Common and Less Well-known Upper-limb Injuries in Elite Tennis Players.

A recent increase in epidemiology studies on injuries in elite tennis players has helped to shed light on the types of injuries these athletes sustain. This article reviews the common upper-limb injuries in elite players and includes less well known, but important, injuries. A search was conducted to identify current relevant studies involving elite tennis players. Injury frequency rates, injuries by regions, and types of injuries together with a list of commonly reported injuries in the upper limb were established. This list was then reviewed and refined by a sports medicine physician who cares for elite tennis players to include both those injuries of the upper limb that are common and those that are less well known but still important and frequently encountered. Common injuries include internal shoulder impingement, rotator cuff pathology, labral tears, elbow tendinopathies, as well as extensor carpi ulnaris tendinopathies and subluxation. Posterior shoulder instability, distal humeral bone stress, elbow medial collateral ligament, and nondominant wrist ulnar collateral ligament injuries are not commonly reported injuries, but they are of significant clinical importance.

The Comma Sign: An Anatomic Study.

The "comma sign" is a comma-shaped arc of tissue located at the superolateral edge of the subscapularis at its insertion on the humeral head. It consists of the coracohumeral ligament (CHL) and the superior glenohumeral ligament (SGHL). It was recently recognized as an important landmark to aid surgeons in identifying the edge of a torn subscapularis tendon. The exact proportion of CHL and SGHL has not been precisely defined. The goal of this study was to dissect and more accurately define the composition of the comma tissue and its exact relationship to the subscapularis tendon. A total of 8 fresh frozen cadaveric shoulder specimens (mean age, 74 years; 5 male, 3 female) were dissected via a wide deltopectoral approach. Anatomic landmarks were identified, and measurements were taken with a digital caliper. The midpoint width of the SGHL and CHL and the composite insertion width of the subscapularis were measured. Measurements were taken 3 times each and averaged to calculate mean width. Mean midpoint width of the SGHL, CHL, and composite insertion was 5.99 mm (range, 5.25-6.91 mm), 5.13 mm (range, 4.28-5.72 mm), and 9.93 mm (range, 6.69-12.05 mm), respectively. The comma sign consists of approximately half SGHL (54%) and half CHL (46%) at its insertion to the subscapularis tendon, with an approximate width of 1 cm. With the increase in arthroscopic subscapularis repairs, knowledge of these dimensions will aid surgeons in discerning the comma tissue from other capsular elements and ultimately help in surgical restoration of native anatomy. [Orthopedics. 2021;44(4):e546-e548.].

Humeral Head Morphology Influences Outcomes of Arthroscopic Interposition Glenoid Patch Allograft for Glenohumeral Arthritis.

PURPOSE: To determine short- to midterm patient-reported outcomes of arthroscopic soft-tissue interposition arthroplasty using acellular dermal allograft with a minimum follow-up of 1 year and to assess outcomes in patients with and without flattening of the humeral head. METHODS: Patients with a diagnosis of primary glenohumeral arthritis who underwent arthroscopic soft-tissue interposition arthroplasty with an acellular dermal allograft from July 2010 to November 2019 were retrospectively enrolled. Inclusion criteria were a primary diagnosis of glenohumeral arthritis and Outerbridge 4 full-thickness cartilage loss of ≥50% of the glenoid articular surface. Patients underwent arthroscopic debridement, microfracture, and biological arthroscopic soft-tissue interposition arthroplasty with an acellular dermal matrix. Postoperative outcomes included American Shoulder and Elbow Surgeon (ASES) score, Single Assessment Numeric Evaluation (SANE) score, Penn Shoulder Score (PSS), numeric rating scale (NRS) pain score, analgesic use, and conversion to total shoulder arthroplasty (TSA). Results were stratified according to humeral head morphology on preoperative radiographs. RESULTS: A total of 25 patients were included, with a mean age of 56.0 years (range 19.2 to 74.8) and a mean follow-up of 3.36 years (range 1.03 to 8.98). The mean postoperative ASES score was 64.1 (range 11.7 to 100.0), SANE score was 62% (range 5% to 100%), and PSS was 61.2 (range 10.6 to 97.9). Additionally, 56% of patients rated their shoulder function as improved or much improved, and 36% of patients converted to TSA at a mean of 2.35 years. Patients with and without humeral flattening had similar postoperative ASES scores (P = .44), SANE scores (P = .90), PSS (P = .73), and conversions to TSA (P = .83). Patients with humeral flattening were more likely to have shoulder pain at night (83.3% versus 28.6%, P = .02). CONCLUSION: Arthroscopic soft-tissue interposition arthroplasty with an acellular dermal allograft resulted in satisfactory short- to mid-term postoperative outcomes for younger patients with glenohumeral arthritis but demonstrated a TSA conversion rate of 36%. Patients with humeral head flattening also had satisfactory shoulder function but were more likely to experience shoulder pain at night. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

The Comma Sign: The Coracohumeral Ligament and Superior Glenohumeral Ligament Exhibit Similar Quantitative Characteristics With Terminal Confluence at the Subscapularis Insertion.

PURPOSE: The purpose of this morphologic cadaveric study was to quantitatively define the composition of the previously described comma tissue along with its relation to the subscapularis tendon insertion. METHODS: Fresh frozen cadaveric shoulder specimens were included for analysis. The coracohumeral ligament (CHL) was exposed at its origin along the base of the coracoid process and freed laterally along its course to the lesser tuberosity adjacent to the bicipital groove. The superior glenohumeral ligament (SGHL) was identified and traced along its course deep to the CHL within the rotator interval with insertion onto the superior aspect of the lesser tuberosity. The midpoint diameters of the SGHL and CHL and their composite insertional diameters on the subscapularis tendon insertion and lesser tuberosity were measured with digital calipers. The mean diameter was determined from 3 measurements taken of each ligament. RESULTS: Eight specimens were included. With the use of digital calipers, the mean midpoint diameters of the SGHL and CHL were identified as 5.99 mm (range, 5.25-6.91 mm) and 5.13 mm (range, 4.28-5.72 mm), respectively. The composite insertional diameter of the SGHL and CHL on both the lesser tuberosity and humeral insertion of the subscapularis tendon was 9.93 mm (range, 6.69-12.05 mm). At its insertion, the SGHL and CHL comprised 54% and 46% of the comma tissue, respectively. Additionally, all specimens were identified as showing a confluence of the SGHL and CHL composite insertion with the subscapularis tendon at the point of its humeral head insertion. CONCLUSIONS: The comma tissue is a pivotal structure for the identification, mobilization, and repair of retracted subscapularis tendon tears. Therefore, quantitative knowledge of the midpoint diameter, insertional diameter, and composite distribution of the CHL and SGHL provided by this morphologic cadaveric analysis may aid surgeons in their efforts to restore the native anatomy. CLINICAL RELEVANCE: Subscapularis tendon tears have often been under-addressed during rotator cuff repair. The comma tissue has been described as an anatomic structure that can aid in the identification, mobilization, and repair of retracted subscapularis tendon tears. Therefore, quantitative knowledge of this important arthroscopic landmark may aid surgeons in their efforts to restore the native anatomy.

The Role of Remplissage in the Setting of Shoulder Instability.

Recurrent anterior shoulder instability is a multifactorial problem for which many solutions exist. Often, the bony surface area of the humeral head and the glenoid needs to be addressed surgically. For large, engaging humeral head defects associated with <25% glenoid bone loss, a remplissage procedure can effectively "fill in" the humeral defect with minimal postoperative morbidity. Remplissage is an effective biological solution that should be considered any time there is a humeral head defect which is contributing to glenohumeral instability.