JAAOS, Volume 2, No. 6

Tibial Plafond Fractures: Changing Principles of Treatment.

Tibial plafond fractures from axial loading are high-energy injuries with significant associated soft-tissue damage. New classification methods include detailed anatomic subgroupings and highlight the soft-tissue injury. The traditional treatment of this intra-articular fracture with open reduction and internal fixation resulted in high rates of wound breakdown and infection. Treatment of these complications is lengthy and costly and not infrequently results in a poor outcome. Newer techniques using external fixation minimize disturbance of the soft-tissue envelope and have decreased these complications. Because the long-term outcome with all techniques is variable and often depends on factors beyond the surgeon's control, it is particularly important to avoid complications of initial treatment. Longer follow-up will determine whether patients treated with these techniques have a different rate of arthrosis.

      • Subspecialty:
      • Trauma

    Radiolucent Lesions of the Extremities.

    There are numerous conditions that produce a radiolucent lesion in a bone. Many of these are benign and of little consequence and need only occasional observation, as they usually heal spontaneously. A few are benign but do not heal spontaneously and require a limited operation. Others are malignant and must be removed surgically or irradiated. The physician evaluating the radiolucent lesion must be able to distinguish lesions that should be observed from those that should be further evaluated or treated. It is unnecessary to evaluate every radiolucent lesion as if it were a malignant tumor. With an understanding of the potential lesions and how they present, it is possible to construct an algorithm that can be used to organize an efficient and appropriate evaluation.

        • Subspecialty:
        • Musculoskeletal Oncology

      Thoracic Outlet Syndrome.

      The manifestations of thoracic outlet syndrome vary according to which of the neurovascular structures are affected. To provide optimal treatment, the pathogenesis must be understood in terms of both the anatomic variants and the dynamic factors. The diagnosis is primarily clinical, although ancillary diagnostic studies are useful in selected patients. Following a careful examination, the orthopaedic surgeon should be able to initiate a program of appropriate therapy depending on the nature and severity of the clinical manifestations. Initial treatment is oriented toward postural reeducation and periscapular muscle strengthening. Glenohumeral instabilities and painful upper-limb conditions that cause disuse atrophy must be addressed. Operative treatment is reserved for patients in whom a conservative program has failed and for those with significant neural or vascular deficits. The surgeon must be cognizant of the potential complications of the various procedures used to correct thoracic outlet syndrome. Proper selection of surgical candidates should produce significant improvement in most patients.

          • Subspecialty:
          • Shoulder and Elbow

          • Pain Management

        Rheumatoid Arthritis of the Foot and Ankle.

        Rheumatoid arthritis of the foot and ankle can be a debilitating problem, particularly for patients who have undergone successful hip or knee arthroplasty. Optimal medical management, use of orthotic devices, and surgical intervention are essential components of patient care. Forefoot involvement with hallux valgus and lesser metatarsophalangeal joint subluxation and dislocation are the most common findings. Reconstruction usually requires lesser metatarsophalangeal joint excisional arthroplasty and first metatarsophalangeal joint arthrodesis. Midfoot tarsometatarsal and intertarsal involvement is treated with orthotic devices and intertarsal fusion for advanced arthropathy. Hindfoot involvement frequently leads to pes planovalgus deformity, which may require isolated talonavicular arthrodesis if treated early or triple arthrodesis for advanced destruction. Ankle involvement is less frequent; when it is unresponsive to conservative measures, ankle symptoms may be improved by arthrodesis. Although great advances have been made in medical and surgical management of rheumatoid arthritis, the disease remains a serious problem. Through prudent use of medical management, orthotic devices, and other conservative measures as well as surgical intervention, long-term function can be enhanced greatly.

            • Subspecialty:
            • Trauma

            • Foot and Ankle

          Pediatric Hematogenous Osteomyelitis: New Trends in Presentation, Diagnosis, and Treatment.

          The character of acute hematogenous osteomyelitis (AHO) in North American children has changed significantly during the past several decades. Although the typical clinical picture of established acute osteomyelitis in children (illness, dehydration, and an acutely painful limb) is still seen, more subtle presentations appear more frequently. Children often present with subacute osteomyelitis. Less common variants include Brodie's abscess, subacute epiphyseal osteomyelitis, and chronic recurrent multifocal osteomyelitis. Some patients present with a bone lesion that may be confused with other disease entities, including neoplasms. Biopsy is often needed to clarify the diagnosis. With the trend toward more invasive procedures in the neonatal intensive care unit, neonatal osteomyelitis is also seen more frequently. Advances in imaging technology, particularly improvements in technetium bone scanning and the advent of magnetic resonance imaging, have contributed to more precise diagnosis and better management of AHO. With the increased concern about medical economics, the recent trend toward decreasing the duration of intravenous antibiotic treatment of these infections appears to be appropriate as long as certain criteria are met. Neither surgery nor antibiotics alone will be associated with successful treatment in all cases, and this fact may explain the rare but continued morbidity that is still seen in children with AHO.

              • Subspecialty:
              • Pediatric Orthopaedics

            Lower-Extremity Local Flaps.

            Some soft-tissue defects of the lower extremities can be covered reliably with local flaps. Five such flaps--the tensor fascia lata, gastrocnemius, soleus, posterior tibial artery fasciocutaneous, and dorsalis pedis flaps--are described. If the indications for each flap are understood and the vascular pedicle is carefully preserved, these flaps can be used to provide relatively simple and reliable coverage of selected soft-tissue defects on the lower extremities. However, the indications must not be overextended in an attempt to avoid a free-tissue transfer. The gastrocnemius flap is most often used. It reliably covers common defects about the knee and the proximal tibia. A skin graft is required for the gastrocnemius flap, as well as the soleus flap, which covers the midportion of the tibia. The soleus requires deeper dissection of the calf for elevation. The tensor fascia lata flap and the more recently described posterior tibial artery fasciocutaneous flap are relatively easy to raise, but there are fewer orthopaedic indications for their use. The dorsalis pedis cutaneous flap is technically more demanding, but it can be used to cover difficult defects around the ankle.

                • Subspecialty:
                • General Orthopaedics