JAAOS

JAAOS, Volume 14, No. 9


Clearing the pediatric cervical spine following injury.

Injury to the pediatric cervical spine is uncommon; however, a missed or delayed diagnosis can lead to disastrous consequences. Thus, following trauma, clearance of the pediatric cervical spine is important. Problematic issues include child compliance with examination, the complex anatomy of the pediatric cervical spine, lack of agreement on definitive imaging modalities, and the coordination of multiple medical specialties. Expediting clearance of the pediatric cervical spine requires an organized, multidisciplinary approach. In addition to systematic procedures within the emergency department, preventing missed and delayed diagnoses of cervical spine injury can be facilitated by applying a clear methodology for reviewing radiographs in conjunction with the child's clinical examination. This algorithm considers the adequacy of the images, alignment of the bony and soft-tissue elements, assessment of the cervical intervals, and the presence of abnormal angulation. Together with standard treatment, this protocol facilitates effective and expeditious clearance of the cervical spine.

    • Keywords:
    • Algorithms|Child|Humans|Spinal Injuries

    • Subspecialty:
    • Trauma

    • Pediatric Orthopaedics

    • Spine

Failed back surgery syndrome: diagnostic evaluation.

Failed back surgery syndrome is a common problem with enormous costs to patients, insurers, and society. The etiology of failed back surgery can be poor patient selection, incorrect diagnosis, suboptimal selection of surgery, poor technique, failure to achieve surgical goals, and/or recurrent pathology. Successful intervention in this difficult patient population requires a detailed history, precise physical examination, and carefully chosen diagnostic tests. The diagnostic evaluation should endeavor to accurately identify symptoms, rule out extraspinal causes, identify a specific spinal etiology, and assess the psychological state of the patient. Only after these factors have been assessed can further treatment be planned.

    • Keywords:
    • Back Pain|Humans|Orthopedic Procedures|Physical Examination|Recurrence|Syndrome|Treatment Failure

    • Subspecialty:
    • Spine

    • Clinical Practice Improvement

    • Pain Management

Highly cross-linked polyethylene in total hip arthroplasty.

Although total hip arthroplasty is a common and highly successful procedure, its long-term durability has been undermined by the cellular response to polyethylene wear debris and the subsequent effects on periprosthetic bone. Research elucidating the effects of sterilization on polyethylene wear has facilitated the development of a more wear-resistant material-highly cross-linked polyethylene. Laboratory testing has demonstrated that highly cross-linked polyethylene has markedly improved wear resistance compared with conventional polyethylene under a variety of conditions. Early clinical data have supported these results. To make informed decisions about this already widely available and frequently used product, the practicing orthopaedic surgeon should have a basic understanding of the production process as well as knowledge of the most current laboratory and clinical data.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Hip|Hip Prosthesis|Humans|Materials Testing|Polyethylene|Prosthesis Design|Sterilization

    • Subspecialty:
    • Adult Reconstruction

    • Basic Science

Perioperative medication management for the patient with rheumatoid arthritis.

The treatment of rheumatoid arthritis has improved dramatically in recent years with the advent of the latest generation of disease-modifying antirheumatic drugs. Despite these advances, in some patients inflammation is not diminished sufficiently to prevent irreversible musculoskeletal damage, thus requiring surgical intervention to reduce pain and improve function. In these cases, the orthopaedic surgeon frequently encounters patients on a drug regimen consisting of nonsteroidal anti-inflammatory drugs, glucocorticoids, methotrexate, and biologic agents (disease-modifying antirheumatic drugs). Consultation with a rheumatologist is recommended, but the surgeon also should be aware of these medications that could potentially affect surgical outcome. Prudent perioperative management of these drugs is required to optimize surgical outcome. A balance must be struck between minimizing potential surgical complications and maintaining disease control to facilitate postoperative rehabilitation of patients with rheumatoid arthritis.

    • Keywords:
    • Adrenal Cortex Hormones|Anti-Inflammatory Agents

    • Non-Steroidal|Antirheumatic Agents|Arthritis

    • Rheumatoid|Humans|Postoperative Complications|Preoperative Care

    • Subspecialty:
    • Adult Reconstruction

    • Clinical Practice Improvement

Posttraumatic proximal interphalangeal joint flexion contractures.

Normal motion of the proximal interphalangeal joint requires bony support, intact articular surfaces, unimpeded tendon gliding, and uncompromised integrity of the collateral ligaments and volar plate. Deficiency in any one of these structural requirements can lead to a loss of finger joint motion and decreased hand function. Once finger extension is lost, options include nonsurgical or surgical treatment. Nonsurgical treatment such as splinting or serial casting should be tried before attempting surgical intervention. When severe flexion deformity exists or the vascular status of the finger has been compromised, arthrodesis or amputation should be undertaken instead of procedures to regain motion. Surgical options for regaining motion include external fixators and open surgical release. Although they can lead to improved extension at the proximal interphalangeal joint, external fixators carry a risk of reduced finger flexion and pin site infection. Most clinical series of patients who have undergone surgical release document improvement in flexion contracture between 25 degrees to 30 degrees and a shift of the flexion/extension arc into a more functional range. Close follow-up after surgery is warranted, with frequent physical therapy and splinting.

    • Keywords:
    • Contracture|Finger Injuries|Finger Joint|Humans|Orthopedic Procedures

    • Subspecialty:
    • Trauma

    • Hand and Wrist

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