Psychological Impact and Posttraumatic Stress Disorder Symptomatology After Ulnar Collateral Ligament Injuries in Baseball Players.

Background: Significant psychological impact and prevalence of posttraumatic stress disorder (PTSD) have been well documented in patients sustaining anterior cruciate ligament injury. Purpose: To examine PTSD symptomatology in baseball players after sustaining elbow ulnar collateral ligament (UCL) injury. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Male baseball players of various competition levels (high school through Minor League Baseball [MiLB]) who underwent surgery for a UCL injury between April 2019 and June 2022 participated in the study. Before surgery, patients completed the Impact of Event Scale-Revised (IES-R) to assess PTSD symptomatology. Subgroup analysis was conducted according to level of play and player position. Results: A total of 104 male baseball players with a mean age of 19.4 years (range, 15-29 years) were included in the study; 32 players (30.8%) were in high school, 65 (62.5%) were in college, and 7 (6.7%) were in MiLB. There were 64 (61.5%) pitchers, 18 (17.3%) position players, and 22 (21.2%) 2-way players (both pitching and playing on the field). A total of 30 (28.8%) patients scored high enough on the IES-R to support PTSD as a probable diagnosis, and another 22 patients (21.2%) scored high enough to support PTSD as a clinical concern. Nineteen patients (18.3%) had potentially severe PTSD. Only 4 players (3.8%) were completely asymptomatic. Subgroup analysis revealed college players as significantly more symptomatic than high school players (P = .02), and 2-way players were found to be significantly less susceptible to developing symptoms of PTSD compared with pitchers (P = .04). Conclusion: Nearly 30% of baseball players who sustained a UCL injury qualified for a probable diagnosis of PTSD based on the IES-R. Pitchers and college athletes were at increased risk for PTSD after UCL injury compared with 2-way players and high school athletes, respectively.

What are our patients asking Google about acromioclavicular joint injuries?-frequently asked online questions and the quality of online resources.

Background: Management of acromioclavicular (AC) joint injuries has been an ongoing source of debate, with over 150 variations of surgery described in the literature. Without a consensus on surgical technique, patients are seeking answers to common questions through internet resources. This study investigates the most common online patient questions pertaining to AC joint injuries and the quality of the websites providing information. Hypothesis: 1) Question topics will pertain to surgical indications, pain management, and success of surgery and 2) the quality and transparency of online information are largely heterogenous. Methods: Three AC joint search queries were entered into the Google Web Search. Questions under the "People also ask" tab were expanded in order and 100 results for each query were included (300 total). Questions were categorized based on Rothwell's classification. Websites were categorized by source. Website quality was evaluated by the Journal of the American Medical Association (JAMA) Benchmark Criteria. Results: Most questions fell into the Rothwell Fact category (48.0%). The most common question topics were surgical indications (28.0%), timeline of recovery (13.0%), and diagnosis/evaluation (12.0%). The least common question topics were anatomy/function (3.3%), evaluation of surgery (3.3%), injury comparison (1.0%), and cost (1.0%). The most common websites were medical practice (44.0%), academic (22.3%), and single surgeon personal (12.3%). The average JAMA score for all websites was 1.0 ± 1.3. Government websites had the highest JAMA score (4.0 ± 0.0) and constituted 45.8% of all websites with a score of 4/4. PubMed articles constituted 63.6% (7/11) of government website. Comparatively, medical practice websites had the lowest JAMA score (0.3 ± 0.7, range [0-3]). Conclusion: Online patient AC joint injury questions pertain to surgical indications, timeline of recovery, and diagnosis/evaluation. Government websites and PubMed articles provide the highest-quality sources of reliable, up-to-date information but constitute the smallest proportion of resources. In contrast, medical practice represents the most visited websites, however, recorded the lowest quality score. Physicians should utilize this information to answer frequently asked questions, guide patient expectations, and help provide and identify reliable online resources.

Heterotopic Ossification Secondary to Motor Vehicle Collision Trauma Leading to Femoroacetabular Impingement Syndrome: A Case Report.

Introduction: A patient presented for recalcitrant right hip pain secondary to femoroacetabular impingement (FAI) after blunt motor vehicle trauma and following the development of a 12 cm heterotopic ossification (HO). FAI is an increasingly recognized diagnosis where the hip joint is exposed to repeated femoral microtrauma from high-level physical activity or trauma, often causing labral ossification, and perhaps underlying a similar biological mechanism to HO. Case Report: In this case report, we have an otherwise healthy 49-year-old male who was involved in a high-speed motor vehicle collision who was diagnosed with right hip FAI secondary to HO (Brooker's Class IV) and indicated for surgical excision of the HO anterior to the right proximal femur. The care team and patient initially trialed non-operative conservative treatment with non-steroidal anti-inflammatories drugs (NSAIDs) and hypothesized therapeutic success using a non-surgical approach. Surgical resection was pursued with the patient after a failure of conservative measures. The patient reported a zero out of ten on a ten-point numerical rating scale for pain, he also stated improved quality of life, satisfaction with the procedure, and subsequent rehabilitation at 1-month post-operative follow-up. Conclusion: HO with near complete ankylosis of the hip joint may be causative of FAI when untreated. Although this case demonstrates a rarely studied traumatic etiology of impingement secondary to HO, initial standard conservative anti-inflammatory treatment can still be pursued. By analyzing the periarticular impact of HO secondary to non-surgical trauma, we can utilize and make inferential correlations from the literature, studying HO and impingement in the setting of prior hip surgery to guide treatment and prognosis in those presenting with FAI symptoms secondary to blunt force trauma.

Posteromedial Osteophyte Resection in Baseball Players Undergoing Ulnar Collateral Ligament Reconstruction Has no Effect on Return to Play but Decreases Patient-Reported Satisfaction and Throwing Control.

Purpose: The purpose of this study was to compare patient-reported outcomes and return to play (RTP) rates following ulnar collateral ligament reconstruction (UCLR) in patients with and without posteromedial elbow impingement (PI) treated with concomitant arthroscopic posteromedial osteophyte resection. Methods: Baseball players who underwent UCLR performed by the senior surgeon with minimum follow-up of 2 years were surveyed in this retrospective cohort study. Primary outcomes included Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow (KJOC) score, Andrews-Timmerman score, and RTP rate. Secondary outcomes included patient satisfaction scores. Results: 35 baseball players were included. Eighteen had no preoperative impingement (mean age: 19.06 ± 3.28 years), while 17 had PI treated with concomitant arthroscopic osteophyte resection (mean age: 20.06 ± 2.68 years). Following surgery, there was no difference in mean Andrews-Timmerman score (no impingement = 91.67 ± 8.04 vs PI = 92.06 ± 7.92, P = .89) nor KJOC score (no impingement = 83.36 ± 11.72 vs PI = 79.88 ± 12.35, P = .40), but there was a decreased mean KJOC throwing control sub-score in the PI group (7.65 ± 2.40 vs 9.11 ± 1.32, P = .04). There was no difference in RTP rate between the groups (no impingement = 72.22%, PI = 94.12%, χ2 = 1.28; P = .26). There was significantly higher mean satisfaction score in the no impingement group (96.67 ± 4.58 vs 90.12 ± 11.91; P = .04), and those patients were also more likely to pursue surgical treatment again (94.44% vs 52.94%, χ2 = 7.88; P = .005). Conclusions: There was no difference in RTP rate following ulnar collateral ligament reconstruction in baseball players with and without posteromedial impingement treated with arthroscopic resection. Outcomes on the KJOC and Andrews-Timmerman scores were good to excellent in both groups. Players in the posteromedial impingement group were less satisfied with their outcome, however, and less likely to elect for surgery if they were to sustain the injury again. Additionally, players in the posteromedial impingement group were found to have decreased throwing control on the KJOC questionnaire, which may suggest that the presence of posteromedial osteophytes represent adaptive changes to stabilize the elbow while throwing. Level of Evidence: Level III, retrospective cohort study.

Radially Based Extensor Retinacular Sling Reconstruction for Extensor Carpi Ulnaris Subsheath Injuries.

Purpose: Extensor carpi ulnaris (ECU) subsheath injuries result in ulnar-sided wrist pain and often present concurrently with intrinsic ECU pathology and ulnocarpal compartment injuries. There is a lack of surgical outcome data despite the variety of described ECU subsheath pathologies and reconstructive strategies. Methods: We retrospectively reviewed our hand-center experience of 33 patients who prospectively underwent radially based extensor retinacular sling ECU subsheath reconstruction by 4 hand surgery-fellowship-trained surgeons between April 2010 and April 2021. Preoperative clinical and magnetic resonance imaging findings, along with intraoperative findings, were cataloged. Statistical analysis was conducted via a 2-tailed paired t test. Results: The median age at the time of surgery was 44 years (range, 18-63 years). Twenty (60.6%) patients underwent reconstruction on their dominant wrist. The median time between symptom onset and surgery was 6.5 months (range, 4 days-16.1 years). Eight (18%) patients were collegiate-level or professional athletes. Ten (30.3%) patients had frank ECU snapping on the preoperative examination with no recurrence or apprehension on the postoperative examination. All 33 patients underwent a preoperative magnetic resonance imaging. Fifteen (45.4%) patients had intrinsic ECU tendinopathy, 19 (57.6%) patients had ECU tenosynovitis, 18 (54.5%) patients had triangular fibrocartilage complex tears, 20 (60.6%) patients had ulnocarpal synovitis, and 2 (6.1%) patients had lunotriquetral interosseous ligament tears. The mean postoperative pain on a visual analog scale was 0.39 ± 0.55. Grip strength, wrist flexion-extension, and pronosupination arcs (P < .05) showed excellent recovery after surgery. The mean time to unrestricted return to sports was 97.3 ± 19.7 days for the athletes in this study. There were no major complications. Conclusions: Radially based extensor retinacular sling ECU subsheath reconstruction resulted in satisfactory improvements in range of motion and grip strength. Although the mean improvements in these parameters were statistically significant, the clinical significance of these postoperative improvements remains to be defined. Type of study/level of evidence: Therapeutic, Level IV.

Radially Based Extensor Retinacular Sling Reconstruction for Extensor Carpi Ulnaris Subsheath Injuries in Elite Athletes.

BACKGROUND: Extensor carpi ulnaris (ECU) subsheath injuries are an increasingly recognized cause of ulnar-sided wrist pain in elite athletes. There is a lack of surgical outcome data in elite athletes, and unique considerations exist for these patients. METHODS: We performed a retrospective review of our hand center experience of 14 elite professional or collegiate athletes who prospectively underwent radially based extensor retinacular sling ECU subsheath reconstruction by 3 hand surgery-fellowship-trained surgeons between April 2011 and April 2021. Clinical, magnetic resonance imaging (MRI), and intraoperative findings were cataloged. Subgroup analyses of elite hockey players and acute subsheath injuries were also conducted. Statistical analysis was performed via a 2-tailed paired t test. RESULTS: Mean age at the time of surgery was 21.3 years (range, 18-34). Mean time from symptom onset to surgery was 102.1 ± 110.7 days. All 14 patients underwent preoperative MRI. Five patients (35.7%) had intrinsic ECU tendinopathy, 9 patients (64.3%) had ECU tenosynovitis, 6 patients (42.9%) had triangular fibrocartilage complex tears, and 9 patients (64.3%) had ulnocarpal synovitis. Mean postoperative pain on a Visual Analog Scale was 0.25 ± 0.43. Grip strength (P = .001), wrist flexion-extension (P = .037), and pronosupination arcs (P = .093) showed excellent recovery postoperatively. Mean time to unrestricted return to sports was 92.5 ± 21.0 days. There were no complications. Subgroup analyses found similar functional improvement and characterized injury patterns. CONCLUSIONS: Overall, our findings suggest surgical management of ECU subsheath injuries is a viable option in both acute and chronic settings in elite athletes and may be favorable compared with nonoperative management.

Association between spinal stenosis and wild-type ATTR amyloidosis.

Age-related cardiac amyloidosis results from deposits of wild-type tranthyretin amyloid (ATTRwt) in cardiac tissue. ATTR may play a role in carpal tunnel syndrome (CTS) and in spinal stenosis (SS), indicating or presaging systemic amyloidosis. We investigated consecutive patients undergoing surgery for SS for ATTR deposition in the resected ligamentum flavum (LF) and concomitant risk of cardiac amyloidosis. Each surgical specimen (LF) was stained with Congo red, and if positive, the amyloid deposits were typed by mass spectrometry. Patients with positive specimens underwent standard of care evaluation with fat pad aspirates, serum and urine protein electrophoresis with immunofixation, free light-chain assay, TTR gene sequencing and technetium 99 m-pyrophosphate-scintigraphy. In 2018-2019, 324 patients underwent surgery for SS and 43 patients (13%) had ATTR in the LF with wild-type TTR gene sequences. Two cases of ATTRwt cardiac amyloidosis were diagnosed and received treatment. In this large series, ATTRwt was identified in 13% of the patients undergoing laminectomy for SS. Patients with amyloid in the ligamentum flavum were older and had a higher prevalence of CTS, suggesting a systemic form of ATTR amyloidosis involving connective tissue. Further prospective study of patients with SS at risk for systemic amyloidosis is warranted.

Lumbar ligamentum flavum burden: Evaluating the role of ATTRwt amyloid deposition in ligamentum flavum thickness at all lumbar levels.

BACKGROUND: Wild-type transthyretin (ATTRwt) amyloid deposition has been found in the ligamentum flavum (LF) of patients undergoing spinal stenosis surgery. Our group previously reported that ATTRwt amyloid is associated with an increased lumbar ligamentum flavum thickness at symptomatic levels that required surgery. A comprehensive evaluation of LF thickness at asymptomatic levels in addition to symptomatic, treated levels has never been performed in ATTRwt patients. In this study, we compare the total LF thickness of all lumbar levels (lumbar LF burden) in ATTRwt and non-ATTRwt patients. METHODS: We retrospectively identified 177 patients who underwent lumbar spine surgery. Ligamentum flavum thickness of 885 lumbar levels was measured on T2-weighted axial MRI. Amyloid presence was confirmed through Congo red staining of specimens, and subtype of ATTRwt was confirmed using mass-spectrometry and gene sequencing. RESULTS: Of the 177 patients, 30 (16.9%) were found to have ATTRwt in the ligamentum flavum. One hundred and fifty ATTRwt levels and 735 non-ATTRwt levels were measured by four different reviewers, with an intraclass coefficient (ICC) of 0.79. Mean ligamentum flavum thickness was 4.64 (±1.31) mm in the ATTRwt group and 3.99 (±1.45) mm in the non-ATTRwt group (p < 0.001). The lumbar LF burden (sum of ligamentum flavum thickness at all lumbar levels) for ATTRwt patients was 23.22 (±4.48) mm, and for non-ATTRwt patients was 19.96 (±5.49) mm (p = 0.003) CONCLUSION: The lumbar LF burden is greater in patients with ATTRwt amyloid compared to non-ATTRwt patients. This supports prior evidence that ATTRwt amyloid deposition might be associated with increased LF thickness and lumbar stenosis. This potential association requires more research and could be an important finding, as medications have recently become available that can treat patients with ATTRwt amyloid deposition.

Increased thickness of lumbar spine ligamentum flavum in wild-type transthyretin amyloidosis.

BACKGROUND: Wild-type transthyretin (ATTRwt) amyloid deposits have been found in the ligamentum flavum of patients undergoing surgery for spinal stenosis. The relationship between ATTRwt and ligamentum flavum thickness is unclear. We used pre-operative magnetic resonance imaging (MRI) to analyze ligamentum flavum thickness in lumbar spinal stenosis patients with and without ATTRwt amyloid. METHODS: We retrospectively identified 178 patients who underwent lumbar spine surgery. Ligamentum flavum thickness of 253 specimens was measured on T2-weighted axial MRI. Amyloid presence was confirmed through Congo red staining of specimens, and ATTRwt was confirmed using mass-spectrometry and gene sequencing. RESULTS: Twenty four of the 178 patients (13.5%) were found to have ATTRwt in the ligamentum flavum. Forty ATTRwt specimens and 213 non-ATTRwt specimens were measured. Mean ligamentum flavum thickness was 4.92 (±1.27) mm in the ATTRwt group and 4.00 (±1.21) mm in the non-ATTRwt group (p < 0.01). The ligamentum flavum was thickest at L4-L5, with a thickness of 5.15 (±1.27) mm and 4.23 (±1.29) mm in the ATTRwt and non-ATTRwt group, respectively (p = 0.007). There was a significant difference in ligamentum flavum thickness between ATTRwt and non-ATTRwt case for both patients younger than 70 years (p = 0.016) and those older than 70 years (p = 0.004). ATTRwt patients had greater ligamentum flavum thickness by 0.83 mm (95% confidence interval (CI): 0.41-1.25 mm, p < 0.001) when controlled for age and lumbar level. CONCLUSION: Patients with ATTRwt had thicker ligamentum flavum compared to patients without ATTRwt. Further studies are needed to investigate the pathophysiology of ATTRwt in ligamentum flavum thickening.

Wild-Type Transthyretin Amyloidosis Occurring in the Ligamentum Flavum of the Cervicothoracic Spine.

BACKGROUND: Wild-type transthyretin amyloid (ATTRwt) has been noted to deposit in the ligamentum flavum of the spine. Prior studies have focused on ATTRwt in the lumbar region, but studies discussing its presence in other levels of the spine are lacking. We report on the presentation of patients with confirmed amyloid in the cervicothoracic regions and discuss the literature to date. METHODS: We retrospectively identified patients at a single institution who underwent surgery for spinal stenosis and had pathologic specimens sent for amyloidosis testing with Congo red staining. ATTRwt was confirmed by the presence of transthyretin amyloid by typing and the absence of mutations in the TTR gene sequence. A final study group of patients with ATTRwt and spinal involvement was established (n = 27). RESULTS: Of 27 patients with amyloid in the spine, 24 (89%) had amyloid present in the lumbar region, 2 (7%) had amyloid in the cervical region, and 1 (4%) had amyloid in the thoracic region. The median age at which patients in the study underwent surgery was 71 years (interquartile range: 9). Spinal stenosis was the indication for surgery in 26 of 27 (96%) patients. Surgery involved 1 or 2 spinal levels in 24 of 27 (89%) patients. CONCLUSIONS: ATTRwt amyloid predominantly deposits in the lumbar region, but it can also be present in the cervical and thoracic regions. While the lumbar regions should remain a focus for evaluation of ATTRwt amyloidosis, the cervicothoracic region should not be ignored.