JAAOS

JAAOS, Volume 17, No. 11


Chordoma of the sacrum and vertebral bodies.

Chordomas are relatively rare tumors of bone. These primary malignant lesions occur throughout the spinal column and often show advanced growth at the time of diagnosis. Because such tumors are minimally responsive to radiation and chemotherapy, surgical resection is the mainstay of treatment. Patient survival and local control are associated with the ability to achieve wide surgical margins during excision. However, surgical morbidity may be substantial given the propensity for chordomas to abut or surround neural, vascular, and visceral structures. Thus, early recognition is essential, and treatment by a multidisciplinary team is ideal.

    • Keywords:
    • Cervical Vertebrae|Chondroma|Combined Modality Therapy|Diagnosis

    • Differential|Humans|Magnetic Resonance Imaging|Sacrum|Spinal Neoplasms|Thoracic Vertebrae

    • Subspecialty:
    • Spine

    • Musculoskeletal Oncology

Heterotopic ossification following traumatic brain injury and spinal cord injury.

Heterotopic ossification associated with neurologic injury, or neurogenic heterotopic ossification, tends to form at major synovial joints surrounded by spastic muscles. It is commonly associated with traumatic brain or spinal cord injury and with other causes of upper motor neuron lesions. Heterotopic ossification can result in a variety of complications, including nerve impingement, joint ankylosis, complex regional pain syndrome, osteoporosis, and soft-tissue infection. The associated decline in range of motion may greatly limit activities of daily living, such as positioning and transferring and maintenance of hygiene, thereby adversely affecting quality of life. Management of heterotopic ossification is aimed at limiting its progression and maximizing function of the affected joint. Nonsurgical treatment is appropriate for early heterotopic ossification; however, surgical excision should be considered in cases of joint ankylosis or significantly decreased range of motion before complications arise. Patient selection, timing of excision, and postoperative prophylaxis are important components of proper management.

    • Keywords:
    • Ankylosis|Brain Injuries|Humans|Orthopedic Procedures|Ossification

    • Heterotopic|Prognosis|Spinal Cord Injuries

    • Subspecialty:
    • Trauma

    • Spine

Meniscal tears and discoid meniscus in children: diagnosis and treatment.

The incidence of traumatic meniscal tears in children is on the rise, likely because of increased sports participation and more accurate diagnostic modalities. The increased vascularity of the developing meniscus is believed to enable greater healing potential. Meniscal tears in children are often amenable to repair, and excellent clinical results have been reported. Knee size must be considered when determining the optimal method of repair. Discoid menisci represent a spectrum of morphologic abnormalities and instability of the lateral meniscus. Highly unstable variants often present with the classic "snapping knee syndrome," whereas stable variants may remain asymptomatic until a tear develops. Asymptomatic discoid menisci should be observed, whereas symptomatic discoid menisci are best treated with saucerization and repair. Early to midterm reports on saucerization and repair of discoid lateral meniscus in children are promising.

    • Keywords:
    • Arthroscopy|Child|Diagnosis

    • Differential|Humans|Knee Injuries|Magnetic Resonance Imaging|Menisci

    • Tibial|Musculoskeletal Abnormalities|Orthopedic Procedures|Prognosis|Rupture

    • Subspecialty:
    • Sports Medicine

    • Pediatric Orthopaedics

Principles of treatment for periprosthetic femoral shaft fractures around well-fixed total hip arthroplasty.

Postoperative periprosthetic femoral fractures around the stem of a total hip arthroplasty are increasing in frequency. To obtain optimal results, full appreciation of the clinical evaluation, classification, and modern management principles and techniques is required. Although periprosthetic femoral fracture associated with a loose stem requires complex revision arthroplasty, fractures associated with a stable femoral stem can be managed effectively with osteosynthesis principles familiar to most orthopaedic surgeons. Femoral fracture around a stable femoral stem is classified as a Vancouver type B1 fracture. The preferred treatment consists of internal fixation, following open or indirect reduction. Emerging techniques, such as percutaneous plating and the use of locking plates, have been used with increasing frequency. Preliminary results of these techniques are promising; however, further prospective comparative studies are required.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Hip|Femoral Fractures|Fracture Fixation|Humans|Postoperative Complications|Practice Guidelines as Topic|Reoperation

    • Subspecialty:
    • Trauma

    • Adult Reconstruction

Suprascapular neuropathy.

Suprascapular neuropathy is a relatively uncommon but significant cause of shoulder pain and dysfunction. The suprascapular nerve follows a tortuous course from the neck to the posterior shoulder. There are several potential causes of nerve entrapment along this path, particularly at the vulnerable suprascapular and spinoglenoid notches, where nerve excursion is limited by bony and ligamentous constraints. Additional extrinsic compression may be caused by glenohumeral joint-related ganglion cysts or soft-tissue masses. Traction neuropathy may occur following excessive nerve excursion during overhead sports or as a result of massive, retracted rotator cuff tears in older patients. Diagnosis is based on a careful history, physical examination, focused imaging, and electrodiagnostic studies. In the absence of a clear structural compression or overtensioning of the nerve, treatment initially should be nonsurgical, with activity modification and physical therapy. Discrete nerve compression or failure of nonsurgical measures warrants early surgical intervention. Arthroscopic alternatives to the traditional open suprascapular and/or spinoglenoid notch decompressions have the benefit of simultaneously diagnosing and addressing intra-articular and/or subacromial pathology while minimizing morbidity. In most patients, both open and arthroscopic approaches provide reliable pain relief and improvements in function; return of strength and muscle bulk is less predictable.

    • Keywords:
    • Arthroscopy|Decompression

    • Surgical|Humans|Nerve Compression Syndromes|Peripheral Nerves|Shoulder|Shoulder Pain

    • Subspecialty:
    • Sports Medicine

    • Shoulder and Elbow

Treatment of pediatric diaphyseal femur fractures.

Methods of treating pediatric diaphyseal femur fractures are dictated by patient age, fracture characteristics, and family social situation. The recent trend has been away from nonsurgical treatment and toward surgical stabilization. The clinical practice guideline on pediatric diaphyseal femur fractures was undertaken to determine the best evidence regarding a number of different options for surgical stabilization. The recommendations address treatments that include Pavlik harness, spica casts, flexible intramedullary nailing, rigid trochanteric entry nailing, submuscular plating, and pain management. The guideline authors conclude that controversy and lack of conclusive evidence remain regarding the different treatment options for pediatric femur fractures and that the quality of scientific evidence could be improved for the revised guideline.

    • Keywords:
    • Child|Diaphyses|Femoral Fractures|Femur|Fracture Fixation|Humans|Practice Guidelines as Topic

    • Subspecialty:
    • Trauma

    • Pediatric Orthopaedics

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