JAAOS

JAAOS, Volume 18, No. 7


Management of Osteoarthritis of the Knee in the Active Patient

Total knee arthroplasty has been extremely successful in elderly patients with osteoarthritis. However, there is considerable controversy regarding how best to treat the younger, athletic patient with advanced arthritis. Treatment options range from nonsurgical management with exercise and nonsteroidal anti-inflammatory drugs, to joint arthroplasty with activity modification. When properly indicated, arthroscopic dbridement, high tibial osteotomy, unicondylar knee arthroplasty, and total knee arthroplasty allow younger patients with arthritis to maintain an active, healthy lifestyle.

      • Subspecialty:
      • Sports Medicine

      • Adult Reconstruction

    Midfoot Arthritis

    Midfoot arthritis is a common cause of significant pain and disability. Although the medial tarsometatarsal (TMT) joints provide<7 of sagittal plane motion, the more mobile lateral fourth and fifth TMT joints provide balance and accommodation on uneven ground. These small constrained TMT joints also provide stability and translate the forward propulsion motion of the hindfoot and ankle joint to the forefoot metatarsophalangeal joints from heel rise to toe-off. Posttraumatic degeneration is the primary cause of midfoot arthritis, although primary degeneration and inflammatory conditions can also affect this area. The result is a painful midfoot that can no longer effectively transmit load from the hindfoot to the forefoot. Shoe modifications and orthotic inserts are the mainstay of nonsurgical management. Successful management of midfoot arthritis with orthoses is predicated on achieving adequate joint stabilization while still allowing function. Surgical intervention typically involves arthrodesis of the medial midfoot, although the best treatment of the more mobile lateral column is a subject of debate.

        • Subspecialty:
        • Foot and Ankle

      Odontoid Fractures: Update on Management

      Recognition of the incidence of odontoid fractures as well as the associated morbidity and unexpectedly high mortality rates has prompted significant changes in the management of these fractures in the past decade. Nonsurgical management of type II odontoid fracture has historically been associated with a high nonunion rate. Thus, new classification systems have been devised to identify patients who might benefit from early surgical treatment. The decision-making process is particularly difficult when treating elderly patients. Increased familiarity with anterior and posterior surgical techniques has led to more aggressive treatment of odontoid fracture, with the intent of hastening functional rehabilitation. However, these clinical decisions have been associated with a significant rate of complications. The treatment algorithm for odontoid fractures continues to evolve based on the improved understanding of, and evidence-based literature on, anterior screw fixation, posterior spinal fusion, and halo-vest immobilization.

          • Subspecialty:
          • Trauma

          • Hand and Wrist

        Pediatric Tibial Eminence Fractures: Evaluation and Management

        Tibial eminence fractures result from both contact and noncontact injuries. Skeletally immature persons are especially at risk. In adults, isolated fractures of the tibial eminence are usually associated with higher-energy mechanisms. The incidence of concomitant intra-articular injuries with tibial eminence fracture is high; MRI is useful in evaluating this injury. Nondisplaced fractures are amenable to nonsurgical management. Displaced fractures are managed with arthroscopic reduction and fixation with either sutures or screws. Although most fractures heal successfully, residual laxity usually persists because of prefracture anterior cruciate ligament midsubstance attenuation. This does not typically manifest in subjective instability, and reconstruction of the anterior cruciate ligament is rarely required. Patient factors, surgeon experience, and fracture pattern must be carefully considered before undertaking surgical repair.

            • Subspecialty:
            • Trauma

            • Pediatric Orthopaedics

          Perioperative Management of Diabetes and Hyperglycemia in Patients Undergoing Orthopaedic Surgery

          Persons with diabetes undergo more surgical procedures, have a higher perioperative risk of complications, and have longer hospital stays than do persons who do not have diabetes. Persons with diabetes are frequently overweight, have a high prevalence of cardiovascular risk factors, and are more likely to suffer from chronic musculoskeletal conditions and traumatic injuries that require orthopaedic attention. Surgery frequently disrupts usual diabetes management, requiring adjustments to the treatment regimen. Suboptimal perioperative glucose control may contribute to increased morbidity, and it aggravates concomitant illnesses. Many patients undergoing elective or urgent orthopaedic surgery may have unrecognized diabetes or may develop stress-related hyperglycemia in the hospital. The challenge is to minimize the effects of metabolic derangements on surgical outcomes, reduce glycemic excursions, and prevent hypoglycemia. Recent guidelines advocate evidence-based glucose targets in the inpatient setting, and regimens for intravenous and subcutaneous insulin are gaining in popularity. Individualized treatment should be based on the ambient level of glycemic control, outpatient treatment regimen, presence of complications, nature of the surgical procedure, and type of anesthesia administered. Management by a multidisciplinary team and attention to discharge planning are key aspects of care during and after orthopaedic surgery.

              • Subspecialty:
              • Trauma

              • Foot and Ankle

              • Shoulder and Elbow

              • Hand and Wrist

              • Spine

              • General Orthopaedics

              • Adult Reconstruction

            Shoulder Outcomes Measures

            General health as well as disease- or condition-specific outcome measures have long been used to assess patients with shoulder conditions. Currently, a variety of validated measures is available. Shoulder outcomes measures may be general (eg, American Shoulder and Elbow Surgeons; Constant; Disabilities of the Arm, Shoulder, and Hand), disease-specific (eg, Rotator Cuff Quality of Life, Western Ontario Rotator Cuff Index), or condition-specific (eg, Oxford Shoulder Instability Questionnaire). The results of shoulder arthroplasty and arthritis treatment can be assessed with the Hospital for Special Surgery score and the validated Western Ontario Osteoarthritis of the Shoulder Index. Combining a general health outcome measure, a general shoulder measure, a disease- or condition-specific shoulder measure, and an activity measure allows for broad patient assessment.

                • Subspecialty:
                • Shoulder and Elbow

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