JAAOS

JAAOS, Volume 14, No. 3


Analgesia for total hip and knee arthroplasty: a multimodal pathway featuring peripheral nerve block.

Patients undergoing total hip and knee arthroplasty experience substantial and sustained postoperative pain. Inadequate analgesia may impede physical therapy and rehabilitative efforts and delay hospital dismissal. Traditionally, postoperative analgesia after total joint replacement was provided by either intravenous patient-controlled analgesia or epidural analgesia. Each, however, had disadvantages as well as advantages. Peripheral nerve blockade of the lumbosacral plexus has emerged as an alternative analgesic approach. In several studies, unilateral peripheral block provided a quality of analgesia and functional outcomes similar to those of continuous epidural analgesia and superior to those of systemic analgesia, but with fewer side effects because of their opioid-sparing properties. Peripheral nerve block techniques may be the optimal analgesic method following total joint arthroplasty.

    • Keywords:
    • Acetaminophen|Analgesia|Analgesia

    • Epidural|Analgesics

    • Non-Narcotic|Anti-Inflammatory Agents

    • Non-Steroidal|Arthroplasty

    • Replacement

    • Hip|Arthroplasty

    • Knee|Autonomic Nerve Block|Cyclooxygenase 2 Inhibitors|Humans|Tramadol

    • Subspecialty:
    • Adult Reconstruction

    • Pain Management

Arthrodesis of the shoulder.

Shoulder arthrodesis is an end-stage salvage option for the failing, painful joint that cannot undergo or has failed reconstruction. It is indicated for irreversible and nonreconstructible massive rotator cuff tears and deltoid muscle denervation as well as for detachment of the deltoid from its origin. Rarely, arthrodesis is done to stabilize the glenohumeral joint after many failed attempts at shoulder reconstruction. Arthrodesis for failed prosthetic arthroplasty or tumor resection presents additional challenges because of the associated bone loss on the humeral and/or glenoid side of the joint. Primary arthrodesis requires rigid internal plate fixation and both an extra- and an intra-articular site of fusion. Depending on bone volume and quality needed, the patient may require bracing for 8 to 10 weeks, autogenous or allograft bone grafting, or a vascularized fibular bone graft to reconstruct the bone deficiency, along with prolonged spica cast immobilization. The optimal position for arthrodesis is 20 degrees of forward flexion, 20 degrees of abduction, and 40 degrees of internal rotation, with modifications based on patient body size or other patient-specific factors. Bone fusion is attained in nearly all patients, with marked pain reduction and improved function. Postoperatively, the patient should be able to lift the arm to near shoulder height and to reach the top of the head, the mouth, the ipsilateral back pocket, and the groin. Complications include nonunion, malposition, pain associated with prominent hardware, and periarticular fractures.

    • Keywords:
    • Arthrodesis|Arthroplasty

    • Replacement|Bone Plates|External Fixators|Humans|Muscle

    • Skeletal|Recovery of Function|Rotator Cuff|Rupture|Shoulder Joint

    • Subspecialty:
    • Trauma

    • Shoulder and Elbow

Knee arthrodesis.

Arthrodesis is one of the last options available to obtain a stable, painless knee in a patient with a damaged knee joint that is not amenable to reconstructive measures. Common indications for knee arthrodesis include failed total knee arthroplasty, periarticular tumor, posttraumatic arthritis, and chronic sepsis. The primary contraindications to knee fusion are bilateral involvement or an ipsilateral hip arthrodesis. A variety of techniques has been described, including external fixation, internal fixation by compression plates, intramedullary fixation through the knee with a modular nail, and antegrade nailing through the piriformis fossa. Allograft or autograft may be necessary to restore lost bone stock or to augment fusion. For the carefully selected patient with realistic expectations, knee arthrodesis may relieve pain and obviate the need for additional surgery or extensive postoperative rehabilitation.

    • Keywords:
    • Arthrodesis|Arthroplasty

    • Replacement

    • Knee|Bone Nails|Bone Transplantation|External Fixators|Fibula|Fracture Fixation

    • Intramedullary|Humans|Joint Instability|Knee Joint|Prosthesis-Related Infections|Transplantation

    • Homologous

    • Subspecialty:
    • Trauma

Meniscal allograft transplantation.

Meniscal allograft transplantation is a reasonable treatment option for the young patient with symptomatic meniscal deficiency. Although clinical results are promising, in most studies only mixed procedures have been performed, with short- or medium-term follow-up. Important potential prognostic factors include patient selection, severity of degenerative changes, limb stability and alignment, graft sizing and processing methods, graft placement, and graft fixation. The use of meniscal allograft transplantation should be considered a salvage operation for the difficult clinical dilemma of meniscal deficiency in young patients. Nonetheless, in carefully selected patients, this procedure can predictably relieve compartmental symptoms, and, in conjunction with anterior cruciate ligament reconstruction, restore knee stability. In addition, the partial restoration of meniscal function provided by this procedure may slow the degenerative arthritic process.

    • Keywords:
    • Animals|Anterior Cruciate Ligament|Biomechanics|Cryopreservation|Humans|Knee Joint|Menisci

    • Tibial|Patient Selection|Postoperative Care|Suture Techniques|Tissue Preservation|Transplantation

    • Homologous

    • Subspecialty:
    • Sports Medicine

    • General Orthopaedics

Orthopaedic trauma in the pregnant patient.

Trauma affects up to 8% of pregnancies and is the leading cause of death among pregnant women in the United States. A pregnancy test is mandated for all females of childbearing age who are involved in trauma. Orthopaedic trauma in the pregnant patient is managed similarly to that for all trauma patients. Initial resuscitation efforts should focus on the pregnant patient because stable patient vital signs provide the best chance for fetal survival. In the stable patient, fetal assessment and a pelvic examination are mandatory. Radiographs as well as abdominal ultrasound of the patient and fetal ultrasound are useful. No known biologic risks are associated with magnetic resonance imaging, and no specific fetal abnormalities have been linked with standard low-intensity magnetic resonance imaging. Emergency surgery can be safely performed in most pregnant patients. Avoiding patient hypotension and using left lateral decubitus positioning increase the likelihood of success for the patient and fetus. An experienced multidisciplinary team consisting of an obstetrician, perinatologist, orthopaedic surgeon, anesthesiologist, radiologist, and nursing staff will optimize the treatment of both the pregnant patient and her fetus.

    • Keywords:
    • Female|Fetus|Fracture Fixation|Fractures

    • Bone|Fractures

    • Comminuted|Humans|Musculoskeletal System|Posture|Pregnancy|Pregnancy Complications|Regional Blood Flow|Tomography

    • X-Ray Computed|Uterus

    • Subspecialty:
    • Trauma

Using the internet to enhance physician-patient communication.

The rise in Internet use by patients with musculoskeletal problems has put orthopaedic surgeons under increased pressure to provide Web-based resources. Patients are researching musculoskeletal conditions online, and many want to communicate electronically with their physicians. Online medical information may be a useful adjunct to traditional physician-patient interaction because it is readily available, is wide in scope, and can provide the patient with basic knowledge on a given topic. A clinical encounter may then be efficiently spent refining information and answering specific questions. Orthopaedic surgeons should be aware of the advantages of using Internet resources as part of their practice as well as the potential legal and confidentiality pitfalls in electronic communication. Some patient concerns may be easily satisfied and communication enhanced through the use of e-mail. Physicians planning to incorporate electronic communication with their patients must be prepared to manage unsolicited e-mail, maintain patient confidentiality, and adopt practices that maximize the use of online resources to enhance patient education.

    • Keywords:
    • Confidentiality|Electronic Mail|Humans|Internet|Patient Education as Topic|Physician-Patient Relations|Practice Management

    • Medical

    • Subspecialty:
    • Clinical Practice Improvement

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