JAAOS, Volume 22, No. 12

Surgical Treatment of Flail Chest and Rib Fractures

Despite significant advances in critical care management, flail chest remains a clinically significant finding, with a mortality rate of up to 33%. Nonsurgical management is associated with prolonged ventilator support, pneumonia, respiratory difficulties, and lengthy stays in the intensive care unit, as well as chronic pain from nonunion and malunion of the bony thorax. Treatment with aggressive pulmonary toilet, ventilator support, and different modalities of pain control remains the benchmark of care. However, several recent randomized controlled studies of surgical intervention of flail chest have demonstrated an improvement in the number of ventilator days, intensive care unit and hospital stays, incidence of pneumonia, and respiratory function and hospital costs, as well as faster return to work. The success of these surgical constructs compared with those of historical attempts at open fixation is largely the result of modern plating technology and improvement in surgical approaches. Clinical evidence continues to grow regarding proper indications and techniques for surgical stabilization of flail chest.

      • Subspecialty:
      • Trauma

    Acute Management of Shoulder Dislocations

    The shoulder joint has the greatest range of motion of any joint in the body. However, it relies on soft-tissue restraints, including the capsule, ligaments, and musculature, for stability. Therefore, this joint is at the highest risk for dislocation. Thorough knowledge of the shoulder's anatomy as well as classification of dislocations, anesthetic techniques, and reduction maneuvers is crucial for early management of acute shoulder dislocation. Given the lack of comparative studies on various reduction techniques, the choice of technique is based on physician preference. The orthopaedic surgeon must be well versed in several reduction methods and ascertain the best technique for each patient.

        • Subspecialty:
        • Shoulder and Elbow

      Antibiotic Stewardship in Orthopaedic Surgery: Principles and Practice

      A thorough knowledge of the principles of antibiotic stewardship is a crucial part of high-quality orthopaedic surgical care. These principles include (1) determining appropriate indications for antibiotic administration, (2) choosing the correct antibiotic based on known or expected pathogens, (3) determining the correct dosage, and (4) determining the appropriate duration of treatment. Antibiotic stewardship programs have a multidisciplinary staff that can help guide antibiotic selection and dosage. These programs also perform active surveillance of antimicrobial use and may reduce Clostridium difficile and other drug-resistant bacterial infections by providing expert guidance on judicious antibiotic usage. The emergence of antibiotic-resistant pathogens, the geographical diversity of these infecting pathogens, and the changing patient population require customization of prophylactic regimens to reduce infectious complications. A multidisciplinary approach to antibiotic stewardship can lead to improved patient outcomes and cost-effective medical care.

          • Subspecialty:
          • General Orthopaedics

        Identification of Common Gait Disruption Patterns in Children With Cerebral Palsy

        Identification and classification of common gait deviation patterns in children with cerebral palsy facilitates communication between healthcare providers, provides insight into the natural history of functional ambulation, guides clinical decision making, and clarifies outcomes assessment. Previous classification schemes have been based on experiential and intuitive approaches or systematic and analytical approaches. The current gait disruption classification system has been refined to incorporate the most clinically useful aspects of previous systems. This paradigm uses the concept of primary versus compensatory deviations to identify common patterns and common causes for these patterns. The primary sagittal plane patterns include jump, crouch, and stiff gait. The primary transverse plane patterns include internal, external, and neutral progression gait. Apparent coronal plane deviation patterns are usually the consequence of sagittal and transverse plane deviations seen out of plane. Individualized assessment is essential because of the great variation in and combinations of possible patterns.

            • Subspecialty:
            • Pediatric Orthopaedics

          Update on Zone II Flexor Tendon Injuries

          Flexor tendon repair in zone II is particularly challenging because tendon gliding must be restored within a tight fibro-osseous sheath while minimizing the formation of adhesions in surrounding tissues. Meticulous surgical technique using a multistrand core suture and a peripheral suture is needed to produce a tendon that is strong enough to withstand early mobilization. Mechanical strength increases with the number of strands crossing the repair, regardless of the core suture configuration. Early mobilization after flexor tendon repair enhances the strength of the repair and decreases the risk of adhesions and joint stiffness. Satisfactory results have been achieved with either early passive or early active motion rehabilitation protocols; therefore, the choice of postoperative rehabilitation program is at the discretion of the surgeon. Factors such as repair integrity, concurrent injuries, and anticipated patient compliance should be considered in the decision-making process.

              • Subspecialty:
              • Hand and Wrist

            Three-dimensional Intraoperative Imaging Modalities in Orthopaedic Surgery: A Narrative Review

            Intraoperative imaging and navigation systems have revolutionized orthopaedic surgery for the spine, joints, and orthopaedic trauma. Imaging modalities such as the isocentric C-arm, O-arm imaging, and intraoperative MRI or navigation systems allow the visualization of surgical instruments and implants relative to a three-dimensional CT image or MRI. Studies show that these technologies lower the rates of implant misplacement and inadequate fracture reduction, thereby improving surgical outcomes and reducing reoperation rates. An additional benefit is reduced radiation exposure compared with that for conventional fluoroscopy. Concerns surrounding adoption of these technologies include cost and increased operating times, but improvements in design and protocol may improve the integration of these imaging modalities into the operating room.

                • Subspecialty:
                • Spine

              Elbow Arthroscopy: Indications, Techniques, Outcomes, and Complications

              Elbow arthroscopy is a tool useful for the treatment of a variety of pathologies about the elbow. The major indications for elbow arthroscopy include débridement for septic elbow arthritis, synovectomy for inflammatory arthritis, débridement for osteoarthritis, loose body extraction, contracture release, treatment of osteochondral defects and selected fractures or instability, and tennis elbow release. Contraindications, technical considerations, and favorable outcomes following treatment with elbow arthroscopy require careful patient evaluation, a thorough understanding of anatomic principles, and proper patient positioning and portal selection to guide preoperative planning and overall patient care. Elbow arthroscopy is an effective procedure for the treatment of inflammatory arthritis, osteoarthritis, and lateral epicondylitis.

                  • Subspecialty:
                  • Shoulder and Elbow