Instructional course lectures最新文献

Percutaneous pin configuration for the management of pediatric supracondylar humerus fractures has been studied extensively both in the biomechanics laboratory and in the clinical setting. Medial entry pins (ie, crossed pinning) increase supracondylar humerus fracture construct stability under certain loading conditions. However, there are noted drawbacks of medial entry pinning, specifically the risk of iatrogenic ulnar nerve injury. In most circumstances, the additional biomechanical stability of crossed pinning is unlikely to be clinically necessary for maintenance of fracture alignment, but there are scenarios in which medial entry pins should be strongly considered. It is important to review the biomechanics of various pin configurations in the setting of pediatric supracondylar humerus fractures, discuss the indications for medial entry pinning (crossed pinning), and discuss a safe technique for applying medial entry pins when indicated.

Total knee arthroplasty (TKA) is one of the most popular and successful procedures of the past century. However, as the number of TKAs continues to increase, the volume of revision surgeries also will increase. Although revision TKAs are often successful, adult reconstruction surgeons will likely continue to see patients with limited arthroplasty options after multiple failed revision TKAs. This raises the question of limb salvage versus transfemoral amputation as the final procedure option. It is important to review modern techniques for the patient who has undergone multiple revision TKAs with significant bone loss or chronic infection. These techniques include distal femur replacement, total femur arthroplasty, knee arthrodesis, and transfemoral amputation.

The transition between medical school and residency is a complex, multifaceted process that is commonly a time of stress and uncertainty for medical students. Occupying most of a student's final year of medical school, the residency application includes a primary Electronic Residency Application Service application, a variable number of program-specific secondary applications, and interviews. The application process culminates with The Match. Orthopaedic surgery is among the more competitive specialties; thus, it is critical that all involved parties understand the complexity of the process and the numerous variables that play into such a critical decision point in the career trajectory of a future physician. It is important to provide a mentor with an overview of the residency application process, specifically with respect to orthopaedic surgery, so that they may be best prepared to guide their medical student mentee through the process and help them find success.

A comprehensive review of scapular pathologies and their effect on shoulder function is necessary to determine the best treatment options. The coordinated motion between the scapulothoracic and glenohumeral joints is essential for shoulder motion and depends on the balanced activity of the periscapular muscles. Disruption in these muscles can cause abnormal scapular motion and compensatory glenohumeral movements, leading to misdiagnosis or delayed diagnosis. Scapular pathologies can arise from muscle overactivity or underactivity/paralysis, resulting in a range of scapulothoracic abnormal motion (STAM). STAM can lead to various glenohumeral pathologies, including instability, impingement, or nerve compression. It is important to highlight the critical periscapular muscles involved in scapulohumeral rhythm (such as the upper, middle, and lower trapezius; rhomboid major and minor; serratus anterior; levator scapulae; and pectoralis minor). A discussion of the different etiologies of STAM should include examples of muscle dysfunction, such as overactivity of the pectoralis minor, underactivity or paralysis of the serratus anterior or trapezius muscles, and dyskinesis resulting from compensatory mechanisms in patients with recurrent glenohumeral instability due to Ehlers-Danlos syndrome. The evaluation and workup of STAM has shown that patients typically present with radiating shoulder pain, especially in the posterior aspect of the shoulder and scapula, and limitations in active shoulder overhead motion associated with glenohumeral pain, instability, or rotator cuff pathologies.

Phalangeal fractures are extremely common in the pediatric and adolescent populations. The incidence of phalangeal fractures peaks in children ages 10 to 14 years, corresponding to the age in which children begin contact sports. Younger children are more likely to experience crush injuries, whereas older children often sustain phalangeal fractures during sports. The physis is particularly susceptible to fracture because of the biomechanically weak nature of the physis compared with the surrounding ligaments and bone. Phalangeal fractures are identified through a thorough physical examination and are subsequently confirmed with radiographic evaluation. Management of pediatric phalangeal fractures is dependent on the age of the child, the severity of the injury, and the degree of fracture displacement. Nondisplaced fractures are often managed nonsurgically with immobilization, whereas unstable, displaced fractures may require surgery, which is often a closed rather than open reduction and percutaneous pinning.

The management of periprosthetic fractures with unstable prosthetic implants is a challenging and commonly encountered problem. It is important to address the many current issues and controversies regarding the treatment of periprosthetic fractures with revision total joint arthroplasty. Key strategies to optimize surgical decision making around the use of arthroplasty and management of complications following these complex injuries will be addressed.

Although total hip arthroplasty (THA) has proved to be a successful surgical procedure, both prosthetic and bone impingement resulting in dislocation continue to occur. Studies have shown that spine pathology resulting in lumbar stiffness and hip arthritis often coexist. Spinopelvic mobility patterns during postural changes affect three-dimensional acetabular component position, which affects the incidence of prosthetic impingement and THA instability. Several spinopelvic risk factors that may affect THA stability have been identified. Numerous reports recommend performing a preoperative spinopelvic mobility analysis to identify risk factors and adjust acetabular component position accordingly to lessen the risk of impingement. In doing so, acetabular component position is individualized based on spinopelvic mobility patterns. Additionally, functional femoral anteversion, affected by individual femoral rotation patterns during dynamic activities, may contribute to the incidence of impingement. It is important to review the interrelationship between spine and pelvic mobility and how it relates to THA and may reduce the incidence of instability.

Elbow fractures are among the most common fractures sustained in pediatric patients. A specific set of pediatric elbow fractures (olecranon, radial neck, and lateral condyle fractures) comprises the ones that occur most often. It is important to review commonly accepted principles in the evaluation and treatment of these injuries as well as highlight some debates that exist within the literature regarding the optimal management of these injuries. Although management of pediatric olecranon, radial neck, and lateral condyle fractures has been well described, controversy persists among orthopaedic surgeons regarding the surgical indications and preferred fixation techniques for these injuries.

Neuroarthropathy of the foot and ankle presents a series of challenges. The treating physician faces a perfect storm of pathomechanics, deformity, and medical comorbidities. Successful treatment requires a systematic approach in diagnosis, nonsurgical management, surgical management, and long-term maintenance of the affected extremity. Nonsurgical care of the Charcot foot remains the mainstay of treatment and is successful in most cases. Surgery has become more accepted for patients with severe deformity. The concept of a superconstruct has been introduced to describe modern surgical techniques and implants that have been developed since the early 2000s where stability and durability are maximized. A superconstruct is defined by four factors: (1) fusion is extended beyond the zone of injury to bridge the area of bony dissolution; (2) aggressive bone resection is performed to allow for adequate reduction of deformity without undue tension on the soft-
tissue envelope; (3) stronger implants are used than for nonneuropathic fusion procedures, including some specifically developed for fixation of the Charcot foot; and (4) the devices are applied in a position that maximizes mechanical stability to allow the implants to become load sharing. It is important to review the current techniques and implants used in fusion of the neuropathic midfoot and discuss the expected outcomes and complications based on the authors' experience.

The treatment of spinal infections is not well defined, and a cursory review of the literature can lead to conflicting treatment strategies. To add to the complexity, infections can include primary infection of the spine, infection secondary to another primary source, and postoperative infections including epidural abscesses, discitis, osteomyelitis, paraspinal soft-tissue infections, or any combination. Furthermore, differing opinions often exist within the medical and surgical communities regarding the outcomes and effectiveness of varying treatment strategies. Given the paucity of defined treatment protocols and long-term follow-up, it is important to develop multidisciplinary treatment teams and treatment strategies. This, along with defined protocols for the treatment of varying infections, can provide the data needed for improved treatment of spinal infections.