Camp, Christopher L.

Abstract Reconstruction of the lateral ulnar collateral ligament of the elbow is the primary treatment for recurrent symptomatic posterolateral rotatory instability. Although a number of lateral ulnar collateral ligament reconstruction techniques have been described, the docking technique has received general acceptance. In this technique, the graft is passed through a tunnel on the ulnar side and the 2 free limbs are docked into the humerus at the isometric point on the lateral condyle. Advantages of this method of reconstruction include reduced bone removal, decreased soft tissue damage, and precise control of graft tensioning. When precise surgical steps are followed, this technique can be performed in a reliable, efficient, and reproducible manner for patients with posterolateral rotatory instability of the elbow. Technique Video video See video under supplementary data.

Background: Although sliding occurs frequently in professional baseball, little is known about the epidemiology and effect of injuries that occur during sliding in this population of elite athletes. Purpose: To describe the incidence and characteristics of sliding injuries, determine their effect in terms of time out of play, and identify common injury patterns that may represent appropriate targets for injury prevention programs in the future. Study Design: Descriptive epidemiologic study. Methods: All offensive sliding injuries occurring in Major League Baseball (MLB) and Minor League Baseball (MLB) that resulted in time out of play during a span of 5 seasons (2011-2015) were identified. In addition to player demographics, data extracted included time out of play, location on field where injury occurred, level of play, treatment (surgical vs nonsurgical), direction of slide (head vs feet first), body region injured, and diagnosis. Descriptive statistics were used to describe the distribution of these injuries, and injury rates were calculated per slide. Results: From 2011 to 2015, 1633 injuries occurred as a result of a slide. The total number of days missed per season was 4263. Surgical intervention was required for 134 (8.2%) injuries, and the mean days missed was 66.5 for players treated surgically and 12.3 days for players treated nonoperatively ( P < .001). MLB players were more likely than MiLB players to require surgical intervention (12.3% vs 7.5%, P = .019). Injuries to the hands/fingers represented 25.3% of all injuries and 31.3% of those requiring surgery. Although the majority of injuries occurred at second base (57%), the per-slide injury rate was similar across all bases ( P = .991). The estimated overall frequency of injury in MLB was once per every 336 slides, and the rate of injury for head- and feet-first slides was 1 in 249 and 413 slides, respectively ( P = .119). Conclusion: Injuries occurring while sliding in professional baseball result in a significant amount of time out of play for these elite athletes. Injuries occurring at second base and those occurring to the hands and fingers were most prevalent and may be an appropriate target for future injury prevention programs.

Purpose To use a national database to determine (1) the incidence of joint infection after elbow arthroscopy, (2) identify independent patient‐related risk factors for infection, and (3) determine the influence of concomitant intra‐articular corticosteroid injection on infection risk. Methods The 100% Medicare Standard Analytic Files were queried to identify patients who underwent elbow arthroscopy from 2005 to 2012. Postoperative elbow infections occurring within 6 months of surgery were identified using both International Classification of Diseases, 9th Revision codes for postoperative infection and Current Procedural Terminology codes for the surgical treatment of a postoperative infection. Patients were excluded if their initial arthroscopic procedure was performed for infection. A multivariate binomial logistic regression analysis was then used to evaluate patient‐related risk factors for postoperative infection. Results Of the 2,704 elbow arthroscopy cases identified, 42 (1.55%) developed a postoperative infection. The annual incidence of infections did not increase significantly over the course of the study ( P = .374). A number of patient demographics and medical comorbidities significantly increased the risk of infection. The most notable factors included age ≥ 65 years (odds ratio [OR] 2.38, P = .006), body mass index > 40 (OR 1.97, P = .024), tobacco usage (OR 1.80, P = .046), alcohol usage (OR 4.01, P < .001), diabetes mellitus (OR 2.10, P = .015), inflammatory arthritis (OR 2.81, P < .001), hypercoagulable disorder (OR 2.51, P = .015), and intra‐articular corticosteroid injection at the time of arthroscopy (OR 2.79, P = .006). Conclusions The annual number of elbow arthroscopies performed in the United States has increased steadily; however, the postoperative infection rate remained consistently low at 1.55%. There are a number of patient‐specific risk factors that increase this risk with OR ranging from 1.97 to 4.01. Similarly, patients who receive an intra‐articular corticosteroid injection at the time of surgery are nearly 3 times (OR 2.79) more likely to develop a postoperative infection. Level of Evidence Level III, case‐control study.

Abstract Posterolateral rotatory instability (PLRI) is the most commonly encountered pattern of elbow instability. It is the result of disruption of the lateral collateral ligament complex leading to a posterolateral rotatory subluxation of the ulna and radial head. A number of examination maneuvers have been described to assist in clinical identification of PLRI. Despite this, some inconsistency in the description of these techniques remains in the orthopaedic literature. This Technical Note details the mechanism of injury and patient presentation, and emphasizes the primacy of the posterolateral rotatory drawer test in the assessment of PLRI while providing video instruction on how it should be performed. Technique Video video See video under supplementary data.

Abstract Currently, a number of examination and imaging techniques exist for diagnosing posterolateral rotatory instability of the elbow. Although the posterolateral rotatory drawer is the primary examination maneuver, other special tests include the lateral pivot‐shift test, prone push‐up test, chair push‐up test, and tabletop push‐up test. In addition, posterolateral rotatory instability can be evaluated using radiography, magnetic resonance imaging, dynamic fluoroscopy, or dynamic ultrasound. In this Technical Note, each of these tests is described in detail. Video instruction is also provided to further explain the techniques and provide examples of positive tests. Technique Video video See video under supplementary data.

Background: Oblique injuries are known to be a common cause of time out of play for professional baseball players, and prior work has suggested that injury rates may be on the rise in Major League Baseball (MLB). Purpose: To better understand the current incidence of oblique injuries, determine their impact based on time out of play, and to identify common injury patterns that may guide future injury prevention programs. Study Design: Descriptive epidemiological study. Methods: Using the MLB Health and Injury Tracking System, all oblique injuries that resulted in time out of play in MLB and Minor League Baseball (MiLB) during the 2011 to 2015 seasons were identified. Player demographics such as age, position/role, and handedness were included. Injury-specific factors analyzed included the following: date of injury, timing during season, days missed, mechanism, side, treatment, and reinjury status. Results: A total of 996 oblique injuries occurred in 259 (26%) MLB and 737 (74%) MiLB players. Although the injury rate was steady in MiLB, the MLB injury rate declined ( P = .037). A total of 22,064 days were missed at a mean rate of 4413 days per season and 22.2 days per injury. The majority of these occurred during batting (n = 455, 46%) or pitching (n = 348, 35%), with pitchers losing 5 days more per injury than batters ( P < .001). The leading side was injured in 77% of cases and took 5 days longer to recover from than trailing side injuries ( P = .009). Seventy-nine (7.9%) players received either a corticosteroid or platelet-rich plasma injection, and the mean recovery time was 11 days longer compared with those who did not receive an injection ( P < .001). Conclusion: Although the rate of abdominal oblique injuries is on the decline in MLB, this is not the case for MiLB, and these injuries continue to represent a significant source of time out of play in professional baseball. The vast majority of injuries occur on the lead side, and these injuries result in the greatest amount time out of play. The benefit of injections for the treatment of oblique injuries remains unknown.

AbstractControl of knee motion in small animal models is necessary to study the effect of mechanical load on the healing process. This can be especially challenging in mice, which are being increasingly used for various orthopedic reconstruction models. We explored the feasibility of botulinum toxin (Botox; Allergan, Dublin, Ireland) paralysis and a newly designed external fixator to restrict motion of the knee in mice undergoing anterior cruciate ligament (ACL) reconstruction. Nineteen C57BL/6 mice were allocated to two groups: (1) Botox group (n = 9) and (2) external fixator group (n = 10). Mice in Botox group received two different doses of Botox: 0.25 unit (n = 3) and 0.5 unit (n = 6). Injection was performed 72 hours prior to ACL reconstruction into the quadriceps, hamstring, and calf muscles of the right hind leg. Mice in external fixator group received an external fixator following ACL reconstruction. Mice were monitored for survival, tolerance, and achievement of complete knee immobilization. All mice were meant for sacrifice on day 14 postoperatively. No perceptible change in gait was observed with 0.25 unit of Botox. All mice that received 0.5 unit of Botox had complete hind limb paralysis documented by footprint analysis 2 days after injection but failed to tolerate anesthesia and were euthanized 24 hours after operation due to their critical condition. In contrast, the external fixator was well tolerated and effectively immobilized the limb. There was a single occurrence of intraoperative technical error in the external fixator group that led to euthanasia. No mechanical failure or complication was observed. Botox paralysis was not a viable option for postoperative restriction of motion and joint loading in mice. However, external fixation was an effective method for complete knee immobilization and can be used in murine models requiring postoperative control of knee loading. This study introduces a robust research tool to allow control of postoperative joint loading in animal models such as ACL reconstruction, permitting study of the effects of mechanical load on the biologic aspects of tendon-to-bone healing.

Abstract As our knowledge and technology advance, the indications for elbow arthroscopy continue to grow rapidly. During this expansion, a number of new portals have been described and reported using variable nomenclature and location descriptions. Accordingly, a comprehensive review of these portals is warranted. Given the concern for potential iatrogenic injury to surrounding neurovascular structures, a discussion of these critical nerves and vessels is also timely. In this work, we review pertinent surface anatomy; portal nomenclature, locations, and utility; and review distances to the nearest structures at risk. Technique Video video See video under supplementary data.

Abstract The field of elbow arthroscopy has evolved significantly since the procedure was first introduced more than 30 years ago. As our knowledge and understanding grows, numerous technical modifications have been made to improve the safety and efficacy of elbow arthroscopy. One of the most significant modifications is the change from the supine hanging position to the supine‐suspended position with the use of a mechanical arm holder. Currently, the supine‐suspended and lateral decubitus positions are the 2 most commonly used techniques. In this work, we discuss the history of the supine position, provide key points for proper patient positioning, and detail the steps of diagnostic elbow arthroscopy. It is our hope that this work will serve as an up‐to‐date review and summary of the most critical components of this procedure for emerging elbow arthroscopists. Technique Video video See video under supplementary data.

Abstract In recent years, arthroscopy has gained popularity as a preferred treatment of a multitude of pathologies affecting the elbow. Since its initial description in 1985, many modifications have been made as our knowledge and technology have advanced. Currently, the majority of arthroscopic procedures are performed in either the lateral decubitus or supine suspended position. In this work, we discuss the history, patient positioning, and key steps for performing elbow arthroscopy in the lateral decubitus position. In addition to key steps, a number of strengths and limitations of this set up are discussed in detail. When properly executed, elbow arthroscopy can be performed in a safe and efficient manner with minimal risk to patients. Technique Video video See video under supplementary data.