J Am Acad Orthop Sur
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J Am Acad Orthop Sur · Aug 2014
ReviewManagement of malunion of the proximal humerus: current concepts.
Proximal humerus fractures remain one of the most common orthopaedic injuries, particularly in the elderly. Displaced fractures often require surgery, and management can be challenging because of comminution and poor bone quality. Despite advances in surgical technique and implant design, reoperation for malunion or nonunion of the tuberosity (arthroplasty) or screw penetration (open reduction and internal fixation) remains problematic. ⋯ Surgical neck malunion can be managed with corrective osteotomy and preservation of the native joint. Arthroplasty is reserved for complex malunions with joint incongruity. Surgical management of symptomatic proximal humeral malunion remains challenging, but good outcomes can be achieved with proper patient selection.
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Over the past 20 to 30 years, arthroscopic shoulder techniques have become increasingly popular. Although these techniques have several advantages over open surgery, surgical complications are no less prevalent or devastating than those associated with open techniques. Some of the complications associated with arthroscopic shoulder surgery include recurrent instability, soft-tissue injury, and neurapraxia. ⋯ The surgeon must maintain a high index of suspicion for this infection. Thromboemoblic complications associated with arthroscopic shoulder techniques are also rare, and studies have shown that pharmacologic prophylaxis has minimal efficacy in preventing these complications. Because high-quality studies on the subject are lacking, minimal evidence is available to suggest strategies for prevention.
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J Am Acad Orthop Sur · May 2014
ReviewOccupational hazards for pregnant or lactating women in the orthopaedic operating room.
Pregnant or lactating staff working in the orthopaedic operating room may be at risk of occupational exposure to several hazards, including blood-borne pathogens, anesthetic gases, methylmethacrylate, physical stress, and radiation. Because the use of proper personal protective equipment is mandatory, the risk of contamination with blood-borne pathogens such as hepatitis B, hepatitis C, and HIV is low. Moreover, effective postexposure prophylactic regimens are available for hepatitis B and HIV. ⋯ Short periods of moderate physical activity are beneficial for pregnant women, but prolonged strenuous activity can lead to increased pregnancy complications. The risk of prenatal radiation exposure during orthopaedic procedures is of concern, as well. However, proper lead protection and contamination control can minimize the risk of occupational exposure to radiation.
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J Am Acad Orthop Sur · Mar 2014
ReviewGuidelines for medial patellofemoral ligament reconstruction in chronic lateral patellar instability.
The standard surgical approach for chronic lateral patellar instability with at least two documented patellar dislocations is to stabilize the patella by using an anatomic medial patellofemoral ligament reconstruction with a mini-open technique and a graft that is stronger than the native ligament to compensate for the uncorrected predisposing factors underlying patellar instability. Even though medial patellofemoral ligament reconstruction has evolved notably during the past two decades, many aspects of the surgical technique need to be refined, and more information is needed toward this end. Adequate positioning of the graft on the femur, as well as inducing the appropriate degree of tension, are critical steps for the overall outcome of medial patellofemoral ligament reconstruction. Moreover, it is necessary in some cases to pair medial patellofemoral ligament reconstruction with other surgical procedures to address additional patellar instability risk factors, such as trochlear dysplasia, malalignment, and patella alta.
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Posterior shoulder dislocation occurs rarely and is challenging to manage. The mechanisms of trauma are varied, which complicates diagnosis. Missed or delayed diagnosis and treatment can have serious deleterious effects on shoulder function. ⋯ Identification of associated injuries, such as fractures and rotator cuff tears, is important to guide treatment. In the acute setting, most patients are treated with closed or open reduction with additional soft-tissue or bony procedures. Patients treated in a delayed fashion for persistent instability may require additional procedures, including arthroplasty.