JAAOS

JAAOS, Volume 11, No. 1


Advances in the management of humeral nonunion.

Approximately 10% of all long-bone fractures occur in the humerus. Although primary treatment usually is successful, humeral nonunion can lead to marked morbidity and functional limitation. Complications include joint contractures of the shoulder and elbow, especially with periarticular pseudarthrosis. Marked osteopenia or bone loss, or both, often occur after fracture and after failure to achieve union. Retained implants often break, impeding fixation and requiring removal. Soft-tissue deficits and incisions from the original injury or prior surgeries also may complicate reconstruction, as can intra-articular fractures and associated nerve palsies. Successful surgical management of humeral nonunion requires stable internal fixation that allows early joint motion and uses autogenous bone graft to promote healing. Contracture release and early joint motion are necessary to optimize function. Shoulder hemiarthroplasty and semiconstrained total elbow arthroplasty are viable options for irreversible joint damage. Advances in preoperative evaluation and surgical reconstruction have improved functional outcomes.

    • Keywords:
    • Arthroplasty|Bone Nails|Elbow Joint|Fracture Fixation

    • Internal|Fractures

    • Ununited|Humans|Humeral Fractures

    • Subspecialty:
    • Trauma

    • Shoulder and Elbow

Correspondence

    • Keywords:
    • Developing Countries|Humans|Musculoskeletal Diseases|Orthopedics

    • Subspecialty:
    • General Orthopaedics

    • Clinical Practice Improvement

Longitudinal radioulnar dissociation.

Proximal translation of the radius is a complication of radial head fractures that occurs in association with disruption of the longitudinal soft-tissue stabilizers of the forearm. The sequelae of this process include debilitating wrist and elbow pain secondary to ulnocarpal and radiocapitellar abutment as well as loss of grip strength. When radioulnar dissociation is recognized early, treatment involves prevention of proximal radial migration by preservation of the radial head and stabilization of the distal radioulnar joint. When primary bony repair of the radial head is not feasible, prosthetic replacement of the radial head is necessary to prevent proximal radial migration. Management is complex in chronic cases in which longitudinal radioulnar dissociation is diagnosed after radial migration has occurred. Treatment goals include normalization of the radioulnar relationship and prevention of further migration. Although several reconstructive treatment options are available, no clear solutions exist, and long-term prognosis is guarded. Therefore, early recognition of longitudinal forearm instability is critically important.

    • Keywords:
    • Arthrodesis|Dislocations|Elbow Joint|Humans|Radius Fractures|Soft Tissue Injuries|Ulna Fractures

    • Subspecialty:
    • Trauma

    • Hand and Wrist

Malignant bone tumors: limb sparing versus amputation.

Amputation, once the mainstay of treatment of malignant bone tumors, now is used selectively and infrequently. Most patients are candidates for limb-sparing procedures because of effective chemotherapeutic agents and regimens, improved imaging modalities, and advances in reconstructive surgery. Patient age as well as tumor location and extent of disease help define the most appropriate surgical alternatives. Options for skeletal reconstruction include modular endoprostheses, osteoarticular or bulk allografts, allograft-prosthetic composites, vascularized bone grafts, arthrodesis, expandable prostheses, rotationplasty, and limb-lengthening techniques. Two key factors must be considered: survival rates should be no worse than those associated with amputation, and the reconstructed limb must provide satisfactory function. Functional outcome studies comparing limb-sparing procedures and amputation have inherent limitations, including the inability to randomize treatment and the subjective nature of important outcome measures.

    • Keywords:
    • Amputation|Arthrodesis|Bone Lengthening|Bone Neoplasms|Bone Transplantation|Humans|Postoperative Complications|Prosthesis Design|Prosthesis Implantation|Transplantation

    • Homologous

    • Subspecialty:
    • Musculoskeletal Oncology

Ordering and interpreting rheumatologic laboratory tests.

Many mechanical and systemic conditions can cause joint pain and synovitis. When rheumatologic illness is suspected, the initial evaluation begins with an accurate history, physical examination, and selective use of confirmatory testing, which can help avoid common pitfalls inherent in serologic evaluation. Tests for erythrocyte sedimentation rate, C-reactive protein level, rheumatoid factor, antinuclear antibodies, anticardiolipin antibodies and lupus anticoagulant, HLA-B27, uric acid level, and Lyme disease, either alone or in combination, may support certain diagnoses. Using these tests nonselectively may yield false-positive results, causing unnecessary concern and expense. However, using these tests effectively may reduce the number of unneeded invasive procedures.

    • Keywords:
    • Acute-Phase Proteins|Adult|Aged|Clinical Laboratory Techniques|Female|Humans|Male|Middle Aged|Rheumatic Diseases

    • Subspecialty:
    • General Orthopaedics

    • Basic Science

Rheumatoid arthritis of the shoulder.

Rheumatoid arthritis affecting the shoulder region is a progressive disorder that results in pain, loss of range of motion, and functional disability. The inflammatory response, which is of unknown etiology, results in synovitis, pannus formation, and articular destruction. Even when patient history and physical examination suggest rheumatoid involvement of the shoulder, laboratory assessment and radiographic evaluation often are necessary to establish the diagnosis. Nonsurgical management is the primary treatment, including pharmacologic and physical therapy regimens for patients with mild symptoms and functional disability. Surgical intervention is indicated in patients with significant pain and functional limitation when nonsurgical treatment fails to provide relief. The procedure selected depends on careful assessment of the degree of articular cartilage injury and compromise of the periarticular soft tissues.

    • Keywords:
    • Algorithms|Anti-Inflammatory Agents|Arthritis

    • Rheumatoid|Arthrodesis|Arthroplasty|Cartilage

    • Articular|Diagnosis

    • Differential|Humans|Physical Therapy Modalities|Shoulder Joint|Steroids

    • Subspecialty:
    • Shoulder and Elbow

    • Pain Management

Treatment of chronic discogenic low back pain with intradiskal electrothermal therapy.

The treatment of chronic, nonradicular, discogenic low back pain remains controversial. The posterior anulus fibrosus appears to be a potential site of origin of the pain, which is mediated by nociceptors in the inner layers of the anulus. Diagnosis requires a thorough history, physical examination, and imaging protocol; provocative diskography is key. Nonsurgical treatment options have been limited to physical therapy and pharmacotherapy. Success rates of spinal fusion range from 39% to 96%. Reported therapeutic success rates of intradiskal electrothermal therapy, a possible intermediate treatment, range from 60% to 80%. Despite this apparent therapeutic effect, however, a more precise quantification of clinical benefits remains to be proved in randomized prospective trials.

    • Keywords:
    • Catheterization|Electric Stimulation Therapy|Humans|Hyperthermia

    • Induced|Intervertebral Disk|Intervertebral Disk Displacement|Low Back Pain

    • Subspecialty:
    • Spine

Use of antibiotic-impregnated cement in total joint arthroplasty.

The use of antibiotic-impregnated cement in revision of total hip arthroplasty procedures is widespread, and a substantial body of evidence demonstrates its efficacy in infection prevention and treatment. However, it is not clear that it is necessary or desirable as a routine means of prophylaxis in primary total joint arthroplasty. In the management of infected implant sites, antibiotic-impregnated cement used in one-stage exchange arthroplasties has lowered reinfection rates. In two-stage procedures, use of beads and either articulating or nonarticulating antibiotic-impregnated cement spacers also has lowered reinfection rates. In addition, spacers reduce "dead space," help stabilize the limb, and facilitate reimplantation. Problems associated with antibiotic-impregnated cement in total joint arthroplasty include weakening of the cement and the generation of antibiotic-resistant bacteria in infected implant sites.

    • Keywords:
    • Animals|Anti-Bacterial Agents|Arthroplasty

    • Replacement|Bone Cements|Humans|Prosthesis-Related Infections|Reoperation

    • Subspecialty:
    • Adult Reconstruction

Advertisements

Advertisement