JAAOS, Volume 18, No. 11

Legg-Calvé-Perthes disease is an idiopathic hip disorder that producesischemic necrosis of the growing femoral head. Permanent femoral head deformityis the most significant sequela. Experimental studies indicate that the pathologicrepair process, which is marked by an imbalance of bone resorption and formation,contributes to the pathogenesis of femoral head deformity. Important prognosticfactors include degree of deformity, age at disease onset, extent of headinvolvement, head-at-risk signs, and lateral pillar collapse. Treatment shouldbe guided by age at disease onset, current best evidence, and prognostic factors.Patients aged<6 years at onset are best managed nonsurgically, whereasolder patients may benefit from surgical treatment. Good surgical resultshave been reported in 40% to 60% of older patients (>8 years), indicatingthe need to develop more effective treatments based on the pathobiology ofthe disease.

Tendinopathy of the long head of the biceps brachii encompasses a spectrumof pathology ranging from inflammatory tendinitis to degenerative tendinosis.Disorders of the long head of the biceps often occur in conjunction with othershoulder pathology. A thorough patient history, physical examination, andradiographic evaluation are necessary for diagnosis. Nonsurgical management,including rest, nonsteroidal anti-inflammatory drugs, physical therapy, andinjections, is attempted first in patients with mild disease. Surgical managementis indicated for refractory or severe disease. In addition to simple bicepstenotomy, a variety of tenodesis techniques has been described. Open bicepstenodesis has been used historically. However, promising results have recentlybeen reported with arthroscopic tenodesis.

External orthoses are used in the management of a variety of spinal disorders.Many types of brace are available to support the cervical, thoracic, and lumbarspine as well as junctional regions, which have special mechanical considerations.Many prefabricated and custom-made devices are available, mady by a varietyof manufacturers in this unregulated area of medical practice. Despite thewidespread use of spinal orthoses, evidence of their efficacy in managingmany spinal conditions is lacking. The most compelling indication for theiruse is in the management of traumatic spine injury. However, studies evaluatingthe efficacy of spinal orthoses have several shortcomings; many have evaluatedorthoses that are no longer used. Recent data provide general guidelines tohelp the clinician choose the appropriate device.

Total knee arthroplasty (TKA) is typically an extremely successful methodof restoring pain-free function and providing good long-term outcomes forpatients with end-stage knee disease. However, outcomes are less predictablein persons with Parkinson disease. The limited literature available and ourexperience lead us to conclude that complication rates in the perioperativeand postoperative periods with TKA are comparatively high in persons withParkinson disease. In addition, a good functional outcome is less certainthan in the general population. For persons with Parkinson disease who requireTKA, we propose an integrative, collaborative approach to avoid complicationsand optimize outcomes.

Traction tables are used in numerous procedures about the hip and femur,including fracture fixation, hip arthroscopy, and less invasive arthroplasty.The use of a traction table is not without risks, however, and significantcomplications have been described, including injury to the perineal integumentand soft tissues, neurologic impairment, and iatrogenic compartment syndromeof the well leg. The orthopaedic surgeon who uses a traction table for thesurgical management of femur fracture must be familiar with the associatedpotential dangers and risks and must develop a plan to avoid traction tableassociatedcomplications, such as use of a radiolucent flat-top operating table for obesepatients, adequate patient positioning, and the minimum possible surgicaltime.

Widening of the tibial and femoral tunnels can present a substantial obstacleduring revision anterior cruciate ligament reconstruction because of the associatedbone loss and poor graft fixation. Delayed incorporation of soft-tissue graftsinto bone and decreased graft stability are of particular concern. The degreeto which mechanical (eg, graft position, fixation method) and biologic (eg,increased cytokine levels, synovial fluid propagation) factors contributeto tunnel widening remains unclear. Radiography, CT, and MRI can be used tocharacterize the extent of widening and aid in preoperative planning. Althoughmany management methods exist, revision surgery remains difficult. Controversypersists regarding the clinical significance, contributing factors, prophylacticmeasures, and effective management of tunnel widening following anterior cruciateligament reconstruction.