The effect of continuous interscalene brachial plexus block for arthroscopic rotator cuff repair.

Background: Arthroscopic rotator cuff repair (ARCR) is a minimally invasive surgical technique. However, it is challenging to control postoperative pain. This study aimed to investigate the difference between a single-shot interscalene block and a combined continuous block for ARCR. Methods: Ninety-four patients who underwent ARCR were included in this study. In the preceding period, 43 patients received a single-shot interscalene block and continuous postoperative intravenous opioid infusion (Single group). In the posterior period, 51 patients received a single-shot interscalene block preoperatively and a continuous block postoperatively (Continuous group). Their mean age at surgery was 64.9 years (range, 43-83 years). The mean follow-up period was 25.4 months (range, 24-54 months). The numerical rating scale (NRS) of pain was evaluated immediately after the surgery, at rest, and at night for 1-4 days after the surgery. One day postoperatively, the amount of food taken was assessed from 0 % (no food intake) to 100 % (all food taken). The University of California at Los Angeles (UCLA) shoulder score, range of motion (ROM), and isometric shoulder strength were evaluated. Results: NRS at rest in the Continuous group on the day of surgery was 3.7 ± 2.5. This was significantly lower than in the Single group (5.2 ± 1.8) (P = 0.002). NRS at rest in the Continuous group on the second day after surgery was 3.0 ± 2.1, significantly lower than in the Single group (3.9 ± 1.8) (P = 0.04). The amount of food taken in the morning in the Continuous group was 61 % ± 37 %, which was significantly greater than in the Single group (35 % ± 41 %) (P = 0.004). The ROM of extension at 6 months postoperatively in the Continuous group was 47 ± 7°, which was significantly greater than in the Single group (43 ± 6°) (P = 0.02). The postoperative strength of the external rotator at 6 months in the Continuous group was 95 ± 33 N, significantly greater than in the Single group (78 ± 28 N) (P = 0.01). There was no significant difference in UCLA score at any time. Conclusion: The continuous interscalene block with ultrasound guidance in ARCR effectively relieved pain. The recovery of ROM for extension and the strength of the external rotator was better in the Continuous group.

Effectiveness of Bone Marrow-Derived Platelet-Rich Fibrin on Rotator Cuff Healing in a Rabbit Degenerative Model.

BACKGROUND: Platelet-rich fibrin (PRF) is a second-generation platelet concentrate. Although peripheral blood-derived PRF (P-PRF) is commonly applied in biological augmentation, there is no report about the therapeutic effect of bone marrow-derived PRF (BM-PRF) for degenerative rotator cuff tears (RCTs). PURPOSE/HYPOTHESIS: To examine the effects of platelet-rich plasma (PRP), P-PRF, and BM-PRF during rotator cuff repair (RCR) in degenerative RCTs in rabbits. We hypothesized that BM-PRF would accelerate the bone-tendon healing after RCR. STUDY DESIGN: Controlled laboratory study. METHODS: Degenerative RCT models were created 2 weeks before beginning the study, and 68 juvenile rabbits were divided into 4 groups: the control, PRP, P-PRF, and BM-PRF groups. RCR without augmentation was done in the control group. PRP was prepared by centrifuging peripheral blood twice using a plastic tube. P-PRF and BM-PRF were prepared by centrifuging peripheral blood and bone marrow, respectively, using a glass tube. Rabbits from PRP, P-PRF, and BM-PRF groups were administered the augmentation in a similar fashion for RCR, between the rotator cuff and the footprint of the humerus. At 4, 8, and 12 weeks, rabbits were euthanized and histologically assessed using hematoxylin and eosin staining, Alcian blue staining, and immunohistochemical staining for type I and III collagen. The sections were also evaluated with immunofluorescence staining of vascular endothelial growth factor (VEGF) at 4 weeks. RESULTS: The continuity was significantly better in the BM-PRF group at 4 weeks (P < .05). Immunofluorescence staining demonstrated that VEGF-positive stained cells were significantly greater in the BM-PRF group than in the control group (P < .01). The modified tendon maturing score was significantly greater in the BM-PRF group than in the control and PRP groups at 12 weeks (P < .05). There was no significant difference in the modified tendon maturing score of the P-PRF group compared with the control group. CONCLUSION: The rabbit model of degenerative RCTs demonstrated that RCR combined with BM-PRF enhanced tendon-bone continuity and increased the VEGF-positive cells at 4 weeks and obtained preferable tendon-bone maturation at 12 weeks. CLINICAL RELEVANCE: RCR augmented with BM-PRF has the potential to improve clinical outcomes for RCTs.

Factors correlated with the optimal tension for arthroscopic rotator cuff repair using Grasper Tensioning Attachment.

BACKGROUND: Little is known about the optimal tension in arthroscopic rotator cuff repair (ARCR). This study aimed to identify preoperative, intraoperative, and postoperative factors that correlate with the tension in ARCR and to determine the optimal intraoperative tension using Grasper Tensioning Attachment, a tension meter attached to the common arthroscopic surgical grasper. METHODS: This study included 63 patients with a mean age at surgery of 65.3 years (range, 45-83 years) who underwent ARCR. The mean follow-up period was 24.1 months (range, 24-28 months). We investigated the patients' demographic data, Japanese Orthopaedic Association score, DeOrio and Cofield classification, and Goutallier stage of the supraspinatus and infraspinatus muscles. We also evaluated cuff integrity based on the Sugaya classification via magnetic resonance imaging. The free edge of the torn retracted tendon was grasped, and the passive tension to the footprint was then measured with Grasper Tensioning Attachment with the arm at the side. The anteroposterior (AP) and mediolateral (ML) diameters were also measured. RESULTS: The preoperative Goutallier stage of the supraspinatus muscle was stage 0 in 7 cases, stage 1 in 34, stage 2 in 20, and stage 3 in 2. The mean intraoperative rotator repair tension was 10.0 ± 2.5 N (range, 7.5-17 N). The mean AP diameter of the rotator cuff tear was 22 ± 10 mm (range, 8-50 mm), and the mean ML diameter was 24 ± 10 mm (range, 10-50 mm). Age, DeOrio and Cofield classification, Goutallier stage, AP diameter, and ML diameter correlated with rotator repair tension. The rotator repair tension in Sugaya classification type III or IV cases (n = 12, 11.4 ± 2.4 N) was significantly larger than that in type I or II cases (n = 51, 9.7 ± 2.4 N; P = .03). Tension ≥ 10 N as a cutoff value from receiver operating characteristic curve analysis was a risk factor for poor cuff integrity (95% confidence interval, 0.53-0.88). CONCLUSIONS: Rotator repair tension ≥ 10 N was a risk factor for poor cuff integrity. Thus, care should be taken when performing intraoperative procedures and administering postoperative regimens.

Influence of fat infiltration, tear size, and post-operative tendon integrity on muscle contractility of repaired supraspinatus muscle.

BACKGROUND: The purpose of this study was to evaluate the effect of fat infiltration, tear size, and post-operative tendon integrity, on post-operative contractility. METHODS: Thirty-five patients who underwent rotator cuff repair were included. The fat infiltration, tear size, and post-operative tendon integrity were evaluated by Goutallier stage, Cofield classification, and Sugaya classification, respectively. The muscle elasticity at rest and at contraction was assessed by real-time tissue elastography pre- and one-year post-operatively. We defined the difference in elasticity between at rest and at contraction as the activity value which reflects muscle contractility. RESULTS: The activity value in patients with Sugaya Type I tended to increase regardless of Cofield classification, whereas those with Sugaya Type III and IV tended to decrease. While the activity value in the patients classified as stage 1 and Type I tended to increase, patients classified as stage 2 showed decreased or constant in contractility even in those subjects classified as Type I. Stepwise multiple regression analysis showed both pre- (p = 0.004, r = -0.47) and post-operative activity values (p = 0.022, r = -0.39) to be significantly correlated only with the Goutallier stage. CONCLUSION: Multiple regression analysis indicated only the Goutallier stage was a significant independent factor for contractility of the supraspinatus muscle. Supraspinatus muscle contractility in patients classified as Types III and IV based on the Sugaya classification tended to decrease post-operatively, while patients whose contractility increased post-operatively were characterized by having a Type I tendon integrity.

Risk factors related to complications of the fingers and hand after arthroscopic rotator cuff repair - carpal tunnel syndrome, flexor tenosynovitis, and complex regional pain syndrome.

HYPOTHESIS/BACKGROUND: Complications involving the fingers and hand after arthroscopic rotator cuff repair (ARCR) include complex regional pain syndrome, carpal tunnel syndrome (CTS), and flexor tenosynovitis (TS). The aims of this study were to diagnose the complications after ARCR and investigate the risk factors that could predispose individuals to these finger and hand complications. METHODS: Fifty patients (50 shoulders) who underwent ARCR participated in this study. The patients' ages ranged from 36 to 84 years (mean, 63 years). Before ARCR, we determined the disease history of the fingers and hand (CTS or TS) and subjectively assessed their symptoms using a questionnaire that included a scale ranging from 1 (no symptoms or no disability) to 5 (the worst symptoms or severest disability). ARCR was performed in all patients using suture anchors. The mean observation period after surgery was 15.5 months (range, 12-48 months). We diagnosed complications involving the fingers and hand after ARCR and investigated the preoperative, intraoperative, and postoperative risk factors that could predispose patients to these complications using univariable and multivariable analyses. RESULTS: After ARCR, 20 patients (20 hands) (40%) had complications of the fingers and hand. Among them, the diagnosis was CTS in 2 hands, TS in 15 hands, and both CTS and TS in 3 hands. None of the hands exhibited complex regional pain syndrome. These complications occurred at an average of 1.8 months (range, 0.1-4 months) after ARCR. In the 47 patients who did not have symptoms just before the operation, both univariable and multivariable analyses between the complication group (n = 17) and the no-complications group (n = 30) showed a significant difference in the presence of a past history of CTS or TS (complication frequency: past history: 88%, no past history: 25%) (P < .05) and the preoperative subjective assessment for edema of the fingers and hand (complication frequency: edema ≥ 2 points: 89%, edema < 2 points: 24%) (P < .05). There were no relationships between the other candidate intraoperative and postoperative factors and complications. CONCLUSION: In all 20 hands with complications of the fingers and hand after ARCR, the diagnosis was CTS or TS. Complications of the fingers and hand after ARCR easily occurred in patients with a past history of CTS or TS and in patients with edema as per a subjective assessment. We speculate that the ARCR triggered the occurrence of CTS and TS postoperatively in patients who had subclinical CTS or TS before surgery.

Elastographic Region of Interest Determination for Muscle with Fat Infiltration.

PURPOSE: Ultrasound elastography has been used to evaluate the skeletal muscle stiffness as a biomarker for sarcopenia assessment. However, there is no consensus with respect to the size and location of the region of interest in assessing such fat infiltrated muscle. The objective of this study was to determine which cross-sectional area should be measured in torn disuse muscle with fat infiltration to accurately measure muscle activity using real-time tissue elastography (RTE). METHODS: Twenty-seven patients, whose rotator cuff muscle with torn tendon was successfully repaired, were followed by programmed rehabilitation. RTE measurements of the supraspinatus muscle were obtained during muscle contraction before and one-year after surgery so that the activity value was defined as the difference between elastography measurements at rest and elastography measurements during contraction. Given that the patients with successfully repaired and completed rehabilitation showed an increased activity value, the sensitivity for three regions of interest; posterior portion of the anterior-middle subregion (AM-p), anterior region (AR), and whole cross-sectional area of the supraspinatus (whole) were compared with the number of patients showing an increase in activity values as sensitivity analysis. RESULTS: The sensitivity showing an increase in activity values was 74.1% for the AM-p area, 70.4% for the AR area, and 81.5% for the whole area. Intraclass correlation coefficient1,3 was 0.87-0.97 for the AM-p area, 0.88-0.98 for the AR area and 0.92-0.99 for the whole area. CONCLUSION: The whole cross-sectional area is suitable to measure muscle activity in muscle with fat infiltration. The results in this study will provide some beneficial information when ultrasound elastography is used for the assessment of sarcopenia muscle with fat infiltration.

Differences in subtrochanteric and diaphyseal atypical femoral fractures in a super-aging prefectural area: YamaCAFe Study.

INTRODUCTION: Atypical femoral fractures (AFFs) have been correlated with long-term use of bisphosphonates (BPs), glucocorticoids (GCs), and femoral geometry. We investigated the incidence and characteristics of subtrochanteric (ST) and diaphyseal (DP) AFFs in all institutes in a super-aging prefectural area. MATERIALS AND METHODS: We performed a blinded analysis of radiographic data in 87 patients with 98 AFFs in all institutes in Yamagata prefectural area from 2009 to 2014. Among the 98 AFFs, 57 AFFs comprising 11 ST fractures in 9 patients and 46 DP fractures in 41 patients with adequate medical records and X-rays were surveyed for time to bone healing and geometry. RESULTS: Of the 87 patients, 67 received BPs/denosumab (77%) and 10 received GCs (11%). Surgery was performed in 94 AFFs. Among 4 AFFs with conservative therapy, 3 required additional surgery. In univariate regression analyses for ST group versus DP group, male-to-female ratio was 2/7 versus 1/40, mean age at fracture was 58.2 (37-75) versus 78 (60-89) years, rheumatic diseases affected 55.5% (5/9) versus 4.9% (2/41), femoral lateral bowing angle was 1.7 (0-6) versus 11.8 (0.8-24)°, GC usage was 67% (6/9) versus 4.9% (2/41), and bone healing time was 12.1 (6-20) versus 8.1 (3-38) months (p < 0.05). In multivariate analyses, higher male-to-female ratio, younger age, greater proportion affected by rheumatic diseases, and higher GC usage remained significant (p < 0.05). CONCLUSIONS: The incidence of AFFs in our prefectural area was 1.43 cases/100,000 persons/year. This study suggests that the onset of ST AFFs have greater correlation with the worse bone quality, vice versa, the onset of DP AFFs correlated with the bone geometry. The developmental mechanisms of AFFs may differ significantly between ST and DP fractures.

A Systolic Blood Pressure of 100 mm Hg Is Optimal for Optimal Visualization in Arthroscopic Rotator Cuff Repair in the Beach-Chair Position.

PURPOSE: To investigate the relationship between visualization and blood pressure during arthroscopic rotator cuff repair (ARCR) in the beach-chair position and to clarify the optimal blood pressure to maintain good visualization during surgery. METHODS: One senior surgeon evaluated intraoperative visualization at the start of arthroscopy, at acromioplasty, at the refresh of the footprint on the greater tuberosity, at marrow vent creation in the footprint on the greater tuberosity, and at rotator cuff fixation. The evaluation grades were: 5, clear; 4, mild bleeding; 3, bleeding but operable; 2, poor visualization due to bleeding; and 1, inability to continue surgery due to massive bleeding. During ARCR, an arterial line was inserted, and blood pressure was measured continuously. The relationship between visualization and blood pressure was analyzed. Receiver operating characteristic analysis was performed with evaluation grades 5 and 4 as the good visualization group and the other evaluation grades as the poor visualization group. RESULTS: Visualization assessment and systolic/diastolic blood pressure were associated at the start of arthroscopy (P = .0257/.0057), at acromioplasty (P = .0023/.0399), and at the refresh of the footprint (P = .0201/.0272). The average blood pressure of evaluation grade 5 cases was 91/50 mm Hg. The cut-off values, based on the area under the curve on receiver operating characteristic analysis, were as follows: 104/60 mm Hg (0.91-0.95) at acromioplasty; 116/70 (0.94-0.96) at the refresh of the footprint; 116/70 mm Hg (0.94-0.96) at the refresh of the footprint; and 106/58 mm Hg (0.73-0.70) at marrow vent creation. CONCLUSIONS: Good visualization during ARCR in the beach-chair position was significantly associated with blood pressure. An optimal blood pressure resulting in good visualization that would not cause excessive hypotension during ARCR surgery in the beach-chair position might be a systolic blood pressure of 100 mm Hg. LEVEL OF EVIDENCE: III, prospective, nonrandomized, observational study.

Contractile property measurement of the torn supraspinatus muscle using real-time tissue elastography.

HYPOTHESIS: In the restoration of shoulder abduction, decreased contractility of the torn rotator cuff muscle may be a cause of a poor result. The aim of this study was to investigate the relationship between the contractile property of the torn supraspinatus muscle measured by real-time tissue elastography and the Goutallier stage as modified by Fuchs et al. METHODS: The muscular hardness of the torn supraspinatus muscle was measured in 32 patients at rest and during isometric contraction with the shoulder abducted to 60° in the scapular plane. The muscular hardness was calculated as the strain ratio. Fatty degeneration was assessed according to the modified Goutallier stage. Because the activity value (defined as the difference between the strain ratio at rest and the strain ratio during isometric contraction) estimated the contractile property of the muscle, stepwise multiple regression analysis was used to compare the activity value with age, sex, side, time from injury onset to obtaining the measurements, and modified Goutallier stage. RESULTS: The mean activity value was 0.26 ± 0.16. Fatty degeneration of the supraspinatus muscle was grade 0 in 5 patients, grade 1 in 16, grade 2 in 10, and grade 3 in 1. The activity value was significantly correlated only with the modified Goutallier stage (r = -0.78, P < .001). CONCLUSION: The contractile property of the supraspinatus muscles decreased with an increase in the modified Goutallier stage. Real-time tissue elastography can measure the contractile property of the muscles before surgery and thus may be a predictor for the resulting restoration of lost muscle function.

Complications of the Fingers and Hand After Arthroscopic Rotator Cuff Repair.

BACKGROUND: Complications of the fingers and hand that occur after Arthroscopic Rotator Cuff Repair (ARCR) have not been examined in detail. OBJECTIVE: The aim of our study was to evaluate the diagnosis and treatment of complications of the fingers and hand that occur after ARCR and to examine treatment outcomes. METHODS: The case records of 40 patients (41 shoulders) who underwent ARCR using suture anchors were retrospectively reviewed to investigate complications of the fingers and hand after ARCR. RESULTS: Twelve patients (29%) experienced numbness, pain, edema, and movement limitations of the fingers and hand. These symptoms occurred on average 1.1 months (range, 0.1-2.5 months) after ARCR. The diagnoses were cubital tunnel syndrome in 2 hands, carpal tunnel syndrome in 3 hands, and flexor tenosynovitis (TS) in 10 hands. None of the 10 hands with TS exhibited triggering of the fingers. The mean interval between treatment initiation and symptom resolution was 2.2 months for the 5 hands treated by corticosteroid injection or surgery and 5.9 months for the 7 hands treated by alternating warm and cold baths alone. None of the hands exhibited Complex Regional Pain Syndrome (CRPS). CONCLUSION: Complications of the fingers and hand after ARCR were observed in 29%. TS was the most frequent complication. When symptoms in the fingers and hand occur after ARCR, rather than immediately suspecting CRPS, TS should be primarily suspected, including when TS symptoms such as triggering are not present, and these patients should be treated proactively using corticosteroid injections or surgery.

Outcome of conservative treatment for Little League shoulder in young baseball players: factors related to incomplete return to baseball and recurrence of pain.

BACKGROUND: The purpose of this study was to investigate the factors associated with poor results and pain recurrence in young baseball players with Little League shoulder (LLS). METHODS: Eighty-seven young baseball players with LLS (mean age, 12.1 years) underwent conservative treatment. Of the players, 68 (78%) underwent conservative treatment involving the prohibition of throwing for an average of 1.2 months whereas the remaining 19 (22%) continued throwing with limitations. We analyzed the factors associated with poor results at 2 months and pain recurrence. RESULTS: At 2 months, 18% of participants reported the presence of pain, and the results regarding the return to baseball were as follows: complete return in 43%, incomplete return in 33%, and no return in 24%. A total of 83 subjects (95%) had completely returned at an average of 2.8 months. Pain recurrence was present in 20 subjects (25%) at an average of 6.2 months. Statistical analysis showed that the following factors were significantly associated with poor results at 2 months: longer period from initial presentation to throwing prohibition and worse shoulder flexibility (P = .04 and P = .01, respectively). It also revealed that the following factors were significantly associated with pain recurrence: higher frequency of pain at 2 months and longer duration until complete return (P = .0003 and P = .04, respectively). CONCLUSIONS: It is important for subjects with LLS to be prohibited from throwing immediately after initial presentation. Good shoulder flexibility was associated with a return to baseball without pain. A complete return in subjects who had pain at 2 months was significantly delayed, and these subjects exhibited more rapidly recurring pain after their return.

Treatment for Ulnar Neuritis Around the Elbow in Adolescent Baseball Players: Factors Associated With Poor Outcome.

BACKGROUND: Ulnar neuritis around the elbow is one of the injuries seen in throwing athletes. Outcomes of nonsurgical treatment and factors associated with failure outcomes have not been reported. PURPOSE: To investigate the outcomes of treatments for ulnar neuritis in adolescent baseball players. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We assessed 40 male baseball players with a mean age of 15.0 years (range, 13-17 years) who presented with ulnar neuritis. There were 19 pitchers and 21 fielders whose throwing side was affected. All patients had elbow pain, and 13 patients had hand numbness on the ulnar side. The mean Kerlan-Jobe Orthopaedic Clinic (KJOC) overhead athlete shoulder and elbow score was 52.5 at the first follow-up visit (n = 36 patients). Thirteen patients were identified with ulnar nerve subluxation, and 23 patients had concomitant elbow ulnar collateral ligament (UCL) injury. All patients underwent nonsurgical treatment, which included rehabilitation exercises and prohibition of throwing. If the nonsurgical treatment failed, we recommended surgical treatment. We investigated the outcomes of the nonsurgical and surgical treatments. Return to sports was evaluated, combined with factors associated with return to sports in nonsurgical treatment by univariate and multivariate statistical analysis. RESULTS: The mean follow-up period was 23.6 months (range, 6-39 months). After nonsurgical treatment, 24 patients (60%) returned to the previous competition level after a mean of 2.4 months. Two patients returned to a recreational level. One patient gave up playing baseball at 2 months. The remaining 13 patients underwent surgery and returned to sports after a mean of 2.0 months postoperatively, and 12 had no limitation of sports activities. Multivariate logistical regression analysis demonstrated that hand numbness, ulnar nerve subluxation, and UCL injury were associated with failure of nonsurgical treatment ( P < .05). In addition, KJOC score of <45 at the first follow-up tended to be associated with poor outcomes of nonsurgical treatment ( P = .06). CONCLUSION: Hand numbness on the ulnar side, ulnar nerve subluxation, and UCL injury are strong predictors of poor outcomes after nonsurgical treatment for ulnar neuritis, and surgery provides excellent results.

Risk factors for elbow injuries among young baseball players.

HYPOTHESIS: There are some risk factors that could predispose a young baseball player to elbow injuries. MATERIALS AND METHODS: Study participants were 294 baseball players aged 9 to 12 years old. A questionnaire, physical examination, and ultrasound imaging to investigate elbow injuries were performed. Data for the groups with and without elbow injuries were analyzed statistically using multivariate logistic regression models. RESULTS: Ultrasound imaging showed that 60 participants had elbow injuries, including medial epicondylar fragmentation in 58 and osteochondritis dissecans of the capitellum in 2. The odds ratio (95% confidence interval) of the risk factors that statistical analysis showed were significant were age older than 11 years, 2.82 (1.30-6.10); height exceeding 150 cm, 2.02 (1.07-3.82); pitching, 4.50 (2.42-8.37); daily training, 1.96 (1.02-3.79); range of motion (ROM) of external rotation of the shoulder below 130 degrees , 1.98 (1.01-3.87); muscle strength (MS) of external rotation of the shoulder exceeding 80 N, 4.11 (1.47-11.55); and MS of internal rotation of the shoulder exceeding 100 N, 2.04 (1.08-3.90). DISCUSSION: Risk factors for elbow injuries are age, height, pitcher, days of training, grip strength, range of motion of external rotation of the shoulder, and muscle strength of the shoulder. CONCLUSION: As new information, our results suggest that decrease of ROM of external rotation of the shoulder and increase of MS of external and internal rotation of the shoulder predispose elbow injuries.

Classification, treatment, and outcome of osteochondritis dissecans of the humeral capitellum. Surgical technique.

BACKGROUND: Indications for the treatment of osteochondritis dissecans of the humeral capitellum have remained unclear. The aims of this study were to analyze the outcomes and to determine the most useful classification for the choice of treatment. METHODS: The cases of 106 patients with osteochondritis dissecans of the capitellum were studied retrospectively. At the time of the initial presentation, the mean age of the patients was 15.3 years. The capitellar growth plate was open in eighteen patients and closed in eighty-eight. Thirty-six patients were treated nonoperatively. Fifty-five patients underwent fragment removal alone, twelve underwent fragment fixation with a bone graft, and three underwent reconstruction of the articular surface with use of osteochondral plug grafts from the lateral femoral condyle. The mean follow-up period was 7.2 years. The outcomes in terms of pain in the elbow, return to sports, and radiographic findings were analyzed and compared. RESULTS: An osteochondritis dissecans lesion with an open capitellar physis and a good range of elbow motion resulted in a good outcome. Continued elbow stress resulted in the worst outcome in terms of pain and radiographic findings. In patients with a closed capitellar physis, surgery provided significantly better results than elbow rest (p < 0.01). Fragment fixation or reconstruction provided significantly better results than fragment removal alone (p < 0.05). The results of removal alone were dependent on the size of the defect in the capitellum. The outcome in terms of pain was closely associated with sports activity and radiographic findings. CONCLUSIONS: We believe that osteochondritis dissecans of the capitellum can be classified as stable or unstable. Stable lesions that healed completely with elbow rest had all of the following findings at the time of the initial presentation: an open capitellar growth plate, localized flattening or radiolucency of the subchondral bone, and good elbow motion. Unstable lesions, for which surgery provided significantly better results, had one of the following findings: a capitellum with a closed growth plate, fragmentation, or restriction of elbow motion of >or=20 degrees . For large unstable lesions, fragment fixation or reconstruction of the articular surface leads to better results than simple excision.

Classification, treatment, and outcome of osteochondritis dissecans of the humeral capitellum.

BACKGROUND: Indications for the treatment of osteochondritis dissecans of the humeral capitellum have remained unclear. The aims of this study were to analyze the outcomes and to determine the most useful classification for the choice of treatment. METHODS: The cases of 106 patients with osteochondritis dissecans of the capitellum were studied retrospectively. At the time of the initial presentation, the mean age of the patients was 15.3 years. The capitellar growth plate was open in eighteen patients and closed in eighty-eight. Thirty-six patients were treated nonoperatively. Fifty-five patients underwent fragment removal alone, twelve underwent fragment fixation with a bone graft, and three underwent reconstruction of the articular surface with use of osteochondral plug grafts from the lateral femoral condyle. The mean follow-up period was 7.2 years. The outcomes in terms of pain in the elbow, return to sports, and radiographic findings were analyzed and compared. RESULTS: An osteochondritis dissecans lesion with an open capitellar physis and a good range of elbow motion resulted in a good outcome. Continued elbow stress resulted in the worst outcome in terms of pain and radiographic findings. In patients with a closed capitellar physis, surgery provided significantly better results than elbow rest (p < 0.01). Fragment fixation or reconstruction provided significantly better results than fragment removal alone (p < 0.05). The results of removal alone were dependent on the size of the defect in the capitellum. The outcome in terms of pain was closely associated with sports activity and radiographic findings. CONCLUSIONS: We believe that osteochondritis dissecans of the capitellum can be classified as stable or unstable. Stable lesions that healed completely with elbow rest had all of the following findings at the time of the initial presentation: an open capitellar growth plate, localized flattening or radiolucency of the subchondral bone, and good elbow motion. Unstable lesions, for which surgery provided significantly better results, had one of the following findings: a capitellum with a closed growth plate, fragmentation, or restriction of elbow motion of > or =20 degrees . For large unstable lesions, fragment fixation or reconstruction of the articular surface leads to better results than simple excision. LEVEL OF EVIDENCE: Prognostic Level II.

Using sonography for the early detection of elbow injuries among young baseball players.

OBJECTIVE: The aim of this study was to determine the usefulness of sonography for detecting elbow injuries among young baseball players. SUBJECTS AND METHODS: One hundred fifty-three volunteers ranging in age from 9 to 12 years and belonging to youth baseball teams participated. Sonography of the elbow was performed in the field when baseball exercises were being conducted. We analyzed the relationship between elbow pain and sonographic abnormalities and the relationship between pitchers and sonographic abnormalities. RESULTS: Sonography showed that 33 subjects had medial epicondylar fragmentation and two had early-stage osteochondritis dissecans of the capitellum. In 25 subjects who agreed to further examination and treatment, radiography confirmed the sonographic findings. All of the 23 subjects with medial epicondylar fragmentation, who stopped throwing, obtained union of the bone and returned to baseball. The two subjects with osteochondritis dissecans of the capitellum underwent surgery before the osteochondral fragment became loosened. Sonographic abnormalities correlated with episodes of elbow pain. Pitchers statistically significantly had sonographic abnormalities. CONCLUSION: Sonography in the field can provide an opportunity to detect and treat elbow injuries before they become more advanced.

The short-term reliability of grip strength measurement and the effects of posture and grip span.

PURPOSE: Because of the difficulty in verifying the reliability and validity of grip strength there is still no consensus regarding its measurement, particularly short-term reliability. The present study was conducted to investigate the short-term reliability of grip strength measurement and the effects of posture and grip span. METHODS: One hundred healthy subjects (50 men, 50 women; mean age, 38.2 y; range, 22-58 y) were evaluated. Grip strength was measured twice as a single set by using a dynamometer and the mean value for each hand was recorded. First 3 sets of measurements were performed using 2 different approaches: (1) continuous measurement without rest and (2) interval measurement with a 1-minute rest after each set. Next 1 set of measurements was performed with 3 types of grip span: standard grip span (which was measured as one half the distance between the index finger tip and the metacarpophalangeal joint flexion crease at the base of the thumb), +10% of the standard grip span, and -10% of the standard grip span. Finally 1 set of measurements was performed in 3 postures: standing, sitting, and supine. RESULTS: During continuous measurement the grip strength decreased gradually as the number of sets increased. During interval measurement, however, there was no change among sets for both genders and each hand. On the basis of this result subsequent studies were performed using interval measurement. There was no significant difference in maximum grip strength between the standard and +10% of standard grip span measurements; however, the -10% of standard model gave the minimum grip strength in both genders. With regard to posture the minimum grip strength in both genders was obtained when the subject was supine, with no difference between standing and sitting. CONCLUSIONS: Our study showed that interval measurement with a 1-minute rest after each set yielded a constant value; therefore, we advocate this approach for rapid evaluation of grip strength under different conditions. In addition the influence of grip span and posture should be considered to maximize data accuracy.

The effect of infraspinatus disruption on glenohumeral torque and superior migration of the humeral head: a biomechanical study.

Rotator cuff ruptures that extend into the infraspinatus tendon may cause dysfunction and superior migration of the humerus. The purpose of this study was to determine whether a threshold size of infraspinatus defect exists beyond which abduction torque generation decreases and superior migration of the humeral head increases. Glenohumeral abduction torque and superior humeral head translations were measured in hanging arms in neutral rotation in cadaver shoulders (n = 10). Loads were applied to the rotator cuff tendons and the middle deltoid. After sequential detachment of the infraspinatus, abduction torque progressively decreased. At three-fifths detachment, abduction torque was significantly lower than after supraspinatus release alone (52% vs 61%, P <.05). Superior translation after complete supraspinatus and infraspinatus detachment increased significantly (P <.05), but no intermediate threshold was detected. Therefore, the entire infraspinatus contributes to abduction torque generation and stabilizes the humeral head against superior subluxation. Even with a tear extending into the superior infraspinatus, the infraspinatus contributes abduction force generation across the glenohumeral joint.