The open orthopaedics journal
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The patient with an unstable shoulder represents a challenge for the anesthesiologist. Most patients will be young individuals in good health but both shoulder dislocation reduction, a procedure that is usually performed under specific analgesia in an urgent setting, and instability surgery anesthesia and postoperative management present certain peculiarities. ⋯ The patient with an acutely dislocated shoulder is usually managed in the emergency room. Although reduction without analgesia is often performed in non-medical settings, an appropriate level of analgesia will ease the reduction procedure avoiding further complications. Intravenous analgesia and sedation is considered the gold standard but requires appropriate monitorization and airway control. Intraarticular local analgesic injection is considered also a safe and effective procedure. General anesthesia or nerve blocks can also be considered. The surgical management of the patient with shoulder instability requires a proper anesthetic management. This should start with an exhaustive preoperative evaluation that should be focused in identifying potential respiratory problems that might be complicated by local nerve blocks. Intraoperative management can be challenging, especially for patients operated in beach chair position, for the relationship with problems related to cerebral hypoperfusion, a situation related to hypotension events directly linked to patient positioning. Different nerve blocks will help attaining excellent analgesia both during and after the surgical procedure. An interescalene nerve block should be considered the best technique, but in certain cases, other blocks can be considered.
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Proximal humeral fractures in elderly patients present with severe comminution and osteoporotic bone quality. Reverse shoulder arthroplasty has lately been proven beneficial in treating patients with complex proximal humeral fractures. The above technique is recommended and has better results in elderly than in younger individuals. ⋯ Although long-term results and randomized studies for reverse prosthesis are lacking, short and mid- term outcomes have given promising results encouraging more shoulder surgeons to use this type of prosthesis in proximal humeral fractures.
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The review evaluates the up-to-date evidence for the treatment of spinal deformities, including scoliosis and hyperkyphosis in adolescents and adults. ⋯ There is at present high quality evidence in support of the conservative treatment of AIS. The current evidence supports the use of PSSE, especially those using PSSR, together with bracing in the treatment of AIS. In view of the lack of medical consequences in adults with AIS, conservative treatment should be considered for curves exceeding the formerly assumed range of conservative indications.There is, however a lack of evidence in support of any treatment of choice for hyperkyphosis in adolescents and spinal deformities in adults. Yet, conservative treatment should be considered first. Yet to date, there is no high quality evidence (RCT`s) demonstrating that surgical treatment is superior to conservative treatment for the management of AIS and hyperkyphosis. Additionally, surgery needs to be considered with caution, as it is associated with a number of long-term complications.
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Simple elbow dislocations are a commonly seen joint dislocation involving a sequential disruption of the soft tissue stabilisers without a significant associated fracture. ⋯ The majority of simple elbow dislocations can be successfully managed non-operatively with good reliable outcomes. Careful follow up is essential, however, to identify patients that may occasionally develop persistent instability or stiffness and require intervention.
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There is ongoing debate about how to obtain correct rotational alignment in total knee arthroplasty (TKA). Two commonly used techniques are the measured resection (MR) and the gap balancing (GB) technique. ⋯ Gap-balancing is a safe and reliable technique. KS for the two study groups at 10 years can be considered equivalent, and the small postoperative advantages may not extend beyond clinical relevance.