Volume 20-2, Summer 2011

As participation in athletics continues to increase, so too will the occurrence of on-field injuries and medical emergencies. The field of sports medicine continues to advance and many events will have onsite medical staff present. This article reviews the most catastrophic injuries and medical emergencies that are encountered in sports and presents the highest level evidence in regards to on-field approach and management of the athlete. Key words: athletic injuries, catastrophic injuries in sport, concussion, heat illness, sideline emergencies, spinal cord injury, sudden cardiac death

Tarsal coalitions often present in young adults as a painful pes planovalgus hindfoot deformity. Resection of moderate and even large coalitions has become accepted as an alternative to arthrodesis. A review of the literature, however, suggests that coalitions with severe preoperative planovalgus malposition treated with resection are associated with continued disability and deformity. The authors believe that malposition contributes to persistent pain and disability after simple coalition resection. The hypothesis is that resection of the coalition with simultaneous hindfoot reconstruction can improve clinical and radiographic outcomes. Seven consecutively treated patients (eight feet) were retrospectively reviewed from the senior author’s practice. Clinical exam, American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores, and radiographic measurements were evaluated after talocalcaneal coalition resection with simultaneous hindfoot reconstruction. All patients were satisfied and would have the same procedure again. All patients were either active students or gainfully employed at last follow-up. Clinical and radiographic hindfoot alignment was corrected reliably. The average increase in medial longitudinal arch height was 8.7 mm. After 2 years the average AOFAS hindfoot score was 88. Most patients had only mildly progressive arthrosis. There were two postoperative complications that resolved (superficial wound breakdown and calf deep vein thrombosis). This hindfoot reconstruction with coalition resection increased motion, reliably corrected malalignment, and improved pain. The authors believe that coalition resection and concomitant hindfoot reconstruction is a better option than resection alone or hindfoot fusion in patients with talocalcaneal coalition and painful pes planovalgus hindfoot deformity. Triple arthrodesis should be reserved as a salvage procedure. Key words: flatfoot deformity, planovalgus foot deformity, talocalcaneal coalition, tarsal coalition

This article reviews recent molecular, biologic, therapeutic, and clinical findings in dedifferentiated chondrosarcoma. Dedifferentiated chondrosarcoma is one of the most malignant primary bone tumors characterized by two distinct histopathologic components: a well-differentiated chondral lesion sharply juxtaposed with a high-grade noncartilaginous component. Wide or radical surgical resection is mandatory. High-dose radiation therapy is confined to inaccessible sites and palliation. Chemotherapy is administered whenever the dedifferentiated component is chemosensitive and the patient is in good general condition. Despite this approach,metastaseswill result in poor survival of these patients. Key words: chondrosarcoma, dedifferentiation, limb salvage surgery

Recently, patient-specific approaches to total knee arthroplasty (TKA)have been introduced that utilize preoperative magnetic resonance imaging data to manufacture custom cutting jigs specific to a patient’s bony anatomy. These approaches intend to provide the benefits of accurate implant alignment while overcoming some of the proposed disadvantages of current computer navigation systems. In this study, a cost and benefit assessment of implementing the patient-specific approach compared to conventional and computer-navigated TKA was conducted at a large academic medical center. Fixed and time-dependent operating room (OR) costs were determined and compared, as well as the cost for processing operative equipment and additional procedure-related expenditures. Overall, patient-specific TKA was not cost saving in this model on a per-case basis compared to conventional methods, although it was less costly overall to the institution compared to implementing intraoperative navigation. However, the patient-specific approach provides the institution with an additional 28 minutes of available OR time per intervention based on reduction in preparation and operative times compared to conventional methods and an additional 67 minutes compared to computer navigation based on this model. This time savings is likely to provide a greater economic impact to the health care system than implant-related cost savings. Key words: computer navigation, cost assessment, patient-specific, total knee arthroplasty

Leadership and business challenges have become increasingly present in the practice of medicine. Orthopaedic residency programs are at the forefront of educating and preparing orthopaedic surgeons. This study attempts to quantify the number of orthopaedic residency programs in the United States that include leadership or business topics in resident education program and to determine which topics are being taught and rate the importance of various leadership characteristics and business topics. A survey was sent to all orthopaedic department chairpersons and residency program directors in the United States via e-mail. The survey responses were collected using a survey collection website. The respondents rated the importance of leadership training for residents as somewhat important. The quality of character, integrity, and honesty received the highest average rating among 19 different qualities of good leaders in orthopaedics. The inclusion of business training in resident education was also rated as somewhat important. The topic of billing and coding received the highest average rating among 14 different orthopaedically relevant business topics. A variety of topics beyond the scope of clinical practice must be included in orthopaedic residency educational curricula. The decreased participation of newly trained orthopaedic surgeons in leadership positions and national and state orthopaedic organizations is concerning for the future of orthopaedic surgery. Increased inclusion of leadership and business training in resident education is important to better prepare trainees for the future. Key words: business, education, leadership, residency, training

A retrospective review was conducted to examine rates of malreduction and nonunion in ipsilateral femoral neck and shaft fractures using different fixation strategies. Twenty-two consecutive patients with 23 fractures were identified. Participants were treated with various fixation strategies for ipsilateral femoral neck and shaft fractures. Cephalomedullary devices were used in 13 cases, while cannulated screws and a retrograde femoral nail were used in nine cases. One patient was treated with cannulated screws and external fixation of the femoral shaft. Radiographic assessment of the quality of reduction and union of both fractures was evaluated. Clinical and radiographic follow-up was available in 20 fractures (87%) with a mean of 12 months (range 3–50). Two femoral neck nonunions occurred; both had fair reductions of the fractures obtained by closed maneuvers, and two-device fixation was used in each. One femoral shaft nonunion occurred in a fracture treated with a cephalomedullary nail. All three united after revision surgery. No cases of osteonecrosis or conversion to hip arthroplasty were noted. A combination of retrograde femoral nailing and screw fixation of the femoral neck or placement of a cephalomedullary nail can provide excellent reduction and rate of union in the treatment of this injury pattern. Excellent reduction of the femoral neck fracture is key to preventing femoral neck nonunion. Key words: cephalomedullary, femoral neck, femoral shaft, fracture, ipsilateral

Exertional compartment syndromes are uncommon but can significantly impair athletic performance. This report describes an unusual case of bilateral forearm compartment syndromes in an elite-level swimmer that was able to be treated successfully using a novel endoscopic fasciotomy method. Key words: compartment syndrome, endoscopic fasciotomy, exertional

Development of malignant peripheral nerve sheath tumors (MPNSTs) is a recognized complication in patients with neurofibromatosis type 1 (NF1). Differentiating benign from malignant lesions can be a difficult clinical problem. Positron emission tomography (PET) is an established method for making this differentiation with a high degree of sensitivity and specificity. There are several reports showing that fluorine-18 fluorodeoxyglucose (FDG) PET is an effective imaging modality for detecting malignant transformation with a sensitivity nearing 100%. There are very few reports of false-negative 18F-FDG PET in a patient with an MPNST. This case report describes a woman with NF1 and a grade 3 MPNST and a negative PET scan. Identification of malignant transformation in NF is a significant clinical challenge. It is important to recognize the potential limitations of 18F-FDG PET in these patients. Key words: 18F-FDG PET, malignant peripheral nerve sheath tumors, neurofibromatosis type 1

Rupture of simple (extraneural) cysts such as popliteal cysts (Baker’s cysts) is a well-known occurrence. The purpose of this report is to introduce the similar occurrence of extraneural rupture of peroneal and tibial intraneural cysts in the knee region, describe the associated magnetic resonance imaging (MRI) findings, and identify risk factors. There was MRI evidence of rupture in 20 of 38 intraneural cases reviewed, mainly in the region of the fibular head and popliteal fossa. Ruptured intraneural cysts and simple cysts share these MRI findings: T2 hyperintense fluid within surrounding intermuscular fascial planes and enhancement with intravenous contrast consistent with inflammation. The mean maximal diameter of the ruptured intraneural cysts was statistically significantly smaller than that of the unruptured cysts. The authors believe that extraneural rupture of an intraneural cyst is due to increased intraarticular pressures transmitted within the cyst and/or elevated extrinsic pressure delivered to the cyst, such as by trauma, akin to the etiology of rupture of extraneural ganglion cysts. Key words: intraneural ganglion cyst, MRI, ruptured cyst, trauma

Placement of running, locking stitches during the harvest and preparation of hamstring tendons can be time consuming and requires placement of suture in the most distal and proximal 2 to 3 cm of the tendons. The authors have regularly used a needleless suture loop technique to both harvest and prepare autograft gracilis and semitendinosis tendons and to tension quadrupled hamstring tendon grafts during anterior cruciate ligament reconstruction. This cost-effective technique reduces exposure to needles, the time required to harvest and prepare the grafts, and the amount of suture in the tibial tunnel, while providing adequate fixation to tension the tendons as needed. Key words: hamstring harvest, needleless suture loop