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Not All Robotic-assisted Total Knee Arthroplasty Are the Same
Siddiqi, Ahmed DO, MBA; Mont, Michael A. MD; Krebs, Viktor E. MD; Piuzzi, Nicolas S. MD
doi : 10.5435/JAAOS-D-20-00654
Volume 29(2), 15 January 2021, p 45-59
Because value in healthcare has shifted to a measurement of quality relative to the cost, a greater emphasis exists on improving clinical and functional outcomes and patient satisfaction. Despite advances in implant design, surgical technique, and postoperative rehabilitation, multiple studies demonstrate that nearly 20% of patients remain dissatisfied with their overall outcomes after primary total knee arthroplasty (TKA). Because implant positioning, alignment, and equal soft-tissue balance are critical for a successful TKA, malalignment in the coronal, sagittal, and rotational planes continue to increase failure rates and cause poor clinical outcomes. Robotic-assisted TKA has gained momentum within the past 10 years to better control surgical variables by mitigating technical errors caused by insecure cutting guides and imprecise bone cuts. Contemporary robotic platforms have evolved along with our ability to collect high-quality patient-reported outcome measures data, and this combination is proving the clinical effectiveness. This comprehensive review investigates the advent of robotic-assisted TKA including advantages, disadvantages, historical, and commercially available newer generation systems, clinical outcomes, and cost analysis to better understand the potential added value of this technology.
Management of Partial Tears of the Anterior Cruciate Ligament: A Review of the Anatomy, Diagnosis, and Treatment
Stone, Austin V. MD, PhD; Marx, Sean MD; Conley, Caitlin W. PhD, ATC
doi : 10.5435/JAAOS-D-20-00242
Volume 29(2), 15 January 2021, p 60-70
Partial anterior cruciate ligament (ACL) tears comprise an estimated 10% to 27% of isolated ACL injuries. Partial ACL tears may be challenging to clinically diagnose. We reviewed relevant studies focusing on the anatomy, diagnosis, imaging, and treatment of a partial injury with the goal of providing guidance to clinicians. Although a comprehensive patient history, thorough clinical examination, and imaging studies are helpful in arriving at a diagnosis, the benchmark for diagnosis remains visualization and examination of the ACL at the time of knee arthroscopy. Currently, limited data exist about the long-term outcomes of nonsurgical treatment. Some studies demonstrate that younger, active patients have the risk of progressing to a complete ACL rupture with conservative treatment. The decision to proceed with surgery is based on careful history and physical examination findings that suggest either a "functional" or "nonfunctional" ACL. Surgical treatment consists of augmenting the intact bundle with a selective bundle reconstruction versus a traditional ACL reconstruction. Selective bundle reconstruction has limited data available but is an option. The best evidence supports traditional ACL reconstruction for the surgical management of patients with documented nonfunctional partial tears of the ACL.
Diagnosis and Management of Traumatic Anterior Shoulder Instability
Provencher, Matthew T. MD; Midtgaard, Kaare S. MD; Owens, Brett D. MD; Tokish, John M. MD
doi : 10.5435/JAAOS-D-20-00202
Volume 29(2), 15 January 2021, p e51-e61
Anterior shoulder instability is the most common form of shoulder instability and is usually because of a traumatic injury. Careful patient selection is key to a favorable outcome. Primary shoulder stabilization should be considered for patients with high risk of recurrence or for elite athletes. Soft-tissue injury to the labrum, capsule, glenohumeral ligament, and rotator cuff influence the outcome. Glenoid bone loss (GBL) and type of bone loss (on-track/off-track) are important factors when recommending treatment strategy. Identification and management of concomitant injuries are paramount. The physician should consider three-dimensional CT reconstructions and magnetic resonance arthrography when concomitant injury is suspected. Good results can be expected after Bankart repair in on-track Hill-Sachs lesions (HSLs) with GBL < 13.5%. Bankart repair without adjunct procedures is not recommended in off-track HSLs, regardless of the size of GBL. If GBL is 13.5% to 25% but on-track, adjunct procedures to Bankart repair should be considered (remplissage and inferior capsular shift). Bone block transfer is recommended when GBL > 20% to 25% or when the HSL is off-track. Fresh tibia allograft or lilac crest autograft are good treatment options after failed bone block procedure.
Staying Out of Trouble With Intramedullary Nailing of Distal Tibia Fractures
Lee, Christopher MD; Brodke, Dane J. MD; Stefanski, James T. MD; Gurbani, Ajay MD
doi : 10.5435/JAAOS-D-20-00309
Volume 29(2), 15 January 2021, p e62-e71
As the biologically friendly and biomechanically sound technique of intramedullary fixation has been increasingly applied to distal tibia diaphyseal fractures, challenges with the technique have emerged. Malalignment, most often valgus and recurvatum, is more common than with mid-diaphyseal patterns, given the lack of endosteal fit, and this can be challenging to prevent. Key technical steps can ensure success. These include recognition and initial fixation of intra-articular fracture planes, the use of percutaneous clamps, a slightly lateral terminal nail position, and the use of blocking wires or screws to prevent malalignment after nail passage. With thorough preoperative planning and early recognition of troublesome patterns, a variety of techniques can be applied to obtain and maintain a stable reduction throughout the procedure.
Restarting Orthopaedic Care in a Pandemic: Ethical Framework and Case Examples
Humbyrd, Casey Jo MD, MBE; Dunham, Alexandra M. MD; Xu, Amy L. BS; Rieder, Travis N. PhD
doi : 10.5435/JAAOS-D-20-00871
Volume 29(2), 15 January 2021, p e72-e78
The question about how to resume typical orthopaedic care during a pandemic, such as coronavirus disease 2019, should be framed not only as a logistic or safety question but also as an ethical question. The current published guidelines from surgical societies do not explicitly address ethical dilemmas, such as why public health ethics requires a cessation of nonemergency surgery or how to fairly allocate limited resources for delayed surgical care. We propose ethical guidance for the resumption of care on the basis of public health ethics with a focus on clinical equipoise, triage tiers, and flexibility. We then provide orthopaedic surgery examples to guide physicians in the ethical resumption of care.
Diabetes Status Affects Odds of Body Mass Index-dependent Adverse Outcomes After Total Hip Arthroplasty
Kebaish, Kareem J. BA; Puvanesarajah, Varun MD; Rao, Sandesh MD; Zhang, Bo MD; Ottesen, Taylor D. BS; Grauer, Jonathan N. MD; Khanuja, Harpal MD
doi : 10.5435/JAAOS-D-20-00028
Volume 29(2), 15 January 2021, p 71-77
Introduction: Obesity and diabetes have independently been shown to predispose to adverse outcomes after total hip arthroplasty (THA). These may have a coupled effect on perioperative risks. The purpose of this study was to evaluate the effect of body mass index (BMI) on adverse outcomes in nondiabetic (ND), non-insulin-dependent diabetes mellitus (NIDDM), and insulin-dependent diabetes mellitus (IDDM) patients.
Reasons for Revision: Primary Total Hip Arthroplasty Mechanisms of Failure
Kelmer, Grayson BS; Stone, Andrea H. MSN, CRNP; Turcotte, Justin PhD, MBA; King, Paul J. MD
doi : 10.5435/JAAOS-D-19-00860
Volume 29(2), 15 January 2021, p 78-87
Background: This study aimed to examine the major reasons for total hip arthroplasty (THA) failure and temporal patterns in THA revisions.
Implications of Admission and Surgical Timing on Hospital Length of Stay in Patients with Hip Fractures
Rashidifard, Christopher H. DO; Bush, Chelsea M. MS; Muccino, Paul P. DO; DiPasquale, Thomas G. DO
doi : 10.5435/JAAOS-D-19-00129
Volume 29(2), 15 January 2021, p e79-e84
Introduction: Hospital reimbursements for geriatric hip fractures are contingent on patient outcomes and hospital length of stay (LOS). This study examined if the day of the week (DOTW) and time of day (TOD) of both admission and surgery are associated with increased LOS.
Demographics and Clinical Presentation of Early-Stage Legg-Calve-Perthes Disease: A Prospective, Multicenter, International Study
Laine, Jennifer C. MD; Novotny, Susan A. PhD; Tis, John E. MD; Sankar, Wudbhav N. MD; Martin, Benjamin D. MD; Kelly, Derek M. MD; Gilbert, Shawn R. MD; Shah, Hitesh MSOrth; Joseph, Benjamin MSOrth, MChOrth, FRCSEd; Kim, Harry K. W. MD; on behalf of the International Perthes Study Group
doi : 10.5435/JAAOS-D-19-00379
Volume 29(2), 15 January 2021, p e85-e91
Background: Children with Legg-Calve-Perthes disease (LCPD) are classically described as small, thin, high-energy children presenting with a painless limp. Epidemiologic studies have historically been retrospective and regional in nature. The purpose of this study was to determine the demographic and clinical features of children presenting in the early stages of LCPD in an international, multicenter cohort.
Incidence of Pseudotumors in a Dual Modular Stem Construct With and Without Metal-on-Metal Bearing Surface
Rahman, Tahsin M. MD; Frisch, Nicholas B. MD, MBA; Darrith, Brian MD; Patel, Ishan MD; Silverton, Craig D. DO
doi : 10.5435/JAAOS-D-19-00652
Volume 29(2), 15 January 2021, p e92-e97
Background: The purpose of this study was to compare the incidence of pseudotumors in metal-on-metal (MoM) titanium modular neck hip arthroplasties to non-MoM modular neck hip arthroplasties. A secondary goal was to determine whether a correlation exists between elevated metal concentrations and pseudotumor incidence.
After Incision, the Skin Knife Blade Is No More Contaminated Than a Fresh Knife Blade
Smith, Eric B. MD; Russo, Kimberly A. BSN; Maltenfort, Mitchell G. PhD; Sharkey, Peter F. MD; Rihn, Jeffery MD
doi : 10.5435/JAAOS-D-20-00203
Volume 29(2), 15 January 2021, p e98-e103
Introduction: The rationale for discarding the skin knife blade and replacing it with another blade for deeper dissection is to prevent bacteria that may be present on the skin from being carried into the deeper layers of the wound. This practice is very controversial because numerous, yet limited, studies exist that support and refute the findings. The purpose of this study was to directly compare the rate of contamination of a skin knife blade with a control blade.
