Google Search Analytics for Lateral Epicondylitis.

BACKGROUND: The use of online search engines for health information is becoming common practice. We analyzed Google search queries to identify the most frequently asked topics and questions related to lateral epicondylitis ("tennis elbow") and the Web sites provided to address these questions. METHODS: Four search terms for lateral epicondylitis were entered into Google Web Search. A list of the most frequently asked questions along with their associated Web sites was extracted and categorized by 2 independent reviewers. RESULTS: A total of 400 questions were extracted with 168 associated Web sites. The most popular question topics were related to indications/management (39.0%), risks/complications (19.5%), and the ability to perform specific activities (18.8%). Frequently asked questions had to do with the duration of symptoms, self-management strategies (eg, brace use and self-massage), and the indications for surgery. The most common Web sites provided to address these questions were social media (27.5%), commercial (24.5%), academic (16.5%), and medical practice (16.3%). CONCLUSION: The most frequently asked questions about lateral epicondylitis on Google centered around symptom duration and management, with most information originating from social media and commercial Web sites. Our data can be used to anticipate patient concerns and set expectations regarding the prognosis and management of lateral epicondylitis.

Performance Outcomes and Return to Sport Following Metacarpal Fractures in Major League Baseball Players.

BACKGROUND: Major League Baseball (MLB) players are at risk for metacarpal fractures; however, little is known regarding the impact of these injuries on future performance. The purpose of this study was to determine whether MLB players who sustain metacarpal fractures demonstrate decreased performance on return to competition in comparison to the performance of control-matched peers. METHODS: Data for MLB position players with metacarpal fractures incurred over 17 seasons were obtained from injury reports, press releases, and player profiles. Age, position, career experience, body mass index (BMI), injury mechanism, handedness, and treatment were recorded. Individual season statistics for the 2 seasons immediately before injury and the 2 seasons after injury were obtained. Controls matched by player position, age, BMI, career experience, and performance statistics were identified. A performance comparison of the cohorts was performed. RESULTS: Overall, 24 players met inclusion criteria. Eleven players with metacarpal fractures were treated with surgery (46%) and 13 (54%) were treated nonoperatively. Players treated nonoperatively missed significantly fewer games following injury compared with those treated operatively (35.5 vs 52.6 games, P = .04). There was no significant difference in postinjury performance when compared with preinjury performance among the fracture cohorts. Players with metacarpal fractures treated nonoperatively had a significant decline in their Wins Above Replacement (WAR) 2 seasons postinjury (1.37 point decline) in comparison to matched controls (0.84 point increase) (P = .02). There was no significant difference in WAR 1 or 2 seasons postinjury for players with metacarpal fractures treated operatively in comparison to the control cohort. CONCLUSIONS: Major League Baseball players sustaining metacarpal fractures can expect to return to their preinjury performance levels following both nonoperative and operative treatment. However, players treated nonoperatively may witness a decline in their performance compared with peers over the long term. Orthopedic surgeons treating professional athletes with metacarpal fractures should consider these outcomes when counseling their patients and making treatment recommendations.

Nonoperative treatment of distal humerus fractures in the elderly yields satisfactory functional outcomes and low conversion to delayed surgery: a systematic review.

Background: Distal humerus fractures (DHFs) pose a treatment challenge in elderly patients. We sought to systematically review and report the clinical outcomes of the nonoperative approach (eg, "bag of bones") for the treatment of these injuries and the rate of conversion to delayed surgery. Methods: A comprehensive review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines was conducted. Studies involving outcomes after nonoperative treatment of DHF in patients >65 years of age were included from 1985 to present. Data regarding patient age, DHF type, nonoperative treatment method, complications, conversion to delayed surgery, range of motion, union rate, and surgeon- and patient-reported outcome measures were extracted. Results: A total of five studies met inclusion criteria (all level IV evidence), yielding a total of 143 patients (mean age: 73.5 years to 87.4 years) with 7.1 months to 55 months of follow-up. The mean Mayo Elbow Performance Index scores were good to excellent across several studies (range 83-93.1). Multiple studies reported good range of motion (mean arc of motion: 81 to 106 degrees) and low levels of upper extremity disability (mean Quick Disability of the Arm-Shoulder-Hand scores: 31.3 to 38.5) at the final follow-up. The rate of conversion to total elbow arthroplasty and operative fixation ranged from 0% to 7.5% and 0% to 5%, respectively. Conclusion: Nonoperative management of distal humerus fractures in the elderly seems to be associated with acceptable functional outcomes and low rates of delayed surgery. This information is important for patient counseling and treatment decision-making.

Return to play and performance after surgical repair of distal biceps tendon ruptures in National Football League athletes.

BACKGROUND: The purpose of this study was to determine whether surgical repair of distal biceps tendon ruptures in professional football players would lead to a decrease in postinjury performance when compared to preinjury performance and control-matched peers. We also sought to define return to sport, postinjury career length, and games played per season in National Football League players following surgical repair of distal biceps tendon ruptures. METHODS: Data for National Football League players who underwent surgical repair of distal biceps tendon ruptures during a 20-year time period were collected. A total of 25 cases in 22 players were included in the analysis. Matched controls based on player position, age, experience, and performance statistics were identified. Performance scores for cases and controls were calculated using a standardized scoring system specific to player position. RESULTS: Of the 25 cases, 21 (84%) were able to return to sport in the National Football League. The overall 1-year survival rate of return to play in players undergoing surgical repair of distal biceps tendon ruptures was 76% and overall 2-year survival was 56%. Players who underwent surgical repair of distal biceps tendon ruptures had significantly shorter postinjury career lengths and played fewer games per season postinjury than matched controls. There was no significant difference by position in postinjury performance scores when compared to matched controls. CONCLUSION: National Football League players undergoing surgical repair of distal biceps tendon ruptures have a high rate of return to sport, though many retire within the next few seasons following surgery. Players who do return to competition can be expected to perform at a level comparable to their peers.

Deep Penetrating Kerosene Exposure in the Hand Mimicking Deep Space Infection.

In this case report, we review the clinical course of an adolescent who sustained a low-velocity, low-pressure, penetrating wound to the midpalmar aspect of the hand with a kerosene containing thermometer. The exposure led to a clinical picture of an acute midpalmar abscess within 24 hours. Despite irrigation and debridement of frank purulent material, cultures and pathology remained negative for infection. This case highlights that kerosene exposure, although rare, can mimic an acute infection with intraoperative findings consistent with sterile purulence. Hand surgeons must be aware of the effects of deep soft tissue exposure with hydrocarbons, such as kerosene and petrol, and should have a low threshold to take the patient to the operating room for thorough irrigation and debridement of the offending substance.

The Essex-Lopresti Injury.

The Essex-Lopresti injury is caused by a high energy mechanism and consists of a characteristic triad: a comminuted radial head fracture, disruption of the distal radioulnar joint, and tearing of the interosseous membrane. These injuries are often difficult to diagnosis on initial evaluation, and the majority are missed acutely. Chronic Essex-Lopresti injuries lead to radioulnar longitudinal instability, proximal radius migration, ulnocarpal impaction, and chronic elbow pain. These injuries present a challenging problem for the treating surgeon.

The naked capitellum: a surgeon's guide to intraoperative identification of posterolateral rotatory instability.

HYPOTHESIS: This study's purpose was to provide a reproducible way for surgeons to intraoperatively assess the elbow's lateral ulnar collateral ligament origin and determine whether there is posterolateral rotatory instability (PLRI) despite an intact common extensor origin (CEO). We hypothesized that we could re-create clinically relevant disruption of lateral supporting structures despite an intact CEO and illustrate progressive elbow PLRI. METHODS: The relationship of the lateral capsule to the capitellum articular surface was noted in 8 cadaveric upper extremities. The lateral capsule and extensor origin were sequentially sectioned at 4 stages: intact, release to the lateral epicondyle, release of the posterior capsular insertion, and release of the CEO. Posterior and lateral translation of the radial head (RH) relative to the capitellum was measured with the forearm in extension and supination. RESULTS: The average specimen age was 78.9 years. The lateral capsule originated within 1 to 2 mm of the capitellum articular surface. Lateral capsular sectioning to the 6-o'clock position of the lateral epicondyle created an unstable elbow with posterior and lateral RH translation. Sequential sectioning of the posterior capsular insertion created significant additional RH translation posteriorly (P < .05). With release of the capsule and the extensor origin, the elbow was grossly unstable. CONCLUSIONS: The elbow's lateral capsuloligamentous complex plays an important role in preventing PLRI. Larger degrees of elbow laxity are associated with further peel back of the capsuloligamentous complex despite an intact CEO. The surgeon must retract the extensor origin intraoperatively to assess for lateral ulnar collateral ligament and/or lateral capsule disruption to prevent a missed case of PLRI.

Performance outcomes after medial ulnar collateral ligament reconstruction in Major League Baseball positional players.

BACKGROUND: We sought to determine whether professional baseball positional players who underwent medial ulnar collateral ligament (MUCL) reconstruction demonstrate decreases in performance on return to competition compared with preoperative performance metrics and their control-matched peers. METHODS: Data for 35 Major League Baseball positional players who underwent MUCL reconstruction during 31 seasons were obtained. Twenty-six players met inclusion criteria. Individual statistics for the 2 seasons immediately before injury and the 2 seasons after injury included wins above replacement (WAR), on-base plus slugging (OPS), and isolated power (ISO). Twenty-six controls matched by player position, age, plate appearances, and performance statistics were identified. RESULTS: Of the 35 athletes who underwent surgery, 7 did not return to their preinjury level of competition (return to play rate of 80%). In comparing preinjury with postinjury statistics, players exhibited a significant decrease in plate appearances, at-bats, and WAR 2 seasons after injury but did not demonstrate declines in WAR 1 season after injury. Compared with matched controls, athletes who underwent MUCL reconstruction did not demonstrate significant decline in statistical performance, including OPS, WAR, and ISO, after return to play from surgery. Of all positional players, catchers undergoing surgery demonstrated lowest rates of return to play (56%) along with statistically significant decreases in home run rate, runs batted in, and ISO. CONCLUSION: Major League Baseball positional players undergoing MUCL reconstruction can reasonably expect to return to their preinjury level of competition and performance after surgery compared with their peers. Positional players return to play at a rate comparable to that of pitchers; catchers may experience more difficultly in returning to preinjury levels of play.

Performance Outcomes After Hook of Hamate Fractures in Major League Baseball Players.

CONTEXT: Major League Baseball (MLB) players are at risk of hook of hamate fractures. There is a paucity of data assessing the effect of a hook of hamate fracture on MLB players' future athletic performance. OBJECTIVE: To determine if MLB players who sustain hook of hamate fractures demonstrate decreased performance upon return to competition when compared with their performance before injury and that of their control-matched peers. DESIGN: Retrospective case-control design. SETTING: Retrospective database study. PARTICIPANTS: 18 MLB players who sustained hook of hamate fractures. METHODS: Data for 18 MLB players with hook of hamate fractures incurred over 26 seasons (1989-2014) were obtained from injury reports, press releases, and player profiles ( www.mlb.com and www.baseballreference.com ). Player age, position, number of years in the league, mechanism of injury, and treatment were recorded. Individual season statistics for the 2 seasons immediately prior to injury and the 2 seasons after injury for the main performance variable-Wins Above Replacement-were obtained. Eighteen controls matched by player position, age, and performance statistics were identified. A performance comparison of the cohorts was performed. MAIN OUTCOME MEASURES: Postinjury performance compared with preinjury performance and matched-controls. RESULTS: Mean age at the time of injury was 25.1 years with a mean of 4.4 seasons of MLB experience prior to injury. All injuries were sustained to their nondominant batting hand. All players underwent operative intervention. There was no significant change in Wins Above Replacement or isolated power when preinjury and postinjury performance were compared. When compared with matched-controls, no significant decline in performance in Wins Above Replacement the first season and second season after injury was found. CONCLUSION: MLB players sustaining hook of hamate fractures can reasonably expect to return to their preinjury performance levels following operative treatment.

Scaphoid Healing Required for Unrestricted Activity: A Biomechanical Cadaver Model.

PURPOSE: To determine if scaphoid fractures with bridging bone of 50% of their width treated with a centrally placed screw will restore biomechanical integrity equivalent to that of the intact scaphoid. METHODS: Twenty-four fresh cadaver scaphoids were used. Six were left intact to serve as the control group. Six were osteotomized 50% of their width and made up the osteotomy without screw group. Six were included in the 50% osteotomy plus compression screw group. The remaining 6 were to be treated with an osteotomy of 25% or 75% with a screw, based upon the results of the 50% osteotomy with screw group. Biomechanical testing was performed using an Instron testing machine, with a load applied to the scaphoid's distal pole. Load to failure and stiffness were measured. RESULTS: Intact scaphoids had an average load to failure of 610.0 N. The average load to failure of the 50% osteotomy group without a screw was 272.0 N and with a screw was 666.3 N. There was no significant difference in load to failure between the 50% osteotomy plus screw and the intact scaphoid. The 75% osteotomy plus screw was found to have a load to failure of 174.0 N, significantly lower than the intact scaphoid. The 50% osteotomy plus screw had a significantly higher stiffness than the intact scaphoid control. CONCLUSIONS: A 50% intact scaphoid with a centrally placed screw showed similar load to failure and significantly higher stiffness than the intact scaphoid when tested in cantilever bending. CLINICAL RELEVANCE: This study demonstrates that patients with scaphoid waist fractures who undergo surgery with a compression screw may be able to return to unrestricted activity with 50% partial healing.

Microsurgery Case Volume During Orthopedic Surgery Residency: A 7-Year Assessment.

BACKGROUND: Microsurgery is a specialized surgical technique with wide clinical application. The purpose of this study was to analyze case logs of graduating orthopedic surgery residents to assess trends in case volume for microsurgery procedures. METHODS: Accreditation Council for Graduate Medical Education case log reports were analyzed for microsurgery experience from 2007 to 2013. The mean number of adult, pediatric, and total microsurgery cases was noted. In addition, the median number of microsurgery procedures performed by the 90th, 50th, and 10th percentiles of residents (by case volume) was recorded. Temporal changes in case volume were calculated utilizing linear regression analyses. RESULTS: The proportion of microsurgery procedures increased significantly (1.3% to 2%; P = .024). The mean number of adult (24.5 to 41.9; P = .01), pediatric (1.9 to 3.4; P = .011), and total (26.3 to 45.3; P = .01) microsurgery procedures also increased significantly. Similarly, residents in both the 90th (63 to 109; P = .01) and 50th (10 to 21; P = .036) percentiles sustained significant increases in the median number of microsurgery procedures. No change was noted for residents in 10th percentile (0 to 0; P > .999). Graduating residents in the 90th percentile performed over 6 times more microsurgery procedures than residents in the 50th percentile. CONCLUSIONS: Microsurgical caseload is increasing among graduating orthopedic residents. However, there is substantial variability in resident microsurgery case volume. Future investigations are needed to explore the educational implications of these findings and should seek to correlate microsurgical caseload with competency.

Bennett Fractures A Review of Management.

A Bennett fracture is a common injury that involves an intra-articular fracture at the base of the first metacarpal. This fracture typically results in a dorsally and radially displaced metacarpal shaft relative to the well-anchored volar ulnar fragment. Most Bennett fractures are treated with operative fixation, including closed reduction and percutaneous fixation, open reduction and internal fixation, or arthroscopically assisted fixation. However, the optimal surgical approach is controversial. There is a paucity of literature comparing the outcomes of the various treatments, leaving the surgeon without a clear treatment algorithm. Moreover, there is no consensus on acceptable reduction parameters, including articular gap or step-off, with some series stating that up to 2 mm of displacement is acceptable.

Performance Outcomes After Metacarpal Fractures in National Basketball Association Players.

Background: The aim was to determine whether players in the National Basketball Association (NBA) who sustain metacarpal fractures demonstrate decreased performance upon return to competition when compared with their performance before injury and that of their control-matched peers. Methods: Data for 32 NBA players with metacarpal fractures incurred over 11 seasons (2002-2003 to 2012-2013) were obtained from injury reports, press releases, and player profiles (www.nba.com and www.basketballreference.com). Player age, body mass index (BMI), position, shooting hand, number of years in the league, and treatment (surgical vs nonsurgical) were recorded. Individual season statistics for the 2 seasons immediately prior to injury and the 2 seasons after injury, including player efficiency rating (PER), were obtained. Thirty-two controls matched by player position, age, and performance statistics were identified. A performance comparison of the cohorts was performed. Results: Mean age at the time of injury was 27 years with an average player BMI of 24. Players had a mean 5.6 seasons of NBA experience prior to injury. There was no significant change in PER when preinjury and postinjury performances were compared. Neither injury to their shooting hand nor operative management of the fracture led to a decrease in performance during the 2 seasons after injury. When compared with matched controls, no significant decline in performance in PER the first season and second season after injury was found. Conclusion: NBA players sustaining metacarpal fractures can reasonably expect to return to their preinjury performance levels following appropriate treatment.

Evaluation of Automated Volumetric Cartilage Quantification for Hip Preservation Surgery.

Automating the process of femoroacetabular cartilage identification from magnetic resonance imaging (MRI) images has important implications to guiding clinical care by providing a temporal metric that allows for optimizing the timing for joint preservation surgery. In this paper, we evaluate a new automated cartilage segmentation method using a time trial, segmented volume comparison, overlap metrics, and Euclidean distance mapping. We report interrater overlap metrics using the true fast imaging with steady-state precession MRI sequence of 0.874, 0.546, and 0.704 for the total overlap, union overlap, and mean overlap, respectively. This method was 3.28× faster than manual segmentation. This technique provides clinicians with volumetric cartilage information that is useful for optimizing the timing for joint preservation procedures.

Everything Achilles: Knowledge Update and Current Concepts in Management: AAOS Exhibit Selection.

Achilles tendon pathology is common and affects athletes and nonathletes alike. The cause is multifactorial and controversial, involving biological, anatomical, and mechanical factors. A variety of conditions characterized by Achilles tendon inflammation and/or degeneration can be clinically and histologically differentiated. These include insertional Achilles tendinopathy, retrocalcaneal bursitis, Achilles paratenonitis, Achilles tendinosis, and Achilles paratenonitis with tendinosis. The mainstay of treatment for all of these diagnoses is nonoperative. There is a large body of evidence addressing treatment of acute and chronic Achilles tendon ruptures; however, controversy remains.

Symptomatic venous thrombo-embolism in low-energy isolated fractures in hospitalised patients.

INTRODUCTION: In the prevention of venous thrombo-embolic events (VTEs) in isolated low-energy fracture patients, management guidelines are conflicting and prior literature is lacking. We aimed to determine the incidence and factors associated with the development of symptomatic VTE in this patient cohort. MATERIALS AND METHODS: To identify patients with isolated, low-energy fractures, we studied billing records from all admissions to our tertiary care orthopaedic hospital from 2007 to 2009. We used International Classification of Diseases, 9th Revision codes to identify patients who developed deep vein thrombosis (DVT) and/or pulmonary embolism (PE) during their hospital admission or within 90 days of discharge. We also collected data on socio-demographics, type of injury, fracture treatment, co-morbidities and anticoagulation therapy at time of admission. This study was a retrospective review of a database. RESULTS: In total, 1701 admissions fit our criteria. Average patient age was 64.27 years and 64.4% were female. There were 479 (28.2%) upper extremity fractures and 1222 (71.8%) lower extremity fractures. Incidence of clinically significant VTE was 1.4%. Of the 24 patients with 25 documented VTE, there were 13 DVTs and 12 PEs, including 2 fatal PEs (0.012%). Nineteen VTEs occurred in association with lower extremity fractures and six with upper extremity fractures; 74% of patients were chemoprophylaxed. Patients with VTE had an average age of 69.5 years and an average body mass index (BMI) of 28 kgm(-2). Logistical regression analysis found female sex (p = 0.05) and elevated BMI (p = 0.003) to be the only significant predictors of VTE. CONCLUSIONS: Clinically significant VTE among patients who sustained isolated, low-energy fractures was found to be low in the setting of standard VTE prophylaxis. Our incidence was consistent with that of patients undergoing total hip arthroplasty. Female sex and increased BMI were statistically significant predictors of VTE.