JAAOS

JAAOS, Volume 18, No. 3


Antifibrinolytics in major orthopaedic surgery.

Total joint arthroplasty and deformity surgery of the spine can require complex reconstructive procedures accompanied by the potential for major blood loss. In an attempt to minimize the perioperative blood loss associated with these procedures, recent focus has concentrated on the efficacy of pharmacologic agents. Antifibrinolytics such as epsilon-aminocaproic acid, tranexamic acid, and aprotinin have been shown to reduce perioperative blood loss, autologous blood donation, transfusions, and associated costs in cardiac as well as major orthopaedic surgery. These agents reduce perioperative blood loss by inhibition of clot breakdown. Prospective, randomized studies have shown that the use of these agents can be effective in reducing the perioperative blood loss and transfusion requirements in total joint arthroplasty, pediatric scoliosis surgery, and adult reconstructive surgery of the spine. Aprotinin, however, is currently under suspension from use pending further evaluation of a trial. Although concerns exist about increased thrombotic events with the use of these agents, large meta-analyses suggest that antifibrinolytics can be safely and efficaciously employed to decrease perioperative blood loss and transfusion requirements.

    • Keywords:
    • 6-Aminocaproic Acid|Antifibrinolytic Agents|Aprotinin|Blood Loss

    • Surgical|Blood Transfusion|Humans|Orthopedic Procedures|Postoperative Hemorrhage|Reconstructive Surgical Procedures|Tranexamic Acid

    • Subspecialty:
    • General Orthopaedics

Clearing the cervical spine in the blunt trauma patient.

The goal of cervical spine clearance is to establish that injuries are not present. Patients are classified into four groups: asymptomatic, temporarily nonassessable secondary to distracting injuries or intoxication, symptomatic, and obtunded. Level I evidence supports that the asymptomatic patient can be cleared on clinical grounds and does not require imaging. The temporarily nonassessable patient may have short-term mental status changes (eg, intoxication, painful distracting injuries) and can be evaluated by two methods. When there is urgency, the evaluation is similar to that for the obtunded patient. Alternatively, the patient can be reevaluated within 24 to 48 hours, after return of mentation or following treatment of painful injuries. The patient then can be assessed as the asymptomatic patient is. The symptomatic patient requires advanced imaging. The obtunded patient should undergo, at minimum, a multidetector CT scan. Two methods are advocated. One uses only multidetector CT; a normal result is sufficient to clear the obtunded patient. The alternative method is obtaining a magnetic resonance image subsequent to a negative multidetector CT scan. Because at present information is insufficient to determine whether MRI is indicated, this is an area of controversy.

    • Keywords:
    • Algorithms|Cervical Vertebrae|Evidence-Based Medicine|Humans|Magnetic Resonance Imaging|Spinal Injuries|Tomography

    • X-Ray Computed|Wounds

    • Nonpenetrating

    • Subspecialty:
    • Trauma

    • Spine

Composite tissue allotransplantation: hand transplantation and beyond.

Recent advances in transplant immunology are shifting the focus from immunosuppression to immunoregulation, making composite tissue allotransplantation with novel and less potent immunosuppressive regimens a possibility. Hand transplantation has been the most frequently performed human composite tissue allotransplantation, with more than 50 upper extremity-based transplants done worldwide. Further research is needed regarding immunomodulating protocols, and careful oversight and individualized screening procedures will be required as patients seeking improved quality of life through human composite tissue allotransplantation come to accept a certain level of risk in these experimental procedures. Still, composite tissue allotransplantation offers to advance transplant medicine and reconstructive surgery.

    • Keywords:
    • Graft Rejection|Hand|Humans|Immunosuppression|Reconstructive Surgical Procedures|Tissue Transplantation|Transplantation Immunology|Transplantation

    • Homologous

    • Subspecialty:
    • Hand and Wrist

Evaluation of the adult patient (aged >40 years) with a destructive bone lesion.

More than one half of cancer patients are likely to develop bone metastasis; thus, most orthopaedic surgeons will be presented with an adult patient with a destructive bone lesion. Proper management requires comprehensive patient evaluation, including history, physical examination, laboratory studies, and radiographic staging. Biopsy should be done in the patient with a possible malignant or metastatic tumor. The differential diagnosis of destructive bone lesions in patients aged >40 years includes metastatic bone disease, multiple myeloma, lymphoma, and, less commonly, primary bone tumors. Inaccurate diagnosis and improper treatment may adversely affect limb or life. Adherence to oncologic principles during the evaluation process aids in minimizing a negative outcome.

    • Keywords:
    • Adult|Aged|Biopsy|Bone Neoplasms|Diagnosis

    • Differential|Diagnostic Imaging|Humans|Medical History Taking|Middle Aged|Neoplasm Staging|Physical Examination|Tumor Markers

    • Biological

    • Subspecialty:
    • Musculoskeletal Oncology

Surgical treatment of distal biceps rupture.

Rupture of the distal biceps tendon accounts for 10% of all biceps brachii ruptures. Injuries typically occur in the dominant elbow of men aged 40 to 49 years during eccentric contraction of the biceps. Degenerative changes, decreased vascularity, and tendon impingement may precede rupture. Although nonsurgical management is an option, healthy, active persons with distal biceps tendon ruptures benefit from early surgical repair, gaining improved strength in forearm supination and, to a lesser degree, elbow flexion. Biomechanical studies have tested the strength and displacement of various repairs; the suspensory cortical button technique exhibits maximum peak load to failure in vitro, and suture anchor and interosseous screw techniques yield the least displacement. Surgical complications include sensory and motor neurapraxia, infection, and heterotopic ossification. Current trends in postoperative rehabilitation include an early return to motion and to activities of daily living.

    • Keywords:
    • Activities of Daily Living|Biomechanics|Diagnostic Imaging|Evidence-Based Medicine|Humans|Muscle

    • Skeletal|Orthopedic Procedures|Physical Examination|Risk Factors|Rupture|Suture Techniques|Tendon Injuries

    • Subspecialty:
    • Sports Medicine

    • Shoulder and Elbow

    • Hand and Wrist

Treatment of distal radius fractures.

The clinical practice guideline is based on a systematic review of published studies on the treatment of distal radius fractures in adults. None of the 29 recommendations made by the work group was graded as strong; most are graded as inconclusive or consensus; seven are graded as weak. The remaining five moderate-strength recommendations include surgical fixation, rather than cast fixation, for fractures with postreduction radial shortening >3 mm, dorsal tilt >10 degrees , or intra-articular displacement or step-off >2 mm; use of rigid immobilization rather than removable splints for nonsurgical treatment; making a postreduction true lateral radiograph of the carpus to assess dorsal radial ulnar joint alignment; beginning early wrist motion following stable fixation; and recommending adjuvant treatment with vitamin C to prevent disproportionate pain.

    • Keywords:
    • Adult|Age Factors|Aged|Arthroscopy|Bone Transplantation|Casts

    • Surgical|Humans|Immobilization|Middle Aged|Orthopedic Procedures|Radius Fractures|Splints

    • Subspecialty:
    • Trauma

    • Hand and Wrist

Upper extremity surgery in children with cerebral palsy.

Pediatric patients with cerebral palsy present unique challenges. Any treatment regimen must take into account potential growth, possible sequelae of surgery, and, in some cases, significant behavioral issues. Careful evaluation of motor and sensory function of the extremity and of use patterns is imperative because these findings play a critical role in determining the ultimate success of any intervention. Every patient is addressed independently and treatment individualized. The patient and parents must understand that surgery can address only the function or position of the anatomic area. Surgery will not correct the underlying problem.

    • Keywords:
    • Cerebral Palsy|Child|Evidence-Based Medicine|Humans|Range of Motion

    • Articular|Upper Extremity

    • Subspecialty:
    • Pediatric Orthopaedics

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