JAAOS, Volume 15, No. 5

Since the 1970s, workforce analysis for orthopaedic surgery has predicted a surplus of physicians into the 21st century. In 1998, the RAND study predicted a surplus of 4,100 orthopaedists in 2010. As we approach 2010, we find no surplus. The projected population growth during the next 20 years of those older than age 65 years presupposes a greater need for orthopaedists, given an increase in degenerative disease and fragility fractures associated with aging. The federal government predicts an overall shortage of physicians by 2020. Given the current nature of workforce analysis models and the concerns evoked by these disparate predictions, we, the authors, advocate change. Rather than large studies separated by decades, we recommend routine monitoring of the orthopaedic workforce. Further, we suggest that national, regional, and local organizations, as well as subspecialty societies, work together to monitor current and future orthopaedic workforce needs. Orthopaedic organizations should develop collaborative relationships with experts in the field and devise a true working model that allows for ongoing strategic planning.

Bioabsorbable polymers have been used in surgery for more than four decades. With increased reliability and decreased incidence of complications, their application has become widespread. Although their role in spinal surgery continues to evolve, the theoretic biomechanical and biologic advantages over contemporary metallic and composite implant materials make bioabsorbable interbody spacers an attractive alternative. The lack of artifact on postoperative imaging studies and the ability to load share across fusion sites in a time-dependent manner can lead to more accurate fusion assessment and increased fusion rates. The preliminary data from small, short-term studies are promising. However, larger studies with long-term follow-up are lacking. The theoretic advantages of bioabsorbable materials must be tempered by the lack of long-term clinical evidence of their benefit. Until the results of more studies in human spinal applications become available, the precise indications for the use of bioabsorbable interbody spacers will continue to evolve.

Athletes are at particular risk of compromise of the neurovascular structures of the shoulder-specifically, neurovascular conditions distal to the brachial plexus. These conditions include thoracic outlet syndrome, axillary artery occlusion, effort thrombosis, suprascapular nerve entrapment, quadrilateral space syndrome, and complex regional pain syndrome. When diagnosed properly and in a timely fashion, function of the limb can be preserved. To accomplish this, the physician must possess a detailed understanding of the various clinical presentations, diagnostic techniques, and treatment options.

Free tissue transfer is a vital adjunct to orthopaedic practice; it may optimize the treatment of many emergency and elective conditions that require soft-tissue or bone augmentation. Consultation with a colleague trained in microsurgery is often necessary in undertaking free tissue transfer techniques. A two-team approach frequently is used to maximize efficiency and minimize fatigue. Flaps with reliable pedicle anatomy are preferred. Flaps typically are raised using an open technique, but endoscopic techniques can be utilized to decrease donor-site scarring. Free tissue transfer is a demanding procedure; careful preoperative planning is essential to ensure optimal results. Free tissue transfer inevitably results in some donor morbidity, and flaps are carefully chosen to minimize this. The most serious complication is failure of the flap. Free muscle flaps used in soft-tissue reconstruction today result in little loss of function.

The bunionette, or tailor's bunion, is a lateral prominence of the fifth metatarsal head. Most commonly, bunionettes are the result of a widened 4-5 intermetatarsal angle with associated varus of the metatarsophalangeal joint. When symptomatic, these deformities often respond to nonsurgical treatment methods, such as wider shoes and padding techniques. When these methods are unsuccessful, surgical treatment is based on preoperative radiographs and associated lesions, such as hyperkeratoses. In rare situations, a simple lateral eminence resection is appropriate; however, the risk of recurrence or overresection is high with this technique. Patients with a lateral bow to the fifth metatarsal are treated with a distal chevron-type osteotomy. A widened 4-5 intermetatarsal angle often requires a diaphyseal osteotomy for correction.