JAAOS, Volume 25, No. 8

The Role of Therapeutic Modalities in Surgical and Nonsurgical Management of Orthopaedic Injuries

Rehabilitation professionals often use therapeutic modalities as a component of the surgical and nonsurgical management of orthopaedic injuries. Myriad therapeutic modalities, including cryotherapy, thermotherapy, ultrasonography, electrical stimulation, iontophoresis, and laser therapy, are available. Knowledge of the scientific basis of each modality and the principles of implementation for specific injuries enables musculoskeletal treatment providers to prescribe these modalities effectively. The selection of specific therapeutic modalities is based on their efficacy during a particular phase of rehabilitation. Therapeutic modalities are an adjunct to standard exercise and manual therapy techniques and should not be used in isolation.

      Acute Wound Complications After Total Knee Arthroplasty: Prevention and Management

      Normal wound healing with avoidance of early wound complications is critical to the success of total knee arthroplasty. The severity of acute complications includes less morbid problems, such as quickly resolved drainage and small superficial eschars, to persistent drainage and full-thickness tissue necrosis, which may require advanced soft-tissue coverage. To achieve proper healing, surgeons must respond to persistent drainage by addressing modifiable patient risk factors, using meticulous surgical technique, and implementing an algorithmic approach to treatment.

          • Subspecialty:
          • Knee

        Revision Total Elbow Arthroplasty

        Despite recent technologic advances, total elbow arthroplasty has complication rates higher than that of total joint arthroplasty in other joints. With new antirheumatic treatments, the population receiving total elbow arthroplasty has shifted from patients with rheumatoid arthritis to those with posttraumatic arthritis, further compounding the high complication rate. The most common reasons for revision include infection, aseptic loosening, fracture, and component failure. Common mechanisms of total elbow arthroplasty failure include infection, aseptic loosening, fracture, component failure, and instability. Tension band fixation, allograft struts with cerclage wire, and/or plate and screw constructs can be used for fracture stabilization.

            • Subspecialty:
            • Elbow

          Management of Acetabular Fractures in the Elderly

          The incidence of acetabular fractures in the elderly population is increasing. Fractures in this population differ from those in younger patients, with more frequent involvement of the anterior column, more comminution, and more severe articular impaction in elderly patients. Although acetabular fractures in geriatric patients are more likely the result of low-energy trauma, outcomes are generally poorer than those in young patients. Multiple management options have been proposed, but no intervention has become the standard of care for these fractures in the elderly. Patient characteristics (eg, prior ambulation status, functional capacity, bone quality), the nature of the fracture, and the experience of the treating orthopaedic surgeon all must be considered when choosing among nonsurgical treatment, percutaneous fixation, open reduction and internal fixation, and immediate or delayed arthroplasty. Each treatment option has the potential for satisfactory results in properly selected patients.

              • Subspecialty:
              • Hip

            Septic Arthritis of the Shoulder: A Comparison of Treatment Methods

            Introduction: In-hospital outcomes were compared among patients with shoulder septic arthritis treated with arthrocentesis, open irrigation and débridement, or arthroscopic irrigation and débridement.

            Methods: The Nationwide Inpatient Sample database was queried for all cases of native shoulder septic arthritis between 2002 and 2011. Patient demographics, comorbidities, and hospitalization complications were compared for the shoulder arthrocentesis (nonsurgical) and open or arthroscopic irrigation and débridement (surgical) groups.

            Results: Data for 7,145 patients were analyzed. Medical comorbidities and complications were more common in the nonsurgical group than in the open surgical group (septicemia, 36.7% versus 23.6%, P < 0.001; death, 6.5% versus 2.5%, P < 0.001; pneumonia, 11.3% versus 6.2%, P < 0.001; septic shock, 4% versus 2.2%, P < 0.001; and urinary tract infection, 15.5% versus 10.2%, P < 0.001). The mean length of stay was longer in the nonsurgical group compared with the open surgical group (11.5 days versus 10.5 days, respectively; P = 0.002) and the percentage of patients discharged to home was lower (55.1% versus 64.0%, respectively; P < 0.001). Compared with the open surgical group, the arthroscopic surgical group had higher incidences of perioperative septicemia and urinary tract infection and similar average length of stay, hospital charges, and blood transfusion rates, but a lower incidence of osteomyelitis (P < 0.001). In a subgroup of patients with septicemia, Staphylococcus aureus was the most frequently cultured causative organism.

            Discussion: Septic arthritis in the shoulder is challenging to manage, and patients often have medical comorbidities and complications. In this study, the nonsurgically treated patients had substantially more preexisting comorbidities and in-hospital complications than the surgically treated patients had, which likely contributed to the longer average length of stay and lower discharge percentage in the nonsurgical group.

            Conclusion: Patients with septic arthritis of the shoulder frequently experience substantial systemic complications regardless of the treatment method. Septicemia was a common complication among all treatment groups, with cultures most frequently indicating Staphylococcus aureus as the causative organism.

            Level of Evidence: Therapeutic level III

                • Subspecialty:
                • Shoulder

              HIV in Orthopaedic Surgery

              The emergence of HIV in the United States has had important implications in the surgical setting. This blood-borne pathogen poses risks to both the surgeon and the patient undergoing an orthopaedic procedure. Although there has been research regarding the likelihood of orthopaedic surgeons contracting HIV during a surgical procedure, the correlation of HIV with postoperative prognosis has not been extensively examined. Because HIV-positive patients may be immunodeficient, they are at increased risk for certain postoperative complications, especially infection. Orthopaedic surgeons should have a thorough understanding of the effects of this disease on patients to optimize preoperative decision making, intraoperative care, and postoperative recovery.

                  • Subspecialty:
                  • Diseases and Conditions

                Iatrogenic Hip Instability Treated With Periacetabular Osteotomy

                Hip dislocation following hip arthroscopy is a devastating complication. Previous reports of arthroscopy–related iatrogenic instability have focused on strategies aimed at restoring the stabilizing effects of the hip joint capsuloligamentous complex. Less has been written about treatment options for patients in whom deficient acetabular coverage of the femoral head is implicated in the functionally unstable hip joint. Given this relative paucity of information, an optimal treatment approach has yet to be elucidated for these patients. Periacetabular osteotomy has been described as a treatment for iatrogenic hip instability related to surgical hip dislocation; however, to our knowledge, this is the first case of a patient with hip arthroscopy–related iatrogenic instability manifesting as recurrent, frank dislocations treated with periacetabular osteotomy.

                    • Subspecialty:
                    • Hip

                  Evaluation of Ulnar-sided Wrist Pain

                  Determining the etiology of ulnar-sided wrist pain is often challenging. The condition may be acute or chronic, and differential diagnoses include injuries to the ulnar carpal bones, ligament tears, tendinitis, vascular conditions, osteoarthritis and systemic arthritis, and ulnar nerve compression. An anatomically based, methodical physical examination coupled with provocative maneuvers, including piano key, ulnar impaction, shuck, foveal stress, and extensor carpi ulnaris synergy tests, further defines the differential diagnosis. Diagnostic imaging used in the evaluation of ulnar-sided wrist pain includes plain radiographs and MRI with or without arthrography. Wrist arthroscopy is becoming increasingly important in the diagnosis and management of ulnar-sided intra-articular wrist pathology.

                      • Subspecialty:
                      • Wrist

                    Guillain-Barré Syndrome After Elective Spinal Surgery

                    Guillain-Barré syndrome is a rare autoimmune condition characterized by ascending motor weakness of the extremities that can ascend to the diaphragm, causing substantial morbidity and mortality. This case report describes a 57-year-old man who exhibited characteristics of Guillain-Barré syndrome 9 days after undergoing lumbar fusion at L3-S1. The diagnosis was based on the patient’s ascending motor weakness and areflexia and was confirmed with electromyography. The patient progressed to respiratory failure, requiring mechanical ventilation. He regained motor function and ambulation within 6 months. Although the syndrome typically manifests initially as ascending paralysis, this patient’s initial symptom was new-onset atrial fibrillation, a sign of autonomic dysfunction. Because it can cause paralysis and respiratory failure, Guillain-Barré syndrome should be included in the differential diagnosis whenever motor weakness is observed after lumbar surgery. The timing of symptoms, imaging results, and the development of atypical symptoms can help distinguish this rare possibility from other postoperative spinal complications.

                        • Subspecialty:
                        • Spine

                      Management of Spinal Conditions in Patients With Parkinson Disease

                      Parkinson disease (PD) is increasingly prevalent in the aging population. Spine disorders in patients with PD may be degenerative in nature or may arise secondary to motor effects related to the parkinsonian disease process. Physicians providing care for patients with PD and spine pathologies must be aware of several factors that affect treatment, including the patterns of spinal deformity, complex drug interactions, and PD-associated osteoporosis. Following spine surgery, complication rates are higher in patients with PD than in those without the disease. Literature on spine surgery in this patient population is limited by small cohort size, the heterogeneous patient population, and variable treatment protocols. However, most studies emphasize the need for preoperative optimization of motor control with appropriate medications and deep brain stimulation, as well as consultation with a movement disorder specialist. Future studies must control for confounding variables, such as the type of surgery and PD severity, to improve understanding of spinal pathology and treatment options in this patient population.

                          • Subspecialty:
                          • Spine

                        Metatarsophalangeal Joint Arthrodesis for Severe Hallux Valgus in Elderly Patients

                        Severe hallux valgus is a common condition involving pain and limitation of range of motion (ROM) of the first metatarsophalangeal (MTP) joint; the condition is frequently associated with degenerative arthritis. Conservative treatments, such as activity modification, stiff-soled shoes, orthoses, NSAIDs, and cortisone injections, have only short-term effectiveness. Commonly performed surgical techniques include proximal osteotomy or distal osteotomy with extreme bone translation that can be associated with other joint-sparing procedures such as cheilectomy, phalangeal osteotomy, and shortening first metatarsal osteotomy. Despite this, pain, ROM limitation, and functional impairment often remain. Although few published studies exist, arthrodesis of the first MTP joint is a reliable procedure to address this condition, with good to excellent results. Postoperatively, weight bearing on the heel in a postoperative shoe is allowed; walking flatfooted is permitted after radiographic healing has been achieved (typically, 4 to 6 weeks). Potential complications include the general surgery risks associated with anesthesia, infection, damage to nerves, and bleeding. Complications specific to MTP fusion include delayed bone healing, malunion, nonunion, and stiffness in neighboring joints. MTP arthrodesis is a reliable and successful procedure to correct severe hallux valgus, especially in elderly patients, with a high rate of bone fusion, with a low rate of complications, without impairment of the ambulation, and without need of a special postoperative rehabilitation protocol. Watch the video trailer: http://links.lww.com/JAAOS/A40

                            • Subspecialty:
                            • Hand

                          Extensor Mechanism Reconstruction in Revision Total Knee Arthroplasty

                          Extensor mechanism insufficiency is a rare but unfortunate event in revision total knee arthroplasty (TKA). This video describes two different techniques used for extensor mechanism reconstruction in revision TKA: reconstruction using a whole extensor mechanism allograft, and the mesh technique described by Hanssen. Postoperatively, the knee is immobilized in a resin cast in full extension for 6 to 8 weeks, and toe-touch weight bearing is allowed. After the resin cast is removed, progressive full weight bearing is allowed in 4 to 6 weeks, and progressive range of motion recovery is permitted. This technique is mainly indicated for chronic patellar fractures or nonunion, patellectomies, or failed reconstructions with allograft. Contraindications for this technique are active infection, inadequate skin coverage, and severe medical comorbidities. A good tension of the graft is mandatory to obtain good results and a low extensor lag rate. Watch the video trailer: http://links.lww.com/JAAOS/A41.

                              • Subspecialty:
                              • Knee

                            Medial Patellofemoral Ligament Reconstruction Using a Partial Thickness Quadriceps Tendon Graft

                            This technique video demonstrates medial patellofemoral ligament (MPFL) reconstruction using a partial thickness quadriceps tendon graft. We’ve performed this procedure since 1998 and described the technique in 2005. We’ve been very pleased with the results. It’s a very simple technique in that you only have to detach and attach one side of the graft. The quadriceps tendon remains attached to the patella. It’s a flat, ribbon-like graft much like the native MPFL. It avoids patellar tunnels which are risks for fractures. We simply dissect and detach the graft proximally, rotate the graft, and attach it to the femur. In this manner, it lies along the course of the normal MPFL. Watch the video trailer: http://links.lww.com/JAAOS/A39.

                                • Subspecialty:
                                • Leg