Prevalence of bilateral ulnar nerve subluxation among professional baseball pitchers.

BACKGROUND: Radiographic and physical examination findings of ulnar nerve instability have been recognized in overhead throwing athletes, despite the fact that some of these abnormalities may be asymptomatic and represent adaptive changes. While recommendations for screening and early detection have been made that can adversely impact an athletes' career, the presence of bilateral ulnar nerve subluxation and its relationship with medial elbow symptoms has not been characterized in professional overhead throwing athletes. PURPOSE: To characterize the prevalence of bilateral ulnar nerve subluxation among professional baseball pitchers. METHODS: A cross-sectional observational analysis was conducted utilizing standardized ultrasonographic examinations of bilateral elbows in 91 consecutive professional baseball pitchers (median age, 22 years; range, 17-30 years). The relationship between ulnar nerve subluxation and ulnar nerve signs, symptoms, and provocative physical examination maneuvers was also investigated. RESULTS: The prevalence of bilateral ulnar nerve subluxation was 26.4% (95% CI, 17.7%-36.7%; 24 of the 91 athletes). Thirty-five athletes (38.5%; 95% CI, 28.4%-49.2%) had subluxation in at least 1 elbow. No athletes with subluxation had positive ulnar nerve signs, symptoms, or provocative tests. CONCLUSION: Ulnar nerve subluxation is common among professional pitchers, and is more often than not bilateral. In this population of athletes, ulnar nerve subluxation does not appear to be associated with pathological findings.

Physical Examination Versus Ultrasonography for Detection of Ulnar Nerve Subluxation in Professional Baseball Pitchers.

Background: Despite the importance of accurately detecting ulnar nerve subluxation in vulnerable athletes, few studies have compared the performance of physical examination and ultrasound in this population. Purpose/Hypothesis: The purpose of this study was to compare the diagnostic validity of physical examination versus ultrasound in detecting ulnar nerve subluxation at the cubital tunnel of the elbow in professional baseball pitchers. It was hypothesized that ultrasound would more sensitively detect ulnar nerve subluxation. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Physical and sonographic examinations for ulnar nerve subluxation were performed on 186 elbows of 95 consecutive male professional baseball pitchers (age, 17-30 years) as a routine part of their spring training assessments. Provocative maneuvers consisting of the Tinel and elbow flexion-compression tests were evaluated over the cubital tunnel. The validity of physical examination for detecting ulnar nerve subluxation at the elbow was determined using ultrasonographic examination for comparison. Results: Ulnar nerve subluxation was detected by physical examination in 58 (31.2%) elbows and by ultrasonography in 61 (32.8%) elbows. Of the 58 elbows with positive physical examination, 47 were positive on ultrasound. Using a positive ultrasound as a reference, the accuracy of the physical examination was 86.6%, with 77% sensitivity and 91.2% specificity. The positive and negative predictive values of physical examination were 81% and 89.1%, respectively. There was no relationship between nerve instability and positive provocative tests overall, in dominant versus nondominant arms, or in right versus left arms (P > .05 for all). Conclusion: Physical examination had moderate sensitivity and high specificity for detecting ulnar nerve subluxation at the cubital tunnel of the elbow when compared with ultrasound. These findings suggest that when detecting the presence of a subluxating ulnar nerve is most important, it may be advisable to obtain an ultrasound evaluation instead of relying on a physical examination; however, physical examination alone may be appropriate for ruling out subluxation.

Bankart Repair With or Without Concomitant Remplissage Results in Similar Shoulder Motion and Postoperative Outcomes in the Treatment of Shoulder Instability.

Purpose: To compare the results of patients who underwent Bankart repair with or without concomitant remplissage for treatment of shoulder instability. Methods: All patients who underwent shoulder stabilization for shoulder instability from 2014 to 2019 were evaluated. Patients who underwent remplissage were matched to those patients who received no remplissage based on sex, age, body mass index, and date of surgery. Glenoid bone loss and presence of an engaging Hill-Sachs lesion were quantified by 2 independent investigators. Postoperative complications, recurrent instability, revision, shoulder range of motion (ROM), return to sport (RTS), and patient-reported outcome measures (Oxford Shoulder Instability, Single Assessment Numeric Evaluation, and American Shoulder and Elbow Surgeons scores) were compared between groups. Results: Overall, 31 patients who underwent remplissage were identified and matched to 31 patients who received no remplissage at a mean follow-up of 2.8 ± 1.8 years. Glenoid bone loss was similar between groups (11% vs 11%, P = .956); however, engaging Hill-Sachs lesions were more prevalent in the patients who underwent remplissage than the patients who received no remplissage (84% vs 3%, P < .001). There were no significant differences in rates of redislocation (remplissage: 12.9% vs no remplissage: 9.7%), subjective instability (45.2% vs 25.8%), reoperation (12.9% vs 0%), or revision (12.9% vs 0%) between groups (all P > .05). Also, there were no differences in RTS rates, shoulder range of motion, or patient-reported outcome measures (all P > .05). Conclusions: If a patient is indicated for Bankart repair with concomitant remplissage, surgeons may expect shoulder motion and postoperative outcomes similar to those of patients without engaging Hill-Sachs lesions who undergo Bankart repair without concomitant remplissage. Level of Evidence: Therapeutic case series, level IV.

Increased rates of subjective shoulder instability after Bankart repair with remplissage compared to Latarjet surgery.

HYPOTHESIS AND BACKGROUND: Controversy exists as to the ideal management of young active patients with subcritical glenoid bone loss and an off-track Hill-Sachs lesion, and the Latarjet and arthroscopic Bankart with remplissage are effective surgical options. The purpose of this study was to compare rates of recurrent instability and reoperation, as well as patient-reported outcome measures, between Latarjet and arthroscopic Bankart repair with remplissage surgery patients. The authors hypothesized that there would be no difference in rates of recurrent instability, reoperation, and postoperative outcomes between patients who underwent Latarjet surgery and patients who underwent Bankart repair with concomitant remplissage postoperatively. MATERIALS AND METHODS: All patients who underwent primary shoulder stabilization for shoulder instability from 2014 to 2019 were screened. Latarjet and Bankart repair with remplissage patients were included if arthroscopic surgery was performed in response to anterior shoulder instability. Recurrent instability, revision, shoulder range of motion, return to sport (RTS), and patient-reported outcome measures (Oxford Shoulder Instability, Single Assessment Numeric Evaluation, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form scores) were compared between groups. RESULTS: Overall, 43 Latarjet patients (age: 29.8 ± 12.1 years, 36 males 7 females) and 28 Bankart repair with remplissage patients (age: 28.2 ± 8.8 years, 25 males 3 females) were included with a mean follow-up of 3.3 ± 1.9 years. Patients who underwent Latarjet surgery had larger amounts of bone loss (19% vs. 11%, P < .001), a lower rate of off-track Hill-Sachs lesions (47% vs. 82%, P < .001), and more frequently had a history of chronic shoulder dislocations (88% vs. 43%, P < .001) compared to Bankart repair with remplissage patients. Latarjet patients less frequently reported feeling subjective shoulder instability after surgery (21% vs. 50%, P = .022), which was defined as feeling apprehension or experiencing a shoulder subluxation or dislocation event. There were no differences in rates of postoperative dislocation, revision, reoperation, or RTS, as well as patient-reported outcome scores, between groups (all P > .05). CONCLUSION: Despite differences in osseous defects, Latarjet and Bankart repair with remplissage patients had similar rates of clinical, patient-reported, and RTS outcomes at a mean of 3.3 years postoperatively. Latarjet surgery patients may be less likely to experience subjective shoulder instability postoperatively than patients who undergo Bankart repair with concomitant remplissage.

Rare Epstein-Barr Virus-Associated Smooth Muscle Tumor in a Patient with AIDS: A Case Report.

CASE: A 34-year-old man with poorly controlled acquired immune deficiency syndrome underwent excision of a left arm mass. The histopathologic workup identified the features of an Epstein-Barr virus-associated smooth muscle tumor (EBV-SMT). The patient was readmitted 5 months later for vomiting and found to have liver metastases that were confirmed to be EBV-SMT. Six months after discharge, there was no recurrence of the arm mass or increase in the size of the liver metastases. CONCLUSION: Most commonly found in immunocompromised patients, EBV-SMTs are rare tumors that can be mistaken for a leiomyosarcoma.

Superior sagittal sinus thrombosis as the initial presentation of renal cell carcinoma.

We describe a 68-year-old man who presented with headaches, nausea, and dizziness and was found to have a superior sagittal sinus venous thrombosis on magnetic resonance imaging. His initial hypercoagulable workup was negative. Computed tomography of the abdomen revealed a large mass originating from the kidney. A radical nephrectomy was performed at an outside hospital, and histological study of the excised mass disclosed clear cell renal carcinoma.

Intracranial germinoma.

Pineal region tumors make up less than 1% of all intracranial neoplasms, with the majority being of germ cell origin. We describe the diagnostic evaluation and treatment of a patient presenting with neurological deficits who was found to have a germinoma of the pineal gland.