Stephen J. Lombardo

Shoulder impingement syndrome in athletes treated by an anterior acromioplasty.

Shoulder pain caused by a impingement syndrome commonly affects an athletes performance. Thirty-five shoulders in 33 athletes had an impingement syndrome treated by an anterior acromioplasty after failure of conservative treatment. Thirty-one of 35 shoulders (89%) were subjectively judged improved by the patients from their preoperative status. The moderate and severe pain was reduced from 97% of the shoulders preoperation to 20% postoperation. The pain at rest and with activities of daily living was reduced from 71% of the shoulders preoperation to 9% postoperation. However, only 15 of 35 operated shoulders (43%) allowed return to the same preinjury level of competitive athletics, and only four of 18 athletes involved in pitching and throwing returned to their former preinjury status. This operation is satisfactory for pain relief but does not allow an athlete to return to his former competitive status. A prolonged rehabilitation program may improve the results.

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.

Performance Outcomes of Anterior Cruciate Ligament Reconstruction in the National Basketball Association

PURPOSE The purpose of this study was to determine the rate of return to play and to quantify the effect on the basketball players performance after surgical reconstruction of the anterior cruciate ligament (ACL). METHODS Surgical injuries involving the ACL were queried for a 10-year period (1993-1994 season through 2004-2005 season) from the database maintained by the National Basketball Association (NBA). Standard statistical categories and player efficiency rating (PER), a measure that accounts for positive and negative playing statistics, were calculated to determine the impact of the injury on player performance relative to a matched comparison group. Over the study period, 31 NBA players had 32 ACL reconstructions. Two patients were excluded because of multiple ACL injuries, one was excluded because he never participated in league play, and another was the result of nonathletic activity. RESULTS Of the 27 players in the study group, 6 (22%) did not return to NBA competition. Of the 21 players (78%) who did return to play, 4 (15%) had an increase in the preinjury PER, 5 (19%) remained within 1 point of the preinjury PER, and the PER decreased by more than 1 point after return to play in 12 (44%). Although decreases occurred in most of the statistical categories for players returning from ACL surgery, the number of games played, field goal percentage, and number of turnovers per game were the only categories with a statistically significant decrease. Players in the comparison group had a statistically significant increase in the PER over their careers, whereas the study group had a marked, though not statistically significant, increase in the PER in the season after reconstruction. CONCLUSIONS After ACL reconstruction in 27 basketball players, 22% did not return to a sanctioned NBA game. For those returning to play, performance decreased by more than 1 PER point in 44% of the patients, although the changes were not statistically significant relative to the comparison group. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Correctable elbow lesions in professional baseball players: a review of 25 cases.

In a retrospective study, 20 of 25 professional baseball pitchers (mean age, 24 years; range, 19 to 28 years) who had had a reconstructive surgical procedure on the dominant elbow had satisfactory results (able to return to competitive throwing for one full season or more after surgery). Gentle motion was initiated 1 week after the operation on each patient. Exercises for mobilization and muscle strengthening of grip, arm, and shoulder were increased until throwing was initiated 10 to 12 weeks postoperatively. Throwing was gradually increased over several weeks from 30 feet at no more than half speed for 15 min to 60 feet at three-quarter speed. Pitchers were instructed to warm up before throwing and warm down and to continue this practice after they began competitive throwing. The longest period of follow-up has been 4 years (mean, 2.8 years). Four of the 25 pitchers had unsatisfactory results (released from their team in less than one full season because of ineffective pitching and were not picked up by another team). The cause of the release of the other patient-player is controversial. This 25- patient group is too small and the follow-up period is too short for definite conclusions. Our evidence does suggest that surgi cal procedures directed at medial soft tissue and posterior intra-articular changes carry better prognosis for competitive throwers than other procedures. The radiohumeral articular condition should be evaluated at surgery.

Posterior shoulder lesions in throwing athletes

Posterior shoulder lesions have terminated the careers of throwing athletes. We wish to present four case reports of posterior shoulder lesions which underwent operative intervention in an attempt to alleviate the individual’s symptomatology and permit a return to throwing. The four cases are those of active professional baseball players whose careers were all but terminated due to intractable posterior shoulder symptoms during and after throwing. None of the individuals responded to multiple conservative regimens. The basic operative approach in the four cases (F. W. J., primary surgeon) was as follows: with the patient prone and the involved extremity draped free, an incision was made over the scapula spine laterally; the deltoid was reflected from

The modified Bristow-Helfet procedure for recurrent anterior shoulder subluxations and dislocations

A review of 107 cases in which the Bristow-Helfet procedure was done for recurrent anterior shoulder subluxation and dislocation is presented. The redis location rate was 2% with very few complications. Eighty-nine percent of the patients were satisfied with the procedure. Mean loss of external rotation was 12.6°. Six of the 41 patients with dominant shoulder surgery were capable of throwing in the same manner as they did prior to injury. Five of 24 patients (21 %) with a diagnosis of recurrent anterior subluxation con tinued to have symptoms of instability following sur gery. Associated symptoms of posterior or voluntary subluxation may preclude a satisfactory result.

Gore-Tex prosthetic Ligament in Anterior Cruciate Deficient Knees

Reconstruction for symptomatic anterior cruciate defi cient knees has yielded varying success rates. Pros thetic cruciate replacement has recently become a po tentially attractive alternative. The results of the Gore- Tex polytetrafluoroethylene ligament, which is intended as a permanent replacement, are reported. Eighty-two patients were followed prospectively, mean age was 28 years (range, 16 to 51 years) and mean followup was 18 months (range, 12 to 30 months). Subjective scores improved in all categories, including pain, swelling, giving way, locking, and stair climbing. All patients without complications had no episodes of actual giving way, considered themselves improved, and returned to activities of daily living at 3 weeks and athletics at 8 months. Range of motion lacking at 3 months was 2° of extension and 10° of flexion, and at 12 months was 0° of extension and 4° of flexion. All mean objective data, including the anterior drawer, Lachman, and pivot shift, demonstrated im provement at final followup. Cybex testing revealed improvement in relative quadriceps strength from 88% to 99%. The KT-1000 Arthrometer showed improve ment in the injured-normal knee difference score throughout the follow-up period. Of importance is that while final objective data was improved over initial data, an early nonprogressive shift toward loosening was indicated by worsening of the drawer, Lachman, pivot shift, and KT-1000 scores. This shift may be attributed to resorption of interposed soft tissue, creep, or loosening of the graft. Subjective scores remained stable after improving. Complications included four ruptures, four chronic sterile effusions with partial attenuation, one infection, and one symptomatic loose body. There were 14 re- operations (17%), a total of 15 complications (18%), and 7 permanent complications (8%). There were no deaths, pulmonary emboli, or medical complications. We feel that the Gore-Tex ligament may become a rational alternative for anterior cruciate reconstruction in selected cases of prior reconstructive failure or older, less active individuals with symptomatic instability. Sur gical dissection is minimal, with maintenance of autog enous tissues yielding rapid recovery and low morbidity. The results presented are based upon preliminary data, and indications for expanded use of the ligament and definitive conclusions regarding the natural history of the graft will have to await further long-term followup.

Stress fractures of the femur in runners

Early diagnosis, followed by conservative manage ment, permitted five of six long-distance runners to return to running after they had suffered stress frac tures of the femur. The sixth patient developed a displaced fracture of the femoral neck which was openly reduced and internally fixated at surgery: this athlete returned to marathoning one year later. In the series there were two fractures of the femoral neck and four of the proximal medial shaft of the femur. Although early diagnosis depends upon a complete history, physical examination and x-ray film results, bone scanning is a further aid when x-ray films still do not confirm the presumptive diagnosis.

Iliotibial band transfer for anterolateral rotatory instability of the knee. Summary of 54 cases.

Forty-eight patients who underwent distal iliotibial band trans fer (Ellison) for anterolateral rotatory instability and who were over 1 year postsurgery presented for examination and an additional six patients completed a written subjective evalua tion. Five patients only had isolated lateral surgery. In 33 patients there was an additional diagnosis of anteromedial rotatory instability. Of the patients 44% had had no previous surgery, while 36% had undergone one procedure and 19% had undergone more than one procedure. In combination with iliotibial band transfer, 74% had a lateral meniscectomy, 44% had a capsular reefing, 38% had a medial meniscectomy, 44% had a pes anserinus transfer, and 8 patients had prosthetic cruciate ligament replacement. In these eight patients, five prosthetic ligaments had fractured and were included but three were intact and were excluded. Thirty-four percent of the patients were initially injured in football. All patients had thorough knee and radiographic examinations; strength mea surements by using the Cybex testing for knee extension; flexion and external rotation; and completed a subjective ques tionnaire. Of the patients 87% responded that they were im proved and thought the surgery was worthwhile. Ninety-one percent had positive jerk tests preoperatively but only 46% were positive at followup. However, while 53% reported no episodes of giving way, 28% reported monthly episodes, 9% weekly episodes, and 8% daily episodes. Only 15% had no difficulty cutting while 55% had some and 26% had extreme difficulty or were unable to do so. Only 23% reported no difficulty with jumping, but 48% had some difficulty, and 30% were unable to jump and had extreme difficulty jumping. Only 28% of patients had returned to their desired level of activity while 46% had reached only 50% of their desired level. Only 13% expressed complete confidence in the knee while 21 (46%) were in the 75 to 90% confidence range, while 22% had less than 50% confidence. Of the patients 29% had lost extension and 57% had lost flexion. Ninety-one percent had increased varus (adduction) instability at followup, but this did not appear to have clinical significance. On follow-up x-ray films 70% had osteophyte formation, 65% had joint space narrowing, 46% had pain requiring aspirin. Eighty percent had atrophy averaging 1.72 cm. Thirty percent had tenderness at Gerdys tubercle. As in all studies involving the knee ligaments, the many variables are dependent and poor results do not reflect failure of this one part of treatment. No patient was made worse by the procedure; there appears to be defmite reduction in anterolateral rotatory instability after iliotibial band transfer, which was maintained for more than 1 year after surgery.

Epidemiology of Isolated Meniscal Injury and Its Effect on Performance in Athletes From the National Basketball Association

Background: The current incidence and outcomes of meniscal injury have not been quantified in professional athletes. Purpose: To describe the incidence, risk, amount of time lost, and effect on performance for isolated meniscal injury in athletes from the National Basketball Association (NBA). Demographic factors predicting the risk of meniscal tears and the effect of injury in return to play were also investigated. Study Design: Descriptive epidemiology study. Methods: A centralized database was queried to identify meniscal injuries occurring in the NBA over 21 seasons. The frequency of injury, time lost, game exposures, and incidence, rate, and risk were calculated. The preinjury and postinjury player efficiency rating (PER) was used to identify changes in player performance. Results: We identified 129 isolated meniscal tears in NBA athletes during a 21-season span. From this number, 77 (59.7%) involved the lateral meniscus and 52 (40.3%) the medial meniscus. Injuries occurred more frequently in games. The lateral meniscus had a statistically significant higher injury rate. Both left and right knees were equally affected. The number of days missed for lateral meniscal tears and medial meniscal tears was 43.8 ± 35.7 days and 40.9 ± 29.7 days, respectively, and was not statistically different. There was a significant inverse relationship between age and rate of lateral meniscal tears, with lateral meniscal tears more likely to occur up to age 30 years; beyond that medial meniscal tears were more common. Players with a body mass index (BMI) greater than 25 had a significantly increased risk of meniscal tears compared with players with a BMI less than 25, specifically with an increased risk of lateral meniscal tears. Twenty-five players (19.4%) did not return to play. For those who did, upon returning to competition, there was no statistical change in PER from their preinjury status, and the mean number of seasons completed was 4.1 ± 3.7 seasons. Conclusion: The lateral meniscus is more frequently torn than the medial meniscus, but there was no difference in the amount of playing time lost. Both right and left knees were equally affected. There was an inverse relationship between age and the rate of lateral meniscal tears. Risk of tears was increased in players having a BMI greater than 25. Injury did not negatively affect playing performance.