JAAOS, Volume 21, No. 2

Anterior Cruciate Ligament Injuries in the Skeletally Immature Athlete: Diagnosis and Management

Intrasubstance anterior cruciate ligament (ACL) injuries in children and adolescents were once considered rare occurrences, with tibial eminence avulsion fractures generally regarded as the pediatric ACL injury equivalent. However, with increased single-sport focus, less free play, and year-round training at younger ages, intrasubstance ACL injuries in children and adolescents are being diagnosed with increased frequency. As in the adult, a knee devoid of ligamentous stability predisposes the pediatric patient to meniscal and chondral injuries and early degenerative changes. Management of ACL injuries in skeletally immature patients includes physeal-sparing, partial transphyseal, and complete transphyseal ACL reconstruction. Complications include iatrogenic growth disturbance resulting from physeal violation.

      • Subspecialty:
      • Pediatric Orthopaedics

    Fracture-dislocations of the Proximal Interphalangeal Joint

    Fracture-dislocations of the proximal interphalangeal joint encompass a spectrum of injury severity, ranging from injuries that require little intervention to those that require advanced reconstructive surgery for optimal outcome. Three fracture-dislocation patterns are recognized: dorsal, volar, and pilon. Acceptable outcome is dependent on achieving and maintaining a well-aligned and well-reduced joint, re-establishing normal joint kinematics, and restoring motion. Anatomic articular surface reduction is desirable but not absolutely necessary for a good outcome. Treatment depends on both the type of injury and patient-dependent factors. Optimal outcome for a specific injury is predicated on expedient diagnosis and recognition of injury severity, which enables initiation of appropriate management.

        • Subspecialty:
        • Hand and Wrist

      Giant Cell Tumor of Bone

      Giant cell tumor (GCT) of bone is one type of giant cell-rich lesion of bone. This benign mesenchymal tumor has characteristic multinuclear giant cells. Mononuclear stromal cells are the physiologically active and diagnostic cell type. Most GCTs are located in the epiphyseal regions of long bones. The axial skeleton—primarily the sacrum—is a secondary site of involvement. Most patients present with pain, swelling, joint effusion, and disability in the third and fourth decades of life. Imaging studies are important for tumor staging and radiographic grading. Typically, these clinically active but slow-growing tumors are confined to bone, with relatively well-defined radiographic borders. Monostotic disease is most common. Metastatic spread to the lungs is rare. Extended intralesional curettage with or without adjuvant therapy is the primary treatment choice. Local recurrence is seen in ≤20% of cases, and a second local intralesional procedure is typically sufficient in cases that are detected early. Medical therapies include diphosphonates and denosumab. Denosumab has been approved for use in osteoporosis as well as breast and prostate cancer metastatic to bone. Medical therapy and radiotherapy can alter the management of GCT of bone, especially in multifocal disease, local recurrences, and bulky central/axial disease.

          • Subspecialty:
          • Musculoskeletal Oncology

        Patient-reported Outcome Measures in Spine Surgery

        The ultimate goals of intervention for spinal pathology are to improve the patient's quality of life, restore function, and relieve pain. Traditional clinician-based assessments typically fall short of adequately addressing these important outcomes because these assessments are inherently biased and may not describe patients' perception of their state of health. Patient-reported outcome measures have been developed to obtain quantitative data regarding general health quality, function, and pain. These data can aid the clinician in stratifying the severity of the disorder to formulate an appropriate treatment plan. This information also can be followed over time to assess treatment efficacy. Patient-reported outcome measures have become increasingly important with increased scrutiny of quality of care. Given the increasing importance and use of patient-reported outcome measures, knowledge regarding proper implementation of these tools is essential for accurate assessment of general health quality, function, and pain.

            • Subspecialty:
            • Spine

          Venous Thrombosis in Athletes

          Because deep vein thrombosis (DVT) can occur following orthopaedic procedures, knowledge of hereditary and acquired risk factors for DVT is essential. Hereditary forms of thrombophilia include factor V Leiden and prothrombin G20210A mutations, and deficiencies of antithrombin III, protein C, and protein S. Acquired risk factors include but are not limited to trauma, immobilization, and surgical procedures. In general, athletes have a low risk of venous thrombosis; however, this population is exposed to many acquired thrombogenic risk factors, including hemoconcentration, trauma, immobilization, long-distance travel, and the use of oral contraceptives. Thus, orthopaedic surgeons should consider screening athletes for thrombogenic risk factors, including history of venous thrombosis, hypercoagulable disorders, or high altitude exercise, during preparticipation physicals and preoperative examinations. If a patient is determined to be at high risk of DVT, preventive measures such as physical antithrombotic measures and/or low-molecular-weight heparin should be instituted. If an athlete develops a DVT, a risk factor assessment should be conducted along with anticoagulation treatment in accordance with the American College of Chest Physicians guidelines.

              • Subspecialty:
              • Sports Medicine

            Workers' Compensation and Outcomes of Upper Extremity Surgery

            Clinical outcomes following upper extremity surgery among workers' compensation patients have traditionally been found to be worse than those of non—workers' compensation patients. In addition, workers' compensation patients take significantly longer to return to their jobs, and they return to their preinjury levels of employment at a lower overall rate. These unfavorable prognoses may stem from the strenuous physical demands placed on the upper extremity in this group of patients. Further, there is a potential financial benefit within this patient population to report severe functional disability following surgery. Orthopaedic upper extremity surgeons who treat workers' compensation patients should be aware of the potentially prolonged period before return to work after surgical intervention and should counsel this group of patients accordingly. Vocational training should be considered if a patient's clinical progress begins to plateau.

                • Subspecialty:
                • Shoulder and Elbow