Selective Dorsal Rhizotomy for the Treatment of Gait Dysfunction in Cerebral Palsy: A Critical Analysis Review »Objective physical examination measures should be developed and improved to identify and measure spasticity and to differentiate it from other types of movement abnormalities.»Using gait analysis as part of the preoperative evaluation of selective dorsal rhizotomy (SDR) can improve the safety and efficacy of this treatment of gait dysfunction in cerebral palsy.»A multidisciplinary team is crucial when assessing and managing children with cerebral palsy because spasticity is only one disease component of cerebral palsy and differentiating between different types of hypertonia is challenging.»A modest percentage of rootlet division (25% to 40%) reliably eliminates spasticity in cerebral palsy.»Long-term studies have shown that SDR is safe and may improve certain aspects of function.

A Review of Bundled Payments in Total Joint Replacement »The Bundled Payments for Care Improvement (BPCI) initiative, developed by the U.S. Center for Medicare & Medicaid Innovation, aims to reduce health-care expenditures while maintaining or improving patient outcomes.»Several published reports evaluating the impact of the BPCI on payment, utilization, and patient outcomes during the first 3 years of the initiative demonstrated a reduction in Medicare payments for major joint replacement of the lower extremity, driven primarily by a reduction in post-acute care utilization, without a sacrifice in quality of care as measured by no change in unplanned readmission rate, emergency department use, or mortality rate during the 90 days from episode start date. However, this reduction in Medicare payments did not translate into savings to the Medicare program, as the Net Payment Reconciliation Amount (NPRA) to providers was not included in any of the cost analyses.»The impact of the BPCI on outcomes important to patients and physicians has not been thoroughly evaluated in the published literature. Important (and standardly trackable) outcome measures that can be considered when assessing the effectiveness of a health-care model for bundled payments for total joint replacement include 30-day postoperative mortality, reoperation, and readmission; hip or knee functional status; hip, knee, or lower back pain; quality of life; work status; and satisfaction with results. Many studies directly evaluated only survival and disutility as manifested by readmission rate and emergency department use.»Multiple pilot studies evaluating cost savings and quality measures using a bundled-payment alternative payment model have demonstrated a reduction in Medicare episode payments, primarily related to decreased length of hospital stay and post-acute care utilization.»Readmission, certain comorbidities, and low socioeconomic status are associated with higher episode costs.»An evaluation of a bundled payment program for orthopaedic procedures in Stockholm, Sweden, revealed a decrease in cost, complication rate, and wait time after the introduction of a bundled payment system. Some of these improvements may be related to an increase in the number of surgical procedures on younger, healthier patients performed at specialized orthopaedic centers, with a concomitant shift of patients with comorbidities to hospitals.

Management and Outcomes of In-Season Anterior Shoulder Instability in Athletes »Anterior shoulder dislocation is a common problem in athletes and has serious implications due to the rate of injury recurrence and the resulting extended time out of play.»There are a variety of management options that address shoulder instability in an in-season athlete, and the decision-making approach should be individualized to the athlete.»Although nonoperative management and return to play in the same season may be a suitable option for a subset of athletes who wish to return to play as soon as possible (during a recruiting season, for an upcoming Combine, or if they are in the last season of their career), given the high risk of recurrence, we recommend that immediate surgical intervention should be considered to decrease the risk of further damage to the glenohumeral joint.»Arthroscopic stabilization currently is the most commonly performed intervention for athletes with anterior shoulder instability in the United States, but open repair remains an excellent option for high-risk patients.»In collision athletes with subcritical glenoid bone loss between 13.5% and 25%, early open anterior capsulolabral reconstruction or a Latarjet procedure is recommended. If glenoid bone loss exceeds 25%, the Latarjet or another glenoid osseous augmentation procedure should be performed to reduce the risk of recurrent anterior instability.

Lower-Extremity Skeletal Traction Following Orthopaedic Trauma: Indications, Techniques, and Evidence »Skeletal traction is a fundamental tool for the orthopaedic surgeon caring for patients with traumatic pelvic and lower-extremity injuries.»Immobilization of fractures in the pelvis, acetabulum, and proximal part of the femur can be difficult with traditional splinting techniques. Skeletal traction has proved to be an effective alternative means of immobilization in such cases.»Traction may be utilized for both temporary and definitive treatment of a variety of orthopaedic injuries.»With the appropriate knowledge of regional anatomy, skeletal traction pins can be placed safely and with a low rate of complications.»Several methods for placing skeletal traction have been described, and it is critical for orthopaedic surgeons not only to be proficient in their application but also to understand the appropriate indications for use.

Anterolateral Complex Reconstruction Augmentation of Anterior Cruciate Ligament Reconstruction: Biomechanics, Indications, Techniques, and Clinical Outcomes »Injury to the anterolateral complex may be identified on advanced imaging and may manifest with a higher level of instability, in particular with pivot-shift testing.»The anterolateral ligament reconstruction or modified Lemaire procedure may be used to reconstruct the anterolateral complex of the knee to augment anterior cruciate ligament (ACL) reconstruction.»Indications for anterolateral ligament reconstruction are evolving, but relative indications include revision ACL reconstruction, grade-III pivot shift, generalized ligamentous laxity, young age (<20 years), or high-level or high-demand athlete.»Early outcomes have suggested that anterolateral ligament augmentation of ACL reconstruction may decrease the risk of re-tear of the ACL reconstruction.

Periprosthetic Humeral Fractures in Shoulder Arthroplasty »The reported combined rates of intraoperative and postoperative periprosthetic humeral fractures range widely, from 1.2% to 19.4%.»The risk factors for an intraoperative humeral fracture and literature-reported strength of association include a press-fit humeral component (relative risk [RR], 2.9), revision arthroplasty (RR, 2.8), history of instability (odds ratio [OR], 2.65), female sex (OR, 4.19), and posttraumatic arthritis (RR, 1.9). The risk factors for a postoperative humeral fracture include osteonecrosis and increased medical comorbidity index (OR, 1.27).»Intraoperative fractures, in order of decreasing frequency, most often occur during implant removal in cases of revision arthroplasty (up to 81%), during reaming or broaching of the humerus (up to 31%), during trial or implant insertion (up to 18% to 19%), or because of excessive humeral torque or forceful retractor placement during exposure or reduction (up to 13% to 15%). Postoperative fractures typically occur from a fall onto the outstretched extremity or through an area of osteolysis.»The treatment of intraoperative or postoperative fractures is based on fracture location, prosthesis type and stability, rotator cuff status, and available bone stock.»Nonoperative treatment for periprosthetic humeral fractures appears to have high failure rates. When treating a periprosthetic humeral fracture operatively, surgical techniques for tuberosity fractures include suture repair, cerclage wiring, or revision to reverse components. For humeral shaft fractures, techniques include revision to a long-stem component, cerclage wiring, plate-and-screw fixation, and use of a strut allograft. For extensive humeral bone loss, techniques include component-allograft composites or humeral endoprostheses. All techniques have the goals of permitting early range of motion and preserving function.

Erratum: Human Immunodeficiency Virus Infection and Hip and Knee Arthroplasty No abstract available