JAAOS, Volume 23, No. 2

Perioperative Implications of End-stage Renal Disease in Orthopaedic Surgery

End-stage renal disease is a prevalent condition that substantially impacts a patient's quality of life. As medical advancements improve function and rates of survival, the number of persons with end-stage renal disease will grow, with orthopaedic surgeons increasingly encountering patients with the disease in their practice. End-stage renal disease is a complex medical condition that is often associated with multiple medical comorbidities. Orthopaedic surgery in patients with this disease is associated with at least a twofold risk of complications and mortality compared with a population without end-stage renal disease. Patients are at an increased risk for cardiovascular, metabolic, hematologic, and infectious complications. Orthopaedic surgeons should be familiar with pertinent issues in the preoperative evaluation and the postoperative management of these patients and should understand the risks of surgery to better inform patients and family. Careful coordination with consulting specialists is necessary to minimize morbidity and improve outcome.

      • Subspecialty:
      • General Orthopaedics

    The Need for Structural Allograft Biomechanical Guidelines

    Because of their osteoconductive properties, structural bone allografts retain a theoretic advantage in biologic performance compared with artificial interbody fusion devices and endoprostheses. Present regulations have addressed the risks of disease transmission and tissue contamination, but comparatively few guidelines exist regarding donor eligibility and bone processing issues with a potential effect on the mechanical integrity of structural allograft bone. The lack of guidelines appears to have led to variation among allograft providers in terms of processing and donor screening regarding issues with recognized mechanical effects. Given the relative lack of data on which to base reasonable screening standards, we undertook basic biomechanical evaluation of one source of structural bone allograft, the femoral ring. Of our tested parameters, the minimum and maximum cortical wall thicknesses of femoral ring allograft were most strongly correlated with the axial compressive load to failure of the graft, suggesting that cortical wall thickness may be a useful screening tool for compressive resistance expected from fresh cortical bone allograft. Development of further biomechanical and clinical data to direct standard development appears warranted.

        • Subspecialty:
        • Spine

      External Fixation of Tibial Fractures

      External fixation for definitive or initial management of tibial fractures has a long history, with pin-to-bar external fixation being the standard of care for definitive management of tibial fractures. However, the use of this method lessened because of the increased popularity of intramedullary nailing and drawbacks associated with external fixation. This method is still commonly in use in the military environment and can be used for temporary stabilization of tibial fractures, especially in the setting of periarticular injuries. These fixators also may be useful for salvage of open and/or infected fractures that are unsuitable for internal fixation.

          • Subspecialty:
          • Trauma

        Management of Hip Fractures in the Elderly

        The purpose of this clinical practice guideline is to help improve treatment and management of hip fractures in the elderly based on current best evidence. The guideline contains twenty-five recommendations, including both diagnosis and treatment. Of those recommendations, strong evidence supports regional analgesia to improve preoperative pain control, similar outcomes for general or spinal anesthesia, arthroplasty for patients with unstable (displaced) femoral neck fractures, the use of a cephalomedullary device for the treatment of patients with subtrochanteric or reverse obliquity fractures, a blood transfusion threshold of no higher than 8 g/dL in asymptomatic postoperative patients, intensive physical therapy postdischarge, use of an interdisciplinary care program in patients with mild to moderate dementia, and multimodal pain management after hip fracture surgery. In addition to the recommendations, the work group highlighted the need for better research in the treatment of hip fractures.

            • Subspecialty:
            • Adult Reconstruction

          Recent Advances in Posterior Meniscal Root Repair Techniques

          Posterior root avulsions of the medial and lateral menisci result in decreased areas of tibiofemoral contact and increased tibiofemoral contact pressures. These avulsions may lead to the development of osteoarthritis. Therefore, two surgical techniques, the transtibial pullout repair and the suture anchor repair, have recently been developed to restore the native structure and function of the meniscal root attachment. Compared with the historical alternative of partial or total meniscectomy, these techniques allow for meniscal preservation and anatomic reduction of the meniscal roots, with the goal of preventing the development and progression of osteoarthritis. However, early biomechanical and clinical studies have reported conflicting results on the effectiveness of both techniques with regard to resisting displacement and facilitating healing. Although there is currently a lack of consensus on which is the superior technique, transtibial pullout and suture anchor repairs are increasingly used in clinical practice.

              • Subspecialty:
              • Sports Medicine

            Evaluation and Management of Pediatric Proximal Humerus Fractures

            In the pediatric population, sports participation, falls, and motor vehicle accidents can result in proximal humerus fractures. Because the proximal humeral growth plate is responsible for up to 80% of the growth of the humerus, the remodeling of these fractures in children is tremendous. Most of these injuries can be treated with a sling or hanging arm cast, although older children with decreased remodeling capacity may require surgery. Special considerations should be taken for management of proximal humerus fractures that occur in the context of Little League shoulder, lesser tuerosity avulsion fractures, fracture-dislocations, birth fractures, and fractures associated with cysts. Most pediatric patients with proximal humerus fractures have favorable results, and complications are infrequent.

                • Subspecialty:
                • Pediatric Orthopaedics

              Calcium Deposits in the Hand and Wrist

              Calcium, or calcific, deposition disease in the form of acute calcific periarthritis of the hand and wrist is an uncommon entity that may be confused with more common crystalline or inflammatory arthropathies as well as infection. It is important for the clinician to be aware of this disease process and to include it in the differential diagnosis of patients presenting with acutely painful, focal inflammation of the hand or wrist. Nonsurgical management is often sufficient; however, considering the self-limited nature of the disease, accurate diagnosis is essential to avoid unnecessary antibiotic or surgical treatment.

                  • Subspecialty:
                  • Hand and Wrist

                Extensor Mechanism Disruption After Total Knee Arthroplasty

                Extensor mechanism disruption is a rare and potentially devastating complication associated with total knee arthroplasty. Disruption can occur at the quadriceps or patellar tendons or, in the setting of a fracture, at the patella. Recognition of the risk factors for disruption and prevention via meticulous surgical technique are critical to avoid this complication. Various management techniques and the challenges associated with treatment have been described. Nonsurgical management consists of the use of walking aids and/or knee braces, which may not be acceptable for the active patient. Surgical options include primary repair and reconstructive techniques using allograft, autograft, synthetic material, and gastrocnemius rotational flaps. However, no single method has reliably demonstrated satisfactory outcomes. Although research on reconstructive procedures with synthetic materials has been promising, further study is need to assess the use of these materials.

                    • Subspecialty:
                    • Adult Reconstruction