JAAOS, Volume 23, No. 10

Spinal Cord Blood Supply and Its Surgical Implications

The blood supply to the spine is based on a predictable segmental vascular structure at each spinal level, but true radiculomedullary arteries, which feed the dominant cord supply vessel, the anterior spinal artery, are relatively few and their locations variable. Under pathologic conditions, such as aortic stent grafting, spinal deformity surgery, or spinal tumor resection, sacrifice of a dominant radiculomedullary vessel may or may not lead to spinal cord ischemia, depending on dynamic autoregulatory or collateral mechanisms to compensate for its loss. Elucidation of the exact mechanisms for this compensation requires further study but will be aided by preoperative, intraoperative, and postoperative comparative angiography. Protocols in place at our center and others minimize the risk of spinal cord ischemia during planned radiculomedullary vessel sacrifice.

      • Subspecialty:
      • Spine

    Surgical Approaches to the Acetabulum and Modifications in Technique

    Acetabular injuries are often difficult to treat because the acetabulum is surrounded by many important structures, making access difficult and sometimes dangerous. Surgical exposures of the acetabulum are complex and require significant skill and in-depth knowledge of pelvic anatomy. Each approach has its limitations, and the potential morbidity associated with these exposures can be daunting. Recent modifications to traditional acetabular approaches have been developed to address these issues. Knowledge of the ilioinguinal, Kocher-Langenbeck, and extended iliofemoral surgical exposures and the potential drawbacks associated with each approach are essential to optimize treatment and minimize morbidity.

        • Subspecialty:
        • Trauma

      Congenital Vertical Talus: Etiology and Management

      Congenital vertical talus is a rare foot deformity. If left untreated, it causes significant disability, including pain and functional limitations. Although the etiology of vertical talus is likely heterogeneous, recent evidence strongly supports a genetic cause linking it to genes expressed during early limb development. Traditional management for vertical talus involves extensive surgeries that are associated with significant short- and long-term complications. A minimally invasive approach that relies on serial manipulation and casting to achieve most of the correction has been shown to produce excellent short-term results with regard to clinical and radiographic correction in both isolated and nonisolated cases of vertical talus. Although long-term studies are needed, achieving correction without extensive surgery may lead to more flexible and functional feet, much as Ponseti method has done for clubfeet.

          • Subspecialty:
          • Pediatric Orthopaedics

        Myositis Ossificans

        Myositis ossificans is a self-limiting, benign ossifying lesion that can affect any type of soft tissue, including subcutaneous fat, tendons, and nerves. It is most commonly found in muscle as a solitary lesion. Ossifying soft-tissue lesions historically have been inconsistently classified. Fundamentally, myositis ossificans can be categorized into nonhereditary and hereditary types, with the latter being a distinct entity with a separate pathophysiology and treatment approach. The etiology of myositis ossificans is variable; however, clinical presentation generally is characterized by an ossifying soft-tissue mass. Advanced cross-sectional imaging alone can be nonspecific and may appear to be similar to more sinister etiologies. Therefore, the evaluation of a suspicious soft-tissue mass often necessitates multiple imaging modalities for accurate diagnosis. When imaging is indeterminate, biopsy may be required for a histologic diagnosis. However, histopathology varies based on stage of evolution. The treatment of myositis ossificans is complex and is often made in a multidisciplinary fashion because accurate diagnosis is fundamental to a successful outcome.

            • Subspecialty:
            • Musculoskeletal Oncology

          Posttraumatic Boutonnière and Swan Neck Deformities

          Boutonnière and swan neck deformities of the finger can be the result of trauma. The complex anatomy of the extensor mechanism of the finger makes understanding the pathomechanics of these deformities challenging. These posttraumatic deformities should not be confused with those associated with inflammatory arthritis because the treatment options are often very different. An accurate clinical assessment is essential for selecting the appropriate treatment method. Physical examination, including Elson and intrinsic-plus tests, and plain radiography are important tools for diagnosis. A variety of nonsurgical and surgical treatment modalities can be used to restore the motion of the proximal and distal interphalangeal joints and rebalance the forces across these joints. An understanding of the anatomy, clinical presentation, treatment options, and expected outcomes is crucial for optimal treatment of posttraumatic boutonnière and swan neck deformities.

              • Subspecialty:
              • Hand and Wrist

            Clinical Evaluation and Preoperative Planning of Articular Cartilage Lesions of the Knee

            Articular cartilage injuries are quite common. Most studies and review articles on cartilage repair and restoration focus on the different techniques available to treat cartilage defects; however, few thoroughly discuss the initial evaluation of patients with these defects. Outcomes are intimately associated with appropriate patient selection and indications for treatment; therefore, understanding the initial evaluation and conservative treatment of cartilage defects is essential to achieving excellent outcomes after surgical intervention, regardless of the chosen procedure. In patients with cartilage injury, a careful history, physical examination, and imaging are required before treating the lesion to ensure the patient's symptoms are actually related to the defect. To address any special considerations, other factors must be considered to improve patient outcomes, including the status of the meniscus, assessing and treating malalignment or offloading the patellofemoral compartment, and reconstructing any ligamentous deficiencies. It is important for medical providers to understand what cartilage lesions may be symptomatic and when to refer these patients to surgeons who manage cartilage injury.

                • Subspecialty:
                • Sports Medicine

              Management of Pediatric Supracondylar Humerus Fractures

              The American Academy of Orthopaedic Surgeons has developed Appropriate Use Criteria (AUC) on the Management of Pediatric Supracondylar Humerus Fractures (PSHF). Evidence-based information, in conjunction with the clinical expertise of physicians, was used to develop the criteria to improve patient care and obtain the best outcomes while considering the subtleties and distinctions necessary in making clinical decisions. The PSHF AUC clinical patient scenarios were derived from patient indications that generally accompany a PSHF as well as from current evidence-based clinical practice guidelines and supporting literature. The 220 patient scenarios and 14 treatments were developed by the Writing Panel, a group of clinicians who are specialists in this AUC topic. Next, the Review Panel, a separate group of volunteer physicians, independently reviewed these materials to ensure that they were representative of patient scenarios that clinicians are likely to encounter in daily practice. Finally, the multidisciplinary Voting Panel (made up of specialists and nonspecialists) rated the appropriateness of treatment of each patient scenario using a 9-point scale to designate a treatment as Appropriate (median rating, 7 to 9), May Be Appropriate (median rating, 4 to 6), or Rarely Appropriate (median rating, 1 to 3).