JAAOS

JAAOS, Volume 25, No. 10


Allergic or Hypersensitivity Reactions to Orthopaedic Implants

Allergic or hypersensitivity reactions to orthopaedic implants can pose diagnostic and therapeutic challenges. Although 10% to 15% of the population exhibits cutaneous sensitivity to metals, deep-tissue reactions to metal implants are comparatively rare. Nevertheless, the link between cutaneous sensitivity and clinically relevant deep-tissue reactions is unclear. Most reactions to orthopaedic devices are type IV, or delayed-type hypersensitivity reactions. The most commonly implicated allergens are nickel, cobalt, and chromium; however, reactions to nonmetal compounds, such as polymethyl methacrylate, antibiotic spacers, and suture materials, have also been reported. Symptoms of hypersensitivity to implants are nonspecific and include pain, swelling, stiffness, and localized skin reactions. Following arthroplasty, internal fixation, or implantation of similarly allergenic devices, the persistence or early reappearance of inflammatory symptoms should raise suspicions for hypersensitivity. However, hypersensitivity is a diagnosis of exclusion. Infection, as well as aseptic loosening, particulate synovitis, instability, and other causes of failure must first be eliminated.

      • Subspecialty:
      • General Orthopaedics

    Basic Knowledge to Improve Your Confidence in Elbow Arthroscopy

    The aim of this educational video is to describe the key points in elbow arthroscopy to improve the surgeon’s self-confidence during this procedure, with a specific emphasis on how to avoid nerve injury. Correct operating room and patient set-up is mandatory for a safe procedure: we prefer the lateral decubitus position because it allows free assessment of the intraoperative range of motion and full access to the airway and does not need traction. Drawing the anatomic landmarks on the skin can be useful. Ulnar nerve prophylactic decompression is usually indicated, in particular in cases of stiff elbow. The procedure starts from the posterior compartment. Several posterior portals are available, with the posterior, the posterolateral, the accessory posterolateral, and the soft spot portals being the most frequently used. The procedure in the anterior compartment is less safe because all three main nerves around the elbow are at risk of injury. The anteromedial portals are created first. The anterolateral portals are the most dangerous because they are very close to the radial nerve, which lies over the anterior capsule at the level of the mid portion of the radial head. For safety reasons, these portals are usually performed under direct visualization from inside the joint. Watch the video trailer: http://links.lww.com/JAAOS/A52.

        • Subspecialty:
        • Elbow

        • Arthroscopy

      Cubital Tunnel Syndrome: Current Concepts

      Cubital tunnel syndrome is the second most common upper extremity compressive neuropathy. In recent years, rates of surgical treatment have increased, and the popularity of in situ decompression has grown. Nonsurgical treatment, aiming to decrease both compression and traction on the ulnar nerve about the elbow, is successful in most patients with mild nerve dysfunction. Recent randomized controlled trials assessing rates of symptom resolution and ultimate success have failed to identify a preferred surgical procedure. Revision cubital tunnel surgery, most often consisting of submuscular transposition, may improve symptoms. However, ulnar nerve recovery after revision cubital tunnel surgery is less consistent than that after primary cubital tunnel surgery.

          • Subspecialty:
          • Hand and Wrist

        Distal Humerus Fractures in the Elderly Population

        Distal humerus fractures present complex challenges in the elderly patient. These fractures often occur in patients who are living independently but have poor bone quality and low physiologic reserve, thus complicating management decisions and treatment. The goal is a painless, functional, stable elbow that allows completion of the activities of daily living. Nonsurgical management is reserved for those who cannot tolerate surgery. Open reduction and internal fixation is the preferred choice in fractures amenable to rigid fixation and early motion. Although total elbow arthroplasty provides improved early function and similar overall outcomes in appropriately selected patients, it has the potential to cause devastating complications. With modern technology and treatment principles, as well as early definitive treatment by an experienced specialist, predictable return to function can be expected.

            • Subspecialty:
            • Trauma

          Efficacy and Treatment Response of Intra-articular Corticosteroid Injections in Patients With Symptomatic Knee Osteoarthritis

          Introduction: Intra-articular corticosteroid injections are often used for short-term pain relief in patients with knee osteoarthritis (OA). This study investigates the efficacy of intra-articular corticosteroid injections in patients with symptomatic knee OA and factors that affect treatment response.

          Methods: This prospective, multicentered cohort study had 100 participants with radiographic evidence of knee OA enrolled. Participants received one corticosteroid injection into the affected knee and were evaluated before the injection (baseline) and at 3 weeks, 6 weeks, 3 months, and 6 months after the injection.

          Results: Participants’ Visual Numeric Scale and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores improved at all time points except for the Visual Numeric Scale score at 6 months, compared with baseline scores (P < 0.001). Participants with Kellgren-Lawrence grade 1 or 2 OA saw clinical improvement in the WOMAC scores at all time points, compared with the baseline score (P < 0.01). Compared with all other subgroups, obese patients with Kellgren-Lawrence grade 3 or 4 OA had significantly worse WOMAC scores at baseline, 6 weeks, and 3 months (P < 0.01 and P < 0.01, respectively).

          Discussion: Our findings validate previously established guidelines for nonsurgical management of knee OA and suggest that intra-articular corticosteroid injections may be an acceptable short-term management option in patients unwilling or unable to undergo surgical treatment. Obesity and OA severity affect the efficacy of intra-articular corticosteroid injections.

          Conclusion: Patients receiving intra-articular corticosteroid injections had improved pain and function. Clinicians should expect less improvement in patients with obesity and/or advanced arthritis. Clinical benefits of intra-articular injections in these patients are less predictable.

              • Subspecialty:
              • Hip

              • Knee

            Ischiofemoral Impingement: From Anatomy to Endoscopic Decompression

            Ischiofemoral impingement (IFI) causes posterior hip pain by impingement of the ischium and the lesser trochanter (LT) of the femur. Congenital or acquired narrowing of the ischiofemoral space results in compression or impingement of the quadratus femoris (QF) muscle, leading to edema, pain, and sometimes sciatic nerve irritation. Lesser trochanterplasty, ischioplasty, or both have been proposed as an effective treatment in cases that do not respond to conservative management. Our purpose was to show the gross anatomy of the deep gluteal space and the abnormal relationship between the LT and ischium, QF muscle and sciatic nerve, and the endoscopic decompression of IFI. We retrospectively reviewed 13 female patients (mean age, 40.2 years) with IFI who underwent endoscopic treatment with resection of the LT. Outcomes were assessed at a mean follow-up of 10 months. The mean modified Harris Hip Score went from 48.6 points to 82.8 points at final follow-up. The mean visual analog scale score for pain decreased from 9.3 to 2.53. Endoscopic lesser trochanterplasty was an effective treatment of patients with posterior hip pain and radiologic and clinical features of IFI. Watch the video trailer: http://links.lww.com/JAAOS/A53.

                • Subspecialty:
                • Hip

              Lawsuits After Primary and Revision Total Knee Arthroplasty: A Malpractice Claims Analysis

              Introduction:As the number of total knee arthroplasties (TKAs) increases, the number of associated complications will also increase. Our goal with this study was to identify common causes of and financial trends relating to malpractice claims filed after TKA.

              Methods:

              We analyzed malpractice claims filed for alleged neglectful primary and revision TKA surgeries performed between 1982 and 2012 by orthopaedic surgeons insured by a large New York state malpractice carrier.

              Results:

              We identified 69 primary and 8 revision TKAs in the malpractice carrier’s database. All cases were performed between 1982 and 2012; all claims were closed between 1989-2015. The most frequent factor leading to lawsuits for primary TKA was chronic pain or dissatisfaction in 12 cases, followed by nerve palsy in 8, postoperative in-hospital falls in 5, and deep vein thrombosis or pulmonary embolism in 3. Medical complications included acute respiratory distress syndrome, cardiac arrest, and decubitus ulcers. Contracture was most common after revision TKA (three of eight cases). Mean indemnity was $325,369, and the largest single settlement was $2.42 million. The average expense relating to the defense of these cases was $66,365.

              Conclusions:

              Orthopaedic surgeons should continue to focus attention on prevention of complications and on preoperative patient education. Preoperative counseling regarding the risks of incomplete pain relief could reduce substantially the number of suits relating to primary TKAs.

                  • Subspecialty:
                  • Knee

                Measuring Surgical Skills in Simulation-based Training

                Simulation-based surgical skills training addresses several concerns associated with the traditional apprenticeship model, including patient safety, efficient acquisition of complex skills, and cost. The surgical specialties already recognize the advantages of surgical training using simulation, and simulation-based methods are appearing in surgical education and assessment for board certification. The necessity of simulation-based methods in surgical education along with valid, objective, standardized techniques for measuring learned skills using simulators has become apparent. The most commonly used surgical skill measurement techniques in simulation-based training include questionnaires and post-training surveys, objective structured assessment of technical skills and global rating scale of performance scoring systems, structured assessments using video recording, and motion tracking software. The literature shows that the application of many of these techniques varies based on investigator preference and the convenience of the technique. As simulators become more accepted as a teaching tool, techniques to measure skill proficiencies will need to be standardized nationally and internationally.

                    • Subspecialty:
                    • General Orthopaedics

                  Spine Surgery Outcomes in Workers’ Compensation Patients

                  Occupational spine injuries place a substantial burden on employees, employers, and the workers’ compensation system. Both temporary and permanent spinal conditions contribute substantially to disability and lost wages. Numerous investigations have revealed that workers’ compensation status is a negative risk factor for outcomes after spine injuries and spine surgery. However, positive patient outcomes and return to work are possible in spine-related workers’ compensation cases with proper patient selection, appropriate surgical indications, and realistic postoperative expectations. Quality improvement measures aimed at optimizing outcomes and minimizing permanent disability are crucial to mitigating the burden of disability claims.

                      • Subspecialty:
                      • Spine

                    Surgical Treatment of Anterior Shoulder Instability by Latarjet-Patte Procedure

                    The standard of treatment in anterior shoulder instability is arthroscopic Bankart repair, with shoulder stabilization success rates between 85% and 90%. The main cause of failure is related to unaddressed osseous defects of either the glenoid rim or the humeral head; arthroscopic Bankart repair is insufficient for safe shoulder stabilization with loss of $20% of the overall glenoid width. Latarjet-Patte procedures with coracoid transfer is considered the treatment of choice for these defects and in patients in whom the arthroscopic procedure has failed. We retrospectively reviewed 34 male and 2 female patients who experienced instability post trauma. Mean follow-up was 2 years. Mean patient age at first shoulder dislocation was 20 years. The mean preoperative Rowe score was 38 (range, 15 to 70), compared with 91 postoperative. Complete bone union was achieved in all cases. The Latarjet-Patte procedure can be a valuable surgical option for the treatment of recurrent anterior shoulder instability in cases of bone defects that are $20% of the glenoid width, providing good clinical results and a low rate of complication. Watch the video trailer: http://links.lww.com/JAAOS/A54.

                        • Subspecialty:
                        • Shoulder

                        • Arthroscopy

                      Survivorship of Hemiarthroplasty With Concentric Glenoid Reaming for Glenohumeral Arthritis in Young, Active Patients With a Biconcave Glenoid

                      Introduction: Hemiarthroplasty with concentric glenoid reaming (known as “ream and run”) may be an option for treating glenohumeral arthritis in younger patients with a biconcave glenoid. The goal of this study was to evaluate early results of this technique.

                      Methods: Two senior, fellowship-trained shoulder surgeons (G.R.W. and M.D.L.) performed a retrospective review of 23 patients (24 shoulders) with a biconcave glenoid and end-stage degenerative glenohumeral arthritis treated with hemiarthroplasty with concentric glenoid reaming. The mean patient age at the time of surgery was 50 years. We evaluated the Penn Shoulder Score (PSS), Single Assessment Numeric Evaluation (SANE) score, and Simple Shoulder Test (SST) score or the time to revision surgery.

                      Results: Twenty-four humeral hemiarthroplasties with concentric glenoid reaming were performed in 23 patients. Twenty patients (21 shoulders) reached the end point of 2-year follow-up or revision surgery. Six shoulders (25%) required revision surgery at an average of 2.7 years (range, 0.7 to 7.2 years), and three were lost to follow-up. The remaining 14 patients (15 shoulders) were followed up for an average of 3.7 years (range, 2.3 to 4.9 years). At 2-year follow-up, these 15 shoulders did not require revision surgery and had an average SANE score, PSS, and SST score of 74.5%, 82.9, and 10.4, respectively. Increasing age correlated positively with the SANE score (r = 0.62; P = 0.015), PSS (r = 0.52; P = 0.047), and SST score (r = 0.63; P = 0.012). Early postoperative forward elevation correlated weakly with the PSS (r = 0.24; P = 0.395), and early postoperative external rotation correlated moderately with the PSS (r = 0.53; P = 0.044). Final external rotation correlated moderately with the PSS (r = 0.69; P = 0.005).

                      Discussion: Modest results were achieved with a hemiarthroplasty and concentric glenoid reaming in young patients with end-stage glenohumeral arthritis and a biconcave glenoid. Younger age and stiffness were associated with worse outcomes. Given the high revision rate and the percentage of patients who had unsatisfactory results, this procedure should be performed only after careful patient selection. Patients who are willing and able to undergo aggressive physical therapy focused on achieving early range of motion are more likely to have a satisfactory outcome after humeral hemiarthroplasty with concentric glenoid reaming.

                          • Subspecialty:
                          • Shoulder and Elbow

                        Understanding the Basics of Computational Models in Orthopaedics: A Nonnumeric Review for Surgeons

                        Computational models represent more than just finite element analysis, a term that many clinicians may know and globally apply. Over the past 30 years, many published studies have addressed clinically relevant orthopaedic questions with speed and precision by using a wide variety of computational approaches. Given such a wide spectrum of techniques, clinicians often do not have a full understanding of the methods used to create models and therefore do not appreciate the strengths, weaknesses, and potential pitfalls of published results. The short, nonnumeric summaries of the methodologies employed for various computational approaches presented here can help address this issue.

                            • Subspecialty:
                            • General Orthopaedics

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