JAAOS

JAAOS, Volume 26, No. 19


Challenges in Treating Acromioclavicular Separations: Current Concepts

Injuries to the acromioclavicular joint constitute approximately 3.2% of shoulder injuries. Although the overall goal of treatment continues to be return to activity with a pain-free shoulder, the treatment of acromioclavicular joint separations has been fraught with conflict since the earliest reports in both ancient and modern literature. Accurate diagnosis and classification are important to determine the optimal treatment. Nonsurgical therapy remains the mainstay for treatment of low- and most mid-grade injuries, although recent biomechanical and biokinetic data might suggest that patients are more affected than traditionally thought. High-grade injuries often necessitate surgical intervention, although little consensus exists on the timing or technique. New surgical techniques continue to evolve as more biomechanical data emerge and kinematic understanding improves. Challenges associated with management of this injury abound from diagnosis to reconstruction.

      • Subspecialty:
      • Shoulder and Elbow

    Comprehensive Review of the Elbow Physical Examination

    Physical examination of the elbow is a critical component in formulating an accurate diagnosis. Various special physical examinations have been described to improve the clinician's ability to establish an accurate diagnosis. A comprehensive approach to the physical examination of the elbow, including special tests, may facilitate improved diagnosis of elbow pathology.

        • Subspecialty:
        • Elbow

        • Shoulder and Elbow

      Management of Bunionette Deformity

      Bunionette deformity, historically known as tailor's bunion, is a forefoot protuberance laterally, dorsolaterally, or plantarlaterally along the fifth metatarsal head. Although bunionette deformity has been compared to hallux valgus deformity, it is likely due to a multifactorial, anatomic interplay between fifth metatarsal bony morphology and forefoot soft-tissue imbalance. Friction generated between the bony prominence, soft tissue, and associated constrictive footwear can result in keratosis, inflammation, pain, and ulceration. Symptomatic bunionettes are usually responsive to nonsurgical management. Surgical options are available based on the underlying bony deformity when nonsurgical treatment fails.

          • Subspecialty:
          • Foot and Ankle

        Surgical Management of Patellofemoral Instability in the Skeletally Immature Patient

        Compared with skeletally mature patients, skeletally immature patients are at a higher risk of acute traumatic patellar dislocation. Surgical treatment is the standard of care for patients with recurrent instability and requires important and technically challenging physeal considerations. Physeal-sparing medial patellofemoral ligament reconstruction is the treatment of choice for these patients, replacing older nonanatomic extensor mechanism realignment techniques. Implant-mediated guided growth is an important adjunct to correct genu valgum angular deformities that contribute to patellar instability. Patient-specific surgical techniques and proper surgical indications are crucial for successful outcomes.

            • Subspecialty:
            • Trauma

            • Pediatric Orthopaedics

          Construct Validation of a Novel Hip Fracture Fixation Surgical Simulator

          Introduction: A surgical simulation platform has been developed to simulate fluoroscopically guided surgical procedures by coupling computer modeling with a force-feedback device as a training tool for orthopaedic resident education in an effort to enhance motor skills and potentially minimize radiation exposure. The objective of this study was to determine whether the simulation platform can distinguish between novice and experienced practitioners of percutaneous pinning of hip fractures.

          Methods: Medical students, orthopaedic residents, orthopaedic trauma fellows, and attending surgeons completed in situ hip-pinning simulation that recorded performance measures related to surgical accuracy, time, and use of fluoroscopy. Linear regression models were used to compare the association between performance and practitioner experience.

          Results: Notable associations were shown between performance and practitioner experience in 10 of the 15 overall measures (P < 0.05) and 9 of 11 surgical accuracy parameters (P < 0.05).

          Conclusion: This novel simulation platform can distinguish between novice and experienced practitioners and defines a performance curve for completion of simulated in situ hip pinning. This important first step lays the groundwork for subsequent validation studies, which will seek to demonstrate the efficacy of this simulator in improving clinical performance by trainees completing a sequence of skills-training modules.

              • Subspecialty:
              • Trauma

              • Adult Reconstruction

            Trends in Deep Vein Thrombosis Prophylaxis and Deep Vein Thrombosis Rates After Total Hip and Knee Arthroplasty

            Introduction: Patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) are at high risk of deep vein thrombosis (DVT) postoperatively, necessitating the use of prophylaxis medications. This investigation used a large claims database to evaluate trends in postoperative DVT prophylaxis and rates of DVT within 6 months after THA or TKA.

            Methods: Truven Health MarketScan Commercial Claims and Encounters and Medicare Supplemental and Coordination of Benefits databases were reviewed from 2004 to 2013 for patients who underwent THA or TKA. Data were collected on patient age, sex, Charlson Comorbidity Index, and hypercoagulability diagnoses. Postoperative medication claims were reviewed for prescribed aspirin, warfarin, enoxaparin, fondaparinux, rivaroxaban, and dabigatran.

            Results: A total of 369,483 patients were included in the analysis, of which 239,949 patients had prescription medication claims. Warfarin was the most commonly prescribed anticoagulant. Patients with a hypercoagulable diagnosis had markedly more DVTs within 6 months after THA or TKA. More patients with a hypercoagulable diagnosis were treated with warfarin or lovenox than other types of anticoagulants. A multivariate regression analysis was performed, showing that patients prescribed aspirin, fondaparinux, and rivaroxaban were markedly less likely than those prescribed warfarin or enoxaparin to have a DVT within 6 months after THA or TKA.

            Conclusion: After THA and TKA, warfarin is the most commonly prescribed prophylaxis. Patients with hypercoagulability diagnoses are at a higher risk of postoperative DVT. The likelihood of DVT within 6 months of THA and TKA was markedly higher in patients treated with warfarin and lovenox and markedly lower in those treated with aspirin, fondaparinux, and rivaroxaban.

            Level of Evidence: Level III

                • Subspecialty:
                • Adult Reconstruction

              Femoral Derotation Osteotomy in Adults for Version Abnormalities

              Background: Version abnormalities of the femur can cause pain and hip joint damage due to impingement or instability. A retrospective clinical review was conducted on patients undergoing a subtrochanteric derotation osteotomy for either excessive anteversion or retroversion of the femur.

              Methods: A total of 55 derotation osteotomies were performed in 43 patients: 36 females and 7 males. The average age was 29 years (range, 14 to 59 years). The osteotomies were performed closed with an intramedullary saw. Fixation was performed with a variety of intramedullary nails. Twenty-nine percent of patients had a retroversion deformity (average, −9° of retroversion; range, +2° to −23°) and 71% had excessive anteversion of the femur (average, +37° of anteversion; range, +22° to +53°). The etiology was posttraumatic in 5 patients (12%), diplegic cerebral palsy in 2 patients (5%), Prader-Willi syndrome in 1 patient (2%), and idiopathic in 35 patients (81%). Forty-nine percent underwent concomitant surgery with the index femoral derotation osteotomy, including hip arthroscopy in 40%, tibial derotation osteotomy in 13%, and a periacetabular osteotomy in 5%. Tibial osteotomies were performed to correct a compensatory excessive external tibial torsion that would be exacerbated in the correction of excessive femoral anteversion.

              Results: No patient was lost to follow-up. Failures occurred in three hips in three patients (5%): two hip arthroplasties and one nonunion that healed after rerodding. There was one late infection treated successfully with implant removal and antibiotics with an excellent final clinical outcome. At an average follow-up of 6.5 years (range, 2 to 19.7 years), the modified Harris Hip Score improved by 29 points in the remaining 52 cases (P < 0.001, Wilcoxon signed-rank test). The results were rated as excellent in 75%, good in 23%, and fair in 2%. Subsequent surgery was required in 78% of hips, 91% of which were implant removals.

              Conclusions: A closed, subtrochanteric derotation osteotomy of the femur is a safe and effective procedure to treat either femoral retroversion or excessive anteversion. Excellent or good results were obtained in 93%, despite the need for subsequent implant removal in more than two-thirds of the patients.

                  • Subspecialty:
                  • Adult Reconstruction

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