Anterior cruciate ligament reconstruction using achilles tendon allograft: an assessment of outcome for patients age 30 years and older.

Achilles allografts have become popular for anterior cruciate ligament (ACL) reconstructions in older patients. Primary ACL reconstructions using Achilles tendon allografts in patients age 30 years and older are successful in restoring the knee to "normal" or "near normal." During a three-year period, the two senior authors performed 65 primary ACL reconstructions using Achilles tendon allografts in patients aged 30 years and older. Our exclusion criteria were periarticular fracture, ipsilateral/contralateral knee ligament injury, and previous or concomitant osteotomy or cartilage restoration procedure. Each patient was evaluated via physical examination, functional and arthrometric testing, and radiographic and subjective outcome. Knees were considered normal, near normal, or abnormal based on the International Knee Documentation Committee (IKDC) system. Forty-three patients were examined at an average of 33 months (minimum, 24 months) postoperatively. At the time of ACL reconstruction, 35% had normal articular cartilage in all three compartments and 70% had meniscal tears. No re-ruptures occurred. While 24% had mean maximal translation differences less than or equal to 3 mm, none had side-to-side differences greater than 5 mm. Postoperative IKDC, Activities of Daily Living, and Activity Rating Scale scores averaged 88, 94, and 7.7, respectively. Despite the overall favorable outcomes, 29% had worsened radiographic grades at follow-up. Using an Achilles allograft for ACL reconstruction in patients older than 30 years, we restored over 90% of knees to normal or near normal while limiting postoperative complications. Poor subjective results may be related less to instability and more to pain, which may result from progressive arthritis.

Internal fixation of unstable Cahill Type-2C osteochondritis dissecans lesions of the knee in adolescent patients.

The treatment of osteochondritis dissecans lesions remains controversial. Twelve adolescent patients, with average 6-year follow-up, underwent compression screw fixation of unstable Cahill Type-2C osteochondritis dissecans lesions. Postoperatively, patients were evaluated with several functional tests and scoring systems, including Lysholm, IKDC, and KOOS. All lesions healed, and no clinical or radiographic evidence of degenerative disease was noted. No significant differences in thigh girth, range of motion, stability, or single-leg-hop distance was observed when compared to the unaffected, contralateral extremity. This technique is appropriate and efficacious for the treatment of unstable osteochondritis dissecans lesions.

Acute compartment syndrome of the thigh in a high school soccer player: indications for expedient action.

Compartment syndrome in the lower leg, most commonly related to exertion, has been well documented in athletes. However, compartment syndrome resulting from trauma is rare in athletes, as in this case of a 17-year-old male goalie who sustained a direct blow to his thigh during a soccer game. He was successfully treated with early fasciotomy and delayed wound closure, and he made a full recovery.

Complete rupture of large tendons: risk factors, signs, and definitive treatment.

Forceful eccentric contraction may cause a partial or complete rupture of a vulnerable large tendon, especially in middle-aged men. When diagnosing a large-tendon rupture, it is essential to rule out a systemic illness or history of local or systemic corticosteroid or anabolic steroid use, because any of these may lead to poor tendon quality and increased risk for rupture. Ultrasound or MRI may help confirm the diagnosis. Treatment is generally surgical with anatomic repair. Return to sport depends on the patient's age, lifestyle, tendon involved, and medical comorbidities.

Improvement in the undertreatment of osteoporosis following hip fracture.

BACKGROUND: Osteoporosis is a common disease characterized by decreased bone mass and increased fracture risk in postmenopausal women and the elderly. Hip fractures are among the most common consequences of osteoporosis and unfortunately usually occur late in the course of the disease. When a patient is admitted to the hospital with a fragility hip fracture, a unique opportunity for diagnosis and treatment presents itself. Fortunately, several medications have proven to be effective in lowering the risk of future fractures. The purposes of the present study were to test the hypothesis that most fragility hip fractures go untreated and to determine whether educational efforts to raise physician awareness have led to an improvement in osteoporosis treatment rates. METHODS: A retrospective cohort study was performed with use of the patient databases at two university medical centers and one university-affiliated community hospital. The charts of 300 randomly selected patients were sorted with use of ICD-9 (International Classification of Diseases, Ninth Revision) codes for femoral neck fractures. There were 100 patients from each center, with twenty-five patients from each year between 1997 and 2000. The admitting diagnosis, mechanism of injury, admission medications, procedures performed during hospitalization, and discharge medications were then extracted and analyzed. During this period, the National Osteoporosis Foundation established guiding principles for the treatment of fragility fractures. RESULTS: Of the seventy-five patients from all centers for each year from 1997 to 2000, 11%, 13%, 24%, and 29%, respectively, were discharged with a prescription for some medication targeting osteopenia, either supplemental calcium or an antiosteoporotic medication (estrogen, calcitonin, a bisphosphonate, or raloxifene). A trended chi-square analysis of this increase revealed a p value of <0.001, indicating that this improvement in treatment was unlikely due to chance alone. Fifty-eight (19.3%) of the 300 patients in the study received a prescription at the time of discharge. However, forty of these patients (13.3% of the overall group) received calcium and only eighteen (6.0% of the overall group) received a medication to actively prevent bone resorption and treat osteoporosis. In addition, no patient underwent a bone density scan while in the hospital. CONCLUSIONS: Elderly patients and postmenopausal women who are admitted to the hospital and diagnosed with a low-energy femoral neck fracture have been undertreated for osteoporosis. However, over the four years of the present study, there was a significant increase in the rate of treatment. It is hoped that treatment rates will continue to increase in the future with continued educational efforts.