Twisting technique for ulnar collateral ligament reconstruction of the elbow: new possibilities toward enhancing the strength of autografts.

Background: Although the ulnar collateral ligament reconstruction procedure has been increasing in popularity annually owing to its stable postoperative outcomes, the number of revision surgeries following ulnar collateral ligament reconstruction has increased. The success of the initial reconstruction surgery and further improvement in the return-to-play rates of the initial surgery are crucial. In this study, we report on ulnar collateral ligament reconstruction using the twisting technique, which aims to enhance the strength of the graft (palmaris longus tendon) to improve return-to-play rates. Methods: We investigated the return-to-play rate and period in 60 cases (2016-2021) that underwent ulnar collateral ligament reconstruction using the twisting technique and 211 cases (2007-2019) that did not use the twisting technique. The twisting technique involved inserting the graft through the bone tunnel and then twisting the doubled tendon. Results: According to the Conway-Jobe scale, the twisting technique group had 98.3% excellent, 1.7% good, 0% fair, and 0% poor results, with a mean return-to-play period of 9.8 months. The non-twisting technique group had 86.7% excellent, 9.0% good, 1.9% fair, and 2.4% poor results, with a mean return-to-play period of 11.4 months. The two groups showed significant differences in return-to-play rate (P = .020) and period (P = .022). Conclusion: The clinical results of the twisting technique showed that the return-to-play rate of the twisting technique group was higher after than before the procedure, and the return-to-play period was shortened by more than 1 month. The twisting technique may improve the results of ulnar collateral ligament reconstruction surgery.

Endoscopic-Assisted Transaxillary Approach for First Rib Resection in Thoracic Outlet Syndrome.

PURPOSE: To assess the feasibility, safety, and clinical outcomes of an endoscopic-assisted transaxillary approach of first rib resection for thoracic outlet syndrome (TOS) and to compare the differences in demographic and clinical data between satisfactory and unsatisfactory outcomes using this approach. METHODS: We retrospectively identified patients who underwent endoscopic-assisted first rib partial resection. A transaxillary approach for the first rib resection and neurovascular decompression were undertaken under magnified visualization. Endoscopic classification of neurovascular bundle (NVB) patterns and interscalene distance (ISD) between anterior and middle scalene muscles were evaluated intraoperatively. We assessed the Roos and DASH scores. RESULTS: We reviewed 131 cases of TOS (48 women and 83 men; mean age 26.2 years; range 12 to 57). Roos classification revealed 80.2% excellent or good results. DASH scores improved significantly from 40.7 ± 20.0 to 15.7 ± 19.6 (P < .001). The complication rate was low (5.3%), with 4 pneumothorax and 3 other complications. Intraoperative NVB classification revealed 30 cases of parallel type, in which the artery and nerve travel in parallel; 69 oblique types, and 30 vertical types, in which the nerve was completely behind the middle scalene muscle or abnormal band. The ISD was narrower (5.4 ± 3.6 mm) than in previous cadaveric studies. The ISD in the parallel patterns was wider than that in the vertical patterns. In the satisfactory group, we found a significantly larger number of men, younger patients, athletes, and patients with a lower preoperative DASH score. CONCLUSIONS: An endoscopic-assisted transaxillary approach for first rib resection in TOS provides an excellent magnified visualization, safely allowing sufficient decompression of the neurovascular bundle and satisfactory surgical outcomes. Younger male athletes with TOS may be better candidates for this procedure. LEVEL OF EVIDENCE: IV, therapeutic case series.

Predictors of Unsuccessful Nonoperative Management of Capitellar Osteochondritis Dissecans.

BACKGROUND: Osteochondritis dissecans of the humeral capitellum (capitellar OCD) is a common injury among adolescent throwing athletes. Some younger patients with incomplete maturity of the epiphysis and early-stage capitellar OCD are good candidates for nonoperative treatment. However, during initial examination, predicting the need for surgical treatment in patients with capitellar OCD is difficult. PURPOSE: To perform multivariate ordered logistic regression analysis of data obtained from patients' medical records and images on initial examination and identify the predictors of unsuccessful nonoperative management of capitellar OCD. STUDY DESIGN: Cohort study (prognosis); Level of evidence, 2. METHODS: This study included 245 elbows with capitellar OCD (all male; mean age, 14 years [range, 10-27 years]). Patients were divided into 3 groups comprising 148 elbows requiring an immediate operation on initial examination, 48 requiring nonsurgical treatment, and 49 requiring an operation after nonoperative management. Baseline data and radiographic parameters, such as lesion location, lesion size, modified Minami classification, radial head size, skeletal age difference between both elbows on initial examination, lesion size on computed tomography, and staging on magnetic resonance imaging, were retrospectively reviewed. Univariate and multivariate ordered logistic regression analyses of spontaneous healing of the lesion were conducted. RESULTS: Univariate logistic regression analysis showed that radial head enlargement and skeletal age difference were significantly associated with spontaneous healing. In multivariate ordered logistic regression analysis, radial head enlargement (anteroposterior and lateral) and skeletal age difference were significant predictors of lack of spontaneous healing (odds ratio [OR], 2.76, P =.025; OR, 7.92, P =.026; and OR, 1.84, P =.0089, respectively). CONCLUSION: To predict spontaneous healing in the moderate stage, plain radiographs would be important to evaluate radiocapitellar congruity and skeletal age. This study showed that preoperative radiographic findings of radial head enlargement and advanced skeletal age of the throwing side compared with that of the nonthrowing side were predictors of advanced-stage capitellar OCD. Despite several limitations, the statistical significance and correlations herein provide important information on preoperative surgical planning to surgeons.

First-Rib Stress Fracture in Overhead Throwing Athletes.

BACKGROUND: First-rib stress fracture is considered a potential cause of nonspecific atraumatic chronic shoulder pain in adolescent athletes. However, the etiology in throwing athletes with first-rib fracture is still unknown. The purpose of this retrospective study was to investigate the characteristic clinical features and radiographic findings of overhead throwing athletes with first-rib fracture. METHODS: Twenty-four first-rib stress fractures in 23 players were studied retrospectively. Clinical features, including age, initial symptom, sports, pain-related activity, diagnostic method, treatment method, and final follow-up, were reviewed. RESULTS: The following characteristic clinical features were identified: mean age of 16.8 years (range, 13 to 25 years), 19 dominant arm injuries and 5 non-dominant arm injuries, and an acute increase in pain while swinging the bat or pitching the ball. Sixteen fractures presented with posterior shoulder or upper thoracic back pain. At a mean time of 7.5 months after the initiation of conservative treatment, 17 healing fractures (71%) and 7 nonunion fractures (29%) among throwing athletes with first-rib stress fracture were identified. On image analysis, first-rib stress fractures were classified into 3 types depending on the direction and location of fracture lines: groove, intrascalene, and posterior types. Three symptomatic patients underwent first-rib resection due to thoracic outlet syndrome. On average, 46% of the first rib was visible on the shoulder radiographs and 97% was visible on the cervical spine radiographs. The Cohen kappa coefficient for the above percentages was 0.87 and the percent agreement was 89.4% for the shoulder, and the Cohen kappa coefficient was 0.80 and the percent agreement was 99.0% for the cervical spine. CONCLUSIONS: First-rib stress fracture should be considered when adolescent overhead throwing athletes have acute-onset posterior shoulder pain while swinging the bat or pitching the ball. Anteroposterior radiography of the cervical spine is available for initial diagnosis. Although 71% of the patients healed at a mean follow-up of 7.5 months with conservative treatment, some patients may have symptoms consistent with thoracic outlet syndrome. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Importance of the Wrist Extensor Muscle Training: Two Cases of Elbow Flexorplasty following Traumatic Brachial Plexus Injuries.

The modified Steindler procedure-a reconstructive surgery used to restore elbow flexion following upper brachial plexus injuries-involves shifting the origins of the muscle groups responsible for wrist flexion and forearm pronation originating from the medial epicondyle to the proximal direction to be used as flexors of the elbow. In the postoperative rehabilitation, we focused on strengthening not only the transferred muscle but also the wrist extensor muscles as antagonist muscles. After reconstruction surgery for elbow flexion via the modified Steindler procedure for traumatic brachial plexus injury, we performed long-term rehabilitation to strengthen the antagonist muscles. As a result, in two cases, excellent elbow flexion strength and gripping strength were achieved, confirming the importance of the antagonist muscles.

Quadrilateral Space Syndrome With Involvement of the Tendon of the Latissimus Dorsi.

Quadrilateral space syndrome (QSS) is the term used to describe axillary nerve palsy due to compression of the axillary nerve and posterior circumflex artery in the quadrilateral space. The precise pathophysiology of QSS is still unclear; hence, a consensus of diagnosis and treatment for QSS has not yet been achieved. The authors present the case of a 17-year-old male baseball player with symptoms of QSS, including right elbow and shoulder joint pain and upper limb numbness while throwing. The symptoms had worsened during baseball. Conservative management for 3 months failed to resolve the symptoms, so surgery was performed. Axillary nerve decompression resulted in functional improvement. The cause of QSS has been previously reported to be fibrous bands, the long head of the triceps, and Bennett lesions. However, the cause of QSS in this case was compression of the axillary nerve between the proximal humerus and the tendinous attachment of the latissimus dorsi. The authors incised a 10- to 15-mm segment of the medial edge of the tendinous insertion of the latissimus dorsi, which resulted in resolution of QSS symptoms. [Orthopedics. 2017; 40(4):e714-e716.].

7. Usefulness of Low-Intensity Pulsed Ultrasound (LIPUS) for the Treatment of Osteochondritis Dissecans (OCD) of the Humeral Capitellum.

OBJECTIVES: LIPUS has been reported to promote bone union in pseudoarthrosis and delayed fracture union as well as to have a beneficial effect in shortening the duration of bone healing in fresh fractures. The purpose of this study was to examine whether LIPUS has an accelerating effect on healing OCD. SUBJECTS AND METHODS: From 2008 to 2012, cases with advanced-stage OCD were randomized, and the study was conducted on 51 patients (LIPUS group) who enabled us to decide the treatment efficacy, and gave consent after receiving an explanation on the benefit of LIPUS. LIPUS was performed for 20 minutes every day by treating the elbow in 2 directions, namely on the external and internal sides. The patients were told to stop pitching and batting. Plain radiography was performed once every 6 weeks and computed tomography (CT) scans were performed approximately once every 3 months. Image repair criteria were that the outside localized type was repaired completely, and the central localized or extensive type had lesion occupancy of less than 20%. Twenty-nine of 51 who did not recover and received surgical operation were excluded in the study, and 22 patients who were healed with LIPUS were compared with 21 patients who received conservative therapy only. RESULTS AND DISCUSSION: The image repair period for the LIPUS group was an average of 4.5 ± 1.9 months, while for the non-LIPUS group it was 6.8 ± 3.8 months. LIPUS treatment for OCD significantly shortened the image repair period (P = 0.037). It is necessary to increase the number of cases, and clarify the utility of LIPUS.

Alteration of Stress Distribution Patterns in Symptomatic Valgus Instability of the Elbow in Baseball Players: A Computed Tomography Osteoabsorptiometry Study.

BACKGROUND: Repetitive valgus stress applied during a throwing motion can lead to various elbow disturbances, including ulnar collateral ligament (UCL) injury. Subchondral bone density reportedly reflects the cumulative force on a joint surface under actual loading conditions. PURPOSE: (1) To evaluate the distribution of subchondral bone density across the elbow joint in asymptomatic baseball pitchers and symptomatic valgus instability pitchers and (2) to clarify the alterations in stress distribution pattern associated with symptomatic UCL insufficiency pitching activities. STUDY DESIGN: Controlled laboratory study. METHODS: Computed tomography (CT) imaging data were collected from the dominant-side elbow of 7 nonathletic volunteers (controls), 12 asymptomatic pitchers (asymptomatic group), and 12 symptomatic valgus instability pitchers with UCL insufficiency (symptomatic group). Bone mineral density across the elbow joint was measured with CT osteoabsorptiometry. A 2-dimensional mapping model was divided into 4 areas of the distal end of the humerus and 5 areas of the ulna with the radial head. The locations and percentages of high-density areas on the articular surface were quantitatively analyzed. RESULTS: High-density areas in the asymptomatic and symptomatic groups were found in the anterolateral and posteromedial parts of the humerus and in the radial head, posteromedial to the ulna. The high-density areas in the anterior and posteromedial of the humerus, the radial head, and the posteromedial part of the ulna in the controls were smaller than those in the baseball group. In the symptomatic group, the percentages of high-density areas in the anterolateral part of the humerus (mean, 36.3%; 95% CI, 31.9%-40.7%) and the anterolateral part of the ulna (mean, 31.7%; 95% CI, 24.3%-39.1) were significantly greater than those in the asymptomatic group (P = .047 and P < .0001, respectively). CONCLUSION: Symptomatic UCL insufficiency was associated with characteristic high-stress distribution patterns on the anterolateral part of the capitellum and the anterolateral part of the ulna. The current results indicate that symptomatic UCL insufficiency produces excessive and cumulative stress in the elbow joint. CLINICAL RELEVANCE: The information obtained from the CT images can useful for early detection of overstress conditions of the elbow joint.

Classification of Olecranon Stress Fractures in Baseball Players.

BACKGROUND: Although the onset mechanism of an olecranon stress fracture (OSF) due to a throwing disorder is believed to involve valgus extension overload, olecranon posteromedial impingement, or triceps traction force, this issue is still debated in the literature. PURPOSE: To establish a classification system for the different types of OSFs to improve diagnosis and clarify the onset mechanism. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 200 baseball players (198 male, 2 female; mean age, 16.1 years; age range, 13-27 years) who were diagnosed with an OSF from January 1987 to July 2012 were studied. Combined disorders as well as the direction and form of the fracture line were analyzed on plain radiographs, computed tomography, and magnetic resonance imaging. Furthermore, the presence or absence of ulnar collateral ligament (UCL) injuries and avulsion fractures of the lower pole of the medial epicondyle was determined by imaging findings to calculate the combined percentage of OSFs. In addition, the prevalence of OSFs was evaluated among patients who were evaluated between April 2008 and March 2011 for throwing elbow disorders. RESULTS: There were 5 types of OSFs identified in the new classification system: physeal, classic, transitional, sclerotic, and distal. The physeal type was further separated into stages 1 to 4 based on severity. The mean age for each type identified was as follows: physeal, 14.1 years; classic, 18.6 years; transitional, 16.9 years; sclerotic, 18.0 years; and distal, 19.6 years. A concomitant UCL injury and/or medial epicondyle avulsion fracture was diagnosed in 71% to 95% of cases, depending on the OSF type. Among baseball-related elbow disorders, the incidence of OSFs was 5.4%. CONCLUSION: This study presents a new classification system for the different types of OSFs based on the origin and direction of the fracture plane. This new system was strongly influenced by the age at symptom onset. Such information is essential for successful open reduction and internal fixation by ensuring that fixation pressure is perpendicular to the fracture plane, which will avoid the recurrence of stress fractures. In addition, the prevalence of UCL injuries suggests that it is a major risk factor for the development of OSFs.

Case report: meralgia paresthetica in a baseball pitcher.

We report a case of meralgia paresthetica occurring in an amateur baseball pitcher who experienced inguinal pain and dysesthesia in the anterolateral thigh during pitching practice. The lateral femoral cutaneous nerve was pushed up by the iliac muscle to the inguinal ligament at the sharp ridge of its fascia and ensheathed in the tendinous origin of the sartorius muscle. Neurolysis of the lateral femoral cutaneous nerve and partial dissection of the inguinal ligament and sartorius muscle promptly relieved the symptoms and the patient resumed pitching 1 month later. These anatomic variations of the lateral femoral cutaneous nerve in the inguinal region might render the nerve susceptible to compression and irritation, and repetitive contraction of inguinal muscles during throwing motion might induce and exacerbate the neuropathy of the lateral femoral cutaneous nerve.

Increase in serum concentrations of inhibin in early onset pre-eclampsia with intrauterine growth restriction.

AIM: Recently, it has been hypothesized that reduced placental blood flow in early pregnancy causes changes in endothelial function, leading to pre-eclampsia. To clarify this clinically, we assessed serum concentrations of inhibin and uric acid in pre-eclamptic women compared with those of normotensive pregnant women. METHODS: One hundred and forty normotensive pregnant women (at 20-41 weeks' gestation) and 50 women with pre-eclampsia (at 24-41 weeks' gestation) were the study subjects. Pre-eclamptic women were classified according to the new criteria for pregnancy-induced hypertension produced by the Japanese Society of Obstetrics and Gynecology (JSOG). Serum concentrations of uric acid and inhibin were measured enzymatically and by radioimmunoassay, respectively. RESULTS: Serum concentrations of inhibin and uric acid in the pre-eclamptic women were significantly higher than in gestational age-matched normotensive pregnant women. There were significant correlations among inhibin and uric acid, blood pressure and birth weight. According to JSOG criteria, of the 50 pre-eclamptic women, 18 were early onset (EO), including 16 cases complicated by intrauterine growth restriction (IUGR), and 32 cases were late onset, including 12 cases complicated by IUGR. In the patients with EO and IUGR, serum concentrations of inhibin, but not uric acid, were significantly elevated as compared with those of the other pre-eclamptic women. CONCLUSION: The results suggest that an increase in the serum concentration of inhibin seen in EO pre-eclampsia, together with IUGR, might be a cause of reduced placental blood flow.

Delta-aminolevulinic acid-based photodynamic therapy for acne on the body.

Intractable acne on the body was clinically treated with photodynamic therapy (PDT) combining oral administration of delta-aminolevulinic acid (ALA) with polychromatic visible light from a metal halide lamp. The total number of body acne patients was 51. A 10 mg/kg B.W. of ALA was administered to the patients, and the acne lesions were exposed to the light emitted from the metal halide lamp. The wavelengths of the light ranged from 540 to 800 nm. The diameter of the irradiated area and the irradiating distance from the lamp were 100 mm and 130 mm, respectively. Under the irradiation conditions, the total fluence rate and the energy-density uniformity of the light were 69.2 mW/cm2 and 11.5%. The total light energy dose in one session was 60-80 J/cm2 for the body. All patients underwent two sessions of PDT and received no other treatments after PDT or during the follow-up period. The interval between the two PDT sessions was 2-4 weeks. The physician's clinical assessment scores as worsened, unchanged, improved, and markedly improved were 0 (0%), 4 (7.8%), 16 (31.4%), and 31 (60.8%) patients, respectively. Adverse effects of very slight discomfort, burning, and stinging were reported during the irradiation. The blood tests of patients before and after oral administration of ALA demonstrated that no liver dysfunction occurred in this study with ALA dosages within 10 mg/kg B.W. Consequently, orally administered ALA-PDT with a metal halide lamp was considered to be effective for treatment of acne on the body.