JAAOS

JAAOS, Volume 13, No. 4


Gene therapy for the treatment of musculoskeletal diseases.

Research into the orthopaedic applications of gene therapy has resulted in progress toward managing chronic and acute genetic and nongenetic disorders. Gene therapy for arthritis, the original focus of research, has progressed to the initiation of several phase I clinical trials. Preliminary findings support the application of gene therapy in the treatment of additional chronic conditions, including osteoporosis and aseptic loosening, as well as musculoskeletal tumors. The most rapid progress is likely to be in tissue repair because it requires neither long-term transgene expression nor closely regulated levels of transgene expression. Moreover, healing probably can be achieved with existing technology. In preclinical studies, genetically modulated stimulation of bone healing has shown impressive results in repairing segmental defects in the long bones and cranium and in improving the success of spinal fusions. An increasing amount of evidence indicates that gene transfer can aid the repair of articular cartilage, menisci, intervertebral disks, ligaments, and tendons. These developments have the potential to transform many areas of musculoskeletal care, leading to treatments that are less invasive, more effective, and less expensive than existing modalities.

    • Keywords:
    • Arthritis

    • Rheumatoid|Gene Therapy|Gene Transfer Techniques|Humans|Lysosomal Storage Diseases|Musculoskeletal Diseases|Myositis Ossificans|Osteoarthritis|Osteogenesis Imperfecta|Osteoporosis|Spinal Fusion

    • Subspecialty:
    • Spine

    • Musculoskeletal Oncology

High tibial osteotomy.

High tibial osteotomy is effective for managing a variety of knee conditions, including gonarthrosis with varus or valgus malalignment, osteochondritis dissecans, osteonecrosis, posterolateral instability, and chondral resurfacing. The fundamental goals of the procedure are to unload diseased articular surfaces and to correct angular deformity at the tibiofemoral articulation. Although the clinical success of total knee arthroplasty has resulted in fewer high tibial osteotomies being done during the past decade, the procedure remains useful in appropriately selected patients with unicompartmental knee disease. Renewed interest in high tibial osteotomy has occurred for a number of reasons. These include the prevalence of physiologically young active patients presenting with medial compartment osteoarthritis; the advent of new techniques for performing the procedure (ie, improved instrumentation and fixation plates for medial opening wedge osteotomy, dynamic external fixation for medial opening wedge osteotomy, and improved instrumentation for lateral closing wedge osteotomy); and the need to concomitantly correct malalignment when performing chondral resurfacing procedures (ie, autologous chondrocyte transplantation, mosaicplasty, and microfracture).

    • Keywords:
    • Arthritis|Arthroplasty|Arthroplasty

    • Replacement

    • Knee|Bone Diseases|Bone Malalignment|Cartilage

    • Articular|Humans|Osteonecrosis|Osteotomy|Regeneration|Tibia|Treatment Outcome

    • Subspecialty:
    • Adult Reconstruction

Management of extremity trauma and related infections occurring in the aquatic environment.

Wounds sustained in oceans, lakes, and streams are exposed to a milieu of bacteria rarely encountered in typical land-based injuries. These include Vibrio species, Aeromonas hydrophila, Pseudomonas and Plesiomonas species, Erysipelothrix rhusiopathiae, Mycobacterium marinum, and other microbes. Failure to recognize and treat these less common pathogens in a timely manner may result in significant morbidity or death. Initial antibiotic therapy should address common gram-positive and gram-negative aquatic bacteria, depending on the environment. Trauma occurring in brackish or salt water should be treated with doxycycline and ceftazidime, or a fluoroquinolone (eg, ciprofloxacin or levofloxacin). Freshwater wounds should be managed with ciprofloxacin, levofloxacin, or a third- or fourth-generation cephalosporin (eg, ceftazidime). Injuries sustained in a marine or freshwater environment may result from bites or venomous stings of aquatic organisms as well as from accidental trauma. Musculoskeletal trauma caused by venomous underwater species (eg, stingrays, stinging fish, sea urchins, and coral) requires immediate neutralization of the heat-labile toxin with immersion in nonscalding water for 30 to 90 minutes. Appropriate management of aquatic wounds requires recognition of the mechanism of injury, neutralization of venom, antibiotic administration, radiographic assessment, surgical d?bridement with irrigation, wound cultures, and structural repair or amputation as indicated by the severity of the injury.

    • Keywords:
    • Aeromonas hydrophila|Animals|Bacterial Infections|Bites and Stings|Catfishes|Eels|Erysipelothrix Infections|Fresh Water|Gram-Negative Bacterial Infections|Humans|Lacerations|Leg Injuries|Mycobacterium Infections

    • Atypical|Mycobacterium marinum|Oceans and Seas|Sea Urchins|Soft Tissue Infections|Vibrio Infections|Wounds and Injuries

    • Subspecialty:
    • Trauma

    • Basic Science

Management of the upper extremity in juvenile rheumatoid arthritis.

Juvenile rheumatoid arthritis is a multifaceted disease. Average age of onset is 6 years, with peaks between 1 and 4 and between 9 and 14 years. Girls are affected more frequently than boys. Nonsteroidal anti-inflammatory drugs are the standard first line of therapy. Second-line therapy of antirheumatic drugs may be used early for progressive disease. Intra-articular corticosteroid injections should be considered to preserve joint mobility and muscle strength when medical treatment fails to control synovitis or when marked functional impairment exists. Historically, surgery has been a last resort, but in appropriate patients, it should be considered soon after failure of conservative management. However, when possible, reconstructive surgery should be delayed until completion of skeletal growth.

    • Keywords:
    • Algorithms|Antibodies

    • Monoclonal|Antirheumatic Agents|Arthritis

    • Juvenile Rheumatoid|Child|Elbow Joint|Finger Joint|Glucocorticoids|Humans|Hydroxychloroquine|Metacarpophalangeal Joint|Methotrexate|Penicillamine|Shoulder Joint|Thumb|Wrist Joint

    • Subspecialty:
    • Pediatric Orthopaedics

Orthopaedic management of ankylosing spondylitis.

Ankylosing spondylitis is an inflammatory disease of unknown etiology that affects an estimated 350,000 persons in the United States and 600,000 in Europe, primarily Caucasian males in the second through fourth decades of life. Worldwide, the prevalence is 0.9%. Genetic linkage to HLA-B27 has been established. Ankylosing spondylitis primarily affects the axial skeleton and is characterized by inflammation and fusion of the sacroiliac joints, spine, and hips. The resultant deformity leads to severe functional impairment in approximately 30% of patients. Orthopaedic management primarily involves correction of hip deformity through total hip arthroplasty and, less frequently, correction of spinal deformity with spine osteotomy. Closing wedge osteotomies have the lowest incidence of complications. Whether patients with ankylosing spondylitis are at increased risk for heterotopic ossification remains controversial, but comparison with age- and sex-matched counterparts suggests no dramatically higher risk. Because of the high rate of missed fractures and complications after minor trauma in patients with ankylosing spondylitis, plain radiographs are usually not sufficient for evaluation. Thorough patient assessment should include a comprehensive history, physical examination, and laboratory studies.

    • Keywords:
    • Anti-Inflammatory Agents

    • Non-Steroidal|Arthroplasty

    • Replacement

    • Hip|Bone Diseases

    • Metabolic|Cervical Vertebrae|Discitis|Hip Joint|Humans|Osteotomy|Physical Examination|Spine|Spondylitis

    • Ankylosing|Traction|Zygapophyseal Joint

    • Subspecialty:
    • Spine

    • Adult Reconstruction

Reading and reviewing the orthopaedic literature: a systematic, evidence-based medicine approach.

The principles of evidence-based medicine are rapidly gaining acceptance in the field of orthopaedic surgery. This approach to patient care requires a careful, systematic review of the literature to appropriately value the merit of studies. Systematic review assists the orthopaedic surgeon in interpreting study results and in understanding the relative validity of these results in the hierarchy of evidence. Sufficiently valid evidence-based information ultimately will help in making decisions regarding patient care.

    • Keywords:
    • Bias (Epidemiology)|Case-Control Studies|Confounding Factors (Epidemiology)|Evidence-Based Medicine|Humans|Orthopedics|Prospective Studies|Research Design

    • Subspecialty:
    • Clinical Practice Improvement

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