JAAOS, Volume 4, No. 6

Patellar Tendon Ruptures.

Rupture of the patellar tendon is a relatively infrequent, yet disabling, injury, which is most commonly seen in patients less than 40 years of age. It tends to occur during athletic activities when a violent contraction of the quadriceps muscle group is resisted by the flexed knee. Rupture usually represents the final stage of a degenerative tendinopathy resulting from repetitive microtrauma to the patellar tendon. This injury may also occur during less strenuous activity in patients whose tendons are weakened by systemic illness or the administration of local or systemic corticosteroid medications. The diagnosis is made on the basis of the presence of a painful, palpable defect in the substance of the tendon; an inability to completely extend the knee against gravity; and the existence of patella alta confirmed by lateral radiographs. Ultrasonography and magnetic resonance imaging are useful in identifying a neglected rupture, as well as when the diagnosis is in question or an intra-articular injury is suspected. The prognosis after a patellar tendon rupture depends in large part on the interval between injury and repair. Surgery soon after the injury is recommended for optimal results. This is best accomplished by accurate reapproximation of the ruptured tendon ends, repair of the torn extensor retinacula, and placement of a reinforcing cerclage suture. An aggressive rehabilitation program, emphasizing early range-of-motion exercises, protected weight bearing, and quadriceps strengthening, will enhance the results of surgery. Patients who undergo delayed repair are at risk for a compromised result secondary to loss of full knee flexion and decreased quadriceps strength, although a functional extensor mechanism is likely to be reestablished.

      • Subspecialty:
      • Sports Medicine

    Human Immunodeficiency Virus Infection: Complications and Outcome of Orthopaedic Surgery.

    Orthopaedic surgeons practicing in areas with a high prevalence of human immunodeficiency virus (HIV) infection may expect that up to 7% of their patients who undergo emergent procedures and 1% to 3% of those who undergo elective surgery will be HIV-positive. Although basic science studies have demonstrated impairment of defenses to routine orthopaedic pathogens as well as to opportunistic organisms, clinical studies have shown that this impairment has not resulted in an increased incidence of postoperative infections or failure of wound healing in the asymptomatic HIV-positive patient. Even for the symptomatic patient, current medical management appears adequate to reduce the risk of early postoperative infection. The HIV-positive patient with a pros-thetic implant may be at increased risk for late hematogenous implant infection as host defenses diminish. Regular medical attention, prophylactic antibiotic therapy before dental work and invasive procedures, and early evaluation and treatment of possible infections are especially important in this setting. Decisions regarding elective surgery should be made on a risk-benefit basis. Because the risk of surgical complications increases with progression of the dis-ease, guidelines for elective surgery should include an assessment of the HIV-positive patient's immune status, including the CD4 lymphocyte count, history of opportunistic infection, serum albumin level, the presence of skin anergy, and the state of nutrition and general health.

        • Subspecialty:
        • Basic Science

        • General Orthopaedics

      Cervical Radiculopathy: Diagnosis and Nonoperative Management.

      Cervical radiculopathy presents as pain in a dermatomal distribution. This frequently represents compression of an exiting cervical nerve root by either a herniated disk or a degenerative cervical spondylotic change. Most patients will improve with nonoperative treatment, and a small percentage will require further diagnostic evaluation and ultimately surgical intervention. An understanding of the normal anatomy and the pathologic changes in cervical radiculopathy will improve the understanding of diagnosis and decision making regarding nonoperative interventions. An algorithmic approach for decision making and a review of nonoperative management are presented.

          • Subspecialty:
          • Spine

        Distraction Histiogenesis: Principles and Indications.

        Distraction histiogenesis is a biologic phenomenon that can be utilized to induce the formation of new bone and soft tissue. This technique has been used after corticotomy or osteotomy of bone to treat patients with limb-length inequality, angular deformities, segmental bone loss, nonunions, and contractures. A distraction force is applied with an external fixator, such as the Ilizarov circular fixator or a uniplanar fixator. The authors review the extensive preoperative planning required, the performance of osteotomy, the application of external fixators, and the timing between the osteotomy and the initiation of correction (the latency phase). The subsequent distraction phase involves active lengthening, transport, or angular correction through frequent small steps (e.g., 0.25 mm every 6 hours). This results in the formation of new bone, or regenerate, in longitudinal columns along the plane of distraction. The consolidation phase begins after the desired correction has been achieved; this period allows for maturation of the regenerate and corticalization before fixator removal.

            • Subspecialty:
            • Basic Science

            • Pediatric Orthopaedics

          Interdigital Neuritis: Diagnosis and Treatment.

          Because it has not yet been established whether the condition commonly referred to as Morton's neuroma results from true neuromatous proliferation or from inflammation in the region of the interdigital nerve, the term "interdigital neuritis" is preferred. The authors review the etiology, diagnosis, and management of interdigital neuritis, including whether a plantar or dorsal approach is preferable and whether neurectomy is more efficacious than incision of the transverse metatarsal ligament, with or without neurolysis. The authors recommend that diagnosis be made on the basis of the history and clinical examination, that surgery be performed through a dorsal approach with release of the transverse ligament but without neurectomy, and that revision surgery be performed through a dorsal incision with excision of the nerve 3 cm proximal to the transverse ligament.

              • Subspecialty:
              • Foot and Ankle

            Distal Humeral Fractures in Adults.

            Distal humeral fractures in adults often pose a challenge to the orthopaedic surgeon. Preoperative planning, minimal devitalization of bone and soft tissue, and adherence to the prerequisites of biomechanical fixation are all important elements in effecting the desired end result. The chevron modification of the olecranon osteotomy affords excellent surgical exposure of the joint surface for fractures with an intra-articular component. When two plates are used to fix the lateral and medial distal humeral columns, it is best to orient them so that, when looked at in cross section, they are at right angles to each other. The achievement and maintenance of an anatomic reduction secure enough to permit early functional, pain-free motion of the elbow can be best ensured by open reduction and internal fixation with careful attention to detail.

                • Subspecialty:
                • Trauma

                • Shoulder and Elbow

                • Hand and Wrist