JAAOS

JAAOS, Volume 14, No. 2


Early onset idiopathic scoliosis.

Children with early onset scoliosis typically present before age 5 years. Radiographic criteria help to distinguish progressive cases from those that will spontaneously resolve. Severe cardiopulmonary problems may occur in untreated progressive cases. A comprehensive evaluation should be performed to identify commonly associated conditions, such as plagiocephaly, congenital heart disease, inguinal hernia, and hip dysplasia. For curves >20 degrees , magnetic resonance imaging of the neural axis is indicated to rule out occult central nervous system lesions. Surgical management should be considered when nonsurgical measures, including bracing and casting, fail to arrest progression. Surgical methods continue to evolve and are primarily directed at obtaining and maintaining curve correction while simultaneously preserving spinal and trunk growth.

    • Keywords:
    • Algorithms|Biomechanics|Child

    • Preschool|Disease Progression|Humans|Prostheses and Implants|Pulmonary Alveoli|Remission

    • Spontaneous|Scoliosis|Spinal Fusion|Spine|Thoracoplasty|Treatment Outcome

    • Subspecialty:
    • Pediatric Orthopaedics

    • Spine

Hardware removal: indications and expectations.

Although hardware removal is commonly done, it should not be considered a routine procedure. The decision to remove hardware has significant economic implications, including the costs of the procedure as well as possible work time lost for postoperative recovery. The clinical indications for implant removal are not well established. There are few definitive data to guide whether implant removal is appropriate. Implant removal may be challenging and lead to complications, such as neurovascular injury, refracture, or recurrence of deformity. When implants are removed for pain relief alone, the results are unpredictable and depend on both the implant type and its anatomic location. Current literature does not support the routine removal of implants to protect against allergy, carcinogenesis, or metal detection. Surgeons and patients should be aware of appropriate indications and have realistic expectations of the risks and benefits of implant removal.

    • Keywords:
    • Device Removal|Fracture Fixation

    • Internal|Fracture Fixation

    • Intramedullary|Humans|Hypersensitivity|Metals|Prostheses and Implants|Tibial Fractures

    • Subspecialty:
    • Trauma

    • General Orthopaedics

Osteochondritis dissecans of the knee.

Osteochondritis dissecans is a condition of the joints that appears to affect subchondral bone primarily, with secondary effects on articular cartilage. With progression, this pathology may present clinically with symptoms related to the integrity of the articular cartilage. Early signs, associated with intact cartilage, may be related to a softening phenomenon and alteration in the mechanical properties of cartilage. Later stages, because of the lack of underlying support of the cartilage, can present with signs of articular cartilage separation, cartilage flaps, loose bodies, inflammatory synovitis, persistent or intermittent joint effusion, and, in severe cases, secondary joint degeneration. Selecting and recommending a surgical intervention require balancing application of nonsurgical interventions with assessment of the degree of articular cartilage stability and the potential for spontaneous recovery.

    • Keywords:
    • Algorithms|Cartilage

    • Articular|Debridement|Disease Progression|Humans|Knee Joint|Magnetic Resonance Imaging|Osteochondritis Dissecans|Prognosis

    • Subspecialty:
    • Foot and Ankle

    • Sports Medicine

Subaxial cervical spine trauma.

Subaxial cervical spine injuries are common, ranging in severity from minor ligamentous strain or spinous process fracture to complete fracture-dislocation with bone and ligament failure, resulting in severe spinal cord injury. Understanding the epidemiology, anatomy, biomechanics, and classification of subaxial cervical spine injuries is important. Emergent management of such injuries is based on obtaining an accurate clinical history, careful physical examination, and organized radiographic evaluation. Attaining a unified approach to the wide spectrum of subaxial cervical injuries is difficult. In addition, controversy exists regarding the safety of closed reduction in certain injury patterns and the administration of methylprednisolone for acute spinal cord injury. Definitive management (surgical or nonsurgical) is based on the assessment of the mechanical instability of the injury, the presence or absence of neurologic impairment, and various patient factors that may influence outcome. Several complications, including the deterioration of neurologic status, may occur with either surgical or nonsurgical management, but the most frequent mistake made is missing the injury on initial evaluation.

    • Keywords:
    • Biomechanics|Cervical Vertebrae|Humans|Immobilization|Joint Instability|Magnetic Resonance Imaging|Methylprednisolone|Spinal Fractures|Spinal Injuries|Tomography

    • X-Ray Computed

    • Subspecialty:
    • Trauma

    • Spine

    • Basic Science

The rheumatoid wrist.

Wrist involvement is common in patients with rheumatoid arthritis. Individual patient assessment is important in determining functional deficits and treatment goals. Patients with persistent disease despite aggressive medical management are candidates for surgery. Soft-tissue procedures offer good symptomatic relief and functional improvement in the short term. Extensor and flexor tendons may rupture because of synovial infiltration and bony irritation. When rupture occurs, direct repair usually is not possible. However, when joints that are motored by the ruptured tendon are still functional, tendon transfer or grafting may be considered. Because of the progressive nature of the disease, dislocation and end-stage arthritis often require stabilization with bony procedures. The distal radioulnar joint is usually affected first and is commonly treated with either the Darrach or the Sauvé-Kapandji procedure. Partial wrist fusion offers a compromise between achieving stability of the affected radiocarpal joint and maintaining motion at the midcarpal joint. For pancarpal arthritis, total wrist fusion offers reliable pain relief at the cost of motion. Total wrist arthroplasty is an alternative that preserves motion; however, the outcomes of total wrist replacement are still being evaluated.

    • Keywords:
    • Arthritis

    • Rheumatoid|Arthroplasty|Carpal Tunnel Syndrome|Humans|Joint Instability|Ligaments

    • Articular|Orthopedic Procedures|Rupture|Tendon Injuries|Tendon Transfer|Tendons|Wrist Joint

    • Subspecialty:
    • Hand and Wrist

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