JAAOS, Volume 13, No. 1

Controlled-release oxycodone.

    • Keywords:
    • Analgesics

    • Opioid|Biological Availability|Delayed-Action Preparations|Dose-Response Relationship

    • Drug|Drug Administration Schedule|Humans|Oxycodone|Pain Measurement|Pain

    • Intractable|Pain

    • Postoperative|Sensitivity and Specificity

    • Subspecialty:
    • Pain Management

    • Adult Reconstruction

    • General Orthopaedics

Removal of solidly fixed implants during revision hip and knee arthroplasty.

The removal of solidly fixed implants during revision hip and knee arthroplasty is a technically challenging procedure with the potential for a large amount of bone loss during component removal. This bone loss may compromise the subsequent reconstruction. Careful preoperative planning is essential before undertaking removal of solidly fixed implants. The surgeon should determine the type and size of the implants and be familiar with any specialized removal equipment that may be available. For both the hip and knee, extensive exposure is often necessary. Removal of a well-fixed femoral component often requires an extended trochanteric osteotomy. The most difficult component to remove from the knee is a well-fixed cementless patellar component. The primary goal in removing well-fixed components is to minimize loss of surrounding bone, which requires effective planning and often access to specialized tools and techniques.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Hip|Arthroplasty

    • Knee|Device Removal|Equipment Design|Equipment Safety|Female|Follow-Up Studies|Hip Prosthesis|Humans|Knee Prosthesis|Male|Prosthesis Failure|Reoperation|Sensitivity and Specificity|Treatment Outcome

    • Subspecialty:
    • Adult Reconstruction

Volar fixed-angle plating of the distal radius.

The treatment of unstable distal radius fractures continues to improve as better methods of skeletal fixation and soft-tissue management are developed. Apart from closed reduction and percutaneous pinning of simpler fracture patterns, the three main methods of management are external fixation, dorsal plating, and volar fixed-angle plating. Specific advantages of volar fixed-angle plating include stable fixed-angle support that permits early active wrist rehabilitation, direct fracture reduction, and fewer soft-tissue and tendon problems. Volar fixed-angle plating also avoids the complications often associated with external fixation and dorsal plating. Biomechanical data indicate that, when loaded to failure, volar fixed-angle plates have significant strength advantages over dorsal plating. Volar fixed-angle plating is advantageous in elderly osteopenic patients and for high-energy comminuted fractures and malunions requiring osteotomy.

    • Keywords:
    • Bone Plates|Female|Fracture Fixation

    • Internal|Fracture Healing|Humans|Injury Severity Score|Joint Instability|Male|Prognosis|Radius Fractures|Range of Motion

    • Articular|Recovery of Function|Risk Assessment|Treatment Outcome|Wrist Injuries

    • Subspecialty:
    • Trauma

    • Hand and Wrist

Injectable corticosteroids in modern practice.

Long-lasting, crystalline suspensions of injectable corticosteroids have been used to treat joint and soft-tissue disorders for many years; they decrease inflammation by reducing local infiltration of inflammatory cells and mediators. Depot formulations differ in their characteristics. Compounds with low solubility are thought to have the longest duration of action but may cause tissue atrophy when used in soft tissues. Intra-articular corticosteroids are commonly used to treat osteoarthritis and inflammatory arthritis: meta-analyses confirm their benefit in reducing pain and symptoms. Intra-articular corticosteroid injections have been shown to be safe and effective for repeated use (every 3 months) for up to 2 years, with no joint space narrowing detected. Fewer clinical trials are available for extra-articular uses for injectable corticosteroids, although there is evidence of efficacy in a variety of soft-tissue conditions. The accuracy of injections affects outcomes. Postinjection flare, facial flushing, and skin and fat atrophy are the most common side effects. Systemic complications of injectable corticosteroids are rare.

    • Keywords:
    • Adrenal Cortex Hormones|Dose-Response Relationship

    • Drug|Drug Administration Schedule|Female|Forecasting|Humans|Injections

    • Intra-Articular|Male|Musculoskeletal Diseases|Orthopedics|Pain Measurement|Prognosis|Range of Motion

    • Articular|Recovery of Function|Rheumatic Diseases|Risk Assessment|Treatment Outcome|United States

    • Subspecialty:
    • Adult Reconstruction

    • General Orthopaedics

Physeal bridge resection.

Growth arrest secondary to physeal bridge formation is an uncommon but well-recognized complication of physeal fractures and other injuries. Regardless of the underlying etiology, physeal bridges may cause angular and/or longitudinal growth disturbances, with progression dependent on the remaining physeal growth potential. Physeal bridge resection and insertion of interposition material releases the tethering effect of the bridge. Physeal bridge resection has become an accepted treatment option for patients with existing or developing deformity and for those with at least 2 years or 2 cm of growth remaining. Current experimental research is focused on the use of gene therapy and other factors that enhance chondrocyte proliferation to improve the management of growth arrest. The use of cartilage and cultured chondrocytes as interposition material after physeal bridge resection is an area of active research.

    • Keywords:
    • Ankle Injuries|Child|Child

    • Preschool|Female|Fracture Fixation|Fractures

    • Bone|Growth Plate|Humans|Magnetic Resonance Imaging|Male|Orthopedic Procedures|Ossification

    • Heterotopic|Positron-Emission Tomography|Prognosis|Risk Assessment|Tomography

    • X-Ray Computed|Treatment Outcome|Wrist Injuries

    • Subspecialty:
    • Trauma

    • Foot and Ankle

Pectoralis major muscle injuries: evaluation and management.

Pectoralis major muscle tears are relatively rare injuries that primarily occur while lifting weights, particularly when doing a bench press. Complete ruptures are most commonly avulsions at or near the humeral insertion. Ruptures at the musculo-tendinous junction and intramuscular tears usually are caused by a direct blow. The patient may hear a snap at the time of injury and report pain, weakness, swelling, or muscular deformity. Physical examination can reveal ecchymosis, a palpable defect, asymmetric webbing of the axillary fold, and weakness on resisted shoulder adduction and internal rotation. A detailed history and physical examination can be augmented by radiologic studies, including magnetic resonance imaging. Nonsurgical treatment is now recommended only for the older, sedentary patient or for proximal muscle belly tears. Surgery, whether early or delayed, consistently yields superior results compared with nonsurgical management. Prompt diagnosis and timely intervention likely will produce improved results.

    • Keywords:
    • Athletic Injuries|Female|Follow-Up Studies|Humans|Injury Severity Score|Magnetic Resonance Imaging|Male|Orthopedic Procedures|Pectoralis Muscles|Recovery of Function|Risk Assessment|Rupture|Tensile Strength|Treatment Outcome

    • Subspecialty:
    • Sports Medicine

    • Shoulder and Elbow

Percutaneous treatment of vertebral body pathology.

Percutaneous vertebral body injection procedures currently are used to stabilize and reinforce weakened or fractured bone resulting from metastatic disease and severe osteoporosis. Both vertebroplasty and kyphoplasty can reinforce the structure of a vertebral body and provide pain relief, but the procedures have technical differences. Kyphoplasty improves vertebral height to varying degrees in nearly three quarters of patients. Kyphosis is improved more effectively when the procedure is performed within 3 months from the onset of fracture pain. To date, it is unknown whether vertebroplasty with preprocedure postural reduction can provide similar improvement of deformity. Complications are relatively infrequent with both vertebroplasty and kyphoplasty. Cement leakage from the vertebral body is more likely with vertebroplasty than with kyphoplasty. Leakage is more common in the treatment of pathologic fractures resulting from metastatic disease. Clinical complications caused by cement leakage and neural compression are infrequent. Specific indications for these injection procedures need to be more clearly refined. Long-term outcomes, including the fate of the injected material and the effect on adjacent vertebrae, have yet to be determined.

    • Keywords:
    • Aged|Aged

    • 80 and over|Bone Cements|Female|Fracture Fixation|Fracture Healing|Fractures

    • Spontaneous|Humans|Injections

    • Intralesional|Magnetic Resonance Imaging|Male|Risk Assessment|Sensitivity and Specificity|Spinal Fractures|Tomography

    • X-Ray Computed|Treatment Outcome

    • Subspecialty:
    • Trauma

    • Spine

Occupational radiation exposure to the surgeon.

Increased use of intraoperative fluoroscopy exposes the surgeon to significant amounts of radiation. The average yearly exposure of the public to ionizing radiation is 360 millirems (mrem), of which 300 mrem is from background radiation and 60 mrem from diagnostic radiographs. A chest radiograph exposes the patient to approximately 25 mrem and a hip radiograph to 500 mrem. A regular C-arm exposes the patient to approximately 1,200 to 4,000 mrem/min. The surgeon may receive exposure to the hands from the primary beam and to the rest of the body from scatter. Recommended yearly limits of radiation are 5,000 mrem to the torso and 50,000 mrem to the hands. Exposure to the hands may be higher than previously estimated, even from the mini C-arm. Potential decreases in radiation exposure can be accomplished by reduced exposure time; increased distance from the beam; increased shielding with gown, thyroid gland cover, gloves, and glasses; beam collimation; using the low-dose option; inverting the C-arm; and surgeon control of the C-arm.

    • Keywords:
    • Female|Film Dosimetry|Follow-Up Studies|Humans|Incidence|Intraoperative Care|Male|Occupational Exposure|Occupational Health|Orthopedics|Radiation Dosage|Radiation Injuries|Radiation Monitoring|Radiation Protection|Risk Factors

    • Subspecialty:
    • Clinical Practice Improvement

The biology of bone grafting.

Many approaches are used to repair skeletal defects in reconstructive orthopaedic surgery, and bone grafting is involved in virtually every procedure. The type of bone graft used depends on the clinical scenario and the anticipated final outcome. Autogenous cancellous bone graft, with its osteogenic, osteoinductive, and osteoconductive properties, remains the standard for grafting. However, the high incidence of morbidity during autogenous graft harvest may make the acquisition of grafts from other sources desirable. The clinical applications for each type of bone graft are dictated by the structure and biochemical properties of the graft. An elegant cellular and molecular cascade follows bone transplantation. Bone graft incorporation within the host, whether autogenous or allogeneic, depends on many factors: type of graft (autogenous versus allogeneic, vascular versus nonvascular), site of transplant, quality of transplanted bone and host bone, host bed preparation, preservation techniques, systemic and local disease, and mechanical properties of the graft.

    • Keywords:
    • Arm Injuries|Biopsy

    • Needle|Bone Transplantation|Bone and Bones|Female|Follow-Up Studies|Fracture Healing|Fractures

    • Bone|Graft Rejection|Graft Survival|Humans|Immunohistochemistry|Injury Severity Score|Leg Injuries|Male|Osteogenesis|Risk Assessment|Transplantation

    • Autologous|Transplantation

    • Homologous|Treatment Outcome

    • Subspecialty:
    • Basic Science