Multiple risk factors related to familial predisposition to anterior cruciate ligament injury: fraternal twin sisters with anterior cruciate ligament ruptures.

OBJECTIVE: A multifactorial combination of predictors may increase anterior cruciate ligament (ACL) injury risk in athletes. The objective of this twin study was to examine these risk factors to identify commonalities in risk factors that predisposed female fraternal twins to ACL injury. METHODS: Female twins in high-risk sports were prospectively measured prior to an injury for neuromuscular control using three-dimensional motion analysis during landing, hamstrings and quadriceps muscular strength on a dynamometer and joint laxity using a modified Beighton-Horan index and a Compu-KT arthrometer. Intraoperative measures of femoral intercondylar notch width were recorded during ACL reconstruction. RESULTS: Abduction angles were increased at one knee in both of the twin sister athletes relative to uninjured controls at initial contact and at maximum displacement during landing. The twin female athletes that went on to ACL injury also demonstrated decreased peak knee flexion motion at both knees than uninjured females during landing. The twin athletes also had increased joint laxity and decreased hamstrings to quadriceps (H/Q) torque ratios compared to controls. Femoral intercondylar notch widths were also below the control mean in the twin siblings. CONCLUSIONS: Prescreened mature female twins that subsequently experienced ACL injury demonstrated multiple potential risk factors including: increased knee abduction angles, decreased knee flexion angles, increased general joint laxity, decreased H/Q ratios and femoral intercondylar notch width.

Revision anterior cruciate ligament reconstruction with a reharvested ipsilateral patellar tendon.

The patellar tendon remains the most popular graft choice for anterior cruciate ligament reconstruction and has been proven to be the strongest substitute. Between 1991 and 1998, we performed revision anterior cruciate ligament reconstruction using the reharvested central third of the ipsilateral patellar tendon in 15 patients. Adequate follow-up was obtained in 13 of these 15 patients. The results in these 13 patients (mean age, 27.2 years) were reviewed. At an average postoperative follow-up of 39.4 months (range, 24 to 65), 11 patients had good or excellent results and 2 patients had fair results. Clinical examination revealed an average Tegner knee score of 5.8 (range, 3 to 9) and an average Lysholm knee score of 77.6 (range, 61 to 98). Postoperative KT-1000 arthrometer results showed an average side-to-side difference of 1.92 mm (range, -2.0 to 4.0). No patient demonstrated any loss of range of motion and only one reported patellofemoral problems, which were moderate. These favorable results demonstrate that, with appropriate patient selection, the use of a reharvested central third patellar tendon is a viable option for revision of a failed anterior cruciate ligament reconstruction.

Complete arthroscopic examination of the long head of the biceps tendon.

We describe an arthroscopic technique that allows complete examination of the long head of the biceps tendon. Important additional information during arthroscopic examination of the shoulder can be obtained by including inspection of the intertubercular portion of the tendon. Failure to inspect this portion of the tendon may lead to an unsuccessful and frustrating postoperative course for both the patient and physician.

Avoidance of soccer injuries with preseason conditioning.

The effect of a preseason conditioning program was studied to evaluate its influence on the occurrence and severity of soccer injuries. Three hundred female soccer players (ages 14 to 18 years) were studied over a 1-year period. Forty-two of these players participated in a 7-week training program before the start of the season. The type, mechanism, and severity of the injury, when the injury occurred, the number of games or practices missed, and type of shoe worn were recorded. All injuries occurred in the lower extremities, with 61.2% occurring at the knee and ankle. Student's t-test evaluations revealed that the trained group experienced a significantly lower incidence of injury than the untrained group (P = 0.0085). Although not statistically significant, the trained group also had a lower percentage (2.4%) of anterior cruciate ligament injuries compared with the untrained group (3.1%). These results suggest that this type of conditioning has a significant influence on lowering the incidence of injury in female adolescent soccer players.

Refracture of proximal fifth metatarsal (Jones) fracture after intramedullary screw fixation in athletes.

This study details six instances of refracture of clinically and radiographically healed fractures of the base of the fifth metatarsal after intramedullary screw fixation. Four professional football players, one college basketball player, and one recreational athlete underwent intramedullary screw fixation of fifth metatarsal fractures. The athletes were released to full activities an average of 8.5 weeks (range, 5.5 to 12) after fixation, when healing was clinically and radiographically documented. Three football players developed refracture within 1 day of return to full activity. The other three athletes refractured at 2.5, 4, and 4.5 months after return to activity. Two football players underwent repeat fixation with larger screws and returned to play in the same season. The college basketball player underwent bone grafting and returned to play in subsequent seasons. The other three athletes underwent nonoperative management and healed uneventfully over 6 to 8 weeks. On the basis of this series, we recommend that 1) screw fixation using a large-diameter screw should be given careful consideration for patients with large body mass for whom early return to activity is important; 2) functional bracing, shoe modification, or an orthosis should be considered for return to play; 3) if refracture occurs, exchange to a larger screw may allow return to play in the same season; and 4) alternative imaging should be considered to help document complete healing.

Treatment of plantar fasciitis by iontophoresis of 0.4% dexamethasone. A randomized, double-blind, placebo-controlled study.

Plantar fasciitis is a common problem in running sports. This study was undertaken to determine whether iontophoresis of dexamethasone in conjunction with other traditional modalities provides more immediate pain relief than traditional modalities alone. Forty affected feet were randomly assigned to one of two groups. Group I feet were treated with traditional modalities and placebo iontophoresis. Group II feet received the traditional modalities plus iontophoresis of dexamethasone. Both groups were treated six times over 2 weeks. The subjects' clinical course was assessed using the Maryland Foot Score. At the conclusion of treatment, Group II patients had significantly greater improvement than Group I patients (increase on Maryland Foot Score of 6.8 +/- 5.6 for Group II and 3.1 +/- 4.1 for Group I). However, at followup 1 month after completion of treatment there was no significant difference between groups (increase of 5.6 +/- 8.0 for Group I and 7.4 +/- 6.3 for Group II). These results suggest that although traditional modalities alone are ultimately effective, iontophoresis in conjunction with traditional modalities provides immediate reduction in symptoms. Based on these results, iontophoresis of dexamethasone for plantar fasciitis should be considered when more immediate results are needed (i.e., performance athletes and active patients.

A review of selected noncontact anterior cruciate ligament injuries in the National Football League.

During five football seasons, from 1989 through 1993, 61 surgically proven, noncontact, anterior cruciate ligament injuries, were identified from among 22 National Football League teams. The variables of surface, shoe type, playing conditions, and whether or not the shoe was spatted were identified for each reported injury. Forty noncontact injuries occurred in conventional cleated shoes on natural grass, and 21 occurred on an artificial surface. Almost half of all injuries (47.5%) occurred during game-day exposures despite the fact that the practice versus game-day exposure rate was 5:1. Of these injuries, 95.2% (N = 58) occurred on a dry field. The factors of cleat and shoe type, type of surface (natural versus artificial), surface conditions (wet/dry), and the effect of "spatting" a shoe are presented. The significance of these factors and their likelihood to be associated with injury is analyzed by use of a statistical tool, the incidence density ratio.

Meniscal repair: outcomes and clinical follow-up.

A retrospective study of arthroscopic meniscal repair in 101 consecutive patients was conducted. Sixty-three patients constituted our study group. The arthroscopic technique used for meniscal repair was the inside-out method using malleable cannulas. Forty-five patients were available for clinical examination, with a mean follow-up of 27 months. Tegner and Lysholm scores were comparable to those previously reported for arthroscopic meniscal repair. The HSQ (similar to the SF-36) scores were equal to those from an age- and sex-matched normal population, indicating that individuals with repaired menisci do not have any residual negative effects on global health at mean 26.9 months' follow-up. The physical functioning subscale of the HSQ was found to be sensitive to patient perception of results. Complications included one case of restricted knee range of motion requiring arthroscopy and lysis of adhesions. Overall clinical results were 64% excellent, 27% good, and 9% failure. Age, sex, and length of the meniscal tear had no affect on clinical outcome.

Differences in friction and torsional resistance in athletic shoe-turf surface interfaces.

This study evaluated the shoe-surface interaction of 15 football shoes made by 3 manufacturers in both anterior translation and rotation using a specially designed pneumatic testing system. The shoes included traditional cleated football shoes, "court" shoes (basketball-style shoes), molded-cleat shoes, and turf shoes. Under an 11.35-kg (25-pound) axial load, all shoes were tested on synthetic turf under wet and dry conditions and on natural stadium grass. Test-retest reliability, as calculated using the Pearson Product-Moment Correlation test, was 0.85 for force of translation and 0.55 for the moment of rotation. The wet versus dry surface values on translation were significantly different for rotation about the tibial axis. Spatting, which is protective taping of the ankle and heel applied on the outside of the shoe, resulted in a reduction of forces generated in both translation and rotation. No overall difference between shoes on grass versus AstroTurf was noted. However, there were significant differences for cleated and turf shoes. Shoes tested in conditions for which they were not designed exhibited reproducible excessive or extreme minimal friction characteristics that may have safety implications. On the basis of this study, we urge shoe manufacturers to display suggested indications and playing surface conditions for which their shoes are recommended.

Localization of the acromioclavicular joint.

Localizing the acromioclavicular joint can be difficult. Using bony landmarks--the clavicle and the spine of the scapula--the acromioclavicular joint can be consistently localized for physical examination, injections, and surgery.

Case report: revision anterior cruciate ligament reconstruction.

A case report is presented in which a professional football player, who was 4 years status post anterior cruciate ligament (ACL) reconstruction with autogenous patellar tendon, ruptured his graft. The contralateral patellar tendon was not available as a graft because of a more recent ACL reconstruction using that autogenous patellar tendon. This case reports the use of a previous donor site for supplying a patellar tendon autograft. Biopsy of the donor graft was consistent with normal tendon. The use of a healed patellar tendon donor site is a viable option for revision anterior cruciate reconstructive surgery. This option prevents the possibility of disease transmission with use of an allograft. We have shown grossly and histologically that the donor site has the potential to regenerate to tissue that has the appearance of normal tendon. This option could be available for revision surgery, but would not be recommended if the initial surgery was < 18 months-2 years in the past.

MR imaging in the prognostication of hamstring injury. Work in progress.

PURPOSE: To correlate morphologic and magnetic resonance (MR) imaging findings in hamstring injury with short-term prognosis and convalescence interval (CI). MATERIALS AND METHODS: A retrospective study of 14 professional athletes with hamstring injury was performed. The injuries were categorized according to muscle group involved, percentage of cross-sectional area affected, location, and signal intensity on T1- and T2-weighted spin-echo images. RESULTS: Longer CIs (> 6 weeks) were seen in injuries with complete transection, greater than 50% cross-sectional muscle involvement, ganglionlike fluid collections (long T1 and T2), hemorrhagelike signal intensity (short T1 and T2), distal myotendinous junction tears, and deep muscular tears. Shorter CIs (< 5 weeks) were seen in superficial muscle injuries and muscle belly injuries that involved small cross-sectional areas of the muscle. CONCLUSION: Prediction of CI for high-performance athletes with complete hamstring injury may be accomplished with use of MR imaging and poor prognostic factors.

Arthroscopic-assisted arthrodesis of the knee.

Arthrodesis of the knee is an accepted procedure to alleviate pain and deformity in posttraumatic degenerative arthritis, in patients who are not candidates for total joint arthroplasty. Most all of the accepted surgical methods involve an arthrotomy to remove bone and prepare the surfaces for fusion. We present an unusual case of posttraumatic arthritis of the knee in a young woman with a history of osteomyelitis. An arthrodesis was planned, but an arthrotomy was precluded. Arthroscopically assisted preparation of the fusion bed was performed for compression arthrodesis of the knee with an external fixator. A successful arthrodesis was obtained in 14 weeks.

Self-bearing, uncemented, ceramic total hip replacement arthroplasty.

The results for young patients in three diagnostic groups--osteoarthritis, posttraumatic arthritis, and osteonecrosis--show clearly that the uncemented procedure requires longer a recovery time than the cemented procedure. A more aggressive physical therapy program has resulted in an earlier return to function, as shown in these graphs. In conclusion, our experience with this operative procedure includes excellent patient acceptance, a failure rate comparable to that in Europe, a longer period of recovery than that for cemented arthroplasty, excellent results in revision of failed cemented arthroplasty, and an encouraging facility in the difficult case.