Percutaneous Fixation of a Fifth Metatarsal Base Fracture.

SUMMARY: Owing to a vascular watershed, zone II and III fifth metatarsal base fractures commonly progress to nonunion without operative intervention. This article and the accompanying video demonstrate the use of intramedullary screw fixation for a fifth metatarsal base fracture and review treatment decisions involved with management of these injuries.

Clinical Outcomes and Quality of Literature Addressing Glenohumeral Internal Rotation Deficit: A Systematic Review.

BACKGROUND: Glenohumeral internal rotation deficit (GIRD) can negatively impact shoulder function particularly in the throwing athlete. QUESTIONS/PURPOSE: This study aimed to systematically evaluate recent trends in clinical outcomes and quality of published evidence pertaining to GIRD. METHODS: A systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, MEDLINE, PubMed Central, and Embase were searched from January 1, 2011, through April 23, 2017, for all articles evaluating GIRD. Two reviewers independently screened articles for eligibility and extracted data for analysis. RESULTS: Eighty-two articles were included in the final review. In general, the overall number of articles published increased over time. Two-thirds of all studies were conducted in the USA. Seventy-eight percent (N = 64) of included studies were level-III to level-V evidence, with no level-I study performed during the study period. Eighty-five percent of studies were either epidemiologic, review, or imaging articles, and only 12% were clinical studies. Significant variability in the clinical definition of GIRD was identified. All studies evaluating non-operative management of GIRD demonstrated significant improvements in internal rotation of the affected extremity. CONCLUSION: Current trends in GIRD-related literature demonstrate limited focus on clinical, therapeutic, or patient-reported outcomes and mostly consist of low-level evidence. There is a lack of consensus in the literature on what clinically constitutes GIRD.

Ankle Arthrodesis Through an Anterior Approach.

Ankle arthritis occurs primarily because of trauma and has a huge impact on patient's quality of life. Ankle arthrodesis is indicated for patients with end-stage ankle arthritis who fail conservative management. High rates of fusion can be achieved through an anterior approach. This video demonstrates an ankle arthrodesis using an anterior approach to the ankle in a patient with posttraumatic ankle arthritis.

Current Workload Recommendations in Baseball Pitchers: A Systematic Review.

BACKGROUND: Several recommendations have been made regarding pitch counts and workload for baseball players of different levels, including Little League, high school, collegiate, and professional baseball. However, little consensus is found in the literature regarding the scientific basis for many of these recommendations. PURPOSE: The primary purpose of this study was to summarize the evidence regarding immediate and long-term musculoskeletal responses to increasing pitching workload in baseball pitchers of all levels. A secondary purpose of this review was to evaluate the extent to which workload influences injury and/or performance in baseball pitchers. STUDY DESIGN: Systematic review. METHODS: We performed a systematic search in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for studies addressing physiologic and/or pathologic musculoskeletal changes in response to a quantifiable pitching workload. We included studies examining the effects of pitching workload on performance, injury rate, and musculoskeletal changes in Little League, high school, collegiate, and professional baseball players. RESULTS: We identified 28 studies that met our inclusion and exclusion criteria: 16 studies regarding Little League and high school pitchers and 12 studies regarding collegiate and professional pitchers. The current evidence presented suggests that increased pitching workload may be associated with an increased risk of pain, injury, and arm fatigue in Little League and high school pitchers. However, little consensus was found in the literature regarding the association between pitching workload and physiologic or pathologic changes in collegiate and professional pitchers. CONCLUSION: Evidence, although limited, suggests the use of pitch counts to decrease injury rates and pain in Little League and high school baseball pitchers. However, further research must be performed to determine the appropriate number of pitches (or throws) for players of different ages. This systematic review reported conflicting evidence regarding the use of pitch counts in college and professional baseball. Future high-quality research is required to determine the role, if any, of pitch counts for collegiate and professional pitchers.

A Clinical Comparison of Linear- and Surface Area-Based Methods of Measuring Glenoid Bone Loss.

BACKGROUND: The purpose of this study was to determine whether linear-based measurement significantly overestimates glenoid bone loss in comparison with surface area-based measurement in patients with recurrent anterior shoulder instability and glenoid bone loss. HYPOTHESIS: Linear-based measurement will significantly overestimate glenoid bone loss in comparison with surface area-based measurement in patients with anterior shoulder instability and glenoid bone loss. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: Thirty patients with anterior shoulder instability underwent preoperative bilateral shoulder computed tomography (CT) scans. Three-dimensional CT (3D-CT) reconstruction with humeral head subtraction was performed to obtain an en face view of the 3D-CT glenoid. Glenoid bone loss was measured with the surface area and linear methods of measurement. Statistical analysis was performed with a paired 2-tailed t test. RESULTS: Twenty-eight patients (5 female and 23 male; mean age, 25.1 years; age range, 15-58 years) were included in the study; 17 patients underwent a glenoid augmentation procedure, and 11 underwent arthroscopic Bankart repair. The mean percentage glenoid bone loss calculated with the surface area and linear methods was 12.8% ± 8.0% and 17.5% ± 9.7% ( P < .0001), respectively. For the 17 patients who underwent glenoid augmentation, mean percentage bone loss with the surface area and linear methods was 16.6% ± 7.9% and 23.0% ± 8.0% ( P < .0001), respectively. CONCLUSION: Linear measurement of glenoid bone loss significantly overestimates bone loss compared with surface area measurement in patients with anterior glenoid bony defects. These results indicate that these different methods cannot be used interchangeably and cannot be used with the same critical thresholds for glenoid bone loss.

Return to Play After Multiligament Knee Injuries in National Football League Athletes.

BACKGROUND:: Return to play (RTP) of National Football League (NFL) athletes after isolated anterior cruciate ligament (ACL) tears has been reported. However, no studies have reported on RTP of NFL athletes after multiligament knee injuries. HYPOTHESES:: NFL athletes with multiligament knee injuries have lower RTP rates and longer recoveries than athletes with isolated ACL tears. Second, athletes with ACL and medial collateral ligament (MCL) injuries will have higher RTP rates and shorter time to RTP than athletes with an ACL tear and posterolateral corner involvement. STUDY DESIGN:: Retrospective cohort study. LEVEL OF EVIDENCE:: Level 4. METHODS:: Publicly available NFL injury data were reviewed for all multiligament knee injuries incurred between 2000 and 2016 with RTP information. Athletes were excluded if RTP was limited for reasons unrelated to the injury. Extracted data included type of injury, RTP, time to RTP (days), number and percentage of games played, and performance. RESULTS:: A total of 50 NFL athletes with multiligament knee injuries met inclusion and exclusion criteria. The overall RTP rate was 64.0%. Athletes with ACL/MCL tears had an RTP rate of 70.8%, whereas athletes with ACL and posterior collateral ligament/lateral collateral ligament (PCL/LCL) tears had an RTP rate of 55.6% ( P = 0.26). Mean time to RTP for all 50 athletes was 388.71 ± 198.52 days. The mean time to RTP for athletes with ACL/MCL injuries was 305.1 ± 58.9 days, compared with 459.2 ± 245.1 days ( P = 0.004) and 609.3 ± 183.1 days ( P < 0.0001) for those with combined ACL and PCL/LCL injuries and frank knee dislocations, respectively. Athletes with ACL/MCL injuries were more likely to return to prior performance level (43.5%) than those with ACL and PCL/LCL injuries (18.5%) ( P < 0.001). CONCLUSION:: The RTP rate for athletes with multiligament knee injuries is significantly less than the RTP rate for athletes with isolated ACL tears. In addition, athletes with ACL and MCL tears have a higher RTP rate, a significantly shorter time to RTP, and a greater likelihood of returning to prior performance than athletes with ACL and PCL/LCL tears. CLINICAL RELEVANCE:: Multiligament knee injuries significantly affect the ability of a football player to return to sport. ACL and MCL tears are associated with better RTP prognosis compared with ACL and PCL/LCL tears.

The Effect of Capsulectomy on Hip Joint Biomechanics.

BACKGROUND: Capsulectomy is performed during hip arthroscopic surgery in young adult patients with hip pain to improve intraoperative visualization. The stability of the hip joint after anterior capsulectomy is relatively unknown. PURPOSE: To evaluate anterior hip stability in capsular sectioned states with a labral injury to test whether the load required for anterior translation would decrease with greater capsular injuries. STUDY DESIGN: Controlled laboratory study. METHODS: Sixteen hips from 8 of 10 human cadaveric pelvises (mean age, 54.25 years) were prepared/mounted onto a custom-built fixture and tested in 5 states: intact capsule, intact labrum (all intact); sutured capsule, intact labrum (sutured intact); sutured capsule, 1-cm partial labrectomy (sutured labrectomy); partial capsulectomy, 1-cm partial labrectomy (partial capsulectomy); and total capsulectomy, 1-cm partial labrectomy (total capsulectomy). Each hip was tested in a neutral position with a 20-N compressive force. The load at 12 mm of anterior translation was recorded for each state after 2 preconditioning trials. RESULTS: A repeated-measures analysis of variance with Bonferroni adjustment showed no difference between the all-intact versus sutured-intact states and demonstrated no significant difference between the sutured-intact and sutured-labrectomy states. There were significant differences between the sutured-labrectomy and partial capsulectomy (P = .01), sutured-labrectomy and total capsulectomy (P < .001), and partial capsulectomy and total capsulectomy (P = .04) states. CONCLUSION: The findings demonstrate that the capsule/labrum plays an important role in anterior hip stability and that the iliofemoral ligament is crucial for preventing anterior translation in labral-injured states. In addition, the ischiofemoral and pubofemoral ligaments provide resistance to anterior translation in iliofemoral- and labral-deficient states. Intraoperative capsulectomy should be avoided in patients with large, irreparable labral tears to prevent postoperative anterior hip instability. CLINICAL RELEVANCE: This study quantifies the roles of the capsulolabral structures in anterior hip stability and demonstrates the importance of maintaining/repairing them during hip arthroscopic surgery.

Does Repair of a Hill-Sachs Defect Increase Stability at the Glenohumeral Joint?

BACKGROUND: The effect of osteoallograft repair of a Hill-Sachs lesion and the effect of allograft fit on glenohumeral translations in response to applied force are poorly understood. PURPOSE: To compare the impact of a 25% Hill-Sachs lesion, a perfect osteoallograft repair (PAR) of a 25% Hill-Sachs lesion, and an "imperfect" osteoallograft repair (IAR) of a 25% Hill-Sachs lesion on glenohumeral translations in response to a compressive load and either an anterior or posterior load in 3 clinically relevant arm positions. STUDY DESIGN: Controlled laboratory study. METHODS: A robotic/universal force-moment sensor testing system was used to apply joint compression (22 N) and an anterior or posterior load (44 N) to cadaveric shoulders (n = 9) with the skin and deltoid removed (intact) at 3 glenohumeral joint positions (abduction/external rotation): 0°/0°, 30°/30°, and 60°/60°. The 25% bony defect state, PAR state, and IAR state were created and the loading protocol was performed. Translational motion was measured in each position for each shoulder state. A nonparametric repeated-measures Friedman test with a Wilcoxon signed-rank post hoc test was performed to compare the biomechanical parameters (P < .05). RESULTS: Compared with the defect shoulder, the PAR shoulder had significantly less anterior translation with an anterior load in the 0°/0° (15.3 ± 8.2 vs 16.6 ± 9.0 mm, P = .008) and 30°/30° (13.6 ± 7.1 vs 14.2 ± 7.0 mm, P = .021) positions. Compared with IAR, the PAR shoulder had significantly less anterior translation with an anterior load in the 0°/0° (15.3 ± 8.2 vs 16.6 ± 9.0 mm, P = .008) and 30°/30° (13.6 ± 7.1 vs 14.4 ± 7.1 mm, P = .011) positions, and the defect shoulder had significantly less anterior translation with an anterior load in the 30°/30° (14.2 ± 7.0 vs 14.4 ± 7.0 mm, P = .038) position. CONCLUSION: PAR resulted in the least translational motion at the glenohumeral joint. The defect shoulder had significantly less translational motion at the joint compared with the IAR. An IAR resulted in the most translational motion at the glenohumeral joint. This demonstrates the biomechanical importance of performing an osteoallograft repair in which the allograft closely matches the Hill-Sachs defect and fully restores the preinjury state of the humeral head. CLINICAL RELEVANCE: This study demonstrates the importance of performing an osteoallograft repair of a Hill-Sachs defect that closely matches the preinjury state and restores normal humeral head anatomy.

The Influence of Surgical Stabilization on Glenohumeral Abduction Using 3-Dimensional Computed Tomography in Patients With Shoulder Instability.

PURPOSE: This study compared the amount of glenohumeral abduction during arm abduction in the affected and unaffected shoulders of 3 groups of patients with shoulder instability: failed surgical stabilization, successful surgical stabilization, and unstable shoulder with no prior surgical intervention. METHODS: All patients underwent bilateral shoulder computed tomography scans in 3 positions: 0° of abduction and 0° of external rotation (0-0 position), 30° of abduction and 30° of external rotation (30-30 position), and arms maximally abducted (overhead position). Three-dimensional computed tomography reconstruction was performed for both shoulders in all 3 positions. A specialized coordinate system marked specific points and directions on the humerus and glenoid of each model. These coordinates were used to calculate the glenohumeral abduction for the normal and affected sides in the 0-0, 30-30, and overhead positions. RESULTS: Thirty-nine patients with shoulder instability were included, of whom 14 had failed surgical repairs, 10 had successful surgical repairs, and 15 had unstable shoulders with no prior surgical intervention. In the overhead position, patients with failed surgical intervention had significantly less glenohumeral abduction in the failed shoulder (95.6° ± 12.7°) compared with the normal shoulder (101.5° ± 12.4°, P = .02). Patients with successfully stabilized shoulders had significantly less glenohumeral abduction in the successfully stabilized shoulder (93.6° ± 10.8°) compared with the normal shoulder (102.1° ± 12.5°, P = .03). Unstable shoulders with no prior surgical intervention (102.1° ± 10.3°) did not differ when compared with the normal shoulders (101.9° ± 10.9°, P = .95). CONCLUSIONS: Surgical intervention, regardless of its success, limits the amount of abduction at the glenohumeral joint. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Comparison of 3-Dimensional Computed Tomography-Based Measurement of Glenoid Bone Loss With Arthroscopic Defect Size Estimation in Patients With Anterior Shoulder Instability.

PURPOSE: The purpose of this study was to compare four 3-dimensional (3D) computed tomography (CT) methods of measuring glenoid bone loss with the arthroscopic estimation of glenoid bone loss. METHODS: Twenty patients with recurrent anterior shoulder instability underwent bilateral shoulder CT scans and were found to have glenoid bone loss. Arthroscopic estimation of glenoid bone loss was performed in all patients. Three-dimensional CT reconstruction was performed on the CT scans of each patient. The glenoid bone loss of each patient was measured using the surface area, Pico, ratio, and anteroposterior distance-from-bare area methods. The mean percent loss calculated with each method was compared with arthroscopy to determine the reliability of arthroscopy in the measurement of glenoid bone loss. RESULTS: The mean percent bone loss calculated with arthroscopic estimation, surface area, Pico, ratio, and anteroposterior distance-from-bare area methods was 18.13% ± 11.81%, 12.15% ± 8.50% (P = .005), 12.77% ± 8.17% (P = .002), 9.50% ± 8.74% (P < .001), and 12.44% ± 10.68% (P = .001), respectively. Repeated-measures analysis of variance showed that the 3D CT methods and arthroscopy were significantly different (F4,76 = 13.168, P = .02). The estimate using arthroscopy is 55% greater than the average of the 3D CT methods. CONCLUSIONS: Our findings suggest that arthroscopy significantly overestimates glenoid bone loss compared with CT and call into question its validity as a method of measurement. A more internally consistent and accurate method for the measurement of glenoid bone loss is necessary to appropriately diagnose and treat shoulder instability. LEVEL OF EVIDENCE: Level IV, case series.