JAAOS, Volume 24, No. 11

Pediatric and Adolescent Forearm Fractures: Current Controversies and Treatment Recommendations

Pediatric and adolescent forearm fractures continue to present treatment challenges. Despite high-level evidence to the contrary, traditional guidelines for nonsurgical treatment have been challenged in favor of surgical intervention, but it is unclear if this results in improved outcomes. Recent evidence suggests that certain open fractures in children may be successfully treated nonsurgically. Good results have been achieved with closed reduction and appropriate casting and clinical follow-up. Further research investigating functional outcomes into adulthood is needed.

      • Subspecialty:
      • Pediatric Orthopaedics

    Soft-tissue Defects After Total Knee Arthroplasty: Management and Reconstruction

    Wound healing complications associated with total knee arthroplasty present a considerable challenge to the orthopaedic surgeon. To ensure preservation of a functional joint, the management of periprosthetic soft-tissue defects around the knee requires rapid assessment, early and aggressive débridement, and durable, contoured coverage. Several reconstructive options are available to tailor soft-tissue coverage to the location, size, and depth of the wound. Special consideration should be given to the timing of the intervention, management of infection, and prosthesis salvage. The merits of each reconstructive option, including perforator, fasciocutaneous, muscular, and free microvascular flaps, should be weighed to select the most appropriate option. The proposed approach can guide surgeons in treating patients with these complex soft-tissue defects.

        • Subspecialty:
        • Adult Reconstruction

      PROMIS for Orthopaedic Outcomes Measurement

      Patient-reported outcome measures have become important tools for assessing health status in a variety of patient populations. Many historically or commonly used patient-reported outcome measures in orthopaedics are narrow in scope and are limited by the burden associated with their administration, making them useful only for specific populations. The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed to overcome these limitations. The system was developed using item response theory, which allows for reliable and efficient estimation of underlying health traits using targeted item banks to assess physical function in the upper and lower extremities. PROMIS has been validated in patient populations with orthopaedic disorders of the foot and ankle, upper extremity, and spine and has demonstrated a marked improvement in measurement characteristics and reduced patient and administrative burden. PROMIS Physical Function measures are useful for assessing orthopaedic outcomes and are superior to legacy measures in several key populations.

          • Subspecialty:
          • General Orthopaedics

        Item Response Theory and Computerized Adaptive Testing for Orthopaedic Outcomes Measures

        The use of patient-reported outcome measures (PROMs) to objectively and quantifiably assess patient symptomatology allows tracking of symptoms over time, measurement of the effect of healthcare interventions, and performance of cost-effectiveness analyses to assess and compare the value of treatment options. Many of the PROMs historically used had limited versatility because they were developed using classical test theory, which generates static tests that are not comparable with other measures assessing similar outcomes. Recently developed PROMs, however, were designed according to the principles of the newer item response theory (IRT), which allows for the creation of dynamic instruments deliverable in a variety of forms that are readily comparable with similar measures. IRT also enables computerized adaptive testing to decrease the burden of using PROMs by allowing rapid and complete data acquisition. IRT-based instruments are suitable for patient care and research and have been validated in a variety of populations, many of which are relevant to orthopaedic populations.

            • Subspecialty:
            • Spine

          Progress of Medical School Musculoskeletal Education in the 21st Century

          The prevalence and cost of musculoskeletal diseases have increased dramatically over the last several decades, with more than half of US adults currently affected by a musculoskeletal condition. In response to this development, multiple institutions began reassessing the depth and effectiveness of their musculoskeletal education curriculum. After reporting a deficiency in required preclinical coursework, medical schools began implementing new and varied musculoskeletal programs. These changes have met with mixed success, as demonstrated by scores on competency examinations. To address discrepancies in knowledge and confidence levels and to ensure that physicians are equipped to manage musculoskeletal diseases in the 21st century, efforts to improve medical school education should continue.

              • Subspecialty:
              • General Orthopaedics

            Minimal Incision, Multifidus-sparing Microendoscopic Diskectomy Versus Conventional Microdiskectomy for Highly Migrated Intracanal Lumbar Disk Herniations

            Background: Highly migrated intracanal disk herniation is not among the exclusion criteria of the interlaminar microendoscopic diskectomy (MED) procedure. The goal of this prospective, randomized, controlled study was to compare the effect of the size of the skin incision and the method of handling the multifidus muscle on the results of the interlaminar MED procedure versus conventional microdiskectomy in retrieving highly migrated intracanal disk herniations.

            Methods: Seventy-three patients with highly migrated intracanal lumbar disk herniations treated with either minimal incision, multifidus-sparing MED or conventional microdiskectomy were observed for 2 years. Primary (clinical) outcomes data included the results of the Numerical Rating Scale (NRS) for back and leg pain and the Oswestry Disability Index (ODI) to quantify pain and disability, respectively. Secondary objective outcomes data included surgical time, blood loss, postoperative analgesics, length of hospital stay, time to return to work, the rates of revision surgery complications, and the results of the patient satisfaction index (PSI) and the modified MacNab criteria.

            Results: At final follow-up, relief of leg pain was statistically significant for both groups. NRS back pain, ODI, PSI, and the modified MacNab criteria showed no improvement in the conventional microdiskectomy group. Secondary outcomes data in the MED group were significantly better than those for the control group.

            Conclusions: Highly migrated intracanal lumbar disk herniations can be sufficiently retrieved using minimal incision, multifidus-sparing MED, which is an effective alternative to conventional microdiskectomy. The minimal skin incision and multifidus-sparing approach of the MED had a positive effect on clinical outcomes, which were stable throughout the 2-year follow-up period.

            Level of Evidence: Therapeutic level II

                • Subspecialty:
                • Spine

              Simultaneous Bilateral Versus Staged Bilateral Carpal Tunnel Release: A Cost-effectiveness Analysis

              The purpose of this study was to determine if simultaneous bilateral carpal tunnel release (CTR) is a cost-effective strategy compared with bilateral staged CTR for the treatment of bilateral carpal tunnel syndrome.

              Methods: A decision analytic model was created to compare the cost effectiveness of three strategies (ie, bilateral simultaneous CTR, bilateral staged CTR, and no treatment). Direct medical costs were estimated from 2013 Medicare reimbursement rates and wholesale drug costs in US dollars. Indirect costs were derived from consecutive patients undergoing unilateral or simultaneous bilateral CTR at our institution and from national average wages for 2013. Health state utility values were derived from a general population of volunteers using the Short Form-6 dimensions (SF-6D) health questionnaire.

              Results: Both surgical strategies were cost effective compared with the no-treatment strategy. Bilateral simultaneous CTR had lower total costs and higher total effectiveness than bilateral staged CTR, and had an incremental cost‐effectiveness ratio of $921 per quality-adjusted life year compared with the no-treatment strategy. The conclusions of the analysis remained unchanged though all sensitivity analyses, displaying robustness against parameter uncertainty.

              Conclusions: Surgical management is cost effective for the treatment of bilateral carpal tunnel syndrome. Bilateral simultaneous CTR, however, has lower total costs and higher total effectiveness compared with bilateral staged CTR.

              Level of Evidence: Economic and Decision Analysis I

                  • Subspecialty:
                  • Hand and Wrist

                Management of Patellofemoral Arthritis: From Cartilage Restoration to Arthroplasty

                The management of patellofemoral cartilage lesions is controversial and should begin with a comprehensive nonsurgical treatment plan. Patients with patellofemoral cartilage lesions in whom nonsurgical treatment fails may be candidates for surgical treatment. Surgical treatment strategies for the management of patellofemoral cartilage lesions are guided by the size, quality, and location of the defect. Recent advancements in cartilage restoration and arthroplasty techniques as well as appropriate patient selection and meticulous surgical technique have resulted in promising outcomes in patients with patellofemoral cartilage lesions who undergo surgical treatment.

                    • Subspecialty:
                    • Adult Reconstruction

                  Pediatric Phalanx Fractures

                  Phalangeal fractures are the most common type of hand fracture that occurs in the pediatric population and account for the second highest number of emergency department visits for fractures in the United States. The incidence of phalangeal fractures is the highest in children aged 10 to 14 years, which coincides with the time that most children begin playing contact sports. Younger children are more likely to sustain a phalangeal fracture in the home setting as a result of crush and laceration injuries. Salter-Harris type II fractures of the proximal phalanx are the most common type of finger fracture. An unmineralized physis is biomechanically weaker compared with the surrounding ligamentous structures and mature bone, which makes fractures about the physis likely. A thorough physical examination is necessary to assess the digital cascade for signs of rotational deformity and/or coronal malalignment. Plain radiographs of the hand and digits are sufficient to confirm a diagnosis of a phalangeal fracture. The management of phalangeal fractures is based on the initial severity of the injury and depends on the success of closed reduction techniques. Nondisplaced phalanx fractures are managed with splint immobilization. Stable, reduced phalanx fractures are immobilized but require close monitoring to ensure maintenance of fracture reduction. Unstable, displaced phalanx fractures require surgical management, preferably via closed reduction and percutaneous pinning.

                      • Subspecialty:
                      • Pediatric Orthopaedics

                    Resident Physician Duty-hour Requirements: What Does the Public Think?

                    Introduction: To date, no study has reported on the public’s opinion of orthopaedic resident duty-hour requirements (DHR).

                    Methods: A survey was administered to people in orthopaedic waiting rooms and at three senior centers. Responses were analyzed to evaluate seven domains: knowledge of duty hours; opinions about duty hours; attitudes regarding shift work; patient safety concerns; and the effects of DHRs on continuity of care, on resident training, and on resident professionalism.

                    Results: Respondents felt that fatigue was unsafe and duty hours were beneficial in preventing resident physician fatigue. They supported the idea of residents working in shifts but did not support shifts for attending physicians. However, respondents wanted the same resident to provide continuity of care, even if that violated DHRs. They were supportive of increasing the length of residency to complete training. DHRs were not believed to affect professionalism. Half of the respondents believed that patient opinion should influence policy on this topic.

                    Discussion: Orthopaedic patients and those likely to require orthopaedic care have inconsistent opinions regarding DHRs, making it potentially difficult to incorporate their preferences into policy.

                        • Subspecialty:
                        • General Orthopaedics

                      Understanding Value-based Reimbursement Models and Trends in Orthopaedic Health Policy: An Introduction to the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015

                      In 2015, the US Congress passed legislation entitled the Medicare Access and CHIP [Children’s Health Insurance Program] Reauthorization Act (MACRA), which led to the formation of two reimbursement paradigms: the merit-based incentive payment system (MIPS) and alternative payment models (APMs). The MACRA effectively repealed the Centers for Medicare and Medicaid Services (CMS) sustainable growth rate (SGR) formula while combining several CMS quality-reporting programs. As such, MACRA represents an unparalleled acceleration toward reimbursement models that recognize value rather than volume. The first pathway, MIPS, consolidates several Medicare quality-reporting programs into one composite score that will be derived by four performance categories, including quality (30%), resource utilization (30%), meaningful use (25%), and clinical practice improvement activities (15%). The APM pathway includes the following programs: Medicare accountable care organizations as part of the Medicare Shared Savings Program, Bundled Payments for Care Improvement, and Comprehensive Primary Care initiative. Existing APMs have yet to be determined as eligible. We provide a contextual framework of the healthcare legislation that has led to the formation of current health policy and offer recommendations regarding SGR how orthopaedic surgeons may best steer through such reimbursement models.

                          Measures for Pain and Function Assessments for Patients With Osteoarthritis

                          Introduction: To develop an osteoarthritis (OA) quality measure that satisfies quality-reporting initiatives, a systematic review of the literature was undertaken to identify and evaluate measures of pain and function commonly used to assess outcomes in patients with upper and lower extremity OA.

                          Methods: English-language systematic reviews and meta-analyses evaluating validity of pain and function instruments in OA patients published between 1995 and 2014 were considered for inclusion. The quality of all included studies was assessed using the Appraisal of Guidelines for Research and Evaluation II instrument (AGREE II).

                          Results: More than 90 pain and/or functional assessment tools were evaluated within the 16 systematic reviews included in this analysis. Of the 16 systematic reviews, 6 articles had high-quality study designs; the remaining 10 reviews had moderate-quality study designs.

                          Conclusion: There currently exists no OA pain and functional assessment tool capable of meeting the stringent requirements established by newer quality-reporting programs. The use of invalidated or unreliable patient-reported outcome measures may improperly estimate patient pain and functional status, which could affect treatment options, patient satisfaction, reimbursement, and/or quality of life.

                          Level of Evidence: II

                              Primary Total Hip Arthroplasty: Equivalent Outcomes in Low and High Functioning Patients

                              Objective: Previous studies suggest that patients with poorer physical function prior to undergoing total hip arthroplasty (THA) have a lower postoperative functional outcome. We sought to determine if the preoperative level of function was predictive of the outcome in patients undergoing THA using modern perioperative protocols and surgical techniques.

                              Methods: A prospective cohort study design evaluated the preoperative and 2-year postoperative health-related quality of life (HRQoL) scores of 200 patients who underwent THA. The cohort was divided into two groups according to the median preoperative Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical function scores.

                              Results: Both high and low function groups had significant improvements in the HRQoL scores (P < 0.001). However, this improvement was substantially greater in the low function group, resulting in no difference in the HRQoL outcomes of the two groups at final follow-up.

                              Conclusion: This study contradicts the previously held belief that patients with worse function before THA do not do as well as those with less preoperative disability.

                              Level of Evidence: Level II.

                                  • Subspecialty:
                                  • Adult Reconstruction