Hypertrophy of the sublime tubercle in elbow ulnar collateral ligament injuries: a case series of baseball pitchers undergoing ulnar collateral ligament reconstruction with short-term follow-up.

Background: The ulnar collateral ligament (UCL) of the elbow is subject to repetitive stress in overhead throwing athletes. This can lead to morphologic changes at the bony attachments of the UCL and hypertrophy of the sublime tubercle. The purpose of this case series is to describe the surgical details and clinical outcomes of a series of competitive baseball pitchers with hypertrophic sublime tubercles who underwent UCL reconstruction (UCLR). Methods: All baseball pitchers who were treated for UCL injuries with significant hypertrophy of the sublime tubercle on preoperative imaging were included in the series. Clinical history, preoperative imaging, intraoperative findings during UCLR, and postoperative outcomes measured with the Conway scale were described. Results: Ten players (average age of 22.9 years [range 13-39]) were included (average follow-up 20.4 months [range 3-38 months]). Five patients also had symptoms of ulnar nerve compression, with 4 requiring transposition at the time of ULCR and 1 at 3 months postoperatively. Bony hypertrophy of the sublime tubercle was confirmed intraoperatively in all cases and excised before UCLR with the docking technique. Of the 7 patients with at least 12-month follow-up postoperatively, 6 had excellent outcomes, and 1 had a fair outcome. Conclusion: Although UCLR in the setting of hypertrophic sublime tubercle can be more complex than typical UCLR, excellent outcomes are achievable with preoperative recognition and surgical planning.

Effects of anterior cruciate ligament reconstruction on patellofemoral joint stress and lower extremity biomechanics at 12 weeks post-surgery and at time of return to sport in adolescent females.

BACKGROUND: The purpose of this study was to examine kinematic and kinetic differences associated with patellofemoral pain after anterior cruciate ligament reconstruction between limbs at 12-week post-surgery and at time of return to sport. METHOD: Twenty-four adolescent females completed 5 consecutive single leg squats on each limb at 12-weeks post-surgery and again during their RTS assessment. Peak knee extension moment, peak hip adduction angle, and patellofemoral joint stress at 45 degrees of knee flexion were calculated. Separate two by two repeated measures ANOVA were performed. FINDINGS: There was a significant interaction (limb × time) for knee extension moment (p < 0.001). Surgical limb knee extension moment was significantly less than the non-surgical limb at return to sport (p < 0.001). At 12-weeks the surgical limb was significantly less than non-surgical limb (p < 0.001), additionally the surgical limb was significantly greater at time of return to sport than at 12 weeks (p < 0.001). There was a significant main effect of limb for hip adduction angle (p = 0.002). Surgical limb was significantly greater than non-surgical limb (Surgical = 9.84 (SE 1.53) degree, non-surgical = 4.79 (SE 1.01) degree). There was also a main effect of time and limb for patellofemoral joint stress. Return to sport was significantly greater than 12 weeks and the surgical limb was significantly less than non-surgical limb (Surgical = 4.93 (SE 0325) MPa, Nonsurgical = 5.29 (SE 0.30) MPa). INTERPRETATION: The surgical limb of participants following ACL-R demonstrated variables that have been associated with the development of patellofemoral pain.

Quadriceps strength changes across the continuum of care in adolescent male and female athletes with anterior cruciate ligament injury and reconstruction.

OBJECTIVES: To examine the quadriceps strength (QUADS) on the surgical (SURG) and non-surgical (Non-SURG) limbs in adolescent male and female athletes at pre-operative (PRE), 12 weeks post-operative (12WK), and return to sport (RTS) time points following ACL injury and reconstruction. DESIGN: Prospective cohort study design. SETTING: Clinical Research Laboratory. PARTICIPANTS: 66 adolescent athletes. MAIN OUTCOME MEASURES: Isokinetic QUADS of the SURG and Non-SURG limbs at the PRE, 12WK, and RTS time points were assessed and compared between each time point. RESULTS: Both male and female participants had significantly lower 12 WK QUADS in the SURG limb than the PRE QUADS, but the RTS QUADS was significantly greater than the 12WK QUAD (p < 0.05). However, only female participants had greater RTS QUADS as compared to the PRE QUADS (p < 0.001). For the Non-SURG limb, only male participants had a significant improvement over time (PRE vs RTS; p < 0.001). CONCLUSION: Adolescent males and females differ in their QUADS recovery across the continuum of care following ACLR. Clinicians should consider this pattern of recovery when treating adolescent males and females.

Computer Assisted Cobb Angle Measurements: A novel algorithm.

BACKGROUND: The standard for evaluating scoliosis is PA radiographs using Cobb angle to measure curve magnitude. Newer PACS systems allow easier Cobb angle calculations, but have not improved inter/intra observer precision of measurement. Cobb angle and its progression are important to determine treatment; therefore, angle variability is not optimal. This study seeks to demonstrate that a performance equivalent to that achieved in the manual method is possible using a novel computer algorithm with limited user input. The authors compared Cobb angles from predetermined spinal levels in the average attending score versus the computer assisted approach. METHODS: Retrospective analysis of PA radiographs from 58 patients previously evaluated for scoliosis was collected. Predesignated spinal levels (e.g., T2-T10) were assigned for different curves and calculated by Cobb method. Four spine surgeons evaluated these Cobb angles. Their average scores were measured and compared to formulated values using the novel computer-based algorithm. Literature reports inter-observer reliability is 6.3-7.2degrees. Limits of accuracy were set at 5 degrees of average orthopedic surgeons' score. RESULTS: The computer-based algorithm calculated Cobb angles within 5 degrees of orthopedic surgeons' average with a standard deviation of 3.2 degrees. This result was based on a 95% confidence interval with p values <0.001. The computer algorithm was plotted against average angle determined by the surgeons, with individual determinations and linear regression (r2 =0.90). The average difference between surgeons' measures and computer algorithm was 0.4 degrees(SD= 3.2degrees, n=79). There was a tendency for the computer algorithm program to overestimate the angle at larger angles, but difference was small with r2 = 0.09. CONCLUSIONS: Our study showed the novel computer based algorithm was an efficient and reliable method to assess scoliotic curvature in the coronal plane with the possibility of expediting clinic visits, ensuring reliability of calculation and decreasing patient exposure to radiation. Level of Evidence: III.

The Development and Validation of a Subjective Assessment Tool for the Hip in the Athletic Population.

BACKGROUND: No validated functional assessments are available that are designed specifically to evaluate the performance and function of the athletic hip. Subsections of some validated outcome assessments address recreation, but a full assessment dedicated to athletic hip function does not exist. Current hip scoring systems may not be sensitive to subtle changes in performance and function in an athletic, younger population. HYPOTHESIS: The patient-athlete subjective scoring system developed in this study will be validated, reliable, and responsive in the evaluation of hip function in the athlete. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Based on the results of a pilot questionnaire administered to 18 athletic individuals, a final 10-item questionnaire was developed. Two hundred fifty competitive athletes from multiple sports completed the final questionnaire and 3 previously validated hip outcome assessments. Each athlete was self-assigned to 1 of 3 injury categories: (1) playing without hip/groin trouble; (2) playing, but with hip/groin trouble; and (3) not playing due to hip/groin trouble. The injury categories contained 196, 40, and 14 athletes, respectively. Correlations between the assessment scores and injury categories were measured. Responsiveness testing was performed in an additional group of 24 injured athletes, and their scores before and after intervention were compared. RESULTS: The Kerlan-Jobe Orthopaedic Clinic (KJOC) Athletic Hip Score showed high correlation with the modified Harris Hip Score, the Nonarthritic Hip Score, and the International Hip Outcome Tool. The new score stratified athletes by injury category, demonstrated responsiveness and accuracy, and varied appropriately with improvements in injury category after treatment of injuries. CONCLUSION: The new KJOC Athletic Hip Score is valid, reliable, and responsive for evaluation of the hip in an athletic population. The results support its use for the functional assessment of the hip in future studies.

Open Navicular Dislocation With Midfoot Dissociation in a 45-Year-Old Man.

Traumatic dislocation of an intact tarsal navicular is an uncommon injury. In this article, we report a case of open medial navicular dislocation in a 45-year-old man. The injury was managed with open reduction and stabilization with Kirschner wires within the acute period. Ten months after injury, the patient developed avascular necrosis of the navicular and exhibited progressive collapse of the medial midfoot. He underwent naviculocuneiform arthrodesis 1 year after the index surgery. Two years after fusion, he was pain-free and ambulating independently. Successful treatment of midfoot fractures and dislocations requires an intimate understanding of anatomy, biomechanics, and both short- and long-term sequelae of injury.

Return to Golfing Activity After Joint Arthroplasty.

BACKGROUND: Many patients who are considering total joint arthroplasty, including hip, knee, and shoulder replacement, are concerned with their likelihood of returning to golf postoperatively as well as the effect that surgery will have on their game. PURPOSE: To review the existing literature on patients who have undergone major joint arthroplasty (hip, knee, and shoulder), to examine the effects of surgery on performance in golf, and to provide surgeon recommendations as related to participation in golf after surgery. A brief review of the history and biomechanics of the golf swing is also provided. STUDY DESIGN: Systematic review. METHODS: We performed a systematic review of the literature in the online Medline database, evaluating articles that contained the terms "golf" and "arthroplasty." Additionally, a web-based search evaluating clinical practice recommendations after joint arthroplasty was performed. The research was reviewed, and objective and anecdotal guidelines were formulated. RESULTS: Total joint arthroplasty provided an improvement in pain during golfing activity, and most patients were able to return to sport with variable improvements in sport-specific outcomes. CONCLUSION: In counseling patients regarding the return to golf after joint arthroplasty, it is our opinion, on the basis of our experience and those reported from others in the literature, that golfers undergoing total hip, knee, and shoulder arthroplasty can safely return to sport.

Transosseous Physeal-Sparing Rotator Cuff Repair in an Adolescent Football Player.

Rotator cuff injuries in the pediatric and adolescent population are rare. These injuries are normally caused by an acute event or by repeated microtrauma as a result of poor mechanics during overhead sporting activities. Overall, these injuries account for fewer than 1% of all rotator cuff tears. Physeal injuries, tuberosity avulsions ("rotator cuff equivalents"), and proximal humeral fractures commonly occur in the pediatric population. Traumatic full-thickness rotator cuff ruptures that occur in this age group during contact sports are an extremely uncommon cause of shoulder pain. The rarity of this type of injury in the pediatric and adolescent population may be the result of the excellent tensile properties of rotator tendons in childhood that often resist mechanical forces better than the growth plate or the apophyses. This report describes a full-thickness rotator cuff tear and a posterior labral tear in a 12-year-old boy who had a direct injury to the shoulder while playing football. The authors' goal in reporting this case is to increase orthopedic surgeons' awareness of this type of injury. Early use of magnetic resonance imaging for persistent shoulder pain after direct injury during contact sports may avoid undue delay in diagnosis. This report also describes the mini-open transosseous extraphyseal technique of cuff repair and reviews the literature on this infrequent injury. Overall, excellent clinical outcomes and return to sports can be expected after surgical repair of torn and often retracted tendons.

Preliminary trauma radiographs misrepresent pubic diastasis injuries.

The goal of this study was to evaluate the role of portable primary trauma survey radiographs in the evaluation and management of anteroposterior (AP) compression pelvic injuries. A retrospective analysis was conducted at a level I academic trauma center. Twenty-seven adults with AP compressive class pelvic ring injuries who received both portable pelvic radiographs and pelvic computed tomography (CT) imaging in an unbound pelvic state were included. Three orthopedic surgeons performed independent measurements of diastasis on portable pelvic radiographs and coronal pelvic CT reconstructions. Measurement techniques were standardized among observers and were repeated after 8 weeks to assess intraobserver reliability. Nonoperative vs operative treatments were correlated with the initial magnitude of pelvic injury on CT and portable radiographic images. Independent measurements of diastasis on both radiographs and CT scans showed excellent intraobserver reliability (average correlation coefficient, 0.986) and interobserver reliability (average correlation coefficient, 0.979). Compared with diastasis measurements on CT scans, portable pelvic radiographs overestimated diastasis by an average of 49%, or 12.6 mm (P<.0001; 95% confidence interval, 9.6-15.6). Portable pelvic films were less precise than standard pelvic radiographs in measuring the size of femoral head controls (R(2)=0.919 vs 0.759; P=.004). In 12 of the 27 patients evaluated, radiographic indications for operative pelvic fixation were met by portable radiographs but not CT scans, and 11 of these patients ultimately underwent operative fixation. Portable AP pelvic radiographs may distort and exaggerate pelvic bony injuries, especially those involving anterior pelvic structures. Surgeons should use caution when making management decisions based on preliminary portable pelvic radiographs.

Impact of Total Shoulder Arthroplasty on Golfing Activity.

OBJECTIVE: Golf is a widely popular sport in the United States with 29 million Americans participating in the game. With an aging population and increased incidence of glenohumeral degenerative arthritis, the number of active golfers requiring total shoulder replacement is on the rise. This study aims to evaluate the effect of total shoulder replacement on golfing activity. DESIGN: Retrospective; questionnaire. SETTING: Survey. PARTICIPANTS: Three hundred sixty-seven patients were identified based on Current Procedural Terminology codes who underwent total shoulder arthroplasty (TSA) between January 2004 and January 2013. INTERVENTIONS: A voluntary anonymous questionnaire was sent to patients by mail including both objective and subjective questions about their level of golf activity and ability both before and after the surgery. MAIN OUTCOME MEASURES: Two hundred sixty-eight (73%) patients responded with 35 (34 right-handed and 1 left-handed patients) golfers completing the questionnaire. Results including visual analog pain scores, handicap change, and driving distance were evaluated statistically using the Student t test. RESULTS: Thirty-five golfers at an average time of 3.2 years after TSA completed the questionnaire with 31/35 being able to return to the sport at an average time of 8.4 months postoperatively. Thirty of 31 patients reported improvement in their pain level during and after golfing activity by an average of 4.3 (P < 0.05) on a visual analog scale (VAS) for pain. On average, driving distances increased by 12.5 yd (P = 0.0012) and handicap improved by 1.4 strokes (P = 0.03). CONCLUSIONS: Patients who undergo TSA for primary glenohumeral arthritis can safely return to golfing activity with a significant decrease in their perceived pain level as per VAS scores. Statistically significant findings included an increase in driving distance by 12.5 yd and an improvement in handicap by 1.4. CLINICAL RELEVANCE: In counseling patients, it is the authors' opinion that based on our experience with golfers undergoing TSA, patients can safely return to sport at an average of 8.4 months. The likelihood of return to play was quite high, but not 100%, and as such no guarantee should be provided to patients. Outcomes of patients with TSA desiring a return to golf are positive, and possible benefits include improvement of pain and possible improvements in driving distance and handicap. LEVEL OF EVIDENCE: IV.

Dedicated orthopaedic operating rooms: beneficial to patients and providers alike.

OBJECTIVE: Dedicated orthopaedic operating rooms (DOORs) are increasingly popular solutions to reducing after-hours procedures, physician fatigue, and elective schedule disruptions. Although the benefits to surgeons are well understood, there are comparatively few studies that explore the effects of DOORs on patient care. We compared treatments and outcomes for all consecutive patients with femoral neck fractures, 4 years before and 4 years after implementation of a DOOR-based schedule. DESIGN: Retrospective case-control study. SETTING: Level 1 academic trauma center. PATIENTS: A total of 111 consecutive trauma patients undergoing surgical management of isolated OTA group 31-B femoral neck fractures. INTERVENTION: Based on individual patient factors and fracture characteristics, patients were managed with either hemiarthroplasty or open reduction internal fixation (ORIF). MAIN OUTCOME MEASURES: Surgical timing, intervention type, perioperative complications, and postoperative length of stay. RESULTS: Retrospective analysis revealed a significant decrease in after-hour surgery (4 PM-7:30 AM) for all femoral neck fractures (66.7%-19.3%; P < 0.001). No significant differences were found between the rates of arthroplasty versus those of open reduction internal fixation. Patients undergoing surgical treatment for femoral neck fractures after DOOR suffered significantly fewer morbidities, including significantly decreased rates of postoperative intensive care unit admissions, stroke, infections, and myocardial infarction or congestive heart failure exacerbations. We also observed a significant decrease in postoperative mortality (5.6% pre-DOOR vs. 0% post-DOOR; P = 0.04). Patients undergoing hemiarthroplasty experienced a significant shorter hospitalization (14.5 days pre-DOOR vs. 9.9 days post-DOOR; P = 0.04). CONCLUSIONS: In our experience, a weekday DOOR is closely associated with improvements in both patient safety and outcomes. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Spontaneous septic arthritis of the lumbar facet caused by methicillin-resistant Staphylococcus aureus in an otherwise healthy adolescent.

We report the case of a 16-year-old boy with isolated septic arthritis of a lumbar facet. This rare presentation of an infection in a lumbar facet joint occurred after minor trauma sustained in a football game. Septic arthritis of the spinal facet joint is an uncommon phenomenon. Only 5 cases have been reported in immunocompromised pediatric patients. To our knowledge, no case of septic arthritis in an immunocompetent pediatric patient has been reported. An otherwise healthy 16-year-old boy presented with 4 weeks of escalating back pain after a minor athletics-related trauma. Evaluation showed incapacitating pain, lumbar musculature spasms, and the absence of fever, hemodynamic, or neurologic changes. Laboratory values were within normal limits. Magnetic resonance images showed a fluid collection within the L3-L4 facet and a localized abscess. Computed tomographic-guided aspiration showed methicillin-resistant Staphylococcus aureus infection, for which the patient received 6 weeks of vancomycin with complete resolution of symptoms. Refractory lumbago in an adolescent requires careful evaluation.

The foot and ankle examination.

Most foot and ankle disorders can be diagnosed after a proper history and clinical examination and can be effectively managed in a primary care setting. It is important to assess the entirety of patient disorders that present as they can be multifactorial in cause. A broad differential should include disorders of bones, joints, muscles, neurovasculature, and surrounding soft tissue structures. Physical examination should be thorough and focused on inspection, palpation, range of motion, and appropriate special tests when applicable. This article highlights some of the salient features of the foot and ankle examination and diagnostic considerations.

Management of chronic musculoskeletal pain.

Chronic musculoskeletal pain results from a complex interplay of mechanical, biochemical, psychological, and social factors. Effective management is markedly different from that of acute musculoskeletal pain. Understanding the physiology of pain transmission, modulation, and perception is crucial for effective management. Pharmacologic and nonpharmacologic therapies such as psychotherapy and biofeedback exercises can be used to manage chronic pain. Evidence-based treatment recommendations have been made for chronic pain conditions frequently encountered by orthopaedic surgeons, including low back, osteoarthritic, posttraumatic, and neuropathic pain. Extended-release tramadol; select tricyclic antidepressants, serotonin reuptake inhibitors, and anticonvulsants; and topical medications such as lidocaine, diclofenac, and capsaicin are among the most effective treatments. However, drug efficacy varies significantly by indication. Orthopaedic surgeons should be familiar with the widely available safe and effective nonnarcotic options for chronic musculoskeletal pain.

Spinal cord compression in pseudohypoparathyroidism.

BACKGROUND CONTEXT: Spinal cord compression associated with pseudohypoparathyroidism (PHP) is an increasingly reported sequelae of the underlying metabolic syndrome. The association of neurologic dysfunction with PHP is not well appreciated. We believe this to be secondary to a combination of underlying congenital stenosis, manifest by short pedicles secondary to premature physeal closure, and hypertrophic ossification of the vertebral bony and ligamentous complexes. PURPOSE: The purpose of this case report is to review the case of spinal stenosis in a child with PHP Type Ia. We are aware of only eight published reports of patients with PHP Type Ia and spinal stenosis-there are only two previously known cases of pediatric spinal stenosis secondary to PHP. STUDY DESIGN/SETTING: This is a case report detailing the symptoms, diagnosis, interventions, complications, and ultimate outcomes of a pediatric patient undergoing spinal decompression and fusion for symptomatic stenosis secondary to PHP Type Ia. Literature search was reviewed regarding the reports of spinal stenosis and PHP, and the results are culminated and discussed. PATIENT SAMPLE: We report on a 14-year-old obese male with PHP and progressive lower extremity weakness secondary to congenital spinal stenosis. Examination revealed functional upper extremities with spastic paraplegia of bilateral lower extremities. The patient's neurologic function was cautiously monitored, but he deteriorated to a bed-bound state, preoperatively. METHODS: The patient's chart was reviewed, summarized, and presented. Literature was searched using cross-reference of PHP and the terms "spinal stenosis," "myelopathy", "myelopathic," and "spinal cord compression." All relevant case reports were reviewed, and the results are discussed herein. RESULTS: The patient underwent decompression and instrumented fusion of T2-T11. He improved significantly with regard to lower extremity function, achieving unassisted ambulation function after extensive rehabilitation. Results from surgical decompression in previously reported cases are mixed, ranging from full recovery to iatrogenic paraplegia. CONCLUSIONS: The association of neurologic dysfunction with PHP is not well appreciated. It is important to highlight this rare association. Surgical decompression in patients with PHP yields mixed results but may be of greatest efficacy in younger patients who receive early intervention.

Bacillus cereus fasciitis: a unique pathogen and clinically challenging sequela of inoculation.

Bacillus cereus is an aerobic, spore-forming, gram-positive rod. It has historically been associated with "fried rice syndrome," a foodborne diarrheal and emetic illness resulting from eating fried rice dishes that have been sitting at room temperature for hours. We report the case of a 9-year-old boy who developed culture-positive B cereus fasciitis of the right lower extremity after being impaled on a tree branch. This case report further elucidates and emphasizes the importance of recognizing B cereus as a possible cause of severe soft-tissue infection. It must be included in the differential diagnosis of gas gangrene and necrotizing fasciitis.

Catastrophic fracture of a stable metal acetabular component.

Various modes of failure of primary and revision total hip arthroplasty have been well documented in the literature over the past 30 years. Concerns over polyethylene wear, osteolysis, and hypersensitivity reactions leading to component loosening and early revision have been evaluated and reported in the literature. Routine follow-up is important to monitor for postoperative issues that might lead to the subsequent need for revision.This article describes a case of a 64-year-old man who initially presented 11 years prior with an intertrochanteric fracture, which failed secondary to varus alignment and femoral head osteonecrosis. The fixation was converted to a total hip replacement using the S-ROM system (DePuy, Warsaw, Indiana). Subsequently, the patient was lost to follow-up after primary total hip arthroplasty and presented with a catastrophic fracture of the metal acetabular cup system. The failure was suggested by clinical presentation and confirmed by imaging studies showing a fractured acetabular shell with femoral head prosthesis resting in the superolateral ileum. The contributing factors that resulted in mechanical failure were polyethylene wear and component fracture. The acetabular component was revised with an in-growth cementless trabecular metal multihole cup (Zimmer, Warsaw, Indiana) with bone grafting of acetabular defects.Routine assessments help educate patients and allow careful monitoring by physicians while establishing a radiographic timeline for the identification, progression, or lack of postoperative complications.

Niacin-induced "flush" involves release of prostaglandin D2 from mast cells and serotonin from platelets: evidence from human cells in vitro and an animal model.

Niacin lowers serum cholesterol, low-density lipoprotein, and triglycerides, and it raises high-density lipoprotein. However, most patients experience cutaneous warmth and vasodilation (flush). Acetylsalicylic acid (ASA) can reduce this flush, presumably by decreasing prostaglandin D(2) (PGD(2)) release from macrophages. Here, we show that methylnicotinate induces significant PGD(2) release from human mast cells and serotonin from human platelets. Intradermal injection of methylnicotinate induces rat skin vasodilation and vascular permeability. Niacin increases plasma PGD(2) and serotonin in a rat model of flush. The phenothiazine prochlorperazine, the H(1), serotonin receptor antagonist cyproheptadine, and the specific serotonin receptor-2A antagonist ketanserin inhibit niacin-induced temperature increase by 90% (n = 5, p < 0.05), 90 and 50% (n = 3, p < 0.05), and 85% (n = 6, p = 0.0008), respectively, in this animal model. These results indicate that niacin-induced flush involves both PGD(2) and serotonin, suggesting that drugs other than ASA are required to effectively inhibit niacin-induced flush.