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Background: Most healthcare providers utilize magnetic resonance imaging (MRI) to assist in diagnosing and treating osteochondritis dissecans (OCD) of the capitellum. However, consensus on imaging features that portend clinically relevant information in the care of these lesions has not been determined. Purpose: To conduct a survey on the MRI features of a capitellar OCD that are salient for clinical decision-making using a classic Delphi protocol. Study Design: A consensus statement. Methods: Invitations to participate were sent to 33 healthcare providers identified as capitellar OCD experts. A classic 3-round survey method was used to gather agreement and consensus on the level of importance for clinical decision-making on 33 MRI features. A concise list of features that guide decision-making on the stability of an OCD lesion and the ability of an OCD lesion to heal with nonoperative care was also identified. Agreement and consensus were determined a priori as ≥66%. Results: Of the 33 identified experts, 20 agreed to participate, and 17 (52%) completed all 3 rounds. Of the 33 MRI features evaluated, 17 reached agreement as important for clinical decision-making by the experts. Consensus was reached for a concise list of MRI features that were significant to decision-making (94%), suggestive of a stable lesion (100%), had the potential to heal with nonoperative treatment (94%), were suggestive of an unstable lesion (100%), and had low potential to heal with nonoperative treatment (88%). Conclusion: This 3-round Delphi process produced consensus on clinically relevant MRI features that contribute to clinical decision-making for capitellar OCD. The results of this study will be used as the basis for an interrater reliability assessment of the identified salient features, creating the foundation for developing a reliable MRI assessment tool rooted in clinical experiences. The development of a standardized assessment of capitellar OCD is intended to improve clinical practice and patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Osteochondritis dissecans (OCD) occurs most commonly in the knees of young individuals. This condition is known to cause pain and discomfort in the knee and can lead to disability and early knee osteoarthritis. The cause is not well understood, and treatment plans are not well delineated. The Research in Osteochondritis Dissecans of the Knee (ROCK) group established a multicenter, prospective cohort to better understand this disease. Purpose: To provide a baseline report of the ROCK multicenter prospective cohort and present a descriptive analysis of baseline data for patient characteristics, lesion characteristics, and clinical findings of the first 1000 cases enrolled into the prospective cohort. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Patients were recruited from centers throughout the United States. Baseline data were obtained for patient characteristics, sports participation, patient-reported measures of functional capabilities and limitations, physical examination, diagnostic imaging results, and initial treatment plan. Descriptive statistics were completed for all outcomes of interest. Results: As of November 2020, a total of 27 orthopaedic surgeons from 17 institutions had enrolled 1004 knees with OCD, representing 903 patients (68.9% males; median age, 13.1 years; range, 6.3-25.4 years), into the prospective cohort. Lesions were located on the medial femoral condyle (66.2%), lateral femoral condyle (18.1%), trochlea (9.5%), patella (6.0%), and tibial plateau (0.2%). Most cases involved multisport athletes (68.1%), with the most common primary sport being basketball for males (27.3% of cases) and soccer for females (27.6% of cases). The median Pediatric International Knee Documentation Committee (Pedi-IKCD) score was 59.9 (IQR, 45.6-73.9), and the median Pediatric Functional Activity Brief Scale (Pedi-FABS) score was 21.0 (IQR, 5.0-28.0). Initial treatments were surgical intervention (55.4%) and activity restriction (44.0%). When surgery was performed, surgeons deemed the lesion to be stable at intraoperative assessment in 48.1% of cases. Conclusion: The multicenter ROCK group has been able to enroll the largest knee OCD cohort to date. This information is being used to further understand the pathology of OCD, including its cause, associated comorbidities, and initial presentation and symptoms. The cohort having been established is now being followed longitudinally to better define and elucidate the best treatment algorithms based on these presenting signs and symptoms. [ABSTRACT FROM AUTHOR]

The incidence of elbow injury experienced by baseball pitchers is on the rise. Biomechanical investigations focusing on the acceleration phase of the pitch have yet to elucidate a singular cause for these injuries. Leading to the question is there an additional significant stress on the elbow during other phases of the pitch? This study sought to determine the magnitude of the elbow varus moment during the deceleration phase of the pitching cycle for the fastball, curveball, slider and change-up. Eighty-seven collegiate-level pitchers were evaluated using motion analysis techniques to determine the magnitude of the elbow varus moment occurring during the deceleration phase. The results indicated that the elbow varus moment during the deceleration phase of the pitch was typically between 40% and 50% of the peak acceleration phase moment and was greatest when throwing a slider. Results also indicated that more pitchers experienced deceleration phase moments in excess of 50% of the acceleration moment when throwing breaking pitches. These moments which are the result of the pitchers' need to rapidly decelerate their arm produce an additional significant elbow varus moment that results in additional stress to the elbow. [ABSTRACT FROM AUTHOR]

Documentation of the lower extremity motion patterns of adolescent pitchers is an important part of understanding the pitching motion and the implication of lower extremity technique on upper extremity loads, injury and performance. The purpose of this study was to take the initial step in this process by documenting the biomechanics of the lower extremities during the pitching cycle in adolescent pitchers and to compare these findings with the published data for older pitchers. Three-dimensional motion analysis using a comprehensive lower extremity model was used to evaluate the fast ball pitch technique in adolescent pitchers. Thirty-two pitchers with a mean age of 12.4 years (range 10.5-14.7 years) and at least 2 years of experience were included in this study. The pitchers showed a mean of 49 ± 12° of knee flexion of the lead leg at foot contact. They tended to maintain this position through ball release, and then extended their knee during the follow through phase (ball release to maximal internal glenohumeral rotation). The lead leg hip rapidly progressed into adduction and flexion during the arm cocking phase with a range of motion of 40 ± 10° adduction and 30 ± 13° flexion. The lead hip mean peak adduction velocity was 434 ± 83°/s and flexion velocity was 456 ± 156°/s. Simultaneously, the trailing leg hip rapidly extended approaching to a mean peak extension of -8 ± 5° at 39% of the pitch cycle, which is close to passive range of motion constraints. Peak hip abduction of the trailing leg at foot contact was -31 ± 12°, which also approached passive range of motion constraints. Differences and similarities were also noted between the adolescent lower extremity kinematics and adult pitchers; however, a more comprehensive analysis using similar methods is needed for a complete comparison. [ABSTRACT FROM AUTHOR]

Background: The incidence of upper extremity injury in baseball pitchers has increased over the past decade. This has resulted in a large body of research mainly focused on the kinematic and kinetic patterns of the elbow and shoulder to elucidate the cause of these injuries, with little attention on studying the associations of forearm rotation and upper arm joint moments. Hypothesis: There will be significant differences in forearm kinematics and kinetics when comparing the fastball pitch with the curveball pitch. There will be a positive association between forearm kinetics, specifically supination and pronation moments, and the elbow varus moment. Study Design: Descriptive laboratory study. Methods: A total of 78 pitchers were recruited for this study, and they underwent a pitching analysis using motion analysis techniques. A random-intercept, mixed-effects regression model was used to determine differences in forearm kinematics and kinetics when pitching a fastball compared with a curveball, as well as to determine if associations existed between forearm supination and pronation moments and the elbow varus moment. Results: There were a number of significant differences in forearm position when pitching a fastball compared with a curveball, with the curveball producing a more supinated forearm position. Significant associations were found between increasing forearm supination moments and an increase in elbow varus moment for both the fastball and the curveball (P = .002 and P < .001, respectively). For every 1-N·m increase in the supination moment, there was a 1-N·m and 1.1-N·m increase in the elbow varus moment for the fastball and curveball, respectively. Conclusion: The results demonstrated that the forearm position was not associated with the elbow varus moment. However, the supination moment was associated with the elbow varus moment. Clinical Relevance: On the basis of these findings, pitching coaches and trainers can understand the implications of proper lower arm pitching mechanics in the later portion of the pitch cycle as a potential risk of injury and, therefore, can develop coaching strategies to reduce incorrect positioning, especially when players are pitching the curveball. [ABSTRACT FROM AUTHOR]

Background: Access to health care services is a critical component of health care reform and may differ among patients with different types of insurance. Hypothesis/Purpose: The purpose was to compare adolescents with private and public insurance undergoing surgery for anterior cruciate ligament (ACL) and/or meniscal tears. We hypothesized that patients with public insurance would have a delayed presentation from the time of injury and therefore would have a higher incidence of chondral injuries and irreparable meniscal tears and lower preoperative International Knee Documentation Committee (IKDC) scores than patients with private insurance. Study Design: Cross-sectional study; Level of evidence, 3. Methods: This was a retrospective study of patients under 21 years of age undergoing ACL reconstruction and/or meniscal repair or debridement from January 2013 to March 2016 at a single pediatric sports medicine center. Patients were identified by a search of Current Procedural Terminology (CPT) codes. A chart review was performed for insurance type; preoperative diagnosis; date of injury, initial office visit, and surgery; preoperative IKDC score; intraoperative findings; and procedures. Results: The study group consisted of 119 patients (mean age, 15.0 ± 1.7 years). Forty-one percent of patients had private insurance, while 59% had public insurance. There were 27 patients with isolated meniscal tears, 59 with combined meniscal and ACL tears, and 33 with isolated ACL tears. The mean time from injury to presentation was 56 days (range, 0-457 days) in patients with private insurance and 136 days (range, 0-1120 days) in patients with public insurance (P = .02). Surgery occurred, on average, 35 days after the initial office visit in both groups. The mean preoperative IKDC score was 53 in both groups. Patients with meniscal tears with public insurance were more likely to require meniscal debridement than patients with private insurance (risk ratio [RR], 2.3; 95% CI, 1.7-3.1; P = .02). Patients with public insurance were more likely to have chondral injuries of grade 2 or higher (RR, 4.4; 95% CI, 3.9-5.0; P = .02). Conclusion: In adolescent patients with ACL or meniscal tears, patients with public insurance had a more delayed presentation than those with private insurance. They also tended to have more moderate-to-severe chondral injuries and meniscal tears, if present, that required debridement rather than repair. More rapid access to care might improve the prognosis of young patients with ACL and meniscal injuries with public insurance. [ABSTRACT FROM AUTHOR]

Background: The reliability of assessing healing on plain radiographs has not been well-established for knee osteochondritis dissecans (OCD). Purpose: To determine the inter- and intrarater reliability of specific radiographic criteria in judging healing of femoral condyle OCD. Study Design: Cohort study (Diagnosis); Level of evidence, 3. Methods: Ten orthopedic sports surgeons rated the radiographic healing of 30 knee OCD lesions at 2 time points, a minimum of 1 month apart. First, raters compared pretreatment and 2-year follow-up radiographs on “overall healing” and on 5 subfeatures of healing, including OCD boundary, sclerosis, size, shape, and ossification using a continuous slider scale. “Overall healing” was also rated using a 7-tier ordinal scale. Raters then compared the same 30 pretreatment knee radiographs in a stepwise progression to the 2-, 4-, 7-, 12-, and 24-month follow-up radiographs on “overall healing” using a continuous slider scale. Interrater and intrarater reliability were assessed using intraclass correlations (ICC) derived from a 2-way mixed effects analysis of variance for absolute agreement. Results: Overall healing of the OCD lesions from pretreatment to 2-year follow-up radiographs was rated with excellent interrater reliability (ICC = 0.94) and intrarater reliability (ICC = 0.84) when using a continuous scale. The reliability of the 5 subfeatures of healing was also excellent (interrater ICCs of 0.87-0.89; intrarater ICCs of 0.74-0.84). The 7-tier ordinal scale rating of overall healing had lower interrater (ICC = 0.61) and intrarater (ICC = 0.68) reliability. The overall healing of OCD lesions at the 5 time points up to 24 months had interrater ICCs of 0.81-0.88 and intrarater ICCs of 0.65-0.70. Conclusion: Interrater reliability was excellent when judging the overall healing of OCD femoral condyle lesions on radiographs as well as on 5 specific features of healing on 2-year follow-up radiographs. Continuous scale rating of OCD radiographic healing yielded higher reliability than the ordinal scale rating. Raters showed substantial to excellent agreement of OCD overall radiographic healing measured on a continuous scale at 2, 4, 7, 12, and 24 months after starting treatment. [ABSTRACT FROM AUTHOR]

Background: The incidence of upper extremity injuries in baseball pitchers is increasing. Over the past decade there has been a great deal of research attempting to elucidate the cause of these injuries, focusing mainly on the mechanics of the pitching arm with no examination of other key segments, such as the trunk. This is surprising, as coaches will often comment on trunk position in an effort to improve pitching outcomes. Purpose: To determine the association between contralateral trunk lean and ball velocity and the moments about the elbow and glenohumeral joint. Study Design: Descriptive laboratory study. Methods: A total of 99 pitchers were recruited for this study and underwent a pitching analysis using 3-dimensional motion analysis techniques. A random intercept mixed-effects regression model was used to determine if statistically significant associations existed between contralateral trunk lean (away from the pitching arm side) and ball velocity, as well as the elbow varus moment and glenohumeral internal rotation moment. Results: The results demonstrated that the greatest contralateral trunk lean occurs around the time of the peak elbow varus moment. Statistically significant associations were found between contralateral trunk lean and increased ball velocity (P = .003) indicating that for every 10 increase in contralateral lean, ball velocity increased 0.5 m/s. Results also indicated that for every 10 increase in contralateral lean, elbow varus moments increased by 3.7 Nm and glenohumeral internal rotation moments increased by 2.5 Nm (P \ .001 for both). Conclusion: Study findings indicate that the positioning of the trunk plays a substantial role in pitching performance and pitcher injury potential. This work helps to demonstrate the importance of proper trunk mechanics in pitching and highlights the need for future research to understand the contribution of the trunk to pitching mechanics. Clinical Relevance: Pitching coaches and trainers can use the results of this study to stress the importance of proper trunk mechanics in pitching. Specifically, improving core strength and trunk control in an effort to maintain a more upright posture through the pitching cycle can reduce upper extremity joint stresses. [ABSTRACT FROM AUTHOR]

Background: Anterior cruciate ligament (ACL) reconstruction failure occurs in up to 10% of cases. Technical errors are considered the most common cause of graft failure despite the absence of validated studies. Limited data are available regarding the agreement among orthopaedic surgeons regarding the causes of primary ACL reconstruction failure and accuracy of graft tunnel Placement.Hypothesis: Experienced knee surgeons have a high level of interobserver reliability in the agreement about the causes of primary ACL reconstruction failure, anatomic graft characteristics, and tunnel placement.Study Design: Cohort study (diagnosis); Level of evidence, 3.Methods: Twenty cases of revision ACL reconstruction were randomly selected from the Multicenter ACL Revision Study (MARS)database. Each case included the patient's history, standardized radiographs, and a concise 30-second arthroscopic video taken at the time of revision demonstrating the graft remnant and location of the tunnel apertures. All 20 cases were reviewed by 10 MARS surgeons not involved with the primary surgery. Each surgeon completed a 2-part questionnaire dealing with each surgeon's training and practice, as well as the placement of the femoral and tibial tunnels, condition of the primary graft, and the surgeon's opinion as to the causes of graft failure. Interrater agreement was determined for each question with the kappa coefficient and the prevalence-adjusted, bias-adjusted kappa (PABAK).Results: The 10 reviewers have been in practice an average of 14 years and have performed at least 25 ACL reconstructions per year, and 9 were fellowship trained in sports medicine. There was wide variability in agreement among knee experts as to the specific causes of ACL graft failure. When participants were specifically asked about technical error as the cause for failure, inter-observer agreement was only slight (PABAK = 0.26). There was fair overall agreement on ideal femoral tunnel placement (PABAK= 0.55) but only slight agreement on whether a femoral tunnel was too anterior (PABAK = 0.24) and fair agreement on whether it was too vertical (PABAK = 0.46). There was poor overall agreement for ideal tibial tunnel placement (PABAK = 0.17).Conclusion: This study suggests that more objective criteria are needed to accurately determine the causes of primary ACL graft failure as well as the ideal femoral and tibial tunnel placement in patients undergoing revision ACL reconstruction. [ABSTRACT FROM AUTHOR]

Current pitching literature focuses primarily on the elbow and glenohumeral joints. This has led to a paucity of information regarding the forearm and wrist, and the limited data available are inconsistent. Therefore, this article seeks to provide a comprehensive description of the kinematics and kinetics of the wrist and forearm for the fastball, curveball, slider/cutter, and change-up for college-level baseball pitchers. Thirty-six collegiate pitchers were evaluated using motion analysis techniques. Results indicated that pitching the curveball generated the greatest forearm supination (16 ± 13°) compared with the other three pitch types (p < 0.05). The curveball and slider/cutter were pitched with less wrist extension and greater ulnar deviation compared with the fastball and change-up. The curveball was found to produce the greatest ulnar moment (7.3 ± 2.2 Nm) and was significantly different from the moments noted when pitching the fastball and change-up (5.1 ± 1.9 and 4.9 ± 1.9 Nm, respectively;p < 0.05). These results indicate that it may be possible to objectively determine pitch type from kinematic data of the wrist and forearm. It may also be possible that coaches may be able to identify abnormal pitching mechanics from more proximal segments by understanding the motion of the wrist. [ABSTRACT FROM PUBLISHER]

The art of hands-on physical examination has discovered a new way to diagnose patients with hip labral tears. Literature has called for improvements in hip physical examination techniques. This article reports a rigorous study that demonstrates this new physical examination technique and correlates it with current practice and standards of care. THIRD test is highly sensitive and specific for diagnosing hip labral tears. The inclusion of this test will improve diagnosis and establishment of treatment plans in the evaluation of patients with hip pain. [ABSTRACT FROM AUTHOR]