Early Onset Rapidly Progressive Osteoarthritis of the Hip in a Young Athlete.

We report and discuss a very rare case of early-stage rapidly progressive osteoarthritis (RPO) in a 33-year-old female athlete. The etiopathology of RPO remained unclear, although in this case mechanical overloading due to constant joint overuse appeared to be the only significant contributing factor to the very early development of RPO. Key words: rapidly progressive osteoarthritis, rapid destructive arthrosis, hip arthrosis, total hip arthroplasty, athlete, osteoarthritis.

Intraspecies and interspecies comparison of the compressive properties of the medial meniscus.

Quantification of the compressive material properties of the meniscus is of paramount importance, creating a "gold-standard" reference for future research. The purpose of this study was to determine compressive properties in six animal models (baboon, bovine, canine, human, lapine, and porcine) at six topographical locations. It was hypothesized that topographical variation of the compressive properties would be found in each animal model and that interspecies variations would also be exhibited. To test these hypotheses, creep and recovery indentation experiments were performed on the meniscus using a creep indentation apparatus and analyzed via a finite element optimization method to determine the material properties. Results show significant intraspecies and interspecies variation in the compressive properties among the six topographical locations, with the moduli exhibiting the highest values in the anterior portion. For example, the anterior location of the human meniscus has an aggregate modulus of 160 +/- 40 kPa, whereas the central and posterior portions exhibit aggregate moduli of 100 +/- 30 kPa. Interspecies comparison of the aggregate moduli identifies the lapine anterior location having the highest value (450 +/- 120 kPa) and the human posterior location having the lowest (100 +/- 30 kPa). These baseline values of compressive properties will be of help in future meniscal repair efforts.

Tibiotalocalcaneal arthrodesis.

The purpose of this multicenter retrospective study of 55 patients (56 ankles) who underwent simultaneous tibiotalocalcaneal arthrodesis with severe disease involving the ankle and subtalar joints was to determine improvement of pain and function. The surgical indications included osteoarthritis, posttraumatic injury, failed previous surgery, talar avascular necrosis, osteoarthritis, and rheumatoid arthritis involving the ankle and subtalar joints. The average age at the time of the operation was 53 years. The average time of follow-up was 26 months after the operation. Fusion was achieved in 48 ankles, with an average time of fusion of 19 weeks. Forty-eight of the 55 patients were satisfied with the procedure. The average leg length discrepancy was 1.4 cm. The average amount of dorsiflexion was 2 degrees and plantar flexion was 5 degrees. Following surgery, 42 patients complained of pain, 40 patients required shoe modification or an orthotic device, and 34 patients had a limp. Fourteen patients described their activity as unlimited. Based on the AOFAS evaluation, the patients scored an average of 66 on the ankle-hind foot scale following surgery. The most common complications were nonunion (8 ankles) and wound infection (6 ankles). This study demonstrates that tibiotalocalcaneal arthrodesis is an effective salvage procedure for patients with disease both involving the ankle and subtalar joints.

Posterior tibial tendon tears in young competitive athletes: two case reports.

Unlike the Achilles tendon, the posterior tibial tendon does not typically undergo acute rupture. We report two cases of posterior tibial tendon tears occurring in young, athletic individuals (<30 years old) that required operative intervention before the patients could return to competitive sports. We believe that these are the first two reports of posterior tibial tendon tears occurring in this population without the patient having a prior history of steroid injections in the tendon. The tears we observed and described at surgical exploration were chronic and degenerative in nature. We also comment on our approach to treatment of posterior tibial tendon injuries in the athletic population.

Hamstring strains in athletes: diagnosis and treatment.

Hamstring strains are among the most common injuries (and reinjuries) in athletes. Studies combining electromyography with gait analysis have elucidated the timing of activity of the three muscles of the hamstring group; they function during the early-stance phase for knee support, during the late-stance phase for propulsion, and during midswing to control the momentum of the leg. Muscle injury, whether partial or complete, occurs at the myotendinous junction, where force is concentrated. The healing response begins with inflammation, associated edema, and localized hemorrhage. After an initial period of reduced tension, the healing muscle regains strength rapidly as long as reinjury does not occur. Although the use of anti-inflammatory medication is a keystone of treatment, a certain degree of inflammation is necessary for removing necrotic muscle fibers and rescaffolding to allow optimal recovery. The protocol of rest, ice, compression, and elevation is still the preferred first-aid approach. After a brief period of immobilization (usually less than 1 week for even the most severe strain), mobilization is begun to properly align the regenerating muscle fibers and limit the extent of connective tissue fibrosis. Concurrent pain-free stretching and strengthening exercises (beginning with isometrics and progressing to isotonics and isokinetics) are essential to regain flexibility and prevent further injury and inflammation. Readiness for return to competition can be assessed by isokinetic testing to confirm that muscle-strength imbalances have been corrected, the hamstring-quadriceps ratio is 50% to 60%, and the strength of the injured leg has been restored to within 10% of that of the unaffected leg. The only indication for surgery is a complete rupture at or near the origin from the ischial tuberosity or distally at its insertion (either soft-tissue avulsion with a large defect or bone avulsion with displacement by 2 cm).

Thromboembolism after foot and ankle surgery. A multicenter study.

Thromboembolic disease presents a potentially fatal complication to patients undergoing orthopaedic surgery. Although the incidence after hip and knee surgery has been studied and documented, its incidence after surgery of the foot and ankle is unknown. For this reason, a prospective multicenter study was undertaken to identify patients with clinically evident thromboembolic disease to evaluate potential risk factors. Two thousand seven hundred thirty-three patients were evaluated for preoperative risk factors and postoperative thromboembolic events. There were six clinically significant thromboembolic events, including four nonfatal pulmonary emboli, after foot and ankle surgery. The incidence of deep vein thrombosis was six of 2733 (0.22%) and that of nonfatal pulmonary emboli was four of 2733 (0.15%). Factors found to correlate with an increased incidence of deep vein thrombosis were nonweightbearing status and immobilization after surgery. On the basis of these results, routine prophylaxis for thromboembolic disease after foot and ankle surgery probably is not warranted.

Primary care of foot and ankle injuries in the athlete.

A thorough knowledge of foot and ankle anatomy is required to allow an accurate and focused examination of the injured athlete. This short review has attempted to educate the treating physician on our approach to foot and ankle injuries commonly seen in athlete. We have tried to elucidate less common injuries that present in similar manner to the more common foot and ankle sprains and strains.

Tarsal coalition.

Tarsal coalition is a bridging between the tarsal bones of the foot. The bridge may be composed of bone, cartilage, fibrous tissue, or a combination of these. When symptomatic, patients usually present with hindfoot pain and frequent sprains as children, adolescents, or young adults. The classical appearance is a rigid flatfoot with heel valgus and abduction of the forefoot. Flexible cavus feet have been reported. The incidence in the general population is less than 1%, and the most common types are talocalcaneal and calcaneonavicular coalitions. The cause is attributed to failure of segmentation and differentiation of the primitive mesenchyme. Calcaneonavicular coalitions can be diagnosed with an oblique radiograph of the hindfoot. Most talocalcaneal coalitions require computerized tomography for diagnostic confirmation. Magnetic resonance Imaging may be useful for cartilaginous and fibrous coalitions. Casting is the usual initial treatment for the symptomatic individual. With treatment failure, in the absence of degenerative changes, resection of the coalition can be performed with good results. Isolated subtalar fusion may be performed for failed talocalcaneal resections. Failed subtalar fusions and failed calcaneonavicular resection may be treated with triple arthrodesis.

Turf toe injury.

Long term morbidity secondary to previous first MP injury has been reported by Coker and associates and involved persistent pain with athletic activities and restricted range of motion. Clanton and coworkers noted hallux valgus and early hallux rigidus as specific long term sequelae. Clanton and Seifert have reviewed 20 athletes with prior turf toe injury with greater than 5 year follow-up noting a 50% incidence of persistent symptoms. Further study is needed regarding the long term effect of turf toe injury, but it is clearly a significant athletic injury that requires appropriate treatment tailored to the severity of the injury.

Chronic leg pain in the athlete.

Chronic leg pain in athletes results from various conditions. Proper diagnosis requires careful examination, knowledge of the various presentations, and appropriate use of diagnostic studies. These conditions can often coexist, making accurate diagnosis difficult. Most exercise-induced leg pain responds to conservative nonsurgical treatment; however, certain syndromes such as chronic compartment syndrome or popliteal artery entrapment syndrome are more appropriately treated surgically to improve the athlete's ability to return to full participation.

Chronic Exercise-Induced Leg Pain in Active People.

In brief "Shin splints" is a catchall term for any kind persistent exercise-related lower leg pain with no obvious cause. Such pain can originate from a number of conditions, such as medial tibial stress syndrome, stress fracture, compartment syndrome, vascular pathology, nerve entrapment, and others. A methodical work-up designed to detect problems in all anatomic structures from bone to skin will narrow the possibilities and lay the basis for appropriate treatment.

Comparison of Chevron osteotomy and modified McBride bunionectomy for correction of mild to moderate hallux valgus deformity.

The purpose of this study was to compare the results of the Chevron osteotomy to the DuVries' modification of the McBride procedure using identical criteria in two groups of patients. Thirty-two patients (48 feet) that had a Chevron osteotomy and 10 patients (17 feet) who had a modified McBride bunionectomy without metatarsal osteotomy for treatment of mild to moderate hallux valgus were retrospectively reviewed using subjective and objective criteria. Both groups were matched according to age, severity of deformity, and length of follow-up. Ninety-two percent of patients in the Chevron group and 88% of patients in the McBride group responded that they were either totally satisfied or improved regarding pain relief and appearance of the foot following surgery. Chevron osteotomy resulted in a statistically significant greater correction of the intermetatarsal 1-2 angle than did the McBride bunionectomy. Postoperative metatarsophalangeal joint range of motion was not significantly different for the two groups. Following Chevron osteotomy, five (10%) metatarsal heads exhibited radiographic changes of cyst formation and/or increased osteodensity and three (6%) of the osteotomies healed in a malunited position. One of the three metatarsal head malunions occurred in a patient that also had a lateral capsular release, however, none of the five cases that developed radiographic changes in the first metatarsal head was associated with a lateral capsular release. Lateral capsular release with the Chevron osteotomy did not improve the amount of correction of the hallux valgus deformity and it may be a contributing factor to instability at the osteotomy site leading to a valgus malunion.

Reconstruction for subtalar instability: a review.

Instability of the subtalar joint has become a more well-defined clinical entity in recent years. While there have been several articles which have discussed diagnosis of this condition, there has been little written on the surgical treatment. Reconstructive techniques with which we have had experience are presented. Technical aspects of these methods are described in detail.

Leiomyosarcoma of the os calcis.

A primary leiomyosarcoma of the os calcis, occurring in a 68-year-old woman and treated by below-the-knee amputation, is reported. The diagnosis was confirmed by electron microscopy, and supported by immunochemistry. These techniques can be performed in a primary spindle cell osseous neoplasm to distinguish leiomyosarcoma from fibrosarcoma and malignant fibrous histiocytoma. A total of 28 cases of primary leiomyosarcoma of extragnathic bones have been reported in the literature with one occurring in the foot. This is the first reported case involving the os calcis and the first reported leiomyosarcoma of the foot in the English literature.

Instability of the subtalar joint.

Instability of the subtalar joint can follow inversion stress injuries to the lateral ankle and hindfoot. Ligaments involved in the injury include the calcaneofibular, lateral talocalcaneal, cervical, interosseous talocalcaneal, or a combination. Although the problem most often occurs in conjunction with lateral ankle instability, it may be an isolated problem and it is not corrected equally well by the various lateral ankle ligament reconstructions. Techniques available for diagnosis include routine stress radiographs of the ankle, which also include the subtalar joint, specific subtalar stress radiographs, stress tomograms, fluoroscopy, or subtalar arthrograms. Once diagnosed, subtalar instability symptoms can be treated by either nonoperative or operative means.

Sports-related spontaneous fractures of the humerus.

An example of a spontaneous spiral fracture of the humerus in a healthy softball player is presented. This rare injury is discussed, addressing the mechanisms of injury, the treatment, and the types of sports in which this type of fracture has been reported to occur.

Hallux rigidus: treatment by cheilectomy.

Cheilectomy, the excision of an irregular osseous rim that interferes with motion of a joint, was performed on the distal part of the first metatarsal of twenty-five patients who had hallux rigidus. Relief of pain was achieved in all but three patients, whose cases were considered as failures. Joint motion improved by an average of 20 degrees, and it was in an acceptable range in twenty-three patients. There were no complications other than persistence of swelling in six patients. No patient required additional operative intervention during an average follow-up of fifty-six months. We concluded that cheilectomy is a better method of treatment for hallux rigidus than arthrodesis, resection arthroplasty, or arthroplasty with the use of a flexible implant.

Injuries to the metatarsophalangeal joints in athletes.

Injury to the metatarsophalangeal joints in sports has become an increasing problem with the advent of more flexible shoewear and artificial playing surfaces. These injuries vary from mild sprains to severe tearing of the capsuloligamentous complex including avulsion fractures. This may include a compression fracture of the metatarsal head in the more severe cases. At the extreme, dislocation or fracture-dislocation of the metatarsophalangeal joint occurs. The findings in 62 cases of these injuries in Rice University athletes from 1971 to 1985 are presented. Treatment follows a standard regimen of ice, taping and anti-inflammatory medication with gradual return to sports activity as symptoms allow. Recommendations for preventive therapy include stiffening the forefoot in athletic shoes or the use of an orthotic device. This should reduce the incidence of long-term sequelae.

Osteochondritis dissecans. History, pathophysiology and current treatment concepts.

The past and current status of osteochondritis dissecans suggests that there is still no clear cut etiology. The etiologic mechanism is generally assumed to be multifactorial and related to minor trauma occurring at a susceptible locations. The existence of two clinical patterns is important. Conservative treatment should be emphasized in the young patient who has open physes and a more aggressive approach in the older symptomatic patient. Drilling has a use in the loose unseparated fragment. Free fragments should be replaced when possible if they involve a portion of the weight-bearing articular surface. When replacement is impossible, treatment must be individualized, either by trephining or spongialization followed by joint ranging exercises with nonweight-bearing, or in cases which involve a large portion of the weight-bearing surface of the femoral condyle, a more radical treatment, including osteotomy, hemiarthroplasty, or allograft

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.