JAAOS

JAAOS, Volume 7, No. 4


Degenerative lumbar stenosis: diagnosis and management.

Degenerative lumbar stenosis is a common cause of disabling back and lower extremity pain among older persons. The process usually begins with degeneration of the intervertebral disks and facet joints, resulting in narrowing of the spinal canal and neural foramina. Associated factors may include a developmentally narrow spinal canal and degenerative spinal instability. Nonoperative management includes restriction of aggravating activities, physical therapy, and anti-inflammatory medications. If nonoperative treatment has failed, surgical treatment may be appropriate. Decompression should be performed so as to address all clinically relevant neural elements while maintaining spinal stability. If instability is present, autogenous intertransverse bone grafting is recommended. There may be an advantage to augmenting some of these procedures with internal fixation. Surgical success rates as high as 85% have been reported, but may be compromised by inadequate decompression, inadequate stabilization, or medical comorbidities. Short-term follow-up data indicate that operative management provides more effective relief than nonoperative treatment, but prospective studies comparing the effects of nonoperative and operative interventions on the long-term natural history of lumbar spinal stenosis are needed.

    • Keywords:
    • Aged|Bone Transplantation|Decompression

    • Surgical|Female|Humans|Lumbar Vertebrae|Male|Middle Aged|Spinal Cord Compression|Spinal Fusion|Spinal Stenosis|Spondylolisthesis|Spondylolysis|Treatment Outcome

    • Subspecialty:
    • Trauma

    • Spine

    • Pain Management

Ganglions of the hand and wrist.

Ganglions of the hand and wrist are common benign lesions. They most frequently arise adjacent to joints and tendons, but may also be intratendinous or intraosseous. Treatment options include observation, aspiration, and surgical excision. Observation is acceptable in most instances. Indications for more aggressive treatment include pain, interference with activity, nerve compression, and imminent ulceration (in the case of some mucous cysts). The recurrence rate after puncture and aspiration is greater than 50% for cysts in most locations, but is less than 30% for cysts in the flexor tendon sheath. Surgical excision is effective, with a recurrence rate of only 5% if care is taken to completely excise the stalk of the cyst along with a small portion of joint capsule. Surgical treatment of occult ganglions is successful with accurate assessment of the source of the pain. Arthroscopic treatment of dorsal wrist ganglions is still experimental, but early results are encouraging. Ganglion surgery requires a formal operative environment and careful technique in order to minimize injury to adjacent structures and minimize the likelihood of recurrence.

    • Keywords:
    • Arthroscopy|Endoscopy|Hand|Humans|Recurrence|Synovial Cyst|Wrist

    • Subspecialty:
    • Hand and Wrist

    • Musculoskeletal Oncology

    • Pain Management

Hallucal sesamoid pain: causes and surgical treatment.

The hallucal sesamoids, although small and seemingly insignificant, play an important role in the function of the great toe by absorbing weight-bearing pressure, reducing friction, and protecting tendons. However, the functional complexity and anatomic location of these small bones make them vulnerable to injury from shear and loading forces. Injury to the hallucal sesamoids can cause incapacitating pain, which can be devastating to an athlete. Although traumatic injuries usually can be diagnosed easily, other pathologic conditions may be overlooked. Careful physical and radiologic examinations are necessary to determine the cause of pain and allow a recommendation of the optimal treatment. Surgical treatment may include partial or complete resection of the sesamoid, shaving of a prominent tibial sesamoid, or autogenous bone grafting for nonunion. Excision of both sesamoids should be avoided if possible.

    • Keywords:
    • Athletic Injuries|Fractures

    • Stress|Hallux|Hallux Valgus|Humans|Osteochondritis|Pain|Sesamoid Bones

    • Subspecialty:
    • Foot and Ankle

    • Pain Management

    • Basic Science

Muscle strain injury: diagnosis and treatment.

Muscle strain is a very common injury. Muscles that are frequently involved cross two joints, act mainly in an eccentric fashion, and contain a high percentage of fast-twitch fibers. Muscle strain usually causes acute pain and occurs during strenuous activity. In most cases, the diagnosis can be made on the basis of the history and physical examination. Magnetic resonance imaging is recommended only when radiologic evaluation is necessary for diagnosis. Initial treatment consists of rest, ice, compression, and nonsteroidal anti-inflammatory drug therapy. As pain and swelling subside, physical therapy should be initiated to restore flexibility and strength. Avoiding excessive fatigue and performing adequate warm-up before intense exercise may help to prevent muscle strain injury. The long-term outcome after muscle strain injury is usually excellent, and complications are few.

    • Keywords:
    • Anti-Inflammatory Agents

    • Non-Steroidal|Combined Modality Therapy|Humans|Muscle

    • Skeletal|Physical Therapy Modalities|Risk Factors|Rupture|Sprains and Strains

    • Subspecialty:
    • Sports Medicine

    • Pain Management

Neurofibromatosis in children: the role of the orthopaedist.

Type 1 neurofibromatosis (NF-1), also known as von Recklinghausen disease, is one of the most common human single-gene disorders, affecting at least 1 million persons throughout the world. It encompasses a spectrum of multifaceted disorders and may present with a wide range of clinical manifestations, including abnormalities of the skin, nervous tissue, bones, and soft tissues. The condition can be conclusively diagnosed when two of seven criteria established by the National Institutes of Health Consensus Development Conference are met. Most children with NF-1 have no major orthopaedic problems. For those with musculoskeletal involvement, the most important issue is early recognition. Spinal deformity, congenital tibial dysplasia (congenital bowing and pseudarthrosis), and disorders of excessive bone and soft-tissue growth are the three types of musculoskeletal manifestations that require evaluation. Statistics gathered from the Cincinnati Children's Hospital Neurofibromatosis Center database show the incidence of spinal deformity in children with NF-1 to be 23.6%; pectus deformity, 4.3%; limb-length inequality, 7.1%; congenital tibial dysplasia, 5.7%; hemihypertrophy, 1.4%; and plexiform neurofibromas, 25%. The orthopaedic complications can be managed, but only rarely are they cured.

    • Keywords:
    • Bone Diseases

    • Developmental|Bone Neoplasms|Child|Humans|Neurofibromatosis 1|Orthopedic Procedures|Patient Care Team

    • Subspecialty:
    • Pediatric Orthopaedics

    • Spine

Osteonecrosis of the femoral head.

New cases of osteonecrosis of the femoral head in the United States number between 10,000 and 20,000 per year. This disease usually affects patients in their late 30s and early 40s. Although a number of authors have related specific risk factors to this disease, its etiology, pathogenesis, and treatment remain a source of considerable controversy. This disorder has been associated with corticosteroid use, substance abuse, and various systemic medical conditions. Either direct damage to osteocytes (e.g., by toxin production) or indirect damage (e.g., due to disorders in fat metabolism or hypoxia) may lead to osteonecrosis. Patients at increased risk for osteonecrosis should be monitored closely. Unfortunately, most cases are diagnosed in an advanced stage of disease, when minimally invasive surgical procedures are no longer helpful. Furthermore, patients in the advanced stage of the disease must undergo total hip replacement at a young age, which carries a poor long-term prognosis.

    • Keywords:
    • Adult|Arthroplasty

    • Replacement

    • Hip|Diagnosis

    • Differential|Diagnostic Imaging|Female|Femur Head Necrosis|Humans|Male|Middle Aged|Prognosis|Risk Factors

    • Subspecialty:
    • Adult Reconstruction

Retrograde nailing of the femoral shaft.

Retrograde intramedullary nailing of fractures of the femoral shaft with use of a distal intercondylar intra-articular entry portal is a relatively new surgical technique. This method of nailing represents a modification of the previously described procedure in which an extra-articular entry portal in the medial femoral condyle was used. The earlier procedure was plagued by technical difficulties, which limited its use; these problems were mainly related to the fact that the entry portal was not in line with the intramedullary canal, as well as to the fact that purpose-specific implants and instrumentation were not available. Modification of this technique, by using the intercondylar entry portal and a nail designed for retrograde insertion, has proved very effective in clinical studies. There have been theoretical concerns regarding postoperative knee function and intraoperative injury to important anatomic structures, such as branches of the femoral nerve; however, laboratory and clinical findings have dispelled many of these concerns and have provided firm support for continued use of the technique. Nonetheless, further study is required to delineate the long-term outcome of knee joint function. Current indications for use of this technique include multisystem injuries, multiple fractures (including ipsilateral lower-limb combination injuries), ipsilateral vascular injuries, periprosthetic fractures, and morbid obesity.

    • Keywords:
    • Equipment Design|Equipment Failure Analysis|Femoral Fractures|Fracture Fixation

    • Intramedullary|Humans|Postoperative Complications

    • Subspecialty:
    • Trauma

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