JAAOS

JAAOS, Volume 19, No. 11


Arthroscopic Releases for Arthrofibrosis of the Knee

Intra-articular inflammation or fibrosis may lead to decreased soft-tissue and capsular compliance, which may result in pain or loss of motion within the knee. Etiology of intra-articular fibrosis may include isolated anterior interval scarring and posterior capsular contracture, as well as fibrosis that involves the suprapatellar pouch or arthrofibrosis that involves the entire synovial space. Initial nonsurgical management, including compression, elevation, and physical therapy, can decrease knee pain and inflammation and maintain range of motion. Surgical management is indicated in the patient who fails conservative treatment. Surgical options include arthroscopic releases of the anterior interval, posterior capsule, and peripatellar and suprapatellar regions. Recent advances in arthroscopic technique have led to improved outcomes in patients with intra-articular fibrosis of the knee.

      • Subspecialty:
      • Sports Medicine

    Arthroscopic Revision Rotator Cuff Repair

    Rotator cuff repair leads to good and excellent outcomes in most patients. However, structural failure of the repair occurs in a substantial number of cases and can lead to an unsatisfactory result. Several factors have been implicated, including patient-related factors (eg, patient age, tear size) and extrinsic factors (eg, surgeon surgical volume, biomechanical failure). Structural failure requires a detailed patient evaluation to elucidate the cause of persistent symptoms. Function can be maintained despite a recurrent tear; therefore, a recurrent tear alone is not an indication for revision repair. The major indication for revision rotator cuff repair is the persistence of clinical symptoms, despite nonsurgical management, in the absence of substantial risk factors for failure. Although the outcome is poorer than after primary repair, satisfactory results have been reported following revision repair of recurrent rotator cuff tears, particularly with arthroscopic techniques.

        • Subspecialty:
        • Sports Medicine

        • Shoulder and Elbow

      Intramedullary Nailing of Extra-articular Proximal Tibia Fractures

      Tibial fractures are the most common long bone fractures. Extra-articular proximal tibia fractures account for approximately 5% to 11% of all tibial shaft fractures. The benefits of intramedullary nailing of these fractures include load sharing, sparing of the extraosseous blood supply, and avoidance of additional soft-tissue dissection, thereby minimizing the risk of postoperative complications. A significant rate of malalignment has been reported with intramedullary nailing of proximal tibia fractures, however. Malalignment typically presents as apex anterior and valgus angulation. Several nailing methods and reduction techniques have been developed to minimize this complication, including the use of a proper starting point and insertion angle, blocking screws, unicortical plates, a universal distractor, and alternative positioning and approaches. Use of one or more of these techniques has resulted in a reported average malreduction rate of 8.2%.

          • Subspecialty:
          • Trauma

          • Adult Reconstruction

        Osteoid Osteoma and Osteoblastoma

        Osteoid osteoma and osteoblastoma are commonly seen benign osteogenic bone neoplasms. Both tumors are typically seen in the second decade of life, with a notable predilection in males. Histologically, these tumors resemble each other, with characteristically increased osteoid tissue formation surrounded by vascular fibrous stroma and perilesional sclerosis. However, osteoblastomas are larger than osteoid osteomas, and they exhibit greater osteoid production and vascularity. Clinically, osteoid osteoma most commonly occurs in the long bones (eg, femur, tibia). The lesions cause night pain that is relieved with nonsteroidal anti-inflammatory drugs (NSAIDs). Osteoblastoma is most frequently located in the axial skeleton, and the pain is usually not worse at night and is less likely to be relieved with NSAIDs. Osteoblastoma can be locally aggressive; osteoid osteoma lacks growth potential. Osteoid osteoma may be managed nonsurgically with NSAIDs. When surgery is required, minimally invasive methods (eg, CT-guided excision, radiofrequency ablation) are preferred. Osteoblastoma has a higher rate of recurrence than does osteoid osteoma, and patients must be treated surgically with intralesional curettage or en bloc resection.

            • Subspecialty:
            • Musculoskeletal Oncology

          Pediatric Disk Herniation

          Pediatric disk herniation is a rare condition that should be considered in the differential diagnosis of the child with back pain or radiating leg pain. Because pediatric disk herniation is relatively uncommon, there is typically a delay in diagnosis compared with time to diagnosis of adult disk herniation. Pediatric disk herniations are often recalcitrant to nonsurgical care, but such measures should be attempted in patients who present with isolated pain symptoms and have a normal neurologic examination. Twenty-eight percent of adolescent disk herniations involve apophyseal fractures; this presentation has a higher rate of surgical intervention than do herniations without fracture. Surgical management of pediatric disk herniation involves laminotomy and fragment excision. Short-term data demonstrate excellent pain relief, with 1% of children requiring repeat surgery for lumbar disk pathology in the first year. Long-term data suggest that 20% to 30% of patients will require additional surgery later in life.

              • Subspecialty:
              • Pediatric Orthopaedics

              • Spine

            Subacromial Impingement Syndrome

            Subacromial impingement syndrome (SIS) represents a spectrum of pathology ranging from subacromial bursitis to rotator cuff tendinopathy and full-thickness rotator cuff tears. The relationship between subacromial impingement and rotator cuff disease in the etiology of rotator cuff injury is a matter of debate. Both extrinsic compression and intrinsic degeneration may play a role. Management includes physical therapy, injections, and, for some patients, surgery. There remains a need for high-quality studies of the pathology, etiology, and management of SIS.

                • Subspecialty:
                • Sports Medicine

                • Shoulder and Elbow

              Surgical Management of Healed Slipped Capital Femoral Epiphysis

              Slipped capital femoral epiphysis (SCFE) results in posterior and inferior displacement of the epiphysis on the femoral neck. In most centers, the recommended initial management of stable SCFE is in situ pinning. Minimal reduction with in situ pinning is recommended for unstable SCFE. This approach does not restore the normal anatomy of the hip joint, and the resulting proximal femoral deformity may cause femoroacetabular impingement. Patients with femoroacetabular impingement experience reduced hip range of motion as well as hip pain, and they are at risk of early-onset hip osteoarthritis. Techniques for managing this deformity include arthroscopic femoral neck osteochondroplasty, a limited anterior hip approach or surgical hip dislocation, and flexion intertrochanteric osteotomy. These surgical techniques should be considered for patients with healed SCFE deformity who present with hip pain at an early age.

                  • Subspecialty:
                  • Pediatric Orthopaedics

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