Medial Proximal Tibia Physeal Overuse Injury of an Athlete

Overuse injuries are well described for both upper and lower extremities among skeletally immature athletes. To our knowledge, there is no description in the literature of an overuse injury affecting the medial tibial physis that is different from the typical Osgood-Schlatter disease or tibial tubercle apophysitis. In this article we present a 13-year-old athlete with medial proximal tibial widening or epiphysiolysis from overuse playing soccer. We need to be aware that with increased early sports specialization we may see injuries we have not seen before. [Orthopedics. 2022;46(6):e345-e347.].

Unusual case of hypotenar Hammer Syndrome and carpal tunnel syndrome association

BACKGROUND AND AIM OF THE WORK

Hypothenar Hammer Syndrome is a relatively rare disease process caused by repetitive stress or injury to the hypothenar eminence leading to chronic injury to the ulnar artery. Our study reports an unusual case.

METHODS

A 57 years old Plumber presented in April 2016 with a history of constant pain and recurrent paresthesia involving the fingers of the right hand for several months, over the previous 1 year, his hand had become more intolerant of exposure to cold temperatures. Angio-RNM and electromyography were performed and showed a severe double compression of ulnar and median nerve and an ulnar artery deformity without thrombosis. Surgery was performed under sedation and axillary anesthesia.

RESULTS

After surgery patient' symptoms immediately improved, and within a few months, his hand had normalized.

CONCLUSION

Hypothenar Hammer Syndrome is a rare disease process which manifests in certain occupations and activities that put undue stress on the hypothenar area. Furthermore, the carpal tunnel syndrome, a pressure damage of the median nerve, caused by repetitive manual tasks with flexion and extension of wrist has been added as well as hypothenar hammer syndrome which are vascular damages of hand caused by shock-type application of force.

[Jumper's Knee]

Zusammenfassung. Sportliche Aktivitäten mit Sprungabläufen stellen für die Kniegelenke eine mechanische Herausforderung dar. Häufig projizieren sich chronisch auftretende, atraumatische Beschwerden auf den Patellaunterpol, welcher pathomorphologisch eine patellare Tendinopathie entspricht. Extrinsische und intrinsische Risikofaktoren können unterschieden werden. In der klinischen Untersuchung zeigt sich ein meist unauffälliges Knie mit einer Druckdolenz am kaudalen Teil der Kniescheibe beim Übergang zum Ligamentum patellae. In der Bildgebung ist sonografisch ein degenerierter Sehnenanteil der tiefen Patellarsehne zu erkennen, der magnettomografisch mit Hyperintensität des Hoffa-Körpers einhergehen kann. Abhängig von der klinischen Entwicklung wird das Jumper’s Knee nach Blazina Grad I–IV eingeteilt. Bis zu 90 % der Patienten können konservativ therapiert werden. Operativ stehen offene und arthroskopische Verfahren mit ordentlichem Resultat zur Verfügung.

Medial Elbow Injuries in the Throwing Athlete

Medial elbow injuries in the throwing athlete are common and increasing in frequency. They occur due to repetitive supraphysiologic forces acting on the elbow during the overhead throw. Overuse and inadequate rest are salient risk factors for injury. Most athletes improve substantially with rest and nonoperative treatment, although some athletes may require surgical intervention to return to play. Because of advances in conservative and surgical treatments, outcomes after medial elbow injury have improved over time. Currently, most athletes are able to return to a high level of play after ulnar collateral ligament reconstruction and experience a low rate of complications.

A Case of Acute Compartment Syndrome of the Thigh Associated with Repetitive Athletic Trauma

We present a case of acute compartment syndrome (ACS) in an athlete who sustained minimal but repetitive trauma to the thigh during a sporting event. During his evaluation, concern was raised regarding the diagnosis of ACS as a cause of his symptoms. This was confirmed by measuring the intra-compartmental pressures and he subsequently underwent successful emergent fasciotomy, eventually making a complete recovery. ACS is a potential complication of muscular-skeletal injuries from various causes, and our case is unusual as the cause was mild but repetitive trauma in an otherwise healthy athlete. It is important to recognize the signs and symptoms of ACS to avoid the potentially significant complications should the diagnosis be missed.

Clinical Outcomes After Suture Anchor Repair of Recalcitrant Medial Epicondylitis

This study evaluated clinical and patient-reported outcomes and return to sport after surgical treatment of medial epicondylitis with suture anchor fixation. Consecutive patients were evaluated after undergoing debridement and suture anchor repair of the flexor-pronator mass for the treatment of medial epicondylitis. Demographic variables, a short version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, Oxford Elbow Score (OES), and 10-point pain and satisfaction scales were collected. Ability and time to return to sport after surgery were evaluated, and the relationship between predictor variables and both elbow function and return to sport was investigated. Median age at the time of surgery was 55 years (range, 29-65 years), with median follow-up of 40 months (range, 12-67 months). Median QuickDASH score and OES at final follow-up were 2.3 (range, 0-38.6) and 45 (range, 22-48), respectively. Most patients returned to premorbid sporting activities at a median of 4.5 months (range, 2.5-12 months), whereas 4 patients (14%) reported significant limitations at final follow-up. Older age at the time of surgery was predictive of better QuickDASH score and OES (P=.05 and P=.02, respectively). Patients who underwent surgery after a shorter duration of symptoms had better outcomes, but the difference did not reach statistical significance (QuickDASH, P=.09; OES, P=.10). Surgical treatment of recalcitrant medial epicondylitis with suture anchor fixation offers good pain relief and patient satisfaction, with little residual disability. Older age at the time of surgery predicts a better outcome.

Calcific Tendinitis of the Gluteus Maximus in a Golfer

Calcific tendinitis is a relatively rare condition in which calcium is inappropriately deposited in tendons, resulting in a local inflammatory reaction that can cause severe symptoms in certain cases. The cause of this disease process is not completely understood, although repetitive microtrauma likely plays a role in its development. Although the disorder most often involves the rotator cuff, it can affect other structures throughout the body, such as the tendons about the ankle and hip-including the rectus femoris and gluteus maximus. Nonoperative management typically involves using an anti-inflammatory medication and activity modification and can be augmented with formal physical therapy and modalities. Although nonoperative management provides adequate relief for many patients, sometimes operative debridement of the calcific deposit with or without repair of the involved tendon is required. The authors report an unusual case of calcific tendinitis of the gluteus maximus insertion in a golfer. The patient had tried nonoperative treatment for approximately 2 years with no real relief, and a recent exacerbation of the pain was significantly delaying his return to sport. Although plain radiographs did not show abnormalities, magnetic resonance imaging showed a calcific deposit in the insertion of the gluteus maximus tendon. After discussing further treatment options with the patient, the decision was made to remove the deposit and repair the insertion. He recovered completely and was able to return to play. The frequency, pathogenesis, and treatment of this condition are discussed in this case report, as well as the possible link to golf in this patient. [Orthopedics.2016; 39(5):e997-e1000.].

Extensor Tendon Impingement in a Gymnast

Wrist injuries in the gymnast are due to the transformation of the upper extremity into a weight bearing entity. Gymnast wrist pain presents a difficult diagnostic and therapeutic challenge. Here, we present a new case of extensor tendon impingement in an elite gymnast. To our knowledge, there is no similar report in the literature.

Chronic Finger Joint Instability Reconstructed With Bone–Ligament–Bone Graft from the Iliac Crest

Five patients with chronic instability of digital joints presented with instability and functional disability. Two patients had ulnar collateral ligament damage of the thumb metacarpophalangeal joint and another had chronic multidirectional instability due to radial collateral ligament, dorsal capsule and palmar plate laxity of the metacarpophalangeal joint of the thumb. The fourth patient had a lax radial collateral ligament and palmar plate of the proximal interphalangeal joint of the little finger and the fifth had chronic laxity of the ulnar collateral ligament of the interphalangeal joint of the thumb. All were reconstructed with bone–ligament–bone graft harvested from the iliac crest. The graft was fixed with screws and joint stability was achieved intra-operatively in all patients. All patients achieved a stable joint with improved functional performance at final followup.

[The Throwing Shoulder]

Repetitive top-performance of overhead athletes induces a tremendous stress for the throwing shoulder. Throwers reach rotational speed of their arm of more than 7000°/s with joint compression and distraction forces of more than 1000 N. This performance is tributary to adaption of the shoulder muscles and the joint itself. These adaptions may, however lead to two specific problems of the throwing shoulder: 1. The posterosuperior internal impingement of the rotator cuff and labrum between glenoid and humeral head during late cooking phase; 2. A decreased internal rotation of the glenohumeral joint (GIRD) with compensatory problems of the scapula-stabilizing muscles. Precise analysis of kinematics and pathomechanics aims to improve understanding and treatment of those specific problems of the throwing shoulder.

Correlation Between Femoral Neck Shaft Angle and Surgical Management in Trainees With Femoral Neck Stress Fractures

The most common overuse injury leading to medical discharge of military recruits is a stress fracture. One of the high-risk stress fractures is of the lateral femoral neck which risks osteonecrosis of the femoral head, the need for arthroplasty and permanent disability. To prevent fracture progression early surgical intervention is recommended. Surgical repairs are performed in about 25% of cases of femoral neck stress fractures at military treatment facilities. Hip geometry is an important intrinsic risk for stress fractures. Loads in the average loading direction will not cause a fracture, but loads of extreme magnitude or extreme orientation may. The purpose of this study was to determine if, in the presence of femoral neck stress fracture, there is a correlation between femoral neck shaft angle, surgical treatment and outcomes. The results of this study suggest there is no correlation between return to full military duty rates, treatment, femoral neck shaft angle or fracture grade on MRI. Patients who underwent surgical fixation had greater fracture grade and pain than those that did not have surgery. Individuals who did not return to duty tended to have higher pain scores at initial evaluation.

[Posterior ankle impingement syndrome]

Posterior ankle impingement syndrome (PAIS) is a clinical syndrome characterized by posterior ankle pain which occurs in maximal forced plantar flexion of the foot. PAIS can be the result of an acute injury of the ankle, which is more often in general population, or it can be the result of the overuse syndrome, which is more often in athletes and ballet dancers. The etiology of PAIS may involve bony structures or soft tissue structures, or, more often, the combination of both. The diagnosis of PAIS is based on patient's clinical history and physical examination with the hyperplantarflexion test as a very important part of it. Physical examination should be completed with imaging techniques, which most often include magnetic resonance imaging (MRI) or computed tomography (CT) to confirm the diagnosis of PAIS. Conservative treatment is recommended as the primary treatment strategy. In those cases where 3 to 6 months of conservative treatment fails, open or, more often, arthroscopic/endoscopic surgery may be recommended. Nowadays, a 2-portal endoscopic approach introduced by van Dijk et al. in 2000 is the method of choice for the treatment of posterior ankle impingement syndrome.

[Destruction of the Humeral Head in Sensory Deficit due to the Spinal Hemorhagia. Case Report]

Degenerative changes of the shoulder are a common complication in patients after spinal cord injury. The main cause is chronic overload to the shoulder joint due to manual wheelchair propulsion and transfers. Reduced shoulder function has a significant impact on all aspects of daily life. Shoulder arthroplasty in this group of patients is a challenging procedure because of the unique demand on the shoulder. This report presents the case of a wheelchair user who additionally experienced a complete loss of sensation around her shoulder. As a result of a repetitive strain during transfers from the wheelchair to the ground, the humeral head was destroyed.

Single portal endoscopic treatment for chronic exertional compartment syndrome of the forearm

Chronic exertional compartment syndrome of the forearm is an unusual disease not commonly found in the daily practice of a hand surgeon. This condition is quite rare in the general population but occurs more frequently among musicians and athletes, with the highest incidence found in professional motorcycle drivers. It is mainly because of a critical augmentation of the extracellular pressure of the forearm compartments. The diagnosis is mainly clinical, based on stress dynamic tests and intracompartmental pressure measurements. Traditionally, the treatment of this disease has revolved around trigger activity suspension. In the case of professional athletes, this solution cannot be considered and thus the standard surgical treatment consists of an open forearm fasciotomy. This procedure usually requires a lengthy operation period and has a long recovery time before patients can resume their regular activity. Different surgical endoscopic solutions with mini-open techniques have been proposed to shorten this time and reduce the incision size. The aim of this study was to present a new technique for endoscopic-assisted fasciotomy of the forearm in chronic exertional compartment syndrome using a single mini-incision. Four surgical procedures were performed in 3 patients. They were all treated at our center for this condition, and in one case the disease was found on both sides.

[Sports injuries and arthroscopy--from science to clinical treatment]

Since the first knee arthroscopy in 1912, it is routine to scope all joints and many extra-articular structures. The effect of arthroscopic procedures in overuse conditions is sparsely documented and should be investigated in randomized studies, but score systems to evaluate clinical effects are lacking. An increased understanding of tissue reaction to loading and ligament healing as well as neuromuscular control is likely to change the basic principles of treatment and prevention in relation to sports injuries.

[Eccentric exercises in the treatment of overuse injuries of the musculoskeletal system]

Overuse injuries of the musculoskeletal system are a common problem in both general population and among athletes. Researches made in the last decade have shown that overuse injuries are mainly caused by degenerative changes and not inflammation, as was thought before. Although they can be present everywhere in musculoskeletal system, overuse injuries are most often seen on tendons. The main goal of this article is to refer to latest guidelines in the treatment of overuse injuries, with special attention to eccentric exercise treatment program for most common tendinopathies (patellar tendinopathy, Achilles tendinopathy and lateral epicondylitis). The main reason is the fact that very good results are accomplished after eccentric exercises in the treatment of tendinopathies and are thus suggested as the first treatment option.

Paradoxical extension phenomenon of the little finger due to repetitive trauma to the palm

We report a case of paradoxical extension phenomenon of the little finger, so called "lumbrical plus deformity" due to repetitive trauma to the ulnar side of the palm. The adhesion between the flexor digitorum profundus tendon and the lumbrical muscle was the cause of this phenomenon. The lumbrical muscle release was sufficient to solve this rare problem.

Hypothenar hammer syndrome: distal ulnar artery reconstruction with autologous descending branch of the lateral circumflex femoral artery

Repetitive trauma to the hypothenar eminence can cause the ulnar artery to become aneurysmal, thrombose, or send emboli to the digital arteries. The symptoms and signs are also known as the hypothenar hammer syndrome. We postulate that an arterial autograft is a superior conduit to the traditional vein graft. In this article, we report 3 cases (2 in 1 patient) of reconstruction of the distal ulnar artery with the descending branch of the lateral circumflex femoral artery (LCFA). Two patients, ages 45 to 50 years, had severe ischemic complaints of the ulnar fingers. Arteriograms confirmed occlusion of the distal ulnar artery without direct perfusion of the superficial palmar arch. All reconstructions were carried out with the descending branch of the LCFA. From the ulnar artery at wrist level to the superficial palmar arch and the involved common digital arteries. Patency was certified during follow-up with color-coded Duplex sonography at 6 to 28 months. Preoperative complaints like cold intolerance and other ischemic symptoms disappeared.

Elbow arthroscopy: valgus extension overload

Valgus torque combined with deceleration produces high compression and shear forces acting on the posteromedial olecranon and the posteromedial trochlea. This valgus extension overload process may cause posteromedial trochlea chondromalacia, chondral flap formation, osteochondrosis, subchondral erosion, a subchondral insufficiency fracture, and marginal exostosis formation. Olecranon pathologies include proximal stress reaction, a posteromedial tip stress fracture, a transverse proximal process stress fracture, exostosis formation, exostosis fragmentation, and intra-articular loose bodies. Symptoms include posteromedial elbow pain during the deceleration phase of the throwing motion. The extension impingement test reproduces posterior or posteromedial pain similar to that experienced while throwing. Special radiographic techniques and CT scans can show loose bodies and osteophyte fragmentation. Surgical treatment is indicated when symptoms persist despite nonsurgical management. Based on clinical and basic science research, all patients with valgus extension overload should be comprehensively evaluated for medial ulnar collateral ligament insufficiency. Surgical treatment is limited to the resection of osteophytes only; normal olecranon should not be resected.

Patellar tendinopathy: histopathological examination and follow-up of surgical treatment

PURPOSE OF THE STUDY

The aim of this study was to determine the exact localization of the histopathological process (bone, bone-tendon junction or tendon), and to determine whether the underlying pathologic process is predominantly of inflammatory or degenerative nature, then to evaluate the outcome of the surgical treatment of patellar tendinopathy.

MATERIALS

A prospective cohort study was performed in order to analyze the outcome of surgical treatment of patellar tendinopathy, as well as to document histopathological changes in bone, bone-tendon junction, and in the patellar ligament in 34 professional athletes treated with patellar apicotomy. All the patients included in the study were classified as stage 3 according to Blazina and showed no improvement after at least 6 months of conservative treatment. The postoperative follow-up was from 1 to 8 years with a mean value of 4.7 years.

METHODS

The postoperative results were analyzed using a semiquantitative scoring system where the functional outcome was classified as very good if the athlete returned to his sporting activity without any negative side effects, good if the athlete resumed his sporting activities with modest painful sensations present only at the maximum level of physical exertion, and poor if any reduction of athletic activity was present. In twenty patients a histopathological examination of resected bone and tendon tissue was performed. The specimens were stained with hematoxylin-eosin and examined under a light microscope using polarization. Special stains used were Alcian blue, to detect any increase in ground substance, and Prussian blue which enhances conspicuity of hyaline degeneration and enables detection of hemosiderin. Immunohistochemistry was performed in order to analyze presence of blood vessels, leukocytes and histiocytes.

RESULTS

Very good results were achieved in 20 of operated knees, good results were achieved in 12 of knees and poor results were achieved in 2 of operated knees. Pathological changes in the bone were found in 35% of analyzed specimens, abnormality at the bone-tendon junction were found in 75% of the specimens, and changes in the patellar tendon were found in all extracted specimens. The histopatholological nature of the lesions found within the tendon tissue in all of the analyzed specimens belongs to the group of degenerative changes.

DISCUSSION

Currently a consenus has been established that the expression tendinitis is "out", and the term tendinopathy should be used instead. No inflammatory cells and no increase in prostaglandins can be detected in the tendons. Histopathological studies of the tissue fibrils affected by tendinosis characteristically demonstrate hypercellularity, hypervascularity, lack of inflammatory infiltrates, and disorganization and loosening of collagen fibers.

CONCLUSION

The clinical results and histopathological examination in our series justified our operative method. In the chronic stage these lesions are irreversible and constitute permanent intratendinous lesions. It thus seems logical to excise these lesions from their origin at the apex of the patella and entry into the adjacent tendon. It is also recommended on the basis of our and other authors' research that the term patellar tendinopathy should be used instead of tendonitis/tendinitis.

Elbow medial ulnar collateral ligament reconstruction: clinical relevance and the docking technique

INTRODUCTION

Elbow ulnar collateral ligament (UCL) reconstruction has become the standard of care for the throwing athlete with a symptomatic ruptured or insufficient ligament and the desire to resume competitive play. Since Jobe's initial description of UCL reconstruction, the technique has evolved. A novel modification was the "docking" technique developed by Altchek. Subsequently, the docking technique as originally described was slightly modified. Arthroscopy is no longer routinely performed, and in some cases, a 3-strand graft is used.

MATERIALS AND METHODS

We treated 21 overhand athletes with clinical and radiographic evidence of UCL insufficiency with ligament reconstruction using a modified version of the docking technique using a 3-strand graft. There were 5 professional, 11 college, and 5 high school baseball players in the reconstructed group. Athletes were evaluated postoperatively by use of the Conway Scale.

RESULTS

Of the 21 patients who underwent the modified docking technique with a three-strand graft, 19 (90%) had excellent results. There were 2 good results and no complications.

DISCUSSION

UCL reconstruction can successfully treat athletes with UCL insufficiency. Several different reconstruction techniques have been described. By use of the docking and modified docking techniques, good to excellent results can be achieved in the majority of cases with a low complication rate.

Freiberg's disease as a rare cause of limited and painful relevé in dancers

Freiberg's disease, or osteonecrosis of the second metatarsal head, is an uncommon cause of forefoot pain that can severely limit a dancer's relevé. Dancers may be predisposed to the condition due to repetitive microtrauma to the ball of the foot during routine dance movements. Freiberg's disease is diagnosed by history, physical examination, and plain film radiographs. Conservative treatment in dancers is disappointing, and surgical options fail to produce uniformly good results. Previously published reports of successful surgical outcomes would, for a dancer, result in an unacceptable loss of dorsiflexion of the MTP joint. This first case report of Freiberg's disease in a dancer serves to discuss the orthopaedic and artistic implications of managing the disease in a young, active, adolescent dancer. A new surgical treatment involving modification of Mann's cheilectomy, normally used for hallux rigidus, is presented. The operation corrected the patient's pain, completely normalized the aberrant relevé, allowed her to resume dance training within three weeks, and return to full dance activity within three months.

[Acute diseases and trauma of thorax and abdomen in patients with hemocontact viral infections]

Screening of hemocontact viral infections (HVI) (HIV, hepatitis B and C) was conducted among patients of the emergency thoraco-abdominal surgery unit. During the 8 years of the study the HVI detection had increased on 57.4%. Gender analysis showed greater HVI prevalence among men. Medico-social criteria of HVI risk-groups among patients of the emergency thoraco-abdominal surgery unit were stated.

New approaches to diagnosis and arthroscopic management of partial-thickness cuff tears

Partial-thickness cuff tears (PTCTs) are increasingly recognized as a source of pain and athletic impairment, especially in overhead athletes. 1,2 Improvements in diagnostic imaging have enhanced the ability to detect and quantify partial cuff disease, and arthroscopic advances have led to novel techniques by which partial cuff tears can be repaired. 2-6 Despite increasing recognition and improved understanding of this condition, the natural history, clinical evaluation, and management of partial tears remain elusive. This is because of the disparity between the extent of partial cuff tearing and the wide variability in clinical impairment and the frequent overlay of concomitant labral and subacromial pathology. When should operating on an athlete with a partial cuff tear be considered? What percentage of cuff tear justifies repair rather than debridement? Does this threshold vary according to the athlete or sport? And if the partial tear is repaired, what can be expected in terms of return to activity, particularly in a high-level thrower? The purpose of this manuscript is to provide an overview of partial cuff tears and their evaluation and management.

Workstyle as a predictor of pain and restricted work associated with upper extremity disorders: a prospective study

PURPOSE

A patient's reaction to a perceived increase in work demand may be related to his or her upper limb symptoms. The purpose of this study was to determine whether a brief measure of a patient's perception of how they respond to perceived increases in demands at work predicts pain levels and work status 6 months after an initial consultation with a hand surgeon.

METHODS

Working patients with diverse upper extremity diagnoses completed a measure of response to job stress at their first clinic visit and were followed for 6 months during their prescribed treatment course. Controlling for age, gender, job type, diagnosis, patient perceptions of work-relatedness, baseline pain, grip strength, and treatment (surgery vs no surgery) analyses were conducted to determine whether self-reported response to perceived job stress was associated with pain and work status 6 months after the initial consultation.

RESULTS

Higher scores on the patient-reported job stress measure predicted higher levels of pain at 6 months. The measure was also a modest but significant predictor of work status at 6 months.

CONCLUSIONS

Evaluation of a working patient's self-reported cognitive and behavioral response to perceived increases in work demands, or what has been referred to as workstyle, predicts subsequent levels of upper extremity pain and work status. Generalization to other practice settings requires further study. This measure provides a brief evaluation of reaction to job stress that can be an important factor in certain patients with upper extremity symptoms. Future controlled studies addressing this aspect of the clinical picture are indicated.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Are "knife and fork" good enough for day case surgery of resistant tennis elbow?

This observational retrospective study was performed on 22 consecutive patients treated surgically in a day surgery unit for resistant tennis elbow to ascertain the effectiveness of the "knife and fork" procedure. All patients had an unfavourable response to nonsurgical treatment lasting at least six months. A simple and inexpensive "knife and fork" technique yielded excellent results in 90.5% of patients and a high percentage (95.2%) of satisfied patients at an average follow-up of two years. There were no fair or poor results and no complications. We conclude that the "knife and fork" technique is a simple and dependable day case procedure. In the present National Health Service (NHS) era of tariff and "payment by results", this approach is more cost effective than an arthroscopic alternative.

[Ulnar neuropathy in a poultry worker]

Three months after he was employed as a poultry worker, a 48-year-old man developed involuntary jerks of his right first, fourth, and fifth fingers, paraesthesiae, weakness, and eventually wasting of the first dorsal interosseous muscle. His job entailed repetitive lifting of boxes weighing 10-25 kg with flexion of the elbow, pronation of the forearm, and ulnar deviation of the wrist. A nerve conduction study indicated ulnar neuropathy just distal to the elbow. Surgery at this level alleviated the symptoms, but shortly after his return to work, he changed jobs because of aggravation.

Use of pubic symphysis curettage for treatment-resistant osteitis pubis in athletes

BACKGROUND

In athletes, osteitis pubis is regarded as a problem of overuse, with instability and movement of the anterior pelvis. There is no evidence to conclusively support any treatment modality. Recovery with nonoperative management can take an extended period of time, often unsatisfactory for professional athletes.

HYPOTHESIS

Curettage of the pubic symphysis is a viable option for nonoperative treatment of resistant osteitis pubis in athletes.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This retrospective study presents the results of curettage of the pubic symphysis in 23 athletes with osteitis pubis that was refractory to initial nonoperative therapies. Patients met the criteria for the study if they had symptoms suggestive of osteitis pubis and underwent isolated pubic symphysis curettage. The discomfort had been present for a mean of 13.22 months before presentation. Patients were reviewed at 24.31 months (range, 12.5-59.6 months) postoperatively. Twelve of the patients also underwent a postoperative magnetic resonance imaging scan at 19.10 months; any findings of residual osteitis pubis were noted.

RESULTS

Mean visual analog scale for pain improved from 6.9 preoperatively to 2.8 postoperatively (P = .36). Twenty-one patients returned to pain-free running by 3.14 months (range, 1.5-6 months), 17 to training by 4.44 months (range, 2.5-7 months), and 16 to full activity by 5.63 months (range, 2.5-12 months). Overall, 61% of patients reported an activity grade of 4 at postoperative review, defined as no pain with full activity. There were no significant postoperative complications in the study group. Marrow edema improved in most cases for which magnetic resonance imaging was available preoperatively and postoperatively. Patient satisfaction with the procedure was high, with 78% of participants feeling their symptoms were better or much better than preoperatively.

CONCLUSION

The authors suggest that this relatively simple procedure can be of significant benefit to those athletes wishing to return to their previous levels of physical activity when more nonoperative measures have proven unsuccessful.

Exertional leg pain: teasing out arterial entrapments

Vascular causes of exertional lower extremity pain are relatively rare, but may be the answer in athletes refractory to treatment for the more common overuse syndromes of the lower extremities. It is important to differentiate these vascular causes from chronic exertional compartment syndrome (CECS), medial tibial stress syndrome (MTSS), and stress fractures in order to develop appropriate treatment plans, avoid complications, and return athletes to play expeditiously. Important vascular etiologies to be considered are popliteal artery entrapment syndrome (PAES), endofibrotic disease, popliteal artery aneurysm, cystic adventitial disease, and peripheral arterial dissections. The diagnostic workup involves angiography or noninvasive vascular studies such as Doppler ultrasound or magnetic resonance angiography in both the neutral and provocative positions. Treatment of these vascular abnormalities typically involves surgical correction of the vascular anomaly.

Superior Bennett lesion: a bone fragment at the posterosuperior glenoid rim in 5 athletes

In throwing athletes, a Bennett lesion is a bony spur that usually forms at the posteroinferior glenoid rim and sometimes becomes painful. We encountered superior Bennett lesions in the shoulders of 5 athletes, which were detected at the posterosuperior glenoid rim as a separate bone fragment. In all 5 athletes this lesion appeared to be the main cause of shoulder pain during throwing or overhead activity. The lesions were easily visualized on plain radiographs (axial view, scapular Y view, and 45 degrees craniocaudal view) or computed tomography scans. Tenderness was detected over the posterior aspect of the glenohumeral joint, the pain provocation test specific for SLAP lesions was positive, and posterior shoulder pain was elicited by forced external rotation at 90 degrees of abduction in all 5 cases. The pain was diminished or decreased by injection of local anesthetic around the lesion. At arthroscopy, detachment of the posterosuperior labrum and posterior capsular tightness were detected in all 5 cases. Through the detached portion of the posterosuperior labrum, we could easily reach an unstable mobile bone fragment, which was resected arthroscopically. Although the pathologic mechanism is unclear, the mobility of the bone fragment appeared to be related to the occurrence of symptoms.

A unique case of ulnar tunnel syndrome in a bicyclist requiring operative release

The continued growth of recreational and competitive sports is accompanied by the need for health care providers to recognize and treat conditions in athletes that have been traditionally associated with other occupational injury. This is particularly important when early diagnosis and prompt intervention for prevention and treatment may alter the outcome. We present an interesting case of ulnar tunnel syndrome in a high-performance bicyclist with compressive ulnar neuropathy refractory to nonoperative management but successfully treated with surgical release. We review evaluation, diagnosis, and historical and current treatment algorithms.

Radial artery aneurysm resulting from repetitive occupational injury: Tailor's thumb

INTRODUCTION

True radial artery aneurysms are very rare and a cause is rarely identified.

CASE REPORT

An unusual case of a true radial artery aneurysm in a tailor of fifty years; presenting with a growing, tender lump at the base of his thumb.

DISCUSSION

Radial artery aneurysms are classically pseudoaneurysms from iatrogenic traumatic injury - arterial cannulation. This is the first case in the literature to demonstrate a true aneurysm secondary to repetitive occupational injury.

Surgical treatment of iliotibial band friction syndrome with the mesh technique

Iliotibial band friction syndrome is an overuse injury caused by repetitive friction of the iliotibial band across the lateral femoral epicondyle. It has been reported to afflict long-distance runners, cyclists and military personnel. Initial treatments include rest, anti-inflammatory medication, modalities (ice or heat), stretching, physical therapy, and possibly a corticosteroid injection. If the conservative treatment is unsuccessful, surgery has been advocated. This report describes a new surgical technique to release the pressure on the lateral femoral epicondyle in a patient who failed the nonoperative efforts. The surgery was performed with the knee held in 30 degrees of flexion and consisted of multiple 2 mm long incisions across the fiber of the iliotibial band covering the lateral femoral epicondyle. There were six incisions, each of which was 4 mm apart. The incisions were spontaneously enlarged and changed to several punctured wounds (mesh appearance) by the tension of iliotibial band, resulted in relaxing the tight iliotibial band over the lateral femoral epicondyle. At the final follow-up 2 years after surgery the patient was pain free and could resume his previous occupational activities. The surgical result of the present technique is encouraging.

Outcome of modified open surgery in tennis elbow

BACKGROUND

Tennis elbow is a common disorder of upper extremity. It can be treated conservatively in majority of the patients but some resistant cases eventually need surgery.

MATERIAL & METHODS

This descriptive study was conducted at Department of Orthopaedics, Ayub Teaching Hospital, Abbottabad, from January 2002 to June 2006. Sixteen patients had surgical release of the extensor tendon origin along with excision of the lateral epicondyle ridge. These patients did not respond to conservative treatment i.e. rest, non- steroidal anti inflammatory drugs (NSAIDS), local steroid injections and physiotherapy. Patients were followed upto six months. Outcome was graded as excellent, good and poor according to pain relief and function of the hand.

RESULTS

Sixteen patients (17 elbows) were studied. Thirteen were female (81.25%) and three were male (18.75%). Fifteen patients (93.75%) had unilateral Tennis Elbow, while one had bilateral involvement (6.25%). In unilateral disease, right side was affected in eleven patients (68.75%) and left side in four (25%). Excellent outcome was noticed in eleven patients (68.75%) and good result in five patient (31.25%).

CONCLUSION

Open surgical technique of releasing extensor tendon origin along with excision of lateral condylar ridge of the humerus is new and simple procedure and yields excellent and good result in patients with resistant Tennis Elbow.

Arthroscopic patellar release for the treatment of chronic patellar tendinopathy

We describe an arthroscopic technique for the treatment of chronic patellar tendinopathy (jumper's knee). Preoperatively, tendon necrosis or rupture is excluded by sonography. Diagnostic arthroscopy is performed and hypertrophic synovitis around the inferior patellar pole is removed with a bipolar cautery system. Two outside-in cannulas mark the clinically symptomatic region, mainly found between the tendon insertion site and the lateral aspects of the patellar tendon. The bipolar cautery is used for a release of the paratenon and a bone denervation at the inferior patellar pole including the tendon insertion site within the marked area. No tendon or bone material is removed or excised throughout the procedure. We treated 15 athletes with stage 3 and 4 chronic patellar tendinopathies on a modified version of the Blazina score (0-5). Patients' mean age was 29 years and the mean follow-up period was 41 months. In 13 cases, clinical symptoms subsided completely within 3 months after surgery. The mean preoperative Blazina score was 3.7 (SD, 0.5) and the mean postoperative Blazina score was 0.4 (SD, 1.0; paired 2-tailed t test, P < .01). Ultrasound showed a reduction of tendon edema within 3 weeks and no signs of edema within a mean period of 5 weeks after surgery. The minimal surgical impact to the tendon allows early and functional rehabilitation. The technique is effective, easy to perform, and safe to apply.

Patient selection

Patient selection is the process by which an evaluating surgeon decides whether to accept responsibility for the care and treatment of a potential patient. It is assumed the physician has the requisite knowledge to assess the anatomic disorder and the technical ability to render appropriate care if needed. The aim of this article is to help the less experienced health care professional sort out which patients, either by true psychological disorder or personality and behavioral traits, pose the highest risk of a poor outcome. An unsatisfactory outcome can be measured not only by failure to resolve the disorder but also by expenditure of a disproportionate amount of practice resources in achieving resolution of the problem.

Unstable isolated SLAP lesion: clinical presentation and outcome of arthroscopic fixation

PURPOSE

The purpose of this study was to describe the clinical presentation and sensitivity of testing of unstable isolated SLAP (superior labrum anterior posterior) lesions and to evaluate the efficacy of arthroscopic treatment.

TYPE OF STUDY

Case series.

METHODS

A retrospective review was made of 44 unstable SLAP lesions in 41 patients (40 male, 1 female) who did not have other pathologic shoulder findings. The mean follow-up period was 33 months (range, 25 to 67 months) and the mean age at the time of surgery was 24 years (range, 17 to 43 years). Twenty-six patients had an injury on the dominant shoulder and 3 had bilateral shoulder involvement. Arthroscopic fixation was performed with the use of a biodegradable tack (Suretac; Acufex, Mansfield, MA) in 14 cases, and with a screw-type metallic suture anchor (mini-Revo; Linvatec, Largo, FL) in 30 cases.

RESULTS

Pain (100%) and clicking (57%) were the most common symptoms. The compression-rotation test was positive in 84% of the patients before surgery. The average UCLA score at the last follow-up was 32.3 points; 22 cases were graded excellent, 16 good, and 6 poor. Based on the postoperative performance data collected from 33 athletes, 25 of them (76%) were able to return to their athletic activities. Among them, throwing athletes showed statistically better performance than did nonthrowing athletes (P = .011).

CONCLUSIONS

Pain, followed by clicking, was the most common symptom, and the most common sign was a positive compression rotation test. Arthroscopic treatment of unstable isolated SLAP lesions resulted in good or excellent UCLA scores in 86% of the patients. Throwing athletes showed more satisfactory results than nonthrowing athletes.

LEVEL OF EVIDENCE

Type IV, case series with no, or historical, control group.

Chronic compartment syndrome, an important cause of work-related upper limb disorder

OBJECTIVES

Work-related upper limb disorders (WRULD) are common and disabling complaints in industry, but a tissue diagnosis can be difficult where the pain is diffuse and variable, and this prevents effective treatment. Diffuse arm pain is frequently found in those doing rapid or strenuous repetitive work, such as factory assembly workers or keyboard operators. Similar symptoms occur in the legs in athletes, where chronic compartment syndrome (CCS) is a recognized entity, so we investigated the possibility that this might also be caused by prolonged repetitive work.

METHODS

Patients were selected if they were unable to continue with work because of chronic forearm pain. They were divided into three groups: 42 patients with symptoms consistent with CCS as defined in the text, 15 volunteers and patients with other arm complaints, and 10 asymptomatic arms of patients with unilateral CCS. We measured the pressure inside the extensor muscle compartment of the forearm at rest and after a 2 min repetitive gripping exercise using an electronic pressure-sensitive probe.

RESULTS

The results show that CCS is a common and disabling forearm complaint associated with prolonged repetitive work. Fifteen patients have now had decompressive surgery on the extensor muscle compartment with good relief of symptoms.

CONCLUSION

CCS is responsible for chronic peripheral neurological dysfunction in addition to muscle pain, and awareness of this diagnosis allows early identification and treatment of a currently unrecognized disorder with potential resolution of a long-lasting arm disability.

Treatment of glenohumeral subluxation using electrothermal capsulorrhaphy

PURPOSE

The purpose of this study was to review the results of a relatively homogenous group of patients with glenohumeral subluxation without labral pathology who were treated with an electrothermal capsulorrhaphy procedure.

TYPE OF STUDY

Case series without controls.

METHODS

From 1997 to 1998, 42 patients underwent electrothermal capsulorrhaphy using a monopolar radiofrequency probe (Oratec Interventions, Menlo Park, CA). Patients with prior capsular repairs, labral pathology that required repair, or capsular avulsion injuries were excluded from the study. Thirty-one patients met the inclusion criteria. Patients had a minimum of 2 years of follow-up (mean, 25 months), and a mean age of 25 years (range, 16 to 38 years). All of the patients had previously failed conservative treatment. There were 25 patients with unidirectional anterior instability, 2 patients with unidirectional inferior instability, 1 patient with unidirectional posterior instability, and 3 patients with multidirectional instability. The patients were assessed using a modified American Shoulder and Elbow Surgeons (ASES) score that examined pain (30 points), function (60 points), and patient satisfaction (10 points). In addition, subjective stability was assessed using a 10-point scale.

RESULTS

The average modified ASES score increased to 88 points from 56 preoperatively (P < .01). The average subjective stability scale increased to 8.5 from 4.4 preoperatively (P < .01). Nineteen patients (61%) had an excellent result, 4 (13%) had a good result, 5 (16%) had a fair result, and 3 (10%) had a poor result; 22 of 26 patients who participated in sports were able to return to their preinjury level of play. The subset of patients with isolated anterior instability had results similar to the overall group. There were no instances of axillary neuritis or other neurologic injury.

CONCLUSIONS

In carefully selected patients with shoulder instability, including unidirectional anterior instability without associated labral pathology, electrothermal capsulorrhaphy was effective and had few complications.

LEVEL OF EVIDENCE

Level IV, case series without controls.

Paratendinopathy

Because most Achilles tendon injuries take place in sports and there has been a general increase in the popularity of sporting activities, the number and incidence of Achilles tendon overuse injuries have increased in the industrialized countries during the last few decades. The term "Achilles paratendinopathy" is used in clinical practice to describe activity-related Achilles pain combined with tenderness on palpation, providing that there is no suspicion of intratendinous pathology on the basis of patient history, clinical examination, or imaging examinations. This article discusses Achilles paratendinopathy.

[Epiphysiolysis capitis femoris caused by a repeat minor trauma]

We discuss the case of a 14-year-old boy who, after two episodes of mild recurrent sports trauma, presented with restricted mobility of the right hip due to substantial pain. Radiography revealed an acute slipped capital femoral epiphysis affecting the right femoral head. We report on the successful emergency osteosynthesis, and follow-up. On the basis of the current literature, we also discuss the clinical course of this lesion.

Sports activity after arthroscopic superior labral repair using suture anchors in overhead-throwing athletes

PURPOSE

To evaluate the results of arthroscopic repair of type II superior labral anterior posterior lesions of the shoulder in overhead athletes.

HYPOTHESIS

Such repair is useful for overhead athletes in terms of postoperative sports activity.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The study group was composed of 40 patients with a mean age of 24 years (range, 15-38 years); mean follow-up was 41 months (range, 24-58 months). They were divided into an overuse (n=22) and a trauma group (n=18). The authors used 2 suture anchors loaded with a nonabsorbable suture at the 11-o'clock and 1-o'clock positions through the anterosuperior and lateral trans-rotator cuff portal. A modified Rowe score and postoperative athletic activities were evaluated.

RESULTS

After arthroscopic repair, mean modified Rowe scores improved from 27.5 to 92.1 points (P<.0001). Rated on this scale, the results were excellent in 30 (75%), good in 6 (15%), and fair in 4 (10%) athletes; there were no poor results. Satisfactory outcomes were achieved in 36 (90%) of these patients; 30 (75%) experienced a return to the preinjury level. The complete return rate of baseball players in the overuse group was lower than that of other overhead athletes in the trauma group.

CONCLUSION

Arthroscopic superior labral repair is a safe and reliable procedure in overhead athletes.

Femoroacetabul�res Impingement

The exact cause of the idiopathic osteoarthritis of the hip has not been identified, although the cause of hip degeneration in developmental dysplasia can clearly be attributed to an excessive axial loading. Based on the development of a surgical technique for the safe surgical dislocation of the hip and the associated possibility of intraoperative joint evaluation, we have found motion-induced joint damage in many of these hips. This begins peripherally at the acetabular rim, progressing centrally. This so-called "femoroacetabular impingement" (FAI), leads, by an increased acetabular coverage and/or a missing sphericity of the femoral head, to an abutment of the femoral head/neck junction against the acetabular rim, or even entering of the non-spherical femoral head into the hip. It initiates damage to the labrum and/or acetabular cartilage. Frequently, this becomes symptomatic in the second or third decade of life in patients with increased sport activity. Based on the predominance of the acetabular or femoral pathology, two different types of FAI, the pincer and the cam can be differentiated. Apart from these morphological alterations, supraphysiological mobility and overuse can contribute to FAI. The impingement concept has led to a new type of mainly intracapsular hip surgery.

Hypothenar hammer syndrome: Distal ulnar artery reconstruction with autologous inferior epigastric artery

Digital artery embolization and ulnar artery thrombosis are consequences of repetitive trauma and can lead to digit loss and debility from ischemia and cold intolerance. We postulate that an arterial autograft is a theoretically superior conduit to traditional saphenous vein, and report reconstruction with inferior epigastric artery. Three adult male smokers, ages 39 to 49 years, had severe digital ischemia and cold-induced vasospasm. Arteriograms confirmed occlusion of the distal ulnar artery without direct perfusion of the superficial palmar arch, distal digital artery embolization, and normal proximal vasculature. All reconstructions were performed from the distal most patent ulnar artery at the wrist to the superficial palmar arch (1 patient) or sequentially to the involved common digital arteries (2 patients), with inferior epigastric artery. Handling characteristics and size match between the arterial autografts and bypassed arteries was excellent. Patency has been confirmed with duplex scanning at follow-up of 8 to 24 months, with resolution of cold intolerance and successful digital preservation.