JAAOS

JAAOS, Volume 15, No. 11


Arthrofibrosis of the knee.

Better understanding of surgical timing, improved surgical technique, and advanced rehabilitation protocols has led to decreased incidence of motion loss after anterior cruciate ligament injury and reconstruction. However, motion loss from high-energy, multiligament injuries continues to compromise functional outcome. Prevention, consisting of control of inflammation and early motion, remains the key element in avoiding motion loss. However, certain techniques, such as manipulation under anesthesia in conjunction with arthroscopic lysis of adhesions, are reliable treatment options. Open surgical dbridement is rarely necessary and should be considered only as a salvage procedure. A greater understanding of the pathogenesis of arthrofibrosis and related inflammatory mediators may result in novel therapies for treating the patient with motion loss.

    • Keywords:
    • Anterior Cruciate Ligament|Arthroplasty|Contracture|Fibrosis|Humans|Knee Joint|Postoperative Complications|Range of Motion

    • Articular|Risk Factors

    • Subspecialty:
    • Sports Medicine

Dynamic anterior cervical plates.

Graft- and plate-related complications are not uncommon problems associated with anterior cervical fusion surgery. Although the reasons for such complications are protean, one potential set of etiologies centers on plate design. Dynamic cervical plates, which allow for better load sharing while providing overall resistance to motion, address perceived biomechanical deficiencies of rigid cervical plates. However, despite the theoretic advantages of dynamic plating over rigid plate fixation, there are concerns that settling associated with dynamic plates could lead to segmental kyphosis or foraminal narrowing and that excessive motion may lead to inferior fusion rates. The surgeon using these implants should be familiar with differences among the various types of dynamic plates and should perform the plating procedure appropriately to accommodate the expected settling.

    • Keywords:
    • Biomechanics|Bone Plates|Cervical Vertebrae|Diskectomy|Humans|Postoperative Complications|Prosthesis Design|Spinal Fusion|Weight-Bearing

    • Subspecialty:
    • Spine

    • Basic Science

Entrapment neuropathy of the ulnar nerve.

Ulnar nerve entrapment is the second most common nerve entrapment syndrome of the upper extremity. Although it may occur at any location along the length of the nerve, it is most common in the cubital tunnel. Ulnar nerve entrapment produces numbness in the ring and little fingers and weakness of the intrinsic muscles in the hand. Patient presentation and symptoms vary according to the site of entrapment. Treatment options are often determined by the site of pathology. Many patients benefit from nonsurgical treatment (eg, physical therapy, bracing, injection). When these methods fail or when sensory or motor impairment progresses, surgical release of the nerve at the site of entrapment should be considered. Surgical release may be done alone or with nerve transposition at the elbow. Most patients report symptomatic relief following surgery.

    • Keywords:
    • Decompression

    • Surgical|Humans|Ulnar Neuropathies

    • Subspecialty:
    • Shoulder and Elbow

    • Hand and Wrist

Orthopaedic management of the patient with osteopetrosis.

Osteopetrosis is a sclerosing bone dysplasia characterized by hard, brittle bone secondary to dysfunctional osteoclast resorption. The three main forms are malignant autosomal recessive, intermediate autosomal recessive, and benign autosomal recessive. These various clinical manifestations ultimately are caused by genetic mutations affecting acidification of Howship's lacuna. Common radiographic features include a generalized sclerosis, rugger jersey spine, and endobone formation. Medical problems include cranial nerve palsies and pancytopenia. Because cortical and cancellous bone thickness is increased, medullary canals and cranial nerve foramina are overgrown with bone. Patients typically present with such orthopaedic problems as frequent fractures, coxa vara, osteoarthritis, and osteomyelitis. Management with open reduction and internal fixation and with intramedullary fixation of fractures is difficult but possible. Reported results of total hip and total knee arthroplasties are excellent.

    • Keywords:
    • Arthroplasty

    • Replacement|Fracture Fixation|Fractures

    • Spontaneous|Humans|Osteopetrosis|Prognosis

    • Subspecialty:
    • Trauma

    • Musculoskeletal Oncology

    • Adult Reconstruction

Subtrochanteric femoral fractures.

Subtrochanteric femoral fractures are complicated injuries that may be associated with other life-threatening conditions. Patients should be carefully evaluated and appropriately treated for hypovolemic shock. These fractures can be effectively stabilized with 95 degrees plates, femoral reconstruction nails, or trochanteric femoral nails with interlocking options. Nails produce very stable constructs and consistently can be placed with the patient in the lateral position on the radiolucent table or in the supine position on the fracture table. Standard antegrade femoral nails may be indicated in certain fracture patterns. The 135 degrees hip screw-plate is not suitable in the treatment of subtrochanteric femoral fractures; use of these implants may result in loss of fixation and fracture displacement. Chemical and mechanical prophylaxis for deep vein thrombosis should be initiated unless contraindicated by other medical comorbidities. An accurate reduction and excellent surgical technique with minimal soft-tissue dissection can routinely produce good results without the need for secondary procedures.

    • Keywords:
    • Bone Nails|Bone Plates|Bone Transplantation|Femoral Fractures|Fracture Fixation

    • Internal|Humans|Venous Thrombosis

    • Subspecialty:
    • Trauma

Surgical outcomes after arthroscopic partial meniscectomy.

Much research has been done to determine clinical and demographic variables associated with outcomes from arthroscopic partial meniscectomy for meniscal tears. We undertook a review of the literature to determine trends regarding outcomes from this procedure. Independent variables were analyzed for associations with outcome, and outcome measures and methods of statistical analysis were reviewed. Results of these studies demonstrate that patient age and sex had no significant association with any clinical or radiographic outcome variables at 8.5, 12, and 15 years. Patients with flap tears had slower return to sports and more revisions than did those with bucket handle tears. Osteoarthritis progressed more after medial partial meniscectomy in patients older than age 40 years than in younger patients. No statistically significant difference in medial versus lateral meniscectomy overall was shown. The best radiographic results in patients who underwent medial meniscectomy occurred in valgus knees compared with varus knees. Increased Modified Outerbridge cartilage scores at the time of surgery correlated with poorer physical results at 12 years.

    • Keywords:
    • Arthroscopy|Data Interpretation

    • Statistical|Disease Progression|Humans|Menisci

    • Tibial|Osteoarthritis

    • Knee|Patient Satisfaction|Prognosis|Treatment Outcome

    • Subspecialty:
    • Sports Medicine

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