Tibial Tubercle Trochlear Groove Distance Does Not Correlate With Patellar Tendon Length in Patients Who Underwent Anterior Cruciate Ligament Reconstruction

Purpose

To examine the relationship between tibial tubercle-trochlear groove (TT-TG) distance and patellar tendon length.

Methods

All healthy athletes who underwent anterior cruciate ligament reconstruction who had a magnetic resonance imaging (MRI) study of the knee on file between July 2018 and June 2019 at a single institution were retrospectively reviewed. Exclusion criteria included patients without an MRI study of the knee on file or with an MRI of insufficient quality precluding reliable calculation of TT-TG and patellar tendon length. MRIs were reviewed to calculate TT-TG, patellar tendon length, and Caton-Deschamps Index (CDI). Patient charts were reviewed to obtain anthropometric characteristics including sex, concomitant injuries, and previous knee procedures as well as age at time of MRI. Spearman correlations were used to assess the relationship between TT-TG, patellar tendon length, and CDI, with regression analysis performed to assess for relationships between TT-TG, patellar tendon length, and patient-specific factors.

Results

Overall, 235 patients (99 female [42.1%], 136 male [57.9%]; mean age: 30.0 years [23.0; 40.0]) were included. Inter-rater reliability between the 2 reviewers was 0.888 for TT-TG, 0.804 for patellar tendon length, and 0.748 for CDI, indicating strong agreement. The correlation between TT-TG and patellar tendon length was 0.021, indicating no true relationship. The correlation between TT-TG and CDI was -0.048 and that of patellar tendon length and CDI was 0.411, indicating a weak positive relationship. Regression analysis found that male sex is strongly correlated with a longer patellar tendon length (odds ratio 2.65, 95% confidence interval 1.33-3.97, P < .001).

Conclusions

In this study, no correlation was found between TT-TG and patellar tendon length or CDI. Male sex was correlated with a longer patellar length.

Level of Evidence

Level III.

Prevalence of bilateral ulnar nerve subluxation among professional baseball pitchers

BACKGROUND

Radiographic and physical examination findings of ulnar nerve instability have been recognized in overhead throwing athletes, despite the fact that some of these abnormalities may be asymptomatic and represent adaptive changes. While recommendations for screening and early detection have been made that can adversely impact an athletes' career, the presence of bilateral ulnar nerve subluxation and its relationship with medial elbow symptoms has not been characterized in professional overhead throwing athletes.

PURPOSE

To characterize the prevalence of bilateral ulnar nerve subluxation among professional baseball pitchers.

METHODS

A cross-sectional observational analysis was conducted utilizing standardized ultrasonographic examinations of bilateral elbows in 91 consecutive professional baseball pitchers (median age, 22 years; range, 17-30 years). The relationship between ulnar nerve subluxation and ulnar nerve signs, symptoms, and provocative physical examination maneuvers was also investigated.

RESULTS

The prevalence of bilateral ulnar nerve subluxation was 26.4% (95% CI, 17.7%-36.7%; 24 of the 91 athletes). Thirty-five athletes (38.5%; 95% CI, 28.4%-49.2%) had subluxation in at least 1 elbow. No athletes with subluxation had positive ulnar nerve signs, symptoms, or provocative tests.

CONCLUSION

Ulnar nerve subluxation is common among professional pitchers, and is more often than not bilateral. In this population of athletes, ulnar nerve subluxation does not appear to be associated with pathological findings.

Injuries in the emerging sport of roundnet (Spikeball): a cross-sectional study of 166 players

Objectives

To describe injury frequency and characteristics in roundnet athletes and compare injury characteristics between elite and non-elite athletes.

Methods

This cross-sectional study was performed by convenience sampling recreational and competitive roundnet athletes via a REDCap survey distributed through social media platforms. The custom survey evaluated athlete demographics, past sport participation, training workload and roundnet-related injuries throughout their whole playing career. Injury characteristics were reported for the full study cohort and compared between elite and non-elite athletes.

Results

166 athletes participated in the study, with 33.7% playing at the elite level. 279 injuries were reported, with 86.1% (n=143) of athletes reporting at least one injury throughout their playing career. Injuries most frequently involved the shoulder (20%), ankle (18%), knee (14%) and elbow (14%). 47% of reported injuries occurred due to overuse, and 67% resulted in missed competition time averaging 2.0 months. There were 10 injuries (3.6%) that required surgery. No differences were found in regards to injury frequency (1.9±1.5 vs 1.6±1.1 injuries per athlete, p=0.159) or any injury characteristics between elite and non-elite athletes.

Conclusion

Roundnet athletes experienced a mean of 1.7±1.2 injuries while playing roundnet. Injuries most frequently involved the shoulder and ankle and often resulted in missed competition time. The level of competition does not significantly impact injury frequency or characteristics. Roundnet athletes may benefit from injury prevention programmes that include shoulder strengthening, maintaining shoulder range of motion and ankle stability.

Similar return to sport between double cortical button and docking techniques for ulnar collateral ligament reconstruction in baseball players

BACKGROUND AND HYPOTHESIS

A double cortical button technique for ulnar collateral ligament reconstruction (UCLR) has advantages including significant control over graft tensioning, less concern about graft length, and minimized risk of bone tunnel fracture compared with traditional UCLR techniques. This double cortical button technique was recently found to be noninferior in mechanical performance to the traditional docking technique regarding joint strength, joint stiffness, and graft strain. However, clinical outcomes have not been compared between these UCLR techniques. Therefore, the purpose of this study was to determine whether baseball players who underwent UCLR with a double cortical button (double button) technique have similar return-to-sport (RTS) outcomes to baseball players who underwent UCLR with the traditional docking (docking) technique.

MATERIALS AND METHODS

Baseball players who underwent primary UCLR from 2011 to 2020 across 2 institutions were identified. Included patients were contacted to complete a follow-up survey evaluating reoperations, RTS, and functional outcome scores. Functional outcome surveys include the Kerlan-Jobe Orthopaedic Clinic score, the Conway-Jobe score, the Andrews-Timmerman elbow score, and the Single Assessment Numeric Evaluation score.

RESULTS

Overall, 78 male baseball players (age: 18.9 ± 2.4 years) with an average follow-up of 3.1 ± 2.4 years were evaluated, with 73 of the players being baseball pitchers. Players in the double button group more frequently received palmaris longus autografts (78% vs. 30%) and less frequently received gracilis autografts (22% vs. 58%) compared with players in the docking group (P = .001); however, all other demographic factors were similar between the groups. All players in the double button group were able to RTS in 11.1 ± 2.6 months, whereas 96% of players in the docking group were able to RTS in 13.5 ± 3.4 months (P > .05). All postoperative outcomes and patient-reported outcomes were statistically similar between the groups and remained similar after isolating pitchers only and after separating partial-thickness from full-thickness UCL tears (all P > .05).

CONCLUSION

RTS and other postoperative outcomes may be similar between baseball players who underwent UCLR with the double button technique and the docking technique. Although future research may be necessary to strengthen clinical recommendations, these findings provide the first clinical outcomes in light of a recent cadaveric study finding similar elbow strength, joint stiffness, and graft strain compared with the docking technique.

Analysis of reasons for failure to return to sport after Latarjet surgery: a systematic review

BACKGROUND

The purpose of this study was to perform a systematic review of the literature to identify Shoulder Instability Return to Sport after Injury (SIRSI) scores in athletes who underwent open Latarjet surgery, determine the reasons why athletes failed to return to play (RTP) after Latarjet surgery, and compare SIRSI scores of those who did vs. did not RTP.

METHODS

According to PRISMA guidelines, the PubMed, SportDiscus, and Ovid MEDLINE databases were queried to identify studies evaluating return to sport after Latarjet surgery. Study quality was assessed using the MINORS criteria. Studies were included if RTP after Latarjet surgery and a psychological factor were evaluated, with potential psychological factors including readiness to RTP and reasons for failure to RTP.

RESULTS

Fourteen studies, 10 of level III evidence and 4 of level IV evidence, with 1034 patients were included. A total of 978 athletes were eligible to RTP. Of these, 792 (79%) successfully returned to play and 447 (56.4%) returned to play at their previous level of play. Mean RTP time was 6.2 months. Postoperative SIRSI scores averaged 71.2 ± 8.8 at a mean of 21 months' follow-up. Postoperative SIRSI scores for those able to RTP was 73.2, whereas athletes unable to RTP scored an average of 41.5. Mean postoperative SIRSI scores for those in contact sports was 71.4, whereas those in noncontact sports was 86.5. There were 31 athletes with a documented reason why they did not RTP, with postoperative shoulder injury being the most common reason (54.5%). Fear of reinjury and feeling "not psychologically confident" each represented 6.5% of the total.

CONCLUSION

Athletes who RTP have higher average SIRSI scores than those who are unable to RTP. Of the athletes who documented why they did not RTP, more than half cited a shoulder injury as their reason for not returning to play, whereas fear of reinjury and lack of psychological readiness were other common reasons.

A systematic review of cartilage procedures for unstable osteochondritis dissecans

OBJECTIVES

Osteochondritis dissecans can result in significant limitations in activity, pain, and early osteoarthritis. There are various treatment modalities to address these defects. The purpose of this study was to provide a qualitative summary of the various treatment options for unstable osteochondritis dissecans in the knee.

METHODS

A literature search was performed on osteochondritis dissecans in the knee using PubMed (MEDLINE), Embase, and Cochrane electronic databases. The search was completed using a combination of the following terms: 'osteochondritis dissecans,' 'OCD,' 'osteochondral,' 'articular cartilage,' 'repair,' 'surgery,' 'treatment,' 'osteochondral allograft,' 'autologous chondrocyte implantation,' 'unstable,' 'knee,' 'clinical studies.'

RESULTS

A total of 682 studies were found, of which 24 were included in the qualitative analysis. The quality score ranged from 46 to 80, and the mean follow-up ranged from 2 to 17 years. The most common surgical procedures were internal fixation (n = 7 studies), ACI (n = 6), fragment excision (n = 3), MACI (n = 2), bone graft + ACI (n = 2), OCA (n = 2), mosaicplasty/OAT (n = 2), and scaffold (n = 2). Overall, the reported outcome measures were heterogeneous in nature. Post-operative International Knee Documentations Committee (IKDC) scores ranged from 75 to 85 and Lysholm scores ranged from 70 to 93.5. Tegner scores ranged from 4 to 5. Rates of failure, complication, and revision were highly variable across studies and surgical techniques.

CONCLUSION

There are a variety of surgical options for the treatment of unstable osteochondritis dissecans. In skeletally immature patients, internal fixation demonstrated acceptable rates of radiographic union and patient reported outcome measures. In skeletally mature patients with large lesions, MACI and OCA transplantation provided similar patient reported outcomes.

Physical Examination Versus Ultrasonography for Detection of Ulnar Nerve Subluxation in Professional Baseball Pitchers

Background

Despite the importance of accurately detecting ulnar nerve subluxation in vulnerable athletes, few studies have compared the performance of physical examination and ultrasound in this population.

Purpose/Hypothesis

The purpose of this study was to compare the diagnostic validity of physical examination versus ultrasound in detecting ulnar nerve subluxation at the cubital tunnel of the elbow in professional baseball pitchers. It was hypothesized that ultrasound would more sensitively detect ulnar nerve subluxation.

Study Design

Cohort study (diagnosis); Level of evidence, 2.

Methods

Physical and sonographic examinations for ulnar nerve subluxation were performed on 186 elbows of 95 consecutive male professional baseball pitchers (age, 17-30 years) as a routine part of their spring training assessments. Provocative maneuvers consisting of the Tinel and elbow flexion-compression tests were evaluated over the cubital tunnel. The validity of physical examination for detecting ulnar nerve subluxation at the elbow was determined using ultrasonographic examination for comparison.

Results

Ulnar nerve subluxation was detected by physical examination in 58 (31.2%) elbows and by ultrasonography in 61 (32.8%) elbows. Of the 58 elbows with positive physical examination, 47 were positive on ultrasound. Using a positive ultrasound as a reference, the accuracy of the physical examination was 86.6%, with 77% sensitivity and 91.2% specificity. The positive and negative predictive values of physical examination were 81% and 89.1%, respectively. There was no relationship between nerve instability and positive provocative tests overall, in dominant versus nondominant arms, or in right versus left arms (P > .05 for all).

Conclusion

Physical examination had moderate sensitivity and high specificity for detecting ulnar nerve subluxation at the cubital tunnel of the elbow when compared with ultrasound. These findings suggest that when detecting the presence of a subluxating ulnar nerve is most important, it may be advisable to obtain an ultrasound evaluation instead of relying on a physical examination; however, physical examination alone may be appropriate for ruling out subluxation.

In Vivo Effect of Partial Ulnar Collateral Ligament Tear Location on Ulnohumeral Joint Gapping With Stress Ultrasound in Baseball Pitchers

BACKGROUND

Stress ultrasonography (SUS) has provided clinicians with an alternative means of evaluating ulnar collateral ligament (UCL) injury by dynamically assessing ulnohumeral joint space gapping under applied valgus stress. However, 3 previous cadaveric studies have evaluated the biomechanical effect of partial UCL tears at different anatomic locations with conflicting results.

PURPOSE/HYPOTHESIS

The purpose of this study was to use in vivo data from patients with magnetic resonance (MR)-confirmed partial UCL tears to determine if anatomic partial tear location influenced the resultant stability of the elbow in terms of ulnohumeral joint gapping on SUS. It was hypothesized that no difference would be seen in the amount of ulnohumeral joint gapping based on MR-identified anatomic partial UCL tear location.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All patients diagnosed with elbow injury from 2015 to 2020 were screened to identify competitive baseball pitchers with a partial UCL tear who received an SUS. Partial UCL tear was diagnosed via surgeon and radiologist interpretation of elbow MR imaging (MRI) as well as confirmation at the time of surgery as documented in the operative report. Demographic, injury, and treatment data were collected from the clinic notes, MRI reports, and stress ultrasound reports. Ulnohumeral joint gapping on SUS was calculated as the difference between ulnohumeral joint gapping without valgus stress versus ulnohumeral joint gapping with valgus stress (delta) as performed by a musculoskeletal radiologist.

RESULTS

Overall, 60 male baseball pitchers (age, 19.2 ± 2.1 years), including 22 (37%) high school, 26 (43%) collegiate, and 12 (20%) professional pitchers, were evaluated. Regarding the location of partial UCL tears, 32 (53%) pitchers had proximal tears and 28 (47%) had distal tears. The mean delta value cohort was 2.1 ± 1.1 mm, and 34 pitchers (57%) had delta values >2.0 mm. Ulnohumeral joint gapping (high school [1.9 mm] vs collegiate [2.6 mm] vs professional [1.6 mm]; P = .004) and the percentage of pitchers with delta values >2.0 mm (45% vs 77% vs 33%; P = .017) differed based on level of competition. After controlling for age, body mass index, and level of competition in a multivariate linear regression, tear location was not related to ulnohumeral joint gapping (P = .499).

CONCLUSION

No difference was observed in the amount of ulnohumeral joint gapping on SUS in symptomatic baseball pitchers with MR-identified partial UCL tears at differing anatomic locations. The findings of this study are contrary to previous cadaveric studies that have evaluated the effects of UCL tear characteristics on delta laxity.

Inequalities in the Evaluation of Male Versus Female Athletes in Sports Medicine Research: A Systematic Review

BACKGROUND

Female sports participation continues to rise; however, inequalities between male and female athletes still exist in many areas and may extend into medical research.

PURPOSE

The purpose of this study was to (1) compare the number of published studies evaluating male versus female athletes in various sports and (2) identify which co-ed sports currently underrepresent female athletes in the sports medicine literature.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

All nonreview research studies published from 2017 to 2021 in 6 top sports medicine journals were considered for inclusion. Sports medicine studies were included that isolated athletes, reported study outcomes specific to male and/or female patients, provided study outcomes for specific sports, and evaluated ≤3 different sports. The total number of studies reporting on male and/or female athletes were compared for all sports, and odds ratios (ORs) were calculated. Comparisons of study design, level of sports participation, outcomes assessed, and study quality were also made according to participant sex.

RESULTS

Overall, 669 studies were included the systematic review. Most studies isolated male athletes (70.7%), while 8.8% isolated female athletes and 20.5% included male and female athletes. Female athletes were more frequently studied in softball and volleyball, while male athletes were more commonly researched in baseball, soccer, American football, basketball, rugby, hockey, and Australian football. Notably, male athletes were largely favored in baseball/softball (91% vs 5%; OR = 18.2), rugby (72% vs 5%; OR = 14.4), soccer (65% vs 15%; OR = 4.3), and basketball (58% vs 18%; OR = 3.2).

CONCLUSION

Sports medicine research has favored the evaluation of male athletes in most sports, including the majority of co-ed sports. Potential reasons for this inequality of research evaluation include availability of public data and database data, financial and promotional incentives, a high percentage of male sports medicine clinicians and researchers, and sex biases in sport. While the causes of these differences are multifaceted, researchers should consider both sexes for study inclusion whenever possible, and journals should support a more balanced representation of research publications regarding male and female athletes.

Rates of Reporting and Analyzing Patient Sex in Sports Medicine Research: A Systematic Review

BACKGROUND

Sex differences in sports medicine are well documented. However, no studies to date have reviewed the rate at which sex is reported and analyzed in the athlete-specific orthopaedic sports medicine literature.

PURPOSE

To determine the rates of reporting and analyzing patient sex in athlete-specific sports medicine literature.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

Articles published by the 3 journals of the AOSSM (American Journal of Sports Medicine [AJSM], Orthopaedic Journal of Sports Medicine, and Sports Health: A Multidisciplinary Approach) between 2017 and 2021 were considered for inclusion. Original sports medicine research studies that isolated athletes were included. Studies that isolated sports that are predominantly single sex at the college and/or professional levels (football, baseball, softball, and wrestling) were excluded.

RESULTS

Of the 5140 publications screened, 559 met the inclusion criteria. In total, 93.9% of all studies reported patient sex, and 34.7% of all studies analyzed patient sex. However, 143 studies only included males and 50 studies only included females (n = 193). When excluding these single-sex studies, analysis of the remaining 366 studies found that the rate of sex-specific analysis increased to 53.0%. Rates of reporting patient sex did not significantly differ by journal or by year. Similarly, rates of analyzing patient sex did not differ by year, but Sports Health analyzed sex the most frequently, and AJSM analyzed sex the least frequently (P = .002). Studies that isolated college (84.1%), youth (66.7%), or recreational (52.6%) athletes analyzed sex at or above the overall rate of 53.0%, but studies of elite athletes (35.7%) tended to analyze sex less frequently.

CONCLUSION

Patient sex is well reported in the athlete-specific sports medicine literature (93.9% of included studies reported sex), demonstrating that most studies include sex as a demographic variable. However, patient sex was analyzed only in 53.0% of studies that included both male and female patients. Given that athlete-specific sex differences are known to exist within the field of sports medicine, many studies that could benefit from using patient sex as a variable for analysis likely fail to do so.

Incidence of Repeat Elbow Capsular Release After Arthroscopic Elbow Capsular Release

Background

Elbow capsular release can be performed arthroscopically or through an open method to improve range of motion (ROM). However, it is unclear how frequently patients require an open capsular release after unsatisfactory results from an arthroscopic release.

Purpose/Hypothesis

The purpose of this study was to determine the percentage of patients who underwent an arthroscopic elbow release for loss of motion who then required a repeat elbow capsular release or other subsequent surgery on the same elbow. It was hypothesized that patients who underwent arthroscopic elbow release would rarely (<5%) require a subsequent elbow release.

Study Design

Case series; Level of evidence, 4.

Methods

Patients who underwent arthroscopic elbow capsular release from January 1, 2010, to December 31, 2019, were identified by chart review and procedure code. Demographic parameters, pre- and postoperative ROM, and surgical history were collected by chart review. Follow-up data included patient satisfaction and the Timmerman-Andrews (TA) elbow score. Data were compared between patients who did and those who did not require subsequent elbow surgery.

Results

Overall, of 140 study patients (116 male, 24 female; mean age, 49.6 years), 18 (12.9%) required subsequent surgery, including 6 capsular releases (4.3%; 1 open and 5 arthroscopic). The most common follow-up procedure was ulnar nerve releases/transpositions (n = 7). Total arc of elbow motion (flexion to extension) improved by a mean of 51.4°. The mean TA score was 76.5 ± 20.4 at a mean of 5.25 years postoperatively. Mean satisfaction score was 77.6 ± 26.3. In this study, 82.4% of patients stated that their symptoms either improved or resolved completely. Patients who required subsequent surgery had a significantly lower preoperative total arc of elbow motion versus those who did not require subsequent surgery (P = .046). There was no difference between the groups in symptom resolution, satisfaction, ROM, or TA score (P ≥ .279 for all).

Conclusion

After arthroscopic elbow release, <5% of patients required a repeat elbow capsular release, 12.9% required some form of follow-up elbow surgery, and 4.3% had a new injury of the elbow. Overall, patients saw improvement in elbow ROM, but many still had residual symptoms from their underlying disease after arthroscopic elbow capsular release.

Differences in the Severity and Location of Patellofemoral Cartilage Damage Between Instability Patients With and Without Patella Alta

Background

Patella alta is a risk factor for recurrent patellar instability. Differences in chondral injury in patients with patellar instability between patella alta and patella norma have not been evaluated.

Purpose

To analyze whether preoperative cartilage damage differs in severity and location between patellar instability patients with and without patella alta.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients with patellar instability who underwent patellar realignment surgery at a single institution with preoperative magnetic resonance imaging (MRI) scans were included. After measurement of Caton-Deschamps index (CDI) on MRI, patients were divided into patella alta (CDI ≥1.3) and patella norma groups. The area measurement and depth and underlying structures (AMADEUS) score was used to quantify cartilage defect severity on MRI.

Results

A total of 121 patients were divided into patella alta (n = 50) and patella norma (n = 71) groups. The groups did not differ significantly in sex ratio, age at MRI, body mass index, mean reported number of previous dislocations, or mean interval between first reported dislocation and date of MRI. A total of 34 (68%) of the patella alta group and 44 (62%) of the patella norma group had chondral defects (P = .625) with no significant between-group differences in defect size (P = .419). In both groups, chondral injuries most affected the medial patellar facet (55% in patella alta vs 52% in patella norma), followed by the lateral facet (25% vs 18%), and lateral femoral condyle (10% vs 14%). A smaller proportion of patients had full-thickness defects in the patella alta compared with the patella norma group (60% vs 82%; P = .030). The overall AMADEUS score was higher for the patella alta versus the patella norma group (68.9 vs 62.1; P = .023), indicating superior articular cartilage status.

Conclusion

Patients with patella alta had less severe cartilage injury after patellar instability, including a lower proportion with full-thickness defects and better overall cartilage grade. The location of injury when present was similar between alta and norma, with most defects affecting the medial facet, lateral facet, and lateral femoral condyle in descending frequency.

Influence of Race on Utilization and Outcomes in Shoulder Arthroplasty: A Systematic Review

BACKGROUND

Studies have shown that utilization and outcomes after shoulder arthroplasty vary by sociodemographic factors, highlighting disparities in care. This systematic review synthesized all available literature regarding the relationship between utilization and outcomes of shoulder arthroplasty and race/ethnicity.

METHODS

Studies were identified using PubMed, MEDLINE (through Ovid), and CINAHL databases. All English language studies of Level I through IV evidence that specifically evaluated utilization and/or outcomes of hemiarthroplasty, total shoulder arthroplasty, or reverse shoulder arthroplasty by race and/or ethnicity were included. Outcomes of interest included rates of utilization, readmission, reoperation, revision, and complications.

RESULTS

Twenty-eight studies met inclusion criteria. Since the 1990s, Black and Hispanic patients have demonstrated a lower utilization rate of shoulder arthroplasty compared with White patients. Although utilization has increased among all racial groups throughout the present decade, the rate of increase is greater for White patients. These differences persist in both low-volume and high-volume centers and are independent of insurance status. Compared with White patients, Black patients have a longer postoperative length of stay after shoulder arthroplasty, worse preoperative and postoperative range of motion, a higher likelihood of 90-day emergency department visits, and a higher rate of postoperative complications including venous thromboembolism, pulmonary embolism, myocardial infarction, acute renal failure, and sepsis. Patient-reported outcomes, including the American Shoulder and Elbow Surgeon's score, did not differ between Black and White patients. Hispanics had a significantly lower revision risk compared with White patients. One-year mortality did not differ significantly between Asians, Black patients, White patients, and Hispanics.

CONCLUSION

Shoulder arthroplasty utilization and outcomes vary by race and ethnicity. These differences may be partly due to patient factors such as cultural beliefs, preoperative pathology, and access to care, as well as provider factors such as cultural competence and knowledge of health care disparities.

LEVEL OF EVIDENCE

Level IV. See Instructions for Authors for a complete description of levels of evidence.

Disruptions in Standard Care in Patients After Arthroscopic Rotator Cuff Repair During the COVID-19 Pandemic

Background

The coronavirus disease-2019 (COVID-19) pandemic led to disruptions in care for orthopaedic patients who underwent surgery just before the outbreak, rendering some unable to participate in standard postoperative care. Many of these patients underwent clinical follow-up and physical therapy via telehealth.

Purpose

To evaluate the methods of postoperative care in patients who underwent arthroscopic rotator cuff repair (RCR) and had follow-ups during the height of the pandemic versus those who received prior standard of care. We aimed to compare the 1-year outcomes between these cohorts.

Study Design

Cohort study; Level of evidence, 3.

Methods

A retrospective chart review was used to identify patients who underwent primary RCR in February and March 2020 (COVID cohort) and the same period in 2019 (control cohort) at a single institution. Excluded were patients who underwent revision RCR, used workers' compensation, or were incarcerated or deceased. The included patients reported the postoperative care received, their satisfaction with care, physical therapy appointment type (in person, home based, telehealth, or self-guided), satisfaction with physical therapy, and minimum 1-year postoperative American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Penn Shoulder Score (PSS) outcomes.

Results

Overall, 428 patients were included for final analysis--199 in the COVID cohort and 229 controls. Follow-up data were collected for 160 patients in the COVID group (80.4%) and 169 control patients (73.8%). In the COVID group, 110 patients (68.8%) had ≥1 clinical visit conducted via telehealth, compared with zero in the control group. There were no differences between the COVID and control groups in the ASES (84.2 ± 16.5 vs 86.5 ± 17; P = .27 ), SANE (83.9 ± 15.4 vs 84.8 ± 17.5; P = .66), PSS (84.8 ± 15.3 vs 87.1 ± 15.1; P = .22), or patient satisfaction with the care received (81.7 ± 22.6 vs 86.3 ± 23.5; P = .09). Satisfaction with physical therapy was significantly higher in the control group (88.3 ± 18.9 vs 81.9 ± 22.5; P = .01).

Conclusion

Despite disruptions in care, RCR patients had comparable 1-year outcomes during the pandemic versus before the pandemic. Telehealth clinical follow-up appointments did not adversely affect patient-reported outcome measures and may be appropriate for RCR patients beyond the pandemic.

Does Prehabilitation Before Surgery Affect Return to Sport in Baseball Pitchers With Partial Ulnar Collateral Ligament Tears?

Background

Purposeful rehabilitation before surgery (prehabilitation) has been researched and implemented in the treatment of anterior cruciate ligament tears. However, it is unclear whether prehabilitation would affect outcomes for baseball pitchers with partial ulnar collateral ligament (UCL) tears.

Purpose/Hypothesis

The purpose of this study was to determine whether baseball pitchers with partial UCL tears who completed ≥4 weeks of prehabilitation (prehab group) have different return to play (RTP) outcomes than pitchers with 0 to 3 weeks of preoperative physical therapy (no prehab group). We hypothesized that pitchers in the prehab group would have similar RTP rates compared with pitchers in the no prehab group.

Study Design

Cohort study; Level of evidence, 3.

Methods

Baseball pitchers of all competitive levels who underwent primary UCL reconstruction (UCLR) or UCL repair between 2010 and 2019 were included. Physician chart notes, magnetic resonance images, and operative notes were screened to confirm primary UCLR or UCL repair of a partial UCL tear and to identify whether the nonoperative treatment had been attempted. Patients were contacted via RedCap for postoperative complications, reoperations, RTP, and patient-reported outcomes (Kerlan-Jobe Orthopaedic Clinic score, Andrews-Timmerman score, Conway-Jobe score, and satisfaction).

Results

Overall, 105 baseball pitchers (n = 55 prehab group; n = 50 no prehab group) were included and evaluated at 3.4 ± 2.5 years postoperatively. Six pitchers underwent UCL repair, and 99 pitchers underwent UCLR. All demographic characteristics were similar between groups except the prehab group received a gracilis graft more frequently (76.5% vs 51.2%; P = .038). The RTP rate (prehab [88.1%] vs no prehab [93.8%]; P = .465) was similar between groups. All other postoperative outcomes were also similar between groups, including revision rates and patient-reported outcomes.

Conclusion

Postoperative and patient-reported outcomes did not differ significantly between pitchers with partial UCL tears who performed rehabilitation before UCL surgery and pitchers who did not attempt a significant period of rehabilitation before UCL surgery. Clinicians should feel comfortable recommending rehabilitation for patients with partial UCL tears who wish to attempt a period of nonoperative treatment, as postoperative outcomes are not affected if UCL surgery is later needed.

Return to recreational sports participation following rotator cuff repair in adults over 40 Years of age: outcomes and return to play analysis

Background

Despite the high prevalence of rotator cuff (RTC) tears in older adults, there is limited literature evaluating the return to recreational sport after repair. The purpose of this study was (1) to assess the patient-reported outcomes and return to sport rates following rotator cuff repair in patients aged more than 40 years with minimum 2-year follow-up; (2) to compare baseline, preoperative and postoperative outcomes, and level of play following repair of self-reported athletes with nonathletes; and (3) to compare return to sport rates in overhead athletes compared to nonoverhead athletes.

Methods

Patients undergoing arthroscopic rotator cuff repair between January 2016 and January 2019 were screened for inclusion. Inclusion criteria included (1) age more than 40 years at the time of surgery, (2) arthroscopic repair of a full thickness RTC tear, and (3) preoperative American Shoulder and Elbow Surgeons score (ASES) available. Eligible patients were contacted and invited to fill out a custom return to sport and patient-reported outcome survey.

Results

Overall, 375 of the 1141 eligible patients completed the survey instrument. There were 210 self-reported athletes (mean age 59.2 ± 9.55 years) and 165 nonathletes (mean age 62.0 ± 8.27 years) (P = .003). Of the athletes, 193 (91.9%) returned to sport. The average age of athletes was 59.4 ± 9.33 years for those who returned to sport and 57.9 ± 12.0 years for those who did not (P = .631). Athletes reported higher ASES scores than nonathletes both preoperatively (49.8 ± 20.3 vs. 44.8 ± 18.9, P = .015) and postoperatively (87.6 ± 16.7 vs. 84.9 ± 17.5, P = .036), but there was no difference in mean ASES improvement between groups (37.7 ± 23.0 vs. 40.3 ± 24.5, P = .307). There was no difference in postoperative Single Assessment Numeric Evaluation scores when comparing self-reported athletes to nonathletes (85.4 ± 17.5 vs. 85.0 ± 18.7, P = .836). After controlling for age, sex, body mass index, and smoking status using a multivariate analysis, there was no difference in mean ASES improvement when comparing athletes to nonathletes.

Conclusion

There is a high rate of return to sport activities (> 90%) in older adult recreational athletes following arthroscopic repair of full thickness RTC tears and rates of return to sport did not significantly differ for overhead and nonoverhead athletes. Self-reported athletes were noted to have higher baseline, preoperative, and postoperative ASES scores than nonathletes, but the mean ASES improvement following repair did not significantly differ between groups.

Preoperative Patella Alta on Caton-Deschamps Index Is a Predictor of Outcome Following Isolated Medial Patellofemoral Ligament Reconstruction

Purpose

The purpose of this study was to determine whether a preoperative Caton-Deschamps index (CDI) ≥ 1.30, as measured by magnetic resonance imaging, is associated with rates of postoperative instability, revision knee surgery, and patient-reported outcomes in patients undergoing isolated medial patellofemoral ligament (MPFL) reconstruction.

Methods

Patients who underwent primary medial patellofemoral ligament reconstruction (MPFLR) between 2015 and 2019 at a single institution were assessed. Only those with at least 2 year follow up were included. Patients who had undergone a previous ipsilateral knee surgery, concomitant tibial tubercle osteotomy and/or ligamentous repair/reconstruction at the time of MPFL reconstruction were excluded from the study. CDIs were evaluated by three investigators based on magnetic resonance imaging measurement. Patients with a CDI ≥ 1.30 were included in the patella alta group, while those with a CDI between 0.70 and 1.29 served as controls. A retrospective review of clinical notes was used to evaluate the number of postoperative instability episodes and revisions. Functional outcomes were measured by the International Knee Documentation Committee (IKDC) and 12-Item Short Form Health Survey (SF-12) physical and mental scores.

Results

Overall, 49 patients (50 knees, 29 males, 59.2%) underwent isolated MPFLR. Nineteen (38.8%) patients had a CDI ≥ 1.30 (mean: 1.41, range: 1.30-1.66). The patella alta group was significantly more likely to experience a postoperative instability episode (36.8% vs 10.0%; P = .023) and was more likely to return to the operating room for any reason (26.3% vs 3.0%; P = .022) compared to those with normal patellar height. Despite this, the patella alta group had significantly greater postoperative IKDC (86.5 vs 72.4; P = .035) and SF-12 physical (54.2 vs 46.5; P = .006) scores. Pearson's correlation showed a significant association between CDI and postoperative IKDC (R ² = 0.157; P = .022) and SF-12P (R ² = .246; P = .002) scores. There was no difference in postoperative Lysholm (87.9 vs 85.1; P = .531). and SF-12M (48.9 vs 52.5; P = .425) scores between the groups.

Conclusion

Patients with preoperative patella alta, as measured by CDI had higher rates of postoperative instability and return to the OR with isolated MPFL reconstruction for patellar instability. Despite this, higher preoperative CDI was associated with greater postoperative IKDC scores and SF-12 physical scores in these patients.

Level of Evidence

Retrospective cohort study, Level IV.

Patient Decision Making in Anterior Cruciate Ligament Reconstruction: A Discrete Choice Experiment Examining Graft Preference

Background

Bone-patellar tendon-bone (BTB) and hamstring autografts are the most common grafts used for anterior cruciate ligament (ACL) reconstruction. Patient preferences should be accounted for as a part of shared decision making.

Purpose/Hypothesis

The purpose of this study was to perform a discrete choice experiment that evaluated patient preferences toward ACL autografts. We hypothesized that there would be no difference in patient preferences between groups.

Study Design

Cross-sectional study.

Methods

Patients aged 18 to 25 years who underwent shoulder arthroscopy at a single institution between 2013 and 2019 were included in the study as a proxy for healthy controls. Patients with a history of ACL tear were excluded. A discrete choice experiment was developed from a literature search and used the following data points as they pertain to BTB or hamstring autograft: risk of developing a significant complication, return-to-play rate, risk of anterior knee pain with kneeling, and risk of additional surgery due to graft failure. Included patients completed a custom survey in which they were asked to choose between "surgery A" (hamstring) and "surgery B" (BTB).

Results

A total of 107 participants were included in the analysis. Of these participants, 39 (36.5%) chose surgery A (hamstring) and 68 (63.6%) chose surgery B (BTB). When comparing the hamstring group with the BTB group, there was no significant difference in age, sex, body mass index, race, level of education, or employment status. However, 80.5% of self-reported athletes preferred BTB (P = .008). When controlling for age, sex, and body mass index, patients in the BTB group were more likely to rate return to sport (risk ratio [RR] = 1.49 [95% CI, 1.18-1.98]; P = .001) and the risk of requiring additional surgery due to graft failure (RR = 1.26 [95% CI, 1.02-1.58]; P = .037) as highly important. Conversely, they were less likely than patients in the hamstring group to rate pain while kneeling (RR = 0.65 [95% CI, 0.98-1.05]; P < .001) and complication risk (RR = 0.75 [95% CI, 0.59-0.94]; P = .013) as important.

Conclusion

The study hypothesis was rejected, as patient values did affect ACL graft choice preference. Utilizing patient-selected values in a quantifiable way can benefit the shared decision-making process before ACL reconstruction.

Surgical management of acute, high-grade acromioclavicular joint separations: a systematic review

Background

While a number of treatment options exist for repair of acute, high-grade acromioclavicular joint (ACJ) separation, none have emerged as the standard of care. The purpose of this study was to systematically review the literature on surgical treatment of acute, high-grade (Rockwood grades III-V) ACJ separations in order to compare outcomes between direct fixation and tendon graft ligament reconstruction.

Methods

A systematic review of the literature evaluating outcomes for acute ACJ separation treatment with direct fixation or free biologic tendon graft reconstruction was performed. The following databases were examined: the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (1980-2021), and Embase (1980-2021). Studies were included if they reported a mean time to surgery as <6 weeks, contained >10 patients with a minimum 1-year follow-up, and reported clinical or radiographic outcomes.

Results

A total of 52 studies met the inclusion criteria. Seven studies reported outcomes following tendon graft ligament reconstruction (n = 128 patients). There were multiple methods of direct fixation. Thirty-three studies utilized suture button constructs (n = 1138), 16 studies used hook plates (n = 567), 2 studies used coracoclavicular screws (n = 94), 2 studies used suture fixation (n = 93), 2 studies used suture anchor (n = 55), 2 studies used suture cerclage fixation (n = 87), 1 used single multistrand titanium cable (n = 24), and 1 used K wire (n = 11). The mean follow-up Constant scores ranged from 77.5 to 97.1 in the fixation group compared to 90.3-96.6 in the tendon graft group. The mean visual analog scale scores ranged from 0 to 4.5 in the fixation group and 0.1-1 in the tendon graft group. Net CC distance ranged from 17.5 to 3.6 mm in the fixation group and 7.4-4 mm in the tendon graft group. The revision rates ranged from 0.0% to 18.18% in the direct fixation group and 5.88%-17% in the tendon graft group.

Conclusion

Direct fixation and tendon graft reconstruction for management of acute, high-grade ACJ separations have similar patient subjective and radiographic outcomes, as well as complication and revision rates at a minimum 1-year follow-up.

Bankart Repair With or Without Concomitant Remplissage Results in Similar Shoulder Motion and Postoperative Outcomes in the Treatment of Shoulder Instability

Purpose

To compare the results of patients who underwent Bankart repair with or without concomitant remplissage for treatment of shoulder instability.

Methods

All patients who underwent shoulder stabilization for shoulder instability from 2014 to 2019 were evaluated. Patients who underwent remplissage were matched to those patients who received no remplissage based on sex, age, body mass index, and date of surgery. Glenoid bone loss and presence of an engaging Hill-Sachs lesion were quantified by 2 independent investigators. Postoperative complications, recurrent instability, revision, shoulder range of motion (ROM), return to sport (RTS), and patient-reported outcome measures (Oxford Shoulder Instability, Single Assessment Numeric Evaluation, and American Shoulder and Elbow Surgeons scores) were compared between groups.

Results

Overall, 31 patients who underwent remplissage were identified and matched to 31 patients who received no remplissage at a mean follow-up of 2.8 ± 1.8 years. Glenoid bone loss was similar between groups (11% vs 11%, P = .956); however, engaging Hill-Sachs lesions were more prevalent in the patients who underwent remplissage than the patients who received no remplissage (84% vs 3%, P < .001). There were no significant differences in rates of redislocation (remplissage: 12.9% vs no remplissage: 9.7%), subjective instability (45.2% vs 25.8%), reoperation (12.9% vs 0%), or revision (12.9% vs 0%) between groups (all P > .05). Also, there were no differences in RTS rates, shoulder range of motion, or patient-reported outcome measures (all P > .05).

Conclusions

If a patient is indicated for Bankart repair with concomitant remplissage, surgeons may expect shoulder motion and postoperative outcomes similar to those of patients without engaging Hill-Sachs lesions who undergo Bankart repair without concomitant remplissage.

Level of Evidence

Therapeutic case series, level IV.

Increased rates of subjective shoulder instability after Bankart repair with remplissage compared to Latarjet surgery

HYPOTHESIS AND BACKGROUND

Controversy exists as to the ideal management of young active patients with subcritical glenoid bone loss and an off-track Hill-Sachs lesion, and the Latarjet and arthroscopic Bankart with remplissage are effective surgical options. The purpose of this study was to compare rates of recurrent instability and reoperation, as well as patient-reported outcome measures, between Latarjet and arthroscopic Bankart repair with remplissage surgery patients. The authors hypothesized that there would be no difference in rates of recurrent instability, reoperation, and postoperative outcomes between patients who underwent Latarjet surgery and patients who underwent Bankart repair with concomitant remplissage postoperatively.

MATERIALS AND METHODS

All patients who underwent primary shoulder stabilization for shoulder instability from 2014 to 2019 were screened. Latarjet and Bankart repair with remplissage patients were included if arthroscopic surgery was performed in response to anterior shoulder instability. Recurrent instability, revision, shoulder range of motion, return to sport (RTS), and patient-reported outcome measures (Oxford Shoulder Instability, Single Assessment Numeric Evaluation, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form scores) were compared between groups.

RESULTS

Overall, 43 Latarjet patients (age: 29.8 ± 12.1 years, 36 males 7 females) and 28 Bankart repair with remplissage patients (age: 28.2 ± 8.8 years, 25 males 3 females) were included with a mean follow-up of 3.3 ± 1.9 years. Patients who underwent Latarjet surgery had larger amounts of bone loss (19% vs. 11%, P < .001), a lower rate of off-track Hill-Sachs lesions (47% vs. 82%, P < .001), and more frequently had a history of chronic shoulder dislocations (88% vs. 43%, P < .001) compared to Bankart repair with remplissage patients. Latarjet patients less frequently reported feeling subjective shoulder instability after surgery (21% vs. 50%, P = .022), which was defined as feeling apprehension or experiencing a shoulder subluxation or dislocation event. There were no differences in rates of postoperative dislocation, revision, reoperation, or RTS, as well as patient-reported outcome scores, between groups (all P > .05).

CONCLUSION

Despite differences in osseous defects, Latarjet and Bankart repair with remplissage patients had similar rates of clinical, patient-reported, and RTS outcomes at a mean of 3.3 years postoperatively. Latarjet surgery patients may be less likely to experience subjective shoulder instability postoperatively than patients who undergo Bankart repair with concomitant remplissage.

Disruptions in standard care: anterior cruciate ligament reconstruction outcomes during the SARS-COV2 pandemic

OBJECTIVE

The SARS-COV2 pandemic led to massive disruptions of care for orthopedic patients. Although many elective procedures were put on hold, a cohort of patients who underwent surgery prior to the outbreak of the pandemic were rendered unable to participate in standard post-operative care. The purpose of this study was to determine the methods of post-operative care in arthroscopic anterior cruciate ligament reconstruction patients who received care during an early height of the pandemic to those who received standard of care in the prior year. We aimed to correlate those results with 1-year clinical outcomes in the form of subjective surveys.

METHODS

Retrospective chart review was used to identify patients who underwent primary anterior cruciate ligament reconstruction in February and March of 2020 (case) and 2019 (control) at a single institution. Workman's compensation patients were excluded. Identified patients were asked to report post-operative care received, satisfaction with care, and complete the IKDC and Lysholm outcome measures. Surveys were conducted minimum 1-year post-operative.

RESULTS

236 patients were identified, including 103 in 2020 and 133 in 2019. Follow-up data was collected for 73 patients (70.9%) in 2020 and 97 patients (72.9%) in 2019. Fifty-one COVID cohort patients (69.9%) had at least one clinical visit conducted via telehealth, compared to zero in the control. There were no differences in IKDC (82.8 ± 13.2 vs 85.0 ± 12.0, P = 0.29) and Lysholm (89.2 ± 11.3 vs 89.6 ± 10.8, P = 0.82) between groups. There were no differences in patient satisfaction with the care received (82.9 ± 22.4 vs 81.9 ± 21.8, P = 0.79).

CONCLUSION

Despite disruptions in care, anterior cruciate ligament reconstruction patients have excellent 1-year outcomes during the pandemic. Telehealth follow-up appointments may be appropriate for anterior cruciate ligament reconstruction patients beyond the pandemic and do not seem to adversely affect short-term patient reported outcome measures.

Blood Flow Restriction Training preserves knee flexion and extension torque following anterior cruciate ligament reconstruction: A systematic review

Background

There is inconsistency in the literature comparing the outcomes of Blood Flow Restriction Training versus Traditional Post-Operative Rehabilitation after anterior cruciate ligament reconstruction.

Purpose

This study aimed to determine if Blood Flow Restriction Training can limit the loss of knee extension and knee flexion muscle torque during early recovery from anterior cruciate ligament reconstruction better than Traditional Post-Operative Rehabilitation.

Methods

Three databases (PubMed, Embase, and Scopus) were searched for level 1 randomized controlled trials pertaining to Blood Flow Restriction Training after anterior cruciate ligament reconstruction. To maximize consistency among included studies, only studies which used knee flexion and knee extension muscle torque as the primary outcome measures were included. Search terms included "cruciate + occlusion", "cruciate + blood flow restriction", and "cruciate + occlusion training".

Results

Two level 1 trials with training protocols of 8 and 16 weeks yielded isokinetic knee flexion torque data in support of Blood Flow Restriction Training. Both trials demonstrated that Blood Flow Restriction Training also yielded significantly increased isokinetic knee extension torque compared to control groups.

Conclusion

The highest-quality level 1 trials evaluating knee extension and knee extension strength via isokinetic torque agree that Blood Flow Restriction Training limits post-operative losses of knee flexion and extension strength. No adverse events were reported in either study. Except for patients of whom Blood Flow Restriction is contraindicated, clinicians may consider utilizing Blood Flow Restriction Training from week 2 of the post-operative period through the conclusion of outpatient rehabilitation using low intensities, multiple times per week; however, further studies comparing Blood Flow Restriction Training protocols are necessary before an optimal protocol could be confidently recommended.

Comparison of post-operative outcomes following anterior cruciate ligament reconstruction between patients with vs. without elevated tibial tubercle-trochlear groove (TT-TG) distance

PURPOSE

It is unclear if an elevated tibial tubercle-trochlear groove (TT-TG) distance is a risk factor for poor outcomes following ACLR. Therefore, the purpose of this study was to determine whether patients with an elevated TT-TG have an increased risk of retear following primary ACLR compared to controls with a normal TT-TG.

METHODS

All patients who underwent primary ACLR between July 2018 and June 2019 with an available preoperative magnetic resonance imaging (MRI) were eligible for inclusion. TT-TG distance was measured on preoperative MRI scans by two independent investigators. Clinical outcomes, return-to-sport rates, and Lysholm scores were compared between patients with a TT-TG < 12.5 mm (normal) and those with a TT-TG ≥ 12.5 mm (elevated).

RESULTS

Overall, 159 patients were included, 98 with normal TT-TG distance and 61 with elevated TT-TG distance. Patients with an elevated TT-TG distance had worse post-operative Lysholm scores than patients with a normal TT-TG distance (83.0 vs. 95.0, p = 0.010). In patients who received a bone-patellar tendon-bone (BTB) graft, an elevated TT-TG distance was associated with higher rates of subjective instability (13.0% vs. 3.0%, p = 0.041), reoperation (13.0% vs. 1.5%, p = 0.012), and post-operative complications (25.0% vs. 8.2%, p = 0.026), as well as lower ACL psychological readiness scores (324.1 vs. 446.7, p = 0.015).

CONCLUSION

Patients with an elevated pre-operative TT-TG distance have worse Lysholm scores than patients with normal TT-TG distance. Patients with an elevated pre-operative TT-TG distance who underwent ACLR with BTB grafts had significantly higher rates of subjective instability, reoperation, and post-operative complications.

LEVEL OF EVIDENCE

III.

Identifying the underlying mechanisms responsible for glenohumeral internal rotation in professional baseball pitchers

Background and Hypothesis

Glenohumeral internal rotation deficit has been identified as a significant risk factor for upper-extremity injuries in pitchers across all ages. Humeral retroversion (HR), posterior capsule thickness (PCT), and posterior rotator cuff muscle pennation angle (PA) have been independently associated with internal rotation range of motion (IR ROM); however, these anatomic structures have not been collectively measured in baseball pitchers to determine the underlying mechanisms responsible for IR ROM. Therefore, the purpose of this study was to determine the contributions of HR, PCT, and posterior rotator cuff PA on IR ROM during a preseason evaluation in healthy professional baseball pitchers. The authors hypothesized that HR, PCT, and posterior rotator cuff PA would have a significant contribution to IR ROM.

Methods

This is a cross-sectional study. Healthy professional pitchers from a single organization were recruited at the beginning of the 2021 Major League Baseball Spring Training. Participants received bilateral IR ROM assessment while laying supine with the shoulder at 90 degrees of abduction and the scapula stabilized. Ultrasound imaging was also performed bilaterally to assess HR, PCT, infraspinatus (superficial + deep) PA, and teres minor (superficial + deep) PA. All ultrasound imaging processes were performed utilizing previously published, highly reliable techniques. A stepwise regression was performed, which included both arms to determine the mechanisms of IR ROM.

Results

Overall, 49 pitchers (88 shoulders) with an average age of 22.5 ± 2.2 years were included in the final data analysis. Stepwise linear regression found that only HR and PCT were associated with the preseason IR ROM. There was a moderate relationship between HR and PCT relative to IR ROM (R = 0.535, P < .001).

Conclusion

HR and PCT were found to be the primary mechanisms responsible for the preseason glenohumeral IR ROM. The posterior rotator cuff was not found to be significantly related to IR ROM. Future research evaluating these anatomic structures longitudinally-both acutely and chronically-will help clinicians optimize ROM management throughout the season. As glenohumeral internal rotation deficit can have harmful effects in baseball pitchers, understanding which anatomic structures are most responsible for IR ROM is important for injury prevention and treatment.

Open Repair of Complete Proximal Hamstring Avulsions in Workers’ Compensation Patients

Background:

Several studies have reported excellent results after surgical repair of proximal hamstring avulsions. However, the effect on these patients of receiving workers’ compensation has not yet been explored.

Hypothesis:

Workers’ compensation patients undergoing proximal hamstring repair of complete tears will have similar outcomes when compared with a matched control group of non–workers’ compensation patients.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Workers’ compensation patients who underwent complete proximal hamstring avulsion open repair between 2010 and 2019 were identified (WC group). A control group was matched by age (±3 years), sex, and body mass index (BMI; ±3). Demographics and patient-reported outcome measures were compared, including standard and custom Marx activity rating scale (MARS), standard and custom lower extremity functional scale (LEFS), and visual analog scale (VAS) for pain. Rate and time to return to work were recorded.

Results:

The WC group was composed of 20 patients (8 men, 12 women) with a mean age of 52.3 years and BMI of 32.4. The 20 matched controls (8 men, 12 women) who underwent repair had a mean age of 50.6 years and a mean BMI of 31.2. There was no difference between the groups regarding age (P = .924), sex (P > .999), or BMI (P = .330). The WC group reported similar mean MARS (3.3 vs 5.4; P = .174), custom MARS (87.5 vs 97.0; P = .215), and VAS pain (3.3 vs 3.8; P = .698) scores compared with controls. However, the WC group had significantly lower standard LEFS (69.1 vs 94.1; P < .001) and custom LEFS (62.3 vs 87.9; P < .001) scores, returned to work at a lower rate (70.0% vs 94.1%; P = .039), and required more time to return to work after repair (4.3 vs 3.5 months; P = .029) compared with controls.

Conclusion:

Workers’ compensation patients who underwent open proximal hamstring repair for complete avulsions experienced inferior patient-reported outcomes, required more time to return to work, and returned to work at a lower rate than a matched control group.

Clinical and Patient-Reported Outcomes for Acute Acromioclavicular Joint Fixation are Similar With or Without Allograft Augmentation

Purpose

Methods

Results

Conclusion

Level of Evidence

Acute Effects of Percussive Therapy on the Posterior Shoulder Muscles Differ Based on the Athlete's Soreness Response

Background

Percussive therapy is hypothesized to speed recovery by delivering gentle, rhythmic pulses to soft tissue. However, patients often present with a differential soreness response after percussive therapy, which may lead to altered clinical outcomes.

Purpose

To compare the acute effects of percussion therapy on passive range of motion (ROM) and tissue-specific ultrasound measures (pennation angle [PA] and muscle thickness [MT]) between healthy individuals responding positively vs. negatively to percussive therapy performed on the dominant arm posterior rotator cuff.

Study Design

Cross-sectional laboratory study.

Methods

Fifty-five healthy individuals were assessed on a subjective soreness scale before and after a five-minute percussive therapy session on the dominant arm posterior rotator cuff muscles. Participants with no change or a decrease in muscle soreness were assigned to the positive response group and participants who reported an increase in muscle soreness were assigned to the negative response group. Passive internal rotation (IR) and external rotation (ER) ROM and strength, and muscle architecture of the infraspinatus and teres minor were measured via ultrasound on the dominant shoulder. All dependent variables were collected before percussive therapy, and 20 minutes following percussive therapy.

Results

The positive response group had greater improvements than the negative response group in dominant arm IR ROM (2.3° positive vs. -1.3° negative, p=0.021) and IR strength (1.1 lbs vs. -1.2 lbs, p=0.011) after percussive therapy. No differences in ER strength or ROM were observed between groups. Regarding muscle architecture, the positive group had a lesser change in teres minor MT (0.00 mm vs. 0.11 mm, p=0.019) after percussive therapy. All other muscle architecture changes were not statistically different between groups.

Conclusion

Participants with a positive response to percussive therapy had increased dominant arm IR ROM and IR strength, and decreased teres minor MT, after percussive therapy compared to the negative response participants.

Level of Evidence

III.

Beach-Chair Versus Lateral Decubitus Positioning for Arthroscopic Posterior Shoulder Labral Repair: A Retrospective Comparison of Clinical and Patient-Reported Outcomes

BACKGROUND

Both beach-chair and lateral decubitus patient positioning are often utilized for shoulder arthroscopy, with each offering its unique advantages and disadvantages. The surgical position is often selected according to each surgeon's preference, with no clear superiority of one position over the other.

PURPOSE/HYPOTHESIS

The purpose was to compare clinical and patient-reported outcomes between patients who underwent arthroscopic posterior labral repair in the beach-chair versus the lateral decubitus position. We hypothesized that patient positioning would not affect clinical and patient-reported outcomes.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A list of all patients diagnosed with the Current Procedural Terminology codes 29806 and 29807 between 2015 and 2019 was obtained from the medical records. Patients were only included if arthroscopic posterior labral repair with or without concomitant superior labral anterior to posterior repair was confirmed. Data collected for eligible patients included the number of anchors used, perioperative and postoperative complications, redislocations, subjective instability, reoperation, and revision. Patients were also contacted to complete several patient-reported outcome surveys. Preoperative data, perioperative data, and postoperative outcomes were compared between patients who underwent surgery in the beach-chair versus lateral decubitus position.

RESULTS

Overall, 126 patients were included-69 patients underwent surgery in the lateral decubitus position and 57 in the beach-chair position-with a mean follow-up of 2.6 ± 1.7 years. There were no significant pre- or perioperative differences between groups. Rates of postoperative dislocations, subjective instability, reoperations, revisions, all complications, and return to sports rates also did not differ between groups (all, P > .05). Finally, there was no difference between groups regarding postoperative pain, function, and subjective instability scores (all, P > .05). Results of the multivariate regression analysis showed that increased age was a weak independent risk factor for subjective recurrent posterior shoulder instability (odds ratio, 1.04; P = .036).

CONCLUSION

Surgical positioning for arthroscopic posterior shoulder labral repair did not affect postoperative clinical and patient-reported outcomes. Both beach-chair and lateral decubitus position provided good outcomes for posterior shoulder labral repair, with an overall recurrence rate of 8.7%. Increased age was a weak independent risk factor for subjective recurrent instability.

Effect of Preoperative MRI Coracoid Dimensions on Postoperative Outcomes of Latarjet Treatment for Anterior Shoulder Instability

Background:

Preoperative coracoid dimensions may affect the size of the bone graft transferred to the glenoid rim and thus the postoperative outcomes of Latarjet coracoid transfer.

Purpose:

To determine the effect of coracoid length and width as measured on preoperative magnetic resonance imaging (MRI) on outcomes after Latarjet treatment of anterior shoulder instability.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Included were patients who underwent primary Latarjet surgery between 2009 and 2019 and had preoperative MRI scans and minimum 2-year postoperative outcomes. Longitudinal coracoid length was measured on axial MRI sequences as the distance from the coracoclavicular ligament insertion to the distal tip. Comparisons were made between shorter and longer coracoids and between narrower and wider coracoids. The outcomes of interest were recurrent instability, reoperation, complications, return to sport (RTS), and American Shoulder and Elbow Surgeons (ASES) score. Independent-samples t test, Mann-Whitney test, chi-square test, and Fisher exact test were used to compare outcomes between groups, and univariate correlation coefficients were calculated to evaluate the relationships between demographics and coracoid dimensions.

Results:

Overall, 56 patients were included (mean age, 28.4 years). The mean ± SD coracoid length was 21.6 ± 2.4 mm and width 10.0 ± 1.0 mm. Relative to patients with a longer coracoid (≥22 mm; n = 26), patients with a shorter coracoid (<22 mm; n = 30) had similar rates of recurrent instability (shorter vs longer; 6.7% vs 3.8%), complications (10.0% vs 15.4%), reoperation (3.3% vs 7.7%), and RTS (76.5% vs 58.8%) and similar postoperative ASES scores (85.0 vs 81.6) ( P ≥ .05 for all). Likewise, relative to patients with a wider coracoid (≥10 mm; n = 27), patients with a narrower coracoid (<10 mm; n = 29) had similar prevalences of recurrent instability (narrower vs wider; 6.9% vs 3.7%), complications (17.2% vs 7.4%), reoperation (3.5% vs 7.4%), and RTS (66.7% vs 68.4%) and similar postoperative ASES scores (87.1 vs 80.0) ( P ≥ .05 for all).

Conclusion:

Patients undergoing Latarjet coracoid transfer had similar postoperative outcomes regardless of preoperative coracoid dimensions. These findings should be confirmed in a larger cohort before further clinical recommendations are made.

Effect of COVID-19 on Injury Rates and Timing in the National Football League

Background:

The coronavirus 2019 (COVID-19) pandemic resulted in the cancellation of the 2020 National Football League (NFL) preseason and a decreased preseason roster size. The effect of this disruption on athlete injury rates is unknown.

Purpose/Hypothesis:

The purpose was to quantify the rates of anterior cruciate ligament (ACL), Achilles tendon, and hamstring tendon injuries in NFL players before and after the COVID-19 pandemic. We hypothesized that injury rates in the 2020 season would be higher than those seen prepandemic.

Study Design:

Descriptive epidemiology study. Level of evidence, 4.

Methods:

An online search using publicly available data was carried out to identify all NFL players who sustained an ACL, Achilles tendon, or hamstring tendon injury between April 1, 2017, and March 31, 2021. Data collected included player characteristics as well as career and season of injury workloads.

Results:

The number of Achilles tendon (27 vs 20; P = .024) and hamstring tendon (186 vs 149; P < .001) injuries, respectively, in the 2020 NFL season were significantly higher than the average of the 2017 to 2019 seasons. However, the number of ACL injuries sustained remained constant (43 vs 46; P = .175). More than half (52.9%) of ACL injuries in the 2017 to 2019 seasons occurred in the preseason, while most of the injuries (34.9%) in the 2020 season occurred in weeks 1 to 4. There was no player characteristic or career workload variable collected that was significantly different for players who sustained an ACL, Achilles tendon, or hamstring tendon injury in the 2020 NFL season compared with the 2017 to 2019 seasons.

Conclusion:

In the 2020 NFL season, the number of Achilles tendon and hamstring tendon injuries rose while the number of ACL injuries remained constant compared with the 2017 to 2019 seasons. Injuries that occurred during the first 4 games of the 2020 NFL season were consistent, with higher rates of injuries seen in the preseason in previous years.

Beach Chair Versus Lateral Decubitus Surgical Positioning for Arthroscopic Anterior Shoulder Stabilization: A Retrospective Comparison of Clinical and Patient-Reported Outcomes

Background:

Surgical positioning can affect both perioperative and postoperative complication rates. It is unclear whether beach-chair versus lateral decubitus positioning affects outcomes in patients undergoing arthroscopic anterior shoulder stabilization surgery.

Purpose:

The purpose of this study was to compare recurrent instability, complications, and patient-reported outcomes between patients who underwent arthroscopic anterior shoulder stabilization in the beach-chair versus the lateral decubitus positions. It was hypothesized that recurrent instability, complications, and patient-reported outcomes would not be affected by surgical positioning.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

The authors reviewed the medical records of patients who underwent shoulder stabilization (Current Procedural Terminology codes 29806 and 29807) from 2015 to 2019. Patients were included only if anterior instability was confirmed, arthroscopic surgery was performed in response to shoulder instability, and a minimum of 2 years of follow-up data were available. Data collected for eligible patients included perioperative and postoperative complications, recurrent instability, reoperation, and revision. Patients also completed surveys for the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, Oxford Shoulder Instability (OSI) score, and a return to any level of sport (RTS) questionnaire.

Results:

Overall, 294 patients (162 lateral decubitus and 132 beach-chair positions) were included, with an average follow-up of 2.4 ± 1.6 years. There were no significant differences in demographics between groups, nor were there differences in the rates of postoperative dislocations, subjective instability, reoperations, revisions, or complications. There was a trend toward a higher revision rate in the beach-chair group (beach-chair, 6.1% vs lateral decubitus, 1.9%; P = .069). There was no significant difference between groups regarding RTS rates or postoperative ASES, SANE, and OSI scores at 3.3 ± 1.1 years postoperatively.

Conclusion:

Surgical positioning for arthroscopic anterior shoulder stabilization did not significantly affect recurrent instability, complications, and patient-reported outcomes. Both beach-chair and lateral decubitus positioning provided good outcomes for anterior shoulder stabilization, with an overall recurrent dislocation rate of 7.8% at a mean of 3.3 years after surgery.

Evaluation of Rotator Cuff Repair With and Without Concomitant Biceps Intervention: A Retrospective Review of Patient Outcomes

BACKGROUND

Biceps tendon pathology is common in patients with rotator cuff tears. Leaving biceps pathology untreated in rotator cuff repairs (RCRs) may lead to suboptimal outcomes.

PURPOSE/HYPOTHESIS

The purpose was to compare clinical outcomes between patients who underwent isolated RCR versus patients who underwent RCR with concomitant biceps treatment. It was hypothesized that there would be no difference in clinical outcomes between groups.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 244 patients who underwent RCR in 2016 were included. Patient characteristics, presence of concomitant biceps pathology, pre- and postoperative American Shoulder and Elbow Surgeons (ASES) scores, rotator cuff failure, revision surgery, and complications were recorded.

RESULTS

There were no significant differences between patients who underwent isolated RCR (n = 143) and those who underwent RCR with biceps treatment (n = 101) at 2 years postoperatively in ASES scores (RCR, 81.5; RCR+biceps treatment, 79.5; P = .532), cuff failure rate (5.6% vs 4.0%; P = .760), revision RCR rate (3.5% vs 2.0%; P = .703), or complication rate (11.9% vs 5.0%; P = .102). Furthermore, when comparing concomitant biceps tenotomy (n = 30) versus concomitant biceps tenodesis (n = 71), there were no differences in ASES scores (P = .149), cuff failure rate (P > .999), revision RCR rate (P > .999), or complication rate (P > .999) postoperatively. Finally, when comparing arthroscopic biceps tenodesis (n = 50) versus subpectoral biceps tenodesis (n = 21), there were no differences in ASES scores (P > .592), cuff failure rate (P > .999), revision RCR rate (P = .507), or complication rate (P > .999) 2 years postoperatively.

CONCLUSION

Addressing biceps pathology when performing RCR resulted in similar rates of cuff failure, revision RCR, and complications, as well as a similar improvement in patient-reported outcomes when compared with isolated RCR at 2 years postoperatively. Furthermore, when comparing tenotomy versus tenodesis and arthroscopic versus subpectoral tenodesis, comparable outcomes with regard to rate of rotator cuff repair failure, revision RCR, complications, and patient-reported outcomes were found.

Chronic adaptations of the long head of the biceps tendon and groove in professional baseball pitchers

BACKGROUND AND HYPOTHESIS

The long head of the biceps tendon (LHBT) plays a significant shoulder stabilizing role during pitching, with the large forces and repetitions involved in overhead throwing likely contributing to LHBT pathology. Determining whether the LHBT undergoes adaptive changes in baseball pitchers and how these changes relate to bicipital groove morphology can improve our understanding of the biceps function at the glenohumeral joint. Therefore, the purpose of this study was to determine the chronic adaptations of the bicipital groove morphology and the LHBT in professional baseball pitchers, with a secondary purpose of evaluating biceps integrity as it relates to torsional changes of the bicipital groove. We hypothesized that the throwing arm of professional baseball pitchers would exhibit chronic adaptations of the LHBT compared with their nonthrowing arm, and that these adaptations would be related to the bicipital groove morphology.

MATERIALS AND METHODS

Fifty-three professional baseball pitchers were enrolled at the beginning of the 2015 Major League Baseball spring training. Ultrasound was used to bilaterally measure humeral retroversion and to capture images of the bicipital groove and the LHBT. MATLAB software was used to calculate the area of the bicipital groove, and ImageJ software was used to quantify the area, echogenicity, and circularity of the LHBT.

RESULTS

The dominant arm LHBT cross-sectional area was significantly smaller than the nondominant arm (9 mm² vs. 10 mm²; P = .011), whereas the dominant arm LHBT echogenicity was significantly higher than the nondominant arm (65 optical density vs. 59 optical density; P = .002). Pitchers with more bicipital groove rotational adaptation (more retroversion) had significantly more LHBT echogenicity adaptation compared with pitchers with less bicipital groove rotational adaptation (12 vs. 2; P = .023).

CONCLUSION

There are significant bilateral differences in the LHBT of professional baseball pitchers. An adaptation in bony rotation was associated with a larger bilateral difference in LHBT echogenicity but was not related to bilateral differences in LHBT area or circularity. Therefore, the bilateral difference in echogenicity is impacted by bony morphology, whereas the bilateral difference in cross-sectional area may be independent of bony morphology in this healthy population.

The Effects of Fatigue on Muscle Synergies in the Shoulders of Baseball Players

BACKGROUND

Muscle synergies are defined as the central nervous system's organizational structure for movement. Muscle synergies change after muscular fatigue, with certain synergies assuming the primary role to compensate for fatigue within another muscle synergy. Owing to the high eccentric forces imposed upon the external rotators (ie, posterior rotator cuff), pitchers that continue to throw while fatigued are at a significantly higher risk of shoulder and/or elbow injury; however, the neuromuscular compensation strategies of baseball players in response to fatigue are currently unknown.

HYPOTHESIS

Players would utilize the same muscle synergy structure following external rotation (ER) fatigue; however, muscle coefficients of nonfatigued muscles would increase (ie, compensate for the external rotators) after fatigue.

STUDY DESIGN

Cross-sectional study conducted in a controlled, laboratory setting.

METHODS

Nine players from an intercollegiate competitive club baseball team voluntarily participated in this study. Surface electromyography was used on 14 muscles of the glenohumeral and scapulothoracic joints of the dominant arm during a reaching protocol. Players completed a baseline reaching protocol (prefatigue), then an ER fatigue protocol until maximum concentric ER was reduced by 40%, and finally repeated the same reaching protocol (postfatigue). Principal component analysis was used to extract muscle synergies, the variance accounted for (VAF) of each synergy, and muscle coefficients. Prefatigue was compared with postfatigue using paired t tests for all dependent variables.

RESULTS

Four muscle synergies were extracted for both pre- and postfatigue. The VAF for the ER/abduction synergy decreased significantly (prefatigue, 34.6%; postfatigue, 32.4%; P = 0.03), showing a decreased reliance on ER/abduction during the reaching task after fatigue. Within synergy 1, the pectoralis major muscle coefficient (-0.489 vs -0.552; P = 0.01; effect size = 1.68) decreased significantly from prefatigue to postfatigue, indicating that the pectoralis major assumed more of an antagonist role during ER/abduction. Within synergy 2 (forward reaching), there were no significant changes in VAF or muscle coefficients observed. For the third synergy, muscle coefficients increased for the serratus anterior (P = 0.02) and middle deltoid (P = 0.01), whereas in the fourth synergy, the pectoralis major (P = 0.01) increased and teres major (P = 0.01) and biceps brachii (P = 0.05) muscle coefficients decreased.

CONCLUSION

The decreased VAF of the ER/abduction synergy after fatigue indicate that other muscles within that synergy could not fully compensate to maintain function. Interestingly, the changes in muscle coefficients suggest that players relied less on the internal rotation (IR) synergy and more on the cross-body synergy following fatigue. This may be due to imbalances between ER and IR while maintaining balance between cross-abduction and adduction.

CLINICAL RELEVANCE

Clinicians may consider implementing low-load, high-repetition training programs to develop posterior shoulder endurance and prolong the onset of muscular fatigue.

Chronic Effects of Pitching on Muscle Thickness and Strength of the Scapular Stabilizers in Professional Baseball Players

BACKGROUND

The posterior scapular muscles eccentrically contract to disperse the high forces observed in the deceleration phase of pitching. Muscular adaptations often occur following chronic eccentric loading, however, no study has evaluated the adaptations of the posterior scapular muscles with regard to throwing and their relationship with humeral retroversion (HR) in professional pitchers.

HYPOTHESIS

Significant chronic adaptations in muscle thickness (MT) and strength of the trapezius and rhomboids would be observed in healthy professional baseball pitchers, and there would be a significant relationship between humeral adaptations (ie, HR) and posterior scapular muscle adaptations (ie, strength and MT).

STUDY DESIGN

Cross-sectional; Level 3.

METHODS

A total of 28 healthy male professional baseball pitchers (age, 22 ± 2 years; mass, 95 ± 17 kg; height, 190 ± 7 cm) were included in the study. Bilateral isometric muscle strength of the upper trapezius (UT), middle trapezius, lower trapezius (LT), and rhomboids was measured during a maximum voluntary isometric contraction. Diagnostic ultrasound images of the UT, middle trapezius, LT, rhomboid major, and rhomboid minor muscles were collected bilaterally to measure MT. HR was also quantified bilaterally with ultrasound. Paired sample t tests were used to compare dominant and nondominant strength and MT. Pearson correlation coefficients were used to assess the relationship between HR, isometric strength, and MT.

RESULTS

A significantly increased MT of the LT was found on the dominant arm compared with the nondominant arm (5.4 ± 1.1 mm vs 4.4 ± 1.5 mm; P = 0.00). The Pearson correlation coefficient demonstrated a significant weak negative relationship between HR and rhomboid major MT (P = 0.03; R = -0.36), and a significant weak negative correlation between HR and middle trapezius isometric strength (P = 0.03; R = -0.37).

CONCLUSION

LT thickness was greater in the throwing arm compared with the nonthrowing arm of pitchers, suggesting a positive adaptation of the LT. Interestingly, there was a weak negative relationship between HR and both rhomboid major MT and middle trapezius isometric strength. This negative relationship suggests that since increased HR leads to decreased internal rotation range of motion during deceleration, the scapula may be forced into anterior tilt and protraction, which can place excessive eccentric load on the rhomboid major and middle trapezius.

Knotted Versus Knotless Medial-Row Transosseous-Equivalent Double-Row Rotator Cuff Repairs Have Similar Clinical and Functional Outcomes

Purpose

To retrospectively investigate the clinical and functional outcomes of patients who underwent knotted medial-row rotator cuff repair (KT-RCR) compared with patients who underwent knotless medial-row rotator cuff repair (KL-RCR).

Methods

A retrospective chart review of patients who underwent double-row transosseous-equivalent rotator cuff repair in 2016 was performed at a single institution with 2-year follow-up. Information regarding demographic characteristics, preoperative tear size (magnetic resonance imaging), surgical variables (including method of suture stabilization), preoperative and postoperative American Shoulder and Elbow Surgeons (ASES) scores, and all complications (e.g., cuff failure, adhesive capsulitis, and persistent pain) was compiled.

Results

A total of 189 patients met the inclusion criteria: 72 in the KL-RCR group and 117 in the KT-RCR group. No significant difference in preoperative ASES scores was found between the KL-RCR and KT-RCR groups (48.3 vs 45.4, P = .327). Postoperative ASES scores did not differ between the groups (82.4 for KL-RCR vs 78.8 for KT-RCR, P = .579). We found no significant difference in cuff failure rates after 2 years, determined by magnetic resonance imaging (5.6% for KL-RCR vs 6.1% for KT-RCR, P > .999), or complication rates (11.1% for KL-RCR vs 8.6% for KT-RCR, P = .743).

Conclusions

The knotted approach and knotless approach to double-row rotator cuff repair showed similar outcome scores, cuff failure rates, and complication rates at minimum 2-year follow-up.

Level of Evidence

Level III, retrospective therapeutic comparative trial.

Return to School After Anterior Cruciate Ligament Reconstruction: A Prospective Study of Adolescents and Young Adults

Background:

The ability to return to school after orthopaedic surgery is an important consideration for young patients, as there is substantial literature indicating that school attendance is correlated strongly with academic performance.

Purpose:

To evaluate the time to return to school, the barriers that students encounter when returning to school, and the academic effect of anterior cruciate ligament reconstruction (ACLR) in high school (HS) and college students.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

Full-time HS and college/graduate school (C/GS) students who underwent ACLR during the 2017 to 2018 and 2018 to 2019 academic periods were included in the study. Patients were contacted 2 weeks postoperatively to complete a questionnaire that assessed their time to return to school and barriers that interfered with their ability to return, and they completed a second questionnaire at 6 weeks postoperatively that assessed academic performance and challenges faced upon returning to school.

Results:

Included were 36 (52.2%) full-time HS students and 33 (47.8%) full-time C/GS students. HS students reported a longer time to return to school compared with C/GS students (8.51 vs 5.89 days; P = .008). In addition, HS students missed more scheduled school days than C/GS students (5.39 vs 2.90 days; P < .001). The majority of HS (73.5%) and C/GS (65.5%) students cited pain as a barrier to return, and more than half of HS (70.6%) and C/GS (55.2%) students also cited restricted mobility as a barrier to return. HS students were more likely to miss an examination in the early postoperative period compared with their C/GS counterparts (65.7% vs 39.3%; P = .037). Many students in both cohorts received a grade less than expected in the early postoperative period; this was not significantly different between the 2 groups (HS, 50.0%; C/GS, 42.9%; P = .489).

Conclusion:

ACLR can have a negative effect on school attendance and academic performance among HS and C/GS students. Orthopaedic surgeons should counsel all students and their families adequately about the potential academic effect of orthopaedic surgery in order to maximize clinical results, academic performance, and satisfaction in their patients.

What Are the All-Cause Survivorship Rates and Functional Outcomes in Patients Younger Than 55 Years Undergoing Primary Knee Arthroplasty? A Systematic Review

BACKGROUND

Approximately one-fourth of TKAs will be performed in patients 55 years or younger within the next decade. Postoperative outcomes for younger patients who had a knee arthroplasty were systematically reviewed in 2011; however, numerous studies evaluating young patients who had both a TKA and unicompartmental knee arthroplasty (UKA) have been reported in the past decade. Therefore, to better counsel this growing population of young patients undergoing knee arthroplasty, an updated understanding of their expected postoperative outcomes is warranted.

QUESTIONS/PURPOSES

In this systematic review, we evaluated (1) all-cause survivorship, (2) reasons for revision, (3) patient-reported outcomes, and (4) return to physical activity and sport in patients 55 years or younger undergoing primary TKA or UKA.

METHODS

A comprehensive search of PubMed, Medline, SportDiscus, and CINAHL was performed to identify all original studies evaluating outcomes after primary knee arthroplasty for young patients (55 years of age or younger) from inception until March 2021. The following keywords were used: knee, arthroplasty, replacement, pain, function, revision, survivorship, sport, physical activity, and return to play. Only original research studies that were related to knee arthroplasty and reported postoperative outcomes with a minimum 1-year follow-up for patients 55 years or younger were included. Unpublished materials, publications not available in English, and studies with a primary diagnosis of rheumatoid arthritis were excluded. The Methodological Index for Non-Randomized Studies (MINORS) score was used to evaluate the study quality of case series and comparative studies, while the Cochrane Risk of Bias tool and the Jadad scale were used for randomized studies. The primary outcomes of interest for this study were all-cause survivorship rate, reasons for all-cause revision, Knee Society and Knee Society Function scores (minimum clinically important difference [MCID] 7.2 and 9.7, respectively), WOMAC scores (MCID 10), Tegner scores (no reported MCID for knee arthroplasty), and return to physical activity or sport. Knee Society and Knee Society Function scores range from 0 to 100, with scores from 85 to 100 considered excellent and below 60 representing poor outcomes. All-cause survivorship rate and reasons for revision were both reported in 17 total studies. Knee Society scores were presented in 19 and Knee Society Function scores were reported in 18 included studies. WOMAC scores and Tegner scores were each found in four included studies, and return to physical activity and return to sport analyses were performed in seven studies. Overall, 21 TKA studies and five UKA studies were included in this analysis, featuring 3095 TKA knees and 482 UKA knees.

RESULTS

Kaplan-Meier estimates of all-cause survivorship ranged from 90% to 98% at 5 to 10 years of follow-up after TKA and from 84% to 99% (95% CI 93% to 98%) at 10 years to 20 years post-TKA. All-cause UKA survivorship was 90% at 10 years and 75% at 19 years in the largest Kaplan-Meier estimate of survivorship for patients younger than 55 who underwent UKA. Common reasons for revision in TKA patients were polyethylene wear/loosening, aseptic tibial loosening, and infection, and in UKA patients the common reasons for revision were knee pain, aseptic loosening, progression of knee osteoarthritis, and polyethylene wear/loosening. Knee Society scores ranged from 85 to 98 for 5-year to 10-year follow-up and ranged from 86 to 97 at 10-year to 20-year follow-up in TKA patients. Knee Society Function scores ranged from 70 to 95 for 5-year to 10-year follow-up and ranged from 79 to 86 at 10-year to 20-year follow-up. Return to physical activity and sport was reported variably; however, most patients younger than 55 have improved physical activity levels after knee arthroplasty relative to preoperative levels.

CONCLUSION

Although all-cause survivorship rates were frequently above 90% and patient-reported outcome scores were generally in the good to excellent range, several studies reported long-term survivorship rates from 70% to 85% and fair patient-reported outcome scores, which must be factored into any preoperative counseling with patients. We could not control for surgeon volume in this report, and prior research suggests that increasing volume is associated with less frequent complications; in addition, the studies we included were variably affected by selection bias, transfer bias, and assessment bias, which makes it likely that the findings of our review represent best-case estimates. To limit the frequency of revision in patients younger than 55 years undergoing TKA, clinicians should be cautious of polyethylene wear/loosening, aseptic tibial loosening, and infection, while knee pain and progression of knee osteoarthritis are also common reasons for revision in patients younger than 55 undergoing UKA. Further research should isolate younger knee arthroplasty patients and evaluate postoperative activity levels while accounting for preoperative physical activity and sport participation.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Chronic Adaptations of Shoulder Muscle Synergies in Healthy Baseball Players

BACKGROUND

Previous research has demonstrated that muscle synergy structure can adapt owing to training and injury; however, muscle synergies have not been evaluated in baseball players.

HYPOTHESIS

The throwing arm would have a similar muscle synergy structure but different levels of individual muscle activity within each synergy, relative to the nonthrowing arm.

STUDY DESIGN

Cross-sectional study in a controlled laboratory setting.

METHODS

Fourteen healthy competitive baseball players were included. Participants were tested bilaterally during a center-out planar reaching task using the KINARM robot, where kinematic data and surface electromyography data from 14 glenohumeral and scapular muscles were synchronized. Principal component analysis was used to extract muscle synergies, the variance accounted for (VAF) of each synergy, and individual muscle coefficients. The dominant (DOM) arm was compared with the nondominant (NDOM) arm using paired t tests for all dependent variables.

RESULTS

The same number of muscle synergies were extracted on the DOM and NDOM arms, along with no differences in VAF. In the first synergy, the infraspinatus (DOM 0.798 vs NDOM 0.587, P = 0.038) and lower trapezius (DOM 0.872 vs NDOM 0.480, P = 0.005) muscle coefficients significantly increased on the DOM arm. The second synergy had a significantly increased anterior deltoid (DOM 0.764 vs NDOM 0.374, P = 0.003) and a significantly decreased posterior deltoid (DOM -0.069 vs NDOM 0.197, P = 0.041) muscle coefficient on the DOM arm.

CONCLUSION

The DOM shoulder exhibits a higher proportion of infraspinatus and lower trapezius muscle activation during the external rotation and abduction synergy. Also, the DOM shoulder has increased muscle activation of the teres major and latissimus dorsi during the internal rotation synergy, and increased muscle activation of the pectoralis major during the cross-body adduction synergy, compared with the NDOM shoulder.

CLINICAL RELEVANCE

By exploring these neuromuscular adaptations, the improved understanding of muscle synergy adaptations in baseball players will help optimize injury prevention and rehabilitation techniques.

The Contribution of Posterior Capsule Hypertrophy to Soft Tissue Glenohumeral Internal Rotation Deficit in Healthy Pitchers

BACKGROUND

The relationship between posterior capsule adaptations and soft tissue glenohumeral internal rotation deficit (GIRD) in healthy pitchers remains unclear.

PURPOSE/HYPOTHESIS

This study aimed to identify if posterior capsule thickness (PCT) was associated with soft tissue GIRD in healthy pitchers. We hypothesized that there would be a positive relationship between soft tissue GIRD and PCT in the dominant arm, no relationship between soft tissue GIRD and PCT in the nondominant arm, and a strong positive relationship between soft tissue GIRD and the bilateral difference in PCT (posterior capsule hypertrophy [PCH]).

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 45 healthy collegiate and professional pitchers were included. Glenohumeral internal rotation and external rotation range of motion, humeral retroversion, and PCT were measured bilaterally. PCT was determined for unilateral posterior capsule measurements, and PCH of the throwing shoulder was calculated as the bilateral difference in PCT. Soft tissue GIRD was calculated as the sum of clinical GIRD and the bilateral difference in humeral retroversion. Pearson correlation coefficients were determined to evaluate the relationships between dominant arm PCT, nondominant arm PCT, and PCH and soft tissue GIRD.

RESULTS

Pearson correlations showed that both dominant arm PCT (R = -0.13; P = .378) and nondominant arm PCT (R = 0.21; P = .165) were not related to soft tissue GIRD. However, Pearson correlations did show that the amount of PCH was moderately related to soft tissue GIRD (R = 0.40; P = .007). Therefore, as the posterior capsule hypertrophied, soft tissue GIRD moderately increased.

CONCLUSION

Increased PCH was associated with an increase in soft tissue GIRD in healthy pitchers. If PCT measurements are feasible, clinicians should consider performing bilateral ultrasound assessments to isolate posterior capsule adaptations (ie, PCH). This will allow clinicians to identify pitchers with potentially maladaptive structural adaptations and optimize management strategies throughout the season to counteract them.

Strong Agreement Between Magnetic Resonance Imaging and Radiographs for Caton-Deschamps Index in Patients With Patellofemoral Instability

PURPOSE

To compare the measurements of the Caton-Deschamps index on preoperative magnetic resonance imaging and radiographs of patients undergoing operative management of patellar instability.

METHODS

Patients who underwent primary medial patellofemoral ligament reconstruction and/or tibial tubercle osteotomy between January 2015 and November 2019 were assessed. Caton-Deschamps indices were measured by 3 independent reviewers on both radiographs and magnetic resonance imaging. Intra- and interclass correlation coefficients and a Bland-Altman analysis were calculated to assess inter-rater reliability and measurement agreement between radiographic and magnetic resonance imaging.

RESULTS

Seventy-two patients (73 knees) were identified. The average Caton-Deschamps index was 1.23 ± 0.18 on radiograph and 1.26 ± 0.18 on magnetic resonance imaging. Strong inter-rater reliability was observed between reviewers for both radiographic and magnetic resonance imaging Caton-Deschamps indices (intraclass correlation coefficients 0.700 and 0.715, respectively). Pooled observer measurements revealed a moderate agreement between radiographic and magnetic resonance imaging for patella to tibia distance, weak agreement for patellar articular cartilage distance, and strong agreement for the Caton-Deschamps index (intraclass correlation coefficients 0.687, 0.485, and 0.749, respectively). Bland-Altman analysis demonstrated a mean difference in Caton-Deschamps index of -0.03 ± 0.15 (95% limits of agreement: -0.29 to 0.23) between radiographic and magnetic resonance imaging, meaning that Caton-Deschamps indices were on average 0.03 lower on radiographic than on magnetic resonance imaging.

CONCLUSIONS

The Caton-Deschamps index has strong agreement between radiographic and magnetic resonance imaging in patients undergoing patellar stabilization surgery. Either modality can be reliably used to preoperatively assess patellar height.

LEVEL OF EVIDENCE

Level IV, diagnostic case series.

Effect of COVID-19 on Ulnar Collateral Ligament Reconstruction in Major League Baseball Pitchers

Background:

The coronavirus disease of 2019 (COVID-19) pandemic led to the suspension and shortening of the 2020 Major League Baseball (MLB) season from 162 to 60 regular season games. The effect of this disruption on injury rates, specifically injury to the ulnar collateral ligament (UCL), has not been quantified.

Purpose/Hypothesis:

The purpose of this study was to compare the rate of UCL reconstruction (UCLR), surgery timing, and pitching workload in MLB pitchers from before and after the COVID-19 pandemic lockdown. We hypothesized that UCLR rates relative to games played would be increased and pitching workload would be decreased in 2020 compared with previous seasons.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

An extensive online search using publicly available data was conducted to identify all MLB pitchers who underwent UCLR between January 1, 2017, and December 31, 2020. Only pitchers who were competing at the MLB level when undergoing reconstruction were included. Player characteristics and surgery date, as well as career and season of surgery pitching workload, were collected for all included pitchers. All data were compared as a pooled sample (2017-2019 vs 2020).

Results:

A similar number of pitchers underwent UCLR during or after the 2020 regular season (n = 18) compared with the 2017-2019 seasons (n = 16, 20, and 16, respectively). However, after accounting for the decrease in games played during the 2020 regular season, an MLB pitcher was 2.9 times more likely to undergo surgery per game after the COVID-19 lockdown compared with the previous years (P < .001). MLB pitchers who underwent surgery in 2020 threw fewer preseason innings than did pitchers who underwent surgery between 2017 and 2019 (5.98 vs 9.39; P = .001).

Conclusion:

MLB pitchers were almost 3 times more likely to undergo UCLR per game after the COVID-19 lockdown. A decreased preseason pitching workload because of the COVID-19 lockdown may have had an effect on per game UCLR rates.

Chronic Adaptations of the Posterior Rotator Cuff in Professional Pitchers

BACKGROUND

Because of the large forces and high frequency of throwing, the upper extremity experiences repetitive stresses that lead to acute and chronic adaptations. While the importance of pennation angle and muscle thickness as predictors of muscle force production has been shown in other populations and other joints, there has been little research done that examines these variables in the shoulders of baseball players.

PURPOSE

(1) To examine the chronic effect pitching has on the rotator cuff muscle architecture (pennation angle and muscle thickness) in healthy professional baseball pitchers, and (2) to examine the correlation between muscle architecture and clinical measures of strength and range of motion (ROM).

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Twenty-eight healthy professional pitchers were recruited during the 2019 spring training. Internal rotation (IR) and external rotation (ER) strength were measured with a handheld dynamometer and IR and ER ROM were measured with an inclinometer. A diagnostic ultrasound machine was utilized to capture images of humeral retroversion, as well as the pennation angle and muscle thickness of the infraspinatus and teres minor muscles. ImageJ software was used to quantify the pennation angle and muscle thickness.

RESULTS

There were no significant differences between the dominant and nondominant arms for ER or IR strength. Also, no pennation angle and muscle thickness differences were found between the dominant and nondominant arms. A weak positive relationship between infraspinatus muscle thickness (superficial and total) and ER strength (P = .016, R = 0.287 and P = .009, R = 0.316) and a moderate negative relationship between soft tissue glenohumeral internal rotation deficit (GIRD) and the bilateral difference of the teres minor deep pennation angle (R = -0.477, P = .008) were observed. No other significant relationships were noted.

CONCLUSION

Our results are contrary to current literature as we expected to see a stronger dominant arm, with a larger pennation angle and greater muscle thickness. Interestingly, we found that ER strength was positively related to only the thickness of the infraspinatus muscle, and that soft tissue GIRD was positively related to only the side-to-side adaptation of the pennation angle within the deep portion of the teres minor. This suggests that when posterior shoulder tightness occurs, specifically the architecture of the teres minor muscle is involved. However, the organization to which these players belonged has a very extensive training protocol throughout the year that emphasizes bilateral training during a large majority of the exercises. Therefore, the results may not be generalizable to all professional players.

Return-to-Play and Competitive Outcomes After Ulnar Collateral Ligament Reconstruction Among Baseball Players: A Systematic Review

Background:

Ulnar collateral ligament (UCL) reconstruction (UCLR) is very common in baseball. However, no review has compared the return-to-play (RTP) and in-game performance statistics of pitchers after primary and revision UCLR as well as of position players after UCLR.

Purpose:

To review, synthesize, and evaluate the published literature on outcomes after UCLR in baseball players to determine RTP and competitive outcomes among various populations of baseball players.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A literature search including studies between 1980 and November 4, 2019, was conducted for articles that included the following terms: ulnar collateral ligament, elbow, medial collateral ligament, Tommy John surgery, throwing athletes, baseball pitchers, biomechanics, and performance. To be included, studies must have evaluated baseball players at any level who underwent UCLR (primary or revision) and assessed RTP and/or competitive outcomes.

Results:

A total of 29 studies with relatively high methodological quality met the inclusion criteria. After primary UCLR, Major League Baseball (MLB) pitchers returned to play in 80% to 97% of cases in approximately 12 months; however, return to the same level of play (RTSP) was less frequent and took longer, with 67% to 87% of MLB pitchers returning in about 15 months. RTP rates for MLB pitchers after revision UCLR were slightly lower, ranging from 77% to 85%, while RTSP rates ranged from 55% to 78%. RTP rates for catchers (59%-80%) were generally lower than RTP rates for infielders (76%) and outfielders (89%). All studies found a decrease in pitching workloads after UCLR. Fastball usage may also decrease after UCLR. Changes in earned run average and walks plus hits per inning pitched were inconclusive.

Conclusion:

Pitchers returned to play after UCLR in approximately 12 months and generally took longer to return to their same level of play. Pitchers also returned to play less frequently after revision UCLR. After both primary and revision UCLR, professional pitchers experienced decreased workloads and potentially decreased fastball usage as well. Catchers may RTP after UCLR less frequently than pitchers, infielders, and outfielders possibly because of the frequency of throwing in the position. These results will help guide clinical decision making and patient education when treating UCL tears in baseball players.

Blocking CTGF/CCN2 reverses neural fibrosis and sensorimotor declines in a rat model of overuse-induced median mononeuropathy

Encapsulation of median nerves is a hallmark of overuse-induced median mononeuropathy and contributes to functional declines. We tested if an antibody against CTGF/CCN2 (termed FG-3019 or Pamrevlumab) reduces established neural fibrosis and sensorimotor declines in a clinically relevant rodent model of overuse in which median mononeuropathy develops. Young adult female rats performed a high repetition high force (HRHF) lever-pulling task for 18 weeks. Rats were then euthanised at 18 weeks (HRHF untreated), or rested and systemically treated for 6 weeks with either an anti-CCN2 monoclonal antibody (HRHF-Rest/FG-3019) or IgG (HRHF-Rest/IgG), with results compared with nontask control rats. Neuropathology was evident in HRHF-untreated and HRHF-Rest/IgG rats as increased perineural collagen deposition and degraded myelin basic protein (dMBP) in median nerves, and increased substance P in lower cervical dorsal root ganglia (DRG), compared with controls. Both groups showed functional declines, specifically, decreased sensory conduction velocity in median nerves, noxious cold temperature hypersensitivity, and grip strength declines, compared with controls. There were also increases of ATF3-immunopositive nuclei in ventral horn neurons in HRHF-untreated rats, compared with controls (which showed none). FG-3019-treated rats showed no increase above control levels of perineural collagen or dMBP in median nerves, Substance P in lower cervical DRGs, or ATF3-immunopositive nuclei in ventral horns, and similar median nerve conduction velocities and thermal sensitivity, compared with controls. We hypothesize that neural fibrotic processes underpin the sensorimotor declines by compressing or impeding median nerves during movement, and that inhibiting fibrosis using an anti-CCN2 treatment reverses these effects.

Forced treadmill running reduces systemic inflammation yet worsens upper limb discomfort in a rat model of work-related musculoskeletal disorders

BACKGROUND

Musculoskeletal disorders can result from prolonged repetitive and/or forceful movements. Performance of an upper extremity high repetition high force task increases serum pro-inflammatory cytokines and upper extremity sensorimotor declines in a rat model of work-related musculoskeletal disorders. Since one of the most efficacious treatments for musculoskeletal pain is exercise, this study investigated the effectiveness of treadmill running in preventing these responses.

METHODS

Twenty-nine young adult female Sprague-Dawley rats were used. Nineteen were trained for 5 weeks to pull a lever bar at high force (15 min/day). Thirteen went on to perform a high repetition high force reaching and lever-pulling task for 10 weeks (10-wk HRHF; 2 h/day, 3 days/wk). From this group, five were randomly selected to undergo forced treadmill running exercise (TM) during the last 6 weeks of task performance (10-wk HRHF+TM, 1 h/day, 5 days/wk). Results were compared to 10 control rats and 6 rats that underwent 6 weeks of treadmill running following training only (TR-then-TM). Voluntary task and reflexive sensorimotor behavioral outcomes were assessed. Serum was assayed for inflammatory cytokines and corticosterone, reach limb median nerves for CD68+ macrophages and extraneural thickening, and reach limb flexor digitorum muscles and tendons for pathological changes.

RESULTS

10-wk HRHF rats had higher serum levels of IL-1α, IL-1β and TNFα, than control rats. In the 10-wk HRHF+TM group, IL-1β and TNFα were lower, whereas IL-10 and corticosterone were higher, compared to 10-wk HRHF only rats. Unexpectedly, several voluntary task performance outcomes (grasp force, reach success, and participation) worsened in rats that underwent treadmill running, compared to untreated 10-wk HRHF rats. Examination of forelimb tissues revealed lower cellularity within the flexor digitorum epitendon but higher numbers of CD68+ macrophages within and extraneural fibrosis around median nerves in 10-wk HRHF+TM than 10-wk HRHF rats.

CONCLUSIONS

Treadmill running was associated with lower systemic inflammation and moderate tendinosis, yet higher median nerve inflammation/fibrosis and worse task performance and sensorimotor behaviors. Continued loading of the injured tissues in addition to stress-related factors associated with forced running/exercise likely contributed to our findings.