JAAOS

JAAOS, Volume 12, No. 6


Articular fractures.

Although injuries to articular cartilage may lead to radiographic osteoarthritis, pain, and decreased joint function, the actual effects of such injury and of its treatment on joint function are not completely understood. The mechanisms of repair after impact loading are different from those after frank disruption by fracture of the articular cartilage, but basic and clinical research both indicate that the resultant articular surface is prone to degeneration. The sensitivity of a joint to resultant incongruity varies considerably, depending on the thickness and modulus of the articular cartilage and the geometry of the joint. Also, factors other than articular congruity play a substantial role in determining outcomes after treatment. For these reasons, defining a single threshold for articular displacement that correlates with outcomes in all joints is not practical. Some articular fractures injure cartilage so severely that the joint will degenerate even with an accurate articular reduction. Also, radiographic evidence of osteoarthritis does not necessarily correlate with poor function. More reliable measurement techniques are needed to accurately assess how treatment affects arthritis, and factors other than articular congruity are needed to predict posttraumatic arthritis.

    • Keywords:
    • Animals|Clinical Trials as Topic|Diagnostic Imaging|Disease Models

    • Animal|Fracture Fixation|Fracture Healing|Fractures

    • Bone|Humans|Injury Severity Score|Joints|Prognosis|Rabbits|Range of Motion

    • Articular|Recovery of Function|Risk Assessment

    • Subspecialty:
    • Trauma

Fondaparinux.

    • Keywords:
    • Biological Availability|Clinical Trials

    • Phase III as Topic|Cost-Benefit Analysis|Dose-Response Relationship

    • Drug|Drug Administration Schedule|Female|Follow-Up Studies|Hip Prosthesis|Humans|Knee Prosthesis|Male|Orthopedic Procedures|Polysaccharides|Postoperative Complications|Risk Assessment|Treatment Outcome|Venous Thrombosis

    • Subspecialty:
    • General Orthopaedics

Hyperbaric oxygen therapy in extremity trauma.

Hyperbaric oxygen therapy potentially can provide enhanced oxygen delivery to peripheral tissues affected by vascular disruption, cytogenic and vasogenic edema, and cellular hypoxia caused by extremity trauma. After appropriate resuscitation, macrovascular repair, and fracture fixation/stabilization, adjunctive hyperbaric oxygen therapy can enhance tissue oxygen content. In patients with crush injury or early compartment syndrome, hyperbaric oxygen therapy may reduce the penumbra of cells at risk for delayed necrosis and secondary ischemia. Animal experiments and human case series suggest the benefits of such therapy, and recent randomized, prospective studies on trauma patients have confirmed its efficacy in those with extremity trauma. However, more data are necessary to determine additional indications as well as optimal timing and dosing for hyperbaric oxygen therapy.

    • Keywords:
    • Animals|Arm Injuries|Disease Models

    • Animal|Female|Humans|Hyperbaric Oxygenation|Injury Severity Score|Leg Injuries|Male|Multiple Trauma|Prognosis|Randomized Controlled Trials as Topic|Rats|Risk Assessment|Wound Healing

    • Subspecialty:
    • Trauma

    • General Orthopaedics

    • Basic Science

Leg pain in the running athlete.

Leg pain is a common complaint among recreational and professional athletes who compete in running sports. Evaluation of the individual with intermittent or constant leg pain should be well organized and inclusive. Duration of the pain, its relation to injury, intensity of the pain, and its pattern are important factors. Additionally, changes in the training regimen, its level, intensity, or duration, or in the nature of the routine are critical components of the assessment. Physical examination can help differentiate bony from soft-tissue etiologies. Studies are dictated by the differential diagnosis but include radiographs in almost all patients and selected use of other modalities. These include bone scans and magnetic resonance imaging for medial tibial stress syndrome and stress fractures and intracompartmental pressure measurements for chronic compartment syndrome. Treatment often requires either rest or a change in training regimen. Surgery for conditions such as chronic compartment syndrome frequently allows a return to preinjury activities.

    • Keywords:
    • Adolescent|Adult|Athletic Injuries|Casts

    • Surgical|Diagnostic Imaging|Female|Fractures

    • Stress|Humans|Leg|Male|Pain|Pain Measurement|Prognosis|Recovery of Function|Risk Assessment|Running|Stress

    • Mechanical|Treatment Outcome

    • Subspecialty:
    • Sports Medicine

    • Pain Management

Posterior instrumentation for thoracolumbar fractures.

Thoracolumbar fractures are relatively common injuries. Numerous classification systems have been developed to characterize these fractures and their prognostic and therapeutic implications. Recent emphasis on short, rigid fixation has influenced surgical management. Most compression and stable burst fractures should be treated nonsurgically. Neurologically intact patients with unstable burst fractures that have >25 degrees of kyphosis, >50% loss of vertebral height, or >40% canal compromise often can be treated with short, rigid posterior fusions. Patients with unstable burst fractures and neurologic deficits require direct or indirect decompression. Posterior stabilization can be effective with Chance fractures and flexion-distraction injuries that have marked kyphosis, and in translational or shear injuries. Advances in understanding both biomechanics and types of fixation have influenced the development of reliable systems that can effectively stabilize these fractures and permit early mobilization.

    • Keywords:
    • Equipment Design|Equipment Safety|Female|Follow-Up Studies|Fracture Fixation

    • Internal|Fracture Healing|Humans|Injury Severity Score|Internal Fixators|Lumbar Vertebrae|Male|Postoperative Care|Recovery of Function|Risk Assessment|Spinal Fractures|Spinal Fusion|Thoracic Vertebrae|Treatment Outcome

    • Subspecialty:
    • Trauma

    • Spine

    • Basic Science

Posterolateral rotatory instability of the elbow.

Posterolateral rotatory instability of the elbow is a three-dimensional displacement pattern of abnormal external rotatory subluxation of the ulna coupled with valgus displacement on the humeral trochlea. This pattern causes the forearm bones to displace into external rotation and valgus during flexion of the elbow. Injury to the lateral ulnar collateral ligament allows abnormal supination of the ulna on the humerus. The radial head, being locked in the sigmoid (radial) notch of the proximal ulna by the annular ligament, subluxates posterior to the capitellum. The abnormality is usually posttraumatic and presents with locking, snapping, clicking, catching, and recurrent dislocation of the elbow. The clinical diagnosis is suspected from history and confirmed by the physical examination, which includes the posterolateral rotatory instability test. This test often is best performed under fluoroscopy or general anesthesia. Usually the instability is managed with either a repair of the ligament or an isometric reconstruction using a tendon graft.

    • Keywords:
    • Arthroscopy|Biomechanics|Dislocations|Elbow Joint|Female|Follow-Up Studies|Humans|Injury Severity Score|Joint Instability|Male|Orthopedic Procedures|Pain Measurement|Range of Motion

    • Articular|Recovery of Function|Rotation|Treatment Outcome

    • Subspecialty:
    • Shoulder and Elbow

Recommendations for optimal care of the fragility fracture patient to reduce the risk of future fracture.

Fragility fractures resulting from low trauma events such as a fall from standing height affect up to one half of women and one third of men after age 50 years. These fractures are frequently associated with osteoporosis. History of a fragility fracture is among the strongest risk factors for future fracture. Therefore, optimal care of the patient with a fragility fracture includes not only treatment of the presenting fracture itself but also evaluation and treatment of the underlying cause or causes to prevent future fractures. However, despite the availability of therapeutic agents that reduce fracture risk among osteoporotic patients who have had a fracture, most patients with fragility fractures are not evaluated for osteoporosis or treated adequately to reduce the risk of future fracture. Orthopaedic surgeons are the first and often the only physicians seen by fracture patients. Thus, they have the unique opportunity to serve as primary advocates to ensure that appropriate action is taken to reduce the risk of future fracture.

    • Keywords:
    • Age Factors|Aged|Bone Density|Combined Modality Therapy|Diphosphonates|Estrogen Replacement Therapy|Female|Follow-Up Studies|Fracture Fixation|Fracture Healing|Fractures

    • Spontaneous|Humans|Male|Middle Aged|Osteoporosis|Osteoporosis

    • Postmenopausal|Recurrence|Risk Assessment

    • Subspecialty:
    • Trauma

The failed total knee arthroplasty: evaluation and etiology.

Evaluation of a patient with a failed total knee arthroplasty begins with a detailed history of the index knee arthroplasty and with the patient's medical history. The nature of the complaint after arthroplasty can help determine the etiology of failure. The primary causes of failure of total knee arthroplasty are pain, postoperative stiffness, and instability. Pain associated with weight bearing is most often mechanical and is caused by loosening, component failure, or patellar dysfunction. Continuous pain can be associated with infection or complex regional pain syndrome. Persistent postoperative stiffness may be caused by inadequate rehabilitation or improper balancing of flexion and extension spaces. However, loss of motion after satisfactory mobility has been achieved may be associated with infection, synovitis, tendinitis, or component loosening. Instability after total knee arthroplasty results from improper balancing, inappropriate component size, and component failure. Posterior instability generally occurs during flexion. Medial-lateral instability can result from either improper balancing of components or incompetent collateral ligaments. Radiographs can detect loosening and osteolysis, as well as component wear, fracture, and malposition. Nuclear scans can aid in detecting loosening and infection. If infection is suspected, aspiration is mandatory to attempt to confirm the diagnosis and identify an organism.

    • Keywords:
    • Age Factors|Aged|Arthroplasty

    • Replacement

    • Knee|Diagnostic Imaging|Female|Follow-Up Studies|Humans|Incidence|Knee Prosthesis|Male|Middle Aged|Prosthesis Design|Prosthesis Failure|Reoperation|Risk Assessment|Sex Factors

    • Subspecialty:
    • Adult Reconstruction

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