JAAOS

JAAOS, Volume 25, No. 4


Anterior Cruciate Ligament Injury Prevention Programs

The American Academy of Orthopaedic Surgeons has developed Appropriate Use Criteria (AUC) for anterior cruciate ligament (ACL) injury prevention programs. Evidence-based information, in conjunction with the clinical expertise of physicians, was used to develop the criteria to improve patient care and obtain best outcomes while considering the subtleties and distinctions necessary in making clinical decisions. The clinical patient scenarios presented in the AUC document ACL Injury Prevention Programs were derived from indications typical of patients who commonly present with ACL injuries in clinical practice as well as from current evidence-based clinical practice guidelines and supporting literature. The 48 patient scenarios and 1 treatment were developed by the Writing Panel, a group of clinicians who are specialists in this AUC topic. Next, 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:
      • Sports Medicine

    Athletic Hip Injuries

    Historically, athletic hip injuries have garnered little attention; however, these injuries account for approximately 6% of all sports injuries and their prevalence is increasing. At times, the diagnosis and management of hip injuries can be challenging and elusive for the team physician. Hip injuries are seen in high-level athletes who participate in cutting and pivoting sports that require rapid acceleration and deceleration. Described previously as the “sports hip triad,” these injuries consist of adductor strains, osteitis pubis, athletic pubalgia, or core muscle injury, often with underlying range-of-motion limitations secondary to femoroacetabular impingement. These disorders can happen in isolation but frequently occur in combination. To add to the diagnostic challenge, numerous intra-articular disorders and extra-articular soft-tissue restraints about the hip can serve as pain generators, in addition to referred pain from the lumbar spine, bowel, bladder, and reproductive organs. Athletic hip conditions can be debilitating and often require a timely diagnosis to provide appropriate intervention.

        • Subspecialty:
        • Sports Medicine

      Femoral Neck Fractures in Adults Treated With Internal Fixation: A Prospective Multicenter Chinese Cohort

      Introduction: Although femoral neck fractures in young patients are rare and their complications are well-documented, there is a paucity of data on patient-reported outcomes for this population. The purpose of this study was to describe the quality of life and the effect of clinical complications on the outcomes of young patients with femoral neck fractures in a Chinese cohort.

      Methods: In this prospective observational cohort study, patients aged 18 to 55 years admitted to one of three participating trauma hospitals in China for treatment of a femoral neck fracture were recruited. The primary outcome was the patient’s health-related quality of life using the Medical Outcomes Study 36-Item Short Form (SF-36) Health Survey at 1 year after injury. Associations between the primary outcome and potential predictors were explored with univariate and multivariate regression analysis.

      Results: One hundred seven patients (mean age, 44 years) completed 1-year follow-up. Nearly all patients were treated with closed reduction and screw fixation. Nine cases of nonunion, 7 cases of malunion, and 11 cases of osteonecrosis were identified. The mean SF-36 Physical Component Score was 48.6 ± 8.5, and the mean Mental Component Score was 51.0 ± 7.4. Fracture displacement, quality of reduction, and nonunion were associated with a poor Physical Component Score outcome.

      Discussion: Our results demonstrate that the quality of life for patients after closed reduction and screw fixation of femoral neck fractures is similar to that of the general population, particularly when complications of nonunion and malunion are avoided.

      Level of Evidence: Level I

          • Subspecialty:
          • Trauma

        Isolated Head and Liner Exchange in Revision Hip Arthroplasty

        As the number of primary total hip arthroplasties increases, so does the burden of revision procedures. The decision to revise well-fixed components in the setting of polyethylene wear and osteolysis is controversial. Modular head and liner exchange offers the advantages of reduced invasiveness, faster recovery, and bone preservation. These advantages come at the expense of higher rates of revision surgery for instability. Using the native locking mechanism for securing the new liner is preferred; however, cementing a liner into a well-fixed acetabular component is a practical alternative. The use of bone allograft or bone graft substitute for areas of osteolysis is controversial. In the setting of osteolysis, outcomes associated with the use of highly cross-linked polyethylene liners have been better than those associated with the use of conventional polyethylene; therefore, thinner liners and larger femoral heads can be used and reduce the risk of instability.

            • Subspecialty:
            • Hip

          Lift-off Test Results After Lesser Tuberosity Osteotomy Versus Subscapularis Peel in Primary Total Shoulder Arthroplasty

          Background: The ideal method for management of the subscapularis tendon during anatomic total shoulder arthroplasty (TSA) remains controversial.

          Methods: In a retrospective cohort study, primary anatomic TSA procedures performed with either a subscapularis peel or a lesser tuberosity osteotomy from 2002 to 2010 were reviewed at a minimum 1-year follow-up. The primary outcome measure was the performance of a normal lift-off test postoperatively. Multivariate logistic regression analysis was performed to determine if other covariates besides surgical technique correlated with an abnormal lift-off test result.

          Results: Ninety TSA procedures were evaluated. Forty-six procedures were performed with subscapularis peel, and 44 were performed with lesser tuberosity osteotomy. Mean follow-up was 4 years. In the subscapularis peel group, 32 of 46 shoulders (69.6%) had a normal lift-off test, compared with 40 of 44 shoulders (90.9%) in the lesser tuberosity osteotomy group (P = 0.01). The results of multivariate logistic regression suggested that lesser tuberosity osteotomy was associated with a normal postoperative lift-off test 4.5 times more often than was subscapularis peel.

          Conclusions: Our study suggests that the use of lesser tuberosity osteotomy as the surgical approach for anatomic TSA is a reliable option that provides the patient with a better chance of maintaining subscapularis function postoperatively than the subscapularis peel does.

          Level of Evidence: Level III retrospective cohort study

              • Subspecialty:
              • Shoulder

              • Back

            Lower Extremity Avulsion Fractures in the Pediatric and Adolescent Athlete

            Lower extremity avulsion fractures are uncommon in the pediatric population and can be misdiagnosed without proper imaging and/or clinical suspicion for these injuries. The most common locations of avulsion injuries are the ischial tuberosity, anterior superior iliac spine, and anterior inferior iliac spine. Less often, avulsion fractures occur in the tibial tubercle, calcaneus, and greater and lesser trochanters. When treated properly with rest and altered weight bearing, most of these injuries heal without complication. Although surgical intervention is rarely necessary, it has a high degree of success when it is used. However, avulsion injuries are often misdiagnosed as muscle strains or apophysitis and are mistakenly treated with early range of motion. An error in diagnosis and/or management can cause nonunion or further displacement, which may require surgery. Improper identification of these injuries can also lead to nerve irritation, chronic pain, and gait dysfunction. Awareness of these injuries and their natural history is important because healed avulsion fractures may resemble neoplastic bone on radiographs.

                • Subspecialty:
                • Pediatric Orthopaedics

              Malignant Lymphoma Mimicking an Infection After Shoulder Surgery

              Involvement of the musculoskeletal system by primary or metastatic malignant neoplasms mimicking common orthopaedic conditions is well recognized. The diagnosis may be delayed in the absence of radiographic abnormalities. Twenty-five percent of lymphoma cases have skeletal involvement, and they can affect both bone and soft tissue. Lymphoma is sometimes discovered by means of routine histologic examination of tissue collected at the time of orthopaedic surgery. To the best of our knowledge, this is the first report of lymphoma occurring at the site of prior shoulder surgery and mimicking an infection.

                  • Subspecialty:
                  • Shoulder and Elbow

                Management of Interprosthetic Femur Fractures

                Femoral fractures between a total hip arthroplasty prosthesis and total knee arthroplasty prosthesis, also called interprosthetic fractures, are challenging clinical problems. The number of patients who have undergone ipsilateral primary or revision joint arthroplasty procedures in both the hip and the knee continues to rise, and the number of interprosthetic fractures is increasing, as well. The growing body of biomechanical and clinical literature on interprosthetic fractures reflects the increased frequency of and interest in these injuries. Similar to the management of periprosthetic fractures, the management of interprosthetic fractures depends on the location of the fracture, the stability of the implant, and the ability to achieve stable fracture fixation. These factors are the basis of recently described classification systems and treatment strategies. In patients with stable implants, fracture fixation alone is performed. When the implant is loose, both revision arthroplasty and fracture fixation may be required to provide stability of the limb.

                    • Subspecialty:
                    • Leg

                    • Femur

                  Physical Examination of Knee Ligament Injuries

                  The knee is one of the most commonly injured joints in the body. A thorough history and physical examination of the knee facilitates accurate diagnosis of ligament injury. Several examination techniques for the knee ligaments that were developed before advanced imaging remain as accurate or more accurate than these newer imaging modalities. Proper use of these examination techniques requires an understanding of the anatomy and pathophysiology of knee ligament injuries. Advanced imaging can be used to augment a history and examination when necessary, but should not replace a thorough history and physical examination.

                      • Subspecialty:
                      • Sports Medicine

                    Strategies for Surgical Management of Large, Stiff Spinal Deformities in Children

                    Management of large, severe, stiff spinal deformities in children can be challenging. Adjunctive treatments used in conjunction with spinal osteotomy, instrumentation, and fusion can improve the ultimate degree of deformity correction. These adjunctive treatments include preoperative halo-gravity traction, intraoperative halo-femoral traction, temporary internal spinal distraction, and anterior spinal release. Each of these techniques has unique indications and individual risks. When the appropriate protocols are followed, these techniques can be safe and efficacious.

                        • Subspecialty:
                        • Spine

                      The Role of Multimodal Analgesia in Spine Surgery

                      Optimal postoperative pain control allows for faster recovery, reduced complications, and improved patient satisfaction. Historically, pain management after spine surgery relied heavily on opioid medications. Multimodal regimens were developed to reduce opioid consumption and associated adverse effects. Multimodal approaches used in orthopaedic surgery of the lower extremity, especially joint arthroplasty, have been well described and studies have shown reduced opioid consumption, improved pain and function, and decreased length of stay. A growing body of evidence supports multimodal analgesia in spine surgery. Methods include the use of preemptive analgesia, NSAIDs, the neuromodulatory agents gabapentin and pregabalin, acetaminophen, and extended-action local anesthesia. The development of a standard approach to multimodal analgesia in spine surgery requires extensive assessment of the literature. Because a substantial number of spine surgeries are performed annually, a standardized approach to multimodal analgesia may provide considerable benefits, particularly in the context of the increased emphasis on accountability within the healthcare system.

                          • Subspecialty:
                          • Spine

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