JAAOS

JAAOS, Volume 1, No. 1


Carpal Instability: Evaluation and Treatment.

Carpal instability is a common cause of wrist pain, motion loss, and disability. Diagnosis and treatment of carpal instability are dependent on a clear understanding of wrist anatomy and carpal kinematics, both normal and pathologic, as well as their relation to the current concepts regarding management. A brief review of anatomy and normal kinematics is presented, followed by a detailed discussion of specific instability patterns, including pathomechanics. A treatment algorithm is provided, detailing the authors' preferred treatment for the most common instability patterns.

      • Subspecialty:
      • Hand and Wrist

      • Basic Science

    Glenohumeral Instability: Evaluation and Treatment.

    Glenohumeral instability encompasses a spectrum of disorders of varying degree, direction, and etiology. The keys to accurate diagnosis are a thorough history and physical examination. Plain radiographs are frequently negative, especially in subtle forms of instability. Computed tomography (CT), CT arthrography, magnetic resonance imaging, arthroscopy, and examination under anesthesia may occasionally yield important diagnostic information. Nonoperative treatment of shoulder instability consists of reduction of the joint (when necessary), followed by immobilization and rehabilitative exercises. The length and the value of immobilization remain controversial. Rehabilitative programs emphasize strengthening f the dynamic stabilizers of the shoulder, particularly the rotator cuff muscles. Both arthroscopic and open techniques can be used for operative stabilization of the glenohumeral joint. Results of these repairs are assessed not only in terms of recurrence rate, but also in terms of functional criteria, including return to athletics. Some standard repairs have declined in popularity, giving way to procedures that directly address the pathology of detached or excessively lax capsular ligaments without distorting surrounding anatomy. Capsular repairs also allow correction of multiple components of instability.

        • Subspecialty:
        • Trauma

        • Sports Medicine

        • Shoulder and Elbow

      Meniscus Tears: Treatment in the Stable and Unstable Knee.

      Basic science research and follow-up studies after meniscectomy have provided convincing evidence of the importance of preservation of the meniscus in decreasing the risk of late degenerative changes. Whether in a stable or an unstable knee, if a meniscus tear cannot be repaired, a conservative partial meniscectomy should be undertaken to preserve as much meniscal tissue as possible. When feasible, repair should be carried out in young patients with an isolated meniscus tear, despite healing rates that are significantly lower than those obtained when meniscus repair is done with anterior cruciate ligament (ACL) reconstruction. The incidence of successful healing is inversely related to the rim width and tear length. In general, meniscus repair should be limited to patients under 50 years of age. Vertical longitudinal tears, including bucket-handle tears, are most amenable to repair. Some radial split tears can be repaired. In an ACL-deficient knee, meniscus repair is more prone to failure if not performed in conjunction with an ACL reconstruction, and is not recommended. Meniscal allograft surgery is investigational but may hold promise for selected patients.

          • Subspecialty:
          • Trauma

          • Sports Medicine

        Osteoporosis: The Role of the Orthopaedist.

        Osteoporosis is one of the most prevalent musculoskeletal disorders encountered in orthopaedic practice today. This review provides an update on the pathophysiology of bone metabolism leading to osteoporosis, describes the latest methodology in the diagnostic workup of patients with low bone mass, and summarizes the current status of osteoporosis treatment regimens. The special needs of the osteoporotic fracture patient are also addressed. In general, load-sharing devices and sliding nail-plate constructs are preferred over rigid internal-fixation systems. Prolonged immobilization should be avoided.

            • Subspecialty:
            • Trauma

            • Spine

            • Basic Science

          Percutaneous Lumbar Diskectomy.

          The development of an approach for percutaneous lumbar diskectomy (PLD) began over 20 years ago. Since then, clinical investigations of manual and automated PLD techniques have recorded an average success rate of 50% to 70%. Currently, the indications for PLD include (1) a major complaint of acute unilateral leg pain localized to a single dermatome associated witha a single-disk herniation; (2) neurologic signs or symptoms appropirate to a single-disk herniation; (3) magnetic resonance imaginng, computed tomographic, or diskographic evidence of a single herniation contained within the annulus of the lumbar disk; and (4) failure of a well-managed course of conservative treatment to relive the pain and symptoms. Conventional laminotomy/laminectomy, with or without the use of a microscope or surgical loupes, remains the usual method of surgical care for symptomatic lumbar disk disease. The role of PLD awaits further prospective randomized controlled studies.

              • Subspecialty:
              • Trauma

              • Spine

              • Pain Management

            Symptomatic Valgus Knee: The Surgical Options.

            Valgus knee deformities requiring surgery are difficult to manage due to the relative rarity and abnormal biomechanics of the condition and the unique soft-tissue and osseous pathologic features. Surgical options include arthroscopic debridement, abrasion arthroplasty, proximal tibial varus osteotomy, distal femoral varus osteotomy, combined femoral-tibial varus osteotomy, unicompartmental knee arthroplasty, and total knee arthroplasty. Each procedure has its own indications, contraindications, and limitations.

                • Subspecialty:
                • Sports Medicine

                • Adult Reconstruction

              Total Joint Replacement: Optimizing Patient Expectations.

              Rehabilitation of the patient who has undergone total hip or knee replacement embraces many facets of care, including prevention of complications, patient education, and a program of gradual resumption of normal functions. This program may be divided into three phases. In the perioperative phase, elimination of factors that contribute to morbidity will facilitate resumption of physical activities. In the interim phase (the first year following surgery), the patient's desire to return to full activities must be tempered by the goal of preserving for the longest possible time the mechanical-biologic construct of the joint replacement. Although a final functional result is usually achieved in the first 2 to 3 years following surgery, the patient must be followed up indefinitely. During this third phase of long-term assessment, the question of whether total joint arthroplasty was a success must be answered by the surgeon, by the patient, and by society.

                  • Subspecialty:
                  • Adult Reconstruction

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