JAAOS

JAAOS, Volume 10, No. 2


Communication.

    • Keywords:
    • Communication|Humans|Orthopedics|Physician-Patient Relations

    • Subspecialty:
    • General Orthopaedics

    • Clinical Practice Improvement

Duchenne muscular dystrophy.

Duchenne muscular dystrophy is an X-linked disease of muscle caused by an absence of the protein dystrophin. Affected boys begin manifesting signs of disease early in life, cease walking at the beginning of the second decade, and usually die by age 20 years. Until treatment of the basic genetic defect is available, medical, surgical, and rehabilitative approaches can be used to maintain patient function and comfort. Corticosteroids, including prednisone and a related compound, deflazacort, have recently been shown to markedly delay the loss of muscle strength and function in boys with Duchenne muscular dystrophy. Surgical release of lower extremity contractures may benefit some patients. Approximately 90% of boys with Duchenne muscular dystrophy will develop severe scoliosis, which is not amenable to control by nonsurgical means such as bracing or adaptive seating. The most effective treatment for severe scoliosis is prevention by intervening with early spinal fusion utilizing segmental instrumentation as soon as curves are ascertained and before the onset of severe pulmonary or cardiac dysfunction.

    • Keywords:
    • Animals|Anti-Inflammatory Agents|Contracture|Creatine Kinase|Disease Progression|Dystrophin|Gait|Glucocorticoids|Humans|Knee Joint|Male|Muscular Dystrophy

    • Duchenne|Physical Examination|Physical Therapy Modalities|Pregnenediones|Prognosis|Range of Motion

    • Articular|Scoliosis|Spinal Fusion

    • Subspecialty:
    • Pediatric Orthopaedics

Evaluation of pain in patients with apparently solidly fixed total hip arthroplasty components.

The cause of pain in a patient with an apparently solidly fixed total hip arthroplasty can be difficult to elucidate. A detailed history, careful examination, and plain radiographs provide the most useful information, especially in excluding causes not primarily related to the hip. Determining whether the pain is related to the implant, to soft tissue, or to bone can require laboratory tests, radiographic and fluoroscopic imaging, and contrast arthrography and local anesthetic injections. Particularly when pain is caused by occult infection, erythrocyte sedimentation rate, C-reactive protein level, hip aspiration, advanced radiologic imaging, and nuclear medicine scans can help determine the diagnosis.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Hip|Blood Sedimentation|Bone and Bones|C-Reactive Protein|Hip Joint|Hip Prosthesis|Humans|Pain

    • Postoperative|Physical Examination|Prosthesis-Related Infections|Radiopharmaceuticals|Technetium Tc 99m Medronate

    • Subspecialty:
    • Adult Reconstruction

Minimally invasive techniques for the treatment of intervertebral disk herniation.

Hemilaminectomy with diskectomy, the original surgical option to address intervertebral disk herniation, was superseded by open microdiskectomy, a less invasive technique recognized as the surgical benchmark with which minimally invasive spine surgery techniques have been compared as they have been developed. These minimally invasive surgical techniques for patients with herniated nucleus pulposus and radiculopathy include laser disk decompression, arthroscopic microdiskectomy, laparoscopic techniques, foraminal endoscopy, and microendoscopic diskectomy. Each has its own complications and requires a long learning curve to develop familiarity with the technique. Patient selection, and especially disk morphology, are the most important factors in choice of technique. The optimal candidate has a previously untreated single-level herniation with limited migration or sequestration of free fragments.

    • Keywords:
    • Decompression

    • Surgical|Diskectomy|Humans|Intervertebral Disk Chemolysis|Intervertebral Disk Displacement|Laminectomy|Laparoscopy|Magnetic Resonance Imaging|Surgical Procedures

    • Minimally Invasive

    • Subspecialty:
    • Spine

Pain management after major orthopaedic surgery: current strategies and new concepts.

Several recently developed analgesic techniques effectively control pain after major orthopaedic surgery. Neuraxial analgesia provided by epidural and spinal administration of local anesthetics and opioids provides the highest level of pain control; however, such therapy is highly invasive and labor intensive. Neuraxial analgesia is contraindicated in patients receiving low-molecular-weight heparin. Continuous plexus and peripheral neural blockades offer excellent analgesia without the side effects associated with neuraxial and parenteral opioids. Intravenous patient-controlled analgesia allows patients to titrate analgesics in amounts proportional to perceived pain stimulus and provide improved analgesic uniformity. Oral sustained-release opioids offer superior pain control and greater convenience than short-duration agents provide. Opioid dose requirements may be reduced by coadministration of COX-2-type nonsteroidal analgesics.

    • Keywords:
    • Analgesia|Analgesia

    • Epidural|Analgesia

    • Patient-Controlled|Analgesics

    • Opioid|Cyclooxygenase Inhibitors|Humans|Nerve Block|Orthopedic Procedures|Oxycodone|Pain

    • Postoperative

    • Subspecialty:
    • General Orthopaedics

    • Pain Management

Physician-patient communication: a lost art?

In the face of rapid advances in technology, there has been a progressive deterioration of effective physician-patient communication. The American Academy of Orthopaedic Surgeons has identified that patients rate the orthopaedic profession as high in technical and low in communication skills. Poor communication, especially patient-interviewing skills, has been identified in medical students as well as in practicing physicians. Effective communication is associated with improved patient and physician satisfaction, better patient compliance, improved health outcomes, better-informed medical decisions, and reduced malpractice suits, and it likely contributes to reduced costs of care. Recognition of the importance of communication has influenced medical schools to revise curricula and to teach communication skills in residency training and continuing medical education programs. National certifying examinations also are being designed to incorporate these skills. Although written material is useful in increasing awareness of the importance of good physician-patient communication, behavioral change is more likely to occur in a workshop environment. The American Academy of Orthopaedic Surgeons is taking leadership in designing and implementing such an approach for its membership.

    • Keywords:
    • Adult|Aged|Communication|Counseling|Decision Making|Female|Humans|Male|Middle Aged|Orthopedics|Patient Satisfaction|Physician-Patient Relations

    • Subspecialty:
    • General Orthopaedics

    • Clinical Practice Improvement

Posttraumatic elbow stiffness: evaluation and management.

Posttraumatic elbow stiffness is a common problem that is often difficult to manage. The goal of treatment is to restore a functional range of elbow motion (> or =30 degrees to 130 degrees ). Nonsurgical treatment includes physical therapy and splinting. If nonsurgical treatment has failed, the type of surgical treatment required depends on the extent of degenerative changes. When degenerative changes are absent or mild, soft-tissue release offers reliable increases in elbow motion. When moderate degenerative changes exist within the joint, debridement arthroplasty of osteophytes and soft tissue has shown some success with increase in joint motion. With advanced degenerative changes, the therapeutic options are more limited. Results from biologic resurfacing arthroplasty are unpredictable, and total elbow arthroplasty should be reserved for the lower-demand elbow in a physiologically older individual.

    • Keywords:
    • Algorithms|Arthroplasty|Arthroscopy|Debridement|Elbow Joint|Fibrosis|Humans|Ossification

    • Heterotopic|Range of Motion

    • Articular

    • Subspecialty:
    • Trauma

    • Shoulder and Elbow

    • Hand and Wrist

Saphenous neuritis: a poorly understood cause of medial knee pain.

Saphenous neuritis is a painful condition caused by either irritation or compression at the adductor canal or elsewhere along the course of the saphenous nerve. The condition also may be associated with surgical or nonsurgical trauma to the nerve, especially at the medial or anterior aspect of the knee. Saphenous neuritis can imitate other pathology around the knee, particularly a medial meniscal tear or osteoarthritis. Unrecognized saphenous neuritis can confuse the patient's clinical picture, complicate treatment, and compromise results. As an isolated entity, saphenous neuritis may appear in conjunction with other common problems, such as osteoarthritis and patellofemoral pain syndrome, and it can have an indolent and protracted course. Its clinical appearance is characterized by allodynia along the course of the saphenous nerve. The diagnosis is confirmed by relief of symptoms after injection of the affected area with local anesthetic. Initial treatment can include non-surgical symptomatic care, treatment of associated pathology, and diagnostic or therapeutic injections of local anesthetic. In recalcitrant cases, surgical decompression and neurectomy are potential options. The key to treatment is prompt recognition; palpation of the saphenous nerve should be part of every routine examination of the knee.

    • Keywords:
    • Decompression

    • Surgical|Humans|Knee|Nerve Compression Syndromes|Neuritis|Pain

    • Subspecialty:
    • Sports Medicine

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