JAAOS, Volume 21, No. 3

Acetabular Bone Loss in Revision Total Hip Arthroplasty: Evaluation and Management

As the number of primary total hip arthroplasty (THA) procedures performed continues to rise, the burden of revision THA procedures is also expected to increase. Proper evaluation and management of acetabular bone loss at the time of revision surgery will be an increasing challenge facing orthopaedic surgeons. Proper preoperative patient assessment and detailed preoperative planning are essential in obtaining a good clinical result. Appropriate radiographs are critical in assessing acetabular bone loss, and specific classification schemes can identify bone loss patterns and guide available treatment options. Treatment options include impaction grafting and cementation of the acetabulum, noncemented hemispheric acetabular reconstruction, structural allograft reconstruction, noncemented reconstruction with modular porous metal augments, ring and cage reconstruction, oblong cup reconstruction, cup-cage reconstruction, and triflange reconstruction.

      • Subspecialty:
      • Adult Reconstruction

    Management of Fractures of the Proximal Ulna

    Proximal ulna fractures can be difficult to manage because of the elbow's complex anatomy. Advances in understanding elbow anatomy and biomechanics, however, have led to new insights. Careful preoperative evaluation is critical because failure to restore normal anatomy of the proximal ulna could have a detrimental effect on postoperative elbow function. Management options include anatomic plates, intramedullary devices, and strong tension band materials. Determining the most appropriate option for an individual fracture is based on analysis of radiographs and CT scans, including three-dimensional reconstruction. Coronoid fractures, olecranon fractures, and associated elbow instability influence the indications for any given fixation device. Appreciating the subtleties of proximal ulna anatomy and biomechanics can lead to improved clinical outcomes. Recent concepts affecting fracture management include proximal ulna dorsal angulation, the importance of the anteromedial facet of the coronoid, and intermediate fragments of the olecranon.

        • Subspecialty:
        • Shoulder and Elbow

      Obesity and Osteoarthritis: More Than Just Wear and Tear

      A link has been established between obesity and osteoarthritis (OA), but the precise relationship has yet to be defined. OA has a multifactorial etiology, and obesity is consistently identified as an independent and modifiable risk factor. The biomechanical relationship is intuitive: increased loads on articular cartilage cause subsequent wear and cartilage breakdown. Less intuitive, and possibly more important, are the systemic effects of obesity on OA. Promising investigations into relationships between lipid metabolism and OA have been rarely reported in the orthopaedic literature. These reports argue that, in obese patients, weight loss may not only help prevent OA but also may be an effective treatment strategy. Orthopaedic surgeons should be aware of the biomechanical and systemic implications of obesity with respect to OA so that patients may be counseled accordingly.

          • Subspecialty:
          • Basic Science

        Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

        The Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures evidence-based clinical practice guideline was codeveloped by the American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association. This guideline replaces the previous AAOS Information Statement, "Antibiotic Prophylaxis in Bacteremia in Patients With Joint Replacement," published in 2009. Based on the best current evidence and a systematic review of published studies, three recommendations have been created to guide clinical practice in the prevention of orthopaedic implant infections in patients undergoing dental procedures. The first recommendation is graded as Limited; this recommendation proposes that the practitioner consider changing the long-standing practice of routinely prescribing prophylactic antibiotic for patients with orthopaedic implants who undergo dental procedures. The second, graded as Inconclusive, addresses the use of oral topical antimicrobials in the prevention of periprosthetic joint infections. The third recommendation, a Consensus statement, addresses the maintenance of good oral hygiene.

            • Subspecialty:
            • Basic Science

          The Pediatric Polytrauma Patient: Current Concepts

          Understanding the pediatric response to polytrauma is essential for the orthopaedic surgeon. The physiologic effects of multisystem injury that manifest in a child have important implications for coordination of treatment, particularly in relation to the timing and incidence of organ failure. The orthopaedic surgeon plays an important role in managing hemodynamic instability, vascular insult, and neurologic damage in the child with multiple injuries. Indications for surgery and postoperative immobilization in the pediatric polytrauma patient differ from those in the patient with an isolated injury. Further research is needed to determine the most appropriate method of management for extremity fractures in the pediatric polytrauma patient, particularly regarding the timing of fixation and management of open fractures.

              • Subspecialty:
              • Trauma

              • Pediatric Orthopaedics

            Total Wrist Arthroplasty

            Over the past 40 years, total wrist arthroplasty (TWA) has emerged as a cost-effective treatment option for wrist arthritis. First-generation implant designs have changed tremendously; current devices are designed to enhance wrist stability, provide greater implant longevity, and minimize surgical and postoperative complications. Although arthrodesis remains the standard for surgical management, TWA outcomes demonstrate that the procedure has excellent clinical promise. Additional prospective studies are needed to compare outcomes of wrist arthrodesis with those of TWA with current implants.

                • Subspecialty:
                • Hand and Wrist