Archive | April 2016

JBJS Editor’s Choice—Prevent Nerve Damage During Anterior Hip Approaches

LFCN_Branches.pngWhile anatomy is the foundation of all surgical practice, we at The Journal do not often publish an-
atomic manuscripts. We make exceptions when papers have the potential to influence the practice of orthopaedic surgery in a major way. Such an exception is the cadaver study by Rudin et al. in the April 6, 2016 JBJS.

The authors focus on the course of the lateral femoral cutaneous nerve (LFCN) of the thigh. This is a highly relevant anatomic structure because of the increasing interest in the anterior approach for hip arthroplasty, for anterior approaches to the hip for open reduction of femoral-head or proximal-femur fractures, and even for surgically treating femoroacetabular impingement.

The major take-home point is the extensive variability of this nerve in terms of where it exits the pelvis and its three different branching patterns from there (see illustration). These anatomic findings should alert the operating surgeon to make skin incisions as lateral as possible and to take extra caution when creating the interval deep to the fascial plane.

Rudin et al. have performed a service to the orthopaedic community by carefully defining the high degree of variability in the course of this nerve, which often is in harm’s way during common surgical exposures. Although injury to the sensory-only LFCN will not lead to major neurological complications, the authors conclude that patients undergoing anterior hip approaches should be informed of the risks of sensory loss or dysesthesia.

Marc Swiontkowski, MD

JBJS Editor-in-Chief

Improved Patellar Stiffness Proves Benefits of Tensioned MPFL Reconstruction

MPFL ReconIn many orthopaedic contexts, post-procedure stiffness is a complication to be avoided. But when it comes to reconstructing the medial patellofemoral ligament (MPFL) to treat recurrent patellar dislocation, stiffness of the patella is, to borrow Hamlet’s phrasing, “a consummation devoutly to be wished.”

In the April 6, 2016 edition of The Journal of Bone & Joint Surgery, Kumahashi et al. report on 17 knees with recurrent patellar dislocation that underwent MPFL reconstruction using an autograft semitendinosus tendon and an interference screw for precise graft tensioning. Medial patellar stiffness was significantly improved three months after surgery, and the reconstructions achieved the normal stiffness levels found in reference knees (n=64) after six months. Moreover, medial and lateral patellar stiffness was found to be well balanced by six months and for up to two years postoperatively.

The authors describe their intraoperative graft-tensioning technique in detail. They measured patellar stiffness (in N/mm) using a Patella Stability Tester (Kishi Engineering, Izumo, Japan) preoperatively and every three months after surgery up to two years. In addition, postoperative radiographic findings and Kujala and Lysholm scores were significantly improved at the time of the latest follow-up relative to preoperative radiographic and clinical evaluations.

Orthopaedists Again Atop Physician-Compensation List

For its 2016 survey of physician compensation, Medscape received information from more than 19,000 physicians across 26 specialties. Orthopaedists again topped the list this year at $443,000 (see graph below), followed by cardiologists ($410,000), and dermatologists ($381,000). Orthopaedists and cardiologists were the top two earners last year also (see related OrthoBuzz post).

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Although orthopaedists were the highest-paid group overall, only 44% of them felt they were fairly compensated (see graph below). Orthopaedists who felt fairly paid made $156,000 more than those who believed their compensation was not fair.

Screen Shot 2016-04-04 at 9.16.31 AMOn a more positive note, nearly half (46%) of orthopedists believe that relationships with patients are a major source of satisfaction (see below). In the comments section included with this question in the Medscape survey, orthopaedists frequently mentioned helping patients and teaching as rewards of practice.

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In  Medscape’s calculations, compensation for employed physicians included salary, bonus, and profit-sharing contributions. For partners, compensation included earnings after business taxes and deductions, but before income taxes.