JAAOS, Volume 26, No. 4

Septic Arthritis of the Wrist

Septic arthritis of the wrist is an uncommon condition, but one that can result in substantial morbidity. Timely identification and treatment is critical to patient care. No serum laboratory values have been shown to consistently confirm wrist joint infection. Thus, diagnosis is made based mainly on a thorough patient history, physical examination, and joint aspiration. When infection is suspected, aspiration of the wrist should be performed to confirm the diagnosis. Broad-spectrum antibiotics and joint aspiration or surgery are required to manage the infection and prevent sequelae.

      • Subspecialty:
      • Hand

      • Hand and Wrist

    Golf Injuries: Epidemiology, Pathophysiology, and Treatment

    Increasing numbers of people are playing golf. Golf is a unique sport in that the ability to participate at a high level is not limited by age. In addition, participants tend to play more rather than less as they grow older. Injuries can occur at any point during the golf swing, from takeaway through follow-through. Upper extremity injuries can affect the hands, elbow, and shoulder and are usually a result of the golf swing at impact. Injuries are also common in the lower back as well as the lower extremities. Most injuries are the result of overuse and poor swing mechanics. When treating golfers, it is important to have a good understanding of the biomechanics and forces of the golf swing to diagnose and manage the vast spectrum of injuries incurred in this sport.

        • Subspecialty:
        • Sports Medicine

      Transforaminal Lumbar Interbody Fusion: Traditional Open Versus Minimally Invasive Techniques

      Recently, minimally invasive spine arthrodesis has gained popularity among spine surgeons. Minimally invasive techniques have advantages and disadvantages compared with traditional open techniques. Comparisons between short-term outcomes of minimally invasive transforaminal interbody fusion and open transforaminal interbody fusion in terms of estimated blood loss, postoperative pain, and hospital length of stay have been well documented and generally favor the minimally invasive technique. However, the advantages of minimally invasive transforaminal interbody fusion must be evaluated in the context of long-term results, such as patient-reported outcomes and the success of arthrodesis. Because the literature is equivocal in identifying the superior technique for successful long-term outcomes, more study is needed. Patient safety, the risk of complications, and the cost of these techniques also must be considered.

          • Subspecialty:
          • Back

          • Spine

        Angiography and Embolization in the Management of Bleeding Pelvic Fractures

        The use, timing, and priority of angioembolization in the management of bleeding pelvic fractures remain ambiguous. The most common vessels for angioembolization are, in decreasing order, the internal iliac artery and its branches, the superior gluteal artery, the obturator artery, and the internal pudendal artery. Technical success rates for this treatment option range from 74% to 100%. The fracture patterns most commonly requiring angioembolization are the Young and Burgess lateral compression and anterior-posterior compression types and Tile type C. Mortality rates after angioembolization of 16% to 50% have been reported, but deaths are usually related to concomitant injuries. The sensitivity and specificity of contrast-enhanced CT in detecting the need for angioembolization range from 60% to 90% and 92% to 100%, respectively. Angioembolization can be effective in the management of bleeding pelvic fractures, but as with any treatment, the risks of complications must be considered. Availability of angioembolization and institutional expertise/preference for the alternative strategy of pelvic packing influence its use.

            • Subspecialty:
            • Trauma

            • Adult Reconstruction

          Management of Biceps Tendon Pathology: From the Glenoid to the Radial Tuberosity

          Management of proximal and distal biceps tendon pathology is evolving. The long head of the biceps tendon, if inflamed, may be a pain-producing structure. In appropriately indicated patients, a symptomatic long head of the biceps tendon can be surgically managed via tenotomy, tenodesis, and/or superior labrum anterior to posterior repair. In some patients, primary superior labrum anterior to posterior pathology can be managed via biceps tenodesis. Determining which procedure is most appropriate and which technique and implant are preferred for a given patient with biceps tendon pathology is controversial. Less debate exists with regard to the timing of distal biceps tendon repair; however, considerable controversy exists with regard to selection of an appropriate surgical technique and implant. In addition, the treatment of patients with a chronic and/or retracted distal biceps tendon tear and patients in whom distal biceps tendon repair fails is extremely challenging. Orthopaedic surgeons should understand the anatomy of, nonsurgical and surgical treatment options for, and outcomes of patients with proximal or distal biceps tendon pathology.

              • Subspecialty:
              • Shoulder and Elbow

            Trends and Variability in the Use of Total Shoulder Arthroplasty for Medicare Patients

            Introduction: As policies are implemented to encourage high-quality care, it is important to identify any persistent limitations to the uniform delivery of anatomic and reverse total shoulder arthroplasty (TSA). The study’s goal was to assess current TSA use and identify predictors of geographic variability.

            Methods: We used data from 2012 through 2014 that was obtained from public Medicare databases to identify the case volume, locations, and names of surgeons performing >10 TSAs annually. We also recorded regional characteristics of the Medicare population, including demographic characteristics and health factors.

            Results: From 2012 through 2014, the number of surgeons performing >10 TSAs annually increased from 824 to 1,060—an increase ranging from 0.75 to 0.95 TSAs per 1,000 beneficiaries. In 2012, there were 59 hospital referral regions with no TSAs performed; the number of regions decreased to 35 by 2014 (P = 0.009). The use of TSA varied widely across regions (range, 0.1 to 6.4 per 1,000 beneficiaries). A larger proportion of white patients and a smaller proportion of patients eligible for Medicaid were independent predictors for increased use of TSA. Despite this finding, 74.4% and 96.9% of the US population resided within 50 km and 200 km, respectively, of a surgeon performing at least 20 TSAs in Medicare patients annually.

            Discussion: TSA utilization in the Medicare population is increasing across the country. Although notable geographic disparities in the use of TSA persist, increased TSA utilization has provided greater access to surgeons with high-volume TSA caseloads.

            Conclusion: Substantial geographic variation in TSA use remains, largely due to socioeconomic factors.

                • Subspecialty:
                • Shoulder and Elbow

              Defining the Key Parts of a Procedure: Implications for Overlapping Surgery

              Introduction: The American College of Surgeons’ Statements on Principles requires attending surgeons to be present for the “key parts” of surgical procedures, but the term is not defined. The research question addressed in this study is whether a functional definition of the critical or key steps of common orthopaedic surgical procedures can be reliably constructed. We used the examples of hip and knee arthroplasty because these procedures are highly structured and divisible into distinct subroutines.

              Methods: We surveyed 100 experienced orthopaedic surgeons regarding whether particular steps in knee and hip arthroplasty procedures were considered “key.” The patterns of individual surgeons’ responses were compared among surgeons for overall reliability. The steps frequently cited as key were also identified.

              Results: The agreement rates among surgeons for the definitions of the key parts of hip and knee arthroplasty were 3.2% and 8.6%, respectively. For both procedures, five steps were identified as key by >90% of the respondents.

              Discussion: The agreement rate on what constitutes the key parts of hip and knee arthroplasty was poor, despite the fact that these are highly structured procedures. Accordingly, defining the key parts for a given procedure must rely on either the operating surgeon’s discretion or a consensus definition. Imposing a single surgeon’s standard on others is not the optimal approach because such a standard is likely to be idiosyncratic.

              Conclusion: A consensus standard articulated by the orthopaedic surgery community may be the best means for identifying the key parts of orthopaedic surgical operations. The data presented here suggest a foundation upon which a consensus definition for the key parts of arthroplasty procedures may be built.

                  • Subspecialty:
                  • General Orthopaedics

                Early Response to Warfarin Initiation and the Risk of Venous Thromboembolism After Total Joint Arthroplasty

                Background: Venous thromboembolism chemoprophylaxis with warfarin is common after total joint arthroplasty. Early response to warfarin initiation has been theorized to engender a transient increase in the risk of venous thromboembolism. We hypothesized that a rapid rise in the international normalized ratio is a risk factor for venous thromboembolism after total joint arthroplasty.

                Methods: This study was a retrospective analysis of Medicare patients undergoing elective total joint arthroplasty who were given nomogram-dosed warfarin for venous thromboembolism prophylaxis. Logistic regression was used to assess the relationship between the postoperative rate of change in the international normalized ratio and the occurrence of symptomatic venous thromboembolism within 30 days postoperatively.

                Results: The study included 948 patients (715 total knee arthroplasty, 233 total hip arthroplasty), of whom 4.4% experienced symptomatic venous thromboembolism within 30 days postoperatively. The change in the international normalized ratio from postoperative day 1 to postoperative day 2 was significantly greater in the symptomatic venous thromboembolism group compared with the group that did not have venous thromboembolism (increase of 0.70 versus 0.46; P = 0.008). Regression analysis showed that a higher rate of change in the international normalized ratio was associated with increased risk of symptomatic venous thromboembolism (odds ratio, 2.59 per unit of change in the international normalized ratio; 95% confidence interval, 1.51-4.38; P = 0.001).

                Conclusion: A rapid rise in the international normalized ratio after warfarin initiation in total joint arthroplasty patients is associated with increased risk of symptomatic venous thromboembolism. This novel finding identifies a population at risk for this complication. Further study of the early effects of warfarin therapy is warranted.

                Level of Evidence: Level III

                    • Subspecialty:
                    • General Orthopaedics