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The Role of Electronic Learning in Orthopaedic Graduate Medical Training: A Consensus From Leaders in Orthopaedic Training Programs
Bostrom, Mathias P. G.; Lewis, Kadriye O.; Berger, Gavin; Orthopaedic Electronic Learning Graduate Medical Education Consensus Working Group
doi : 10.5435/JAAOS-D-20-00821
Journal of the American Academy of Orthopaedic Surgeons. 29(8):317-325, April 15, 2021.
The US orthopaedic graduate medical education system is based on long established methods in education, but academic leaders at orthopaedic institutions now have the ability to use electronic learning innovations. Hospital for Special Surgery gathered graduate medical education leaders from orthopaedic training programs around the country and an electronic learning expert to review current orthopaedic residency and fellowship program practices. This group came to consensus with the following points: (1) current training methods do not take full advantage of available technology/innovations, (2) trainees inappropriately use electronic resources in the absence of or in an underdeveloped formal electronic training program, (3) trainees learn at different rates and in different ways requiring individualized plans for optimal content engagement, and (4) formal electronic learning programs better use time dedicated to educating trainees than informal programs. Orthopaedic graduate medical training programs that adopt these points can establish an electronic learning program to complement their traditional education program by (1) guaranteeing online content is standardized and approved, (2) reducing time spent covering standard lecture material and increasing time spent reviewing cases, and (3) engaging students of all learning backgrounds with content in both asynchronous and synchronous formats.
Cementless Fixation in Primary Total Knee Arthroplasty: Historical Perspective to Contemporary Application
Kamath, Atul F.; Siddiqi, Ahmed; Malkani, Arthur L.; Krebs, Viktor E
doi : 10.5435/JAAOS-D-20-00569
Journal of the American Academy of Orthopaedic Surgeons. 29(8):317-325, April 15, 2021.
Cemented total knee arthroplasty (TKA) has been considered the benchmark, with excellent clinical outcomes and low rates of aseptic loosening at the long-term follow-up. However, alterations of the bone/cement interface leading to aseptic loosening, particularly in younger and obese patients, along with increased life expectancy have led to a renewed interest in noncemented TKA fixation. Certain early noncemented designs exhibited higher rates of subsidence and component failure. Improvements in designs, materials, and surgical technique offer promise for improved results with contemporary noncemented TKA applications. In an increasing cost-conscious healthcare environment, implant cost is important to consider because press-fit prostheses are generally more expensive. However, this cost may be offset by shorter surgical times, cement costs, and the potential for osseous integration. Technological advances have improved the manufacturing of porous metals, with reported excellent midterm survivorship. Future prospective, randomized trials, and registry data are needed to delineate differences between cemented and noncemented fixation, survivorship, and patient-reported outcomes, especially in young, functionally active, and/or obese populations.
Evolution in ACL Autograft Harvesting Techniques: Transition to Minimally Invasive Autograft Harvesting
Dennison, James M.; Andrews, James R.
doi : 10.5435/JAAOS-D-20-00803
Journal of the American Academy of Orthopaedic Surgeons. 29(8):e380-e387, April 15, 2021.
Surgical techniques for anterior cruciate ligament (ACL) reconstruction continue to evolve. Harvesting techniques for commonly used ACL autografts such as bone patellar tendon bone, hamstring, and quadriceps tendon have similarly continued to progress. Traditional larger incisions for graft harvesting that were described in the 1980s have given way to smaller or more minimally invasive techniques. Advantages of these techniques are primarily anatomy based and include the following: decreased nerve complaints such as hypoesthesia or dysesthesia, improved cosmesis, decreased surgical site pain or morbidity, and, in the case of hamstring harvesting, easier tendon identification. The current literature supports reproducible minimally invasive or modified graft harvesting techniques for bone patellar tendon bone, hamstring, and quadriceps tendon autografts. Specialized instrumentation is available to simplify the harvesting process. Each of these techniques is described in detail outlining surgical steps, technical considerations, and precautions. Knowledge and review of these techniques provides the surgeon with greater flexibility and options when choosing and harvesting autograft tissue for ACL reconstruction.
Deltoid Ligament Injuries Associated With Ankle Fractures: Arguments For and Against Direct Repair
Doty, Jesse F.; Dunlap, Burton D.; Panchbhavi, Vinod K.; Gardner, Michael J
doi : 10.5435/JAAOS-D-20-00323
Journal of the American Academy of Orthopaedic Surgeons. 29(8):e388-e395, April 15, 2021.
Ankle fractures are an extremely common orthopaedic injury treated by surgeons on a routine basis. The deltoid ligament is torn in a large number of these fractures and is commonly seen with associated radiographic changes of medial clear space widening. The clinical relevance of addressing the injured deltoid ligament with acute surgical repair has been debated for decades. The early literature documenting repair or reconstruction of the deltoid ligament dates back to the 1950s. Most commonly, orthopaedic surgeons restore the lateral column directly with fibula fracture fixation. The injury may then be further evaluated intraoperatively by stress testing to ensure syndesmosis integrity and mortise stability with indirect medial column reduction, which allows for secondary healing of the medial deltoid ligamentous complex. This popular treatment paradigm is based primarily on literature from the 1980s and has not been thoroughly evaluated with modern surgical implants, techniques, and research methods. A review and background of the supportive literature for and against deltoid ligament repair in the setting of acute ankle fractures is presented. Undeniably, the deltoid ligament complex has been proven to confer some element of stability to maintaining a congruent ankle mortise. The commonly cited data in favor of not repairing the deltoid ligament warrants careful consideration to allow accuracy in obtaining the best patient outcomes with the most predictable surgical methods available.
Aseptic Tibial Implant Loosening After Total Knee Arthroplasty: Preventable?
Menken, Luke G.; Fleuriscar, Jean; Weiner, Travis; Berliner, Zachary P.; Rodriguez, Jose A
doi : 10.5435/JAAOS-D-20-00452
Journal of the American Academy of Orthopaedic Surgeons. 29(8):326-330, April 15, 2021.
Aseptic loosening is a considerable complication that affects the longevity of total knee arthroplasty (TKA) implants. Surgeon technique may help minimize aseptic loosening after TKA. Meticulous cementation of the prosthesis and the bone surface during various stages of cement polymerization will maximize cement adherence to the prosthesis and the bone, respectively. Pressurization of the cement in the canal and at the cut surface to achieve at least 2 mm of cement depth penetration has been reported to increase TKA implant longevity.
A Simple, Stepwise, Outside-in Technique for Lateral Retinacular Release for Management of Patellar Maltracking During Total Knee Arthroplasty
Maniar, Adit R.; Maniar, Rajesh N.
doi : 10.5435/JAAOS-D-20-00678
Journal of the American Academy of Orthopaedic Surgeons. 29(8):331-335, April 15, 2021.
Lateral retinacular release is done to correct patellar maltracking in total knee arthroplasty. The inside-out technique is widely used but has associated risks. Our video describes a simple outside-in technique, done stepwise, and titrated according to the grade of maltracking that maximizes preservation of the superior lateral geniculate artery and preserves the synovium, avoiding complications such as hematoma formation, skin tenting, and wound discolouration. The technique is also effective in all severities of maltracking and with all types of implants.
Analysis of Online Reviews of Orthopaedic Surgeons and Orthopaedic Practices Using Natural Language Processing
Langerhuizen, David W. G.; Brown, Laura E.; Doornberg, Job N.; Ring, David; Kerkhoffs, Gino M. M. J.; Janssen, Stein J
doi : 10.5435/JAAOS-D-20-00288
Journal of the American Academy of Orthopaedic Surgeons. 29(8):337-344, April 15, 2021.
There is growing interest in measuring and improving patient experience. Machine learning–based natural language processing techniques may help identify instructive themes in online comments written by patients about their healthcare provider. Separating individual surgeon and orthopaedic office reviews, we analyzed themes that are discussed based on the rating category, the association with review length, the number of people posting more than one review for a surgeon or office, the mean number of reviews per rating category, and the difference in review tones.
Risk Adjustment for Episode-of-Care Costs After Total Joint Arthroplasty: What is the Additional Cost of Individual Comorbidities and Demographics?
Fillingham, Yale A.; Zachwieja, Erik; Rondon, Alexander J.; Vannello, Chris; Austin, Matthew S.; Courtney, P. Maxwell
doi : 10.5435/JAAOS-D-19-00889
Journal of the American Academy of Orthopaedic Surgeons. 29(8):345-352, April 15, 2021.
Concerns exist regarding the lack of risk adjustment in alternative payment models for patients who may use more resources in an episode of care. The purpose of this study was to quantify the additional costs associated with individual medical comorbidities and demographic variables.
Radiographic Risk Factors Associated With Adverse Local Tissue Reaction in Head-Neck Taper Corrosion of Primary Metal-on-Polyethylene Total Hip Arthroplasty
Kwon, Young-Min; An, Shuai; Yeo, Ingwon; Tirumala, Venkatsaiakhil; Chen, Wenhao; Klemt, Christian
doi : 10.5435/JAAOS-D-20-00473
Journal of the American Academy of Orthopaedic Surgeons. 29(8):353-360, April 15, 2021.
Adverse local tissue reactions (ALTRs) in metal-on-polyethylene (MoP) total hip arthroplasty (THA) with head-neck taper corrosion are multifactorial, involving implant and patient factors. This study aimed to identify any potential clinical risk factors associated with failed MoP THA due to head-neck taper corrosion.
Preoperative Platelet and International Normalized Ratio Thresholds and Risk of Complications After Primary Hip Fracture Surgery
Varady, Nathan H.; Yeung, Caleb M.; Amen, Troy B.; Schwab, Pierre-Emmanuel; Chen, Antonia F
doi : 10.5435/JAAOS-D-19-00793
Journal of the American Academy of Orthopaedic Surgeons. 29(8):e396-e403, April 15, 2021.
A paucity of data exists on safe platelet and international normalized ratio (INR) thresholds for hip fracture surgery. Recent work has called into question the safety of preoperative INRs < 1.5 for total knee arthroplasty, and optimal platelet thresholds are unknown. The purpose of this study was to identify the risk of 30-day postoperative morbidity and mortality in patients with thrombocytopenia or elevated INRs undergoing hip fracture surgery.
Factors Associated With Perioperative Transfusion in Lower Extremity Revision Arthroplasty Under a Restrictive Blood Management Protocol
Rao, Sandesh S.; Chaudhry, Yash P.; Hasan, Syed A.; Puvanesarajah, Varun; Amin, Raj M.; Oni, Julius K.; Sterling, Robert S.; Khanuja, Harpal S
doi : 10.5435/JAAOS-D-20-00185
Journal of the American Academy of Orthopaedic Surgeons. 29(8):e404-e409, April 15, 2021.
Approximately 37% of patients undergoing lower extremity revision total joint arthroplasty (TJA) receive allogeneic blood transfusions (ABTs), which are associated with increased risk of morbidity and death. It is important to identify patient factors associated with needing ABT because the health of higher-risk patients can be optimized preoperatively and their need for ABT can be minimized. Our goal was to identify the patient and surgical factors independently associated with perioperative ABT in revision TJA.
Defining Outpatient Hip and Knee Arthroplasties: A Systematic Review
McClatchy, Samuel G.; Rider, Carson M.; Mihalko, William M.; Pharr, Zachary K.; Toy, Patrick C
doi : 10.5435/JAAOS-D-19-00636
Journal of the American Academy of Orthopaedic Surgeons. 29(8):e410-e415, April 15, 2021.
The term “outpatient” has a variety of meanings regarding the location of arthroplasty and the duration of stay postoperatively. The purpose of this systematic review was to evaluate the literature and more accurately define the term “outpatient.”
