Instructional course lectures
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The management of nonunion and malunion in the metacarpals and phalanges is influenced by the multiple gliding structures and the propensity for stiffness, the ability of adjacent digits to substitute functionally for compromised digits, the small size of the bones, and associated complications. Amputation and arthrodesis are useful treatment options for nonunions in the hand because they are nearly always atrophic, are frequently associated with joint stiffness and tendon adhesions, and often occur in digits with poor nerve function, vascularity, or skin cover. Surgical fixation with autogenous bone grafts and stable internal fixation has a high union rate with resultant restoration of alignment and stability, but achieves modest improvements in motion. ⋯ This is particularly true for articular fractures. Once these fractures are mature, it may be preferable to perform an extra-articular osteotomy. If a late intra-articular osteotomy is performed, it should be done in such a way as to create large fragments that are easier to repair and more likely to retain their blood supply.
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Injuries of the cervical spine in the pediatric and adolescent athlete are less common than other musculoskeletal injuries. Although many of these injuries are relatively minor, serious and potentially unstable or progressive spinal injury must be excluded. Important anatomic differences between the child younger than 10 years and older children and adolescents influence the types of injuries sustained and make assessment of the child's cervical spine sometimes difficult for practitioners accustomed to treating adolescent and adult athletes. ⋯ Young athletes sustain CCN secondary to hypermobility of the immature cervical spine. Return to play after these injuries is controversial. The athlete with Down syndrome and potential cervical hypermobility requires a careful cervical and neurologic evaluation prior to clearance for participation in sports.
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The Smith-Petersen osteotomy has been a mainstay in the treatment of sagittal deformity since it was first described in 1945. The primary indication for an osteotomy is fixed sagittal deformity. When an osteotomy is performed in a patient with ankylosing spondylitis, it can be combined with an anterior column osteoclasis to achieve a correction of up to 40 degrees to 50 degrees. When performed for other indications, the osteotomy can result in approximately 10 degrees of correction per level treated.
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The two-incision minimally invasive technique for total hip arthroplasty is described in detail, with attention to pearls of technique, for a prospective group of 200 patients, as well as a matched-pair group of 43 patients who underwent either the two-incision procedure or the mini-incision (single-incision posterior) procedure. The importance of a total hip critical pathway is emphasized, and the economic benefits are presented. Results reveal that the two-incision and mini-incision techniques have acceptable complication rates, are cost effective, and are beneficial to the patient, with reduced hospital stays, high patient satisfaction, and earlier return to function.
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Performing hip arthroscopy with the patient in the lateral decubitus position is advantageous in aiding in visualization of the hip joint, in maneuvering instruments in obese patients, and in facilitating entry to the hip joint in patients with spurs on the anterolateral aspect of the acetabulum. The patient is placed in the lateral decubitus position with the hip on which the surgery is being performed on the top. The leg is placed in traction and a well-padded perineal post is applied for countertraction. ⋯ A regular traction table requires adjustments of the perineal and traction posts to apply traction to the leg of a patient in the lateral decubitus position. Special traction devices make setup easier. The lateral approach to hip arthroscopy provides a safe and consistent method of entering, visualizing, and performing surgical procedures on the hip.