JAAOS

JAAOS, Volume 16, No. 6


Gene therapy for the treatment of degenerative disk disease.

Recent biologic and biochemical advances have furthered our understanding of the complex environment of the intervertebral disk. This new understanding has allowed researchers to pursue novel treatments of intervertebral disk degeneration, targeting the biochemical pathways involved in the degenerative cascade. Gene therapy has shown much promise in this regard. Many new targets for gene therapy in the intervertebral disk have been identified, such as TGF-beta1, TIMP-1, and LMP-1. In addition, new vectors, such as the adeno-associated virus, are being investigated for use in intervertebral disk applications. Cell-based therapy has also shown significant promise in the biologic treatment of intervertebral disk degeneration. With continued efforts, gene therapy may prove to be an extremely powerful tool in the treatment of intervertebral disk degeneration.

    • Keywords:
    • Animals|Gene Therapy|Humans|Intervertebral Disk|Osteoarthritis

    • Subspecialty:
    • Spine

Locked plating in orthopaedic trauma: a clinical update.

Locked plating for fracture fixation has enjoyed widespread popularity despite a paucity of published data on outcomes. Anatomically precontoured locked plates that allow fixation in various anatomic regions are widely available. New technologies incorporate subchondral support locking pegs, polyaxial bushings, and locking washers to improve intraoperative versatility. However, limited data are available on the efficacy of these new implants. The clinical performance of locked plates generally has been good. However, several unique complications have been noted, such as difficulty with implant removal, malalignment, fracture distraction, and loss of diaphyseal fixation, especially with percutaneous techniques and unicortical screws. The expense of locked plate constructs is a concern. This technology typically costs three times more than similar unlocked constructs. Locked constructs should be reserved for problematic fractures that have demonstrated poor outcomes with unlocked constructs.

    • Keywords:
    • Bone Plates|Fracture Fixation

    • Internal|Fractures

    • Bone|Humans

    • Subspecialty:
    • Trauma

Management of acute triangular fibrocartilage complex injury of the wrist.

Acute trauma to the triangular fibrocartilage complex includes tears of the fibrocartilage articular disk substance and meniscal homolog as well as radioulnar ligament avulsions, with or without an associated fracture. Patient evaluation includes clinical examination, imaging studies, and wrist arthroscopy (diagnostic). The Palmer classification is typically used to define injuries to the triangular fibrocartilage complex. The critical distinction is in differentiating injuries that produce instability of the distal radioulnar joint from those that do not. Also important is the recognition of acute injuries in the context of an ongoing degenerative pattern (ie, Palmer class 2 lesions). Nonsurgical management includes temporary splint immobilization of the wrist and forearm, oral nonsteroidal anti-inflammatory medication, corticosteroid joint injection, and physical therapy. Surgical strategies include débridement, acute repair, and subacute repair. Most surgical procedures can be performed arthroscopically. However, open ligament repair may be needed in the setting of distal radioulnar joint instability.

    • Keywords:
    • Humans|Orthopedic Procedures|Trauma Severity Indices|Triangular Fibrocartilage|Wrist Injuries

    • Subspecialty:
    • Hand and Wrist

Osteogenesis imperfecta: diagnosis and treatment.

Osteogenesis imperfecta is a heritable disorder characterized by extremely fragile bones, blue sclerae, dentinogenesis imperfecta, hearing loss, and scoliosis. In 1979, Sillence classified the condition into four types based on genetic and clinical criteria. Three more classifications have subsequently been added. Diagnosis of osteogenesis imperfecta may be done prenatally (in severe cases), clinically, radiographically, or via biochemical or genetic examination. Medical treatment consists of bisphosphonate use, even in patients younger than age 2 years. Surgical treatment consists of internal splinting of long bones. Research is currently being done on the use of smart intramedullary rods (ie, composed of nitinol shape-memory alloy) for correction of bone deformity and on the use of bone marrow transplantation to increase osteoblast density, thereby reducing fracture frequency.

    • Keywords:
    • Bone Density Conservation Agents|Diagnosis

    • Differential|Humans|Orthopedic Procedures|Osteogenesis Imperfecta

    • Subspecialty:
    • Pediatric Orthopaedics

    • General Orthopaedics

Plantar fasciitis: evaluation and treatment.

Plantar fasciitis is the most common cause of plantar heel pain. Its characteristic features are pain and tenderness, predominately on the medial aspect of the calcaneus near the sole of the heel. Considering a complete differential diagnosis of plantar heel pain is important; a comprehensive history and physical examination guide accurate diagnosis. Many nonsurgical treatment modalities have been used in managing the disorder, including rest, massage, nonsteroidal anti-inflammatory drugs, night splints, heel cups/pads, custom and off-the-shelf orthoses, injections, casts, and physical therapy measures such as shock wave therapy. Most reported treatment outcomes rely on anecdotal experience or combinations of multiple modalities. Nevertheless, nonsurgical management of plantar fasciitis is successful in approximately 90% of patients. Surgical treatment is considered in only a small subset of patients with persistent, severe symptoms refractory to nonsurgical intervention for at least 6 to 12 months.

    • Keywords:
    • Anti-Inflammatory Agents

    • Non-Steroidal|Diagnosis

    • Differential|Fasciitis

    • Plantar|Humans|Incidence|Orthopedic Procedures|Physical Therapy Modalities|Prognosis|Severity of Illness Index

    • Subspecialty:
    • Foot and Ankle

Postoperative spinal wound infections.

Surgical site infection is a common adverse event and a significant source of morbidity after any spinal procedure. A patient who presents with postoperative infection often requires prolonged hospitalization, revision surgical procedures, and long-term intravenous antibiotics. Awareness of risk factors and preventive measures can lead to improved outcomes. Infection after spinal surgery may pose diagnostic challenges and difficult management questions. Postoperative spinal infections present with a diverse degree of severity, from superficial skin incision infections to deep subfascial infections with myonecrosis. Definitive management is based on etiology, clinical course, and patient risk factors.

    • Keywords:
    • Debridement|Evidence-Based Medicine|Humans|Incidence|Orthopedic Procedures|Prognosis|Severity of Illness Index|Spinal Diseases|Surgical Wound Infection|United States

    • Subspecialty:
    • Spine

    • Clinical Practice Improvement

The use of scaffolds in the management of articular cartilage injury.

Managing articular cartilage injury continues to be a difficult challenge for the clinician. Although the short- and intermediate-term results of autologous chondrocyte implantation appear to be favorable, resources are being directed toward research to improve the technology. One promising area of investigation is the combination of cultured chondrocytes with scaffolds. Clinicians desire techniques that may be implanted easily, reduce surgical morbidity, do not require harvesting of other tissues, exhibit enhanced cell proliferation and maturation, have easier phenotype maintenance, and allow for efficient and complete integration with surrounding articular cartilage. The characteristics that make scaffolds optimal for clinical use are that they be biocompatible, biodegradable, permeable, reproducible, mechanically stable, noncytotoxic, and capable of serving as a temporary support for the cells while allowing for eventual replacement by matrix components synthesized by the implanted cells. Clinical experience is growing with three scaffold-based cartilage repair techniques, each using a different type of scaffold material: matrix-induced autologous chondrocyte implantation, a hyaluronic acid-based scaffold, and a composite polylactic/polyglycolic acid polymer fleece. Clinical results are encouraging. Future directions in scaffold-based cartilage repair include bioactive and spatially oriented scaffolds.

    • Keywords:
    • Cartilage

    • Articular|Humans|Joints|Prosthesis Implantation|Tissue Scaffolds|Wounds and Injuries

    • Subspecialty:
    • General Orthopaedics

    • Basic Science

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