JAAOS

JAAOS, Volume 10, No. 6


Arthrogryposis and amyoplasia.

Arthrogryposis (multiple congenital joint contractures) is an uncommon problem. Because there are many causes, correct diagnosis is important to predict the natural history and determine appropriate treatment. Inconsistent terminology has caused confusion about both diagnosis and treatment. Amyoplasia, the most common type of arthrogryposis, is characterized by quadrimelic involvement and replacement of skeletal muscle by dense fibrous tissue and fat. Early physical therapy and splinting may improve contractures, but surgical intervention is often necessary. Aggressive soft-tissue releases in addition to casting may improve joint position. In more severe contractures, osseous surgery also may be needed. Deformity recurrence is common, particularly in skeletally immature patients.

    • Keywords:
    • Arthrogryposis|Child|Clubfoot|Diagnosis

    • Differential|Hip Dislocation|Humans|Knee Joint|Physical Therapy Modalities|Scoliosis|Splints|Terminology as Topic

    • Subspecialty:
    • Pediatric Orthopaedics

Heterotopic ossification after hip and knee arthroplasty: risk factors, prevention, and treatment.

Symptomatic heterotopic ossification (HO) after total hip arthroplasty (THA) and total knee arthroplasty (TKA) is relatively rare. Patients at high risk for developing HO after THA include men with bilateral hypertrophic osteoarthritis, patients with a history of HO in either hip, and patients with posttraumatic arthritis characterized by hypertrophic osteophytosis. Patients at moderate risk are those with ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis, Paget's disease, or unilateral hypertrophic osteoarthritis. Patients at high risk for developing HO after TKA include those with limited postoperative knee flexion, increased lumbar bone mineral density, hypertrophic arthrosis, excessive periosteal trauma and/or notching of the anterior femur, and those who require forced manipulation after TKA. Preoperative radiation is effective for preventing HO after THA, as are post-operative prophylactic drug regimens and single-dose radiation treatments. Recurrence of HO after surgical excision should be expected unless prophylaxis is administered. Prophylactic measures against HO after THA and TKA should be administered before the fifth postoperative day, optimally within 24 to 48 hours.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Hip|Arthroplasty

    • Knee|Humans|Ossification

    • Heterotopic|Recurrence|Risk Factors

    • Subspecialty:
    • Adult Reconstruction

Perioperative blood management practices in elective orthopaedic surgery.

Concern about the cost and safety of allogenic blood transfusion, including the risk of viral infection and immunosuppression, has led to refinements in and new approaches to blood conservation, including the development of transfusion practice standards and improvements in surgical practice. Preoperative autologous blood collection, the use of hemostatic agents, perioperative blood salvage, and the use of recombinant human erythropoietin (epoetin alfa) to stimulate erythropoiesis have contributed to decreased use of allogenic blood services. Development of appropriate blood management strategies to help reduce or eliminate exposure to allogenic blood requires a preoperative assessment of the likelihood of transfusion and of the risks as well as costs associated with conservation and replacement options. The informed selection of alternatives based on preoperative assessment of hematologic status, estimated blood loss, and sources for blood replacement may enhance blood management practices in major elective orthopaedic surgery.

    • Keywords:
    • Anemia|Blood Loss

    • Surgical|Blood Transfusion|Epoetin Alfa|Hematinics|Hemodilution|Humans|Intraoperative Period|Orthopedic Procedures|Quality of Life|Surgical Procedures

    • Elective|Treatment Outcome

    • Subspecialty:
    • General Orthopaedics

    • Adult Reconstruction

    • Clinical Practice Improvement

Thigh pain after cementless total hip arthroplasty: evaluation and management.

Data from short- and long-term follow-up studies indicate that thigh pain is a significant complication after apparently successful cementless total hip arthroplasty. In most cases, reported symptoms are mild to moderate, resolve spontaneously or do not progress, and require little or no therapeutic intervention. However, persistent thigh pain may be a source of dissatisfaction or may present as severe, disabling pain. Possible causes include bone-prosthesis micromotion, excessive stress transfer to the femur, periosteal irritation, or a mismatch in Young's modulus of elasticity that increases the structural rigidity of the prosthetic stem relative to the femur. Thorough diagnostic evaluation of thigh pain is essential to rule out prosthetic infection or loosening, stress fracture, or spinal pathology as the primary source. Treatment options in the aseptic, well-fixed femoral component include medical management, revision of the femoral component, or cortical strut grafting at the tip of the implant.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Hip|Diagnosis

    • Differential|Hip Prosthesis|Osseointegration|Pain|Prosthesis Design|Reoperation|Thigh

    • Subspecialty:
    • Adult Reconstruction

    • Pain Management

Timing of closure of open fractures.

Traditionally, closure of open fractures after initial debridement has been delayed to minimize the risk of complications, particularly infection. This practice developed before the widespread use of systemic antibiotics, local antibiotic bead pouches, advanced debridement methods, and improved fracture stabilization techniques. Current evidence indicates that infections after treatment of open fractures frequently are not caused by initial contaminating organisms but often are acquired in the hospital. Recent studies comparing primary with delayed closure have not demonstrated an increased rate of complications. Considering the improvements in open fracture wound care, the increasing incidence of resistant nosocomial infections, and the cost implications of a dogmatic delayed-closure strategy, wound care protocols for open fractures should be reevaluated. Because of lack of data specifically addressing the timing of closure of such wounds, studies comparing primary versus delayed closure are needed.

    • Keywords:
    • Anti-Bacterial Agents|Antibiotic Prophylaxis|Cross Infection|Debridement|Fracture Fixation|Fractures

    • Open|Humans|Irrigation|Time Factors|Wound Infection

    • Subspecialty:
    • Trauma

    • Basic Science

Vascular problems of the upper extremity: a primer for the orthopaedic surgeon.

A focused history and thorough physical examination, combined with a working knowledge of the normal vascular anatomy, can help identify most vascular abnormalities of the upper extremity. Technologic improvements now allow accurate diagnosis by noninvasive methods. Most abnormalities can be categorized into one of five major diagnostic groups: traumatic, compressive, occlusive, tumoral (malformation), and vasospastic. Behavioral modifications and pharmacologic agents may improve symptoms. Appropriately selected surgical candidates often experience pain relief and functional improvement.

    • Keywords:
    • Arm|Blood Vessels|Fingers|Glomus Tumor|Humans|Nail Diseases|Physical Examination|Raynaud Disease|Skin Neoplasms|Thromboangiitis Obliterans|Upper Extremity|Vascular Diseases

    • Subspecialty:
    • Shoulder and Elbow

    • Hand and Wrist

    • General Orthopaedics

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