James A. Tom

Degenerative meniscus: Pathogenesis, diagnosis, and treatment options.

The symptomatic degenerative meniscus continues to be a source of discomfort for a significant number of patients. With vascular penetration of less than one-third of the adult meniscus, healing potential in the setting of chronic degeneration remains low. Continued hoop and shear stresses upon the degenerative meniscus results in gross failure, often in the form of complex tears in the posterior horn and midbody. Patient history and physical examination are critical to determine the true source of pain, particularly with the significant incidence of simultaneous articular pathology. Joint line tenderness, a positive McMurray test, and mechanical catching or locking can be highly suggestive of a meniscal source of knee pain and dysfunction. Radiographs and magnetic resonance imaging are frequently utilized to examine for osteoarthritis and to verify the presence of meniscal tears, in addition to ruling out other sources of pain. Non-operative therapy focused on non-steroidal anti-inflammatory drugs and physical therapy may be able to provide pain relief as well as improve mechanical function of the knee joint. For patients refractory to conservative therapy, arthroscopic partial meniscectomy can provide short-term gains regarding pain relief, especially when combined with an effective, regular physiotherapy program. Patients with clear mechanical symptoms and meniscal pathology may benefit from arthroscopic partial meniscectomy, but surgery is not a guaranteed success, especially with concomitant articular pathology. Ultimately, the long-term outcomes of either treatment arm provide similar results for most patients. Further study is needed regarding the short and long-term outcomes regarding conservative and surgical therapy, with a particular focus on the economic impact of treatment as well.

Sports Hernia in National Hockey League Players Does Surgery Affect Performance

Background: Athletic pubalgia is a complex injury that results in loss of play in competitive athletes, especially hockey players. The number of reported sports hernias has been increasing, and the importance of their management is vital. There are no studies reporting whether athletes can return to play at preinjury levels. Purpose: The focus of this study was to evaluate the productivity of professional hockey players before an established athletic pubalgia diagnosis contrasted with the productivity after sports hernia repair. Study Design: Cohort study; Level of evidence, 3. Methods: Professional National Hockey League (NHL) players who were reported to have a sports hernia and who underwent surgery from 2001 to 2008 were identified. Statistics were gathered on the players’ previous 2 full seasons and compared with the statistics 2 full seasons after surgery. Data concerning games played, goals, average time on ice, time of productivity, and assists were gathered. Players were divided into 3 groups: group A incorporated all players, group B were players with 6 or fewer seasons of play, and group C consisted of players with 7 or more seasons of play. A control group was chosen to compare player deterioration or improvement over a career; each player selected for the study had a corresponding control player with the same tenure in his career and position during the same years. Results: Forty-three hockey players were identified to have had sports hernia repairs from 2001 to 2008; ultimately, 80% would return to play 2 or more full seasons. Group A had statistically significant decreases in games played, goals scored, and assists. Versus the control group, the decreases in games played and assists were supported. Statistical analysis showed significant decreases in games played, goals scored, assists, and average time on ice the following 2 seasons in group C, which was also seen in comparison with the control group. Group B (16 players) showed only statistical significance in games played versus the control group. Conclusion: Players who undergo sports hernia surgeries return to play and often perform similar to their presurgery level. Players with over 7 full seasons return but with significant decreases in their overall performance levels. Less veteran players were able to return to play without any statistical decrease in performance and are likely the best candidates for repair once incurring injury.

Diagnosis and treatment of triceps tendon injuries: a review of the literature.

Objective:To elucidate mechanism of injury, nonoperative protocols, surgical techniques, rehabilitation schedules, and return to sports guidelines for partial and complete triceps tendon injuries. Data Sources:The PubMed and OVID databases were searched in 2010 and peer-reviewed English language articles in 2011. Main Results:After a fall on an outstretched hand, direct trauma on the elbow, or lifting against resistance, patients often present with pain and weakness of extension. Examination may reveal a palpable tendon gap, and radiographs may reveal a Flake sign. Acute partial injuries have positive outcomes with immobilization in 30-degree flexion for 4 to 6 weeks. Primary repair for complete rupture can restore normal extensor function after 3 to 4 months. Reconstruction returns normal extensor function up to 4 years. Most authors support postoperative immobilization for 2 to 3 weeks at 30- to 40-degree flexion, flexion block bracing for an additional 3 weeks, and unrestricted activity at 6 months. Athletes may be able to return to sports after 4 to 5 weeks of recovery from a partial injury, but return may be delayed if operative tendon repair is performed. Conclusions:Acute partial triceps tendon injuries may be managed conservatively at first and should be repaired primarily if this fails or if presentation is delayed. Reconstruction should first use the anconeus rotation technique. If the anconeus is devitalized, the Achilles tendon may be the allograft of choice.

Outcomes of Isolated Glenoid Labral Injuries in Professional Baseball Pitchers

Background:Major League Baseball (MLB) pitchers who return to competition after labral surgery show a decline in their pitching performance. Design:Retrospective cohort. Setting:Tertiary institution. Patients:MLB starting or relief pitchers with isolated glenoid labral injuries. Interventions:Open or arthroscopic surgical repair of isolated glenoid labral injuries. Main Outcome Measurements:Individual statistics were reviewed for 42 MLB pitchers who underwent surgical repair of isolated glenoid labral injuries of their throwing shoulder between 1998 and 2003. Pertinent statistical data, including earned run average (ERA), innings pitched (IP), and walks plus hits per inning pitched (WHIP), were obtained for all players and compared before and after surgery. These statistics were evaluated for an association with demographic factors, pitching role, and rehabilitation time. Results:A total of 42 MLB pitchers (26 starters, 16 relievers) were included in the study with an average age of 27.5 years for starters and 29.9 years for relievers at injury time. There were 30 right-handed pitchers and 12 left-handed pitchers. In all, 69% of pitchers returned postoperatively to MLB for at least one season; 29% pitched for three seasons or more. For both relievers and starters, there was no statistically significant postoperative change in ERA or WHIP at 1 and 3 years. Starters had significantly decreased IP at 1 year, but not at 3 years. Relievers had no significant change in IP at 1 year postoperatively, but IP were significantly decreased at 3 years. Relievers missed less time after surgery than did starters (11.4 vs. 18.4 months). Conclusions:Most pitchers who were able to return to competition after surgery showed insignificant changes in ERA and WHIP and significant decreases in IP. Age, MLB experience, and pitching role as a reliever were the most significant factors related to a successful return after surgery.

Tibial Tubercle Avulsion Fractures in Adolescent Basketball Players

Tibial tubercle avulsion fractures most commonly occur in adolescent boys and usually result from pushing off or landing while jumping. These fractures are relatively uncommon but can have a significant functional effect. The purpose of this study was to determine the long-term outcome with return to play in 8 adolescent basketball players with at least 4 years of postoperative reconditioning. Results with return to play at the preinjury level are favorable after treatment of acute tibial avulsion fractures in adolescent basketball players. Long-term outcome was excellent in all patients regardless of fracture type. Open reduction and internal fixation using 1 or 2 cancellous bone screws achieved union in all cases.

Incidence of Orthopedic Surgery Intervention in a Level I Urban Trauma Center With Motorcycle Trauma

BACKGROUND This study summarizes orthopedic injuries sustained in motorcycle collisions in patients presenting to a Level I trauma center. METHODS We performed a retrospective review of orthopedic injuries in motorcycle trauma victims brought into the emergency department. Of 2,634 presenting cases, 151 were identified as involving motorcycle collisions. Variables included age, gender, mechanism of injury, type and location of injury, concomitant injuries, length of hospitalization, number of orthopedic procedures during primary admission, and subsequent readmission. RESULTS A total of 71.5% of patients required orthopedic consultation. Average age was 35.0 years, with men injured at a ratio of 8:1. The most common mechanism of injury was motorcycle versus automobile (n=48). A total of 206 fractures in 108 patients were discovered. The most common site of fracture involved the lower extremities. Open reduction with internal fixation was performed on 110 fractures (69 patients) during primary admission. Fifty-seven patients (52.8%) sustained open fractures requiring emergent orthopedic intervention. Fifty-three patients had various concomitant complications. Two patients died during initial hospitalization. Average hospitalization for patients without orthopedic consultation was 11.9 days versus 13.8 days with orthopedic consultation. The average number of orthopedic procedures performed on patients was 1.6. CONCLUSIONS Motorcycle collisions frequently involve patients in their working prime, thus placing substantial burden on the individual and society. Although these patients must continue to receive Level I trauma care, strengthened prevention and improved education efforts are warranted.

Anatomical Considerations of the Suprascapular Nerve in Rotator Cuff Repairs

Introduction. When using the double interval slide technique for arthroscopic repair of chronic large or massive rotator cuff tears, the posterior interval release is directed toward the scapular spine until the fat pad that protects the suprascapular nerve is reached. Injury to the suprascapular nerve can occur due to the nerves proximity to the operative field. This study aimed to identify safe margins for avoiding injury to the suprascapular nerve. Materials and Methods. For 20 shoulders in ten cadavers, the distance was measured from the suprascapular notch to the glenoid rim, the articular margin of the rotator cuff footprint, and the lateral border of the acromion. Results. From the suprascapular notch, the suprascapular nerve coursed an average of 3.42 cm to the glenoid rim, 5.34 cm to the articular margin of the rotator cuff footprint, and 6.09 cm to the lateral border of the acromion. Conclusions. The results of this study define a safe zone, using anatomic landmarks, to help surgeons avoid iatrogenic injury to the suprascapular nerve when employing the double interval slide technique in arthroscopic repair of the rotator cuff.

Pitch Characteristics Before Ulnar Collateral Ligament Reconstruction in Major League Pitchers Compared With Age-Matched Controls.

Background: Ulnar collateral ligament reconstruction (UCLR) is commonly performed in Major League Baseball (MLB) pitchers, but little is known about the preoperative pitch type and velocity characteristics of pitchers who go on to undergo UCLR. Hypothesis: Pitchers who required UCLR have thrown a greater percentage of fastballs and have greater pitch velocities compared with age-matched controls in the season before injury. Study Design: Case-control study; Level of evidence, 3. Methods: MLB pitchers active during the 2002 to 2015 seasons were included. The UCLR group consisted of MLB pitchers who received UCLR between 2003 and 2015, utilizing the season before surgery (2002-2014) for analysis. The control group comprised age-matched controls of the same season. Players who pitched less than 20 innings in the season before surgery were excluded. Pitch types were recorded as percentage of total pitches thrown. Pitch velocities were recorded for each pitch type. Pitch type and pitch velocities during preoperative seasons for UCLR pitchers were compared with age-matched controls using univariate and multivariate models. Results: A total of 114 cases that went on to UCLR and 3780 controls were included in the study. Pitchers who went on to UCLR appear to have greater fastball, slider, curveball, changeup, and split-fingered fastball velocities; there were no significant differences in pitch selection between the 2 groups. Conclusion: In the season before surgery, MLB pitchers who underwent UCLR demonstrated greater fastball, slider, curveball, changeup, and split-fingered fastball velocities, with no significant difference in pitch type.

Pelvic Fractures in Professional Cyclists: A Report of 3 Cases

Background: Professional riders demonstrate increased risk factors for such injuries including both extensive time on the bike in addition to a possible underlying osteopenia secondary to the nonimpact nature of the sport. Hypothesis: Nonoperative management of stable, nondisplaced pelvic fractures in professional cyclists offers excellent results. Study Design: Case series. Methods: Three cases of professional cyclists with pelvic fractures were reviewed. Results: All 3 cyclists were able to return to professional competition and remain symptom free. Conclusion: Accurate early diagnosis of pelvic fractures, with the aid of computed tomography, is crucial. Early non-weightbearing with a progression to weightbearing as tolerated and early return to stationary training are appropriate. Accurate diagnosis and careful nonoperative management of stable, nondisplaced pelvic fractures in professional cyclists offers excellent results. Clinical Relevance: Accurate diagnosis of pelvic fractures in high-demand athletes with few complaints and no obvious findings on plain film radiographs. Control of weightbearing and competitive status to prevent injury progression. Gauged return to competition at professional level.

An experimental knee joint effusion does not affect plasma catecholamine concentration in humans

Knee joint effusion causes quadriceps inhibition and is accompanied by increased soleus muscle excitability. In order to reverse the neurological alterations that occur to the musculature following effusion, we need to understand the extent of neural involvement. Ten healthy adults were tested on two occasions; during one session, subjects had their knees injected with saline and in the other admission, they did not. Soleus Hmax, Mmax, plasma epinephrine, and norepinephrine concentrations were obtained at five intervals. Results showed that Hmax increased following the effusion, while norepinephrine and epinephrine levels were not altered. We suggest that the soleus facilitation seen following knee effusion results from stimulation of joint mechanoreceptors and removal of descending spinal and supraspinal inhibition and is not the result of a sympathetic response.