JAAOS, Volume 26, No. 10

Osteoimmunology: Effects of Standard Orthopaedic Interventions on Inflammatory Response and Early Fracture Healing

Achieving fracture union is highly dependent on the initial inflammatory phase of fracture healing, which is influenced by both the local and systemic inflammatory environments. The rapidly emerging field of osteoimmunology involves the study of the interactions between the immune system and the skeletal system. Recent research has advanced the current state of knowledge regarding the effects of the surrounding soft-tissue injury, fracture hematoma, and the method of fracture fixation on the inflammatory phase of fracture healing. Acute systemic inflammation, as seen in patients with polytrauma, and chronic systemic inflammation, as seen in patients with diabetes or rheumatoid arthritis, affects the inflammatory phase of fracture healing. The use of NSAIDs can influence early fracture healing. Understanding the effects of standard orthopaedic interventions on the local and systemic inflammatory responses and early fracture healing is important for optimizing fracture union.

      • Subspecialty:
      • Trauma

    Design Rationale for Total Ankle Arthroplasty Systems: An Update

    The design of total ankle arthroplasty systems is evolving as a result of findings from longer-term studies. Our understanding of modes of failure has increased, and surgical techniques have become more refined. Currently, five total ankle arthroplasty systems are used in the United States. The landscape has changed considerably in the decade since the latest article reviewing total ankle design was published. Some implants with acceptable intermediate results had much poorer outcomes at 7- to 10-year follow-up. As more research showing mid- to long-term outcomes is published, the design rationale and current outcomes data for each of these implants must be considered.

        • Subspecialty:
        • Ankle

        • Foot and Ankle

      Bony Reconstruction of the Anterior Glenoid Rim

      Recurrent anterior shoulder instability is associated with glenohumeral bone loss. Glenoid deficiency compromises the concavity-compression mechanism. Medial Hill-Sachs lesions can result in an off-track humeral position. Anterior glenoid reconstruction or augmentation prevents recurrence by addressing the pathomechanics. In Bristow and Latarjet procedures, the coracoid process is harvested for conjoint tendon transfer, capsular reinforcement, and glenoid rim restoration. Complications and the nonanatomic nature of the procedure have spurred research on graft sources. The iliac crest is preferred for autogenous structural grafts. Tricortical, bicortical, and J-bone grafts have shown promising results despite the historical association of Eden-Hybinette procedures with early degenerative joint disease. Allogeneic osteochondral grafts may minimize the risk of arthropathy and donor site morbidity. Tibial plafond and glenoid allografts more closely match the native glenoid geometry and restore the articular chondral environment, compared with conventional grafts. Graft availability, cost, risk of disease transmission, and low chondrocyte viability have slowed the acceptance of osteochondral allografts.

          • Subspecialty:
          • Shoulder and Elbow

          • Shoulder

        Arthroscopic Management of Tibial Spine Avulsion Fractures: Principles and Techniques

        Tibial spine fractures are uncommon injuries affecting the insertion of the anterior cruciate ligament on the tibia. They typically occur in skeletally immature patients aged 8 to 14 years and result from hyperextension of the knee with a valgus or rotational force. Diagnosis is based on history, physical examination, and standard radiographs. The use of MRI can identify entrapped soft tissue that may prevent reduction. Open or arthroscopic repair is indicated in patients with partially displaced fractures (>5 mm) with one third to one half of the avulsed fragment elevated, in patients who have undergone unsuccessful nonsurgical reduction and long leg casting or bracing, and in patients with completely displaced fractures. Arthroscopy offers reduced invasiveness and decreased morbidity. Suture fixation and screw fixation have produced successful results. Suture fixation can eliminate the risk of fracture fragment comminution during screw insertion, the risk of neurovascular injury, and the need for hardware removal. Suture fixation is ideal in cases in which existing comminution prevents screw fixation.

          • Keywords:
          • OVT

          • Subspecialty:
          • Spine

          • Spine

        Early Recurrence of a Solid Variant of Aneurysmal Bone Cyst in a Young Child After Resection: Technique and Literature Review and Two-year Follow-up After Corpectomy

        Aneurysmal bone cysts (ABCs) are considered to be rare benign tumors that may affect long bones or the vertebral column. Their incidence varies and is reported to be 1.4% of all benign skeletal tumors. The solid-variant aneurysmal bone cyst (S-ABC) is even rarer and constitutes 3.5% to 7% of all vertebral ABCs. We report the case of an Enneking stage 3 S-ABC in a 5-year-old boy at C7 that showed rapid local recurrence after primary excision from posterior and dorsal stabilization requiring ventral corpectomy and posterior excision of the right lateral mass and right posterolateral fusion. Histologic examination disclosed an S-ABC. To our knowledge, this is the first case of S-ABC described in the literature that used both anterior and posterior approaches and complete corpectomy. Over a 2-year period, the patient showed no radiologic or clinical signs of local recurrence with excellent neurologic function. Solid-variant aneurysmal bone cysts are difficult to diagnose and treat, and careful clinical and radiologic assessment should be done to tailor an appropriate surgical plan to prevent recurrence and neurologic sequelae. To the best of our knowledge, there are to date no publications that studied the behavior of this subtype.

            • Subspecialty:
            • Pediatric Orthopaedics

          Does Total Intravenous Anesthesia With Short-acting Spinal Anesthetics in Primary Hip and Knee Arthroplasty Facilitate Early Hospital Discharge?

          Introduction: Our study assessed the effect of total intravenous anesthesia (TIVA) with short-acting spinal anesthesia and aggressive day-of-surgery postoperative day 0 physical therapy (POD#0 PT) on hospital length of stay (LOS) in patients who underwent primary total joint arthroplasty.

          Methods: A retrospective chart review compared the hospital LOS of 116 patients who underwent primary total hip arthroplasty and total knee arthroplasty with TIVA and short-acting spinal blockade (“Updated protocol group”) with that of the control group of 228 patients who were under standard anesthesia (“Traditional protocol group”).

          Results: Both total hip arthroplasty and total knee arthroplasty patients in the Updated protocol group had markedly reduced LOS compared with those in the Traditional protocol group (1.5 ± 0.1 days versus 2.4 ± 0.1 days; P < 0.05 and 1.4 ± 0.1 days versus 2.3 ± 0.1 days; P < 0.05). A higher proportion of patients in the Updated protocol group received at least 1 POD#0 PT session compared with those in the Traditional protocol group.

          Conclusion: Total intravenous anesthesia combined with short-acting spinal anesthetics provided the following benefits for patients who underwent primary total joint arthroplasty: more day-of-surgery PT sessions and earlier discharge by nearly 1 full day.

          Level of Evidence: III.

              • Subspecialty:
              • Knee

              • Adult Reconstruction

              • Hip