Instructional course lectures最新文献

Limb salvage surgery has become the primary means of treatment for patients with malignant tumors of the extremities and pelvis. For these patients, endoprostheses have become the principal means to reconstruct the extremity following an oncologic resection because they offer an off-the-shelf-option that is modular, cost effective, and durable. As with other forms of arthroplasty, several modes of failure can occur, with infection being common. Management of an infected endoprosthesis is individualized based on numerous factors that the treating surgeon needs to consider. It is important to provide a framework for the workup and subsequent treatment of patients with an infected endoprosthesis.

With the rise of internet and social media usage in the 21st century, patients have increasingly been looking to online resources for information regarding their health care. It is imperative for physicians to recognize the trends and role of these tools in clinical orthopaedic practice, and to harness these tools to educate users, connect with other physicians, and interact with current and potential patients. It is important to review the current literature regarding social media in orthopaedics; some commonly used social media platforms and their individual characteristics; and general guidelines for creating content and managing an online reputation.

Tendinopathies around the hand and wrist are common. Most are diagnosed easily with a thorough history and clinical examination. Common conditions involving the hand and wrist include trigger finger, de Quervain tenosynovitis, intersection syndrome, third and fourth extensor compartment tenosynovitis, extensor carpi ulnaris tendinitis, and flexor carpi radialis tendinitis. Management strategies include nonsurgical treatments comprising immobilization, corticosteroid injections, or hand therapy, and surgical techniques including tendon release.

The medial ulnar collateral ligament of the elbow is the primary stabilizer against valgus load. It can tear acutely or through attritional damage as in repetitive overhead sports. Although baseball players, particularly pitchers, are the most vulnerable athletes, these injuries also occur in contact athletes, gymnasts, and javelin throwers. Presentation consists of acute medial elbow pain with associated loss of command, control, and throwing velocity in pitchers. Attention should be given to associated risk factors including workload. Ulnar neuritis is a commonly associated condition because of its close proximity to the posterior band of the ulnar collateral ligament. Physical examination focuses on the ulnar collateral ligament, but also identifies associated pathology and kinetic chain factors that may predispose a player to injury. Tears are classified by location (proximal, midsubstance, distal) and extent (partial versus full thickness). Nonsurgical treatment may be a viable option for partial-thickness tears and includes rest from activity, flexor-pronator strengthening, and possible platelet-rich plasma injections.

With an estimated incidence of 0.02% to 0.2%, multiligamentous knee injuries are rare, often devastating injuries that can occur with concomitant vascular or neurologic involvement. Generally, outcomes of surgical treatment have been superior to those of nonsurgical treatment for active individuals and the general population. Surgical treatment options include primary repair, reconstruction, or augmentation. However, the ideal timing of treatment, both surgery and rehabilitation, is unclear. Options include acute (ie, within 3 weeks), subacute (3 to 8 weeks), and delayed treatment of all ligaments simultaneously, or alternatively managed in two stages. Primary repair can be considered in avulsion injuries of the posterior cruciate ligament and posteromedial corner and distal posterolateral corner avulsions; however, treatment paradigms are still evolving. Reconstruction is preferred in younger patients, for most midsubstance injuries and cruciate ligament injuries, and when presentation is delayed. Early surgery may be associated with better outcomes and a lower incidence of cartilage lesions compared with delayed surgery, although there may be an increased risk of arthrofibrosis. More traditional protocols often restrict weight bearing in the first weeks to protect ligament healing. Although early range-of-motion exercises decrease the risk of stiffness following surgery for multiligamentous knee injury, concern remains regarding attenuation or loosening of the surgically repaired or reconstructed ligaments. The Surgical Timing and Rehabilitation trial has been designed to assess the outcomes of early versus delayed surgery and early versus delayed rehabilitation.

Osteochondral and chondral injuries of the patellofemoral joint are common in active patients, and effective management requires a thorough physical and imaging evaluation, a detailed understanding of the unique anatomic and biomechanical joint properties contributing to these injuries, and an appropriate selection of treatment modality. Diagnosis of patellofemoral chondral injuries can be challenging, and differentiating between various causes of anterior knee pain is crucial to successful outcomes. Once identified, nonsurgical treatments including physical therapy, bracing, and injections are a mainstay of initial management. Surgical interventions for patellofemoral chondral injuries include palliative, restorative, and reconstructive techniques. It is important to consider overall limb alignment and patellar tracking in these patients to determine the appropriate role of realignment osteotomy procedures in addition to directly addressing the chondral lesion. An understanding of the array of multiple nonsurgical and surgical treatment modalities can allow for improvement in symptoms and function for this challenging clinical problem.

Osteotomies around the knee have a variety of indications, including pain reduction, functional improvement, knee joint stabilization, and articular cartilage preservation. Thorough preoperative planning is essential, including a determination of the precise location of any deformity (proximal tibia, distal femur, or both). High tibial osteotomies and distal femoral osteotomies can be performed in isolation, or jointly in the form of a double-level osteotomy, for correction of coronal and/or sagittal deformity of the knee. There are many technical tips and tricks to simplify these cases for safe and effective execution, including selection of the proper procedure for a given deformity, selection of optimal osteotomy hinge points, and soft-tissue handling for different surgical approaches.

Extensor tendon injuries are commonly encountered after trauma. These injuries often result in acute weakness and have widely differing treatment options depending on the severity and the location of the injury within the upper extremity. Zone I injuries can often be treated nonoperatively with the potential for pinning of any large bony avulsion fragments. For zone II injuries, the tendons are often amenable to surgical repair with extension splinting for 6 weeks. Injuries at the central slip in zone III are often treated with closed extension splinting. In zone IV, these injuries are often treated similarly to those in zone II. Zone IV injuries without any extensor lag can often be treated nonoperatively with splinting; however, extension weakness is an indication for surgical repair. In zone V, the tendon is often substantial enough to hold sutures; however, because these injuries are often a result of a human bite wound, these are susceptible to more delayed repair or reconstruction following irrigation and débridement. Injuries in zone VI are often treated with direct repair as well as immobilization. More proximally, over the level of the wrist joint and up through to the forearm, these injuries are often treated with direct repair.

Fracture-related infection (FRI) is a serious complication that occurs primarily in surgically treated fractures. FRIs occur when bacteria enter the site of bony injury and alter the healing inflammatory response within the bone. This can prevent bone regeneration and can lead to long-lasting complications such as chronic infection, pain, nonunion, and amputation. FRIs can span a wide range of severity, and only recently has the international community come to a consensus on specific definitions and guidelines for treatment. Principles of FRI management include identification of at-risk injuries with correction of modifiable risk factors, the achievement of adequate bony union and fracture healing, thorough eradication of the offending microorganism, and restoration of function. Treatment strategies involving implant retention versus removal depend on several factors, including the acuity of the infection, host physiology, initial reduction quality and fracture stability, and implant stability. Antibiotic treatment of FRI has historically been intravenous; however, emerging data suggest oral antibiotics may be just as efficacious.

Revision total knee arthroplasty (rTKA) is an increasingly common challenge for arthroplasty surgeons. The survivorship of rTKA is significantly lower than that of primary total knee arthroplasty, resulting in increasing numbers of repeat rTKA. These repeat rTKAs present unique challenges including potentially massive bone loss and increased risk of infection. It is important to highlight advanced implant fixation techniques in the setting of massive bone loss as well as the management of periprosthetic joint infection following rTKA and repeat rTKA.