Domenick J. Sisto

An electromyographic analysis of the elbow in pitching

Elbow injuries are common in baseball pitchers. Curve balls are thought to increase this risk, particularly if the athlete begins throwing this pitch at an early age. The purpose of this paper is to identify forearm muscle firing patterns during the pitching cycle in an effort to under stand this etiology. Dynamic EMG was performed on eight collegiate pitchers to evaluate extensor digitorum communis, brachioradialis, flexor carpi radialis, flexor digitorum superficialis, extensor carpi radialis longus, extensor carpi radialis brevis, pronator teres, and supinator. Each subject threw a fast ball and curve ball, which were filmed at 450 frames per second and synchronized with the EMG. These signals were converted from analog to digital records. Results showed low to moderate activity in all muscles during all phases of the pitch. The function is probably positioning to accept the transfer of energy from the larger trunk and girdle structures. The most notable difference between the fast ball and curve ball is a slight increase in the extensor carpi radialis longus and extensor carpi radialis brevis activity during late cocking, acceleration, and follow-through of the curve ball as compared to the fast ball. This differ ence, however, is not significant. In addition, there was no significant difference between the fast ball and the curve ball in the flexor-pronator group in any phase. We cannot substantiate that medial elbow problems are a result of an increase in the use of flexor muscles during the curve ball pitch.

The operative treatment of scapulothoracic bursitis in professional pitchers

Four professional pitchers with resistant scapulotho racic bursitis who have required surgical excision of the thickened bursa are reported. The average time dura tion of symptoms prior to surgery was 18.8 months. Conservative therapy consisting of rest, shoulder ex ercises, antiinflammatory medications, and cortisone injections failed to resolve the bursitis, and each pitcher was unable to compete secondary to pain. The incision was posterior, just distal to the tip of the scapula. The specimens contained cleft-like spaces lined by synovial tissue consistent with a bursa. All four pitchers returned to professional baseball the year following surgical excision of the bursa. We rec ommend early, aggressive, conservative therapy for scapulothoracic bursitis in the throwing athlete. Pitch ers with a thickened, resistant scapulothoracic bursitis should have the bursa surgically excised.

Intraoperative decision making in the treatment of shoulder instability

Between April 1990 and April 1994, 100 patients with a preoperative diagnosis of anterior instability underwent a diagnostic arthroscopy of the shoulder. Patients with isolated SLAP lesions were excluded from the study. Patients with multidirectional instability, bony Bankart lesions, and large Hill-Sachs lesions were also excluded. Football players and dominant arm throwing athletes were also excluded. Thirty patients remained who had post-traumatic, unidirectional, anterior instability and a repairable Bankart lesion and did not have any exclusions as noted above. All of these patients underwent an initial attempt at an arthroscopic Sure-Tac stabilization (Smith & Nephew, Andover, MA). Twenty-three patients met our criteria for a secure fixation but 7 did not. These 7 underwent an immediate arthrotomy and open Bankart repair. All of the patients were available at follow-up at an average of 47 months (range, 36 to 72 months). The patients were evaluated by the Rowe shoulder rating scale. There have been two cases of recurrent subluxation and one case of recurrent dislocation in the Sure-Tac group. All three occurred over 2 years later. All three had recurrent Bankart lesions and underwent an arthrotomy and Bankart repair. There were no cases of recurrence of subluxation or dislocation in our initial open Bankart repair group. Sure-Tac arthroscopic anterior stabilization of the shoulder can initially give good results but these results appear to deteriorate over time and increased activity of the patient. We currently do not recommend a Sure-Tac repair even in a selective group of patients with an isolated Bankart lesion. This is based on our excellent results following an open Bankart repair and a 13% recurrence rate following Sure-Tac stabilization in carefully selected patients.

The results of operative treatment of osteochondritis dissecans of the patella

The course of osteochondritis dissecans (OCD) of the patella and the results of operative treatment are ana lyzed retrospectively in a review of 31 operatively treated cases in 25 patients. Followup was obtained for 21 cases, with an average of 73 months (range, 15 months to 20 years). These 25 patients were predom inantly males, and averaged 18 years of age at the time of surgery. A history of trauma was associated with the lesion in 38% of the cases, and the lesion was bilateral in one out of four patients. The most common present ing complaints were subpatellar pain and swelling. The most common initial physical findings were patellofem oral crepitus and joint effusion. Forty-four operations were performed on 31 knees. The most commonly performed procedures were cu rettage of the patella and removal of loose bodies, in combination or as part of another procedure. A new patellofemoral rating scale was used to evaluate re sults. Thirty-eight percent of the knees had a good or excellent result, while 62% had a fair or poor result. Persistent pain with restricted function and residual patellofemoral crepitus were common findings. In general, the patients who come to surgery for OCD of the patella have a guarded prognosis for full recovery of knee function.

The synovial response after CO2 laser arthroscopy of the knee

The CO2 laser is a precision surgical laser because of its high degree of absorption in soft tissue with limited lateral damage. The tissue, which absorbs the CO2 laser energy, and has a high water content, will be converted to vapor with a small residue of ash and a by-product of heat. The laser can only be effective if these by-products, i.e. vapors, heat, and carbon ash residue, are not injurious and are well tolerated by the joint. These by-products must be either reabsorbed by the synovium or remain as a nonviable substance in the joint. From April 1989 through April 1990, 40 patients underwent 43 operative arthroscopies of the knee using the Pfizer CO2 laser. All procedures were chondroplasties, synovectomies, and/or meniscectomies. All accessible CO2 carbon ash residue was removed from the joint after the procedures using an intraarticular shaver and hand rasp. Postoperatively there were no cases of hemorrhagic effusions, subcutaneous emphysema, or synovitis. Histologic examinations performed on 10 patients undergoing subsequent surgery showed no evidence of carbon ash residue or synovitis seen grossly or microscopically. The carbon ash residue is not noxious to the joint and is completely removed from the joint, presumably by the synovial response.

Unicompartment arthroplasty for osteoarthrosis of the knee

Sixty-eight consecutive unicompartment knee arthroplasties were reviewed. Seven patients were lost to follow-up evaluation, and the review group consisted of 55 patients with 61 medial compartment replacements. Follow-up periods averaged 51 months, with a range of 24 to 70 months. All of the knees had a Robert Brigham unicompartment arthroplasty. All patients were evaluated using The Knee Society Clinical Rating System. Overall results revealed that 70% (42 patients) rated excellent, 10% (seven patients) rated good, 10% (six patients) rated fair, and 10% (six patients) were failures. Preoperative scores in the pain, range of motion, and stability sections averaged 54 points of a maximum of 100. Postoperatively, the scores averaged 87 points. Postoperative roentgenographs were evaluated using The Knee Society Roentgenographic Evaluation and Scoring System. Roentgenographs revealed at least one radiolucent line in 16 femoral components and 15 tibial components, and nine in both. Four of the six failures in the series had lucent lines in both the femur and tibia. This procedure is recommended in active patients between the ages of 55 to 65 years with single compartment disease. Also, a unicompartment arthroplasty is recommended in more sedentary patients 65 years and older with single compartment disease.

Avoiding Graft-Tunnel Mismatch in Endoscopic Anterior Cruciate Ligament Reconstruction: A New Technique

A common problem encountered in endoscopic anterior cruciate ligament reconstruction is graft-tunnel mismatch. A technique not previously described in the literature is illustrated. This technique provides direct measurement of the tibial tunnel length plus the intra-articular distance. This allows direct calculation of the length of the femoral tunnel necessary to avoid a graft-tunnel mismatch. This technique has been used very effectively in our institution with excellent, reproducible results.

Disassembly of a modular humeral prosthesis: A case report

A modular humeral hemiarthroplasty utilizing a prosthesis with a taper-lock design was performed on a 77-year-old woman with a diagnosis of rotator cuff arthropathy. Radiographic examination at 3 months after surgery revealed disarticulation of the modular head and neck from the humeral prosthetic stem. This is a case report of a disarticulated modular humeral hemiarthroplasty.

Ho:YAG laser arthroscopy of the knee

The HO:YAG laser is a near-contact laser with a capacity to ablate or cut tissues. The ablation function allows the surgeon to remove meniscal tissue, lyse and resect adhesions, melt loose bodies, and dissolve inflamed synovium. The cutting function of the laser is utilized to perform a lateral release or resect torn menisci. The laser can also be utilized to drill holes in Grade IV chondromalacic lesions to initiate a healing response. The laser has been embraced by orthopaedic surgeons because of its shape and versatility. The tip is only 2 mm wide and can be delivered into the tight posterior compartments of the knee with no damaging contact with the articular surfaces. The laser coagulates as it works and bleeding is minimized. The laser can function both as a cutting and ablating tool. The laser can also drill holes into subchondral bone to, hopefully, initiate a healing response.