Tyler S. Pidgeon

Trends in Revision Elbow Ulnar Collateral Ligament Reconstruction in Professional Baseball Pitchers.

PURPOSE To determine the frequency of revision elbow ulnar collateral ligament (UCL) reconstruction in professional baseball pitchers. METHODS Data were collected on 271 professional baseball pitchers who underwent primary UCL reconstruction. Each player was evaluated retrospectively for occurrence of revision UCL reconstructive surgery to treat failed primary reconstruction. Data on players who underwent revision UCL reconstruction were compiled to determine total surgical revision incidence and revision rate by year. The incidence of early revision was analyzed for trends. Average career length after primary UCL reconstruction was calculated and compared with that of players who underwent revision surgery. Logistic regression analysis was performed to assess risk factors for revision including handedness, pitching role, and age at the time of primary reconstruction. RESULTS Between 1974 and 2014, the annual incidence of primary UCL reconstructions among professional pitchers increased, while the proportion of cases being revised per year decreased. Of the 271 pitchers included in the study, 40 (15%) required at least 1 revision procedure during their playing career. Three cases required a second UCL revision reconstruction. The average time from primary surgery to revision was 5.2 ± 3.2 years (range, 1-13 years). The average length of career following primary reconstruction for all players was 4.9 ± 4.3 years (range, 0-22 years). The average length of career following revision UCL reconstruction was 2.5 ± 2.4 years (range, 0-8 years). No risk factors for needing revision UCL reconstruction were identified. CONCLUSIONS The incidence of primary UCL reconstructions among professional pitchers is increasing; however, the rate of primary reconstructions requiring revision is decreasing. Explanations for the decreased revision rate may include improved surgical technique and improved rehabilitation protocols. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Triangular Fibrocartilage Complex

The triangular fibrocartilage complex is a multifaceted ligamentous structure providing support to the ulnocarpal articulation. Improved understanding of the complicated anatomy of the triangular fibrocartilage complex coupled with recent advances in surgical techniques will improve orthopaedic care. The triangular fibrocartilage complex supports the ulnar side of the wrist, provides stability to the distal radioulnar joint, and is the most common source of ulnar-sided wrist pain when injured1-3. Knowledge of the anatomy, biomechanics, and pathology of the triangular fibrocartilage complex has increased greatly over the last three decades, leading to increased awareness of this structure among physicians4. In one cadaveric study, more than half (thirty-two) of sixty-one specimens had perforations of the triangular fibrocartilage complex5. All specimens with tears had evidence of damage to the lunate and/or distal ulnar cartilage, illustrating that damage to the triangular fibrocartilage complex and subsequent instability of the distal radioulnar joint can be associated with ulnolunate abutment5. This was reiterated by Lee et al., who found that the majority (fifty-eight) of ninety-six cadaveric specimens (average age at the time of death, seventy-five years) had disruption …

Analysis of mortality and fixation failure in geriatric fractures using quantitative computed tomography

OBJECTIVES While osteoporosis has been shown to be a contributing factor in low energy fractures in the elderly, limited data exists regarding the correlation of bone mineral density (BMD) and T-Scores to mortality and failure of fracture fixation. This study seeks to determine the relationship between femoral neck BMD in elderly patients with typical geriatric fractures and mortality and fracture fixation failure using Quantitative Computed Tomography (QCT). MATERIALS AND METHODS Patients over the age of 65 who sustained fractures of the proximal humerus, distal radius, pelvic ring, acetabulum, hip, proximal tibia, and ankle who also underwent a CT scan that included an uninjured femoral neck were retrospectively reviewed. QCT was used to assess bone mineral density and T scores. Mortality and fixation failure were recorded. Standard descriptive statistics, as well as logistic regression were used to correlate BMD and mortality, and BMD and fixation failure. RESULTS Of the 173 patients initially screened, 150 met inclusion criteria. Patients who remained alive at the end of the study (LP) had significantly (P = .019) higher adjusted mean femoral neck BMD (0.502 g/cm2) than non-polytrauma patients who died (MNPT) (0.439 g/cm2) when controlling for age, time to mortality, follow up, CCI, and ASA. Patients who had fixation failure events (FE) had significantly (P = .002) lower adjusted mean femoral neck BMD (0.342 g/cm2) than patients without failure events (NE) (0.525 g/cm2) when controlling for age and time to radiographic follow-up. CONCLUSIONS Our study illustrates that QCT is a reliable method for the determination of femoral neck BMD in elderly patients with geriatric fractures. Furthermore, lower BMD/T-Scores are associated with increased mortality and fixation failures in this patient population.

Understanding Multiple Sclerosis: Essentials for the Orthopaedic Surgeon.

Multiple sclerosis is an inflammatory disorder that primarily affects the central nervous system and ultimately causes widespread neurodegeneration and axonal injury, leading to motor and sensory disability1,2. Multiple sclerosis has secondary effects on the musculoskeletal system that present challenges to the orthopaedic surgeon. Understanding multiple sclerosis will assist the surgeon in caring for these patients. The pathophysiology of the disease is not fully understood; however, research recently has focused on T-cell-mediated autoimmune mechanisms2. The disease primarily damages the myelin sheath of nerves in the brain and central nervous system and manifests clinically by affecting vision, balance, muscle strength and endurance, and mobility3. Multiple sclerosis is highly variable and may follow three distinct courses: relapse and remission (acute exacerbations followed by remissions), primary progression (gradual worsening over time), and secondary progression (relapse and remission followed by gradual progression)1. All patients with multiple sclerosis have worsening of the symptoms; approximately 20% of patients have a primarily progressive course whereas 65% have a relapse-and-remission course or a secondarily progressive course1. Among those who have a relapse-and-remission course, 50% develop a secondarily progressive course within ten years after diagnosis; virtually all will eventually have progression2. More than 400,000 individuals in the United States and >2,000,000 individuals worldwide have multiple sclerosis, and three to seven individuals per 100,000 are newly diagnosed each year1,2. Multiple sclerosis tends to occur in patients between the ages of twenty and …

Upper Extremity Arthroplasty

With improvements in techniques and implants, upper extremity arthroplasty is becoming increasingly popular. Total shoulder arthroplasty has been demonstrated to be effective in patients with osteoarthritis and reverse total shoulder arthroplasty has become a viable option in such patients with concomitant rotator cuff deficiency. Arthroplasty of the elbow, wrist, and finger joints also have roles in the treatment of multiple arthritic conditions.

Lower Extremity Tibial Plateau Fractures

Tibial plateau fractures are seen in both young patients with high-energy mechanisms and older patients with lower energy mechanisms. They may involve one or both sides of the tibial plateau and can extend into the metaphysis separating the articular surface from the tibial shaft. They can be associated with meniscus tears, compartment syndrome, and even vascular injuries. Displaced fractures of the tibial plateau are often treated with open reduction and internal fixation.

Lower Extremity Tibia and Fibula Shaft Fractures

Tibia and fibula fractures can occur in both high-energy and low-energy mechanisms and are among the most common long-bone fractures. Due to the subcutaneous nature of the medial tibia, this bone is often associated with open fractures. Compartment syndrome is also a concern in patients with tibia and fibula factures. Treatment can range from casting, to intramedullary nailing, to plating, to external fixation depending on the location and type of fracture.

Finger (Phalangeal) Dislocations

Proximal interphalangeal and distal interphalangeal joint dislocations are relatively common injuries of the hand. When untreated or under-treated, these dislocations can result in permanent deformities of the digit such as swan neck and boutonniere deformities. Treatment can range from nonoperative splinting or taping to various open procedures.

Upper Extremity Physical Exam

Examination of the upper extremity is a critical component in the diagnosis and ultimate treatment of conditions which affect the arm and hand. While advanced imaging and other testing such as EMG have an increasing role in diagnosis, physical exam remains the cornerstone of the discovery of upper extremity pathology.

Ulnar Styloid Base Fractures Cause Distal Radioulnar Joint Instability in a Cadaveric Model

Background: The deep portion of the distal radioulnar ligaments (DRUL) inserts on the ulnar fovea and is the most important stabilizer of the distal radioulnar joint (DRUJ). Ulnar styloid base fractures that include the ulnar fovea may cause DRUJ instability. Methods: DRUJ stability in pronosupination was evaluated in 12 fresh-frozen upper extremities (4 female) aged 52 to 68 years (mean: 58.8 years) using a custom fixture, which allowed free rotation of the radius around the fixed ulna. Optical motion capture was used to record rotation of the radius with respect to the ulna. Each specimen was subjected to 3 N m of torque in both supination and pronation under 4 conditions: intact, ulnar styloid osteotomy with disruption of the foveal insertion of the DRUL, ulnar styloid fixation, and DRUL transection. Group differences were compared using a 1-way repeated-measures analysis of variance and Tukey multiple comparison post hoc tests. Results: When compared with the intact condition, both ulnar styloid osteotomy and DRUL transection significantly increased mean pronation (by 9.40° and 15.21°, respectively) and supination (by 9.05° and 17.42°, respectively) of the forearm. Screw fixation only significantly reduced pronation compared with osteotomy (by 2.62°). Screw fixation did not significantly affect supination. Conclusions: Ulnar styloid fractures that disrupt the fovea cause instability of the DRUJ in pronation and supination under 3 N m of torque in a cadaveric model. Screw fixation of ulnar styloid base fractures achieves anatomic reduction; however, it only partially returns rotational stability acutely to the DRUJ and only during pronation.