JAAOS

JAAOS, Volume 11, No. 5


Chronic massive rotator cuff tears: evaluation and management.

Most studies of rotator cuff repairs report high success rates. However, the majority of these studies combine the results of surgical management of rotator cuff tears of various sizes; few published reports specifically evaluate the management of chronic massive tears. Chronic massive rotator cuff tears may be acute traumatic, chronic atraumatic, or acute-on-chronic. A detailed history and thorough physical examination often are sufficient to establish the diagnosis. Radiographic evaluation can reveal osseous changes suggestive of pathology. Magnetic resonance imaging can determine the size of rotator cuff tears and status of the muscles but generally is not necessary for patients who are not candidates for surgery. Chronic massive rotator cuff tears without glenohumeral arthritis can be managed nonsurgically or with sub-acromial debridement, rotator cuff repair, or rotator cuff reconstruction. However, treatment of these patients is challenging, and results are comparatively inferior to those of treating patients with smaller rotator cuff tears.

    • Keywords:
    • Acromion|Age Factors|Arthrodesis|Chronic Disease|Debridement|Humans|Magnetic Resonance Imaging|Physical Examination|Reconstructive Surgical Procedures|Rotator Cuff|Shoulder|Shoulder Joint

    • Subspecialty:
    • Shoulder and Elbow

Common rotational variations in children.

Most rotational variations in young children, such as in-toeing, out-toeing, and torticollis, are benign and resolve spontaneously. Understanding the normal variations in otherwise healthy children is vital to identifying true structural abnormalities that require intervention. A deliberate assessment of the rotational profile is necessary when evaluating children who in-toe or out-toe. In-toeing is usually attributable to metatarsus adductus in the infant, internal tibial torsion in the toddler, and femoral anteversion in children younger than 10 years. Out-toeing patterns largely result from external rotation hip contracture, external tibial torsion, and external femoral torsion. Although congenital muscular torticollis is the most common explanation for the atypical head posture in children, more serious disorders, including osseous malformations, inflammation, and neurogenic disorders, should be excluded.

    • Keywords:
    • Child|Child

    • Preschool|Femur|Foot|Foot Deformities

    • Congenital|Gait|Hip Contracture|Humans|Infant|Posture|Rotation|Tibia|Torsion Abnormality

    • Subspecialty:
    • Pediatric Orthopaedics

Lower extremity angular malunion: evaluation and surgical correction.

The lower extremity has a mechanical axis with joint orientation that allows joint longevity and efficiency in bipedal gait. When normal alignment is lost because of trauma or other conditions, deviations from this anatomic norm may be deleterious to long-term joint function. In fractures that have healed with angular malunion, all facets of the deformity must be carefully considered, including alteration in length, rotation, alignment, and translation. Once all elements are fully defined, the effects of the malunion on mechanical axis and joint orientation can be understood. Techniques for surgical correction include wedge, dome, and oblique osteotomies and distraction osteogenesis. Each method possesses characteristics appropriate for certain clinical situations. Judicious patient selection and thoughtful preoperative planning may allow restoration of normal mechanics.

    • Keywords:
    • Biomechanics|Femoral Fractures|Fractures

    • Malunited|Humans|Leg Bones|Leg Length Inequality|Osteotomy|Tibial Fractures

    • Subspecialty:
    • Trauma

    • Basic Science

New-generation implant arthroplasties of the finger joints.

Prosthetic replacement in the hand must address such unique challenges as preservation of the collateral ligaments, tendon balancing, and stability. Some recently developed implant arthroplasties of the metacarpophalangeal and proximal interphalangeal joints have anatomically designed articular components; others have non-cemented, press-fit, carefully contoured intramedullary stems. The rationale behind developing the unlinked or semiconstrained prosthesis with anatomic geometry is that it would create balanced forces across the joint. Low-profile, anatomically designed implants limit the amount of bone removed and preserve the integrity of the collateral ligaments. A metacarpophalangeal joint implant with an elliptical metacarpal head and a nonfixed center of rotation can enhance stability in flexion through greater articular contact. A proximal interphalangeal joint implant that preserves the collateral ligaments also can achieve improved stability. Component loosening is not an early complication with these recent designs, and arc of motion is satisfactory.

    • Keywords:
    • Arthroplasty

    • Replacement|Collateral Ligaments|Finger Joint|Humans|Joint Prosthesis|Prosthesis Design

    • Subspecialty:
    • Hand and Wrist

    • Basic Science

Pediatric soft-tissue tumors.

Soft-tissue tumors in children (<18 years) are a heterogeneous group of lesions. Masses may be asymptomatic or associated with pain or discomfort. Although most lesions are benign, developing an appropriate differential diagnosis requires knowledge of the clinical and radiographic characteristics of tumors and tumorlike conditions in children. A thorough history and physical examination, followed by appropriate imaging studies, when indicated, can establish a correct diagnosis and help determine appropriate treatment recommendations.

    • Keywords:
    • Adolescent|Biopsy|Child|Child

    • Preschool|Humans|Magnetic Resonance Imaging|Neoplasm Staging|Physical Examination|Soft Tissue Neoplasms

    • Subspecialty:
    • Pediatric Orthopaedics

    • Musculoskeletal Oncology

The unstable patella after total knee arthroplasty: etiology, prevention, and management.

In total knee arthroplasty, most complications related to the extensor mechanism are caused by patellar maltracking or instability. Patellar maltracking may result from component malpositioning and limb malalignment, prosthetic design, improper patellar preparation, or soft-tissue imbalance. Patellofemoral instability likely results most frequently from internal malrotation of the femoral or tibial components. Although a patellofemoral radiograph may display the lateral subluxation of the patella, only computed tomography can quantify rotational malalignment of the femoral or tibial component. Nonsurgical treatment is generally unsuccessful; major malposition of components is best managed by implant revision. In the absence of component malposition, proximal realignments (lateral patellar retinacular release with lateral advancement of the vastus medialis obliquus muscle) or tibial tubercle transfers have been used. Surgical procedures on the patellar tendon itself may risk rupture of the extensor mechanism.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Knee|Humans|Patella|Postoperative Complications

    • Subspecialty:
    • Adult Reconstruction

Thoracolumbar fracture management: anterior approach.

The surgeon who treats patients with spine trauma must be able to apply a variety of management techniques to achieve optimal care of the patient. The anterior surgical approach is appropriate for some thoracolumbar burst fractures in patients with neurologic deficit and without posterior ligamentous injury. Surgery is most often indicated for patients with incomplete deficit, especially those with a large retropulsed fragment, marked canal compromise, severe anterior comminution, or kyphosis <30 degrees. This approach provides excellent visualization of the anterior aspect of the dura mater for decompression. Reconstruction of the anterior body defect can be done with autograft, allograft, or a cage. Supplementation of the graft with anterior internal fixation helps prevent kyphosis. Clinical results demonstrate improved neurologic function in most patients as well as low pseudarthrosis rates. In patients with incomplete deficit, improvement in neurologic function usually can be expected with few complications.

    • Keywords:
    • Fracture Fixation

    • Internal|Humans|Lumbar Vertebrae|Orthopedic Fixation Devices|Spinal Fractures|Thoracic Vertebrae

    • Subspecialty:
    • Trauma

    • Spine

Use of physical forces in bone healing.

During the past two decades, a number of physical modalities have been approved for the management of nonunions and delayed unions. Implantable direct current stimulation is effective in managing established nonunions of the extremities and as an adjuvant in achieving spinal fusion. Pulsed electromagnetic fields and capacitive coupling induce fields through the soft tissue, resulting in low-magnitude voltage and currents at the fracture site. Pulsed electromagnetic fields may be as effective as surgery in managing extremity nonunions. Capacitive coupling appears to be effective both in extremity nonunions and lumbar fusions. Low-intensity ultrasound has been used to speed normal fracture healing and manage delayed unions. It has recently been approved for the management of nonunions. Despite the different mechanisms for stimulating bone healing, all signals result in increased intracellular calcium, thereby leading to bone formation.

    • Keywords:
    • Bone and Bones|Electric Stimulation Therapy|Electromagnetic Fields|Fracture Healing|Fractures

    • Ununited|Humans|Spinal Fusion|Ultrasonic Therapy|Wound Healing

    • Subspecialty:
    • Trauma

    • Basic Science

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