JAAOS, Volume 2, No. 3

Local injections of corticosteroids are commonly used in orthopaedic practice on the assumption that they will diminish the pain of inflammation and accelerate healing. Less often considered is the possibility that their use may delay the normal repair response. Among the multitude of conditions treated with corticosteroids are acute athletic injuries, overuse syndromes, nerve compression, bone cysts, and osteoarthritis. Unfortunately, there is a paucity of well-controlled studies that provide definitive recommendations for nonrheumatologic use of corticosteroids. Also troubling are the significant potential complications that can occur with their use. The authors believe that use of corticosteroids should be limited to the few conditions that have been proved to be positively influenced by them. Their use must be accompanied by a well-orchestrated treatment plan including close follow-up, physical therapy, and limitation of activities.

Hip fractures remain a major source of morbidity and mortality in the elderly, and their incidence is increasing as the population ages. Surgical management followed by early mobilization is the treatment of choice for most patients with hip fractures. However, all comorbid medical conditions, particularly cardiopulmonary and fluid- electrolyte imbalances, must be evaluated and stabilized prior to operative intervention. Nondisplaced femoral-neck fractures should be stabilized with multiple parallel lag screws or pins. The treatment of displaced femoral-neck fractures is based on the patient's age and activity level: young active patients should undergo open reduction and internal fixation; older, less active patients are usually treated with hemiarthroplasty, either uncemented or cemented. Regardless of treatment method, the goal is to return the patient to his or her prefracture level of function.

Surgical stabilization followed by early mobilization is the treatment of choice for both nondisplaced and displaced intertrochanteric fractures. Fracture stability is dependent on the status of the posteromedial cortex. The sliding hip screw is the device mostly commonly used for fracture stabilization. The most important aspect of its insertion is secure placement within the femoral head. Although the sliding hip screw allows postoperative fracture impaction, it is essential to obtain an impacted reduction at the time of surgery. If there is a large posteromedial fragment, an attempt should be made to internally fix the fragment with a lag screw or cerclage wire. Although intramedullary hip screws have not been shown to be superior to the sliding hip screw, they may have selected indications.

Chronic disability generates most of the growing costs of occupational low back injuries. When back problems persist for more than a few months, traditional diagnostic and therapeutic approaches are rarely curative. Beyond the challenges of physical impairment, disabling back pain is commonly complicated by psychosocial issues, including depression, fear of reinjury, family discord, and vocational dissatisfaction. The biopsychosocial complexity of chronic disability often demands integrated care from physicians, physical and occupational therapists, psychologists, and vocational counselors. In the past decade, the care of back-injured workers has shifted emphasis from symptom palliation toward functional restoration. This evolution has been possible, in part, through improved quantification of physical capacities. Repeated objective measurements of function guide rehabilitation and recommendations for return to work and other activities. Published results of function-oriented multidisciplinary care depend on the outcome variables reported and the particular socioeconomic setting.

Fracture of the femoral shaft around a hip prosthesis presents the simultaneous problems of prosthetic stability and femoral- fracture management. Treatment options include nonoperative stabilization (traction) and operative stabilization by means of intramedullary fixation, extramedullary fixation, or proximal femoral prosthetic replacement.

Spontaneous osteonecrosis of the knee is a common cause of knee pain, principally seen in women over 60 years of age. This condition is distinguished from secondary conditions with known causes, such as corticosteroid-induced osteonecrosis. Although originally described and most common in the medial femoral condyle, it can also occur in the tibial plateaus and on the lateral side of the femur. The radionuclide bone scan will show focally increased uptake before the radiographs are abnormal. Magnetic resonance imaging can also be diagnostic, but the findings may be normal early in the course of the disease. The etiology remains unknown, but it is speculated that primary vascular ischemia or microfractures in osteoporotic bone are causative. Many patients have a benign course followed by resolution of symptoms. Therefore, conservative management is indicated initially. If progressive collapse accompanied by severe symptoms occurs, high tibial osteotomy, unicompartmental replacement, and total knee replacement are therapeutic alternatives. Recognition of this entity is important to avoid needless surgical intervention.

On the basis of clinical outcome measures, endoscopic carpal tunnel release is an effective operation for treating idiopathic carpal tunnel syndrome. Patients who have undergone bilateral carpal tunnel operations have routinely preferred endoscopic release over the open release. An endoscopic release allows many patients to return to work sooner. However, the benefits of more rapid functional recovery and return to work are tempered by the increased cost and higher complication rate of the procedure. Endoscopic carpal tunnel release is a technically demanding procedure with low tolerances for error. Despite its widespread use, its role is not yet clearly defined.