JAAOS

JAAOS, Volume 10, No. 1


Bone mineral density deficiency in children.

With the development of improved diagnostic and treatment options, reduced bone mineral density in children is receiving increased attention. The etiology of osteopenia in healthy children is multifactorial and incompletely understood, but poor calcium intake during the adolescent growth spurt may be an important (and potentially reversible) factor. Other clinically relevant causes of reduced bone mineral density in children include osteogenesis imperfecta, rickets, juvenile rheumatoid and other chronic arthritides, osteopenia associated with neuromuscular disorders, and idiopathic osteoporosis. To provide effective treatment, it is important to understand the process of normal skeletal mineralization, the techniques of bone mineral density measurement, the pathophysiology of osteopenia, and the evaluation and treatment options for the general pediatric population as well as for patients with specific pediatric disorders.

    • Keywords:
    • Arthritis

    • Juvenile Rheumatoid|Bone Density|Bone Development|Bone Diseases

    • Metabolic|Child|Fractures

    • Spontaneous|Humans|Neuromuscular Diseases|Osteogenesis Imperfecta|Osteomalacia|Osteoporosis|Rickets|Risk Factors

    • Subspecialty:
    • Pediatric Orthopaedics

    • Basic Science

Current status of scapholunate interosseous ligament injuries.

Injuries to the scapholunate complex present the surgeon with both diagnostic and treatment dilemmas. The anatomic features, biomechanical properties, radiographic appearance, and surgical treatment algorithms of this small but structurally and kinematically important joint continue to be refined. A thorough history and physical examination, combined with a radiographic evaluation that can include plain radiographs, tomography, motion studies, arthrography, or MRI, usually will define the nature of the ligament injury. Arthroscopy is considered the gold standard for complete evaluation of scapholunate interosseous ligament injury and often is performed as a first step before repair or reconstruction. Procedures such as carpal fusions or capsulodesis can limit excessive scaphoid motion, promote wrist stability, and potentially prevent arthritis, but advances continue to be made in direct scapholunate interosseous ligament reconstruction. Challenges for the future involve improving noninvasive evaluation, defining the degree of extrinsic ligament injury, and improving direct repair and reconstruction.

    • Keywords:
    • Arthroscopy|Humans|Ligaments

    • Articular|Lunate Bone|Magnetic Resonance Imaging|Scaphoid Bone|Wrist Injuries|Wrist Joint

    • Subspecialty:
    • Hand and Wrist

    • Basic Science

Elder abuse: the role of the orthopaedic surgeon in diagnosis and management.

Increased awareness of elder abuse has led to the recognition that mistreatment of individuals over the age of 65 years is a widespread public health problem. It is estimated that the prevalence of elder abuse is 32 cases per 1,000 persons and is increasing with the growing elderly population. Elder abuse is suspected to be a major source of morbidity and mortality, representing a high economic burden to society. The diagnosis of elder abuse is seldom straightforward due to social issues, cognitive impairment, and comorbid conditions, and requires careful correlation of historical and clinical findings. Comprehensive evaluation, including a detailed history, systematic physical examination, and appropriate laboratory and radiographic assessment, is essential. The orthopaedic surgeon consulted to evaluate an elderly individual with musculoskeletal injuries must be cognizant of the potential for elder abuse, especially when circumstances are suspect. The role of the orthopaedic surgeon is often fundamental to establishing whether musculoskeletal injuries are consistent with the stated mechanism of injury. Due to the variety of presentations, there are no fracture patterns considered pathognomonic of elder abuse. Rather, the nature and pattern of injury must be viewed in the context of the general health and psychosocial environment of the patient to determine whether abuse has occurred. Once the diagnosis of elder abuse has been made, a comprehensive, multidisciplinary long-term care plan must be formulated to ensure patient safety while respecting the autonomy of a competent individual. Physicians have an ethical and legal responsibility to protect patients from suspected abuse, and most states mandate reporting by health-care personnel.

    • Keywords:
    • Aged|Diagnosis

    • Differential|Elder Abuse|Hematologic Tests|Humans|Mandatory Reporting|Orthopedics|Physical Examination|Risk Factors

    • Subspecialty:
    • Trauma

    • Clinical Practice Improvement

Fluoroquinolones.

    • Keywords:
    • Anti-Infective Agents|Costs and Cost Analysis|Drug Interactions|Fluoroquinolones|Humans|Osteomyelitis|Pseudomonas Infections|Staphylococcal Infections

    • Subspecialty:
    • General Orthopaedics

    • Adult Reconstruction

Gene therapy and tissue engineering in orthopaedic surgery.

A new biologic era of orthopaedic surgery has been initiated by basic scientific advances that have resulted in the development of gene therapy and tissue engineering approaches for treating musculoskeletal disorders. The terminology, fundamental concepts, and current research in this burgeoning field must be understood by practicing orthopaedic surgeons. Different gene therapy approaches, multiple gene vectors, a multitude of cytokines, a growing list of potential scaffolds, and putative stem cells are being studied. Gene therapy and tissue engineering applications for bone healing, articular disorders, intervertebral disk pathology, and skeletal muscle injuries are being explored. Innovative methodologies that ensure patient safety can potentially lead to many new treatment strategies for musculoskeletal conditions.

    • Keywords:
    • Animals|Biocompatible Materials|Bone Development|Cartilage

    • Articular|Cell Transplantation|Cells

    • Cultured|Gene Therapy|Gene Transfer Techniques|Genetic Vectors|Humans|Intervertebral Disk|Ligaments

    • Articular|Muscle

    • Skeletal|Musculoskeletal Diseases|Orthopedics|Tissue Engineering

    • Subspecialty:
    • General Orthopaedics

Morphologic and mechanical basis of delayed-onset muscle soreness.

Muscle pain after unaccustomed exercise is believed to result from repetitive active lengthening of skeletal muscle. This "eccentric exercise" initiates a sequence of events that includes muscle cytoskeletal breakdown, inflammation, and remodeling such that subsequent exercise sessions result in less injury and soreness. Recent studies of eccentric exercise using well-defined animal models have identified the mechanical and cellular events associated with the injury-repair process. In addition, neurophysiologic studies have elucidated mechanisms of pain that operate in skeletal muscle. Taken together, these studies improve our understanding of the muscle injury process and will lead to rational therapeutic interventions to facilitate recovery.

    • Keywords:
    • Animals|Exercise|Humans|Muscle Contraction|Muscle Fibers

    • Skeletal|Muscle

    • Skeletal|Pain|Reflex

    • Subspecialty:
    • Sports Medicine

    • Basic Science

The optimal fixation of the cementless acetabular component in primary total hip arthroplasty.

The optimal fixation of the acetabular component in primary total hip arthroplasty remains controversial. Long-term follow-up studies show that significant loosening rates occur with cemented acetabular components and that these problems persist despite attempts to improve cementing technique. Cementless acetabular components that rely on biologic fixation can have lower rates of radiographic loosening at 10 years compared with cemented acetabular components. Although revision rates for both modes of fixation are largely equivalent at 10 years, the superior radiographic performance of cementless acetabular components at 10 years suggests that biologic fixation through bone ingrowth may provide more durable long-term implant survival compared with cemented fixation. Osteolysis is the major obstacle to long-term cementless acetabular component survival. Potential future options that may inhibit osteolysis include decreasing bone resorption that results from debris-stimulated foreign body response through the use of medications; decreasing the number of particles generated by using alternative bearing surfaces; and improving bone ingrowth, particularly through the use of growth factors and improved implant materials and designs.

    • Keywords:
    • Acetabulum|Arthroplasty

    • Replacement

    • Hip|Bone Screws|Cementation|Chromium Alloys|Coated Materials

    • Biocompatible|Durapatite|Hip Prosthesis|Humans|Osteolysis|Porosity|Prosthesis Design|Prosthesis Failure|Titanium

    • Subspecialty:
    • Adult Reconstruction

    • Basic Science

Total knee arthroplasty in the valgus knee.

The valgus knee presents a unique set of problems that must be addressed during total knee arthroplasty. Both bone and soft-tissue deformities complicate restoration of proper alignment, positioning of components, and attainment of joint stability. The variables that may need to be addressed include lateral femoral condyle or tibial plateau deficiencies secondary to developmental abnormalities, and/or wear; primary or acquired contracture of the lateral capsular and ligamentous structures; and, occasionally, laxity of the medial collateral ligament. Understanding the specific pathologic anatomy associated with the valgus knee is a prerequisite to selecting the proper surgical method to optimize component position and restore soft-tissue balance.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Knee|Humans|Joint Deformities

    • Acquired|Knee Joint

    • Subspecialty:
    • Adult Reconstruction

    • Basic Science

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