Controversies in Orthopaedics: Editorial Comment

Our symposium is a collection of papers inspired by topics presented at a September 2009 American Academy of Orthopaedic Surgeons-sponsored meeting on Top Controversies in Orthopaedics in New York City (http://www.aaos.org/news/aaosnow/jul09/clinical14.asp). A variety of contentious topics related to the spine, hip, knee, elbow, and shoulder were presented and debated.

Intraoperative fluoroscopy has been invaluable in orthopaedics, whether it be for assessing tunnel placement in ACL reconstruction, alignment of a prosthesis, or the articular surface reduction in fracture fixation. Intraoperative imaging may also be useful in spine surgery as well. The use of intraoperative three-dimensional computed tomography in posterior cervical spine surgery may help to prevent return trips to the operating room for hardware complications while also helping to reduce costs.

Recent developments in hip arthroscopy have allowed for the treatment of pathologies including loose bodies, labral tears, and femoroacetabular impingement. The treatment of cam lesions involves reshaping the femoral-head neck junction to a normal contour, yet the extent of the amount of acetabular rim to resection for a pincer lesion is not as well defined. The development of guidelines for resection of the pincer lesion can be helpful in preoperative planning and in preventing overresection.

Arthroscopy has also facilitated ACL reconstruction, helping to restore stability to the knee. Multiple questions still exist, including what the optimal graft choice is and the appropriate femoral tunnel position. Postoperative rehabilitation and timing of return to sports also vary. Secure graft fixation is an important factor in allowing early weightbearing and range of motion exercises, especially in hamstring autografts which can take longer than bone-patellar tendon-bone autografts to heal. Joint line fixation on the femoral side with interference screws may be associated with fewer surgical failures with hamstring autografts. Cysts can occur when bioabsorbable screws are used for tibial fixation; however, this is most likely related to a foreign body reaction rather than an infectious etiology. Furthermore, they typically do not recur after screw removal.

Foreign body reaction has also been a concern with silastic radial head implants in the past. Currently, most radial head prostheses that are in use are metallic. However, there have been problems with “overstuffing,” cartilage wear, and motion loss. Thus, alternatives to metal have been sought. With functional or reconstructed elbow ligamentous stabilizers, silastic radial head arthroplasty may offer a better option.

On the other hand, the materials used for total shoulder replacement prostheses are relatively standard. However, controversy exists as to the safety of joint replacement in the elderly. As the population ages, more elderly patients have improved their function as a result of a total hip and/or knee arthroplasty—albeit, with an increased risk of a major perioperative complication or mortality. Conversely, total shoulder replacement in the patient 80 years of age and older actually demonstrates similar rates of complications and mortality as replacement in patients younger than 70 years old.

Surgical treatment of proximal biceps tendinopathy has also been a controversial issue. Techniques for performing an arthroscopic proximal biceps tenodesis have varied both in terms of type of tenodesis and location. Unfortunately, it is still possible to have pain in the bicipital groove even after a tenodesis has been performed. Placing the tenodesis distal to the groove may help to eliminate residual pain and improve patient outcome. When the biceps anchor is involved, as in a Type II superior labrum anterior posterior (SLAP) tear, a paralabral ganglion cyst can also arise in the spinoglenoid. The cyst can potentially compress the suprascapular nerve, leading to weakness in external rotation. There has been debate as to whether the cyst needs to be addressed, along with the tear. Decompressing the cyst, in addition to repairing the tear, may lead to improved external rotation strength, versus repairing the tear alone.

This collection of papers seeks to offer some insight into some pressing issues in orthopaedics today. We hope you enjoy this symposium.

Fig. 1

Alexis Colvin, MD, is shown.

Fig. 2

Evan Flatow, MD, is shown.