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Impingment is a chronic syndrome characterized by microtrauma, which causes progressive injury to the rotator cuff tendon. In recent years, arthro- scopic subacromial decompression/acromioplasty has been frequently used for the treatment of impingement syndrome and is quickly becoming the preferred surgical treatment when conservative modalities fail. Arthroscopic acromioplasty offers many benefits over open acromioplasty, including better cosmesis, lessened preoperative morbidity, a more complete intraoperative examination, and a hastened, early rehabilitation program.

Background: The incidence of ulnar collateral ligament (UCL) injuries of the elbow has increased in adolescents over the past decade because of widespread participation in athletics and heightened awareness among physicians. Hypothesis: Ulnar collateral ligament reconstruction using the docking technique would result in a successful return to athletic activity in this age group. Study Design: Case series; Level of evidence, 4. Methods: Study participants were 55 skeletally mature adolescent athletes (mean age, 17.6 years; range, 15-18 years) who underwent UCL reconstruction between 2008 and 2010. While the majority of patients were baseball players (n = 47), there were 3 gymnasts and 5 javelin throwers included in the study. Each patient underwent UCL reconstruction utilizing the docking technique after an adequate trial of nonoperative management (mean, 5.8 months). At the latest follow-up, patients were evaluated to determine their ability to return to athletic activity. Clinical outcomes were classified using the Conway scale, the Andrews-Timmerman score, and the Kerlan-Jobe Orthopaedic Clinic (KJOC) score. Results: At a minimum 2-year follow-up, 87% (48/55) of patients had excellent results using the Conway scale. Overall, there were only 2 poor results (3.6%) that were observed in patients with concomitant osteochondritis dissecans lesions of the capitellum. There were 4 postoperative complications in 4 patients (2 gymnasts and 2 javelin throwers) who developed ulnar neuritis after UCL reconstruction. The mean Andrews-Timmerman score was 83.6 ± 7.2 (range, 30-100), and the mean KJOC score was 88.0 ± 6.0 (range, 40-100). Conclusion: The docking technique results in favorable clinical outcomes in adolescent athletes with UCL insufficiency at a minimum of 2 years postoperatively. Patients with concomitant intra-articular lesions should be cautioned preoperatively that they might experience inferior clinical outcomes. Postoperatively, adolescent gymnasts and javelin throwers may be at an increased risk for transient paresthesia of the ulnar nerve caused by increased stress on the medial elbow.

Objectives: The incidence of ulnar collateral ligament (UCL) insufficiency of the elbow has drastically increased in the adolescent population over the last decade due to widespread participation in overhead athletics. Previous reports suggest clinical outcomes in teenage athletes are inferior to results in higher-level adult athletes. We hypothesized that UCL reconstruction using the docking technique would result in improved outcomes in this age group. Methods: 46 adolescent athletes (mean age 17 years, range 12-18 years) underwent UCL reconstruction using the docking technique. The majority of patients were baseball players; there were three gymnasts and three javelin throwers. Retrospective review revealed each patient had a history and physical exam consistent with UCL injury along with advanced imaging demonstrating corresponding UCL pathology (24 distal tears, 22 proximal tears). Patients were evaluated at a minimum of 2 years postoperatively based on their ability to return to athletic activity. Clinical outcomes were classified using the Conway Scale, the Andrews-Timmerman Score, and the Kerlan-Jobe Orthopaedic Clinic (KJOC) Score. Results: At most recent follow-up, 89% (41/46) of patients had excellent results using the Conway Scale. There was one good, two fair and two poor results. One fair result was noted in a revision case and the two poor results occurred in patients who had concomitant capitellar OCD lesions. UCL tear location did not affect clinical outcome. There were four postoperative complications in four patients (two gymnasts and two javelin throwers) who developed ulnar neuritis following reconstruction. The average Andrews-Timmerman Score was 86.7 and the mean KJOC score was 88. Conclusion: The docking technique results in favorable clinical outcomes in adolescent athletes with UCL insufficiency at a minimum of 2 years postoperatively. Overall, results were better than previously published reports in this age group and this may be attributed to technique specific factors. Patients with concomitant intraarticular pathology should be counseled preopreratively that they may experience inferior clinical outcomes. Additionally, gymnasts and javelin throwers may be at increased risk for postoperative complications due to increased stress on the medial elbow.

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.

Although primary ACL reconstructions have been considered a successful operation, success rates have still only ranged from 75 to 97 %. Consequently, several thousand revision ACL reconstructions are performed annually. Failures include frank graft rupture and structural failure as well as functional failure with residual instability and pivoting despite the presence of an intact graft. When planning a revision ACL reconstruction, one of the most important considerations is the graft choice. Despite the prevalence of revision ACL reconstruction, there is no universally agreed upon graft choice. Generally, autografts are the preferred graft for revision ACL reconstructions due to their more rapid and complete incorporation into the host tissue, but allograft tissue is used if there are limited autograft options available or if autograft use is relatively contraindicated secondary to patellofemoral pathology. This chapter will focus on the qualities of the different graft sources available (autografts, allografts, and synthetic grafts) along with the advantages and disadvantages of each option.

Traumatic cartilage lesions of the shoulder, such as glenolabral articular disruption (GLAD), have previously been recognized in patients with shoulder instability. We describe a new lesion in which the entire anteroinferior quadrant of the glenoid articular cartilage is sheared off in association with an adjacent labral tear. Both patients were teenage athletes who were being treated arthroscopically for shoulder instability. Preoperative imaging showed some evidence of an articular cartilage lesion. One patient was treated with removal of an irreparable fragment and microfracture, while in the other case the cartilage flap was reattached to the glenoid with a chondral fixation device. This GLAD lesion variant is a serious cartilage injury to the shoulder in young athletes that may be subtle, but needs to be recognized for proper arthroscopic treatment.

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.

A method for directly measuring the position of the humeral head on the face of the glenoid in different positions of abduction of the arm was developed. We studied three subject groups: 12 patients with normal shoulders (group 1), 15 patients with stage II impingement syndrome (group 2), and 20 patients with rotator cuff tears or stage III impingement (group 3). The study consisted of a series of anteroposterior roentgenograms in the plane of the scapula with the arm in neutral rotation. Roentgenograms were obtained at 20 degrees intervals as the arm was elevated in the plane of the scapula from 0 degree to 120 degrees. Patients held a weight equal to 2 1/2% of body weight in the hand. The parameters measured were excursion of the humeral head on the glenoid face, expressed as the distance that the center of the head lies above or below the center of the glenoid, arm angle, scapulothoracic angle, and glenohumeral angle. For patients with normal shoulders (group 1), there was no significant change in position of the humeral head with arm elevation. In contrast, those with stage II impingement (group 2) had significant (p0.05) superior displacement of the center of the humeral head with arm elevation. Patients with rotator cuff tears (group 3) demonstrated a significant rise (p0.05) during the first 40 degrees of abduction. The average position of the humeral head in the two pathologic patient groups was superior (p0.05) to the average head position in the normal patient group. There was no significant difference in head position between patients with stage II impingement and patients with rotator cuff tear. The ratio of the glenohumeral angle to the scapulothoracic angle during abduction was calculated for our patient groups. In both patient groups, arm abduction had a larger scapulothoracic component than for normal shoulders. The superior migration of the humeral head is a probable result of cuff failure, either partial or complete.

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.

Full article available online at Healio.com/Orthopedics. Search: 20120919-16 The management of acromioclavicular joint separations, in particular Rockwood types III and V, remains controversial. The purpose of this study was to investigate the observer reliability of shoulder surgeons when presented with the same cases of acromioclavicular joint separations. The authors retrospectively identified 28 patients who were diagnosed with a type III, IV, or V acromioclavicular joint separation. A PowerPoint presentation was compiled that contained an anteroposterior and axial radiograph from each patient prior to treatment. Radiographs were sent to surgeons, who diagnosed each injury according to the Rockwood classification and stated whether they recommended operative or nonoperative treatment for each patient. Inter- and intraobserver reliability were calculated from the surgeons’ reviews. Repeat diagnoses were returned by 8 surgeons. A single-measure intraclass correlation coefficient (ICC) was used to determine interobserver reliability for the surgeons’ Rockwood classifications (ICC 50.602) and their decision to operate (ICC50.469). Intraobserver reliability also was calculated for Rockwood classifications ( r50.694) and decision to operate (k50.366). Two (25%) of 8 surgeons stated that they would have used open and arthroscopic techniques for repairing the dislocations, whereas the remaining (75%) surgeons would have performed open techniques. Individual surgeons were consistent in their grading of acromioclavicular joint dislocations, but less observer agreement existed among the surgeons. Poor agreement among surgeons for the decision to operate indicates that this decision is heavily influenced by clinical factors and the radiographic classification.

Isolated ulnar collateral ligament (UCL) injury from repetitive throwing was first described by Waris in 1946 in javelin throwers1. Although these injuries were once considered career-ending for athletes, a surgical technique pioneered by Jobe in 1974 facilitated successful return to competition2. Since that time, modifications of the original procedure have resulted in improved clinical results. The present article provides a comprehensive review of current concepts related to UCL injury in throwing athletes, including a review of relevant anatomy and biomechanics, the mechanism of UCL injury and associated elbow pathology, and the evolution of UCL reconstruction procedures and clinical outcomes. The UCL is composed of three bundles: anterior, posterior, and oblique; the oblique bundle is commonly termed the transverse ligament3,4 (Fig. 1). Gross anatomical studies have demonstrated that the anterior bundle is easily distinguished from the underlying joint capsule5,6. The anterior bundle consists of two separate histological layers: the deeper layer is composed of collagen bundles contained within the capsule, and the shallower layer is a distinct ligamentous structure superficial to the capsule7. The anterior bundle originates from the anteroinferior edge of the medial humeral epicondyle and inserts onto the sublime tubercle of the ulna. There is a distinct ridge on the sublime tubercle that divides the anterior bundle into two equally sized bands, the anterior and posterior bands5,6 (Fig. 2). The area of the origin of the anterior bundle on the medial humeral epicondyle is 45.5 ± 9.3 mm2, whereas the insertion on the sublime tubercle is much broader, measuring 127 ± 35.7 mm2 (Fig. 3)6. Fig. 1 Anatomy of the ulnar collateral ligament. (Reproduced from: Conway JE, Jobe FW, Glousman RE, Pink M. Medial instability of the elbow in …

Background The Latarjet procedure is used to treat anterior shoulder instability. Authors contend that the main concept of the operation is using the conjoined tendon as a sling to lower the subscapularis, reinforcing the anteroinferior capsule. The effects of the “sling,” as well as stability and range of motion (ROM), after the Latarjet procedure have not been documented. In this study, we test the Latarjet procedure, attempting to account for the effect of the conjoined tendon. We also use the model to characterize the kinematic effects and stabilizing mechanism of the Latarjet procedure. Materials and methods Six cadaveric shoulders were tested in the intact state, after anterior capsulotomy, and after the Latarjet procedure. An apparatus was designed that allowed for loading of the conjoined tendon. ROM and translation were quantified. After conclusion of testing in the Latarjet group, the conjoined tendon was released and specimens were retested to determine stability attributable to the sling effect versus the osseous effect alone. Results We found no statistically significant differences with regard to ROM after the Latarjet procedure. The Latarjet procedure did significantly decrease anteroinferior translation. However, when the conjoined tendon was unloaded, there was a significantly decreased resistance to anterior translation. After conjoined tendon release, there was no effect on inferior translation. Conclusion This study confirmed that the Latarjet procedure successfully decreases anteroinferior translation while maintaining ROM. It did not support the belief that inferior stability is provided by the sling effect. The model developed can serve as the basis for future testing.

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.

Background: There are several large series of outcomes after ulnar collateral ligament (UCL) reconstruction that have 1 or 2 javelin throwers included. To our knowledge, however, there are no reports that focus solely on the results of UCL reconstruction in this group of athletes. Hypothesis/Purpose: We hypothesize that by using modern UCL reconstruction techniques, javelin throwers can reliably expect to return to their sport. Additionally, we review the principles behind postoperative rehabilitation in these athletes, as it differs from the usual approach used with baseball players. Study Design: Case series; Level of evidence, 4. Methods: This was a retrospective review of 10 javelin throwers who underwent UCL reconstruction between 2006 and 2009 using the docking technique. There were 5 college and 5 high school javelin throwers. The average age was 18.5 years (range, 18-21 years). All patients, before being indicated for ligament reconstruction, failed a course of nonoperative management that included rest, physical therapy, and a structured attempt to return to throwing. Postoperatively, patients were evaluated using the Conway Scale and the Andrews-Timmerman Score. Results: Patients were evaluated at a minimum 2-year follow-up. The average follow-up was 28.9 months after surgery (range, 24-45 months). On the Conway Scale, 9 of the 10 players had excellent outcomes (90%). There was one fair (10%) outcome. Average time to return to previous level of competition was 15 months. The mean Andrews-Timmerman Score was 97 (range, 85-100). Overall, 100% (10/10) of the patients were subjectively satisfied with their clinical outcome. Conclusion: Similar to other overhand athletes with UCL insufficiency, javelin throwers can reliably expect to return to their previous level of play after surgical reconstruction. A thorough understanding of the unique demands placed on these athletes because of the different throwing motion is helpful when tailoring their postoperative rehabilitation protocol. Additionally, these athletes must be counseled that the postoperative course is associated with an extended period of time until return to previous level of competition when compared with baseball players.

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.

A rotator cuff registry was established to prospectively evaluate the effectiveness of all-arthroscopic repairs. This study reports those results at 5 years.The study enrolled 193 patients who underwent all-arthroscopic rotator cuff repairs. Patients were evaluated preoperatively and at 1, 2, and 5 years postoperatively. Outcome measurements included the American Shoulder and Elbow Surgeons (ASES) score, range of motion, manual muscle testing, and ultrasonography.At 5-years, 106 patients completed follow-up, representing 55% of the patients originally enrolled but 77% of those who returned for evaluation at 1 year. ASES scores improved from 52.6 ± 23.2 preoperatively to 92.6 ± 14.8 at 5 years (P.001). Paired analyses showed no differences between the ASES scores at 2 and 5 years, but the scores improved from 1 to 5 years (P = .002). Between years 2 and 5, passive forward elevation decreased from 173° ± 10.3° to 168.6° ± 16.8° (P = .02) and external rotation decreased from 73.6° ± 21.3° to 67.8° ± 19.6° (P = .04). Patients improved a full motor grade in forward elevation and external rotation and this remained stable over time. The healing rates for all patients were 64.3% at 1 year, 75.4% at 2 years, and 81.2% at 5 years. Paired analyses showed increased healing rates from 1 to 5 years (P = .001) and from 2 to 5 years (P = .05).The midrange results of all-arthroscopic rotator cuff repairs are good, and functional results remain constant over 5 years. The ultrasound healing rates continued to increase with time; however, the mechanism and the clinical significance of this are uncertain at this time.

Background: Since 1963, the Orthopaedic In-Training Examination (OITE) has been administered to orthopaedic residents to assess resident knowledge and measure the quality of teaching within individual programs. The OITE has evolved dramatically over the years and now maintains a standardized format consisting of 275 questions divided among 12 sections. Purpose: To provide a detailed analysis of the OITE sports medicine section to identify patterns in question content, recommended references, and resident performance. Study Design: Cross-sectional study. Methods: All OITE sports medicine questions from 2005 to 2009 were analyzed, and the following data were recorded: resident performance scores, tested topics, type of imaging modalities, tested treatment modalities, taxonomy classification, and recommended references. Results: From 2005 to 2009, the sports medicine section composed 7.8% of the OITE. Mean resident performance on the entire OITE as well as on the sports medicine section improved during each year of training. Imaging modalities typically involved questions on radiographs and magnetic resonance imaging and constituted 27.4% of the OITE sports medicine section. Treatment modalities involved 36.8% of the OITE sports medicine section questions, including most treatment questions relating to ligament reconstruction or rehabilitation. The authors’ assessment of taxonomy classification showed that recall-type questions were most common; however, mean resident performance was minimally affected by type of taxonomy question. Finally, there were trends noted in recommended references; namely, the American Journal of Sports Medicine and Orthopaedic Knowledge Update Sports Medicine were the most commonly and consistently cited journal and review book, respectively. Conclusion: The current study provides some unique information relating to content, recommended references, and resident performance on the OITE sports medicine section. It is hoped this information will provide orthopaedic trainees, orthopaedic residency programs, and the American Academy of Orthopaedic Surgeons Evaluation Committee valuable information relating to improving resident knowledge and performance and optimizing sports medicine educational curricula.

Both open and arthroscopic anterior shoulder stabilization procedures are commonly performed to address shoulder instability and have been shown to be successful in restoring shoulder stability and patient function. However, a critical review of the risk factors for recurrent instability following anterior stabilization is required to determine which patients may benefit from open stabilization, as recurrence rates following arthroscopic stabilization have historically been higher than with open stabilization. Multiple prospective studies have implicated younger patient age, capsular stretching, ligamentous laxity, contact athletics, and glenoid or humeral bone loss as risk factors for arthroscopic anterior shoulder stabilization failure [1–7].

In brief Though pain, swelling, and instability can suggest one of many acute knee injuries, a systematic method for evaluation can help primary care physicians pinpoint the injury on the initial exam. Sophisticated evaluation techniques aren't always needed. A complete history, a physical exam with thorough palpation, tests to evaluate ligament function, and a standard radiographic series can usually provide enough information to specifically diagnose the patient's injury in the office.

Atraumatic spontaneous posterior dislocation of the sternoclavicular joint (SCJ) is an extremely rare event. Only three recorded cases exist in the literature, and they are poorly documented and without roentgenographic confirmation. Spontaneous posterior dislocation of the SCJ occurred in an active 50-year-old woman without any known underlying pathology. Closed reduction attempted five days later was unsuccessful, and the patient was treated conservatively with short-term modification of activity. The patient is asymptomatic and followed carefully one year postdislocation. A review of the literature discloses a 25% complication rate involving the vital structures of the superior mediastinum after posterior dislocation of the SCJ. Because of this high complication rate, a thoracic or vascular surgeon must be available should closed or open reduction become necessary.

Since 1986, 20 shoulder orthroplasties have been performed for chronic, posttroumatic changes of the proximal humerus with a modular prosthetic system. The average patient follow-up was 33 months, range 24 to 47 months. Sixteen women and four men with an average age of 69.6 years were studied. The procedure was carried out for malunion of the tuberosities or humeral head in eight patients, nonunion of the humeral head in six patients, osteonecrosis in three patients, and chronic impression fractures associated with dislocations of the humeral head in three patients. Fair, good, or excellent results were achieved in 90% of patients. The average postoperative motions were forward elevation, 111°; external rotation, 30°; and internal rotation to L2. Two failures occurred. One patient had nonunion of a tuberosity repair with superior instability and secondary impingement requiring revision surgery. A second patient had a postoperative neuropothy and posterior subluxotion with poor function. Patients younger than 70 years of age and those who did not require tuberosity osteotomy had better results. The success of orthroplasty in these difficult occurrences is dependent upon appropriate patient selection, extensive preoperative evaluation, strict attention to surgical detail, and postoperative rehabilitation. Avoidance of tuberosity osteotomy, when feasible, is advised. A modular design has advantages because it facilitates soft-tissue tensioning and tuberosity repair.

Arthroscopic stabilization using the Suretac is indicated in patients with anterior instability in whom the pathology is limited to labral detachment. A successful outcome requires an adequate debridement of the glenoid neck, proper retensioning of the labral ligament complex, and use of a robust portion of the tissue for fixation.

Thermal capsular shrinkage was popular for the treatment of shoulder instability, despite a paucity of outcomes data in the literature defining the indications for this procedure or supporting its long-term efficacy. The purpose of this study was to perform a clinical evaluation of radiofrequency thermal capsular shrinkage for the treatment of shoulder instability, with a minimum 2-year follow-up. From 1999 to 2001, 101 consecutive patients with mild to moderate shoulder instability underwent shoulder stabilization surgery with thermal capsular shrinkage using a monopolar radiofrequency device. Follow-up included a subjective outcome questionnaire, discussion of pain, instability, and activity level. Mean follow-up was 3.3 years (range 2.0-4.7 years). The thermal capsular shrinkage procedure failed due to instability and/or pain in 31% of shoulders at a mean time of 39 months. In patients with unidirectional anterior instability and those with concomitant labral repair, the procedure proved effective. Patients with multidirectional instability had moderate success. In contrast, four of five patients with isolated posterior instability failed. Thermal capsular shrinkage has been advocated for the treatment of shoulder instability, particularly mild to moderate capsular laxity. The ease of the procedure makes it attractive. However, our retrospective review revealed an overall failure rate of 31% in 80 patients with 2-year minimum follow-up. This mid- to long-term cohort study adds to the literature lacking support for thermal capsulorrhaphy in general, particularly posterior instability.The online version of this article (doi:10.1007/s11420-010-9187-7) contains supplementary material, which is available to authorized users.

The pathomechanics of the throwing shoulder have yet to be fully elucidated. The focus of this study reported here was to further characterize the morphology of the glenoid in a population of elite throwing athletes. We obtained magnetic resonance imaging scans of 38 professional baseball players (dominant shoulders) and of 35 age matched nonthrowing control patients (17 dominant and 18 nondominant shoulders). Seven measurements were made by 3 blinded reviewers on 3 axial images per patient: version of superior glenoid, middle glenoid, inferior glenoid, superior capsulolabral junction, middle capsulolabral junction, inferior capsulolabral junction, and depth of concavity of glenoid in a middle slice. Mean age of the 38 players (24 pitchers, 14 fielders) was 26.8 years, and mean age of the 35 control patients was 27.6 years. Intraclass correlation coefficients ranged from .55 to .84 for the version measurements. There were no statistically significant differences between the pitchers and the fielders on any of the 7 measurements, but such differences were found between the throwers and the dominant-shoulder control patients on all 7 measurements. There were only 2 differences (version of superior glenoid, depth of concavity of glenoid in a middle slice) between dominant- and nondominant- shoulder control patients. There was significantly more retroversion in the osseous and soft tissues of the elite throwing athletes than in the nonthrowing control patients. This increased retroversion may play a role in development of internal impingement in the overhead athlete.

Shoulder injuries in pediatric and adolescent athletes are being increasingly encountered by orthopaedic surgeons as early participation in throwing sports continues to grow at a rapid rate1-8. While shoulder pain is a common complaint of both adult and pediatric athletes, the etiology of their symptoms is often very different. Rotator cuff tears and labral pathology are common causes of shoulder pain in skeletally mature throwing athletes, yet these structures have rarely been reported as a cause of shoulder pain in the skeletally immature thrower9-13. Chronic overuse resulting in proximal humeral epiphysiolysis (Little League shoulder syndrome), osteolysis of the distal end of the clavicle, or injury to the capsulolabral complex have more frequently been implicated1-8. We present the case of an eleven-year-old baseball player with a symptomatic superior labral tear and paralabral cyst. The parents of the patient were informed that data concerning the case would be submitted for publication, and they consented. An eleven-year-old, right-hand-dominant, avid baseball player presented to our clinic with pain in the right shoulder. While he had no history of a single traumatic event or dislocation, the symptoms had developed over the previous three months with overhead throwing. He complained of diffuse soreness and weakness of the right shoulder precipitated by throwing and occasionally during batting practice. He was evaluated by his pediatrician, who diagnosed a Little League shoulder syndrome secondary to overuse and recommended a four-week period of rest with cessation of overhead sports. While the rest reduced the pain somewhat, the symptoms immediately recurred with his return to baseball and then precluded his completion of the season. He presented to our office as a normal-appearing adolescent in no apparent distress. Clinical examination revealed no gross atrophy of the deltoid, trapezius, or rotator …

Background Ulnar collateral ligament reconstruction techniques have afforded baseball players up to a reported 90% return to prior or higher level of play. A subpopulation exists with less impressive clinical outcomes potentially related to the presence of a concomitant flexor-pronator mass injury. Hypothesis/Purpose Combined flexor-pronator and ulnar collateral ligament injuries occur in older players, and results in this group are inferior to those reported for isolated ulnar collateral ligament reconstructions. Study Design Case Series; Level of evidence, 4. Methods All baseball players who had ulnar collateral ligament reconstructions by 1 surgeon over a 6-year period were identified, and the authors studied those treated for a combined flexor-pronator and ulnar collateral ligament injury. The ulnar collateral ligament reconstruction was accomplished using the docking technique, and the flexor-pronator injury was treated with debridement if tendinotic or reattachment if torn. A 2-sample t test was conducted to evaluate the likelihood of developing the combined flexor-pronator/ulnar collateral ligament compared with ulnar collateral ligament injury based on age, while a Pearson χ 2 test was used to evaluate the likelihood of a patient being ≥30 years of age in the combined flexor-pronator/ulnar collateral ligament versus ulnar collateral ligament groups. Outcome was assessed using a modified Conway classification. Results A total of 187 male baseball players between 14 and 42 years of age (mean, 20.7 years) had an ulnar collateral ligament reconstruction by 1 surgeon. Eight (4%) of 187 baseball players were treated for the combined flexor-pronator/ulnar collateral ligament injury. There was a statistically significant difference in age between the ulnar collateral ligament group (20.1 years) and the flexor-pronator/ulnar collateral ligament group (33.4 years) (P < .001). Age ≥30 years was a statistically significant age limit to predict the presence of a combined flexor-pronator/ulnar collateral ligament injury (88%) compared with an isolated ulnar collateral ligament injury (1%) (P < .001). Outcomes were 1 excellent (12.5%), 2 fair (25%), and 5 poor (62.5%). Conclusion Combined fflexor-pronator and ulnar collateral ligament injuries in baseball players may portend a worse prognosis, with a 12.5% return to prior level of play. Older age (≥30 years) is a risk factor in the development of this combined injury. When combined flexor-pronator/ulnar collateral ligament injury is suspected preoperatively, patients should be counseled on expected outcomes appropriately.

The vast majority of common arthroscopic procedures are performed with a 30° arthroscope for visualization. Although the 70° arthroscope has been described for a myriad of applications, its utility has recently been forgotten. We have explored the use of the 70° arthroscope for a myriad of arthroscopic procedures and identified a number of circumstances in which it offers superior visualization to a 30° arthroscope. These procedures include arthroscopic shoulder stabilization, distal clavicle resection, acromioclavicular joint reconstruction, rotator cuff repair, elbow arthroscopy, anterior cruciate ligament reconstruction, posterior cruciate ligament reconstruction, arthroscopy of the posterior knee compartments, hip arthroscopy, and subdeltoid shoulder arthroscopy.

A new biomodular prosthesis was used for the treatment of a displaced fracture of the proximal part of the humerus in twenty-two shoulders in twenty-two patients. The fractures were classified according to the Neer system; there were thirteen four-part, five three-part, and four head-splitting fractures. There were fifteen women and seven men, and the mean age was seventy years (range, forty-nine to eighty-seven years). The hemiarthroplasty was performed an average of eleven days (range, one to forty-five days) after the injury. The deltopectoral interval was used in all patients, and the prosthesis was implanted with cement in twenty of the shoulders. All of the patients participated in a supervised program of rehabilitation. The patients were followed for an average of thirty-six months (range, twenty-six to forty-nine months). Twenty of the twenty-two patients had a good or excellent result. The active forward elevation averaged 119 degrees; external rotation, 40 degrees; and internal rotation, to the twelfth thoracic vertebra. All of the patients except for the two who had a poor result had satisfactory relief of pain. The two patients who had a poor result had a successful revision with a modular prosthesis of the same design. The modular head could be removed, enabling the surgeon to gain access to the glenoid and to adjust the soft tissues. The over-all scores correlated inversely with the age of the patients and the interval from the injury to the operation.(ABSTRACT TRUNCATED AT 250 WORDS)

Background: To our knowledge, there has been no prospective study on the results of arthroscopic repair of superior labrum-biceps anchor complex (SLAP) tears with use of modern techniques. The purpose of the present study was to prospectively evaluate the minimum two-year results for patients with type-II SLAP tears that were treated with arthroscopic suture anchor fixation. Methods: Forty-seven patients with symptomatic type-II SLAP tears were evaluated preoperatively and at least two years postoperatively with use of the American Shoulder and Elbow Surgeons (ASES) and L'Insalata outcomes instruments and physical examination. The study group included thirty-nine male and eight female patients with a mean age of thirty-six years; thirty-four of the forty-seven patients were athletes. Patients with rotator cuff tears requiring repair or concomitant shoulder instability were excluded. Results: At an average of 2.7 years, the median ASES and L'Insalata scores were 97 and 93, respectively, compared with baseline scores of 62 and 65 (p < 0.05). The median patient-reported satisfaction rating was 9 (of 10); forty-one patients (87%) rated the outcome as good or excellent. The median patient-reported satisfaction rating was significantly higher for patients with a discrete traumatic etiology than for those with an atraumatic etiology (9 compared with 7); however, there was no significant difference between these groups in terms of the ASES or L'Insalata outcome scores. Overall, twenty-five (74%) of the thirty-four athletes were able to return to their preinjury level of competition, whereas eleven (92%) of the twelve athletes who reported a discrete traumatic event were able to return to their previous level of competition. There were five complications, including four cases of refractory postoperative stiffness. Conclusions: Our findings indicate that favorable outcomes can be anticipated in the majority of patients after arthroscopic SLAP lesion repair. While only three of four patients overall may be capable of returning fully to their previous level of competition, patients with a distinct traumatic etiology have a greater likelihood of a successful return to sports. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Background Recent studies have demonstrated predictable healing after arthroscopic rotator cuff repair at a single time point, but few studies have evaluated tendon healing over time. Hypothesis Rotator cuff tears that are intact on ultrasound at 1 time point will remain intact, and clinical results will improve regardless of healing status. Study Design Cohort study; Level of evidence, 3. Methods The Arthroscopic Rotator Cuff Registry was established to determine the effectiveness of arthroscopic rotator cuff repair with clinical outcomes using the American Shoulder and Elbow Surgeons score and ultrasound at 1 and 2 years, postoperatively. Patients were assigned to 1 of 3 groups based on ultrasound appearance: group 1, rotator cuff tendon intact at 1 and 2 years (n = 63); group 2, rotator cuff tendon defect at 1 and 2 years (n = 23); group 3, rotator cuff tendon defect at 1 year but no defect at 2 years (n = 7). Results The ultrasound appearance was consistent at 1 and 2 years for 86 of the 93 patients (92.5%). The patients in group 1 had a significantly lower mean age (57.8 ± 9.8 years) than the patients of group 2 (63.6 ± 8.6 years; P = .04). Group 2 had a significantly greater rotator cuff tear size (4.36 ± 1.6 cm) than group 1 (2.84 ± 1.1 cm; P = .00025). Each group had a significant improvement in American Shoulder and Elbow Surgeons scores from baseline to 2-year follow-up. Conclusion All intact rotator cuff tendons at 1 year remained intact at 2 years. A small group of patients with postoperative imaging did not appear healed by ultrasound at 1 year but did so at 2 years. Patients demonstrated improvement in American Shoulder and Elbow Surgeons shoulder scores, range of motion, and strength, regardless of tendon healing status on ultrasound.

Introduction Throughout the field of orthopedic surgery, there has been a trend toward using smaller incisions and implants that preserve as much normal anatomy as possible. The use of bone sparing technology, such as partial and full surface replacements of the humeral head, while attractive in younger patients, does not allow the best exposure for proper glenoid replacement. Additionally, there are other situations when the use of surface replacements is contraindicated. There are also patients with an existing total elbow replacement or a humeral malunion or deformity in which a traditional long-stem component would not fit. For these reasons, a mini-stem humeral component for total shoulder arthroplasty was developed. In this study, we hypothesized that total shoulder replacement using the mini-stem humeral component could provide low complication rates and good to excellent results, as measured by postoperative Constant–Murley and UCLA shoulder scores at minimum 2 years postoperatively. Materials and Methods This was a retrospective review of the first 49 mini-stem shoulder replacements (47 patients) for primary osteoarthritis. There were 26 male and 23 female patients. UCLA Shoulder Score and Constant Murley Scores were obtained on all patients at a minimum of 2 years postoperatively (average 29 months; range 24–43 months). Radiographs were interpreted by a musculoskeletal radiologist. Intraoperative blood loss was documented as was postoperative pain using a visual analog pain scale. Results Patients experienced over 90% good to excellent results at minimum 2 year follow up. ROM improved significantly in all parameters. Postoperative UCLA scores at final follow up averaged 27.5 while Constant–Murley scores averaged 91. Small lucent lines (Conclusions This is the first report to document the efficacy of mini-stemmed humeral components used during total shoulder arthroplasty. Our study group showed good to excellent results as well as improvement in range of motion at minimum 2-year follow-up. The results presented in this study are comparable to previous outcomes achieved with conventional length humeral components, and suggest that mini-stem humeral components are an effective option for total shoulder arthroplasty.

Synopsis Superior labral tears (SLAP lesions) can pose a significant challenge to orthopaedic surgeons and rehabilitation specialists alike. Although advancement in arthroscopic techniques has enhanced arthroscopic repair of SLAP lesions, the clinical diagnosis of SLAP lesions can still be difficult. There is a variety of etiologic factors associated with SLAP lesions and a thorough clinical evaluation is crucial to make the diagnosis. Concomitant injury to the capsular-labral complex or rotator cuff is not uncommon and can further confuse the clinical presentation. The purpose of this paper is to review the pathomechanics, diagnosis, and treatment of SLAP lesions. We will specifically review some of the physical examination tests that are used to diagnose SLAP lesions and report on our technique of arthroscopic repair. Additionally, we will discuss the operative management of associated intra-articular pathology and, finally, we will briefly discuss our postoperative rehabilitation guidelines. Level of E...