Orthopedic Injuries in Professional Surfers: A Retrospective Study at a Single Orthopedic Center.

BACKGROUND: Literature regarding surfing injuries is scarce and most studies report a high number of minor injuries. Recent literature suggests that musculoskeletal injuries are more common than previously reported. In the mid 2000s, competitive surfing has seen an increase in aerial maneuvers, as they have become more highly rewarded by the judging panel, which may be contributing to a change in injury patterns. Our goal was to evaluate orthopedic injuries in professional surfers. HYPOTHESIS: Orthopedic injuries in professional surfers are diverse and have evolved with skill and technology. STUDY DESIGN: Retrospective observational study. LEVEL OF EVIDENCE: Level 4 Case Series. METHODS: Medical records of professional surfers from a single orthopedic center between 1991 and 2016 were reviewed. Injuries sustained while surfing and chronic injuries related to surfing were included. Site of injury, diagnosis, and treatment were recorded along with demographic data. RESULTS: In total, 163 injuries in 86 athletes were recorded. The median injury age was 28.5 years (range 12-62 years) and 92.6% of patients were male. The most frequently injured body parts were the knee (28.2%), ankle (22.1%), and shoulder (19%). Most knee injuries were of the medial collateral ligament at 49%, with 75% of ankle injuries being sprains, and in shoulder, 48% had instability, 42% had a rotator cuff tear, and 35% had a superior anterior-posterior labral tear. Lower extremity injuries primarily affected the surfers' back leg (72.5%). In all, 34.6% of all injuries required surgical intervention and involved shoulder injuries most the time. CONCLUSIONS: The most common orthopedic injuries in professional surfers involve the knee, ankle, shoulder, hip, and back. Surfers' rear extremities were preferentially injured which is the extremity responsible for power and torque. Shoulder injuries increased the probability of an operative intervention. Last, overuse injuries (femoral-acetabular impingement, rotator cuffs) occurred in the older surf population compared with more acute injuries (ankle sprains/fractures, anterior cruciate ligament tears) which is also consistent with time to surgery.

Assessment of Cartilage Growth After Biopsy of Osteochondral Loose Bodies in Adolescent Knees for Use in Autologous Chondrocyte Implantation.

BACKGROUND: The goal of this study is to determine whether harvested cartilage from an osteochondral loose body maintains the same viability for implantation as cartilage harvested from the traditional locations within the adolescent knee for autologous chondrocyte implantation (ACI). METHODS: A retrospective study was performed on all ACI procedures performed from 2014 to 2017 at a single institution. Biopsies were derived from 2 groups: osteochondral loose body verses the intercondylar notch. The viability, yield, identity, potency, and density were obtained from each sample in addition to basic demographics and concomitant injuries. A total of 12 patients with osteochondral loose bodies 14.6 (SD=2.9) and 20 patients 13.6 (SD=3.3) with intercondylar notch biopsies were evaluated for the study. RESULTS: In the microscopic and histologic comparison, there was no significant difference in viability: 94% in the loose bodies and 93% in the intercondylar notch groups, identity: 7.4 d5L versus 6.3 d5L, or yield. Minimum yield is presented as different units in Carticel (1.2×10 cells/vial) and matrix-induced ACI (>8500 relative fluorescent units) products; however, there was no difference between groups and all samples were above the acceptable limit. Minimum identity value is recorded as d5L> -2.00 and all samples were above this limit. In addition, no sample had signs of contamination or endotoxin in either group. CONCLUSION: These results demonstrate an alternative method for obtaining cartilage biopsies in ACI procedures that may limit short-term and long-term donor site morbidity. LEVEL OF EVIDENCE: Level III.

Outpatient Total Shoulder Arthroplasty Does Not Increase the 90-Day Risk of Complications Compared With Inpatient Surgery in Prescreened Patients.

Outpatient total joint arthroplasty is becoming a more attractive option for hospitals, surgeons, and patients. In this study, the authors evaluated the safety of outpatient shoulder arthroplasty by comparing an outpatient cohort with an inpatient cohort. Ninety-day outcomes of consecutively performed elective shoulder arthroplasty cases from 2012 to 2016 were retrospectively reviewed. Patients were preoperatively assigned to outpatient or inpatient care. Primary outcomes were emergency department visits, readmissions, mortality, and surgical morbidity within 90 days of surgery. Two-tailed t tests were used to evaluate differences. Bivariate and multivariate logistic regressions were used to determine if the odds of emergency department visit, readmission, or complications were significantly different between the cohorts. There were 118 outpatient and 64 inpatient shoulder arthroplasty procedures. Mean age and American Society of Anesthesiologists score were lower in the outpatient group compared with the inpatient group-68.1 vs 72.4 years (P=.01) and 2.3 vs 2.6 (P<.01), respectively. In the multivariate logistic regression model including all arthroplasty cases, the odds of outpatient to inpatient readmission was significantly different (odds ratio, 0.181; P=.027). However, when only total shoulder arthroplasty cases were included, no difference was detected. No statistically significant difference was noted for number of emergency department visits, mortality, or surgical morbidity within 90 days of surgery in any of the models. There was 1 death in the ambulatory group at 28 days after surgery. On the basis of these findings, the authors believe that, for carefully selected patients, an outpatient shoulder arthroplasty protocol is safe when compared with inpatient protocols. [Orthopedics. 2018; 41(4):e563-e568.].

Acute Compartment Syndrome after Non-Contact Peroneus Longus Muscle Rupture.

This case demonstrates a rare variation in the pattern of injury and the presentation of acute lateral compartment syndrome of the leg. Although uncommon, lateral compartment syndrome of the leg after an ankle inversion leading to peroneus longus muscle rupture has been previously documented. This case was unusual because there was no overt ankle injury and the patient was able to continue physical activity, in spite of a significant rupture of the peroneus longus muscle that was determined later. This case highlights the necessary vigilance clinicians must maintain when assessing non-contact injuries in patients with possible compartment syndrome.

Surgical excision of a symptomatic congenital coracoclavicular joint.

The coracoclavicular joint is a rare anatomic variant that consists of an articulation between the conoid tubercle of the clavicle and the superior surface of the coracoid process of the scapula. The coracoclavicular joint is most often asymptomatic and is found incidentally. A symptomatic coracoclavicular joint is exceedingly rare, with only 17 cases reported from 1915 to 2009. Symptoms may include limited range of motion, paresthesia, and brachialgia with radiation to the ipsilateral extremity. In the case of symptomatic coracoclavicular joints for which treatment data are reported, the response to conservative management with rest, analgesics, and physical therapy has been poor. Operative management resulted in complete resolution of symptoms in most patients and symptomatic improvement in the rest. This article reports the case of a 63-year-old man who presented with chronic left anterior shoulder pain exacerbated by forward flexion and overhead activities. Radiographs and computed tomography scan of the affected shoulder showed a bony articulation between the clavicle and the coracoid process of the scapula. The patient did not achieve long-term relief through conservative measures and corticosteroid injections, so the joint was surgically excised by an open procedure. Intraoperative findings were significant for a fully formed synovial joint with a capsule articulating between the clavicle and the coracoid process. After resection, the patient had minimal residual pain, improved range of motion, and symptomatic improvement with activity. The current case provides further data that the coracoclavicular joint can be the cause of significant shoulder pain and can be treated successfully with total resection of the joint if symptoms do not improve with conservative non-operative measures.

Does patient sex affect the anatomic relationships between the sternoclavicular joint and posterior vascular structures?

BACKGROUND: Despite increased concern for injury during surgical reconstruction of the sternoclavicular joint, to our knowledge there are few studies detailing the vascular relationships adjacent to the joint. QUESTIONS/PURPOSES: We investigated sex differences in the following relationships for sternoclavicular joint reconstruction: (1) safe distance from the posterior surface of the medial clavicle's medial and lateral segments to the major vessels, (2) length of the first costal cartilage and safe distance from the first rib to the internal mammary artery, (3) minimum distance medial to the sternoclavicular joint for optimal hole placement, and (4) safe distance from the manubrium to the great vessels. METHODS: Fifty normal postcontrast CT scans of the chest were reviewed. Means, standard deviations, and 95% CI were calculated for each aforementioned measurement. A t-test was used to determine if a sex difference exists (p≤0.05). RESULTS: At the medial end of the clavicle, the safe distance from the medial segment (first 10 mm) to the major vessels was greater in males than in females (3.5 mm versus 2.4 mm, respectively; 95% CI, 3 mm-4 mm versus 1.7 mm-3 mm, respectively; p=0.014). For the lateral segment (next 10 mm), the distance also was safer in males than in females (3.3 mm versus 1.7 mm, respectively; 95% CI, 2.7 mm-4 mm versus 1.1 mm-2.3 mm, respectively; p<0.001). The mean length of the first costal cartilage also was greater in males (35.8 mm versus 30.1 mm, respectively; 95% CI, 33.8 mm-37.8 mm versus 28.5 mm-31.9 mm, respectively; p<0.001); the distance from the first costochondral joint to the internal mammary artery was safer in males than in females (19.1 mm versus 15.4 mm, respectively; 95% CI, 16.5 mm-21.8 mm versus 13 mm-17.9 mm, respectively; p=0.05). The minimum distance to avoid inadvertent penetration of the sternoclavicular joint was greater in males than in females (16 mm versus 12.3 mm, respectively; 95% CI, 14.6 mm-17.5 mm versus 11 mm-13.6 mm, respectively; p<0.001). The distance to vessels after penetration of the manubrium was not different between males and females (5.6 mm versus 3.9, respectively; 95% CI, 4.4 mm-6.8 mm versus 2.6 mm-5.2 mm, respectively; p=0.06). CONCLUSIONS: This study makes apparent the intimate relationships between vessels and the musculoskeletal structures associated with sternoclavicular reconstruction. Based on our findings, we recommend considering the sex of the patient, using caution when drilling, and protecting essential structures posterior to the joint.

Serum interleukin-6 as a marker of periprosthetic shoulder infection.

BACKGROUND: Infection after shoulder arthroplasty can be a devastating complication, and subacute and chronic low-grade infections have proven difficult to diagnose. Serum marker analyses commonly used to diagnose periprosthetic infection are often inconclusive. The purpose of this study was to evaluate the effectiveness of serum interleukin-6 (IL-6) as a marker of periprosthetic shoulder infection. METHODS: A prospective cohort study of thirty-four patients who had previously undergone shoulder arthroplasty and required revision surgery was conducted. The serum levels of IL-6 and C-reactive protein (CRP), the erythrocyte sedimentation rate (ESR), and the white blood-cell count (WBC) were measured. The definitive diagnosis of an infection was determined by growth of bacteria on culture of intraoperative specimens. Two-sample Wilcoxon rank-sum (Mann-Whitney) tests were used to determine the presence of a significant difference in the ESR and WBC between patients with and those without infection, while the Fisher exact test was used to assess differences in IL-6 and CRP levels between those groups. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of each marker were also calculated. RESULTS: There was no significant difference in the IL-6 level, WBC, ESR, or CRP level between patients with and those without infection. With a normal serum IL-6 level defined as <10 pg/mL, this test had a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 0.14, 0.95, 0.67, 0.61, and 0.62, respectively. CONCLUSIONS: IL-6 analysis may have utility as a confirmatory test but is not an effective screening tool for periprosthetic shoulder infection. This finding is in contrast to the observation, in previous studies, that IL-6 is more sensitive than traditional serum markers for periprosthetic infection.

Tension band plating of a nonunion anterior tibial stress fracture in an athlete.

The authors present a rare technique of tension band plating of the anterior tibia in the setting of a nonunion stress fracture. Surgical management with an intramedullary nail is a viable and proven option for treating such injuries. However, in treating elite athletes, legitimate concerns exist regarding the surgical disruption of the extensor mechanism and the risk of anterior knee pain associated with intramedullary nail use. The described surgical technique demonstrates the use of tension band plating as an effective treatment of delayed union and nonunion anterior tibial stress fractures in athletes without the potential risks of intramedullary nail insertion.

Latissimus dorsi tendon transfer for irreparable rotator cuff tears: a modified technique using arthroscopy.

Latissimus dorsi transfer is a well-established method for the treatment of posterosuperior massive irreparable rotator cuff tears. We propose using an arthroscopically assisted technique that avoids insult to the deltoid. With the patient in the lateral decubitus position, an L-shaped incision is made along the anterior belly of the latissimus muscle and then along the posterior axillary line. The latissimus and teres major are identified and separated. The tendon insertion of the latissimus is isolated, and a FiberWire traction suture (Arthrex, Naples, FL) is placed, facilitating dissection of the muscle to the thoracodorsal neurovascular pedicle and subsequent mobilization. The interval deep to the deltoid and superficial to the teres minor is developed into a subdeltoid tunnel for arthroscopic tendon transfer. The latissimus tendon is then transferred and stabilized arthroscopically to the lateral aspect of the infraspinatus and supraspinatus footprints by multiple suture anchors.

Accelerated wound closure in a diabetic mouse model after exposure to phenanthrenequinone.

BACKGROUND: Reactive oxygen species (ROS) have been shown to be important in wound healing by promoting angiogenesis (also mentioned by Ushio-Fukai and Nakamura). Likewise ROS have been implicated by toxicological studies as a primary mechanism of air pollution-associated morbidity. We sought to determine how exposure to a reactive diesel exhaust chemical (phenanthrenequinone [PQ]), which promotes formation of ROS and is considered an air pollutant, would affect wound healing. Since wound healing is compromised in diabetic (db) individuals, we examined the effects of PQ on wound healing in a db mouse model. METHODS: db mice consumed PQ-containing chow for a short period (2 weeks) before wounding and through generations. Wound closure rates and wound vascularization were evaluated 10 days after wounding. The effects of PQ on endothelial cell proliferation and ROS generation in vitro were also measured. RESULTS: db mice exposed to short-term PQ and PQ-exposed first-generation db mice demonstrated the highest closure rates, significantly better than control db mice (P < 0.05). Furthermore, a higher concentration of PQ in sera of db mice coincides with the higher rate of closure. PQ was also shown to produce ROS in cell culture and stimulate endothelial cell proliferation at nanomolar concentrations. Second- and third-generation db mice exposed to PQ did not show improved wound healing. CONCLUSIONS: This study suggests that the free radical-generating air pollutant PQ enhances wound closure in the db mouse model possibly by stimulating angiogenesis, as suggested by in vitro results. We speculate that PQ may increase oxidation levels systemically and therefore help modulate inflammation at the wound site. Alternatively, antioxidant mechanisms recruited for wound healing may interfere with PQ metabolism and elimination as it accumulates in sera. Generational resistance to improve wound healing in PQ-exposed db mice could also be due to disturbances in metabolism caused by continuous exposure. In either case, these results introduce a new perspective on the effects of air pollution on wound healing.