Posterior cruciate ligament (PCL) injuries are a rare form of
knee injury often seen in the setting of high energy polytraumas; however, these injuries can occur in isolation as well.
Often, the posterolateral corner (PLC) is involved, which
imparts further posterior translational and rotational instability to these injuries. While non-operative management is
certainly a reliable option for low grade isolated PCL tears,
high grade injuries with concomitant PLC involvement,
additional intra-articular pathologies requiring operative
management, multiligamentous injuries, or patients who
have failed non-operative management require PCL repair
or reconstruction. The current review focuses on the many
facets of PCL reconstruction, including single versus double
bundle reconstruction, tibial slope implications, graft selection, multiligamentous injury considerations, tunnel management, and onlay versus inlay tibial footprint creation.
We conclude with a proposed algorithm in the management
of this injury.
Total Elbow Arthroplasty
Historical and Current Concepts
Amy Birnbaum, MD, Hilary Campbell, MD, Nirmal Tejwani, MD, Omri Ayalon, MD, and
Young Kwon, MD, PhD
The evolution of total elbow arthroplasty (TEA) has laid
the groundwork for modern day TEA and has contributed
to our understanding of elbow biomechanics. Trends in the
usage of TEA have also varied significantly over time. This
article aims to review the history and evolution of the TEA
implant with a focus on modern day implant biomechanics
and the trends in TEA indications. Additionally, this review
discusses various complications that can occur with modern
day TEA and looks toward the future to identify innovation
and future trends.
Stiffness After Total Knee Arthroplasty
A Review
Daniel Buchalter, MD, Benjamin C. Schaffler, MD, Amit Manjunath, MD,
Ran Schwarzkopf, MD, MSc, Joel Buchalter, MD, Vinay Aggarwal, MD, and
Joshua Rozell, MD
Postoperative stiffness is a challenging problem in the
setting of primary total knee arthroplasty. There remains
a relatively high prevalence of patients suffering from this
condition, and it can lead to unsatisfactory outcomes and
need for revision surgery as well as a large financial burden
on the health care system. There are a number of factors that
predispose patients to developing arthrofibrosis, including
patient-specific factors and intraoperative and postoperative
considerations. Arthrofibrosis can be treated effectively in
the early stages with manipulation under anesthesia with
or without lysis of adhesions, however, those who fail to
respond to these interventions may require revision surgery,
which generally has poorer outcomes when performed for
this indication. Current research is focused on understanding
the pathologic cascade of arthrofibrosis and novel targeted
therapeutics that may decrease stiffness in these patients
and improve outcomes.
Endoscopic Carpal Tunnel Release
Past, Present, and Future Directions
Jeffrey Chen, MD, Samantha Rettig, MD, Omri Ayalon, MD, and Jacques Hacquebord, MD
Carpal tunnel release is a safe and reliable option for the
surgical treatment of carpal tunnel syndrome. It has traditionally been performed under direct visualization through
an open approach. Endoscopic carpal tunnel release (ECTR)
was developed as a minimally invasive alternative with
the goals of decreasing soft tissue trauma and accelerating functional recovery. Endoscopic carpal tunnel release
continues to increase in popularity from both a surgeon and
patient perspective. Endoscopic carpal tunnel release has
been shown to result in earlier functional improvement compared to traditional open techniques but with no meaningful
differences in long-term outcomes. The cost-effectiveness of
ECTR remains unclear. This review highlights the history of
ECTR, the current literature regarding outcomes and cost,
and the future directions of carpal tunnel surgery.
Orthopedic Training in the United States
A Continuously Evolving Process
Michael G. Doran, MD, James H. Beaty, MD, Kenneth A. Egol, MD, and
Joseph D. Zuckerman, MD
Orthopedic surgery in the United States has gone through
many changes over the past few centuries. Starting with a
small sect of subspecialized surgeons, advances in technology and surgical skills have paralleled the growth of the
specialty. To keep up with demand, the training of orthopedic
surgeons has undergone many iterations. From apprenticeships to the current residency model, the field has always
adapted to ensure the constant production of well-trained
surgeons to take care of the growing orthopedic needs in
the population. In order to guarantee this, many regulatory
committees have been formed over the years to help guide
the regulation and certification of orthopedic training programs. With current day residents facing new challenges,
the specialty continues to adapt the way it trains its future.
Talk It Out to Walk It Out
A Guide for Residents and Medical Students on the
Fundamentals of Gait
Christina Herrero, MD, Neha Jejurikar, MD, Ariana Trionfo, MD, and
Mara Karamitopoulos, MD
Although gait is one of the most globally ubiquitous concepts�traversing all geographic, cultural, and language
barriers�it is often seen as an overwhelming and confusing concept. This review describes the phases and components of gait to help the clinician identify what is normal,
evaluate what is not normal, and understand some common
pathologic gait patterns seen in the different orthopedic
subspecialties.
The Role of Distraction Osteogenesis in Limb
Salvage for Tumors
Neha Jejurikar, MD, Christina Herrero, MD, and Nicola Fabbri, MD
Modern technology and advances in medicine have facilitated increasing rates of limb salvage in the treatment of
sarcomas. Orthopedic oncologists have a wide array of
reconstruction options for limb salvage, ranging from allografts to endoprosthesis reconstruction. Limb lengthening
is another option available to an orthopedic oncologist faced
with bony defects and limb length discrepancies following resection. This review provides a brief history of limb
lengthening, the principles of distraction osteogenesis, and
current applications in orthopedic oncology. Considering
the complications and challenges associated with the lengthening process, appropriate patient selection and thorough
patient counseling is key to optimizing outcomes.
Patellar Instability
Current Concepts and Controversies
Ajay C. Kanakamedala, MD, Bradley A. Lezak, MD, Michael J. Alaia, MD, and
Laith M. Jazrawi, MD
Recurrent patellar instability can significantly impact
patients� quality of life and function. A large amount of
research on patellar instability has been conducted in
the past two decades, and a number of traditionally held
principles of treatment have been challenged. This review
addresses three current concepts and controversies in the
treatment of patellar instability, specifically what factors lead to an increased tibial tubercle-trochlear groove
distance and how to address them, when to add a tibial
tubercle osteotomy to a medial patellofemoral ligament
(MPFL) reconstruction, and which medial patellar stabilizers should be reconstructed. Based on current evidence,
there are a few recommendations that can be made at this
time. While trochleoplasty does have concerns with regard
to reproducibility and complication risk, surgeons should
consider this technique especially in cases with Dejour D
trochlear dysplasia given high failure rates with other techniques. When evaluating whether to concomitantly perform
a tibial tubercle osteotomy (TTO) with a MPFL, a TTO does
appear to improve outcomes in the presence of maltracking
or a positive J sign even with a tibial tuberosity-trochlear
grove distance (TT-TG) of 18 to 20 mm, whereas patients
without maltracking with a TT-TG of up to 25 mm may do
well with an isolated MPFL reconstruction. Lastly, while
MPFL reconstruction continues to have the most robust data
supporting favorable outcomes, a number of biomechanical studies and short-term clinical studies have suggested
promising results with medial quadriceps tendon femoral
ligament and hybrid techniques.
Focus on POCUS
Point of Care Ultrasound in the Upper Extremity
David J. Kirby, MD, Matt L. Duenes, MD, Jacques H. Hacquebord, MD, and
Lauren E. Borowski, MD
Ultrasound technologies are infrequently utilized in orthopedics as a first line diagnostic method, however, advances in
technology and the applied techniques have opened the door
for how and when ultrasound can be used. One specific avenue
is the use of point of care ultrasound in which ultrasound is
used at the time of initial patient evaluation by the evaluating
physician. This use expedites time to diagnosis and can even
guide therapeutic interventions. In the past two decades there
have been numerous studies demonstrating the effectiveness
of ultrasound for the diagnosis of many orthopedic conditions in the upper extremity, often demonstrating that it can
be used in the place of and with greater diagnostic accuracy
than magnetic resonance imaging. This review elaborates on
these topics and lays a groundwork for how to incorporate
point of care ultrasound into a modern orthopedic practice.
Prevention of Prosthetic Joint Infection Prior to
David Kugelman, MD, Amit Manjunath, MD, Benjamin Schaffler, MD, Joshua Rozell, MD,
Vinay Aggarwal, MD, and Ran Schwarzkopf, MD, MSc
Prosthetic joint infection (PJI) remains a major cause of
failure in total joint arthroplasty. This complication begets
an increase in morbidity and mortality along with significant costs to the healthcare system. The use of prophylactic
antibiotics has significant decreased the incidence of this
complication. However, the incidence of PJI has not drastically decreased over the last 50 years. This review explores
the history, current concepts, and future developments for
prevention of PJI prior to incision in total joint arthroplasty.
The Expanding Use of Knee Osteotomies in the
Treatment of Malalignment and Joint Preservation
Ariana Lott, MD, Eric J. Strauss, MD, Laith M. Jazrawi, MD, and Michael J. Alaia, MD
This review highlights the expanding use of knee-based
osteotomies in the treatment of knee joint malalignment and
joint preservation. Planning and outcomes of traditional
high tibial osteotomies and distal femoral osteotomies are
discussed in addition to some of the challenges encountered
with these procedures. Lastly, the role of patient-specific
instrumentation and three-dimensional guided templating in performing osteotomies is discussed with respect
to procedures that involve biplanar corrections and those
performed in combination with other joint preservation
procedures.
The Evolution of the Treatment of Distal Radius
Fractures
How We Got to Now
David B. Merkow, MD, Matthew L. Duenes, MD, Kenneth A. Egol, MD, Jacques H.
Hacquebord, MD, and Steven Z. Glickel, MD
Distal radius fractures are one of the most common fractures in adults and historically have frequently led to significant disability. Originally described over 5,000 years
ago, until recently these fractures were almost exclusively
treated by closed methods. Since the introduction of osteosynthesis in 1907, followed by the founding of the AO
in 1958, and more recently the development of the volar
locked plate in the early 2000s, over the past century the
surgical treatment of these fractures has evolved greatly.
While technological advancements have changed management for specific fracture patterns, closed treatment still
has an important role and is definitive for many patients.
The following review provides a historical perspective for
current treatment strategies as well as an overview of the
important factors that must be considered when treating
patients with these injuries.
Demystifying the Radial Nerve
The Management of Radial Nerve Palsy in the Setting of Humeral
Shaft Fracture
Emily M. Pflug, MD, Nader Paksima, MD, and Omri Ayalon, MD
The association of radial nerve palsy and humeral shaft
fracture is well known. Primary exploration and fracture
fixation is recommended for open fractures and vascular
injury while expectant management remains the standard
of care for closed injuries. In the absence of nerve recovery, exploration and reconstruction is recommended 3 to 5
months following injury. When direct repair or nerve grafting
is unlikely to achieve a suitable outcome, nerve and tendon
transfers are potential options for the restoration of wrist
and finger extension.
Current and Emerging Techniques in Articular
Cartilage Repair
Keir A. Ross, MD, Sehar Resad Ferati, MD, Michael J. Alaia, MD, John G. Kennedy, MD, and
Eric J. Strauss, MD
Osteochondral lesions (OCL) of the knee are a common
pathology that can be challenging to address. Due to the
innate characteristics of articular cartilage, OCLs generally do not heal in adults and often progress to involve the
subchondral bone, ultimately resulting in the development
of osteoarthritis. The goal of articular cartilage repair is to
provide a long-lasting repair that replicates the biological
and mechanical properties of articular cartilage, but there
is no widely adopted technique that results in true pre-injury
state hyaline cartilage. Current treatment modalities have
seen reasonable clinical success, but significant limitations
remain. Microfracture provides short-term benefit with a
fibrocartilage-based repair. While osteochondral autograft
or allograft and autologous chondrocyte implantation can
be effective, each have their strengths and shortcomings.
Emerging concepts in cartilage repair, including scaffold
engineering and one stage cell-based options, are continually advancing. These have the benefits of reduced surgical
morbidity and potentially improved integration with surrounding articular cartilage but have not yet reached widespread
clinical application. Tissue engineering strategies and gene
therapy have the potential to advance the field, however, they
remain in the early stages. The current article reviews the
structure and physiology of articular cartilage, the strengths
and limitations of present treatment modalities, and the newer
ongoing innovations that may change the way we approach
osteochondral lesions and osteoarthritis.