Orthopedics

Probe, R. A. and T. Britten (2020). “Correction of Lateral Tibial Plateau Malunion.” J Orthop Trauma 34 Suppl 2: S31-s32.

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The results of open reduction and internal fixation for tibial plateau fractures are generally favorable when articular morphology and stability are restored. When these goals of treatment are not achieved, limited function often results. The patient presented in this video complained of pain and an inability to resume his previous work. Evaluation suggested that root causes of these difficulties included widening of the plateau, significant depression of the articular surface, resultant valgus instability, and a displaced nonfunctioning lateral meniscus. This video demonstrates the planning and correction of a long-standing intraarticular malunion of a lateral tibial plateau fracture.

Page, B. J. and M. Lee Brennan (2020). “Total Elbow Arthroplasty for Distal Humerus Fractures.” J Orthop Trauma 34 Suppl 2: S7-s8.

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Distal humerus fractures in elderly patients are challenging due to poor bone quality and may threaten the independence of elderly patients due to loss of functional range of motion. Total elbow arthroplasty has gained popularity in the treatment of these injuries. This video demonstrates total elbow arthroplasty in an elderly patient with a comminuted distal humerus fracture.

Pfeffer, G. B., T. Gonzalez, J. Brodsky, J. Campbell, C. Coetzee, S. Conti, G. Guyton, D. N. Herrmann, K. Hunt, J. Johnson, W. McGarvey, M. Pinzur, S. Raikin, B. Sangeorzan, A. Younger, M. Michalski, T. An and N. Noori (2020). “A Consensus Statement on the Surgical Treatment of Charcot-Marie-Tooth Disease.” Foot Ankle Int 41(7): 870-880.

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BACKGROUND: Charcot-Marie-Tooth (CMT) disease is a hereditary motor-sensory neuropathy that is often associated with a cavovarus foot deformity. Limited evidence exists for the orthopedic management of these patients. Our goal was to develop consensus guidelines based upon the clinical experiences and practices of an expert group of foot and ankle surgeons. METHODS: Thirteen experienced, board-certified orthopedic foot and ankle surgeons and a neurologist specializing in CMT disease convened at a 1-day meeting. The group discussed clinical and surgical considerations based upon existing literature and individual experience. After extensive debate, conclusion statements were deemed “consensus” if 85% of the group were in agreement and “unanimous” if 100% were in support. CONCLUSIONS: The group defined consensus terminology, agreed upon standardized templates for history and physical examination, and recommended a comprehensive approach to surgery. Early in the course of the disease, an orthopedic foot and ankle surgeon should be part of the care team. This consensus statement by a team of experienced orthopedic foot and ankle surgeons provides a comprehensive approach to the management of CMT cavovarus deformity. LEVEL OF EVIDENCE: Level V, expert opinion.

Yohe, N., S. J. Swiggett, A. Razi, J. R. Bowman, S. L. Watson, J. M. Pearson, P. W. Hudson, J. C. Patt, S. E. Ames, L. R. Leddy, J. G. Khoury, C. C. Tubb, G. McGwin and B. Ponce (2020). “Acute Workplace Hazards in Orthopedic Surgery: Resident Survey Regarding Splash and Workplace Violence Events.” J Surg Educ Jun 3;S1931-7204(20)30142-2. [Epub ahead of print].

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INTRODUCTION: Orthopedic surgery residents are at risk for daily work-related hazards and exposures. Hazards related specific to this specialty includes radiation exposure, smoke inhalation (from electrocautery), and disease transmission through contact with surgical instruments or sharps during procedures. However, minimal research has been focused on other occupational hazard risks in orthopedic surgery including surgical splash events and workplace violence. This study focused on determining (1) whether or not use of protective eyewear in the workplace would be related to the availability of personal protective equipment (PPE); (2) resident education; and (3) the rate of workplace violence toward orthopedic surgery residents during their training. METHODS: An invitation to participate in a web-based, anonymous survey to 46 US allopathic orthopedic surgery residency programs (1207 potential resident respondents). The survey was conceptually divided into the following areas: (1) demographics; (2) training and attitudes concerning occupational hazards; (3) PPE provision and use; (4) sharps injuries and reporting; and (5) general safety knowledge and violence in the workplace. Those who answered yes to having a splatter event or receiving a threat at the hospital were compared to those who did not. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between these outcomes and selected independent variables of interest. p-Values of <0.05 were considered statistically significant. RESULTS: From January 18 to March 31, 2016, 518 surveys were received and included for analysis for a response rate of 42.9% (518/1207). One survey was excluded from analysis due to <50% completed response items. Self-reported program types were 64.5% (334/518) public university-affiliated, 23.2% (120/518) private university affiliated, 7.1% (37/518) community, and 5.2% (27/518) military. Residents were 83.0% = male and 17.0% = female. Overall, reported eye protection usage was 95% amongst all residents and 22% of residents reported experiencing a violent threat in the workplace. The risk of experiencing a splatter event was not statistically associated with residency type, gender, or geographic region. Senior residents were at an increased likelihood of experiencing a splatter event (OR 1.22, [95% CI 1.06-1.41], p = 0.006) when compared to PGY-1 residents. The risk of a violent experience at work was not statistically associated with residency type, year of residency training, or gender. Residents in the Northeast were more likely to have a violent experience (OR 2.78 [95% CI 1.41-5.49] p = 0.003). Overall, residents felt that they had adequate training to prevent occupational hazards (mean of 3.9/5 on Likert scale) and respond to hazards (mean of 3.7/5 Likert). CONCLUSIONS: Occupational hazards are not uncommon in orthopedic surgery training with high rates of improper eyewear PPE use and poor awareness of Occupational Safety and Health Administration and AAOS guidelines. Violence in the workplace impacts over one in 4 residents and training programs and hospitals should improve education and report efforts. Continual yearly PPE training and awareness of AAOS guidelines could be intertwined with duty hour and/or case logs in order to ensure residents are exposed to this material on a regular basis.

Rizkalla, J. M., B. P. Gladnick, A. A. Bhimani, D. S. Wood, K. J. Kitziger and P. C. Peters, Jr. (2020). “Triaging Total Hip Arthroplasty During the COVID-19 Pandemic.” Curr Rev Musculoskelet Med May 22;1-9. [Epub ahead of print].

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PURPOSE OF REVIEW: The purpose of this review was to evaluate the available literature to determine what may be considered urgent indications for total hip arthroplasty, in the unprecedented setting of the worldwide COVID-19 pandemic. RECENT FINDINGS: SARS-CoV-2 is a novel coronavirus currently presenting in the form of a global pandemic, referred to as COVID-19. In this setting, multiple states have issued executive orders prohibiting “elective” surgery, including arthroplasty, in order to preserve healthcare resources. However, during this unprecedented reduction in elective surgery, there is likely to be some controversy as to what constitutes a purely “elective” procedure, versus an “urgent” procedure, particularly regarding hip arthroplasty. We reviewed the available literature for articles discussing the most commonly encountered indications for primary, conversion, and revision hip arthroplasty. Based upon the indications discussed in these articles, we further stratified these indications into “elective” versus “urgent” categories. In patients presenting with hip arthroplasty indications, the decision to proceed urgently with surgery should be based upon (a) the potential harm incurred by the patient if the surgery was delayed and (b) the potential risk incurred by the patient in the context of COVID-19 if surgery was performed. The authors present a decision-making algorithm for determining surgical urgency in three patients who underwent surgery in this context. Urgent total hip arthroplasty in the setting of the COVID-19 pandemic is a complex decision-making process, involving clinical and epidemiological factors. These decisions are best made in coordination with a multidisciplinary committee of one’s peers. Region-specific issues such as hospital resources and availability of PPE may also inform the decision-making process.