JAAOS, Volume 26, No. 14

Comprehensive Review of Current Constraining Devices in Total Hip Arthroplasty

Hip instability after total joint arthroplasty is a devastating complication. Appropriate management of instability is a challenge. Three components that are commonly used in these challenging scenarios are constrained liners, constrained tripolar components, and nonconstrained tripolar components. The biomaterials and biomechanics of these devices vary. Surgeons must take into account the risks associated with each of these components and some surgical pearls for their use. A thorough review of the recent literature allows comparison of results addressing the short-, medium-, and long-term survival of each component. Constraining devices are a good option when used in salvage procedures in elderly and/or low-demand patients with hip instability. However, constraining devices should not be used to correct deficiencies in surgical technique or implant placement.

      • Subspecialty:
      • Adult Reconstruction

      • Hip

    Venous Thromboembolism Prophylaxis in Spine Surgery

    Venous thromboembolism (VTE) is a source of morbidity and mortality in patients undergoing orthopaedic surgery. A substantial body of literature supports the use of VTE prophylactic agents in patients undergoing lower extremity surgery. Treatment options include early mobilization, mechanical prophylaxis via pneumatic compression devices, pharmacologic agents, and venous filters. No consensus has been established regarding utilization or timing of VTE prophylaxis measures after spine surgery. The risk of VTE in patients undergoing spine surgery is not well characterized and varies substantially by the procedure and degree of neurologic compromise. In addition, the risk of clinically notable VTE must be weighed against the risk of postoperative bleeding and epidural hematoma after spine surgery. A standardized approach to VTE prophylaxis in patients undergoing spine surgery must take into account the available studies of risk factors, choice of prophylactic agents, and timing of prophylaxis.

        • Subspecialty:
        • Spine

        • Spine

      Reverse-reamed Intercalary Allograft: A Surgical Technique

      Allograft reconstruction of large segmental intercalary bone defects after tumor resection is a well-accepted surgical technique. Although results generally have been satisfactory, nonunion at the allograft-host bone junction site remains a notable concern. Various reports have described attempts to enhance junctional healing with a variety of complex osteotomies, often complicating an already complex procedure. The use of an innovative reverse reaming technique can decrease the level of intraoperative difficulty mating the allograft-host junction and theoretically may improve junctional healing by enhancing stability and increasing the contact surface area.

          • Subspecialty:
          • Musculoskeletal Oncology

          • General Orthopaedics

          • Foot and Ankle

        Extremity War Injuries XII: Homeland Defense as a Translation of War Lessons Learned

        The 12th Extremity War Injuries Symposium focused on issues related to the transitions in medical care that are occurring as the focus of the war on terror changes. The symposium highlighted the results of Department of Defense–funded research in musculoskeletal injury, the evolution of combat casualty care, and the readiness of the fighting force. Presentations and discussions focused on force readiness of both troops and their medical support as well as the maintenance of the combat care expertise that has been developed during the previous decade of conflict.

            • Subspecialty:
            • Trauma

          Teaching Professionalism in Orthopaedic Residency: Efficacy of the American Academy of Orthopaedic Surgeons Ethics Modules

          Introduction: To aid implementing an ethics curriculum in an orthopaedic residency program, the American Academy of Orthopaedic Surgeons (AAOS) created 14 ethics scenarios. Because delivery of this curriculum could be burdensome, an online module–based curriculum might be optimal.

          Methods: Two cohorts of orthopaedic residents participated: cohort I completed 14 online ethics modules converted from the 14 AAOS ethics scenarios. For each module, we gave a multiple-choice assessment immediately before the module, immediately afterward, and 3 months afterward. Cohort II completed only the 14-module assessments at similar time intervals without any educational content.

          Results: Cohort I demonstrated improvement in 3-month postmodule assessment scores in 11 of the 14 modules, 3 of which had statistical differences in baseline scores for cohort I and cohort II. We observed no statistical difference in scores within cohort II on repeat testing.

          Discussion: This study demonstrates that 11 of the 14 AAOS ethics scenarios, converted to online modules, teach ethical concepts to orthopaedic residents. Orthopaedic residency programs may find it valuable to engage their residents in the ethics scenarios created by the AAOS to complement their ethics curriculum.

              • Subspecialty:
              • General Orthopaedics

            Spinopelvic Dissociation: A Retrospective Case Study and Review of Treatment Controversies

            Introduction: Spinopelvic dissociation is a rare injury resulting in discontinuity between the spine and pelvis. We review the English- language literature and discuss critical treatment controversies. We present a series of spinopelvic dissociation cases from a level I trauma center.

            Methods: In this retrospective review of 18 consecutive cases treated surgically over a period of 4 years, we collected patient, injury, and surgical demographics and clinical and radiographic outcome measures.

            Results: Twelve patients had associated injuries, five were intubated on arrival, and six had neurologic deficits at presentation. No patient had spinal decompression, and all patients underwent closed reduction and percutaneous fixation. There were no cases of iatrogenic nerve injury, despite the use of partially threaded sacroiliac screws and closed reduction techniques. Five patients showed progressive neurologic improvement postoperatively. After reduction, eight patients (44%) had radiographic loss of the sacrococcygeal angle at the latest follow-up, but correction of fracture translation was preserved in all.

            Discussion: Spinopelvic dissociation represents a heterogeneous group of injuries often in the context of polytraumatized patients with other injuries. Our closed reduction and fixation technique resulted in satisfactory outcomes. We present a treatment algorithm for these rare injuries.

                • Subspecialty:
                • Spine