JAAOS, Volume 18, No. 2

Open tibial shaft fractures: II. Definitive management and limb salvage.

Definitive treatment of open fractures of the tibial diaphysis is challenging. The high-energy nature of these fractures, as well as the contamination of the fracture site and devitalization of the soft-tissue envelope, greatly increases the risk of infection, nonunion, and wound complications. The goals of definitive treatment include wound coverage or closure; prevention of infection; restoration of length, alignment, rotation, and stability; fracture healing; and return of function. Advances in orthobiologics, modern plastic surgical techniques, and fracture stabilization methods, most notably locked intramedullary nailing, have led to improved prognosis for functional recovery and limb salvage. Despite improved union and limb salvage rates, the prognosis for severe type III open fracture of the tibial shaft remains guarded, and outcomes are often determined by patient psychosocial variables.

    • Keywords:
    • Amputation|Animals|Bone Morphogenetic Proteins|Bone Plates|External Fixators|Fracture Fixation

    • Internal|Fracture Fixation

    • Intramedullary|Fracture Healing|Fractures

    • Open|Humans|Limb Salvage|Prognosis|Reconstructive Surgical Procedures|Tibial Fractures|Treatment Outcome

    • Subspecialty:
    • Trauma

Early management of ballistic hand trauma.

Complex hand wounds are an unfortunate consequence of conflict. Increased battlefield survival rates have resulted in an evolving range of ballistic hand trauma encountered by deployed surgical teams, requiring increased knowledge and understanding of these injuries. In the civilian setting, the combined threats of gun crime and acts of terrorism warrant appreciation for such injury among all surgeons. Surgeons often have to relearn the management of ballistic hand trauma and other aspects of war surgery under difficult circumstances because the experiences of their predecessors may be forgotten. Current evidence regarding these injuries is scarce. Ballistic hand trauma is rarely isolated. The demand on surgical resources from combat injury is significant, and it is imperative that a phased strategy be followed in this setting. Minimal, accurate débridement and decompression with early stability are crucial. Delayed primary closure and an awareness of future reconstructive options are fundamental.

    • Keywords:
    • Biomechanics|Decompression

    • Surgical|Forensic Ballistics|Hand Injuries|Humans|Reconstructive Surgical Procedures|Treatment Outcome|Wounds

    • Gunshot

    • Subspecialty:
    • Trauma

    • Hand and Wrist

Thoracolumbar spine trauma classification.

Thoracolumbar spine trauma is among the most common musculoskeletal injuries worldwide. However, there is little consensus on the adequate management of spine injury, in part because there is no widely accepted classification system. Several systems have been developed based on injury anatomy or inferred mechanisms of action, but they have demonstrated poor reliability, have yielded little prognostic information, and have not been widely used. The Thoracolumbar Injury Classification and Severity Score (TLICS) was developed to address these limitations. The TLICS defines injury based on three clinical characteristics: injury morphology, integrity of the posterior ligamentous complex, and neurologic status of the patient. The severity score offers prognostic information and is helpful in medical decision making. Initial application of the TLICS has shown good to excellent reliability and validity. Additional evaluation of the TLICS is needed to prospectively define its clinical utility and identify potential limitations.

    • Keywords:
    • Adolescent|Adult|Female|Humans|Ligaments

    • Articular|Lumbar Vertebrae|Male|Middle Aged|Prognosis|Reproducibility of Results|Severity of Illness Index|Spinal Fractures|Thoracic Vertebrae|Tomography

    • X-Ray Computed

    • Subspecialty:
    • Trauma

    • Spine

Challenges with health-related quality of life assessment in arthroplasty patients: problems and solutions.

Assessment of health-related quality of life (HRQOL) using patient-reported outcomes in arthroplasty has become popular because it provides a unique perspective on successful elective procedures. However, challenges exist in the assessment of HRQOL in clinical practice and in clinical research. Patient compliance with multiple and sometimes lengthy HRQOL assessments administered at multiple follow-up visits is problematic. Many well-validated HRQOL instruments are available, and progress has been made in defining the minimal clinically important difference in hip and knee arthroplasty that denotes the minimal change perceived to be important by patients. Challenges in understanding the literature are attributable to the use of various HRQOL scales, with different scoring ranges and scoring algorithms, different interpretations of highest score, and differences in the presentation of raw versus transformed scores.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Hip|Arthroplasty

    • Knee|Health Status|Health Status Indicators|Humans|Outcome and Process Assessment (Health Care)|Quality of Life

    • Subspecialty:
    • Adult Reconstruction

    • Clinical Practice Improvement

Single-row versus double-row rotator cuff repair: techniques and outcomes.

Double-row rotator cuff repair techniques incorporate a medial and lateral row of suture anchors in the repair configuration. Biomechanical studies of double-row repair have shown increased load to failure, improved contact areas and pressures, and decreased gap formation at the healing enthesis, findings that have provided impetus for clinical studies comparing single-row with double-row repair. Clinical studies, however, have not yet demonstrated a substantial improvement over single-row repair with regard to either the degree of structural healing or functional outcomes. Although double-row repair may provide an improved mechanical environment for the healing enthesis, several confounding variables have complicated attempts to establish a definitive relationship with improved rates of healing. Appropriately powered rigorous level I studies that directly compare single-row with double-row techniques in matched tear patterns are necessary to further address these questions. These studies are needed to justify the potentially increased implant costs and surgical times associated with double-row rotator cuff repair.

    • Keywords:
    • Arthroscopy|Biomechanics|Equipment Failure Analysis|Finite Element Analysis|Humans|Materials Testing|Rotator Cuff|Rupture|Suture Anchors|Treatment Outcome|Wound Healing

    • Subspecialty:
    • Sports Medicine

    • Shoulder and Elbow

Ewing sarcoma family of tumors.

The Ewing sarcoma family of tumors (ESFT) consists of a group of tumors characterized by morphologically similar round-cell neoplasm and by the presence of a common chromosomal translocation. Although rare, such tumors constitute the third most frequent primary sarcoma of bone after osteosarcoma and chondrosarcoma. ESFT most commonly affects young children and adolescents. Because most patients with clinically apparent localized disease at diagnosis may also have occult metastatic (ie, systemic) disease, multidrug chemotherapy as well as local disease control with surgery and/or radiation therapy are indicated for all patients. Despite marked improvements in survival during the past 40 years for patients with localized disease, lesser improvements have been seen in patients with metastatic or recurrent disease. A better understanding of the complex biology of ESFT may lead to the successful development of biologically targeted therapies. As the regulatory pathways responsible for transformation, growth, and metastasis of ESFT become more refined, the number of potential therapeutic targets will expand.

    • Keywords:
    • Algorithms|Bone Neoplasms|Combined Modality Therapy|Humans|Neoplasm Recurrence

    • Local|Neoplasm Staging|Neoplasms

    • Second Primary|Prognosis|Sarcoma

    • Ewings|Translocation

    • Genetic

    • Subspecialty:
    • Musculoskeletal Oncology

    • Pediatric Orthopaedics