JAAOS, Volume 25, No. 11

Metabolic Bone Diseases and Total Hip Arthroplasty: Preventing Complications

Metabolic bone diseases are a diverse group of conditions characterized by abnormalities in calcium metabolism and/or bone cell physiology. These unbalanced processes can eventually lead to bony deformities and altered joint biomechanics, resulting in degenerative joint disease. Not infrequently, patients with metabolic bone diseases have restricting hip joint pain that ultimately necessitates hip arthroplasty. To minimize complications, the surgeon must consider the particular characteristics of these patients. The surgical and medical management of patients with metabolic bone diseases undergoing hip arthroplasty requires appropriate preoperative diagnosis, careful attention to the technical challenges of surgery, and strategies to maximize the long-term results of the surgical intervention, such as the use of bone anabolic and anticatabolic agents.

      • Subspecialty:
      • Hip

    Discoid Lateral Meniscus in Children: Diagnosis, Management, and Outcomes

    Discoid meniscus is a congenital variant of the knee joint that typically involves abnormal morphology and potential instability of the lateral meniscus. Some discoid menisci have abnormal peripheral attachments and are unstable. Discoid menisci are prone to tearing secondary to increased thickness, poor tissue quality, and instability. Patients may or may not be symptomatic. Torn or unstable discoid menisci cause mechanical symptoms, pain, and swelling. Symptomatic patients in whom nonsurgical management fails most frequently are treated with arthroscopic surgery. Historically, complete meniscectomy has successfully alleviated symptoms but has resulted in poor midterm results, with degenerative changes to the knee joint. Current treatment emphasizes the saucerization of the meniscus, with removal of the central disk and retention of the peripheral crescent. Peripheral meniscal repair is performed when instability is present. Short-term results are good; however, degenerative changes have been reported at intermediate follow-up.

        • Subspecialty:
        • Knee

      Pedicled Rotational Medial and Lateral Gastrocnemius Flaps: Surgical Technique

      Gastrocnemius flaps have been used for decades to reconstruct defects of the proximal tibia and knee. They have proven to be useful in the soft-tissue reconstruction of defects caused by trauma, tumors, and infections about the knee, and the reconstruction of extensor mechanism discontinuity with and without total joint arthroplasty. The flaps have low failure rates and a distinct proximally based blood supply that allows them to be elevated and rotated up to 15 cm above the level of the knee joint. The vascular anatomy is reproducible because rotational flaps do not require microvascular anastomosis. An understanding of the applied surgical anatomy, approaches, and utility of the gastrocnemius flap makes the technique a useful tool for the orthopaedic surgeon when plastic surgery assistance is not readily available.

          • Subspecialty:
          • Knee

        The Posteromedial Corner of the Knee: Anatomy, Pathology, and Management Strategies

        The posteromedial corner of the knee encompasses five medial structures posterior to the medial collateral ligament. With modern MRI systems, these structures are readily identified and can be appreciated in the context of multiligamentous knee injuries. It is recognized that anteromedial rotatory instability results from an injury that involves both the medial collateral ligament and the posterior oblique ligament. Like posterolateral corner injuries, untreated or concurrent posteromedial corner injuries resulting in rotatory instability place additional strain on anterior and posterior cruciate ligament reconstructions, which can ultimately contribute to graft failure and poor clinical outcomes. Various options exist for posteromedial corner reconstruction, with early results indicating that anatomic reconstruction can restore valgus stability and improve patient function. A thorough understanding of the anatomy, physical examination findings, and imaging characteristics will aid the physician in the management of these injuries.

            • Subspecialty:
            • Knee

          The Diagnostic Utility of Synovial Fluid Markers in Periprosthetic Joint Infection: A Systematic Review and Meta-analysis

          Introduction: This study is a systematic review of all reported synovial fluid markers for the diagnosis of periprosthetic joint infection and a meta-analysis of the most frequently reported markers to identify those of greatest diagnostic utility.

          Methods: A search of six databases was conducted to identify all studies evaluating the utility of synovial fluid markers in the diagnosis of periprosthetic joint infection. Two observers assessed methodologic quality and extracted data independently. A meta-analysis of the most frequently reported markers was performed.

          Results: Twenty-three studies were included in the meta-analysis. The most common markers (and their respective area under the curve) were interleukin-17 (0.974), leukocyte esterase (0.968), α-defensin (0.958), interleukin-6 (0.956), interleukin-1β (0.948), and C-reactive protein (0.927). Among these markers, α-defensin had the highest diagnostic odds ratio but did not achieve statistically significant superiority.

          Conclusion: The most frequently studied synovial fluid markers for the diagnosis of periprosthetic joint infection are C-reactive protein, leukocyte esterase, interleukin-6, interleukin-1β, α-defensin, and interleukin-17, all of which have high diagnostic utility.

          Level of Evidence: Level II

              • Subspecialty:
              • Joints

            The Effect of Obesity on Surgical Treatment of Achilles Tendon Ruptures

            Introduction: We conducted a retrospective comparison of surgical treatment outcomes for acute Achilles tendon ruptures in nonobese and obese patients.

            Methods: Between October 2006 and April 2014, we studied 76 patients with acute midsubstance Achilles tendon rupture: 44 nonobese and 32 obese (body mass index >30 kg/m2). Preoperative and postoperative function and pain were graded with the Foot and Ankle Ability Measure (FAAM) Sports subscale and the visual analog scale for pain, respectively.

            Results: All 76 patients presented for follow-up. On a scale of 100, the mean FAAM score for the nonobese patients increased from 38.1 preoperatively to 90.2 at final visit, and on a scale of 10, the mean pain score decreased from 7.1 preoperatively to 1.6 at latest follow-up. For obese patients, the mean FAAM score increased from 34.2 preoperatively to 83.3 at final visit, and the mean pain score decreased from 6.2 preoperatively to 1.9 at the latest follow-up. The postoperative scores of the two groups were not significantly different (P > 0.05). Postoperative wound complications developed in six nonobese patients and one obese patient (13.6% and 3.1%, respectively; P < 0.05).

            Discussion: To our knowledge, comparing outcomes from surgically treated acute Achilles ruptures in nonobese and obese patients has not been previously reported. We found that both obese and nonobese patients can achieve improved Achilles tendon function and pain as a result of surgery.

            Conclusions: The findings of this study demonstrate that both nonobese and obese patients can achieve a high rate of improvement in ankle function and pain relief after surgical repair of the Achilles tendon.

                • Subspecialty:
                • Ankle

              Findings Associated With Knee Pathology on MRI in Patients Without Osteoarthritis

              Introduction: We conducted a retrospective study in patients with minimal or no radiographically evident knee osteoarthritis to determine whether presenting signs and symptoms were predictive of knee pathology that was evident on MRI and could be treated with nonarthroplasty knee surgery or could alter nonsurgical treatment.

              Methods: We reviewed records of patients for whom sports medicine orthopaedic surgeons had ordered an MRI of the knee. Univariate analysis identified factors that were associated with positive MRI findings (eg, surgically treatable lesion, meniscal tear) or a finding that could alter treatment. We used multivariate logistic regression to determine independent predictors of evidence of pathology on MRI.

              Results: Of the 434 patients in the study, 281 (64.7%) had evidence of knee pathology on MRI. Acute injury, effusion, and ligamentous instability were among the independent predictors of positive MRI results. Patients with evidence of knee pathology on MRI were more likely to have undergone surgery.

              Discussion: Specific aspects of patient history and physical examination are associated with evidence of knee pathology on MRI.

              Conclusions: In patients without osteoarthritis, positive findings on knee MRI could be associated with a number of presenting signs and symptoms, and this information could aid physicians in deciding which patients should undergo knee MRIs. Additional prospective research is needed to validate the relationships discovered in our study.

              Level of Evidence: Level III retrospective study

                  • Subspecialty:
                  • Knee

                Using Lean Process Improvement to Enhance Safety and Value in Orthopaedic Surgery: The Case of Spine Surgery

                Lean methodology was developed in the manufacturing industry to increase output and decrease costs. These labor organization methods have become the mainstay of major manufacturing companies worldwide. Lean methods involve continuous process improvement through the systematic elimination of waste, prevention of mistakes, and empowerment of workers to make changes. Because of the profit and productivity gains made in the manufacturing arena using lean methods, several healthcare organizations have adopted lean methodologies for patient care. Lean methods have now been implemented in many areas of health care. In orthopaedic surgery, lean methods have been applied to reduce complication rates and create a culture of continuous improvement. A step-by-step guide based on our experience can help surgeons use lean methods in practice. Surgeons and hospital centers well versed in lean methodology will be poised to reduce complications, improve patient outcomes, and optimize cost/benefit ratios for patient care.

                    • Subspecialty:
                    • Spine

                  Reduction Techniques for Diaphyseal Femur Fractures

                  Achieving and maintaining reduction in patients with a diaphyseal femur fracture may be difficult; therefore, thorough preoperative planning is required. To fully prepare for successful surgical management of diaphyseal femur fractures, surgeons must consider appropriate patient positioning and necessary tools, including surgical tables, traction devices, and instruments. Principles of acceptable reduction rely on the restoration of length, alignment, and rotation. Reduction of diaphyseal femur fractures should be attained in the least invasive manner, via percutaneous reduction techniques, if possible, to preserve fracture biology and promote successful fracture healing. Intraoperative assessment of reduction often requires imaging studies of the contralateral extremity as a reference. Intraoperative assessment for associated femoral neck fractures and postoperative clinical examination of the hip and knee are imperative to the successful management of diaphyseal femur fractures. Other reference modalities and clinical examinations are required in patients with bilateral diaphyseal femur fractures.

                      • Subspecialty:
                      • Femur

                    Management of Failed Rotator Cuff Repair in Young Patients

                    Management of failed rotator cuff repair may be difficult, especially in young patients. Various nonmodifiable and modifiable patient factors, including age, tendon quality, rotator cuff tear characteristics, acute or chronic rotator cuff tear, bone quality, tobacco use, and medications, affect rotator cuff repair healing. Surgical variables, such as the technique, timing, tension on the repair, the biomechanical construct, and fixation, as well as the postoperative rehabilitation strategy also affect rotator cuff repair healing. Variable outcomes have been reported in patients who undergo revision rotator cuff repair; however, a systematic surgical approach may increase the likelihood of a successful outcome. Numerous cellular and mechanical biologic augments, including platelet-rich plasma, platelet-rich fibrin matrix, mesenchymal stem cells, and acellular dermal matrix grafts, have been used in rotator cuff repair; however, conflicting or inconclusive outcomes have been reported in patients who undergo revision rotator cuff repair with the use of these augments. A variety of tendon transfer options, including latissimus dorsi, teres major, lower trapezius, pectoralis minor, pectoralis major, combined pectoralis major and latissimus dorsi, and combined latissimus dorsi and teres major, are available for the management of massive irreparable rotator cuff tears. Ultimately, the optimization of surgical techniques and the use of appropriate biologic/tendon transfer techniques, if indicated, is the best method for the management of failed rotator cuff repair.

                        • Subspecialty:
                        • Shoulder