Biomechanical Comparison of Anatomic Restoration of the Ulnar Footprint vs Traditional Ulnar Tunnels in Ulnar Collateral Ligament Reconstruction.

BACKGROUND: Current techniques for ulnar collateral ligament (UCL) reconstruction do not reproduce the anatomic ulnar footprint of the UCL. The purpose of this study was to describe a novel UCL reconstruction technique that utilizes proximal-to-distal ulnar bone tunnels to better re-create the anatomy of the UCL and to compare the biomechanical profile at time zero among this technique, the native UCL, and the traditional docking technique. HYPOTHESIS: The biomechanical profile of the anatomic technique is similar to the native UCL and traditional docking technique. STUDY DESIGN: Controlled laboratory study. METHODS: Ten matched cadaveric elbows were potted with the forearm in neutral rotation. The palmaris longus tendon graft was harvested, and bones were sectioned 14 cm proximal and distal to the elbow joint. Specimen testing included (1) native UCL testing performed at 90° of flexion with 0.5 N·m of valgus moment preload, (2) cyclic loading from 0.5 to 5 N·m of valgus moment for 1000 cycles at 1 Hz, and (3) load to failure at 0.2 mm/s. Elbows then underwent UCL reconstruction with 1 elbow of each pair receiving the classic docking technique using either anatomic (proximal to distal) or traditional (anterior to posterior) tunnel locations. Specimen testing was then repeated as described. RESULTS: There were no differences in maximum load at failure between the anatomic and traditional tunnel location techniques (mean ± SD, 34.90 ± 10.65 vs 37.28 ± 14.26 N·m; P = .644) or when including the native UCL (45.83 ± 17.03 N·m; P = .099). Additionally, there were no differences in valgus angle after 1000 cycles across the anatomic technique (4.58°± 1.47°), traditional technique (4.08°± 1.28°), and native UCL (4.07°± 1.99°). The anatomic group and the native UCL had similar valgus angles at failure (24.13°± 5.86° vs 20.13°± 5.70°; P = .083), while the traditional group had a higher valgus angle at failure when compared with the native UCL (24.88°± 6.18° vs 19.44°± 5.86°; P = .015). CONCLUSION: In this cadaveric model, UCL reconstruction with the docking technique utilizing proximal-to-distal ulnar tunnels better restored the ulnar footprint while providing valgus stability comparable with reconstruction with the docking technique using traditional anterior-to-posterior ulnar tunnel locations. These results suggest that utilization of the anatomic tunnel location in UCL reconstruction has similar biomechanical properties to the traditional method at the time of initial fixation (ie, not accounting for healing after reconstruction in vivo) while keeping the ulnar tunnels farther from the ulnar nerve. Further studies are warranted to determine if an anatomically based UCL reconstruction results in differing outcomes than traditional reconstruction techniques. CLINICAL RELEVANCE: Current UCL reconstruction techniques do not accurately re-create the ulnar UCL footprint. The UCL is a dynamic constraint to valgus loads at the elbow, and a more anatomic reconstruction may afford more natural joint kinematics. This more anatomic technique performs similarly to the traditional docking technique at time zero, and the results of this study may offer a starting point for future in vivo studies.

Management and outcomes of latissimus dorsi and teres major injuries in professional baseball pitchers.

BACKGROUND: Very little data exist on latissimus dorsi (LD) and teres major (TM) injuries in professional baseball pitchers. PURPOSE: This review was undertaken to report on the management and outcomes of baseball pitchers with injury to 1 or both of these muscles. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review of 16 professional baseball pitchers diagnosed and treated for an LD and/or TM tear between 2002 and 2008 was performed. Magnetic resonance imaging confirmed the diagnosis in all cases. The mean age was 28.1 years. All were treated nonoperatively with rest, rehabilitation, and return to pitching after a throwing program. The injuries included tendon avulsions in 6 athletes and strains in 10. Length of disabled time, return to prior level of pitching, and recurrences were noted. RESULTS: Fifteen of 16 pitchers (94%) returned to the same or higher level of play. The mean time to throwing was 35.6 days. Mean time to pitching was 61.9 days. Nine of 16 injuries (56%) were season-ending. Mean total time lost for athletes returning the same season was 82.4 days. Two of 16 pitchers (13%) sustained recurrent injuries. Prior shoulder and elbow injuries were noted in 75% (12 of 16). CONCLUSION: Injury of the LD and/or TM can occur in pitchers. Nonoperative treatment is successful in allowing a return to high-level pitching.

Open luxatio erecta: a case report and literature review.

Luxatio erecta humeri is a rare clinical entity, comprising 0.5% of all glenohumeral dislocations. Even more uncommon, open luxatio erecta has only been described three times dating back to the 1800s. These cases report poor results including death from sepsis, avascular necrosis, and severely limited motion. We now report a fourth case of open luxatio erecta secondary to a work-related injury.

Cost analysis of outpatient anterior cruciate ligament reconstruction: autograft versus allograft.

BACKGROUND: Prior studies suggest the cost of allograft anterior cruciate ligament (ACL) reconstruction is less than that for autograft reconstruction. Charges in these studies were influenced by patients requiring inpatient hospitalization. QUESTION/PURPOSE: We therefore determined if allograft ACL reconstruction would still be less costly if all procedures were performed in a completely outpatient setting. METHODS: We retrospectively reviewed 155 patients who underwent ACL reconstruction in an ambulatory surgery center between 2001 and 2004; 105 had an autograft and 50 had an allograft. Charges were extracted from itemized billing records, standardized to eliminate cost increases, and categorized for comparison. Surgeon and anesthesiologist fees were not included in the analysis. Groups were compared for age, gender, mean total cost, mean cost of implants, and several other cost categories. RESULTS: The mean total cost was $5465 for allograft ACL reconstruction and $4872 for autograft ACL reconstruction. There were no differences in complications between the two groups. CONCLUSIONS: Allograft ACL reconstruction was more costly than autograft ACL reconstruction in the outpatient setting. The cost of the allograft outweighs the increased surgical time needed for harvesting an autograft. LEVEL OF EVIDENCE: Level II, economic and decision analyses. See Guidelines for Authors for a complete description of levels of evidence.

Neer Award 2005: Peripheral nerve function during shoulder arthroplasty using intraoperative nerve monitoring.

The incidence of neurologic injury after shoulder arthroplasty has been reported to be 1% to 4%. However, the true incidence may be higher, because injury is identified only clinically and examination of the post-arthroplasty shoulder is difficult. This study used intraoperative nerve monitoring to identify the incidence, pattern, and predisposing factors for nerve injury during shoulder arthroplasty. Continuous intraoperative monitoring of the brachial plexus was performed in 30 consecutive patients undergoing shoulder arthroplasty. Impending intraoperative compromise of nerve function was signaled by sustained neurotonic electromyographic activity or greater than 50% amplitude attenuation of transcranial electrical motor evoked potentials (or both). Arm and retractor positions were recorded and adjusted to relieve tension. Patients with intraoperative nerve alerts underwent diagnostic electromyography at least 4 weeks postoperatively. Of the patients, 17 (56.7%) had 30 episodes of nerve dysfunction (ie, nerve alerts) during surgery. None of these 30 nerve alerts returned to baseline with retractor removal alone. Of the 30 alerts, 23 (76.7%) returned to baseline after repositioning of the arm into a neutral position. Postoperative electromyography results were positive in 4 of 7 patients (57.1%) who did not have a return to baseline transcranial electrical MEPs intraoperatively and in 1 of 10 (10%) whose nerve function did return to baseline. In all cases of positive postoperative electromyographic results, the pattern of nerve involvement matched the pattern of intraoperative nerve dysfunction. The affected nerves included the following: combined (ie, mixed plexopathy) (46.7%), musculocutaneous (20%), axillary (16.7%), ulnar (10%), and radial (6.7%). Prior shoulder surgery and passive external rotation of less than 10 degrees were associated with an increased incidence of nerve dysfunction (P < .05). The incidence of nerve injury during shoulder arthroplasty is likely greater than reported. Positioning of the arm at the extremes of motion should be minimized. Patients with decreased motion (<10 degrees passive external rotation with the arm at the side) and a history of prior open shoulder surgery are at higher risk for nerve injury and should be counseled on the increased risk. This patient population may also be considered for routine nerve monitoring.

Heterotopic ossification in a throwing athlete after elbow arthroscopy.

A case of heterotopic ossification occurring after elbow arthroscopy in a young, healthy, throwing athlete is reported. The heterotopic bone caused a loss of motion post-arthroscopy in the patient and was confirmed with plain radiographs and bone scan. Twenty-two months after elbow arthroscopy, the patient underwent an open excision of the heterotopic bone. He returned to competitive throwing the next season. While this complication is rare after such minimally invasive procedures, this entity should be considered in the differential diagnosis in the throwing athlete who is unable to recover full range of motion after elbow arthroscopy.

Thermal modification of partial tears of the anterior cruciate ligament.

PURPOSE: Partial tears of the anterior cruciate ligament (ACL) are common, representing 10% to 28% of all ACL tears. Untreated partial tears of the ACL may go on to complete rupture in up to 42% of cases, and as few as 30% of patients return to their preinjury activity level. The purpose of this study was to evaluate the effectiveness of thermal modification for the treatment of partial tears of the ACL. TYPE OF STUDY: A prospective, nonrandomized consecutive case series. METHODS: Thirteen patients with a partial tear of a native ACL were treated with thermal modification of the ACL. All patients had a preoperative office examination significant for an end-point to Lachman examination and pivot-glide. All patients had bilateral preoperative KT-1000 measurements. All tears were confirmed by arthroscopy to constitute a 50% or less loss of structural integrity of the ligament. The ACL underwent thermal modification using the Oratec thermal probe (Oratec Interventions, Menlo Park, CA), and was examined by intraoperative KT-1000 testing. Patients were evaluated postoperatively at 6 weeks, and at 3, 6, 12, and 24 months by office examination and functional outcome scoring. RESULTS: KT-1000 arthrometer testing revealed a mean side-to-side difference of 4.35 mm preoperatively (SD = 1.1 mm). At the most recent follow-up, averaging 23 months (range, 18 to 28 months), 10 patients had a negative Lachman examination and no pivot-shift. Two patients had persistent grade II Lachman and complaints of giving way 3 months postoperative. Both patients underwent ACL reconstruction. One patient was lost to follow-up. Of the remaining 10 patients, all patients achieved full extension, and the average flexion range of motion was 131 degrees (SD = 5.6). Compared with the preoperative KT-1000 arthrometer testing, the most recent evaluation revealed a decrease in mean side-to-side difference to 1.9 mm (SD = 1.5 mm). At most recent follow-up, the mean Lysholm score was 96.3 (SD = 4.4), the mean Tegner score was 6.1 (SD = 1.2), and the mean Cincinnati score was 94 (SD = 3.0). CONCLUSIONS: With cautious application, thermal modification may be a viable treatment option for partial tears of the ACL in a select subset of patients. Further investigation is necessary to determine the long-term effectiveness of this procedure. LEVEL OF EVIDENCE: Level IV, Therapeutic Case Series Study (no or historical control group).