JAAOS

JAAOS, Volume 23, No. 12


Acute Management of Traumatic Knee Dislocations for the Generalist

Acute knee dislocations are an uncommon injury that can result in profound consequences if not recognized and managed appropriately on presentation. Patients presenting with knee pain in the setting of high- or low-energy trauma may have sustained a knee dislocation that spontaneously reduced. Prompt reduction of the dislocated knee and serial neurovascular examinations are paramount. Damage to the popliteal artery is a common associated injury that can be diagnosed on physical examination using ankle brachial indices (ABIs), CT angiography, or standard angiography. After reduction, patients with a normal pulse examination and an ABI ≥0.9 may be observed, with serial examination performed to document vascular status and monitor for compartment syndrome. Patients with asymmetric pulses or an ABI <0.9 in the presence of pulses may be treated urgently depending on the results of additional vascular imaging, and patients with absent pulses and clear signs of vascular compromise should be treated emergently. Some knee dislocations are not reducible and should be taken emergently to the operating room for an open reduction. Persistent joint subluxation or severe soft-tissue injuries after reduction require temporary external fixation before definitive repair or reconstruction of ligaments is performed.

      • Subspecialty:
      • Trauma

    Avoiding and Managing Intraoperative Complications During Cervical Spine Surgery

    The incidence of intraoperative complications in cervical spine surgery is low. However, when they do occur, such complications have the potential for causing considerable morbidity and mortality. Spine surgeons should be familiar with methods of minimizing such complications. Furthermore, if they do occur, surgeons must be prepared to immediately treat each potential complication to reduce any associated morbidity.

        • Subspecialty:
        • Spine

      Body Morphology and Its Associations With Thoracolumbar Trauma Sustained in Motor Vehicle Collisions

      Objective: This study investigates the relationship between body mass index (BMI) and the patterns of thoracolumbar spinal fractures sustained by patients in motor vehicle collisions (MVCs).

      Design: The Crash Injury Research and Engineering Network (CIREN) database was used to analyze prospective data on patients involved in MVCs of moderate severity.

      Methods: Thoracolumbar fractures in 631 subjects were analyzed for patient-, vehicle-, and crash-related factors. Spine injuries were classified according to a modified Denis classification system. Subjects were stratified into BMI subgroups that were then analyzed by injury level, fracture pattern, associated systemic injury, and mortality.

      Results: Obesity (BMI ≥30.0) was found to be associated with a more cephalad level of injury. Mean BMI was higher in 67 patients with fatal outcomes compared with 557 survivors. Patients who sustained a thoracolumbar fracture and another system injury were more likely to be overweight and obese. Among the various fracture patterns analyzed, BMI was highest in patients with extension injuries.

      Conclusion: This study characterizes the relationship between body morphology and the thoracolumbar injury patterns associated with MVC to improve understanding of the overall morbidity and mortality of these injuries. These results corroborate research demonstrating the unique relationships between patients who are obese and specific patterns of injury and higher injury severity caused by MVCs and establish a rationale for specifically including thoracolumbar spine parameters in crash safety standards.

          • Subspecialty:
          • Spine

        Establishing Realistic Patient Expectations Following Total Knee Arthroplasty

        Nearly 20% of patients are dissatisfied following well-performed total knee arthroplasty with good functional outcomes. Surgeons must understand the drivers of dissatisfaction to minimize the number of unhappy patients following surgery. Several studies have shown that unfulfilled expectations are a principal source of patient dissatisfaction. Patients contemplating total knee arthroplasty expect pain relief, improved walking ability, return to sports, and improvement in psychological well-being and social interactions. However, patients are typically overly optimistic with regard to expected outcomes following surgery. Patient expectations and satisfaction can be influenced by age, socioeconomic factors, sex, and race. The interplay of these factors can be complex and specific to each person. Published data on clinical and functional outcomes show that persistence of symptoms, such as pain, stiffness, and failure to return to preoperative levels of function, are common and normal. Therefore, the surgeon needs to help the patient to establish realistic expectations.

            • Subspecialty:
            • Adult Reconstruction

          Functional and Clinical Outcomes of Upper Extremity Amputation

          Upper extremity amputation is an uncommon but often necessary procedure. It can be required as a result of trauma, infection, or malignancy. Amputation is a life-changing procedure. Careful planning for it must not only include the level of amputation and assurance of durable soft-tissue coverage of the amputation site, but it must also consider patients’ goals and occupations, as well as social factors affecting amputees. The choice of prosthesis is an individual matter, but new technology permits lighter and more multifunctional prostheses. Targeted muscle reinnervation can be used to achieve improved myoelectric signaling and possibly decrease limb pain following amputation. Rehabilitation is crucial to achieving favorable results.

              • Subspecialty:
              • Shoulder and Elbow

            Metal-on-metal Total Hip Arthroplasty: Patient Evaluation and Treatment

            Metal-on-metal (MoM) hip articulations were thought to represent a biologic and biomechanically favorable alternative to conventional metal-on-polyethylene total hip arthroplasty implants. However, concerns emerged when registry data reported significantly higher failure rates associated with MoM implants compared with other contemporary hip implants. These high implant failure rates have been attributed to the release of metal particles into the periprosthetic space, creating macroscopic necrosis; corrosive osteolysis; large, sterile hip effusions; and periprosthetic solid and cystic masses (ie, pseudotumors)-a spectrum of findings termed adverse reaction to metal debris. A thorough clinical history and physical examination, along with laboratory data and imaging surveillance of these patients, is critical for appropriate diagnosis and treatment. The decision to perform revision hip arthroplasty of a metal-on-metal implant is multifactorial and should be based on documented, objective clinical indications. A systematic and objective approach to this evaluation and treatment is essential to optimize the care of patients who undergo total hip arthroplasty with MoM implants.

                • Subspecialty:
                • Adult Reconstruction

              Natural History of Adolescent Idiopathic Scoliosis in Skeletally Mature Patients: A Critical Review

              The surgical treatment of adolescent idiopathic scoliosis is dependent on several factors, including curve type and magnitude, degree of curve progression, skeletal maturity, and other considerations, such as pain and cosmesis. The most common indication for surgery is curve progression. Most authors agree that surgical treatment should be considered in skeletally mature patients with curves >50° because of the risk of progression into adulthood. Furthermore, most authors would agree that curves measuring <40° to 45° in skeletally mature patients should be observed. When a skeletally mature patient with a curve measuring between 45° to 55° is presenting to an orthopaedic surgeon, it is not uncommon that the patient has no pain, no progression, and no imbalance. The generally accepted belief has been that curves that reach 50° are likely to progress into adulthood, progressing at a rate of 1° per year, based largely on the Iowa studies. However, the level of evidence for this is relatively weak, and the existing literature is equivocal in supporting the practice of performing surgery on these patients.

                  • Subspecialty:
                  • Spine

                Open Reduction Techniques for Supracondylar Humerus Fractures in Children

                Supracondylar humerus fractures are the most common elbow fractures in children. Displaced supracondylar humerus fractures that are associated with neurologic and/or vascular injuries are treated with timely reduction through closed techniques. When closed techniques fail, reduction by open methods is indicated. Controversy exists as to which surgical approach yields the best outcomes in terms of cosmetic and functional results, while minimizing postoperative complications. Open reduction, when indicated, has been shown to yield good outcomes when closed reduction methods fail.

                    • Subspecialty:
                    • Pediatric Orthopaedics

                  Radiographic Stage Does Not Correlate With Symptom Severity in Thumb Basilar Joint Osteoarthritis

                  Background: We hypothesize that thumb basilar joint osteoarthritis (TBJA) radiographic stage does not correlate with patient-reported measures of symptom severity.

                  Methods: Patients with unilateral TBJA who completed the 11-item QuickDASH (Disabilities of the Arm, Shoulder, and Hand), Short-Form 12 Health Survey (SF-12) Mental Component and SF-12 Physical Component surveys were prospectively enrolled in the study. The Eaton-Littler radiographic stage was assigned for each patient. The correlation between the radiographic score and disease stage was calculated.

                  Results: Sixty-two patients (15 men, 47 women; average age, 62.3 years) formed the basis of this study. The average QuickDASH score (and standard deviation) for patients with stage 1 TBJA was 31.5 (11.4); for those with stage 2, it was 37.9 (17.4); with stage 3, it was 30.1 (13.0), and with stage 4, it was 39.4 (12.5). Eaton-Littler stage did not correlate significantly with QuickDASH scores (rho = -0.014, P = 0.91). Neither SF-12 Mental Component scores (MCS-12: rho = 0.019, P = 0.89) nor the SF-12 Physical Component scores (PCS-12: rho = 0.145, P = 0.26) correlated with TBJA stage.

                  Conclusion: Radiographic severity in TBJA does not correlate with validated patient-reported symptom scores. Metrics that link radiographic and subjective components of TBJA may improve surgical decision making and monitoring of treatment response.

                  Level of Evidence: Prognostic, level II

                      • Subspecialty:
                      • Hand and Wrist

                    Readability of Orthopaedic Oncology-related Patient Education Materials Available on the Internet

                    Introduction: A person's health literacy is one of the most important indicators of a patient’s health status. According to national recommendations, patient education materials should be written at no higher than the sixth- to eighth-grade reading level. The purpose of our study was to assess the readability of online patient education materials related to orthopaedic oncology on the websites of the American Academy of Orthopaedic Surgeons (AAOS), American Cancer Society (ACS), Bone and Cancer Foundation (BCF), and National Cancer Institute (NCI).

                    Methods: We searched the online patient education libraries of the AAOS, ACS, BCF, and NCI for all articles related to orthopaedic oncology. The Flesch-Kincaid (FK) readability score was calculated for each article and compared between sources.

                    Results: A total of 227 articles were identified with an overall mean FK grade level of 9.8. Stratified by source, the mean FK grade levels were 10.1, 9.6, 11.1, and 9.5 for the AAOS, ACS, BCF, and NCI, respectively (P < 0.003). Only 31 articles (14%) and 1 article (0.4%) were at or below the recommended eighth- and sixth-grade levels, respectively.

                    Discussion: Online patient education materials related to orthopaedic oncology appear to be written at a level above the comprehension ability of the average patient.

                        • Subspecialty:
                        • Musculoskeletal Oncology

                      Tendinopathies of the Hand and Wrist

                      Tendinopathies involving the hand and wrist are common. Many are diagnosed easily, and in many cases, the management is straightforward, provided the pathology and principles are understood. Common conditions involving the tendons of the hand and wrist include trigger finger, tenosynovitis of the first through sixth dorsal extensor compartments, and flexor carpi radialis tendonitis. Management strategies include nonsurgical treatments, such as splinting, injection, or therapy, and surgical techniques such as tendon release.

                          • Subspecialty:
                          • Hand and Wrist

                        The Relationship Between Glenohumeral Internal Rotational Deficits, Total Range of Motion, and Shoulder Strength in Professional Baseball Pitchers

                        Introduction: Although the lack of internal rotation (IR) and total range of motion (TRM) has been identified as a significant contributing factor of shoulder injuries, our goal was to determine whether a relationship exists between glenohumeral internal rotational deficits (GIRD), TRM, and shoulder strength in professional baseball pitchers. Our hypothesis was that GIRD with TRM differences within 5° will not lead to decreased shoulder strength; however, a shoulder with >5° of TRM difference with GIRD will lead to decreased shoulder strength.

                        Methods: The study was conducted over a 4-year period and included 193 major and minor league pitchers. All measurements were taken prior to the pitcher’s engaging in any baseball-related activities on the day of measurements. The entire measurement arc of passive range of motion (PROM), including external rotation (ER) and IR, was defined as the TRM. GIRD was defined as a loss of 25° or more of IR of the throwing shoulder compared with the nonthrowing shoulder. Shoulder strength measurements were obtained using a validated digital dynamometer with the arm in 90° of abduction and with the arm in 110° of flexion and 30° of abduction measured in pounds.

                        Results: The IR deficit was 5.89° (SD = 9.24°) in non-GIRD pitchers and 25.52° (SD = 4.35°) in GIRD pitchers (P > 0.001). The ER change was 124.08° (SD = 11.21°) in non-GIRD pitchers and 127.79° (SD = 9.15°) in GIRD pitchers. The total arc of motion was 179.54° (SD = 14.53°) in non-GIRD pitchers and 171.93° (SD = 12.34°) in GIRD pitchers (P > 0.001). The strength in the shoulder, measured with the arm in 90° of abduction, was 29.61 lb (SD = 4.76 lb) in non-GIRD pitchers versus 28.65 lb (SD = 4.81 lb) in GIRD pitchers. The strength with the arm in 110° of flexion and 30° of abduction was 29.43 lb (SD = 5.01 lb) in non-GIRD pitchers versus 28.13 lb (SD = 4.76 lb) in pitchers with GIRD (P = 0.043). Deficiencies in total arc of motion (P < 0.001) and shoulder strength (P < 0.043) were significantly associated with GIRD.

                        Discussion: In our evaluation of 193 pitchers examined during their preseason physical examinations, we identified a statistically significant association between decreased total arc of motion, decreased shoulder strength, and GIRD.

                            • Subspecialty:
                            • Sports Medicine

                          Tranexamic Acid in Hip and Knee Arthroplasty

                          Perioperative blood loss is a significant concern for patients undergoing total joint arthroplasty. A growing body of evidence has shown tranexamic acid (TXA) to be effective in decreasing perioperative blood loss and transfusion requirements in both primary and revision hip and knee arthroplasty. TXA is a synthetic drug that limits blood loss through inhibition of fibrinolysis and clot degradation. Both topical and intravenous administration of TXA, in a variety of dosing regimens, has proven effective. Further investigation is required to determine the optimal dose and dosing regimens; however, evidence exists to recommend an initial intravenous dose be given before beginning the procedure, with at least one additional intravenous dose administered postoperatively. Additionally, topical TXA doses >2 g appear to be more efficacious than lower doses. Finally, relatively few adverse reactions have been reported in arthroplasty patients, and no study to date has demonstrated an increased risk of symptomatic venous thromboembolic events in this patient population.

                              • Subspecialty:
                              • Adult Reconstruction

                            Treating the Aging Spine

                            Demographic trendsmake it incumbentonorthopaedic spinesurgeons to recognize the special challenges involved in caring for older patients with spine pathology. Unique pathologies, such as osteoporosis and degenerative deformities, must be recognized and dealt with. Recent treatment options and recommendations for themedical optimization of bone health include vitamin D and calcium supplementation, diphosphonates, and teriparatide. Optimizing spinal fixation in elderly patients with osteoporosis is critical; cement augmentation of pedicle screws is promising. In the management of geriatric odontoid fractures, nonsurgical support witha collarmay beconsidered for the low-demand patient, whereas surgical fixation is favored for high-demand patients. Management of degenerative deformity must address sagittal plane balance, including consideration of pelvic incidence. Various osteotomies may prove helpful in this setting.

                                • Subspecialty:
                                • Spine

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