JAAOS, Volume 22, No. 7

Motorized Intramedullary Nail for Management of Limb-length Discrepancy and Deformity

Distraction osteogenesis has been used for more than 50 years to address limb-length discrepancy and deformity. Intramedullary fixation has been used in conjunction with external fixation to decrease the time in the external fixator and prevent deformity and refracture. A new generation of motorized intramedullary nails is now available to treat limb-length discrepancy and deformity. These nails provide bone fragment stabilization and lengthening with reliable remote-controlled mechanisms, obviating the need for external fixation. Motorized intramedullary nails allow accurate, well-controlled distraction, and early clinical results have been positive.

      • Subspecialty:
      • Trauma

    Complications of Shoulder Arthroscopy

    Over the past 20 to 30 years, arthroscopic shoulder techniques have become increasingly popular. Although these techniques have several advantages over open surgery, surgical complications are no less prevalent or devastating than those associated with open techniques. Some of the complications associated with arthroscopic shoulder surgery include recurrent instability, soft-tissue injury, and neurapraxia. These complications can be minimized with thoughtful consideration of the surgical indications, careful patient selection and positioning, and a thorough knowledge of the shoulder anatomy. Deep infection following arthroscopic shoulder surgery is rare; however, the shoulder is particularly susceptible to Propionibacterium acnes infection, which is mildly virulent and has a benign presentation. The surgeon must maintain a high index of suspicion for this infection. Thromboemoblic complications associated with arthroscopic shoulder techniques are also rare, and studies have shown that pharmacologic prophylaxis has minimal efficacy in preventing these complications. Because high-quality studies on the subject are lacking, minimal evidence is available to suggest strategies for prevention.

        • Subspecialty:
        • Shoulder and Elbow

      Surgical Treatment for Ossification of the Posterior Longitudinal Ligament in the Cervical Spine

      Although classically associated with patients of East Asian origin, ossification of the posterior longitudinal ligament (OPLL) may cause myelopathy in patients of any ethnic origin. Degeneration of the PLL is followed by endochondral ossification, resulting in spinal cord compression. Specific genetic polymorphisms and medical comorbidities have been implicated in the development of OPLL. Patients should be evaluated with a full history and neurologic examination, along with cervical radiographs. Advanced imaging with CT and MRI allows three-dimensional evaluation of OPLL. Minimally symptomatic patients can be treated nonsurgically, but patients with myelopathy or severe stenosis are best treated with surgical decompression. OPLL can be treated via an anterior (ie, corpectomy and fusion) or posterior (ie, laminectomy and fusion or laminoplasty) approach, or both. The optimal approach is dictated by the classification and extent of OPLL, cervical spine sagittal alignment, severity of stenosis, and history of previous surgery. Anterior surgery is associated with superior outcomes when OPLL occupies >50% to 60% of the canal, despite increased technical difficulty and higher complication rates. Posterior surgery is technically easier and allows decompression of the entire cervical spine, but patients may experience late deterioration because of disease progression.

          • Subspecialty:
          • Spine

        The Role of Activity Level in Orthopaedics: An Important Prognostic and Outcome Variable

        A patient's activity level is increasingly recognized as an important factor that can influence orthopaedic outcomes. Validated, reliable activity measurement tools now exist for the shoulder, hip, knee, and ankle. These tools can be directly applied as outcome measures that determine whether interventions restored function. It is now evident that activity level is a powerful prognostic factor for outcomes in orthopaedic procedures such as anterior cruciate ligament reconstruction, articular cartilage repair, and total joint arthroplasty. Yet despite the recent increase in studies that have made use of quantitative, joint-specific activity scales, much room remains for further understanding of the exact role of activity level in the progression, treatment, and patient perception of musculoskeletal disorders, particularly in the shoulder and ankle, as well as in pediatric patients.

            • Subspecialty:
            • Sports Medicine

          Management of Adult Diaphyseal Both-bone Forearm Fractures

          Simultaneous diaphyseal fractures of the radius and ulna, often referred to as both-bone forearm fractures, are frequently encountered by orthopaedic surgeons. Adults with this injury are typically treated with open reduction and internal fixation because of the propensity for malunion of the radius and ulna and the resulting loss of forearm rotation. Large case series support the use of plate and screw fixation for simple fractures. More complex fractures are managed according to strain theory, with the intention of controlling rather than eliminating motion at the fracture site. This can be achieved with flexible plate and screw constructs or intramedullary nails. In general, results of surgical fixation have been good, with only modest losses of forearm strength and rotation. Notable complications include nonunion, malunion, and refracture after device removal.

              • Subspecialty:
              • Hand and Wrist

            The Integration of Radiosurgery for the Treatment of Patients With Metastatic Spine Diseases

            Significant evidence emerging in the spinal oncology literature recommends radiosurgery as a primary modality of treatment of spinal metastasis. Improvements in the methods of delivering radiation have increased the ability to provide a higher and more exacting dose of radiation to a tumor bed than previously. Using treatment-planning software, radiation is contoured around a specific lesion with the intent of administering a tumoricidal dose. Combined with a minimally invasive, tumor-load reducing surgery, this advanced form of radiation therapy can provide better local control of the tumor compared with conventional external beam radiation.

                • Subspecialty:
                • Musculoskeletal Oncology

              Osteonecrosis of the Femoral Head: Evaluation and Treatment

              Osteonecrosis of the femoral head may lead to progressive destruction of the hip joint. Although the etiology of osteonecrosis has not been definitely delineated, risk factors include corticosteroid use, alcohol consumption, trauma, and coagulation abnormalities. Size and location of the lesion are prognostic factors for disease progression and are best assessed by MRI. The efficacy of medical management of osteonecrosis with pharmacologic agents and biophysical modalities requires further investigation. Surgical management is based on patient factors and lesion characteristics. Preservation of the femoral head may be attempted in younger patients without head collapse by core decompression with vascularized bone grafts, avascular grafts, bone morphogenetic proteins, stem cells, or combinations of the above or rotational osteotomies. The optimal treatment modality has not been identified. When the femoral head is collapsed, arthroplasty is the preferred option.

                  • Subspecialty:
                  • Sports Medicine