JAAOS, Volume 8, No. 2

Operative treatment of metacarpal and phalangeal shaft fractures.

Diaphyseal fractures of the metacarpals and phalanges are common injuries that can lead to impairment of hand function. The fracture pattern and soft-tissue injury vary with the mechanism of injury. The imbalance of the flexor and extensor forces created by displaced fractures will often produce a secondary angulatory deformity. Nonoperative treatment is indicated for reducible and stable fracture configurations. Irreducible or unstable fracture patterns require open or closed reduction and fixation. Reduction must be assessed in flexion and extension to ensure correct rotatory alignment. Fracture fixation can be achieved with the use of Kirschner wires, interfragmentary screws, or plates. The outcome after surgery is greatly influenced by the condition of the surrounding soft tissues; therefore, surgical trauma should be minimized to optimize the result.

    • Keywords:
    • Adult|Aged|Female|Finger Injuries|Fracture Fixation

    • Internal|Fracture Healing|Fractures

    • Bone|Humans|Male|Metacarpophalangeal Joint|Metacarpus|Middle Aged|Prognosis|Range of Motion

    • Articular|Treatment Outcome

    • Subspecialty:
    • Trauma

    • Hand and Wrist

Complications of open anterior stabilization of the shoulder.

Complications of surgery for glenohumeral instability are relatively uncommon. When they occur, salvaging failures and obtaining a stable joint can be awesome challenges. Accurate recognition of the cause of the instability and application of the appropriate surgical technique are critical. Deficiencies of the glenoid concavity, the anterior capsule, or the subscapularis may be present and require correction. Overtightening a shoulder and eliminating its normal laxity should be avoided. Loose or malpositioned hardware about the glenohumeral joint must be recognized as soon as possible and removed. The goal of treatment is to correct the deficient stabilizing mechanisms without altering normal glenohumeral function.

    • Keywords:
    • Adult|Biomechanics|Disease Progression|Female|Humans|Joint Instability|Male|Orthopedic Procedures|Postoperative Complications|Prognosis|Range of Motion

    • Articular|Recurrence|Shoulder Joint|Treatment Failure

    • Subspecialty:
    • Shoulder and Elbow

Quality and outcome determination in health care and orthopaedics: evolution and current structure.

Quality health care has many definitions. Among those definitions is "care that consistently contributes to the improvement or maintenance of the quality and/or duration of life." The current evolution in health care has been fueled by three necessities frequently demanded by payers and employers: improvement in access, lowering of cost, and definition and quantification of the quality of care. This evolution has been facilitated by the so-called industrialization of medicine. This concept includes the adoption of industrial economic principles and techniques that facilitate the measurement of processes and outcomes. Quality health care is currently recognized as health care that is characterized by three elements: the use of practice guidelines or standards, the implementation of continuous quality improvement techniques, and the use of outcome determination and management. Practice guidelines demand the adoption of evidence-based principles in evaluation and care, as well as minimization of variations in evaluation and care. Continuous quality improvement seeks to determine why variations in processes of care occur and then to minimize those variations. Outcomes may be measured in terms of both very objective and very subjective variables and also on the basis of cost-efficiency. Most tools currently used to quantify outcomes, especially in orthopaedics, involve measurements of general health and of specific body part or organ system function. This evolution in health care is producing significant alterations in methods of traditional health-care delivery. The accumulating evidence indicates that these changes, although frequently unpopular, are improving the quality of health care.

    • Keywords:
    • Female|Forecasting|Humans|Male|Orthopedics|Outcome Assessment (Health Care)|Quality of Health Care|United States

    • Subspecialty:
    • Clinical Practice Improvement

    • General Orthopaedics

Patellar resurfacing in total knee arthroplasty.

Whether or not to resurface the patella when performing a primary total knee arthroplasty remains an open question. A number of recent studies have added new information relevant to this controversy. Anatomic studies show that there is normally substantial variability in the anatomy of the trochlear groove. Implanting a femoral component therefore results in a change in the surface topography of the knee in a high percentage of cases. Even though a number of intraoperative techniques have been described in an attempt to accurately reproduce femoral and tibial component rotation, studies of the application of these techniques reveal that component malpositioning or malrotation of a measurable degree occurs in 10% to 30% of cases, depending on the surgical technique and landmarks used. There has been substantial change in the design of both femoral and patellar components in recent years. Even with current designs, biomechanical studies indicate that some degree of change in kinematics and contact stresses occurs following total knee arthroplasty. However, the results of clinical studies have been extremely variable, with most showing either no difference or very little difference between resurfaced and nonresurfaced patellae in osteoarthritic knees. The decision to resurface the patella or not must be individualized on the basis of the surgeon's training and experience and an intraoperative assessment of the patellofemoral articulation.

    • Keywords:
    • Arthroplasty

    • Replacement

    • Knee|Clinical Trials as Topic|Female|Humans|Knee Joint|Knee Prosthesis|Male|Patella|Prognosis|Prosthesis Design|Range of Motion

    • Articular|Severity of Illness Index|Surface Properties|Treatment Outcome

    • Subspecialty:
    • Adult Reconstruction

Intramedullary nailing of the femur: reamed versus nonreamed.

All intramedullary nailing creates some loss of endosteal blood supply and an increase in intramedullary pressure, resulting in marrow embolization. In laboratory studies, both reamed and nonreamed intramedullary nailing have led to alteration in selected pulmonary variables. This effect, although transient, appeared more pronounced with reamed techniques than with nonreamed techniques. Concern about the systemic pulmonary effects of reamed intramedullary nailing has led to an increase in the use of nonreamed nailing. The authors of most clinical studies have reported that reamed intramedullary nailing has not been associated with a concomitant increase in pulmonary complications in multiply injured patients, although this point is still controversial. Femoral shaft fractures treated with nonreamed nailing have been shown to have slightly higher rates of delayed union and nonunion compared with those treated with reamed nails. Reamed interlocking intramedullary fixation remains the treatment of choice for femoral shaft fractures in adults. Further study is required to determine whether an identifiable subgroup of trauma patients is adversely affected by intramedullary reaming, which would suggest the need for alternative fixation techniques.

    • Keywords:
    • Adult|Bone Nails|Female|Femoral Fractures|Fracture Fixation

    • Intramedullary|Fracture Healing|Humans|Incidence|Male|Postoperative Complications|Prognosis|Risk Factors|Sensitivity and Specificity

    • Subspecialty:
    • Trauma

Domestic violence: the role of the orthopaedic surgeon in identification and treatment.

Domestic violence is a major public health problem in the United States. As many as 35% of women visiting hospital emergency departments for trauma care are there because of injuries caused by intimate partner violence. The practicing orthopaedic surgeon may come in contact with these women in the emergency department as well as in the office setting. The ability to identify victims of abuse requires a sensitive approach and a specific set of skills. Once the victim has been identified, appropriate referral to local agencies is critical to help ensure the victim's safety. The issues surrounding identification, documentation, inquiry about safety, and activation of community services need to be incorporated into the core curriculum of resident training programs and the continuing education of the practicing orthopaedic surgeon.

    • Keywords:
    • Domestic Violence|Education

    • Medical

    • Graduate|Female|Guidelines as Topic|Humans|Male|Orthopedics|Physicians Role|Spouse Abuse|United States|Wounds and Injuries

    • Subspecialty:
    • Clinical Practice Improvement

Acute and chronic posterolateral rotatory instability of the knee.

Isolated posterolateral rotatory instability of the knee is an uncommon injury pattern that may result in significant degrees of functional disability. This injury complex can be a challenging diagnostic and therapeutic problem for the orthopaedic surgeon. The presence of associated ligamentous and soft-tissue injuries, resulting in combined instability patterns, further complicates management. The results of recent research have enhanced our understanding of the complex anatomy and biomechanics of the posterolateral aspect of the knee. Numerous surgical techniques have been described for both repair and reconstruction of the injured posterolateral structures; however, long-term functional results have been only moderately successful.

    • Keywords:
    • Acute Disease|Arthroscopy|Biomechanics|Chronic Disease|Collateral Ligaments|Female|Humans|Joint Instability|Knee Injuries|Male|Orthopedic Procedures|Prognosis|Range of Motion

    • Articular

    • Subspecialty:
    • Sports Medicine

    • Basic Science