JAAOS

JAAOS, Volume 16, No. 8


Cauda equina syndrome.

Cauda equina syndrome is a relatively uncommon condition typically associated with a large, space-occupying lesion within the canal of the lumbosacral spine. The syndrome is characterized by varying patterns of low back pain, sciatica, lower extremity sensorimotor loss, and bowel and bladder dysfunction. The pathophysiology remains unclear but may be related to damage to the nerve roots composing the cauda equina from direct mechanical compression and venous congestion or ischemia. Early diagnosis is often challenging because the initial signs and symptoms frequently are subtle. Classically, the full-blown syndrome includes urinary retention, saddle anesthesia of the perineum, bilateral lower extremity pain, numbness, and weakness. Decreased rectal tone may be a relatively late finding. Early signs and symptoms of a developing postoperative cauda equina syndrome are often attributed to common postoperative findings. Therefore, a high index of suspicion is necessary in the postoperative spine patient with back and/or leg pain refractory to analgesia, especially in the setting of urinary retention. Regardless of the setting, when cauda equina syndrome is diagnosed, the treatment is urgent surgical decompression of the spinal canal.

    • Keywords:
    • Decompression

    • Surgical|Humans|Hypesthesia|Low Back Pain|Polyradiculopathy|Spinal Canal|Treatment Outcome|Urinary Retention

    • Subspecialty:
    • Spine

Orthopaedic management of the upper extremity of stroke patients.

Cerebrovascular accidents often produce significant pathology, including upper extremity muscle contractures and deformities that may be painful and aesthetically unappealing and that interfere with activities of daily living and hygiene. Orthopaedic intervention may be required to manage these disabilities. Nonsurgical management includes brachial plexus and phenol nerve blocks, which provide temporary relief of painful contractures and allow for a period of spontaneous neurologic recovery of up to 6 months. Definitive surgical procedures should be avoided during this time. After this period, surgical management can be valuable in releasing muscle spasticity, managing painful contractures, and positioning the deformed extremity in a more functional and aesthetically appealing position. Current surgical management is directed at reducing or eliminating muscle spasticity and joint contractures, with the goal of correcting deformities in shoulder adduction, elbow flexion, forearm pronation, wrist and finger flexion, intrinsic muscle spasticity, thumb-in-palm deformity, wrist extension, and finger extension.

    • Keywords:
    • Contracture|Humans|Joint Deformities

    • Acquired|Muscle Spasticity|Orthopedic Procedures|Shoulder Dislocation|Stroke

    • Subspecialty:
    • Shoulder and Elbow

    • Hand and Wrist

Revision total knee arthroplasty.

Revision total knee arthroplasty presents numerous technical challenges and decisions for the operating surgeon. Preoperative planning includes critically reviewing radiographs and ordering necessary equipment, including prosthetic components, extraction devices, and bone graft materials. In some cases, surgical exposure requires the use of extensile exposure techniques. Component removal is facilitated by the use of appropriate tools (eg, specialized osteotomes) as well as by the patience to ensure preservation of host bone. Bone loss is managed with bone grafts or prosthetic augmentation. Attention to balancing the flexion and extension gaps is essential to avoid problems with instability as well as excessively constrained prosthetic components. Intramedullary stem extensions improve long-term clinical results. Intraoperative extensor mechanism complications can be avoided with meticulous surgical technique; late complications may require surgical intervention.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Knee|Biomechanics|Bone Resorption|Device Removal|Humans|Joint Instability|Knee Joint|Reoperation

    • Subspecialty:
    • Adult Reconstruction

Symptomatic bipartite patella: treatment alternatives.

Bipartite patella is usually an asymptomatic, incidental finding. However, in adolescents, it may be a cause of anterior knee pain following trauma or a result of overuse or strenuous sports activity. Most patients improve with nonsurgical treatment. Surgery is considered when nonsurgical treatment fails. Excision of the fragment is the most popular surgical option, with good results. However, when the fragment is large and has an articular surface, excision may lead to patellofemoral incongruity. Lateral retinacular release and detachment of the vastus lateralis muscle insertion are other surgical options and are reported to produce good pain relief and union in some patients. These procedures reduce the traction force of the vastus lateralis on the loose fragment. Internal fixation of the separated fragment has limited support in the literature. Understanding the possible consequences of different treatment approaches to painful bipartite patella is necessary to preserve quadriceps muscle strength and patellofemoral joint function.

    • Keywords:
    • Humans|Internal Fixators|Knee Joint|Orthopedic Procedures|Ossification

    • Heterotopic|Patella

    • Subspecialty:
    • Sports Medicine

The use of locked plating in skeletally immature patients.

The philosophy and techniques for the management of fractures in the pediatric patient have changed over the past several decades. The immature skeleton has unique properties, and injuries in children have different characteristics, management options, and complications than do similar injuries in adults. The basic surgical techniques used in the management of pediatric fractures include closed reduction and casting, closed or open reduction with internal fixation, and external fixation. The concept of bridging plate osteosynthesis has evolved based on scientific insight into bone biology and the importance of blood supply to bone. The use of locked plating is gaining favor in the treatment of certain fractures in adults. However, the role for this technique in the skeletally immature patient has not been described.

    • Keywords:
    • Adolescent|Biomechanics|Bone Plates|Child|Child

    • Preschool|Fracture Fixation

    • Internal|Fracture Healing|Fractures

    • Bone|Humans|Infant|Orthopedic Procedures

    • Subspecialty:
    • Trauma

    • Pediatric Orthopaedics

    • Basic Science

Transient osteoporosis.

Transient osteoporosis is characterized primarily by bone marrow edema. The disease most commonly affects the hip, knee, and ankle in middle-aged men. Its cause remains unknown. The hallmark that separates transient osteoporosis from other conditions presenting with a bone marrow edema pattern is its self-limited nature. Laboratory tests usually do not contribute to the diagnosis. Plain radiographs may reveal regional osseous demineralization. Magnetic resonance imaging is used primarily for early diagnosis and monitoring disease progression. Early differentiation from more aggressive conditions with long-term sequelae is essential to avoid unnecessary treatment. Clinical entities such as transient osteoporosis of the hip and regional migratory osteoporosis are spontaneously resolving conditions. However, early differential diagnosis and surgical treatment are crucial for the patient with osteonecrosis of the hip or knee.

    • Keywords:
    • Bone Marrow Diseases|Diagnosis

    • Differential|Disease Progression|Edema|Humans|Magnetic Resonance Imaging|Osteonecrosis|Osteoporosis

    • Subspecialty:
    • Spine

    • Adult Reconstruction

    • Basic Science

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