JAAOS

JAAOS, Volume 4, No. 2


Current Status of Anticoagulation Therapy After Total Hip and Total Knee Arthroplasty.

Postoperative venous thromboembolism in the pelvis and lower extremities is a potentially life-threatening complication in patients undergoing elective total hip and total knee arthroplasty. Numerous pharmacologic methods of prophylaxis have been used in the past with varying degrees of success. Warfarin has been proved effective as a prophylactic agent after total hip arthroplasty but has been less efficacious after total knee arthroplasty. The low-molecular-weight heparins have recently been approved for prophylaxis after total hip and total knee arthro-plasty and are an acceptable alternative to warfarin. This new class of drugs appears to have the advantage of predictable subcutaneous bioavailability, which allows less frequent administration and laboratory monitoring and offers a decrease in the occurrence of side effects.

      • Subspecialty:
      • Adult Reconstruction

    Neuropathic Arthropathy: Review of Current Knowledge.

    Neuropathic arthropathy is a chronic, progressive degenerative disorder affecting one or more peripheral or vertebral articulations, which develops as the result of a disturbance in the normal sensory (pain or proprioceptive) innervation of joints. Diabetes, syphilis, and syringomelia are the most commonly associated clinical entities. When neuropathic arthropathy is suspected, careful clinical evaluation should be performed to identify an underlying neurologic disorder. Patient education, joint protection, and early recognition of fractures are the most important general management principles. Surgery can be considered in cases of advanced joint destruction when there is significant disability.

        • Subspecialty:
        • Trauma

        • Spine

      Osteochondral Lesions of the Talar Dome.

      Osteochondral lesions of the talar dome are relatively common causes of ankle pain and disability. Trauma is the most common cause, but ischemic necrosis, en-docrine disorders, and genetic factors may have etiologic significance. Medial lesions are usually located posteriorly on the dome of the talus, whereas lateral lesions are most frequently located anteriorly. Although the staging system described by Berndt and Harty remains popular, it may not accurately reflect the integrity of the articular cartilage. Small lesions of the talar dome may be present despite a normal appearance on plain radiography. Bone scintigraphy may show increased radionuclide uptake in the talar dome. Magnetic resonance imaging is also sensitive for identifying intraosseous abnormalities in the talus and has the added benefit of revealing other types of soft-tissue lesions not visible on routine radiographic studies. Computed tomography remains the imaging technique of choice when delineation of a bone fragment is desired. Nonoperative management of osteochondral lesions, including restricted weight-bearing and/or immobilization, is recommended unless a loose fragment is clearly present. Surgical options include drilling (usually reserved for intact lesions), debridement of the lesion with curettage or abrasion of the bone bed, internal fixation of the fragment, and bone grafting. Recent technical advances allow these procedures to be performed arthroscopically, with potential reduction of surgical trauma, length of hospital stay, and complication rates.

          • Subspecialty:
          • Trauma

          • Sports Medicine

        Periarticular Fractures After Total Knee Arthroplasty: Principles of Management.

        Periarticular fractures about total knee replacements are sustained by 0.3% to 2% of patients who have undergone knee arthroplasty. The patient with such a fracture is usually a woman in her seventh decade who has osteoporosis and may also have rheumatoid arthritis that is being treated with corticosteroids. The treatment of such fractures is aimed at restoring the patient's functional status to the pre-fracture level. Accomplishing this requires healing of the fracture and retention of a mobile and painless prosthesis in correct alignment. These goals are often difficult to achieve because there is little experience with these uncommon fractures, the healing environment is suboptimal, and knee arthroplasties have a low tolerance for any resulting alteration in alignment. In general, nondisplaced fractures are treated nonoperatively, and displaced fractures require open reduction, rigid internal fixation, and bone grafting. If the prosthesis is loose, or if rigid fixation cannot be obtained, component revision is the treatment of choice.

            • Subspecialty:
            • Trauma

            • Adult Reconstruction

          The Painful Knee: Arthroscopy or MR Imaging?

          While neither arthroscopy nor magnetic resonance (MR) imaging is perfect, both can delineate pathologic changes in the knee with reasonable accuracy. The greatest advantage of MR imaging is that it is noninvasive and can be used to detect pathologic changes both inside and outside the synovial cavity. Arthroscopy has the distinct advantage of allowing definitive treatment at the time of diagnosis in most cases, but carries with it the potential risks associated with any invasive diagnostic technique. Both modalities are expensive, and their judicious use is therefore dictated, especially in this era of cost containment. The decision to use one or both studies is best made by the orthopaedic surgeon.

              • Subspecialty:
              • Sports Medicine

              • Pain Management

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