OKOJ, Volume 5, No. 3

Venous Thromboembolic Disease in Orthopaedic Surgery

A practicing orthopaedic surgeon should acknowledge the risk of venous thromboembolic disease (VTED) following orthopaedic surgical procedures on the lower extremity. Specifically, patients undergoing total hip arthroplasty or total knee arthroplasty and patients with complex trauma appear to be at particular risk. The recommendation of the Seventh American College of Chest Physicians (ACCP) Conference on Antithrombotic and Thrombolytic Therapy are discussed for patients undergoing total hip replacement, total knee replacement, hip fracture surgery, knee arthropscopy, elective spine surgery, and surgical treatment of lower extremity fractures distal to the femur.

    • Keywords:
    • deep vein thrombosis

    • DVT

    • pulmonary embolism

    • PE

    • pulmonary embolus

    • venous thromboembolism

    • venous thrombosis

    • lower extremity thrombosis

    • leg thrombosis

    • incidence

    • etiology

    • prophylaxis

    • epidural anesthesia

    • diagnosis

    • venography

    • ultrasound

    • clinical signs

    • electrocardiogram

    • arterial blood gas

    • pulmonary angiogram

    • ventilation-perfusion scan

    • spiral CT angiography

    • treatment

    • heparin

    • warfarin

    • THA

    • TKA

    • deep venous thrombosis

    • low-molecular-weight heparin

    • LMWH

    • ascending contrast venography

    • color Dopplar ultrasound

    • magnetic resonance venography

    • electrocardiography

    • arterial blood gas analysis

    • pulmonary angiography

    • V-Q scan

    • spiral computed tomography angiography

    • aspirin therapy

    • Subspecialty:
    • Trauma

    • Adult Reconstruction

    • Basic Science

Instability of the Lesser Metatarsophalangeal Joints

Instability of the lesser metatarsophalangeal (MTP) joints is a common problem that may occur with synovitis, systemic arthritis, and trauma. MTP joint instability is generally manifested clinically as an ill-defined forefoot pain that can be mistaken as neuritic in origin. Conservative treatment is recommended initially and consists of wearing shoes with roomy toe box areas to accommodate the toes and metatarsal pads to help reduce the pressure under the MTP joint and reduce the synovitis. Surgical treatment is determined by the magnitude of the deformity and its rigidity. For flexible, reducible deformities, the author recommends a metatarsal-shortening Weil osteotomy, following tenotomy and dorsal capsulotomy, to shorten the collateral ligaments and reduce the MTP joint. For fixed, dislocated deformities, an extensive release of the dorsal, medial, or lateral structures should be performed, followed by a Weil osteotomy. Reefing of the elongated structures should complete the correction, and a tendon transfer should be added to aid in the stability of the joint.

    • Keywords:
    • lesser toe deformity

    • lesser toe instability

    • metatarsophalangeal joint instability

    • MTP joint instability

    • metatarsal shortening

    • Weil osteotomy

    • Subspecialty:
    • Foot and Ankle

Ligament Reconstruction in Thumb Basal Joint Arthroplasty

Osteoarthritis of the thumb trapeziometacarpal (TM) joint due to degeneration of the anterior oblique "beak" ligament results in pathologic laxity, abnormal translation of the metacarpal on the trapezium, and generation of excessive shear forces between the joint surfaces during grip and pinch activity. This article describes our rationale for performing ligament reconstruction and trapezium excision (LRTI arthroplasty) in the treatment of thumb basal joint arthritis. Surgical procedure steps are detailed, and normal TM joint anatomy and biomechanics, as well as pathoanatomy, are also presented to provide a better understanding of this region of the hand.

    • Keywords:
    • thumb basal joint arthritis

    • thumb carpometacarpal joint arthritis

    • thumb CMC joint arthritis

    • thumb trapeziometacarpal joint arthritis

    • thumb TM joint arthritis

    • anatomy

    • biomechanics

    • kinematics

    • etiology

    • diagnosis

    • physical examination

    • imaging

    • surgical management

    • indications

    • contraindications

    • trapezium excision

    • ligament reconstruction tendon interposition arthroplasty

    • LRTI arthroplasty

    • abductor pollicis longus suspensionplasty

    • APL suspensionplasty

    • outcomes

    • rehabilitation

    • Subspecialty:
    • Hand and Wrist

The Reverse Total Shoulder Prosthesis: Pearls and Pitfalls

Reverse total shoulder arthroplasty is a unique surgical solution for patients with pain and dysfunction from advanced glenohumeral joint arthritis associated with severe rotator cuff deficiency. In the normal shoulder, the rotator cuff and deltoid muscles work together to elevate the arm. However, with massive rotator cuff tears and advanced degenerative joint disease, the normal mechanics of the shoulder are disrupted, making arm elevation difficult if not impossible. The reverse shoulder prosthesis corrects this by providing a fixed fulcrum for the shoulder joint that allows the patient to use the deltoid muscle instead of the torn rotator cuff to lift the arm. Reverse total shoulder arthroplasty is still in its infancy, and a number of issues have yet to be resolved with this procedure; however, with thorough patient evaluation and careful patient selection, complications can be minimized, and satisfactory pain relief and increased range of motion can be achieved in most patients.

    • Keywords:
    • reverse total shoulder

    • shoulder prosthesis

    • total shoulder prosthesis

    • cuff tear arthropathy

    • cuff-tear arthopathy

    • rotator cuff tear

    • reverse ball-and-socket prosthesis

    • reverse shoulder prosthesis

    • Subspecialty:
    • Shoulder and Elbow

Preparation and Use of Antibiotic-Impregnated Beads for Orthopaedic Infections

Localized antibiotic therapy using antibiotic-impregnated bone cement has become an attractive option for treating severe orthopaedic infections. In the form of beads and spacers, antibiotic-impregnated cement can provide high concentrations of local antibiotic to a wound with minimal systemic toxic exposure. Clinical uses of antibiotic beads and spacers include prophylaxis for open fractures and total joint arthroplasties and in the treatment of acute and chronic osteomyelitis. Limited clinical data indicate that the use of antibiotic beads decreases the incidence of adverse effects observed with systemic antibacterial therapy. A detailed description of the"bead pouch"technique for the prevention of infection in open fractures is provided in this article.

    • Keywords:
    • antibiotic-impregnated bone cement

    • antibiotic-impregnated polymethylmethacrylate cement

    • antibiotic impreganted PMMA cement

    • antibiotic-impregnated polymethylmethacrylate beads

    • antibiotic-impregnated PMMA beads

    • tobramycin-impregnated beads

    • tobramycin-impregnated PMMA beads

    • gentamicin-impregnated beads

    • gentamicin-impregnated PMMA beads

    • open fracture

    • acute and chronic osteomyelitis

    • periprosthetic infection

    • bone cement

    • Subspecialty:
    • Trauma