Instructional course lectures
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The management of acute scaphoid fractures should be oriented on the concept of fracture stability, ease of reduction, associated ligamentous injury, and risk of impaired blood supply, rather than the direction of the fracture line or location of the fracture within the scaphoid. The lack of predictability of successful fracture union and prognostic discrepancies of historic and contemporary classifications may be related to subtle differences of the internal vascular architecture of each scaphoid. ⋯ Improved healing rates in a shorter time and earlier rehabilitation with percutaneous techniques of internal fixation have produced a clear shift from classic conservative treatment to internal skeletal fixation. Although the rates of union of well-vascularized nonunions have not been dramatically improved with the use of internal fixation as compared with inlay bone grafting, the restoration of scaphoid anatomy and prevention of malunion and associated carpal collapse with interpositional bone grafting techniques will reduce the risk of osteoarthritis.
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Patellofemoral complications following TKA are largely avoided with proper surgical technique. A variety of surgical exposures, including the midvastus and subvastus approach, has resulted in good clinical success. It is critical to maintain the integrity of the extensor mechanism. ⋯ Proper patellofemoral tracking must be obtained at the time of the primary TKA. The diagnosis and treatment of the more frequent complications of the extensor mechanism following TKA have been discussed. Although these complications may be successfully treated, most may be largely avoided with proper surgical technique and prosthetic component design.
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The outside-in technique of arthroscopic repair is effective for repair of most meniscal tears. The overall indications for the use of this technique are similar to those for the commonly used inside-out technique. The outside-in technique is especially useful for suturing the anterior horn of the meniscus as well as for suturing meniscal replacement devices such as a collagen meniscal implant or a meniscal allograft. ⋯ As healing was demonstrated in 8 of 13 patients with an unrepaired tear of the anterior cruciate ligament, consideration should still be given to meniscal repair in patients who refuse reconstruction of the anterior cruciate ligament. In this setting, it may be advisable to use multiple permanent sutures, and the patient must be counseled regarding the higher rate of failure with this approach. Repairs of the lateral meniscus have a higher rate of success, and repair of the lateral meniscus should be considered even in the presence of injury of the anterior cruciate ligament.
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Compressive neuropathy of the ulnar nerve in the upper limb is a common problem that frequently results in severe disabilities. At the elbow, Lundborg concluded that the nerve was "asking for trouble" because of its anatomic course through confined spaces and posterior to the axis of elbow flexion. Normally, the ulnar nerve is subjected to stretch and compression forces that are moderated by its ability to glide in its anatomic path around the elbow. ⋯ Compression can occur in 1 of 3 zones. Zone 1 is in the most proximal portion of the canal, where the nerve is a single structure consisting of motor and sensory fascicles, and zones 2 and 3 are distal where the ulnar nerve has divided into motor and sensory branches. The clinical picture correlates with the zone in which compression occurs.