JAAOS

JAAOS, Volume 13, No. 3


Graft selection in anterior cruciate ligament reconstruction.

The ideal graft for use in anterior cruciate ligament reconstruction should have structural and biomechanical properties similar to those of the native ligament, permit secure fixation and rapid biologic incorporation, and limit donor site morbidity. Many options have been clinically successful, but the ideal graft remains controversial. Graft choice depends on surgeon experience and preference, tissue availability, patient activity level, comorbidities, prior surgery, and patient preference. Patellar tendon autograft, the most widely used graft source, appears to be associated with an increased incidence of anterior knee pain compared with hamstring autograft. Use of hamstring autograft is increasing. Quadriceps tendon autograft is less popular but has shown excellent clinical results with low morbidity. Improved sterilization techniques have led to increased safety and availability of allograft, although allografts have a slower rate of incorporation than do most types of autograft. No graft has clearly been shown to provide a faster return to play. However, in general, patellar tendon autografts are preferable for high-performance athletes, and hamstring autografts and allografts have some relative advantages for lower-demand individuals. No current indications exist for synthetic ligaments.

    • Keywords:
    • Anterior Cruciate Ligament|Athletic Injuries|Humans|Ligaments|Patellar Ligament|Reconstructive Surgical Procedures|Tendons|Transplantation

    • Autologous|Transplantation

    • Homologous

    • Subspecialty:
    • Sports Medicine

Nerve and tendon lacerations about the foot and ankle.

Nerve and tendon lacerations of the foot and ankle region are relatively common. Acute nerve and tendon injuries should be repaired with appropriate techniques at the time of initial wound exploration. Primary nerve repair may help minimize the risk of painful neuroma formation; primary tendon repair can lead to better functional results than delayed repair. Most chronic nerve injuries, except those to the tibial nerve or its major divisions, are managed by resection of a painful neuroma and burying the nerve ending in a protected area. Delayed reconstruction of tendon injuries is performed when correction of the functional deficit outweighs the morbidity of surgery.

    • Keywords:
    • Ankle|Ankle Injuries|Foot|Foot Injuries|Humans|Lacerations|Neuroma|Reconstructive Surgical Procedures|Tendon Injuries

    • Subspecialty:
    • Foot and Ankle

    • Sports Medicine

Osteochondral lesions of the talus.

Osteochondral lesions of the talus occur infrequently and usually represent late sequelae of ankle trauma. Because of the functional significance of the talus and its limited capacity for repair, correct early diagnosis is important. Osteochondral fractures should be suspected in patients with chronic ankle pain, especially those with a prior ankle injury. Historically, plain radiographs have been used to stage lesions; more recently, magnetic resonance imaging and arthroscopy have been used. Non-surgical management remains the mainstay of treatment of acute, nondisplaced osteochondral lesions. Surgical management is reserved for unstable fragments or failure of nonsurgical treatment. Recent advances in osteochondral grafting have allowed reconstruction of the talar dome, leading to more predictable relief of pain and improvement of function.

    • Keywords:
    • Bone Transplantation|Cartilage

    • Articular|Fractures

    • Bone|Fractures

    • Cartilage|Humans|Talus

    • Subspecialty:
    • Trauma

    • Foot and Ankle

Plating of the distal radius.

Distal radius fractures are common injuries that can be treated by a variety of methods. Restoration of the distal radius anatomy within established guidelines yields the best short- and long-term results. Guidelines for acceptable reduction are (1) radial shortening < 5 mm, (2) radial inclination > 15 degrees , (3) sagittal tilt on lateral projection between 15 degrees dorsal tilt and 20 degrees volar tilt, (4) intra-articular step-off < 2 mm of the radiocarpal joint, and (5) articular incongruity < 2 mm of the sigmoid notch of the distal radius. Treatment options range from closed reduction and immobilization to open reduction with plates and screws; options are differentiated based on their ability to reinforce and stabilize the three columns of the distal radius and ulna. Plating allows direct restoration of the anatomy, stable internal fixation, a decreased period of immobilization, and early return of wrist function. Buttress plates reduce and stabilize vertical shear intra-articular fractures through an antiglide effect, where-as conventional and locking plates address metaphyseal comminution and/or preserve articular congruity/reduction. With conventional and locking plates, intra-articular fractures are directly reduced; with buttress plates, the plate itself helps reduce the intra-articular fracture. Complications associated with plating include tendon irritation or rupture and the need for plate removal.

    • Keywords:
    • Bone Plates|Bone Screws|Equipment Design|Fracture Fixation

    • Internal|Humans|Radius Fractures|Treatment Outcome

    • Subspecialty:
    • Trauma

    • Hand and Wrist

Shoulder and elbow injuries in the skeletally immature athlete.

The intensity of training and competition among young athletes can place them at increased risk of acute and chronic injuries, which occur in patterns unique to the skeletally immature athlete. Prompt recognition and treatment of these injuries are critical to prevent long-term functional disability and deformity. Children and adolescents participating in recreational and organized sports are particularly susceptible to a broad spectrum of shoulder and elbow injuries involving both osseous and soft-tissue structures. Understanding the relevant functional anatomy, biomechanics of throwing, and pathophysiology of injury can help the clinician manage common acute traumatic injuries, some of which may result in chronic problems. Over-use injuries occur more frequently than do acute, traumatic injuries, and early recognition, coupled with appropriate treatment or prevention, can help restore and maintain normal shoulder and elbow function.

    • Keywords:
    • Adolescent|Athletic Injuries|Biomechanics|Bone Development|Child|Cumulative Trauma Disorders|Elbow Joint|Humans|Joint Diseases|Shoulder Joint

    • Subspecialty:
    • Sports Medicine

    • Pediatric Orthopaedics

    • Shoulder and Elbow

    • Basic Science

Total hip arthroplasty in sickle cell hemoglobinopathies.

Advances in medical treatment have led to improved life expectancy in patients with sickle cell hemoglobinopathies. Improved life expectancy has, in turn, led to an increasing number of patients with osteonecrosis requiring total hip arthroplasty. Patient evaluation begins with understanding the extent of the disease process and the patient's musculoskeletal manifestations (ie, pyogenic infection, marrow hyperplasia, osteonecrosis). A multidisciplinary approach to implementing effective preoperative treatment strategies increases the likelihood of a successful surgical outcome. Intraoperatively, consideration of bone stock, bone quality, and method of component fixation may help minimize the risk of eccentric reaming, perforation or fracture of either the acetabulum or the femur, and loosening. The optimal mode of acetabular and femoral fixation in these patients has not been conclusively determined, but recent results of cementless total hip arthroplasty have been encouraging. Although patients with sickle cell disease are at increased risk of medical and surgical complications, total hip arthroplasty in the appropriately selected patient can provide significant pain relief, restoration of function, and patient satisfaction.

    • Keywords:
    • Anemia

    • Sickle Cell|Arthroplasty

    • Replacement

    • Hip|Humans|Patient Care Planning|Treatment Outcome

    • Subspecialty:
    • Trauma

    • Adult Reconstruction

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