Dartmouth Orthopaedic Journal, 2014

Home , Tuck School of Business

Dartmouth Orthopaedic Journal 2014; Vol I CONTENTS Rowan J. Michael MD and Dipak B. Ramkumar MD International Orthopaedics at Dartmouth 61 Ana Mata-Fink MD Letter From The Editors 4 A Tribute to Dr. Philip Bernini and Dr. Thomas Shirreffs Brendan T. Higgins MD MS and Timothy J. Lin MD MS 62 Chairman’s Update 5 Wayne M. Moschetti MD MS Sohail K. Mirza MD MPH Orthopaedic Teaching Awards 64 Program Director’s Update 7 Charles F. Carr MD Charles F. Carr, MD Freddie Fu Award 64 How do video decision aids affect patients considering Charity A. Jacobs MD total joint arthroplasty for symptomatic hip or knee DHMC Courage to Teach Award 65 osteoarthritis? 8 Dipak R. Ramkumar MD Wayne Moschetti1 MD MS, Jared Conley2 MPH, Garrett New Faculty 66 Davis1 MD MBA MS, Kevin F. Spratt3 PhD, Stephen R. Welcome to the incoming Orthopaedic Interns 67 Kantor1 MD, Ivan Tomek1,4 MD FRCSC Graduating Residents 68 Predicting electrodiagnostic study results in CTS 15 Erik R. Bergquist1 MD, Jeffrey A. Cohen1 MD, Kevin F. Update on Recent Graduates 69 Spratt2 PhD, Lance G. Warhold1 MD Faculty 70 Establishment of a Designated Transfer Center Im- Associate Providers 73 proves Care of Orthopaedic Trauma Patients 21 Alumni of the Dartmouth Orthopaedic Surgery Resi- Eugene W. Brabston2 MD, John E. Bell1 MD MS, Robert dency Program 74 V. Cantu1 MD MS Comparison of Two Fusionless Scoliosis Surgery Methods in the Treatment of Progressive Adolescent Idiopathic Scoliosis: A Preliminary Study 25 DOJo Staff John T. Braun MD The Dartmouth Orthopaedic Journal is a resident-run, peer- Patient Education and Compliance with Deep Vein reviewed publication that aims to increase Dartmouth’s contribution to orthopaedic knowledge and foster camaraderie Thrombosis Prophylaxis after Discharge from Total among Dartmouth Orthopaedic residents, staff and alumni. Joint Replacement 34 Chairman, Department of Orthopaedics Brooks Crowe BA, Reema Vaze BA, Andrew Banos MD, Sohail K. Mirza, MD, MPH James Slover MD MS Residency Program Director Intramedullary Screw Fixation of Transverse Olecra- Charles F. Carr, MD non Fractures 41 Editors Alexander R. Orem MD MS and Robert V. Cantu MD MS Brendan T. Higgins, MD MS Timothy J. Lin, MD MS Case Report 44 Faculty Advisors Femoral artery occlusion after total hip Arthroplasty John-Erik Bell, MD MS through the direct anterior approach: A case report Robert V. Cantu, MD MS 44 Reviewers Wayne Moschetti MD MS, Spencer Amundsen MD James B. Ames, MD MS Total Knee Arthroplasty in a Patient with an Ipsilateral John-Erik Bell, MD MS Robert V. Cantu, MD MS Transtibial Amputation: A Case Report and Surgical Marcus P. Coe, MD MS Technique for Addressing a Short Residual Tibia 47 Kevin W. Dwyer, MD MS Joshua M. Murphy MD, Scott M. Sporer MD Brendan T. Higgins, MD MS Karl M. Koenig, MD MS A History of the Dartmouth Hitchcock Medical Center Timothy J. Lin, MD MS Orthopaedic Residency Training Program 52 Wayne E. Moschetti, MD MS Charles F. Carr MD Matthew E. Oetgen, MD Adam M. Pearson, MD MS Level V Evidence 56 Timothy J. Lin MD Administrative Staff Linda S. Eickhoff Development of a Surgical Skills Curriculum for DHMC Orthopedic Surgery Residents 60 Special thanks to Dr. Bob Porter and Dr. Pete Hall

3 Letter From The Editors

Brendan T. Higgins MD MS and Timothy J. Lin MD MS Chairman’s Update

Sohail K. Mirza MD MPH

Dear Alumni and Friends of Dartmouth Orthopaedics,

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

Our department believes that quality can be defned and measured, that benchmarks matter, that clinical practice must be science-based, and that patient-interests have priority over clinician preferences. Nearly a hundred years ago, an orthopedic surgeon in Boston named Ernest Amory Codman ad- vocated “Te End Result Idea”: “Te common sense notion that every hospital should follow every patient it treats, long enough to determine whether or not the treatment has been successful, and then to inquire, ‘If not, why not?’ with a view Figure 1. Goals of the GreenCare Program to preventing similar failures in the future.” In 1996, James N. Weinstein, a spine surgeon at Dartmouth at the time and now our CEO and President, expanded Codman’s idea to include measuring patient reported outcomes during routine care in Te Spine Center, and established the nation’s frst Center for Shared Decision Making to help patients make more informed choices.

Te Dartmouth GreenCare program further enhances these innovations by using information technology to support patient centered, evidence-based decisions. We have worked hard over the past 5 years to re-design our care delivery processes to adjust to the changes we see and the direction we anticipate in the healthcare environment. We have moved to team-based Figure 2. Design and implementation timeline for GreenCare care rather than solo surgeon practice, standardizing things as much as possible using clinical evidence and trustworthy guidelines, and integrating formal shared decision making and failure in 1918, seven years afer it opened. We are seeing that patient reported measurements into the care process (Figure Codman’s End Result Idea, when implemented with a team- 1). Te scale of change was very difcult for our surgeons and based care approach, electronic health records, patient-fo- staf, but results have been encouraging at each implemen- cused information technology, and thoughtful operations tation phase so far (Fig ure 2). We have called this model engineering, can serve as the core business model for contin- of clinical practice “GreenCare.” uously improving outcomes and remaining fnancially sus- tainable. Our early results show GreenCare improves patient Codman’s End Result Hospital in Boston was a fnancial experience and outcomes, and reduces costs. Dartmouth Orthopaedic Journal 2014; Vol I

Figure 3. Schematic of the Center for Surgical Innovation

Secondly, we are proud to announce the opening of the http://med.dartmouth-hitchcock.org/csi.html. Center for Surgical Innovation, a one-of-a-kind research facility dedicated to improving surgical procedures and developing Tese are just two examples of how Dartmouth Ortho- new surgical technologies to improve patient outcomes (Fig- paedics continues to innovate patient care, improve value, ure 3). CSI is a collaborative investment by Dartmouth-Hitch- outcomes research and resident education. In summary, I am cock Medical Center, Geisel School of Medicine, Tayer happy to report that the status of the DHMC Orthopaedic De- School of Engineering, and grant funding from the National partment is strong and continuously improving. We welcome Institutes of Health. our graduate residents to come back and visit at any time!

Surgeons are too ofen limited by what they cannot see. Sincerely, At Dartmouth, that constraint will soon be removed, with Sohail K. Mirza, MD MPH MRI and CT machines that can move in and out of operating Chair, Department of Orthopaedics rooms. For surgeries in which a few millimeters means the May 16, 2014 diference between restoring physical ability or causing permanent disability, or between curing cancer and missing a bit of tumor that may grow back, 3-D imaging during surgery is priceless. CSI will allow surgeons and engineers to innovate like never before, rapidly developing, testing, and validating new surgical tools and techniques, with the goal of achieving better, safer, and, over the longer term, less-costly care for patients everywhere. I encourage you to visit the CSI website at

6 Program Director’s Update

Charles F. Carr MD

Alumni and Friends of Dartmouth Orthopaedics, I am also extremely happy to report that the state of your orthopaedic residency program is excellent. Te program un- Greetings and welcome to the inaugural issue of the Dart- derwent an accreditation site review last year by the Orthopae- mouth Orthopaedic Journal. I congratulate Dr. John-Erik Bell dic Residency Review Committee and received a full ACGME and the frst two resident editors, Drs. Tim Lin and Brendan accreditation with no citations and the maximum ten year Higgins, on all of their hard work and efort in completing this cycle for a re-evaluation. Te board certifcation rate for all initial publication. Te frst issue always seems to be the most of our graduating residents over 57 years remains 100%. Our difcult to fnish. graduates continue to enter the most competitive fellowship programs in all the subspecialty areas and nearly 20% have Since many of you who receive this may have had little con- continued on in an academic setting. tact with the program over the past two decades, included in this Journal is A History of the Dartmouth Hitchcock Medical Tanks to you all for being a part of our success and pride. Center Orthopaedic Residency Training Program which was written to give you a historical update on our program from our inception to our most recent developments. Te changes Sincerely, in orthopaedic surgery training and in the DHMC program Charles F. Carr, MD have been profound. Much of the credit for the program’s DHMC Orthopaedic Residency Program Director structure, foundation and personality go to my predecessors – Drs. Staples, Hall, Bernini and Murphy. Tanks to their work and eforts we continue to attract the best resident applicants in the country to DHMC. How do video decision aids affect patients considering total joint arthroplasty for symptomatic hip or knee osteoarthritis?

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

ABSTRACT and hip arthritis groups (71% vs. 81%, p=.028). Knowledge regarding complication risk improved in those with hip arthritis Introduction: (73% vs. 94 %, p<.0001), but not in those with knee arthritis Video decision aids (DAs) summarizing current evi- (68% vs. 69%, p=.54). dence-based practices are adjuncts to communication between provider and patient, and useful when a preference-sensitive Conclusions: decision is being made, such as consideration of arthroplasty for Video DAs improved decision readiness and basic knowl- severe hip and knee osteoarthritis. edge in patients with hip and knee osteoarthritis. However, viewing a DA did not lead to greater concordance between Methods: patient values and treatment choices. Patients with an initial 123 patients (80 knees, 43 hips), mean age 63 years, with treatment preference were not likely to change their prefer- symptomatic hip and knee osteoarthritis, were enrolled ence, while those who were unsure about their treatment pref- prospectively to evaluate the value of a video DA. Patients erence were more likely to report a preference afer watching completed a questionnaire before and afer viewing the DA, the video. answering questions related to patient knowledge, treatment preference, personal values, decision readiness, and preferred Level of Evidence: role in treatment decision making. Level II Results: Approximately 80% of the patients reported that the DA INTRODUCTION prepared them to discuss their values related to the treatment decisions, but concordance between treatment choice and im- Shared medical decision making (SDM) empowers pa- portance of symptom relief and wishing to avoid surgery were tients to make better quality health decisions by presenting not changed in either cohort. Decision readiness signifcantly evidence-based treatment options, clarifying values, and al- improved afer viewing the DA in both knee and hip patients. lowing patients to have more meaningful discussions with Te majority of patients reported a treatment preference prior their care providers. SDM is poised to play a greater role in to seeing the DA and demonstrated no signifcant treatment the healthcare of patients in the United States, including those preference shif afer viewing the video (p=0.28). Pre- to post- with symptomatic hip and knee osteoarthritis (OA). It is felt DA concordance between treatment choice and importance that participating in SDM increases a patient’s knowledge of of symptom relief (r=0.09 vs. r=0.39 p=0.28) and wishing their condition and the risks associated with available treat- to avoid surgery (r=.-0.54 vs. r=-0.49, p=0.76) were not im- ment options, thus improving the quality of the decision.1 proved. Afer viewing the DA, basic knowledge about joint Much of the SDM literature has involved the utility of decision replacement improved in both knee (59% vs. 77%, p<0.0001) aids on patients’ knowledge of options and outcomes regarding non-orthopaedic disease.2-7 Less is understood about the role of SDM on individuals undergoing total joint arthroplas- 1. Dartmouth-Hitchcock Medical Center, Lebanon NH ty (TJA). New federal and state legislation has emphasized 2. Case Western Medical School, Cleveland, OH 3. Dartmouth Medical School, Hanover NH patient-centered care, and participating health systems will 4. Te Dartmouth Institute for Health Policy and Clinical Practice, Lebanon be incentivized if they include SDM in their care pathways. NH Integral to most SDM processes are decision aids (DAs), of- ten video-based, that review treatment-related knowledge Corresponding Author: Wayne Moschetti, MD, MS and personal values, which may lead to choosing one option E-mail: [email protected] over the other. DAs are felt to be especially helpful in preference-sensitive decisions like treatment of osteoarthritis where DISCLOSURE: None of the authors received payments or services, either there are multiple potential options that have difering bene- directly or indirectly, from a third party in support of any aspect of this work. Te complete disclosures of potential conficts of interest submitted by au- fts, risks, and tradeofs. In those cases DAs have been shown thors is available upon request through correspondence with the DOJo ofce. to increase patient involvement in decision making, leading to Dartmouth Orthopaedic Journal 2014; Vol I value-based decisions about treatment.8 ed measures of whether the DA improved treatment-related general knowledge, accuracy of risk perceptions, congruence Patients with pain and/or disability secondary to hip or between patient values and the chosen treatment option, the knee OA face numerous treatment options, both surgical and efect of the DA on decision readiness, the perceived useful- non-operative, each of which is associated with varying de- ness of the DA, and the patients preferred role in decision grees of potential risk and beneft. Te treatment decision may making. be made more complicated by the waxing and waning nature of osteoarthritis symptoms. Furthermore, patients’ pre-opera- METHODS tive expectations of joint replacement surgery are variable and may be unrealistically high or low, with expectations that are Te study protocol was approved by the institutional re- sometimes dramatically misaligned with reality.9,10 Current view board at the study institution. A prospective, observa- population demographics and recent utilization trends sug- tional cohort clinical trial was conducted, consisting of a study gest that demand for TJA surgery is growing, with an estimat- population of patients 40-80 years of age with symptomatic hip ed 4.5 million annual procedures costing Medicare $50 billion or knee OA and no prior history of knee arthroplasty surgery. dollars by the year 2030.11,12 Evidence suggests that SDM in All patients were either self-referred or had been referred by musculoskeletal surgery can improve knowledge, adjust un- their primary care provider to one of two, arthroplasty-fellow- realistic expectations, and elicit vlues about benefts desired ship trained, Orthopaedic surgeons (SRK, IMT), for opinion and the degree of acceptable risks.13 Yet there is relatively little and treatment recommendations. information regarding how decision aids and shared decision making afect patients with osteoarthritis who are considering Te study site is an academic medical center, where pa- TJA.14 Tere are also many patients limited by severe osteo- tient-reported outcomes collection and shared medical deci- arthritis who choose not to pursue the potential benefts of sion making have been integrated into clinical care pathways, arthroplasty surgery because of their perceived understanding including hip and knee osteoarthritis. Patients with moderate of the potential risks and benefts. Tere are seemingly perfect to severe osteoarthrosis of the hip or knee were referred to candidates for TJA who choose not to undergo the procedure receive a video DA at the institution’s Center for Shared De- and it is believed that a lack of understandable, quality infor- cision Making. Te patients completed pre-video SDM ques- mation is one of the main factors infuencing their decision tionnaires assessing treatment preference, preferred role in making.15,16 To date, much of the SDM literature has focused decision making, osteoarthritis and complication knowledge on the efect of DA’s on patients’ knowledge of options and scores, as well as their decision readiness. All participants outcomes, most commonly in association with conditions viewed a 50 minute-long video decision aid (Health Dialog such as benign prostate disease, ischemic heart disease, hor- Inc., Boston, MA) about hip or knee osteoarthritis and com- mone therapy, and treatment options for breast cancer includ- pleted a post-video questionnaire. Te pre- and post-survey ing lumpectomy versus mastectomy.2-7 Less well understood results were then compared in an efort to better understand is the role and potential beneft of SDM on individuals con- the impact the video had on patients with hip and knee osteo- sidering TJA. arthritis.

Te purpose of the current study was to prospectively ex- Potential study patients were pre-screened by a research amine the impact of a video DA on patients with symptom- coordinator who previewed the upcoming clinic schedules of atic hip or knee OA who were failing medical management the two co-investigators (SRK, IMT), and identifed individ- and were seeking assessment and advice from an orthopae- uals who had (1) a presenting complaint of symptomatic hip dic surgeon specializing in hip and knee arthroplasty. Te or knee osteoarthritis and (2) were meeting with the ortho- primary outcome measures of this study were related to the paedic surgeon for the very frst time. Immediately afer the decision-making process and decision quality, rather than clinic visit, if the orthopaedic surgeon agreed that the patient condition-specifc outcomes or health-related quality-of-life was a candidate for TJA, enrollment in the study was ofered. outcomes. In particular, the study sought to answer the ques- Complete inclusion and exclusion criteria appear in Table 1. tion of whether a video DA for hip and knee OA improved pa- If the patient accepted the ofer to enroll, the research coor- tient decision quality, as defned by the International Patient dinator explained the study methodology, the study consent Decision Aid Standards (IPDAS) collaboration.17 Tis includ- was signed, and the patients were provided with the pre-video

Table 1: Inclusion and exclusion criteria for SDM study participation. Inclusion Criteria t"EVMUQBUJFOUTXJUITZNQUPNBUJDIJQPSLOFFPTUFPBSUISPTJTXIPBSFTFFLJOH0SUIPQBFEJDPQJOJPOGPSNBOBHFNFOU t1BUJFOUBHFZFBSTBUUJNFPGFOSPMMNFOU Exclusion Criteria t1BUJFOUIBTQSFWJPVTMZIBEBQBSUJBMPSUPUBMKPJOUSFQMBDFNFOUPGUIFIJQPSLOFF t1BUJFOUIBTQSFWJPVTMZWJFXFEUIFIJQPSLOFFEFDJTJPOBJE

9 Dartmouth Orthopaedic Journal 2014; Vol I questionnaire. Patients were asked to complete the frst part cruited into the study. Te mean age in both groups was 63 of the questionnaire, then watch the video DA, and fnally to years. complete the second set of survey questions. Te data from the pre and post-video questionnaires were then entered into Treatment Preference a secure database for statistical analysis. One hundred and eighteen patients (78 knees, 40 hips) Statistical Analysis reported their treatment preference. A majority reported a treatment preference prior to seeing the video and this group Bowker’s Symmetry was used to compute a p-value as it demonstrated no signifcant treatment preference shif afer compares two categorical responses and tests the null-hypoth- viewing the video, (85% knee patients p=0.28; 88% hip pa- esis that the responses on the pre-video questionnaire did not tients p=0.81; Table 2, Figure 1). difer from the responses on the post-video questionnaire. Of those unsure before the video, 67% (8 of 12) in the knee Source of Funding cohort and 40% (2 of 5) in the hip cohort had a treatment preference afer the video. Afer watching the video, 9% (7 of 78) No external or internal funds were received in the conduct with knee OA and 13% (5 of 40) with hip OA remained un- of this report. Te authors of this study have no related disclosure about their treatment decision. Te majority of patients sures or conficts of interest to report. in this cohort were leaning towards surgery prior to viewing the video and the overall number of patients choosing surgery RESULTS afer watching the video increased in both groups, though this was not statistically signifcant (p>0.2). Interestingly, despite Group Demographics pre- to post-video preference shifs, the overall distributions of pre- and post-video treatment preferences were quite sim- One hundred and twenty three patients, 80 with knee ilar. OA (61% female) and 43 with hip OA (47% female) were re- Role in Decision Making One hundred and nineteen patients reported on their role in decision making. In the hip cohort, females preferred the shared decision-making process include both themselves and their physician more so than men (70% vs. 30%, p < .012), who more of the time preferred being the sole decision maker (Table 3). Overall, 60.5% of patients wished to be the sole decision maker while knowing their doctors opinion, while 39.5% of patients felt the decision should be shared between them and their physician.

Knowledge Figure 1: Treatment preference shif before and afer viewing a Five questions were used to assess patient knowledge decision aid on total joint arthroplasty Table 2: Patient Treatment Preference Before and Afer Viewing the Video # of patients Before Decision Aid (%) Afer Decision Aid (%) Hip Osteoarthritis 40 § Non-operative 3 (8%) 2 (5%) Not Sure 5 (13%) 5 (13%) Surgery 32 (80%) 33 (82%) Knee Osteoarthritis 78 ¥ Non-operative 7 (9%) 11 (14%) Not Sure 12 (15%) 7 (9%) Surgery 59 (76%) 60 (77%) § Hip group with missing data on 3 patients ¥ Knee group with missing data on 2 patients

10 Dartmouth Orthopaedic Journal 2014; Vol I

Table 3: Efects of Video Decision Aid on Patients’ Preferred Role in Shared-decision Making Hip Cohort Knee Cohort Male Female Male Female Total Who should make decision? (n = 23) (n = 17) (n=31) (n=48) My doctor and I should both 7 12 11 17 47 make the decision (39.5%) Mainly I should make the 16 5 20 31 72 decision, while knowing my (60.5%) doctor’s opinion

Table 4: Efects of Video Decision Aid on Patients’ Knowledge Regarding Hip and Knee Osteoarthritis # of patients Before Decision Aid Afer Decision Aid P value Hip Osteoarthritis 43 Basic Knowledge (%) 71 81 <0.028 Complication 73 94 <0.001 Knowledge (%) Knee Osteoarthritis 80 Basic Knowledge (%) 59 77 <0.001 Complication 68 69 >0.2 Knowledge (%) regarding pain, expected implant survival, post-operative re- Decision readiness in both cohorts improved afer covery, and complications. In the knee cohort, basic knowl- watching the video. Post-video decision readiness in those edge improved afer the video (59% vs. 77%, p<.0001); howev- with knee OA was signifcantly improved as 50% of patients er a slight improvement in complication risk knowledge was reported greater decision readiness afer viewing the video not statistically signifcant, (68% vs. 69%, p=.54). In the hip compared to 6.6% of patients reporting lower decision read- cohort, both basic knowledge and knowledge about complica- iness (p < .001). In those with hip OA, 83% of patients re- tions improved afer viewing the video, (71% vs. 81%, p<.028) ported greater decision readiness afer viewing the video com- and (73% vs. 94 %, p<.0001), respectively (Table 4). pared to 18% of patients reporting lower decision readiness (p < .001). Values Evaluation of the Decision Aid When asked about their values, 80% (63 of 79) of those with knee arthritis and 79% (31 of 39) of those with hip ar- In all, 72% of patients stated they would “defnitely recom- thritis reported that the video prepared them to discuss their mend” the DA to other patients, while another 21% said they values. Patient values and their concordance with treatment would “probably recommend” the DA. preference were quantifed by asking participants how important it was for them to obtain relief from their pain and DISCUSSION how important it was for them to avoid surgery on 10-point Likert scales. Although 80% of knee patients reported that the Despite the increased emphasis on patient involvement in video prepared them to discuss their values, pre- to post-vid- medical decision making, there is little evidence in the medical eo concordance between treatment choice and both impor- literature related to SDM or the use of patient DAs in Ortho- tance of symptom relief (r=.26 vs. r=.40 p=0.20) and wishing paedic surgery specifcally. An opinion survey demonstrated to avoid surgery (r=-0.47 vs. r=-0.57, p=0.83) were not im- that orthopaedic surgeons in the United Kingdom were gen- proved. In the hip cohort, despite 79% of patients reporting erally positive about the use of patient DAs for joint replace- that the video prepared them to discuss their values, pre- to ment surgery, with 79% responding that DAs were a good or post-video concordance between treatment choice and both excellent idea.18 DAs were not typically used in daily practice, importance of symptom relief (r=0.09 vs. r=0.39 p=0.28) and though. In a recent review of the literature, Slover et. al. (2011) wishing to avoid surgery (r=-0.54 vs. r=-0.49, p=0.76) were determined that there were limited studies suggesting that not improved. DAs enhance decision-making and that conclusions about the use of these aids in orthopaedic clinical practice could not be 14 Decision Readiness made. It was suggested that further research examining the 11 Dartmouth Orthopaedic Journal 2014; Vol I best type, timing, and content of decision aids that will lead general knowledge and complication knowledge as two im- to maximum patient involvement and knowledge gains, with portant goals of DAs.17 Previous studies from the orthopaedic minimal clinical workfow disruptions, is needed. spine literature have suggested that video DAs are successful in improving patient knowledge and that they may enhance Te major fnding of this study is that hip and knee osteo- involvement in clinical decisions.20 Perhaps one of the great- arthritis patients found the video DA to be helpful, and felt est incentives to adopt DA use by Orthopaedic surgeons that viewing the DA improved their preparedness to make a would be the fact that DAs strengthen the informed consent decision about possible treatment options. Tere was no evi- process, by reviewing evidence based knowledge and improv- dence that viewing a DA either reduced or increased the rate ing patient understanding of the benefts and risks of surgical of hip or knee replacement surgery in the current study pop- versus non-operative treatment. Te fact that the DA used in ulation. In fact, the majority of patients who had made a deci- this study was not successful in improving knee-related com- sion about treatment before viewing a DA stuck to that treat- plication knowledge suggests that either the information pre- ment choice even afer viewing the DA video. Tis fnding is sented in the video, or the questions used to assess knowledge, similar to those reported in a recent musculoskeletal clinical might need to be reviewed. trial concerning spine surgery where patients with specifc lumbar spine disorders who watched an evidence-based DA Patient values as they relate to preference-sensitive deci- formed and/or strengthened their treatment preferences in a sions such as total hip or knee replacement are important to balanced way that did not appear biased toward or away from consider. Preference-sensitive decisions are those where there surgery.19 In this study the video DA did appear to help some is more than one feasible treatment option, and the risks, ben- of the undecided patients make a decision about treatment. It efts, and outcomes vary considerably between the potential also appears that a video DA strengthens the convictions of options. Patient values relevant to severe hip or knee OA have those patients who have already made a treatment decision. ofen been distilled down to the “desire to avoid surgery” and Afer viewing the DA, treatment decision readiness improved “desire to alleviate pain” as was the case in this study. Te in both hip and knee patient cohorts, with the majority of pa- premise is that if a patient expresses the desire to avoid sur- tients reporting greater decision readiness afer viewing the gery, they should ultimately choose non-operative treatment DA. modalities. Conversely, a patient whose main goal is to alleviate pain should select arthroplasty surgery, which is more ef- In all, 72% of patients stated they would “defnitely recom- fective in pain relief in the cases of severe hip or knee OA than mend” the DA to other patients, while another 21% said they other treatment options. Tis matching of values to treatment would “probably recommend” the DA. About 80% of patients choice has been described as “concordance”, and in the shared reported that the DA prepared them to discuss treatment op- decision making literature it is considered to be the hallmark tions with their provider. Tis should diminish the concerns of a high quality healthcare decision. Tus, a non-concordant that some Orthopaedic surgeons have about whether a DA decision would be one in which a patient whose stated values would be helpful to, and accepted by, their patient population. were to avoid surgery eventually ended up seeking operative Vieeeevewing a DA did help those OA patients decide on a management, or vice versa. treatment who were undecided about a treatment course afer meeting with their Orthopaedic surgeon. In the current study, there was no evidence that DAs improved concordance between values and treatment choice in Some patients who had a treatment preference prior to the hip and knee OA patients. While approximately 80% of pa- video became unsure afer viewing the DA. In the hip OA patients reported that the video prepared them to discuss their tients, despite 2 of the 5 unsure patients choosing a treatment values, the relationship between treatment choice and both preference afer the video, 2 patients who had a preference be- importance of symptom relief and wishing to avoid surgery came unsure; thus, there was no signifcant efect of viewing a was not concordant. While some may consider this to be a decision aid on the total number of undecided patients. While failure of DAs, an alternative explanation is that the currently 12 of 78 knee patients were unsure of treatment prior to view- accepted defnition of concordance may be overly simplistic ing the DA, only 7 were undecided aferwards. when it comes to evaluating the quality of OA treatment decisions. While many patients may initially express the strong Tis study demonstrated that a video DA improved the desire to avoid surgery, the relative inefectiveness of non-op- general knowledge of disease and treatment options for hip erative modalities for severe hip and knee OA may push many and knee arthritis patients who were seeking Orthopaedic patients towards a surgical treatment choice. It has been pre- opinion for possible surgery. While general knowledge im- viously suggested that the desire to obtain pain relief was the proved in both hip and knee groups, only the hip DA group most important factor identifed by patients who chose sur- demonstrated signifcant improvement in complication-re- gery instead of non-operative management.21 It may be that lated knowledge related to the decision. Tis shortcoming is pain relief is such a strong motivator for arthroplasty that afer important, given that the International Patient Decision Aid reviewing the DA, even those patients who initially wanted to Standards (IPDAS) group has identifed the improvement of 12 Dartmouth Orthopaedic Journal 2014; Vol I avoid surgery will choose operative management. patients with hip OA. Improved preparedness to discuss their values and decision readiness did not translate into greater In some clinical trials, decision aids have been shown concordance between patients’ values and treatment choices. to decrease the rates of major surgery by 20% to 40%.22 In Patients with an initial treatment preference were not likely to spine surgery, for example, patients with intervertebral disc change their preference while those who werre unsure about herniation who viewed a video DA were more likely to switch their treatment preference were more likely to report a pref- from surgical to non-operative treatment. 23 Te use of SDM erence afer watching the video. Ultimately, the total number and video DAs in a cohort of patients considering TJA might of people choosing surgery did not change afer viewing the therefore be expected to drive down the utilization of surgery. decision aid. In fact, this may be one of the unspoken fears of Orthopaedic surgeons and health systems regarding SDM. Interestingly, af- REFERENCES ter viewing the DA, the overall number of patients preferring surgery as a treatment option demonstrated no statistically 1. O’Connor AM, Rostom A, Fiset V, et al. Decision aids for patients signifcant change. Tis observation is contradictory to some facing health treatment or screening decisions: systematic review. BMJ. Sep 18 1999;319(7212):731-734. evidence which has suggested that SDM may hold the key to 2. Bernstein SJ, Skarupski KA, Grayson CE, Starling MR, Bates 1,2,6,24 reducing rates of costly, elective surgery . A potential ex- ER, Eagle KA. A randomized controlled trial of information-giving to planation for why video DAs failed to reduce patient enthusi- patients referred for coronary angiography: effects on outcomes of asm for surgery is that there is signifcant asymmetry in the care. Health Expect. Jun 1998;1(1):50-61. known outcomes of non-operative versus operative treatment 3. Lerman C, Biesecker B, Benkendorf JL, et al. Controlled trial of pretest education approaches to enhance informed decision-making for severe hip and knee OA. Te video DA reports an overall for BRCA1 gene testing. J Natl Cancer Inst. Jan 15 1997;89(2):148- satisfaction with non-operative modalities of approximate- 157. ly 40%, while surgical modalities have patient satisfaction 4. O’Connor AM, Tugwell P, Wells GA, et al. Randomized trial of a of 85% to 90%. It may not be surprising, therefore, that pa- portable, self-administered decision aid for postmenopausal women considering long-term preventive hormone therapy. Med Decis Mak- tients tend to gravitate towards the more successful treatment ing. Jul-Sep 1998;18(3):295-303. option. Even the risk of acute perioperative complications, 5. Rothert ML, Holmes-Rovner M, Rovner D, et al. An educational which has been estimated at 2%, does not seem to be enough intervention as decision support for menopausal women. Res Nurs to discourage patients from pursuing arthroplasty treatment. Health. Oct 1997;20(5):377-387. 6. Street RL, Jr., Voigt B, Geyer C, Jr., Manning T, Swanson GP. Increasing patient involvement in choosing treatment for early breast In this study, women seemed to prefer sharing the deci- cancer. Cancer. Dec 1 1995;76(11):2275-2285. sion making process with their physician, compared to men 7. Barry MJ, Cherkin DC, Chang YC, Fowler FJ, S S. A randomized who preferred to be the sole decision maker. Tis suggests trial of a multimedia shared decision-making program for men facing gender, in addition to patient values and goals may play a large a treatment decision for benign prostatic hyperplasia. Disease Man- role in determining how patients arrive at treatment decisions agement and Clinical Outcomes. 1997;1:5–14. 8. O’Connor AM, Bennett CL, Stacey D, et al. Decision aids for for severe hip and knee OA. people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2009(3):CD001431. Tere are several potential limitations to this study. 9. Mancuso CA, Jout J, Salvati EA, Sculco TP. Fulfillment of patients’ All patients recruited to this study had been referred to an or- expectations for total hip arthroplasty. J Bone Joint Surg Am. Sep thopaedic surgeon, suggesting they had time to contemplate 2009;91(9):2073-2078. TJA prior to viewing the video DA. It may be that hip and knee 10. Mancuso CA, Sculco TP, Wickiewicz TL, et al. Patients’ expectations of knee surgery. J Bone Joint Surg Am. Jul 2001;83-A(7):1005- OA patients should be exposed to DAs much earlier in the 1012. disease process. Another limitation was the assumption that 11. Wilson NA, Schneller ES, Montgomery K, Bozic KJ. Hip and each patient watched the video in its entirety and completed knee implants: current trends and policy considerations. Health Aff the questionnaire appropriately afer the video was complete. (Millwood). Nov-Dec 2008;27(6):1587-1598. Tis study only looked at a video DA and did not consider the 12. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from infuence of other sources of information patients common- 2005 to 2030. J Bone Joint Surg Am. Apr 2007;89(4):780-785. ly use before deciding on surgery. Te questions used were 13. Weinstein JN, Clay K, Morgan TS. Informed patient choice: written in accordance with the best known data available on patient-centered valuing of surgical risks and benefits. Health Aff gathering these types of outcome measures and the validity of (Millwood). May-Jun 2007;26(3):726-730. substantiating some of these values could potentially be called 14. Slover J, Shue J, Koenig K. Shared Decision-making in Ortho- paedic Surgery. Clin Orthop Relat Res. Nov 5 2011. into question. 15. Ballantyne PJ, Gignac MA, Hawker GA. A patient-centered perspective on surgery avoidance for hip or knee arthritis: lessons for Information on the timing and efect of SDM on patient the future. Arthritis Rheum. Feb 15 2007;57(1):27-34. preference and treatment decision continues to expand and 16. Clark JP, Hudak PL, Hawker GA, et al. The moving target: further study into this aspect of SDM is needed. In patients a qualitative study of elderly patients’ decision-making regarding with symptomatic hip and knee OA, a video DA improved total joint replacement surgery. J Bone Joint Surg Am. Jul 2004;86- A(7):1366-1374. basic knowledge and improved complication knowledge in 13 Dartmouth Orthopaedic Journal 2014; Vol I

17. O’Connor AM, Bennett C, Stacey D, et al. Do patient decision 21. Bozzuto L KS, Clay C, Kantor S, Tomek I. Hip and Knee Os- aids meet effectiveness criteria of the international patient decision teoarthritis: Shared Decision Making and Factors affecting Patient aid standards collaboration? A systematic review and meta-analysis. Treatment Choice. AAOS Annual Meeting Paper Presentations. 2011. Med Decis Making. Sep-Oct 2007;27(5):554-574. 22. O’Connor AM, Stacey D, Rovner D, et al. Decision aids for 18. Adam JA, Khaw FM, Thomson RG, Gregg PJ, Llewellyn-Thomas people facing health treatment or screening decisions. Cochrane HA. Patient decision aids in joint replacement surgery: a literature Database Syst Rev. 2001(3):CD001431. review and an opinion survey of consultant orthopaedic surgeons. 23. Deyo RA, Cherkin DC, Weinstein J, Howe J, Ciol M, Mulley AG, Ann R Coll Surg Engl. Apr 2008;90(3):198-207. Jr. Involving patients in clinical decisions: impact of an interactive vid- 19. Lurie JD, Spratt KF, Blood EA, Tosteson TD, Tosteson AN, Wein- eo program on use of back surgery. Med Care. Sep 2000;38(9):959- stein JN. Effects of viewing an evidence-based video decision aid 969. on patients’ treatment preferences for spine surgery. Spine (Phila Pa 24. Morgan M. A randomized trial of the ischemic heart disease 1976). Aug 15 2011;36(18):1501-1504. shared decision making program: an evaluation of a decision aid 20. Phelan EA, Deyo RA, Cherkin DC, et al. Helping patients decide [Master’s thesis]. Toronto:University of Toronto. 1997. about back surgery: a randomized trial of an interactive video program. Spine (Phila Pa 1976). Jan 15 2001;26(2):206-211;discussion 212.

14 Predicting electrodiagnostic study results in CTS

Erik R. Bergquist1 MD, Jeffrey A. Cohen1 MD, Kevin F. Spratt2 PhD, Lance G. Warhold1 MD

ABSTRACT: Discussion: Introduction: Demographics and comorbidities can be used to identifying patients with a high likelihood of a positive or negative Carpal tunnel syndrome is the most common compressive EDS in patients with a positive history and physical exam. neuropathy in the United States and has a signifcant fnancial Tis knowledge can help physicians diagnose CTS upon initial burden on the health care system. Te diagnosis is based upon evaluation of a patient. history, physical exam and electrodiagnostic studies. Te purpose of this study was to determine if patient demographics Level of Evidence: and medical comorbidities could be used in the clinic to aid Level II in the diagnosis of carpal tunnel syndrome (CTS) by predicting the results of electrodiagnostic studies (EDS) in patients diagnosed with carpal tunnel syndrome based on history and physical exam. INTRODUCTION: Methods: Carpal tunnel syndrome (CTS) is the most common com- A retrospective chart review of consecutive patients re- pressive neuropathy in the United States. Te prevalence is 1 ferred for EDS with the presumed diagnosis of CTS based on believed to be approximately 3.7% in the United States. Tere history and physical exam was performed to identify charac- are approximately 400,000-500,000 surgeries performed per teristics that could predict a positive or negative EDS. Two year in the US for CTS with an estimated economic impact 2 Orthopaedic surgeons independently evaluated each chart of $2 billion annually. Multiple associations of CTS with and resolved diferences by consensus. Patient profles includ- patient demographics and comorbidities, such as age, female ing demographics and medical comorbidities were recorded. sex, smoking, diabetes, and thyroid disorder have been report- 3,4,5,6,7 Chi-squared test was used to identify signifcance diferences ed. for each variable and binary regression was used to evaluate Several provocative tests assist in diagnosing CTS but no prediction of CTS status. one test is defnitively diagnostic. Te sensitivity and speci- Results: fcity of Phalen’s test range from 0.46 – 0.80 and 0.51 – 0.91, Tree hundred thirty-four of the 431 (77%) patients re- Tinel’s sign 0.28 - 0.73 and 0.44 - 0.95, Median nerve compres- viewed had positive EDS. Predictors for positive EDS include sion test 0.04 - 0.79 and 0.25 – 0.96, respectively. Combining age greater than or equal to 50 years, male sex, retired, dia- these tests is believed to increase both the sensitivity and spec- betes, negative smoking status, and cardiac or renal/urinary ifcity.8,9,10,11,12,13 2-point discrimination and threshold sensory medical comorbidities. Negative predictors for a positive EDS measurements using Semmes-Weinstein monoflament or include unemployment and psychiatric medical comorbidi- vibrometry has a sensitivity of 0.91 and specifcity of 0.8 for ties. Binary regression of EDS status on all nine positive pre- detecting CTS.14 Steroid injection can be used diagnostically, dictors simultaneously indicated that patient age great than or since therapeutically it has been found to improve 70% of pa- equal to 50 years, male sex, cardiac comorbidity, and negative tients with CTS at two weeks in a double blinded randomized smoking status remained signifcant predictors for a positive controlled trial.15 EDS. Electrodiagnostic studies (EDS), the combination of elec- tromyography and nerve conduction studies, are performed 1. Dartmouth-Hitchcock Medical Center, Lebanon NH regularly to assist in diagnosis of CTS. Practice Parameters 2. Geisel School of Medicine at Dartmouth produced by the American Academy of Neurology, American Corresponding Author: Association of Electrodiagnostic Medicine, and the American Erik R. Bergquist, MD Academy of Physical Medicine and Rehabilitation give a sensi- E-mail: [email protected] tivity ranging from 0.04 - 0.85 and specifcity of 0.52 – 0.99 for a number of diferent electrodiagnostic tests for carpal tunnel DISCLOSURE: None of the authors received payments or services, either 16 directly or indirectly, from a third party in support of any aspect of this work. syndrome. Te complete disclosures of potential conficts of interest submitted by authors is available upon request through correspondence with the DOJo ofce. In patients suspected to have CTS based on their history Dartmouth Orthopaedic Journal 2014; Vol I and physical exam, it was hypothesized that patient demo- ancy. Variables extracted were based on previously reported graphics and medical comorbidities (medical condition or predictors of CTS in the literature. 3,19,20,21,22,23 Tese included: disease process) could be examined independently and simul- patient age and sex; specifc medical comorbidities of active taneously to determine those that best predict the chance of smoking, diabetes, and thyroid disorder; profession; workers a patient having a positive or negative based on EDS evalua- compensation status; referring provider type; total number of tion. Te ability to predict CTS status based on EDS results medical comorbidities; and specifc medial comorbidities re- can assist physicians in making the diagnosis of carpal tunnel corded on a health system basis: cardiac, pulmonary, gastro- syndrome upon initial evaluation and determine the next step enterological, renal/urinary, rheumatologic, musculoskeletal, in treatment. We performed a retrospective cohort study to neurologic, endocrine, psychiatric, reproductive, hematolog- determine if demographics and medical comorbidities could ic/oncologic, dermatologic, and eyes/ears/nose/throat. predict EDS results in patients with a diagnosis of CTS based on history and physical exam. EDS protocol

MATERIALS AND METHODS: EDSs were performed in accordance with the standards set by the American Association of Electrodiagnostic Medi- Study Design and Cohort Identification cine, American Academy of Neurology, and the American Academy of Physical Medicine and Rehabilitation (Appendix Institutional Review Board approval was obtained for this A).16 Te values used in regards to an abnormal EDS are those study. A cohort of consecutive patients was identifed by re- set as the institutional standard for our institution (Appendix viewing the clinic schedules for the providers in the Depart- B). ment of Neurology at our institution that performed EDSs for CTS in accordance with the recommendations of the Amer- Data Analysis ican Academy of Orthopaedic Surgeons (AAOS) Clinical Practice (CPG).17 Schedules were reviewed from November Data analyses described the overall sample and evaluated 2008 through August 2011. for diferences in patient demographics and comorbidities relative to CTS status. Chi-square tests for categorical variables All patients over this period were included if their refer- and analysis of variance (ANOVA) for continuous variables ring diagnosis was CTS or median nerve compression at the were used to evaluate the association of each variable with CTS wrist and excluded if their referring diagnosis was hand pain, status with type I error set at 0.05. Unadjusted and adjusted hand numbness, fnger numbness, or anything other than relative risks (URR and ARR) associated with signifcant pre- CTS/median nerve compression at the wrist. If a patient had dictors identifed in the preliminary chi-square and ANOVA multiple visits for the diagnosis of CTS, the patient was en- results were evaluated with generalized regression using the tered into the study only once with the EDS from the initial GLIMMIX procedure that specifed a binary distribution with visit used. a log link and specifying patient id as a random efect.

Data from clinic notes and the hospital information system Source of Funding: were abstracted by two evaluators and entered independently into a REDCap electronic data capture.18 REDCap (Research No external or internal funds were received in the conduct Electronic Data Capture) is a secure, web-based application of this report. Te authors of this study have no disclosures or designed to support data capture for research studies, provid- conficts of interest to report. ing: 1) an intuitive interface for validated data entry; 2) audit trails for tracking data manipulation and export procedures; RESULTS: 3) automated export procedures for seamless data downloads to common statistical packages; and 4) procedures for import- Four-hundred forty-nine consecutive patient visits to the ing data from external sources. Department of Neurology at our institution for an EDS to rule in CTS between November 2008 and August 2011 were iden- Chart Review Protocol tifed. Four-hundred thirty-one (96%) met study inclusion/ exclusion criteria. Of the 18 patients excluded, 17 were repeat Afer receiving internal review board approval, patient referrals and one patient did not have an adequate medical demographic, medical comorbidity, and EDS result data were history for collection of patient demographics and medical recorded. Medical comorbidities as reported by the patients comorbidities. were defned as persistent medical issues afecting the patient at the time of the EDS. Te double data entry comparison Patient demographics and medical comorbidities are tools built into the sofware was used to identify discrepancies summarized in Table 1. Overall, 334 of the 431 (77%) patients in data entry that were then clarifed by the two evaluators presumed to have CTS were had positive EDS for CTS. Nine by returning to the source data and resolving each discrep- demographics/comorbidities were associated with (p < 0.05) 16 Dartmouth Orthopaedic Journal 2014; Vol I

Table 1. Patient Demographics / Medical Comorbidities and EDS Result Overall CTS+ CTS- N p Value n = 431 n = 334 n = 97 Age in years: Mean (SD) 431 55.4 (14.5) 58.0 (15.2) 46.4 (12.8) <0.001 >=50 272 63.1% 70.1% 39.2% <0.001 <50 159 36.9% 29.9% 60.8% <0.001 Gender <0.001 % Male 154 35.7% 42.2% 13.4% <0.001 % Female 277 64.3% 57.8% 86.6% <0.001 Tobacco Use %Smoking 82 19.0% 15.3% 32.0% 0.001 Working status 0.001 Working - Active 157 36.4% 35.3% 40.2% 0.064 Working - Sedentary 93 21.6% 20.7% 24.7% 0.075 Not Working - Retired 103 23.9% 28.4% 8.3% <0.001 Not Working - Student 5 1.2% 1.2% 1.0% 0.408 Not Working - Unemployed 58 13.5% 11.4% 20.6% 0.010 Unknown 15 3.5% 3.0% 5.2% 0.136 Referring provider type 0.504 PCP 171 39.7% 39.8% 39.2% Neurosurgeon 4 0.9% 1.2% 0.0% Orthopeadic Surgeon 103 23.9% 22.8% 27.8% Plastic Surgeon 110 25.5% 27.0% 20.6% Neurologist 22 5.1% 4.8% 6.2% Rheumatologist 11 2.6% 2.7% 2.1% Other 10 2.3% 1.8% 4.1% Medical comorbidities Mean No. of comorbidities (SD) 431 4.50 (2.8) 4.6 (2.9) 4.0 (2.6) 0.068 cardiac comorbidities % Yes 266 61.7% 66.8% 44.3% <0.001 pulmonary comorbidities % Yes 104 24.1% 22.4% 26.8% 0.484 GI comorbidities % Yes 153 35.5% 33.2% 43.3% 0.068 renal/urinary comorbidities % Yes 63 14.6% 16.5% 8.3% 0.044 rheumatologic comorbidities % Yes 66 15.3% 15.9% 13.4% 0.553 musculoskeletal comorbidities % Yes 206 47.8% 49.4% 42.3% 0.216 neurologic comorbidities % Yes 101 23.4% 21.6% 29.9% 0.088 endocrine comorbidities % Yes 138 32.0% 32.6% 29.9% 0.611 psychiatric comorbidities % Yes 159 36.9% 32.6% 51.6% 0.001 reproductive comorbidities % Yes 68 15.8% 15.6% 16.5% 0.826 heme/onc comorbidities % Yes 55 12.8% 14.1% 8.3% 0.130 dermatologic comorbidities % Yes 65 15.1% 16.8% 9.3% 0.070 EENT comorbidities % Yes 70 16.2% 17.7% 11.3% 0.137 Diabetes %Yes 69 16.0% 18.0% 9.3% 0.040 Tyroid Disease %Yes 69 16.0% 15.6% 17.5% 0.644 Workers compensation 27 6.3% 6.0% 7.2% 0.660

17 Dartmouth Orthopaedic Journal 2014; Vol I CTS. Patients who had clinical evidence of CTS and posi- to their relative populations in the cohort, male gender was tive EDS were more likely to be 50 years of age or older, male, more predictive of a positive EDS. Tis could suggest that fe- retired, diabetic, or report comorbidities involving cardiac or males may be more likely to seek treatment earlier in the dis- renal/urinary systems. Patients who had clinical evidence of ease process than males when their EDS are not yet positive. CTS but paradoxically had negative EDS were more likely to be unemployed, be a smoker, or report a psychiatric comor- Studies have provided mixed results regarding the rela- bidity. Table 2 classifes the variables relative to their relation- tionship of tobacco use and CTS.3,29,30 Tis study found tobac- ship with the EDS result. co use to be associated with negative EDS for CTS. Tis does not negate the role of smoking in vascular disease, nerve inju- Univariate binary regression results for each of the nine ry, and carpal tunnel syndrome, but instead suggests an over- demographics/comorbidities related to the EDS results pro- powering presence of smoking use as a surrogate for other fac- vides both the unadjusted relative risks (URR) and the adjust- tor(s) in these patients leading to a negative EDS. Psychiatric ed relative risks (ARR) associated with each predictor and for medical comorbidities have not previously been found to have the overall model (Table 2). Multi-variable binary regression an association with CTS.31 Although, patients with CTS and analysis demonstrated signifcant (p < 0.05) ARRs for four of psychiatric medical comorbidities report more intense symp- the nine predictive demographics/comorbidities. Tese in- toms.32 Tis study found psychiatric medical comorbidities clude age greater than or equal to 50, male sex, presence of to be associated with a negative EDS. Tis negative associa- cardiac comorbidities, and lack of smoking, Table 3. Model tion may be due to a hypersensitive state where patients seek sensitivity and specifcity were both 0.72 with positive predic- medical attention before their EDS meet the threshold for a tive value (PPV) of 0.90, and negative predictive value (NPV) diagnosis of CTS. Finally, employment status has been asso- of 0.43. ciated with CTS.22 Although this study did not examine employment versus unemployment, it did compare patients who DISCUSSION: reported to be “unemployed” vs. other work status (working, retired, student). Unemployed status was predictive of a neg- Patient demographics and comorbidities can predict the ative EDS. Tis, in association with the other predictors of a results of EDS in patients believed to have CTS based on his- negative EDS (younger age, smoking, and psychiatric med- tory and physical exam. Multi-variable analysis indicate the ical comorbidities) presents a psychosocial/socioeconomic demographics/comorbidities that best predict the results of a component to those patients with a history and physical exam patient’s EDS for CTS include a patient’s age, sex, presence of consistent with CTS but paradoxical negative EDS. a cardiac comorbidity, and smoking status. Demographics and medical comorbidities previous- History and physical exam predicted CTS on EDS in this ly associated with CTS but not found to be associated with study at rates similar to those already published.8,9,10,11,12,13,14 CTS, either positive or negative, include thyroid disorder, CTS was also associated with increasing age,1,11,19,24,25 diabe- rheumatologic medical comorbidities, and workers compen- tes,3,26 cardiac comorbidities,23 renal/urinary comorbidities,27 sation.3,21,33 When thyroid disorder is treated, EDS for CTS and retired working status11,28 on univariate analysis. have been found to normalize.20 It is possible the patients in this study had their thyroid disorder well managed, as they Tis research agrees with the reported literature, fnding a required a referral to have their EDS and were consumers of greater incidence of females referred with presumptive CTS as healthcare. Tere is a clear correlation between synovial pro- 1,19 well as females who had a positive EDS. Despite this fact, liferative rheumatologic diseases such as rheumatoid arthritis when sex was analyzed for rates of CTS with EDS in relation and CTS.34 Other rheumatologic diseases such as fbromyal- gia do not have these correlations. It is possible that patients Table 2. Predictors of CTS on EDS with these other rheumatologic comorbidities diluted the Positive Negative Not predictive number of patients with synovial proliferative rheumatologic Age >= 50 Tobacco use Other medical diseases thus fnding no correlation between rheumatologic comorbidities comorbidities and CTS. Tis study found no statistically sig- Male sex Psychiatric Tyroid disease nifcant association between worker compensation claims and comorbidities EDS results for CTS. Tus, workers compensation does not Diabetes Unemployed Number of medial play a role in diagnosis of CTS. comorbidities Tis study did not fnd a signifcant diference in the rates Cardiac Referring provider comorbidities type of predicting CTS with EDS between the diferent types of referring physicians. Tis could suggest that the cohort was Renal/urinary Workers without subgroups that could skew the data based upon a sin- comorbidities compensation gle type of provider (Ex. Primary care physician) referring a Retired disproportionate number of patients in the cohort using ei- 18 Dartmouth Orthopaedic Journal 2014; Vol I

Table 3. Multiple Variable Analysis Using the 9 Predictors Found on Univariate Analysis Univariate Regression Results Multiple Regression Results Variable Contrast URR 95% CI c*** p < ARR 95% CI c*** p <

Full Model* PV+ ref (1 - PV-)** 1.57 1.37-1.82 0.78 0.0001 Age >=50 ref < 50 1.367 1.20-1.56 0.65 0.0001 1.179 1.03-1.35 0.78 0.0160

Sex Male ref 1.314 1.19-1.44 0.64 0.0001 1.254 1.12-1.40 0.0001 Female No tobacco use Yes ref No 1.304 1.08-1.45 0.58 0.003 1.181 1.01-1.39 0.0310 Retired Yes ref No 1.265 1.15-1.39 0.60 0.0001 1.033 0.90-1.18 0.6300 Unemployed Yes ref No 0.826 0.68-1.01 0.55 0.0206 0.917 0.77-1.09 0.3200 Diabetes Yes ref No 1.149 1.03-1.29 0.54 0.0440 1.042 0.90-1.20 0.5600 Cardiac Yes ref No 1.246 1.10-1.41 0.61 0.0001 1.133 1.01-1.28 0.0490 Renal/urinary Yes ref No 1.151 0.91-1.14 0.54 0.0490 1.035 0.90-1.19 0.6500 Psychiatric Yes ref No 0.829 0.73-0.94 0.59 0.0008 1.104 0.80-1.02 0.0910 * Full model included all 9 variables ** PV+ ref (1 -PV-) = (the likelihood of CTS + given that the model predicts CTS+ or Positive Predictive Value) / (the likelihood of CTS+ given that the model predicts CTS- or 1 - Negative Predictive Value) *** c is the area under the ROC curve (plotting Sensitivity (y) against 1-Specifcity (x) ther a better or worse clinical acumen. 1. Papanicolaou GD, McCabe SJ, Firrell J. The prevalence and characteristics of nerve compression symptoms in the general population. J Hand Surg. 2001;26(3):460–466. Tis was a retrospective cohort study and this design 2. Palmer DH, Hanrahan LP. Social and economic costs of carpal comes with known limitations. Te greatest limitation is the tunnel surgery. Instr Course Lect. 1995;44:167–172. accuracy of the referral diagnosis. Te history and physical 3. Karpitskaya Y, Novak CB, Mackinnon SE. Prevalence of smoking, exam that lead to that diagnosis was not available for many obesity, diabetes mellitus, and thyroid disease in patients with carpal patients, as the referral came from outside the institution per- tunnel syndrome. Ann Plast Surg. 2002;48(3):269–273. forming the EDS. Te rate of positive EDS was consistent with 4. Ablove RH, Ablove TS. Prevalence of carpal tunnel syndrome in pregnant women. WMJ. 2009;108(4):194–196. the literature. Additionally, the accuracy and completeness of 5. Goodman CM, Steadman AK, Meade RA, et al. Comparison of the data in the medical record limits the quality of the conclu- carpal canal pressure in paraplegic and nonparaplegic subjects: clini- sions. To minimize this limitation, two independent review- cal implications. Plast Reconstr Surg. 2001;107(6):1464–1471 ers performed double data entry. Discrepancies may also exist 6. Andersen JH, Thomsen JF, Overgaard E, et al. Computer use between the interpretations of which medical system a medi- and carpal tunnel syndrome: a 1-year follow-up study. JAMA. 2003;289(22):2963–2969. cal comorbidity should be attributed or the strenuous nature 7. Franklin GM, Haug J, Heyer N, Checkoway H, Peck N. Occupa- of a profession. Te two independent reviewers agreed upon tional carpal tunnel syndrome in Washington State, 1984-1988. Am J these interpretations but their judgment may difer from that Public Health. 1991;81(6):741–746. of the medical body. Te patients in this study come from a 8. Gomes I, Becker J, Ehlers JA, Nora DB. Prediction of the neuro- rural portion of New England and may not be generalizable physiological diagnosis of carpal tunnel syndrome from the demographic and clinical data. Clin Neurophysiol 2006;117(5):964–971. to other regions. Finally, this study provides data for patients 9. de Krom MC, Knipschild PG, Kester AD, Spaans F. Efficacy of believed to have CTS based on history and physical exam. It provocative tests for diagnosis of carpal tunnel syndrome. Lancet. does not provide information on patients with an equivocal 1990;335(8686):393–395. diagnosis of CTS. 10. Raudino F. Tethered median nerve stress test in the diagnosis of carpal tunnel syndrome. Electromyogr Clin Neurophysiol. 40(1):57– Patient demographics and medical comorbidities were 60. 11. Katz JN, Larson MG, Sabra A, et al. The carpal tunnel syndrome: identifed that can be used in the clinic to predict the results diagnostic utility of the history and physical examination findings. Ann of EDS and thereby assist in the diagnosis of CTS upon initial Intern Med. 1990;112(5):321–327. evaluation. Tis knowledge can help physicians better treat 12. Fertl E, Wöber C, Zeitlhofer J. The serial use of two provocative their patients. tests in the clinical diagnosis of carpal tunel syndrome. Acta Neurol Scand. 1998;98(5):328–332. 13. Kaul MP, Pagel KJ, Wheatley MJ, Dryden JD. Carpal compres- REFERENCES sion test and pressure provocative test in veterans with median-distri-

19 Dartmouth Orthopaedic Journal 2014; Vol I bution paresthesias. Muscle Nerve. 2001;24(1):107–111. in-hospital carpal tunnel syndrome in the general population and 14. Gellman H, Gelberman RH, Tan AM, Botte MJ. Carpal tunnel possible associations with marital status. BMC Public Health. syndrome. An evaluation of the provocative diagnostic tests. J Bone 2008;8:374. Joint Surg Am. 1986;68(5):735–737. 25. Atroshi I, Gummesson C, Johnsson R, et al. Prevalence of carpal 15. Armstrong T, Devor W, Borschel L, Contreras R. Intracarpal tunnel syndrome in a general population. JAMA. 1999;282(2):153– steroid injection is safe and effective for short-term management of 158. carpal tunnel syndrome. Muscle Nerve. 2004;29(1):82–88. 26. Chammas M, Bousquet P, Renard E, et al. Dupuytren’s disease, 16. Jablecki CK, Andary MT, Floeter MK, et al. Practice parameter: carpal tunnel syndrome, trigger finger, and diabetes mellitus. J Hand Electrodiagnostic studies in carpal tunnel syndrome. Report of the Surg. 1995;20(1):109–114. American Association of Electrodiagnostic Medicine, American Acad- 27. Halter SK, DeLisa JA, Stolov WC, Scardapane D, Sherrard DJ. emy of Neurology, and the American Academy of Physical Medicine Carpal tunnel syndrome in chronic renal dialysis patients. Arch Phys and Rehabilitation. Neurol. 2002;58(11):1589–1592. Med Rehabil. 1981;62(5):197–201. 17. Keith MW, Masear V, Amadio PC, et al. Treatment of carpal tun- 28. Lo J. Community-based referrals for electrodiagnostic studies in nel syndrome. J Am Acad Orthop Surg. 2009;17(6):397–405. patients with possible carpal tunnel syndrome: What is the diagno- 18. Harris PA, Taylor R, Thielke R, et al. Research electronic data sis? Arch Phys Med Rehabil. 2002;83(5):598–603. capture (REDCap)--a metadata-driven methodology and workflow 29. Geoghegan JM, Clark DI, Bainbridge LC, Smith C, Hub- process for providing translational research informatics support. J bard R. Risk factors in carpal tunnel syndrome. J Hand Surg Br. Biomed Inform. 2009;42(2):377–381. 2004;29(4):315–320. 19. Hobby JL, Venkatesh R, Motkur P. The effect of age and gender 30. Nathan PA, Keniston RC, Lockwood RS, Meadows KD. Tobacco, upon symptoms and surgical outcomes in carpal tunnel syndrome. J caffeine, alcohol, and carpal tunnel syndrome in American industry. Hand Surg Br. 2005;30(6):599–604. A cross-sectional study of 1464 workers. J Occup Environ Med. 20. Palumbo CF, Szabo RM, Olmsted SL. The effects of hypothy- 1996;38(3):290–298. roidism and thyroid replacement on the development of carpal tunnel 31. Chan L, Turner JA, Comstock BA, et al. The relationship between syndrome. J Hand Surg. 2000;25(4):734–739. electrodiagnostic findings and patient symptoms and function in car- 21. Cranford CS, Ho JY, Kalainov DM, Hartigan BJ. Carpal tunnel pal tunnel syndrome. Arch Phys Med Rehabil. 2007;88(1):19–24. syndrome. J Am Acad Orthop Surg. 2007;15(9):537–548. 32. Hobby JL, Venkatesh R, Motkur P. The effect of psycholog- 22. Roquelaure Y, Ha C, Pelier-Cady M-C, et al. Work increases ical disturbance on symptoms, self-reported disability and sur- the incidence of carpal tunnel syndrome in the general population. gical outcome in carpal tunnel syndrome. J Bone Joint Surg Br. Muscle Nerve. 2008;37(4):477–482. 2005;87(2):196–200. 23. Shiri R, Heliövaara M, Moilanen L, et al. Associations of cardio- 33. Szabo RM. Carpal tunnel syndrome as a repetitive motion disor- vascular risk factors, carotid intima-media thickness and manifest der. Clin Orthop Relat Res. 1998;(351):78–89. atherosclerotic vascular disease with carpal tunnel syndrome. BMC 34. Dorwart BB. Carpal tunnel syndrome: a review. Semin Arthritis Musculoskelet Disord. 2011;12:80. Rheum. 1984;14(2):134–140. 24. Mattioli S, Baldasseroni A, Curti S, et al. Incidence rates of

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

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

ABSTRACT: thopaedic trauma patients was also examined. Approximately 29% of survey respondents stated that it was ofen easier to Introduction have an orthopaedic trauma patient transferred to a Level I Tis study aims to evaluate what impact the establishment trauma center than have the on-call staf evaluate the patient. of a “Transfer Center” has on the transfer process from the An equal number of respondents, however, felt the transfer perspective of the referring Emergency Department (ED) phy- process was “very frustrating.” sician. Methods In an efort to facilitate the process of transferring patients, a designated Transfer Center was established at a northern Paper surveys were mailed to all ED directors in NH and New England Level I trauma center. Te Transfer Center in- VT to assess their perception of a newly established Transfer cludes a triage secretary who is available 24 hours per day. Te Center at a Level I trauma center on patient care and on the triage secretary receives the incoming transfer request call and transfer process. contacts the appropriate accepting service(s). A conference call Results with all of the parties is then recorded with the triage secretary 19 out of 38 (50%) of surveys were returned. 59% of re- acting as facilitator. Prior to the establishment of the Transfer spondents said the Transfer Center improved the process of Center, incoming requests for transfer did not follow any set transferring patients while 35% said it made no diference. pattern. Sometimes the calls went through the hospital op- Despite overall improvement, 33% said the process is still ei- erator, other times through the ED physician, and sometimes ther “very” or “somewhat” frustrating. through department answering services. Tis study sought to see, from the ED physicians’ perspective, what impact the Discussion Transfer Center has had on the transfer process. Establishing a dedicated Transfer Center can improve communication and facilitate the transfer of patients to tertiary METHODS care hospitals. Level of Evidence Institutional Review Board approval was obtained prior IV to commencing this survey. Self-addressed anonymous enve- lopes were mailed to each of the 38 Emergency Department INTRODUCTION directors in Northern New England. Te survey assessed the ED director’s perception of transferring orthopaedic trauma Recent years have seen what some describe as a “crisis” patients to a regional Level I trauma center both before and in the availability of orthopaedic surgeons to provide trauma afer the institution of the Transfer Center. Statistical analysis 1-5 care. In a previous study conducted by this group, ED pro- utilizing Fisher’s exact test was used to compare responses to viders in NH and VT were surveyed regarding their experi- previous responses published by the group. An open-ended 6 ence with their orthopaedic call coverage. Te transfer of or- response section was placed at the end of the survey to solicit recommendations for improvement as well as allow for a general assessment of the “Transfer Center”. 1. Dartmouth-Hitchcock Medical Center, Lebanon NH 2. New York-Presbyterian Hospital, Columbia University, NYC Source of Funding Corresponding Author: Robert V. Cantu, MD, MS No external or internal funds were received in the conduct E-mail: [email protected] of this report. Te authors of this study have no disclosures or conficts of interest to report. DISCLOSURE: None of the authors received payments or services, either directly or indirectly, from a third party in support of any aspect of this work. Te complete disclosures of potential conficts of interest submitted by au- RESULTS thors is available upon request through correspondence with the DOJo ofce. Dartmouth Orthopaedic Journal 2014; Vol I

Figures 1-3 demonstrate responses to the following questions: 19 out of 38 surveys (50% response rate) were returned. Of the respondents 50% had completed Emergency Medicine 1. How would you rank your access to speaking with the orthopaedic residency training, 30% Family Practice, and 20% Internal surgeon or resident through the Transfer center? Medicine. Te majority (90%) had been an ED physician for more than 10 years. Almost all respondents (95%) were aware 2. How frustrating is it to transfer a patient to DHMC afer the Trans- the accepting facility had a designated Transfer Center. In ad- fer Center? dressing the overall premise of the study, 59% of respondents treplied that the Transfer Center has made the transfer of or- 3. Do you feel that having the ability for the orthopaedic team to view thopaedic trauma patients easier, while 35% of respondents x-rays prior to transfer through a shared digital imaging has been benefcial to the transfer process for the patient? stated that it made no diference (Figure 1.) Despite the overall improvement, 33% stated that the process was still either “very” or “sometimes” frustrating (Figure 2.)

Of the respondents, 83% stated that speaking with the orthopaedic surgeon/resident improved quality of care and assisted with the transfer process, while 12% stated that it made no diference. Interestingly, 67% stated that they would rather speak with the attending orthopaedic surgeon, 11% would prefer to speak with the emergency medicine attending staf, and only 6% would prefer to speak with the resident on call.

Regarding the transparency of bed availability at the accepting facility, 71% of respondents stated that the Transfer Center had improved the knowledge of available beds for a Figure 1. ED Provider satisfaction with communication afer imple- patient requiring an inpatient stay. Approximately 18% of re- mentation of the Transfer Center spondents stated that it had not improved the process.

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

Although not directly related to the transfer center, the survey also assessed the availability of the accepting facility to view radiographs prior to transfer of the patient. 57% of respondents felt that the accepting facility being able to view radiographs prior to transfer was “always benefcial” to the Figure 2. General frustration level by referring ED provider on transfer process with 35% stating that it was “sometimes ben- transfer of patient to DHMC afer implementation of Transfer efcial” (Figure 3.) Center Responses to the open-ended questions were general- ly positive in regard to the function of the Transfer Center. “Te Transfer Center has enhanced communication and bed availability determination.” Several responses echoed similar sentiments, however there were some replies that voiced frustration with the transfer process. “To some degree, it slows the process on our end because I have to speak to more people.” Te time being on hold and waiting for paged residents and staf was surmised as a reason for the time delay in one response. Te writer ofered, “other transfer centers work this out in the background and call us back rather than have us hold throughout the entire process.”

Figure 3. Efect of viewing radiographs prior to transfer of patient. 22 Dartmouth Orthopaedic Journal 2014; Vol I

DISCUSSION radiographic images prior to the transfer of a patient. Most respondents found the pre-transfer review of images to be Prior studies have examined on-call coverage and the benefcial to the transfer process as well as the overall care of function of a transfer center from the viewpoint of the ac- the patient. Due to the growing use of electronic medical re- 7-8 cepting facility. Esposito et al. concluded the problems with cords, it is the hope of this group that shared viewing of imag- the transfer of patients are due to a “reticence and functional ing could prompt an immediate transfer for patients needing inability on the part of individual providers and institutions acute care and also prevent patients from the time and efort to care for trauma patients.” Between 2000 and 2006, Rudkin of an unnecessary transfer. et al. found orthopaedic call coverage to have become more “problematic”. Te increasing difculties in coverage oc- Most respondents stated that being able to speak with ei- curred despite increased reimbursement for on-call coverage ther a resident or attending staf has improved the quality of (35% receiving payments up from 21% in 2000). care and improved the transfer process. Although the majority of respondents stated that they would rather discuss the case Our study is unique in that it looks at the impact of a trans- with an attending orthopaedic physician over having a dis- fer center from the perspective of the referring ED physician. cussion with the orthopaedic resident, most did not feel the Te survey results show most ED directors feel the transfer current practice hindered the adequacy of care for the ortho- center has improved the process, with less time involved and paedic patient. fewer phone calls needed to arrange transfer. For a busy ED physician this means more time can be spent seeing new pa- Tere are several weaknesses to our study. Te study, by tients. design, is open to bias as it looks at the transfer center through the lens of the transferring ED provider. A second defciency Southard et al. studied the impact of a transfer center on in this paper is the response rate. An attempt was made at tar- 9 interhospital referrals. In this case the transfer center was geting the ED staf that had the best perception of the process. stafed by ED physicians and the initial phase of the process Only 50% of the 38 surveys were returned. Tis response rate, was determining the appropriateness of transfer. Te num- however, correlates with another study that was sent to ED ber of transfers to the center increased from 1,532 requests directors.7 (7) In this study,43% of surveys were returned from for transfer to 2,082 requests afer the “transfer center” was the ED directors in their 2000 study and 51% in their 2006 established. Of the transferred patients, 90% either met the study. Emergency Medical Treatment and Labor Act (EMTALA) criteria or tertiary center criteria for transfer. Te other 10% were Although our study shows some advantages to a designat- deemed “convenience” transfers. Te authors concluded, “en- ed Transfer Center, it also points to areas of further improve- hancements to the acute medical center transfer center cou- ment. Tis was perhaps most clear in the response to the open pled with the faculty education and partnership with a senior ended questions. One respondent ofered valuable insight into clinical administrator worked to ensure appropriate transfers placing a caller on hold while assisting with the transfer pro- and a stable payer mix.” cess. “Other transfer centers work this out in the background and call us back rather than have us hold throughout the en- Te transfer of complex trauma patients to regional Level I tire process.” Tis was noted to consume time during a busy 10-12 trauma centers has been demonstrated to reduce mortality. ED shif. Te ability to transfer patients efciently is an important factor. When Menchine et al. examined the timeliness of trans- REFERENCES fer, they found approximately 44% of orthopaedic transfers to a higher level of care facility took more than 3 hours to coor- 1. Vanlandingham BD, et al. On Call Specialist Coverage in U.S. dinate and locate an accepting facility.13 A report released by Emergency Departments. ACEP Survey of Emergency Department Directors. American College of Emergency Physicians. 2006 the Joint Commission on Accreditation of Healthcare Organi- 2. Bosse, Michael J., et al., “Access to Emergent Musculoskeletal zations (JCAHO) stated that over half of all hospital sentinel Care: Resuscitating Orthopaedic Emergency Department Coverage,” events involving death or permanent disability resulting from Journal of Bone and Joint Surgery, Vol. 88A(6):1385-94. delays in treatment occur in EDs.14 In the same study, ap- 3. Cryer HM 3rd. The future of trauma care: at the crossroads. J proximately 21% of ED patient deaths or permanent injuries Trauma 2005;58: 425-36. were directly attributed to delays in treatment due to shortag- 4. Crichlow RJ, Zeni A, et al. Appropriateness of patient transfer with associated orthopaedic injuries to a Level I Trauma Center. J Orthop es of specialist physicians. In our survey, the majority (87%) of Trauma. 2010 Jun;24(6):331-5. calls for transfer took less than 30 minutes. Furthermore, the 5. Rotondo MF, Esposito TJ, Reilly PM et al. The position of the number of facilities contacted prior to transfer has decreased Eastern Association for the Surgery of Trauma on the future of trau- pointing to an improved process. Te study did not assess the ma surgery. J Trauma. 2005;59: 77-9 6. Cantu RV, Bell JE, et al. How Do Emergency Department Physi- actual time of transfer of patients. cians Rate Their Orthopaedic On-Call Coverage? JOT: January 2012 - Volume 26 - Issue 1 - pp 54-56 Our survey assessed the utility of being able to review 23 Dartmouth Orthopaedic Journal 2014; Vol I

7. Esposito TJ, Crandall M. Socioeconomic Factors, Medicolegal 11. Mullins RJ, Veum-Stone J, Helfand M, et al. Outcome of hospital- Issues, and Trauma Patient Transfer Trends: Is There a Connection? ized injured patients after institution of a trauma system in an urban The Journal of Trauma: Injury, Infection, and Critical Care 2006;61(6): area. JAMA 1994;271:1919–1924. 1380-1388. 12. Papa L, Langland-Orban B, Kallenborn C, et al. Assessing ef- 8. Rudkin et al. The worsening of ED on-call coverage in California: fectiveness of a mature trauma system: association of trauma center 6-year trend. Am J Emerg Med. 2009;27(7):785-91. presence with lower injury mortality rate. J Trauma 2006;61:261–266. 9. Southard PA, Hedges JR, Hunter JG, Ungerleider RM. Impact of 13. Menchine MD, Baraff LJ. On call specialists and higher level of a transfer center on interhospital referrals and transfers to a tertiary care transfers in California. Acad Emerg Med. 2008;15(4):329-36. care center. Acad Emerg Med 2005;12(7):653-7. 14. The Joint Commission. Sentinel Event Alert, No. 26. The Joint 10. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evalu- Commission, 2002. Delays in Treatment. Available at: http://www. ation of the effect of trauma-center care on mortality. N Engl J Med. jointcommission.org/SentinelEvents/SentinelEventAlert/sea_26.htm. 2006;354: 366–378

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

John T. Braun MD ABSTRACT control was poor with progression over 22 months to 44.5°. Tethered curves initially corrected from 36.6° pre-op to 21.4° Summary post-op with good control over 14.4 months with additional Initial correction and subsequent control of progression correction to 17.8°. Ligament tethering demonstrated signif- were evaluated in 9 adolescent idiopathic scoliosis (AIS) pa- cantly greater initial correction (p=.001) and subsequent con- tients treated with one of two methods of fusionless scoliosis trol of curve progression (p=.002) when compared to verte- surgery (FSS): vertebral stapling versus ligament tethering. bral stapling. No signifcant complications were encountered; Ligament tethering demonstrated signifcantly greater initial however, 1 stapled patient required fusion for a progressive correction and subsequent control of curve progression than curve to 55°. stapling. Ligament tethering, unlike bracing or fusion surgery, allows signifcant scoliosis correction without sacrifcing Conclusion growth, motion and function of the spine. Both initial correction and subsequent control of curve progression are important in the fusionless treatment of AIS. Introduction In this preliminary study, it appears that ligament tethering Fusionless scoliosis surgery (FSS) is a novel treatment op- provides greater initial correction and subsequent control of tion for AIS patients not amenable to brace treatment and at AIS curve progression than vertebral stapling. high risk (>90%) for progression to fusion surgery. Tough two FSS methods, vertebral stapling and ligament tether- Level of Evidence: ing, have demonstrated efectiveness in controlling AIS pro- III gression, these have never been compared clinically in well matched groups with similar indications. INTRODUCTION Methods Fusionless scoliosis surgery is a novel treatment option Retrospective study of 9 consecutive AIS patients (average for idiopathic scoliosis that ofers perceived advantages over age 12+11) treated with stapling versus tethering for thoracic the current standard forms of treatment. When compared to curves >30° (average 35.6°) in the setting of skeletal immatu- bracing, fusion surgery or other nonfusion options (for exam- rity (average Risser 0 to 1). Risk of progression was assessed ple, growing rods or the vertical, expandable, prosthetic titani- using 3 methods (Lonstein, Sanders, ScoliScore). All patients um rib, VEPTR, Synthes Spine, West Chester, PA), fusionless had >90% risk of progression to fusion surgery by at least 2 of scoliosis surgery ofers the potential for signifcant deformity the 3 methods. Cobb angles pre-op, post-op and fnal were correction via a single, minimally invasive intervention that compared. preserves the growth, motion and function of the spine. Results Over the past decade or so, fusionless scoliosis surgery has Nine well matched female patients with 14 curves under- been referred to by many names – endoscopic vertebral sta- went endoscopic FSS: 4 had stapling of 6 curves and 5 had pling, anterior ligament tethering, convex scoliosis tethering, tethering of 8 curves. Stapled curves were initially correct- mechanical modulation of spinal growth and internal bracing ed from 34.5° pre-op to 31.3° post-op but subsequent curve of spinal deformity. However, regardless of the descriptive term used, or even the device employed, the goal of all fusion- 1. Dartmouth-Hitchcock Medical Center, Lebanon NH less scoliosis surgery is the same. Tat is, to harness the scoliosis child’s inherent spinal growth and redirect it to achieve Corresponding Author: correction, rather than progression, of the spinal deformity. John T. Braun, MD E-mail: [email protected] Implant choices in anterior fusionless scoliosis surgery es- DISCLOSURE: None of the authors received payments or services, either sentially fall into two categories, staples and ligament tethers. directly or indirectly, from a third party in support of any aspect of this work. Tough extensive pre-clinical testing of both types of devic- Te complete disclosures of potential conficts of interest submitted by au- es has demonstrated their safety and efcacy in experimental thors is available upon request through correspondence with the DOJo ofce. Dartmouth Orthopaedic Journal 2014; Vol I models,1-9 human studies have been limited to the retrospec- a 90% or greater risk – these included 2 standard radiographic tive analysis of a single implant type.10-13 Te current study methods, described by Lonstein and Carlson14 and by Sand- compares fusionless scoliosis surgery treatment using two ers,15 and prognostic genetic testing using ScoliScore, Axial diferent implant types – a shape memory alloy staple (SMA Biotech, Salt Lake City, UT).16,17 (Figure 1) Staple, Medtronic, Memphis, TN) versus a vertebral screw and 2. Te child was not amenable to brace treatment due to 1 ligament tether construct (Dynesys Dynamic Stabilization or more factors including a clear refusal on the part of the System, Zimmer Spine, Warsaw, IN) – in two well matched child or family to embark on brace treatment (6 patients); a idiopathic scoliosis patient groups with similar indications refusal on the part of the child and family due to a medical for surgery. It should be noted that neither implant type in co-morbidity such as ADHD or claustrophobia (1 patient); or this study enjoys FDA approval for the fusionless treatment non-compliance (2 patients). of idiopathic scoliosis in children, thus, both were used in an of-label manner in this study. 3. Te child and family participated in an extensive program of self education that included the use of printed and web ma- METHODS terials as well as patient contacts and they understand both standard and novel treatment options for idiopathic scoliosis. Under an Institutional Review Board approved study pro- 4. Te child and family demonstrated a reasonable under- tocol, a retrospective analysis was performed on 9 consecu- standing of the FDA status of fusionless scoliosis surgery de- tive female patients treated for progressive idiopathic scoliosis vices. with fusionless scoliosis surgery over a one year period from November 2009 to October 2010. Fusionless scoliosis surgery 5. Te child and family unanimously agreed with the treat- was contemplated as a treatment option in these 9 patients ment plan. when 5 criteria were met: Of the 9 patients who underwent fusionless scoliosis surgery, the frst 4 underwent stapling of 6 curves. All 4 had 1. Te idiopathic scoliosis curve progressed to 30° or greater thoracic curves that were treated with stapling. Two of the in the setting of signifcant skeletal immaturity and was highly 4 had single thoracic curves while the other 2 had additional likely (90% estimated risk or greater) to progress beyond 40° secondary lumbar curves measuring 25° or greater that were to a “surgical curve” (a high likelihood of progression was es- also treated. Te second 5 patients underwent ligament teth- tablished if at least 2 of 3 methods of risk assessment suggested

TABLE I. Demographic, Curve, and Skeletal Maturity Characteristics of Staple vs. Tether Patients Age Sex Pre-op Pre-op TR Sanders SS Rx Post-op Final Final F/U Curve(s) Risser Curve(s) Risser

Staple 12+11 F 35°T 0 Closed 3 140 Staple 36°T 55°T 3 20 mo Patients 30°L T, L 15°L 28°L (PSF)

14+3 F 35°T 1 Closed 3 166 Staple 28°T 38°T 4 18 mo. T 13+4 F 35°T 0 Closing 3 NA Staple 30°T 40°T 4 24 mo. 26°L T, L 10°L 20°L 13+3 F 33°T 0 Closed 3 186 Staple 31°T 45°T 4 24 mo. T Tether 12+9 F 32°T 1 Closed 3 NA Tether 20°T 23°T 4 20 mo. Patients 34°L T,L 0°L -8°L 15+3 F 37°T 2 Closed 3 74 Tether 20°T 16°T 4 20 mo. T 9+6 F 38°T 0 Open NA NA Tether 26°T 13°T 0 16 mo. 29°L T,L -3°L -1°L 14+3 F 41°TL 3 Closed 5 120 Tether 21°TL 18°TL 4 11 mo. 19°L TL, L -2°L -5°L 12+6 F 35°T 0 Closed 3 NA Tether 20°T 19°T 1 5 mo. T

26 Dartmouth Orthopaedic Journal 2014; Vol I

1. 2. 3.

Figure 1. Risk of progression was estimated using two radiographic methods and one genetic method: 1. Lonstein and Carlson (Risser sign); 2. Sanders (lef hand flm); and 3. ScoliScore. In this example, the child has a 33 degree progressive adolescent idiopathic scoliosis with an estimated risk of progression of 90%,100% and 80%, respectively, using these three methods. ering of 8 curves. All 5 had thoracic curves that were treat- vessels were ligated with a harmonic scapel. ed with ligament tethering. Two of the 5 had single thoracic curves; two had primary thoracic curves with secondary lum- Implantation of proportional SMA staples was accom- bar curves that were also treated; and 1 had a primary lumbar plished at all appropriate levels once a second marking flm curve with a secondary thoracic curve, both of which were was obtained fuoroscopically to confrm that the appropriate treated. No patient underwent treatment of a single lumbar levels were addressed. Staples cooled in a sterile ice bath were curve. implanted across the disc spaces afer pilot holes were created using the appropriate size trial. Two staples were placed an- Toracic curves were treated endoscopically using the terolaterally at all levels of the curve with 3 staples at 1 or 2 of same standard anterior approach for both stapling and liga- the apical segments. Automatic deployment or crimping of ment tethering.18 Prior to positioning, general endotrachial the staples occurred within a few minutes as they warmed to anesthesia was induced using a double lumen endotrachial body temperature. tube. Standard SSEP and MEP spinal cord monitoring were used in all cases. As all thoracic curves in this study were right Implantation of vertebral body screws in preparation for sided, the patients were placed in a lef lateral decubitus po- ligament tethering was performed afer creation of a trial hole sition on the operating table (radiolucent OSI fat top table) with a pedicle probe starting in the middle of the right lateral to allow access to the right thorax. Appropriate padding was vertebral cortex and extending to the lef lateral cortex. Ap- applied to all bony prominences across the torso as well as propriate screw length was estimated fuoroscopically and en- the upper and lower extremities. Te patient was then taped doscopically. Bicortical screw purchase was preferred. Screw in place to minimize any potential for movement during sur- placement proceeded in a distal to proximal fashion with gery. Care was taken to assure that the axilla and groin were subsequent tensioning of the ligament in a proximal to distal free of pressure prior to prepping and draping. Fluoroscopic fashion. (Figure 2) Tensioning of the ligament to correct the images were then used to guide the placement of 3 to 4 small deformity was guided at each disc level by fuoroscopy. oblique incisions or portals equally spaced along the right posterior axillary line. Afer entry into the chest, frst distally, At the completion of implantation of either staples or a then proximally, the lung was defated and then both the lung ligament tether, fnal fuoroscopic images were taken and the and diaphragm appropriately retracted to allow visualization chest prepared for closure. A small 20 French chest tube was of the right thoracic spine. A marking fuoroscopic image was placed and removed on post-operative day 1. Patients were used to assure that the appropriate levels were addressed. Te mobilized post-operatively in a standard manner as tolerat- pleura was then split vertically on the right across the desired ed without a brace. Activity restrictions included minimal levels using electrocautery. In patients undergoing vertebral bending, lifing or twisting for 6 weeks and no athletics for 12 stapling the segmental vessels were preserved. However, in weeks with gradual return to full activity afer 12 weeks. those patients undergoing ligament tethering the segmental For patients undergoing additional treatment of a lumbar 27 Dartmouth Orthopaedic Journal 2014; Vol I

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

Pre-operative, post-operative and fnal follow-up plain radiographs in the posterior-anterior and lateral planes were Figure 2: An endoscopic view of the proximal portion of a tether- used to determine the magnitude of the deformity and the ing construct afer tensioning of the ligament and securing of the set gross integrity of the implants throughout the study. Progres- screws. Te vertebral screws are implanted on the right side of the sion of deformity was defned as an increase in curve magni- spine spanning T6 (top) to T9 (bottom). Te distal implants are not tude of 5° or greater as measured with the Cobb method.19 All visualized in this view. Te posterior ribs are evident on the lef and staples and screws that demonstrated evidence of loosening, the defated lung on the right. including radiolucency, drif, or backout, were noted. Statis- tical analyses were performed on all of the radiographic data curve under the same anesthetic, a mini-open, lateral retro- with the use of standard t tests, with a level of signifcance peritoneal approach was used.18 As all lumbar curves in this defned as a p value (alpha) of <0.05. study were lef-sided, the patients were repositioned in a right

Figure 3: Tis child is a 13+3 year old girl with a progressive adolescent idiopathic scoliosis involving a single right thoracic curve measuring 33 degrees in the setting of relative skeletal immaturity with a Risser sign of 0, a Sanders grade of 3 and a ScoliScore of 186. Te curve corrected 2 degrees afer an anteri- or endoscopic stapling procedure but then progressed 13 degrees over the next 24 months.

28 Dartmouth Orthopaedic Journal 2014; Vol I

Source of Funding Te average age in this group was 13+5 (range 12+11 to 14+3). Te average skeletal maturity was Risser 0.2 (range 0 to 1), No external or internal funds were received in the conduct with closed triradiate cartilages in all patients. Te average of this report. Te authors of this study have no disclosures or Sanders’ stage was 3 (range 3 only) and the average ScoliScore conficts of interest to report. was 164 (range 140 to 186 in 3 patients).

RESULTS Te average thoracic curve in this stapling group was initially corrected from 34.5° (range 33° to 35°) pre-operatively Nine consecutive female patients with 14 idiopathic scoli- to 31.5° (range 28° to 36°) post-operatively for a correction of osis curves (9 thoracic, 5 lumbar) were treated with fusionless 3.0°. Over an average follow-up of 22 months (range 18 to 24 scoliosis surgery during the 1 year study period. Te aver- months) subsequent thoracic curve control was poor, with an age age at the time of surgery was 12+11 years (range 9+6 to average progression of 13.0° to 44.5° (range 38° to 55°). (Fig- 15+3). Te average skeletal maturity was Riser 0.8 (range 0 to ure 3) Te average skeletal maturity at study completion was 3), with open triradiate cartilages in only 1 patient. Te aver- Risser 3.8 (range 3 to 4). One patient’s stapled thoracic curve age Sanders’ stage was 2.9 (range 0 to 5). Five of the 9 patients progressed from 35° pre-operatively to 55° at 20 months, de- were eligible, early in their evaluation, for prognostic genetic spite stability of a stapled lumbar curve in the 30° range. Tis testing using ScoliScore, with an average score of 137.2 (range patient underwent a standard posterior instrumented fusion 74 to 186) on a scale of 1 to 200. from T2-L2 at 20 months for signifcant curve progression in the setting of relative skeletal maturity (Risser 3). Te frst group of 4 patients treated in this series underwent stapling of 6 curves (2 single thoracic curves and 2 pri- Stapled lumbar curves remained relatively stable when mary thoracic curves, both with secondary lumbar curves). 15+3 15+3 16+11 pre-op post-op 20mo R=2, S=3 R=4 SS=74

37º 20º 16º

Figure 4. Tis child is a 15+3 year old girl with a progressive adolescent idiopathic scoliosis involving a single right thoracic curve measuring 37 degrees in the setting of relative skeletal immaturity with a Risser sign of 2, a Sanders grade of 3 and a ScoliScore of 74. Te curve corrected 17 degrees afer an anterior endoscopic tethering procedure and an additional 4 degrees of correction over the next 20 months. 29 Dartmouth Orthopaedic Journal 2014; Vol I treated, but 1 of 2 untreated curves progressed. As a thresh- kyphosis of 25° (range 11° to 42°) remained stable in this liga- old of 25° was established for stapling of secondary lumbar ment tethering group at 26.4° (range 5° to 48°) at 14.4 months. curves, two curves measuring 28° on average (range 26° to Te average pre-operative lumbar lordosis of 54.8° (range 47° 30°) were stapled and remained stable at 24° (range 20° to 28°) to 60°) remained stable at 55.8° (range 50° to 70°) over the over 22 months. Of two untreated lumbar curves measuring same period. Te average pre-operative lumbar lordosis of 17° on average (range 17° only), 1 progressed to 29° while the 52.3° (range 47° to 60°), in the subgroup of 3 patients with other remained stable at 17° over the same time period. tethered lumbar curves, also remained stable at 50.3° (range 50° to 51°) over 14.4 months. In the sagittal plane, the average pre-operative thoracic kyphosis of 30.3° (range 17° to 42°) increased in the stapling No signifcant complications were encountered intra-op- group over 22 months to 36.8° (range 24° to 53°). Te aver- eratively or post-operatively in either the stapling or ligament age pre-operative lumbar lordosis of 63.5° (range 50° to 76°) tethering group. However, the frst stapling patient treated in remained stable at 61.8° (range 53° to 77°) for over the same this series required reinsertion of her chest tube on post-op- period. In the subgroup of 2 patients with stapled lumbar erative day one for reaccumulation of a pneumothorax. Tis curves, the average pre-operative measurement of 63° (range resolved uneventfully. Estimated blood loss was 161cc on 50° to 76°) remained stable at 65° (range 53° to 77°) at 22 average for all 9 patients, with no signifcant diference be- months. tween the stapled (175cc) and ligament tether (150cc) groups. Tere was a diference, however, in EBL between single tho- Te second group of 5 patients treated in this series un- racic curves treated endoscopically (100cc) and double curves derwent ligament tethering of 8 curves (2 single thoracic treated with both an endoscopic thoracic procedure and a curves; 2 primary thoracic curves, both with secondary lum- mini-open lumbar procedure (210cc). Te length of stay was bar curves; and 1 primary lumbar curve with a secondary tho- 4 days on average (range 2 to 6 days) for all 9 patients, with no racic curve). Te average age in this group was 13+10 (range signifcant diference between stapled (4.2 days) and ligament 9+6 to 15+3). Te average skeletal maturity was Risser 1.2 tether (3.8 days) groups. A diference was noted, however, (range 0 to 3), with open triradiate cartilages in 1 patient. Te in length of stay between patients treated for a single thorac- average Sanders’ stage was 2.8 (range 0 to 5) and the average ic curve (3 days) and those treated for thoracic and lumbar ScoliScore was 97 (range 74 to 120 in 2 patients). curves (4.8 days).

Te average thoracic curve in this ligament tethering With respect to implant integrity over time, 2 patients in group was initially corrected from 36.6° (range 32° to 41°) the stapling group demonstrated partial backout of a single pre-operatively to 21.4° (range 20° to 25°) post-operatively for thoracic staple, but in each case, the staple remained in a func- a correction of 15.2°. Te average skeletal maturity at study tional position. A single patient demonstrated evidence of a completion was Risser 2.6 (range 0 to 4). When compared to broken lumbar staple without backout or dislodgement. Two the initial correction with stapling (3.2°), the initial correc- patients in the tethering group demonstrated slight drif of the tion achieved by ligamentous tethering (15.2°) was signifcant proximal thoracic screw, at the T5 and T6 levels, without loss (p=0.001). Over an average follow-up of 14.4 months (range of correction or evidence of lucency or backout. 5 to 20 months) curve control was good, with additional correction to 17.8° (range 13° to 23°). When compared to subsequent loss of correction with stapling (13.0° progression), the DISCUSSION subsequent correction with ligament tethering (3.6° correc- In this preliminary study of 9 well-matched female idio- tion) was signifcant (p=0.002). (Figure 4) pathic scoliosis patients who underwent fusionless scoliosis surgery for similar indications, the data demonstrated liga- Lumbar curves not only remained stable in this ligament ment tethering to be superior to vertebral stapling in initial tethering group, but untreated curves tended to correct and curve correction and subsequent control of curve progression treated curves to overcorrect. Tough a threshold of 25° was over time. While vertebral stapling initially corrected thorac- again used to guide treatment of secondary lumbar curves, an ic curves 3.0°, this efect was lost over time, with subsequent exception was made for a 19° lef lumbar curve, below a 41° progression of 13.0° over the study period. All 4 patients in right thoracic curve, associated with a large right trunk shif the vertebral stapling group demonstrated progression of their of nearly 5 cm. Tree lumbar curves measuring 27.3° on av- thoracic curves past 40°, with 1 of 4 eventually undergoing a erage (range 19° to 34°) initially corrected to -1.7° (range 0° to - posterior instrumented fusion for a curve that reached 55°. In 3°) with ligament tethering then subsequently overcorrected contrast, ligament tethering initially corrected thoracic curves to -4.7° (range -1° to -8°) over 14.4 months. Two untreated 15.2°, with an additional correction of 3.6° over time. All 5 lumbar curves measuring 22° on average (range 21° to 23°) patients in the ligament tethering group demonstrated good remained stable at 13.5° on average (range 13° to 14°). control of their thoracic curves, with all curves measuring less than 25° at study completion. In the sagittal plane, the average pre-operative thoracic

30 Dartmouth Orthopaedic Journal 2014; Vol I

Te data on lumbar curve control are more difcult to in- plant related factors, including specifc device characteristics terpret as some curves were stable while others progressed, and requirements for implantation, highlight 4 areas in which corrected or overcorrected. Te likely dependence of lumbar these implants are distinguished: 1) strength of initial fxation; curve behavior on thoracic curve behavior is a potential con- 2) modularity; 3) rigidity or fexibility; and 4) integrity over founder as is the fact that an arbitrary threshold of 25° was time. established for treatment of a secondary lumbar curve (with only one exception). Tis resulted in treated and untreated With respect to the strength of initial fxation, it should lumbar curves of various magnitudes adjacent to thoracic be noted that implant testing was not performed in this study. curves that progressed or corrected. In the vertebral stapling However, a previous study by our group demonstrated a sig- group, where all thoracic curves progressed, 2 stapled and 1 nifcant diference in initial pullout strength between a shape untreated secondary lumbar curves remained stable while 1 memory alloy staple (100N) and a unicortical screw device or untreated lumbar curve progressed. In the ligament tether- bone anchor (495N).2 In the current study, it is likely that the ing group, where all thoracic curves corrected, 2 untreated threaded, bicortical screw, measuring 6.0 to 6.5mm in diam- secondary lumbar curves corrected while 3 tethered lumbar eter and 25 to 40mm in length, provided signifcantly greater curves mildly overcorrected. Te data suggest that the 25° initial fxation to bone than the smooth, unicortical staple tine, threshold for treatment of a secondary lumbar curve could measuring less than 4mm in diameter and less than 15mm in be adjusted up or down depending on the implant type used length. to treat the thoracic curve. For ligament tethering cases, in which good control of the thoracic curve is likely, consider- While greater initial fxation and, perhaps, improved me- ation should be given to raising the threshold for tethering of chanical advantage are important, the value only becomes ap- secondary lumbar curves. Conversely, for vertebral stapling parent when these attributes can be exploited for deformity cases, where thoracic curve control may be less optimal, con- correction. Te highly modular or adjustable ligament teth- sideration should be given to lowering the threshold for sta- er construct allowed for signifcant active curve correction at pling a secondary lumbar curve. each disc level through tensioning of the ligament across each pair of well fxed, mechanically advantageous, bicortical verte- Tough the sagittal plane parameters of thoracic kyphosis bral screws. Te minimally modular shape memory alloy sta- and lumbar lordosis are always a concern when treating spinal ple allowed for some crimping of the staple with deployment, deformities with instrumentation, changes in these regions of but the small, unicortical tine provided little if any active cor- the spine were not signifcant during this study overall and no rection of deformity. Methods were employed to overcome signifcant diferences were noted between groups. Tough the limitations of the staple in achieving active correction, in- the pre-operative thoracic kyphosis was slightly greater than cluding optimal patient positioning on the operating table and would be expected for the typically hypokyphotic idiopathic corrective manual maneuvers during implantation, but these scoliosis patient population at 30.3°, the kyphogenic vertebral were unsatisfactory in achieving signifcant curve correction. stapling and ligament tethering only increased this kyphosis to 36.8° over the study period. Lumbar lordosis was relatively Te signifcant active correction achieved in the ligament stable in the 60° range throughout the study period, with little tethering group not only improved spinal alignment but like- diference between treated and untreated, stapled and teth- ly increased the chances for additional passive correction of ered, curves. deformity over time with growth. Like scoliosis progression, passive deformity correction afer vertebral stapling or lig- Tough the above data are preliminary, the results are ament tethering, is also governed by the Hueter-Volkmann supported by a previous study in an experimental scoliosis law.3,6,20-24 Tis law describes a vicious cycle of progression in model in which we demonstrated greater curve control with scoliosis initiated by a spinal asymmetry and propagated by a ligament tethering versus vertebral stapling.2 In the experi- force and growth diferential from concavity to convexity. Te mental scoliosis model, curves measuring 77.3° on average initial asymmetry results in excessive forces on the vertebral pre-operatively progressed to 94.3° despite vertebral stapling growth plates that alter vertebral growth, with excessive con- over a 12 to 16 week observation period. Curves of a sim- cave compression inhibiting growth and excessive convex ten- ilar magnitude, measuring 73.4° on average pre-operatively, sion stimulating growth. Tis growth diferential from con- were better controlled afer ligament tethering with modest cave to convex leads to progressive vertebral wedging which correction to 69.9° over the same period. Te limitations of only exacerbates the force diferential, furthers asymmetric this experimental model study included the use of fusionless growth and increases the overall deformity. scoliosis surgery implants in extremely severe, perhaps, even malignant curves, and the use of a single staple per disc level. Passive correction of scoliosis is achieved by reversing or redirecting the vicious cycle described by Hueter-Volkmann. It is speculated that several implant related factors con- Te ligament tethering group demonstrated some passive cor- tributed to the greater control of scoliosis progression in the rection over time likely due to decreased exuberant growth on ligament tethering versus vertebral stapling groups. Tese im- the convexity of the curve and increased growth on the concav- 31 Dartmouth Orthopaedic Journal 2014; Vol I ity of the curve. It is likely that the improved force diferential fortunately, due to regulatory restrictions, prospective studies in the actively corrected ligament tether patients allowed for involving the of label use of implants or devices is prohibited some passive correction over time. With little change in this without formal FDA approval. Further, follow-up on these force diferential in the stapled group, no passive correction patients was relatively short, with full 2 year follow-up in only was demonstrated. In a previous study using an experimental 2 of 9 patients. However, 7 of 9 patients had at least 1 year model, our group demonstrated a relationship between active follow-up and the majority had achieved a defnitive outcome and passive curve correction in which the amount of passive (skeletal maturity, defned as Risser 4, in 6 of 9, and a posterior correction achieved with growth was directly related to the instrumented fusion in a single additional patient). Despite amount of initial active correction achieved at the time of sur- these limitations, this preliminary study does provide signif- gery.25 cant insights into the safety and efcacy of 2 fusionless scoliosis surgery treatment strategies in 2 well-matched groups of Te fexibility of the ligament tether construct may also patients with similar indications. Further study, however, is have contributed to passive curve correction over time due to warranted. dynamic loading of the vertebral growth plates. Tough we did not measure the fexibility of the implants in this study, our RefeRences: group has analyzed the biomechanics of multiple diferent fusionless implant strategies in the past.26 In comparing 2 staple 1. Braun JT, Akyuz E, Ogilvie JW: The use of animal models in and 3 staple constructs to various screw ligament constructs, fusionless scoliosis investigations. Spine (Phila Pa 1976) 2005;30(17 Suppl):S35-S45. an almost 30% diference in spinal motion was demonstrated 2. Braun JT, Akyuz E, Ogilvie JW, Bachus KN: The efficacy and – the 2 and 3 staples constructs being the most rigid and the integrity of shape memory alloy staples and bone anchors with liga- ligament tether constructs being the most fexible. Tough ment tethers in the fusionless treatment of experimental scoliosis. J dynamism of a device afer implantation can only be inferred, Bone Joint Surg Am 2005;87(9):2038-2051. a fexible device is more likely to be dynamic than a rigid de- 3. Braun JT, Hines JL, Akyuz E, Vallera C, Ogilvie JW: Relative versus absolute modulation of growth in the fusionless treatment of vice. In a separate well-controlled experimental model com- experimental scoliosis. Spine (Phila Pa 1976) 2006;31(16):1776- paring static and dynamic asymmetric loading across a single 1782. immature rat tail vertebra, a 50% greater change in angulation 4. Braun JT, Ogilvie JW, Akyuz E, Brodke DS, Bachus KN: Fusion- due to growth modulation was demonstrated using dynamic less scoliosis correction using a shape memory alloy staple in the 27 anterior thoracic spine of the immature goat. Spine (Phila Pa 1976) versus static loading. If, indeed, the fexible ligament con- 2004;29(18):1980-1989. struct in the present study resulted in dynamic loading, this 5. Hunt KJ, Braun JT, Christensen BA. The effect of two clinically might explain some of the improved curve control, as evi- relevant fusionless scoliosis implant strategies on the health of the denced by passive curve correction, over the more rigid and, intervertebral disc: analysis in an immature goat model. Spine (Phila Pa 1976). Feb 15;35(4):371-377. perhaps, static, loading scenario that resulted from stapling. 6. Braun JT, Hoffman M, Akyuz E, Ogilvie JW, Brodke DS, Bachus KN. Mechanical modulation of vertebral growth in the fusionless And fnally, the integrity of the implants over time was treatment of progressive scoliosis in an experimental model. Spine likely related to their ability to control curve progression. (Phila Pa 1976). May 20 2006;31(12):1314-1320. Tough we have demonstrated a signifcant rate of halo for- 7. Braun JT, Akyuz E, Udall H, Ogilvie JW, Brodke DS, Bachus KN. mation around staple tines in an experimental model,2 and Three-dimensional analysis of 2 fusionless scoliosis treatments: a 10-12 flexible ligament tether versus a rigid-shape memory alloy staple. Betz has confrmed these fndings in his studies of children Spine (Phila Pa 1976). Feb 1 2006;31(3):262-268. with idiopathic scoliosis, we did not fnd signifcant halo for- 8. Newton PO, Faro FD, Farnsworth CL, et al: Multilevel spinal mation in this study. We did note staple backout in 2 patients growth modulation with an anterolateral flexible tether in an immature and 1 broken staple, but other than these staple integrity was bovine model. Spine (Phila Pa 1976) 2005;30(23):2608-2613. reasonable. Integrity of the screws was good, perhaps relat- 9. Wall EJ, Bylski-Austrow DI, Kolata RJ, Crawford AH: Endoscopic mechanical spinal hemiepiphysiodesis modifies spine growth. Spine ed to the size of the implant, the bicortical purchase across (Phila Pa 1976) 2005;30(10):1148-1153. the vertebra and they hydroxyappetite coating on the screw. 10. Betz RR, D’Andrea LP, Mulcahey MJ, Chafetz RS: Vertebral Some protection of implant integrity may also have been af- body stapling procedure for the treatment of scoliosis in the growing forded by the fexible ligament tether dissipating, more than child. Clin Orthop Relat Res. 2005;434:55-60. a staple, the high peak forces generated with spinal motion. 11. Betz RR, Kim J, D’Andrea LP, Mulcahey MJ, Balsara RK, Clements DH: An innovative technique of vertebral body stapling Nevertheless, 2 patients demonstrated a mild change in the for the treatment of patients with adolescent idiopathic scolio- position of the most proximal thoracic screw over time, sug- sis: A feasibility, safety, and utility study. Spine (Phila Pa 1976) gesting some drif in the implant but no loss of correction or 2003;28(20):S255-S265. evidence of lucency. Loss of implant integrity was likely not a 12. Betz RR, Ranade A, Samdani AF, et al. Vertebral body stapling: A fusionless treatment option for a growing child with moderate idio- signifcant factor in this study. pathic scoliosis. Spine (Phila Pa 1976) 2010;35(2):169-176. 13. Crawford CH III, Lenke LG. Growth modulation by means of an- Te limitations of this study are not insignifcant in that it terior tethering resulting in progressive correction of juvenile idiopath- is a retrospective analysis of a small number of patients treat- ic scoliosis: a case report. J Bone Joint Surg Am 2010:92(1):202-209. ed with 2 diferent fusionless scoliosis surgery implants. Un- 14. Lonstein JE, Carlson JM: The prediction of curve progression in 32 Dartmouth Orthopaedic Journal 2014; Vol I untreated idiopathic scoliosis during growth. J Bone Joint Surg Am 22. Stokes IA, Spence H, Aronsson DD, Kilmer N. Mechanical modu- 1984:66(7):1061-1071. lation of vertebral body growth. Implications for scoliosis progression. 15. Sanders JO, Khoury JG, Kishan S, et al: Predicting scoliosis Spine (Phila Pa 1976).1996:21:1162-1167. progression from skeletal maturity: a simplified classification during 23. Volkmann R, Verletzungen und krankenheiten der bewegungsor- adolescence. J Bone Joint Surg Am 2008:90(3):540-553. gane. In: Billroth T, editor. Handbuch der allgemeinen und speciellen 16. Ward K, Ogilvie JW, Singleton MV, Chettier R, Engler G, Nelson chirurgie Bd II Teil II. Stuttgart: Ferdinard Enke; 1882. LM. Validation of DNA-based prognostic testing to predict spinal 24. Braun JT, Hunt KJ, Sorenson S, Ogilvie JW. “Can Fusionless curve progression in adolescent idiopathic scoliosis. Spine (Phila Pa Scoliosis Surgery Reverse the Hueter-Volkmann Effect?” Forty-sec- 1976). Dec 1;35(25):E1455-1464. ond Annual Meeting of the Scoliosis Research Society, Edinburgh, 17. Braun JT, Lavelle WF, Ogilvie JW: The impact of genetics re- Scotland, UK, September 5-8, 2007. search on adolescent idiopathic scoliosis, in Newton PO, O’Brien MF, 25. Braun JT, Hunt KJ, Sorenson S, Ogilvie JW. “Active and Passive Shufflebarger HL, Betz RR, Dickson RA, Harms J, eds: Idiopathic Tethering Effects of Four Clinically Relevant Fusionless Scoliosis Scoliosis: The Harms Study Group Treatment Guide. New York, NY, Implant Strategies.” Forty-second Annual Meeting of the Scoliosis Thieme, 2010, pp 408-415. Research Society, Edinburgh, Scotland, UK, September 5-8, 2007. 18. Braun JT: “Fusionless Scoliosis Surgery.” In Advanced Re- 26. Braun JT, Akyuz E, Bachus K. “Biomechanical Evaluation of construction Spine. American Academy of Orthopaedic Surgeons Seven Different Fusionless Scoliosis Surgery Treatment Strategies.” Publications, Rosemont, IL 2011. Poster presentation at the Thirteenth International Meeting on Ad- 19. Cobb JR: Outline for the study of scoliosis. Instr Course Lecture. vanced Spine Techniques, Athens, Greece, July 2006. 1948;5:261-275. 27. Akyuz E, Braun JT, Brown N, Bachus K. Static Versus Dynamic 20. Hueter C: Anatomische studien an den extremitutengelenken Loading in the Mechanical Modulation of Vertebral Growth. Spine. neugeborener und erwachsener. Arch Pathol Anat. 1862;25:572-599. 31(25):E952-E958, 2006. 21. Mente PL, Aronsson DD, Stokes IA, Iatridis JC: Mechanical modulation of growth for the correction of vertebral wedge deformities. J Orthop Res. 1999;17:518-524.

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

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

ABSTRACT Conclusion: Objectives Venous thromboembolism (VTE) remains the most common complication following hip and knee replacement and Patients undergoing total joint arthroplasty are at high risk the clinical consequences can be signifcant. 10.8% and 17.7% for postoperative thromboembolic disease. A course of anti- of injection and oral patients respectively missed one or more coagulation prophylaxis following surgery has been shown to doses of prophylaxis. Given the concern for VTE afer ma- lower the risk of thromboembolic disease. Te primary objec- jor orthopedic surgery, eforts to maximize appropriate pre- tive of this study is to determine the degree of compliance with scribing, patient education, and compliance should be made. prophylaxis and the presence of possible barriers to compli- Specifc eforts towards patient education and awareness re- ance for patients receiving outpatient prophylaxis afer prima- garding post-operative VTE prophylaxis at home may help ry hip and knee arthroplasty. We also hope to assess quality of improve compliance further, which may improve outcomes training and education prior to discharge for patients receiv- by reducing the VTE events associated with these procedures. ing outpatient prophylaxis following arthroplasty. Level of Evidence: Methods: IV A total of 150 patients who had undergone primary total hip or knee arthroplasty with one of fourteen surgeons at our INTRODUCTION: institution were surveyed over a fve-month period by telephone, one to two months following surgery. Patients were Patients undergoing total joint arthroplasty are at high grouped according to method of prophylaxis administration, risk for postoperative venous thromboembolic (VTE) disease. either oral or by injection. Consequently, anticoagulation prophylaxis with either oral or injectable medications is recommended postoperatively.1 Te Results: most recent guidelines from the American College of Chest Out of 150 patients surveyed, 136 were included in the Physicians recommends prophylaxis for a minimum of 10 to data analysis. 74 were prescribed injectable anticoagulation 14 days following total knee or hip arthroplasty with a sug- while 62 used oral prophylaxis. 8 patients from the injection gested duration of up to 35 days postoperatively.2 However, group (10.8%) and 11 from the oral group (17.7%) reported questions still remain in regards to patients’ knowledge of and missing one or more doses. Of these 136 patients, 113 (83.1%) compliance with their prescribed outpatient regimen.3 While were able to recall the reason for taking prophylaxis. Howev- many studies have attempted to evaluate efectiveness of pro- er, 22 patients (29.7%) were unable to recall the name of their phylaxis at preventing VTE, less attention has been devoted to prescribed injection medication and 8 patients (12.9%) were gauging patient compliance with their outpatient treatment. unable to recall the name of their prescribed oral medication. Te mean copayment amount for injections was $173 (median Te demand for total joint arthroplasty (TJA) has been $100) compared with $53 (median $20) for oral medication. steadily increasing in recent years and is projected to acceler- Overall, 93.4% of all patients believed taking the medication as ate as the population ages. It is estimated that approximately instructed was either important or very important. 650,000 total knee arthroplasty (TKA) and 250,000 total hip arthroplasty (THA) procedures occurred in the United States during 2010 and these fgures are expected to rise dramatically 1. NYU Hospital for Joint Diseases, NYC to reach 3.48 million total knee replacements and 572,000 total 4 Corresponding Author: hip replacements by 2030. Given the large volume of arthro- Brooks Crowe, BA plasty procedures that occur each year, it is vital to ensure ad- E-mail: [email protected] equate attention is given to prophylaxis treatment to not only DISCLOSURE: None of the authors received payments or services, either reduce morbidity and mortality, but also to help control the directly or indirectly, from a third party in support of any aspect of this work. burden of rising health care costs. Te complete disclosures of potential conficts of interest submitted by authors is available upon request through correspondence with the DOJo ofce. In prior studies that show data on compliance, practical Dartmouth Orthopaedic Journal 2014; Vol I issues related to obtaining the medication following discharge surgeons at our institution. Patients who did not receive any were not closely examined as the medication was given as part form of prophylaxis treatment or completed their entire proof the study protocol.5 In recent years, more emphasis has phylactic course while in inpatient rehabilitation were exclud- been placed on properly educating patients about the risks of ed from our analysis. Patients who spent a short duration of VTE disease following major orthopedic surgery and the im- time in inpatient rehab but completed their prophylaxis on portance of ensuring adequate prophylaxis.6,7 Te goal of this an outpatient basis were included for analysis. A baseline study was to determine the compliance of patients with either questionnaire was designed by our research team to evalu- oral or injectable anticoagulation prophylaxis and to ascertain ate patient experience regarding medications with a specifc the presence of any barriers to compliance that may have af- focus on education, access, and compliance. We attempted fected the successful completion of an outpatient prophylaxis to contact approximately 260 patients in order to achieve 150 course. Additionally, we hoped to evaluate the efectiveness of completed surveys from patients all of whom were prescribed inpatient hospital instruction in preparing patients for their outpatient VTE prophylaxis. However, only 136 patients were self-administered outpatient regimen. By surveying patients included in the fnal analysis. Te fourteen patients who only about these issues, we hoped to gain a clearer understanding took their medication while in an inpatient facility were ex- of knowledge and compliance for routine patients afer dis- cluded. charge. Te questionnaire was designed to gauge patient under- METHODS: standing of the importance of outpatient prophylaxis treatment (Appendix A). It included questions regarding under- Patients who underwent total knee or hip arthroplasty standing of reasons for taking the medication, method of over a fve-month period in 2012 and received outpatient VTE education, cost of treatment, and compliance. Te question- prophylaxis were surveyed by phone one to two months fol- naire also assisted in grouping patients into two categories lowing surgery. Te potential study group was identifed from based on the type of prophylaxis administered. Tose patients a population of consecutive patients from fourteen diferent receiving injections were asked additional questions related to

Table 1. Patient Demographics, Knowledge of Regimen and Prophylaxis Dsuration Oral: N=62 Injection: N=74 Procedure Total Hip Arthroplasty 32 42 Total Knee Arthroplasty 30 32 Gender 42 Male 24 22 Female 38 52 Age: Average (Range) 63.8 (26-86) 60.9 (22-85) Race/Ethnicity Caucasian 45 57 African American 11 13 Spanish/Hispanic 2 2 Other 4 2 % Knew Name of Drug 87.1 70.3 % Knew Reason for Taking Medication 85.5 81.1 Length of Prophylactic Regimen: <10 Days 6.5% 5.4% 10-21 Days 9.7% 35.1% 21-30 Days 54.8% 52.7% 1-2 Months 17.7% 5.4% >2 Months 9.7% 1.4% Unknown 1.6% 0 35 Dartmouth Orthopaedic Journal 2014; Vol I previous experience with self-injections, difculty performing of this report. Te authors of this study have no disclosures or injections, and pain rating. No outside funding was obtained conficts of interest to report. for this study and exempt status for this study was granted by our Institutional Review Board. RESULTS: A major component of our study was to investigate Of 136 patients included in our analysis, 74 were pre- barriers that afected the respective prophylactic treatment. scribed injectable anticoagulation while 62 used oral prophy- Patients were surveyed regarding diferences in associated laxis. As indicated in Table 1, 29.7% (N=22) and 12.9% (N=8) costs and medication schedules for injectable prophylaxis ver- of patients taking injectable and oral prophylaxis respectively sus those taking oral prophylaxis. Other factors such as dif- were unable to recall the name of the medication prescribed, culty in obtaining as well as remembering to take the medica- while 83.1% (N=113) of all patients were aware of the reason tion were assessed. Descriptive statistics were used to analyze for taking the medication. When asked about the importance the data. of taking medication as scheduled, 93% (N=127) believed taking the medication as instructed was either very important or Source of Funding important (Table 2). No external or internal funds were received in the conduct From the 74 members of the injection group, 62 per-

Table 2. Patient Opinion, Barriers to Treatment and Adherence Oral (N=62) Injection (N=74) Opinion of Taking Medication as Instruction: Somewhat Important 1.6% 1.4% Important 19.4% 14.9% Very Important 74.2% 78.4% N/A 4.8% 5.4% Difculty Obtaining Medication* Mean (Standard Deviation) 1.5 (1.7) 1.5 (1.9) Copayment: Cannot Recall 13.1% 13.5% No Copayment 9.8% 25.7% Copayment of Unknown Amount 32.8% 24.3% Average (median) of Dollar Amounts $54 ($20) $173 ($100) Average Copayment Impact on obtaining 1.0 1.4 Medication# Difculty Remembering to take Medication Not Difcult 90.3% 90.4% Somewhat Difcult 8.1% 9.6% Difcult 1.6% 0 Number of Missed Doses Stopped Early 0 2.7% None 80.6% 86.5% One or More 17.7% 10.8% Unknown 1.6% 0

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

36 Dartmouth Orthopaedic Journal 2014; Vol I

Table 3. Data Specifc to Injection Group Only – prior experience, education, difculty, taining the medication and little and preparedness impact of cost on obtaining the medication as scheduled rated Self-Injection 83.8% on a scale of 1-10 with 10 repre- Non self-injection 16.2% senting extreme difculty. Prior Experience with Self-Injections*: Overall, 53.7% (N=73) of all 3.5 (3.7) Mean (Standard Deviation) patients took the prophylactic Person Providing Education regimen for a period of 21-30 Nurse at Bedside 79.0% days compared to 23.5% (N=32) who took the medication for 10- Other 8.1% 21 days with variations in pro- No One 1.6% phylaxis length infuenced by pa- No Education Required 11.3% tient characteristics and varying Patient Observed Performing Injection surgeon preferences (Table 1). Approximately 90% of patients Yes 75.8% responded that it was not difcult No 17.7% to remember to take each dose. Unkown 3.2% Of oral and injection patients, Prior Experience 3.2% 80.6% (N=50) and 86.5% (N=64) respectively reported taking each Difculty Performing Injection#: dose as scheduled. Mean (Standard Deviation) 2.0 (1.7) Preparedness to Perform Injection at Discharge^ DISCUSSION: 8.8 (2.2) Mean (Standard Deviation) Considerable efort has been Pain on Injection@ directed towards determining Mean (Standard Deviation) 2.5 (2.0) the efectiveness of various forms of VTE prophylaxis following *Rated on a scalte of 1-10 with 1 indicating “no experience” and 10 indicating “very experienced” elective hip and knee arthroplas- #Rated on a scale of 1-10 with 1 indicating “not difcult” and 10 indicating “very difcult” ty. Te rate of deep vein throm- ^Rated on a scale of 1-10 with 1 indicating “not prepared” and 10 indicating “very prepared” bosis following surgery may @Rated on a scale of 1-10 with 1 indicating “no pain” and 10 indicating “very painful” be as high as 45-57% following THA and 40-84% following TKA 8 formed self-injections with a mean prior experience of 3.5 Furthermore, postoperative mortalitywithout adequaterates due to prophylaxis. pulmonary rated on a scale of 1-10 (Table 3) with 1 indicating “no prior embolism following THA can be as high as 3-6% without ad- experience” and 10 meaning “very experienced.” Te majority equate prophylaxis and venous thromboembolism is the most of self-injection patients (79%, N=49) were trained by a nurse common cause of emergency re-hospitalization following at the bedside typically for one session while 11.3% (N=7) these procedures.8 Risk of VTE following arthroplasty sur- were already experienced in giving self-injections. Patients gery can be reduced with appropriate prophylaxis9,1,10 with rated their level of preparedness to perform self-injections minimal efects on the risk of major bleeding events.10,11 It is upon discharge at an average of 8.8 with 10 representing “very critical that patients be prescribed prophylaxis and are com- prepared” and 1 indicating “not prepared.” On a scale of 1-10 pliant following THA or TKA to help lower risk of VTE relat- with 1 representing “not difcult” and 10 representing “very ed complications. difcult,” the average difculty for performing injections was 2.0. Te average rating for the pain associated with the injec- While many studies have evaluated the efectiveness of tion was 2.5 with 1 representing “no pain” and 10 indicating diferent pharmacologic agents, few have investigated compli- “very painful.” ance with prescribed regimens under regular outpatient cir- cumstances. Given that patients are now routinely discharged In regards to possible barriers to compliance, among the within a few days afer surgery, determining typical levels of 92 patients who reported being responsible for a copayment, compliance in the days and weeks afer discharge is important 27 oral and 27 injection patients recalled the specifc dollar as strong adherence is necessary for proper VTE prevention. amount (Table 2). Te injection group paid a mean of $173 (median $100), and the oral group had a mean of $54 (median Te administration of prophylaxis can be with oral or in- $20). Most patients in the study reported no difculty in ob- jectable medication. It has been shown that compliance of or-

37 Dartmouth Orthopaedic Journal 2014; Vol I thopedic surgeons with prescribing prophylaxis in accordance able to recall the reason for taking the prescribed medication. with the American College of Chest Physicians recommended Moreover, many patients responded that they believed taking dose, timing, and duration was lower in the United States than the medication was important because their surgeon said it in other countries for both THA (47% vs. 62%, respectively) was. However, 22 patients (29.7%) using injections and 8 pa- and TKA patients (61% vs. 69%, respectively).12 However, tients (12.9%) using oral medication were unable to recall the this is only the frst step, as appropriate patient education and name of their medication. Still, many of the patients who were compliance is also important. unable to spontaneously recall the names of their medication were able to identify the prescribed regimen when prompted In our study, 79% of the patients that were prescribed with a list of common choices. injectable prophylaxis received education by a nurse at their bedside. For comparison, a study in 2008 found 18.7% of hos- Given that patients now typically spend only a few days as pitalized non-orthopedic patients had no knowledge of either an inpatient afer surgery, emphasis on education regarding DVT or PE, and of the patients who had heard of either DVT signs and symptoms of VTE can help improve early detection or PE, 22.6% and 51.6% respectively could not provide any and intervention since clots are more likely to occur afer dis- accurate information about the condition.13 Of the 136 pa- charge. In a study reviewing VTE incidence among 14,875 tients we surveyed, 93% believed that taking the medication patients undergoing arthroplasty, Warwick et al found a mean was important or very important, however only 83.1% were time to VTE of 21.5 days and 9.7 days following total hip and

Appendix A. Prophylaxis Survey Study Data Collection Form

38 Dartmouth Orthopaedic Journal 2014; Vol I knee arthroplasty respectively. Te events occurred afer the by telephone to participate, not all patients were successfully median time to discharge for 75% of THA and 57% of TKA reached and not all agreed to participate. Tus, a selection patients.14 Tis demonstrates the importance of patient com- bias may be present in our study population. Additionally, pliance beyond the frst few days in the hospital. A 2005 study since all information in our study was obtained only from the examining compliance found that afer specifc education and patients and was not independently verifed in the medical instruction for the 51 study participants, 98% of patients were record, a recall bias may be present. Some patients also had aware of the reason for enoxaparin administration on follow home nurses or other assistance with care afer surgery, which up interview.15 Te observed compliance with enoxaparin may have had an infuence on adherence. Tose patients who among the forty participants assessed in this study showed had undergone prior orthopaedic surgery may have been 55% with complete compliance and 37.5% with partial com- more knowledgeable about prophylaxis from past experience. pliance defned as missing no more than one dose in frst seven days and one dose in the next fourteen days. Te study has several important strengths. We recruited a total of 150 patients and included 136 in the fnal analysis, A multicenter study in 2010 included 1315 patients for which created a diverse patient population in age, race and analysis to quantify nonadherence with outpatient use of low gender. While other multicenter studies contained larger molecular weight heparin following major orthopedic sur- study groups to analyze efcacy of prophylaxis, our study fo- gery. Defnite or probable nonadherence occurred in 19.8% of cused on compliance and was larger than similar studies de- patients and non-adherent patients typically missed between signed specifcally to evaluate compliance. Participants sur- 38% and 53% of their outpatient doses.16 Watts et al. found veyed were identifed from among fourteen surgeons at our that among 34 evaluated patients 85% of patients achieved institution, which minimized selection bias and created a di- a 90% compliance rate or better with six weeks of daily verse population to evaluate possible barriers and compliance. fondaparinux injections following knee or hip arthroplasty.17 A study in 2012 examining compliance with oral prophylaxis CONCLUSION: for 56 patients following total hip replacement revealed that 98.1% of dabigatran doses were taken correctly.18 A study of VTE remains the most common complication following 68 patients undergoing lower limb arthroplasty found 95.5% hip and knee replacement and the clinical consequences can of patients achieved full compliance with a 10 day prophylaxis be signifcant. Given the major concern for VTE disease af- course of LMWH.19 ter major orthopedic surgery, eforts to maximize appropriate prescribing, patient education and compliance should be Tese studies reveal rates of compliance with VTE pro- made. Specifc eforts towards patient education and aware- phylaxis upwards of 80%. However, in some studies address- ness regarding post-operative VTE prophylaxis at home may ing compliance, patients were included in the study at the help increase compliance further, which may improve out- beginning of therapy. We attempted to avoid this possible comes by reducing the VTE events associated with these pro- bias by recruiting patients afer the conclusion of their ther- cedures. apy window. Out of the 150 patients surveyed in our study, 136 were included in the data analysis with 74 using injectable anticoagulation and 62 using oral prophylaxis. Eight patients REFERENCES from the injection group (10.8%) and 11 from the oral group (17.7%) reported missing at least one dose. We found that 1. Colwell CW, Froimson MI, Mont MA, Ritter MA, Trousdale RT, Buehler KC, et al. Thrombosis Prevention after Total Hip Arthroplasty 83.8% of our surveyed patients reported full compliance hav- - a Prospective, Randomized Trial Comparing a Mobile Compression ing missed no doses which is consistent with other studies. Device with Low-Molecular-Weight Heparin. JBJS. 2010; 92-A(3): Our compliance values difer somewhat from some studies 527-535. that either provided the medication for patients or looked at 2. Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ. Executive Summary: Antithrombotic Therapy and Prevention shorter durations of prophylaxis. In addition, our study group of Thrombosis, 9th ed: American College of Chest Physicians was larger than several other studies designed to look specif- Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141(2 cally at compliance. For our patients that had missed a dose, suppl.): 7S-47S. the most common reasons given were that they had forgot or 3. Sadideen H, O’Callaghan JM, Navidi M, Sayegh M. Educating surgical patients to reduce the risk of venous thromboembolism: an because did not have access to their medication. While some audit of an effective strategy. JRSM Short Rep. 2011; 2(12): 97. patients did report varying degrees of burden related to med- 4. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of ication costs, most reported little to no difculty obtaining Primary and Revision Hip and Knee Arthroplasty in the United States medication with regards to cost. Tese fndings seem to indi- from 2005 to 2030. JBJS. 2007; 89(4): 780-785. cate that cost did not in fact play a signifcant role in compli- 5. Vallano A, Arnau JM, Miralda GP, Bartoli, JP. Use of venous thrombopropyhlaxis and adherence to guideline recommendations: a ance for this patient population. cross-sectional study. Thrombosis Journal. 2004; 2(3): 1-7. 6. Sadideen H, O’Callaghan JM, Navidi M, Sayegh M. Educating Despite attempts to reduce possible bias in our study, there surgical patients to reduce the risk of venous thromboembolism: an were still some limitations. Given that we recruited patients 39 Dartmouth Orthopaedic Journal 2014; Vol I audit of an effective strategy. J R Soc Med Sh Rep. 2011;2(12):97. boembolism (VTE) Prevention Among Hospitalized Patients. Journal 7. Vallano A, Arnau JM, Miralda GP, Pérez-Bartolí J. Use of venous of Vascular Nursing. 2008; 26(4): 109-116. thromboprophylaxis and adherence to guideline recommendations: a 14. Warwick D, Friedman RJ, Agnelli G, Gil-Garay E, Johnson K, cross-sectional study. Thrombosis Journal. 2004; 2: 3. Fitzgerald G, Turibio FM. Insufficient Duration of Venous Thrombo- 8. Friedman RJ. Extended Thromboprophylaxis after Hip or Knee embolism Prophylaxis after Total Hip or Knee Replacement when Replacement. Orthopedics. 2003; 26(2 - supplement): 225-30. Compared with the Time Course of Thromboembolic Events. JBJS. 2007; 89-B(6): 799-807. 9. Planes A, Vochelle N, Darmon J-Y, Fagola M, Bellaud M, Huet Yann. Risk of deep-venous thrombosis after hospital discharge 15. Colwell CW Jr., Pulido P, Hardwick ME, Morris BA. Patient in patients having undergone total hip replacement: double-blind Compliance with Outpatient Prophylaxis: An Observational Study. randomised comparison of enoxaparin versus placebo. Lancet. 1996; Orthopedics. 2005; 28(2): 143-147. 348: 224-228. 16. Wilke T, Moock J, Muller S, Pfannkuche M, Kurth A. Nonad- 10. Eikelboom JW, Quinlan DJ, Douketis JD. Extended-duration herence in Outpatient Thrombosis Prophylaxis with Low Molecular prophylaxis against venous thromboembolism after total hip or knee Weight Heparins after Major Orthopaedic Surgery. Clinical Orthopae- replacement: a meta-analysis of the randomised trials. Lancet. 2001; dics and Related Research. 2010; 468(9): 2437-2453. 358: 9-15. 17. Watts AC, Howie CR, Simpson AH. Assessment of a Self-admin- 11. Geerts WH, Heit JA, Clagett GP, Pineo GF, Colwell CW, Ander- istration Protocol for Extended Subcutaneous Thromboprophylaxis in son FA, et al. Prevention of Venous Thromboembolism. Chest. 2001; Lower Limb Arthroplasty. JBJS. 2006; 88-B(1): 107-110. 119:132S–175S. 18. Lebel B, Melherbe M, Gouzy S, Parienti JJ, Dutheil JJ, Barrellier 12. Friedman RJ, Gallus AS, Cushner FD, Fitzgerald G, Anderson MT, Vielpeau C. Oral Thromboprophylaxis Following Total Hip Re- FA Jr. Physcian Compliance with Guidelines for Deep-Vein Throm- placement: the Issue of Compliance. Orthopaedics & Traumatology: bosis Prevention in Total Hip and Knee Arthroplasty. Current Medical Surgery & Research. 2012; 98: 186-192. Research and Opinion. 2008; 24(1): 87-97. 19. Rajkumar S, Tavares S. Patient Compliance with Deep Vein 13. Le Sage S, McGee M, Emed JD. Knowledge of Venous Throm- Thrombosis Prophylaxis Following Lower Limb Arthroplasty Surgery. The Online Journal of Clinical Audits. 2010; 2(2): 2-10.ee

40 Intramedullary Screw Fixation of Transverse Olecranon Fractures

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

ABSTRACT

Multiple options exist for fxation of transverse olecranon length, resulting in mismatch between the diameters of the fractures. Intramedullary (IM) screw fxation has the advan- screw and the canal.3 A technique is presented here that has tage of minimizing prominent hardware thereby decreasing allowed our team to consistently and accurately measure the the need for secondary surgery. Maintaining fracture reduc- length of an intramedullary screw to provide stable fxation for tion while placing the screw and determining proper screw transverse olecranon fractures. length can present a challenge. We describe a technique that addresses these issues by using an intramedullary tap to accu- SURGICAL TECHNIQUE rately and consistently measure the appropriate length for an intramedullary screw. Te patient is placed in a lateral decubitus position with Level of Evidence: the afected arm draped over a bump (Figure 2). A standard posterior approach is made to the proximal ulna and the frac- V ture is exposed in the usual fashion. A 2.5mm drill is used to INTRODUCTION create opposing drill holes approximately two to three centi- meters distal to the fracture on the radial and ulnar sides of Displaced olecranon fractures in active patients do best the ulna (Figure 3). Two tenaculum clamps are then placed with open reduction and internal fxation with primary goals on each side of the ulna with one tong in the drill hole and of articular restoration, stable fxation and early range of mo- the second tong on the proximal fracture fragment. Te frac- tion.1 For transverse, intra-articular, two-part fractures (Fig- ture is then reduced and the clamps are tightened to hold the ure 1), the tension band technique has been described as a reduction (Figure 4). Te guide wire for a 7.3mm screw is method of fxation.2 Multiple authors have referred to this then placed through the proximal tip of the ulna, driven across technique as the “gold standard.”3,4 Tis method of fxation is not without issues, however, including a rate of revision surgery for symptomatic hardware removal approaching 65- Figure 1. Transverse, intraarticular olecranon Fractures 90%.4-6 In addition, irritation of the proximal radioulnar joint by prominent k-wires and damage to neurovascular structures have both been described.7

Placement of an intramedullary implant for fxation has the advantage of minimal prominent hardware and may reduce the need for revision surgery.8 Biomechanical studies on fxation of olecranon fractures with intramedullary screws have shown inconsistent results when compared to other olecranon fxation constructs.3 One study concluded the inconsistent results were due to difculty determining the appropriate

1. Dartmouth Hitchcock Medical Center, Lebanon, NH

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

DISCLOSURE: None of the authors received payments or services, either directly or indirectly, from a third party in support of any aspect of this work. Te complete disclosures of potential conficts of interest submitted by authors is available upon request through correspondence with the DOJo ofce. Dartmouth Orthopaedic Journal 2014; Vol I

Figure 2. Te olecranon is approached Figure 3. A 2.5mm drill bit is used to create Figure 4. Two tenaculum clamps are placed through a standard posterior approach Post two opposing holes in the ulna distal to the in the drill holes and are used to reduce and operative X-ray of intramedullary olecranon fracture line. hold the proximal fragment screw

the fracture fragment and then down the intramedullary canal with the fgure-of-eight wire had the greatest energy to failure using C-arm guidance to ensure an intramedullary trajectory when tested by rapid loading. In a similar cadaver study Fyfe on orthogonal views. A cannulated drill is used to open the et al. compared fve techniques of fxation and found “incon- intramedullary canal across the fracture. Next the cannulated sistent” results with the IM cancellous screw.3 Te authors tap is used to prepare the canal for screw placement. Te total used the same size (6.0mm) and length (90mm) screw on all length of the tap is frst measured. Te tap is then advanced specimens. Tey concluded the inconsistent results were due carefully by hand until it begins to experience solid resistance to the lack of “correlation between the size of the screw thread in the canal, at which point advancement is stopped. Te and the diameter of the medullary cavity.” Our technique ad- length of the tap remaining external to the bone is measured dresses this problem by using the tap to directly measure the (Figure 5), and this is subtracted from the total length of the intramedullary distance needed to consistently obtain suf- tap, giving an accurate measurement of the length of the in- cient screw purchase. Tis typically occurs as the tap advanc- ternal portion of the tap. Tis is the length chosen for the es from the metaphyseal to the more narrow diaphyseal region 7.3mm cannulated intramedullary screw. Te screw is then of the proximal ulna. Morphologic study of the canal diam- placed over the wire and both the reduction and rotational eter and shape of the proximal ulna have found the smallest alignment are held with the tenaculum clamps as the screw diameter to range from 3.5mm-7mm in the anterior-posteri- is tightened. Once the screw is in position the clamps are re- or dimension and 3-6mm in the medial-lateral dimension.10 moved (Figure 6 & 7). At this point there is the option to add Terefore a 7.3mm screw should achieve purchase in even a fgure-of-eight tension band suture through the drill holes the largest canal diameters. For some younger patients with and under the triceps tendon, to provide additional compres- narrower intramedullary canals a cannulated screw of smaller sive force to the fracture. A posterior splint is placed until diameter might be considered. the frst post-operative visit at 10-14 days at which time gentle elbow motion is begun. In addition, the use of two tenaculum clamps is helpful both to obtain reduction of the fracture and to maintain it as DISCUSSION the screw is tightened. Typically the screw achieves solid purchase and the clamps are needed to prevent rotation of the Studies looking at the fxation strength of olecranon frac- proximal fragment. Te drill holes used to place the clamps tures with intramedullary screws have shown varied results. can then be used to pass a suture for fgure-of-eight fxation to Murphy et al. used a cadaver model with a transverse osteot- supplement the screw fxation. Carofno et al. has shown that omy in the semilunar notch and compared a fgure-of-eight a non-absorbable suture (FiberWire) provides similar fxation wire, a cancellous screw, a screw plus a wire, and an AO ten- strength to a metal tension wire.11 Te suture is typically less sion band construct.9 Teir study found the cancellous screw noticeteeeable to the patient provided the knot is placed to the

42 Dartmouth Orthopaedic Journal 2014; Vol I

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

side of the ulna and not directly posterior. 6. Macko D, Szabo RM. Complications of tension-band wiring of olecranon fractures. The Journal of Bone & Joint Surgery. 1985;67(9):1396-1401. SUMMARY 7. Catalano LW, 3rd, Crivello K, Lafer MP, Chia B, Barron OA, Glickel SZ. Potential dangers of tension band wiring of In this paper we have presented a technique to allow for olecranon fractures: an anatomic study. J Hand Surg [Am]. intramedullary fxation of olecranon fractures by consistently Oct 2011;36(10):1659-1662. and accurately measuring the distance from the proximal cor- 8. Argintar E, Cohen M, Eglseder A, Edwards S. Clinical results of olecranon fractures treated with multiplanar locked tex to the point in the intramedullary canal where a 7.3mm intramedullary nailing. J Orthop Trauma. Mar 2013;27(3):140- cannulated screw will fnd secure purchase and allow stable 144. compression across the fracture. Te intramedullary screw 9. MURPHY DF, GREENE WB, GILBERT JA, DAMERON technique has been shown in previous research to have ade- TBJ. Displaced Olecranon Fractures in Adults: Biomechani- cal Analysis of Fixation Methods. Clinical Orthopaedics and quate biomechanical stability when the implant has sufcient Related Research. 1987;224:210-214. osseous purchase and may also avoid the major pitfalls of 10. Akpinar F, Aydinlioglu A, Tosunand N, Tuncay I. tension-band techniques, most notably the need for revision Morphologic evaluation of the ulna. Acta Orthopaedica. surgery for symptomatic prominent hardware and the dan- 2003;74(4):415-419. ger to anterior neurovascular structures caused by prominent 11. Carofino BC, Santangelo SA, Kabadi M, Mazzocca AD, Browner BD. Olecranon Fractures Repaired With FiberWire k-wires through the anterior ulnar cortex. or Metal Wire Tension Banding: A Biomechanical Compar- ison. Arthroscopy: The Journal of Arthroscopic & Related REFERENCES Surgery. 2007;23(9):964-970.

1. Cabanella M, Morrey B. Fractures of the Proximal Ulna and Olecranon. 2nd ed. Philadelphia: WB Saunders; 1993. 2. Wolfgang G, Burke F, Bush D, et al. Surgical Treatment of displaced olecranon fractures by tension band wiring technique. Clin Orthop. 1987;224:192-204. 3. Fyfe I, Mossad M, Holdsworth B. Methods of Fixation of Olecranon Fractures. J Bone Joint Surg Br. 1985;67- B(3):367-372. 4. Chalidis BE, Sachinis NC, Samoladas EP, Dimitriou CG, Pournaras JD. Is tension band wiring technique the “gold standard” for the treatment of olecranon fractures? A long term functional outcome study. Journal of Orthopaedic Sur- gery and Research. 2008;3. 5. Rommens PM, Kuchle R, Schneider RU, Reuter M. Olec- ranon fractures in adults: factors influencing outcome. Injury. 2004;35(11):1149-1157. 43 Case Report Femoral artery occlusion after total hip Arthroplasty through the direct anterior approach: A case report

Wayne Moschetti MD MS, Spencer Amundsen MD

ABSTRACT: with peripheral vascular disease the risk of occlusion or em- bolization is increased8 and the risk to intra-pelvic vascular Iatrogenic vascular injury during primary total hip arthro- structures secondary to acetabular screw placement are well plasty is an uncommon but serious complication. Te direct described7. To our knowledge, no previous report describing a anterior approach for THA has experienced a resurgence in femoral artery injury resulting in a pulseless limb with the use popularity due to the muscle sparing nature of the procedure, of the direct anterior approach for total hip arthroplasty has yet difculties with exposure and a steep learning curve to per- been published and we believe this represents an important form the procedure are risk factors for complications. Tis original observation. Approval from the subject of the case re- case report describes a femoral artery injury during this ap- port was obtained prior to its submission. Institutional Review proach leading to a dysvascular limb. It emphasizes the impor- Board Approval was not required for this case report. tance of rapid identifcation of any potential vascular insult. Immediate vascular surgery consultation and intervention when vascular compromise is suspected is highlighted. Source of Funding Level of Evidence No external or internal funds were received in the conduct V of this report. Te authors of this study have no disclosures or conficts of interest to report. INTRODUCTION: PRESENTATION OF THE CASE: Total hip arthroplasty (THA) is a successful procedure in restoring function in patients with severely symptomatic hip A 73-year-old woman with hypertension, hypothyroidism, osteoarthritis who have failed conservative non-operative osteopenia and right hip pain from severe degenerative osteo- management1. Despite the success of this procedure there arthritis, which was refractory to conservative management is continual focus on refning the operative technique to fur- presented to an outside facility within our referral area and ther improve patient outcomes and minimize complications. underwent a total hip arthroplasty through a direct anterior Tere are several commonly used surgical approaches with approach. varying complication risks2,3. Over the past decade the direct anterior approach has been reintroduced in the United States Te procedure was carried out under spinal anesthesia. Te and has become popular with surgeons and patients. Push patient was positioned supine on a HANA® table (MIZUHO from patients and institutions are driving surgeons to abandon OSI Union City, CA) with the feet placed in well-padded other approaches and use this approach despite little evidence boots. A padded perineal post and the independent leg ad- supporting its superiority. Exposure and positioning of the leg justment function of this table allows for controlled intra-op- with this approach can be difcult and a learning curve associ- erative rotation, traction and hyperextension of the limbs. An ated with case volume has been identifed4. anterior skin incision was carried down to the tensor fascia lata, which was sharply divided. Blunt digital dissection en- Vascular injuries are uncommon but potentially devastat- sued around the tensor down to the capsule. Te circumfex ing complications afer total hip arthroplasty5,6. In patients vessels were coagulated with electrocautery. Manual traction was applied during the case to allow for hip dislocation and 1. Dartmouth Hitchcock Medical Center, Lebanon, NH femoral broaching with the leg hyperextended and adducted. A Zimmer Press-Fit M/L Taper stem with a 36mm head was Corresponding Author: used on the femoral side with a 50mm Press-Fit trabecular Wayne Moschetti, MD, MS E-mail: [email protected] metal cup and a standard polyethylene liner (Zimmer, Inc, Warsaw IN) on the acetabular side (Figure 1). Tere were no DISCLOSURE: None of the authors received payments or services, either apparent intra-operative complications. Te patient was taken directly or indirectly, from a third party in support of any aspect of this work. to the recovery room where adequate capillary refll and nor- Te complete disclosures of potential conficts of interest submitted by authors is available upon request through correspondence with the DOJo ofce. mal limb appearance in the operative extremity were noted. Dartmouth Orthopaedic Journal 2014; Vol I

Approximately six hours afer surgery on the hospital ward and a large burden of thrombus. Te arteriotomy was closed the patient began complaining of increasing right foot pain. with a bovine pericardial patch. Four compartment fascioto- On clinical examination her foot was cool to touch, slightly mies were performed in the right lower extremity to prevent mottled with a bluish hue. Dorsalis pedis and posterior tibial reperfusion compartment syndrome. At the end of the pro- artery pulses were non-palpable and no doppler signal could cedure posterior tibial and dorsalis pedal doppler signals had be identifed. Tis prompted emergent transfer to our facility returned. for vascular surgery evaluation. Post operatively the patient was anticoagulated with sub- Upon arrival approximately 9 hours later, she had absent cutaneous heparin 5000 units three times daily for three days right femoral, popliteal, dorsalis pedis, and posterior tibial afer which she was transitioned to Coumadin. She began pulses both by palpation and doppler evaluation. Her report- physical therapy the day afer the surgery and was allowed to ed normal post-operative motor exam had changed now with weight bear as tolerated. Te fasciotomy sites were found to no ankle or foot voluntary movement. She demonstrated de- have healthy viable muscle with minimal edema on post-op- creased sensation to light touch up to the level of her mid- erative day three and were closed primarily. Te patient was calf. Te Vascular Surgery team emergently evaluated her, discharged to a rehabilitation facility on post-operative day subcutaneous heparin was started, and she was taken to the able to ambulate a few steps with an assistive device. operating room expeditiously. An aortogram demonstrated stagnant fow to the right common femoral artery consistent At her two week follow up from the vascular repair she with thrombosis and occlusion (Figure 2). Te common fem- was ambulating without difculty, her ankle/brachial systol- oral artery was then exposed via a longitudinal cutdown and ic pressure index was one, and there was no signifcant low- hematoma was noted in the sof tissues. No femoral pulse was er extremity arterial occlusive disease identifed. Tere was palpable. A transverse intimal rupture within the common persistent diminished sensation over the foot globally but this femoral artery causing vessel thrombosis with proximal mi- improved by 4 months. gration was found at the time of surgery and repaired primarily afer local direct thrombectomy. Subsequently, a balloon DISCUSSION: thrombectomy of the superfcial femoral, popliteal, and tibial arteries was performed due to insufcient back bleeding Iatrogenic vascular injury afer Orthopaedic surgery

Figure 2. Aortogram demonstrating lack of blood fow Figure 1. Post-operative pelvis x-ray afer a right total hip Arthroplasty through the right common femoral artery (arrow) with through the direct anterior approach with no apparent intra-operative compli- pronounced iliac collaterals consistent with common femoral cations artery occlusion

45 Dartmouth Orthopaedic Journal 2014; Vol I is a rare but potentially devastating complication. As with CONCLUSION other newly adopted procedures, the risk of complications are greatest in the earlier stages of the learning curve and this Vascular injuries are uncommon but potentially devas- holds true for the direct anterior approach for total hip arthro- tating complications afer total hip Arthroplasty. Iatrogenic plasty4,9. Proponents of this approach believe that by spar- vascular injury with the use of the direct anterior approach ing the posterior and lateral musculature during the surgical to the hip for total hip Arthroplasty poses a risk to the neigh- dissection, patients may be aforded a quicker recovery with boring femoral artery. Te specifc cause of injury to the fewer functional limitations and a lower dislocation risk10- common femoral artery in this case is unknown but one must 13. Despite the successful use of this approach for total hip be cognizant of appropriate retractor placement, identifying arthroplasty10-12 there has been notable emphasis placed on the appropriate intermuscular plane, and the amount of trac- the potential for higher complication rates14,15. A review tion placed on the operative leg. Diligence in comparing the of 800 primary THAs performed through a direct anterior pre-operative to post-operative neurovascular exam is crucial approach with 1.8 years of follow up described trochanteric in the rapid identifcation of a vascular problem and emergent fractures, femoral perforations, and wound complications as vascular surgery consultation and intervention in the setting being common with this approach9. Tere was one vascular of a vascular insult can dramatically improve outcomes and injury reported in this series resulting from a drain that punc- limit catastrophic complications. tured a superfcial varicose vein. REFERENCES: To our knowledge this case represents the frst described common femoral artery injury resulting in a dysvas- 1. Ethgen O, Bruyere O, Richy F, Dardennes C, Reginster JY. Health-related quality of life in total hip and total knee arthroplasty. A cular limb using the direct anterior approach for THA and is qualitative and systematic review of the literature. J Bone Joint Surg an important original observation. Te exact cause of the vas- Am 2004;86-A:963-74. cular injury in this case can only be speculated and the close 2. Jolles BM, Bogoch ER. Posterior versus lateral surgical approach proximity to the femoral neurovascular bundle with this ap- for total hip arthroplasty in adults with osteoarthritis. Cochrane Data- base Syst Rev 2006;3:CD003828. proach needs to be respected. With placement of a retractor 3. Masonis JL, Bourne RB. Surgical approach, abductor function, over the anterior column of the acetabulum care must be tak- and total hip arthroplasty dislocation. Clin Orthop Relat Res 2002:46- en to stay beneath the muscle belly of the rectus femoris as the 53. neurovascular bundle lies on the opposite side of this struc- 4. Masonis J, Thompson C, Odum S. Safe and accurate: learning ture. When considering all Orthopaedic surgeries the major- the direct anterior total hip arthroplasty. Orthopedics 2008;31. ity of vascular injuries occur in total knee (67%) and total hip 5. Wilson JS, Miranda A, Johnson BL, Shames ML, Back MR, Bandyk DF. Vascular injuries associated with elective orthopedic (19%) arthroplasties. Unless brisk bleeding is noted afer an procedures. Ann Vasc Surg 2003;17:641-4. intra-operative laceration of a vessel, most injuries are discov- 6. Rossi G, Mavrogenis A, Angelini A, Rimondi E, Battaglia M, Ruggi- ered post-operatively with as many as 25% being noted afer eri P. Vascular complications in orthopaedic surgery. J Long Term Eff 24 hours5. Tis emphasizes the overwhelming importance of Med Implants 2011;21:127-37. performing serial post-operative neurovascular examinations 7. Wasielewski RC, Cooperstein LA, Kruger MP, Rubash HE. Ace- tabular anatomy and the transacetabular fixation of screws in total hip and the early recognition of any change in comparison to the arthroplasty. J Bone Joint Surg Am 1990;72:501-8. pre-operative exam. Te neurovascular exam should be fol- 8. Barrack RL, Butler RA. Avoidance and management of neurovas- lowed beyond the initial 24 hours and if any discrepancy in cular injuries in total hip arthroplasty. Instr Course Lect 2003;52:267- the exam is noted suspicion for a vascular injury should be 74. raised with the appropriate work up ensuing. 9. Jewett BA, Collis DK. High complication rate with anterior total hip arthroplasties on a fracture table. Clin Orthop Relat Res 2011;469:503-7. Identifying a vascular injury promptly and proceeding 10. Chimento GF, Pavone V, Sharrock N, Kahn B, Cahill J, Sculco with expeditious vascular surgery consultation and interven- TP. Minimally invasive total hip arthroplasty: a prospective random- tion was imperative for success in the case described. A femo- ized study. J Arthroplasty 2005;20:139-44. ral artery injury unrecognized and lef untreated can result in 11. Matta JM, Shahrdar C, Ferguson T. Single-incision anterior approach for total hip arthroplasty on an orthopaedic table. Clin Orthop an amputation rate approximately 50% while early diagnosis Relat Res 2005;441:115-24. and intervention can lower that rate to near 9%16,17. Tis 12. Sculco TP, Boettner F. Minimally invasive total hip arthroplasty: case highlights the importance of respecting the close prox- the posterior approach. Instr Course Lect 2006;55:205-14. imity of the femoral vessels and to a degree the neighboring 13. Siguier T, Siguier M, Brumpt B. Mini-incision anterior approach femoral nerve to the proximal femur. Caution must be tak- does not increase dislocation rate: a study of 1037 total hip replace- en when considering the direct anterior approach when per- ments. Clin Orthop Relat Res 2004:164-73. 14. Barton C, Kim PR. Complications of the direct anterior approach forming low volumes of total hip Arthroplasty as it is techni- for total hip arthroplasty. Orthop Clin North Am 2009;40:371-5. cally demanding and has a documented learning curve where 15. Woolson ST, Pouliot MA, Huddleston JI. Primary total hip arthro- the risk of complications are higher4,9. plasty using an anterior approach and a fracture table: short-term results from a community hospital. J Arthroplasty 2009;24:999-1005. 16. Carrillo EH, Spain DA, Miller FB, Richardson JD. Femoral vessel 46 Total Knee Arthroplasty in a Patient with an Ipsilateral Transtibial Amputation: A Case Report and Surgical Technique for Addressing a Short Residual Tibia

Joshua M. Murphy MD, Scott M. Sporer MD

ABSTRACT: 2000, Pasquina and Dahl reported excellent results and unlimited ambulation in a 73-year old patient with a transtibial am- Te presence of knee arthrosis in the setting of ipsilateral putation treated with TKA.2 In 2003, Crawford and Coleman transtibial amputation is uncommon. Terefore, there have reported good results in a 75 year old female who underwent been limited reports regarding total knee arthroplasty (TKA) TKA in the setting of an ipsilateral transtibial amputation.3 In in this patient population. We present the case of a 44-year old 2008, Konstantakos et al published a novel technique for ad- man with symptomatic knee arthrosis and ipsilateral transtibi- dressing tibial alignment in a patient with a BKA. At 8 year al amputation with a residual tibia measuring 4.7 cm in length follow-up the patient maintained a good result.4 treated with TKA. Our surgical technique is presented and involved the use of Steinman Pins in the residual tibia for control Te current case describes a unique surgical technique for of the limb along with intra-operative fuoroscopy to verify addressing limb control and limb alignment in the setting of correct tibia cutting guide placement. Tis technique has not an extremely short residual tibia afer transtibial amputation. been previously described and is an efcient, inexpensive and reproducible technique for addressing TKA in patients with CASE REPORT ipsilateral transtibial amputation. Te patient is a 44-year old man who presented to the clin- INTRODUCTION ic of the senior author (S.M.S.) for expert opinion regarding Total knee arthroplasty (TKA) is accepted as a highly suc- surgical management of symptomatic knee arthrosis in the cessful operation. Alignment of the implanted components is setting of an ipsilateral transtibial amputation. Te patient critical to the biomechanics of the limb and to the survival of was involved in a severe motorcycle accident seven years pri- the implants.1 Patients with transtibial amputations and ip- or to presentation to our clinic. His lef lower extremity was silateral knee arthrosis present a unique challenge to the sur- severely injured and he underwent multiple operations in an gical technique as it relates to proper component alignment. attempt at limb salvage ultimately resulting is an extremely Te lack of an ipsilateral ankle and foot makes identifcation proximal transtibial amputation. Afer a prolonged hospi- of anatomic landmarks used for limb and component align- talization the patient eventually functioned well for several ment difcult. Standard extramedullary alignment guides rely years. He was pain free and ambulated with the aid of a pros- on recreating the mechanical axis of the tibia with the distal thetic leg (patella-tendon-bearing with a silicone lined sock- alignment target being the center of the ankle. Additionally, et extending to supracondylar ft, standard prosthetic shank the lack of a foot limits the tactile control of the limb distal to and foot attached). He subsequently developed symptomatic the knee, which creates surgical technical challenges. post-traumatic knee arthritis. Non-operative treatment including non-steroidal anti-infammatory drugs, corticosteroid Tere are very few published reports concerning TKA in injections, and viscosupplementation injections initially pro- patients with ipsilateral transtibial amputation. Tree such vided the patient with relief but progressively failed to provide case reports were identifed in a pubmed literature search. In symptomatic relief. Te referring surgeon counseled the patient regarding transfemoral amputation as surgical treatment given the extremely proximal below knee amputation. Prior to proceeding with transfemoral amputation the patient was 1. Ruch University Medical Center, Chicago, IL referred to our clinic for second opinion and consideration of total knee arthroplasty. Corresponding Author: Scott M. Sporer, MD E-mail: [email protected] Te patient had no other medical problems. He was fve feet eleven inches in height and weighed 260 pounds. On DISCLOSURE: None of the authors received payments or services, either exam, his extensor mechanism was intact with full active ex- directly or indirectly, from a third party in support of any aspect of this work. tension was without fexion contracture. He maintained ac- Te complete disclosures of potential conficts of interest submitted by authors is available upon request through correspondence with the DOJo ofce. tive fexion of the knee with fexion greater than 120 degrees Dartmouth Orthopaedic Journal 2014; Vol I although exact fexion arc could not be measured secondary joint space narrowing and osteophyte formation. His residual to the extremely proximal nature of his residual limb. His tibia measured 4.7 cm in length. collateral ligaments appeared to be intact although his short residual limb did not provide a signifcant lever arm for varus Te referring surgeon had exhausted non-operative op- and valgus stress maneuvers of the knee joint. His traumat- tions for this patient. Te patient was indicated for TKA, how- ic and surgical incisions were all healed and without physical ever, he presented unique technical challenges with increased exam fndings of infection. His radiographs (Figures 1 and peri-operative risk, most notably continued pain afer TKA, 2) demonstrated tricompartmental arthrosis with signifcant potential issues with prosthetic ft and comfort, and rehabil- itative eforts. Prior to the development of symptomatic arthrosis the patient had ambulated and functioned pain free Figure 1. Pre-operative standing AP radiograph of the bilateral with a prosthetic limb. Although transfemoral amputation knees. Te residual tibia measures 4.7 cm. was an option for treating his symptomatic arthrosis in the presence of his short residual tibia, our opinion was that the patient would be higher functioning with less energy expen- diture during ambulation if he retained his knee. Given these considerations, the patient was ofered a TKA ipsilateral to his transtibial amputation with the understanding that complication or unsatisfactory pain relief could potentially lead to transfemoral amputation. Afer discussion of these factors and consideration of the benefts and risks of transfemoral amputation versus TKA, the patient elected to proceed with TKA.

SURGICAL TECHNIQUE Combined spinal anesthesia with IV sedation was utilized, a tourniquet was applied to the patient’s thigh, and the limb was draped and prepared for surgery in a sterile fashion (Figure 3). We performed a longitudinal incision in line with the medial aspect of the tibial tubercle extending proximally. A medial arthrotomy was used to access the knee. Steinman pins were placed in the tibia directed anterior medial to poste- Figure 2. Pre-operative standing lateral radiograph of the lef knee. rior lateral and anterior lateral to posterior medial (Figure 4) and utilized to control the residual tibia. Te femur was cut in 5 degrees of valgus alignment using a standard intramedullary alignment guide. Nine millimeters of bone was resected from the medial femoral condyle. A gap balancing technique was employed in order to obtain appropriate coronal alignment of the tibia cutting guide. Laminar spreaders were placed medially and laterally in the tibiofemoral space with the knee in extension, and then the tibia cutting guide was positioned such that the collateral ligaments would be under equal tension. Biplanar fuoroscopy was utilized to ensure proper tibia cutting guide with approximately 5 degrees of posterior slope (Figures 5 and 6). An angel wing was placed in the cutting guide slot in order to project the angle of the planned tibia resection on lateral fuoroscopy image thus estimating the planned posterior slope. Afer tibial resection was completed the posterior cruciate ligament was examined and found to be intact and functional. We decided to proceed with a cruciate retaining knee prosthesis. Te femur was then sized in 3 degrees of external rotation, followed by anterior, posterior and chamfer cuts. Te tibia was sized with rotation based on the medial and middle third of the tibial tubercle. A trial tibial tray was provisionally pinned. Te patella was recessed

48 Dartmouth Orthopaedic Journal 2014; Vol I

Figure 5. Intra-operative AP fuoroscopy view demonstrating posi- Figure 3. Intra-operative photograph of the knee prior to incision. tion of the tibial cutting guide.

Figure 6. Intra-operative lateral fuoroscopy view demonstrating position of the tibial cutting. Note a saw blade was placed in the Figure 4. Intra-operative view afer medial arthrotomy and inser- cutting slot to verify correct tibial posterior slope prior to making tion of Steinman Pins into the residual tibia. tibial cut.

and a patella trial placed. A 10-millimeter trial cruciate retaining tibial insert was placed. Te knee was taken through and the tibia was drilled and punched for a four-pegged tib- full range of motion utilizing the previously placed Steinman ial component. Simplex P bone cement with tobramycin was pins to control the tibia. Te knee was ligamentously stable used to cement the tibial, femoral, and patellar components when varus and valgus stresses were applied, was able to reach in place (Zimmer, Nexgen CR Flex, Fixed Bearing). Once the full extension, and the patella tracked centrally without lat- cement had polymerized, the fnal 10-millimeter insert was eral subluxation or tilt. Te trial components were removed placed. Te Steinman pins were removed from the tibia, an

49 Dartmouth Orthopaedic Journal 2014; Vol I

Figure 7. Post-operative standing AP radiograph of the bilateral therapy. Te patient mobilized immediately with Aspirin 325 knees taken on POD#13. milligrams twice daily for deep venous thrombosis prophylaxis. Te patient was discharged to home on post-operative day four with no complications or events.

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

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

Figure 8. Post-operative standing lateral radiograph of the lef knee Te current patient presented a unique challenge even for taken on POD#13. patients with ipsilateral transtibial amputation. Tis patient had a severely shortened residual tibia measuring 4.7 cm in length, which is substantially shorter than those previously reported. Te cases previously referenced had residual tibia lengths measuring 17 cm, 12.5 cm, and 17 cm.2,3,4,9

Crawford and Coleman described the use of a sterile poly- styrene box intra-operatively in order to maintain knee fexion while intramedullary tibial alignment rod was used to align the tibial cutting guide.3 Konstantakos et al’s report described the construction of a modifed prosthesis that was sterilized and brought into the operative feld and then used as a distal landmark for an extramedullary alignment guide.4 We faced signifcant limitations with respect to these techniques secondary to the extremely shortened residual tibia. By placing Steinman pins in the patient’s residual tibia we were able to ex- tend the lever arm and gain control of the tibia. With the use of intra-operative fuoroscopy and gap balancing technique, the tibia cutting guide was positioned in order to ensure equal collateral ligamentous tension and thus tibial alignment. We chose a four pegged tibial component as the remaining tibial intra-articular drain was placed and a layered closure was per- bone was unlikely to support and completely contain a keeled formed. Te patient was recovered in the post-operative anes- tibia base plate. Post-operative radiographs are shown in Fig- thesia care unit and admitted for standard post-operative care. ures 7 and 8.

Post-operative activity modifcations included non-weight- In summary, we have presented an inexpensive and time bearing on the residual limb with free active range of motion efcient technique for aligning a TKA in a patient with an ip- as tolerated. No bracing or splinting was utilized post-opera- silateral BKA. By allowing collateral ligamentous tension to tively. Te shortened residual tibia limited the passive range of guide the proximal tibia coronal resection and utilizing fu- motion rehabilitation that could be performed with physical oroscopy to guide posterior tibial slope, this method can be 50 Dartmouth Orthopaedic Journal 2014; Vol I reproduced without requiring additional instruments. Unlike 5. Burke MJ, Roman V, Wright V. Bone and joint changes in lower limb amputees. Ann Rheum Dis. 1978;37(3):252-254. previous reported techniques3,4 for addressing the intra-oper- 6. Nolan L, Lees A. The functional demands on the intact limb during ative challenges of performing TKA with an ipsilateral BKA, walking for active trans-femoral and trans-tibial amputees. Prosthet this technique is not limited by a shortened residual tibia from Orthot Int. 2000;24(2):117-125. a proximal transtibial amputation. 7. Norvell DC, Czerniecki JM, Reiber GE, Maynard C, Pecoraro JA, Weiss NS. The prevalence of knee pain and symptomatic knee osteoarthritis among veteran traumatic amputees and nonamputees. REFERENCES: Arch Phys Med Rehabil. 2005;86(3):487-493. 8. Dudhniwala AG, Singh S, Morgan-Jones R. Bilateral total knee 1. Ritter M, Faris P, Keating E, Meding J. Postoper- ative alignment replacement in a congenital amputee with bilateral fibular deficien- of total knee replacement. Its effect on survival. Clin Orthop Relat cy. Knee. 2011 Dec;18(6):488-90. doi: 10.1016/j.knee.2010.08.013. Res. 1994 Feb;(299):153-6. Epub 2010 Sep 21. 2. Pasquina PF, Dahl E. Total knee replacement in an amputee pa- 9. Karam MD, Willey M, Shurr DG. Total knee replacement in patient: a case report. Arch Phys Med Rehabil. 2000 Jun;81(6):824-6. tients with below-knee amputation. Iowa Orthop J. 2010;30:150-2. 3. Crawford JR, Coleman N. Total knee arthroplasty in a below-knee amputee. J Arthroplasty. 2003 Aug;18(5):662-5. 4. Konstantakos EK, Finnan RP, Krishnamurthy AB. Eight-year follow-up of total knee arthroplasty in a patient with an ipsilateral below-knee amputation. Am J Orthop (Belle Mead NJ). 2008 Oct;37(10):528-30.

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

Charles F. Carr MD

Te roots of the Dartmouth Hitchcock Medical Center paedic Surgery (ABOS) for a residency training program be- (DHMC) orthopaedic residency training program date back gan in 1949. He was unsuccessful in his frst two attempts. to its founding father, Dr. O. Sherwin Staples, (Figure 1) who Ultimately, the ABOS approved a residency training program came to Mary Hitchcock Memorial Hospital (MHMH) in at Mary Hitchcock Memorial Hospital in 1957 as long as pe- 1946 from Harvard/Massachusetts General Hospital. He was diatric orthopaedics was taught elsewhere. Te frst resident, the frst orthopaedic surgeon in the state of New Hampshire Dr. Robert Orth, started his three-year orthopaedic residency and was joined shortly thereafer by Dr. Stuart Russell from in 1957, spending the frst year at MHMH, the second year at Michigan State University in 1948. Te fnal two “founding” the White River Junction VA Hospital and the third year at the orthopaedists were Dr. Robert Shoemaker from the University Newington Children’s Hospital in Connecticut. Te residency of Pennsylvania in 1955 and Dr. Leland Hall from the Univer- training continued as a three-year program (preceded by two sity of Minnesota in 1963. years of general surgery) with one resident per year until 1970. Drs. Roger Hansen and Howard Black (Figure 2) were the frst Dr. Staples’ application to the American Board of Ortho- residents to be admitted as a pair. Tis same year, the residen-

Figure 1. Dr. Staples at bedside; 1946. Dartmouth Orthopaedic Journal 2014; Vol I

Figure 2. Orthopaedic surgery residents; 1970-1971.

Figure 3. Dr. Hall at bedside; 1967.

voted orthopaedic surgery training from three to four. Te fnal three-year orthopaedic class and the frst four-year orthopaedic class of residents were selected to begin training in 1984. By 1986, Dr. Hall turned over the reins of the residency program to Dr. Phil Bernini who stayed in this position until 1988 when he assumed the chairmanship of the section. Dr. Jim Mur- phy assumed the position of program director at that time. By 1990, the attending staf members had swelled to eight with the additions of Drs. Shirrefs, Bernini, Murphy, Nutting, and Carr cy program director position was handed from Dr. Staples to over the previous ffeen years. Afer thirty-three years of the Dr. Hall (Figure 3) who accepted reluctantly. Te landmark ffy-seven year history of the Dartmouth-Hitchcock Residen- procedure of the frst total hip replacement at MHMH was cy Training Program, there had been forty-four residents who performed in April of 1971. One year later, the frst total knee had started and completed the program. replacement was performed. Two longstanding members of the section of orthopaedics, Drs. Michael Mayor and Robert October 5, 1991 was a historical day for Dartmouth-Hitch- Porter arrived to increase the number of attending physicians cock Medical Center as the entire institution moved from the to fve. 100 year old campus in Hanover to a new million square foot complex, four miles away in Lebanon (Figure 4). Te Spine Te next signifcant change to the residency program oc- Center at DHMC opened in 1997 and created an innovative, curred in 1980 when the length of rotations at the VA Hospi- comprehensive, multispecialty approach to the care of spine tal and Newington Children’s Hospital were shortened to six patients. Te development was under the guidance of Dr. months each. Tis allowed for four residents to always be at James Weinstein who had joined the clinical staf of DHMC MHMH while the other two were ofsite. 1984 saw perhaps orthopaedics in 1996 afer completing a master’s degree at the the most signifcant change that has occurred in orthopaedic Center for Evaluative Clinical Sciences (CECS) at Dartmouth training when the ABOS increased the required years of de- Medical School. Tis program would soon become a core ele- 53 Dartmouth Orthopaedic Journal 2014; Vol I

Figure 4. Dartmouth Hitchcock Medical Center shortly afer the move. ment of the Dartmouth Orthopaedic Training Program. Our thopaedics, was introduced. Several years prior to this change frst residents to start and complete the CECS program (Fig- (1994), the section had made the decision to join the National ure 5) and receive their master’s degrees during their fve-year Residency Match Program, selecting residents directly out of residency were Drs. Scott Sporer and Randall Schultz in 2001 medical school, making Dartmouth one of the last programs and 2002. in the country to make this change. 1998 also was a year of change in leadership of the residency program, as Dr. Jim 1998 saw a change in the PGY-1 intern year made by the Murphy stepped down to pursue other administrative duties ABOS. A mandate to complete month long rotations on vari- and Dr. Charlie Carr took on the challenges of residency pro- ous subspecialty services, including up to three months in or- gram director. Te Spine Patient Outcomes Research Trial (SPORT), a multicenter study based out of DHMC, designed to address the need for high-quality, prospectively collected data on the operative and non-operative treatment of spinal conditions began in 1999. Tis project allowed for the initi- Figure 6. Dr. James N. Weinstein replaces Dr. ation of many research projects by our orthopaedic residents Jack Wennberg as Di- and brought DHMC orthopaedics national and international rector of CECS in 2007 recognition. In 2001, our program added a third resident position. Te approval of the “extra” resident was coupled with our new Orthopaedic Physician Leadership Training Program at Dartmouth and completion of a sixth year, obtaining a master’s degree at the CECS focusing on evidence based medicine and health care policy. Te frst resident admitted to the new program was in 2001. Te chairmanship of the section of orthopaedics changed hands in 2002. Dr. Phil Bernini stepped down from the position afer serving for ffeen years. Dr. James Weinstein assumed the role as section chair in July 2002

54 Dartmouth Orthopaedic Journal 2014; Vol I and his frst accomplishment was to successfully gain institutional acceptance for orthopaedic surgery to become its own department. He also led a restructur- ing of the new department and residency program into clinical and academic programs that were subspecialty team-based.

As our department continued to grow, so did our residency program, which added a fourth resident per year in 2004. We chose to ofer two positions as a fve-year clinical tract and the two other positions as a six-year clinical + CECS experience tract. Trough an NIH educational grant we have been able to maintain funding for two residents per year in the masters degree program given through the renamed Dartmouth Institute for Health Figure 8. Bioskills Lab in Simulation Center. Policy and Clinical Practice (TDI). Te frst group of trainees admitted with four residents per class graduated in 2009 and educational program is robust with conferences held every 2010. Te department’s most recent change in leadership also morning including a two year cycle didactic core curriculum occurred in 2009 when Dr. Weinstein (Figure 6) took over the taught by faculty, grand rounds with visiting lecturers, indi- role as Director of Te Dartmouth Institute relinquishing the cations conference, pathology conference, research update role of Orthopaedic Department chairman to Dr. Sohail Mir- conference, anatomy prosections and other various confer- za, who had arrived from the University of Washington in the ences throughout the year. Te most recent educational ofer- previous year as the inaugural vice-chair of the department. ing demonstrating the transition to an earlier, more focused experience in orthopaedics provided to our PGY-1 residents Over the past twelve years the Dartmouth Orthopaedic is a bio-skills course. PGY-1 residents are provided a weekly Residency Program has fourished under the leadership of hands-on surgical simulation experience using simulators, or- Drs. Weinstein and Mirza. Tey have championed academic thopaedic surgical equipment with sawbones, and cadavers to and educational pursuits allowing the program to innovate in perform surgical approaches. (Figure 8) many areas. (Figure 7) Presently, our twenty two residents (20 on clinical rotations and two in the TDI) rotate through six Te history and evolution of the orthopaedic training subspecialty teams at DHMC, spend three months in ortho- program at DHMC has “mirrored” several other preeminent paedic oncology at Beth-Israel Deaconness Medical Center in programs across the country. We feel we deserve to be includ- Boston with Dr. Mark Gebhardt, rotate through a three month ed amongst the best orthopaedic residency programs as the block in pediatric orthopaedics at Children’s Hospital in Bos- products of our training (many of you) are proof of that. ton, and complete a recently “renewed” rotation in general orthopaedics at the White River Junction VA Hospital. Our

55 Level V Evidence

Timothy J. Lin MD

Dr. Hall the Dartmouth Orthopaedic Department into what it has become today, though his humility prevents him from taking Dr. Peter Wesley Hall was born on November 2nd, 1928, in such credit. Seeing Dr. Hall’s potential and ability, Dr. Staples Forest Grove, Oregon, 15 miles west of Portland. He traveled soon “pushed” Dr. Hall into the position of residency direc- to the Midwest for his rotating internship at Minneapolis Gen- tor. Dr. Hall describes the frst resident he worked with as a eral Hospital, where he was exposed to one-month rotations in “hard-working boy,” and he ensured this would remain the diferent services, including Orthopaedics, OB/Gyn, and Neu- character of the department. Taking call each Friday night, rosurgery. Due to a delay in pursuing a stint in the Air Force, every third weekend, and another day per week, Dr. Hall saw Dr. Hall spent one year in general practice afer his internship his practice grow along with the volume of patients seeking back in Oregon. Tough he requested Europe as a destination, care in the department, and as a result the department slowly high demand forced him to Korea where he spent a year as a grew. A second resident was soon added, as were other pillars fight surgeon in 1956. On the Kunsan air force base on the of Dartmouth Orthopaedics, Dr. Mayor in 1971 and Dr. Porter western coast of South Korea Dr. Hall practiced general med- in 1972. icine and performed physicals for recruits. He lef the service and returned to Salem, OR, where he chose the direction of All in all, Dr. Hall trained 52 residents in his tenure as head his future career, but not before he met his future wife, Mau- of the department, many of whom stayed on as staf. Te frst reen, on the ski slopes in Turin, NY. He soon would return to such resident was Dr. Philip Bernini, who retired from oper- Minneapolis General Hospital for fve years of orthopaedics ating this year. Dr. Hall dismisses the idea that he was crucial residency, and graduated in 1962. to resident learning: “the residency essentially ran itself -there were not much didactics, but the residents were a group of Mary Hitchcock Memorial hospital beckoned from the go-getters.” However, his closest peers dismiss such a falsity. east coast, afer one of its three orthopaedic attendings had recently lef for Rochester, NY. Te two remaining surgeons, Dr. Hall’s practice spanned what he describes as the “glory Dr. Russell and Dr. Staples, were growing a young Orthopae- times in medicine. Tere were no quotas and time with pa- dic department, that was not in existence several years prior. tients was unlimited.” Total hip arthroplasty began to rise in Tey looked to the Midwest where they found the future of popularity in the early 1970’s in the US. Te hospital, seeing the department. Dr. Hall moved nearly 1,400 miles across the the early success of this new procedure, sent Dr. Hall to En- country to settle in the Upper Valley area of NH, and joined gland where he spent a week with Sir John Charnley to learn the nascent Dartmouth Orthopaedics department. the technique. When he returned, his luggage included six acetabular components and six femoral components that he Dr. Hall has fond and unwavering memories of his new would soon implant in patients. From there “the frst year was surroundings, such as the bygone basement of Mary Hitch- gangbusters,” recalls Dr. Hall. Total knee arthroplasty’s rise cock hospital, built in 1892, connected by tunnels made of ensued, and soon arthroplasty made up a signifcant portion stone, or the natural beauty of the mountains and the valley, of Dr. Hall’s practice. whose charm has never let him leave. He also remembers his frst month on the job. Dr. Hall recalls that Hitchcock was the He fnished operating and taking call in 1995, then retired “only thing close to a tertiary care center between Burlington from Dartmouth Hitchcock in 2002. He’s had some time to re- and Boston at the time.” Lef alone with his partners away at fect on a successful career since then. Dr. Hall led a balanced a conference, Dr. Hall cared for 26 tibial fractures in January life, and looked for this trait in those he hired as residents and of 1963, most of which were the result of skiing accidents. He staf. He would ofen ski two afernoons a week at the Dart- soon learned to enjoy trauma patients, many falling victim mouth Skiway, learned woodworking and spent time making to the diverse outdoor recreational activities the twin-states and fxing furniture, and with the help of his lovely wife, Mau- of Vermont and New Hampshire ofer. What he loved most reen, grew a family of four children during and afer residency. about trauma was having enough time with patients to devel- He did admit that Mrs. Hall deserves all the credit for raising op a bond while ofen seeing the fnal result of their treatment their kids. When asked what advice he would give to young in a short period of time. orthopaedic surgeons the answer came more in what was not said than what was, as his confdent humility is enviable. Dr. By all accounts Dr. Hall is a pleasant, humorous, caring, Hall attributes much of his own success to those around him, and dedicated individual. Tere is no doubt that he poured and said having Dr. Staples to learn from early in his practice signifcant amounts of time and energy into helping to mold was invaluable. While he understands some prefer indepen- Dartmouth Orthopaedic Journal 2014; Vol I dent practice, he suggests that continually learning techniques air force as a fight surgeon, on a tactical air base in Glasgow, and tips from partners makes you a better surgeon. He also Montana, and helped in the operating room when needed. He placed emphasis on spending time with family, and preventing enjoyed taking care of “the jocks with orthopaedic problems” oneself from becoming enveloped by the narrow blanket of a and enjoyed the simplicity of dealing with one body region demanding career. When choosing residents and partners he at a time, confrming his choice of Orthopaedics. In the Air thought would be successful, he “looked for people with broad Force for two years, more than learning medicine, Dr. Por- interests outside of medicine” and was notorious for being ter learned much in his late twenties as he few on supersonic untrusting of the match in favor of gut instinct. While none fghter jets and B-52’s, dealt with nuclear weaponry, and sim- would question Dr. Hall’s surgical abilities, it is the culture, ulated bomb runs in Guam. now engrained in the Dartmouth Orthopaedic Community, of hard work, dedication to patients and colleagues, and a Dr. Porter recalls the lack of fellowships upon fnishing sense of duty to one’s family that will remain his lasting legacy. his orthopaedic residency, and decided to go into academic practice at Syracuse University. A desire for more patient care, Dr. Porter less academics, and a rural landscape led Dr. Porter to look into Dartmouth Hitchcock medical center. A ski trip to Stowe Dr. Robert E. Porter was born and raised in small-town with his daughter added more attraction, and Dr. Porter made Wisconsin to two educators. His father was a teacher and the transition to DHMC afer a transition year at the Universi- his mother was a music professor at Beloit, a small liberal ty of Shefeld in Yorkshire, England. Prior to returning state- arts college. Athletics helped shape Dr. Porter’s childhood, side Dr. Porter received some specialty training on the Spina from soccer in grade school to becoming a 7-Letter athlete Bifda team, and also refned his English accent, which he was in high school, excelling in football, basketball, and track, able to fake well. He arrived at DHMC in 1972 and stayed as a pole-vaulter. At age 17 Dr. Porter was honored with a there for a successful career. scholarship from the MIT club in Chicago, which aforded him a summer at MIT to study engineering. He remembers Tinted by grueling winters from 1972-1977 and a share of being dropped of by his mother at a Cambridge YMCA, lef call only ft for a junior attending, Dr. Porter’s frst few years at to manage alone in a new, big city, prior to returning to the DHMC were no cakewalk. Working with Drs. Hall, Russell, Midwest to attend Beloit. Tere he majored in biology and and Staples, as well as a slightly more junior attending, Dr. minored in history, but MIT lef him with a continued interest Mayor, Dr. Porter soon established himself as a valuable ad- in engineering. Under the guidance of a classmate’s father, the dition to the Dartmouth Orthopaedic department. Not only chair of the biology department, who was an important men- treating one another, these founding fathers of Dartmouth tor, Dr. Porter became interested in medicine and orthopae- Orthopaedics cared for each other’s children and formed a dics. Glimpses into the medical feld cultivated his early love tight-knit group that has since grown in size, with no sacrifce of medicine. As an orderly in a local hospital he remembers of camaraderie. Dr. Porter fondly speaks of barbeques, staf emptying bedpans and performing other menial tasks, while versus resident volleyball games, and basketball contests, de- “peeking in on surgeries as much as possible.” spite one such match that saw his chin meet a resident’s elbow, leaving him unable to open his mouth or talk. Having graduated from Beloit College in 1901, and then Johns Hopkins Medical School, Dr. Porter’s grandfather was Dr. Porter recalls Dr. Russell mentoring him as he became a physician from the old school – he delivered his grandson, involved with the NH Board of Registration in Medicine. performed tonsillectomies, and set broken bones. In his Seeking a side of medicine beyond orthopaedics, he became grandfather’s footsteps and along with fve other Beloit class- involved in licensure and discipline, and saw this as an oppor- mates, Dr. Porter attended medical school at the University of tunity to help colleagues through tough times. He then joined Chicago. Looking back he asserts that medicine is a calling, the Federation of State Medical Boards, was on the nation- not a second choice. He remembers reading books about be- al board of directors, and helped institute the standardized ing a doctor during high school and college and marveling patient program in all ACGME accredited medical schools. at the opportunity to bring satisfaction and happiness to pa- While Dr. Porter found these activities rewarding, he strong- tients by taking care of their problems and returning them to ly advocates “following one’s bliss” rather than rushing to get functional lives. It’s with the passion of a brand new medical involved. While running hearings for the NH Board of Med- student that Dr. Porter speaks of a profession from which he icine, Dr. Porter observed that misguided aspirations, such as retired several years ago. using fnancial reward as motivation, didn’t ofen pay of.

While internal medicine seemed to be his initial choice Te theme of mentorship was clear in speaking with Dr. of specialty, delivering babies in the inner city later piqued a Porter. He has undying gratitude for those mentors that brief interest in Obstetrics. Ultimately he felt orthopaedics shaped his career, and was appreciative of the opportunity to matched best with his personality and skills, and he was of to give back to young physicians as a mentor himself. Today, begin a surgical internship at Iowa. He spent some time in the he enjoys returning to Hanover for “Golf Day” and the Chief 57 Dartmouth Orthopaedic Journal 2014; Vol I Resident roast and graduation each June, to meet new residents and catch up with former colleagues, and derives the most satisfaction from seeing former residents returning as attendings. He also recently returned to a track meet at Beloit College where he volunteered, managing the pole vault pit.

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

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

58 Development of a Surgical Skills Curriculum for DHMC Orthopedic Surgery Residents

Rowan J. Michael MD and Dipak B. Ramkumar MD

Over the past several years, surgical simulation has come One of the major criticisms of surgical skills laboratories to the forefront of residency education. Te original model of for surgical training has been a paucity of objective criteria for surgical residency developed by William Halsted was based on evaluating performance. It has proven even harder to correlate an apprenticeship pattern. With greater restrictions on resi- this performance in a lab setting to performance in the op- dent work hours, an emphasis on improving operating room erating room. In order to tackle this defcit, several research efciency and an increasing complexity of surgical cases, reli- projects are underway in order to develop objective scoring ance on pure apprenticeship within the operating room may systems of performance on some of the simulated tasks. Addi- no longer be feasible. tionally, the use of video-assisted feedback with Google Glass® is also being explored to bridge the gap between performance Simulation training has proven invaluable in the areas of in the simulation lab and the operating room. fight and military training. In these settings pilots are able to practice in a controlled environment so that they are comfort- In the changing environment of orthopedic residency ed- able landing in an unexpected emergent situation. Within gen- ucation it seems as though simulation training will play an eral surgery, simulation trainers have also been used for some increasingly important role. With the development of a struc- time and have successfully been shown to improve perfor- tured surgical skills curriculum and several research projects mance within the operating room. Most orthopedic surgery relating to objectively measuring performance on simulated training programs have been slow to adopt a formal surgical tasks, we are excited to be at the forefront of a new paradigm skills curriculum as a part of residency education; however, in surgical training. interest in them has grown. A recent survey demonstrated that 80% of orthopedic residency program directors and 86% REFERENCES of residents believed a laboratory based surgical skills curriculum should be a part of orthopedic residency training. Te 1. Atesok K, Mabrey JD, Jazrawi LM, Egol KA: Surgical simulation in orthopedic skills training. J AM Acad Orthop Surg 2012;20(7):410-422 ABOS mandated development of a surgical skills curriculum 2. Karam MD, Pedowitz RA, Mevis H, Marsh JL: Surgical skills labo- for PGY-1 interns starting in 2012. ratories in orthopaedic surgery residency training: Results of a survey. J Bone Joint Surg Am Tis year, under the mentorship of Dr. Marcus Coe and 3. Karam MD, Westerlind B, Anderson DD, Marsh JL: Development Dr. Charles Carr, the PGY-1 class completed the frst dedicated of an orthopedic surgical skills curriculum for post-graduate year one orthopedic surgical skills program at Dartmouth-Hitchcock. resident learners – the University of Iowa experience. Iowa Orthope- dic J 2013;33:178-84. Te curriculum was largely based on the ABOS Surgical Skills 4. Yehyawi, Karam MD, Brown TD, Anderson DD: A simulation Modules for PGY-1 residents, the University of Toronto Com- trainer for complex articular fracture surgery. J Bone Joint Surg Am petency Based Curriculum workshop and the Te ACGME 2013 Jul 3:95(13) Orthopaedic Milestone’s Project. Tis curriculum included topics essential to the core orthopedic fund of knowledge for junior residents, such as traction pin placement, compartment syndrome diagnosis and treatment (using a unique Sawbones model developed for this purpose) basic arthroscopy skills, casting/splinting and sterile operating room technique.

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

Ana Mata-Fink MD

Tere has been a growing interest in international work that it will disrupt the education of the local Orthopaedic res- among residents in the Department of Orthopaedic Surgery, idents. following the lead of John Nutting, MD and Michael Sparks, MD. Although unable to travel with Dr. Nutting and Dr. Sparks to Haiti, Dartmouth Orthopaedic residents have become more Since 2011, Dr. Nutting and Dr. Sparks have been travel- involved in international work. Ana Mata-Fink, PGY4, spent 2 ing yearly to Haiti with Partners in Health. Tey have been weeks in Managua, Nicaragua in June 2013 with Orthopaedics to Cange and Hinche, performing urgent surgeries and train- Overseas. Orthopaedics Overseas is based on an education ing two local residents. Most recently in February 2014, Dr. and sustainability model, sending volunteers to established Nutting went to Mirebalais, where there is a new clinic, oper- sites repeatedly. While in Nicaragua, Ana worked with the res- ative, inpatient, and emergency treatment facility. While the idents at Hospital Lenin Fonseca (the public trauma hospital in facilities are new and there is a large case mix, there remains Managua) in the OR and in the clinic. She reviewed trauma inadequate orthopaedic coverage and equipment issues, such and ED care and studied techniques with the residents. as no functional C-arm and insufcient inventory. With the new facility, the hope is that the focus can now be transferred Katie Fuchs, PGY3, will be going to Nieva, Columbia for to orthopaedic training and education. 1 week in June with Heal the Children. She will be joining Dr. Snyder and the pediatric orthopaedic fellows from Boston Dr. Nutting has also become involved with designing a Children’s Hospital. She plans to establish a DDH education new operative facility at L’Hospital de St. Boniface in Fond des program to teach new swaddling techniques to the local com- Blancs, Haiti. As this site is constructed, there is a possibility munity. Katie will also work in the operating room with Dr. that residents from Dartmouth will be able to travel with Dr. Snyder and Dr. Fajardo to bring operative orthopaedic care to Nutting to Haiti. Currently, Partners in Health does not allow Nieva. American residents to travel to Haiti with them out of concern A Tribute to Dr. Philip Bernini and Dr. Thomas Shirreffs

Wayne M. Moschetti MD MS

It is with great honor and privilege that I have the oppor- by example. His skillset went far beyond arthroplasty and he tunity to pay tribute to the careers of doctors Philip Bernini was recognized as an expert in multiple conditions including and Tomas Shirrefs. Combined they have dedicated almost hemophilia, myelomeningocele, coccydynia and the treatment eight decades to patient care and resident education, training of spine conditions. His leadership roles spanned far beyond multiple generations of current and future orthopaedic sur- the department including roles in the New Hampshire Medi- geons under the Dartmouth banner. Tis year they will both cal Society, New Hampshire Bar Association, American Board retire from Dartmouth-Hitchcock’s operating rooms, leaving of Orthopaedic Surgery, AOA and Dartmouth Hitchcock. Be- an enormous legacy behind. yond orthopaedics, Dr. Bernini’s love for art and culture makes him a true renaissance man. Tese men each have lef a mark on the Dartmouth Hitchcock Department of Orthopaedics that will echo for years Dr. Shirrefs graduated from Colgate University with a to come. On an individual level each man will be remembered Bachelor of Arts prior to attending medical school at Case for the many ways he has impacted orthopaedic care, not only Western Reserve University in Cleveland, Ohio, not far from on the local level, but also in the region as a whole. Tey have his birthplace of Columbus. He later fnished his residency at set the highest standard of patient care, exemplifying the Dart- Case Western afer completing his internship at the University mouth Hitchcock mission by providing every patient the best of Washington in Seattle. Before joining Dartmouth Hitch- care, in the right place, at the right time, every time. Trainees cock as an Assistant Professor, Dr. Shirrefs served his country have been taught that being a good doctor is paramount and in the United States Navy at the National Naval Medical Cen- that taking a medical history encompasses more than just inter in Bethesda, Maryland. Afer completing his military ser- quiring about a painful arthritic joint. On a daily basis the vice he joined the staf at Dartmouth and had a diverse Ortho- “art” of medicine was taught by example with great precision. paedic practice with interests ranging from spine surgery and pediatric disorders to disorders of the foot and ankle. Towards Dr. Bernini and Dr. Shirrefs have both been predominant the end of his career Dr. Shirrefs saw his practice morph into forces in the Arthroplasty division at Dartmouth Hitchcock one dedicated to treating osteoarthritis of the knee and he per- Medical Center (DHMC). Between the two, they’ve replaced formed thousands of knee replacements. greater than ten thousand joints, which is an impressive feat. Te joint replacements performed were in grateful and pro- Anyone who has worked with Dr. Bernini in clinic knows foundly loyal patients (regardless of how long they may have that no stone is lef unturned when he takes a medical history, had to wait to be seen). Some expressed their thanks through which is performed with the bedside manner of Sir William tears of joy, while others ofered jugs of homemade maple syr- Osler. He is also one of the few orthopaedic surgeons who still up. What many of these patients and those that have worked carry a stethoscope in his white coat. He does this partly on alongside them may not have realized is how distinguished a principle, making sure his residents remember that they are career each of these two men had beyond joint replacement. physicians frst and foremost, and not solely technicians. Te truth of the matter is that Dr. Bernini treats his stethoscope Afer obtaining a degree in Psychology from Fordham with the same regard as any other tool, and as with any other University in his hometown, New York City, Dr. Bernini trav- tool, he did not hesitate to use it. He knew the act of placing eled to Philadelphia where he completed medical school at one’s hands on a patient was, at times, more important than Jeferson Medical College. He then moved north to the Up- the surgery itself and took great pride in taking care of his paper Valley and began his internship in general surgery at Dart- tients regardless of the aliment. mouth Hitchcock. Afer completing a second year of general surgery training, as was required at the time, he began his or- Dr. Shirrefs was a true general orthopaedic surgeon for thopaedic residency at Dartmouth and ended it at Newing- much of his career. He treated a multitude of orthopaedic ton Children’s hospital in Connecticut afer spending a year problems while in the Navy and this continued once in prac- learning pediatric orthopaedics. Afer residency he completed tice. Whether he was performing a complex foot surgery or a yearlong spine fellowship at the University of Pennsylvania’s a Laterjet procedure at the VA, he was always a pleasure to Pennsylvania Hospital. Upon completion of fellowship he re- work with. As his career matured Dr. Shirrefs commonly turned to Dartmouth as an Assistant professor. Over his 35 found himself on the opposite side of the operating table from year career on staf at DHMC he was promoted to Associate Dr. Bernini during simultaneous, bilateral total knee replace- Professor and later to Full Professor. Dr. Bernini spent rough- ments. Tese cases were intimidating to the junior resident ly 13 years as Chairman of the department where he truly led who was trying to follow each and every step, but an absolute Dartmouth Orthopaedic Journal 2014; Vol I delight for the senior resident - who typically had the honor program. As a former trainee of theirs, I fnd it hard to believe of being on the lef side of the table with Dr. Shirrefs. In the the day has come for these two men to hand in their gloves, midst of the chaos, Dr. Shirrefs would provide valuable in- but I count myself among the lucky to have been able to learn sight on the technical aspects of balancing a total knee. As the from them, because despite their physical absence from the wound was being closed, you would be lucky to hear stories operating rooms their legacy will continue in all those they from his days in training. One would learn about the times have trained. when he carried resterilizable needles on his belt buckle for drawing his own daily labs, which he then reviewed under the Dr. Moschetti trained under Dr. Bernini and Dr. Shirrefs microscope, himself, something unimaginable to current res- from 2008-2013 and graduated from the Dartmouth Orthopae- idents. He also shared many stories from his military days, dic Surgery residency in 2013. when he served in the Navy and few in military aircraf. His non-medical advice and insight was just as useful, such as how to develop your sons into collegiate and professional hockey players. Te truth is, whatever the topic of conversation, it was always a joy to be working with such a humble man who had such an acclaimed career.

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

62 Orthopaedic Teaching Awards

Charles F. Carr MD

Te Dartmouth Orthopaedic Surgery Training Program dents to a faculty member for excellence in teaching and men- has long been considered one of the premiere teaching pro- toring. Appropriately, the frst recipient of the award as voted grams at Dartmouth-Hitchcock Medical Center. Tat distinc- upon by the residents was Dr. Phil Bernini. tion is brought about by committed faculty and residents who deserve to be recognized for their tireless eforts. As such, it Te resident teacher award can be given to any level res- seemed well overdue that our best educators should be hon- ident and is awarded by the residents to the “Outstanding ored with an annual award. 2013 marked the frst year of both Resident Teacher of the Year.” Te inaugural recipient of the a faculty and resident teaching awards determined by a vote award was one of our chief residents, Dr. Wayne Moschetti. of the residents for each award. Te faculty award has been Dr. Moschetti is completing an arthroplasty fellowship at the named in honor of our most notable, devoted educator over Brigham and Women’s Hospital in Boston and will be return- the past half century and is called “Te Philip M. Bernini Fac- ing to DHMC in the fall to join our attending staf. Congratu- ulty Teaching Award.” It is given from the orthopaedic resi- lations to our frst 2 honorees.

Freddie Fu Award

Charity A. Jacobs MD

**** DHMC Courage to Teach Award

Dipak R. Ramkumar MD

Program directors routinely handle multiple challenges year, the award recipient is announced at the Annual Program while administering a residency or fellowship program. In Directors’ Retreat. Tis year, Dr. Charlie Carr from the De- 2005, Dartmouth-Hitchcock Medical Center established the partment of Orthopaedic Surgery was recognized for his con- “Courage to Teach Award”, a prestigious recognition bestowed tributions. upon a program director who fnds innovative ways to teach residents to provide high quality patient care, learn research Dr. Carr has served as program director for the orthopae- techniques, model professionalism and regularly champion dic surgery residency program for more than fourteen years. the academic ethos of a program. Nominations are solicited His tenure has been instrumental in developing a training pro- from all current residents and fellows at Dartmouth-Hitch- gram that is nationally recognized as one of the best. One res- cock, with the goal of recognizing one program director who ident nomination specifcally appreciated Dr. Carr’s mentor- demonstrates efectiveness and dedication in teaching, elicits ship by stating, “Dr. Carr motivates me to be a better person, excitement surrounding education, functions as a strong role husband, father, and physician.” Both current residents and model, demonstrates behaviors that are value-based and high- alumni have all experienced Dr. Carr’s commitment to excel- ly principled and incorporates a sense of their authentic self as lence in education and we are all thankful to have benefted well as a sense of humor while directing their program. Each from his mentorship. Congratulations, Dr. Carr! New Faculty

MARCUS P. COE, MD, MS MICHELLE M. PRINCE, MD

Marcus Coe joined the orthopaedics department in 2013. In 2013 the Dartmouth Orthopaedic Department was for- Dr. Coe graduated from Dartmouth College with a degree in tunate to welcome Dr. Michelle Prince to the staf. Tis is a English and Creative Writing in 2000. He taught English and return to New England for Dr. Prince; she grew up in Maine coached swimming and baseball at a boarding school for two where she graduated from Gould Academy. She remained in years prior to obtaining his MD at Yale. Dr. Coe completed Maine at Bowdoin College before transferring to Smith Col- his residency in orthopaedic surgery at Dartmouth Hitchcock lege in western MA where she graduated cum laude. Afer in 2012, during which time he received an MS in Health Care working in labs in Boston and Los Angeles, Dr. Prince attend- Leadership from Te Dartmouth Institute. Dr. Coe completed ed Stritch School of Medicine of Loyola University, Illinois. a fellowship in foot and ankle reconstruction at the University She completed her residency in Orthopaedic Surgery at the of British Columbia in 2013. Dr. Coe practices at Dartmouth University of Massachusetts Medical Center in Worcester, MA Hitchcock and the White River Junction VA hospital. He and was the recipient of the Dr. John J. Monahan award. She specializes in general orthopaedics and foot and ankle recon- then moved to Georgia for a pediatric orthopaedic fellowship. struction. He has an interest in residency education and runs Dr. Prince comes to New Hampshire from a private practice in the intern surgical skills course throughout the year. Austin, Texas and Locum Tenens in Springfeld, Illinois.

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

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

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

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

Daniel Austin grew up in Mechanicsburg, Pennsylvania. Kelly Esposito is from Wilmington, North Carolina. She He majored in Biology at Williams College where he was a grew up playing soccer and running cross country and plays member of theTrack and Field Team. Afer graduation, Dan the fute. She also worked as an ocean lifeguard for three sum- continued to pursue his passion for the discus throw and had mers in Carolina Beach, North Carolina. the opportunity to compete in the 2008 Olympic Trials. Kelly attended the University of North Carolina at Chapel Before entering medical school, Dan worked as a fy fsh- Hill, where she majored in journalism and biology and stud- ing guide in Colorado and as a middle school science teacher ied abroad for a semester in Puebla, Mexico. She played on in New York City as part of Teach for America. He attended the varsity soccer team for two years, which won an NCAA medical school at the University of Pennsylvania. In his free Division I National Championship her sophomore year. She time, Dan enjoys spending time outdoors with his wife, Juli- continued on to medical school at UNC and also completed anne, and chocolate labrador, Mousse. an MBA at UNC’s Kenan-Flagler Business School, making her a Triple Tar Heel. In her free time, she enjoys sports, the outdoors, cooking and traveling.

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

Matt DeWolf is from Pittsfeld, MA. He went to Boston Samuel Kunkel is originally from Cincinnati, OH. He University for his undergraduate education and the Universi- completed his undergraduate degree at the University of Chi- ty of Massachusetts Medical School. His interests are working cago, and returned to Cincinnati to obtain a masters degree in out, hiking, and he has completed 2 Tough Mudder races. He physiology as well has his medical doctorate at the University also enjoys cooking, traveling, and spending time with family of Cincinnati. Sam competed in wrestling during his youth and friends. and was a member of the varsity wrestling team at the Uni- versity of Chicago. His current interests outside of medicine include outdoor activities such as hiking and mountain biking, and he has an avid interest in history. Graduating Residents

ADEWALE O. ADENIRAN, MD SARA C. GRAVES, MD, MS

Dr. Adeniran graduated from Te Jacksonville University Dr. Graves graduated from Smith College and the Dart- with a Bachelor of Science in Biochemistry. He then attended mouth 12-college exchange program with a Bachelor of Arts in Washington University in St. Louis School of Medicine where he Biochemistry. She received a Doctorate of Medicine from the served as class president, built lasting friendships and received University of Southern California’s Keck School of Medicine. his MD. Afer graduation, he looks forward to completing a fel- During residency, she received a Master’s of Science Degree from lowship in Spine Surgery at Texas Back Institute in Plano, TX. the Dartmouth Institute for Health Policy and Clinical Practice. Afer graduation, she will complete a one year Trauma fellowship at the University of Minnesota’s Regions Hospital in St. Paul, MN.

GARRETT C. DAVIS, MD, MBA, MS R. BRAD WASHBURN, MD

Dr. Davis graduated from Brigham Young University with Dr. Washburn graduated from Wake Forest University with a BS in General Management. He obtained his MD from Dart- a Bachelors degree in Economics. Afer spending several years mouth Medical School. While earning his medical degree he also as a fy-fshing guide in Montana and as an innkeeper with his obtained his MBA from the Tuck School of Business at Dart- family in North Carolina, he obtained his MD from the Univer- mouth. During his residency at Dartmouth -Hitchcock, he ob- sity of North Carolina at Chapel Hill. Following graduation, Dr. tained an MS from Te Dartmouth Institute for Health Policy Washburn will complete a one year fellowship in Sports Medicine and Clinical Practice. Afer graduation, he is planning to com- and Shoulder Reconstruction at the Steadman-Hawkins Clinic in plete a one-year fellowship in Adult Reconstructive Surgery at Greenville, SC with Dr. Richard Hawkins. the Rothman Institute at Tomas Jeferson University in Phila- Update on Recent Graduates

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

Dr Brabston graduated from Grove City College with a de- Jennie completed her undergraduate studies at Yale Uni- gree in philosophy and pre-medical studies. Following grad- versity and did her medical training at University of Penn- uation, he worked as an admissions counselor for his alma sylvania. Afer graduating from the Dartmouth Orthopaedic mater before returning to Alabama to complete his Doctorate Surgery residency in 2013, she returned to New Haven, where of Medicine. He continued his orthopaedic training at Dart- she is currently fnishing a fellowship in Shoulder and Elbow mouth Hitchcock Medical Center followed by a fellowship in Surgery at Yale New Haven Hospital. She plans to work in New Shoulder, Elbow and Sports Medicine at Columbia Presbyteri- England upon fnishing her fellowship this summer. an Medical Center in New York City. Upon completion of his fellowship, he will return to his home state with an academic appointment at the University of Alabama at Birmingham.

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

Dr. Dwyer graduated from the College of the Holy Cross in Dr. Moschetti graduated from the University of New Worcester, MA and received his medical degree from Tufs Hampshire magna cum laude with a BA in Political Science. University. He fnished his orthopaedic surgery residency Afer working in healthcare technology in New York City he at Dartmouth Hitchcock Medical Center in 2013. He obtained his MD from Boston University School of Medicine joined Connecticut Valley Orthopaedics afer graduation where he graduated magna cum laude. While completing his and he is practicing general orthopaedics in a small critical residency at Dartmouth-Hitchcock, he obtained a Masters of access hospital in Springfeld Vermont. He has been Science from Te Dartmouth Institute for Health Policy and working to build a general orthopaedic practice focusing on Clinical Practice. He is currently completing a one-year fel- arthroplasty(shoulder, hip, and knee), arthroscopy(shoulder lowship in Adult Reconstructive Surgery at the Brigham and and knee), and fracture care. He has also been enjorying Women’s hospital in Boston, MA. Afer fellowship he plans more free time with his wife and three children. to pursue an academic appointment and return to Dartmouth with an interest in primary knee and hip arthroplasty with an emphasis on the direct anterior approach, revision hip and knee arthroplasty, periprosthetic fracture management, and periprosthetic infections. Faculty

William A. Abdu James B. Ames John-Erik Bell Spine Sports Shoulder & Elbow

Philip M. Bernini John T. Braun Robert V. Cantu Arthroplasty Pediatric Spine Trauma

Charles F. Carr Marcus P. Coe Roland G. Hazard Sports Foot & Ankle Spine Faculty

Paul J. Hecht James D. Heckman Eric R. Henderson Foot & Ankle General Orthopaedics Orthopaedic Oncology

Stephen R. Kantor Kristine A. Karlson Karl M. Koenig Arthroplasty Sports Medicine Arthroplasty

Franklin Lynch Jr. William E. Minsinger Sohail K. Mirza General Orthopaedics General Orthopaedics Spine Chair of Orthopaedics Faculty

John T. Nutting Adam M. Pearson Michelle M. Prince Shoulder & Elbow Spine Pediatrics

Dilip K. Sengupta Tomas G. Shirrefs Michael B. Sparks Spine Arthroplasty Lower Extremity

Ivan M. Tomek Lance G. Warhold James N. Weinstein Arthroplasty Hand Spine Associate Providers Alumni of the Dartmouth Orthopaedic Surgery Residency Program

1961 1973 1981 Mitchel B. Harris, MD 1985-1989 Robert H. Orth, MD H. Roger Hansen, MD J. Michael Whitaker, MD (Deceased) 1970-1973 1978-1981 1990 1958-1961 Howard M. Black, Jr., MD Franklin Lynch, MD William A. Abdu, MD 1970-1973 1978-1981 1986-1990 1962 Christopher N. Walton, MD Keith D. Woolpert, MD 1974 1982 1986-1990 1959-1962 Edward Bradley, MD Derrik F. Woodbury, MD 1971-1974 1979-1982 1991 1963 Preston R. Clark, MD W. Kevin Olehnik, MD Walter N. Garger, MD (Deceased) 1983 1987-1991 1960-1963 1971-1974 Thomas M. Barton, MD Lance G. Warhold, MD 1980-1983 1987-1991 1964 1975 Deborah R. Fabian, MD George M. Hazel, MD Bradford A. Stephens, MD 1980-1983 1992 1961-1964 1972-1975 Gregg J. Fasulo, MD Thomas E. Clarke, MD 1984 1988-1992 1965 1972-1975 James M. Murphy, MD Carol J. Pelmas, MD Francis P. Saunders, MD 1981-1984 1988-1992 1962-1965 1976 Philippe S. Cote, MD Kenneth C. Spengler, Jr., MD 1993 1966 1981-1984 1973-1976 Jonathan E. Fuller, MD Richard J. Hastings, MD 1985 Sterling E. Doster, MD 1989-1993 1963-1966 Gary C. Bessette, MD 1973-1976 John T. Gorczyca, MD 1982-1985 1967 1989-1993 1977 John T. Nutting, MD Richard A. McArthur, MD Edward W. King, MD 1982-1985 1994 1964-1967 1974-1977 Geoffrey M. McCullen, MD 1986 1968 1990-1994 1978 James L. Telfer, MD Stephen R. Shaffer, MD Peter G. Noordsij, MD Philip M. Bernini, MD 1983-1986 1965-1968 1990-1994 1975-1978 Edward N. Powell, MD 1983-1986 1969 John W. Lyons, MD 1995 1975-1978 Michael B. Sparks, MD Thomas M. Malloy, MD 1987 1966-1969 1991-1995 Charles F. Carr, MD 1979 James M. Hartford, MD 1984-1987 1970 James M. Perry, MD 1991-1995 (Deceased) Samuel S. Scott, MD Kenneth W. Gregg, MD 1976-1979 1984-1987 1967-1970 1996 Thomas S. Eagan, MD Diane C. Riley, MD 1988 1971 1976-1979 1992-1996 Joseph Sirois, MD Richard L. Withington, MD Jim A. Youssef, MD 1984-1988 1968-1971 1980 1992-1996 James J. O’Connor, MD G. Raymond Payne, MD 1972 (Deceased) 1984-1988 1997 1977-1980 David W. Moore, MD Charles A. Hope, MD 1969-1972 Jeffrey A. Metheny, MD 1989 1993-1997 1977-1980 R. Mark Caulkins, MD Thomas M. Mitchell, MD 1985-1989 1993-1997 Dartmouth Orthopaedic Journal 2014; Vol I

1998 2007 Scott Faucett, MD 2007-2012 Bertrand P. Kaper, MD Brian Aros, MD (6 year TDI) 1994-1998 2001-2007 2013 Michael R. Yorgason, MD Jason Fanuele, MD Kevin Dwyer, MD (6 year TDI) 1994-1998 2002-2007 2007-2013 1999 2008 Wayne Moschetti, MD (6 year TDI) 2007-2013 Dirk Asherman, MD Kane Anderson, MD (6 year TDI) 1994-1999 2002-2008 Jennie Garver, MD 2008-2013 Justin Cummins, MD (6 year TDI) 2000 2002-2008 Eugene “Will” Brabston, MD 2008-2013 John F. Parker, MD Dan Bullock, MD 1995-2000 2003-2008 David G. Goss, MD 2014 1995-2000 2009 Sara Graves, MD (6 year TDI) 2008-2014 Karl Koenig, MD (6 year TDI) 2001 2003-2009 Garrett Davis, MD (6 year TDI) 2008-2014 Jeffrey W. Wiley, MD Jamie Genuario, MD (6 year TDI) 1996-2001 2003-2009 Richard “Brad” Washburn, MD 2009-2014 Thomas L. Martin, MD Brian Leung, MD 1996-2001 2004-2009 Adewale Adeniran, MD 2009-2014 2002 2010 Scott Sporer, MD (5 year TDI) Jamie Ames, MD (6 year TDI) 1997-2002 2004-2010 Gregory Sassmannshausen, MD Adam Pearson, MD (6 year TDI) 1997-2002 2004-2010 Xan Courville, MD (6 year TDI) 2003 2004-2010 Randall Schultz, MD (5 year TDI) Anthony Albert, MD 1998-2003 2005-2010 Ronald Michalak, MD (5 year TDI) Joseph Signorelli, MD 1998-2003 2005-2010 2004 Wayne McGough, MD 2005-2010 Andrew Myrtue, MD 1999-2004 2011 2005 Patrick Olson, MD (6 year TDI) 2005-2011 Elizabeth Weber, MD 1999-2005 Ryan Pizinger, MD 2006-2011 Eric Marsh, MD (5 year TDI) 2000-2005 2012 Jorge Brito, MD Greg Ford, MD (6 year – all 2000-2005 clinical) 2006-2012 2006 Ryan Donegan, MD (6 year TDI) James D. Slover, MD (5 year TDI) 2006-2012 2001-2006 Marcus Coe, MD (6 year TDI) Michael Hoffman, MD (5 year TDI) 2006-2012 2001-2006 Erik Bergquist, MD 2007-2012

74 Dartmouth Orthopaedic Journal Submission Guidelines

SUBMISSION GUIDELINES, DARTMOUTH ORTHOPAEDIC JOURNAL, 2014 Any original article relevant to orthopaedic surgery, orthopaedic science or the teaching of either will be considered for publication in Te Dartmouth Orthopaedic Journal. Additionally, we encourage submissions of editorials and/or essays pertaining to orthopaedics and the history of orthopaedics. Submissions are encouraged from alumni, visitors to the department, residents, and friends of Dartmouth-Hitchcock Medical Center Department of Orthopaedics. Te frst edition of the journal will be published in June 2014, and annually thereafer.

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

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

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

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

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

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

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

Preparation of manuscripts: Manuscripts must be typewritten and double spaced using wide margins and submitted as a Microsof Word fle. Tey should not exceed 4000 words excluding references and fgure legends. Write out numbers under 10 except percentages, degrees or numbers expressed as decimals. Direct quotations should include the exact page number on which they appeared in the book or article. All measurements should be given in SI metric units. Use only standard abbreviations. Avoid abbreviations in the title of the manuscript. Te spelled-out abbreviation followed by the abbreviation in parenthesis should be used on frst mention unless the Dartmouth Orthopaedic Journal 2014; Vol I abbreviation is a standard unit of measurement.

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

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

3. Manuscript: in “IMRAD format”

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

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

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

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

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

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

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

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

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

76 Dartmouth Orthopaedic Journal 2014; Vol I 4. Tables: must be labeled individually and submitted as separate electronic fles. Tables should be submitted in their original fle format (Word or Excel) and not as graphics fles. Number tables consecutively in the order of their frst citation in the text and supply a title for each. Titles in tables should be short but self-explanatory, containing information that allows readers to understand the table’s content without having to go back to the text. Be sure that each table is cited in the text. Give each column a short or an abbreviated heading. Authors should place explanatory matter in footnotes, not in the heading. Explain all nonstan- dard abbreviations in footnotes. Identify statistical measures of variation in standard deviation.

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

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

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

8. Cover Letter (optional)

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

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

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

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

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

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

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

77 Dartmouth Orthopaedic Journal 2014; Vol I