Performance and Return to Play After Surgery for Thoracic Outlet Syndrome in Professional Baseball Players: A Matched Cohort Analysis.

BACKGROUND: Thoracic outlet syndrome (TOS) remains a rare diagnosis but is being recognized as a cause of upper extremity dysfunction in professional baseball players. PURPOSE/HYPOTHESIS: The purpose was to determine performance and return-to-play (RTP) outcomes in professional baseball players after surgical treatment of TOS. The hypothesis was that there would be a high RTP rate in professional baseball players after TOS surgery with no statistical differences in performance between pitchers who had TOS surgery and matched controls. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All professional baseball players who underwent surgical treatment of TOS between 2010 and 2017 were identified using the Major League Baseball Health and Injury Tracking System database. Demographic and performance data (before and after surgery) for each player were recorded. Performance variables were then compared between players who underwent TOS surgery and matched controls. The matching criteria were no history of previous surgeries on affected arm, age at time of surgery, throwing side, level of play (Major or Minor League Baseball), and years of experience playing professional baseball. RESULTS: Overall, 52 players underwent surgery for TOS, of whom 46 (88%) were pitchers. The type of TOS was neurogenic in 69% and venous in 29%. One player had arterial TOS. After TOS surgery, 79% of players returned to play at the same or higher level (RTSP) by 9.5 months and played ≥3 years after surgery. No differences were found in RTSP rate based on the type of TOS. No statistical difference was found in RTP rates between major and minor league players. Pitchers had a 76% RTSP, which was similar to the natural attrition for control pitchers (P = .874). After TOS surgery, pitchers saw a decline in several performance metrics, but these declines were not different from those of control pitchers, indicating that the decline in performance after TOS surgery was no faster than is seen in healthy professional pitchers as they age. CONCLUSION: The rate of RTSP after surgery for TOS in professional baseball players was 79%. There was no difference in RTP based on the type of TOS. Pitchers who underwent surgery for TOS had no significant differences in pitching performance metrics after surgery compared with matched controls.

Management of Pediatric and Adolescent Sublime Tubercle Injuries: Isolated and Complex Patterns Demonstrate Distinct Etiologies and Radiographic Outcomes.

BACKGROUND: The aim of this study was to assess the patient demographics, epidemiology, mechanism of injury, and natural history of sublime tubercle avulsion injuries. METHODS: A multicenter retrospective study was performed in which sublime tubercle avulsion injuries were identified by surgeon records and database query of radiology reports. Demographic data and imaging were reviewed for each case, and injuries were classified as type 1 (isolated injuries with a simple bony avulsion or periosteal stripping) or type 2 (complex injuries with an associated elbow fracture or dislocation). Treatment modality and evidence of radiographic healing at a minimum of 3 months were collected. RESULTS: Forty patients (78% male) with a median age of 15 years (range, 8 to 19 years) were identified with sublime tubercle avulsion injuries. Sixty-eight percent of cases (n=27) were determined to be type 1 injuries, and 32% (n=13) were classified as type 2 injuries. The majority of type 1 injuries (59%) occurred via a noncontact mechanism in overhead-throwing athletes, whereas 100% of the type 2 injuries were sustained via a contact mechanism. Type 1 injuries presented in a delayed manner in 19% of cases, whereas no type 2 injuries (0%) were delayed in presentation. Type 1 injuries infrequently underwent surgical intervention (19%), whereas 54% of type 2 injuries required surgery. Of those that did not undergo initial surgical management at a minimum of 3-month radiographic follow-up, 9/11 (82%) of type 1 injuries and 0/4 (0%) of type 2 injuries demonstrated evidence of healing. Only 1 case required reoperation (type 2 injury). CONCLUSIONS: This series of adolescents with sublime tubercle avulsion injuries expands our understanding of the epidemiology of this rare injury, which was previously only described as a noncontact injury in baseball players. Type 1 injuries are more likely to occur via a noncontact mechanism and generally demonstrate radiographic evidence of healing after a period of rigid immobilization. Conversely, type 2 injuries are more likely to undergo initial surgical intervention, and those managed nonoperatively are less likely to achieve radiographic healing. Further studies are needed to elucidate treatment protocols and long-term functional outcomes. LEVEL OF EVIDENCE: Level IV-case series.

Editorial Commentary: Baseline Motion Analysis of Baseball Pitchers Provides a Valuable Tool for Evaluation, Rehabilitation, and Return to Play Should Injury Occur.

The role of motion analysis to study throwing athletes has blossomed as the technology resolution and accuracy have continued to improve and the relative cost has decreased. As applied to baseball pitchers, including professionals, a challenge is the wide spectrum of pitching motion that successful, uninjured pitchers demonstrate. Although most pitching coaches agree on some common elements of effective pitching mechanics, each pitcher may have specific and unique characteristics of delivery. These are related to the player's age, workload, conditioning, and genetic aspects. Perhaps the best "control" when evaluating throwing kinematics in an injured pitcher is the same athlete before injury. Although the data may not always be available, obtaining baseline motion analysis (in spring training, preseason, and so on) for high-risk players (pitchers) would be optimal. This information may serve as a rehabilitation and training tool for research and may help to facilitate "return-to-play" determination. Preinjury and post-treatment kinematics assist with the initial evaluation and subsequent treatment of the injured athlete. Furthermore, this information may elucidate the cause of the abnormal kinematics, that is, whether the injury caused the irregular motion or the abnormal kinematics induced the injury.

Professional Advancement and Performance of Amateur Baseball Players Selected in the Major League Baseball Draft With Previous Anterior Cruciate Ligament Reconstruction.

BACKGROUND: The effect that an anterior cruciate ligament injury requiring reconstructive surgery has on the professional advancement and performance of amateur baseball players selected in the Major League Baseball draft is not known. Return to sports after anterior cruciate ligament reconstruction (ACLR) in professional athletes has been shown to be high, but mixed results with regard to performance and return to preinjury level have been demonstrated in other sports. PURPOSE: To (1) investigate the highest level of professional advancement among Major League Baseball draftees with a history of ACLR before entering the draft, (2) examine how much time these players spent on the disabled list (DL) and determine if it was related to the knee, and (3) compare the batting and pitching performance of these players against healthy matched controls. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Predraft medical records of all players selected in the Major League Baseball draft from 2004 to 2008 were reviewed. Players with a documented anterior cruciate ligament injury treated with ACLR before the draft were included. For each study player, 3 controls were identified. Data were accumulated from the time when players were drafted through the 2015 season. Outcome variables included highest professional level of advancement, DL time, and batting and pitching performance. RESULTS: Forty draftees with a history of ACLR (22 pitchers, 18 position players) were identified and matched to 120 controls (66 pitchers, 54 position players). The difference in the highest level of professional advancement between the groups was not statistically significant (P = .488). The mean total number of times and the mean total number of days on the DL were similar between the groups (1.83 vs 1.47, P = .297; 121.54 vs 109.62, P = .955); however, the mean number of times on the DL because of a knee injury was significantly different (0.28 vs 0.11, P = .004), as was the mean number of days on the DL because of a knee injury (17.36 vs 7.72, P = .009). Among pitchers, there were no differences in performance. Similarly, there were no differences among position players in batting performance. CONCLUSION: There was no difference between draftees with a history of ACLR and their controls in terms of advancement from the minor to the major leagues. Additionally, pitching and batting performance were similar. Although the 2 groups spent similar time on the DL, the ACLR group spent more time on the DL because of a knee injury than the control group.

Nonoperative Treatment of Elbow Ulnar Collateral Ligament Injuries With and Without Platelet-Rich Plasma in Professional Baseball Players: A Comparative and Matched Cohort Analysis.

BACKGROUND: Recent studies evaluating nonoperative treatment of elbow ulnar collateral ligament (UCL) injuries augmented with platelet-rich plasma (PRP) have shown promising results. To date, no comparative studies have been performed on professional baseball players who have undergone nonoperative treatment with or without PRP injections for UCL injuries. HYPOTHESIS: Players who received PRP injections would have better outcomes than those who did not receive PRP. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The Major League Baseball (MLB) Health and Injury Tracking System identified 544 professional baseball players who were treated nonoperatively for elbow UCL injuries between 2011 and 2015. Of these, 133 received PRP injections (PRP group) before starting their nonoperative treatment program, and 411 did not (no-PRP group). Player outcomes and a Kaplan-Meier survival analysis were compared between groups. In addition, to reduce selection bias, a 1:1 matched comparison of the PRP group versus the no-PRP group was performed. Players were matched by age, position, throwing side, and league status: major (MLB) and minor (Minor League Baseball [MiLB]). A single radiologist with extensive experience in magnetic resonance imaging (MRI) interpretation of elbow injuries in elite athletes analyzed 243 MRI scans for which images were accessible for tear location and grade interpretation. RESULTS: Nonoperative treatment of UCL injuries resulted in an overall 54% rate of return to play (RTP). Players who received PRP had a significantly longer delay in return to throwing (P < .001) and RTP (P = .012). The matched cohort analysis showed that MLB and MiLB pitchers in the no-PRP group had a significantly faster return to throwing (P < .05) and the MiLB pitchers in the no-PRP group had a significantly faster RTP (P = .045). The survival analysis did not reveal significant differences between groups over time. The use of PRP, MRI grade, and tear location were not statistically significant predictors for RTP or progression to surgery. CONCLUSION: In this retrospective matched comparison of MLB and MiLB pitchers and position players treated nonoperatively for a UCL tear, PRP did not improve RTP outcomes or ligament survivorship, although there was variability with respect to PRP preparations, injection protocols, time from injury to injection, and rehabilitation programs. MRI grade and tear location also did not significantly affect RTP outcomes or progression to surgery.

Professional advancement, performance, and injury characteristics of baseball players entering the Major League Baseball draft after treatment for shoulder injuries.

BACKGROUND: How shoulder injuries treated before the Major League Baseball (MLB) draft affect the player's performance over their career is unclear. The purpose of this study was to determine whether prior shoulder injuries were associated with a difference in the level of performance and advancement of MLB draftees. METHODS: Before entering the draft, 119 professional baseball players from 2004 to 2010 were treated for a shoulder injury (73% treated surgically) as an amateur. A 3:1 matched case-control was performed to players without prior shoulder injuries by age, position, round selected, and signing bonus. Follow-up data were collected in 2016, and professional advancement, disabled list time, and in-game performance statistics for pitchers were analyzed and compared. RESULTS: Players with a prior shoulder injury had a statistically higher chance to be assigned to the disabled list then controls (P = .03), but there was no difference in disabled list time or professional advancement. Pitchers with a prior shoulder injury pitched a statistically lower number of innings per game than controls (P = .04). All other in-game performance statistics were not statistically different. The type of treatment did not have any effect on future performance or advancement. CONCLUSIONS: Professional baseball players treated for prior shoulder injuries at the amateur level were more likely to sustain future disability than their matched controls, but it did not affect professional advancement.

Performance and Injury Characteristics of Pitchers Entering the Major League Baseball Draft After Ulnar Collateral Ligament Reconstruction.

BACKGROUND: Ulnar collateral ligament (UCL) reconstruction (UCLR) has been studied and shown to be a successful procedure for returning overhead athletes to sport. Many studies of Major League Baseball (MLB) players have shown high levels of return to play with successful statistical performance. No study has followed professional advancement of drafted pitchers who underwent UCLR as amateurs when compared with drafted pitchers who did not undergo the procedure before selection in the MLB draft. HYPOTHESIS: There would be no difference in professional advancement, statistical performance, or injury rate between the UCLR and control groups. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Thirty-eight pitchers with a UCLR as an amateur and 114 controls were identified in the MLB draft between 2006 and 2010. Highest level of professional baseball achieved was collected from all players, as well as statistical performance metrics including velocity, wins, earned run average (ERA), and walks and hits per inning pitched (WHIP). Additional data on future injuries were analyzed for days on the disabled list (DL), risk of being placed on the DL, and DL assignment for elbow injury. RESULTS: Thirteen of 38 UCLR pitchers reached the major league level (34.2%) compared with 29 of 114 (25.4%) control pitchers, which was not statically significant (P = .295). The UCLR and control groups were similar for average velocity, peak velocity, innings pitched, games, games started, innings per game, ERA, WHIP, wins, losses, saves, batters faced, and innings pitched per year, as well as hits, runs, home runs allowed, strikeouts, batters walked, and batters struck per inning. The UCLR group had a significantly increased rate of DL assignment when compared with controls (86.8% vs 64.0%; P = .008); however, days on DL (152.8 vs 135.6; P = .723) and DL assignment for elbow injury (45.5% vs 43.8%; P = .877) were similar. CONCLUSION: There was no difference in the rate of professional advancement among pitchers drafted by the MLB who had undergone UCLR as amateurs compared with controls. Both groups had similar statistical performance. Pitchers in the UCLR group had an increased risk of DL assignment but no increase in the number of days on DL or risk of DL placement for elbow injury.

Long head of the biceps brachii tendon: unenhanced MRI versus direct MR arthrography.

OBJECTIVE: We sought to determine the diagnostic accuracy of unenhanced MRI and direct MR arthrography (MRA) for evaluation of the intra-articular long head of the biceps brachii tendon (LHBT) using arthroscopy as the gold standard. MATERIALS AND METHODS: A retrospective review of patients who underwent shoulder MRI (n = 132) and MRA (n = 67) within 12 months prior to arthroscopy was performed. MR images were independently reviewed by two blinded musculoskeletal radiologists. Routinely recorded arthroscopic photos/videos were reviewed by an orthopedic surgeon. The LHBT was graded as normal, tendinosis, partial thickness tear less or greater than 50%, and complete tear. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for tendinosis and tear detection were calculated. RESULTS: MRI correctly diagnosed fewer normal LHBTs compared to MRA (39-54% versus 74-84%, respectively; p < 0.005). MRI and MRA did not differ significantly in the diagnosis of tendinosis (18-36% and 15-38%, respectively; p > 0.05) and tears (75-83% and 64-73%, respectively; p > 0.05). For tendinosis, MRI versus MRA showed 18-36% and 15-38% sensitivity, 69-79% and 83-91% specificity, 22-28% and 18-50% PPV, 74-76% and 80-86% NPV, and 61-64% and 70-81% accuracy; respectively. For tears, MRI versus MRA showed 75-83% and 64-73% sensitivity, 73-75% and 82-91% specificity, 66-69% and 41-62% PPV, 82-87% and 92-94% NPV, and 74-78% and 79-88% accuracy; respectively. CONCLUSIONS: No significant difference was found between unenhanced MRI and direct MRA for the detection of tendinosis and tears of LHBTs.

Shoulder functional performance status of National Collegiate Athletic Association swimmers: baseline Kerlan-Jobe Orthopedic Clinic scores.

BACKGROUND: Shoulder trouble, described in the literature as "swimmer's shoulder," has been associated with competitive swimmers. The Kerlan-Jobe Orthopedic Clinic (KJOC) Shoulder and Elbow Score is a validated survey used to define functional and performance measures of the upper extremity in overhead athletes. To date, no study has investigated the baseline functional scores for swimmers actively competing in the sport. PURPOSE: To establish a baseline score for National Collegiate Athletic Association (NCAA) swimmers actively competing in the sport. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: After institutional review board approval, the KJOC Shoulder and Elbow Score was administered to 5 NCAA swim teams (N = 99 participants; 46 men, 53 women). The results on 10 specific individual questions and on the total score were calculated according to the survey's original description. The mean scores were calculated for all participants. The Mann-Whitney U test was used to determine differences between sexes, years swimming, and self-reported injury status. RESULTS: The mean ± SD baseline KJOC score (out of a possible 100) for all participants was 79.0 ± 18.7; the mean score for men was 81.9 ± 15.6 and for women 76.6 ± 20.8. The score for athletes identifying themselves as injured at baseline was 53.9 ± 18.8, compared with 84.4 ± 13.6 for those not reporting as injured (P < .001). Athletes competing ≥11 years had a mean score of 72.0 ± 22.1; those competing ≤10 years scored 86.4 ± 11.4 (P = .007). CONCLUSION: Baseline scores for swimmers, which were lower than expected, were lower than baseline scores seen in studies of other overhead sports athletes. The data corroborate previous studies identifying swimmers as having a high level of shoulder trouble. Further research is indicated for improving shoulder symptoms and performance in competitive swimmers.

Shoulder functional performance status of Minor League professional baseball pitchers.

BACKGROUND AND HYPOTHESIS: The Overhead Shoulder and Elbow Score (Kerlan-Jobe Orthopaedic Clinic [KJOC] score) among healthy or uninjured professional baseball pitchers is lacking. We hypothesized that shoulder function and performance status measured by the KJOC score among active Minor League professional baseball pitchers were high at pre-participation and that the pitchers who had not been previously treated for a shoulder injury and were playing without arm trouble had significantly higher KJOC scores than their counterparts. METHODS: In this cross-sectional survey, data on pre-participation KJOC scores, along with other study measures, were collected from a cohort of Minor League professional baseball pitchers. Generalized estimating equations with a Poisson distribution were used for analysis. RESULTS: A total of 366 Minor League professional pitchers were included, with a mean KJOC score of 92.8 points (SD, 12.1 points), suggesting that participating pitchers' shoulder function and performance were high. Participating pitchers who had not received treatment for a shoulder injury had significantly higher KJOC scores than those who had received treatment, either surgical or nonsurgical (ß = 0.0238, P = .0495). In addition, pitchers who were not currently injured, were playing without arm trouble, or had not missed games in the past 12 months because of a shoulder injury also had statistically significantly higher KJOC scores than their counterparts. CONCLUSION: This study provides an empirical profile of the KJOC score for a large sample of active Minor League professional baseball pitchers and identifies risk factors associated with decreased KJOC scores.

The use of an orthopaedic rating system in major league baseball.

BACKGROUND: Although the majority of Major League Baseball teams use an orthopaedic rating system to evaluate draft picks, little has been published on the topic. HYPOTHESIS: Our goal was to assess the attitudes among Major League Baseball physicians regarding 3 common diagnoses in pitching prospects, through the use of an orthopaedic rating system. Our hypothesis was that the assigned orthopaedic grades would vary among physicians, diagnoses, and operative-versus-nonoperative and recent-versus-past treatment. STUDY DESIGN: Survey. LEVEL OF EVIDENCE: Level 4. METHODS: A survey in the form of 12 clinical vignettes was used to query Major League Baseball physicians regarding ulnar collateral ligament (UCL) injuries, type II superior labrum anterior posterior (SLAP) tears, and internal impingement. Respondents graded draft picks using an orthopaedic rating system. The vignettes covered both operative and nonoperative and recent and past treatment (successful return to pitching for 1 year). RESULTS: THE ORTHOPAEDIC GRADES ASSIGNED BY RESPONDENTS WERE AS FOLLOWS (MINIMAL, MODERATE, SEVERE RISK): past UCL reconstruction (73%, 27%, 0%), recent UCL reconstruction (19%, 77%, 4%), past UCL strain (28%, 60%, 12%), recent UCL strain (0%, 48%, 52%), past SLAP repair (52%, 48%, 0%), recent SLAP repair (4%, 64%, 32%), past SLAP nonoperative (28%, 60%, 12%), recent SLAP nonoperative (0%, 36%, 64%), past internal impingement operative (24%, 68%, 8%), recent internal impingement operative (8%, 32%, 60%), past internal impingement nonoperative (24%, 68%, 8%), and recent internal impingement nonoperative (4%, 48%, 44%). CONCLUSION: Team physicians are optimistic regarding the outcome of UCL reconstruction. In contrast, UCL strains, type II SLAP lesions, and internal impingement carry a guarded prognosis. For all diagnoses, regardless of treatment, the prognosis improved if a player returned to pitching for 1 full season. CLINICAL RELEVANCE: This study represents a first step toward developing a standardized orthopaedic rating system that will facilitate more accurate player assessment and clearer communication among physicians.

Humeral avulsions of the inferior glenohumeral ligament complex involving the axillary pouch in professional baseball players.

INTRODUCTION: Humeral avulsion of the inferior glenohumeral ligament is a rare injury in athletes and can involve different parts of the complex. Axillary pouch avulsion, in particular, has only recently been recognized in the literature, but has never been described in professional baseball pitchers. MATERIALS AND METHODS: A retrospective review of professional baseball players presenting to our institution over 5 years was performed. Patients with Bankart lesions or fractures were excluded. Preoperative MRI was retrospectively correlated with the clinical and arthroscopic findings, as available. RESULTS: Four professional baseball pitchers were identified, all who had axillary pouch humeral avulsions of the inferior glenohumeral ligament. There was a concomitant avulsion of the anterior band in one patient. Associated findings included labral tears (n = 2) and partial thickness tear of the rotator cuff (n = 2). Three patients ultimately had their axillary pouch avulsions repaired at most recent follow-up. CONCLUSIONS: APHAGL lesions can be seen in overhead athletes such as baseball pitchers and should be carefully considered as a potential cause of disability. Appropriate diagnosis is important to ultimately elucidate the optimal management of these lesions.

Medial supracondylar stress fracture in an adolescent pitcher/.

We report the occurrence of a medial supracondylar stress fracture in an adolescent pitcher. To our knowledge, this fracture has not been described in the literature, and awareness of this entity allows initiation of therapy and precludes further unnecessary work-up. The radiographic, computed tomography, and magnetic resonance imaging appearances are reviewed and the mechanism of injury is discussed.

Humeral shaft fracture treatment in the elite throwing athlete: a unique application of flexible intramedullary nailing.

Humeral shaft stress fractures are being increasingly recognized as injuries that can significantly impact throwing mechanics if residual malalignment exists. While minimally displaced and angulated injuries are treated nonoperatively in a fracture brace, the management of significantly displaced humeral shaft fractures in the throwing athlete is less clear. Currently described techniques such as open reduction and internal fixation with plate osteosynthesis and rigid antegrade/retrograde locked intramedullary nailing have significant morbidity due to soft tissue dissection and damage. We present a case report of a high-level baseball pitcher whose significantly displaced humeral shaft stress fracture failed to be nonoperatively managed and was subsequently treated successfully with unlocked, retrograde flexible intramedullary nailing. The athlete was able to return to pitching baseball in one year and is currently pitching in Major League Baseball. We were able to recently collect 10-year follow-up data.

The efficacy of continuous bupivacaine infiltration following arthroscopic rotator cuff repair.

PURPOSE: This prospective, randomized, double-blind study with a placebo group and 2 experimental groups evaluated the efficacy of continuous low-dose bupivacaine infiltration by infusion pump after arthroscopic rotator cuff repair. METHODS: Sixty patients undergoing arthroscopic rotator cuff repair received a bolus injection in the subacromial space of 35 mL of 0.25% bupivacaine with 1:200,000 epinephrine at surgical closure and were randomized to 1 of 3 groups: 0.25% bupivacaine at 2 mL/hr (n = 20), 0.25% bupivacaine at 5 mL/hr (n = 20), or saline at 5 mL/hr (n = 20) via infusion pump into the subacromial space. Pain was evaluated using the visual analog scale (VAS) and narcotic consumption was measured until 48 hours after surgery and converted to dose equivalents (DE). RESULTS: Sixty patients used the infusion pump for a mean of 43.9 hours (range, 15.50 to 50.75 hrs). Mean total narcotic consumption, expressed in DEs, was 2.24 for the 2-mL group, 3.52 for the 5-mL group, and 2.32 for the placebo group. Mean pain score was 2.9 for the 2-mL group, 3.6 for the 5-mL group, and 3.3 for the placebo group. There were no differences in operating room time or infusion pump use time among groups. The 2-mL group had a nonsignificant trend toward less pain and lower narcotic consumption. The 5-mL group evidenced a nonsignificant trend toward more pain and higher narcotic consumption. CONCLUSIONS: This study neither supports nor refutes the use of infusion pumps. We hypothesized that the placebo group would experience greater pain than the 5-mL group; however, a nonsignificant trend toward the contrary occurred. A trend toward less pain in the 2-mL group was not significant. LEVEL OF EVIDENCE: Level II, randomized controlled trial of therapeutic treatment that lacks statistical significance and narrow confidence intervals.

Posterior capsular fibrosis in professional baseball pitchers: case series of MR arthrographic findings in six patients with glenohumeral internal rotational deficit.

In the high-performance athlete, acquired thickening of the posterior joint capsule is a proposed etiology for glenohumeral internal rotational deficit (GIRD). The purpose of this study was to present our MR arthrographic imaging observations of posterior capsular thickening in professional baseball players who present with reduced throwing velocity related to pain and clinical findings of internal rotational deficit of the glenohumeral joint. Our observations of MR imaging features in patients with clinical and arthroscopic manifestations of GIRD lesions include articular surface partial thickness tears of the supraspinatus and infraspinatus tendons, superoposterior subluxation of the humeral head and SLAP tears of the labrum. Although no empiric standard currently exists for the axial dimension thickness of the shoulder capsule, we have observed a thickened appearance of the posterior band of the inferior glenohumeral ligament in these patients.

The posterior-medial portal.

Repair of the posterior superior labrum usually involves placing an anchor posterior to the biceps attachment through an anterior-superior or Wilmington portal. Access to the posterior-superior labrum can be accomplished by establishing a portal medial to the posterior viewing portal. The initial posterior arthroscopic viewing portal is established slightly lateral to a traditional position to allow viewing of the posterior labrum and maintain separation from the posterior-medial portal. The suture anchor can be placed behind the biceps attachment through an anterior portal. The posterior-medial portal is started approximately 3 cm medial to the viewing portal with an 18-gauge needle. The needle is directed anterolateral into the intra-articular space under arthroscopic visualization to determine the appropriate course of the suture retriever. The needle is replaced with a sharp suture retrieval device. The suture from the anchor is pulled through the labrum to achieve a simple or mattress type repair. The suture is retrieved through the anterior-superior portal by finding it medial to the labrum. The sutures can be tied through the anterior-superior portal. The posterior-medial portal can be safely established with attention to technical considerations.

Glenohumeral joint instability: the orthopedic approach.

The goal of this article is to present a concise review of the current concepts of shoulder instability. This chapter supplements the radiologic assessment of glenohumeral instability, which follows this section.

The modified beachchair position for arthroscopic shoulder surgery: the La Jolla beachchair.

Arthroscopic surgery of the shoulder is usually performed in the lateral decubitus or beachchair position. The modified beachchair position described here allows arthroscopic procedures to be performed as in the lateral position yet maintains a semiupright orientation and permits conversion to open procedures as in the beachchair position. The results of this technique are reported for 50 consecutive patients with a variety of diagnoses. This modified beachchair position was found to be quickly and easily accomplished with a minimum of special equipment.

The efficacy of continuous bupivacaine infiltration following anterior cruciate ligament reconstruction.

PURPOSE: The purpose of this study was to determine whether continuous infiltration of a local anesthetic into the surgical wound for 48 hours will diminish the need for narcotics and improve the postoperative pain experience for patients undergoing anterior cruciate ligament (ACL) reconstruction using a patellar tendon autograft. TYPE OF STUDY: Prospective, randomized, double-blind study with a placebo and an experimental group. METHODS: Twenty-six patients were randomly assigned to receive either normal saline (placebo) or bupivacaine (experimental) for 48 hours. Both groups received a single intra-articular bolus injection of 35 mL of 0.25% bupivacaine and 5 mg. of morphine at the conclusion of surgery. The placebo group received an infusion of 2 mL/h of normal saline and the experimental group received an infusion of 2 mL/h of 0.25% bupivacaine, both for 48 hours. The anesthetic was infused using a disposable elastomeric pump (Baxter Healthcare, Deerfield, IL). Patients were evaluated using a pain and pain relief assessment questionnaire and visual analogue scale (VAS). Narcotic consumption was also documented. The pump was discontinued either by the patient at home or by a physical therapist. RESULTS: There was a statistically significant (P <.05) difference in VAS pain and pain relief scores reported by patients receiving the infusion of 0.25% bupivacaine. Patients in the treatment group also consumed 37% less narcotics than the placebo group. The operating room time, tourniquet time, weight, and age of this population were similar in the 2 groups. There were no complications with the catheter technique. CONCLUSION: This report of a new technique suggests that surgical knee patients receiving local anesthetic infusion postoperatively experience less pain and require less narcotics. The disposable pump allowed administration of the medication on an outpatient basis.