JAAOS

JAAOS, Volume 27, No. 12


Challenges to Orthopaedic Resident Education

Orthopaedic resident educators confront many important issues. This may be the most challenging time yet for orthopaedic education. A survey of program directors and chairs aimed to identify the major challenges in orthopaedic education. Many issues were identified, and the following four major themes emerged: (1) loss of professionalism, (2) too much emphasis on procedures, (3) lack of clinical experience, and (4) challenges with external oversight. Professionalism in taking care of patients may be compromised by work-hour limitations and affected by generational differences. Limitations to progressive, graduated responsibility include internal and external factors, resulting in a lack of opportunity. Overemphasis on case volume fosters a training environment where technical skill is seen as most important and can detract from teaching the basic principles of being a doctor, including shared decision making. This paper explores these major challenges to orthopaedic resident education in 2018. Substantial changes will be required to address these challenges, but better understanding of the issues they face should help educators identify, minimize, or ideally avoid threats to optimal resident education.

      • Subspecialty:
      • General Orthopaedics

    Revision Reverse Shoulder Arthroplasty

    As shoulder arthroplasty becomes increasingly common, the burden of revision shoulder arthroplasty is also increasing. Revision reverse shoulder arthroplasty requires an understanding of the causes of failure and the evaluation of these causes and their sequelae, including infection, instability, component loosening, humeral bone loss, and glenoid bone loss. Revision reverse shoulder arthroplasty is technically complex. On the humeral side, corticotomy may be required for component removal, and bone grafting may be necessary to achieve rotational stability and to restore humeral length and avoid undertensioning and instability. On the glenoid side, bone loss is common, structural bone grafting is not infrequently required, and proper component positioning is required to avoid impingement and component loosening. Although the outcomes are generally inferior to primary reverse total shoulder arthroplasty and complications and revision surgeries are common, revision procedures still lead to notable improvements in pain, motion, and function.

        • Subspecialty:
        • Shoulder and Elbow

      Treatment of Adhesive Capsulitis of the Shoulder

      Adhesive capsulitis presents clinically as limited, active and passive range of motion caused by the formation of adhesions of the glenohumeral joint capsule. Radiographically, it is thickening of the capsule and rotator interval. The pathology of the disease, and its classification, relates to inflammation and formation of extensive scar tissue. Risk factors include diabetes, hyperthyroidism, and previous cervical spine surgery. Nonsurgical management includes physical therapy, corticosteroid injections, extracorporeal shock wave therapy, calcitonin, ultrasonography-guided hydrodissection, and hyaluronic acid injections. Most patients will see complete resolution of symptoms with nonsurgical management, and there appears to be a role of early corticosteroid injection in shortening the overall duration of symptoms. Surgical intervention, including manipulation under anesthesia, arthroscopic capsular release both limited and circumferential, and the authors' technique are described in this article. Complications include fracture, glenoid and labral injuries, neurapraxia, and rotator cuff pathology. Postoperative care should always include early physical therapy.

      STATUSONLINE-ONLY

          • Subspecialty:
          • Shoulder and Elbow

        Cervical Spine Deformity: Indications, Considerations, and Surgical Outcomes

        Cervical spinal deformity (CSD) in adult patients is a relatively uncommon yet debilitating condition with diverse etiologies and clinical manifestations. Similar to thoracolumbar deformity, CSD can be broadly divided into scoliosis and kyphosis. Severe forms of CSD can lead to pain; neurologic deterioration, including myelopathy; and cervical spine–specific symptoms such as difficulty with horizontal gaze, dysphagia, and dyspnea. Recently, an increased interest is shown in systematically studying CSD with introduction of classification schemes and treatment algorithms. Both major and minor complications after surgical intervention have been analyzed and juxtaposed to patient-reported outcomes. An ongoing effort exists to better understand the relationship between cervical and thoracolumbar spinal alignment, most importantly in the sagittal plane.

        STATUSONLINE-ONLYCMEYES

            • Subspecialty:
            • Spine

          Reducing Lateral Femoral Cutaneous Nerve Palsy in Obese Patients in the Beach Chair Position: Effect of a Standardized Positioning and Padding Protocol

          Introduction: To report on the effectiveness of a standardized patient positioning and padding protocol in reducing lateral femoral cutaneous nerve (LFCN) palsy in obese patients who have undergone shoulder surgery in the beach chair position.

              • Subspecialty:
              • General Orthopaedics

            Synthetic Graft Compared With Allograft Reconstruction for Extensor Mechanism Disruption in Total Knee Arthroplasty: A Multicenter Cohort Study

            Background: Extensor mechanism disruption after total knee arthroplasty is a serious complication leading to notable patient morbidity. The purpose of this study is to compare the outcomes of extensor mechanism allograft with synthetic graft reconstruction.

                • Subspecialty:
                • Adult Reconstruction

              Three Different Databases, Three Different Complication Rates for Knee and Hip Arthroplasty: Comparing the National Inpatient Sample, National Hospital Discharge Survey, and National Surgical Quality Improvement Program, 2006 to 2010

              Background: National databases are increasingly used to research complication rates, risk factors, and the role of comorbidities. Three commonly used databases are the Healthcare Cost and Utilization Program's National Inpatient Sample (NIS), the National Hospital Discharge Survey (NHDS), and the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). Despite many publications, the accuracy of results from these databases remains unclear.

                  • Subspecialty:
                  • Adult Reconstruction

                Fracture of a Carbon Fiber Reinforced Intramedullary Femoral Nail

                Carbon fiber reinforced implants have emerged as an alternative to traditional stainless steel and titanium implants because of the improved visibility on advanced imaging and excellent biomechanical strength. This can be advantageous in patients with concern about fracture healing, tumor recurrence, or additional imaging requirements. However, limited long-term data are available to present complications from the use of these implants. We present the case of a failure of a carbon fiber reinforced intramedullary femoral nail used in a closed distal femur fracture.

                STATUSONLINE-ONLY

                    • Subspecialty:
                    • General Orthopaedics

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