JAAOS

JAAOS, Volume 4, No. 1


Ankle Arthroscopy: I. Technique and Complications.

Arthroscopic surgery of the ankle allows the direct visualization of all intra-articular structures of the ankle without an arthrotomy or malleolar osteotomy. Technological advances and a thorough understanding of anatomy have resulted in an improved ability to perform diagnostic and operative arthroscopy of the ankle. The decreased morbidity and faster recovery times make it an appealing technique compared with open arthrotomy. A keen understanding of the anatomy of the foot and ankle is critical to safe performance of arthroscopic procedures and prevention of complications.

      • Subspecialty:
      • Foot and Ankle

    Ankle Arthroscopy: II. Indications and Results.

    Diagnostic indications for the use of ankle arthroscopy include unexplained pain, swelling, stiffness, instability, hemarthrosis, and locking or popping, as well as a negative workup in a patient with significant ankle symptoms unresponsive to conservative care. Therapeutic indications include injuries of the articular cartilage and soft tissue, bone impingement, debridement of soft-tissue lesions, synovectomy and loose-body removal, arthrofibrosis, ankle fractures, and osteochondral defects. Ankle arthroscopy can also be used in ankle-stabilization procedures and arthrodesis, as well as for irrigation and debridement of septic arthritis. An algorithm has been developed to facilitate selection of the appropriate treatment for a patient with chronic ankle pain of unknown etiology. When used for the appropriate indications, ankle arthroscopy appears to give good results.

        • Subspecialty:
        • Foot and Ankle

      Clavicular Nonunion and Malunion: Evaluation and Surgical Management.

      Nonunions and malunions of the clavicle are uncommon but can be disabling. Pain, limitation of shoulder mobility, or local compression of the brachial plexus can produce profound functional impairment. Nonunions usually are associated with more severe fractures, open injuries, or failures of operative treatment. Reconstructive procedures are focused on gaining union and restoring clavicular anatomy-most often achieved with plates and screws and autogenous bone graft. Salvage procedures include excision of a bony prominence, partial or total clavicular resection, and resection of the first rib. While most patients with a malunited clavicular fracture are asymptomatic, osteotomy and correction of the deformity should be considered when there is associated functional or neurovascular impairment.

          • Subspecialty:
          • Trauma

          • Shoulder and Elbow

        Closed Tibial-Shaft Fractures: Which Ones Benefit From Surgical Treatment?

        Closed tibial-shaft fractures can usually be managed effectively with cast or brace immobilization if acceptable alignment is maintained and cyclic loading (weight-bearing) is initiated early. However, certain tibial fractures are at greater risk for nonunion or malunion and merit consideration for early operative stabilization. Among the tibial fracture characteristics that warrant fixation are instability, metaphyseal-diaphyseal location, significant limb edema, and the need for repeated realignment procedures. Deleterious patient-specific factors, such as obesity, poor compliance, and health conditions favoring immediate function, should also be considered. Absolute criteria for stabilization include coronal angulation exceeding 5 degrees, sagittal angulation greater than 10 degrees, rotation greater than 5 degrees, shortening exceeding 1 cm, displacement greater than 50%, and severe comminution (loss of 50% or more of cortical circumferential continuity). Relative indications for fixation include an inability to bear weight, distal or oblique fractures, prominent edema, and patient-specific considerations necessitating early function. When tibial stabilization is preferable, the authors believe that closed locked intramedullary nailing is the treatment of choice.

            • Subspecialty:
            • Trauma

            • Basic Science

          Fingertip Injuries: Evaluation and Treatment.

          The primary goal of treatment of an injury to the fingertip is a painless fingertip with durable and sensate skin. Knowledge of fingertip anatomy and the available techniques of treatment is essential. For injuries with soft-tissue loss and no exposed bone, healing by secondary intention or skin grafting is the method of choice. When bone is exposed and sufficient nail matrix remains to provide a stable and adherent nail plate, coverage with a local advancement flap should be considered. If the angle of amputation does not permit local flap coverage, a regional flap (cross-finger or thenar) may be indicated. If the amputation is more proximal or if the patient is not a candidate for a regional flap because of advanced age, osteoarthritis, or other systemic condition, shortening with primary closure is preferred. Composite reattachment of the amputated tip may be successful in young children. The outcome of nail-bed injuries is most dependent on the severity of injury to the germinal matrix.

              • Subspecialty:
              • Hand and Wrist

            Halo Skeletal Fixation: Techniques of Application and Prevention of Complications.

            The halo skeletal fixator provides the most rigid cervical immobilization of all orthoses. However, complications such as pin loosening and infection are common. Appreciation of local anatomy and adherence to established application guidelines should minimize pin-related problems. A relatively safe zone for anterior pin placement is located 1 cm above the orbital rim and superior to the lateral two thirds of the orbit. Posterior pin-site locations are less critical; positioning on the posterolateral aspect of the skull, diagonal to the contralateral anterior pins, is generally desirable. Pins should enter the skull perpendicular to the cortex, with the ring or crown sitting below the widest portion of the skull and passing about 1 cm above the helix of the ear. Pins are inserted at a torque of 8 in-lb and retightened once to 8 in-lb at 48 hours. A loose pin can be retightened to 8 in-lb if resistance is met; otherwise, a loose pin should be replaced at a nearby site. Superficially infected pins are managed with local pin care and oral antibiotics. Persistent or severe infections require pin replacement to a nearby site, parenteral antibiotic therapy, and incision and drainage as needed. In-ability to maintain acceptable cervical reduction with a halo fixator is an indication for alternative treatment, such as internal fixation or traction.

                • Subspecialty:
                • Trauma

                • Spine

              Legg-Calve-Perthes Disease.

              Legg-Calve,-Perthes disease is a self-limited disease of the femoral head that presents in the first decade. The pathogenesis is thought to involve bone necrosis, collapse, and repair. The presenting complaint is often a painless limp or hip pain, with decreased abduction and internal rotation of the hip. Factors that are believed to correlate with a poor prognosis are onset of symptoms after age 8 years, lateral head subluxation, involvement of over 50% of the femoral head with collapse of the lateral pillar, and the combination of an aspherical femoral head and an incongruent joint. The current cornerstones of treatment are maintenance of hip motion, relief of symptoms, and containment. Containment may be achieved by bracing or surgical means. The literature remains inconclusive on the indications for and effects of treatment. A long-term study has suggested that disabling arthritis of the hip develops in the sixth decade of life in 50% of untreated patients.

                  • Subspecialty:
                  • Pediatric Orthopaedics

                Ligament Healing: Current Knowledge and Clinical Applications.

                The treatment of ligament injuries, particularly knee-ligament injuries, has occupied a substantial portion of the orthopaedic literature for several decades. It remains unclear, however, what orthopaedic surgeons can do to optimize the recovery of patients with ligament problems. In this review, the reasons for this lack of clarity are proposed, and the current state of laboratory knowledge about the response of isolated and multiple ligament injuries to various treatment modalities is reviewed for the ligaments that have been studied thus far (all of which are in the knee). In general, it appears that ligaments heal with scar tissue similar to that involved in skin-wound healing. The early controlled motion of stable (or surgically stabilized) joints appears to improve ligament scar behavior, but no treatment identified to date stimulates true ligament regeneration.

                    • Subspecialty:
                    • Sports Medicine

                    • Basic Science

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