What topics should be covered in a talk about orthopedic trauma and arthroscopy?

Orthopedic Trauma and Arthroscopy: A Comprehensive Talk Framework for APOA 2026

Topic 1: Modern Management of Severe Limb Trauma - The Damage Control Paradigm

Patient Risk Stratification and Surgical Timing

The cornerstone of modern orthopedic trauma management is risk-stratified surgical timing based on physiologic status, not arbitrary time windows. 1

Three-Tier Risk Classification System

Low-Risk Patients - Proceed to early definitive surgery 1:

• Hemodynamically stable without vasopressor requirements
• Lactate < 2 mmol/L
• Prothrombin time ratio < 1.2
• Core temperature > 35°C
• ISS < 25 with no AIS grade 4 injuries
• No severe associated injuries requiring emergent procedures

Intermediate-Risk Patients - Use PRISM approach (Prompt Individualized Safe Management) 1:

• Moderate hypothermia (32-35°C)
• Prothrombin time ratio 1.2-1.5
• ISS > 25 or single AIS grade 4 injury
• Moderate ARDS (PaO₂/FiO₂ 150-300)
• Requires initial resuscitation and temporary stabilization before individualized definitive management

High-Risk Patients - Mandatory damage control orthopedics 1:

• Vasopressor-dependent or requiring multiple transfusions
• Lactate > 4 mmol/L
• Severe hypothermia < 32°C
• Prothrombin time ratio > 1.5
• ISS > 40 or AIS grade 5 injury
• Severe ARDS (PaO₂/FiO₂ < 150)
• Requires mid-term stabilization with external fixation followed by delayed definitive surgery

Critical Pitfall to Avoid

Never rely solely on scoring systems like MESS to determine amputation versus limb salvage - studies demonstrate a 43.2% amputation rate in patients with MESS scores >8, indicating the score alone is insufficient for decision-making. 2

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Topic 2: Urgent Surgical Indications in Limb Trauma

Absolute Indications Requiring Immediate Operative Intervention

Compartment syndrome, uncontrollable hemorrhage, and necrotizing soft tissue infections demand urgent surgical decompression in virtually all cases. 2

Clinical Recognition of Compartment Syndrome 2:

• Pain out of proportion to injury (earliest and most sensitive sign)
• Pain with passive muscle stretch
• Paresthesias in nerve distribution
• Progressive neurologic deficit

Vascular Emergencies Requiring Immediate Surgery 2:

• Uncontrollable life-threatening hemorrhage
• Avulsion of vascular structures
• Pulsating or expanding hematomas
• Signs of limb ischemia: pallor, pulselessness, paresthesia, paralysis, poikilothermia

For hemodynamically stable patients with arterial contrast extravasation, pseudoaneurysms, or arteriovenous fistulas, angiography with super-selective angioembolization is indicated rather than immediate open surgery. 2

Mangled Extremity Decision Algorithm 2:

Clinical situations favoring urgent surgical intervention include:

• Complete traumatic amputation
• Large tissue loss making skin coverage impossible
• Proven nerve section with extensive tissue damage
• Multiple fractures with significant bone loss
• Ischemic vascular lesions

Use temporary external fixation rather than skeletal traction when definitive osteosynthesis cannot be performed within 24-36 hours. 2

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Topic 3: Arthroscopy in Acute Knee Trauma - Evidence-Based Indications

Appropriate Use of Arthroscopy in Trauma Settings

MRI, not arthroscopy, should be the primary diagnostic tool for acute knee trauma with suspected internal derangement. 1

When Arthroscopy IS Indicated in Acute Trauma 1:

• Persistent objective locked knee that cannot be reduced
• Confirmed ACL rupture requiring surgical reconstruction
• Acute traumatic meniscal tears in young patients with mechanical symptoms and failed conservative management
• Acute hemarthrosis with suspected intra-articular fracture fragments requiring removal

Critical Evidence on Diagnostic Imaging 1:

MRI demonstrates superior diagnostic accuracy for:

• ACL tears (sensitivity approaching 95%)
• Meniscal tears with high specificity
• Bone contusions predicting focal osteoarthritis development
• Anterolateral ligament injuries associated with ACL tears
• Posterolateral corner injuries (present in 19.7% of ACL ruptures)

MRI can change management from surgical to conservative in up to 48% of patients presenting with a locked knee. 1

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Topic 4: Arthroscopy in Degenerative Knee Disease - Strong Recommendation AGAINST

The Evidence is Clear and Definitive

Arthroscopic surgery should NOT be performed in patients with degenerative knee disease, including those with meniscal tears, mechanical symptoms, or imaging evidence of osteoarthritis. 1

What Constitutes Degenerative Knee Disease 1:

• Patients >35 years old with knee pain
• With or without imaging evidence of osteoarthritis
• With or without meniscus tears
• With or without mechanical symptoms (except persistent objective locked knee)
• With or without acute/subacute symptom onset

This recommendation explicitly excludes patients with recent major knee trauma causing acute joint swelling or hemarthrosis. 1

The Evidence 1:

• No sustained benefit: Less than 15% of patients experience small improvements in pain or function at 3 months, which disappear by 1 year
• Natural history: Most patients experience important improvement in pain and function WITHOUT arthroscopy
• Global burden: Over 2 million arthroscopic procedures performed annually for degenerative disease despite evidence against use
• Cost: Exceeds $3 billion annually in the US alone for procedures with no proven benefit

Conservative management (exercise therapy, injections, medications) produces equivalent or superior outcomes compared to arthroscopy with no surgical risks or recovery time. 1

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Topic 5: Psychosocial Factors in Orthopedic Trauma Recovery

Mandatory Screening and Assessment

Psychosocial factors are as critical as physical injuries in determining long-term outcomes after orthopedic trauma and must be systematically evaluated by the interdisciplinary trauma team. 1

Key Psychosocial Risk Factors Requiring Assessment 1:

Behavioral Health Conditions (strongly associated with negative outcomes):

• Pre-existing anxiety disorders
• Depression (premorbid or post-injury)
• Post-traumatic stress disorder
• Any premorbid psychiatric conditions
• These correlate with increased pain, decreased function, decreased quality of life, and decreased return to work

Social Support and Marital Status 1:

• Married patients return to work markedly faster than single, divorced, or widowed patients
• Widowed/divorced patients demonstrate higher depression levels
• Presence and strength of significant other relationships critically impacts outcomes

Resiliency and Coping Mechanisms 1:

• Enhanced resiliency correlates with improved physical function and higher quality of life
• Catastrophic/negative thinking patterns predict worse outcomes
• Lower self-efficacy associated with more negative outcomes

Educational Level 1:

• Seven high- and moderate-quality studies document association between higher education and improved outcomes
• Enhanced mental health outcomes, physical function, and lower pain/anxiety levels

Implementation Strategy 1:

An interdisciplinary approach is essential, with all qualified team members (surgeons, physicians, physician extenders, nurses, physical/occupational therapists, behavioral health providers) participating in psychosocial assessment and referral. 1

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Topic 6: Perioperative Safety in Orthopedic Trauma Surgery

Aerosol Risk Mitigation

Orthopedic procedures carry increased aerosol transmission risk compared to other surgical specialties due to power tool use, requiring specific protective protocols. 1

Essential Operating Room Protocols 1:

• Use N95 respirators with face shields (reusable shields acceptable)
• Do NOT use pulse lavage (high aerosol generation)
• Limit personnel during high-risk periods (intubation/extubation)
• Use electrocautery with smoke evacuator
• Maximize absorbable sutures
• Use clear dressings for remote wound assessment
• Prefer splints and removable casts over circumferential casts

Minimizing Postoperative Imaging 1:

A 2018 systematic review found immediate postoperative imaging provides only 0.22% absolute benefit in identifying complications - avoid imaging that will not change management. 1

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Topic 7: Open Fracture Management - Modern Protocols

Streamlined Approach to Reduce Procedures

For open fractures, consider washout with application of windowed cast rather than multiple staged procedures. 1

Key Management Principles 1:

• Minimize total number of procedures
• Place PICC line at time of initial surgery for prolonged antibiotic therapy
• Keep imaging to minimum - choose single most useful modality
• Consider at-home intravenous antibiotic treatment when feasible
• Reduce emergency department to operating room for dislocations whenever possible
• Manage as day surgery if admission required for reduction

Septic Arthritis and Osteomyelitis 1:

These conditions with subperiosteal collections require operative surgery and ongoing inpatient management, but aim to minimize repeat procedures through comprehensive initial treatment. 1