JAAOS

JAAOS, Volume 24, No. 1


Bacterial Spine Infections in Adults: Evaluation and Management

Bacterial spinal infections in adults can have notable adverse consequences, including pain, neurologic deficit, spinal instability and/or deformity, or death. Numerous factors can predispose a person to spinal infection, many of which affect the immune status of the patient. These infections are typically caused by direct seeding of the spine, contiguous spread, or hematogenous spread. Infections are generally grouped based on anatomic location; they are broadly categorized as vertebral osteomyelitis, discitis, and epidural abscess. In some cases, the diagnosis may not be elucidated early without a reasonable index of suspicion. Diagnosis is based on history and physical examination, laboratory data, proper imaging, and culture. Most infections can be treated with an appropriate course of antibiotics and bracing if needed. Surgical intervention is usually reserved for infections resistant to medical management, the need for open biopsy/ culture, evolving spinal instability or deformity, and neurologic deficit or deterioration.

      • Subspecialty:
      • Spine

    Evaluation and Diagnosis of Back Pain in Children and Adolescents

    Although traditionally it has been accepted that back pain in young children and adolescents most often has an organic etiology, nonorganic back pain in this population is becoming more common. The most common identifiable clinical entities responsible for such pain are spondylolysis, spondylolisthesis, Scheuermann kyphosis, overuse syndromes, disk herniation, apophyseal ring fracture, spondylodiscitis, vertebral osteomyelitis, and neoplasm. Appropriate clinical workup leads to earlier diagnosis and management of back pain and avoids unnecessary cost. Knowledge of the most common diagnoses associated with back pain in children and adolescents and the use of a systematic method to select the appropriate diagnostic tests can help the clinician to minimize costs and maximize the likelihood of making the correct diagnosis and providing appropriate treatment.

        • Subspecialty:
        • Pediatric Orthopaedics

        • Spine

        • Musculoskeletal Oncology

      Flexor Tendon Reconstruction

      Improved methods of primary flexor tendon repair have diminished the need for tendon reconstruction. Nonetheless, reconstruction remains an option for neglected digital flexor tendon lacerations and for failed flexor tendon repair in patients who have a supple, sensate finger and who are able to comply with an extensive rehabilitation program. Preoperative and intraoperative findings dictate whether a one-stage or two-stage procedure is appropriate. The first stage of a two-stage procedure involves insertion of a silicone rod-and-pulley reconstruction; at the second stage, the rod is replaced with a tendon graft. Some improvements have been made in surgical techniques as well as rehabilitation protocols. Future techniques, such as tissue engineering, may provide better functional results.

          • Subspecialty:
          • Hand and Wrist

        Peroneal Nerve Palsy: Evaluation and Management

        Peroneal nerve palsy is the most common entrapment neuropathy of the lower extremity. Numerous etiologies have been identified; however, compression remains the most common cause. Although injury to the nervemayoccur anywhere alongits course fromthe sciatic origin to the terminal branches in the foot and ankle, the most common site of compressive pathology is at the level of the fibular head. The most common presentation is acute complete or partial foot drop. Associated numbness in the foot or leg may be present, as well. Neurodiagnostic studies may be helpful for identifying the site of a lesion and determining the appropriate treatment and prognosis. Management varies based on the etiology or site of compression. Many patients benefit from nonsurgical measures, including activity modification, bracing, physical therapy, and medication. Surgical decompression should be considered for refractory cases and those with compressive masses, acute lacerations, or severe conduction changes. Results of surgical decompression are typically favorable. Tendon and nerve transfers can be used in the setting of failed decompression or for patients with a poor prognosis for nerve recovery.

            • Subspecialty:
            • Foot and Ankle

            • Basic Science

            • General Orthpaedics

          Renal and Gastrointestinal Considerations in Patients Undergoing Elective Orthopaedic Surgery

          To minimize perioperative complications after orthopaedic procedures, patients may undergo medical optimization, which includes an assessment of their renal function and gastrointestinal (GI) system. The GI and renal systems are complex, and their proper optimization in the preoperative period can influence the success of any procedure. Several factors can prevent complications and reduce morbidity, mortality, and the cost of care, including a thorough evaluation and screening, with particular emphasis on anemia and its renal and GI causes; management of medications that are metabolized by the liver and excreted by the kidneys; and careful attention to the patient’s nutritional status.

              • Subspecialty:
              • General Orthpaedics

            Risk Prediction Tools for Hip and Knee Arthroplasty

            The current healthcare environment in America is driven by the concepts of quality, cost containment, and value. In this environment, primary hip and knee arthroplasty procedures have been targeted for cost containment through quality improvement initiatives intended to reduce the incidence of costly complications and readmissions. Accordingly, risk prediction tools have been developed in an attempt to quantify the patient-specific assessment of risk. Risk prediction tools may be useful for the informed consent process, for enhancing risk mitigation efforts, and for risk-adjusting data used for reimbursement and the public reporting of outcomes. The evaluation of risk prediction tools involves statistical measures such as discrimination and calibration to assess accuracy and utility. Furthermore, prediction tools are tuned to the source dataset from which they are derived, require validation with external datasets, and should be recalibrated over time. However, a high-quality, externally validated risk prediction tool for adverse outcomes after primary total joint arthroplasty remains an elusive goal.

                • Subspecialty:
                • Foot and Ankle

              Role of Fresh Osteochondral Allografts for Large Talar Osteochondral Lesions

              Osteochondral lesions of the talus, large or small, present a challenge to the treating orthopaedic surgeon. These cartilage and bony defects can cause substantial pain and functional disability. Surgical treatment of small lesions of the talus has been thoroughly explored and includes retrograde drilling, arthroscopic débridement and marrow stimulation, osteochondral autografting from cartilage/bone unit harvested from the ipsilateral knee (mosaicplasty), and autologous chondrocyte implantation. Although each of these reparative, replacement, or regenerative techniques has various degrees of success, they may be insufficient for the treatment of large osteochondral lesions of the talus. Large-volume osteochondral lesions of the talus (>1.5 cm in diameter or area >150 mm2) often involve sizable portions of the weight-bearing section of the talar dome, medially or laterally. To properly treat these osteochondral lesions of the talus, a fresh structural osteochondral allograft is a viable treatment option.

                  • Subspecialty:
                  • Foot and Ankle

                Surgical Treatment of Displaced Greater Tuberosity Fractures of the Humerus

                Greater tuberosity fractures of the humerus can be successfully treated nonsurgically in most patients. However, as little as 3 to 5 mm of superior greater tuberosity displacement may adversely affect rotator cuff biomechanics and lead to subacromial impingement in patients who are active. In these cases, surgical treatment is recommended. Multiple surgical techniques include open and arthroscopic options tailored to fracture morphology, and strategies for repair include the use of suture anchors, transosseous sutures, tension bands, and plates/screws. Three classification systems are commonly used to describe greater tuberosity fractures: the AO, Neer, and morphologic classifications. Several hypotheses have been discussed for the mechanism of greater tuberosity fractures and the deforming forces of the rotator cuff, and the use of advanced imaging is being explored.

                    • Subspecialty:
                    • Trauma

                    • Shoulder and Elbow

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