JAAOS, Volume 24, No. 5

Management of Posterior Cruciate Ligament Injuries: An Evidence-Based Review

Isolated injuries of the posterior cruciate ligament are uncommon, are often caused by a posteriorly directed force to the proximal tibia, and result in abnormal knee kinematics and function. A thorough clinical evaluation, including history, physical examination, and imaging, is required to rule out a concomitant structural knee injury. No clear prognostic factors predict outcomes, and ideal management remains uncertain. Nonsurgical management is advocated for isolated grade I or II posterior cruciate ligament injuries or for grade III injuries in patients with mild symptoms or low activity demands. Surgical management is reserved for high-demand athletes or patients in whom nonsurgical management has been unsuccessful. Although biomechanical studies have identified differences between singlebundle, double-bundle, transtibial, and tibial inlay reconstruction techniques, the optimal surgical technique has not been established. No high-quality evidence is available regarding immobilization, weight-bearing, bracing, or rehabilitation protocols for patients treated either nonsurgically or surgically. Additional long-term clinical studies with homogeneous patient populations are needed to identify the ideal management of these injuries.

      • Subspecialty:
      • Sports Medicine

    Proximal Junctional Kyphosis

    Proximal junctional kyphosis (PJK) is a common complication following adult spinal deformity surgery. It is defined by two criteria: a proximal junctional sagittal Cobb angle (1) ≥10° and (2) at least 10° greater than the preoperative measurement. PJK is multifactorial in origin and likely stems from surgical, radiographic, and patient- related risk factors. The diagnosis of PJK represents a broad spectrum of disease ranging from asymptomatic patients with recurrence of deformity to those presenting with increased pain, functional deficit, and, in the most severe cases, neurologic deficits. Recent studies have demonstrated increased pain levels in select patients with PJK. In keeping with the broad spectrum of the disease, classification schemes are needed to better describe and stratify the severity of PJK. The most severe form is proximal junctional failure. A consensus on a uniform definition of proximal junctional failure is needed to allow for more systematic study of this phenomenon.

        • Subspecialty:
        • Spine

      Glenoid Dysplasia

      Glenoid dysplasia is a developmental anomaly of the scapula that is characterized by a bony deficiency of the posteroinferior glenoid and the adjacent scapular neck. Glenoid dysplasia may occur as a primary isolated condition or in association with various syndromes. It is thought to be related to defective ossification of the inferior glenoid precartilage. Radiographs typically demonstrate bilateral, symmetric dysplasia of the scapular neck with a range of associated bony changes. Glenoid dysplasia has been associated with instability and premature glenohumeral arthritis, although the clinical presentation is highly variable. Symptoms are delayed or mitigated as a result of compensatory glenoid labral hyperplasia. The treatment of glenoid dysplasia remains challenging. Nonsurgical treatment is reasonably successful in younger patients, but premature degenerative changes frequently occur. Although favorable results can be obtained with the use of anatomic arthroplasty, continued subluxation and glenoid component failure can lead to unacceptable outcomes.

          • Subspecialty:
          • Shoulder and Elbow

        Arthrodesis of the Metacarpophalangeal and Interphalangeal Joints of the Hand: Current Concepts

        Metacarpophalangeal arthrodesis and interphalangeal arthrodesis are excellent tools in the surgeon’s armamentarium to restore function of the disabled hand. Typical indications for these procedures are pain, deformity, and/or stiffness. Arthrodesis is generally considered a salvage procedure to be used when other reconstructive procedures, such as arthroplasty, are not possible or would be associated with a high rate of complication or failure. To determine the most functional position for arthrodesis in each patient, the surgeon should preoperatively evaluate the compromised joint in the context of the disease process, determine the initial cause of the joint pathology, and assess the condition of the surrounding joints. Current methods of achieving fusion of metacarpophalangeal and interphalangeal joints include options for incisions, bone preparation techniques, and surgical implants; each has advantages and associated risks.

            • Subspecialty:
            • Hand and Wrist

          Arthroscopic Treatment of Traumatic Hip Dislocation

          Traumatic hip dislocations are high-energy injuries that often result in considerable morbidity. Although appropriate management improves outcomes, associated hip pathology may complicate the recovery and lead to future disability and pain. Historically, open reduction has been the standard of care for treating hip dislocations that require surgical intervention. The use of hip arthroscopy to treat the sequelae and symptoms resulting from traumatic hip dislocations recently has increased, however. When used appropriately, hip arthroscopy is a safe, effective, and minimally invasive treatment option for intra-articular pathology secondary to traumatic hip dislocation.

              • Subspecialty:
              • Trauma

            Orthopaedic Considerations for the Adult With Osteogenesis Imperfecta

            Osteogenesis imperfecta is a heritable group of collagen-related disorders that affects up to 50,000 people in the United States. Although the disease is most symptomatic in childhood, adults with osteogenesis imperfecta also are affected by the sequelae of the disease. Orthopaedic manifestations include posttraumatic and accelerated degenerative joint disease, kyphoscoliosis, and spondylolisthesis. Other manifestations of abnormal collagen include brittle dentition, hearing loss, cardiac valve abnormalities, and basilar invagination. In general, nonsurgical treatment is preferred for management of acute fractures. High rates of malunion, nonunion, and subsequent deformity have been reported with both closed and open treatment. When surgery is necessary, surgeons should opt for load-sharing intramedullary devices that span the entire length of the bone; locking plates and excessively rigid fixation generally should be avoided. Arthroplasty may be considered for active patients, but the procedure frequently is associated with complications in this patient population. Underlying deformities, such as malunion, bowing, rotational malalignment, coxa vara, and acetabular protrusio, pose specific surgical challenges and underscore the importance of preoperative planning.

                • Subspecialty:
                • General Orthopaedics