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.

The cyclops lesion: a cause of diminished knee extension after rupture of the anterior cruciate ligament.

Four patients presented with persistent diminution of knee motion after rupture of the anterior cruciate ligament with a novel lesion as the cause. Each had participated in an aggressive rehabilitation program for a minimum of 2 months with emphasis on regaining full range of knee motion. Because chronic impairment of knee extension can be disabling, in those who did not regain full range of motion, arthroscopy of the knee ensued. All had a lesion in the intercondylar notch near the tibial insertion of the anterior cruciate ligament that acted as a mechanical obstruction to full knee extension. Grossly and histologically, these were similar to the cyclops lesion that also has been shown to cause loss of knee extension after anterior cruciate ligament reconstruction. Arthroscopic debridement of the cyclops lesion and manual manipulation of the knee under anesthesia lead to restoration of full knee extension in all knees. In 1 other knee with chronic instability after anterior cruciate ligament rupture, the cyclops lesion was present but was very small and was not associated with diminished knee extension. When loss of full extension persists for 2 months after anterior cruciate ligament disruption despite aggressive rehabilitation, the presence of a cyclops lesion should be considered.

Dynamic stability of the elbow: electromyographic analysis of the flexor pronator group and the extensor group in pitchers with valgus instability.

The medical collateral ligament is a common site of injury in baseball pitchers, causing substantial morbidity and loss of pitching time. Twenty-six skilled baseball pitchers with medial collateral ligament insufficiency were studied before surgery with high-speed cinematography and fine-wire electromyography of eight muscles around the elbow. Data from the pitchers with injured elbows were compared with data obtained from uninjured pitchers. The flexor carpi radialis muscle in the pitchers with medial collateral ligament deficiencies revealed significantly decreased firing during the acceleration and deceleration phase of the fastball when compared with that of the pitchers with normal elbows, and the flexor carpi radialis muscle was significantly depressed during the early cocking and deceleration phases. The extensor muscles revealed slightly increased activity in the injured elbows; however, this was not statistically significant. Although the muscles of the flexor pronator group (especially the flexor carpi ulnaris muscle and the flexor digitorum superficialis muscles) are anatomically positioned to provide dynamic stability of the elbow, they did not demonstrate increased electrical activity in pitchers with medial collateral ligament deficiencies. This finding suggests that the muscles on the medial side of the elbow do not supplant the role of the medial collateral ligament during the fastball pitch.

Arthroscopic debridement of glenoid labral tears in athletes.

UNLABELLED: This is a retrospective study of 46 patients who underwent arthroscopic glenoid labral debridement from June 1988 to June 1990. All patients complained of pain in the involved shoulder and all were active in sports involving overhead use of the shoulder, including 30 baseball players (16 professional, 14 collegiate/high school). The average age was 22 years (range 16 to 45) and the average follow-up was 2.7 years (range 18 to 50 months). At operation, 35 patients had posterior glenoid lesions, 9 had anterior-superior lesions, and 2 had anterior-inferior lesions. The posterior lesions were further divided into those that involved a horizontal flap tear (n = 19), and those that involved fraying (n = 16). Overall, at an average of 31 months follow-up. 54% (25 of 46) of patients had good to excellent results. Professional baseball players had a statistically significant enhanced outcome with 75% (12 of 16) good-excellent compared with the remaining nonprofessional group, with 43% (13 of 30) good-excellent results. Outcome did not correlate with shoulder laxity, labral lesion location, mechanism of injury, or the presence of a rotator cuff lesion. CONCLUSIONS: Arthroscopic debridement of glenoid labral lesions does not yield consistent long-term results. Aggressive, supervised physical therapy in highly motivated individuals may be the most important factors in influencing outcome in patients having arthroscopic labral debridement in the absence of overt shoulder instability.

Instability versus impingement syndrome in the throwing athlete.

Shoulder pain in the throwing athlete has become a well recognized phenomenon. Shoulder pain in the athlete is often due to overuse and typically responds with a well managed conservative program that includes rest and rotator cuff rehabilitation exercises. The author's experience has demonstrated that persistent pain and symptoms of an impingement syndrome are often due to an unrecognized instability syndrome in the athlete.

An electromyographic analysis of the elbow in normal and injured pitchers with medial collateral ligament insufficiency.

Electromyography and high-speed film were used to examine the muscle activity in the elbows of pitchers with medial collateral ligament insufficiency compared to the activity in uninjured elbows. Ten competitive baseball pitchers with medial collateral insufficiency and 30 uninjured competitive pitchers were tested while throwing the fastball and the curveball. The extensor carpi radialis brevis and longus in the injured pitchers showed greater activity than in the uninjured pitchers for both pitches. The triceps, flexor carpi radialis, and pronator teres all showed less activity in the injured pitchers during the fastball, but only the triceps had less activity during the curveball. The differences were seen during the late cocking and acceleration phases, which place the greatest stress on the medial collateral ligament. If the flexor carpi radialis and pronator teres were substituting for the deficient medial collateral ligament and functioning as dynamic stabilizers, one would expect enhanced muscle activity. However, the opposite was found. This pattern of asynchronous muscle action with medial collateral ligament injury may predispose the joint to further injury. The muscular differences seen are critical to the understanding of the pathomechanics of patients with medial collateral ligament deficiency, and provide a basis for rehabilitation.

Medial instability of the elbow in throwing athletes. Treatment by repair or reconstruction of the ulnar collateral ligament.

From September 1974 to December 1987, seventy-one patients were operated on for valgus instability of the elbow. The average length of follow-up of sixty-eight patients (seventy operations) was 6.3 years (range, two to fifteen years). At the operation, a torn or incompetent ulnar collateral ligament was found. Fourteen patients had a direct repair of the ligament, and fifty-six had a reconstruction of the ligament using a free tendon graft. The result was excellent or good in ten patients in the repair group and in forty-five (80 per cent) in the reconstruction group. Seven of the fourteen patients who had a direct repair returned to the previous level of participation in their sport. Of the fifty-six who had a reconstruction, thirty-eight (68 per cent) returned to the previous level of participation. Twelve of the sixteen major-league baseball players who had a reconstruction as the primary operation (no previous operation on the elbow) were able to return to playing major-league baseball, and two of the seven major-league players who had a direct repair returned to playing major-league baseball. Previous operations on the elbow decreased the chance of returning to the previous level of sports participation (p = 0.04). Fifteen patients had postoperative ulnar neuropathy. This was transient in six patients, only one of whom was unable to return to the previous level of sport. The other nine patients had an additional operation for the neuropathy; four were able to return to the previous level of sport.

Anterior capsulolabral reconstruction of the shoulder in athletes.

We did an anterior capsulolabral reconstruction for recurrent subluxation or dislocation of the shoulder in 75 athletes after failure of conservative therapy. Average follow-up was 39 months (range 28 to 60 months). The results were 77% excellent, 75% good, 3% fair, and 5% poor. Seventy-five percent of the professional and 100% of the college baseball players returned to their previous level of competition. Seventy-seven percent of the professional pitchers were able to return to professional pitching. The range of motion at follow-up was full in 79% of the athletes. No infections or nerve injuries occurred. The anterior capsulolabral reconstruction procedure combined with an early rehabilitation program appears to provide an improved outcome compared with previously reported procedures for anterior instability of the shoulder in athletes.

Anterior capsulolabral reconstruction of the shoulder in athletes in overhand sports.

From April 1, 1985, through June 30, 1987, 25 skilled athletes with shoulder pain secondary to anterior glenohumeral instability that had failed to improve with conservative therapy had an anterior capsulolabral reconstruction. All but one athlete completed a formal rehabilitation program with an average followup of 39 months. The results at followup were rated excellent in 68%, good in 24%, fair in 4%, and poor in 4%. Seventeen patients returned to their prior competitive level for at least 1 year. This operation and rehabilitation program may allow many athletes who participate in overhand activities or throwing sports to return to their prior level of competition.

Ulnar nerve problems in the athlete's elbow.

Ulnar neuritis at the elbow is a common entity affecting the athlete especially those involved in overhand sports. Inflammation of the ulnar nerve is a component of the disorders that affect the medial side of the elbow in athletics owing to the large tensile forces encountered. The treatment of the athlete with medial elbow pain should not be isolated to the findings of ulnar neuritis especially when attenuation of the ulnar collateral ligament is encountered. The prognosis of the athlete to return to their prior level of competition is related to their preoperative presentation. Patients with long-standing ulnar neuritis and severe lesions that include intrinsic muscle dysfunction and profound findings on EMG and nerve conduction studies have a less favorable outcome. The prognosis is also related to other associated conditions such as ulnar collateral ligament attenuation and degenerative arthritis. In athletes with symptoms primarily secondary to ulnar neuritis with minimal neurologic deficits and early treatment, the prognosis for return to competitive play is excellent.

Injections and techniques in athletic medicine.

The use of corticosteroids in the treatment of athletic injuries can provide dramatic relief of pain and inflammation. The proper use of injectable steroids must be carefully understood to avoid complications. It is critical to know the anatomy and use your needle as carefully as you would a scalpel. Bring the anatomy close to you so that you can use the shortest delivery system and the smallest caliber needle. Have the patient in an optimal position: sitting up for subacromial injections, lying supine for anterior shoulder injections with rotation of the anatomy under your fingers until the area is specifically identified, lying prone for posterior shoulder problems, and sitting up for knee injections, especially for the tibial collateral ligament bursa. Remember that injection of the material should be free and easy. Resistance means you are not in planes between tissues but in the tissue, which is not desirable. Understand the importance of a therapeutic test for both diagnostic and treatment purposes. Judicious use of any medication is critical in the treatment armamentarium, including injectable corticosteroids. Remember that an injection does not substitute for a well-managed rehabilitation program. The key to the successful treatment of an athletic injury is predicted on an accurate diagnosis and a well-managed treatment program.

Tibial collateral ligament bursitis.

In 91 patients evaluated between 1982 and 1985, tibial collateral ligament bursitis was diagnosed. This entity has not been described since the work of Brantigan and Voshell in 1943. The diagnosis was based on the findings of tenderness over the tibial collateral ligament at the joint line, without a history of mechanical symptoms. With a nonsurgical program, 62% of the patients improved and subsequently required no further treatment. Fifteen percent did not improve; of this group, one-third had a negative arthrogram or arthroscopy. Another 23% did not improve and ultimately underwent an arthroscopic partial medial meniscectomy. Tibial collateral ligament bursitis is an entity that should be considered in any patient with medial joint pain in the knee. Treatment is simple, effective, and offers low morbidity.