Bicompartmental Bucket Handle Meniscal Tear with Chronic ACL Deficiency Causing a Rare Triple PCL and Triple Cruciate Sign: A Case Report

CASE

A 16-year-old football player presented with chronic ACL deficiency along with bicompartmental bucket handle meniscal tears.

CONCLUSION

We present a "triple cruciate" sign in addition to the triple posterior cruciate ligament (PCL) sign seen on Magnetic Resonance Imaging (MRI) to aid in diagnosing this injury.

Innate Arthroscopic & Laparoscopic Surgical Skills: A Systematic Review of Predictive Performance Indicators Within Novice Surgical Trainees

OBJECTIVE

To query the literature for predictive factors for performance on arthroscopic and laparoscopic surgical simulators in novice surgical trainees. These predictive factors may prove a valuable tool in identifying certain innate potential to becoming a future skilled surgeon that could benefit both surgical residency candidates and program directors alike, while also improving patient care.

DESIGN

Systematic Review.

RESULTS

The initial searches yielded 249 articles. After screening titles/abstracts and implementing inclusion and exclusion criteria, 36 studies were included in the final systematic review.

CONCLUSIONS

Current literature suggests that video game experience/frequency, psychomotor and visuospatial aptitude, and perceptual ability are among the most promising predictive indicators of baseline simulator performance. Study limitations include utilization of different standards for characterizing predictive factors. Future studies should aim to utilize standard guidelines for accurate quantification of innate predictive factors. Future research should also focus on utilizing standardized simulator platforms and aptitude tests to allow for more accurate cross-study comparisons and meta-analyses with larger sample sizes.

Regional Interdependence and the Role of the Lower Body in Elbow Injury in Baseball Players: A Systematic Review

BACKGROUND

Elbow injuries are exceedingly common in baseball players. Previous studies have identified that upper extremity strength and range of motion deficits pose a risk for these injuries, but few studies have examined the effect of lower extremity deficits. Given the role of the lower extremity in the kinetic chain of the baseball throwing motion, lower body deficits may affect the kinematics of the upper extremity and play a role in the elbow injury of baseball players.

PURPOSE

To systematically review the current literature investigating the association of trunk and lower extremity deficits with elbow pain or injury in baseball players.

STUDY DESIGN

Systematic review.

METHODS

A systematic review of the literature was performed according to the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines to identify and analyze all previous studies focused on the association of elbow pain and/or injury with functional deficits of the trunk and lower extremities.

RESULTS

A total of 14 studies met inclusion criteria, examining a range of baseball players extending from youth to professional athletes. One of the 14 studies examined other types of overhead throwing athletes alongside baseball players. Lower extremity-related risk factors for elbow pain and injury in these athletes were found and stratified per level of play. Factors included specific hip range of motion, lower extremity injury or pain, balance, and foot arch posture. Associations were also found with lower extremity injury and noncompliance with primary prevention programs.

CONCLUSION

Specific lower extremity deficits were found to be independent risk factors for elbow pain and injury in throwing athletes at certain levels of play. Additionally, prevention programs designed to correct deficits in identified risk factors were effective in reducing the incidence of elbow injury in youth athletes. These results highlight the potential of screening and subsequent intervention to reduce the incidence of elbow injury in certain subsets of baseball players.

Predictors of Performance on the Arthrobox Arthroscopy Simulator for Medical Students

Purpose

The purpose of this study was to analyze the effects of past participation in athletics, the playing of musical instruments and video games and other variables on medical students’ performance on an arthroscopic simulator task as well as other assessments of visuospatial ability.

Methods

We assessed 50 medical students by using previously validated tests of manual dexterity and spatial reasoning as well as performance on an arthroscopic surgical simulator. Inclusion criteria were to be 18 years of age or older and to be a student studying in the M.D. program at a single public state university. Exclusion criteria were previous use of an arthroscopic surgery training device or active participation in an actual arthroscopic surgery, defined as participating as a surgeon, resident trainee, physician’s assistant, or other similarly credentialed professional. Students were also assessed by the use of a high-fidelity ultrasound simulator as a marker of visuospatial capacity. Students were then surveyed about lifestyle characteristics and personal attributes hypothesized to predict surgical skill, such as playing sports, instruments or video games.

Results

A total of 49 participants were included in this study. High levels of athletic experience were significantly associated with improved performance on the arthroscopic surgical simulator (P = .008). Participants with higher levels of athletic experience were more likely to achieve competence on the arthroscopic surgical simulator (P = .006). Scores on the arthroscopic simulator task were significantly correlated with both ultrasound simulator shape-identification task scores and masked mirror-tracing task scores, as independent measures of visuospatial ability (P = .015 and P = .013, respectively).

Conclusions

This study provides evidence of a statistically significant correlation between increased experience in athletics and single-use test performance on an arthroscopic surgical simulator. Subjects who reported higher levels of experience in athletics were significantly more likely to achieve competence in the arthroscopic surgical simulator task. Finally, statistically significant correlations were found between subjects’ performance scores on tasks assessed by the surgical simulator, masked mirror-trace assessment and ultrasound simulator.

Clinical Relevance

Simulator-based training and education allow for the development of arthroscopic skills prior to operating on a live patient in a clinical situation. This is an area of great interest in orthopaedic education. Our study evaluates parameters in a trainee that may relate to a higher performance level in technical skills on an arthroscopic surgical simulator.

The efficacy of continuous cryotherapy on the postoperative shoulder: a prospective, randomized investigation

This prospective, randomized investigation evaluated the efficacy of cryotherapy on subjective responses after both open and arthroscopic procedures on the shoulder. Seventy patients were randomly assigned to one of two study groups: (1) continuous cryotherapy group and (2) age-matched control group. Visual analog scales were used to assess subjective responses on postoperative days 1, 7, 14, and 21. On day 1, patients receiving cryotherapy reported significantly less pain during sleep and significantly more comfort in bed and rated their sleep as more restful than the control subjects. During days 7 through 21, cryotherapy subjects reported a significant reduction in frequency and intensity of pain, as well as less pain during shoulder rehabilitation, than the control subjects. These results indicate that cryotherapy is an effective method for postoperative pain control because it decreases the severity and frequency of pain and allows a return to normal sleep patterns while increasing overall postoperative comfort and satisfaction.

Valgus laxity of the ulnar collateral ligament of the elbow in collegiate athletes

In this investigation, we determined the patterns of valgus laxity and acquired valgus laxity of the ulnar collateral ligament in the elbows of collegiate athletes involved in overhead and nonoverhead sports. Acquired valgus laxity of the elbow is defined as the differential amount of stress valgus opening between the dominant and nondominant elbows. Forty-eight asymptomatic male athletes involved in sports that require overhead arm movements (baseball, tennis, and swimming) and 88 asymptomatic male athletes involved in nonoverhead sports (track, lacrosse, fencing, and wrestling) underwent fluoroscan examination of both their elbows with (13 daN) and without (0 N) valgus stress. There were no statistically significant differences in the amount of valgus stress opening or in acquired valgus laxity between the two groups. In fact, 25% (34 of 136) of the athletes showed an acquired valgus laxity of more than 0.5 mm, and 51.5% (70 of 136) had an acquired valgus laxity that was actually negative. There was also no correlation between the number of years played and acquired valgus laxity. Our results show that acquired valgus laxity does not exist in asymptomatic athletes involved in overhead sports, and there is no threshold value of measurement indicative of acquired valgus laxity.

Acromial morphotype in the young asymptomatic athletic shoulder

Several studies have documented an association between the type III acromion and rotator cuff tears. However, controversy exists as to whether the shape of the acromion is an innate anatomic characteristic. The purpose of this study was to evaluate the prevalence of the type III acromion in young asymptomatic athletes. Bilateral supraspinatus outlet radiographs were obtained in 100 Division 1 collegiate athletes (average age, 19.9 years). Only 4 (2%) of 200 shoulders were found to have a type III acromion by use of the standard subjective Bigliani classification. Eight (4%) acromion were found to be type III by the use of previously published objective criteria for acromial measurement. Our results show the type III acromion to be relatively rare in asymptomatic, young athletes, but the incidence of type III acromion in a general population of both young and older individuals is still not completely understood. However, our results accentuate the possibility that the higher incidence of type III acromion seen in older populations may in fact be related to secondary acromial changes.

Biomechanical analysis of the deadlift during the 1999 Special Olympics World Games

PURPOSE

Improper lifting techniques may increase injury risks and decrease performance. The aim of this study was to compare and contrast biomechanical parameters between sumo and conventional style deadlifts and between high- and low-skilled lifters who participated in the powerlifting event during the 1999 Special Olympics World Games.

METHODS

Two synchronized video cameras collected 60 Hz of data from 40 subjects. Parameters were quantified at barbell liftoff (LO), when the barbell passed the knees (KP), and at lift completion.

RESULTS

Compared with the conventional group, the sumo group had a 100% greater stance width, 20% smaller hand width, 10% less vertical bar distance, a more vertical trunk at LO, a more horizontal thigh at LO and KP, a less vertical shank at KP, and greater forefoot abduction. The sumo group generated ankle dorsiflexor, knee extensor, and hip extensor moments, whereas the conventional group produced ankle plantar flexor, knee flexor and extensor, and hip extensor moments. Compared with low-skilled lifters, high-skilled lifters had a 40% greater barbell load, 15% greater stance width (sumo group only), greater knee flexion at LO (conventional group only), greater knee extension at KP, a less vertical shank position at LO (sumo group only), 15% less vertical bar distance, less first peak bar velocity between LO and KP (conventional group only), smaller plantar flexor and hip extensor moment arms at LO and KP, and greater knee extensor moment arms at LO.

CONCLUSIONS

The sumo deadlift may be more effective in working ankle dorsiflexors and knee extensors, whereas the conventional deadlift may be more effective in working ankle plantar flexors and knee flexors. High-skilled lifters exhibited better lifting mechanics than low-skilled lifters by keeping the bar closer to the body, which may both enhance performance and minimize injury risk.

Function of the long head of the biceps at the shoulder: electromyographic analysis

The purpose of this study was to delineate, through electromyographic analysis, the function of the long head of the biceps at the shoulder. Ten shoulders were examined with dynamic electromyography. The long head of the biceps was instrumented with thin wire electrodes. The supraspinatus, infraspinatus, deltoid, brachialis, and brachioradialis were instrumented as controls. Because the biceps functions primarily as a forearm supinator and elbow flexor, a long arm brace was used to lock the elbow in extension with the forearm in neutral pronation/supination. Each motion was tested in a full arc at fast (170 degrees per second) and slow (36 degrees per second) speeds and repeated with and without a 5-pound weight attached to the distal end of the brace. No electrical activity was identified in the long head of the biceps muscle in response to isolated shoulder motion with the elbow and forearm position controlled. The data demonstrate that the long head of the biceps is not active in isolated shoulder motion when the elbow and forearm are controlled. Thus, any hypothesis on bicipital function at the shoulder must be based on either a passive role of the tendon or tension in association with elbow and forearm activity.

Low-risk stress fractures

Stress fractures can occur in almost any bone in the body, with the lower extremity weightbearing bones, especially the tibia, tarsals, and metatarsals, being affected most frequently. Although the cause of these fractures is multifactoral, repetitive physical forces without adequate rest are the primary culprits. Stress fractures may be broadly classified as low-risk or high-risk injuries. Low-risk stress fractures, the topic of this review article, can be diagnosed through a thorough history, physical examination, and radiographs. Nuclear scintigraphy is occasionally necessary for confirmation, especially for fractures of the spine and pelvis. When diagnosed early and treated with restriction of activity, low-risk stress fractures have a favorable prognosis.

High-risk stress fractures: evaluation and treatment

Stress fractures are common overuse injuries seen in athletes and military recruits. The pathogenesis is multifactorial and usually involves repetitive submaximal stresses. Intrinsic factors, such as hormonal imbalances, may also contribute to the onset of stress fractures, especially in women. The classic presentation is a patient who experiences the insidious onset of pain after an abrupt increase in the duration or intensity of exercise. The diagnosis is primarily clinical, but imaging modalities such as plain radiography, scintigraphy, computed tomography, and magnetic resonance imaging may provide confirmation. Most stress fractures are uncomplicated and can be managed by rest and restriction from the precipitating activity. A subset of stress fractures can present a high risk for progression to complete fracture, delayed union, or nonunion. Specific sites for this type of stress fracture are the femoral neck (tension side), the patella, the anterior cortex of the tibia, the medial malleolus, the talus, the tarsal navicular, the fifth metatarsal, and the great toe sesamoids. Tensile forces and the relative avascularity at the site of a stress-induced fracture often lead to poor healing. Therefore, high-risk stress fractures require aggressive treatment.

An arthroscopic technique for treating patients with frozen shoulder

Forty-three patients with a diagnosis of primary or secondary frozen shoulder who had symptoms for an average of 12 months and failed conservative treatment of at least 12 weeks of physical therapy, were treated with an arthrosopic capsular release. On completion of standard shoulder arthroscopy, intra-articular cautery was used to completely divide the anterior-inferior capsule, the intra-articular portion of the subscapularis tendon, and the middle glenohumeral, the superior glenohumeral, and the coracohumeral ligaments. The subacromial space was inspected in all patients. Eighteen patients had extensive subacromial fibrosis that required debridement. Subacromial decompression was reserved for patients with evidence of an acromial spur seen at the time of arthroscopy. Postoperatively, all patients showed substantial gains in shoulder range of motion, as well as diminished shoulder pain. Thirty-five patients completed a telephone survey at an average of 22 months after surgery. The average modified shoulder score was 19 (scale, 13 to 65), with 83% of patients indicating that their shoulder was normal or caused only mild symptoms. In conclusion, the authors believe that arthroscopic capsular release is an effective and safe alternative to manipulation in patients with a recalcitrant frozen shoulder.