Showing papers in "Jbjs reviews in 2020"

Posterior Malleolar Fractures: A Critical Analysis Review.

Abstract: In patients with ankle fractures, the presence of a posterior malleolar fracture has a negative impact on the prognosis. Computed tomography (CT) scanning is essential for fracture classification and treatment planning, as the indication for surgery depends on the 3-dimensional fragment outline and displacement, incisura involvement, and the presence of joint impaction. Anatomic reduction of a posterior malleolar fragment restores the incisura, facilitating reduction of the distal part of the fibula, and it also restores the integrity of the posterior portion of the syndesmosis, reducing the need for additional syndesmotic stabilization. Direct open reduction and fixation of posterior malleolar fragments from a posterior orientation is biomechanically more stable and provides a more accurate reduction than does indirect reduction and anterior-to-posterior screw fixation. Intra-articular step-off of >=2 mm is an independent risk factor for an inferior outcome and the development of posttraumatic arthritis, irrespective of the fragment size.

Osseointegration for Amputees: Current Implants, Techniques, and Future Directions.

Abstract: Osseointegrated prostheses provide a rehabilitation option for amputees offering greater mobility, better satisfaction, and higher use than traditional socket prostheses. There are several different osseointegrated implant designs, surgical techniques, and rehabilitation protocols with their own strengths and limitations. The 2 most prominent risks, infection and periprosthetic fracture, do not seem unacceptably frequent or insurmountable. Proximal amputations or situations leading to reduced mobility are exceptionally infrequent. Osseointegrated implants can be attached to advanced sensory and motor prostheses.

Bacterial Septic Arthritis of the Adult Native Knee Joint: A Review.

Abstract: » Acute bacterial septic arthritis of the knee is an orthopaedic emergency and, if left untreated, can result in substantial joint degradation. » Important risk factors for development of septic arthritis include age of >60 years, recent bacteremia, diabetes, cancer, cirrhosis, renal disease, drug or alcohol abuse, a history of corticosteroid injection, a recent injury or surgical procedure, a prosthetic joint, and a history of rheumatoid arthritis. » The diagnosis is primarily based on history and clinical presentation of a red, warm, swollen, and painful joint with limited range of motion. Laboratory values and inflammatory markers from serum and joint fluid may serve as adjuncts when there is clinical suspicion of septic arthritis. » The initial and general antibiotic regimen should cover methicillin-resistant Staphylococcus aureus and gram-negative and gram-positive organisms. The antibiotic regimen should be specified following the culture results of the infected joint. » Operative management involves either arthrotomy or arthroscopy of the knee with thorough irrigation and debridement of all infected tissue. The Gachter classification is useful in establishing a prognosis or in determining the need for an extensive debridement.

Rotator Cuff Retears.

Abstract: » Regardless of recent advances in rotator cuff repair techniques, the rate of unhealed or recurrent rotator cuff tears remains high, with most recurrent rotator cuff tears occurring within the first 6 months after surgery. » Factors that can negatively affect tendon healing include older age, greater tear size, tendon retraction, and fatty infiltration. However, several clinical features that are often underestimated, including osteoporosis, diabetes, smoking, and hyperlipidemia, have proven to have an important influence on rotator cuff healing. » Recent meta-analyses that evaluated studies with Level-I and Level-II evidence have shown an overall increase in retear rates after single-row repair compared with double-row repair. However, to our knowledge, there are no Level-I clinical studies comparing different double-row configurations and, to date, no double-row repair technique has proven to be superior to the others. » The influence of postoperative rotator cuff healing on clinical outcomes is controversial. Although clinical differences may not be apparent in the short term, healed tendons have had better functional outcomes and greater strength in the midterm. » In general, a period of immobilization for 2 to 4 weeks, depending on tear size, is recommended. Graded supervised rehabilitation has proven to facilitate tendon healing without associated stiffness compared with early unprotected range of motion.

Dropped Head Syndrome: An Update on Etiology and Surgical Management.

Abstract: » Dropped head syndrome is a group of disorders with diverse etiologies involving different anatomical components of the neck, ultimately resulting in a debilitating, flexible, anterior curvature of the cervical spine. » Causes of dropped head syndrome include myasthenia gravis, amyotrophic lateral sclerosis, Parkinson disease, radiation therapy, and cumulative age-related changes. Idiopathic cases have also been reported. » Nonoperative treatment of dropped head syndrome includes orthotic bracing and physical therapy. » Surgical treatment of dropped head syndrome consists of cervical spine fusion to correct the deformity. » The limited data available examining the clinical and radiographic outcomes of surgical intervention indicate a higher rate of complications with the majority having favorable outcomes in the long term.

Mechanisms of Bone Tunnel Enlargement Following Anterior Cruciate Ligament Reconstruction.

Abstract: Although anterior cruciate ligament reconstruction (ACL-R) yields generally favorable results, bone tunnel enlargement (BTE) commonly has been reported after ACL-R. While the exact clinical ramifications of tibial widening on functional outcomes are variable, it is thought that widening may potentially play a role in late failure following ACL-R. The prevalence of tunnel enlargement is related particularly to hamstring autografts, with some authors reporting rates ranging from 25% to 100% in femoral tunnels and 29% to 100% in tibial tunnels after ACL-R. BTE is difficult to manage, particularly in the setting of revision ACL-R. The mechanisms underlying BTE after ACL-R are associated with a complex interplay between biological and mechanical factors.

The Biology of Sex and Sport.

Abstract: Sex and gender are not the same. Sex is defined by the human genotype and pertains to biologic differences between males and females. Gender is a fluid concept molded by self-perception, social constructs, and culturally laden attitudes and expectations of men and women. In general, males have longer limb levers, stronger bones, greater muscle mass and strength, and greater aerobic capacity. Females exhibit less muscle fatigability and faster recovery during endurance exercise. Physiologic sex-based differences have led to an average performance gap of 10% that has remained stable since the 1980s. The performance disparity is lowest for swimming and highest for track and field events. The International Olympic Committee currently mandates that female athletes with differences of sex development, or intersex traits, and transgender female athletes must limit their blood testosterone to <10 nmol/L for 12 months to be eligible for competition in the female classification.

Soft-Tissue Balancing Technology for Total Knee Arthroplasty.

Abstract: » Improperly balanced total knee arthroplasties are at increased risk for complications including residual pain and/or instability, which are often corrected by a revision surgical procedure. » Because of the morbidity and financial burden associated with revision total knee arthroplasty, different technological applications, such as tibial insert sensors and computer-assisted gap balancing, are being used to assist with soft-tissue balancing during primary total knee arthroplasty. » Computer-assisted gap balancing increases the accuracy of mechanical alignment and improves the precision of balancing flexion and extension gaps during total knee arthroplasty. It is unclear whether this translates to improved short-term or long-term outcome measures. Considerations of this technology include increased cost, increased operative time, and a steep learning curve. » Intraoperative sensors increase the accuracy of balancing by quantifying the mediolateral intercompartmental load distribution through the range of motion, which may lead to improved outcome scores, patient satisfaction, higher activity levels, and decreased pain. The advantages of this technology compared with computer assistance include decreased cost and no disruption of operative time or workflow. Limited availability with constrained implants, limited implant choices, and a lack of long-term follow-up data have reduced utilization of intraoperative sensors. » Computer-assisted gap balancing and intraoperative sensors are not yet universally accepted, and the cost-benefit ratio associated with their use remains a consideration in today’s cost-conscious health-care environment. Future research should focus on longer-term follow-up to evaluate implant survivorship, cost-effectiveness, and clinical outcomes.

Analysis of Tools Used in Assessing Technical Skills and Operative Competence in Trauma and Orthopaedic Surgical Training: A Systematic Review.

Abstract: BACKGROUND Robust assessment of skills acquisition and surgical performance during training is vital to ensuring operative competence among orthopaedic surgeons A move to competency-based surgical training requires the use of tools that can assess surgical skills objectively and systematically The aim of this systematic review was to describe the evidence for the utility of assessment tools used in evaluating operative performance in trauma and orthopaedic surgical training METHODS We performed a comprehensive literature search of MEDLINE, Embase, and Google Scholar databases to June 2019 From eligible studies we abstracted data on study aim, assessment format (live theater or simulated setting), skills assessed, and tools or metrics used to assess surgical performance The strengths, limitations, and psychometric properties of the assessment tools are reported on the basis of previously defined utility criteria RESULTS One hundred and five studies published between 1990 and 2019 were included Forty-two studies involved open orthopaedic surgical procedures, and 63 involved arthroscopy The majority (85%) were used in the simulated environment There was wide variation in the type of assessment tools in used, the strengths and weaknesses of which are assessor and setting-dependent CONCLUSIONS Current technical skills-assessment tools in trauma and orthopaedic surgery are largely procedure-specific and limited to research use in the simulated environment An objective technical skills-assessment tool that is suitable for use in the live operative theater requires development and validation, to ensure proper competency-based assessment of surgical performance and readiness for unsupervised clinical practice CLINICAL RELEVANCE Trainers and trainees can gain further insight into the technical skills assessment tools that they use in practice through the utility evidence provided

Glenohumeral Osteoarthritis: The Role for Orthobiologic Therapies Platelet-Rich Plasma and Cell Therapies

Abstract: The glenohumeral (GH) joint ranks third on the list of the large joints that are most commonly affected by osteoarthritis, after the knee and the hip.General nonsurgical modalities, including changes in daily activities, physical therapy, pharmacotherapy, and corticosteroid injections, constitute th

Radiation Exposure in Orthopaedics.

Abstract: » The damaging effects to human tissue caused by radiation exposure have been documented since the first reports regarding use of radiographs in the late nineteenth century. » Orthopaedic surgeons and residents often are undereducated about the risks associated with radiation exposure and the recommended safety precautions to help mitigate these potential risks. » Orthopaedic surgeons need to adopt the ALARA (as low as reasonably achievable) principle: whenever possible, all available precautions should be taken to keep all members of the operating room safe from radiation exposure while emphasizing the best appropriate care for patients. » An emphasis on radiation safety and protection should be universally incorporated into graduate medical education.

Three-Dimensional Printing: A Catalyst for a Changing Orthopaedic Landscape.

Abstract: Three-dimensional (3D) printing is an emerging tool in provider and patient education, surgical planning, and the design and implementation of medical devices and implants.Recent decreases in the cost of 3D printers along with advances in and cost reduction of printable materials have elevated 3D pr

Abductor Deficiency-Induced Recurrent Instability After Total Hip Arthroplasty.

Abstract: » Operative intervention for deficient hip abductor muscles may require muscle transfer or the use of synthetic materials, possibly with biologic augmentation, to help stabilize the hip joint and prevent further dislocation following total hip arthroplasty (THA). » Direct repair of the abductor mechanism onto the greater trochanter can be used in patients who present with instability <15 months following primary THA. » Augmentation of soft tissue with acellular dermal allografts can be considered for patients with abductor avulsion that requires posterior capsular reconstruction. » The Achilles tendon + calcaneal bone allograft is indicated for patients who have undergone multiple prior revision surgeries, who have experienced failure of nonoperative management, and have tissue inadequacy in the posterior wall of the hip joint. » The gluteus maximus tendon transfer is indicated in patients with chronic abductor tears, limited or loss of function in the gluteus medius and minimus, and a fully functioning gluteus maximus. » Vastus lateralis transfer may benefit patients with a history of multiple revision procedures, large separation between the gluteus medius tendon and the proximal part of the femur, and the ability to observe the postoperative protocol of splinting for 6 weeks. » The latissimus dorsi tendon transfer should be reserved as a reconstructive procedure for patients with acute abductor insufficiency, such as those who have undergone extensive tumor resection. » Synthetic mesh can be used to enable capsular reconstruction and prosthesis stabilization in patients undergoing salvage procedures for tumors of the hip and associated soft tissues. » Synthetic ligament prostheses can be used in patients with recurrent posterior dislocations in the setting of normal components. » The fascia lata plasty is indicated for patients with recurrent posterior instability without an identifiable cause. » Although the quality of literature is limited, surgical interventions utilizing techniques of soft-tissue augmentation have shown promising outcomes with regard to pain relief, limping, ambulation, and the reduction of instability following THA.

Factors Predictive of Prolonged Postoperative Narcotic Usage Following Orthopaedic Surgery.

Abstract: Background The purpose of this comprehensive review was to investigate risk factors associated with prolonged opioid use after orthopaedic procedures. A comprehensive review of the opioid literature may help to better guide preoperative management of expectations as well as opioid-prescribing practices. Methods A systematic review of all studies pertaining to opioid use in relation to orthopaedic procedures was conducted using the MEDLINE, Embase, and CINAHL databases. Data from studies reporting on postoperative opioid use at various time points were collected. Opioid use and risk of prolonged opioid use were subcategorized by subspecialty, and aggregate data for each category were calculated. Results There were a total of 1,445 eligible studies, of which 45 met inclusion criteria. Subspecialties included joint arthroplasty, spine, trauma, sports, and hand surgery. A total of 458,993 patients were included, including 353,330 (77%) prolonged postoperative opioid users and 105,663 (23%) non-opioid users. Factors associated with prolonged postoperative opioid use among all evaluated studies included body mass index (BMI) of ≥40 kg/m (relative risk [RR], 1.06 to 2.32), prior substance abuse (RR, 1.08 to 3.59), prior use of other medications (RR, 1.01 to 1.46), psychiatric comorbidities (RR, 1.08 to 1.54), and chronic pain conditions including chronic back pain (RR, 1.01 to 10.90), fibromyalgia (RR, 1.01 to 2.30), and migraines (RR, 1.01 to 5.11). Age cohorts associated with a decreased risk of prolonged postoperative opioid use were those ≥31 years of age for hand procedures (RR, 0.47 to 0.94), ≥50 years of age for total hip arthroplasty (RR, 0.70 to 0.80), and ≥70 years of age for total knee arthroplasty (RR, 0.40 to 0.80). Age cohorts associated with an increased risk of prolonged postoperative opioid use were those ≥50 years of age for sports procedures (RR, 1.11 to 2.57) or total shoulder arthroplasty (RR, 1.26 to 1.40) and those ≥70 years of age for spine procedures (RR, 1.61). Identified risk factors for postoperative use were similar across subspecialties. Conclusions We provide a comprehensive review of the various preoperative and postoperative risk factors associated with prolonged opioid use after elective and nonelective orthopaedic procedures. Increased BMI, prior substance abuse, psychiatric comorbidities, and chronic pain conditions were most commonly associated with prolonged postoperative opioid use. Careful consideration of elective surgical intervention for painful conditions and perioperative identification of risk factors within each patient's biopsychosocial context will be essential for future modulation of physician opioid-prescribing patterns. Level of evidence Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Clinical Management of Arthrofibrosis: State of the Art and Therapeutic Outlook.

Abstract: * Arthrofibrosis is a pathologic condition that is characterized by excessive periarticular scar-tissue formation. Arthrofibrosis may occur secondary to injury, surgical trauma, hemarthrosis, or infection, or it may occur idiopathically.* The pathogenesis of arthrofibrosis is incompletely understood but involves the dysregulation of normal reparative pathways, with transforming growth factor-beta (TGF-[beta]) as a principal mediator.* Current treatment options for arthrofibrosis primarily involve physiotherapy, operative manipulation, and surgical debridement, all with imperfect results.* Currently, there are no pharmacologic treatment options for arthrofibrosis. This has prompted increased investigational interest in the development of antifibrotic intra-articular therapies.

Relationship of Graft Type and Vancomycin Presoaking to Rate of Infection in Anterior Cruciate Ligament Reconstruction: A Meta-Analysis of 198 Studies with 68,453 Grafts.

Abstract: BACKGROUND Infection is a devastating complication in anterior cruciate ligament reconstruction (ACLR) surgery. Given the rarity of infection, pooling individual studies via meta-analysis can allow more meaningful evaluation of factors influencing infection rates. We aimed to determine the relationship of graft type and vancomycin graft presoaking to bacterial infection rates following ACLR. METHODS A systematic literature search was conducted on PubMed, Ovid MEDLINE, Embase, and CENTRAL (Cochrane Register of Controlled Trials). Included articles were those reporting on primary arthroscopic or open ACLR procedures, using hamstring (HT) or bone-patellar tendon-bone (BPTB) autografts or allografts of any type, with regard to the outcome of infection (deep infection or septic arthritis). Meta-analyses were performed to estimate the overall infection rates in ACLR surgery according to graft type and to examine the effect of presoaking grafts in vancomycin on infection rates. RESULTS We identified 306 bacterial infections in 68,453 grafts across 198 studies. The overall estimated ACL graft infection rate in our meta-analysis was 0.9% (95% confidence interval [CI] = 0.8% to 1.0%). HT autografts were associated with a higher infection rate (1.1%, CI = 0.9% to 1.2%) than BPTB autografts (0.7%, CI = 0.6% to 0.9%) and allografts (0.5%, CI = 0.4% to 0.8%) (Q = 15.58, p < 0.001). Presoaking HT autografts in vancomycin reduced infection rates to 0.1% (CI = 0.0% to 0.4%) (Q = 10.62, p = 0.001). CONCLUSIONS Infection following ACLR remains a rare but serious complication. HT autografts are associated with higher infection rates than other graft types. Presoaking HT autografts in vancomycin reduces infection rates by an estimated tenfold. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Surgical Approaches for Primary Total Hip Arthroplasty from Charnley to Now: The Quest for the Best Approach.

Abstract: » Total hip arthroplasty is one of the most successful surgical interventions of the last century, yet questions remain as to the best surgical approach to use in order to achieve an optimal result. The main approaches to access the hip joint, which will be reviewed in this article, have a long history in the orthopaedic literature. » The evidence behind the advantages and disadvantages of each approach also will be reviewed. In general, it can be said that the anterior approach affords the best early recovery as measured in the first 2 to 4 weeks after surgery. Lateral approaches have the lowest rates of dislocation. The posterior approach has the lowest rates of overall complications, and concerns regarding dislocation have been mitigated with the use of larger-diameter prosthetic femoral heads and advanced soft-tissue repair techniques. » In the end, the selection of approach for total hip arthroplasty should be based on surgeon experience and familiarity with the approach. The pros and cons of each approach seem to equalize by 6 weeks postoperatively. Overall, the reproducibility of the operation is a testament to its continued success.

Botulinum Toxin A Injection in Treatment of Upper Limb Spasticity in Children with Cerebral Palsy: A Systematic Review of Randomized Controlled Trials.

Abstract: Background Cerebral palsy (CP) is the most common cause of childhood disability globally. Botulinum toxin A injections are widely used to manage limb spasticity in children with CP. Intramuscular botulinum toxin A has been used in the upper limbs of children with CP to manage preoperative and postoperative pain, facilitate nursing, and achieve functional and/or cosmetic improvement of hand position. These goals are achieved primarily through reduction of spasticity. The aim of this review was to assess the evidence for the effect of botulinum toxin A injections used to manage upper limb spasticity in children with spastic CP. Specifically, we examined the role of botulinum toxin A as an adjunctive treatment to other physical therapy modalities. Additionally, we analyzed the associated complications. Methods The literature extraction process involved 4 phases: identification, screening, eligibility, and inclusion. We used a combination of Google Scholar, PubMed, and ScienceDirect. The choice of the search terms was based on the Medical Subject Headings. We extracted the relevant studies using a combination of words or terms related to (1) patient population, (2) pathology, (3) clinical intervention, and (4) anatomical distribution of pathology. Studies were included if they were randomized controlled trials conducted on children and/or adolescents with CP targeting the upper extremities in which botulinum toxin A was used as an adjunctive treatment to a primary intervention. Results The literature extraction process yielded 15 randomized controlled trials for inclusion in this review. The total number of participants enrolled in the included studies was 499, with 255 in the intervention group (51%) and 244 controls (49%). All participants in the eligible studies had unilateral spastic CP except for those in 4 studies (27%) with 198 participants (40%) that included a heterogeneous sample of unilateral and bilateral spastic CP. The mean age of participants in the intervention group ranged from 2.6 to 10.7 years among the individual studies. The mean age of participants in the control group ranged from 3.1 to 10.55 years among the individual studies. This review indicated that botulinum toxin A had a positive effect on the degree of spasticity and cosmetic appearance of the injected upper limb. The results with respect to functional gains and quality of life were either conflicting or not significant. Conclusions Randomized controlled trials of botulinum toxin A injection in the treatment of upper limb spasticity in children with CP used variable outcome measures and yielded mixed results. Overall, there is some evidence to support the use of botulinum toxin A as an adjuvant treatment to other physical therapy regimens or placebo to reduce spasticity in the short term. There is insufficient evidence to support its use as an adjunctive treatment to improve upper limb function or quality of life. The complications were acceptable and did not outweigh the clinical gains incurred. Level of evidence Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Outcome Reporting Patterns in Total Hip Arthroplasty: A Systematic Review of Randomized Clinical Trials.

Abstract: Background There has been a shift toward using patient-reported outcome measures (PROMs) to capture functional improvement and patient satisfaction after total hip arthroplasty (THA). Because there is no standard measure or set of measures, variability in reporting patterns makes comparison across studies difficult. Methods We performed a review of the literature using the keywords "total hip arthroplasty" and "total hip replacement" to electronically search PubMed, using the date range August 1, 2014, to August 1, 2019. Randomized clinical trials (RCTs) that were published in 12 high-impact journals were analyzed. Results One hundred and fifty-nine RCTs were included. The most common topic of investigation was hip implant design and materials, followed by the effect of different hip approaches on patient outcomes. The follow-up period was classified as short-term ( 10 years). Only 6% of the RCTs reported long-term outcomes. The comprehensiveness of studies was determined on the basis of how many of the 7 following outcome domains were assessed: subjective hip function (PROMs), objective outcome measures (examination findings, laboratory values, etc.), imaging analysis, survivorship, patient satisfaction, pain assessment, and postoperative complications. Subjective hip function and imaging findings were the most commonly reported outcome domains, while implant survivorship and patient satisfaction were the least frequently reported. There was substantial variation in outcome reporting, with 35 unique PROMs utilized to assess subjective hip function. Although the Harris hip score was the most commonly used joint-specific PROM, it was only reported in 42% of the studies. None of the RCTs reported results in all 7 outcome domains, and 13.8% of studies reported results in only 1 outcome domain. Conclusions There is substantial variability and a lack of comprehensiveness in outcome measures used to report results in THA clinical trials, making it nearly impossible to perform cross-study comparisons. Clinical relevance There is an immediate need for the establishment of a standardized set of measures to allow comparison of outcomes across studies.

Lateral Unicompartmental Knee Arthroplasty.

Abstract: Lateral unicompartmental knee arthroplasty affords excellent functional results and implant survivorship for properly selected patients. More high-quality studies are necessary to determine whether expanded indications for medial unicompartmental knee arthroplasty also apply to lateral unicompartmental knee arthroplasty. Operative adjuncts such as robotics, custom implants, and navigation technology hold promise in minimizing the technical burden and unfamiliarity of lateral unicompartmental knee arthroplasty. Improvements in lateral-specific implants may translate to operational efficiency and improved outcomes, but few lateral-specific implants currently exist. Mobile-bearing devices have increased rates of failure due to bearing dislocation, and further studies are warranted to evaluate this complication with newer designs. Future registry and cohort studies should show medial unicompartmental knee arthroplasty and lateral unicompartmental knee arthroplasty separately to allow for better understanding of the nuances and technical differences between these uniquely different procedures.

Anterior Interosseous Nerve Syndrome Reconsidered: A Critical Analysis Review.

Abstract: Anterior interosseous nerve syndrome (AINS) represents a form of neuralgic amyotrophy (Parsonage-Turner syndrome). AINS does not originate from external compression of the AIN in the forearm. Fascicular constrictions (FCs) of the median nerve are identified within the anterior interosseous fascicular group at or above the medial epicondyle. Spontaneous recovery is not ensured, leaving up to 30% of patients with permanent weakness or palsy. Fascicular microneurolysis of the median nerve, performed at or above the elbow, is a treatment option for patients who do not recover spontaneously.

Diagnosis and Management of Osteomyelitis in Children: A Critical Analysis Review.

Abstract: The most common causative organism of pediatric osteomyelitis is Staphylococcus aureus, although, more recently, organisms such as Kingella kingae and methicillin-resistant S aureus have been increasing in prevalence Magnetic resonance imaging is the best diagnostic imaging modality for pediatric osteomyelitis given its high sensitivity and specificity Most cases of early osteomyelitis without a drainable abscess can be adequately treated with a short course of intravenous antibiotics followed by at least 3 weeks of oral antibiotics Surgical management of pediatric osteomyelitis is usually indicated in the presence of an abscess and/or failed treatment with antibiotic therapy Clinical examination, fever, and C-reactive protein testing should be used to guide the conversion to oral antibiotics, the total antibiotic regimen duration, and the need for an additional debridement surgical procedure

Direct Anterior Approach Total Hip Arthroplasty Revisited.

Abstract: In total hip arthroplasty, the advantages of the direct anterior approach (DAA) compared with the direct lateral and posterior approaches include a true intermuscular approach that spares the abductor musculature, protects the soft tissues surrounding the hip, and thus maintains hip joint stability. The disadvantages of the DAA compared with the direct lateral and posterior approaches include a steep learning curve; intraoperative radiation exposure; injury to the nerves, vessels, and muscles; and intraoperative and early postoperative complications including blood loss, wound-healing problems, increased time under anesthesia, proximal femoral fractures and dislocations, complex femoral exposure and bone preparation, and sagittal malalignment of the stem leading to loosening and an increased revision rate. Stem implantation in flexed sagittal position and early femoral-stem failures are more common with the DAA compared with the direct lateral and posterior approaches.

Epidemiology, Diagnosis, and Management of Tibial Tubercle Avulsion Fractures in Adolescents

Abstract: Although rare, tibial tubercle avulsion fracture must be considered in the differential diagnosis for the pediatric patient presenting with acute knee pain. In the adolescent population, tibial tubercle avulsion fracture is a rare injury that is typically seen in boys who engage in sporting activities that involve jumping or sprinting. The proximal tibial physis closes distally in the posteromedial to anterolateral direction, creating an environment that predisposes the tubercle to a potential avulsion injury. Historically, the Ogden classification has guided nonoperative and operative management of this condition. Multiple fracture fixation methods have been described with the overall goal of restoring the extensor mechanism and the joint surface.

Physician-Review Websites in Orthopaedic Surgery.

Abstract: As consumerism in health care increases, physician-review websites (PRWs) are becoming a common online resource for patients to seek out information. The vast majority of ratings and comments are positive across all orthopaedic subspecialties. Surgeon-related factors that tend to be associated with higher ratings are younger age, having an active presence on social media, demonstrating trustworthiness, spending time with patients, and answering questions. Non-surgeon-related factors that tend to impact ratings include staff courtesy and ease of scheduling.

Management of Hip Disorders in Patients with Cerebral Palsy.

Abstract: Hip disorders are the second most common musculoskeletal abnormality seen in children with cerebral palsy, affecting nearly 1 in 3. The goal of surgical intervention is to provide a mobile, located, and painless hip. Reconstructive procedures are indicated for children with migration percentages of >40%. Reconstructive procedures typically result in a long-term satisfactory outcome, although recurrence is seen particularly in nonambulatory children and when the reconstruction is performed earlier than 6 years of age. Salvage procedures are performed when reconstructive procedures are no longer an option and degenerative changes have occurred. They include proximal femoral valgus osteotomy, proximal femoral resection, and hip arthroplasty.

Tibial Slope and Anterior Cruciate Ligament Reconstruction Outcomes.

Abstract: The tibial slope represents an important risk factor for both primary anterior cruciate ligament (ACL) injury and subsequent reconstruction failure. A high tibial slope has been associated with increased anterior tibial translation, increased strain on the ACL, and increased posteromedial compartment contact pressure. Patients with ACL-deficient knees who also have coronal tibiofemoral malalignment may potentially benefit from concomitant high tibial osteotomy and ACL reconstruction. Understanding the impact of the tibial slope on ACL reconstruction outcomes and the treatment options with regard to coronal tibiofemoral alignment allows for the appropriate care of patients with both morbidities.

Rehabilitation After Anatomic and Reverse Total Shoulder Arthroplasty: A Critical Analysis Review.

Abstract: Postoperative rehabilitation is believed to be essential in optimizing clinical outcome and function following shoulder arthroplasty. Despite this long-held notion, there is a paucity of high-quality evidence to guide rehabilitation protocols and practice. For patients undergoing anatomic total shoulder arthroplasty (ATSA), there are insufficient comparative data regarding type or duration of sling utilization. Based on current evidence, there is no appreciable benefit to early motion compared with a delayed-motion protocol following ATSA. There is insufficient literature to support the use of formal physical therapy over a physician-directed program following ATSA. At the present time, no high-quality evidence exists to guide the postoperative rehabilitation of patients undergoing reverse total shoulder arthroplasty (RTSA). Prospective randomized controlled trials evaluating postoperative management and rehabilitation following ATSA and RTSA are needed to guide best practices and optimize clinical outcomes.

Popliteal Artery Entrapment Syndrome.

Abstract: » Popliteal artery entrapment syndrome is a commonly misdiagnosed condition that should be considered in patients presenting with exertional lower-extremity pain. » In addition to a focused physical examination, the ankle-brachial index and advanced imaging consisting of computed tomography and computed tomographic angiography or magnetic resonance imaging and magnetic resonance angiography are crucial in evaluating the underlying cause of entrapment. » Consultation with a vascular surgeon or team is necessary when planning surgical treatment of popliteal artery entrapment syndrome.