JAAOS, Volume 15, No. 8

The effects of medications on bone.

Medications taken for the treatment of arthritis and psychotropic and epileptic disorders, as well as anticoagulants, antacids, bisphosphonates, corticosteroids, and antineoplastic drugs, can profoundly affect bone metabolism. In some scenarios (eg, osteoporosis), these effects are intended; in others (eg, rickets, osteomalacia secondary to antiepileptic drugs), potentially adverse side effects of medications on bone may occur. Nonsteroidal anti-inflammatory drugs appear to delay fracture healing and bone ingrowth, although these effects are reversible. Disease-modifying antirheumatic drugs do not appear to affect bone metabolism adversely when taken in the low dosages currently prescribed. Bisphosphonates are useful in restoring bone mass in cases of postmenopausal osteoporosis, glucocorticoid-induced osteoporosis, Paget's disease, and neoplastic conditions with bone loss and hypercalcemia. Corticosteroids and cancer chemotherapeutic agents generally affect bone adversely and increase fracture risk.

    • Keywords:
    • Anti-Inflammatory Agents|Antineoplastic Agents|Antipsychotic Agents|Bone Density|Bone and Bones|Fractures

    • Bone|Humans|Prognosis|Risk Factors

    • Subspecialty:
    • Trauma

    • Musculoskeletal Oncology

Disasters and mass casualties: II. explosive, biologic, chemical, and nuclear agents.

Terrorists' use of explosive, biologic, chemical, and nuclear agents constitutes the potential for catastrophic events. Understanding the unique aspects of these agents can help in preparing for such disasters with the intent of mitigating injury and loss of life. Explosive agents continue to be the most common weapons of terrorists and the most prevalent cause of injuries and fatalities. Knowledge of blast pathomechanics and patterns of injury allows for improved diagnostic and treatment strategies. A practical understanding of potential biologic, chemical, and nuclear agents, their attendant clinical symptoms, and recommended management strategies is an important prerequisite for optimal preparation and response to these less frequently used agents of mass casualty. Orthopaedic surgeons should be aware of the principles of management of catastrophic events. Stress is less an issue when one is adequately prepared. Decontamination is essential both to manage victims and prevent further spread of toxic agents to first responders and medical personnel. It is important to assess the risk of potential threats, thereby allowing disaster planning and preparation to be proportional and aligned with the actual casualty event.

    • Keywords:
    • Biological Warfare|Chemical Warfare|Disasters|Humans|Morbidity|Nuclear Warfare|World Health|Wounds and Injuries

    • Subspecialty:
    • Trauma

    • Basic Science

    • Clinical Practice Improvement

Percutaneous fixation of scaphoid fractures.

Recent advances in techniques and implants have led to renewed interest in percutaneous screw fixation of acute scaphoid fractures. The closed (cast) treatment of acute scaphoid fractures generally has good outcome, with bony union resulting; however, closed treatment can result in delayed union, nonunion, malunion, cast- induced joint stiffness, and lost time from employment and avocations. Acute percutaneous fixation of scaphoid fracture has been proposed as a means to minimize some of the complications of closed (cast) treatment. Percutaneous treatment of both nondisplaced and displaced scaphoid fractures reportedly can achieve a nearly 100% union rate with minimal complications. Fixation of scaphoid fractures with headless compression screws can be done using both volar and dorsal approaches. The fracture reduction and alignment are assessed by fluoroscopy and arthroscopy. Appropriately performed acute percutaneous internal fixation is now a standard treatment option for a selected group of patients with acute scaphoid fracture.

    • Keywords:
    • Bone Screws|Fracture Fixation

    • Internal|Fractures

    • Bone|Humans|Scaphoid Bone|Treatment Outcome

    • Subspecialty:
    • Trauma

    • Hand and Wrist

Cervical radiculopathy.

Cervical radiculopathy is a disorder involving dysfunction of cervical nerve roots that commonly manifests as pain radiating from the neck into the distribution of the affected root. Acute cervical radiculopathy generally has a self-limited clinical course, with up to a 75% rate of spontaneous improvement. Thus, nonsurgical treatment is the appropriate initial approach for most patients. When nonsurgical treatment fails to relieve symptoms or if a significant neurologic deficit exists, surgical decompression may be necessary. Surgical outcomes for relief of arm pain range from 80% to 90% with either anterior or posterior approaches.

    • Keywords:
    • Cervical Vertebrae|Humans|Immobilization|Magnetic Resonance Imaging|Orthopedic Procedures|Radiculopathy|Treatment Outcome

    • Subspecialty:
    • Pain Management

    • Spine

Patellofemoral arthroplasty.

Patellofemoral arthroplasty can be an effective intermediate treatment for the patient with isolated arthritis of the anterior compartment of the knee. In the absence of patellar malalignment, results are optimized when an implant with sound geometric features is used, the prosthesis is appropriately aligned, and the soft tissues are balanced. Although previous prosthesis designs resulted in a relatively high prevalence of failure because of patellofemoral maltracking, patellofemoral catching, and anterior knee pain, newer prosthesis designs show promise in reducing the prevalence of patellofemoral dysfunction. Progressive tibiofemoral cartilage degeneration is another so-called failure mechanism; such progressive degeneration underscores the importance of restricting the procedure to patients who do not have tibiofemoral chondromalacia. Because long-term failure as a result of tibiofemoral degeneration may occur in approximately 25% of patients, patellofemoral arthroplasty may be considered an intermediate procedure for select patients with patellofemoral arthritis.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Knee|Femur|Humans|Osteoarthritis

    • Knee|Patella|Treatment Outcome

    • Subspecialty:
    • Adult Reconstruction

    • Foot and Ankle

Sports hernia: diagnosis and therapeutic approach.

Groin pain is a common entity in athletes involved in soccer, ice hockey, Australian Rules football, skiing, running, and hurdling. An increasingly recognized cause of groin pain in these athletes is a sports hernia, an occult hernia caused by weakness or tear of the posterior inguinal wall, without a clinically recognizable hernia, that leads to a condition of chronic groin pain. The patient typically presents with an insidious onset of activity-related, unilateral, deep groin pain that abates with rest. Although the physical examination reveals no detectable inguinal hernia, a tender, dilated superficial inguinal ring and tenderness of the posterior wall of the inguinal canal are found. The role of imaging studies in this condition is unclear; most imaging studies will be normal. Unlike most other types of groin pain, sports hernias rarely improve with nonsurgical measures; thus, open or laparoscopic herniorrhaphy should be considered.

    • Keywords:
    • Athletic Injuries|Diagnosis

    • Differential|Groin|Hernia

    • Inguinal|Humans|Laparoscopy|Magnetic Resonance Imaging|Physical Therapy Modalities|Reconstructive Surgical Procedures|Treatment Outcome

    • Subspecialty:
    • Sports Medicine