JAAOS, Volume 24, No. 10

Limits of Growth Modulation Using Tension Band Plates in the Lower Extremities

Growth modulation using tension band plates (TBP) has been shown to be a safe, effective, and popular method for correcting pediatric frontal plane angular deformity around the knee. Recently, TBPs have been used to achieve reversible epiphysiodesis to treat limb-length discrepancy. Many surgeons have expanded the indications to include diagnoses other than frontal plane angular deformities, anatomic sites other than the knee, and correction of sagittal and oblique plane deformities. Despite the rapid acceptance of TBPs, the limits of this option have not been explored. We undertook a systematic literature review and found that the success rate for idiopathic cases approaches 100% with a low complication rate. Pathologic cases have a slightly lower success rate and a higher complication rate. The potential to avoid osteotomy with growth modulation makes TBPs a reasonable option for all but the most extreme pediatric frontal and sagittal plane lower extremity deformities. Applications to hip deformities remain unproven.

      • Subspecialty:
      • Pediatric Orthopaedics

    Stress Modulation of Fracture Fixation Implants

    Stress modulation is the concept of manipulating bridge plate variables to provide a flexible fixation construct that allows callus formation through uneventful secondary bone healing. Obtaining absolute stability through the anatomic reduction of all fracture fragments comes at the expense of fracture biology, whereas intramedullary nailing, which is more advantageous for diaphyseal fractures of the lower extremity, is technically demanding and often may not be possible when stabilizing many metaphyseal fractures. Overly stiff plating constructs are associated with asymmetric callus formation, early implant failure, and fracture nonunion. Numerous surgeon-controlled variables can be manipulated to increase flexibility without sacrificing strength, including using longer plates with wellspaced screws, choosing titanium or stainless steel implants, and using locking or nonlocking screws. Axially dynamic emerging concepts, such as far cortical locking and near cortical overdrilling, provide further treatment options when bridge plating techniques are used.

        • Subspecialty:
        • Trauma

      The Morel-Lavallée Lesion: Diagnosis and Management

      The Morel-Lavallée lesion is a closed soft-tissue degloving injury commonly associated with high-energy trauma. The thigh, hip, and pelvic region are the most commonly affected locations. Timely identification and management of a Morel-Lavallée lesion is crucial because distracting injuries in the polytraumatized patient can result in a missed or delayed diagnosis. Bacterial colonization of these closed soft-tissue injuries has resulted in their association with high rates of perioperative infection. Recently, MRI has been used to characterize and classify these lesions. Definitive management is dictated by the size, location, and age of the injury and ranges from percutaneous drainage to open débridement and irrigation. Chronic lesions may lead to the development of pseudocysts and contour deformities of the extremity.

          • Subspecialty:
          • Trauma

        Nationwide Databases in Orthopaedic Surgery Research

        The use of nationwide databases to conduct orthopaedic research has expanded markedly in recent years. Nationwide databases offer large sample sizes, sampling of patients who are representative of the country as a whole, and data that enable investigation of trends over time. The most common use of nationwide databases is to study the occurrence of postoperative adverse events. Other uses include the analysis of costs and the investigation of critical hospital metrics, such as length of stay and readmission rates. Although nationwide databases are powerful research tools, readers should be aware of the differences between them and their limitations. These include variations and potential inaccuracies in data collection, imperfections in patient sampling, insufficient postoperative follow-up, and lack of orthopaedic-specific outcomes.

            • Subspecialty:
            • General Orthopaedics

          Total Hip and Knee Arthroplasty in Patients Older Than Age 80 Years

          A rapidly aging population is currently reshaping the demographic profile of the United States. Among older patients, the cohort aged.80 years is not only living longer but also is electing to undergo more total hip and knee arthroplasties. To improve perioperative safety, orthopaedic surgeons should understand the risks and clinical outcomes of arthroplasty in patients of advanced age. Although morbidity and mortality rates are higher for patients aged .80 years than for younger patients undergoing total hip and knee arthroplasties and revision surgeries, functional outcomes, pain relief, and patient satisfaction are consistent between groups. In addition, geriatric co-management before total hip and total knee arthroplasty has reduced the rate of minor complications and the length of hospital stays in elderly patients. Surgeons should inform older patients and their families of the increased risks of morbidity and mortality before these procedures are undertaken.

              • Subspecialty:
              • Adult Reconstruction

            Perioperative Vision Loss in Spine Surgery and Other Orthopaedic Procedures

            Perioperative vision loss is a rare complication of orthopaedic surgery and has been documented after spine, knee, hip, and shoulder procedures. It is associated with several ophthalmologic diagnoses, most commonly ischemic optic neuropathy. Although the pathophysiology remains unclear, current evidence suggests that systemic hemodynamic compromise and altered balance of intraocular perfusion contribute to the development of ischemic optic neuropathy. Although vision recovery has been reported, the prognosis of perioperative vision loss is poor, and no proven effective treatment is available. Perioperative vision loss is unpredictable and can occur in healthy patients. Associated risk factors include pediatric or elderly age, male sex, obesity, anemia, hypotension or hypertension, perioperative blood loss, prolonged surgical time, and prone positioning. Preventive strategies include avoiding direct pressure to the eye, elevating the head, optimizing perioperative hemodynamic status, and minimizing surgical time with staged surgical procedures as appropriate.

                • Subspecialty:
                • Spine

              Admission Through the Emergency Department Is an Independent Risk Factor for Lower Satisfaction With Physician Performance Among Orthopaedic Surgery Patients: A Multicenter Study

              Background: Patient experience data are increasingly used to guide performance improvement and to determine physician and hospital reimbursement. We studied the relationship between emergency department (ED) admission and patient satisfaction with physicians' performance, and identified other associated predictors.

              Methods: We evaluated 6,524 inpatient Press Ganey patient experience surveys from two academic level I trauma centers over 5 years. We stratified patients by ED admission or other admission and compared the proportions of patients in each group who were satisfied with physician performance. We used logistic regression to control for demographic differences and characteristics of hospitalizations.

              Results: Among patients admitted through the ED, 85.18% were satisfied, compared with 89.44% of patients admitted through other pathways (P < 0.001). Admission through the ED predicted decreased satisfaction, with an odds ratio of 0.67 (P = 0.032) after controls were applied through logistic regression.

              Conclusions: Admission through the ED is an independent risk factor for lower satisfaction with physician performance. Understanding the determinants of patient satisfaction will help improve physician-patient interactions and guide quality improvement and value-based reimbursement initiatives.

              Level of Evidence: This retrospective survey-based analysis of satisfaction does not fall clearly under any of the Journal's established categories of level of evidence. The most closely aligned choice would be Level III Prognostic.

                  • Subspecialty:
                  • General Orthopaedics

                Factors Affecting Functional Outcomes After Clavicle Fracture

                Introduction: This study evaluated the effects that patient demographics, injury, and social characteristics have on functional outcomes after clavicle fracture.

                Methods: After a mean follow-up of 56 months, 214 patients with a mean age of 44.4 years completed the American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form. The effects that age, sex, fracture location, open fracture, associated injuries, tobacco use, employment status, and timing of surgery had on functional outcomes were assessed.

                Results: The mean ASES score for the entire group of 214 patients was 80.5. Seventy-seven patients (36%) were treated surgically and 137 patients (64%) were treated nonsurgically. The mean ASES scores were 84.0 and 78.5, respectively, in the surgical and nonsurgical groups (P = 0.06). Patients with lateral fractures who were treated surgically had better ASES scores than those treated nonsurgically (91.3 versus 72.7, P = 0.011); this was also true of patients with isolated fractures (P = 0.02). Smokers in the surgical and nonsurgical groups had scores of 74.1 and 83.6, respectively (P = 0.003). Patients who were unemployed had the worst ASES scores regardless of surgical or nonsurgical treatment (70.5 and 86.1, respectively; P < 0.001). Surgical timing was not related to outcome; no difference in ASES scores was noted in patients treated surgically within ≤10 weeks versus those treated after 10 weeks after injury and in those treated within <20 weeks versus those treated >20 weeks after injury (both, P > 0.34).

                Discussion: We identified factors associated with better functional outcomes, which could aid in developing treatment recommendations. Additionally, initial nonsurgical management of clavicle fractures may be reasonable because patients had similar functional outcomes even when surgery was delayed.

                Level of Evidence: Level III retrospective comparative study

                    • Subspecialty:
                    • Trauma

                  Functional Outcomes of Type V Acromioclavicular Injuries With Nonsurgical Treatment

                  Introduction: This study investigated nonsurgicalmanagement of type V acromioclavicular (AC) injuries to determine functional outcomes and to attempt to identify factors associated with positive results.

                  Methods: In a retrospective chart review, patients with radiographic and clinical evidence of type V AC injuries per the Rockwood classification were included in the study. Patients treated nonsurgically for ≤6 months were considered eligible for analysis. Functional outcomes were assessed using Disabilities of the Arm, Shoulder, and Hand (DASH) and American Shoulder and Elbow Surgeons (ASES) scores.

                  Results: Twenty-two patients with a mean age of 42.2 ± 12.8 years were included in the study. The average coracoclavicular distance at the time of presentation was 26.3 mm (1199%). Mean DASH and ASES scores were 27.8 ± 17.7 and 62.8 ± 17.1, respectively, at an average of 34 months from the time of injury. Patients with normal DASH (≤10) and ASES (>92) scores were younger than those with abnormal scores. At final assessment, 77% of the patients were currently working, with nine patients performing manual labor.

                  Conclusion: Following nonsurgical management of type V AC injuries, most patients are able to return to work but have limited functional outcome scores. A small subset of patients with type V AC injuries can achieve normal functional outcomes with nonsurgical management.

                  Level of Evidence: Level IV, Case Series

                      • Subspecialty:
                      • Sports Medicine