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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.

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.

In the overhead athlete, medial ulnar collateral ligament (MUCL) insufficiency can develop from repetitive valgus loads across the elbow during the throwing motion. This injury can be potentially career ending for the athlete. Treatment options include conservative care or potential surgical intervention with ligament reconstruction. Given the prolonged recovery period after surgical intervention, other avenues for successful treatment of MUCL insufficiency have been explored, including potential injections into the ligament such as platelet-rich plasma (PRP) and autologous stem cells. Recently, PRP has drawn interest as a tool for biologic augmentation of tendon and ligamentous healing as it is an autologous concentration of platelets and growth factors including vascular endothelial growth factor, insulin-like growth factor-1, fibroblast growth factor-2, platelet-derived growth factor, and transforming growth factor-s. Despite some evidence that supports the use of PRP injections for partial MUCL tears, there is no current consensus regarding its use. Research into the use of stem cell therapy remains primitive and while initial animal studies appear promising, their true clinical utility is unclear. Although the current literature is limited regarding the true efficacy of these treatment options, continued interest into the field of biologic augmentation still exists due to the potential for tissue regeneration. More specifically, biologic agents are especially appealing in the young overhead athlete with acute damage to an isolated part of the MUCL and in those athletes who are unwilling or unable to undergo the extended rehabilitation required after surgical reconstruction of the ligament.

The anterior bundle of the ulnar collateral ligament (UCL) is the primary stabilizer against valgus stress in the elbow. However, when the UCL is compromised, the flexor-pronator mass becomes the primary dynamic valgus stabilizer of the elbow. Combined UCL and flexor-pronator mass injuries are a subset of medial elbow injuries sustained by overhead throwing athletes. Compared to athletes who suffer isolated UCL injuries, the group with combined UCL and flexor-pronator mass injuries tend to be older and have worse outcomes after surgical reconstruction. There are few studies describing these injuries in the orthopedic literature, and it is unclear what causes them to fail surgical management at a higher rate than UCL injuries alone. Treatment of this group requires a thorough history and physical exam, as well as a magnetic resonance imaging (MRI) for surgical planning. Based on the amount of flexor-pronator mass injury, different operative approaches may be warranted. It is important to counsel these patients about their prognosis, especially elite baseball players regarding their chances of returning to their previous level of play.

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.

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.

Injury to the medial collateral ligament (MCL) of the elbow is a debilitating condition in overhead throwing athletes, particularly baseball pitchers. In order to restore the primary ligamentous restraint against valgus stress at the elbow, MCL reconstruction is increasingly performed in both adolescent and elite throwing athletes in order to return to competition. We describe the pertinent surgical anatomy and indications for ligament reconstruction. Although various surgical techniques have been reported, we describe our preferred reconstruction with the docking technique through a muscle-splitting approach, which allows for secure graft fixation over bone bridges, identification and treatment of intra-articular pathology, and minimization of ulnar nerve-related complications. Excellent outcomes have been reported in approximately 90% of patients following MCL reconstruction with the docking technique.

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.

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.

Introduction 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. Methods 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. Results 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. Discussion 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: 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 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.

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.

Tennis continues to be one of the most popular sports in the world, and as interest grows, our understanding of the physiologic demands of the sport also increases. During the course of a standard tennis match, players are required to repetitively exert themselves in short, but explosive, bursts of energy several hundred times [1]. This is especially true during the serve, but all types of strokes place very unique demands on the upper extremity [2–4]. To better understand the physiologic processes occurring during the serve, it has been broken down into five distinct phases: (1) windup, (2) early cocking, (3) late cocking, (4) acceleration, and (5) follow-through [4, 5]. In order to successfully execute these phases, energy must be transferred efficiently and effectively along the entire kinetic chain of motion. Although the greatest stress to the shoulder occurs during the cocking and acceleration phases, disruption of the kinetic chain at any point in the process can place the shoulder at risk for injury [6].

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 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.

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: 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.

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.

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.

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.

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.

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.

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.]

Injury to the superior glenoid labrum is increasingly recognized as a significant source of shoulder pain and dysfunction in the throwing athlete. Several theories have been proposed to explain the pathogenesis of superior labral anterior posterior (SLAP) tears. The clinical examination of the superior labrum–biceps tendon complex remains challenging because of a high association of other shoulder injuries in overhead athletes. Many physical examination findings have high sensitivity and low specificity. Advances in soft tissue imaging such as magnetic resonance arthrography allow for improved detection of labrum and biceps tendon lesions, although correlation with history and physical examination is critical to identify symptomatic lesions. Proper treatment of throwers with SLAP tears requires a thorough understanding of the altered biomechanics and the indications for nonoperative management and arthroscopic treatment of these lesions.

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

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.

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.