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PURPOSE OF REVIEW: The goal of this review article is to help medical personnel of all levels and backgrounds identify and appropriately manage on-field acute shoulder and elbow injuries in the baseball athlete. This article discusses the most common acute shoulder and elbow injuries in baseball players along with recommendations for appropriate on-field management. RECENT FINDINGS: Shoulder and elbow injuries are very common in baseball players and can be problematic because of the unique demands placed on the shoulder and elbow during the throwing and swinging motions. While many shoulder and elbow injuries in baseball players are chronic, some acute injuries, including dislocations and fractures, require urgent on-field management. Evaluation should begin with a broad assessment to rule out life-threatening emergencies prior to performing a neurovascular evaluation of the affected extremity. Red-flag signs during examination, such as difficulty breathing, asymmetric pulses, weakness, and limb discoloration, require emergent treatment. In the absence of an emergency, the evaluating medical team should complete a basic neurovascular exam before performing any further on-field care. SUMMARY: Contusions, dislocations, and fractures are the most commonly seen acute shoulder and elbow injuries in baseball athletes. Athletic trainers and physicians caring for these athletes should be familiar with these injuries and their appropriate on-field management.

Background: Open debridement (OD) of the extensor carpi radialis brevis tendon, both with and without repair to the lateral epicondyle, are effective treatments for recalcitrant lateral epicondylitis. However, few comparative studies exist within the literature. Purpose: To (1) compare the 5-year reoperation rates of patients who underwent OD alone versus OD with tendon repair (ODR) and (2) identify the 90-day adverse event rates, total same-day reimbursement amounts, and national usage trends for these 2 procedures from 2010 to 2019. Study Design: Cohort study; Level of evidence, 3. Methods: The PearlDiver MUExtr database was reviewed for patients diagnosed with lateral epicondylitis who underwent OD alone and ODR or reattachment between January 2010 and December 2019. These patients were stratified into 2 cohorts: the OD cohort and ODR cohort. The 5-year reoperation rates were assessed and compared, and the incidence of 90-day postoperative complications and risk factors were identified. The number of ODs and ODRs performed each year and the mean same-day reimbursement amounts (in US$) for both procedures were assessed. Results: Overall, 41,932 lateral epicondylitis patients who underwent debridement were identified, with 17,139 OD patients and 24,793 ODR patients. There were no significant changes in the proportion of OD versus ODR procedures performed during the study period ( P = .18). A significantly higher incidence of hematoma was seen after OD compared with ODR (0.19% vs 0.12%; P = .04), but ODR had a significantly lower 5-year reoperation rate than OD (2.8% vs 3.9%; P = .006), with an absolute risk reduction of 1.1% and a number needed to treat of 91. Finally, ODR ($1683.17 ± $12.15) had a higher mean same-day reimbursement than OD ($1479.05 ± $15.78) ( P = .001). Conclusion: Both OD and ODR had low complication rates. The 5-year reoperation rates were low for both procedures, but they were significantly higher for OD. Over the 10-year study period, there were no significant changes in the relative percentages of OD versus ODR performed. ODR had a significantly higher mean same-day reimbursement.

Background Analyzing outcomes and the minimal clinically important difference (MCID) after anterior cruciate ligament reconstruction (ACLR) is of increased interest in the orthopaedic literature. The purposes of this study were to report outcomes after ACLR at medium to long-term follow-up, identify the threshold preoperative outcome values that would be predictive of achieving the MCID postoperatively, and analyze outcome maintenance at medium to long-term follow-up after ACLR. Methods Active athletes who underwent ACLR were identified in an institutional ACL registry. Patient-reported outcome measures (PROMs) were administered preoperatively and at the 2-year and >5-year postoperative follow-up; measures included the International Knee Documentation Committee (IKDC) form, the 12-item Short Form Health Survey (SF-12) Physical Component Summary (PCS) and Mental Component Summary (MCS), and Lysholm scale. We calculated the MCID from baseline to each of the 2 follow-up periods (2-year and mean 7.7-year). Logistic regression was performed to investigate factors associated with achievement of the MCID. Results A total of 142 patients (mean follow-up, 7.7 years [range, 6.6 to 9.1 years]) underwent ACLR. The mean age and body mass index at the time of surgery were 27.2 ± 13.0 years and 23.2 ± 3.0 kg/m2, respectively. Final postoperative outcome scores improved significantly from baseline for the IKDC (50.9 ± 14.7 to 87.9 ± 11.2), SF-12 PCS (41.6 ± 8.9 to 55.6 ± 3.2), and Lysholm scale (62.2 ± 17.6 to 90.5 ± 10.3) (p 5-year follow-up, the SF-12 PCS showed significant improvement (54.6 ± 4.5 to 55.6 ± 3.2; p = 0.036), while no change was noted in the IKDC (87.6 ± 11.1 to 87.9 ± 11.2), SF-12 MCS (55.5 ± 5.3 to 54.4 ± 6.0), and Lysholm scale (89.8 ± 10.6 to 90.5 ± 10.3) (p ≥ 0.09). At the time of final follow-up, the MCID was achieved by 94.7% of patients for the IKDC, 80.8% for the Lysholm, 79.0% for the SF-12 PCS, and 28.2% for the SF-12 MCS. At 2-year follow-up, 95.3% of patients were either "very" or "somewhat" satisfied with their surgery, compared with 88.6% at the time of final follow-up. Conclusions We found a high level of maintained function following ACLR. The IKDC, SF-12 PCS, and Lysholm scores improved significantly after ACLR at the time of final follow-up and were not significantly different between follow-up periods. Approximately 95% and 89% of patients reported being satisfied with the outcome of surgery at the 2-year and final follow-up, respectively. Level of Evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: Anterior cruciate ligament (ACL) injuries are occurring with increasing frequency in the adolescent population. Outcomes after ACL reconstruction (ACLR) are inconsistently reported in homogeneous patient populations. Purpose/Hypothesis: To evaluate outcomes after bone–patellar tendon–bone (BTB) autograft ACLR in competitive high school–aged athletes by examining return to sport (RTS), patient satisfaction, and reinjury rates. Our hypothesis was that RTS rates and satisfaction will be high and reinjury rates will be low. Study Design: Case series; Level of evidence, 4. Methods: An institutional ACL registry was utilized to identify competitive high school–aged athletes (14-18 years old) who underwent primary ACLR using BTB autograft with a minimum 2-year follow-up. A postoperative questionnaire was administered to determine rates and types of RTS, quality of sports performance, reinjury, and satisfaction. Uni- and multivariable analyses were used to identify demographic, sport-specific, and clinical factors related to RTS. Results: A total of 53 patients were included (mean ± SD age at the time of surgery, 16.6 ± 1.34 years). Mean follow-up was 3.78 ± 0.70 years (range, 2.60-4.94 years). The overall ipsilateral ACL retear rate was 7.5% (n = 4). There were 10 subsequent ACL tears to the contralateral knee (19%). Forty-four (83%) patients successfully returned to at least their prior level of sport at a mean 10.5 ± 8.7 months (range, 3-48 months). Overall satisfaction was high, with 91% of patients very satisfied with the outcome. Higher confidence levels regarding performance of the reconstructed knee were associated with increased probability of RTS on multivariate analysis. Conclusion: BTB autograft ACLR results in high rates of RTS and satisfaction and low rates of subsequent ipsilateral ACL injuries in competitive high school–aged athletes. Patients with higher confidence in performance of the reconstructed knee are more likely to return to at least their prior level of sport.

BACKGROUND: Medial epicondylitis (ME), or “golfer’s elbow,” is often treated initially by conservative means. Up to 15% of recalcitrant cases require surgical intervention, according to small sample populations, but no national study has determined the incidence of the diagnosis or corroborated the rate of surgical intervention. PURPOSE/QUESTION: We sought to review the annual incidence of ME, surgical rates, and health care costs in a population setting. METHODS: A national database was queried for ME from 2007 to 2014. Annual rates and the percentage of diagnosed cases subjected to surgical intervention were recorded. Epidemiologic data was reported with descriptive statistics, and the significant trends over time were analyzed using linear regression. RESULTS: We identified 19,856 cases of ME in the study period. There was a significant increase in the annual incidence and overall incidence per 10,000 patients. The proportion of diagnoses in patients under 65 years of age decreased significantly, while the proportion in those 65 years of age or older significantly increased. The annual number of surgical interventions significantly increased over the study period, although the annual proportion of diagnosed cases proceeding to surgery remained constant. The proportion of patients 65 years of age or older undergoing surgery significantly increased. Total reimbursement for the management of ME during the study period was $1,877,189. While there was a significant increase in the total annual reimbursement, annual per-patient reimbursement did not change significantly. CONCLUSIONS: While the annual incidence of ME and surgical treatment of ME increased significantly from 2007 to 2014, the proportion of cases treated surgically did not. Notably, the proportion of patients 65 years of age or older diagnosed with and being surgically treated for ME has increased in recent years. Total reimbursement for ME has steadily risen, although per-patient reimbursement rates have not significantly changed.

National rates of lateral epicondylitis and surgical treatment are poorly defined. Disease burden of lateral epicondylitis (LE) continues to increase annually. Further study is necessary to optimize treatment algorithms to reduce associated health-care expenditures.The purpose of this study is to review the annual incidence of LE, surgical rates, and associated health-care costs in a population setting.A national database was queried for LE from 2007 to 2014. Surgical cases were identified and annual rates were recorded. Demographic and epidemiologic data were reported with descriptive statistics, while trends over time were analyzed using linear regression.Eighty-five thousand three hundred eighteen cases of LE were identified. The annual incidence per 10,000 patients remained constant (The annual incidence of LE and rate of surgical intervention have remained constant from 2007 to 2014. The proportion of patients over65 years diagnosed with, and receiving surgical treatment for, LE has significantly increased in recent years. Total reimbursement and average per-patient reimbursement have steadily risen, demonstrating the increasing burden of cost on the health-care system.

Purpose Posterior elbow impingement can cause disabling pain and limited motion during activities involving elbow extension. Less understood is whether arthroscopic treatment, compared to open surgery, can result in effective management of pain, loss of range of motion, and return athletes to previous levels of activity. This study determined whether arthroscopic debridement is a safe and effective treatment for posterior elbow impingement and whether it enables athletes to return to a previous level of function. Methods A retrospective review of 36 consecutive patients that underwent arthroscopic debridement of the posterior elbow was performed. There were 34 male and 2 female patients, with a median age of 32 years (17–54 years). There were 7 professional athletes, 6 college athletes, and 23 high school or recreational athletes. All patients had a positive posterior impingement test for posterior pain with extension and limitations of activity. Arthroscopic debridement and additional surgical procedures were performed, and patients underwent follow-up visits at a median 51 months (range 14–81). Results Significant improvements were seen in pain, motion, and function. No neurovascular complications were seen related to the arthroscopic debridement. The mean Andrews and Timmerman elbow score improved from 159 ± 27 to 193 ± 11 (p

Background: Ulnar collateral ligament (UCL) reconstruction of the elbow is commonly performed on professional baseball pitchers. Recent reports have suggested that revision rates are on the rise and may be higher than previously thought. Purpose: To provide a comprehensive report on current trends, surgical techniques, and outcomes of revision UCL reconstructions performed on professional baseball pitchers between 2010 and 2016. Study Design: Case series; Level of evidence, 4. Methods: The Major League Baseball Health and Injury Tracking System (HITS) was used to compile records of all revision UCL reconstructions performed on professional baseball pitchers between 2010 and 2016. Player data and outcomes were obtained from HITS, and surgical details were obtained from operative reports. Descriptive statistical analysis was performed on epidemiologic data. Outcomes (return to play [RTP] rates, RTP times, subsequent injuries, and subsequent surgeries) were compared across the most common surgical techniques (docking vs modified Jobe) and graft sources (palmaris longus autograft vs hamstring autograft). Results: A total of 69 professional baseball pitchers underwent revision UCL reconstruction from 2010 to 2016 at an average of 1424 days (47 months) after their primary surgery. A trend was seen toward increasing numbers of revision surgeries over time ( R2 = 0.441; P = .104). The most commonly used tunnel configuration was the modified Jobe technique (n = 41; 59.4%), and the most commonly used graft was hamstring autograft (n = 34; 49.3%). A majority (76.6%) of pitchers achieved RTP, and 55.3% were able to return to the same level of play. Mean time to RTP was 436 days (14.5 months) for players with a palmaris longus autograft versus 540 days (18 months) for those with a hamstring autograft ( P = .108). Further, the mean time to RTP was 423 days (14 months) for the docking technique versus 519 days (17 months) for the modified Jobe technique ( P = .296). Similar rates of subsequent injuries and surgeries were noted between the 2 revision techniques and 2 most commonly used graft constructs. Conclusion: Revision UCL reconstruction showed relatively high RTP rates (77%), but only 55% of players returned to their same level of play. Mean time to RTP was shorter than that found in other, smaller investigations. Although general trends were seen toward decreased time to RTP for the docking technique and palmaris longus autograft, these differences did not reach statistical significance.

PURPOSE OF REVIEW: To summarize the current anatomy, biomechanics, presentation, treatment, and outcomes of injuries to the biceps and superior labral complex in overhead athletes. RECENT FINDINGS: The biceps and superior labral complex is composed of anatomically distinct zones. The inability to accurately diagnose biceps lesions contributes to continued morbidity especially as arthroscopy and advanced imaging fail to fully evaluate the entire course of the biceps tendon. Superior labrum anterior and posterior (SLAP) repair, long head of biceps tenodesis, and tenotomy are the most common operative techniques for surgical treatment of biceps-labral complex (BLC) pathology. Labral repair in overhead athletes has resulted in mixed outcomes for athletes and is best indicated for patients under age 40 years old. SUMMARY: Injuries to the BLC are potentially challenging injuries to diagnose and treat, particularly in the overhead athlete. SLAP repair remains the treatment of choice for high-level overhead athletes and patients younger than 40 years of age, while biceps tenodesis and tenotomy are preferred for older patients.

Objectives: Professional baseball pitchers are at high risk for tears of the ulnar collateral ligament (UCL) of the elbow, often requiring subsequent surgical reconstruction. Despite acceptable published return to play outcomes, multiple techniques and graft types have been described. There is a paucity of clinical data in the current literature comparing UCL reconstruction surgical technique and graft type. Even less is known about the risks for subsequent injury, surgery, or revision UCL reconstruction. Accordingly, this study compares UCL reconstruction outcomes based on tunnel configuration and graft type. Methods: Following approval from our institutional review board and Major League Baseball (MLB), 566 professional baseball pitchers who underwent UCL reconstruction between 2010 and 2014 were identified and included. The following patient demographics were analyzed: age, pitching role (starter vs. reliever), level of play (MLB vs. Minor League Baseball [MiLB]), and throwing side dominance. Surgical factors analyzed included reconstruction technique (Docking vs. Modified Jobe), graft type (palmaris longus autograft vs. gracilis autograft), and concomitant procedures. Primary outcome measures consisted of: the ability to return to play at any level (RTP), to return to the same level of play (RSL), the time to return, subsequent elbow injuries, and the need for subsequent or revision elbow surgery. The impact of the patient and surgical factors on outcomes were analyzed using multivariate linear and logistic regression modeling. Results: The overall RTP was 79.9% and RSL was 71.2%. There were no significant differences in the time to RTP or RSL based on reconstruction technique or graft type. RTP rates were similar for the Docking vs. Modified Jobe techniques (80.1% vs. 82.4%; p=0.537) and for the two primary graft types (83.1% for palmaris vs. 80.7% for gracilis; p=0.596). The risk of subsequent elbow surgery was 10.5% for the Docking Technique vs. 14.8% for the Modified Jobe (p=0.203); and the risk for subsequent UCL revision reconstruction surgery was 2.9% vs. 6.2% for the Docking vs. Modified Jobe Techniques, respectively (p=0.128). Significant trends towards an increasing use of palmaris autograft (p=0.023) and the docking technique (p=0.006) were observed. MLB pitchers were more likely than MiLB pitchers to RTP (pConclusion: Surgical outcomes in professional baseball players are not significantly influenced by ulnar collateral ligament reconstruction technique or graft type usage. Major League players are more likely to RTP and RSL, but they have a higher frequency of subsequent elbow and forearm injuries. Both the Docking Technique and palmaris autograft are increasing in popularity amongst surgeons treating professional baseball players.

Background: Although cubital tunnel release is a commonly performed orthopaedic procedure, the overall incidence of and independent risk factors for infection largely remain undefined in the current literature. Purpose: To establish the rate of postoperative infection after isolated cubital tunnel release and define relevant patient-related risk factors. Study Design: Case-control study; Level 3. Methods: All Medicare-insured patients undergoing ulnar nerve decompression at the cubital tunnel from 2010 through 2012 were identified. A multivariate binomial logistic regression analysis was utilized to evaluate the impact of patient-related risk factors for postoperative infection. Results: A total of 330 (2.17%) postoperative infections were identified in 15,188 cases. The majority (87%) were managed nonoperatively, while 13% required surgical debridement. The most significant risk factors for infection included hemodialysis use (odds ratio [OR], 2.47), chronic anemia (OR, 2.24), age Conclusion: The present study was adequately powered to determine numerous patient-related risk factors for infection following cubital tunnel release.

Background: Although vascularity plays a critical role in healing after ulnar collateral ligament (UCL) reconstruction, intraosseous blood flow to the medial epicondyle (ME) and sublime tubercle remains undefined. Purpose: To quantify vascular disruption caused by tunnel drilling with the modified Jobe and docking techniques for UCL reconstruction. Study Design: Controlled laboratory study. Methods: Eight matched pairs (16 specimens) of fresh-frozen cadaveric upper extremities were randomized to 1 of 2 study groups: docking technique or modified Jobe technique. One elbow in each pair underwent tunnel drilling by the assigned technique, while the contralateral elbow served as a control. Pregadolinium and postgadolinium magnetic resonance imaging were performed to quantify intraosseous vascularity within the ME, trochlea, and proximal ulna. Three-dimensional computed tomography (CT) and gross dissection were performed to assess terminal vessel integrity. Results: Ulnar tunnel drilling had minimal impact on vascularity of the proximal ulna, with maintenance of >95% blood flow for each technique. Perfusion in the ME was reduced 14% (to 86% of baseline) for the docking technique and 60% (to 40% of baseline) for the modified Jobe technique (mean difference, 46%; P = .029). Three-dimensional CT and gross dissection revealed increased disruption of small perforating vessels of the posterior aspect of the ME for the modified Jobe technique. Conclusion: Although tunnel drilling in the sublime tubercle appears to have a minimal effect on intraosseous vascularity of the proximal ulna, both the docking and modified Jobe techniques reduce flow in the ME. This reduction was 4 times greater for the modified Jobe technique, and these findings have important implications for UCL reconstruction surgery. Clinical Relevance: As the rate of revision UCL reconstructions continues to rise, investigation into causes for failure of primary surgery is needed. One potential cause is poor tendon-to-bone healing due to inadequate vascularity. This study quantifies the amount of vascular insult that is incurred in the ME during UCL reconstruction. While vascular insult is only one of many factors that affects the surgical success rate, surgeons performing this procedure should be mindful of this potential for vascular disruption.

BACKGROUND: As the use of biologic therapies for the management of knee pathology continues to expand, it is more likely that patients will turn to the Internet to gather information on this topic. Given the lack of scientific consensus on the use of biologics, care providers must understand what information is available online. QUESTIONS/PURPOSES: The purpose of this study was to evaluate the quality of websites that patients may use to educate themselves on knee biologics. METHODS: Websites were identified using search terms relevant to multiple biologic therapies available for knee pathology. Websites were scored based on an author-derived grading rubric, with a total of 25 possible points relating to the role of knee biologics in the diagnosis, evaluation, and treatment of knee pathology. Websites were categorized based on the source (e.g., physician-operated website vs. industry-related website). Reading level was assessed with the Flesch-Kincaid readability test. RESULTS: The initial search yielded 375 results, with 96 websites meeting final inclusion criteria. Mean website score was poor, at 6.01 of the 25 possible points (24.0%). Physician websites were the most common, with 60% of the articles identified. Industry-related websites scored the lowest (mean, 3.2 ± 0.97) while hospital-related websites scored the highest (mean, 8.3 ± 2.93). Overall, websites published from hospitals or orthopedic professional societies had significantly higher scores than other websites. The search term “knee PRP” yielded higher-quality results than “knee platelet rich plasma.” Similarly, “knee BMAC” led to better results than “knee bone marrow aspirate concentrate.” The average reading level was 11.4. CONCLUSION: Many online resources are available for patients seeking information about knee biologic therapies, but the quality of websites identified was very poor. Patients should be counseled that the information available online for knee biologic therapy is unreliable. Surgeons should play an increased role in providing resources to patients and educating them on biologic options.

This review discusses the diagnostic and treatment challenges presented by injuries to the biceps and superior labral complex. A focused patient history, numerous physical examination maneuvers, and appropriate advanced imaging studies must be utilized to reach an accurate diagnosis. Nonoperative management, even in overhead athletes, has demonstrated relatively good outcomes, while operative outcomes have yielded mixed results. The surgeon must take into account a number of variables when choosing the appropriate surgical procedure: labral repair versus biceps tenodesis. Rehabilitation, either as nonoperative management or as a postoperative protocol, should focus on restoring glenohumeral and scapulothoracic strength, endurance, and full, pain-free range of motion, while correcting any deficiencies in balance or rhythm throughout the overhead motion. Despite the operative treatment challenges that SLAP tears present, with new techniques and proper patient selection, overhead athletes with injuries to the biceps and superior labrum complex can return to sport at a high level.

Dislocation of the sternoclavicular joint is a rare injury and typically requires high-energy forces applied through the joint. Initial treatment is dependent on the direction of dislocation, with acute reduction indicated for posterior dislocations presenting with signs of tracheal, esophageal, or neurovascular compression. Although most patients do well with conservative treatment after the initial trauma, some can have persistent pain and scapular dyskinesia due to instability or locked dislocation of the sternoclavicular joint. Stabilization of the sternoclavicular joint with reconstruction may be indicated for those with persistent symptoms despite a trial of steroid injections and physical therapy. In this report and video, we present a figure-of-8 reconstruction technique to reduce and stabilize a posterior dislocation of the sternoclavicular joint using a gracilis autograft. Ultimately, this reconstruction technique can be performed in a safe, efficient, and reliable manner when appropriate surgical steps are followed.

Objectives: The rate of revision medial ulnar collateral ligament (UCL) reconstruction continues to rise annually, and two common modes of failure for are inadequate healing at the bone-tendon interface or bony fracture through drill tunnels. Although, vascularity may play a critical role in these processes, the intra-osseous blood flow to the medial epicondyle (ME) and sublime tubercle (ST) remains undefined. The purpose of this work was to better understand the vascularity of the ME and ST at baseline and to quantify vascular disruption caused by tunnel drilling for the two most common UCL reconstruction techniques: the Figure of Eight and Docking. Methods: Eight matched pairs (16 total specimens) of fresh-frozen cadaveric upper extremities were randomized to one of the two study groups: Docking or Figure of Eight UCL reconstruction. One elbow in each pair underwent drilling of the medial epicondyle and sublime tubercle by the assigned technique, while the contralateral elbow underwent surgical exposure without drilling to serve as a matched control. For all specimens, the brachial artery was cannulated 10 cm distal to the greater tuberosity, and the ulnar artery was cannulated 10 cm proximal to the wrist. All identified remaining vessels were tied off. Pre- and post- gadolinium MRI scans were performed on all study elbows to quantify intra-osseous vascularity by contrast enhancement, which was compared to the contralateral elbow as a matched control. Intra-osseous flow is quantified within a standardized region of interest (ROI) using customized IDL 6.4 software (Exelis, Boulder, Colorado). Following MRI, contrast-enhanced polyurethane latex was injected into all vessels and CT with 3D reconstruction and gross dissection was performed to correlate findings with the MRI and assess vessel integrity. Results: MRI quantification revealed drilling of the ulnar tunnels (which was the same for each group) had a minimal impact on intra-osseous vascularity of the ulna with maintenance of 96% and 99% (p=0.448) of blood flow for the Docking and Figure Eight techniques respectively (Table 1). However, perfusion to the medial epicondyle was reduced 14% (to 86% of baseline) for the Docking Technique and 60% (to 40% of baseline) for the Figure Eight technique (Figure 1). This resulted in a mean difference of 46% in reduced perfusion between the two techniques (p=0.012). Subsequent CT analysis and gross dissection revealed increased disruption of small perforating vessels of the posterior aspect of the medial epicondyle for the Figure of Eight Technique (Figure 1). Conclusion: Although tunnel drilling in the sublime tubercle appears to have minimal effect on intra-osseous vascularity of the proximal ulna, both the Docking Technique and the Figure of Eight Technique reduce flow in the medial epicondyle. This reduction is four times greater for the Figure of Eight Technique, and these findings may have important implications for UCL reconstruction surgery.

Background: There are many risk factors for shoulder and elbow injuries in professional baseball pitchers. The elbow carrying angle has not been studied as a potential risk factor. Purpose/Hypothesis: The aim of this study was to determine whether elbow carrying angle is a risk factor for shoulder or elbow injuries in professional baseball pitchers. We hypothesized that pitchers with a higher elbow carrying angle would be less likely to sustain an injury during the season than pitchers with a lower elbow carrying angle. Study Design: Cohort study; Level of evidence, 2. Methods: All professional pitchers for a single baseball club during the 2018 season had the carrying angle of both elbows measured at spring training by a single examiner. The pitchers were followed prospectively throughout the season. Shoulder and elbow injuries were recorded prospectively. Results: A total of 52 pitchers (21 [40%] Major League Baseball and 31 [60%] Minor League Baseball) were included. During the season, 23 (44%) pitchers became injured. The mean carrying angle in the throwing arm was 12.5° ± 4.2° versus 9.9° ± 2.8° in the nonthrowing arm ( P < .001). Comparing the injured and noninjured groups, there were no differences in level of play ( P = .870), throwing hand dominance ( P = .683), batting hand dominance ( P = .554), throwing-side carrying angle ( P = .373), nonthrowing-side carrying angle ( P = .773), or side-to-side difference in carrying angle ( P = .481). Conclusion: The elbow carrying angle was not associated with an injury risk during a single season in professional baseball pitchers.

Background: In recent years, understanding of the anatomy of the ulnar collateral ligament (UCL) has evolved, demonstrating that the insertional footprint of the UCL on the ulna is more elongated and distally tapered than previously described. Current UCL reconstruction configurations do not typically re-create this native anatomy, which may represent a potential area for improvement. Purpose/Hypothesis: The purposes of this study were (1) to describe a novel anatomic UCL reconstruction technique designed to better replicate the native UCL anatomy and (2) to biomechanically compare this with the docking technique. The hypothesis was that the ultimate load to failure for the anatomic technique would not be inferior to the docking technique. Study Design: Controlled laboratory study. Methods: A total of 16 fresh-frozen cadaveric upper extremities (8 matched pairs) were utilized. One elbow in each pair was randomized to receive UCL reconstruction via the docking technique or the novel anatomic UCL reconstruction technique with palmaris tendon autograft. Following reconstruction, biomechanical testing was performed by applying valgus rotational torque at a constant rate of 5 deg/s until ultimate mechanical failure of the construct occurred. Maximal torque (N·m), rotation stiffness (N·m/deg), and mode/location of failure were recorded for each specimen. Results: The mean ultimate load to failure for elbows in the docking technique group was 23.8 ± 6.1 N·m, as compared with 31.9 ± 8.4 N·m in the anatomic technique group ( P = .045). Mean rotational stiffness was 1.9 ± 0.7 versus 2.3 ± 0.9 N·m/deg for the docking and anatomic groups, respectively ( P = .338). The most common mode of failure was suture pullout from the graft, which occurred in all 8 (100%) docking technique specimens and 7 of 8 (88%) specimens that underwent the anatomic UCL reconstruction technique. Conclusion: Ultimately, the anatomic UCL reconstruction technique demonstrated superior strength and resistance to valgus torque when compared with the docking technique, and this was comparable with that of the native UCL from prior studies. Increased initial strength may allow for earlier initiation of throwing postoperatively and potentially shorten return-to-play times. Clinical Relevance: Current UCL reconstruction techniques do not accurately reproduce the UCL insertional anatomy on the ulna. The novel anatomic technique described may result in more natural joint kinematics. This study demonstrated load-to-failure rates that are significantly higher than with the docking technique and consistent with the native ligament, as reported from previous studies. These findings may serve as a foundation for future clinical study and optimization of this technique.

Background: Recent awareness of latissimus dorsi/teres major (LD/TM) injuries has led to an increase in diagnoses. No magnetic resonance imaging (MRI) classification system specific to the LD/TM exists, nor has tear severity been correlated with ability to return to sport (RTS). Purpose/Hypothesis: The purpose of this study was to report a novel MRI classification system for LD/TM tears as well as to correlate tear grade with performance and RTS. We hypothesized that the new MRI classification system would have high intra- and interobserver reliabilities and that players with higher grade tears would require operative management. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: All patients with LD/TM tears diagnosed by MRI who were under the care of 2 orthopaedic surgeons were included. On 2 occasions 60 days apart, MRIs were reviewed and graded by 2 authors using a new classification system. Intra- and interobserver reliabilities were calculated. Timing from injury to RTS was recorded, and performance upon RTS was analyzed. Results: The proposed grading system had excellent intra- and interrater reliabilities (Cohen kappa >0.850). A total of 20 male patients (mean ± SD age, 26 ± 9.3 years) with LD/TM tears were included (80% were baseball pitchers). Of the 16 players treated operatively, 5 were initially treated nonoperatively by an outside physician but could not RTS (all professional baseball pitchers); 2 of these players had grade IIIA tears and 3 of the players had grade IVA tears. Regardless of initial treatment, ultimately 100% of the professional baseball players were able to RTS at a mean of 8.7 ± 3.3 months, although the initial nonoperative management failed for some of these players and they needed surgical intervention. No statistically significant differences were found between pre- versus postoperative performance in those professional players who were treated surgically. Conclusion: The proposed MRI-based grading system for LD/TM tears had excellent reliability. This system may allow physicians to better advise patients and all involved health care providers. Consideration should be given to acutely treat grade III and IV tears with operative repair.

Background: The medial ulnar collateral ligament (UCL) insertion of the elbow has been shown to extend distally beyond the sublime tubercle. The contribution to valgus stability of the distal aspect of the footprint is unknown. Purpose/Hypothesis: The purpose of this study was to determine the contribution of each part of the UCL footprint to the elbow valgus stability provided by the UCL. It was hypothesized that the distal two-thirds of the ulnar UCL footprint would not contribute significantly to valgus stability provided by the UCL. Study Design: Descriptive laboratory study. Methods: Fifteen cadaveric arms were dissected to the capsuloligamentous elbow structures and potted. A servohydraulic load frame was used to place 5 N·m of valgus stress on the intact elbow at 30°, 60°, 90°, and 120° of flexion. The UCL insertional footprint was measured and divided into thirds (proximal, middle, and distal). One-third of the UCL footprint was elevated off the bone (leaving the ligament in continuity), and the elbow was retested at the same degrees of flexion. This was repeated until the entire UCL footprint on the ulna was sectioned. Each elbow was randomized for how the UCL would be sectioned (sectioning the proximal, then middle, and then distal third or sectioning the distal, then middle, and then proximal third). Ulnohumeral joint gapping (millimeters) was recorded with a 3-dimensional motion capture system using physical and virtual markers. Two-group comparisons were made between each sectioned status versus the intact condition for each flexion angle. Results: When the UCL was sectioned from distal to proximal, none of the ligaments failed prior to complete sectioning. When the UCL was sectioned from proximal to distal, 3 of the 6 ligaments failed after sectioning of the proximal third, while 2 more failed after the proximal and middle thirds were sectioned. Of the specimens with the distal third of the ligament sectioned first, no significant differences were found between intact, distal third cut, and distal plus middle thirds cut at all flexion angles. Conclusion: The middle and distal thirds of the insertional footprint of the UCL on the ulna did not significantly contribute to gap resistance at 5 N·m of valgus load. The proximal third of the footprint is the primary resistor of valgus load. Clinical Relevance: This cadaveric biomechanical study demonstrated that the middle and distal thirds of the native UCL insertion onto the ulna did not significantly contribute to valgus resistance at the elbow. When a UCL reconstruction is performed, the proximal third of the UCL insertion may be the most clinically important portion of the ligament to reconstruct.

Shoulder instability is a relatively common problem. Even with contemporary surgical techniques, instability can recur following both open and arthroscopic fixation. Surgical management of capsular insufficiency in anterior shoulder stabilization represents a significant challenge, particularly in young, active patients. There are a limited number of surgical treatment options. The Laterjet technique can present with a number of intraoperative challenges and postoperative complication.We report an arthroscopic subscapularis tenodesis technique as a salvage procedure for challenging glenohumeral instability cases. Sutures are passed through the subscapularis tendon and capsule before they are tied as one in the subdeltoid psace. The rotator interval is closed with superior and medial advancement of anterior and inferior tissue. This technical note carefully describes this procedure with useful technical tips, illustrations, and diagrams.Two clinical cases are described involving patients with recurrent instability following failed surgery who were successfully managed with this procedure.Both cases described resulted in improved shoulder stability, range of motion, and function following management with this surgical technique. This arthroscopic subscapularis tenodesis procedure is proposed as a useful alternative repair technique for cases of recurrent instability after failed surgery with isolated capsular insufficiency.It is believed that this arthroscopic subscapularis tenodesis technique can potentially provide similar outcomes to open bone block stabilization procedures, while reducing the risks associated with those procedures.

This case study describes a Major League Baseball player who was diagnosed with an axillary artery thrombosis due to arterial compression from throwing. The purpose of this article is to create awareness as to the signs and symptoms associated with arterial positional compression and the rehabilitative implications to surgical intervention.

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.

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.

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.

Background: Recent clinical investigations have identified inadequate autograft hamstring graft diameter (Purpose/Hypothesis: The objective of this study was to determine the utility of preoperative magnetic resonance imaging (MRI) variables of the hamstring tendons for the prediction of graft diameter at the time of surgery. The hypothesis was that cross-sectional area (CSA) of the hamstring tendon measured on MRI could accurately predict graft diameter, and threshold measurements could be established to predict graft diameter at the time of surgery. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: A total of 84 consecutive skeletally mature patients prospectively enrolled in our ACL reconstruction patient registry were identified for study purposes. Patients were included if they underwent an MRI of the affected knee at our institution prior to ACL reconstruction with hamstring (HT) autograft. Graft preparation was performed via a standard quadrupled hamstring technique after harvesting both the gracilis and semitendinosus (4-GST). The smallest diameter end of the HT autograft was then utilized for measurement analysis. Total CSA was calculated for both hamstring tendons using the “region of interest tool” on the corresponding proton density–weighted axial image of the knee at the widest condylar dimension. Three independent reviewers measured the MRI scans so that intra- and interrater reliability of the measurements could be determined. A trend analysis was then undertaken to establish correlations between the MRI CSA and graft diameter. Predictive analysis was then performed to establish threshold MRI measurement values for specific graft diameters and determine whether any patient-specific factors would affect graft diameter (age, sex, and body mass index). Results: Mean patient age at the time of surgery was 36 years (range, 11-57 years). Intra- and interrater reliability measurements achieved near-perfect agreement for CSA measurements, with intraclass correlation coefficients (ICCs) of 0.994 and 0.932, respectively. Trend analysis demonstrated that increasing CSA correlated well with increasing overall diameter of the graft ( P < .001). Receiver operating characteristic (ROC) curves were generated to evaluate threshold CSA measurements for various graft diameters. Maximum sensitivity values of 21.64, 25.25, and 28.256 mm2 were established for the respective graft diameters of 8, 9, and 10 mm in the 4-GST group. Independent patient factors of younger age, shorter stature, and female sex were significantly associated with graft diameter ( P = .019, .034, and .028, respectively). Conclusion: Preoperative MRI can be used to accurately predict quadrupled hamstring autograft diameter at the time of surgery. A total cross-sectional area of >22 mm2 can reliably provide a graft diameter of >8 mm at the time of surgery.

Ulnar nerve (UN) injuries are a common complaint amongst overhead athletes. The UN is strained during periods of extreme valgus stress at the elbow, especially in the late-cocking and early acceleration phases of throwing. Although early ulnar collateral ligament (UCL) reconstruction techniques frequently included routine submuscular UN transposition, this is becoming less common with more modern techniques. We review the recent literature on the sites of UN compression, techniques to evaluate the UN nerve, and treatment of UN pathology in the overhead athlete. We also discuss our preferred techniques for selective decompression and anterior transposition of the UN when indicated. More recent studies support the use of UN transpositions only when there are specific preoperative symptoms. Athletes with isolated ulnar neuropathy are increasingly being treated with subcutaneous anterior transposition of the nerve rather than submuscular transposition. When ulnar neuropathy occurs with UCL insufficiency, adoption of the muscle-splitting approach for UCL reconstructions, as well as using a subcutaneous UN transposition have led to fewer postoperative complications and improved outcomes. Prudent handling of the UN in addition to appropriate surgical technique can lead to a high percentage of athletes who return to competitive sports following surgery for ulnar neuropathy.

Injury to the ulnar collateral ligament (UCL) most commonly occurs in the overhead throwing athlete. Knowledge surrounding UCL injury pathomechanics continues to improve, leading to better preventative treatment strategies and rehabilitation programs. Conservative treatment strategies for partial injuries, improved operative techniques for reconstruction in complete tears, adjunctive treatments, as well as structured sport specific rehabilitation programs including resistive exercises for the entire upper extremity kinetic chain are all important factors in allowing for a return to throwing in competitive environments. In this review, we explore each of these factors and provide recommendations based on the available literature to improve outcomes in UCL injuries in athletes.

Context: Ulnar collateral ligament (UCL) insufficiency of the elbow can be a debilitating injury that often prevents athletes from competing effectively. The overhead athlete is particularly susceptible to this injury because the anterior bundle of the UCL is the primary restraint to the valgus stress that is created during the throwing motion. Repetitive trauma from constant overhead or throwing activity can ultimately render the ligament incompetent and cause recurrent pain and instability. Results: The authors currently use a “docking” technique that provides excellent graft fixation and reduces ulnar nerve related complications. Conclusions: This article details the assessment of the throwing athlete with valgus instability secondary to UCL insufficiency and highlights the technical aspects for reconstruction. The majority of athletes who undergo UCL reconstruction of the elbow can successfully return to their preinjury function. Strength-of-Recommendation Taxonomy (SORT): A

The purpose of the present study is to describe the technique of margin convergence for U-shaped rotator cuff tears and report the clinical outcomes and ultrasonography with a minimum of 2 years follow-up. Three hundred eleven patients with a rotator cuff tear were prospectively enrolled in a registry at one institution. Inclusion criteria included any patient undergoing arthroscopic margin convergence for a rotator cuff tear. Exclusion criteria included open or mini-open rotator cuff repairs or suture anchor fixation to the cuff insertion without margin convergence. The outcome measurements included physical examination, manual muscle testing, the American Shoulder and Elbow Surgeons (ASES) score, and ultrasonography. Nineteen patients met the study criteria and 13 were available for 2-year follow-up (68.4%). The mean age of this cohort was 62.2 ± 7.5 years with a mean pre-operative rotator cuff tear size of 4.0 ± 1.6 cm. The ASES score increased significantly from 50.0 ± 17.7 before surgery to 83.3 ± 19.5 at 2 years ( P = 0.01). The active forward elevation also improved from 156.2 ± 11.9° before surgery to 168.0 ± 12.1 at 2 years ( P = 0.03). The active external rotation 54.4 ± 14.5 at baseline and improved to 57.1 ± 19.1 at 2 years ( P = 0.04). The strength also increased significantly from 6.7 ± 6.4 to 10.6 ± 4.9 lb at 1 year ( P = 0.048). The post-operative ultrasound demonstrated that 46.2% of rotator cuff tears were healed at 2 years. In conclusion, margin convergence is a useful technique for U-shaped tears that are difficult to mobilize.

Achilles allografts have become popular for anterior cruciate ligament (ACL) reconstructions in older patients. Primary ACL reconstructions using Achilles tendon allografts in patients age 30 years and older are successful in restoring the knee to “normal” or “near normal.” During a three-year period, the two senior authors performed 65 primary ACL reconstructions using Achilles tendon allografts in patients aged 30 years and older. Our exclusion criteria were periarticular fracture, ipsilateral/contralateral knee ligament injury, and previous or concomitant osteotomy or cartilage restoration procedure. Each patient was evaluated via physical examination, functional and arthrometric testing, and radiographic and subjective outcome. Knees were considered normal, near normal, or abnormal based on the International Knee Documentation Committee (IKDC) system. Forty-three patients were examined at an average of 33 months (minimum, 24 months) postoperatively. At the time of ACL reconstruction, 35% had normal articular cartilage in all three compartments and 70% had meniscal tears. No re-ruptures occurred. While 24% had mean maximal translation differences less than or equal to 3 mm, none had side-to-side differences greater than 5 mm. Postoperative IKDC, Activities of Daily Living, and Activity Rating Scale scores averaged 88, 94, and 7.7, respectively. Despite the overall favorable outcomes, 29% had worsened radiographic grades at follow-up. Using an Achilles allograft for ACL reconstruction in patients older than 30 years, we restored over 90% of knees to normal or near normal while limiting postoperative complications. Poor subjective results may be related less to instability and more to pain, which may result from progressive arthritis.

Background: A more detailed assessment of the anatomy of the entire medial ulnar collateral ligament complex (MUCLC) is desired as the rate of medial elbow reconstruction surgery continues to rise. Purpose: To quantify the anatomy of the MUCLC, including the anterior bundle (AB), posterior bundle (PB), and transverse ligament (TL). Study Design: Descriptive laboratory study. Methods: Ten unpaired, fresh-frozen cadaveric elbows underwent 3-dimensional (3D) digitization and computed tomography with 3D reconstruction. Ligament footprint areas and geometries, distances to key bony landmarks, and isometry were determined. A surgeon digitized the visual center of each footprint, and this location was compared with the geometric centroid calculated from the outline of the digitized footprint. Results: The mean surface area of the AB was 324.2 mm2, with an origin footprint of 32.3 mm2 and an elongated insertional footprint of 187.6 mm2 (length, 29.7 mm). The mean area of the PB was 116.6 mm2 (origin, 25.9 mm2; insertion, 15.8 mm2), and the mean surface area of the TL was 134.5 mm2 (origin, 21.2 mm2; insertion, 16.7 mm2). The geometric centroids of all footprints could be predicted within 0.8 to 1.3 mm, with the exception of the AB insertion centroid, which was 7.6 mm distal to the perceived center at the apex of the sublime tubercle. While the PB remained relatively isometric from 0° to 90° of flexion ( P = .606), the AB lengthened by 2.2 mm ( P < .001). Conclusion: Contrary to several historical reports, the insertional footprint of the AB was larger, elongated, and tapered. The TL demonstrated a previously unrecognized expansive soft tissue insertion directly onto the AB, and additional analysis of the biomechanical contribution of this structure is needed. Clinical Relevance: These findings may serve as a foundation for future study of the MUCLC and help refine current surgical reconstruction techniques.

Injuries to the ulnar collateral ligament (UCL) in throwing athletes frequently occurs from the repetitive valgus loading of the elbow during the throwing motion, which often results in surgical reconstruction of the UCL requiring a structured postoperative rehabilitation program. Several methods are currently used and recommended for UCL reconstruction using autogenous grafts in an attempt to reproduce the stabilizing function of the native UCL. Rehabilitation following surgical reconstruction of the UCL begins with range of motion and initial protection of the surgical reconstruction, along with resistive exercise for the entire upper extremity kinetic chain. Progressions for resistive exercise are followed that attempt to fully restore strength and local muscular endurance in the rotator cuff and scapular stabilizers, in addition to the distal upper extremity musculature, to allow for a return to throwing and overhead functional activities. Rehabilitation following UCL reconstruction has produced favorable outcomes, allowing for a return to throwing in competitive environments.

Background The treatment of type II superior labral anterior posterior (SLAP) lesions remains controversial. Many surgeons are reluctant to combine a SLAP repair with an acromioplasty for fear of postoperative shoulder stiffness and a poor clinical outcome. Hypothesis A SLAP repair and an acromioplasty done concomitantly may yield acceptable outcomes. Study Design Case series; Level of evidence, 4. Methods We compared the clinical results of 50 patients who had either an isolated type II SLAP repair (SLAP group, 34 patients) or a combined type II SLAP repair and acromioplasty (combined group, 16 patients). Patients were excluded for full-thickness rotator cuff tears or instability. All patients were evaluated with the L'Insalata Functional Shoulder Rating Questionnaire, with the American Shoulder and Elbow Surgeons (ASES) questionnaire, and by subjective evaluation. Results At an average of 3.4 years postoperatively, the L'Insalata and ASES scores were similar for the 2 groups: 87.1 and 85.8 for the SLAP group and 85.1 and 86.5 for the combined group, respectively (P > .05). Subjectively, only 65% of the patients in the SLAP group reported a “good” or “excellent” satisfaction with the surgery, compared with an 81% “good” or “excellent” satisfaction rating among the patients in the combined group. Seven patients (21%) in the SLAP group had postoperative clinical impingement, compared with no patients (0%) in the combined group (P < .03). Conclusions According to our data, these 2 procedures done concomitantly may yield acceptable outcomes. Our findings indicated that a combined type II SLAP repair and acromioplasty had no negative effect clinically and, furthermore, appeared to prevent residual clinical impingement.

Reconstruction of the ulnar collateral ligament (UCL) is one of the most commonly performed surgical procedures in overhead throwing athletes. Since its initial description, the procedure has undergone a number of technical modifications and advancements. This has resulted in multiple described techniques for UCL reconstruction. One of the most commonly performed UCL reconstruction methods is the docking technique. It has the advantages of minimizing injury to the flexor-pronator mass, avoiding the ulnar nerve, allowing robust graft tensioning, and reducing the amount of bone removed from the medial epicondyle compared with previously described techniques. This article provides a detailed description and video demonstration of how to perform this technique. When precise surgical steps are followed and postoperative rehabilitation appropriately progresses, this procedure has a well-documented history of reliably returning athletes to competitive throwing.

Background Medial ulnar collateral ligament insufficiency of the elbow can be a devastating injury in the throwing athlete. Reconstruction of the medial ulnar collateral ligament was initially described by Jobe and associates; good clinical results have been described after this procedure. The authors' experience with this technique raised several concerns, and thus the “docking” procedure was developed as an alternative method for medial ulnar collateral ligament reconstruction of the elbow. The early results of the docking technique were good. The authors wish to investigate the intermediate-term clinical results of this method in a large group of athletes. Hypothesis The docking technique can return overhead-throwing athletes to sport with minimal perioperative morbidity. Study Design Case series; Level of evidence, 4. Methods During a 3-year period, 100 consecutive overhead-throwing athletes were treated with surgical reconstruction using the docking technique. The inclusion criteria were as follows: (1) a history of medial elbow pain that prevented throwing, (2) a preoperative standard noncontrast magnetic resonance image demonstrating medial ulnar collateral ligament injury, (3) clinically apparent medial ulnar collateral ligament insufficiency, and (4) an overhead-throwing athlete. At the time of surgery, all patients underwent routine arthroscopic assessment. The ulnar nerve was transposed in 22 cases. The mean follow-up was 36 months (range, 24-60 months). Results Ninety of 100 (90%) patients were able to compete at the same or a higher level than before medial ulnar collateral ligament injury for more than 12 months as noted at the follow-up interval; 7 patients were able to compete at a lower level. Only 3 patients suffered postoperative complications. Conclusion The docking technique reliably returns athletes to competitive throwing with a low perioperative morbidity.

Background With the recent rise in the number of Tommy John surgeries, a proportionate rise in revisions is expected. However, much is unknown regarding the current revision rate of Tommy John surgery, return to play, and change in performance in Major League Baseball (MLB) pitchers. Methods Publicly available databases were used to obtain a list of all MLB pitchers who underwent primary and revision Tommy John surgery. Pitching performance preoperatively and postoperatively for pitchers who returned to 1 or more MLB games after revision surgery was compared with controls matched for age and position. Results Since 1999, 235 MLB pitchers have undergone Tommy John surgeries; 31 pitchers (13.2%) underwent revision surgery, and 37% underwent revision within 3 years of the index procedure. Twenty-six revisions had more than 2 years of follow-up; 17 pitchers (65.4%) returned to pitch at least 1 major league game, whereas only 11 (42.3%) returned to pitch 10 or more games. Of those who returned to MLB competition, the average length of recovery was 20.76 months. Compared with controls matched for age and position, MLB pitchers undergoing revision surgery had a statistically shorter career after revision surgery (4.9 vs 2.6 seasons, P = .002), pitched fewer innings, and had fewer total pitches per season. Conclusions The rate of revision Tommy John surgery is substantially higher than previously reported. For MLB pitchers, return to play after revision surgery is much lower than after primary reconstruction. The overall durability of MLB pitchers after revision ulnar collateral ligament reconstruction decreases significantly compared with controls matched for age and matched controls.

Objectives: Likely due to the high level of strain exerted across the elbow during the throwing motion, elbow injuries are on the rise in baseball. In order to identify at risk athletes and guide post-injury return to throw programs, a better understanding of the variables that influence elbow varus torque is desired. The purpose of this work was to describe the within-subject relationship between elbow varus torque and arm slot, arm speed, and shoulder rotation in professional baseball pitchers. Methods: A total of 81 professional pitchers performed 81,999 throws while wearing a motusBASEBALL sensor and sleeve (Motus Global, Massapequa, NY, USA). These throws represented a combination of throw types, such as warm-up/catch, structured long-toss, bullpen throwing from a mound, and live game activity. Variables recorded for each throw included arm slot, arm speed, shoulder rotation, and elbow varus torque. Linear mixed-effects models and likelihood ratio tests were utilized to estimate to the relationship between elbow varus torque and arm slot, arm speed, and shoulder rotation within individual pitchers. Results: All three metrics, arm slot (χ2 = 428, p2 = 57683, p2 = 1392, pConclusion: Elbow varus torque increased significantly as pitchers increased shoulder rotation during the arm cocking phase and rotational velocity of the arm during the arm acceleration phase of throwing. Thus shoulder flexibility, arm speed, and elbow varus torque (and likely injury risk) are inter-related and should be considered collectively when treating pitchers.

Objectives: The purpose of this study was to investigate the role of pre-operative outcome scores for predicting minimal clinically important difference (MCID) and return to play (RTP) after anterior cruciate ligament reconstruction (ACLR). Methods: Patients enrolled as part of a prospective institutional ACL registry were eligible for this study. 294 active athletes with a minimum two-year follow-up were eligible for inclusion. A telephone-based questionnaire was administered to elicit factors associated with RTP. Patient reported outcome measures were captured as part of the registry at pre-operative, one-year and two-year follow-up. Outcome measures captured included: International Knee Documentation Committee (IKDC) Subjective Knee Evaluation, Lysholm scale, and SF-12 Physical and Mental component scales (PCS and MCS). Pre-operative outcome score thresholds predictive of RTP were determined using receiver operating characteristic (ROC) with area under the curve (AUC) analysis. MCID was calculated using a distribution-based method. Multivariable logistic models were fitted for achieving MCID and RTP while adjusting for age, sex and body mass index (BMI). Results: 231 patients at a mean follow-up of 3.7 years were included from 294 eligible patients. Mean age and BMI was 26.7 (SD+12.5) years and 23.7 (SD+3.1) respectively. Of the 231 patients, 201 returned to play (87.0%) at a mean time of 10.1 months. Mean pre-operative outcome scores on the IKDC, Lysholm, SF-12 PCS and SF-12 MCS were 50.1, 61.2, 41.5, and 53.6 respectively. Mean scores at two-year follow-up were 87.4, 89.5, 54.7 and 55.7 respectively. Corresponding MCID values were 9.0, 10.0, 5.1 and 4.3 on the IKDC, Lysholm, SF-12 PCS, and SF-12 MCS respectively. Pre-operative scores (AUC) most predictive of RTP were 60.9 (0.54), 57.0 (0.52), 42.3 (0.61) and 48.3 (0.63) however none of these score thresholds independently achieved significance. Pre-operative scores on each outcome tool were predictive of achieving MCID on that same tool across all outcome tools (pConclusion: The rate of RTP after ACLR is high. Pre-operative outcome score on each tool is predictive of achieving a meaningful post-operative outcome score on that tool. Additionally, the SF-12 MCS is robustly predictive of achieving MCID across other outcome tools. Both pre-operative SF-12 MCS and PCS scores are independently predictive of RTP. We propose that the SF-12 is a highly useful post-ACL injury screening tool. These findings have implications for screening patients pre-operatively and counseling athletes on expected probabilities for RTP.