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The histologic and clinical characteristics of 54 patients with osteosarcoma are reviewed. The association of rapid linear bone growth with the occurrence of this tumor is confirmed, and evidence for increased growth in these adolescent patients is presented. A significant increase in female survival is seen in this study, and the literature relevant to gender and survival is reviewed. A histologic characterization of six predominant tumor patterns is presented with correlation to survival. Increased survival is seen with two specific histologic patterns, but there is great variability in the histology and sampling of osteosarcomas, and the series is small.

The purpose of this investigation was to report on the interaction between different types of athletic shoes and playing surfaces using physiologic loads of 40 and 220 lbs. This is a continuation of our previous report using a load of 25 lbs. Nine shoes by three manufacturers were characterized as turf, court, molded cleat, or traditional cleat and tested on both natural grass and synthetic turf. A specially designed pneumatic testing device was used in order to measure translational resistance and rotational torque of the shoe-surface interface. Measurements were acquired for 1) force-X describing translational loading, 2) moment-Y describing the torque generated by linear translation, and 3) moment-Z describing the moment generated by axial rotation, and data were analyzed using repeated measures analysis of variance and Tukey's post-hoc comparison. It was found that increased the axial loads from 40 to 220 lbs significantly increased the frictional resistance ( p < .05) between the shoe and the artificial turf surface in a nonlinear fashion. Turf shoes demonstrated the most frictional resistance of any group for this condition. Increases in the forces generated in linear translation from the axial load of 40 to 220 lbs produced the most significant increases of any resistance test on the turf surface. The cleated shoes (both traditional and molded) generated the highest frictional and torsional resistance on the grass surface when compared to the other categories of shoes. Grass generated higher peak moments than turf for the cleated shoes. These results demonstrate the considerable differences between laboratory and physiologic conditions and that the increase in frictional resistance is nonlinear with increasing loads.

The OATS technique is one of several cartilage repair procedures that exhibits promising short- to intermediate-term results in the surgical management of OLTs. Although the OATS procedure is generally reserved for salvage of failed debridement and drilling, some investigators are suggesting that it may have applications in primary surgical management of OLTs, particularly those that are associated with subchondral cysts. Long-term outcome of the OATS procedure for OLTs is not yet available.

Syndesmosis injuries at the ankle are a common injury that may be missed easily as a result of the fact that normal roentgenograms fail to reveal the magnitude of soft-tissue injury. Magnetic resonance imaging or external rotational stress roentgenograms under anesthesia will assist in making the diagnosis. Syndesmosis injuries can occur with or without proximal fibular fractures, interposed deltoid ligament, or peroneal tendons. Technically demanding, accurate surgery with transfibular screw fixation, including three or four cortices, will ensure a satisfactory result.

Purpose: The use of blunt-threaded titanium interference screws for arthroscopic-assisted fixation of a quadruple-strand hamstring anterior cruciate ligament (ACL) reconstruction has recently been reported. However, the pitfalls of the low medial portal technique, rehabilitation protocol, and long-term results have not. The purpose of this multicenter study was to prospectively evaluate this technique's application to ACL instability in symptomatic patients as well as to develop a standardized rehabilitation protocol. Type of Study: Observation cohort study. Methods: One hundred-twenty patients had quadruple hamstring ACL reconstructions, followed the study protocol, and were seen at 2 years follow-up. They were evaluated using Lysholm score, Lachman test, anterior drawer test, pivot-shift test, KT-1000, effusion assessment, and the Tegner Sports Activity Scale. Results: The average Lysholm score improved 42 points; Lachman test, effusion assessment, anterior drawer test, KT-1000, and Tegner Sports Activity Scale scores all improved. Of 120 ACL reconstructions, 5 failed. Of these, 3 failed from new late injury, 1 from technical error, and 1 from patient nonadherence to rehabilitation protocol. Some anterior knee pain was present in 30% of patients, and 22% had at some time experienced hamstring pain that did not interfere with athletic activity. Conclusions: This multicenter study reports success with quadruple hamstring ACL reconstruction using the low medial portal technique. Specific pitfalls and a rehabilitation protocol are also discussed. Low medial portal position is critical in successful surgery. Variations in screw size to accommodate the variation in graft construct size are also recommended. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 7 (September), 2002: pp 715–724

Nineteen metatarsal head resections are evaluated at an average followup of 18 months. A subjective patient questionnaire and objective clinical evaluation reveal that in the rheumatoid patient with severe foot involvement, this operation is quite successful. The cholesterol-crystal force plate is shown to be helpful in pre- and postoperative evaluation of these patients.

Treatment of symptomatic large cystic lesions of the talus has had mixed results. A technique of treatment using a cored osteochondral graft taken from the ipsilateral knee is presented. Preliminary results in ten consecutive patients show significant improvement in all patients with an average increase of 27 points in the AOFAS Hindfoot score.

Ten patients were identified with traumatic, complete common peroneal nerve palsy, with no previous foot or ankle surgery or trauma distal to the knee, who had undergone anterior transfer of the posterior tibial tendon to the midfoot. Six of these patients had a transfer to the midfoot and four had a Bridle procedure with tenodesis of half of the posterior tibial tendon to the peroneus longus tendon. Average follow-up was 74.9 months (range, 18–351 months). All patients] feet were compared assessing residual muscle strength, the longitudinal arch, and motion at the ankle, subtalar, and Chopart's joint. Weightbearing lateral X-rays and Harris mat studies were done on both feet. In no case was any valgus hindfoot deformity associated with posterior tibial tendon rupture found. It seems that the pathologic condition associated with a posterior tibial tendon deficient foot will not manifest itself if peroneus brevis function is absent.

Isolated subtalar joint arthrodesis is an established salvage procedure that can be performed in various ways for varying diagnoses. The purpose of this article is to report a new arthroscopic subtalar arthrodesis technique that has been developed. The results of this method versus an open technique were compared. Length of hospital stay, tourniquet time, morbidity, and fusion rate were studied in 17 fusion patients between 1990 and 1997. Twelve patients had open arthrodesis with bone graft and 5 patients had arthroscopic arthrodesis with supplemental, injectable, osteoinductive enhanced-graft gel. The length of stay decreased 1.7 days with the arthroscopic procedure. Tourniquet time was not significantly different. One open procedure required refusion, whereas none did in the arthroscopic group. One patient in each group required AO screw removal. In selected patients with subtalar arthrosis without significant hind-foot deformity, arthroscopic arthrodesis can be an effective. It is too early to determine if there are specific advantages in this procedure compared with a conventional open arthrodesis.

The orthopaedic department at Providence Medical Center, Seattle, Washington, instituted a streamlined care pathway and product standardization for total knee arthroplasty (TKA) in July 1995. The goal was to reduce operating room time and to streamline the care pathway for a safe, expedited hospitalization of patients. The hospital staffs standardized nursing orders, cut the instrument systems from 13 to 4 sets, and coordinated the expedited care pathway. Fifty-two consecutive primary TKAs were compared prepathway to 77 consecutive primary TKAs postpathway. The average length of stay declined 1.9 days from 5.1 to 3.2. The tourniquet time declined from 61 minutes to 56 minutes. The average dollar charges were $1,063 less. There were no infections in either group. The manipulation rate for adhesions declined 37%.

During five football seasons, from 1989 through 1993, 61 surgically proven, noncontact, anterior cruciate ligament injuries, were identified from among 22 National Football League teams. The variables of surface, shoe type, playing conditions, and whether or not the shoe was spatted were identified for each reported injury. Forty noncontact injuries occurred in conventional cleated shoes on natural grass, and 21 occurred on an artificial surface. Almost half of all injuries (47.5%) occurred during game-day exposures despite the fact that the practice versus game-day exposure rate was 5:1. Of these injuries, 95.2% (N = 58) occurred on a dry field. The factors of cleat and shoe type, type of surface (natural versus artificial), surface conditions (wet/dry), and the effect of “spatting” a shoe are presented. The significance of these factors and their likelihood to be associated with injury is analyzed by use of a statistical tool, the incidence density ratio.

A new technique is presented for an endoscopic, quadruple, hamstring, anterior cruciate ligament reconstruction technique. The technique involves the use of a quadrupled hamstring construct, blunt-threaded titanium screws, and a low medial portal. This simple technique, on the average, is performed in less than an hour. To date, more than 100 outpatient cases have been performed with good results. The results are measured by the self-assessment International Knee Documentation Committee (IKDC) and K-T 1000 (Medmetric Corp, San Diego, CA) measurements.

When conservative treatment is unsuccessful, there are many surgical options to treat patients with symptomatic chronic osteochondral lesions of the talus. The chosen treatment depends on the patient's symptoms, clinical examination findings, preoperative imaging results, and whether prior surgery was unsuccessful. It is important to be aware of treatment alternatives such as marrow stimulation, osteochondral autograft or allograft plugs, autologous chondrocyte implantation, and newer techniques currently being investigated outside the United States.

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.

The subtalar joint is an important joint, playing a major role in eversion and inversion of the foot as it transmits and dissipates forces applied to the calcaneus proximally. Arthrosis of the subtalar joint may be a significant source of pain and dysfunction. It may have a rheumatoid, inflammatory, posttraumatic, or degenerative etiology. In patients with painful subtalar arthrosis with or without progressive deformity, arthrodesis is an accepted form of salvage.1 If the arthritic subtalar joint is well aligned, a simple subtalar arthrodesis without the use of bone graft has been shown to be effective. Mann and Baumgarten reported a high rate of success by denuding the posterior facet articular surface, feathering the bony surface, and using internal fixation.2 This and other open techniques for subtalar arthrodesis may be significantly painful and may require hospitalization for pain control.

Background: The Lapidus bunionectomy is a popular procedure for severe bunion deformity where metatarsus primus varus is equal to or exceeds 15 degrees. We evaluated a new locking compression plate which may improve outcomes with the Lapidus procedure. Methods: Ten matched pairs of cadaver feet were used to compare the standard crossed 4.0-mm compression screw method of fixation to the LPS Lapidus plate. After performing the matched operations the cadaver constructs were stressed to failure using the INSTRON and Wavemaker software. Results: The LPS Lapidus plate load to failure was 108 Nm with a bending moment of 6.0 Nm. The crossed screw technique was inferior at 78 Nm with a bending moment of 4.4 Nm ( p = 0.02) Conclusion: Unlike other H-plates or locking plates, load to failure was higher with the Lapidus plate constructs. Clinical Relevance: The increased rigidity provided by these plates may help to minimize the risk of nonunion or malunion.

Background: Suture anchors have been developed for the fixation of ligaments, capsules, or tendons to bone. These devices have led to improved fixation, smaller incisions, earlier limb mobility, and improved outcomes. They were originally developed for use in shoulder reconstructions but are now used in almost all extremities. In the lower leg they are used in the tibia, the talus, the calcaneus, tarsal bones, and phalanges. Nevertheless, techniques for insertion and mechanisms of failure are not well described. Methods: Five suture anchors were studied to determine the pullout strength in four distal cadaver femurs and four proximal cadaver tibias from 55- and 62-year-old males. Eight hundred ninety Newton line was used, testing the anchors to failure with an Instron testing device (Instron, Norwood, MA). The anchor devices were inserted randomly and tested blindly (12 tests per anchor device, 60 tests in all). Results: Two anchors in each group tested failed at low loads. Both types of plastic anchors had failures at the eyelet. Average pullout strength varied from 85.4 to 185.6 N. Conclusions: Insertion techniques are specific for each device, and they must be followed for optimal fixation. In this study, in all five groups of anchors tested two of the 12 anchors in each group failed with minimal force. On the basis of this finding we recommend that, if suture anchor fixation is necessary, at least two anchors should be used. Since there appears to be a percentage of failure in all devices, the second anchor can serve as a backup. It is imperative that surgeons be familiar with the insertion techniques of each device before use.

Background: Proprioceptive deficiencies, peroneal muscle weakness, varus hindfoot, and varus tibial plafond have each been implicated as a predisposing factor in recurrent ankle instability. Another predisposing factor for instability is a position of the fibula posterior to the transverse axis of the talus. This study examined the relationship of fibular position and ankle instability with anatomic dissection and magnetic resonance imaging (MRI). Methods: Data were obtained from 100 consecutive MRI scans of adult ankles: the malleolar index in degrees and the fibular position anterior or posterior to the anteromedial malleolar plane and relative to the transverse axis of the talus. Twenty cadaver ankles also were studied by MRI and then by anatomic dissection. The malleolar index, the talar length, and the length of the anterior talofibular (ATF) ligament were recorded. Results: The MRI study showed that variation of the malleolar index ranged from 2 to 30 degrees. There was no correlation between the malleolar index and the talar length or the length of the ATF ligament. Conclusions: There is a bell-shaped curve of variation of the position of the fibula relative to the transverse axis of the talus. An ankle mortise with a more posteriorly positioned fibula has less structural stability and is more susceptible to sprain. Neither talar length nor ATF ligament length correlated with fibular position.

The use of blunt-threaded titanium interference screws for arthroscopic-assisted fixation of a quadruple-strand hamstring anterior cruciate ligament (ACL) reconstruction has recently been reported. However, the pitfalls of the low medial portal technique, rehabilitation protocol, and long-term results have not. The purpose of this multicenter study was to prospectively evaluate this technique's application to ACL instability in symptomatic patients as well as to develop a standardized rehabilitation protocol.Observation cohort study.One hundred-twenty patients had quadruple hamstring ACL reconstructions, followed the study protocol, and were seen at 2 years follow-up. They were evaluated using Lysholm score, Lachman test, anterior drawer test, pivot-shift test, KT-1000, effusion assessment, and the Tegner Sports Activity Scale.The average Lysholm score improved 42 points; Lachman test, effusion assessment, anterior drawer test, KT-1000, and Tegner Sports Activity Scale scores all improved. Of 120 ACL reconstructions, 5 failed. Of these, 3 failed from new late injury, 1 from technical error, and 1 from patient nonadherence to rehabilitation protocol. Some anterior knee pain was present in 30% of patients, and 22% had at some time experienced hamstring pain that did not interfere with athletic activity.This multicenter study reports success with quadruple hamstring ACL reconstruction using the low medial portal technique. Specific pitfalls and a rehabilitation protocol are also discussed. Low medial portal position is critical in successful surgery. Variations in screw size to accommodate the variation in graft construct size are also recommended.

Autologous iliac crest graft has been a standard source of supplementary bone for treating bony defects, fractures and arthrodeses. Bone graft substitutes have recently become widely available. This paper reports on the use of bone graft substitute in 28 patients that otherwise would have required an iliac crest graft. Twenty-four of the 28 operations were successful in the primary procedure with four patients requiring a second procedure that was then successful.

This article reviews 33 patients who presented with persistent pain, inadequate knee motion, or both after total knee arthroplasty. Of 33 patients, 26 had inadequate motion treated by closed manipulation, arthroscopic manipulation, or a modified open release manipulation. In 23 patients, these procedures were successful. Of the 26 patients, 85% had a history of previous knee surgery or diabetes mellitus. The average gain in range of motion was not different in comparing early (12 weeks) manipulation versus late (12 weeks) manipulation. Seven of the 33 patients presenting with pain, swelling, inadequate motion, or snapping sensations had either failure of bonding between the polymethyl methacrylate and the components (4 patients) or painful fibrous intra-articular bands (3 patients). These patients were treated successfully either by recementing the components or by arthroscopic fibrous band release.

Thirty-five patients undergoing a Bröstrom procedure for ankle instability were studied retrospectively as to the presence or absence of spurs and loose bodies, outcome, and mortise relationships. 100 adult volunteers had their ankles radiographically and clinically examined for spurs, loose bodies, and laxity. 100 patients’ ankles with computed axial tomography were examined to define malleolar relationships. The AOFAS Hindfoot scores on the Bröstrom patients with or without spurs were not different. Patients undergoing a Bröstrom procedure had a 3.37 times incidence of spurs and/or loose bodies compared to normal adult population. The incidence of asymmetric but asymptomatic ankle laxity in normal adults was 11%. The fibula has a 38° range of position relative to the axis of the talus and the medial malleolus. A posterior fibular position may predispose to injury.

We reviewed our results of nonoperative and operative treatment of chronic Achilles tenosynovitis to further define outcomes and treatment parameters. Forty-one patients presented with an average of 14 weeks of Achilles tendon symptoms. All patients received nonsurgical treatment initially, and 21 patients (51%) recovered after an average of 18 weeks of therapy. Three additional patients improved after brisement of the tendon/peritenon interspace. Seventeen of 41 patients eventually underwent soft tissue tenolysis and/or excision of degenerative tendon cysts.Those patients who responded to nonoperative therapy tended to be younger (average age, 33 years) than those who had degenerative tendon changes requiring surgery (average age, 48 years). All surgical patients were able to return to unrestricted activity after 31 weeks (range, 27–48 weeks). We believe 4 to 6 months of nonsurgical therapy is appropriate for middle aged patients or athletes with chronic Achilles tenosynovitis. Those that fail this treatment will improve with a limited debridement of diseased tissue without excessive soft tissue dissection of the tendon.

This study evaluated the shoe-surface interaction of 15 football shoes made by 3 manufacturers in both ante rior translation and rotation using a specially designed pneumatic testing system. The shoes included tradi tional cleated football shoes, "court" shoes (basketball- style shoes), molded-cleat shoes, and turf shoes. Un der an 11.35-kg (25-pound) axial load, all shoes were tested on synthetic turf under wet and dry conditions and on natural stadium grass. Test-retest reliability, as calculated using the Pearson Product-Moment Corre lation test, was 0.85 for force of translation and 0.55 for the moment of rotation. The wet versus dry surface values on translation were significantly different for rotation about the tibial axis. Spatting, which is protec tive taping of the ankle and heel applied on the outside of the shoe, resulted in a reduction of forces generated in both translation and rotation. No overall difference between shoes on grass versus AstroTurf was noted. However, there were significant differences for cleated and turf shoes. Shoes tested in conditions for which they were not designed exhibited reproducible exces sive or extreme minimal friction characteristics that may have safety implications. On the basis of this study, we urge shoe manufacturers to display sug gested indications and playing surface conditions for which their shoes are recommended.

Between 1977 and 1992, 42 patients were seen who had 51 feet operated upon for bunions in which the surgery failed. A total of 105 procedures were done on these 51 feet until the patients either achieved satisfactory correction (N = 28) or they declined (N = 14) further surgery. An analysis of these failures and review of literature revealed 12 anatomic variations and 7 secondary factors that were seen in association with surgical failure. These findings were correlated with published criteria and our experience with various bunion procedures to advance general indications and contraindications for specific bunion procedures.

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.

This study documents changes in momentary distri bution of forces under the foot, comparing barefoot gait to that with heel cups, medial arch supports, and low-dye taping. Cholesterol crystal force plate analy sis and a computerized Kistler force platform were used in the study. Low-dye taping or a heel cup significantly diminished the duration of forces under the midfoot, medializing the instant center of forces. A medial arch support shifted the instant center of forces laterally, though it did not diminish the duration of forces under the arch. The relationship between these alterations of force distribution and the treat ment of common runner's ailments such as plantar fasciitis, posterior tibial tendinitis, metatarsalgia, and shin splints is much clearer in the light of these results.