JAAOS

JAAOS, Volume 6, No. 2


Amputations of the fingers and hand: indications for replantation.

With hand and digital replantation now widely available in most urban settings, initial treating physicians must be aware of the factors that may influence outcome, so that informed decisions can be made regarding referral for replantation and appropriate early treatment. The author outlines the factors pertaining to amputations of the fingers and hand, provides general guidelines for indications for and contraindications to replantation, and discusses reported results.

    • Keywords:
    • Age Factors|Aged|Amputation

    • Traumatic|Child|Cold Temperature|Decision Making|Finger Injuries|Fingers|Hand|Hand Injuries|Humans|Ischemia|Motor Skills|Referral and Consultation|Replantation|Risk Factors|Sensation|Socioeconomic Factors|Time Factors|Tissue Preservation|Treatment Outcome

    • Subspecialty:
    • Hand and Wrist

Beyond HMOs: understanding the next wave of change in health-care organization.

The growing strength of managed care has diminished the financial and clinical autonomy of many orthopaedic surgeons. In part to offset these negative trends, new relationships are being developed to define doctors' methods of contracting with health-maintenance organizations. These include physician practice management companies (PPMs), independent practice associations, management service organizations, and physician-sponsored organizations. Each entity offers distinct advantages and disadvantages. While the PPM is the most popular new vehicle to offset adverse market trends, it carries with it some of the greatest potential pitfalls. In every case, before negotiating to join one of these new entities, it is important for a physician to have a solid understanding of the competing claims made by each entity, as well as insight into the fiscal health of the particular company in question. For some doctors, these arrangements offer a solution to current woes. For others, PPMs interpose another meddlesome intermediary in a market already bloated by layers of bureaucracy.

    • Keywords:
    • Contract Services|Financial Management|Health Maintenance Organizations|Hospital-Physician Joint Ventures|Humans|Independent Practice Associations|Interinstitutional Relations|Managed Care Programs|Marketing of Health Services|Negotiating|Orthopedics|Practice Management

    • Medical|Preferred Provider Organizations

    • Subspecialty:
    • Clinical Practice Improvement

Coxa vara in childhood: evaluation and management.

Coxa vara in childhood may be clinically classified as developmental, congenital, dysplastic, or traumatic and may occur at the physis or in the trochanteric or subtrochanteric area. Evaluation should include a search for a family history of similar deformity, a history of trauma or infection, and evidence of associated skeletal abnormality. Radiographs will illustrate whether the deformity is unilateral or bilateral and whether it occurs at or below the physis. With this information, coxa vara can be classified, and the optimal treatment can be selected. Surgical treatment of coxa vara in childhood is usually indicated when the disease is progressive, painful, unilateral, or associated with leg-length discrepancy.

    • Keywords:
    • Bone Diseases|Bone Diseases

    • Developmental|Bone and Bones|Child|Child

    • Preschool|Diagnosis

    • Differential|Disease Progression|Femur|Hip Injuries|Hip Joint|Humans|Infant|Joint Diseases|Leg Length Inequality|Patient Care Planning

    • Subspecialty:
    • Trauma

    • Pediatric Orthopaedics

Ipsilateral femoral neck and shaft fractures.

Ipsilateral femoral neck and shaft fractures are uncommon injuries that present a surgical challenge. Patients are relatively young, are usually victims of high-energy trauma, and have frequently sustained multisystem injuries. A comminuted midshaft femoral fracture secondary to axial loading should alert the treating physician to the possibility of an associated femoral neck fracture. This is important in light of the frequency of unrecognized ipsilateral femoral neck fractures. Several treatment options are described in the literature, but no clear consensus exists regarding the optimal treatment of these complex fractures. The authors contend that, given the potentially devastating complications of the femoral neck fracture in young patients (e.g., avascular necrosis, nonunion, and malunion), the neck fracture should be treated first and the shaft fracture second. The authors present an algorithm for the diagnosis and management of this injury based on a review of the literature, an understanding of the biology and severity of this injury, and the technical aspects of surgical treatment.

    • Keywords:
    • Accidents

    • Traffic|Adult|Age Factors|Algorithms|Diagnosis

    • Differential|Female|Femoral Fractures|Femur Neck|Fracture Fixation

    • Internal|Fracture Fixation

    • Intramedullary|Fractures

    • Comminuted|Fractures

    • Malunited|Fractures

    • Ununited|Humans|Male|Middle Aged|Multiple Trauma|Osteonecrosis

    • Subspecialty:
    • Trauma

    • Pediatric Orthopaedics

    • Basic Science

Perilunate injuries: diagnosis and treatment.

Perilunate injuries are severe disruptions of the carpus, which present a formidable challenge to the treating physician. Accurate recognition of the pattern of injury is not always straightforward. The injury can propagate through ligaments and/or bone, creating multiple variations of a basic injury pattern. Posteroanterior and lateral radiographs will depict a perilunate injury, but additional views may be necessary to appreciate subtle carpal fractures. Once the diagnosis has been established, early intervention is necessary for optimal results. An initial closed reduction with sedation and traction is performed to restore overall carpal alignment. However, subsequent closed or open reduction is necessary to restore anatomic alignment of all injured structures. The outcome of perilunate injuries correlates with the adequacy of reduction. Complications such as chondrolysis, carpal instability, and traumatic arthritis can occur despite satisfactory treatment.

    • Keywords:
    • Arthritis|Carpal Bones|Cartilage Diseases|Fracture Fixation|Fractures

    • Bone|Humans|Hypnotics and Sedatives|Joint Instability|Ligaments

    • Articular|Lunate Bone|Traction|Treatment Outcome|Wrist Injuries|Wrist Joint

    • Subspecialty:
    • Trauma

    • Hand and Wrist

Superior labral lesions in the shoulder: pathoanatomy and surgical management.

Progress in shoulder arthroscopy has led to the identification of previously undiagnosed lesions involving the superior labrum and the biceps tendon anchor. Additional research has substantiated the role of the long head of the biceps tendon in anterior and rotational glenohumeral stability. Careful attention to the history and physical examination and directed diagnostic imaging may arouse suspicion of injury to the biceps tendon and the superior labral complex. Identification of injuries to the superior labrum extending from anterior to posterior, or "SLAP" injuries, can be made with diagnostic glenohumeral arthroscopy. Appropriate treatment can then be based on the type of lesion encountered (generally, debridement of most type I and III lesions and repair of type II and many type IV lesions).

    • Keywords:
    • Arthroscopy|Debridement|Diagnostic Imaging|Humans|Medical History Taking|Physical Examination|Range of Motion

    • Articular|Rotation|Shoulder Joint|Surgical Stapling|Suture Techniques|Tendon Injuries|Tendons

    • Subspecialty:
    • Shoulder and Elbow

    • Basic Science

Surgical approaches in revision hip replacement.

Revision hip arthroplasty will be performed with frequency in the future. A successful outcome depends on careful preoperative planning, and a key component of that plan is the surgical approach. The choice of the approach should be based on the indication for revision, the particular implant to be removed, the presence of acetabular or femoral bone loss, previous surgical approaches used, and the preferences and training of the surgeon. For simple revision procedures, one of the standard approaches used in primary hip arthroplasty may be adequate. More complex cases may necessitate an extended exposure or one of the techniques developed specifically for revision arthroplasty. No single approach is suitable for all revision procedures, and the surgeon must be familiar with a range of exposures if the clinical result is to be optimized.

    • Keywords:
    • Acetabulum|Arthroplasty

    • Replacement

    • Hip|Bone Cements|Bone Resorption|Buttocks|Femur|Hip Prosthesis|Humans|Osteotomy|Patient Care Planning|Prosthesis Design|Prosthesis Failure|Prosthesis-Related Infections|Reoperation|Treatment Outcome

    • Subspecialty:
    • Adult Reconstruction

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