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Estimation of the hip joint contact area and pressure distribution during activities of daily living is important in predicting joint degeneration mechanism, prosthetic implant wear, providing biomechanical rationales for preoperative planning and postoperative rehabilitation. These biomechanical data were estimated utilizing a generic hip model, the Discrete Element Analysis technique, and the in vivo hip joint contact force data. The three-dimensional joint potential contact area was obtained from the anteroposterior radiograph of a subject and the actual joint contact area and pressure distribution in eight activities of daily living were calculated. During fast, normal, and slow walking, the peak pressure of moderate magnitude was located at the lateral roof of the acetabulum during mid-stance. In standing up and sitting down, and during knee bending, the peak pressures were located at the edge of the posterior horn and the magnitude of the peak pressure during sitting down was 2.8 times that of normal walking. The peak pressure was found at the lateral roof in climbing up stairs which was higher than that in going down stairs. These results can be used to rationalize rehabilitation protocols, functional restrictions after complex acetabular reconstructions, and prosthetic component wear and fatigue test set up. The same model and analysis can provide further insight to soft tissue loading and pathology such as labral injury. When the pressure distribution on the acetabulum is inverted onto the femoral head, prediction of subchondral bone collapse associated with avascular necrosis can be achieved with improved accuracy.

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Presentamos la experiencia de nuestro Servicio en el tratamiento del cáncer prostático clínicamente órgano-confinado, mediante prostatectomía radical, en la perspectiva de un análisis de largo plazo. Se efectuó una revisión retrospectiva sobre un universo de 227 pacientes, cumpliendo los datos exigidos 164, que representan el 72,2 por ciento de la serie original. El tiempo máximo de seguimiento fue de 11 años 6 meses, exigiéndose un mínimo de 3 años, resultando una media de seguimiento de 6,66 años. La edad promedio fue 64 años. Los estadios órgano-confinados se mantuvieron libres de progresión en 72 por ciento, lo que se invierte en estadios como pT3C, 96 por ciento de progresión, y 7 casos, N1 y N2 que progresaron todos. Radioterapia complementaria se aplicó en 50 pacientes, exclusiva en 39 con 71,7 por ciento de remisión. La sobrevida global fue de 86,5 por ciento y cáncer específica de 95 por ciento.

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Presentamos la experiencia de nuestro servicio en el tratamiento del cáncer prostático clínicamente órgano confinado, mediante prostatectomía radical retropúbica (PRR) con linfadenectomía ilioobturatriz. Se realizó un estudio retrospectivo de 227 pacientes sometidos a este tratamiento, entre abril de 1993 y febrero de 2002, con un seguimiento mínimo de seis meses. Observamos una subetapificación global de 62,11 porciento y un antígeno prostático específico (APE) promedio de 15,73 ng/ml. Se obtuvo una continencia completa en 96,4 porciento; sólo 2 casos de incontinencia total. Disfunción eréctil se manifestó como severa en 45,9 porciento de 183 pacientes que pudieron ser evaluados en este aspecto. La mortalidad perioperatoria fue de 0,88 porciento (2 pacientes). Progresión de la enfermedad sin terapia complementaria se observó en 37,5 porciento, mientras que la sobrevida global superior a 60 meses fue de 94,3 porciento.

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Injuries to the proximal interphalangeal (PIP) joint are common in athletes, especially in contact and ball sports(1). Most PIP injuries involve disruption of the volar plate or dorsal dislocation. Less common is the "boutonniére" injury, which, if left undiagnosed and untreated, results in a boutonniére deformity. This deformity is difficult to manage and often requires prolonged immobilization and/or surgery to regain function(2).

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The purpose of this study was to evaluate the relative risk of anterior cruciate ligament injury in female versus male midshipmen at the United States Naval Academy. From 1991 to 1997, we recorded the incidence of anterior cruciate ligament injury during intercollegiate athletics, intramural athletics, and military training. The subjects were male and female varsity athletes, coed intramural athletes, and participants in military training consisting of the obstacle course and instructional wrestling. All patient data were collected at the time of injury. Records filed at the intramural sports office, along with a questionnaire completed by coaches and trainers, were used to estimate midshipmen exposures. Results showed that in intercollegiate soccer, basketball, and rugby, women had a relative injury risk of 3.96 compared with men. In coed soccer, basketball, softball, and volleyball, the women's relative injury risk was 1.40 compared with men. In military training, women had a relative injury risk of 9.74 compared with men. In comparing overall annual anterior cruciate ligament injury rates among midshipmen, we found that women had a relative injury risk of 2.44 compared with men. We concluded that female midshipmen have an increased relative risk of anterior cruciate ligament injury as compared with men in intercollegiate athletics, basic military training, and throughout their service academy career. This increase was not statistically significant at the intramural level of athletics.

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A 38-year-old active-duty Marine Corps officer with a history of ankle instability presented to the orthopedic clinic complaining of left lateral ankle and leg pain. A diagnosis of rupture of the tendon of the peroneus longus was made. This is an unusual diagnosis in an active Marine Corps officer. Surgical treatment markedly improved his symptoms.

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Twenty-three subacute scaphoid fractures were retrospectively reviewed to determine the efficacy of nonoperative treatment. All of the patients sought medical attention between 4 weeks and 6 months after injury, and their fractures were classified according to location and stability. Nineteen fractures were observed to radiographic union or until closed treatment was abandoned; four patients were lost to followup. Nine of 10 stable subacute middle-third scaphoid fractures healed with cast immobilization in an average of 19 weeks (range, 11 to 38), and these were compared with a randomly selected group of acute middle-third fractures that healed in an average of 10 weeks (range, 6 to 13). Five of six unstable subacute middle-third fractures healed in an average of 20 weeks. One of these had a symptomatic humpback deformity treated by cheilectomy. Of three subacute proximal-third fractures, only one healed after 29 weeks of closed treatment. This study demonstrates that stable subacute middle-third scaphoid fractures will heal with cast treatment but may take twice as long to do so as stable acute middle-third fractures. Unstable subacute middle-third scaphoid fractures and subacute proximal-third fractures appear less likely to heal with closed treatment.

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We studied patients who participated in our accelerated rehabilitation program after anterior cruciate ligament reconstructive surgery to determine if they showed signs of patellar tendon graft stretching. This program initiated in 1987 emphasizes early full hyperextension, early weightbearing as tolerated, and closed-chain functional activities with rapid return to sports when the patient has attained full range of motion, approximately 65% of strength, and has accomplished the running and agility drills prescribed. A total of 209 patients met the criteria of KT-1000 arthrometer followup at the time full range of motion (5 degrees/0 degrees/135 degrees) was attained and at 2 years or more after surgery. The KT-1000 arthrometer manual maximum difference between the reconstructed and normal knees was used as the indicator of change in the graft length. All patients completed postoperative subjective questionnaires. The mean KT-1000 arthrometer value was 2.06 mm (SD, +/- 2.2) at full range of motion and 2.10 mm (SD, +/- 1.9) at more than 2 years of followup (P = 0.7961). The patients' subjective stability scores averaged 19.6 with 97% reporting no instability episodes. Based on our findings, we conclude that an accelerated rehabilitation program after this type of reconstruction does not affect long-term stability as measured by the KT-1000 arthrometer.

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We reviewed a consecutive series of young symptomatic patients with chronic anterior cruciate ligament-deficient knees to determine if an autogenous patellar tendon graft reconstruction decreased their symptoms and increased the stability of the knee. All patients had radiographic evidence of posttraumatic arthritis. Thirty-three patients met our criteria for inclusion in the study. Time from injury to reconstruction of the anterior cruciate ligament averaged 105 months. All patients underwent an accelerated rehabilitation program designed to help them regain full range of motion as soon as possible. Preoperative and postoperative range of motion, strength, stability, and subjective evaluations were compared. Followup averaged 44.8 months. Follow-up range of motion was not significantly different from preoperative measurements (P = 0.51). Postoperative stability, as measured by KT-1000 arthrometer maximum manual test, averaged 2.7 mm versus 8.4 mm preoperatively (P < 0.001). Isokinetic testing revealed no difference in the quadriceps strength after reconstruction (P = 0.99). Patients' subjective scores on a modified Noyes questionnaire improved for pain, stability, and activity level, with a total improvement from 55 to 81 points. Although the procedure and rehabilitation were successful in providing stability and decreasing pain, patients were still encouraged to limit high-impact athletic and occupational activity.

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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.

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Arthrofibrosis is a potential complication of acute ACL reconstruction. Arthrofibrosis prevents the patient from regaining full range of motion, particularly the terminal 5 degrees of full extension, postoperatively. We did a retrospective study of 169 acute ACL reconstructions in a population of young athletes (average age, 22 years). We sought to determine the optimal time to perform acute ACL reconstruction with respect to arthrofibrosis and the effects of an accelerated versus conventional rehabilitation program. The short-term results were evaluated by range of motion measurements and 13 week Cybex scores. Patients whose ligaments were reconstructed within the 1st week after injury (Group I) had a statistically significant (P less than 0.05) increased incidence of arthrofibrosis (limited extension, scar tissue) over patients who had ACL reconstruction delayed 21 days or more (Group III). At 13 weeks after the reconstruction procedure, Group III patients scored an average of 70% (compared to 51% for Group I, P less than 0.05) on the Cybex evaluation. They also showed a trend toward more flexion of the knee as well as near full extension. Patients who had an ACL reconstruction between 8 and 21 days after injury (Group II) had a similar incidence of arthrofibrosis as Group I when they followed a conventional rehabilitation program postoperatively. However, only a small number of cases (approximately 4%) of Group II patients who followed an accelerated postoperative rehabilitation program had any arthrofibrosis--an observation we also made in the Group III patients.(ABSTRACT TRUNCATED AT 250 WORDS)

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Eight years of experience in performing only bone-patellar tendon-bone autograft reconstructions of the anterior cruciate ligament (ACL) are presented, with an emphasis on an accelerated post-operative rehabilitation protocol. Past patient non-compliance to previously established protocols still yielded very acceptable results that demanded further investigation. Gradually we developed a three-phase rehabilitation plan that is implemented after surgical correction of ACL deficiencies. The first phase (zero to two weeks) focuses primarily on wound healing, full extension, control of swelling, and leg control. The second phase (two to five weeks) involves increasing flexion, developing a functional gait, and resuming activities of daily living. The third phase (greater than 5 weeks) identifies a safe return to competitive athletics. This protocol evolved with close observation of approximately 1,000 reconstructions and has been used on the last 650 patients since January 1987. A decreased postoperative morbidity was noted without a compromised clinical stability.

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