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Bilateral patellar tendon rupture is rare, and usually occurs in patients with ligamentous laxity, a predisposing rheumatologic disorder, chronic renal failure, or exogenous corticosteroid use1-3. We describe a patient who sustained traumatic bilateral patellar tendon ruptures nearly ten years apart. Surgical repair of each knee was successfully performed with use of an open technique, and the patient was followed for more than two years after each procedure. The most recent radiographs demonstrated bilateral patella alta; however, the patient was asymptomatic. To our knowledge, this is the first case report of an individual with asymptomatic bilateral patella alta after surgical repair of bilateral patellar tendon rupture. The patient was informed that data concerning the case would be submitted for publication, and he consented. A forty-seven-year-old man sustained a patellar tendon rupture in each knee, with the ruptures occurring ten years apart. Both tendon ruptures were repaired surgically. No previous knee problems were reported. He had no other medical conditions or surgical procedures and was on no medication. He had no personal or family history of ligamentous laxity. He denied using corticosteroids, tobacco, alcohol, and recreational drugs. He was physically active regularly and worked on his feet daily as a manual laborer. The right patellar tendon ruptured in 2000, after a fall from a standing height; it was repaired acutely at another institution with use of nonabsorbable sutures tied superiorly through transpatellar bone tunnels with no operative or postoperative complications. The patient wore a knee immobilizer for eight weeks postoperatively, and was fully compliant with weight-bearing as tolerated. After eight weeks, he was allowed full active and passive knee motion and experienced no pain. Physical examination ten years later revealed full active knee extension and lower-extremity strength. He was able to actively flex the hip and lift the …

Septic arthritis necessitates prompt recognition and treatment, which optimally includes a combination of medical and surgical interventions. Initial management includes adequate surgical drainage of the infection site, collection of joint and blood specimens for culture and antibiotic-susceptibility testing, and prompt initiation of appropriate antibiotic therapy1. Delayed diagnosis can produce substantial long-term morbidity, including damage to the articular cartilage, physeal injury with growth disturbance, pathologic fractures, and joint stiffness or dislocation2,3. Septic arthritis is becoming more common in the pediatric population, with an estimated incidence of 1/10,000 per year in children younger than twelve years of age4. A variety of bacteria may cause septic arthritis, but the most commonly identified pathogen is Staphylococcus aureus, which causes between 25% and 60% of cases3-5. Posttraumatic septic arthritis is relatively common following open injuries and fractures, but septic arthritis from a closed injury is rarely reported and can be challenging to diagnose2. We present the case of a five-year-old patient who sustained relatively minor trauma and developed septic arthritis in two joints. Permission from both the patient and the family was obtained prior to the submission of this article. A five-year-old otherwise healthy girl with left elbow and left hip pain who refused to walk was transferred to our local pediatric hospital for evaluation. The left elbow pain started eight days prior to presentation, after she was pushed off of a bicycle and landed on her left side. The left leg pain started six days prior to presentation after she had been playing on a trampoline. The day after the hip pain began, the patient was taken to a hospital for evaluation of the pain and refusal to bear weight on the lower limb. Radiographs of the left hip (Fig. …

Objectives Rupture of the ulnar collateral ligament (UCL) is a frequent injury of the hand. When untreated, this injury may lead to decreased pinch strength, pain, instability, and osteoarthritis. There is currently no consensus on treatment of acute or chronic UCL injuries. Our primary purpose was to compare nonoperative treatment with surgical repair and surgical reconstruction of thumb UCL injuries. A secondary purpose was to compare graft choice and surgical technique for reconstruction. Data sources A systematic review of multiple medical databases was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines with specific inclusion and exclusion criteria. Clinical outcome studies after nonoperative or operative treatment of thumb UCL injuries, with a minimum of 2 years mean follow-up, were included. Pain, range of motion, key-pinch strength, and stability testing were used as outcome measures. Main results Fourteen articles were included and analyzed (293 thumbs). All but 2 were level IV evidence. Mean Quality Appraisal Tool score was 13.1 (55% overall rating study methodological quality). Thirty-two thumbs were treated nonoperatively and 261 operatively. Mean subject age was 33.9 years. There were 200 acute injuries and 93 chronic injuries. Mean study follow-up was 42.8 months. Nonoperative treatment often failed, necessitating surgery. Acute UCL repair and autograft UCL reconstruction for chronic injury led to excellent clinical outcomes, without a significant difference between the 2 groups. After significant delay to treatment or even failed nonoperative treatment, excellent clinical outcomes can be achieved, without a difference between initially treating the injury surgically. Complications after surgery were rare. Conclusions This review has demonstrated excellent clinical outcomes after surgical treatment of both acute and chronic UCL injury, without any significant difference between repair and reconstruction for acute and chronic injury, respectively.

Our purpose was to evaluate evidence regarding the effectiveness of open iliopsoas release and lengthening with arthroscopic approaches, which combine iliopsoas release with the treatment of intra-articular pathology as treatments for internal snapping hip syndrome. Searches were performed of 4 databases and 12 reports on the surgical treatment of internal snapping hip were reviewed. The authors tabulated data according to year of study, journal, study type, level of evidence, patient demographics, procedure, and outcomes. We found that surgical treatment of internal snapping hip improves patient symptoms in the majority of patients. Endoscopic release is associated with fewer reported complications compared with open release. All studies of endoscopic treatment of internal snapping hip syndrome also performed intra-articular examination and treatment of intra-articular pathology. The incidence of associated intra-articular pathology was reported in 5 of 6 studies. These results suggest that a painful snapping iliopsoas tendon in many cases may be a result of intra-articular hip pathology rather than an independent entity. Early studies suggest no difference in efficacy or associated complications rate when comparing extracapsular to transcapsular iliopsoas tendon release. Further studies are needed comparing operative to nonoperative treatment and methods of determining patients likely to benefit from operative intervention.

Thusvarious procedures emphasizing glenoid reconstitution havebecome gold standard in patients with recurrent anteriorshoulder instability associated with bony defects. Many ofthese procedures are based on the Bristow or Latarjetprocedures or their modification.In 1954, Latarjet discussed four patients with recurrentanterior dislocation in whom he treated by transferring thecoracoid process with the conjoined tendon to the anteriorscapular neck, securing it with a bone screw.

Background Various methods of bony stabilization, including modifications of Bristow and Latarjet procedures, are considered gold-standard treatment for recurrent anterior shoulder instability but are associated with unique complications and risk of reoperation. The purpose of this study was to identify the prevalence of these complications. We hypothesized that the Bristow-Latarjet procedure would be a successful technique for treatment of shoulder instability but associated with a risk of recurrent postoperative instability, reoperation, and other complications. Methods A systematic review of multiple medical databases included studies reporting outcomes with complication and reoperation rates following original or modified versions of the Bristow or Latarjet shoulder stabilization surgeries. Results Forty-five studies were analyzed (1,904 shoulders) (all Level IV evidence). Most subjects were male (82%). The dominant shoulder was the operative shoulder in 64% of cases. Mean subject age was 25.8 years. Mean clinical follow-up was 6.8 years. Ninety percent of surgeries were done open; 9.3% were all-arthroscopic. Total complication rate was 30%. Recurrent anterior dislocation and subluxation rates were 2.9% and 5.8%, respectively. When reported, most dislocations occurred within the first year postoperatively (73%). Nearly 7% of patients required an unplanned reoperation following surgery. Conclusion Osseous stabilization shoulder surgery using original or modified Bristow and Latarjet procedures has a 30% complication rate. Rates of recurrent dislocation and reoperation were 2.9% and 7%, respectively. Mild loss of external rotation is common. Reoperation rates were lower following all-arthroscopic techniques. There was a greater loss of postoperative external rotation with all-arthroscopic surgery.

Cartilage lesions are among the most commonly reported knee injuries1 and can progress to osteoarthritis2-4. These lesions have been reported to cause limitations in quality of life similar to severe osteoarthritis4. A number of biological treatment approaches have been proposed, and these approaches can be classified into one of five categories: palliative, reparative, restorative, reconstructive, and corrective. Debridement is a palliative measure aimed at stabilizing the lesion and eliminating mechanical symptoms. Marrow stimulation, such as microfracture or chondroplasty, is an example of a reparative technique. In contrast, chondral and osteochondral transplantation aim to restore injured tissue. Allografts and prosthetic devices are used to reconstruct defects, and osteotomy is used to address the underlying anatomy of the disease. With the exception of palliative treatment and reconstruction involving the use of a prosthetic device, all of these approaches require prolonged rehabilitation to ensure adequate biological response, remodeling, and healing. While excellent long-term results have been reported …

Although a number of new methods have improved our ability to treat articular injuries of the knee, no procedures have yet been proven to restore injured hyaline cartilage to its original state. Multiple techniques are used to address full-thickness chondral or osteochondral defects. This review briefly examines surgical options for this pathology. If amenable, all attempts should be made to repair osteochondral injuries. If unable to do so, preoperative anatomic factors, such as alignment, ligamentous stability, and meniscal integrity, should be carefully considered. Additionally, indications for surgery and patient factors must be thoroughly reviewed to identify appropriate candidates for treatment. Size and previous attempts at treatment often dictate care, which may include microfracture, osteochondral transplantation (osteoarticular transfer system and mosaicplasty), or autologous chondrocyte implantation. Upcoming advances intend to minimize surgical morbidity while improving cartilage regeneration and articular incorporation. Despite the new developments surrounding this field, much is still unknown, and novel treatments should be addressed with caution.

Objective We evaluated the quality-of-life of patients who have had an internal hemipelvectomy with and without (flail hip) prosthetic reconstruction and external hemipelvectomy. Design We reviewed the cases of 15 patients who had undergone either internal or external hemipelvectomy for tumor. Fifteen patients who were previously treated operatively with either a type II periacetabular internal (n = 5) or external (n = 10) hemipelvectomy were evaluated using the Toronto Extremity Salvage Score (TESS), Musculoskeletal Tumor Society (MSTS), and the 36-item Short-Form Health Survey. There were 11 (73%) men and 4 (27%) women in the study, with a mean age at operation of 46.9 ± 18.0 yrs (range, 18-69 yrs). Results Follow-up was 30.6 ± 19.6 mos (range, 6-70 mos). Overall mean MSTS score was 45.2 (range, 6.7 to 83.3), and TESS score was 60.4 ± 16.1 (range, 31.8-88.0). The 36-item Short-Form Health Survey physical component score results were lower than the general population. TESS and MSTS were all positively correlated to physical component score. There were no significant influences of postsurgery time on MSTS, TESS, or physical component score. Age had a negative correlation with physical function. Conclusions Quality-of-life and functional outcome were significantly reduced for patients with internal and external hemipelvectomies on the TESS, MSTS, and the 36-item Short-Form Health Survey physical component scores.

Proximal hamstring ruptures are increasingly treated surgically, despite little high-level supporting evidence. We sought to determine whether there are differences in clinical outcome after surgical vs. non-surgical treatment of proximal hamstring tendinous avulsions/ruptures and acute vs. chronic surgical repair of tendinous avulsions. Multiple medical databases were searched for Level I-IV evidence. 18 studies were included. 298 subjects (300 proximal hamstring injuries) were analyzed with mean age of 39.7 years. 286 injuries were managed with surgical repair vs. 14 non-operative. 95 surgical cases were performed within 4 weeks of the injury (acute), while 191 were performed beyond 4 weeks (chronic). 292 injuries were tendinous avulsions while 8 were bony tuberosity avulsions. Surgical repair resulted in significantly (p < 0.05) better subjective outcomes, greater rate of return to pre-injury level of sport, and greater strength/endurance than non-surgical management. Similarly, acute surgical repair had significantly better patient satisfaction, subjective outcomes, pain relief, strength/endurance, and higher rate of return to pre-injury level of sport than chronic repair (p < 0.001) with reduced risk of complications and re-rupture (p < 0.05). Chronic surgical repair also improves outcomes, strength and endurance, and return-to-sport, but not as well as acute repair. Non-operative treatment results in reduced patient satisfaction, with significantly lower rates of return to pre-injury level of sport and reduced hamstring muscle strength.

Marjolin's ulcer defines the occurrence of malignancy, usually squamous cell carcinoma, in the setting of a post-traumatic scar often following thermal injury. The latency period from the time of injury to the onset of malignant transformation averages 30 years with the earliest documented incidence occurring 6 weeks after injury. In addition, the occurrence of multiple primary malignancies is a rare event. To our knowledge, we report the first case in the literature of a well-differentiated squamous cell carcinoma developing within 1 month of thermal injury to an elderly patient's right index finger with an incidental synchronous primary lung moderately differentiated squamous cell carcinoma that was morphologically and genetically different as confirmed by allelotyping. There is scant precedent literature on acute Marjolin's ulcers, and the most acute cases have arisen 6 weeks post-burn. There is also little published literature on the incidence of multiple primary malignancies. The quoted incidence of this event is

The authors present a report of a bicondylar tibial plateau fracture in an adolescent athlete after posterior cruciate ligament (PCL) reconstruction. The procedure was performed via arthroscopic transtibial PCL reconstruction with quadrupled semi-tendinosus and gracilis autograft. The patient recovered uneventfully postoperatively and was able to participate in high-level sports activity, such as baseball and track, with no limitations, no subjective complaints, and no episodes of instability. He continued to be asymptomatic up to 3.5 years postoperatively. Almost 4 years postoperatively, the patient reinjured the left knee during recreational noncontact football and was seen emergently. Plain radiographs, magnetic resonance image scan, and computed tomography scan at the time of injury showed a bicondylar tibial plateau fracture with intra-articular involvement. Operative intervention was undertaken for open reduction and internal fixation of the bicondylar tibial plateau fracture. A plate was placed along the medial aspect of the tibia with locking and nonlocking screws, and the joint line was restored appropriately. The patient recovered uneventfully and at the most recent follow-up had full active and passive range of motion, had no subjective or objective evidence of instability, and had returned to full activity with no restrictions. The patient had no history of multiple fractures or any medical or pharmacologic history that predisposed him to decreased bone density. This case shows a unique possible complication after transtibial PCL reconstruction in an adolescent patient. [ Orthopedics. 2015; 38(3):e240–e243.]

Purpose The purpose of this study was to perform a systematic review of the literature to compare outcomes of revision anterior stabilization surgeries based on technique. This study also sought to compare the impact of bone defects on outcomes. Methods A systematic review of the electronic databases PubMed, Cochrane Central Register of Controlled Trials, and Scopus was performed in July 2012 and March 2013. Of 345 articles identified in the search, 17 studies with Level I to IV Evidence satisfied the inclusion criteria and were analyzed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Recurrent instability was defined as redislocation, resubluxation, or a positive apprehensive test after revision surgery. Procedures were categorized as arthroscopic Bankart repair, open Bankart repair, Bristow-Latarjet procedure, and other open procedures. Results In total, 388 shoulders were studied. Male patients comprised 74.1% of patients, 66.7% of cases involved the dominant shoulder, the mean age was 28.2 years, and the mean follow-up period was 44.2 months. The surgical procedures classified as "other open procedures" had the highest rate of recurrent instability (42.7%), followed by arthroscopic Bankart repair (14.7%), the Bristow-Latarjet procedure (14.3%), and open Bankart repair (5.5%). Inconsistent reporting of bone defects precluded drawing significant conclusions. Conclusions A number of different procedures are used to address recurrent instability after a primary operation for anterior shoulder instability has failed. There is significant variability in the rate of recurrent instability after revision anterior shoulder stabilization surgery. Level of Evidence Level IV, systematic review of Level I to IV studies.

We conducted a systematic review to determine whether the literature supports the use of free vascularised fibular graft (FVFG) over other salvage procedures for the treatment of avascular necrosis (AVN) of the femoral head, and if there are patient-specific and defect-specific factors that may predict better outcomes after FVFG. Fifteen total studies were identified for inclusion. Three comparative studies showed an overall statistically significant superiority of FVFG over NVFG; two comparative studies demonstrated FVFG better than core decompression. One study show a better but not statistically significant superiority of FVFG comparing with vascularised iliac pedicle bone graft procedures, likely due to small sample size. This review suggests that vascularised fibular grafting is a better treatment option than core decompression and nonvascularised fibular grafting.

Purpose To determine whether the basic science evidence supports the use of continuous passive motion (CPM) after articular cartilage injury in the knee. Methods A systematic review was performed identifying and evaluating studies in animal models that focused on the basic science of CPM of the knee. Databases included in this review were PubMed, Biosis Previews, SPORTDiscus, PEDro, and EMBASE. All functional, gross anatomic, histologic, and histochemical outcomes were extracted and analyzed. Results Primary outcomes of CPM analyzed in rabbit animal models (19 studies) included histologic changes in articular cartilage (13 studies), biomechanical changes and nutrition of intra-articular tissue (3 studies), and anti-inflammatory biochemical changes (3 studies). Nine studies specifically examined osteochondral defects, 6 of which used autogenous periosteal grafts. Other pathologies included were antigen-induced arthritis, septic arthritis, medial collateral ligament reconstruction, hemarthrosis, and chymopapain-induced proteoglycan destruction. In comparison to immobilized knees, CPM therapy led to decreased joint stiffness and complications related to adhesions while promoting improved neochondrogenesis with formation and preservation of normal articular cartilage. CPM was also shown to create a strong anti-inflammatory environment by effectively clearing harmful, inflammatory particles from within the knee. Conclusions Current basic science evidence from rabbit studies has shown that CPM for the knee significantly improves motion and biological properties of articular cartilage. This may be translated to potentially improved outcomes in the management of articular cartilage pathology of the knee. Clinical Relevance If the rabbit model is relevant to humans, CPM may contribute to improved knee health by preventing joint stiffness, preserving normal articular tissue with better histologic and biologic properties, and improving range of motion as compared with joint immobilization and intermittent active motion.

This article describes a series of 3 patients who presented with lower-extremity soft tissue infections. Each patient was treated with prompt debridement by an orthopedic surgeon (J.F.G.) and required at least 1 additional procedure by another surgeon. These infections vary from superficial cellulitis to rapidly advancing necrotizing fasciitis. At times, the source of these infections is clear. Other times, no obvious source of infection exists, in which case the abdomen must be considered as a possible source of infection. A high level of suspicion, complete history and physical examination, and appropriate ancillary studies are required to make an accurate and prompt diagnosis. Options for the treatment of the intra-abdominal source of infection depend on the etiology of the infection and anatomic location of the process. Psoas abscesses can often be decompressed by an interventional radiologist using computed tomography guidance. In the case of bowel involvement, such as suspected carcinoma or diverticulitis, a general surgeon is necessary. When the appropriate diagnosis is made, soft tissue infections of the thigh often respond to appropriate surgical debridement and antibiotic therapy. It is important to remember the whole patient when evaluating soft tissue infections, especially in the thigh. A low threshold for imaging of the abdomen and pelvis is important, especially when the physical examination or medical history reveals the abdomen as a possible source of infection.

BACKGROUND Although the musculoskeletal physical examination is an essential part of patient encounters, we believe that it is underemphasized in residency education and that residents' physical examination skills may be lacking. We sought to assess attitudes regarding teaching of the physical examination in orthopaedic residencies, to assess physical examination knowledge and skills among residents, and to develop a method to track the skill level of residents in order to improve our physical examination curriculum. METHODS We created a thirty-question multiple-choice musculoskeletal physical examination test and administered it to our residents. We created a five-question survey assessing attitudes toward physical examination teaching in orthopaedic residencies and distributed it to U.S. orthopaedic department chairs We developed an Objective Structured Clinical Examination (OSCE), in which standardized patients enact four clinical scenarios, to observe and assess physical examination skills. RESULTS The mean score on the multiple-choice physical examination test was 76% despite the fact that our residents consistently scored above 90% on the Orthopaedic In-Training Examination. Department chairs and residents agreed that, although learning to perform the physical examination is important, there is not enough time in the clinical setting to observe and critique a resident's patient examination. The overall score of our residents on the OSCE was 66%. CONCLUSIONS We have exposed a deficiency in the physical examination knowledge and skills of our residents. Although the musculoskeletal physical examination is a vital practice component, our data indicate that it is likely underemphasized in training. Clinic time alone is likely insufficient for the teaching and learning of the musculoskeletal physical examination.

We present the case of an 18-year-old woman who was healthy other than a history of multiple arthroscopic right knee surgeries culminating in subtotal lateral meniscectomy in a valgus knee. The patient was referred to our office for evaluation for realignment osteotomy and meniscal transplantation. Her diagnosed case of neuroma of the infrapatellar branch of the saphenous nerve was managed with neurectomy, which produced prompt and complete resolution of pain.

We retrospectively evaluated healing with ultraporous β-tricalcium phosphate (β-TCP [Vitoss; Orthovida, Malvern, Pennsylvania]) bone graft in patients who underwent surgical excision or curettage of benign bone lesions subsequently filled with bone void filler. Twentynine patients were treated with curettage and ultraporous β-TCP morsels. Radiologic defect size at initial postoperative presentation and subsequent visits (minimum follow-up, 6 months) was evaluated. Results suggested that an ultraporous β-TCP synthetic bone graft is effective in managing bone voids. The vast majority of patients who undergo curettage for benign bone lesions can expect to have complete or near complete healing of these defects within 6 months of their surgical procedure with use of ultraporous β-TCP morsels.

In this article, we report a case of intramuscular synovial cyst of the rotator cuff musculature with associated supraspinatus and infraspinatus tears. The patient was treated arthroscopically with cyst decompression and inside-out rotator cuff repair. We also present a review of the current literature on intramuscular synovial cysts of the rotator cuff.

Purpose This study was conducted to evaluate reports of clinical outcomes of isolated capitellar fractures. Materials and methods We conducted a systematic review of medical databases reporting clinical outcomes of patients undergoing nonoperative and operative management of isolated capitellar fractures. Results We identified 28 studies for inclusion comprising 174 patients. All included studies were level IV evidence. Capitellar fractures were more common among women than men and were more likely to involve the nondominant arm. Type I fractures (84%) were more common than type II (14%) and III fractures (2%). Operative and nonoperative management both led to satisfactory clinical outcomes. No significant difference in outcomes was observed in those undergoing operative management compared with those undergoing closed reduction and immobilization. Conclusions Nonoperative and operative management of isolated capitellar fractures leads to satisfactory clinical outcomes as determined by postoperative range of motion, improvement in pain, and a return to previous levels of function. No statistical difference in outcomes was observed between those undergoing operative management compared with those treated with closed reduction and immobilization.

Chondroblastomas usually present in the epiphyseal region of bones in skeletally immature patients. These uncommon, benign tumors are usually treated with curettage and use of a bone-void filler. Here we report a case of a hip fracture secondary to an underlying chondroblastoma in a 19-year-old woman. Open biopsy with intraoperative frozen section pointed toward a diagnosis of chondroblastoma. Extended curettage was performed, followed by cryotherapy with a liquid nitrogen gun and filling of the defect with calcium phosphate bone substitute. The femoral neck fracture was stabilized with a sliding hip screw construct. The patient progressed well and continued to regain functional status. A final pathology report confirmed the lesion to be a chondroblastoma. Clinicians should have heightened awareness of a pathologic lesion in a young person presenting with a femoral neck fracture and should consider the uncommon differential diagnosis that the lesion is located in the greater trochanter apophysis.

Second impact syndrome (SIS) occurs when a person sustains a second brain injury before the symptoms of an initial brain injury resolve [1,2]. Severe brain edema develops due to cerebral vasculature dysautoregulation and causes significant neurologic deficits [1-3]. SIS is a rare condition that occurs primarily in adolescents and young adults. Severe neurologic deficits and death typically occur with SIS [1,2,4]. This report describes an exceptional neurologic recovery in a teenage football player after SIS with a thin subdural hematoma (SDH). Institutional review board approval was obtained for this case study.

Primary adhesive capsulitis, or “frozen shoulder,” is a common condition encountered in the outpatient orthopaedic clinic. It is characterized by the spontaneous onset of shoulder pain and global limitation of both active and passive shoulder motion. This condition was first described by Codman in 19341 and was most recently defined by the American Academy of Orthopaedic Surgeons as “a condition of varying severity characterized by the gradual development of global limitation of active and passive shoulder motion where radiographic findings other than osteopenia are absent.”2 This condition has a prevalence of 2% to 5% in the outpatient setting, but in patients with insulin-dependent diabetes mellitus, the prevalence increases to about 30%3. The pathogenesis of this condition remains unclear, although factors associated with it include female sex, trauma, an age of more than forty years, diabetes, prolonged immobilization, thyroid disease, stroke, myocardial infarction, and the presence of autoimmune disease4. Adhesive capsulitis is commonly described as passing through three stages3-5. Stage 1 is referred to as “freezing” and consists of increasing pain and stiffness lasting for period of as long as nine months. Stage 2 is termed “frozen” and involves a steady state for a period lasting between four and twenty months. Finally, Stage 3 is termed “thawing,” which is a period of spontaneous recovery lasting anywhere from five to twenty-six months. This diagnosis is made clinically on the basis of pain and limitation of both passive and active range of shoulder motion. Although typically described as a self-limiting disease process6, the natural history of adhesive capsulitis is not completely known, and recent studies have shown that it can lead to longer-term disability over the course of several years7-10. Common nonoperative interventions used for the treatment …

We report a unique case of elbow synovial chondromatosis with sudden onset of severe loss of elbow extension and flexion range of motion caused by mechanical block from deposition of chondral fragments in the olecranon and coronoid fossae, respectively. We performed successful arthroscopic surgical treatment of synovial chondromatosis of the elbow. Arthroscopy examination revealed an acutely evolving synovial chondromatosis. Three-year follow-up indicated that arthroscopic removal of loose bodies and partial synovectomy can yield lasting improvement in motion without disease recurrence.

Background Chronic anterior shoulder instability with glenoid bone loss can be a very challenging clinical problem. Significant bone loss is commonly managed with the Latarjet procedure. However, in some cases with severe glenoid bone loss, iliac crest bone grafting is required to obtain a graft of adequate size. Iliac crest bone graft is associated with high rates of donor-site complications. Whereas glenoid dimensions can be determined by use of 3-dimensional computed tomography reconstructions, the thickness of the coracoid cannot be easily measured. This study aims to define a ratio between glenoid width and coracoid thickness that can be used in preoperative planning to determine whether coracoid transfer will yield adequate bone graft to restore glenoid contour or whether iliac crest bone graft must be taken. Methods We studied 100 paired cadaveric scapulae (50 male and 50 female scapulae). The bony dimensions of the coracoid and glenoid were measured for each specimen. Results Coracoid and glenoid dimensions are provided. The mean thickness of the male coracoid was 35.4% of the width of the glenoid. The mean female coracoid thickness was 34.4% of the glenoid width. Discussion A new biomorphologic model is presented to predict coracoid thickness and the ability of the Latarjet procedure to restore stability to a given bone-deficient glenoid. This model may aid the shoulder surgeon in preoperative planning and help promote successful outcomes in glenoid reconstruction surgery by determining whether a Latarjet procedure or iliac crest bone graft is the most appropriate procedure given the predicted amount of coracoid bone graft available.

A 17-year-old male presented to us following a hyperflexion injury to his right knee sustained while playing soccer. Immediately after the traumatic event, he developed a large, tense knee effusion. Physical examination revealed limited range of motion. MRI revealed a lobulated mass in the posteromedial aspect of the knee joint. The mass was excised and sections submitted to pathology. A pathologic, microscopic, and immunohistochemical characteristics revealed the final diagnosis of fibroma of tendon sheath in the knee. At 12 months followup, the patient reported no subjective symptoms, such as pain or limitation of athletic activities and has full range of motion. Additionally, he has demonstrated no signs of recurrence. We report a case of fibroma of the tendon sheath originating from the synovial membrane of the joint capsule of the knee.

While the musculoskeletal (MSK) physical examination (PE) is an essential part of a patient encounter, we believe it is an underemphasized component of orthopedic residency education and that resident PE skills may be lacking. The purpose of this investigation was to (1) assess the attitudes regarding PE teaching in orthopedic residencies today; (2) develop an MSK objective structured clinical examination (OSCE) to assess the MSK PE knowledge and skills of our orthopedic residents.Prospective, uncontrolled, observational.A major Midwestern tertiary referral center and academic medical center.The orthopedic surgery residents in our program. Twenty-two of 24 completed the OSCE.Surveys showed that residents agreed that although learning the PE is important, there is not enough time in clinic to actually observe and critique a resident examining a patient. For the 22 residents (postgraduate year [PGY] 2-5) who participated in the OSCE, the overall score was 66%. Scores were significantly better for the trauma scenario (78%; p0.05) than for the shoulder (67%), spine (64%), and knee (59%) encounters. The overall scores for each component of the OSCE were: (1) history 53%; (2) PE 60%; (3) 5-question posttest 64%; and (4) communication skills 90%.We have exposed a deficiency in the PE knowledge and skills of our residents. Clinic time alone may be insufficient to both teach and learn the MSK PE. The use of a MSK OSCE, while novel in orthopedics, will allow more direct observation of our residents MSK PE skills and also allow us to follow resident skills longitudinally through their training. We hope that our efforts will encourage other programs to assess their PE curriculum and perhaps prompt change.

We evaluated the clinical evidence of using continuous passive motion postoperatively after treating articular cartilage lesions of the knee. We hypothesized that postoperatively, the use of continuous passive motion improves the outcomes of cartilage restoration procedures. Multiple medical databases (MEDLINE, EMBASE, CINAHL, PubMed, Sport-Discus, and Cochrane) were searched for Level I through IV evidence with specific study inclusion and exclusion criteria. The following key words were searched: microfracture, mosaicplasty, OATS, ACI, osteochondral autograft, osteochondral allograft, autologous chondrocyte implantation, autologous chondrocyte transplantation, CPM, continuous passive motion, motion therapy, postoperative knee rehabilitation, cartilage, knee. All studies were independently reviewed by the authors and the references were checked for any missed articles. Four Level III studies were identified that met inclusion criteria for our hypothesis. No randomized, controlled studies were identified. A meta-analysis could not be performed as a result of the heterogeneity of the procedures and outcome measures. Definitive conclusions regarding the benefits of continuous passive motion postoperatively in knee cartilage surgery could not be made secondary to this heterogeneity. Continuous passive motion is commonly used postoperatively following cartilage surgery. Unfortunately, the clinical evidence (only 4 studies) to support the use of continuous passive motion is lacking despite an overwhelming abundance of basic science support and the common clinical practice of continuous passive motion implementation postoperatively in knee cartilage restoration procedures. There is a great need for well-conducted, high-level evidence studies to address this void in our literature.

Sodium hyaluronate injection into the glenohumeral joint is a treatment option in the management of adhesive capsulitis of the shoulder. We hypothesized that a systematic review would demonstrate that intra-articular sodium hyaluronate injections would result in significant improvements in passive range-of-motion, shoulder and general clinical outcome measures, and pain scales at short- and mid-term follow-up. Multiple medical databases were searched for levels I–IV evidence with a priori defined specific inclusion and exclusion study criteria. Clinical outcome measures used included Constant score, VAS pain scores, Cho functional scores, JOA scores, and range-of-motion measurements. Seven studies were included (four Level I and three Level IV; 292 subjects, 297 shoulders). Mean subject age was 59.1 years and mean pre-treatment duration of symptoms was 7.3 months. 140 subjects underwent one or multiple hyaluronate injections (120 glenohumeral joint; 20 subacromial bursa). Clinical follow-up was mean 9.0 weeks. Sodium hyaluronate injection into the glenohumeral joint has significantly improved shoulder range-of-motion, constant scores, and pain at short-term follow-up following treatment of adhesive capsulitis. Isolated intra-articular hyaluronate injection has significantly better constant scores than control. Isolated intra-articular hyaluronate injection has equivalent clinical outcomes and range-of-motion compared to intra-articular corticosteroid injection. Intra-articular hyaluronate injection was safe, with no reported complications within the studies in this review. Sodium hyaluronate injection into the glenohumeral joint is a safe, effective treatment in the management of adhesive capsulitis of the shoulder. Short-term evidence indicates that clinical outcomes are better than control and equivalent to intra-articular corticosteroid injection.

The optimal surgical treatment for symptomatic os acromiale that has failed nonoperative management is unclear in the literature. We conducted a systematic review of multiple medical databases for level I–IV evidence. Both radiographic and clinical outcomes were analyzed. Nine studies met the inclusion criteria (118 subjects, 125 shoulders). One hundred and fifteen subjects were treated surgically (122 shoulders). The mean age of the subjects was 49±11 years. The mean preoperative duration of symptoms was 12±8.6 months. Mesoacromiale was the most common type treated (94%). Internal fixation was the most common surgical technique used (60%), followed by excision (27%) and acromioplasty (13%). Rotator cuff repair was the most common concurrent surgical technique (performed in 59% of the surgically treated shoulders), followed by distal clavicle excision (25%). All surgical techniques resulted in improvement in clinical outcomes. Surgical management of symptomatic os acromiale that has failed nonoperative measures may predictably lead to improved outcomes.