Odontoid Fractures: A Critical Analysis Review »Odontoid fractures are common cervical spine fractures with a bimodal age distribution, which is gradually shifting to more representation in the elderly population.»Type-II odontoid fractures are associated with higher nonunion rates compared with Type I and Type III.»A surgical procedure for Type-II fractures in the elderly population is associated with a higher union rate and potentially less mortality.»Certain Type-II fractures can be treated nonoperatively, depending on fracture morphology and displacement.»Type-I and III fractures can typically be treated nonoperatively.

The Use of Preoperative Antibiotics in Elective Soft-Tissue Procedures in the Hand: A Critical Analysis Review »The use of preoperative antibiotic prophylaxis is not supported for elective cases of patients undergoing soft-tissue hand procedures that are ≤2 hours in length.»The use of preoperative antibiotic prophylaxis is not supported for patients with diabetes undergoing elective, soft-tissue hand surgical procedures.»There is a paucity of literature evaluating the use of preoperative antibiotic prophylaxis in patients with rheumatoid arthritis, those with cardiac valves, and those taking corticosteroids; because of this, there is no evidence to vary from our general recommendations.

Team Approach: Role of Medical and Surgical Management in Rheumatoid Arthritis of the Hand and Wrist »Treatment of the patient with rheumatoid arthritis affecting the hand and wrist can be a challenging endeavor. Optimal management for best outcomes includes careful collaboration between providers managing the medical treatment of the disease, therapists, hand surgeons, and the patient.»In this review, we present a challenging clinical scenario with input from key voices from various medical fields to provide a balanced and unbiased diagnosis and treatment recommendation for a patient with complex rheumatoid pathology affecting her hand and wrist.

Combined Massive Allograft and Intramedullary Vascularized Fibula as the Primary Reconstruction Method for Segmental Bone Loss in the Lower Extremity: A Systematic Review and Meta-Analysis Background: Reconstruction of segmental bone loss due to malignancy, infection, or trauma is a challenge for the reconstructive surgeon. The combination of a vascularized fibular flap with a cortical allograft provides a reliable reconstructive option in the lower extremity. In this systematic review, we describe the outcome of this technique for the treatment of segmental bone loss. Methods: A systematic review was performed on the use of a combined massive allograft and intramedullary vascularized fibula as a reconstruction method for large bone defects. We used PubMed, Embase, and the Wiley Cochrane Library. Results: Seventeen clinical articles were included between 1997 and 2017, reporting 329 cases of lower-extremity reconstructions. A meta-analysis was performed on primary union rates. The main outcome measures were primary union rate, complication rate, reintervention rate, and function after reconstruction. All publications showed relatively high complication (5.9% to 85.7%) and reintervention rates (10% to 91.7%) with good primary union rates (66.7% to 100%) and functional outcome (range of mean Musculoskeletal Tumor Society [MSTS] scores, 24 to 29 points). Conclusions: The combination of a massive allograft with intramedullary vascularized fibula provides a single-step reconstruction method for large bone defects (>6 cm) in the lower extremity, with good long-term outcomes. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A Comparison of Treatment Effects for Nonsurgical Therapies and the Minimum Clinically Important Difference in Knee Osteoarthritis: A Systematic Review Background: The minimum clinically important difference (MCID) was developed to ascertain the smallest change in an outcome that patients perceive as beneficial. The objectives of the present review were (1) to compare the MCIDs for pain assessments used among guidelines and meta-analyses investigating different nonsurgical therapies for knee osteoarthritis and (2) to compare the effect estimates of different nonsurgical interventions against a single commonly-utilized MCID threshold. Methods: Systematic and manual searches were conducted to identify guidelines and meta-analyses evaluating pain outcomes for nonsurgical knee osteoarthritis interventions. Individual treatment effects for pain were presented on a common scale (the standardized mean difference [SMD]). To evaluate the perception of the relative benefit of each nonsurgical treatment, the variation in MCIDs selected from the published MCID literature was assessed. Results: Thirty-seven guidelines and meta-analyses were included. MCIDs were often presented as an SMD or a mean difference (MD) on a validated scale and varied in magnitude across sources. This analysis demonstrated that intra-articular hyaluronic acid, intra-articular corticosteroids, and acetaminophen all had relatively larger effect sizes than topical nonsteroidal anti-inflammatory drugs (NSAIDs). Higher-molecular-weight intra-articular hyaluronic acid had a greater relative effect compared with both non-selective and cyclooxygenase-2-selective oral NSAIDs. Evaluating the treatment effect estimates against a commonly utilized MCID revealed similarities in which observations attained clinical significance among treatments; however, this observation varied across the range of reported MCIDs. Conclusions: The present review confirmed the variability in the MCIDs for pain assessments that are used across guidelines and meta-analyses evaluating nonsurgical interventions for knee osteoarthritis. This variability may yield conflicting treatment recommendations, ranging from rejecting treatments that are indeed efficacious to accepting treatments that may not be beneficial. Additional research is required to determine why some nonsurgical therapies are more consistently recommended in knee osteoarthritis guidelines than others as these findings suggest similarities in their effect estimates for pain. Relevant stakeholders need to reach a consensus on a standard approach to determining the MCIDs for these therapies to ensure that appropriate and effective treatment options are available to patients prior to invasive surgical intervention. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

“Is There a Doctor on Board?” The Plight of the In-Flight Orthopaedic Surgeon »The most common in-flight medical emergencies are syncope, gastrointestinal distress, and cardiac conditions that include arrhythmias and cardiac arrests. Treatment algorithms for these emergencies are important to review and are included in this article.»If confronted with a challenging in-flight medical emergency in which an orthopaedic surgeon believes that he or she is unable to offer sufficient help, consulting with ground-based physicians hired by the airlines is always an appropriate and readily available option.»While providing care to the patient, the doctor is absolved from liability unless the care offered is grossly negligent and/or deliberately harmful.»If the aircraft is registered in or is departing from countries within the European Union block or Australia, or if the patient is a citizen of one of those international bodies, the doctor is legally required to assist.

Sarcopenia, Cerebral Palsy, and Botulinum Toxin Type A »Sarcopenia is common in both the elderly and children with cerebral palsy.»Children with cerebral palsy have muscles that are much smaller than muscles in typically developing peers.»Injections of botulinum toxin type A (BoNT-A) result in acute muscle atrophy in animal models and in human subjects.»It is not known when or if muscles recover fully after injection of BoNT-A.»These findings have implications for management protocols.

Turf Toe: Presentation, Diagnosis, and Management »Turf toe is a common injury in athletes. The prevalence of this injury has increased since the implementation of artificial turf and has been reported to be as high as 45% in professional football players.»The mechanism of injury, first described by Bowers and Martin in 1976, is hyperextension of the first metatarsophalangeal (MTP) joint, which causes disruption of the plantar structures. Turf toe can be classified as grade I, II, or III depending on the severity of the injury.»Patients typically present with tenderness, swelling, and/or loss of motion at the MTP joint. Physical examination includes palpation of the key structures surrounding the joint, along with varus and valgus stress and drawer testing of the MTP joint. Weight-bearing radiographs and magnetic resonance imaging are the most commonly utilized imaging modalities.»Turf toe typically is treated nonoperatively with rest, ice, nonsteroidal anti-inflammatory drugs, and compression. Operative treatment may be indicated when nonoperative measures are unsuccessful or in patients with severe disruptions of the plantar structures. Outcomes of turf toe are generally good, but in rare cases, the injury can be career-ending.»The purpose of this review is to highlight the current literature on the epidemiology, risk factors, classifications, diagnosis, treatment, and clinical outcomes of turf toe.

Surgical Approaches, Postoperative Care, and Outcomes Associated with Intra-Articular Hoffa Fractures: A Comprehensive Review »Hoffa fractures are intra-articular distal femoral condylar fractures commonly arising from high-energy trauma with the knee in a flexed position.»Motor vehicle accidents and falls from a height are the most commonly cited mechanisms that engage the lateral or the medial condyle, depending on the internal or external rotation of the knee.»Standard weight-bearing after screw fixation should be delayed for approximately 12 weeks.»Most of the literature found on Hoffa fractures placed more focus on the surgical approach or fixation method rather than outcomes associated with the number or type of screws used.

Correlation of PROMIS with Orthopaedic Patient-Reported Outcome Measures »The Patient-Reported Outcomes Measurement Information System (PROMIS) has been shown to correlate well with legacy measures used in orthopaedic surgery outcome studies.»PROMIS domains, particularly when administered as a computer adaptive test, are more efficient to administer and often have improved test characteristics when compared with historical patient-reported outcome measures.»As more researchers use PROMIS to track patient outcomes in orthopaedics, clinicians and researchers may consider using PROMIS in future research as it allows for easy comparison between studies.