Perioperative Use of Novel Oral Anticoagulants in Orthopaedic Surgery: A Critical Analysis Review »The use of novel oral anticoagulants (NOACs) in the perioperative setting is an important issue that is particularly relevant to orthopaedic procedures, but no official recommendations currently exist for NOACs in orthopaedic surgery.»Given the lack of a current consensus in the orthopaedic literature, a standardized approach is essential in order to help minimize both the duration of time without chronic anticoagulation and complications that can arise from excessive bleeding.»We propose a combined profile assessment that takes into account the type of anticoagulant as well as both patient-specific and procedure-specific risk factors and provide an algorithm to help guide periprocedural NOAC use.

Surgical Management of the Spastic Forearm, Wrist, and Hand: Evidence-Based Treatment Recommendations: A Critical Analysis Review »The surgical approach for the patient with a spastic upper limb must be individualized and goal-focused.»An injury to the central nervous system can lead to spinal reflex hyperexcitability with exaggerated muscle activation in response to quick stretch stimuli (i.e., spasticity).»Surgical treatment options are dependent on the potential for function in the spastic upper limb.»If volitional motor control is present, spastic motor units can be lengthened or released while preserving function.»In the absence of volitional motor control, spastic muscles can be divided, released, or denervated with selective neurectomies.

Team Approach: Modern-Day Prostheses in the Mangled Hand »Early prosthesis fitting enhances prosthesis acceptance and utilization.»Establishing a relationship early with the team can improve surgical planning and expedite postoperative care.»Targeted muscle reinnervation performed in the acute phases of care can greatly improve neuroma pain control and prosthesis functionality.»There is a high rate of mental health issues at various times during treatment. A high suspicion for these problems is paramount in effective treatment.»Peer-driven support has been instrumental in successful recovery in these devastating injuries.

Team Approach: Patellofemoral Instability in the Skeletally Immature »Conservative management with bracing and physical therapy remains the treatment of choice following acute, first-time dislocation in adolescent patients, but certain high-risk individuals may benefit from a surgical procedure as a first-line treatment.»The physical therapist is intimately involved in patient care regardless of the chosen treatment strategy and must set realistic expectations to improve compliance and to minimize frustration. Through comprehensive biomechanical evaluation, factors such as quadriceps and hip abductor weakness that contribute to patellar dislocation are identified and are addressed.»Surgical intervention consists of medial patellofemoral ligament reconstruction alongside an á la carte approach to correcting other anatomic abnormalities. In the adolescent population, open growth plates dictate available surgical options, and care must be taken to avoid physeal damage.»Given the propensity for recurrent instability, a thorough team approach is needed from the outset to successfully guide the patient through the treatment and recovery process.

Proximal Tibial Reconstruction After Tumor Resection: A Systematic Review of the Literature Background: The proximal part of the tibia is a common location for primary bone tumors, and many options for reconstruction exist following resection. This anatomic location has a notoriously high complication rate, and each available reconstruction method is associated with unique risks and benefits. The most commonly utilized implants are metallic endoprostheses, osteoarticular allografts, and allograft-prosthesis composites. There is a current lack of data comparing the outcomes of these reconstructive techniques in the literature. Methods: A systematic review of peer-reviewed observational studies evaluating outcomes after proximal tibial reconstruction was conducted, including both aggregate and pooled data sets and utilizing a Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) review for quality assessment. Henderson complications, amputation rates, implant survival, and functional outcomes were evaluated. Results: A total of 1,643 patients were identified from 29 studies, including 1,402 patients who underwent reconstruction with metallic endoprostheses, 183 patients who underwent reconstruction with osteoarticular allografts, and 58 patients who underwent with reconstruction with allograft-prosthesis composites. The mean follow-up times were 83.5 months (range, 37.3 to 176 months) for the metallic endoprosthesis group, 109.4 months (range, 49 to 234 months) for the osteoarticular allograft group, and 88.8 months (range, 49 to 128 months) for the allograft-prosthesis composite reconstruction group. The mean patient age per study ranged from 13.5 to 50 years. Patients with metallic endoprostheses had the lowest rates of Henderson Type-1 complications (5.1%; p < 0.001), Type-3 complications (10.3%; p < 0.001), and Type-5 complications (5.8%; p < 0.001), whereas, on aggregate data analysis, patients with an osteoarticular allograft had the lowest rates of Type-2 complications (2.1%; p < 0.001) and patients with an allograft-prosthesis composite had the lowest rates of Type-4 complications (10.2%; p < 0.001). The Musculoskeletal Tumor Society (MSTS) scores were highest in patients with an osteoarticular allograft (26.8 points; p < 0.001). Pooled data analysis showed that patients with a metallic endoprosthesis had the lowest rates of sustaining any Henderson complication (23.1%; p = 0.009) and the highest implant survival rates (92.3%), and patients with an osteoarticular allograft had the lowest implant survival rates at 10 years (60.5%; p = 0.014). Conclusions: Osteoarticular allograft appears to lead to higher rates of Henderson complications and amputation rates when compared with metallic endoprostheses. However, functional outcomes may be higher in patients with osteoarticular allograft. Further work is needed using higher-powered randomized controlled trials to definitively determine the superiority of one reconstructive option over another. In the absence of such high-powered evidence, we encourage individual surgeons to choose reconstructive options based on personal experience and expertise. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Clinical Efficacy of Liposomal Bupivacaine: A Systematic Review of Prospective, Randomized Controlled Trials in Orthopaedic Surgery Background: There has been a surge in interest with regard to the utility of liposomal bupivacaine as part of a perioperative pain management protocol. The current study was proposed to critically assess the efficacy of liposomal bupivacaine as a local anesthetic for pain relief following orthopaedic procedures. Methods: A systematic review of prospective, randomized trials involving liposomal bupivacaine was performed using searches of the PubMed, Embase, and Cochrane databases. The primary outcomes of interest included postoperative subjective pain scores and narcotic consumption. The length of stay and postoperative mobility were reviewed as secondary outcomes. Results: Twenty-seven studies met inclusion criteria and were included for review. Twelve of 17 studies concluded that periarticular or local infiltrative liposomal bupivacaine offered no additive benefit compared with other local anesthetic injections. Peripheral nerve blocks without liposomal bupivacaine conferred more optimal pain relief and decreased narcotic consumption in the immediate postoperative period when compared with liposomal bupivacaine, with no differences thereafter. Twelve studies listed a conflict of interest related to the drug manufacturer (Pacira Pharmaceuticals). Eight of these studies (67%) demonstrated clinical superiority of liposomal bupivacaine when compared with the study control. In the 15 studies that did not show a conflict of interest, only 1 study (7%) demonstrated therapeutic superiority with use of periarticular liposomal bupivacaine when compared with a historical cohort that received no local or regional anesthesia. Conclusions: Current prospective, randomized controlled trials in patients undergoing orthopaedic surgery fail to support the routine use of liposomal bupivacaine compared with other local injectable analgesics, particularly in the setting of knee replacement surgery. We were unable to find consistent support for the potential of superior pain relief and narcotic use reduction with the use of liposomal bupivacaine. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Revision Rates and Functional Outcomes Among Severely, Morbidly, and Super-Obese Patients Following Primary Total Knee Arthroplasty: A Systematic Review and Meta-Analysis Background: Obesity has been associated with a greater burden of symptomatic knee osteoarthritis. There is some evidence that patients with a very high body mass index (BMI) may have a higher risk of complications and poor outcomes following total knee replacement compared with non-obese patients or obese patients with a lower BMI. We hypothesized that increasing degrees of obesity would be associated with deteriorating outcomes for patients following total knee replacement. Methods: We performed a comprehensive systematic review of 4 medical databases (MEDLINE, AMED, Ovid Healthstar, and Embase) from inception to August 2016. We extracted data to determine revision risk (all-cause, septic, and aseptic) and functional outcome scores (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], Knee Society Score, Oxford Knee Score, EuroQol-5D, and Short Form [SF]-12 Physical Component Summary) in patients with severe obesity (BMI ≥35 kg/m2), morbid obesity (BMI ≥40 kg/m2), and super-obesity (BMI ≥50 kg/m2) in comparison with patients with a normal BMI (<25 kg/m2). Meta-analysis was performed using a random effects model. Results: We screened 3,142 titles and abstracts and 454 full-text articles to identify 40 eligible studies, of which 37 were included in the meta-analysis. Compared with patients with a normal BMI, the risk ratio for an all-cause revision surgical procedure was 1.19 (95% confidence interval [CI], 1.03 to 1.37; p = 0.02) in patients with severe obesity, 1.93 (95% CI, 1.27 to 2.95; p < 0.001) in patients with morbid obesity, and 4.75 (95% CI, 2.12 to 10.66; p < 0.001) in patients with super-obesity. The risk ratio for septic revision was 1.49 (95% CI, 1.28 to 1.72; p < 0.001) in patients with severe obesity, 3.69 (95% CI, 1.90 to 7.17; p < 0.001) in patients with morbid obesity, and 4.58 (95% CI, 1.11 to 18.91; p = 0.04) in patients with super-obesity. There were no significant differences (p > 0.05) in risk of aseptic revision. Based on the Knee Society Scores reported in a single study, patients with super-obesity had outcome scores, expressed as the standardized mean difference, that were 0.52 lower (95% CI, 0.80 lower to 0.24 lower; p < 0.001) than non-obese controls; however, no difference was observed for severe or morbidly obese patients. Conclusions: The risk of septic revision is greater in patients with severe obesity, morbid obesity, and super-obesity, with progressively higher BMI categories associated with a higher risk. However, the risk of aseptic revision was similar between all obese and non-obese patients. Functional outcome improvements are also similar, except for super-obese patients, in whom data from a single study suggested slightly lower scores. These findings may serve to better inform evidence-based clinical, research, and policy decision-making. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Electronic Patient-Reported Outcome Collection Systems in Orthopaedic Clinical Practice »The recent emphasis on the electronic collection of patient health information has catalyzed the development of numerous platforms for capturing electronic patient-reported outcome measures (EPROMs).»There are several important considerations for selecting the most appropriate PROM for each orthopaedic practice.»In this article, we evaluate various aspects of PROMs, examine the challenges and obstacles that are associated with routine collection, and review 6 commonly used electronic collection systems for orthopaedic clinical practice.

Diagnosis and Management of Periprosthetic Joint Infection After Shoulder Arthroplasty »The indolent microorganisms responsible for shoulder periprosthetic joint infection make diagnosis difficult because they do not have clear clinical signs or reliable serum laboratory markers.»Administering benzoyl peroxide to the skin of the surgical site and intra-articular injections of antibiotics during a surgical procedure have shown potential for preventing periprosthetic joint infection in patients undergoing shoulder arthroplasty.»Measuring the synovial levels of interleukin (IL)-6 and alpha (α)-defensin have demonstrated promise for predicting periprosthetic joint infection in patients undergoing shoulder arthroplasty.»Two-stage revision shoulder arthroplasty has been consistently shown in the literature to effectively eradicate infection and have substantial functional improvement, especially in healthy patients.»One-stage revision shoulder arthroplasty has been shown to have eradication rates comparable with those of 2-stage exchange and has the advantages of being more cost-effective and having expedited treatment time.

Etiology, Evaluation, and Management of Dislocation After Primary Total Hip Arthroplasty »The rate of dislocation after primary total hip arthroplasty has decreased, but given the high volume of total hip arthroplasty procedures that are performed, dislocation remains a common complication.»The etiology of dislocation after total hip arthroplasty is multifactorial and depends on the patient’s characteristics as well as the orthopaedic surgeon’s operative techniques and decisions regarding implants.»A detailed assessment of the patient, preoperative planning, a thorough understanding of the anatomy, proper surgical technique, and knowledge of the biomechanics of the implant decrease the likelihood of dislocations following total hip arthroplasty.»The advent of new techniques and procedures has further reduced the occurrence of dislocation following total hip arthroplasty. However, should dislocation occur, primary management or revision total hip arthroplasty techniques provide excellent results to salvage the mobility and function of the hip.