Acupuncture after total knee arthroplasty (TKA) may decrease the incidence of postoperative nausea and vomiting (PONV). Acupuncture did not decrease visual analog scale (VAS) scores in the 0 to 48-hour interval but did decrease VAS scores at >48 hours after TKA. The heterogeneity of the studies prevented meta-analysis of opioid use with acupuncture after TKA; a systematic review demonstrated mixed results. Additional studies are needed to investigate opioid reduction with acupuncture after TKA.

Theoretically, orthopaedic specialty hospitals (OSHs) offer multiple advantages compared with general hospitals; however, their overall benefit is debated. This review aims to compare patient characteristics and outcomes between OSHs and general hospitals in the United States. A systematic review was performed by querying PubMed and Embase from inception to April 2020 for articles comparing patient characteristics and clinical and economic outcomes between OSHs and general hospitals. Two researchers reviewed the articles according to prespecified criteria. The literature review yielded 3,715 articles, of which 19 were included. All articles were retrospective in nature. There were conflicting results with regard to preferential patient selection and profitability. OSHs generate a greater surgical volume, while decreasing operative time and length of stay, compared with general hospitals. Adverse outcomes have been reported to be less common at OSHs; however, this benefit is not supported by recent matched-cohort studies. Only 1 study evaluated patient satisfaction, and this study demonstrated improved satisfaction with OSHs. The literature with regard to OSHs is limited by low-quality studies, often yielding inconsistent results. OSHs appear to offer some benefits; however, it is unclear if improved outcomes are due to better patient care or preferential patient selection.

In the United States, orthopaedic surgeons have a legal obligation to obtain informed consent from patients before performing surgery; it is a process that includes a signed written document. There are specific legal requirements that vary somewhat by state but generally include disclosure and documentation of the diagnosis, an explanation of the recommended procedure, a conversation about the risks and benefits of the procedure, and a discussion about alternative treatments. Inadequate disclosure of risks and alternatives is associated with increased indemnity risk. Studies have shown that many consent processes and forms are suboptimal.

Tranexamic acid (TXA) is a drug used to control hemorrhage by preventing the breakdown of fibrin. TXA is a cost-effective treatment for trauma patients across a variety of economic settings. Concerns of TXA causing thromboembolic events (TEEs) in orthopaedic trauma patients are not supported by evidence. TXA has been shown to reduce blood loss in hip fracture surgery.

Achilles tendinopathy is a common clinical problem that can be either insertional or noninsertional, and effective treatment of each type can vary. We sought to investigate the current evidence on different treatment methods for insertional Achilles tendinopathy with a focus on functional outcomes. We performed a systematic review of the available literature using the PubMed/MEDLINE and Cochrane Central Register of Controlled Trials databases. Data from included studies were categorized according to treatment method and reported with respect to functional outcomes and complications. A total of 1,457 abstracts were reviewed; 54 studies with 2,177 patients met the inclusion criteria. Among the 54 studies, 6 operative techniques and 6 nonoperative treatments were evaluated. Eccentric exercises and low-energy extracorporeal shockwave therapy (ESWT) have the greatest evidence for the initial management of insertional Achilles tendinopathy. ESWT has been increasingly studied in recent years, but more high-quality evidence is needed. Operative treatment with tenotomy, debridement, retrocalcaneal bursectomy, and calcaneal exostectomy is effective. Flexor hallucis longus tendon transfer may benefit cases of more severe disease. Minimally invasive procedures have a potential role in the treatment algorithm and require more rigorous study. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The potential benefits of computer-assisted surgical (CAS) navigation and robotic total knee arthroplasty (TKA) systems, such as increased reliability of restoring the mechanical axis, fewer outliers, more rapid hospital discharge, less physical therapy requirements, decreased blood loss, and decreased revision rates, have led to their application not only in primary cases but also in complex cases such as preoperative deformity and revision. Early evidence demonstrates that CAS navigation may help to improve alignment in complex cases of femoral and tibial deformity and in cases of femoral bowing. Data regarding deformity correction with robotic systems are similar to CAS navigation with regard to alignment, but are more limited. There are also scant data regarding revision cases and cases of previous intramedullary canal instrumentation. Concerns remain regarding cost, learning curves, and operative times. There are potential long-term cost savings associated with a decrease in revisions and readmissions that require additional investigation. Early evidence for the use of these emerging technologies for deformity correction and revision cases is promising, but their impact on long-term functional outcomes remains to be demonstrated. Additional well-designed comparative studies are warranted.

Acetaminophen is an effective addition to a multimodal pain regimen; however, evidence to support intravenous versus oral administration requires further evaluation. While nonsteroidal anti-inflammatory drugs are a valuable addition to a multimodal pain strategy, concerns regarding their effect on healing after certain procedures (i.e., rotator cuff repair) in select patients may preclude their use. The use of perioperative gabapentinoids have varied results for pain control, and additional research is warranted to support their use after certain shoulder procedures. Opioid-prescribing should be limited and reserved for severe postoperative pain. When prescribed, opioids should be taken at the lowest possible dose and for the shortest period. Centrally acting analgesics such as tramadol have been shown to be as effective as opioids and have a lower risk of complications. Nerve blocks are an excellent addition to multimodal pain management strategies. Longer-lasting formulations of perioperative single-shot injections and indwelling catheters may reduce rebound pain.

Knee arthroplasty is a high-risk, resource-intensive procedure that should be reserved for patients in whom the benefit will outweigh the risks. The provision of high-quality, publicly available decision aids can help patients to balance the benefits against the harms of treatments and to assist informed decision-making. The aim of this study was to identify and evaluate the content and readability of freely available knee arthroplasty decision aids. A systematic search using an environmental scan methodology of publicly available online materials was performed in December 2018. Included materials were assessed for quality using the International Patient Decision Aid Standards instrument (IPDASi), understandability and actionability from a patient's perspective using the Patient Education Materials Assessment Tool (PEMAT), and readability grade level using the Flesch-Kincaid Grade Level and the Gunning Fog Index. Of 761 online materials screened, 26 decision aids were identified. Only 18 (69%) may be considered to meet criteria to be defined as a decision aid and 4 (15%) met criteria suggesting that the material did not introduce potential harmful bias according to the IPDASi. The mean score (and standard deviation) for all decision aids was 74% ± 12% for understandability and 44% ± 19% for actionability using the PEMAT. Readability indices indicated a mean minimum reading level of Grade 10 (10.8 ± 2.5). No decision aid included a wait-and-see option. Few high-quality decision aids exist for patients considering knee arthroplasty and none include a wait-and-see option. Many do not provide actionable options and are pitched at above-average reading levels. Developers need to address these issues to encourage high-quality decision-making, especially for those with low health literacy.

» Orthopaedic surgeons are expected to exercise leadership within a variety of departmental and organizational roles, such as in the context of the clinic, the operating room, private or academic practices, and, more broadly, their respective professional organizations.» Effective leadership can improve patient outcomes and satisfaction, as well as increase team efficacy and gratification.» Exercising insight and understanding as to how and when to employ different leadership styles can help orthopaedic surgeons lead effectively. Additionally, open and effective communication and emotional intelligence play an integral role in effective leadership.» This article reviews some of the current understanding regarding effective leadership in orthopaedic surgery, with a focus on highlighting strategies that are aimed at being a more effective leader.