Thoracic outlet syndrome in overhead athletes.

Background: We aimed to retrospectively compare the clinical outcomes of endoscopy-assisted first-rib resection for thoracic outlet syndrome (TOS) between overhead athletes and nonathletes and investigate the return to same-level sports rate in overhead athletes. Methods: We retrospectively reviewed 181 cases with TOS (75 women, 106 men; mean age, 28.4 years; range, 12-57 years) who underwent endoscopy-assisted first-rib resection. We divided into two groups: 79 overhead athletes and 102 nonathletes groups. A transaxillary approach for first-rib resection and neurovascular decompression was performed under magnified visualization. Endoscopic findings related to the neurovascular bundle, interscalene distance, and scalene muscle were evaluated intraoperatively. We assessed the Roos and Disability of the Arm, Shoulder, and Hand scores, return to same-level sports rate, and ball velocity. Results: Overhead athletes were significantly more likely to be men, younger, used the dominant side more frequently, and have a larger physique, more shoulder and elbow pain, and shorter symptom duration. The outcomes of the Roos score revealed significant differences in excellent or good results between overhead athletes (91.1%) and nonathletes (62.8%). The two groups significantly differed in preoperative and postoperative Disability of the Arm, Shoulder, and Hand and recovery rate scores (P = .007, < .001, < .001). Conclusion: Overhead athletes with TOS were more likely to be men, younger, dominant side more frequently, and have more shoulder and elbow pain, and a shorter symptom duration. Endoscopy-assisted transaxillary first-rib resection and neurolysis provided superior clinical outcomes in overhead athletes with TOS compared with nonathletes and a high return-to-same-level-play rate in sports.

Management of ulnar collateral ligament injury in baseball athletes: An online survey in Japanese surgeons.

BACKGROUND: The management of ulnar collateral ligament (UCL) injuries widely varies among surgeons. Although various treatment options have been proposed including surgical and conservative treatments, no golden standard treatment strategy has been established of yet. The American survey reported an overall experienced and well-trained cohort of surgeons often reached consensus opinions on how to approach UCL injury. However, the consensus among Japanese surgeons on the treatment of UCL injuries remains unclear. The purpose of this study was to survey current trends among Japanese orthopaedic surgeons in the treatment of UCL injuries in baseball players. METHODS: An online survey was distributed to the active members of the Japanese doctor's network for baseball injury prevention, which was formed by partial members of the medical committee in the Japan Baseball Council. The survey was composed of three sections: demographics of the surveyees, preferred operative and nonoperative management of UCL injuries, and five fictional clinical case scenarios of baseball players with a UCL injury. RESULTS: The 131 e-mailed invitations to society members yielded 78 completed online surveys with a participation rate of 60%. Sixty-four respondents (82%) reported >15 years of clinical experience. Sixty-five respondents (83%) performed ≤5 UCL reconstructions per year. As nonsurgical management of UCL injuries, seventy-four surgeons (95%) preferred physiotherapy followed by intraarticular injection (46%). For surgical management, seventy-three surgeons (93%) preferred UCL reconstruction. Of the five case scenarios, a consensus was reached in three cases: to perform surgery on the patient with full-thickness UCL tear. When operative management was the preferred option, a consensus was reached to perform UCL reconstruction. CONCLUSION: Japanese doctors involved in the treatment of baseball injuries reached a consensus to indicate high-level athletes with a full-thickness UCL tear for surgery. When operative management was the preferred option, a consensus was reached to perform UCL reconstruction. These results may contribute to the decision-making for managing UCL injuries.

Arthroscopic superior capsule reconstruction augmentation using a semitendinosus autograft in massive reparable rotator cuff tears.

Background: Arthroscopic superior capsule reconstruction (SCR) augmentation is a viable treatment option for massive reparable cuff tears. This study aimed to retrospectively compare clinical and imaging outcomes of patients with reparable massive rotator cuff tears after arthroscopic rotator cuff repair (ARCR) with those after SCR augmentation using a semitendinosus autograft. Methods: We retrospectively compared 50 patients with massive reparable rotator cuff tears who underwent ARCR and SCR augmentation (n = 25 each). Patients were clinically followed up for at least 2 years, and the American Shoulder and Elbow index, other patient-reported outcomes, active range of motion, and radiography and magnetic resonance imaging findings were assessed. Results: At the final follow-up, both patient groups showed significant improvements in forward elevation in range of motion and visual analog scale scores. Improvements in the American Shoulder and Elbow scores in the SCR augmentation group were significantly superior to those in the ARCR group (48.3 and 28.9, P < .01). There was a significant difference in the retear rate between the SCR augmentation group and ARCR group (20% and 56%, respectively; P = .009). Conclusion: Our study demonstrated that patient-reported outcomes and retear rates in patients who underwent SCR augmentation with rotator cuff repair for massive rotator cuff tears significantly improved compared with those in patients who underwent ARCR without augmentation. Augmentation with semitendinosus autografting during rotator cuff repair represents a solution for patients with massive reparable rotator cuff tears.

Drug-dependent analgesic efficacy in interscalene block for postoperative pain after arthroscopic rotator cuff repair: a comparison between ropivacaine and levobupivacaine.

Background: Interscalene brachial plexus block (ISB) for arthroscopic rotator cuff repair (ARCR) provides high analgesic efficacy for postoperative pain. However, different drug efficacies remain unclear. This retrospective study compared the efficacy of ropivacaine and levobupivacaine in a single-dose ISB for pain control after ARCR. Methods: This study included 173 patients who underwent ARCR; they were divided into the ISBR group (n = 61) that received ISB with 20 mL 0.375% ropivacaine and 3.3 mg dexamethasone, and the ISBL group (n = 112) that received ISB with 20 mL 0.25% levobupivacaine and 3.3 mg dexamethasone. Visual analog scale (VAS) pain scores were evaluated at 1, 4, 8, 12, 24, and 48 hours, postoperatively. Rebound pain was defined as a difference of ≥ 5 points between the highest and lowest VAS pain scores. Results: The mean VAS pain scores at 1 hour were not significantly different between the groups. ISBL administration resulted in significantly lower VAS pain scores at 4, 8, 12, and 24 hours than ISBR administration. Rebound pain rates in the ISBR and ISBL groups were 41.0% and 17.9%, respectively. Rebound pain was more frequent in the ISBR than in the ISBL group. Conclusion: ISB with levobupivacaine and dexamethasone can provide more effective postoperative pain control after ARCR than ropivacaine and dexamethasone.

Evaluation of hypervascularity in synovitis of the shoulder using ultrasound: comparison of preoperative ultrasound findings and intraoperative arthroscopic findings.

Background: Synovitis of the shoulder causes pain; however, it is difficult to accurately determine the area and degree of synovitis from preoperative images. This study investigated the correlation between intraoperative arthroscopic findings and preoperative power Doppler ultrasonography (PDUS) findings for synovitis evaluation. Methods: Forty patients (mean age = 62.0 years; 24 men and 16 women) underwent arthroscopic surgery for partial rotator cuff tears. Three observation areas were evaluated: rotator interval (RI), subacromial bursa, and bicipital groove. The Doppler flow areas and PDUS grade were measured one day before surgery. Arthroscopic findings were visualized intraoperatively and classified into 3 groups: pale, pink, and red. The correlation between the arthroscopic classification and PDUS findings was analyzed. Results: The correlation between intraoperative arthroscopic classification and preoperative PDUS findings, Doppler flow area and PDUS grade, was high for the RI (r = 0.82, 0.70). There was no correlation for the subacromial bursa (r = 0.01, -0.02) and the bicipital groove (r = -0.03, 0.3). Conclusion: Hypervascularity findings in the PDUS were highly correlated with arthroscopic color classification in the RI. Therefore, visualization of hypervascularity in the RI area could be a reliable measure for the assessment of glenohumeral synovitis in patients with partial-thickness rotator cuff tear.

Endoscopic-Assisted Transaxillary Approach for First Rib Resection in Thoracic Outlet Syndrome.

PURPOSE: To assess the feasibility, safety, and clinical outcomes of an endoscopic-assisted transaxillary approach of first rib resection for thoracic outlet syndrome (TOS) and to compare the differences in demographic and clinical data between satisfactory and unsatisfactory outcomes using this approach. METHODS: We retrospectively identified patients who underwent endoscopic-assisted first rib partial resection. A transaxillary approach for the first rib resection and neurovascular decompression were undertaken under magnified visualization. Endoscopic classification of neurovascular bundle (NVB) patterns and interscalene distance (ISD) between anterior and middle scalene muscles were evaluated intraoperatively. We assessed the Roos and DASH scores. RESULTS: We reviewed 131 cases of TOS (48 women and 83 men; mean age 26.2 years; range 12 to 57). Roos classification revealed 80.2% excellent or good results. DASH scores improved significantly from 40.7 ± 20.0 to 15.7 ± 19.6 (P < .001). The complication rate was low (5.3%), with 4 pneumothorax and 3 other complications. Intraoperative NVB classification revealed 30 cases of parallel type, in which the artery and nerve travel in parallel; 69 oblique types, and 30 vertical types, in which the nerve was completely behind the middle scalene muscle or abnormal band. The ISD was narrower (5.4 ± 3.6 mm) than in previous cadaveric studies. The ISD in the parallel patterns was wider than that in the vertical patterns. In the satisfactory group, we found a significantly larger number of men, younger patients, athletes, and patients with a lower preoperative DASH score. CONCLUSIONS: An endoscopic-assisted transaxillary approach for first rib resection in TOS provides an excellent magnified visualization, safely allowing sufficient decompression of the neurovascular bundle and satisfactory surgical outcomes. Younger male athletes with TOS may be better candidates for this procedure. LEVEL OF EVIDENCE: IV, therapeutic case series.

Suprascapular nerve block versus interscalene block for analgesia after arthroscopic rotator cuff repair.

OBJECTIVE: To retrospectively compare the efficacy of suprascapular nerve block (SSNB) versus interscalene block (ISB) for analgesia after arthroscopic rotator cuff repair (ARCR). METHODS: Ninety-seven patients who underwent ARCR were retrospectively divided into three groups. Group S comprised 33 patients who received SSNB, group I comprised 52 patients who received ISB, and group C comprised 12 patients who received a glenohumeral injection as a control. SSNB and ISB were performed with 20 ml of 0.375% ropivacaine before surgery, while glenohumeral injection was performed after surgery. The Visual analog scale (VAS) pain scores were recorded at 1,3, and 6 h and 1, 3, and 6 days postoperatively. The total number of additional analgesic administrations was also counted for 6 days postoperatively. RESULTS: Compared with group C, the VAS pain score was significantly lower in group S at 1 h and 6 days postoperatively, and in group I at 1 and 3 h postoperatively. There were no significant differences between groups S and I in the VAS pain scores, or the administration of additional analgesia. There were no major complications associated with SSNB or ISB. CONCLUSION: There were no significant differences between SSNB and ISB in the duration of analgesia and the VAS pain scores after ARCR.

Predictors of Unsuccessful Nonoperative Management of Capitellar Osteochondritis Dissecans.

BACKGROUND: Osteochondritis dissecans of the humeral capitellum (capitellar OCD) is a common injury among adolescent throwing athletes. Some younger patients with incomplete maturity of the epiphysis and early-stage capitellar OCD are good candidates for nonoperative treatment. However, during initial examination, predicting the need for surgical treatment in patients with capitellar OCD is difficult. PURPOSE: To perform multivariate ordered logistic regression analysis of data obtained from patients' medical records and images on initial examination and identify the predictors of unsuccessful nonoperative management of capitellar OCD. STUDY DESIGN: Cohort study (prognosis); Level of evidence, 2. METHODS: This study included 245 elbows with capitellar OCD (all male; mean age, 14 years [range, 10-27 years]). Patients were divided into 3 groups comprising 148 elbows requiring an immediate operation on initial examination, 48 requiring nonsurgical treatment, and 49 requiring an operation after nonoperative management. Baseline data and radiographic parameters, such as lesion location, lesion size, modified Minami classification, radial head size, skeletal age difference between both elbows on initial examination, lesion size on computed tomography, and staging on magnetic resonance imaging, were retrospectively reviewed. Univariate and multivariate ordered logistic regression analyses of spontaneous healing of the lesion were conducted. RESULTS: Univariate logistic regression analysis showed that radial head enlargement and skeletal age difference were significantly associated with spontaneous healing. In multivariate ordered logistic regression analysis, radial head enlargement (anteroposterior and lateral) and skeletal age difference were significant predictors of lack of spontaneous healing (odds ratio [OR], 2.76, P =.025; OR, 7.92, P =.026; and OR, 1.84, P =.0089, respectively). CONCLUSION: To predict spontaneous healing in the moderate stage, plain radiographs would be important to evaluate radiocapitellar congruity and skeletal age. This study showed that preoperative radiographic findings of radial head enlargement and advanced skeletal age of the throwing side compared with that of the nonthrowing side were predictors of advanced-stage capitellar OCD. Despite several limitations, the statistical significance and correlations herein provide important information on preoperative surgical planning to surgeons.

First-Rib Stress Fracture in Overhead Throwing Athletes.

BACKGROUND: First-rib stress fracture is considered a potential cause of nonspecific atraumatic chronic shoulder pain in adolescent athletes. However, the etiology in throwing athletes with first-rib fracture is still unknown. The purpose of this retrospective study was to investigate the characteristic clinical features and radiographic findings of overhead throwing athletes with first-rib fracture. METHODS: Twenty-four first-rib stress fractures in 23 players were studied retrospectively. Clinical features, including age, initial symptom, sports, pain-related activity, diagnostic method, treatment method, and final follow-up, were reviewed. RESULTS: The following characteristic clinical features were identified: mean age of 16.8 years (range, 13 to 25 years), 19 dominant arm injuries and 5 non-dominant arm injuries, and an acute increase in pain while swinging the bat or pitching the ball. Sixteen fractures presented with posterior shoulder or upper thoracic back pain. At a mean time of 7.5 months after the initiation of conservative treatment, 17 healing fractures (71%) and 7 nonunion fractures (29%) among throwing athletes with first-rib stress fracture were identified. On image analysis, first-rib stress fractures were classified into 3 types depending on the direction and location of fracture lines: groove, intrascalene, and posterior types. Three symptomatic patients underwent first-rib resection due to thoracic outlet syndrome. On average, 46% of the first rib was visible on the shoulder radiographs and 97% was visible on the cervical spine radiographs. The Cohen kappa coefficient for the above percentages was 0.87 and the percent agreement was 89.4% for the shoulder, and the Cohen kappa coefficient was 0.80 and the percent agreement was 99.0% for the cervical spine. CONCLUSIONS: First-rib stress fracture should be considered when adolescent overhead throwing athletes have acute-onset posterior shoulder pain while swinging the bat or pitching the ball. Anteroposterior radiography of the cervical spine is available for initial diagnosis. Although 71% of the patients healed at a mean follow-up of 7.5 months with conservative treatment, some patients may have symptoms consistent with thoracic outlet syndrome. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Quadrilateral Space Syndrome With Involvement of the Tendon of the Latissimus Dorsi.

Quadrilateral space syndrome (QSS) is the term used to describe axillary nerve palsy due to compression of the axillary nerve and posterior circumflex artery in the quadrilateral space. The precise pathophysiology of QSS is still unclear; hence, a consensus of diagnosis and treatment for QSS has not yet been achieved. The authors present the case of a 17-year-old male baseball player with symptoms of QSS, including right elbow and shoulder joint pain and upper limb numbness while throwing. The symptoms had worsened during baseball. Conservative management for 3 months failed to resolve the symptoms, so surgery was performed. Axillary nerve decompression resulted in functional improvement. The cause of QSS has been previously reported to be fibrous bands, the long head of the triceps, and Bennett lesions. However, the cause of QSS in this case was compression of the axillary nerve between the proximal humerus and the tendinous attachment of the latissimus dorsi. The authors incised a 10- to 15-mm segment of the medial edge of the tendinous insertion of the latissimus dorsi, which resulted in resolution of QSS symptoms. [Orthopedics. 2017; 40(4):e714-e716.].

7. Usefulness of Low-Intensity Pulsed Ultrasound (LIPUS) for the Treatment of Osteochondritis Dissecans (OCD) of the Humeral Capitellum.

OBJECTIVES: LIPUS has been reported to promote bone union in pseudoarthrosis and delayed fracture union as well as to have a beneficial effect in shortening the duration of bone healing in fresh fractures. The purpose of this study was to examine whether LIPUS has an accelerating effect on healing OCD. SUBJECTS AND METHODS: From 2008 to 2012, cases with advanced-stage OCD were randomized, and the study was conducted on 51 patients (LIPUS group) who enabled us to decide the treatment efficacy, and gave consent after receiving an explanation on the benefit of LIPUS. LIPUS was performed for 20 minutes every day by treating the elbow in 2 directions, namely on the external and internal sides. The patients were told to stop pitching and batting. Plain radiography was performed once every 6 weeks and computed tomography (CT) scans were performed approximately once every 3 months. Image repair criteria were that the outside localized type was repaired completely, and the central localized or extensive type had lesion occupancy of less than 20%. Twenty-nine of 51 who did not recover and received surgical operation were excluded in the study, and 22 patients who were healed with LIPUS were compared with 21 patients who received conservative therapy only. RESULTS AND DISCUSSION: The image repair period for the LIPUS group was an average of 4.5 ± 1.9 months, while for the non-LIPUS group it was 6.8 ± 3.8 months. LIPUS treatment for OCD significantly shortened the image repair period (P = 0.037). It is necessary to increase the number of cases, and clarify the utility of LIPUS.