Evaluation of the Painful Total Knee Arthroplasty Total knee arthroplasty (TKA) has been associated with notable improvements in health-related quality of life of patients with end-stage knee arthritis. Although most patients experience substantial symptomatic relief after TKA, up to 19% of patients are unsatisfied with their outcome. With the dramatic, projected increase in the number of TKAs performed annually, it is crucial to appreciate the various modes of failure associated with this procedure. A comprehensive understanding of the symptomatology and thorough clinical examination aid in identifying the etiology of ongoing knee pain. Ancillary testing including conventional laboratory analyses, imaging studies, and diagnostic injections supplement a thorough history and physical examination. In addition, novel laboratory markers, RNA/DNA-based tests, and novel imaging modalities are emerging as beneficial tools in evaluating patients with a painful TKA. A well-structured, algorithmic approach in the management of these patients is essential in correctly diagnosing the patient and optimizing clinical outcomes.

The Significance of Osteoarthritis-associated Bone Marrow Lesions in the Knee Bone marrow lesions of the knee in patients with osteoarthritis (OA-BML) are an important clinical entity that may explain progressive pain, decreased quality of life, and impaired function. MRI of OA-BMLs demonstrates a region of subchondral bone with hyperintense marrow signal on T2-weighted images. Histopathology retrieval studies have demonstrated that these lesions correlate with microdamage of the trabecular bone, and subsequently, this leads to a vicious cycle of subchondral bone attrition, attempts at repair, pain, and progressive deformity. These lesions have also been linked to accelerated loss of adjacent articular cartilage and increases in the severity of knee pain, prompting patients to seek musculoskeletal care and treatment. Multiple studies have also correlated the presence of an OA-BML with an increased probability of seeking knee arthroplasty. Knowledge of these lesions is important in the context that knee OA is both a cartilage-based and bone-based disease. Further study of OA-BMLs may provide opportunities for early intervention and OA disease–modifying treatments.

Hip Surveillance in Children With Cerebral Palsy Hip dysplasia is common in children with cerebral palsy (CP), especially in those children with notable functional impairment. Severity of hip dysplasia has been shown to correlate with higher Gross Motor Function Classification System levels. Migration percentage measured on AP pelvis radiographs is the key radiographic measure quantifying hip displacement in CP. Hip surveillance programs for children with CP exist in Europe, Australia, and parts of Canada and have been adopted as standard of care. These programs have demonstrated improved detection of hip subluxation and appropriate early intervention with a resultant decrease in the number of painful dislocations. Hip surveillance programs provide healthcare providers with guidance for a schedule of obtaining hip radiographs based on patients' age, Gross Motor Function Classification System level, and migration percentage. Although systematic surveillance programs have yet to be adopted in the United States, several centers and organizations are currently investigating the potential and efficacy of hip screening in CP.

Management of Pediatric Tibial Shaft Fractures Diaphyseal tibia fractures in the pediatric population have dynamic treatment strategies that depend on injury pattern, mechanism, patient skeletal maturity and size. Treatment strategies include closed reduction and cast immobilization, flexible nails, uniplanar or multiplanar external fixation or plate osteosynthesis. Accepted parameters for sagittal and coronal alignment vary based on age and potential for remodeling, although all fractures should have minimal rotational malalignment and less than 1 cm of shortening. Stable union generally occurs in 3 to 4 weeks for the common toddler's fracture and 6 to 8 weeks in other fracture patterns. Complications such as compartment syndrome are possible with both open and closed injuries, and nonunions, although rare, are more common in patients treated with external fixation or flexible nailing. Overall, treatment should be predicated on a full evaluation of the patient, fracture, local soft tissues, and any concomitant injuries.

Intercarpal Ligament Injuries Associated With Distal Radius Fractures Injuries to the scapholunate (SL) and lunotriquetral (LT) interosseous ligaments occur in approximately one third of distal radius fractures. The diagnosis of these injuries is challenging because plain radiographs are not reliably diagnostic. Wrist arthroscopy may be the most accurate way to examine and diagnose soft-tissue injuries of the carpus adjacent to a distal radius fracture. Treatment options for SL and LT ligament injuries include open repair and/or percutaneous pinning. Because the natural history of these injuries is unclear, the necessity of diagnosing and treating these SL and LT interosseous ligament defects remains speculative.

Diagnosis and Treatment of Osteoporosis: What Orthopaedic Surgeons Need to Know Osteoporosis, often called a silent disease, is a systemic condition of bone as a result of loss of bone mass and deterioration of its microarchitecture. The result is weakened bone, leading to an increased risk of fragility fractures. An estimated 9 million osteoporotic fractures occur every year worldwide. However, the true incidence of osteoporotic fractures is unknown because many are undetected. Astoundingly, this epidemic equates to an osteoporotic fracture every 3 seconds. Orthopaedic surgeons need to not only treat these fractures but also understand the underlying pathogenesis and risk factors to help prevent them. The management of osteoporosis is a critical part of musculoskeletal care. We must be familiar with the tools to assess osteoporosis and the treatments available, including risks and benefits. This review article is intended to deliver a review of the vast literature and provide the orthopaedic surgeon with the essential information necessary to manage the current osteoporosis epidemic.

Stem Cells and Platelet-rich Plasma for Knee Osteoarthritis: Prevalence and Cost in South Florida Introduction: The use of stem cell therapy (SCT) and platelet-rich plasma (PRP) injection for knee osteoarthritis (OA) is extremely controversial and at best experimental stage. These treatments are being offered across the nation for “cash-only payments.” Our objectives were to determine (1) what proportion of board-certified orthopedic surgeons in Miami-Dade County offer SCT or PRP and (2) how much do practices charge for these services. Methods: All board-certified orthopedic surgeons' offices in Miami-Dade County were identified by their American Academy of Orthopaedic Surgeons active membership. Offices were contacted and presented a hypothetical patient with end-stage OA searching for treatment (SCT or PRP injections) before having to undergo surgery. Results: Of the 96 registered American Academy of Orthopaedic Surgeons member's offices, 91 (94.7%) were contacted, 36% of offices offered PRP, and 24.5% offered SCT. However, 81% of the offices were transparent on the pricing of PRP, whereas 42% gave a price for SCT. Remaining practices stated that pricing would be “determined or discussed” during a scheduled visit. Mean cost for PRP injection was $897 (range, $350 to $1,700), and for SCT injection, it was $3,100 (range, $1,200 to $6,000). Discussion: Biological injectables as treatment of knee OA have potential use in the nonsurgical management of this disease. Data on the effectiveness are lacking and are conflicting. Data should continue to be investigational. Level of Evidence: Level IV

Utilization of Drains and Association With Outcomes: A Population-Based Study Using National Data on Knee Arthroplasties Introduction: Although surgical drains have been used routinely in total knee arthroplasties (TKAs), results from several large trials have led to recommendations against their use. Because national data are lacking, we aimed at assessing utilization patterns of drains and perioperative outcomes in TKA procedures. Methods: We included 1,130,124 TKA procedures from the national claims-based Premier Healthcare Database (2006 to 2016). Patients receiving a drain were compared with those who did not. Multivariable multilevel models measured associations between drain use and blood transfusions, postoperative infections, 30-day readmission, and length/cost of hospitalization. Odds ratios and 95% confidence intervals are reported. Propensity score analyses were performed to assess the robustness of results. Results: Drain use decreased from 33.0% (n = 22,901 of 69,370) in 2006 to 15.6% (n = 19,418 of 124,440) in 2016 and was particularly higher in large (>500 beds; 27.1%) and nonteaching hospitals (26.9%). After adjustment for relevant covariates, the use of drains (compared with no use) was significantly associated with increases in particularly blood transfusions (odds ratio, 1.27; 95% confidence interval, 1.24 to 1.30 n = 138,306 total transfusions), whereas minimal effects were seen for other outcomes. Propensity score analyses confirmed these results. Discussion: Although retrospective, the current study provides an important insight into real-world clinical practice regarding the use of drains. With current evidence not supporting their use in TKA, we found that national utilization is slowly decreasing. Moreover, because drain use is associated with negative outcomes, future studies should focus on drivers of their continued use. Level of Evidence: Level III, therapeutic study

Blood Transfusion Trends in Primary and Revision Total Joint Arthroplasty: Recent Declines Are Not Shared Equally Introduction: This study examined whether recent nationwide declines in the incidence of transfusion following total joint arthroplasty were equal across inpatient facilities. Methods: This analysis used the Premier database (2010 to 2015). Cohorts of primary total hip or knee arthroplasty (THA or TKA) and revision THA or TKA were defined. Results: Among 1,013,024 patients who met selection criteria, the overall incidence of transfusion declined from 2010 through 2015 (primary THA: 22.1% to 7.1%; primary TKA: 18.1% to 3.2%; revision THA: 30.6% to 18.5%; and revision TKA: 19.8% to 9.8%; all P < 0.001). However, patients older than 65 years were associated with lower odds of transfusion relative to those younger than 65 years (P < 0.05 for three of four cohorts); smaller hospitals were associated with higher odds versus large hospitals (P < 0.05 all cohorts), and academic hospitals were associated with higher odds of transfusion versus community facilities (P < 0.05 for three of four cohorts). Discussion: During this study period, a meaningful proportion of total joint arthroplasty procedures were performed at facilities with the most room to improve. Decreases in transfusion rates were dependent on specific hospital characteristics; these results may help direct targeted improvement initiatives. Level of Evidence: Level III

Risk Factors for Surgical Site Infections After Orthopaedic Surgery in the Ambulatory Surgical Center Setting Introduction: This study was designed to determine the incidence of surgical site infections (SSIs) after orthopaedic surgery in an ambulatory surgery center (ASC) and to identify patient and surgical risk factors associated with SSI. Methods: Patients who underwent orthopaedic surgery at an ASC over a 6.5-year period were reviewed for evidence of SSI. Data on patient and surgical factors were collected, and stepwise multivariate logistic regression determined the risk factors for SSI. Results: The incidence of SSIs was 0.32%. Five independent factors were associated with SSI: anatomic area (odds ratio [OR] = 18.60, 11.24, 6.75, and 4.01 for the hip, foot/ankle, knee/leg, and hand/elbow versus shoulder, respectively), anesthesia type (OR = 4.49 combined general and regional anesthesia versus general anesthesia), age ≥70 (OR = 2.85), diabetes mellitus (OR = 2.27), and tourniquet time (OR = 1.01 per minute tourniquet time). Discussion: The risk of infection after orthopaedic surgery in ASCs is low, but patient and surgical factors are independently associated with SSIs.