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Mark C. Gebhardt, MD
Third Session
Moderator: Mark C. Gebhardt, MD

Khemarin R. Seng, MD David Lhowe, MD
Knee Pain Following Tibial Nailing: Role of Nail Prominence
Khemarin R. Seng, MD
Advisor: Tim Bhattacharya, MD
Discussor: David Lhowe, MD

Intramedullary nailing of the tibia for treatment of tibia fractures is one of the most common procedures done by Orthopaedic trauma surgeons today. Many surgeons have noted that patients treated with this form of fixation experience anterior knee pain post-operatively that, in some patients, can be quite debilitating. Dr. Seng sought to determine if one factor, nail prominence, was associated with the development of anterior knee pain in this population. Utilizing the Partners Trauma Registry, Dr. Seng performed a retrospective analysis of 70 patients with healed tibia fractures that had been treated with an intramedullary nail. Patients were asked to provide information about knee pain by filling out a visual analogue scale and a Lysholm knee score assessment. Forty-nine percent of these patients had anterior knee pain. Of the numerous factors explored, nail prominence was found to be highly correlated with anterior knee pain. Dr. Seng suggests that surgeons can decrease, but not eliminate, the severity of knee pain by burying the tip of the nail greater than 25mm (as measured on the lateral radiograph)

Dr. Lhowe congratulated Dr. Seng for addressing a topic that is very important to trauma surgeons. He noted the bias that may be present in a study based on a mailed survey with a 57% response rate. He suggested that some of these patients have anterior knee pain from underlying osteoarthritis or a meniscal injury (from original injury) and this data was not available for this study. Despite some of the limitations, Dr. Lhowe applauded Dr. Seng for providing a valuable adjunct to the knowledge base in this area as this study provides useful information about how we as orthopaedic surgeons can act to reduce the incidence of this negative outcome. Dr. Seng’s manuscript with Dr. Bhattacharyya has been accepted by Clinical Orthopaedics and Related Research for future publication.

Neal C. Chen, MD Thomas Thornhill, MD
Transfusion Predictors in Shoulder Arthroplasty
Neal C. Chen, MD
Advisor: Peter Millett, MD, Jon JP Warner, MD, and Thomas Holovacs, MD
Discussor: Thomas Thornhill, MD

One of the many difficult questions that Orthopaedic Surgeons face in pre-operative planning with their patients who are undergoing total joint arthroplasty is whether or not to have patients donate autologous units of blood prior to surgery. Seeing that there were no previous studies that examined predictive factors for blood transfusion after shoulder arthroplasty, Dr. Chen sought to provide an understanding of which patients would be more likely to receive a blood transfusion after surgery and provide guidance to orthopaedic surgeons performing total shoulder arthroplasty as to which, if any patients, should pre-donate blood. Dr. Chen performed a retrospective analysis of 119 patients who had undergone 124 shoulder arthroplasties over a four-year period. He performed a logistic regression analysis to determine which clinic variables were predictive of transfusion. Additionally he documented the use and waste of pre-donated blood units in this population. Dr. Chen found that the strongest predictor for blood transfusion after shoulder arthroplasty was preoperative hemoglobin: patients with a preoperative hemoglobin <110g/l had an estimated risk of blood transfusion that was twenty times greater than those with a preoperative Hemoglobin>130g/L. Those between 110 g/L and 130g/L had a five times greater estimated risk of transfusion. Of note, gender, BMI, preoperative diagnosis, comorbid conditions, use of anticoagulants or aspirin, autologous pre-donation status, type of anesthesia, operative time and decrease in hemoglobin or hematocrit were not predictors for blood transfusion. Seventy-eight percent of the pre-donated blood units were not utilized and were discarded. Those patients with pre-operative hemoglobin levels greater than 130g/L had the highest percent of wasted units (90%).

Dr. Thornhill congratulated Dr. Chen for the publication of his thesis in the June issue of the JBJS. He questioned whether operative technique – such as how a particular surgeon mobilizes the subscapularis – is associated with increased blood loss and ultimately need for transfusion. This was not a variable analyzed by Dr. Chen as he felt the effect of this would be captured by the blood loss variable.

Jennifer A. Graham, MD Richard De Asla, MD
Results of a Proximal Metatarsal Oblique Closing Wedge Osteotomy for the Correction of Adult Hallux Valgus
Jennifer A. Graham, MD
Advisor: Michael Wilson, MD
Discussor: Richard De Asla, MD

The treatment of adult hallus valgus is controversial. Dr. Graham reviewed the pathophysiology, classification and general treatment options of this common orthopaedic problem. She noted that over 130 different surgical procedures have been described for the treatment of this condition. Dr. Graham presented her work in which she performed a retrospective review of the first thirty patients of Dr. Wilson’s that had undergone lateral closing wedge osteomy, release of distal soft tissues and medial eminence resection for the treatment of moderate to severe hallux valgus deformity. With an average of 15.4 months follow-up, this technique resulted in an improvement in the mean hallux valgus angle from 36 pre-operatively to 18 post-operatively and in the first intermetatarsal angles of 16 pre-op for 7 post-operatively with an average 1st metatarsal shortening of 0.98mm. Dr. Graham noted that the advantages of this technique are that it is straightforward, creates minimal shortening compared to other proximal osteotomies and the apex of correction is at the apex of deformity and is therefore a useful technique for severe hallux valgus deformities.

Dr. De Asla reflected on his experience with hallux valgus surgery by noting that bunion surgery is underestimated – it can be far more complicated than it is acknowledged to be. He congratulated Dr. Graham on her thesis and Dr. Wilson on his work, noting that it is important to develop an effective technique that is applicable and reproducible given that most bunion surgery is performed by general orthopaedists and podiatrists. As Dr. Graham noted, one major advantage of this approach is that it is the same procedure every time. Dr. Warren acknowledged the difficulty in osteotomies for hallux valgus given the ease with which rotation can occur or violation of the joint. Dr. Wilson shared that his development of this technique grew out of his frustration with loss of fixation or malunion with previous techniques. He will continue to evaluate the outcomes of his patients treated with this technique.

Links of interest: