JAAOS, Volume 17, No. 9

Timing of fracture fixation in multitrauma patients: the role of early total care and damage control surgery.

The optimal timing of surgical stabilization of fractures in the multitrauma patient is controversial. There are advantages to early definitive surgery for most patients. Early temporary fixation using external fixators, followed by definitive fixation (ie, the damage control approach), may increase the chance for survival in a subset of patients with severe multisystem injuries. Improved understanding of the pathophysiology of trauma has led to a greater ability to identify patients who would benefit from damage control surgery. A patient is classified as physiologically stable, unstable, borderline, or in extremis. The stable patient can undergo fracture surgery as necessary. An unstable patient should be resuscitated and adequately stabilized before receiving definitive orthopaedic care. The decision whether to perform initial temporary or definitive fixation in the borderline patient is individualized based on the clinical condition. In patients presenting in extremis, life-saving measures are pivotal, followed by a damage control approach to their injuries.

    • Keywords:
    • Fracture Fixation|Humans|Multiple Trauma|Patient Care Planning|Patient Care Team|Time Factors|Trauma Severity Indices

    • Subspecialty:
    • Trauma

Use of all-pedicle-screw constructs in the treatment of adolescent idiopathic scoliosis.

All-pedicle-screw constructs are safe and biomechanically advantageous in the management of adolescent idiopathic scoliosis. Safe and reproducible placement of thoracic pedicle screws is dependent on a thorough understanding of normal and abnormal anatomy, meticulous technique, and the use of neuromonitoring and fluoroscopy. Improvement in the biomechanical properties secondary to the use of pedicle screw fixation has led to shorter fusions with improved deformity correction. Coronal, sagittal, and rotational correction is superior to that obtained with hook instrumentation. Improved derotation may decrease the need for thoracoplasty, thus eliminating the risk of associated morbidity. Superior control of the deformity with all-pedicle-screw fixation, as well as the use of adjunctive posterior releases, often obviates the need for an anterior approach, even in severe curves measuring 70 degrees to 100 degrees . Improved correction, shorter fusion, and the lower morbidity associated with posterior-only approaches may compensate for higher implant costs.

    • Keywords:
    • Adolescent|Biomechanics|Bone Screws|Cost-Benefit Analysis|Humans|Orthopedic Procedures|Outcome Assessment (Health Care)|Scoliosis

    • Subspecialty:
    • Pediatric Orthopaedics

    • Spine

    • Basic Science

Charcot neuroarthropathy of the foot and ankle.

Charcot neuroarthropathy is a common cause of morbidity in persons with diabetes mellitus and sensory neuropathy. Although Charcot neuroarthropathy is rare, it likely will become more prevalent in conjunction with increased incidence of diabetes mellitus. Prevention of disease progression remains the mainstay of treatment, with surgical intervention usually reserved for refractory cases. Late deformities are often complicated by chronic ulceration, infection, and osteomyelitis. The clinical presentation is best summarized with the Eichenholtz classification, and progression often follows a predictable pattern. Although Charcot neuroarthropathy is a clinical diagnosis, recent advances in diagnostic imaging have eased the clinical challenge of deciphering infection from Charcot changes. Advances in surgical treatment have demonstrated new options for limb salvage. Pharmacologic therapies directed toward decreasing bone resorption have also shown promise for treatment, but clinical application remains theoretical.

    • Keywords:
    • Ankle Joint|Arthropathy

    • Neurogenic|Casts

    • Surgical|Diabetes Complications|Foot Joints|Humans|Limb Salvage|Weight-Bearing

    • Subspecialty:
    • Foot and Ankle

Marfan syndrome.

Marfan syndrome is a variable autosomal dominant disorder; most cases result from mutations of fibrillin-1. Diagnosis is guided by the Ghent nosology. The condition may manifest in the cardiovascular and ocular systems. Musculoskeletal manifestations include scoliosis, dural ectasia, protrusio acetabuli, and ligamentous laxity. Compared with patients with idiopathic scoliosis, patients with Marfan syndrome tend to have scoliosis that progresses at a faster rate and is more resistant to bracing; undergo scoliosis surgery complicated by greater blood loss, pseudarthrosis, and additional curvature; and have more frequent occurrences of dural ectasia, which may cause headaches, leg pain, or perineal pain. Protrusio acetabuli may result in hip joint arthritis and may require valgus osteotomy or total hip arthroplasty.

    • Keywords:
    • Acetabulum|Cardiovascular Diseases|Eye Diseases|Humans|Marfan Syndrome|Microfilament Proteins|Mutation|Orthopedic Procedures|Scoliosis

    • Subspecialty:
    • General Orthopaedics

Treatment of osteoarthritis of the knee (nonarthroplasty).

The clinical practice guideline was explicitly developed to include only treatments less invasive than knee replacement (ie, arthroplasty). Patients with symptomatic osteoarthritis of the knee are to be encouraged to participate in self-management educational programs and to engage in self-care, as well as to lose weight and engage in exercise and quadriceps strengthening. The guideline recommends taping for short-term relief of pain as well as analgesics and intra-articular corticosteroids, but not glucosamine and/or chondroitin. Patients need not undergo needle lavage or arthroscopy with débridement or lavage. Patients may consider partial meniscectomy or loose body removal or realignment osteotomy, as conditions warrant. Use of a free-floating interpositional device should not be considered for symptomatic unicompartmental osteoarthritis of the knee. Lateral heel wedges should not be prescribed for patients with symptomatic medial compartmental osteoarthritis of the knee. The work group was unable either to recommend or not recommend the use of braces with either valgus- or varus-directing forces for patients with medial unicompartmental osteoarthritis; the use of acupuncture or of hyaluronic acid; or osteotomy of the tibial tubercle for isolated symptomatic patellofemoral osteoarthritis.

    • Keywords:
    • Adrenal Cortex Hormones|Analgesics|Humans|Osteoarthritis

    • Knee|Osteotomy|Resistance Training|Self Care|United States|Weight Loss

    • Subspecialty:
    • Adult Reconstruction