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Medial ulnar collateral ligament (UCL) repair utilization is increasing in recent years, bolstered by shorter rehabilitation and satisfactory clinical outcomes. Although previous literature has illustrated the importance of tunnel position on restoring graft isometry in reconstruction, there remains a paucity of literature guiding anchor placement in UCL repair. The purpose of this study is to design a 3-dimensional (3D) elbow model to understand the effect of anchor location on UCL repair isometry. A 3D computer model of an elbow joint was created using computed tomographic and magnetic resonance imaging MRI scans from a single patient. The humeral and ulnar attachments of the UCL were plotted using 3 methodologies: (1) geometric cloud mapping and (2) quantitative measurements from the anatomic studies by Camp et al and (3) Frangiamore et al. A 3.5-mm-diameter clockface was placed on each attachment site, which allowed for simulation of 12 distinct 1.75-mm deviations in anchor position. The 3 models were ranged through 0°-120° at 10° increments, and the 3D distances were measured between the ligament centroids. The humeral and ulnar anchors were sequentially repositioned around the clockfaces, and construct lengths were again measured to evaluate changes in isometry. A paired Student t test was performed to determine if there was a significant difference in isometry between the humeral and ulnar anchor deviations. Using method 1, the UCL repair length at 90° of elbow flexion was 26.8 mm. This construct underwent 13.6 mm of total excursion for a 46.4% change in length throughout its arc of motion. Method 2 produced a 19.3-mm construct that underwent 0.8 mm of excursion for a 3.9% length change throughout the arc. Method 3 produced a 24.5-mm construct that underwent 2.3 mm of excursion for a 9.4% length change. Identifying ligament footprints using the quantitative anatomic measurements from Camp et al and Frangiamore et al improved construct isometry through 120° of flexion (length changes of 3.9% and 9.4%, respectively) when compared to using the geometric cloud technique alone (46.4% length change). Humeral anchor deviations produced a significant increase in repair construct excursion compared with ulnar anchor deviations (P <.001). When performing UCL repair, small deviations in humeral anchor position may significantly influence ligament repair isometry. Using quantitative anatomic data may help identify anchor positions with improved repair isometry. Particularly when addressing detachments of the humeral footprint, surgeons should be critical of the humeral anchor position in order to restore native anatomy and optimal biomechanics. [ABSTRACT FROM AUTHOR]

Paget-Schroetter syndrome (PSS) is a rare condition of axillosubclavian vein thrombosis often seen in athletes with a history of repetitive external rotation and abduction of the shoulder. The purpose of this review was to analyze the literature and characterize PSS in the athletic population, including risk of PSS by sport. We also provide a comprehensive review of PSS to inform clinicians on the pathophysiology, detection, and management of the condition. Four databases were reviewed to identify cases of PSS occurring in athletes. Data on patient demographics, reported sport, diagnosis, treatment, management, return to sport, and complications were extracted and analyzed by 2 independent reviewers. Of the 123 cases of PSS identified, baseball and weight lifting had the highest incidence (26.8% and 19%, respectively), followed by swimming, football, and basketball. The average return to sport was 4.7 months, and 26.7% of subjects reported complications, most commonly pulmonary embolism. In athletes presenting with upper extremity pain and swelling with a history of playing baseball or weight lifting, PSS should be higher on a clinicians differential diagnosis list. Swimmers, football, and basketball players are less likely to present with PSS but are still more likely than other types of athletes to develop the condition. Clinician awareness of PSS in athletes is critical to avoid delays in treatment and misdiagnosis, and to allow for a timely return to sport with minimal complications. [ABSTRACT FROM AUTHOR]

The purpose of this study was to increase our understanding of the pathoanatomy of the ulnar collateral ligament (UCL) by performing a descriptive analysis of the surgical inspection of the anterior bundle in patients undergoing reconstruction. A single-surgeon series of 163 patients who underwent UCL reconstruction between 2009 and 2017 was retrospectively analyzed. Descriptions of the pathoanatomy of injury were obtained from the operative reports. Magnetic resonance imaging data were reviewed to assess whether the presence and location of tissue disruptions were accurately recognized. Demographic and clinical characteristics were obtained from medical records and correlated to observed pathoanatomy. Injuries to the anterior bundle were characterized by a single tissue disruption (65%), tissue disruptions at more than 1 location (23%), or injuries without distinct fiber tissue disruptions (12%). The presence and location of tissue disruptions matched magnetic resonance imaging findings in 124 of 153 patients (81%). Partial tears more frequently affected the anterior band of the anterior bundle distally as opposed to the posterior band of the anterior bundle proximally (P =.012). Patients with single tissue disruptions more frequently reported a popping sensation than patients with non-tear insufficiency (P =.030). This study shows the heterogeneity of anterior bundle injuries in patients undergoing UCL reconstruction. A variety of injury configurations and chronic attritional damage to the anterior bundle were observed, as well as distinct tear patterns at the distal and proximal attachment sites. Future research may elucidate the diagnostic value of a pop sign for UCL injury. [ABSTRACT FROM AUTHOR]

Background Female softball pitchers commonly throw more pitches per game and season than their baseball counterparts. The greatest stress to the shoulder during a softball windmill pitch is at ball release (BR). This study investigated shoulder torques at BR among female softball pitchers and identified relationships to the kinematics of the elbow and forearm and alignment of the elbow (carrying angle and elbow extension). Methods High-speed 3-dimensional biomechanical analyses were performed in 33 pitchers (25 high school, 8 collegiate). Elbow and shoulder biomechanics at BR during fastball pitches and goniometric measures of carrying angle and elbow extension were collected and analyzed. Results Carrying angle correlated positively with shoulder extension torque at BR (r s = 0.371, P =.048) and forearm pronation at BR (r s = 0.370, P =.048). During the windmill pitch, the greater the elbow flexion, the greater shoulder adduction torque at BR (r s = –0.522, P =.007). Multiple regression analysis revealed that the carrying angle, passive elbow extension, and elbow flexion/extension angle at BR predicted shoulder flexion/extension torque at BR (F 3,24 = 3.463, R 2 =.302, P =.032.) Conclusions Our findings demonstrate that shoulder torques during the softball fastpitch are influenced by the carrying angle and the kinematic elbow flexion angle at BR. Sports medicine clinicians and coaches should consider the role that the elbow carrying angle plays in creating shoulder stress when treating and training fastpitch softball players. [ABSTRACT FROM AUTHOR]

Purpose: To find the best topographic subchondral bone match between the capitellum and 2 proposed alternative donor sites of the ipsilateral elbow for capitellar osteochondral autologous transplantation: the non-articulating part of the radial head and the lateral olecranon tip.Methods: In our retrospective database, 20 patients with an unremarkable computed tomography scan of the elbow despite clinical suspicion were identified for analysis. Included were patients aged 11 to 20 years with intact osseous structures and a computed tomography slice thickness of 1.25 mm or less. Three-dimensional polygon models were created using a standard predefined threshold, after which 4 articular surface lesions on the capitellum were created: central 40°, central 60°, lateral 40°, and lateral 60°. In addition, 3 donor locations on the non-articulating part of the radial head (diameter, 5 mm) and the lateral olecranon tip (diameter, 3.5 mm) were created. For each of 24 donor-recipient combinations, the donor graft surface was virtually placed on the recipient surface to quantify the mean distance between surfaces.Results: The group of 20 patients consisted of 16 male and 4 female patients with a mean age of 15.9 years (range, 12-18 years). For a central 40° lesion, the mean distance across all 6 donor-recipient combinations ranged from 0.085 ± 0.023 to 0.118 ± 0.036 mm; for a central 60° lesion, the mean distance ranged from 0.075 ± 0.018 to 0.117 ± 0.062 mm; for a lateral 40° lesion, the mean distance ranged from 0.087 ± 0.030 to 0.182 ± 0.226 mm; and for a lateral 60° lesion, the mean distance ranged from 0.084 ± 0.048 to 0.115 ± 0.045 mm. There were no differences in topographic matching between donor-recipient combinations.Conclusions: The findings of this study show a less than 0.2-mm difference in the topographic subchondral bone match between 4 common lesion locations on the capitellum and 2 alternative donor sites of the ipsilateral elbow for capitellar osteochondral autologous transplantation: the non-articulating part of the radial head and the lateral olecranon tip.Clinical Relevance: These findings suggest that the non-articulating part of the radial head and the lateral olecranon tip may potentially be used as a donor source when treating capitellar osteochondritis dissecans. [ABSTRACT FROM AUTHOR]

Background The goals of this study were to evaluate the reliability of a quantitative 3-dimensional computed tomography (Q3DCT) technique for measurement of the capitellar osteochondritis dissecans (OCD) surface area, to analyze OCD distribution using a mapping technique, and to investigate associations between Q3DCT lesion quantification and demographic characteristics and/or clinical examination findings. Methods We identified patients with capitellar OCD who presented to our orthopedic sports medicine practice between January 2001 and January 2016 and who had undergone a preoperative computed tomography scan (slice thickness ≤1.25 mm). A total of 17 patients with a median age of 15 years (range, 12-23 years) were included in this study. Three-dimensional polygon models were reconstructed after osseous structures were marked in 3 planes. Surface areas of the OCD lesion as well as the capitellum were measured. Observer agreement was assessed with the intraclass correlation coefficient (ICC). Heat maps were created to visualize OCD distribution. Results Measurements of the OCD surface area showed almost perfect intraobserver agreement (ICC, 0.99; confidence interval [CI], 0.98-0.99) and interobserver agreement (ICC, 0.93; CI, 0.86-0.97). Measurements of the capitellar surface area also showed almost perfect intraobserver agreement (ICC, 0.97;CI, 0.91-0.99) and interobserver agreement (ICC, 0.86; CI, 0.46-0.96). The median OCD surface area was 101 mm 2 (range, 49-217 mm 2 ). On the basis of OCD heat mapping, the posterolateral zone of the capitellum was most frequently affected. OCDs in which the lateral wall was involved were associated with larger lesion size ( P  = .041), longer duration of symptoms ( P  = .030), and worse elbow extension ( P  = .013). Conclusions The ability to quantify the capitellar OCD surface area and lesion location in a reliable manner using Q3DCT and a mapping technique should be considered when detailed knowledge of lesion size and location is desired. [ABSTRACT FROM AUTHOR]

Background/Aim: Nursemaid's elbow usually occurs in young children when longitudinal traction is placed on the arm. Several manipulative maneuvers have been described, although, the most effective treatment technique is yet unclear. The aim of this systematic review and meta-analysis was to compare the two most commonly performed maneuvers (supination-flexion and hyperpronation) in the treatment of nursemaid's elbow. Methods: A literature search was performed in PubMed, Embase, and Cochrane databases to identify randomized controlled trials comparing supination-flexion and hyperpronation. Data were extracted and pooled independently by two authors. Methodological quality assessment of included studies was performed. Meta-analysis was performed using a fixed-effect model in case of homogeneity across studies, and using a random-effect model in case of heterogeneity. Heterogeneity was calculated with the χ² test and inconsistency in study effects across trials was quantified by I² values. Results: Seven randomized trials, including 701 patients (62% female), were included. A total of 350 patients were treated with the hyperpronation maneuver versus 351 patients who underwent the supination-flexion maneuver. Meta-analysis showed that hyperpronation was more effective than supination-flexion (risk ratio, 0.34; 95% confidence interval, 0.23 to 0.49; I², 35%). The absolute risk difference between maneuvers was 26% in favor of hyperpronation, resulting in a number needed to treat of 4 patients. Trials lacked blinding of assessors and universal pain measures. Conclusions: Hyperpronation was more effective in terms of success rate and seems to be less painful compared to the supination-flexion maneuver in children with nursemaid's elbow. [ABSTRACT FROM AUTHOR]

Background Factors associated with adverse events after distal biceps tendon repair or reconstruction are incompletely understood. This study examined factors associated with adverse events, prevalence of adverse events, and rate of second surgeries after distal biceps repair or reconstruction. Methods Between January 2002 and March 2015, 373 adult patients who underwent repair or reconstruction of the distal biceps tendon at 1 of 3 area hospitals were analyzed to determine factors associated with adverse events after surgical repair or reconstruction of the distal biceps tendon. Results Of 373 distal biceps tendon repairs or reconstructions, 82 (22%) had an adverse event; 5.3% were major adverse events. In multivariable analysis, a single-incision anterior approach and obesity were associated with a higher rate of adverse events. Fifteen patients (18% of patients with an adverse event and 4% of all patients) had a second surgery after distal biceps tendon surgery. Conclusion Patients should be counseled that 1 in 5 patients will have a minor complication and 1 in 20 patients will have a major complication after surgery on the distal biceps tendon. The most common adverse event is lateral antebrachial cutaneous neurapraxia. [ABSTRACT FROM AUTHOR]

Hypothesis: The anteromedial approach to the shoulder with detachment of the anterior deltoid from its clavicular and anterior acromial origins is a method of enhancing exposure for difficult shoulder arthroplasty cases. The aim of this study is to describe the current frequency of use, indications, complications, and results of this approach. Materials and methods: Between 2000 and 2003, 723 consecutive shoulder arthroplasties were performed. In 110 (15%) an anteromedial approach was used. Patient data; previous surgery; indications for surgery; pain, motion, and strength before and after surgery; complications; and the need for reoperation were assessed. Results: This approach was used in 9.5% of primary cases and 39% of revision cases. Seventy percent had had previous surgery. For primary arthroplasty, the most frequent diagnoses were osteoarthritis and the sequelae of fractures. In revision cases the most common diagnoses were instability and glenoid loosening. The structural indications for the anteromedial approach were severe scarring, protection of a frail deltoid, improvement in rotator cuff or glenoid exposure, protection of osteopenic bone, or enhancement of exposure in oncologic cases or resections. Ninety patients had more than 2 years of follow-up. Pain improved after primary and revision arthroplasty. Motion only improved in primary arthroplasty. There was little change in strength. No proximal deltoid detachments or other approach-related complications were identified. Conclusions: The anteromedial approach is a reliable technique to improve surgical exposure in difficult shoulder arthroplasty cases. When performed adequately, it can be applied safely without anterior deltoid detachment or clinically evident major complications. [Copyright &y& Elsevier]

Purpose: The aims of this study were to determine: (1) the kinematic effect of subtotal medial meniscectomy on the anterior cruciate ligament (ACL)–deficient knee and (2) the effect of ACL reconstruction on kinematics of the knee with combined ACL deficiency and subtotal medial meniscectomy under anterior tibial and simulated quadriceps loads. Methods: Eight human cadaveric knees were sequentially tested using a robotic testing system under 4 conditions: intact, ACL deficiency, ACL deficiency with subtotal medial meniscectomy, and single-bundle ACL reconstruction using a bone–patellar tendon–bone graft. Knee kinematics were measured at 0°, 15°, 30°, 60°, and 90° of flexion under an anterior tibial load of 130 N and a quadriceps muscle load of 400 N. Results: Subtotal medial meniscectomy in the ACL-deficient knee significantly increased anterior and lateral tibial translations under the anterior tibial and quadriceps loads (P < .05). These kinematic changes were larger at high flexion (≥60°) than at low flexion angles. ACL reconstruction in knees with ACL deficiency and subtotal medial meniscectomy significantly reduced the increased anterior tibial translation, but could not restore anterior translation to the intact level with differences ranging from 2.6 mm at 0° to 5.5 mm at 30° of flexion. ACL reconstruction did not significantly affect the medial–lateral translation and internal–external tibial rotation in the presence of subtotal meniscectomy. Conclusions: Subtotal medial meniscectomy in knees with ACL deficiency altered knee kinematics, especially at high flexion angles. ACL reconstruction significantly reduced the increased tibial translation in knees with combined ACL deficiency and subtotal medial meniscectomy, but could not restore the knee kinematics to the intact knee level. Clinical Relevance: This study suggests that meniscus is an important secondary stabilizer against anterior and lateral tibial translations and should be preserved in the setting of ACL reconstruction for restoration of optimal knee kinematics and function. [Copyright &y& Elsevier]

Background/aim: Nursemaid's elbow usually occurs in young children when longitudinal traction is placed on the arm. Several manipulative maneuvers have been described, although, the most effective treatment technique is yet unclear. The aim of this systematic review and meta-analysis was to compare the two most commonly performed maneuvers (supination-flexion and hyperpronation) in the treatment of nursemaid's elbow.Methods: A literature search was performed in PubMed, Embase, and Cochrane databases to identify randomized controlled trials comparing supination-flexion and hyperpronation. Data were extracted and pooled independently by two authors. Methodological quality assessment of included studies was performed. Meta-analysis was performed using a fixed-effect model in case of homogeneity across studies, and using a random-effect model in case of heterogeneity. Heterogeneity was calculated with the χ2 test and inconsistency in study effects across trials was quantified by I2 values.Results: Seven randomized trials, including 701 patients (62% female), were included. A total of 350 patients were treated with the hyperpronation maneuver versus 351 patients who underwent the supination-flexion maneuver. Meta-analysis showed that hyperpronation was more effective than supination-flexion (risk ratio, 0.34; 95% confidence interval, 0.23 to 0.49; I2, 35%). The absolute risk difference between maneuvers was 26% in favor of hyperpronation, resulting in a number needed to treat of 4 patients. Trials lacked blinding of assessors and universal pain measures.Conclusions: Hyperpronation was more effective in terms of success rate and seems to be less painful compared to the supination-flexion maneuver in children with nursemaid's elbow. [ABSTRACT FROM AUTHOR]

Purpose: To identify clinical variables that affect a surgeon''s decision to recommend arthroscopic partial meniscectomy (APM). Methods: Members of 2 orthopaedic specialty societies were invited to participate in an online survey by e-mail. The survey consisted of surgeon demographics and case scenarios to evaluate clinical decision making for APM. Posterior probabilities were calculated to determine the effect of clinical factors on the likelihood of recommending APM. Results: Of the respondents with valid e-mail addresses, 733 (19.3%) returned a completed survey, but only 533 (14.1%) met the eligibility criteria (treated or referred an APM candidate within the past year). Respondents were aged 46.7 ± 9.4 and had performed a mean of 115 APMs in the previous year. Posterior probabilities for a combination of 6 clinical indicators identified 3 factors that most influenced a surgeon''s decision to recommend APM: radiographic findings, McMurray test, and failure of nonoperative management. Conclusions: Significant variation exists among practicing orthopaedic surgeons with regard to decision making for APM. The 3 clinical factors that most influenced a surgeon''s decision to recommend APM were normal radiographic findings, failed nonoperative treatment, and the presence of positive physical examination findings (i.e., positive McMurray test, joint line tenderness, and effusion). Level of Evidence: Level III, decision analysis. [Copyright &y& Elsevier]