JAAOS

JAAOS, Volume 14, No. 4


Extracorporeal shock wave therapy in the treatment of chronic tendinopathies.

Many clinical trials have evaluated the use of extracorporeal shock wave therapy for treating patients with chronic tendinosis of the supraspinatus, lateral epicondylitis, and plantar fasciitis. Although extracorporeal shock wave therapy has been reported to be effective in some trials, in others it was no more effective than placebo. The multiple variables associated with this therapy, such as the amount of energy delivered, the method of focusing the shock waves, frequency and timing of delivery, and whether or not anesthetics are used, makes comparing clinical trials difficult. Calcific tendinosis of the supraspinatus and plantar fasciitis have been successfully managed with extracorporeal shock wave therapy when nonsurgical management has failed. Results have been mixed in the management of lateral epicondylitis, however, and this therapy has not been effective in managing noncalcific tendinosis of the supraspinatus. Extracorporeal shock wave therapy has consistently been more effective with patient feedback, which enables directing the shock waves to the most painful area (clinical focusing), rather than with anatomic or image-guided focusing, which are used to direct the shock wave to an anatomic landmark or structure.

    • Keywords:
    • Biofeedback

    • Psychology|Chronic Disease|Fasciitis

    • Plantar|High-Energy Shock Waves|Humans|Muscle

    • Skeletal|Tendinopathy|Tendons|Tennis Elbow|Ultrasonic Therapy|Ultrasonics

    • Subspecialty:
    • Sports Medicine

    • Basic Science

Nontraumatic disorders of the clavicle.

Other than those resulting from trauma and arthritis, disorders of the clavicle are uncommon. Some nontraumatic disorders are found only in infancy and childhood, such as birth fracture, infantile cortical hyperostosis, congenital pseudarthrosis, cleidocranial dysplasia, and short clavicle syndrome. Other nontraumatic disorders occur in both children and adults; these include anterior subluxation of the sternoclavicular joint, Friedrich's disease, hypertrophic osteitis, chronic multifocal periosteitis and arthropathy, and osteomyelitis. Some nontraumatic clavicular disorders are found only in adults, such as distal osteolysis. Because the description and nomenclature of these disorders arise from several medical disciplines, they often are confusing. Until clear, distinguishing features are described, it is advisable to combine some of the entities. This is especially true of the nonsuppurative inflammatory disorders of the clavicle, which appear to fall under the heading of spondyloarthropathy. Treatment varies by disorder and may include symptomatic and expectant management, drug therapy, and nonsurgical or surgical treatment.

    • Keywords:
    • Adolescent|Adult|Birth Injuries|Bone Diseases|Child|Child

    • Preschool|Clavicle|Fractures

    • Bone|Humans|Infant|Infant

    • Newborn

    • Subspecialty:
    • Pediatric Orthopaedics

    • Shoulder and Elbow

Nontraumatic upper cervical spine instability in children.

The upper cervical spine begins at the base of the occiput, continues caudally to the C2-C3 disk space, and includes the occipitoatlantal and atlantoaxial joints. Nontraumatic upper cervical spine instability can result from abnormal development of osseous or ligamentous structures or from gradually increasing ligamentous laxity associated with connective tissue disorders. Such instability can lead to compression of the spinal cord during movement of the cervical spine. Establishing a correct diagnosis includes performing a thorough physical examination as well as evaluating radiographic relationships and measurements. Appropriate management of syndromes associated with instability of the upper cervical spine includes preventive care and recommendations for sports participation. Surgical treatment for the upper cervical spine includes a posterior surgical approach, used for instability, and the use of rigid plate implants, wiring, and bone graft materials to achieve a solid spinal fusion.

    • Keywords:
    • Age Factors|Cervical Vertebrae|Child|Humans|Joint Instability|Spinal Cord Compression|Spinal Diseases|Spinal Fusion

    • Subspecialty:
    • Pediatric Orthopaedics

    • Spine

Spinal surgery and patient safety: a systems approach.

In every spinal procedure, identifying the specific patient, proper surgical site, and pathologic lesion for surgical intervention are crucial patient safety concerns. The 1999 Institute of Medicine report "To Err is Human" identified adverse events associated with surgery. Both the American Academy of Orthopaedic Surgeons and the North American Spine Society have had voluntary, systems-based programs in place for several years to address wrong patient, wrong procedure, and wrong site surgery. Beginning July 1, 2004, the Joint Commission on the Accreditation of Healthcare Organizations mandated that hospitals comply with the JCAHO Universal Protocol. In addition to surgical site marking, the protocol incorporates additional factors, such as calling a time out before skin incision to do a final systems check of patient identification, surgical site, records, imaging studies, equipment, and review of preoperative medication.

    • Keywords:
    • Humans|Medical Errors|Orthopedic Procedures|Outcome and Process Assessment (Health Care)|Patient Identification Systems|Safety Management|Spine

    • Subspecialty:
    • Clinical Practice Improvement

The geographic incidence and treatment variation of common fractures of elderly patients.

Fractures of the hip, wrist, proximal humerus, and ankle frequently are observed among the elderly patient population in the United States. The Medicare patient population has shown dramatic geographic variation in the rates of these common fractures, with an increased incidence observed throughout the Southeast. Treatment (surgical versus nonsurgical) is also highly variable and dependent on the geographic location but not necessarily on the type of injury. Whereas regional variation in medical treatment may be attributed to variations in practice patterns, the etiology behind the dramatic variations in fractures is less well-defined and is likely multifactorial, related to environmental, occupational, genetic, or nutritional factors.

    • Keywords:
    • Aged|Fractures

    • Bone|Humans|Incidence|Medicare|Southeastern United States

    • Subspecialty:
    • Trauma

    • Foot and Ankle

    • Shoulder and Elbow

    • Hand and Wrist

Use of bisphosphonates to improve the durability of total joint replacements.

Total joint arthroplasty is very effective for improving the quality of life of patients with end-stage arthritis. Despite advances in materials, surgical technique, and rehabilitation regimens, joint replacements are still fraught with complications leading to their premature failure. Aseptic loosening and osteolysis are the primary causes of implant failure. Other reasons include early migration of components leading to instability, lack of ingrowth into implant porosities, and bone loss caused by stress shielding. Pharmaceutical agents used for preventing and managing postmenopausal osteoporosis (eg, bisphosphonates) may in the future play an important role in improving the long-term duration of joint arthroplasties. Early findings indicate that bisphosphonates upregulate bone morphogenetic protein-2 production and stimulate new bone formation. Because of their anabolic effect on osteoblasts, bisphosphonates have the potential to enhance bone ingrowth into implant porosities, prevent bone resorption under adverse conditions, and dramatically extend the long-term durability of joint arthroplasties. The long-term effects of bisphosphonate use on the mechanical properties of bone have not been adequately investigated. Along with improvements in implant design and material properties, bisphosphonates and other pharmaceutical agents may, in the near future, be part of the growing armamentarium that provides more durable joint arthroplasties.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Knee|Bed Rest|Bone Density Conservation Agents|Bone Morphogenetic Protein 2|Bone Morphogenetic Proteins|Bone Resorption|Diphosphonates|Humans|Hydroxymethylglutaryl-CoA Reductase Inhibitors|Osseointegration|Osteogenesis|Osteoporosis|Prosthesis Failure|Transforming Growth Factor beta

    • Subspecialty:
    • Adult Reconstruction

    • Basic Science

Advertisements

Advertisement