JAAOS

JAAOS, Volume 2, No. 5


Heterotopic Ossification: Two Rare Forms and What They Can Teach Us.

Heterotopic ossification is characterized by the formation of normal bone at ectopic soft-tissue locations. Regardless of the etiology of heterotopic ossification, requisite pathogenetic conditions include an inductive signal capable of stimulating morphogenesis, a population of inducible osteoprogenitor cells, and a heterotopic environment conducive to osteogenesis. Two rare heritable and developmental forms of heterotopic ossification, fibrodysplasia ossificans progressiva and progressive osseous heteroplasia, provide valuable clinical and pathogenetic insights into heterotopic ossification in humans. A fundamental understanding of the developmental and molecular pathology of these disorders may lead to more effective strategies for preventing and treating heterotopic ossification in humans.

      • Subspecialty:
      • Trauma

      • Basic Science

    Knee Bracing.

    The authors present an overview of the design and functional features of knee braces and their relationship to knee biomechanics. Four types of knee braces-prophylactic, rehabilitative, functional, and patellofemoral-have been developed to cover the wide variety of indications in patients who have suffered knee injuries or hope to prevent them. Important considerations when choosing specific brace types are discussed, and summaries of relevant research are presented. Clinical criteria for brace selection are offered to help physicians and sports medicine professionals in choosing the right brace for each patient.

        • Subspecialty:
        • Sports Medicine

        • Basic Science

      Nonsteroidal Anti-inflammatory Drugs: Making the Right Choices.

      Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most prescribed pharmacologic agents in medicine. The ability of these drugs to decrease inflammation is linked to their inhibitory effect on the synthesis of prostaglandins. This mechanism also results in toxicity that can cause gastrointestinal ulceration and bleeding, renal failure, and worsening of preexisting congestive heart failure. The superiority of one NSAID over another has not been clinically demonstrated in musculoskeletal conditions, nor has the efficacy of NSAIDs in noninflammatory rheumatic conditions been shown to be better than that of simple analgesics, such as acetaminophen. The use of these drugs, particularly in the elderly patient with osteoarthritis, should be carefully considered, and alternative, less toxic therapies should be sought whenever possible.

          • Subspecialty:
          • Pain Management

        Patellofemoral Pain After Total Knee Arthroplasty.

        The incidence of patellofemoral complications after total knee arthroplasty has been reported to range from 2% to 7%. Such complications include pain, sub-luxation, dislocation, loosening, and wear. Usually these complications are attrib-utable to prosthetic design or surgical technique. Today, it is understood that patellofemoral prostheses must have a degree of congruence; must allow smooth, not abrupt, motion; and must restore a relatively normal size relationship between the patella and the femur. Surgical technique requires strict attention to (1) restoration of the patellofemoral spacing while avoiding "overstuffing" of the patellofemoral compartment; (2) accurate superior and medial positioning of the patellar component; (3) restoration of the rotational alignment of the femoral and tibial components; and (4) appropriate balancing of the patellofemoral soft tissues.

            • Subspecialty:
            • Trauma

            • Adult Reconstruction

            • Pain Management

          Persistently Painful Sprained Ankle.

          Chronic discomfort sufficient to limit activity may affect 20% to 40% of patients after an ankle sprain. These patients complain of vague and diffuse pain, most often localized to the lateral and/or anterolateral aspect of the ankle. They may also complain of a giving-way sensation, swelling, stiffness, and locking and crepitation. Examination may show tenderness, swelling, and reduced range of motion, especially in dorsiflexion. Ankle instability is sometimes demonstrable. Severe cases exhibit discoloration, glossy skin, and temperature changes suggestive of reflex sympathetic dystrophy. Incomplete rehabilitation is the most common cause of chronic pain. Other common problems are intra-articular lesions (e.g., osteochondral and meniscoid lesions), chronic instability, undetected syndesmotic or deltoid sprains, chronic tendon degeneration, stress fractures, and, in rare cases, congenital lesions and tumors. Reflex sympathetic dystrophy occurs occasionally, even after minor trauma. With correct diagnosis and appropriate treatment, it is often possible to restore acceptable ankle function

              • Subspecialty:
              • Trauma

              • Foot and Ankle

              • Sports Medicine

              • Pain Management

            Valgus Extension Injuries of the Elbow in the Throwing Athlete.

            Valgus extension injuries of the elbow are common among throwing athletes. There is a wide spectrum of these injuries, ranging from early soft-tissue inflammatory changes to attenuation and incompetence of the ulnar collateral ligament, as well as bone changes, including chondromalacia, osteochondritis, and osteophyte formation. Early treatment should be directed toward decreasing pain and inflammation, followed by global strengthening and conditioning of the elbow with special emphasis on plyometric strengthening of the flexor-pronator musculature. In patients who remain symptomatic after an initial course of nonoperative treatment, arthroscopy of the elbow can address many of the later changes, including chondromalacia, osteochondritis, and osteophyte formation. Reconstruction of the ulnar collateral ligament should be reserved for those patients who wish to remain active at a highly competitive level and for whom rehabilitation and less invasive procedures have failed. Appropriate rehabilitation remains the cornerstone of successful treatment of these patients, facilitating their return to competitive play.

                • Subspecialty:
                • Sports Medicine

                • Shoulder and Elbow

                • Pain Management

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