JAAOS

JAAOS, Volume 12, No. 3


Displaced intra-articular calcaneal fractures.

Deciding how to manage displaced intra-articular calcaneal fractures is challenging. Preoperative assessment of the fracture, patient status, and the patient's functional needs are important in determining treatment approach. In general, older, sedentary patients and those with no or with minimally displaced fractures may be treated successfully with nonsurgical management. Traits strongly predictive of satisfaction with surgery include age younger than 40 years, simple fracture pattern, and accurate reduction. Smoking, diabetes, and peripheral vascular disease markedly increase the risk of surgical complications. In addition, the quality of surgical reduction affects outcome.

    • Keywords:
    • Adolescent|Adult|Age Factors|Aged|Calcaneus|Child|Dislocations|Evidence-Based Medicine|Female|Fractures

    • Bone|Humans|Male|Middle Aged|Postoperative Complications|Risk Factors|Sex Factors|Smoking|Wound Healing

    • Subspecialty:
    • Trauma

    • Foot and Ankle

Effects of nonsteroidal anti-inflammatory drugs on bone formation and soft-tissue healing.

Nonsteroidal anti-inflammatory drugs continue to be prescribed as analgesics for patients with healing fractures even though these drugs diminish bone formation, healing, and remodeling. Inhibition of bone formation can be clinically useful in preventing heterotopic ossification in selected clinical situations. In this regard, naproxen may be more efficacious than the traditional indomethacin, and short-term administration is as effective as long-term. When fracture healing or spine fusion is desired, nonsteroidal anti-inflammatory drugs should be avoided. Some nonsteroidal anti-inflammatory drugs have a positive effect on soft-tissue healing; they stimulate collagen synthesis and can increase strength in the early phases of repair during skin and ligament healing. Cyclooxygenase-2 inhibitors have an adverse effect on bone healing and may have an adverse effect on ligament healing. Therefore, further investigation is necessary to confirm that traditional nonsteroidal anti-inflammatory drugs may be preferable for the healing of collagenous tissues.

    • Keywords:
    • Anti-Inflammatory Agents

    • Non-Steroidal|Bone Regeneration|Collagen|Cyclooxygenase Inhibitors|Drug Administration Schedule|Fracture Healing|Humans|Indomethacin|Ligaments|Naproxen|Osseointegration|Ossification

    • Heterotopic|Spinal Fusion|Tendon Injuries|Wound Healing

    • Subspecialty:
    • Adult Reconstruction

On-the-field management of athletic head injuries.

Head injuries are prevalent in collision sports. Concussions represent the relatively benign end of the spectrum of injuries. Severe closed head injuries include epidural hematomas, acute subdural hematomas, intracerebral hematomas, intraventricular hematomas, subarachnoid hemorrhages, and diffuse axonal injuries. Second impact syndrome represents a severe cerebral autoregulatory dysfunction that can lead to death in an athlete who sustains a second (often minor) closed head trauma while still symptomatic from a previous head injury. Generally, athletes who have suffered a severe closed head injury should not return to play. Exceptions include athletes asymptomatic for 1 year who return to a noncontact sport and those who recover completely from an epidural hematoma without underlying brain injury. Several guidelines for returning athletes to play have been proposed and are commonly used. The team physician has the responsibility of on-the-field evaluation and management of athletes with head injuries, as well as of advising them when it is safe to return to play.

    • Keywords:
    • Athletic Injuries|Craniocerebral Trauma|Guidelines as Topic|Humans|Recovery of Function|Recurrence

    • Subspecialty:
    • Sports Medicine

Spinal epidural abscess in adults.

Spinal epidural abscess is a potentially life-threatening disease that can cause paralysis by the accumulation of purulent material in the epidural space. Although modern diagnostic and management methods have improved the prognosis, morbidity and mortality remain significant. Outcome usually is determined by the rapidity of the diagnosis and initiation of appropriate treatment. A high index of suspicion is warranted when a patient presents with spinal pain or a neurologic deficit in conjunction with fever or an elevated erythrocyte sedimentation rate. Gadolinium-enhanced magnetic resonance imaging should be done in suspected cases to localize and define the abscess. For spinal epidural abscess associated with neurologic compromise, the treatment of choice is emergent surgical decompression and débridement (with or without spinal stabilization), followed by long-term antimicrobial therapy. In the absence of a neurologic deficit, medical management is an alternative to surgery when the risk of neurologic complications is low based on the location and morphology of the abscess, immune status of the patient, and virulence of the organism.

    • Keywords:
    • Adult|Anti-Bacterial Agents|Debridement|Drainage|Epidural Abscess|Humans|Image Enhancement|Magnetic Resonance Imaging|Postoperative Care|Prognosis|Treatment Outcome

    • Subspecialty:
    • Spine

Stiffness after total knee arthroplasty.

Postoperative stiffness is a debilitating complication of total knee arthroplasty. Preoperative risk factors include limited range of motion, underlying diagnosis, and history of prior surgery. Intraoperative factors include improper flexion-extension gap balancing, oversizing or malpositioning of components, inadequate femoral or tibial resection, excessive joint line elevation, creation of an anterior tibial slope, and inadequate resection of posterior osteophytes. Postoperative factors include poor patient motivation, arthrofibrosis, infection, complex regional pain syndrome, and heterotopic ossification. The first steps in treating stiffness are mobilizing the patient and instituting physical therapy. If these interventions fail, options include manipulation, lysis of adhesions, and revision arthroplasty. Closed manipulation is most successful within the first 3 months after total knee arthroplasty. Arthroscopic or modified open lysis of adhesions can be considered after 3 months. Revision arthroplasty is preferred for stiffness from malpositioned or oversized components. Patients who initially achieve adequate range of motion (>90 degrees of flexion) but subsequently develop stiffness more than 3 months after surgery should be assessed for intrinsic as well as extrinsic causes.

    • Keywords:
    • Algorithms|Arthroplasty

    • Replacement

    • Knee|Contracture|Debridement|Humans|Intraoperative Period|Joint Diseases|Knee Joint|Motion Therapy

    • Continuous Passive|Musculoskeletal Manipulations|Physical Therapy Modalities|Postoperative Complications|Range of Motion

    • Articular|Reoperation|Risk Factors|Tissue Adhesions

    • Subspecialty:
    • Adult Reconstruction

Surgical management of the lower extremity in ambulatory children with cerebral palsy.

Despite the increasing popularity of nonorthopaedic treatment alternatives for children with cerebral palsy, bony and soft-tissue surgery remains a common component in the management of ambulatory patients. Multisite simultaneous tendon surgery provides improvement in gait by addressing hip, knee, and ankle contractures together. Careful preoperative physical examination is required; computerized gait analysis can be useful in confirming a plan for multiple tendon surgeries. Rotational osteotomies can improve transverse-plane malalignment. Shorter periods of immobilization and aggressive postoperative gait training and strengthening may optimize improvements in gait.

    • Keywords:
    • Cerebral Palsy|Child|Equinus Deformity|Foot Deformities

    • Acquired|Gait|Hip Contracture|Humans|Leg|Muscle Spasticity|Postoperative Care|Preoperative Care

    • Subspecialty:
    • Pediatric Orthopaedics

Unstable intertrochanteric hip fractures in the elderly.

Unstable intertrochanteric hip fractures account for approximately one quarter of all hip fractures in the elderly and are increasing in frequency. Treatment goals include immediate mobilization while limiting complications. Preoperatively, medical comorbidities should be identified and managed. For stable intertrochanteric hip fractures, consistently good results have been achieved with compression hip screw fixation. However, with more unstable fracture patterns, problems with compression hip screw fixation, such as excessive fracture collapse and implant cutout, increase. For these fractures, adding a trochanteric stabilizing plate or using an axial compression hip screw or intramedullary hip screw is warranted. Surgical care should maximize the patient's chance of a successful outcome by realigning the fracture with minimal additional surgical insult, selecting the appropriate implant, and positioning it properly.

    • Keywords:
    • Aged|Bone Plates|Bone Screws|Comorbidity|Fracture Fixation|Hip Fractures|Hip Joint|Humans|Joint Instability|Pain|Postoperative Care|Preoperative Care|Risk Factors

    • Subspecialty:
    • Trauma

Use of the Ilizarov method to correct lower limb deformities in children and adolescents.

The introduction to the West in the early 1980s of the Ilizarov circular external fixator and method resulted in rapid advances in limb lengthening, deformity correction, and segmental long-bone defect reconstruction. The mechanical features of and biologic response to using distraction osteogenesis with the circular external fixator are the unique aspects of Ilizarov's contribution. The most common indications for children and adolescents are limb lengthening and angular deformity correction. Surgical application and postoperative management of the device require diligent attention to detail by both patient and surgeon. Also required of the surgeon is a thorough appreciation of the basic principles of the apparatus, mechanical axial realignment, potential complications, and biologic response to stretching.

    • Keywords:
    • Adolescent|Blood Vessels|Child|Female|Growth Disorders|Humans|Ilizarov Technique|Joint Diseases|Leg Bones|Leg Length Inequality|Male|Nerve Compression Syndromes|Peripheral Nerves|Postoperative Care|Stress

    • Psychological|Surgical Wound Infection

    • Subspecialty:
    • Pediatric Orthopaedics

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