JAAOS

JAAOS, Volume 23, No. 3


Detection and Nonoperative Management of Pediatric Developmental Dysplasia of the Hip in Infants up to Six Months of Age

Detection and Nonoperative Management of Pediatric Developmental Dysplasia of the Hip in Infants up to Six Months of Age: Evidence-Based Clinical Practice Guideline is based on a systematic review of the current scientific and clinical research. This guideline has been endorsed by the Society of Diagnostic Medical Sonography, the Society for Pediatric Radiology, American Academy of Pediatrics, and the Pediatric Orthopaedic Society of North America. The purpose of this clinical practice guideline is to help improve treatment and management based on the current evidence. This guideline contains nine recommendations, including both diagnosis and treatment. In addition, the work group highlighted the need for better research in the early diagnosis and treatment of developmental dysplasia of the hip.

      • Subspecialty:
      • Pediatric Orthopaedics

    Evaluating the Progression of Osteolysis After Total Knee Arthroplasty

    Osteolysis around the knee following total knee arthroplasty continues to be a leading cause for revision total knee arthroplasty. Risk factors for periprosthetic knee osteolysis are associated with excessive polyethylene wear and include, but may not be limited to, malalignment of the mechanical axis, early-generation polyethylene sterilization techniques, excessive backside polyethylene wear, metal-backed patellar components, patient age, and an elevated body mass index. The initial diagnosis of osteolysis is frequently discovered on routine surveillance radiographs. The location, size, progressive nature, and associated symptomatology of the defect guides treatment. Surgical indications and timing are predicated on the risk of failure with continued observation. Advanced imaging helps to quantitate the size and location of osteolytic lesions as accurately as possible and aids in preoperative planning. When deciding whether surgery or management with continued radiographic surveillance is indicated, a global assessment of the character and progression of the osteolysis must be weighed with the risk factors associated with the patient.

        • Subspecialty:
        • Adult Reconstruction

      Management of Segmental Bone Defects

      Segmental bone defects cause significant disability in patients. Modern orthopaedic surgical techniques have proved to be reliable for reconstruction of these defects. Autogenous bone graft remains the standard of care for reconstruction of small defects (<5 cm). Induced membrane technique and distraction osteogenesis are contemporary strategies of choice for reconstruction of larger bony defects. The use of vascularized fibular grafts has waned in popularity because of donor site morbidity and the success of alternative methods. Complications are ubiquitous with all methods of reconstruction for segmental bone defects but can be limited with careful surgical judgment and technique. In most cases, the rehabilitation period is prolonged, although some treatment options are shorter and enable a more active recovery than do others.

          • Subspecialty:
          • Trauma

        Multiple Epiphyseal Dysplasia

        Multiple epiphyseal dysplasia is a genotypically and phenotypically heterogeneous disorder affecting the epiphysis of long bones. Inheritance may be autosomal dominant or autosomal recessive. Autosomal dominant variants include mutations of the collagen oligomeric matrix protein, collagen type IX α-1, collagen type IX α-2, collagen type IX α-3, and matrilin-3 genes. The autosomal recessive variant is caused by a mutation of the sulfate transporter gene SLC26A2. These mutations cause disorganized endochondral ossification of the epiphysis, ultimately leading to destruction of the articular cartilage. Patients typically present in childhood, but some may not present until early adulthood. A presumptive diagnosis can be made with clinical history, physical examination, detailed family history, and radiographic findings. Definitive diagnosis requires genetic testing. Treatment is based on the age of the patient, the amount of limb deformity, the level of joint destruction, and the needs of the patient. Children can greatly benefit from limb realignment procedures, and adults can have excellent outcomes with joint arthroplasty.

            • Subspecialty:
            • Pediatric Orthopaedics

          Reverse Shoulder Arthroplasty for the Management of Proximal Humerus Fractures

          The use of reverse shoulder arthroplasty is becoming increasingly popular for the treatment of complex three- and four-part proximal humerus fractures in the elderly compared with the often unpredictable and poor outcomes provided by open reduction and internal fixation and by hemiarthroplasty. Inferior results with plate osteosynthesis are often a result of complications of humeral head osteonecrosis, loss of fixation, and screw penetration through the humeral head, whereas major concerns with hemiarthroplasty are tuberosity resorption, malunion, and nonunion resulting in pseudoparalysis. Comparative studies support the use of reverse shoulder arthroplasty in elderly patients with complex proximal humerus fractures because the functional outcomes and relief of pain are reliably improved. Repair and union of the greater tuberosity fragment during reverse shoulder arthroplasty demonstrates improved external rotation, clinical outcomes, and patient satisfaction compared with outcomes after tuberosity resection, nonunion, or resorption. Satisfactory results can be obtained with careful preoperative planning and attention to technical details.

              • Subspecialty:
              • Shoulder and Elbow

            Tennis Injuries: Epidemiology, Pathophysiology, and Treatment

            Tennis places high loads on the joints of players, with supraphysiologic forces being generated at the shoulder and elbow hundreds of times per match. Acute injuries tend to affect the lower extremity; chronic injuries usually involve the upper extremity. Commonly encountered upper extremity conditions include rotator cuff injury, internal impingement, superior labral tears, and epicondylitis of the elbow. Serving is the most strenuous stroke in tennis, with the highest peak muscle activity in the shoulder and forearm occurring during this stroke. The kinetic chain links upper extremity, lower extremity, and core muscle segments by transmitting coordinated activation and motion; in this regard, any pathologic process that disturbs the groin, hip, and abdominal musculature can further result in an increased risk of injury to the shoulder and upper extremity. Evolution in equipment and in play surfaces has also affected the type and frequency of injuries. Prevention programs that address the muscular imbalances throughout the kinetic chain may help reduce the incidence of both acute and chronic injuries experienced by tennis athletes.

                • Subspecialty:
                • Sports Medicine

              The Impact of the Multicenter Orthopaedic Outcomes Network (MOON) Research on Anterior Cruciate Ligament Reconstruction and Orthopaedic Practice

              With an estimated 200,000 anterior cruciate ligament reconstructions performed annually in the United States, there is an emphasis on determining patient-specific information to help educate patients on expected clinically relevant outcomes. The Multicenter Orthopaedic Outcomes Network consortium was created in 2002 to enroll and longitudinally follow a large population cohort of anterior cruciate ligament reconstructions. The study group has enrolled >4,400 anterior cruciate ligament reconstructions from seven institutions to establish the large level I prospective anterior cruciate ligament reconstruction outcomes cohort. The group has become more than a database with information regarding anterior cruciate ligament injuries; it has helped to establish a new benchmark for conducting multicenter, multisurgeon orthopaedic research. The changes in anterior cruciate ligament reconstruction practice resulting from the group include the use of autograft for high school, college, and competitive athletes in their primary anterior cruciate ligament reconstructions. Other modifications include treatment options for meniscus and cartilage injuries, as well as lifestyle choices made after anterior cruciate ligament reconstruction.

                  • Subspecialty:
                  • Sports Medicine

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