JAAOS, Volume 21, No. 4

Meniscal Repair

Historically, treatment of meniscus tears consisted of complete meniscectomy. Over the past few decades, however, the long-term morbidities of meniscal removal, namely the early development of knee osteoarthritis, have become apparent. Thus, management of meniscal tears has trended toward meniscal preservation. Recent technological advances have made repairs of the meniscus easier and stronger. In addition, adjunctive therapies used to enhance the healing process have advanced greatly in the past few years. Today, with increased understanding of the impact of meniscal loss and the principles of meniscal repair and healing, meniscal preservation is viewed as an increasingly realistic and important goal in the management of meniscus tears.

      • Subspecialty:
      • Sports Medicine

    Snapping Scapula Syndrome: Diagnosis and Management

    Scapulothoracic bursitis and snapping scapula syndrome are rare diagnoses that contribute to considerable morbidity in some patients. These conditions represent a spectrum of disorders characterized by pain with or without mechanical crepitus. They are commonly identified in young, active patients who perform repetitive overhead activities. Causes include anatomic scapular or thoracic variations, muscle abnormalities, and bony or soft-tissue masses. Three-dimensional CT and MRI aid in detecting these abnormalities. Nonsurgical therapy is the initial treatment of choice but is less successful than surgical management in patients with anatomic abnormalities. In many cases, scapular stabilization, postural exercises, or injections eliminate symptoms. When nonsurgical treatment fails, open and endoscopic techniques have been used with satisfactory results. Familiarity with the neuroanatomic structures surrounding the scapula is critical to avoid iatrogenic complications. Although reported outcomes of both open and endoscopic scapulothoracic decompression are encouraging, satisfactory outcomes have not been universally achieved.

        • Subspecialty:
        • Shoulder and Elbow

      Chondroblastoma and Chondromyxoid Fibroma

      Chondroblastoma and chondromyxoid fibroma are benign but locally aggressive bone tumors. Chondroblastoma, a destructive lesion with a thin radiodense border, is usually seen in the epiphysis of long bones. Chondromyxoid fibroma presents as a bigger, lucent, loculated lesion with a sharp sclerotic margin in the metaphysis of long bones. Although uncommon, these tumors can be challenging to manage. They share similarities in pathology that could be related to their histogenic similarity. Very rarely, chondroblastoma may lead to lung metastases; however, the mechanism is not well understood.

          • Subspecialty:
          • Musculoskeletal Oncology

        Pediatric Physeal Ankle Fracture

        Ankle fracture is the second most common fracture type in children, and physeal injury is a particular concern. Growing children have open physes that are relatively weak compared with surrounding bone and ligaments, and traumatic injuries can cause physeal damage and fracture. Tenderness to palpation over the physis can aid in the clinical diagnosis of ankle fracture. Swelling, bruising, and deformity may be identified, as well. Plain radiographs are excellent for initial evaluation, but CT may be required to determine displacement and to aid in surgical planning, particularly in the setting of intra-articular fractures. The Salter-Harris classification is the most widely used system to determine appropriate management and assess long-term prognosis. Complications of physeal injury include shortening and/or angular deformity. Tillaux and triplane fractures occur in the 18-month transitional period preceding physeal closure, which typically occurs at age 14 years in girls and age 16 years in boys. Management is determined by the amount of growth remaining, with the intent of maintaining optimum function while limiting the risk of physeal damage and joint incongruity.

            • Subspecialty:
            • Pediatric Orthopaedics

            • Foot and Ankle

          Understanding Systematic Reviews and Meta-analyses in Orthopaedics

          The systematic literature review is a powerful tool for summarizing and evaluating current knowledge related to a specific research question. Systematic reviews have many advantages over traditional narrative reviews. A meta-analysis of data from a systematic review can provide a better estimate of a treatment effect than can individual studies. To ensure quality conclusions, rigorous methods must be applied to systematic reviews, such as formulation of a specific research question, systematic literature search, selection and assessment of included studies, data extraction, quality assessment of included studies, meta-analysis and presentation of results, and formation of conclusions. Threats to the internal validity and generalizability of the conclusions of systematic reviews include lack of clarity or appropriateness of the research question, poor quality of the included studies, heterogeneity of results between studies, inappropriate conclusions, and inappropriate application in clinical practice.

              • Subspecialty:
              • Basic Science