JAAOS, Volume 24, No. 7

AAOS Research Symposium Updates and Consensus: Biologic Treatment of Orthopaedic Injuries

Strategies that seek to enhance musculoskeletal tissue regeneration and repair by modulating the biologic microenvironment at the site of injury have considerable therapeutic potential. Current and emerging biologic approaches include the use of growth factors, platelet-rich plasma, stem cell therapy, and scaffolds. The American Academy of Orthopaedic Surgeons hosted a research symposium in November 2015 to review the current state-of-the-art biologic treatments of articular cartilage, muscle, tendon, and bone injuries and identify knowledge gaps related to these emerging treatments. This review outlines the findings of the symposium and summarizes the consensus reached on how best to advance research on biologic treatment of orthopaedic injuries.

      • Subspecialty:
      • Basic Science

    An Approach to Lumbar Revision Spine Surgery in Adults

    Along with the increase in lifestyle expectations in the aging population, a dramatic rise in surgical rates has been observed over the past 2 decades. Consequently, the rate of revision spine surgery is expected to increase. A systematic approach to treatment is required for the adult patient presenting with late or chronic complications after spinal surgery. Patient assessment includes elucidating current symptoms and knowledge of the previous surgery, performing a detailed assessment, and obtaining appropriate studies. Subsequently, differential diagnoses are formulated based on whether the pathology arisesfromthe same levels oradjacent levels of the spineandwhether it relates to the previous decompression or fusion. Finally, familiarity with different surgical approaches is imperative in treating the common pathologies encountered in this patient population.

        • Subspecialty:
        • Spine

      Anatomic Tunnel Placement in Anterior Cruciate Ligament Reconstruction

      The anatomic anterior cruciate ligament (ACL) reconstruction concept has developed in part from renewed interest in the insertional anatomy of the ACL, using surgical techniques that can reproduce this anatomy reliably and accurately during surgical reconstruction. Several technical tools are available to help identify and place the tibial and femoral grafts anatomically, including arthroscopic anatomic landmarks, a malleable ruler device, and intraoperative fluoroscopy. The changes in technique for anatomic tunnel placement in ACL reconstruction follow recent biomechanical and kinematic data that demonstrate improved time zero characteristics. A better re-creation of native ACL kinematics and biomechanics is achieved with independent femoral drilling techniques that re-create a central footprint single-bundle ACL reconstruction or double-bundle reconstruction. However, to date, limited short-term and long-term clinical outcome data have been reported that support using either of these techniques rather than a transtibial drilling technique. This lack of clear clinical advantage for femoral independent and/or doublebundle techniques may arise because of the potentially offsetting biologic incorporation challenges of these grafts when placed using these techniques or could result from modifications made in traditional endoscopic transtibial techniques that allow improved femoral and tibial footprint restoration.

          • Subspecialty:
          • Sports Medicine

        Chronic Elbow Dislocation: Evaluation and Management

        Chronic elbow dislocation is defined as a dislocation that has remained unreduced for >2 weeks. The soft-tissue and skeletal changes that develop during this time usually prevent successful closed reduction. These changes include the development of extensive intra-articular fibrotic tissue, as well as contracture of the triceps, collateral ligaments, and elbow capsule. Ulnar nerve involvement and associated fractures may also be present. Because treatment of chronic elbow dislocation is challenging, a stepwise approach is used in the evaluation and management of this condition. No large series of data are available to guide treatment. Most patients are treated on the basis of the surgeon's anecdotal experience. Treatment typically involves open reduction, often with the use of hinged external fixators. The role of triceps lengthening or primary collateral ligament reconstruction remains a topic of debate.

            • Subspecialty:
            • Shoulder and Elbow

          Complications After Surgical Management of Proximal Femoral Metastasis: A Retrospective Study of 417 Patients

          Background: Proximal femoral fractures resulting from metastatic disease often require surgical management. Few studies have compared surgical techniques, and physicians' preferred strategies vary. This study compared revision and complication rates among surgical strategies.

          Methods: The study consisted of a retrospective review of electronic medical records of 417 consecutive patients with proximal femoral metastasis or multiple myeloma who underwent intramedullary nailing (n = 302), endoprosthetic reconstruction (n = 70), and open reduction and internal fixation (n = 45) between 1999 and 2014 at two orthopaedic oncology centers. Primary outcome measures were revisions and 30-day systemic complications. Secondary outcome measures were total estimated blood loss, anesthesia time, duration of hospital admission, and 30-day survival.

          Results: Revision rates did not differ between strategies (5.3% after intramedullary nailing, 11% after endoprosthetic reconstruction, and 13% after open reduction and internal fixation; P = 0.134). When reasons for revision were assessed separately, fixation failure was most common after open reduction and internal fixation (13% versus 3.0% after intramedullary nailing and none after endoprosthetic reconstruction; P < 0.001), whereas deep infection was most common after endoprosthetic reconstruction (8.6% versus 2.0% after intramedullary nailing and none after open reduction and internal fixation; P = 0.010). Overall systemic complication rates did not differ between strategies (8.3% after intramedullary nailing, 14% after endoprosthetic reconstruction, and 11% after open reduction and internal fixation; P = 0.268).

          Conclusion: Implant-specific complications and their timing should be considered in the choice of surgical strategy. Analysis of secondary outcomes and risk factors for systemic complications could aid in surgical decision making.

          Level of Evidence: Therapeutic Level III.

              • Subspecialty:
              • Musculoskeletal Oncology

            Femoral Deformity May Be More Predictive of Hip Range of Motion Than Severity of Acetabular Disease in Patients With Acetabular Dysplasia: An Analysis of the ANCHOR Cohort

            Background: It is generally believed that acetabular dysplasia (AD) is associated with increased hip range of motion (ROM). The purpose of this study was to investigate the associations between dysplasia severity and hip ROM in a large multicenter cohort.

            Methods: A prospective registry of patients undergoing periacetabular osteotomy for symptomatic AD by 1 of 13 surgeons was used to analyze 1,051 patients (mean age, 26 ± 10 years). Multivariable linear regression modeling was used to investigate for associations between dysplasia severity (severe, <5°; moderate, 5° to 15°; mild, >15°), α angle, and hip ROM.

            Results: When controlling for age, sex, body mass index, and α angle, only internal (α = 1.94; P = 0.005) and external (α = −2.63; P < 0.001) rotation in extension were significantly different between groups with increasing dysplasia severity. Alpha angle was greater for those with severe AD compared with subjects with mild disease (60° ± 16° versus 57° ± 15°; P = 0.038). Alpha angle was also significantly correlated with rotational ROM parameters (internal and external rotation in flexion and extension) (Pearson r, range: −0.077 to −0.216; P < 0.05 for all), but not with linear motion.

            Conclusions: Internal rotation in extension was directly associated with dysplasia severity, whereas external rotation in extension was inversely associated. Furthermore, α angle was greater with increasing dysplasia severity and predictive of rotational ROM parameters. Taken together, these data suggest that femoral-sided deformity, including α angle and possibly femoral version, may be responsible for differences in ROM based on dysplasia severity.

            Level of Evidence: Level III, Prognostic

                Intramedullary Fixation of Clavicle Fractures: Anatomy, Indications, Advantages, and Disadvantages

                Historically, management of displaced midshaft clavicle fractures has consisted of nonsurgical treatment. However, recent literature has supported surgical repair of displaced and shortened clavicle fractures. Several options exist for surgical fixation, including plate and intramedullary (IM) fixation. IM fixation has the potential advantages of a smaller incision and decreased dissection and soft-tissue exposure. For the last two decades, the use of Rockwood and Hagie pins represented the most popular form of IM fixation, but concerns exist regarding stability and complications. The use of alternative IM implants, such as Kirschner wires, titanium elastic nails, and cannulated screws, also has been described in limited case series. However, concerns persist regarding the complications associated with the use of these implants, including implant failure, migration, skin complications, and construct stability. Second-generation IM implants have been developed to reduce the limitations of earlier IM devices. Although anatomic and clinical studies have supported IM fixation of midshaft clavicle fractures, further research is necessary to determine the optimal fixation method.

                    • Subspecialty:
                    • Trauma

                  Percutaneous Trigger Finger Release: A Cost-effectiveness Analysis

                  Introduction: Percutaneous trigger finger releases (TFRs) performed in the office setting are becoming more prevalent. This study compares the costs of in-hospital open TFRs, open TFRs performed in ambulatory surgical centers (ASCs), and in-office percutaneous releases.

                  Methods: An expected-value decision-analysis model was constructed from the payer perspective to estimate total costs of the three competing treatment strategies for TFR. Model parameters were estimated based on the best available literature and were tested using multiway sensitivity analysis.

                  Results: Percutaneous TFR performed in the office and then, if needed, revised open TFR performed in the ASC, was the most costeffective strategy, with an attributed cost of $603. The cost associated with an initial open TFR performed in the ASC was approximately 7% higher. Initial open TFR performed in the hospital was the least cost-effective, with an attributed cost nearly twice that of primary percutaneous TFR.

                  Discussion: An initial attempt at percutaneous TFR is more costeffective than an open TFR. Currently, only about 5% of TFRs are performed in the office; therefore, a substantial opportunity exists for cost savings in the future.

                  Level of Evidence: Decision model level II

                      • Subspecialty:
                      • Hand and Wrist

                    Shared Decision Making, Fast and Slow: Implications for Informed Consent, Resource Utilization, and Patient Satisfaction in Orthopaedic Surgery

                    Introduction: Through shared decision making, the physician and patient exchange information to arrive at an agreement about the patient's preferred treatment. This process is predicated on the assumption that there is a single preferred treatment, and the goal of the dialog is to discover it. In contrast, psychology theory (ie, prospect theory) suggests that people can make decisions both analytically and intuitively through parallel decision-making processes, and depending on how the choice is framed, the two processes may not agree. Thus, patients may not have a single preferred treatment, but rather separate intuitive and analytic preferences. The research question addressed here is whether subjects might reveal different therapeutic preferences based on how a decision is framed.

                    Methods: Five clinical scenarios on the management of tibial plateau fractures were constructed. Healthy volunteers were asked to select among treatments offered. Four weeks later, the scenarios were presented again; the facts of the scenario were unchanged, but the description was altered to test the null hypothesis that minor changes in wording would not lead the subjects to change their decision about treatment. For example, incomplete improvement after surgery was described first as a gain from the preoperative state and then as a loss from the preinjury state.

                    Results: In all five cases, the variation predicted by psychology theory was detected. Respondents were affected by whether choices were framed as avoided losses versus potential gains; by emotional cues; by choices reported by others (ie, bandwagon effect); by the answers proposed to them in the question (ie, anchors); and by seemingly irrelevant options (ie, decoys).

                    Discussion: The influence of presentation on preferences can be highly significant in orthopaedic surgery. The presence of parallel decision-making processes implies that the standard methods of obtaining informed consent may require further refinement. Furthermore, if the way that information is portrayed makes surgery more or less appealing, the use of services may be subject to unwanted influence. If surgery were accepted preoperatively by the patient's intuitive process but evaluated after the fact by the analytic process (or vice versa), well-indicated and well-performed surgery may still fail to provide patient satisfaction.

                        • Subspecialty:
                        • Basic Science

                      Supramalleolar Osteotomies for the Treatment of Ankle Arthritis

                      Supramalleolar osteotomy is a joint-preserving surgical treatment for patients with asymmetric valgus or varus ankle arthritis. The primary goal of the procedure is to realign the spatial relationship between the talus and tibia and thereby normalize joint loading within the ankle. Procedures to balance the soft tissues, as well as hindfoot osteotomy and arthrodesis, may also be necessary. Clinical studies of supramalleolar osteotomy demonstrate that correction of the altered biomechanics associated with asymmetric arthritis improves functional outcomes.

                          • Subspecialty:
                          • Foot and Ankle