Instructional course lectures
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Fractures of the foot and ankle are common injuries that often are successfully treated nonsurgically; however, some injuries require surgical intervention. To restore anatomy and avoid the need for additional surgery, surgeons must pay attention to detail and understand common, avoidable complications. The surgeon should have an understanding of the pathologic characteristics of three common injuries of the foot and ankle as well as the potential complications and their prevention.
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Femoral neck fractures in physiologically young adults, which often result from high-energy trauma, are less common than intracapsular femoral neck fractures in elderly patients. They are associated with higher incidences of femoral head osteonecrosis and nonunion. Understanding the multiple factors that play a significant role in preventing these complications will contribute to a good outcome. ⋯ The timing of the open reduction and internal fixation is controversial. Until conclusive data are available through prospective, controlled studies, performing a capsulotomy followed by open reduction and internal fixation on an urgent basis is recommended. The goals of treating femoral neck fractures should include early diagnosis, early surgery, anatomic reduction, capsular decompression, and stable internal fixation.
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Blood management during total hip arthroplasty is a critical component of successful patient care, and an overall strategy is necessary. Multiple options for blood management are available, including the use of predeposited autologous blood, perioperative blood salvage, hemodilution techniques, erythropoietic agents, hemostatic agents, and allogeneic blood. Rather than relying on automatic so-called transfusion triggers, the surgeon should identify patient-specific risk factors such as the anticipated difficulty of the procedure, preoperative hemoglobin level, comorbidities, and a plan for blood management.
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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.