Retrograde headless compression screw fixation of olecranon stress fractures in throwing athletes: a novel technique.

Background: An olecranon stress fracture (OSF) is a rare injury most commonly seen in high-level overhead throwing athletes with no clear consensus on surgical treatment. The most common surgical treatment described in the literature is cannulated screw fixation but there have been high rates of reported hardware irritation and need for subsequent hardware removal. Hypothesis/Purpose: This study describes a novel surgical technique in the treatment of OSFs in high-level throwing athletes using retrograde headless compression screws. We hypothesized that patients would have excellent outcomes and decreased rates of hardware irritation postoperatively. Methods: A retrospective review of competitive-level throwing athletes who sustained OSFs that were treated operatively using a novel technique using retrograde cannulated headless compression screws to avoid disruption of the triceps tendon. Postoperative outcome measures obtained included the Disabilities of the Arm, Shoulder and Hand score, Mayo Elbow Performance Score, Simple Elbow Test score, Single Assessment Numerical Evaluation score, Visual Analog Scale, arch of motion, and time to return to sport as well as level returned to. Radiographs were obtained routinely at 2-week, 6-week, 12-week, 6-month, 1-year, and 2-year follow-up. Results: Five of 5 patients who met inclusion criteria were available for final follow-up. Mean age at time of surgery was 20 years (range 17-24). Mean follow-up was 17 months (range 4-33). All patients were baseball players, 4 of which were pitchers and 1 position player. All patients were able to return to sport at the same level or higher at a mean of 5.8 months (range 3-8). Postoperatively, mean arch of motion was 138°, Visual Analog Scale score was 0, Single Assessment Numerical Evaluation score was 90, Disabilities of the Arm, Shoulder and Hand score was 2.0, Mayo Elbow Performance Score was 100, and Simple Elbow Test score was 12. There was no incidence of hardware removal. Conclusion: This study presents a novel surgical technique in the treatment of OSFs in high-level throwing athletes. The results presented demonstrate that this technique is safe and effective for getting athletes back to play quickly without any complications of hardware irritation which has previously shown to be a significant problem in prior literature.

Importance of radar gun inclusion during return-to-throwing rehabilitation following ulnar collateral ligament reconstruction in baseball pitchers: a simulation study.

BACKGROUND: Rehabilitation following elbow ulnar collateral ligament reconstruction in baseball pitchers relies on a progression of pitching activities to ensure protection and gradual strengthening of the reconstructed ligament. The purpose of this study was to determine the medial elbow torque associated with pitches at various effort levels and determine whether radar gun assistance improves players' abilities to accurately match partial-effort pitches with true references based on maximum pitch velocity. METHODS: Thirty-seven healthy high school and collegiate baseball pitchers were included in this study. Participants were excluded if they were injured, recovering from injury, or otherwise not currently pitching at full effort. Pitch parameters were collected using a validated wearable sensor. Participants threw 5 pitches at 50%, 75%, and 100% subjective effort. Pitchers then threw 5 pitches at 50% maximum velocity and 75% maximum velocity, as measured by a radar gun. RESULTS: Thirty-seven pitchers completed this study. Pitches thrown at 50% and 75% partial effort were significantly faster and generated higher elbow torque than did pitches thrown at 50% and 75% velocity, respectively (P < .001). A 10% decrease in percentage of maximum velocity was associated with a 13% decrease in percentage of maximum elbow torque (ß coefficient = 1.3, R2 = 0.81, P < .001). CONCLUSION: Pitchers generate higher-than-intended forces when throwing at 50% and 75% effort during a subjective partial-effort throwing protocol. Use of a radar gun to guide partial-effort throwing during throwing rehabilitation programs may protect the reconstructed elbow from excess medial torque.

Relationship Between Glenohumeral Internal Rotation Deficit and Medial Elbow Torque in High School Baseball Pitchers.

BACKGROUND: Alterations in throwing mechanics have been identified as a risk factor for overuse injuries in baseball players. Glenohumeral internal rotation deficit (GIRD) has been found to adversely affect throwing mechanics, but the effect of GIRD on medial elbow torque is unclear. PURPOSE: To investigate the relationship between GIRD and medial elbow torque in high school-aged baseball pitchers. STUDY DESIGN: Descriptive laboratory study. METHODS: High school baseball pitchers (14-18 years old) were recruited for participation in this study. Players' height, weight, body mass index, and arm measurements were recorded as well as shoulder and elbow range of motion measurements. GIRD was calculated from the difference between dominant and nondominant shoulder internal rotation. Participants then pitched 5 fastballs at maximum effort while wearing a wireless sensor that recorded elbow torque, arm slot, arm speed, shoulder rotation, and ball velocity. Principal component analysis was performed to determine which variables were associated with elbow torque or ball velocity. RESULTS: Twenty-three high school pitchers participated in this study; 35% (n = 8) of participants exhibited GIRD of at least 20°. The mean GIRD was 15.3°± 11.2° and was not a predictor of medial elbow torque (P = .205) or ball velocity (P = .333). Ball velocity, age, and height were predictors of medial elbow torque (P = .012, P = .003, and P = .024, respectively). CONCLUSION: In high school baseball pitchers, GIRD was not associated with medial elbow torque during the pitching motion. Instead, ball velocity, player age, and player height carried greater significance. CLINICAL RELEVANCE: This study suggests that high school pitchers with GIRD do not have an inherently greater risk for increased medial elbow torque during the throwing motion. It is recommended that pitchers instead assess their ball velocity to evaluate for relative differences in medial elbow torque.

The biomechanical evaluation of a novel 3-strand docking technique for ulnar collateral ligament reconstruction in the elbow.

BACKGROUND AND HYPOTHESIS: The original 2-strand docking technique for elbow ulnar collateral ligament reconstruction has recently been modified to use a 3-strand graft. To date, no biomechanical study has compared the 2 techniques. We hypothesized that the 3-strand docking technique would restore valgus laxity to its native state, with comparable load-to-failure characteristics to the 2-strand docking technique. MATERIALS AND METHODS: Sixteen fresh cadaveric elbows were matched to the corresponding contralateral side from the same individual to create 8 matched pairs and were then randomized to undergo ulnar collateral ligament reconstruction using either the 2- or 3-strand technique. Valgus laxity and rotation measurements were quantified using a MicroScribe 3DLX digitizer at various flexion angles for the native state, transected state, and 1 of the 2 tested reconstructed ligaments. Each reconstruction was then tested to failure. RESULTS: Valgus laxity for the intact state at elbow flexion angles of 30°, 60°, 90°, and 120° was 7° ± 2°, 7° ± 2°, 6° ± 1°, and 5° ± 2°, respectively. These values were similar to those of both reconstruction techniques. On load-to-failure testing, there was no significant difference in any parameter recorded. Yield torques for the 3- and 2-strand reconstructions were 13.4 ± 4.80 N/m and 11.8 ± 4.76 N/m, respectively (P = .486). The ultimate torques were 15.7 ± 6.10 N/m and 14.4 ± 5.58 N/m for the 3- and 2-strand techniques, respectively (P = .582). CONCLUSION: The 3-strand docking technique was able to restore valgus laxity to the native state, with similar load-to-failure characteristics to the 2-strand docking technique.

Evaluation, management and prevention of lower extremity youth ice hockey injuries.

Ice hockey is a fast-paced sport played by increasing numbers of children and adolescents in North America and around the world. Requiring a unique blend of skill, finesse, power and teamwork, ice hockey can become a lifelong recreational activity. Despite the rising popularity of the sport, there is ongoing concern about the high frequency of musculoskeletal injury associated with participation in ice hockey. Injury rates in ice hockey are among the highest in all competitive sports. Numerous research studies have been implemented to better understand the risks of injury. As a result, rule changes were adopted by the USA Hockey and Hockey Canada to raise the minimum age at which body checking is permitted to 13-14 years (Bantam level) from 11-12 years (Pee Wee). Continuing the education of coaches, parents and players on rules of safe play, and emphasizing the standards for proper equipment use are other strategies being implemented to make the game safer to play. The objective of this article was to review the evaluation, management and prevention of common lower extremity youth hockey injuries.

Prevalence of Vitamin D Insufficiency in Professional Hockey Players.

BACKGROUND: Vitamin D is a fat-soluble hormone that plays a role in bone health, muscle function, and athletic performance. Studies have shown that low levels of vitamin D can lead to slower muscle recovery and function, increased rates of stress fractures, and even poorer athletic performance. Insufficient vitamin D levels have been demonstrated in professional basketball and football players, however, there have been no studies to date reviewing vitamin D insufficiency in professional hockey players. PURPOSE/HYPOTHESIS: The purpose of this study was to perform a cross-sectional review to determine the prevalence of vitamin D deficiency and insufficiency in professional hockey players. The hypothesis was that there would be a high percentage of players with vitamin D insufficiency. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: The preseason serum 25-hydroxy (OH) vitamin D laboratory test results of 105 professional hockey players were retrospectively reviewed. All players on 3 National Hockey League (NHL) teams were included. Player parameters evaluated included age, height, weight, body mass index, and 25(OH) vitamin D level. Players were divided into 4 groups based on serum vitamin D levels: deficient (<20 ng/mL), insufficient (20-31.9 ng/mL), sufficient (≥32 ng/mL), and ideal (≥40 ng/mL). Descriptive statistics were performed, in addition to 2-group and 3-group comparisons. RESULTS: The average 25(OH) vitamin D level of 105 players was 45.8 ± 13.7 ng/mL (range, 24-108 ng/mL). No players in the study were considered deficient. A total of 14 players (13.3%) were considered insufficient, while 91 players (86.7%) were considered sufficient. However, only 68 players (64.8%) were considered ideal. When comparing groups, athletes with sufficient vitamin D levels were older than athletes with insufficient vitamin D levels (25.9 vs 23.1 years; P = .018). All other player parameters demonstrated no significant difference between groups. CONCLUSION: Despite playing a winter sport and spending a great deal of time training indoors, professional hockey players have low levels of vitamin D insufficiency.

Arthroscopic anterior shoulder stabilization with percutaneous assistance and posteroinferior capsular plication.

To study the technique and clinical outcomes of arthroscopic shoulder stabilization with anterior labral repair and percutaneous posteroinferior capsular plication, we retrospectively reviewed 20 cases. Mean (SD) final postoperative follow-up was 3.4 (0.6) years (range, 2.7-5.1 years). A mean (SD) of 4.9 (0.9) suture anchors (range, 4-7) was used during surgery, with 1.6 (0.7) (range, 1-3) devoted to the posteroinferior plication. There were statistically significant improvements in forward elevation (P = .016) and internal rotation (P = .018) from before surgery to final postoperative follow-up; external rotation did not change (P = .336). Significant improvements (P < .001) were also seen in visual analog scale pain ratings, American Shoulder and Elbow Surgeons survey scores, and Simple Shoulder Test scores. Mean (SD) Rowe instability score at final follow-up was 81.1 (28.9). Eighty-five percent of the patients returned to sport at or above preinjury level, and 70% returned to a degree of athletic physical contact at or above preinjury level. Two cases (10%) were categorized as treatment failures (redislocation). Percutaneously assisted arthroscopic anterior stabilization with posteroinferior capsular plication produces acceptable results, with functional outcomes and redislocation rates comparable to those reported in the literature.

Markedly elevated intra-articular white cell count caused by gout alone.

Joint pain accompanied by erythema, swelling, and decreased range of motion is concerning for septic arthritis and typically warrants joint aspiration. The synovial fluid white blood cell count plays a central role in the decision-making process regarding these patients. Traditional teaching holds that a cell count greater than 50,000 white blood cells/µL is likely caused by infection and therefore warrants either operative intervention or serial aspiration. This report describes 2 patients with extremely high synovial fluid white blood cell counts in the absence of infection. Case 1 involved a 59-year-old man who presented to the emergency department with sudden onset of atraumatic left elbow pain and was found to have a white blood cell count of 168,500 white blood cells/µL on joint aspiration and innumerable monosodium urate crystals. The patient ultimately improved with treatment with oral prednisone, avoiding operative intervention. Case 2 involved a 69-year-old man who presented to the emergency department with acute onset of atraumatic left knee pain. On arthrocentesis, the patient had a cell count of 500,000 white blood cells/µL and was therefore taken to the operating room for arthroscopic irrigation and debridement. Final analysis of the synovial fluid showed monosodium urate crystals and negative culture findings. These cases illustrate the highest synovial fluid white blood cell count reported in patients with gout and highlight the potential difficulty in differentiating between acute gout and septic arthritis in the setting of markedly elevated white blood cell count.

Comparison of radiographic stress tests for syndesmotic instability of supination-external rotation ankle fractures: a cadaveric study.

OBJECTIVE: According to the classification of Lauge-Hansen, supination-external rotation IV (OTA 44-B) injuries should not have syndesmotic instability; yet, several studies have suggested disruption is present in up to 40% of these injuries based on stress tests. In this study, we examine various stress radiographic parameters in a cadaver model of supination-external rotation IV equivalent injury. We hypothesize that external rotation stress testing and widening of the medial clear space do not always represent syndesmotic instability. Rather, the better predictor of syndesmotic instability will be an increased tibia-fibula clear space with the lateral stress test. METHODS: Eleven fresh frozen human lower limbs were each secured into a custom frame. External rotation stress test was performed by applying an external moment of 7.5 Nm, and lateral stress test was performed by applying 100 N lateral pull at the distal fibula. True mortise radiographs were taken of intact ankles and while performing external rotation and lateral stress tests at each stage of sequentially sectioning the ankle ligaments. The deltoid ligament was sectioned first, then anterior-inferior tibiofibular ligament, posterior-inferior tibiofibular ligament, and interosseous membrane. Tibiofibular clear space and medial clear space were measured on each radiograph. RESULTS: External rotation stress test produced significant medial clear space widening when the deltoid ligaments were sectioned (P < 0.05). Lateral stress test produced no significant widening of the tibiofibular clear space until interosseous membranes were sectioned (P < 0.05). CONCLUSIONS: Lateral stress test with widening of the tibiofibular clear space is the preferred indicator of syndesmotic instability. The external rotation stress is a poor indicator of syndesmotic injury in the setting of deltoid ligament injury.

Management of septic arthritis following anterior cruciate ligament reconstruction: a review of current practices and recommendations.

Septic arthritis following anterior cruciate ligament reconstruction is a rare and potentially devastating complication that often leads to articular destruction and adverse clinical outcomes. Because of its rare occurrence, best practices for diagnosis and management have yet to be established. However, graft retention and favorable outcomes are possible with early diagnosis, surgical intervention, and appropriate antibiotic management. Clinicians must be familiar with the diagnostic criteria and management options for septic arthritis. Most patients require multiple procedures to effectively eradicate infection. When the original reconstructed graft cannot be salvaged, a staged anterior cruciate ligament reconstruction revision is required.

Management of articular cartilage defects of the knee.

Articular cartilage injuries of the knee present a difficult clinical dilemma and their treatment is controversial. Hyaline articular cartilage is an avascular, low-friction, and wear-resistant weightbearing surface that has limited capacity for self-repair. The optimal treatment for cartilage lesions has yet to be established. Various treatment methods are employed to reestablish a stable cartilage surface, including microfracture, autologous and allograft osteochondral transplantation, autologous chondrocyte implantation, matrix-associated chondrocyte implantation, and scaffold-assisted methods. Treatment algorithms help to guide physicians' decision making in the care of these injuries. In this article, results from outcomes studies as well as prospective randomized clinical trials comparing treatment methods are reviewed, and current practice guidelines are summarized.

A case of factitious subfascial emphysema.

A 44-year-old woman with a history of borderline personality disorder, Hepatitis C, and multiple hospital admissions for cellulitis and cutaneous abscesses presented with pain of several days duration in her left upper extremity following getting her left arm "stuck" in a subway turnstile. The pain and swelling had progressively worsened following the injury. At the time of presentation the patient's temperature was 98.6 degrees F, heart rate was 82 beats/minute, blood pressure of 116/60, and an oxygen saturation of 98% on room air. The left upper extremity was diffusely swollen but minimally tender throughout. Crepitus was noted along the left arm, elbow and forearm areas. No open wounds were visualized during the examination. Radiographs and computed tomography revealed diffuse subcutaneous emphysema extending from the left axillary region to the wrist, as well as gas beneath the fascia extending between multiple muscles in both the upper and lower areas of her left upper extremity. The possibility of necrotizing fasciitis or gas gangrene prompted immediate operative exploration. No evidence of infection was found during the exploration. Stat gram stains sent during the procedure revealed no organisms. Aerobic, anaerobic, fungal, and acid-fast bacteria cultures taken during the operation revealed no final growth. The patient was stable throughout the hospitalization, remaining afebrile with a normal white blood cell count. The gas in the subcutaneous and subfascial layers was not caused by infection but presumably was due to factitious self-injection of air.