ORTHOSuperSite Education Lab CME

Patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) are at risk for venous thromboembolisms, including deep vein thrombosis and pulmonary embolism. The risk of complications of venous thromboembolisms depends on the location of thrombi; potential long-term complications include recurrent venous thromboembolism, postthrombotic syndrome, and chronic thromboembolic pulmonary hypertension. Risk of recurrence persists for several years after the initial event. The causal relationship between deep vein thrombosis and pulmonary embolism remains controversial. Some consider them distinct clinical entities, while others have found asymptomatic distal deep vein thrombosis to be associated with elevated risk of developing pulmonary embolism. Thromboprophylaxis is important in patients undergoing THA or TKA. However, traditional anticoagulants are not ideal, particularly for long-term use. Orthopedic surgeons should be aware of the causes and potential sequelae of venous thromboembolism and of the new thromboprophylactic agents that can help prevent it.

A Monteggia fracture is a fracture of the proximal ulna coupled with a radial head dislocation. Numerous classification systems have been developed to characterize these fractures, with the Bado classification being the most common. Elbow radiographs are the primary diagnostic modality, demonstrating dislocation when a line drawn extending through the radial head from the radial shaft does not penetrate the capitellum in all views. Notable differences exist in the prevalence, treatment, and outcomes of Monteggia fractures for pediatric and adult patient populations, with adolescents often achieving a better prognosis. Nonoperative management with closed reduction and cast immobilization often prevails in pediatric patients, dictated by the pattern of the ulnar fracture more so than the direction of the radial head dislocation. However, in adults, operative intervention is frequently indicated because angulation and shortening of the ulna often occur after closed reduction.

Dupuytren’s disease is a benign contractile disorder of the hand. The condition commonly affects older men of Celtic descent. Although fibroproliferation and collagen alteration play a role in its etiology, defining a cause remains elusive. Nonoperative intervention for advanced disease has shown only short-term benefit. Therefore, open fasciectomy has become the mainstay of treatment. Associated morbidity and recurrence have prompted investigation into less invasive techniques, including needle aponeurotomy and enzymatic fasciotomy. Data from phase III studies using injectable collagenase are changing treatment algorithms. Postoperative rehabilitation includes nighttime splinting and immediate active range of motion exercises to facilitate return to function.

Infection of tumor prostheses has been a major concern because of the extensive soft tissue dissection, long operating times, and patients’ immunosuppression by cancer and adjuvant treatments. Infections most often present within 2 years postoperatively, with approximately 70% of postoperative deep infections presenting within 12 months after surgery. They are typically low organism burden infections, the pathogenesis of which is related to bacteria growing in biofilms. Staphylococci are the most common pathogens involved in prosthetic joint infections, accounting for approximately 50% of infections overall, followed by streptococci, enterococci, Enterobacteriaceae species, Pseudomonas aeruginosa, and anaerobe species. Multiple pathogens may be isolated in approximately 25% of cases, with the most common combination being coagulase-negative Staphylococcus and group-D Streptococcus. Early diagnosis and appropriate treatment are necessary. However, diagnosis may be challenging because clinical symptoms are highly variable and numerous preoperative and intraoperative diagnostic laboratory tests are nonspecific. In most cases, a 1- or 2-stage revision surgery is necessary for eradicating the megaprosthetic infection. Prevention of infection is important. The future will see technical advances for infections of tumor prostheses in areas such as microbiological diagnostics and biofilm-resistant prostheses.

Osteoarthritis (OA) is a chronic, progressive and multifactorial disease characterized by degenerative and inflammatory processes affecting joints and surrounding tissues, resulting in pain and functional disability. Despite the availability of practice guidelines for the management of OA, inadequacies in practices of clinicians and patients have been found, leading to suboptimal outcomes. This publication series explores a structured, multidisciplinary approach to care to optimize long-term outcomes for patients with this chronic disease.

Traumatic intrasubstance ruptures of the biceps brachii are rare and historically specific to military static line parachute jumps; however, these injuries have recently been reported in the civilian literature. Diagnosis is made by history, clinical weakness in supination and elbow flexion, extensive ecchymosis and edema, and a palpable defect. Ultrasound and magnetic resonance imaging are useful to confirm the diagnosis and injury severity. Nonoperative treatment involves splinting in acute flexion. Early surgical intervention with primary repair has been shown to be more successful than late reconstruction.

Osteoarthritis (OA) is a chronic, progressive and multifactorial disease characterized by degenerative and inflammatory processes affecting joints and surrounding tissues, resulting in pain and functional disability. Despite the availability of practice guidelines for the management of OA, inadequacies in practices of clinicians and patients have been found, leading to suboptimal outcomes. This publication series explores a structured, multidisciplinary approach to care to optimize long-term outcomes for patients with this chronic disease.

Outpatient use of anticoagulants to prevent venous thromboembolism after total hip or knee arthroplasty may be hampered either by requirements for parenteral administration or high variability and frequent monitoring of anticoagulant activity. Trials of the new oral direct factor Xa inhibitors rivaroxaban and apixaban and the direct thrombin inhibitor dabigatran indicate that they can be administered in fixed doses without monitoring and that they generally have efficacy at least equivalent to enoxaparin, although with potential minor differences in the balance of efficacy vs risk for bleeding. This article reviews the results and pharmacokinetic properties that may influence their use in clinical practice.

Infection is a feared complication and a common cause of loss of function following open fractures. Despite the evidence supporting the administration of prophylactic antibiotics after open fractures, data demonstrating the optimal regimen is lacking. We reviewed the data supporting the current prophylaxis recommendations and the changing epidemiology of Staphylococcus aureus, the most common cause of surgical site infection in patients with open fractures. Until well-designed randomized trials are conducted, we recommend that providers consider selecting antibiotics active against MRSA for open fracture prophylaxis based on the local prevalence of MRSA carriage and individualized risk factors.

Mobility of the glenohumeral joint is facilitated through the complex interplay of soft tissue and osseous anatomy. Arthroscopic shoulder stabilization is commonly used in the surgical management of shoulder instability. However, the management of the unstable shoulder associated with bony defects (glenoid, humeral, or combined) can be challenging. Adequate recognition of bony defects is paramount to successful treatment and entails a careful history, clinical examination, and advanced radiographic imaging. Nonoperative methods of treatment are often insufficient for treating patients with large bony defects. Bony procedures, as opposed to soft procedures, may yield better outcomes in this patient population. However, respective surgical techniques used to address these defects are technically challenging with a significant learning curve and may lead to significant morbidity. This represents a paradigm shift in treatment and replaces the old paradigm of “open vs arthroscopic” instability surgery.