Gregory R. Waryasz

Patellofemoral pain syndrome (PFPS): a systematic review of anatomy and potential risk factors

BackgroundPatellofemoral Pain Syndrome (PFPS), a common cause of anterior knee pain, is successfully treated in over 2/3 of patients through rehabilitation protocols designed to reduce pain and return function to the individual. Applying preventive medicine strategies, the majority of cases of PFPS may be avoided if a pre-diagnosis can be made by clinician or certified athletic trainer testing the current researched potential risk factors during a Preparticipation Screening Evaluation (PPSE). We provide a detailed and comprehensive review of the soft tissue, arterial system, and innervation to the patellofemoral joint in order to supply the clinician with the knowledge required to assess the anatomy and make recommendations to patients identified as potentially at risk. The purpose of this article is to review knee anatomy and the literature regarding potential risk factors associated with patellofemoral pain syndrome and prehabilitation strategies. A comprehensive review of knee anatomy will present the relationships of arterial collateralization, innervations, and soft tissue alignment to the possible multifactoral mechanism involved in PFPS, while attempting to advocate future use of different treatments aimed at non-soft tissue causes of PFPS.MethodsA systematic database search of English language PubMed, SportDiscus, Ovid MEDLINE, Web of Science, LexisNexis, and EBM reviews, plus hand searching the reference lists of these retrieved articles was performed to determine possible risk factors for patellofemoral pain syndrome.ResultsPositive potential risk factors identified included: weakness in functional testing; gastrocnemius, hamstring, quadriceps or iliotibial band tightness; generalized ligamentous laxity; deficient hamstring or quadriceps strength; hip musculature weakness; an excessive quadriceps (Q) angle; patellar compression or tilting; and an abnormal VMO/VL reflex timing. An evidence-based medicine model was utilized to report evaluation criteria to determine the at-risk individuals, then a defined prehabilitation program was proposed that begins with a dynamic warm-up followed by stretches, power and multi-joint exercises, and culminates with isolation exercises. The prehabilitation program is performed at lower intensity level ranges and can be conducted 3 days per week in conjunction with general strength training. Based on an objective one repetition maximum (1RM) test which determines the amount an individual can lift in good form through a full range of motion, prehabilitation exercises are performed at 50–60% intensity.ConclusionTo reduce the likelihood of developing PFPS, any individual, especially those with positive potential risk factors, can perform the proposed prehabilitation program.

Fungal osteomyelitis and septic arthritis.

Management of fungal osteomyelitis and fungal septic arthritis is challenging, especially in the setting of immunodeficiency and conditions that require immunosuppression. Because fungal osteomyelitis and fungal septic arthritis are rare conditions, study of their pathophysiology and treatment has been limited. In the literature, evidence-based treatment is lacking and, historically, outcomes have been poor. The most common offending organisms are Candida and Aspergillus, which are widely distributed in humans and soil. However, some fungal pathogens, such as Histoplasma, Blastomyces, Coccidioides, Cryptococcus, and Sporothrix, have more focal areas of endemicity. Fungal bone and joint infections result from direct inoculation, contiguous infection spread, or hematogenous seeding of organisms. These infections may be difficult to diagnose and eradicate, especially in the setting of total joint arthroplasty. Although there is no clear consensus on treatment, guidelines are available for management of many of these pathogens.

Orthopedic Manifestations of Ochronosis: Pathophysiology, Presentation, Diagnosis, and Management

Ochronotic arthropathy occurs in patients with alkaptonuria, manifesting first in the intervertebral discs of the lumbar spine, with subsequent degeneration most often observed in the knee, hip, and shoulder joints. Efforts at treatment are targeted at minimizing the damaging effects of the underlying metabolic disorder on the articular cartilage. Vitamin E and N-acetyl cysteine are potential therapies because of their scavenging of free radicals and consequent limitation of oxidative damage to joint tissue. Arthroscopy has been found to be an effective diagnostic tool in cases of suspected ochronosis. Arthroplasty performed in patients with ochronotic arthropathy suggests that the procedure is effective in the alleviation of joint pain and the improvement of mobility. Perioperative management of these patients may require more careful consideration pertinent to the associated comorbidities of this disorder.

Adolescent differences in knee stability following computer-assisted anterior cruciate ligament reconstruction.

Anterior cruciate ligament (ACL) surgery is being increasingly performed in the adolescent population. Computer navigation offers a reliable way to quantitatively measure knee stability during ACL reconstruction. A retrospective review of all adolescent patients (<18 years old) who underwent computer-assisted primary single bundle ACL reconstruction by a single surgeon from 2007 to 2012 was performed. The average age was 15.8 years (SD 3.3). Female adolescents were found to have higher internal rotation than male adolescents both pre- (25.6° vs 21.7°, P=0.026) and post-reconstruction (20.1° vs 15.1°, P=0.005). Compared to adults, adolescents demonstrated significantly higher internal rotation both pre- (23.3° vs 21.5°, P=0.047) and post-reconstruction (17.1° vs 14.4°, P=0.003). They also had higher total rotation both pre- (40.9° vs 38.4°, P=0.02) and post-reconstruction when compared to adults (31.56° vs 28.67°, P=0.005). In adolescent patients, anterior translation was corrected more than rotation. Females had higher pre- and residual post-reconstruction internal rotation compared to males. When compared to adults, adolescents had increased internal rotation and total rotation both pre-and post-reconstruction.

Hypersensitivity to Orthopedic Implants: A Review of the Literature

Awareness of rare etiologies for implant failure is becoming increasingly important. In addition to the overall increase in joint arthroplasties, revision surgeries are projected to increase dramatically in the coming years, with volume increasing up to seven-fold between 2005 and 2030. The literature regarding the relationship between metal allergy and implant failure is controversial. It has proven difficult to determine whether sensitization is a cause or a consequence of implant failure. Testing patients with functional implants is not a clinically useful approach, as the rate of hypersensitivity is higher in implant recipients than in the general population, regardless of the status of the implant. As a result of the ineffectiveness of preoperative patch testing for predicting adverse outcomes, as well as the high cost of implementing such patch testing as standard procedure, most orthopedists and dermatologists agree that an alternative prosthesis should only be considered for patients with a history of allergy to a metal in the standard implant. In patients with a failed implant requiring revision surgery, hypersensitivity to an implant component should be considered in the differential diagnosis. Because a metal allergy to implant components is currently not commonly considered in the differential for joint failure in the orthopedic literature, there should be improved communication and collaboration between orthopedists and dermatologists when evaluating joint replacement patients with a presentation suggestive of allergy.

Triangular Fibrocartilage Complex

The triangular fibrocartilage complex is a multifaceted ligamentous structure providing support to the ulnocarpal articulation. Improved understanding of the complicated anatomy of the triangular fibrocartilage complex coupled with recent advances in surgical techniques will improve orthopaedic care. The triangular fibrocartilage complex supports the ulnar side of the wrist, provides stability to the distal radioulnar joint, and is the most common source of ulnar-sided wrist pain when injured1-3. Knowledge of the anatomy, biomechanics, and pathology of the triangular fibrocartilage complex has increased greatly over the last three decades, leading to increased awareness of this structure among physicians4. In one cadaveric study, more than half (thirty-two) of sixty-one specimens had perforations of the triangular fibrocartilage complex5. All specimens with tears had evidence of damage to the lunate and/or distal ulnar cartilage, illustrating that damage to the triangular fibrocartilage complex and subsequent instability of the distal radioulnar joint can be associated with ulnolunate abutment5. This was reiterated by Lee et al., who found that the majority (fifty-eight) of ninety-six cadaveric specimens (average age at the time of death, seventy-five years) had disruption …

Isolated dorsal dislocations of the talonavicular and calcaneocuboid articulations (Chopart joints) from a low-energy mechanism

The transverse tarsal (Chopart) joints are defined as the talonavicular and calcaneocuboid articulations [1]. Dislocations of Chopart joints, although uncommon, have been reported from a variety of high-energy mechanisms, resulting in medial, lateral, plantar, or dorsal displacement [2]. In this article, we describe a case of isolated dorsal fracture dislocations of the talonavicular and calcaneocuboid articulations in a 25-yearold man after a low-energy missed-step mechanism. The mechanism of injury, diagnosis, andmanagement in the emergency department, operative intervention, and follow-up are discussed. Given the high rate of missed and delayed diagnosis of Chopart dislocations, emergency medicine physicians must be aware of this debilitating injury [3,4]. The transverse tarsal (Chopart) joints consist of the talonavicular and calcaneocuboid articulations [1]. The talonavicular joint derives its stability from the spring ligament, which consists of the superior medial calcaneonavicular and inferior calcaneonavicular ligament. The calcaneocuboid joint derives its support plantarly from the superficial and deep inferior calcaneocuboid ligaments and superiorly by the lateral limb of the bifurcate ligament. Reported isolated fracture dislocations of the Chopart joints, although rare, have been attributed to high-energy mechanisms given the inherent stability of these robust periarticular ligaments, and often have associated injuries in the polytrauma patient [5]. We describe the case of a 25-year-old man sustaining an isolated dorsal fracture dislocation of the Chopart joints resulting from a relatively lowenergy mechanism, missing a step while walking down stairs. A 25-year-old man was transferred from an outside hospital to our emergency department at a level 1 trauma center after missing a step while walking down stairs. The patient reported immediate pain in the left foot and an inability to bearweight on the extremity. Orthopedic surgery was consulted and evaluated the patient in the emergency department. No neurovascular deficits, signs of compartment syndrome, or associated injuries were found at the time of evaluation. Initial radiographs of the left foot revealed dorsal dislocations of the talonavicular and calcaneocuboid joints (Fig. 1A-C). The patient subsequently underwent conscious sedation in the emergency department, closed reduction of the traverse tarsal joints (Fig. 2), and application of a wellpadded plaster short-leg splint (Fig. 3). Postreduction radiographs revealed a persistent dorsal subluxation of the talonavicular joint (Fig. 4). A computed tomographic scan of the left footwas then obtained showing a comminuted fracture of the navicular and persistent subluxation of the talonavicular joint (Fig. 5A, B). The patient was admitted to the orthopedic surgery service and underwent open reduction internal fixation of the talonavicular joint. Postoperative radiographs showed a concentrically reduced talonavicular and calcaneocuboid joint with appropriately placed hardware (Fig. 6A–C). The patient returned to the http://dx.doi.org/10.1016/j.ajem.2015.12.054 0735-6757/© 2016 Elsevier Inc. All rights reserved. Please cite this article as: Harris AP, et al, Isolated dorsal dislocations of the low-energy mechanism, Am J Emerg Med (2016), http://dx.doi.org/10.101 orthopedic surgery floor and was discharged home without incident 2 days postoperatively with strict instruction to remain non–weight bearing. At 2-week follow-up, the incision was well healed and sutures were removed. The transverse tarsal (Chopart) joints include the talonavicular and calcaneocuboid joints. Main and Jowett [4] classified a series of 71 transverse tarsal joint injuries according to the direction of the deforming force and the resulting displacement: medial forces, longitudinal forces, lateral forces, plantar forces, and crush injury. In this series, only 2 cases of transverse tarsal joint dislocations were reported: pure plantar transverse tarsal joint dislocation and plantar subtalar dislocation associated with plantar dislocation of the talonavicular joint [4]. Current literature review reveals 2 cases of isolateddorsal transverse tarsal joint dislocations resulting from high-energy mechanisms including falls from height [2,6]. To the best of our knowledge, this is thefirst reported case of isolated dorsal transverse tarsal joint dislocation from a low-energy mechanism. Isolated dislocations of transverse tarsal joints are rare due to strong periarticular ligamentous structural support. The inferior calcaneocuboid ligament, calcaneonavicular (spring) ligament, and bifurcate ligament all confer stability to the transverse tarsal joints and are important to the support of the foot arch. For this reason, dislocations in the dorsal direction are infrequent, requiring disruption of these plantar ligaments [6]. As reported byWilson et al [7], transverse tarsal joint injuries occur in nearly 10% of polytrauma patients as a result of motor vehicle accidents, with 41% of these injuries having a delay in diagnosis. Emergency medicine physicians must have a high suspicion for these injuries when presented with a polytrauma patient for this reason. Initial radiographs of the foot should be obtained if there is suspicion for a foot injury. Further delineation of foot injuries may require a computed tomographic scan to detect small fractures, or possible dislocations that reduced prior to evaluation [8]. Any dislocations should be emergently reduced and immobilized tomitigate the consequences of delayeddiagnosis; avascular necrosis, osteoarthritis, or surgical intervention that may have been avoided (Figs. 2 and 3) [9]. Orthopedic surgery consultation should ensue, as studies have shown open reduction and internal fixation results in improved maintenance of the transverse tarsal joint reduction, especially when these joints are unstable after closed reduction [5,10]. Isolated dorsal transverse tarsal joint dislocations are rare injuries, but have been reported to occur in 10% of polytraumatized patients in motor vehicle accidents [7]. Emergency medicine physicians must be aware of this association with high-energy trauma and in rare cases of isolated dorsal dislocations to avoid a delay in diagnosis treatment. Although often seen in high-energy situations, our case report demonstrates that emergency medicine providers must remain vigilant, as these serious injuries can result from low-energymechanisms. All dislocations should be emergently reduced with covering of any open talonavicular and calcaneocuboid articulations (Chopart joints) from a 6/j.ajem.2015.12.054 Fig. 1. Injury radiographs demonstrating dorsal transverse tarsal joint dislocations on anteroposterior (A), lateral (B), and oblique views (C). Fig. 2. Reduction maneuver for transverse tarsal (Chopart) joints. 1. Place thumb over the navicular bone (C) and (B). 2. With contralateral hand, grab the talus and calcaneus as a unit (C). 3. Apply dorsal to plantar pressure on the navicular while stabilizing the talus. 2 A.P. Harris et al. / American Journal of Emergency Medicine xxx (2016) xxx–xxx wounds. Orthopedic surgery consultation should follow for further evaluation and treatment, as irreducible dislocations are an indication for urgent operative intervention; although stable, closed reductions may be managed nonoperatively or operatively on a delayed outpatient basis [10]. Andrew P. Harris MD Joey Johnson MD Gregory R. Waryasz MD Department of Orthopaedics, Alpert Medical School of Brown University, Providence, RI Corresponding author. Department of Orthopaedics, Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI 02903 Tel.: + 1 401 444 4030; fax: + 1 401 444 6182 E-mail addresses: andrew_harris@brown.edu, aharri26@gmail.com http://dx.doi.org/10.1016/j.ajem.2015.12.054

Septic Ankle With Purulence Tracking Up the Flexor Hallucis Longus Tendon Sheath Leading to Deep Venous Thrombosis/ Pulmonary Embolism and Compartment Syndrome

The differential diagnosis for lower extremity swelling and ankle pain is broad and can have overlapping and related diagnoses. If there is concern for more than one diagnosis, the practitioner should perform a thorough physical examination, order the appropriate studies, and perform the correct procedures to completely diagnose and treat the patient. This article presents the case of a 19-year-old male who presented with 5 days of left ankle pain, fevers, and swelling without any known trauma to the area. Physical examination was concerning for a septic ankle joint, cellulitis, deep venous thrombosis, and compartment syndrome. Duplex venous ultrasound confirmed a deep venous thrombosis in the popliteal vein. Joint aspiration of the ankle had gross purulence with the presence of methicillin-resistant Staphylococcus aureus. The patient was taken emergently to the operating room where he was found to have gross purulence in the deep posterior compartment, medial and lateral soft tissues of the ankle, and gross purulence in the ankle joint. The deep posterior compartment also had significant muscle necrosis and evidence of compartment syndrome. This case presents the possibility of a septic ankle leading to compartment syndrome and deep venous thrombosis/pulmonary embolism due to the intra-articular nature of the flexor hallucis longus tendon sheath. Level of Evidence: Case report, Level IV

Ensuring Correct Placement of Proximal Fixation in Reconstruction Intramedullary Nailing for Subtrochanteric Femur Fractures

Subtrochanteric femur fractures present a challenge to orthopedic surgeons. Anatomic reduction and stabilization can be technically difficult. A variety of intramedullary and extramedullary devices have been used to stabilize these fractures. The authors describe a novel technique for easier proximal interlock fixation for reconstruction intramedullary nailing to ensure proper placement into the nail. This will likely save time in a patient population that may be either frail and elderly or young with high-energy polytrauma, and it may reduce radiation exposure for both patients and surgeons.

Epidemiology of Navicular Injury at the NFL Combine and Their Impact on an Athlete’s Prospective NFL Career

Background: Navicular injuries can result in persistent pain, posttraumatic osteoarthritis, and diminished performance and function. Purpose: To determine the epidemiology of navicular fracture in players participating in the National Football League (NFL) Scouting Combine and evaluate the impact of a navicular injury on the NFL draft position and NFL game play compared with matched controls. Study Design: Cohort study; Level of evidence, 3. Methods: Data were collected on players who previously sustained a navicular injury and participated in the NFL Combine between 2009 and 2015. The epidemiology of navicular injury was determined through an evaluation of the number of injuries, surgeries, and collegiate games missed as well as the position played, a physical examination, the surgical technique, and imaging findings. Players with a previous navicular injury (2009-2013) were compared with a set of matched controls. NFL performance outcomes included the draft position, career length ≥2 years, and number of games played and started within the first 2 years. Results: Between 2009 and 2015, 14 of 2285 (0.6%) players were identified as having sustained a navicular injury. A total of 11 of 14 (79%) athletes had sustained an overt navicular fracture, while 3 of 14 (21%) were diagnosed with stress reactions on magnetic resonance imaging. Eight patients who sustained a navicular fracture underwent surgery. There was evidence of ipsilateral talonavicular arthritis in 75% of players with a navicular fracture versus only 60% in the uninjured foot (odds ratio, 1.3; P = .04). Fifty-seven percent of players with navicular injury (72.7% of fractures) were undrafted versus 30.9% in the control group (P = .001). Overall, 28.6% of players with navicular fracture played ≥2 years in the NFL compared with 69.6% in the control group (P = .02). Conclusion: A previous navicular fracture results in a greater risk of developing posttraumatic osteoarthritis. Although only a low prevalence of navicular injury in prospective NFL players was noted, players with these injuries had a greater probability of not being drafted and not competing in at least 2 NFL seasons when compared with matched controls without an injury history to the NFL Combine.