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We compared the difference in operative time, hospitalization and recovery time in two groups of patients who underwent open or arthroscopic resection of anterior, tibiotalar, impinging spurs. The operative time was approximately the same, but the average length of hospitalization and time to recovery were shorter in the arthroscopic group. A classification system is proposed that grades the degree of spur formation and assists in predicting the length of recovery time and whether the patient is a candidate for open or arthroscopic spur resection. In this series, grade I spur patients recovered and resumed full activity at 5.0 weeks, grade II at 5.6 weeks, grade III at 6.4 weeks, and grade IV at 10.0 weeks postoperatively. Grade IV patients are not suitable candidates for an arthroscopic debridement.

To The Editor: Regarding "Anterior Cruciate Ligament Replacement: Comparison of Bone-Patellar Tendon-Bone Grafts with Two-Strand Hamstring Grafts. A Prospective, Randomized Study" (2002;84:1503-13), by Beynnon et al., the authors are to be congratulated on an exhaustive, very difficult study that evaluated multiple parameters and outcomes over a substantial period of time. Additionally, the difficulty of the study is evidenced by the fact that this report was published twelve years after the study was initiated. The problem with this study, however, is that it represents a comparison of two dissimilar techniques with completely different methods of fixation and thus the results would be expected to be different as well. In effect, it is similar to comparing two operations—one that was done poorly and one that was done well—and concluding after three years of follow-up that anterior cruciate ligament replacement with hamstring grafts is a poorer choice. In their hamstring grafting technique, the authors left the distal attachment of the semitendinosus and gracilis grafts intact, stripped out the tendons, sutured them together, and then passed them under the sartorius tendon insertion and through the tibial and femoral tunnels. Then they fixed the proximal end of the graft to the distal aspect of the femur with use of a belt-buckle-type double-staple technique, which they had described previously in a fairly obscure publication 1. They then stapled the distal attachment of the hamstring graft just before it entered the tibial tunnel. As a consequence, the two strands of hamstring tendon sawed back and forth through an incredibly long construct that was stapled at each end with bone staples, and the graft probably either worked loose or was amputated by the staples. This technique contrasted with the bone-patellar tendon-bone grafting technique, in which the graft was fixed with interference screws at a substantially shorter distance …

Total hip or knee joint replacement has been one of the great gifts of medicine to mankind. Millions of individuals who would otherwise spend the remainder of their life inactive, limping painfully with a stick or crutches or wheelchair-bound, can now live relatively painless, enjoyable, productive lives. However, the physical and emotional devastation that is wreaked if an infection involving the total joint replacement occurs is almost immeasurable1. Morbidity is substantial and may be permanent. In addition, if revision arthroplasty is required, the mortality rate is elevated and the economic cost to the hospital averages almost four times that of a primary joint replacement2. On the average, a total hip or knee replacement endures about one million cycles of use per year. As a result, these mechanical devices would be expected to eventually loosen and/or wear out. This gradual process may take one or more decades. Bone cement may loosen, and high-density polyethylene spacers may wear down to create pseudo-laxity of the ligaments. The polyethylene wear-particle debris will also excite an erosive inflammatory reaction that further exacerbates the wear process. A …

This well-constructed study examines the treatment outcome of open reduction and internal fixation in calcaneal fractures as related to patient age. It is a study that will be repeated time and again, across the spectrum of orthopaedic procedures, as improvements are made in surgical devices and technique and as our perceptions change with regard to the age at which a patient might be considered to be an “older” patient. Given the previous literature1,2, which indicated that patients who were older than fifty years of age and had calcaneal fractures were not candidates for open reduction and internal fixation, …

A 10-year prospective study was carried out on arthrodesis surgery of the major tarsal joints of the foot. The guiding principle of the study was that foot symmetry would be preserved, except where both feet were deformed. Correction in the frontal, coronal, and sagittal planes would be used to restore normal talocalcaneal relationships. In patients with normal relationships, triple, subtalar (talocalcaneal), and isolated tarsal arthrodesis would be carried out by iliac-crest-inlay grafting to preserve tarsal relationships. In 41 patients, 47 arthrodeses were carried out. There were 31 triple arthrodeses, 10 talocalcaneal fusions, four talonavicular fusions, and two naviculocuneiform fusions. In patients with deformity, significant improvement in the angles of anteroposterior talocalcaneal divergence and lateral talocalcaneal convergence was recorded. There were 27 good results, 15 fair results, and five poor results. Supplementary bone grafting and the use of internal fixation improved the rate of arthrodesis.

The results of bunion surgery on 50 feet in 31 adolescents are reviewed. Average follow-up was 3 years 2 months. The failure rate was 36%. Fifty-one percent of the children had hypermobile flatfeet, and 32% had a long first ray. The recurrence rate in these groups was 56 and 50%, respectively. There were 20 reoperations for either recurrence (12) or hardware removal (eight). Elective bunion surgery in adolescents should only be performed in the face of progressive, painful deformity where both the patient and the patient's parents fully understand the goals and risks of surgery.

Twenty adult males were tested with the Cybex II isokinetic dynamometer, comparing in each leg the torque produced by the anterior and posterior muscle compartments. Significant torque is produced by the gastroc soleus muscle group, even when the knee is bent 90°. There is a significant increase in anterior compartment dorsiflexion torque produced with the knee in extension as compared to flexion. There is no difference in right or left handedness in comparing the results of torque generation in the lower extremity. On the average, dorsiflexion torque is approximately one-third of plantarflexion torque at slow speeds and half that of plantarflexion at fast speeds.

We reviewed 40 patients who had undergone 57 operations for tarsal coalition between 1965 and 1980. Ten patients were treated for talocalcaneal coalitions. Four had successful resections and the remainder had successful single or combination arthrodesis. Thirty patients had 39 calcaneonavicular resections and five primary triple arthrodeses. In the entire series only two patients had a poor end result due to either technically poor surgery or failed calcaneonavicular resection because of advanced degeneration. Polytomography, computed tomography, or both were valuable in determining if talocalcaneal coalition resection was feasible. Care must be taken in evaluating the talonavicular joint for degenerative changes. The talar "beak" is not necessarily a degenerative spur, but rather a traction process occurring secondary to increased motion.

The association between osteosarcoma and growth, including altered carbohydrate metabolism has been investigated in 5 osteosarcoma patients. Serum from an adolescent osteosarcoma patient has been noted to consistently enhance 3-H-thymidine uptake in cultured chondrocytes and tumor cells. Females survive osteosarcoma more frequently than males. In vitro serum-enhanced proliferation of osteosarcoma cells is suppressed by estradiol.

This paper reviews 26 patients who presented with disorders of one or both sesamoids of the foot. There is a high association between long-distance running and chondromalacia or stress fractures in these bones. Thirty-eight per cent of these patients had variations in the anatomy at this articulation, including asymmetry in sesamoid size, symmetrical sesamoid enlargement, metatarsal condylar hypoplasia, and metatarsal rotational abnormalities.

Altered carbohydrate metabolism associated with fibrosarcomas and chondrosarcomas has been well-documented in past literature. This report describes abnormal carbohydrate metabolism in 2 osteosarcoma patients, and abnormalities in growth hormone and somatomedin serum levels. Experimental evidence is presented showing in vitro suppression of osteosarcoma tumor cell proliferation by 17 beta Estradiol. Estrogen inhibition of linear bone growth, cartilage proliferation, and somatomedin is discussed with reference to possible estrogen therapy in osteosarcoma.

A syndrome of ankle pain on weight-bearing while running due to post-traumatic ossification of the tibiofibular ligament is described. Pain is caused by failure of normal downward and lateral motion of the fibula. Treatment consists of complete excision of the synostosis, followed by cast immobilization for 3 weeks.

Superficial disorders of the forefoot are frequently seen in any office practice. Soft corns, ingrown toenails, plantar calluses, and plantar warts are the most common of these disorders. Their etiology, recognition, and operative and nonoperative management are discussed.

Metatarsalgia is the symptom of pain in the region of the metatarsophalangeal articulations. In a careful analysis of 98 patients who presented with complaints of forefoot pain, 23 distinct diagnoses were made as to the etiology of their pain. These diagnoses were grouped under primary metatarsalgia, secondary metatarsalgia, and pain under the forefoot. Specialized tests, such as stance phase cholesterol-crystal force plate analysis and intraarticular or digital nerve block, are helpful in determining the diagnosis and the likelihood of effective treatment.

Dissection and roentgenographic findings in 35 nonoperative cadaveric and freshly amputated feet were correlated with disorders of the first day--specifically the sesamoids. There are four noteworthy factors associated with first ray pathology. The most significant are axial rotation of the first metatarsal bone and degenerative changes at the first metatarsophalangeal joint. Significant anatomic variations can be correlated with failed bunion surgery.

Recent evidence suggests that endocrine factors play an important role in the natural history of osteosarcoma. The occurrence of this tumor in the metaphysis of rapidly growing adolescents, coupled with increased female survival led to the investigation of the effects of various hormones on cultured osteosarcoma cells. The in vitro effects of physiologic concentrations of human growth hormone, 17beta estradiol, and progesterone on cultured osteosarcoma cells and chondrocytes are presented. Growth hormone significantly enhances 3H-thymidine incorporation in osteosarcoma cells and chondrocytes, in the presence of human serum. The use of other sera, culture media, or heat inactivation of the human serum abolishes this effect. Estradiol and progesterone, alone, or in combination produce significant suppression of DNA synthesis in cultured tumor cells. Several sera contain a heat-labile factor which has the capacity to block the suppressive effect of estradiol. This factor could be overcome by increasing the concentration of hormone, or by heat-inactivation of the serum. The use of hormone therapy in the treatment of osteosarcoma has never been reported, despite its demonstrated value in certain other malignancies. In light of these observations and considering the poor prognosis in this disease it seems reasonable to initiate a study of adjunctive hormone therapy in osteosarcama.

Arthrodesis of the ankle joint is difficult to achieve when there are associated problems with bony deformity or abnormalities of the surrounding soft tissues. In a series of 50 ankle arthrodeses, in which 68% had either damaged soft tissues or fixed ankle deformity, the pseudarthrosis rate was 30%. This high failure rate led us to devise biomechanical studies to evaluate the inherent stability of the Charnley-type compression arthrodesis, the R.A.F. fusion, and a new dynamic compression T-plate. The stability of the Charnley apparatus was directly related to the tension upon the wingnuts. However, in spite of the massive compression generated by the Charnley apparatus, it was relatively unable to resist rotatory forces. The T-plate had excellent rotatory and flexion-extension stability and developed approximately 25 pounds/inch compression across the ankle fusion. The T-plates's clinical application is demonstrated in eight successful arthrodeses. The importance of an intraoperative roentgenogram to confirm satisfactory ankle alignment cannot be overemphasized.

Fibular function has long been a point of controversy in the literature. Until recently the fibula's role during gait has been thought of as entirely static. A review of the literature reveals an important dynamic function for the fibula in maintaining ankle mortise stability during weight bearing. Roentgenographic and anatomical studies confirm the hypothesis of progressive distal fibular descent. A taut interosseous membrane and deepened mortise result when be flexors of the foot contract during stance phase. Congenital deformities of the ankle may stem from aberration in the dynamic role of the fibula. Stress fractures and problems resulting from impaired distal migration and synostosis formation are interpreted as disorders of the dynamic role of the fibula.

Cadaveric and fresh amputation dissection studies revealed that condylar anomalies, metatarsal axial rotation, and bowstrung flexor tendos will commonly produce subluxation and degenerative changes at the metatarsophalangeal-sesamoid joint. The average arc of motion of the sesamoids from maximum plantar- and dorsiflexion was measured at 71.9 +/- 11 degrees. The anatomic variations presented are correlated with the incidence of chronic sesamoiditis, painful bipartite sesamoids, and chronic nonunions.

In the assessment of the child with flat feet a sound knowledge of arch and subtalar biomechanics, epidemiology, and etiology is important. The occurrence and natural history of flat feet are presented, and treatment modalities that have withstood the test of time are discussed.

Any hemorrhage in a hemophilic patient must be regarded as a serious problem. A small percentage of hemophiliacs have an inhibitor that will destroy factor VIII or IX clotting activity, thus making control even more difficult. This occurrence predisposes these patients to joint contractures and deformities secondary to repeated, uncontrolled hemorrhages into muscle compartments and joints. Patients with an inhibitor must, therefore, be recognized, and any bleeding should be treated as an emergency. A combined treatment protocol has been developed by the hematology and orthopedic departments in a effort to achieve early hemorrhage control and prevent subsequent deformity. (JAMA241:2028-2030, 1979)