JAAOS

JAAOS, Volume 20, No. 8


Degenerative Lumbar Spinal Stenosis: Evaluation and Management

Degenerative lumbar spinal stenosis is caused by mechanical factors and/or biochemical alterations within the intervertebral disk that lead to disk space collapse, facet joint hypertrophy, soft-tissue infolding, and osteophyte formation, which narrows the space available for the thecal sac and exiting nerve roots. The clinical consequence of this compression is neurogenic claudication and varying degrees of leg and back pain. Degenerative lumbar spinal stenosis is a major cause of pain and impaired quality of life in the elderly. The natural history of this condition varies; however, it has not been shown to worsen progressively. Nonsurgical management consists of nonsteroidal anti-inflammatory drugs, physical therapy, and epidural steroid injections. If nonsurgical management is unsuccessful and neurologic decline persists or progresses, surgical treatment, most commonly laminectomy, is indicated. Recent prospective randomized studies have demonstrated that surgery is superior to nonsurgical management in terms of controlling pain and improving function in patients with lumbar spinal stenosis.

      • Subspecialty:
      • Spine

    Displaced Clavicle Fractures in Adolescents: Facts, Controversies, and Current Trends

    There is an increasing trend toward stabilization and fixation of markedly displaced midshaft clavicle fractures in adolescents. Recent studies in the adult literature have shown a greater prevalence of symptomatic malunion, nonunion, and poor functional outcomes after nonsurgical management of displaced fractures. Fixation of displaced midshaft clavicle fractures can restore length and alignment, resulting in shorter time to union. Symptomatic malunion after significantly displaced fractures in adolescents may be more common than previously thought. Adolescents often have high functional demands, and their remodeling potential is limited. Knowledge of bone biology and the effects of shortening, angulation, and rotation on shoulder girdle mechanics is critical in decision making in order to increase the likelihood of optimal results at skeletal maturity. Selection of fixation is dependent on many factors, including fracture type, patient age, skeletal maturity, and surgeon comfort.

        • Subspecialty:
        • Pediatric Orthopaedics

      Management of Mid-season Traumatic Anterior Shoulder Instability in Athletes

      Shoulder dislocation and subluxation injuries are common in young athletes and most frequently occur during the competitive season. Controversy exists regarding optimal treatment of an athlete with an in-season shoulder dislocation, and limited data are available to guide treatment. Rehabilitation may facilitate return to sport within 3 weeks, but return is complicated by a moderate risk of recurrence. Bracing may reduce the risk of recurrence, but it restricts motion and may not be tolerated in patients who must complete certain sport-specific tasks such as throwing. Surgical management of shoulder dislocation or subluxation with arthroscopic or open Bankart repair reduces the rate of recurrence; however, the athlete is unable to participate in sport for the remainder of the competitive season. When selecting a management option, the clinician must consider the natural history of shoulder instability, pathologic changes noted on examination and imaging, sport- and position-specific demands, duration of treatment, and the athlete's motivation.

          • Subspecialty:
          • Sports Medicine

          • Shoulder and Elbow

        Nerve Transfers for the Upper Extremity: New Horizons in Nerve Reconstruction

        Nerve transfers are key components of the surgeon's armamentarium in brachial plexus and complex nerve reconstruction. Advantages of nerve transfers are that nerve regeneration distances are shortened, pure motor or sensory nerve fascicles can be selected as donors, and nerve grafts are generally not required. Similar to the principle of tendon transfers, expendable donor nerves are transferred to denervated nerves with the goal of functional recovery. Transfers may be subdivided into intraplexal, extraplexal, and distal types; each has a unique role in the reconstructive process. A thorough diagnostic workup and intraoperative assessment help guide the surgeon in their use. Nerve transfers have made a positive impact on the outcomes of nerve surgery and are essential tools in complex nerve reconstruction.

            • Subspecialty:
            • Hand and Wrist

          Orthogenomics: An Update

          The study of genomics in orthopaedics has considerably lagged behind such study in other medical disciplines. Seminal work from other lines of medical research demonstrates the importance of genomic information in the evolution of personalized medicine. Common techniques for studying genome-phenotype associations include single nucleotide polymorphism, haplotype, and quantitative trait loci analysis. The few genome-based studies in major orthopaedic and related conditions have focused on osteoporosis, osteoarthritis, neuropathy and nerve compression, spinal deformity, trauma and inflammatory response, and pain and analgesia. The nascent field of orthogenomics, newly defined here as the application of genomic study to orthopaedic practice, has produced findings that could affect the practice of orthopaedics. However, more work is required, and the findings must be distilled and harnessed into applicable and achievable steps to improve clinical orthopaedic practice.

              • Subspecialty:
              • Basic Science

            The Use of Dual-mobility Components in Total Hip Arthroplasty

            Dual-mobility hip components provide for an additional articular surface, with the goal of improving range of motion, jump distance (ie, vertical or inferior head displacement required for dislocation), and stability of the total hip arthroplasty. A large polyethylene head articulates with a polished metal acetabular component, and an additional smaller metal head is snap-fit within the polyethylene. New components have recently been released for use in North America. Although these devices are routinely used in some European centers for primary hip arthroplasty, their greatest utility may be to manage recurrent dislocation in the setting of revision hip arthroplasty. Several small retrospective series have shown satisfactory results for this indication at short- to midterm follow-up. Polyethylene wear and intraprosthetic dislocation are concerns, as is the lack of long-term data. Caution is thus advised in the routine use of dual-mobility components in primary and revision total hip arthroplasty.

                • Subspecialty:
                • Adult Reconstruction

              Total Hip Arthroplasty in the Very Young Patient

              The surgical management of end-stage hip disease in patients aged <30 years remains a challenge. Hip-preserving surgical procedures in the setting of advanced disease often do not provide adequate pain relief, but the implications of joint arthroplasty surgery in the very young patient are a matter of concern. The outcome of total hip arthroplasty (THA) in these patients varies, largely because of the wide spectrum of diagnoses associated with hip disease in this group, the complexity of deformities requiring THA, and the need for prolonged durability. The greatest number of THAs in this population is performed for secondary osteoarthritis or osteonecrosis, whereas most reports in the orthopaedic literature have focused on the outcomes of cemented THA in patients with juvenile rheumatoid arthritis. Given the frequent complexity of THA in the very young patient, special attention should be given to preoperative planning, implant selection, and patient education as well as to joint-preservation techniques to facilitate future hip arthroplasty surgery.

                  • Subspecialty:
                  • Pediatric Orthopaedics

                  • Adult Reconstruction

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