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Diagnosis and Treatment of Syndesmotic Unstable Injuries: Where We Are Now and Where We Are Headed
Bejarano-Pineda, Lorena MD; DiGiovanni, Christopher W. MD; Waryasz, Gregory R. MD; Guss, Daniel MD, MBA
doi : 10.5435/JAAOS-D-20-01350
December 1, 2021 - Volume 29 - Issue 23 - p 985-997
Up to 10% of ankle sprains are considered “high ankle” sprains with associated syndesmotic injury. Initial diagnosis of syndesmotic injury is based on physical examination, but further evaluation of the distal tibiofibular joint in the sagittal, coronal, and rotational planes is necessary to determine instability. Imaging modalities including weight-bearing CT and ultrasonography allow a physiologic and dynamic assessment of the syndesmosis. These modalities in turn provide the clinician useful information in two and three dimensions to identify and consequently treat syndesmotic instability, especially when subtle. Because there is notable variability in the shape of the incisura between individuals, contralateral comparison with the uninjured ankle as an optimal internal control is advised. Once syndesmotic instability is identified, surgical treatment is recommended. Several fixation methods have been described, but the foremost aspect is to achieve an anatomic reduction. Identifying any associated injuries and characteristics of the syndesmotic instability will lead to the appropriate treatment that restores the anatomy and stability of the distal tibiofibular joint.
Use of Adjunct Antiseptic Agents in Periprosthetic Joint Infections
Plate, Johannes F. MD, PhD; Zuskov, Andrey MD; Seyler, Thorsten M. MD, PhD
doi : 10.5435/JAAOS-D-21-00154
December 1, 2021 - Volume 29 - Issue 23 - p e1151-e1158
Periprosthetic joint infection is a leading cause for failure of contemporary total hip arthroplasty and total knee arthroplasty projected to nearly double in the next decade and reach an economic burden of $1.85 billion in the United Sates by 2030. Although multiple treatments for periprosthetic joint infection have been described, a thorough débridement and joint lavage to decrease bacterial bioburden and to remove biofilm remains a critical component of treatment. Various adjunct antiseptic agents such as chlorhexidine, povidone-iodine, hydrogen peroxide, acetic acid, and chlorine compounds are currently in off-label use in this capacity. Each antiseptic agent, however, has a distinct mechanism of action and targets different organisms, and some combinations of agents may lead to tissue toxicity. In this review, currently available adjunct antiseptic washes will be described in detail based on their mechanism of action and the evidence for their use will be reviewed. Furthermore, this review puts forward an evidence-based treatment algorithm based on the specific causative organism.
Neuropathic (Charcot) Arthropathy of the Knee
Rees, Harold MD; Lyons, Madeline MD; Belich, Paul MD; Brown, Nicholas MD
doi : 10.5435/JAAOS-D-21-00482
December 1, 2021 - Volume 29 - Issue 23 - p e1159-e1166
Neuropathic arthropathy of the knee (Charcot knee) is a rare pathology defined by progressive destruction of bone and soft tissue in a patient with underlying peripheral neuropathy. Historically, Charcot knee was associated with neurosyphilis, but it has been increasingly described as a late stage of diabetes. The pathophysiology of the disease is not completely understood, but theories include repetitive microtrauma and an abnormal neurovascular response. Patients present with a warm, swollen, and unstable joint and have rapid bone resorption and characteristic findings on pathology. Nonsurgical options for pain and dysfunction include total contact casting and bracing treatment. Pharmacologic management includes diphosphonates, although this use is considered off-label. Surgical management historically included knee fusion. However, recent case series have suggested that newer prostheses allow for successful arthroplasty in this cohort, although complications are higher when compared with joint arthroplasty in patients with normal neurologic function.
Noninvasive Expandable Endoprostheses From Reconstruction to Skeletal Maturity: A Surgical Technique and Lengthening Guide
Voskuil, Ryan T. MD; Miles, Daniel T. MD; Scharschmidt, Thomas J. MD; Alexander, John H. MD
doi : 10.5435/JAAOS-D-21-00183
December 1, 2021 - Volume 29 - Issue 23 - p 998-1007
Limb salvage is the benchmark for pediatric extremity bone sarcomas. However, reconstructive strategies must account for any anticipated remaining growth potential and the resultant limb inequality. Expandable endoprostheses offer the theoretical advantage of immediate weight-bearing, predictable function, and reliable maintenance of leg-length equality. The evolution of the lengthening mechanism now permits noninvasive lengthening, opposed to the multiple open procedures of the past. These design improvements have contributed to their growing popularity. Experience has indicated that these noninvasive implants more reliably achieve leg-length equality, have longer failure-free survival, and decreased complications, although some have noted gearbox and lengthening failures. Currently, no standardize technique exists for managing patients with noninvasive expandable implants from the time of reconstruction to final lengthening at skeletal maturity. This blueprint aims to provide a detailed surgical technique, lengthening schedule, and recommendations for the mitigation and management of complications to achieve successful limb salvage with noninvasive expandable endoprostheses.
The Effect of Operating Room Size on Orthopaedic Surgical Site Infection Rates
Tantillo, Tyler DO; Petrone, Brandon DO; Stapleton, Erik DO; Frane, Nicholas DO; Matai, Prashant MBBS; Lutsky, Larry PhD; Schilling, Mary RN; Armellino, Donna DNP; Katsigiorgis, Gus DO; Bitterman, Adam DO
doi : 10.5435/JAAOS-D-20-01022
December 1, 2021 - Volume 29 - Issue 23 - p 1009-1016
With many preventable causes of surgical site infections (SSIs) identified, the effect of operating room (OR) size on SSI rates has not been assessed. This study investigated the effect of OR size on incidence of SSIs for orthopaedic procedures.
Ethnic Disparities and Incidence of Postoperative Complications in Obese Patients Undergoing Total Knee Arthroplasty: Analysis of the American College of Surgeons National Surgical Quality Improvement Program Data Set
Alfaro, Robert BS; Kinter, Kevin MS; Mihas, Alexander BS; Castro, Grettel MPH; Rodriguez, Pura MPH; Zevallos, Juan MD; Elkbuli, Adel MD, MPH; Barengo, Noel MD, PhD, MPH; Ruiz-Pelaez, Juan MD
doi : 10.5435/JAAOS-D-20-01089
December 1, 2021 - Volume 29 - Issue 23 - p 1017-1023
Total knee arthroplasty (TKA) is common but complex operation. A paucity of literature exists on differences between Hispanics and non-Hispanics with TKA. Our study aims to investigate the association between Hispanic ethnicity and complications in obese patients undergoing TKA.
Outcomes and Risk Factors Associated With Failures of Debridement, Antibiotics, and Implant Retention in Patients With Acute Hematogenous Periprosthetic Joint Infection
Chen, Wenhao MD; Klemt, Christian PhD; Smith, Evan J. MD; Tirumala, Venkatsaiakhil MSc; Xiong, Liang MD; Kwon, Young-Min MD, PhD
doi : 10.5435/JAAOS-D-20-00939
December 1, 2021 - Volume 29 - Issue 23 - p 1024-1030
Acute hematogenous periprosthetic joint infections (PJI) accounts for 20% to 35% of all PJI cases. Treatment options include débridement, antibiotics, and implant retention (DAIR) or implant revision (single-stage/two-stage revision). Because the reported success rates of DAIR for acute PJIs as reported in the literature varies widely, this study aimed to investigate (1) the outcome of DAIR as revision surgery procedure and (2) the potential risk factors for treatment failure of DAIR in patients with acute hematogenous PJI.
Altered Glenohumeral Biomechanics in Proximal Humeral Fracture Malunion
Wright, Melissa A. MD; Lobao, Mario H. MD; Abbasi, Pooyan MSME; Parks, Brent G. MSc; Mistretta, Katherine L. MD; Murthi, Anand M. MD
doi : 10.5435/JAAOS-D-20-00555
December 1, 2021 - Volume 29 - Issue 23 - p e1167-e1175
There is little biomechanical evidence to support the traditional guideline that 45° represents acceptable proximal humerus deformity. We evaluated glenohumeral contact pressure (GP) and area, subacromial contact pressure, and joint abduction to assess biomechanical changes with different proximal humerus deformities.
Rheumatoid Arthritis Versus Osteoarthritis in Patients Receiving Revision Total Knee Arthroplasty in the United States: Increased Perioperative Risks? A National Database-Based Propensity Score–Matching Study
Pan, Xin MD, PhD; Wang, Jian MD, PhD; Shi, Zhe MD, PhD; Cheng, Hao MD, PhD; Lin, Zeming MD, PhD; Wu, Xuanping MD, PhD; Shi, Zhanjun MD, PhD
doi : 10.5435/JAAOS-D-20-00979
December 1, 2021 - Volume 29 - Issue 23 - p e1176-e1183
The impacts of rheumatoid arthritis (RA) on perioperative risks among patients undergoing revision total knee arthroplasty (rTKA) have not been investigated yet. Thus, we hypothesized that patients with RA sustained increased perioperative risks and higher resource consumption burdens as compared to patients with osteoarthritis (OA) during the perioperative period.
Total Knee Arthroplasty in Freestanding Ambulatory Surgery Centers: 5-Year Retrospective Chart Review of 90-Day Postsurgical Outcomes and Health Care Resource Utilization
Mascioli, Anthony A. MD; Shaw, Marian L. RN, BS, CCRP; Boykin, Shawn PhD; Mahadevan, Prakash PhD; Wilder, J. Heath BS; Bell, J. Weston BS; Dabov, Gregory D. MD; Toy, Patrick C. MD
doi : 10.5435/JAAOS-D-20-00934
December 1, 2021 - Volume 29 - Issue 23 - p e1184-e1192
Migration of total knee arthroplasty (TKA) procedures from the inpatient setting to outpatient venues, especially freestanding ambulatory surgery centers (ASCs), requires the use of reliable patient selection algorithms and standardized perioperative pathways to facilitate favorable outcomes for patients.
Emergency Department Visits After Total Joint Arthroplasty for Concern for Deep Vein Thromboses
Grosso, Matthew J. MD; Chisari, Emanuele MD; Vannello, Christina RN, BSN; Hozack, William J. MD
doi : 10.5435/JAAOS-D-20-00878
December 1, 2021 - Volume 29 - Issue 23 - p e1193-e1199
Concern for deep vein thrombosis (DVT) is the most common reason for emergency department (ED) referral after total joint arthroplasty (TJA) at our institution. We aim to investigate the referral pathway, together with the cost and outcomes associated with patients who access an ED because of concern for DVT after TJA.
Intraoperative and Postoperative Iron Supplementation in Elective Total Joint Arthroplasty: A Systematic Review
Chaudhry, Yash P. DO; MacMahon, Aoife BA; Hasan, Syed A. DO; Mekkawy, Kevin DO; Valaik, Daniel MD; Oni, Julius K. MD; Sterling, Robert S. MD; Khanuja, Harpal S. MD
doi : 10.5435/JAAOS-D-20-01171
December 1, 2021 - Volume 29 - Issue 23 - p e1200-e1207
Postoperative anemia is associated with substantial morbidity and mortality in total joint arthroplasty (TJA). Our primary objective was to determine whether perioperative iron supplementation improves postoperative hemoglobin levels in TJA. Secondary objectives were to determine the effects of perioperative iron on adverse events, quality of life, and functional measures in TJA.
Time to Complete Legacy Patient-Reported Outcome Measures in Patients with Lumbar Decompression
Cha, Elliot D. K. MS; Lynch, Conor P. MS; Mohan, Shruthi BS; Geoghegan, Cara E. BS; Jadczak, Caroline N. BS; Singh, Kern MD
doi : 10.5435/JAAOS-D-20-01207
December 1, 2021 - Volume 29 - Issue 23 - p e1208-e1216
Patient-reported outcome measures (PROMs) are used to capture the true extent of postoperative improvement. Use of lengthier and repetitive PROMs can increase question burden on patients. This study aims to determine whether the length of time to complete (TTC) legacy PROMs has an impact on scores after lumbar decompression.
Low Incidence of Asymptomatic Positive Patients Detected During Preoperative Testing for Total Joint Arthroplasty During the COVID-19 Pandemic
Zangrilli, Julian DO; Hameed, Daniel BS; Chisari, Emanuele MD; Vannello, Chris RN, BSN; Courtney, P. Maxwell MD; Krueger, Chad A. MD
doi : 10.5435/JAAOS-D-20-01213
December 1, 2021 - Volume 29 - Issue 23 - p e1217-e1224
Although the pause in elective surgery was necessary to preserve healthcare resources at the height of the novel coronavirus disease 2019 (COVID-19) pandemic, recent data have highlighted the worsening pain, decline in physical activity, and increase in anxiety among cancelled total hip and knee arthroplasty patients. The purpose of this study was to evaluate the effectiveness of our staged reopening protocol and the incidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among elective arthroplasty patients.
Analysis of the Basic Science Questions on the Orthopaedic In-Training Examination From 2014 to 2019
Shen, Tony S. MD; Driscoll, Daniel A. MD; Ellsworth, Bridget K. MD; Premkumar, Ajay MD; Lebrun, Drake G. MD; Bostrom, Mathias P. G. MD; Cross, Michael B. MD
doi : 10.5435/JAAOS-D-20-00862
December 1, 2021 - Volume 29 - Issue 23 - p e1225-e1231
The Orthopaedic In-Training Examination (OITE), produced by the American Academy of Orthopaedic Surgeons (AAOS), plays an important role in the educational mission of orthopaedic residency programs nationwide. An up-to-date understanding of this examination is critical for programs to develop an appropriate curriculum and for individuals to identify learning resources. This study presents an updated analysis of the basic science section of the OITE from 2014 to 2019.
Reimbursement for Orthopaedic Surgeries in Commercial and Public Payors: A Race to the Bottom
Wang, Kevin Y. BA; Margalit, Adam MD; Thakkar, Savyasachi C. MD; Hsu, Nigel N. MD; Srikumaran, Uma MD; Ficke, James R. MD; Jain, Amit MD
doi : 10.5435/JAAOS-D-20-01397
December 1, 2021 - Volume 29 - Issue 23 - p e1232-e1238
The purpose of this study was to compare surgeon professional fee reimbursement and trends from Medicare versus commercial payors for inpatient orthopaedic surgeries: total knee arthroplasty (TKA), total hip arthroplasty (THA), total shoulder arthroplasty (TSA), anterior cervical diskectomy and fusion (ACDF), and posterior lumbar fusion (PLF).
Impact of Conventional and Open Access Publications in Orthopaedic Surgery
Zhang, Dafang MD; Blazar, Philip MD; Kilgallen, Elliott E.; Earp, Brandon E. MD
doi : 10.5435/JAAOS-D-20-01074
December 1, 2021 - Volume 29 - Issue 23 - p e1239-e1245
The academic impact of open access publications compared with conventional publications in orthopaedic surgery is not well described. The primary objective of this study was to compare the number of academic citations and social media posts between recent conventional and open access publications in orthopaedic surgery. Secondary objectives of this study were (1) to determine the correlation between academic citations and social media posts and (2) to study the trend of academic citations and social media posts over time.
Optimal Synovial Fluid Leukocyte Count Cutoff for Diagnosing Native Joint Septic Arthritis After Antibiotics: A Receiver Operating Characteristic Analysis of Accuracy
Massey, Patrick A. MD; Clark, Michael D. MD; Walt, Jennifer S. MD; Feibel, Benjamin M. MD; Robichaux-Edwards, Lindy R. MD; Barton, R. Shane MD
doi : 10.5435/JAAOS-D-20-01152
December 1, 2021 - Volume 29 - Issue 23 - p e1246-e1253
Urgent treatment of septic arthritis is key in preventing devastating morbidity or mortality. Accurate diagnosis is critical, and the standard diagnostic cutoff of 50,000 synovial leukocytes may be altered by previous administration of antibiotics. Our objective was to identify and compare a cutoff synovial leukocyte count with a high sensitivity and specificity for diagnosis of septic arthritis in patients who received antibiotics and those who had not. A receiver operating characteristic (ROC) curve was used to provide a discriminate cutoff value for diagnosing septic arthritis.
Opioid Claims Prior to Elective Total Joint Arthroplasty and Risk of Prolonged Postoperative Opioid Claims
Ross, Bailey J. BA; Wu, Victor J. MD; Mansour, Alfred A. III MD; Lee, Olivia C. MD; Sherman, William F. MD, MBA
doi : 10.5435/JAAOS-D-20-01184
December 1, 2021 - Volume 29 - Issue 23 - p e1254-e1263
The United States is experiencing a national opioid epidemic. This study seeks to analyze recent trends in opioid claims after elective total joint arthroplasty and quantify the effect of preoperative opioid use on risk of prolonged postoperative claim rates.
The Pathologic Fracture Mortality Index: A Novel Externally Validated Tool for Predicting 30-day Postoperative Mortality
Raad, Michael MD; Suresh, Krishna V. BS; Puvanesarajah, Varun MD; Forsberg, Jonathan MD, PhD; Morris, Carol MD; Levin, Adam MD
doi : 10.5435/JAAOS-D-20-01309
December 1, 2021 - Volume 29 - Issue 23 - p e1264-e1273
Current mortality predictive tools, in the setting of completed or impending pathologic fractures, are nonspecific. Clinical decision making and mortality prediction in research would benefit from creation of a high-fidelity scoring system for calculating the risk of 30-day postoperative mortality. The purpose of this study is to develop a validated research and clinical tool that is superior to existing methods in estimating postoperative mortality risk after fixation of pathologic fractures.
Impact of Level of Evidence on Citation of Orthopaedic Articles
Scott, Bryan L. MD; Dirschl, Douglas R. MD; Landy, David C. MD PhD
doi : 10.5435/JAAOS-D-20-00733
December 1, 2021 - Volume 29 - Issue 23 - p e1274-e1281
Level of evidence grading has become widely used in orthopaedics. This study reviewed clinical research articles published in leading orthopaedic journals to describe the association between level of evidence and number of future citations, which is one measure of an article's impact in the field.
