JAAOS

JAAOS, Volume 10, No. 3


A practical guide to gait analysis.

The act of walking involves the complex interaction of muscle forces on bones, rotations through multiple joints, and physical forces that act on the body. Walking also requires motor control and motor coordination. Many orthopaedic surgical procedures are designed to improve ambulation by optimizing joint forces, thereby alleviating or preventing pain and improving energy conservation. Gait analysis, accomplished by either simple observation or three-dimensional analysis with measurement of joint angles (kinematics), joint forces (kinetics), muscular activity, foot pressure, and energetics (measurement of energy utilized during an activity), allows the physician to design procedures tailored to the individual needs of patients. Motion analysis, in particular gait analysis, provides objective preoperative and postoperative data for outcome assessment. Including gait analysis data in treatment plans has resulted in changes in surgical recommendations and in postoperative treatment. Use of these data also has contributed to the development of orthotics and new surgical techniques.

    • Keywords:
    • Adult|Biomechanics|Child

    • Preschool|Female|Gait|Humans|Male|Walking

    • Subspecialty:
    • Foot and Ankle

    • Pediatric Orthopaedics

    • Basic Science

Gabapentin.

    • Keywords:
    • Acetic Acids|Amines|Analgesics|Cyclohexanecarboxylic Acids|Humans|Neuralgia|Pain|gamma-Aminobutyric Acid

    • Subspecialty:
    • General Orthopaedics

    • Pain Management

Management of hip disorders in patients with cerebral palsy.

Hip disorders are common in patients with cerebral palsy and cover a wide clinical spectrum, from the hip at risk to subluxation, dislocation, and dislocation with degeneration and pain. Although the hip is normal at birth, a combination of muscle imbalance and bony deformity leads to progressive dysplasia. The spasticity or contracture usually involves the adductor and iliopsoas muscles; thus, the majority of hips subluxate in a posterosuperior direction. Many patients with untreated dislocations develop pain by early adulthood. Because physical examination alone is unreliable, an anteroposterior radiograph of the pelvis is required for diagnosis. Soft-tissue lengthening is recommended for children as soon as discernable hip subluxation (hip abduction <30 degrees, migration index >25%) is recognized. One-stage comprehensive hip reconstruction is effective treatment for children 4 years of age or older who have a migration index >60% but who have not yet developed advanced degenerative changes of the femoral head. Salvage options for the skeletally mature patient with a neglected hip are limited.

    • Keywords:
    • Adolescent|Adult|Cerebral Palsy|Child|Child

    • Preschool|Hip Joint|Humans|Joint Diseases|Orthopedic Procedures

    • Subspecialty:
    • Pediatric Orthopaedics

Meniscal injury: I. Basic science and evaluation.

The patient with meniscal injury may present with pain, swelling, or mechanical symptoms and often requires surgical intervention for symptom resolution. Treatment of such injuries relies on understanding the gross and microanatomic features of the meniscus that are important in maintaining meniscal function. The ability of the meniscus to participate in load bearing, shock absorption, joint lubrication, and joint stability depends on the maintenance of its structural integrity. The diagnosis of meniscal injury often can be made by clinical evaluation utilizing the history, physical examination, and plain radiographs. Magnetic resonance imaging can be useful in confirming the diagnosis when clinical findings are inconclusive. Treatment depends on tear pattern, vascularity, and an assessment of tissue quality. Surgical decision making for the treatment of meniscal injury is based on patient factors and understanding of the meniscal structure, function, and pathology.

    • Keywords:
    • Humans|Knee Injuries|Knee Joint|Menisci

    • Tibial

    • Subspecialty:
    • Sports Medicine

Meniscal injury: II. Management.

Meniscal repair is a viable alternative to resection in many clinical situations. Repair techniques traditionally have utilized a variety of suture methods, including inside-out and outside-in techniques. Bioabsorbable implants permit all-inside arthroscopic repairs. The success of meniscal repair depends on appropriate meniscal bed preparation and surgical technique and is also influenced by biologic factors such as tear rim width and associated ligamentous injury. Successful repair in >80% of cases has been reported in conjunction with anterior cruciate ligament reconstruction. Success rates are lower for isolated repairs. Complications related to repair include neurologic injury, postoperative loss of motion, recurrence of the tear, and infection. Meniscal allograft transplantation may provide a treatment option when meniscus salvage is not possible or when a previous total meniscectomy has been done.

    • Keywords:
    • Arthroscopy|Humans|Knee Injuries|Menisci

    • Tibial|Orthopedic Procedures|Transplantation

    • Homologous

    • Subspecialty:
    • Sports Medicine

Pedicled vascularized bone grafts for disorders of the carpus: scaphoid nonunion and Kienbock's disease.

The use of reverse-flow pedicled vascularized bone grafts from the dorsal distal radius makes it possible to transfer bone with a preserved circulation and viable osteoclasts and osteoblasts. The resultant primary bone healing without creeping substitution within the dead bone is an alternative to conventional bone grafting in aiding or accelerating healing, replacing deficient bone, and/or revascularizing ischemic bone. Recent advances in understanding the anatomy and physiology of vascularized pedicled bone grafts have increased their use in treating a variety of carpal maladies. A basic understanding of the vascular anatomy, as well as the surgical principles and experimental and clinical results of pedicled vascularized bone grafts from the dorsal distal radius, is critical to understanding the use of these grafts in the treatment of scaphoid nonunions and Kienbock's disease.

    • Keywords:
    • Bone Transplantation|Carpal Bones|Fractures

    • Ununited|Humans|Osteochondritis|Radius|Scaphoid Bone|Wrist

    • Subspecialty:
    • Trauma

    • Hand and Wrist

Single-stage bilateral total hip arthroplasty.

The number of single-stage bilateral total hip arthroplasties done each year is increasing. The risk of postoperative complications in medically stable patients is acceptable; complications are approximately 1.3 times more frequent than with unilateral total hip arthroplasty. Although there are no absolute indications for a single-stage bilateral total hip arthroplasty, the procedure is usually contraindicated in patients with such comorbidities as heart disease, pulmonary insufficiency, or diabetes, and it is absolutely contraindicated in patients with a documented patent ductus arteriosus or septal defect. The primary postoperative concern is that the cardiopulmonary insult associated with two surgical wounds and surgeries can lead to an increase in thromboembolic events. The cost for single-stage bilateral total arthroplasty is less than that for a two-stage bilateral total hip arthroplasty, with savings predominantly due to reduced length of acute hospital stay. However, the decision to undergo single-stage bilateral total hip arthroplasty is one that must be made in concert with the patient.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Hip|Hip Joint|Humans|Joint Diseases

    • Subspecialty:
    • Adult Reconstruction

Spinal infections.

Spinal infections can occur in a variety of clinical situations. Their presentation ranges from the infant with diskitis who is unwilling to crawl or walk to the adult who develops an infection after a spinal procedure. The most common types of spinal infections are hematogenous bacterial or fungal infections, pediatric diskitis, epidural abscess, and postoperative infections. Prompt and accurate diagnosis of spinal infections, the cornerstone of treatment, requires a high index of suspicion in at-risk patients and the appropriate evaluation to identify the organism and determine the extent of infection. Neurologic function and spinal stability also should be carefully evaluated. The goals of therapy should include eradicating the infection, relieving pain, preserving or restoring neurologic function, improving nutrition, and maintaining spinal stability.

    • Keywords:
    • Adult|Bone Diseases

    • Infectious|Child|Discitis|Epidural Abscess|Humans|Osteomyelitis|Spinal Diseases|Tuberculosis

    • Spinal

    • Subspecialty:
    • Pediatric Orthopaedics

    • Spine

    • General Orthopaedics

Total ankle arthroplasty.

First-generation total ankle arthroplaty designs had unacceptably high complication and failure rates compared with ankle arthrodesis. More recent prostheses have had encouraging intermediate results because of refined surgical techniques and improved designs. Mobile-bearing designs theoretically offer less wear and loosening through full conformity and minimal constraint. The less complex fixed-bearing designs avoid bearing dislocation and the potential for added wear from a second articulation. Four second-generation designs have demonstrated reasonable functional outcomes: the Scandinavian Total Ankle Replacement, the Agility Ankle, the Buechel-Pappas Total Ankle Replacement, and the TNK ankle. Intermediate results are promising but should be interpreted with care.

    • Keywords:
    • Ankle Joint|Arthroplasty

    • Replacement|Forecasting|Humans|Joint Diseases|Joint Prosthesis

    • Subspecialty:
    • Trauma

    • Foot and Ankle

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