Osseointegration reduces aseptic loosening of primary distal femoral implants in pediatric and adolescent osteosarcoma patients: a retrospective clinical and radiographic study.

AIM: The challenge of distal femoral replacement (DFR) longevity remains a priority for orthopaedic oncologists as the overall survival and activity level of young patients with osteosarcoma continues to improve. This study hypothesized that increased extracortical osseointegration at the bone-implant shoulder (i.e., where the metal implant shaft abuts the femur) will improve stress transfer adjacent to the implant, as evidenced by reduced cortical bone loss, radiolucent line progression and implant failure in young patients (< 20 years) following DFR surgery. METHODS: Twenty-nine patients of mean age 13.09 ± 0.56 years received a primary DFR. The clinical outcome of 11 CPS®, 10 GMRS®, 5 Stanmore® and 3 Repiphysis® implants was evaluated over a mean follow-up period of 4.25 ± 0.55 years. The osseous response to a bone-implant shoulder composed of either a hydroxyapatite-coated grooved ingrowth collar (Stanmore®), a porous metal coating (GMRS®) or a polished metal surface (Repiphysis®) was quantified radiographically. RESULTS: All (100.0%) of the Stanmore® implants, 90.0% of GMRS®, 81.8% of CPS® and 33.3% of the Repiphysis® implants survived. Significantly increased extracortical bone and osseointegration were measured adjacent to the Stanmore® bone-implant shoulder when compared with the GMRS® and Repiphysis® implants (p < 0.0001 in both cases). Significantly decreased cortical loss was identified in the Stanmore® group (p = 0.005, GMRS® and p < 0.0001, Repiphysis®) and at 3 years, the progression of radiolucent lines adjacent to the intramedullarly stem was reduced when compared with the GMRS® and Repiphysis® implants (p = 0.012 and 0.026, respectively). CONCLUSIONS: Implants designed to augment osseointegration at the bone-implant shoulder may be critical in reducing short- (≤ 2 years) to mid- (≤ 5 years) term aseptic loosening in this vulnerable DFR patient group. Further longer-term studies are required to confirm these preliminary findings.

CURRENT CONCEPTS IN THE TREATMENT OF GROSS PATELLOFEMORAL INSTABILITY.

Patellofemoral instability is a painful and commonly recurring condition, which often must be managed surgically. Diagnosis can be aided by the use of a variety of physical exam signs, such as the Q angle, Beighton hypermobility score, glide test, J sign, patellar tilt test, and apprehension test. Imaging modalities including x-ray, CT, and MRI guide both diagnosis and management by revealing trochlear dysplasia, bony malalignment, and ligamentous injury that contribute to instability. Following an initial patellar dislocation, nonoperative management with bracing and physical therapy is an acceptable option, despite limited evidence that operative management may improve functional outcome and reduce recurrent dislocations. For recurrent dislocations, operative management is indicated, and the appropriate procedure depends on the patient's anatomy and the cause of instability. Reconstruction of the medial patellofemoral ligament (MPFL) restores the primary soft tissue restraint to lateral patellar dislocations, and can be performed using a variety of techniques. In patients whose instability is related to bony malalignment, a tibial tubercle osteotomy is commonly performed to realign the extensor mechanism and establish proper patellar tracking. In patients with trochlear dysplasia, a trochleoplasty may be performed to create a sufficient groove for the patella to traverse. Often these procedures must be combined to address all causes of instability. The reported outcomes following all three of these procedures are generally very good, with the majority of patients experiencing functional improvements and a low rate of recurrent instability, although more large randomized controlled trials are needed to determine which techniques are most effective. The purpose of this clinical commentary is to provide an overview of the current methods employed by orthopedic surgeons to diagnose and manage patellar instability. LEVEL OF EVIDENCE: 5.

Delayed Pseudoaneurysm of the Popliteal Artery Following ACL Reconstruction.

Arterial complications following arthroscopic anterior cruciate ligament (ACL) reconstruction of the knee are rare. Injuries to vascular structures around the knee have historically been reported more commonly, with reconstructive procedures occurring more posteriorly, such as posterior cruciate ligament (PCL) reconstruction. The authors present a report of sequelae following a postoperative popliteal artery spasm in an 18-year-old female soccer player who underwent ACL reconstruction using an ipsilateral autologous hamstring graft along with a medial meniscal repair and developed immediate spasm of the popliteal artery responding to sustained balloon angioplasty. Seven weeks postoperatively, she developed foot paresthesias and was noted to have a 3.5×3.1×1.3-cm pseudoaneurysm of her popliteal artery. She underwent popliteal artery bypass with reverse saphenous vein autograft and had an uneventful recovery. This case highlights the importance of prolonged follow-up and maintaining a high degree of suspicion for further arterial complications, even after routine arthroscopic knee procedures. In addition to maintaining close and extended follow-up, the authors agree with other authors' suggestions that urgent computed tomography angiogram be obtained to evaluate the vascular tree in a patient presenting with a cold, pulseless extremity after routine arthroscopic knee procedures. In this particular case, angiography of the uninvolved side also proved useful in identifying the patient's aberrant vascular anatomy and may be useful in patients with bilateral aberrant vascular anatomy to better facilitate interpretation of the injured side. To the author's knowledge, this is the first case of popliteal artery spasm initially responding to sustained angioplasty with the delayed development of a pseudoaneurysm.

Traumatic laryngeal fracture in a collegiate basketball player.

Laryngotracheal trauma is a rare condition that accounts for less than 1% of blunt trauma. Laryngotracheal fractures are uncommon in sports, even in settings where athletes are more vulnerable, including football, basketball, and hockey. If a laryngeal injury is suspected, immediate evaluation is required to avoid a delay in the diagnosis of a potentially life-threatening injury. A collegiate basketball player sustained an unusual fracture involving the cricoid and thyroid cartilage during practice. This case illustrates the importance of rapid identification and early management of patients with blunt laryngotracheal trauma in sports.

Sports health benefits of vitamin d.

CONTEXT: Vitamin D is a potent secosteroid hormone that provides many skeletal and extraskeletal health benefits. Musculoskeletal injury prevention and recovery are potentially affected by sufficient circulating levels of the storage form of vitamin D: 25-hydroxyvitamin D3, or 25(OH)D. Vitamin D deficiency can exist among young, active, and healthy people, which may put them at increased risk for injury and prolonged recovery. EVIDENCE AQUISITION: PubMed was searched using vitamin D and skeletal muscle, vitamin D and athletic performance, and vitamin D review articles. Studies from the 1930s to 2012 were used for the review. RESULTS: There is strong correlation between vitamin D sufficiency and optimal muscle function. Increasing levels of vitamin D reduce inflammation, pain, and myopathy while increasing muscle protein synthesis, ATP concentration, strength, jump height, jump velocity, jump power, exercise capacity, and physical performance. 25(OH)D levels above 40 ng/mL are required for fracture prevention, including stress fractures. Optimal musculoskeletal benefits occur at 25(OH)D levels above the current definition of sufficiency (> 30 ng/mL) with no reported sports health benefits above 50 ng/mL. CONCLUSIONS: Vitamin D deficiency is common in athletes. For athletes presenting with stress fractures, musculoskeletal pain, and frequent illness, one should have a heightened awareness of the additional likely diagnosis of vitamin D deficiency. Correction of this deficiency is completed by standardized and supervised oral supplementation protocols producing significant musculoskeletal sports health benefits.

Osteochondral avulsion fracture of the anterior cruciate ligament femoral origin in a 10-year-old child: a case report.

OBJECTIVE: To describe the case of a 10-year-old football player who sustained a comminuted osteochondral avulsion fracture of the femoral origin of the anterior cruciate ligament (ACL) via a low-energy mechanism. BACKGROUND: In children, both purely cartilaginous and osteochondral avulsion fractures have been described; most such ACL avulsions are from the tibial eminence. In the few previous case reports describing femoral osteochondral avulsion fractures, high-energy injury mechanisms were typically responsible and resulted in a single fracture fragment. DIFFERENTIAL DIAGNOSIS: Femoral osteochondral avulsion fracture at the ACL origin, femoral cartilaginous avulsion fracture at the ACL origin, midsubstance ACL tear, meniscal tear. TREATMENT: Sutures and a button were used to repair the comminuted fragments. Postoperatively, a modified ACL reconstruction rehabilitation program was instituted. UNIQUENESS: Most injuries of this nature in youngsters are caused by a high-energy mechanism of injury, result in an osteochondral avulsion fracture of the tibial eminence, and involve a single fracture fragment. CONCLUSIONS: Although they occur infrequently, ACL femoral avulsion fractures in children can result from a low-energy injury mechanism. Identifying the mechanism of injury, performing a thorough physical examination, and obtaining appropriate diagnostic studies will enable the correct treatment to be implemented, with the goal of safely returning the athlete to play.

Multiple ligament knee injury: complications.

Non-operative and operative complications are common following multiple ligament knee injuries. This article will describe common complications seen by the surgeon and physical therapist following this complex injury. Complications include fractures, infections, vascular and neurologic complications following injury and surgery, compartment syndrome, complex regional pain syndrome, deep venous thrombosis, loss of motion and persistent laxity issues. A brief description of these complications and methods for evaluation and treatment will be described.