JAAOS

JAAOS, Volume 12, No. 1


Advances in radionuclide therapeutics in orthopaedics.

Radiopharmaceuticals not only are used for diagnostic purposes but also increasingly in the treatment of many orthopaedic-related disorders. With the development of specific bone-seeking radiopharmaceuticals, the side effects of treatment are minimized, therapeutic effects are sustained, and concomitant use with other modalities may have synergistic effects. These new radiopharmaceuticals, such as strontium 89 and samarium 153-ethylene diamine tetramethylene phosphate, have been used as palliative treatment for patients with bone pain from osseous metastases. Excellent clinical responses with acceptable hematologic toxicity have been observed, and clinical results rival those of external beam radiation therapy. Radiosynovectomy has become a procedure of choice at many institutions to treat recurrent hemarthrosis and chronic synovitis in patients whose hemophilia is poorly controlled with medical management. Radiosynovectomy also remains a viable option to treat chronic synovitis secondary to inflammatory arthropathies, particularly rheumatoid arthritis.

    • Keywords:
    • Humans|Musculoskeletal Diseases|Orthopedics|Radiopharmaceuticals|Samarium|Strontium Radioisotopes

    • Subspecialty:
    • General Orthopaedics

    • Musculoskeletal Oncology

Coccygodynia: evaluation and management.

Coccygodynia is pain in the region of the coccyx. In most cases, abnormal mobility is seen on dynamic standing and seated radiographs, although the cause of pain is unknown in other patients. Bone scans and magnetic resonance imaging may show inflammation and edema, but neither technique is as accurate as dynamic radiography. Treatment for patients with severe pain should begin with injection of local anesthetic and corticosteroid into the painful segment. Coccygeal massage and stretching of the levator ani muscle can help. Coccygectomy is done only when nonsurgical treatment fails, which is infrequent. Coccygectomy usually is successful in carefully selected patients, with the best results in those with radiographically demonstrated abnormalities of coccygeal mobility.

    • Keywords:
    • Coccyx|Diagnosis

    • Differential|Humans|Pain|Physical Examination

    • Subspecialty:
    • Spine

    • Pain Management

Exercise prescription.

Although many studies suggest that exercise provides various health benefits, the optimal dimensions of exercise (ie, frequency, intensity, duration, type) remain to be carefully defined. Research encompasses many areas, from activities of daily living to elite athletic performance. To properly prescribe a beneficial exercise program, a physician must have a basic understanding of the elements of exercise physiology and energy metabolism, as well as of the cardiovascular, respiratory, and musculoskeletal responses to exercise and training. Also, integration of specific programs for muscle strengthening with aerobic conditioning is important to achieve optimal results in patients with musculoskeletal conditions such as osteoarthritis and osteoporosis.

    • Keywords:
    • Exercise|Exercise Therapy|Humans|Osteoarthritis|Osteoporosis

    • Subspecialty:
    • Sports Medicine

    • General Orthopaedics

Management of posttraumatic segmental bone defects.

Because of difficulty in managing posttraumatic segmental bone defects and the resultant poor outcomes, amputation historically was the preferred treatment. Massive cancellous bone autograft has been the principal alternative to amputation. Primary shortening or use of the adjacent fibula as a graft also has been used to attempt limb salvage. Of more recent methods of management, bone transport with distraction osteogenesis has been suggested as the leading option for defects of 2 to 10 cm, but problems include delayed union at the docking site and prolonged treatment time. Free vascularized bone transfer has been suggested as the leading option for defects of 5 to 12 cm, but hypertrophy of the graft is unreliable and late fracture, common. Bone graft substitutes continue to be developed, but they have not yet reached clinical efficacy for posttraumatic segmental bone defects. Although each of the new techniques has shown some limited success, complications remain common.

    • Keywords:
    • Amputation|Bone Transplantation|Bones of Upper Extremity|Fracture Fixation|Humans|Leg Bones|Salvage Therapy

    • Subspecialty:
    • Trauma

Periprosthetic femoral fractures above total knee replacements.

Periprosthetic femoral fractures above total knee replacements can be managed by a variety of methods, including casting, open reduction and internal fixation, external fixation, or revision arthroplasty. Because no single method has emerged as the optimal choice for all such fractures, it is important to understand which options are appropriate for each fracture pattern. Early classification systems focused on displacement as a major indication for either surgical or nonsurgical management. However, recent techniques and current implants have made surgical management preferable for most periprosthetic fractures. Classification based on fracture location can help guide such treatment. Generally, intramedullary nails are best for proximal fractures, fixed-angle devices for fractures originating at the component, and revision arthroplasty for very distal fractures or those with implant loosening.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Knee|Bone Transplantation|Femoral Fractures|Fracture Fixation|Humans|Knee Prosthesis|Risk Factors

    • Subspecialty:
    • Trauma

    • Adult Reconstruction

Rotator cuff ultrasonography: diagnostic capabilities.

Dynamic shoulder ultrasonography is a noninvasive, accurate method used to assess the rotator cuff tendons. It can be incorporated into the in-office physical examination of patients at risk for rotator cuff problems. The low cost, convenience, and lack of risk make dynamic ultrasonography an excellent imaging tool for evaluating the biceps, subscapularis, infraspinatus, teres minor, and supraspinatus tendons. In-office ultrasound also provides an opportunity for patient education and explanation of management options.

    • Keywords:
    • Diagnosis

    • Differential|Humans|Rotator Cuff|Ultrasonography

    • Subspecialty:
    • Shoulder and Elbow

Surgical treatment of congenital syndactyly of the hand.

Syndactyly is a congenital anomaly of the hand that is more common in males, is present bilaterally in 50% of affected patients, and often is associated with other musculoskeletal malformations or systemic syndromes. The goal of syndactyly release is to create a functional hand with the fewest surgical procedures while minimizing complications. For simple syndactyly, surgical reconstruction can begin at approximately 6 months, although many surgeons prefer to wait until the infant is 18 months old. Special situations, such as complex syndactyly and involvement of border digits, may warrant surgical intervention earlier than 6 months. Reconstruction of the web commissure is the most technically challenging part of the operation, followed by separation of the remaining digits. Full-thickness skin grafting is almost always required for soft-tissue coverage. Complex syndactyly and syndactyly associated with other hand anomalies warrant special consideration. After reconstruction, patients should be examined periodically until they have achieved skeletal maturity because late complications such as web creep can occur.

    • Keywords:
    • Hand Deformities

    • Congenital|Humans|Surgical Flaps|Syndactyly

    • Subspecialty:
    • Pediatric Orthopaedics

    • Hand and Wrist

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