JAAOS, Volume 18, No. 9

Significant advances have recently been made in understanding the mechanismsinvolved in noncontact anterior cruciate ligament (ACL) injury. Most ACL injuriesinvolve minimal to no contact. Female athletes sustain a two- to eightfoldgreater rate of injury than do their male counterparts. Recent videotape analysesdemonstrate significant differences in average leg and trunk positions duringinjury compared with control subjects. These findings as well as those ofcadaveric and MRI studies indicate that axial compressive forces are a criticalcomponent in noncontact ACL injury. A complete understanding of the forcesand risk factors associated with noncontact ACL injury should lead to thedevelopment of improved preventive strategies for this devastating injury.

Guided growth is useful in correcting pediatric angular deformities. Althoughgrowth manipulation has been applied to various deformities, it is most commonlyused to correct coronal plane deformity about the knee. Temporary hemiepiphysiodesisis performed using staples, percutaneous transphyseal screws, or a tensionband plate. Permanent hemiepiphysiodesis can be done using either an openPhemister or a percutaneous approach. These techniques function by tetheringone side of a growing physis, thereby allowing differential growth. Appliedcorrectly, this can also result in angular deformity correction. Undercorrectionand overcorrection are common problems with guided growth. However, carefulpreoperative planning and appropriate follow-up can minimize complicationsand allow for excellent deformity correction with minimal morbidity.

Dural tears are among the most commonly seen complications in spine surgery.Most studies in the literature indicate that long-term outcomes are not negativelyaffected, provided that the tears are diagnosed early and managed appropriately.Direct suture repair remains the preferred method for the management of durotomycaused by or found during surgery. However, recent literature reports encouragingresults with sutureless repair. Understanding dural anatomy, dural healing,and cerebrospinal fluid dynamics is helpful in choosing among the availablemanagement options for dural tear.

Foot and ankle injuries are commonplace in competitive sports. Improvementsin injury surveillance programs and injury reporting have enabled physiciansto better recognize and manage specific foot and ankle injuries, with a primarygoal of efficient and safe return to play. Athletes are becoming stronger,faster, and better conditioned, and higher-energy injuries are becoming increasinglycommon. Close attention is required during examination to accurately identifysuch injuries as turf toe, ankle injuries, tarsometatarsal (ie, Lisfranc)injuries, and stress fractures. Early diagnosis and management of these injuriesare critical. Ultimately, however, pressure to return to play must not compromiseappropriate care and long-term outcomes.

Osteochondritis dissecans (OCD) of the capitellum is an uncommon disorderseen primarily in the adolescent overhead athlete. Unlike Panner disease,a self-limiting condition of the immature capitellum, OCD is multifactorialand likely results from microtrauma in the setting of cartilage mismatch andvascular susceptibility. The natural history of OCD is poorly understood,and degenerative joint disease may develop over time. Multiple modalitiesaid in diagnosis, including radiography, MRI, and magnetic resonance arthrography.Lesion size, location, and grade determine management, which should attemptto address subchondral bone loss and articular cartilage damage. Early, stablelesions are managed with rest. Surgery should be considered for unstable lesions.Most investigators advocate arthroscopic dbridement with marrow stimulation.Fragment fixation and bone grafting also have provided good short-term results,but concerns persist regarding the healing potential of advanced lesions.Osteochondral autograft transplantation appears to be promising and shouldbe reserved for larger, higher grade lesions. Clinical outcomes and returnto sport are variable. Longer-term follow-up studies are necessary to fullyassess surgical management, and patients must be counseled appropriately.

Pressure ulcers can be a devastating complication in the care of orthopaedicpatients. Their presence leads to increased morbidity, mortality, and costof care. Therapy and rehabilitation cannot progress on a normal postoperativecourse in the patient with a pressure ulcer. Risk factors for the developmentof pressure ulcers include spinal cord injury, advanced age, and cognitiveimpairment. Several grading scales have been developed for the assessmentof pressure ulcer. Frequent patient turning, close monitoring, and frequentskin checks are important factors in the prevention of pressure ulcer.

For this technology overview, the tools of evidence-based medicine wereused to summarize information on the effectiveness and clinical outcomes relatedto the usage of bone void fillers specifically, synthetic graft materials.Comprehensive literature searches were conducted to address five key questions,which the task force that prepared the report posed as follows. Question 1addressed the use of synthetic bone void fillers alone. Question 2 was designedto determine whether synthetic bone void fillers could successfully serveas graft extenders and eliminate the need for iliac crest bone graft. Questions3, 4, and 5 addressed the use of allografts as a comparison with syntheticfillers because clinical results with allografts are perceived as being muchcloser to autografts in these areas of the spine.