Paul M. Sethi

Intercondylar Notch Stenosis Is Not a Risk Factor for Anterior Cruciate Ligament Tears in Professional Male Basketball Players An 11-Year Prospective Study

Background The value of femoral notch size and the notch width index in predicting anterior cruciate ligament injury has been debated. This study examined the relationship between the notch width index and anterior cruciate ligament injury in professional basketball players. Hypothesis No significant difference exists between the notch width index of anterior cruciate ligament–injured and noninjured professional basketball players. Study Design Case-control study; Level of evidence, 3. Methods Using a notch view radiograph, the authors prospectively measured the femoral notch and the condylar widths and then calculated the notch width index of 615 male athletes who participated in the National Basketball Associations combine workouts between 1992 and 1999. Players who participated in at least 1 professional game were included. After an 11-year follow-up period, the National Basketball Associations leaguewide injury database was reviewed to identify injured players. The players were then categorized into anterior cruciate ligament–injured or noninjured groups. Notch width, condylar width, and notch width index were compared between the 2 groups. Results A total of 305 players were followed for a period of up to 11 years. Anterior cruciate ligament trauma was suffered by 14 (4.6%) of the subjects. The average notch width index was 0.235 ± 0.031 for anterior cruciate ligament–injured players and 0.242 ± 0.041 for noninjured players (t305 –0.623, P=. 534). This difference was not significantly different. Two (3.9%) of the subjects with critical notch stenosis (notch width index 0.20) had noncontact anterior cruciate ligament injuries. Conclusions The notch width index did not predict the rate of anterior cruciate ligament injury. A level of critical notch stenosis was not detected. Anterior cruciate ligament injury could not be predicted by the absolute measurement of the femoral intercondylar notch. Use of a preparticipation notch view radiograph in male professional basketball players as a predictor of anterior cruciate ligament injury is not recommended.

Partial-thickness rotator cuff tears.

&NA; Partial‐thickness rotator cuff tears are not a single entity; rather, they represent a spectrum of disease states. Although often asymptomatic, they can be significantly disabling. Overhead throwing athletes with partial‐thickness rotator cuff tears differ with respect to etiology, goals, and treatment from older, nonathlete patients with degenerative tears. Pathogenesis of degenerative partial‐thickness tears is multifactorial, with evidence of intrinsic and extrinsic factors playing key roles. Diagnosis of partial‐thickness rotator cuff tears should be based on the patients symptoms together with magnetic resonance imaging studies. Conservative treatment is successful in most patients. Surgery generally is considered for patients with symptoms of sufficient duration and intensity. The role of acromioplasty has not been clearly delineated, but it should be considered when there is evidence of extrinsic causation for the partial‐thickness rotator cuff tear.

Surgical treatment of distal biceps rupture.

Rupture of the distal biceps tendon accounts for 10% of all biceps brachii ruptures. Injuries typically occur in the dominant elbow of men aged 40 to 49 years during eccentric contraction of the biceps. Degenerative changes, decreased vascularity, and tendon impingement may precede rupture. Although nonsurgical management is an option, healthy, active persons with distal biceps tendon ruptures benefit from early surgical repair, gaining improved strength in forearm supination and, to a lesser degree, elbow flexion. Biomechanical studies have tested the strength and displacement of various repairs; the suspensory cortical button technique exhibits maximum peak load to failure in vitro, and suture anchor and interosseous screw techniques yield the least displacement. Surgical complications include sensory and motor neurapraxia, infection, and heterotopic ossification. Current trends in postoperative rehabilitation include an early return to motion and to activities of daily living.

Quantitative Assessment of Glenohumeral Translation in Baseball Players A Comparison of Pitchers Versus Nonpitching Athletes

Background Objective data quantifying differences in glenohumeral range of motion in baseball pitchers versus position players are established. There is limited information objectively comparing glenohumeral laxity in this same population. Hypothesis Baseball pitchers have greater difference in side-to-side anteroposterior translation of their throwing shoulders compared with position players. Study Design Prospective cross-sectional study. Methods Cutaneous electromagnetic sensors quantified anteroposterior shoulder translation of college and professional baseball players. Range of motion was measured. Results Nineteen position players and 37 pitchers were studied. Pitchers had a significant increase in external rotation of the dominant arm as compared with the nondominant arm (P = .02); the difference was not significant in position players (P = .34). The mean range of motion for pitchers’ dominant arm was 110° external rotation to 68° internal rotation, and it was 100° external rotation to 85° internal rotation for position players (P = .278). The mean anteroposterior translation in pitchers’ dominant arm was 33.30 mm and 29.84 mm in the nondominant side (P = .0001). This difference was not present in position players (P = .88). One of 19 position players had a side-to-side shoulder translation difference greater than 3 mm, compared with 22 of 37 pitchers (P = .0001). Conclusions Pitchers have a greater amount of glenohumeral translation in the dominant arm. This difference is not seen in position players. These differences make the side-to-side comparison less useful in pitchers and should be considered when making therapeutic decisions.

Distal triceps rupture.

Distal triceps rupture is an uncommon injury. It is most often associated with anabolic steroid use, weight lifting, and laceration. Other local and systemic risk factors include local steroid injection, olecranon bursitis, and hyperparathyroidism. Distal triceps rupture is usually caused by a fall on an outstretched hand or a direct blow. Eccentric loading of a contracting triceps has been implicated, particularly in professional athletes. Initial diagnosis may be difficult because a palpable defect is not always present. Pain and swelling may limit the ability to evaluate strength and elbow range of motion. Although plain radiographs are helpful in ruling out other elbow pathology, MRI is used to confirm the diagnosis, classify the injury, and guide management. Incomplete tears with active elbow extension against resistance are managed nonsurgically. Surgical repair is indicated in active persons with complete tears and for incomplete tears with concomitant loss of strength. Good to excellent results have been reported with surgical repair, and very good results have been achieved even for chronic tears.

Accuracy of intra-articular injection of the glenohumeral joint: a cadaveric study.

: Intra-articular glenohumeral injections are an important part of orthopedic practices for both therapeutic and diagnostic purposes. Forty human cadaver shoulders were injected, 20 anteriorly and 20 posteriorly, to assess the accuracy of injections placed in the glenohumeral joint. After the needle was placed, 1 cc of gadolinium was injected into the joint to determine accuracy of position. The radiographic presence of intra-articular contrast was judged as an accurate injection. The anterior approach had an 80% accuracy rate and .75 positive predictive value. The posterior approach had a 50% accuracy rate and a .67 positive predictive value. Anterior injections produce a higher rate of accuracy than posterior injections.

Biomechanical evaluation of distal biceps reconstruction with cortical button and interference screw fixation.

HYPOTHESIS Tension slide repair maintains the strength of the standard cortical button repair but reduces gap formation at the repair. Distal biceps tendon repair with a suspensory cortical button has yielded the strongest published repair, despite observed gap formation and tendon pistoning. The tension slide technique (TST) was described to reduce gap formation while maintaining the strength of cortical button repair. This study evaluates the biomechanics of the TST compared with previously described EndoButton (Smith & Nephew, Memphis, TN) repair and the TST with and without an interference screw. MATERIALS AND METHODS The study used 20 matched specimens: 5 had a standard cortical button repair, and 5 had biceps repair with the TST. An additional 10 specimens underwent a TST, 5 with an interference screw and 5 without. All were cyclically loaded for 3600 cycles. Gap formation and load to failure were measured. RESULTS The mean (SD) load to failure for standard technique was at 389 (148) N vs 432 (66) N for the TST (P = .28). The mean (SD) gap formation was 2.79 (1.43) mm with the standard repair and 1.26 (0.61) mm with the TST (P = .03). The mean (SD) load to failure with TST repair was 436 (103) N without the interference screw and 439 (94) N (P = 0.48) with the screw. The mean gap formation was 1.63 (1.09) mm without the screw and 1.45 (0.67) mm with the screw (P = .38.) CONCLUSION This TST maintains the strength of the standard cortical button repair, but significantly reduces gap formation and motion at the repair site. LEVEL OF EVIDENCE Basic science study.

The Distal Triceps Tendon Footprint and a Biomechanical Analysis of 3 Repair Techniques

Background Anatomic repair of tendon ruptures is an important goal of surgical treatment. There are limited data on the triceps brachii insertion, footprint, and anatomic reconstruction of the distal triceps tendon. Hypothesis An anatomic repair of distal triceps tendon ruptures more closely imitates the preinjury anatomy and may result in a more durable repair. Study Design Descriptive and controlled laboratory studies. Methods The triceps tendon footprint was measured in 27 cadaveric elbows, and a distal tendon rupture was created. Elbows were randomly assigned to 1 of 3 repair groups: cruciate repair group, suture anchor group, and anatomic repair group. Biomechanical measurement of load at yield and peak load were measured. Cyclic loading was performed for a total of 1500 cycles and displacement measured. Results The average bony footprint of the triceps tendon was 466 mm2. Cyclic loading of tendons from the 3 repair types demonstrated that the anatomic repair produced the least amount of displacement when compared with the other repair types (P < .05). Load at yield and peak load were similar for all repair types (P > .05). Conclusion The triceps bony footprint is a large area on the olecranon that should be considered when repairing distal triceps tendon ruptures. Anatomic repair of triceps tendon ruptures demonstrated the most anatomic restoration of distal triceps ruptures and showed statistically significantly less repair-site motion when cyclically loaded. Clinical Relevance Anatomic repair better restores preinjury anatomy compared with other types of repairs and demonstrates less repair-site motion, which may play a role in early postoperative management.

Repair results of 2-tendon rotator cuff tears utilizing the transosseous equivalent technique

BACKGROUND The purpose of this study was to examine the healing rate of 2-tendon rotator cuff tears repaired by the use of a transosseous-equivalent (TOE) suture bridge technique. MATERIALS AND METHODS Forty-three patients with combined supraspinatus and infraspinatus tendon tears underwent arthroscopic repair using TOE technique. Forty of these patients were then evaluated by MRI and clinical exam at a minimum of 1-year follow-up to determine the rate of healing of the repair and clinical outcomes associated with healing. RESULTS Eighty-three percent of the repairs demonstrated intact rotator cuff repairs at a mean of 16 months post-op. Larger tears (3.5 vs 2.8 cm) were associated with failure (P = .01), as was more advanced fatty infiltration (Goutallier 1.3 vs 0.3, P = .01). Age was not different between intact and nonintact tendons. Strength was the only clinical finding that differed between intact and nonintact tendons. CONCLUSION Two-tendon tears of the rotator cuff can heal at a high rate with the use of TOE suture bridge repair technique. Furthermore, tear size and Goutallier grading were negatively correlated with postoperative healing. The incremental improvement in the rate of observed rotator cuff healing still does not translate to statistical differences in the objective shoulder scoring systems.

The Effect of Tennis Racket Grip Size on Forearm Muscle Firing Patterns

Background Inappropriately sized tennis racket grip is often cited in the popular media as a risk factor for overuse injuries about the forearm and elbow. Currently, a hand measurement technique developed by Nirschl is commonly used by tennis racket manufacturing companies as the method for determining a players “recommended” grip size. Hypothesis Quarter-inch changes from that recommended by Nirschl in tennis racket grip size will have no significant effect on forearm muscle firing patterns. Study Design Controlled laboratory study. Methods Sixteen asymptomatic Division I and II collegiate tennis players performed single-handed backhand ground strokes with rackets of 3 different grip sizes (recommended measurement, undersized 1/4 in, and oversized 1/4 in). Fine-wire electromyography was used to measure muscle activity in extensor carpi radialis longus and brevis, extensor digitorum communis, flexor carpi radialis, and pronator teres. Repeated-measure analysis of variance was used for within-group comparisons, comparing different grips in specified phases for backhand ground strokes (P [.lessequal]. 05). Results There were no significant differences in muscle activity between small, recommended, or big grips in any muscle tested. Conclusion Based on these findings, tennis racket grip size 1/4 in above or below Nirschls recommended measurement does not significantly affect forearm muscle firing patterns. Clinical Relevance Alterations in tennis racket grip size within 1/4 in of Nirschls recommended sizing do not have a significant effect on forearm muscle activity and therefore may not represent a significant risk factor for upper extremity cumulative trauma, such as lateral epicondylitis.