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Introduction and hypothesis Our aim was to determine the effects of pelvic floor physical therapy (PT) and levatordirected trigger-point injections (LTPI) on sexual function and levator-related pelvic pain. Study design A randomized trial among women with pelvic floor myalgia (PFM) was performed wherein participants received either PT or LTPI. Pain was assessed and 1 month posttreatment completion. Levator-based pain was assessed using a numeric rating scale (NRS) and the Patient Global Impression of Improvement (PGI-I) scale. Sexual function was assessed using the Female Sexual Function Index (FSFI). Results Twenty-nine women completed the study (17 had PT, 12 had LTPI). Both groups reported reduction in vaginal pain: mean NRS change from baseline of 4.47 [standard deviation (SD) 2.12) for PT and 4.67 (SD 1.72) for LTPI (p=0.8)]. A >50 % improvement in NRS was documented among 59 % of women receiving PTand 58 % receiving LTPI (p=1.0). ConsistentwithNRSscores,meanPGI-Iscorewas2.50(SD 1.17) for PTand 2.17 (SD 1.01) for LTPI (p=0.5). Mean change in FSFI favored PT [PT +8.87 (SD 5.60), LTPI +4.00 (SD 5.24), p=0.04], reflecting improvement in the sexual pain domain favoring PT (p=0.02). However, the time in weeks to effect improvement favored LTPI if controlling for the degree of change in NRS (p=0.01) and FSFI (p=0.01). Conclusions Vaginal myalgia and sex-related pain improved with pelvic floor PT and LTPI. Time-to-effect improvement and significance of therapy are dependent on treatment type.

This study aimed to determine the quality of available patient-centered information for pelvic organ prolapse (POP) on the Internet using a modified validated scale. Two independent investigators using three search engines (Google, Yahoo, Bing) searched and reviewed the top 30 unique sites for four terms: bladder prolapse; dropped bladder; uterine prolapse; dropped uterus. A total of 219 websites were reviewed by both reviewers excluding redundancies. A two-stage, 6-point rating scale with score range per question of 0–5 was developed from the DISCERN instrument. Also recorded was whether a site had Health On the Net (HON) Foundation certification. The 400 sites were (as stated) a separate search where in the the domain suffix for the top 100 sites per serach term was recorded. The summary of 400 sites reviewed across the four search terms identified 64 % .com, 19 % .org, 8 % .edu, 6 % other and 3 % .gov; .gov yielded the highest quality information. Only 23 (9.5 %) sites were HON certified, yet these sites possessed higher DISCERN scores (p

Fallopian tube vaginal fistula, a form of peritoneovaginal fistula, is an uncommon cause of persistent vaginal leakage after hysterectomy. Fallopian tube vaginal fistula resulting in peritoneal leakage has been reported in conjunction with a prolapsed fimbria. Herein is presented a case of fallopian tube vaginal fistula without a visibly prolapsed tubal fimbria. The patient was a 43-year-old woman with a 6-year history of cyclic vaginal leakage with onset shortly after vaginal hysterectomy. Examination using a vaginal speculum revealed a clear vaginal fluid but no distinct lesion or mass in the vagina, and bimanual examination did not reveal a vesicovaginal or ureterovaginal fistula. Laparoscopic surgical exploration revealed a densely adherent fallopian tube attached to the vaginal cuff, forming a fallopian tube vaginal fistula.

Previous studies have shown that patients who present at first or a later presentation with a cluster of new basal cell carcinoma (BCC) comprise a subgroup, termed multiple presentation phenotype (MPP), that is at increased risk of developing further lesions. In this study, we examined the hypothesis that patients who develop multiple clusters are a high-risk subgroup. We found, in a total group of 926 BCC patients, 32 patients with 2-5 BCC clusters (multiple cluster MPP) and 113 cases with only one cluster (single cluster MPP). Multiple cluster MPP cases had mean of 11.3 BCC compared with 3.7 in single cluster MPP cases during similar follow-up. Ultraviolet (UV) exposure in these groups was similar. We determined whether the multiple cluster MPP was associated with characteristics associated with sensitivity to UV or glutathione S-transferase (GST) GSTT1, GSTM1, cytochrome P450 (CYP) CYP2D6, tumour necrosis factor (TNF)-alpha and vitamin D receptor (VDR) genotypes previously associated with BCC presentational phenotypes. While the frequencies of blue eyes and male gender were greater in multiple cluster than single cluster cases, these differences were not significant. In multiple cluster cases, mean age at first presentation with single tumours occurred earlier and the frequencies of CYP2D6 extensive metabolizer (EM) (94.4%) and GSTT1 null (41.2%) were significantly greater (P = 0.028 and P = 0.004) than in single cluster cases (67.1% and 14.3%, respectively). The odds ratios for the individual associations of CYP2D6 EM and GSTT1 null with the multiple cluster MPP were relatively larger; 15.5 and 7.39, respectively. TNF-alpha and VDR genotypes were not associated with multiple cluster MPP. We propose that the MPP is not the consequence of excessive UV exposure but rather reflects the presence of a distinct BCC subgroup which is defined by combinations of risk genes.

Sacrocolpopexy is an effective treatment for advanced pelvic organ prolapse with predictable anatomic and functional outcomes. We describe a rare complication of mesh erosion into the rectum and subsequent multidisciplinary management. Multidisciplinary, experienced subspecialty care can address difficult complications of pelvic floor surgery with a minimally invasive approach.

une, 18 years ago, I was standing on the front lawn of the in women undergoing pelvic reconstructive surgery that J First Baptist Church in Augusta, GA, having just recited the Hippocratic Oath as part of graduation ceremonies. My brother, having also just graduated from a different medical school asks me, “So what do you think you can actually treat?” My reply belies reality. “I guess I could treat a UTI.” For many medical professionals, a urinary tract infection (UTI) is simple. Throw some antibiotic at the problem and it will go away. Simple things, however, do not often remain so simple with improved understanding. UTIs are a problem. About 20% of the US population (with >80% of that number being women) will have at least 1 UTI during their lifetime. Millions of office visits and dollars are spent on the problem with the therapies in many cases spawning new problems and more spending. The issue is particularly vexing in the context of gynecologic surgery. The most common complication of pelvic floor surgery is UTI. In the randomized Stress Incontinence Surgical Treatment Efficacy trial that compared Burch colposuspension to autologous fascial sling in women with stress urinary incontinence, 48% of women in the sling group and 32% women in the Burch group reported UTI within the first 24 months of follow-up. Among women pursuing obliterative surgery for pelvic organ prolapse, 45% had UTI within 3 months of surgery. Given the morbidity, and in some cases mortalityeapproximately 13,000 deaths attributable to UTI occur annually in the United Statesefinding an effective prophylaxis is a worthy goal. Unfortunately, trials of UTI prophylaxis in the context of female pelvic floor surgery arrive at opposite conclusions. In a multicentered, randomized trial comparing nitrofurantoin to placebo among women with a suprapubic tube following pelvic floor surgery, antibiotics decreased UTI incidence. Similarly, a randomized placebo-controlled trial with nitrofurantoin among women undergoing a midurethral sling also concluded that antibiotics decreased UTI incidence in this high-risk context. In contrast, a recent randomized trial

The elbow is a vital part of the complicated and intricate mechanism known as throwing. The athlete that participates in a throwing sport walks a fine line between success and injury. It is this line that the clinician must monitor. When an athlete admits that an injury has occurred, it is up to the physician to listen, observe, and examine the player in great detail. Injuries that involve the elbow are complex and difficult to evaluate; therefore, it is essential that a thorough, complete, and reproducible evaluation be performed every time. Not only is this important initially, but is invaluable when following up on the athlete over the course of the injury. The patient's history is the initial tool used to narrow the differential diagnoses. Questioning is concise, structured, and not leading. The result is a workable list of possible diagnosis that will aid the examiner when the physical examination is performed. The physical, like the history, is well outlined and defined. This methodology allows the clinician to be structured when evaluating the results. In the end, a complete history and physical examination may not be enough to draw a final conclusion to the etiology of the athlete's elbow injury. Ancillary studies should then be evaluated for their value and effectiveness in aiding the examiner to achieve a correct diagnosis. The purpose of this report is to provide the clinician a template that will give consistent results and aid in the diagnosis of elbow injuries.

BACKGROUND: Although obstetric mortality due to complications of Clostridium perfringens infection is rare at present, we report a case of fatal clostridial sepsis secondary to a septic spontaneous abortion. CASE: A woman at 6–8 weeks’ gestation presented with vaginal bleeding and abdominal pain. Although afebrile, the patient was hypotensive, tachycardic, and tachypneic. Physical examination was remarkable for a 10-weeks’-gestation-size uterus, mild pelvic tenderness, a closed cervix without signs of trauma, and moderate vaginal bleeding. Laboratory studies were consistent with infection, hemolysis, and coagulopathy. Sonography demonstrated echolucencies consistent with gas formation in the endometrial cavity. Despite fluid resuscitation, transfusions, antibiotic therapy, and a dilation and curettage, persistent vaginal bleeding required an emergency hysterectomy. Hypotension ensued, and despite aggressive resuscitation attempts, the patient died. CONCLUSION: Rare cases of fatal sepsis secondary to pelvic infection with Clostridium perfringens continue to occur. Hemolysis, anuria, coagulopathy, and characteristic sonographic findings should heighten suspicion of this potentially fatal infection.

In 2008 and again in July of this year, the U.S. Food and Drug Administration (FDA) issued safety communications regarding the use of transvaginally placed surgical mesh. These FDA communications have been the subject of much discussion in the literature. One issue raised by these communications and in the medical literature is the matter of informed consent. Informed consent is an established bioethical principle in modern health care, but it is evolving. The legal interpretations of informed consent are also in flux. A review of contemporary ethical and legal elements of informed consent is presented as it relates to the use of medical innovation, with a focus on transvaginally placed surgical mesh.

The optimal surgery for combined apical and posterior vaginal prolapse is not well defined. Our objective was to examine the anatomic and functional outcomes following sacrocolpopexy (SCP) with or without posterior colporrhaphy (PC).We retrospectively evaluated 258 women who underwent abdominal (n = 62) or laparoscopic (n = 196) SCP with or without PC. Preoperative anatomic support and standardized bowel symptoms were compared to 6-week and 1-year postoperative values, using Student's t test and Wilcoxon rank sum test, respectively.Six-week follow-up data were available for 235 of 258 (91.1 %) women, while 125 of 258 (48.4 %) women had 1-year anatomic and functional outcomes recorded. While the SCP + PC group had worse posterior descent and bowel function preoperatively, there were no significant differences in postoperative anatomic support or symptoms. Long-term pelvic floor function was similar, as measured by three validated instruments. Reduction in the proportion of women with splinting was greater in the SCP + PC group.SCP with or without PC is associated with improved posterior support and decreased obstructive and irritative bowel symptoms at 1 year in women with apical and posterior prolapse.

Because of the popularity of sports participation, sports physical therapists must recognize in the athlete the many clinical conditions that occur about the elbow. The purpose of this paper is to present the most common elbow problems that an athlete may encounter and to provide information to facilitate recognition of elbow pathology. This information is essential before initiating treatment. An attempt is made to include sprains, strains, neuropathies, dislocations, fractures, contusions, vascular insults, and skin problems in the distal humerus, elbow, and proximal forearm of both the immature and mature athlete. Comprehension of the mechanism of injury aids clinical evaluation and rehabilitation and enhances early return to activity.

Fibrin sealant commonly is used topically for hemostasis in cardiovascular surgery. Complicated vulvar and vaginal bleeding after vaginal delivery can be difficult to manage using traditional techniques.A 21-year-old primipara, after a spontaneous vaginal delivery of a twin gestation, was found to have expanding right labial swelling and ecchymosis extending from the superior part of the labia majora to the ischial fossa that was approximately 10 cm wide. Surgical exploration was pursued, but poor tissue quality limited the effectiveness of traditional hemostatic techniques. Prompt hemostasis was achieved with application of fibrin sealant.Fibrin sealant may be useful for hemostasis when traditional techniques fail in complicated lacerations of the vulva and vagina associated with obstetric delivery.

The demands that throwing places on the vulnerable immature elbow frequently produce multiple injuries. Significant clues in the history include persistent medial elbow soreness, stiffness, and discomfort that lead to poor performance. Diagnosis involves identifying the injury sites by palpation and x-rays that pinpoint growth-plate separation or osteochondral changes. Nonoperative treatment, which can proceed if growth-plate separation at the medial apophysis is less than 3 mm, involves stretching, strengthening, sport-specific activities, and interval throwing. Prevention includes conditioning, limiting the number of pitches, and using age guidelines for learning new pitches.

Mitral repair has evolved to a point where three methods can be used to address most pathologies: full ring annuloplasty (RA) for annular disease; Gore-Tex artificial chordal replacement (ACR) for chordal disease; and autologous pericardial augmentation (PA) for leaflet disease. The study aim was to assess the impact of the increasing application of these methods on operative results over time.Of 328 consecutive mitral valve procedures, 34% involved myxomatous prolapse, 23% rheumatic, 13% ischemic, 12% pure annular dilatation, 7% prosthetic dysfunction, 6% endocarditis, 3% hypertrophic obstructive cardiomyopathy (HOCM), and 2% 'other'. All patients underwent RA. Myxomatous prolapse was repaired with ACR, and ischemic and annular dilatation with RA alone. Rheumatic, endocarditis, and HOCM etiologies were repaired with all three methods. Patients were allocated to two-year increments, and also to repair versus replacement groups. Operative outcomes over time were assessed with linear and binomial regression.Overall, 66% of mitral valves were repaired; the average operative mortality was 6% (2% for repair, 7% for replacement), and 18% involved multiple valve procedures (mortality 16%). The extent of repair increased over time, from 55% to 100% of all etiologies. Over the same period, operative mortality fell from 6% in 1994 to 0% over the past six years. Other variables, such as age, presentation status, left ventricular dysfunction and etiology were relatively constant over the period. Reoperation rates after repair have been only 2% over the past 10 years of follow up.With recent innovations, most mitral disease can be repaired with combinations of RA, ACR and PA. Today, operative mortality is approaching zero, and one factor may be the increasing application of repair to all mitral pathologies. These data support the trend of expanding valve repair across most mitral disorders.

Visualization and biopsy of suspicious peritoneum can confirm endometriosis. Endoscopic India ink tattooing can lead to peritoneum that visually mimics endometriosis.A woman with chronic pelvic pain and a history of treated endometriosis underwent diagnostic laparoscopy. Previously, a small bowel endoscopy had been performed to evaluate the pain. At laparoscopy, black peritoneal lesions were seen and biopsied due to concern for endometriosis. Pathology concluded the lesions to be carbon-based ink. Investigation revealed that tattoos placed during the small bowel endoscopy used India ink.Endoscopic India ink tattooing used to demarcate an area of bowel for later identification can stain peritoneal surfaces and mimic endometriotic implants.

The aim of this study was to determine gross and neuroanatomic features of a novel periurethral neuromuscular electrostimulator. Periurethral leads were placed in eight female cadavers. In two cases, leads were imaged after placement to enhance anatomic understanding. Pelvic viscera were removed en bloc for analysis of lead placement in the six remaining cadavers. Excised tissue was sectioned and immunostained to identify general, afferent, sympathetic, and nitric oxide synthase efferent nerve fibers. The electrodes were found within/lateral (n = 4), within/posterolateral (n = 9), and anterolateral (n = 1) to the external urethral sphincter (distance 0.25 +/- 0.5, 2.9 +/- 3.3, and 1.0 +/- 0.0 mm, respectively). The electrode to the urethra and vagina distance averaged 7.6 +/- 3.4 and 8.8 +/- 4.3 mm, respectively. Variable density staining for all nerve types was found around the electrode. A periurethral electrode interfaces the external urethral sphincter, and the adjacent distribution of nerve fibers supports proposed neuromuscular therapeutic mechanisms.

UVA should receive significant consideration as a human health risk as it is a large proportion of the solar spectrum that reaches the earth's surface and because of its ability to penetrate human skin. It is only relatively recently that this has been recognized and this previously under-researched part of the UV spectrum is becoming increasingly well characterized at doses that are quite low in relation to those experienced by humans. Absorption of UVA in a cell leads to the production of reactive oxygen and nitrogen species that can damage major biomolecules including DNA and membrane lipids. Various types of damage induced in these molecules lead to significant biological effects including cytotoxicity, mutations and alterations in cell signalling pathways. Longer-term effects such as persistent genomic instability and bystander effects have also been observed following UVA treatment of mammalian cells and, as with ionizing radiation, this changes some of the fundamental thinking around tissue effects of irradiation. Antioxidants have been assessed extensively for their ability to protect against the biological effects of UVA and a number have been shown to be successful at least in-vitro, for example vitamin E and epigallocatechin-3-gallate. Other potential targets for protection are suggested through the increased understanding of some of the signalling mechanisms activated following treatment, for example the inhibition of NADPH oxidase is seen to reduce a bystander effect. The search for appropriate and successful photoprotective agents remains an important area of research.

To determine if pelvic organ prolapse reduction decreases cystometric leak point pressure.A retrospective review was performed of women with pelvic organ prolapse points Aa, Ba or Cor = -1 cm that leaked with and without vaginal support (barrier testing) during multichannel urodynamic investigation (N=44). An analysis of the mean and difference between leak point pressure (LPP) (vesicle pressure) with and without prolapse reduction was used to determine significance.Among 460 possible study subjects, 15% (71/460) leaked only with and 4% (17/460) only without prolapse reduction. Among the 44 women who leaked both with and without prolapse reduction, prolapse reduction was associated with a mean decrease in LPP of 16.1 cm H2O (95% CI 7.4-24.7, p = 0.0005).Reduction of pelvic organ prolapse is associated with a mean decrease in LPP of 16.1 cm H2O.

OBJECTIVE To estimate the reliability and interobserver consistency of urodynamic interpretations of female bladder and urethral function. METHODS Three urogynecologists and three female urologists at a tertiary care medical center reviewed masked, abstracted clinical and urodynamic information from 100 charts, selected for adequate completeness from a consecutive series of 135 women referred for urodynamic testing. For each of the 100 cases, the reviewers assigned International Continence Society filling and voiding phase diagnoses, and overall clinical diagnoses. Raw agreement proportions and weighted kappa chance-corrected agreement statistics (kappa) were used jointly to describe both reliability and interobserver agreement. Reliability was estimated from duplicate reviews, masked and separated by at least 4 months, of each case by each physician. Interobserver agreement was estimated from comparisons of all pairs of responses from different physicians. RESULTS For clinical diagnosis of stress incontinence (present, absent, indeterminate), the within- and across-physician weighted kappa's were, respectively, 0.78 and 0.68. Corresponding results were 0.40 and 0.13 for detrusor overactivity without incontinence, 0.58 and 0.38 for detrusor overactivity with incontinence, and 0.51 and 0.26 for voiding dysfunction. Standard errors of each kappa were between 0.023 and 0.043. CONCLUSION In our group, lower urinary tract diagnoses of stress urinary incontinence from both clinical and urodynamic data demonstrated substantial reliability and interobserver agreement. However, by conventional interpretation of kappa-statistics, reliability of diagnoses of detrusor overactivity or voiding dysfunction was only moderate, and interobserver agreement on these diagnoses was no better than fair. Urodynamic interpretations may not be satisfactorily reproducible for these diagnoses.

Ilioinguinal nerve entrapment is one of the most common nerve injuries following pelvic surgery. We present a case of intractable right lower quadrant pain successfully treated with neurectomy.A 31-year-old woman, following her third elective cesarean section, noted intense, right inguinal pain immediately upon awaking from anesthesia. The pain was burning and constant and exacerbated by standing and movement. After a period of failed conservative management, a workup concluded probable nerve entrapment. Trigger point injections, amitriptyline and gabapentin therapy resulted in minimal improvement. At 10 months the patient underwent a right ilioinguinal neurectomy with excellent sustained pain relief.Low transverse fascial incisions risk injury to the iliohypogastric and ilioinguinal nerves. While pain from entrapment of these nerves often resolves spontaneously, neurectomy may offer resolution in recalcitrant cases.

One hundred seventy-six women who underwent surgical repair for vaginal prolapse (stage II or more) and incontinence and who had a 1-year postoperative examination were evaluated to identify demographic or clinical factors associated with recurrent prolapse. The pelvic organ prolapse quantification (POP-Q) staging system was used to describe vaginal prolapse. Recurrence was defined as stage II or worse at any vaginal site or the most advanced site of prolapse by centimeter measure beyond the hymen. In general, women with stage II prolapse were younger, more likely to have taken estrogen replacement therapy, and had fewer pregnancies than those with stage III or stage IV prolapse. One hundred two patients (58%) had recurrent prolapse at the 1-year follow up. Nearly all of these (n = 96, 94.1%) had stage II prolapse, including 42 with maximal extent 1 cm above the hymen, 43 with prolapse at the hymen, and 11 with prolapse 1 cm beyond the hymen. Four women had stage III (prolapse 2 cm beyond the hymen) and 2 had stage IV prolapse (stage III with vaginal length 4 cm or less). A multivariate analysis of patient characteristics found that women over 50 years of age and women with more than 1 site of preoperative prolapse had a higher rate of prolapse recurrence (P = 0.02 and P = 0.055, respectively). More women with preoperative stage III or IV prolapse (64.5%) than with preoperative stage II prolapse (50.6%) developed a recurrence, but the difference was not significant. Logistic regression analysis of patient characteristics or surgical procedures found patient age above 60 years and preoperative stage III or IV prolapse to be independently associated with recurrent prolapse atl year (P = 0.001 and P = 0.005, respectively). Forty-seven percent of women who had 1 or 2 concomitant operative procedures had recurrent vaginal prolapse compared with 63% of those who had 3 to 7 additional procedures performed (P = 0.07). Bladder neck plication and posterior colporrhaphy were associated with anterior recurrent prolapse (P = 0.005 and P = 0.003, respectively). Bladder neck suspension, either Burch or sling, had a smaller risk of recurrent anterior vaginal prolapse (P = 0.003), and a greater risk of recurrent posterior vaginal prolapse (P = 0.008).

Recently, when asked why “cosmetogynecology” was wrong a colleague retorted, “Because there is no evidence.” The response poses an interesting question in whether evidence renders an ethic since ethics are dedicated to right conduct and correspondingly assign the labels right and wrong or good and bad. The outcry for restraint in the adoption of new pelvic floor repair kits or cosmetogynecology largely stems from the lack of evidence [1–3]. While evidence-based medical practice is certainly ethical, evidence is not an ethic, and if evidence is not an ethic, but a compliment to an ethic, how do we judge medical practice? Medicine is not ethically neutral. When we identify disease as “bad” and health as “good” we pronounce judgment on equally natural processes. While it is true that medicine can borrow ethical principles from a physician’s individual world-view, medicine has an intrinsic ethic. It can be convincingly argued that the Hippocratic Oath captures the salient features of this intrinsic ethic [4]. What is the fundamental goal of medicine? According to the Hippocratic oath a physician intervenes to “benefit the sick.” In essence physicians restore health, since this is what will benefit the sick. Who and in what ways an individual is sick can be reasonably debated, but physician duties are restorative. In one sense health is a unidirectional concept (e.g., healthy bowel function cannot be improved) and as such physicians do not apply therapies to create super-normal function. The ethics of medical enhancement to otherwise normal human function is ethically and culturally charged [5] and beyond this editorial. It will suffice to say that evidence can aid in defining normal, and with this medical practice, but the evidence only informs the overarching ethical principle to restore health; not included, as a first principle, is remuneration, ego, or personal advancement. It has been said that management of pelvic floor dysfunction is not about what could be done but what should be done. This is not a neutral statement. Questions of “should” bespeak judgments that are rooted in ethics. If physicians regularly practice interventions that evidence has consistently shown to be ineffective, this is fraud. Conversely, if a practice has abundant evidence documenting efficacy, is it de facto ethical? Obviously not, since harvesting organs from non-consenting trauma victims is wrong despite the evidence that organ transplantation can be highly effective (it is worth noting the presently simmering issue of presumed consent in organ donation). Ignorance can soften the first situation but the latter arises from a darkened world-view that is outside of any intrinsic medical ethic. When looking for a rule for practice and likewise rules to judge the ethics of any practice in medicine, we must recognize that individual world-views, in cooperation with the intrinsic medical ethic, can underlie the process. Such individual world-views can reorder care priorities to where the ends justify the means. If evidence demonstrated a therapy ineffective, yet it was practiced routinely, this would be bad. As stated above the situation is at least dishonest, but why is dishonesty bad? If self-interest is the prevailing human ethic then would not any medical practice that does not majority benefit the physician be bad? In 1991 Dr. L.D. Rue proposed at the American Academy for the Advancement of Science that modern culture needed a “noble lie” to foster moral behavior. The “lie” would be necessary as an authority to impart value to the universe and ourselves. While medicine Int Urogynecol J (2008) 19:745–746 DOI 10.1007/s00192-008-0617-8

Underhand pitching has received minimal attention in the sports medicine literature. This may be due to the perception that, compared with overhead pitching, the underhand motion creates less stress on the arm, which results in fewer injuries. The purpose of this study was to calculate kinematic and kinetic parameters for the pitching motion used in fast pitch softball. Eight female fast pitch softball pitchers were recorded with a four-camera system (200 Hz). The results indicated that high forces and torques were experienced at the shoulder and elbow during the delivery phase. Peak compressive forces at the elbow and shoulder equal to 70-98% of body weight were produced. Shoulder extension and abduction torques equal to 9-10% of body weight x height were calculated. Elbow flexion torque was exerted to control elbow extension and initiate elbow flexion. The demand on the biceps labrum complex to simultaneously resist glenohumeral distraction and produce elbow flexion makes this structure susceptible to overuse injury.

Our objective was to determine the relationships between a trans-obturator sling and anatomic structures within the obturator region. The obturator regions of six cadavers were dissected and distances from the mid-point of the ischiopubic ramus to the muscles, nerves, and vessels of the region were measured. A trans-obturator sling was placed and distances from the device to the same anatomic structures were determined. Four additional cadavers were dissected to determine the device route of passage. The obturator canal is on average 4.4 cm from the midpoint of the ischiopubic rami. The trans-obturator sling passes on average 2.4 cm inferior-medial to the obturator canal. The anterior and posterior divisions of the obturator nerve are on average 3.4 and 2.8 cm, respectively, from a passed trans-obturator device. The device passed on average 1.1 cm from the most medial branch of the obturator vessels. Vascular and nerve structures are within 1-3 cm of the path of any device passed through the obturator foramen. A trans-obturator sling risks injury to these structures, although the small caliber of the vessels and the confined space in which they would bleed make the consequences of injury uncertain.