Ischial apophyseal avulsions: proximal hamstring repair with bony fragment excision.

BACKGROUND: Avulsion injury of the hamstring muscles from their origin on the ischium is an uncommon injury. In persons aged 14 to 25 years, such an avulsion may include detachment of an epiphyseal fragment at the growth plate of the ischial apophysis. The literature suggests that surgery is not necessary unless there is a large displacement of the fragment. The objective of this report is to present evidence that treatment planning should be based on symptoms, regardless of displacement. METHODS: Between July 1998 and July 2002, 3 consecutive patients with avulsion of the immature ischial apophysis were evaluated by the senior author. In each case the bony fragment was excised and the hamstrings were reattached to the ischium with suture anchors. All patients were assessed postoperatively by biodex strength testing. RESULTS: The average age of the patients was 15 years and the average time to repair was 7 months from the time of injury. The average retraction was 3.7 cm. The average follow-up period was 78 months. The average strength was 86% and the average power was 100% compared with the contralateral side at the final follow-up. In all 3 cases pain was relieved, and with adequate rehabilitation normal strength was regained and the subjects returned to sport. There was one complication involving an activity-related peroneal nerve palsy. This was treated by neurolysis with good functional return. CONCLUSIONS: The 3 cases presented here suggest that treatment should be planned on the basis of pain and disability rather than pathology, and that surgical treatment can effectively address a chronic condition. Each case requires an individualized treatment plan and should include a consideration of the patient's functional goals.

Correlating MRI findings with disability in syndesmotic sprains of NFL players.

BACKGROUND: Syndesmotic sprains may be a significant source of missed playing time, especially in football players. Advanced imaging is frequently used to confirm the clinical diagnosis. Our purpose was to evaluate the prognostic ability of MRI in predicting time of disability. METHODS: Training room records from 1993 to 2007 for three National Football League teams were reviewed. Forty-three players were diagnosed with syndesmotic ankle injuries and underwent radiographs and magnetic resonance imaging. A blinded musculoskeletal radiologist interpreted all images. Players with fractures were excluded. RESULTS: Thirty-six professional football players were included in the final analysis. Twenty-three players had a positive squeeze test which was correlated with increased missed practices (p = 0.012) and increased missed games (p ≤ 0.01). The average number of games missed was 3.3 (range, 0 to 20) and the average number of practices missed was 16.7 (range, 0 to 114). Four players had isolated injury to the anterior tibio-fibular ligament (AITFL) (MRI Grade I). Five players had injury to the AITFL and interosseous ligament (MRI Grade II). Twenty-four players sustained injury to the AITFL, interosseous ligament, and posterior inferior tibio-fibular ligament (MRI Grade III). Three players had Grade III injuries with additional injury to the deltoid ligament (MRI Grade IV). Increasing grade of injury was positively correlated with increased number of missed games (p = 0.033) and missed practices (p = 0.002). CONCLUSION: MRI can be useful to help delineate the injury pattern and associated injuries, and may be useful in predicting time of disability using a grading system. Positive squeeze test can also be useful to determine prognosis.

Potential market for new meniscus repair strategies: evaluation of the MOON cohort.

This study aimed to determine the incidence of meniscal tears and describe the tear morphology and selected treatment in patients undergoing anterior cruciate ligament (ACL) reconstruction. We also will discuss the potential market for future tissue engineering aimed at preserving meniscal function. A multicenter cohort of 1014 patients undergoing ACL reconstruction between January 2002 and December 2003 was evaluated. Data on patient demographics, presence of a meniscus tear at time of ACL reconstruction, tear morphology, and meniscal treatment were collected prospectively. Meniscal tears were categorized into 3 potential tissue engineering treatment strategies: all-biologic repair, advanced repair, and scaffold replacement. Of the knees, 36% had medial meniscal tears and 44% had lateral meniscal tears. Longitudinal tears were the most common tear morphology. The most frequent treatment method was partial meniscectomy. Thirty percent of medial meniscal tears and 10% of lateral meniscal tears are eligible for all-biologic repair; 35% of medial meniscal tears and 35% of lateral meniscal tears are eligible for an advanced repair technique; and 35% of medial meniscal tears and 55% of lateral meniscal tears are eligible for scaffold replacement. Although meniscal preservation is generally accepted in the treatment of meniscal tears, most tears in this cohort were not repairable, despite contemporary methods. The results of this cohort will hopefully stimulate and focus future research and development of new tissue engineering strategies for meniscus repair.

Bracing after ACL reconstruction: a systematic review.

Bracing after anterior cruciate ligament (ACL) reconstruction for rehabilitation and functional return to activities has been a common practice. Clinicians have believed braces improve the outcome of ACL reconstruction by improving extension, decreasing pain and graft strain, and providing protection from excessive force. However, we hypothesized the use of these braces could not be rationalized by evidence of improved outcome including measurements of pain, range of motion, graft stability, or protection from injury. Several randomized controlled trials (RCTs) have been performed to address these issues. This study represents a systematic review of the Level I evidence (12 RCTs) to determine if appropriate evidence exists to support brace use. We found no evidence that pain, range of motion, graft stability, or protection from subsequent injury were affected by brace use, thus supporting our hypothesis.

Metatarsal shaft fractures and fractures of the proximal fifth metatarsal.

Metatarsal fractures represent a relatively common injury, especially in athletes. The pertinent anatomy, evaluation, diagnosis, classification, and treatment of acute and chronic (stress) metatarsal shaft fractures are discussed. Fractures of the proximal fifth metatarsal, which are unique and important injuries, are also discussed. Treatment remains relatively straightforward for the traumatic metatarsal injury, whereas traditional stress fractures typically heal with decreased activity. The problematic proximal fifth metatarsal fracture (Jones fracture) frequently requires surgical intervention in patients who want to avoid non-weight-bearing cast immobilization. The authors' current treatment for this fracture includes the option of intramedullary fixation versus cast immobilization.

Posterior cruciate-retaining modular total knee arthroplasty: a 9- to 12-year follow-up investigation.

Between November 1988 and January 1991, 101 press-fit condylar (PFC; Johnson & Johnson, Raynham, MA) posterior cruciate-retaining total knee arthroplasties were performed in 75 patients. All tibial components were modular metal-backed, and all patellar components were all-polyethylene. All living patients were evaluated at an average 10.5 years (range, 9.5-11.8 years). Only 1 knee required revision (at 11.1 years after the procedure), and only 1 other knee had evidence of radiographic failure. The average range of motion was 1 degrees (range, 0 degrees -10 degrees ) to 110 degrees (range, 86 degrees -130 degrees ). At 10 years of follow-up, the probability of prosthesis survival was 100%, and at 12 years, the probability of prosthesis survival was 93.3% (endpoint defined as revision for any reason).