Ligament augmentation repair is broadly applied across different orthopaedic subspecialities: an ISAKOS international survey of orthopaedic surgeons.

OBJECTIVES: To evaluate how ligament augmentation repair (LAR) techniques are currently used in different anatomic regions in orthopaedic sports medicine, and to identify the most common indications and limitations of LAR. METHODS: We sent survey invitations to 4,000 members of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine society. The survey consisted of 37 questions total, with members only receiving some branching questions specific to their area of specialisation. Data were analysed using descriptive statistics, and the significance between groups was evaluated using chi-square tests of independence. RESULTS: Of 515 surveys received, 502 were complete and included for the analysis (97% completion rate). 27% of respondents report from Europe, 26% South America, 23% Asia, 15% North America, 5.2% Oceania, and 3.4% Africa. 75% of all survey respondents report using LAR, most frequently using it for the anterior talofibular ligament ( 69%), acromioclavicular joint ( 58%), and the anterior cruciate ligament (51%). Surgeons in Asia report using LAR the most (80%), and surgeons in Africa the least (59%). LAR is most commonly indicated for additional stability (72%), poor tissue quality (54%), and more rapid return-to-play (47%). LAR users state their greatest limitation is cost (62%), while non-LAR users state their greatest reason not to use LAR is that patients do well without it (46%). We also find that the frequency of LAR use among surgeons may differ based on practice characteristics and training. For example, surgeons who treat athletes at the professional or Olympic level are significantly more likely to have a high annual use of LAR (20+ cases) compared to surgeons that treat only recreational athletes (45% and 25%, respectively, p â€‹= â€‹0.005). CONCLUSION: LAR is broadly applied in orthopaedics but its rate of use is not homogeneous. Outcomes and perceived benefits vary depending on factors such as surgeon specialty and treatment population. LEVEL OF EVIDENCE: Level V.

Os supranaviculare and navicular osteochondral lesion contributing to the development of a navicular stress fracture in an adolescent male athlete: Case report.

Stress fractures of the tarsal navicular bone can be problematic in the athlete. This case details the injury and outcome of an adolescent male athlete who experienced one year of intermittent foot pain without acute trauma. Radiographs and computed tomography demonstrated a triad of a navicular stress fracture, an os supranaviculare, and an osteochondral defect of the navicular bone. The patient underwent successful operative fixation and returned to painless full function with imaging demonstrating healing at six months. Diagnosis of a navicular stress fracture in the setting of both an os supranaviculare and osteochondral lesion of the navicular bone have not been reported elsewhere in the literature. While repetitive loading on the navicular bone can independently produce a stress fracture, the patient had an increased risk for this injury; the presumably pre-existing navicular osteochondral lesion and os supranaviculare may have resulted in decreased effective articular surface area, thereby increasing force on the navicular bone and producing a stress fracture. Understanding navicular stress fractures and concomitant bony pathology contributing to injury is crucial to successful diagnosis, management, and prevention of recurrence.

Significant variations in surgical construct and return to sport protocols with syndesmotic injuries: an ISAKOS global perspective.

OBJECTIVES: Although the body of literature on syndesmosis injuries is growing with regard to both the biomechanics and clinical outcomes for various fixation constructs, there is little consensus on the optimal treatment and return to sport strategy for these injuries. We endeavoured to assess the current approaches to managing syndesmotic injuries through a Research Electronic Data Capture survey. METHODS: The survey consisted of 27 questions, including respondent demographics, indications for treatment of syndesmotic injuries, preferred treatment and technique, and postoperative management. Responses were generated through six different athlete scenarios: moderate impact, high impact, and very high impact athletes with/without complete deltoid injury. Frequencies and percentages were calculated for all categorical responses. RESULTS: A total of 742 providers responded to the survey, including 457 American surgeons and 285 members of various international societies. Flexible devices were the preferred fixation construct (47.1%), followed by screws (29.6%), hybrid fixation (e.g. combination of flexible device and screw, 18%), and other (5.3%). Sixty-four percent of respondents noted that their rehabilitation protocols would not change for each athlete scenario. Considerable variability was present in anticipated return to full participation, largely dependent on the presence or absence of a deltoid ligament injury. CONCLUSION: The most common elements used as surgical indications were syndesmosis widening > 2 mm on x-ray, an anterior inferior talofibular ligament injury in combination with a posterior inferior talofinular ligament or deltoid ligament involvement on magnetic resonance imaging, and widening of the distal tibiofibular joint during arthroscopic evaluation. Overall, flexible fixation (e.g. suture button) was the preferred device choice for the repair of an injured syndesmosis. Most respondents did not alter their rehab protocol or anticipated return to play timeline based on the injury severity. However, there was considerable variability between respondents on the time to weight-bearing, running, and full participation. Further pragmatic outcomes data are necessary to guide safe return to play protocols for syndesmotic injuries. LEVEL OF EVIDENCE: Level IV.

Dynamic Loading Assessment at the Fifth Metatarsal in Elite Athletes With a History of Jones Fracture.

OBJECTIVE: We hypothesize that athletes who have suffered Jones fractures will apply significantly higher loads at the fifth metatarsal base during athletic activities compared with matched uninjured athletes. DESIGN: Sixteen athletes were recruited to participate. Eight athletes had a history of Jones fracture, and 8 age, gender, and position-matched athletes without a history of foot injury were recruited as controls. SETTING: Institutional study at Stanford University. PARTICIPANTS: Sixteen athletes with/without a history of foot injury from Stanford University. INTERVENTIONS: Athletes performed a standardized series of movements while wearing calibrated, wireless pressure mapping insoles, and then again with their custom corrective insoles. MAIN OUTCOME MEASURES: Peak pressure, mean pressure, maximum force, and force-time integral (ie, impulse) were recorded for each activity. RESULTS: Athletes with a history of Jones fracture showed a significantly increased peak pressure (183 ± 23 vs 138 ± 7 kPA), mean pressure (124 ± 14 vs 95 ± 4 kPA), and maximum force (15 ± 1.2 vs 12 ± 1.2%BW) at the fifth metatarsal base during walking and running compared with uninjured matched controls (all P < 0.05). CONCLUSIONS: Athletes with a history of Jones fracture exert significantly increased peak and mean forces at the base of the fifth metatarsal during common athletic activities. Custom orthoses do not seem to offload this region in all cases. Increased loads may contribute to the development of stress injury to the fifth metatarsal during repetitive loading, and ultimately fracture of the bone.

Normal Kinematics of the Syndesmosis and Ankle Mortise During Dynamic Movements.

BACKGROUND: Documenting the healthy articulation of the syndesmosis and talocrural joints, and measurement of 3D medial and lateral clear spaces may improve diagnostic and treatment guidelines for patients suffering from severe syndesmotic injury or chronic instability. This study aimed to define the range of motion (ROM) and displacement of the fibula and talus during static and dynamic activities, and measure the 3D movement in the tibiofibular (syndesmosis) and medial clear space. METHODS: Six healthy volunteers performed dynamic weightbearing motions on a single-leg: heel-rise, squat, torso twist, and box jump. Participants posed in a nonweightbearing neutral stance as well as weightbearing neutral standing, plantarflexion, and dorsiflexion. High-speed stereoradiography measured 3D rotation and translation of the fibula and talus throughout each task. Medial clear space and tibiofibular gap distances were measured under each condition. RESULTS: Total ROM for the fibula was greatest in internal-external rotation (9.3 ± 3.5 degrees), and anteroposterior (3.3 ± 2.2 mm) and superior-inferior (2.5 ± 0.9 mm) translation, rather than lateral widening (1.7 ± 1.0 mm). The total rotational ROM of the talus was greatest in dorsiflexion-plantarflexion (34.7 ± 12.9 degrees) and internal-external rotation (15.0 ± 3.4 degrees). Single-leg squatting increased the lateral clear space (P = .045) and widened the medial tibiofibular joint, whereas single-leg heel-rises decreased the lateral clear space (P = .001) and widened the tibiotalar space. Gap spaces in the tibiofibular and medial clear spaces did not exceed 2.3 ± 0.9 mm and 2.7 ± 1.2 mm, respectively. CONCLUSION: These data support a potential shift in the clinical understanding of fibula displacements during dynamic activities and how implant device constructs might be developed to restore physiologic mechanics. CLINICAL RELEVANCE: Syndesmosis stabilization and rehabilitation should consider restoration of normal physiologic rotation and translation of the fibula and ankle mortise rather than focusing solely on the restriction of lateral translation.

Lymphatic Malformation of the Nasopharynx in a Young Pregnant Female: A Case Report.

BACKGROUND Lymphangiomas represent the focal proliferation of benign, well-differentiated lymphatic tissue. They are most likely congenital, thus more commonly diagnosed at birth and before the age of 2 years. When they are found in adults, they favor the head, neck and axillary region. Rarely do they involve the nasopharynx region or occur in a pregnant patient. CASE REPORT A 21-year-old primagravida in the third trimester of pregnancy developed difficulty swallowing that progressed into difficulty breathing over a 1-month period. Imaging and examination suggested a benign mass in the nasopharynx and the patient underwent surgical removal of the stalk with bipolar cautery. The pathology report revealed a simple 4.5×1.5×0.8 cm lymphangioma. She had no fetal compromise during anesthesia. CONCLUSIONS Surgical removal of a nasopharyngeal lymphangioma during the third trimester of pregnancy is indicated if respiratory obstruction may be a complication.

Clear-Cell Carcinoma of the Ovary with Bilateral Breast Metastases.

Ovarian clear-cell carcinoma is an uncommon subtype of epithelial ovarian carcinoma. It carries a generally poor prognosis because of its resistance to standard treatment and metastatic spread to vital organs. Metastasis to the breast is rare and bilateral breast metastasis is unreported. A 61-year-old white female with a 5-year status poststandard therapy for stage IC clear-cell ovarian carcinoma presented with widespread metastasis. Tissue analysis revealed ovarian cancer metastasis to the breasts bilaterally. Clinical awareness of this metastatic potential is important when staging and developing a treatment plan for patients with ovarian clear-cell cancer.