JAAOS

JAAOS, Volume 8, No. 3


Ankle arthrodesis: indications and techniques.

Patients with ankle arthritis and deformity can experience severe pain and functional disability. Those patients who do not respond to nonoperative treatment modalities are candidates for ankle arthrodesis, provided pathologic changes in the subtalar region can be ruled out. Several techniques are available for performing the procedure; the most successful combine an open approach with compression and internal fixation. The foot must be positioned with regard to overall limb alignment and in the optimal position for function. A nonunion rate as high as 40% has been reported. Osteonecrosis of the talus and smoking are known risk factors for nonunion. When good surgical technique is used in carefully selected patients, ankle arthrodesis can be a reliable procedure for the relief of functionally disabling ankle arthritis, deformity, and pain.

    • Keywords:
    • Ankle Joint|Arthrodesis|Bone Nails|Bone Plates|Female|Humans|Male|Osteoarthritis|Pain Measurement|Prognosis|Range of Motion

    • Articular

    • Subspecialty:
    • Trauma

    • Foot and Ankle

Lunotriquetral instability: diagnosis and treatment.

Isolated injury of the lunotriquetral interosseous ligament complex and associated structures is less common and is poorly understood compared with the other proximal-row ligament injury, scapholunate dissociation. The spectrum of injuries ranges from isolated partial tears to frank dislocation, and from dynamic to static carpal instability. The diagnosis may be difficult to establish because of the many possible causes of ulnar-sided wrist pain and the often normal radiographic appearance. The mechanism of injury is variable and includes attrition by age, positive ulnar variance, and perilunate or reverse perilunate injury. Appropriate treatment requires assessment of the degree of instability and the chronicity of the injury. Options include corticosteroid injection, immobilization, ligament repair, ligament reconstruction with tendon grafts, limited intercarpal arthrodesis, and ulnar shortening.

    • Keywords:
    • Arthroscopy|Biomechanics|Carpal Bones|Female|Humans|Joint Instability|Ligaments

    • Articular|Male|Range of Motion

    • Articular|Treatment Outcome|Wrist Injuries

    • Subspecialty:
    • Hand and Wrist

Necrotizing soft-tissue infections.

Necrotizing fasciitis is a rare and often fatal soft-tissue infection involving the superficial fascial layers of the extremities, abdomen, or perineum. Necrotizing fasciitis typically begins with trauma; however, the inciting event may be as seemingly innocuous as a simple contusion, minor burn, or insect bite. Differentiating necrotizing infections from common soft-tissue infections, such as cellulitis and impetigo, is both challenging and critically important. A high degree of suspicion may be the most important aid in early diagnosis. Prompt diagnosis is imperative because necrotizing infections typically spread rapidly and can result in multiple-organ failure, adult respiratory distress syndrome, and death. Although group A Streptococcus is the most common bacterial isolate, a polymicrobial infection with a variety of Gram-positive, Gram-negative, aerobic, and anaerobic bacteria is more common. Orthopaedic surgeons are often the first physicians to evaluate patients with such infections and therefore need to be familiar with this potentially devastating disease and its management. Prompt diagnosis, immediate administration of broad-spectrum antibiotic coverage, and emergent aggressive surgical debridement of all compromised tissues are critical to reduce the morbidity and mortality of these rapidly progressing infections.

    • Keywords:
    • Adolescent|Adult|Anti-Bacterial Agents|Child

    • Preschool|Combined Modality Therapy|Debridement|Fasciitis

    • Necrotizing|Female|Humans|Immunohistochemistry|Magnetic Resonance Imaging|Male|Middle Aged|Prognosis|Soft Tissue Infections|Survival Analysis

    • Subspecialty:
    • General Orthopaedics

Noncontact anterior cruciate ligament injuries: risk factors and prevention strategies.

An estimated 80,000 anterior cruciate ligament (ACL) tears occur annually in the United States. The highest incidence is in individuals 15 to 25 years old who participate in pivoting sports. With an estimated cost for these injuries of almost a billion dollars per year, the ability to identify risk factors and develop prevention strategies has widespread health and fiscal importance. Seventy percent of ACL injuries occur in noncontact situations. The risk factors for non-contact ACL injuries fall into four distinct categories: environmental, anatomic, hormonal, and biomechanical. Early data on existing neuromuscular training programs suggest that enhancing body control may decrease ACL injuries in women. Further investigation is needed prior to instituting prevention programs related to the other risk factors.

    • Keywords:
    • Adult|Anterior Cruciate Ligament|Biomechanics|Female|Guidelines as Topic|Humans|Knee Injuries|Male|Physical Education and Training|Prevalence|Primary Prevention|Risk Factors|United States

    • Subspecialty:
    • Sports Medicine

Role of neurophysiologic evaluation in diagnosis.

The electrodiagnostic evaluation assesses the integrity of the lower-motor-neuron unit (i.e., peripheral nerves, neuromuscular junction, and muscle). Sensory- and motor-nerve conduction studies measure compound action potentials from nerve or muscle and are useful for assessing possible axon loss and/or demyelination. Needle electromyography measures electrical activity directly from muscle and provides information about the integrity of the motor unit; it can be used to detect loss of axons (denervation) as well as reinnervation. The electrodiagnostic examination is a useful tool for first detecting abnormalities and then distinguishing problems that affect the peripheral nervous system. In evaluating the patient with extremity trauma, it can differentiate neurapraxia from axonal transection and can be helpful in following the clinical course. In patients with complex physical findings, it is a useful adjunct that can help discriminate motor neuron disease from polyneuropathy or myeloradiculopathy due to spondylosis.

    • Keywords:
    • Aged|Diagnosis

    • Differential|Electromyography|Electrophysiology|Female|Humans|Male|Middle Aged|Musculoskeletal Diseases|Neural Conduction|Neurologic Examination|Peripheral Nervous System Diseases|Sensitivity and Specificity

    • Subspecialty:
    • Trauma

    • General Orthopaedics

Surgical alternatives for treatment of articular cartilage lesions.

Articular cartilage injuries in the knee are common; fortunately, full-thickness articular cartilage defects constitute only a small portion of this group. These lesions may be incidentally encountered during ligament or meniscal surgery, having been silent or asymptomatic for an unknown period of time. However, when they are large and symptomatic, the surgeon may choose from a wide array of techniques available for treatment. The relatively small number of natural history studies regarding full-thickness articular surface lesions complicates the decision-making process. Accurate evaluation and classification of the anatomic defect aids in the development of a clinical algorithm for treatment. Surgical techniques are either reparative or restorative in nature. Reparative techniques fall short of complete reestablishment of the articular cartilage; however, the resultant repairs may remain quite functional for varying periods of time. Restorative techniques attempt to reestablish the native articular surface. To date, no peer-reviewed, prospective, randomized, controlled studies of operative versus nonoperative treatment for full-thickness articular cartilage lesions have been published. Even though the long-term results of surgical treatment for full-thickness articular surface lesions remain unknown, the early results are encouraging.

    • Keywords:
    • Adult|Arthroscopy|Biomechanics|Cartilage

    • Articular|Female|Humans|Knee Injuries|Knee Joint|Male|Middle Aged|Prognosis|Range of Motion

    • Articular|Tissue Transplantation

    • Subspecialty:
    • Sports Medicine

Thoracic disk disease: diagnosis and treatment.

Symptomatic degenerative disk disease is much less common in the thoracic spine than in the cervical and lumbar regions. Accurate diagnosis relies on a strong clinical suspicion that is confirmed with appropriate diagnostic imaging. Presenting symptoms vary tremendously, from atypical pain patterns to myelopathy. The use of computed tomography in combination with myelography and magnetic resonance imaging have greatly increased the ability to accurately visualize thoracic spine disorders. The superior resolution of available imaging modalities has made the incidental detection of asymptomatic thoracic disk abnormalities more frequent. Most patients with symptomatic thoracic disk disease will respond favorably to nonoperative management. Surgery is indicated for the rare patient with an acute thoracic disk herniation with progressive neurologic deficit (i.e., signs or symptoms of thoracic spinal cord myelopathy). Once surgical intervention has been chosen, careful preoperative planning is necessary. The level, anatomic location, and morphology of the herniation must be precisely determined to select the optimal approach. Posterior laminectomy has largely been abandoned for the treatment of symptomatic thoracic disk protrusions. Surgeons still may choose among anterior, lateral, and posterior approaches when surgically addressing the thoracic intervertebral disk.

    • Keywords:
    • Adult|Aged|Diagnostic Imaging|Female|Humans|Intervertebral Disk|Laminectomy|Male|Middle Aged|Physical Therapy Modalities|Prognosis|Spinal Diseases|Thoracic Surgery

    • Video-Assisted|Thoracic Vertebrae|Treatment Outcome

    • Subspecialty:
    • Spine

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