JAAOS, Volume 13, No. 6

Posterior ankle impingement syndrome.

Posterior ankle impingement syndrome is a clinical disorder characterized by posterior ankle pain that occurs in forced plantar flexion. The pain may be acute as a result of trauma or chronic from repetitive stress. Pathology of the os trigonum-talar process is the most common cause of this syndrome, but it also may result from flexor hallucis longus tenosynovitis, ankle osteochondritis, subtalar joint disease, and fracture. Patients usually report chronic or recurrent posterior ankle pain caused or exacerbated by forced plantar flexion or push-off maneuvers, such as may occur during dancing, kicking, or downhill running. Diagnosis of posterior ankle impingement syndrome is based primarily on clinical history and physical examination. Radiography, scintigraphy, computed tomography, and magnetic resonance imaging depict associated bone and soft-tissue abnormalities. Symptoms typically improve with nonsurgical management, but surgery may be required in refractory cases.

    • Keywords:
    • Algorithms|Ankle Joint|Diagnosis

    • Differential|Diagnostic Imaging|Humans|Joint Diseases|Nerve Compression Syndromes|Orthopedic Procedures

    • Subspecialty:
    • Foot and Ankle

    • Sports Medicine

Tumors and tumor-like conditions of the spine in children.

Tumors and tumor-like conditions of the spine, although rare, should be included in the differential diagnosis of infants and children with back pain. Skeletal pathology is more frequently the cause of back pain in children than in adults. Although most tumors and tumor-like conditions of the spine in children are benign, many require surgery. Children with malignant tumors of the spine (with the exception of leukemia and lymphoma) may require multimodality therapy, including surgery, to achieve long-term cure. Advances in imaging, surgical technique, surgical technology, and adjuvant therapy have led to improvements in diagnosis and treatment and, thus, outcomes. In many cases, however, early and accurate diagnosis is often possible based on only clinical history, physical examination, and plain radiographic imaging.

    • Keywords:
    • Back Pain|Child|Child

    • Preschool|Combined Modality Therapy|Diagnosis

    • Differential|Diagnostic Imaging|Humans|Infant|Physical Examination|Spinal Cord Neoplasms|Spinal Neoplasms

    • Subspecialty:
    • Musculoskeletal Oncology

    • Pediatric Orthopaedics

    • Spine

Adult traumatic brachial plexus injuries.

Adult traumatic brachial plexus injuries are devastating, and they are occurring with increasing frequency. Patient evaluation consists of a focused assessment of upper extremity sensory and motor function, radiologic studies, and, most important, preoperative and intraoperative electrodiagnostic studies. The critical concepts in surgical treatment are patient selection as well as the timing and prioritizing of restoration of function. Surgical techniques include neurolysis, nerve grafting, neurotization, and free muscle transfer. Results are variable, but increased knowledge of nerve injury and repair, as well as advances in microsurgical techniques, allow not only restoration of elbow flexion and shoulder abduction but also of useful prehension of the hand in some patients.

    • Keywords:
    • Adult|Brachial Plexus|Brachial Plexus Neuropathies|Diagnosis

    • Differential|Diagnostic Imaging|Electrodiagnosis|Humans

    • Subspecialty:
    • Shoulder and Elbow

Orthopaedics and the law.

Understanding the relevant legal context is critical to the safe and successful practice of orthopaedic surgery. Specifically, three areas of liability are relevant to most physicians: medical malpractice, products liability, and the liability of health care organizations. Medical malpractice encompasses the professional physician-patient relationship with its implied contract, consent, fiduciary responsibilities, and duty to provide the standard of care, as well as certain common-law duties pertinent in special circumstances. Orthopaedic surgeons who design implants or who have a relationship with a device manufacturer are at risk for liability for a failed product. In general, the hospital entity is responsible for the actions of its physician-employees. Still unclear is the degree to which a physician is obligated to appeal to a third-party payer on behalf of a patient. Physicians should remember that, above all else, common sense with regard to the treatment, informed consent, and advocacy of patients is essential to avoiding many medical-legal pitfalls.

    • Keywords:
    • Ethics

    • Medical|Humans|Informed Consent|Liability

    • Legal|Malpractice|Orthopedic Equipment|Orthopedics|Physician-Patient Relations|Refusal to Treat|United States

    • Subspecialty:
    • Clinical Practice Improvement

Orthopaedic care of the aging athlete.

Increasing numbers of middle-aged and older adults participate in sports, and athletes wish to remain active as they age. Understanding the anatomic, physiologic, and psychosocial differences between older and younger athletes can help aging athletes maintain function. Athletic capacity may be sustained well into advanced age, and many of the physiologic consequences of aging may be mitigated or reversed by regular exercise. Most injuries in older athletes are chronic and overuse injuries that result in diminished flexibility and endurance. In addition, many aging athletes have medical and musculoskeletal problems that mandate tailoring athletic activity to the patient's general health and functional requirements.

    • Keywords:
    • Age Factors|Aged|Aging|Arthroplasty

    • Replacement|Athletic Injuries|Exercise|Exercise Tolerance|Humans|Middle Aged|Orthopedics|Osteoarthritis|Physical Endurance|Risk Factors

    • Subspecialty:
    • Sports Medicine

    • Basic Science

Chronic posttraumatic osteomyelitis and infected nonunion of the tibia: current management concepts.

Chronic posttraumatic osteomyelitis and infected nonunion of the tibia are complex problems that result in considerable morbidity and can threaten viability of the limb. Development of infection may result from compromised soft tissue and bone vascularity, systemic compromise of the host, and virulent or resistant organisms. Biofilm formation on implant and devascularized bone surfaces protects pathogens and may lead to persistence of infection. Management is based on a detailed evaluation of the patient, the involved bone and soft tissues, degree of associated lower extremity injury, and type of bacterial pathogens. Infection control is achieved with radical débridement, skeletal stabilization, and microbial-specific antibiotics. Local antibiotic delivery is a useful supplement to systemic administration. Local or free muscle flaps may be necessary to achieve soft-tissue coverage. Restoration of bone defects and bony union can be accomplished with bone grafting. However, large defects require complex reconstructive procedures, such as distraction osteogenesis and vascularized bone grafting.

    • Keywords:
    • Chronic Disease|Combined Modality Therapy|Diagnostic Imaging|Fractures

    • Ununited|Humans|Osteomyelitis|Tibia

    • Subspecialty:
    • Trauma