoperative pharmacological intervention, and concomitant concerns over side effects. We aim to investigate the influence of psychotherapy before THA on surgical outcomes, medical complications, and resource utilization. METHODS: A retrospective chart review of Truven MarketScan Databases was performed to generate 3 cohorts: patients without depression, patients with depression who did not receive preoperative psychotherapy, and patients with depression who received psychotherapy before surgery. Outcomes of interest were resource utilization, surgical and medical complications, narcotic requirements, and 1-year and 3-year revision rates. RESULTS: On multivariate analysis, depressed patients who did not receive psychotherapy were more likely to be discharged to inpatient rehabilitation facility (odds ratio [OR] 1.28, 95% confidence interval [CI] 1.10-1.48, P < .001) and require 2 or more postoperative narcotic prescriptions (OR 1.20, 95% CI 1.06-1.37, P = .004) than depressed patients who received psychotherapy. Patients who did not receive psychotherapy were more likely to have continued narcotic requirements within 1 year after surgery (OR 1.23, 95% CI 1.08-1.39, P < .001) and undergo revision at 1 year (OR 1.74, 95% CI 1.17-2.58, P = .006) and 3 years (OR 1.92, 95% CI 1.10-3.34, P = .021) than depressed patients who received psychotherapy. CONCLUSION: The negative influence of depression on narcotic requirements, resource utilization, and implant survivorship after THA appears to be modifiable with preoperative psychotherapy.

The American Board of Orthopaedic Surgery Response to COVID-19.

The COVID-19 pandemic has disrupted every aspect of society in a way never previously experienced by our nation's orthopaedic surgeons. In response to the challenges the American Board of Orthopaedic Surgery has taken steps to adapt our Board Certification and Continuous Certification processes. These changes were made to provide flexibility for as many Candidates and Diplomates as possible to participate while maintaining our high standards. The American Board of Orthopaedic Surgery is first and foremost committed to the safety and well-being of our patients, physicians, and families while striving to remain responsive to the changing circumstances affecting our Candidates and Diplomates.

Prosthetic Joint Infection Trends at a Dedicated Orthopaedics Specialty Hospital.

INTRODUCTION: Historically, a majority of prosthetic joint infections (PJIs) grew Gram-positive bacteria. While previous studies stratified PJI risk with specific organisms by patient comorbidities, we compared infection rates and microbiologic characteristics of PJIs by hospital setting: a dedicated orthopaedic hospital versus a general hospital serving multiple surgical specialties. METHODS: A retrospective review of prospectively collected data on 11,842 consecutive primary hip and knee arthroplasty patients was performed. Arthroplasty cases performed between April 2006 and August 2008 at the general university hospital serving multiple surgical specialties were compared to cases at a single orthopaedic specialty hospital from September 2008 to August 2016. RESULTS: The general university hospital PJI incidence rate was 1.43%, with 5.3% of infections from Gram-negative species. In comparison, at the dedicated orthopaedic hospital, the overall PJI incidence rate was substantially reduced to 0.75% over the 8-year timeframe. Comparing the final two years of practice at the general university facility to the most recent two years at the dedicated orthopaedics hospital, the PJI incidence was significantly reduced (1.43% vs 0.61%). Though the overall number of infections was reduced, there was a significantly higher proportion of Gram-negative infections over the 8-year timeframe at 25.3%. CONCLUSION: In transitioning from a multispecialty university hospital to a dedicated orthopaedic hospital, the PJI incidence has been significantly reduced despite a greater Gram-negative proportion (25.3% versus 5.3%). These results suggest a change in the microbiologic profile of PJI when transitioning to a dedicated orthopaedic facility and that greater Gram-negative antibiotic coverage could be considered.

Utilization Patterns, Efficacy, and Complications of Venous Thromboembolism Prophylaxis Strategies in Primary Hip and Knee Arthroplasty as Reported by American Board of Orthopedic Surgery Part II Candidates.

BACKGROUND: Many strategies for venous thromboembolism (VTE) prophylaxis following hip and knee arthroplasty exist, with extensive controversy regarding the optimum strategy to minimize risk of VTE and bleeding complications. Data from the American Board of Orthopedic Surgery Part II (oral) Examination case list database was analyzed to determine efficacy, complication rates, and prescribing patterns for different prophylactic strategies. METHODS: The American Board of Orthopedic Surgery case database was queried utilizing Current Procedural Terminology codes 27447 and 27130 for primary total knee and hip arthroplasty, respectively. Geographic region, patient age, gender, deep vein thrombosis prophylaxis strategy, and complications were obtained. Less aggressive prophylaxis patterns were considered if only aspirin and/or sequential compression devises were utilized. More aggressive VTE prophylaxis patterns were considered if any of low-molecular-weight heparin (enoxaparin), warfarin, rivaroxaban, fondaparinux, or other strategies was used. RESULTS: In total, 22,072 cases of primary joint arthroplasty were analyzed from 2014 to 2016. The national rate of less aggressive VTE prophylaxis strategies was 45.4%, while more aggressive strategies were used in 54.6% of patients. Significant regional differences in prophylactic strategy patterns exist between the 6 regions. The predominant less aggressive prophylaxis pattern was aspirin with sequential compression devises at 84.8% with 14.8% receiving aspirin alone. Use of less aggressive prophylaxis strategy was significantly associated with patients having no complications (95.5% vs 93.0%). Use of more aggressive prophylaxis patterns was associated with higher likelihood of mild thrombotic (0.9% vs 0.2%), mild bleeding (1.3% vs 0.4%), moderate thrombotic (1.2% vs 0.4%), moderate bleeding (2.7% vs 2.1%), severe thrombotic (0.1% vs 0.0%), severe bleeding events (1.2% vs 0.9%), infections (1.9% vs 1.3%), and death within 90 days (0.7% vs 0.3%). Similar results were found in subgroup analysis of total hip and knee arthroplasty patients. CONCLUSION: It was not possible to ascertain the individual rationale for use of more aggressive VTE prophylaxis strategies; however, more aggressive strategies were associated with higher rates of bleeding and thrombotic complications. Less aggressive strategies were not associated with a higher rate of thrombosis. LEVEL OF EVIDENCE: Therapeutic Level III. DISCLAIMER: All views expressed in the study are the sole views of the authors and do not represent the views of the American Board of Orthopedic Surgery.

Author Correction: Factors of the bone marrow microniche that support human plasma cell survival and immunoglobulin secretion.

The original version of this Article omitted a declaration from the Competing Interests statement, which should have included the following: 'A patent has been applied for by Emory University with F.E.L, I.S. and D.C. N. as named inventors. The patent application number is PCT/US2016/036650'. This has now been corrected in both the PDF and HTML versions of the Article.

Knee MRI Primary Care Ordering Practices for Nontraumatic Knee Pain: Compliance With ACR Appropriateness Criteria and Its Effect on Clinical Management.

PURPOSE: To evaluate the appropriateness of MRI ordering practices and their effect on clinical management for nontraumatic knee pain at the primary care clinics of a large public urban hospital. MATERIALS AND METHODS: In all, 196 consecutive MRIs for nontraumatic knee pain ordered from primary care clinics in a large public urban hospital over an 18-month period were studied. ACR Appropriateness Criteria (AC) scores for nontraumatic knee pain were retrospectively calculated from medical record reviews. The record was also reviewed to assess whether knee MRI changed clinical management. Knee osteoarthritis grading was performed. Tests were performed for differences in age, body mass index (BMI), gender, and ethnicity among appropriate and inappropriate MRIs. RESULTS: Of the MRIs, 57% (108 knees) had "usually appropriate" (ie, 7-9) and 43% (8 knees) had "usually not appropriate" (ie, 1-3) AC scores (P > .1). Clinical management was changed in 26% of knees with "usually appropriate" and 20% of knees with "usually inappropriate" scores (P < .05), and 70% of the knees with "usually appropriate" and 61% of the knee with "usually not appropriate" scores had moderate to severe osteoarthritis. Age, BMI, gender, and ethnicity had no significant effect on AC scores. CONCLUSION: In patients referred from primary care for MRI for nontraumatic knee pain, adherence to AC was low. Additional focus on reducing "appropriate" studies that do not impact clinical management (eg, cases with radiographically evident moderate to severe osteoarthritis) is also warranted.

Factors of the bone marrow microniche that support human plasma cell survival and immunoglobulin secretion.

Human antibody-secreting cells (ASC) in peripheral blood are found after vaccination or infection but rapidly apoptose unless they migrate to the bone marrow (BM). Yet, elements of the BM microenvironment required to sustain long-lived plasma cells (LLPC) remain elusive. Here, we identify BM factors that maintain human ASC > 50 days in vitro. The critical components of the cell-free in vitro BM mimic consist of products from primary BM mesenchymal stromal cells (MSC), a proliferation-inducing ligand (APRIL), and hypoxic conditions. Comparative analysis of protein-protein interactions between BM-MSC proteomics with differential RNA transcriptomics of blood ASC and BM LLPC identify two major survival factors, fibronectin and YWHAZ. The MSC secretome proteins and hypoxic conditions play a role in LLPC survival utilizing mechanisms that downregulate mTORC1 signaling and upregulate hypoxia signatures. In summary, we identify elements of the BM survival niche critical for maturation of blood ASC to BM LLPC.

Long-term results of extensor mechanism reconstruction using Achilles tendon allograft after total knee arthroplasty.

PURPOSE: Disruption of the extensor mechanism after total knee arthroplasty (TKA) is an infrequent but devastating complication. Presently, limited data exists regarding the optimal treatment and long-term outcomes. METHODS: Patients who underwent reconstruction of their knee extensor mechanism using Achilles tendon allograft following TKA between January 2003 and January 2012 were identified. Sixteen patients with 17 reconstructions (10 patellar tendons, 7 quadriceps tendons) were studied. All patients underwent evaluation at an average of 45.7 months. Ten of the patients were followed to an average of 65.4 months. RESULTS: After reconstruction, the average extensor lag was 6.6° and average knee flexion was 105.1°. Of the patients with a minimum follow-up of two years and an average follow-up of 65.4 months, the average extensor lag and knee flexion was 8.4° and 107.9°, respectively, with quadriceps strength maintained at an average of 4/5. The quadriceps tendon reconstructions had an average extensor lag and flexion of 2.9° and 103°, respectively. The patellar tendon reconstructions, excluding one re-rupture, had an average extensor lag and flexion of 9.6° and 105.1°, respectively. Four patients died during the follow-up period. All but one of the patients were below the mean for age-matched controls on the SF-36. CONCLUSION: Achilles tendon allograft reconstruction is a reliable and durable treatment for patients who sustain not only patellar tendon ruptures, but also quadriceps tendon ruptures following TKA. Despite the success of this technique, the injury and procedure have a profound impact on overall function.

Modified Frailty Index Is an Effective Risk Assessment Tool in Primary Total Hip Arthroplasty.

BACKGROUND: Frailty is described as decreased physiological reserve and typically increasing with age. Hospitals are being penalized for reoperations and readmissions, which can affect reimbursement. The purpose of this study was to determine if the modified frailty index (MFI) could be used as a risk assessment tool for preoperative counseling and to make an objective decision on whether to perform total hip arthroplasty (THA) on a frail patient. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried by Current Procedural Terminology code for primary THA (27130) from 2005 to 2014. MFI was calculated using 11 variables extracted from the medical record. Bivariate analysis was performed for outcomes and complications, and the multiple logistic regression model was used to compare MFI with other predictors of readmission, any complication, and reoperation. RESULTS: A total of 51,582 patients underwent primary THA during the study period. MFI was a significant and stronger predictor than the American Society of Anesthesiologists class and age for readmission (odds ratio [OR], 14.72; 95% confidence interval [CI], 6.95-31.18; P < .001), any complication (OR, 3.63; 95% CI, 1.64-8.05; P = .002), and reoperation (OR, 8.78; 95% CI, 3.67-20.98; P < .001). As MFI increased, adverse discharge, any complication, readmission, reoperation, and mortality significantly increased (P < .001). Rates of systemic complications and length of stay significantly increased with increasing MFI. CONCLUSION: MFI is a simple and effective risk assessment tool to preoperatively counsel and make an objective decision on whether to perform THA on a frail patient.

Total Wrist Arthroplasty Versus Wrist Fusion: Utilization and Complication Rates as Reported by ABOS Part II Candidates.

BACKGROUND: The aim of this study was to assess national trends in the utilization and complication rates of total wrist arthroplasty (TWA) and total wrist fusion (WF) as identified via review of the American Board of Orthopedic Surgery (ABOS) Part II candidate database. METHODS: The ABOS Part II candidate database is a collection of cases reported by candidates of the ABOS Part II board certification oral exam. The ABOS database was queried for all TWA and WF cases performed from 2005 to 2014. Linear regression analyses were used to assess trends in procedure utilization. Treatment diagnoses, patient characteristics, and reported complications were also compared between the 2 treatment cohorts. RESULTS: No significant increases in the proportion of candidates performing TWA or WF, number of TWA or WF cases, nor the number of TWA or WF cases performed per candidate performing those procedures were noted during the study period. Significantly less TWA cases were performed when compared with WF cases (68 vs 327; P = .006). Patients undergoing TWA were significantly older ( P = .005), more likely female ( P < .001), and more likely to have a diagnosis of osteoarthritis ( P = .003) than patients undergoing WF. There were no significant differences in complication rates, including postoperative infection, nerve palsy, or rate of secondary surgery, between the TWA and WF cohorts. CONCLUSIONS: Utilization of both TWA and WF has remained unchanged among emerging career orthopedic surgeons. Although WF is performed nearly 5 times more frequently than TWA, our short-term findings suggest that TWA compares favorably with WF.

Early Complications Following Osteosynthesis of Distal Radius Fractures: A Comparison of Geriatric and Nongeriatric Cohorts.

BACKGROUND: Distal radius fractures (DRFs) are common geriatric fractures with the overall incidence expected to increase as the population continues to age. The purpose of this investigation was to compare the short-term complication rates in geriatric versus nongeriatric cohorts following osteosynthesis of DRFs. METHODS: The American Board of Orthopaedic Surgery (ABOS) part II database was queried for adult DRF cases performed from 2007 to 2013. Current Procedural Terminology codes were used to identify cases treated via osteosynthesis. Patient demographic information and reported complication data were analyzed. Comparisons between geriatric (age ≥65 years) and nongeriatric (age <65 years) patients were performed. RESULTS: From 2007 to 2013, a total of 9867 adult DRFs were treated via osteosynthesis by ABOS part II candidates. Geriatric patients comprised 28% of the study cohort. Mean age of the geriatric and nongeriatric cohorts was 74 ± 7 and 46 ± 13 years, respectively. There was a greater proportion of female patients (P < .001) in the geriatric cohort as compared with the nongeriatric cohort. The geriatric cohort demonstrated higher rates of anesthetic complications (P = .021), iatrogenic bone fracture (P = .021), implant failure (P = .031), loss of reduction (P = .001), unspecified medical complications (P = .007), and death (P = .017) than the nongeriatric cohort. The geriatric cohort also showed lower rates of nerve palsy (P = .028) when compared with the nongeriatric cohort, though no differences in rates of secondary surgery were noted between the two cohorts. CONCLUSION: Increased rates of complications related to poor bone quality and poor health status may be expected among geriatric patients following osteosynthesis of DRFs. However, geriatric and nongeriatric patients have similarly low rates of secondary surgery. Future studies are needed to delineate the economic, functional, and societal impact of geriatric DRFs treated via osteosynthesis.

A Validated Single-View Radiographic Alternative to Computed Tomography for the Measurement of Femoral Anteversion: A Method-Comparison Study.

BACKGROUND: Although preoperative templating in total hip arthroplasty is helpful to ensure appropriate component position, there is no single-view radiographic method to determine femoral anteversion (FA) preoperatively. The aim of the present study was to validate the use of radiographic measurement of FA using a modified Budin view. METHODS: This prospective study reports on 105 limbs from 65 patients. Computed tomography (CT) scans and radiographs were obtained to measure native FA. Radiographs were obtained using the modified Budin protocol with 90° flexion at the knee and 90° flexion and 30° abduction at the hip. Pearson correlation analyses, paired-samples t-test, and Bland-Altman plots were performed to assess correlation and agreement between methods. Data were grouped into subsets based on CT-derived FA in 5° intervals. Groups included all limbs, FA < 35°, FA < 30°, and FA < 25°. RESULTS: For all limbs, Bland-Altman analysis revealed a fixed bias (mean bias, -0.8°; 95% confidence interval, -1.4° to -0.2°) and showed that radiographic methods underestimated FA. Subset analyses were performed and revealed excellent correlation between CT and radiographic measurements for all subgroups (r = 0.97, P < .001). Paired-samples t-tests revealed no significant difference between methodologies for any of the subgroups. Radiographic and CT methods showed excellent agreement, and the bias between methods was within 0.5° for all subgroups. There was no fixed bias and thus no systematic difference in methods within any of the subgroup analyses. CONCLUSION: Radiographic measurement of FA using a modified Budin view is a valid and reliable technique.

Humeral Shaft Fracture Fixation: Incidence Rates and Complications as Reported by American Board of Orthopaedic Surgery Part II Candidates.

BACKGROUND: Despite extensive research regarding patient outcomes after operative fixation of humeral shaft fractures by means of open reduction and internal fixation (ORIF) or intramedullary nailing (IMN), no current consensus exists regarding the optimal surgical treatment. The objective of this study was to compare IMN and plate fixation (ORIF) of humeral shaft fractures by using the American Board of Orthopaedic Surgery (ABOS) Part II operative database to analyze incidence rates, changes in management trends over time, early complications, and factors affecting the management choice. METHODS: The ABOS database is a collection of surgical cases that are self-reported by orthopaedic candidates approved for admission to the ABOS oral examination. The database was searched for records from 2004 to 2013 for humeral shaft surgical cases as indicated by Current Procedural Terminology (CPT) codes 24515 (open reduction internal fixation) and 24516 (insertion of intramedullary nail) pertaining to humeral shaft fractures. The geographic region and fellowship training of the candidates; the year of surgery, diagnosis code, age, and sex of the patients; and the surgeon-reported complications were analyzed. RESULTS: The search identified 3,430 surgically treated humeral shaft fractures that were reported to the ABOS database from 2004 to 2013. A significant decline in IMN use was seen from 2004 (42.9%) to 2013 (21.2%, p < 0.001). The IMN cohort had lower complication rates pertaining to both infections (1.5% compared with 3.0% for ORIF, p = 0.007) and nerve palsies (3.1% compared with 7.8%, p < 0.001). No significant difference was seen in the rate of nonunion (1.3% for IMN compared with 1.6% for ORIF, p = 0.63), although follow-up may be too short to demonstrate a difference. The IMN cohort did have significantly higher mortality (4.9% compared with 0.7% for ORIF, p < 0.001). Subset analysis demonstrated that the IMN cohort had significantly more pathologic fractures (26.8% compared with 1.5% of the fractures treated with ORIF, p < 0.001). CONCLUSIONS: Although the overall incidence of fixation of humeral shaft fractures was unchanged from 2004 to 2013, there was a significant shift from IMN to ORIF using plate fixation during this time period. Possible reasons for this shift in treatment to ORIF include the potential impact of recent publications highlighting complications of IMN and increased surgeon attention to cost containment. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Trends in Primary and Revision Hip Arthroplasty Among Orthopedic Surgeons Who Take the American Board of Orthopedics Part II Examination.

BACKGROUND: A certified list of all operative cases performed within a 6-month period is a required prerequisite for surgeons taking the American Board of Orthopaedic Surgery Part II oral examination. Using the American Board of Orthopaedic Surgery secure Internet database database containing these cases, this study (1) assessed changing trends for primary and revision total hip arthroplasty (THA) and (2) compared practices and early postoperative complications between 2 groups of examinees, those with and without adult reconstruction fellowship training. METHODS: Secure Internet database was searched for all 2003-2013 procedures with a Current Procedural Terminology code for THA, hip resurfacing, hemiarthroplasty, revision hip arthroplasty, conversion to THA, or removal of hip implant (Girdlestone, static, or dynamic spacer). RESULTS: Adult reconstruction fellowship-trained surgeons performed 60% of the more than 33,000 surgeries identified (average 28.1) and nonfellowship-trained surgeons performed 40% (average 5.2) (P < .001). Fellowship-trained surgeons performed significantly more revision surgeries for infection (71% vs 29%)(P < .001). High-volume surgeons had significantly fewer complications in both primary (11.1% vs 19.6%) and revision surgeries (29% vs 35.5%) (P < .001). Those who passed the Part II examination reported higher rates of complications (21.5% vs 19.9%). CONCLUSION: In early practice, primary and revision hip arthroplasties are often performed by surgeons without adult reconstruction fellowship training. Complications are less frequently reported by surgeons with larger volumes of joint replacement surgery who perform either primary or more complex cases. Primary hip arthroplasty is increasingly performed by surgeons early in practice who have completed an adult reconstructive fellowship after residency training. This trend is even more pronounced for more complex cases such as revision or management of infection.

Trends in primary and revision knee arthroplasty among orthopaedic surgeons who take the American Board of Orthopaedics part II exam.

PURPOSE: A certified list of all operative cases performed within a six month period is required of surgeons by the American Board of Orthopaedic Surgery (ABOS) as a prerequisite to taking the Part II Oral Examination. Using the data on these cases collected and maintained by ABOS, this study assessed the influence of prior fellowship training in adult reconstruction on the volume and surgeon-reported complication rate of knee joint arthroplasty cases over time. METHODS: All data were self reported to a secure Internet database (SCRIBE) by candidates who applied to take Part II of the ABOS Examination for the first time. This database was searched for all procedures done between 2003 and 2013 with CPT codes for total and revision knee arthroplasty and removal of knee implant (static or dynamic spacer) to determine procedural volumes and early complication rates among Board-eligible orthopaedic surgeons with and without adult reconstructive fellowship training. RESULTS: More than 43,000 knee arthroplasty surgeries were identified. Surgeons who had completed adult reconstruction fellowship training after residency performed 55 % of total knee arthroplasties, averaging 33.5 knee arthroplasties during the six month case-collection period compared to 7.4 procedures by non-fellowship-trained surgeons (p < 0.001). Adult reconstruction fellowship-trained surgeons performed significantly more revisions for infection (average 6.6 versus 2.2 revisions) (p < 0.001). Adult reconstruction fellowship training did not significantly affect complication rates for primary arthroplasty but was associated with an increased complication rate for revisions. Those surgeons who performed more than 100 arthroplasties a year reported significantly fewer complications in primary arthroplasties (12.7 % versus 16.9 %) (p < 0.001). Over time, an increasing percentage of arthroplasties were done by surgeons with adult reconstruction fellowship training. CONCLUSIONS: Adult reconstruction fellowship-trained surgeons performed an increasing number of primary and more complex knee arthroplasties from 2003 to 2013. Surgeons who perform a larger volume of knee arthroplasty surgeries report fewer early complications than surgeons with fewer cases. LEVEL OF EVIDENCE: 4.