As indicated in the preface, the Instructional Course Lecture Series (ICLS) were first presented in the American Association of Orthopaedic Surgeons (AAOS) meeting in 1942 and since then and following their huge success continue to be the cornerstone and poster boy for the annual meetings since. As the editors point out, at the 2006 meeting in Chicago (which I have personally attended and can testify to), 178 courses were taught by 844 faculty members and attended by a staggering 11,000 participants. This current ICLS volume represents the ongoing endurance and legacy of the lecture series.
This current volume encompasses all that is important and relevant today in the world of Orthopaedics. All sub-specialities have been represented and more importantly burning issues addressed and in classic AAOS style, clear and concise take-home messages are provided. Of importance to the practising surgeon in search for refinement of technique and for the resident in search of the best technique this book provides valuable diamond studded pointers.
The upper limb coverage starts with treatment of the shoulder and covers not only rotator cuff tears and shoulder fractures but also management of the shoulder disorder in the overhead athlete. The accompanying DVD seals off the already excellent content on offer most appropriately. Of particular interest is the small but significant section on graft application in treatment of rotator cuffs.
Practical and plug-and-play tips are available for treatment of the chronic irreparable cuff tear, an all too common presentation on arthroscopy or open procedures. The flowchart for the irreparable cuff is indispensable for the upper limb enthusiast. A few interesting concepts are presented in the section on shoulder instability and the glenoidogram, stability ratios and balance stability angles are elucidated. Invaluable aids to growing up for the residents in training.
Traumatic wrist instability is comprehensively covered and the section on percutaneous scaphoid fixation is excellent. The references and arguments to switch to percutaneous techniques are relevant and convincing. The chapter on post-traumatic hand reconstruction could have been more detailed yet the emphasis on finger stiffness and its management couldn’t have been more appropriate. The classification for the stiff finger is useful and applicable and provides answers to some common unsolved hand problems in everyday practice.
The sections on joint reconstruction start out appropriately with pain management, but all too-commonly it is the anaesthetist and the pain control team who have a bigger share in the pie in post-surgical decision making. The voice of the surgeon is often lost in the din. The controversies surrounding conventional hip arthroplasty versus the often touted MIS hip is appropriately presented and of use to the younger surgeon wanting to cross the line to newer techniques. Interestingly no significant differences have been found in blood loss, transfusion requirements, postoperative pain and length of hospital stay. The authors go on to advocate the usage of minimally invasive approaches only if the classic principles of surgical technique are not violated. This chapter emphasises the fact that minimally invasive is not necessarily minimally traumatic. The recommendations for use of local periarticular injections in the management of postoperative pain are not wholly convincing.
Metal-on-metal hip resurfacing systems have been researched in greater depth and the authors profess that inspite of superior short and medium-term results for metal-on-metal arthroplasty, the inexperience of the surgeon and consequently the chance of disastrous complications is equally high. Osteonecrosis is extremely well treated and the role of cell modulators and genetics involved are elaborated. The newer techniques for managing femoral head osteonecrosis have been well outlined.
The role and the argument for use of newer yet unconventional treatment modalities like hyperbaric oxygen therapy, electrical bone stimulation, pulsed electromagnetic therapy and extracorporeal shock wave therapy are touched upon. Some controversial treatment options have been elaborated like cementation of the femoral head, arthrodiastasis and use of tantalum as mechanical support. The long term results are hitherto unknown and unpredictable, yet these modalities apart from being less morbid have surprisingly demonstrated effective results comparable to core decompression or non-vascularised bone grafting. The advances in hip arthroplasty for treatment of osteonecrosis are valuable in content and practical in advice.
Of particular interest to the spinal community is the use of pedicle screw fixation in the upper dorsal spine, a region previously thought not amenable to variable screw fixation and traditionally fixed with hooks or sublaminar wiring. Surprisingly, contrary to popular opinion, thoracic spine pedicle screw fixation seems safe and effective. The complication rates are low in experienced hands and the technique is most recommended. Helpful pointers are offered in the management of lumbar degenerative disease in the elderly and the osteoporotic patient. Vertebroplasty or percutaneous injection of bone cement directly into a fractured vertebral body and Kyphoplasty which involves percutaneous insertion of an inflatable bony tamp in the fractured vertebral body are superbly covered. Treatment decisions recommended for patients with radiculopathy and herniated lumbar disk disease are eye-openers. Surgical treatments should be based on intractable radicular pain or presence of neurological defecit. It is recommended that surgical decisions should not be based on size of disk herniations as large extruded herniations tend to resolve more predictably.
Lower limb fractures and injuries, the bread and butter of the orthopaedic surgeon like treatment for the tibial plafond fractures is well elucidated. Plafond fractures are now treated more aggressively and a case is made out for the same. The use of temporary spanning external fixators, use of low profile plates, limited or percutaneous incisions and avoidance of the medial tibia have all contributed to improved outcomes. The merits and demerits of the current rage – the locking plates are well debated. As rightly pointed out locked and minimally invasive plating is not synonymous and the jury is still out on the best biomechanical construct to maximise fracture healing.
The section on sports medicine deals with newer concepts and application of newer technologies to everyday orthopaedic problems. The recommendations for the prevention of non-contact ACL injuries in athletes are equally applicable to the weekend athlete and the younger sportsperson. The technique of microfractures is discussed in great depth and the technical simplicity, cost-effectiveness and low morbidity makes this technique an excellent tool for treatment of small full-thickness cartilage lesions. The indications for the procedure, the technique itself and the results are well elucidated and convincing. Other techniques like ACI (Autologous Cartilage Implantation) and Osteochondral Autograft transplantation are discussed in superb depth and offer substance for the readers. A last small section on finding orthopaedic information on the net is invaluable to the trainee and the practising surgeon alike.
The DVD presented at the end of the book keeps all access to this informative, useful and indispensable bible at your fingertips. Going through this volume is like attending the AAOS itself in person – well almost. A must-have, a must- read and a must-implement manual for the orthopaedic practitioner.