JAAOS

JAAOS, Volume 24, No. 9


A Novel Algorithm for Isolated Weber B Ankle Fractures: A Retrospective Review of 51 Nonsurgically Treated Patients

Introduction: Stability of isolated Weber B ankle fractures can be difficult to determine. Using weight-bearing radiographs, a reliable method to determine the stability of isolated Weber B ankle fractures is described.

Methods: A retrospective review of prospectively gathered data was performed. Weber B ankle fractures were defined as stable when having a medial clear space (MCS) of ,7 mm on initial gravity stress radiographs and a normal mortise relationship on weight-bearing radiographs. Fifty-one patients meeting these criteria were treated nonsurgically with protected weight bearing and serial radiography for 1 year.

Results: Average functional score results were: American Orthopaedic Foot and Ankle Society Hindfoot, 93.2; Foot and Ankle Ability Measure for Activities of Daily Living, 93.2; Olerud-Molander Ankle Score, 91.0; and visual analog scale pain score, 0.57. Despite a mean gravity stress MCS of 4.42 mm, no patient demonstrated subsequent MCS widening. Mean MCS on 1-year follow-up weightbearing radiographs was 2.64 mm.

Conclusion: Weight-bearing ankle radiographs are predictive of stability in isolated Weber B ankle fractures. Gravity stress radiographs using traditional measurement criteria may overestimate instability in these injuries. Nonsurgical treatment with protected weight bearing shows good early outcomes.

Level of Evidence: IV

      • Subspecialty:
      • Foot and Ankle

    Cervical Spine Injuries in the Athlete

    Cervical spine injuries are extremely common and range from relatively minor injuries, such as cervical muscle strains, to severe, life-threatening cervical fractures with spinal cord injuries. Although cervical spine injuries are most common in athletes who participate in contact and collision sports, such as American football and rugby, they also have been reported in athletes who participate in noncontact sports, such as baseball, gymnastics, and diving. Cervical spine injuries in athletes are not necessarily the result of substantial spine trauma; some athletes have chronic conditions, such as congenital stenosis, that increase their risk for a serious cervical spine injury after even minor trauma. Therefore, physicians who cover athletic events must have a thorough knowledge of cervical spine injures and the most appropriate ways in which they should be managed. Although cervical spine injuries can be careerending injuries, athletes often are able to return to play after appropriate treatment if the potential for substantial re-injury is minimized.

        • Subspecialty:
        • Spine

      Direct Observation: Assessing Orthopaedic Trainee Competence in the Ambulatory Setting

      The Accreditation Council of Graduate Medical Education requires that residency programs teach and assess trainees in six core competencies. Assessments are imperative to determine trainee competence and to ensure that excellent care is provided to all patients. A structured, direct observation program is feasible for assessing nontechnical core competencies and providing trainees with immediate constructive feedback. Direct observation of residents in the outpatient setting by trained faculty allows assessment of each core competency. Checklists are used to document residents’ basic communication skills, clinical reasoning, physical examination methods, and medical record keeping. Faculty concerns regarding residents’ professionalism, medical knowledge, fatigue, or ability to self-assess are tracked. Serial observations allow for the reinforcement and/or monitoring of skills and attitudes identified as needing improvement. Residents who require additional coaching are identified early in training. Progress in educational milestones is recorded, allowing an individualized educational program that ensures that future orthopaedic surgeons excel across all domains of medical and surgical competence.

          • Subspecialty:
          • General Orthopaedics

        Enchondroma of the Hand: Evaluation and Management

        Enchondroma is the most common primary bone tumor of the hand. This benign, cartilaginous tumor often presents as a pathologic fracture. When hand enchondroma is suspected, less common conditions, such as multiple enchondromatosis syndromes and benign and malignant lesions, should be ruled out. Surgical management with curettage is the standard of care for symptomatic lesions. However, controversy surrounds the timing of surgery for pathologic fractures and the use of surgical adjuncts and postcurettage void management. Microscopically distinguishing hand enchondroma from low-grade hand chondrosarcoma is a diagnostic challenge for pathologists, but the primary surgical treatment for both conditions is curettage because the latter has a low metastatic potential. Postoperative complications are typically joint stiffness and soft-tissue‒related deformities, whereas recurrence and malignant degeneration of solitary lesions are much less common. Most patients return to full function after surgery.

            • Subspecialty:
            • Hand and Wrist

          Extremity War Injuries X: Return to Health and Function

          The symposium Extremity War Injuries X: Return to Health and Function, presented by the American Academy of Orthopaedic Surgeons, the Orthopaedic Trauma Association, the Society of Military Orthopaedic Surgeons, and the Orthopaedic Research Society, was held in Washington, DC, on January 27 and 28, 2015. Course chairs Marc F. Swiontkowski, MD, and COL Jeffrey N. Davila, MD, presided over 2 days of general session lectures focusing on war/ trauma-related musculoskeletal injuries resulting in service member disability, followed by small group discussions, with a goal of identifying knowledge gaps in the treatment of these injuries. Recognized civilian and military clinicians and researchers summarized the current state of knowledge in their topic areas and led these discussion groups with meeting participants. Musculoskeletal conditions discussed included posttraumatic osteoarthritis of the knee, foot, and ankle and their relationship to chronic ligament injuries; back disability; peripheral nerve injury; hand transplantation updates; the role of biologics; and prosthetic acceptance and function. A scientific program highlighting research presented by 12 investigators was led by COL (Ret) Romney C. Andersen, MD. Keynote speaker LT GEN Douglas J. Robb, MD, discussed the future of military research funding and the anticipated consolidation of medical care among the three military branches. Additional presentations referencing the impact of military medical care and the government's continued commitment to funding medical research occurred throughout the symposium and were given by five congressional representatives.

              • Subspecialty:
              • Trauma

            Management of Osteochondritis Dissecans of the Femoral Condyle

            The American Academy of Orthopaedic Surgeons has developed the Appropriate Use Criteria (AUC) document Management of Osteochondritis Dissecans of the Femoral Condyle. Evidence-based 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 osteochondritis dissecans of the femoral condyle, as well as from current evidence-based clinical practice guidelines and supporting literature. The 64 patient scenarios and 12 treatments were developed by the Writing Panel, a group of clinicians who are specialists in this AUC topic. Lastly, a separate, 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:
                • Foot and Ankle

              Management of Spinal Deformity in Adult Patients With Neuromuscular Disease

              A wide range of neuromuscular diseases, including Parkinson disease, cerebral palsy, multiple sclerosis, and myopathy, are associated with spinal deformities. The most common postural deformities include anterocollis, Pisa syndrome (pleurothotonus), scoliosis, and camptocormia. Nonsurgical management of spinal deformity in patients with neuromuscular disease centers on maximizing the medical management of the underlying neurodegenerative pathology before surgical intervention is contemplated. Surgical management can include decompression alone, or decompression and fusion with short or long fusion constructs. Patients with neuromuscular disease are susceptible to postoperative medical complications, such as delirium, epidural hematomas, pulmonary emboli, and cardiac events. Compared with outcomes in the typical patient with spinal deformity, postoperative outcomes in patients with neuromuscular disease have higher rates of surgical complications, such as instrumentation failure, proximal junctional kyphosis, loss of correction, and the need for revision surgery, regardless of the magnitude of surgical treatment.

                  • Subspecialty:
                  • Spine

                Prevalence of Obesity in Patients With Legg-Calvé-Perthes Disease

                Introduction: Children with Legg-Calvé-Perthes disease classically have been described as thin, small, and socioeconomically disadvantaged. Despite the obesity epidemic, no study has determined the prevalence of obesity in this patient population and its effect on treatment.

                Methods: This is a retrospective study of 150 patients (172 hips) with Legg-Calvé-Perthes disease seen between 2009 and 2014. Patients were grouped based on body mass index at the initial visit. This cohort was analyzed on the basis of the treatment received and socioeconomic status.

                Results: Of 150 patients with Legg-Calvé-Perthes disease, 16% were overweight and 32% were obese. Patients who were obese had a 2.8 lower likelihood of receiving a bony operation (confidence interval: 1.1 to 7.7). Obesity in patients with the disease was associated with later Waldenström stage at presentation (P = 0.003), lower median household income by zip code (P < 0.001), and greater use of government-funded health insurance (P < 0.001).

                Discussion: Obesity is common in patients with Legg-Calvé-Perthes disease and is associated with a later stage of disease presentation.

                Level of Evidence: Level III

                    • Subspecialty:
                    • Pediatric Orthopaedics

                  Providing Orthopaedic Care for the Incarcerated: Obstacles and Challenges

                  Scant information on healthcare delivery to inmates is available in the medical literature. Healthcare provision to inmates has different rules thanthat for thegeneral population andpresents particular challenges for orthopaedic surgeons because of the nature of this population and restrictions imposed by their confinement. This population is typically of a lower socioeconomic status and is less well educated, has accumulated injuries over a lifetime, and has a considerable prevalence of communicable and blood-borne diseases, along with a high prevalence of smoking and high-risk behavior, such as drug-seeking, abuse, and self-inflicted injury. These variables add levels of complexity of care, including the determination ofmedical necessity for orthopaedic referral, the logistics of transportation and follow-up, access to durable medical equipment and ancillary services, and the choices the orthopaedic provider must make to optimize care within these limitations.

                      • Subspecialty:
                      • General Orthopaedics

                    Review of Lower Extremity Traction in Current Orthopaedic Trauma

                    Although methods of traction for temporizing and definitive treatment of orthopaedic injuries are described in dated textbooks, current literature and recommendations on the use of skin and skeletal traction in orthopaedic trauma are lacking. Elaborate traction schemas have been described, but few of them have been retained in practice and even fewer have been supported by scientific data. Several options exist for traction modalities that involve the pelvis and lower extremities, including portable traction devices and traction pins.

                        • Subspecialty:
                        • Trauma

                      Surgical Management of Pediatric Developmental Dysplasia of the Hip

                      In pediatric patients with developmental dysplasia of the hip with late presentation or failure of nonsurgical treatment, surgical management is indicated. The goal of surgery is to obtain a stable reduction to promote development of the femoral head and acetabulum while avoiding osteonecrosis of the femoral head and the need for further surgery. Treatment is related to the age of the patient and the degree of soft-tissue contracture or bony deformity present. As a general rule, in children aged <12 months, closed reduction and spica casting is preferred. Children aged 12 to 18 months may require open reduction, which can be performed safely through a medial or anterior approach. In children aged 18 months to 3 years, residual bony deformity can be corrected with a femoral or pelvic osteotomy in addition to open reduction. In children with complex deformity or in children aged >3 years, both pelvic and femoral osteotomies are commonly required to stabilize an open reduction.

                          • Subspecialty:
                          • Pediatric Orthopaedics

                        The Use of MRI in Evaluating Knee Pain in Patients Aged 40 Years and Older

                        Introduction: The use of MRI is increasing when evaluating patients with knee pain because it is highly sensitive for detecting intra-articular pathology. However, such changes can be associated with degenerative joint disease, which may be demonstrated with weight-bearing radiographs. The purpose of this study was to determine how often MRI was obtained before orthopaedic referral in patients aged$40 years with knee pain, how often weight-bearing radiographs were obtained before MRI, and whether such imaging influenced treatment recommendations.

                        Methods: In a study of 599 new patients, participating physicians documented the presence of a prereferral MRI and/or plain radiographic studies, the results of weight-bearing radiographs, treatment recommendations, and the impact of any prereferral imaging.

                        Results: Prereferral use of MRI occurred in 130 patients (22%). Of these patients, plain radiographic studies were obtained for 58% before MRI and 13% had weight-bearing radiographs. Ultimately, 17% had weight-bearing radiographs that demonstrated .50% loss of joint space. Forty-eight percent of prereferral MRIs did not contribute to treatment recommendations. In patients with.50% loss of joint space, MRI was considered unnecessary in 95% of the cases.

                        Discussion: Many prereferral MRIs do not contribute to clinical decision making. Weight-bearing radiographs can help identify those patients in whom MRI is unlikely to be helpful.

                        Level of Evidence: Level III

                            • Subspecialty:
                            • Adult Reconstruction

                          Update in Pediatric Musculoskeletal Infections: When It Is, When It Isn't, and What to Do

                          Musculoskeletal infections, including osteomyelitis, septic arthritis, and pyomyositis, are a substantial cause of morbidity in children and adolescents. The increased virulence of infectious agents and the increased prevalence of antimicrobial-resistant pathogens, particularly methicillin-resistant Staphylococcus aureus, have resulted in a more complicated clinical course for diagnosis and management, which is evidenced by an increased length of hospital stays, incidence of complications, and number of surgical interventions. Musculoskeletal infections are a challenge for surgeons because they vary substantially in their presentation and in their required treatment, which is based on the causative organism, the location of the infection, and the age of the patient. The necessity for a prompt diagnosis is complicated by several diseases that may mimic musculoskeletal infection, including transient synovitis, autoimmune arthritis, and tumors. Recent innovations in diagnosis and management have provided surgeons with new options to differentiate musculoskeletal infections from these rapidly evolving disease pathologies. As diagnostic and treatment modalities improve, collaboration among surgeons from multiple disciplines is required to develop evidence-based clinical practice guidelines that minimize the effect of musculoskeletal infection and optimize clinical outcomes for patients.

                              • Subspecialty:
                              • Basic Science

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