JAAOS

JAAOS, Volume 15, No. 2


Current issues in health policy: a primer for the orthopaedic surgeon.

Political, social, and economic forces occupy an increasingly larger role in health care. It is essential that orthopaedic surgeons become familiar with the ever-changing landscape within which they practice. Greater comprehension of the current issues in health policy will enable practitioners to appreciate these issues and understand the importance of the involvement of the AAOS in the political process. Five topics in particular will continue to have a great impact on the practice of orthopaedic surgery: the flawed Medicare payment formula, implementation of a pay-for-performance program, the creation of gainsharing agreements between hospitals and physicians, the medical liability crisis, and the importance of advocacy with the political action committee of the AAOS.

    • Keywords:
    • Cost Savings|Health Policy|Humans|Liability

    • Legal|Medicare|Orthopedics|Quality of Health Care|Reimbursement Mechanisms

    • Subspecialty:
    • Clinical Practice Improvement

Double-bundle reconstruction of the anterior cruciate ligament: anatomic and biomechanical rationale.

Patients continue to suffer residual pain and instability following anterior cruciate ligament reconstruction. Although overall outcomes of anterior cruciate ligament reconstruction are favorable, improved outcomes can be achieved. Recent biomechanical studies have questioned the ability of conventional single-bundle anterior cruciate ligament constructs to adequately restore normal knee kinematics. Consequently, the use of double-bundle anterior cruciate ligament constructs has been recommended to restore knee stability more effectively. Recent biomechanical data indicate that double-bundle anterior cruciate ligament reconstruction may provide better anteroposterior and rotational knee stability than do conventional single-bundle techniques. Studies are needed to evaluate the clinical impact of double-bundle reconstruction techniques on long-term functional outcomes.

    • Keywords:
    • Anterior Cruciate Ligament|Biomechanics|Humans|Joint Instability|Orthopedic Procedures

    • Subspecialty:
    • Sports Medicine

    • Basic Science

Evaluation of the elderly patient with an abnormal gait.

Distinguishing between the normal gait of the elderly and pathologic gaits is often difficult. Pathologic gaits with neurologic causes include frontal gait, spastic hemiparetic gait, parkinsonian gait, cerebellar ataxic gait, and sensory ataxic gait. Pathologic gaits with combined neurologic and musculoskeletal causes include myelopathic gait, stooped gait of lumbar spinal stenosis, and steppage gait. Pathologic gaits with musculoskeletal causes include antalgic gait, coxalgic gait, Trendelenburg gait, knee hyperextension gait, and other gaits caused by inadequate joint mobility. A working knowledge of the characteristics of these gaits and a systematic approach to observational gait examination can help identify the causes of abnormal gait. Patients with abnormal gait can benefit from the treatment of the primary cause of the disorder as well as by general fall-prevention interventions. Treatable causes of gait disturbance are found in a substantial proportion of patients and include normal-pressure hydrocephalus, vitamin B(12) deficiency, Parkinson's disease, alcoholism, medication toxicity, cervical spondylotic myelopathy, lumbar spinal stenosis, joint contractures, and painful disorders of the lower extremity.

    • Keywords:
    • Aged|Aged

    • 80 and over|Apraxias|Gait|Gait Disorders

    • Neurologic|Humans

    • Subspecialty:
    • Foot and Ankle

    • Adult Reconstruction

Internet-based reference case managers for clinical practice and research collaboration.

Historically in medicine, the internet has been used for unidirectional information extraction via search engines that provide database and literature output. Current Web-based case managers allow submission and reception of digital media and have been used to link specialists and provide forums for rapid, bidirectional information sharing.

    • Keywords:
    • Case Management|Humans|Internet|Interprofessional Relations|Medical Informatics Applications|Orthopedics|Research|Software

    • Subspecialty:
    • Clinical Practice Improvement

Intramedullary nailing of the lower extremity: biomechanics and biology.

The intramedullary nail or rod is commonly used for long-bone fracture fixation and has become the standard treatment of most long-bone diaphyseal and selected metaphyseal fractures. To best understand use of the intramedullary nail, a general knowledge of nail biomechanics and biology is helpful. These implants are introduced into the bone remote to the fracture site and share compressive, bending, and torsional loads with the surrounding osseous structures. Intramedullary nails function as internal splints that allow for secondary fracture healing. Like other metallic fracture fixation implants, a nail is subject to fatigue and can eventually break if bone healing does not occur. Intrinsic characteristics that affect nail biomechanics include its material properties, cross-sectional shape, anterior bow, and diameter. Extrinsic factors, such as reaming of the medullary canal, fracture stability (comminution), and the use and location of locking bolts also affect fixation biomechanics. Although reaming and the insertion of intramedullary nails can have early deleterious effects on endosteal and cortical blood flow, canal reaming appears to have several positive effects on the fracture site, such as increasing extraosseous circulation, which is important for bone healing.

    • Keywords:
    • Biomechanics|Bone Nails|Bone Screws|Bones of Lower Extremity|Femoral Fractures|Fracture Fixation

    • Intramedullary|Fracture Healing|Humans|Tibial Fractures

    • Subspecialty:
    • Trauma

    • Foot and Ankle

    • Basic Science

Reconstruction of the rheumatoid thumb.

Thumb deformities are common manifestations of rheumatoid arthritis and represent a significant source of disability. A clear understanding of the pathophysiology of the disease is essential in directing treatment. Differential diagnosis for flexible deformities includes soft-tissue imbalances as well as tendon ruptures. In its early stages, thumb involvement can be treated nonsurgically or with soft-tissue reconstruction. With more advanced disease, arthrodesis and arthroplasty often are required. Isolated interphalangeal involvement is best addressed with arthrodesis. Metacarpophalangeal involvement can be treated with arthroplasty in low-demand patients or with arthrodesis in more active patients. Trapezium resection arthroplasty provides excellent relief for patients with carpometacarpal joint destruction.

    • Keywords:
    • Arthritis

    • Rheumatoid|Hand Deformities

    • Acquired|Humans|Orthopedic Procedures|Thumb

    • Subspecialty:
    • Hand and Wrist

The 36-item short form.

The use of patient-derived, objective outcome measures has expanded substantially within the orthopaedic literature. Quality-of-life instruments are categorized as general health or as condition-specific questionnaires. The Medical Outcomes Study 36-Item Short Form (SF-36) is a general health-based survey of quality of life. It has been validated, is used widely across medical disciplines, and can be self-administered by the patient with reliability. The SF-36 has been implemented to define disease conditions, to determine the effect of treatment, to differentiate the effect of different treatments, and to compare orthopaedic conditions with other medical conditions. However, a bias of lower over upper extremity function has been demonstrated with the SF-36, as have limitations in assessment of certain physical activities of daily living as well as upper and lower limits on the detection of certain changes in quality-of-life status. Nevertheless, with an adequate knowledge of its effectiveness and limitations, the SF-36 can be a useful tool in many branches of orthopaedic surgery.

    • Keywords:
    • Activities of Daily Living|Health Status Indicators|Health Surveys|Humans|Musculoskeletal Diseases|Outcome Assessment (Health Care)|Quality of Life|Questionnaires

    • Subspecialty:
    • Clinical Practice Improvement

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