Orthopaedics and Trauma最新文献

Acromioclavicular joint (ACJ) injuries represent approximately 10% of all shoulder girdle injuries and their assessment and management can be clinically challenging. This may be for several reasons, including a lack of consensus concerning the reliability of the classification systems, contributing to suboptimal clinical outcomes. A paucity of literature regarding predictive factors for ACJ pathology may also be a factor. Controversy regarding conservative versus surgical management to provide optimal care also continues to be a factor in this clinical challenge, as similar results have been shown with both approaches. There is consensus that low-grade injuries can be treated with non-operative management, but some will go on to have long-term complications. However, the risks of surgical intervention may not out-weigh the benefits. In higher grade injuries there is further controversy over conservative versus surgical management. Improved classification systems and shared decision-making to individualize treatment plans are likely to improve patient outcomes. This review provides an overview of current assessment and management of ACJ injuries in adults.

The sternoclavicular joint is the only true joint connecting the upper limb with the axial skeleton and is reliant on its capsular and ligamentous attachments for stability. Injuries to the sternoclavicular joint are uncommon and include sprains, dislocations, and fractures. Dislocations and medial clavicle fractures are often associated with high-energy trauma and can lead to life-threatening complications secondary to mediastinal injuries, particularly with posterior sternoclavicular joint dislocations. Given the rarity of these injuries, there are multiple case reports and retrospective studies detailing novel surgical techniques for managing injuries of the sternoclavicular joint and no single option has been implemented. We conducted a literature search on Medline, EMBASE and CINAHL to identify relevant articles focusing on sternoclavicular joint dislocation and subluxation, and medial clavicle fractures in adults. This review article aims to describe: the anatomy of the sternoclavicular joint; injuries including dislocation and medial clavicle fractures; and current investigation and management options including closed and open reduction techniques.

Clavicle fractures account for approximately 2.6% of all fractures. Non-union following a clavicle fracture is associated with morbidity. The management of clavicle fractures, specifically operative and non-operative, has been debated. This article aims to provide clear, evidence-based guidance to direct clinical decision-making.

Management of pre-collapse atraumatic avascular necrosis of the femoral head remains a controversial topic. We conduct this scoping literature review to discuss current perspectives on management. Avascular necrosis of the femoral head (AVNFH) is a progressive pathology of the hip. If left untreated, 80% of cases progress to collapse of the femoral head and require total hip arthroplasty (THA). It is the third commonest reason for THA in the UK (and this proportion is even higher in other parts of the world) and, compared to other indications for THA, affects a disproportionately young population. Successful management demands early diagnosis and interventions to prolong native hip-joint preservation and delay femoral head collapse. Pathophysiology is poorly understood and aetiologies are varied. The ultimate cause of the disease is loss of blood supply to the proximal femur. AVNFH can be traumatic (fracture or dislocation) or atraumatic (80% due to corticosteroid use or alcohol excess). Traumatic causes of AVNFH require accurate and expedient management to prevent AVNFH post-injury. Fixation of fractures requires anatomical reduction to reduce the risk of AVNFH. Dislocation of the proximal femur requires reduction within 12 hours. Hips reduced after this time are much more likely (5.627 odds ratio) to suffer AVNFH. Atraumatic AVNFH can be managed conservatively, pharmacologically or surgically. Surgical interventions such as core decompression or osteotomy have a large body of evidence demonstrating that they can improve symptoms, delay progression and reduce the need for conversion to THA. There are many emerging augmentation procedures, and variations to established procedures, that utilize non-vascularized bone grafts, vascularized bone grafts and bone morphogenetic protein. There is a growing body of evidence to suggest that these augmentations improve outcomes.

An understanding of biomechanics underpins our appreciation of the structure and function of the musculoskeletal system and informs clinical decisions and treatment choices. Since it is so fundamental it frequently features in end-of-training examinations in trauma and orthopaedic surgery, often in questions testing higher order thinking in which knowledge of the basics is assumed and it is the application of these principles that is the focus. This article arms the trainee with these basics, starting with the application of Newtonian principles to statics and dynamics, applying these and then introducing material properties including the viscoelastic tissues that build the musculoskeletal system.

Whilst robotics have been used in surgery since their first application in neurosurgical biopsies in 1985, many surgeons have limited familiarity or experience with robotics through access or exposure to current or developing applications, particularly the systems that have brought robotics to orthopaedics. This paper reviews the well-established applications of operative orthopaedic robotics, developing and future applications, and extraoperative surgical robotics, with due consideration to their limitations. This review describes the different types of fundamental robotic systems, including master–slave, passive, semi-active and active systems. Its discussion of system types gives the reader insight into the different relationships between surgeon and robot, varying from full active systems, autonomous image-based surgical operating, through to the master–slave direct relationship with the surgeon, with the robot's replication of the surgeon's live tracked movements. A review of widely adopted systems within arthroplasty and developing concepts allows the reader to develop their understanding of how these systems operate and their future potential, giving a broad understanding of robotics. This narrative review discusses the fundamentals of orthopaedic robotics, as systematic reviews of each application, their data sets and evidence have been documented elsewhere. The paper concludes by highlighting the advantages of robotic systems in orthopaedic surgery, such as precision and reproducibility, and insight into the future of orthopaedic robotics and provides a useful basis for understanding the role of robotics in orthopaedics and their potential applications for surgeons.

Hyperbaric oxygen (HBO) therapy involves intermittent inhalation by the patient of 100% oxygen under a pressure greater than 1 atmosphere. Both therapeutic and toxic effects can result from two features of this form of treatment; mechanical effects arising from exposure to increased ambient pressure and the physiological effects of hyperoxia. Substantial evidence supports the use of HBO therapy in certain carefully defined settings, though many patients who might benefit go untreated because of their physicians' unfamiliarity with recent research and overall uncertainty about the legitimacy of HBO as a therapy. The author discusses the mechanism of action of HBO therapy and the commonly accepted clinical indications.

Surgical site infections (SSI) continue to represent a significant postoperative burden. SSI is associated with an increased risk of morbidity and mortality. Systemic antibiotic prophylaxis (SAP) is used to reduce the risk of SSI. Several factors must be considered for appropriate antibiotic use: antibiotic selection, timing, and duration. The evidence and use of antibiotics differs between closed fractures, open fractures, arthroplasty and percutaneous fixation. The use of SAP is a balance between reducing the incidence of SSI whilst maintaining proper antibiotic stewardship to limit adverse effects and the emergence of antibiotic resistance. This paper will discuss the evidence for the use of SAP in orthopaedic surgery and the potential adverse effects of the injudicious use of antibiotics.