JAAOS

JAAOS, Volume 15, No. 1


Innovations in the management of displaced proximal humerus fractures.

The management of displaced proximal humerus fractures has evolved toward humeral head preservation, with treatment decisions based on careful assessment of vascular status, bone quality, fracture pattern, degree of displacement, and patient age and activity level. The AO/ASIF fracture classification is helpful in guiding treatment and in stratifying the risk for associated disruption of the humeral head blood supply. Nonsurgical treatment consists of sling immobilization. For patients requiring surgery, options include closed reduction and percutaneous fixation; transosseous suture fixation; open reduction and internal fixation, with either conventional or locking plate fixation; bone graft; and hemiarthroplasty. Proximal humerus fractures must be evaluated on an individual basis, with treatment tailored according to patient and fracture characteristics.

    • Keywords:
    • Algorithms|Fracture Fixation|Humans|Humeral Fractures|Orthopedic Fixation Devices|Risk Assessment

    • Subspecialty:
    • Trauma

    • Shoulder and Elbow

Malunion of the distal radius.

Fractures of the distal radius are common injuries. Acceptable results typically can be obtained with appropriate surgical or nonsurgical management. However, a small percentage of these fractures can progress to symptomatic malunion, which traditionally has been treated with osteotomy of the distal radius. Proper understanding of anatomy, biomechanics, indications, and contraindications can help guide patient selection for surgery. In formulating a treatment plan, the surgeon also must consider such technical variables as the type of osteotomy, the use of bone graft or bone-graft substitute, and the means of fixation to stabilize the osteotomy. Simultaneous implementation of an ulnar-side procedure, an intra-articular osteotomy, and soft-tissue releases also may be necessary. Some cases may be more appropriate for wrist fusion or other salvage procedures.

    • Keywords:
    • Biomechanics|Bone Transplantation|Fracture Fixation

    • Internal|Fractures

    • Malunited|Humans|Internal Fixators|Osteotomy|Postoperative Complications|Radius Fractures

    • Subspecialty:
    • Trauma

    • Hand and Wrist

    • Basic Science

Radial longitudinal deficiency.

Radial longitudinal deficiency encompasses a spectrum of upper limb dysplasias and hypoplasias. The bony abnormalities of the thumb and radius are the most pronounced, but deficiencies of the accompanying muscles, nerves, vessels, and joints also greatly influence the ultimate upper extremity function. The striking clinical presentation of the involved upper limb is often more obvious than the potentially life-threatening associated systemic conditions. All children presenting with radial longitudinal deficiency, regardless of severity, require a renal ultrasound, echocardiogram, and complete blood count to evaluate the potential for associated systemic conditions; these include Fanconi's anemia, the Holt-Oram syndrome, and the VATER (vertebral anomalies, anal atresia, tracheoesophageal fistula, esophageal atresia, renal agenesis) syndrome or VACTERL (vertebral anomalies, anal atresia, cardiac abnormalities, tracheoesophageal fistula, renal agenesis, and limb defects) association. The overall health of the child, as well as the severity of the osseous and soft-tissue deformities of the affected limb, guides the long-term treatment plans.

    • Keywords:
    • Abnormalities

    • Multiple|Child|Child

    • Preschool|Humans|Infant|Infant

    • Newborn|Radius|Thumb|Upper Extremity Deformities

    • Congenital|Wrist Joint

    • Subspecialty:
    • Pediatric Orthopaedics

    • Hand and Wrist

The efficacy of subacromial corticosteroid injection in the treatment of rotator cuff disease: A systematic review.

To investigate whether subacromial corticosteroid injections are effective in the treatment of rotator cuff disease, an evidence-based systematic review was undertaken of nine randomized controlled trials that compared subacromial corticosteroid injection with placebo in patients with rotator cuff disease. Each study was systematically evaluated for biases, and outcome measures were scrutinized for statistical significance and clinical importance. One study demonstrated clinically important differences in pain relief. Two studies showed clinically important improvement in range of motion at final follow-up. This systematic review of the available literature indicates that there is little reproducible evidence to support the efficacy of subacromial corticosteroid injection in managing rotator cuff disease.

    • Keywords:
    • Adrenal Cortex Hormones|Evidence-Based Medicine|Humans|Injections

    • Intra-Articular|Pain Measurement|Randomized Controlled Trials as Topic|Range of Motion

    • Articular|Rotator Cuff|Shoulder Pain|Tendinopathy|Treatment Outcome

    • Subspecialty:
    • Shoulder and Elbow

    • Pain Management

Wear and osteolysis around total knee arthroplasty.

Osteolysis induced by wear debris of ultra-high-molecular-weight polyethylene has emerged as a significant problem after total knee arthroplasty. The generation of polyethylene wear and the development of osteolysis around total knee arthroplasty are caused by a combination of patient, implant, and surgical factors. Activity level over time may be the most important patient factor affecting the loads placed on a total knee replacement, but it is the most difficult to manage. Multiple factors related to the manufacturing of the polyethylene implant influence the extent of wear, and surgeons should be cautious in considering enhanced polyethylenes pending results of further investigations. The optimal design of the articular bearing surface remains controversial but needs to be considered with respect to the stresses imparted on component-bone and modular tibial backside interfaces. Surgical factors, including restoration of alignment and ligament balance, are important for long-term durability of the implant. Methods of measuring the wear of total knee implants are still evolving. Thus, when confronted with a worn total knee implant and developing osteolysis, the surgeon should consider each of these factors in selecting the best management option to eliminate the source of debris and minimize the potential for wear and osteolysis following revision.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Knee|Device Removal|Humans|Knee Prosthesis|Osteolysis|Polyethylenes|Prosthesis Design|Prosthesis Failure|Reoperation|Risk Factors|Surface Properties

    • Subspecialty:
    • Basic Science

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