JAAOS

JAAOS, Volume 17, No. 12


Central cord syndrome.

Central cord syndrome is the most common type of incomplete spinal cord injury. This syndrome most often occurs in older persons with underlying cervical spondylosis caused by a hyperextension mechanism. It also occurs in younger persons who sustain trauma to the cervical spine and, less commonly, as a result of nontraumatic causes. The upper extremities are more affected than the lower extremities, with motor function more severely impaired than sensory function. Central cord syndrome presents a spectrum, from weakness limited to the hands and forearms with sensory preservation, to compete quadriparesis with sacral sparing as the only evidence of incomplete spinal cord injury. Historically, treatment has been nonsurgical, but recovery is often incomplete. Early surgical treatment of central cord syndrome remains controversial. However, recent studies have shown benefits, particularly of early surgery to decompress the spinal cord in patients with pathologic conditions revealed by radiography or MRI.

    • Keywords:
    • Central Cord Syndrome|Cervical Vertebrae|Diagnostic Imaging|Humans|Laminectomy|Prognosis|Time Factors|Trauma Severity Indices

    • Subspecialty:
    • Spine

Commonly missed peritalar injuries.

Because of the effect on hindfoot kinematics, missed or delayed diagnosis of peritalar injuries often results in impairment. The seemingly innocuous nature of these injuries, subtle radiographic findings, and low incidence limit familiarity, thereby increasing the likelihood of misdiagnosis. Because of delay in diagnosis, salvage arthrodesis may be necessary to restore function to the extremity. Talar head fracture, talar process fracture, subtalar fracture-dislocation, transverse tarsal joint fracture, and transverse tarsal ligamentous disruption with instability are recurrently misdiagnosed. The keys to proper diagnosis of these potentially devastating injuries are the recognition of their existence, their injury patterns, and their radiographic appearance. The threshold for additional imaging studies should be lowered when a patient has pain and physical examination findings are out of proportion to a provisional diagnosis, or when symptoms fail to improve.

    • Keywords:
    • Ankle Injuries|Arthrography|Diagnosis

    • Differential|Diagnostic Errors|Fractures

    • Bone|Humans|Talus|Tomography

    • X-Ray Computed

    • Subspecialty:
    • Trauma

    • Foot and Ankle

Pedicled vascularized bone grafts for scaphoid and lunate reconstruction.

Conventional bone grafts have some osteogenic potential, whereas vascularized bone grafts retain live, functional osteocytes and osteoblasts. High rates of scaphoid union have been achieved with conventional bone grafting in the absence of osteonecrosis or prior surgery. Vascularized bone grafting is valuable in the management of wrist disorders with compromised bone vascularity (eg, scaphoid nonunion with proximal pole necrosis, Preiser disease, Kienbck disease) or when previous grafting has failed. Improved understanding of the vascular anatomy of the wrist has allowed the use of an array of vascularized bone grafts that do not require microsurgical anastomosis. Successful outcome depends on careful patient selection and appropriate surgical technique.

    • Keywords:
    • Bone Transplantation|Humans|Joint Diseases|Lunate Bone|Orthopedic Procedures|Reconstructive Surgical Procedures|Scaphoid Bone|Surgical Flaps|Treatment Outcome|Wrist Joint

    • Subspecialty:
    • Hand and Wrist

Soft-tissue balancing during total knee arthroplasty in the varus knee.

Soft-tissue balancing during total knee arthroplasty is an important step in optimizing the mechanical balance of the knee joint. Soft-tissue contractures that result from varus coronal plane deformity can pose a difficult problem, and the surgeon should have a standard procedure for managing such situations in the operating room. Balance may be assessed intraoperatively with the use of spacer blocks, laminar spreaders, and tensioning devices as well as by placement of trial components. Techniques used to balance the varus knee during primary total knee arthroplasty include femoral component rotation, osteophyte resection, soft-tissue release, and bone resection. Flexion and extension gap balancing is crucial for long-term success and patient satisfaction.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Knee|Elastic Tissue|Humans|Joint Deformities

    • Acquired|Knee Joint|Range of Motion

    • Articular|Tendons

    • Subspecialty:
    • Adult Reconstruction

The role of fibrin sealants in orthopaedic surgery.

Blood conservation, specifically the avoidance of allogeneic blood transfusion, is becoming an important aspect of preoperative planning and intraoperative decision making in orthopaedic surgery. Knee and hip arthroplasty, as well as certain spine procedures, place patients at risk of significant blood loss. Fibrin sealants are topically applied hemostatic agents that reduce the time required to achieve hemostasis as well as the volume of blood loss. Fibrin sealants may provide additional benefits beyond hemostasis, such as improvements in wound healing and postoperative range of motion as well as lower rates of wound infections.

    • Keywords:
    • Blood Loss

    • Surgical|Fibrin Tissue Adhesive|Hemostatic Techniques|Hemostatics|Humans|Orthopedic Procedures|Wound Healing

    • Subspecialty:
    • Spine

    • Adult Reconstruction

    • Clinical Practice Improvement

The use of radiofrequency ablation in the treatment of musculoskeletal tumors.

Musculoskeletal tumors, both primary neoplasms and metastatic lesions, present a therapeutic challenge for the physician who wishes to provide palliative pain relief using the least invasive approach. The increasing sophistication of imaging modalities such as CT in precisely localizing neoplasm, coupled with the widespread use of radiofrequency ablation (RFA) for treatment of other types of tumor, has generated interest in using RFA to treat musculoskeletal tumors. Primary bone tumors (eg, osteoid osteoma) and metastatic bone tumors have been successfully treated with RFA. Success rates with RFA are equal to those with standard surgical curettage, but RFA has the advantage of decreased surgical morbidity. The procedure is relatively safe, is well-tolerated by the patient, and typically can be performed on an outpatient basis. The most common serious complication reported is localized skin necrosis, which occurs rarely. RFA appears to be a viable minimally invasive approach for palliative treatment of selected bone tumors.

    • Keywords:
    • Bone Neoplasms|Catheter Ablation|Humans|Muscle Neoplasms|Treatment Outcome

    • Subspecialty:
    • Musculoskeletal Oncology

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