Stephen M. Gryzlo

Efficacy of Surgical Preparation Solutions in Shoulder Surgery

BACKGROUND Deep infection following shoulder surgery is a rare but devastating problem. The use of an effective skin-preparation solution may be an important step in preventing infection. The purposes of the present study were to examine the native bacteria around the shoulder and to determine the efficacy of three different surgical skin-preparation solutions on the eradication of bacteria from the shoulder. METHODS A prospective study was undertaken to evaluate 150 consecutive patients undergoing shoulder surgery at one institution. Each shoulder was prepared with one of three randomly selected solutions: ChloraPrep (2% chlorhexidine gluconate and 70% isopropyl alcohol), DuraPrep (0.7% iodophor and 74% isopropyl alcohol), or povidone-iodine scrub and paint (0.75% iodine scrub and 1.0% iodine paint). Aerobic and anaerobic cultures were obtained prior to skin preparation for the first twenty patients, to determine the native bacteria around the shoulder, and following skin preparation for all patients. RESULTS Coagulase-negative Staphylococcus and Propionibacterium acnes were the most commonly isolated organisms prior to skin preparation. The overall rate of positive cultures was 31% in the povidone-iodine group, 19% in the DuraPrep group, and 7% in the ChloraPrep group. The positive culture rate for the ChloraPrep group was lower than that for the povidone-iodine group (p < 0.0001) and the DuraPrep group (p = 0.01). ChloraPrep and DuraPrep were more effective than povidone-iodine in eliminating coagulase-negative Staphylococcus from the shoulder region (p < 0.001 for both). No significant difference was detected among the agents in their ability to eliminate Propionibacterium acnes from the shoulder region. No infections occurred in any of the patients treated in this study at a minimum of ten months of follow-up. CONCLUSIONS ChloraPrep is more effective than DuraPrep and povidone-iodine at eliminating overall bacteria from the shoulder region. Both ChloraPrep and DuraPrep are more effective than povidone-iodine at eliminating coagulase-negative Staphylococcus from the shoulder.

The Professional Athlete Spine Initiative: outcomes after lumbar disc herniation in 342 elite professional athletes.

BACKGROUND CONTEXT Although clinical outcomes after lumbar disc herniations (LDHs) in the general population have been well studied, those in elite professional athletes have not. Because these athletes have different measures of success, studies on long-term outcomes in this patient population are necessary. PURPOSE This study seeks to define the outcomes after an LDH in a large cohort of professional athletes of American football, baseball, hockey, and basketball. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE A total of 342 professional athletes from four major North American sports from 1972 to 2008 diagnosed with an LDH were identified via a previously published protocol. Two hundred twenty-six players underwent lumbar discectomy, and 116 athletes were treated nonoperatively. Only those players who had at least 2 years of follow-up were included. OUTCOME MEASURES Functional outcome measures as defined by successful return-to-play (RTP), career games, and years played for each player cohort were recorded both before and after treatment. Conversion factors based on games/regular season and expected career length (based on individual sport) were used to standardize the outcomes across each sport. METHODS Using Statistical Analysis Software v. 9.1, outcome measures were compared in each cohort both before and after treatment using linear and mixed regression analyses and Cox proportional hazards models. A Kaplan-Meier survivorship curve was calculated for career length after injury. Statistical significance was defined as p<.05. RESULTS After the diagnosis of an LDH, professional athletes successfully returned to sport 82% of the time, with an average career length of 3.4 years. Of the 226 patients who underwent surgical treatment, 184 successfully returned to play (81%), on average, for 3.3 years after surgery. Survivorship analysis demonstrated that 62.3% of players were expected to remain active 2 years after diagnosis. There were no statistically significant differences in outcome in the surgical and nonoperative cohorts. Age at diagnosis was a negative predictor of career length after injury, whereas games played before injury had a positive effect on outcome after injury. Major League Baseball (MLB) players demonstrated a significantly higher RTP rate than those of other sports, and conversely, National Football League (NFL) athletes had a lower RTP rate than players of other sports (p<.05). However, the greatest positive treatment effect from surgery for LDH was seen in NFL players, whereas for MLB athletes, a lumbar discectomy led to a shorter career compared with the nonoperative cohort (p<.05). CONCLUSIONS Professional athletes diagnosed with an LDH successfully returned to play at a high rate with productive careers after injury. Whereas older athletes have a shorter career length after diagnosis of LDH, experienced players (high number of games played) demonstrate more games played after treatment than inexperienced athletes. Notably, surgical treatment in baseball players led to significantly shorter careers, whereas for NFL athletes, posttreatment careers were longer than those of the corresponding nonoperative cohort. The explanation for this is likely multifactorial, including the age at diagnosis, respective contractual obligations, and different physical demands imposed by each individual professional sport.

Nerve Block of the Infrapatellar Branch of the Saphenous Nerve in Knee Arthroscopy A Prospective, Double-Blinded, Randomized, Placebo-Controlled Trial

BACKGROUND With the rising use of outpatient knee arthroscopy over the past decade, interest in peripheral nerve blocks during arthroscopy has increased. Femoral nerve blocks are effective but are associated with an inherent risk of the patient falling postoperatively because of quadriceps weakness. We studied blocks of the infrapatellar branch of the saphenous nerve, which produce analgesia in the knee that is similar to that resulting from a femoral nerve block but without associated quadriceps weakness. METHODS Thirty-four patients were enrolled into each arm of this prospective, randomized, double-blinded trial comparing 10 mL of 0.25% bupivacaine used as a block of the infrapatellar branch of the saphenous nerve with a placebo during simple knee arthroscopy. Immediate outcome measures included Numeric Rating Scale (NRS) pain scores (0 to 10 points), mobility and discharge times, opioid usage, subjective adverse side effects, and forty-eight-hour anesthesia recovery surveys. Short-term measures included one-week and twelve-week Lysholm knee scores. RESULTS No adverse effects or increased quadriceps weakness were observed following use of the nerve block. Improvement in early NRS scores and subjective nausea (p = 0.03) were detected. Patients for whom the block was successful also had improved twelve-week Lysholm knee scores (p = 0.04). No differences in opioid usage, mobility time, forty-eight-hour anesthesia recovery scores, or one-week Lysholm knee scores were found. CONCLUSIONS No significant adverse effect or disadvantage was identified for blocks of the infrapatellar branch of the saphenous nerve used in simple knee arthroscopy. In addition to decreased early NRS scores and nausea, blocks of the infrapatellar branch of the saphenous nerve demonstrated potential benefit at twelve weeks after simple knee arthroscopy.

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.

Effects of Lumbar Disk Herniation on the Careers of Professional Baseball Players

Outcomes after lumbar disk herniation in baseball athletes are currently unknown. It has been postulated that the repetitive torque-producing motions of a baseball player may have negative implications after a disk injury. Sixty-nine lumbar disk herniations (40 treated operatively, 29 nonoperatively) in 64 professional baseball players were identified, and important outcome measures including successful return to play, time to recovery, career longevity, and performance based on vital statistics to each position were documented. Ninety-seven percent of baseball athletes successfully returned to play at an average of 6.6 months after diagnosis. Athletes treated operatively required significantly more time to return to play than those managed nonoperatively (8.7 vs 3.6 months, respectively; P<.0001).

Changes in pitching mechanics after ulnar collateral ligament reconstruction in major league baseball pitchers

BACKGROUND Medial ulnar collateral ligament (UCL) reconstruction is a common procedure performed on Major League Baseball pitchers. Variations in pitching mechanics before and after UCL reconstructive surgery are not well understood. METHODS Publicly available pitch tracking data (PITCHf/x) were compared for all Major League Baseball pitchers who underwent UCL reconstruction between 2008 and 2013. Specific parameters analyzed were fastball percentage, release location, velocity, and movement of each pitch type. These data were compared before and after UCL reconstructive surgery and compared with a randomly selected control cohort. RESULTS There were no statistically significant changes in pitch selection or pitch accuracy after UCL reconstruction, nor was there a decrease in pitch velocity. The average pitch release location for 4-seam and 2-seam fastballs, curveballs, and changeups is more medial after UCL reconstruction (P < .01). Four-seam fastballs and sliders showed decreased horizontal breaking movement after surgery (P < .05), whereas curveballs showed increased downward breaking movement after surgery (P < .05). CONCLUSIONS Pitch selection, pitch velocity, and pitch accuracy do not significantly change after UCL reconstruction, nor do players who require UCL reconstruction have significantly different pitch selection, velocity, or accuracy than a randomly selected control cohort. Pitch release location is more medial after UCL reconstruction for all pitch types except sliders. Breaking movement of fastballs, sliders, and curveballs changes after UCL reconstruction.

Arthroscopic Treatment of Type II Superior Labral Anterior to Posterior (SLAP) Lesions in a Younger Population: Traditional Repair versus Biceps Tenodesis with Accelerated Rehabilitation

Objectives: Biceps tenodesis is a viable surgical alternative to repair for type II SLAP lesions in an older population; however, its efficacy in a younger population is not well studied. The objective of this study was to compare clinical outcomes between arthroscopic biceps tenodesis and labral repair for type II SLAP lesions in a young active population. Methods: Patients aged 15 to 40 who underwent primary arthroscopic shoulder surgery for type II SLAP tear between 2009 and 2015 with either a suprapectoral biceps tenodesis or labral repair were included in the study. Shoulders with intraarticular chondral damage, full thickness rotator cuff tear or rotator cuff repair, labral repair outside of the superior labrum, bony subacromial decompression, and acromioclavicular joint resection were excluded. Patient-reported outcomes (PRO) pre-operatively and at a minimum of one year after surgery were evaluated using the American Shoulder and Elbow Surgeons (ASES) score, Disabilities of the Arm, Shoulder, and Hand Sports/Performing Arts Module (DASH-sport), visual analog scale (VAS) for pain, and patient satisfaction. Complications and reoperation rates were also recorded. Statistical comparisons between the two groups were performed using the student t-test and chi-squared test with an alpha level of 0.05 indicating statistical significance. Results: Fifty-three patients were available for follow-up at an average of 3.2 years (range: 1.0-6.5 years). Twenty underwent biceps tenodesis and 33 underwent repair. Pre-operatively, there were no significant differences in mean ASES, DASH-sport, and VAS between biceps tenodesis and repair groups. Both groups had significant postoperative improvement in all PROs, and the average amount of change from preoperative to postoperative scores between the two groups was not significantly different for any of the PRO scores. Post-operatively, there were no significant differences in mean ASES, DASH-sport, VAS, and satisfaction between biceps tenodesis and repair groups (ASES: biceps tenodesis 87.1 vs. repair 86.9, P=0.97; DASH-sport: 17.0 vs. 19.5, P=0.75; VAS: 1.8 vs. 1.6, P=0.73; Satisfaction: 8.6 vs. 8.2, P=0.45). Rate of return to pre-injury level of play in sport/physical activity was also similar between groups (biceps tenodesis 55% vs. repair 50%, P=0.73). In the repair group, there was one minor complication involving a superficial paresthesia, and one other patient required reoperation (capsular release) after two years for persistent difficulty throwing in softball. There were no complications or reoperations in the biceps tenodesis group. Conclusion: In a young active population, biceps tenodesis may be a viable surgical alternative for type II SLAP lesions and may facilitate earlier return to activity compared to repair. Further research, particularly prospective randomized studies with longer time to follow-up, is warranted given the limitations of this preliminary study.

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 …

Prophylactic Ankle Taping Effects on Knee Joint Kinematics During Lateral-Cutting and Jump Landing in an Open Field Environment in Female Division I Soccer Athletes

Objective: Ankle taping has become standard procedure in many athletic events with the hope of preventing ankle instability. A number of studies have investigated the effects of ankle taping on the knee joint; however, to our knowledge, no study has collected data in an open-field environment. This is the first study to evaluate the effects of ankle taping on knee joint motion during open field cutting and off-axis vertical jump landings by using wireless inertial sensors. Methods: Fifteen (mean: 19.8 years) NCAA Division I female soccer athletes were recruited. Wireless motion-detecting sensors were placed on the leg, thigh and low back of each subject. Data was collected at the knee while the subjects performed unanticipated lateral-cutting maneuvers, at 3⁄4 maximum speed, with and without ankle tape. Knee kinematics were also recorded when landing onto a slant board from a vertical jump with and without ankle tape. Results: During unanticipated lateral cutting, immobilization of the ankle joint with tape significantly reduced peak varusvalgus moments at the knee joint (8.3%, p=0.0264). Ankle taping also significantly reduced (8.4%, p=0.0315) peak external knee rotation. During the jump landing trials, subjects with ankle taping demonstrated a significant (7.7%, p=0.041) decrease in knee joint flexion. Conclusion: The authors conclude that prophylactic ankle taping significantly reduces knee varus-valgus movements and knee rotation during lateral-cutting while running in an open field environment. The jump landing trials demonstrate a significant decrease in knee flexion with prophylactic ankle taping. Our data suggests that immobilization of the ankle with tape has a potentially protective effect on the knee joint during lateral-cutting tasks but may exacerbate damaging knee kinematics during uneven jump landings in female athletes.