JAAOS, Volume 20, No. 3

Vitamin D in Orthopaedics

Vitamin D is an important component in musculoskeletal development, maintenance, and function. Adequate levels of vitamin D correlate with greater bone mineral density, lower rates of osteoporotic fractures, and improved neuromuscular function. Debate exists about both adequate levels required and intake requirements needed to prevent deficiency of vitamin D. Epidemiologic data have identified an increasing number of orthopaedic patients at risk for vitamin D deficiency, with potentially widespread consequences for bone healing, risk of fracture, and neuromuscular function.

      • Subspecialty:
      • Basic Science

    Management of Scapular Fractures

    With the exception of displaced articular glenoid fractures, management of scapular fractures has largely consisted of benign neglect, with an emphasis on motion as allowed by the patient's pain. Better understanding of this injury has resulted in greater acceptance of surgical management of highly displaced variants. However, little agreement exists on indications for surgery, and there is no clear comparative evidence on outcomes for surgically versus nonsurgically managed fractures. Scapular fractures are the result of high-energy mechanisms of injury, and they often occur in conjunction with other traumatic injuries. In addition to performing meticulous physical and neurologic examination, the surgeon should obtain plain radiographs, including AP shoulder, axillary, and scapular Y views. Three-dimensional CT is used to determine accurate measurements in surgical candidates. Surgical approach, technique, and timing are individualized based on fracture type and other patient-related factors.

        • Subspecialty:
        • Shoulder and Elbow

      Induced Membrane Technique for Reconstruction To Manage Bone Loss

      Multiple surgeries are often required to manage segmental bone loss because of the complex mechanics and biology involved in reconstruction. These procedures can lead to prolonged recovery times, poor patient outcomes, and even delayed amputation. A two-stage technique uses induced biologic membranes with delayed placement of bone graft to manage this clinical challenge. In the first stage, a polymethyl methacrylate spacer is placed in the defect to produce a bioactive membrane, which appears to mature biochemically and physically 4 to 8 weeks after spacer placement. In the second, cancellous autograft is placed within this membrane and, via elution of several growth factors, the membrane appears to prevent graft resorption and promote revascularization and consolidation of new bone. Excellent clinical results have been reported, with successful reconstruction of segmental bone defects >20 cm.

          • Subspecialty:
          • Trauma

        Radionuclide Imaging in the Diagnosis and Management of Orthopaedic Disease

        Nuclear medicine imaging is often used in the diagnosis and management of several orthopaedic conditions. Bone scintigraphy measures gamma ray emission to detect the distribution of an injected radiolabeled tracer on multiple image projections. In general, this imaging modality has relatively high sensitivity but low specificity in the diagnosis of occult fractures, bone tumors, metabolic bone disease, and infection. Positron emission tomography measures tissue metabolism and perfusion by detecting short half-life positron ray emission of an injected radiopharmaceutical tracer. Historically, positron emission tomography has been used only to monitor bone metastasis and aid in the diagnosis of osteomyelitis; however, this technology has recently been applied to other orthopaedic conditions for which current imaging modalities are insufficient.

            • Subspecialty:
            • Musculoskeletal Oncology

          The Impact of the Spine Patient Outcomes Research Trial (SPORT) Results on Orthopaedic Practice

          The benefits of spinal surgery for relief of low back and leg pain in patients with degenerative spinal disorders have long been debated. The Spine Patient Outcomes Research Trial (SPORT) was designed to address the need for high-quality, prospectively collected data in support of such interventions. SPORT was intended to provide an evidential basis for spinal surgery in appropriate patients, as well as comparative and cost-effectiveness data. The trial studied the outcomes of the surgical and nonsurgical management of three conditions: intervertebral disk herniation, degenerative spondylolisthesis, and lumbar spinal stenosis. Both surgical and nonsurgical care of intervertebral disk herniation resulted in significant improvement in symptoms of low back and leg pain. Still, the treatment effect of surgery for intervertebral disk herniation was less than that seen in patients who underwent surgical versus nonsurgical treatment of degenerative spondylolisthesis and lumbar spinal stenosis. Across SPORT, more significant degrees of improvement with surgery were noted in chronic conditions of lumbar spinal stenosis and lumbar spinal stenosis with spondylolisthesis. In addition, no catastrophic progressions to neurologic deficit occurred as a result of watchful waiting.

              • Subspecialty:
              • Spine

            Stress Fractures About the Tibia, Foot, and Ankle

            In competitive athletes, stress fractures of the tibia, foot, and ankle are common and lead to considerable delay in return to play. Factors such as bone vascularity, training regimen, and equipment can increase the risk of stress fracture. Management is based on the fracture site. In some athletes, metabolic workup and medication are warranted. High-risk fractures, including those of the anterior tibial diaphysis, navicular, proximal fifth metatarsal, and medial malleolus, present management challenges and may require surgery, especially in high-level athletes who need to return to play quickly. Noninvasive treatment modalities such as pulsed ultrasound and extracorporeal shock wave therapy may have some benefit but require additional research.

                • Subspecialty:
                • Foot and Ankle

              Sprengel Deformity: Pathogenesis and Management

              Sprengel deformity (ie, congenital elevation of the scapula) is a rare clinical entity. However, it is the most common congenital anomaly of the shoulder. Sprengel deformity is caused by abnormal descent of the scapula during embryonic development. Sprengel deformity is associated with cosmetic deformity and decreased shoulder function. Diagnostic confusion with limited scoliosis can be dangerous to the patient because it may delay proper treatment of other abnormalities that may be present with even mild cases. Sprengel deformity is commonly linked to a variety of conditions, including Klippel-Feil syndrome, scoliosis, and rib anomalies. Nonsurgical management can be considered for mild cases. Surgical management is typically warranted for more severe cases, with the goal of improving cosmesis and function. Surgical techniques are centered on resection of the protruding portion of the scapula and inferior translation of the scapula. Recent long-term studies indicate that patients treated surgically maintain improved shoulder function and appearance.

                  • Subspecialty:
                  • Pediatric Orthopaedics