Preparing for an Era of Episode-Based Care in Total Joint Arthroplasty

With a history of steadily rising healthcare costs, the United States faces an unprecedented set of health and financial challenges. The COVID-19 pandemic will only exacerbate these challenges, and it is of paramount importance to reform and refine health systems to maximize the value of care delivered to the patient. Recent developments related to value improvement in total joint arthroplasty suggest that episode-based payment is likely to become standard practice given the current healthcare environment. Consequently, developing episode-based care models for total joint arthroplasty is in the best interests of surgeons, health systems, and patients. In this article, we review important developments related to value-based care in total joint arthroplasty and present an episode-based framework for delivering high-value, patient-centric care. We examine each phase of a total joint arthroplasty episode—preoperative, acute, post-acute, and follow up—and present several ideas with developing bodies of evidence that can improve the value of care delivered to the patient.     

Frakturendoprothetik der medialen Schenkelhalsfraktur

A paradigm shift in the treatment of elderly patients has recently taken place leading to an increase in joint replacement surgery. The aim of this article is to highlight new developments and to present a treatment algorithm for femoral neck fractures. The age limit must be individually determined considering the comorbidities and perioperative risk profile. Pertrochanteric femoral fractures are nearly exclusively treated by osteosynthesis regardless of age. The situation for femoral neck fractures is more complex. Patients younger than 65 years should generally be treated by osteosynthesis but patients older than 65 years benefit from hemiarthroplasty or total hip arthroplasty. In patients aged between 65 and 75 years with high functional demands and a justifiable perioperative risk, total joint replacement is the treatment of choice. In physically less active patients older than 75 years and poor general condition, preference should be given to hemiarthroplasty.     

人工指关节的过去、现在和未来

以往使用的人工指关节为强制连接式、非强制式、间隔式三种模式 ,常因磨损、老化等因素而导致失败。目前 ,人工指关节的设计融合了解剖形状设计、骨整合概念、高新科技材料三种新概念 ,在一定程度上提高了关节功能的恢复。将来 ,同时具有目前研究三个方向优点的材料 ,将是指关节假体设计的新方向。此外 ,通过生物学重建的方法和组织工程 ,将解决现存的各项问题 ,从而使人工关节更趋完美。     

Current advances in the surgical approach to abdominal trauma

The management of abdominal injury has changed dramatically during the past two decades.This review examines the historic perspectives and recent developments of diagnosis and treatment of liver injuries, splenic injuries, and pancreatic injuries. The incorporation of non-operative management for liver injuries has had a very positive effect on mortality. Likewise, splenic conservative therapy is routinely used. The early treatment of pancreatic injury has changed very little; however, the ability to recognize these difficult injuries has improved with higher quality CT scanning. The authors present their preferred treatment for these three common types of abdominal solid organ injury and present an illustrative case example.     

Antibiotic-impregnated PMMA hip spacers: Current status

The infection rate after primary hip arthroplasty lies at 1–2%. In the past few years, a two-stage protocol with the implantation of an antibiotic-loaded spacer has become a popular procedure in the treatment of infected hip joint arthroplasties. In this review, we pay special attention to the elution characteristics of the spacers, their mechanical stability and the clinical response. We conclude that hip spacers are an effective method in the treatment of hip joint infections, with success rates of over 90%.     

Antibiotic-impregnated PMMA hip spacers: Current status

The infection rate after primary hip arthroplasty lies at 1-2%. In the past few years, a two-stage protocol with the implantation of an antibiotic-loaded spacer has become a popular procedure in the treatment of infected hip joint arthroplasties. In this review, we pay special attention to the elution characteristics of the spacers, their mechanical stability and the clinical response. We conclude that hip spacers are an effective method in the treatment of hip joint infections, with success rates of over 90%.     

Behandlung und Ergebnisse der akuten bakteriellen Entzündung großer Gelenke

Pyogenic arthritis poses a serious complication to the opening of a joint. In the past eight years we have treated 22 patients suffering from acute infection of the knee joint and the talo-crural joint. Cases with infection of osseous origin were excluded. Infection was mainly caused by contamination during ligament reconstruction. Our therapy consisted of emergency operative revision of the joint, removal of necrotic tissue, and installation of an irrigation-suction-drainage system. The joints were immobilized and systemic antibiotics were administered in all cases. In four cases the installation of the irrigation-suction-drainage system in the knee joint was performed percutaneously without opening the joint. Of these, three had to be reoperated as the infection could not be controlled. During recent years we prefered to use a 0.5% PVP-I-solution for irrigation, because of the antiseptic effect. Irrigation treatment is limited to a period of seven days. Two out of 15 cases of knee-joint infection and three cases out of seven of talo-crural-joint infection resulted in ankylosis. In cases in which treatment began in the first week after contamination almost all had excellent clinical results. Substantial previous damage to the joint or delayed treatment usually prevented complete restoration of the joint's function.     

Fractures and luxations of the mid- and forefoot

Fractures of the mid- and forefoot, as well as luxations of the Chopart and Lisfranc joints, have in the past often been treated conservatively if not with therapeutic nihilism. In light of the modern operative techniques and claims regarding anatomic and functional restitution, this management from should be reconsidered. Shortening and malposition can be corrected by internal fixation and joint surfaces are being reconstructed, thus restoring the load-bearing capacity of the plantar arch. Post-traumatic impairment can be completely or at least partially avoided by early specific measures. The present study describes fractures and luxations of the fore-foot distal to Chopart joint and the present state of treatment, including complications and risks arising from the treatment of these injuries.     

Mini-invasive computer assisted bi-unicompartimental knee replacement

In the treatment of knee osteoarthritis there are no reports using bi-unicompartimental implants and many orthopaedic surgeons are sceptical about this demanding surgical procedure despite its theoretical advantages in terms of less invasive surgery. The bi-unicompartmental approach also offers the potential advantage of maximal preservation of normal anatomy, with benefits for functional aspects such as gait, muscle activity, and proprioception.Computer-aided knee replacement surgery has been gaining popularity and an improvement in limb alignment and kinematics has been demonstrated in several studies. During the procedure the surgeon can check both implant position and ligament balance during the full range of joint movements, which helps to reduce the complications traditionally associated with failure in the past. The authors present a computer-aided technique for performing bi-unicompartimental knee replacement which permits a less invasive alternative for knee replacement surgery.     

小腿开放伤术后重度感染1例

患者,男,46岁,2011年3月11日因“外伤致左小腿出血、疼痛4h”入院.入院查体：左小腿中下段前外侧见1个“V”形裂口,长约9 cm,皮缘挫伤重,出血,污染,创口内见腓浅神经裸露、挫伤,部分肌肉挫裂,足背侧皮肤感觉减退,踝、趾关节活动可,足背动脉搏动可及（图1a）.患者合并高血压与糖尿病,完善相关检查后急诊在硬膜外麻醉下行清创探查缝合术.术中可见：创口深约1指,由外下方通达腓骨后上部,腓浅神经挫伤、裸露,连续性存在,趾长伸肌大部分,拇长伸肌、胫前肌部分及腓骨长短肌部分肌束挫裂,腓骨部分皮质外露;创口组织内粘附大量泥沙样污染物.术中延长创口,清除污染物和挫灭组织,双氧水盐水反复冲洗,碘伏消毒,肌肉部分修复,置皮片引流,关闭创口.术后常规抗感染活血补液对症治疗.术后24 h患者出现高热（体温39.5℃）,畏寒,左小腿弥漫性红、肿、疼痛,创口渗液,脓性,灰白色,伴腐恶臭,创口周缘局部出现坏死表现,皮肤色加深、发黑,创缘皮肤按压有捻发感（图1b）.     

初次全膝关节置换术后膝前痛预防的研究进展

全膝关节置换术（total knee arthroplasty,TKA）是治疗终极膝关节病变的有效方法,能有效缓解疼痛,纠正畸形,改善功能,进而提高患者的生活质量.目前,患者的满意程度越来越被认为是评价TKA的一个重要因素.而膝前痛作为初次TKA后的常见并发症,是指发生于膝前或者髌骨周围的疼痛,这严重影响了患者膝关节功能的改善和其对手术的满意程度.因此,膝前痛的减轻成为TKA的重要目标.目前,认为膝前痛的主要机制是髌股关节的高接触应力造成的软骨下骨内压升高和并发于髌骨运行轨迹异常导致的髌骨周围软组织病变.近年来针对如何预防全膝关节置换术后膝前痛的发生进行了大量研究,但是由于各种各样的原因,至今为止不管是髌骨置换,保留髌骨行髌骨周围去神经化,还是活动平台体都不能取得确切而良好的效果.由此可见,初次TKA后膝前痛的防治仍然是一个棘手的问题.此问题的解决,需要对膝前痛发生原因、膝关节假体及髌股关节生物力学特性做进一步研究,并经过大规模的随机对照试验的论证.     

Perspectives on bone densitometry: Past/present/future

Osteoporosis is defined as a decrease in bone mass and structural changes in bone leading to an increased fracture incidence. Therefore, early diagnosis in terms of prophylaxis and treatment are of great interest. Over the past several decades there has been considerable progress in the development and application of non-invasive methods of bone mass measurements or bone densitometry. This article reviews basic methodology and developments in bone densitometry including the early approaches like radiogrammetry, photo densitometry, neutron activation analysis and compton scattering techniques, present methods like single and dual x-ray absorptiometry and quantitative computed tomography, and recent developments like quantitative ultrasound, magnetic resonance techniques and structural analysis. The widespread interest in bone densitometry will initiate further improvement of established methods and development of new applications.     

The modern era of orthotics

The past 40 years has seen the field of orthotics change from a craft-based industry into a modern clinical specialty. The author describes his personal view of some of the most important developments during this period in the areas of manufacturing and materials, patient/orthosis matching, biomechanics, joint design and standards. Some likely areas of future development are suggested.     

Modeling Metastatic Breast Cancer in Mice

Metastatic disease is the major cause of death in breast cancer patients. Patients presenting with metastases cannot be cured, and as a consequence, treatment is palliative and focuses on prolonging survival and maintaining quality of life. Numerous mouse models have been generated in which human breast cancer development and metastasis have been studied, ranging from spontaneous and carcinogen-induced models to transplantation models and genetically engineered mouse models. Here, we summarize past progress and highlight present developments in modeling breast cancer invasion and metastasis in genetically modified mice, and the impact it may have on the development of innovative anticancer therapies.     

High-energy bilateral talar neck fractures secondary to motocross injury.

The authors present a case of bilateral Hawkins type II talar neck fractures sustained during a motocross race in a 23 year old man. Due to the complexity of the injuries, open reduction with internal fixation and primary subtalar joint arthrodesis was performed bilaterally. This is one of the few cases of bilateral talar neck fractures reported in the literature in the past 15 years and one of the first utilizing open reduction and internal fixation with concomitant subtalar joint arthrodesis as a primary treatment.     

Arthrolysis of the hip joint in para-articular calcification and ankylosis

Para-articular ossification of the hip joint represents a severe complication after hip surgery for joint replacement or various forms of trauma. It is always accompanied by tremendous loss of function and is therefore disabling for the patient. The results of past years have drastically reduced this complication in high-risk groups-recurrent joint replacement, acetabular fractures, severe head injuries-by means of hip irradiation and non-steroidal anti-inflammatory medication. In cases, in which significant functional disability results from heterotopic bone formation, it is possible to restore function of the hip joint through surgery. The diagnostics, preoperative planning, surgical therapy, and postoperative treatment protocol are presented.     

Osteochondritis Dissecans of the Head of the Femur

The history and occurrence of osteochondritis dissecans (O.D.) are briefly reviewed. Various factors which have been regarded as essential or contributory causes of the disease are discussed on the basis of the literature. It is concluded that the most plausible causal theory is that O.D. occurs on the basis of a fatigue fracture of a joint with mechanical inferiority. In the elbow and knee joints it may be due to the epiphyseal changes described by Ribbing, and in the hip joint to deviations from the normal form. In addition, the theory advanced by Bentzon is considered; according to this theory, aseptic necrosis occurs due to contusional injury to the vessels resulting in periarterial sympathectomy, which in turn gives rise to an abnormal callus reaction. Ten cases, of which two were bilateral, are reported. In one case, developments were followed from normal hip joints on both sides to O.D. in its complete form. Symptoms, differential diagnosis and treatment are briefly considered.     

Empyembehandlung

Since untreated joint infections lead to destruction of the affected joints, rapid and consistent action is required to establish the diagnosis of such infections. The aims of treatment are to cure the infection and to maintain the joint function: in the case of the lower extremity restoration of joint function combined with stability is the priority, while when the upper extremity is affected good function is the main objective. As most of the classification systems in current use take account only of the observed extent of the damage to the joint, we use a classification of our own, which is based on pretreatment and extension of infection in addition to the damage to the joint. Clinical examination, simple laboratory investigations, ultrasound examination and analysis of the joint fluid are all of critical importance in the diagnosis. Treatment must be carried out as an emergency in an accident and emergency department. If an acute infection is present immediate surgery is essential, while if there is chronic infection treatment can be postponed for 1–2 days to allow more comprehensive diagnostic investigations. Systemic antibiotic treatment is generally required during and after the operation. Early physiotherapy is essential for restoration of joint function. In this paper we go into some detail on treatment of the individual stages of joint infection (our own classification system) and present personal results.     

Fluoroscopic Method for Localization of the Anteromedial Portal for Use in Ankle Arthoscopy: Technique Tip

Ankle arthroscopy has become a standard surgical technique for the treatment of many ankle pathologies. Over the past 30 years, the technique has undergone modification and standardization in order to improve surgical performance and outcomes. In contrast to the ankle joint, the hip joint is a deep joint, which makes visualization and palpation of the topographical anatomy quite difficult. The use of fluoroscopy has enabled the surgeon to successfully perform hip arthroscopy for the treatment of selective hip pathologies. Fluoroscopy also can improve the localization of the anteromedial portal for use in ankle arthroscopy. This technique is valuable for the less-experienced ankle arthroscopist, in resident education, and for the experienced arthroscopist when surface anatomy palpation and visualization is less than ideal due to soft tissue edema and obesity.