Shoulder Range of Motion Deficits in Youth Throwers Presenting With Elbow Pain.

BACKGROUND: Glenohumeral internal rotation deficit (GIRD) and total arc of motion difference (TAMD) have been associated with elbow injuries in throwing athletes. HYPOTHESIS: Youth pitchers with elbow pain will have greater GIRD and TAMD compared with youth pitchers without elbow pain. STUDY DESIGN: Cross-sectional study. LEVEL OF EVIDENCE: Level 3. METHODS: Glenohumeral range of motion of 25 consecutive throwing athletes presenting with elbow pain and that of a matched control group of 18 asymptomatic throwing athletes were compared. Bilateral glenohumeral internal rotation, external rotation, and horizontal adduction at 90° were measured and GIRD and TAMD were then calculated. An analysis of variance was performed to compare range of motion between throwers with and without elbow pain. RESULTS: The average GIRD of the elbow pain group was 32.7° compared with 14.5° in the control group (P < 0.05). The average TAMD in the elbow pain group was 28.3° compared with 6.7° in the control group (P < 0.05). GIRD and TAMD were present in 88% (22 of 25) and 96% (24 of 25) of the elbow pain group versus 33.3% (6 of 18) and 55.6% (10 of 18) of the control group, respectively. CONCLUSION: Compared with asymptomatic youth pitchers, those presenting with elbow pain have a statistically significant GIRD and TAMD. CLINICAL RELEVANCE: This study suggests that a GIRD and TAMD may predispose youth pitchers to present with symptomatic elbow pain.

Minimizing Graft-Tunnel Mismatch in Allograft Anterior Cruciate Ligament Reconstruction Using Blumensaat's Line: A Cadaveric Study.

PURPOSE: To evaluate the accuracy of Blumensaat's line (BL) in predicting the tendinous graft length and tibial tunnel length (TTL) in an independent-tunnel anterior cruciate ligament reconstruction (ACLR) using a bone-patellar tendon-bone (BTB) allograft. METHODS: Eighteen ACLRs were performed on cadaveric specimens using an anteromedial portal technique. All knees had no previous surgeries or deformities. Lateral knee radiographs of each specimen were taken prior to the ACLR, and BL was measured. Length-specific allografts for the tendinous portion of the grafts were then ordered by adding 20 mm to the length of BL. The TTL was predicted by subtracting BL and femoral tunnel length (FTL) from the overall graft length. Graft-tunnel mismatch (GTM) was recorded for each specimen. Statistical analysis compared overall results with the gold standard (0 mm) of GTM. RESULTS: The average lateral femoral condyle width measured in line with the femoral tunnel was 33 ± 3.43 mm. The average FTL was 25 ± 0.54 mm. The average intra-articular distance (IAD) between femoral and tibial tunnel apertures was 31 ± 3.65 mm. The average TTL was 35 ± 2.21 mm. The difference between the predicted TTL and the actual TTL was not statistically significant (P = .3). The mean GTM was -0.9 ± 3.15 mm. There was no statistically significant difference between the BL method and the gold standard (P = .45). The mean percent difference between BL and the IAD was 5.2%. CONCLUSIONS: The BL method can accurately predict the desired length for the tendinous portion of a BTB allograft as well as the TTL, thereby potentially minimizing GTM during arthroscopic BTB allograft ACLR. Patient-specific allografts can be ordered preoperatively based on BL. CLINICAL RELEVANCE: This method provides the surgeon a way to avoid GTM preoperatively by ordering patient-specific grafts prior to performing an independent-tunnel BTB allograft ACLR.

Radial Shaft Stress Fracture in a Major League Pitcher.

Upper extremity injuries are associated with significant morbidity in throwing athletes, and prevention and diagnosis of overuse injuries in these athletes are increasingly being emphasized. Although stress fractures are common overuse injuries, stress fractures of the upper extremity are relatively rare. To our knowledge, a stress fracture of the radial shaft has not been reported in a throwing athlete. In this article, we describe the case of a Major League Baseball pitcher who presented with a stress fracture of the lateral cortex of the radius, likely caused by contractile forces of the supinator muscle, arising after his attempt to develop a new pitch.

Biomechanical Evaluation of Classic Solid and All-Soft Suture Anchors for Medial Patellofemoral Ligament Reconstruction.

BACKGROUND: Multiple techniques for patellar fixation with classic solid suture anchors (SAs) in medial patellofemoral ligament (MPFL) reconstruction have been described. Fixation of the graft to the patella with all-soft suture anchors (ASAs) has not been studied. Purpose/Hypothesis: To evaluate the biomechanical performance of 2 different MPFL patellar fixation techniques: ASA fixation and SA fixation. We hypothesized that the ASA group would show no statistical difference in the ultimate failure load and stiffness compared with the SA group. STUDY DESIGN: Controlled laboratory study. METHODS: Reconstruction of the MPFL with gracilis autografts was performed in 16 fresh-frozen cadaveric knees (mean age, 52.6 ± 9.0 years). The specimens were randomly assigned to 2 groups of 8 specimens each based on the method used to fix the graft to the medial patella: ASA or SA fixation. Patellar fixation with ASAs was completed with 2 parallel 1.8-mm anchors (Q-Fix, Smith & Nephew). Fixation with SAs was completed with 2 parallel 2.9-mm anchors (Osteoraptor, Smith & Nephew). The reconstructions were cyclically loaded for 10 cycles to 25 N and then loaded in tension at 6 mm/s until failure. Ultimate failure load (N), displacement (mm), stiffness (N/mm), and mode of failure were recorded for each specimen. RESULTS: Load to failure testing showed an ultimate failure load of 228.5 ± 53.1 N in the ASA group. In the SA group, the ultimate failure load was 156.2 ± 84.9 N. The difference between the 2 groups was not statistically significant ( P = .064). Stiffness values between the ASA and SA groups were not significantly different (21.3 ± 4.1 N/mm vs 20.9 ± 9.3 N/mm, respectively, P = .905). The most common mode of failure in both groups was anchor pullout (8 of 8 in the ASA group; 6 of 8 in the SA group). CONCLUSION: This experimental study showed no statistically significant differences in biomechanical performance between 1.8-mm ASAs and 2.9-mm SAs. CLINICAL RELEVANCE: Patellar fixation with 2 parallel ASAs may provide adequate patellar fixation for MPFL reconstruction, while their smaller diameter could potentially decrease the risks for patella fracture and violation of the articular surface in the cadaver model.

Valgus Extension Overload: Arthroscopic Decompression in the Supine-Suspended Position.

Elbow arthroscopy is a useful tool for managing diseases of the elbow, including valgus extension overload, when conservative treatments have failed. Arthroscopic access to the elbow in the supine-suspended position is simple and reproducible with the technique described in this report. Synovial tissue can be cleared, optimizing visualization of the anatomic structures in the elbow including the posterior ulnohumeral joint. This report describes, in detail, arthroscopy of the elbow in the supine-suspended position and basic principles for arthroscopic decompression of the posterior elbow for valgus extension overload.

Is resurfacing the patella cheaper? An economic analysis of evidence based medicine on patellar resurfacing.

BACKGROUND: Primary total knee arthroplasty is a high volume procedure which is expected to grow dramatically in the near future. The decision to resurface the patella has been discussed extensively in the literature yet the financial implications of resurfacing versus not resurfacing have not been demonstrated. METHODS: We identified all randomized controlled trials comparing patellar resurfacing to nonresurfacing in the past ten years and identified the total number of patellofemoral revision surgeries for both resurfaced and nonresurfaced patellas in each study. An expected-value decision tree analysis was created using only data from the randomized controlled trials. Actual costs collected from Medicare reimbursement rates were then applied to the model and a sensitivity analysis was performed. RESULTS: The expected value of primary total knee arthroplasty with patellar resurfacing was $13,788.48 while a primary total knee arthroplasty without patellar resurfacing was $14,016.41 after five years. The difference represents an additional $227.92 of Medicare dollars for every primary total knee arthroplasty performed without patellar resurfacing at five years. The model remains valid as long as patellofemoral revision rates after patellar resurfacing remain below 3.54% and patellofemoral revision rates after nonresurfaced patellas remain above 0.77%. CONCLUSIONS: While initially counterintuitive, resurfacing the patella during a primary total knee arthroplasty is the optimal financial strategy from a Medicare perspective over a mid term period.

A cost analysis of internal fixation versus nonoperative treatment in adult midshaft clavicle fractures using multiple randomized controlled trials.

BACKGROUND: To determine whether the cost of nonoperative treatment, including those who require delayed operative treatment, is less than those receiving initial operative management. METHODS: We identified 4 recent randomized controlled trials comparing operative and nonoperative treatment of displaced midshaft clavicle fractures in adults with a minimum of 1-year follow-up. A decision tree was then created from these data using reoperation for those treated with surgery or delayed operative treatment of those treated nonoperatively as end points. Actual costs estimated from 2013 Medicare reimbursement rates were applied and adjusted to better reflect private insurance rates. We then performed a 2-way sensitivity analysis to test the stability of our model. RESULTS: Based on our decision tree, the expected costs for operative and nonoperative treatment were $14,763.21 and $3112.65, respectively, producing a cost savings of $11,650.56 with nonoperative treatment. After application of a 2-way sensitivity analysis, our model remains valid until delayed operative treatment for nonoperative patients approaches 95% and reoperation after initial operative management falls below 15%. CONCLUSIONS: From the perspective of a single payer, initial nonoperative treatment of midshaft clavicle fractures followed by delayed surgery as needed is less costly than initial operative fixation. LEVEL OF EVIDENCE: Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

Smoking synthetic marijuana leads to self-mutilation requiring bilateral amputations.

Synthetic cannabinoids have become a worldwide epidemic because they provide a sometimes legal, easily accessible, and presumably safe alternative to marijuana. Recently published reports have linked acute psychosis, myocardial infarctions, convulsions, self-harm, and even terrorist organizations to these designer substances. This case report outlines the first reported case of Black Diamond, a synthetic cannabis, leading to a self-inflicted burn to the bilateral upper extremities requiring a transradial amputation of the right arm and a toe transfer procedure of the left hand after loss of all digits. The patient presented to the emergency department with self-inflicted fourth-degree burns to the bilateral hands and forearms with second-degree burns of the face, for a total body surface area of 14.5%. The patient was found by firefighters with his hands aflame on his kitchen stove. With no previous medical or psychiatric history and collateral information to confirm the patient's mental status prior to use of Black Diamond, the patient's acute psychotic episode was attributed to Black Diamond. After multiple procedures and a lengthy recovery, the patient completed his post-graduate education and entered the professional world. As orthopedic surgeons, we should be involved in educating the public on the harm of these designer drugs, including self-mutilation. The popularity of synthetic drugs in the United States will continue to present a major challenge to all health care providers. Orthopedists are on the front lines of this epidemic because these drugs push patients into risky, traumatic behavior.