JAAOS, Volume 26, No. 24

Biomechanics and Clinical Outcomes of Partial Meniscectomy

Partial meniscectomy for meniscus tears is one of the most common procedures performed by orthopaedic surgeons. Much research has been done to evaluate the biomechanical consequences and clinical outcomes from meniscus débridement. Biomechanically, as the portion of the meniscus that is removed increases, greater contact pressures are experienced by the cartilage, which leads to altered knee mechanics. The use of partial meniscectomy to manage degenerative meniscus tears in knees with mild preexisting arthritis and mechanical symptoms may be beneficial; however, its routine use in the degenerative knee over physical therapy alone is not supported. In younger populations, partial meniscectomy may provide equal long-term symptom relief, earlier return to play, and lower revision surgery rate compared with meniscal repair. Partial meniscectomy may result in earlier development of osteoarthritis. Treatment should be patient specific in a shared-decision making process with the patient after discussion about known outcomes.

      • Subspecialty:
      • Knee

      • Sports Medicine

      • Adult Reconstruction

    Surgical Management of Atypical Femur Fractures Associated With Bisphosphonate Therapy

    Atypical femur fractures associated with long-term bisphosphonate use can be challenging injuries to manage. Not only do they have a prolonged healing time and increased rate of nonunion as compared to typical femur fractures, intraoperative complications are not infrequent and can be catastrophic. Given the pathologic nature of these fractures, a multidisciplinary approach to the patient's care is necessary. Treatment begins with medical optimization and careful surgical planning. Radiographic characteristics of the fracture and femoral osteology dictate reduction strategy, adjunctive surgical techniques, and implant choice. Intraoperative complications including malreduction, iatrogenic fracture, and fracture propagation can be avoided with thoughtful planning. The purpose of this article is to discuss the technical aspects of surgical management of atypical femur fractures. We also discuss management of intraoperative complications and treatment failure. Finally, we provide an update on recommendations for postoperative medical treatment and management of the contralateral femur.

        • Subspecialty:
        • Trauma

      Challenges of Medical Care Delivery in Professional Sports: Lessons From Professional Baseball

      Team medical management for professional sports teams is a demanding and high-risk activity. Every different sport has unique features and the stresses athletes place on themselves, be it from collisions or repetitive stress, result in specific challenges for the medical team and team organization in general. Injuries in professional sports are costly both to the player and organization. The challenges of managing a professional baseball team exemplify these concerns and correlate well with other professional sports. Multiple strategies exist for improvement of medical care in baseball based on observed deficiencies in player evaluation, injury prevention, and injury treatment, which will require prospective evaluation to determine their success. These include draft strategies, individualized motion and strength analyses, customized in-season and off-season training programs for individuals, and standardized treatment protocols for injuries all based on best practices. Best practices are currently poorly defined in all of these areas.

          • Subspecialty:
          • Sports Medicine

        Implementation of a Hip Fracture Care Pathway Using Lean Six Sigma Methodology in a Level I Trauma Center

        Introduction: The application of Lean Six Sigma (LSS) methodology with regard to hip fracture care remains unexamined. The aim of this study is to illustrate the application of LSS principles in the implementation of a hip fracture integrated care pathway (ICP).

        Methods: A multidisciplinary team at a level I trauma center formed a hip fracture ICP using LSS principles. An ICP aimed toward decreasing time to surgery to <48 hours was implemented in April 2012.

        Results: A total of 505 hip fracture patients met inclusion criteria. A total of 221 patients entered the preimplementation cohort, and 284 were incorporated in the postimplementation cohort. The percentage of patients who received surgical fixation beyond 48 hours significantly decreased (9.50% versus 4.23%; P = 0.01). Significantly more complications were detected in the postimplementation cohort (62.44% versus 80.10%; P < 0.01). The postimplementation cohort showed a significantly shorter length of stay (P = 0.02) and decreased hospital cost (P = 0.016).

        Conclusion: Our findings suggest that using LSS methods in an ICP at our institution resulted in markedly greater percentage of patients receiving surgical care within 48 hours, greater detection of complication, and reduced resource consumption.

            • Subspecialty:
            • Trauma

          Incidence and Risk Factors for Postoperative Hypothermia After Orthopaedic Surgery

          Introduction: Postoperative hypothermia is a common complication of orthopaedic surgery associated with increased morbidity. We identified the incidence and risk factors for postoperative hypothermia across orthopaedic surgical procedures.

          Methods: A total of 3,822 procedures were reviewed. Hypothermia was defined as temperature <36.0°C. Incidences were calculated and associated risk factors were evaluated by mixed-effects regression analyses.

          Results: Hypothermia was observed in 72.5% of patients intraoperatively and 8.3% postoperatively. Risk factors for postoperative hypothermia included intraoperative hypothermia (odds ratio [OR], 2.72), lower preoperative temperature (OR, 1.46), female sex (OR, 1.42), lower body mass index (OR, 1.06 per kg/m2), older age (OR, 1.02 per year), adult reconstruction by specialty (OR, 4.06), and hip and pelvis procedures by anatomic region (OR, 8.76).

          Discussion: Intraoperative and postoperative hypothermia are common in patients who have undergone orthopaedic surgery. The high-risk groups identified in this study warrant increased attention and should be targets for interventions to prevent hypothermia and limit morbidity.

          Level of Evidence: Level IV, prognostic study

              • Subspecialty:
              • General Orthopaedics

            Comparative Utilization of Reverse and Anatomic Total Shoulder Arthroplasty: A Comprehensive Analysis of a High-volume Center

            Introduction: The purpose of this study was to determine how reverse and total shoulder arthroplasty (RTSA and TSA) comparative utilization, postoperative diagnoses, demographics, and perioperative data have changed between 2005 and 2015.

            Methods: This was a single-center retrospective review of all primary TSAs and RTSAs.

            Results: Our cohort included 1,192 RTSAs and 1,600 TSAs. Although both RTSA and TSA volume increased, RTSA increased from 27% to 52% of shoulder arthroplasty. The number of RTSAs performed for osteoarthritis and irreparable rotator cuff tears increased, and the proportion of RTSAs performed for rotator cuff tear arthropathy decreased. The mean age decreased for RTSA and TSA, and American Society of Anesthesiologists scores increased for both.

            Discussion: Over the past decade, RTSA has become the most common primary shoulder arthroplasty, reflecting the clinical success of the procedure. This increase is due to both an increase in the number of RTSAs performed for rotator cuff tear arthropathy as well as expanding surgical indications for RTSA.

            Level of Evidence: Retrospective, level IV

                • Subspecialty:
                • Shoulder and Elbow

              Using Patient-reported Outcomes Measurement Information System Measures to Understand the Relationship Between Improvement in Physical Function and Depressive Symptoms

              Introduction: This investigation determined whether improved physical function and decreased pain would reduce depressive symptoms using the Patient-reported Outcomes Measurement Information System (PROMIS).

              Methods: This cohort study analyzed PROMIS Depression, Physical Function, and Pain Interference CAT scores from 3,339 patients presenting to a tertiary orthopaedic center. Patients demonstrating at least a-five point (effect size, 0.5) improvement in PROMIS Physical Function between consecutive visits were eligible for inclusion.

              Results: Patients presented, on average, with Physical Function and Pain Interference scores nearly one SD worse than population averages and Depression scores that approximated the normal population. Improved Physical Function and Pain Interference scores demonstrated no correlation with change in Depression scores (r = −0.13; r = 0.25).

              Conclusion: Substantial early improvement in PROMIS Physical Function scores is not associated with change in PROMIS Depression scores. PROMIS Depression scores likely reflect underlying mental health rather than situational depressive symptoms.

              Level of Evidence: Prognostic, level III

                  • Subspecialty:
                  • General Orthopaedics