Atypical presentation of Parsonage-Turner syndrome confounded by surgical rotator cuff injury.

Parsonage-Turner syndrome (PTS) is a rare neuropathy that commonly presents as unexpected severe shoulder and arm pain that eventually subsides while weakness or paralysis ensues. During exceptions to this classic presentation, confirming PTS can be challenging. Alternative causes of upper extremity pain may confound the diagnostic algorithm. Moreover, objective findings from necessary diagnostic tests depend on when those tests are performed. We present an atypical onset of PTS, whereby the initial presentation of severe neuropathic pain was preceded by mild shoulder pain that should decrease one's clinical suspicion for PTS. This milder pain coincided with the presence of a rotator cuff injury, whereby surgical intervention preceded impending paralysis and hindered postoperative rehabilitation. Physicians should be aware of the possibility of atypical presentations of PTS in hopes of avoiding either untimely surgery or delays in diagnosis.

Association between GRIN2A promoter polymorphism and recovery from concussion.

OBJECTIVE: To determine genetic variability within the N-methyl-D-aspartate receptor 2A sub-unit (GRIN2A) gene promoter and its association with concussion recovery time. The hypothesis tested was that there would be a difference in allele and/or genotype distribution between two groups of athletes with normal and prolonged recovery. METHODS: DNA was extracted from saliva collected from a total of 87 athletes with a physician-diagnosed concussion. The (GT) variable number tandem repeats (VNTR) within the promoter region of GRIN2A was genotyped. The long (L) allele was an allele with ≥25 repeats and the short (S) allele was an allele with <25 repeats in the GT tract. Participants' recovery time was followed prospectively and was categorized as normal (≤60 days) or prolonged (>60 days). RESULTS: LL carriers were 6-times more likely to recover longer than 60 days following the concussive event (p = 0.0433) when compared to SS carriers. Additionally, L allele carriers were found more frequently in the prolonged recovery group (p = 0.048). CONCLUSION: Determining genetic influence on concussion recovery will aid in future development of genetic counselling. The clinical relevance of genotyping athletes could improve management of athletes who experience concussion injuries.

Hypertensive patients show delayed wound healing following total hip arthroplasty.

BACKGROUND: Prolonged wound-discharge following total hip arthroplasty (THA) is associated with an increased risk of infection. However, the potential role of hypertension in prolonging the duration of wound healing in this population has not yet been investigated. The aim of the present study was to compare healing in this population that has not yet been investigated. The aim of the present study was to compare hypertensive and normotensive THA patients in terms of the length of time required to achieve a dry wound and the length of stay in the hospital. METHODS: One hundred and twenty primary THA patients were evaluated. Pre-operative clinical history and physical examination revealed that 29 were hypertensive and 91 were normotensive. The two groups were statistically matched using optimal propensity score matching. The outcomes of interest were the number of days until a dry wound was observed and the duration of hospital stay. RESULTS: The average systolic blood pressures were 150.1 mmHg and 120.3 mmHg for the hypertensive and normotensive groups, respectively. The mean number of days until the wound was dry was 3.79 for the hypertensive group and 2.03 for the normotensive group. Hypertensive patients required more days for their wounds to dry than normotensive patients (odds ratio  =  1.65, p<0.05). No significant difference in the duration of hospital stay was found between the two groups. CONCLUSIONS: Hypertensive patients had a higher risk of prolonged wound discharge after THA than their normotensive counterparts. Patients with prolonged wound drainage are at greater risk for infection. Clinicians should pay particular attention to infection-prevention strategies in hypertensive THA patients.

The non-surgical and surgical treatment of tarsal navicular stress fractures.

Stress fractures of the tarsal navicular, first described in 1970, were initially thought to be rare injuries. Heightened awareness and increased participation in athletics has resulted in more frequent diagnosis and more aggressive treatment. The vascular supply of the tarsal navicular results in a relatively avascular zone in the central one-third, which experiences severe compressive forces during explosive manoeuvers such as jumping and sprinting. Repetitive activities can result in stress reactions or even fracture. Patients often initially complain of vague midfoot pain localized to the medial border of the foot. The pain is usually exacerbated by activity and relieved with rest. The diagnosis of tarsal navicular stress fracture is challenging because of the high false negative rate of plain radiographs. Additional diagnostic testing with bone scan, CT and MRI are often required for diagnosis. The proper treatment of tarsal navicular stress fractures has become a topic of debate as surgical intervention for these injuries has increased. In a recent meta-analysis, Torg et al. found that 96% of tarsal navicular stress fractures treated with non-weight-bearing (NWB) conservative treatment for 5 weeks went on to successful outcomes. However, only 44% of patients treated with weight-bearing (WB) conservative treatment had successful outcomes. Surgical treatment resulted in successful outcome in 82% of patients. Interestingly, the meta-analysis also found that fracture type did not correlate with outcomes, regardless of treatment. The meta-analysis also found no difference in time to return to activity between patients treated surgically and those who underwent NWB conservative treatment. The recent literature indicates that patients are undergoing surgery or are receiving WB conservative management as a first-line treatment option with the expectation that they will return to their activity more quickly. Although surgical treatment seems increasingly common, the results statistically demonstrate an inferior trend to conservative NWB management. Conservative NWB management is the standard of care for initial treatment of both partial and complete stress fractures of the tarsal navicular. WB conservative treatment and surgical intervention are not recommended.

Noncontact anterior cruciate ligament injuries: mechanisms and risk factors.

Significant advances have recently been made in understanding the mechanisms involved in noncontact anterior cruciate ligament (ACL) injury. Most ACL injuries involve minimal to no contact. Female athletes sustain a two- to eightfold greater rate of injury than do their male counterparts. Recent videotape analyses demonstrate significant differences in average leg and trunk positions during injury compared with control subjects. These findings as well as those of cadaveric and MRI studies indicate that axial compressive forces are a critical component in noncontact ACL injury. A complete understanding of the forces and risk factors associated with noncontact ACL injury should lead to the development of improved preventive strategies for this devastating injury.

Management of tarsal navicular stress fractures: conservative versus surgical treatment: a meta-analysis.

PURPOSE: This study was conducted to provide a statistical analysis of previously reported tarsal navicular stress fracture studies regarding the outcomes and effectiveness of conservative and surgical management. STUDY DESIGN: Systematic review. METHODS: A systematic review of the published literature was conducted utilizing MEDLINE through Ovid, PubMed, ScienceDirect, and EBSCOhost. Reports of studies that provided the type of tarsal navicular stress fracture (ie, complete or incomplete), type of treatment, result of that treatment, and the time required to return to full activity were selected for analysis. Using a mixed generalized linear model with study as a random effect and treatment as a fixed effect, cases were separated and compared based on 3 different types of treatment: conservative, weightbearing permitted (WBR); conservative, non-weightbearing (NWB); and surgical treatment. The outcome of the treatment was recorded as either successful or unsuccessful based on radiographic and/or clinical healing of the fracture and time from onset of treatment to return to activity. RESULTS: There was no statistically significant difference between NWB conservative treatment and surgical treatment regarding outcome (P = .6441). However, there is a statistical trend favoring NWB management (96% successful outcomes) over surgery (82% successful outcomes). Weightbearing as a conservative treatment was shown to be significantly less effective than either NWB (P = .0001) or surgical treatment (P <.0003). CONCLUSION: Non-weightbearing conservative management should be considered the standard of care for tarsal navicular stress fractures. The authors could find no advantage for surgical treatment compared with NWB immobilization. However, there is a statistical trend favoring NWB over surgery. Rest or immobilization with weightbearing was inferior to both other treatments analyzed. The authors concluded that conservative NWB management is the standard of care for initial treatment of both partial and complete stress fractures of the tarsal navicular.

The pathomechanics, pathophysiology and prevention of cervical spinal cord and brachial plexus injuries in athletics.

Cervical spinal cord injuries may occur with catastrophic sequelae (e.g. quadriplegia) in collision sport activities. The discovery was made that the head-down tackling technique in football straightens the spine into a position vulnerable for compression and, thus, is responsible for these incidents. This led to rule changes requiring head-up tackling, which in turn resulted in the reduction of the incidence of these injuries. However, the dramatic initial reduction in the occurrence - from 32 and 34 catastrophic injuries in 1975 and 1976, respectively, down to 12 in 1977 - has levelled off with ten and eight reported cases in 2006 and 2007, respectively. The football community has increased their efforts to prevent head-down tackling with additional rule changes. Brachial plexus injury prevention must rely on properly fitted shoulder pads and use of equipment such as 'cowboy' collars. Furthermore, physicians must take into consideration cervical cord neurapraxia, congenital stenosis and other risk factors in patients who wish to return to contact sports.

Video analysis of anterior cruciate ligament injury: abnormalities in hip and ankle kinematics.

BACKGROUND: Most anterior cruciate ligament research is limited to variables at the knee joint and is performed in the laboratory setting, often with subjects postinjury. There is a paucity of information on the position of the hip and ankle during noncontact anterior cruciate ligament injury. HYPOTHESIS: When landing after maneuvers, athletes with anterior cruciate ligament injury (subjects) show a more flatfooted profile and more hip flexion than uninjured athletes (controls). STUDY DESIGN: Case control study; Level of evidence, 3. METHODS: Data from 29 videos of subjects were compared with data from 27 videos of controls performing similar maneuvers. Joint angles were analyzed in 5 sequential frames in sagittal or coronal planes, starting with initial ground-foot contact. Hip, knee, and ankle joint angles were measured in each sequence in the sagittal plane and hip and knee angles in the coronal plane with computer software. The portion of the foot first touching the ground and the number of sequences required for complete foot-ground contact were assessed. Significance was set at P< .05. RESULTS: In sagittal views, controls first contacted the ground with the forefoot; subjects had first ground contact with the hind-foot or entirely flatfooted, attained the flatfoot position significantly sooner, had significantly less plantar-flexed ankle angles at initial contact, and had a significantly larger mean hip flexion angle at the first 3 frames. In coronal views, no significant differences in knee abduction (initial contact) or hip abduction angle were found between groups; knee abduction was relatively unchanged in controls but progressed in subjects. CONCLUSION: Initial ground contact flatfooted or with the hindfoot, knee abduction and increased hip flexion may be risk factors for anterior cruciate ligament injury.

Cervical spine injuries and the return to football.

BACKGROUND: The literature dealing with the diagnosis and treatment of cervical spine injuries is considerable. Absent, however, are comprehensive criteria or guidelines for permitting or prohibiting return to collusion activities such as tackle football. OBJECTIVE: The purpose of this report is to describe developmental and posttraumatic conditions of the cervical spine as presenting (1) no contraindication, (2) relative contraindication, or (3) an absolute contraindication to continued participation in tackle football and other contact activities. STUDY DESIGN: Systematic review. METHODS: Analysis of data compiled from more than 1200 cervical spine injuries documented by the National Football Head and Neck Registry, in addition to a review of the limited published literature, plus an understanding of the recognized axial load injury mechanism and extensive anecdotal experience. CONCLUSION: The one overriding principle regarding the return to football or, for that matter, any collusion activity is that the individual be asymptomatic, pain-free, and neurologically intact and have full strength and full range of cervical motion.

National Athletic Trainers' Association Position Statement: Head-Down Contact and Spearing in Tackle Football.

OBJECTIVE: To present recommendations that decrease the risk of cervical spine fractures and dislocations in football players. BACKGROUND: Axial loading of the cervical spine resulting from head-down contact is the primary cause of spinal cord injuries. Keeping the head up and initiating contact with the shoulder or chest decreases the risk of these injuries. The 1976 rule changes resulted in a dramatic decrease in catastrophic cervical spine injuries. However, the helmet-contact rules are rarely enforced and head-down contact still occurs frequently. Our recommendations are directed toward decreasing the incidence of head-down contact. RECOMMENDATIONS: Educate players, coaches, and officials that unintentional and intentional head-down contact can result in catastrophic injuries. Increase the time tacklers, ball carriers, and blockers spend practicing correct contact techniques. Improve the enforcement and understanding of the existing helmet-contact penalties.

Complications of joint arthroplasty in patients with end-stage renal disease on hemodialysis.

The mortality and morbidity after hip and knee arthroplasty were reviewed retrospectively during a 3-year period in 14 patients who had chronic renal failure and who were receiving hemodialysis. The patients had a primary total hip or knee replacement, or a revision arthroplasty or resection arthroplasty. Four of the patients (29%) died in the hospital during the postoperative period. One of the seven patients (14%) having a primary joint replacement died, whereas three of the seven patients (86%) having a revision or resection died. Every patient had multiple medical comorbidities, and every patient had a complication. The results indicate that arthroplasty procedures, especially revisions and resections, in this patient population are associated with a high rate of complications and death, and that in-depth informed consent should be provided for all patients contemplating these procedures. Meticulous treatment of medical comorbidities is mandatory. Finally, data in the literature and in the current report question whether joint arthroplasty procedures should be done in patients with end-stage renal disease who are receiving hemodialysis.

Cervical spinal stenosis with cord neurapraxia: evaluations and decisions regarding participation in athletics.

Cervical spinal cord neurapraxia (CCN) leads to transient episodes ranging from paresthesia to paresis to plegia (complete paralysis), and occurs in athletes with some demonstrable degree of cervical spinal stenosis. Determination of spinal stenosis requires demonstrating a sagittal diameter of the spinal canal less than 14 mm from C4 to C6. Because radiologic techniques vary affecting the accuracy of this measure, a ratio method was developed comparing the spinal canal to the vertebral body width, demonstrating that a ratio of less than 0.8 is indicative of cervical spinal stenosis. Although this has high sensitivity (93%), the low predictive value of 0.2% makes this a poor screening tool for athletic participation. Further complicating the challenge of determining which athletes are at risk for quadriplegia are data showing that athletes who suffered permanent injury did not recall transient episodes of CCN, and conversely none of the athletes with CCN later developed permanent neurologic injury. Nevertheless, 56% of football athletes returning to sport after an episode of CCN experienced a recurrence as determined by survey data. Those with CCN and documented ligamentous instability, magnetic resonance imaging evidence of cord defects or swelling, neurologic symptoms or signs for greater than 36 hours, or more than one recurrence have an absolute contraindication.

Head Trauma in Football Players with Infectious Mononucleosis.

Are football players who have infectious mononucleosis more susceptible to cerebral disorders from minor head trauma? The authors discuss three case reports.