JAAOS

JAAOS, Volume 20, No. 5


Assessment of Compromised Fracture Healing

No standard criteria exist for diagnosing fracture nonunion, and studies suggest that assessment of fracture healing varies among orthopaedic surgeons. This variability can be problematic in both clinical and orthopaedic trauma research settings. An understanding of risk factors for nonunion and of diagnostic tests used to assess fracture healing can facilitate a systematic approach to evaluation and management. Risk factors for nonunion include medical comorbidities, age, and the characteristics of the injury. The method of fracture management also influences healing. Comprehensive evaluation includes an assessment of the patient's symptoms, signs, and immune and endocrine status as well as the biologic capacity of the fracture, presence of infection, and quality of reduction and fixation. Diagnostic tests include plain radiography, CT, ultrasonography, fluoroscopy, bone scan, MRI, and several laboratory tests, including assays for bone turnover markers in the peripheral circulation. A systematic approach to evaluating fracture union can help surgeons determine the timing and nature of interventions.

      • Subspecialty:
      • Trauma

    Complications Associated With Posterior and Transforaminal Lumbar Interbody Fusion

    Posterior lumbar interbody fusion and transforaminal lumbar interbody fusion are commonly performed to obtain a 360� arthrodesis through a posterior-only approach. These techniques are currently used in the management of spondylolisthesis, degenerative scoliosis, pseudarthrosis, recurrent disk herniation, and chronic low back pain with associated degenerative disk disease. Several adverse events have been described, including intraoperative neurologic injury, implant migration or subsidence, dural tears, infection, heterotopic ossification, BMP-related radiculitis, and osteolysis. Although the use of newer materials (eg, bone morphogenetic proteins) and procedures (eg, minimally invasive surgery) is on the rise, they are associated with unique concerns. Understanding the potential adverse events and steps that can be taken to prevent, detect, and manage complications is critical in patient counseling and perioperative decision making.

        • Subspecialty:
        • Spine

      Idiopathic Toe Walking

      Toe walking is a bilateral gait abnormality in which a normal heel strike is absent and most weight bearing occurs through the forefoot. This abnormality may not be pathologic in patients aged <2 years, but it is a common reason for referral to an orthopaedic surgeon. Toe walking can be caused by several neurologic and developmental abnormalities and may be the first sign of a global developmental problem. Cases that lack a definitive etiology are categorized as idiopathic. A detailed history, with careful documentation of the developmental history, and a thorough physical examination are required in the child with a primary report of toe walking. Treatment is based on age and the severity of the abnormality. Management includes observation, stretching, casting, bracing, chemodenervation, and surgical lengthening of the gastrocnemius-soleus complex and/or Achilles tendon. An understanding of idiopathic toe walking as well as treatment options and their outcomes can help the physician individualize treatment to achieve optimal results.

          • Subspecialty:
          • Foot and Ankle

        Management of Failed Arthroscopic Rotator Cuff Repair

        Most patients experience pain relief and functional improvement following arthroscopic rotator cuff repair, but some continue to experience symptoms postoperatively. Patients with so-called failed rotator cuff syndrome, that is, with continued pain, weakness, and limited active range of motion following arthroscopic rotator cuff repair, present a diagnostic and therapeutic challenge. A thorough patient history, physical examination, and imaging studies (eg, plain radiography, MRI, magnetic resonance arthrography, ultrasonography) are required for diagnosis. Management is determined based on patient age, functional demands, rotator cuff competence, and the presence or absence of glenohumeral arthritis. Treatment options include revision repair, nonanatomic repair with or without biologic or synthetic augmentation, tendon transfer, and arthroplasty.

            • Subspecialty:
            • Shoulder and Elbow

          Safe Tourniquet Use: A Review of the Evidence

          Due in part to an emphasis on quality and cost control within healthcare institutions, protocols for healthcare practice are increasingly being developed in an effort to maintain normative guidelines and set acceptable standards. For example, the Association of periOperative Registered Nurses, the National Quality Forum, and the Association of Surgical Technologists have made recommendations regarding tourniquet use. In the institution of the senior authors (C.D. and E.A.), an effort to establish a protocol for tourniquet use prompted a review of the evidence behind standard practices and existing recommendations for safe tourniquet use in the upper and lower extremities. Sparse evidence exists in support of strict limits for tourniquet use, including tourniquet duration, inflation pressure, and reperfusion periods. However, simple principles and general guidelines regarding tourniquet use can be extrapolated to guide safe practice.

              • Subspecialty:
              • Trauma

            Surgical Options for Meniscal Replacement

            As a result of biologic issues and technical limitations, repair of the meniscus is indicated for unstable, peripheral vertical tears; most other types of meniscal tears that are degenerative, significantly traumatized, and/or located in an avascular area of the meniscus are managed with partial meniscectomy. Options to restore the meniscus range from allograft transplantation to the use of synthetic technologies. Recent studies demonstrate good long-term outcomes from meniscal allograft transplantation, although the indications and techniques continue to evolve and the long-term chondroprotective potential has yet to be determined. Several synthetic implants, none of which has US Food and Drug Administration approval, have shown some promise for replacing part or all of the meniscus, including the collagen meniscal implant, hydrogels, and polymer scaffolds.

                • Subspecialty:
                • Sports Medicine

                • Shoulder and Elbow

              The Treatment of Pediatric Supracondylar Humerus Fractures

              Based on the best current evidence and a systematic review of published studies, 14 recommendations have been created to guide clinical practice and management of supracondylar fractures of the humerus in children. Two each of these recommendations are graded Weak and Consensus; eight are graded Inconclusive. The two Moderate recommendations include nonsurgical immobilization for acute or nondisplaced fractures of the humerus or posterior fat pad sign, and closed reduction with pin fixation for displaced type II and III and displaced flexion fractures.

                  • Subspecialty:
                  • Pediatric Orthopaedics

                Advertisements

                Advertisement