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1.  Osteochondral Avulsion Fracture of the Anterior Cruciate Ligament Femoral Origin in a 10-Year-Old Child: A Case Report 
Journal of Athletic Training  2011;46(4):451-455.
Objective:
To describe the case of a 10-year-old football player who sustained a comminuted osteochondral avulsion fracture of the femoral origin of the anterior cruciate ligament (ACL) via a low-energy mechanism.
Background:
In children, both purely cartilaginous and osteochondral avulsion fractures have been described; most such ACL avulsions are from the tibial eminence. In the few previous case reports describing femoral osteochondral avulsion fractures, high-energy injury mechanisms were typically responsible and resulted in a single fracture fragment.
Differential Diagnosis:
Femoral osteochondral avulsion fracture at the ACL origin, femoral cartilaginous avulsion fracture at the ACL origin, midsubstance ACL tear, meniscal tear.
Treatment:
Sutures and a button were used to repair the comminuted fragments. Postoperatively, a modified ACL reconstruction rehabilitation program was instituted.
Uniqueness:
Most injuries of this nature in youngsters are caused by a high-energy mechanism of injury, result in an osteochondral avulsion fracture of the tibial eminence, and involve a single fracture fragment.
Conclusions:
Although they occur infrequently, ACL femoral avulsion fractures in children can result from a low-energy injury mechanism. Identifying the mechanism of injury, performing a thorough physical examination, and obtaining appropriate diagnostic studies will enable the correct treatment to be implemented, with the goal of safely returning the athlete to play.
PMCID: PMC3419159  PMID: 21944079
injury mechanisms; knee injuries; pediatric injuries
2.  Surgical Treatment Options for Osteochondritis Dissecans of the Knee 
Sports Health  2009;1(4):326-334.
Osteochondritis dissecans of the knee is identified with increasing frequency in the young adult patient. Left untreated, osteochondritis dissecans can lead to the development of osteoarthritis at an early age, resulting in progressive pain and disability. Treatment of osteochondritis dissecans may include nonoperative or operative intervention. Surgical treatment is indicated mainly by lesion stability, physeal closure, and clinical symptoms. Reestablishing the joint surface, maximizing the osteochondral biologic environment, achieving rigid fixation, and ensuring early motion are paramount to fragment preservation. In cases where the fragment is not amenable to preservation, the treatment may include complex reconstruction procedures, such as marrow stimulation, osteochondral autograft, fresh osteochondral allograft, and autologous chondrocyte implantation. Treatment goals include pain relief, restoration of function, and the prevention of secondary osteoarthritis.
doi:10.1177/1941738109334216
PMCID: PMC3445128  PMID: 23015890
osteochondritis dissecans; knee; cartilage; surgical treatment
3.  Cartilage lesions in patellofemoral dislocations: Incidents/locations/when to treat 
Patellofemoral dislocations are frequently associated with chondral injury. Chondral and osteochondral lesions are often associated with traumatic (high energy) patellofemoral dislocations whereas atraumatic (low energy) patellofemoral dislocations in patients with significant patellofemoral risk factors have a much lower incidence of osteochondral damage. This article provides a historical overview and delineates the current state of radiographic and clinical outcomes of osteochondral lesions after patellofemoral dislocation. The importance of understanding risk factors of redislocation is emphasized and the current treatment options for these cartilage lesions associated with patellofemoral dislocation are briefly summarized.
doi:10.1097/JSA.0b013e318259bc40
PMCID: PMC3968778  PMID: 22878659
patella dislocation; osteochondral lesions; articular cartilage
4.  Meniscoplasty for stable osteochondritis dissecans of the lateral femoral condyle combined with a discoid lateral meniscus: a case report 
Introduction
Osteochondritis dissecans of the lateral femoral condyle is relatively rare, and it is reported to often be combined with a discoid lateral meniscus. Given the potential for healing, conservative management is indicated for stable osteochondritis dissecans in patients who are skeletally immature. However, patients with osteochondritis dissecans of the lateral femoral condyle combined with a discoid lateral meniscus often have persistent symptoms despite conservative management.
Case presentation
We present the case of a seven-year-old Korean girl who had osteochondritis dissecans of the lateral femoral condyle combined with a discoid lateral meniscus, which healed after meniscoplasty for the symptomatic lateral discoid meniscus without surgical intervention for the osteochondritis dissecans. In addition, healing of the osteochondritis dissecans lesion was confirmed by an MRI scan five months after the operation.
Conclusions
Meniscoplasty can be recommended for symptomatic stable juvenile osteochondritis dissecans of the lateral femoral condyle combined with a discoid lateral meniscus when conservative treatment fails.
doi:10.1186/1752-1947-5-434
PMCID: PMC3177932  PMID: 21896174
5.  Radiologic Assessment of Patellofemoral Pain in the Athlete 
Sports Health  2011;3(2):195-210.
Context:
Although disorders of the patellofemoral joint are common in the athlete, their management can be challenging and require a thorough physical examination and radiologic evaluation, including advanced magnetic resonance imaging techniques.
Evidence Acquisition:
Relevant articles were searched under OVID and MEDLINE (1968 to 2010) using the keywords patellofemoral joint, patellofemoral pain or patella and radiography, imaging, or magnetic resonance imaging, and the referenced sources were reviewed for additional articles. The quality and validity of the studies were assessed on the basis of careful analysis of the materials and methods before their inclusion in this article.
Results:
Physical examination and imaging evaluation including standard radiographs are crucial in identifying evidence of malalignment or instability. Magnetic resonance imaging provides valuable information about concomitant soft tissue injuries to the medial stabilizers as well as injuries to the articular cartilage, including chondral shears and osteochondral fractures. Quantitative magnetic resonance imaging assessing the ultrastructure of cartilage has shown high correlation with histology and may be useful for timing surgery.
Conclusions:
Evaluation of patellofemoral disorders is complex and requires a comprehensive assessment. Recent advancements in imaging have made possible a more precise evaluation of the individual anatomy of the patient, addressing issues of malalignment, instability, and underlying cartilage damage.
doi:10.1177/1941738110397875
PMCID: PMC3445133  PMID: 23016009
Patellofemoral joint; patellofemoral pain; chondromalacia patella; Magnetic Resonance Imaging
6.  Bilateral atraumatic medial meniscal tears in a 17-year-old rower 
BMJ Case Reports  2009;2009:bcr11.2008.1258.
Meniscal injury produces disability in a large portion of the population, and sports injuries are a common cause. Atraumatic meniscal tears may occur after repetitive low-energy loading. Rowing is a highly technical sport and very demanding on an athlete’s body. There are numerous reports on patellofemoral and iliotibial band friction syndrome in rowers but there is an extremely low incidence of meniscal tears reported in these athletes. This is a unique case report of a young adolescent athlete who suffered bilateral medical meniscal tears during sporting activity. Rowing is a low impact sport making this an unusual occurrence, especially in a young individual. This case report highlights the importance of considering all training activities when trying to isolate the mechanism of injury in an athlete.
doi:10.1136/bcr.11.2008.1258
PMCID: PMC3028201  PMID: 21686387
7.  Time to Stabilization of Anterior Cruciate Ligament–Reconstructed Versus Healthy Knees in National Collegiate Athletic Association Division I Female Athletes 
Journal of Athletic Training  2010;45(6):580-585.
Abstract
Context:
Jump landing is a common activity in collegiate activities, such as women's basketball, volleyball, and soccer, and is a common mechanism for anterior cruciate ligament (ACL) injury. It is important to better understand how athletes returning to competition after ACL reconstruction are able to maintain dynamic postural control during a jump landing.
Objective:
To use time to stabilization (TTS) to measure differences in dynamic postural control during jump landing in ACL-reconstructed (ACLR) knees compared with healthy knees among National Collegiate Athletic Association Division I female athletes.
Design:
Case-control study.
Setting:
University athletic training research laboratory.
Patients or Other Participants:
Twenty-four Division I female basketball, volleyball, and soccer players volunteered and were assigned to the healthy control group (n  =  12) or the ACLR knee group (n  =  12). Participants with ACLR knees were matched to participants with healthy knees by sport and by similar age, height, and mass.
Intervention(s):
At 1 session, participants performed a single-leg landing task for both limbs. They were instructed to stabilize as quickly as possible in a single-limb stance and remain as motionless as possible for 10 seconds.
Main Outcome Measure(s):
The anterior-posterior TTS and medial-lateral TTS ground reaction force data were used to calculate resultant vector of the TTS (RVTTS) during a jump landing. A 1-way analysis of variance was used to determine group differences on RVTTS. The means and SDs from the participants' 10 trials in each leg were used for the analyses.
Results:
The ACLR group (2.01 ± 0.15 seconds, 95% confidence interval [CI]  =  1.91, 2.10) took longer to stabilize than the control group (1.90 ± 0.07 seconds, 95% CI  =  1.86, 1.95) (F1,22  =  4.28, P  =  .05). This result was associated with a large effect size and a 95% CI that did not cross zero (Cohen d  =  1.0, 95% CI  =  0.91, 1.09).
Conclusions:
Although they were Division I female athletes at an average of 2.5 years after ACL reconstruction, participants with ACLR knees demonstrated dynamic postural-control deficits as evidenced by their difficulty in controlling ground reaction forces. This increased TTS measurement might contribute to the established literature reflecting differences in single-limb dynamic control. Clinicians might need to focus rehabilitation efforts on stabilization after jump landing. Further research is needed to determine if TTS is a contributing factor in future injury.
doi:10.4085/1062-6050-45.6.580
PMCID: PMC2978009  PMID: 21062181
postural control; jump landings; dynamic stability
8.  Refixation of osteochondral fractures by ultrasound-activated, resorbable pins 
Bone & Joint Research  2013;2(2):26-32.
Objectives
Osteochondral injuries, if not treated adequately, often lead to severe osteoarthritis. Possible treatment options include refixation of the fragment or replacement therapies such as Pridie drilling, microfracture or osteochondral grafts, all of which have certain disadvantages. Only refixation of the fragment can produce a smooth and resilient joint surface. The aim of this study was the evaluation of an ultrasound-activated bioresorbable pin for the refixation of osteochondral fragments under physiological conditions.
Methods
In 16 Merino sheep, specific osteochondral fragments of the medial femoral condyle were produced and refixed with one of conventional bioresorbable pins, titanium screws or ultrasound-activated pins. Macro- and microscopic scoring was undertaken after three months.
Results
The healing ratio with ultrasound-activated pins was higher than with conventional pins. No negative heat effect on cartilage has been shown.
Conclusion
As the material is bioresorbable, no further surgery is required to remove the implant. MRI imaging is not compromised, as it is with implanted screws. The use of bioresorbable pins using ultrasound is a promising technology for the refixation of osteochondral fractures.
doi:10.1302/2046-3758.22.2000099
PMCID: PMC3626216  PMID: 23610699
Osteochondral fracture; Ultrasound-activated pin; Bioresorbable implant; Sheep study; Cartilage; Polylactide
9.  Osteochondral Repair of Primate Knee Femoral and Patellar Articular Surfaces: Implications for Preventing Post-Traumatic Osteoarthritis 
The risk of post-traumatic osteoarthritis following an intra-articular fracture is determined to large extent by the success or failure of osteochondral repair. To measure the efficacy of osteochondral repair in a primate and determine if osteochondral repair differs in the patella (PA) and the medial femoral condyle (FC) and if passive motion treatment affects osteochondral repair, we created 3.2 mm diameter 4.0 mm deep osteochondral defects of the articular surfaces of the PA and FC in both knees of twelve skeletally mature cynomolgus monkeys. Defects were treated with intermittent passive motion (IPM) or castimmobilization (CI) for two weeks, followed by six weeks of ad libitum cage activity. We measured restoration of the articular surface, and the volume, composition, type II collagen concentration and in situ material properties of the repair tissue. The osteochondral repair response restored a mean of 56% of the FC and 34% of the PA articular surfaces and filled a mean of 68% of the chondral and 92% of the osseous defect volumes respectively. FC defect repair produced higher concentrations of hyaline cartilage (FC 83% vs. PA 52% in chondral defects and FC 26% vs. PA 14% in osseous defects) and type II collagen (FC 84% vs. PA 71% in chondral defects and FC 37% vs. PA 9% in osseous defects) than PA repair. IPM did not increase the volume of chondral or osseous repair tissue in PA or FC defects. In both PA and FC defects, IPM stimulated slightly greater expression of type II collagen in chondral repair tissue (IPM 81% vs. CI 74%); and, produced a higher concentration of hyaline repair tissue (IPM 62% vs. CI 42%), but IPM produced poorer restoration of PA articular surfaces (IPM 23% vs. CI 45%). Normal articular cartilage was stiffer, and had a larger Poisson's ratio and less permeability than repair cartilage. Overall CI treated repair tissue was stiffer and less permeable than IPM treated repair tissue. The stiffness, Poisson's ratio and permeability of femoral condyle cast immobilized (FC CI) treated repair tissue most closely approached the normal values. The differences in osteochondral repair between FC and PA articular surfaces suggest that the mechanical environment strongly influences the quality of articular surface repair. Decreasing the risk of posttraumatic osteoarthritis following intra-articular fractures will depend on finding methods of promoting the osteochondral repair response including modifying the intra-articular biological and mechanical environments.
PMCID: PMC1888400  PMID: 14575253
10.  Does ORIF of an OCD Loose Body Result in Healing and Long Term Maintenance of Knee Function? 
Background
Osteochondritis dissecans (OCD) can progress to loose body formation resulting in a Grade IV defect. The decision to fix versus excise the loose body is controversial. Published operative fixation outcomes are small case series with short follow-up.
Hypothesis
Operative fixation (ORIF) of the loose body into the grade IV defect will heal and approximate “normal” knee function at long-term follow-up.
Study Design
Case series
Methods
Twelve patients were identified who underwent ORIF of a knee OCD loose body into the Grade IV osteochondral defects ranging in size from 2.0 to 8.0 cm2 (mean 3.5 cm2). After 12 weeks, hardware was removed and healing was assessed. Long-term outcomes were assessed with a Knee injury and Osteoarthritis Outcome Score (KOOS) and a Marx activity score.
Results
Arthroscopy for screw removal revealed stable healing in 92% (11/12) of patients. No patients required subsequent surgery for a loose body. At an average of 9.2 years follow-up (range 3.8-15.8 years) 83 % (10/12) of patients completed the KOOS. KOOS subscale scores for pain (mean 87.8, range 67-100), other symptoms (mean 81.8, range 61-96), function in activities of daily living (mean 93.1, range 72-100), and sports and recreation function (mean 74.0, range 40-100) were not significantly lower than published age matched controls. However the KOOS subscale for knee related quality of life (mean 61.9, range 31-88) was significantly lower (p = 0.003).
Conclusions
Operative fixation of Grade IV OCD loose bodies results in stable fixation. At an average 9 years after surgery, patients did not have symptoms of osteoarthritis pain and had normal function in activities of daily life. However, patients reported significantly lower knee related quality of life. Operative fixation of OCD loose bodies is a better alternative to lesion excision.
doi:10.1177/0363546508328119
PMCID: PMC3692365  PMID: 19204369
11.  Osteochondral Fracture Lateral Femoral Condyle Treated with ORIF Using Z-Plasty: A Modification of Coonse and Adams Approach 
Case Reports in Orthopedics  2011;2011:957196.
Osteochondral fractures of lateral femoral condyle are common in adolescents and young adults. They are usually caused by direct trauma or twisting injuries of the knee. We present a case of large osteochondral fracture of lateral femoral condyle involving the articular surface in a fifteen-year-old male with a positive history of significant weight gain of 5 kilograms in last six months. Blood investigations reported low vitamin D and testosterone levels with elevated alkaline phosphatase. Adequate exposure was achieved by doing Z-plasty of quadriceps apparatus. The fracture was treated with open reduction and internal fixation using Herbert's screws. Medical management in the form of vitamin D and calcium along with testosterone was given. After the surgery, full weight-bearing was allowed at three months. At one year followup, patient has good quadriceps function without any weakness of the muscle.
doi:10.1155/2011/957196
PMCID: PMC3505926  PMID: 23259106
12.  Traumatic Hemarthrosis of the Knee Secondary to Hemophilia A in a Collegiate Soccer Player: A Case Report 
Journal of Athletic Training  2002;37(3):315-319.
Objective: To present the case of a collegiate soccer player who suffered from a traumatic knee hemarthrosis secondary to hemophilia A. This case presents an opportunity to discuss the participation status of athletes with hemophilia.
Background: Hemophilia is a hereditary blood disease characterized by impaired coagulability of the blood. Hemophilia A is the most common of the severe, inherited bleeding disorders. This type, also called classic hemophilia, is due to a deficiency of clotting factor VIII. The athlete with hemophilia A reported pain and loss of function of his knee during a soccer game despite the absence of injury.
Differential Diagnosis: Anterior cruciate ligament tear, intra-articular fracture, meniscus tear, capsular tear, hemarthrosis.
Treatment: After the injury, the athlete was admitted to the hospital, where his knee joint was aspirated and he was infused with factor VIII. Later, he participated in traditional knee rehabilitation and was returned to play at the discretion of the orthopaedist and the hematologist.
Uniqueness: In past participation guidelines, individuals with bleeding disorders were disqualified from athletic participation; however, with advances in medical care, these individuals may be permitted to participate in accordance with the law.
Conclusions: Individuals with hemophilia participate in athletics; therefore, team physicians and athletic trainers must be prepared to care for these individuals.
PMCID: PMC164362  PMID: 12937588
Americans with Disabilities Act; desmopressin acetate; factor VIII; preparticipation physical examination; blood coagulation
13.  Establishing proof of concept: Platelet-rich plasma and bone marrow aspirate concentrate may improve cartilage repair following surgical treatment for osteochondral lesions of the talus 
World Journal of Orthopedics  2012;3(7):101-108.
Osteochondral lesions of the talus are common injuries in the athletic patient. They present a challenging clinical problem as cartilage has a poor potential for healing. Current surgical treatments consist of reparative (microfracture) or replacement (autologous osteochondral graft) strategies and demonstrate good clinical outcomes at the short and medium term follow-up. Radiological findings and second-look arthroscopy however, indicate possible poor cartilage repair with evidence of fibrous infill and fissuring of the regenerative tissue following microfracture. Longer-term follow-up echoes these findings as it demonstrates a decline in clinical outcome. The nature of the cartilage repair that occurs for an osteochondral graft to become integrated with the native surround tissue is also of concern. Studies have shown evidence of poor cartilage integration, with chondrocyte death at the periphery of the graft, possibly causing cyst formation due to synovial fluid ingress. Biological adjuncts, in the form of platelet-rich plasma (PRP) and bone marrow aspirate concentrate (BMAC), have been investigated with regard to their potential in improving cartilage repair in both in vitro and in vitro settings. The in vitro literature indicates that these biological adjuncts may increase chondrocyte proliferation as well as synthetic capability, while limiting the catabolic effects of an inflammatory joint environment. These findings have been extrapolated to in vitro animal models, with results showing that both PRP and BMAC improve cartilage repair. The basic science literature therefore establishes the proof of concept that biological adjuncts may improve cartilage repair when used in conjunction with reparative and replacement treatment strategies for osteochondral lesions of the talus.
doi:10.5312/wjo.v3.i7.101
PMCID: PMC3399015  PMID: 22816065
Osteochondral lesion; Cartilage repair; Platelet-rich plasma; Bone marrow aspirate concentrate
14.  Arthroscopically-assisted reduction and fixation of an old osteochondral fracture of the lateral femoral condyle 
Summary
Background
Osteochondral fracture (OCF) of the lateral femoral condyle has a low incidence and old OCF is even more rarely seen; it is difficult to differentiate from late osteochondritis dissecans (OCD).
Case Report
In this report, we present the case of a 20-year-old male patient with an old OCF of the lateral femoral condyle. The possible etiology of OCF is discussed, along with its clinical manifestation, diagnosis, and treatment. He underwent arthroscopically-assisted reduction and fixation with cannulated screws. Four months after the surgery, arthroscopy showed good osteochondral healing, and screws were removed. He had achieved good functional recovery by the follow-up visit.
Conclusions
Old OCF should be distinguished from OCD in clinical practice, and osteochondral bodies should be preserved as much as possible. Osteochondral reduction and fixation under arthroscopy was minimal and the clinical effect was good.
doi:10.12659/MSM.883637
PMCID: PMC3560805  PMID: 23235545
osteochondral fracture (OCF); arthroscopy; femoral condyle
15.  Osteochondritis Dissecans of the Talar Dome in a Collegiate Swimmer: A Case Report 
Journal of Athletic Training  1998;33(4):365-371.
Objective:
To present the case of an intercollegiate swimmer with a stage IV lateral talar dome injury and associated bony fragments.
Background:
Lack of distinct diagnostic symptoms, low index of clinical suspicion, and the difficulty of visualizing the early stages of this injury on standard x-rays cause frequent misdiagnosis of talar dome lesions.
Differential Diagnosis:
Ganglion cyst, with inflammatory synovitis secondary to rupture of cyst; loose bodies from previous occult fracture; osteochondral fracture.
Treatment:
Initial treatment with nonsteroidal antiinflammatory drugs and a posterior splint for comfort, followed by arthroscopic excision of loose bodies with abrasion and drilling arthroplasty.
Uniqueness:
Patient presented to the team physician for care of acute left medial ankle pain after the athletic trainer had attempted to rupture a ganglion cyst on the anterolateral aspect of the patient's ankle.
Conclusions:
Increased clinical suspicion is necessary to correctly diagnose osteochondral lesions, particularly in the early stages. Aggressive treatment of talar dome lesions has a good success rate and may be an attractive option for competitive athletes.
Images
PMCID: PMC1320590  PMID: 16558537
ganglion cyst; inflammatory synovitis; osteochondral fracture
16.  Fixation of osteochondral fragments in the human knee using Meniscus Arrows® 
The aim of this study is to compare the hold in bone of Meniscus Arrows® and Smart Nails®, followed by the report of the results of the clinical application of Meniscus Arrows® as fixation devices. First, pull-out tests were performed to analyse the holdfast of both nails in bone. Statistical analysis showed no significant difference; therefore, the thinner Meniscus Arrow® was chosen as fixation device in the patient series of two patients with a symptomatic Osteochondritis dissecans fragment and three patients with an osteochondral fracture of a femur condyle. The cartilage margins were glued with Tissuecoll®. All fragments consolidated. Second look arthroscopy in three patients showed fixed fragments with stable, congruent cartilage edges. At an average follow-up period of 5 years no pain, effusion, locking, restricted range of motion or signs of osteoarthritis were reported. Based on the results of the pull-out tests and available clinical studies, Meniscus Arrows® and Smart Nails® are both likely to perform adequately as fixation devices in the treatment of Osteochondritis dissecans and osteochondral fractures in the knee. They both provide the advantage of one stage surgery. However, based on their smaller diameter, the Meniscus Arrows® should be preferred for this indication.
doi:10.1007/s00167-010-1158-5
PMCID: PMC3023860  PMID: 20464370
Osteochondritis dissecans; Osteochondral fragments; Biodegradable; Fixation devices; Meniscus Arrows®
17.  Traumatic Hyphema in an Intercollegiate Baseball Player: A Case Report 
Journal of Athletic Training  1999;34(1):25-28.
Objective:
To present the case of a collegiate baseball player struck in the right eye.
Background:
While attempting a bunt, a 20-year-old collegiate baseball player was hit in the right eye when the ball was deflected off the bat. The athlete bled from the nose, and the right eye swelled shut from eyelid edema. Initial nasal hemorrhage was controlled, and the athlete was referred to the emergency room for further care due to pain in the inferior orbit.
Differential Diagnosis:
Eyelid contusion, traumatic iritis, or traumatic microhyphema to the right eye secondary to blunt trauma.
Treatment:
Immediate treatment consisted of controlling the nasal bleeding with sterile gauze pads. Because of palpable tenderness over the inferior orbit, the athlete was immediately transported to the emergency room.
Uniqueness:
Hyphema is one of the most common sport-related eye injuries: the incidence is 12.2 cases per 100,000 population, with approximately 37% resulting from sports injury. Racquet sports, baseball, and softball account for more than half of all hyphema injuries in athletics. Individuals with traumatic hyphema rarely require surgery; however, proper initial care, treatment, and referral are imperative to a good prognosis.
Conclusions:
Athletic trainers need to be able to recognize the signs and symptoms of hyphema and seek medical evaluation immediately in order to avoid secondary complications. With proper recognition, initial care and referral, and appropriate, well-fitted protective eyewear as needed, hyphema can have minimal complications, and the athlete may be able to compete again within 1 to 2 weeks.
Images
PMCID: PMC1322870  PMID: 16558544
cycloplegia; fundoscopy; gonioscopy; limbal tissue; tonometry
18.  Acute Atraumatic Compartment Syndrome in an Athlete: A Case Report 
Journal of Athletic Training  1997;32(3):248-250.
Objective:
To present the case of a college football player with acute, atraumatic, exercise-induced compartment syndrome in the leg.
Background:
Acute, atraumatic, exercise-induced compartment syndrome is an infrequently reported cause of leg pain in the athlete. If left untreated, acute compartment syndrome can cause muscle necrosis.
Differential Diagnosis:
Chronic exertional compartment syndrome, medial tibial syndrome, stress fracture.
Treatment:
Treatment consists of compartment fasciotomy.
Uniqueness:
This previously healthy, but unconditioned, athlete developed severe anterolateral left leg pain after two days of fall practice in which he was unable to run a mile in 7.5 minutes. Physical examination by the team physician revealed acute compartment syndrome, and an emergency anterolateral compartment fasciotomy was performed. Second-look débridement performed 48 hours later revealed no significant change in the necrotic appearance of the anterior compartment soft tissue. Therefore, the dead muscle was completely débrided, and a free-flap latissumus dorsi graft was used for coverage of the wound. With recovery, strength returned to normal in the lateral compartment but remained 0/5 in the anterior compartment. The patient had persistent sensory loss in the distributions of the superficial and deep peroneal nerves.
Conclusions:
Although much less common than the more frequent causes of leg pain (ie, chronic exertional compartment syndrome, medial tibial syndrome, stress fracture), acute compartment syndrome is potentially more devastating. When the increased intracompartmental pressure within a closed tissue space exceeds capillary perfusion pressure, tissue perfusion is decreased, the soft tissue becomes ischemic, and cells die. The most important clinical diagnostic signs of compartment syndrome are pain with passive stretching of the compartment and pain out of proportion to the results of the physical examination.
Images
PMCID: PMC1320246  PMID: 16558458
leg pain; fasciotomy; rhabdomyolysis
19.  Midterm results of biologic fixation or mosaicplasty and drilling in osteochondritis dissecans 
Indian Journal of Orthopaedics  2011;45(5):445-449.
Background:
Osteochondritis dissecans (OCD) primarily affects subchondral bone. Multiple drilling, fixation implant or autogenous osteochondral grafts are reported as treatment options. We present the midterm results of cases in which an OCD lesion was treated by osteochondral autograft transfer and drilling.
Materials and Methods:
Between 2002 and 2006, 14 knees with International Cartilage Repair Society (ICRS-OCD) type II and III lesions were treated in our clinic using osteochondral autograft transfer and drilling by arthroscopic or open surgery. The average age of our patients was 22.14 years (range 17-29 years) and average followup was of 24.3 months (range 11-40 months). Lesion type was ICRS type II in five patients (35.7%) and ICRS type III in nine patients (64.3%). In cases with ICRS-OCD type II lesions, in situ fixation was applied following circumferential multiple drilling, while mosaicplasty was done following debridement and multiple drilling in cases with ICRS-OCD type III lesion. Mosaicplasty was performed in the lesion area by an average of 2.5 (range 1-3) cylindrical osteochondral autografts. Patients were not allowed to perform loading activities for 3 weeks in the postoperative period; movement was initiated by using CPM device in the early phase; full range of motion was achieved in third week, and full weight bearing was permitted in 6 to 8 weeks
Results:
While 6 and 8 patients were classified preoperatively as fair and poor, respectively, according to Hughston scale, excellent and good results were obtained postoperatively in 10 and 4 patients, respectively. During the followup, no problems were detected in any of the patients in the regions where osteochondral graft was harvested.
Conclusion:
Biologic fixation or mosaicplasty and drilling as a technique to treatment of the lesion in OCD by osteochondral autograft transfer has resulted in good and excellent clinical outcomes in our patients and it is considered that providing blood flow to subchondral bone by circumferencial drilling leads to an increase in the robustness of biological internal fixation and shortens the duration of recovery.
doi:10.4103/0019-5413.83137
PMCID: PMC3162682  PMID: 21886927
Osteochondritis dissecans; Hughston scale; knee; mosaicplasty
20.  Case Report: Osteochondral Avulsion Fracture of the Posteromedial Bundle of the PCL in Knee Hyperflexion 
Background
Injury of the PCL of the knee in adults usually results in rupture rather than avulsion fracture and avulsions usually occur at the tibial insertion.
Case Description
We report an avulsion of the PCL with a femoral origin in a 22-year-old man who was injured by hyperflexion of the knee and was treated with arthroscopy. There were two parts in the partial osteochondral avulsion fracture of the PCL posteromedial (PM) bundle. One part was fixed with polydioxanone suture through drill holes and the other was removed. The fracture healed after 3 months and the knee was stable. At 11 months postoperatively the patient had returned to full-time work without pain or restrictions. The Lysholm II knee score was 95 points. Physical examination showed a negative posterior drawer sign.
Literature Review
We identified four other reported cases of PCL femoral origin avulsion fractures in adults. The subjects were 20 to 25 years old in four of five reports, including our patient. Three of the five patients had involvement of only the lateral cortex of the medial femoral condyle whereas two other patients including our patient, had an osteochondral fracture. The mechanism of PCL avulsion seems to be similar to that of a PCL rupture.
Purposes and Clinical Relevance
The hyperflexion injury may result in injury of the PM bundle of the PCL. Our case and one other in the literature suggest such avulsions need not involve the entire PCL.
doi:10.1007/s11999-012-2632-9
PMCID: PMC3492605  PMID: 23054525
21.  Isolated Hyoid Bone Fractures in Collegiate Football Players 
Sports Health  2012;4(1):51-56.
Hyoid fractures in athletes are rare injuries that can be difficult to diagnose. Typically resulting from a direct blow to the anterior neck, hyoid fractures can lead to subcutaneous edema and subsequent airway compromise. The treatment of this fracture depends largely on the severity of the presenting symptoms. Generally, these fractures do not require surgical intervention but warrant close observation for delayed onset of airway obstruction. To raise awareness of this potentially dangerous fracture, the authors present 2 cases of isolated hyoid fractures in collegiate football players at our institution.
doi:10.1177/1941738111419963
PMCID: PMC3435900  PMID: 23016069
hyoid fracture; athletes; football
22.  An Acute, Traumatic Supraspinatus Lesion in an Intercollegiate Football Player: A Case Report 
Journal of Athletic Training  2000;35(2):198-203.
Objective:
To describe the evaluation, management, and rehabilitation of an acute, supraspinatus tendon injury in an intercollegiate football player.
Background:
While attempting to block a defender, a 19-year-old collegiate football player slipped on the artificial turf and landed on his right elbow, causing an injury to his right shoulder. The athlete was initially seen by the head athletic trainer and then referred to the team physician for further evaluation.
Differential Diagnosis:
acromioclavicular joint sprain, brachial plexopathy, subacromial impingement syndrome, supraspinatus lesion.
Treatment:
The athlete was managed surgically with an open acromioplasty and a 3-bone tunnel repair of the supraspinatus tendon. After surgery, the athlete underwent a 4-month rehabilitation protocol in preparation for return to competition.
Uniqueness:
This case involved a teenage athlete rather than the older individuals who normally sustain rotator cuff lesions. Also, the mechanism was a compressive force on the supraspinatus tendon rather than the tensile force common to rotator cuff lesions.
Conclusions:
By presenting this case report, we hope to give sports medicine clinicians a better understanding of rotator cuff injuries and how to successfully manage and rehabilitate supraspinatus lesions.
Images
PMCID: PMC1323418  PMID: 16558631
acromioplasty; rotator cuff repair; shoulder injury
23.  Traumatic Acetabular Fracture in an Intercollegiate Football Player: A Case Report 
Journal of Athletic Training  2000;35(1):103-107.
Objective:
To present the case of a 22-year-old football player who sustained an acute posterior-wall acetabular fracture.
Background:
Acetabular fractures can be a difficult injury for the athletic trainer to assess. Aside from the obvious immediate ramifications, proper assessment and care are necessary to decrease the chance of developing posttraumatic arthritis and other long-term complications.
Differential Diagnosis:
Anterior column fracture, T-shaped acetabular fracture, segmental fracture of the femoral head, femoral neck fracture, capsular tear, retroperitoneal hematoma, posterior column acetabular fracture.
Treatment:
The athlete was treated with open reduction internal fixation using 5 screws and a plate. He pursued a rehabilitation program and returned to full activity 9 months later.
Uniqueness:
Acetabular fractures are usually associated with motor vehicle accidents. However, this athlete sustained an injury mechanism that rarely occurs in athletes.
Conclusions:
Certified athletic trainers need to recognize the signs and symptoms associated with acetabular fractures. Initial recognition and appropriate management and treatment are essential to avoid long-term complications.
Images
PMCID: PMC1323449  PMID: 16558600
posterior wall segment; antalgic gait; avascular necrosis; open reduction; internal fixation
24.  Medial Impingement of the Ankle in Athletes 
Sports Health  2010;2(6):495-502.
Context:
Medial impingement syndrome of the ankle is common in the athletic population. A marginal osteophyte on the leading edge of the medial talar facet and a corresponding “kissing” osteophyte on the tibia, in front of the medial malleolus, may abut and cause pain and limited dorsiflexion.
Background:
Palpation of the talar osteophyte and standard imaging—especially, the oblique view of the foot—are useful in making the diagnosis. Surgical removal of the osteophyte may be necessary.
Conclusions:
Ankle impingement is commonly seen in running and jumping sports, especially if the athlete has a subtle cavus foot. It may be associated with ankle instability, osteochondritis dissecans of the talus, and stress fractures of the foot.
doi:10.1177/1941738110384570
PMCID: PMC3438865  PMID: 23015980
ankle; impingement; sports injuries; talus; medial malleolus
25.  The Thrower's Elbow: Arthroscopic Treatment of Valgus Extension Overload Syndrome 
HSS Journal  2006;2(1):83-93.
Injury to the medial collateral ligament of the elbow (MCL) can be a career-threatening injury for an overhead athlete without appropriate diagnosis and treatment. It has been considered separately from other athletic injuries due to the unique constellation of pathology that results from repetitive overhead throwing. The past decade has witnessed tremendous gains in understanding of the complex interplay between the dynamic and static stabilizers of the athlete's elbow. Likewise, the necessity to treat these problems in a minimally invasive manner has driven the development of sophisticated techniques and instrumentation for elbow arthroscopy.
MCL injuries, ulnar neuritis, valgus extension overload with osteophyte formation and posteromedial impingement, flexor pronator strain, medial epicondyle pathology, and osteochondritis dissecans (OCD) of the capitellum have all been described as sequelae of the overhead throwing motion. In addition, loose body formation, bony spur formation, and capsular contracture can all be present in conjunction with these problems or as isolated entities. Not all pathology in the thrower's elbow is amenable to arthroscopic treatment; however, the clinician must be familiar with all of these problems in order to form a comprehensive differential diagnosis for an athlete presenting with elbow pain, and he or she must be comfortable with the variety of open and arthroscopic treatments available to best serve the patient.
An understanding of the anatomy and biomechanics of the thrower's elbow is critical to the care of this population. The preoperative evaluation should focus on a thorough history and physical examination, as wellas on specific diagnostic imaging modalities. Arthroscopic setup, including anesthesia, patient positioning, and portal choices will be discussed. Operative techniques in the anterior and posterior compartments will bereviewed, as well as postoperative rehabilitationandsurgical results. Lastly, complications will be reviewed.
doi:10.1007/s11420-005-5124-6
PMCID: PMC2504117  PMID: 18751853

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