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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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.
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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 two-incision minimally invasive technique for total hip arthroplasty is described in detail, with attention to pearls of technique, for a prospective group of 200 patients, as well as a matched-pair group of 43 patients who underwent either the two-incision procedure or the mini-incision (single-incision posterior) procedure. The importance of a total hip critical pathway is emphasized, and the economic benefits are presented. Results reveal that the two-incision and mini-incision techniques have acceptable complication rates, are cost effective, and are beneficial to the patient, with reduced hospital stays, high patient satisfaction, and earlier return to function.
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Injuries of the cervical spine in the pediatric and adolescent athlete are less common than other musculoskeletal injuries. Although many of these injuries are relatively minor, serious and potentially unstable or progressive spinal injury must be excluded. Important anatomic differences between the child younger than 10 years and older children and adolescents influence the types of injuries sustained and make assessment of the child's cervical spine sometimes difficult for practitioners accustomed to treating adolescent and adult athletes. ⋯ Young athletes sustain CCN secondary to hypermobility of the immature cervical spine. Return to play after these injuries is controversial. The athlete with Down syndrome and potential cervical hypermobility requires a careful cervical and neurologic evaluation prior to clearance for participation in sports.