Faculty Bibliography

Professional ballet dancers require an extraordinary anatomic, physiologic, and psychologic makeup to achieve and sustain their level of ability and activity. They are subject to a myriad of injuries as a result of the extreme demands of this profession. Tendon injuries are common and often coexist with other pathologies of the bone, ligaments, and psyche. It is critical that the dance doctor not examine the tendon injury in isolation, but rather the cause of the injury, either intrinsic from anatomic malalignment or from external sources, including poor form.

Dancers, particularly ballet dancers, are artists and athletes. In dance, the choreographer acts as a sculptor, using the dancer as a medium of expression. This often entails placing the dancer's body in positions that require extraordinary flexibility and movement, which requires controlled power and endurance. Ballet and other forms of dance can be highly demanding activities, with a lifetime injury incidence of up to 90%. Ballet is stressful particularly on the dancer's forefoot. The en pointe position of maximal plantarflexion through the forefoot, midfoot, and hindfoot requires tremendous flexibility and strength that only can be attained safely through many years of training. The forces experienced by the toes and metatarsals are extraordinary.

Although dancers put a great deal of stress through the first metatarsophalangeal joint (MTPJ), it is unlikely that dancing causes bunions; however, such forces may produce an environment in which bunions may develop. It is best to employ conservative measures rather than surgical intervention in dancers who have a painful bunion. Any surgery on the first MTPJ will adversely affect dorsiflexion of this joint, which is a critical motion for dancers. Two types of bunions (slowly progressive and rapidly progressive) are commonly seen; arthritic bunions occur in dancers who have mild arthrosis and loss of cartilage on the head of the first MTPJ. Secondary problems arising from bunions include metatarsalgia, stress fractures, sesamoiditis, and flexor hallucis longus tendonitis.

Dancers are required to perform at the extreme of physiologic and functional limits. Under such conditions, peripheral nerves are prone to compression. Entrapment neuropathies in dance can be related to the sciatic nerve or from a radiculopathy related to posture or a hyperlordosis. The most reproducible and reliable method of diagnosis is a careful history and clinical examination. This article reviews several nerve disorders encountered in dancers, including interdigital neuromas, tarsal tunnel syndrome, medial hallucal nerve compression, anterior tarsal tunnel syndrome, superficial and deep peroneal nerve entrapment, and sural nerve entrapment.

UNLABELLED:For patients with refractory retrocalcaneal bursitis (Haglund's syndrome), the most effective surgical approach has not been defined. We asked whether patients undergoing the tendon-splitting approach and the lateral approach would have comparably effective relief of pain for both types of calcaneal ostectomies. We retrospectively reviewed 30 patients (31 feet) who underwent the tendon-splitting approach and compared their results with 32 previous patients (35 feet) who had a lateral incision. Minimum followup was 12 months (mean, 16 months; range, 12-23 months) for the tendon-splitting group and 15 months (mean, 51 months; range, 15-109 months) for the lateral group. The mean American Orthopaedic Foot and Ankle Society score improved from 43 points preoperatively to 81 points (range, 8-100 points) postoperatively in the tendon-splitting group and from 54 points to 86 points (range, 55-100 points) in the lateral group. The mean physical component score of the Short Form-36, version 2, at followup was 52 (range, 22-61) in the tendon-splitting group and 49 (range, 34-63) in the lateral group. The median return to normal function was 4.1 months (range, 3-13 months) in the tendon-splitting group and 6.4 months (range, 4-20 months) in the lateral group. Both approaches to calcaneal ostectomy provided symptomatic pain relief. However, patients in the tendon-splitting group returned to normal function quicker than patients in the lateral group. LEVEL OF EVIDENCE/METHODS:Level III, retrospective comparative study.

Contemporary methods of bone grafting osteochondral defects, in which the remaining overlying cartilage is relatively well preserved, have inherent problems. The bony defects are often saucer-shaped and the cylindrical graft may not fill the void, leaving areas of cartilage with no underlying scaffold and obviating early weight bearing. Furthermore, to obtain a proper fill of the defect, tamping of the graft can cause excessive pressure and disruption of the overlying cartilage. In an effort to address these concerns, the authors propose the use of a biological viscous paste of calcium sulfate that hardens within 5 minutes when injected in a retrograde fashion into the talus. This confers a mechanical advantage of complete cystic fill of the cyst which allows early weight bearing. Calcium sulfate acts as an osteoconductive material that incorporates into host bone within 8 weeks. Donor site morbidity is eliminated using this system.

The purpose of this prospective study was to determine the clinical outcomes of patients who had total hip arthroplasties with a zirconia (Zr) - Hylamer pairing. Fifty-eight consecutive cemented total hip arthroplasties with a Hylamer cup and 22.25 mm Zr head were examined for component wear and failure. The SF-36 and Mayo hip score were used to evaluate patient outcome. Regression and Kaplan Meier survival analyses were used to determine outcome. The mean Mayo postoperative score was 94 points. The median post-operative SF-36 score was 84 points. The mean rate of wear was 0.097 +/- 0.02 mm/year, with no evidence of loosening or significant osteolysis at a minimum follow-up of 5 years. Kaplan-Meier survival analysis was 98% at 3-year follow-up and 94% at 5-year follow-up. This study has confounded previous reports relating to Zirconia-Hylamer counter-surface components.

BACKGROUND:Procedures utilized to address the flatfoot in this study included medializing calcaneal osteotomy, posterior tibial tendon reconstruction with flexor digitorum longus tendon transfer, and in patients with more severe deformity, lateral column lengthening. We evaluated patients age 50 and less at the time of surgery, who underwent surgical reconstruction for Stage 2 posterior tibial tendon dysfunction. Pre- and postoperative activity levels were evaluated to assess the effect of surgical reconstruction in the younger patient. MATERIALS AND METHOD/METHODS:Thirty-four feet in 30 patients (11 male, 19 female) with an average age of 41.2 (range, 17 to 50) years had surgery between 1997 and 2004. All feet were examined at an average followup of 44.5 (range, 24 to 65) months and were evaluated with the American-Orthopaedic-Foot and Ankle Society (AOFAS) Hindfoot-Score and SF-36 score. RESULTS:The average preoperative AOFAS-Score was 53.1 +/- 14.5 points and 83.2 +/- 12.2 points at final postoperative followup. The mean improvement was 29.5. The difference between the preoperative and postoperative AOFAS score was significant (p < 0.0001) using a two-tailed t-test. The difference in the AOFAS pain and alignment subscales was also significant (p < 0.0001). The function subscale improvement was also significant (p = 0.018). The mean physical function component of the postoperative SF-36 score was 79.2. A correlation was found between the SF-36 physical component score and the post operative AOFAS score (r(2) = 0.754). CONCLUSION/CONCLUSIONS:While some lateral discomfort or pain occurred in patients with or without a lateral column lengthening, the posterior tibial tendon reconstruction utilizing medial calcaneal displacement osteotomy with flexor digitorum longus transfer and a lateral column lengthening with more deformity was successful in the higher-functioning, younger patients.

Traumatic injuries of the hip and pelvis are common in child athletes and typically require minimal treatment. However, the presentation of such injuries can at times be clinically indistinguishable from the onset of a benign or malignant neoplastic process. In these circumstances, the orthopedic surgeon relies on modern diagnostic tools including imaging-predominantly magnetic resonance imaging (MRI) and computed tomography-and pathology studies. This article presents the cases of 2 adolescent boys with traumatic injuries to the hip, in which the threat of neoplasm could not be ruled out by in both initial imaging studies. In one case, biopsy could not conclusively rule out malignancy. In both cases, serial MRIs to monitor changes in lesion size proved valuable in determining treatment approach. The authors recommend a diagnostic algorithm to approach the differentiation of iliac hematoma from neoplasm and address the issue of waiting time in the diagnostic process. Early-and if necessary repeated-biopsy to rule out these conditions is advised, as conclusive pathologic findings are the only evidence that can rule out Ewing's sarcoma or an aneurysmal bone cyst. Given the morbidity of these conditions, the authors advocate this course of action to minimize distress to the patient and family members. Careful observation in combination with radiographic findings can yield a successful diagnosis, but the orthopedic surgeon must carefully weigh the increased risk of tumor growth against the need for biopsy.