Thoracic outlet syndrome in overhead athletes.

Background: We aimed to retrospectively compare the clinical outcomes of endoscopy-assisted first-rib resection for thoracic outlet syndrome (TOS) between overhead athletes and nonathletes and investigate the return to same-level sports rate in overhead athletes. Methods: We retrospectively reviewed 181 cases with TOS (75 women, 106 men; mean age, 28.4 years; range, 12-57 years) who underwent endoscopy-assisted first-rib resection. We divided into two groups: 79 overhead athletes and 102 nonathletes groups. A transaxillary approach for first-rib resection and neurovascular decompression was performed under magnified visualization. Endoscopic findings related to the neurovascular bundle, interscalene distance, and scalene muscle were evaluated intraoperatively. We assessed the Roos and Disability of the Arm, Shoulder, and Hand scores, return to same-level sports rate, and ball velocity. Results: Overhead athletes were significantly more likely to be men, younger, used the dominant side more frequently, and have a larger physique, more shoulder and elbow pain, and shorter symptom duration. The outcomes of the Roos score revealed significant differences in excellent or good results between overhead athletes (91.1%) and nonathletes (62.8%). The two groups significantly differed in preoperative and postoperative Disability of the Arm, Shoulder, and Hand and recovery rate scores (P = .007, < .001, < .001). Conclusion: Overhead athletes with TOS were more likely to be men, younger, dominant side more frequently, and have more shoulder and elbow pain, and a shorter symptom duration. Endoscopy-assisted transaxillary first-rib resection and neurolysis provided superior clinical outcomes in overhead athletes with TOS compared with nonathletes and a high return-to-same-level-play rate in sports.

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.

Location and Size of the Reverse Hill-Sachs Lesion in Patients with Traumatic Posterior Shoulder Instability.

BACKGROUND: In patients with traumatic posterior shoulder instability, little is known about the precise location and size of the reverse Hill-Sachs lesion. METHODS: Forty-nine shoulders of 47 patients with traumatic posterior instability were included in this study based on the following inclusion criteria: 1) a primary or recurrent traumatic posterior shoulder dislocation, and 2) the initial event was caused by trauma. Patients were excluded if they had: 1) no history of trauma, 2) prior shoulder surgery, 3) no CT examination, or 4) seizure cases. Three-dimensional images of the humerus reconstructed from CT images were reviewed using an image analysis software. The location and size of the reverse Hill-Sachs lesion were measured and described on a clock face on the humeral head. RESULTS: The reverse Hill-Sachs lesion was observed in 25 of 49 shoulders (51%). The reverse Hill-Sachs lesions were located between 1:37 and 2:48. The depth of the reverse Hill-Sachs lesion (mean ± SD) was 5.8 ± 2.2 mm. The extent of the reverse Hill-Sachs lesion was 35° ± 12°. The average orientation of the reverse Hill-Sachs lesion, represented by an angle measured from the 12 o'clock position, was 64° ± 12° and pointing towards 2:09 on a clock face. Length and width of reverse Hill-Sachs lesions were 9.7 ± 4.7 mm, 11.1 ± 3.6 mm, respectively. CONCLUSION: The reverse Hill-Sachs lesion was a semicircular compression fracture located on the anteromedial aspect of the humeral head. Compared with shoulders with anterior shoulder instability, the humeral defect was smaller and located more inferiorly in shoulders with posterior instability.

Arthroscopic superior capsule reconstruction augmentation using a semitendinosus autograft in massive reparable rotator cuff tears.

Background: Arthroscopic superior capsule reconstruction (SCR) augmentation is a viable treatment option for massive reparable cuff tears. This study aimed to retrospectively compare clinical and imaging outcomes of patients with reparable massive rotator cuff tears after arthroscopic rotator cuff repair (ARCR) with those after SCR augmentation using a semitendinosus autograft. Methods: We retrospectively compared 50 patients with massive reparable rotator cuff tears who underwent ARCR and SCR augmentation (n = 25 each). Patients were clinically followed up for at least 2 years, and the American Shoulder and Elbow index, other patient-reported outcomes, active range of motion, and radiography and magnetic resonance imaging findings were assessed. Results: At the final follow-up, both patient groups showed significant improvements in forward elevation in range of motion and visual analog scale scores. Improvements in the American Shoulder and Elbow scores in the SCR augmentation group were significantly superior to those in the ARCR group (48.3 and 28.9, P < .01). There was a significant difference in the retear rate between the SCR augmentation group and ARCR group (20% and 56%, respectively; P = .009). Conclusion: Our study demonstrated that patient-reported outcomes and retear rates in patients who underwent SCR augmentation with rotator cuff repair for massive rotator cuff tears significantly improved compared with those in patients who underwent ARCR without augmentation. Augmentation with semitendinosus autografting during rotator cuff repair represents a solution for patients with massive reparable rotator cuff tears.

Drug-dependent analgesic efficacy in interscalene block for postoperative pain after arthroscopic rotator cuff repair: a comparison between ropivacaine and levobupivacaine.

Background: Interscalene brachial plexus block (ISB) for arthroscopic rotator cuff repair (ARCR) provides high analgesic efficacy for postoperative pain. However, different drug efficacies remain unclear. This retrospective study compared the efficacy of ropivacaine and levobupivacaine in a single-dose ISB for pain control after ARCR. Methods: This study included 173 patients who underwent ARCR; they were divided into the ISBR group (n = 61) that received ISB with 20 mL 0.375% ropivacaine and 3.3 mg dexamethasone, and the ISBL group (n = 112) that received ISB with 20 mL 0.25% levobupivacaine and 3.3 mg dexamethasone. Visual analog scale (VAS) pain scores were evaluated at 1, 4, 8, 12, 24, and 48 hours, postoperatively. Rebound pain was defined as a difference of ≥ 5 points between the highest and lowest VAS pain scores. Results: The mean VAS pain scores at 1 hour were not significantly different between the groups. ISBL administration resulted in significantly lower VAS pain scores at 4, 8, 12, and 24 hours than ISBR administration. Rebound pain rates in the ISBR and ISBL groups were 41.0% and 17.9%, respectively. Rebound pain was more frequent in the ISBR than in the ISBL group. Conclusion: ISB with levobupivacaine and dexamethasone can provide more effective postoperative pain control after ARCR than ropivacaine and dexamethasone.

Japanese version of the Patient-rated elbow evaluation score correlates with physician-rated Japanese orthopaedic association-Japan elbow society elbow function score.

BACKGROUND: The association between Patient-Rated Elbow Evaluation: Japanese version (PREE-J) and Japanese Orthopaedic Association-Japan Elbow Society Elbow Function score (JOA-JES score) is unclear. This study evaluated the association between PREE-J and JOA-JES scores. METHODS: The patients with elbow disorders were divided into two groups: Group A (conservative treatment, n = 97) and Group B (surgical treatment, n = 156). The patients were also divided into four disease subgroups according to the JOA-JES classification (rheumatoid arthritis, trauma, sports, and epicondylitis groups), and the association between PREE-J and JOA-JES scores in each disease category was examined. In group B, associations between PREE-J and JOA-JES scores were examined pre-and postoperatively. RESULTS: In group A, there were significant associations between PREE-J and JOA-JES scores. In group B, a strong association between preoperative PREE-J and JOA-JES scores was observed in all disease categories. There was also a significant association between postoperative PREE-J and JOA-JES scores. Additionally, group B showed significant postoperative improvements in PREE-J and JOA-JES scores. CONCLUSIONS: The PREE-J score correlates well with the JOA-JES score and reflects treatment response before and after treatment.

Arthroscopic findings of the glenohumeral joint in symptomatic anterior instabilities: comparison between overhead throwing disorders and traumatic shoulder dislocation.

BACKGROUND: The term shoulder instability refers to a variety of mechanisms and clinical presentations. One of the common pathologies of throwing disorders is internal impingement with anterior instability. Most throwing athletes with symptomatic internal impingement with anterior instability exhibit positive apprehension and relocation test results, whereas those with recurrent anterior shoulder instability display positive apprehension test results. While the glenoid labrum-inferior glenohumeral ligament complex is a significant critical stabilizer for the prevention of anterior shoulder dislocation, the characteristics of the essential lesion in internal impingement with anterior instability have not been determined yet. This study aimed to compare the intra-articular lesion of athletes with internal impingement related to the overhead throwing motion in athletes with a traumatic shoulder dislocation. METHODS: Sixty-one athletes (all men; mean age, 25.2 ± 12.6 yr) who underwent an arthroscopic procedure were divided into 2 groups: 25 in the throwing group and 36 in the dislocation group. All shoulders had subtle glenohumeral instability defined by a positive anterior apprehension test and a relocation test. Those with voluntary and multidirectional instability and large glenoid bone loss (more than 25%) were excluded from the current study. All shoulders were evaluated for the following evidence: rotator cuff injury, superior labrum tear anterior and posterior lesions, labral pathologies including Bankart lesions, osteochondral lesions to the humeral head, biceps tendon fraying or rupture, and inferior glenohumeral ligament and middle glenohumeral ligament (MGHL) conditions. RESULTS: Arthroscopic findings of the throwing group showed more supraspinatus injuries (92% and 25%, P < .001), type II superior labrum tear anterior and posterior lesions (60% and 3%, P < .001), posterosuperior labral lesions (92% and 39%, P < .001), and hypoplastic MGHLs (56% and 6%, P < .001) and lesser Bankart lesions (8% and 92%, P < .05) than those of the dislocation group. CONCLUSIONS: These results indicate that the characteristic lesions of internal impingement with anterior instability in throwing athletes include partial thickness rotator cuff tears, superior labrum tear anterior and posterior lesions, posterosuperior labral tears, and hypoplastic MGHLs. As expected, the physiopathology of internal impingement with anterior instability in throwing athletes may be related to the dysfunction of the anterosuperior glenohumeral capsular ligament, including the MGHL, rather than the inferior glenohumeral ligament as in traumatic anterior shoulder dislocations. These findings would be useful for defining treatment strategies for internal impingement with anterior instability in overhead throwing athletes.

Evaluation of hypervascularity in synovitis of the shoulder using ultrasound: comparison of preoperative ultrasound findings and intraoperative arthroscopic findings.

Background: Synovitis of the shoulder causes pain; however, it is difficult to accurately determine the area and degree of synovitis from preoperative images. This study investigated the correlation between intraoperative arthroscopic findings and preoperative power Doppler ultrasonography (PDUS) findings for synovitis evaluation. Methods: Forty patients (mean age = 62.0 years; 24 men and 16 women) underwent arthroscopic surgery for partial rotator cuff tears. Three observation areas were evaluated: rotator interval (RI), subacromial bursa, and bicipital groove. The Doppler flow areas and PDUS grade were measured one day before surgery. Arthroscopic findings were visualized intraoperatively and classified into 3 groups: pale, pink, and red. The correlation between the arthroscopic classification and PDUS findings was analyzed. Results: The correlation between intraoperative arthroscopic classification and preoperative PDUS findings, Doppler flow area and PDUS grade, was high for the RI (r = 0.82, 0.70). There was no correlation for the subacromial bursa (r = 0.01, -0.02) and the bicipital groove (r = -0.03, 0.3). Conclusion: Hypervascularity findings in the PDUS were highly correlated with arthroscopic color classification in the RI. Therefore, visualization of hypervascularity in the RI area could be a reliable measure for the assessment of glenohumeral synovitis in patients with partial-thickness rotator cuff tear.

Anterior glenohumeral capsular ligament reconstruction with hamstring autograft for internal impingement with anterior instability of the shoulder in baseball players: preliminary surgical outcomes.

BACKGROUND: Shoulder pain and dysfunction are common in baseball players, and although "internal impingement" is recognized as one of the most common pathologies of shoulder dysfunction, the optimal surgical treatment for internal impingement with anterior instability of the shoulder remains controversial. This study evaluated baseball players' preliminary outcomes following anterior glenohumeral capsular ligament reconstruction for internal impingement with anterior instability of the shoulder. METHODS: Twelve baseball players (all male; mean age, 20.5 ± 2.2 years) with internal impingement and anterior instability managed via anterior glenohumeral capsular ligament reconstruction were examined. The mean follow-up period was 25.3 ± 4.6 months. Anterior glenohumeral capsular ligament reconstruction was performed with a knee hamstring autograft for balanced stability and laxity with two major targets: to prevent hyperangulation and translation in horizontal abduction and to mimic the individual arm cocking position at the final decision of tension. Preoperative and final follow-up evaluations were performed using Jobe's postoperative grading system; the Kerlan-Jobe Orthopaedic Clinic Overhead Athletes Shoulder and Elbow Score; Disabilities of the Arm, Shoulder and Hand sports module; plain radiographs; and magnetic resonance imaging. RESULTS: Jobe's postoperative grading system score, the Kerlan-Jobe Orthopaedic Clinic Overhead Athletes Shoulder and Elbow Score, and the Disabilities of the Arm, Shoulder and Hand sports module score improved significantly from 20.4 ± 12.2, 28.4 ± 8.3, and 80.2 ± 11.1 points preoperatively to 88.8 ± 13.6, 80.8 ± 7.7, and 22.4 ± 18.7 points postoperatively, respectively (P < .001, .0025, <0.001, respectively). Both clinical and imaging evaluations revealed improved internal impingement with anterior instability after anterior glenohumeral capsular ligament reconstruction. The mean external rotation at abduction significantly decreased from 113° preoperatively to 104° postoperatively. At follow-up, 10 of the 12 athletes (83.3%) returned to their prior competitive level. Plain radiographs and magnetic resonance imaging revealed no obvious loosening of the graft or screws. CONCLUSIONS: Anterior glenohumeral capsular ligament reconstruction resulted in preferable clinical outcomes for young baseball players who experienced pain during the throwing motion. Stabilization of the glenohumeral joint with autografting of the knee hamstring may thus represent a solution for internal impingement with anterior instability in overhead throwing athletes.

Dynamic Evaluation of Intraneural Microvascularity of the Ulnar Nerve Using Contrast-Enhanced Ultrasonography in Patients With Cubital Tunnel Syndrome.

PURPOSE: The purpose of this study was to compare the intraneural microvascular patterns of the ulnar nerve at 2 elbow flexion angles in asymptomatic volunteers and patients with cubital tunnel syndrome (CuTS) and to evaluate the effects of surgery on the microvascular pattern in patients with CuTS by using contrast-enhanced ultrasonography (CEUS). METHODS: This study included 10 elbows in 10 asymptomatic volunteers (control group) and 10 elbows in 10 patients with CuTS who underwent anterior subcutaneous transposition of the ulnar nerve (CuTS group). The CuTS group underwent clinical and electrophysiologic examinations and CEUS before surgery and at 1, 2, and 3 months after surgery. The intraneural enhancement pattern was calculated as an area under the curve (AUC) value in the entrapment site of the ulnar nerve within the cubital tunnel and in the area 1 cm proximal to the site (proximal site) at elbow flexion angles of 20° and 110°. RESULTS: Serial electrophysiologic examinations showed improvements at 1, 2, and 3 months after surgery compared with before surgery. In the control group, the AUC values of the central part of the cubital tunnel and proximal sites showed no substantial changes with the increase in elbow flexion. In the CuTS group, the AUC in the proximal site at 110° of elbow flexion was decreased compared with that at 20° of flexion before surgery. The AUC values for both the entrapment and proximal sites at 20° and 110° of elbow flexion were the most increased at 2 months after surgery compared with before surgery. CONCLUSIONS: Increased elbow flexion in patients with CuTS influences the intraneural blood flow of the ulnar nerve. Surgery for CuTS alters the intraneural blood flow. CLINICAL RELEVANCE: Quantitative evaluation of the intraneural blood flow of the ulnar nerve using CEUS may be a new supplementary diagnostic tool for CuTS and an indicator for the evaluation of postoperative recovery from nerve damage.

Acellular Cartilage Repair Technique Based on Ultrapurified Alginate Gel Implantation for Advanced Capitellar Osteochondritis Dissecans.

BACKGROUND: One of the most important limitations of osteochondral autograft transplant is the adverse effect on donor sites in the knee. Ultrapurified alginate (UPAL) gel is a novel biomaterial that enhances hyaline-like cartilage repair for articular defects. To avoid the need for knee cartilage autografting when treating osteochondritis dissecans (OCD) of the capitellum, we developed a surgical procedure involving a bone marrow stimulation technique (BMST) augmented by implantation of UPAL gel. HYPOTHESIS: BMST augmented by UPAL gel implantation improves the cartilage repair capacity and provides satisfactory clinical outcomes in OCD of the capitellum. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 5 athletes with advanced capitellar OCD in the dominant elbow underwent BMST augmented by implantation of UPAL gel. The osteochondral defects were filled with UPAL gel after BMST. At a mean follow-up of 97 weeks, all patients were evaluated clinically and radiographically. RESULTS: At final follow-up, all 5 patients had returned to competitive-level sports, and 4 patients were free from elbow pain. The mean Timmerman-Andrews score significantly improved from 100 to 194 points. Radiographically, all patients exhibited graft incorporation and a normal contour of the subchondral cortex. Magnetic resonance imaging showed that the preoperative heterogeneity of the lesion had disappeared, and the signal intensity had returned to normal. Arthroscopic examinations consistently exhibited improvement in the International Cartilage Regeneration and Joint Preservation Society (ICRS) grade of lesions from 3 or 4 to 1 or 2 in 4 patients at 85 weeks postoperatively. Histologic analysis of biopsy specimens revealed an average total ICRS Visual Assessment Scale II histologic score of 1060. CONCLUSION: The acellular cartilage repair technique using UPAL gel for advanced capitellar OCD provided satisfactory clinical and radiographic results. The present results suggest that this novel technique is a useful, minimally invasive approach for treating cartilaginous lesions in athletes.

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

Thoracic outlet syndrome (TOS) is a complex disorder with signs and symptoms resulting from compression of the brachial plexus and subclavian vessels. Although transaxillary first-rib resection is a well-established surgical treatment for patients with symptomatic TOS, this approach sometimes does not allow adequate exposure of the insertion point of the middle scalene muscle to the posterior part of the first rib and neurovascular bundle. The objective of this Technical Note is to describe an endoscopic-assisted transaxillary approach for first-rib resection and neurolysis. An endoscopic-assisted transaxillary approach for first-rib resection in TOS can provide excellent magnified visualization and safely allow sufficient decompression of the neurovascular bundle.

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.

Suprascapular nerve block versus interscalene block for analgesia after arthroscopic rotator cuff repair.

OBJECTIVE: To retrospectively compare the efficacy of suprascapular nerve block (SSNB) versus interscalene block (ISB) for analgesia after arthroscopic rotator cuff repair (ARCR). METHODS: Ninety-seven patients who underwent ARCR were retrospectively divided into three groups. Group S comprised 33 patients who received SSNB, group I comprised 52 patients who received ISB, and group C comprised 12 patients who received a glenohumeral injection as a control. SSNB and ISB were performed with 20 ml of 0.375% ropivacaine before surgery, while glenohumeral injection was performed after surgery. The Visual analog scale (VAS) pain scores were recorded at 1,3, and 6 h and 1, 3, and 6 days postoperatively. The total number of additional analgesic administrations was also counted for 6 days postoperatively. RESULTS: Compared with group C, the VAS pain score was significantly lower in group S at 1 h and 6 days postoperatively, and in group I at 1 and 3 h postoperatively. There were no significant differences between groups S and I in the VAS pain scores, or the administration of additional analgesia. There were no major complications associated with SSNB or ISB. CONCLUSION: There were no significant differences between SSNB and ISB in the duration of analgesia and the VAS pain scores after ARCR.

Trapeziectomy with Ligament Reconstruction and Interposition Arthroplasty Using the Palmaris Longus Tendon: An Average 5-Year Follow-up.

BACKGROUND: Trapeziectomy with ligament reconstruction and tendon interposition (LRTI) with the flexor carpi radialis (FCR) tendon is one of the most common procedures for the treatment of trapeziometacarpal osteoarthritis. We modified the LRTI, using the palmaris longus (PL) tendon instead of the FCR tendon. The aim of this retrospective study was to evaluate the clinical outcomes of trapeziectomy with our modified LRTI procedure at a mean follow-up of 5 years. METHODS: Fourteen thumbs in 13 patients (12 women) with a mean age of 64 years (range, 50 to 77 years) were available for assessment for a mean duration of 62 months (range, 41 to 97 months). The patients were evaluated subjectively and objectively. RESULTS: The modified LRTI procedure provided good pain relief, motion, strength, and stability without any severe complications related to the PL tendon harvesting. Radiography showed that compared to the preoperative status, the trapezial space decreased by about 40% at the final follow-up. CONCLUSIONS: The modified LRTI procedure provided significant subjective and objective improvements without severe complications particularly related to the harvesting of the PL tendon. This procedure is a valuable surgical option for trapeziometacarpal osteoarthritis and could be a useful salvage modality if the FCR tendon ruptures during the conventional LRTI procedure.

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.

Hill-Sachs Lesion Classification by the Glenoid Track Paradigm in Shoulder Instability: Poor Agreement Between 3-Dimensional Computed Tomographic and Arthroscopic Methods.

PURPOSE: The purpose of this study was to determine the amount of agreement between preoperative 3-dimensional computed tomographic (3D-CT) and intraoperative arthroscopic classification of Hill-Sachs lesions (HSLs) according to the glenoid track (GT) paradigm. METHODS: Records for patients treated surgically for anterior shoulder instability from a single surgeon's practice from August 2013 until March 2016 were retrospectively reviewed. Inclusion criteria were presence of an HSL, < 25% glenoid bone loss, bilateral 3D-CT, and arthroscopically recorded bone loss measurements. Records for patients with chronic dislocations or prior operations were excluded. Calculations by 3D-CT and arthroscopy were performed as follows: Hill-Sachs interval (HSI) was the distance from rotator cuff insertion to medial edge of the HSL; GT was 83% of the normal glenoid width minus any glenoid defect; on-track was HSI less than GT; off-track was HSI greater than GT. RESULTS: Sixteen shoulders with HSL status determined as on- or off-track demonstrated agreement between the 2 methods in 10 of 16 cases (63%, Cohen's κ = 0.16). All 6 cases with disagreement were calculated as on-track by 3D-CT and off-track by arthroscopic measurement. The GT was larger as determined by 3D-CT measurement (22 ± 1 mm [21-24]) compared with arthroscopy (18 ± 1 mm [17-20], P = .002). CONCLUSIONS: Preoperative 3D-CT showed slight agreement compared with intraoperative arthroscopic measurements in classifying HSL as on-track versus off-track in the GT paradigm; larger GT size by 3D-CT versus arthroscopy accounted for all discrepancies. Determination of off-track status based on preoperative 3D-CT versus determination with the arthroscopic method would result in fewer HSLs treated with remplissage if the GT treatment paradigm were followed. Surgeons using the GT paradigm to determine treatment of HSL by remplissage should recognize the potential for discordance between arthroscopic and radiographic measurements.

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.

Venipuncture Nerve Injuries in the Upper Extremity From More Than 1 Million Procedures.

OBJECTIVES: The purpose of this study was to investigate the nerve injury rate for 1 million venipunctures and the efficacy of attempts to avoid severe nerve injury. METHODS: We collected data for outpatients from whom a venipuncture blood sample was obtained in our hospital from 2005 to 2014. Every venipuncture procedure for outpatients was performed by a trained nurse or clinical technologist at the center for blood sampling in our hospital. In addition, a series of lectures by a specialist is held in our hospital at various times. All complaints related to venipuncture blood sampling were reported to our division of hospital safety management and were followed up using the guidelines for injuries related to the venipuncture. RESULTS: The number of venipuncture-related complications was 293 (0.027%, 1/3700) of 1,082,053 during the 10 years. A total of 40 of the 1,082,053 venipunctures were referred to the department of orthopedic surgery, and 16 (0.0015%, 1/67,000) were diagnosed with obvious nerve injuries. The average duration of the treatment was 46.4 days (range, 1-126 days); 69% of the patients recovered within 5 weeks, and all patients recovered within 18 weeks. CONCLUSIONS: Although it is impossible to completely prevent venipuncture-related complications, appropriate venipuncture skills and risk management decrease the incidence of chronic or permanent nerve injury risk after venipuncture.

Alteration in stress distribution patterns through the elbow joint in professional and college baseball pitchers: Using computed tomography osteoabsorptiometry.

BACKGROUND: Long-term pitching activities change the stress distribution across the elbow joint surface in living subjects, however the influence of the different strength of stress on the stress distribution patterns remain unclear. The aims of this study were to evaluate the distribution of subchondral bone density across the elbow joint in different levels of pitchers, and to reveal the influence of the strength of stress on the elbow joint surface under long-term loading conditions of baseball pitching. METHODS: The current analysis was performed using computed tomography (CT) image data obtained from the throwing side elbow of 12 nonthrowing athletes (controls), 15 college baseball pitchers (college group) and 13 professional baseball pitchers (professional group). The distribution patterns of subchondral bone density through the articular surface of the elbow joints were assessed using a CT osteoabsorptiometry method. The quantitative analysis was based on location and percentages of high-density area on the articular surface. RESULTS: High-density area in the college and professional groups were found in the anterior part of the captellum, posterior part of the trochlea and radial head. In the professional group, the percentages of high-density area in the anterior part of the capitellum, posterior part of the trochlea, radial head and olecranon were significantly greater than in the college group. CONCLUSIONS: Stress distribution on the articular surface of the elbow joint was affected by pitching abilities or competitive levels. Our analysis indicates that high strength of stress in professional baseball players produce potential risk of elbow injuries.