Instructional course lectures
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Review
Acromioclavicular and sternoclavicular injuries and clavicular, glenoid, and scapular fractures.
Injuries to the acromioclavicular joint and the sternoclavicular joint and fractures of the clavicle, glenoid, and scapula vary widely in incidence, treatment, and prognosis. The treatment for acromioclavicular joint and clavicle injuries, which are relatively common, has significantly evolved. Controversy exists regarding the ideal treatment of type III acromioclavicular separations, whereas significant research has shown many potential benefits for surgically treating significantly displaced midshaft clavicle fractures that had traditionally been treated nonsurgically. ⋯ Most of these injuries can be treated conservatively, although some injuries will benefit from surgical fixation. Identifying floating shoulders or unstable glenoid neck fractures without bony or ligamentous stabilization requires an understanding of the multiple anatomic stabilizers of the glenoid. Floating shoulders, glenoid neck fractures with 1 cm or 40 degrees or more of displacement, and intra-articular glenoid fractures with associated glenohumeral instability or intra-articular displacement of 5 mm or more may require surgical repair.
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Comparative Study
Mobile- versus fixed-bearing unicompartmental knee arthroplasty.
Unicompartmental knee arthroplasty using either a mobile- or fixed-bearing technique is an attractive alternative to osteotomy or total knee arthroplasty in selected patients with osteoarthritis. Both techniques appear to yield equivalent early results. ⋯ They also offer the potential for decreased long-term wear complications because of the high conformity of the articulation. The longevity of fixed-bearing components will likely be improved in the future with better prosthetic designs and improved polyethylene to minimize the incidence of late wear complications.
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The demand for total hip arthroplasty is increasing, as are patients' expectations to return to high activity levels. Metal-on-metal bearings are being used in an effort to maximize the longevity of primary hip replacements. Acetabular component inclination has been a recognized aspect of surgical technique for more than 20 years; it now is considered critical, especially in hip resurfacing or implantation of a stem-type device with a larger diameter femoral head and a monoblock acetabular component. It is important to understand the indications for using metal-on-metal bearings as well as the key clinical factors for avoiding early implant failure.
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The introduction of minimally invasive total knee arthroplasty has been accompanied by substantial changes in anesthesia and analgesia techniques. It is well recognized that the goals of minimally invasive surgery, which include rapid rehabilitation and improved patient function, cannot be achieved without excellent postoperative analgesia. ⋯ Numerous adverse effects are associated with traditional opioid medications, including respiratory depression, urinary retention, nausea, sedation, constipation, and pruritus. Safe, effective, and well-tolerated early pain relief after a minimally invasive knee replacement can be accomplished using a multimodal oral pain regimen, peripheral nerve blocks, and local injections.
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Most fractures of the phalanges or metacarpals are amenable to closed treatment, with favorable outcomes. However, two groups of complex fractures are difficult to diagnose and treat. The first group includes unicondylar and bicondylar fractures, fracture-dislocations, and fracture-related instability of the proximal interphalangeal joint. ⋯ Some unstable fracture-dislocations are characterized by loss of the volar aspect of the articular surface of the base of the middle phalanx; they can be treated by using a sculpted osseous articular graft from the dorsal hamate. The second group includes displaced diaphyseal fractures associated with a soft-tissue injury, instability, or multiple fracturing. Articular fractures and fracture-dislocations at the base of the metacarpal also can be difficult to diagnose and treat.