Biceps Tenodesis Has Greater Expected Value Than Repair for Isolated Type II SLAP Tears: A Meta-analysis and Expected-Value Decision Analysis.

PURPOSE: To use an expected-value decision analysis to determine the optimal treatment decision between repair and biceps tenodesis (BT) for an isolated type II SLAP injury. METHODS: An expected-value decision analysis with sensitivity analysis was performed to systematically quantify the clinical decision. To determine outcome probabilities, a decision tree was constructed (repair vs BT) and a meta-analysis was conducted. To determine outcome utilities, we evaluated 70 patients with a chief complaint of shoulder pain regarding age, sex, Shoulder Activity Level, and visual analog scale score in terms of potential outcome preferences. Statistical fold-back analysis was performed to determine the optimal treatment. One-way sensitivity analysis determined the effect of changing the reinjury rate on the expected value of BT. RESULTS: The overall expected value was 8.66 for BT versus 7.19 for SLAP repair. One-way sensitivity analysis showed that BT was the superior choice if reinjury rates were expected to be lower than 28%. Meta-analysis of 23 studies and 908 patients revealed that the probability of a "well" outcome was significantly greater for BT (87.8%; 95% confidence interval [CI], 74.9%-94.6%; I2 = 0.0%) than for SLAP repair (62.9%; 95% CI, 55.9%-69.3%; I2 = 65.9%; P = .0023). The rate of reinjury was 1.5% for BT (95% CI, 0.05%-33.8%; I2 = 0.0%) and 6.4% for repair (95% CI, 4.2%-9.6%; I2 = 24%), which was not statistically significantly different (P = .411). A total of 50 participants (mean age, 25.4 years [standard deviation, 8.9 years]; 76% male patients; 50% overhead athletes) met the inclusion criteria. Forty-six percent of participants had a high Shoulder Activity Level score. CONCLUSIONS: Decision analysis showed that BT is preferred over repair for an isolated type II SLAP tear based on greater expected value of BT versus repair. Meta-analysis showed more frequent favorable outcomes with BT. Surgeons can use this information to tailor discussions with patients. LEVEL OF EVIDENCE: Level IV, meta-analysis of Level I-IV studies.

The Impact of Drive Leg Impulse and Slope on Throwing Velocity and Kinematics in the Competitive Throwing Athlete.

BACKGROUND: Multiple studies have analyzed pitching kinematics using motion analysis technology, but lower extremity drive leg impulse (DLI) and drive leg slope (DLS) are not as well characterized. The purpose of this study was to investigate associations between DLI and DLS and pitch velocity as well as angular velocity of the pelvis, trunk, and humerus. HYPOTHESIS: Increased DLI and DLS will be correlated positively with pitch velocity and associated with increased angular velocities in the humerus, trunk, and pelvis. STUDY DESIGN: Retrospective case series. LEVEL OF EVIDENCE: Level 4. METHODS: Three-dimensional motion analyses data from 174 pitchers (age, 17.0 ± 1.0 years; height, 1.82 ± 0.07 m; weight, 80.0 ± 11.3 kg) throwing combined 613 fastball pitches were included. Pitchers threw 2 to 5 pitches, and the variables collected between pitches were averaged and recorded. Statistical analysis was performed using linear regressions to determine the association between DLS as well as DLI and pitch velocity and angular velocities of the pelvis, trunk, and humerus. RESULTS: Pitchers with higher DLI were associated with lower pitch velocities (ß = -22.32; 95% CI, -32.75 to -11.88, P < 0.01). There were no significant associations for DLS and velocity (ß = -0.60; 95% CI, -1.48 to 0.29, P = 0.18) or DLS and DLI with rotational velocities except for DLI and trunk kinematics (ß = -0.60; 95% CI, -1.48 to 0.29, P = 0.18). CONCLUSION: In the combined cohort, DLI correlated negatively with pitch velocity, although this relationship does not exist in the subgroup analysis. Higher DLS was found in pitchers with slower pitch velocities in the elite, high school, and youth groups, although not statistically significant. No associations were found with DLS and any angular velocities between any level of play analyzed in this study, suggesting no consistent association regardless of playing level.

An Expedited Sling Immobilization Protocol After Isolated Biceps Tenodesis Results in Clinical and Patient-Reported Postoperative Outcomes Equivalent to a Standard Rehabilitation Protocol.

Purpose: To characterize clinical and patient-reported outcomes for patients after isolated biceps tenodesis (BT) who underwent either standard or expedited sling immobilization protocols following surgery. Methods: This retrospective cohort study compared patients who were assigned to use a sling for either 4 to 6 weeks (standard) or 0 to 2 weeks (expedited) following an isolated BT. Primary endpoint included rate of re-rupture, surgical revision, loss of fixation, and Popeye deformity. Secondary endpoints included shoulder range of motion (ROM) as well as pre- and postoperative patient-reported outcomes (PROs) of pain and function. Missing data were managed via multiple imputation with chained equations. Complication prevalence 95% confidence intervals were calculated using the Clopper Pearson method and a series of hierarchical mixed effects linear regressions were performed to assess differences between sling interventions in PROs and ROM. Results: The average age of the standard cohort (n = 66) was 49 years (±14 years), and the average age of the expedited cohort (n = 69) was 47 years (±14 years). The expedited and standardized cohorts demonstrated 0.4 and 0.3 complications per 10,000 exposure days, respectively, with no significant difference between groups (1.4 [95% confidence interval 0.2-10.0], P = .727). There was no demonstrated difference in forward flexion, abduction, or external ROM. The expedited group had less improvement in visual analog scale for pain scores that was not clinically significant and there were no differences in PROs of function. Conclusions: No statistically significant difference in the rate of re-rupture, surgical revision, loss of fixation, or Popeye deformity was noted between protocols after isolated BT. Furthermore, there were no clinically significant differences in ROM or PROs identified between protocols after isolated BT. This study suggests that patients who have undergone isolated BT may safely discontinue sling use within 2 weeks after surgery. Level of Evidence: Level III, retrospective comparative study.

Shared and unique risk factors for readmission exist following upper and lower extremity arthroplasty in the 30-day postoperative period.

PURPOSE: Joint arthroplasty has become increasingly more common in the United States, and it is important to examine the patient-based risk factors and surgical variables associated with hospital readmissions. The purpose of this study was to identify stratified rates and risk factors for readmission after upper extremity (shoulder, elbow, and wrist) and lower extremity (hip, knee, and ankle) arthroplasty. METHODS: All patients undergoing upper and lower extremity arthroplasty from 2008-2018 were identified using the National Surgical Quality Improvement Program dataset. Patient demographics, medical comorbidities and surgical characteristics were examined utilizing uni- and multi-variate analysis for significant predictors of 30-days hospital readmission. RESULTS: A total of 523,523 lower and 25,215 upper extremity arthroplasty patients were included in this study. A number of 22,183 (4.2%) lower and 1072 (4.4%) upper extremity arthroplasty patients were readmitted within 30 days of discharge. Significant risk factors for 30-days readmission after lower extremity arthroplasty included age, Body Mass Index (BMI), operative time, dependent functional status, American Society of Anesthesiologists (ASA) score ≥3, increased length of stay, and various medical comorbidities such as diabetes, tobacco dependency, and chronic obstructive pulmonary disease (COPD). An overweight BMI was associated with a lower odds of 30-days readmission when compared to a normal BMI for lower extremity arthroplasty. Analysis for upper extremity arthroplasty revealed similar findings of significant risk factors for 30-days hospital readmission, although diabetes mellitus was not found to be a significant risk factor. CONCLUSION: Nearly one in 25 patients undergoing upper and lower extremity arthroplasty experiences hospital readmission within 30-days of index surgery. There are several modifiable risk factors for 30-days hospital readmission shared by both lower and upper extremity arthroplasty, including tobacco smoking, COPD, and hypertension. Optimization of these medical comorbidities may mitigate the risk short-term readmission following joint arthroplasty procedures and improve overall cost effectiveness of perioperative surgical care.

Baseball Pitchers who Suffer Latissimus Dorsi and Teres Major Tendon Injuries Have a High Return to Play Rate After Either Operative or Nonoperative Treatment.

Purpose: To provide a concise overview of the prevalence, diagnostic workup, management options, surgical techniques, and reported outcomes in the treatment of latissimus dorsi (LD) and teres major (TM) injuries in professional baseball pitchers. Methods: A systematic review of studies reporting on professional baseball players who sustained LD or TM injuries was performed. Data were collected including patient presentation, injury management strategies, return-to-play (RTP) rates, time to RTP, patient-reported outcome measures, player performance after RTP, preinjury factors associated with injury, and complications. Results: Nine studies with 159 professional baseball players with a LD or TM injury were identified. All studies (2 retrospective cohort studies with high risk of bias and 7 case series) reported shoulder pain after pitching, and magnetic resonance imaging was performed in all cases to confirm diagnosis. Twenty-three patients underwent surgical treatment, whereas 136 patients underwent nonsurgical treatment. Overall RTP rates and performance between surgical and nonsurgical groups were similar (75% to 100% vs 75% to 93%), although the largest study reported improved performance with surgery. Two studies described a surgical technique with a posterior axillary approach and endosteal button fixation of the LD tendon. All studies reported a progressive strengthening and throwing program prior to returning to sport. Conclusion: Professional baseball players who suffer a LD or TM injury have predictable clinical presentations and imaging findings. There is a high RTP rate and performance with both surgical and nonsurgical management. The heterogeneity and low level of evidence of available literature precludes comparative conclusions between treatment approaches. Level of Evidence: IV systematic review of Level III and IV studies.

Forward Surgical Teams as a Model for Humanitarian Orthopedic Surgical Care: A Review of Current Literature.

INTRODUCTION: Orthopedic trauma is a significant portion of global burden of disease in low- and middle-income countries (LMICs). This has led the World Health Organization to advocate for increased surgical intervention in LMICs. The two largest barriers to orthopedic surgical care for LMICs are cost of procedure and geographic access to centers with appropriate surgical capabilities. There is no current consensus on how to structure surgical interventional teams. The overall objective of this study is to describe the composition of a forward surgical team (FST), including its abilities and limitations. It is hypothesized that an FST is an effective model for orthopedic surgical relief efforts in LMICs. METHODS: A narrative literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis standards published by the National Academies of Medicine. Studies were evaluated by structured review procedures to identify an FST's capacity for orthopedic surgery, as well as applicability for humanitarian care. Articles detailing FST logistics, types of orthopedic treatment provided, and instances of humanitarian care while deployed in austere environments were included for review. RESULTS: The FST is a military surgical unit operating with a small crew of surgeons and supporting staff who use tents or trailers that can be positioned near points of conflict, often in remote or austere environments. FSTs were designed to treat traumatic injuries, including orthopedic trauma from RTIs. If used as a sponsored humanitarian aid mission, FSTs can provide surgical care at free or greatly reduced costs. Because FSTs carry limited supplies and personnel, they are highly mobile surgical units that can be transported via truck. CONCLUSION: FSTs are effective models for humanitarian orthopedic surgery in LMICs. FSTs were designed to treat orthopedic trauma, the largest burden of orthopedic care in LMICs. Efficient use of limited equipment allows FSTs to be cost effective for funding sources and highly mobile to reduce the geographic barrier to care. Further research is needed to determine the cost to operate an FST and ethical consideration for military intervention for foreign humanitarian aid.

Knowledge and Habits of Exercise in Medical Students.

Objective. To examine the exercise habits, knowledge, and self-efficacy of incoming medical students. Methods. Mixed-methods study consisting of (1) cross-sectional surveys and (2) qualitative key-informant interviews. (1) International Physical Activity Questionnaire (IPAQ), American Adult's Knowledge of Exercise Recommendations Survey (AAKERS), and Self-Efficacy for Exercise Scale (SEES) to assess student's physical activity level, knowledge of exercise recommendations, and self-efficacy for exercise. (2) Scripted questions explored exercise habits, sources of exercise knowledge, attitude toward exercise. Results. (1) Results of IPAQ classified students as 50% having high, 40% moderate, and 10% low levels of physical activity (n = 132). AAKERS demonstrated a mean total score of 16.2/20 (n = 130) (81% correct), similar to the national average (mean = 16/20) (n = 2002). SEES mean score of 48.5/90 (n = 128) is similar to previous studies (mean = 48.6/90, 52.75/90). (2) Interviews revealed that most students have a consistent exercise routine. Few students received formal education in exercise (10%), while the rest cited either peers, sports, or internet as primary sources of exercise knowledge. Less than half stated they would be comfortable designing an exercise routine for patients. Conclusions. Incoming medical students live an active lifestyle but have limited knowledge and formal training in exercise. Student's knowledge is predominantly self-taught from independent resources.