Commonly missed orthopedic problems.

When not diagnosed early and managed appropriately, common musculoskeletal injuries may result in long-term disabling conditions. Anterior cruciate ligament tears are some of the most common knee ligament injuries. Slipped capital femoral epiphysis may present with little or no hip pain, and subtle or absent physical and radiographic findings. Femoral neck stress fractures, if left untreated, may result in avascular necrosis, refractures and pseudoarthrosis. A delay in diagnosis of scaphoid fractures may cause early wrist arthrosis if nonunion results. Ulnar collateral ligament tears are a frequently overlooked injury in skiers. The diagnosis of Achilles tendon rupture is missed as often as 25 percent of the time. Posterior tibial tendon tears may result in fixed bony planus if diagnosis is delayed, necessitating hindfoot fusion rather than simple soft tissue repair. Family physicians should be familiar with the initial assessment of these conditions and, when appropriate, refer patients promptly to an orthopedic surgeon.

Primary repair without augmentation for early neglected Achilles tendon ruptures in the recreational athlete.

From 1987 to 1994, the senior author performed 41 Achilles tendon repairs. We identified 11 patients during this period (age, 35.3 years; range, 26-60 years) who fit the criterion for neglected Achilles tendon rupture (repair > or = 4 weeks and < or = 12 weeks from injury). All patients underwent proximal release of the gastrocsoleus complex, imbrication of the early fibrous scar without excision of any local tissue, and primary repair of the tendinous ends with two No. 5 Ticron sutures (5R, 6L). Several (three to five) No. 0 Vicryl sutures were used to augment the repair. The ankle was placed in a 20 degree plantarflexion nonweightbearing short leg cast for 3 weeks. All skin closures were primary. At 3 weeks, weightbearing as tolerated was initiated in a short leg cast. The cast was discontinued at 6 weeks, and physical therapy was initiated, consisting of range of motion exercises and closed kinetic exercises, progressing to functional exercises as swelling, strength, and pain allowed. Minimal follow-up was 18 months (mean, 3.5 years; range, 1.5-5.8 years). There have been no subsequent ruptures to date. All patients returned to a preinjury level of activity at a mean of 5.8 months (range, 2.5-9 months). Total range of motion was not different (P > 0.05) between the involved (67 degree) and uninvolved (74 degree) ankle. Plantarflexion loss of strength in the involved ankle was the same (98.4%, 88.1%, and 87.6% respectively, involved to uninvolved) as that seen after acute repair at all speeds tested. Visual analog pain scale (0 to 10) revealed a mean score of 0.7 (range 0-2) during activities of daily living and 1.0 (range, 0-3) during sports activity. The subjective and objective outcome was similar (P > 0.05) to that seen after an acute repair by the same surgeon. There were no complications including skin sloughs or nerve damage. We believe this is the first article to report the results after primary repair without augmentation for the neglected Achilles tendon rupture. We conclude that this approach can result in excellent clinical and functional outcome, a low rate of subsequent rupture, and a high rate of return to sports in the recreational athlete whose repair is performed between 4 and 12 weeks after injury.

Surgical treatment of Freiberg's infraction in athletes.

Ten patients with 11 cases of Freiberg's infraction were studied retrospectively. The patients had varying amounts of sports participation. All cases were treated surgically, most after some form of nonoperative intervention. Surgery consisted of metatarsophalangeal joint debridement, except in 1 patient where the metatarsal head was resected. All patients had improvement of their symptoms and 80% of normal joint range of motion was restored. No patient had joint space narrowing or major arthritic changes on follow-up roentgenographic studies.

The significance of intracompartmental pressures in the diagnosis of chronic exertional compartment syndrome.

Chronic exertional compartment syndrome is one cause of pain in the lower extremity, a common disability in athletes. The significance of intracompartmental pressures in the diagnosis of chronic exertional compartment syndrome is somewhat controversial. The goal of this study was to review the compartment pressure tests in a group of patients that underwent fasciotomy for refractory exertional compartment syndrome and to compare these pressures with an asymptomatic control group. The results are presented and compared with those of previous studies.

Bateman bipolar hip arthroplasty. A review of 44 cases.

A consecutive series of 71 Bateman hemiarthroplasties were performed in a single hospital over a 20-month period. Forty-four hips or 62% were available for review with an average follow up of 22 months. Of the 44 cases, the Bateman Universal Proximal Femur, original design was used in 40 acute, displaced femoral neck fractures, two failed Austin Moore prostheses, and two cases of femoral head osteonecrosis unassociated with fracture. The mean Harris hip score was 84.7%. Of the patients 93.2% had minimal or no pain. The range of motion was excellent and the dislocation rate was 1.8%. Morbidity was not increased compared to more conventional unipolar implant procedures. The Bateman Universal Proximal Femur (UPF) is felt to offer improved surgical results compared to Austin Moore and Thompson prostheses, and this may be due to the low friction inner bearing motion that occurs with this bipolar implant.