JAAOS

JAAOS, Volume 14, No. 8


Hip resurfacing arthroplasty.

Hip resurfacing arthroplasty is a type of hip replacement that involves capping the femoral head and preserving bone of the proximal femur. Metal-on-metal surface replacements have been manufactured since the early 1990s. Recent studies indicate excellent clinical results with low failure rates at 1- to 5-year follow-up. Although these early results are encouraging, resurfacing devices must be used with caution because less is known about their long-term safety and efficacy. The best candidates for resurfacing are patients younger than age 60 years with good bone stock. The surgical approach is similar to that for standard total hip replacements, but with slightly more dissection because the femoral head must be preserved and displaced to visualize the acetabulum. To reduce complications, resurfacing arthroplasty should be performed by surgeons who have received training specifically in this technique.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Hip|Hip Prosthesis|Humans|Prosthesis Design

    • Subspecialty:
    • Adult Reconstruction

Nonsurgical management of acute and chronic low back pain.

A variety of nonsurgical treatment alternatives exists for acute and chronic low back pain. Patients should receive appropriate education about the favorable natural history of low back pain, basic body mechanics, and methods (eg, exercises, activity modification, behavioral modification) that can reduce symptoms. Nonprescription medication is efficacious for mild to moderate pain. Nonsteroidal anti-inflammatory drugs, alone or in combination with muscle relaxants, relieve pain and improve overall symptoms of acute low back pain. Exercise therapy has limited value for acute low back pain, but strong evidence supports exercise therapy in the management of chronic low back pain. Moderately strong evidence supports the use of manipulation in acute back pain. Evidence is weak for the use of epidural corticosteroid injections in patients with acute low back pain, strong for short-term relief of chronic low back pain, and limited for long-term relief of chronic low back pain. The use of facet injections in the management of acute low back pain is not supported by evidence, nor is the effectiveness of orthoses, traction, magnets, or acupuncture. Trigger point injections are not indicated for nonspecific acute or chronic low back pain, and sacroiliac joint injections are not indicated in the routine management of low back pain. Conflicting evidence exists regarding the use of transcutaneous electrical nerve stimulation.

    • Keywords:
    • Acute Disease|Chronic Disease|Humans|Low Back Pain

    • Subspecialty:
    • Spine

    • Pain Management

Recurrent posterior shoulder instability.

Recurrent posterior shoulder instability is an uncommon condition. It is often unrecognized, leading to incorrect diagnoses, delays in diagnosis, and even missed diagnoses. Posterior instability encompasses a wide spectrum of pathology, ranging from unidirectional posterior subluxation to multidirectional instability to locked posterior dislocations. Nonsurgical treatment of posterior shoulder instability is successful in most cases; however, surgical intervention is indicated when conservative treatment fails. For optimal results, the surgeon must accurately define the pattern of instability and address all soft-tissue and bony injuries present at the time of surgery. Arthroscopic treatment of posterior shoulder instability has increased application, and a variety of techniques has been described to manage posterior glenohumeral instability related to posterior capsulolabral injury.

    • Keywords:
    • Biomechanics|Humans|Joint Instability|Orthopedic Procedures|Recurrence|Shoulder Dislocation|Shoulder Joint

    • Subspecialty:
    • Trauma

    • Shoulder and Elbow

Spondylolysis and spondylolisthesis in children and adolescents: II. Surgical management.

Surgical management is indicated for children and adolescents with spondylolysis and low-grade spondylolisthesis (< or =50% slip) who fail to respond to nonsurgical measures. In situ posterolateral L5 to S1 fusion is the best option for those with a low-grade slip secondary to L5 pars defects or dysplastic spondylolisthesis at the lumbosacral junction. Pars repair is reserved for patients with symptomatic spondylolysis and low-grade, mobile spondylolisthesis with pars defects cephalad to L5 and for those with multiple-level defects. Screw repair of the pars defect, wiring transverse process to spinous process, and pedicle screw-laminar hook fixation are surgical options. The ideal surgical management of high-grade spondylolisthesis (>50% slip) is controversial. Spinal fusion has been indicated for children and adolescents with high-grade spondylolisthesis regardless of symptoms. In situ L4 to S1 fusion with cast immobilization is safe and effective for alleviating back pain and neurologic symptoms. Instrumented reduction and fusion techniques permit improved correction of sagittal spinal imbalance and more rapid rehabilitation but are associated with a higher risk of iatrogenic nerve root injuries than in situ techniques. Wide decompression of nerve roots combined with instrumented partial reduction may diminish the risk of neurologic complications. Pseudarthrosis and neurologic injury presenting as L5 radiculopathy and sacral root dysfunction are the most common complications associated with surgical management of high-grade spondylolisthesis.

    • Keywords:
    • Adolescent|Child|Humans|Orthopedic Procedures|Spondylolisthesis|Spondylolysis

    • Subspecialty:
    • Pediatric Orthopaedics

    • Spine

The case for patient-centered care in orthopaedics.

Now is a critical time to develop a patient-centered care model in the field of orthopaedic surgery. Patient-centered care is defined by the American Academy of Orthopaedic Surgeons as the provision of safe, effective, and timely musculoskeletal care achieved through cooperation between the orthopaedic surgeon; an informed, respected patient (and family); and a coordinated health care team. Patient-centered care, a paradigm shift from disease-centered care, is being championed by government agencies, patient advocacy groups, and insurance companies. Orthopaedic organizations must develop a comprehensive education program to provide surgeons the tools they need to navigate this paradigm shift.

    • Keywords:
    • Adult|Female|Humans|Middle Aged|Orthopedics|Patient-Centered Care

    • Subspecialty:
    • Clinical Practice Improvement

The floating shoulder.

The floating shoulder is an uncommon but important injury pattern. Although it is frequently defined as an ipsilateral fracture of the clavicle and scapular neck, recent studies suggest that ligament disruption associated with a scapular neck fracture contributes to the functional equivalent of this injury pattern, with or without an associated clavicle fracture. Determining the specific injury patterns indicates the potential for significant instability, and correlating these patterns with clinical outcome is a challenge. Because the degree of ligament disruption is difficult to assess on radiographs, indications for nonsurgical and surgical management are not well defined. Minimally displaced fractures typically do well with nonsurgical care. However, the degree of fracture displacement and ligament disruption that results in less predictable outcomes after nonsurgical treatment is uncertain, and the indications for surgery can be controversial. Internal fixation of a displaced clavicle fracture restores the contour of the shoulder, regulates soft-tissue tension, and often indirectly reduces the scapular neck fracture. Fixation of both fractures is recommended in certain fracture patterns. Because these controversies cannot be resolved by current evidence, surgeons must choose an individualized approach based on an understanding of the pathoanatomy and personal experience.

    • Keywords:
    • Clavicle|Fractures

    • Bone|Humans|Ligaments

    • Articular|Multiple Trauma|Scapula|Shoulder Joint

    • Subspecialty:
    • Shoulder and Elbow

Advertisements

Advertisement