This marks the 8th edition of The Duke Orthopaedic Journal (DOJ). We would like to thank past editorial boards and journal founders, Selene Parekh, Will Eward, and Stephanie Mayer, who have brought the journal from infancy to a critical component of the Duke Orthopaedic tradition. We have been overwhelmed by the high-quality scientific submissions, as well as special interest articles that update our readers on the year’s highlights and accomplishments within Duke Orthopaedics.

It once again gives me great pleasure to present to you the 8th edition of the Duke Orthopaedic Journal (DOJ). Duke Orthopedic Surgery continues to grow and flourish with significant growth into the Triangle area with expansion into Apex, Raleigh, North Raleigh, and Wake. Duke Orthopedics, in conjunction with the Department of Physical Therapy and School of Nursing, has broken ground on a new building on campus. This building will be home for the Doctor of Physical Therapy Division along with administration of Graduate Medical Education offices for the Department of Orthopedic Surgery and the School of Nursing’s PhD program, Center for Nursing Research, Office of Diversity and Inclusion, and Office of Student Services.

Radiographic anatomic findings have been defined to help surgeons and physicians understand both normal and pathologic anatomy. These findings have been defined in terms of know angles and lines drawn on radiographs. Through understanding the normal geometry, bony alignment, and range of morphology the provider can more easily identify aberrancies that can potentially be corrected to address a patient’s symptoms. One such pathology, patella alta, has had many iterations of radiographic measures to help in diagnosis and treatment. It is important for the surgeon to understand the history of the many measures and the utility of each in determining which measure should be used.

Keywords: Patella, Patella alta, Patellofemoral.

How to cite this article: Ewing CK, Grimm NL. A Review of Radiographic Measurements to assess the Patellofemoral Joint. The Duke Orthop J 2018;8(1):1-6.

Source of support: Nil

Conflict of interest: None

Lateral ankle instability is a common sequela of ankle sprains. Surgical treatment may be required if nonoperative treatment fails, and the modified Broström procedure is considered the gold standard. Many techniques have been described, with a suture anchor in the lateral malleolus commonly utilized. More recently,suture implants with surgical tape have been introduced. These are proposed to provide immediate stability, allowing more aggressive rehabilitation. However, they require a 3.4 mm drill hole in the talus, along with the 2.7 mm drill hole in the fibula. We present a case of avascular necrosis (AVN) of the talus after utilization of this suture tape construct, requiring total talus replacement.

Keywords:Avascular necrosis, Lateral ligament reconstruction, Talus, Total talus.

How to cite this article:Wilde SA, Guerrero EM, Parekh SG. Iatrogenic Talar Avascular Necrosis Secondary to Lateral Ligament Reconstruction Suture Anchor Placement requiring Total Talar Replacement. The Duke Orthop J 2018;8(1):7-10.

Source of support: Nil

Conflict of interest: None

Arthroscopy with debridement and/or repair is commonly performed for meniscal tears; the understanding of meniscal anatomy is important for successful treatment of meniscal injuries. This case report focuses on an aberrant insertion site of the medial meniscus (MM) anterior horn, visualized during an arthroscopic procedure to debride an MM tear.

Keywords:Anatomy, Anterior cruciate ligament, Arthroscopy, Insertion, Knee, Medial, Meniscal tear, Meniscus, Posterior cruciate ligament, Tibial.

How to cite this article:Chen F, Guerrero EM, Moorman III CT. Intercruciate Anterior Horn of Medial Meniscus with Posterior Tibial Insertion. The Duke Orthop J 2018;8(1):11-12.

Source of support: Nil

Conflict of interest: None

There are multiple congenital differences in the anatomy of the long head biceps tendon origin, course, and sling. Here, we report a case of biceps tendon congenital accessory superior glenohumeral ligament (SGHL) and biceps tendon fused to anterior superior capsule under the coracohumeral ligament without a history of prior shoulder surgery or trauma, “the Aggeris Fusion.” The diagnosis of this fusion was possible with “the Ramp Test,” originally described by the senior author. “The Ramp Test” was developed to evaluate biceps intra-articular pathology and ultimately diagnose the biceps “Hidden Lesion,” described by Walch et al. The reported lesion was found to have a negative (abnormal) Ramp Test, due to the abnormal, congenital fusion. The fusion was released arthroscopically. Postoperatively, the patient progressed successfully. The patient achieved a full range of motion and reports no pain.

Keywords:Arthroscopy, Biceps tendon, Coracohumeral ligament, Hidden lesion, Joint capsule, Proximal biceps tendon, Ramp test, Shoulder, Superior glenohumeral ligament.

How to cite this article:Motley GS, Moorman CT III, Guengerich B, Schuller T, Turbyfill A. Proximal Biceps Tendon Congenital Accessory Superior Glenohumeral Ligament and Biceps Tendon fused to Anterior Superior Capsule Under the Coracohumeral Ligament: The Aggeris Fusion. The Duke Orthop J 2018;8(1):13-15.

Source of support: Nil

Conflict of interest: None

Psoriatic arthritis (PsA) mutilans is a rare form of PsA that is extremely destructive, mimicking a charcot-like arthropathy. To date, the mutilans form of PsA has been described in the knee, spine, and elbow, but, to the best of our knowledge, this is the first report of this condition in the shoulder. This is a case presentation of a 59-year-old male with PsA demonstrating near complete and rapid disappearance of his right proximal humerus over the span of a few weeks. After a thorough diagnostic work-up, the patient was treated definitively with a hemiarthroplasty with improvement in his pain and range of motion (ROM) and satisfactory functional outcomes. Currently, there have not been any published recommendations for the diagnosis and management of arthritis mutilans of the shoulder, and we review our diagnostic and treatment strategy.

Keywords:Charcot-like arthropathy, Psoriatic arthritis mutilans, Rapidly destructive arthritis, Shoulder hemiarthroplasty.

How to cite this article:Laver L, Paiste MR, Lazarus MD, Garrigues GE. Arthritis Mutilans of the Shoulder: A Rare Cause for Rapidly Destructive Arthritis of the Shoulder. The Duke Orthop J 2018;8(1):16-21.

Source of support: Nil

Conflict of interest: None

An elbow dislocation with associated incarcerated coronoid fracture in a child is a rare injury. No prior cases of this clinical scenario have been described in the English literature. Radiographs, including a true lateral and contralateral elbow views, are vital to identify the lack of joint congruency. This case underscores the importance of thorough postreduction physical examination, including range of motion and stability, and radiograph interpretation. Suspicion for an entrapped fracture should be high in a patient with a lack of joint congruency, residual joint instability, and limited range of motion following attempted reduction.

Keywords:Case report, Coronoid fracture, Elbow dislocation, Incarcerated fracture, Pediatric elbow.

How to cite this article:Grier AJ, Godin JA, Tainter DM, Klement MR, Templeton EL, Lark RK, Alman BA, Reilly RM. Incarcerated Coronoid Fracture at the Time of Pediatric Elbow Dislocation. The Duke Orthop J 2018;8(1):22-27.

Source of support: Nil

Conflict of interest: None

In patients with particularly high-energy injuries causing open ankle fractures, the medial malleolus can be extruded from the ankle and either lost at the scene of the injury or unable to be fixed at the time of operative intervention. Minimal reporting of this devastating injury exists in the literature. Our study aims to report the outcomes in patients with open ankle fractures and loss of the medial malleolus. We retrospectively reviewed eight patients with this injury pattern over a 14-year span (2000–2014). Two of these patients were treated with below-knee amputation for a mangled extremity. Five of the patients were treated with tibiotalocalcaneal (TTC) arthrodesis. Of the five patients treated with ankle and subtalar arthrodesis, two were treated with open reduction and internal fixation (ORIF) prior to their arthrodesis. The remaining three patients were treated with arthrodesis after their initial surgical treatment with irrigation and debridement (I&D) and external fixation. Four of the six patients required soft tissue coverage with a rotational or free flap. All patients undergoing TTC arthrodesis went on to fusion; at final followup (average 2.7 years; 1.1–8.2 years), they reported minimal pain in the operative extremity and were able to ambulate. We found TTC arthrodesis to be a viable option for patients with this devastating injury. These findings could aid orthopedic surgeons not only in preoperative patient education and prognosis but also in operative planning in patients with this rare injury.

Keywords:Bone loss, Medial malleolus, Open ankle fracture, Outcomes.

How to cite this article:Lampley A, Dekker T, Catanzano A, Adams SB Jr. Open Ankle Fractures with Loss of the Medial Malleolus: A Case Series on a Rare Injury. The Duke Orthop J 2018;8(1):28-32.

Source of support: Nil

Conflict of interest: None

Angiotensin-converting enzyme inhibitors (ACEIs) are among the most frequently prescribed medications used to treat hypertension and are commonplace among patients undergoing elective total hip and knee arthroplasty. It is the purpose of this study to evaluate the perioperative effects of ACE-Is in an elective total hip and knee arthroplasty patient group.

Materials and methods:
A total of 46 patients were randomized to one of two study arms: An ACE-I cessation arm, who were instructed to stop their ACE-I 2 days prior to surgery (last dose >48 hours prior to surgery), and an ACE-I continuation arm, who continued their ACE-I prior to surgery.
Results:
Despite being underpowered to detect a significant difference between cessation and continuation arms of the study, the continuation arm had more intraoperative hypotension (61 vs 39%, p = 0.140), more intraoperative vasopressors (83 vs 61%, p = 0.102), more postoperative hypotension (13 vs 9%, p = 1.000), and more acute kidney injury (AKI) (22 vs 14%, p = 0.700). Further, a patient in the continuation arm sustained severe intraoperative hypotension and required escalation of care.
Conclusion:The results of this randomized controlled trial did not reach statistical significance, but showed a clear trend toward worse outcomes in total joint arthroplasty patients who continued ACE-Is through the perioperative period.

Keywords:Angiotensin-converting enzyme inhibitors, Postoperative hypotension, Randomized clinical trial, Total joint arthroplasty.

How to cite this article:Wilde S, Vovos T, McCoy K, Mangiapani D, Friend J, Green C, Wellman S, Bolognesi M. Angiotensin-converting Enzyme Inhibitors taken on Day of Total Joint Replacement are associated with Adverse Outcomes: A Randomized Controlled Trial. The Duke Orthop J 2018;8(1):33-36.

Source of support: Nil

Conflict of interest: None

Total knee arthroplasty (TKA) is commonly performed in the geriatric population in which osteoporosis (OP) is a common medical condition. This study aimed to compare complications in Medicare patients undergoing primary TKA with or without OP.

Materials and methods:The Medicare Standard Analytical Files were analyzed from 2005 to 2010, and patients undergoing primary TKA with and without OP were identified. Perioperative complications and revision rates were compared betweengroups.

Results:Osteoporosis patients undergoing TKA had a higher rate of periprosthetic fracture, but a decreased rate of revision surgery. In the postoperative period, OP patients had an increased risk of surgical wound complications and thromboembolic complications.

Conclusion:Caution should be taken when performing TKA in osteoporotic patients.

Keywords:Osteoporosis, Periprosthetic joint fracture, Total knee arthroplasty.

How to cite this article:Lampley A, Penrose C, Watters T, Green CL, Wellman S, Chen AF. Osteoporosis Patients have Higher Rates of Periprosthetic Fracture but Lower Rates of All-cause Revision Surgery following Total Knee Arthroplasty. The Duke Orthop J 2018;8(1):37-42.

Source of support: Nil

Conflict of interest: None

Hemostasis is an essential component of surgical procedures and tranexamic acid (TXA), an antifibrinolytic, is widely used empirically in orthopedic patients. We hypothesized that TXA would significantly decrease intraoperative blood loss, the need for blood transfusion, and would decrease patient length of stay (LOS).

Materials and methods:We performed a retrospective review of 496 primary total joint arthroplasties (TJAs). We recorded clinical outcomes of those given TXA since the drug was first available at our hospital in November 2012. As a control group, we reviewed all total hip arthroscopies (THAs) or total knee arthroscopies (TKAs) during the 3 months just prior to availability of TXA.

Results:A total of 306 consecutive TKAs and 190 THAs were included. There were no differences in age or preoperative hemoglobin between groups. For TKAs, the difference between the preoperative hemoglobin to the first postoperative day (POD1) was 2.74 gm/dL for the “No TXA” cohort, compared with 2.07 gm/dL for the TXA cohort. Total blood loss was 571.1 vs 387.3 mL (p < 0.01). For THAs, the difference between the hemoglobin values from preoperative levels to POD1 was 3.16 gm/dL compared with 2.36 gm/dL. Total blood loss was greater for the “No TXA” group, 649.4 vs 464.1 mL (p < 0.01). Only the “No TXA” group underwent transfusion, 13.83%. Hospital LOS was longer in the “No TXA” group, 4.24 vs 3.57 days (p < 0.01). More “No TXA” were discharged to a skilled nursing or rehab compared with “home,” 35.1 vs 13.7% (p < 0.01).

Conclusion:Patients with TXA had statistically significant differences in intraoperative, postoperative, and total blood loss. No patient given TXA required a transfusion. The THA patients given TXA had statistically significant shorter LOS and were more likely to be discharged to home. Therefore, TXA has the potential to improve clinical outcomes following TJA and possibly also reduce cost.

Keywords:Arthroplasty, Blood loss, Tranexamic acid, Transfusion.

How to cite this article:Bradley KE, McClellan TR, Attarian D, Hallows R, Wellman SS, Bolognesi MP. Tranexamic Acid results in Less Blood Loss in Total Joint Arthroplasty: A Retrospective Study. The Duke Orthop J 2018;8(1):43-48.

Source of support: Nil

Conflict of interest: None

Exercising athletes lose electrolytes during exercise. Hydration and electrolyte supplementation have been extensively researched regarding cramping and performance, often with conflicting results. The purpose was to study the perceived impact electrolyte replacement strips have on cramping and recovery. These strips are absorbed buccally, bypassing the gastrointestinal route.

Materials and methods:Our hypothesis was: During exercise, subjects using electrolyte replacement strips will feel that performance, cramping, and recovery are improved. The electrolyte strips used, Enlyten SportStrips™ a product of Healthsport Inc., are a bioabsorbable strip containing sodium, chloride, and potassium. A total of 100 subjects participated in this survey study. The institutional review board approved the study and waived consent. Subjects completed a survey addressing their perceptions of the effects of using electrolyte strips during exercise. Questions were related to cramping, performance, and overall perception of how hydration and electrolytes affect these parameters, specifically addressing the effectiveness of these electrolyte strips.

Results:Average age of subjects was 29.5 years, with 81 males and 18 females (one subject did not indicate gender); 69% of the subjects used the product correctly. On the survey, “Agree” represented a score of 4 or 5 on a 5-point Likert scale; 94% of subjects believe that hydration helps performance, 71% believe that electrolytes help performance, and 49% believe that sports drinks help performance; 81% believe that electrolytes prevent cramping, and 56% believe that sports drinks prevent cramping. There were differences in responses between correct and incorrect users of the strips: 74% of those who used the product correctly felt that strips help performance, compared with 51% of incorrect (p > 0.05); 69% of those using the strips correctly indicated that they cramped less when using the strips, compared with 61% of those using them incorrectly (p > 0.05); 63% of those using the strips correctly indicated that they recovered quicker with the strips, compared with 32% of those using them incorrectly (p =0.005).

Conclusion:Athletes identify hydration and electrolytes as important components to preventing cramping and enhancing performance. During exercise, a majority of respondents felt that electrolyte strips helped performance, reduced cramping, and enhanced recovery. Those who used the product correctly tended to find the product more beneficial. Electrolyte supplementation may play a role in enhanced performance and recovery in exercising athletes. Buccal absorption is emerging in a variety of markets, and its use for athletic performance is a logical next step.

Keywords:Electrolytes, Enlyten, Exercise, Recovery.

How to cite this article:Berkoff DJ, Boggess B, Howes C, Boggess S, Moorman III CT. Electrolyte Replacement Strips and their Perceived Effect on Performance and Cramping: A Survey Study. The Duke Orthop J 2018;8(1):49-54.

Source of support: Funding for the study was provided by a grant from Healthsport Inc., the company that manufactures Enlyten SportStrips™.

Conflict of interest: An author, Claude T Moorman III, is on the medical advisory board for Enlyten SportStrips™.

The purpose of this study was to characterize gender differences in lower extremity kinematics during three different soccer kicking tasks.

Materials and methods:Twelve male and 13 female collegiate soccer athletes participated in this study. Seven trials of three soccer kicking tasks were collected: Maximal instep kick, crossing kick, side-foot pass. The three-dimensional lower extremity joint angles at ball contact and at their peak during the swing phase were obtained during each task.

Results:Instep kick: Males had significantly greater peak knee adduction (p = 0.042), and less peak knee internal rotation (p = 0.046) and peak hip extension (p = 0.033). Side-foot pass: At ball contact, males exhibited significantly greater knee flexion (p = 0.025), knee adduction (p = 0.003), knee external rotation (p = 0.003), and hip internal rotation (p = 0.036). Males exhibited significantly less peak knee extension (p < 0.001), peak knee internal rotation (p < 0.001), and peak hip external rotation (p = 0.05). Crossing kick: Males exhibited greater peak knee flexion (p = 0.05) and peak knee external rotation (p = 0.023), and less peak knee adduction (p = 0.027) and peak knee abduction (p = 0.005).

Conclusion:More gender-specific kinematic differences in the execution of the kicking tasks examined here were observed during both the side-foot pass and crossing kick than during the instep kick. Further characterization of gender differences in kick performance will aid in the development and evaluation of performance enhancement training programs and potentially identify gender-specific injury mechanisms related to kicking mechanics.

Keywords:Athletic performance, Crossing kick, Genderspecific differences, Instep kick, Lower extremity kinematics, Side-foot pass, Soccer.

How to cite this article:Grier AJ, Garrett WE, Moorman III CT, Queen RM. Genderspecific Lower Extremity Kinematic Differences in Collegiate Soccer Athletes during Three Kicking Tasks. The Duke Orthop J 2018;8(1):55-60.

Source of support: Nil

Conflict of interest: None