Essentials of Orthopedic Surgery, third edition / 14-Answers to Questions

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repair the preferred surgical technique, as compared to menisectomy. Return to sport is possible with this technique at 6 to 9 months. Long-term results are dictated by not only providing the patient with a stable reconstruction but also through preserving the patient’s meniscal structures as well as articular cartilage.

Shoulder Osteoarthritis

RAYMOND M. CARROLL

History

A 57-year-old man presents to your office with a chief complaint of right shoulder pain. On further questioning, the patient reports that the pain began a few years ago with sharp pain in the shoulder with various activities such as reaching overhead and out to the side. He denies trauma or injury. He notes that the pain has become constant and dull at rest. With activity, the pain is sharp and is becoming unbearable. He reports that he is unable to use the extremity because of the pain and loss of motion. Nonsteroidal antiinflammatory medications alleviated the pain in the past but have minimal effect at this time. He denies any systemic symptoms. He has no significant past medical history other than hypertension, which is controlled with diet and exercise.

Physical Examination

In general, the patient is mildly overweight. His cervical spine motion is within normal range and is pain free. His right shoulder girdle reveals a loss of the normal contour of the anterior aspect relative to the left shoulder girdle. He has no scars, wounds, or localized atrophy. He has tenderness diffusely on the anterior and posterior joint lines. There is no fluctuance or induration noted on palpation. His active range of motion is as follows: forward elevation to 100 degrees with sharp pain at the end range of motion, external rotation is limited to 15 degrees, also painful, and internal rotation is limited to the buttock region. His passive range of motion is similarly affected. He has no focal motor or sensory deficits in the upper extremity. He has a strong and symmetrical radial pulse.

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578 R.M. Carroll

Differential Diagnosis

There are a number of important aspects to consider in this patient when formulating a differential diagnosis. The age of the patient is critical. Common diagnoses in this age group include rotator cuff disease and osteoarthritis. Also, it is important to note that there is no history of trauma or prior surgery. The documentation of a loss of active and passive motion in the shoulder suggests arthropathy or capsular adhesion as is seen with adhesive capsulitis. The most likely diagnoses are osteoarthritis or adhesive capsulitis (idiopathic). Although the patient may have a degenerative rotator cuff condition, the loss of passive motion indicates that the rotator cuff is not likely to be the culprit. Patients can develop secondary adhesive capsulitis following shoulder injuries such as a traumatic rotator cuff tear, but this patient does not have a history that is consistent with such an event.

Laboratory Results and Studies

Because of the lack of systemic or additional joint involvement, there is no indication to obtain any laboratory studies. A radiographic shoulder series including anteroposterior (AP), lateral, and axillary views is the next diagnostic step.

Imaging

The first image is an AP radiograph of the shoulder (see Fig. 1). The radiograph shows a loss of the glenohumeral joint space, subchondral sclerosis, and osteophyte formation at the inferior aspects of the humeral head and glenoid, and subchondral cysts are easily identified. The second image is an axillary view of the shoulder (see Fig. 2). The findings are similar to those noted on the AP radiograph. There is mild wear on the posterior aspect of the glenoid, which is commonly seen in osteoarthritis of the glenohumeral joint.

Treatment

Treatment for osteoarthritis of the glenohumeral joint includes activity modification, rest, and antiinflammatory medication. Corticosteroid injections may be used sparingly but are often not helpful in alleviating pain. Patients with osteoarthritis who have pain that is not responsive to these modalities may require narcotic pain medicine for relief of their symptoms.

Shoulder Osteoarthritis

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FIGURE 1. Anteroposterior (AP) radiograph of the shoulder.

FIGURE 2. Axillary view of the shoulder.

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FIGURE 3. AP view of the shoulder after total shoulder arthroplasty.

Patients with osteoarthritis who require pain medicine for relief of symptoms are good candidates for joint replacement. The patient in this vignette has pain that is not responsive to standard nonoperative modalities. This fact in conjunction with the radiographic evidence of end-stage osteoarthritis makes him a good candidate for total shoulder arthroplasty. The third image is an AP view of the shoulder after total shoulder arthroplasty (see Fig. 3). The metallic humeral head replacement is obvious. The radiopaque horizontal line in the glenoid is evidence of the polyethylene glenoid component that has been cemented into the glenoid.

Glossary

abscess: a collection of purulent material which usually consists of bacteria, both alive and dead, and the byproducts of local infection including viable and nonviable neutrophils, lymphocytes, and lysosomal enzymes. The presence of neutrophils within an abscess often results in a localized inflammatory reaction which can become systemic and life threatening if allowed to persist.

acute osteomyelitis: bacterial colonization of bone or bone marrow with signs of acute inflammation and periostitis. Radiographic changes are usually present within the first 6 weeks.

adjuvant therapy: therapy which is administered to assist in the treatment of a neoplasm. Adjuvant therapy can include radiation therapy or chemotherapy and usually is utilized to improve the results of a primary type of treatment (i.e., surgery).

allograft: tissue for transplantation which is acquired from donated cadaveric sources. Musculoskeletal allografts are generally processed by either deep freezing or dehydration utilizing freeze-drying techniques. Sterilization is generally performed with either gamma radiation, aseptic acquisition in an operating room setting, or treatment with ethylene oxide.

ankylosis: spontaneous bony fusion of a joint.

antalgic gait: a type of limp characterized by shortening the stance phase of gait, in an attempt to relieve pain on weight-bearing.

apophysis: secondary ossification center which develops in response to tension, and ultimately forms a process for muscular attachment.

arthrodesis: fusion performed surgically between two articulating bones by removal of the joint cartilage, removal of cortical bone, bone grafting, and immobilization.

arthrofibrosis: restricted joint motion due to formation of dense scar tissue around the articulation (contracture).

arthroplasty: an operation to improve function and relieve pain caused by arthritis in a peripheral joint. Joint resection or replacement, as well as interposition between joint surfaces, are forms of arthroplasty.

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582 Glossary

arthroscopy: a procedure to inspect, and operate on, the contents of a joint through a small portal utilizing a fiber-optic light source and specialized viewing and operative instruments.

benign: a neoplasm which has local capability for growth, with welldifferentiated cells that are not capable of vascular or lymphatic invasion. Benign neoplasms can be either latent, with limited local growth, or aggressive, with growth proceeding in a destructive manner.

biopsy: the acquisition of material from a lesion, whether it be neoplastic or infectious, for diagnostic review. An adequate biopsy requires obtaining enough material for complete pathological review to arrive at a definitive diagnosis.

bone cement: polymethylmethacrylate (PMMA), used as a filler to enhance the fixation of total joint components.

bone graft: bone used to promote fracture healing, reconstruct a defect in bone, or enhance fusion by providing an organic matrix, osteoblasts, and hormonal factors that contribute to osteogenesis.

calcification: the deposition of calcium within a cartilaginous matrix. This occurs secondary to mineralization of an existing lobule of cartilage which may appear punctate, comma shaped, or popcorn-like on radiographs.

callus: reparative tissue at the site of a fracture that evolves and matures, leading to fracture healing.

cancellous bone: mature bone found in the epiphysis and metaphysis of long bones, and in flat bones, comprised of a three-dimensional lattice of trabecular bone that is less densely packed than cortical bone.

chondrocyte: cartilage matrix-producing cells which rely on nutrition from synovial fluid and not blood vessels. These cells are often arranged in lacunae which are arranged in rather distinct layers.

chronic osteomyelitis: a chronic infection of bone, usually involving the presence of an involucrum or sequestrum, in addition to radiographic changes within the bone. Sclerosis surrounding chronic sites of radiolucency on radiographs and a sinus tract may be present. Chronic osteomyelitis generally requires at least 6 weeks in order to demonstrate radiographic changes.

Codman’s triangle: a region at the periphery of a bone tumor which is formed secondary to the deposition of reactive bone underneath the periosteum. As the periosteum lays down new bone in response to stress, the bony trabecular patterns in this region are usually at a right angle to the underlying cortical bone. A Codman’s triangle usually represents a rapidly growing tumor or osteomyelitis, with elevation of the periosteum off of the bone secondary to neoplastic tissue, bone edema, or purulent material.

comminution: disruption of a fractured bone into more than two fragments.

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compartment syndrome: an increase in the resting pressure in a contained fibro-osseous compartment, such as the forearm or leg, resulting sequentially in decreased lymphatic drainage, decreased venous drainage, loss of arterial inflow, and finally death to the muscle contained in the affected compartment. Sequelae include contracture, pain, and severe functional disability.

computerized axial tomography/computerized tomography (CAT/CT scan): an imaging modality which utilizes computer-generated analysis and imaging resulting from multi-planar exposure through either an extremity or the spine. These scans provide clinicians with excellent axial representation of body segments that were previously not available. Tissue density is graded based on Hounsfield units with dense structures being represented by a bright or white image.

contracture: fixed loss of motion in one direction caused by hypertrophy and shortening of periarticular soft-tissue structures such as tendon, ligament or capsule.

cortical bone: mature, organized, densely packed bone, making up the periphery of flat bones and the diaphysis of long bones.

crepitus: audible or palpable grinding, usually located in a peripheral joint, with motion.

curettage: the mechanical removal of neoplastic or infectious tissue from a primary site. This generally involves entering a lesion and scraping its contents from within its lesional cavity, and has the potential for leaving residual disease, at the microscopic level, in the periphery. This type of “intralesional resection” is generally utilized for benign neoplasms.

cyst: a fluid-filled cavity which results from the production of fluid from a surrounding glandular membrane. The majority of cysts in orthopaedic terminology, such as a simple bone cyst or aneurysmal bone cyst are not true cysts, since the fluid does not directly result from the surrounding mesenchymal tissue present in the wall lining, but from the passive accumulation of fluid within the marrow cavity of bone.

debridement: the removal of infected or devitalized bone, muscle, and skin. The purpose of debridement is to remove any material that can serve as a substrate which harbors bacteria and to enable antibiotics, via parental or local routes, to reach colonies of bacteria.

delayed union: failure of a fracture to heal within the desired and expected time frame, with the potential still present for eventual union.

developmental: pertaining to growth and differentiation.

diarthrodial joint: a joint which consists of connections between two rigid parts of the musculoskeletal system which is lined by synovial tissue, lubricated by synovial fluid, and demonstrates appreciable ranges of motion. The ends of bones in diathrodial joints are usually covered with hyaline cartilage.

diaphysis: the tubular midportion of a long bone, consisting primarily of cortical bone.

584 Glossary

dislocation: loss of normal articular congruity of a joint, with no contact between opposing articular surfaces.

dysostosis: an isolated disruption of normal bone growth with no identifiable etiology.

dysplasia: intrinsic defect in normal bone growth, which may be localized or generalized.

dystrophy: alteration in bone growth due to extrinsic defect, typically an endocrine abnormality.

electromyography (EMG): recording of the variations of electric potential or voltage from skeletal muscle. The EMG/nerve conduction velocity test is useful in determining the site of injury of a peripheral nerve or nerve root, and in identifying peripheral neuropathy caused by metabolic abnormalities.

enchondral ossification: bone formation following the template of a cartilaginous matrix.

enchondroma: a benign tumor of bone, with a cartilaginous matrix, commonly occurring in the hand.

epiphysis: a secondary ossification center, adjacent to the physis, which develops in response to compression and is covered by articular cartilage.

external fixation: the use of an extracorporeal device to stabilize a part of the skeleton, usually following an open fracture.

fracture: a cortical disruption, ranging from incomplete and non-displaced to completely displaced.

fracture healing: the process of biologic repair of a fracture in response to hormonal, biochemical, and mechanical factors. Fracture healing encompasses the phases of inflammation, soft callus, hard callus, and remodeling.

free tissue transfer: one-stage transplantation of distant autogenous composite tissue from a donor site to a recipient site. Free tissue transfer can involve transplantation of muscle, fasciocutaneous tissue, or bone with or without attached soft tissue. This type of transfer requires immediate revascularization, utilizing microsurgical anastomosis of graft and recipient site arteries and veins.

frozen section: the preparation of pathological sections from fresh tissue, used primarily in the operating room for rapid diagnosis which may impact on surgical decision making.

ganglion: a soft, mucin-filled cyst arising from a tendon, tendon-sheath, or joint capsule. Most common about the hand and wrist, and more common in women.

gigantism (overgrowth): hypertrophy of a single digit or entire limb, primarily involving soft tissues. Causes include neurofibromatosis, tumor, or vascular anomaly.

haversian bone: cortical bone composed of vascular channels surrounded by mature (lamellar) bone.

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herniated nucleus pulposus (HNP): Extrusion of gelatinous nucleus pulposus through the anulus fibrosus, into the spinal canal or neural foramen. When an HNP results in nerve root compression, radicular pain, numbness, or weakness may be seen. Herniated disc, ruptured disc.

hydroxyapatite: the calcium mineral crystal component of bone. internal fixation: the use of an implant to stabilize the skeleton, usually

after a fracture.

involucrum: newly formed reactive bone, usually occurring at the interface between diseased bone and healthy tissue. An involucrum consists of viable bone which is the opposite of a sequestrum, which is composed of dead bone.

joint reaction force: the force across a joint that results from a combination of weight bearing and muscular contraction.

kyphosis: forward bending of the spine, when viewed from the side, which is normal in the thoracic spine.

laminectomy: removal of a lamina from its superior to its inferior margin, performed as surgical treatment for spinal stenosis or HNP. Laminotomy or hemilaminectomy refer to partial removal of the lamina.

lordosis: backward bending, or “sway,” of the spine when viewed from the side. Lordosis is normal in the neck and low back.

low back strain: nonspecific term referring to acute onset of pain in the low back, occasionally radiating into the buttocks, with associated muscle spasm. Low back sprain, lumbago.

magnetic resonance imaging (MRI): an imaging modality utilizing resonance phenomenon resulting in the absorption and/or emission of electromagnetic energy by nuclei or electrons in a static magnetic field. Magnetic resonance imaging requires unpaired electrons that are excited by exposure to a magnetic field with a particular signal being emitted once that field is removed. Differences in density of tissues are then represented on images as varying shades of gray, black, or white, depending on their concentration of hydrogen. The modality is extremely useful in the evaluation of musculoskeletal tumors, as well as disorders of the spine, knee, shoulder, and foot.

malignancy: a neoplasm consisting of undifferentiated or dedifferentiated cells which have the active capability of vessel invasion, transport, and establishment of a secondary site of neoplastic growth in a distant organ.

malunion: healing of a fracture in a nonanatomic position.

membranous bone formation: bone formation occurring directly from a

fibrous, mesenchymal, connective tissue template.

metaphysis: the transition segment of a long bone from the enlarged end (epiphysis) to the tubular shaft (diaphysis). The funnel-shaped metaphysis is usually made up of abundant cancellous bone, and during growth, woven bone.