Nariyuki Mura

Classification, Treatment, and Outcome of Osteochondritis Dissecans of the Humeral Capitellum

BACKGROUND Indications for the treatment of osteochondritis dissecans of the humeral capitellum have remained unclear. The aims of this study were to analyze the outcomes and to determine the most useful classification for the choice of treatment. METHODS The cases of 106 patients with osteochondritis dissecans of the capitellum were studied retrospectively. At the time of the initial presentation, the mean age of the patients was 15.3 years. The capitellar growth plate was open in eighteen patients and closed in eighty-eight. Thirty-six patients were treated nonoperatively. Fifty-five patients underwent fragment removal alone, twelve underwent fragment fixation with a bone graft, and three underwent reconstruction of the articular surface with use of osteochondral plug grafts from the lateral femoral condyle. The mean follow-up period was 7.2 years. The outcomes in terms of pain in the elbow, return to sports, and radiographic findings were analyzed and compared. RESULTS An osteochondritis dissecans lesion with an open capitellar physis and a good range of elbow motion resulted in a good outcome. Continued elbow stress resulted in the worst outcome in terms of pain and radiographic findings. In patients with a closed capitellar physis, surgery provided significantly better results than elbow rest (p < 0.01). Fragment fixation or reconstruction provided significantly better results than fragment removal alone (p < 0.05). The results of removal alone were dependent on the size of the defect in the capitellum. The outcome in terms of pain was closely associated with sports activity and radiographic findings. CONCLUSIONS We believe that osteochondritis dissecans of the capitellum can be classified as stable or unstable. Stable lesions that healed completely with elbow rest had all of the following findings at the time of the initial presentation: an open capitellar growth plate, localized flattening or radiolucency of the subchondral bone, and good elbow motion. Unstable lesions, for which surgery provided significantly better results, had one of the following findings: a capitellum with a closed growth plate, fragmentation, or restriction of elbow motion of >or=20 degrees . For large unstable lesions, fragment fixation or reconstruction of the articular surface leads to better results than simple excision.

Risk factors for elbow injuries among young baseball players

HYPOTHESIS There are some risk factors that could predispose a young baseball player to elbow injuries. MATERIALS AND METHODS Study participants were 294 baseball players aged 9 to 12 years old. A questionnaire, physical examination, and ultrasound imaging to investigate elbow injuries were performed. Data for the groups with and without elbow injuries were analyzed statistically using multivariate logistic regression models. RESULTS Ultrasound imaging showed that 60 participants had elbow injuries, including medial epicondylar fragmentation in 58 and osteochondritis dissecans of the capitellum in 2. The odds ratio (95% confidence interval) of the risk factors that statistical analysis showed were significant were age older than 11 years, 2.82 (1.30-6.10); height exceeding 150 cm, 2.02 (1.07-3.82); pitching, 4.50 (2.42-8.37); daily training, 1.96 (1.02-3.79); range of motion (ROM) of external rotation of the shoulder below 130 degrees , 1.98 (1.01-3.87); muscle strength (MS) of external rotation of the shoulder exceeding 80 N, 4.11 (1.47-11.55); and MS of internal rotation of the shoulder exceeding 100 N, 2.04 (1.08-3.90). DISCUSSION Risk factors for elbow injuries are age, height, pitcher, days of training, grip strength, range of motion of external rotation of the shoulder, and muscle strength of the shoulder. CONCLUSION As new information, our results suggest that decrease of ROM of external rotation of the shoulder and increase of MS of external and internal rotation of the shoulder predispose elbow injuries.

Using sonography for the early detection of elbow injuries among young baseball players.

OBJECTIVE The aim of this study was to determine the usefulness of sonography for detecting elbow injuries among young baseball players. SUBJECTS AND METHODS One hundred fifty-three volunteers ranging in age from 9 to 12 years and belonging to youth baseball teams participated. Sonography of the elbow was performed in the field when baseball exercises were being conducted. We analyzed the relationship between elbow pain and sonographic abnormalities and the relationship between pitchers and sonographic abnormalities. RESULTS Sonography showed that 33 subjects had medial epicondylar fragmentation and two had early-stage osteochondritis dissecans of the capitellum. In 25 subjects who agreed to further examination and treatment, radiography confirmed the sonographic findings. All of the 23 subjects with medial epicondylar fragmentation, who stopped throwing, obtained union of the bone and returned to baseball. The two subjects with osteochondritis dissecans of the capitellum underwent surgery before the osteochondral fragment became loosened. Sonographic abnormalities correlated with episodes of elbow pain. Pitchers statistically significantly had sonographic abnormalities. CONCLUSION Sonography in the field can provide an opportunity to detect and treat elbow injuries before they become more advanced.

Outcome of Nonoperative Treatment for Humeral Medial Epicondylar Fragmentation Before Epiphyseal Closure in Young Baseball Players

Background: Nonoperative treatment for humeral medial epicondylar fragmentation in baseball players, involving prohibition and limitation of throwing, has been reported to give good results. However, in some cases, such nonoperative treatment fails to yield an acceptable outcome. Hypothesis: In nonoperative treatment for patients with medial epicondylar fragmentation, achievement of bone union of the fragmentation provides better clinical outcomes compared with those of patients with delayed bone union or nonunion. Study Design: Cohort study; Level of evidence, 3. Methods: Fifty-five young baseball players with medial epicondylar fragmentation before epiphyseal closure, aged between 9 and 13 years (mean, 11.0 years), participated in this study. They belonged to baseball teams in a youth league and underwent nonoperative treatment involving prohibition of throwing for an average of 2.0 months and subsequent limitation of throwing for an average of 1.8 months. We investigated whether achievement of bone union of the fragmentation was associated with better clinical outcomes. Results: Bone union was achieved in 40 (73%) of 55 participants at 6 months after initial presentation, 31 (76%) of 41 participants at 1 year, and 32 (94%) of 34 participants at 2 years. Elbow pain was present in 7 participants (17%) at 1 year after initial presentation and in 6 participants (18%) at 2 years. At 1 year after initial presentation, statistical analysis showed that most participants with elbow pain had significant fragmentation (P = .0055). At 2 years after initial presentation, there was no significant relationship between elbow pain and medial epicondylar fragmentation (P = .32). Statistical analysis also showed that, at both 6 months and 1 year after initial presentation, bone union was significantly delayed in most participants who had not accepted nonoperative treatment and consequently resumed throwing vigorously before bone union. Conclusion: At 1 year after initial presentation, bone union of the medial epicondylar fragmentation was correlated with a decreased prevalence of elbow pain. At 6 months and 1 year after initial presentation, delayed bone union of the medial epicondylar fragmentation was associated with resumption of throwing at maximum strength before bone union had occurred.

Treatment for Ulnar Neuritis Around the Elbow in Adolescent Baseball Players: Factors Associated With Poor Outcome:

Background: Ulnar neuritis around the elbow is one of the injuries seen in throwing athletes. Outcomes of nonsurgical treatment and factors associated with failure outcomes have not been reported. Purpose: To investigate the outcomes of treatments for ulnar neuritis in adolescent baseball players. Study Design: Case series; Level of evidence, 4. Methods: We assessed 40 male baseball players with a mean age of 15.0 years (range, 13-17 years) who presented with ulnar neuritis. There were 19 pitchers and 21 fielders whose throwing side was affected. All patients had elbow pain, and 13 patients had hand numbness on the ulnar side. The mean Kerlan-Jobe Orthopaedic Clinic (KJOC) overhead athlete shoulder and elbow score was 52.5 at the first follow-up visit (n = 36 patients). Thirteen patients were identified with ulnar nerve subluxation, and 23 patients had concomitant elbow ulnar collateral ligament (UCL) injury. All patients underwent nonsurgical treatment, which included rehabilitation exercises and prohibition of throwing. If the nonsurgical treatment failed, we recommended surgical treatment. We investigated the outcomes of the nonsurgical and surgical treatments. Return to sports was evaluated, combined with factors associated with return to sports in nonsurgical treatment by univariate and multivariate statistical analysis. Results: The mean follow-up period was 23.6 months (range, 6-39 months). After nonsurgical treatment, 24 patients (60%) returned to the previous competition level after a mean of 2.4 months. Two patients returned to a recreational level. One patient gave up playing baseball at 2 months. The remaining 13 patients underwent surgery and returned to sports after a mean of 2.0 months postoperatively, and 12 had no limitation of sports activities. Multivariate logistical regression analysis demonstrated that hand numbness, ulnar nerve subluxation, and UCL injury were associated with failure of nonsurgical treatment (P < .05). In addition, KJOC score of <45 at the first follow-up tended to be associated with poor outcomes of nonsurgical treatment (P = .06). Conclusion: Hand numbness on the ulnar side, ulnar nerve subluxation, and UCL injury are strong predictors of poor outcomes after nonsurgical treatment for ulnar neuritis, and surgery provides excellent results.

The Incidence of Atypical Femoral Fractures in Patients with Rheumatic Disease: Yamagata Prefectural Committee of Atypical Femoral Fractures (YamaCAFe) Study

Atypical femoral fractures (AFFs) have been reported to occur with minimal or spontaneous subtrochanteric and femoral shaft fractures with a characteristic transverse pattern, compared with typical femoral fractures in young patients with high-energy trauma. AFFs are related to long-term use of bisphosphonates (BPs), glucocorticoids and rheumatic diseases. We have estimated a blind analysis of AFFs in rheumatic patients receiving BPs and glucocorticoids ordinary over a long time in all Yamagata prefectural area through radiographic examination. The 123 AFFs including suspected cases over six years were collected and reviewed by two independent orthopedic surgeons. We found 86 patients with a total of 99 AFFs between 2009 and 2014 (1.43 cases/100,000 person/year). Of these 99 AFFs, 11 were in 8 rheumatic patients including three patients with bilateral AFFs. The incidence of AFFs in rheumatic patients had trend to increase from 2012. The mean age of all 8 patients was 54.9 years. All 8 patients received BPs and 7/8 received prednisolone (PSL). The mean dose of PSL was 14 mg/day. Compared to patients with unilateral AFFs, those with bilateral AFFs in rheumatic patients were on a higher dose of PSL (20 mg/day vs. 7 mg/day) and had less femoral neck-shaft angle (129° vs. 136°, p < 0.05). In conclusion, the incidence of AFFs in rheumatic patients showed a trend to increase from 2012 to 2014 in Yamagata prefecture. Careful management of AFFs is of particular importance in rheumatic patients who have taken high doses of PSL and have small femoral neck-shaft angle.

Outcome of conservative treatment for Little League shoulder in young baseball players: factors related to incomplete return to baseball and recurrence of pain

BACKGROUND The purpose of this study was to investigate the factors associated with poor results and pain recurrence in young baseball players with Little League shoulder (LLS). METHODS Eighty-seven young baseball players with LLS (mean age, 12.1 years) underwent conservative treatment. Of the players, 68 (78%) underwent conservative treatment involving the prohibition of throwing for an average of 1.2 months whereas the remaining 19 (22%) continued throwing with limitations. We analyzed the factors associated with poor results at 2 months and pain recurrence. RESULTS At 2 months, 18% of participants reported the presence of pain, and the results regarding the return to baseball were as follows: complete return in 43%, incomplete return in 33%, and no return in 24%. A total of 83 subjects (95%) had completely returned at an average of 2.8 months. Pain recurrence was present in 20 subjects (25%) at an average of 6.2 months. Statistical analysis showed that the following factors were significantly associated with poor results at 2 months: longer period from initial presentation to throwing prohibition and worse shoulder flexibility (P = .04 and P = .01, respectively). It also revealed that the following factors were significantly associated with pain recurrence: higher frequency of pain at 2 months and longer duration until complete return (P = .0003 and P = .04, respectively). CONCLUSIONS It is important for subjects with LLS to be prohibited from throwing immediately after initial presentation. Good shoulder flexibility was associated with a return to baseball without pain. A complete return in subjects who had pain at 2 months was significantly delayed, and these subjects exhibited more rapidly recurring pain after their return.

Complications of the Fingers and Hand After Arthroscopic Rotator Cuff Repair

Background: Complications of the fingers and hand that occur after Arthroscopic Rotator Cuff Repair (ARCR) have not been examined in detail. Objective: The aim of our study was to evaluate the diagnosis and treatment of complications of the fingers and hand that occur after ARCR and to examine treatment outcomes. Methods: The case records of 40 patients (41 shoulders) who underwent ARCR using suture anchors were retrospectively reviewed to investigate complications of the fingers and hand after ARCR. Results: Twelve patients (29%) experienced numbness, pain, edema, and movement limitations of the fingers and hand. These symptoms occurred on average 1.1 months (range, 0.1-2.5 months) after ARCR. The diagnoses were cubital tunnel syndrome in 2 hands, carpal tunnel syndrome in 3 hands, and flexor tenosynovitis (TS) in 10 hands. None of the 10 hands with TS exhibited triggering of the fingers. The mean interval between treatment initiation and symptom resolution was 2.2 months for the 5 hands treated by corticosteroid injection or surgery and 5.9 months for the 7 hands treated by alternating warm and cold baths alone. None of the hands exhibited Complex Regional Pain Syndrome (CRPS). Conclusion: Complications of the fingers and hand after ARCR were observed in 29%. TS was the most frequent complication. When symptoms in the fingers and hand occur after ARCR, rather than immediately suspecting CRPS, TS should be primarily suspected, including when TS symptoms such as triggering are not present, and these patients should be treated proactively using corticosteroid injections or surgery.

Contractile property measurement of the torn supraspinatus muscle using real-time tissue elastography

HYPOTHESIS In the restoration of shoulder abduction, decreased contractility of the torn rotator cuff muscle may be a cause of a poor result. The aim of this study was to investigate the relationship between the contractile property of the torn supraspinatus muscle measured by real-time tissue elastography and the Goutallier stage as modified by Fuchs et al. METHODS: The muscular hardness of the torn supraspinatus muscle was measured in 32 patients at rest and during isometric contraction with the shoulder abducted to 60° in the scapular plane. The muscular hardness was calculated as the strain ratio. Fatty degeneration was assessed according to the modified Goutallier stage. Because the activity value (defined as the difference between the strain ratio at rest and the strain ratio during isometric contraction) estimated the contractile property of the muscle, stepwise multiple regression analysis was used to compare the activity value with age, sex, side, time from injury onset to obtaining the measurements, and modified Goutallier stage. RESULTS The mean activity value was 0.26 ± 0.16. Fatty degeneration of the supraspinatus muscle was grade 0 in 5 patients, grade 1 in 16, grade 2 in 10, and grade 3 in 1. The activity value was significantly correlated only with the modified Goutallier stage (r = -0.78, P < .001). CONCLUSION The contractile property of the supraspinatus muscles decreased with an increase in the modified Goutallier stage. Real-time tissue elastography can measure the contractile property of the muscles before surgery and thus may be a predictor for the resulting restoration of lost muscle function.

A Comparison of Biceps Labrum Complex Findings in Patients With and Without Superior Migration of the Humeral Head in Large or Massive Rotator Cuff Tears: 比較在患有旋轉袖肌巨大破裂的病人中有和沒有肱骨頭向上遷移對於肱二頭肌盂唇複合體的影響

Background The purpose of this study was to clarify the relationship between superior migration of the humeral head and findings of biceps labrum complex (BLC) in large or massive rotator cuff tears. Methods Forty-nine shoulders that underwent surgery for torn supraspinatus and infraspinatus tendons were included. Patients were divided into two groups according to the acromio—humeral interval (AHI). Arthroscopic findings of BLC were classified into five types; Type 0; normal shape, Type 1: fraying; Type 2: detachment; Type 3: attrition of BLC and superior glenoid; and Type 4: defect. Results The group without migration (AHI ≥ 7 mm) consisted of 21 shoulders and that with migration (AHI < 7 mm) was 28 shoulders. There were significantly more patients with Types 2, 3, and 4 in the group with migration than without migration. Conclusion This study indicates a potential relationship between BLC injury and superior humeral head migration accompanied by a rotator cuff tear.