-
George A Paletta
Clinics in sports medicine 10/2011; 30(4):779-88. · 1.33 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To describe the spectrum of axillary artery pathology seen in high-performance overhead athletes and the outcomes of current treatment.
A retrospective review of patients that had undergone management of axillary artery lesions in a specialized center for thoracic outlet syndrome (TOS). Treatment outcomes were assessed with respect to arterial pathology and operative management.
Nine male athletes were referred for arterial insufficiency in the dominant arm between January 2000 and August 2010, representing 1.6% of 572 patients treated for TOS (19% of 47 patients treated for arterial TOS). Seven were elite baseball pitchers (six professional, one collegiate), and two were professional baseball coaches with practice pitching responsibilities, with a mean age of 30.9 ± 2.9 years. Presenting symptoms included arm fatigue (five), finger numbness (four), cold hypersensitivity/Raynaud's (two), rest pain (one), and cutaneous fingertip embolism (one). Three patients underwent transcatheter thrombolysis prior to referral, including one with angioplasty and stenting. At angiography and surgical exploration 2.5 ± 0.8 weeks after symptom presentation (range, 1-8 weeks), six patients had occlusion of the distal axillary artery opposite the humeral head either at rest (three) or with arm elevation (three), one had axillary artery dissection with positional occlusion, and two had thrombosis of circumflex humeral artery aneurysms. Five patients had embolic arterial occlusions distal to the elbow. Treatment included segmental axillary artery repair with saphenous vein (n = 7; five interposition bypass grafts and two patch angioplasties), ligation/excision of circumflex humeral artery aneurysms (n = 2), and distal artery thrombectomy/thrombolysis (n = 2). Mean postoperative hospital stay was 3.8 ± 0.5 days, and the time until resumption of unrestricted overhead throwing was 10.8 ± 2.7 weeks. At a median follow-up of 15 months (range, 3-123 months), primary-assisted patency was 89%, and secondary patency was 100%. All nine patients had continued careers in professional baseball, although one retired during long-term follow-up.
Repetitive positional compression of the axillary artery can cause a spectrum of pathology in the overhead athlete, including focal intimal hyperplasia, aneurysm formation, segmental dissection, and branch vessel aneurysms. Prompt recognition of these rare lesions is crucial given their propensity toward thrombosis and distal embolism, with positional arteriography necessary for diagnosis. Full functional recovery can usually be anticipated within several months of surgical treatment, consisting of mobilization and segmental reconstruction of the diseased axillary artery or ligation/excision of branch aneurysms, as well as concomitant management of distal thromboembolism.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 01/2011; 53(5):1329-40. · 3.52 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The results of treatment for subclavian vein effort thrombosis were assessed in a series of competitive athletes.
A retrospective review was conducted of high-performance athletes who underwent multidisciplinary management for venous thoracic outlet syndrome in a specialized referral center. The overall time required to return to athletic activity was assessed with respect to the timing and methods of diagnosis, initial treatment, operative management, and postoperative care.
Between January 1997 and January 2007, 32 competitive athletes (29 male and 3 female) were treated for venous thoracic outlet syndrome, of which 31% were in high school, 47% were in college, and 22% were professional. The median age was 20.3 years (range, 16-26 years). Venous duplex ultrasound examination in 21 patients had a diagnostic sensitivity of 71%, and the mean interval between symptoms and definitive venographic diagnosis was 20.2 +/- 5.6 days (range, 1-120 days). Catheter-directed subclavian vein thrombolysis was performed in 26 (81%), with balloon angioplasty in 12 and stent placement in one. Paraclavicular thoracic outlet decompression was performed with circumferential external venolysis alone (56%) or direct axillary-subclavian vein reconstruction (44%), using saphenous vein panel graft bypass (n = 8), reversed saphenous vein graft bypass (n = 3), and saphenous vein patch angioplasty (n = 3). In 19 patients (59%), simultaneous creation of a temporary (12 weeks) adjunctive radiocephalic arteriovenous fistula was done. The mean hospital stay was 5.2 +/- 0.4 days (range, 2-11 days). Seven patients required secondary procedures. Anticoagulation was maintained for 12 weeks. All 32 patients resumed unrestricted use of the upper extremity, with a median interval of 3.5 months between operation and the return to participation in competitive athletics (range, 2-10 months). The overall duration of management from symptoms to full athletic activity was significantly correlated with the time interval from venographic diagnosis to operation (r = 0.820, P < .001) and was longer in patients with persistent symptoms (P < .05) or rethrombosis before referral (P < .01).
Successful outcomes were achieved for the management of effort thrombosis in a series of 32 competitive athletes using a multidisciplinary approach based on (1) early diagnostic venography, thrombolysis, and tertiary referral; (2) paraclavicular thoracic outlet decompression with external venolysis and frequent use of subclavian vein reconstruction; and (3) temporary postoperative anticoagulation, with or without an adjunctive arteriovenous fistula. Optimal outcomes for venous thoracic outlet syndrome depend on early recognition by treating physicians and prompt referral for comprehensive surgical management.
Journal of Vascular Surgery 04/2008; 47(4):809-820; discussion 821. · 3.21 Impact Factor
-
The American Journal of Sports Medicine 07/2007; 35(6):1003-6. · 3.79 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Ulnar collateral ligament injury is most common in the overhead-throwing athlete. Jobe et al published the first report of ulnar collateral ligament reconstruction in throwing athletes with a 62.5% success rate. Recently, Altchek developed a new docking technique for reconstruction of the ulnar collateral ligament. The authors report the first series using a further modification of the docking technique using a 4-strand palmaris longus graft for reconstruction of the ulnar collateral ligament.
The modified docking technique yields a high rate of successful return to preinjury level of competition in elite baseball players.
Case series; Level of evidence, 4.
The authors retrospectively reviewed 25 elite professional or scholarship collegiate baseball players who underwent elbow ulnar collateral ligament reconstruction using the modified docking procedure with a minimum 2-year follow-up.
Twenty-three of 25 (92%) were able to return to their preinjury levels of competition. The mean time to return was 11.5 months (range, 10-16 months). Complications included 1 transient postoperative ulnar nerve neurapraxia and 1 stress fracture of the ulnar bone bridge that occurred at 14 months postoperatively, after a full return to pitching.
The modified docking technique yields highly successful return to preinjury level of competition rates (92%) in a select group of elite baseball players.
The American Journal of Sports Medicine 11/2006; 34(10):1594-8. · 3.79 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Elbow medial ulnar collateral ligament tears often result in pain and instability that may be career threatening in overhead-throwing athletes. Surgical reconstruction is frequently chosen to treat this injury. Ulnar collateral ligament reconstruction as described by Jobe is the most commonly used technique. Testing of this construct has not demonstrated that the biomechanical parameters of the native ligament are restored. A more recent construct, the docking technique, may more reliably reproduce these factors.
Increasing the number of strands of palmaris longus tendon graft used in ulnar collateral ligament reconstruction and tensioning them using the docking technique result in a construct with improved biomechanical parameters as compared with the Jobe technique.
Controlled laboratory study.
Thirty-three fresh-frozen human cadaveric elbows were randomized into 3 subgroups: Jobe (11), docking (12), and native (10). The Jobe and docking groups underwent reconstruction using their described palmaris tendon graft constructs. The ulnar collateral ligament was left intact in the native group. Elbows were potted and tested using a servohydraulic materials testing machine to apply a valgus moment at 30 degrees of elbow flexion. Maximal moments to failure, stiffness, and strain at maximal moment and with a 3 N.m force applied were determined using a 2-camera motion analysis system to track reflective markers spanning the site.
The docking (14.3 N.m) and native (18.8 N.m) subgroups resulted in higher maximal moment to failure than did the Jobe (8.9 N.m) subgroup (P < .001). There was no significant difference between native and docking groups (P > .05). Native ligaments were stiffer (301.4 N.m) than were Jobe (74.3 N.m) or docking (80.8 N.m; P < .001). Native ligaments demonstrated lower strain at maximal force (0.087 mm/mm) and 3 N.m forces (0.030 mm/mm) than did the Jobe (0.198/0.057 mm/mm) or docking (0.287/0.042 mm/mm) subgroups. There was no difference in stiffness or strain between the Jobe and docking subgroups (P > .05).
Neither technique reproduced the biomechanical profile of the native ulnar collateral ligament; the findings of this study suggest that the docking construct may offer initial biomechanical advantage over the Jobe construct.
The American Journal of Sports Medicine 10/2006; 34(10):1599-603. · 3.79 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Physicians involved with the care of baseball players have noted elbow range of motion changes in pitchers. Objective data regarding the extent of these changes have rarely been documented.
Dominant and nondominant elbow range of motion differences are common in baseball pitchers, and these differences are related to player age, amount and length of time professionally pitched, and history of surgical procedures on the dominant extremity.
Cross-sectional study; Level of evidence, 4.
Thirty-three professional pitchers were evaluated for elbow range of motion during spring training preseason physical examination. Dominant and nondominant elbow range of motion including flexion, extension, supination, and pronation were measured with a goniometer. Range of motion measures from the dominant and nondominant sides were compared. Baseball records were reviewed for arm dominance, age, years of professional pitching, professional innings pitched, and history of elbow surgery. These factors were evaluated for their possible association with range of motion for each side and the difference between sides.
Statistically significant differences between dominant and nondominant sides were noted for elbow extension (dominant decreased 7.9 degrees +/- 7.4 degrees, P < .0001), flexion (dominant decreased 5.5 degrees +/- 7.8 degrees, P = .0003), and total flexion-extension arc (dominant decreased 13.3 degrees +/- 13.7 degrees, P < .0001). No significant difference between sides was found for the supination or pronation measures. No correlation was noted for age, pitching history, surgery, or arm dominance and the motion differences.
Professional pitchers demonstrate elbow flexion and extension differences between dominant and nondominant elbows. No correlation was found between motion differences and age, pitching history, surgery, or arm dominance.
The American Journal of Sports Medicine 02/2006; 34(2):190-3. · 3.79 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Elbow injuries in skeletally immature athletes continue to increase as juvenile and adolescent athletes participate in organized athletics at earlier ages and with greater intensity. Specialization in specific sports at younger ages has led to an increase in injuries related to repetitive microtrauma. As a result, the spectrum of injuries commonly seen in skeletally immature athletes has increased at a time when long-term outcomes and less invasive interventions with biologic principles are gaining greater attention. Optimal treatment of these injuries requires a knowledge of the complex developmental and radiographic anatomy, the pathophysiology and natural history, and the indications and expected outcomes for conservative and operative management.
Clinics in Sports Medicine 11/2004; 23(4):581-608, ix. · 1.55 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Shoulder injuries are common in young throwing athletes. Most injuries are overuse types related to excessive pitch counts, premature use of breaking pitches, and improper pitching mechanics. These etiologic factors should be recognized early and treated. Prevention of injuries should play a major role in decreasing shoulder injury.
Orthopedic Clinics of North America 08/2003; 34(3):427-37. · 1.25 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Although common, AC joint injuries and their treatments are not benign. The injury itself and both nonsurgical and surgical treatments may result in complications yielding persistent pain, deformity, or dysfunction. Sternoclavicular joint injuries are far less common and are typically the result of higher energy trauma. As such, the associated complications may be more serious. Familiarity with the potential complications of these injuries can help the treating physician to develop strategies to minimize their incidence and sequelae.
Clinics in Sports Medicine 05/2003; 22(2):387-405. · 1.55 Impact Factor
-
George A Paletta
[show abstract]
[hide abstract]
ABSTRACT: ACL injury in children is being recognized with greater frequency because of improved diagnostic techniques as well as heightened awareness of the condition. Unfortunately, the diagnosis is still missed because the attitude persists that children do not suffer ligament injuries. Hemarthrosis must be considered an indication of a significant intra-articular injury. During the past decade, ACL reconstruction has evolved to a reproducible technique with low morbidity. Aggressive rehabilitation programs allow accelerated return to activity while allowing the biology of graft maturation to progress. The basic principle of diagnosis and the treatment goals in the skeletally immature patient are the same as those in the adult patient. The diagnosis approach to ACL injury in the scholastic-age patient, however, must also include evaluation of the patient's skeletal maturity because it plays a major role in treatment decisions. Maturity is evaluated on the basis of the patient's chronologic age; various physiologic factors, such as family height, patient's projected height, and estimation of sexual development; and radiographic findings in the knee, pelvis (Risser sign), or hand and wrist (bone-age study). Because of the special characteristics of the skeletally immature patient, the orthopedic surgeon must act as "knee counselor" by attempting to identify at-risk patients, particularly those who abuse their knees for any of a variety of reasons. The nonoperative treatment principles are the same as those in an adult. Consideration of surgical treatment must take into account assessment of skeletal maturity. If questions remain about the status of the femoral and tibial physes, polytomography or MRI is used to assess the extent of physeal closure. The surgical reconstruction used reflects the patient's skeletal maturity. As the skeletal maturity threshold is reached, transphyseal reconstructions may be done with diminished reservation about causing sequelae of physeal arrest.
Orthopedic Clinics of North America 02/2003; 34(1):65-77. · 1.25 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: We assessed the ability of high-resolution sonography to reveal the size and echogenicity of the anterior bundle of the normal medial collateral ligament of the elbow in cadavers and uninjured male volunteers.
The anterior bundle of the medial collateral ligament in five cadaveric elbows was imaged and injected with contrast material by experienced musculoskeletal radiologists using a 12-MHz linear array transducer. Immediate ligament dissection was performed. The bilateral ligaments in 30 healthy 21- to 34-year-old male volunteers were imaged with gravitational stress. Of these, five randomly selected subjects also received approximately 5 lb (11.3 kg) of applied stress.
Contrast material was injected directly into all five cadaveric ligaments. The anterior bundle of the medial collateral ligament in all 30 asymptomatic male volunteers was hyperechoic in comparison with surrounding muscle and had a fibrillar pattern and fanlike shape. Its mean dimensions were 2.6 +/- 0.31 x 2.2 +/- 0.47 x 4.0 +/- 0.88 mm on the right and 2.6 +/- 0.36 x 2.1 +/- 0.42 x 4.0 +/- 0.86 mm on the left, in longitudinal short, transverse short, and transverse long axes, respectively. Differences in ligament measurements in sidedness, stress application, and hand dominance did not approach statistical (Bonferroni corrected, p > 0.01) or clinical (all differences, <0.2 mm) significance.
Radiologists can accurately use sonography to identify and measure the size of the anterior bundle of the normal medial collateral ligament of the elbow. These baseline parameters for the normal ligament may prove useful when evaluating the injured ligament.
American Journal of Roentgenology 02/2003; 180(2):389-94. · 2.78 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The Bennett lesion is a mineralization of the posterior inferior glenoid noted in overhead throwing athletes. Although previous studies have debated appropriate treatment of the lesion, no studies have indicated the lesion prevalence in throwing athletes.
The Bennett lesion is more common than previously believed and may represent an asymptomatic finding.
Uncontrolled retrospective review.
Fifty-five asymptomatic major league pitchers underwent routine preseason radiographic screening. Radiographs were reviewed for the presence of a Bennett's lesion. Player demographics, pitching, and baseball records were reviewed to obtain the patient's dominant arm, age, years and innings pitched, and time on the disabled list or surgery.
Twelve pitchers (22%) were noted to have a radiographic Bennett lesion. No statistically significant difference was noted in age, years pitched, or innings pitched between pitchers with and without a Bennett lesion. No player who demonstrated a Bennett lesion required surgical treatment for shoulder pain during his time with the club. Two players required time on the disabled list, but neither player had complaints of posterior shoulder pain.
This lesion is a relatively common finding in major league pitchers. Concomitant pathology should be suspected when evaluating throwers with posterior shoulder pain and this lesion.
The American Journal of Sports Medicine 32(1):121-4. · 3.79 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Upper extremity vascular injuries are uncommon in the elite throwing athlete. However, the extreme stresses that are placed on the upper extremity of elite baseball players, especially pitchers, puts them at risk for such injuries. One such injury is upper extremity venous thrombosis or "effort thrombosis."
We wanted to review the common initial clinical symptoms and physical examination findings of effort thrombosis in elite baseball players and to review the associated clinical conditions such as hypercoagulable states and pulmonary embolism.
Retrospective review of a series of cases.
A retrospective review of the medical records of a Major League Baseball organization and a Division I college was performed for the period 1987 to 1997.
We located four cases of effort thrombosis involving elite baseball players. Contrast venography was used to confirm the diagnosis in all cases. All patients were successfully treated with transluminal catheter-directed urokinase thrombolysis followed by first rib resection and systemic anticoagulant therapy for up to 3 months. All four players returned to play at or above their previous level of competition with no long-term chronic sequelae.
Prompt clinical recognition, diagnosis, and treatment of effort thrombosis in the elite baseball player provides the player with an excellent prognosis for return to the previous level of play.
The American Journal of Sports Medicine 30(5):708-12. · 3.79 Impact Factor
