JAAOS

JAAOS, Volume 20, No. 1


Brachial Plexus Blocks for Upper Extremity Orthopaedic Surgery

Regional anesthesia of the upper extremity has several clinical applications and is reported to have several advantages over general anesthesia for orthopaedic surgery. These advantages, such as improved postoperative pain, decreased postoperative opioid administration, and reduced recovery time, have led to widespread acceptance of a variety of regional nerve blocks. Interscalene block is the most commonly used block for shoulder surgery. Other brachial plexus nerve blocks used for orthopaedic surgery of the upper extremity are supraclavicular, infraclavicular, and axillary. Several practical and theoretical aspects of regional nerve blocks must be considered to optimize the beneficial effects and minimize the risk of complications.

      • Subspecialty:
      • Shoulder and Elbow

    Hemiarthroplasty for Three- and Four-part Proximal Humerus Fractures

    Displaced three- and four-part proximal humerus fractures are among the most challenging shoulder conditions to manage. Because of the risk of symptomatic malunion, nonunion, and humeral head osteonecrosis, surgical management is preferred. Locking plate technology has provided an alternative to hemiarthroplasty for certain three- and four-part fracture patterns, even in the setting of osteopenic bone. Prosthetic humeral head replacement has been advocated for head-splitting fractures and fracture-dislocations as well as four-part fractures with significant initial varus displacement (>20°). Technical challenges, including obtaining proper humeral head height, retroversion, and optimal positioning and fixation of the tuberosities, have a substantial effect on patient outcomes.

        • Subspecialty:
        • Shoulder and Elbow

      Psoriatic Arthritis

      Psoriatic arthritis is a chronic inflammatory arthropathy that affects approximately 6% to 48% of patients with psoriasis. Arthritis is not correlated with the extent of skin disease. Classic radiographic findings of the involved joint include erosion, ankylosis, and fluffy periostitis. Site-specific characteristic deformities such as pencil-in-cup deformity of the phalanges also may be present. The disease typically follows a moderate course, but up to 47% of cases develop into destructive arthritis in which the inflammatory process leads to bony erosion and loss of joint architecture. The mainstay of treatment is biologic therapy (eg, tumor necrosis factor-α inhibitors) in conjunction with disease-modifying antirheumatic drugs. Patients with end-stage joint destruction may require surgery to alleviate pain and restore function. Orthopaedic surgeons should be cognizant of the risk factors (eg, increased risk of cardiovascular disease) and potential complications (eg, poor wound healing and increased risk of infection) associated with psoriatic arthritis.

          • Subspecialty:
          • Hand and Wrist

          • Pain Management

        Surgical Exposures of the Wrist and Hand

        The neurovascular anatomy of the carpus and hand is complex. Therefore, precise exposures are required to avoid iatrogenic injury. In general, dorsal exposures are more forgiving than volar exposures because major neurovascular structures lie on the volar aspect of the hand and fingers; however, volar, ulnar, and radial approaches to the carpal bones are also commonly used. Exposure of the metacarpals and phalanges is relatively straightforward by comparison. Exposure of the carpus and hand is also complicated by the dense and often superficial innervation network. Therefore, a thorough knowledge of the pertinent anatomy is required for safe surgical approaches to the wrist and hand.

            • Subspecialty:
            • Hand and Wrist

          The Use of Intramedullary Nails in Tibiotalocalcaneal Arthrodesis

          Tibiotalocalcaneal arthrodesis is a salvage procedure undertaken for hindfoot problems that affect both the ankle and subtalar joints (eg, two-joint arthritis, severe acute trauma, osteonecrosis of the talus, severe malalignment deformities, significant hindfoot bone loss). Methods of achieving fusion include Steinmann pins, screws, plates, external fixators, and retrograde intramedullary nailing. Retrograde intramedullary nailing provides a load-sharing fixation device with superior biomechanical properties and is an excellent choice for use in tibiotalocalcaneal arthrodesis. This technique can be performed through relatively small incisions. In addition, recent design modifications include the availability of dynamization and the choice of curved or straight nails. Contraindications to the technique include the presence of infection, severe vascular disease, and severe malalignment of the tibia.

              • Subspecialty:
              • Foot and Ankle

            Variations in Sacral Morphology and Implications for Iliosacral Screw Fixation

            Posterior pelvic percutaneous fixation following either closed or open reduction is a popular procedure. Knowledge of the posterior pelvic anatomy, its variations, and related imaging is critical to performing reproducibly safe surgery. The dysmorphic sacrum has several key characteristics. The upper portion of the sacrum is relatively colinear with the iliac crests on the outlet radiographic view. Other characteristics include the presence of mammillary bodies (ie, underdeveloped transverse processes) at the sacral mid-alar area, anterior upper sacral foramina that are not circular, residual upper sacral disks, an acute alar slope oriented from cranial-posterior-central to caudal-anterior-lateral on the outlet and lateral views of the sacrum, a tongue-in-groove sacroiliac joint surface visualized on CT, and cortical indentation of the anterior ala on the inlet radiographic view. The surgeon must be knowledgeable about individual patient anatomy to ensure safe iliosacral screw placement.

                • Subspecialty:
                • Trauma

                • Adult Reconstruction

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