Refracture of proximal fifth metatarsal (Jones) fracture after intramedullary screw fixation in athletes.

This study details six instances of refracture of clinically and radiographically healed fractures of the base of the fifth metatarsal after intramedullary screw fixation. Four professional football players, one college basketball player, and one recreational athlete underwent intramedullary screw fixation of fifth metatarsal fractures. The athletes were released to full activities an average of 8.5 weeks (range, 5.5 to 12) after fixation, when healing was clinically and radiographically documented. Three football players developed refracture within 1 day of return to full activity. The other three athletes refractured at 2.5, 4, and 4.5 months after return to activity. Two football players underwent repeat fixation with larger screws and returned to play in the same season. The college basketball player underwent bone grafting and returned to play in subsequent seasons. The other three athletes underwent nonoperative management and healed uneventfully over 6 to 8 weeks. On the basis of this series, we recommend that 1) screw fixation using a large-diameter screw should be given careful consideration for patients with large body mass for whom early return to activity is important; 2) functional bracing, shoe modification, or an orthosis should be considered for return to play; 3) if refracture occurs, exchange to a larger screw may allow return to play in the same season; and 4) alternative imaging should be considered to help document complete healing.

Magnetic resonance imaging as a tool to predict meniscal reparability.

One hundred six patients who underwent high field strength magnetic resonance imaging and subsequent arthroscopy of the knee were evaluated to determine the accuracy of magnetic resonance imaging in predicting meniscal tear reparability. Each scan was independently read by three examiners with varying degrees of expertise: a musculoskeletal radiologist, a senior orthopaedic surgeon, and a general radiologist. Each suspected tear was characterized by its morphologic type, maximum length, and minimum distance from the meniscosynovial junction. A prediction was then made of whether the tear was reparable. There were 115 meniscal tears noted in the 106 patients studied. The examiners' ability to correctly estimate tear type was only fair, with correct estimates made only 14% to 67% of the time. The overall correlation of the three examiners to correctly predict the method of treatment was fair. The average accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of magnetic resonance imaging in predicting meniscal reparability were 74%, 29%, 89%, 50%, and 80%, respectively; for predicting meniscectomy, these values were 69%, 68%, 75%, 90%, and 43%, respectively. There were no significant differences between the three examiners in the accuracy of their treatment predictions. The results of this study suggest that magnetic resonance imaging is only moderately reliable for the prediction of meniscus reparability. In addition, the training of the reader does not appear to significantly influence the results.

Septic arthritis of the knee following anterior cruciate ligament reconstruction: results of a survey of sports medicine fellowship directors.

To determine the incidence of joint sepsis following anterior cruciate ligament (ACL) reconstruction and the prevailing attitudes toward its treatment, we surveyed the directors of Sports Medicine Fellowship programs about their practices in treating and preventing this complication. Of the 74 surgeons surveyed, 61 (82%) responded. These 61 surgeons performed an average of 98 ACL reconstructions yearly; 31 (51 %) routinely used a drain after ACL surgery, 18 (30%) had treated an ACL infection within the past 2 years, and 26 (43%) had treated an infection within the past 5 years. There was no significant difference in the number of infections and the surgeons' case load, graft choice, or method of reconstruction. Fifty-two surgeons (85%) selected culture-specific intravenous (IV) antibiotics and surgical irrigation of the joint with graft retention as initial treatment for the infected patellar tendon autograft, and 39 (64%) chose this regimen to treat the infected allograft. For the resistant infection unresponsive to initial treatment, IV antibiotics with surgical irrigation and graft retention were also selected as the most common treatment combination for 25 (39%) of the 61 respondents. After graft removal, the earliest a revision procedure would be considered was 6 to 9 months. The results of this survey confirm the widely held belief that septic arthritis of the knee is a relatively rare complication following ACL reconstruction. Once an infection is encountered, culture-specific IV antibiotics and surgical joint irrigation with graft retention are recommended as initial treatment. Graft excision and hardware removal is considered only for those infections resistant to initial treatment and for the infected allograft.

Geometrical relationships between bone plug configuration and patellar tendon graft width.

There is a lack of information in the orthopedic literature regarding the optimal shape of the patellar and tibial bone plugs when using the central one third of the patellar tendon graft for reconstruction of the anterior cruciate ligament. Clinically, we have observed that the final bone plug and patellar tendon graft width are narrower than the intended width of the graft secondary to contouring the bone plugs to accommodate the bone tunnel. This study mathematically evaluates the relationship between the bone plug cross-sectional configuration and its influence on osseous area and patellar tendon graft width. This mathematical study was divided into three parts using accepted trigonometric and geometric methods. The first part compares the maximum cross-sectional area of four commonly used bone plug shapes: a triangle, rectangle, trapezoid, and square for 8-, 9-, 10-, and 11-mm wide bone-patellar tendon-bone grafts. Area values were calculated as a function of the radius of a circle (bone tunnel) and were compared to determine which configuration provided maximum fill of the tunnel. In the second part, the minimum tunnel diameter needed to accommodate a graft of a given width (8 to 11 mm) for each of the four bone plug shapes was calculated. In Part 3, the maximum bone plug width that would fit in a tunnel of a given diameter (8 to 11 mm) was calculated for each of the four bone plug shapes. Results from Part 1 showed a 47% increase in the area of each shape from 8- to 11-mm wide grafts. Regardless of the bone plug size or tunnel diameter, a square plug filled 64% of the area of a circle; a trapezoid, 59%; a rectangle, 51%; and a triangle, 41%. In Part 2, the minimum tunnel diameter required to accommodate a square was 4 mm greater than the desired graft width for 8- and 9-mm wide grafts, and 5 mm greater for 10- and 11-mm wide grafts. The minimum tunnel diameter needed to accommodate a trapezoidal, rectangular, or triangular-shaped bone plug was only 2 mm greater than the desired graft width. In Part 3, the maximum graft width of the trapezoid, rectangle, and triangle was 0.8 to 1.5 mm smaller (10% to 14% less) than the corresponding tunnel diameters of 8 to 11 mm. Yet, the maximum width of the square was 2.3 to 3.2 mm smaller (29% less) than the corresponding tunnel diameters of 8 to 11 mm. These results confirm our clinical observation that the actual bone plug that would fit the bone tunnel is much narrower than the intended graft width. It is recommended that a trapezoidal or rectangular bone plug be harvested as these two shapes would provide a satisfactory amount of bone (cross-sectional area) compared with a square or triangle, with less tunnel-bone plug size difference.

Effects of ketorolac and bupivacaine on recovery after outpatient arthroscopy.

The effects of intraarticular bupivacaine, systemic ketorolac, and a combination of both treatments on postoperative pain and mobilization were evaluated in 60 healthy outpatients undergoing arthroscopic knee surgery under general anesthesia. After induction of anesthesia, patients received 2 mL of either ketorolac (60 mg) or saline solution (1 mL IV and 1 mL IM). On completion of surgery, the patient's knee joint was injected with 30 mL of either 0.5% bupivacaine or saline solution, according to a randomized, double-blind protocol. Only one patient (6%) receiving both medications complained of pain on awakening, compared with seven patients receiving either bupivacaine (37%) or ketorolac (41%) alone. Postoperative fentanyl was required by significantly fewer patients receiving combined therapy (n = 4, 21%) than either bupivacaine (n = 13, 62%) or ketorolac (n = 12, 60%) alone; however, there were no significant differences among the three treatment groups in terms of perioperative pain, nausea, or sedation visual analogue scale scores. Similarly, there were no differences in the times to ambulation or discharge or in analgesic requirements at home. In conclusion, a combination of systemic ketorolac and intraarticular bupivacaine decreased analgesic requirements and pain on awakening after arthroscopic surgery. However, the use of ketorolac alone or in combination with bupivacaine offered no advantage over bupivacaine alone with respect to recovery times after outpatient arthroscopy.

Stimulation of craniofacial and intramedullary bone formation by negatively charged beads.

To test for their osteogenic stimulating capacity, charged beads were implanted into cranial or mandibular defects, used as an onlay on the nasal bone surface, or injected into femoral medullary cavities of young adult rats. One month later, negatively charged beads were found to have stimulated extensive bone formation resulting in closure of craniofacial defects, a new layer of bone on the nasal bone surface, and a bead-bone lattice within marrow cavities of long bones. Positively charged beads were nonosteogenic, but elicited a pronounced fibroblastic response in the craniofacial skeleton. Positively charged beads were found associated with multinucleated giant cells at all implantation sites. Uncharged beads failed to elicit formation of new bone and were associated with connective tissue that was less cellular and less organized than was seen with positively charged beads. It was concluded that beads that have ben chemically treated to confer either a negative or positive surface charge, when placed in contact with bone, evoke osteogenesis or formation of dense connective tissue, the response depending on the surface charge of the bead. The mechanism(s) by which the charged beads foster the osteogenic or fibroblastic response is not clear. The use, however, of alloplastic materials with charged surfaces in repair and augmentation of bone, and in wound repair, warrants further investigation.

Quantification of the perfusion of the anterior cruciate ligament and the effects of stress and injury to supporting structures.

The perfusion of the normal ACL was quantitated using the hydrogen washout technique in a canine model. This was compared to the perfusion of the synovium in the suprapatellar pouch. Changes in the ACL perfusion were quantitated after the application of anterior stress, division of the infrapatellar fat pad, and dissection of the synovium enveloping the ACL. The ACL is relatively hypovascular, with one-half the blood flow of the synovium of the suprapatellar pouch. Application of an anterior stress diminishes the blood flow to the ACL to one-fifth of the baseline value, an effect which is reversible. Division of the infrapatellar fat pad causes a two-fold decrease in perfusion to the ACL, whereas dissection of the enveloping synovium results in a complete cessation of blood flow.

Electrical stimulation versus voluntary exercise in strengthening thigh musculature after anterior cruciate ligament surgery.

Twenty patients who had undergone anterior cruciate ligament reconstructive surgery were placed randomly and independently in an Electrical Stimulation Group (n = 10) or Voluntary Exercise Group (n = 10) to compare the effectiveness of these two muscle-strengthening protocols. Patients in both groups used simultaneous contraction of quadriceps femoris and hamstring muscles during a training regimen that consisted of either voluntary exercise or electrical stimulation trials five days a week for a three-week period within the first six postoperative weeks. After patients completed the training regimen, bilateral maximal isometric measurements of gravity-corrected knee extension and flexion torque were obtained for both groups and percentages were calculated. Results showed that patients in the Electrical Stimulation Group finished the three-week training regimen with higher percentages of both extension and flexion torque when compared with patients in the Voluntary Exercise Group (extension: t = 4.35, p less than .05; flexion; t = 6.64, p less than .05). These results indicate that patients in an electrical stimulation regimen can achieve higher individual thigh musculature strength gains than patients in a voluntary exercise regimen when simultaneous contraction of thigh muscles is prescribed during an early phase of postoperative rehabilitation.

An in vivo analysis of the effect of transcutaneous electrical stimulation of the quadriceps and hamstrings on anterior cruciate ligament deformation.

Transcutaneous electrical muscle stimulation (TEMS) has been advocated as a method to rehabilitate the postoperative ACL repaired/reconstructed lower extremity. Isolated quadriceps contraction can potentially disrupt the ACL repair/reconstruction; to minimize this risk simultaneous quadriceps and hamstring stimulation has been used. This study measured the in vivo deformation of the ACL during TEMS of the quadriceps and hamstrings. Six legs in four Rhesus monkeys were immobilized in 0 degrees, 45 degrees, and 90 degrees of flexion in neutral rotation using a Hoffman frame and pins placed through the proximal femur and distal tibia. The hamstrings and quadriceps muscles were stimulated with a dual channel electrical stimulator individually and simultaneously at each point of flexion, and ACL deformation was measured using a Hall effect device placed on the anterior medial fibers of the ACL. The following conclusions were made: 1) Isolated quadriceps contraction produces ACL elongation at 0 degrees and 45 degrees of knee flexion and produces ACL shortening at 90 degrees of knee flexion. 2) Isolated hamstrings contraction produces ACL shortening at 45 degrees and 90 degrees of knee flexion and negligible effects at full knee extension. 3) It is not possible to simultaneously contract the quadriceps and hamstrings using separate stimulator pads for each muscle group. 4) At 45 degrees of knee flexion when the quadriceps muscles are stimulated before the hamstring muscles and simultaneous contraction of both is then sustained, ACL lengthening occurs. 5) When the hamstring muscles are fired before the quadriceps muscles and simultaneous contraction of both is sustained, ACL shortening occurs.

Electrically elicited co-contraction of thigh musculature after anterior cruciate ligament surgery. A description and single-case experiment.

The purpose of this article is to describe a method for strengthening the quadriceps femoris muscle in a patient after anterior cruciate ligament (ACL) surgery. The method incorporates electrically elicited co-contraction of the quadriceps femoris and hamstring muscles. A single-case experimental design based on a split-middle (ABAB) technique was used to assess the effects of the systematic administration and withdrawal of electrical stimulation with respect to changes in knee isometric extension and flexion torque and circumferential measurements of the thigh in a patient six weeks after ACL reconstruction. Results show increases in extension and flexion torque and thigh circumferential measurements that are associated with both stimulation (treatment) phases in addition to a maintenance effect demonstrated during the withdrawal phase. In this patient, the technique appears to be effective in increasing muscle strength and circumferential measurements, particularly quadriceps femoris muscle torque. Implications and suggestions for future research are included.

Radiostrontium clearance and bone formation in response to simulated internal screw fixation.

Changes in radiostrontium clearance (SrC) and bone formation (tetracycline labeling) were observed in the femurs of skeletally mature dogs following the various operative steps involved in bone screw fixation. Drilling, but not periosteal stripping, produced a small but statistically significant increase in SrC and endosteal bone formation in the distal third of the bone. Strontium clearance values equivalent to those produced by drilling alone were recorded after screw fixation at low or high torque (5 versus 20 inch pounds), as well as by the insertion of loosely fitting stainless steel implants. Bone formation (equals the percentage tetracycline-labeled trabecular bone surfaces) was increased by 30% when SrC values exceeded 3.5 ml/100 g bone/min, and the relationship was linear when SrC values ranged between 1.0 and 7.0 ml/100 g bone/min. The changes in SrC and bone formation one-week after bone screw application are primarily those associated with a response to local trauma caused by drilling.

Effects of standard surgical procedures on the patellar blood flow in monkeys.

The effects of various surgical dissections on the patellar blood flow were studied in ten monkeys by the use of the hydrogen washout technique. The patellar blood flow was decreased to an average of 65% of the control value after an extensive medial parapatellar arthrotomy. When the infrapatellar fat pad was completely removed following extensive medial arthrotomy, the blood flow further decreased to an average of 49% of the control. When a lateral retinacular release with sacrifice of the lateral superior genicular artery was performed following the medial arthrotomy, the blood flow decreased to an average of 53% of the control. When a lateral release was combined with removal of the fat pad following the main medial arthrotomy, the patellar blood flow showed marked decrease to an average of only 17% of the control. The vascular anatomic study demonstrated that many vessels penetrate from the fat pad into the inferior pole of the patella. It is suggested that the lateral superior genicular artery and/or the fat pad should be carefully preserved to avoid ischemia of the patella during extensive procedures such as total knee arthroplasty.

Radiocarpal fracture--dislocation.

Radiocarpal fracture-dislocation was associated with fracture of the distal articular surface of the radius in five patients (six extremities). Closed manipulation resulted in satisfactory reduction of both the dorsal dislocation of the carpus on the distal radius and displaced articular fracture fragment(s) in two of four extremities. In four extremities, open reduction was necessary as the only means of satisfactorily managing this severe wrist injury. Direct visualization through a dorsolateral incision alone allows for maximal restoration of the often extensive bony injury of the dorsal articular surface of the radius. A volar incision is required for anatomic reduction of the carpus, and median reconstitution of the radiocarpal ligament nerve decompression. Functional results were generally satisfactory; however, radiographic degenerative changes appearing early portend traumatic arthritis as a sequela of this complex injury.

High School Sports Injuries.

In brief: A comparison of injury between boys and girls in eight similar sports showed that there was no difference in overall or individual injury rates. The girls had a significantly greater number of knee injuries and significantly more loss of time because of ankle injury. Although these differences existed, the girls did not show any general increase in joint injury or any increase in severity of knee or other joint injury.

Bilateral elbow dislocations with intra-articular displacement of the medial epicondyles.

Described is a case of bilateral epicondylar entrapment following fracture dislocations of elbows in a 13-year-old girl who fell while performing on parallel bars. Close manipulative reduction was unsuccessful. Open reduction and internal fixation yielded excellent results. Ulnar nerves were not transposed anteriorly as has been recommended by some authors. Long-term follow-up in five previous cases has shown no evidence of tardy ulnar nerve palsy. The need for transposing the ulnar nerve is questioned.

Jejunal intussusception following small bowel bypass for morbid obesity.

In 600 patients who have undergone small bowel bypass for the treatment of morbid obesity, we have encountered three patients who developed intussusception in the bypassed intestine. Diagnosis in these cases has been difficult but in two patients with surgical marker clips applied to the transected fixed jejunum as well as to the adjacent mesocolon, diagnosis was made easier by the radiographic finding of separation of these clips. Clinical symptoms are difficult to evaluate and valuable time may be wasted before a diagnosis is arrived at. Once a diagnosis is made, operation with either reduction or resection of the area of intussusception should be carried out with refixation of the bowel to the mesocolon and reapplication of surgical marker clips. These marker clips are of great value in the diagnosis of intussusception occurring in the bypassed loop.