JAAOS

JAAOS, Volume 24, No. 4


Greater Trochanteric Pain Syndrome

Patients who have lateral hip pain historically have been diagnosed with trochanteric bursitis and treated with nonsteroidal antiinflammatory medications, corticosteroid injections, and physical therapy. Although this strategy is effective for most patients, a substantial number of patients continue to have pain and functional limitations. Over the past decade, our understanding of disorders occurring in the peritrochanteric space has increased dramatically. Greater trochanteric pain syndrome encompasses trochanteric bursitis, external coxa saltans (ie, snapping hip), and abductor tendinopathy. A thorough understanding of the anatomy, examination findings, and imaging characteristics aids the clinician in treating these patients. Open and endoscopic treatment options are available for use when nonsurgical treatment is unsuccessful.

      • Subspecialty:
      • Sports Medicine

      • Adult Reconstruction

    Orthopaedic Surgeon Burnout: Diagnosis, Treatment, and Prevention

    Burnout is a syndrome marked by emotional exhaustion, depersonalization, and low job satisfaction. Rates of burnout in orthopaedic surgeons are higher than those in the general population and many other medical subspecialties. Half of all orthopaedic surgeons show symptoms of burnout, with the highest rates reported in residents and orthopaedic department chairpersons. This syndrome is associated with poor outcomes for surgeons, institutions, and patients. Validated instruments exist to objectively diagnose burnout, although family members and colleagues should be aware of early warning signs and risk factors, such as irritability, withdrawal, and failing relationships at work and home. Emerging evidence indicates that mindfulness-based interventions or educational programs combined with meditation may be effective treatment options. Orthopaedic residency programs, departments, and practices should focus on identifying the signs of burnout and implementing prevention and treatment programs that have been shown to mitigate symptoms.

        • Subspecialty:
        • General Orthopaedics

      Osteomyoplastic Transtibial Amputation: The Ertl Technique

      Amputation may be required for management of lower extremity trauma and medical conditions, such as neoplasm, infection, and vascular compromise. The Ertl technique, an osteomyoplastic procedure for transtibial amputation, can be used to create a highly functional residual limb. Creation of a tibiofibular bone bridge provides a stable, broad tibiofibular articulation that may be capable of some distal weight bearing. Several different modified techniques and fibular bridge fixation methods have been used; however, no current evidence exists regarding comparison of the different techniques. Additional research is needed to elucidate the optimal patient population, technique, and postoperative protocol for the Ertl osteomyoplastic transtibial amputation technique.

          • Subspecialty:
          • Trauma

          • Foot and Ankle

        Preoperative Planning in Primary Total Knee Arthroplasty

        Preoperative planning is of paramount importance in primary total knee arthroplasty. A thorough preoperative analysis helps the surgeon envision the operation, anticipate any potential issues, and minimize the risk of premature implant failure. Obtaining a thorough history is critical for appropriate patient selection. The physical examination should evaluate the integrity of the soft tissues, the neurovascular status, range of motion, limb deformity, and the status of the collateral ligaments to help determine the soft-tissue balancing and constraint strategy required. Standard radiographs, with a known magnification, should be obtained for preoperative total knee arthroplasty templating. Routine standing AP, lateral, and skyline radiographs of the knee can help the surgeon plan the bone cuts and tibial slope as well as the implant size and position at the time of surgery. In certain circumstances, such as severe coronal deformities, bone deficiencies, and/or extra-articular deformities, additional measures are frequently necessary to successfully reconstruct the knee. Constrained implants, metal augments, and bone graft must be part of the surgeon’s armamentarium.

            • Subspecialty:
            • Adult Reconstruction

          Spinal Fractures in Patients With Ankylosing Spondylitis: Etiology, Diagnosis, and Management

          In patients with ankylosing spondylitis, the altered biomechanics of the spine increase the incidence of spinal fractures and the risk of subsequent displacement and neurologic injury. Radiographic evaluation is difficult and requires imaging of the entire spine and the use of advanced imaging. Nonsurgical treatment has a high rate of complications and is typically pursued only when surgical intervention would carry unacceptably high perioperative risks. The surgical approach depends on the fracture location and any deformity present. Anterior fixation alone has been associated with high failure rates; therefore, posterior or combined anterior-posterior fixation should be considered. With either nonsurgical or surgical management, complications are frequent and can result in high mortality rates; however, good outcomes can be achieved if an appropriate level of suspicion of fracture is maintained and care is taken to avoid complications related to patient transport, transfer, and positioning.

              • Subspecialty:
              • Trauma

              • Spine

            Surgical Exposures of the Shoulder

            Surgical repair, reduction, fixation, and reconstruction for glenohumeral trauma, instability, and degenerative joint disease often require an open surgical exposure. Open shoulder surgery is challenging because the deltoid and rotator cuff musculature envelop the joint, and in most approaches, exposure is limited by the proximity and importance of the axillary nerve. An understanding of the importance of the deltoid and the rotator cuff for glenohumeral function has led to a progression of innovative, advanced, and less invasive approaches to the shoulder. Various advantages, disadvantages, and risks are encountered when performing deltopectoral, deltoidsplitting, and posterior approaches to the glenohumeral joint, with variations of each approach and techniques to extend them and maximize exposure. The ability to perform each of these exposures provides the surgeon with the flexibility to best address the widest variety of pathology.

                • Subspecialty:
                • Trauma

                • Sports Medicine

                • Shoulder and Elbow

                • General Orthopaedics

              The Use of Cell Transplantation in Spinal Cord Injuries

              Acute spinal cord injuries are life-changing events that lead to substantial morbidity and mortality, but the role of cell-based treatment for these injuries is unclear. Cell therapy is a rapidly evolving treatment methodology, with basic science and early phase I/II human trials showing promise. Multiple cell lines can be used in cell therapy, including adult or embryonic stem cells, Schwann cells, olfactory ensheathing cells, and induced pluripotent stem cells. Adult stem cells, Schwann cells, and olfactory ensheathing cells are readily available but lack the ability to differentiate into cells of the central nervous system. Mesenchymal stem cells can decrease cell death by modifying the local environment into which they are introduced. Peripheral nerve cells, such as Schwann cells and olfactory ensheathing cells, can myelinate existing axons and foster axonal growth in the central nervous system, and embryonic stem cells can differentiate into neural progenitor stem cells of the central nervous system. Induced pluripotent stem cells are the basis of an emerging technology that has yet to be implemented in human trials but may offer a means of cell therapy without the ethical dilemmas associated with embryonic cells.

                  • Subspecialty:
                  • Trauma

                  • Spine

                  • Basic Science

                Advertisements

                Advertisement