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Objectives: Superior labrum from anterior to posterior (SLAP) tears are increasingly common shoulder injuries in adolescent athletes who participate in repetitive overhead throwing. The purpose of this study is to evaluate adolescent baseball athletes who undergo SLAP repair in order to determine their long-term progression of play, surgical outcomes, and overall satisfaction with surgery. Methods: Patients between the ages of 10-19 who underwent a SLAP repair over a 10-year period from 2008-2018 with minimum two year follow-up were identified by a database query in the medical records of a single institution. From this cohort, non-baseball athletes and injuries to non-throwing shoulders were excluded. After identifying the cohort, patients were contacted via phone to complete functional outcome scores including Conway Score, Western Ontario Shoulder Instability (WOSI) Index, Kerlan-Jobe Orthopedic Clinic (KJOC) Shoulder and Elbow Score, Short Form 12 Mental (MCS)/Physical (PCS) survey and a custom return to play questionnaire. Results: During this time period, 59 baseball players met the inclusion criteria for this study and 76.3% (45/59) of patients were available to be contacted to complete final follow-up surveys at a minimum of 2 years. All patients were male with a mean age of 17.4 +/- 1.5 (14-19) years. The mean follow-up of this cohort was 5.3 +/- 2.6 (2.1-12.1) years. The overall return to play rate was 75.6% (34/45). The average time from surgery to initiation of throwing was 5.9 +/- 2.0 (2-12) months and the average time to return to full competition was 11.3 +/- 3.5 (6-22) months after the surgery. After the SLAP repair, those who returned to play continuing playing baseball competitively for 3.0 +/- 1.9 (0.5-8.0) years after surgery. At the time of final follow-up, 71.1% (32/45) of players had stopped playing baseball. Of those who had stopped playing competitive baseball, 12 (37.5%) reported it was because they were not recruited to the next level, 10 (31.3%) reported they lost the desire to play and 10 (31.3%) reported their shoulder prevented them from playing. The overall mean KOJC, WOSI, SF-12 MCS and SF-12 PCS scores were 60.0 +/- 27.4 (range, 0-100), 21.0+/-20.6% (0-73.8%), 55.2+/-3.9 (37.4-59.8) and 55.2+/-5.6 (range, 37.9-65.7) respectively. The overall satisfaction score was 83.2% with 86.7% (39/45) saying they given the opportunity they would undergo surgery again. Conclusions: The results of this study demonstrated a low return to play rate and low patient reported outcomes on baseball specific surveys among adolescent baseball players who underwent a SLAP repair. Mean functional outcome scores between pitchers and position players were not found to be significantly different. Based on these findings, orthopedic surgeons can better counsel their adolescent baseball players on expectations for future return to play and functional outcomes after SLAP repair.

Objectives: While results following ulnar collateral ligament (UCL) injury in baseball players has been well documented, results following UCL injury in gymnasts are not well documented. As such, the purpose of this study was to report the operative and non-operative outcomes of UCL injury in gymnasts. Methods: Gymnasts who underwent UCL injury treatment whether non-operative or operative at a single institution were evaluated at a minimum of 2 years post-operatively. Patients were assessed with Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow Score (KJOC), Mayo Elbow Performance Score (MEPS), Andrews-Timmerman (A-T) Elbow score, Quick Disabilities of the Arm, Shoulder and Hand (qDASH) score and a custom return to play survey. Results: There were 11 patients who met inclusion criteria and complete follow-up was available in 9 patients. Overall, 6 patients were treated operatively (4 UCL reconstructions (UCLR) and 2 UCL repairs) and 3 patients were treated non-operatively. One UCLR was performed after 2 months of failed non-operative management. All patients were female with a mean age of 16.1 (range, 12-20) and mean BMI of 24.46 (range 19.2-34.1) at time of surgery or initial visit. Average follow-up was 4.04 years. Overall, 66.7% of operative versus 100% of non-operative were able to RTP at an average of 7.5 and 7 months, respectively. One re-injury was reported in the non-operative group, which was a re-dislocation of the elbow unrelated to gymnastics and was ultimately treated non-operatively. The mean KJOC, MEPS, A-T and qDASH scores for the operative group were 70.0 (range, 48.5-89), 97.5 (range, 95-100), 90.8 (range, 75-100) and 24.6 (range, 22.7-29.5), respectively. The mean scores for the non-operative group were 75.9 (range, 61-91.2), 71.7 (range, 65-75), 71.7 (range, 55-80) and 34.1 (range, 22.7-40.9), respectively. Conclusions: Both operative and non-operative treatments can be offered as successful treatment options for UCL injuries in gymnasts. Further investigation is needed to determine the optimal management of UCL injuries in gymnasts.

Background: Injury to the ulnar collateral ligament (UCL) leading to medial elbow instability and possible ulnar neuritis is common in overhead-throwing athletes. Treatment may require UCL reconstruction (UCLR) and concomitant ulnar nerve transposition (UNT) for those with preoperative ulnar neuritis. Purpose: To evaluate the return-to-play (RTP) rates, clinical outcomes, and rates of persistent ulnar neuritis after concomitant UCLR and UNT in a cohort of baseball players with confirmed preoperative ulnar neuritis. Study Design: Case series; Level of evidence, 4. Methods: Eligible patients were those who underwent concomitant UCLR and UNT at a single institution between January 2008 and June 2018 and who had a minimum of 2 years of follow-up. Additional inclusion criteria were athletes who identified as baseball players and who had a confirmed history of ulnar neuritis. Patients were contacted at a minimum of 2 years from surgery and assessed with the Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow Score, Andrew-Timmerman (A-T) Elbow Score, Mayo Elbow Performance Score (MEPS), Single Assessment Numeric Evaluation (SANE) score, and a custom RTP questionnaire. Results: Included were 22 male baseball players with a mean age of 18.9 ± 2.1 years (range, 16-25 years). The mean follow-up was 6.1 ± 2.4 years (range, 2.5-11.7 years). Preoperatively, all 22 patients reported ulnar nerve sensory symptoms, while 4 (18.2%) patients reported ulnar nerve motor symptoms. At the final follow-up, 7 (31.8%) patients reported persistent ulnar nerve sensory symptoms, while none of the patients reported persistent ulnar nerve motor symptoms. Overall, 16 (72.7%) players were able to return to competitive play at an average of 11.2 months. The mean postoperative patient-reported outcome scores for the KJOC Shoulder and Elbow Score, MEPS, A-T Elbow Score, and SANE score were 77.9 ± 20.9 (range, 14-100), 92.7 ± 12.7 (range, 45-100), 86.1 ± 17.1 (range, 30-100), and 85.5 ± 14.8 (range, 50-100), respectively. Conclusion: This study demonstrated that after concomitant UCLR and UNT for UCL insufficiency and associated ulnar neuritis, baseball players can expect reasonably high RTP rates and subjective outcomes; however, rates of persistent sensory ulnar neuritis can be as high as 30%.

Background: Injury to the quadriceps tendon is rare and most commonly occurs in middle-aged men. Few reports are available regarding outcomes after quadriceps tendon rupture in younger patients. Purpose/Hypothesis: To review the clinical outcomes of patients who underwent quadriceps tendon repair at age ≤40 years. We hypothesized that this cohort would experience better clinical outcomes in comparison to historical older controls. Study Design: Case series; Level of evidence, 4. Methods: Using an institutional database, we retrospectively identified patients who underwent quadriceps tendon repair between January 2009 and December 2017. Patients were included in the study if they were aged ≤40 years at the time of surgery and had sustained an isolated, complete tendon rupture. Patient and injury characteristics were recorded. Patients were contacted to complete a custom survey, the 2000 International Knee Documentation Committee (IKDC) form, the Lysholm scale, and the Tegner scale. Results: Included were 38 patients (86.8% male; mean age, 32.0 ± 6.9 years; age range, 15-40 years), with a mean follow-up of 5.9 ± 2.3 years (range, 2.4-11.3 years). At final follow-up, the mean IKDC score was 74.1 ± 22.6 (range, 26.4-100.0), and the mean Lysholm score was 85.4 ± 20.0 (range, 30-100), which were similar if not inferior to historical controls of patients >40 years. Only 16 patients (42.1%) had unchanged or higher Tegner scores after surgery, whereas 22 patients (57.9%) reported lower postoperative activity level. Overall, 91.2% (31/34) of workers returned at a mean 3.9 months after surgery, whereas 63% (12/19) of athletes were able to return to play at 8.8 months. At final follow-up, 12 patients (31.6%) reported persistent pain and stiffness in their knees. Additionally, 3 patients (7.9%) reported pain without stiffness, and 4 (10.5%) reported stiffness without pain. Patients reporting pain or stiffness had significantly lower IKDC scores, Lysholm scores, postoperative Tegner scores, and change in their Tegner score at final follow-up in comparison to those who did not report pain or stiffness. Conclusion: Although patients aged ≤40 years had satisfactory outcomes after quadriceps tendon repair, this injury resulted in significant long-term sequelae in a substantial percentage of patients, despite their youth. Further, this group did not have better outcomes compared with historical controls aged > 40 years.

Background: While the incidence of ulnar collateral ligament reconstruction (UCLR) has increased across all levels of play, few studies have investigated the long-term outcomes in nonprofessional athletes. Purpose: To determine the rate of progression to higher levels of play, long-term patient-reported outcomes (PROs), and long-term patient satisfaction in nonprofessional baseball players after UCLR. Study Design: Case series; Level of evidence, 4. Methods: We evaluated UCLR patients who were nonprofessional baseball athletes aged Results: A total of 91 baseball players met the inclusion criteria, and 67 (74%) patients were available to complete the follow-up surveys at a mean follow-up of 8.9 years (range, 5.5-13.9 years). At the time of the surgery, the mean age was 18.9 ± 1.9 years (range, 15-24 years). Return to play at any level was achieved in 57 (85%) players at a mean time of 12.6 months. Twenty-two (32.8%) of the initial cohort returned to play at the professional level. Also, 43 (79.1%) patients who initially returned to play after surgery reported not playing baseball at the final follow-up; of those patients, 12 reported their elbow as the main reason for eventual retirement. The overall KJOC, MEPS, and T-A scores were 82.8 ± 18.5 (range, 36-100), 96.7 ± 6.7 (range, 75-100), and 91.9 ± 11.4 (range, 50-100), respectively . There was an overall satisfaction score of 90.6 ± 21.5 out of 100, and 64 (95.5%) patients reported that they would undergo UCLR again. Conclusion: In nonprofessional baseball players after UCLR, there was a high rate of progression to higher levels of play. Long-term PRO scores and patient satisfaction were high. The large majority of patients who underwent UCLR would undergo surgery again at long-term follow-up, regardless of career advancement.

Objectives: Injury to the ulnar collateral ligament (UCL)—leading to medial elbow instability and concomitant ulnar neuropathy symptoms—is common in the overhead throwing athlete secondary to the repetitive stress that these individuals place on the elbow during the throwing motion. Treatment customarily involves UCL reconstruction (UCLR) and for those with preoperative ulnar neuropathy symptoms, concomitant ulnar nerve transposition (UNT) may also be warranted. The purpose of this study was to evaluate the return to play rates, clinical outcomes and more specifically rates of persistent ulnar nerve symptoms after concomitant UCLR and UNT in a cohort of baseball players with confirmed preoperative ulnar neuropathy symptoms. Methods: Patients who underwent concomitant UCLR and UNT from January 2008 to June 2018 were identified at one institution with a minimum of 2 years of follow-up. Additional inclusion criteria included athletes who identified as baseball players with a confirmed history of ulnar neuropathy symptoms. Exclusion criteria included patients who had any other concomitant open procedures at the time of surgery. After identifying the cohort, patients were contacted via phone to complete a Kerlan-Jobe Orthopedic Clinic Shoulder and Elbow Score (KJOC), Andrews-Timmerman (AT) Elbow Score, Mayo Elbow Performance Score (MEPS), Single Assessment Numeric Evaluation (SANE) score and a custom return to play questionnaire. Evidence for preoperative and postoperative ulnar nerve symptoms was elicited within the custom survey and corroborated with the provider’s clinical notes. Sensory ulnar nerve symptoms were defined as having numbness and/or tingling sensations in the 5th and ulnar half of the 4th fingers. Motor ulnar nerve symptoms were defined as either exhibiting 1st dorsal interosseous muscle weakness by inability to maintain finger abduction resistance, ulnar-sided hand grip weakness of inability to control precise movement of the 5th digit. Results: During this time period, a total of 22 male baseball players underwent concomitant UCLR and UNT at a mean age of 18.9+/-2.1 years (range, 16-25). The mean follow-up was 6.1+/-2.4 years (range, 2.5-11.7 years). The cohort consisted of 15 pitchers and 7 position players. In total, 7 players competed in high school and 15 competed in college. Preoperatively, all 22 patients reported ulnar nerve sensory symptoms while only 4 (18.2%) patients reported ulnar nerve motor symptoms. Overall, 16 (72.3%) players were able to return to competitive play at an average of 11.2 months. Of the 6 that failed to return to play after surgery, 3 reported that persistent elbow symptoms were the reason for not returning to play while the other 3 reported losing the desire to return to play. At final follow-up, 7 (31.8%) patients reported of persistent sensory ulnar nerve sensory symptoms while 1 (4.5%) of these patients additionally reported persistent ulnar nerve motor symptoms. The mean postoperative patient reported outcome scores were as follows: KJOC: 77.9+/-20.9 (range, 14-100); MEPS: 92.7+/-12.7 (range, 45-100); AT Elbow Score: 86.1+/-17.1 (range, 30-100); SANE score: 85.5+/-14.8 (range, 50-100). Conclusions: While patient-reported outcome scores and return to play rates are reasonably high, this study demonstrates that following concomitant UCL reconstruction and ulnar nerve transposition for UCL insufficiency and associated ulnar neuropathy, rates of persistent ulnar neuropathy symptoms are persistently present in over 30% of patients. Currently, handling of the ulnar nerve in the setting of UCL insufficiency is debated and thus further investigation is warranted to optimize outcomes for this group of patients.

Background:The application of continuous passive motion (CPM) after anterior cruciate ligament reconstruction (ACLR) was popularized in the 1990s, but advancements in the understanding of ACLR rehabilitation have made the application of CPM controversial. Many sports medicine fellowship–trained surgeons report using CPM machines postoperatively.Purpose:To determine the efficacy of CPM use for recovery after ACLR with respect to knee range of motion (ROM), knee swelling, postoperative pain, and postoperative complications.Study Design:Systematic review; Level of evidence, 3.Methods:The PubMed (MEDLINE), EMBASE, Cochrane, Cumulative Index of Nursing, and Allied Health Literature databases were searched from inception to January 1, 2020, for studies with evidence levels 1 to 3 on the use of CPM for ACLR rehabilitation. Included studies were those that comparatively evaluated postoperative outcomes after ACLR between at least 2 groups of patients, with 1 having received CPM rehabilitation and the other not having received CPM.Results:A total of 12 studies from 1989 to 2019 met the inclusion criteria. These studies included 808 patients who underwent ACLR. There was no evidence of CPM improving knee stability, final postoperative ROM, or subjective pain scores. Additionally, CPM did not lead to decreased muscle atrophy or improved International Knee Documentation Committee scores. Regarding pain medication intake during postoperative hospitalization, 2 studies found that the CPM group used less pain medication, 1 study found the CPM group used more pain medication, and 1 study found that there was no difference between the 2 groups. Complications varied widely, with 2 of 12 studies reporting complications that required a return to the operating room.Conclusion:A clinical benefit of postoperative CPM use after ACLR was not identified in this review. While our systematic review identified a number of studies that suggest CPM use may be associated with lower usage of pain medication in hospitalized patients, this cannot be confirmed without further investigation with standardized CPM protocols and larger sample sizes. Routine CPM use after ACLR was not supported by this systematic review.

Background: Children are more vulnerable to ionizing radiation which increases health risks later in life including cancer. An interdepartmental team developed an algorithm to guide providers ordering extremity radiographs in pediatric patients with musculoskeletal (MSK) injuries. Purpose: Reduce unnecessary pediatric radiation/extremity radiographs through development and implementation of an interdepartmental designed algorithm. Determine utility, safety, and efficacy of the algorithm through retrospective and prospective analysis. Methods: Our study was performed at an academic pediatric trauma center. An interdepartmental committee including pediatric orthopedic surgery, emergency medicine, trauma, and radiology providers created a MSK injury imaging algorithm (Figure 1). We retrospectively validated the algorithm for efficacy and safety through chart review of pediatric patients seen in the ED with MSK extremity injury, identified through CPT code, from 6/24/2016 through 8/31/2016. We determined the number of extra radiographs per patient and identified if injuries would be missed utilizing our protocol. After retrospective validation, guideline implementation was undertaken through multidisciplinary education. The imaging guideline was prospectively implemented in the pediatric ED from 6/24/2018 through 8/31/2018. We continued to prospectively evaluate through selecting one week every month over the following eight months to determine sustainability of the implemented algorithm. Results: Our interdepartmental team in 2016 developed a pediatric MSK radiograph protocol (Figure 1). A retrospective chart and radiograph review of 295 pediatric patients between 6/24/2016 through 8/31/2016 was analyzed correlating physical examination to appropriate radiographs. Utilizing the protocol, the review revealed an average of 2.75 extra radiographs per patient. No injuries were missed. Providers including orthopedic and emergency medicine attendings, mid-levels, and residents were educated through meetings, emails, and having the protocol posted and easily accessible. Our protocol was implemented 6/24/18 and underwent prospective enrollment and review through 8/31/18 which revealed a reduction to 0.72 radiographs per patient (P-value Conclusion: Reduction of unnecessary radiation to pediatric patients with MSK extremity injuries was accomplished through development and implementation of a safe and effective imaging algorithm. The multidisciplinary approach combined with widespread education of pediatric providers improved buy-in driving a sustainable system improvement. [Figure: see text][Figure: see text][Figure: see text]

Objectives: Tibial tuberosity osteotomy is often performed to correct excessive lateralization of the tuberosity in patients with patellar instability. An anteriorizing component has been recommended in the setting of chondral pathology, yet the ideal anterior-posterior relationship of the tibial tuberosity to the trochlear groove is unknown. Methods: Patients with symptomatic patellar instability underwent static CT imaging, and were compared to age- and gender-matched controls. All knees were imaged in full extension. Tibial-tuberosity-trochlear-groove (TTTG) distance was measured to quantify lateralization of the tuberosity, as well as the anterior-posterior distance between these two points (APTTTG distance). Lateral trochlear inclination (LTI), sulcus angle (SA) and trochlear depth (TD) were measured as indicators of trochlear dysplasia. Measurements were compared between the symptomatic and control groups using paired t-tests. Correlations between APTTTG with LTI, SA and TD were assessed using linear regression analyses. Results: 22 knees in 18 patients with symptomatic patellar instability were included in the study group, with 22 control knees. TTTG and APTTTG distances were 19.9 mm and 8.3 mm in the symptomatic group, versus 16.8 mm and -0.5 mm in the control group, with a difference of 3.1 mm (p=0.002) and 8.8 mm (pConclusion: Our findings demonstrate that the trochlear groove is almost 9mm more anterior to the tibial tuberosity in patients with symptomatic instability, and this distance correlates with measurements of trochlear dysplasia. While further studies are needed to determine the relationship between APTTTG distance and patellar instability, these findings suggest that the anterior-posterior relationship between the trochlea and tuberosity may be a factor to consider when planning for tibial tuberosity osteotomy in patients with trochlear dysplasia.