Instructional course lectures
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Lumbar spinal stenosis associated with adult scoliosis is being increasingly recognized and studied. Degenerative changes leading to spinal stenosis can precede a spinal deformity resulting in de novo scoliosis. Conversely, degenerative changes leading to spinal stenosis can occur in a preexisting deformity. ⋯ The optimal surgical procedure depends on a careful evaluation of involved segments and patient comorbidities. Positive sagittal imbalance is associated with significant morbidity and should be corrected when feasible. Data that continue to be collected in this patient population will guide future efforts in treating this complicated disease.
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Surgical management of a thoracolumbar fracture varies according to many factors. Fracture morphology, neurologic status, and surgeon preference play major roles in deciding on an anterior, a posterior, or a combined approach. ⋯ Unstable burst fractures can be treated with anterior-only fixation using a strut graft and a modern thoracolumbar plating system or with a posterior-only construct using pedicle screws and possibly hooks. A circumferential construct is considered for extremely unstable injuries.
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Two factors are primarily responsible for complications after treatment of proximal femoral fractures. First, the strong deforming forces across the hip joint and proximal femur can make fracture reduction difficult. ⋯ In intertrochanteric fractures, lag screw cutout can be prevented by correct implant positioning. In femoral neck fractures, nonunion can be avoided by careful attention to reduction and hardware positioning.
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Adequate control of postoperative pain following hip and knee arthroplasty can be a challenging task fraught with potential complications. Postoperative pain is perceived by the patient via a complex network and a multitude of molecular messengers in both the peripheral and central nervous systems. ⋯ Using both contemporary and traditional pain modulators, the delivery and timing of these medications can affect postoperative pain and, ultimately, rehabilitation of the arthroplasty patient. Current techniques for controlling pain use both multimodal and preemptive analgesia to improve the outcome of the surgery while minimizing the potential adverse effects of the medications given.
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Athletes sustain ankle syndesmosis injuries far less frequently than they do lateral ankle sprains; however, syndesmosis injuries are more challenging to detect and treat. Grade II injuries, which are occultly unstable, may be overlooked or treated too conservatively (nonsurgically), leading to latent diastasis, chronic instability, further injury, arthritic changes, chronic pain, osteochondral lesions, and other sequelae. Surgical intervention for chronic syndesmosis injuries produces mixed results and creates an uncertain future for athletes who desire to return to their sport. ⋯ All acute unstable syndesmosis injuries (grades II and III) should be treated with surgery, which can include repair of the deltoid ligament with open reduction and internal fixation of the syndesmosis. Isolated deltoid sprains also are often repaired surgically in athletes. This more aggressive treatment helps avoid the chronic pain and instability and osteochondral abnormalities associated with chronic injury.