Instructional course lectures最新文献

Revision total knee arthroplasty (rTKA) is an increasingly common challenge for arthroplasty surgeons. The survivorship of rTKA is significantly lower than that of primary total knee arthroplasty, resulting in increasing numbers of repeat rTKA. These repeat rTKAs present unique challenges including potentially massive bone loss and increased risk of infection. It is important to highlight advanced implant fixation techniques in the setting of massive bone loss as well as the management of periprosthetic joint infection following rTKA and repeat rTKA.

Periprosthetic fractures and their associated complications present significant challenges for orthopaedic surgeons. It is important to provide an overview of the current management of periprosthetic fractures, including techniques for osteosynthesis and revision total hip and knee arthroplasty, as well as special considerations for periprosthetic acetabular fractures, periprosthetic tibial fractures, and interprosthetic femur fractures. In addition, the guiding principles for the management of potential subsequent complications including infection, nonunion, and instability are discussed.

Fracture-related infection (FRI) is a serious complication that occurs primarily in surgically treated fractures. FRIs occur when bacteria enter the site of bony injury and alter the healing inflammatory response within the bone. This can prevent bone regeneration and can lead to long-lasting complications such as chronic infection, pain, nonunion, and amputation. FRIs can span a wide range of severity, and only recently has the international community come to a consensus on specific definitions and guidelines for treatment. Principles of FRI management include identification of at-risk injuries with correction of modifiable risk factors, the achievement of adequate bony union and fracture healing, thorough eradication of the offending microorganism, and restoration of function. Treatment strategies involving implant retention versus removal depend on several factors, including the acuity of the infection, host physiology, initial reduction quality and fracture stability, and implant stability. Antibiotic treatment of FRI has historically been intravenous; however, emerging data suggest oral antibiotics may be just as efficacious.

Multimodal analgesia and anesthesia have become the gold standard in total joint arthroplasty to reduce postoperative pain and opioid consumption and minimize complications associated with opioid use. There are several elements in an effective multimodal protocol, including oral medications, periarticular injection, regional nerve blocks, and spinal and general anesthesia. Many nonopioid medications are often used, such as acetaminophen and NSAIDs. Gabapentinoids and selective serotonin reuptake inhibitors are available and used in select cases, but have risks associated with their use. Corticosteroids are effective anti-inflammatory medications that reduce pain, opioid consumption, and postoperative nausea and vomiting. Nerve ablation may also be used preoperatively or in patients who have persistent pain after total knee arthroplasty.

Following fracture fixation, fracture-related infection (FRI) is a common complication and requires systematic evaluation to allow for an optimal treatment strategy. A high index of suspicion is necessary for early and timely diagnosis, to diagnose occult infection, and to prevent untreated infections from worsening. Diagnosis of FRI includes evaluation based on history and clinical examination, surgical exploration, serum inflammatory markers, imaging modalities, microbiology, histopathology, and, when needed, molecular biology. FRI can be early, delayed, or late onset, and symptom presentation and the pathogenic organism may vary with each type. Key considerations during the evaluation of FRI include if the fracture has united, the onset of symptoms, the location of the infection, the stability of fixation, the quality of reduction, the quality of soft tissues, history of infection, and host physiology. Although the common treatment for early FRI includes débridement, implant retention, and antibiotics, the treatment for delayed-onset or late-onset FRI typically includes staged surgeries starting with removal of implants and antibiotic treatment.

Partial-thickness rotator cuff tears (PTRCTs) are a common source of shoulder pathology, both in the aging population and in younger overhead athletes. Advanced imaging modalities used currently have led to increases in recognition, diagnosis, and treatment of these tears. The anatomy, five-layer histology, and relationship to the Ellman classification of PTRCTs have been well studied, with recent interest in radiographic predictors, such as the critical shoulder angle and acromial index. Almost all PTRCTs should be managed nonsurgically initially. If nonsurgical management is unsuccessful, the surgical options are either arthroscopic débridement with or without acromioplasty if the tear thickness is less than 50%, or arthroscopic conversion repair or in situ repair if the tear thickness is greater than 50%. The biologic augmentation of PTRCTs is promising, with leukocyte-poor platelet-rich plasma having the most robust supporting data. Mesenchymal signaling cell biologics and the variety of scaffold onlay augments have been receiving increased attention in clinical practice but require more rigorous studies before widespread usage.

The medial ulnar collateral ligament (MUCL) complex is integral for valgus elbow stability, especially in individuals engaged in repetitive overhead activities such as throwing. MUCL injuries often necessitate surgical intervention to restore elbow stability. Early studies reporting outcomes after MUCL repair demonstrated suboptimal return to play compared with ulnar collateral ligament reconstruction, prompting a shift toward reconstruction techniques. The first widely popular MUCL reconstruction technique was the Jobe technique. Many reconstruction techniques have since been described. Despite advancements, most reconstruction techniques do not fully restore native MUCL stiffness. Internal brace augmentation to MUCL reconstruction presents a promising adjunct to traditional MUCL reconstruction, with recent studies showing improved biomechanical performance compared with MUCL reconstruction alone. Clinical studies have yet to prove better clinical outcomes or shorter recovery time after MUCL reconstruction with an internal brace. It is important for the surgeon to have comprehensive knowledge about MUCL anatomy, the historical evolution of surgical techniques, biomechanical considerations, and clinical outcomes of MUCL reconstruction.

The opioid crisis has been an issue in the United States since the mid-1990s, claiming numerous lives and presenting a significant challenge to health care clinicians. Various preoperative, intraoperative, and postoperative strategies aimed at reducing opioid consumption can be used by orthopaedic surgeons to help minimize this crisis. Preoperative screening tools can help identify patients at risk for prolonged opioid use, allowing for tailored interventions and counseling. Patient education initiatives, including multimedia presentations and handouts, have shown promising results in decreasing opioid consumption postoperatively. Intraoperatively, administering local and regional anesthesia in collaboration with anesthesia colleagues has proved effective for minimizing postoperative pain and opioid requirements. Postoperatively, alternative therapies such as acetaminophen, NSAIDs, and cryotherapy offer viable options for pain management while reducing reliance on opioids. In addition, the prudent prescribing of opioids, based on patient needs and expectations, coupled with refill options, helps minimize excess opioid supply and potential diversion. Orthopaedic surgeons are urged to embrace a multimodal approach to pain management and decrease opioids prescription while integrating these various strategies to optimize outcomes while mitigating the risks associated with opioid use.

Gun-related violence is becoming increasingly more common in the United States, and ballistic injuries pose a challenge to the orthopaedic surgeon on trauma call. The guiding principles of trauma care are almost exclusively based on blunt trauma, and the management principles do not always translate. Ballistic long bone fractures, particularly of the lower extremity, can often be managed with similar principles, although the injury pattern can make restoration of anatomic alignment a challenge. Some data suggest that patients with ballistic arthrotomies can be safely treated with medical management and antibiotic therapy alone; however, gross contamination can be encountered, and this decision is at the surgeon's discretion. Retained ballistic fragments may result in intra-articular changes and elevated lead levels over time, warranting consideration for surgical excision. Ballistic injuries to the hand and wrist are often present with concomitant soft-tissue injury, including nerve and tendon injuries. Providing stable bony fixation while also facilitating early motion for rehabilitation is a difficult balance to reach. In addition, the management of ballistic nerve injuries is controversial, as many injuries are not simply neurapraxic, and either early exploration or evaluation with ultrasonographic imaging may help detect injuries for which repair or grafting can be considered. Last, ballistic trauma can have mental health implications for patients and families and even contribute to the burnout epidemic demonstrated in health care professionals.

Revision total knee arthroplasty (rTKA) is an increasingly common challenge for arthroplasty surgeons. The survivorship of rTKA is significantly lower than that of primary total knee arthroplasty, resulting in an increasing incidence of repeat rTKA. These cases present multifactorial challenges including the skin and soft-tissue envelopes, bone loss, ligamentous compromise, and often a history of periprosthetic joint infection. This is compounded by difficult exposure, iatrogenic trauma from additional surgery, and often challenging implant removal. Here, strategies to prevent perioperative repeat rTKA complications are discussed by highlighting key components of preoperative planning and techniques for advanced exposure, implant removal, and extensor mechanism reconstruction.