Biomedical subjects
Publications and source records attributed to A C Rettig.
Evaluation and treatment of closed tendon injuries in the athlete is usually fairly straightforward if seen in the acute stages. These usually respond well in most cases to nonoperative treatment; a small percentage require initial operative treatment, however. In most cases, continued participation in sports is possible during treatment as long as protective splinting is allowed.
Complete knee dislocations are infrequent but serious injuries resulting from a wide spectrum of traumatic events. Significant soft tissue and ligamentous damage usually result. Previous experience and several reports in the literature had led us to believe that complete dislocations were associated with both ACL and PCL rupture. Three cases of documented complete knee dislocation in which the PCL is preserved intact are presented.
Complete knee dislocation is an uncommon but potentially devastating injury with a reported high rate of neurovascular injury. Treatment of this ligamentous injury is controversial. The operative (repair of all ligaments) and nonoperative management of ligament injuries appears to result in a stiff knee (decreased range of motion [ROM]), and/or a significant incidence of clinical instability and pain. We report our data on low-velocity knee dislocations and present a treatment plan of noninvasive assessment of the vascular status, a stabilizing procedure centered on posterior cruciate ligament reconstruction (PCL) and an aggressive rehabilitation program that can result in improved ROM, acceptable stability, and a more optimal functional outcome.
Neurovascular syndromes in the wrist and hand are uncommon occurrences in the athlete. They are usually related to repetitive use of the wrist such as in racquet sports or sports with repetitive impact to the hands such as handball and catching. Common syndromes are discussed with regard to anatomy, pathophysiology, diagnosis, treatment, and return to sport.
Injuries of the ankle and foot in athletes are quite common. They range from the extremely simple sprain to the difficult stress fracture, and may result in long-term disability. In all cases, the athlete is best treated after an accurate diagnosis is achieved.
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Primary coccidioidal synovitis of the knee is a rare disorder and controversy exists in the literature over the efficacy of treatment with synovectomy and Amphotericin B therapy. Four cases are presented illustrating features of the natural history, diagnosis, and treatment of the disease.
Eight cases of glomus tumor of the digits seen during an 8-year period are reviewed. This number comprised 1.2% of all hand tumors encountered. Symptoms of cold intolerance and exquisite tenderness were common to all. The average duration of symptoms prior to diagnosis and treatment was 7 years. Five patients gave a history of either frostbite (two) or trauma (three) prior to onset of symptoms. The tumor was subungual in six of the eight patients, with a relatively even distribution among all digits. Roentgenographic changes of erosion of the distal phalanx were present in 50% of the tumors. Surgical excision was curative in all instances.
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In 1950, Wolin and his colleagues described nine patients who exhibited a "meniscoid" lesion of the ankle. He used this term to describe a mass of hyalinized tissue that formed following an inversion sprain of the ankle. This band of tissue was predisposed to trapping between the fibula and the talus. His patients presented with persistent pain and swelling over the anterior aspect of the ankle. In the last 3 years, four patients have presented with this lesion at the Methodist Sports Medicine Center in Indianapolis. They were all soccer players who had experienced repeated ankle sprains accompanied by persistent pain, swelling and trapping. Initially, these patients were treated with physical therapy, taping, and antiinflammatory medication. After 6 months of treatment, they continued to have symptoms and underwent arthroscopic examination. In each case a band of white, fibrous tissue was found during surgery and was removed. After an appropriate period of rehabilitation, all four patients returned to competition with a cessation of symptoms. However, one patient reported recurrent pain on rare occasions.
From 1980 to 1985, 40 patients under the age of 14 with open physes were treated for midsubstance tears of the ACL at the Methodist Sports Medicine Center. In this series, 16 were treated conservatively with rehabilitation, bracing, and counseling on activity modification. The remaining 24 patients underwent arthroscopic examination and either an extraarticular or intraarticular reconstruction based on growth potential. The average followup was 27 months for the conservative group and 26 months for the surgical group. In the conservative group, six patients underwent arthroscopy for meniscal tears, four medial and two lateral. Only seven patients returned to sports, all experiencing recurrent episodes of giving way, effusions, and pain. In the surgical group, 12 medial and 6 lateral meniscal tears were found at arthroscopy. There were 10 extraarticular reconstructions and 14 intraarticular reconstructions. All 24 returned to sports activity, and 22 of the 24 are still competing. The two remaining patients both suffered reinjury 3 years after their surgery. We recommend arthroscopy and examination under anesthesia for the young patient with ACL tears. Based on the amount of instability, presence or absence of meniscal tears, and athletic desires of the patient and his or her family, a treatment plan can be undertaken.
Six athletes, all engaged in running activities at the time of injury, presented with tenderness over the medial malleolus and ankle effusion. Three patients had a fracture line which could be seen on radiographs. These patients were treated by open reduction and internal fixation using two 4.0 cancellous screws. The other three patients had normal radiographs but bone scans showed increased uptake over the medial malleolus. These patients were treated with cast and immobilization. We believe that each of these patients suffered a stress fracture of the medial malleolus. We suggest that the possibility of a stress fracture be considered in the differential diagnosis of patients who present with 1) chronic or subacute pain over the medial malleolus and ankle effusion, and 2) a history of running activity at the time of injury or running activities aggravating the pain. Bone scans appear to be more sensitive than radiographs in detecting a stress fracture of the medial malleolus. We propose that athletes with radiographic signs of a medial malleolar fracture who desire early return to full participation should be treated by open reduction and internal fixation. For these patients, early motion can be initiated. Other athletes whose fracture cannot be detected on radiographs but whose malleolus shows increased uptake in the area on bone scans can be treated nonsurgically with immobilization and then progressive increase in activity. All of our patients returned to full activity between 6 and 8 weeks after treatment was initiated.
This study presents eight patients with stress fracture of the anterolateral cortex of the midshaft of the tibia. All of the patients, ranging in age from 14 to 23 years, were competitive basketball players who experienced pain while running or jumping for an average of 4.4 months before the diagnosis was made. Eight patients were treated with rest and/or pulsing electromagnetic field therapy. Although one of the patients required bone grafting procedure, all eight of these patients showed complete healing and were able to return to full activity after an average of 8.7 months of treatment. They have remained asymptomatic for an average of 14.7 months. The overall time from initial symptoms to return to competition averaged 12.5 months in this group of athletes. The results presented in this paper suggest that rest and pulsing electromagnetic field therapy may result in healing in some patients with delayed union stress fractures of the anterolateral cortex of the midshaft of the tibia. Although this injury is associated with a prolonged healing period, seven of eight patients with adequate followup in our study were able to return to competition without complications following treatment. One patient was asymptomatic for 33 months before experiencing a reinjury. In conclusion, we feel that diagnosis of stress fracture should be primary consideration in basketball players presenting with a prolonged history of pain on the anterolateral aspect of the midthird of the tibia. Once the diagnosis is made we recommend initial treatment consist of rest and external electrical stimulation for a minimum time of 3 to 6 months prior to considering surgical intervention.
The dynamic posterior shift test, a clinical method for evaluating both straight posterior instability and posterolateral rotatory instability, (PLRI), is a simple, dynamic, and reliable (reproducible) test that serves as an adjuvant to other clinical tests designed to evaluate an injury or insufficiency of posterior structures in the knee. The examiner maintains the hip at near 90 degrees of flexion to control rotation of the femur while slowly extending the knee passively. The hamstrings should be stretched to maintain their tightness. The tightened hamstrings assist gravity in subluxating the tibia posteriorly; they also provide dynamic axial loading to the joint as the knee is extended. In knees with posterior instability, the posteriorly subluxated tibia suddenly reduces as the knee joint nears full extension, and a jerk or "clunk" is felt by both the patient and the examiner. Thus, the patient's feeling of instability is reproduced by the test. We have used the dynamic posterior shift test for 5 years (as an adjuvant in our physical examination) to evaluate signs of posterior instability of the knee. Not only is the test reliable, but it is more definitive than other tests in evaluating straight posterior instability and PLRI. It is easy to perform and the results are reproducible. Because this test is dynamic rather than passive, it enhances the accuracy of evaluating posterior instability of the knee.
Fifty-six fractures of the metacarpal occurring in 53 athletes were studied from September 1985 to December 1986, regarding mechanism of injury, type of fracture, type of treatment, and time lost from sport. Age range of the patients was 8 to 28 years with greater than 77% being in the 14 to 18 year age range, the high school athlete. Twenty-nine of the fractures occurred in football, 14 in basketball, and the remainder were divided between various other sports. The most common mechanism of injury involved falls or hitting an object such as a helmet or another player. Fractures were evenly divided regarding which digit was involved in football, whereas most basketball injuries occurred in the fourth and fifth metacarpal. Fractures were analyzed as to type of radiographic appearance and this was correlated with time lost from competition or participation. No significant difference among fracture type regarding time lost was noted. Forty-six of the fractures (82%) were minimally displaced or undisplaced and were treated by means of simple casting and/or splinting whereas 10 were displaced. Two of the 10 underwent closed reduction and casting; 3 underwent closed reduction and percutaneous pin fixation; and 5 (9%) underwent open reduction internal fixation using AO type plates and screws. All fractures healed primarily clinically and radiographically. The average time lost from practice or competition in this group overall was 13.7 days, (range, 0 to 56 days). Average time lost from basketball was 19.8 days and from football 10.63 days overall. Average time lost from sport in stable fractures treated with casting or splinting was 12.3 days.(ABSTRACT TRUNCATED AT 250 WORDS)
To evaluate the effectiveness of our treatment regimen, we retrospectively studied the surgically treated knees of 155 athletes, aged 15 to 42 years, who had sustained acute ACL tears. All were treated with ligament excision and intraarticular bone-patellar tendon-bone reconstruction followed by early motion with emphasis on full extension. The follow-up period ranged from 2 to 7 years. Of the 155 patients, 140 were available for final followup at a minimum of 2 years after reconstruction. The patients were evaluated by objective measures (KT-1000, Cybex, Lachman test, range of motion, and postoperative competition level) and subjective assessment scores (pain, swelling, stability, activity level, walking, stair climbing, running, jumping, or twisting). The subjective scores were tabulated for stability level, total score, and activity level. After the patients achieved full range of motion, the KT-1000 measurements at a 20 pound force revealed an average difference of 1.3 mm between the injured and noninjured knees. All but 3 of the 140 patients had a firm endpoint on the Lachman test, and the Cybex tests showed a mean hamstring strength of 98% and mean quadriceps strength of 90%. Sixty of the 69 varsity athletes who were eligible to play returned to preinjury competition level the following season. One had reconstruction failure and eight chose not to continue competition for academic reasons. The questionnaire score average was 92.7 (maximum, 100 points, normal athletic knee score 93.5). We concluded that the surgical procedure, with emphasis on early full extension postoperatively, achieved excellent results and provided a stable knee.
Eight athletes developed symptomatic nonunions of the base of the proximal fifth metatarsal in the metaphyseal region. All of the athletes were initially treated conservatively without success. We reviewed their case histories and outlined a simple, effective, low morbidity surgical management of these lesions. Two nonunions successfully healed with internal fixation with an intramedullary compression screw. Five additional nonunions were shelled out through a lateral incision of the peroneus brevis without disturbing its insertion. An eighth nonunion fragment was large and articulated the cuboid; it was fixed successfully with an intramedullary compression screw to preserve lateral foot mechanics. There were no complications. All patients returned to full activities 2 to 4 months after surgery.