JAAOS

JAAOS, Volume 6, No. 1


Acute elbow dislocation: evaluation and management.

Most elbow dislocations are stable after closed reduction. Treatment with an early range-of-motion program generally leads to favorable results. Care must be taken to rule out neurovascular involvement and associated osseous or ligamentous injury in the wrist. Late elbow instability and stiffness are rare after simple dislocations. Complex elbow dislocations with associated fractures may require surgical intervention to obtain joint stability; ligament and/or fracture repair is frequently necessary in this situation. Larger periarticular fractures adversely affect functional results. Potential late complications of elbow dislocation include posttraumatic stiffness, posterolateral joint instability, ectopic ossification, and occult distal radioulnar joint disruption.

    • Keywords:
    • Acute Disease|Dislocations|Elbow Joint|Humans|Joint Instability|Range of Motion

    • Articular|Treatment Outcome

    • Subspecialty:
    • Trauma

    • Shoulder and Elbow

    • Hand and Wrist

Dupuytren's contracture.

Dupuytren's contracture is a fibroproliferative disorder of autosomal dominant inheritance that most commonly affects men over age 60 who are of Scandinavian, Irish, or eastern European descent. Local microvessel ischemia in the hand and specific platelet-derived and fibroblast growth factors act at the cellular level to promote the dense myofibroblast population and altered collagen profiles seen in affected tissue. Surgical treatment depends to some degree on patient preference and a clear understanding of the possible complications and considerable postoperative therapy commitment. Operative management is appropriate when metacarpophalangeal or proximal interphalangeal joint contracture exceeds 30 degrees. A volar zigzag Brunner incision in the digit and palm provides reliable exposure and leads to predictable healing in most cases. The mainstay of postoperative hand therapy is early active-flexion range-of-motion exercises to restore grip strength. A nighttime extension splint is often used for several months postoperatively to maintain the correction achieved in the operating room. Early recurrence of disease is most common in individuals with Dupuytren's diathesis; use of full-thickness skin grafts may be helped for these patients.

    • Keywords:
    • Dupuytren Contracture|Humans|Male|Middle Aged|Recurrence|Treatment Outcome

    • Subspecialty:
    • Hand and Wrist

Multidirectional instability of the shoulder: pathophysiology, diagnosis, and management.

Multidirectional instability of the shoulder is a complex entity. Relatively few series of patients with this condition have been reported. Affected patients have global (anterior, inferior, and posterior) excessive laxity of the glenohumeral joint capsule and a rotator interval capsule defect. The onset of symptoms is frequently related to atraumatic events. The chief complaint is more often related to pain than to instability per se. Symptoms are mostly experienced within the midrange of glenohumeral motion. Because the contralateral shoulder is often equally lax and asymptomatic, it appears that factors in addition to excessive capsular laxity play a pathophysiologic role. These factors may include subtle losses of strength and/or neuromotor coordination of the rotator cuff and scapular stabilizing muscles, defective proprioceptive responses, and the absence of a limited joint volume. Most patients can be successfully treated nonoperatively with a specific exercise program. If a 6-month trial of nonoperative management fails, the patient is a candidate for surgical reconstruction. The most time-honored procedure is an open inferior capsular shift, which corrects excessive global laxity of the capsule and the rotator interval defect.

    • Keywords:
    • Arthroscopy|Endoscopy|Humans|Joint Instability|Physical Therapy Modalities|Range of Motion

    • Articular|Shoulder Joint|Treatment Outcome

    • Subspecialty:
    • Shoulder and Elbow

    • Basic Science

Revascularization of the femoral head in osteonecrosis.

Osteonecrosis of the femoral head accounts for as many as 18% of total hip arthroplasties performed in western countries. The young age of affected patients and the potentially poor outcome have sparked an interest in alternative treatment modalities. Extracapsular placement of a vascularized fibular graft in the subchondral region of the femoral head has shown great promise as a treatment option. The authors have used this procedure in the treatment of 646 symptomatic hips, of all grades of osteonecrosis, with a follow-up of 1 to 17 years. The resultant 10-year survival rate of greater than 80% suggests that this procedure may be preferable to total hip arthroplasty for the young patient with osteonecrosis of the femoral head.

    • Keywords:
    • Angiography|Bone Transplantation|Femur Head|Femur Head Necrosis|Fibula|Follow-Up Studies|Humans|Survival Rate

    • Subspecialty:
    • Pediatric Orthopaedics

Scheuermann's kyphosis in adolescents and adults: diagnosis and management.

Scheuermann's thoracic kyphosis is a structural deformity classically characterized by anterior wedging of 5 degrees or more of three adjacent thoracic vertebral bodies. Secondary radiographic findings of Schmorl's nodes, endplate narrowing, and irregular endplates confirm the diagnosis. The etiology remains unclear. Adolescents typically present to medical attention because of cosmetic deformity; adults more commonly present because of increased pain. The indications for treatment are similar to those for other spinal deformities, namely, progression of the deformity, pain, neurologic compromise, and cosmesis. The adolescent with pain associated with Scheuermann's kyphosis usually responds to physical therapy and a short course of anti-inflammatory medications. Bracing has been shown to be effective in controlling a progressive curve in the adolescent patient. For the adult who presents with pain, the early mainstays of treatment are physical therapy, anti-inflammatory medications, and behavioral modification. In patients, either adolescent or adult, with a progressive deformity, refractory pain, or neurologic deficit, surgical correction of the deformity may be indicated. Surgical correction should not exceed 50% of the initial deformity. Distally, instrumentation should be extended beyond the end vertebral body to the first lordotic disk to prevent the development of distal junctional kyphosis.

    • Keywords:
    • Adolescent|Adult|Anti-Inflammatory Agents|Humans|Kyphosis|Physical Therapy Modalities|Scheuermann Disease|Spinal Fusion

    • Subspecialty:
    • Pediatric Orthopaedics

    • Spine

Surgical exposures in revision total knee arthroplasty.

A well-planned operative approach to revision total knee arthroplasty is crucial to a successful outcome. Wide exposure must be achieved to allow component removal, soft-tissue balancing, management of bone loss, and reimplantation without damaging important structures. These structures include skin, the extensor mechanism, the collateral ligaments, the remaining bone stock, and neurovascular structures. Skin necrosis can be avoided by selecting the appropriate incision and dissecting deep to the fascia. Extensile exposure by dissection of scar, quadriceps snip or turndown, tibial tubercle osteotomy, or medial epicondylar osteotomy should be performed early to prevent patellar tendon disruption. In certain cases, the distal femur can be exposed circumferentially by using a quadriceps myocutaneous flap or femoral peel. Special care should be taken with the infected or ankylosed knee.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Knee|Humans|Postoperative Complications|Reoperation|Risk Factors|Treatment Outcome

    • Subspecialty:
    • Adult Reconstruction

The Human Genome Project: implications for the treatment of musculoskeletal disease.

The ultimate goal of the Human Genome Project is the determination of the molecular sequence of the entire human chromosomal complement. Realization of this goal will include characterization of all the genes that cause or predispose to disease, which will most certainly lead to the development of powerful new tools for diagnosis, prevention, and treatment in all medical fields, including orthopaedics. The authors review the fundamentals of human genetics and gene mapping, summarize the progress of the Human Genome Project thus far, and discuss the implications of this research as it relates to the treatment of musculoskeletal diseases.

    • Keywords:
    • Chromosome Mapping|Chromosomes

    • Human|DNA|Gene Therapy|Human Genome Project|Humans|Musculoskeletal Diseases|Orthopedics

    • Subspecialty:
    • General Orthopaedics

    • Musculoskeletal Oncology

    • Basic Science

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