Instructional course lectures
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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.
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The symptoms associated with lumbar spinal stenosis can decrease quality of life and may cause patients to seek treatment. Except in rare cases of rapid neurologic progression or cauda equina syndrome, nonsurgical modalities should be the initial treatment choice. Activity modification, a variety of medications, epidural steroid injections, and other methods are recommended for pain reduction. ⋯ Arthrodesis, either with or without instrumentation, is also indicated in some patients. Several studies report that surgical treatment produces better outcomes than nonsurgical treatment in the short term; however, the results tend to deteriorate with time. Lumbar decompressive surgery can be complicated by epidural hematoma, deep venous thrombosis, dural tear, infection, nerve root injury, and recurrence of symptoms.
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In some groups of polytrauma patients, particularly those with chest injuries, head injuries, and those with mangled extremities, early total care of major bone fractures may be potentially harmful. Delaying all orthopaedic surgery, however, is also not always the best approach. In these situations, damage control orthopaedics, which emphasizes the stabilization and control of the injury rather than repair will add little additional physiologic insult to the patient and is a treatment option that should be considered.