Obesity and the orthopedic trauma patient: a review of the risks and challenges in medical and surgical management.

The medical and surgical care of obese trauma patients presents a variety of unique and important challenges. Over the past 30 years, this population has increased dramatically in number, and the optimization of their care demands the attention of the medical community. The problems of caring for an obese trauma patient begin before the actual traumatic event occurs due to their substantially higher incidence of serious comorbidities, such as diabetes mellitus, hypertension, and cardiopulmonary issues. In the setting of trauma, important considerations for the obese patient include careful and expeditious preoperative medical optimization; appropriate deep vein thrombosis prophylaxis; planning for and preventing operative and postoperative challenges (eg, pulmonary and wound complications); and ensuring adequate hospital equipment and staffing resources in the acute and rehabilitative phases of care. This article outlines the scope of the obesity epidemic, reviews the medical consequences of obesity, and highlights surgical considerations specific to the care of orthopedic injuries in the obese trauma patient.

Idiopathic chondrolysis treated with etanercept.

Idiopathic chondrolysis of the hip in children has been well documented in the literature. The insidious nature of the symptoms and lack of early radiographic findings and diagnostic testing often delay diagnosis. Children often report a stiff, painful hip and have an associated limp in the absence of trauma or constitutional symptoms. Despite these symptoms it remains a poorly understood diagnosis with no identifiable cause. Some have speculated an inflammatory cause, as this disease exhibits joint space narrowing, presumably due to enzymatic activity similar to juvenile rheumatoid arthritis. Despite case reports attempting traction, physical therapy, nonsteroidal anti-inflammatories, steroids, and even operative intervention, no current treatment regimen exists that offers proven appreciable benefit. We hypothesized the powerful anti-inflammatory properties of etanercept would provide symptomatic and radiographic improvement of idiopathic chondrolysis of the hip. This article presents a case of an adolescent boy with a stiff, painful left hip that failed treatment with traction, physical therapy, naproxen, and methotrexate, prior to initiating etanercept. After 1 year of daily etanercept therapy, the patient's hip motion improved in all directions and his pain completely resolved. This novel therapeutic approach offered symptomatic relief and radiographic improvement, and may provide an effective treatment strategy for this difficult disease.