JAAOS, Volume 16, No. 7

The urgency of surgical débridement in the management of open fractures.

Emergent débridement of open fractures within 6 hours of injury has long been considered to be critical to prevention of infection. The basis for this mandate is unclear, however. In clinical practice, physiologic and logistical challenges frequently limit the degree to which such emergent surgical care can effectively be rendered. Furthermore, concerns exist that quality of care might be improved when services are performed during normal working hours. The current literature suggests no obvious advantage to performing surgical débridement within 6 hours after injury versus doing so between 6 and 24 hours after injury. The effect of delays >24 hours is unclear. Further research in this area would be helpful, but development of definitive level I evidence seems unlikely. Surgical débridement of open fractures should be accomplished urgently, as soon as the patient's physiologic condition permits and as soon as appropriate resources are available to safely perform the procedure.

    • Keywords:
    • Bacterial Infections|Debridement|Fractures

    • Open|Humans|Orthopedic Procedures|Time Factors

    • Subspecialty:
    • Trauma

Controversies in soft-tissue anterior cruciate ligament reconstruction: grafts, bundles, tunnels, fixation, and harvest.

Increased stability has been reported with both autografts and allografts for anterior cruciate ligament (ACL) reconstruction. However, meta-analysis has shown significantly lower overall knee stability rates and more than double the abnormal stability rate with allografts. Some issues surrounding allograft sterilization (ie, risk of disease transmission) are unresolved, and cost is also a concern. Single-bundle ACL reconstruction can produce high stability rates when tunnels are properly placed, but there is evidence that double-bundle repair may offer greater rotatory stability. Cortical fixation has been associated with increased stability owing to the high stiffness of cortical bone. Anterior and posterior approaches are both recommended. The controversy related to single-bundle versus double-bundle ACL reconstruction remains unresolved.

    • Keywords:
    • Anterior Cruciate Ligament|Bacterial Infections|Bone Screws|Humans|Internal Fixators|Orthopedic Procedures|Transplantation

    • Autologous|Transplantation

    • Homologous

    • Subspecialty:
    • Sports Medicine

Chronic glenohumeral dislocation.

The evaluation and management of chronic glenohumeral dislocations can be challenging. By definition, chronic glenohumeral dislocations represent injuries that were not identified at the time of injury. Therefore, the primary goal is to avoid circumstances in which these injuries are not recognized. This includes undertaking a comprehensive clinical evaluation as well as appropriate imaging studies to understand the pathoanatomic changes-specifically, the humeral head impression fracture and any associated glenoid changes. The size of the impression fracture and duration of the dislocation are important factors in determining the appropriate treatment approach. Satisfactory outcomes can be achieved by using a variety of techniques, including open reduction combined with tendon transfers, allograft reconstruction, disimpaction and bone grafting and prosthetic replacement. Equally important, however, is recognizing patients in whom successful outcomes can be achieved with nonsurgical management.

    • Keywords:
    • Artificial Limbs|Bone Transplantation|Humans|Orthopedic Procedures|Shoulder Dislocation|Tendons|Transplantation

    • Homologous|Treatment Outcome

    • Subspecialty:
    • Shoulder and Elbow

Adult-acquired flatfoot deformity.

Originally known as posterior tibial tendon dysfunction or insufficiency, adult-acquired flatfoot deformity encompasses a wide range of deformities. These deformities vary in location, severity, and rate of progression. Establishing a diagnosis as early as possible is one of the most important factors in treatment. Prompt early, aggressive nonsurgical management is important. A patient in whom such treatment fails should strongly consider surgical correction to avoid worsening of the deformity. In all four stages of deformity, the goal of surgery is to achieve proper alignment and maintain as much flexibility as possible in the foot and ankle complex. However, controversy remains as to how to manage flexible deformities, especially those that are severe.

    • Keywords:
    • Adult|Disease Progression|Flatfoot|Foot Deformities

    • Acquired|Humans|Orthopedic Procedures|Osteotomy|Tendons|Treatment Outcome

    • Subspecialty:
    • Foot and Ankle

Syringomyelia-associated scoliosis with and without the Chiari I malformation.

Although there may be a hereditary component to true idiopathic scoliosis, the condition has no known cause and is not associated with dysraphism. However, scoliosis with an associated syrinx, with or without the Chiari I malformation, sometimes presents as an idiopathic-type curve. Physical examination findings and subtle clues on diagnostic imaging may help the orthopaedic surgeon diagnose scoliosis associated with syringomyelia. Examination findings include asymmetric reflexes and presentation at ages younger than those of patients who present with adolescent idiopathic curves (i.e., 10 to 14 years). Radiologic findings include kyphosis at the apex of the curve. Indications for surgical decompression include progressive neurologic deficits, weakness, pain, and progressive curves. Most orthopaedic surgeons agree that a syrinx should be evaluated neurosurgically before any planned spinal arthrodesis to decrease the risk of neurologic injury connected with surgical correction. The indications for arthrodesis in these patients compared with those with idiopathic curves are evolving.

    • Keywords:
    • Disease Progression|Humans|Magnetic Resonance Imaging|Neurosurgical Procedures|Orthopedic Procedures|Rhombencephalon|Scoliosis|Syringomyelia

    • Subspecialty:
    • Pediatric Orthopaedics

    • Spine

Basal joint arthritis of the thumb.

The carpometacarpal joint of the thumb is the second most common site of arthritis in the hand. Patients in whom conservative treatment fails benefit from surgical intervention, although no consensus exists as to the best method to provide maximum pain relief and functional outcomes. The pathophysiology of carpometacarpal arthritis is loss of the integrity of the palmar oblique ligament, which allows for dorsal subluxation of the metacarpal on the trapezium. Most treatments revolve around resection or replacement of the arthritic carpometacarpal joint and restoration of the palmar oblique ligament. A critical appraisal of the current evidence-based research offers no guidance in treatment in the early stages of carpometacarpal arthritis; however, several evidence-based studies exist for more advanced stages. Although these studies exhibit limitations in regard to validated outcomes, power analysis, and blinded assessment, their conclusions question the clinical benefits of ligament reconstruction and tendon interposition. Further research is needed to delineate the best treatment of early stages of arthritis as well as the clinical significance of metacarpal subluxation and subsidence. Further, a standardized set of outcome tools is needed for the interpretation and comparison of data in regard to clinical outcomes.

    • Keywords:
    • Arthritis|Biomechanics|Carpometacarpal Joints|Humans|Orthopedic Procedures|Thumb|Treatment Outcome

    • Subspecialty:
    • Hand and Wrist