JAAOS

JAAOS, Volume 21, No. 7


Blount Disease

In 1937, Blount described progressive tibial varus deformity observed in otherwise healthy children and adolescents. Although he called the condition "osteochondrosis deformans tibiae," the disorder is most frequently referred to as Blount disease. Two distinct clinical and radiographic forms have been recognized: infantile and adolescent. A third form, which was called "juvenile" Blount disease by Thompson, is recognized by some authors and is intermediate in severity and age of onset. The etiology of Blount disease is unknown. If the condition remains unresolved, it can lead to progressive varus deformity, with or without associated deformities of the distal femur and/or tibia; leg length inequality; and significant articular distortion, leading to premature osteoarthritis of the knee. A strong, but not universal, association exists between Blount disease and childhood obesity, increasing the prevalence and making effective treatment of this condition a challenge. Infantile Blount disease may resolve, respond to nonsurgical treatment, or be relentlessly progressive, so the surgeon must be astute in recognizing the features of true infantile Blount disease to determine effective treatment options.

      • Subspecialty:
      • Pediatric Orthopaedics

    Defining the Value of Spine Care

    The increased cost and frequency of spine-related procedures, expanding indications, and regional variation in care has led to a shift toward delivery of value-based spine care. In this model, payers show preference for interventions and treatments with proven value and incentivize providers who use such interventions and demonstrate value in their practices. Thus, spine care providers must understand how to determine the value of interventions and treatments. Determining value (ie, cost and quality of care, measured over time) can be challenging in the setting of spine care. Data collection and reporting are complicated by variation in diagnostic coding and surgical techniques. Typically, outcomes in spine care are based on subjective patient-reported measures that are influenced by concomitant orthopaedic, medical, and psychological disease. Health utility is a preferable measure of quality that can be converted into quality-adjusted life years and used in cost-effectiveness analysis. Although no standard currently exists, estimates of cost should include both direct and indirect costs of care over an adequate time horizon.

        • Subspecialty:
        • Spine

      Shoulder Arthroscopy in Children and Adolescents

      Arthroscopy is increasingly being used to manage a wide range of pathologies in the pediatric population. Knee arthroscopy is an efficacious treatment method for skeletally immature patients, and an increasing number of shoulder conditions can be managed with minimally invasive techniques. Special considerations are needed with regard to anatomy, anesthetic technique, equipment, and patient positioning when performing shoulder arthroscopy in a child or an adolescent. Several shoulder ailments can be managed arthroscopically in this patient population, including infection, contractures resulting from brachial plexus palsy, traumatic instability, atraumatic multidirectional instability, hemophilia, and rotator cuff injuries.

          • Subspecialty:
          • Pediatric Orthopaedics

          • Shoulder and Elbow

        Total Elbow Arthroplasty: Current Options

        Total elbow arthroplasty (TEA) has changed considerably in the past three decades. Based on the good long-term results with TEA in patients with rheumatoid arthritis, the indications expanded to include management of acute traumatic and posttraumatic conditions in young, higher-demand patients. Today, unlinked, linked semiconstrained, and convertible devices are available. The high complication rate with earlier surgeries led to surgical advances such as new cementing technique and a focus on managing the triceps. Complications such as infection, aseptic loosening, polyethylene wear, periprosthetic fracture, triceps insufficiency, wound breakdown, and ulnar nerve injury will continue to spur the evolution of surgical technique and implant design. Refinement of surgical indications and improvement in implant fixation, polyethylene design, component implantation, and pathology-specific implants will determine the future success of TEA.

            • Subspecialty:
            • Shoulder and Elbow

          Triceps Surae Contracture: Implications for Foot and Ankle Surgery

          Restricted ankle dorsiflexion secondary to contracture of the gastrocnemius-soleus complex is frequently encountered in patients with foot and ankle pain and is well documented in the literature. During gait, decreased dorsiflexion shifts weight-bearing pressures from the heel to the forefoot, which may result in or exacerbate one of several pathologic conditions. Modest success has been achieved with nonsurgical management of triceps surae contracture, including splinting and stretching exercises. Surgical lengthening of the gastrocnemius-soleus complex at multiple levels has been described, and early clinical results have been promising. Additional research is required to further elucidate the long-term outcomes of various lengthening techniques.

              • Subspecialty:
              • Foot and Ankle

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