Treatment of osteochondral injuries of the humeral head using fresh osteochondral allograft transplantation.

Background: Large osteochondral lesions of the humeral head can result from locked posterior dislocations, avascular necrosis, and osteochondritis dissecans. Fresh osteochondral allograft (OCA) transplantation is a treatment option for young patients with focal osteochondral defects of the humeral head. The purpose of this case series was to assess graft survivorship, subjective patient-reported outcomes, and satisfaction among 7 patients who underwent OCA transplantation of the humeral head. Methods: We identified 7 patients who underwent humeral head OCA transplantation between 2008 and 2017. A custom questionnaire including the American Shoulder and Elbow Surgeons score, Quick Disabilities of the Arm, Shoulder, and Hand score (QuickDash), Likert satisfaction, and reoperations was mailed to each patient. Clinical failure was defined as further surgery that involved removal of the allograft. Results: Median follow-up duration was 10 years (range, 4.6 to 13.5 years) with a median age of 21.6 years (range, 18.5 to 43.5 years). Most patients (86%) reported improved function and reduced pain. At the final follow-up, 71% of patients reported ongoing problems with their shoulder including pain, stiffness, clicking/grinding, limited range of motion, and instability. Return to recreational activities was high at 86% but 43% expressed limitations with activity due to their shoulder. Overall satisfaction was high at 71% with mean American Shoulder and Elbow Surgeons and QuickDASH scores at 62.4 and 29.2, respectively. Reoperation after OCA occurred in 1 patient (14%). Conclusion: Among this case series of 7 patients who underwent OCA transplantation of the humeral head, patient satisfaction was high at 10-year follow-up and most returned to recreational activity although most also had persistent shoulder symptoms.

Participation in Sports or Recreational Activities After Osteochondral Allograft Transplantation of the Talus.

BACKGROUND: Fresh osteochondral allograft (OCA) transplantation is a viable treatment option for osteochondral defects of the talus. However, sufficient data are not available on patients' participation in sports or recreational activities after the procedure. PURPOSE: To assess whether patients undergoing OCA transplantation of the talus participated in sports or recreational activities postoperatively. STUDY DESIGN: Case series; level of evidence, 4. METHODS: A total of 36 ankles in 34 patients underwent OCA transplantation of the talus. At a mean follow-up of 9.2 years, information on participation in sports or recreational activities pre- and postoperatively was obtained, as well as postoperative pain, function, and satisfaction. RESULTS: The mean age at the time of surgery was 36.1 years (range, 20.5-57.7 years), and 50% of patients were men. The mean graft size was 3.6 cm2 (range, 1-7.2 cm2) or 41.1% of the talar dome. Before the injury, 63.9% of patients (23/36 ankles) reported being highly competitive athletes or well trained and frequently sporting; 36.1% of patients (13/36 ankles) reported sometimes sporting or were nonsporting. Also, 66.7% of patients (24/36 ankles) were able to participate in sports or recreational activities after OCA transplantation and 50% (18/36 ankles) were still participating in sports or recreational activities at the latest follow-up. In a subset of well-trained or highly competitive athletes, 73.9% (17/23 ankles) were able to return to sports or recreational activities at any point after OCA transplantation, and 65.2% (15/23 ankles) were still participating at the latest follow-up. Further surgery occurred in 16.7% of patients (6/36 ankles). Graft survivorship was 94.3% at 5 years and 85.3% at 10 years. There was a significant improvement in the mean Olerud-Molander Ankle Scores, and the mean Foot and Ankle Ability Measure scores were high postoperatively. Moreover, 79.4% of patients (27/34 ankles) were either satisfied or extremely satisfied with the allograft surgery. CONCLUSION: Fresh OCA transplantation is a reasonable surgical option for osteochondral defects of the talus for young, active patients who have failed previous operative management or have massive defects.

Evolution of the throwing shoulder: why apes don't throw well and how that applies to throwing athletes.

BACKGROUND: Humans have unique characteristics making us the only primate that can throw well while most other primates throw predominately underhand with poor speed and accuracy. The purpose of this study is to illuminate the uniquely human characteristics that allow us to throw so well. When treating an injury such as a labral tear or capsule tear, this study hopes the reader can gain a better understanding of the issues that lead to the tear and those that may determine the success of treatment besides the actual repair. METHODS: In addition to a review of scientific and medical literature, information was obtained from interviews and experience with primate veterinarians, anthropologists, archeologists, and professional baseball players. These sources were used to study the connection between evolutionary throwing activities and current sports medicine issues. RESULTS: Arm acceleration requires a functional kinetic chain, rapid motor sequences, and the ability to absorb elastic energy in the shoulder. Successful treatment of the throwing shoulder requires awareness of the shoulder's position in the kinetic chain and correction of defects in the ability to execute the kinetic chain. Some problems in the shoulder could reflect regression to a more primitive anatomy or dyskinesis. Return of performance requires regaining the elasticity in the tissues of the shoulder to temporarily store kinetic energy. For example, tissue remodeling after rotator cuff repair continues for months to years; however, the newly formed tissue lacks the same elasticity of the native tendon. This suggests why throwing performance typically does not return for 7 or more months after repair even though there may be structural integrity at 3-4 months. CONCLUSION: The shoulder has developed uniquely in modern man for the act of throwing. The anatomic deficiencies in primates for throwing provide an illustration of the more subtle changes that a throwing athlete might have that are detrimental to throwing. Nonhuman primates have been unable to demonstrate the kinetic chain sequence for throwing secondary to the lack of neurologic pathways required. Humans are more sophisticated and precise in their movements but lack robusticity in their bone and muscle architecture, seen especially in the human rotator cuff. Successful treatment of a throwing injury requires familiarity with the conditions that cause the injury or affect the rehabilitation process. The return of performance following injury or surgery requires regaining the elasticity in the tissues of the shoulder to temporarily store kinetic energy from the kinetic chain.