Inlay total shoulder arthroplasty for primary glenohumeral arthritis.

BACKGROUND: Anatomic total shoulder arthroplasty with a nonspherical humeral head and inlay glenoid replacement has been introduced in the past; however, clinical evidence remains limited. We hypothesized that patients with advanced glenohumeral arthritis demonstrate significant improvements in pain and function. METHODS: Prospective patient-reported outcomes (PROs) included the American Shoulder and Elbow Surgeons score, a pain visual analog scale, and satisfaction. Range of motion was compared to the preoperative status. A sensitivity analysis examined responder rates and compared them to literature thresholds using the minimal clinically important difference and substantial clinical benefit. The preoperative glenoid morphology was determined using the Walsh classification. Zone-specific periprosthetic radiolucent lines were quantified at the last follow-up. RESULTS: Thirty-nine shoulders in 36 patients (3 bilateral) with a mean age of 65.9 years (26 males, 13 females) and a mean follow-up of 41.0 months were included. Ninety-three percent had grade III osteoarthritis, and 7% grade II. The glenoid Walsh classification included A1 (25%), A2 (25%), B1 (22%), B2 (25%), and C (3%). All PROs improved significantly (P < .001) with a mean American Shoulder and Elbow Surgeons score from 30.4 to 77.1, a pain visual analog scale from 8.1 to 1.5, and excellent (9.1/10) patient satisfaction. PRO-related responder rates for minimal clinically important difference and substantial clinical benefit were ≥85%. Forward elevation improved from 107° to 155°, and external rotation from 22° to 51°. One intraoperative glenoid rim fracture led to advanced radiolucency; no other clinically relevant lucency was observed. CONCLUSION: Treatment with inlay total shoulder arthroplasty demonstrated significant functional improvement, excellent pain relief, and patient satisfaction in patients with advanced shoulder arthritis and various glenoid morphology types. Our initial results provide further support for this new option in primary shoulder replacement.

Glanzmann's Thrombasthenia Diagnosed following Knee Arthroscopy.

A 41-year-old man with an unremarkable medical history presented with a painful knee after a sports injury. He was diagnosed with a medial meniscal tear. Symptoms did not abate after 6 months of physical therapy, and he underwent arthroscopic partial medial meniscectomy. A week after beginning physical therapy he experienced a knee effusion, decreased ROM, and inability to flex his quadriceps. His knee was aspirated. Blood tests were ordered and his complete blood count, liver functions tests, and INR/PTT were normal. The patient had recurrent effusions requiring three additional joint aspirations. Ten weeks after the initial surgery, the patient underwent a second arthroscopy, during which a hematoma was removed and a synovectomy performed. The patient continued bleeding from the incisions after portals were sutured, and he was admitted to the hospital. A hematologist was consulted and comprehensive platelet aggregation testing revealed previously undiagnosed Glanzmann's thrombasthenia. The patient began treatment with platelet infusions and desmopressin and progressed to a full recovery. Clinical suspicion for surgical patients with unusual repetitive postoperative bleeding should include previously undetected rare bleeding disorders even in adults.

Isokinetic concentric quadriceps and hamstring normative data for elite collegiate American football players participating in the NFL Scouting Combine.

Isokinetic concentric quadriceps and hamstring strength data using a Cybex dynamometer are collected for elite collegiate American football players invited to the annual National Football League Scouting Combine. We constructed a normative (reference) database of the Cybex strength data for the purpose of allowing comparison of an individual's values to his peers. Data reduction was performed to construct frequency distributions of hamstring/quadriceps (H/Q) ratios and side-to-side strength differences. For the cohort (n = 1,252 players), a statistically significant but very small (1.9%) mean quadriceps strength preference existed for dominant side vs. nondominant side. Peak torque (Newton meters, best repetition) for quadriceps and hamstrings was significantly correlated to player body mass (weight) (the same relationship was found for other variables using peak torque in the calculation). Peak torque varied by player position, being greatest for offensive linemen and lowest for kickers (p < 0.0001). Adjusting for body weight overcorrected these differences. The H/Q ratios and frequency distributions were similar across positions, with a mean of 0.6837 ± 0.137 for the cohort dominant side vs. 0.6940 ± 0.145 for the nondominant side (p = 0.021, n = 1,252). Considerable variation was seen for dominant-to-nondominant side difference for peak torque. For quadriceps, 47.2% of players had differences between -10% and +10%, 21.0% had a peak torque dominant-side deficit of 10% or greater compared to nondominant side, and for 31.8% of players, dominant-side peak torque was greater than 10% compared to nondominant side. For hamstrings, 57.0% of players had differences between -10% and +10%, 19.6% had a peak torque dominant-side deficit of 10% or greater compared to nondominant side, and 23.4% of players, dominant-side peak torque was greater than 10% compared to nondominant side. We observed that isokinetic absolute strength variables are dependent on body weight and vary across player position. The H/Q ratios vary only within a relatively narrow range. Side-to-side differences in strength variables >10% are common, not the exception.

Isokinetic concentric quadriceps and hamstring strength variables from the NFL Scouting Combine are not predictive of hamstring injury in first-year professional football players.

BACKGROUND: There are conflicting reports regarding the association between isokinetic concentric quadriceps and hamstring strength deficits and ratios and risk for hamstring injuries in athletes. PURPOSE: To determine if isokinetic concentric Cybex data collected during the annual National Football League (NFL) Scouting Combine are predictive of hamstring injury in professional American football players during their first season. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: All 32 NFL teams identified players selected during the first 5 rounds of the NFL annual draft who had hamstring injuries during their first professional season. Of these, 164 players with 172 injuries also had Cybex data from the previous year's Combine. Analyses compared injured legs with contralateral uninjured legs and also injured players with uninjured controls using a database of Cybex data from all players who participated in the NFL Scouting Combine from 2006 to 2011. RESULTS: No Cybex strength variable differentiated the injured legs from the contralateral uninjured legs or injured players from uninjured controls, even after taking into account days lost from activity. Mean ± SD peak torque for the injured and contralateral uninjured sides was as follows: 315.7 ± 70.0 and 313.5 ± 68.3 N · m, respectively (P = .773, paired t test), for quadriceps and 203.0 ± 42.4 and 205.3 ± 42.5 N · m, respectively (P = .608, paired t test), for hamstrings. The sensitivity and specificity for the hamstrings-to-quadriceps ratio predicting hamstring injury were 0.513 (95% confidence interval, 0.419-0.607) and 0.524 (0.495-0.554), indicating that the hamstrings-to-quadriceps ratio was not a useful predictor of injury (calculation used the mean ± SD ratio for injured legs, 0.656 ± 0.133). Side-to-side peak torque differences were also not predictive of injury, with more than a 10% difference (plus or minus) occurring commonly in both injured and uninjured players for quadriceps (53% prevalence for both injured and uninjured) and hamstrings (injured, 41% prevalence; uninjured, 43% prevalence). CONCLUSION: Isokinetic strength data collected from collegiate players at the NFL Scouting Combine were not useful for predicting risk of hamstring injury in subsequent professional NFL competition. These data call into question commonly accepted assumptions about risk factors for hamstring injury, at least for elite collegiate American football players, when the temporal relationship between Cybex testing and actual injury is several months.

Long-term results of ulnar collateral ligament reconstruction in throwing athletes based on a hybrid technique.

BACKGROUND: Tearing or attenuation of the ulnar collateral ligament (UCL) of the elbow is a common injury in the throwing athlete. Several techniques for reconstruction of the attenuated or torn UCL have been developed. HYPOTHESIS: Ulnar collateral ligament reconstruction based on a hybrid technique, with an ulnar osseous tunnel and suture anchor fixation on the humerus, allows throwing athletes to return to prior activity level and has a low complication rate. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review was performed of the UCL reconstructions performed in 34 throwing athletes, as based on a hybrid technique, over a 6-year period. All elbows were reconstructed with a tendon graft fixed through an osseous tunnel placed at the sublime tubercle and with 2 suture anchors placed into a bony trough at the humeral origin of the native ligament. RESULTS: Average postoperative follow-up was 6.9 years (range, 4.2 to 8.7 years). The average age was 20.2 years, with symptoms present for an average of 22.4 weeks before clinic presentation. Each athlete had pain with valgus stress or milking maneuver in addition to a documented tear of the UCL on magnetic resonance imaging. All experienced pain on the medial aspect of the elbow while throwing. Only 1 patient had new onset of temporary ulnar nerve paresthesia, for a complication rate of 2%. Of 34 athletes, 29 (85%) had an excellent result, defined as the ability to return to play at or above preinjury level. Of the 5 patients who did not return to preinjury level, only 2 were unable to do so secondary to pain. CONCLUSION: Ulnar collateral ligament reconstruction based on a hybrid fixation technique results in a low complication rate and allows full recovery to preinjury level of performance in the majority (85%) of patients.

A minimally disruptive surgical technique for the treatment of osteitis pubis in athletes.

BACKGROUND: MULTIPLE SURGICAL PROCEDURES EXIST FOR THE TREATMENT OF OSTEITIS PUBIS: curettage of the symphysis joint, wedge resection, complete resection of the joint, placement of extraperitoneal retropubic synthetic mesh, and arthrodesis of the joint. However, a paucity of literature has reported long-term successful outcomes with the aforementioned approaches. Patients treated operatively have reported recalcitrant pain resulting from iatrogenic instability. The article presents the results of a conservative operative technique that avoids disruption of adjacent ligaments. HYPOTHESIS: Preserving the adjacent ligamentous structures will allow competitive athletes to return to competition and activities of daily living free of iatrogenic pelvic instability and pain. STUDY DESIGN: Case series. METHODS: Four competitive athletes (2 professional and 2 collegiate football players) diagnosed with osteitis pubis were treated conservatively for a minimum of 6 months. Patients underwent surgical intervention upon failure to respond to nonoperative management. The degenerative tissue was resected, allowing only bleeding cancellous bone to remain while preserving the adjacent ligaments. An arthroscope was used to assist in curettage, allowing the debridement to be performed through a small incision in the anterior capsule. RESULTS: The symptoms of all 4 patients resolved, and they returned to competitive athletics. This ligament-sparing technique provided a solid, stable repair and pain relief. CONCLUSION: This surgical technique preserves the adjacent ligamentous structures and allows competitive athletes to return to competition and activities of daily living free of pain and void of pelvic instability. CLINICAL RELEVANCE: This technique is a surgical treatment option for athletes with osteitis pubis who fail conservative treatment.

Isolated tears of pectoralis minor muscle in professional football players: a case series.

Our objective is to include pectoralis minor injuries in the comprehensive assessment of differential diagnoses for anterior chest wall pain or medial anterior shoulder pain sustained during blocking activities, which may present in football players. In this article, we report 2 cases of isolated pectoralis minor tears in professional football players and present mechanisms of injury, clinical presentations, appropriate diagnostic studies, and treatments.

Salvage procedure for chronic acromioclavicular dislocation subsequent to overzealous distal clavicle resection.

This article presents our surgical technique for reestablishing acromioclavicular stability after overzealous distal clavicular resection. Two cases are presented in which the clavicle of the affected acromioclavicular joint was unstable, causing pain with range of motion (ROM). To address the pathology, reconstruction of the coracoclavicular ligament and reattachment of the trapezius and deltoid to the clavicle were required. We reconstructed the coracoclavicular ligaments using an Achilles tendon calcaneal allograft. The bony end of the Achilles tendon allograft was used as an extension to lengthen the clavicle and the tendinous portion to reconstruct the coracoacromial ligament, thus stabilizing the clavicle. Once allograft reconstruction and stability had been achieved, a 1.5-cm gap remained between the acromion and the new allograft end of the clavicle. There was no evidence of acromioclavicular impingement. Supplemental fixation was not required. The trapezius, pectoralis, and deltoids were all reefed over the clavicle using Vicryl sutures (Ethicon, Inc, West Somerville, New Jersey) to reinforce the reduction and restore the natural contour of the shoulder girdle. Fifteen months postoperatively, both patients had maintained a reduced acromioclavicular joint. They had no pain with ROM, and full muscular strength was evident in all planes. Radiographs of their shoulders revealed a completely incorporated graft and a reduced clavicle. We recommend this novel technique for reestablishing acromiclavicular stability, as it provides good functional and subjective results.

Pectoralis major tears: correlation of magnetic resonance imaging and treatment strategies.

BACKGROUND: Controversy exists in the diagnosis and treatment of pectoralis major tear patterns. HYPOTHESIS: Magnetic resonance imaging is useful in determining the grade and the location of pectoralis major tears and in guiding toward an appropriate treatment plan. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between January 1998 and December 2002, 27 patients were treated for pectoralis major tears. All patients were evaluated by history and physical examination. A clinical impression was formed regarding the location and grade of injury, and a treatment plan was established. All patients underwent magnetic resonance imaging, and images were reviewed by an orthopaedic surgeon and a board-certified musculoskeletal radiologist, resulting in a final treatment plan. The mean follow-up was 12 months. All patients were evaluated by questionnaire and clinical examination to assess pain, function, deformity, and overall satisfaction. RESULTS: In 19 of 27 patients, the clinical impression and magnetic resonance imaging agreed regarding the location and the grade of the injury. A total of 19 patients underwent surgical repair, and 8 patients were treated nonoperatively. The magnetic resonance imaging result changed the treatment plan in 3 patients from operative to nonoperative. CONCLUSION: The clinical impression appeared to overestimate the severity, the location, and the grade of the injury. Magnetic resonance imaging provided a more accurate assessment and, in conjunction with the clinical examination, helped to identify those patients who would benefit most from surgical repair.

Rotator cuff repair in spinal cord injury patients.

Previous studies on the treatment of rotator cuff tears in wheelchair-bound patients have concentrated on nonsurgical management. We conducted a retrospective review to determine the effectiveness of surgical repair of rotator cuff tears in spinal cord-injured patients. Five male patients with rotator cuff tears confirmed by physical examination and magnetic resonance imaging underwent rotator cuff repair. Two of eight shoulders were revisions. The patients were evaluated postoperatively with the American Shoulder and Elbow Surgeons Scoring System. These results were compared with preoperative functional assessment. Patients were given a subjective questionnaire to assess their overall experience. Postoperative range of motion improved in 6 of 8 shoulders. Strength was increased in 6 of 8 shoulders. Patients reported satisfaction with the results in 7 of 8 shoulders, and all 5 patients would recommend the procedure to other spinal cord injury patients. At recent follow-up, 7 of 8 shoulders returned to their preinjury level of function. Surgery for spinal cord injury patients with rotator cuff tears can improve their functional capability and autonomy while reducing their pain. Compliance with the demanding postoperative rehabilitation is essential; therefore proper patient selection is crucial for optimal results.

Failure of polymerized lactic acid tacks in shoulder surgery.

The purpose of this study was to evaluate 4 cases in which bioabsorbable polymerized lactic acid tacks failed after arthroscopic shoulder surgery. Four male elite athletes with recurrent shoulder pain were seen a mean of 7.5 months (range, 3-10 months) after initial arthroscopy. Three of the cases involved superior labrum anterior-to-posterior (SLAP) lesion stabilization, and the fourth case was a rotator cuff (RTC) repair. In the three labral repairs, the implant had broken and the unabsorbed fragments were visible with magnetic resonance imaging. The device used in the RTC repair showed no signs of absorption. All 4 patients underwent arthroscopic removal of the polymer tack fragments to alleviate their symptoms, 2 of whom had foreign-body reactions that required synovectomy. On the basis of clinical examination and magnetic resonance imaging, 2 of the SLAP lesions and the RTC tear had healed. The third patient with a SLAP lesion required arthroscopic debridement of a portion of the labrum. The intact RTC implant had backed out of its insertion point. In all 3 labral repairs, the polymerized lactic acid implant experienced a mechanical failure near the head-shaft junction. We theorize that the labral implants failed because of the variable rate of degradation along the shaft of the devices from the intraarticular to intraosseous regions.

Extensive lipoma causing suprascapular nerve entrapment.

Suprascapular nerve entrapment is a frequently misdiagnosed phenomenon. In this case report, we describe a benign lipomatous tumor causing suprascapular nerve entrapment in the spinoglenoid notch, and we describe the history, clinical examination, and radiographic evaluation. Benign lipomatous tumor compressing the suprascapular nerve is mentioned in the literature, but we believe this is the first case report.

Intra-articular anterior cruciate ligament reconstruction using patellar tendon allograft in the skeletally immature patient.

PURPOSE: Tears of the anterior cruciate ligament (ACL) are becoming more prevalent in the skeletally immature patient. We report our results with intra-articular transphyseal ACL reconstruction in this patient population. TYPE OF STUDY: Retrospective analysis. METHODS: Ten skeletally immature athletes underwent transphyseal intra-articular ACL reconstruction using patellar tendon allograft. The patients ranged from 9 to 15 years of age. Clinical outcomes were measured using the Lysholm and International Knee Documentation Committee scoring systems, follow-up radiographs, clinical examination, and KT-1000 testing. RESULTS: Mean follow-up was 40 months. The average Lysholm score was 95, and 9 of 10 patients reported normal or nearly normal knee function. There was no clinical or objective evidence of instability, limb-length discrepancy, or early physeal arrest. Nine of 10 patients returned to their preinjury level of athletics. CONCLUSIONS: Skeletally immature athletes with symptomatic complete ACL tears who do not want to modify their athletic activity may benefit from intra-articular ACL reconstruction using patellar tendon allografts. Special attention to bone plug and interference screw placement will reduce the risk of early physeal arrest.

Arthroscopic posterior cruciate ligament repair.

PURPOSE: We present our technique of arthroscopic repair for femoral avulsion soft-tissue tears of the posterior cruciate ligament (PCL) and its results. TYPE OF STUDY: Case series, retrospective review. METHODS: We performed 13 arthroscopic repairs of the PCL and reviewed them retrospectively. Follow-up was available for 11 (85%) patients. Nonabsorbable monofilament sutures were placed through the loose fibers of the ligament and tied over a bone bridge. Patients were evaluated using magnetic resonance imaging, comparative stress views, and according to the scoring systems of Lysholm and Gillquist and the International Knee Documentation Committee (IKDC). RESULTS: Mean follow-up was 51.4 months. IKDC scores revealed 4 (36.4%) patients with normal knee function, and 7 (63.6%) with nearly normal function. Average Lysholm and Gillquist score was 95.4 (90 to 100). All athletes returned to the same or a higher level of competition. CONCLUSIONS: Arthroscopic repair of the PCL in patients with a femoral avulsion is effective in reducing postoperative instability and improving functional outcome.

Avulsion fracture of the ulnar sublime tubercle in overhead throwing athletes.

BACKGROUND: Injuries to the ulnar collateral ligament are relatively common in throwing athletes and result from either acute traumatic or repeated valgus stress to the elbow. Avulsion fracture of the sublime tubercle of the ulna is a rarely reported site of ulnar collateral ligament injury. PURPOSE: We retrospectively reviewed our cases of ulnar collateral ligament injuries to study avulsion fractures of the sublime tubercle of the ulna. STUDY DESIGN: Case series. METHODS: Data, including radiographs and magnetic resonance imaging scans, were obtained by review of hospital and office records and by follow-up examination. Of 33 consecutive patients treated for ulnar collateral ligament injuries, 8 had avulsion fractures of the sublime tubercle of the ulna. All eight were male baseball players with dominant arm involvement, an average age of 16.9 years, and an average follow-up of 23.6 months. RESULTS: Six of eight patients had failure of nonoperative treatment and required surgical repair. Two of the six underwent ulnar collateral ligament reconstruction and four had direct repair of the sublime tubercle avulsion with bioabsorbable suture anchors. At last follow-up, all eight had returned to their preinjury level of activity. No patient had residual medial elbow pain or laxity. CONCLUSIONS: Diagnosis of sublime tubercle avulsion fracture is made with history, physical examination, and radiographic studies. Magnetic resonance imaging can help identify an avulsion fracture not visible radiographically and can help determine whether direct repair or reconstruction is needed.

Analysis of arthroscopically assisted ankle arthrodesis.

PURPOSE: Evaluation of an arthroscopically assisted ankle arthrodesis technique for clinical and radiographic union, function, and patient satisfaction. TYPE OF STUDY: Retrospective analysis and review of the literature. METHODS: Twenty-one patients with a mean age of 52.7 years who underwent arthroscopic ankle arthrodesis were examined at an average follow-up time of 34 months. The mean duration of symptoms was 4.4 years. The most common diagnosis for patients who underwent arthrodesis was post-traumatic arthritis (19 of 21) with 1 patient having a diagnosis of avascular necrosis of the talus and the other patient having rheumatoid arthritis. All patients described severe mechanical pain as the most important reason for undergoing the procedure. RESULTS: Fusion occurred in 20 of 21 patients. The average time to clinical and radiographic union was 8.9 weeks. Nine patients were graded as excellent; no pain, limp, or occupational restriction, and a stable fusion. Eleven were graded as good; mild pain, occasional limp, or occupational restriction with a stable fusion. One was graded as poor; failed union and pain. The failure had extensive avascular necrosis involving approximately 50% of the talus as a preoperative diagnosis. CONCLUSIONS: The advantages of the arthroscopic technique include a high fusion rate, decreased time to fusion, and decreased cost. There are considerable advantages to the arthroscopic technique in appropriately selected patients with no or mild angular deformity and no avascular necrosis greater than 30% of the talus. There is a substantial reduction in time to fusion in the arthroscopic procedure compared with published reports on open procedures for ankle arthrodesis. While this procedure is not indicated in all instances, selected patients with disabling ankle arthrosis may be more appropriately treated with an arthroscopic arthrodesis than by open surgery.