Faculty Bibliography

OBJECTIVE: The aims of this study were to assess, grade, and surgically correlate previously unreported MRI features of superior peroneal retinacular injuries in nine surgically proven cases and to record all soft-tissue and bony abnormalities associated with these injuries. CONCLUSION: MRI was found to be a useful tool for detecting and grading superior peroneal retinacular injuries and providing information, important for presurgical planning, regarding common concomitant soft-tissue and osseous abnormalities of the lateral collateral ligaments, peroneal tendons, and fibular groove. Superior peroneal retinacular injuries are frequently associated with MRI evidence of peroneal tendon dislocations and tears. Conversely, routine MRI studies may not depict dislocated peroneal tendon injuries, despite clinical history to that effect

Elbow injuries in athletes who perform overhead throwing motions often present diagnostic challenges because of the undue stresses and often chronic, repetitive patterns of injury. Accurate and efficient assessment of the injured elbow is essential to maximize functional recovery and expedite return to play. Radiographic evaluation should be tailored to the specific injury suspected and requires a thorough understanding of normal anatomic relationships as well as familiarity with common injuries affecting these athletes

Although AC pathology usually represents a late manifestation of outlet impingement, it typically presents as a cause of pain that is resistant to nonoperative and operative measures designed to treat purely anterior acromial pathology. The bursitis that occurs with AC joint impingement may be indistinguishable from anterior acromial impingement on clinical presentation; however, physical examination, diagnostic injection, and radiographic evaluation are generally sufficient to establish the diagnosis of AC joint impingement. Nonoperative measures are indicated for the treatment of acute bursitis, although operative intervention may be necessary in cases of large, distally projecting osteophytes in the presence of AC joint degeneration. Acromioclavicular pathology, when present, should be addressed at the time of subacromial decompression, and may involve distal clavicular resection, beveling of the AC joint, or excision of marginal osteophytes. The results of surgery to address the AC contribution to impingement are generally favorable; future investigation may further clarify the role of coplaning and its potential contribution to continued postoperative AC pain and symptomatic instability

Proprioceptive ability was prospectively evaluated in patients with recurrent traumatic anterior instability who subsequently underwent anterior shoulder repair. Thirty consecutive patients were evaluated for passive position sense and detection of motion with the shoulder in flexion, abduction, and external rotation 1 week before surgery. They were then retested at 6 and 12 months postoperatively. A significant deficit in proprioception was found when the unstable side was compared with the uninvolved side before surgery. Six months after surgical repair, position sense showed an improvement of approximately 50% but was still found to be significantly different on the involved side; detection of motion was no longer significantly different from the uninvolved shoulder. One year after open anterior shoulder repair, both position sense and detection of motion were equivalent to those of the uninvolved shoulder

This study performed the first in vitro histological analysis of the effects of bipolar thermal energy on human meniscal tissue. Sixteen fresh human menisci were mounted on a cutting block and placed in a water bath simulating an arthroscopic environment. Each specimen was divided into four sections and randomized to one of four treatment options: 1. thermal ablation with a bipolar multielectrode 3 mm Covac wand (power 3 setting); 2. thermal ablation with a bipolar multielectrode 3 mm Covac wand (power setting 7); 3. resection with a scalpel blade; and 4. resection with a motorized 4.5 full-radius resector. Six micron sections were cut and stained with Hematoxylin and Eosin and Masson's trichrome stain. Menisci were evaluated for the contour of the cut edge: straight, jagged, frayed, or combined. The zone of thermal necrosis and zone of thermal alteration were determined by examining the differential staining of the connective tissue and measuring the affected area. Menisci treated with the bipolar thermal probe were noted to have a smoother contoured edge in comparison to motorized cutters. The zone of thermal penetration for the Arthrocare power setting 3 averaged 0.18 mm (range: 0.09 to 0.20; SD 0.04) and for Arthrocare power setting 7 averaged 0.33 mm (range: 0.26 to 0.36; SD 0.03). The difference in thermal penetration between Arthrocare power settings 3 and 7 was 0.15 mm. This was statistically significant at p < 0.0001 (95% CI: 0.11 to 0.19 mm). The zone of thermal penetration was non-existent for the shaver and scalpel groups. This study provides the first histological description of the effects of bipolar radiofrequency energy on meniscal tissue. It demonstrates that there is intra-substance thermal penetration and alteration of the meniscal tissue. Its clinical significance is unclear and further in vivo studies are needed to address its clinical applicability

We report the case of an 'overhead' athlete (a collegiate tennis player) who developed severe ulnar neuropathy after anterior subcutaneous transposition and placement of a fasciodermal sling. Treatment consisted of opening the sling, excising suture material, releasing all other areas of potential compression, and performing anterior submuscular transposition of the ulnar nerve deep to the flexor muscle group. Two years after surgery, subjective symptoms were significantly improved, though the patient continued to experience mild medial-side elbow discomfort and intermittent paresthesia along the ulnar nerve distribution. Pain relief achieved without full sensory and motor recovery is consistent with results reported elsewhere. In short, extreme care must be taken when creating a fasciodermal sling during anterior subcutaneous transposition of the ulnar nerve

This investigation compared the stability of 2 methods of fixation for acromioclavicular (AC) joint separations. A complete AC joint separation was simulated in 6 matched pairs of fresh-frozen human cadaveric shoulders. One specimen from each pair was repaired with two No. 5 nonabsorbable braided sutures passed around the base of the coracoid and the other with 2 suture anchors preloaded with the same suture material placed into the base of the coracoid process. The specimens were cyclically loaded for 10(4) cycles to simulate our early postoperative rehabilitation protocol for coracoclavicular repairs. Before cycling, the repairs had a mean superior laxity of 1.68 +/- 0.44 mm for the sutures alone and 1.23 +/- 0.31 mm for the suture anchors. After 10(4) cycles, the laxity was 1.32 +/- 0.59 mm and 1.33 +/- 0.94 mm, respectively. These differences were not statistically significant (P =.2). This study demonstrated that similar stability can be achieved for coracoclavicular fixation with suture anchors or with sutures placed around the base of the coracoid for the treatment of AC joint separations. The clinical relevance includes the following: (1) the potentially diminished risk of neurovascular injury with the use of suture anchors compared with the passage of sutures around the base of the coracoid and (2) the potentially reduced surgical time associated with the use of suture anchors

The extreme range of motion at the shoulder, the high angular velocities and torques, and the repetitious nature of the pitching motion combine to make the shoulder vulnerable to injury during the baseball pitch. An understanding of the biomechanics that contribute to shoulder injuries during each phase of the pitching motion can facilitate the athlete's diagnosis, treatment, and rehabilitation. The athlete's symptoms and signs, as well as radiographic imaging, are key elements in arriving at a diagnosis of shoulder injuries. Nonoperative treatment consisting of an initial period of rest and NSAIDS, followed by physical therapy and a gradual return to activity, is usually successful. When this approach fails, surgical intervention, either arthroscopic or open, may be necessary. Physical therapy and rehabilitation are directed toward restoring the integrity and strength of the dynamic and static stabilizers of the shoulder joint, yet preserving the range of motion necessary for performance. Through rehabilitation, the dedicated athlete can often return to the pitching mound at his previous level of performance

The extreme range of motion at the shoulder, the high angular velocities and torques, and the repetitious nature of the pitching motion combine to make the shoulder vulnerable to injury during the baseball pitch. An understanding of the biomechanics that contribute to shoulder injuries during each phase of the pitching motion can facilitate the athlete's diagnosis, treatment, and rehabilitation. Common injuries that occur during the late cocking and acceleration phases of the pitch include anterior instability and impingement, bicipital tendinitis, and subacromial impingement. Nonoperative treatment consisting of an initial period of rest and NSAIDS, followed by physical therapy and a gradual return to activity, is usually successful. When this approach fails, surgical intervention, either arthroscopic or open, may be necessary. Physical therapy and rehabilitation are directed toward restoring the integrity and strength of the dynamic and static stabilizers of the shoulder joint, yet preserving the range of motion necessary for performance. Through rehabilitation, the dedicated athlete can often return to the pitching mound at his previous level of performance