Alexander Kalenak

The Effect of a Pneumatic Leg Brace on Return to Play in Athletes with Tibial Stress Fractures

A total of 18 competitive and recreational athletes were enrolled in a randomized, prospective study looking at the effect of pneumatic leg braces on the time to return to full activity after a tibial stress fracture. All patients had positive bone scans and 15 had positive radio graphic findings by Week 12. There were two treat ment groups. The traditional treatment group was treated with rest and, after 3 pain-free days, a gradual return to activity. The pneumatic leg brace (Aircast) group had the brace applied to the affected leg and then followed the same return to activity guidelines. The guidelines consisted of a detailed functional pro gression that allowed pain-free return to play. The brace group was able to resume light activity in 7 days (median) and the traditional group began light activity in 21 days (median). The brace group returned to full, unrestricted activity in 21 ± 2 days, and the traditional group required 77 ± 7 days to resume full activity. The Aircast pneumatic brace is effective in allowing ath letes with tibial stress fractures to return to full, unre stricted, pain-free activity significantly sooner than tra ditional treatment.

Repair of Peripheral Meniscal Tears: Open Versus Arthroscopic Technique

Tears in the peripheral vascular zone of 71 menisci in 68 knees were repaired by us from 1978 to 1986. The meniscus repair was done by open arthrotomy in 26 cases and by arthroscopic techniques in 45 cases. We have assessed the relative efficacies of open and arthroscopic repair techniques. The results were compared in knees with and without anterior cruciate laxity. The indications for meniscal repair included unstable peripheral detachments and longitudinal tears of the outer third of the meniscus. Open repair was performed by a posteromedial arthrotomy incision. Arthroscopic repair was done using the double-lumen guide system with a limited posterior incision for retrieval of needles. We have found that the arthroscopic technique is easier to perform than the open repair because some tears are too far inside the rim to lend themselves to open suture. The average follow-up is 4 years, 2 months, with a range of 2-10 years. There have been no neurologic or vascular injuries from either technique. Twenty-five patients have had a repeat arthroscopy. The overall failure rate was 9.8%. The difference between the failure rate of 11% in the open-repair group and 8.8% in the arthroscopic repair group was not statistically significant. The failure rate in anterior cruciate-stable knees was 8% versus a 13% failure in cruciate-deficient knees. We conclude that both open and arthroscopic meniscus repair techniques are safe and effective with few complications in both stable and unstable knees. Anterior cruciate ligament stability is ideal, but it is not mandatory for a successful result.

A comparison of patient-controlled analgesia and continuous lumbar plexus block after anterior cruciate ligament reconstruction

Anterior cruciate ligament (ACL) reconstruction is often a painful operation. Fifty-eight patients who underwent ACL reconstruction using patellar tendon autograft received either a lumbar plexus block (LPB) or patient-controlled analgesia (PCA) for pain relief during the first 24 h after surgery. The average total dose of narcotic used was dramatically less for the LPB group (10.1 mg) than for the PCA group (91.9 mg). The common narcotic analgesic side effects of nausea, pruritus, sedation, and urinary retention were significantly less in the LPB group. The LPB is a safe and effective alternative analgesia after ACL reconstruction.

Saphenous nerve entrapment at the adductor canal

A retrospective study of 30 patients who met the clinical criteria for saphenous nerve entrapment at the adductor canal is described. Patients experienced symptoms, usually anterior knee pain, for an average of 36 ± 7 months. Each patient received an average of 1.9 ± 0.4 saphenous nerve blocks at the adductor canal during treatment. Baseline pain level (measured by the visual analog scale) was 6.4 ± 0.3. Final pain level at followup was significantly decreased (2.8 ± 0.5, P < 0.001). Eighty percent of patients had improved after a series of blocks. Age, medications taken, number of blocks performed, and length of followup were unrelated to outcome. Length of symptoms did significantly corre late with final pain level (r = 0.39, P < 0.05). The diagnosis of this syndrome, description of the saphen ous nerve block at the adductor canal, and the possible etiology are presented.

Meniscus repair in the anterior cruciate deficient knee

From 1979 to 1986, isolated repair of a peripheral vascular zone meniscal tear was performed in 22 pa tients (23 menisci) who had ACL insufficiency. For various reasons none of these patients underwent re pair or reconstruction of their ACL. The meniscus repair was done by open arthrotomy in 12 cases and by arthroscopic techniques in 11 cases. The purpose of this study was to evaluate the success rate of a men iscal repair in an anterior cruciate deficient knee. The average age of the patients at the time of surgery was 25 years and the average followup was 56 months. Six patients (26%) had mild occasional pain not requiring medication and one patient had moderate pain requiring nonnarcotic pain medication. Eight patients (26%) had occasional giving way episodes and one of them under went ACL reconstruction 5 years later because of frequent giving way. One patient required a postoper ative manipulation for inadequate range of motion, but there were no neurovascular injuries or infections. There were three patients (13%) who had failed repairs or a retear and required subsequent subtotal meniscec tomies. None of the other patients had any clinical symptoms or signs of a meniscal tear. There were no significant differences between the results of open or arthroscopic repair. Even though the failure rate of meniscus repair may be greater in an unstable knee, we conclude that meniscus repair is not contraindicated in an anterior cruciate deficient knee.

Stress fractures of the carpal scaphoid. A report of four cases.

Repeated trauma that is insufficient to create an acute fracture may cause non-specific pain and tenderness in the wrist. Although the initial radiographs may appear normal, a high index of suspicion and a bone scan may lead to the early diagnosis of a stress fracture

The Ellison iliotibial-band transfer for a torn anterior cruciate ligament of the knee. Long-term follow-up.

We studied the long-term results of the Ellison technique of extra-articular transfer of the iliotibial band, without advancement of the biceps tendon, as the sole operative treatment for a torn anterior cruciate ligament. Thirty-two patients (thirty-two knees) were evaluated an average of eleven years (range, seven to fifteen years) after the operation. The average age at the time of the operation was twenty-two years (range, sixteen to thirty-four years). Eighteen patients (56 per cent) had a modified Lysholm score of less than 84 points, indicating symptoms during the activities of daily living. Only six patients (19 per cent) had a subjectively normal knee (a modified Lysholm score of more than 94 points). The most common reason for a poor subjective score was the presence of symptoms of instability, in twenty-four patients (75 per cent). Twenty-four patients (75 per cent) had a positive pivot-shift test and twenty-nine patients (91 per cent), a positive Lachman test. Twelve patients (38 per cent) had severe (grade 3 or 4) radiographic changes. The radiographs of the knee appeared normal (grade 0) in only eight patients (25 per cent). There was a significant association between a meniscal injury and radiographic changes (p < 0.05). Fourteen patients (44 per cent) had subsequent procedures due to persistent instability or pathological changes in the articular cartilage or in a meniscus. There was a significant decline in the subjective and objective knee scores in the twenty-one patients who were evaluated at both two and eleven years. The number of patients who had a positive pivot-shift test increased from five (24 per cent) to sixteen (76 per cent). Subjectively, the number of patients who had a good result decreased from fourteen (67 per cent) to five (24 per cent). Objectively, nine patients (43 per cent) had a rating of good at two years; this fell to three (14 per cent) at eleven years. Symptomatic instability, pain, and a positive pivot-shift test were the most common reasons for a poor result. Because of the decline in the subjective and objective scores, we no longer recommend the Ellison procedure as the sole operative treatment for a torn anterior cruciate ligament of the knee.

A pelvic stress fracture in a female jogger A case report

The following case report is of a female jogger’s inferior pubic ramus fracture. Important clues in the conditioned athlete are recent changes in training techniques, mileage, or footwear. New joggers usually develop stress fractures two to three months after beginning the exercise. Plain roentgenographic findings in pelvic stress fractures may be delayed but radionuclide bone imaging is a simple and useful tool for early diagnosis.

Fibular stress fracture associated with distal tibiofibular synostosis in an athlete. A case report and literature review.

A 19-year-old collegiate football player with progressive ankle syndesmosis ossification developed acute localized fibular tenderness. Roentgenograms demonstrated a fibular stress fracture proximal to the superior extent of the ossific mass. Surgical resection of the mass resulted in uneventful fibular healing, with resolution of acute and chronic symptoms.

The accessory soleus muscle

The accessory soleus muscle, as a clinically significant finding, has been infrequently reported in the English literature. Prior to the advent of the computerized tomography (CT) scanner, the diagnosis could only be suspected and was confirmed only at surgery. The CT scanner assists in differential diagnosis of a painful ankle mass and reveals the size and extent of the mass as well as its density. The density determinations in this case were most consistent with a muscle mass and led to the preoperative diagnosis of an accessory soleus muscle.