JAAOS, Volume 24, No. 8

Nonsurgical Management of Adolescent Idiopathic Scoliosis

Pediatric patient visits for spinal deformity are common. Most of these visits are for nonsurgical management of scoliosis, with approximately 600,000 visits for adolescent idiopathic scoliosis (AIS) annually. Appropriate management of scoliotic curves that do not meet surgical indication parameters is essential. Renewed enthusiasm for nonsurgical management of AIS (eg, bracing, physical therapy) exists in part because of the results of the Bracing in Adolescent Idiopathic Scoliosis Trial, which is the only randomized controlled trial available on the use of bracing for AIS. Bracing is appropriate for idiopathic curves between 20° and 40°, with successful control of these curves reported in >70% of patients. Patient adherence to the prescribed duration of wear is essential to maximize the effectiveness of the brace. The choice of brace type must be individualized according to the deformity and the patient's personality as well as the practice setting and brace availability.

      • Subspecialty:
      • Spine

    Ultrasonography for Hand and Wrist Conditions

    Ultrasonography facilitates dynamic, real-time evaluation of bones, joints, tendons, nerves, and vessels, making it an ideal imaging modality for hand and wrist conditions. Ultrasonography can depict masses and fluid collections, help locate radiolucent foreign bodies, characterize traumatic or overuse tendon or ligament pathology, and help evaluate compressive peripheral neuropathy and microvascular blood flow. Additionally, this modality improves the accuracy of therapeutic intra-articular or peritendinous injections and facilitates aspiration of fluid collections, such as ganglia.

        • Subspecialty:
        • Spine

      Hip Vascularity: A Review of the Anatomy and Clinical Implications

      Throughout development, the vascular supply to the proximal femur and acetabulum undergoes a series of changes during which it is susceptible to injury. Before age 3 months, the ligamentum teres and lateral epiphyseal arteries are the dominant supply to the developing head. The dominant supply shifts to the lateral epiphyseal vessels by age 18 months. The distinct metaphyseal and epiphyseal circulations of the adult proximal femur form in adolescence when an increasingly rich metaphyseal circulation supplies the subphyseal region, terminating at the physeal plate. The acetabular blood supply derives from two independent systems, with the dominance of each changing throughout maturity. Most descriptions of the vascular contributions to the proximal femur and acetabulum have been gross anatomic and histologic studies. Advanced imaging studies (eg, CT angiography, perfusion MRI) have added to our understanding of the vascular anatomy of the proximal femur and acetabulum, its changes throughout development, and its clinical implications.

          • Subspecialty:
          • Pediatric Orthopaedics

        Swimmer’s Shoulder: Painful Shoulder in the Competitive Swimmer

        Swimmer's shoulder is a broad term often used to diagnose shoulder injury in swimmers. However, research has elucidated several specific shoulder injuries that often are incurred by the competitive swimmer. Hyperlaxity, scapular dyskinesis, subacromial impingement, labral damage, os acromiale, suprascapular nerve entrapment, and glenohumeral rotational imbalances all may be included within a differential diagnosis for shoulder pain in the competitive swimmer. An understanding of the mechanics of the swim stroke, in combination with the complex static and dynamic properties of the shoulder, is essential to the comprehension and identification of the painful swimmer's shoulder. It is important for the athlete, coach, and clinician to be aware of the discerning characteristics among these different injuries to ensure a proper diagnosis and treatment plan to aid the swimmer in his or her return to competition.

            • Subspecialty:
            • Shoulder and Elbow

          Medical Device Regulation: A Comparison of the United States and the European Union

          Medical device regulation is a controversial topic in both the United States and the European Union. Many physicians and innovators in the United States cite a restrictive US FDA regulatory process as the reason for earlier and more rapid clinical advances in Europe. The FDA approval process mandates that a device be proved efficacious compared with a control or be substantially equivalent to a predicate device, whereas the European Union approval process mandates that the device perform its intended function. Stringent, peer-reviewed safety data have not been reported. However, after recent high-profile device failures, political pressure in both the United States and the European Union has favored more restrictive approval processes. Substantial reforms of the European Union process within the next 5 to 10 years will result in a more stringent approach to device regulation, similar to that of the FDA. Changes in the FDA regulatory process have been suggested but are not imminent.

              • Subspecialty:
              • General Orthopaedics

            Retention of Skills After Simulationbased Training in Orthopaedic Surgery

            Simulation-based surgical skills training has become essential in orthopaedic practice because of concerns about patient safety and an increase in technically challenging procedures. Surgical skills training in specifically designed simulation laboratories allows practice of procedures in a risk-free environment before they are performed in the operating room. The transferability of acquired skills to performance with patients is the most effective measure of the predictive validity of simulation-based training. Retention of the skills transferred to clinical situations is also critical. However, evidence of simulation-based skill retention in the orthopaedic literature is limited, and concerns about sustainability exist. Solutions for skill decay include repeated practice of the tasks learned on simulators and reinforcement of areas that are sensitive to decline. Further research is required to determine the retention rates of surgical skills acquired in simulation-based training as well as the success of proposed solutions for skill decay.

                • Subspecialty:
                • General Orthopaedics

              Clinical Outcomes of Surgical Stabilization of Flail Chest Injury

              Introduction: Recent reported success in surgical stabilization of flail chest has been described in small series, but scant evidence exists for this procedure in the orthopaedic literature.

              Methods: We reviewed 88 consecutive patients who underwent surgical stabilization of flail chest, along with 88 consecutive patients with flail chest who underwent traditional closed management before initiation of our algorithm change to surgical management.

              Results: Surgical stabilization of flail chest injuries led to statistically significant decreases in hospital length of stay, ventilator-dependency time, pneumonia, tracheostomy, and mortality rate. In addition, the presence of pulmonary contusion did not eliminate the significant improvements in the aforementioned variables.

              Discussion: Surgical stabilization of flail chest with modern techniques and implants provides significant improvements in both mortality and short-term outcomes. Although pulmonary contusion decreased overall outcomes across both cohorts, this factor did not alter the ability of rib fixation to improve outcomes.

                  • Subspecialty:
                  • Trauma

                Complications of Primary Total Knee Arthroplasty Among Patients With Rheumatoid Arthritis, Psoriatic Arthritis, Ankylosing Spondylitis, and Osteoarthritis

                Background: Although several studies have reported outcomes of primary total knee arthroplasty (TKA) in patients with rheumatoid arthritis, very little has been reported on the outcomes of this procedure in patients with other inflammatory arthritides.

                Methods: This study used a national database to evaluate 90-day postoperative complication rates, readmission rates, and revision rates after TKA in patients with inflammatory arthritis. Patients with rheumatoid arthritis (n = 153,531), psoriatic arthritis (n = 7,918), and ankylosing spondylitis (n = 4,575) were compared with patients with osteoarthritis (n = 1,751,938) who underwent TKA from 2005 to 2012.

                Results: The rates of systemic complications, infection, revision, and 90-day readmission after TKA in patients with different types of inflammatory arthritis were significantly higher than those in controlpatients with osteoarthritis (P < 0.0001). No differences were found in the rates of systemic or local complications, revision, or readmission among the types of inflammatory arthritis.

                Conclusion: Inflammatory arthritis is associated with increased rates of perioperative complications, revision, and 90-day readmission after primary TKA.

                Level of Evidence: Level III.

                    • Subspecialty:
                    • Adult Reconstruction

                  Revision Anterior Cruciate Ligament Reconstruction: Results of a Single-stage Approach Using Allograft Dowel Bone Grafting for Femoral Defects

                  Introduction: The purpose of this study was to present results of single-stage revision anterior cruciate ligament (ACL) reconstruction using an allograft bone dowel for isolated femoral bony deficiency.

                  Methods: Sixteen patients underwent single-stage revision ACL reconstruction using an allograft bone dowel for isolated femoral bony deficiency between 2007 and 2012. Twelve patients (75%)completed study visits, which included CT scans as well as completion of validated outcomes measures.

                  Results: The average KT-1000 side-to-side difference was 1.0 mm ±2.9 mm. The average International Knee Documentation Committee score was 70.2 ± 17.8, the Tegner score was 4.8 ± 2.8, and the visual analog scale pain score was 2.86 ± 2.4. An analysis of CT scans showed that all 12 dowels had excellent (>75%) incorporation.

                  Conclusions: A single-stage approach for revision ACL reconstruction using allograft dowels for isolated femoral bony deficiency yields objective and subjective outcomes comparable to those reported in the literature for two-stage and other single-stage techniques, with good incorporation of the dowels.

                  Level of Evidence: Retrospective case series, level IV.

                      • Subspecialty:
                      • Sports Medicine

                    Treatment of Anterior Cruciate Ligament Injuries

                    The American Academy of Orthopaedic Surgeons has developed the Appropriate Use Criteria (AUC) documentTreatment of Anterior Cruciate Ligament Injuries. Evidence-based information, in conjunction with the clinical expertise of physicians, was used to develop the criteria to improve patient care and obtain the best outcomes while considering the subtleties and distinctions necessary in making clinical decisions. The AUC clinical patient scenarios were derived from patient indications that generally accompany an anterior cruciate ligament injury, as well as from current evidence-based clinical practice guidelines and supporting literature. The 56 patient scenarios and 8 treatments were developed by the Writing Panel, a group of clinicians who are specialists in this AUC topic. Lastly, a separate, multidisciplinary Voting Panel (made up of specialists and nonspecialists) rated the appropriateness of treatment of each patient scenario using a 9-point scale to designate a treatment as Appropriate (median rating, 7 to 9), May Be Appropriate (median rating, 4 to 6), or Rarely Appropriate (median rating, 1 to 3).

                        • Subspecialty:
                        • Adult Reconstruction

                      Surgical Management of Osteoarthritis of the Knee: Evidence-based Guideline

                      Surgical Management of Osteoarthritis of the Knee: Evidence-based Guidelineis based on a systematic review of the current scientific and clinical research. The guideline contains 38 recommendations pertaining to the preoperative, perioperative, and postoperative care of patients with osteoarthritis (OA) of the knee who are considering surgical treatment. The purpose of this clinical practice guideline is to help improve surgical management of patients with OA of the knee based on current best evidence. In addition to guideline recommendations, the work group highlighted the need for better research on the surgical management of OA of the knee.

                          • Subspecialty:
                          • Adult Reconstruction