Matthew Gulbrandsen’s research while affiliated with Loma Linda University and other places

Background Cerclage techniques have been used in the humerus in the setting of fractures and shoulder arthroplasty. Cerclage usage in the humerus has the potential to injure neurovascular structures. There is current literature describing deeper anatomic structures surrounding the humerus but not more superficial landmarks in reference to neurovascular structures. The purpose of this study was to determine safe zones for cerclage passage around the humerus. Methods Eight fresh-frozen cadaveric specimens with no history of deformity, prior surgery, or trauma to the shoulder or arm were used in this study. A standard extended deltopectoral approach was performed in all 8 specimens. Dissection was performed to identify the various musculotendinous and neurovascular structures surrounding the humerus. Cerclage sutures were placed around the humerus. Measurements were made from the radial and axillary nerve to anatomic structures and the cerclage sutures. Results The radial nerve entered the spiral groove on average 45.8 mm distal (range: 30.4 to 63.3 mm) to the inferior aspect of the pectoralis major tendon. Cerclage suture passed just distal to the inferior aspect of the pectoralis major tendon did not violate the radial nerve. The axillary nerve was located on the humerus an average of 5.3 mm (range: 2.4-10 mm) proximal to the superior aspect of the latissimus dorsi tendon insertion. A safe zone for cerclage passage was not identified distal to the radial nerve entering the spiral groove. Conclusion The radial nerve entered the spiral groove on the humerus distal to the pectoralis insertion in all specimens. The axillary nerve started to contact the humerus proximal to the latissimus dorsi in all specimens. In this study, we found that cerclage passage medial to lateral from the latissimus dorsi proximally to the area just distal to the inferior pectoralis major insertion distally is a safe zone for cerclage passage.

OBJECTIVES Does marijuana smoking increase the risk of surgical site infection (SSI) after open reduction and internal fixation of fractures? METHODS Design Retrospective Setting Single academic level 1 trauma center in Southern California Patient Selection Criteria Adult patients who underwent open treatment for closed fractures between January 2009 and December 2021, had hardware placed, and had at least 6 months of postoperative follow up. Outcome Measures and Comparisons Risk factors associated with the development of SSI were compared between current inhalational marijuana users and non-marijuana users. RESULTS Complete data was available on 4,802 patients after exclusion of 82 who did not have a complete variable set. At the time of surgery 24% (1,133 patients) were current users of marijuana. At final follow up (minimum 6 months), there was a 1.6% infection rate (75 patients). The average age of the infection free group was 46.1 ± 23.1 and the average age of the SSI group was 47.0 ± 20.3 (p=0.73). 2,703 (57%) in the infection free group were male compared to 48 (64%) in the SSI group (p=0.49). On multivariate analysis, longer operative times (OR 1.002 [95% CI: 1.001-1.004]), diabetic status (OR 2.084 [95% CI: 1.225-3.547]), and current tobacco use (OR 2.493 [95% CI: 1.514-4.106]) (p<0.01 for all) were associated with an increased risk of SSI; however, current marijuana use was not (OR 0.678 [95% CI: 0.228-2.013], p=0.48). CONCLUSIONS Tobacco use, diabetes, and longer operative times were associated with the development of SSI after open reduction and internal fixation of fractures; however, marijuana smoking was not shown to be associated with the development of SSI. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Artificial intelligence (AI) constructs and machine learning (ML) algorithms have demonstrated utility in predicting various clinical, surgical, and financial outcomes. In this study, we applied AI to shoulder hemiarthroplasty (HA) to predict various post-operative complications. Methods: The sample was queried from the American college of surgeons-national surgical quality improvement program (ACS-NSQIP) database for all shoulder HA cases from 2008-2018. Six ML algorithms-random forest classifier, gradient boosting classifier, decision tree classifier, SVM classifier-tuned model, Gaussian Naïve Bayes classifier, multi-layer perception-analyzed the sample dataset. Postoperative complications included extended length of stay, non-home discharge destination, transfusion, and any adverse event. Each ML model was compared to logistic regression (LR), and model strength was evaluated. Results: We identified a total of 1585 shoulder HA cases. Mean age, BMI, operative time, and length of stay were 66±12 years, 31±8 kg/m2, 114±61 minutes, and 2.93±6.61 days. Preop hematocrit, longer operative time, and older age were most predictive of extended length of stay. Preop hematocrit, operative time, and ASA class had the highest importance in any adverse events (AAE) prediction. ML models outperformed traditional comorbidity indices, LR, for predicting extended length of stay (79% vs. 66%), non-home discharge destination (79% vs. 65%), any adverse event (78% vs. 66%), and transfusion requirement (82% vs. 63%). Conclusions: ML algorithms predicted post-surgical outcomes of interest following shoulder HA at a higher rate to conventional LR and can assist orthopedic surgeons in decision making.

Purpose To assess the utility of using dynamic ultrasound for postoperative evaluation after superior capsular reconstruction (SCR) by evaluating graft integrity and its correlation with clinical outcomes at a minimum 2-year follow-up. Methods A retrospective chart review was conducted to identify patients who underwent SCR between July 2015 and July 2020 with a minimum 2-year clinical and ultrasound follow-up. Clinical outcome measures included Simple Shoulder (SS) and American Shoulder and Elbow Surgeon (ASES) scores. Integrity of the SCR graft was evaluated by dynamic ultrasound. Results We evaluated 22 shoulders in 21 patients with a mean follow-up of 44.8 months (range, 24-71 months). The graft was found to be intact by ultrasound evaluation in 82% (18/22). Patients with intact grafts had higher mean SS (11.6 vs 7.8, P = .00079) and ASES (91.2 vs 64.1, P = .0296) scores at latest follow-up compared to those with failed grafts. Those with intact grafts also had significant improvement in SS (3.7 vs 11.6, P < .00001) and ASES (23.2 vs 91.2, P < .00001) scores at latest follow-up compared to their preoperative scores. In contrast, patients with graft failure had no significant improvement in SS (6.3 vs 9.0, P = .123) and ASES (40.4 vs 58.3, P = .05469) scores at latest follow-up compared to their preoperative scores. There was no difference between clinical outcomes at 6 to 12 months vs latest follow-up for both SS (P = .11, P = .5) and ASES (P = .27, P = .21) scores. Conclusions SCR grafts were found by ultrasound to be intact in 82% of cases. Patients with intact grafts on ultrasound had significant improvement in functional outcome scores while those with graft failure did not. Functional outcome scores suggest that maximal recovery from this procedure occurs by 6 to 12 months. Level of Evidence Level IV, therapeutic case series.

Introduction Little is known about the perioperative management of Pediculus capitis (lice) infestations, including risk of contamination to the sterile field, whether to delay surgery, and optimal time to treat and/or operate. Case Report Two identical twin patients presented for elective in situ percutaneous pinning of chronic slipped capital femoral epiphyses. Active pediculosis capitis was noted intraoperatively by the anesthesia team during the first patient’s surgery. Meticulous examination of the sterile field at that time demonstrated no organisms or other sources of contamination. The second patient’s surgery was delayed to discuss her case with the infectious disease team. Scant literature exists to guide recommendations. Ultimately, a single permethrin treatment immediately before surgery was recommended and followed by our team. After careful prepping and draping, a louse was observed on the sterile field near the planned pin insertion site. The case was immediately canceled and delayed indefinitely. After two additional treatments over the next 4 days, only eggs (but no active insects) were observed in the patient’s hair. We elected to proceed to surgery at that time, which concluded without issue. Conclusion The surgical implications of an active lice infestation are numerous. Administration of antiparasitic medication in the immediate pre-operative period causes increased movement in pediculosis capitis, which may increase risk of sterile field contamination. Elective procedures should be postponed to complete multiple rounds of permethrin. In cases of urgent/emergent surgery, or in which treatment delay is unfeasible, foregoing delousing treatment in the immediate pre-operative period may be recommended.

Objectives Spin is a reporting bias that misrepresents research. Ultimately it can impact surgeon decision making and patient care. Anterior Cruciate Ligament (ACL) reconstruction is common; however debate continues over the optimal graft choice. The quadriceps tendon has become an increasingly popular graft. The purpose of this study was to identify the prevalence of spin in meta-analysis and systematic review abstracts regarding the treatment of ACL injuries with quadriceps tendon graft. Methods Electronic libraries (MEDLINE, Embase, Web of Science, Google Scholar) were searched for meta-analyses and systematic reviews regarding the treatment of ACL tears with quadriceps tendon graft. The key words used for searches included (ACL or Anterior Cruciate Ligament) and (Quad or Quadricep or Quadriceps). All meta-analyses and systematic reviews that contained analysis for quadriceps tendon graft for ACL reconstruction were included. The nine most severe types of spin commonly found in abstracts were used as an evaluation tool to assess the articles. Further evaluation included year of publication, number of citations, journal impact factor, and AMSTAR-2 score. Results The electronic database search resulted in 986 articles, of which 13 met our inclusion criteria. After review of these papers, it was found that 53.8% (7/13) of the included articles contained one of the nine most severe forms of spin. Of the types of spin evaluated, type 3 spin (selective reporting of or overemphasis on efficacy outcomes or analysis favoring the beneficial effect of the experimental intervention) was found to be the most prevalent (4/13, 30.8%). The other common types of spin found included type 5: conclusion claims the beneficial effect of the experimental treatment despite high risk of bias in primary studies (2/13, 15.4%); and type 9: conclusion claims the beneficial effect of the experimental treatment despite reporting bias (2/13, 15.4%). A detailed accounting of the prevalence of each type of spin can be found in Table 1. There was no relationship between the presence or total types of spin when comparing the publication year, journal impact factor, number of citations per year for the article, or the A MeaSurement Tool to Assess systematic Reviews-2 (AMSTAR-2) rating. Conclusions This study demonstrated the presence of spin in a significant portion (53.8%) of meta- analysis and systematic review abstracts pertaining to quadriceps tendon graft for ACL reconstruction. Orthopedic surgeons should learn to recognize spin as they review articles when deciding the treatment course for ACL injuries. Additionally, strict criteria should be considered to reduce the prevalence of spin in orthopedic literature. [Table: see text]

Background The American Medical Association and National Institutes of Health recommend online health information be written at a 6th grade or lower reading level for clear understanding. While syntax reading grade level has previously been utilized, those analyses do not determine whether readers are processing key information (understandability) or identifying available actions to take (actionability). The Patient Education Materials Assessment Tool (PEMAT-P) is a method to measure the understandability and actionability of online patient education materials. The purpose of this study was to evaluate online resources regarding rotator cuff repair utilizing measures of readability, understandability, and actionability. Methods The search term “rotator cuff surgery” was used in two independent online searches to obtain the top 50 search results. The readability of included resources was quantified using valid objective algorithms: Flesch-Kincaid Grade-Level, Simple Measure of Gobbledygook grade, Coleman-Liau Index, and Gunning Fog Index. The PEMAT-P form was used to assess actionability and understandability. Results A total of 49 unique websites were identified to meet our inclusion criteria and were included in our analysis. The mean Flesch-Kincaid Grade Level graded materials at a 10.6 (approximately a 10th grade reading level), with only two websites offering materials at a 6th grade reading level or below. The remaining readability studies graded the mean reading level at high school or greater, with the Gunning Fog Index scoring at a collegiate reading level. Mean understandability and actionability scores were 64.6% and 29.5%, respectively, falling below the 70% PEMAT score threshold for both scales. Fourteen (28.6%) websites were above the threshold for understandability, while no website (0%) scored above the 70% threshold for actionability. When comparing source categories, commercial health publishers provided websites that scored higher in understandability (P < .05), while private practice materials scored higher in actionability (P < .05). Resources published by academic institutions or organizations scored lower in both understandability and actionability than private practice and commercial health publishers (P < .05). No readability, understandability, or actionability score was significantly associated with search result rank. Conclusion Overall, online patient education materials related to rotator cuff surgery scored poorly with respect to readability, understandability, and actionability. Only two (4.1%) of the patient education websites scored at the American Medical Association and National Institutes of Health recommended reading level. Fourteen (28.6%) scored above the 70% PEMAT score for understandability; however, no website met the threshold for actionability.

Introduction: Acute compartment syndrome (ACS) occurs due to decreased perfusion of an osseofascial space due to increased compartmental pressure. Due to its potentially devastating sequelae, emphasis is placed on its prompt diagnosis. While fractures continue to be the most common cause of ACS, mechanisms such as crush injuries and even surgical positioning are described etiologies of compartment syndrome. ACS of the well-leg from hemilithotomy positioning has been previously depicted in medical literature; however, there have been no illustrations of this complication after elective arthroscopic-assisted posterior cruciate ligament (PCL) reconstruction. Case report: This report discusses a patient undergoing PCL reconstruction who developed an ACS in the non-operative extremity that was positioned in hemilithotomy in a leg positioner. Conclusion: ACS is an uncommon but serious complication that can occur from hemilithotomy positioning. Surgeons should be mindful of risk factors that can place a patient at higher risk, including length of the case, body habitus, height of elevation of the leg, and method of leg support. The prompt recognition and surgical management of ACS can prevent the devastating long-term complications.

Background: Spin is a reporting bias that misrepresents research. Ultimately it can affect surgeon decision making and patient care. Anterior cruciate ligament (ACL) reconstruction is common, but debate continues over optimal treatment modalities. Purpose: To identify the prevalence of spin in meta-analysis and systematic review abstracts regarding the treatment of ACL injuries with quadriceps tendon graft. Study design: Cross-sectional study. Methods: Electronic libraries (MEDLINE, Embase, Web of Science, Google Scholar) were searched for meta-analyses and systematic reviews regarding the treatment of ACL tears with quadriceps tendon graft. The 9 most severe types of spin commonly found in abstracts were used as an evaluation tool to assess the articles. Two reviewers each performed a blinded assessment of each article for spin. A third reviewer helped after review was done to address any discrepancies between the original reviewers. Further evaluation included year of publication, number of citations, journal impact factor, and A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR-2) score. Results: The electronic database search resulted in 986 articles, of which 13 met our inclusion criteria. After review, we found that 53.8% (7/13) of the included articles contained 1 of the 9 most severe forms of spin. Of the 13 articles, 15.4% (n = 2) contained 2 types of spin, and 38.5% (n = 5) contained 1 type of spin. No studies contained ≥3 types of spin. Of the types of spin evaluated, the most prevalent (n = 4; 30.8%) was type 3 ("selective reporting of or overemphasis on efficacy outcomes or analysis favoring the beneficial effect of the experimental intervention"). All studies, regardless of the presence of spin, were found to be low or critically low quality according to the AMSTAR-2 assessment. Conclusion: This study demonstrated the presence of spin in 53.8% of meta-analysis and systematic review abstracts pertaining to quadriceps tendon graft for ACL reconstruction. Orthopaedic surgeons should learn to recognize spin as they review articles when deciding the treatment course for ACL injuries. Additionally, strict criteria should be considered to reduce the prevalence of spin in orthopaedic literature.