Christopher C. Dodson

Propionibacterium acnes infection after shoulder arthroplasty: a diagnostic challenge.

HYPOTHESIS This study reviewed a series of patients diagnosed with Propionibacterium acnes infection after shoulder arthroplasty in order to describe its clinical presentation, the means of diagnosis, and provide options for treatment. MATERIALS AND METHODS From 2002 to 2006, 11 patients diagnosed with P acnes infection after shoulder arthroplasty were retrospectively reviewed and analyzed for (1) clinical diagnosis; (2) laboratory data, including white blood cell count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP); (3) fever; (4) number of days for laboratory growth of P acnes; (5) organism sensitivities; (6) antibiotic regimen and length of treatment; and (7) surgical management. Infection was diagnosed by 2 positive cultures. RESULTS Five patients had an initial diagnosis of infection and underwent implant removal, placement of an antibiotic spacer, and staged reimplantation after a course of intravenous antibiotics. In the remaining 6 patients, surgical treatment varied according to the clinical diagnosis. When infection was recognized by intraoperative cultures, antibiotics were initiated. The average initial ESR and CRP values were 33 mm/h and 2 mg/dL, respectively. The average number of days from collection to a positive culture was 9. All cultures were sensitive to penicillin and clindamycin and universally resistant to metronidazole. DISCUSSION Prosthetic joint infection secondary to P acnes is relatively rare; yet, when present, is an important cause of clinical implant failure. Successful treatment is hampered because clinical findings may be subtle, many of the traditional signs of infection are not present, and cultures may not be positive for as long as 2 weeks.

Anterior glenohumeral joint dislocations.

The glenohumeral joint is the most mobile articulation in the body and the most commonly dislocated diarthroidal joint. Anterior dislocation is by far the most common direction and can lead to instability of the glenohumeral joint, which ranges from subtle increased laxity to recurrent dislocation. Overtime, understanding of anterior shoulder dislocations and the resulting instability has improved. Likewise, significant advances in arthroscopic equipment have allowed use of the arthroscope to address anatomically the various lesions that cause instability. This article reviews the anatomy, pathophysiology, clinical evaluation, and treatment of anterior shoulder instability.

Arthroscopic Intratendinous Repair of the Delaminated Partial-Thickness Rotator Cuff Tear in Overhead Athletes

A distinct type of partial-thickness rotator cuff tear has been observed in overhead athletes, characterized by partial failure of the undersurface of the posterior supraspinatus and anterior infraspinatus tendons with intratendinous delamination. We present a technique of percutaneous intratendinous repair using nonabsorbable mattress sutures designed for the management of articular-side delaminated partial-thickness tears. After tear evaluation and preparation, the torn rotator cuff undersurface is held in a reduced position with a grasper through an anterolateral rotator interval portal while viewing intra-articularly. Two spinal needles are then placed percutaneously through the full thickness of the torn and intact rotator cuff. A polydioxanone suture is passed through each needle, retrieved out the anterior portal, and used to shuttle a single nonabsorbable No. 2 suture through the tissue, creating a mattress suture. Multiple mattress sutures can be placed as dictated by tear size and morphology, with suture retrieval and knot securing then proceeding in the subacromial space. We have adopted this approach with the goals of anatomically re-establishing the rotator cuff insertion and sealing the area of intratendinous delamination while preventing significant alteration to the anatomy of the rotator cuff insertion, which could lead to motion deficits, internal impingement, and potential tear recurrence.

The docking technique for lateral ulnar collateral ligament reconstruction: surgical technique and clinical outcomes

HYPOTHESIS Lateral ulnar collateral ligament (LUCL) reconstruction is a commonly used surgical approach for the treatment of posterolateral rotatory instability (PLRI). We hypothesized that favorable clinical results could be obtained using the docking technique. MATERIALS AND METHODS Between 1996 and 2009, the docking technique was used for surgical reconstruction of the LUCL in 8 patients with purely ligamentous posterolateral rotatory instability of the elbow. The clinical results of these patients were retrospectively reviewed. RESULTS At a mean follow-up of 7.1 years (range, 5.2-9.4 years), 6 patients (75%) demonstrated complete resolution of lateral elbow instability, and 2 (25%) reported occasional instability with activities of daily living. The mean Mayo Elbow Performance Score was 87.5 (range, 75-100). Subjective assessment revealed that all patients were satisfied with their clinical outcome. CONCLUSION LUCL reconstruction using the docking technique facilitates simple graft tensioning and excellent graft fixation. Clinical results are comparable with previously reported studies with a low complication rate.

Return to Play After Type II Superior Labral Anterior-Posterior Lesion Repairs in Athletes: A Systematic Review

BackgroundSuperior labral anterior-posterior (SLAP) lesions are a common cause of pain and disability in athletes. Individual studies have suggested low patient satisfaction with SLAP repairs in throwing athletes in particular and it is unclear how frequently athletes return to their previous level of competetion.Questions/purposesWe systematically reviewed the literature to determine (1) patient satisfaction and (2) return to play at previous level of competition among throwing athletes compared to all athletes who underwent repair of Type II SLAP tears using various types of fixation.MethodsWe searched databases for English-language articles in peer-reviewed journals from 1950 to 2010 reporting Type II SLAP repairs with 2-year followup for our systematic review. A total of 506 patients with Type II SLAP tears were reviewed from 14 studies; of these, 327 had SLAP lesions repaired by anchor, 169 by tacks, and 10 by staples. Of the 506 patients, 198 were overhead athletes with a pooled subset of 81 identified baseball players.ResultsFor the entire patient population, 83% had “good-to-excellent” patient satisfaction and 73% returned to their previous level of play whereas only 63% of overhead athletes returned to their previous level of play. Anchor repair in overhead athletes resulted in a higher percentage of “good-to-excellent” patient satisfaction (88% versus 74%) and a slightly higher return to play rate (63% versus 57%) compared with tack repair.ConclusionsRepair of Type II SLAP tears leads to a return to previous level of play in most patients. Overhead athletes appear to have a lower rate of return to level of previous of play. Anchor fixation appears to be the most favorable fixation in both subjective scores and return to previous level of play.

Treatment of Femoroacetabular Impingement in Athletes Using a Mini–Direct Anterior Approach

Background: Femoroacetabular impingement (FAI) is an increasingly common diagnosis in active patients with hip pain. Surgical options for FAI include arthroscopy, open surgical dislocation, or mini–direct anterior approaches. Arthroscopic and open treatments of FAI have been commonly performed and have had promising results in athletes. Hypothesis/Purpose: We hypothesized that the mini–direct anterior approach would provide the advantages of a minimally invasive procedure and still allow adequate exposure of the hip joint to successfully treat FAI in an athletic population. The purpose of this study was to determine if a mini-open approach for the treatment of FAI in athletic patients would allow a return to preoperative activity. Study Design: Case series; Level of evidence, 4. Methods: A total of 234 patients (257 hips) with FAI were treated by a mini-open approach; 59 were athletic patients (66 hips) with a preoperative University of California, Los Angeles (UCLA) activity score of 7 or higher or Super Simple Hip (SUSHI) activity score of 70 or greater. Forty-four of the 59 athletic patients (47 hips) have reached 1-year minimum follow-up. No patients were lost to follow-up. The mini-open approach was performed through a 4-cm incision and modified Smith-Peterson approach with no muscle detachment. All patients were prospectively evaluated using the following outcome measures: preoperative and postoperative UCLA activity, Short-Form 36 Health Survey (SF-36), Western Ontario and McMaster Osteoarthritis Index (WOMAC), modified Harris Hip Score (HHS), and SUSHI scores. Results: The average age at the time of surgery was 32 years (range, 17-60 years), with an average follow-up of 22 months. Labral changes—whether tear, detachment, or ossification—were present in all patients, and 84% had chondral lesions. The mean HHS improved from 55 preoperatively to 79 postoperatively (P < .001). The WOMAC scores also improved from 47.9 to 8.3 (P < .001). Mean SF-36 scores improved from 65 to 85 postoperatively (P < .001). The mean preoperative SUSHI general score was 31.1, pain score was 26.6, and limitation score was 28.9. The mean postoperative SUSHI general score was 53.6, pain score was 47.5, and limitation score was 51.6 (P < .001). There was minimal change from preinjury to postoperative UCLA (8.0 to 8.7, respectively; P = .07) or SUSHI activity scores (76.3 to 67.7, respectively; P = .048), indicating a reliable return to preinjury activity levels. Twenty-four of 44 patients (55%) reported a return to their specific preoperative sports. Nine patients (20%) developed meralgia paresthetica postoperatively, which resolved within 1 year. Conclusion: The mini-open approach for the treatment of FAI is a safe and effective procedure that allows surgical treatment of FAI in athletic patients and a successful return to high activity levels. The outcome of the mini-open approach for athletes may be comparable with open and arthroscopic treatment of FAI.

Stress Sonography of the Ulnar Collateral Ligament of the Elbow in Professional Baseball Pitchers A 10-Year Study

Background: An injury to the ulnar collateral ligament (UCL) of the elbow is potentially career threatening for elite baseball pitchers. Stress ultrasound (US) of the elbow allows for evaluation of both the UCL and the ulnohumeral joint space at rest and with stress. Hypothesis: Stress US can identify morphological and functional UCL changes and may predict the risk of a UCL injury in elite pitchers. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 368 asymptomatic professional baseball pitchers underwent preseason stress US of their dominant and nondominant elbows over a 10-year period (2002-2012). Stress US examinations were performed in 30° of flexion at rest and with 150 N of valgus stress by a single musculoskeletal radiologist. Ligament thickness, ulnohumeral joint space width, and ligament abnormalities (hypoechoic foci and calcifications) were documented. Results: There were 736 stress US studies. The mean UCL thickness in the dominant elbow (6.15 mm) was significantly greater than that in the nondominant elbow (4.82 mm) (P < .0001). The mean stressed ulnohumeral joint space width in the dominant elbow (4.56 mm) was significantly greater than that in the nondominant elbow (3.72 mm) (P < .02). In the dominant arm, hypoechoic foci and calcifications were both significantly more prevalent (28.0% vs 3.5% and 24.9% vs 1.6%, respectively; P < .001). In the 12 players who incurred a UCL injury, there were nonsignificant (P > .05) increases in baseline ligament thickness, ulnohumeral joint space gapping with stress, and incidence of hypoechoic foci and calcifications. More than 1 stress US examination was performed in 131 players, with a mean increase of 0.78 mm in joint space gapping with subsequent evaluations. Conclusion: Stress US indicates that the UCL in the dominant elbow of elite pitchers is thicker, is more likely to have hypoechoic foci and/or calcifications, and has increased laxity with valgus stress over time.

Prospective evaluation of arthroscopic rotator cuff repairs at 5 years: part I - Functional outcomes and radiographic healing rates

BACKGROUND A rotator cuff registry was established to prospectively evaluate the effectiveness of all-arthroscopic repairs. This study reports those results at 5 years. MATERIALS AND METHODS 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. RESULTS 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). DISCUSSION 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.

Posteromedial Elbow Impingement: Magnetic Resonance Imaging Findings in Overhead Throwing Athletes and Results of Arthroscopic Treatment

PURPOSE The purpose of this study was to define the magnetic resonance imaging (MRI) pattern and assess the results of arthroscopic treatment of posteromedial elbow impingement in overhead throwers. METHODS Over an 8-year period, 9 throwing athletes diagnosed with posteromedial elbow impingement were retrospectively identified. All patients had either a noncontrast or direct arthrogram-MRI study that was reviewed by a single, fellowship-trained musculoskeletal radiologist blinded to the clinical diagnosis. Arthroscopic treatment included debridement of posteromedial synovitis, loose body removal, and excision of the olecranon spur. All patients underwent a physical examination and completion of the Andrews-Carson scale at a mean of 68 months (range, 25 to 112 months). RESULTS All patients were male, with a mean age of 21.0 years (range, 17 to 34 years). The dominant arm was affected in all patients. The mean length of symptoms before surgery was 9 months (range, 5 to 24 months). At MRI, a reproducible pattern of pathology was noted. All patients had pathology at the articular surfaces of the posterior trochlea and the anterior, medial olecranon. The findings ranged from abnormal edema-like signal in the hyaline cartilage to cartilage defects and subjacent, subchondral bone marrow edema. Findings at surgery included posteromedial synovitis and olecranon spurring in all patients and loose bodies in 3 patients. On the basis of the Andrews-Carson scale, the subjective and objective outcome was considered excellent in 7 patients and good in 2. CONCLUSIONS Posteromedial elbow impingement is a source of disability in the overhead throwing athlete. Correlation of history and physical examination with imaging findings is essential to confirm the diagnosis. This study indicates that MRI identifies a reproducible pattern of pathology in throwing athletes with this disorder. These MRI findings correlate highly with arthroscopic evaluation. Arthroscopic debridement, olecranon spur excision, and loose body removal allow return to throwing sports and reliable subjective and objective results in carefully selected patients.

Ulnar collateral ligament injuries of the elbow in professional football quarterbacks

BACKGROUND Ulnar collateral ligament (UCL) injuries of the elbow can cause significant pain and disability in the overhead thrower. Most studies in the literature have focused on baseball players and demonstrated that surgical reconstruction is the most reliable way to allow these athletes to return to their previous level of performance. Little is known about whether or not surgical reconstruction is necessary for other types of elite throwing athletes. We hypothesize that professional football quarterbacks with UCL injuries of the elbow can return to competitive play after nonoperative management. METHODS The NFL Injury Surveillance System (NFLISS) was reviewed for any UCL injuries of the elbow in quarterbacks from 1994 to 2008, including the type and mechanism of injury, player demographics, method of treatment, and time to return to play. RESULTS A total of 10 cases of UCL injuries in quarterbacks were identified starting in 1994. Nine cases were treated nonoperatively and the mean return to play was 26.4 days. CONCLUSION UCL injuries of the elbow are uncommon injuries in professional quarterbacks. This group of overhead athletes can be successfully treated nonoperatively, in contrast to baseball players, who more commonly need surgical reconstruction to return to competitive play. The difference between the 2 groups of overhead athletes is most likely secondary to biomechanics and demand.