JAAOS

JAAOS, Volume 20, No. 11


Advances in Wrist Arthroscopy

Since its introduction more than three decades ago, wrist arthroscopy has continually evolved. The procedure has a wide list of indications, including diagnostic and management applications. The scope of practice for the wrist arthroscopic surgeon includes management of triangulofibrocartilage complex pathology, evaluation and management of carpal instability, assistance in fracture reduction of the radius and scaphoid, treatment of trapeziometacarpal synovitis and arthritis, distal ulnar and carpal bone excisions, and salvage procedures. In addition, innovations such as new portals and smaller arthroscopes have expanded the applications of wrist arthroscopy.

      • Subspecialty:
      • Hand and Wrist

    Benign Tumors of the Spine

    Benign tumors in the spine include osteoid osteoma, osteoblastoma, aneurysmal bone cyst, osteochondroma, neurofibroma, giant cell tumor of bone, eosinophilic granuloma, and hemangioma. Although some are incidental findings, some cause local pain, radicular symptoms, neurologic compromise, spinal instability, and deformity. The evaluation of spinal tumors includes a thorough history and physical examination, imaging, sometimes laboratory evaluation, and biopsy when indicated. Appropriate treatment may be observational (eg, eosinophilic granuloma) or ablative (eg, osteoid osteoma, neurofibroma, hemangioma), but generally is surgical, depending on the level of pain, instability, neurologic compromise, and natural history of the lesion. Knowledge of the epidemiology, common presentation, imaging, and treatment of benign bone tumors is essential for successful management of these lesions.

        • Subspecialty:
        • Spine

        • Musculoskeletal Oncology

      Foot and Ankle Infections: Diagnosis and Management

      Infections of the foot are a common source of morbidity, disability, and potential limb loss. A large proportion of lower extremity infections occurs in the setting of diabetic neuropathy, with or without circulatory compromise, and are potentially preventable with regular surveillance. Adequate diagnosis and treatment of foot infections can be challenging. Successful treatment is dependent on factors such as etiology; vascular, neurologic, and immune status; and the identity of the offending organism.

          • Subspecialty:
          • Foot and Ankle

        Management of Extra-articular Fractures of the Distal Tibia: Intramedullary Nailing Versus Plate Fixation

        Intramedullary nailing and plate fixation represent two viable approaches to internal fixation of extra-articular fractures of the distal tibia. Although both techniques have demonstrated success in maintaining reduction and promoting stable union, they possess distinct advantages and disadvantages that require careful consideration during surgical planning. Differences in soft-tissue health and construct stability must be considered when choosing between intramedullary nailing and plating of the distal tibia. Recent advances in intramedullary nail design and plate-and-screw fixation systems have further increased the options for management of these fractures. Current evidence supports careful consideration of the risk of soft-tissue complications, residual knee pain, and fracture malalignment in the context of patient and injury characteristics in the selection of the optimal method of fixation.

            • Subspecialty:
            • Trauma

            • Adult Reconstruction

          Posttraumatic Elbow Arthritis in the Young Adult: Evaluation and Management

          Degenerative joint disease following trauma to the elbow is difficult to manage in any patient. However, this condition becomes substantially more challenging in the young, active population. Increased activity demands and limited functional capacity of total elbow arthroplasty mean that joint arthroplasty should be regarded as a salvage procedure. The primary goal of treatment is to restore a pain-free or minimally painful functional joint while preserving future surgical options. This requires accurate assessment of the primary patient complaint, be it terminal pain and stiffness or pain along the entire arc of motion. Patients who report stiffness and pain at terminal motion may benefit from arthroscopic or open osteocapsular débridement. Those with advanced degenerative changes and pain throughout the entire arc of motion may require joint resurfacing with interposition arthroplasty, partial joint arthroplasty, or total joint arthroplasty.

              • Subspecialty:
              • Trauma

              • Pediatric Orthopaedics

              • Shoulder and Elbow

            Radiologic Assessment of Spinal Fusion

            Since surgical fusion of the spine was first described in 1911, multiple methods have been used to assess it. Although open surgical exploration remains the standard of care for determination of fusion, it is impractical in most clinical situations. Static radiographs have long been used as a practical method of fusion assessment, but they tend to significantly overestimate the presence of a solid fusion. Dynamic radiographs improve accuracy but limitations include measurement reliability, disagreement on allowable motion, and the two-dimensional nature of radiographs. Ultimately, lack of movement at a fused segment does not confirm fusion. Radiostereometric analysis further improves accuracy; however, methodological demands make it largely impractical for routine use. CT is now widely accepted as the standard for noninvasive assessment of spinal fusion. Fine-cut imaging, multiplanar reconstruction, and metal artifact reduction have increased the ability to assess fusion on CT. However, significant concerns remain regarding the effects of high radiation exposure. Although MRI is appealing, its utility in assessing fusion remains unproven. Understanding the limitations of each technique allows judicious use of radiology in the assessment of spinal fusion.

                • Subspecialty:
                • Spine

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