JAAOS, Volume 7, No. 2

Nerve injuries in total hip arthroplasty.

Nerve injury occurs in 1% to 2% of patients who undergo total hip arthroplasty and is more frequent in patients who need acetabular reconstruction for dysplasia and those undergoing revision arthroplasty. Injury to the peroneal division of the sciatic nerve is most common, but the superior gluteal, obturator, and femoral nerves can also be injured. Nerve injury can be classified as neurapraxia, axonotmesis, or neurotmesis. The worst prognosis is seen in patients with complete motor and sensory deficits and in patients with causalgic pain. Prevention is of overriding importance, but use of ankle-foot orthoses and prompt management of pain syndromes can be useful in the treatment of patients with nerve injury. Electrodiagnostic studies hold promise in complex cases; however, their intraoperative role requires objective, prospective, controlled scientific study before routine use can be recommended.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Hip|Axons|Causalgia|Electrodiagnosis|Femoral Nerve|Hip|Humans|Intraoperative Complications|Nerve Degeneration|Neural Conduction|Obturator Nerve|Orthotic Devices|Peroneal Nerve|Prognosis|Sciatic Nerve

    • Subspecialty:
    • Pain Management

    • Adult Reconstruction

Posterior tibial tendon insufficiency: diagnosis and treatment.

Posterior tibial tendon insufficiency is the most common cause of acquired adult flatfoot deformity. Although the exact etiology of the disorder is still unknown, the condition has been classified, on the basis of clinical and radiographic findings, into four stages. In stage I, there is no notable clinical deformity; patients usually present with pain along the course of the tendon and evidence of local inflammatory changes. Stage II is characterized by a dynamic deformity of the hindfoot. Stage III involves a fixed deformity of the hindfoot and typically also a fixed forefoot supination deformity but no obvious evidence of ankle abnormality. In stage IV, ankle involvement is secondary to long-standing fixed hindfoot deformities. The initial treatment of patients in any stage should be nonoperative, with immobilization, a nonsteroidal anti-inflammatory drug, and perhaps an orthotic device. Corticosteroid injections continue to be controversial. When nonoperative management fails, the treatment options consist of soft-tissue procedures alone or in combination with osteotomy or arthrodesis. Stage I insufficiency is generally treated with debridement and tenosynovectomy. Soft-tissue transfer does not appear to correct the underlying deformity in stage II disease; however, there is growing interest in joint-sparing operations that attempt to compensate for the underlying deformities with osteotomies or arthrodeses, supplemented with dynamic transfers to replace the insufficient posterior tibial tendon. Subtalar, double, or triple arthrodesis is the procedure of choice for stage III disease, frequently in conjunction with heel-cord lengthening. Tibiocalcaneal arthrodesis or pantalar arthrodesis is most commonly used to treat stage IV disease.

    • Keywords:
    • Adult|Ankle Joint|Anti-Inflammatory Agents

    • Non-Steroidal|Arthrodesis|Calcaneus|Debridement|Female|Flatfoot|Foot Deformities

    • Acquired|Forefoot

    • Human|Humans|Immobilization|Male|Muscular Diseases|Orthotic Devices|Osteotomy|Pain|Subtalar Joint|Synovial Membrane|Tendon Transfer|Tendons|Tibia

    • Subspecialty:
    • Sports Medicine

    • Foot and Ankle

Loss of extension after reconstruction of the anterior cruciate ligament.

The most common complication of anterior cruciate ligament (ACL) reconstruction is loss of extension, which is often functionally worse for patients than their preoperative instability. Many preventable surgical and nonsurgical etiologic factors have been identified. Accurate placement of the tibial tunnel, adequate notchplasty, and the routing of the femoral side of the graft are all critical factors. Several studies report that early range-of-motion therapy emphasizing immediate postoperative "hyperextension" and avoiding immobilization in flexion reduces the rate of loss of extension. Initial studies investigating the effect of acute versus chronic ACL reconstruction suggested that acute reconstruction is associated with a higher rate of loss of extension. However, the authors of two recent studies in which modern techniques were used have disputed this conclusion. It is likely that the loss of extension historically seen with acute ACL reconstructions was related to tibial tunnel placement and postoperative immobilization. It is possible that the timing of acute ACL reconstruction has less of an effect than originally postulated. On the basis of the results of several biomechanical studies, it appears that ACL reconstruction may be performed with the knee in full extension during graft placement with excellent results and a very low rate of loss of extension. Use of the descriptive term "loss of extension" is preferred to the often misleading terms "arthrofibrosis" and "flexion contracture."

    • Keywords:
    • Anterior Cruciate Ligament|Biomechanics|Exercise Therapy|Femur|Humans|Immobilization|Joint Diseases|Joint Instability|Knee Joint|Patellar Ligament|Range of Motion

    • Articular|Reconstructive Surgical Procedures|Tibia|Time Factors

    • Subspecialty:
    • Sports Medicine

Surgical treatment of acetabular fractures in elderly patients with osteoporotic bone.

The incidence of acetabular fractures in the elderly has recently shown a marked increase due to the combination of greater longevity for the population as a whole and a relative decrease in the incidence of alcohol-related trauma in younger adults. The compromised physiologic reserve and the diminished healing capacity of the typical elderly patient have an adverse effect on the potential for a favorable clinical outcome. The presence of osteopenic bone or degenerative arthritis and the effects of previous radiation therapy to the hip and pelvis hamper diagnostic imaging and the utility of some treatment alternatives that were designed primarily for younger patients. The diverse clinical presentations include major polytrauma, minor trauma, and insufficiency fractures. An assessment of the prior health and functional status of the patient is crucial in determining the optimal therapeutic protocol. Treatment options vary according to the clinical presentation and include conservative methods, percutaneous fixation in situ, open reduction, and acute total hip arthroplasty. The feasibility of acute total hip arthroplasty rests on the use of newly developed techniques for minimally invasive stabilization of the acetabular fracture with cables and the application of morselized or structural autograft harvested from the femoral head. Whichever surgical method is chosen, the objective is rapid mobilization of the patient on a walker or crutches. Late complications that may occur after nonoperative or operative treatment include posttraumatic arthritis, nonunion, wound infection, and heterotopic bone formation.

    • Keywords:
    • Acetabulum|Adult|Aged|Aged

    • 80 and over|Aging|Arthroplasty

    • Replacement

    • Hip|Bone Diseases

    • Metabolic|Bone Transplantation|Fracture Fixation|Fracture Healing|Fractures

    • Bone|Fractures

    • Spontaneous|Health Status|Humans|Incidence|Osteoarthritis|Osteoporosis|Postoperative Complications|Surgical Procedures

    • Minimally Invasive|Walking

    • Subspecialty:
    • Trauma

    • Adult Reconstruction

Anesthesia and analgesia for the ambulatory management of fractures in children.

The goal of anesthesia in the ambulatory management of fractures in children is to provide analgesia and relieve anxiety in order to facilitate successful closed treatment of the skeletal injury. Numerous techniques short of general anesthesia are available. These methods include blocks (local, regional, and intravenous), sedation (conscious and deep), and dissociative anesthesia (ketamine sedation). Important factors in choosing a particular technique include ease of administration, efficacy, safety, cost, and patient and parent acceptance. Local and regional techniques, such as hematoma, axillary, and intravenous regional blocks, are particularly effective for upper-extremity fractures. Sedation with inhalation agents, such as nitrous oxide, and parenterally administered narcotic-benzodiazepine combinations, are not region-specific and are suitable for patients over a wide range of ages. Ketamine sedation is an excellent choice for children less than 10 years old. With any technique, proper monitoring and adherence to safety guidelines are essential.

    • Keywords:
    • Adolescent|Ambulatory Care|Analgesia|Analgesics

    • Opioid|Anesthesia

    • Conduction|Anesthesia

    • General|Anesthesia

    • Intravenous|Anesthesia

    • Local|Anesthetics

    • Dissociative|Anesthetics

    • Inhalation|Anti-Anxiety Agents|Benzodiazepines|Bones of Upper Extremity|Child|Child

    • Preschool|Conscious Sedation|Fractures

    • Bone|Humans|Ketamine|Nerve Block|Nitrous Oxide

    • Subspecialty:
    • Trauma

    • Pediatric Orthopaedics

Operative correction of swan-neck and boutonniere deformities in the rheumatoid hand.

A swan-neck or boutonniere deformity occurs in approximately half of patients with rheumatoid arthritis. The cause of boutonniere deformity is chronic synovitis of the proximal interphalangeal joint. Swan-neck deformity may be caused by synovitis of the metacarpophalangeal, proximal interphalangeal, or distal interphalangeal joints. Numerous procedures are available for the operative correction of these finger deformities. The choice of surgical procedure is dependent on accurate staging of the deformity, which is based on the flexibility of the proximal interphalangeal joint and the state of the articular cartilage. The patient's overall medical status and corticosteroid use, the condition of the cervical spine, the need for operative treatment of large joints, and the presence of deformities of the wrist and metacarpophalangeal joints must also be considered when planning treatment. In the later stages of both deformities, soft-tissue procedures alone may not result in lasting operative correction.

    • Keywords:
    • Adrenal Cortex Hormones|Arthritis

    • Rheumatoid|Arthrodesis|Arthroplasty

    • Replacement|Cartilage

    • Articular|Cervical Vertebrae|Finger Joint|Hand Deformities

    • Acquired|Health Status|Humans|Joint Deformities

    • Acquired|Joint Prosthesis|Metacarpophalangeal Joint|Patient Care Planning|Range of Motion

    • Articular|Silicones|Synovitis|Tendons|Wrist Joint

    • Subspecialty:
    • Hand and Wrist