J Am Acad Orthop Sur
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Recent studies have demonstrated that sagittal balance is the most important and reliable radiographic predictor of clinical health status in the adult with a spinal deformity. Affected persons typically present with intractable pain, early fatigue, and a perception of being off-balance. Nonsurgical management with nonsteroidal and analgesic medications as well as physical therapy plays a limited role. ⋯ Options include posterior-only or combined anterior-posterior surgery. The decision-making process often includes posterior-based osteotomies, such as the Smith-Petersen or pedicle subtraction, or vertebral column resection. Regardless of approach or osteotomy technique, spinal fusion with restored sagittal balance is the goal of any reconstructive procedure.
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J Am Acad Orthop Sur · Jun 2009
ReviewComplications of volar plate fixation for managing distal radius fractures.
Volar locking plate fixation via open reduction and internal fixation is an increasingly accepted method for managing displaced distal radius fractures. Volar plating offers biomechanically stable fixation, allows early rehabilitation, and enables fixation of comminuted or osteopenic bone. ⋯ The surgeon must be mindful of potential soft-tissue, neurovascular, and osseous complications, such as extensor tendon and flexor tendon injury, flexor pollicis rupture, carpal tunnel syndrome, complex regional pain syndrome, and loss of reduction, as well as hardware failure. Increased awareness of potential complications may lead to more prompt recognition and treatment when they do arise.
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Acromioclavicular joint injuries represent nearly half of all athletic shoulder injuries, often resulting from a fall onto the tip of the shoulder with the arm in adduction. Stability of this joint depends on the integrity of the acromioclavicular ligaments and capsule as well as the coracoclavicular ligaments and the trapezius and deltoid muscles. Along with clinical examination for tenderness and instability, radiographic examination is critical in the evaluation of acromioclavicular joint injuries. ⋯ Management of type III injuries remains controversial, with nonsurgical treatment favored in most instances and reconstruction of the acromioclavicular joint reserved for symptomatic instability. Recommended techniques for stabilization in cases of acute and late symptomatic instability include screw fixation of the coracoid process to the clavicle, coracoacromial ligament transfer, and coracoclavicular ligament reconstruction. Biomechanical studies have demonstrated that anatomic acromioclavicular joint reconstruction is the most effective treatment for persistent instability.
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Fracture-dislocations of the elbow remain among the most difficult injuries to manage. Historically, the combination of an elbow dislocation, a radial head fracture, and a coronoid process fracture has had a consistently poor outcome; for this reason, it is called the terrible triad. ⋯ Recent literature has improved our understanding of elbow anatomy and biomechanics along with the pathoanatomy of this injury, thereby allowing the development of a systematic approach for treatment and rehabilitation. Advances in knowledge combined with improved implants and surgical techniques have contributed to better outcomes.
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Necrotizing fasciitis is a rare but life-threatening soft-tissue infection characterized by rapidly spreading inflammation and subsequent necrosis of the fascial planes and surrounding tissue. Infection typically follows trauma, although the inciting insult may be as minor as a scrape or an insect bite. Often caused by toxin-producing, virulent bacteria such as group A streptococcus and associated with severe systemic toxicity, necrotizing fasciitis is rapidly fatal unless diagnosed promptly and treated aggressively. ⋯ Thus, a high degree of clinical suspicion is necessary to avert potentially disastrous consequences. Orthopaedic surgeons are often the first to evaluate patients with necrotizing fasciitis and as such must be aware of the presentation and management of this disease. Timely diagnosis, broad-spectrum antibiotic therapy, and aggressive surgical débridement of affected tissue are keys to the treatment of this serious, often life-threatening infection.