Ortho Journal 2022 Desktop + Mobile

Joshua J. Jacobs, MD Chair, Department of Orthopedic Surgery

“By addressing the new realities shaping our specialty but not wavering from our academic mission, we can continue to make life-changing discoveries in orthopedics.”

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Articles

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Adam B. Yanke, MD, PhD Corresponding Author

Navya Dandu, MD / Tristan J. Elias, BA / Erik Haneberg, BS / Mario Hevesi, MD, PhD Kevin T. Credille, BSE, MS / Zachary Wang, BS Nozomu Inoue, MD, PhD / Adam B. Yanke, MD, PhD

Effect of Bone Marrow Aspirate Concentrate Augmentation on Allograft Volume, Ligamentization, and Concurrent Injury in Anterior Cruciate Ligament Reconstruction: A Double-Blinded Randomized Controlled Trial

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Concepts and Controversies in Acute Distal Biceps Tendon Rupture Repair: The RUSH Repair

Mark Cohen, MD Corresponding Author

Mark Cohen, MD / John Fernandez, MD / Nitin Goyal, MD / Andre Sabet, MS Samuel Shuman, BA / Xavier Simcock, MD / Robert Wysocki, MD

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Distal biceps tendon rupture is an uncommon injury which can result in significant functional consequences. Surgical treatment is typically reserved for patients with functional demands that cannot be met with conservative treatment. Either the single-incision or dual-incision approaches can be utilized for repair of the tendon. Debate exists as to the superiority of each approach given their associated risks and benefits. Both, however, have been shown to be safe and effective. The post-operative protocol following repair varies between studies. Overall outcomes in multiple series following repair are usually excellent, highlighting consistent return of strength and motion with a good safety profile. We aim to review the literature surrounding the distal biceps tendon repair, summarize the evolution of the repair and present our strategies and clinical pearls in managing distal biceps tendon repair.

Lateral patellar dislocation represents a common clinical pathology with an annual incidence of 23.2 per 100,000 person-years. Patellar instability and its related injuries are associated with significant apprehension with activities of daily living and sports in a young, active population. Furthermore, recurrent instability events increase the risk of cartilage damage, patellofemoral joint degeneration, and patient disability. Predisposing factors to instability include a lateralized tibial tubercle and trochlear dysplasia, which may contribute to abnormal patellar tracking and contact pressures. Identifying predisposing pathoanatomy and defining clinically useful measurements ultimately guide management decisions. The objective of this study was to compare the traditional TT-TG distances to novel three-dimensional measures generated from automated trochlear groove detection with sequential radial cuts. The authors hypothesized that the three-dimensional measurements would differ from the traditional measurements, and furthermore the offset between the tibial tubercle and trochlear groove will vary through flexion.

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Brian J. Cole, MD, MBA

Kern Singh, MD

Nikhil Verma, MD

Good Bones:

Addressing new business realities facing orthopedic practices

A roundtable discussion about the new business realities facing orthopedic practices and what that means for clinical care

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Does the Traditional TT-TG Distance Accurately Reflect the Relative Position of the Tibial Tubercle to the Trochlear Groove? A Three-Dimensional Analysis of Knees with and without Trochlear Dysplasia

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Brian Forsythe, MD Corresponding Author

Bernard R. Bach, MD / Won C. Bae, PhD / Elyse Berlinberg, BS / Jorge Chahla, MD, PhD Christine B. Chung, MD / Brian Cole MD, MBA / Brian Forsythe, MD / Vahram Gamsarian, BE Vikranth Mirle, BS / Nikhil N. Verma, MD / Adam B. Yanke, MD, PhD

Although anterior cruciate ligament reconstruction (ACLR) is one of the most common orthopedic procedures performed in the United States, few advances have been made to reduce the healing time of the anterior cruciate ligament graft and the subsequent development of degenerative joint disease. One promising regenerative approach in prevention of post-ACLR osteoarthritis is the use of bone marrow aspirate concentrate (BMAC). BMAC consists of several growth factors and progenitor cells (mesenchymal stem/stromal cells) that can be applied directly to the site of injury intraoperatively. The pluripotent potential of these progenitor cells has been demonstrated to positively impact healing, regeneration, and biomechanical strength of ACLR grafts.

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Does Perioperative Radiation Affect Implant Survivorship of Primary Total Hip Arthroplasty in the Setting of Metastatic Bone Disease?

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Alan T. Blank, MD, MS Corresponding Author

Laith Z. Abwini, BS / Alan T. Blank, MD, MS / Matthew W. Colman, MD / Steven Gitelis, MD / Linus Lee, BE Kyle Sweeney, MD / Alex Tang, MD / Sarah C. Tepper, MD / Dylan Vance, BS / Gayathri Vijayakumar, BS / Richard S. Yoon, MD

Management of metastatic lesions about the hip involves complex clinical decision making. Roughly 50% of patients who have solid tumors with metastatic cancer receive radiation therapy in an attempt to treat the underlying malignancy. Radiation can compromise bone quality as well as ingrowth potential of implants. Additional known complications associated with radiation include infection and fibrosis. In previously irradiated hips, implants such as tantalum cups and porous titanium components containing porous ingrowth surfaces may prove beneficial by promoting osseointegration as early as five weeks after implantation. Although the long-term survival of acetabular cups have been studied in patients with a history of pelvic radiation for primary tumors, there is a paucity of data reporting functioning and long-term implant survival of acetabular cups used for THA in patients with a history of radiation to the operative hip for metastatic bone disease (MBD). The purpose of this investigation was to examine the differences in rates of reoperation, implant survival, and postoperative complications in patients after primary THA for MBD in the setting of perioperative radiation.

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Spinopelvic Parameters and Hip Arthroscopy

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Shane J. Nho, MD, MS Corresponding Author

Ian M. Clapp, MD, MS / Thomas W. Fenn, BS / Derrick M. Knapik, MD / Shane J. Nho, MD, MS / Daniel M. Wichman, BS

The purpose of the current investigation was to evaluate the influence of spinopelvic parameters on short-term postoperative patient reported outcomes (PROs) following primary hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS). We hypothesized no clinically significant differences would be appreciated in any PRO measure based on differences in spinopelvic parameters.

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Multiple investigations have reported decreased PI to be associated with increased rates of patients possessing FAIS morphology, while other investigations have cited increased PI to be associated with FAIS. Meanwhile, the influence of spinopelvic parameters on outcomes in patients undergoing operative management for FAIS remains largely unknown.

Opinions on USMLE Step 1 Score Reporting Changes and Downstream Effects: Survey of Residency Applicants from Multiple Specialties and Institutions

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Shane J. Nho, MD, MS Corresponding Author

Ian M. Clapp, MD, MS / Thomas W. Fenn, BS / Derrick M. Knapik, MD Shane J. Nho, MD, MS / Daniel M. Wichman, BS

Femoroacetabular impingement syndrome (FAIS) is a dynamic process that has gained increasing recognition as a common cause of non-arthritic hip pain and functional impairment, predisposing patients to progressive chondrolabral damage and premature osteoarthritis (OA). While abnormalities in pelvic incidence (PI) have been reported in patients with various spinal disorders, recent investigations have suggested variations in PI to be associated with FAIS. However, that association has been largely contradictory. Multiple investigations have reported decreased PI to be associated with increased rates of patients possessing FAIS morphology, while other investigations have cited increased PI to be associated with FAIS. Meanwhile, the influence of spinopelvic parameters on outcomes in patients undergoing operative management for FAIS remains largely unknown. The purpose of the current investigation was to evaluate the influence of spinopelvic parameters on short-term postoperative patient reported outcomes (PROs) following primary hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS). We hypothesized no clinically significant differences would be appreciated in any PRO measure based on differences in spinopelvic parameters.

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Monica Kogan, MD Corresponding Author

Alexandra M. Arguello, BS / Edie Y. Chan, MD / Matthew R. Cohn, MD / Grant E. Garrigues, MD / Scott G. Hasler, MD Michael D. Johnson, MD / Monica Kogan, MD / Johnathon R. McCormick, MD / Gerald Z. McGwin, MS, PhD / Vincent K. Morgan, MD Michele H. Nichols, MD / Brent A. Ponce, MD / John R. Porterfield, MD / Bridget L. Voigt, MD / Sloane L. York, MD, MPH

Since its inception in the early 1990s, medical students have been required to pass the three-part United States Medical Licensing Examination (USMLE) series to become licensed physicians. The first of these, typically administered at the end of the second year of medical school, is known as USMLE Step 1. Some physicians, students, and educators believe medical students’ well-being is negatively affected by the importance placed on Step 1. In February of 2020, the National Board of Medical Examiners (NBME) and Federation of State Medical Boards (FSMB) announced the change of the Step 1 exam from three-digit scoring to a pass/fail reporting system beginning after January 1, 2022. The purpose of this study is to investigate the perspectives of medical students who applied to residency during the 2019-2020 interview season from geographically diverse programs regarding the Step 1 pass/fail change. In addition, the degree of impact on future applicants and resident selection was analyzed from the students’ perspective.

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Establishing Clinically Significant Outcomes After Shoulder Arthroplasty at Minimum 5-Year Follow-Up

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Brian J. Cole MD, MBA Corresponding Author

Christopher M. Brusalis, MD / Brian J. Cole MD, MBA / Landon P. Frazier, BS / Katie J. McMorrow, BS Zachary D. Meeker, BS / Armaan F. Mazra, MS / Ryan A. Quigley, MD / Kyle R. Wagner, BS

Increased emphasis on patient-centered care across medicine has led to the widespread adoption of patient-reported outcome measures (PROMs) for evaluating the efficacy of shoulder arthroplasty. However, a significant limitation of existing PROMs is that it is not inherently clear what level of improvement in outcome score confers clinical value. To improve our interpretation of PROMs, multiple thresholds for clinical improvement, termed clinically significant outcomes (CSO), have been defined. The mean clinically important difference (MCID) defines the smallest incremental improvement in a PROM that patients associate with an improved pain state. Substantial clinical benefit (SCB) refers to the score improvement threshold at which the patient experiences a meaningful improvement in their symptoms. Patient acceptable symptomatic state (PASS) assesses whether patients find their current condition acceptable, as a binary response of “yes” or “no.” The purpose of this study was to determine MCID, SCB, and PASS thresholds for American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores at a minimum of 5-year follow-up in patients who have undergone either total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA).

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Quantitative Ultrasound Imaging: Artificial Intelligence and Machine Learning Algorithms to Solve Complex Neural Anatomy in the Lateral Transpsoas Approach

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Kern Singh, MD Corresponding Author

Timothy J. Hartman, MD / Keith R. MacGregor, BS / James W. Nie, BS Omolabake O. Oyetayo, BS / Kern Singh, MD / Eileen Zheng, BS

To prevent injury to the lumbar plexus, lateral lumbar interbody fusion utilized electromyography (EMG) to identify the location of the plexus before dissection of the psoas. Despite the utilization of EMG, neurologic complication rates have been reported to be as high as 36%. Furthermore, EMG suffers from a high rate of false positives from interference from cautery, electrocardiogram, and drills. Additionally, EMG suffers from high rates of false negatives from the usage of muscle relaxants and pre-existing nerve damage. As EMG evaluates muscle and not the nerve root, nerve injury from surgical manipulation may also not be detected. From the limitations of EMG, our team has developed a device to efficiently and accurately identify the lumbar plexus. This device is an ultrasound that utilizes artificial intelligence (AI) and machine learning (ML) to distinguish muscle, nerve, and bone. This article will expand upon the traditional methods of intraoperative neuromonitoring utilized in LLIF, current intraoperative imaging techniques, and the capabilities of this novel ultrasound device, SonoVision™.

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The Department of Orthopedic Surgery at RUSH University Medical Center is home to the Midwest’s largest team of bone and joint scientists — and an unparalleled training environment for resident physicians and fellows. With surgeons and clinicians partnering with elite laboratory researchers and data scientists, RUSH continues to educate future experts and devise new solutions that push the boundaries of what’s possible in the treatment of musculoskeletal conditions. Bone and joint experts trained at RUSH, coupled with research advanced in RUSH labs, informs orthopedic care around the world. This academic mission is fueled by donors — patients and families committed to helping more people lead active lives, free of pain.

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2022 RUSH Orthopedics Journal

Special thanks to our editorial team for this year’s RUSH Orthopedics Journal.

Editor Adam B. Yanke, MD, PhD

Associate editors Omar A. Behery, MD, MPH Alan T. Blank, MD, MS Daniel D. Bohl, MD Jorge A. Chahla, MD, PhD

Vasili Karas, MD, MS Xavier C. Simcock, MD Gayathri Vijayakumar, PhD Robert W. Wysocki, MD

The William A. Hark, MD-Suzanne G. Swift Professor of Orthopedic Surgery

Joshua J. Jacobs, MD

As academic orthopedic surgeons, one of our greatest challenges is balancing our commitment to teaching and research with the demands of clinical care. During the past few years, maintaining this delicate balancing act has become even more difficult for high-volume surgical specialties like orthopedics. While caseloads have recovered to pre-pandemic levels, even robust orthopedic practices and medical centers are experiencing financial pressures due to a variety of market factors. For those of us in academic settings, the implications may be especially significant, as financial pressures complicate our ability to pursue our academic mission. So, while orthopedic surgeons everywhere face greater pressures to be more productive clinically, many of us teacher-researcher-practitioners cannot help but ask: How do we maintain our academic mission in the face of new financial realities? Three of my esteemed colleagues at RUSH consider this and other challenges facing orthopedic surgeons in our roundtable discussion, “Good Bones: Addressing new business realities facing orthopedic practices. Despite significant headwinds, we can never lose sight of our academic mission: to train future leaders in orthopedic surgery and to discover new preventive strategies and treatments for musculoskeletal disease, while at the same time providing the highest quality clinical care. At RUSH, we have a longstanding commitment to this mission, which has helped us earn a place among the Top 5 orthopedics programs in the country, as ranked by U.S. News & World Report. To stay focused on this meaningful work, we recognize that we need to be more strategic and re-engineer our premier clinical, training, and research programs to match these new realities. As more procedures shift to outpatient settings, we give our trainees at RUSH real-world experience in ambulatory surgery centers so they can flourish in these environments. We also aim to create a clinical organization that can compete for top talent at every level by adhering to our values and maintaining a positive working environment in our clinics. While rethinking our training and clinical atmosphere is critical, we also cannot lose sight of our research endeavors at a time when securing robust funding, particularly federal grants, is as competitive as ever. If leading academic organizations like RUSH are to remain destinations for orthopedic training and clinical care, we must maintain our successful research enterprise through a diversified portfolio of support. At RUSH, it is in our faculty’s DNA to pursue research and education, and we often collaborate with internal and external partners on new discoveries. Whether that means interdisciplinary collaborations with our PhD colleagues or working with industry on translational research and clinical trials of new devices, we understand the value of partnership. Many faculty have generously used their own funds to support research as well, demonstrating their strong personal commitment to improving patient care through scientific discovery. Meanwhile, philanthropic support from individuals, families, corporations and foundations is also essential to unleash new discoveries and foster the next generation of orthopedic researchers. At RUSH, we are fortunate to have 11 endowed professorships in the department, thanks to the foresight and generosity of our supporters. Without philanthropic investment like this, we would not be able to embark on so many projects aimed at improving patients’ lives. Because of these varied sources of support, and strong personal commitments to our academic mission, the faculty in the Department of Orthopedic Surgery continue to excel, leading new advances in orthopedics that will ultimately transform patient care. As always, I am honored to share their accomplishments in the pages that follow. By addressing the new realities shaping our specialty but not wavering from our academic mission, we can continue to make life-changing discoveries in orthopedics. I look forward to sharing even more of these exciting breakthroughs with you in the future.

Chair, Department of Orthopedic Surgery, RUSH University Medical Center

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EDITORIAL TEAM

The William A. Hark, MD-Suzanne G. Swift Professor of Orthopedic Surgery Chair, Department of Orthopedic Surgery, RUSH University Medical Center

Joshua J. Jacobs, MD

Because of these varied sources of support, and strong personal commitments to our academic mission, the faculty in the Department of Orthopedic Surgery continue to excel, leading new advances in orthopedics that will ultimately transform patient care. As always, I am honored to share their accomplishments in the pages that follow. By addressing the new realities shaping our specialty but not wavering from our academic mission, we can continue to make life-changing discoveries in orthopedics. I look forward to sharing even more of these exciting breakthroughs with you in the future.

partnership. Many faculty have generously used their own funds to support research as well, demonstrating their strong personal commitment to improving patient care through scientific discovery. Meanwhile, philanthropic support from individuals, families, corporations and foundations is also essential to unleash new discoveries and foster the next generation of orthopedic researchers. At RUSH, we are fortunate to have 11 endowed professorships in the department, thanks to the foresight and generosity of our supporters. Without philanthropic investment like this, we would not be able to embark on so many projects aimed at improving patients’ lives.

While rethinking our training and clinical atmosphere is critical, we also cannot lose sight of our research endeavors at a time when securing robust funding, particularly federal grants, is as competitive as ever. If leading academic organizations like RUSH are to remain destinations for orthopedic training and clinical care, we must maintain our successful research enterprise through a diversified portfolio of support. At RUSH, it is in our faculty’s DNA to pursue research and education, and we often collaborate with internal and external partners on new discoveries. Whether that means interdisciplinary collaborations with our PhD colleagues or working with industry on translational research and clinical trials of new devices, we understand the value of

At RUSH, we have a longstanding commitment to this mission, which has helped us earn a place among the Top 5 orthopedics programs in the country, as ranked by U.S. News & World Report. To stay focused on this meaningful work, we recognize that we need to be more strategic and re-engineer our premier clinical, training, and research programs to match these new realities. As more procedures shift to outpatient settings, we give our trainees at RUSH real-world experience in ambulatory surgery centers so they can flourish in these environments. We also aim to create a clinical organization that can compete for top talent at every level by adhering to our values and maintaining a positive working environment in our clinics.

clinically, many of us teacher-researcher-practitioners cannot help but ask: How do we maintain our academic mission in the face of new financial realities? Three of my esteemed colleagues at RUSH consider this and other challenges facing orthopedic surgeons in our roundtable discussion, “Good Bones: Addressing new business realities facing orthopedic practices. Despite significant headwinds, we can never lose sight of our academic mission: to train future leaders in orthopedic surgery and to discover new preventive strategies and treatments for musculoskeletal disease, while at the same time providing the highest quality clinical care.

s academic orthopedic surgeons, one of our greatest challenges is balancing our commitment to teaching and research with the demands of clinical care. During the past few years, maintaining this delicate balancing act has become even more difficult for high-volume surgical specialties like orthopedics. While caseloads have recovered to pre-pandemic levels, even robust orthopedic practices and medical centers are experiencing financial pressures due to a variety of market factors. For those of us in academic settings, the implications may be especially significant, as financial pressures complicate our ability to pursue our academic mission. So, while orthopedic surgeons everywhere face greater pressures to be more productive