JAAOS, Volume 26, No. 1

The Weight-Bearing Shoulder

The shoulder achieves a wide spectrum of motion, and in a subset of patients, including those who use manual wheelchairs and upper extremity walking aids, the shoulder also serves as the primary weight-bearing joint. Because the weight-bearing shoulder is subject to considerable joint reaction forces and overuse, a broad spectrum of pathology can affect the joint. The combination of muscle imbalance and repetitive trauma presents most commonly as subacromial impingement syndrome but can progress to other pathology. Patients with high-level spinal cord injury, leading to quadriplegia and motor deficits, have an increased incidence of shoulder pain. Understanding the needs of patients who use manual wheelchairs or walking aids can help the physician to better comprehend the pathology of and better manage the weight-bearing shoulder.

      • Subspecialty:
      • Shoulder and Elbow

    Local Modalities for Preventing Surgical Site Infections: An Evidence-based Review

    Surgical site infections remain a dreaded complication of orthopaedic surgery, affecting both patient economics and quality of life. It is important to note that infections are multifactorial, involving both surgical and patient factors. To decrease the occurrence of infections, surgeons frequently use local modalities, such as methicillin-resistant Staphylococcus aureus screening; preoperative bathing; intraoperative povidone-iodine lavage; and application of vancomycin powder, silver-impregnated dressings, and incisional negative-pressure wound therapy. These modalities can be applied individually or in concert to reduce the incidence of surgical site infections. Despite their frequent use, however, these interventions have limited support in the literature.

        • Subspecialty:
        • Surgery and Treatment

      Comprehensive Review of Skiing and Snowboarding Injuries

      Skiing and snowboarding have increased in popularity since the 1960s. Both sports are responsible for a substantial number of musculoskeletal injuries treated annually by orthopaedic surgeons. Specific injury patterns and mechanisms associated with skiing and snowboarding have been identified. No anatomic location is exempt from injury, including the head, spine, pelvis, and upper and lower extremities. In these sports, characteristic injury mechanisms often are related to the position of the limbs during injury, the athlete’s expertise level, and equipment design. Controversy exists about the effectiveness of knee bracing and wrist guards in reducing the incidence of these injuries. Understanding these injury patterns, proper training, and the use of injury prevention measures, such as protective equipment, may reduce the overall incidence of these potentially debilitating injuries.

          • Subspecialty:
          • Broken Bones

          • Sports Medicine

          • Trauma

        The Utility of Biologics, Osteotomy, and Cartilage Restoration in the Knee

        The management of complex cartilage and meniscal pathology in young, athletic patients is extremely challenging. Joint preservation surgery is most difficult in patients with concomitant knee pathologies, including cartilage defects, meniscal deficiency, malalignment, and/or ligamentous insufficiency. Clinical decision making for these patients is further complicated by articular cartilage lesions, which often are incidental findings; therefore, treatment decisions must be based on the confirmed contribution of articular cartilage lesions to symptomatology. Surgical management of any of the aforementioned knee pathologies that is performed in isolation typically results in acceptable patient outcomes; however, concomitant procedures for the management of concomitant knee pathologies often are essential to the success of any single procedure. The use of biologic therapy as an alternative to or to augment more conventional surgical management has increased in popularity in the past decade, and indications for biologic therapy continue to evolve. Orthopaedic surgeons should understand knee joint preservation techniques, including biologic and reconstructive approaches in young, high-demand patients.

            • Subspecialty:
            • Knee

            • Adult Reconstruction

            • Surgery and Treatment

          Management of Periprosthetic Joint Infection Following Total Hip Arthroplasty: The One-Stage Exchange

          Periprosthetic joint infection (PJI) remains a significant complication following total hip arthroplasty (THA), with infection rates ranging from 0.5% to 2%. Several strategies have been described for managing the infected THA, and although two-stage exchange remains the standard in North America, the optimal treatment strategy is controversial. One-stage (ie, single-stage) exchange is used predominantly in Europe. Several recent studies have compared one- and two-stage exchanges for chronic PJI when treatment options were determined through an algorithmic approach; one-stage exchange showed equivalent success rates, higher Harris hip scores (HHSs), lower complication rates, and greater patient satisfaction. At our institution, four female patients and one male patient have undergone one-stage exchange for PJI following THA. Mean time to revision was 27.2 days (range, 10 to 62 days). At the time of revision, the average patient age was 73.54 years (range, 64 to 89 years), and mean body mass index was 35.98 kg/m2 (range, 24 to 45.1 kg/m2). Four different infecting organisms were identified, including Enterococcus faecalis, Pseudomonas aeruginosa, Staphylococcus aureus (in two cases), and S epidermidis. All five patients received intravenous antibiotics for 6 weeks, and three patients were prescribed suppression antibiotics (range, 6 weeks to lifetime). The mean postoperative HHS was 88.83 (range, 74.8 to 99.85) at a mean follow-up of 459 days (range, 309 to 733 days). The mean postoperative erythrocyte sedimentation rate and C-reactive protein level were 50.25 mm/hr and 3.0 mg/L, respectively, at a mean follow-up of 92.5 days (range, 6 to 309 days). All five patients had retained their implants at a mean follow-up of 459 days. This video contains a case presentation, footage on the seven-part surgical method that has been successful at our institution, the previously mentioned outcomes on one-stage exchange performed at our institution, and a review of the related literature. Watch the video trailer: http://links.lww.com/JAAOS/A74.

              • Subspecialty:
              • General Orthpaedics

            Laminectomy and Instrumented Fusion in Lordosis for Multilevel Cervical Myelopathy

            The goal of surgical management of multilevel cervical spondylotic myelopathy (CSM) is to decompress the spinal cord and restore a more physiologic sagittal alignment. Several surgical options for CSM exist, consisting of posterior and anterior procedures. Posterior decompression and stabilization in lordosis allow the spinal cord “back shift,” resulting in indirect decompression of the anterior neural elements. This video shows posterior decompression and instrumented fusion in a 59-year-old man affected by CSM at C5-C7, who had numbness and weakness in the upper extremities. The surgical steps shown include lateral mass identification by anatomic landmarks and lateral mass screw fixation technique according to Roy-Camille, cervical decompression by C5-C7 laminectomy, and attempted fusion via bone graft positioning. A total of 40 patients affected by multilevel CSM underwent this technique and were followed both clinically and electrophysiologically. Thirty-six patients were clinically assessed at a mean follow-up of 5.7 years. European myelopathy scale (EMS) scores, modified Japanese Orthopaedic Association (mJOA) scores, and Neck Disability Index scores improved significantly (P < 0.001). Ninety percent of patients would undergo the same surgery again. There was no deterioration of the cervical alignment, posterior grafted bones had completely fused, and there were no instrumentation failures. The mean spinal cord back shift was 3.9 mm (range, 2.5 to 4.5 mm). EMS and mJOA recovery rates were significantly correlated with the postoperative posterior cord migration (P < 0.05). Posterior decompression and stabilization in lordosis is a valuable procedure for patients affected by multilevel CSM, leading to marked clinical improvement resulting from the spinal cord back shift. Postoperative lordotic alignment of the cervical spine is a key factor for successful treatment. Watch the video trailer: http://links.lww.com/JAAOS/A73.

                • Subspecialty:
                • Back

                • Spine

              The Relative Effects of Manual Versus Automatic Exposure Control on Radiation Dose to Vital Organs in Total Hip Arthroplasty

              Introduction: Technologic advances have reduced medical radiation exposure while maintaining image quality. The purpose of this study was to determine the effects of the presence of total hip arthroplasty implants, compared with native hips, on radiation exposure of the most radiosensitive organs when manual and automatic exposure control settings are used.

              Methods: Detection probes were placed at six locations (stomach, sigmoid colon, right pelvic wall, left pelvic wall, pubic symphysis, and anterior pubic skin) in a cadaver. Radiographs were obtained with the use of manual and automatic exposure control protocols, with exposures recorded. A total hip arthroplasty implant was placed in the cadaver, probe positioning was confirmed, and the radiographs were repeated, with exposure values recorded.

              Results: The control probe placed at the stomach had values ranging from 0.00 mSv to 0.01 mSv in protocols with and without implants. With the manual protocol, exposures in the pelvis ranged from 0.36 mSv to 2.74 mSv in the native hip and from 0.33 mSv to 2.24 mSv after implant placement. The increases in exposure after implant placement, represented as relative risk, were as follows: stomach, 1.000; pubic symphysis, 0.818; left pelvic wall, 1.381; sigmoid colon, 1.550; right pelvic wall, 0.917; and anterior pubic skin, 1.015. With automatic exposure control, exposures in the pelvis ranged from 0.07 mSv to 0.89 mSv in the native hip and from 0.21 mSv to 1.15 mSv after implant placement. With automatic exposure control, the increases in exposure after implant placement, represented as relative risk, were as follows: stomach, 1.000; pubic symphysis, 1.292; left pelvic wall, 1.476; sigmoid colon, 2.182; right pelvic wall, 3.000; and anterior pubic skin, 1.378.

              Discussion: The amount of radiation to which patients are exposed as a result of medical procedures or imaging, and whether exposure is associated with an increased risk of malignant transformation, are the subject of ongoing debate. We found that after insertion of a total hip arthroplasty implant, exposure values increased threefold at some anatomic locations and surpassed 1 mSv, the generally accepted threshold for concern.

              Conclusion: Radiation exposure to radiosensitive organs increased up to threefold after total hip implantation with automatic exposure control and up to approximately 1.5 times with the manual protocol. Doses were greater with manual exposures than with automatic exposure control (except at the control probe on the stomach, where exposure was negligible, as expected). However, after implant placement, doses increased more with automatic exposure control than with manual exposure. This difference can be attributed to increased scatter and the difficulty of dose modification because of the density of the implant. Current radiographic protocols should be reassessed to determine if the benefits of frequent radiographs outweigh the newly demonstrated risks.

                  • Subspecialty:
                  • Adult Reconstruction