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To compare complication rates and 5-year reoperation rates between open debridement (OD) and arthroscopic debridement (AD) for lateral epicondylitis.The PearlDiver MUExtr database (2010-2019) was reviewed for patients diagnosed with lateral epicondylitis (queried by International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision [ICD-10] codes) undergoing OD or AD of the common extensor tendon without repair (queried by Current Procedural Terminology codes). Patients were stratified into 2 cohorts: those who underwent AD and those who underwent OD. Nonoperative treatment modalities were reported for both groups within 1 year before index procedure. The rates of 90-day postoperative complications were compared, and multivariate logistic regression analysis was used to identify risk factors for complications. The 5-year reoperation rates, using laterality-specific ICD-10 codes, were also compared between the 2 groups.In total, 19,280 patients (OD = 17,139, AD = 2,141) were analyzed in this study. The most common nonoperative treatments for patients who underwent OD or AD were corticosteroid injections (49.5% vs 43.2%), physical therapy (24.8% vs 25.7%), bracing (2.8% vs 3.2%), and platelet-rich plasma injections (1.3% vs 1.0%). There were no significant differences in radial nerve injuries, hematomas, surgical site infections, wound dehiscence, and sepsis events between the 2 procedures (P = .50). The 5-year reoperation rate was not significantly different between the AD (5.0%) and OD (3.9%) cohorts (P = .10).For lateral epicondylitis, both AD and OD of the extensor carpi radialis brevis (without repair) were found to have low rates of 90-day adverse events, with no significant differences between the 2 approaches. Similarly, the 5-year reoperation rate was low and not statistically different for those treated with OD or AD.Level III, cross-sectional study.

Background: The number of ulnar collateral ligament (UCL) tears in professional baseball players is increasing. UCL reconstruction (UCLR) is the treatment of choice in players with failed nonoperative treatment who wish to return to sports (RTS). It is unknown if UCL tear location influences the ability of players to RTS or affects their performance upon RTS. Purpose/Hypothesis: The purpose was to compare the RTS rate and performance upon RTS in professional baseball players who underwent UCLR based on UCL tear location (proximal vs distal). It was hypothesized that no difference in RTS rate or performance upon RTS will exist between players with proximal or distal UCL tears. Study Design: Cohort study; Level of evidence, 3. Methods: All professional baseball players who underwent primary UCLR by a single surgeon between 2016 and 2018 were eligible for inclusion. Players with purely midsubstance tears or revision UCLR were excluded. Tear location was determined based on preoperative magnetic resonance imaging (MRI) and intraoperative findings. RTS rate and performance were compared between players with proximal versus distal UCL tears. Results: Overall, 25 pitchers (15 proximal and 10 distal tears) and 5 position players (2 proximal and 3 distal) underwent primary UCLR between 2016 and 2018. Of the 25 pitchers, 84% were able to RTS. Of the 5 position players, 80% were able to RTS. Among the total cohort of pitchers and position players, 12 out of 17 (71%) players with proximal tears were able to RTS, while of the 13 distal tears, 13 out of 13 (100%) players were able to RTS ( P = .05). With regard to performance data, pitchers with distal tears had higher utilization postoperatively and, as such, allowed statistically more hits ( P = .03), runs ( P = .015), and walks ( P = .021) postoperatively. However, the WHIP ([walks + hits]/innings pitched) was not different between players with proximal or distal tears, indicating that efficacy in games was not significantly different between groups. Conclusion: Professional baseball players who sustain a distal UCL tear and undergo UCLR may be more likely to RTS than those who sustain a proximal UCL tear and undergo UCLR. Players with distal UCL tears who underwent UCLR saw higher utilization postoperatively than those with proximal UCL tears. Further work is needed in this area to confirm this result.

Background Injury to the lateral ulnar collateral ligament (LUCL) complex of the elbow often results in posterolateral rotatory instability. Although surgical reconstruction of the LUCL is often required, gaps in our understanding of the LUCL complex remain. The purpose of this study was to provide a robust and accurate characterization of the lateral elbow ligamentous complex. Methods The LUCLs, radial collateral ligaments, and annular ligaments in 10 cadaveric elbows were 3-dimensionally digitized and reconstructed using computed tomography. Surface areas, origin and insertion footprint areas, distances between perceived footprint centers and geometric footprint centroids, distances to key landmarks, and ligament isometry were measured. Results The mean surface area of the LUCL was 229.3 mm2. The mean origin and insertion footprint areas were 26.0 mm2 and 22.9 mm2, respectively. The mean distance between the apparent centers and the geometric centroids of the footprints was 1 mm. The center of the LUCL origin was 10.7 mm distal to the lateral epicondyle and 8.2 mm from the capitellar articular margin. The center of the LUCL insertion was 3.3 mm distal to the apex of the supinator crest. The LUCL showed anisometric properties as elbow flexion increased (P Conclusions The LUCL origin center was 10.7 mm from the lateral epicondyle, whereas the insertion center was 3.3 mm from the apex of the supinator crest. The visually estimated footprint centers were generally within 1 mm of the geometric centroid. These geometries and distances to key landmarks will be informative for surgeons seeking to perform anatomic ligament reconstruction procedures.

To report clinical and functional outcomes including return to preinjury activity level following arthroscopic-assisted coracoclavicular (CC) ligament reconstruction (AA-CCR) and to determine associations between return to preinjury activity level, radiographic outcomes, and patient-reported outcomes following AA-CCR.A institutional registry review of all AA-CCR using free tendon grafts from 2007 to 2016 was performed. Clinical assessment included Single Assessment Numeric Evaluation (SANE) score and return to preinjury activity level at final follow-up. Treatment failure was defined as (1) revision acromioclavicular stabilization surgery, (2) unable to return to preinjury activity level, or (3) radiographic loss of reduction (RLOR,25% CC distance compared with contralateral side). SANE scores, return to activity, and RLOR were compared between patients within each category of treatment failure, by grade of injury, and whether concomitant pathology was treated.There were 88 patients (89.8% male) with mean age of 39.6 years and minimum 2-year clinical follow-up (mean 6.1 years). Most injuries were Rockwood grade V (63.6%). Mean postoperative SANE score was 86.3 ± 17.5. Treatment failure occurred in 17.1%: 8.0% were unable to return to activity, 5.7% had RLOR, and 3.4% underwent revision surgery due to traumatic reinjury. SANE score was lower among patients who were unable to return to activity compared with those with RLOR and compared with nonfailures (P = .0002). There were no differences in revision surgery rates, return to activity, or SANE scores according to Rockwood grade or if concomitant pathology was treated.AA-CCR with free tendon grafts resulted in good clinical outcomes and a high rate of return to preinjury activity level. RLOR did not correlate with return to preinjury activity level. Concomitant pathology that required treatment did not adversely affect outcomes. Return to preinjury activity level may be a more clinically relevant outcome measure than radiographic maintenance of acromioclavicular joint reduction.IV (Case Series).

Background: Loss of upper and lower extremity range of motion (ROM) is a significant risk factor for injuries in professional baseball players. Purpose/Hypothesis: The purpose was to determine changes in ROM in professional baseball players over the course of a single season and their careers. We hypothesized that pitchers and position players would lose ROM, specifically total shoulder motion (total ROM [TROM]) and hip internal rotation (IR), over the course of a season and their careers. Study Design: Case series; Level of evidence, 4. Methods: Upper and lower extremity ROM measurements were recorded during pre-, mid-, and postseason on all professional baseball players for a single organization between 2011 and 2018. ROM measurements were compared for pitchers and position players over the course of the season and their careers. Also, ROM measurements over the pre-, mid-, and postseason were compared between pitchers and position players. Results: A total of 166 professional baseball players (98 pitchers, 68 position players) were included. Pitcher hip external rotation (ER; P < .001), IR ( P = .010), and TROM ( P < .001) for lead and trail legs decreased over the course of the season. Pitcher shoulder ER ( P = .005), TROM ( P = .042), and horizontal adduction ( P < .001) significantly increased over the course of the season. Position player shoulder flexion ( P = .046), hip ER ( P < .001, lead leg; P < .001, trail leg), and hip TROM ( P = .001; P = .002) decreased over the course of the season. Position player shoulder ER ( P = .031) and humeral adduction ( P < .001) significantly increased over the course of the season. Over the course of pitchers’ careers, there was decreased shoulder IR ( P = .014), increased shoulder horizontal adduction ( P < .001), and hip IR ( P = .042) and hip TROM ( P = .027) for the lead leg. Position players experienced loss of hip TROM ( P = .010, lead leg; P = .018, trail leg) over the course of their careers. Pitchers started with and maintained more shoulder ER and gained more shoulder TROM over a season as compared with position players. Conclusion: Pitchers and position players saw overall decreases in hip ROM but increases in shoulder ROM over the course of the season and career.

Background: Recent epidemiologic reports have demonstrated rising injury rates in Major League Baseball (MLB) and Minor League Baseball (MiLB). Although several studies have recently been published on specific injuries, the majority of injuries have not yet been formally studied. Purpose: The purpose of this study is to (1) generate a summative analysis of all injuries that occur in MLB and MiLB, (2) identify the 50 most common injuries, and (3) generate focused reports and fact sheets on the characteristics of each of those diagnoses. Study Design: Case series; Level of evidence, 4. Methods: The MLB Health and Injury Tracking System was used to identify injuries occurring in MLB and MiLB players from 2011 to 2016. Injuries were defined as those that occurred during normal baseball activity and resulted in at least 1 day out of play. A multitude of player and injury characteristics were analyzed, and detailed reports of the 50 most commonly occurring injuries were generated. Results: A total of 49,955 injuries occurred during the study period; 45,123 were non–season ending, and they resulted in 722,176 days out of play. The mean (median) days missed per injury was 16 (6) days. Overall, 39.1% of all injuries occurred in pitchers. The upper extremity was involved in 39% of injuries, while 35% occurred in the hip/groin/lower extremity. Surgery was required in 6.5% of cases, and 9.7% of injuries were season ending. Hamstring strains were the most common injury (n = 3337), followed by rotator cuff strain/tear (n = 1874), paralumbar muscle strain (n = 1313), biceps tendinitis (n = 1264), oblique strain (n = 1249), and elbow ulnar collateral ligament injury (n = 1191). The diagnoses that were most likely to end a player’s season were elbow ulnar collateral ligament injury (60% season ending) and superior labrum anterior and posterior tear (50.9% season ending). Conclusion: Contrary to prior reports relying on disabled list data, the annual number of injuries in professional baseball remained steady from 2011 to 2016. Similar trends were noted for the annual number of days missed and mean days missed per injury. Although the mean days missed per injury was high (16), the median was much lower at 6 days.

To identify risk factors for failure of a therapeutic injection leading to operative management of both medial and lateral epicondylitis.A national database was used to query Medicare Standard Analytic Files from 2005-2012 for patients treated with therapeutic injections for medial or lateral epicondylitis using CPT codes for injections associated with corresponding ICD-9 diagnostic codes (726.31 and 726.32, respectively). Those who subsequently underwent surgical treatment following injection were identified. A multivariate binomial logistic regression analysis was utilized to evaluate patient-related risk factors for requiring surgery within 2 years after therapeutic injection.1,837 patients received therapeutic injections for medial epicondylitis. 52 (2.8%) required ipsilateral surgery at a mean of 429 ± 28 days post-injection. Risk factors for requiring surgical intervention included age 65, obesity, and morbid obesity. 6,561 patients received therapeutic injections for lateral epicondylitis. 201 (3.1%) required subsequent surgery at a mean of 383 ± 128 days' post-injection. Risk factors included age 65, tobacco use, diabetes mellitus and peripheral vascular disease.The incidence of surgical intervention following a failed therapeutic injection for medial or lateral epicondylitis is low (~3%). Risk factors for failing a therapeutic injection include age 65 years and obesity (BMI 30) for medial epicondylitis and age 65 years, smoking, diabetes mellitus and peripheral vascular disease for lateral epicondylitis. Patients with these identified risk factors presenting with medial or lateral epicondylitis should be cautioned that they carry a higher risk of subsequent surgical treatment.Therapeutic, III.

Background: Likely due to the high level of strain exerted across the elbow during the throwing motion, elbow injuries are on the rise in baseball. To identify at-risk athletes and guide postinjury return-to-throw programs, a better understanding of the variables that influence elbow varus torque is desired. Purpose: To describe the within-subject relationship between elbow varus torque and arm slot and arm rotation in professional baseball pitchers. Study Design: Descriptive laboratory study. Methods: A total of 81 professional pitchers performed 82,000 throws while wearing a motusBASEBALL sensor and sleeve. 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 (angle of the forearm relative to the ground at ball release), arm speed (maximal rotational velocity of the forearm), arm rotation (maximal external rotation of the throwing arm relative to the ground), and elbow varus torque. Linear mixed-effects models and likelihood ratio tests were used to estimate the relationship between elbow varus torque and arm slot, arm speed, and arm rotation within individual pitchers. Results: All 3 metrics—arm slot (χ2 = 428, P < .001), arm speed (χ2 = 57,683, P < .001), and arm rotation (χ2 = 1392, P < .001)—were found to have a significant relationship with elbow varus torque. Within individual athletes, a 1-N.m increase in elbow varus torque was associated with a 13° decrease in arm slot, a 116 deg/s increase in arm speed, and an 8° increase in arm rotation. Conclusion: Elbow varus torque increased significantly as pitchers increased their arm rotation during the arm cocking phase, increased the rotational velocity of their arm during the arm acceleration phase of throwing, and decreased arm slot at ball release. Thus, shoulder flexibility, arm speed, and elbow varus torque (and likely injury risk) are interrelated and should be considered collectively when treating pitchers. Clinical Relevance: It is well established that elbow varus torque is related to ulnar collateral ligament injuries in overhead throwers. This study describes the relationship of arm slot, arm speed, and arm rotation to elbow varus torque in an attempt to identify modifiable risk factors for injury.

Background: There is increased interest in understanding the preoperative determinants of postoperative outcomes. Return to play (RTP) and the patient-reported minimal clinically important difference (MCID) are useful measures of postoperative outcomes after anterior cruciate ligament reconstruction (ACLR). Purpose: To define the MCID after ACLR and to investigate the role of preoperative outcome scores for predicting the MCID and RTP after ACLR. Study Design: Case-control study; Level of evidence, 3. Methods: There were 294 active athletes enrolled as part of an institutional ACL registry with a minimum 2-year follow-up who were eligible for inclusion. A questionnaire was administered to elicit factors associated with RTP. Patient demographic and clinical data as well as patient-reported outcome measures were captured as part of the registry. Outcome measures included the International Knee Documentation Committee (IKDC) subjective knee evaluation form, Lysholm scale, and 12-Item Short Form Health Survey (SF-12) physical component summary (PCS) and mental component summary (MCS). Preoperative outcome score thresholds predictive of RTP were determined using a receiver operating characteristic (ROC) with area under the curve (AUC) analysis. The MCID was calculated using a distribution-based method. Multivariable logistic models were fitted to identify predictors for achieving the MCID and RTP. Results: At a mean (±SD) follow-up of 3.7 ± 0.7 years, 231 patients were included from a total 294 eligible patients. The mean age and body mass index were 26.7 ± 12.5 years and 23.7 ± 3.2 kg/m2, respectively. Of the 231 patients, 201 (87.0%) returned to play at a mean time of 10.1 months. Two-year postoperative scores on all measures were significantly increased from preoperative scores (IKDC: 50.1 ± 15.6 to 87.4 ± 10.7; Lysholm: 61.2 ± 18.1 to 89.5 ± 10.4; SF-12 PCS: 41.5 ± 9.0 to 54.7 ± 4.6; SF-12 MCS: 53.6 ± 8.1 to 55.7 ± 5.7; P < .001 for all). The corresponding MCID values were 9.0 (IKDC), 10.0 (Lysholm), 5.1 (SF-12 PCS), and 4.3 (SF-12 MCS). Preoperative score thresholds predictive of RTP were the following: IKDC, 60.9; Lysholm, 57.0; SF-12 PCS, 42.3; and SF-12 MCS, 48.3. These thresholds were not independently predictive but achieved significance as part of the multivariable analysis. In the multivariable analysis for RTP, preoperative SF-12 PCS scores above 42.3 (odds ratio [OR], 2.73; 95% CI, 1.09-7.62) and SF-12 MCS scores above 48.3 (OR, 4.41; 95% CI, 1.80-10.98) were predictive for achieving RTP; an ACL allograft (OR, 0.26; 95% CI, 0.06-1.00) was negatively predictive of RTP. In the multivariable analysis for the MCID, patients with higher preoperative scores were less likely to achieve the MCID ( P < .0001); however, a higher preoperative SF-12 MCS score was predictive of achieving the MCID on the IKDC form (OR, 1.27; 95% CI, 1.11-1.52) and Lysholm scale (OR, 1.08; 95% CI, 1.00-1.16). Medial meniscal injuries, older age, and white race were also associated with a decreased likelihood for achieving the MCID. Conclusion: Preoperative SF-12 MCS and PCS scores were predictive of RTP after ACLR; patients scoring above 42.3 on the SF-12 PCS and 48.3 on the SF-12 MCS were more likely to achieve RTP. Additionally, we defined the MCID after ACLR and found that higher SF-12 MCS scores were predictive of achieving the MCID on knee-specific questionnaires.

To use a national database to determine (1) the incidence of joint infection after elbow arthroscopy, (2) identify independent patient-related risk factors for infection, and (3) determine the influence of concomitant intra-articular corticosteroid injection on infection risk.The 100% Medicare Standard Analytic Files were queried to identify patients who underwent elbow arthroscopy from 2005 to 2012. Postoperative elbow infections occurring within 6 months of surgery were identified using both International Classification of Diseases, 9th Revision codes for postoperative infection and Current Procedural Terminology codes for the surgical treatment of a postoperative infection. Patients were excluded if their initial arthroscopic procedure was performed for infection. A multivariate binomial logistic regression analysis was then used to evaluate patient-related risk factors for postoperative infection.Of the 2,704 elbow arthroscopy cases identified, 42 (1.55%) developed a postoperative infection. The annual incidence of infections did not increase significantly over the course of the study (P = .374). A number of patient demographics and medical comorbidities significantly increased the risk of infection. The most notable factors included age ≥ 65 years (odds ratio [OR] 2.38, P = .006), body mass index40 (OR 1.97, P = .024), tobacco usage (OR 1.80, P = .046), alcohol usage (OR 4.01, P.001), diabetes mellitus (OR 2.10, P = .015), inflammatory arthritis (OR 2.81, P.001), hypercoagulable disorder (OR 2.51, P = .015), and intra-articular corticosteroid injection at the time of arthroscopy (OR 2.79, P = .006).The annual number of elbow arthroscopies performed in the United States has increased steadily; however, the postoperative infection rate remained consistently low at 1.55%. There are a number of patient-specific risk factors that increase this risk with OR ranging from 1.97 to 4.01. Similarly, patients who receive an intra-articular corticosteroid injection at the time of surgery are nearly 3 times (OR 2.79) more likely to develop a postoperative infection. LEVEL OF EVIDENCE: Level III, case-control study.

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

To investigate return to play (RTP) and functional performance after anterior cruciate ligament reconstruction (ACLR) in National Basketball Association (NBA) players and to perform a systematic review of the literature to understand RTP after ACLR in professional basketball.NBA players undergoing ACLR between 2008 and 2014 by two surgeons were identified. RTP and performance were assessed based on a review of publically available statistics. A systematic review of the literature was performed using the MEDLINE database. Inclusion criteria were: English language, ACL surgery outcome, professional basketball and RTP outcome. We reviewed studies for RTP rates and RTP performance.Our study included 12 professional basketball players with NBA level experience. Eleven of the 12 players returned to their prior level of play. Eight of the 9 (88.9%) players actively playing in the NBA returned to play in the NBA at a mean 9.8 months. Among players returning to NBA play, during RTP season 1, mean per game statistics decreased for the following: minutes, points, rebounds, assists, steals, blocks, turnovers and personal fouls - none of these changes reached statistical significance. Player efficiency ratings significantly declined from pre-injury (12.5) to the first RTP season (7.6) (p = 0.05). By RTP season 2, player performance metrics approximated pre-injury levels and were not significantly different. Six studies met inclusion criteria; reported RTP rates ranged from 78-86%. Identified studies similarly found a decline in functional performance after RTP.There is a high rate (89%) of return to NBA play for NBA players undergoing ACLR. After RTP, however, there is a quantitative decline in initial season 1 RTP statistics with a significant decrease in player efficiency rating. By RTP season 2, performance metrics demonstrated an improvement compared to RTP season 1 but did not reach pre-injury functional performance, though performance metrics are not significantly different between pre-injury and RTP season 2.

The literature investigating risk factors for failure after decompression of the ulnar nerve at the elbow (cubital tunnel release [CuTR]) is limited. The purpose of this study was to identify risk factors for failure of isolated CuTR, defined as progression to subsequent ipsilateral revision surgery.The 100% Medicare Standard Analytic Files from 2005 to 2012 were queried for patients undergoing CuTR. Patients undergoing any concomitant procedures were excluded. A multivariate binomial logistic regression analysis was used to evaluate patient-related risk factors for ipsilateral revision surgery. Adjusted odds ratios (ORs) and 95% confidence intervals were calculated for each risk factor.A total of 25,977 patients underwent primary CuTR, and 304 (1.4%) of those with ≥2 years of follow-up required revision surgery. Although the rate of primary procedures is on the rise (P = .002), the revision rate remains steady (P = .148). Significant, independent risk factors for revision surgery included age65 years (OR, 1.5; P .001), obesity (OR, 1.3; P = .022), morbid obesity (OR, 1.3; P = .044), tobacco use (OR, 2.0; P .001), diabetes (OR, 1.3; P = .011), hyperlipidemia (OR, 1.2; P = .015), chronic liver disease (OR, 1.6; P = .001), chronic anemia (OR, 1.6; P = .001), and hypercoagulable disorder (OR, 2.1; P = .001).The incidence of failure requiring ipsilateral revision surgery after CuTR remained steadily low (1.4%) during the study period. There are numerous patient-related risk factors that are independently associated with an increased risk for revision surgery, the most significant of which are tobacco use, younger age, hypercoagulable disorder, liver disease, and anemia.

This study was conducted to identify the rate of failure of operative treatment of lateral epicondylitis, defined as progression to ipsilateral revision surgery, and associated patient-specific risk factors for failure.A national database was used to identify patients undergoing surgical treatment of lateral epicondylitis from 2005 to 2012. Patients undergoing concomitant procedures were excluded. Patients who then required subsequent ipsilateral extensor carpi radialis brevis débridement or release within 2 years were identified using similar methods. A multivariate binomial logistic regression analysis was used to evaluate patient-related risk factors for revision surgery. In addition, the number of preoperative injections (1, 2, or ≥3) in the ipsilateral elbow was identified and included in the regression analysis. Adjusted odds ratios (OR) and 95% confidence intervals were calculated for each risk factor.Of 3863 patients who underwent operative treatment of lateral epicondylitis, 58 (1.5%) required ipsilateral revision surgery. Risk factors for revision surgery included age65 years (OR, 2.95; P = .003), male gender (OR, 1.53; P = .017), morbid obesity (OR, 2.13; P = .002), tobacco use (OR, 1.87; P .001), and inflammatory arthritis (OR, 1.79; P = .009). Having ≥3 ipsilateral preoperative injections was the most significant risk factor (OR, 3.55; P .001), whereas having 2 (OR, 1.44; P = .135) or 1 (OR, 1.15; P = .495) was not significant.The incidence of failure requiring revision surgery for lateral epicondylitis in the studied population is low (1.5%). Risk factors for revision surgery include younger age, male gender, morbid obesity, tobacco use, and inflammatory arthritis. The most significant risk factor for revision surgery is having ≥3 ipsilateral preoperative injections.

Purpose To investigate differences between sport types for patient-reported outcome after anterior cruciate ligament reconstruction (ACLR). Methods Included patients were enrolled as part of a prospective institutional ACL registry. Inclusion criteria were preoperative self-identification as a competitive athlete, maximum score on the preoperative Marx Activity Scale, and minimum 2-year follow-up. Demographic, intraoperative, and outcome data were extracted from the registry. Outcome tools administered as part of the registry included International Knee Documentation Committee (IKDC), Lysholm-Tegner Scales, Marx Activity Scale (MAS), and 12-Item Short Form Health Survey (SF-12). Results A total of 294 patients with a mean age of 25.5 years (standard deviation 12.1) met the study inclusion criteria; mean follow-up was 3.7 years. Included sports categories were soccer (n = 92; 31.3%), skiing (n = 67; 22.8%), basketball (n = 56; 19.1%), lacrosse (n = 38; 12.9%), football (n = 29; 9.9%), and Tennis (n = 12; 4.1%). At baseline, compared with other sports, lacrosse players have higher outcome scores while skiers had lower scores. At 2-year follow-up, however, across all outcome tools, football players demonstrated significantly higher outcome scores than all other athletes (IKDC, 93.2, P = .001; Lysholm, 93.2, P = .03; MAS, 13.1, P = .03; SF-12 Mental Component Summary, 57.9, P = .0002). Conversely, at 2-year follow-up, soccer players demonstrated a significantly lower Lysholm (86.7, P = .02) and a trend toward lower IKDC (85.6, P = .09) scores. Conclusions Patient-reported outcomes after ACLR among active athletes are comparable. Football players demonstrate quantitatively higher outcome scores whereas soccer players have lower scores. However, these outcome score differences may not be clinically significant and may be subject to confounding variables. Continued attention should be paid to understanding sport-specific outcome after ACLR. Level of Evidence Level IV, therapeutic case series.

Introduction Ulnar collateral ligament (UCL) reconstructions are being performed with an increasing annual incidence. The purpose of this study was to evaluate trends in UCL surgery among recently trained orthopaedic surgeons. Methods The American Board of Orthopaedic Surgeons (ABOS) database was used to identify all UCL reconstructions from 2004 to 2013. Procedures were identified by Current Procedural Terminology (CPT) codes and verified by International Classification of Disease, Ninth Revision (ICD-9) codes. Data on surgeon fellowship, practice location, concomitant surgical procedures, and complications were collected. Results One hundred sixty-four UCL reconstructions were performed by 133 ABOS Part II candidates. The annual incidence increased from 1.52 to 3.46 cases per 10,000 (P = 0.042). Reconstructions were most commonly performed by surgeons with fellowship training in sports medicine (65.9%), hand and upper extremity (18.9%), and shoulder and elbow (9.1%). Most reconstructions were performed in isolation (57.3%), or with ulnar nerve transposition (32.9%) or elbow arthroscopy (9.8%). Concomitant elbow arthroscopy rates decreased significantly (P = 0.022). Complications occurred in 9.8% of cases, although the rates did not significantly change (P = 0.466). Conclusions UCL reconstructions are being performed with increasing frequency. Concomitant procedure rates remained the same, although arthroscopy was less commonly performed. Complication rates did not change considerably over the observed period. Further study of the surgical trends and associated long-term outcomes is warranted. Level of evidence Level IV.

Purpose To develop and validate a standardized patient satisfaction measurement tool for adult patients undergoing primary anterior cruciate ligament reconstruction (ACLR). Methods A 4-phase iterative process that included item generation and pilot survey development, item reduction, survey readability, and survey validation was used. To develop and validate the Hospital for Special Surgery ACL Satisfaction Survey (HSS ACL-SS), 70 patients were included in the survey development phase and 77 patients were included in the validation phase. The HSS ACL-SS was compared with other currently used ACLR outcome measures including the International Knee Documentation Committee score, Tegner-Lysholm score, Short Form 12 (SF-12) Mental Component Score, and SF-12 Physical Component Score. Test-retest reliability, internal consistency, convergent and discriminant validity, and floor and ceiling effects were assessed. Results The HSS ACL-SS consists of 10 items identified by patients as being important for satisfaction after ACLR. In the validation phase, the mean score on the HSS ACL-SS (of 50) among all patients was 37.9 ± 9.9 (range, 10-50). Statistically significant positive correlations were seen between the HSS ACL-SS score and the International Knee Documentation Committee score (r = 0.351, P = .002) and Tegner-Lysholm score (r = 0.333, P = .003). No statistically significant correlation was found between the satisfaction score and the SF-12 Mental or Physical Component Score. The lowest possible score (10 of 50 points) was achieved in 1 patient (1.3%) and the highest possible score (50 of 50 points) was achieved in 7 patients (9.1%), indicating no significant floor or ceiling effects of the instrument. Internal consistency for all 10 items was strong (Cronbach α, 0.995). The mean intraclass correlation coefficient between test and retest responses was 0.701, indicating moderate agreement. Conclusions The HSS ACL-SS is a validated and reliable patient-derived satisfaction measure with excellent psychometric properties for active adults undergoing ACLR. The results of this study show that the HSS ACL-SS may be a useful tool to measure postoperative patient satisfaction. Level of Evidence Level II, development of diagnostic or monitoring criteria in consecutive patients.

Purpose To evaluate the effects of retensioning and knot tying on the biomechanical properties of an adjustable loop anterior cruciate ligament (ACL) reconstruction device. Methods Testing consisted of 3 phases, which used both adjustable loop devices (ALD) and closed loop devices (CLD) tested under cyclic loading to 4,500 cycles. Phase 1 consisted of implant-only testing using cyclic loading from 50 to 250 N. Phase 2 used relatively unloaded cyclic loading of 10 to 250 N. Phase 3 used a tendon/bone/implant model. Subsets of the ALD implants were subjected to isolated retensioning, isolated knot tying, or a combination of both to allow for independent examination of these interventions. Results In phase 1, retensioning and knot tying reduced final ALD elongation by 60% (0.38 v 0.96 mm; P = .00004). In phase 2, retensioning and knot tying reduced final ALD elongation by 88% (0.51 v 4.22 mm, P = .014). In phase 3, retensioning and knot tying reduced final ALD elongation by 45% (1.5 v 2.7 mm; P = .001), which was half of the elongation of the CLD (3.0 mm; P = .0007). Conclusions The ALD did demonstrate an increase in cyclic elongation as compared with the CLD during both extended loading conditions. The phase 1 ALD elongation (0.96 mm), while statistically greater than the CLD (0.52 mm), was likely not of clinical importance. However, the ALD elongation in phase 2 (4.22 mm) could be of clinical concern. Both of these increased elongations were eliminated by retensioning and knot tying. Furthermore, when evaluating in a graft-femur construct, retensioning and knot tying of the ALD reduced final cyclic elongation by 50% when compared with CLD. Clinical Relevance Retensioning and knot tying after initial reduction of the tendon graft with an adjustable loop ACL fixation device may help to further reduce concerns of loop slippage and displacement with cyclic loading during postoperative rehabilitation.

There is a paucity of reporting on surgical outcomes of isolated posterior cruciate ligament reconstruction (PCLR). We hypothesize that isolated PCL injuries failing nonoperative treatment achieve good outcomes and are able to return to sport following PCLR.A retrospective analysis was performed to identify patients with isolated PCL injuries that underwent reconstruction between 2001 and 2014. Patients with multi-ligamentous injury or another concomitant knee pathology were excluded. Medical records were reviewed for demographic, clinical and operative data. Patients were contacted for administration of a telephone-based questionnaire which included the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation form, Lysholm-Tegner scales, Marx activity scale (MAS), return to sport status, and patient satisfaction instruments.A total of 15 isolated PCL reconstructions in 14 patients with a mean age of 27.5 years (range 17-43) met the study inclusion criteria; mean follow up was 6.3 years (range 1.4-15.2). Pre-operatively, the primary complaint was knee instability in all patients; on physical examination, lack of a firm end point during posterior drawer testing was found in 93% (14/15) of the knees. In total, 12 of 15 knees underwent transtibial, single-bundle PCLR and three of 15 underwent tibial inlay, double bundle PCLR. Graft types included: quadriceps autograft (7/15), Achilles allograft (6/15), and hamstring autograft (2/15). There were no graft failures in our patient cohort. At most recent follow up the mean scores respectively on the IKDC form, Lysholm-Tegner scales and MAS were (standard deviation): 77.3 (16.5), 83.1 (17.9), 6.13 (2.6), and 7.1 (6.0). All fourteen patients were athletes prior to their injury and 79% (11/14) returned to sport and overall patient satisfaction was 9.2/10.Isolated PCLR provides good outcomes at mean medium-term follow up with restoration of function, high rate of return to sport and overall patient satisfaction.

The purpose of this study was to determine whether surgical arthroscopic decompression or ultrasound-guided aspiration of a paralabral cyst would result in suprascapular nerve recovery from axonal regeneration based on electrodiagnostic testing.Nine patients with preoperative electromyography (EMG) evidence of suprascapular neuropathy due to paralabral cysts at the suprascapular or spinoglenoid notch were prospectively studied. Eight patients underwent arthroscopic surgical decompression, and 1 patient underwent ultrasound-guided aspiration. Postoperative EMG was performed in all patients to evaluate nerve regeneration.Three (33%) patients had cysts at the suprascapular notch, whereas 6 (67%) patients had cysts at the spinoglenoid notch. All patients showed complete electrophysiological recovery after decompression.Decompression of paralabral cysts at the suprascapular or spinoglenoid notch resulted in postoperative EMG evidence of nerve recovery. Long-term studies with a greater number of patients are required to elucidate time to recovery. Muscle Nerve 59:247-249, 2019.

Background Amid evidence that the number of ulnar collateral ligament (UCL) reconstructions performed annually is on the rise, there continues to be significant variation among surgeons in the management of UCL injuries. The purpose of this paper was to survey the members of the American Shoulder and Elbow Surgeons (ASES) to assess current trends related to the comprehensive treatment of athletes presenting with UCL injury. Methods An online survey was distributed to the active members of the ASES. The survey was composed of 3 sections assessing the demographics of the survey-takers, presenting 7 distinct fictional clinical case scenarios of athletes with UCL injury, and posing a series of more general questions about operative and nonoperative management of UCL injuries. Results There were 159 ASES members who responded to the survey (24% of the active membership); 65 respondents (40.9%) reported >15 years of clinical experience. Of the 7 case scenarios presented, a consensus was reached to indicate the patient for surgery in 4 cases. In all 7 cases, when operative management was the preferred option, a consensus was reached to perform UCL reconstruction. The preferred method of UCL reconstruction among respondents was the docking technique (66.0%); 36.3% of respondents used platelet-rich plasma in their treatment of UCL injuries. Conclusion The survey presented here shows that an overall experienced and well-trained cohort of surgeons tended to agree and often reached consensus opinions on how to approach UCL injury. Professional athletes and those with complete tears were indicated for surgery by consensus, whereas opinion was more divided on how to treat partial tears or nonprofessionals.

Background: Elbow injuries cause significant disability for the throwing athlete. Scant data are available on the distribution and characteristics of these injuries in elite baseball players. No study exists that focuses solely on the epidemiological characteristics of elbow injuries in professional baseball players using a comprehensive injury surveillance system. Hypothesis: Professional baseball players have a high occurrence of elbow injuries influenced by factors including length of time playing, time period within the annual baseball season, and specific position played. Study Design: Descriptive epidemiological study. Methods: Data on elbow injuries occurring during the 2011-2014 seasons were collected from Major League Baseball’s Health Injury and Tracking System, a comprehensive injury surveillance system. Each specific type of elbow injury was evaluated with respect to overall injury rate, years as a professional player, mechanism of injury, treatment, average time lost, and return to play. Results: During the study period, 3185 elbow injuries (n = 430 Major League; n = 2755 Minor League) occurred. The mean number of days missed and percentage requiring surgery were similar between Major and Minor League players. Overall, 20.0% (650/3185) of the injuries required surgical treatment. Pitchers were the most likely to incur an elbow injury (40.0% of injured athletes were pitchers), were the most likely to require surgery (34.2% of injured pitchers required surgery), and had the greatest mean number of days missed when treated nonsurgically (33.2 days). Medial injuries composed 42.1% (1342/3185) of all elbow injuries. Of all elbow surgeries performed during the study period, the highest percentage involved ligaments (372/650; 57.2%). Conclusion: Elbow injuries are a considerable source of disability in professional baseball players. Pitchers are most likely to incur these injuries, are most likely to require surgery, and have the highest mean number of days missed when treated nonsurgically. The most common injuries involve the medial elbow, with ligament injuries most often requiring surgery. This study represents the only investigation to date using a comprehensive injury surveillance system to examine elbow injuries in professional baseball players. It provides a basis for injury prevention and treatment recommendations, establishes the most thorough framework for determining elbow injury risk, and focuses continued research on elbow injury prevention in the elite baseball player.

Acromioclavicular joint injuries are among the most common shoulder girdle injuries in athletes and most commonly result from a direct force to the acromion with the arm in an adducted position. Acromioclavicular joint injuries often present with associated injuries to the glenohumeral joint, including an increased incidence of superior labrum anterior posterior (SLAP) tears that may warrant further evaluation and treatment. Anteroposterior stability of the acromioclavicular joint is conferred by the capsule and acromioclavicular ligaments, of which the posterior and superior ligaments are the strongest. Superior-inferior stability is maintained by the coracoclavicular (conoid and trapezoid) ligaments. Type-I or type-II acromioclavicular joint injuries have been treated with sling immobilization, early shoulder motion, and physical therapy, with favorable outcomes. Return to activity can occur when normal shoulder motion and strength are obtained and the shoulder is asymptomatic as compared with the contralateral normal extremity. The management of type-III injuries remains controversial and is individualized. While a return to the previous level of functional activity with nonsurgical treatment has been documented in a number of case series, surgical reduction and coracoclavicular ligament reconstruction has been associated with a favorable outcome and can be considered in patients who place high functional demands on their shoulders or in athletes who participate in overhead sports. Surgical management is indicated for high-grade (≥type IV) acromioclavicular joint injuries to achieve anatomic reduction of the acromioclavicular joint, reconstruction of the coracoclavicular ligaments, and repair of the deltotrapezial fascia. Outcomes after surgical reconstruction of the coracoclavicular ligaments have been satisfactory with regard to achieving pain relief and return to functional activities, but further improvements in the biomechanical strength of these constructs are necessary to avoid loss of reduction and creep with cyclic loading.

In the world of glenoid labral chondral injuries, perhaps the most recognizable by magnetic resonance imaging is the "teardrop" version, and the glenoid labral teardrop lesion is the glenoid chondral lesion most frequently associated with shoulder instability.

A complex interplay exists between the static and dynamic stabilizers in the glenohumeral joint, especially in overheard athletes who need a shoulder hypermobile enough to perform overhead activity yet stable enough to prevent joint subluxation. Concomitant shoulder pathologies commonly occur in the setting of microinstability and internal impingement. Before any surgical intervention, a 3- to 6-month course of conservative measures should first be attempted, with exercises focused on rotator cuff and scapular stabilizer strengthening combined with posterior capsule stretching. If surgery is needed, arthroscopic suture plication with treatment of concomitant lesions has been shown to provide the best clinical outcomes.

Purpose The primary aims of this work were to (1) describe normal range of motion (ROM) profiles for elite pitchers, (2) describe the characteristics of shoulder and elbow injuries in professional pitchers over a 6-year period in one Major League Baseball organization, and (3) identify ROM measures that were independently associated with a future shoulder or elbow injury. Methods Over 6 seasons (2010-2015), a preseason assessment was performed on all pitchers invited to Major League Baseball Spring Training for a single organization. ROM measures included shoulder flexion, horizontal adduction, external rotation (ER), internal rotation, as well as elbow flexion and extension, were measured for both the dominant and nondominant arm, and total range of motion and deficits were calculated. All noncontact shoulder and elbow injuries were identified. Using multivariate binomial logistic regression analysis to control for age, height, weight, and all other ROM measures, the factors associated with an increased risk of subsequent shoulder or elbow injury were identified. Results A total of 53 shoulder (n = 25) and elbow (n = 28) injuries occurred during 132 pitcher seasons (n = 81 pitchers). The most significant categorical risk factor associated with increased elbow injury rates was the presence of a shoulder flexion deficit >5° (odds ratio [OR] 2.83; P = .042). For continuous variables, the risk of elbow injury increased by 7% for each degree of increased shoulder ER deficit (OR 1.07; P = .030) and 9% for each degree of decreased shoulder flexion (OR 1.09; P = .017). None of the measures significantly correlated with shoulder injuries. Conclusions Preseason shoulder ER and flexion deficits are independent risk factors for the development of elbow injuries during the upcoming season. Although prior work has supported the importance of reducing glenohumeral internal rotation deficits in pitchers, this study demonstrates that deficits in shoulder ER and flexion are more significant predictors of subsequent elbow injury. Level of Evidence Level III, retrospective comparative study.

We describe an unusual case of acute ulnar neuropathy with a flexible claw hand deformity in a baseball pitcher. Treatment involved ulnar nerve decompression at the elbow with subsequent recurrence of symptoms upon return to pitching. Definitive treatment included a wide secondary release of tethered locations resulting in return of function. At final follow-up the patient has returned to unrestricted baseball throwing activities.

This study evaluated clinical and patient-reported outcomes and return to sport after surgical treatment of medial epicondylitis with suture anchor fixation. Consecutive patients were evaluated after undergoing debridement and suture anchor repair of the flexor-pronator mass for the treatment of medial epicondylitis. Demographic variables, a short version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, Oxford Elbow Score (OES), and 10-point pain and satisfaction scales were collected. Ability and time to return to sport after surgery were evaluated, and the relationship between predictor variables and both elbow function and return to sport was investigated. Median age at the time of surgery was 55 years (range, 29–65 years), with median follow-up of 40 months (range, 12–67 months). Median QuickDASH score and OES at final follow-up were 2.3 (range, 0–38.6) and 45 (range, 22–48), respectively. Most patients returned to premorbid sporting activities at a median of 4.5 months (range, 2.5–12 months), whereas 4 patients (14%) reported significant limitations at final follow-up. Older age at the time of surgery was predictive of better QuickDASH score and OES ( P =.05 and P =.02, respectively). Patients who underwent surgery after a shorter duration of symptoms had better outcomes, but the difference did not reach statistical significance (QuickDASH, P =.09; OES, P =.10). Surgical treatment of recalcitrant medial epicondylitis with suture anchor fixation offers good pain relief and patient satisfaction, with little residual disability. Older age at the time of surgery predicts a better outcome. [ Orthopedics. 2016; 39(1):e104–e107.]

Hypothesis Lateral ulnar collateral ligament (LUCL) reconstruction is a commonly used surgical approach for the treatment of posterolateral rotatory instability (PLRI). We hypothesized that favorable clinical results could be obtained using the docking technique. Materials and methods Between 1996 and 2009, the docking technique was used for surgical reconstruction of the LUCL in 8 patients with purely ligamentous posterolateral rotatory instability of the elbow. The clinical results of these patients were retrospectively reviewed. Results At a mean follow-up of 7.1 years (range, 5.2-9.4 years), 6 patients (75%) demonstrated complete resolution of lateral elbow instability, and 2 (25%) reported occasional instability with activities of daily living. The mean Mayo Elbow Performance Score was 87.5 (range, 75-100). Subjective assessment revealed that all patients were satisfied with their clinical outcome. Conclusion LUCL reconstruction using the docking technique facilitates simple graft tensioning and excellent graft fixation. Clinical results are comparable with previously reported studies with a low complication rate.

Using 3-dimensional high-resolution magnetic resonance imaging (MRI), we sought to compare femoral and tibial tunnel position and resultant graft obliquity with single-bundle anterior cruciate ligament (ACL) reconstruction using transtibial (TT) or anteromedial (AM) portal femoral tunnel reaming techniques.Thirty patients were prospectively enrolled after primary, autogenous bone-patellar tendon-bone ACL reconstruction by 2 groups of high-volume, fellowship-trained sports medicine surgeons. With the TT technique, an external starting point was used to maximize graft obliquity and femoral footprint capture. By use of high-resolution MRI and imaging analysis software, bilateral 3-dimensional knee models were created, mirrored, and superimposed. Differences between centroids for each femoral and tibial insertion, as well as corresponding ACL/graft obliquity, were evaluated with paired t tests and 2-sided Mann-Whitney nonparametric tests, with P.05 defined as significant.No significant differences were observed between groups in position of reconstructed femoral footprints. However, on the tibial side, AM centroids averaged 0.8 ± 1.9 mm anterior to native ACL centroids, whereas the TT group centered 5.23 ± 2.4 mm posterior to native ACL centroids (P.001). Sagittal obliquity was closely restored with the AM technique (mean, 52.2° v. 53.5° for native ACL) but was significantly more vertical (mean, 66.9°) (P = .0001) for the TT group.In this clinical series, AM portal femoral tunnel reaming more accurately restored native ACL anatomy than the TT technique. Although both techniques can capture the native femoral footprint with similar accuracy, the TT technique requires significantly greater posterior placement of the tibial tunnel, resulting in decreased sagittal graft obliquity. When a tibial tunnel is drilled without the need to accommodate subsequent femoral tunnel reaming, more accurate tibial tunnel position and resultant sagittal graft obliquity are achieved.Level III, retrospective comparative study.

Purpose The purpose of this study was to objectively evaluate the anatomic and biomechanical outcomes of anterior cruciate ligament (ACL) reconstruction with transtibial versus anteromedial portal drilling of the femoral tunnel. Methods Ten human cadaveric knees (5 matched pairs) without ligament injury or pre-existing arthritis underwent ACL reconstruction by either a transtibial or anteromedial portal technique. A medial arthrotomy was created in all cases before reconstruction to determine the center of the native ACL tibial and femoral footprints. A 10-mm tibial tunnel directed toward the center of the tibial footprint was prepared in an identical fashion, starting at the anterior border of the medial collateral ligament in all cases. For transtibial femoral socket preparation (n = 5), a guidewire was placed as close to the center of the femoral footprint as possible. With anteromedial portal reconstruction (n = 5), the guidewire was positioned centrally in the femoral footprint and the tunnel drilled through the medial portal in hyperflexion. An identical graft was fixed and tensioned, and knee stability was assessed with the following standardized examinations: (1) anterior drawer, (2) Lachman, (3) maximal internal rotation at 30°, (4) manual pivot shift, and (5) instrumented pivot shift. Distance from the femoral guidewire to the center of the femoral footprint and dimensions of the tibial tunnel intra-articular aperture were measured for all specimens. Statistical analysis was completed with a repeated-measures analysis of variance and Tukey multiple comparisons test with P ≤ .05 defined as significant. Results The anteromedial portal ACL reconstruction controlled tibial translation significantly more than the transtibial reconstruction with anterior drawer, Lachman, and pivot-shift examinations of knee stability ( P ≤ .05). Anteromedial portal ACL reconstruction restored the Lachman and anterior drawer examinations to those of the intact condition and constrained translation with the manual and instrumented pivot-shift examinations more than the native ACL ( P ≤ .05). Despite optimal guidewire positioning, the transtibial technique resulted in a mean position 1.94 mm anterior and 3.26 mm superior to the center of the femoral footprint. The guidewire was positioned at the center of the femoral footprint through the anteromedial portal in all cases. The tibial tunnel intra-articular aperture was 38% larger in the anteroposterior dimension with the transtibial versus anteromedial portal technique (mean, 14.9 mm v 10.8 mm; P ≤ .05). Conclusions The anteromedial portal drilling technique allows for accurate positioning of the femoral socket in the center of the native footprint, resulting in secondary improvement in time-zero control of tibial translation with Lachman and pivot-shift testing compared with conventional transtibial ACL reconstruction. This technique respects the native ACL anatomy but cannot restore it with a single-bundle ACL reconstruction. Eccentric, posterolateral positioning of the guidewire in the tibial tunnel with the transtibial technique results in iatrogenic re-reaming of the tibial tunnel and significant intra-articular aperture expansion. Clinical Relevance Anteromedial portal drilling of the femoral socket may allow for improved restoration of anatomy and stability with ACL reconstruction compared with conventional transtibial drilling techniques.

BackgroundPrevious studies have documented increased posteromedial contact forces with the elbow at lower flexion angles associated with valgus extension overload; however, the authors believe that posteromedial elbow impingement in association with valgus laxity is a complex pathological process that may occur throughout the entire throwing motion in the form of ulnohumeral chondral and ligamentous overload.HypothesisValgus laxity with the elbow at 90° of flexion may lead to chondromalacia secondary to a subtle shift in the contact point between the tip of the olecranon and the distal humeral trochlea.Study DesignControlled laboratory study.MethodsSix fresh human cadaveric elbows were dissected and subjected to a static valgus load. Pressure-sensitive Fuji film measured the contact pressure, contact area, and shift in contact area across the posteromedial elbow before and after sectioning the anterior bundle of the ulnar collateral ligament.ResultsThe contact pressure between the tip of the olecranon process and the medial crista of the posterior humeral trochlea significantly increased, from an average of 0.27 ± 0.06 kg/cm2 to 0.40 ± 0.08 kg/cm2. The contact area also significantly decreased, from an average of 30.34 ± 9.17 mm2 to 24.59 ± 6.44 mm2, and shifted medially on the medial humeral crista, which corresponds to the position of the posteromedial chondral lesions that was observed in throwing athletes in the authors’ clinical practice.ConclusionWhile simulating the early acceleration phase of the throwing motion with the elbow in 90° of flexion, the results illustrate that abnormal contact may occur as a result of valgus laxity through increased contact pressures across the posteromedial elbow between the medial tip of the olecranon and medial crista of the humeral trochlea. In addition, congruency of the ulnohumeral joint changed, as there was a statistically significant medial shift of the olecranon on the posterior humeral trochlea with the elbow at 90° of flexion after sectioning the anterior bundle of the ulnar collateral ligament.Clinical RelevanceIn the throwing athlete who continues the repetitive, throwing motion despite valgus laxity from ulnar collateral ligament insufficiency, the authors believe that these results provide a plausible mechanism for injury throughout the entire throwing motion secondary to ulnohumeral chondral and ligamentous overload. As throwing athletes may produce a tremendous amount of force and subsequent chondromalacia within the posteromedial aspect of the elbow, the findings of this study illustrate the importance of prompt clinical recognition of ulnar collateral ligament insufficiency.

Introduction Elbow ulnar collateral ligament (UCL) reconstruction has become the standard of care for the throwing athlete with a symptomatic ruptured or insufficient ligament and the desire to resume competitive play. Since Jobe's initial description of UCL reconstruction, the technique has evolved. A novel modification was the "docking" technique developed by Altchek. Subsequently, the docking technique as originally described was slightly modified. Arthroscopy is no longer routinely performed, and in some cases, a 3-strand graft is used. Materials and methods We treated 21 overhand athletes with clinical and radiographic evidence of UCL insufficiency with ligament reconstruction using a modified version of the docking technique using a 3-strand graft. There were 5 professional, 11 college, and 5 high school baseball players in the reconstructed group. Athletes were evaluated postoperatively by use of the Conway Scale. Results Of the 21 patients who underwent the modified docking technique with a three-strand graft, 19 (90%) had excellent results. There were 2 good results and no complications. Discussion UCL reconstruction can successfully treat athletes with UCL insufficiency. Several different reconstruction techniques have been described. By use of the docking and modified docking techniques, good to excellent results can be achieved in the majority of cases with a low complication rate.

Background Arthroscopic treatment has evolved to become the primary surgical option in the management of anterior shoulder instability as studies show comparable outcomes between open and arthroscopic techniques. Objective To evaluate prospectively the results of our institutional database for arthroscopic Bankart repairs at a minimum 2-year follow-up for patients with anterior instability treated with suture anchors. Study Design Case series; Level of evidence, 4. Methods Eighty-three consecutive patients underwent arthroscopic Bankart repair with suture anchors. The mean age at the time of surgery was 33 years (range, 15-55 years). At an average follow-up of 33 months (range, 24-49 months), 73 patients (61 males, 12 females) were assessed with outcomes scores including the American Shoulder and Elbow Surgeons, L'Insalata, and visual analog scores. The rate of recurrent instability, range of motion, and risk factors for postoperative recurrence were evaluated. Results Thirteen patients (18%) suffered a recurrence after surgery. Seven patients (10%) had a subsequent dislocation and 6 (8%) a subluxation event or apprehension. Six of the 13 had a traumatic event that resulted in recurrent episodes of instability. Revision surgery was needed for 2 patients (3%) for instability and 2 for postoperative shoulder stiffness. On average there was no significant loss of external rotation postoperatively (average, 71° pre- and postoperatively). The American Shoulder and Elbow Surgeons and L'Insalata scores improved from 75.4 to 94.9 and 66.5 to 90.9, respectively (P < .0001). The visual analog score improved from 2.4 to 0.4 (P < .001). Patient age under 25, ligamentous laxity, and the presence of a large (>250 mm 3) Hill-Sachs lesion were associated with recurrence (P < .05). Patients under age 20 had a 37.5% recurrence rate. Conclusion In the arthroscopic treatment of anterior instability, identification of risk factors for recurrence allows for appropriate patient counseling and consideration of open stabilization. In our series, patients under age 25, with ligamentous laxity, and with a large (>250 mm3) Hill-Sachs lesion were at the greatest risk of recurrence.

Internal impingement of the shoulder refers to a constellation of pathologic conditions, including, but not limited to, articular-sided rotator cuff tears, labral tears, biceps tendinitis, anterior instability, internal rotation deficit, and scapular dysfunction. Physiologic adaptations to throwing include increased external rotation, increased humeral and glenoid retroversion, and anterior laxity, all of which may predispose an individual to internal impingement. Nonoperative treatment should always be attempted first, with a focus on increasing the range of motion and improving scapular function. When an operative intervention is chosen, it is important to address microinstability in order to have a good outcome and prevent failure.

BackgroundRetears of the rotator cuff are not uncommon after arthroscopic and mini-open rotator cuff repairs. In most studies, the clinical results in patients with persistent defects demonstrated significantly less pain and better function and strength compared with their preoperative state at an early follow-up.HypothesisThe clinical and structural outcomes of patients with known rotator cuff defects will remain unchanged after a longer period of follow-up.Study DesignCase series; Level of evidence, 4.MethodsThis study was performed in 15 patients (18 shoulders) from a previous study who had recurrent rotator cuff defects 3.2 years after repair. Each patient completed the American Shoulder and Elbow Surgeons Scoring Survey, the Simple Shoulder Test, the L'Insalata Scoring Survey, and a visual analog scale for pain. Eleven patients (13 shoulders) were clinically reexamined at an average of 7.9 years for range of motion and strength, with targeted ultrasound.ResultsAt the 7.9 year follow-up the average scores were 95 (American Shoulder and Elbow Surgeons), 95 (L'Insalata), 11 (Simple Shoulder Test), and 0 (visual analog for pain), which were not statistically significantly different from the scores at 3.2 years. There was no change in the average range of motion; however, there was a statistically significant reduction in forward flexion strength and external rotation strength, as measured by a dynamometer. The average external rotation strength decreased by a mean of 42% and the mean forward flexion strength decreased by a mean of 45% (P < .001). Furthermore, there was a statistically significant increase in the mean size of the defect, from 273 mm2 to 467 mm2 (P < .001). Finally, the size of the defect increased in all patients, and no defects healed structurally.ConclusionAt an average of 7.9 years, patients with recurrent defects after rotator cuff repair still had an improvement in terms of pain, function, and satisfaction. However, the rotator cuff defect significantly increased in size, and there was a progression of strength deficits. These findings suggest that patients with recurrent defects can remain asymptomatic over the long term but will predictably lose strength in the involved extremity. Furthermore, the study demonstrated that defects after rotator cuff repair increase in size but often remain asymptomatic.

The rotator cuff registry was established to evaluate prospectively the effectiveness of arthroscopic rotator cuff repair. The purpose of the present study is to report the preliminary data at the 1- and 2-year time point and perform subgroup analysis to identify factors that may affect outcome.A total of 193 patients underwent all-arthroscopic repair of a rotator cuff tear and met the inclusion criteria and 127 (65.8%) completed 2-year follow-up. The outcome measurements included physical examination, manual muscle testing, the American Shoulder and Elbow Surgeons (ASES) score, and ultrasonography.The pre-operative ASES score was 52.37 +/- 24.09 and improved to 83.88 +/- 19.28 at 1 year (P.0001) and 92.65 +/- 11.36 at 2 years (P0.0001). The percent healing for all patients was 64.10% at 3 months and 64.34% at 1 year (P = .4080). At 2 years, there was a significant increase in the percentage of healed tendon at 75.42% compared to the 3-month (P (1/4) .0001) and 1-year (P = 0.0332) time points. Patients with intact tendons had an ASES score of 93.9 +/- 10.2 compared to tendon defects with a score of 88.0 +/- 15.6 (P = .0623). Gender, tear size, and acromioclavicular joint involvement have a significant effect on ASES score. Rotator cuff characteristics such as tear size, biceps pathology, acromioclavicular joint pathology, and tissue quality have a significant effect on postoperative tendon integrity.Arthroscopic rotator cuff repair demonstrates significant improvement in clinical outcomes and good rate of healing by postoperative ultrasound. Longer-term studies are necessary to determine the efficacy over time.

Several all-arthroscopic techniques have been described to address patellar instability. Most arthroscopic procedures focus on soft tissue plication or "tightening" of the medial retinacular structures to correct lateral patellar instability. We found these techniques to be ineffective when the medial stabilizers were avulsed from the patella. As a result, we have developed an arthroscopic technique to repair medial patellofemoral ligament avulsions to the patella using suture anchors.

The purpose of this study was to identify potential predictors of function and tendon healing after arthroscopic rotator cuff repair that will enable the orthopaedic surgeon to determine which patients can expect a successful outcome. Between 2003 and 2005, the Arthroscopic Rotator Cuff Registry was established to collect demographic, intraoperative, functional outcome, and ultrasound data prospectively on all patients who underwent primary arthroscopic rotator cuff repair. At total of 193 patients met the study criteria, and 127 (65.8%) completed the 2-year follow-up. The most significant independent factors affecting ultrasound outcome were age (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.02-1.14; P = .006) and tear size (OR, 2.29; 95% CI, 1.55-3.38; P < .001). After adjustment for age and tear size, the intraoperative factors found to be significantly associated with a tendon defect were concomitant biceps procedures (OR, 11.39; 95% CI, 2.90-44.69; P < .001) and acromioclavicular joint procedures (OR, 3.85; 95% CI, 1.46-10.12; P = .006). In contrast to the ultrasound data, the functional outcome variables, such as satisfaction (OR, 3.92; 95% CI, 2.00-7.68; P < .001) and strength (OR, 10.05; 95% CI, 1.61-62.77; P = .01), had a greater role in predicting an American Shoulder and Elbow Surgeons score greater than 90. The progression from a single-tendon rotator cuff tear to a multiple-tendon tear with associated pathology increased the likelihood of tendon defect by at least 9 times, and therefore, earlier surgical intervention for isolated, single-tendon rotator cuff tears could optimize the likelihood of ultrasound healing and an excellent functional outcome.

Purpose Using a cadaver shoulder instability model and load-testing device, we compared biomechanical characteristics of double-row and single-row capsulolabral repairs. We hypothesized a greater reduction in glenohumeral motion and translation and a higher load to failure in a mattress double-row capsulolabral repair than in a single-row repair. Methods In 6 matched pairs of cadaveric shoulders, a capsulolabral injury was created. One shoulder was repaired with a single-row technique, and the other with a double-row mattress technique. Rotational range of motion, anterior-inferior translation, and humeral head kinematics were measured. Load-to-failure testing measured stiffness, yield load, deformation at yield load, energy absorbed at yield load, load to failure, deformation at ultimate load, and energy absorbed at ultimate load. Results Double-row repair significantly decreased external rotation and total range of motion compared with single-row repair. Both repairs decreased anterior-inferior translation compared with the capsulolabral-injured condition, however, no differences existed between repair types. Yield load in the single-row group was 171.3 ± 110.1 N, and in the double-row group it was 216.1 ± 83.1 N ( P = .02). Ultimate load to failure in the single-row group was 224.5 ± 121.0 N, and in the double-row group it was 373.9 ± 172.0 N ( P = .05). Energy absorbed at ultimate load in the single-row group was 1,745.4 ± 1,462.9 N-mm, and in the double-row group it was 4,649.8 ± 1,930.8 N-mm ( P = .02). Conclusions In cases of capsulolabral disruption, double-row repair techniques may result in decreased shoulder rotational range of motion and improved load-to-failure characteristics. Clinical Relevance In cases of capsulolabral disruption, repair techniques with double-row mattress repair may provide more secure fixation. Double-row capsulolabral repair decreases shoulder motion and increases load to failure, yield load, and energy absorbed at yield load more than single-row repair.

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.

Tennis places high loads on the joints of players, with supraphysiologic forces being generated at the shoulder and elbow hundreds of times per match. Acute injuries tend to affect the lower extremity; chronic injuries usually involve the upper extremity. Commonly encountered upper extremity conditions include rotator cuff injury, internal impingement, superior labral tears, and epicondylitis of the elbow. Serving is the most strenuous stroke in tennis, with the highest peak muscle activity in the shoulder and forearm occurring during this stroke. The kinetic chain links upper extremity, lower extremity, and core muscle segments by transmitting coordinated activation and motion; in this regard, any pathologic process that disturbs the groin, hip, and abdominal musculature can further result in an increased risk of injury to the shoulder and upper extremity. Evolution in equipment and in play surfaces has also affected the type and frequency of injuries. Prevention programs that address the muscular imbalances throughout the kinetic chain may help reduce the incidence of both acute and chronic injuries experienced by tennis athletes.

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.

Interscalene block (ISB) of the brachial plexus is frequently used for patients undergoing ambulatory shoulder surgery. We previously reported that the incidence of postoperative complaints (neurapraxia) after an ISB was low (3% at 2 weeks), but objective neurologic assessment was not included in the study. The present study combines subjective findings with both preoperative and postoperative objective sensory and motor assessments after an ISB. We prospectively evaluated 133 patients undergoing elective ambulatory shoulder surgery. ISB anesthesia was accomplished by use of 1.5% mepivacaine alone or in combination with bupivacaine (0.5%-0.75%) via a paresthesia technique and a 23-gauge needle. All of the blocks were performed by experienced anesthesiologists. The number of passes with the needle, site of paresthesia, ease of performing the block, and success of the ISB were recorded for each patient. Neurologic assessment was performed preoperatively and up to 2 weeks postoperatively by 1 of 4 health care professionals but not by the anesthesiologists who performed the ISB and included diminished sensation, localized nerve pain, Semmes-Weinstein monofilament pressure threshold sensibility, Weber static 2-point discrimination, and grip strength changes. Patients with postoperative changes were followed up until resolution of symptoms occurred. Successful surgical anesthesia was achieved in 98% of the patients. There was 1 major perioperative complication (0.7%), a seizure that occurred within 5 minutes of the ISB. Two (1.4%) complained of transient postoperative neurapraxias. Neither patient had any changes in objective sensory and motor measurements. Hence, there was no correlation between subjective complaints and objective findings in this study. This study demonstrates that, in the hands of anesthesiologists doing predominantly regional anesthesia, there is a 1.4% incidence of neurologic complications after an ISB. ISB is a safe and effective technique for patients undergoing ambulatory shoulder surgery when an anesthesiologist experienced with regional anesthesia is involved.

Open posterior capsular shift is used for posterior glenohumeral instability that has failed nonoperative treatment. Few series have fully evaluated the outcome after open posterior stabilization. The purpose of this series was to evaluate the clinical and radiographic outcome after open posterior stabilization of the shoulder. Preoperative and intraoperative factors were analyzed with regard to their impact on results. Forty-eight consecutive shoulders were identified that had undergone primary open shoulder stabilization by use of open posterior capsular shift. Of the shoulders, 4 were lost to follow-up, resulting in a study group of 44 shoulders in 41 patients. Shoulders were evaluated at a range of 1.8 to 22.5 years after surgery by use of the L'Insalata shoulder form, Short Form-36 (SF-36), and a subjective shoulder rating in 44 shoulders. Thirty-nine shoulders were evaluated by physical examination, and thirty-seven underwent radiographic examination. A recurrence of posterior instability occurred in 8 shoulders (19%). Of the patients, 84% were satisfied with the current status of their shoulder. The mean L'Insalata score was 81.25+/-17.8 points, the mean SF-36 physical component score was 50.81+/-7.87, and the mean mental component score was 53.82+/-7.55. Significantly poorer satisfaction and outcome scores were seen in shoulders found to have a chondral defect at the time of stabilization and in patients aged greater than 37 years at the time of surgery. No progressive radiographic signs of glenohumeral arthritis were seen up to 22 years after surgery. Open posterior shoulder stabilization is a reliable procedure for treating significant posterior instability without causing arthritic changes. Patients found to have chondral damage within the shoulder and older patients were found to have less success after stabilization.

Despite being one of the more commonly injured joints in recreational and elite athletes, diagnosis of soft-tissue injuries of the elbow remains problematic. Although plain radiographs remain the initial mainstay for imaging of the elbow, the superior soft-tissue contrast and direct multiplanar capabilities of magnetic resonance (MR) imaging has afforded the ability to more accurately diagnose the site and extent of soft-tissue pathology, including tendinous injuries and trauma to the static stabilizers. In addition, the ability of MR imaging to noninvasively assess the integrity of the articular cartilage provides for more comprehensive information that was previously unavailable and has prognostic significance in the athlete.

The purpose of this study is to define the prevalence of peripheral nerve injury associated with full-thickness tears of the rotator cuff presenting with shoulder muscle atrophy. Twenty-five patients with the diagnosis of full-thickness rotator cuff tear were included. Electrodiagnostic testing, including nerve conduction studies and needle examination, was performed on all patients. There were 7 abnormal electromyographic examinations. The most common diagnosis was upper trunk brachial plexopathy severely affecting the axillary nerve (4/7), followed by suprascapular neuropathy (2/7) and cervical radiculopathy (1/7). The prevalence of associated peripheral neuropathy was found to be 28%. Greater degrees of atrophy were significantly associated with the presence of neuropathy in these patients. Careful neurologic screening in all patients and electromyographic examination in clinically suspicious groups are recommended in patients with full-thickness cuff tears before surgical repair.

Patients' preoperative expectations of shoulder surgery affect both the decision to proceed with surgery and how patients assess outcomes of surgery. Our goals were to identify patients' expectations of shoulder surgery, to develop and test a patient-derived shoulder surgery expectations survey, and to determine the prevalence of major expectations by diagnosis. An initial sample of 409 patients (mean age, 51 +/- 17 years; 58% men) with diverse shoulder diagnoses were asked open-ended questions preoperatively about their expectations of shoulder surgery. Their responses were grouped into 38 categories including the following: pain relief, increasing range of motion, improving the ability to wash and dress, returning to sports, improving the ability to interact and care for others, and for the shoulder to be back to the way it was before shoulder symptoms started. Expectations varied by demographic characteristics, diagnosis, and functional status measured by the L'Insalata Shoulder Rating Questionnaire and the Short Form 36. The most frequently cited categories were then assembled into closed-format questions to form a draft survey. A second sample of 100 patients with diverse shoulder diagnoses completed the draft survey on 2 separate occasions to establish test-retest reliability. Items retained to form the final survey were frequently cited, represented clinically relevant or potentially unrealistic expectations, and had concordance levels of 0.40 to 0.83 measured by the kappa statistic (71% had kappa >or= 0.60). The final 17-item Hospital for Special Surgery Shoulder Surgery Expectations Survey requires less than 5 minutes to complete. This patient-derived, self-administered survey has several possible uses in daily clinical practice, such as providing a way to learn about the patient's perspectives, providing the orthopaedist with a template to guide a formal discussion about realistic and unrealistic goals, and providing a prospective record that can be used jointly by the orthopaedist and patient postoperatively to assess the outcome of surgery.