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Background Injury to the lateral ulnar collateral ligament (LUCL) complex of the elbow often results in posterolateral rotatory instability. Although surgical reconstruction of the LUCL is often required, gaps in our understanding of the LUCL complex remain. The purpose of this study was to provide a robust and accurate characterization of the lateral elbow ligamentous complex. Methods The LUCLs, radial collateral ligaments, and annular ligaments in 10 cadaveric elbows were 3-dimensionally digitized and reconstructed using computed tomography. Surface areas, origin and insertion footprint areas, distances between perceived footprint centers and geometric footprint centroids, distances to key landmarks, and ligament isometry were measured. Results The mean surface area of the LUCL was 229.3 mm2. The mean origin and insertion footprint areas were 26.0 mm2 and 22.9 mm2, respectively. The mean distance between the apparent centers and the geometric centroids of the footprints was 1 mm. The center of the LUCL origin was 10.7 mm distal to the lateral epicondyle and 8.2 mm from the capitellar articular margin. The center of the LUCL insertion was 3.3 mm distal to the apex of the supinator crest. The LUCL showed anisometric properties as elbow flexion increased (P Conclusions The LUCL origin center was 10.7 mm from the lateral epicondyle, whereas the insertion center was 3.3 mm from the apex of the supinator crest. The visually estimated footprint centers were generally within 1 mm of the geometric centroid. These geometries and distances to key landmarks will be informative for surgeons seeking to perform anatomic ligament reconstruction procedures.

The anterior bundle of the ulnar collateral ligament (UCL) is the primary stabilizer against valgus stress in the elbow. However, when the UCL is compromised, the flexor-pronator mass becomes the primary dynamic valgus stabilizer of the elbow. Combined UCL and flexor-pronator mass injuries are a subset of medial elbow injuries sustained by overhead throwing athletes. Compared to athletes who suffer isolated UCL injuries, the group with combined UCL and flexor-pronator mass injuries tend to be older and have worse outcomes after surgical reconstruction. There are few studies describing these injuries in the orthopedic literature, and it is unclear what causes them to fail surgical management at a higher rate than UCL injuries alone. Treatment of this group requires a thorough history and physical exam, as well as a magnetic resonance imaging (MRI) for surgical planning. Based on the amount of flexor-pronator mass injury, different operative approaches may be warranted. It is important to counsel these patients about their prognosis, especially elite baseball players regarding their chances of returning to their previous level of play.

To use a national database to determine (1) the incidence of joint infection after elbow arthroscopy, (2) identify independent patient-related risk factors for infection, and (3) determine the influence of concomitant intra-articular corticosteroid injection on infection risk.The 100% Medicare Standard Analytic Files were queried to identify patients who underwent elbow arthroscopy from 2005 to 2012. Postoperative elbow infections occurring within 6 months of surgery were identified using both International Classification of Diseases, 9th Revision codes for postoperative infection and Current Procedural Terminology codes for the surgical treatment of a postoperative infection. Patients were excluded if their initial arthroscopic procedure was performed for infection. A multivariate binomial logistic regression analysis was then used to evaluate patient-related risk factors for postoperative infection.Of the 2,704 elbow arthroscopy cases identified, 42 (1.55%) developed a postoperative infection. The annual incidence of infections did not increase significantly over the course of the study (P = .374). A number of patient demographics and medical comorbidities significantly increased the risk of infection. The most notable factors included age ≥ 65 years (odds ratio [OR] 2.38, P = .006), body mass index40 (OR 1.97, P = .024), tobacco usage (OR 1.80, P = .046), alcohol usage (OR 4.01, P.001), diabetes mellitus (OR 2.10, P = .015), inflammatory arthritis (OR 2.81, P.001), hypercoagulable disorder (OR 2.51, P = .015), and intra-articular corticosteroid injection at the time of arthroscopy (OR 2.79, P = .006).The annual number of elbow arthroscopies performed in the United States has increased steadily; however, the postoperative infection rate remained consistently low at 1.55%. There are a number of patient-specific risk factors that increase this risk with OR ranging from 1.97 to 4.01. Similarly, patients who receive an intra-articular corticosteroid injection at the time of surgery are nearly 3 times (OR 2.79) more likely to develop a postoperative infection. LEVEL OF EVIDENCE: Level III, case-control study.

Purpose Posterior elbow impingement can cause disabling pain and limited motion during activities involving elbow extension. Less understood is whether arthroscopic treatment, compared to open surgery, can result in effective management of pain, loss of range of motion, and return athletes to previous levels of activity. This study determined whether arthroscopic debridement is a safe and effective treatment for posterior elbow impingement and whether it enables athletes to return to a previous level of function. Methods A retrospective review of 36 consecutive patients that underwent arthroscopic debridement of the posterior elbow was performed. There were 34 male and 2 female patients, with a median age of 32 years (17–54 years). There were 7 professional athletes, 6 college athletes, and 23 high school or recreational athletes. All patients had a positive posterior impingement test for posterior pain with extension and limitations of activity. Arthroscopic debridement and additional surgical procedures were performed, and patients underwent follow-up visits at a median 51 months (range 14–81). Results Significant improvements were seen in pain, motion, and function. No neurovascular complications were seen related to the arthroscopic debridement. The mean Andrews and Timmerman elbow score improved from 159 ± 27 to 193 ± 11 (p

Introduction Ulnar collateral ligament (UCL) reconstructions are being performed with an increasing annual incidence. The purpose of this study was to evaluate trends in UCL surgery among recently trained orthopaedic surgeons. Methods The American Board of Orthopaedic Surgeons (ABOS) database was used to identify all UCL reconstructions from 2004 to 2013. Procedures were identified by Current Procedural Terminology (CPT) codes and verified by International Classification of Disease, Ninth Revision (ICD-9) codes. Data on surgeon fellowship, practice location, concomitant surgical procedures, and complications were collected. Results One hundred sixty-four UCL reconstructions were performed by 133 ABOS Part II candidates. The annual incidence increased from 1.52 to 3.46 cases per 10,000 (P = 0.042). Reconstructions were most commonly performed by surgeons with fellowship training in sports medicine (65.9%), hand and upper extremity (18.9%), and shoulder and elbow (9.1%). Most reconstructions were performed in isolation (57.3%), or with ulnar nerve transposition (32.9%) or elbow arthroscopy (9.8%). Concomitant elbow arthroscopy rates decreased significantly (P = 0.022). Complications occurred in 9.8% of cases, although the rates did not significantly change (P = 0.466). Conclusions UCL reconstructions are being performed with increasing frequency. Concomitant procedure rates remained the same, although arthroscopy was less commonly performed. Complication rates did not change considerably over the observed period. Further study of the surgical trends and associated long-term outcomes is warranted. Level of evidence Level IV.

Introduction The purpose of this study was to determine whether surgical arthroscopic decompression or ultrasound-guided aspiration of a paralabral cyst would result in suprascapular nerve recovery from axonal regeneration based on electrodiagnostic testing. Methods Nine patients with preoperative electromyography (EMG) evidence of suprascapular neuropathy due to paralabral cysts at the suprascapular or spinoglenoid notch were prospectively studied. Eight patients underwent arthroscopic surgical decompression, and 1 patient underwent ultrasound-guided aspiration. Postoperative EMG was performed in all patients to evaluate nerve regeneration. Results Three (33%) patients had cysts at the suprascapular notch, whereas 6 (67%) patients had cysts at the spinoglenoid notch. All patients showed complete electrophysiological recovery after decompression. Discussion Decompression of paralabral cysts at the suprascapular or spinoglenoid notch resulted in postoperative EMG evidence of nerve recovery. Long-term studies with a greater number of patients are required to elucidate time to recovery. Muscle Nerve 59:247-249, 2019.

PURPOSE OF REVIEW: To summarize the current anatomy, biomechanics, presentation, treatment, and outcomes of injuries to the biceps and superior labral complex in overhead athletes. RECENT FINDINGS: The biceps and superior labral complex is composed of anatomically distinct zones. The inability to accurately diagnose biceps lesions contributes to continued morbidity especially as arthroscopy and advanced imaging fail to fully evaluate the entire course of the biceps tendon. Superior labrum anterior and posterior (SLAP) repair, long head of biceps tenodesis, and tenotomy are the most common operative techniques for surgical treatment of biceps-labral complex (BLC) pathology. Labral repair in overhead athletes has resulted in mixed outcomes for athletes and is best indicated for patients under age 40 years old. SUMMARY: Injuries to the BLC are potentially challenging injuries to diagnose and treat, particularly in the overhead athlete. SLAP repair remains the treatment of choice for high-level overhead athletes and patients younger than 40 years of age, while biceps tenodesis and tenotomy are preferred for older patients.

This review discusses the diagnostic and treatment challenges presented by injuries to the biceps and superior labral complex. A focused patient history, numerous physical examination maneuvers, and appropriate advanced imaging studies must be utilized to reach an accurate diagnosis. Nonoperative management, even in overhead athletes, has demonstrated relatively good outcomes, while operative outcomes have yielded mixed results. The surgeon must take into account a number of variables when choosing the appropriate surgical procedure: labral repair versus biceps tenodesis. Rehabilitation, either as nonoperative management or as a postoperative protocol, should focus on restoring glenohumeral and scapulothoracic strength, endurance, and full, pain-free range of motion, while correcting any deficiencies in balance or rhythm throughout the overhead motion. Despite the operative treatment challenges that SLAP tears present, with new techniques and proper patient selection, overhead athletes with injuries to the biceps and superior labrum complex can return to sport at a high level.

In the world of glenoid labral chondral injuries, perhaps the most recognizable by magnetic resonance imaging is the "teardrop" version, and the glenoid labral teardrop lesion is the glenoid chondral lesion most frequently associated with shoulder instability.

Background: Recent awareness of latissimus dorsi/teres major (LD/TM) injuries has led to an increase in diagnoses. No magnetic resonance imaging (MRI) classification system specific to the LD/TM exists, nor has tear severity been correlated with ability to return to sport (RTS). Purpose/Hypothesis: The purpose of this study was to report a novel MRI classification system for LD/TM tears as well as to correlate tear grade with performance and RTS. We hypothesized that the new MRI classification system would have high intra- and interobserver reliabilities and that players with higher grade tears would require operative management. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: All patients with LD/TM tears diagnosed by MRI who were under the care of 2 orthopaedic surgeons were included. On 2 occasions 60 days apart, MRIs were reviewed and graded by 2 authors using a new classification system. Intra- and interobserver reliabilities were calculated. Timing from injury to RTS was recorded, and performance upon RTS was analyzed. Results: The proposed grading system had excellent intra- and interrater reliabilities (Cohen kappa >0.850). A total of 20 male patients (mean ± SD age, 26 ± 9.3 years) with LD/TM tears were included (80% were baseball pitchers). Of the 16 players treated operatively, 5 were initially treated nonoperatively by an outside physician but could not RTS (all professional baseball pitchers); 2 of these players had grade IIIA tears and 3 of the players had grade IVA tears. Regardless of initial treatment, ultimately 100% of the professional baseball players were able to RTS at a mean of 8.7 ± 3.3 months, although the initial nonoperative management failed for some of these players and they needed surgical intervention. No statistically significant differences were found between pre- versus postoperative performance in those professional players who were treated surgically. Conclusion: The proposed MRI-based grading system for LD/TM tears had excellent reliability. This system may allow physicians to better advise patients and all involved health care providers. Consideration should be given to acutely treat grade III and IV tears with operative repair.

In recent years, arthroscopy has gained popularity as a preferred treatment of a multitude of pathologies affecting the elbow. Since its initial description in 1985, many modifications have been made as our knowledge and technology have advanced. Currently, the majority of arthroscopic procedures are performed in either the lateral decubitus or supine suspended position. In this work, we discuss the history, patient positioning, and key steps for performing elbow arthroscopy in the lateral decubitus position. In addition to key steps, a number of strengths and limitations of this set up are discussed in detail. When properly executed, elbow arthroscopy can be performed in a safe and efficient manner with minimal risk to patients.

Background: Recent clinical investigations have identified inadequate autograft hamstring graft diameter (Purpose/Hypothesis: The objective of this study was to determine the utility of preoperative magnetic resonance imaging (MRI) variables of the hamstring tendons for the prediction of graft diameter at the time of surgery. The hypothesis was that cross-sectional area (CSA) of the hamstring tendon measured on MRI could accurately predict graft diameter, and threshold measurements could be established to predict graft diameter at the time of surgery. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: A total of 84 consecutive skeletally mature patients prospectively enrolled in our ACL reconstruction patient registry were identified for study purposes. Patients were included if they underwent an MRI of the affected knee at our institution prior to ACL reconstruction with hamstring (HT) autograft. Graft preparation was performed via a standard quadrupled hamstring technique after harvesting both the gracilis and semitendinosus (4-GST). The smallest diameter end of the HT autograft was then utilized for measurement analysis. Total CSA was calculated for both hamstring tendons using the “region of interest tool” on the corresponding proton density–weighted axial image of the knee at the widest condylar dimension. Three independent reviewers measured the MRI scans so that intra- and interrater reliability of the measurements could be determined. A trend analysis was then undertaken to establish correlations between the MRI CSA and graft diameter. Predictive analysis was then performed to establish threshold MRI measurement values for specific graft diameters and determine whether any patient-specific factors would affect graft diameter (age, sex, and body mass index). Results: Mean patient age at the time of surgery was 36 years (range, 11-57 years). Intra- and interrater reliability measurements achieved near-perfect agreement for CSA measurements, with intraclass correlation coefficients (ICCs) of 0.994 and 0.932, respectively. Trend analysis demonstrated that increasing CSA correlated well with increasing overall diameter of the graft ( P < .001). Receiver operating characteristic (ROC) curves were generated to evaluate threshold CSA measurements for various graft diameters. Maximum sensitivity values of 21.64, 25.25, and 28.256 mm2 were established for the respective graft diameters of 8, 9, and 10 mm in the 4-GST group. Independent patient factors of younger age, shorter stature, and female sex were significantly associated with graft diameter ( P = .019, .034, and .028, respectively). Conclusion: Preoperative MRI can be used to accurately predict quadrupled hamstring autograft diameter at the time of surgery. A total cross-sectional area of >22 mm2 can reliably provide a graft diameter of >8 mm at the time of surgery.

Injury to the superior glenoid labrum is increasingly recognized as a significant source of shoulder pain and dysfunction in the throwing athlete. Several theories have been proposed to explain the pathogenesis of superior labral anterior posterior (SLAP) tears. The clinical examination of the superior labrum–biceps tendon complex remains challenging because of a high association of other shoulder injuries in overhead athletes. Many physical examination findings have high sensitivity and low specificity. Advances in soft tissue imaging such as magnetic resonance arthrography allow for improved detection of labrum and biceps tendon lesions, although correlation with history and physical examination is critical to identify symptomatic lesions. Proper treatment of throwers with SLAP tears requires a thorough understanding of the altered biomechanics and the indications for nonoperative management and arthroscopic treatment of these lesions.

Using 3-dimensional high-resolution magnetic resonance imaging (MRI), we sought to compare femoral and tibial tunnel position and resultant graft obliquity with single-bundle anterior cruciate ligament (ACL) reconstruction using transtibial (TT) or anteromedial (AM) portal femoral tunnel reaming techniques.Thirty patients were prospectively enrolled after primary, autogenous bone-patellar tendon-bone ACL reconstruction by 2 groups of high-volume, fellowship-trained sports medicine surgeons. With the TT technique, an external starting point was used to maximize graft obliquity and femoral footprint capture. By use of high-resolution MRI and imaging analysis software, bilateral 3-dimensional knee models were created, mirrored, and superimposed. Differences between centroids for each femoral and tibial insertion, as well as corresponding ACL/graft obliquity, were evaluated with paired t tests and 2-sided Mann-Whitney nonparametric tests, with P.05 defined as significant.No significant differences were observed between groups in position of reconstructed femoral footprints. However, on the tibial side, AM centroids averaged 0.8 ± 1.9 mm anterior to native ACL centroids, whereas the TT group centered 5.23 ± 2.4 mm posterior to native ACL centroids (P.001). Sagittal obliquity was closely restored with the AM technique (mean, 52.2° v. 53.5° for native ACL) but was significantly more vertical (mean, 66.9°) (P = .0001) for the TT group.In this clinical series, AM portal femoral tunnel reaming more accurately restored native ACL anatomy than the TT technique. Although both techniques can capture the native femoral footprint with similar accuracy, the TT technique requires significantly greater posterior placement of the tibial tunnel, resulting in decreased sagittal graft obliquity. When a tibial tunnel is drilled without the need to accommodate subsequent femoral tunnel reaming, more accurate tibial tunnel position and resultant sagittal graft obliquity are achieved.Level III, retrospective comparative study.

The purpose of the present study is to describe the technique of margin convergence for U-shaped rotator cuff tears and report the clinical outcomes and ultrasonography with a minimum of 2 years follow-up. Three hundred eleven patients with a rotator cuff tear were prospectively enrolled in a registry at one institution. Inclusion criteria included any patient undergoing arthroscopic margin convergence for a rotator cuff tear. Exclusion criteria included open or mini-open rotator cuff repairs or suture anchor fixation to the cuff insertion without margin convergence. The outcome measurements included physical examination, manual muscle testing, the American Shoulder and Elbow Surgeons (ASES) score, and ultrasonography. Nineteen patients met the study criteria and 13 were available for 2-year follow-up (68.4%). The mean age of this cohort was 62.2 ± 7.5 years with a mean pre-operative rotator cuff tear size of 4.0 ± 1.6 cm. The ASES score increased significantly from 50.0 ± 17.7 before surgery to 83.3 ± 19.5 at 2 years ( P = 0.01). The active forward elevation also improved from 156.2 ± 11.9° before surgery to 168.0 ± 12.1 at 2 years ( P = 0.03). The active external rotation 54.4 ± 14.5 at baseline and improved to 57.1 ± 19.1 at 2 years ( P = 0.04). The strength also increased significantly from 6.7 ± 6.4 to 10.6 ± 4.9 lb at 1 year ( P = 0.048). The post-operative ultrasound demonstrated that 46.2% of rotator cuff tears were healed at 2 years. In conclusion, margin convergence is a useful technique for U-shaped tears that are difficult to mobilize.

Purpose The purpose of this study was to objectively evaluate the anatomic and biomechanical outcomes of anterior cruciate ligament (ACL) reconstruction with transtibial versus anteromedial portal drilling of the femoral tunnel. Methods Ten human cadaveric knees (5 matched pairs) without ligament injury or pre-existing arthritis underwent ACL reconstruction by either a transtibial or anteromedial portal technique. A medial arthrotomy was created in all cases before reconstruction to determine the center of the native ACL tibial and femoral footprints. A 10-mm tibial tunnel directed toward the center of the tibial footprint was prepared in an identical fashion, starting at the anterior border of the medial collateral ligament in all cases. For transtibial femoral socket preparation (n = 5), a guidewire was placed as close to the center of the femoral footprint as possible. With anteromedial portal reconstruction (n = 5), the guidewire was positioned centrally in the femoral footprint and the tunnel drilled through the medial portal in hyperflexion. An identical graft was fixed and tensioned, and knee stability was assessed with the following standardized examinations: (1) anterior drawer, (2) Lachman, (3) maximal internal rotation at 30°, (4) manual pivot shift, and (5) instrumented pivot shift. Distance from the femoral guidewire to the center of the femoral footprint and dimensions of the tibial tunnel intra-articular aperture were measured for all specimens. Statistical analysis was completed with a repeated-measures analysis of variance and Tukey multiple comparisons test with P ≤ .05 defined as significant. Results The anteromedial portal ACL reconstruction controlled tibial translation significantly more than the transtibial reconstruction with anterior drawer, Lachman, and pivot-shift examinations of knee stability ( P ≤ .05). Anteromedial portal ACL reconstruction restored the Lachman and anterior drawer examinations to those of the intact condition and constrained translation with the manual and instrumented pivot-shift examinations more than the native ACL ( P ≤ .05). Despite optimal guidewire positioning, the transtibial technique resulted in a mean position 1.94 mm anterior and 3.26 mm superior to the center of the femoral footprint. The guidewire was positioned at the center of the femoral footprint through the anteromedial portal in all cases. The tibial tunnel intra-articular aperture was 38% larger in the anteroposterior dimension with the transtibial versus anteromedial portal technique (mean, 14.9 mm v 10.8 mm; P ≤ .05). Conclusions The anteromedial portal drilling technique allows for accurate positioning of the femoral socket in the center of the native footprint, resulting in secondary improvement in time-zero control of tibial translation with Lachman and pivot-shift testing compared with conventional transtibial ACL reconstruction. This technique respects the native ACL anatomy but cannot restore it with a single-bundle ACL reconstruction. Eccentric, posterolateral positioning of the guidewire in the tibial tunnel with the transtibial technique results in iatrogenic re-reaming of the tibial tunnel and significant intra-articular aperture expansion. Clinical Relevance Anteromedial portal drilling of the femoral socket may allow for improved restoration of anatomy and stability with ACL reconstruction compared with conventional transtibial drilling techniques.

Achilles allografts have become popular for anterior cruciate ligament (ACL) reconstructions in older patients. Primary ACL reconstructions using Achilles tendon allografts in patients age 30 years and older are successful in restoring the knee to “normal” or “near normal.” During a three-year period, the two senior authors performed 65 primary ACL reconstructions using Achilles tendon allografts in patients aged 30 years and older. Our exclusion criteria were periarticular fracture, ipsilateral/contralateral knee ligament injury, and previous or concomitant osteotomy or cartilage restoration procedure. Each patient was evaluated via physical examination, functional and arthrometric testing, and radiographic and subjective outcome. Knees were considered normal, near normal, or abnormal based on the International Knee Documentation Committee (IKDC) system. Forty-three patients were examined at an average of 33 months (minimum, 24 months) postoperatively. At the time of ACL reconstruction, 35% had normal articular cartilage in all three compartments and 70% had meniscal tears. No re-ruptures occurred. While 24% had mean maximal translation differences less than or equal to 3 mm, none had side-to-side differences greater than 5 mm. Postoperative IKDC, Activities of Daily Living, and Activity Rating Scale scores averaged 88, 94, and 7.7, respectively. Despite the overall favorable outcomes, 29% had worsened radiographic grades at follow-up. Using an Achilles allograft for ACL reconstruction in patients older than 30 years, we restored over 90% of knees to normal or near normal while limiting postoperative complications. Poor subjective results may be related less to instability and more to pain, which may result from progressive arthritis.

Several arthroscopic techniques have been described to address patellar instability. Most arthroscopic procedures focus on soft-tissue plication or “tightening” of the medial retinacular structures to correct lateral patellar instability. Good results have been reported using these techniques; however, we have found these techniques to be ineffective when the medial stabilizers have been avulsed from the patella. As a result, we have developed an arthroscopic technique to repair medial patellofemoral ligament avulsions to the patella using suture anchors. The purpose of this article is to review our indications for arthroscopic management of patellar instability and describe our 2 most common techniques.

Introduction Elbow ulnar collateral ligament (UCL) reconstruction has become the standard of care for the throwing athlete with a symptomatic ruptured or insufficient ligament and the desire to resume competitive play. Since Jobe's initial description of UCL reconstruction, the technique has evolved. A novel modification was the "docking" technique developed by Altchek. Subsequently, the docking technique as originally described was slightly modified. Arthroscopy is no longer routinely performed, and in some cases, a 3-strand graft is used. Materials and methods We treated 21 overhand athletes with clinical and radiographic evidence of UCL insufficiency with ligament reconstruction using a modified version of the docking technique using a 3-strand graft. There were 5 professional, 11 college, and 5 high school baseball players in the reconstructed group. Athletes were evaluated postoperatively by use of the Conway Scale. Results Of the 21 patients who underwent the modified docking technique with a three-strand graft, 19 (90%) had excellent results. There were 2 good results and no complications. Discussion UCL reconstruction can successfully treat athletes with UCL insufficiency. Several different reconstruction techniques have been described. By use of the docking and modified docking techniques, good to excellent results can be achieved in the majority of cases with a low complication rate.

Background Arthroscopic treatment has evolved to become the primary surgical option in the management of anterior shoulder instability as studies show comparable outcomes between open and arthroscopic techniques. Objective To evaluate prospectively the results of our institutional database for arthroscopic Bankart repairs at a minimum 2-year follow-up for patients with anterior instability treated with suture anchors. Study Design Case series; Level of evidence, 4. Methods Eighty-three consecutive patients underwent arthroscopic Bankart repair with suture anchors. The mean age at the time of surgery was 33 years (range, 15-55 years). At an average follow-up of 33 months (range, 24-49 months), 73 patients (61 males, 12 females) were assessed with outcomes scores including the American Shoulder and Elbow Surgeons, L'Insalata, and visual analog scores. The rate of recurrent instability, range of motion, and risk factors for postoperative recurrence were evaluated. Results Thirteen patients (18%) suffered a recurrence after surgery. Seven patients (10%) had a subsequent dislocation and 6 (8%) a subluxation event or apprehension. Six of the 13 had a traumatic event that resulted in recurrent episodes of instability. Revision surgery was needed for 2 patients (3%) for instability and 2 for postoperative shoulder stiffness. On average there was no significant loss of external rotation postoperatively (average, 71° pre- and postoperatively). The American Shoulder and Elbow Surgeons and L'Insalata scores improved from 75.4 to 94.9 and 66.5 to 90.9, respectively (P < .0001). The visual analog score improved from 2.4 to 0.4 (P < .001). Patient age under 25, ligamentous laxity, and the presence of a large (>250 mm 3) Hill-Sachs lesion were associated with recurrence (P < .05). Patients under age 20 had a 37.5% recurrence rate. Conclusion In the arthroscopic treatment of anterior instability, identification of risk factors for recurrence allows for appropriate patient counseling and consideration of open stabilization. In our series, patients under age 25, with ligamentous laxity, and with a large (>250 mm3) Hill-Sachs lesion were at the greatest risk of recurrence.

The rotator cuff registry was established to evaluate prospectively the effectiveness of arthroscopic rotator cuff repair. The purpose of the present study is to report the preliminary data at the 1- and 2-year time point and perform subgroup analysis to identify factors that may affect outcome.A total of 193 patients underwent all-arthroscopic repair of a rotator cuff tear and met the inclusion criteria and 127 (65.8%) completed 2-year follow-up. The outcome measurements included physical examination, manual muscle testing, the American Shoulder and Elbow Surgeons (ASES) score, and ultrasonography.The pre-operative ASES score was 52.37 +/- 24.09 and improved to 83.88 +/- 19.28 at 1 year (P.0001) and 92.65 +/- 11.36 at 2 years (P0.0001). The percent healing for all patients was 64.10% at 3 months and 64.34% at 1 year (P = .4080). At 2 years, there was a significant increase in the percentage of healed tendon at 75.42% compared to the 3-month (P (1/4) .0001) and 1-year (P = 0.0332) time points. Patients with intact tendons had an ASES score of 93.9 +/- 10.2 compared to tendon defects with a score of 88.0 +/- 15.6 (P = .0623). Gender, tear size, and acromioclavicular joint involvement have a significant effect on ASES score. Rotator cuff characteristics such as tear size, biceps pathology, acromioclavicular joint pathology, and tissue quality have a significant effect on postoperative tendon integrity.Arthroscopic rotator cuff repair demonstrates significant improvement in clinical outcomes and good rate of healing by postoperative ultrasound. Longer-term studies are necessary to determine the efficacy over time.

Several all-arthroscopic techniques have been described to address patellar instability. Most arthroscopic procedures focus on soft tissue plication or "tightening" of the medial retinacular structures to correct lateral patellar instability. We found these techniques to be ineffective when the medial stabilizers were avulsed from the patella. As a result, we have developed an arthroscopic technique to repair medial patellofemoral ligament avulsions to the patella using suture anchors.

Background The treatment of type II superior labral anterior posterior (SLAP) lesions remains controversial. Many surgeons are reluctant to combine a SLAP repair with an acromioplasty for fear of postoperative shoulder stiffness and a poor clinical outcome. Hypothesis A SLAP repair and an acromioplasty done concomitantly may yield acceptable outcomes. Study Design Case series; Level of evidence, 4. Methods We compared the clinical results of 50 patients who had either an isolated type II SLAP repair (SLAP group, 34 patients) or a combined type II SLAP repair and acromioplasty (combined group, 16 patients). Patients were excluded for full-thickness rotator cuff tears or instability. All patients were evaluated with the L'Insalata Functional Shoulder Rating Questionnaire, with the American Shoulder and Elbow Surgeons (ASES) questionnaire, and by subjective evaluation. Results At an average of 3.4 years postoperatively, the L'Insalata and ASES scores were similar for the 2 groups: 87.1 and 85.8 for the SLAP group and 85.1 and 86.5 for the combined group, respectively (P > .05). Subjectively, only 65% of the patients in the SLAP group reported a “good” or “excellent” satisfaction with the surgery, compared with an 81% “good” or “excellent” satisfaction rating among the patients in the combined group. Seven patients (21%) in the SLAP group had postoperative clinical impingement, compared with no patients (0%) in the combined group (P < .03). Conclusions According to our data, these 2 procedures done concomitantly may yield acceptable outcomes. Our findings indicated that a combined type II SLAP repair and acromioplasty had no negative effect clinically and, furthermore, appeared to prevent residual clinical impingement.

Background Medial ulnar collateral ligament insufficiency of the elbow can be a devastating injury in the throwing athlete. Reconstruction of the medial ulnar collateral ligament was initially described by Jobe and associates; good clinical results have been described after this procedure. The authors' experience with this technique raised several concerns, and thus the “docking” procedure was developed as an alternative method for medial ulnar collateral ligament reconstruction of the elbow. The early results of the docking technique were good. The authors wish to investigate the intermediate-term clinical results of this method in a large group of athletes. Hypothesis The docking technique can return overhead-throwing athletes to sport with minimal perioperative morbidity. Study Design Case series; Level of evidence, 4. Methods During a 3-year period, 100 consecutive overhead-throwing athletes were treated with surgical reconstruction using the docking technique. The inclusion criteria were as follows: (1) a history of medial elbow pain that prevented throwing, (2) a preoperative standard noncontrast magnetic resonance image demonstrating medial ulnar collateral ligament injury, (3) clinically apparent medial ulnar collateral ligament insufficiency, and (4) an overhead-throwing athlete. At the time of surgery, all patients underwent routine arthroscopic assessment. The ulnar nerve was transposed in 22 cases. The mean follow-up was 36 months (range, 24-60 months). Results Ninety of 100 (90%) patients were able to compete at the same or a higher level than before medial ulnar collateral ligament injury for more than 12 months as noted at the follow-up interval; 7 patients were able to compete at a lower level. Only 3 patients suffered postoperative complications. Conclusion The docking technique reliably returns athletes to competitive throwing with a low perioperative morbidity.

Open posterior capsular shift is used for posterior glenohumeral instability that has failed nonoperative treatment. Few series have fully evaluated the outcome after open posterior stabilization. The purpose of this series was to evaluate the clinical and radiographic outcome after open posterior stabilization of the shoulder. Preoperative and intraoperative factors were analyzed with regard to their impact on results. Forty-eight consecutive shoulders were identified that had undergone primary open shoulder stabilization by use of open posterior capsular shift. Of the shoulders, 4 were lost to follow-up, resulting in a study group of 44 shoulders in 41 patients. Shoulders were evaluated at a range of 1.8 to 22.5 years after surgery by use of the L'Insalata shoulder form, Short Form-36 (SF-36), and a subjective shoulder rating in 44 shoulders. Thirty-nine shoulders were evaluated by physical examination, and thirty-seven underwent radiographic examination. A recurrence of posterior instability occurred in 8 shoulders (19%). Of the patients, 84% were satisfied with the current status of their shoulder. The mean L'Insalata score was 81.25+/-17.8 points, the mean SF-36 physical component score was 50.81+/-7.87, and the mean mental component score was 53.82+/-7.55. Significantly poorer satisfaction and outcome scores were seen in shoulders found to have a chondral defect at the time of stabilization and in patients aged greater than 37 years at the time of surgery. No progressive radiographic signs of glenohumeral arthritis were seen up to 22 years after surgery. Open posterior shoulder stabilization is a reliable procedure for treating significant posterior instability without causing arthritic changes. Patients found to have chondral damage within the shoulder and older patients were found to have less success after stabilization.

Despite being one of the more commonly injured joints in recreational and elite athletes, diagnosis of soft-tissue injuries of the elbow remains problematic. Although plain radiographs remain the initial mainstay for imaging of the elbow, the superior soft-tissue contrast and direct multiplanar capabilities of magnetic resonance (MR) imaging has afforded the ability to more accurately diagnose the site and extent of soft-tissue pathology, including tendinous injuries and trauma to the static stabilizers. In addition, the ability of MR imaging to noninvasively assess the integrity of the articular cartilage provides for more comprehensive information that was previously unavailable and has prognostic significance in the athlete.

Mini-open rotator cuff repair has been used successfully to treat small- and moderate-sized rotator cuff tears but not large tears (>3 cm and

BackgroundMedial collateral ligament insufficiency of the elbow with resultant valgus instability in throwing athletes is typically treated with free tendon graft reconstruction as described by Jobe.HypothesisImproved results could be obtained with the use of the docking technique.Study DesignUncontrolled retrospective review.MethodsThe study group consisted of 36 athletes who had symptomatic insufficiency of the medial collateral ligament confirmed by magnetic resonance imaging and by surgical findings. Average follow-up was 3.3 years. Key elements of the docking technique included a muscle-splitting approach without routine transposition of the ulnar nerve, routine arthroscopic assessment, treatment of associated lesions, and docking the two ends of the tendon graft into a single humeral tunnel.ResultsThirty-three of 36 patients (92%) returned to or exceeded their previous level of competition for at least 1 year, meeting the Conway-Jobe classification criteria of “excellent.” All 22 professional or collegiate athletes returned to or exceeded their previous competition level.ConclusionsThe docking technique allowed simplified graft tensioning and improved graft fixation.

Context:Reconstruction of the anterior cruciate ligament (ACL) is one of the most common surgical procedures, with more than 200,000 ACL tears occurring annually. Although primary ACL reconstruction is a successful operation, success rates still range from 75% to 97%. Consequently, several thousand revision ACL reconstructions are performed annually and are unfortunately associated with inferior clinical outcomes when compared with primary reconstructions.Evidence Acquisition:Data were obtained from peer-reviewed literature through a search of the PubMed database (1988-2013) as well as from textbook chapters and surgical technique papers.Study Design:Clinical review.Level of Evidence:Level 4.Results:The clinical outcomes after revision ACL reconstruction are largely based on level IV case series. Much of the existing literature is heterogenous with regard to patient populations, primary and revision surgical techniques, concomitant ligamentous injuries, and additional procedures performed at the time of the revision, which limits generalizability. Nevertheless, there is a general consensus that the outcomes for revision ACL reconstruction are inferior to primary reconstruction.Conclusion:Excellent results can be achieved with regard to graft stability, return to play, and functional knee instability but are generally inferior to primary ACL reconstruction. A staged approach with autograft reconstruction is recommended in any circumstance in which a single-stage approach results in suboptimal graft selection, tunnel position, graft fixation, or biological milieu for tendon-bone healing.Strength-of-Recommendation Taxonomy (SORT):Good results may still be achieved with regard to graft stability, return to play, and functional knee instability, but results are generally inferior to primary ACL reconstruction: Level B.

Forty-seven rotator interval regions from fetuses and 10 fresh-frozen rotator interval regions from adult cadavers were evaluated by gross dissection and light microscopy. Specimens from adults also were evaluated with ultrasound and magnetic resonance imaging. An analysis of 37 fetal specimens (> 14 weeks gestation) revealed two rotator interval types: Type I (9 of 37) was defined by a contiguous bridge of capsule consisting of poorly organized collagen fibers. A Type II rotator interval (28 of 37) had a complete defect covered by only a thin layer of synovium. Similar to the Type II rotator interval in the fetus, a rotator interval defect was present in six of eight specimens from adults. Histologically, the capsular tissue within the rotator interval consisted of poorly organized collagen fibers in specimens from the fetus and adult. Maximal opening of the rotator interval was seen by ultrasound with internal rotation and downward traction of the hyperextended arm in the coronal, oblique, and sagittal planes. Magnetic resonance imaging of the rotator interval region permitted anatomic evaluation. The complete absence of tissue in 28 of 37 fetuses suggests that the rotator interval defect is congenital. The authors recommend that surgeons carefully evaluate the integrity of the tissue within the rotator interval. When rotator interval closure is desired such as in patients with a persistent sulcus sign after arthroscopic stabilization, suturing the edges of more substantial tissue immediately adjacent to the boundaries of the rotator interval region would seem prudent.

Sporting activities, such as throwing, swimming, tennis, and the javelin, require the shoulder to rotate at high speeds with the arm abducted, which places the rotator cuff at risk for microtraumatic injury. The rotator cuff works with the labrum and glenohumeral ligaments to restrain abnormal motion of the humeral head on the glenoid. If microtraumatic injury occurs to one component of this restraint system, greater forces are placed on the other components, often resulting in combined injuries, for example to the rotator cuff and labrum. The clinician should be aware that combined injuries are common, and it is difficult to isolate an injury to a single structure by using history, physical examination, or imaging.

The nonoperative management of shoulder injuries in the throwing athlete requires a team approach. The physician, trainer, physical therapist, and coaches must work together with the athlete to enable a complete recovery. Each member of the team must have a clearly defined role. The trainer should initiate the process by recognizing the injury as early as possible. The physician must do a thorough evaluation and arrive at a clear diagnosis. A complete history and physical examination should be supplemented by appropriate radiographs and imaging studies. The physician needs to perform the evaluation in a manner such that the athlete and trainer feel confident in the diagnosis. The physician needs to spend an adequate amount of time with the player during the evaluation process to allow the player to express any concerns. Athletes often have their own insights into the injury that the physician should take the time to hear. Once a diagnosis is made the physician must, in consultation with the trainer, make several decisions: 1Can the athlete continue to participate? Only in exceptional circumstances is the athlete allowed to play through the injury. 2What medications are needed? In most incidences, an oral anti-inflammatory is indicated. Steroidal medications are not used because of the potential associated risks. Only in exceptional instances are narcotic pain medications used. 3Modalities such as cryotherapy, electric stimulation, and ultrasound are prescribed to decrease tissue edema and muscle stiffness. 4Injection therapy, particularly cortisone, rarely is indicated in this population. 5Physical therapy is usually the cornerstone of the treatment protocol. The conceptual structure of the program is designed by the physician in consultation with the physical therapist. The therapist and trainer carry out the program. Although the timing depends on the specific injury, in general, the player should demonstrate significant improvement in symptoms by the sixth week. If not, the player should be re-evaluated by the physician. On occasion the original diagnosis is modified at this juncture.

Previous studies report that noncontrast magnetic resonance imaging is limited in the evaluation of the superior glenoid labrum. From our magnetic resonance imaging database of 2552 patients, we prospectively identified 104 patients with superior labral lesions who subsequently went on to arthroscopic surgery. Magnetic resonance images were assessed to identify fraying, flap tears, bucket-handle tears, or displaced flap of fibrocartilage. The biceps tendon was also evaluated. Patients were categorized according to Snyder's classification, and the findings on the magnetic resonance images were correlated with surgical findings. One hundred of the 104 tears suspected on the images were confirmed at surgery. There were four false-positives and two false-negatives, the former reflecting one normal labrum, two meniscoid-type labra, and one sublabral foramen. With arthroscopic surgery as the standard, magnetic resonance imaging had a sensitivity of 98.0% (100 of 102), a specificity of 89.5% (34 of 38), and an accuracy of 95.7% (134 of 140) for detection of superior labral lesions. We concluded that high-resolution noncontrast magnetic resonance imaging can accurately diagnose superior labral lesions and aid in surgical management.

Forty-three athletes under age 40, more than half of which were collegiate or professional, with partial rota tor cuff tears were treated arthroscopically and ob served for a minimum of 24 months. By history and mechanism of injury, two main groups were identified. Group A had 14 patients with acute, traumatic injuries. All 14 had inflamed subacromial bursas, but increased glenohumeral translation and labral lesions were un common. Twelve patients (86%) had satisfactory post operative results and nine (64%) returned to preinjury sports after arthroscopic subacromial decompression and tear debridement. Group B had 29 overhead ath letes with insidious, atraumatic shoulder pain. They were not as successful with debridement (19 [66%] satisfactory and 13 [45%] return to preinjury sports). Within Group B, three subgroups were identified based on the examination under anesthesia and subacromial inflammation. Group B1 (8 patients) had normal-ap pearing subacromial spaces and often increased ante rior glenohumeral translation with posterior labral tears. These patients did poorly after arthroscopic tear debridement (3 [38%] satisfactory and 2 [25%] return to sports). Group B2 (12 patients) had inflamed sub acromial bursas and increased glenohumeral transla tion. This group had marginal results with debridement (7 [58%] satisfactory and 6 [50%] return to sports). Group B3 (9 patients) with subacromial inflammation, yet without increased glenohumeral translation, had excellent pain relief (100%) but less than half (4) re turned to preinjury sports.

Injury to the acromioclavicular joint is common and represents the source of many shoulder-related symptoms.Frequently, nonoperative treatment regimens such as physical therapy, oral antiinflamatory medication, and corticosteroid injections resolve symptoms. However, certain patients with cases refractory to conservative therapy require an operative intervention. The traditional open resection of the distal clavicle, as described independently by Mumford and Gurd has been a reproducible and reliable surgical method of treatment in patients with posttraumatic, degenerative disease of the acromioclavicluar joint associated with osteoarthritis, distal clavicle osteolisis, fractures and separations, and shoulder impingement syndrome. Advances in arthroscopic shoulder surgery and subacromial decompression have made debridement of the acromioclavicular joint and resection of the distal clavicle a viable alternative to the open approach, avoiding complication such as AC joint instability and residual postoperative shoulder weakness, and with distinct advantages like 1) evaluation of glenohumeral joint, 2) evaluation and treatment of coexistent impingement and rotator cuff pathology, 3) generally, performed on an outpatient basis, which decreases hospital cost and increases patient convenience.

Background: Tearing of the anterior capsule of the shoulder is a rare but debilitating injury for throwing athletes. However, there is very little in the literature to guide its diagnosis and treatment. In this case series, we outline our experience with anterior capsular tears of the shoulder in professional baseball players. Methods: Five professional baseball players were diagnosed with midsubstance tears of their anterior capsule. A trial of rest and rehabilitation failed in all patients, and they eventually underwent surgery. These patients were retrospectively reviewed. The presenting symptoms and findings were documented, and outcomes were assessed by the player’s ability to return to play. Results: The mean age was 33.5 years (range, 31-37 years), and all patients presented with anterior shoulder pain and the inability to throw. No patient had an acute traumatic injury. Magnetic resonance imaging provided the correct diagnosis in 4 patients, and the diagnosis was made with diagnostic arthroscopy in the fifth. Three underwent arthroscopic repair, and 2 underwent open repair of the anterior capsule. Of the 5 players, 4 (80%) returned to their preinjury level by a mean of 13.3 months (range, 8-18 months). Conclusions: Anterior capsular tears can occur in older throwing athletes. Surgical repair, whether arthroscopic or open, can yield good results in most patients. Level of evidence: Level IV, Case Series, Treatment Study. 2014 Journal of Shoulder and Elbow Surgery Board of Trustees.

Arthroscopic Bankart repair using degradable polymers is a relatively new procedure. Initial reports describing results among the first patients treated for instability of the shoulder using degradable tacks found rates of recurrent instability significantly higher than those for open repair procedures. A 21% postoperative recurrence rate was reported in the initial group of 62 patients studied. Modifications of the operative procedure and, more importantly, the indications for the procedure have led to substantially improved results. Using the following indications, a 2-year followup group of patients was found to have a 10% recurrence of instability rate : (1) traumatic instability, which primarily was anterior, unidirectional ; (2) presence of a Bankart lesion ; (3) presence of a robust inferior glenohumeral ligament ; and (4) minimal to mild amount of bony erosions present at the glenoid. It is concluded that with more precise patient selection, arthroscopic stabilization using a degradable polymeric tack can provide high levels of patient satisfaction with low rates of recurrence.

A comprehensive review of the history, indications, applications, results, and arthroscopic technique for the evaluation and treatment of common lesions of the rotator cuff and subacromial space is presented.

PURPOSE: To prospectively assess the accuracy of unenhanced magnetic resonance (MR) imaging in the detection and localization of labral injuries. MATERIALS AND METHODS: One hundred three patients with clinically suspected shoulder injuries were prospectively examined with unenhanced MR imaging. A combination of gradient-echo and high-resolution fast-spin-echo axial pulse sequences were used. Surgical correlation was obtained in all patients. RESULTS: At surgery, 37 torn anterior, 36 torn superior, and 19 torn posterior labral were identified. The sensitivity for detection of these tears with MR imaging was 100%, 86%, and 74%, respectively; the specificity was 95%, 100%, and 95%, respectively. Overall, unenhanced MR imaging was 95% accurate in the detection of labral injuries. CONCLUSION: With appropriate pulse sequences, unenhanced MR imaging of the shoulder is an accurate technique for the detection and localization of labral injuries.

Thirty-seven of 41 consecutive patients with recurrent anterior instability of the shoulder were retrospectively observed for a mean of 5.6 years (range, 4 to 10) after an arthroscopic stabilization procedure had been per formed. The operative technique involved the use of transglenoid sutures to repair the capsule and labrum. According to the criteria established by Rowe, 27 pa tients (74%) had good or excellent results, and 3 pa tients (7%) were graded as fair. Seven patients (19%) developed recurrent instability after the procedure and had failed results. Failure rates were equal in patients with a history of recurrent dislocation and those with recurrent subluxation. Absence of a Bankart lesion at operation was associated with postoperative instability ( P = 0.03). The presence or size of humeral head defects did not influence the result. Eight of 12 athletes who engaged in sports requiring repetitive overhead shoulder motion returned to full activity, and none of the 12 developed instability after operation. Four of the 13 patients who participated in contact sports or rec reational skiing developed postoperative instability ( P = 0.21). All failures occurred within 2 years of the procedure.

Seven fresh-frozen cadaveric elbows were used to evaluate the extent to which the medial collateral ligament must be injured before arthroscopic evidence of valgus instability is seen, the amount of ulnohumeral joint opening that does occur after such an injury, and the elbow position that maximizes visualization of this opening. While visualizing the most medial aspect of the ulnohumeral joint arthroscopically through the anterolateral portal, we sequentially sectioned the medial collateral ligament complex until all of the medial ligamentous restraints were cut. A valgus load was applied after each incision, and the extent to which the ulnohumeral joint opened was measured. Ulnohumeral joint opening was not visualized in any specimen until complete sectioning of the anterior bundle was performed. After the anterior bundle was released, 1 or 2 mm of joint opening was present in all specimens. Complete release of the medial collateral ligament led to dramatic increases in medial joint opening in all seven specimens (4 to 10 mm). Varying the angle of elbow flexion from 15 degrees to 120 degrees revealed that visualization of the medial joint opening was best at 60 degrees to 75 degrees. Finally, forearm pronation increased ulnohumeral joint opening and supination decreased joint opening in all specimens. We found that the entire anterior bundle must be sectioned before measurable and reproducible medial joint opening can occur.

The selective capsular repair for anterior shoulder instability allows the surgical technique to address the pathology encountered. An initial transverse capsulotomy allows visualization of the joint and flexibility in determining the site of the repair. The capsular tensioning can be performed either medially or laterally as determined by the presence of a Bankart lesion. Examination of the joint following the procedure should reveal the elimination of the pathologic anterior translation, reduction in the inferior translation, and the degree of external rotation desired to meet the specific goals of the patient.

PURPOSE: To determine the value of magnetic resonance (MR) imaging in the clinical management of chronic refractory lateral epicondylitis. MATERIALS AND METHODS: Coronal three-dimensional Fourier transform, multiplanar gradient-recalled-echo, and fat-suppressed sagittal images were obtained in 33 patients. Twenty of these patients underwent surgical debridement and/or primary tendon repair and were included in the correlative study. Surgical and pathologic reports were reviewed to determine the location and gross characteristics of the tissue. RESULTS: Findings at MR imaging correlated with the surgical findings of primary degeneration of the extensor carpi radialis brevis (n = 20). Histopathologic examination demonstrated neovascularization, disruption of collagen, and mucoid degeneration without inflammation. CONCLUSION: The use of MR imaging in patients with recalcitrant lateral epicondylitis assists in surgical planning. The definition of tendon degeneration and degree of tear, as depicted on MR image...

The throwing athlete with shoulder pain presents a diagnostic and treatment challenge to the orthopaedic surgeon. Because pitching a baseball requires the arm to accelerate at 7,000 degrees per second, tremendous forces are experienced at the shoulder joint. Electromyographic studies have shown that the larger scapular and trunk muscles are primarily responsible for arm acceleration. The smaller and more fragile rotator cuff muscles play a significant role in decelerating the arm. During the entire throwing mechanism, the rotator cuff and the capsulolabral complex act to stabilize the humeral head on the glenoid fossa. As a result, the labrum, the capsule, and the rotator cuff are frequently the site of shoulder injury in throwers. The diagnosis of injury to these structures is based on the findings from the history, physical examination, and imaging studies. The majority of throwing injuries respond well to a carefully designed rehabilitation program. Athletes who do not improve within 6 months are candidates for surgical repair. The procedure is planned so as to minimize the amount of surgical trauma and thereby to facilitate an early return to sport. Arthroscopy is a valuable first step to confirm the pathologic diagnosis. The arthroscope alone is used to perform subacromial debridement, labral repair, or debridement of undersurface partial-thickness rotator cuff tears. If the athlete has clinical evidence of shoulder instability and arthroscopic evidence of capsular stretch, an open stabilization procedure is performed.

Twenty-two patients were treated for symptomatic lesions of the superior glenoid labrum in association with instability of the tendinous insertion of the long head of the biceps brachii. A biodegradable implant was used to fix the labrum to the bony glenoid using an arthroscopic technique. At 2-year average follow-up, satisfactory results were obtained in 86% of the patients. Two patients, both of whom had undergone concomitant subacromial decompression, continued to complain of pain after the procedure; 3 patients had restricted motion postoperatively, and 1 required manipulation under anesthesia. Twelve of 13 overhead athletes were able to return to full premorbid function. Arthroscopic fixation of unstable lesions of the superior labrum led to a resolution of symptoms in the majority of patients. There were no complications related to the use of the biodegradable implant.

One of the most common pathologic processes seen in overhead throwing athletes is posterior shoulder pain resulting from internal impingement. “Internal impingement” is a term used to describe a constellation of symptoms which result from the greater tuberosity of the humerus and the articular surface of the rotator cuff abutting the posterosuperior glenoid when the shoulder is in an abducted and externally rotated position. The pathophysiology in symptomatic internal impingement is multifactorial, involving physiologic shoulder remodeling, posterior capsular contracture, and scapular dyskinesis. Throwers with internal impingement may complain of shoulder stiffness or the need for a prolonged warm-up, decline in performance, or posterior shoulder pain. On physical examination, patients will demonstrate limited internal rotation and posterior shoulder pain with a posterior impingement test. Common imaging findings include the classic “Bennett lesion” on radiographs, as well as articular-sided partial rotator cuff tears and concomitant SLAP lesions. Mainstays of treatment include intense non-operative management focusing on rest and stretching protocols focusing on the posterior capsule. Operative management is variable depending on the exact pathology, but largely consists of rotator cuff debridement. Outcomes of operative treatment have been mixed, therefore intense non-operative treatment should remain the focus of treatment.

To prospectively evaluate the return-to-sports rates after arthroscopic anterior stabilization in patients aged younger than 25 years.Fifty-eight patients underwent arthroscopic capsulolabral repair for isolated anterior instability. The mean age at the time of surgery was 19.5 years (range, 12 to 24 years). At a mean follow-up of 27 months (range, 20 to 32 months), 53 patients (42 male and 11 female patients) were assessed with American Shoulder and Elbow Surgeons, L'Insalata, and visual analog scale scores, as well as physical examination. The rate of return to sports and risk factors for postoperative recurrence were evaluated.The overall rate of return to sports at final follow-up was 87%. Forty patients returned to a preinjury level of sports activity after surgery. Six patients returned to less competitive activities. Seven patients who had a subsequent traumatic event resulting in dislocation or subluxation did not return to sports activities. Open revision repairs were performed in 5 patients with recurrent instability. The American Shoulder and Elbow Surgeons and L'Insalata scores improved from 66.9 to 83.2 and from 60.4 to 79.2, respectively (P.001). The visual analog scale score improved from 3.1 to 1 (P.001). No significant loss of external rotation was noted postoperatively (mean, 79°). Mattress repair was associated with a higher return-to-sports rate (P.05). Multiple instability episodes (5) and the presence of a Hill-Sachs lesion were associated with postoperative failure (P.05).Arthroscopic stabilization is a feasible surgical option in the young, athletic population. Mattress labral repair was associated with a higher rate of return to sports, whereas patients who had ligamentous laxity, multiple instability episodes (5), and Hill-Sachs lesions had the greatest risk of recurrence. These factors should be given consideration in planning the appropriate treatment for anterior instability in this age group.Level IV, therapeutic case series.

Biomechanical studies suggest ulnohumeral chondral and ligamentous overload (UCLO) explains the development of posteromedial chondromalacia (PMC) in throwing athletes with ulnar collateral ligament (UCL) insufficiency. UCL reconstruction reportedly allows 90% of baseball players to return to prior or a higher level of play; however, players with concomitant posteromedial chondromalacia may experience lower rates of return to play.The purpose of this investigation is to determine: (1) the rates of return to play of baseball players undergoing UCL reconstruction and posteromedial chondromalacia; and (2) the complications occurring after UCL reconstruction in the setting of posteromedial chondromalacia.We retrospectively reviewed 29 of 161 (18%) baseball players who were treated for the combined posteromedial chondromalacia and UCL injury. UCL reconstruction was accomplished with the docking technique, and the PMC was addressed with nothing or débridement if Grade 2 or 3 and with débridement or microfracture if Grade 4. The mean age was 19.6 years (range, 16-23 years). Most players were college athletes (76%) and pitchers (93%). We used a modified four-level scale of Conway et al. to assess return to play with 1 being the highest level (return to preinjury level of competition or performance for at least one season after UCL reconstruction). The minimum followup was 24 months (mean, 37 months; range, 24-52 months).Return to play was Level 1 in 22 patients (76%), Level 2 in four patients (14%), Level 3 in two patients (7%), and Level 4 in one (3%) patient.Our data suggest baseball players with concomitant PMC, may have lower rates of return to the same or a higher level of play compared with historical controls.Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

Over the past several years, the indications for elbow arthroscopy have expanded. Currently, elbow arthroscopy is used for the removal of loose bodies, the treatment of lateral epicondylitis, synovectomy, the debridement of osteophytes, the evaluation of instability contracture release, and the treatment of osteochondritis dissecans1-5. Although elbow arthroscopy is a relatively safe procedure, the prevalence of neurovascular complications has been reported to range from 0% to 14%1,3,6-9. In the literature, there have been a few reports of complete nerve transections during elbow arthroscopy6-9. We recently reported the case of a patient who presented from an outside institution after undergoing a revision arthroscopic contracture release that resulted in a complete transaction of the ulnar nerve10. A thorough understanding of the elbow anatomy and how it is affected by certain abnormalities can reduce the risk of complications associated with elbow arthroscopy. Elbows with a posttraumatic contracture have a decreased compliance of the capsule, resulting in limited displacement of neurovascular structures with insufflation. These effects should be thoroughly considered during portal placement and capsular debridement, especially because most reported complications have occurred in patients with posttraumatic contractures6-11. On the medial side of the elbow, it is imperative that the location of the ulnar nerve be identified prior to the placement of medial-side portals. This can be done by means of direct palpation, ultrasonography, or open exposure12. Dodson et al. recommended avoiding an arthroscopic procedure if the patient has undergone a previous ulnar nerve transposition1. If there has been previous surgery on the lateral aspect of the elbow, it has been suggested that an arthroscopic procedure not be attempted because of possible adherence of the radial nerve to …

Background A rotator cuff registry was established to prospectively evaluate the effectiveness of all-arthroscopic repairs. The purpose of this study is to report prognostic factors for successful clinical and radiographic outcomes at 5 years. Methods One-hundred ninety-three patients underwent all-arthroscopic rotator cuff repairs. Pre- and intraoperative data were compared to the American Shoulder and Elbow Surgeon (ASES) score, range of motion, muscle strength, and ultrasound results at 5 years using univariate, and multivariate analyses. Results At 5 years, 106 patients completed follow-up. There were no pre- or intraoperative variables that were predictive of an ASES score >90. Factors predictive of a radiographic defect were larger size of the lesion (OR 1.72, 95% CI 1.04-2.85, P = .03), multiple tendon involvement (OR 5.56, 95% CI 1.23-25.22, P = .02), older age (OR 1.15, 95% CI 1.04-1.28, P = .01), concomitant biceps (OR 16.16, 95% CI 3.01-86.65, P = .001), and acromioclavicular joint procedures (OR 6.70, 95% CI 1.46-30.73, P = .01). Radiographic healing did not correspond to clinical outcomes. Resolution of a radiographic defect was seen in 14 patients. Younger age (OR 0.84, 95% CI 0.74-0.95, P = .004) and single-tendon tears (OR 7.59, 95% CI 1.71-84.45, P = .04) were predictive. Discussion Larger tears in older patients who undergo concomitant procedures are predictive of radiographic defects at 5 years; however, radiographic healing did not correspond to clinical results. Younger patients with single tendon tears are more likely to undergo spontaneous resolution of a radiographic defect. This information can be useful in counseling patients regarding the mid-term results of this procedure.