Previous Level Of Activity Research Articles

Surgical treatment of post-traumatic kyphosis using modified pedicle subtraction osteotomy

Background data Pedicle subtraction osteotomy (PSOS) is a pure closed wedge osteotomy that has been recently introduced for the correction of post-traumatic kyphosis (PTK). Modified PSOS uses the disc as part of the resected wedge together with the upper endplate, thus allowing excision of the degenerated disc material for better fusion and preventing failure. In PTK, the upper endplate is deficient and the upper disc is degenerated. Insertion of a spacer into the intervertebral gap ensures good bony contact and fusion and increases the angle of correction by making the correction in a manner of closed-open wedge rather than a pure closed wedge osteotomy. Purpose The aim of this work was to study the clinical and radiological results of surgical treatment of PTK using modified PSOS with insertion of a cage as a spacer into the intervertebral defect. Study design This was a prospective study conducted on 24 patients with symptomatic PTK. Patients and methods All patients were treated using the modified PSOS technique, with insertion of a cage into the intervertebral gap. Patients were assessed clinically and radiologically. Functional results were assessed using the Oswestry disability index (ODI) score and the Denis pain and work scale. Radiological assessment included local kyphosis angle and sagittal index immediately postoperatively and at the final follow-up, and the state of bony fusion and loss of correction at the last follow-up. Results The average follow-up period was 34.21 ± 4.47 (range 24-50 months). Local kyphosis angle improved from 39.08 ± 3.86° preoperatively to -0.25 ± 4.74° postoperatively, with insignificant change at the last follow-up. The sagittal index significantly improved from 41.33 ± 4.89° preoperatively to 1.81 ± 1.26° postoperatively, without significant change at the last follow-up. All patients showed solid bony fusion at the last follow-up. There were no major complications. All patients improved clinically as evidenced by improvement in pain and neurological status. Functional outcome significantly improved as evidenced by improvement in ODI score and return of most of the patients to their previous level of activity. Conclusion Modified PSOS is more anatomical, less technically demanding, and safe procedure that achieves good radiological and clinical outcomes with lower operative morbidity.

Double layer repair of tibialis anterior muscle hernia in a soccer player: a case report and review of the literature

muscle herniations usually present in athletes especially in the lower legs; occurring through defects in the deep fascial layer of the muscles and typically seen following local blunt trauma or muscle hypertrophy after strenuous exercise. Management of muscle hernias varies from conservative therapy to surgical repair and usually needs multidisciplinary collaboration for differential diagnosis. herein tibialis anterior muscle hernia in 17-year-old male soccer player was presented. The diagnosis was confirmed with dynamic ultrasonographic views changing with the different movements of the ankle. Since the symptoms were not relieved with conservative methods, surgical repair of the defect was offered. we preferred to repair fascial defect with double layer and Mesh graft that were placed over primary suture repair. No complications were reported such as wound or mesh infection postoperatively. The patient was clinically satisfied and returned his previous activity level after 3 months of surgery. After 2 years of follow-up the feature of the bulge was dissolved and player was satisfied with the operation. knowledge of the lower extremity muscle herniation is essential for both proper management and/or surgical referral. The importance of protective devices in prevention, dynamic ultrasonography in diagnosis and double layer repair of the fascial defect with Mesh graft in treatment of muscle herniations were highlighted.

Partial tearing of the anterior cruciate ligament: diagnosis and treatment

Partial tears of the anterior cruciate ligament (ACL) are common and represent 10–27% of the total. The main reasons for attending to cases of non-torn bundles are biomechanical, vascular and proprioceptive. Continued presence of the bundle also serves as protection during the healing process. There is controversy regarding the definition of these injuries, which is based on anatomy, clinical examination, translation measurements, imaging examinations and arthroscopy. The way in which it is treated will depend on the existing laxity and instability. Conservative treatment is optional for cases without instability, with a focus on motor rehabilitation. Surgical treatment is a challenge, since it requires correct positioning of the bone tunnels and conservation of the remnants of the torn bundle. The pivot shift test under anesthesia, the magnetic resonance findings, the previous level and type of sports activity and the arthroscopic appearance and mechanical properties of the remnants will aid the orthopedist in the decision-making process between conservative treatment, surgical treatment with strengthening of the native ACL (selective reconstruction) and classical (anatomical) reconstruction.

Lesão parcial do ligamento cruzado anterior: diagnóstico e tratamento

Parcial tears of of the anterior cruciate ligament (ACL) is common and represents 10%‐27% of the totals. The main reasons for attending to cases of non‐torn bundles are biomechanical, vascular and proprioceptive. Continued presence of the bundle also serves as protection during the healing process. There is controversy regarding the definition of these injuries, which is based on anatomy, clinical examination, translation measurements, imaging examinations and arthroscopy. The way in which it is treated will depend on the existing laxity and instability. Conservative treatment is optional for cases without instability, with a focus on motor rehabilitation. Surgical treatment is a challenge, since it requires correct positioning of the bone tunnels and conservation of the remnants of the torn bundle. The pivot shift test under anesthesia, the magnetic resonance findings, the previous level and type of sports activity and the arthroscopic appearance and mechanical properties of the remnants will aid the orthopedist in the decision‐making process between conservative treatment, surgical treatment with strengthening of the native ACL (selective reconstruction) and classical (anatomical) reconstruction.

Ultrasound-Guided EPI® Technique and Eccentric Exercise, New Treatment for Achilles and Patellar Tendinopathy Focused on the Region-Specific of the Tendon

Treatment of tendon injuries is a subject of frequent debate in sports medicine and physiotherapy. Achilles and patellar tendinopathy is a common, painful, overuse disorder, and is associated with a failure of the tendon repair process they have a low potential for healing with the usual techniques. Therefore, new treatments for tendinopaties drawn from the existing literature as well as from their own experience dealing with this condition to deal with this delicate pathology have been developed over recent past decades. This brief review aims to update recent information on the treatment with the ultrasound-guided EPI® technique and eccentric exercise in Achilles and patellar tendinopathy resulted in a great improvement in function and a rapid return to the previous level of activity.

Risk Factors Associated With Revision and Contralateral Anterior Cruciate Ligament Reconstructions in the Kaiser Permanente ACLR Registry

Background: Patients generally choose to undergo anterior cruciate ligament reconstruction (ACLR) to return to their active lifestyles. However, returning to their previous activity level may result in a retear of their reconstructed knee or an injury to their contralateral anterior cruciate ligament (CACL). Purpose: To determine the risk factors associated with revision ACLR and contralateral ACLR (CACLR), compare the survival of the reconstructed ACL with the CACL, and determine how the risk factors associated with revision ACLR compare with those for CACLR. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective cohort study of prospectively collected data from the Kaiser Permanente ACLR registry between February 1, 2005, and September 30, 2012, was conducted. Primary ACLR cases without history of contralateral knee ACL injury were included. The study endpoints included revision ACLR and CACLR. Graft type (bone–patellar tendon–bone [BPTB] autograft, hamstring autograft, and allograft) was the main exposure of interest, and patient characteristics were evaluated as risk factors for revision ACLR and CACLR. Survival analyses were conducted. Results: A total of 17,436 ACLRs were evaluated. The median age was 27.2 years (interquartile range, 18.7-37.7 years), and 64% were males. The 5-year survival for index ACLR was 95.1% (95% CI, 94.5%-95.6%), and for CACL it was 95.8% (95% CI, 95.2%-96.3%). Overall, the cohort had a mean of 2.4 ± 1.7 years of follow-up; 18.2% were lost to follow-up. There were fewer CACLRs per 100 years of observation (0.83) than there were revision ACLRs (1.05) during the study period (P < .001). There was a statistically significant difference in the density of revision ACLR and CACL in BPTB autografts (0.74 vs 1.06, respectively; P = .010), hamstring autografts (1.07 vs 0.81; P = .042), and allografts (1.26 vs 0.67; P < .001). The risk factors for revision ACLR and contralateral surgery were different (P < .05). After adjusting for covariates, factors associated with higher risk of revision ACLR were as follows: allografts, hamstring autografts, male sex, younger age, lower body mass index (BMI), and being white as opposed to black. Factors associated with higher risk of CACLR were as follows: younger age, female sex, and lower BMI. Conclusion: The 5-year revision-free and CACLR-free survival rate in this study was 95.1% and 95.8%, respectively. Allografts and hamstring autografts had a higher risk of revision ACLR surgery, and BPTB autografts had a higher risk of CACLR. Males were found to have a higher risk of revision ACLR, and females had a higher risk of CACLR. Increasing age and increasing BMI decreased the risk of both revision and CACLR.

Unusual Orthopaedic Injuries from the World's Most Popular Sport.

When it comes to numbers of participants and spectators, there’s little doubt that soccer is the world’s most popular sport. It makes sense, then, that soccer sees its share of musculoskeletal injuries. The majority of soccer injuries affect the feet and legs, with sprains, strains, and ligament injuries of the knees and ankles being the most common. This month’s “Case Connections” focuses on the diagnosis and treatment of four not-so-common soccer injuries. In the December 10, 2014, JBJS Case Connector, Huri et al. present the case of a teenage professional soccer player with a chronic rupture of the rectus femoris muscle. The initial injury had occurred two years earlier when he kicked another player’s foot instead of the ball. Nonoperative approaches had not facilitated a return to running or kicking. At the time of presentation, doctors noted a prominence on the right thigh that was suggestive of a proximal rupture and distal displacement of the rectus femoris muscle. At an isokinetic speed of 240°/sec, the knee extension strength difference between the injured and normal limbs was 40%; pain prevented the patient from being tested at other isokinetic speeds. MRI of the thigh revealed extensive soft-tissue edema and a complete avulsion of the reflected head of the rectus femoris. Figure 1 shows the rupture location preoperatively and intraoperatively. Fig. 1 Arrows indicate the location of the rectus femoris rupture preoperatively (top) and intraoperatively (bottom). Intraoperatively, surgeons moved the muscle belly proximally as far as possible …

Equine Bone Marrow and Adipose Tissue Mesenchymal Stem Cells: Cytofluorimetric Characterization, In Vitro Differentiation, and Clinical Application

The aim of the present work was to isolate, cultivate, differentiate, and conduct cellular characterization of mesenchymal stem cells (MSCs) derived from equine adipose tissue (eAT) and bone marrow (eBM). Isolated and characterized cells were used in racehorses suffering from a superficial flexor tendon injury. Equine adipose tissue collection was performed at the base of the horse tail, whereas eBM was aspirated from iliac crest. Mononuclear cell fraction was isolated and cultured. In vitro differentiation and molecular characterization at P3 of culture were performed. No statistically significant differences in the number of cell doublings were found among different culture passages (P > .05). Doubling time was greater for eBM than eAT (3.2 ± 1.5 vs. 1.3 ± 0.7; P < .05). Positive von Kossa and Alizarin Red staining confirmed osteogenesis. Alcian Blue and Oil Red O staining illustrated chondrogenesis and adipogenesis, respectively. Isolated cells resulted positive for CD90, CD44, and CD105, whereas negative for hematopoietic markers, CD14, CD45, and CD34. Using isolated cells for injured tendon therapy, no adverse reactions were observed, and all inoculated horses returned to race competitions. In vitro results revealed the immunophenotypic characterization of isolated cells similar to that observed in human MSCs from the same sources; furthermore, in the present study, their clinical use proves the safety of eBM-derived and eAT-derived MSCs and a successful outcome for the treated animals that returned to their previous level of sport activity.

A Unique Rectus Femoris Injury in an Adolescent Professional Soccer Player: A Case Report.

A sixteen-year-old professional soccer player presented with persistent pain in the right thigh of two years' duration and the inability to return to play. Evaluation revealed a chronic rupture of the rectus femoris muscle. Because physiotherapy and rehabilitation failed to help, a surgical repair was performed. He returned to his previous activity level within nine months after surgery. Rupture of the proximal part of the rectus femoris should be acknowledged in the differential diagnosis, especially when presenting with persistent pain in the anterior aspect of the thigh lasting more than one year. Delayed repair might be recognized as a reasonable option for chronic rupture of the proximal part of the rectus femoris.

Geriatric trauma hip fractures: is there a difference in outcomes based on fracture patterns?

BackgroundAnnually in the US, there are over 300,000 hospital admissions due to hip fractures in geriatric patients. Consequently, there have been several large observational studies, which continue to provide new insights into differences in outcomes among hip fracture patients. However, few hip fracture studies have specifically examined the relationship between hip fracture patterns, sex, and short-term outcomes including hospital length of stay and discharge disposition in geriatric trauma patients.MethodsWe performed a retrospective study of hip fractures in geriatric trauma patients. Hip fracture patterns were based on ICD -9 CM diagnostic codes for hip fractures (820.00-820.9). Patient variables were patient demographics, mechanism of injury, injury severity score, hospital and ICU length of stay, co-morbidities, injury location, discharge disposition, and in-patient mortality.ResultsA total of 325 patient records met the inclusion criteria. The mean age of the patients was 82.2 years, and the majority of the patients were white (94%) and female (70%). Hip fractures patterns were categorized as two fracture classes and three fracture types. We observed a difference in the proportion of males to females within each fracture class (Femoral neck fractures Z-score = -8.86, p < 0.001, trochanteric fractures Z-score = -5.63, p < 0.001). Hip fractures were fixed based on fracture pattern and patient characteristics. Hip fracture class or fracture type did not predict short-term outcomes such as in-hospital or ICU length of stay, death, or patient discharge disposition. The majority of patients (73%) were injured at home. However, 84% of the patients were discharged to skilled nursing facility, rehabilitation, or long-term care while only 16% were discharged home. There was no evidence of significant association between fracture pattern, injury severity score, diabetes mellitus, hypertension or dementia.ConclusionsHip fracture patterns differ between geriatric male and female trauma patients. However, there was no significant association between fracture patterns and short-term patient outcomes. Further studies are planned to investigate the effect of fracture pattern and long-term outcomes including 90-day mortality, return to previous levels of activity, and other quality of life measures.

Comparison of Mesenchymal Stem Cell Versus Bone Marrow Treatment to Enhance Tendon to Bone Healing in an Animal Model

Objectives:Although anterior cruciate ligament reconstruction is one of the most common procedures in the field of sports medicine, less than 50% can return to previous activity level partially due to poor biological incorporation of tendon to bone. The aim of the study is to investigate the biological and mechanical effects of Mesenchymal Stem Cell (MSC) and Bone Marrow (BM) treatment for early tendon graft healing in a bone tunnel.Methods:60 Wistar Albino rats were enrolled in the study and divided in 3 groups equal in number. In all animals a bilateral 1.2 mm bone tunnel was created in proximal tibia. 15 mm Digital Flexor tendons were harvested from each lower extremity and passed from each tunnel. Medial ends of the graft was secured to bone using a custom made endobutton while lateral portion was sutured to periosteum. 100μl whole Bone marrow was aspirated from group 1 animals and injected into the tunnel after tendon transfer while 106 MSCs in 50μl HBSS was injected in the tunnel in group 2. Group 3 was taken as control. Tendon to bone healing was evaluated via immunohistochemistry and mechanical testing at 2 and 6 weeks.Results:At 2 weeks the tendon to bone interface tissue was found to be stronger in the BM treatment group whereas there was no difference in stiffness between group 1 and 2. Interface tissue width was found to be significantly decreased in the BM group compared to control and MSC treatment groups (p=0.0012, p=0.0001). At 2 weeks the number of M1 macrophages at the interface tissue was found to be significantly low in the BM group while M2 macrophages were highest in the MSC group. Cellularity was observed significantly high in the MSC group while tissue density was lowest in the BM group due to accelerated graft degradation at 2 weeks.Conclusion:Although both Bone Marrow and Mesenchymal Stem Cell treatments enhance tendon to bone healing by accelerating the remodeling process, Bone Marrow treatment reveals a more anti-inflammatory healing with improved mechanical properties.

Thumb volar plate reconstruction utilizing extensor pollicis brevis autograft: evaluation of a new technique.

Sagittal plane instability of the thumb metacarpophalangeal joint is a difficult problem with numerous surgical techniques described. The purpose of the study is to demonstrate a technique in which a distally based extensor pollicis brevis tendon autograft is utilized to reconstruct the deficient volar plate. This is a retrospective case series of four patients who were followed a minimum of 2years after this procedure. Patient demographics, return to work status, and objective outcomes are reported. This technique compared favorably to those previously described, in terms of technical ease, functional results, and patient satisfaction. Each patient returned to his previous activity level and was maintained on active duty in his current military occupational specialty. None required a permanent profile to limit the physical demands of his job. Preliminary data suggests this technique is anatomically sound, technically less demanding, and requires minimal surgical dissection compared to previously described procedures.

Arthroscopic therapy of septic hip infections in childhood

The treatment goal is to rapidly make a diagnosis and establish an effective arthroscopic therapy in order to allow the hip joint to develop normally throughout childhood with respect to anatomical and functional development. Coxarthritis suspected of being septic arthritis No experience with arthroscopy, osteomyelitis of the dorsal femoral neck requiring an intervention. Relative contraindication: absence of cannulated systems. Arthroscopic lavage of the hip joint, including revision of the femoral neck and debridement of osteomyelitis of the femoral neck with placement of an antibiotic carrier if necessary. The arthroscopy is performed using the two portal technique, placing the patient supine on a normal operation table (traction table not required). Drain for 2-3 days with mobilization after removal of the drainage. A second look arthroscopy is not normally planned but may become necessary in cases without improvement of the clinical or laboratory test parameters and after follow-up magnetic resonance imaging (MRI). The two portal hip joint arthroscopy using an irrigation volume of 6-9 l is an efficient minimally invasive method to safely treat septic arthritis of the hip joint with or without concomitant femoral neck osteomyelitis. It is associated with low morbidity and offers all advantages of an arthroscopic procedure. Out of 23 children 19 could be sufficiently treated by a single arthroscopic lavage of the hip joint. In three patients an additional osseous component required a second intervention. Out of 23 children 22 achieved an excellent Harris hip score, with one girl only achieving a moderate outcome. The 22 children had an unrestricted hip function at follow-up and could return fully to previous activity levels.

Outcome Following Surgical Treatment of 23 Cases of Primary Plantar/Palmar Annular Ligament Desmopathy: A Retrospective Study

Reasons for performing studyLittle exists in the literature regarding the outcome of endoscopically‐guided desmotomy of the palmar/plantar annular ligament (PAL) where injury to the PAL was the only diagnosis.ObjectivesTo report the return to previous level of exercise in horses treated with endoscopically guided PAL resection in which PAL injury was considered to be the primary condition.Study designRetrospective case series.MethodsMedical records of surgical cases at Donnington Grove Veterinary Surgery between 2005 and 2013 were reviewed. The inclusion criteria were cases that had undergone surgical transection of the palmar/plantar annular ligament under general anaesthesia and endoscopic guidance using a No. 12 scalpel blade where annular ligament injury was the only notable finding at surgery. Follow‐up was obtained by a telephone questionnaire.ResultsTwenty‐three horses were included in the study. Twenty horses were noted to have restriction to passage of the arthroscope within the digital flexor tendon sheath at the time of surgery. Following the initial 3‐month post operative rest period 21 horses were sound. Three horses did not return to their previous level of activity due to unrelated lameness issues and 2 returned to a lower level of competition due to owner preference. Of the remaining 18 horses, 16 returned to their previous level of athletic performance. Two horses had recurrent or persistent lameness associated with the residual PAL desmopathy.ConclusionsIn this case series surgical treatment of primary PAL injury carries a good prognosis (89% return to previous level of exercise) in contrast to a previously reported study (&lt;50% of horses were able to return to athletic function) [1].Ethical animal research: Ethical committee approval not currently required by this congress: retrospective study of clinical records. Explicit owner informed consent for participation in this study was not stated. Sources of funding: None. Competing interests: None.

Comparison of Allograft Versus Autograft Anterior Cruciate Ligament Reconstruction Graft Survival in an Active Adolescent Cohort

Background: Graft selection for anterior cruciate ligament (ACL) reconstructive surgery is a controversial topic. Few studies have compared graft outcomes in adolescents. Purpose: To identify factors related to ACL graft failure in an adolescent cohort. Study Design: Case-control study; Level of evidence, 3. Methods: After institutional review board approval was obtained, adolescent subjects (age range, 11-18 years) who underwent primary ACL reconstruction surgery at a large tertiary pediatric hospital between July 2005 and July 2009 were identified through a query of International Classification of Diseases, 9th Revision, diagnostic and Current Procedural Terminology codes. Subject data were obtained by means of a retrospective chart review, phone survey, and the administration of functional knee outcome instruments. A multivariate Cox proportional hazards regression analysis was used to analyze factors related to graft survival. Results: The average ages at surgery in the allograft (n = 38) and autograft (n = 35) groups were 15.29 ± 2.24 and 15.60 ± 1.57 years, respectively. There were 11 graft failures (28.95%) in the allograft group compared with 4 graft failures (11.43%) in the autograft group. In the multivariate model, graft type (P = .0352) and postoperative knee laxity according to the Lachman test (P = .0217) were the only variables significantly related to graft survival. The hazard of graft failure was 4.4 (95% CI, 1.23-18.89) times greater in the allograft group compared with the autograft group. The hazard of graft failure was 5.28 times (95% CI, 1.1-12.72; P = .0217) greater for a subject who demonstrated increased postoperative knee laxity relative to the contralateral knee. The risk for autograft failure tended to remain constant 24 to 48 months after initial surgery, whereas the risk for allograft failure continued to increase during postoperative months 24 to 48. There were no differences (P > .05) between the allograft and autograft groups with respect to International Knee Documentation Committee score, Lysholm score, and the rate of return to previous activity level. Conclusion: Graft type and postoperative knee laxity were identified as significant predictors of graft survival. On the basis of this large retrospective cohort, we recommend the use of autogenous grafts in children and adolescents undergoing primary, transphyseal ACL reconstruction. Patients who demonstrate increased translation during a postoperative Lachman test should be carefully followed because of concerns for subsequent graft failure.

Single space transforaminal lumbar interbody fusion in spondylolisthesis: initial experience of 30 cases.

Spondylolisthesis in adults is characterized by the loss of disc height across the affected segment with sagital translation. The goal of stabilizing the spine is accomplished by fusion. Transforaminal approach for lumbar interbody fusion is a very good approach and reduces the complications associated with traditional posterior approach. It has been reported to be safe and effective in the treatment of spondylolisthesis. It has done to assess the functional outcome of Transforaminal Lumbar Interbody Fusion (TLIF) in spondylolisthesis. This prospective interventional study was performed from July 2008 to June 2011 included 30 patients (male 07, female 23), within a age range of 30-59 years. Nineteen cases were lytic, 08 cases were degenerative, 02 were post-traumatic and 01 dysplastic variety of spondylolisthesis. Follow up ranged from 12 to 24 months and outcome assessed by VAS and ODI regarding pain and disability. Achievement of fusion and complications were documented accordingly. Statistical analysis was done by unpaired t-test and chi-squared test in appropriate instances. We included twenty One (70.00%) patient had Grade-II Spondylolisthesis and L4 over L5 had been the commonest level (53.33%) involved. Pain and disability improved significantly and 22 (73.33%) patients returned to their previous level of activity. One (03.33%) patient developed superficial wound infection and 01 (03.33%) had persistent low back pain. All patients had neurological improvement. We concluded that Transforaminal Lumbar Interbody Fusion is an effective alternative surgical procedure for the treatment of spondylolisthesis. Overall outcome is satisfactory in 93.33% cases.

Subpectoral Biceps Tenodesis for the Treatment of Type II and IV Superior Labral Anterior and Posterior Lesions

Background: Surgical repair remains the gold standard for most type II and type IV superior labral anterior and posterior (SLAP) lesions that fail nonoperative management. However, most recently, there have been data demonstrating unacceptably high failure rates with primary repair of type II SLAP lesions. Biceps tenodesis may offer an acceptable, if not better, alternative to primary repair of SLAP lesions. Hypothesis: Subpectoral biceps tenodesis provides satisfactory, reproducible outcomes for the treatment of type II and type IV SLAP lesions. Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent subpectoral biceps tenodesis and labral debridement for type II and type IV SLAP lesions by a single board-certified shoulder surgeon from 2006 to 2012 were evaluated. Exclusion criteria included those patients who underwent biceps tenodesis with an associated rotator cuff repair, anterior labral repair, or posterior labral repair. Outcome measures included the visual analog scale (VAS) for pain, the American Shoulder and Elbow Surgeons (ASES) score, and demographic data. Results: Between 2006 and 2012, a total of 36 subpectoral biceps tenodesis procedures were performed in 33 patients for type II or IV SLAP lesions. Twenty-six patients with 29 shoulder surgeries were available for follow-up. The average age was 46.7 years, with 16 male and 10 female patients participating in the study. The average follow-up was 40.17 months. There was a significant improvement in ASES and VAS scores: 48.1 and 6.4 preoperatively compared with 87.5 and 1.5 postoperatively, respectively (P < .001). There was no significant difference based on SLAP lesion type, patient age, or patient sex. Of 29 shoulders, 26 (89.66%) were able to return to the previous level of activity. Conclusion: This study adds to the evolving literature supporting biceps tenodesis as a viable treatment for type II and IV SLAP lesions. Patient age had no effect on the outcomes. Based on these results, biceps tenodesis is a safe, effective, and technically straightforward alternative to primary SLAP repair in patients with type II and IV SLAP tears.

Talonavicular arthroscopy for osteochondral lesions: technique and case series.

Traditional treatment of talonavicular osteochondral lesions (OCLs) requires an open procedure. Arthroscopic microfracture of talonavicular OCLs may provide a viable, minimally invasive approach. The purpose of this study was to describe an arthroscopic approach for treatment of talonavicular OCLs, describe the proximity of arthroscopic portals to important structures in cadaver specimens, and report magnetic resonance imaging (MRI) findings and clinical outcomes of this technique. Five cadaver specimens were dissected so proximity of portals to adjacent tendons and neurovascular structures could be assessed. Subsequently, 3 athletic patients with OCLs of the talonavicular joint were treated with arthroscopic debridement and microfracture. Patient records and imaging studies were retrospectively reviewed. In the cadaver specimens, the mean distance between the neurovascular bundle and the medial border of the extensor hallucis longus (EHL) was 9.0 (range, 8 to 10) mm. The saphenous nerve was located a mean of 6.8 (range, 6 to 7) mm from the medial border of the tibialis anterior tendon. Therefore, portals were placed just medial to the EHL and tibialis anterior tendon to avoid the neurovascular bundle and saphenous nerve, respectively. In all patients, access, identification of the OCL, debridement, and microfracture were successfully performed. All patients demonstrated improvements in Foot and Ankle Outcome Scores and Short Form-12 scores and began gradual return to activity within 12 weeks following the operation. No significant complications occurred. MRI indicated signal consistent with reparative fibrocartilage in all patients. Talonavicular arthroscopy allowed visualization, curettage, synovectomy, loose body removal, and microfracture of OCLs that would have otherwise required an open approach. At early follow-up, all patients had returned to their previous activity levels. Arthroscopy of the talonavicular joint was a viable approach for microfracture of OCLs. Level IV, case series.

Rotator Cuff Tears in the Throwing Athlete

Tears of the rotator cuff, both partial, and less commonly, full thickness, are relatively common in the throwing athlete. The rotator cuff is subjected to enormous stresses during repetitive overhead activity. The supraphysiological strains, especially when combined with pathology elsewhere in the kinetic chain, can lead to compromise of the cuff fabric, most commonly on the undersurface where tensile overload occurs. Exacerbation by a tight posterior capsular, anterior instability, and internal impingement render the cuff progressively compromised, with intrinsic shear stresses and undersurface fiber failure. Advances in imaging technology, including contrast magnetic resonance imaging, dynamic ultrasound, and arthroscopic visualization have enhanced our understanding of cuff pathology in this athletic population. Unfortunately, this has not yet translated into how to best approach these athletes to return them to their previous level of activity. Nonoperative management remains the mainstay for most throwers, with arthroscopic debridement an effective surgical option for those with refractory symptoms. Despite technological advances in cuff repair in the general population, comparable outcomes have not been achieved in high-level throwers. Widespread appreciation that securing the cuff operatively will likely end an athletes' throwing career has led to adopting a surgical approach that emphasizes debridement over repair for nearly all partial and full-thickness tears. Whether advances in surgical technique will ultimately permit definitive and lasting repairs that allow overhead throwers to return to their previous level of sports remains unknown at this time.

Chronic Ankle Pain After An Initial ‘Twisting’ Injury To The Ankle

A 42-year-old woman was admitted to our outpatient clinic with chronic left ankle pain that began after having a twisting ankle injury fifteen days prior. Immediately after the injury, she was admitted to the nearest emergency department and foot radiographs were taken. Lateral and oblique foot radiographs revealed no abnormal findings, and the patient was diagnosed as simple ankle sprain and was treated with anti-inflammatory medications, elastic bandage, rest, and ice. Although the soft tissue swelling subsided gradually, the patient suffered from chronic ankle pain and persistent antalgic gait. On physical examination, there was tenderness over the foot distal and inferior to the anterior talofibular ligament (ATFL). The range of ankle movements was slightly painful and inversion of the ankle produced considerable pain. Neurovascular examination was normal. The initial foot radiographs were available and re-evaluated (Figure 1). Figure 1 (a) Lateral and (b) oblique foot radiographs of the patient. DIAGNOSIS: Fracture of Anterior Superior Process of Calcaneus: A Commonly Missed Fracture A careful examination of the initial lateral foot radiograph raised the suspicion of fracture of the anterior superior process of calcaneus (ASPC) (Figure 2a). Further imaging with computerized tomography (CT) and multiplanar reconstruction confirmed our preliminary diagnosis (Figure 2b, c). Below-knee plaster cast was applied and continued for four weeks, after which a gradual return to full activities was allowed. At the final follow-up six months after the initial injury, the patient was free of pain and was able to return to his previous level of activity. Figure 2 (a) Lateral foot radiograph validated a suspected fracture line at the anterior superior process of calcaneous (black drawing). (b) Sagittal and (c) axial CT demonstrated the fracture (white arrows). Fracture of ASPC is a rare fracture that constitutes 3% of all calcaneal fractures.1, 2 The mechanism of the injury is often an inversion injury with the foot in plantar flexion, similar to simple ankle sprain.1, 2, 3 Because of its infrequency, the similarity between typical history and clinical presentation of an ankle sprain and difficulties in direct radiographic evaluationof the fractures of the ASPC is usually misdiagnosed as ankle sprain at initial emergency visits. On the other hand, early identification and prompt treatment of these moderately seeming fractures may prevent chronic ankle problems as observed in our patient. Therefore, emergency physicians should be aware of this fracture. In order to prevent misdiagnosis, a high level of suspicion and investigation is necessary. Furthermore, the physical examination the tenderest point on palpation should be correctly identified. In the fracture of the ASPC, the tender point is 3–4 cm distal to the lateral malleolar tip over the bifurcate ligament.2, 3 Whereas in ankle sprain of the ATFL is usually tender. [4] In addition to a careful physical examination, a careful examination of the foot radiographs is important. Anteroposterior and lateral foot radiographs should be obtained as the first line imaging work-up. However, complex anatomic structure of the foot and superimposition on direct radiography makes the evaluation difficult causing these fractures may easily be missed. In case of suspicion, computed tomography (CT) is the most useful imaging method to detect and define the extent of the fracture.[4] Sagittal reconstruction best demonstrates the fracture.[3] The os calcaneus secundarius is an uncommon accessory ossicle of the midfoot which is present in the 5% of the normal population.3, 4, 5 However, in the context of foot trauma, this normal anatomic variant may be misdiagnosed as a fracture of the ASPC. Thus, os calcaneus secundarius should be considered in the differential diagnosis of acute fractures of the ASPC. The most important radiographic clue to differentiate an os calcaneus secundarius from an acute fracture is the oval configuration and well-corticated margins.3, 4 Conservative treatment in the form of plaster cast immobilization that last 4 weeks is sufficient for the treatment.1, 4