OKOJ, Volume 10, No. 4

Prevention and Management of Instability After Total Hip Arthroplasty: Current Concepts

Total hip arthroplasty (THA) is one of the most successful orthopaedic procedures, and has been shown to be exceedingly effective in improving function and decreasing pain. Dislocation is one of the most common and most devastating complications after THA, with reported rates of 0.3% to 10% after primary THA and up to 28% after revision THA. Risk factors for dislocation include previous hip surgery, neuromuscular and cognitive disorders, patient noncompliance, and THA for femoral neck fracture. Surgical risk factors for instability after THA include the surgical approach, postoperative soft-tissue tension, component positioning, impingement, head size, liner profile, and surgeon experience. Appropriate management includes a detailed patient history, physical examination, and radiographic evaluation to determine the proper intervention. Most dislocations after THA are solitary events that can be managed with closed reduction and nonsurgical treatment; however, some patients eventually require revision to address recurrent instability. Revision for instability should involve a thorough assessment of the underlying etiology for dislocation, and revision should directly target the underlying problem. THA revision for instability can be a frustrating endeavor for both the patient and the surgeon, and the patient should be counseled thoroughly prior to any revision operation.

    • Keywords:
    • dislocation

    • instability

    • total hip arthroplasty

    • THA

    • total hip replacement

    • revision total hip arthroplasty

    • revision THA

    • risk factors

    • surgical approach

    • modular component exchange

    • femoral head size

    • constrained liner

    • component revision

    • trochanteric advancement

    • bipolar arthroplasty

    • tripolar arthroplasty

    • Subspecialty:
    • Adult Reconstruction

Adult Cavovarus Foot

Pes cavovarus is defined by the clinical finding of an elevated medial longitudinal arch in association with a varus hindfoot, and is commonly associated with clawing of the hallux and lesser toes. Typically, the cavovarus foot is the result of an abnormal balance of the muscle forces about the foot, often from a neuromuscular disorder. Weakness of the intrinsic muscles of the foot and/or foot dorsiflexors causes an initial flexible deformity, which becomes rigid over time. Treatment is guided by the location and rigidity of the deformity, with the goal of creating a plantigrade, pain-free foot for ambulation. More severe or progressive deformities may require surgical management. The potential combinations of soft-tissue and bony procedures are numerous, and selection of the appropriate procedures is based on the particular clinical features of the patient.

    • Keywords:
    • pes cavovarus

    • pes cavus

    • cavus foot

    • Charcot-Marie-Tooth disease

    • CMT

    • hereditary motor sensory neuropathy

    • HMSN

    • foot reconstruction

    • plantar fascia release

    • gastrocnemius recession

    • Strayer procedure

    • percutaneous Achilles lengthening

    • modified Jones procedure

    • peroneus brevis to longus tenodesis

    • posterior tibial tendon transfer

    • first metatarsal dorsiflexion osteotomy

    • lateralizing calcaneal osteotomy

    • fusion

    • Subspecialty:
    • Foot and Ankle

HOT TOPIC: Nerve Transfers in the Upper Extremity

Nerve injuries to the upper extremity can have devastating functional consequences for patients. The gold standard of treatment when an irreducible nerve defect is not present is prompt, tension-free, primary repair. However, when a nerve gap does exist, an alternative form of reconstruction, such as nerve grafting, must be utilized. Traditionally, nerve grafting has been met with slow and suboptimal results, particularly with more proximal nerve injuries. The use of nerve transfers in peripheral nerve reconstruction is an expanding and ever-evolving field that endeavors to improve these outcomes. This article reviews the basic principles of nerve transfer, indications and contraindications for use, and some of the critical surgical techniques necessary to perform them.

    • Keywords:
    • upper extremity nerve injury

    • nerve repair

    • nerve grafting

    • peripheral nerve electromyography

    • nerve conduction studies

    • end-to-end repair

    • end-to-side repair

    • reverse end-to-side repair

    • sensory nerve transfer

    • motor nerve transfer

    • double fascicular nerve transfer

    • Subspecialty:
    • Hand and Wrist

Surgical Management of Pediatric Acute Hematogenous Osteomyelitis

Acute hematogenous osteomyelitis is a common disorder that is unique to children because of anatomic and physiologic differences present in the immature skeleton. The diagnosis and treatment of this condition is straightforward in most circumstances. Prompt evaluation with laboratory and radiographic studies will guide decision making for antibiotic therapy and surgical intervention. Common pitfalls may be avoided with anticipation and careful management during the treatment process. Overall, outcomes are excellent in the majority of children with this condition following appropriate and timely treatment.

    • Keywords:
    • pediatric musculoskeletal infection

    • osteomyelitis

    • chronic osteomyelitis

    • acute hematogenous osteomyelitis

    • AHO

    • bone infection

    • pyomyositis

    • septic arthritis

    • laboratory evaluation

    • diagnosis

    • differential diagnosis

    • Staphylococcus aureus

    • MRSA

    • methicillin-resistant Staphylococcus aureus

    • surgical debridement

    • Subspecialty:
    • Pediatric Orthopaedics