Benton A. Emblom

Ulnar Collateral Ligament Reconstruction Using the Modified Jobe Technique

Ulnar collateral ligament (UCL) reconstruction has been successful in treating medial elbow instability due to injury to the anterior band of the UCL in high-level overhead athletes. This chapter offers detailed, step-by-step guidance needed to perform the UCL reconstruction using the modified Jobe technique.

Biceps Tenodesis in Pitchers

Objectives: SLAP tears are a common occurrence in baseball pitchers. There is not a clear consensus on the treatment of these injures in the overhead athlete, especially in the setting of a failed SLAP repair. SLAP repair in overhead athletes has had relatively poor results with return to play outcomes in several reports. Biceps tenodesis has become an option for failed SLAP repair or chronic biceps tendinitis in older patients with excellent results, but little has been reported concerning biceps tenodesis in overhead athletes. The purpose of this study was to evaluate the outcomes and function of elite level baseball pitchers after undergoing biceps tenodesis. Methods: Retrospective review was performed of 13 baseball pitchers with primary or repeat SLAP tears or biceps tendinitis who were treated with biceps tenodesis. Results: Twelve of thirteen (92%) players were contacted who underwent biceps tenodesis at mean follow-up of 3.4 years (range 1-12.3 years). Outcome measures included the ASMI labral repair outcomes questionnaire, ASES scoring system, overhead athlete shoulder and elbow score, KJOC, and the veterans rand 12 item health survey (VR-12). Eleven of 12 (92 %) contacted were able to return to playing with the most common complaint being subjective weakness and a decrease in velocity. Patients had an average score on the VR12 physical of 63, VR12 mental of 42, KJOC 79, and ASES 97. Conclusion: Biceps tenodesis in an overhead throwing athlete is an acceptable option for a failed slap repair or biceps tendonitis that fails to respond to conservative treatment. Throwing athletes should expect to get back to baseball with good outcomes, however some pain or discomfort with maximum velocity is common.

Ulnar Collateral Ligament Repair with Internal Brace Augmentation A Novel UCL Repair Technique in the Young Adolescent Athlete

Objectives: Objective: Our purpose is to describe a novel surgical technique for Ulnar Collateral Ligament repair in the young adolescent, and present the clinical results of a retrospective cohort of patients. We hypothesized that using an internal brace to augment the repair of the native ulnar collateral ligament would allow for a more aggressive physical therapy protocol and ultimately facilitate both an expeditious return to sport and a high level of patient satisfaction. Methods: Methods: After obtaining IRB approval for this study, our institutional electronic database was utilized to identify all patients who had undergone our novel technique for UCL repair between the years 2013-2014. An orthopedic fellow conducted phone surveys and the KJOC questionnaire was administered. Primary outcome measures included KJOC scores at 6 and 12 months, time to initiation of a plyometrics regimen, an interval throwing program and return to sports. Secondary measures including patient satisfaction, level of competition achieved and percent return to normal were also collected. Results: Results: Twenty-two patients (19 male/3 female, average age 17.8 years) underwent surgery between 2013-2014. All patients were high school level athletes at the time of injury and included nineteen baseball players (13 pitchers), two football players, a javelin thrower and a cheerleader. Injury patterns included seven proximal tears, one mid substance, thirteen distal and four avulsions. Nine patients underwent ulnar transposition at the time of surgery, one had undergone prior transposition and the remainder of the patient’s ulnar nerves were left in situ. At six and twelve months the average KJOC scores respectively were 88.3 and 93. Patients that underwent transposition had KJOC scores of 78.3 at six months and 97.5 at twelve while patients that were left in-situ scored 82 and 91. These differences were not significant. The average number of weeks until initiation of plyometrics was seven and an interval throwing program was initiated on average, by week eleven. The average time to throwing from the mound was twenty weeks and full return to sports was twenty-one. Twelve of the thirteen pitchers made it back to the same or next level and six of them did so by transitioning from another position back to pitcher. The remaining athletes in the cohort all returned to competition at their pre injury level. At six months all but one patient was “very” satisfied and at twelve months, all were satisfied. At six months, patients deemed themselves to be at 92% normal and at twelve months, 96%. Conclusion: Conclusion: Recently, there have been an increasing number of throwing athletes with injuries to the ulnar collateral ligament (UCL) and a seemingly exponential rise amongst adolescents. The argument for repair rather than reconstruction in younger athletes is supported by both the observation that ligaments in these patients are absent the chronic attritional damage and secondary pathologic joint changes so frequently observed in injuries amongst higher-level athletes and the results of several recent clinical studies where a reliable and rapid return to overhead sports in this patient subset has been achieved. The current study demonstrates that our novel technique of UCL repair with internal brace augmentation shows early promise for accelerated therapy and ultimately faster return to play in adolescent athletes.

Return to Play Following Metacarpal Fractures in Football Players.

Objectives: Injuries involving fractures of the metacarpals are common among football players of all levels. These injuries are typically treated conservatively with casting or splinting among non-in-season athletes, a method that involves a relatively lengthy recovery time (four weeks). To our knowledge, there are no previous reports documenting return to play in elite football players after operative management of metacarpal fractures. The purpose of this study was to retrospectively review and describe the results of operative treatment of metacarpal shaft fractures in 19 high level football players with respect to return to play. We hypothesized that in-season football players with metacarpal fractures treated surgically would be able to return to play more quickly than the typical recovery time following non-operative treatment. Methods: Surgically treated metacarpal fractures in elite football players were queried over a three-year period (2009-2012) from a database maintained by American Sports Medicine Institute (ASMI) in Birmingham, AL. Over the study period, 19 football players were identified who underwent open reduction internal fixation of metacarpal fractures by one of three attending surgeons. Retrospective chart review and phone interviews with the patient and their athletic trainers were performed to identify player position, level of competition, mechanism of injury, return to play, post-operative bracing, and re-fracture event. Radiographs were used to classify the fractures, and operative reports were reviewed for implant choice. Numerical means were calculated for in-season return to play as well as for brace time. Results: Ten high school players (53%) and nine college players (47%) were injured. The most common injured positions were wide receivers and defensive backs (26% each). Most injuries occurred through player to player contact (63%) at a game (37%) or practice (47%). The long finger (58%) was the most commonly involved metacarpal. Two players (11%) had multiple metacarpal fractures. The most common location was mid-diaphyseal (74%). Twelve patients were stabilized with plates and screws, five of whom underwent lag screw augmentation. Six patients were stabilized with a metacarpal nail and one was stabilized with only lag screws. All athletes were able to return to their pre-injury level of play without recurrence of fracture. Return to play for in-season athletes (N=11) was 6.3 days. The average time to return to play for in-season high school football players (N=6) was 9.2 days and 2.8 days for in-season collegiate football players (N=5). All in-season athletes returned to play with protective equipment in the form of a padded glove, bivalve padded cast, padded club cast, or padded splint. The protective equipment was used for an average of 21 days. Conclusion: This study provides support for the surgical treatment of displaced metacarpal shaft fractures with immediate return to play as tolerated for in-season football players. No re-fractures or complications were identified with the use of a plate, nail, or with lag screws. Elite football players can return to play with or without protective bracing depending on the position played and within a week of operative fixation.

Athletic Pubalgia Secondary to Rectus Abdominis–Adductor Longus Aponeurotic Plate Injury: Diagnosis, Management, and Operative Treatment of 100 Competitive Athletes

Background: A rectus abdominis–adductor longus (RA-AL) aponeurotic plate injury, commonly associated with athletic pubalgia, sports hernia, or a core muscle injury, causes significant dysfunction in athletes. Increased recognition of this specific injury distinct from inguinal hernia abnormalities has led to better management of this debilitating condition. Hypothesis: Surgical repair of RA-AL aponeurotic plate injuries will result in decreased symptoms and high rates of return to play. Study Design: Case series; Level of evidence, 4. Methods: Using our billing and clinical database, patients who underwent RA-AL aponeurotic plate repair by a single surgeon at a single institution were contacted for Hip Outcome Score (HOS) and return-to-play data. Patients with a confirmed diagnosis by history, physical examination, and magnetic resonance imaging who failed 6 to 12 weeks of appropriate conservative treatment were indicated for surgery. Surgical repair involved adductor longus fractional lengthening, limited adductor longus tenotomy, and a turn-up flap of the released adductor tendon and aponeurosis onto the rectus abdominis for imbrication reinforcement. Results: Of 100 patients who met the inclusion criteria, 85 (85%) were contacted. A total of 82 (96%) patients were able to return to play at a mean of 4.1 months after repair. Hip function was rated as 98% of normal and sports function as 92% of normal. Factors associated with negative outcomes were multiple procedures, prior inguinal hernia repair, and female sex. Negative outcomes were demonstrated by decreased HOS scores and decreased sports function. The overall complication rate was 7%. Conclusion: RA-AL aponeurotic plate repair by the method of an adductor-to–rectus abdominis turn-up flap is a safe procedure with high return-to-play success. Patients who had previously undergone inguinal hernia repair or other hip/pelvic-related surgery and female patients had worse outcomes.

Sports Hernia: Diagnosis, Management and Operative Treatment

Objectives: Athletic Pubalgia, also known as sports hernia or core muscle injury, causes significant dysfunction in athletes. Increased recognition of this specific injury distinct from inguinal hernia pathology has led to better management of this debilitating condition. We hypothesize that patients who undergo our technique of athletic pubalgia repair will recover and return to high-level athletics. Methods: Using our billing and clinical database, patients who underwent sports hernia repair by single surgeon at a single institution were contacted for Harris hip score, functional outcome, and return to play data. Results: Of 101 patients who met criteria, 43 were contacted. 93% of patients were able to return to play at an average of 4.38 mo. Normal activities were rated at 95.5% and athletic function was rated at 88.9%. Negative predictors were female sex, multiple operations, and prior inguinal hernia repair. Overall complication rate was 4.6%, and reoperation rate was 4.6%. Conclusion: Our method of adductor to rectus abdominis turn up flap is a safe procedure with high return to play success. Patients who had previously undergone inguinal hernia repair or other hip/pelvic related surgery had a worse outcome.

Comparison of Anterior Cruciate Ligament Graft Isometry between Paired Femoral and Tibial Tunnels

&NA; Accurate tunnel placement is important for a successful anterior cruciate ligament (ACL) reconstruction. Controversy exists concerning the preferred method of femoral tunnel preparation, with proponents of both medial portal and transtibial drilling techniques. Current ACL literature suggests that placement of the femoral ACL attachment site posterior or “low” in the ACL footprint leads to more anatomically correct ACL mechanics and better rotational control. There is limited literature focusing on ACL graft displacement through knee range of motion based on specific paired placement of femoral and tibial tunnels. Our purpose was to assess ACL isometry between multiple combinations of femoral and tibial tunnels. We hypothesized that placement of the graft at the posterior aspect of the ACL footprint on the femur would be significantly less isometric and lead to more graft displacement as compared with central or anterior placement. The ACL of matched pairs of cadaveric knees was arthroscopically debrided while leaving the soft tissue footprint on the femur and tibia intact. One knee from each pair underwent notchplasty. In all knees, three femoral and three tibial tunnels were created at the anterior, central, and posterior aspects of the ACL footprint. A suture was passed through each tunnel combination (nine potential pairs), and the change in isometry was measured throughout full knee range of motion. Placement of the femoral tunnel along the posterior aspect of the ACL footprint was less isometric compared with a central or anterior position in the femoral footprint. Placement of a posterior tibial tunnel also led to decreased isometry, but tibial tunnel placement affected isometry to a lesser extent than femoral tunnel placement. The combination of a posterior femoral and posterior tibial tunnel resulted in greater than 1 cm of graft excursion from full flexion to extension. Placement of ACL tunnels at anisometric sites may adversely affect the mechanical properties and behavior of the ACL graft, resulting in either graft laxity in flexion or overconstraint and loss of extension.

Mini-open Incision Sports Hernia Repair: A Surgical Technique for Core Muscle Injury

One cause of groin pain in highly active patients may be a core muscle injury, commonly referred to as sports hernia. When patients fail nonoperative management, there are a number of surgical options that may be pursued. Typically, they will involve the direct repair of the rectus abdominis back to the pubis. However, we believe that this repair can be further strengthened by the appropriate lengthening of the adductor longus from the conjoined tendon. Therefore, we present a surgical technique that involves both rectus abdominis repair and adductor longus lengthening in those who show a core muscle injury that is refractory to conservative management. We believe that this technique can be easily replicated by practitioners reading this Technical Note.

Rotator Cuff Repair in Adolescent Athletes

Background: Rotator cuff tears are rare injuries in adolescents but cause significant morbidity if unrecognized. Previous literature on rotator cuff repairs in adolescents is limited to small case series, with few data to guide treatment. Hypothesis: Adolescent patients would have excellent functional outcome scores and return to the same level of sports participation after rotator cuff repair but would have some difficulty with returning to overhead sports. Study Design: Case series; Level of evidence 4. Methods: A retrospective search of the practice’s billing records identified all patients participating in at least 1 sport who underwent rotator cuff repair between 2006 and 2014 with an age <18 years at the time of surgery and a minimum follow-up of 2 years. Clinical records were evaluated for demographic information, and telephone follow-up was obtained regarding return to play, performance, other surgery and complications, a numeric pain rating scale (0-10) for current shoulder pain, American Shoulder and Elbow Surgeons (ASES) Shoulder Assessment Form, and the Western Ontario Rotator Cuff Index. Results: Thirty-two consecutive adolescent athletes (28 boys and 4 girls) with a mean age of 16.1 years (range, 13.2-17.9 years) met inclusion criteria. Twenty-nine patients (91%) had a traumatic event, and 27 of these patients (93%) had no symptoms before the trauma. The most common single tendon injury was to the supraspinatus (21 patients, 66%), of which 2 were complete tendon tears, 1 was a bony avulsion of the tendon, and 18 were high-grade partial tears. Fourteen patients (56%) underwent single-row repair of their rotator cuff tear, and 11 (44%) underwent double-row repair. All subscapularis injuries were repaired in open fashion, while all other tears were repaired arthroscopically. Twenty-seven patients (84%) completed the outcome questionnaires at a mean 6.2 years after surgery (range, 2-10 years). The mean ASES score was 93 (range, 65-100; SD = 9); mean Western Ontario Rotator Cuff Index, 89% (range, 60%-100%; SD = 13%); and mean numeric pain rating, 0.3 (range, 0-3; SD = 0.8). Overall, 25 patients (93%) returned to the same level of play or higher. Among overhead athletes, 13 (93%) were able to return to the same level of play, but 8 (57%) were forced to change positions. There were no surgical complications, but 2 patients did undergo a subsequent operation. Conclusion: Surgical repair of high-grade partial-thickness and complete rotator cuff tears yielded successful outcomes among adolescents, with excellent functional outcomes at midterm follow-up. However, overhead athletes may have difficulty playing the same position after surgery.