OKOJ, Volume 10, No. 5

Osteonecrosis of the Knee

Osteonecrosis of the knee is a rare disease classified into three types—secondary, spontaneous, and postarthroscopic—which are distinguished by location, condyles involved, patient age, symptoms, and associated risk factors. Plain radiography as well as MRI should be performed for correct diagnosis and staging of the disease, using the modified Ficat and Arlet system. Patients with early-stage spontaneous osteonecrosis or postarthroscopic osteonecrosis of the knee (Ficat and Arlet stages I and II) can usually be successfully treated with nonsurgical or joint-preserving management, including arthroscopy, bone grafting, core decompression, or high tibial osteotomy. In patients with late-stage disease with severe degenerative changes (Ficat and Arlet stages III and IV), or those with symptomatic secondary osteonecrosis, a unicompartmental or total knee arthroplasty is recommended.

    • Keywords:
    • secondary osteonecrosis

    • spontaneous osteonecrosis

    • postarthroscopic osteonecrosis

    • idiopathic bone necrosis

    • atraumatic osteonecrosis

    • avascular osteonecrosis

    • Ficat and Arlet staging system

    • core decompression

    • high tibial osteotomy

    • unicompartmental knee arthroplasty

    • unicompartmental knee replacement

    • total knee arthroplasty

    • total knee replacement

    • osteochondral grafting

    • knee arthroscopy

    • Subspecialty:
    • Adult Reconstruction

Advances in the Treatment of Scaphoid Nonunions

Surgeons can directly impact the success of treating patients with scaphoid nonunion by separating waist nonunions from proximal pole nonunions. Most proximal pole nonunions have osteonecrosis, and in such situations a dorsal approach combined with vascularized bone grafting provides a reasonable treatment option. For patients with scaphoid waist nonunion, the surgeon must determine whether or not there is osteonecrosis and/or a collapse deformity. In the rare event that no collapse is present, the nonunion can be treated using a volar approach or dorsal approach with or without a vascularized bone graft, depending on the presence of osteonecrosis. If collapse is present, then use of a volar approach is necessary, combined with a volar rotation of a vascularized bone graft supplied by the 1,2- intercompartmental supraretinacular artery if osteonecrosis is present.

    • Keywords:
    • scaphoid nonunion

    • proximal pole scaphoid nonunion

    • scaphoid waist nonunion

    • scaphoid fracture

    • osteonecrosis

    • avascular necrosis

    • scaphoid humpback deformity

    • vascularized bone graft

    • vascularized pedicled bone graft

    • 1

    • 2-intercompartmental supraretinacular artery

    • Subspecialty:
    • Hand and Wrist

Diagnosis and Management of Complex Regional Pain Syndrome I and II

Complex regional pain syndrome (CRPS) is a chronic neuropathic pain syndrome that primarily affects the extremities, with sprains and fractures being the most common inciting events. CRPS type I, previously known as reflex sympathetic dystrophy, is characterized by the absence of a distinct nerve injury, whereas type II, once referred to as causalgia, occurs after an illness or injury in which there was a documented nerve injury. The past few decades have seen an evolution and an improvement in our understanding of the pathophysiology and treatment of CRPS. Diagnosis is based on clinical findings, and treatment remains a challenge. An interdisciplinary approach, with use of pharmacotherapy and interventional modalities coordinated with psychological and physical therapies, provides the best outcome.

    • Keywords:
    • complex regional pain syndrome

    • reflex sympathetic dystrophy

    • causalgia

    • CRPS

    • CRPS type 1

    • CRPS type II

    • diagnosis

    • pharmacological treatment

    • psychological therapies

    • physical therapy

    • occupational therapy

    • Subspecialty:
    • Pain Management

Fingertip Injuries in Children

Fingertip injuries are common in children, accounting for approximately two thirds of all pediatric hand injuries. Children of all ages suffer from hand trauma; however, fingertip injuries most frequently occur in young children. Fingertip and nail bed damage can lead to long-term cosmetic consequences, which can adversely affect hand function. The goal of treatment is to provide adequate padding and maintain the length of the digit. Treatment of these injuries is varied, and includes healing by secondary intention, shortening of the bone, and primary closure and coverage by local or regional skin flap. Ultimate treatment decisions should be tailored to the individual patient based on the size and extent of the wound; the presence of exposed bone, tendon, or neurovascular structures; the degree of wound contamination; the availability of soft-tissue coverage using local or remote sources; and the sophistication and ability of the patient and family to comply with postoperative instructions. An experienced hand surgeon should treat complex fingertip injuries requiring replantation and flap coverage.

    • Keywords:
    • finger injury

    • fingertip amputation

    • fingertip laceration

    • fingertip replantation

    • nail bed injury

    • nail bed hematoma

    • nail bed laceration

    • subungual hematoma

    • Seymour fracture

    • Subspecialty:
    • Pediatric Orthopaedics