JAAOS

JAAOS, Volume 3, No. 1


Alternatives to Autogenous Bone Graft: Efficacy and Indications.

Bone grafting is frequently used to augment bone healing with the numerous approaches to reconstructing or replacing skeletal defects. Autologous cancellous bone graft remains the most effective grafting material because it provides the three elements required for bone regeneration: osteoconduction, osteoinduction, and osteogenic cells. Autologous cortical bone graft provides these three components to a limited extent as well and also provides the structural integrity important in reconstruction of larger defects. However, because autogenous grafting is associated with several shortcomings and complications, including limited quantities of bone for harvest and donor-site morbidity, alternatives have been used in a wide range of orthopaedic pathologic conditions. Grafting substitutes currently available include cancellous and cortical allograft bone, ceramics, demineralized bone matrix, bone marrow, and composite grafts. No single alternative graft material provides all three components for bone regeneration. The clinical applications for each type of material are dictated by its particular structural and biochemical properties. Composite grafts consisting of several materials are often used to maximize bone healing, especially where the grafting site is compromised.

      • Subspecialty:
      • Adult Reconstruction

      • Basic Science

    Disorders of the First Metatarsophalangeal Joint.

    The two most common disorders of the first metatarsophalangeal (MTP) joint are hallux valgus and hallux rigidus. The hallux valgus deformity has been the subject of numerous clinical studies in the past decade. This information has enabled the creation of an algorithm to assist the clinician in evaluating the patient with hallux valgus and selecting the appropriate surgical procedure. The technical aspects of various operative procedures and the most common complications are reviewed. The other major disorder of the first MTP joint is arthrosis, which results in hallux rigidus. As the arthrosis progresses, there is often proliferation of bone on the dorsal aspect of the metatarsal head, which results in impingement of the proximal phalanx during dorsiflexion. The impingement causes jamming, instead of gliding, of the proximal phalanx on the metatarsal head, which results in pain. The treatment for this condition consists of debridement of the MTP joint to relieve the dorsal impingement and, in most cases, the pain. If the arthrosis is advanced in an active individual, arthrodesis is indicated.

        • Subspecialty:
        • Foot and Ankle

        • Pain Management

      Flexor Tendon Injuries: I. Foundations of Treatment.

      During the past 20 years, the difficult process of reestablishing satisfactory function after primary repair of flexor tendons has evolved from scientifically unsupported trial-and-error efforts to protocols based on sound laboratory and clinical investigations. Enhanced appreciation of tendon structure, nutrition, and biomechanical properties and investigation of factors involved in tendon healing and adhesion formation have had significant clinical applications. In particular, it has been found that repaired tendons subjected to early motion stress will increase in strength more rapidly and develop fewer adhesions than immobilized repairs. As a result, new and stronger tendon repair techniques have evolved, permitting the application of early passive and even light active forces. The author reviews the most recent and clinically pertinent research in flexor tendon surgery and discusses repair techniques and rehabilitation protocols based on the information provided by these studies.

          • Subspecialty:
          • Sports Medicine

          • Hand and Wrist

          • Basic Science

        Flexor Tendon Injuries: II. Operative Technique.

        The repair of flexor tendons (zones I and II) is a technique-intensive surgical undertaking. It requires a strong understanding of the anatomy of the tendon sheath and the normal relationship between the pulleys and the flexor digitorum superficialis and flexor digitorum profundus tendons in the digit. Meticulous exposure, careful tendon retrieval, and atraumatic repair are extremely important, and the repair should be of sufficient strength to resist gapping and permit the early postrepair application of motion forces. Whenever possible, the tendon sheath should be preserved or repaired, and a smooth gliding surface should be reestablished. The author describes an effective method of tendon retrieval and a simplified technique for a four-strand tendon repair with a supplementary peripheral running-lock suture. The repair is considered to maintain sufficient strength throughout healing to allow a postrepair rehabilitation protocol that will impart passive and modest active stress forces to the repaired tendons. Complications include tendon rupture, digital joint flexion contractures, and adhesions that restrict tendon gliding and ultimately necessitate tenolysis.

            • Subspecialty:
            • Trauma

            • Sports Medicine

            • Hand and Wrist

            • Basic Science

          Isolated Medial Collateral Ligament Injuries in the Knee.

          The management of ligament injuries in the knee has progressed significantly over the past two decades as a result of both laboratory and clinical studies that better define the healing capacity of these supporting structures. The intracapsular ligaments (the anterior and posterior cruciate ligaments) appear to have limited potential for spontaneous healing and frequently require surgical reconstruction. The extracapsular ligaments (the medial and lateral collateral ligaments), however, appear to have a fairly robust potential for healing. As a result, the need for surgical intervention is limited to specific clinical situations.

              • Subspecialty:
              • Sports Medicine

            Revision Total Hip Arthroplasty: The Acetabular Component.

            Intermediate and long-term results of revision total hip arthroplasty performed with the use of a cemented acetabular component have been disappointing, with high rates of radiographic and clinical failure. Other methods of acetabular revision involving the use of threaded cups and bipolar implants have also met with high failure rates. Although the long-term results of revision arthroplasty with uncemented acetabular components, especially in terms of polyethylene wear and pelvic osteolysis, are not yet available, the intermediate results have been excellent.

                • Subspecialty:
                • Adult Reconstruction

              Scapular Fractures and Dislocations: Diagnosis and Treatment.

              Traumatic injuries of the scapula and the scapulothoracic articulation have received little attention in the literature, since they are uncommon. Scapular fractures constitute only 1% of fractures in general, and scapulothoracic dissociations and dislocations are extremely rare. The vast majority can and should be managed nonoperatively. However, recent experience has shown that injuries that involve significant displacement can have long-term adverse functional consequences for both the shoulder complex and the upper extremity as a whole. In these situations, surgery should at least be considered. Various scapular fractures and dislocations are discussed, with particular emphasis on those requiring operative care.

                  • Subspecialty:
                  • Trauma

                  • Shoulder and Elbow

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