JAAOS

JAAOS, Volume 27, No. 5


Degenerative Rotator Cuff Tears: Refining Surgical Indications Based on Natural History Data

Degenerative rotator cuff tears are the most common cause of shoulder pain and have a strong association with advanced aging. Considerable variation exists in surgeons' perceptions on the recommended treatment of patients with painful rotator cuff tears. Natural history studies have better outlined the risks of tear enlargement, progression of muscle degeneration, and decline in the function over time. This information combined with the known factors potentially influencing the rate of successful tendon healing such as age, tear size, and severity of muscle degenerative changes can be used to better refine appropriate surgical indications. Although conservative treatment can be successful in the management of many of these tears, risks to nonsurgical treatment also exist. The application of natural history data can stratify atraumatic degenerative tears according to the risk of nonsurgical treatment and better identify tears where early surgical intervention should be considered.

      • Subspecialty:
      • Shoulder and Elbow

    Medial Unicompartmental Arthroplasty of the Knee

    Indications for medial unicompartmental knee arthroplasty (UKA) have expanded over the past two decades. Proposed advantages include faster recovery, improved kinematics, and better functional outcomes compared with total knee arthroplasty (TKA) in age-matched control subjects. A focused preoperative examination and imaging is essential to identify appropriate surgical candidates. No difference has been demonstrated between fixed- and mobile-bearing implants for implant survivorship or patient-reported outcomes. The most common reasons for conversion to a TKA are aseptic loosening and progression of osteoarthritis. Ten-year survival for UKA in cohort studies has shown to be >90% with outcomes after conversion to TKA being similar to outcomes for revision TKA. Registries have consistently shown lower implant survival for UKA compared with that for TKA, which is likely secondary to use of several different implants by surgeons of varying levels of experience. UKA has the potential to be a cost-effective alternative to TKA in certain patient populations when performed at high-volume centers with advanced surgical techniques.

        • Subspecialty:
        • Adult Reconstruction

      Necrotizing Soft-tissue Infections: An Orthopaedic Emergency

      Necrotizing soft-tissue infections are caused by a variety of bacterial pathogens that may affect patients at any age or health status. This orthopaedic emergency initially presents with nonspecific signs such as erythema and edema. As the disease progresses, classic signs such as bullae, cutaneous anesthesia, ecchymosis, tense edema, and gas can be seen. A high level of suspicion is needed to properly identify and treat in a timely manner. Pain out of proportion to presentation and rapid progression even with appropriate antibiotic treatment should heighten suspicion of a necrotizing soft-tissue infection. The mainstay of management is extensive débridement and decompression of all necrotic tissue and broad-spectrum antibiotics. Débridements are repeated to ensure that disease progression has been halted. Early surgical débridements should take precedent over transfer because of the high rate of limb loss and mortality as a result of surgical delay.

      STATUSONLINE-ONLY

          • Subspecialty:
          • General Orthopaedics

        Robotic-assisted Medial Unicompartmental Knee Arthroplasty: Options and Outcomes

        Medial unicompartmental knee arthroplasty (UKA) has several benefits over total knee arthroplasty for the surgical treatment of isolated medial compartmental arthritis in the knee, including reduced surgical risk and postoperative morbidity, rapid recovery, more normal kinematics, greater patient satisfaction, and shorter hospitalization. Nonetheless, there is substantial concern about the higher revision rates and lower survivorship in UKA compared to those in total knee arthroplasty. Robotic assistance has been advanced to improve the precision of bone preparation, component alignment, and quantified ligament balance in UKA, with the ultimate goal of improving kinematics and implant survivorship. Two currently available semiautonomous robotic platforms have demonstrated improved accuracy, and emerging short-term follow-up has demonstrated satisfactory functional outcomes. Further studies will be needed to determine if these technologies indeed have a meaningful impact on patient outcomes and survivorship in the mid- to long term.

        STATUSONLINE-ONLY

            • Subspecialty:
            • Adult Reconstruction

          Three-dimensional Bioprinting for Bone and Cartilage Restoration in Orthopaedic Surgery

          Notable shortcomings exist in the currently available surgical options for reconstruction of bone and articular cartilage defects. Three-dimensional (3D) printing incorporating viable cells and extracellular matrix, or 3D bioprinting, is an additive manufacturing tissue engineering technique that can be used for layer-by-layer fabrication of highly complex tissues such as bone and cartilage. Because of the scalability of 3D bioprinting, this technology has the ability to fabricate tissues in clinically relevant volumes and addresses the defects of varying sizes and geometries. To date, most of our in vitro and in vivo success with cartilage and bone tissue bioprinting has been with extrusion-based bioprinting using alginate carriers and scaffold free bioinks. Fabrication of composite tissues has been achieved, including bone which includes vascularity, a necessary requisite to tissue viability. As this technology evolves, and we are able to integrate high-quality radiographic imaging, computer-assisted design, computer-assisted manufacturing, with real-time 3D bioprinting and ultimately in situ surgical printing, this additive manufacturing technique can be used to reconstruct both bone and articular cartilage and has the potential to succeed where our currently available clinical technologies and tissue manufacturing strategies fail.

          STATUSONLINE-ONLY

              • Subspecialty:
              • General Orthopaedics

            The Healing Rate of Type II Odontoid Fractures Treated With Posterior Atlantoaxial Screw-rod Fixation: A Retrospective Review of 77 Patients

            Background: In theory, temporary posterior atlantoaxial screw-rod fixation for type II odontoid fractures is a way to preserve rotatory motion. However, the healing rate of type II odontoid fractures treated in this way is unknown; that is, the risk associated with conducting a temporary screw-rod fixation for type II odontoid fractures is unknown. This study investigates the healing rate of type II odontoid fractures treated with posterior atlantoaxial screw-rod fixation by CT imaging and evaluates the feasibility of conducting a temporary screw-rod fixation for type II odontoid fractures.

                • Subspecialty:
                • Trauma

                • Spine

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