Phillip Langer

Evolution of the treatment options of ulnar collateral ligament injuries of the elbow

Ulnar collateral ligament (UCL) insufficiency is potentially a career threatening, or even a career ending, injury, particularly in overhead throwing athletes. The evolution of treating modalities provides afflicted athletes with the opportunity to avoid premature retirement. There have been several clinical and basic science research efforts which have investigated the pathophysiology of UCL disruption, the biomechanics specific to overhead throwing, and the various types of treatment modalities. UCL reconstruction is currently the most commonly performed surgical treatment option. An in depth analysis of the present treatment options, both non-operative and operative, as well as their respective results and biomechanical evaluation, is lacking in the literature to date. This article provides a comprehensive current review and comparative analysis of these modalities. Over the last 30 years there has been an evolution of the original UCL reconstruction. Yet, despite the variability in modifications, such as the docking technique, interference screw fixation, and use of suture anchors, the unifying concepts of UCL reconstruction are that decreased dissection of the flexor-pronator mass and decreased handling of the ulnar nerve leads to improved outcomes.

In Vitro Evaluation of the Effect Lateral Process Talar Excision on Ankle and Subtalar Joint Stability

Background: Recent literature reflects a substantial increase in interest surrounding lateral talar process fractures. Previous anatomic investigations discovered that excision of a 1 cm3 fracture fragment from the lateral talar process involves approximately 100% of the lateral talocalcaneal ligament origin and 10% to 15% of both the posterior and anterior talofibular ligament insertions. The objective of this study was to determine the effect that excision of this 1 cm3 fragment has on ankle and subtalar joint stability. Methods: Ten fresh-frozen cadaver lower limbs were thawed before testing and placed in a clinical stress apparatus (Model SE 20, Telos, Marburg, Germany). Radiographs were taken before and after application of a 150 N of force. Three views (lateral, anteroposterior, 30-degree Bróden) were used to asses anterior tibiotalar translation (AT), talar tilt (TT), medial talocalcaneal motion (TCM), and talocalcaneal tilt (TCT) before and after excision of the 1 cm3 fragment the lateral talar process. Results: The mean increases in AT, TT, TCM and TCT after excision of the 1 cm3 fragment were: AT = 1.0 mm ± 0.94 mm (p = 0.0085); TT = 0.4 ± 0.52 degrees (p = 0.0368); TCM = 1.0 mm ± 1.25 mm (p = 0.0319); TCT = 1.2 ± 1.32 degrees (p = 0.0181). Conclusions: Since it has been generally accepted that a 3 mm increase in AT, 3-degree increase in TT, 5-mm increase in TCM, more than 5-degree increase in TCT define instability of the ankle and subtalar joints, respectively. These results suggest that excision of a 1 cm3 fragment causes neither ankle nor subtalar instability as defined by radiographic stress examination.

Proximity of the Lateral Talar Process to the Lateral Stabilizing Ligaments of the Ankle and Subtalar Joint

Background: Fractures of the lateral process of the talus have become more frequent as the sport of snowboarding has gained popularity. The anatomy of the ligamentous attachments to the process has been described, but ligament proximity to the lateral talar process has never been specified. The objective of this cadaver study was to measure the proximity of the lateral talar process to the various lateral stabilizing ligaments of the ankle and subtalar joint: the anterior talofibular ligament, lateral talocalcaneal ligament, posterior talofibular ligament, interosseous ligament, cervical ligament, and lateral root of the extensor retinaculum. Methods: After thawing, all musculotendinous structures from 10 fresh-frozen cadaver lower limbs were carefully removed and the distal fibula was reflected to enable adequate exposure of the lateral talar process and ligamentous attachments. The apex of the lateral process was defined. Subsequently, the distance from the apex to the nearest edge and center of these surrounding ligaments was independently measured by two examiners. Results: The average apex-edge distances were 9.3 mm (posterior talofibular); 8.7 mm (anterior talofibular), 3.4 mm (lateral talocalcaneal), 13.9 mm (interosseous), 19.1 mm (cervical), and 13.0 mm (lateral root of extensor retinaculum). The average apex-center distances for those ligaments found to actually insert on the lateral talar process were 18.0 mm (posterior talofibular), 15.7 mm (anterior talofibular), and 6.2 mm (lateral talocalcaneal). Conclusions: Contrary to previous reports, our cadaver dissections identified that only three ligaments attach to the lateral process of the talus: lateral talocalcaneal, anterior talofibular, and posterior talofibular. Clinical Relevance: Familiarity with these anatomic relationships may help guide the clinical treatment of lateral talar process fractures.

Catastrophic neck injuries in the collision sport athlete

Catastrophic neck injury is defined as a structural distortion of the cervical spinal column associated with actual (or potential) damage to the spinal cord. Although uncommon, this type of traumatic injury can lead to severe neurologic sequelae in the collision sport athlete. Emergency care is complicated by the helmet and shoulder pads worn by the athlete. A thorough understanding of the clinical anatomy, diagnostic considerations, and protocols for on-site evaluation and management is necessary to optimize outcome.

The Diagnostic Value of MRI in Foot and Ankle Surgery

Background: MRI is being used with increasing frequency and seems to have become more popular as a screening tool rather than as an adjunct to narrow specific diagnoses or plan operative interventions. Our hypothesis was that the rising accessibility of this test may be resulting in its overuse. Methods: We retrospectively reviewed 221 consecutive patients referred over a 3-month period for treatment of a lower extremity problem to determine: (1) the number of patients who presented with an MRI already obtained from an outside source, (2) the number of patients who obtained an MRI from the foot and ankle specialist after referral, and (3) the number of times the foot and ankle specialist used these studies or found them helpful in the care of the patient. Fractures (20) were excluded. Results: Of the 201 patients without fractures included in the study, 19.9% (40 of 201) had MRI scans during the course of their treatment; 15.4% (31 of 201) presented to their initial visit with an MRI scan from an outside source, and 4.5% (9 of 201) received MRI scans as ordered by the foot and ankle specialist. Eighty-seven percent (27 of 31) of the pre-referral MRI scans were thought to be unnecessary, and 48.4% (15 of 31) had radiographic interpretations that were considered either immaterial to the patients pertinent clinical diagnosis or inconsistent with the specialists interpretations. All nine MRI scans ordered by the specialist were useful in the care of the patient. Therefore, of the 221 consecutive patients, the foot and ankle specialist would have ordered MRI scans in only 5.9% (13 of 221). Conclusions: This study suggests that many of the pre-referral foot or ankle MRI scans obtained before evaluation by a foot and ankle specialist are not necessary. Further studies need to be performed to determine the role of MRI in the screening of foot and ankle disorders.