Ethical Considerations in Total Joint Arthroplasty.

Hip and knee arthroplasty surgeries have excellent outcomes and notably improve quality of life. However, ethical issues permeate the practice of adult reconstruction, and as economics and technology evolve, these issues have become increasingly important. This article will review the currently published literature on ethical issues including industry influences, implants and instrumentations, surgical innovation, new technology adoptions, and healthcare policy-relevant issues, including patient cost sharing and bundled care programs. In addition, the direct marketing of implants from the manufacturer to the general public may falsely raise patient expectations concerning the long-term clinical outcome and performance of newer devices in the absence of long-term studies. This article will also focus on relevant contemporary ethical issues that do not necessarily have preexisting published literature or guidelines but, nonetheless, are crucial for adult reconstruction surgeons to address. These issues include access to care and challenges with orthopaedic resident and fellow education. Surgeons must understand the ethical issues that can arise in their clinical practice and how those issues affect patients. Clinicians are tasked with making the best-reasoned judgment possible to optimize their patients' outcomes. Still, the ability to standardize treatment while optimizing individual outcomes for unique patients remains a challenge.

Industry Payments Among Editorial Board Members of Orthopaedic Journals: An Open Payments Analysis From 2014 to 2019.

INTRODUCTION: Although industry payments to physicians and surgeons remain a subject of controversy, relationships between industry and orthopaedic surgeons continue to grow. Notably, recent analyses have demonstrated significant increases in the rate and magnitude of payments among orthopaedic surgeons, despite the passing of the Physician Payments Sunshine Act in 2010. Given the concerns regarding how these relationships may affect the peer-review process, our analysis aimed to evaluate how payments among editorial board members of orthopaedic journals have changed over a contemporary time frame. METHODS: The Clarivate Analytics Impact Factor tool was used to identify all orthopaedic journals with a 2019 impact factor of ≥1.5. Editorial board members from these respective journals were identified from each journal's website. Subsequently, the Open Payments database by the Centers for Medicare and Medicaid Services was queried to identify industry payments received by these board members between 2014 and 2019. The quantity and magnitude of payments were then evaluated and compared over this study period. All monetary values were adjusted for inflation. RESULTS: A total of 18 orthopaedic journals were included in our analysis. Of the 1,519 editorial board members identified, 711 (46.81%) received some form of industry payment in 2019. The total, average, and median payments over this study period decreased for 6 (31.6%), 7 (36.8%), and 8 of the included journals (44.44%), respectively. Six hundred twenty board members had higher average payments in 2019 than in 2014. CONCLUSION: Our analysis demonstrated high rates of industry payments among editorial board members of high-impact orthopaedic journals. In addition, we demonstrated marked growth in the total, average, and median magnitude of these payments since the inception of the Open Payments database. Our findings encourage a continued need for transparency in related payments to ensure a fair and unbiased peer-review process, one that is separated from undue industry influence.

Anatomical considerations of the internal iliac artery in association with the ilioinguinal approach for anterior acetabular fracture fixation.

INTRODUCTION: Vascular injury may be encountered during an anterior approach to the pelvis or acetabulum-be it due to hematoma decompression, clot dislodgement during fracture manipulation, or iatrogenic. This can be associated with significant bleeding, hemodynamic instability, and subsequent morbidity. If the exact source of bleeding cannot be easily identified, compression of the internal iliac artery may be a lifesaving procedure. MATERIALS AND METHODS: We describe an extension of the lateral window of the ilioinguinal (or Olerud) approach elaborated on cadavers. RESULTS: The approach allows emergent access the internal iliac artery and intraoperative cross-clamping of the internal iliac vessels to control bleeding. CONCLUSION: The approach allows rapid access to the internal iliac artery. The surgeon should be familiar, however, with the surgical anatomy of this region to avoid potential injury to the ureter, peritoneum, lymphatics, and sympathetic nerves overlying the vessels when using the approach described.

Use of a 30-degree external rotation view for posteromedial tubercle fractures of the talus.

A fracture of the posteromedial talar tubercle is also referred to as the Cedell fracture and is an infrequently described injury. Failure to recognize this injury may lead to posteromedial ankle pain and tarsal tunnel syndrome. It is therefore important to diagnose these fractures at the time of the initial presentation to avoid future morbidity. Although plain radiography forms the mainstay of initial radiological evaluation of the ankle, these fractures are commonly missed and misdiagnosed because of poor visualization on routine ankle radiographs. Computed tomography helps for better visualization of this fracture at the higher risk of radiation. We evaluated the use of the 30-degree external rotation view for the diagnosis of fractures of the posteromedial tubercle of the talus using cadaver specimens. On the 30-degree external rotation view of the ankle, all fractures of the posteromedial tubercle of the talus were revealed. In contrast, the fracture was visualized in only 2 cases using the standard lateral radiograph of the ankle, and not once in the anteroposterior or mortise views. In conclusion, a 30-degree external rotation view is likely to show a fracture of the posteromedial tubercle of the talus in contrast to the 3 routine trauma views of the ankle, aiding in diagnosis and treatment strategy at time of initial presentation.

Angled posteroanterior fluoroscopy for L5-S1 discography: a technical note.

Lumbar discography, a useful modality for evaluating patients with lower back pain, is performed under fluoroscopy with posteroanterior and lateral fluoroscopic imaging. Despite use of fluoroscopy, needle placement into the L5-S1 disc may be difficult, especially in the presence of degenerative changes. We describe use of angled posteroanterior fluoroscopy with the fluoroscopy beam directed 30 degrees to 40 degrees caudally in a prone patient for clear visualization of the L5-S1 disc space. Use of this radiographic view aids in accurate needle placement and might decrease both procedure duration and fluoroscopic exposition.

Effect of the increase in the height of lumbar disc space on facet joint articulation area in sagittal plane.

STUDY DESIGN: Computerized tomography (CT) of the lumbar spine cadaveric specimens was used to evaluate the effect of increasing the height of the disc space in the lumbar spine to the facet joint articulation in the sagittal plane. OBJECTIVE: To show how the facet joint articulation is affected by increasing the height of the disc space in the lumbar spine. SUMMARY OF BACKGROUND DATA: The Charité Artificial Disc (DePuy Spine, Inc., Raynham, MA) was successful in relieving low back pain in the majority of patients, yet there was still a significant number of patients who did not obtain pain relief, or their pain even worsened. The etiology of their pain is still not known. To our knowledge, no study has addressed the effect on the facet joints when the disc height is increased. METHODS: CT images passing through the center of the L3-S1 facet joints (sagittal plane) were obtained from 15 cadaveric lumbar spine specimens. The articulation overlap of facet joints in sagittal plane from the L3 to S1 was measured. A 1-mm incremental increase to a total 5 mm in disc space height was performed to simulate the changes seen in disc replacement. The change in the facet joint articulation overlap in sagittal plane at normal and each displacement was then measured. There were 5 lumbar spine specimens dissected to validate the technique and standardize the measurements. Mean, percentages, and standard deviation values were calculated for all measured dimensions. RESULTS: No significant difference was found between the measurements on CT and gross specimens (P > 0.05). In 15 specimens, the mean facet joint articulation overlap on the sagittal plane was: 16.29 +/- 1.20 mm (left) and 16.22 +/- 1.16 (right) at the L3-L4 level; 17.81 +/- 1.18 mm (left) and 17.74 +/- 1.18 mm (right) at the L4-L5 level; and 18.18 +/- 1.18 mm (left) and 18.23 +/- 1.15 mm (right) at the L5-S1 level. There is no significant difference between the measured values on left and right sides (P > 0.05). Each 1-mm incremental increase in disc space at the L3-L4 level translated to a decrease in the facet joint articulation overlap in the sagittal plane by 6%, and the mean facet joint space increased 0.4 mm. At the L4-L5 level, the articulation overlap decreased by 6%, and the facet joint space increased 0.5 mm. At the L5-S1 level, the articulation overlap decreased by 4%, and the facet joint space increased 0.7 mm. CONCLUSIONS: There is a significant decrease of the facet joint articulation overlap in sagittal plane and an increase in the facet joint space following an increase in the lumbar disc space. The inappropriate increase of the height of disc space will result in facet joint subluxation.

Value of intraoperative true lateral radiograph of C2 pedicle for C1-2 transarticular screw insertion.

BACKGROUND CONTEXT: Transarticular C1-2 screws are widely used in posterior cervical spine instrumentation. Injury to the vertebral artery during insertion of transarticular Cl-2 screw remains a serious complication. Use of a computer-assisted surgery system decreases this complication considerably. However, this system encounters problems in ensuring complete accuracy because of positional variations during preoperative and intraoperative imaging generation. Therefore, intraoperative fluoroscopy still is one of the commonly used methods to guide insertion of transarticular Cl-2 screw. Evaluation of a true lateral radiographic view of the C2 pedicle for screw trajectory during C1-2 transarticular screw insertion may help to minimize this potential complication. PURPOSE: To evaluate the value of intraoperative true lateral radiograph of the C2 pedicle for screw trajectory during C1-2 transarticular screw insertion. STUDY DESIGN: To compare the height of the C2 pedicle area allowing instrumentation on true lateral view radiograph of the C2 pedicle and computed tomographic (CT) scan with multiplanar reconstruction. METHODS: Twenty embalmed human cadaveric cervical spine specimens were used to insert a total of 40 C1-2 transarticular screws using Magerl and Seemann technique. One side of the C2 transverse foramen was filled with radiopaque material (lead oxide) to simulate the artery and to demarcate the danger zone for better visualization on radiography. Measurements and calculation of the mean and standard deviation of the height of the area allowing instrumentation of the C2 pedicle were done on true lateral view radiograph of the C2 pedicle, the sagittal and 30 degrees sagittal views relative to the frontal plane passing exactly through the center of the C2 pedicle of CT scans. Student t test was applied to calculate the statistical significance of measured values. Statistical significance was defined as por=.36. Using sagittal CT scan views, the height of pedicles was 7.71+/-0.7 mm (right) and 7.58+/-1.01 mm (left), p>or=.23. On 30 degrees sagittal CT scan views, the height of pedicles was 7.84+/-1.00 mm (right) and 7.76+/-1.02 mm (left), p>or=.27. The p value was >or=.78, >or=.56, and >or=.49 for true lateral radiographic view and sagittal CT scan view, true lateral radiographic view and 30 degrees sagittal CT scan view, and sagittal CT scan view and 30 degrees sagittal CT scan views, respectively. On lateral view of cervical spine, the decline angle of the transarticular screw was 51.3+/-0.50 degrees (right) and 50.68+/-0.41 degrees (left), p>or=.17. Mean decline angle was 51+/-0.43 degrees . On the anteroposterior (AP) view, radiograph median angle was 6.87+/-0.53 degrees (right) and 6.0+/-0.59 degrees (left), p>or=.25. Mean median angle was 6.44+/-0.62 degrees. CONCLUSIONS: True lateral radiographic views of the pedicles provide useful information for defining screw trajectory intraoperatively. Using this view along with AP and lateral view of cervical spine and preoperative three-dimensional CT scan may narrow the margin of error in this delicate area.