Instructional course lectures
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Although total hip arthroplasty has been shown to be an effective surgical procedure, long-term outcomes are compromised by wear of the bearing surfaces. Recent technologic advances have been made in the design of bearing surfaces that offer extended performance to these artificial joints.
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The management of nonunion and malunion in the metacarpals and phalanges is influenced by the multiple gliding structures and the propensity for stiffness, the ability of adjacent digits to substitute functionally for compromised digits, the small size of the bones, and associated complications. Amputation and arthrodesis are useful treatment options for nonunions in the hand because they are nearly always atrophic, are frequently associated with joint stiffness and tendon adhesions, and often occur in digits with poor nerve function, vascularity, or skin cover. Surgical fixation with autogenous bone grafts and stable internal fixation has a high union rate with resultant restoration of alignment and stability, but achieves modest improvements in motion. ⋯ This is particularly true for articular fractures. Once these fractures are mature, it may be preferable to perform an extra-articular osteotomy. If a late intra-articular osteotomy is performed, it should be done in such a way as to create large fragments that are easier to repair and more likely to retain their blood supply.
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The Smith-Petersen osteotomy has been a mainstay in the treatment of sagittal deformity since it was first described in 1945. The primary indication for an osteotomy is fixed sagittal deformity. When an osteotomy is performed in a patient with ankylosing spondylitis, it can be combined with an anterior column osteoclasis to achieve a correction of up to 40 degrees to 50 degrees. When performed for other indications, the osteotomy can result in approximately 10 degrees of correction per level treated.
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Total hip arthroplasty was originally indicated for older, sedentary patients because of concerns that catastrophic wear and failure would occur in younger and more active patients. With advances in implant design, tribology, and surgical technique, total hip arthroplasty has now become a viable option for younger patients seeking excellent pain relief and improvement in function. Long-term studies are needed to evaluate the outcome of hip arthroplasty in younger patients using the modern generation of implants and bearing surfaces.
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Fixed sagittal imbalance of the spine leads to a disabling posture with compensatory hip and knee flexion. The most common causes of fixed sagittal imbalance include degenerative lumbar disease, complications from the use of distraction instrumentation in the lower lumbar spine, ankylosing spondylitis, and posttraumatic kyphosis. Surgical procedures to correct sagittal deformities include the posterior Smith-Petersen osteotomy, pedicle subtraction osteotomy, and posterior vertebral column resection. ⋯ Current reports of these procedures stress the importance of patient selection, radiographic evaluation, and meticulous surgical technique. Complications include excessive blood loss, incomplete correction, wound infection, and pseudarthrosis. Most patients who are treated with these procedures report a high level of satisfaction with the outcome.