J Am Acad Orthop Sur
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The goal of cervical spine clearance is to establish that injuries are not present. Patients are classified into four groups: asymptomatic, temporarily nonassessable secondary to distracting injuries or intoxication, symptomatic, and obtunded. Level I evidence supports that the asymptomatic patient can be cleared on clinical grounds and does not require imaging. ⋯ One uses only multidetector CT; a normal result is sufficient to clear the obtunded patient. The alternative method is obtaining a magnetic resonance image subsequent to a negative multidetector CT scan. Because at present information is insufficient to determine whether MRI is indicated, this is an area of controversy.
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Total joint arthroplasty and deformity surgery of the spine can require complex reconstructive procedures accompanied by the potential for major blood loss. In an attempt to minimize the perioperative blood loss associated with these procedures, recent focus has concentrated on the efficacy of pharmacologic agents. Antifibrinolytics such as epsilon-aminocaproic acid, tranexamic acid, and aprotinin have been shown to reduce perioperative blood loss, autologous blood donation, transfusions, and associated costs in cardiac as well as major orthopaedic surgery. ⋯ Prospective, randomized studies have shown that the use of these agents can be effective in reducing the perioperative blood loss and transfusion requirements in total joint arthroplasty, pediatric scoliosis surgery, and adult reconstructive surgery of the spine. Aprotinin, however, is currently under suspension from use pending further evaluation of a trial. Although concerns exist about increased thrombotic events with the use of these agents, large meta-analyses suggest that antifibrinolytics can be safely and efficaciously employed to decrease perioperative blood loss and transfusion requirements.
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Thoracolumbar spine trauma is among the most common musculoskeletal injuries worldwide. However, there is little consensus on the adequate management of spine injury, in part because there is no widely accepted classification system. Several systems have been developed based on injury anatomy or inferred mechanisms of action, but they have demonstrated poor reliability, have yielded little prognostic information, and have not been widely used. ⋯ The severity score offers prognostic information and is helpful in medical decision making. Initial application of the TLICS has shown good to excellent reliability and validity. Additional evaluation of the TLICS is needed to prospectively define its clinical utility and identify potential limitations.
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Because of the effect on hindfoot kinematics, missed or delayed diagnosis of peritalar injuries often results in impairment. The seemingly innocuous nature of these injuries, subtle radiographic findings, and low incidence limit familiarity, thereby increasing the likelihood of misdiagnosis. ⋯ The keys to proper diagnosis of these potentially devastating injuries are the recognition of their existence, their injury patterns, and their radiographic appearance. The threshold for additional imaging studies should be lowered when a patient has pain and physical examination findings are out of proportion to a provisional diagnosis, or when symptoms fail to improve.
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J Am Acad Orthop Sur · Nov 2009
ReviewPrinciples of treatment for periprosthetic femoral shaft fractures around well-fixed total hip arthroplasty.
Postoperative periprosthetic femoral fractures around the stem of a total hip arthroplasty are increasing in frequency. To obtain optimal results, full appreciation of the clinical evaluation, classification, and modern management principles and techniques is required. Although periprosthetic femoral fracture associated with a loose stem requires complex revision arthroplasty, fractures associated with a stable femoral stem can be managed effectively with osteosynthesis principles familiar to most orthopaedic surgeons. ⋯ The preferred treatment consists of internal fixation, following open or indirect reduction. Emerging techniques, such as percutaneous plating and the use of locking plates, have been used with increasing frequency. Preliminary results of these techniques are promising; however, further prospective comparative studies are required.