JAAOS

JAAOS, Volume 10, No. 4


Classification systems in orthopaedics.

Classification systems help orthopaedic surgeons characterize a problem, suggest a potential prognosis, and offer guidance in determining the optimal treatment method for a particular condition. Classification systems also play a key role in the reporting of clinical and epidemiologic data, allowing uniform comparison and documentation of like conditions. A useful classification system is reliable and valid. Although the measurement of validity is often difficult and sometimes impractical, reliability-as summarized by intraobserver and interobserver reliability-is easy to measure and should serve as a minimum standard for validation. Reliability is measured by the kappa value, which distinguishes true agreement of various observations from agreement due to chance alone. Some commonly used classifications of musculoskeletal conditions have not proved to be reliable when critically evaluated.

    • Keywords:
    • Classification|Humans|Musculoskeletal Diseases|Observer Variation|Orthopedics|Reproducibility of Results

    • Subspecialty:
    • Trauma

    • General Orthopaedics

Foot tumors: diagnosis and treatment.

Several large clinical series have demonstrated that benign and malignant tumors occur in the foot and ankle at a much higher rate than previously thought. Vigilance is warranted in investigating any foot mass, including those with an apparently indolent course. Although tumors in the foot tend to produce symptoms relatively early because of the foot's compact structure, many tumors are initially misdiagnosed. Given the comparatively small size of the anatomic compartments in the foot, tumors often present outside the original compartment, making timely diagnosis essential. Major treatment errors can be avoided if physicians consider the potential for malignancy when evaluating all foot masses. A high index of suspicion, an organized approach to diagnosis, and evaluation of and adherence to the basic principles of treatment of musculoskeletal neoplasms increase the likelihood of acceptable results.

    • Keywords:
    • Bone Neoplasms|Foot|Humans|Orthopedic Procedures|Soft Tissue Neoplasms

    • Subspecialty:
    • Foot and Ankle

    • Musculoskeletal Oncology

Hip arthrodesis: current indications and techniques.

The management of young adults with severe osteoarthritis of the hip remains a problem because of the increased failure rates of total hip arthroplasty (THA) as well as the prospect of multiple revisions in this population. Although hip arthrodesis is not perceived favorably as an alternative by most orthopaedic surgeons or patients because of the presumption of less than optimal functional outcomes, it is a viable technique, especially for younger patients with a recent history of local infection and/or trauma. With current internal fixation techniques, a fusion rate >80% can be achieved with maximal preservation of bone stock. Proper patient selection and optimal arthrodesis position (flexion of 20 degrees to 30 degrees, adduction of 5 degrees, external rotation of 5 degrees to 10 degrees, and limb-length discrepancy <2 cm) are essential for a successful, long-term result. Back and ipsilateral knee pain are the most common complaints leading to secondary conversion of a hip fusion to a THA. Symptoms improve markedly after conversion. Survivorship of the conversion THA is comparable to that of a primary THA when the patient is older than 50 years of age and multiple surgical procedures have been avoided. However, the procedure can be technically challenging and has a high risk of postoperative complications.

    • Keywords:
    • Adolescent|Adult|Age Factors|Aged|Aged

    • 80 and over|Arthrodesis|Arthroplasty

    • Replacement|Biomechanics|Gait|Hip Joint|Humans|Middle Aged|Osteoarthritis

    • Hip|Reoperation

    • Subspecialty:
    • Trauma

Idiopathic congenital talipes equinovarus.

The etiology of idiopathic congenital talipes equinovarus is unknown, and there is no consensus as to the best treatment. Increasingly, ultrasound is being used to diagnose the condition prenatally, but the diagnosis remains clinical postnatally. Radiographs can help confirm the diagnosis and ascertain the severity of the condition. There are many classification schemes, but none offers adequate prognostic value. The mainstay of treatment is manipulation and casting, usually followed by soft-tissue release. However, some patients have been successfully treated with intensive physiotherapy instead of surgery.

    • Keywords:
    • Biomechanics|Casts

    • Surgical|Clubfoot|Female|Foot|Humans|Infant

    • Newborn|Male|Musculoskeletal Manipulations|Orthopedic Procedures|Physical Examination|Postoperative Complications|Splints|Treatment Outcome

    • Subspecialty:
    • Foot and Ankle

    • Basic Science

The use of constrained components in total hip arthroplasty.

The use of a constrained component may be appropriate for the surgical treatment of recurrent dislocation due to soft-tissue insufficiency following a total hip arthroplasty. Constrained components usually include a locking mechanism incorporated into the polyethylene acetabular liner to keep the prosthetic femoral head in place. Two different prosthetic designs are available and have been approved by the U.S. Food and Drug Administration. The S-ROM constrained component uses additional polyethylene in the rim, which deforms to more fully capture the femoral head and then is held in place by a metal locking ring. The Howmedica Osteonics constrained component is a tripolar device; its bipolar component articulates with another polyethylene liner. These constrained components transfer hip forces that would otherwise lead to dislocation to the locking mechanism, the liner-shell interface, or the bone-prosthesis interface. These forces may eventually contribute to failure of the component due to loosening, dissociation, breakage, or recurrent dislocation. Studies of these components show a failure rate of 4% to 29% at relatively short-term follow-up.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Hip|Biocompatible Materials|Biomechanics|Dislocations|Hip Prosthesis|Humans|Polyethylene|Prosthesis Design|Prosthesis Failure|Recurrence|Treatment Outcome

    • Subspecialty:
    • Adult Reconstruction

    • Basic Science

Treatment of complex regional pain syndrome of the lower extremity.

Complex regional pain syndrome, formerly known as reflex sympathetic dystrophy or causalgia, is a difficult therapeutic problem for the orthopaedic surgeon treating an affected lower extremity. Despite many divergent and often conflicting theories, the cause of the severe pain, alterations in regional blood flow, and edema is unknown. Interventions that have proved successful for treating similar conditions in the arm and hand frequently do not relieve pain similarly in the lower extremity. Common treatment regimens target individual components of this symptom complex, namely, sympathetic or afferent nerve hyperactivity, vasomotor instability, or regional osteoporosis. Despite widespread use of some of these treatments, few controlled clinical trials quantify their effectiveness. This challenging syndrome is best managed by a multidisciplinary team, including chronic pain management specialists, physical therapists, and orthopaedic surgeons.

    • Keywords:
    • Complex Regional Pain Syndromes|Humans|Lower Extremity|Treatment Outcome

    • Subspecialty:
    • Foot and Ankle

    • Sports Medicine

Upper cervical spine injuries.

The unique anatomy of the upper cervical spine and the typical mechanisms of injury yield a predictable variety of injury patterns. Traumatic ligamentous injuries of the atlanto-occipital joint and transverse atlantal ligament are relatively uncommon, have a poor prognosis for healing, and often respond best to surgical stabilization. Bony injuries, including occipital condyle fractures, atlas fractures, most odontoid fractures, and traumatic spondylolisthesis of the axis, generally respond well to nonsurgical management. Controversy in management remains, however, especially with type II odontoid fractures.

    • Keywords:
    • Atlanto-Occipital Joint|Axis|Cervical Atlas|Cervical Vertebrae|Dislocations|Humans|Joint Instability|Ligaments|Occipital Bone|Odontoid Process|Skull Fractures|Spinal Fractures|Spinal Injuries|Spondylolisthesis

    • Subspecialty:
    • Trauma

    • Spine

Advertisements

Advertisement