Faculty Bibliography

SUMMARY: The purpose of our pre-post intervention study was to reduce the number of near-miss events pertaining to wrong-site surgery, including incorrectly sided surgical bookings and incorrectly performed preoperative time-out procedures. Pre- and postintervention, incorrectly booked cases, and improperly performed presurgical time-out procedures were recorded. We then educated each surgeon and their staff regarding the importance of and proper way to perform these tasks. Subsequently, the monthly percentage of incorrectly booked surgical procedures and improperly performed time-outs were significantly decreased. INTRODUCTION: In 2004, the Joint Commission published comprehensive guidelines to prevent wrong-site surgery. Seven years have passed, and the incidence has not declined. The Joint Commission estimates that in the United States, wrong-site procedures including surgeries occur at least 40 times a week. "Near misses" are events that could have harmed a patient, but did not due to chance or mitigation. Improperly performed time-out procedures and inaccurate surgical bookings are considered near misses and could ultimately lead to "never events," such as wrong-site surgery. Near-miss analysis is a highly effective method of preventing rare, "never events." We hypothesize that proper education of surgeons and staff will be effective in reducing the number of near misses. METHODS: All cases analyzed were performed at an academic, orthopedic surgery specialty institution. From August 2010 to May 2011, near misses were identified and stored in Patient Safety Net (PSN), an electronic database. We tracked these cases and educated each offending attending physician and his or her staff about the importance of accurate surgical bookings. Additionally, we began an observational program to carefully review presurgical time-out procedures as they occurred. We tracked the percentage of these improperly performed time-outs and counseled offenders (attending surgeon, or any member of the operating room staff who made the error) regarding the deficiencies that caused the time-out to be ineffective. The number of near misses that occurred before and after the interventions were recorded and analyzed. RESULTS: Of the 12,215 cases included in this study, 6,126 cases formulated the "pre-education" cohort, while a total of 6,089 cases formulated the "post-education" cohort. In the first four months of the study, the monthly rate of incorrectly booked cases was 0.75%. Since the intervention, the rate decreased to 0.41% (p = .0139). The percentage of improperly performed time-out procedures decreased from 18.7% to 5.9% after the educational interventions were performed (p < .0001). CONCLUSION: A program designed to educate physicians to the importance of decreasing near misses for wrong-site surgery is effective. When analyzing the literature, it is clear that the reduction in near misses observed in this study decreases the likelihood of a wrong-site surgery.

PURPOSE: To compare clinical outcomes between transtibial drilling and anteromedial portal techniques for anterior cruciate ligament (ACL) reconstruction using soft-tissue grafts secured with expandable fixation. METHODS: Patients undergoing soft-tissue ACL reconstruction using expandable fixation between 2007 and 2011 were reviewed for inclusion in this study. Revision ACL cases were excluded. All surgeries were performed by 1 of 2 sports medicine fellowship-trained surgeons (T.S.D., K.D.M.). A total of 128 patients (67 comprising transtibial cohort and 61 comprising anteromedial portal cohort) had a minimum of 24 months' follow-up (mean, 27 months) and met the inclusion criteria. The patients were divided into 2 groups based on the method used for creation of the femoral tunnel. At final follow-up, outcomes were assessed with KT-1000 (MEDmetric, San Diego, CA) measurements, as well as International Knee Documentation Committee, Lysholm, and Tegner scores. Data were screened for normality and skew before use of parametric statistics and were transformed if necessary. Data were analyzed by 1-way analysis of variance with post hoc paired comparisons using the Bonferroni approximation. RESULTS: No differences in demographic characteristics were observed between the 2 groups. There was no significant difference in postoperative KT-1000 measurements between the 2 cohorts (1.571 +/- 0.2275 mm in transtibial cohort [n = 35] and 1.246 +/- 0.09249 mm in anteromedial cohort [n = 61], P = .1259). A significant improvement in International Knee Documentation Committee scores was observed in the anteromedial cohort, increasing from 41 +/- 16 to 89 +/- 7.4 (mean +/- SD) (P < .0001). Similar changes were observed for the Lysholm score. There was no significant difference between cohorts for any postoperative scores measured (P > .2). CONCLUSIONS: Our data show comparable KT-1000 measurements for both anteromedial and transtibial femoral drilling techniques when using a soft-tissue graft with expandable fixation. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Patellar instability is a complex pathoanatomical phenom- enon that requires an intricate understanding in order to properly treat patients. Often, the etiology of this entity is multifactorial, combining a series of physiologic and anatomic variables. A thorough history and physical as well as correct radiographic examinations are critical in both establishing the diagnosis and instituting the correct treatment. Non-operative management of recurrent insta- bility has a high failure rate. Current operative techniques have been shown to be instrumental in correcting anatomic abnormalities, reducing symptoms of instability, and giving patients an appropriate chance of returning to their previous level of activity.

PURPOSE: The purpose of this study was to determine the incidence of venous thromboembolism (VTE) after hip arthroscopy. METHODS: Over the course of 13 months, four surgeons that routinely perform hip arthroscopy participated in a protocol to screen all patients postoperatively for deep venous thrombosis (DVT) using bilateral venous duplex ultrasound at or about the 2 week postoperative time point. All patients were assessed and stratified for VTE risk prior to surgery. Mechanical intraoperative and postoperative chemoprophylaxis were not administered. Perioperative factors, such as weightbearing status after surgery, traction time, and anesthesia type, were recorded. RESULTS: We identified 139 eligible patients (average age 37.7, SD = 12.0) that underwent hip arthroscopy. The incidence of symptomatic VTE was 1.4 percent (2/139). Of the entire patient pool, 81 obtained a follow-up ultrasound. There were no cases of asymptomatic deep vein thrombosis (DVT). There were two symptomatic venous thromboembolic events noted; one DVT and one pulmonary embolus. One patient had no risk factors; the other was overweight and routinely took oral contraceptives. Amongst the patient co- hort, the mean BMI was 25.9 (SD = 4.8). The mean traction time was 58.9 minutes (SD = 23.1). Most patients (71%) were partial weightbearing after the procedure. CONCLUSION AND CLINICAL RELEVANCE: In patients under- going hip arthroscopy, the rate of postoperative VTE was low, despite the use of prolonged axial traction and surgi- cal proximity to the pelvic veins. Although patients should be counseled preoperatively regarding the risk of VTE, we believe that routine use of pharmacologic prophylaxis is not indicated following hip arthroscopy if patients are properly risk stratified prior to surgery and found to be at low risk for VTE.

Ice hockey is a fast paced sport with unique injury potential. A covering physician must be prepared to acutely manage injuries to the face, neck, and chest that are not common in orthopedic practice. Injuries about the face seen in ice hockey include facial fractures, lacerations, and eye and dental injuries. Neck trauma can result in lacerations and neurologic injury. Commotio cordis and sudden cardiac death are potentially fatal conditions seen in ice hockey. This review details the appropriate acute management of these conditions for the physician covering an ice hockey game. Knowledge of these conditions and appropriate rink-side management can be potentially life-saving.

Traumatic injuries of the hand and fingers may be devastating and can result in irreversible functional and psychological problems in individuals who sustain them. They occur in all age groups, ranging from the elderly to young children. The management of these injuries can be challenging and onerous. As a result, it is imperative that the surgeon be both knowledgeable and meticulous in order to afford the best possible outcomes. This review focuses on the anatomy, initial evaluation, and acute management of these injuries. A variety of treatment algorithms are discussed as well, including primary closure, grafting, commonly utilized flaps, and replantation.

Aneurysmal bone cysts are rare skeletal tumors that most commonly occur in the first two decades of life. They primarily develop about the knee but may arise in any portion of the axial or appendicular skeleton. Pathogenesis of these tumors remains controversial and may be vascular, traumatic, or genetic. Radiographic features include a dilated, radiolucent lesion typically located within the metaphyseal portion of the bone, with fluid-fluid levels visible on MRI. Histologic features include blood-filled lakes interposed between fibrous stromata. Differential diagnosis includes conditions such as telangiectatic osteosarcoma and giant cell tumor. The mainstay of treatment is curettage and bone graft, with or without adjuvant treatment. Other management options include cryotherapy, sclerotherapy, radionuclide ablation, and en bloc resection. The recurrence rate is low after appropriate treatment; however, more than one procedure may be required to completely eradicate the lesion.

Since the 1980s, hip arthroscopy has become an accepted treatment modality for a variety of hip conditions. It is generally considered a low-risk procedure with a low rate of complications. The risk of developing a deep venous thrombosis (DVT) or venous thromboembolism following these procedures is also thought to be low, and most patients undergoing these procedures receive no pharmacologic prophylaxis postoperatively.This article presents a case of a 33-year-old woman with a history of oral contraceptive use who presented 13 days after a routine hip arthroscopy with pain and swelling in the contralateral thigh. Ultrasonography revealed acute DVTs in the left common femoral, superficial femoral, and popliteal veins. She was admitted to the hospital and treated accordingly. A workup for thrombophilic disorders was negative. We believe that her history of oral contraceptive use, the use of axial traction, and asymmetric forces about the pelvis during the procedure contributed to this postoperative complication.Although this complication is rare and the use of pharmacologic prophylaxis is not common, physicians must be aware of this potential complication following hip arthroscopy