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.

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.

Outcomes following arthroscopic posteromedial osteophyte resection and risk of future ulnar collateral ligament reconstruction.

BACKGROUND AND HYPOTHESIS: Despite successful return-to-sport (RTS) outcomes after posteromedial osteophyte resection, one possible consequence of osteophyte removal is increased stress on the ulnar collateral ligament (UCL), leading to a UCL injury. It is currently unknown how often overhead athletes who undergo isolated posteromedial osteophyte resection subsequently require UCL reconstruction (UCLR). Therefore, the purpose of this study was to report outcomes following arthroscopic resection of posteromedial osteophytes in overhead athletes and determine whether overhead athletes who underwent arthroscopic posteromedial osteophyte resection for posteromedial impingement went on to require UCL surgery. We hypothesized that there would be a high rate of RTS following osteophyte resection and that players who underwent arthroscopic posteromedial osteophyte resection would have a >10% risk of requiring subsequent UCLR or UCL repair. MATERIALS AND METHODS: All patients who underwent elbow arthroscopy from 2010-2020 at a single institution were reviewed. Patients were included if they underwent isolated arthroscopic posteromedial osteophyte resection without concomitant UCL surgery, were overhead athletes at the onset of posteromedial impingement symptoms, and had no history of elbow surgery. Primary outcomes included RTS rate, complications, and subsequent shoulder and/or elbow injury and surgery, as well as several patient-reported outcome measures (Kerlan-Jobe Orthopaedic Clinic score, Timmerman-Andrews elbow score, and Conway-Jobe score). RESULTS: Overall, 36 overhead athletes were evaluated at 5.1 ± 3.4 years postoperatively, including 28 baseball pitchers, 3 baseball catchers, 3 softball players, 1 tennis player, and 1 volleyball player. Of the overhead athletes, 77% were able to RTS; the mean Kerlan-Jobe Orthopaedic Clinic and satisfaction scores were 70 and 75, respectively; and 89% of athletes had either excellent (73%) or good (16%) Conway-Jobe scores at long-term follow-up. Subsequent UCLR was required in 18% of baseball pitchers (n = 5) at a median of 13 months postoperatively. Of the 5 UCLRs, 3 were performed shortly after posteromedial osteophyte resection (6, 7, and 13 months postoperatively) whereas the other 2 were performed at 6.2 and 7.5 years postoperatively. CONCLUSION: Following arthroscopic posteromedial osteophyte resection, 77% of athletes were able to RTS. Baseball pitchers who undergo arthroscopic resection of posteromedial osteophytes for posteromedial impingement have an 18% risk of subsequent UCLR.

American Shoulder and Elbow Surgeons SLAP/Biceps Anchor Study Group evidence review: pathoanatomy and diagnosis in clinically significant labral injuries.

Glenoid superior biceps-labral pathology diagnosis, treatment, and outcomes are an evolving area of shoulder surgery. Historically, described as superior labrum anterior posterior (SLAP) tears, these lesions were identified as a source of pain in throwing athletes. Diagnosis and treatments applied to these SLAP lesions resulted in less than optimal outcomes in some patients and a prevailing sense of confusion. The purpose of this paper is to perform a reappraisal of the anatomy, examination, imaging, and diagnosis by the American Shoulder and Elbow Surgeons/SLAP biceps study group. We sought to capture emerging concepts and suggest a more unified approach to evaluation and identify specific needs for future research.

Ulnar collateral ligament reconstruction in javelin throwers: an analysis of return to play rates and patient outcomes.

BACKGROUND: Although results after ulnar collateral ligament reconstruction (UCLR) in baseball players have been well documented, the literature is replete regarding the outcomes after UCLR in javelin throwers. PURPOSE: To report outcomes after UCLR in javelin throwers. HYPOTHESIS: UCLR in javelin throwers will result in a high rate of return to play similar to that of previously published studies from athletes of other sports. METHODS: All patients who were identified preoperatively as javelin throwers and underwent UCLR between 2011 and 2017 with a minimum 2-year follow-up were eligible for inclusion. Patients were assessed with the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow score, Timmerman-Andrews Elbow score, Conway-Jobe score, patient satisfaction, return to sport rate questionnaire, and the occurrence of any postoperative complications. RESULTS: Eighteen patients met the inclusion criteria. Complete follow-up was available in 16 (88.9%) patients. The average age at surgery was 21.2 ± 2.0 (range, 18.6-24.9) years. At the final follow-up, the average Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow score and Timmerman-Andrews Elbow score were 77.3 (range, 18.7-98.4) and 91.8 (range, 70.0-100.0), respectively. Outcomes on the Conway-Jobe scale were as follows: excellent (n = 6; 37.5%), good (n = 4; 25%), fair (n = 6; 37.5%). Ten (62.5%) patients returned to play at an average of 12.2 ± 3.6 (range, 6.0-18.0) months after surgery. Two (12.5%) patients sustained a shoulder injury postoperatively; however, neither required surgery. CONCLUSION: UCLR in javelin throwers results in good outcomes with a low rate of reinjury/reoperation. However, the return to play rate (62.5%) and good/excellent outcomes per the Conway-Jobe scale (68.8%) are lower than what has been previously reported in baseball players and javelin throwers. Further investigation regarding outcomes in javelin throwers after UCLR is warranted.

Development of a return to play checklist following patellar instability surgery: a Delphi-based consensus.

PURPOSE: To date, there is no consensus for the appropriate timing or functional evaluation for safe return to play following patellar instability surgery. The purpose of this study is to develop a consensus-based return to play checklist following patellar stabilization surgery using the Delphi method. METHODS: A 3-part survey series was conducted following the systematic guidelines of the Delphi technique for gathering consensus from experts in the management of patellofemoral instability. All surveys were completed between July and November of 2017. A literature search was performed in SCOPUS and PubMed to identify existing sources on return to play following patellar instability surgery and determining patellofemoral joint strength in athletes, which served as the basis for the surveys. RESULTS: 12 of the 19 selected participants (63%) completed the first-round survey, 11 of those 12 participants (92%) completed the second-round survey, and 10 of these 11 participants (91%) completed the final survey. Of the final ten participants, there was representation from seven different states in the USA. Nine of the ten (90%) respondents endorsed the final checklist. The final checklist included eight overarching domains with defined and reproducible objective criteria. CONCLUSION: The standardized list of objective and reproducible criteria for rehabilitation outlined below should help practitioners focus more on patient-centred factors and less on arbitrary timelines. No prior study has gathered consensus from experts on this topic; therefore, this study should serve as a benchmark to help guide patients back to sport safely. LEVEL OF EVIDENCE: V.

Contact Versus Noncontact Anterior Cruciate Ligament Injuries: Is Mechanism of Injury Predictive of Concomitant Knee Pathology?

PURPOSE: To determine if mechanism of injury is predictive of concomitant knee pathology found at the time of anterior cruciate ligament (ACL) reconstruction. METHODS: All patients aged 16 to 35 who underwent ACL reconstruction at our institution between January 2009 and December 2015 were retrospectively reviewed. Mechanism of injury was determined from patient history. The presence of meniscal or chondral damage was determined from operative records, while collateral ligament injuries were determined by the treating surgeon's diagnosis after physical examination and their review of magnetic resonance imaging findings. Patients with inadequate documentation, history of a subsequent instability episode following the initial injury, or prior history of knee pathology were excluded. RESULTS: Six hundred eighty-seven patients (169 contact and 518 noncontact) were included. A 2-fold increase in the incidence of collateral ligament injury was identified between the 2 groups with 114 (67.5%) in the contact group and 175 (33.8%) in the noncontact group (P < .001). Twenty-six patients (15.4%) in the contact group compared with 9 (1.7%) in the noncontact group had a grade III collateral ligament injury (P < .001). Chondral injury was identified in 41 (24.3%) patients in the contact group and 87 (16.8%) in the noncontact group (P = .05) with 9 (5.3%) grade IV lesions in the contact group and 4 (0.8%) in the noncontact group (P < .001). Eleven patients in the contact group (6.5%) and 15 in the noncontact group (2.9%) had a chondral injury to the lateral femoral condyle (P = .04). CONCLUSIONS: Although we found no difference in the incidence or type of meniscal tears, we found a significant increase in the incidence of grade IV chondral injury, chondral injury to the lateral femoral condyle, and grade III collateral ligament damage in the setting of contact ACL injuries. This knowledge can aid surgeons in preoperative planning and patient counseling. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Length of time between surgery and return to sport after ulnar collateral ligament reconstruction in Major League Baseball pitchers does not predict need for revision surgery.

HYPOTHESIS: Pitchers who return to sport (RTS) sooner will have a higher risk of revision ulnar collateral ligament reconstruction (UCLR) than those who return later. METHODS: All professional (major and minor league) baseball pitchers who underwent UCLR between 1974 and 2016 were identified. Date of the index UCLR was recorded. The date of the first game back at any professional level after surgery and the date the pitcher returned to the same level of play (if applicable) were recorded. Length of time between these dates was compared for pitchers who required a revision UCLR and those who did not. RESULTS: Overall, 569 pitchers (average age, 24.8 ± 4.1 years) underwent UCLR and had reliable game logs after surgery. No statistically significant difference existed in the length of time to RTS at any professional level or at the same professional level between those pitchers who did not require a revision UCLR and those who did (P = .442, P = .238). Pitchers who required revision UCLR returned to any level of play almost 2 months earlier (14.7 vs. 16.5 months) and returned to the same level of play >2 months earlier (15.2 vs. 17.7 months) than matched controls who did not require revision UCLR, although this was not statistically significant (P = .179, P = .204). CONCLUSION: No statistically significant difference existed in the length of time to RTS after UCLR in professional baseball players who required a revision UCLR and those who did not.

Anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft versus allograft in skeletally mature patients aged 25 years or younger.

PURPOSE: The purpose of this study is to evaluate the clinical outcomes and revision rates of skeletally mature patients aged 25 years or younger who have undergone either BPTB autograft or deep-frozen, non-irradiated BPTB allograft ACL reconstruction by a single surgeon. METHODS: Two hundred and twenty-four patients aged 25 or younger at the time of surgery were identified as having a transtibial ACL reconstruction with either a BPTB autograft or deep-frozen, non-irradiated BPTB allograft by one senior surgeon (101 autografts vs. 123 allografts) over the study time period. Primary outcome measure included the need for ACL revision. One hundred and nineteen patients with at least 2-year clinical follow-up agreed to participate in secondary outcome measurement arm of the study and were administered the Lysholm Knee Scoring Scale and IKDC Subjective Knee Evaluation Form. RESULTS: The median Lysholm scores were 95 (40-100) and 95 (68-100) and the median IKDC scores were 95.4 (54.0-100) and 95.4 (72.4-100) in the allograft and autograft groups, respectively. The differences in the Lysholm scores and the IKDC scores were not statistically significant (P = n.s.). There were 13 patients requiring ACL revision, 12 allograft versus one autograft (P = 0.005). CONCLUSION: Although there is no significant difference in patient-rated outcome between ACL reconstructions using BPTB autografts versus BPTB allografts, a significantly higher rate of ACL revision was found in allograft patients. The results of our study support a growing body of literature that BPTB autograft reconstruction leads to lower retear rates in younger individuals, an important factor in the graft selection process for these patients. LEVEL OF EVIDENCE: III.

Functional outcomes after bilateral arthroscopic rotator cuff repair.

BACKGROUND: Arthroscopic repair of rotator cuff tears is a common procedure performed by orthopedic surgeons. There is a well-known incidence of up to 35% of bilateral rotator cuff tear disease in patients who have a known unilateral tear. The majority of the literature focuses on outcomes after unilateral surgery. The purpose of this study was to determine if there are clinical differences in shoulders of patients who underwent staged bilateral rotator cuff repairs during their lifetime. METHODS: A retrospective review of all patients who underwent staged bilateral arthroscopic rotator cuff surgery at our institution was performed. All patients had at least 2 years of follow-up. Clinical outcome scores including the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation, and Rowe measures were obtained. A subset of patients returned for clinical and ultrasound evaluation performed by an independent fellowship-trained musculoskeletal radiologist. RESULTS: Overall, 110 shoulders in 55 patients, representing 68% of all eligible patients, participated. No clinical or statistical difference was found in any outcome measure. ASES scores averaged 86.5 (36.7-100) in the dominant shoulder compared with 89.6 (23.3-100) in the nondominant shoulder (P = .42). Ultrasound was available on 34 shoulders and showed complete healing rate of 88%. The shoulders with retearing of the rotator cuff (12%) demonstrated clinically relevant lower ASES scores (72.5) compared with shoulders with confirmed healed repairs (86.2; P = .2). DISCUSSION: Patients who undergo staged bilateral rotator cuff repair can expect to have similarly good clinical outcomes regardless of hand dominance or chronologic incidence with excellent healing rates in both shoulders.

Knee Arthroplasty After Subchondroplasty: Early Results, Complications, and Technical Challenges.

BACKGROUND: Calcium phosphate bone substitutes (CPBS) are commonly used to augment and repair bone voids and defects after fractures around the knee joint. The purpose of this study was to determine whether prior arthroscopic application of a CPBS, for repair of magnetic resonance imaging-identified subchondral fractures associated with osteoarthritis (procedure referred to as subchondroplasty) adversely affected the performance and/or outcome of subsequent knee arthroplasty. METHODS: Twenty-two patients who had arthroscopic repair of a periarticular fracture combined with use of a CPBS who later had knee arthroplasty were identified. Average follow-up for study patients was 23.5 months (range 12-52 months). These patients were matched demographically and for follow-up duration in a 2:1 ratio to a group of control subjects undergoing arthroplasty who had not undergone prior surgery. RESULTS: Technical challenges related to surgical performance, clinical outcomes, and complications were determined for both the groups. At most recent follow-up, study patients had an average Oxford score of 40.6 (range, 25-48) compared with control subjects with an average score of 40.1 (range, 12-48). There was no difference in complications or surgical complexity between groups, and only standard primary components were used. CONCLUSION: The results of our study suggest that prior arthroscopic repair combined with CPBS of periarticular fractures around the knee does not compromise the early outcomes and surgical performance or increase complications related to subsequent arthroplasty. However, longer follow-up of these patients is warranted to confirm that implant durability remains uncompromised.

Biomechanical comparison of graft fixation at 30° and 90° of elbow flexion for ulnar collateral ligament reconstruction by the docking technique.

BACKGROUND: Ulnar collateral ligament (UCL) injuries have been successfully treated by the docking reconstruction. Although fixation of the graft has been suggested at 30° of elbow flexion, no quantitative biomechanical data exist to provide guidelines for the optimal elbow flexion angle for graft fixation. METHODS: Testing was conducted on 10 matched pairs of cadaver elbows with use of a loading system and optoelectric tracking device. After biomechanical data on the native UCL were obtained, reconstruction by the docking technique was performed with use of palmaris longus autograft with one elbow fixated at 30° and the contralateral elbow at 90° of elbow flexion. Biomechanical testing was undertaken on these specimens. RESULTS: The load to failure of the native UCL (mean, 20.1 N-m) was significantly higher (P = .004) than that of the reconstructed UCL (mean, 4.6 N-m). There was no statistically significant difference in load to failure of the UCL reconstructions fixated at 30° of elbow flexion (average, 4.86 N-m) compared with those at 90° (average, 4.35 N-m). Elbows reconstructed at 30° and 90° of elbow flexion produced similar kinematic coupling and valgus laxity characteristics compared with each other and with the intact UCL. Although not statistically significant, the reconstructions fixated at 30° more closely resembled the biomechanical characteristics of the intact elbow than did reconstructions fixated at 90°. CONCLUSION: No statistically significant difference was found in comparing the docking technique of UCL reconstruction with graft fixation at 30° vs. 90° of elbow flexion.

Outcomes for ulnar collateral ligament reconstruction: a retrospective review using the KJOC assessment score with two-year follow-up in an overhead throwing population.

BACKGROUND: Injury to the ulnar collateral ligament (UCL) often results in valgus elbow instability requiring reconstruction. No standardized and validated outcome measure has compared outcomes between surgical techniques and institutions in the overhead throwing athlete. The aim of this study was to use the Kerlan-Jobe Orthopaedic Clinic shoulder and elbow score (KJOC score) to report functional outcomes in overhead throwing athletes undergoing UCL reconstruction. We predict that the KJOC score in our general throwing population will provide an accurate assessment of postoperative outcomes consistent with previously published reports. METHODS: A retrospective review of 33 patients undergoing UCL reconstruction was carried out during a 5-year period between 2004 and 2009. Minimum follow-up was 2.2 years with an average of 3.7 years. All surgeries were performed by fellowship-trained surgeons using either the docking (n = 12) or modified Jobe technique (n = 21). Age, sport, position, and return to play status were obtained. The KJOC score was administered to assess final functional outcome. RESULTS: A total of 33 athletes underwent UCL reconstruction-30 baseball players and 3 javelin throwers. Of these, 27 (82%) returned to their sport at their previous level in an average of 12.25 months. The overall average KJOC score was 76. Athletes who returned to their previous level of play had a mean KJOC score of 77. Those who were unable to return to play had a mean score of 69. CONCLUSION: Our study demonstrates consistent outcomes for UCL reconstruction using the KJOC shoulder and elbow score compared with previously reported data.

Functional results following surgical repair of simultaneous bilateral quadriceps tendon ruptures.

BACKGROUND: Unilateral quadriceps tendon ruptures are common conditions treated by orthopedic surgeons. There is a paucity of information concerning functional outcomes in bilateral tendon ruptures. The aim of this study is to assess a series of 5 cases with simultaneous quadriceps tendon ruptures that underwent acute surgical repair with the purpose of identifying the functional outcomes as compared with unilateral injuries. We hypothesize that patients with bilateral quadriceps tendon ruptures have worse functional outcomes than patients with unilateral ruptures. METHODS: Five cases of bilateral quadriceps tendon ruptures were identified. All patients underwent acute surgical extensor tendon repair employing a 3-patellar hole and a locked, running, nonabsorbable suture technique followed by a 6-week period of immobilization and bracing for 10 to 12 weeks. Mechanism of injury, medical history, social history, operative report, and postoperative exam were recorded with a minimum 1-year follow-up. In addition, each patient completed a subjective International Knee Documentation Committee (IKDC) score at 18 months. Five patients with unilateral injuries and with similar medical history were included as age-matched controls. RESULTS: The mean age for the bilateral group was 54.8 years (range, 44-68 years). Mean postoperative knee flexion was 129 degrees and all patients had active, resisted knee extension. Only 1 patient had a medical comorbidity (diabetes mellitus). The mean IKDC score (mean follow-up, 25.4 months; range, 22-29 months) was 71.9 (range, 34.4 to 91.6), whereas the age-matched control group had a mean IKDC score of 88.3 (P = 0.23). There was no statistical significance between the 2 groups with regard to range of motion (P = 0.24), IKDC score, and return to activity (P = 0.29). CONCLUSION: Patients with early surgical repair of bilateral, simultaneous extensor mechanism ruptures exhibit adequate recovery and return to a high level of function. Our patients were younger than those reported in the literature and had minimal comorbidities. The IKDC scores reflected good outcomes in the bilateral rupture group, albeit lower than in the unilateral group.

Pectoralis major ruptures in professional American football players.

BACKGROUND: Pectoralis major injuries are an infrequent shoulder injury that can result in pain, weakness, and deformity. These injuries may occur during the course of an athletic competition, including football. The purpose of this study was to determine the incidence of pectoralis major ruptures in professional football players and time lost from the sport following injury. We hypothesized that ruptures most frequently occur during bench-press strength training. METHODS: The National Football League Injury Surveillance System was reviewed for all pectoralis major injuries in all players from 2000 to 2010. Details regarding injury setting, player demographics, method of treatment, and time lost were recorded. RESULTS: A total of 10 injuries-complete ruptures-were identified during this period. Five of the 10 were sustained in defensive players, generally while tackling. Nine occurred during game situations, and 1 occurred during practice. Specific data pertinent to the practice injury was not available. No rupture occurred during weight lifting. Eight ruptures were treated operatively, and 2 cases did not report the method of definitive treatment. The average days lost was 111 days (range, 42-189). The incidence was 0.004 pectoralis major ruptures during the 11-year study period. CONCLUSIONS: Pectoralis major injuries are uncommon while playing football. In the National Football League, these injuries primarily occur not during practice or while bench pressing but rather during games. When pectoralis major ruptures do occur, they are successfully treated operatively. Surgery may allow for return to full sports participation. LEVEL OF EVIDENCE: IV, case series.

Association Between Draft Order and Stress Sonography of the Ulnar Collateral Ligament of the Elbow in Professional Baseball Pitchers: An 18-Year Study.

BACKGROUND: The Major League Baseball (MLB) draft is a common route for players to enter professional baseball in the United States. Players taken in earlier rounds are typically higher-performing players. When looking at pitchers specifically, higher performance at the amateur level may be associated with an increased frequency of adaptive change in the throwing elbow. PURPOSE: To determine whether pitchers taken in earlier rounds of the MLB draft have a greater frequency or extent of pathological change in the elbow, as measured by dynamic stress ultrasound. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Dynamic stress ultrasounds (SUSs) were performed over 18 years on the dominant and nondominant arms of 651 professional pitchers. The 383 drafted players were grouped according to the round in which they were drafted (rounds 1-5, 6-10, 11-20, 21+). Groups were compared with respect to "relative" ulnar collateral ligament (UCL) thickness (dominant-nondominant), relative ulnohumeral joint laxity (joint space distance under stress minus joint space at rest), and the presence of pathology (calcifications, tears, hypoechoic foci, osteophytes). In addition, a subgroup analysis was done to compare the progression of SUS findings over 3 years in players for which data were available. RESULTS: Draft round groups did not differ by age, number of previous spring training, or handedness. Comparing baseline measurements, there was no significant relationship between draft round and relative UCL thickness (P = .932), relative laxity (P = .996), or presence of pathology detectable on SUS (P = .642). However, increased relative UCL thickness was significantly associated with the presence of pathology on SUS (odds ratio, 1.45; 95% CI, 1.26-1.69; P < .001). Longitudinally, there was no significant relationship between draft round and 3-year progression of relative laxity, relative UCL thickness, or clinical progression of pathology. CONCLUSION: Higher-performing pitchers are drafted earlier in the MLB draft. This may be attributable to peak pitch velocity, in-game performance, visibility gained during player showcases, or any number of other sport-specific variables. However, despite this, there was no significant relationship between draft round and adaptive changes to the elbow or specific properties of the UCL on stress ultrasound.

Impact of Climate on Stress Ultrasound Findings of the Elbow Ulnar Collateral Ligament in Professional Baseball Pitchers: An 18-Year Study.

Background: The ulnar collateral ligament (UCL) is the primary soft tissue stabilizer to valgus stress in the elbow and is placed under this valgus stress during the throwing motion. Although there are known risk factors for UCL injury, it is unknown whether the UCL undergoes adaptive changes in athletes from different climates. Purpose: To compare elbow stress ultrasound (SUS) findings between professional baseball pitchers from warm climates versus cold climates and assess significant differences in adaptive and morphologic changes in the UCL. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Dynamic SUS evaluations were performed over 18 years on the dominant and nondominant arms of 643 professional pitchers from warm and cold climates as determined by the player's country/state of origin. Studies were compared with respect to relative UCL thickness (dominant arm vs nondominant arm), relative glenohumeral joint laxity (joint space distance under stress vs joint space distance at rest), and the presence of morphologic changes such as tears or calcifications. In addition, a subgroup analysis was performed to compare the progression of SUS findings over 3 years in players with sequential yearly data. Results: Players from warmer climates had significantly greater relative UCL thicknesses than players from colder climates (1.75 vs 1.50 mm, respectively; P = .047). There were no differences between these 2 groups in terms of relative ulnohumeral joint laxity (P = .201), presence of morphologic changes (P = .433), 3-year progression of relative UCL thickness (P = .748), or relative joint laxity (P = .904). Conclusion: Professional pitchers from warm climates had a greater side-to-side difference in UCL thickness between the dominant and nondominant arms. This may be due to the potential for year-round throwing among baseball players from warm climates. There was no difference in laxity, thickness progression, laxity progression, or the presence of additional morphologic changes.

The Utility of Stress Ultrasound in Identifying Risk Factors for Elbow Ulnar Collateral Ligament Tear: A Longitudinal Study of 203 Professional Baseball Players.

BACKGROUND: Injuries to the medial ulnar collateral ligament (UCL) are common among baseball pitchers due to repetitive stress on the soft tissue stabilizers of the elbow during pitching. Dynamic stress ultrasound (SUS) can be used to evaluate the UCL and ulnohumeral joint to identify anatomic risk factors of those who will require UCL reconstruction (UCLR). PURPOSE: To determine whether any adaptive or morphological changes detectable on SUS can predict injury to the UCL in professional baseball pitchers. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 203 professional baseball pitchers who underwent SUS at preseason training sessions over the course of 18 years were categorized into 1 of 2 groups: those without a history of shoulder, arm, elbow, or forearm surgery or injuries (healthy cohort; n = 184) and those who underwent UCLR the same season as SUS (UCLR cohort; n = 19). Ligament thickness, joint spacing, and laxity were compared. An additional matched cohort analysis was conducted using 10 players from each group to detect differences in the progression of UCL and ulnohumeral joint measures in the year before injury. RESULTS: The UCLR cohort, when compared with the healthy cohort, had higher relative (ie, nondominant-side measurements subtracted from dominant-side measurements) resting ulnohumeral joint space (median, 0.50 vs 0.20 mm, respectively; P = .006) and higher rates of hypoechoic foci (57.9% vs 30.4%, respectively; P = .030). Players of both groups had similar dominant UCL thickness (P = .161), ulnohumeral joint space at rest (P = .321), space under stress (P = .498), and laxity (P = .796). Groups did not differ in terms of relative UCL thickness, ulnohumeral joint space under stress, or relative laxity. In the year before UCL injury, the UCLR cohort, compared with the matched healthy cohort, had a greater increase in mean dominant UCL thickness (0.94 vs -0.60 mm, respectively; P = .038) and a greater increase in relative median UCL thickness (1.35 vs -0.35 mm, respectively; P = .045). Players in the healthy cohort were statistically older than those in the UCLR cohort (23 vs 22 years, respectively; P = .004). No differences in ulnohumeral stress spacing or laxity were detected. CONCLUSION: SUS of players who underwent UCLR demonstrated a progressive increase in UCL thickness over 1 year, higher rates of hypoechoic foci, and increased ulnohumeral rest space compared with SUS of uninjured players.

Dynamic Stress Ultrasound Assessment of Professional Baseball Players' Elbows After Ulnar Collateral Ligament Reconstruction.

BACKGROUND: There is a paucity of data analyzing dynamic stress ultrasound (SUS) findings in elite pitchers who have undergone ulnar collateral ligament (UCL) reconstruction (UCLR) and returned to sport. PURPOSE: To identify longitudinal, perioperative changes in the elbows of professional baseball pitchers who have undergone UCLR and to compare these findings with a matched cohort of healthy pitchers. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This study used prospectively collected data from dynamic elbow SUS analyses of professional baseball pitchers within a single Major League Baseball organization. Pitchers were divided into 2 cohorts: a UCLR cohort and healthy cohort. The UCLR cohort eligibility included availability of (1) SUS from preseason of injury/UCLR and (2) SUS from ≥2 years after surgery. These players were 1:1 matched to players with no history of upper extremity injury to form the healthy cohort. Ligament thickness and ulnohumeral joint space at rest and under stress were directly measured. Joint laxity was calculated by subtracting joint space at rest from joint space under stress. The term "relative" was used to describe calculated differences where nondominant measurements were subtracted from dominant-side measurements. RESULTS: Eight pitchers were included in the UCLR group and matched to 8 healthy pitchers (mean age at initial SUS examination, 19.6 years). At a minimum follow-up of 2 years, there were no significant differences between groups in terms of relative or dominant arm rest space, stress space, or laxity. Longitudinally (final measurements - baseline measurements), the mean relative ulnohumeral rest space decreased in the UCLR group and increased in the healthy group (-0.36 mm vs +0.50 mm; P = .032). The finding of increased UCL thickness in the UCLR group was expected, as UCL grafts are typically thicker than native ligaments. CONCLUSION: Ulnhohumeral joint stability was achieved after UCLR as indicated by similar rest space, stress space, and joint laxity in dominant arms compared with a matched healthy cohort. A significant decrease in relative rest space after UCLR may represent the achievement of stability in surgery patients. Alternatively, the increase in ulnohumeral rest space seen in the healthy cohort may represent adaptive changes from pitching at a professional level.

Patients With First-Time or Recurrent Patellar Dislocation Have a Similar High Rate and Extent of Articular Cartilage Injury Observed on Magnetic Resonance Imaging.

Purpose: To use magnetic resonance imaging (MRI) scans to compare the prevalence of articular cartilage damage in patients with a single patellar dislocation versus those with multiple dislocations and to compare the locations and severity of chondral injury between the groups. Methods: Patients with patellar dislocation between January 2017 and July 2021 were retrospectively identified. Patients with a documented history of patellar dislocation and an MRI scan of the affected knee were included. Patients with articular cartilage injury prior to the dislocation event were excluded. Articular cartilage injury was graded using a validated system: AMADEUS (Mean Total Area Measurement and Depth & Underlying Structures). Caton-Deschamps Index (CDI) scores and Dejour classifications of trochlear dysplasia were also collected. Data were calculated by performing t tests, Mann-Whitney tests, and χ2 or Fisher Exact tests to calculate P values for categorical data. Results: In total, 233 patients were included: 117 with primary dislocations and 116 with recurrent dislocations. Articular cartilage injuries were present in 51 patients with primary dislocations (43.6%) and 68 patients with recurrent dislocations (58.6%, P = .026). On comparison of the groups, the recurrent group contained a significantly larger proportion of female patients (65.5% vs 46.2%, P = .004). There was no difference in lesion size, subchondral bone defect, presence of bone edema, or total AMADEUS score between groups (P = .231). Caton-Deschamps Index scores were not significant when comparing between groups; however, the Dejour classifications showed higher grades in the recurrent group (P = .013 for A-D grading scale and P = .005 for high/low grading scale). Subgroup analysis revealed that when cartilage damage was present, patients from the primary group had significantly more full-thickness lesions (P < .001) and lower AMADEUS scores (P = .016). Conclusions: There was a similarly high prevalence of cartilage injury seen on MRI after both a primary patellar dislocation and a recurrent patellar dislocation. Chondral injury primarily affected the medial and lateral patellar facets and the lateral femoral condyle in both the primary and recurrent dislocation groups. However, the primary group showed an increased number of full-thickness lesions. There was no difference in lesion size, subchondral bone defect, presence of bone edema, or total AMADEUS score between the primary and recurrent groups. Level of Evidence: Level III, retrospective comparative prognostic investigation.