Postless Hip Arthroscopy: A Technical Note on Obtaining Distraction.

Hip arthroscopy techniques continue to evolve. Historically, a post has been used as an aid to establish adequate hip joint distraction. However, this technique is associated with potentially devastating postoperative pudendal nerve injury and other urologic and gynecologic complications. In this article, we present our technique for postless hip arthroscopy.

Adhesive Capsulitis.

Adhesive capsulitis, colloquially known as "frozen shoulder," is a relatively common disorder, affecting approximately 2% to 5% of the general population. The incidence may be higher as the condition can be relatively mild and self-limited and thus many patients who experience it may never present for treatment. It involves a pathologic process of gradual fibrosis of the glenohumeral joint that leads to limited active and passive range of motion, contracture of the joint capsule, and shoulder pain.

Bone Grafting Technique in Revision ACL Reconstruction: Coring Reamer and Dowel Trick.

One- or two-staged bone grafting is sometimes required for tunnel malposition and/or tunnel widening in revision anterior cruciate ligament (ACL) reconstruction. The aim of this procedure is to restore the correct position of the ACL graft in the revision setting to provide a stable and functional ACL, thereby reproducing normal knee kinematics. We present a technique that allows for a cost-effective, convenient tunnel grafting of a femoral head allograft bone dowel into both femoral and tibial defects in revision ACL reconstruction.

Innovations in Shoulder Arthroplasty.

Innovations currently available with anatomic total shoulder arthroplasty include shorter stem designs and augmented/inset/inlay glenoid components. Regarding reverse shoulder arthroplasty (RSA), metal augmentation, including custom augments, on both the glenoid and humeral side have expanded indications in cases of bone loss. In the setting of revision arthroplasty, humeral options include convertible stems and newer tools to improve humeral implant removal. New strategies for treatment and surgical techniques have been developed for recalcitrant shoulder instability, acromial fractures, and infections after RSA. Finally, computer planning, navigation, PSI, and augmented reality are imaging options now available that have redefined preoperative planning and indications as well intraoperative component placement. This review covers many of the innovations in the realm of shoulder arthroplasty.

Good Surgical Outcomes After Concomitant Repair of Double Radial Tears of the Lateral Meniscus and Anterior Cruciate Ligament Reconstruction.

PURPOSE: To describe double radial tears of the lateral meniscus (LM), report early clinical treatment outcomes, and determine reoperation and failure rates. METHODS: Twenty-one (N = 21) consecutive cases of arthroscopic-treated lateral meniscus double radial tears treated between 2012 and 2018 were reviewed, including 15 males (71.4%) and 6 females (28.6%). Meniscus repairs were all performed at the time of anterior cruciate ligament (ACL) reconstruction. Patients with associated fractures or prior surgeries were excluded. Concomitant injuries were reported, as were preinjury and postoperative Tegner scores, preoperative and postoperative visual analogue pain scale (VAS) scores, and postoperative International Knee Documentation Committee (IKDC) subjective scores. Reoperation and failure rates were documented. RESULTS: Twenty-one (N = 21) tears were located in the posterior horn of the meniscus near the root attachment; 15 (71.4%) underwent all-inside repair, 4 (19.0%) underwent transtibial pull-through repair, 1 (4.8%) was partially debrided, and 1 (4.8%) was left untreated. Twenty-one tears (N = 21) were in the body of the meniscus; 7 (33.3%) were repaired, 7 (33.3%) were partially debrided, and 7 (33.3%) were left untreated. Thirteen patients (62%) had associated medial collateral ligament (MCL) injuries. Mean follow-up was 2.6 years. VAS at rest and with activity improved by 2.1 points (P < .001) and 3.1 points (P = .017) after surgery. The mean postoperative Tegner activity score was 6.4, and the mean IKDC score was 83.2 at final follow-up. Reoperation was required in 5 patients (23.8%), and the surgical treatment failed in 1 patient (4.7%). CONCLUSIONS: Double radial tears of the LM are uncommon injuries that occur in the setting of ACL tears, usually combined with MCL injury. The variety of surgical treatment techniques have a low failure rate at short-term follow-up. Patients tend to have good clinical outcomes with improvement in pain and overall function after surgically treating these injuries with simultaneous ACL reconstruction. LEVEL OF EVIDENCE: Level IV, therapeutic study, case series.

Arthroscopic Centralization of the Extruded Medial Meniscus.

Tears of the posterior medial meniscus root commonly result in extrusion of the meniscus and disruption of tibiofemoral contact mechanics. Transtibial pull-through repair of the root often results in healing of the tear, but postoperative extrusion may persist. In this scenario, the meniscus is unlikely to be chondroprotective. Therefore, an additional centralization procedure is necessary to improve the extrusion. Biomechanical studies have demonstrated that centralization can improve meniscus mechanics and potentially reduce the risk of osteoarthritis. This Technical Note describes an arthroscopic technique for medial meniscus posterior root repair that combines transtibial pullout and centralization sutures.

Pediatric Seymour Fractures of the Toe.

BACKGROUND: Seymour fractures of the toe are physeal fractures with often occult concomitant nail bed injuries and thus are open fractures. They are uncommon injuries that without proper treatment can result in osteomyelitis. The literature has sparse information regarding the clinical outcomes for these injuries. METHODS: A single-center retrospective review included juxta-epiphyseal fractures or Salter-Harris I/II fracture of the toe with documented concomitant nail bed injury or laceration. Clinical and radiographic data were recorded for consecutive fractures. The primary outcome was the incidence of osteomyelitis. Secondary outcomes included premature physeal arrest, development of nail dystrophy, and functionality of the toe. RESULTS: Between 2006 and 2019, 19 patients were treated for this injury by the pediatric orthopaedic division. Complications included osteomyelitis (n=6), physeal arrest (n=4), and nail dystrophy (n=1). Days from injury to definitive treatment were significantly greater in patients who developed osteomyelitis compared with those who did not (P<0.01). Patients were significantly more likely to develop osteomyelitis if they did not receive acute definitive treatment (<48 h) (P<0.001; likelihood ratio, 17.9). CONCLUSIONS: Prompt definitive treatment of Seymour fractures of the toe was associated with a lower incidence of osteomyelitis. Greater awareness for these seemingly innocuous injuries is needed to provide an early treatment that may reduce the rate of osteomyelitis. LEVEL OF EVIDENCE: Level IV-case series.

Outcomes and Direct Costs of Needle Aponeurotomy, Collagenase Injection, and Fasciectomy in the Treatment of Dupuytren Contracture.

PURPOSE: The aims of our study were to evaluate the rates and predictors of reinterventions and direct costs of 3 common treatments of Dupuytren contractures-needle aponeurotomy, collagenase injection, and surgical fasciectomy. METHODS: A retrospective review identified 848 interventions for Dupuytren contracture in 350 patients treated by a single surgeon from 2005 to 2016. The treatments included needle aponeurotomy (NA) (n = 444), collagenase injection (n = 272), and open fasciectomy (n = 132). We collected information on demographics, contracture details, and comorbidities. Outcomes included reintervention rates, time to reintervention, and direct cost of treatments. Standardized costs were calculated by applying 2017 Medicare reimbursement to professional services and cost-to-charge ratios to hospital charges. RESULTS: Demographics were similar among the 3 treatment groups. The fifth finger was the most commonly affected digit including 43% of the NA, 60% of the collagenase, and 45% of the fasciectomy groups. The 2-year rates of reintervention following NA, collagenase, and fasciectomy were 24%, 41%, and 4%, respectively, and the 5-year rates were 61%, 55%, and 4%, respectively. Younger age and severity of preintervention proximal interphalangeal (PIP) joint contracture were predictive of reintervention in the NA and collagenase groups. The standardized direct costs for NA, collagenase, and fasciectomy were $624, $4,189, and $5,291, respectively. Including all reinterventions, the cumulative costs per digit following NA, collagenase, and surgery at 5 years were $1,540, $5,952, and $5,507, respectively. CONCLUSIONS: Treatment with collagenase resulted in the highest rate of reintervention at 2 years, comparable reintervention rates to NA at 5 years, and the highest cumulative costs. The NA was the least expensive and resulted in longer duration before reintervention compared with collagenase. More severe PIP joint contractures and younger age at time of initial intervention were predictive of reintervention after collagenase and NA. Fasciectomy has a high initial cost but the lowest reintervention rate. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Variability in Baseball Throwing Metrics During a Structured Long-Toss Program: Does One Size Fit All or Should Programs Be Individualized?

BACKGROUND: The variability of throwing metrics, particularly elbow torque and ball velocity, during structured long-toss programs is unknown. HYPOTHESES: (1) Elbow torque and ball velocity would increase as throwers progressed through a structured long-toss program and (2) intrathrower reliability would be high while interthrower reliability would be variable. STUDY DESIGN: Descriptive laboratory study. LEVEL OF EVIDENCE: Level 3. METHODS: Sixty healthy high school and collegiate pitchers participated in a structured long-toss program while wearing a validated inertial measurement unit, which measured arm slot, arm velocity, shoulder rotation, and elbow varus torque. Ball velocity was assessed by radar gun. These metrics were compared within and between all pitchers at 90, 120, 150, and 180 ft and maximum effort mound pitching. Intra- and interthrower reliabilities were calculated for each metric at every stage of the program. RESULTS: Ball velocity significantly changed at each progressive throwing distance, but elbow torque did not. Pitching from the mound did not place more torque on the elbow than long-toss throwing from 120 ft and beyond. Intrathrower reliability was excellent (intraclass correlation coefficient >0.75) throughout the progressive long-toss program, especially on the mound. Ninety-one percent of throwers had acceptable interthrower reliability (coefficient of variation <5%) for ball velocity, whereas only 79% of throwers had acceptable interthrower reliability for elbow torque. CONCLUSION: Based on trends in elbow torque, it may be practical to incorporate pitching from the mound earlier in the program (once a player is comfortable throwing from 120 ft). Ball velocity and elbow torque do not necessarily correlate with one another, so a degree of caution should be exercised when using radar guns to estimate elbow torque. Given the variability in elbow torque between throwers, some athletes would likely benefit from an individualized throwing program. CLINICAL RELEVANCE: Increased ball velocity does not necessarily equate to increased elbow torque in long-toss. Some individuals would likely benefit from individualized long-toss programs for rehabilitation.

Arthroscopic Repair of Double Radial Tears of the Lateral Meniscus.

Double radial tears of the lateral meniscus are rare injuries that typically occur in the setting of an acute anterior cruciate ligament rupture. Full-thickness radial tears of the meniscus body and root render the meniscus nonfunctional from a loss of hoop stress resistance. Repair of these tears can normalize contact pressures in the lateral compartment and delay arthritic changes. We describe our technique for repairing a lateral meniscus body radial tear and concomitant posterior root tear, via inside-out suture repair and transtibial suture repair, respectively. This investigation was performed at Mayo Clinic.

Cystic Adventitial Disease of the Tibial Vein Arising From the Subtalar Joint: A Case Report.

Soft tissue ganglion cysts are a well-known cause of tibial nerve compression in the tarsal tunnel. We describe a patient who presented with tibial nerve symptoms and was found to have an adventitial cyst of the tibial vein arising from the subtalar joint, with the joint connection confirmed both on imaging and at surgery. Surgical decompression of the cyst with transection of the vascular pedicle arising from the subtalar joint improved her symptoms at 6 months, and postoperative magnetic resonance imaging showed resolution of the cyst. Cystic adventitial disease is a rare, poorly understood condition in which a cyst is identified in the adventitia of a vessel, usually an artery. Only 3 cases of adventitial cysts have been reported in the foot and ankle region, 2 in the lesser and 1 in the greater saphenous vein. None of the previous cases have been recognized to be joint connected. This case provides additional evidence for an articular origin for adventitial cysts and helps guide management strategies for these joint-connected cysts.

Injury Prevention in Baseball: from Youth to the Pros.

PURPOSE OF REVIEW: This review examines recent literature on injury epidemiology and prevention in the sport of baseball from youth to professional levels. RECENT FINDINGS: Overuse is the predominant mechanism of injury in youth baseball players. Newer stretching and exercise protocols may help prevent these injuries. At the professional level, however, overuse has not been proven to correlate with increased injury incidence, but pitch counts are still monitored. There continues to be a rise in operations performed for baseball-related injuries, including ulnar collateral ligament (UCL) reconstruction, particularly in younger athletes. As the level of play increases, there is significant loss of participation due to injuries, such as the UCL in the upper extremity and the hamstrings in the lower extremity. Baseball is a widely popular sport, which has led to a focus on injury epidemiology and prevention. While the majority of research regarding baseball injuries focuses on pitchers, fielders and catchers are also at risk. In an attempt to decrease non-contact injuries in the upper and lower extremities, stretching and strengthening exercises are vitally important. Because injury profiles demonstrate significant variability from youth to professional baseball, unique prevention strategies are likely necessary at each level. More research is needed to develop and validate appropriately targeted injury prevention programs.

Management of the spastic wrist and hand in cerebral palsy.

Research from the last 5 years on the pathophysiology and treatment of upper extremity sequelae of cerebral palsy (CP) is presented. The development of new treatments of CP-affected limbs, utilizing the brain's inherent neuroplasticity, remains an area of promising and active research. Functional magnetic resonance imaging scans have evaluated the role of neuroplasticity in adapting to the initial central nervous system insult. Children with CP appear to have greater recruitment of the ipsilateral brain for motor and sensory functions of the affected upper limb. Studies have also shown that constraint-induced movement therapy results in localized increase in gray matter volume of the sensorimotor cortex contralateral to the affected arm targeted during rehabilitation. Recent therapy interventions have emphasized the role of home therapy programs, the transient effects of splinting, and the promise of constraint-induced movement therapy and bimanual hand training. The use of motion laboratory analysis to characterize the movement pattern disturbances in children with CP continues to expand. Classification systems for CP upper limb continue to expand and improve their reliability, including use of the House Classification, the Manual Ability Classification System, and the Shriner's Hospital Upper Extremity Evaluation. Surgical outcomes have greater patients' satisfaction when they address functional limitations, also in addition to aesthetics, which may improve patients' self-esteem. Surgical techniques for elbow, wrist, fingers, and thumb continue to be refined. Research into each of these areas continues to expand our understanding of the nervous system insults that cause CP, how they may be modified, and how hand surgeons can continue to serve patients by improving their upper limb function and aesthetics.