JAAOS

JAAOS, Volume 13, No. 2


Atraumatic disorders of the sternoclavicular joint.

The sternoclavicular joint is the diarthrodial articulation between the axial and appendicular skeletons. It is subject to the same disease processes that occur in joints, including degenerative arthritis, rheumatoid arthritis, infection, and subluxation. Most of these conditions present with swelling of the joint, which may be associated with pain and/or tenderness. Plain radiographs can demonstrate changes on both sides of the joint. Because of variations in anatomy, computed tomography scans and magnetic resonance images are often necessary to clarify the pathology. With the exception of acute infection, most conditions can be managed nonsurgically, with joint resection reserved for patients with persistent symptoms.

    • Keywords:
    • Arthritis

    • Rheumatoid|Dislocations|Friedreich Ataxia|Hyperostosis|Infection|Joint Diseases|Osteitis|Osteoarthritis|Spinal Diseases|Sternoclavicular Joint

    • Subspecialty:
    • Shoulder and Elbow

Manifestations of hereditary multiple exostoses.

The solitary osteochondroma, a common pediatric bone tumor, is a cartilage-capped exostosis. Hereditary multiple exostosis is an autosomal dominant disorder manifested by the presence of multiple osteochondromas. Linkage analysis has implicated mutations in the EXT gene family, resulting in an error in the regulation of normal chondrocyte proliferation and maturation that leads to abnormal bone growth. Although exostoses are benign lesions, they are often associated with characteristic progressive skeletal deformities and may cause clinical symptoms. The most common deformities include short stature, limb-length discrepancies, valgus deformities of the knee and ankle, asymmetry of the pectoral and pelvic girdles, bowing of the radius with ulnar deviation of the wrist, and subluxation of the radiocapitellar joint. For certain deformities, surgery can prevent progression and provide correction. Patients with hereditary multiple exostosis have a slight risk of sarcomatous transformation of the cartilaginous portion of the exostosis.

    • Keywords:
    • Ankle|Bone and Bones|Exostoses

    • Multiple Hereditary|Femur|Forearm|Hand Deformities|Humans|Knee

    • Subspecialty:
    • Foot and Ankle

    • Pediatric Orthopaedics

    • Hand and Wrist

    • Spine

    • Musculoskeletal Oncology

Salvage of failed treatment of hip fractures.

Typically, patients with failed internal fixation of a hip fracture have marked pain and disability. These patients may present treatment challenges. Salvage is tailored to the anatomic site of the nonunion, the quality of the remaining bone and articular surface, and patient factors such as age and activity level. In younger patients with either a femoral neck or intertrochanteric fracture nonunion with a satisfactory hip joint, treatment typically involves revision internal fixation with or without osteotomy or bone grafting. In older patients with poor remaining proximal bone stock or a badly damaged hip joint, conversion to hip arthroplasty can restore function effectively and reduce pain. For femoral head salvage procedures, choosing a fixation device and accurate preoperative planning are the major challenges in decision making. For conversion to arthroplasty, the major challenges are assessing the need for acetabular resurfacing, selecting the femoral implant, and managing the greater trochanter. Technical challenges include broken hardware, deformity, and femoral bone defects. Attention to technical details can minimize potential complications.

    • Keywords:
    • Age Factors|Femoral Neck Fractures|Hip Fractures|Humans|Reoperation|Salvage Therapy|Treatment Failure

    • Subspecialty:
    • Trauma

Surgical approaches to the posteromedial and posterolateral aspects of the knee.

Surgical approaches to the posterior aspect of the knee are not commonly needed, and their use has become even rarer with the increasing sophistication of arthroscopic technology. As a result, physicians in orthopaedic surgical training are not often exposed to the practical use of surgical dissection around the posterior corners of the knee. For certain procedures, however, greater clinical utility and decreased surgical morbidity render focused posterior exposure the preferred alternative to the classic popliteal dissection with its wide exposure of the popliteal anatomy. Surgical indications include ligament repair or reconstruction around the posteromedial or posterolateral aspect of the knee, inside-out meniscal repair, posterior cruciate ligament tibial inlay reconstruction, and Baker's cyst excision. To minimize complications, these focused approaches require adeptness with the complex anatomy of the posterior, posteromedial, and posterolateral aspects.

    • Keywords:
    • Humans|Knee|Orthopedic Procedures

    • Subspecialty:
    • Foot and Ankle

    • Sports Medicine

The effects of surgical fracture fixation on the systemic inflammatory response to major trauma.

Early stabilization of major long bone fractures is beneficial in reducing the incidence of acute respiratory distress syndrome and multiple organ failure, both of which are caused by activation of the systemic inflammatory response. This activation results in tissue recruitment of and injury by circulating polymorphonuclear leukocytes. The reasons for clinical benefits of early fracture stabilization in major trauma are unknown. Published studies indicate that fracture surgery increases the posttraumatic inflammatory response. Major surgery to stabilize fractures carries a higher complication rate when performed on patients whose hypovolemic shock is not fully corrected. Thus, fracture care should be tailored to the patient, not dictated by the injured bone. Understanding the impact of fracture surgery on the systemic inflammatory response to major trauma is necessary to refine treatment and to apply it optimally to all patients.

    • Keywords:
    • Fracture Fixation|Fractures

    • Bone|Humans|Inflammation|Multiple Organ Failure|Respiratory Distress Syndrome

    • Adult|Wounds and Injuries

    • Subspecialty:
    • Trauma

Use of osteopromotive growth factors, demineralized bone matrix, and ceramics to enhance spinal fusion.

Recently developed materials that can enhance fusion rates for posterolateral lumbar arthrodesis may be used alone or in combination with autogenous bone grafts. Novel osteopromotive growth factor preparations are currently under scrutiny; these include autogenous growth factor concentrate, bovine bone-derived osteoinductive protein, and recombinant human MP52. Demineralized bone matrix products may enhance or extend grafts. However, few studies, especially prospective randomized clinical trials, have assessed their efficacy, so it is difficult to compare formulations. Ceramics have been evaluated in animal studies and human clinical trials for a variety of applications in spinal surgery. These materials function best as bone graft extenders or as bioactive osteoinductive material carriers in posterolateral lumbar fusions. They have the advantage of variable porosity, low cost, and ease of manufacture. Hydroxyapatite/tricalcium phosphate ceramics have been shown to perform as well as autogenous bone grafts but with fewer complications.

    • Keywords:
    • Bone Matrix|Bone Transplantation|Ceramics|Growth Substances|Humans|Spinal Fusion

    • Subspecialty:
    • Spine

    • Basic Science

Advertisements

Advertisement