JAAOS

JAAOS, Volume 11, No. 3


Cavus foot deformity in children.

A cavus deformity of the foot is easily recognizable, but appropriate neurologic assessment can help to determine the etiology. Cavovarus, the most frequent type of cavus foot, presents with an elevated medial longitudinal arch, first ray plantarflexion, and, if rigid, a fixed heel varus. Common causes include progressive motor sensory conditions, typically Charcot-Marie-Tooth disease, and nonprogressive conditions such as cerebral palsy and poliomyelitis. A calcaneocavus foot may be seen in poliomyelitis, spinal dysraphism, and peripheral neuropathy. Initially, the cavus deformity is flexible, but if left untreated, it becomes a fixed bony deformity. Physical examination should include the cavovarus block test, which assesses flexibility of the hindfoot deformity and can direct surgical treatment. Standing radiographs of the feet and spine, magnetic resonance imaging, and electrodiagnostic studies may be useful. Management goals are to obtain a plantigrade, mobile, pain-free, stable, motor-balanced foot. Surgical options include soft-tissue and plantar fascia releases for a flexible deformity, osteotomy for a fixed deformity, and tendon transfers to restore muscle balance. Triple arthrodesis has poor long-term results in patients with progressive deformity and sensory impairment.

    • Keywords:
    • Child|Foot Deformities|Humans

    • Subspecialty:
    • Foot and Ankle

    • Pediatric Orthopaedics

Degenerative lumbar scoliosis: evaluation and management.

Degenerative lumbar scoliosis is a lateral deviation of the spine that typically develops after age 50 years. Clinical presentation varies, but the deformity frequently is associated with loss of lordosis, axial rotation, lateral listhesis, and spondylolisthesis. Although the etiology is unclear, degenerative scoliosis is associated with degenerative disk disease, facet incompetence, and hypertrophy of the ligamenta flava, typically leading to neurogenic claudication and back pain. Rarely, sagittal or coronal imbalance may develop. Indications for treatment include pain, progressive deformity, radiculopathy or myelopathy, and cosmetic deformity. Nonsurgical care focuses on patient education, exercise, and nonnarcotic medication. Surgical management should be considered carefully, balancing the benefits and risks for the patient.

    • Keywords:
    • Decompression

    • Surgical|Humans|Lumbar Vertebrae|Postoperative Complications|Scoliosis|Spinal Fusion

    • Subspecialty:
    • Spine

    • Pain Management

Metacarpophalangeal joint arthroplasty in rheumatoid arthritis.

Although metacarpophalangeal joint arthroplasty is occasionally performed for joints affected by osteoarthritis, it is most often done in patients with rheumatoid arthritis. The metacarpophalangeal joint is critical for proper finger function but is the most common site of involvement in the rheumatoid hand. A thorough understanding of the anatomy, pathophysiology, and mechanics of the metacarpophalangeal joint is a prerequisite for the evaluation and treatment of patients requiring metacarpophalangeal arthroplasty. Silicone rubber implants are the most frequently used device for treatment of revised metacarpophalangeal arthroplasty. Follow-up studies show that this surgery improves function and deformity and achieves nearly uniform patient satisfaction.

    • Keywords:
    • Arthritis

    • Rheumatoid|Arthroplasty

    • Replacement|Humans|Joint Deformities

    • Acquired|Joint Prosthesis|Metacarpophalangeal Joint|Reoperation|Silicone Elastomers

    • Subspecialty:
    • Hand and Wrist

Office ambulatory surgery centers: creation and management.

Among orthopaedic surgeons, the popularity of in-office ambulatory surgery has steadily increased. Changing practice patterns, including utilization of office surgery centers, have resulted in improved efficiency and increased revenue. However, accurate feasibility and market analyses are necessary before considering the addition of a surgery center to an orthopaedic practice. The legal requirements to operate a center include state licensure, Medicare certification, and accreditation. In addition, approved construction design and effective operations management are essential.

    • Keywords:
    • Ambulatory Care Facilities|Ambulatory Surgical Procedures|Facility Design and Construction|Orthopedics|Personnel Staffing and Scheduling|Practice Management

    • Subspecialty:
    • Clinical Practice Improvement

Open fractures: evaluation and management.

Open fractures are complex injuries that involve both the bone and surrounding soft tissues. Management goals are prevention of infection, union of the fracture, and restoration of function. Achievement of these goals requires a careful approach based on detailed assessment of the patient and injury. The classification of open fractures is based on type of fracture, associated soft-tissue injury, and bacterial contamination present. Tetanus prophylaxis and intravenous antibiotics should be administered immediately. Local antibiotic administration is a useful adjunct. The open fracture wound should be thoroughly irrigated and debrided, although the optimal method of irrigation remains uncertain. Controversy also exists regarding the optimal timing and technique of wound closure. Extensive soft-tissue damage may necessitate the use of local or free muscle flaps. Techniques of fracture stabilization depend on the anatomic location of the fracture and characteristics of the injury.

    • Keywords:
    • Fractures

    • Open|Humans|Soft Tissue Injuries|Wound Infection

    • Subspecialty:
    • Trauma

    • Basic Science

Phytoestrogens.

    • Keywords:
    • Animals|Bone Density|Dietary Supplements|Estrogens

    • Non-Steroidal|Female|Humans|Isoflavones|Osteoporosis

    • Postmenopausal|Phytoestrogens|Phytotherapy|Plant Preparations|Soybean Proteins

    • Subspecialty:
    • Basic Science

Quadriceps tendon rupture.

Rupture of the quadriceps tendon is an uncommon yet serious injury requiring prompt diagnosis and early surgical management. It is more common in older (>40 years) individuals and sometimes is associated with underlying medical conditions. In particular, bilateral spontaneous rupture may be associated with gout, diabetes, or use of steroids. Clinical findings typically include the triad of acute pain, impaired knee extension, and a suprapatellar gap. Imaging studies are useful in confirming the diagnosis. Although incomplete tears may be managed nonsurgically, complete ruptures are best treated with early surgical repair.

    • Keywords:
    • Animals|Humans|Knee Injuries|Rupture|Tendon Injuries

    • Subspecialty:
    • Trauma

    • Sports Medicine

Trochanteric osteotomy and fixation during total hip arthroplasty.

Once used routinely, trochanteric osteotomy in total hip arthroplasty now is usually limited to difficult primary and revision cases. There are three types: the standard trochanteric osteotomy and its variations, the trochanteric slide, and the extended trochanteric osteotomy. Each has unique indications, fixation techniques, and complications. Primary total hip arthroplasty procedures requiring the enhanced exposure provided by trochanteric osteotomy may be needed in patients with hip ankylosis or fusion, protrusio acetabuli, proximal femoral deformities, developmental dysplasia, or abductor muscle laxity. Trochanteric osteotomies in revision arthroplasties, primarily the extended trochanteric osteotomy, facilitate the removal of well-fixed femoral components, provide direct access to the diaphysis for distal fixation, and enhance acetabular exposure.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Hip|Bone Wires|Femur|Humans|Osteotomy|Postoperative Complications

    • Subspecialty:
    • Adult Reconstruction

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