Peter G. Gerbino

Back injuries in the young athlete.

Back pain in children and young athletes is very different from back pain in adults. Macrotrauma must be carefully evaluated and managed, even in the absence of definitive radiographic findings. Microtrauma must be suspected in at-risk athletes. These athletes require persistent diagnostic evaluation and may require SPECT bone scan to uncover a posterior element stress reaction. Atraumatic back pain requires the elimination of neoplastic, infectious, rheumatologic, or congenital causes.

Tibial Eminence Fractures in Children: Prevalence of Meniscal Entrapment:

Background Meniscal entrapment under a displaced tibial eminence fragment may be a rationale for arthroscopic or open reduction in type 2 and 3 tibial eminence fractures. Purpose To determine the prevalence of meniscal entrapment in children with type 2 and 3 tibial eminence fractures. Study Design Case series. Methods Records of a consecutive series of 80 skeletally immature patients (mean age, 11.6 years; range, 5 to 16) who underwent arthroscopic (71), open (5), or combined arthroscopic and open (4) reduction and internal fixation of type 3 tibial eminence fractures (57) or type 2 fractures that did not reduce in extension (23) from 1993 to 2001 were reviewed. Results Entrapment of the anterior horn of the medial meniscus (36), intermeniscal ligament (6), or anterior horn of the lateral meniscus (1) was seen in 26% (6 of 23) of type 2 fractures and 65% (37 of 57) of type 3 fractures. An associated meniscal tear was seen in 3.8% of patients (3 of 80). Conclusions Meniscal entrapment is common in patients with type 2 and 3 tibial eminence fractures. Arthroscopic or open reduction should be considered for type 3 fractures and for type 2 fractures that do not reduce in extension to remove the incarcerated meniscus, allowing for anatomic reduction.

Discoid lateral meniscus: prevalence of peripheral rim instability.

The purpose of this study was to determine the prevalence of peripheral rim instability in discoid lateral meniscus. A consecutive series of 112 patients (128 knees) (mean age 10.0 years [range 1 month to 22 years]) who underwent arthroscopic evaluation and treatment of a discoid lateral meniscus between 1993 and 2001 was reviewed. Of those discoid menisci classified intraoperatively (n = 87), 62.1% (n = 54) were complete discoid lateral menisci and 37.9% (n = 33) were incomplete discoid lateral menisci. An associated meniscal tear was present in 69.5% (n = 89) of all knees studied. Overall, 28.1% (n = 36) of discoid lateral menisci had peripheral rim instability: 47.2% (n = 17) were unstable at the anterior-third peripheral attachment, 11.1% (n = 4) at the middle-third peripheral attachment, and 38.9% (n = 14) at the posterior-third peripheral attachment. Thirty-one of the 36 unstable discoid menisci underwent repair of the peripheral meniscal rim attachment. One patient underwent a complete, open meniscectomy. Peripheral rim instability was significantly more common in complete discoid lateral menisci (38.9% vs. 18.2%; P = 0.043) and in younger patients (8.2 vs. 10.7 years; P = 0.002). The frequency of peripheral instability mandates a thorough assessment of meniscal stability at all peripheral attachments during the arthroscopic evaluation and treatment of discoid lateral meniscus, particularly in complete variants and in younger children.

Does football cause an increase in degenerative disease of the lumbar spine

Degenerative disease of the lumbar spine is exceedingly common. Whether any specific activity increases the likelihood of developing degenerative disc disease (DDD) or facet degeneration (FD) has enormous implications. Within the field of occupational medicine there are specific activities, occupations, and morphologic characteristics that have been related to low back pain. Several specific risk factors have been conclusively linked to low back pain, and in particular DDD and FD. Within the sport of American football, there has long been the feeling that many athletes have or will develop low back pain, DDD, and FD. Proving that certain risk factors present in football will predictably lead to an increase in LBP, DDD, and FD is more difficult. At this time, it can be said that football players, in general, increase their risk of developing low back pain, DDD, and FD as their years of involvement with their sport increase. Because specific spine injuries like fracture, disc herniation, and spondylolysis are more frequent in football players, the resulting DDD and FD are greater than that of the general population. The weightlifting and violent hyperextension that are part of American football are independent risk factors for degenerative spine disease.

The young dancer.

The injuries that are prevalent in and unique to dancers have their origins inextricably linked to faulty technique or poor biomechanics, combined with other risk factors. It is this combination of factors that must be addressed when considering diagnosis, treatment, and rehabilitation. For the dancer to return to full activity with minimal risk of recurrent injury, neuromuscular re-education is mandatory. This process best entails using a team approach, accessing the resources of healthcare professionals and those who train the dancer on a daily basis. In some cases, parents also may need to be involved. Communication, interaction, and mutual understanding among these groups will assist the dancer in regaining and maintaining health.

Long-Term Functional Outcome After Lateral Patellar Retinacular Release in Adolescents : An Observational Cohort Study With Minimum 5-Year Follow-Up

Background: Lateral patellar retinacular release has been recommended for patients with patellar tilt, tight lateral retinaculum, patellar subluxation, patellar dislocation, and patellofemoral pain. Studies of long-term outcomes after lateral release are limited, especially for differing indications. Hypothesis: Adolescents do well after lateral retinacular release in the 5- to 22-year time frame. Methods: Patients having undergone lateral retinacular release between the years of 1981 and 1999 were contacted. Evaluation was by the Cincinnati and Lysholm scales and by level of satisfaction and need for reoperation. Results: One hundred forty knees were studied. Mean age at operation was 15.4 years (SD, 2.7 years). Average follow-up was 8.5 (SD, 4.1 years; range, 5.2-22.5 years). Twenty-five patients had needed reoperation, indicating failure of the index operation. Kaplan-Meier survivorship was 78% at 15 years. Cincinnati and Lysholm scores indicated well-functioning knees in those not requiring reoperation. Overall satisfaction improved as time from operation increased. Comparisons were made between the group requiring reoperation and those who did not. Focus was placed on knees with patellar maltracking or tilt versus patellar instability and between males and females. No differences were found among groups for reoperation rate, level of satisfaction, average Lysholm score, or average Cincinnati score. There were no differences in demographics or outcome measures between patients with patellar instability and those with tilt. Instability patients trended toward higher reoperation rates than did tilt patients, but the difference was not significant. There were no differences between males and females. Conclusion: The majority of patients are satisfied with their knee 5 to 22 years after lateral patellar retinacular release and scored well on questions rating knee health and function. Level of Evidence: Retrospective cohort study: level 2.

Elbow disorders in throwing athletes

Skeletally immature throwing athletes are injured when they throw too frequently or use throwing styles and pitches that overstress their elbows. Despite safety guidelines for throwing that recommend throwing more than 300, but less than 600, pitches per season, compliance is almost impossible to monitor, given multiple opportunities for throwing abuse away from organized, supervised league play. All throwers should avoid the side-arm throwing style. Pitchers should not play in multiple leagues, should not play hard-throwing positions when not pitching, and should not pitch when having elbow or shoulder pain. When the elbow becomes painful, pitching should cease and a thorough evaluation performed. Once the diagnosis is made, appropriate nonoperative treatment is undertaken. Operative intervention in this age group uncommonly is needed. Rehabilitation includes identifying and eliminating causative risk factors. Educating the athlete, coach, and parents results in a longer, pain-free throwing career and enhanced enjoyment of the sport.

Patella alta and the adolescent growth spurt.

The presence of patella alta has been linked to recurrent dislocation of the patella and the patello-femoral stress syndrome. It is not known whether patella alta is an inherited or acquired trait. To investigate the relationship of patella during the adolescent growth spurt, serial orthoroentgenograms (growth study films) were retrospectively analyzed in 19 patients. Two were found in whom proximal patella migration could be correlated (r = 0.85) with femoral growth rate. This was significant at the p = 0.01 level. Girls had a higher correlation of patella height to growth rate than boys. In certain cases, patella alta is an acquired rather than inherited condition; this supports the theory that overgrowth during the growth spurt can lead to patella alta in some individuals.

Arthroscopic percutaneous lateral patellar retinacular release

Thirty-four arthroscopic lateral patellar retinacular re leases in 26 patients were evaluated retrospectively. Patients were carefully assessed for residual pain; they were also evaluated by various physical examination criteria. In addition, objective measurements of quadri ceps and hamstring strength were obtained with the Cybex II Isokinetic Dynamometer. The surgical technique and postoperative manage ment are presented. Overall, there were 9% excellent results, 53% good results, 26% fair results, and 12% poor results. A total of 64.7% of the knees were im proved by the procedure.

Waterproof casts for immobilization of children's fractures and sprains.

This study was designed to determine the efficacy of waterproof cast-lining materials in children with short-arm, long-arm, and short-leg casts. Eligible patients had healing fractures 2 weeks after reduction, stable fractures requiring no reduction, or sprains. A total of 165 waterproof-lined casts were applied and 124 children and parents completed a survey (76.9%) upon cast removal. Results revealed 79% very satisfied, 21% satisfied, and 0% dissatisfied. There were 16 (12.9%) minor skin integrity issues. Waterproof casts in stable fractures and sprains allow acceptable immobilization with no significant associated unusual risk and allow children to resume their usual recreational water activities and hygiene regimen without risk of adverse results.