The influence of a single 30-pitch session on elbow laxity in adolescent and collegiate baseball pitchers.

BACKGROUND: Ulnar collateral ligament (UCL) injuries are a source of significant injury among baseball players, and are increasingly evaluated under ultrasound. The purpose of this study is to determine the effect of a single session of pitching upon UCL thickness and laxity via a cross sectional, controlled ultrasonographic study. We hypothesize that a single session of pitching will cause the ulnar collateral ligament to thicken and become more lax. METHODS: This was a cross sectional comparative study of collegiate and high school pitchers. Pitchers underwent an ultrasonographic assessment of the UCL before and after a thirty-pitch bullpen warm-up. Laxity was measured as the change in the distance between the ulna and the trochlea with and without a 5-pound weight held in hand with the elbow at 30° of flexion. Pre- and post-throwing UCL thickness and medial laxity were statistically compared with paired tests. RESULTS: Our study included 15 pitchers, 8 collegiate and 7 high school level athletes. All played baseball at least 6 days a week, and nearly all played for at least 10 months a year. Pitchers reported a peak velocity of 89 ± 6 (77 to 98) miles per hour. In the prior season, these pitchers pitched 56 ± 33 (10 to 120) games, throwing 62 ± 34 (25-140) pitches per game on average. After throwing, there was significantly less UCL laxity (P = .013). Post-throwing laxity was significantly positively correlated with both peak pitch velocity (P = .009) and an average number of pitches thrown per game (P = .10). CONCLUSION: Throwing 30 pitches significantly decreases medial elbow laxity with stress, possibly due to flexor-pronator activation. Post-throwing medial laxity is correlated with both peak pitch velocity and average number of pitches thrown per game. Future studies should be conducted to determine the number of throws at which laxity begins to increase, as this may provide a workload management guideline for injury prevention.

Effect of cryoablation in Nuss bar placement on opioid utilization and length of stay.

BACKGROUND: Our institution recently transitioned from paravertebral nerve blocks (PVBs) to intercostal nerve cryoablation (INC) for pain control following minimally invasive repair of pectus excavatum (MIRPE). This study aimed to determine how INC affected the operative time, length of stay, complication rates, inpatient opioid use, and outpatient prescription of opioids at a single center. METHODS: A retrospective review was performed at a single pediatric referral center of all patients who underwent MIRPE between 2018 and 2023. Patient demographics, operative details, and perioperative course were collected. The use of INC versus PVB was recorded. Univariate analyses were performed using Wilcoxon rank sum tests for continuous variables and chi-squared tests for categorical variables. RESULTS: 255 patients were included with a median age of 15 years, median BMI of 18.50 kg/m2, and median Haller index of 4.40. INC was utilized in 41% (105/255), and 59% (150/255) received PVB. The two groups did not differ significantly in BMI, Haller index, or complications, though the INC patients were older by 1 year (15.0 vs. 16.0, p = 0.034). INC was associated with an increased operative time (INC: 92 min vs. PVB: 67 min, p < 0.001), decreased length of stay (3 vs. 4 days, p = < 0.001), more than twofold decrease in inpatient opioids per day (INC: 16 MME vs. PVB: 41 MME, p < 0.001), and a fourfold decrease in the amount of opioids prescribed at discharge (INC: 90 MME vs. PVB: 390 MME, p < 0.001). CONCLUSION: INC after MIRPE significantly decreased both the inpatient opioid utilization and our outpatient prescribing practices while also decreasing our overall length of stay without increasing complications. LEVEL OF EVIDENCE: Level III.

Scheduled Postoperative Ketorolac Does Not Decrease Opiate Use following Free Flap Breast Reconstruction.

BACKGROUND: In the setting of the opioid crisis, managing postoperative pain without the exclusive use of opiates has become a topic of interest. Many hospitals have begun implementing enhanced recovery after surgery protocols to decrease postoperative complications, hospital costs, and opiate utilization. Ketorolac has been added to many of these protocols, but few studies have examined its effects independently. METHODS: A retrospective chart review was performed on all patients that received autologous breast reconstruction from October 2020 to June 2022 at an academic institution. We identified patients who did and did not receive postoperative ketorolac. Use of ketorolac was based upon surgeon preference. The two groups were compared in basic demographics, reconstruction characteristics, length of stay, complications, reoperations, and morphine milligram equivalents (MMEs). RESULTS: One-hundred ten patients were included for the analysis, with 55 receiving scheduled postoperative ketorolac and 55 who did not receive ketorolac. There were seven incidences of postoperative complications in each group (12.7%, p = 1.00). The total mean postoperative MMEs were 344.7 for the nonketorolac group and 336.5 for the ketorolac group (p = 0.81). No variable was found to be independently associated with postoperative opiate use. Ketorolac was not found to contribute significantly to any postoperative complication. CONCLUSION: In this study, the use of ketorolac did not significantly reduce opiate use in a cohort of 110 patients. Surgeons should consider whether the use of ketorolac alone is the best option to reduce postoperative opiate use following free flap breast reconstruction.

Three-month Delay in Rotator Cuff Repair: 2-year Follow-up.

INTRODUCTION: This study examined 2-year outcomes of patients who underwent delayed rotator cuff repair (RCR) compared with those who underwent RCR without delay. METHODS: In this prospective comparative study, two groups were formed: (1) patients planning RCR during a 6-week elective surgery ban and (2) patients undergoing RCR at least 6 weeks after the ban. The Simple Shoulder Test, American Shoulder and Elbow Surgeon score, and visual analog scale for pain were collected preoperatively and at 2 years postoperatively. Magnetic resonance imaging assessed healing 6 months postoperatively. RESULTS: With a 93.3% 2-year follow-up (13/15 delay group, 15/15 control), there was an 87-day difference in presentation to surgery (P = 0.001), with no significant preoperative demographic or tear characteristic differences between groups. Intraoperatively, there were no differences between groups in repair characteristics. Preoperative versus postoperative differences in American Shoulder and Elbow Surgeon score (P < 0.001), visual analog scale (P < 0.001), and Simple Shoulder Test scores (P < 0.001) were significant but not between groups (P = 0.650, 0.586, 0.525). On MRI, 58% in the delay group and 85% in the control group had healed (P = 0.202). DISCUSSION: Although a 3-month delay showed no statistically significant effect on outcomes, the delay group had an approximately 27% higher failure rate. Thus, although a 3-month period of nonsurgical treatment before RCR may be reasonable, larger studies are warranted for definitive conclusions.

Single anterior shoulder dislocation patients demonstrate higher rates of posterior labral repair and biceps procedures than multiple dislocators at the time of arthroscopic stabilization surgery.

Hypothesis: The purpose of this study is to identify and compare demographic, clinical, historical, and intraoperative variables in patients who have received arthroscopic treatment for single vs. multiple anterior shoulder dislocations. Methods: This is a retrospective chart review of patients who underwent arthroscopic labral repair of the shoulder by six surgeons at a single institution between 2012 and 2020. Patients with a documented anterior shoulder dislocation were included. Patients with pain-only, subluxation-only, multidirectional or posterior instability, and prior shoulder surgeries of any kind were excluded. Studied variables included age, sex, laterality, body mass index, contact/collision sports, Charlson comorbidity index, tobacco use, number of dislocations (1, >1), labral tear size, time from first dislocation to surgery, anchor number, and concomitant procedures. Study groups were compared using student's t-tests and Mann-Whitney U test for continuous variables and chi-square or Fisher's exact tests for discrete variables with a significance of 0.05. Results: Six hundred thirty-three patients were identified, and 351 (85 single dislocators [SDs], 266 multiple dislocators [MDs]) met inclusion criteria (mean age: 27 years; range: 14-71 years). There were no demographic differences between the study groups. SD received surgery significantly sooner at 17 ± 44 months after injury, while MD received surgery 53 ± 74 months postinitial dislocation. SDs (30/85, 35%) were significantly more likely than MDs (56/266, 21%) to receive concomitant posterior labrum repair. MDs (46/266, 17%) were significantly more likely than SDs (5/85, 6%) to receive a remplissage. SDs (11/85, 13%) were significantly more likely than MDs (11/266, 4%) to receive a concomitant biceps tenotomy/tenodesis. There were no other significant differences in injury or surgery characteristics. Conclusion: MDs will have more time between their initial dislocation and arthroscopic labral repair and are more likely to receive a remplissage procedure, yet they are less likely than SDs to receive a concomitant posterior labral repair or biceps tenodesis/tenotomy despite no differences in age, sex, and activity level. Whether the greater extent of labrum injury in SD is due to a more severe initial injury vs. earlier recognition and intervention requires further study.

Routine Urology Consultation and Follow-up After Pediatric Blunt Renal Trauma is Likely Unnecessary.

INTRODUCTION: This study examines the outcomes of high-grade renal trauma in pediatric patients and evaluates the intervention rate. In our hospital, we routinely consult urology on all high-grade injuries. We anticipated minimal intervention, casting doubt on the need for routine urology consultation and follow-up. METHODS: We conducted a retrospective review at a single pediatric trauma center from January 2018 to June 2023, focusing on patients with severe (grade III-V) renal injuries. Data collected included demographics, trauma-related variables, hospital course, interventions, and follow-up. When the grade was not readily available in the electronic medical record, we had a board-certified pediatric radiologist review the imaging and provide the grade. Follow-up was included only if it was with a pediatric urologist. RESULTS: There were 92 patients that met our inclusion criteria. Of these, 47 were grade III, 32 were grade IV, and 13 were grade V. Six (6.5%) patients required inpatient renal stent procedures. Follow-up occurred in 55/92 (60%) patients with a pediatric urologist. Follow-up by grade is as follows: 22/47 (47%) grade III, 22/32 (69%) grade IV, and 11/13 (85%) grade V. Overall 5.8% of patients required antihypertensive medications and this was more likely as injury grade increased. All stents were removed outpatient and there were 3 (3.3%) additional outpatient interventions, all in patients that were symptomatic. CONCLUSION: Given the low prevalence of interventions after discharge, routine consultation and follow-up with urology is likely unnecessary in the absence of an inpatient urologic procedure during the index hospitalization. Patients with high-grade injuries should instead follow up with a trauma clinic or general provider with urology follow-up based on symptoms. TYPE OF STUDY: Retrospective Review. LEVEL OF EVIDENCE: Level III.

Optimizing patient selection for ECMO after pediatric hypothermic cardiac arrest.

BACKGROUND: In 2004, our level 1 regional pediatric trauma center created a protocol to activate ECMO for children with suspected hypothermic cardiac arrest based on inclusion criteria: serum potassium ≤9, submersion <90 min, and core body temperature <30 °C. In 2017, Pasquier et al. developed a model to help predict the survival of adults after hypothermic cardiac arrest (HOPE score) that has not been validated in children. We sought to apply this score to our pediatric patient population to determine if it can optimize our patient selection. METHODS: This was a retrospective review of all patients cannulated onto VA ECMO for hypothermic cardiac arrest between 2004 and 2022. We used abstracted data points to calculate the HOPE score for our patient population, both with and without presumed asphyxia. RESULTS: Over 19 years, 18 patients were cannulated for suspected hypothermic arrest, with three survivors (17 %). The HOPE score survival prediction ranged from 1 to 86 % with presumed asphyxia and 6-98 % without presumed asphyxia. Survivor HOPE scores ranged from 9 to 86 % with presumed asphyxia and 42-98 % without presumed asphyxia. Non-survivors' scores ranged 1-29 % with asphyxia and 6-57 % without asphyxia. A cutoff of >5 % predicted survival with asphyxia for ECMO could have decreased our cannulations by half without missing survivors. CONCLUSION: ECMO can be a lifesaving measure for specific children after hypothermic arrest. However, identifying the patients that will benefit from this resource-intensive intervention remains difficult. HOPE score utilization may decrease the rate of futile cannulation in children, but multi-centered research is needed in the pediatric population.

Complementary Medicine and Expressive Arts Therapy: Adjuvant for Recovery Following Neurosurgical Procedures.

Art as a way of healing is primordial in many cultures. Expressive Arts Therapy (ExAT) uses art, music, dance, and writing to help individuals navigate their healing journey. Patient self-expression as a mode of recovery has been observed in patients with Parkinson's disease, epilepsy, Amyotrophic Lateral Sclerosis (ALS) and cancer. Complementary medical approaches such as acupuncture and mindfulness have also demonstrated benefits in patients suffering from neurological injury. Complementary medicine and ExAT are not mainstream approaches following neurosurgical procedures. There are very few systematic studies evaluating the benefits of expressive arts in neurosurgery. Advances in telemedicine and mobile applications may facilitate the incorporation of complementary medicine and ExAT into patient recovery. The purpose of our study is to explore the use of complementary medicine and ExAT in neurosurgical recovery. We start with a brief introduction of ExAT followed by available treatments offered. We discuss the benefits of multidisciplinary care and emerging technologies and how they can facilitate incorporation of complementary medicine and ExAT in neurosurgery. Finally, we review several clinical studies that have demonstrated success in using complementary medicine. Our goal is to provide alternative approaches to neurosurgery recovery so that patients may receive with the best care possible.

Revision Subpectoral Biceps Tenodesis Demonstrates a High Patient Satisfaction and Good Functional Outcomes.

Purpose: To clinically evaluate a subset of patients who underwent a revision subpectoral biceps tenodesis for a clinically failed proximal biceps tenodesis. Methods: This is a retrospective case series of patients with at least 2-year follow-up who had undergone a revision biceps tenodesis after clinical failure of a proximal biceps tenodesis between January 2008 and February 2020 by a single surgeon. Patients who underwent concomitant procedures, such as revision cuff repair, were excluded. Patients with a minimum of 2 years duration status postrevision subpectoral tenodesis were contacted for informed consent and outcome data, which included Simple Shoulder Test, American Shoulder and Elbow Surgeons score, visual analog scale for pain, and subjective reporting of arm weakness and satisfaction. Results: Fourteen patients were initially identified as meeting inclusion criteria with a minimum 2-year follow-up achieved for 11 of 14 patients (78.5% follow-up). The mean follow-up time was 8.1 years (range, 2.7-14.8 years). After the primary biceps tenodesis, a mean of 8.0 ± 9.6 months passed before the revision subpectoral biceps tenodesis was performed. The average postoperative active forward elevation and adducted external rotation were 159 ± 7° and 47 ± 17°, respectively. The mean ± standard deviation (range) follow-up American Shoulder and Elbow Surgeons score was 79 ± 23 (30-100), Simple Shoulder Test was 11 ± 2 (7-12), and visual analog scale for pain was 2.6 ± 2.8 (0-9). All 11 patients reported being satisfied with their operation and would elect to have the operation again. Conclusions: Revision subpectoral biceps tenodesis is a viable procedure for addressing patients with persistent pain following initial proximal biceps tenodesis. Although some persistent pain is common, revision subpectoral biceps tenodesis demonstrates a high patient satisfaction and good functional outcomes. Level of Evidence: Level IV, therapeutic case series.

Progression of symptomatic bilateral rotator cuff disease.

Background: Prior studies have demonstrated that conservatively treated rotator cuff tears and rotator cuff tendinopathy may continue to progress. It is unclear whether that rate of progression differs between sides in patients with bilateral disease. This study evaluated the likelihood of progression of rotator cuff disease as confirmed via magnetic resonance imaging (MRI) in individuals with symptomatic bilateral pathology, treated conservatively for a minimum of 1 year. Methods: We identified patients with bilateral rotator cuff disease confirmed via MRI within the Veteran's Health Administration electronic database. A retrospective chart review via the Veteran's Affairs electronic medical record was performed. Progression was determined using 2 separate MRIs with a minimum of 1 year apart. We defined progression as (1) a progression from tendinopathy to tearing, (2) an increase from partial-thickness to full-thickness tearing, or (3) an increase in tear retraction or tear width of at least 5 mm. Results: Four hundred eighty MRI studies from 120 Veteran's Affair patients with bilateral, conservatively treated rotator cuff disease were evaluated. Overall, 42% (100/240) of rotator cuff disease had progressed. No significant difference was found between progression of right vs. left rotator cuff pathology, with right shoulder pathology progressing at a rate of 39% (47/120), while left shoulder disease progressed at a rate of 44% (53/120). The likelihood of disease progression was associated with less initial tendon retraction (P value = .016) and older age (P value = .025). Conclusions: Rotator cuff tears are no more likely to progress on the right, as compared to the left side. Older age and less initial tendon retraction were found to be predictors of disease progression. These suggest that higher activity level may not associate with greater progression of rotator cuff disease. Future prospective studies evaluating progression rates between dominant vs. nondominant shoulders are warranted.

Surgical Management of Pachyonychia Congenita in a 3-Year-Old.

Pachyonychia congenita is a rare genetic disorder characterized by hypertrophic nail plates, hyperkeratotic nail beds, and thickened hyponychium of the fingers and toes, impairing manual dexterity and resulting in poor aesthetics. The current body of literature describes various treatment modalities, but no singular approach has been defined as the gold standard. In this case, the authors employed different surgical techniques for treating pachyonychia congenita to evaluate the most effective approach. A 3-year-old boy presented with hypertrophic nail growth involving all digits of both hands and feet. Three surgical procedures were performed on the patient's fingers and toes using germinal matrix excision (GME) alone, GME plus partial sterile matrix excision (pSME), or GME plus complete sterile matrix excision (cSME). The digits treated with GME + cSME exhibited no recurrence of nail growth. Those treated with GME alone exhibited recurrence of hypertrophic nail growth, although their growth slowed. Excision of GME + cSME prevented recurrence of hypertrophic nails, while GME alone or with pSME led to slower-growing hypertrophic nails. Complete excision of the germinal and sterile matrices with skin graft closure may be a definitive treatment for pachyonychia congenita, but further studies are needed to validate these findings.

Anchorless Labral Repair for Recurrent Shoulder Instability in the Skeletally Immature.

The optimal treatment of recurrent shoulder instability in skeletally immature athletes remains controversial, especially if there is significant growth remaining. Some investigators advocate conservative treatment until patients are close to skeletal maturity, whereas others push for earlier surgery to avoid further damage. The objective of this technical note is to describe a technique for labral repair using an anchorless approach to avoid potential damage to the glenoid physis.