JAAOS

JAAOS, Volume 25, No. 1


Acute Achilles Tendon Ruptures: An Update on Treatment

Acute rupture of the Achilles tendon is common and seen most frequently in people who participate in recreational athletics into their thirties and forties. Although goals of treatment have not changed in the past 15 years, recent studies of nonsurgical management, specifically functional bracing with early range of motion, demonstrate rerupture rates similar to those of tendon repair and result in fewer wound and soft-tissue complications. Satisfactory outcomes may be obtained with nonsurgical or surgical treatment. Newer surgical techniques, including limited open and percutaneous repair, show rerupture rates similar to those of open repair but lower overall complication rates. Early research demonstrates no improvement in functional outcomes or tendon properties with the use of platelet-rich plasma, but promising results with the use of bone marrow–derived stem cells have been seen in animal models. Further investigation is necessary to warrant routine use of biologic adjuncts in the management of acute Achilles tendon ruptures.

      • Subspecialty:
      • Foot and Ankle

    Ambulatory Surgical Centers: A Review of Complications and Adverse Events

    An increasing number of orthopaedic surgeries are performed at ambulatory surgical centers (ASCs), as is exemplified by the 272% population-adjusted increase in outpatient rotator cuff repairs from 1996 to 2006. Outpatient surgery is convenient for patients and cost effective for the healthcare system. The rate of complications and adverse events following orthopaedic surgeries at ASCs ranges from 0.05% to 20%. The most common complications are pain and nausea, followed by infection, impaired healing, and bleeding; these are affected by surgical and patient risk factors. The most important surgeon-controlled factors are surgical time, type of anesthesia, and site of surgery, whereas the key patient comorbidities are advanced age, female sex, diabetes mellitus, smoking status, and high body mass index. As the use of ASCs continues to rise, an understanding of risk factors and outcomes becomes increasingly important to guide indications for and management of orthopaedic surgery in the outpatient setting.

        • Subspecialty:
        • General Orthopaedics

      Assessment of the Pediatric Foot Mass

      Masses in the pediatric foot are relatively uncommon and can present a diagnostic challenge. The literature lacks a comprehensive overview of these types of lesions. Most are benign soft-tissue lesions that can be diagnosed on the basis of history and physical examination. However, some rare malignant neoplasms can mimic benign masses. It is imperative to recognize these lesions because the consequences of a delayed or missed diagnosis can be substantial. A thorough history and physical examination of all pediatric patients with foot lesions are crucial to ensure that any lesion not readily identified as benign is appropriately managed.

          • Subspecialty:
          • Pediatric Orthopaedics

        Effect of Time of Operation on Hip Fracture Outcomes: A Retrospective Analysis

        Introduction: Hip fractures are a common source of morbidity, mortality, and cost burden for elderly patients. We conducted a retrospective analysis of patients with hip fracture treated during the day or night at a rural level I academic trauma center and compared the postoperative outcomes and resource utilization for both groups.

        Methods: Patients aged ≥55 years with hip fractures treated with definitive surgical fixation from April 2011 to April 2013 were included in this study. Patients who underwent surgery between 7 am and 5 pm were included in the day cohort, while those who underwent surgery between 5 pm and 7 am were included in the night cohort. A total of 441 patients met the study inclusion criteria.

        Results: Comparison of the baseline characteristics of the two cohorts did not demonstrate significant variance. Although postoperative outcomes and resource utilization trends varied between the day and night cohort, only in-hospital cost was significantly higher in the day cohort (P = 0.04). Postoperative variables, including blood loss, ∆hematocrit level, length of surgery, length of stay, time to surgery, in-hospital mortality, and 30-day readmission, did not vary significantly.

        Conclusion: Our study demonstrates a significantly higher cost associated with hip fracture procedures performed between 7 am and 5 pm. In addition, perioperative blood loss and length of surgery were used as markers of physician fatigue; however, no statistically significant difference among these variables was found between hip fracture intervention performed during the day versus at night.

        Level of Evidence: III, retrospective observational study

            • Subspecialty:
            • Trauma

          Management of Acute Proximal Humeral Fractures

          Proximal humeral fractures, which typically occur in elderly persons, are among the most common fractures. A myriad of nonsurgical and surgical treatment options exist for these injuries, including short-term immobilization and early physical therapy, percutaneous fixation, plate osteosynthesis, intramedullary nailing, hemiarthroplasty, and reverse shoulder arthroplasty. The choice of treatment depends on the fracture type and severity, surgeon expertise, patient age, and patient health status.

              • Subspecialty:
              • Shoulder and Elbow

            Orthopaedic Surgery Residency: Perspectives of Applicants and Program Directors on Medical Student Away Rotations

            Introduction: Senior medical students frequently rotate at orthopaedic residency programs away from their home medical schools. However, to our knowledge, the perspective of program directors (PDs) and applicants on the value, objectives, and costs of these rotations has not been studied.

            Methods: Surveys evaluating the frequency, costs, benefits, and objectives of away rotations were distributed to all orthopaedic residency PDs in the United States and applicants in the 2014-2015 Match cycle. Data analysis was conducted to perform inferential and descriptive statistics; comparisons were made between and among PD and applicant groups using two-tailed means Student t-test and analysis of variance.

            Results: A total of 74 PD (46.0%) and 524 applicant (49.3%) responses were obtained from a national distribution. Applicants completed an average of 2.4 away rotations, with an average cost of $2,799. When stratified on self-reported likelihood of Matching, there were no substantial differences in the total number of rotations performed. The only marked differences between these groups were the United States Medical Licensing Examination Step 1 score and the number of applications to residency programs. PDs reported that significantly fewer rotations should be allowed, whereas applicants suggested higher limits (2.42 rotations versus 6.24, P < 0.001). PDs and applicants had similar perspectives on the value of away rotations; both groups reported more value in finding a “good fit” and making a good impression at the program and placed less value on the educational impact.

            Discussion: The value of orthopaedic away rotations appears more utilitarian than educational for both PDs and applicants. Rotations are performed regardless of perceived likelihood of Matching and are used by students and programs to identify a “good fit.” Therefore, given the portion of an academic year that is spent on orthopaedic rotations, findings showing perceived low educational value and marked discrepancies between the expected number of rotations by PDs and applicants indicate that the current structure of away rotations may not be well aligned with the mission of undergraduate medical education.

            Level of Evidence: V

                • Subspecialty:
                • General Orthopaedics

              Postoperative Rehabilitation of Low Energy Hip Fractures in the Elderly

              Evidence-based information, in conjunction with the clinical expertise of physicians, was used to develop the Appropriate Use Criteria (AUC) document Postoperative Rehabilitation of Low Energy Hip Fractures in the Elderly 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 typically accompany hip fractures, as well as from current evidence-based clinical practice guidelines and supporting literature. The 72 patient scenarios and 10 treatments were developed by the Writing Panel, a group of clinicians who are specialists in this AUC topic. 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

                The Effect of Two Factors on Interobserver Reliability for Proximal Humeral Fractures

                Introduction: The purpose of this study was to assess whether training observers and simplifying proximal humeral fracture classifications improve interobserver reliability among a large number of orthopaedic surgeons.

                Methods: One hundred eighty-five observers were randomized to receive training or no training in a simple classification for proximal humeral fractures before evaluating preoperative radiographs of a consecutive series of 30 patients who were treated with open reduction and internal fixation.

                Results: The overall interobserver reliability of the simple proximal humeral fracture classification system was low and not significantly different between the training and the no training group (κ = 0.20 and κ = 0.18, respectively; P = 0.10). Subgroup analyses showed that training improved the agreement among surgeons who have been in independent practice ≤5 years (κ = 0.23 versus κ = 0.14; P < 0.001), surgeons from the United States (κ = 0.23 versus κ = 0.16; P = 0.002), and general orthopaedic surgeons (κ = 0.42 versus κ = 0.15; P = 0.021).

                Discussion: Simplifying classifications and training observers did not improve the interobserver reliability for the diagnosis of proximal humeral fractures. However, training observers improved interobserver reliability of a simple proximal humeral fracture classification system among surgeons from the United States and, in particular, younger and less specialized surgeons. This finding may suggest that our interpretations of radiographic information might become more fixed and immutable with experience.

                    • Subspecialty:
                    • Trauma

                  Total Wrist Arthrodesis: Indications and Clinical Outcomes

                  Total wrist arthrodesis remains an important technique in the surgical armamentarium of upper extremity surgeons. The procedure has evolved over time but continues to provide reliable pain relief at the expense of wrist motion. It is indicated for management of a wide variety of upper extremity conditions, including rheumatoid arthritis, posttraumatic osteoarthritis, cerebral palsy, and brachial plexus injuries, and as a salvage technique after failed implant arthroplasty. Recent studies demonstrate high levels of patient satisfaction and good functional outcomes after bilateral wrist fusion. Compared with total wrist arthroplasty, total wrist arthrodesis provides more reliable pain relief with lower rates of complications, but further studies are needed to compare functional outcomes and cost-effectiveness.

                      • Subspecialty:
                      • Hand and Wrist

                    Ulnar Tunnel Syndrome, Radial Tunnel Syndrome, Anterior Interosseous Nerve Syndrome, and Pronator Syndrome

                    In addition to the more common carpal tunnel and cubital tunnel syndromes, orthopaedic surgeons must recognize and manage other potential sites of peripheral nerve compression. The distal ulnar nerve may become compressed as it travels through the wrist, which is known as ulnar tunnel or Guyon canal syndrome. The posterior interosseous nerve may become entrapped in the proximal forearm as it travels through the radial tunnel, which results in a pain syndrome without motor weakness. The median nerve may become entrapped in the proximal forearm, which can result in a variety of symptoms. Spontaneous neuropathy of the anterior interosseous nerve of the median nerve can be observed without external compression. Electrodiagnostic and imaging studies may aid surgeons in the diagnosis of these syndromes; however, a thorough physical examination is paramount to localize compressed segments of these nerves. An understanding of the anatomy of each of these nerve areas allows practitioners to appreciate a patient’s clinical findings and helps guide surgical decompression.

                        • Subspecialty:
                        • Shoulder and Elbow

                      Advertisements

                      Advertisement