JAAOS

JAAOS, Volume 15, No. 6


Acute proximal hamstring rupture.

Hamstring strain is common in athletes, and both diagnosis and surgical treatment of this injury are becoming more common. Nonsurgical treatment of complete ruptures has resulted in complications such as muscle weakness and sciatic neuralgia. Surgical treatment recently has been advocated to repair the complete rupture of the hamstring tendons from the ischial tuberosity. Surgical repair involves a transverse incision in the gluteal crease, protection of the sciatic nerve, mobilization of the ruptured tendons, and repair to the ischial tuberosity with the use of suture anchors. Reports in the literature of surgical treatment of proximal hamstring rupture are few, and most series have had a relatively small number of patients. Surgical repair results project 58% to 85% rate of return to function and sports activity, near normal strength, and decreased pain.

    • Keywords:
    • Adult|Algorithms|Braces|Humans|Magnetic Resonance Imaging|Middle Aged|Muscle

    • Skeletal|Physical Examination|Rupture|Thigh

    • Subspecialty:
    • Trauma

    • Sports Medicine

    • Pain Management

Ankle syndesmotic injury.

Ankle syndesmotic injury does not necessarily lead to ankle instability; however, the coexistence of deltoid ligament injury critically destabilizes the ankle joint. Syndesmotic injury may occur in isolation or may be associated with ankle fracture. In the absence of fracture, physical examination findings suggestive of injury include ankle tenderness over the anterior aspect of the syndesmosis and a positive squeeze or external rotation test. Radiographic findings usually include increased tibiofibular clear space decreased tibiofibular overlap, and increased medial clear space. However, syndesmotic injury may not be apparent radiographically; thus, routine stress testing is necessary for detecting syndesmotic instability. The goals of management are to restore and maintain the normal tibiofibular relationship to allow for healing of the ligamentous structures of the syndesmosis. Fixation of the syndesmosis is indicated when evidence of a diastasis is present. This may be detected preoperatively, in the absence of fracture, or intraoperatively, after rigid fixation of the medial malleolus and fibula fractures. Failure to diagnose and stabilize syndesmotic disruption adversely affects outcome.

    • Keywords:
    • Ankle Injuries|Bone Screws|Fracture Fixation

    • Internal|Fractures

    • Bone|Humans|Joint Instability|Ligaments

    • Articular|Postoperative Care|Soft Tissue Injuries

    • Subspecialty:
    • Trauma

    • Foot and Ankle

Lower extremity injuries in the skeletally immature athlete.

The heightened intensity of training and competition among young athletes places them at increased risk for both acute and chronic injuries. Prompt recognition and treatment of such injuries are critical to prevent long-term functional disability and deformity. These injuries occur in patterns unique to the skeletally immature athlete, given their developing epiphyses and ossification centers and supporting ligamentous structures. Children and adolescents who participate in recreational and organized sports are particularly susceptible to a broad spectrum of lower extremity injuries involving both the osseous and soft-tissue structures. Fundamental knowledge of the pathophysiology of injury helps the clinician in determining management. Early recognition of acute traumatic injuries, along with preventive regimens and knowledge of both nonsurgical and surgical treatment protocols, has helped to restore and maintain normal lower extremity function in the skeletally immature athlete.

    • Keywords:
    • Adolescent|Athletic Injuries|Bone Diseases|Child|Cumulative Trauma Disorders|Humans|Leg Injuries|Magnetic Resonance Imaging|Muscle

    • Skeletal|Osteochondritis|Patellar Dislocation|Patellofemoral Pain Syndrome|Tibial Fractures

    • Subspecialty:
    • Trauma

    • Foot and Ankle

    • Sports Medicine

    • Pediatric Orthopaedics

Minimally invasive lumbar spinal fusion.

Minimally invasive techniques for lumbar spine fusion have been developed in an attempt to decrease the complications related to traditional open exposures (eg, infection, wound healing problems). Anterior minimally invasive procedures include laparoscopic and mini-open anterior lumbar interbody fusion as well as the lateral transpsoas and percutaneous presacral approaches. Posterior techniques typically use a tubular retractor system that avoids the muscle stripping associated with open procedures. These techniques can be applied to both posterior and transforaminal lumbar interbody fusion procedures. Many initial reports have shown similar clinical results in terms of spinal fusion rates for both traditional open and minimally invasive posterior approaches. However, the anterior minimally invasive procedures are often associated with significantly greater incidence of complications and technical difficulty than their associated open approaches. There is a steep learning curve associated with minimally invasive techniques, and surgeons should not expect to master them in the first several cases.

    • Keywords:
    • Adult|Clinical Competence|Diskectomy|Female|Humans|Intervertebral Disk Displacement|Laparoscopy|Patient Selection|Punctures|Spinal Fusion

    • Subspecialty:
    • Spine

Open hindfoot injuries.

Successful management of open talar and calcaneal injuries of the hindfoot is a formidable orthopaedic challenge. The soft-tissue disruption associated with these high-energy traumatic injuries adds to treatment complexity. Extensive fracture comminution and cartilage damage are often present with calcaneal fracture. Osteonecrosis is commonly associated with talar injury. Treatment may be divided into acute and reconstructive phases. Successful outcome is dependent on several variables--accurate fracture reduction, timing of intervention, prevention of infection, and meticulous soft-tissue handling. Anatomic fracture or joint reconstruction may not be possible. Joint stiffness and posttraumatic arthritis are common and may be debilitating. Complications, such as infection and osteonecrosis, also can be devastating. Long-term outcomes are frequently unsatisfactory. Chronic ambulatory dysfunction and persistent neurogenic pain may result despite appropriate management. With severe complex open fractures and extended soft-tissue injury, limb amputation may be the best treatment option.

    • Keywords:
    • Ankle Injuries|Calcaneus|Debridement|Foot Injuries|Fracture Fixation

    • Internal|Fractures

    • Bone|Humans|Irrigation|Orthopedic Procedures|Soft Tissue Injuries|Talus|Treatment Outcome

    • Subspecialty:
    • Trauma

    • Foot and Ankle

Rotator cuff tear arthropathy.

Rotator cuff tear arthropathy represents a spectrum of shoulder pathology characterized by rotator cuff insufficiency, diminished acromiohumeral distance with impingement syndromes, and arthritic changes of the glenohumeral joint. Additional features may include subdeltoid effusion, humeral head erosion, and acetabularization of the acromion. Although the progression of rotator cuff tears seems to play a role in the development of cuff tear arthropathy, information is lacking regarding the natural progression of rotator cuff tears to cuff tear arthropathy. Controversy remains about the role of basic calcium phosphate crystals in the development of cuff tear arthropathy. Nonsurgical management is the first line of treatment in most patients. Traditionally, surgical management of rotator cuff tear arthropathy has been disappointing because of the development of complications long-term and poor patient satisfaction with functional outcomes. Recent studies, however, report promising experience with reverse ball-and-socket arthroplasty.

    • Keywords:
    • Acromion|Arthroplasty|Biomechanics|Disease Progression|Humans|Joint Diseases|Joint Prosthesis|Muscular Atrophy|Prosthesis Design|Rotator Cuff|Rupture|Shoulder Joint

    • Subspecialty:
    • Shoulder and Elbow

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