JAAOS, Volume 18, No. 8

Because of advances in the treatment of cancer, the average rateof patient survival is increasing. As patients with cancer live longer,the incidence of spinal metastasis also likely will increase. To helpcontrol pain and maintain function, some of these metastases willrequire surgical intervention. Because>60% of spinal metastases arehypervascular, preoperative embolization may be considered in orderto decrease hemorrhage risk and improve outcomes. Embolization forspinal metastasis can be performed through the angiogram catheter.When such embolization is performed carefully, the complication rateis low.

Randomized clinical trials (RCTs) generally provide the highestquality and least biased evidence for treatment effectiveness. Relativelyfew high-quality RCTs have been published in the orthopaedic literature.Barriers to increasing the quantity of trials include the orthopaedicculture, patient preferences, and the availability of treatment outsidetrials. Challenges to conducting better quality trials include samplesize, random allocation, and blinding. Undertaking more high-qualitytrials can improve the evidence available for determining treatmenteffectiveness, resulting in better patient care.

Surgical and nonsurgical management of upper extremity disordersbenefits from the collaboration of a therapist, the treating physician,and the patient. Hand therapy plays a role in many aspects of treatment,and patients with upper extremity injuries may spend considerablymore time with a therapist than with a surgeon. Hand therapists coordinateedema control; pain management; minimization of joint contractures;maximization of tendon gliding, strengthening, and work hardening;counseling; and ongoing diagnostic evaluation. Modalities used tomanage hand injuries include ultrasound, splinting, Fluidotherapy(Chattanooga Group, Chattanooga, TN), cryotherapy, various electricalmodalities, phonophoresis, and iontophoresis.

Metatarsalgia (ie, metatarsal pain) is one of the most common reportsin patients with foot problems. This pain is confined to the areaacross the plantar forefoot, including the second through fourth metatarsalheads. However, it is frequently accompanied by deformity of the firstand fifth rays as well as of the toes. There is great variabilityin possible causative factors, but all of them seem to be relatedto gait mechanics, foot anatomy, and foot and ankle deformity. Anindividualized treatment protocol is required. Nonsurgical managementis usually sufficient to achieve satisfactory results. Surgical correctionmust be precise, and all pain-producing deformities must be corrected.Most patients present with abnormalities of the distal metatarsals.Metatarsal osteotomy, long a staple of treatment, always fails inthe long term. Improved equipment and internal fixation methods maylead to better long-term outcomes.

The Ponseti method for the management of idiopathic clubfoot hasrecently experienced a rise in popularity, with several centers reportingexcellent outcomes. The challenge in achieving a successful outcomewith this method lies not in correcting deformity but in preventingrelapse. The most common cause of relapse is failure to adhere tothe prescribed postcorrective bracing regimen. Socioeconomic status,cultural factors, and physician-parent communication may influenceparental compliance with bracing. New, more user-friendly braces havebeen introduced in the hope of improving the rate of compliance. Strategiesthat may be helpful in promoting adherence include educating the familyat the outset about the importance of bracing, encouraging calls andvisits to discuss problems, providing clear written instructions,avoiding or promptly addressing skin problems, and refraining fromcriticism of the family when noncompliance is evident. A strong physician-familypartnership and consideration of underlying cognitive, socioeconomic,and cultural issues may lead to improved adherence to postcorrectivebracing protocols and better patient outcomes.

Spinal epidural hematoma is a rare condition that usually presentswith acute, severe pain at the location of the hemorrhage, with radiationto the extremities. It can rapidly develop to include progressiveand severe neurologic deficit. The pathophysiology often remains unclear.However, epidural hematoma in the lumbar spine is best described asthe result of internal rupture of the Batson vertebral venous plexus.Clinical evaluation of pain control and neurologic deficit is themost important tool in early diagnosis. Currently, MRI is the diagnosticmethod of choice. Regardless of the setting, symptomatic spinal epiduralhematoma is typically managed with urgent surgical decompression ofthe spinal canal.

This clinical practice guideline is based on a series of systematicreviews of published studies in the available literature on the diagnosisand treatment of acute Achilles tendon rupture. None of the 16 recommendationsmade by the work group was graded as strong; most are graded inconclusive;four are graded weak; two are graded as moderate strength; and twoare consensus statements. The two moderate-strength recommendationsinclude the suggestions for early postoperative protective weightbearing and for the use of protective devices that allow for postoperativemobilization.