JAAOS

JAAOS, Volume 15, No. 3


Correspondence

    • Keywords:
    • Animals|Arthroplasty

    • Replacement

    • Hip|Hip Prosthesis|Humans|Porosity|Prosthesis Design|Tantalum

    • Subspecialty:
    • Adult Reconstruction

Corticosteroid injections in the treatment of trigger finger: a level I and II systematic review.

Trigger finger is a tendinitis (stenosing tenosynovitis) with multiple management approaches. We conducted an evidence-based medicine systematic review of level I and II prospective randomized controlled trials to determine the effectiveness of corticosteroid injection in managing trigger finger. MEDLINE, Cochrane database, and secondary references were reviewed to locate all English-language prospective randomized controlled trials evaluating trigger finger treatment. Four studies using injectable corticosteroids were identified, based on the following inclusion criteria: all were prospective randomized controlled trials of adults with >85% follow-up. This review indicates that the incidence of trigger finger is greatest in women (75%), with an average patient age range of 52 to 62 years. Combined analysis of these four studies shows that corticosteroid injections are effective in 57% of patients.

    • Keywords:
    • Adrenal Cortex Hormones|Evidence-Based Medicine|Humans|Randomized Controlled Trials as Topic|Trigger Finger Disorder

    • Subspecialty:
    • Hand and Wrist

Indications for orthoses to improve gait in children with cerebral palsy.

Orthoses are frequently used to improve the gait of children with cerebral palsy. Optimal clinical decision-making for improving gait through orthotic management requires an understanding of the biomechanics of the foot and ankle during normal gait, the pathophysiology and pathomechanics of gait disruption in children with cerebral palsy, and the biomechanical characteristics of various orthoses. The clinician must seek to integrate his or her own goals with those of the child and family, the therapist, and the orthotist. Design, indications, and cost should be considered when choosing an orthosis. The physician can construct a paradigm for clinical decision-making, focusing on the evaluation of ankle/foot alignment, range of motion, and assessment of dynamic gait deviations. This paradigm will guide the clinician in the use of orthoses to improve gait in children with cerebral palsy. For optimal orthotic management, the physician must clearly identify the gait deviation and functional deficits to be addressed with the orthosis. The outcome of the orthotic intervention should be documented as objectively as possible.

    • Keywords:
    • Ankle Joint|Cerebral Palsy|Child|Equipment Design|Foot|Gait|Humans|Orthotic Devices

    • Subspecialty:
    • Foot and Ankle

    • Pediatric Orthopaedics

    • Basic Science

Ophthalmologic complications associated with prone positioning in spine surgery.

Visual impairment and blindness associated with general anesthesia and prone positioning in spine surgery have been increasing in incidence over the past several decades. Corneal abrasion, the most common ophthalmologic injury, is usually self-limiting. However, prolonged surgical procedures (>7 hours) associated with acute blood loss anemia, hypotension, and hypoxia may lead to posterior ischemic optic neuropathies. Direct pressure to the periorbital region of the eye can cause increased intraocular pressure and blindness as the result of central retinal artery occlusion. Hypoxia and cerebral embolism are associated with occipital cortical infarct or cortical blindness. The prognosis for visual recovery from ischemic neuropathy and retinal artery occlusion is poor. Cortical blindness usually improves to varying degrees. Effective treatment of perioperative amaurosis is lacking and usually ineffective, making prevention the cornerstone of management. To best prevent permanent ophthalmologic complications associated with prone positioning during spine surgery, orthopaedic surgeons should be aware of pathophysiology and related risks associated with spine surgery in the prone position, and initiate preventive measures and predictable treatment options.

    • Keywords:
    • Eye Diseases|Humans|Optic Neuropathy

    • Ischemic|Orthopedic Procedures|Posture|Practice Guidelines as Topic|Risk Factors|Spine

    • Subspecialty:
    • Spine

Optimal duration of prophylaxis for venous thromboembolism following total hip arthroplasty and total knee arthroplasty.

Elective total hip arthroplasty and total knee arthroplasty are associated with a high risk of postoperative venous thromboembolism. Traditionally, antithrombotic prophylaxis has been administered during the hospital stay. However, with patients spending less time in the hospital after surgery, there is a need to continue thromboprophylaxis beyond hospital discharge. The current recommendation for prophylaxis in total joint arthroplasty patients is a minimum of 10 days, with extended prophylaxis up to 28 to 35 days following total hip arthroplasty. Prophylaxis with low-molecular-weight heparins for approximately 4 weeks following hip arthroplasty has resulted in clinically significant reductions in the incidence of venographically confirmed deep vein thrombosis. Currently, no data support extended thromboprophylaxis beyond 10 days following total knee arthroplasty. Using weighted risk factors to assess individual risk for venous thromboembolism can help the physician determine the optimal duration of prophylaxis.

    • Keywords:
    • Anticoagulants|Arthroplasty

    • Replacement

    • Hip|Arthroplasty

    • Knee|Embolism|Heparin

    • Low-Molecular-Weight|Humans|Meta-Analysis as Topic|Risk Assessment|Time Factors|Venous Thrombosis

    • Subspecialty:
    • Trauma

    • Foot and Ankle

    • Adult Reconstruction

Pediatric pelvic fractures.

Pediatric pelvic fractures account for only 1% to 2% of fractures seen by orthopaedic surgeons who treat children. They are typically associated with high-energy trauma, requiring a comprehensive workup for concomitant life-threatening injuries. Anteroposterior radiographs and rapid-sequence computed tomography are the standards of diagnostic testing to identify the fracture and recognize associated injuries. Treatment is individualized based on patient age, fracture classification, stability of the pelvic ring, extent of concomitant injuries, and hemodynamic stability of the patient. Most pelvic injuries in children are treated nonsurgically, with protected weight bearing and gradual return to activity. Open reduction and internal fixation is required for acetabular fractures with >2 mm of fracture displacement and for any intra-articular or triradiate cartilage fracture displacement >2 mm. To prevent limb-length discrepancies, external fixation is necessary for pelvic ring displacement >2 cm. Fractures involving immature triradiate cartilage may lead to growth disturbance of the acetabulum, resulting in acetabular dysplasia, hip subluxation, or hip joint incongruity. Osteonecrosis of the femoral head may develop after acetabular fractures associated with hip dislocation. Other complications include myositis ossificans and neurologic deficits secondary to sciatic, femoral, and/or lumbosacral plexus nerve injuries.

    • Keywords:
    • Child|Fractures

    • Bone|Humans|Pelvic Bones

    • Subspecialty:
    • Trauma

    • Pediatric Orthopaedics

Understanding shoulder and elbow injuries in baseball.

Repetitive overhead throwing exerts significant mechanical stress on the shoulder and elbow joint; this stress can lead to developmental anatomic changes in the young thrower. Asymptomatic pathology in the shoulder and elbow joint is prevalent and, with overuse, can progress to disabling injury. Joint injury occurs as a result of the body's inability to properly coordinate motion segments during the pitching delivery, leading to further structural damage. Identifying and preventing overuse is the key to avoiding injury, particularly in the young pitcher. Injury prevention and rehabilitation should center on optimizing pitching mechanics, core strength, scapular control, and joint range of motion.

    • Keywords:
    • Adaptation

    • Physiological|Athletic Injuries|Baseball|Elbow Joint|Humans|Shoulder Joint

    • Subspecialty:
    • Sports Medicine

    • Shoulder and Elbow

    • Basic Science

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