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In brief Stress fracture of the ribs, an uncommon overuse injury, may mimic recalcitrant intercostal or back muscle strain. This report describes a 36-year-old man who sustained multiple rib stress fractures after he took up golf. Fatigue of the serratus anterior muscle appeared to be the mechanism for his injury. Relative rest followed by strengthening exercises helped the patient return to pain-free activity.

Background Wakeboarding is a popular water sport that has the potential to produce serious injuries. To date, there has been only one article describing an injury caused by wakeboarding. Hypothesis Wakeboarding injuries are common. Study Design Analysis of data obtained from physician and patient questionnaires. Methods Analysis of questionnaire data obtained from 156 orthopaedic surgeons and 86 wakeboarders. Results Of 156 orthopaedic surgeons completing a wakeboarding injuries questionnaire, 49% reported no wakeboarding injuries, 36% (57) reported treating at least 1 wakeboarding injury, and 15% had never heard of wakeboarding. Fifty-seven orthopaedic surgeons reported 122 injuries, of which 47% were either anterior cruciate ligament (ACL) tears (31%) or shoulder dislocations (15%). In addition, 21% of all the injuries were some type of fracture. Of 86 wakeboarders completing the injuries survey, 77% reported sustaining an injury. There were 82 reported injuries in this group, of which 34% were either ACL tears (17%) or ankle sprains (17%). Conclusions This survey of wakeboarding injuries demonstrates that serious injuries can occur from participation in this sport. The most common injuries reported were ACL tears, shoulder dislocations, and ankle sprains. In addition, 21% of all the injuries were some type of fracture.

Our technique of diagnostic and surgical shoulder arthroscopy is presented, and normal variational arthroscopic anatomy of the shoulder is described. This report was based on the diagnostic findings of 118 patients (120 shoulders) who, over a 26-month period, presented with pain, popping, or instability of the shoulder and who underwent diagnostic or operative shoulder arthroscopy. The average duration of symptoms prior to surgery was 12 months. Arthroscopic examination revealed one or more abnormalities in 88% of the patients. We found that diagnostic arthroscopy of the shoulder is systematic and reproducible when attention is given to normal and variational shoulder anatomy and consistent technical detail.

Twenty-three cases of Little Leaguer's shoulder were reviewed including the history and physical examination findings, as well as bilateral internal and external rotation anteroposterior comparison radiographs of the proximal humerus. The average follow-up was 9.6 months (range, 1.5 to 54), and all patients were observed until they had either returned to baseball or their symptoms had resolved. The average age of the patients in this series was 14 years. The chief complaint in all patients was pain localizing to the proximal humerus during the act of throwing. The average duration of symptoms was 7.7 months. Nineteen patients (83%) were pitchers. Physical examination revealed tenderness to palpation over the proximal humerus in 20 patients (87%), with 16 (70%) demonstrating specific tenderness over the lateral aspect of the proximal humerus. Swelling, weakness, atrophy, and loss of motion were uncommon findings. All 23 patients demonstrated radiographic widening of the proximal humeral physis of the throwing arm on internal and external rotation comparison anteroposterior radiographs of the shoulder. All patients were treated with rest from baseball throwing for an average of 3 months. Twenty-one of the 23 patients (91%) returned to playing baseball and were asymptomatic. The classic radiographic finding of widening of the proximal humeral physis can easily be seen on bilateral anteroposterior internal and external rotation radiographs of the proximal humerus. Rest from throwing for at least 3 months is recommended, followed by a gradual return to throwing in an asymptomatic shoulder.

We report our single-center experience in treating 101 type II endoleaks with ethylene-vinyl-alcohol copolymer (EVOH, Onyx). In all, 65 endoleaks were embolized transarterially, and 36 were treated through a translumbar approach. Since the first transarterial embolization, when we began attempts to treat all patients initially via common femoral access, 58 (65.9%) of 88 patients were successfully embolized transarterially. All endoleaks in the translumbar group were successfully treated. At a median follow-up length of 15 weeks, a decrease or stabilization in aneurysm size was observed in 39 (73.6%) of the 53 endoleaks that had adequate follow-up computed tomography imaging. The overall residual endoleak rate was 34.0%. There was no difference in efficacy when comparing transarterial and translumbar approaches. We demonstrate that in most cases, transarterial access of the endoleak nidus is feasible, and controlled embolization is possible using EVOH. Furthermore, EVOH appears effective in long-term stabilization of aneurysm size and in preventing residual endoleaks.

Stress fracture of the ribs, an uncommon overuse injury, may mimic recalcitrant intercostal or back muscle strain. This report describes a 36-year-old man who sustained multiple rib stress fracture...

A new surgical technique to uniformly harvest the middle one-third of the patellar tendon for anterior cruciate ligament reconstruction is described. The technique uses a guide system of 8 templates of varying widths to guide the saw cuts and "collared," depth-controlled saw blades and drill bits to produce a standard cutting and drilling depth. This kind of template system lessens the risks of graft harvesting complications such as patella fracture, bone graft fragmentation, suture pull out, and judgment errors pertaining to graft depth, length, or width. The Patellar Tendon Graft Guide was used to obtain a patellar tendon graft in 65 patients. Fifty-nine arthroscopic-assisted and 6 open anterior cruciate ligament reconstructions were performed. Of the 65 grafts harvested, 63 consistently demonstrated bone portions 20 mm in length, 7 mm in depth, and a width corresponding to the template chosen (usually 10 mm). Two grafts supposed to be 10 mm in width turned out to be 9 mm in width because of a technique related problem.

Unsatisfactory results following partial meniscectomy and problems related to a retained posterior horn of the medial meniscus are problems often attributed to inadequate arthroscopic partial meniscectomy. Although there are multiple techniques to gain better access to the various compartments in a truly tight knee, most of the problems in obtaining maximum visualization and instrumentation to the posterior aspects of the medial or lateral meniscus can usually be solved by adhering to a strict surgical technique that attempts to control the multiple variables encountered during arthroscopic surgery. These include the use of a tourniquet, leg holder, maximum distention of the knee provided by a large inflow cannula with large-bore tubing connected to 3-L bags, and an 18-gauge needle as a predecessor to the larger arthroscopic instruments. Of utmost importance is establishing the correct portal for the arthroscope, and it is time well spent at the beginning of the surgical procedure to verify the proper location of the arthroscope and not simply insert the arthroscope "a thumb-breadth above the joint line." Once these variables have been controlled, one can usually visualize and perform arthroscopic surgery on most meniscal lesions with minimal scuffing to the articular surfaces.

A comprehensive physical examination of the patellofemoral joint and the entire lower extremity is often required to detect some of the more subtle extensor mechanism disorders. The standing, sitting, and supine examinations of the patient with patellar complaints are presented. In addition, the various radiographic techniques available to evaluate the patellofemoral joint are reviewed.

This article describes the surgical technique of arthroscopy of the ankle and the indications for its use. In addition to describing the common anterolateral and anteromedial arthroscopic portals, a discussion is also given regarding portal anatomy of ankle arthroscopy and the various neurovascular structures that lie in close proximity to the arthroscopic portals. Arthroscopy of the ankle has a definite role in the management of certain lesions of the ankle, such as loose bodies, or osteochondral or chondral defects of the talus. Ankle arthroscopy is a technically demanding surgical procedure and great attention to detail is required to perform this procedure in a safe and reproducible fashion.

The goal of any surgical procedure to correct the instability caused by loss of the ACL is to control the abnormal anterior excursion of the tibia on the femur. Because the main problem is loss of the ACL, it would seem most reasonable to approach this problem by performing an intra-articular reconstruction of the ACL, thus approximating as closely as possible the normal anatomy of the ACL. The classic open intra-articular ACL reconstructions are technically demanding surgical procedures that usually require a significant "learning curve" to achieve a level of technical expertise and confidence. In addition, postoperative complications such as adhesions, loss of motion, prolonged muscle atrophy, and a long rehabilitation period are well known. Thus, it would appear that the extra-articular reconstructive procedures for the anterior cruciate-deficient knee would offer some advantage over these more formidable surgical procedures. Whereas the main problem is certainly the loss of the ACL, the extra-articular procedures are directed more toward the most symptomatic anterior excursion of the tibia on the femur, the pivot shift phenomenon, where the anterolateral portion of the tibia moves anterior in relation to the femur. Thus, the goal of the extra-articular reconstructive procedures for anterolateral rotatory instability is to eliminate functional instability. These goals are most readily achieved by positioning some portion of the iliotibial tract posterior to the transverse center of rotation of the knee to provide a reinforcement for the lateral tibial plateau as the knee approaches terminal extension. All of the extra-articular procedures discussed in this article have been used successfully as reported by the various authors. There are many technical details inherent in each of these surgical procedures, and the reader is referred to the original articles for a more explicit description of these surgical procedures. For the individual surgeon to participate in and view the actual surgical procedure that he or she intends to perform would be the ideal situation. Various workshops where surgical procedures of the knee are actually performed and studied are currently available and are of great value to the surgeon. Of equal importance to the technical demands of the various surgical procedures is selection of the appropriate procedure for each patient. The selection must be based on many factors. The most important factor is the identification of the patient with a high level of athletic activity who is unwilling to modify his or her activity level to compensate for a deficient ACL.(ABSTRACT TRUNCATED AT 400 WORDS)

Several extra-articular procedures have been shown to be successful in controlling anterolateral rotatory instability. These procedures are performed as an extra-articular reconstruction alone or are combined with an intra-articular reconstruction. The common goal of these extra-articular procedures is the control of the abnormal anterior subluxation of the lateral tibial plateau and, thus, the elimination of the lateral pivot shift phenomenon. This goal is achieved most readily by placing some portion of the iliotibial tract posterior to the transverse center of rotation of the knee in order to provide a check-rein effect on the lateral tibial plateau to prevent anterior subluxation as the knee approaches terminal extension.

Rehabilitation of the injured throwing arm should not be directed simply toward beginning strengthening exercises and returning the athlete to throwing as soon as possible. The total comprehensive program has been described and consists of seven phases that begin with making the proper diagnosis of a shoulder injury. Once the proper diagnosis is made, the pathophysiology of throwing injuries has to be understood by the physician, the trainer, and the athlete, and then the actual treatment begins in phase III. Initial treatment many times consists of a short period of relative rest as well as physical therapy modalities to relieve pain, and once pain is relieved phase IV begins, which is the actual techniques of range of motion, flexibility, and strengthening maneuvers. Once adequate flexibility, range of motion, and pain-free motion have been achieved, as well as adequate endurance strength, proper warm-up techniques are begun, and then a return to throwing is achieved in phase VI. The total rehabilitative cycle is concluded with phase VII, which consists of an off-season conditioning program to verify that the athlete will maintain year-round maximum condition of not only the throwing shoulder but of the entire athlete.

A technique of diagnostic and operative arthroscopy of the elbow and its indications are presented, and the intra-articular anatomy is described. The close proximity of vital neurovascular structures and the size constraints of the joint itself make a thorough knowledge of the anatomy and close attention to detail crucial to this procedure.

Tears of the glenoid labrum were observed in 73 base ball pitchers and other throwing athletes who under went arthroscopic examination of the dominant shoul der. Most of the tears were located over the anterosu perior portion of the glenoid labrum near the origin of the tendon of the long head of the biceps muscle into the glenoid. At arthroscopy, the tendon of the long head of the biceps appeared to originate through and be continuous with the superior portion of the glenoid labrum. In many cases it appeared to have pulled the anterosuperior portion of the labrum off the glenoid. This observation was verified at arthroscopy by viewing the origin of the biceps tendon into the glenoid labrum as the muscle was electrically stimulated. With stimulation of the mus cle, the tendinous portion became quite taut, particu larly near its attachment to the glenoid labrum, and actually lifted the labrum off the glenoid. Three-dimensional high-speed cinematography with computer analysis revealed that the moment acting about the elbow joint to extend the joint through an arc of about 50° was in excess of 600 inch-pounds. The extremely high velocity of elbow extension which is generated must be decelerated through the final 30° of elbow extension. Of the muscles of the arm that provide the large deceleration forces in the follow-through phase of throwing, only the biceps brachii traverses both the elbow joint and the shoulder joint. Additional forces are generated in the biceps tendon in its function as a "shunt" muscle to stabilize the glenohumeral joint during the throwing act. On the basis of our observations that (1) the biceps tendon is subjected to large forces during throwing, (2) most tears of the glenoid labrum occur at the antero superior portion near the origin of the biceps tendon, and (3) the biceps tendon lifts the labrum off the glenoid when its muscle is stimulated, we believe that the tendon of the long head of the biceps may be a cause of tearing of the glenoid labrum in the throwing athlete.

A technique of diagnostic and surgical arthroscopy of the elbow is presented, and the normal intraarticular anatomy as viewed from the anterolateral, anteromedial, and posterolateral portals is described. A preliminary study of 12 patients who underwent surgical arthroscopy of the elbow demonstrated that removal of loose bodies produced the best objective and subjective results. Less satisfactory results were obtained when procedures such as capitellum and radial head chondroplasties were performed. Using a preoperative and postoperative point accumulation rating system for four objective and four subjective criteria, the following results were noted. Before surgery 50% of the patients objectively rated their elbows as satisfactory (excellent or good), whereas postoperative ratings increased to 83%. Subjectively, 17% rated their elbows as satisfactory before surgery, improving to 58% satisfactory ratings postoperatively. The only complication was a transient median nerve palsy caused by the extracapsular extravasation of a local anesthetic. From this preliminary study, it was concluded that attention to detail is essential in performing a safe, reproducible arthroscopic examination of the elbow, that arthroscopy of the elbow is an effective diagnostic procedure, and that operative elbow arthroscopy is effective in the treatment of certain elbow disorders.

We present our technique of diagnostic and surgical arthroscopy of the shoulder and describe the normal and normal variational arthroscopic anatomy of the structures within the shoulder joint. To ensure accu racy, strict attention is given to consistent patient po sition and technical detail. Posterior and anterior portals are consistently located with the aid of bony anatomic landmarks. Using a large diameter angled arthroscope, structures within the shoulder joint are identified and examined in sequential order. Diagnostic arthroscopy of the shoulder can be systematic and reproducible when the surgeon is knowledgeable of the normal and normal variational anatomy of the shoulder and when attention is given to accurate placement of the arthro scopic portals and to consistent surgical technique.

The authors present a modified technique of ankle arthroscopy and describe the intra-articular anatomy of the ankle joint as it relates to the establishment of arthroscopic portals. Cadaveric dissection was used to demonstrate the relationship of the tendons and neurovascular structures to the placement of the arthroscope. Diagnostic arthroscopy of the ankle can be systematic and reproducible when the surgeon is knowledgeable of the intra-articular and extra-articular anatomy of the ankle and when attention is given to accurate placement of the arthroscopic portals and to consistent surgical technique.

Thirty-six patients with partial tears of the supraspinatus portion of the rotator cuff underwent arthroscopic examination and debridement of the lesion. All patients, whose average age was 22 years, were involved in competitive athletics; 64% were baseball pitchers. The average duration of symptoms prior to arthroscopy was 12 months. The most common presenting complaint was pain felt in the shoulder during overhead activities. Associated pathology included tears of the glenoid labrum and partial tearing or tendinitis of the long head of the biceps tendon. Of the 34 patients available for follow-up, 26 (76%) had excellent results, three (9%) had good results, and five (15%) had poor results. Eighty-five percent of the patients returned satisfactorily to their preoperative athletic activity. Our preliminary experience with arthroscopy of the shoulder in the management of patients with partial rotator cuff tears is encouraging. Not only can a partial rotator cuff tear be debrided to initiate a healing response, but a definitive diagnosis can also be made and associated pathology identified, permitting the establishment of an appropriate rehabilitation program.

A radiographic study of 45 knees immediately and at least two years after operation showed that the average depth of cement penetration was 1.5-3.0 mm at different locations around the interface and that there was a strong inverse relation between the development of radiolucency and initial cement penetration. In laboratory studies of penetration in the upper tibia, penetration was approximately proportional to bone pore diameter and to the square root of the applied pressure and inversely proportional to the time after initial mixing. There was a low correlation of the tensile strength of the cement-bone bond with the depth of penetration, probably due to the variability of the trabecular bone strength. Failure occurred by direct cement pullout or by partial or total fracture through the bone. In light of all factors, the suggested ideal depth of cement penetration is 3-4 mm. This penetration can be achieved by using the left-lift method about four minutes after initial cement mixing, but with some selective prepenetration around the periphery of the tibia.