Instructional course lectures
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Athletes sustain ankle syndesmosis injuries far less frequently than they do lateral ankle sprains; however, syndesmosis injuries are more challenging to detect and treat. Grade II injuries, which are occultly unstable, may be overlooked or treated too conservatively (nonsurgically), leading to latent diastasis, chronic instability, further injury, arthritic changes, chronic pain, osteochondral lesions, and other sequelae. Surgical intervention for chronic syndesmosis injuries produces mixed results and creates an uncertain future for athletes who desire to return to their sport. ⋯ All acute unstable syndesmosis injuries (grades II and III) should be treated with surgery, which can include repair of the deltoid ligament with open reduction and internal fixation of the syndesmosis. Isolated deltoid sprains also are often repaired surgically in athletes. This more aggressive treatment helps avoid the chronic pain and instability and osteochondral abnormalities associated with chronic injury.
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Lumbar spinal stenosis, which affects an ever-increasing number of patients, is best defined as a collection of clinical symptoms that includes low back pain, bilateral lower extremity pain, paresthesias, and other neurologic deficits that occur concomitantly with anatomic narrowing of the neural pathway through the spine. The narrowing may be centrally located in the spinal canal or more laterally in the lateral recesses or neuroforamina. Lumbar spinal stenosis can have a congenital or acquired etiology, and the origin of acquired lumbar stenosis is classified as degenerative, posttraumatic, or iatrogenic. ⋯ A significant number of patients improve after nonsurgical treatment, although most studies have found that patients treated surgically have better clinical results. Delaying surgical treatment until after a trial of nonsurgical treatment does not affect the outcome. Surgical intervention should be considered only if a comprehensive program of nonsurgical measures fails to improve the patient's quality of life.
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The field of hip arthroscopy continues to grow as surgeons become more familiar with disorders of the intra-articular and extra-articular compartments of the hip. Recent studies have described the endoscopic treatment of injuries to the lateral peritrochanteric compartment of the hip, including recalcitrant trochanteric bursitis, external coxa saltans, and tears of the gluteus medius and minimus tendons.
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Blood management during total hip arthroplasty is a critical component of successful patient care, and an overall strategy is necessary. Multiple options for blood management are available, including the use of predeposited autologous blood, perioperative blood salvage, hemodilution techniques, erythropoietic agents, hemostatic agents, and allogeneic blood. Rather than relying on automatic so-called transfusion triggers, the surgeon should identify patient-specific risk factors such as the anticipated difficulty of the procedure, preoperative hemoglobin level, comorbidities, and a plan for blood management.
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Lumbar spinal stenosis associated with adult scoliosis is being increasingly recognized and studied. Degenerative changes leading to spinal stenosis can precede a spinal deformity resulting in de novo scoliosis. Conversely, degenerative changes leading to spinal stenosis can occur in a preexisting deformity. ⋯ The optimal surgical procedure depends on a careful evaluation of involved segments and patient comorbidities. Positive sagittal imbalance is associated with significant morbidity and should be corrected when feasible. Data that continue to be collected in this patient population will guide future efforts in treating this complicated disease.