JAAOS, Volume 19, No. 5

Posttraumatic Stress Disorders in Civilian Orthopaedics

Posttraumatic stress disorder (PTSD) is a well-characterized anxiety disorder that may occur after exposure to a traumatic event. Research is ongoing to document neuroanatomic, neuroendocrine, and genetic correlates to the behavioral phenotype. PTSD occurs in 20% to 51% of patients with musculoskeletal injury. Orthopaedic outcomes, including return to work, activities of daily living, patient perception of physical recovery, and objective physical parameters, suffer considerably in patients with PTSD. There are several ways by which treating orthopaedic surgeons can recognize at-risk patients and help prevent the development of PTSD. Should prevention prove unsuccessful, effective treatment strategies exist, as well. Research is needed to investigate whether a correlation exists between successful management of the psychiatric manifestations of PTSD and improved physical outcomes.

      • Subspecialty:
      • Trauma

    Complications of Anterior Lumbar Surgery

    The incidence of anterior lumbar surgery is increasing. Although adverse events are uncommon, several have been described. Complications can be categorized based on the time of occurrence (ie, intraoperative, postoperative), patient positioning, surgical exposure, and spinal procedure. Notable approach-related complications involve vascular, visceral, and neural structures. Abdominal complications have been reported. Clinically significant complications related to spinal decompression and reconstruction consist primarily of neurologic injuries and graft- and device-related problems. The rate of complications is higher in the setting of revision anterior surgery than with initial anterior lumbar surgery. A thorough understanding of the complications associated with anterior lumbar surgery will aid in prevention, recognition, and management of these rare problems. The assistance of a vascular, neurologic, or general surgeon may be helpful in avoiding or effectively managing complications.

        • Subspecialty:
        • Spine

      Autografts Commonly Used in Anterior Cruciate Ligament Reconstruction

      Anterior cruciate ligament reconstruction is among the most common orthopaedic procedures in the United States, with >200,000 performed annually. Much has been published regarding the use of autograft versus allograft. Bonepatellar tendonbone is the most frequently used autograft, but hamstring and quadriceps tendon grafts are common alternatives. Each graft has distinct advantages and disadvantages, and selection is individualized. Fixation methods vary by graft type. Fixation resulting in a construct that is too rigid may restrict knee range of motion. Donor site morbidity must be considered, as well. Autograft harvest may result in anterior knee pain, kneeling pain, anterior knee numbness, muscle weakness, and patellar fracture. Appropriate graft selection is essential to optimize outcomes.

          • Subspecialty:
          • Sports Medicine

        Arthroscopic Management of the Stiff Elbow

        Elbow stiffness is a challenge to manage effectively. Elbow contractures commonly result from both intrinsic and extrinsic factors, causing limited motion. Recent technical advances in elbow arthroscopy have led to the development of minimally invasive procedures for the management of select cases of recalcitrant elbow stiffness. As with most arthroscopic procedures, a notable learning curve is associated with the safe, effective execution of these surgical techniques. Certain clinical scenarios require that special attention be paid to the ulnar nerve and the posterior bundle of the medial ulnar collateral ligament to improve motion safely. Arthroscopic capsular release of the elbow is effective for restoring a functional arc of motion in the short term in most patients with extrinsic contractures.

            • Subspecialty:
            • Shoulder and Elbow

          Surgical Management of the Problematic Hip in Adolescent and Young Adult Patients

          Surgical management of the problematic hip in adolescent and young adult patients can be challenging. In many of these patients, hip arthrosis and pain occur secondary to hip dysplasia associated with chronic instability, whether the result of prior treatment or chronic unmanaged acetabular dysplasia. Surgical techniques such as the Bernese periacetabular osteotomy are performed to correct acetabular deficiency, restore hip joint stability, and eliminate pain. Patients with previous Legg-Calv-Perthes disease or slipped capital femoral epiphysis frequently note onset of symptomatic hip arthrosis and pain in adolescence or young adulthood. Pain occurs secondary to pathologic impingement of the deformed proximal femur against the anterolateral acetabulum (ie, femoroacetabular impingement). The recent successful innovation of the transtrochanteric surgical hip dislocation approach provides complete access to the hip and offers the potential for comprehensive correction of both the often severe proximal femoral deformity and associated labral chondral disease secondary to Legg-Calv-Perthes disease and slipped capital femoral epiphysis. Restoration of more normal proximal femoral morphology results in marked improvement in functional outcome. Effective orthopaedic management requires an understanding of the mechanisms of hip disease as well as surgical expertise.

              • Subspecialty:
              • Pediatric Orthopaedics

            Collateral Ligament Injuries of the Thumb Metacarpophalangeal Joint

            The ulnar and radial collateral ligaments are primary stabilizers of the thumb metacarpophalangeal (MP) joint. Injury to these ligaments can lead to instability and disability. Stress testing is essential to establish the diagnosis. Complete tear is diagnosed on physical examination when the proximal phalanx of the thumb can be angulated ulnarly or radially on the metacarpal head by 30 to 35 with the MP joint in either zero degrees of extension or 30 of flexion. Lack of a firm end point or angulation measuring >15 on stress testing compared with the contralateral thumb MP joint are also indicative of complete tear. Partial ligament injuries may be managed nonsurgically, but complete tears are usually managed surgically. Various techniques are used to reattach the ligament to bone, including suture anchors and, less commonly, repair of midsubstance tears. Options for managing chronic injuries include ligament repair, ligament reconstruction with a free tendon graft, and arthrodesis of the MP joint.

                • Subspecialty:
                • Hand and Wrist

              Diagnosis and Treatment of Osteochondritis Dissecans

              This clinical practice guideline is based on a series of systematic reviews of published studies in the available literature on the diagnosis and treatment of osteochondritis dissecans of the knee. None of the 16 recommendations made by the work group is graded as strong; most are graded inconclusive; two are graded weak; and four are consensus statements. Both of the weak recommendations are related to imaging evaluation. For patients with knee symptoms, radiographs of the joint may be obtained to identify the lesion. For patients with radiographically apparent lesions, MRI may be used to further characterize the osteochondritis dissecans lesion or identify other knee pathology.

                  • Subspecialty:
                  • Sports Medicine