JAAOS, Volume 17, No. 3

Complex shoulder disorders: evaluation and treatment.

Evaluation of patients with shoulder disorders often presents challenges. Among the most troublesome are revision surgery in patients with massive rotator cuff tear, atraumatic shoulder instability, revision arthroscopic stabilization surgery, adhesive capsulitis, and bicipital and subscapularis injuries. Determining functional status is critical before considering surgical options in the patient with massive rotator cuff tear. When nonsurgical treatment of atraumatic shoulder stability is not effective, inferior capsular shift is the treatment of choice. Arthroscopic revision of failed arthroscopic shoulder stabilization procedures may be undertaken when bone and tissue quality are good. Arthroscopic release is indicated when idiopathic adhesive capsulitis does not respond to nonsurgical treatment; however, results of both nonsurgical and surgical treatment of posttraumatic and postoperative adhesive capsulitis are often disappointing. Patients not motivated to perform the necessary postoperative therapy following subscapularis repair are best treated with arthroscopic débridement and biceps tenotomy.

    • Keywords:
    • Aged|Arthroscopy|Bursitis|Cartilage

    • Articular|Debridement|Exercise Therapy|Female|Humans|Joint Instability|Range of Motion

    • Articular|Recovery of Function|Reoperation|Rotator Cuff|Shoulder Dislocation|Shoulder Joint|Splints|Tendon Injuries|Treatment Outcome

    • Subspecialty:
    • Trauma

    • Shoulder and Elbow

Terrible triad injury of the elbow: current concepts.

Fracture-dislocations of the elbow remain among the most difficult injuries to manage. Historically, the combination of an elbow dislocation, a radial head fracture, and a coronoid process fracture has had a consistently poor outcome; for this reason, it is called the terrible triad. An elbow dislocation associated with a displaced fracture of the radial head and coronoid process almost always renders the elbow unstable, making surgical fixation necessary. The primary goal of surgical fixation is to stabilize the elbow to permit early motion. Recent literature has improved our understanding of elbow anatomy and biomechanics along with the pathoanatomy of this injury, thereby allowing the development of a systematic approach for treatment and rehabilitation. Advances in knowledge combined with improved implants and surgical techniques have contributed to better outcomes.

    • Keywords:
    • Biomechanics|Causality|Comorbidity|Dislocations|Elbow Joint|Fracture Fixation

    • Internal|Fracture Healing|Humans|Joint Instability|Postoperative Complications|Radius Fractures|Range of Motion

    • Articular|Treatment Outcome|Ulna Fractures

    • Subspecialty:
    • Trauma

    • Shoulder and Elbow

    • Basic Science

Treatment of medial collateral ligament injuries.

The medial collateral ligament is the most frequently injured ligament of the knee. The anatomy and biomechanical role of this ligament and the associated posteromedial structures of the knee continue to be explored. Prophylactic knee bracing has shown promise in preventing injury to the medial collateral ligament, although perhaps at the cost of functional performance. Most isolated injuries are treated nonsurgically. Recent studies have investigated ligament-healing variables, including modalities such as ultrasound and nonsteroidal anti-inflammatory drugs. Concomitant damage to the anterior or posterior cruciate ligaments is a common indication to surgically address the high-grade medial collateral ligament injury. The optimal treatment of multiligamentous knee injuries continues to evolve, and controversy exists surrounding the role of medial collateral ligament repair/reconstruction, with data supporting both conservative and surgical management.

    • Keywords:
    • Animals|Anterior Cruciate Ligament|Biomechanics|Braces|Causality|Humans|Knee Injuries|Medial Collateral Ligament

    • Knee|Orthopedic Procedures|Physical Therapy Modalities|Posterior Cruciate Ligament|Range of Motion

    • Articular|Reconstructive Surgical Procedures|Severity of Illness Index|Treatment Outcome

    • Subspecialty:
    • Sports Medicine

Hip fractures in children.

Hip fractures account for <1% of all pediatric fractures. Most are caused by high-energy mechanisms, but pathologic hip fractures also occur, usually from low-energy trauma. Complications occur at a high rate because the vascular and osseous anatomy of the child's proximal femur is vulnerable to injury. Surgical options vary based on the child's age, Delbet classification type, and degree of displacement. Anatomic reduction and surgical stabilization are indicated for most displaced hip fractures. Other options include smooth-wire or screw fixation, often supplemented by spica cast immobilization in younger children, or compression screw and side plate fixation. Achievement of fracture stability is more important than preservation of the proximal femoral physis. Capsular decompression after reduction and fixation may diminish the risk of osteonecrosis. Osteonecrosis, coxa vara, premature physeal closure of the proximal femur, and nonunion are complications that account for poor outcomes.

    • Keywords:
    • Child|Child

    • Preschool|Epiphyses|Fracture Fixation|Fracture Healing|Fractures

    • Spontaneous|Fractures

    • Ununited|Growth Plate|Hip Fractures|Humans|Joint Capsule|Joint Deformities

    • Acquired|Osteonecrosis|Postoperative Care|Surgical Wound Infection|Treatment Outcome

    • Subspecialty:
    • Trauma

    • Pediatric Orthopaedics

Necrotizing fasciitis.

Necrotizing fasciitis is a rare but life-threatening soft-tissue infection characterized by rapidly spreading inflammation and subsequent necrosis of the fascial planes and surrounding tissue. Infection typically follows trauma, although the inciting insult may be as minor as a scrape or an insect bite. Often caused by toxin-producing, virulent bacteria such as group A streptococcus and associated with severe systemic toxicity, necrotizing fasciitis is rapidly fatal unless diagnosed promptly and treated aggressively. Necrotizing fasciitis is often initially misdiagnosed as a more benign soft-tissue infection. The single most important variable influencing mortality is time to surgical débridement. Thus, a high degree of clinical suspicion is necessary to avert potentially disastrous consequences. Orthopaedic surgeons are often the first to evaluate patients with necrotizing fasciitis and as such must be aware of the presentation and management of this disease. Timely diagnosis, broad-spectrum antibiotic therapy, and aggressive surgical débridement of affected tissue are keys to the treatment of this serious, often life-threatening infection.

    • Keywords:
    • Anti-Bacterial Agents|Chemotherapy

    • Adjuvant|Debridement|Drug Therapy

    • Combination|Fasciitis

    • Necrotizing|Humans|Mortality|Postoperative Care|Risk Factors|Treatment Outcome

    • Subspecialty:
    • General Orthopaedics

Prevention of symptomatic pulmonary embolism in patients undergoing total hip or knee arthroplasty.

This clinical practice guideline is based on a systematic review of published studies on the management of adult patients undergoing total hip replacement (THR) or total knee replacement (TKR) aimed specifically at preventing symptomatic pulmonary embolism (PE). The guideline emphasizes the need to assess the patient's risk for both PE and postoperative bleeding. Mechanical prophylaxis and early mobilization are recommended for all patients. Chemoprophylactic agents were evaluated using a systematic literature review. Forty-two studies met eligibility criteria, of which 23 included patients who had TKR and 25 included patients who had THR. The following statements summarize the recommendations for chemoprophylaxis: Patients at standard risk of both PE and major bleeding should be considered for aspirin, low-molecular-weight heparin (LMWH), synthetic pentasaccharides, or warfarin with an international normalized ratio (INR) goal of < or =2.0. Patients at elevated (above standard) risk of PE and at standard risk of major bleeding should be considered for LMWH, synthetic pentasaccharides, or warfarin with an INR goal of < or =2.0. Patients at standard risk of PE and at elevated (above standard) risk of major bleeding should be considered for aspirin, warfarin with an INR goal of < or =2.0, or none. Patients at elevated (above standard) risk of both PE and major bleeding should be considered for aspirin, warfarin with an INR goal of < or =2.0, or none.

    • Keywords:
    • Anticoagulants|Arthroplasty

    • Replacement

    • Hip|Arthroplasty

    • Knee|Aspirin|Evidence-Based Medicine|Heparin

    • Low-Molecular-Weight|Humans|Inpatients|Intraoperative Care|Patient Discharge|Platelet Aggregation Inhibitors|Polysaccharides|Postoperative Care|Practice Guidelines as Topic|Preoperative Care|Prothrombin Time|Pulmonary Embolism|Review Literature as Topic|Risk Assessment|Warfarin

    • Subspecialty:
    • Adult Reconstruction