JAAOS

JAAOS, Volume 10, No. 5


Arthroscopic management of osteoarthritis of the knee.

Recent advances in instrumentation and a growing understanding of the pathophysiology of osteoarthritis have led to increased use of arthroscopy for the management of degenerative arthritis of the knee. Techniques include lavage and dbridement, abrasion arthroplasty, subchondral penetration procedures (drilling and microfracture), and laser/thermal chondroplasty. In most patients, short-term symptomatic relief can be expected with arthroscopic lavage and débridement. Greater symptomatic relief and more persistent pain relief can be achieved in patients who have acute onset of pain, mechanical disturbances from cartilage or meniscal fragments, normal lower extremity alignment, and minimal radiographic evidence of degenerative disease. Arthroscopic chondroplasty techniques provide unpredictable results. Concerns include the durability of the fibrocartilage repair tissue in subchondral penetration procedures and thermal damage to subchondral bone and adjacent normal articular cartilage in laser/thermal chondroplasty. Although recent prospective, randomized, double-blinded studies have demonstrated that outcomes after arthroscopic lavage or débridement were no better than placebo procedure for knee osteoarthritis, controversy still exists. With proper selection, patients with early degenerative arthritis and mechanical symptoms of locking or catching can benefit from arthroscopic surgery.

    • Keywords:
    • Arthroplasty|Arthroscopy|Cartilage

    • Articular|Debridement|Humans|Irrigation|Menisci

    • Tibial|Osteoarthritis

    • Knee|Prognosis

    • Subspecialty:
    • Sports Medicine

    • Adult Reconstruction

Classifications of thoracic and lumbar fractures: rationale and supporting data.

Classification systems are generalizations that attempt to identify common attributes within a group to predict behavior or outcome without sacrificing too much detail. Because of the inherent variability of fractures, classifying them can be difficult. To properly apply any of the commonly cited classification schemes for thoracic and lumbar fractures, one must not only know the injury categories described in the original studies but also be familiar with the rationale for developing the classification. Many original reports describing common thoracic and lumbar injury classifications lack a rigorous scientific foundation. They were based largely on the insights of experienced surgeons and researchers. Although the ideal classification for thoracic and lumbar fractures does not exist, it would incorporate neurologic as well as structural factors. Standardization of terminology as related to treatment decisions and prognosis is key to an improved understanding of the clinical behavior of these injuries and identification of optimal treatment options.

    • Keywords:
    • Dislocations|Humans|Joint Instability|Lumbar Vertebrae|Spinal Fractures|Spinal Injuries|Thoracic Vertebrae

    • Subspecialty:
    • Trauma

    • Spine

Fractures around the knee in children.

Traumatic forces applied to the immature knee result in fracture patterns different from those in adults. The relative abundance of cartilage in the knee of the growing child may make the diagnosis of certain injuries more challenging. If plain radiographs fail to reveal a fracture, a stress radiograph, computed tomography scan, or magnetic resonance imaging study may help to establish the diagnosis. Certain fractures, such as hyperextension injuries to the distal femoral or proximal tibial epiphysis, or displaced tibial tuberosity fractures, may be especially susceptible to neurovascular problems. Although the use of appropriate treatment techniques may minimize the occurrence of late complications such as malunion and physeal bridging, not all problems are preventable. A careful discussion of the injury with both patient and parents should stress the importance of follow-up so that any problems that do occur can be promptly addressed.

    • Keywords:
    • Child|Femoral Fractures|Humans|Knee Injuries|Patella|Tibial Fractures|Treatment Outcome

    • Subspecialty:
    • Trauma

    • Pediatric Orthopaedics

Musculoskeletal manifestations of human immunodeficiency virus infection.

Musculoskeletal manifestations of the human immunodeficiency virus (HIV) are common and are sometimes the initial presentation of the disease. Knowledge of the conditions affecting muscle, bone, and joints in HIV-infected patients is essential for successful management. Myopathies may be caused by pyogenic infection (eg, pyomyositis), idiopathic inflammation (eg, polymyositis), or drug effect (eg, AZT myopathy). Characteristic skeletal infections, such as tuberculosis and bacillary angiomatosis, require a high index of suspicion for accurate diagnosis. Neoplastic processes, such as non-Hodgkin's lymphoma and Kaposi's sarcoma, occur more frequently as the immune system deteriorates. Inflammatory and reactive arthropathies are more prevalent in HIV-positive than HIV-negative individuals and include Reiter's syndrome, psoriatic arthritis, HIV-associated arthritis, painful articular syndrome, acute symmetric polyarthritis, and hypertrophic osteoarthropathy. Patients with atypical musculoskeletal complaints and a suspected history of exposure should be tested for HIV.

    • Keywords:
    • Angiomatosis

    • Bacillary|Arthritis

    • Infectious|Arthritis

    • Psoriatic|Arthritis

    • Reactive|HIV Infections|Humans|Lymphoma

    • Non-Hodgkin|Musculoskeletal Diseases|Myositis|Osteomyelitis|Osteonecrosis|Polymyositis|Tuberculosis

    • Osteoarticular

    • Subspecialty:
    • General Orthopaedics

    • Musculoskeletal Oncology

New techniques in wound management: vacuum-assisted wound closure.

Vacuum-assisted wound closure (VAC) is a wound management technique that exposes the wound bed to negative pressure by way of a closed system. Edema fluid is removed from the extravascular space, thus eliminating an extrinsic cause of microcirculatory embarrassment and improving blood supply during this phase of inflammation. In addition, the mechanical tension from the vacuum may directly stimulate cellular proliferation of reparative granulation tissue. Orthopaedic indications for VAC include traumatic wounds after d?bridement, infection after d?bridement, and fasciotomy wounds for compartment syndrome. VAC also can be used as a dressing for anchoring an applied split-thickness skin graft. The technique is contraindicated in patients with thin, easily bruised or abraded skin; those with neoplasm as part of the wound floor; and those with allergic reactions to any of the components that contact the skin. Clinical experience with the technique has resulted in a low incidence of minor, reversible irritation to surrounding skin and no major complications. Further experience is required, as well as clinical and basic research, to define optimal indications and benefits compared with traditional methods of wound management.

    • Keywords:
    • Atmospheric Pressure|Debridement|Humans|Soft Tissue Injuries|Surgical Sponges|Vacuum|Wound Healing|Wounds and Injuries

    • Subspecialty:
    • Trauma

    • General Orthopaedics

Surgical treatment of developmental dysplasia of the hip in adults: I. Nonarthroplasty options.

Hip dysplasia is a developmental disorder that results in anatomic abnormalities leading to increased contact pressure in the joint and, eventually, coxarthrosis. However, many patients with hip dysplasia become symptomatic before the development of severe degenerative changes because of abnormal hip biomechanics, mild hip instability, impingement, or associated labral pathology. Several nonarthroplasty treatment options are available. Because the primary deformity is mostly acetabular, for many patients, a reconstructive osteotomy that restores more nearly normal pelvic anatomy is preferable. The Bernese periacetabular osteotomy is presently favored because it provides good correction while creating little secondary pelvic deformity or destabilizing the pelvis. Proximal femoral osteotomy is occasionally needed as a complement to pelvic osteotomy and may also be indicated as an isolated procedure when most deformity is located on the femoral side (coxa valga subluxans). Arthroscopy can be beneficial when symptoms seem to be related only to labral tears or loose bodies in the absence of severe structural abnormalities about the hip. Fusion and resection arthroplasty are rarely indicated and are reserved for occasional patients who are not candidates for total hip replacement or other procedures but who complain of refractory hip pain.

    • Keywords:
    • Acetabulum|Adult|Arthrodesis|Arthroscopy|Debridement|Femur|Hip Dislocation|Humans|Osteotomy|Treatment Outcome

    • Subspecialty:
    • Trauma

    • Adult Reconstruction

    • Pain Management

    • Basic Science

Surgical treatment of developmental dysplasia of the hip in adults: II. Arthroplasty options.

Total hip arthroplasty is the procedure of choice for most patients with symptomatic end-stage coxarthrosis secondary to hip dysplasia. The anatomic abnormalities associated with the dysplastic hip increase the complexity of hip arthroplasty. When pelvic bone stock allows, it is desirable to reconstruct the socket at or near the normal anatomic acetabular location. To obtain sufficient bony coverage of the acetabular component, the socket can be medialized or elevated, or a lateral bone graft can be applied. Uncemented acetabular components allow biologic fixation with potentially improved results compared with cemented cups, especially in young patients. The location of the acetabular reconstruction and the desired leg length influence the type of femoral reconstruction. Cemented and uncemented implants can be used in femoral reconstruction, depending on the clinical situation. Femoral shortening is required in some cases and can be performed by metaphyseal resection with a greater trochanteric osteotomy and advancement or by a shortening subtrochanteric osteotomy. The results of total hip arthroplasty demonstrate a high rate of pain relief and functional improvement. The long-term durability of cemented total hip arthroplasty reconstruction in these patients is inferior to that in the general population. The results of uncemented implants are promising, but only limited early and midterm data are available.

    • Keywords:
    • Acetabulum|Adult|Arthroplasty

    • Replacement

    • Hip|Cementation|Femur|Hip Dislocation|Hip Prosthesis|Humans|Osteotomy|Treatment Outcome

    • Subspecialty:
    • Adult Reconstruction

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