JAAOS

JAAOS, Volume 17, No. 6


Anterior iliopsoas impingement and tendinitis after total hip arthroplasty.

Anterior iliopsoas impingement and tendinitis is a poorly understood and likely underrecognized cause of groin pain and functional disability after total hip arthroplasty. The patient history and physical examination findings are usually only suggestive, and the symptoms frequently subtle. The diagnosis may be confirmed by one or more imaging studies, including a cross-table lateral radiograph, computed tomography, magnetic resonance imaging, and ultrasonography, in combination with a confirmatory diagnostic injection. Nonsurgical management may not resolve the problem. Surgical treatment, consisting of release or resection of the iliopsoas tendon, alone or in combination with acetabular revision for an anterior overhanging component, usually provides permanent pain relief.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Hip|Humans|Pain

    • Postoperative|Postoperative Complications|Psoas Muscles|Severity of Illness Index|Tendinopathy

    • Subspecialty:
    • Adult Reconstruction

    • Pain Management

Complications of volar plate fixation for managing distal radius fractures.

Volar locking plate fixation via open reduction and internal fixation is an increasingly accepted method for managing displaced distal radius fractures. Volar plating offers biomechanically stable fixation, allows early rehabilitation, and enables fixation of comminuted or osteopenic bone. The literature reporting complications of volar plate fixation is limited primarily to case reports and small case series. The surgeon must be mindful of potential soft-tissue, neurovascular, and osseous complications, such as extensor tendon and flexor tendon injury, flexor pollicis rupture, carpal tunnel syndrome, complex regional pain syndrome, and loss of reduction, as well as hardware failure. Increased awareness of potential complications may lead to more prompt recognition and treatment when they do arise.

    • Keywords:
    • Bone Plates|Fracture Fixation

    • Internal|Humans|Prosthesis Failure|Radius Fractures

    • Subspecialty:
    • Trauma

    • Hand and Wrist

Diagnosis of carpal tunnel syndrome.

This clinical practice guideline was created to improve patient care by outlining the appropriate information-gathering and decision-making processes involved in managing the diagnosis of carpal tunnel syndrome. The methods used to develop this clinical practice guideline were designed to combat bias, enhance transparency, and promote reproducibility. The guideline's recommendations are as follows: The physician should obtain an accurate patient history. The physician should perform a physical examination of the patient that may include personal characteristics as well as performing a sensory examination, manual muscle testing of the upper extremity, and provocative and/or discriminatory tests for alternative diagnoses. The physician may obtain electrodiagnostic tests to differentiate among diagnoses. This may be done in the presence of thenar atrophy and/or persistent numbness. The physician should obtain electrodiagnostic tests when clinical and/or provocative tests are positive and surgical management is being considered. If the physician orders electrodiagnostic tests, the testing protocol should follow the American Academy of Neurology/American Association of Neuromuscular and Electrodiagnostic Medicine/American Academy of Physical Medicine and Rehabilitation guidelines for diagnosis of carpal tunnel syndrome. In addition, the physician should not routinely evaluate patients suspected of having carpal tunnel syndrome with new technology, such as magnetic resonance imaging, computed tomography, and pressure-specified sensorimotor devices in the wrist and hand. This decision was based on an additional nonsystematic literature review following the face-to-face meeting of the work group.

    • Keywords:
    • Carpal Tunnel Syndrome|Electrodiagnosis|Humans|Practice Guidelines as Topic

    • Subspecialty:
    • Hand and Wrist

    • Clinical Practice Improvement

Osteonecrosis of the humeral head.

Osteonecrosis of the humeral head is considerably less common than osteonecrosis of the hip. However, as in the hip, the interaction between a genetic predisposition and certain risk factors may lead to increased intraosseous pressure, loss of circulation, and eventual bone death. The most common risk factor remains corticosteroid use, which accounts for most reported cases. Radiographic staging and measurement of lesion size are predictive of disease progression and can be used to determine appropriate intervention. Recent studies have reported the use of various treatment modalities such as pharmacologics, core decompression with small-diameter drilling, arthroscopic-assisted core decompression, and bone grafting. Prospective, randomized studies are needed to determine the efficacy of these joint-preserving procedures. Newer resurfacing techniques have a role in treating articular surface loss. Hemiarthroplasty and total shoulder arthroplasty are recommended for patients with end-stage disease.

    • Keywords:
    • Humans|Humerus|Orthopedic Procedures|Osteonecrosis|Prognosis|Severity of Illness Index

    • Subspecialty:
    • Shoulder and Elbow

Sagittal plane deformity in the adult patient.

Recent studies have demonstrated that sagittal balance is the most important and reliable radiographic predictor of clinical health status in the adult with a spinal deformity. Affected persons typically present with intractable pain, early fatigue, and a perception of being off-balance. Nonsurgical management with nonsteroidal and analgesic medications as well as physical therapy plays a limited role. Surgical correction is the primary method of alleviating symptoms. The surgical approach depends largely on the amount of correction required to restore overall balance. Options include posterior-only or combined anterior-posterior surgery. The decision-making process often includes posterior-based osteotomies, such as the Smith-Petersen or pedicle subtraction, or vertebral column resection. Regardless of approach or osteotomy technique, spinal fusion with restored sagittal balance is the goal of any reconstructive procedure.

    • Keywords:
    • Adult|Humans|Laminectomy|Lumbar Vertebrae|Osteotomy|Postural Balance|Spinal Diseases|Thoracic Vertebrae

    • Subspecialty:
    • Spine

    • Pain Management

Static and mobile antibiotic-impregnated cement spacers for the management of prosthetic joint infection.

Two-stage treatment is currently the most common approach for management of an infected joint prosthesis in the United States. Static antibiotic-impregnated polymethylmethacrylate cement spacers have traditionally been used; increasingly, however, mobile or articulating spacers are being utilized. Advocates of mobile spacers have cited potential advantages, including more effective maintenance of the joint space, allowing for limited weight bearing and facilitating joint motion; possible reduction in bone loss; and local delivery of antibiotics. Because a variety of materials and construction methods is used to make knee and hip spacers, comparisons are difficult. Randomized, prospective studies are needed to determine the best spacers for total knee and total hip arthroplasties.

    • Keywords:
    • Anti-Bacterial Agents|Bone Cements|Coated Materials

    • Biocompatible|Humans|Joint Prosthesis|Prosthesis Design|Prosthesis-Related Infections

    • Subspecialty:
    • Trauma

Treatment of carpal tunnel syndrome.

In September 2008, the Board of Directors of the American Academy of Orthopaedic Surgeons approved a clinical practice guideline on the treatment of carpal tunnel syndrome. This guideline was subsequently endorsed by the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. The guideline makes nine specific recommendations: A course of nonsurgical treatment is an option in patients diagnosed with carpal tunnel syndrome. Early surgery is an option with clinical evidence of median nerve denervation or when the patient so elects. Another nonsurgical treatment or surgery is suggested when the current treatment fails to resolve symptoms within 2 to 7 weeks. Sufficient evidence is not available to provide specific treatment recommendations for carpal tunnel syndrome associated with such conditions as diabetes mellitus and coexistent cervical radiculopathy. Local steroid injection or splinting is suggested before considering surgery. Oral steroids or ultrasound are options. Carpal tunnel release is recommended as treatment. Heat therapy is not among the options to be used. Surgical treatment of carpal tunnel syndrome by complete division of the flexor retinaculum is recommended. Routine use of skin nerve preservation and epineurotomy is not suggested when carpal tunnel release is performed. Prescribing preoperative antibiotics for carpal tunnel surgery is an option. It is suggested that the wrist not be immobilized postoperatively after routine carpal tunnel surgery. It is suggested that instruments such as the Boston Carpal Tunnel Questionnaire and the Disabilities of the Arm, Shoulder, and Hand questionnaire be used to assess patient responses to carpal tunnel syndrome treatment for research.

    • Keywords:
    • Carpal Tunnel Syndrome|Humans|Orthopedic Procedures|Practice Guidelines as Topic

    • Subspecialty:
    • Hand and Wrist

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