1/440. Osteochondral mosaicplasty for the treatment of focal chondral and osteochondral lesions of the knee and talus in the athlete. Rationale, indications, techniques, and results. New techniques for articular cartilage transplantation have become available recently for traumatic chondral injuries. Applications to the athlete have generated considerable interest in the sports medicine community. The autogenous osteochondral grafting mosaicplasty has been used to treat these injuries in the athlete population for the past six years. The rationale, indications, operative technique, results, and limitations of mosaicplasty in the athlete are presented and discussed. ( info) |
2/440. Recognition and management of Tillaux fractures in adolescents. Tillaux fractures are relatively uncommon Salter Harris III fractures of the tibia. The importance of recognizing this fracture is that a residual deformity in the joint surface can lead to premature degenerative arthritis. For this reason, it is important that accurate imaging to assess the congruity of the joint, as well as adequate reduction, is obtained. These fractures can occur in adolescents in the 18-month period during which the distal tibial epiphysis is closing. These injuries occur either by lateral rotation of the foot or by medial rotation of the leg on the fixed foot. Closed reduction is sufficient in most cases; however, if a gap of > or = 2 mm of the articular surface remains, open reduction is usually required to adequately reduce the articular surface. Orthopedic injuries are one of the most common reasons children are brought to the emergency department (ED). Most of these injuries are easily managed by splinting, with outpatient orthopedic follow-up. However, certain fractures need closer evaluation and immediate consultation with an orthopedic surgeon. One relatively uncommon fracture that needs special attention is the Tillaux fracture. Paul Jules Tillaux first described this particular fracture in 1892. He performed experiments on cadavers and found that stress to the anterior inferior tibiofibular ligament could lead to this type of avulsion fracture, which today is termed the Tillaux fracture. The distal tibial epiphysis is involved, and the mechanism usually is forced external rotation of the foot in a 12- to 14-year-old adolescent. This fracture only occurs during a certain time of adolescence, owing to the differential growth rate of the epiphysis, and only under certain circumstances. The fracture is of great importance because it involves a major weight-bearing articular surface. A residual deformity of the joint surface can lead to premature degenerative arthritis. We present a patient with a Tillaux fracture to elaborate on the mechanism of injury and to summarize the importance of its recognition and imaging and treatment options. ( info) |
3/440. Subtalar subluxation in ballet dancers. ankle injuries frequently occur in dancers. Among these injuries, only a few cases of talar subluxation have been reported in the literature. In our series, we diagnosed and treated 25 subtalar subluxations over a 1-year period in the Ballet Bejart Lausanne company. The subluxations occurred after a grand plie on pointes or at the landing of a jump on demi-pointes, without any mechanism of ankle sprain. The dancer usually noted a sudden and sharp pain in the talonavicular joint and hindfoot with a feeling of "forward displacement" of the foot. At palpation, the talonavicular ligament, the anterior talofibular ligament, and the posteromedial part of the subtalar joint were painful. A limitation of the ankle extension and a clear hypomobility of the subtalar joint were noted. Under the effect of shearing forces on the midtarsal joint, a posteromedial subtalar subluxation occurred. Treatment consisted of a manipulation that reduced the subluxation. Continuous taping, which locks the talonavicular joint in the anterior direction, was recommended for 6 weeks. dancing could be resumed in a swimming pool after 2 weeks, and on the ground after 3 to 4 weeks. We found that subluxation could recur, and that it could eventually become chronic. ( info) |
4/440. Radiologic case study. Fractures of the foot masquerading as ankle injuries. An ankle radiographic series frequently is obtained when a patient presents with an acute ankle and foot injury. Although many fractures are confined to the ankle and are readily apparent, fractures of the foot can mimic ankle injuries. It is important to differentiate these fractures of the foot from the more common ankle sprain. Most ankle sprains are treated with ice, compression, and elevation, followed by range-of-motion exercises and progressive weight bearing as tolerated. When foot fractures are not identified, however, lack of appropriate treatment can result in late complications. Concentration on key areas as described here will reduce the incidence of missed fractures of the foot in these patients. ( info) |
5/440. Strategy of exercise prescription using an unloading technique for functional rehabilitation of an athlete with an inversion ankle sprain. STUDY DESIGN: Case study. OBJECTIVES: To demonstrate how an exercise program can be designed with specific sets, repetitions, and rest periods, and to enhance the healing process in early stages of rehabilitation when injured tissues cannot tolerate full body weight. Our goal was to enhance ankle tissue healing by reducing gravitational force through a prescriptive exercise and unloading program. BACKGROUND: This report describes a treatment method that we used to rehabilitate a collegiate soccer player with a Grade II inversion ankle sprain. This athlete sprained his ankle 6 weeks before the start of rehabilitation and was unable to participate in soccer due to persistent pain and impaired function. methods AND MEASURES: A 2-week functional training program was implemented, consisting of exercises chosen for specific task simulation related to soccer. Gravitational force was mechanically altered by suspending the subject or by supporting the subject on a variable incline plane. weight-bearing was controlled so that the subject could perform exercises without pain. The outcome measures were ankle range of motion (ROM), maximum pain-free isometric strength, vertical force during unilateral squats, and unilateral hop time and distance. RESULTS: pain-free weight-bearing capacity increased over the 2-week course of rehabilitation and the subject was able to return to playing soccer without pain. The ratios (involved to uninvolved extremity) at time of discharge from physical therapy were 87% to 103% for ankle ROM, 75% to 93% for isometric ankle strength, 91% for unilateral squats, 88% for unilateral hop time, and 86% for unilateral hop distance. CONCLUSIONS: Return to function can be achieved in a short period by exercise that is performed with a gradual increase in pain-free weight-bearing capacity. ( info) |
6/440. Anterior tibial artery pseudoaneurysm after ankle arthroscopy. arthroscopy of the ankle has dramatically expanded its role in diagnostic and therapeutic value afforded to the patient; however, it is not without complications. Although the majority of the complications described are neurological in origin, vascular injuries can occur. A case of a patient with normal coagulation parameters who underwent a purely diagnostic ankle arthroscopy and later developed a pseudoaneurysm of her distal anterior tibial artery is described. The pseudoaneurysm was resected without complications and early postoperative recovery has been uneventful. ( info) |
| STUDY DESIGN: Case study. OBJECTIVES: To describe a protocol used in the rehabilitation of a grade II lateral ankle sprain, emphasizing brief immobilization with a removable boot, weight bearing as tolerated, and progression of early exercise. BACKGROUND: The optimum conservative treatment of severe grade II ankle sprains remains undefined. Short-term benefits of early mobilization have won favor over immobilization by casting; however, pain and ankle joint instability often linger. The timing of weight bearing as a variable that influences recovery has largely been ignored when either treatment is considered. methods AND MEASURES: The patient was a 17-year-old girl who had sustained a left ankle inversion sprain while playing high school basketball. The sprained ankle was placed in an immobilizer boot for 1 week, and weight bearing was encouraged. She received instructions for active exercise and for resistive exercise with elastic tubing. Volumetric and active range of motion measurements and gait observation provided indicators of rehabilitation progress. A digital inclinometer was used to measure active range of motion in the sagittal plane. Vertical ground reaction forces recorded with an instrumented treadmill documented gait symmetry. RESULTS: The patient responded well to the course of treatment, returning to full participation in basketball 2 weeks after the injury. The injured ankle had 29% (19 degrees) less active range of motion than the nonimpaired ankle at the beginning of physical therapy. The injured ankle also displaced 50 mL more water compared with the nonimpaired ankle at the start of treatment. Four weeks after beginning treatment, the sprained ankle had 4 degrees less active range of motion and displaced 5 mL more water compared with the nonimpaired ankle. As a college athlete, the patient has remained free of subjective complaints of ankle pain, instability, and swelling. CONCLUSION: weight-bearing immobilization combined with early exercise provided safe and effective treatment for this patient, who suffered a grade II lateral ankle sprain. ( info) |
8/440. Peroneal tendon subluxation in athletes: new exam technique, case reports, and review. Traumatic peroneal tendon subluxation is an uncommon cause of ankle pain. As a result, the diagnosis is often delayed. A new technique of examining the patient in the prone position, allowing for easier visualization of the subluxation or dislocation, is described. Three illustrative cases, including a rare case of midsubstance rupture of the peroneal retinaculum are presented along with a review the literature. An acute repair in athletes and in those patients who do not want to risk the chance of a 40-50% failure rate after 4-6 wk of casting is currently recommended. Surgical repair can be facilitated using Mitek suture anchors for acute, symptomatic chronic, and subacute injuries. Deepening of the groove is performed only in those patients that have no sulcus or a convexity of the groove. ( info) |
9/440. Os trigonum syndrome with flexor hallucis longus tenosynovitis in a professional football referee. The presentation of posterior ankle pain in any patient poses a diagnostic dilemma. The os trigonum syndrome and flexor hallucis longus stenosing tenosynovitis have been reported to occur in professional and amateur ballet dancers. It is important to consider these diagnoses in a patient who is not a dancer, as is shown in the case presented here. The patient in this case is a professional referee who injured his ankle while working on artificial turf. The treatment for os trigonum syndrome and flexor hallucis longus tenosynovitis is initially conservative, but in refractory cases, surgical removal of the os and release of the flexor hallucis longus tendon can be successfully performed. This is the first reported case of os trigonum syndrome and flexor hallucis longus tenosynovitis presenting simultaneously in a patient who is not a dancer. ( info) |
10/440. Congenital absence of the lateral metatarso-phalangeal sesamoid bone of the human hallux: a case report. A case of congenital absence of the lateral metatarsophalangeal sesamoid bone of the hallux is reported, in a 47-year-old woman. The lateral sesamoid bone was absent on the right hallux, and extremely reduced on the left hallux. The normal intersesamoidean crest and both sesamoidean grooves of the metatarsal head were absent. physical examination was normal, and no functional disturbance resulted from this variant. Only two previous cases have been found in the literature. It must be distinguished from a total resorption due to an infectious process, or from an absence due to surgical excision. This absence can be related to the general tendency of disappearance of the sesamoid bones within hominoid primates. ( info) |