JAAOS, Volume 22, No. 9

ACGME Duty Hour Requirements: Perceptions and Impact on Resident Training and Patient Care

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) created national guidelines for resident work hours to promote safe care and high-quality learning. However, some reports suggested that the 2003 rules did not reduce resident fatigue or improve patient care. Since July 2011, further restrictions have been in effect. The changes have been the source of much controversy regarding their impact on resident education and patient safety. We reviewed existing literature on the effects of the new and old rules, with a focus on the field of orthopaedics. In addition, we conducted a national survey of orthopaedic residents and residency directors to assess the general opinions of the orthopaedic community. Overall, only 19.7% of all respondents were satisfied with the new 2011 regulations, whereas 58.9% believe the 80-hour work week averaged over 4 weeks is appropriate. The results will inform discussions and decisions related to changing residency education in the future.

      • Subspecialty:
      • General Orthopaedics

    Os Trigonum Syndrome

    Os trigonum syndrome is the result of an overuse injury of the posterior ankle caused by repetitive plantar flexion stress. It is predominantly seen in ballet dancers and soccer players and is primarily a clinical diagnosis of exacerbated posterior ankle pain while dancing on pointe or demi-pointe or while doing push-off maneuvers. Symptoms may improve with rest or activity modification. Imaging studies, including a lateral radiographic view of the ankle in maximal plantar flexion, will typically reveal the os trigonum between the posterior tibial lip and calcaneus. If an os trigonum is absent on radiography, an MRI may reveal scar tissue behind the posterior talus, a condition associated with similar symptoms. Os trigonum syndrome is often associated with pathology of the flexor hallucis longus tendon. Treatment begins with nonsurgical measures. In addition to physical therapy, symptomatic athletes may need surgical excision of os trigonum secondary to unavoidable plantar flexion associated with their sport. This surgery can be performed using open or arthroscopic approaches.

        • Subspecialty:
        • Sports Medicine

      Etiology, Diagnosis, and Management of Failed SLAP Repair

      In general, favorable outcomes have been achieved with arthroscopic repair of superior labral anterior-posterior (SLAP) tears. However, some patients remain dissatisfied or suffer further injury after SLAP repair and may seek additional treatment to alleviate their symptoms. The cause of persistent pain or recurrent symptoms after repair is likely multifactorial; therefore, careful preoperative workup is required to elucidate the cause of pain. Review of the details of previous surgical procedures is crucial because certain fixation methods are prone to failure or can cause additional injury. Failed SLAP repair can be managed with nonsurgical or surgical options. Nonsurgical modalities include physical therapy and strengthening programs, anti-inflammatory agents, and activity modification. Surgical options include revision SLAP repair and biceps tenotomy or tenodesis with or without revision SLAP repair. Outcomes after surgical management of failed SLAP repair are inferior to those of primary repair. Select patients may be better served by primary biceps tenodesis rather than SLAP repair.

          • Subspecialty:
          • Shoulder and Elbow

        Controversies in the Management of Distal Radius Fractures

        Controversies span the entire spectrum of management of distal radius fractures—fracture assessment, diagnosis, treatment, and evaluation of outcomes. The utility of multiple radiographic views described in the literature has not been validated. Likewise, the several classification systems that exist have yet to demonstrate substantial interobserver and intraobserver reliability. Nonsurgical controversies involve fracture reduction, use of anesthesia, type of fracture immobilization, and forearm position during healing. Surgical controversies include surgical indications, need for release of carpal tunnel, fracture fixation method, and the need for augmentation (ie, bone graft). Postoperatively, rehabilitation, medication, and physical therapy also remain highly controversial. The best outcome measure has yet to be established. A strong need remains for high-level, prospective studies to determine the most effective way to assess, diagnose, treat, and measure outcomes in patients with distal radius fractures.

            • Subspecialty:
            • Hand and Wrist

          The Effects of Fitness on the Aging Process

          Decades of research support the fact that much age-related deterioration is the result of the effects of sedentary lifestyles and the development of medical conditions rather than of aging itself. Elite older athletes, who demonstrate enhanced performance compared with historic cohorts and even some younger peers, are models of this paradigm. Many non-elite middle-aged adults and older adults continue to remain increasingly active throughout middle age and beyond. A continually growing body of basic science and clinical evidence demonstrates how active persons modulate physical decline through training. An updated understanding of how active adults defy age helps orthopaedic surgeons not only manage their patients' performance but also improve their lives. A large segment of sedentary older adults will benefit from counseling that encourages the pursuit of more active and healthier lifestyles.

              • Subspecialty:
              • Sports Medicine

            Malignant Transformation in Chronic Osteomyelitis: Recognition and Principles of Management

            Malignant transformation as a result of chronic osteomyelitis represents a relatively rare and late complication with a declining incidence in the modern world. For most patients, the interval between the occurrence of the original bacterial infection and the transformation to malignant degeneration is several years. The diagnosis of malignant transformation in a chronic discharging sinus requires a high index of clinical suspicion. Wound biopsies should be obtained early, especially with the onset of new clinical signs such as increased pain, a foul smell, and changes in wound drainage. Squamous cell carcinoma is the most common presenting malignancy. Definitive treatment is amputation proximal to the tumor or wide local excision, combined with adjuvant chemotherapy and radiation therapy in selected patients. Early diagnosis may sometimes allow for treatment consisting of en bloc excision and limb salvage techniques. However, the most effective treatment is prevention with definitive treatment of the osteomyelitis, including adequate débridement, wide excision of the affected area, and early reconstruction.

                • Subspecialty:
                • Basic Science

              Direct Anterior Approach for Total Hip Arthroplasty: Indications, Technique, and Results

              The direct anterior approach (DAA) to the hip was initially described in the 19th century and has been used sporadically for total hip arthroplasty (THA). In the past decade, enthusiasm for the approach has been renewed because of increased demand for minimally invasive techniques. New surgical instruments and tables designed specifically for use with the DAA for THA have made the approach more accessible to surgeons. Some authors claim that this approach results in less muscle damage and pain as well as rapid recovery, although limited data exist to support these claims. The DAA may be comparable to other THA approaches, but there is no evidence to date that shows improved long-term outcomes for patients. The steep learning curve and complications unique to this approach (fractures and nerve damage) have been well described. However, the incidence of these complications decreases with greater surgeon experience. A question of keen interest to hip surgeons and patients is whether the DAA results in improved early outcomes and long-term results comparable to those of other approaches for THA.

                  • Subspecialty:
                  • Adult Reconstruction