Faculty Bibliography

To encourage consistent care for patients with musculoskeletal complaints, the AAOS developed treatment algorithms to aid primary care physicians in the management of these patients. A survey was designed to assess whether a random group of primary care physicians treated their patients in a manner consistent with these algorithms. The AAOS algorithm for shoulder pain was used to develop a questionnaire for primary care physicians. An Internet company provided access to a national base of physicians who volunteered to complete the survey. Ten questions were presented on five shoulder conditions: rotator cuff disease, fractures, instability, arthritis, and frozen shoulder The 'correct' answer was based upon the AAOS algorithm. The survey was completed by 706 physicians who treated variable (one to greater than ten) numbers of shoulder patients per month. Forty-eight percent of the physicians treated acute trauma according to the algorithm, 87% treated arthritis, and 58% treated instability. Only 46% of physicians chose the correct answer for an acute rotator cuff tear and 29% for chronic rotator cuff symptoms. Forty-four percent followed the algorithm for frozen shoulder. Overall only 49% of the patients described were treated according to the AAOS algorithms. Based on the number of shoulder patients seen each month, in one month over 2000 patients could be tested by the surveyed physicians in a manner inconsistent with the treatment algorithms, suggesting the need for improved musculoskeletal education for primary care physicians

INTRODUCTION: It has been shown that the asymptomatic, dominant elbow of professional baseball pitchers can demonstrate magnetic resonance (MR) imaging signal abnormalities of the ulnar collateral ligament (UCL) consistent with a strain. The purpose of this study was to determine if younger, asymptomatic, adolescent baseball pitchers exhibit similar signal abnormalities in the UCL. METHODS: Magnetic resonance images of both elbows of 14 asymptomatic, young male baseball pitchers (ranging in age from 12 to 20 years) were performed on an outpatient basis using a 1.5-T Sigma MRI unit with a dedicated extremity coil to obtain T1 and T2 coronal and axial images which were subsequently evaluated by a musculoskeletal radiologist. Chronic tears of the UCL were suspected if the signal was attenuated or absent. Magnetic resonance images of the UCL were also evaluated for high-intensity signal or thinning. Morphologic changes such as complete tears, avulsions or thickening were identified. The images were classified into 4 grades from 0 to 3 depending on the degree of signal abnormality. RESULTS: No discrete tears were found in any of the subjects. For the dominant pitching arm, 4 of 14 subjects had increased thickness of the ulnar collateral ligament, 3 of 14 demonstrated Grade 1 changes, and 11 of 14 demonstrated no abnormal signal within the ligament. No focal tears were present in any of the subjects. Contralateral elbows in 13 of 14 patients demonstrated Grade 0 signals with 1 patient demonstrating morphological thickening of the ligament without increased signal. DISCUSSION: Signal abnormalities in the throwing elbow of asymptomatic, adolescent pitchers were uncommon. These pitchers may not have experienced sufficient pitching time to develop changes in the UCL

PURPOSE: Classification and treatment of tibial eminence fractures are determined by the degree of fragment displacement. A variety of surgical procedures have been proposed to stabilize displaced fractures using both open and arthroscopic techniques. Two common fixation techniques involve use of cannulated screws and sutures tied over an anterior tibial bone bridge. We are unaware of any biomechanical studies that have compared the strength of various techniques of fixation. TYPE OF STUDY: Biomechanical study in a cadaveric model. METHODS: Seven matched pairs of fresh-frozen human cadaveric knees were stripped of all soft tissue except the anterior cruciate ligament (ACL). Simulated type III tibial eminence fractures were created using an osteotome. Fragments of each matched pair were randomized to fixation with either a single 4-mm cannulated cancellous screw with a washer or an arthroscopic suture technique using 3 No. 2 Fiberwire sutures (Arthrex, Naples, FL) passed through the tibial base of the ACL and tied over bone tunnels on the anterior tibial cortex. Specimens were then loaded with a constant load rate of 20 mm/min, and load-deformation curves were generated. The ultimate strength and stiffness were computed for each curve. The failure mode for each test was observed. A paired 2-tailed t test was used to determine the statistically significant difference between the two methods. RESULTS: Specimens fixed with Fiberwire had a mean ultimate strength of 319 N with a standard deviation of 125 N. Those fixed with cannulated screws had a mean ultimate strength of 125 N with a standard deviation of 74 N. This difference was statistically significant (P = .0038). There was no significant difference between the mean stiffness of Fiberwire constructs (63 N; SD, 50 N) and the mean stiffness of the cannulated screw constructs (20 N; SD, 32 N). The failure modes of the Fiberwire constructs included 1 ACL failure, 3 failures of suture cutting through the anterior tibial cortex, and 3 of suture cutting through the tibial eminence fragment. The single mode of failure for the cannulated screw constructs was screw pullout of cancellous bone. CONCLUSIONS: The initial ultimate strength of Fiberwire fixation of tibial eminence fractures in these specimens was significantly stronger than that of cannulated screw fixation. CLINICAL RELEVANCE: It appears that Fiberwire fixation of eminence fractures provides biomechanical advantages over cannulated screw fixation and may influence the type of treatment one chooses for patients with tibial eminence fractures

The simultaneous diagnosis of ipsilateral patellar tendon rupture and anterior cruciate ligament tear is rare. Surgical repair is complicated by different rehabilitation regimens as well as anterior cruciate ligament graft choices. We present a case where at the same operative setting, the patellar tendon was repaired, and the anterior cruciate ligament reconstructed with autologous hamstring graft

During exercise, muscular expansion and swelling occur. Chronic exertional compartment syndrome represents abnormally increased compartment pressures and pain in the involved extremity secondary to a noncompliant musculofascial compartment. Most commonly, it occurs in the lower leg, but has been reported in the thigh, foot, upper extremity, and erector spinae musculature. The diagnosis is obtained through a careful history and physical exam, reproduction of symptoms with exertion, and pre- and post-exercise muscle tissue compartment pressure recordings. It has been postulated that increased compartment pressures lead to transient ischemia and pain in the involved extremity. However; this is not universally accepted. Other than complete cessation of causative activities, nonoperative management of CECS is usually unsuccessful. Surgical release of the involved compartments is recommended for patients who wish to continue to exercise

Arthroscopic treatment of meniscal pathology is one of the most common orthopaedic procedures in the United States, constituting 10-20% of all surgeries performed in many centers. This review summarizes the surgical indications and the actual operative techniques in arthroscopic meniscal repair

Superior labral lesions and internal impingement are believed to be the primary cause of shoulder pathology in the overhead athlete, particularly the baseball player. Increased shoulder external rotation can lead to repetitive impingement of the rotator cuff and superior labrum resulting in a superior labrum anterior and posterior lesion and partial articular-sided rotator cuff tearing. Although the etiology for this phenomenon remains controversial, the end result remains the same: pathology in the rotator cuff and superior labrum. Isolated treatment of the pathology alone, without addressing the capsular laxity, results in lower return to play rates. Addressing the capsular laxity arthroscopically at the same time as the intra-articular pathology is necessary to give these athletes the best chance to return to their prior competitive level. Although short-term results are promising, long-term follow-up is necessary to determine the ultimate usefulness of this treatment philosophy