Anatomical considerations of the suprascapular nerve in rotator cuff repairs.

Introduction. When using the double interval slide technique for arthroscopic repair of chronic large or massive rotator cuff tears, the posterior interval release is directed toward the scapular spine until the fat pad that protects the suprascapular nerve is reached. Injury to the suprascapular nerve can occur due to the nerve's proximity to the operative field. This study aimed to identify safe margins for avoiding injury to the suprascapular nerve. Materials and Methods. For 20 shoulders in ten cadavers, the distance was measured from the suprascapular notch to the glenoid rim, the articular margin of the rotator cuff footprint, and the lateral border of the acromion. Results. From the suprascapular notch, the suprascapular nerve coursed an average of 3.42 cm to the glenoid rim, 5.34 cm to the articular margin of the rotator cuff footprint, and 6.09 cm to the lateral border of the acromion. Conclusions. The results of this study define a safe zone, using anatomic landmarks, to help surgeons avoid iatrogenic injury to the suprascapular nerve when employing the double interval slide technique in arthroscopic repair of the rotator cuff.

Subacute superior patellar pole sleeve fracture.

Patellar fractures are uncommon, representing 1% of pediatric fractures. Most of these injuries are sleeve avulsions of the inferior pole. Sleeve avulsion of the superior pole is rare, with only 14 cases reported in the English-language literature. These injuries occur in adolescents after forced knee flexion or direct anterior blow. Radiographs may reveal patella baja, anterior tilt, and suprapatellar calcifications. Ultrasound and magnetic resonance imaging (MRI) can confirm the diagnosis. We present a subacute superior pole sleeve fracture in a 15-year-old boy who sustained a left knee injury. Initial radiographs were negative. Ten days later, the patient returned with hemarthrosis and suprapatellar calcification. MRIs were read as "distal quadriceps tendon tear." Twenty-three days after the injury, the patient presented with a limp, palpable quadriceps tendon gap, and inability to maintain a straight leg raise. A superior pole sleeve fracture was repaired surgically the following day. An understanding of the injury demographics and radiological findings associated with superior pole sleeve fractures can prevent missed diagnosis of a rare injury. We review the literature for injury demographics, operative and nonoperative treatment methods, and outcomes.

Diagnosis and treatment of triceps tendon injuries: a review of the literature.

OBJECTIVE: To elucidate mechanism of injury, nonoperative protocols, surgical techniques, rehabilitation schedules, and return to sports guidelines for partial and complete triceps tendon injuries. DATA SOURCES: The PubMed and OVID databases were searched in 2010 and peer-reviewed English language articles in 2011. MAIN RESULTS: After a fall on an outstretched hand, direct trauma on the elbow, or lifting against resistance, patients often present with pain and weakness of extension. Examination may reveal a palpable tendon gap, and radiographs may reveal a Flake sign. Acute partial injuries have positive outcomes with immobilization in 30-degree flexion for 4 to 6 weeks. Primary repair for complete rupture can restore normal extensor function after 3 to 4 months. Reconstruction returns normal extensor function up to 4 years. Most authors support postoperative immobilization for 2 to 3 weeks at 30- to 40-degree flexion, flexion block bracing for an additional 3 weeks, and unrestricted activity at 6 months. Athletes may be able to return to sports after 4 to 5 weeks of recovery from a partial injury, but return may be delayed if operative tendon repair is performed. CONCLUSIONS: Acute partial triceps tendon injuries may be managed conservatively at first and should be repaired primarily if this fails or if presentation is delayed. Reconstruction should first use the anconeus rotation technique. If the anconeus is devitalized, the Achilles tendon may be the allograft of choice.

Is formal decompression necessary for parameniscal cysts associated with meniscal tears?

BACKGROUND: Meniscal tears and associated parameniscal cysts have good outcomes after partial meniscectomy and cyst evacuation. Good outcomes have been noted after partial meniscectomy with recurrent cysts. This investigation asks if partial meniscectomy without meniscal cyst decompression is sufficient for positive patient outcome. METHODS: Sixteen patients treated between 2005 and 2010 for a meniscal cyst and concomitant meniscal tear. Inclusion criteria were meniscal tear and parameniscal cyst per MRI, no prior surgery on the affected knee, and Outerbridge classification of I/II. Two patients were excluded. Fourteen patients completed the study until final follow-up. Lysholm knee scores were documented at 6 months post-operatively and at final follow-up. Re-evaluation or second surgery of the treated knee was documented. RESULTS: Eight lateral cysts and six medial cysts were diagnosed. Eight cysts were associated with a horizontal cleavage tear, while six menisci had a complex tear with a horizontal cleavage component. The average cyst size was 1.3 cm (0.5 to 3.5) at the largest diameter. At 6 months, the average Lysholm knee score was 94.1. At mean 5 years, the average score was 89.1. Patients with medial cysts, cysts greater than 1.0 cm, horizontal cleavage tears, or without simultaneous chondroplasty scored higher in the short and medium-term than their respective counterparts. CONCLUSIONS: Excellent short and medium-term outcomes can be achieved following partial meniscectomy without cyst decompression for patients with meniscal cysts and associated meniscal tears. LEVEL OF EVIDENCE: Level IV.

Incidence of orthopedic surgery intervention in a level I urban trauma center with motorcycle trauma.

BACKGROUND: This study summarizes orthopedic injuries sustained in motorcycle collisions in patients presenting to a Level I trauma center. METHODS: We performed a retrospective review of orthopedic injuries in motorcycle trauma victims brought into the emergency department. Of 2,634 presenting cases, 151 were identified as involving motorcycle collisions. Variables included age, gender, mechanism of injury, type and location of injury, concomitant injuries, length of hospitalization, number of orthopedic procedures during primary admission, and subsequent readmission. RESULTS: A total of 71.5% of patients required orthopedic consultation. Average age was 35.0 years, with men injured at a ratio of 8:1. The most common mechanism of injury was motorcycle versus automobile (n=48). A total of 206 fractures in 108 patients were discovered. The most common site of fracture involved the lower extremities. Open reduction with internal fixation was performed on 110 fractures (69 patients) during primary admission. Fifty-seven patients (52.8%) sustained open fractures requiring emergent orthopedic intervention. Fifty-three patients had various concomitant complications. Two patients died during initial hospitalization. Average hospitalization for patients without orthopedic consultation was 11.9 days versus 13.8 days with orthopedic consultation. The average number of orthopedic procedures performed on patients was 1.6. CONCLUSIONS: Motorcycle collisions frequently involve patients in their working prime, thus placing substantial burden on the individual and society. Although these patients must continue to receive Level I trauma care, strengthened prevention and improved education efforts are warranted.

Anatomical considerations of subcoracoid neurovascular structures in anterior shoulder reconstruction.

Anterior shoulder surgery, using open or arthroscopic technique, places subcoracoid neurovasculature at risk. This study examines the relationships of the brachial plexus and axillary artery to four bony landmarks and provides clinical correlations for anterior shoulder surgery. The musculocutaneous nerve (MN), posterior cord (PC), lateral cord (LC), and axillary artery (AA) were identified in 27 shoulders. Minimum distances (mm) were measured between neurovasculature and the coracoid tip, anterior midglenoid, inferior surface of the midclavicle, and anteromedial aspect of the acromioclavicular joint. Average distances from the coracoid to the MN, PC, LC, and AA were 69.7 ± 31.6, 50.5 ± 9.2, 41.8 ± 9.4, and 60.0 ± 8.0 mm, respectively; from the glenoid equator to the MN, PC, LC, and AA were 61.5 ± 38.5, 37.0 ± 6.1, 35.2 ± 8.7, and 45.2 ± 7.1 mm, respectively; from the midclavicle to the MN, PC, LC, and AA were 114.1 ± 33.9, 62.0 ± 13.6, 56.0 ± 19.7, and 69.9 ± 7.8 mm, respectively; and from the AC joint to the MN, PC, LC, and AA were 112.7 ± 36.5, 87.9 ± 10.6, 84.0 ± 12.0, and 100.9 ± 1.0 mm, respectively. The lateral cord was the closest structure to each bony landmark. The musculocutaneous nerve was the furthest structure from each bony landmark. Open procedures using a deltopectoral approach with the shoulder in the anatomical position, such as the Neer capsular shift and Warner capsular reconstruction, can use these results to prevent direct or retraction injuries. Results indicate a potential safe zone of 30 mm in diameter around the anteromedial coracoid tip for anteroinferior portal placement.

Outcomes of microfracture in professional basketball players.

Surgical treatment for chondral defects of the knee in competitive running and jumping athletes remains controversial. This study evaluated the performance outcomes of professional basketball players in the National Basketball Association (NBA) who underwent microfracture. Data from 24 professional basketball players from 1997 to 2006 was obtained and analyzed. NBA player efficiency ratings (PER) were calculated for two seasons before and after injury. A control group of 24 players was used for comparison. Study group and control group demographics including age, NBA experience, and minutes per game demonstrated no statistical difference. Mean time to return to an NBA game was 30.0 weeks from the time of surgery. The first season after returning to competition PER and minutes per game decreased by 3.5 (P < 0.01) and 4.9 min (P < 0.05), respectively. The 17 players who continued to play two or more seasons after surgery, the average reduction in their PER and minutes per game was 2.7 (P > 0.05) and 3.0 min (P < 0.26), respectively. A multivariant comparison versus controls demonstrated that power rating during the 2 years after surgery decreased by 3.1 (P < 0.01); while minutes per game decreased by 5.2 (P < 0.001). Twenty-one percent (n = 5 of 24) of the players treated with microfracture did not return to competition in an NBA game. On return to competition player performance and minutes per game are diminished.

Surgical outcomes after traumatic open knee dislocation.

The purpose of this study is to describe the types of injuries and surgical treatments associated with open knee dislocations and to present the functional outcomes of these patients. Between 2001 and 2005, the medical records of patients that sustained traumatic open knee dislocations at our Level 1 Trauma Center were retrospectively reviewed. Initial surgical intervention was performed in all patients including placement of spanning external fixator, repair of vascular injuries if necessary, and irrigation and debridement of the open wounds. Ligamentous reconstruction was delayed until after limb salvage. The Short Form-12 was the primary outcome measure. Seven patients (five male, two female) had a mean age of 31.9 years (range 22-44) at the time of injury (five right, two left). Motorcycle accident was the most common cause (57%). Follow-up was a mean 27.6 months. The PCL was damaged in all patients. Three patients underwent angiography for absent/diminished pulses on initial exam with two requiring operative intervention. Three patients had associated common peroneal nerve injury (one iatrogenic). Ten (10.7) operative procedures were performed per patient (range 5-18) with an average of 6.6 debridements (range 2-11). Infection rate was 43% with one patient undergoing amputation for infection. Good to excellent results were found in 33% of patients. Most patients (86%) report some residual symptomatic or functional deficit. Due to the injury complexity in open traumatic knee dislocations, the surgical treatment is extensive and challenging. While infection rates are high, aggressive, individualized treatment can lead to satisfactory outcome although full return to activity is difficult to achieve using current treatment methods.

Pelvic fractures in professional cyclists: a report of 3 cases.

BACKGROUND: Professional riders demonstrate increased risk factors for such injuries including both extensive time on the bike in addition to a possible underlying osteopenia secondary to the nonimpact nature of the sport. HYPOTHESIS: Nonoperative management of stable, nondisplaced pelvic fractures in professional cyclists offers excellent results. STUDY DESIGN: Case series. METHODS: Three cases of professional cyclists with pelvic fractures were reviewed. RESULTS: All 3 cyclists were able to return to professional competition and remain symptom free. CONCLUSION: Accurate early diagnosis of pelvic fractures, with the aid of computed tomography, is crucial. Early nonweightbearing with a progression to weightbearing as tolerated and early return to stationary training are appropriate. Accurate diagnosis and careful nonoperative management of stable, nondisplaced pelvic fractures in professional cyclists offers excellent results. CLINICAL RELEVANCE: Accurate diagnosis of pelvic fractures in high-demand athletes with few complaints and no obvious findings on plain film radiographs. Control of weightbearing and competitive status to prevent injury progression. Gauged return to competition at professional level.

Outcomes of isolated glenoid labral injuries in professional baseball pitchers.

BACKGROUND: Major League Baseball (MLB) pitchers who return to competition after labral surgery show a decline in their pitching performance. DESIGN: Retrospective cohort. SETTING: Tertiary institution. PATIENTS: MLB starting or relief pitchers with isolated glenoid labral injuries. INTERVENTIONS: Open or arthroscopic surgical repair of isolated glenoid labral injuries. MAIN OUTCOME MEASUREMENTS: Individual statistics were reviewed for 42 MLB pitchers who underwent surgical repair of isolated glenoid labral injuries of their throwing shoulder between 1998 and 2003. Pertinent statistical data, including earned run average (ERA), innings pitched (IP), and walks plus hits per inning pitched (WHIP), were obtained for all players and compared before and after surgery. These statistics were evaluated for an association with demographic factors, pitching role, and rehabilitation time. RESULTS: A total of 42 MLB pitchers (26 starters, 16 relievers) were included in the study with an average age of 27.5 years for starters and 29.9 years for relievers at injury time. There were 30 right-handed pitchers and 12 left-handed pitchers. In all, 69% of pitchers returned postoperatively to MLB for at least one season; 29% pitched for three seasons or more. For both relievers and starters, there was no statistically significant postoperative change in ERA or WHIP at 1 and 3 years. Starters had significantly decreased IP at 1 year, but not at 3 years. Relievers had no significant change in IP at 1 year postoperatively, but IP were significantly decreased at 3 years. Relievers missed less time after surgery than did starters (11.4 vs. 18.4 months). CONCLUSIONS: Most pitchers who were able to return to competition after surgery showed insignificant changes in ERA and WHIP and significant decreases in IP. Age, MLB experience, and pitching role as a reliever were the most significant factors related to a successful return after surgery.

Blisters on the anterior shin in 3 research subjects after a 1-MHz, 1.5-W/cm , continuous ultrasound treatment: a case series.

CONTEXT: Clinicians should consider multiple factors when estimating tissue-heating rates. OBJECTIVE: To report 3 separate occurrences of blisters during an ultrasound treatment experiment. BACKGROUND: While we were conducting a research experiment comparing the measurement capabilities of 2 different intramuscular temperature devices, 3 female participants (age = 26.33 +/- 3.79 years, height = 169.34 +/- 3.89 cm, mass = 63.39 +/- 3.81 kg) out of 16 healthy volunteers (7 men: age = 22.83 +/- 1.17 years, height = 170.61 +/- 7.77 cm, mass = 74.62 +/- 19.24 kg; 9 women: age = 24.22 +/- 2.73 years, height = 171.88 +/- 6.35 cm, mass = 73.99 +/- 18.55 kg) developed blisters on the anterior shin after a 1-MHz, 1.5-W/cm (2) continuous ultrasound treatment delivered to the triceps surae muscle. DIFFERENTIAL DIAGNOSIS: Allergies; chemical reaction with cleaning agents; sunburn; negative interaction between the temperature measurement instruments and the ultrasound field; the ultrasound transducer not being calibrated properly, producing a nonuniform field and creating a hot spot or heating differently when compared with other ultrasound devices; the smaller anatomy of our female subjects; or a confounding interaction among these factors. TREATMENT: Participants were given standard minor burn care by a physician. UNIQUENESS: (1) The development of blisters on the anterior aspect of the shin as a result of an ultrasound treatment to the posterior aspect of the triceps surae muscle and (2) muscle tissue heating rates ranging from 0.19 degrees C to 1.1 degrees C/min, when ultrasound researchers have suggested tissue heating in the range of 0.3 degrees C/min with these settings. CONCLUSIONS: These adverse events raise important questions regarding treatment application and potential differences in heating and quality control among different ultrasound devices from different manufacturers.

Pre-synaptic modulation of quadriceps arthrogenic muscle inhibition.

Arthrogenic muscle inhibition (AMI) impedes rehabilitation following knee joint injury by preventing activation of the quadriceps. AMI has been attributed to neuronal reflex activity in which altered afferent input originating from the injured joint results in a diminished efferent motor drive to the quadriceps muscles. Beginning to understand the mechanisms responsible for muscle inhibition following joint injury is vital to control or eliminate this phenomenon. Therefore, the purpose of this investigation is to determine if quadriceps AMI is mediated by a presynaptic regulatory mechanism. Eight adults participated in two sessions: in one session their knee was injected with saline and in the other session it was not. The maximum Hoffmann reflex (H-reflex), M-wave, reflex activation history, plasma epinephrine, and norepinephrine were recorded at: baseline, post needle stick, post lidocaine, and 25 and 45 min post effusion. Measures for the control condition were matched to the effusion condition. The percent of the unconditioned reflex amplitude for reflex activation history and the maximum H-reflex were decreased at 25 and 45 min post effusion as compared to measures taken at baseline, post needle stick, and post lidocaine (P<0.05). No differences were noted for the maximum M-wave or plasma epinephrine and norepinephrine levels in either the effusion or noneffusion admission (P>0.05). No differences were detected at any time interval for any measure during the control admission (P>0.05). Quadriceps AMI elicited via an experimental knee joint effusion is, at least in part, mediated by a presynaptic mechanism.

Arthrogenic muscle response induced by an experimental knee joint effusion is mediated by pre- and post-synaptic spinal mechanisms.

Knee joint effusion results in quadriceps inhibition and is accompanied by increased excitability in the soleus musculature. The purpose of this study was to determine if soleus arthrogenic muscle response is regulated by pre- or post-synaptic spinal mechanisms. Ten healthy adults (two females and eight males) were measured on two occasions. At the first session, subjects had their knee injected with 60 ml of saline and in the other session they did not. Pre- and post-synaptic spinal mechanisms were measured at baseline, immediately following a needle stick, immediately following a Xylocaine injection, and 25 and 45 min post-saline injection. A mixed effects model for repeated measures was used to analyze each dependent variable. The a priori alpha level was set a P < or = 0.05. The percentage of the unconditioned reflex amplitude for recurrent inhibition (P < 0.0001) and reflex activation history (P < 0.0001) significantly increased from baseline at 25 and 45 min post-effusion. Soleus arthrogenic muscle response seen following knee joint effusion is mediated by both pre- and post-synaptic mechanisms. In conclusion, the arthrogenic muscle response seen in the soleus musculature following joint effusion is regulated by both pre- and post-synaptic control mechanisms. Our data are the first step in understanding the neural networks involved in the patterned muscle response that occurs following joint effusion.

An experimental knee joint effusion does not affect plasma catecholamine concentration in humans.

Knee joint effusion causes quadriceps inhibition and is accompanied by increased soleus muscle excitability. In order to reverse the neurological alterations that occur to the musculature following effusion, we need to understand the extent of neural involvement. Ten healthy adults were tested on two occasions; during one session, subjects had their knees injected with saline and in the other admission, they did not. Soleus Hmax, Mmax, plasma epinephrine, and norepinephrine concentrations were obtained at five intervals. Results showed that Hmax increased following the effusion, while norepinephrine and epinephrine levels were not altered. We suggest that the soleus facilitation seen following knee effusion results from stimulation of joint mechanoreceptors and removal of descending spinal and supraspinal inhibition and is not the result of a sympathetic response.

Soft tissue allografts for knee reconstruction in sports medicine.

Soft tissue allografts are an important substitute tissue for the reconstruction of deficient ligaments, torn menisci, and osteochondral defects during knee surgery. Interest in allografts for soft tissue reconstruction has arisen from the demand to obtain a stable knee with restoration of function and protection against additional injury. Use of allografts for soft tissue reconstruction is associated with less donor tissue site morbidity and reduced surgical time. Nevertheless, use of allografts has a potential for disease transmission, delayed graft incorporation, and host versus donor immunologic response to the graft. Experimental studies and animal models have provided information about the biologic aspects of graft incorporation and remodeling and have contributed to the development of methods of graft preparation and transplantation. Clinical studies of allograft transplantation in humans have helped to define surgical indications and techniques and have allowed for the assessment of clinical outcome. The current authors review the current literature concerning the basic and clinical principles of soft tissue allografts for knee reconstruction, and underscore the scientific basis for the clinical application of allograft tissue during knee surgery.