AbstractText: Youth baseball players are at high risk for elbowinjuries, which can lead to future functional disability AbstractText: To evaluate ... of a prevention program to lower the risk of medial elbowinjury in these athletes AbstractText: Cohort study; Level of evidence, 2 ... physical function were predictive of a lower rate of medial elbowinjury: increased total shoulder total rotation (odds ratio [OR], 0.973; 95 ...
BACKGROUND: Studies investigating the annular ligament have presented confusing information about its anatomy and nomenclature. Cadaver elbow dissections were used to clarify the anatomy and terminology of the annular ligament.
METHODS: Nineteen elbows were dissected (7 fresh frozen and 12 embalmed). Target structures were identified, photographed, and measured by independent observers.
RESULTS: There are 3 layers to the lateral elbow ligaments: the superficial lateral ulnar collateral and radial collateral ligament; a deeper layer of the superior oblique band (SOB) and inferior oblique band (IOB) of the annular ligament; and the deepest capsular layer. The annular ligament measured 9.5 ± 1.4 mm anteriorly. The SOB (15/19) was 3.9 ± 1.0 mm wide by 10.5 ± 3.8 mm long. The IOB (13/19) was 3.6 ± 1.1 mm wide by 11.4 ± 4.2 mm long. The IOB inserts onto the anterior proximal ulna rather than the supinator crest. The anterior oblique band (8/19) was 3.8 ± 1.7 mm wide.
CONCLUSION: The SOB and IOB were present in the majority of specimens. The previously described accessory lateral collateral ligament is a localized thickening on the lateral ligament complex arising from the supinator insertion independent of the IOB that attaches to the annular ligament inferiorly and distally and attaches onto the proximal anterior ulna at the bicipital fossa floor, medial to the supinator crest.
BACKGROUND: Previous randomized controlled studies and meta-analyses have failed to collectively favor either open reduction-internal fixation (ORIF) or intramedullary nailing (IMN) fixation. The purpose of our investigation was to elucidate the optimal decision between ORIF and IMN for acute traumatic operative humeral shaft fractures through an expected value decision analysis.
METHODS: We performed an expected value decision analysis and sensitivity analysis to elucidate the difference between ORIF and IMN fixation for patients with acute traumatic humeral shaft fractures. We surveyed 100 consecutive, randomly selected volunteers for their outcome preferences. Outcomes included union, delayed union, major complications, minor complications, and infection. A literature review was used to establish probabilities for each of these respective outcomes. A decision tree was constructed and a fold-back analysis was performed to find an expected patient value for each treatment option.
RESULTS: The overall patient expected values for ORIF and IMN were 12.7 and 11.2, respectively. Despite artificially decreasing the rates of major complications, infection, delayed union, and nonunion each to 0% for IMN fixation (sensitivity analysis), ORIF continued to maintain a greater overall patient expected value (12.7 vs. 11.4, 11.2, 11.2, and 12.1, respectively). Only if the rate of nonunion after ORIF was increased from 6.1% to 16.8% did the overall expected outcome after ORIF equal that of IMN (11.2).
CONCLUSION: Our expected value decision analysis demonstrates that patients favor ORIF over IMN as the optimal treatment decision for an acute traumatic humeral shaft fracture.
The management of primary osteoarthritis of the shoulder has been well investigated. However, the etiology and management of posterior humeral head subluxation in the context of primary glenohumeral osteoarthritis remain controversial. The finding of static posterior subluxation of the humeral head before the development of posterior bone erosion of the glenoid in young men with radiographic findings of primary osteoarthritis has been described as arthrogenic posterior subluxation of the humeral head. It demonstrates the earliest form of the osteoarthritic evolution, and an excessive glenoid retroversion is the only probable cause of this static subluxation, although this is controversial. The clinical relevance of these findings is important in allowing the identification of patients at risk for development of glenohumeral osteoarthritis and in developing an early treatment for the subluxation to try to alter the natural course of this disease. The aim of our summary paper was to review the current literature on this matter in an attempt to better understand the pathophysiologic mechanism of this condition, which we named pre-osteoarthritic posterior subluxation of the humeral head, or Walch B-zero (B0) glenoid. It appears that Walch B0 glenoid is a pathologic condition (initially dynamic, eventually evolving into a static condition) that may lead to posterior erosion of the glenoid, taking place once there is asymmetric increased posterior glenohumeral contact forces and possibly associated with increased glenoid retroversion.
Muscular and Skeletal Diseases (4) Osteoarthritis (4), more mentions
BACKGROUND: Elite-level women's fastpitch softball players place substantial biomechanical strains on the elbow that can result in medial elbow pain and ulnar neuropathic symptoms. There is scant literature reporting the expected outcomes of the treatment of these injuries. This study examined the results of treatment in a series of these patients.
METHODS: We identified 6 female softball pitchers (4 high school and 2 collegiate) with medial elbow pain and ulnar neuropathic symptoms. Trials of conservative care failed in all 6, and they underwent surgical treatment with subcutaneous ulnar nerve transposition. These patients were subsequently monitored postoperatively to determine outcome.
RESULTS: All 6 female pitchers had early resolution of elbow pain and neuropathic symptoms after surgical treatment. Long-term follow-up demonstrated that 1 patient quit playing softball because of other injuries but no longer reported elbow pain or paresthesias. One player was able to return to pitching at the high school level but had recurrent forearm pain and neuritis 1 year later while playing a different sport and subsequently stopped playing competitive sports. Four patients continued to play at the collegiate level without further symptoms.
CONCLUSIONS: Medial elbow pain in women's softball pitchers caused by ulnar neuropathy can be treated effectively with subcutaneous ulnar nerve transposition if nonsurgical options fail. Further study is necessary to examine the role of overuse, proper training techniques, and whether pitching limits may be necessary to avoid these injuries.
BACKGROUND: Conservative management is commonly recommended as the first-line treatment for multidirectional instability (MDI) of the shoulder. Despite this, the evidence for efficacy of treatment is limited, and until recently, guidance for clinicians on conservative rehabilitation programs has been inadequate. This study evaluated the effectiveness of a physiotherapy-led exercise program for participants with MDI.
METHODS: In a single-group study design, 43 participants (16 male, 27 female; mean age, 19.8 years, standard deviation, 4.9 years) diagnosed with MDI undertook a 12-week exercise program. Primary outcome measures were the Melbourne Instability Shoulder Score, Western Ontario Shoulder Instability Index, and Oxford Shoulder Instability Score. Secondary outcomes were strength and scapular position. All measures were taken at baseline and repeated at the conclusion of the program. Test differences before and after rehabilitation were evaluated with dependent t tests and single-group effect size calculations (standardized mean difference [SMD]) to provide a measure of the magnitude of the difference.
RESULTS: Large effects were found between pre- and postrehabilitation scores on all functional instability questionnaires, with the Western Ontario Shoulder Instability Index demonstrating the largest effect (SMD, -3.04). Scapular upward rotation improved significantly in the early ranges of abduction (0°-60°), with moderate to large effects (SMDs, 0.54-0.95). All strength measures significantly improved, with large differences identified (SMDs, 0.69-2.08).
CONCLUSION: The identified improvement in functional status, shoulder muscle strength, and scapular positioning after rehabilitation allows greater confidence in the value of conservative management of MDI and informs further research by way of clinical trials in the area.
HYPOTHESIS: We hypothesized that National Football League (NFL) players sustaining a shoulder destabilizing injury could return to play (RTP) successfully at a high rate regardless of treatment type.
METHODS: We identified and evaluated 83 NFL players who sustained an in-season shoulder instability event while playing in the NFL. NFL RTP, incidence of surgery, time to RTP, recurrent instability events, seasons/games played after the injury, and demographic data were collected. Overall RTP was determined, and players who did and did not undergo operative repair were compared.
RESULTS: Ninety-two percent of NFL players returned to NFL regular season play at a median of 0.0 weeks in those sustaining a shoulder subluxation and 3.0 weeks in those sustaining a dislocation who did not undergo surgical repair (P = .029). Players who underwent operative repair returned to play at a median of 39.3 weeks. Forty-seven percent of players had a recurrent instability event. For players who were able to RTP, those who underwent surgical repair (31%) had a lower recurrence rate (26% vs. 55%, P = .021) and longer interval between a recurrent instability event after RTP (14.7 vs. 2.5 weeks, P = .050).
CONCLUSION: There is a high rate of RTP after shoulder instability events in NFL players. Players who sustain shoulder subluxations RTP faster but are more likely to experience recurrent instability than those with shoulder dislocations. Surgical stabilization of the shoulder after an instability event decreases the chances of a second instability event and affords a player a greater interval between the initial injury and a recurrent event.
Desmostylia is a clade of marine mammals belonging to either Tethytheria or Perissodactyla. Rich fossil records of Desmostylia were found in the Oligocene to Miocene strata of the Northern Pacific Rim, especially in the northwestern region, which includes the Japanese archipelago. Fossils in many shapes and forms, including whole or partial skeletons, skulls, teeth, and fragmentary bones have been discovered from this region. Despite the prevalent availability of fossil records, detailed taxonomic identification based on fragmentary postcranial materials has been difficult owing to to our limited knowledge of the postcranial diagnostic features of many desmostylian taxa. In this study, I propose the utilization of diagnostic characters found in the humerus to identify desmostylian genus. These characters can be used to identify isolated desmostylian humeri at the genus level, contributing to a better understanding of the stratigraphic and geographic distributions of each genus.
OBJECTIVE: The aim of this study was to determine factors associated with the likelihood of a better clinical outcome after the peritendinous injection of PRP for the treatment of chronic tendinopathy and identify whether PRP represents an effective treatment option for chronic tendinopathies.
METHODS: The study included 214 patients (86 males and 128 females; mean age: 39.3 (18-75) years) who received PRP injections for tendinopathy refractory to conventional treatments. The mean duration of symptoms at the moment of the PRP treatment was 8.3 months. Primary outcome measurement was perceived improvement in symptoms for each anatomic compartment for upper and lower limbs at 6 months after treatment. Also, a visual analog scale (VAS) score (pain intensity on a 0-10 scale) was used for pain scoring questionnaire before treatment, 6 weeks and 6 months following the PRP injection(s). To identify factors associated with the likelihood of a better clinical outcome, patients were categorized on the basis of their perceived improvement in symptoms 6 months after the PRP injection(s)-that is, as lower (less than 50% global improvement) or higher (more than 50% global improvement).
RESULTS: A visual analogue scale score and perceived improvement in symptoms were significantly lower after peritendinous injection in 6-week and 6-month follow-ups compared with the baseline (P < 0.001) except for peroneal and Achilles tendons. Overall, 83% of patients indicated moderate to complete improvement in symptoms. The most common injection sites were the lateral epicondyle, Achilles, and patellar tendons. Furthermore, 30% of patients received only 1 injection, 30% received 2 injections, and 40% received 3 or more injections. A total of 85% of patients were satisfied (more than 50% global improvement) with the procedure. In addition, upper limb tendons, increase in the age, and female gender were associated with a higher likelihood of perceived improvement in symptoms.
CONCLUSIONS: In the present retrospective study assessing PRP injections in the treatment of chronic tendinopathy, a moderate improvement (>50%) in pain symptoms was observed in most of the patients. Our research found that results were most promising with patellar and lateral epicondylar tendinopathy in the short to medium term. Female patients, patients with upper extremity tendinopathy and older patients appeared to benefit more from PRP injection.
LEVEL OF EVIDENCE: Level IV, Therapeutic study.
HYPOTHESIS: It was hypothesized that the long-term survivorship and clinical outcome are reasonable, justifying total elbow arthroplasty (TEA) in patients with end-stage hemophilic arthropathy.
METHODS: From 2002 to 2012, 13 primary TEAs (Coonrad-Morrey design) were implanted in 9 consecutive patients with an average age of 55 (range, 39-76) years. Type A hemophilia was diagnosed in 7 patients and type B hemophilia in 2 patients. Clinical and radiographic results of all (11 TEAs) but 1 patient were retrospectively analyzed.
RESULTS: After a mean of 9.1 (range, 5-14) years, the mean visual analog scale score for pain, total Mayo Elbow Performance Score, and subjective elbow value were significantly improved from 5 (standard deviation, ±3) to 2 (±2; P = .007) points, from 64 (±16) to 89 (±11; P = .008) points, and from 47% (±15%) to 81% (±11%; P < .001), respectively. Whereas the flexion arc remained unchanged (P = .279), mean active pronation improved significantly (P = .024). Postoperative complications were recorded in 8 TEAs (62%), whereas 5 TEAs (38%) underwent partial component exchange after a mean of 7.2 (range, 3-10) years: 2 for periprosthetic infection, 2 for polyethylene wear, and 1 for humeral component loosening. Of the living patients after partial component exchange (n = 3), the mean final total Mayo Elbow Performance Score, flexion and rotation arc, visual analog scale score for pain, and subjective elbow value were comparable with the results of the living patients without revision surgery (n = 8).
CONCLUSIONS: TEA for patients with advanced hemophilic arthropathy is associated with a substantial complication and revision rate. However, even after revision without implant removal, it provides good functional and subjective long-term results.
Individual trabecular segmentation was utilized to identify differences in trabecular bone structure in premenopausal women with wrist fractures and non-fracture controls. Fracture subjects had reduced trabecular plate volume, number, thickness, and connectivity. Identifying altered trabecular microarchitecture in young women offers opportunities for counseling and lifestyle modifications to reduce fracture risk.
INTRODUCTION: Premenopausal women with distal radius fractures (DRF) have worse trabecular bone microarchitecture than non-fracture controls (CONT), yet the characteristics of their trabecular bone structure are unknown.
METHODS: Premenopausal women with DRF (n = 40) and CONT (n = 80) were recruited. Primary outcome variables included trabecular structure at the distal radius and tibia, assessed by volumetric decomposition of individual trabecular plates and rods from high-resolution peripheral quantitative CT images. Trabecular morphology included plate and rod number, volume, thickness, and connectivity. Areal bone mineral density (aBMD) of the femoral neck (FN aBMD), and ultradistal radius (UDR aBMD) were measured by DXA.
RESULTS: Trabecular morphology differed between DRF and CONT at the radius and tibia (OR per SD decline 1.58-2.7). At the radius, associations remained significant when adjusting for age and FN aBMD (ORs = 1.76-3.26) and age and UDR aBMD (ORs = 1.72-3.97). Plate volume fraction, number and axially aligned trabeculae remained associated with DRF after adjustment for trabecular density (ORs = 2.55-2.85). Area under the curve (AUC) for discriminating DRF was 0.74 for the proportion of axially aligned trabeculae, compared with 0.60 for FN aBMD, 0.65 for UDR aBMD, and 0.69 for trabecular density. Plate number, plate-plate junction, and axial bone volume fraction remained associated with DRF at the tibia (ORs = 2.14-2.77) after adjusting for age, FN aBMD, or UDR aBMD. AUCP.P.Junc.D was 0.72 versus 0.61 for FNaBMD, 0.66 for UDRaBMD, and 0.70 for trabecular density.
CONCLUSION: Premenopausal women with DRF have lower trabecular plate volume, number, thickness, and connectivity than CONT. Identification of young women with altered microarchitecture offers opportunities for lifestyle modifications to reduce fracture risk.
Muscular and Skeletal Diseases (4) Osteoporosis (1), more mentions
OBJECTIVE: To assess the end of treatment and three months after treatment effects of diacutaneous fibrolysis as adjuvant of physical therapy for chronic lateral epicondylalgia.
DESIGN: Double-blind (patient and evaluator) randomized controlled trial.
SETTING: Primary Care Center of the Spanish NHS.
SUBJECTS: A total of 54 people with 60 elbows affected with chronic lateral epicondylalgia, 33 women, mean (SD) age was 48.43 (8.69) years.
INTERVENTIONS: All three groups (Intervention, Placebo and Control) received three weeks of physical therapy treatment and in addition Intervention Group received six sessions of real diacutaneous fibrolysis and Placebo Group received six sessions of sham diacutaneous fibrolysis.
MAIN MEASURES: Pain intensity, pressure pain threshold, pain free grip strength, function and subjective assessment were assessed at baseline, at the end of treatment and three months after treatment.
RESULTS: Between-group results at three months after treatment showed a statistically significant improvement of the Intervention Group in pain free grip strength (mean, 7.91 km/cm(2); SD, 9.23) compared to the Placebo Group (mean, 1.47 km/cm(2); SD, 7.86) and to the Control Group (mean, 2.09 km/cm(2); SD, 4.45) ( P values <0.01 and <0.03, respectively) and also in function (mean, 20.87; SD, 14.25) compared to the Control Group (mean, 4.17; SD, 18.02) ( P < 0.01). Subjective assessment was statistically better in the Intervention Group both at the end of treatment ( P < 0.01) and three months after treatment ( P < 0.03).
CONCLUSION: Diacutaneous fibrolysis added to physical therapy provides better results in the treatment of chronic lateral epicondylalgia, with greater clinical satisfaction among patients.
Whether reduced supraspinal activation contributes to age-related reductions in maximal torque during dynamic contractions is not known. The purpose was to determine whether there are age differences in voluntary activation and its variability when assessed with stimulation at the motor cortex and the muscle during maximal isometric, concentric, and eccentric contractions. Thirty young (23.6 ± 4.1 years) and 31 old (69.0 ± 5.2 years) adults performed maximal isometric, shortening (concentric) and lengthening (eccentric) contractions with the elbow flexor muscles. Maximal isometric contractions were performed at 90° elbow flexion and dynamic contractions at a velocity of 60°/s. Voluntary activation was assessed by superimposing an evoked contraction with transcranial magnetic stimulation (TMS) or with electrical stimulation over the muscle during maximal voluntary contractions (MVCs). Old adults had lower MVC torque during isometric (- 17.9%), concentric (- 19.7%), and eccentric (- 9.9%) contractions than young adults, with less of an age difference for eccentric contractions. Voluntary activation was similar between the three contraction types when assessed with TMS and electrical stimulation, with no age group differences. Old adults, however, were more variable in voluntary activation than young (standard deviation 0.99 ± 0.47% vs. 0.73 ± 0.43%, respectively) to both the motor cortex and muscle, and had greater coactivation of the antagonist muscles during dynamic contractions. Thus, the average voluntary activation to the motor cortex and muscle did not differ with aging; however, supraspinal activation was more variable during maximal dynamic and isometric contractions in the old adults. Lower predictability of voluntary activation may indicate subclinical changes in the central nervous system with advanced aging.
BACKGROUND: Humeral shaft fractures can be managed conservatively or operatively. Fracture characteristics were analyzed to identify patients who would benefit from early operative fixation.
METHODS: We performed a retrospective cohort study of 126 consecutive humeral shaft fractures (2008-2015). Fractures were classified according to fracture type, location, separation, and comminution.
RESULTS: Of 126 patients, 96 were managed conservatively. In 54%, union occurred before 26 weeks, and 13% had delayed union after 26 weeks, whereas 33% did not achieve union. Of 30 patients managed surgically, 63% had union before 26 weeks, 33% had delayed union, and 4% did not achieve union. A statistically significant difference favored operative management. This difference was maintained in specific fracture patterns (simple and spiral fractures) and locations (proximal- or distal-third humeral fractures). Early surgery had a significantly higher union rate than delayed surgery. No difference was present between plate and nail fixation regarding union or neurologic injury. Separation of fragments, open injury, and comminution were not associated with nonunion. A psychiatric history (including psychotic disorders, bipolar disorder, multiple involuntary psychiatric admissions, or dementia) was significantly associated with nonunion after conservative management (P = .016). Two patients with dementia died after their conservatively managed fractures progressed to open injuries.
CONCLUSION: This study found high rates of delayed union and nonunion with conservative management. Patients with a significant psychiatric history may benefit from consideration of operative intervention.
... the threshold to detection of passive motion (TTDPM) in patients after unilateral TEA compared with the contralateral side AbstractText: A continuous passive motion device moving the elbow at 0.5°/s was used to evaluate TTDPM in 8 patients (mean ± standard deviation age, 69.1 ± 9.93 years) at least 1 year after ...
Muscular and Skeletal Diseases (1) Arthritis (1), Joint Diseases (1), more mentions
AIMS: Resection of the proximal humerus for the primary malignant bone tumour sometimes requires en bloc resection of the deltoid. However, there is no information in the literature which helps a surgeon decide whether to preserve the deltoid or not. The aim of this study was to determine whether retaining the deltoid at the time of resection would increase the rate of local recurrence. We also sought to identify the variables that persuade expert surgeons to choose a deltoid sparing rather than deltoid resecting procedure.
PATIENTS AND METHODS: We reviewed 45 patients who had undergone resection of a primary malignant tumour of the proximal humerus. There were 29 in the deltoid sparing group and 16 in the deltoid resecting group. Imaging studies were reviewed to assess tumour extension and soft-tissue involvement. The presence of a fat rim separating the tumour from the deltoid on MRI was particularly noted. The cumulative probability of local recurrence was calculated in a competing risk scenario.
RESULTS: There was no significant difference (adjusted p = 0.89) in the cumulative probability of local recurrence between the deltoid sparing (7%, 95% confidence interval (CI) 1 to 20) and the deltoid resecting group (26%, 95% CI 8 to 50). Patients were more likely to be selected for a deltoid sparing procedure if they presented with a small tumour (p = 0.0064) with less bone involvement (p = 0.032) and a continuous fat rim on MRI (p = 0.002) and if the axillary nerve could be identified (p = 0.037).
CONCLUSION: A deltoid sparing procedure can provide good local control after resection of the proximal humerus for a primary malignant bone tumour. A smaller tumour, the presence of a continuous fat rim and the identification of the axillary nerve on pre-operative MRI will persuade surgeons to opt for a deltoid resecting procedure. Cite this article: Bone Joint J 2017;99-B:1244-9.
BACKGROUND: Distal biceps brachii tendon ruptures lead to substantial deficits in elbow flexion and supination; surgical repair restores muscle strength and endurance.
PURPOSE: To examine clinical and surgical outcomes for distal biceps tendon repairs in a large, multispecialty, integrated health care system.
STUDY DESIGN: Cohort study; Level of evidence, 3.
METHODS: Retrospective cohort study of distal biceps tendon repairs performed between January 1, 2008, and December 31, 2015. The repair methods were classified as double-incision approach using bone tunnel-suture fixation or anterior single-incision approach. Anterior single incisions were further classified according to the fixation method: cortical button alone, cortical button and interference screw, or suture anchors alone. Patient demographics, surgeon characteristics, range of motion, and complications were analyzed for all repair types.
RESULTS: Of the 784 repairs that met the inclusion criteria, 639 (81.5%) were single-incision approaches. When comparing double-incision and single-incision repairs, there was a significantly higher rate of posterior interosseous nerve palsy (3.4% vs 0.8%, P = .010), heterotopic bone formation (7.6% vs 2.7%, P = .004), and reoperation (8.3% vs 2.3%, P < .001). The most common nerve complication encountered was a lateral antebrachial cutaneous nerve palsy (n = 162), which was significantly more common in the single-incision repairs than in the double-incision repairs (24.4% vs 4.1%, P < .001). When excluding lateral antebrachial cutaneous nerve palsies, there was no significant difference in the overall nerve palsies between single-incision and double-incision (5.8% vs 6.9%, P = .612). The overall rate of tendon rerupture was 1.9% (single incision, 1.6%; double incision, 2.8%; P = .327). The overall rate of postoperative wound infection was 1.5% (single incision, 1.3%; double incision, 2.8%; P = .182). The average time from surgery to release from medical care was 14.4 weeks (single incision, 14 weeks; double incision, 16 weeks; P = .286). Patients treated with cortical button plus interference screw were released significantly sooner than were patients with other single-incision repair types (13.1 ± 8.01 weeks, P = .011). There were no significant differences in rates of motor neurapraxia, infection, rerupture, and reoperation with regard to surgeon's years of practice, fellowship training, or case volume.
CONCLUSION: The surgical repair of distal biceps tendon ruptures has an overall low rate of serious complications, regardless of approach or technique. However, the double-incision technique has a higher rate of posterior interosseous nerve palsy, heterotopic bone formation, and reoperation rate. Surgeon's years of practice, fellowship training, and case volume do not affect the rate of major complications.
Paralysis (3), Tendinosis (1), Surgical Wound Infections (1), more mentions