JAAOS

JAAOS, Volume 2, No. 1


Acute Calcaneal Fractures: Treatment Options and Results.

The treatment of choice for acute displaced intra-articular calcaneal fractures remains controversial. The authors present a brief historical review of treatment options and results, coupled with the biomechanical rationale for open reduction and internal fixation. Their current management protocol and surgical technique are outlined, along with preliminary functional results at an average follow-up of 2.5 years.

      • Subspecialty:
      • Trauma

      • Foot and Ankle

    Anterior Cruciate Ligament Insufficiency: Principles of Treatment.

    Anterior cruciate ligament (ACL) injuries often result in functional disability, particularly in jumping, cutting, and deceleration activities. Some patients can accommodate to this functional loss, while others require surgical reconstruction of the ligament to provide stability and to protect the meniscus from further injury. Nonoperative management involves an intensive rehabilitation program, patient counseling about high-risk activities, and measures to prevent recurrent injuries. Surgical reconstruction of the ACL involves the technical factors of graft selection, positioning, fixation, and tensioning and the avoidance of stress risers. A supervised and intensive rehabilitation program is necessary to achieve optimal results.

        • Subspecialty:
        • Trauma

        • Sports Medicine

      Degenerative Spondylolisthesis: Diagnosis and Treatment.

      Degenerative spondylolisthesis is most often seen at the L4-5 level. The most common complaint is back pain, but the advent of leg symptoms, such as claudication and restless legs syndrome, is often the reason for seeking specialized medical attention. Conservative treatment usually suffices; extended bed rest is of little value. The 15% of patients who are surgical candidates are those with clinical signs and symptoms of cauda equina abnormality, progressive muscular weakness, or progressive incapacitating radicular pain or claudication. The author advocates pedicle-to-pedicle decompression with preservation of the articular facets as the essential operation. The indications for fusion have been debated, but recent prospective studies show improved outcomes after fusion. The risk of significant morbidity associated with laminectomy and fusion increases as a function of age and magnitude of operation; therefore, careful patient selection for surgical intervention is vital.

          • Subspecialty:
          • Trauma

          • Spine

          • Pain Management

        Displaced Proximal Humeral Fractures: Evaluation and Treatment.

        Successful treatment of proximal humeral fractures relies on the surgeon's ability to make an accurate diagnosis. Treatment must be predicated on a thorough understanding of the complex shoulder anatomy, a precise radiographic evaluation, and use of a well-designed classification system. Appropriate and realistic goals must be established for each patient. The patient's general medical health, physiologic age, and ability to cooperate with intense and prolonged rehabilitation are all considerations when selecting the optimal treatment.

            • Subspecialty:
            • Trauma

            • Shoulder and Elbow

          Infected Total Knee Replacements.

          Deep infection is a devastating complication following total knee arthroplasty. Prompt diagnosis and definitive treatment of this complication are essential for a successful outcome. The treatment options for an infected total knee replacement include (1) antibiotic suppression alone; (2) aggressive wound debridement, drainage, and antibiotic suppression therapy; (3) resection arthroplasty; (4) arthrodesis; (5) two-stage reimplantation; and (6) amputation. Successful salvage of this complication can be accomplished only by extensive investment of surgical and infectious disease efforts in eradicating the infection. Two-stage reimplantation has been the most successful functional option and should be used whenever possible to definitively eradicate the infection and ensure good function of the knee joint.

              • Subspecialty:
              • Adult Reconstruction

            Lateral and Medial Epicondylitis of the Elbow.

            Epicondylitis of the elbow involves pathologic alteration in the musculotendinous origins at the lateral or medial epicondyle. Although commonly referred to as "tennis elbow" when it occurs laterally and "golfer's elbow" when it occurs medially, the condition may in fact be caused by a variety of sports and occupational activities. The accurate diagnosis of these entities requires a thorough understanding of the anatomic, epidemiologic, and pathophysiologic factors. Nonoperative treatment should be tried first in all patients, beginning with an initial phase of rest, ice, nonsteroidal anti-inflammatory agents, and possibly corticosteroid injection. A second phase includes coordinated rehabilitation, consisting of range-of-motion and strengthening exercises and counterforce bracing, as well as technique enhancement and equipment modification if a sport or occupation is causative. Nonoperative treatment has been deemed highly successful, yet the few prospective reports available suggest that symptoms frequently persist or recur. Operative treatment is indicated for debilitating pain that is diagnosed after the exclusion of other pathologic causes for pain and that persists in spite of a well-managed nonoperative regimen spanning a minimum of 6 months. The surgical technique involves excision of the pathologic portion of the tendon, repair of the resulting defect, and reattachment of the origin to the lateral or medial epicondyle. Surgical treatment results in a high degree of subjective relief, although objective strength deficits may persist.

                • Subspecialty:
                • Sports Medicine

                • Shoulder and Elbow

                • Pain Management

              Modularity of Prosthetic Implants.

              The vast majority of total-joint-replacement components currently utilized are modular to some degree. Modularity reduces inventory and increases the surgeon's options in both primary and revision total-joint arthroplasty. Use of a modular interface, however, increases the risk of fretting, wear debris, and dissociation and mismatching of components. The use of modular heads in total hip replacement is firmly established. The occurrence of corrosion and fretting has been recognized, and most manufacturers have improved the quality of the interface to minimize these problems. Modular polyethylene liners also offer advantages, particularly in revision procedures, where the option of additional screw fixation remains important. Many uncemented acetabular components are inserted without screws, which may generate renewed interest in one-piece factory-preassembled components. The conformity, locking mechanism, and nonarticular interface of modular acetabular components have all been studied and improved. Modular tibial components offer additional flexibility in the performance of total knee replacement but introduce the risk of dissociation and increased polyethylene wear; in revision procedures, modularity provides a valuable option for dealing with bone loss and an additional method of fixation by means of press-fit stems. Modular humeral components offer a significant advantage with limited apparent risk; however, longer clinical experience is required to assess potential problems.

                  • Subspecialty:
                  • Adult Reconstruction

                  • Basic Science

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