The discoid lateral-meniscus syndrome.

Discoid lateral meniscus has been described as a morphologically variable anomaly, and several classifications have been proposed. We have seen twelve patients with the so-called complete type of discoid lateral meniscus, with intact ligament attachments as an incidental finding at the time of arthroscopy. Ten of the twelve patients were without significant symptoms attributable to the meniscus; that is, they had no meniscal tears or laxity. We also have seen six patients with the Wrisberg-ligament type of discoid lateral meniscus, in which there is abnormal meniscal mobility. All six patients were symptomatic and had the so-called snapping-knee syndrome, for which they had arthroscopic lateral meniscectomy. During arthroscopy, care should be taken not to confuse the asymptomatic complete type of discoid lateral meniscus with the Wrisberg-ligament type.

Subtalar dislocation of the foot.

We studied a series of seventeen cases of subtalar dislocation of the foot. There were on anterior, twelve medial, and four lateral dislocations. Of the seventeen dislocations, fourteen were closed and three, open. Two of the four lateral dislocations were open. Associated fractures involving the talocalcaneal or talonavicular joints were noted in eight feet, including three of the four with a lateral dislocation. In two feet these fractures were noted only on post-reduction polytomography. Associated fractures of the ankle mortise and of the metatarsals were present in seven feet. Associated fractures involving the subtalar or talonavicular joints, open dislocations, and associated injuries requiring immobilization of the foot for more than three weeks produced poor results due to pain and limitation of subtalar motion. Lateral dislocations were particularly prone to poor results, due to the frequency of open injuries and associated fractures. Cast immobilization for three weeks and early range-of-motion exercises of the subtalar joint are recommended for the best results.

Anterior dislocation of the hip and associated femoral-head fractures.

Fourteen of fifteen anterior dislocations of the hip, all fifteen being of the obturator variety, were treated initially by closed reduction. In thirteen of the patients fractures of the femoral head were noted, four being transchondral and nine of the indentation type. The fractures of the femoral head were definitely related to the outcome. Seven of the thirteen patients with fractures had fair or poor results, including all four with transchondral fractures and three of the six patients with indentation fractures that were more than four millimeters deep. Roentgenographic evidence of degenerative joint disease was present in ten of the thirteen patients with femoral-head fractures. The two patients without fracture had excellent results.

Reflex sympathetic dystrophy of the knee. Treatment using continuous epidural anesthesia.

We retrospectively reviewed the cases of fourteen patients who had reflex sympathetic dystrophy of the knee. All fourteen were hospitalized, and epidural block anesthesia was instituted with an indwelling catheter for an average of four days, during which continuous passive motion, manipulation (as necessary), stimulation of muscles, and alternating hot and cold soaks were used. The average length of follow-up was thirty-two months. Eleven patients had complete resolution of the symptoms, two had sufficient intermittent aching with changes in the weather to need medication, and one had no relief. The diagnosis was confirmed if the symptoms were relieved by a lumbar sympathetic block. Pain that was out of proportion to the severity of the injury was the most consistent finding, being present in all fourteen patients. However, variation in clinical severity is characteristic of the syndrome. Eleven of the fourteen patients had had a previous patellar operation. After the onset of the symptoms, nine patients had two or more arthroscopic examinations, without notable findings. All fourteen patients had had extensive physical therapy and medical treatment before the epidural block was performed.

Nutritional status: importance in predicting wound-healing after amputation.

Protein-calorie malnutrition, or both, affects the morbidity and mortality of patients undergoing operations. Laboratory assessments of nutritional status consisting of evaluations of serum albumin levels and total lymphocyte counts are valid tests of a patient's nutritional status. In this study we examined the influence of preoperative nutritional status on morbidity in twenty-three diabetic patients who underwent a Syme amputation. All of the patients met Wagner's criteria for a Syme-level amputation, but in only 43 per cent (ten patients) did the amputation heal at this level, which was chosen by Wagner's criteria alone. Of the seven patients who, in addition to meeting Wagner's criteria, had a serum albumin level of at least 3.5 grams per deciliter and a total lymphocyte count of at least 1500 cubic millimeters, in six (86 per cent) the amputation healed at the Syme level. In contrast, the Syme-level amputation healed in only two of the eleven patients who met the criteria of Wagner but who had a serum albumin level of less than 3.5 grams per deciliter and a total lymphocyte count of less than 1500 cubic millimeters.

Closed treatment of subtrochanteric fractures of the femur in a modified cast-brace.

We studied a series of fifteen consecutive subtrochanteric fractures treated in a long quadrilateral cast-brace with a pelvic band. Patients with severely comminuted fractures in which stability cannot be obtained by internal fixation, as well as those with open fractures, are considered candidates for such treatment. Treatment with preliminary traction followed by a ambulatory cast-brace with a pelvic band resulted in a shorter period of treatment, an excellent range of motion of the hip and knee, and no non-unions in the fifteen comminuted or open fractures. Shortening, angulation, and rotational deformity were not significant complications. It must be emphasized that this treatment regimen requires exacting attention to detail by the treating physician. The amount of time needed from the physician in this form of treatment is considerably greater than that after open reduction and internal fixation.

Partial fibulectomy for ununited fractures of the tibia.

Despite the improved rate of union reported with early weight-bearing in tibial shaft fractures, there continues to be a small number of patients with delayed union and non-union who present a dilemma to the surgeons. Partial fibular ostectomy (fibulectomy) is one means of promoting union in ununited fractures of the tibia. Fifty-one patients at our hospital underwent that treatment between December 1, 1971 and June 30, 1979, at twenty to fifty-nine weeks after the date of injury. Following the partial fibulectomy, 77 per cent of the tibial fractures healed. Failure of union after fibulectomy was associated with either failure of the patient to bear weight postoperatively, the presence of a true pseudarthrosis at the fracture site, or previous prolonged treatment of the initial fracture with external fixation. Partial fibulectomy proved to be a relatively effective and simple method for the treatment of ununited fractures of the tibial shaft.

Knee ligament injuries in children.

Nine children who were less than fourteen years old and had open physes and ligament injuries of the knee were studied. Despite an initial thorough physical and roentgenographic evaluation, the full extent of the lesion was determined only at operation in seven of the nine patients. The intercondylar eminence of the tibia was avulsed in five patients, four of whom had associated collateral ligament injuries and a positive anterior drawer sign. Despite surgical repair, all nine patients demonstrated some degree of postoperative ligament instability. This was increased in those patients in whom menisectomy had been performed concomitantly with ligament repair. Although none of the children were symptomatic at the time of writing, development of degenerative arthritis in the future must be considered. Ligament injury must be considered in the differential diagnosis of the child suffering from knee trauma. The association of avulsion of the tibial spine and collateral ligament injury is emphasized.

Supracondylar-intercondylar fractures of the femur treated with a supracondylar plate and lag screw.

Twenty-six patients ranging from nineteen to ninety-two years old underwent rigid internal fixation of supracondylar-intercondylar fractures of the distal end of the femur, using a supracondylar plate and lag screw to achieve two-plane fixation. The congruity of the articular surface of the knee was anatomically restored, as were the mechanical and anatomical axes of the lower extremity. The time to clinical and roentgenographic union averaged four months. There were no non-unions or postoperative infections. The average postoperative range of motion of the knee was 120 degrees. The average length of follow-up was twenty-one months. This series demonstrates the advantages of stable internal fixation using a supracondylar plate and lag screw over other types of fixation.

Fracture-separation of the distal humeral epiphysis.

Sixteen patients were seen with fracture-separation of the distal humeral epiphysis. The difficulty that may be encountered in making the diagnosis is thought to be partly responsible for the relative paucity of previous reports of this condition. All sixteen patients revealed posteromedial displacement of the distal humeral epiphysis on the initial roentgenogram. Child-abuse was documented or suspected as a cause in six of the sixteen fractures. Treatment consisted of closed reduction and immobilization with the elbow in 90 degrees of flexion and the forearm pronated, for three weeks. Post-injury cubitus varus, which developed in three patients and was thought to be due to inadequate reduction, did not progress.

Chronic non-hematogenous osteomyelitis treated with adjuvant hyperbaric oxygen.

Between 1979 and 1982, thirty-eight patients with chronic non-hematogenous osteomyelitis were treated by local débridements of the wound, prolonged parenteral administration of antibiotics, and an average of forty-eight once-a-day treatments with hyperbaric oxygen. Of these thirty-eight patients, thirty-four remained free of clinical signs of osteomyelitis for an average of thirty-four months (range, twenty-four to fifty-nine months) after this regimen of treatment. Only four of the thirty-eight patients had been free of clinical signs of osteomyelitis for as long as three months during the two years preceding this treatment. Three of the four failures of treatment were evident within one month after treatment. This method of treatment appears to prolong the infection-free interval of patients with chronic non-hematogenous osteomyelitis.

The diagnosis and treatment of medial subluxation of the patella after lateral retinacular release.

Five patients with medial subluxation of the patella occurring after isolated lateral retinacular release were treated between July 1985 and July 1989. The diagnosis was made by clinical examination. The patients complained of pain, swelling, and giving way after the lateral release. All five patients had increased medial passive patellar mobility, a positive gravity subluxation test, and a positive medial apprehension test. All patients failed conservative treatment. The patients were treated by reconstruction of the lateral retinaculum using sensory epidural anesthesia. At an average followup of 3.3 years, four of the five patients had no symptoms of instability and the medial patellar mobility and gravity subluxation tests were negative. There were three excellent and two good results using the grading system of Merchant and Mercer.

Incidence of injury in Texas high school football.

This study was undertaken to determine the incidence of injury in high school football based on evaluation of 100 high schools in the State of Texas during a single football season (1989). Certified athletic trainers were the initial medical professionals providing on-site diagnosis and treatment of all injuries. An injury was defined as: 1) an incident causing an athlete to miss all or part of a single practice or game; 2) any incident treated by a physician; and 3) all head injuries reported to the athletic trainer. Data were collected that allowed calculation of the time of exposure to injury per athlete in the sample. There was 75.5% participation in the study by the certified athletic trainers in the 100 schools. A total of 4399 athletes in varsity football programs participated in the study. There were 2228 injuries, as defined in the study, during the period of study, giving an incidence of injury of 0.506 injury per athlete per year. Severe injuries--those requiring hospitalization--were found in 137 cases, for an incidence rate of 0.031 injury per athlete per year. The incidence of reportable defined injury was calculated to be 0.003 injury per hour of exposure per student athlete. The knee was found to be the most commonly injured anatomic site; the ankle ranked second.

Stress fracture of the fifth metatarsal.

Stress fractures of the fifth metatarsal have been reported with increasing frequency, especially in athletes. Prolonged healing time and the risk of refracture following conservative treatment have led to recommendations for operative treatment including bone grafting of these fractures. An axial intramedullary screw, inserted without opening the fracture site, was used in 10 athletes with stress fractures of the fifth metatarsal. Union was obtained in all patients in an average of 7.5 weeks. All patients returned to their sports in an average of 8.5 weeks postoperatively. There were no operative complications or refractures after screw insertion. Complaints of local pain over the screw head and/or the fifth metatarsal head, seen in 7 of the 10 patients, were relieved by local shoe modifications.

Incidence of injury in Texas girls' high school basketball.

We studied the incidence of injury in girl's varsity basketball to characterize injury demographics in high school athletics. We defined a reportable injury as one that occurred during organized practice or competition, resulted in either missed practice or game time, required physician consultation, or involved the head or face. We prospectively evaluated the athletes on team rosters during the 1993 to 1994 season from 100 randomly selected Class 4A and 5A Texas public high schools that employed full-time certified athletic trainers. The 890 student athletes from 80 schools ranged in age from 14 to 18 years. Four hundred thirty-six injuries were reported for a rate of 0.49 per athlete per season. Injury risk, calculated on the basis of exposure time, was 0.4% per hour per athlete. Although game time accounted for only 12.5% of exposure time, it represented one half of the total injuries. Sprains and strains (56%) were the most common injuries, followed by contusions (15%) and dental injuries (14%). Injuries to the ankle (31%) and knee (19%) were by far the most common. There were 34 severe injuries defined as requiring surgery or hospitalization, for a rate of 0.038 per athlete per season. Knee injuries were by far the most likely to require surgeries, and ACL injuries accounted for 69% of the severe knee injuries.

Reconstruction of the anterior cruciate ligament with freeze dried fascia lata allografts in dogs. A preliminary report.

In 16 adult dogs the anterior cruciate ligament (ACL) was transected and then reconstructed using freeze dried fascia lata allografts. Eight of the dogs had the intraarticular graft passed through drill holes in the tibia and femur, while in the other eight dogs the graft was passed through a drill hole in the tibia and routed "over-the-top" of the lateral femoral condyle. In all dogs the grafts were then passed deep to the lateral collateral ligament and secondarily secured to the tibia as an extraarticular reconstruction. Specimens from each group underwent histologic study and biomechanical testing on a mechanical testing system at 3, 6, 12, and 24 week intervals. All grafts were found to be intact at sacrifice with no overt evidence of biologic incompatibility. The knees displayed only mild instability to clinical testing without evidence of arthrosis. Histologically, the grafts appeared to function as a collagenous scaffolding for revascularization and fibrovascular creeping substitution. The mean maximum load at failure in the 24 week specimens reached 536.44 N, compared to values of 801.85 N in contralateral knees with an intact ACL.

Acute straight lateral instability of the knee.

Although ligamentous injuries of the knee joint represent a common orthopaedic problem, damage to the lateral supporting structures is a relatively rare occurrence.

The incidence of injury in Texas high school basketball. A prospective study among male and female athletes.

Recent publications have reported differences in the incidence, rate, risk, and type of sports injury among men and women. We undertook a prospective study to determine the incidence of injury among high school basketball players and to examine the differences in injury type, incidence, rate, and risk between male and female athletes. During a single basketball season, an injury survey of girls' varsity teams at 100 class 4A and 5A high schools in Texas was conducted. These data were previously reported. We surveyed the same 100 high schools during a subsequent season to gather injury data from the boys' varsity teams. The athletic trainer collected data on each reportable injury and reported the data weekly to the University Interscholastic League. A reportable injury was defined as one that occurred during a practice or a game, resulted in missed practice or game time, required physician consultation, or involved the head or the face. The boys' and girls' data were compared and statistically analyzed. The rate of injury was 0.56 among the boys and 0.49 among the girls. The risk of injury per hour of exposure was not significantly different between the two groups. In both groups, the most common injuries were sprains, and the most commonly injured area was the ankle, followed by the knee. Female athletes had a significantly higher rate of knee injuries including a 3.79 times greater risk of anterior cruciate ligament injuries. For both sexes, the risk of injury during a game was significantly higher than during practice.

Anterior cruciate ligament reconstruction using bone-patellar tendon-bone allografts. A biological and biomechanical evaluation in goats.

Twenty-eight goats underwent ACL reconstruction with freeze-dried bone-patellar tendon-bone allografts in one knee, the opposite knee serving as a control. One group of 16 knees was evaluated, in groups of four, at 6, 12, 26, and 52 weeks by histologic and vascular injection techniques. The other group of 12 knees was evaluated in two groups of six at 26 and 52 weeks by morphological and biomechanical techniques of analysis. Within the first 12 weeks these allografts were revascularized; in the first 26 weeks they had matured to resemble normal connective tissue. Graft stiffness was 29% of the control value and maximum force to failure was 43% of the control value. The results of this study indicated that freeze-dried bone-patellar tendon-bone allografts are biomechanically and biologically similar to patellar tendon autografts.

Meniscal repair. An experimental study in the goat.

To evaluate the healing potential of the meniscus, we created a longitudinal medial meniscal tear in both knees of 24 adult goats (48 knees). In all goats, the meniscus was repaired in one knee and left unrepaired in the other. The goats were placed into one of three groups based on the location of the tear and the status of the anterior cruciate ligament. At 6 months' followup, an arthrogram was obtained and the menisci were examined. In knees with an intact anterior cruciate ligament, tears in the peripheral 20% to 25% of the meniscus healed in six of seven repaired menisci, but in only one of seven of the unrepaired menisci. Tears in the peripheral 40% to 50% healed in only one of the eight repaired menisci and in none of the unrepaired menisci. When the anterior cruciate ligament was incised, tears in the peripheral 20% to 25% of the meniscus healed in only 1 of 8 repaired menisci and in none of the unrepaired menisci; the rest developed into complex tears. Arthrography was 92% accurate in predicting the status of meniscal repair. This study supports current clinical practices in meniscal repair and emphasizes the importance of tear location and knee stability in successful meniscal repair.