Patient-Specific E-mailed Discharge Instructions Improve Patient Satisfaction and Patient Understanding After Surgical Arthroscopy

Purpose

The purpose of this study is to determine whether patient-specific e-mails after surgical arthroscopy improve patient satisfaction and patient understanding of their procedure compared to traditional, preprinted discharge instructions.

Methods

Sixty patients who underwent surgical arthroscopy were prospectively, randomized into two separate groups. One cohort received a detailed e-mail of their procedure, discharge instructions, and labeled intraoperative arthroscopic images, while the second cohort received the standard preprinted instructions, while their arthroscopic images were discussed at the time of follow-up. The procedures were performed by a single surgeon. All patients were seen at 1-week follow-up and given a 14-question survey specific to their postoperative course, discharge instructions, and overall satisfaction using a 5-point Likert Scale. Demographic information was collected and data points comparing overall patient satisfaction, ease of understanding instructions, quality of information, and the number of times referenced were analyzed using nonparametric tests between the two cohorts.

Results

Patients in the e-mail cohort were significantly more satisfied with their surgery than patients in the printed cohort (medians: 5 versus 4, Wilcoxon chi-square = 9.98; P =.002). Patients in the e-mail cohort indicated that their instructions more greatly enhanced their overall understanding of their surgery (medians: 5 vs 3, Wilcoxon chi-square = 10.84; P = .001) and were more helpful to their recovery (medians: 5 vs 3, Wilcoxon chi-square = 7.37; P = .007). E-mail patients were significantly more likely to recommend similar instructions be sent to a friend undergoing surgery (medians: 5 versus 3, Wilcoxon chi-square = 11.10; P < .001) and share their instructions with others 72% (18/25) versus 34.5% (10/29). There was no significant difference between the e-mail cohort and the print cohort for the number of times patients referred to their instructions (medians: 3 versus 3, Wilcoxon chi-square = 2.41; P =.121).

Conclusions

Patient-specific e-mailed discharge instructions improve patient satisfaction and overall understanding of the procedure compared with traditional printed discharge instructions after surgical arthroscopy.

Level of Evidence

Level II, prospective randomized trial.

Functional Rehabilitation and Return to Play After Arthroscopic Surgical Stabilization for Anterior Shoulder Instability

BACKGROUND

There exists limited objective functional return-to-play criteria after surgical stabilization for anterior shoulder instability in the competitive athlete.

HYPOTHESIS

The proposed functional rehabilitation program and psychological evaluation after arthroscopic Bankart repair will help athletes return to sport with a decreased redislocation rate on return.

STUDY DESIGN

Case series.

LEVEL OF EVIDENCE

Level 4.

METHODS

Participants were contact or overhead athletes at the high school or collegiate level. Each underwent arthroscopic Bankart repair after a single dislocation event, with less than 10% glenoid bone loss. Western Ontario Shoulder Instability Index (WOSI) scores, Single Assessment Numeric Evaluation (SANE) scores, and American Shoulder and Elbow Surgeons (ASES) scores were evaluated pre- and postoperatively. Athletes were only allowed to return to competition after completing the proposed functional and psychological rehabilitation protocol.

RESULTS

A total of 62 participants were enrolled (52 male, 10 female; average age, 18.7 years (range 16-24 years); mean Instability Severity Index Score, 5.63 ± 0.55). All returned to sport for 1 full season and completed a minimum of 2 years of follow-up. The average time to pass functional testing was 6.2 ± 0.7 months, psychological testing was 5.2 ± 0.5 months, and return to sport was 6.5 ± 0.7 months. SANE scores improved from 44.3 to 90.0, ASES from 45.5 to 89.3, and WOSI from 1578.0 to 178.9 (all P < 0.001). Redislocation rate was 6.5% (4 of 62).

CONCLUSION

The proposed functional rehabilitation and psychological assessment protocol is safe and effective in returning athletes to sport after arthroscopic surgical intervention for anterior shoulder instability. This demonstrated a low redislocation rate after 2-year follow-up.

CLINICAL RELEVANCE

Most return-to-play protocols after arthroscopic Bankart repair are centered on recovery time alone, with limited focus on functional rehabilitation, psychological assessment, and return-to-play testing parameters. To our knowledge, this is the first study to propose a dedicated rehabilitation program incorporating functional testing, psychological readiness, and return-to-play criteria for competitive athletes recovering from arthroscopic shoulder stabilization.

Core Muscle and Adductor Injury

Core muscle injury is a common but difficult problem to treat. Although it can affect all individuals, it is most commonly seen in male athletes in cutting, twisting, pivoting, and explosive sports. Owing to the high association of femoroacetabular impingement, we believe these individuals are best treated with a multidisciplinary approach involving both orthopedic and general surgeons. Conservative treatment should be the first step in management. When conservative means are unsuccessful, operative intervention to correct all the pathologic issues around the pubis can have extremely high success rates.

ERRATUM: Surgical treatment of a chronically fixed lateral patella dislocation in an adolescent patient

Due to a technical error, part of the surname of an author (i.e. Stein instead of Shubin Stein) was omitted in the original published version of this paper [Orthop Rev (Pavia). 2013;5:45-7. doi: 10.4081/or.2013.e9].

Assessing the effectiveness of neuromuscular training programs in reducing the incidence of anterior cruciate ligament injuries in female athletes: a systematic review

BACKGROUND

Anterior cruciate ligament (ACL) injuries are more common in female athletes because of anatomic and biomechanical factors. These injuries can have detrimental ramifications for the athlete and the health care system. Neuromuscular training programs have been designed to modify risk factors and prevent ACL injuries.

PURPOSE

This systematic review evaluates studies that assess the effectiveness of neuromuscular training programs in reducing ACL injuries in female athletes and provides an update to 2 previously published reviews.

STUDY DESIGN

Systematic review.

METHODS

Medline, Cochrane, and CINAHL databases were searched for relevant journal articles published from 1995 to 2011. We performed a manual review of relevant articles, authors, and journals, including bibliographies from identified articles. Ten studies were included in this review.

RESULTS

Only 2 studies demonstrated a statistically significant decrease in ACL injuries with neuromuscular training programs. Two additional studies showed a statistically significant decrease in subgroup analyses only. Four studies did show a trend toward reduced ACL injuries with neuromuscular training programs but were unable to achieve statistical significance. Neuromuscular training programs utilizing plyometric exercises and a preseason component were the most beneficial. Two studies actually showed an increase in injuries with intervention programs.

CONCLUSION

Neuromuscular training programs may be a useful adjunct to training, but current literature precludes our universal recommendation of them.

Surgical treatment of a chronically fixed lateral patella dislocation in an adolescent patient

Acute patellar dislocation or subluxation is a common cause for knee injuries in the United States and accounts for 2% to 3% of all injuries. Up to 49% of patients will have recurrent subluxations or dislocations. Importance of both soft tissue (predominantly, the medial patellofemoral ligament, MPFL, which is responsible for 60% of the resistance to lateral dislocation) and bony constraint of femoral trochlea in preventing subluxation and dislocation is well documented. Acute patella dislocation will require closed reduction and management typically consist of conservative or surgical treatment depending on the symptoms and recurrence of instability. Most patients are diagnosed and treated in a timely manner. We present a 15 years old male with a missed traumatic lateral patella dislocation during childhood. The patient presented as an adolescent with a chronically fixed lateral patella dislocation and was management with surgery. The key steps in the surgical reconstruction of this patient required first mobilizing the patella with a lateral retinacular release and V-Y lengthening of the shortened or contracted quadriceps tendon. Then a combination of MPFL reconstruction using the semitendinosis autograft, tibial tubercle osteotomy with anterio-medialization, and lateral facetectomy was performed. At the one-year follow-up, our patient had improved knee range of motion and decrease in pain. Chronically fixed lateral dislocated patella is a rare and complex problem to manage in older patients that will require a thorough work-up and appropriate surgical planning along with reconstruction.

Evaluation of sterilization methods following contamination of hamstring autograft during anterior cruciate ligament reconstruction

PURPOSE

Inadvertent contamination of the hamstring autograft during ACL reconstruction is infrequent, but can result in significant complications. The purpose of this study is to evaluate bacterial contamination of hamstring autografts dropped onto the operating room floor and methods of graft decontamination.

METHODS

Hamstring tendons were harvested from patients. Excess tendon not used in the ACL procedure was divided into 6 segments. Segments were assigned to 6 groups (A through F, N = 30 in each group): group A: uncontaminated graft immediately postharvest (control), group B: graft dropped onto the floor (5 s), group C: graft dropped onto the floor (15 s). grafts in groups D to F were dropped onto floor for 15 s then rinsed with saline (group D), bacitracin solution (group E) or chlorhexidine 4 % solution (group F) for 3 min. All grafts were sent to the microbiology laboratory for anaerobic and aerobic cultures.

RESULTS

Cultures were positive in 23 % of graft segments from group A (7/30), 33 % of grafts from group B (10/30), 23 % from group C (7/30), 30 % from group D (9/30) and 3 % from both group E (1/30) and group F (1/30). Sixteen unique organisms were identified, with Staphylococcus aureus as the most common isolate. Grafts rinsed in either bacitracin solution or 4 % chlorhexidine solutions were significantly less likely to be culture positive when compared to control graft segments (p < 0.05). However, there was no significant difference between uncontaminated grafts retrieved in <5 versus 15 s from the floor.

CONCLUSION

This study supports the practice of decontaminating a dropped ACL hamstring autograft using either 4 % chlorhexidine or bacitracin solution. Specimens should be retrieved sterilely and washed for at least 3 min. This study also demonstrates no advantage in retrieval time of less than 5 s as compared to 15 s for uncontaminated graft. Hamstring harvest in ACL reconstruction may result in positive cultures, thus routine soaking of the hamstring autograft in either bacitracin or 4 % chlorhexidine solution is recommended. In addition, dropped hamstring autograft can be effectively sterilized with bacitracin or 4 % chlorhexidine solution.

LEVEL OF EVIDENCE

II.

MRI study of associated shoulder pathology in patients with full-thickness subscapularis tendon tears

Subscapularis tendon tears are a well-established cause of shoulder pain. The objective of the current study was to evaluate the associated shoulder pathology in patients with full-thickness subscapularis tendon tears using magnetic resonance imaging. Forty-seven magnetic resonance imaging studies taken between 2008 and 2009 with a diagnosis of full-thickness subscapularis tendon tears were reviewed. The size of the subscapularis tendon tear, amount of muscle volume loss, Goutallier grade, biceps tendon pathology, coracohumeral distance, and associated rotator cuff tears were recorded. Statistical analysis was performed. Patients 55 years and older vs those 54 years and younger had an average subscapularis tear size of 35 vs 19 mm, an average Goutallier grade of 2.7 vs 0.8, and a total muscle volume loss of 25% vs 5%, respectively. Patients with a dislocated vs normal biceps tendons had an average subscapularis tear size of 37 vs 23 mm, an average Goutallier grade of 3 vs 0.9, and a total muscle volume loss of 28% vs 7%, respectively. Patients with vs without concomitant rotator cuff tears had an average subscapularis tear size of 32 vs 17 mm, an average Goutallier grade of 2.3 vs 0.6, and a total muscle volume loss of 21% vs 3%, respectively. Overall average coracohumeral distance measured in the axial plane was 10.8±4.6 mm. Average coracaohumeral distance was 14.8 vs 8.1 mm in patients with a Goutallier grade of 0 vs 3 or 4, resepectively, and 13.6 vs 8.5 mm in patients with no rotator cuff tear vs those with a supra- and infraspinatus tear, respectively. Increased age, dislocated biceps tendons, and concomitant rotator cuff tears in patients with full-thickness subscapularis tendon tears are associated with larger subscapularis tendon tear size, higher Goutallier grades, and increased subscapularis muscle volume loss. Decreased coracohumeral distance is associated with a higher Goutallier grade and rotator cuff tears.

Soft tissue pathology around the hip

Snapping hip syndromes have been treated with open surgery for many years. Recently, endoscopic techniques have been developed for treatment of snapping hip syndromes with results that are at least comparable if not better than those reported for open procedures. The greater trochanteric pain syndrome is well known by orthopedic surgeons. However, deep understanding of the pathologic conditions generating pain in the greater trochanteric region and endoscopic access to it has only recently been described. Although evidence regarding endoscopic techniques for the treatment of the greater trochanteric pain syndrome is mainly anecdotal, early published reports are encouraging.

Radiology

Hip and groin pain are a common complaint among athletes of all ages, and may result from an acute injury or from chronic, repetitive trauma. Hip injuries can be intraarticular, extraarticular, or both. Labral abnormalities may occur in asymptomatic patients as well as in those with incapacitating symptoms and signs. Athletic hip injury leading to disabling intraarticular hip pain most commonly involves labral tear. The extraarticular causes are usually the result of overuse activity, leading to inflammation, tendonitis, or bursitis. In clinical practice, the term athletic pubalgia is used to describe exertional pubic or groin pain.

Management of type II superior labrum anterior posterior lesions: a review of the literature

Superior labrum anterior and posterior lesions were first described in 1985 by Andrews et al. and later classified into four types by Synder et al. The most prevalent is type II which is fraying of the superior glenoid labrum with detachment of the biceps anchor. Superior labrum anterior posterior (SLAP) lesions can also be associated with other shoulder pathology. Both MRI and MRA can be utilized in making the diagnosis with the coronal images being the most sensitive. The mechanism of injury can be either repetitive stress or acute trauma with the superior labrum most vulnerable to injury during the late cocking phase of throwing. A combination of the modified dynamic labral shear and O'Brien test can be used clinically in making the diagnosis of SLAP lesion. However, the most sensitive and specific test used to diagnosis specifically a type II SLAP lesion is the Biceps Load Test II. The management of type II SLAP lesions is controversial and dependent on patient characteristics. In the young high demanding overhead athlete, repair of the type II lesion is recommended to prevent glenohumeral instability. In middle-aged patients (age 25-45), repair of the type II SLAP lesion with concomitant treatment of other shoulder pathology resulted in better functional outcomes and patient satisfaction. Furthermore, patients who had a distinct traumatic event resulting in the type II SLAP tear did better functionally than patients who did not have the traumatic event when the lesion was repaired. In the older patient population (age over 45 years), minimum intervention (debridement, biceps tenodesis/tenotomy) to the type II SLAP lesion results in excellent patient satisfaction and outcomes.

Treatment of chronic lateral ankle instability: a modified Broström technique using three suture anchors

Ankle sprains are very common injuries seen in the athletic and young population. Majority of patients will improve with a course of rest and physical therapy. However, with conservative management about twenty percent of all patients will go on to develop chronic lateral ankle instability. This manuscript describes our detailed surgical technique of a modification to the original Broström procedure using three suture anchors to anatomically reconstruct the lateral ankle ligaments to treat high demand patients who have developed chronic lateral ankle instability. The rationale for this modification along with patient selection and workup are discussed. Both the functional outcomes at the two year follow up along with the complications and the detailed postoperative rehabilitation protocol for the high demand athletes are also presented. This modified Broström procedure is shown in both illustrative format and intra-operative photos.

Arthroscopic treatment of concomitant superior labral anterior posterior (SLAP) lesions and rotator cuff tears in patients over the age of 45 years

BACKGROUND

Rotator cuff tears commonly occur in combination with other shoulder injuries such as superior labral anterior posterior (SLAP) lesions. The incidence of these associated lesions increases with age; however, the management of concomitant SLAP and rotator cuff tears has yet to be convincingly addressed in the literature.

HYPOTHESIS

Patients over the age of 45 years who have concomitant arthroscopic rotator cuff repair and debridement of their type II SLAP lesions will have improved patient satisfaction and functional outcome compared with those who undergo simultaneous rotator cuff and type II SLAP repair.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

We recruited 48 patients (mean age, 51.9 years; range, 45-60 years) who had concomitant rotator cuff and type II SLAP tears. All underwent arthroscopic rotator cuff repair with subacromial decompression. Patients were randomized intraoperatively into 2 groups: repair versus debridement of their type II SLAP lesions. Ten patients were lost at final follow-up (4 in debridement and 6 in repair group). The outcome was assessed by the Tegner score and University of California at Los Angeles (UCLA) score and clinically to evaluate range of motion (forward elevation/internal rotation/external rotation).

RESULTS

At 2 years postoperatively, both the debridement and repair groups showed significant improvement in Tegner score, UCLA score, and range of motion. Patients who underwent rotator cuff repair in combination with debridement of their SLAP tears had significantly better overall UCLA scores (34 vs 31; P < .001) and improved function (5.5 vs 3.8; P < .005) and pain relief (9.6 vs 7.7; P < .001) compared with those who underwent simultaneous rotator cuff and SLAP repair. Range of motion in both internal and external rotation was also significantly better in those patients who had SLAP debridement as compared to SLAP repair.

CONCLUSION

In patients over the age of 45 years with a minimally retracted rotator cuff tear and associated SLAP lesion, arthroscopic repair of the rotator cuff with combined debridement of the type II SLAP lesion may provide greater patient satisfaction and functional outcome in terms of pain relief and motion.

Anatomical reconstruction for chronic lateral ankle instability in the high-demand athlete: functional outcomes after the modified Broström repair using suture anchors

BACKGROUND

Modification of the Bröstrom repair with suture anchors has been used to address chronic lateral ankle instability. However, there are few studies in the literature reporting the functional outcomes after this particular procedure in the high-demand athlete.

HYPOTHESIS

Anatomical reconstruction of the lateral ankle ligaments for chronic instability will return the high-demand athlete functionally to his or her previous level of activity.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Sixty-two patients who had grade III ankle sprain that failed at least a 6-month course of supervised conservative management with a preinjury Tegner score of > or = 6 underwent a variant of the Gould-modified Broström procedure with suture anchors for lateral ankle instability. Each patient was given the Tegner and Karlsson questionnaire at the 6-month, 1-year, and 2-year time points. Range of motion of the operative ankle was also assessed. The mean age was 19.6 years (range, 16-26 years), and 10 patients were lost to follow-up.

RESULTS

The mean follow-up was 29 months (minimum, 24 months) in the remaining 52 patients (84%). Mean Tegner scores at the 1- and 2-year time points were 8.2 (range, 5-9) and 8.6 (range, 5-9), respectively. The mean Karlsson scores were 92 +/- 5.2 and 95 +/- 3.1 at the 1- and 2-year time points, respectively. Range of motion was equal to the contralateral ankle in all but 3 patients at the 2-year follow up. A 6% major complication rate included 3 reruptures.

CONCLUSION

Anatomical ligament reconstruction for chronic lateral ankle instability using a variant of the Gould-modified Broström procedure with suture anchors was effective in returning high-demand athletes to their preinjury functional level.

Primary repair of knee dislocations: results in 25 patients (28 knees) at a mean follow-up of four years

OBJECTIVE

To investigate the outcomes of knee dislocations treated with primary repair and an early rehabilitation protocol.

DESIGN

Retrospective.

SETTINGS

Level 1 Trauma Center.

PATIENTS

Consecutive patients with knee dislocation referred to a single surgeon for care between 1994 and 2002 were included, for a total of 27 patients with 30 knee dislocations. Twenty-five patients (28 knees) were evaluated by an independent observer at a mean of 48 months (13-82 months).

INTERVENTION

All patients underwent primary repair of all injured ligaments using a consistent technique and early rehabilitation protocol.

MAIN OUTCOME MEASUREMENTS

In addition to range of motion and stability assessment, Lysholm and Tegner scores were used to evaluate outcome.

RESULTS

The mean post-operative Lysholm score was 89.0. Range of motion analysis for the 22 unilateral dislocations available for examination showed a mean extension loss of 1.9 degrees and mean flexion loss of 10.2 degrees , with a mean arc of motion of 119.3 degrees . Overall, the knees were found to be clinically stable.

CONCLUSIONS

Primary repair of ligaments coupled with an early rehabilitation program provides comparable outcomes to published results of ligament reconstruction. Primary repair of ligaments in the dislocated knee should be considered as an effective option in the trauma population.

Arthroscopy for hip dislocation and fracture-dislocation

We reviewed consecutive patients undergoing hip arthroscopy for loose bodies after sustaining hip dislocations and fracture-dislocations not requiring open fracture management. Eleven patients were identified, all with intra-articular loose bodies diagnosed by computed tomography. After 3 weeks, all patients underwent hip arthroscopy in which loose bodies were removed and labral pathology debrided. No patient developed any of the complications (avascular necrosis, heterotopic ossification, nerve injury) associated with hip arthrotomy. Arthroscopic treatment of intraarticular loose bodies after hip dislocations and fracture-dislocations allows excellent joint visualization for loose body removal and labral tear diagnosis and treatment.

Radiofrequency energy: applications and basic science

Interest in using radiofrequency energy devices in orthopedics has been growing recently. The basic science of this intervention is similar to that of laser energy application and involves the heating of tissue. Collagen responds characteristically to heat--it becomes denatured, and its configuration becomes disorganized. Thus, this application of heat can be used to shorten collagenous soft tissue. Radiofrequency energy can also be used at higher parameters for tissue ablation. Although early clinical trials have shown promising results for many applications, long-term study is needed.

Treatment of type III tibial intercondylar eminence fractures in skeletally immature athletes

Our retrospective study of 12 skeletally immature athletes with type III intercondylar eminence fractures showed that arthroscopic evaluation with mini-open arthrotomy and repair of the tibial intercondylar eminence fracture with absorbable suture can be successful in repairing anterior cruciate ligament avulsion fractures and in helping such patients return to their athletic endeavors.

Assessment and differential diagnosis of the painful hip

Hip pain is a common problem seen by orthopaedic surgeons. The current authors provide an approach to the patient with hip pain, including important information to be gained from the history and physical examination and relevant radiographic studies and laboratory tests. A differential diagnosis for patients presenting with the complaint of hip pain and indications for hip arthroscopy are provided.

Hip arthroscopy in the pediatric population

Hip arthroscopy has obvious advantages over arthrotomy in the pediatric population. Hip arthroscopy, used as a diagnostic or therapeutic tool, is significantly less invasive than arthrotomy and allows for quicker recovery and return to activities. In addition, arthroscopy avoids dislocation of the femoral head and the corresponding risk of osteonecrosis. Current indications for hip arthroscopy in pediatric patients include septic arthritis, labral disorders, slipped capital femoral epiphysis, and Legg-Calvé-Perthes disease. The role of hip arthroscopy in the pediatric population will continue to expand because of its attractiveness as a less invasive option for evaluating the hip.

Hip arthroscopy: surgical approach, positioning, and distraction

The hip is the most deeply recessed joint in the body making it difficult to access arthroscopically. However, for the patient with a symptomatic loose body or labral tear open techniques are less advantageous. It is for this reason that, however difficult, minimally-invasive approaches to the hip have been developed. Meticulous attention to proper positioning and portal placement is paramount for safe and successful arthroscopy of the hip. The current authors will review the seminal features of positioning and minimally-invasive surgical approaches to the hip.

Prospective analysis of radiofrequency versus mechanical debridement of isolated patellar chondral lesions

PURPOSE

Debridment is used to treat Outerbridge grades 2 and 3 lesions in a mechanically aligned and properly tracking patella. It removes fibrillation and provides a stable rim of chondral tissue. Recent basic science reports suggest that radiofrequency probes are superior to mechanical shavers for articular cartilage debridement. The goal of this study was to compare the clinical outcomes of debridement of patellar grade 2 and 3 chondral lesions using radiofrequency and mechanical devices.

TYPE OF STUDY

Patients were prospectively randomized into 2 treatment groups.

METHODS

Consecutive female patients undergoing arthroscopy for symptomatic, isolated patellar cartilage lesions without evidence of instability, malalignment, or patellar tracking dysfunction were prospectively randomized into radiofrequency and mechanical debridement groups based on medical record number. All patients had failed a 6-month course of conservative treatment and had chondral pathology documented by magnetic resonance imaging. Patients were assessed before and after surgery using the Fulkerson-Shea Patellofemoral Joint Evaluation Score.

RESULTS

Nineteen patients (mean age, 37.5 years) underwent chondral debridement using a mechanical shaver and 20 patients (mean age, 36.9 years) underwent chondral debridement using a bipolar radiofrequency probe at nonablative energy levels. The mechanical group had a mean preoperative score of 59.2 and the radiofrequency group had a mean preoperative score of 59.6. Postoperative scores at 12-month follow-up were 80.0 for the mechanical group and 87.9 for the radiofrequency group (P =.0031). At 24 months, the mean score of the mechanical group was 77.5 and the mean of the radiofrequency group was 86.6 (P =.0006).

CONCLUSIONS

This study presents clear evidence of superior clinical outcome of debridement of patellar grade 2 and 3 chondral lesions with the use of bipolar radiofrequency versus a mechanical shaver.

Bone density in competitive figure skaters

OBJECTIVES

To compare the bone mineral density (BMD) of competitive female teenage figure skaters with a history of fracture with the BMD of skaters without fracture and to compare each group to age-matched, nonathletic controls.

DESIGN

Retrospective age-matched cohort.

SETTING

Tertiary care medical center and 3 local skating clubs.

PARTICIPANTS

Thirty-six adolescent female competitive skaters (10 with fracture, 26 without fracture) to 22 age-matched controls.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

BMD was estimated by quantitative ultrasound.

RESULTS

Skaters who had suffered stress fractures had BMD values comparable with those of healthy nonathletic controls. However, skaters who had not suffered stress fractures had calcaneal BMD values 15% to 24% greater than either the controls or skaters with fractures. Among the skaters without fracture, there was a 14% to 19% higher calcaneal BMD in skaters who executed triple jumps relative to skaters who performed only double jumps. Furthermore, there was 7% to 11% greater BMD in the landing foot of the skaters relative to the takeoff foot.

CONCLUSIONS

Stress fractures in adolescent skaters are not caused by low bone mass but may result from excessive forces placed on a normal skeleton. Our findings also support the hypothesis that higher peak forces are applied to the landing foot relative to the takeoff foot.

Chronic, painful ankle instability in skeletally immature athletes. Ununited osteochondral fractures of the distal fibula

We report 10 cases of chronic, painful ankle instability in skeletally immature athletes associated with ununited osteochondral fragments of the distal fibula. All the patients experienced multiple inversion injuries with recurrent pain and instability that failed to improve after a supervised exercise and rehabilitation program. Osteochondral fragments of the distal fibula were visible on all standard radiographs of the affected ankles. Treatment consisted of operative excision of the bony fragment and an anatomic nonaugmented repair of the lateral ligament complex and capsule. All 10 patients were available for long-term followup an average of 6.5 years (+/-2) after surgery; all ankles improved functionally, with no recurrences of instability.

Anterior thigh compartment syndrome following prolonged tourniquet application and lateral positioning

A case presentation of anterior thigh compartment syndrome following prolonged tourniquet application and lateral decubitus positioning is presented with a review of the literature regarding thigh compartment syndrome. In this case, an 18-year-old man underwent a 12-hour scapular fasciocutaneous-free flap grafting procedure for a non-healed ulcer of the medial heel. Postoperatively, the patient developed anterior thigh compartment syndrome that was delayed in diagnosis because of the epidural analgesics he received for pain control. The patient was returned to the operating room and was successfully treated by an anterior decompression fasciotomy.

Traumatic popliteal artery thrombosis and compartment syndrome of the leg following blunt trauma to the knee: a discussion of treatment and complications

Blunt trauma to the knee has been associated with both musculoskeletal and neurovascular injury to the leg. Popliteal artery thromboses secondary to such trauma can be complicated by a compartment syndrome. The loss of distal pulses in the leg following blunt knee trauma should always be attributed to a suspected vascular lesion and not to the presence of the compartment hypertension. We present a case in which the diagnosis of a popliteal artery thrombosis was delayed because the loss of distal pulses was initially attributed to the compartment syndrome.