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Ulnar Collateral Ligament Reconstruction in Adolescent Athletes: Minimum Two-year Follow-up Utilizing the Docking Technique (SS-40)
ABSTRACTS
neck osteoplasty and labral debridement. Eighty-two hips (82%) were contacted and available for followup at a mean of 60 months (range, 40-74). Patients were assessed with preoperative and postoperative physical examination, nonarthritic hip score (NAHS), Western Ontario and McMasters Universities (WOMAC) score, and radiographs to assess the Tonnis Grade for osteoarthritis and alpha-angle. Postoperative evaluation included pain score assessment with a visual analog scale and satisfaction assessment. Results: Eighty-two hips were contacted for followup evaluation. There were 54 patients who had not undergone additional surgeries. Six patients required revision hip arthroscopies. Twenty-two patients underwent hip arthroplasty, summing up to an overall revision rate of 28%. Of the patients who had not undergone revision surgeries, the mean NAHS rose from 48.9 to 78 and the WOMAC increased from 66.8 to 77. Patient satisfaction was 70 percent. Twenty-five of the 54 hips were available for clinical evaluation. Presence of internal rotation impingement sign decreased from 92.6 to 37.5 percent. Repeat radiograph showed improved alpha angles from 76.8 to 61.6 degrees. Of the patients with pre-existing osteoarthritis (Tonnis Grade 2-3), 84.6% went on to require hip arthroplasty. Of the patients with minimal to no pre-existing osteoarthritis (Tonnis Grade 0-1), 16.4% went on to require hip arthroplasty. Conclusion: Arthroscopic femoral neck resection in patients with cam-type FAI results in improved clinical outcomes, decreased physical symptoms, and a high patient satisfaction at a mean followup of 5 years. In the subset of patients with pre-existing osteoarthritis, there is high risk of needing an arthroplasty procedure within 5 years. Impact of Ulnar Collateral Ligament Tear on Contact Pressure and Contact Area in the Posteromedial Compartment of the Elbow (SS-39) PRASHANTH ANAND, M.D., PRESENTING AUTHOR BRENT PARKS, B.S. DARYL OSBAHR, M.D. Introduction: Ulnar collateral ligament (UCL) attenuation or rupture in overhead throwing athletes results in impingement of the posteromedial tip of the olecranon process on the medial wall of the olecranon fossa, leading to chondral damage and osteophyte formation. Resulting contact pressure and contact area changes have not been studied with digital pressure sensors. We measured and compared joint contact pressure and area in the posteromedial compartment of the elbow in a cadaveric model using digital sensors in two elbow states: UCL intact and UCL deficient. Methods: Seven elbow cadaveric specimens were tested in a MTS electromechanical test frame with 90 and 30 of elbow flexion to simulate late cocking/acceleration and deceleration phases of pitching respectively. I-scan sensors (Model 6900,Tekscan, South Boston, M.A.) were placed in the posteromedial compartment to measure the contact pressure and contact area across the posteromedial
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ulnohumeral articulation. Valgus torque of 2.5Nm was applied. After testing the specimen with intact UCL, we transected the anterior band of UCL at midsubstance and repeated the testing. Results: At 90 of elbow flexion, after UCL transection, the contact pressure increased from an average of 443.00 175.33 kpa to 540.00 167.70 kpa (p<0.05) and the contact area decreased from an average of 106.00 24.18 mm2 to 83.14 23.20 mm2 (p<0.05). At 30 of elbow flexion, similarly the contact pressure increased from an average of 353.00 110.35 kpa to 474.00 170.86 kpa (p<0.05) and the contact area decreased from an average of 79.29 29.77 mm2 to 64.29 33.18 mm2 (p<0.05). Conclusion: Under the conditions tested, deficiency of the UCL increased contact pressure within the posteromedial compartment of the elbow with associated decrease in the contact area. These findings accentuate the importance of early diagnosis in throwing athletes with valgus instability due to associated UCL insufficiency, prior to the development of pathological chondromalacia in the posteromedial compartment. Ulnar Collateral Ligament Reconstruction in Adolescent Athletes: Minimum Two-year Followup Utilizing the Docking Technique (SS-40) KRISTOFER JONES, M.D., PRESENTING AUTHOR JOSHUA DINES, M.D. BRIAN REBOLLEDO, M.D. KENNETH WEEKS, M.D. DAVID DINES, M.D. DAVID ALTCHEK, M.D. Introduction: The incidence of ulnar collateral ligament (UCL) insufficiency of the elbow has drastically increased in the adolescent population over the last decade due to widespread participation in overhead athletics. Previous reports suggest clinical outcomes in teenage athletes are inferior to results in higher-level adult athletes. We hypothesized that UCL reconstruction using the docking technique would result in improved outcomes in this age group. Methods: 46 adolescent athletes (mean age 17 years, range 12-18 years) underwent UCL reconstruction using the docking technique. The majority of patients were baseball players; there were three gymnasts and three javelin throwers. Retrospective review revealed each patient had a history and physical exam consistent with UCL injury along with advanced imaging demonstrating corresponding UCL pathology (24 distal tears, 22 proximal tears). Patients were evaluated at a minimum of 2 years postoperatively based on their ability to return to athletic activity. Clinical outcomes were classified using the Conway Scale, the AndrewsTimmerman Score, and the Kerlan-Jobe Orthopaedic Clinic (KJOC) Score. Results: At most recent follow-up, 89% (41/46) of patients had excellent results using the Conway Scale. There were one good, two fair and two poor results. The fair result was noted in a revision case and the two poor results occurred in patients who had concomitant
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ABSTRACTS
capitellar OCD lesions. UCL tear location did not affect clinical outcome. There were four postoperative complications in four patients (two gymnasts and two javelin throwers) who developed ulnar neuritis following reconstruction. The average Andrews-Timmerman Score was 86.7 and the mean KJOC score was 88. Conclusion: The docking technique results in favorable clinical outcomes in adolescent athletes with UCL insufficiency at a minimum of 2 years postoperatively. Overall, results were better than previously published reports in this age group and this may be attributed to techniquespecific factors. Patients with concomitant intraarticular pathology should be counseled preopreratively that they may experience inferior clinical outcomes. Additionally, gymnasts and javelin throwers may be at increased risk for postoperative complications due to increased stress on the medial elbow. Ulnar Nerve Decompression in Cubital Tunnel Syndrome e Open in Situ Decompression Versus Endoscopic Decompression (SS-41) RODERICH HEIKENFELD, M.D. PH.D., PRESENTING AUTHOR RICO LISTRINGHAUS, M.D. PH.D. GEORGIOS GODOLIAS, M.D. Introduction: The purpose of this study was to evaluate the results after decompression of the ulnar nerve. Are the results of endoscopic treatment comparable to open in situ decompression? Methods: Thirty patients with clinically and electrophysiologically proved Cubital Tunnel Syndrome were scheduled for operative treatment. After randomization 15 patients were treated with open in situ decompression, 15 patients were operated using an endoscopic technique. In these cases the ulnar nerve is identified via an approximately 2-cm wide incision in the cubital tunnel. The next steps of the procedure are performed endoscopically distally (up to 15 cm distal of the cubital tunnel) and proximally (approx. 10 cm proximal of the cubital tunnel). A transposition of the nerve was not necessary in the endoscopic group; in the open group one subcutaneous transposition was performed. Patients were followed prospectively after 10 days, 3 and 12 months clinically and electrophysiologically. The results were analyzed according to the Dellon classification and the postoperative results according to the modified Bishop classification and patient satisfaction. Comparison between open and endoscopic results was statistically analyzed by parametric method, using 2-tailed t test. The level of significance was set up at p<0.05. Results: 13 patients in the open group and 14 patients in the endoscopic group could be completely evaluated. All patients showed a clinical improvement compared to the preoperative situation. The modified Bishop Score revealed at last follow-up in the open group 6 very good, 6 good and 1 satisfying result; in the endoscopic group 8 very good and 6 good results. In the endoscopic group one superficial hematoma was noted that did not require a revision. Functional improvement was quicker in the endoscopic group. 12 patients in the open group and 14
patients in the endoscopic group were satisfied with the postoperative result and would choose surgery again. Conclusion: The endoscopic decompression of cubital tunnel syndrome leads to comparable results to open in situ decompression after 12 months. The Endoscopic Repair of Partial Lesions of the Distal Triceps Tendon: First Prospective Results of 14 Cases (SS-42) RODERICH HEIKENFELD, M.D., PH.D., PRESENTING AUTHOR RICO LISTRINGHAUS, M.D. PH.D. GEORGIOS GODOLIAS, M.D. Introduction: Partial tears of the distal triceps tendon are not well documented. Can the clinical and functional outcome by minimally invasive surgery of these injuries be improved? Methods: We diagnosed a partial tear of the distal triceps tendon in 14 patients. 10 of these patients were suffering of chronic olecranon bursitis. All of these patients were treated with endoscopic surgery including a bursectomy and repair of the distal triceps tendon with double loaded suture anchors. First we performed an endoscopic bursectomy and created a subcutaneous working space. Then a mobilization of the tendon and a debridement of the footprint at the olecranon were done. One or two double loaded absorbable suture anchors were inserted in the olecranon and the tendon was repaired with modified Mason Allen sutures. We used the Mayo Elbow Performance index and the Quick DASH Score before surgery as well as 6 and 12 months after surgery in order to evaluate our results. Furthermore an isokinetic strength measurement in comparison to the unaffected contralateral side and a MRI was performed before surgery and 12 months after surgery. Results: All 14 patients were completely evaluated. This included 12 men and 2 women with an average age of 58.4 years. In 11 cases the dominant arm was affected and 12 patients remembered at least a minor trauma in their history. 10 of 14 patients showed chronic olecranon bursitis, 6 of these patients had previous surgery. The Mayo Elbow performance index preOP showed an average value of 67 points that increased after 6 months up to 89 points and after 12 months up to 91 points. The Quick DASH Score showed preOP 20.1 points, after 6 months 7.7 points and after 12 months 4.5 points. In the preoperative isokinetic measurement we found 38.9% of the maximum isometric strength for the elbow extension compared to the contralateral arm. After 12 months we found an improvement of the isometric maximum strength up to 94.7%. Two of our 14 patients developed a recurrent olecranon bursitis. In MRI we found one reruptured partial tear of the triceps tendon. Conclusion: The rare partial tears of the distal triceps tendon are typically found in elderly patients or in power athletes. Nevertheless they are often masked by a more remarkable olecranon bursitis. The patients benefit from surgery especially with an improvement of extension strength. Endoscopic repair of partial distal triceps tendon tears leads to good clinical and radiological results after 12 months.
neck osteoplasty and labral debridement. Eighty-two hips (82%) were contacted and available for followup at a mean of 60 months (range, 40-74). Patients were assessed with preoperative and postoperative physical examination, nonarthritic hip score (NAHS), Western Ontario and McMasters Universities (WOMAC) score, and radiographs to assess the Tonnis Grade for osteoarthritis and alpha-angle. Postoperative evaluation included pain score assessment with a visual analog scale and satisfaction assessment. Results: Eighty-two hips were contacted for followup evaluation. There were 54 patients who had not undergone additional surgeries. Six patients required revision hip arthroscopies. Twenty-two patients underwent hip arthroplasty, summing up to an overall revision rate of 28%. Of the patients who had not undergone revision surgeries, the mean NAHS rose from 48.9 to 78 and the WOMAC increased from 66.8 to 77. Patient satisfaction was 70 percent. Twenty-five of the 54 hips were available for clinical evaluation. Presence of internal rotation impingement sign decreased from 92.6 to 37.5 percent. Repeat radiograph showed improved alpha angles from 76.8 to 61.6 degrees. Of the patients with pre-existing osteoarthritis (Tonnis Grade 2-3), 84.6% went on to require hip arthroplasty. Of the patients with minimal to no pre-existing osteoarthritis (Tonnis Grade 0-1), 16.4% went on to require hip arthroplasty. Conclusion: Arthroscopic femoral neck resection in patients with cam-type FAI results in improved clinical outcomes, decreased physical symptoms, and a high patient satisfaction at a mean followup of 5 years. In the subset of patients with pre-existing osteoarthritis, there is high risk of needing an arthroplasty procedure within 5 years. Impact of Ulnar Collateral Ligament Tear on Contact Pressure and Contact Area in the Posteromedial Compartment of the Elbow (SS-39) PRASHANTH ANAND, M.D., PRESENTING AUTHOR BRENT PARKS, B.S. DARYL OSBAHR, M.D. Introduction: Ulnar collateral ligament (UCL) attenuation or rupture in overhead throwing athletes results in impingement of the posteromedial tip of the olecranon process on the medial wall of the olecranon fossa, leading to chondral damage and osteophyte formation. Resulting contact pressure and contact area changes have not been studied with digital pressure sensors. We measured and compared joint contact pressure and area in the posteromedial compartment of the elbow in a cadaveric model using digital sensors in two elbow states: UCL intact and UCL deficient. Methods: Seven elbow cadaveric specimens were tested in a MTS electromechanical test frame with 90 and 30 of elbow flexion to simulate late cocking/acceleration and deceleration phases of pitching respectively. I-scan sensors (Model 6900,Tekscan, South Boston, M.A.) were placed in the posteromedial compartment to measure the contact pressure and contact area across the posteromedial
e19
ulnohumeral articulation. Valgus torque of 2.5Nm was applied. After testing the specimen with intact UCL, we transected the anterior band of UCL at midsubstance and repeated the testing. Results: At 90 of elbow flexion, after UCL transection, the contact pressure increased from an average of 443.00 175.33 kpa to 540.00 167.70 kpa (p<0.05) and the contact area decreased from an average of 106.00 24.18 mm2 to 83.14 23.20 mm2 (p<0.05). At 30 of elbow flexion, similarly the contact pressure increased from an average of 353.00 110.35 kpa to 474.00 170.86 kpa (p<0.05) and the contact area decreased from an average of 79.29 29.77 mm2 to 64.29 33.18 mm2 (p<0.05). Conclusion: Under the conditions tested, deficiency of the UCL increased contact pressure within the posteromedial compartment of the elbow with associated decrease in the contact area. These findings accentuate the importance of early diagnosis in throwing athletes with valgus instability due to associated UCL insufficiency, prior to the development of pathological chondromalacia in the posteromedial compartment. Ulnar Collateral Ligament Reconstruction in Adolescent Athletes: Minimum Two-year Followup Utilizing the Docking Technique (SS-40) KRISTOFER JONES, M.D., PRESENTING AUTHOR JOSHUA DINES, M.D. BRIAN REBOLLEDO, M.D. KENNETH WEEKS, M.D. DAVID DINES, M.D. DAVID ALTCHEK, M.D. Introduction: The incidence of ulnar collateral ligament (UCL) insufficiency of the elbow has drastically increased in the adolescent population over the last decade due to widespread participation in overhead athletics. Previous reports suggest clinical outcomes in teenage athletes are inferior to results in higher-level adult athletes. We hypothesized that UCL reconstruction using the docking technique would result in improved outcomes in this age group. Methods: 46 adolescent athletes (mean age 17 years, range 12-18 years) underwent UCL reconstruction using the docking technique. The majority of patients were baseball players; there were three gymnasts and three javelin throwers. Retrospective review revealed each patient had a history and physical exam consistent with UCL injury along with advanced imaging demonstrating corresponding UCL pathology (24 distal tears, 22 proximal tears). Patients were evaluated at a minimum of 2 years postoperatively based on their ability to return to athletic activity. Clinical outcomes were classified using the Conway Scale, the AndrewsTimmerman Score, and the Kerlan-Jobe Orthopaedic Clinic (KJOC) Score. Results: At most recent follow-up, 89% (41/46) of patients had excellent results using the Conway Scale. There were one good, two fair and two poor results. The fair result was noted in a revision case and the two poor results occurred in patients who had concomitant
e20
ABSTRACTS
capitellar OCD lesions. UCL tear location did not affect clinical outcome. There were four postoperative complications in four patients (two gymnasts and two javelin throwers) who developed ulnar neuritis following reconstruction. The average Andrews-Timmerman Score was 86.7 and the mean KJOC score was 88. Conclusion: The docking technique results in favorable clinical outcomes in adolescent athletes with UCL insufficiency at a minimum of 2 years postoperatively. Overall, results were better than previously published reports in this age group and this may be attributed to techniquespecific factors. Patients with concomitant intraarticular pathology should be counseled preopreratively that they may experience inferior clinical outcomes. Additionally, gymnasts and javelin throwers may be at increased risk for postoperative complications due to increased stress on the medial elbow. Ulnar Nerve Decompression in Cubital Tunnel Syndrome e Open in Situ Decompression Versus Endoscopic Decompression (SS-41) RODERICH HEIKENFELD, M.D. PH.D., PRESENTING AUTHOR RICO LISTRINGHAUS, M.D. PH.D. GEORGIOS GODOLIAS, M.D. Introduction: The purpose of this study was to evaluate the results after decompression of the ulnar nerve. Are the results of endoscopic treatment comparable to open in situ decompression? Methods: Thirty patients with clinically and electrophysiologically proved Cubital Tunnel Syndrome were scheduled for operative treatment. After randomization 15 patients were treated with open in situ decompression, 15 patients were operated using an endoscopic technique. In these cases the ulnar nerve is identified via an approximately 2-cm wide incision in the cubital tunnel. The next steps of the procedure are performed endoscopically distally (up to 15 cm distal of the cubital tunnel) and proximally (approx. 10 cm proximal of the cubital tunnel). A transposition of the nerve was not necessary in the endoscopic group; in the open group one subcutaneous transposition was performed. Patients were followed prospectively after 10 days, 3 and 12 months clinically and electrophysiologically. The results were analyzed according to the Dellon classification and the postoperative results according to the modified Bishop classification and patient satisfaction. Comparison between open and endoscopic results was statistically analyzed by parametric method, using 2-tailed t test. The level of significance was set up at p<0.05. Results: 13 patients in the open group and 14 patients in the endoscopic group could be completely evaluated. All patients showed a clinical improvement compared to the preoperative situation. The modified Bishop Score revealed at last follow-up in the open group 6 very good, 6 good and 1 satisfying result; in the endoscopic group 8 very good and 6 good results. In the endoscopic group one superficial hematoma was noted that did not require a revision. Functional improvement was quicker in the endoscopic group. 12 patients in the open group and 14
patients in the endoscopic group were satisfied with the postoperative result and would choose surgery again. Conclusion: The endoscopic decompression of cubital tunnel syndrome leads to comparable results to open in situ decompression after 12 months. The Endoscopic Repair of Partial Lesions of the Distal Triceps Tendon: First Prospective Results of 14 Cases (SS-42) RODERICH HEIKENFELD, M.D., PH.D., PRESENTING AUTHOR RICO LISTRINGHAUS, M.D. PH.D. GEORGIOS GODOLIAS, M.D. Introduction: Partial tears of the distal triceps tendon are not well documented. Can the clinical and functional outcome by minimally invasive surgery of these injuries be improved? Methods: We diagnosed a partial tear of the distal triceps tendon in 14 patients. 10 of these patients were suffering of chronic olecranon bursitis. All of these patients were treated with endoscopic surgery including a bursectomy and repair of the distal triceps tendon with double loaded suture anchors. First we performed an endoscopic bursectomy and created a subcutaneous working space. Then a mobilization of the tendon and a debridement of the footprint at the olecranon were done. One or two double loaded absorbable suture anchors were inserted in the olecranon and the tendon was repaired with modified Mason Allen sutures. We used the Mayo Elbow Performance index and the Quick DASH Score before surgery as well as 6 and 12 months after surgery in order to evaluate our results. Furthermore an isokinetic strength measurement in comparison to the unaffected contralateral side and a MRI was performed before surgery and 12 months after surgery. Results: All 14 patients were completely evaluated. This included 12 men and 2 women with an average age of 58.4 years. In 11 cases the dominant arm was affected and 12 patients remembered at least a minor trauma in their history. 10 of 14 patients showed chronic olecranon bursitis, 6 of these patients had previous surgery. The Mayo Elbow performance index preOP showed an average value of 67 points that increased after 6 months up to 89 points and after 12 months up to 91 points. The Quick DASH Score showed preOP 20.1 points, after 6 months 7.7 points and after 12 months 4.5 points. In the preoperative isokinetic measurement we found 38.9% of the maximum isometric strength for the elbow extension compared to the contralateral arm. After 12 months we found an improvement of the isometric maximum strength up to 94.7%. Two of our 14 patients developed a recurrent olecranon bursitis. In MRI we found one reruptured partial tear of the triceps tendon. Conclusion: The rare partial tears of the distal triceps tendon are typically found in elderly patients or in power athletes. Nevertheless they are often masked by a more remarkable olecranon bursitis. The patients benefit from surgery especially with an improvement of extension strength. Endoscopic repair of partial distal triceps tendon tears leads to good clinical and radiological results after 12 months.