JAAOS

JAAOS, Volume 6, No. 3


Forearm and distal radius fractures in children.

Pediatric forearm and distal radius fractures are common injuries. Resultant deformities are usually a product of indirect trauma involving angular loading combined with rotational displacement. Fractures are classified by location, completeness, angular and rotational deformity, and fragment displacement. Successful outcomes are based on restoration of adequate pronation and supination and, to a lesser degree, acceptable cosmesis. When several important concepts are kept in mind, these goals are usually met with conservative treatment by reduction and immobilization. Greenstick fractures are reduced by rotating the forearm such that the palm is directed toward the fracture apex. Complete fractures are manipulated and reduced with traction and rotation; extremities are then immobilized in well-molded plaster casts until healing, which usually takes about 6 weeks. Radiographs should be obtained between 1 and 2 weeks after initial reduction to detect early angulation. In fractures in any level in children less than 9 years of age, complete displacement, 15 degrees of angulation, and 45 degrees of malrotation are acceptable. In children 9 years of age or older, 30 degrees of malrotation is acceptable, with 10 degrees of angulation for proximal fractures and 15 degrees for more distal fractures. Complete bayonet apposition is acceptable, especially for distal radius fractures, as long as angulation does not exceed 20 degrees and 2 years of growth remains. Operative intervention is used when the fracture is open and when acceptable alignment cannot be achieved or maintained. Single-bone intramedullary fixation has proven useful.

    • Keywords:
    • Anesthesia|Child|Child

    • Preschool|Forearm Injuries|Fracture Fixation|Fracture Healing|Humans|Radius|Radius Fractures|Ulna|Ulna Fractures

    • Subspecialty:
    • Trauma

    • Pediatric Orthopaedics

Role of the posterior cruciate ligament in total knee arthroplasty.

Since the introduction of condylar knee designs, total knee arthroplasty has become a remarkably successful and durable procedure. Improvements in instrumentation systems, fixation, and patellar resurfacing have been widely applied and have made total knee arthroplasty a reproducible procedure. The appropriate role for the posterior cruciate ligament in total knee arthroplasty, however, continues to be debated. Proponents of both cruciate substitution and cruciate retention can point to excellent clinical and radiographic results in the literature with knee designs of both types. Recent research findings in the areas of biomechanics, histology, and gait analysis, combined with refinements in intraoperative technique, have further sharpened the focus of the posterior cruciate ligament debate.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Knee|Biomechanics|Gait|Humans|Posterior Cruciate Ligament|Proprioception|Range of Motion

    • Articular

    • Subspecialty:
    • Adult Reconstruction

Tendinitis and other chronic tendinopathies.

Chronic tendon problems are common in orthopaedic patients. Relatively little is known about the etiology of these common problems and the efficacy of available treatments. It is believed that the cause of many injuries is repetitive mechanical trauma followed by an inflammatory response. Other factors, such as age-related degeneration and relative avascularity in the tendon, may play an important etiologic role as well. Histopathologic studies have generally revealed degenerative lesions consistent with tendinosis and/or inflammation of the peritendinous tissues consistent with peritendinitis. Initial treatment should focus on patient counseling and correction of associated mechanical factors, if present. Nonsteroidal anti-inflammatory drugs can give pain relief, but there is no convincing evidence that they alter the natural history. Corticosteroid injections can be used selectively in resistant cases, but recurrences are frequent. Surgery can be very successful when the affected tendon is treated directly.

    • Keywords:
    • Anti-Inflammatory Agents|Anti-Inflammatory Agents

    • Non-Steroidal|Chronic Disease|Humans|Magnetic Resonance Imaging|Physical Therapy Modalities|Steroids|Tendinopathy|Tendons|Ultrasonography

    • Subspecialty:
    • Trauma

    • Sports Medicine

    • Pain Management

Triple arthrodesis in adults.

Surgical fusion of the subtalar, talonavicular, and calcaneocuboid joints historically evolved for the treatment of paralytic deformities of the foot where there was often notable bone deformity. Today most of these procedures are performed in adults for posttraumatic arthritis, rheumatoid arthritis, or end-stage posterior tibial tendon rupture with fixed bone deformity. Triple arthrodesis is a technically demanding procedure that generally involves a prolonged recovery time. When proper alignment is obtained, predictable and significant improvement in symptoms occurs, but the resultant loss of hindfoot motion is not without consequence. Residual discomfort and secondary arthrosis of the ankle and tarsometatarsal joints should be expected. Because of the complications of residual deformity, pseudarthrosis, avascular necrosis of the talus, and ankle and midtarsal arthritis, it has been recommended that it be used only as a salvage operation in older patients who have a painful, fixed deformity or disabling instability refractory to other treatment options. Despite these caveats, most patients who undergo triple arthrodesis for appropriate indications report significant improvement in their symptoms and level of function.

    • Keywords:
    • Adult|Arthritis

    • Rheumatoid|Arthrodesis|Calcaneus|Foot Deformities|Humans|Joint Diseases|Osteoarthritis|Talus|Tarsal Bones

    • Subspecialty:
    • Trauma

    • Foot and Ankle

Use of allografts in knee reconstruction: I. Basic science aspects and current status.

Allografts were first used in reconstructive surgery of the knee early in this century. Their widespread use and acceptance paralleled the development of modern tissue banks and our increased understanding of the immune system. Advantages of allogeneic tissue use include less surgical morbidity, shorter surgical time, smaller incisions, and the wider selection of graft sizes and types of tissue. Disadvantages include the risk of disease transmission, a slower biologic remodeling process, and the potential for a subclinical immune response. Allografts can be obtained in several forms, including fresh, fresh-frozen, freeze-dried, and cryopreserved, each with its own advantages and disadvantages. Graft sterility is most commonly ensured by aseptic techniques of harvest and procurement. Other methods, such as irradiation and chemical sterilization, have the potential to damage the collagen structure of the graft and must be used with care. Surgeons who use allografts should make sure that the tissue bank supplying their graft adheres to any applicable guidelines of the Food and Drug Administration and the American Association of Tissue Banks, and uses top-quality testing procedures. In addition, the physician should thoroughly understand the structural and biologic influence of the preservation technique used for that tissue.

    • Keywords:
    • Cartilage

    • Articular|Humans|Knee Injuries|Knee Joint|Ligaments|Organ Preservation|Reconstructive Surgical Procedures|Sterilization|Tissue and Organ Procurement|Transplantation

    • Homologous

    • Subspecialty:
    • Sports Medicine

    • Basic Science

Use of allografts in knee reconstruction: II. Surgical considerations.

The first allograft used in the knee was articular cartilage. The need to use fresh grafts and the absence of proper instruments for shaping and sizing implants have prevented widespread usage of articular cartilage allografts. Patient selection is very important; young, active, well-motivated individuals with defects smaller than 4 cm2 caused by trauma or osteochondritis dissecans have the best results. Failure is evidenced by crumbling of the supporting bone and fragmentation of the graft, a process identical to that seen in osteonecrosis. The use of allografts to reconstruct knee ligaments has gained wider acceptance. The availability of high-quality tissue from modern tissue banks, excellent preservation methods, a decrease in short-term surgical morbidity, and results at 2- to 5-year follow-up that are essentially equivalent to those obtained with autogenous grafts have combined to make allografts an alternative to using the patient's own tissue. However, long-term stability results are needed for comparison with autogenous grafts. Replacing an unsalvageable meniscus with an allograft is an appealing concept, with the potential for restoring normal load distribution, lubrication, and stability in the knee. Healing of the grafts and pain reduction have been reported by several investigators, but concerns about graft shrinkage, central hypocellularity, and long-term functional survival remain.

    • Keywords:
    • Cartilage

    • Articular|Humans|Knee Injuries|Knee Joint|Ligaments|Osteoarthritis

    • Knee|Patient Selection|Reconstructive Surgical Procedures|Transplantation

    • Homologous

    • Subspecialty:
    • Sports Medicine

    • Basic Science

Use of magnetic resonance imaging in spinal trauma: indications, techniques, and utility.

Magnetic resonance (MR) imaging of acute spinal injury provides excellent visualization of neurologic and soft-tissue structures in a noninvasive format. Advances in imaging-sequence techniques have made possible more rapid acquisition of images with greater spatial resolution. Appropriate selection of imaging sequences allows improved imaging and contrast of the pathologic processes involved in acute spinal trauma, including spinal cord, soft-tissue, and ligamentous injury. Three patterns of spinal cord injury have been identified. Type I is representative of acute cord hemorrhage. Type II represents spinal cord edema. Type III is a mixed hemorrhagic-edematous presentation. Correlation of MR findings with experimental and clinical spinal cord injury has given a relative predictive value to spinal cord injury patterns on MR images indicative of long-term neurologic outcome. Magnetic resonance imaging is useful in delineating soft-tissue injuries associated with spinal column trauma. Despite the improved spatial resolution of MR imaging, plain radiography and computed tomography remain the standard modalities for visualizing spinal fractures.

    • Keywords:
    • Acute Disease|Edema|Hemorrhage|Humans|Magnetic Resonance Imaging|Spinal Cord|Spinal Cord Diseases|Spinal Cord Injuries|Spinal Fractures|Tomography

    • X-Ray Computed

    • Subspecialty:
    • Trauma

    • Spine

    • Basic Science

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