JAAOS

JAAOS, Volume 16, No. 2


Community-acquired methicillin-resistant Staphylococcus aureus: an emerging pathogen in orthopaedics.

Staphylococcus aureus (S aureus) remains one of the most common pathogens for skin and soft-tissue infections encountered by the orthopaedic surgeon. Community-acquired methicillin-resistant S aureus (CA-MRSA) has become increasingly prevalent, particularly among athletes, children in day care, homeless persons, intravenous drug users, men who have sex with men, military recruits, certain minorities (ie, Alaskan Natives, Native Americans, Pacific Islanders), and prison inmates. Risk factors include antibiotic use within the preceding year, crowded living conditions, compromised skin integrity, contaminated surfaces, frequent skin-to-skin contact, shared items, and suboptimal cleanliness. When a patient presents with a skin or soft-tissue infection, the clinician should determine whether an abscess or other infection needs to be surgically incised and drained. Cultures should be performed. When the patient is a member of an at-risk group or has any of the risk factors for CA-MRSA, beta-lactam antibiotics (eg, methicillin) are no longer a reasonable choice for treatment. Empiric treatment should consist of non-beta-lactam antibiotics active against CA-MRSA.

    • Keywords:
    • Anti-Bacterial Agents|Community-Acquired Infections|Diagnosis

    • Differential|Disease Progression|Humans|Methicillin Resistance|Orthopedics|Prevalence|Risk Factors|Soft Tissue Infections|Staphylococcal Infections|Staphylococcal Skin Infections|Staphylococcus aureus

    • Subspecialty:
    • Pediatric Orthopaedics

    • General Orthopaedics

Femoral nonunion: risk factors and treatment options.

Despite advances in surgical technique, fracture fixation alternatives, and adjuncts to healing, femoral nonunion continues to be a significant clinical problem. Femoral fractures may fail to unite because of the severity of the injury, damage to the surrounding soft tissues, inadequate initial fixation, and demographic characteristics of the patient, including nicotine use, advanced age, and medical comorbidities. Femoral nonunion is a functional and economical challenge for the patient, as well as a treatment dilemma for the surgeon. Surgeons should understand the various treatment alternatives and their role in achieving the goals of deformity correction, infection management, and optimization of muscle strength and rehabilitation. Used appropriately, nail dynamization, exchange nailing, and plate osteosynthesis can help minimize pain and disability by promoting osseous union. A review of the potential risk factors and treatment alternatives should provide insight into the etiology and required treatment of femoral nonunion.

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

    • Ununited|Humans|Risk Factors

    • Subspecialty:
    • Trauma

Primary osteoarthritis of the elbow: current treatment options.

In the elbow, as in other joints, primary osteoarthritis is characterized by pain, stiffness, mechanical symptoms, and weakness. But primary osteoarthritis of the elbow is unique in that there is relative preservation of articular cartilage and maintenance of joint space, with hypertrophic osteophyte formation and capsular contracture. Medical treatment and physical therapy may be initiated in the early stages of the disease process. Surgical treatment options include arthroscopic osteocapsular débridement, open ulnohumeral arthroplasty, distraction interposition arthroplasty, and total elbow arthroplasty. The potential for instability and loosening following total elbow arthroplasty in the setting of primary osteoarthritis limits the clinical application of this procedure. This patient population is generally younger than that recommended for total elbow arthroplasty, and their higher functional demands have limited the long-term success of this treatment option. The improvement in arthroscopic débridement techniques is perhaps the greatest advancement in the treatment of osteoarthritis of the elbow in recent years.

    • Keywords:
    • Arthroplasty

    • Replacement|Arthroscopy|Debridement|Elbow Joint|Humans|Joint Prosthesis|Osteoarthritis

    • Subspecialty:
    • Shoulder and Elbow

    • Pain Management

Psychological evaluation of the spine patient.

The biopsychosocial perspective focuses on the interaction among biologic, psychological, and medicolegal variables of patients coping with a persistent medical condition. It is considered the most comprehensive and heuristic approach to psychological evaluation in the spine patient. Assessment proceeds in three steps, from global indices of emotional distress to evaluation of more specific diagnoses of psychopathology. Step 1, the initial screening, uses psychometrically sound instruments to determine the level of patient distress. Step 2, the psychosocial interview, indicates whether additional psychological testing is needed. Step 3, the presurgical evaluation, assesses patients being considered for a surgical procedure. This stepwise assessment approach significantly aids in yielding evidence-based outcomes as well as in identifying the patient who may be most recalcitrant to treatment intervention.

    • Keywords:
    • Disability Evaluation|Evidence-Based Medicine|Humans|Neuropsychological Tests|Pain Measurement|Psychometrics|Spinal Diseases

    • Subspecialty:
    • Spine

    • Clinical Practice Improvement

Regenerative medicine for the musculoskeletal system based on muscle-derived stem cells.

The identification and characterization of stem cells is introducing a paradigm shift in the field of orthopaedic surgery. Whereas in the past, diseased tissue was replaced with allograft material, current trends in research revolve around regenerating damaged tissue. Muscle-derived stem cells have an application in regeneration of articular cartilage, bone, and skeletal muscle. These postnatal (ie, adult) stem cells can be readily isolated via muscle biopsy. They can display long-term proliferation, high self-renewal, and multipotent differentiation. They also can be genetically modified to secrete growth factors important to tissue healing, thereby functioning as implantable, long-lasting reservoirs for these molecules. Taken together, this evidence suggests that muscle-derived stem cells are well suited for gene therapy and tissue engineering applications for the musculoskeletal system. Effective implementation of even just a few applications of muscle-derived stem cell-based tissue engineering has the potential to revolutionize the way certain musculoskeletal diseases are managed.

    • Keywords:
    • Animals|Cell Differentiation|Humans|Musculoskeletal Diseases|Musculoskeletal Physiological Phenomena|Regenerative Medicine|Satellite Cells

    • Skeletal Muscle|Stem Cells|Wound Healing

    • Subspecialty:
    • General Orthopaedics

    • Basic Science

Removal of broken hardware.

Despite advances in metallurgy, fatigue failure of hardware is common when a fracture fails to heal. Revision procedures can be difficult, usually requiring removal of intact or broken hardware. Several different methods may need to be attempted to successfully remove intact or broken hardware. Broken intramedullary nail cross-locking screws may be advanced out by impacting with a Steinmann pin. Broken open-section (K?ntscher type) intramedullary nails may be removed using a hook. Closed-section cannulated intramedullary nails require additional techniques, such as the use of guidewires or commercially available extraction tools. Removal of broken solid nails requires use of a commercial ratchet grip extractor or a bone window to directly impact the broken segment. Screw extractors, trephines, and extraction bolts are useful for removing stripped or broken screws. Cold-welded screws and plates can complicate removal of locked implants and require the use of carbide drills or high-speed metal cutting tools. Hardware removal can be a time-consuming process, and no single technique is uniformly successful.

    • Keywords:
    • Device Removal|Humans|Orthopedic Equipment|Prosthesis Failure

    • Subspecialty:
    • Trauma

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