jaaos, Volume 16, No. 10

Musculoskeletal allograft risks and recalls in the United States.

There have been several improvements to the US tissue banking industry over the past decade. Tissue banks had limited active government regulation until 1993, at which time the US Food and Drug Administration began regulatory oversight because of reports of disease transmission from allograft tissues. Reports in recent years of disease transmission associated with the use of allografts have further raised concerns about the safety of such implants. A retrospective review of allograft recall data was performed to analyze allograft recall by tissue type, reason, and year during the period from January 1994 to June 30, 2007. During the study period, more than 96.5% of all allograft tissues recalled were musculoskeletal. The reasons underlying recent musculoskeletal tissue recalls include insufficient or improper donor evaluation, contamination, recipient infection, and positive serologic tests. Infectious disease transmission following allograft implantation may occur if potential donors are not adequately evaluated or screened serologically during the prerecovery phase and if the implant is not sterilized before implantation.

    • Keywords:
    • Disease Transmission

    • Infectious|Donor Selection|Government Regulation|Humans|Musculoskeletal System|Retrospective Studies|Risk|Safety|Tissue Banks|Tissue Donors|Tissue Transplantation|Tissue and Organ Procurement|Transplantation

    • Homologous|Transplants|United States|United States Food and Drug Administration

    • Subspecialty:
    • Clinical Practice Improvement

Randomized controlled trials of the treatment of lumbar disk herniation: 1983-2007.

Randomized controlled trials are considered to provide the strongest data regarding the relative benefits of treatment alternatives for medical conditions. Uncertainty persists regarding the optimal treatment of patients with symptomatic lumbar disk herniation. Five randomized controlled trials were published between 1983 and 2007 that compared lumbar diskectomy with nonsurgical treatment. The studies enrolled more than 1,000 patients. Inclusion and exclusion criteria were generally similar, but there was substantial variation in the outcomes measurements used. In all studies, more than one third of patients assigned to nonsurgical care crossed over to have surgery. Crossover in the opposite direction ranged from 0% to almost 40%. As a result of the large number of crossovers, the estimated treatment effect size of diskectomy likely is underestimated. Valid inferences about the safety and effectiveness of continued nonsurgical care cannot be made. The use of frequentist statistical techniques threatens the validity of post hoc subgroup analysis. Large cohort studies and alternative statistical techniques may yield more accurate estimates of the effectiveness of lumbar diskectomy and aid in identifying patients who may benefit from early surgical intervention.

    • Keywords:
    • Diskectomy|Humans|Intervertebral Disk Displacement|Lumbar Vertebrae|Pain Measurement|Patient Satisfaction|Randomized Controlled Trials as Topic|Research Design|Treatment Outcome

    • Subspecialty:
    • Spine

    • Clinical Practice Improvement

Elbow arthroscopy.

Arthroscopy of the elbow was originally considered to be an unsafe procedure because of the small size of the elbow joint capsule and its proximity to several crucial neurovascular structures. Over the past decade, however, the procedure has become safer and more effective. These improvements can be attributed to a better understanding of elbow anatomy and of the disorders about the elbow as well as to advances in arthroscopic equipment and surgical technique. The most common indications for elbow arthroscopy include removal of loose bodies, synovectomy, débridement and/or excision of osteophytes, capsular release, and the assessment and treatment of osteochondritis dissecans. More recent advances have expanded the indications of elbow arthroscopy to include fracture management (eg, radial head fractures) and the treatment of lateral epicondylitis.

    • Keywords:
    • Arthralgia|Arthroscopes|Arthroscopy|Debridement|Diagnosis

    • Differential|Elbow|Elbow Joint|Humans|Joint Loose Bodies|Osteochondritis Dissecans|Postoperative Complications|Radius Fractures|Range of Motion

    • Articular|Synovial Membrane|Tennis Elbow

    • Subspecialty:
    • Shoulder and Elbow

Fractures of the proximal phalanx and metacarpals in the hand: preferred methods of stabilization.

Treatment of fractures of the proximal phalanx and metacarpals is based on the presentation of the fracture, degree of displacement, and difficulty in maintaining fracture reduction. A wide array of treatment options exists for the variation in fracture patterns observed. Inherently stable fractures do not require surgical treatment; all other fractures should be considered for additional stabilization. In general, of the many combinations of internal fixation possible, Kirschner wires and screw-and-plate fixation predominate. Early closed reduction typically is successful for unicondylar fractures of the head of the proximal phalanx. Bicondylar proximal phalanx fractures usually are treated with plate fixation. Transverse and short oblique proximal phalanx fractures generally are treated with Kirschner wires, although a stable short oblique transverse shaft fracture can be managed with an intrinsic plus splint. Plate fixation is used in comminuted proximal phalanx as well as comminuted metacarpal fractures, and lag screws in spiral long oblique phalanx shaft fractures and metacarpal head fractures. Kirschner wire fixation is successful in metacarpal neck fractures as well as both short and long transverse oblique shaft fractures.

    • Keywords:
    • Finger Injuries|Finger Phalanges|Fracture Fixation|Fractures

    • Bone|Humans|Metacarpal Bones|Orthopedic Fixation Devices|Range of Motion

    • Articular|Treatment Outcome

    • Subspecialty:
    • Trauma

    • Hand and Wrist

Surgical management of hip fractures: an evidence-based review of the literature. I: femoral neck fractures.

During the past 10 years, there has been a worldwide effort in all medical fields to base clinical health care decisions on available evidence as described by thorough reviews of the literature. Hip fractures pose a significant health care problem worldwide, with an annual incidence of approximately 1.7 million. Globally, the mean age of the population is increasing, and the number of hip fractures is expected to triple in the next 50 years. One-year mortality rates currently range from 14% to 36%, and care for these patients represents a major global economic burden. Surgical options for the management of femoral neck fractures are closely linked to individual patient factors and to the location and degree of fracture displacement. Nonsurgical management of intracapsular hip fractures is limited. Based on a critical, evidence-based review of the current literature, we have found minimal differences between implants used for internal fixation of displaced fractures. Cemented, unipolar hemiarthroplasty remains a good option with reasonable results. In the appropriate patient population, outcomes following total hip arthroplasty are favorable and appear to be superior to those of internal fixation.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Hip|Bone Cements|Evidence-Based Medicine|Femoral Neck Fractures|Fracture Fixation|Humans|Practice Guidelines as Topic|Prognosis|Randomized Controlled Trials as Topic

    • Subspecialty:
    • Trauma

    • Adult Reconstruction

    • Clinical Practice Improvement

Management of acute and chronic ankle instability.

Acute lateral ankle ligament injuries are common. If left untreated, they can result in chronic instability. Nonsurgical measures, including functional rehabilitation, are the management methods of choice for acute injuries, with surgical intervention reserved for high-demand athletes. Chronic lateral ankle instability is multifactorial. Failed nonsurgical management after appropriate rehabilitation is an indication for surgery. Of the many surgical options available, anatomic repair of the anterior talofibular and calcaneofibular ligaments is recommended when the quality of the ruptured ligaments permits. Anatomic reconstruction with autograft or allograft should be performed when the ruptured ligaments are attenuated. Ankle arthroscopy is an important adjunct to ligamentous repair and should be performed at the time of repair to identify and address intra-articular conditions associated with chronic ankle instability. Tenodesis procedures are not recommended because they may disturb ankle and hindfoot biomechanics.

    • Keywords:
    • Acute Disease|Ankle Injuries|Arthroplasty|Arthroscopy|Chronic Disease|Humans|Joint Instability|Ligaments

    • Articular|Physical Therapy Modalities|Prognosis|Range of Motion

    • Articular|Rupture|Splints|Tenodesis

    • Subspecialty:
    • Sports Medicine

    • Basic Science

    • Foot and Ankle