JAAOS

JAAOS, Volume 7, No. 1


Fractures of the posterior wall of the acetabulum.

Only 30% of posterior-wall acetabular fractures involve a single large fragment. The majority are multifragmentary or have areas of impaction. Unsatisfactory clinical results occur in more than 80% of patients treated non-surgically. Operative management usually offers the best chance of preserving long-term joint function, but only if an anatomically reconstructed acetabulum can be achieved without complication. The keys to surgical success include maintaining the viability of the fracture fragments and the femoral head itself, using bone grafts and buttress plating to support elevated and comminuted fragments, and protecting the neurovascular structures at risk. Complications can include sciatic nerve injury (incidence, 3% to 18%), heterotopic ossification (7% to 20%), and osteonecrosis of the femoral head (5% to 8%). Despite the relative simplicity of this acetabular fracture, unsatisfactory outcomes after surgical repair of the posterior wall occur in at least 18% to 32% of cases, results that are worse than for most of the other more complex acetabular fracture patterns.

    • Keywords:
    • Acetabulum|Bone Plates|Bone Transplantation|Femur Head|Femur Head Necrosis|Fracture Fixation|Fractures

    • Bone|Fractures

    • Comminuted|Hip Joint|Humans|Incidence|Ossification

    • Heterotopic|Postoperative Complications|Sciatic Nerve|Tissue Survival|Treatment Outcome

    • Subspecialty:
    • Trauma

    • Adult Reconstruction

Functional fracture bracing.

Functional bracing is an effective therapeutic modality in the management of selected fractures of the tibia, humerus, and ulna, particularly low-energy injuries. In the case of tibial fractures, it is applicable only to reduced transverse fractures and to axially unstable fractures with an acceptable degree of shortening. The rate of union of tibial fractures after functional bracing is approximately 97%. The initial shortening noted with closed tibial fractures rarely increases with weight bearing. Shortening has been reported to be as little as 12 mm in 95% of patients, with angulation of 8 degrees in 90%. Such minimal shortening and angulation do not affect functional results. In closed and type I open diaphyseal humeral fractures treated with functional braces, the nonunion rate is approximately 3%. Most of the reported residual angular deformities have been functionally and cosmetically acceptable. For isolated ulnar fractures, the nonunion rate is approximately 2%. Functional fracture bracing is predicated on the premise that motion at the fracture site encourages osteogenesis. The method is applicable only to selected fractures, and it is necessary to have a clear understanding of its rationale, indications, and technique.

    • Keywords:
    • Braces|Esthetics|Fracture Healing|Fractures

    • Closed|Fractures

    • Open|Fractures

    • Ununited|Humans|Humeral Fractures|Osteogenesis|Tibial Fractures|Ulna Fractures|Weight-Bearing

    • Subspecialty:
    • Trauma

Management of neuropathic fractures in the foot and ankle.

Neuroarthropathy, a rapid, painless destructive process, has become increasingly prevalent among long-lived diabetic patients. It is characterized by warm, swollen joints with a grossly disorganized radiographic appearance, in spite of which the patient is often pain-free. Neglect of this condition results in progressive deformity or instability, often complicated by ulceration and infection, which can ultimately result in loss of independent mobility, loss of the affected limb, and even death. In most cases, a plantigrade, stable, and functional foot can be achieved with simple nonoperative techniques, such as the use of a total-contact cast or shoe modification. A few patients in whom uncontrolled instability or major osseous prominences cause recurrent ulceration will require reconstructive surgery (either exostectomy or osteotomy/arthrodesis). Although some patients will have an improvement in function, ongoing vigilance is necessary.

    • Keywords:
    • Amputation|Ankle Injuries|Arthrodesis|Arthropathy

    • Neurogenic|Bacterial Infections|Casts

    • Surgical|Diabetes Complications|Disease Progression|Foot Injuries|Foot Ulcer|Fractures

    • Spontaneous|Humans|Joint Instability|Osteotomy|Shoes

    • Subspecialty:
    • Trauma

    • Foot and Ankle

Osteoporosis: current modes of prevention and treatment.

The most common metabolic bone disorder is osteoporosis, which affects 25 million Americans, of whom 80% are women. Bone loss in women occurs most commonly after menopause, when the rate of loss may be as high as 2% per year. Bone mass can be determined with dual-energy x-ray absorptiometry. The rate of active loss can be assayed by the detection of bone collagen breakdown products (e.g., N-telopeptide, pyridinoline) in the urine. Although it has been suggested that white women are most commonly affected, Hispanic and Asian women are also affected. Strategies for the prevention and treatment of osteoporosis are directed at maximizing peak bone mass by optimizing physiologic intake of calcium, vitamin D therapy, exercise, and maintenance of normal menstrual cycles from youth through adulthood. Coupled with drug therapy should be a comprehensive approach to exercise and fall prevention. Stretching, strengthening, impact, and balance exercises are effective. Of the balance exercises, tai chi chuan has proved to be the most successful in decreasing falls. Prevention of bone loss is obviously preferable to any remedial measures, but new therapeutic strategies provide a means of restoring deficient bone.

    • Keywords:
    • Absorptiometry

    • Photon|Adult|Aged|Amino Acids|Asian Continental Ancestry Group|Biological Markers|Bone Density|Calcium|Collagen|Collagen Type I|European Continental Ancestry Group|Exercise Therapy|Female|Hispanic Americans|Humans|Male|Menstrual Cycle|Middle Aged|Osteoporosis

    • Postmenopausal|Peptides|Vitamin D

    • Subspecialty:
    • Spine

    • Basic Science

Partial-thickness tears of the rotator cuff: evaluation and management.

The approach to management of a partial-thickness rotator cuff tear is best made with the understanding that this is not a singular condition. Rather, partial tears represent the common outcome of a variety of insults to the rotator cuff. Degenerative changes due to aging, anatomic impingement, and trauma may all be etiologic agents. Overhead athletes may develop tears due to repetitive microtrauma or internal impingement. Outlet radiographs and magnetic resonance imaging are recommended for routine preoperative evaluation. A nonoperative treatment program for rotator cuff strengthening and stretching is appropriate as initial treatment; modification of activities and anti-inflammatory medication are often used as well. Operative management may be considered when nonoperative treatment fails. Arthroscopic evaluation is required to determine the true extent of the cuff lesion. Arthroscopic subacromial decompression is recommended when outlet impingement is present. Rotator cuff debridement or formal cuff repair is dependent on the size of the cuff defect and the age and activity level of the patient. The importance of recognizing the different causes of partial-thickness rotator cuff tears is emphasized in this review of pathogenesis, clinical diagnosis, imaging, and treatment.

    • Keywords:
    • Acromion|Aging|Anti-Inflammatory Agents|Arthroscopy|Athletic Injuries|Cumulative Trauma Disorders|Debridement|Endoscopy|Humans|Magnetic Resonance Imaging|Physical Therapy Modalities|Rotator Cuff|Rupture|Shoulder Impingement Syndrome

    • Subspecialty:
    • Sports Medicine

    • Shoulder and Elbow

Pediatric flatfoot: evaluation and management.

Although the exact incidence of flatfoot in children is unknown, it is a common finding. All children have only a minimal arch at birth, and more than 30% of neonates have a calcaneovalgus deformity of both feet. This condition is not painful and generally resolves without treatment; very rarely is corrective casting necessary. Most children who present to an orthopaedist for evaluation of flatfoot will have a flexible flatfoot that does not require treatment. Nevertheless, the examining physician must rule out other conditions that do require treatment, such as congenital vertical talus, tarsal coalition, and skew-foot. Untreated, congenital vertical talus may result in an awkward gait; manipulation and casting have been tried, but most authors now agree that surgical treatment is required. Although tarsal coalitions can become asymptomatic in adulthood, the anatomy will never be normal. Resection and inter-position of the extensor digitorum brevis is the treatment of choice for calcaneonavicular coalitions; the results of treatment of talocalcaneal coalitions are less predictable. Skewfoot should be treated by manipulation and serial casting as soon as it is detected. In the older child, hindfoot stabilization and realignment of the midfoot may be necessary. Surgical management is rarely indicated for a true flexible flatfoot. A variety of tendon transfers and reconstructive procedures have been advocated, but none has proved uniformly successful. Nor has any of the various types of supports ever been shown to change the arch architecture. Although parents are often concerned about pediatric flatfoot, the child is usually found to be asymptomatic, and no treatment is indicated. In most instances, the best treatment is simply taking enough time to convince the family that no treatment is necessary.

    • Keywords:
    • Adolescent|Casts

    • Surgical|Child|Child

    • Preschool|Flatfoot|Foot Deformities

    • Congenital|Gait|Humans|Incidence|Infant|Infant

    • Newborn|Manipulation

    • Orthopedic|Movement Disorders|Muscle

    • Skeletal|Orthotic Devices|Tendon Transfer

    • Subspecialty:
    • Foot and Ankle

    • Pediatric Orthopaedics

Use of reconstruction rings for the management of acetabular bone loss during revision hip surgery.

Aseptic loosening remains the leading cause of failure after total hip replacement. Extensive bone loss and acetabular bone stock deficiency are frequently encountered. Simple autografting techniques are often not possible, and copious amounts of allograft may be required to reconstruct the defect. The mechanically stable environment that is a prerequisite for successful graft incorporation cannot be achieved with routine acetabular fixation techniques alone. A reconstruction ring that is secured to the surrounding pelvis provides a more rigid construct. Several types of reconstruction rings are available for the management of acetabular bone loss during revision hip surgery. Early results suggest that these devices may prove to be a useful alternative for treatment of a difficult problem.

    • Keywords:
    • Acetabulum|Arthroplasty

    • Replacement

    • Hip|Biocompatible Materials|Bone Cements|Bone Screws|Bone Transplantation|Coated Materials

    • Biocompatible|Hip Prosthesis|Humans|Polyethylenes|Prosthesis Design|Prosthesis Failure|Reoperation|Surgical Mesh|Transplantation

    • Autologous|Transplantation

    • Homologous

    • Subspecialty:
    • Adult Reconstruction

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