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Diagnosis and Management of Partial Thickness Rotator Cuff Tears: A Comprehensive Review
Plancher, Kevin D. MD, MPH; Shanmugam, Jaya MD; Briggs, Karen MPH; Petterson, Stephanie C. MPT, PhD
doi : 10.5435/JAAOS-D-20-01092
December 15, 2021 - Volume 29 - Issue 24 - p 1031-1043
Partial thickness rotator cuff tears (PRCTs) are a challenging disease entity. Optimal management of PRCTs continues to be controversial. Although advances in magnetic resonance imaging and ultrasonography have aided in early diagnosis, arthroscopic evaluation remains the benchmark for diagnosis. Conservative treatment is often the first line of management for most patients; however, evidence suggests that surgical intervention may limit tear progression and the long-term sequelae. Surgical decision making is driven by factors such as age, arm dominance, etiology, activity level, tear thickness, and tear location. Many surgical options have been described in the literature to treat PRCTs including arthroscopic débridement, transosseous, in situ repair techniques, and tear completion and repair. Biologic supplements have also become an attractive alternative to aid in healing; however, the long-term efficacy of these modalities is largely unknown. This article will provide a detailed review of the etiology and natural history of PRCTs, as well as diagnosis, and current management to guide clinical decision-making and formulate an algorithm for management of PRCTs for the orthopaedic surgeon.
Diffuse Idiopathic Skeletal Hyperostosis of the Spine: Pathophysiology, Diagnosis, and Management
Le, Hai V. MD; Wick, Joseph B. MD; Van, Benjamin W. BS; Klineberg, Eric O. MD
doi : 10.5435/JAAOS-D-20-01344
December 15, 2021 - Volume 29 - Issue 24 - p 1044-1051
Diffuse idiopathic skeletal hyperostosis (DISH) is an ankylosing condition affecting up to 32.5% of the general cohort. Although often asymptomatic, affected individuals may present with back pain, stiffness, dysphagia, functional decline, and neurologic deficits. Radiographically, DISH is characterized by flowing ossifications along the anterior spine spanning ?4 vertebral bodies. Although the etiology of DISH remains unknown, diabetes mellitus and other metabolic derangements are strongly associated with DISH. Importantly, spinal ankylosis in DISH predisposes patients to unstable spine fractures from low-energy trauma, and careful consideration must be taken in managing these patients. This article reviews the epidemiology and pathophysiology of DISH, and its clinical findings, diagnostic criteria, and management.
Deep Gluteal Pain in Orthopaedics: A Challenging Diagnosis
Gonzalez-Lomas, Guillem MD
doi : 10.5435/JAAOS-D-21-00707
December 15, 2021 - Volume 29 - Issue 24 - p e1282-e1290
Identifying the specific source of gluteal pain can elude the most seasoned orthopaedic diagnosticians. Patients will often present with a protracted course of symptoms, and failure to successfully identify and treat the underlying etiology leads to frustration for both patient and clinician. Pain deep in the buttocks can arise from compression, inflammation, or injury of one or more of the structures in this anatomically dense area. Although sacroiliitis, hip arthritis, and trochanteric bursitis may also masquerade as gluteal pain, sciatic nerve irritation in its various presentations causes a substantial percentage of cases. Deep gluteal syndrome, hamstring syndrome, and ischiofemoral impingement can have overlapping presentations but can be differentiated by clinical examination and judiciously placed diagnostic corticosteroid injections. Although nonsurgical management, including physical therapy, relative rest, and injections represent the mainstay of treatment, open and endoscopic surgical approaches have yielded encouraging success rates in refractory cases.
Damage Control Orthopaedics in Spinal Trauma
Oitment, Colby MD, MSc(c), FRCSC; Thornley, Patrick MD, FRCSC; Jentzsch, Thorsten DrMed, MSc; Pahuta, Mark MD, PhD, FRCSC
doi : 10.5435/JAAOS-D-21-00312
December 15, 2021 - Volume 29 - Issue 24 - p e1291-e1302
There has been a shift in the management of the polytrauma patients from early total care to damage control orthopaedics (DCO), whereby patients with borderline hemodynamic stability may be temporized with the use of external fixators, traction, or splinting with delayed osteosynthesis of fractures. Recently, there has been an increasing trend toward a middle ground approach of Early Appropriate Care for polytrauma patients. The concepts of DCO for the spine are less clear, and the management of trauma patients with combined pelvic ring and spinal fractures or patients with noncontiguous spinal injuries present unique challenges to the surgeon in prioritization of patient needs. This review outlines the concept of DCO and Early Appropriate Care in the spine, prioritizing patient needs from the emergency department to the operating room. Concepts include the timing of surgery, minimally invasive versus open techniques, and the prioritization of spinal injuries in the setting of other orthopaedic and nonorthopaedic injuries. Contiguous and noncontiguous spinal injuries are considered in construct planning, and the principles are discussed.
Telehealth Utilization in Response to the COVID-19 Pandemic in Pediatric Orthopaedic Surgery
Parisien, Robert L. MD; Shin, Max BA; Trofa, David P. MD; Prasad, Aman BS; Li, Xinning MD; Levine, William N. MD; Flynn, John M. MD; Ganley, Theodore J. MD
doi : 10.5435/JAAOS-D-20-00694
December 15, 2021 - Volume 29 - Issue 24 - p 1053-1060
The purpose of this investigation was to assess the utilization of telehealth capabilities by pediatric orthopaedic departments across the United States in response to the COVID-19 pandemic.
Centers for Medicare & Medicaid Services' 2018 Removal of Total Knee Arthroplasty From the Inpatient-only List Led to Broad Changes in Hospital Length of Stays
Rankin, Kelsey A. BA; Freedman, Isaac G. MPH; Rubin, Lee E. MD; Grauer, Jonathan N. MD
doi : 10.5435/JAAOS-D-20-01228
December 15, 2021 - Volume 29 - Issue 24 - p 1061-1067
Centers for Medicare & Medicaid Services (CMS) removed total knee arthroplasty (TKA) from the “inpatient-only” list from January 1, 2018. The impact of this change on actual hospital length of stay (LOS) and patient coding is of interest.
A Comparison of Interobserver Reliability Between Orthopedic Surgeons Using the Centers for Disease Control Surgical Wound Class Definitions
Sessums, Price O. MD; Ledford, Cameron K. MD; Sherman, Courtney E. MD; Bosch, Wendelyn MD; Libertin, Claudia R. MD; Brumble, Lisa M. MD; Wilke, Benjamin K. MD
doi : 10.5435/JAAOS-D-20-01128
December 15, 2021 - Volume 29 - Issue 24 - p 1068-1071
The Centers for Disease Control (CDC) created a classification to help stratify surgical wounds based on contamination and risk of developing a surgical site infection. The classification includes four options (I to IV) depending on the level of contamination present. Although universally applied to a variety of surgical specialties, it is unknown whether the current system is reliable when considering orthopaedic surgeries. The purpose of this study was to compare the degree of interobserver reliability between orthopaedic surgeons using the current CDC wound class definitions.
Out-of-Network Billing in Privately Insured Patients Undergoing Elective Orthopaedic Surgery
Wang, Kevin Y. BA; Suresh, Krishna V. BS; Harris, Andrew MD; Marrache, Majd MD; Puvanesarajah, Varun MD; Levy, Joseph PhD; Jain, Amit MD
doi : 10.5435/JAAOS-D-21-00081
December 15, 2021 - Volume 29 - Issue 24 - p 1072-1078
Out-of-network charges during hospital care can result in unexpected or surprise bills for the patient. The aim of this study was to ascertain the frequency of out-of-network (OON) billing by the primary orthopaedic surgeon for commonly performed elective, inpatient procedures: total hip arthroplasty (THA), total knee arthroplasty (TKA), anterior cervical diskectomy and fusion (ACDF), and posterior lumbar fusion (PLF).
Preventing Acute Kidney Injury and Hypotension After Elective Total Joint Arthroplasty Is Possible: An Update to an Established Multidisciplinary Protocol
Malige, Ajith MD; Carmona, Aldo MD; Roscher, Christopher MD; Herman, Daniel MD; Filipkowski, Amy MHA, BSN, RN; Rowbotham, Jaclyn MSN, RN; Sgro, Jessica MBA, BSN; Gould, William MD; DeLong, William MD; Gayner, Robert MD
doi : 10.5435/JAAOS-D-20-01352
December 15, 2021 - Volume 29 - Issue 24 - p e1303-e1312
Based on preoperative and perioperative risk factors that have been found to correlate with the development of acute kidney injury (AKI), our institution developed a protocol aimed at managing and improving outcomes in all elective THA and TKA patients. This article highlights the continued success and growth of our protocol aimed at decreasing AKI and hypotension in elective total joint arthroplasty patients.
Effects of Skilled Nursing Facility Partnerships on Outcomes Following Total Joint Arthroplasty
Kaidi, Austin C. MSc; Shah, Roshan P. MD, JD; Doucet, Mary G. LCSW; Neuwirth, Alexander L. MD; Geller, Jeffrey A. MD; Cooper, H. John MD
doi : 10.5435/JAAOS-D-20-01378
December 15, 2021 - Volume 29 - Issue 24 - p e1313-e1320
Post-total joint arthroplasty (TJA) discharge to a skilled nursing facility (SNF) is associated with higher costs and more complications than home discharge; however, some patients still require postoperative SNF care. To improve outcomes for patients requiring postoperative SNF care, this article analyzed the effect of SNF-surgeon partnerships on TJA postoperative costs and patient outcomes.
Patient Perspectives on the Cancellation of Elective Primary Hip and Knee Arthroplasty During the COVID-19 Pandemic
Sequeira, Sean B. BS; Novicoff, Wendy M. PhD; McVey, Eric D. MEd; Noble, David M. MD; Harb, Matthew A. MD; Taliaferro, John P. MD; Browne, James A. MD
doi : 10.5435/JAAOS-D-20-00765
December 15, 2021 - Volume 29 - Issue 24 - p e1321-e1327
The coronavirus disease 2019 (COVID-19) pandemic resulted in the unprecedented widespread cancellation of scheduled elective primary total joint arthroplasty (TJA) in the United States. The impact of postponing scheduled total hip arthroplasty and total knee arthroplasty procedures on patients has not been well studied and may have physical, emotional, and financial consequences.
Robotic-arm–assisted Knee Arthroplasty Associated With Favorable In-hospital Metrics and Exponentially Rising Adoption Compared With Manual Knee Arthroplasty
Emara, Ahmed K. MD; Zhou, Guangjin PhD; Klika, Alison K. MS; Koroukian, Siran M. PhD; Schiltz, Nicholas K. PhD; Krebs, Viktor E. MD; Molloy, Robert M. MD; Piuzzi, Nicolas S. MD
doi : 10.5435/JAAOS-D-21-00146
December 15, 2021 - Volume 29 - Issue 24 - p e1328-e1342
Technology-assisted knee arthroplasty (KA), including robotic-arm-assisted knee arthroplasty (RA-KA) and computer-assisted (CA-KA) knee arthroplasty, was developed to improve surgical accuracy of implant positioning and alignment, which may influence implant stability, longevity, and functional outcomes. However, despite increased adoption over the past decade; its value is still to be determined.
Outcomes of Tourniquet-Less Revision Total Knee Arthroplasty: A Matched Cohort Analysis
Tirumala, Venkatsaiakhil MS; Klemt, Christian PhD; Oganseyan, Ruben MD; Walker, Paul BS; Padmanabha, Anand MD; Kwon, Young-Min MD, PhD
doi : 10.5435/JAAOS-D-20-00796
December 15, 2021 - Volume 29 - Issue 24 - p e1343-e1352
A tourniquet is routinely used in total knee arthroplasty (TKA) to limit perioperative blood loss and increase the visibility of the surgeon's field of view. This study aims to evaluate the postoperative clinical outcomes and complications associated with tourniquet use in revision TKA.
Reverse Total Shoulder Arthroplasty Versus Hemiarthroplasty for the Treatment of Proximal Humerus Fractures: A Model-Based Cost-Effectiveness Analysis
Sheibani-Rad, Shahin MD; Kuhn, Andrew W. MD; Berrigan, Patrick S. MA; Bedi, Asheesh MD
doi : 10.5435/JAAOS-D-21-00166
December 15, 2021 - Volume 29 - Issue 24 - p e1353-e1361
Compared with hemiarthroplasty (HA), reverse total shoulder arthroplasty (RTSA) may provide greater cost and health-related benefits for patients with complex three- and four-part proximal humeral fractures. This study set out to compare RTSA versus HA for the incremental cost per incremental improvement in quality adjusted life years (QALYs) for a hypothetical cohort of patients with proximal humerus fractures.
The Interconnected Ancestral Network of Hip Arthroplasty Device Approval
Premkumar, Ajay MD, MPH; Zhu, Andrew BSE; Ying, Xiaohan BS; Pean, Christian A. MD, MS; Sheth, Neil P. MD; Cross, Michael B. MD; Gonzalez Della Valle, Alejandro MD
doi : 10.5435/JAAOS-D-21-00138
December 15, 2021 - Volume 29 - Issue 24 - p e1362-e1369
In the United States, the most overwhelming medical devices, including hip arthroplasty devices, are cleared for human use by demonstration of “substantial equivalence” to a predicate, previously approved marketed device. This study examined the predicate approval lineages of modern hip arthroplasty devices.
Do Orthopaedic In-Training Examination Scores Predict the Likelihood of Passing the American Board of Orthopaedic Surgery Part I Examination? An Update With 2014 to 2018 Data
Fritz, Erik MD; Bednar, Michael MD; Harrast, John MS; Marsh, J. Lawrence MD; Martin, David MD; Swanson, David PhD; Tornetta, Paul MD; Van Heest, Ann MD
doi : 10.5435/JAAOS-D-20-01019
December 15, 2021 - Volume 29 - Issue 24 - p e1370-e1377
Previous research shows a correlation in performance between the Orthopaedic In-Training Examination (OITE) and the American Board of Orthopaedic Surgery (ABOS) Certifying Examination Part I; however, these studies are not current, with the most recent data from 2009. The purpose of this study was to update the relationship between the OITE and ABOS Part I scores with the five most recent nationwide cohorts of Part I scores and their corresponding OITE scores.
Orthopaedic Surgeon Physiological Indicators of Strain as Measured by a Wearable Fitness Device
Jevsevar, David S. MD, MBA; Molloy, Ilda B. MD, MS; Gitajn, Ida Leah MD, MS; Werth, Paul M. MS, PhD
doi : 10.5435/JAAOS-D-21-00078
December 15, 2021 - Volume 29 - Issue 24 - p e1378-e1386
Symptoms of stress, depression, and burnout are prevalent in medicine, adversely affecting physician performance. We investigated real-time measurements of physiological strain in orthopaedic resident and faculty surgeon volunteers and identified potential daily stressors.
Outcomes and Patient Safety in Overlapping vs. Nonoverlapping Total Joint Arthroplasty: A Systematic Review and Meta-Analysis
Malahias, Michael-Alexander MD, PhD; Antoniadou, Thekla MD; Jang, Seong J. BA; Dimopoulos, Leonidas MD, PhD; Windsor, Eric N. MD; Loucas, Marios MD; Gkiatas, Ioannis MD, PhD; Gu, Alex MD; Manolopoulos, Philip P. MD; Denti, Matteo MD; Sculco, Peter K. MD
doi : 10.5435/JAAOS-D-20-01130
December 15, 2021 - Volume 29 - Issue 24 - p e1387-e1395
Overlapping surgery is defined as two cases occurring in separate operating rooms (ORs), where the same attending surgeon conducts the critical surgical portions of each case at different times. Although it has been suggested that this established practice may improve the utilization of resources, allow for more opportunities to teach surgical trainees, and facilitate timely access to care, there is still no consensus on its use in elective orthopaedic surgery, such as total joint arthroplasty (TJA).
Temporal and Geographic Trends in Medicare Reimbursement of Primary and Revision Shoulder Arthroplasty: 2000 to 2020
Testa, Edward J. MD; Haglin, Jack M. MD, MS; Li, Neill Y. MD; Moore, M. Lane BS; Gil, Joseph A. MD; Daniels, Alan H. MD; Paxton, E. Scott MD
doi : 10.5435/JAAOS-D-20-01369
December 15, 2021 - Volume 29 - Issue 24 - p e1396-e1406
A comprehensive understanding of the trends for financial reimbursement of shoulder arthroplasty is important as progress is made toward achieving sustainable payment models in orthopaedics. This study analyzes Medicare reimbursement trends for shoulder arthroplasty. We hypothesize that Medicare reimbursement has decreased for shoulder arthroplasty procedures from 2000 to 2020 and that revision procedures have experienced greater decreases in reimbursement.
Oral Ketorolac as an Adjuvant Agent for Postoperative Pain Control After Arthroscopic Rotator Cuff Repair: A Prospective, Randomized, Controlled Study
Sivasundaram, Lakshmanan MD; Mengers, Sunita MD; Trivedi, Nikunj N. MD; Strony, John MD; Salata, Michael J. MD; Voos, James E. MD; Victoroff, Brian N. MD; Karns, Michael R. MD; Gillespie, Robert J. MD
doi : 10.5435/JAAOS-D-20-01432
December 15, 2021 - Volume 29 - Issue 24 - p e1407-e1416
Arthroscopic rotator cuff repair (RCR) is associated with substantial postoperative pain. Oral narcotic agents are the preferred analgesic postoperatively. However, these agents are associated with several side effects and a potential for abuse. This study evaluates the efficacy of ketorolac as an adjunctive agent for postoperative pain control after arthroscopic RCR.
Preoperative Patient-Reported Outcomes Measurement Information System Global Health Scores Predict Patients Achieving the Minimal Clinically Important Difference in the Early Postoperative Time Period After Total Knee Arthroplasty
Darrith, Brian MD; Khalil, Lafi S. MD; Franovic, Sreten MS; Bazydlo, Michael MS; Weir, Robb M. MD; Banka, Trevor R. MD; Davis, Jason J. MD
doi : 10.5435/JAAOS-D-20-01288
December 15, 2021 - Volume 29 - Issue 24 - p e1417-e1426
The patient-specific factors influencing postoperative improvement after total knee arthroplasty (TKA) are important considerations for the surgeon and patient. The primary purpose of this study was to determine which patient demographic factors influence the postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health (GH) scores. In addition, we aimed to compare the prognostic utility of preoperative PROMIS-GH scores and the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) in predicting postoperative improvement.
