Effectiveness of Fulkerson Osteotomy with Femoral Nerve Stimulation for Patients with Severe Femoral Trochlear Dysplasia.

BACKGROUND: Patients with femoral trochlear dysplasia are at risk for chronic recurrent patellofemoral dislocations, with extreme cases often requiring a surgical procedure. Anteromedialization of the tibial tubercle with intraoperative femoral nerve stimulation and concurrent medial patella-femoral ligament (MPFL) reconstruction is a previously reported method of maximizing patello-femoral congruency. We hypothesize the Fulkerson osteotomy with intraoperative femoral nerve stimulation and concurrent MPFL reconstruction in patients with severe trochlear dysplasia provides equivalent postoperative clinical outcomes to the same procedure in patients with low level trochlear dysplasia. METHODS: 48 knees underwent Fulkerson osteotomy with intraoperative femoral nerve stimulation and concurrent MPFL reconstruction for recurrent lateral patellar dislocations. MRI, surgeon intraoperative assessment, and X-ray were used to assess degrees of trochlear dysplasia; inter-observer and intra-observer error were measured. The knees positive for severe dysplasia on MRI, intraoperative assessment, and X-ray were considered as a comparison cohort to the rest of the study population. We considered postoperative dislocation events and patellar tracking kinematics as outcome measures. Independent student t tests and Fisher exact tests were used to evaluate differences between groups. Significance was set at P<0.05. RESULTS: 11 knees were positive for severe dysplasia (SD) by combined MRI, surgeon intraoperative assessment, and X-ray with the remaining 37 knees categorized as low dysplasia (LD). No patients in either group exhibited apprehension or required re-operation. Mean sulcus angle in the SD group was 175.8 +-2.45 degrees (95% CI 171.0-180.6); the LD group mean sulcus angle was 154.3 +- 0.98 degrees (95% CI 152.4-156.2) (P<.001). Postoperatively there was no significant difference in dislocation events between the SD group (0/11) and the LD group (2/37) (P>0.999). Patellar maltracking decreased in both groups and there were no significant differences in estimates of patellofemoral congruency between the SD (2/11) and LD (8/37) (P>0.999) groups. CONCLUSION: The Fulkerson osteotomy with femoral nerve stimulation aimed at maximizing patellofemoral congruency may be an equally effective procedure for patients with either severe or mild trochlear dysplasia. LEVEL OF EVIDENCE: Level III, Retrospective comparative study.

Urinary incontinence in elite nulliparous athletes.

OBJECTIVE: To determine the prevalence of the symptom of urinary incontinence during athletic endeavors among a group of nulliparous, elite college varsity female athletes. METHODS: All women currently participating in varsity athletics at a large state university were asked to fill out a questionnaire about the occurrence of urinary incontinence while participating in their sport and during activities of daily life. One hundred forty-four of 156 eligible women (92%) responded. RESULTS: The mean age was 19.9 years, and all women were nulliparous. Overall, 40 athletes (28%) reported urine loss while participating in their sport. The proportions in different sports were: gymnastics 67%, basketball 66%, tennis 50%, field hockey 42%, track 29%, swimming 10%, volleyball 9%, softball 6%, and golf 0%. Two-thirds of the women who noted urine loss during athletics were incontinent more often than rarely. There were no statistically significant relations between incontinence and amenorrhea, weight, hormonal therapy, or duration of athletic activity. Activities most likely to provoke incontinence included jumping, high-impact landings, and running. Forty percent and 17% of the women first noted incontinence during their sport while in high school and junior high school, respectively. CONCLUSIONS: Incontinence during physical stresses is common in young, highly fit, nulliparous women. This suggests that there is a continence threshold which, when exceeded, can result in urine loss, even in the absence of known risk factors for incontinence.

Treatment for fixation complications: Femoral neck fractures.

Of 102 hips with femoral neck fracture complications, 75 required major secondary procedures such as total hip replacement, femoral prosthesis, cup arthroplasty, tibial bone grafting, and head and neck resection. The method chosen depended on the specific problem: nonunion, aseptic necrosis, infection, degenerative arthritis, or a failed primary prosthesis. Other factors influencing treatment were the patient's chronological and physiological age, his general health, his life pattern, and the familiarity of the surgeon with the technique and the advantages and disadvantages of the various salvage procedures.

Use of knee braces in sport. Current recommendations.

This article provides a review of the progress that has been made on the biomechanical, functional performance and epidemiological investigations into the effectiveness of prophylactic knee braces (PKBs) since the position statement against their use was issued in 1987 by the American Academy of Orthopaedics and a review of this subject was last published in Sports Medicine in 1989 by Montgomery and Korziris. The evolution of the salient design features of three surrogate knee models are reviewed along with the results of PKB effectiveness and safety factor testing. While still too limited in scope to be totally realistic, major advances have been made in the sophistication of the present biomechanics laboratory testing conditions. The on-the-field functional performance effects of wearing a knee brace are not always manifest in all individuals. The efficacy of PKBs remains in question but recent studies have taught us enough to put their use into perspective. While they may play some role, PKBs probably represent the least important factor in influencing the likelihood that a medial collateral ligament (MCL) sprain will occur. On the other hand, there is no evidence that such braces put added valgus pressure on some knees, or that wearing a brace is associated with an increased frequency or severity of knee or ankle injury. All else being equal, from the biomechanical studies, we know that whilst some braces are better than others, currently available PKBs can provide 20 to 30% greater resistance to a lateral blow, with the possibility that the anterior cruciate ligament (ACL) is given even greater protection than the MCL. This appears to be true when the lateral blow is of sufficient magnitude to cause significant medial joint line opening, but is not as great at the very lowest levels of impact. Regardless of the material they are made of, the most effective PKBs are those sufficiently stiff to prevent an external blow at the joint line from causing brace hinge contact with the knee tissues. Based on the superior results of the custom-fit functional braces, the most important future design feature appears to be the sizing and fitting of the thigh and tibial cuffs. On the negative side, the presence of a brace may slow an athlete's straight-ahead sprint speed and cause early fatigue to its wearer. This effect appears to vary from one brace to another according to its weight, design features, and pressure from the leg and thigh straps. However, it appears that knee braces do have the potential to restrict performance of the athlete for high-speed running but the effect is related to several factors. The weight of the brace resultant friction of the hinges, completeness of fit, and tightness of straps appear to be important. The most measurable effects include: increased muscular relaxation pressures; increased energy expenditure; and a related increase in blood lactate levels, maximal torque output, oxygen consumption and heart rate. On the other hand, experienced brace wearers and larger, stronger individuals displayed fewer, or no effects of donning a brace. Improvements in the protectiveness of the PKB are likely to accompany improvements in the ability to contour the braces to fit each individual's leg in the equipment room without the added expense of the cast-moulding process. Further improvement may be realised by friction-free polycentric joints, as well as an attachment system that minimises thigh and calf soft tissue compression perhaps by incorporating the braces into the trousers of the uniform to provide suspension from the waist.

Load-carrying effects on the adult beagle tibia.

The response of the skeleton to carrying extra weight while exercising was studied in 30 young adult male beagles. Following 34 wk of a caged control period, 18 dogs carried lead-weighted jackets for 1 h and 15 min, 5 d/wk for 2 yr, on a carousel-type treadmill at 3.3 kph. During the next 23 wk, the load carried was gradually increased to 130% of the animal's body weight, and then maintained for 48 wk. The other 12 dogs served as controls. The dogs remained healthy and responded to exercise showing decreased skinfolds and body weight. All dogs showed increases in both tibial mineral content and width with time; but, the exercise group increased significantly more in mineral content than the controls. It is concluded that the gradual increase in bone mineral and width of the tibia is normal in the epiphyseal-closed skeleton of a young adult beagle. Also important is the fact that the intervention of exercise with added weight will increase tibial mineral content above these normal levels.

Cross-sectional thigh components: computerized tomographic assessment.

The purpose of this study was to examine the efficacy of the Picker Synerview Fourth Generation CT Scanner in assessing cross-sectional areas of muscle, bone, and subcutaneous fat of the thigh. A secondary purpose was to resolve individual muscle bellies using the CT scanner and to determine the effects of body composition in isolating those muscles. Both limbs of one cadaver were used to compare actual cross-sectional areas with the CT images. Each limb was dissected and photographed. Accuracy of repeated measurements was assessed using human volunteers. Absolute and percent error between the CT measurements and the measurements of the cross-sectional areas differed most at the bone. No differences were found between repeat scans. CT images and photographic measurements of individual muscles were generally quite similar, as assessed by absolute and percent error. The gracilis and sartorious were reasonably well defined in those individuals with more than 8% body fat. The results are discussed in terms of possible applications of the CT scanner in sports medicine research.

Arthrotomography of the glenoid labrum in shoulder instability.

Instability of the shoulder is a disabling problem which may be difficult to evaluate by routine radiographs. As detachment or absence of the labrum can lead to shoulder instability, arthrotomography of the glenoid labrum is a helpful adjunct in substantiating this diagnosis and in planning the choice of surgical reconstruction. We have found excellent correlation between the arthrotomographic findings and the glenohumeral lesion found at operation. Thirty-eight arthrotomograms of the glenoid labrum were performed in thirty-seven patients who had either shoulder pain or instability, or both. The patients were divided into three groups: those with painful subluxation (Group I), those with voluntary subluxation (Group II), and those with persistent shoulder pain (Group III). Twenty-five of the twenty-eight patients in Group I had an abnormality of the labrum shown on arthrotomography. All of the Group-II and Group-III patients had a normal labrum. There were no false-positive arthrotomograms in the eighteen patients in whom a lesion of the labrum subsequently was found at operation. Three patients with a normal labrum on arthrotomography underwent surgical exploration and no abnormalities were found.

Women's intercollegiate gymnastics. Injury patterns and "permanent" medical disability.

A prospective study was established to record the patterns of injury incurred by all members of women's college gymnastics team. Twenty-six women were followed over a 4-year period (53 gymnast seasons) from 1983 to 1987. To identify which injuries resulted in persisting impairment, these same athletes were contacted again 3 years later. The 26 athletes sustained 106 injuries. Sixty (57%) of these were of acute onset and were related to an identifiable gymnastics event. The remaining 46 (43%) were of gradual onset or overuse injuries. For the follow-up phase, 22 of the 26 women were contacted from 10 to 70 months (38.5 average) after completion of their gymnastics careers. Forty-five percent of the injuries recorded in their competitive years still bothered them at the time of followup, especially low back, ankle, great toe, shoulder, and knee injuries. Athletic and recreational activity exacerbated the complaints. Twenty-nine percent felt that their sports activity level was now limited. Forty-six percent felt that their injury was at less than full recovery, yet most felt that they were capable of strenuous physical activity and continued to be active despite complaints such as pain and stiffness.

Sports injuries at the 1985 Junior Olympics. An epidemiologic analysis.

The XIX Junior Olympic Games, hosted in Iowa City, Iowa, in August of 1985, involved 3,028 athletes who participated for 7 days in 13 different sports at 8 separate sites. Medical coverage for the Games was provided by the University of Iowa Sports Medicine Service. Staffing for the events involved approximately 75 physicians, 60 athletic trainers, and other health care personnel. A triage protocol was established prior to the Games whereby the athletic trainer would make first contact with the injured athlete and would evaluate and treat the injury based on standing orders. If in the judgment of the trainer, the athlete needed to be referred to a physician, one would be available, either on site or on call. During the Games, 1,113 medical encounters were recorded, 121 of those being deemed serious enough to withhold an athlete from competition pending further evaluation and treatment. The 121 significant injuries and illnesses involved 116 athletes (66% male, 34% female). Thirty-four percent of the significant injuries only required treatment by the trainer, while 46% were referred to an on site physician and 20% needed a specialty consultant. Seventeen percent of the significant injuries resulted in the athlete being medically disqualified for the remainder of the event. The most common injuries/illnesses were contusions (26%), sprains (21%), heat (17%), strains (9%), and other illnesses (12%). According to body region, 44% of the 121 injuries were to the lower extremity, 26% to the head, neck, and trunk, and 12% to the upper extremity.(ABSTRACT TRUNCATED AT 250 WORDS)

Cortical desmoid-like lesion of the proximal humerus and its occurrence in gymnasts (ringman's shoulder lesion).

Eighteen gymnasts were interviewed and examined radiographically for a cortical irregularity of the proximal humerus simulating malignancy. Fifty percent of the gymnasts had the lesion which is considered to be a benign reactive lesion secondary to excessive forces at the pectoralis major insertion to the proximal humerus. All patients were asymptomatic. The lesion is probably unique to gymnasts, particularly those involved with strength moves.

Patterns of knee injuries in wrestling: a six year study.

Data on knee injuries sustained by the University of Iowa wrestling team over a 6 year period were compiled. There were a total of 136 wrestlers during this time. Fifty-one different wrestlers sustained 136 injuries (64 knees). Multiple parameters were examined for each injury, including date of injury; days lost; diagnosis; side injured; mechanism; occurrence during competition or practice; whether the wrestler was in control, "on the bottom," or both wrestlers standing; type of move being made at the time of injury; how far into a match or practice the injury happened; initial versus recurrent injury; principal form of management; weight-bearing status; and presence of knee pads. Each wrestler's weight class, years of experience, rank on the team, lead leg, and compliance were noted. We found an incidence of 30 knee injuries per 100 wrestlers per year. There were 11.5 knee injuries per 100 wrestlers per year requiring a week or greater time loss. This comprises over one third of all serious wrestling injuries. Exposure data revealed injury rates in matches to be almost 40 times those of practice. Wrestlers with previous knee injuries were at high risk for reinjury. Early season competition is an extremely high risk period. The most frequent injuries were prepatellar bursitis, lateral and medial sprains, and lateral and medial meniscal tears. We noted a relatively higher rate of lateral versus medial meniscal tears compared to other sports and a somewhat common presentation of a meniscal tear resulting from minimal trauma. The lead leg was injured most often. The takedown was the most frequent situation where any injury occurred. Defensive wrestlers appeared to be at higher risk during takedowns. The wrestler "underneath" was also injured more often. Compliance correlated with decreased recurrence of injury. Approximately 50% of wrestlers were found to be noncompliant with medical recommendations. Junior varsity wrestlers lost significantly more time than varsity wrestlers with equivalent injuries. There was no correlation of injury rate with weight class, period of match, timing in practice, or years of experience.

Prepatellar bursitis in wrestlers.

As part of a larger retrospective study examining all knee injuries sustained by the University of Iowa wrestling team over 6 years, prepatellar bursitis was found to be the most frequent injury and, therefore, was examined in depth. Of the 136 wrestlers studied, 13 developed an initial case of prepatellar bursitis. This represented 21% of all initial episodes of knee injuries. Five of these wrestlers had no recurrences, but the other eight together had 20 recurrences. Median time lost for the initial injury was only 4 days, but recurrences and surgeries added significantly to the total time lost. There were only two cases of septic prepatellar bursitis, but there have been six cases (in four wrestlers) in the three seasons since the end of the larger study period. The infecting organism in all but one case was Staphylococcus aureus and was penicillin-resistant in all but one. There was no clinical evidence of infection in 50% of the cases, emphasizing the need to do a Gram's stain and culture (and, therefore, an aspiration) on all cases of prepatellar bursitis. The prognosis appeared better if the wrestler had no previous history of bursitis, suggesting that pathologic changes in the bursal wall may impair its defense mechanisms. In sharp contrast to all other knee injuries, most prepatellar bursitis cases occurred in the off-season. Most developed insidiously, but direct impact during a takedown maneuver is suspected as being the most frequent cause.(ABSTRACT TRUNCATED AT 250 WORDS)

Injuries in women's gymnastics. The state of the art.

This article takes a three-stage approach to the topic of injuries in women's gymnastics. In the first stage, we review the literature and summarize our current knowledge of injury rates, injuries in specific events, and anatomical location of injuries. In the second, we critically evaluate the relative contributions of these studies in terms of their generalizability, methods, and conceptual approaches. Finally, we present possible directions for future research in the area of women's gymnastic injuries.

Injuries in women's gymnastics. The state of the art.

This article takes a three-stage approach to the topic of injuries in women's gymnastics. In the first stage, we review the literature and summarize our current knowledge of injury rates, injuries in specific events, and anatomical location of injuries. In the second, we critically evaluate the relative contributions of these studies in terms of their generalizability, methods, and conceptual approaches. Finally, we present possible directions for future research in the area of women's gymnastic injuries.

Winner of the 1996 Cabaud Award. The effect of lifelong exercise on canine articular cartilage.

The effect of long-term exercise on canine knees was studied to determine whether an increased level of lifelong weightbearing exercise causes degeneration, or changes that may lead to degeneration, of articular cartilage. Eleven dogs were exercised on a treadmill at 3 km/hr for 75 minutes 5 days a week for 527 weeks while carrying jackets weighing 130% of their body weight. Ten control dogs were allowed unrestricted activity in cages for the 550 weeks. At the completion of the study all knee joints were inspected for evidence of joint injury and degeneration. Articular cartilage surfaces from the medial tibial plateau were examined by light microscopy, the cartilage thickness was measured, and the intrinsic material properties were determined by mechanical testing. No joints had ligament or meniscal injuries, cartilage erosions, or osteophytes. Light microscopy did not demonstrate cartilage fibrillation or differences in safranin O staining of the tibial articular cartilages between the two groups. Furthermore, the tibial articular cartilage thickness and mechanical properties did not differ between the two groups. These results show that a lifetime of regular weightbearing exercise in dogs with normal joints did not cause alterations in the structure and mechanical properties of articular cartilage that might lead to joint degeneration.

Midfoot sprains in collegiate football players.

We studied midfoot sprains in collegiate football players to define and document incidence, mechanisms, injury patterns, and disabilities. Twenty-three athletes with 24 injuries from 1987 through 1991, with a mean followup of 30.8 months, were identified for the study. The injuries occurred in 4% of the football players per year with offensive linemen incurring 29.2% of the injuries. The location of maximal tenderness on physical examination was an important prognostic indicator such that injuries with medial and global midfoot tenderness to palpation had the longest time loss from participation and time until full healing. Lateral midfoot sprains required short periods of disability, and players were able to return to participation with the use of an orthosis. Nineteen athletes with 20 injuries responded to a questionnaire. Four players reported residual functional problems. Only 1 of these players had to modify his recreational activities because of pain. The other players remained very active with only mild complaints of pain after high-demand activities. Midfoot sprains were associated with acute disability that required prolonged restriction from competition, but for most players the long-term residual problems were minor.

Quality assessment of athletic trainers.

This paper reports the first published assessment of the quality of services provided by athletic trainers. Medical coverage for the 1985 Junior Olympic Games was provided by certified athletic trainers (ATC), physicians, and other health care personnel. This study assessed the services of the 30 attending ATCs who managed 121 significant injuries. Standard injury information was collected by the ATCs and separately collected by their physicians. Nine months after the Games, phone interviews were conducted with the injured participants and assessment questionnaires were given to the attending physicians. Results revealed that young, injured, Junior Olympic participants generally did not inform their parents about their injuries or medical contact while at the Games. Athletes and physicians overwhelmingly agreed that they were positively impressed with the capabilities of the ATCs with whom they had contact. About 70% recovered from the symptoms and limitations of injury, as determined by the athlete, within the month following the Games. About 17% sustained some type of injury recurrence to the same body part, and at 9 months about 97% of the athletes had fully recovered from their injuries. These data not only indicate that athletic trainers can accurately identify minor athletic injury but signify the importance of long-term followup in our athletic populations. Multisport events, such as the Junior Olympic Games, impose considerable problems to a communication effort. The athletic trainer, as an ever-present figure in collegiate and professional circles, can be the central focus of an adequate communication effort regarding the patient care of other athletic populations.

Head and neck injuries in college football: an eight-year analysis.

The present study documented head and neck injuries in a study group of 342 college football players at a single institution for a period of 8 years. All freshmen players were screened for evidence of: (1) past history of head and neck injuries, and (2) abnormalities of the cervical spine on physical examination and x-ray film. By recording all head injuries and those neck injuries with time loss, incidence rates and patterns of injury incurred in college competition were determined. A total of 175 head and neck injuries were sustained by 100 players over the 8 year period. Those players with abnormal findings on screening examination were twice as likely to have a head or neck injury at some point in their college careers as those players with a normal screening examination. The greater the degree of abnormality on freshman screening examination, the more severe the neck injury in college was likely to be. Twenty-nine percent of all players in the study group sustained a head or neck injury during their college careers. The probability of a subsequent head or neck injury escalated sharply following a single incident. The overall incidence of injury was found to have been dramatically reduced over the 8 years. Influential factors such as legislative rule changes, medical status of recruits, and general coaching philosophies are discussed with regard to injury reduction and prevention of head and neck injuries in college football.

Cervical spinal stenosis and stingers in collegiate football players.

We evaluated the relationship of cervical spinal stenosis with the occurrence of "stingers" in collegiate football players who participated at our institution from 1987 through 1991. Preparticipation cervical spine radiographs of 266 players were used to measure Torg ratio. Forty players with stingers were identified: 34 had an extension-compression mechanism; 6 had a brachial plexus stretch mechanism. Time-loss neck injuries occurred in 31 players; the remaining 195 players were asymptomatic. The mean Torg ratio was significantly smaller for the stinger group (P = 0.02). The Torg ratio was less than 0.8 at 1 or more levels in 47.5% of the stinger group, 32.3% of the time-loss neck pain group, and 25.1% of the asymptomatic group. No player with a brachial plexus stretch mechanism had a mean Torg ratio less than 0.8, but 20.6% of the players with an extension-compression mechanism had a mean Torg ratio less than 0.8. Players with a Torg ratio less than 0.8 had 3 times the risk of incurring stingers. We conclude that cervical spinal stenosis increases the risk for having stingers with complicated clinical courses.

Medial collateral ligament knee sprains in college football. Effectiveness of preventive braces.

This is the second of 2 articles on a 3-year investigation of medial collateral ligament sprains of the knee to assess the effectiveness of prophylactic knee braces in NCAA Division I college football players. Position, string, type of session, and daily brace wear were recorded. The injury rates for braced and unbraced knees were used to create an incidence density ratio. The data were stratified and simultaneously controlled for position, string, and session and evaluated for their statistical significance. The 987 Big Ten players generated 155,772 knee exposures over the study period (50% braced). Noticeable differences existed in the rates of injury for the braced and unbraced knees in almost every position during practices, depending on player or nonplayer status. When the influential factors of position, string, and session are considered, there is a consistent but not statistically significant tendency for the players wearing preventive knee braces to experience a lower injury rate than for their unbraced counterparts. For starters and substitutes in the line positions, as well as the linebackers and tight ends, there was a consistent trend toward a lower injury rate in both practices and games. The braced players in the skill positions (backs/kickers), at least during games, exhibited a higher injury rate.