JAAOS

JAAOS, Volume 24, No. 2


Ankle Arthritis: You Can’t Always Replace It

End-stage arthritis of the tibiotalar joint is disabling and causes substantial functional impairment. Most often it is the residual effect of a previous traumatic injury. Nonsurgical treatment of endstage arthritis of the ankle includes bracing, shoe-wear modifications, and selective joint injections. For patients who fail to respond to nonsurgical modalities, the two primary treatment options are arthroplasty and arthrodesis. Each has its proponents. Although no ideal treatment of ankle arthritis exists, high-quality studies can help guide treatment in patients of varying demographics. Inherent risks are linked with each treatment option, but those of greatest concern are early implant loosening that requires revision following arthroplasty and the acceleration of adjacent joint degeneration associated with arthrodesis.

      • Subspecialty:
      • Foot and Ankle

    Arthroscopic Management of Osteoarthritis

    Arthroscopic surgery is commonly performed in the knee, shoulder, elbow, and hip. However, the role it plays in the management of osteoarthritis is controversial. Routine arthroscopic management of osteoarthritis was once common, but this practice has been recently scrutinized. Although some believe that there is no role for arthroscopic treatment in the management of osteoarthritis, it may be appropriate and beneficial in certain situations. The clinical success of such treatment may be rooted in appropriate patient selection and adherence to a specific surgical technique. Arthroscopy may serve as an effective and less invasive option than traditional methods of managing osteoarthritis.

        • Subspecialty:
        • Sports Medicine

        • General Orthopaedics

      Current Strategies in Anesthesia and Analgesia for Total Knee Arthroplasty

      Total knee arthroplasty is associated with substantial postoperative pain that may impair mobility, reduce the ability to participate in rehabilitation, lead to chronic pain, and reduce patient satisfaction. Traditional general anesthesia with postoperative epidural and patient-controlled opioid analgesia is associated with an undesirable adverse-effect profile, including postoperative nausea and vomiting, hypotension, urinary retention, respiratory depression, delirium, and an increased infection rate. Multimodal anesthesia—incorporating elements of preemptive analgesia, neuraxial perioperative anesthesia, peripheral nerve blockade, periarticular injections, and multimodal oral opioid and nonopioid medications during the perioperative and postoperative periods—can provide superior pain control while minimizing opioid-related adverse effects, improving patient satisfaction, and reducing the risk of postoperative complications.

          • Subspecialty:
          • Adult Reconstruction

        Fixation of Soft Tissue to Bone: Techniques and Fundamentals

        A myriad of orthopaedic injuries require surgical fixation of torn connective tissue to an osseous insertion site with either direct repair or reconstruction with a soft-tissue graft. Numerous factors influence the strength of a soft–tissue-to-bone fixation construct, including tissue quality, implant strength, contact area and pressure, and tensioning. Each fixation technique differs with respect to biologic integration, biomechanical stability, and failure mechanism. Fixation methods may or may not require an implant, such as interference screws, staples, internal buttons, transfixion pins, or suture anchors. Understanding the optimal method of soft-tissue fixation for a given scenario is crucial for successful repair or reconstruction.

            • Subspecialty:
            • Foot and Ankle

            • Sports Medicine

            • Shoulder and Elbow

            • Basic Science

          Lateral Lumbar Interbody Fusion: Indications, Outcomes, and Complications

          Lateral lumbar interbody fusion is a minimally invasive spinal fusion technique that uses the retroperitoneal approach to the anterior spinal column. Mechanical and technical results of the technique compare favorably with those of anterior lumbar interbody fusion in regard to large graft placement, graft volumes, and early initial stability. Lateral lumbar interbody fusion uses the transpsoas approach and traverses near the lumbar plexus. It is not, however, without its unique complications. Groin pain or numbness is well tolerated and often temporary; however, quadriceps palsy can be long-lasting and debilitating. Rarer but serious complications include vascular and visceral injury. Lateral lumbar interbody fusion has been used successfully to treat common degenerative spinal conditions such as spinal instability, stenosis, scoliosis, and degenerative disk disease. While understanding of the lumbar plexus and the technical challenges of the procedure improves, lateral lumbar interbody fusion will continue to provide safe and successful clinical outcomes with less morbidity than traditional procedures.

              • Subspecialty:
              • Spine

            Management of Pediatric Supracondylar Humerus Fractures With Vascular Injury

            The American Academy of Orthopaedic Surgeons has developed the Appropriate Use Criteria (AUC) document Management of Pediatric Supracondylar Humerus Fractures With Vascular Injury. Evidencebased information, in conjunction with the clinical expertise of physicians, was used to develop the criteria to improve patient care and obtain the best outcomes while considering the subtleties and distinctions necessary in making clinical decisions. The AUC clinical patient scenarios were derived from patient indications that generally accompany a pediatric supracondylar humerus fracture with vascular injury, as well as from current evidence-based clinical practice guidelines and supporting literature. The 6 patient scenarios and 18 treatments were developed by the Writing Panel, a group of clinicians who are specialists in this AUC topic. Next, the Review Panel, a separate group of volunteer physicians, independently reviewed these materials to ensure that they were representative of patient scenarios that clinicians are likely to encounter in daily practice. Finally, the multidisciplinary Voting Panel (made up of specialists and nonspecialists) rated the appropriateness of treatment of each patient scenario using a 9-point scale to designate a treatment as Appropriate (median rating, 7 to 9), May Be Appropriate (median rating, 4 to 6), or Rarely Appropriate (median rating, 1 to 3).

                • Subspecialty:
                • Pediatric Orthopaedics

                • Shoulder and Elbow

              Metal Hypersensitivity and Total Knee Arthroplasty

              Metal hypersensitivity in patientswith a total knee arthroplasty (TKA) is a controversial topic. The diagnosis is difficult, given the lack of robust clinical validation of the utility of cutaneous and in vitro testing. Metal hypersensitivity after TKA is quite rare and should be considered after eliminating other causes of pain and swelling, such as low-grade infection, instability, component loosening or malrotation, referred pain, and chronic regional pain syndrome. Anecdotal observations suggest that two clinical presentations of metal hypersensitivity may occur after TKA: dermatitis or a persistent painful synovitis of the knee. Patients may or may not have a history of intolerance to metal jewelry. Laboratory studies, including erythrocyte sedimentation rate, C-reactive protein level, and knee joint aspiration, are usually negative. Cutaneous and in vitro testing have been reported to be positive, but the sensitivity and specificity of such testing has not been defined. Some reports suggest that, if metal hypersensitivity is suspected and nonsurgical measures have failed, then revision to components fabricated of titanium alloy or zirconium coating can be successful in relieving symptoms.Revision should be considered as a last resort, however, and patients should be informed that no evidence-basedmedicine is available to guide the management of these conditions, particularly for decisions regarding revision. Given the limitations of current testing methods, the widespread screening of patients for metal allergies before TKA is not warranted.

                  • Subspecialty:
                  • Adult Reconstruction

                Orthobiologics in Foot and Ankle Surgery

                Exploration into the molecular aspects of the healing process has led to the development of autologous and recombinant biologic agents. These products, collectively known as orthobiologics, have the potential to optimize favorable outcomes with respect to bone and soft-tissue restoration and to maximize the natural healing response. These orthobiologics include platelet-derived growth factor, bone morphogenetic proteins, and platelet-rich plasma. Although the usefulness of these growth factors is well described in various fields of surgery, few data exist to support or oppose the specific application of growth factors in foot and ankle surgery.

                    • Subspecialty:
                    • Foot and Ankle

                    • Basic Science

                  Transphyseal Fracture of the Distal Humerus

                  Transphyseal fractures of the distal humerus typically occur in children younger than 3 years secondary to birth trauma, nonaccidental trauma, or a fall from a small height. Prompt and accurate diagnosis of the injury is crucial for a successful outcome. Recognizing that the forearm is not aligned with the humerus on plain radiography can aid in the diagnosis of the injury. Surgical management is most commonly performed with the aid of an arthrogram. Closed reduction and percutaneous pinning techniques similar to those used for supracondylar humerus fractures are employed. The most common complication is cubitus varus caused by a malunion, osteonecrosis of the medial condyle, or growth arrest. A corrective lateral closing wedge osteotomy can be performed to restore a nearly normal carrying angle.

                      • Subspecialty:
                      • Shoulder and Elbow

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