Excision of symptomatic nonunions of proximal fifth metatarsal avulsion fractures in elite athletes.

BACKGROUND: An avulsion fracture of the proximal fifth metatarsal may result in a symptomatic nonunion and hinder athletic performance. Nonoperative management is often successful in alleviating symptoms. When symptoms persist, surgery can be undertaken to repair the nonunion or excise the avulsed fragment. PURPOSE: The excision of the avulsed bone fragment is evaluated in the management of symptomatic nonunions. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Excision of the avulsed fifth metatarsal fragment was performed in 6 male high-performance athletes with symptomatic nonunions. The remaining edge of bone was contoured and smoothed. RESULTS: All 6 patients experienced an uneventful operation and recovery, returning to competitive play at a mean of 11.7 weeks. Activity-related pain and discomfort abated after the excision and rehabilitation. No surgical complications were noted. CONCLUSION: Surgical excision of the avulsed fragment from the proximal fifth metatarsal is a safe and effective alternative intervention when nonoperative methods fail.

Unlocking the 'pivot shift' in ACL surgery: medial meniscus evaluation and treatment.

Meniscal injury commonly occurs in conjunction with anterior cruciate ligament (ACL) disruption. Failure to recognize and treat these injuries may lead to less than ideal outcomes in ACL reconstruction. With their unique anatomical location, often at the peripheral rim of the posterior horn of the medial meniscus, the instability pattern of ACL deficiency may contribute to failure of injury recognition. Standard anterior viewing portals do not allow adequate visualization of a large portion of the posterior horn of the medial meniscus. Alternative viewing techniques, such as an accessory posteromedial arthroscopy portal or the Gillquist maneuver, may improve visualization of the posteromedial compartment, but require additional surgery and/or equipment. The pattern of instability inherent to ACL deficiency, or the "pivot shift," occurs when the surgeon attempts to visualize the posteromedial compartment with full extension of the knee and a valgus load. The knee "pivots" as the lateral tibial plateau anteriorly subluxes and rotates around the tibial spines. This rotation and subluxation closes down the posteromedial compartment and blocks visualization. A simple maneuver helps to eliminate this pathologic motion, or "unlock the pivot." During attempted visualization of the medial meniscus, the leg is held in mild flexion (207) with a valgus moment on the knee. While this position is held, the surgical assistant externally rotates the lower leg about the knee axis as the knee is extended and valgus is applied. This maneuver increases the surgeon's viewing area of the posteromedial compartment, which may decrease the need for accessory portals and additional equipment in the ACL deficient knee.

Impact of ankle-foot orthoses on static foot alignment in children with cerebral palsy.

BACKGROUND: Children with cerebral palsy who are able to walk are often managed with an ankle-foot orthosis to assist with walking. Previous studies have shown kinematic, kinetic, and energetic benefits during gait with the addition of an ankle-foot orthosis, although the mechanism of this gait improvement is unknown. The ability of orthoses to correct foot malalignment in children with cerebral palsy is not known. The current study was performed to determine the impact of orthoses on static foot alignment in children with cerebral palsy. METHODS: A retrospective radiographic review was performed for 160 feet (102 patients). All patients had a diagnosis of cerebral palsy. Standing anteroposterior and lateral radiographs of the foot and ankle were made with the patient barefoot and while wearing the prescribed orthosis and were compared with use of the technique of quantitative segmental analysis of foot and ankle alignment. RESULTS: Analysis of the foot and ankle radiographs made with the patient barefoot and while wearing the brace revealed significant changes in all measurements of segmental alignment (p < 0.05). The magnitudes of these differences were small (<6 degrees or <10%) and would be considered clinically unimportant. The coupled malalignment of equinoplanovalgus (clinical flatfoot) showed radiographic correction of at least one segment (hindfoot, midfoot, or forefoot) to within the normal range in 24% to 44% of the feet. The coupled malalignment of equinocavovarus (clinical high arched foot) showed correction of at least one segment to within the normal range in 5% to 20% of feet. CONCLUSIONS: The present study demonstrates that the use of the ankle-foot orthoses failed to improve the static foot alignment in the majority of feet in children with cerebral palsy who were able to walk. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.