OKOJ

OKOJ, Volume 14, No. 4


Arthroplasty for Unreconstructable Acute Fractures and Failed Fracture Fixation About the Hip and Knee in the Active Elderly: A New Paradigm

The techniques, materials, and designs for total joint arthroplasty underwent major improvements in the past 30 years. During this time, trauma surgeons classified the severity of fractures as well as identified certain articular fractures that do not have good outcomes and have a high rate of failure after internal fixation. Advanced improvements in arthroplasty have increased its reliability and longevity. Total joint arthroplasty is becoming a standard of care for some acute articular fractures, particularly displaced femoral neck fractures in the active elderly. Total joint arthroplasty also has become the standard of care after failed internal fixation in patients who have very complicated fractures about the knee, hip, and shoulder. As the population ages, fractures worldwide continue to rapidly increase. Elderly patients have a high risk for fractures that result from falls because of their poor bone quality. The current active elderly population participates in higher risk activities than previous elderly populations, which places them at risk for more injuries. This has become both a worldwide healthcare problem and an economic problem. Surgeons need to treat fractures in the active elderly with the latest advancements in technology and patient selection to ensure rapid recovery and the reduction of complications.

    • Keywords:
    • active elderly

    • arthroplasty

    • acute fractures

    • failed fracture fixation

    • hip

    • knee

    • Subspecialty:
    • Trauma

Congenital Dislocations: Knee and Patella

Congenital dislocation of the knee is a rare condition. It is apparent at birth, and infants usually present with a dramatic hyperextension deformity. Treatment with serial casting should begin as soon as possible in infancy. In knees with more severe quadriceps contractures that prevent effective gradual flexion, a femoral nerve block or botulinum toxin can be a helpful adjunct. A trial of nonsurgical management is appropriate until 12 months of age. Surgical management, including lengthening of the quadriceps mechanism via either V-Y quadricepsplasty or a relative lengthening via an acute femoral shortening (2-3 cm), is indicated in patients who do not respond to casting. Mini-open and percutaneous quadricepsplasty also have been described with good short-term results. Congenital patellar dislocation is a laterally displaced, hypoplastic patella with severe trochlear dysplasia or an absent trochlea. This condition is often present at birth, but a diagnosis may not be made until years later. If the child has progressive functional decline or developmental milestones are not achieved, surgical treatment should be considered. Extensive lateral release with release of the iliotibial band and occasionally the biceps femoris should be performed. If this release does not allow for centralization of the patella and extensor mechanism, then a V-Y quadricepsplasty or acute femoral shortening should be performed. After centralization, medial imbrication is necessary to maintain reduction.

    • Keywords:
    • congenital dislocation of the knee

    • congenital patellar dislocation

    • pediatrics

    • Subspecialty:
    • Pediatric Orthopaedics

Current Treatment for Talar Fractures

Talar fractures are some of the most challenging injuries that orthopaedic traumatologists manage. The current knowledge of functional alterations with respect to malreduction of talar fractures is well established. Decision making with regard to timing, approach, and implant selection as well as strategies to help achieve accurate restoration of talar anatomy substantially affect outcomes and must be carefully considered. Perfect anatomic talar reconstruction should always be attempted, and orthopaedic surgeons should have a strong working knowledge of the vascular, three-dimensional, and radiographic anatomy of the talus before performing talar surgery. Almost the entire talus is surgically accessible via several approaches, all of which surgeons should be clinically familiar with to optimize reduction and fixation and safely preserve the soft-tissue envelope. Furthermore, surgeons must appreciate the plantar medial vascular area of the talus, which must be avoided during dissection. The complication rates in patients who have talar fractures are high, particularly in those who have talar neck and talar body fractures; therefore, patients should be counseled on their expected outcome, with a specific discussion on the risk of osteonecrosis and subtalar arthritis.

    • Keywords:
    • artery of the tarsal canal

    • astragalus

    • internal fixation

    • subtalar

    • talus

    • talar neck

    • Subspecialty:
    • Trauma

    • Foot and Ankle

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