JAAOS, Volume 25, No. 7

Surgical Techniques for Total Knee Arthroplasty: Measured Resection, Gap Balancing, and Hybrid

Total knee arthroplasty (TKA) is effective in managing end-stage degenerative joint disease. Achieving favorable clinical outcomes is predicated on proper implant alignment, sizing, and rotation as well as adequate soft-tissue balancing. Modern TKA implants are designed to address the fundamental needs of attaining stability in both flexion and extension and of optimizing patellar tracking. Measured resection and gap balancing are the two different techniques used to implant the TKA components used today. Both techniques have been validated as durable and successful, and each has unique advantages and disadvantages. A hybrid technique has been developed that combines the benefits of measured resection and gap balancing and minimizes the limitations associated with both techniques. This hybrid approach has the potential for achieving improved TKA kinematics and refined surgical technique.

      • Subspecialty:
      • Knee

    Chronic Anterior Pelvic Instability: Diagnosis and Management

    Chronic anterior pelvic ring instability can cause pain and disability. Pain typically is localized to the suprapubic area or inner thigh; often is associated with lower back or buttock pain; and may be exacerbated by activity, direct impact, or pelvic ring compression. Known etiologies of chronic anterior pelvic ring instability include pregnancy, parturition, trauma, insufficiency fractures, athletics, prior surgery, and osteitis pubis. Diagnosis often is delayed. Physical examination may reveal an antalgic or waddling gait, tenderness over the pubic bones or symphysis pubis, and pain with provocative maneuvers. AP pelvic radiographs may demonstrate chronic degenerative changes at the pubic symphysis or nonhealing fractures. Standing single leg stance (flamingo view) radiographs can demonstrate pathologic motion at the pubic symphysis. CT may be useful in assessing posterior pelvic ring involvement. The initial management is typically nonsurgical and may include the use of an orthosis, activity modification, medication, and physical therapy. If nonsurgical modalities are unsuccessful, surgery may be warranted, although little evidence exists to guide treatment. Surgical intervention may include internal fixation alone in select patients, the addition of bone graft to fixation, or symphyseal arthrodesis. In some patients, additional stabilization or arthrodesis of the posterior pelvic ring may be indicated.

        • Subspecialty:
        • Trauma

      Management of Tarsometatarsal Joint Injuries

      Joint disruptions to the tarsometatarsal (TMT) joint complex, also known as the Lisfranc joint, represent a broad spectrum of pathology from subtle athletic sprains to severe crush injuries. Although injuries to the TMT joint complex are uncommon, when missed, they may lead to pain and dysfunction secondary to posttraumatic arthritis and arch collapse. An understanding of the appropriate anatomy, mechanism, physical examination, and imaging techniques is necessary to diagnose and treat injuries of the TMT joints. Nonsurgical management is indicated in select patients who maintain reduction of the TMT joints under physiologic stress. Successful surgical management of these injuries is predicated on anatomic reduction and stable fixation. Open reduction and internal fixation remains the standard treatment, although primary arthrodesis has emerged as a viable option for certain types of TMT joint injuries.

          • Subspecialty:
          • Foot

        Perioperative Blood Management in Pediatric Spine Surgery

        Blood management strategies are integral to successful outcomes in many types of orthopaedic surgery. These strategies minimize blood loss and transfusion requirements, ultimately decreasing complications, improving outcomes, and potentially eliminating risks associated with allogeneic transfusion. Practices to achieve these goals include preoperative evaluation and optimization of hemoglobin, the use of pharmacologic agents or anesthetic methods, intraoperative techniques to improve hemostasis and cell salvage, and the use of predonated autologous blood. Guidelines can also help manage allogeneic transfusions in the perioperative period. Although the literature on blood management has focused primarily on arthroplasty and adult spine surgery, pediatric spinal fusion for scoliosis involves a large group of patients with a specific set of risk factors for transfusion and distinct perioperative considerations. A thorough understanding of blood management techniques will improve surgical planning, limit transfusion-associated risks, maintain hemostasis, and optimize outcomes in this pediatric population.

            • Subspecialty:
            • Pediatric Orthopaedics

            • Spine

          Management of Lumbar Conditions in the Elite Athlete

          Lumbar disk herniation, degenerative disk disease, and spondylolysis are the most prevalent lumbar conditions that result in missed playing time. Lumbar disk herniation has a good prognosis. After recovery from injury, professional athletes return to play 82% of the time. Surgical management of lumbar disk herniation has been shown to be a viable option in athletes in whom nonsurgical measures have failed. Degenerative disk disease is predominately genetic but may be accelerated in athletes secondary to increased physiologic loading. Nonsurgical management is the standard of care for lumbar degenerative disk disease in the elite athlete. Spondylolysis is more common in adolescent athletes with back pain than in adult athletes. Nonsurgical management of spondylolysis is typically successful. However, if surgery is required, fusion or direct pars repair can allow the patient to return to sports.

              • Subspecialty:
              • Spine

            An Accurate Full-flexion Anterolateral Portal for Needle Placement in the Knee Joint With Dry Osteoarthritis

            Introduction: Accurate delivery of an injection into the intra-articular space of the knee is achieved in only two thirds of knees when using the standard anterolateral portal. The use of a modified full-flexion anterolateral portal provides a highly accurate, less painful, and more effective method for reproducible intra-articular injection without the need for ultrasonographic or fluoroscopic guidance in patients with dry osteoarthritis of the knee.

            Methods: The accuracy of needle placement was assessed in a prospective series of 140 consecutive injections in patients with symptomatic degenerative knee arthritis without clinical knee effusion. Procedural pain was determined using the Numerical Rating Scale. The accuracy rates of needle placement were confirmed with fluoroscopic imaging to document the dispersion pattern of injected contrast material.

            Results: Using the standard anterolateral portal, 52 of 70 injections were confirmed to have been placed in the intra-articular space on the first attempt (accuracy rate, 74.2%). Using the modified full-flexion anterolateral portal, 68 of 70 injections were placed in the intra-articular space on the first attempt (accuracy rate, 97.1%; P = 0.000).

            Conclusion: This study revealed that using the modified full-flexion anterolateral portal for injections into the knee joint resulted in more accurate and less painful injections than those performed by the same orthopaedic surgeon using the standard anterolateral portal. In addition, the technique offered therapeutic delivery into the joint without the need for fluoroscopic confirmation.

            Level of Evidence: Therapeutic Level II

                • Subspecialty:
                • Knee

              Association Between Opioid Intake and Disability After Surgical Management of Ankle Fractures

              Background: Opioid-centric pain management strategies have created an epidemic of prescription opioid abuse. This study assesses whether opioid intake is associated with disability, satisfaction with treatment, and pain at the time of suture removal and at 5 to 8 months after suture removal following open reduction and internal fixation of ankle fractures.

              Methods: We enrolled 102 adult patients in the study at the time of suture removal, 59 of whom were available for follow-up at 5 to 8 months. At the time of suture removal, we recorded opioid use; trauma-related factors; and scores on measures of disability, pain, and treatment satisfaction. Patients who were available for follow-up completed the disability, pain, and treatment satisfaction measures at 5 to 8 months and their opioid use at that time was recorded.

              Results: No association was found between opioid intake and disability at the time of suture removal. No association was found between opioid intake and satisfaction with treatment or satisfaction with pain management at the time of suture removal. At 5 to 8 months after suture removal, no variables were associated with opioid intake. The psychologic measures of pain anxiety and catastrophic thinking were the factors most consistently associated with disability, treatment satisfaction, satisfaction with pain management, pain at rest, and pain with activity at both of the time points.

              Conclusion: Patients with ankle fractures may be able to use fewer opioids than are currently prescribed and experience levels of disability and treatment satisfaction comparable with those of patients who take greater amounts of opioids, independent of injury characteristics.

              Level of Evidence: Prognostic level II

                  • Subspecialty:
                  • Ankle

                The Timing and Relevance of Relapsed Deformity in Patients With Idiopathic Clubfoot

                Background: The timing and relevance of relapsed deformity after correction of idiopathic clubfoot have not been well documented.

                Methods: All patients with idiopathic clubfoot seen at the authors’ institution during the study period who were followed for ≥2 years (range, 2.0 to 9.8 years) were included (N = 191). Survival analysis and multivariate regression analysis were used to analyze the data.

                Results: The median age at first relapse was 20 months. The probability of relapse remained approximately 30% at age 2 years and increased to 45% by 4 years and 52% by 6 years. Parent-reported adherence with bracing reduced the odds of a relapse by 15 times (P < 0.01). After an initial relapse, adherence with bracing was successful in avoiding a subsequent relapse in 68% of patients. Feet graded as very severe on the Diméglio scale were 5.75 times more likely to relapse than those graded severe and were 7.27 times more likely than those graded as moderate.

                Discussion: Patients whose parents reported nonadherence with bracing and patients with very severe deformities were most likely to relapse. After an initial relapse, regaining correction of the foot and resuming bracing were beneficial to avoid further relapses. These findings can be useful to clinicians in advising families regarding the prognosis of treatment.

                Conclusions: The development of a relapse affects the subsequent management and outcome of clubfoot deformity. The importance of bracing should be reinforced to parents. Bracing until at least age 4 years may be beneficial. For patients whose families are especially resistant to brace use and for older patients who experience a second relapse, regaining correction of the deformity via cast treatment followed by an Achilles lengthening procedure and/or tendon transfer may be the best alternative.

                    • Subspecialty:
                    • Pediatric Orthopaedics

                  Factors Motivating Medical Students in Selecting a Career Specialty: Relevance for a Robust Orthopaedic Pipeline

                  Introduction: Selection of a career specialty by medical students is a complex and individualized decision. Our goals were to understand the factors that influenced medical students in selecting their career specialty, identify the stage at which this decision was made, and understand the role of demographics, mentors, and curricula in this process.

                  Methods: Medical students from 10 institutions participated in a web-based survey. Results were stratified by sex, race/ethnicity, and level of interest in orthopaedic surgery.

                  Results: A total of 657 students responded to the survey. Specialty content (mean rating, 8.4/10) and quality of life/lifestyle/stress level (7.5/10) were the primary motivating factors in selecting a specialty. Interest in orthopaedic surgery was lower in women than in men (2.7 versus 3.9; P < 0.01) and was equivalent among race/ethnicity groups. Although 27% of students reported moderate or extensive medical school curriculum exposure to orthopaedics, this education did not sway them toward the specialty.

                  Conclusions: Levels of interest in orthopaedics among medical students may be lower than generally assumed. Increasing the attractiveness of the specialty will require a multifaceted approach, including recognition of lifestyle factors, adjustments in the orthopaedic clerkship to make the specialty more appealing, mentorship by orthopaedic faculty, and conversion of high levels of interest in the specialty among minority medical students into successful residency applications.

                  Level of Evidence: IV

                      • Subspecialty:
                      • General Orthopaedics

                    Management of Patients with Orthopaedic Implants Undergoing Dental Procedures

                    The American Academy of Orthopaedic Surgeons, in collaboration with the American Dental Association, has developed Appropriate Use Criteria (AUC) for the Management of Patients with Orthopaedic Implants Undergoing Dental Procedures. Evidence-based information, in conjunction with the clinical expertise of physicians, was used to develop the criteria to improve patient care and obtain best outcomes while considering the subtleties and distinctions necessary in making clinical decisions. The Management of Patients with Orthopaedic Implants Undergoing Dental Procedures AUC clinical patient scenarios were derived from indications of patients with orthopaedic implants presenting for dental procedures, as well as from current evidence-based clinical practice guidelines and supporting literature to identify the appropriateness of the use of prophylactic antibiotics. The 64 patient scenarios and 1 treatment were developed by the writing panel, a group of clinicians who are specialists in this AUC topic. Next, 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).