Partial posteromedial olecranon resection: a kinematic study.

BACKGROUND: The posteromedial aspect of the olecranon process is a site of impingement and subsequent osteophyte development in throwing athletes. Treatment with débridement, with resection of osteophytes and varying amounts of normal olecranon bone, is common. We found no reports in the literature concerning the effects of resecting different amounts of normal bone from the posteromedial aspect of the olecranon. We hypothesized that excessive resection would increasingly alter elbow kinematics and that an optimum amount of olecranon resection could be identified. METHODS: We investigated the kinematic effects of increasing valgus and varus torques and posteromedial olecranon resections, in twelve cadaveric elbows, with use of an electromagnetic tracking device. Two valgus and two varus torques were applied, and three sequential resections were performed in 3-mm steps from 0 mm to 9 mm. Statistical analyses included paired t tests, 95% confidence intervals, a one-factor analysis of variance with repeated measures, and a post hoc test when significance was established. RESULTS: Sequential partial resection of the posteromedial aspect of the olecranon resulted in stepwise increases in valgus angulation with valgus torque. Clear differences were seen at each level of resection. A pattern of increased valgus angulation also was seen in association with increased valgus torque. Increased valgus torque resulted in a trend toward increased axial internal rotation of the ulna, whereas increased osseous resection resulted in a decrease in the absolute degree of internal rotation or, in some specimens, increased external rotation. CONCLUSIONS: Although no single critical amount of olecranon resection was identified, valgus angulation of the elbow increased in association with all resections, with a marked increase occurring in association with a 9-mm resection. Our findings challenge the rationale of removing any amount of normal olecranon bone in throwing athletes as doing so may increase strain on the medial collateral ligament. The implications for the professional throwing athlete are important, and we recommend that bone removal from the olecranon be limited to osteophytes, without the removal of normal bone.

Arthroscopy of the elbow: a long-term clinical review.

PURPOSE: The purpose of this study was to review a large group of patients who had arthroscopy of the elbow to determine the efficacy and relative risks of this procedure. TYPE OF STUDY: We retrospectively reviewed a convenient sample of 172 patients who underwent 187 arthroscopies of the elbow over a 7-year period. MATERIALS AND METHODS: All patients had their charts and radiographs reviewed, and 104 of these patients were also contacted for a telephone interview at an average follow-up of 42.3 months (range, 7 to 115 months). RESULTS: The procedures were performed primarily by 7 different surgeons, using all 3 standard operating positions and a variety of arthroscopic portals. The most common diagnosis was posterior impingement in 96 patients (51%), followed by loose bodies in 72 patients (31%), and degenerative joint disease in 32 patients (22%). The average preoperative modified Figgie score was 27.7 points (range, 17-43) for all patients. The average postoperative score was 45.4 points (range, 29-50), with the largest increase occurring in the pain score. There were 51 patients (56%) with an excellent surgical result, 37 patients (36%) with a good result, 12 patients (11%) with a fair result, and 4 patients (4%) with a poor result. The average modified Figgie score increased from 31.2 points (range, 22-43) to 46.9 (range, 29-50) postoperatively in professional athletes; from 26.3 to 42.6 in patients who had Workers' Compensation claims but were not professional athletes; from 29.4 to 45.6 in patients with a diagnosis of loose bodies; and from 30.1 to 43.7 in patients with degenerative joint disease. There were 3 known surgical complications (1.6%) overall, 1 of which was a patient who had a transection of the ulnar nerve requiring microsurgical repair. Of the 104 patients who were contacted, 6 patients felt that their symptoms had not improved after surgery. Eight of the 55 baseball players contacted were not able to return to their same level of competition. CONCLUSIONS: Arthroscopy of the elbow appears to be a safe and efficacious procedure with a relatively low complication rate.

Arthroscopic findings in the overhand throwing athlete: evidence for posterior internal impingement of the rotator cuff.

SUMMARY: The purpose of this article is to describe the outcome of an arthroscopic examination and the pathology in symptomatic shoulders of 41 professional overhand throwing athletes. With the arm in the position of the relocation test, 100% of the subjects had either contact between the rotator cuff undersurface and the posterosuperior glenoid rim or osteochondral lesions. Other key findings included undersurface cuff fraying in 93%, posterosuperior labral fraying in 88%, and anterior labral fraying in 36% of the subjects. This study supports the concept of impingement of the posterior cuff undersurface with the posterosuperior glenoid rim in the overhand throwing athlete with shoulder pain.

The anterior band of the inferior glenohumeral ligament: biomechanical properties from tensile testing in the position of apprehension.

The shoulder is the most commonly dislocated joint in the body. The primary restraint to anterior instability is the anterior band of the inferior glenohumeral ligament, where lesions are found after dislocation. The amount of surgical plication required to eliminate instability and maintain full range of shoulder motion remains unclear. We performed tensile testing with the shoulder in abduction and external rotation in 11 human, fresh-frozen, cadaveric glenohumeral joints to improve understanding of the glenoid origin of the anterior band of the inferior glenohumeral ligament and to quantify midsubstance irrecoverable elongation. After measuring the length, width, and thickness of the anterior bands with digital micrometry, biomechanical properties were obtained on bone-ligament-labrum-bone (b-l-l-b) complexes. The complexes were aligned for tensile testing with the humerus abducted 60 degrees and externally rotated. The b-l-l-b complexes were then loaded to failure at a strain rate of 100%/sec. Seven of the complexes failed at the glenoid insertion site (representing the Bankart lesion), 2 at the humeral insertion site, and 2 at the anterior band midsubstance. The ultimate load for the b-l-l-b complexes was 353+/-32 N (mean+/-SE), and tensile stress at failure of the glenoid insertion site averaged 9.6+/-2.1 MPa. When the complex failed at the glenoid insertion site, total elongation of the b-l-l-b complex was 9.1+/-0.5 mm, and the ligament midsubstance strain was 13.0%+/-1.8%. Irrecoverable elongation was only 0.8 mm when failure occurred at the glenoid insertion site. Our results indicate patients with initial anterior glenohumeral instability have small irrecoverable capsuloligamentous elongation so that meaningful plication in addition to repair of the Bankart lesion may be unnecessary.

Reconstruction of the lateral collateral ligament of the knee with patellar tendon allograft. Report of a new technique in combined ligament injuries.

This is a retrospective study of 10 patients with combined cruciate ligament and posterolateral instability who underwent surgical reconstruction between 1991 and 1994. All knees had at least 20 degrees increased external rotation at 30 degrees of knee flexion and from 1+ to 3+ varus instability. Five knees with posterior cruciate ligament ruptures had at least a 2+ Lachman test result. (One knee had both anterior and posterior cruciate ligament injuries). In all cases the lateral collateral ligament was reconstructed with a bone-patellar tendon-bone allograft secured with interference screws. Fixation tunnels were placed in the fibular head and at the isometric point on the femur. The cruciate ligaments were reconstructed with autograft or allograft material. The average follow-up was 28 months. Excessive external rotation at 30 degrees of flexion was corrected in all but one knee. Six patients had no varus laxity, and four patients had 1+ varus laxity at 30 degrees of flexion. The posterior drawer test result decreased, on average, to 1+, and the Lachman test result decreased to between 0 and 1+. The average Tegner score was 4.6, with five patients returning to their preinjury level of activity and four returning to one level lower. These results indicate that this is a promising new procedure for patients with instability resulting from lateral ligament injuries of the knee.

Strain of the anterior band of the inferior glenohumeral ligament during capsule failure.

Efficacious surgical treatment of glenohumeral instability requires a combination of anterior band origin repair and capsuloligamentous plication. The purpose of this article was to determine anterior band of the inferior glenohumeral ligament stretching at the time of glenohumeral failure. Thirteen fresh-frozen cadaver glenohumeral joints were thawed and dissected of soft tissue except for the capsuloligamentous structures. Testing was performed with a material testing system device, simulating the anterior instability apprehension position of the shoulder with 90 degrees of shoulder abduction and the humerus externally rotated until the bicipital groove was aligned with the supraglenoid tubercle. The length of each anterior band of the inferior glenohumeral ligament was obtained, and a variable reluctance transducer was applied to the anterior band midsubstance. Tensile testing at a strain rate of 100%/sec ensued until complete capsular failure occurred. Mid-substance strain of the anterior band of the inferior glenohumeral ligament at the time of capsular failure averaged 7.23% +/- 2.25% (mean +/- SD) with a range of 3.68% to 10.68%. Load to failure was 712.9 +/- 238.2 N (range 363.6 to 1136.9 N). All of the glenohumeral capsules failed at the glenoid origin, simulating a Bankart lesion, except for one that failed at the humeral insertion. When the intact capsuloligamentous tissue of the glenohumeral joint is tensile-tested in the apprehension position, there is only slight anterior band strain and failure occurring, predominantly at the glenoid insertion site. This has implications for the success of surgical procedures designed for acute repair of Bankart lesions.

Thoracic spine fracture in a football player. A case report.

Compression fractures of the thoracic spine are less common than injuries to the cervical, thoracolumbar, or lumbar regions because of the inherent stability and geometry of the thoracic spinal region. This injury may be difficult to detect acutely because of the lack of localizing symptoms. An appropriate index of suspicion should be present when examining a player experiencing acute back pain associated with localized spinal tenderness. Early recognition and appropriate treatment are needed to maximize the patient's chances of return to normal function while avoiding further injury from lack of recognition of the injury or too early return to play.