Instructional course lectures最新文献

Osteochondral lesions of the talus involve injury to the articular cartilage and underlying subchondral bone. These lesions are difficult to treat because of the poor blood supply and poor regenerative capacity of the talar articular cartilage. It is important to provide a comprehensive overview of the clinical presentation, diagnostic tools, and nonsurgical and surgical treatment strategies for osteochondral lesions of the talus.

Chronic fracture-related infection is a complex, costly clinical problem with a wide spectrum of clinical presentations. The goals of treatment are infection control with a healed fracture covered by well-vascularized soft tissue and improvement of patient pain and function. Management is both medical, with culture-targeted antimicrobial agents, and surgical, requiring meticulous irrigation and débridement. Overall surgical treatment paradigms depend on several critical factors, including whether the bone is united, the location of fracture-related infection, implant stability, soft-tissue status, and host fitness for undergoing surgeries. Specific surgical considerations such as the technical management of bony defects are a source of controversy and ongoing research, although there is emerging evidence that suggests bone transport methods may be the most reliable option for large bone defects. With host optimization and proper treatment, high rates of infection control can be achieved. However, relapse of infection may occur, which would add a costly burden to both the patient and society.

Periprosthetic femur fractures around the hip are one of the most common aseptic complications following total hip arthroplasty. Understanding the risk factors of periprosthetic femur fracture can aid surgeons in the prevention of these injuries. The Vancouver classification provides a reproducible description of the factors that should be considered in the treatment of patients with periprosthetic femur fractures: fracture site, implant stability, and bone stock. It is important for the surgeon to review the epidemiology and risk factors for periprosthetic femur fractures around the hip along with contemporary strategies for the management of these fractures based on fracture type, location, and status of the femoral prosthesis.

In the young, active patient with osteoarthritis, the optimal treatment of B2 glenoid morphology remains a subject of continued debate. Current treatment options have specific advantages and disadvantages. These treatments include hemiarthroplasty with or without glenoid reaming, total shoulder arthroplasty (TSA) with or without eccentric reaming, TSA with bone graft or posteriorly augmented glenoid implant, and reverse TSA. Eccentric glenoid reaming can be effective but has the risk of excessive reaming of subchondral bone for greater retroversion deformities, compromising implant purchase with the risk of future subsidence and diminished remaining bone stock for future revision. Bone graft augmentation, although a technically challenging procedure, can be effective in select patients with excellent bone quality, but has a high risk of postoperative complications. Posteriorly augmented anatomic glenoid components can correct glenoid version while maintaining native bone stock, presenting an intriguing option for further research. Finally, the long-term success of an anatomic total shoulder relies on version and inclination correction and preservation of subchondral bone, while maintaining stability. If all three of these parameters cannot be adequately achieved, then reverse TSA may be the best option: this treatment is a more stable construct that is more tolerant to glenoid deformity, loss of glenoid bone stock, and muscular imbalance.

Musculoskeletal injuries in children offer unique challenges compared with those in adults. Even low-energy injuries that involve the physis have the potential to cause a growth disturbance that could require treatment. Higher-energy injuries can be complicated by the same soft-tissue disruption, fracture contamination, and bone loss that are seen in adults. However, small patient size and injury proximity to a physis can complicate both immediate and long-term management. It is important to be aware of treatment tools and strategies when managing complex injuries in young patients.

Lateral epicondylitis, de Quervain tenosynovitis, and trigger finger are among the most common tendinopathies of the upper extremity. Lateral epicondylitis is a common condition that can be very frustrating to patients. Many patients will improve without any acute interventions. Physical therapy has been shown to be helpful as initial treatment, and surgery can be helpful for persistent symptoms. de Quervain tenosynovitis similarly responds well to nonsurgical modalities, including brace treatment and injections, and surgery can be effective for recalcitrant cases. Finally, trigger finger is a common condition that can result from thickening and scarring of the A1 pulley, which can be bothersome to patients. Typical treatment in this area involves corticosteroid injections or surgery as definitive management. The treatments for these conditions are straightforward following the approach described herein and could be managed by any general orthopaedic surgeon.

Orthopaedic surgery has a higher risk of iatrogenic nerve injury than other surgical specialties. The initial management depends on the etiology, which requires early recognition and an appreciation for the injury. Three perspectives are given to guide the surgeon through the initial management of these devastating complications. An orthopaedic surgeon with a knowledge of case law emphasizes the importance of clear documentation and frequent communication with the patient. An anesthesiologist discusses the improvements in regional anesthesiology and the risks inherent in motor-sparing blocks. Finally, a peripheral nerve surgeon offers next steps in confirming the diagnosis and the importance of prompt referral.

Ankle arthritis is a severely disabling condition. Treatment poses many unique challenges to orthopaedic surgeons because ankle kinematics differs from that seen in the hip or knee joint and the loads transmitted through the ankle are greater during activity. Historically, motion-sacrificing procedures dominated management of ankle arthritis. It is important to review the updates on joint-preserving and joint-sacrificing strategies for the management of ankle arthritis.

The management of massive irreparable rotator cuff tears is commonly debated without consensus. With reverse shoulder arthroplasty often reserved for the older patient (older than 60 years) with rotator cuff arthropathy, treatment of the younger patient population (younger than 60 years) without arthritis is more complex. When determining a surgical approach, the clinical presentation including history and physical examination plays a vital role in the decision tree. The nonarthroplasty surgical treatment options include débridement, partial repair, superior capsule reconstruction, tendon transfer, and balloon spacers. It is important to discuss the overall approach to management, with a focus on the evidence-based advantages and disadvantages of each treatment option. The fundamental conclusion is that in the setting of insufficient randomized controlled trials comparing treatment options, surgical decisions should be based on surgeon experience, patient history, examination, advanced imaging findings, patient expectations, ability to complete postoperative rehabilitation, and shared decision making.

Fracture-related infections are a significant burden to the patient, associated with high health care costs and use of resources. Therefore, prevention is more critical than treatment of infection. There are injury- and patient-related risk factors that are mostly not modifiable, with the exception of a few patient-specific ones such as control of blood glucose levels in patients with diabetes. Measures of prevention can be implemented preoperatively, intraoperatively, and postoperatively.