Stephanie W. Mayer

Stress Fractures of the Foot and Ankle in Athletes

Context: Stress fractures of the foot and ankle are a common problem encountered by athletes of all levels and ages. These injuries can be difficult to diagnose and may be initially evaluated by all levels of medical personnel. Clinical suspicion should be raised with certain history and physical examination findings. Evidence Acquisition: Scientific and review articles were searched through PubMed (1930-2012) with search terms including stress fractures and 1 of the following: foot ankle, medial malleolus, lateral malleolus, calcaneus, talus, metatarsal, cuboid, cuneiform, sesamoid, or athlete. Study Design: Clinical review. Level of Evidence: Level 5. Results: Stress fractures of the foot and ankle can be divided into low and high risk based upon their propensity to heal without complication. A wide variety of nonoperative strategies are employed based on the duration of symptoms, type of fracture, and patient factors, such as activity type, desire to return to sport, and compliance. Operative management has proven superior in several high-risk types of stress fractures. Evidence on pharmacotherapy and physiologic therapy such as bone stimulators is evolving. Conclusion: A high index of suspicion for stress fractures is appropriate in many high-risk groups of athletes with lower extremity pain. Proper and timely work-up and treatment is successful in returning these athletes to sport in many cases. Low-risk stress fracture generally requires only activity modification while high-risk stress fracture necessitates more aggressive intervention. The specific treatment of these injuries varies with the location of the stress fracture and the goals of the patient.

Functional Testing Differences in Anterior Cruciate Ligament Reconstruction Patients Released Versus Not Released to Return to Sport

Background: No standardized return-to-activity or sport guidelines currently exist after anterior cruciate ligament (ACL) reconstruction. Isokinetic testing and unilateral hop testing, which have construct validity, are often used to make the determination of when a patient is ready to return to sport. Neither of these measures has been reported to be predictive of subsequent injuries. Purpose: To compare the performance on 2 functional tests of ACL reconstruction patients released to return to activity versus those who have not been released based on clinical impairment measures. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 98 patients were examined by the treating orthopaedic surgeon 6 months after ACL reconstruction for traditional impairment measures, including swelling, range of motion, strength, and graft stability. After this examination, all subjects completed the functional testing, consisting of the Functional Movement Screen (FMS) and the Lower Quarter Y Balance Test (YBT-LQ), by an experienced tester who was blinded to the results of the clinical examination. On the basis of the clinical examination, all patients were grouped as being ready to return to sport or not being ready. Performance on the functional tests, as measured by overall performance and side-to-side asymmetry, was compared between the 2 groups using independent-samples t tests (P < .05). Results: No difference existed between the groups with regard to the descriptive characteristics, with the exception that the group not cleared was younger (21.0 ± 7.4 years) than the group that was cleared (25.6 ± 13.2 years). Performance on the YBT-LQ revealed that no differences existed between groups when examining reach symmetry for any of the reach directions. In addition, no differences were found between groups when looking at the average reach score normalized to limb length for either the surgical or nonsurgical leg. Patients in the cleared group exhibited a similar score on the FMS (12.7 ± 2.9) compared with the noncleared group (12.8 ± 2.7). Similarly, no differences were observed for the number of asymmetries; however, both groups averaged 1 asymmetry during the testing. Conclusion: Clinical impairment measures do not appear to be related to measured functional ability. Performance on both functional tests, the FMS and YBT-LQ, at 6 months would suggest that the typical patient in both groups would be at a greater risk of lower extremity injury, based on currently published research.

Pediatric Knee Dislocations and Physeal Fractures About the Knee.

Given the high incidence of vascular and neurologic injury associated with pediatric knee dislocations and displaced physeal injuries about the knee, a thorough understanding of the clinical and radiographic signs associated with these injuries, relevant anatomy, workup, reduction techniques, and surgical management is crucial. A higher incidence of these injuries in children is anticipated because of increased participation in high-energy activities that result in contact or collision during sports or recreation. Complications, such as vascular and nerve injuries and compartment syndrome, can be diagnosed early in the workup to prevent catastrophic outcomes. The clinical examination should include evaluation of the motor and sensory status of the limb, palpation of pulses, and measurement of ankle brachial indices. Radiographic examination should include plain radiography and supplemental advanced imaging, if indicated. Vascular imaging or expert consultation should be considered when the pulse or ankle brachial index is abnormal on clinical examination. Selection of nonsurgical or surgical treatment depends on the fracture pattern and stability.

All-Inside, All-Epiphyseal Anterior Cruciate Ligament Reconstruction in Skeletally Immature Athletes: Return to Sport, Incidence of Second Surgery, and 2-Year Clinical Outcomes:

Background: Anterior cruciate ligament (ACL) injuries in skeletally immature athletes are increasing. Purpose: To evaluate the 2-year clinical outcomes of all-inside, all-epiphyseal ACL reconstruction in skeletally immature athletes with 3 to 6 years of remaining growth, with a focus on return to sport and the incidence of second surgery. Study Design: Case series; Level of evidence, 4. Methods: Twenty-three skeletally immature athletes were prospectively evaluated after all-epiphyseal ACL reconstruction utilizing a hamstring autograft. The athletes’ age, sex, sport, mechanism of injury, radiographs, and magnetic resonance imaging (MRI) findings were noted. The evaluation included a physical examination, KT-1000 arthrometer measurements, isokinetic testing, and validated outcome scores. Standing radiographs and spoiled gradient recalled echo MRI scans were obtained at 6, 12, and 24 months postoperatively. A quality of movement assessment and return-to-sport performance analysis were also performed. Results: Of the 23 athletes, 6 were female (mean age, 11.3 years), and 17 were male (mean age, 12.6 years). At a minimum follow-up of 2 years (range, 24-45 months), the mean International Knee Documentation Committee score was 94.6 ± 4.9, the mean Lysholm score was 97.9 ± 4.0, the mean Marx activity rating scale score was 13.4 ± 3.6, and the mean Hospital for Special Surgery Pediatric Functional Activity Brief Scale score was 23.9 ± 7.0. Lachman and pivot-shift test results were negative in all patients. The mean side-to-side difference on the KT-1000 arthrometer was 0.9 ± 0.5 mm and less tight on the operated side. No significant growth disturbances were noted; however, 6 athletes had a leg-length discrepancy of more than 5 mm (range, 6-18 mm). Two patients had overgrowth in the femur of more than 15 mm (16 mm and 18 mm). Two athletes (8.7%) required second surgery. The mean time to return to unrestricted activity was 13.5 months (range, 8-22 months). Conclusion: The all-inside, all-epiphyseal ACL reconstruction technique using a hamstring autograft demonstrates excellent subjective and objective clinical outcomes in skeletally immature athletes without physeal arrest.

Total Knee Arthroplasty in Osteopetrosis Using Patient-Specific Instrumentation

Osteopetrosis is an uncommon endocrine disease characterized by defective osteoclast resorption of bones. This causes a hard, sclerotic, and brittle bone throughout the skeleton. Fractures and unforgiving subchondral bone are common in this condition, both of which can lead to osteoarthritis. Total knee arthroplasty is often the treatment of choice but presents challenges due to the hard and sclerotic bone present throughout the metaphysis and diaphysis of the femur and the tibia. We present a case of knee osteoarthritis in a patient with osteopetrosis who underwent total knee arthroplasty using patient-specific instrumentation. This technique eliminates intramedullary alignment and minimizes drilling, reaming, and saw passes, making it attractive in the setting of diseases such as osteopetrosis to decrease operative time and potential complications.

Patient Characteristics and Early Functional Outcomes of Combined Arthroscopic Labral Refixation and Periacetabular Osteotomy for Symptomatic Acetabular Dysplasia

Background: Symptomatic labral tears are common in patients with acetabular dysplasia; however, optimal treatment of the labrum remains controversial. Purpose: To present patient characteristics and early functional outcomes associated with combined arthroscopic labral refixation and Bernese periacetabular osteotomy (PAO) for symptomatic acetabular dysplasia with a displaced labral tear from the acetabular rim. Study Design: Cohort study; Level of evidence, 3. Methods: Patients undergoing PAO from a single-center prospective hip preservation registry were eligible (N = 73 patients; mean clinical follow-up, 23 months). Indications for combined arthroscopic labral refixation included symptomatic labral injury and MRI findings suggestive of labral detachment from the acetabular rim indicating a repairable tear. The study group consisted of patients undergoing combined arthroscopic labral refixation and PAO (scope/PAO group: n = 21 patients). Patients undergoing PAO alone (PAO group: n = 52 patients) were included as a comparison. Demographic characteristics, pre- and postoperative radiographic findings, and hip-specific functional outcome scores were recorded. Results: The scope/PAO group was older relative to PAO alone (27 vs 23 years; P = .047). Preoperative computed tomography showed increased acetabular version at the 3-o’clock position in the scope/PAO group relative to PAO alone (median [quartile 1, quartile 3]: 24° [20°, 25°] vs 19° [14°, 24°]; P = .026). PAO operative time, achievement of radiographic correction, or postoperative complications did not differ between groups. Improvements by minimum important change for modified Harris Hip Score, Hip Outcome Score (HOS)–ADL, HOS-Sport, and International Hip Outcome Tool (iHOT-33) were seen in 90%, 79%, 74%, and 100% of patients, respectively, undergoing scope/PAO at most recent follow-up. There was greater improvement from baseline in the iHOT-33 at most recent follow-up in the scope/PAO versus PAO group after adjusting for age and Tönnis grade (mean change ± SD: 48 ± 22 [scope/PAO] vs 37 ± 24 [PAO]; P = .03). Conclusion: Patients undergoing combined arthroscopic labral refixation and PAO were older and had increased acetabular anteversion versus patients undergoing PAO alone. Combined arthroscopic labral refixation and PAO was safe, did not affect PAO operative time or radiographic correction achievement, and may benefit clinical outcomes in this patient subset.

The Influence of Thumb Metacarpophalangeal Joint Rotation on the Evaluation of Ulnar Collateral Ligament Injuries: A Biomechanical Study in a Cadaver Model

PURPOSE To determine whether variation in thumb metacarpophalangeal (MCP) joint pronosupination influences perceived ulnar collateral ligament (UCL) stability during clinical stress testing. METHODS Twelve fresh-frozen specimens underwent sequential evaluation for the following conditions: ligament intact (LI), proper UCL deficient (-pUCL), and proper and accessory UCL deficient (UCL). Valgus stress testing was completed in both 0° and 30° MCP joint flexion for thumb pronation, neutral, and supination. RESULTS Compared with neutral MCP joint rotation, supination decreased and pronation increased stability such that established treatment guidelines could be incorrectly applied. During evaluation in supination and 0° flexion, 9/12 -pUCL had greater than 35° laxity and, similarly, the mean laxity of -pUCL was similar to the UCL group in neutral rotation and 0° flexion, incorrectly suggesting a complete ligament tear. In comparison, mean laxity of the *UCL in pronation and 0° flexion was not different than -pUCL in neutral rotation and 0° flexion, emphasizing the stabilizing effect of pronation. CONCLUSIONS Thumb MCP joint pronosupination significantly influenced the evaluation of joint stability, where pronation improved valgus stability in contrast to supination that tended to increase joint instability, In pronation and 0° flexion, a complete UCL injury could be misdiagnosed as a partial injury. In supination and 30° flexion, an intact UCL could be misdiagnosed as a partial UCL injury. In supination and 0°, a partial UCL injury could be misdiagnosed as a complete UCL injury. CLINICAL RELEVANCE Accurate evaluation of thumb UCL stability is critical for guiding treatment. Variations in thumb MCP joint rotation during stress testing may influence clinical interpretation and, therefore, we recommend standardization of testing with the thumb MCP joint in neutral rotation.

Late Liner Disassociation of a Pinnacle System Acetabular Component

This article describes a case of late locking mechanism failure and disassociation of a Pinnacle acetabular cup (DePuy, Warsaw, Indiana) and Marathon polyethylene liner (DePuy) 53 months after routine primary total hip arthroplasty in an active patient. Following an uncomplicated initial postoperative recovery, the patient felt a pop while kneeling for gardening activities. The patient had no prodromal symptoms but reported pain with range of motion and weight bearing following the episode. Radiographs appeared to show a fractured liner with intact acetabular and femoral components. Intraoperatively, the liner was disassociated and dislocated inferior to the acetabulum, and 3 consecutive antirotational tines were sheared off the liner at their bases. The acetabular cup and femoral stem were well fixed. Extensive metallosis existed from the femoral head and acetabular shell articulating in the absence of a liner. The patient underwent revision of the acetabular cup, polyethylene liner, and femoral head due to the concern for osteolysis given the extensive metallosis. Revision of the acetabular cup and liner were performed with no further complications. No conclusions could be made as to the exact mechanism of failure following laboratory analysis of the retrieved polyethylene liner. Several possible mechanisms of failure are possible. Although cases of acute disassociation of this system have been reported, this is the first article to our knowledge to report failure at such a late postoperative time.

The Epidemiology and Effect of Sliding Injuries in Major and Minor League Baseball Players

Background: Although sliding occurs frequently in professional baseball, little is known about the epidemiology and effect of injuries that occur during sliding in this population of elite athletes. Purpose: To describe the incidence and characteristics of sliding injuries, determine their effect in terms of time out of play, and identify common injury patterns that may represent appropriate targets for injury prevention programs in the future. Study Design: Descriptive epidemiologic study. Methods: All offensive sliding injuries occurring in Major League Baseball (MLB) and Minor League Baseball (MLB) that resulted in time out of play during a span of 5 seasons (2011-2015) were identified. In addition to player demographics, data extracted included time out of play, location on field where injury occurred, level of play, treatment (surgical vs nonsurgical), direction of slide (head vs feet first), body region injured, and diagnosis. Descriptive statistics were used to describe the distribution of these injuries, and injury rates were calculated per slide. Results: From 2011 to 2015, 1633 injuries occurred as a result of a slide. The total number of days missed per season was 4263. Surgical intervention was required for 134 (8.2%) injuries, and the mean days missed was 66.5 for players treated surgically and 12.3 days for players treated nonoperatively (P < .001). MLB players were more likely than MiLB players to require surgical intervention (12.3% vs 7.5%, P = .019). Injuries to the hands/fingers represented 25.3% of all injuries and 31.3% of those requiring surgery. Although the majority of injuries occurred at second base (57%), the per-slide injury rate was similar across all bases (P = .991). The estimated overall frequency of injury in MLB was once per every 336 slides, and the rate of injury for head- and feet-first slides was 1 in 249 and 413 slides, respectively (P = .119). Conclusion: Injuries occurring while sliding in professional baseball result in a significant amount of time out of play for these elite athletes. Injuries occurring at second base and those occurring to the hands and fingers were most prevalent and may be an appropriate target for future injury prevention programs.

Return to Play Following Open Treatment of Femoroacetabular Impingement in Adolescent Athletes.

Introduction:After treatment of femoroacetabular impingement (FAI) in adolescent competitive athletes, the rate, timing, and level of return to play have not been well reported. Methods:Adolescent athletes who underwent open FAI treatment were assessed at a minimum 1-year follow-up. Patients completed a self-reported questionnaire centered on the time and level of return to play. Pain and functional outcomes were assessed using the modified Harris Hip Score (mHHS) and the Hip Disability and Osteoarthritis Outcome Score (HOOS). Results:Among the 24 athletes included, 21 (87.5%) (95% confidence interval [CI], 67.6% to 97.3%) successfully returned to play after open FAI treatment. The median time to return to play was 7 months (95% CI, 6 to 10 months). Of the 21 who returned to play, 19 (90%) returned at a level that was equivalent to or greater than their level of play before surgery. Three athletes (12.5%) did not return to play and indicated that failure to return to play was unrelated to their hip. There was significant improvement in the mHHS (P < 0.0001), HOOS (P < 0.0001), &agr; angle (P < 0.0001), and offset (P < 0.0001). Discussion:Most adolescent athletes can expect to return to the same or better level of sports participation during the first year after open treatment of FAI.