JAAOS

JAAOS, Volume 3, No. 5


Coxa Saltans: The Snapping Hip Revisited.

Coxa saltans, or "snapping hip," has several causes. These can be divided into three types: external, internal, and intra-articular. Snapping of the external type occurs when a thickened area of the posterior iliotibial band or the leading anterior edge of the gluteus maximus snaps forward over the greater trochanter with flexion of the hip. The internal type has a similar mechanism except that it is the musculotendinous iliopsoas that snaps over structures deep to it (usually the femoral head and the anterior capsule of the hip). Intra-articular snapping is due to lesions in the joint itself. Diagnosis of the external and internal types is usually made clinically. Radiography can be useful in confirming the diagnosis, particularly when bursography shows the iliopsoas tendon snapping with hip motion. Other radiologic modalities, such as computed tomography, magnetic resonance imaging, and arthrography, may also be helpful, especially when there is an intra-articular cause. Most cases of snapping hip are asymptomatic and can be treated conservatively. However, if the snapping becomes symptomatic, surgery may be necessary. There may also be a role for arthroscopy in the treatment of intra-articular lesions.

      • Subspecialty:
      • Trauma

      • Sports Medicine

    Flatfoot in the Adult.

    Flatfoot in the adult has long been a poorly understood "wastebasket" diagnosis, often used to unfairly deny asymptomatic individuals equal employment opportunities in our society. Now that flatfoot has been classified into a variety of congenital and acquired conditions, the parameters for assessment have been well defined, and rational treatment protocols have been established. Clearly, if the foot painlessly supinates/inverts to become a rigid lever for push-off and pronates/everts to absorb stress during stance, then it "functions normally" no matter what the height of the arch. However, the biomechanically offset position of pes planus with excessive heel valgus coupled with rigidity or instability can alter the connected interplay of the bones of the foot and weaken the entire kinetic chain of the lower extremity. Careful clinical and radiographic evaluation, coupled with a thorough understanding of the anatomy and biomechanics of the foot, will allow accurate evaluation and appropriate treatment.

        • Subspecialty:
        • Foot and Ankle

        • Basic Science

      Genu Valgum in Children: Diagnostic and Therapeutic Alternatives.

      Genu valgum is a common orthopaedic problem in children. The vast majority of cases are physiologic variants, which resolve normally. However, there are pathologic entities due to both focal and systemic processes in which the deformity often progresses and usually requires treatment. Differentiating between the two forms is facilitated by a thorough understanding of the natural history of the development of the tibiofemoral angle in children. In this review, an approach to the evaluation and diagnosis of genu valgum is presented, and therapeutic alternatives are discussed.

          • Subspecialty:
          • Pediatric Orthopaedics

        Infected Total Hip Arthroplasty: Diagnosis and Treatment.

        The diagnosis of a deep infection complicating total hip arthroplasty is not difficult in most patients. When the diagnosis is not evident on the basis of the medical history, physical examination, routine blood work, and plain radiographs, indium-111-labeled leukocyte scintigraphy can be diagnostic. New immunologic techniques may allow differentiation of aseptic loosening from septic loosening of a painful total hip arthroplasty. Once the diagnosis of a deep infection about a total hip arthroplasty has been established, there are several treatment options. Oral antimicrobial therapy combining rifampin with a fluoroquinolone may prove to be an attractive alternative to surgical intervention in the treatment of some staphy-lococcal infections. If the causal microorganism is considered to be less virulent and does not elaborate glycocalyx, a one-stage procedure for reconstructing the hip with a cemented total hip arthroplasty incorporating antibiotics that are cidal to the microorganism has been successful in as many as 90% of patients. If the causal microorganism is considered to be virulent, a two-stage procedure with a prolonged interval between the Girdlestone resection arthroplasty and the second-stage reconstructive procedure is the treatment of choice.

            • Subspecialty:
            • Adult Reconstruction

          Pedicle-Screw Fixation in the Lumbar Spine.

          This article provides a perspective on the development of pedicle-screw fixation in the lumbar spine, the biomechanics of its application, the possible complications, and the scientific evidence that supports specific applications in selected disorders. The overall goal is to objectify the debate currently surrounding the use of these devices. Lumbar-pedicle fixation devices are currently considered class III med-ical devices. According to the Food and Drug Administration, such devices are investigational or experimental, have not been proved safe and effective, and may potentially pose a risk to patients.

              • Subspecialty:
              • Trauma

              • Spine

              • Basic Science

            The Dislocated Knee.

            Knee dislocation, although relatively rare, may be the result of high-or low-velocity injuries. Well established is the need for urgent diagnosis and treatment to avoid vascular complications and amputation. The initial evaluation should include objective assessment of arterial circulation by means of Doppler pressure measurements; the finding of any asymmetric pressure warrants an arteriogram. Late arterial occlusion may occur, which mandates careful serial reexamination in all patients, including those with initially symmetric pressure. Injury to the peroneal nerve is also common, and the recovery of neurologic function is unpredictable. An operative approach for the young and otherwise healthy patient is outlined. In the absence of definitive clinical studies, the timing and extent of the repair/reconstruction and the optimum rehabilitation still remain uncertain. Therefore, individual patient management must be dictated by circumstances such as instability, swelling, activity level, and the risk of postoperative joint stiffness.

                • Subspecialty:
                • Sports Medicine

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