JAAOS, Volume 1, No. 2

The treatment of elbow arthritis is conceptually similar to that for arthritis of other major joints. The treatment of elbow arthritis has been evolving rapidly due to advances in arthroscopic techniques and surgical treatment for contractures and improved prosthetic designs. The reliability of total elbow replacement is approaching that of total replacement of the knee, hip, and shoulder. There remain a number of controversies and unanswered questions that require further experience and longer follow-up for resolution.

A fold that occurs within a joint is referred to as a plica synovialis. Three such plicae are seen with regularity within the human knee joint. These folds are normal structures that represent remnants of mesenchymal tissue and/or septa formed during embryonic development of the knee joint, and can be seen during arthroscopic inspection of the knee joint. Controversy exists within the orthopaedic community as to whether a plica can develop pathologic changes sufficient to cause disabling knee symptoms. The author defines the clinical syndrome, describes the arthroscopic appearance of pathologic plica, and outlines nonsurgical and surgical methods of management of this uncommon condition.

A new agenda in outcomes research has developed in the past decade. The stimulus has come as the result of rapidly increasing health care costs, marked variations in utilization of health care services, and deficiencies in the research literature. Outcomes research includes methods such as analysis of large databases, small-area analysis, structured literature reviews (meta-analysis), prospective clinical trials, decision analysis, and guideline development. Clinical research should be prospective and should employ modern statistical and assessment methods. The focus of this research is on patient-oriented outcomes of care rather than on assessments of the process of care. To illustrate these applications in orthopaedics, lumbar spine fusion with internal fixation for "spinal instability" is presented as an example. Completed large-database analyses, small-area variation studies, and a meta-analysis indicate the need for clinical studies. An outline of the form and content of such a study is presented.

Posterior cruciate ligament (PCL) injuries represent 3% to 20% of all knee ligamentous injuries, but the diagnosis often is missed at initial evaluation. Diagnostic acumen is increased by knowledge of knee biomechanics and selective ligament-cutting studies. The examiner must differentiate the isolated PCL injury from combined ligamentous injury to determine appropriate treatment. Isolated acute PCL tears with less than 10 mm of posterior laxity at 90 degrees of flexion should be treated with an aggressive rehabilitative program. This amount of laxity is found in the majority of isolated acute PCL tears. Isolated acute PCL tears with more than 10 to 15 mm of posterior laxity and PCL tears with combined ligamentous injuries should be reconstructed. Large PCL bony avulsions should be fixed internally. Small PCL bony avulsions with more than 10 mm of posterior laxity should be reconstructed. Chronic PCL injuries initially should be treated with an aggressive rehabilitation program. If such a program is not successful in a patient with more than 10 to 15 mm of posterior laxity and no significant radiographic evidence of degenerative changes, the PCL should be reconstructed.

Metastatic disease of the spine occurs in as many as 70% of patients with disseminated cancer and may result in vertebral collapse, spinal instability, and progressive neurologic compromise. Today, magnetic resonance imaging is the most effective means of differentiating benign from malignant causation of vertebral collapse, based on the imaging patterns and extent of marrow ablation. The more rapid the onset of the neurologic deficit, the worse the prognosis for recovery, no matter what treatment is instituted. The majority of vertebral lesions requiring decompression and stabilization emanate from the vertebral body and are best managed by anterior decompression and stabilization alone. With posterior element destruction, spinal subluxation through the involved segment, or involvement of the lumbar spine, a combination of both anterior and posterior stabilization is required. The author's preference is to perform anterior vertebral replacement with methylmethacrylate incorporating a Knodt distraction rod. This construct affords instantaneous stability that is not adversely affected by postoperative irradiation. Many devices can provide adequate posterior stabilization, but the author prefers to use Luque rods with sublaminar wire fixation. In a series of 77 patients with major neurologic compromise treated with this technique, 62% showed improvement by at least two Frankel grades, compared with fewer than 5% who improved after laminectomy decompression with or without irradiation. Nineteen of the 77 patients remained alive more than 4 years postoperatively.

Attritional and traumatic injuries to the tendons around the foot and ankle are not uncommon. Treatment of overuse-type injuries (tendinitis) remains straightforward. However, surgical treatment of peroneal subluxation, Achilles tendon ruptures, and posterior tibial tendon insufficiency remains somewhat controversial. Generally speaking, soft-tissue reconstruction of the superior peroneal retinaculum is superior to bony procedures for peroneal dislocation. Open repair of a torn Achilles tendon is more predictable than closed treatment. Good clinical judgment is needed in determining the best treatment for posterior tibial tendon problems. The painful os peroneum syndrome is a newly described spectrum of posttraumatic conditions that may be the cause of lateral foot pain, which is frequently difficult to identify.

Locked intramedullary nailing has become the standard of care for most femoral fractures. Originally designed to prevent rotation and shortening in comminuted fractures of the midshaft, its application has been extended proximally and distally to nearly all femoral fractures from the lesser trochanter to the supracondylar area. Achieving a closed reduction and selecting the proper starting point in the piriformis region are crucial to a successful result. Following the proper surgical technique for the specific nail used is more important than nail material or design. Large-diameter reamed nails provide greater strength than unreamed nails. Static locking has been shown to yield nearly the same high union rates as dynamic locking and is now the accepted standard. Distal targeting of the interlocking screw remains the most difficult aspect of the surgical technique; most surgeons prefer freehand targeting with a sharp trocar. Second-generation (reconstruction) nails, with screws directed toward the femoral head, has extended the indications for locked nailing proximally to subtrochanteric fractures and combined femoral neck-shaft fractures.