Kevin M. Kaplan

Surgical Management of Hip Fractures: An Evidence-based Review of the Literature. I: Femoral Neck Fractures

&NA; During the past 10 years, there has been a worldwide effort in all medical fields to base clinical health care decisions on available evidence as described by thorough reviews of the literature. Hip fractures pose a significant health care problem worldwide, with an annual incidence of approximately 1.7 million. Globally, the mean age of the population is increasing, and the number of hip fractures is expected to triple in the next 50 years. One‐year mortality rates currently range from 14% to 36%, and care for these patients represents a major global economic burden. Surgical options for the management of femoral neck fractures are closely linked to individual patient factors and to the location and degree of fracture displacement. Nonsurgical management of intracapsular hip fractures is limited. Based on a critical, evidence‐based review of the current literature, we have found minimal differences between implants used for internal fixation of displaced fractures. Cemented, unipolar hemiarthroplasty remains a good option with reasonable results. In the appropriate patient population, outcomes following total hip arthroplasty are favorable and appear to be superior to those of internal fixation.

Surgical Management of Hip Fractures: An Evidence-based Review of the Literature. II: Intertrochanteric Fractures

&NA; Treatment of intertrochanteric hip fracture is based on patient medical condition, preexisting degenerative arthritis, bone quality, and the biomechanics of the fracture configuration. A critical review of the evidence‐based literature demonstrates a preference for surgical fixation in patients who are medically stable. Stable fractures can be successfully treated with plate‐and‐screw implants and with intramedullary devices. Although unstable fractures may theoretically benefit from load‐sharing intramedullary implants, this result has not been demonstrated in the current evidencebased literature.

A Profile of Glenohumeral Internal and External Rotation Motion in the Uninjured High School Baseball Pitcher, Part II: Strength

CONTEXT A database describing the range of normal rotator cuff strength values in uninjured high school pitchers has not been established. Chronologic factors that contribute to adaptations in strength also have not been established. OBJECTIVES To establish a normative profile of rotator cuff strength in uninjured high school baseball pitchers and to determine whether bilateral differences in rotator cuff strength are normal findings in this age group. DESIGN Cohort study. SETTING Baseball playing field. PATIENTS OR OTHER PARTICIPANTS A total of 165 uninjured male high school baseball pitchers (age = 16 ± 1 years, height=1.8±0.1 m, mass=76.8±10.1 kg, pitching experience =7±2 years). MAIN OUTCOME MEASURE(S) Isometric rotator cuff strength was measured bilaterally with a handheld dynamometer. We calculated side-to-side differences in strength (external rotation [ER], internal rotation [IR], and the ratio of ER:IR at 90° of abduction), differences in strength by age, and the influence of chronologic factors (participant age, years of pitching experience) on limb strength. RESULTS Side-to-side differences in strength were found for ER, IR, and ER:IR ratio at 90° of abduction. Age at the time of testing was a significant but weak predictor of both ER strength (R(2)=0.032, P = .02) and the ER:IR ratio (R(2)=0.051 , P = .004) at 90° of abduction. CONCLUSIONS We established a normative profile of rotator cuff strength for the uninjured high school baseball pitcher that might be used to assist clinicians and researchers in the interpretation of muscle strength performance in this population. These data further suggested that dominant-limb adaptations in rotator cuff strength are a normal finding in this age group and did not demonstrate that these adaptations were a consequence of the age at the time of testing or the number of years of pitching experience.

Comparison of shoulder range of motion, strength, and playing time in uninjured high school baseball pitchers who reside in warm- and cold-weather climates.

Background: There is an assumption that baseball athletes who reside in warm-weather climates experience larger magnitude adaptations in throwing shoulder motion and strength compared with their peers who reside in cold-weather climates. Hypotheses: (1) The warm-weather climate (WWC) group would exhibit more pronounced shoulder motion and strength adaptations than the cold-weather climate (CWC) group, and (2) the WWC group would participate in pitching activities for a greater proportion of the year than the CWC group, with the time spent pitching predicting throwing shoulder motion and strength in both groups. Study Design: Cross-sectional study; Level of evidence, 3. Methods: One hundred uninjured high school pitchers (50 each WWC, CWC) were recruited. Rotational shoulder motion and isometric strength were measured and participants reported the number of months per year they pitched. To identify differences between groups, t tests were performed; linear regression was used to determine the influence of pitching volume on shoulder motion and strength. Results: The WWC group pitched more months per year than athletes from the CWC group, with the number of months spent pitching negatively related to internal rotation motion and external rotation strength. The WWC group exhibited greater shoulder range of motion in all planes compared with the CWC group, as well as significantly lower external rotation strength and external/internal rotation strength ratios. There was no difference in internal rotation strength between groups, nor a difference in the magnitude of side-to-side differences for strength or motion measures. Conclusion: Athletes who reside in cold- and warm-weather climates exhibit differences in throwing shoulder motion and strength, related in part to the number of months spent participating in pitching activities. The amount of time spent participating in pitching activities and the magnitude of range of motion and strength adaptations in athletes who reside in warm-weather climates may make these athletes more susceptible to throwing-related injuries.

Knotless Rotator Cuff Repair in an External Rotation Model: The Importance of Medial-Row Horizontal Mattress Sutures

PURPOSE To evaluate the effect of the addition of 2 horizontal mattress knots to the medial row of a knotless rotator cuff construct on the biomechanical properties in terms of both cyclic and failure testing parameters in an external rotation model. METHODS In 8 fresh-frozen human cadaveric shoulders, a knotless transosseous repair was performed, whereas in 8 contralateral matched-pair specimens, 2 horizontal mattress knots were added to the medial-row fixation. A custom jig was used that allowed external rotation (0° to 30°) with loading. A materials testing machine was used to cyclically load repairs from 0 to 180 N for 30 cycles and then to failure. Video digitizing software was used for analysis. Data from paired specimens were compared by use of paired Student t tests. RESULTS Ultimate load to failure was significantly higher in the modified construct (549 N v 311 N, P = .01). Linear stiffness in the first cycle, at the 30th cycle, and at failure was significantly higher (P = .02, P = .02, and P = .04, respectively) in the modified construct as well. Energy absorbed by the repaired tissue was significantly less in the modified construct at the first cycle, at the 30th cycle, and at ultimate load to failure (P = .03, P = .02, and P = .04, respectively). Significantly greater anterior gap formation occurred with the knotless technique at the first cycle (4.55 v 1.35) and 30th cycle (7.67 mm v 1.77 mm) (P = .02). CONCLUSIONS The modified construct shows improved biomechanical properties when allowing for external rotation during high-load testing. Using an additional horizontal mattress from separate sutures in the medial-row anchors helps to neutralize forces experienced by the repair. CLINICAL RELEVANCE The addition of medial-row fixation to a knotless construct will enhance the stability of rotator cuff repairs with the goal of improved patient outcomes.