JAAOS

JAAOS, Volume 11, No. 4


Chronic exertional compartment syndrome.

Chronic exertional compartment syndrome is an often overlooked and uncommon cause of pain in the extremities of individuals who engage in repetitive physical activity. A thorough history, a careful physical examination, and compartment pressure testing are essential to establish the diagnosis. Catheter measurements can provide useful information on baseline resting compartment pressures as well as compartment pressures after exercise or trauma. Patients with chronic exertional compartment syndrome usually do not respond to nonsurgical therapy other than completely ceasing the activities that cause the symptoms. Surgical intervention entails fasciotomies of the involved compartments. Although obtaining accurate compartment pressure measurements can be difficult and fascial releases must be done carefully, patients typically have satisfactory functional results and are able to return to their usual physical activities after fasciotomy.

    • Keywords:
    • Angiography|Anterior Compartment Syndrome|Chronic Disease|Cumulative Trauma Disorders|Decompression

    • Surgical|Female|Follow-Up Studies|Humans|Magnetic Resonance Imaging|Male|Pain Measurement|Risk Assessment|Severity of Illness Index|Tomography

    • X-Ray Computed|Treatment Outcome|Ultrasonography

    • Doppler

    • Subspecialty:
    • Trauma

    • Sports Medicine

Extensor mechanism failure associated with total knee arthroplasty: prevention and management.

Extensor mechanism complications are the most commonly reported reasons for revision surgery after total knee arthroplasty and are a frequent source of postoperative morbidity. Patellofemoral instability is the most commonly reported extensor mechanism complication and has multiple etiologies, including prosthetic malalignment and soft-tissue imbabalce. Patellar fracture or rupture of either the quadriceps or patellar tendon can cause catastrophic disruption of the extensor mechanism. Although some stable fractures can be successfully managed nonsurgically, displaced fractures or tendon rupture often lead to poor results. Other complications include patellar clunk and soft-tissue adhesions, prosthetic wear or loosening, and osteonecrosis. Increased understanding of implant alignment, rotation, and soft-tissue balance, as well as improved design of the trochlear groove of femoral implants and patellar components, has resulted in a decline in extensor mechanism complications. Appropriate prosthetic selection and meticulous surgical technique remain the keys to avoiding unsatisfactory results and revision surgery.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Knee|Female|Follow-Up Studies|Humans|Joint Instability|Knee Prosthesis|Male|Muscle

    • Skeletal|Osteoarthritis

    • Knee|Prosthesis Design|Prosthesis Failure|Range of Motion

    • Articular|Recovery of Function|Reoperation|Risk Assessment|Rupture

    • Spontaneous|Tendon Injuries|Tendons

    • Subspecialty:
    • Adult Reconstruction

Injury to the tarsometatarsal joint complex.

Tarsometatarsal joint complex fracture-dislocations may result from direct or indirect trauma. Direct injuries are usually the result of a crush and may involve associated compartment syndrome, significant soft-tissue injury, and open fracture-dislocation. Indirect injuries are often the result of an axial load to the plantarflexed foot. Midfoot pain after even a minor forefoot injury should raise suspicion; up to 20% of tarsometatarsal joint complex injuries are missed on initial examination. An anteroposterior radiograph with abduction stress may reveal subtle injury, but computed tomography is the preferred imaging modality. The goal of treatment is the restoration of a pain-free, functional foot. The preferred treatment is open reduction and internal fixation, using screw fixation for the medial three rays and Kirschner wires for the fourth and fifth tarsometatarsal joints. Satisfactory outcome can be expected in approximately 90% of patients.

    • Keywords:
    • Accidental Falls|Accidents

    • Traffic|Bone Nails|Female|Follow-Up Studies|Foot Injuries|Fracture Fixation

    • Internal|Fracture Healing|Fractures

    • Bone|Humans|Injury Severity Score|Male|Recovery of Function|Risk Assessment|Tarsal Joints|Treatment Outcome

    • Subspecialty:
    • Trauma

    • Foot and Ankle

Magnetic resonance imaging of the pediatric spine.

Magnetic resonance is an excellent modality for imaging the pediatric spine. Its successful use requires understanding both the basic physics and the sedation protocols necessary for acquiring high-resolution images. Interpreting the images accurately depends on appreciating the differences between the normal anatomy of the pediatric and the adult spine. Evaluating the images requires familiarity with the differential diagnosis of pediatric spine disease, including the most common processes (infections, neoplasms, and trauma) as well as spinal dysraphism. Despite the acknowledged usefulness of magnetic resonance imaging of the pediatric spine, controversies remain related to its safety in this age group and its limitations in diagnosing and evaluating scoliosis and tethered cord syndrome.

    • Keywords:
    • Adolescent|Adult|Arnold-Chiari Malformation|Child|Child Development|Child

    • Preschool|Female|Humans|Infant|Infant

    • Newborn|Magnetic Resonance Imaging|Male|Neural Tube Defects|Risk Assessment|Scoliosis|Sensitivity and Specificity|Severity of Illness Index|Spinal Diseases|Spinal Dysraphism|Spine

    • Subspecialty:
    • Pediatric Orthopaedics

    • Spine

    • Basic Science

MD Consult

    • Keywords:
    • Aged|Arthroscopy|Female|Follow-Up Studies|Humans|Male|Middle Aged|Osteoarthritis

    • Knee|Pain Measurement|Range of Motion

    • Articular|Risk Assessment|Severity of Illness Index|Surgical Procedures

    • Minimally Invasive|Treatment Outcome

    • Subspecialty:
    • Sports Medicine

Metastatic bone disease of the humerus.

Metastatic bone disease is the most common cause of destructive bone lesions in adults, and involvement of the humerus is common. Patients with destructive lesions involving <50% of the cortex are treated nonsurgically with external beam irradiation. Patients with diaphyseal lesions involving > or =50% of the cortex or those with pain after irradiation can be treated with intramedullary nailing to achieve rigid fixation. Although closed intramedullary nailing is used most often, open nailing with methylmethacrylate is appropriate for destructive lesions in which rigid fixation cannot be achieved with closed nailing. Plate fixation is acceptable when adequate proximal and distal cortical bone is present for screw purchase, although proximal humeral lesions usually are treated with prosthetic arthroplasty. Postoperative external beam irradiation can help prevent disease progression and subsequent loss of fixation. However, when disease progression persists or rigid internal fixation is not feasible because of extensive bone destruction, wide resection and reconstruction with a custom prosthesis can be done.

    • Keywords:
    • Adult|Bone Nails|Bone Neoplasms|Bone Plates|Female|Fracture Fixation

    • Internal|Fractures

    • Spontaneous|Humans|Humeral Fractures|Humerus|Male|Middle Aged|Prognosis|Risk Assessment|Survival Rate|Treatment Outcome

    • Subspecialty:
    • Shoulder and Elbow

    • Musculoskeletal Oncology

Proximal row carpectomy and intercarpal arthrodesis for the management of wrist arthritis.

For advanced noninflammatory wrist arthritis, the most common surgical treatments to preserve motion are proximal row carpectomy and scaphoid excision with capitohamate-lunotriquetral arthrodesis. Both procedures have documented successful outcomes. Proximal row carpectomy is simpler but typically is contraindicated when degeneration of the capitate head cartilage exists. Scaphoid excision with capitohamate-lunotriquetral arthrodesis is more complex but may provide greater grip strength and can be successful in the presence of capitate degeneration. Treatment selection should be based on surgeon preference and experience as well as on the patient's understanding of the possible complications and benefits of each procedure.

    • Keywords:
    • Arthritis|Arthrodesis|Carpal Bones|Female|Hand Deformities

    • Acquired|Humans|Lunate Bone|Male|Prognosis|Range of Motion

    • Articular|Recovery of Function|Risk Assessment|Scaphoid Bone|Severity of Illness Index|Treatment Outcome|Wrist Joint

    • Subspecialty:
    • Hand and Wrist

Spinal manipulative therapy for low back pain.

Growing interest in complementary and alternative medicine in the United States has been paralleled by increased use of spinal manipulative therapy in an attempt to manage symptoms of low back pain, spinal stenosis, and spondylolisthesis. Chiropractors have been the main practitioners of spinal manipulative therapy, with osteopaths and physical therapists providing a smaller fraction of these services. Theories explaining the mode of action of spinal manipulative therapy are largely preliminary and have focused on the mechanical effects of manipulative forces on the spine and neurologic responses to manipulation. The effects of spinal manipulation on patients with both acute and chronic low back pain have been investigated in randomized clinical trials. Most reviews of these trials indicate that spinal manipulative therapy provides some short-term benefit to patients, especially with acute low back pain.

    • Keywords:
    • Acute Disease|Chronic Disease|Clinical Trials as Topic|Female|Humans|Intervertebral Disk Displacement|Low Back Pain|Male|Manipulation

    • Spinal|Pain Measurement|Prognosis|Recovery of Function|Risk Assessment|Severity of Illness Index|Spinal Stenosis|Treatment Outcome

    • Subspecialty:
    • Spine

    • Pain Management

Thoracoscopic anterior instrumentation and fusion for idiopathic scoliosis.

Thoracoscopically assisted surgery is a new approach to access the anterior spine to perform biopsies, anterior releases, diskectomies, and anterior instrumentation and fusion for idiopathic thoracic scoliosis. This approach compromises the chest wall less than an open thoracotomy does because it uses several small portal incisions. It has been suggested that this approach allows fusion of fewer motion segments and better correction of curvature than does posterior spinal fusion and instrumentation. The technique, which is still evolving, is technically demanding, requiring advanced training and special instrumentation and anesthesia techniques.

    • Keywords:
    • Female|Follow-Up Studies|Humans|Internal Fixators|Male|Risk Assessment|Scoliosis|Sensitivity and Specificity|Severity of Illness Index|Spinal Fusion|Thoracic Vertebrae|Thoracoscopy|Tomography

    • X-Ray Computed|Treatment Outcome

    • Subspecialty:
    • Pediatric Orthopaedics

    • Spine

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