JAAOS

JAAOS, Volume 17, No. 10


Adult isthmic spondylolisthesis.

Isthmic spondylolisthesis is present in a small subset of the adult population. Although the incidence of low back pain in these persons is similar to that of the general population, both pars interarticularis defect and forward slip can serve as unique pain generators. Neurologic symptoms may result from nerve root impingement related to the pars defect or degenerative changes associated with the deformity. Most symptomatic cases are successfully managed nonsurgically, but patients with intractable pain or neurologic symptoms may benefit from surgical decompression and stabilization. Surgical intervention has shown >80% success in appropriately selected patients, with a low incidence of complications. Surgical techniques include decompression, posterolateral fusion, anterior lumbosacral interbody fusion, and circumferential fusion methods. Circumferential fusion results in improved fusion rates and, in some studies, superior clinical outcomes. The choice of procedure is generally guided by the patient's radiographic and clinical findings as well as risk-benefit considerations.

    • Keywords:
    • Adult|Decompression

    • Surgical|Humans|Low Back Pain|Lumbar Vertebrae|Sacrum|Spinal Fusion|Spondylolisthesis

    • Subspecialty:
    • Spine

    • Pain Management

Failure of fracture plate fixation.

Failure of fracture fixation after plating often leads to challenging surgical revision situations. Careful analysis of all patient and fracture variables is helpful in both determining the causes of the fixation failure and maximizing the success of subsequent interventions. Biologic and mechanical factors must be considered. Biologic considerations include traumatic soft-tissue injury and atrophic fracture site. Common mechanical reasons for failure include malreduction, inadequate plate length or strength, and excessive or insufficient construct stiffness. Reliance on laterally based implants in the presence of medial comminution may be a cause of fixation failure and subsequent deformity, particularly with conventional nonlocking implants. Management of dead space with cement or beads has been effective in conjunction with staged approaches. An antibiotic cement rod in the diaphysis may provide fracture stabilization. Locking full-length constructs should be considered for osteoporotic fractures.

    • Keywords:
    • Bone Screws|Femoral Fractures|Fracture Fixation

    • Internal|Fractures

    • Bone|Fractures

    • Stress|Humans|Humeral Fractures|Osteoporosis|Treatment Failure

    • Subspecialty:
    • Trauma

    • Basic Science

Pediatric musculoskeletal infection: trends and antibiotic recommendations.

In the past decade, the incidence of methicillin-resistant Staphylococcus aureus infections in children has increased. This phenomenon has led to a rise in complex, deep infections involving the musculoskeletal system for which a comprehensive approach of evaluation and treatment has become necessary. Whenever possible, cultures should be obtained to guide specific antibiotic selection. The potential for infections involving multiple tissue locations within the same patient and the risk for complications such as deep vein thrombosis necessitate a thorough, often multidisciplinary, approach in the care of these children. MRI is valuable in defining the anatomic and spatial extent of infection as well as in guiding the decision and approach for surgery. Most patients have favorable outcomes with sequential parenteral to oral antibiotic therapy after adequate surgical débridement of the infection. Close outpatient follow-up is essential to ensure antibiotic compliance and to identify late consequences of the infection.

    • Keywords:
    • Anti-Bacterial Agents|Arthritis

    • Infectious|Bone Diseases

    • Infectious|Child|Humans|Magnetic Resonance Imaging|Methicillin-Resistant Staphylococcus aureus|Musculoskeletal Diseases|Osteomyelitis|Staphylococcal Infections

    • Subspecialty:
    • Pediatric Orthopaedics

    • General Orthopaedics

Platelet-rich plasma: current concepts and application in sports medicine.

Platelet-rich plasma is defined as autologous blood with a concentration of platelets above baseline values. Platelet-rich plasma has been used in maxillofacial and plastic surgery since the 1990s; its use in sports medicine is growing given its potential to enhance muscle and tendon healing. In vitro studies suggest that growth factors released by platelets recruit reparative cells and may augment soft-tissue repair. Although minimal clinical evidence is currently available, the use of platelet-rich plasma has increased, given its safety as well as the availability of new devices for outpatient preparation and delivery. Its use in surgery to augment rotator cuff and Achilles tendon repair has also been reported. As the marketing of platelet-rich plasma increases, orthopaedic surgeons must be informed regarding the available preparation devices and their differences. Many controlled clinical trials are under way, but clinical use should be approached cautiously until high-level clinical evidence supporting platelet-rich plasma efficacy is available.

    • Keywords:
    • Achilles Tendon|Anterior Cruciate Ligament|Humans|Musculoskeletal System|Orthopedics|Platelet-Rich Plasma|Rotator Cuff|Sports Medicine|Tendon Injuries|Tennis Elbow|Therapies

    • Investigational|Wound Healing

    • Subspecialty:
    • Sports Medicine

    • Clinical Practice Improvement

Superior labral tears of the shoulder: pathogenesis, evaluation, and treatment.

Lesions of the superior glenoid labrum and biceps anchor are a well-recognized cause of shoulder pain. Advances in shoulder arthroscopy have led to improvements in recognizing and managing superior labral anterior-posterior (SLAP) tears. Recent biomechanical studies have postulated several theories for the pathogenesis of SLAP tears in throwing athletes and the effect of these injuries on normal shoulder kinematics. Advances in soft-tissue imaging techniques have resulted in improved accuracy in diagnosing SLAP tears. However, the diagnosis of clinically relevant SLAP tears remains challenging because of the lack of specific examination findings and the frequency of concomitant shoulder injuries. Definitive diagnosis of suspected SLAP tears is confirmed on arthroscopic examination. Advances in surgical techniques have made it possible to achieve secure repair in selected patterns of injury. Recent outcomes studies have shown predictably good functional results and an acceptable rate of return to sport and/or work with arthroscopic treatment of SLAP tears.

    • Keywords:
    • Arthroscopy|Athletic Injuries|Biomechanics|Humans|Magnetic Resonance Angiography|Physical Examination|Range of Motion

    • Articular|Shoulder Joint|Shoulder Pain|Tendon Injuries|Treatment Outcome

    • Subspecialty:
    • Sports Medicine

    • Shoulder and Elbow

    • Basic Science

The efficacy and duration of intra-articular corticosteroid injection for knee osteoarthritis: a systematic review of level I studies.

We performed a systematic review of the current literature to determine the efficacy and duration of intra-articular corticosteroid injection in reducing pain caused by knee osteoarthritis and to determine whether the type of corticosteroid used affected these results. Following an electronic search of multiple databases and a review of reference lists from various articles, we found six trials in five papers that compared corticosteroid versus placebo and four papers that compared different corticosteroids. Results of corticosteroid compared with placebo showed both a statistically and clinically significant reduction in pain at 1 week, with an average difference between groups of 22%. Two of four trials showed triamcinolone to be more effective in pain reduction than other corticosteroids. We concluded that intra-articular corticosteroids reduce knee pain for at least 1 week and that intra-articular corticosteroid injection is a short-term treatment of a chronic problem.

    • Keywords:
    • Glucocorticoids|Humans|Injections

    • Intra-Articular|Osteoarthritis

    • Knee|Pain Measurement|Treatment Outcome|Triamcinolone

    • Subspecialty:
    • Adult Reconstruction

    • Pain Management

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