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Reconstructive Options for Tibial Bone Defects
McClure, Philip K. MD; Abouei, Mehdi MD; Conway, Janet D. MD
doi : 10.5435/JAAOS-D-21-00049
November 1, 2021 - Volume 29 - Issue 21 - p 901-909
Segmental bone defects of the tibia are amenable to multiple treatment options including classic bone transport, shortening and then lengthening, induced membrane technique, transport over a nail, free fibular grafting, and medial transport of the ipsilateral fibula. These treatment options have relative advantages and disadvantages, depending on defect size, soft-tissue characteristics, the presence or absence of infection, and associated morbidity. Relatively, few large comparative studies exist, and surgeons are left to their own experience and the opinion of experts within the field to guide surgical decision-making.
Functional Outcomes and Return to Sport After Cartilage Restoration of the Knee in High-level Athletes
Mehran, Nima MD; Singla, Varun MD; Okoroha, Kelechi R. MD; Mitchell, Justin J. MD
doi : 10.5435/JAAOS-D-21-00242
November 1, 2021 - Volume 29 - Issue 21 - p 910-919
Articular cartilage injuries of the knee are being observed with increasing frequency in athletes and have proven to be difficult to treat given the limited regenerative ability of cartilage and the potential for progressive joint degeneration. A wide range of surgical treatments such as microfracture, autologous chondrocyte implantation, and osteochondral autograft and allograft have demonstrated promising results in these high-demand individuals. These procedures permit healing of cartilage defects while decreasing pain and restoring function with patient-reported outcomes demonstrating significant improvement at short-, mid-, and long-term follow-up. Most athletes are able to return to play after cartilage restoration of the knee, regardless of the surgical technique used. Although there is a large degree of heterogeneity across the literature and no consensus as to the optimal technique, osteochondral autograft transfer seems to offer the highest rate of return to sport and return to play at preinjury level. However, autologous chondrocyte implantation and osteochondral allograft transplantation are often used for larger defects or salvage after previous procedures, so results may be confounded. In addition, a multitude of factors including patient history, characteristics of the chondral lesion, and postoperative management may affect functional outcomes in athletes.
Evaluation and Management of Posterior Wall Acetabulum Fractures
Perdue, Paul W. Jr MD; Tainter, David MD; Toney, Clarence MD; Lee, Christopher MD
doi : 10.5435/JAAOS-D-20-01301
November 1, 2021 - Volume 29 - Issue 21 - p e1057-e1067
Posterior wall acetabulum fractures typically result from high-energy mechanisms and can be associated with various orthopaedic and nonorthopaedic injuries. They range from isolated simple patterns to multifragmentary with or without marginal impaction. Determination of hip stability, which can depend on fragment location, size, and displacement, directs management. Although important in the assessment of posterior wall fractures, CT is unreliable when used to determine stability. The dynamic fluoroscopic examination under anesthesia (EUA) is the benchmark in assessment of hip stability, and fractures deemed stable by EUA have good radiographic and functional outcomes. In fractures that meet surgical criteria, accurate joint reduction guides outcomes. Joint débridement, identification and elevation of impaction, and adjunctive fixation of posterosuperior and peripheral rim fragments along with standard buttress plate fixation are critical. Complications of the fracture and surgical fixation include sciatic nerve injury, posttraumatic osteoarthritis, osteonecrosis of the femoral head, and heterotopic ossification. Although accuracy of joint reduction is paramount for successful results, other factors out of the surgeon's control such as comminution, femoral head lesions, and dislocation contribute to poor outcomes. Even with anatomic restoration of the joint surface, good clinical outcomes are not guaranteed and residual functional deficits can be expected.
Tibial Sagittal Slope in Anterior Cruciate Ligament Injury and Treatment
Alaia, Michael J. MD; Kaplan, Daniel J. MD; Mannino, Brian J. MD; Strauss, Eric J. MD
doi : 10.5435/JAAOS-D-21-00143
November 1, 2021 - Volume 29 - Issue 21 - p e1045-e1056
Although anterior cruciate ligament reconstruction (ACLR) is a generally successful procedure, failure is still relatively common. An increased posterior tibial slope (PTS) has been shown to increase the anterior position of the tibia relative to the femur at rest and under load in biomechanical studies. Increased PTS has also been shown to increase forces on the native and reconstructed ACL. Clinical studies have demonstrated elevated PTS in patients with failed ACLR and multiple failed ACLR, compared with control subjects. Anterior closing-wedge osteotomies have been shown to decrease PTS and may be indicated in patients who have failed ACLR with a PTS of ?12°. Available clinical data suggest that the procedure is safe and effective, although evidence is limited to case series. This article presents the relevant biomechanics, clinical observational data on the effects of increased PTS, and an algorithm for evaluating and treating patients with a steep PTS.
The Orthopaedic Match: Defining the Academic Profile of Successful Candidates
Ngaage, Ledibabari M. MA; MB, Cantab BChir; Xue, Shan BS; A. Benzel, Caroline BS; Andrews, Akhil MD; M. A. Rawes, Catherine MBChB, BSc (Hons); Wilson, Robert H. MD; Ludwig, Steven C. MD; M. Rasko, Yvonne MD
doi : 10.5435/JAAOS-D-20-00727
November 1, 2021 - Volume 29 - Issue 21 - p 921-928
Research productivity forms a vital part of the resident selection process and can markedly affect the chance of a successful match. Current reports regarding the publication record among prospective orthopaedic surgery residents are likely inaccurate. Potential applicants have a poor understanding of the strength of their research credentials in comparison to other candidates.
A Comparison of Acute Complications and Mortality Between Geriatric Knee and Hip Fractures: A Matched Cohort Study
Wolfstadt, Jesse I. MD, MSc, FRCSC; Atrey, Amit MD, MSc, FRCSC; Nowak, Lauren L. BSc, MSc, PhD; Stavrakis, Alexandra MD; Melo, Luana T. BScPT, PhD; Backstein, David MD, MEd, FRCSC; Schemitsch, Emil H. MD, FRCSC; Nauth, Aaron MD, MSc, FRCSC; Khoshbin, Amir MD, MSc, FRCSC
doi : 10.5435/JAAOS-D-20-00090
November 1, 2021 - Volume 29 - Issue 21 - p 929-936
To compare acute complication and mortality rates for operatively treated, closed, isolated, low-energy geriatric knee fractures (distal femur [DFF] or tibial plateau [TPF]) with hip fractures (HFs).
Does Removing the Photograph and Name Change the Reviewer's Perception of Orthopaedic Residency Applicants?
Caldwell, Lindsey S. MD; Garcia-Fleury, Ignacio MD; An, Qiang MPH, MBBS; Lawler, Ericka A. MD
doi : 10.5435/JAAOS-D-20-00213
November 1, 2021 - Volume 29 - Issue 21 - p 937-942
Orthopaedic surgery remains the least diverse field in medicine regarding female and minority representation. Scarce literature exists evaluating the role of implicit bias in the residency application process. We hypothesized that applicants perceived as underrepresented minorities in orthopaedic surgery (URMs) based on their photograph or name would have a decreased likelihood of being invited to interview.
Candidate Quality Measures for Orthopaedic Surgery Outreach Trips: A Systematic Review
Shapiro, Lauren M. MD; Park, Meewon O. BA; Mariano, David J. BS, MS; Welch, Jessica M. BA; Kamal, Robin N. MD, MBA
doi : 10.5435/JAAOS-D-20-00263
November 1, 2021 - Volume 29 - Issue 21 - p e1068-e1077
Up to 30% of the global burden of disease is secondary to surgical conditions, most of which falls on those in low- and middle-income countries (LMICs). Ensuring that the quality of care delivered during outreach trips to address these conditions is foundational. Limited work has been done to develop and implement tools to assess and improve the quality of care for these trips. The purpose of this study was to identify candidate quality measures that address orthopaedic surgery outreach trips in LMICs.
Levels of Urgency for Orthopaedic Procedures: Reliability and Adoption of a Consensus-driven Classification
Cheng, Edward Y. MD; Matson, David M. MD; Morgenstern, Kyle D. MD; Agel, Julie MA; Hoogervorst, Paul MD
doi : 10.5435/JAAOS-D-20-00631
November 1, 2021 - Volume 29 - Issue 21 - p e1078-e1086
The current COVID-19 disease pandemic has delayed nonurgent orthopaedic procedures to adequately care for those affected by the severe acute respiratory syndrome coronavirus 2, resulting in a backlog in orthopaedic surgical care. As the capacity for orthopaedic surgeries expands or contracts, allocation of limited resources in a manner that adequately reflects medical necessity and urgency is paramount. An orthopaedic surgery-specific prioritization schema with proven reliability is lacking. The primary aim of this study was to assess the reliability of a newly developed prioritization list used for the phased reinstatement of orthopaedic surgical procedures during the COVID-19 pandemic and afterward. The secondary aim was to report its implementation.
The Implementation of Lean Six Sigma Principles to Improve the Value of Care Delivery for Total Joint Arthroplasty Patients: The Perioperative Institute of Surgical Excellence Experience
El-Othmani, Mouhanad M. MD; Crespi, Zachary BS; Pallekonda, Vinay MD; Sayeed, Zain MD, MHA; Saleh, Khaled J. MD, MSc, FRCS(C), MHCM, CPE
doi : 10.5435/JAAOS-D-20-00497
November 1, 2021 - Volume 29 - Issue 21 - p e1087-e1096
With the projected increase in the volume of total joint arthroplasty (TJA), minimizing variations in surgery times, hospital length of stay (LOS), discharge dispositions, and inhospital complication rates would help reduce costs and improve the quality of care. As the move toward bundle payment models gains further traction, providers will be reimbursed based on the quality and cost associated with the surgical episode. As such, it remains critical to design and implement high-quality cost-effective perioperative delivery care models. Lean Six Sigma (LSS) methodology has been well described in the healthcare field as a superior strategy in designing processes aimed at reducing waste while minimizing error rates. We present an institutional experience with the design and implementation of a LSS quality improvement process specific to the TJA pathway, with a hypothesis of expected decrease in case cancellation rate, inhospital LOS, 30-day readmissions, and inpatient rehabilitation utilization after program implementation.
