JAAOS

JAAOS, Volume 19, No. 6


Cervical Spine Trauma in Children and Adults: Perioperative Considerations

A wide spectrum of cervical spine injuries, including stable and unstable injuries with and without neurologic compromise, account for a large percentage of emergency department visits. Effective treatment of the polytrauma patient with cervical spine injury requires knowledge of cervical spine anatomy and the pathophysiology of spinal cord injury, as well as techniques for cervical spine stabilization, intraoperative positioning, and airway management. The orthopaedic surgeon must oversee patient care and coordinate treatment with emergency department physicians and anesthesia services in both the acute and subacute settings. Children are particularly susceptible to substantial destabilizing cervical injuries and must be treated with a high degree of caution. The surgeon must understand the unique anatomic and biomechanical properties associated with the pediatric cervical spine as well as injury patterns and stabilization techniques specific to this patient population.

      • Subspecialty:
      • Spine

    Complications of Total Elbow Arthroplasty

    Modifications in implant design and improvements in surgical technique have expanded the applications of total elbow arthroplasty. Complications associated with reconstructive elbow surgery persist, however, often leading to profound and sometimes nonsalvageable disability. The most recognized complications include implant loosening, periprosthetic fracture, implant failure, infection, triceps insufficiency, and nerve palsy. Although far fewer elbow arthroplasties than lower extremity arthroplasties are performed, the proportion of complications is greater with elbow arthroplasty, and the outcomes of secondary reconstruction are less favorable.

        • Subspecialty:
        • Shoulder and Elbow

      Four Common Types of Bursitis: Diagnosis and Management

      Bursitis is a common cause of musculoskeletal pain and often prompts orthopaedic consultation. Bursitis must be distinguished from arthritis, fracture, tendinitis, and nerve pathology. Common types of bursitis include prepatellar, olecranon, trochanteric, and retrocalcaneal. Most patients respond to nonsurgical management, including ice, activity modification, and nonsteroidal anti-inflammatory drugs. In cases of septic bursitis, oral antibiotics may be administered. Local corticosteroid injection may be used in the management of prepatellar and olecranon bursitis; however, steroid injection into the retrocalcaneal bursa may adversely affect the biomechanical properties of the Achilles tendon. Surgical intervention may be required for recalcitrant bursitis, such as refractory trochanteric bursitis.

          • Subspecialty:
          • Sports Medicine

        Hip Instability

        Understanding of the etiology and pathology of hip instability has increased in recent years as new information has emerged regarding the disease processes of the hip. Hip instability, heretofore considered uncommon in clinical practice, is increasingly recognized as a pathologic entity. Instability may be classified as traumatic or atraumatic, and diagnosis is made based on patient history, physical examination, and imaging studies. Plain radiography, MRI, MRI arthrography, and hip instability tests (eg, posterior impingement, dial) can be used to confirm the presence of instability. Nonsurgical management options include physical therapy and protected weight bearing. Surgical intervention, whether arthroscopic or open, is required for large acetabular fractures and refractory instability. Knowledge of the etiology and evolving research of hip instability is essential to understand the spectrum of hip disease.

            • Subspecialty:
            • Adult Reconstruction

          Management of Lateral Humeral Condylar Fracture in Children

          Lateral condylar fractures constitute 12% to 20% of all pediatric distal humerus fractures. These fractures are easily missed and when not managed appropriately can displace. Missed fracture is a common cause of nonunion and deformity; thus, a high index of suspicion and adequate clinical and radiographic evaluation are required. Displaced fractures are associated with a high rate of nonunion. Nondisplaced fractures or those displaced ≤2 mm are managed with cast immobilization and frequent radiographic follow-up. Fractures displaced >2 mm are managed with surgical fixation. Successful outcomes have been reported with closed reduction, open reduction, and arthroscopically assisted techniques. Complications associated with pediatric lateral condylar fracture include cubitus varus, cubitus valgus, fishtail deformity, and tardy ulnar nerve palsy.

              • Subspecialty:
              • Pediatric Orthopaedics

            Metaphyseal Fixation in Revision Total Knee Arthroplasty: Indications and Techniques

            The need for revision total knee arthroplasty (TKA) is on the rise. Challenges to attaining durable, stable, well-functioning revision TKA include bony deficiency, periarticular osteopenia, deformity, and soft-tissue imbalance. Defect management often requires the use of stems, cement, metal augmentation, or allograft. Recently, there has been interest in obtaining fixation in the metaphyseal region in an attempt to improve construct stability while managing bony deficiency. Often, the metaphyseal bone is well vascularized, which provides an opportunity for additional fixation with cement, allograft, trabecular metal cones, or stepped porous-coated sleeves. Multiple series have documented good survivorship at short-term follow-up with trabecular metal cones and porous-coated sleeves. These newer technologies offer biologic fixation and are useful for treating bony defects that are not easily managed with other methods. Long-term studies are needed to determine the durability of these constructs. Concerns persist regarding stress shielding and difficulty of removal. Familiarity with the rationale and strategies for metaphyseal fixation in revision TKA is a valuable addition to the armamentarium of the revision surgeon.

                • Subspecialty:
                • Adult Reconstruction

              Optimizing the Management of Rotator Cuff Problems

              Of the 31 recommendations made by the work group, 19 were determined to be inconclusive because of the absence of definitive evidence. Of the remaining recommendations, four were classified as moderate grade, six as weak, and two as consensus statements of expert opinion. The four moderate-grade recommendations include suggestions that exercise and nonsteroidal anti-inflammatory drugs be used to manage rotator cuff symptoms in the absence of a full-thickness tear, that routine acromioplasty is not required at the time of rotator cuff repair, that noncross-linked, porcine small intestine submucosal xenograft patches not be used to manage rotator cuff tears, and that surgeons can advise patients that workers' compensation status correlates with less favorable outcomes after rotator cuff surgery.

                  • Subspecialty:
                  • Shoulder and Elbow

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