Nirav H. Amin

The Thrower’s Elbow

Overhead throwing activities expose the elbow to tremendous valgus stress, making athletes vulnerable to a specific constellation of injuries. Although baseball players, in particular pitchers, are the athletes affected most commonly, overhead throwing athletes in football, volleyball, tennis, and javelin tossing also are affected. The purpose of this review is to review the anatomy, biomechanics, pathophysiology, and treatment of elbow disorders related to overhead throwing athletes. Although focus is on management of ulnar collateral ligament injuries, all common pathologies are discussed.

Complications from a Distal Bicep Repair: A Meta-Analysis of a Single Incision Versus Double Incision Surgical Technique.

Objectives: Anatomical reinsertion of the distal biceps is critical for restoring elbow flexion and forearm supination strength. Surgical techniques utilizing one and two incisions have been reported in the literature, describing complications and outcomes. However, which technique is associated with a lower complication rate remains unclear. Methods: A systematic review was conducted using the PubMed, Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), SPORTSDiscus, and the Cochrane Central Register of Controlled Trials database to identify articles reporting distal biceps ruptures through August 2013. We included English language publications based on adult patients with a minimum of three cases. Both single and dual incision technique studies were incorporated. The demographic and outcome data of all studies was retrieved and pooled. A Meta-analysis on the pooled data was then conducted to determine the role of surgical technique on different complications. This was adjusted for age, gender and other independent variables. Results: Fifty-five articles met the inclusion criteria. The complication rate in the single incision group was 28.3% (222/785) versus 20.9% (104/498) in the double incision group. Neuropraxia was the most common complication in the single incision group at 9.8% (77/785), while heterotopic ossification was the most common in double incision cases at 7% (35/498). Re-rupture and failed reattachment occurred in 2.5% of single incision cases, versus 0.6% of double-incision cases (p < 0.034). Posterior interosseous nerve (PIN) palsy occurred in 2.7 % (13/785) of single incision procedures versus 0.2% (1/498) in the double incision group (p< 0.001). When combining heterotopic ossification and synostosis rates, the double incision group demonstrated complications in 9.8% of cases versus 3.2% for single incision cases. Conclusion: Surgical intervention for distal biceps ruptures may help restore function to an active individual; however, this procedure is not without risk of complications. The single incision technique has a higher rate of failed re-attachment and re-rupture compared to the double incision technique. The single incision technique also has a higher rate of overall nerve palsy (PIN, LABC, and Radial Nerve) compared to the double incision technique. The double incision technique does have higher rates of HO compared to the single incision. These complications are important for surgeons to consider and disclose to patients deciding on operative repair.

Management of Bone Loss in Glenohumeral Instability

This review discusses the evaluation and management of bone loss in glenohumeral instability. The glenohumeral joint may experience a dislocation or subluxation associated with traumatic injury or through repetitive atraumatic events. Nearly 62% of cases with recurrent dislocation have both Hill-Sachs and bony Bankart defects. Treatment of unstable bone defects may require soft-tissue repair, bone grafting, or both, depending on the size and nature of the defects. The most common treatment is isolated soft-tissue repair, leaving the bone defects untreated, although emerging evidence supports directly addressing these bony defects.

Changes within clinical practice after a randomized controlled trial of knee arthroscopy for osteoarthritis

Background: In 2002, Moseley et al published a randomized controlled trial (RCT) that showed no difference between knee arthroscopy and placebo for patients with osteoarthritis (OA). We wanted to assess the impact of the trial on clinical practice in the United States. Purpose/Hypothesis: To evaluate changes in knee arthroscopy practice before and after publication of the article by Moseley et al and to assess the effect of this landmark RCT on the behavior of practicing orthopaedic surgeons. We hypothesized that after publication of the Moseley trial, the overall frequency of knee arthroscopy would decrease, that the mean age of patients undergoing knee arthroscopy would decrease, and that the proportion of arthroscopies for a diagnosis of OA would decrease. Study Design: Descriptive epidemiology study. Methods: The State Ambulatory Surgery Database was used to analyze cases from 1998 to 2006, which were classified as meniscus tear, OA, or OA with meniscus tear. Changes in age, surgery rates, and case classification were evaluated before and after Moseley’s trial using Student t tests and analysis of variance. Results: After publication of the trial, the number of knee arthroscopies per year increased from 155,057 in 1998 to 172,317 in 2006 (P ≤ .001). Mean patient age increased from 47.6 to 49.2 years (P < .001). Meniscus tears increased from 69.1% to 70.8%, representing approximately 15,500 additional cases per year. OA decreased from 10.6% to 7.2%, representing approximately 4000 fewer cases per year. OA with meniscus tear increased from 20.3% to 22.0%, representing approximately 6400 additional cases per year. Conclusion: While overall age and rates of knee arthroscopy increased contrary to our hypothesis, we identified a decrease in rates of knee arthroscopy for OA after publication of the Moseley trial, demonstrating that well-publicized RCTs can influence patterns of clinical practice.

Distal tibia fractures: locked or non-locked plating? A systematic review of outcomes

Background and purpose — Although plating is considered to be the treatment of choice in distal tibia fractures, controversies abound regarding the type of plating for optimal fixation. We conducted a systematic review to evaluate and compare the outcomes of locked plating and non-locked plating in treatment of distal tibia fractures. Patients and methods — A systematic review was conducted using PubMed to identify articles on the outcomes of plating in distal tibia fractures that were published up to June 2012. We included English language articles involving a minimum of 10 adult cases with acute fractures treated using single-plate, minimally invasive techniques. Study-level binomial regression on the pooled data was conducted to determine the effect of locking status on different outcomes, adjusted for age, sex, and other independent variables. Results — 27 studies met the inclusion criteria and were included in the final analysis of 764 cases (499 locking, 265 non-locking). Based on descriptive analysis only, delayed union was reported in 6% of cases with locked plating and in 4% of cases with non-locked plating. Non-union was reported in 2% of cases with locked plating and 3% of cases with non-locked plating. Comparing locked and non-locked plating, the odds ratio (OR) for reoperation was 0.13 (95% CI: 0.03–0.57) and for malalignment it was 0.10 (95% CI: 0.02–0.42). Both values were statistically significant. Interpretation — This study showed that locked plating reduces the odds of reoperation and malalignment after treatment for acute distal tibia fracture. Future studies should accurately assess causality and the clinical and economic impact of these findings.

Medial Patellofemoral Ligament Reconstruction

In the general population, the overall incidence of acute patellar dislocation is 5.8 per 100,000 people in the United States1. The rate of patellar dislocation is estimated to be highest in the age group of ten to seventeen years, with reported rates of 29% to 43%1-3. Women have a 33% increased prevalence of acute patellar dislocation compared with men1. Patellar instability typically occurs in patients with several anatomic risk factors, including both soft-tissue and osseous abnormalities. Conlan et al. studied twenty-five cadaveric specimens to analyze soft-tissue restraints associated with patellar instability and found the medial patellofemoral ligament to be a critical medial soft-tissue restraint in preventing lateral instability4. Furthermore, biomechanical and radiographic findings have led many surgeons to state that disruption of the medial patellofemoral ligament is the “essential lesion” required for patellar dislocation1,4-7. Disruption of the medial patellofemoral ligament was diagnosed on magnetic resonance imaging (MRI) in twenty-six (96%) of twenty-seven patients8; the lesion most commonly occurs at the femoral attachment site9,10 (Fig. 1). In addition, the deep capsular layer, the medial patellomeniscal ligament, and the medial patellotibial ligament all have been found to contribute to the soft-tissue stabilization of the patella against lateral …

Stress Fractures of the Pelvis

Stress fractures are a very common overuse injury in the athletic population. Overall, these injuries consist of approximately 15–20 % of all visits to sports medicine clinics. A stress fracture not only leads to discomfort of the affected extremity but also can cause decreased athletic performance, lost training time, and medical expense. Pelvic stress fractures are less common than lower extremity stress fractures and can be divided based on location into: sacral stress fractures, pubic ramus stress fractures, and iliac wing stress fractures as well as apophyseal avulsion fractures. These “low-risk” stress fractures generally present in female long distance runners and military recruits; however, these injuries should be considered in any athlete who experience repetitive loads to the axial skeleton. Diagnosis can be difficult and requires a high-level of suspicion as patients present with vague low back pain (sacral stress fractures) or groin discomfort. Radiographic evaluation can aid in diagnosis and consists of plain radiographs as well as advanced imaging such as magnetic resonance imaging (MRI) and/or bone scintigraphy. Treatment rarely requires operative management and involves cessation of the causative activity for 4–10 weeks with gradual return to physical activity. Additionally, any patient with a suspected pelvic stress fracture should undergo a metabolic evaluation consisting of blood and urine work as well as the intake of calcium and vitamin D. The purpose of this chapter is to evaluate the clinical presentation, evaluation, diagnostic tools, and management of stress fractures of the pelvis in the athletic population.

Elbow Injuries in the Throwing Athlete

Overhead throwing athletes place a substantial amount of stress on the elbow during the throwing cycle. In athletes such as baseball players, repetition leads to attritional damage to the elbow. While injury to the medial ulnar collateral ligament is the most publicized, and perhaps most important, of these conditions, a collection of other disorders commonly afflict this population. These injuries include (1) ulnar neuritis, (2) flexor pronator injury, (3) medial epicondylar apophysitis or avulsion, (4) valgus extension overload syndrome with posterior impingement, (5) olecranon stress fractures, and (6) osteochondritis dissecans of the capitellum1. The purpose of the present review article is to describe the biomechanics of the throwing motion and the diagnosis and treatment of elbow injuries common to a thrower other than injuries to the ulnar collateral ligament. The osseous anatomy of the proximal part of the ulna and the olecranon fossa provides primary stability at 120° of flexion. The radial head provides secondary restraint to valgus stress at 30°. The primary coronal stability during the functional arc of an overhead …