JAAOS, Volume 19, No. 2

Enhancement of Bone Formation During Distraction Osteogenesis: Pediatric Applications

Delayed bone healing during distraction osteogenesis negatively affects clinical outcome. In addition to autologous bone grafting, several mechanical, chemical, biologic, and external treatment modalities may be employed to promote bone growth during distraction osteogenesis in the pediatric patient. Mechanical approaches include compressive loading of the distraction regenerate, increased frequency of small increments of distraction, and compression-distraction. Intramedullary nailing and submuscular plating can reduce the time in external fixation; however, these techniques are associated with technical difficulties and complications. Exogenous application of low-intensity pulsed ultrasound or pulsed electromagnetic fields may shorten the duration of external fixation. Other promising modalities include diphosphonates, physician-directed use (off-label use) of bone morphogenetic proteins, and local injection of bone marrow aspirate and platelet gel at the osteotomy site. Well-designed clinical studies are needed to establish safe and effective guidelines for various modalities to enhance new bone formation during distraction osteogenesis in children.

      • Subspecialty:
      • Pediatric Orthopaedics

    Bone Grafting in Surgery About the Foot and Ankle: Indications and Techniques

    Bone grafting is a common procedure in foot and ankle surgery. Historically, autogenous bone graft has most often been harvested from the ipsilateral iliac crest. However, other sites offer similar volumes of cancellous bone and are associated with fewer complications. The ipsilateral proximal tibia, distal tibia, and calcaneus provide adequate amounts of bone graft material for most arthrodesis procedures about the foot and ankle. Emerging techniques have enabled the development of a seemingly unlimited supply of alternative bone graft materials with osteoconductive properties. The osteoprogenitor cells in bone marrow aspirates can be concentrated by use of selective retention systems. These aspirate-matrix composites may be combined with allograft preparations, resulting in a product that promotes osteoconduction, osteoinduction, and osteogenesis with limited morbidity.

        • Subspecialty:
        • Foot and Ankle

      Posterior Fixation of the Upper Cervical Spine: Contemporary Techniques

      Instrumentation in the upper cervical spine has changed considerably in the past two decades. Previous stand-alone wiring techniques have been made largely obsolete with the development of occipital segmental plating, transarticular screws, and C1 lateral mass screws, as well as a myriad of C2 fixation options, including pedicle, pars, and translaminar screws. Polyaxial screws and segmental fixation are more user-friendly than stand-alone wiring and provide a stronger construct. Awareness of the risks and benefits associated with the use of modern instrumentation and thorough familiarity with the anatomy of the upper cervical spine are essential to avoid complications and optimize outcomes.

          • Subspecialty:
          • Spine

        Success in Orthopaedic Training: Resident Selection and Predictors of Quality Performance

        Multiple studies have attempted to determine which attributes are predictive of success during residency as well as the optimal method of selecting residents who possess these attributes. Factors that are consistently ranked as being important in the selection of candidates into orthopaedic residency programs include performance during orthopaedic rotation, United States Medical Licensing Examination (USMLE) Step 1 score, Alpha Omega Alpha Honor Medical Society membership, medical school class rank, interview performance, and letters of recommendation. No consensus exists regarding the best predictors of resident success, but trends do exist. High USMLE Step 1 scores have been shown to correlate with high Orthopaedic In-Training Examination scores and improved surgical skill ratings during residency, whereas higher numbers of medical school clinical honors grades have been correlated to higher overall resident performance, higher residency interpersonal skills grading, higher resident knowledge grading, and higher surgical skills evaluations. Successful resident performance can be measured by evaluating psychomotor abilities, cognitive skills, and affective domain.

            • Subspecialty:
            • Clinical Practice Improvement

          Reconstruction of Soft-tissue Injury Associated With Lower Extremity Fracture

          Soft-tissue loss associated with lower extremity fracture poses a substantial reconstructive challenge. Following stabilization of life-threatening conditions and bony disruptions, the reconstructive team must address the soft-tissue envelope of the limb. The wound is managed with dbridement followed by coverage. Coverage options range from basic to complex and include delayed primary closure, healing by secondary intention, skin grafting, local flap coverage, and distant tissue transfer. The choice of soft-tissue coverage method is based on its ability to provide an environment conducive to fracture healing. Understanding the merits and disadvantages of each reconstructive option helps to avoid undertreatment or overtreatment.

              • Subspecialty:
              • Trauma

            Lyme Disease and the Orthopaedic Implications of Lyme Arthritis

            Lyme disease is the most common tick-borne disease in the United States and Europe. Increased awareness of the clinical manifestations of the disease is needed to improve detection and treatment. In the acute and late stages, Lyme disease may be difficult to distinguish from other disease processes. The epidemiology and pathophysiology of Lyme disease are directly related to the Borrelia burgdorferi spirochete and its effects on the integumentary, neurologic, cardiac, and musculoskeletal systems. Lyme arthritis is a common clinical manifestation of Lyme disease and should be considered in the evaluation of patients with monoarticular or pauciarticular joint complaints in a geographic area in which Lyme disease is endemic. Management of Lyme arthritis involves eradication of the spirochete with antibiotics. Generally, the prognosis is excellent. Arthroscopic synovectomy is reserved for refractory cases that do not respond to antibiotics.

                • Subspecialty:
                • General Orthopaedics