OKOJ, Volume 10, No. 8

The foot and ankle are common sites of involvement in adult-onset rheumatoid arthritis and its seronegative variants, which include psoriatic arthritis, reactive arthritis, and ankylosing spondylitis. Multiple findings on physical examination are typical of these diseases, including pain, swelling, deformity, and stiffness of joints in the forefoot, midfoot, and hindfoot. Characteristic findings on imaging studies include subchondral erosion of bone into the articular surface, joint destruction, and joint-space narrowing. Nonsurgical treatment for immunologic rheumatic disorders of the foot and ankle usually includes a combination of pharmacologic therapy and the appropriate use of orthoses, bracing, or other modalities. Surgical treatment may be necessary, and is directed to the joints, tendons, and ligaments that are involved.

Congenital pseudarthrosis of the tibia is a rare pathologic condition characterized by anterolateral bowing of the tibia that typically progresses toward loss of continuity of the tibial diaphysis. Nearly half of all patients with this condition also have neurofibromatosis. Congenital pseudarthrosis of the tibia presents significant treatment challenges, not only in obtaining bony union of the tibia but also in maintaining union and preventing future deformity. Success rates for surgical reconstruction are improving with newer technologies, but amputation may still be the eventual outcome of a recalcitrant pseudarthrosis. This article outlines the diagnosis, pathology, and various treatment strategies for this difficult pediatric condition.

Lumbar and lumbosacral fractures and dislocations represent a challenging group of injuries that are not infrequently associated with other injuries in the polytraumatized patient. Most injuries to the lumbar and lumbosacral spine do not incur any neurologic deficit. However, there is a 20% incidence of associated injuries, including intra-abdominal bleeding, vessel disruption, and pulmonary injury. The goals in treating a lumbar or sacral spinal injury include preserving neurologic function, restoring overall alignment and stability, and mobilizing the patient as soon as possible. Appropriate care hinges on timely evaluation, with a thorough and detailed physical examination as well as imaging studies. Decompression of the neural elements of such injuries in cases of evolving neurologic deficit is of the utmost importance, as the most appropriate methods of surgical reduction and fixation of unstable fractures and dislocations continue to evolve.

The Latarjet procedure involves a transfer of the coracoid process to the medial glenoid via a slit in the subscapularis muscle. This increases the anterior-posterior diameter of the glenoid fossa and makes it more difficult for the humeral head to subluxate or dislocate. In addition, the conjoined tendon acts as a stabilizer with the arm abducted and externally rotated. In this video, I describe my preferred technique for this procedure. With proper patient selection and systematic surgical technique, instability can be eliminated without loss of external rotation in more than 98% of patients.

The rigid plating of diaphyseal and periarticular fractures has limitations associated with primary bone healing, including porosis induced by stress shielding, delayed healing, and refracture. In contrast, the fixation of periarticular and diaphyseal fractures through locked plating with far cortical locking (FCL) screws permits axially flexible osteosynthesis while providing durable bone fixation and actively promoting fracture healing through callus formation. FCL screws have a flexible shaft that provides an envelope of controlled motion in the near cortex of the bone, facilitating controlled and symmetric motion within a fracture. Constructs based on FCL mimic the biomechanical behavior of Ilizarov fixators in permitting the symmetric axial motion of a fixed fragment of bone, with progressive stiffening, and providing a high degree of rotational stability. Outcomes at week 6 of a prospective study of FCL for the fixation of fractures of the distal femur included the presence of bridging callus in 20 of 26 patients who were available for follow-up. Radiographs made at 12 weeks demonstrated bridging callus in all of the patients' fractures. The mean area of periosteal callus was significantly greater at both week 6 ( = 0.003) and week 12 ( = 0.016) than that of historical controls treated with locked plating and standard locking screws. No hardware or fixation failure related to FCL screws has been observed at an average follow-up time of 22 weeks. Of the 59 FCL constructs applied by the authors, four case examples are presented.