As the number of upper extremity arthroplasty procedures increases, the incidence of periprosthetic upper extremity fractures is expected to rise. It is important to evaluate the approach to the workup and management of periprosthetic shoulder and elbow fractures, along with technical considerations Recent evidence regarding the management of these injuries should be reviewed.
The recent legalization of cannabinoids across the United States, both recreationally and medically, has presented an opportunity for cannabinoids to be used for a wide array of medical applications, most notably as an alternative to opiate pain medication. Despite this changing landscape and the growing cultural attention, much is still unknown about cannabinoids and their effect on the human body, specifically in the orthopaedic patient. There is basic science evidence that cannabinoids can positively affect bone metabolism; however, clinical studies are lacking to validate this. Moreover, clinical studies that have examined the effect of cannabinoids on orthopaedic outcomes are primarily retrospective database studies and have yielded conflicting results. Thus, despite growing usage of cannabinoids by patients and even some clinicians, substantiating evidence is lacking. The onus is on medical professionals and researchers alike to produce high-level evidence before any strong conclusions or clinical recommendations can be made.
Middiaphyseal clavicle fractures are prevalent in children and adolescents, and they are typically treated nonsurgically because of their strong bone-healing capabilities. However, increasing trends toward surgical intervention in adult patients have sparked debate over whether younger populations could experience similar benefits from the surgical approach. Recent studies have suggested that surgical fixation may offer quicker pain relief and faster recovery, particularly in adolescents and specific fracture cases involving severe displacement or complications. However, despite these potential short-term benefits, there are no long-term differences in patient-reported function and satisfaction between surgical and nonsurgical treatment. The decision to perform surgery should be individualized, balancing potential complications against possible improvements in early recovery. Ultimately, nonsurgical management remains the standard, with surgical intervention reserved for select cases and determined collaboratively between families and health care clinicians.
Tibial shaft fractures are common injuries in children and may occur as a result of trauma, sports-related activity, or falls. Casting has historically been considered the gold standard form of treatment; however, the inherent risks associated with casting, such as malunion and prolonged immobilization, have led to a rise in surgical techniques to treat these injuries. Minimally invasive, elastic stable intramedullary nailing is commonly used, whereas rigid intramedullary nailing is better suited for older children. Patients with complex fractures and severe soft-tissue injury or bone loss are treated with external fixation, whereas plate fixation is reserved for specific fracture patterns not amenable to intramedullary fixation. There is ongoing debate regarding the ideal pediatric and adolescent tibial shaft fracture management algorithm. It is important to assess changing treatment paradigms, comparing the surgical stabilization options and making evidence-based recommendations tempered by the authors' experience.
As the field of pediatric sports medicine continues to evolve, there are several advances in the management of anterior cruciate ligament tears, tibial spine fractures, juvenile osteochondritis dissecans, and patellar instability. The role of limb alignment and guided growth is increasingly recognized as an important determinant of clinical outcomes. It is important to review the latest information on each of these injuries and conditions, based on recently published studies and current practices.
Patient-specific risk factors play a significant role in determining the outcome of total joint arthroplasty. Optimizing risk factors that are modifiable can improve surgical results. The proper assessment of these factors preoperatively is critical in determining a plan of intervention. Clear, evidence-based guidelines are evolving regarding the best assessment tools for deciding the necessity of and the proper degree of intervention. It is important to review current research on the assessment of modifiable risk factors. A thorough understanding of the definition, assessment, and current investigation surrounding the assessment of these modifiable risk factors is critical to optimizing total joint arthroplasty.
The path to becoming a successful orthopaedic surgeon is long and arduous. It takes dedication, motivation, perseverance, hard work, grit, self-drive, and most importantly, a passion for the field. The training takes 4 years of undergraduate studies, 4 years of medical school education, 5 or 6 years (academic track with a research year) of residency, and another year of specialized training in fellowship. There will be times during training that the trainee will fail and want to give up. There will be both good times and bad times during this long journey, and the trainee will need the support of family, friends, mentors, and colleagues to navigate this path. After 14 or more grueling years of education, residency, and fellowship, the trainee can finally start their career path as an attending orthopaedic surgeon. It is important for faculty and mentors to provide trainees with career and life advice to help them achieve a successful career.
Proximal humerus fractures are a common upper extremity injury that the pediatric orthopaedic surgeon will certainly encounter. Most of these fractures are managed with closed reduction with expectant remodeling. However, inevitably, some fractures are not well suited to minimal or nonsurgical management. Whether the fracture alignment would cause functional impingement or rotational impairment, if the fracture is irreducible, or if the patient is an adolescent with minimal remodeling potential, there are various treatment options. Closed reduction and creative immobilization techniques can adequately treat some otherwise unacceptable fracture patterns. Some fractures require surgical intervention with open reduction to release entrapped soft tissues. Fixation strategies ranging from percutaneous pin fixation, percutaneous screw fixation, flexible nailing, and plates and screws are valuable assets in the pediatric orthopaedic surgeon's toolbox.
The study of modifiable risk factors and preoperative optimization is critical to improving outcomes of total joint arthroplasty and lowering complications and the cost of care. Multiple attempts were made by the American Association of Hip and Knee Surgeons and the American Academy of Orthopaedic Surgeons to offer clinical practice guidelines based on the available literature. However, high-quality evidence to support that any comorbidity, including obesity, represents a modifiable risk for prosthetic joint infection was lacking. It is important to examine these guidelines, review the more recent literature, and discuss the practicality of evidence-based medicine when the quality of evidence is limited and also discuss the five conditions necessary to consider any disorder a modifiable risk factor.
Carpal tunnel syndrome (CTS) is a common condition affecting up to 3.7% of the population, with patients typically presenting for evaluation of numbness, pain, or hand weakness. When evaluating symptoms suggestive of CTS, it is essential that surgeons consider clinical entities that mimic CTS. It is important to define the characteristics of CTS mimics, assess their incidence, discuss diagnostic means to differentiate them from CTS, and guide selection of appropriate therapies.
Pediatric diaphyseal femur fractures are a fairly common fracture type for which all trained orthopaedic surgeons should develop a treatment framework. Treatment goals are to restore an acceptable limb length, alignment, and rotation. Nuances exist regarding acceptable tolerances depending on the age and remaining growth of the patient. Various treatment modalities exist, including flexible nailing, plate fixation, and rigid nail fixation, each with its own advantages, disadvantages, and limitations. Proper identification of key patient factors and fracture type is important for optimal decision making regarding fixation modality. Flexible nailing is typically reserved for patients age 5 to 11 years with stable fracture patterns and who weigh less than 100 lb. Plate fixation, typically via a submuscular application, is typically indicated in patients with unstable fractures and can be a reasonable choice for patients older than 5 years with no weight limitation. Rigid nail fixation, specifically antegrade nailing via a lateral-entry starting point, can be indicated in patients older than 11 years with any fracture pattern. Understanding how each fracture and patient factor affects healing can help the savvy surgeon choose which fixation modality to use when the clinical situation inevitably falls in the gray zones shared by multiple modalities.
Lateral condyle fractures of the distal humerus are the second most common elbow fracture among children. These fractures present unique considerations because of their intra-articular nature and potential for growth disturbances. Management of lateral condyle fractures depends on the amount of fracture fragment displacement, joint congruency, and presence or lack thereof of rotational deformity. Patients with nondisplaced and minimally displaced fractures can be treated nonsurgically, whereas those with displaced fractures (>2 mm) warrant surgical intervention either by closed reduction and percutaneous fixation or by open reduction and internal fixation. There is controversy regarding the optimal method of fixation regarding Kirschner wires or cannulated screws. Cannulated screws have recently increased in popularity because of improved stability in combination with reduced rates of infection and elbow stiffness; however, most surgeons recommend secondary surgery for removal of the hardware. The more traditional Kirschner wire fixation still exhibits satisfactory outcomes and avoids the need for secondary surgery but comes with longer immobilization periods and an increased lateral bump following fixation. Therefore, both modalities of fixation remain viable options, with their own advantages and disadvantages, which surgeons should consider when selecting their preferred method of fixation.
The incidence of pediatric meniscal tears has increased in recent years, with complex injuries such as bucket-handle and discoid meniscus tears presenting unique challenges. It is important to provide an updated overview of the diagnosis and nonsurgical and surgical management of pediatric meniscal tears, emphasizing MRI interpretation, repair techniques, and the risks associated with total meniscectomy. In addition, the orthopaedic surgeon should be knowledgeable about the critical role of lower limb alignment in pediatric knee pathology, developmental changes in coronal plane alignment, and the use of implant-mediated guided growth.
Pediatric phalangeal neck fractures occur distal to the collateral ligament recess, often with apex volar angulation. These fractures are at an increased risk for various complications including malunion, nonunion, stiffness, and osteonecrosis. The Al-Qattan classification system categorizes these fractures into three types: type I fractures are nondisplaced, type II fractures are displaced while maintaining cortical contact, and type III fractures lack cortical contact with associated malrotation or partial amputation. Type I fractures are typically managed nonsurgically. Recent reports have shown that minimally displaced type II fractures can also be successfully managed nonsurgically. However, type II fractures with greater than 30° of angulation, 25% translation, and/or clinical malrotation or deviation warrant surgical intervention via closed reduction and percutaneous pinning. Open reduction is reserved for open fractures or when closed reduction techniques fail. Open reduction is associated with higher complication rates and poorer overall outcomes. Unsatisfactory outcomes are common in fractures with poor prognostic factors, including vascular compromise, concurrent distal epiphyseal or juxtaphyseal fractures, comminution of the phalangeal head, open fractures, and all type III fractures. Phalangeal neck fractures require special attention and should be managed using an algorithmic approach to optimize outcomes and mitigate complications.
It is important to review treatment considerations and provide a framework to guide decision making for nonsurgical and surgical treatment of distal tibia physeal fractures in pediatric patients. In most closed injuries, attempted closed reduction and immobilization is the initial treatment for stabilization of these fractures. Postreduction fracture alignment evaluation with a focus on residual fracture displacement at the articular surface and the physis combined with residual angulation will guide further treatment after closed reduction. Discussion of commonly occurring distal tibia physeal fracture patterns includes treatment-specific recommendations for Salter-Harris type II distal tibia fractures, medial malleolar physeal fractures, and transitional distal tibia physeal fractures including triplane fractures and Tillaux fracture patterns. Treatment recommendations include intraoperative considerations covering surgical approach, reduction techniques, and fixation options for specific fracture patterns. Surgeons should be knowledgeable about the role of skeletal maturity assessment when deciding acceptable fracture alignment, treatment strategies, follow-up, and physeal monitoring. Pertinent topics in the discussion of complications include the occurrence rate and clinical relevance of posttraumatic physeal arrest, as well as rates of further complications for specific fracture patterns and how these are influenced by surgical intervention.
The management of rotator cuff tears has evolved significantly with advances in the understanding of natural history, as well as treatment options and surgical techniques for repair, augmentation, and replacement. It is important to provide a comprehensive overview of current treatment options for rotator cuff tears, emphasizing the importance of individualized decision making based on tear characteristics, tissue quality, and functional goals. Nonsurgical treatment remains a viable first-line approach for many degenerative tears. Arthroscopic repair should be performed when repairable. When not repairable, pain-reducing procedures such as isolated biceps management, subacromial balloon, and tuberoplasty should be considered. Tendon transfers, patch augmentation, superior capsule reconstruction, and reverse shoulder arthroplasty are options that can help improve function. A thorough understanding of the indications, limitations, and expected outcomes of each modality is essential.
Articular cartilage lesions of the knee, ranging from focal defects to tricompartmental osteoarthritis, present significant clinical challenges because of cartilage's limited regenerative capacity. It is important to highlight modern surgical advancements in the treatment of chondral pathology beyond injection therapy, traditional osteotomies, and arthroplasty options. Surface- and cell-based repair techniques, including matrix-induced autologous chondrocyte implantation, offer improved long-term outcomes, with emerging fourth-generation variants facilitating single-stage arthroscopic implantation. Off-the-shelf cartilage repair strategies, such as particulated juvenile cartilage, micronized allografts, and viable cartilage allografts, represent promising alternatives that bypass the need for two-stage procedures. For osteochondral defects, osteochondral autograft transfer and fresh allograft transplantation remain the gold standard, although decellularized and cryopreserved viable allografts are under investigation. Recently approved artificial osteochondral scaffolds, such as Agili-C, offer an FDA-cleared, acellular biphasic implant with promising midterm results. For patients with malalignment-associated osteoarthritis, patient-specific instrumentation in high tibial and distal femoral osteotomies enhances accuracy, particularly in biplanar corrections, and reduces intraoperative variability. Novel load-sharing implants, such as fiber-reinforced rafting nails and the MISHA knee system, provide less invasive alternatives to osteotomy, showing early success in reducing medial compartment load and improving functional outcomes. There is an expanding arsenal of biologically and biomechanically innovative treatments for articular cartilage restoration and osteoarthritis management.
Total knee arthroplasty (TKA) has become an increasingly valuable solution for managing acute periarticular fractures and failed fixation, particularly in elderly patients with severe comminution or underlying arthritis. Its key advantage lies in enabling immediate weight bearing and potentially reducing the need for reoperation compared with traditional fixation methods such as open reduction and internal fixation or intramedullary nailing. Although open reduction and internal fixation and intramedullary nailing remain standard fixation methods for many fracture types, primary TKA is gaining traction as a definitive treatment in complex cases. TKA, although technically demanding in these settings, offers reliable restoration of function when guided by thorough preoperative planning. TKA is no longer confined to salvage scenarios; it is evolving into a primary option that merges trauma principles with arthroplasty expertise. It is important to critically examine the role of TKA in fracture management, with a focus on patient selection, surgical technique, postoperative care, and outcomes to optimize results in both primary and revision settings.
General orthopaedic surgeons should have up-to-date information on the most common types of hand and wrist injuries, including distal radius fractures, scaphoid fractures, proximal interphalangeal joint injuries, scapholunate and perilunate injuries, nerve lacerations, common pediatric upper extremity injuries, and metacarpal and phalangeal fractures. These topics represent a broad swath of the typical pathologies the common hand surgeon will face in their practice. Providing the most up-to-date evidence and rationale for current treatments should help clinicians identify current themes in the treatment of these conditions and provide rationale regarding when to use certain up-and-coming techniques.
Femoral neck fractures are common injuries sustained by patients of all ages and are caused by both low- and high-energy mechanisms. The physician must diagnose the fracture expeditiously to initiate treatment. The surgeon must then evaluate the patient's medical condition and fracture characteristics to determine a treatment regimen that will minimize the all-too-common risks of osteonecrosis and fixation failure or fracture nonunion. In elderly, frail, and inactive patients, hip arthroplasty is usually the best treatment. In younger patients, efforts should be directed at expedient reduction of the fracture and surgical stabilization with multiple screws or with a sliding compression screw construct. The rationale of proper patient selection and the intraoperative tactics for optimal results are important topics to be reviewed.
