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.

Publication Rates of Podium Presentations at an Annual Orthopedic Surgery Resident and Fellow Research Symposium.

Introduction Research is an important aspect of residency and fellowship programs across the country. Developing strategies to foster research productivity is worthwhile. An annual research project is one strategy that some programs implement. Methods All resident and fellow (Sports Medicine, Adult Reconstruction, Spine) presentations at an orthopedic surgery department's annual research symposium from June 2016 through June 2021 were identified. Abstract titles, title keywords, and author names were searched in PubMed and Google Scholar to identify the presence of a peer-reviewed publication. Using the total number of research symposium presentations given, the publication rate was calculated for each year, as well as collectively for 2016 to 2021. In addition to publication rate, first author percent, number of citations, Altmetric score, and journal impact factor were recorded. Current PGY-2 through PGY-5 residents completed a survey to assess the perceived value of the annual research symposium. Results Ninety-eight research symposium presentations were reviewed (69 residents, 29 fellows). Forty (58%) resident studies were published and 28 were first-author publications (70%). Thirteen (45%) fellow studies were published and seven were first-author publications (54%). Combining residents and fellows, the overall publication rate was 54% (53/98), and 66% of these (35/53) were first-author publications. There was a wide range of published manuscript journal impact factors, Altmetric scores, and number of citations. All residents surveyed reported finding value in the research symposium. Conclusion The overall publication rate of presentations at an annual orthopedic surgery department research symposium between 2016 and 2021 was 54%, consistent with publication rates reported at National Orthopedic Surgery Society meetings. All residents reported finding value in the annual research symposium. The results of this study support the academic value of implementing a required annual research project and may provide a useful gauge to inform residency and fellowship curricula at other institutions.

Rehabilitation and return to sport criteria following surgical treatment of osteochondritis dissecans of the capitellum: a systematic review.

Background: Osteochondritis dissecans (OCD) of the capitellum is a well-described condition that most commonly affects adolescent throwing athletes and gymnasts. There is no gold standard rehabilitation protocol or timing for return to sport (RTS) after surgical management of OCD of the capitellum. Hypothesis/Purpose: The purpose of the study was to identify in the existing literature any criteria used for RTS following surgical treatment of OCD of the capitellum. The hypothesis was that surgeons would utilize length of time rather than functional criteria or performance benchmarks for RTS. Methods: Level 1 to 4 studies evaluating athletes who underwent surgery for OCD of the capitellum with a minimum follow-up of 1-year were included. Studies not describing RTS criteria, including less than 1-year follow-up, non-operative management only, and revision procedures were excluded. Each study was analyzed for RTS criteria, RTS rate, RTS timeline, sport played, level of competition, graft source (if utilized), and postoperative rehabilitation parameters. Assessment of bias and methodological quality was performed using the Coleman methodology score and RTS value assessment. Results: All studies reported a rehabilitation protocol with immobilization followed by bracing with progressive range of motion. RTS rate was 80.9% (233/288). The majority of studies reported using time-based criteria for RTS (11/15). The most commonly reported timeline was 6 months (range: 3-12 months). Conclusion: The overall RTS rate after surgical treatment of capitellar OCD is high with no consensus on RTS criteria. The two most consistent RTS criteria reported in the literature are return of elbow range of motion and healing demonstrated on postoperative imaging. There is a wide range of time to RTS in the literature, which may be sport dependent. Further research is needed to develop functional and performance-based metrics to better standardize RTS criteria and rehabilitation protocols.

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.

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.

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.

Return to Sport and Performance After Thumb Metacarpophalangeal Joint Collateral Ligament Surgery in the National Basketball Association.

Introduction Basketball players are at increased risk of thumb collateral ligament injury (ulnar collateral ligament (UCL) and radial collateral ligament (RCL)). Methods The National Basketball Association (NBA) players with thumb collateral ligament surgery were identified using publicly available data. Performance statistics, ligament injuries (UCL or RCL), return to sport (RTS) time, laterality, and injury dates were recorded. Cases were matched 1:1 with controls based on age (±1 year), body mass index (BMI), NBA experience (±1 year), and performance statistics prior to the index date. RTS was defined as playing in one NBA game postoperatively. Career longevity was evaluated. Summary statistics were calculated, and Student's t-tests (ɑ = 0.001) were performed. Results All 47 players identified with thumb collateral ligament surgeries returned to sport. Thirty-three players (age: 26.9 ± 3.0) had one year of postoperative NBA experience for performance analysis. Career length (case: 9.6 ± 4.1, control: 9.4 ± 4.3, p > 0.001) was not significantly different from controls (p > 0.001). The same season time to RTS (n = 20) was 7.1 ± 2.4 weeks. Off-season or season-ending surgery (n = 13) RTS time was 28.4 ± 18.7 weeks. Neither thumb collateral ligament (UCL, n = 7; RCL, n = 10; unknown, n = 16) had an identifiable difference between the groups when evaluating career length. Career length, games/season, and performance were not different for players who underwent surgery on their dominant thumb (63.6%, 21/33) compared to controls (p > 0.001). Conclusion RTS rate is high in NBA athletes undergoing thumb collateral ligament surgery. Players do not experience decreased performance or career length due to thumb collateral ligament surgery, regardless of a dominant or non-dominant thumb injury.

Shear wave elastography of the ulnar collateral ligament in division IA pitchers across a competitive collegiate season.

Background: The ulnar collateral ligament (UCL) is a commonly injured elbow stabilizer during throwing. Shear wave elastography (SWE) is a technique that may reveal structural changes in the UCL that are indicative of ligament health and injury risk. The purpose of this study was to assess preseason and inseason shear wave velocity (SWV) in the UCL of collegiate pitchers and to asses repeatability of this measurement technique in healthy volunteers. Methods: Seventeen collegiate baseball pitchers and 11 sex-matched volunteers were recruited. Two-dimensional SWE of the UCL was performed by a single radiologist. In pitchers, SWV was measured at the proximal, midsubstance, and distal UCL for dominant and nondominant elbows preseason, midseason, and postseason, and Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow questionnaire scores were recorded. In volunteers, SWV was measured at UCL midsubstance in dominant elbows at 3 separate occasions over 1 week. An independent samples t-test was used to compare preseason midsubstance measures between pitchers and the healthy volunteers. A mixed-model analysis of covariance (covaried on preseason measures) was used to compare SWV measures at the preseason, midseason, and postseason time points. A similar generalized linear model for nonparametric data was used to compare KJOC scores. Type-I error was set at P < .05. Results: Mean preseason midsubstance dominant arm UCL SWV did not significantly differ between the pitchers (5.40 ± 1.65 m/s) compared to the healthy volunteers (4.35 ± 1.45 m/s). For inseason measures among the pitchers, a decrease in midsubstance (-1.17 ± 0.99 m/s, P = .021) and proximal (-1.55 ± 0.91 m/s, P = .001) SWV was observed at midseason compared to preseason. The proximal measure was also observed to be significantly lower than the nondominant arm (-1.97 ± 0.95 m/s, P < .001). Proximal SWV remained reduced relative to the preseason and the postseason mark (-1.13 ± 0.91 m/s, P = .015). KJOC scores decreased at midseason compared to preseason (P = .003) but then increased to a similar preseason value at the postseason measurement (preseason = 92 ± 3, midseason = 87 ± 3, postseason = 91 ± 3). The repeatability coefficient of SWE in the volunteer cohort was 1.98 m/s. Conclusion: Decreased SWV in the proximal and midsubstance of the dominant arm UCL at midseason suggests structural changes indicative of increasing laxity or 'softening' of the UCL. Associated decline in KJOC scores suggests that these changes are associated with functional decline. Future studies with more frequent sampling would be invaluable to further explore this observation and its significance for predicting and managing UCL injury risk.

Orthopedists Report High Prevalence of Work-Related Pain and Low Ergonomic Awareness.

The purpose of this study was to determine the prevalence of work-related pain among practicing orthopedic surgeons, quantify knowledge of operating room (OR) and clinic ergonomics, and examine the use of occupational health resources. A survey was distributed, which included orthopedic surgeons from four states and five institutions. Data collected included years in practice, practice setting, orthopedic subspecialty, hours operating per week, days per week exercising, location and significance of pain, occupational health awareness, and use of OR/clinic ergonomics. One hundred ten of 194 surveys (56.7%) were completed, representing all orthopedic subspecialties. Eighty-three surgeons (75.5%) experienced pain because of occupational responsibilities. The lumbar spine, neck, and shoulders were the most affected areas. Seventeen (20.5%) identified this pain as significant. Ten (12.0%) stated that the pain did subjectively affect their OR performance. Hand surgeons had a statistically significant decreased risk of musculoskeletal pain (P=.007), whereas spine surgeons had a statistically significant increased risk of musculoskeletal pain (P=.028). Forty-nine (44.5%) were not aware of any institutional resources available if an injury was sustained at work. Forty-eight (43.6%) were aware of OR ergonomics, with 34 (30.9%) taking steps to make their OR more ergonomic. The vast majority of orthopedic surgeons experience pain as a result of occupational responsibilities. A clear lack of knowledge regarding institutional resources as well as OR ergonomics implementation was identified. Education in training, at the institutional and national levels, would expand surgeon knowledge and promote surgeon health. [Orthopedics. 2023;46(5):280-284.].

Blood Flow Restriction Therapy Preserves Lower Extremity Bone and Muscle Mass After ACL Reconstruction.

BACKGROUND: Muscle atrophy is common after an injury to the knee and anterior cruciate ligament reconstruction (ACLR). Blood flow restriction therapy (BFR) combined with low-load resistance exercise may help mitigate muscle loss and improve the overall condition of the lower extremity (LE). PURPOSE: To determine whether BFR decreases the loss of LE lean mass (LM), bone mass, and bone mineral density (BMD) while improving function compared with standard rehabilitation after ACLR. STUDY DESIGN: Randomized controlled clinical trial. METHODS: A total of 32 patients undergoing ACLR with bone-patellar tendon-bone autograft were randomized into 2 groups (CONTROL: N = 15 [male = 7, female = 8; age = 24.1 ± 7.2 years; body mass index [BMI] = 26.9 ± 5.3 kg/m2] and BFR: N = 17 [male = 12, female = 5; age = 28.1 ± 7.4 years; BMI = 25.2 ± 2.8 kg/m2]) and performed 12 weeks of postsurgery rehabilitation with an average follow-up of 2.3 ± 1.0 years. Both groups performed the same rehabilitation protocol. During select exercises, the BFR group exercised under 80% arterial occlusion of the postoperative limb (Delfi tourniquet system). BMD, bone mass, and LM were measured using DEXA (iDXA, GE) at presurgery, week 6, and week 12 of rehabilitation. Functional measures were recorded at week 8 and week 12. Return to sport (RTS) was defined as the timepoint at which ACLR-specific objective functional testing was passed at physical therapy. A group-by-time analysis of covariance followed by a Tukey's post hoc test were used to detect within- and between-group changes. Type I error; α = 0.05. RESULTS: Compared with presurgery, only the CONTROL group experienced decreases in LE-LM at week 6 (-0.61 ± 0.19 kg, -6.64 ± 1.86%; P < 0.01) and week 12 (-0.39 ± 0.15 kg, -4.67 ± 1.58%; P = 0.01) of rehabilitation. LE bone mass was decreased only in the CONTROL group at week 6 (-12.87 ± 3.02 g, -2.11 ± 0.47%; P < 0.01) and week 12 (-16.95 ± 4.32 g,-2.58 ± 0.64%; P < 0.01). Overall, loss of site-specific BMD was greater in the CONTROL group (P < 0.05). Only the CONTROL group experienced reductions in proximal tibia (-8.00 ± 1.10%; P < 0.01) and proximal fibula (-15.0±2.50%,P < 0.01) at week 12 compared with presurgery measures. There were no complications. Functional measures were similar between groups. RTS time was reduced in the BFR group (6.4 ± 0.3 months) compared with the CONTROL group (8.3 ± 0.5 months; P = 0.01). CONCLUSION: After ACLR, BFR may decrease muscle and bone loss for up to 12 weeks postoperatively and may improve time to RTS with functional outcomes comparable with those of standard rehabilitation.

Surgical Techniques and Clinical Outcomes for Medial Epicondylitis: A Systematic Review.

BACKGROUND: Medial epicondylitis (ME) is a pathological condition that arises in laborers and athletes secondary to repetitive wrist flexion and forearm pronation causing degeneration of the common flexor tendon. Although nonoperative management has demonstrated high rates of success, no standardized surgical technique has been established for situations when operative management is indicated. PURPOSE/HYPOTHESIS: The purpose of this study was to perform a systematic review of the surgical treatment options for ME and evaluate the associated patient-reported outcomes (PROs). We hypothesized that surgical management of ME would vary across studies but no technique would prove to be superior. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: Searches were conducted using PubMed, EMBASE, Cumulative Index of Nursing Allied Health Literature (CINAHL), SPORTDiscus, and Cochrane databases between 1980 and April 2020. All level 1 to 4 studies were identified that focused on surgical management and PROs in the setting of ME. Description of surgical technique and PROs were required for inclusion. Investigators independently dually abstracted and reviewed the studies for eligibility. Weighted means were calculated for demographic characteristics and available PROs. RESULTS: Overall, 851 studies were identified according to the search criteria. A total of 16 studies met the inclusion and exclusion criteria and therefore were evaluated. Three surgical techniques were found: open (13 studies), arthroscopic (2 studies), and percutaneous (1 study). Descriptions of the open technique were subdivided into those with (7 studies) and without (6 studies) common flexor tendon repair. Analysis included 479 elbows; patients were primarily male (58.3%) with a weighted mean age of 47.2 years. Weighted mean follow-up was 4.6 years. Tennis and manual laborer were the most common sport and occupation, respectively. Surgical success ranged from 63% to 100%, with a low complication rate of 4.3%. Success rates for return to sports and work were 81%-100% and 66.7%-100%, respectively, and only 1 study reported a return to work rate <90%. CONCLUSION: This systematic review demonstrates that surgical intervention for refractory ME often has a high success rate. Regardless of surgical technique performed, patients generally demonstrated an improvement in PROs, and an encouraging number returned to work with limited complications. Further investigation is necessary to determine superiority among open, arthroscopic, and percutaneous techniques.

Rehabilitation and Return to Sport Criteria Following Ulnar Collateral Ligament Reconstruction: A Systematic Review.

BACKGROUND: Ulnar collateral ligament (UCL) reconstruction (UCLR) is a viable treatment option for patients with UCL insufficiency, especially in the overhead throwing athlete. Within the clinical literature, there is still no universally agreed upon optimal rehabilitation protocol and timing for return to sport (RTS) after UCLR. HYPOTHESIS: There will be significant heterogeneity with respect to RTS criteria after UCLR. Most surgeons will utilize time-based criteria rather than functional or performance-based criteria for RTS after UCLR. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: All level 1 to 4 studies that evaluated UCLR with a minimum 1-year follow-up were eligible for inclusion. Studies lacking explicit RTS criteria, studies that treated UCL injury nonoperatively or by UCL repair, or studies reporting revision UCLR were excluded. Each study was analyzed for methodologic quality, RTS, timeline of RTS, and RTS rate. RESULTS: Overall, 1346 studies were identified, 33 of which met the inclusion criteria. These included 3480 athletes across 21 different sports. All studies reported RTS rates either as overall rates or via the Conway-Jobe scale. Timelines for RTS ranged from 6.5 to 16 months. Early bracing with progressive range of motion (ROM) (93.9%), strengthening (84.8%), and participation in an interval throwing program (81.8%) were the most common parameters emphasized in these rehabilitation protocols. While all studies included at least 1 of 3 metrics for the RTS value assessment, most commonly postoperative rehabilitation (96.97%) and set timing after surgery (96.97%), no article completely defined RTS criteria after UCLR. CONCLUSION: Overall, 93.9% of studies report utilizing bracing with progressive ROM, 84.8% reported strengthening, and 81.8% reported participation in an interval throwing program as rehabilitation parameters after UCLR. In addition, 96.97% reported timing after surgery as a criterion for RTS; however, there is a wide variability within the literature on the recommended time from surgery to return to activity. Future research should focus on developing a comprehensive checklist of functional and performance-based criteria for safe RTS after UCLR.

Return-to-Sport Time and Postoperative Performance in MLB Players Undergoing Wrist Arthroscopy.

BACKGROUND: Wrist injuries are common in sports and can result in prolonged time missed from playing. This study aimed to determine in Major League Baseball-players after arthroscopic wrist surgery the return-to-sport (RTS) rate, postoperative career length, and changes in performance compared with preoperative statistics and matched controls. METHODS: Major League Baseball players who underwent arthroscopic wrist surgery from 1990 to 2019 were identified. Demographic and performance data were collected for each player, and matched controls were identified. Comparisons were made via paired samples Student t tests. RESULTS: Twenty-six players (27 surgeries) were identified. The average age of included players was 28.9 ± 2.9 years with an average professional experience of 5.2 ± 3.4 years. Eighty-four percent of players returned to sport, with an average RTS time of 5.0 ± 2.7 months. A statistically significant (P < .05) decrease was seen in preoperative and postoperative runs scored per season (95.6 ± 91.3 vs 41.0 ± 29.5), batting average (BA) (0.270 ± 0.024 vs 0.240 ± 0.036), and average wins above replacement (WAR) (1.5 ± 1.1 vs 0.8 ± 0.9). CONCLUSION: Major League Baseball players who underwent arthroscopic wrist surgery had an RTS rate of 84% at a mean time of 5.0 months. There was no significant difference in performance statistics between cases postoperatively and matched controls overall, with some differences in performance found when categorized by position. However, a significant decrease in performance among case players was observed between preoperative and postoperative performance, including runs per season, BA, and WAR.

Return-to-Play Rates and Clinical Outcomes of Baseball Players After Concomitant Ulnar Collateral Ligament Reconstruction and Selective Ulnar Nerve Transposition.

BACKGROUND: Injury to the ulnar collateral ligament (UCL) leading to medial elbow instability and possible ulnar neuritis is common in overhead-throwing athletes. Treatment may require UCL reconstruction (UCLR) and concomitant ulnar nerve transposition (UNT) for those with preoperative ulnar neuritis. PURPOSE: To evaluate the return-to-play (RTP) rates, clinical outcomes, and rates of persistent ulnar neuritis after concomitant UCLR and UNT in a cohort of baseball players with confirmed preoperative ulnar neuritis. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Eligible patients were those who underwent concomitant UCLR and UNT at a single institution between January 2008 and June 2018 and who had a minimum of 2 years of follow-up. Additional inclusion criteria were athletes who identified as baseball players and who had a confirmed history of ulnar neuritis. Patients were contacted at a minimum of 2 years from surgery and assessed with the Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow Score, Andrew-Timmerman (A-T) Elbow Score, Mayo Elbow Performance Score (MEPS), Single Assessment Numeric Evaluation (SANE) score, and a custom RTP questionnaire. RESULTS: Included were 22 male baseball players with a mean age of 18.9 ± 2.1 years (range, 16-25 years). The mean follow-up was 6.1 ± 2.4 years (range, 2.5-11.7 years). Preoperatively, all 22 patients reported ulnar nerve sensory symptoms, while 4 (18.2%) patients reported ulnar nerve motor symptoms. At the final follow-up, 7 (31.8%) patients reported persistent ulnar nerve sensory symptoms, while none of the patients reported persistent ulnar nerve motor symptoms. Overall, 16 (72.7%) players were able to return to competitive play at an average of 11.2 months. The mean postoperative patient-reported outcome scores for the KJOC Shoulder and Elbow Score, MEPS, A-T Elbow Score, and SANE score were 77.9 ± 20.9 (range, 14-100), 92.7 ± 12.7 (range, 45-100), 86.1 ± 17.1 (range, 30-100), and 85.5 ± 14.8 (range, 50-100), respectively. CONCLUSION: This study demonstrated that after concomitant UCLR and UNT for UCL insufficiency and associated ulnar neuritis, baseball players can expect reasonably high RTP rates and subjective outcomes; however, rates of persistent sensory ulnar neuritis can be as high as 30%.

Performance and Return to Sport After Open Fracture in National Football League Players.

BACKGROUND: Open fractures are debilitating injuries for athletes. No prior studies have investigated open fractures in National Football League (NFL) players. PURPOSE: To compare outcomes after open fracture in NFL players in terms of (1) time to return to sport (RTS), (2) postinjury career length and games played per season, (3) postinjury performance, and (4) postinjury performance compared with matched controls. STUDY DESIGN: Retrospective comparative series; Level of evidence, 3. METHODS: Publicly available records were used to identify NFL players who had sustained an open fracture between 1970 and 2018. Controls were matched to injured players by age, experience, position, and preinjury performance. RTS was defined as playing in at least 1 NFL game after open fracture. Comparisons between injured and control players were made using the paired-samples Student t test. RESULTS: Injuries in 37 players were analyzed (age, 27.2 ± 3.6 years; experience, 4.4 ± 3.6 seasons).  The 3 most common locations for open fracture were the tibia/fibula (n = 16), hand/finger (n = 12), and forearm/wrist (n = 3). A total of 30 (81%) players had a mean time of RTS of 9.3 ± 8.2 months after open fracture; of these players, 4 (13.3%) who sustained hand/finger open fracture did not undergo surgical treatment. There was no difference in postinjury career length or games played per season between control and injured players. Postinjury performance was similar to preinjury performance in injured players, and postinjury performance scores were similar between injured and control players. There were significant differences between players who sustained upper extremity and lower extremity open fractures in RTS time (4.0 ± 4.8 vs 14.6 ± 7.4 months, respectively; P = .00007) and postinjury performance (6.4 ± 4.3 vs 3.3 ± 2.1, respectively; P = .03). CONCLUSION: RTS after open fracture among NFL players was high. Players who sustained an open fracture had similar games played per season, career length, and performance compared with matched controls. Players who sustained an upper extremity open fracture had a faster RTS time, higher RTS rate, and improved postinjury performance compared with players who sustained a lower extremity open fracture.

Rehabilitation and Return-to-Play Criteria After Fresh Osteochondral Allograft Transplantation: A Systematic Review.

BACKGROUND: Fresh osteochondral allograft (OCA) is a treatment option that allows for the transfer of size-matched allograft cartilage and subchondral bone into articular defects of the knee. Although long-term studies show good functional improvement with OCA, there continues to be wide variability and a lack of consensus in terms of postoperative rehabilitation protocols and return to sport. PURPOSE: To systematically review the literature and evaluate the reported rehabilitation protocols after OCA of the knee, including weightbearing and range of motion (ROM) restrictions as well as return-to-play criteria. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: PubMed, EMBASE, Cumulative Index of Nursing Allied Health Literature, SPORTDiscus, and Cochrane databases were searched according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for studies on knee OCA. Studies were included if they reported return-to-play data or postsurgical rehabilitation protocols. RESULTS: A total of 62 studies met the inclusion criteria, with a total of 3451 knees in 3355 patients. Concomitant procedures were included in 30 of these studies (48.4%). The most commonly cited rehabilitation protocols included weightbearing restrictions and ROM guidelines in 100% and 90% of studies, respectively. ROM was most commonly initiated within the first postoperative week, with approximately half of studies utilizing continuous passive motion. Progression to weightbearing as tolerated was reported in 60 studies, most commonly at 6 weeks (range, immediately postoperatively to up to 1 year). Of the 62 studies, 37 (59.7%) included an expected timeline for either return to play or return to full activity, most commonly at 6 months (range, 4 months to 1 year). Overall, 13 studies (21.0%) included either objective or subjective criteria to determine return to activity within their rehabilitation protocol. CONCLUSION: There is significant heterogeneity for postoperative rehabilitation guidelines and the return-to-play protocol after OCA of the knee in the literature, as nearly half of the included studies reported use of concomitant procedures. However, current protocols appear to be predominantly time-based without objective criteria or functional assessment. Therefore, the authors recommend the development of objective criteria for patient rehabilitation and return-to-play protocols after OCA of the knee.

Long-Term Sports Participation and Satisfaction After UCL Reconstruction in Amateur Baseball Players.

BACKGROUND: While the incidence of ulnar collateral ligament reconstruction (UCLR) has increased across all levels of play, few studies have investigated the long-term outcomes in nonprofessional athletes. PURPOSE: To determine the rate of progression to higher levels of play, long-term patient-reported outcomes (PROs), and long-term patient satisfaction in nonprofessional baseball players after UCLR. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We evaluated UCLR patients who were nonprofessional baseball athletes aged <25 years at a minimum of 5 years postoperatively. Patients were assessed with the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow Score (KJOC), the Timmerman-Andrews (T-A) Elbow score, the Mayo Elbow Performance Score (MEPS), and a custom return-to-play questionnaire. RESULTS: A total of 91 baseball players met the inclusion criteria, and 67 (74%) patients were available to complete the follow-up surveys at a mean follow-up of 8.9 years (range, 5.5-13.9 years). At the time of the surgery, the mean age was 18.9 ± 1.9 years (range, 15-24 years). Return to play at any level was achieved in 57 (85%) players at a mean time of 12.6 months. Twenty-two (32.8%) of the initial cohort returned to play at the professional level. Also, 43 (79.1%) patients who initially returned to play after surgery reported not playing baseball at the final follow-up; of those patients, 12 reported their elbow as the main reason for eventual retirement. The overall KJOC, MEPS, and T-A scores were 82.8 ± 18.5 (range, 36-100), 96.7 ± 6.7 (range, 75-100), and 91.9 ± 11.4 (range, 50-100), respectively . There was an overall satisfaction score of 90.6 ± 21.5 out of 100, and 64 (95.5%) patients reported that they would undergo UCLR again. CONCLUSION: In nonprofessional baseball players after UCLR, there was a high rate of progression to higher levels of play. Long-term PRO scores and patient satisfaction were high. The large majority of patients who underwent UCLR would undergo surgery again at long-term follow-up, regardless of career advancement.

The Utility of Continuous Passive Motion After Anterior Cruciate Ligament Reconstruction: A Systematic Review of Comparative Studies.

BACKGROUND: The application of continuous passive motion (CPM) after anterior cruciate ligament reconstruction (ACLR) was popularized in the 1990s, but advancements in the understanding of ACLR rehabilitation have made the application of CPM controversial. Many sports medicine fellowship-trained surgeons report using CPM machines postoperatively. PURPOSE: To determine the efficacy of CPM use for recovery after ACLR with respect to knee range of motion (ROM), knee swelling, postoperative pain, and postoperative complications. STUDY DESIGN: Systematic review; Level of evidence, 3. METHODS: The PubMed (MEDLINE), EMBASE, Cochrane, Cumulative Index of Nursing, and Allied Health Literature databases were searched from inception to January 1, 2020, for studies with evidence levels 1 to 3 on the use of CPM for ACLR rehabilitation. Included studies were those that comparatively evaluated postoperative outcomes after ACLR between at least 2 groups of patients, with 1 having received CPM rehabilitation and the other not having received CPM. RESULTS: A total of 12 studies from 1989 to 2019 met the inclusion criteria. These studies included 808 patients who underwent ACLR. There was no evidence of CPM improving knee stability, final postoperative ROM, or subjective pain scores. Additionally, CPM did not lead to decreased muscle atrophy or improved International Knee Documentation Committee scores. Regarding pain medication intake during postoperative hospitalization, 2 studies found that the CPM group used less pain medication, 1 study found the CPM group used more pain medication, and 1 study found that there was no difference between the 2 groups. Complications varied widely, with 2 of 12 studies reporting complications that required a return to the operating room. CONCLUSION: A clinical benefit of postoperative CPM use after ACLR was not identified in this review. While our systematic review identified a number of studies that suggest CPM use may be associated with lower usage of pain medication in hospitalized patients, this cannot be confirmed without further investigation with standardized CPM protocols and larger sample sizes. Routine CPM use after ACLR was not supported by this systematic review.

Double Tension Slide Technique as a Novel Repair for Distal Biceps Tendon Tear: A Biomechanical Evaluation.

Background A comparative biomechanical analysis of two distal biceps tendon repair techniques was performed: a single suture tension slide technique (TST) and two suture double tension slide (DTS) technique. Methodology Ten matched pairs of fresh frozen human cadaveric elbows (20 elbows) were randomly separated into two cohorts for distal biceps tendon repair. One cohort underwent the TST, and the other underwent the DTS technique. The tendon was preconditioned with cyclic loading from 0° to 90° at 0.5 Hz for 3,600 cycles with a 50 N load. The specimens were then loaded to failure at a rate of 1 mm/s. The difference in the load to failure between the groups was analyzed using the Student's t test. The mode of failure was compared between groups using the chi-square test. All p-values were reported with significance set at p < 0.05. Results Overall, 77.8% of the included matched pairs demonstrated greater load to failure in the DTS group. The mean load to failure in the DTS group was 383.3 ± 149.3 N compared to 275.8 ± 98.1 N in the TST group (p = 0.13). The DTS specimens failed at the tendon (5/9), suture (3/9), and bone (1/9). The TST specimens failed at the tendon (4/9) and suture (5/9) only. There was no significant difference in failure type between groups (p = 0.76). Conclusions DTS demonstrates a similar to greater load to failure compared to TST with a trend towards statistical significance. The redundancy provided by the second suture has an inherent advantage without compromising the biomechanical testing.

Extensor Tenosynovitis due to Mycobacterium marseillense Infection in a Renal Transplant Recipient.

Renal transplant recipients are at an increased risk of atypical nontuberculous mycobacterial (NTM) infections. Infections caused by NTM are uncommon in the general population, rarely occurring in immunocompetent individuals. NTM infections are an uncommon cause of tenosynovitis. Mycobacterium marseillense is a rare, atypical mycobacteria that has been reported to cause pulmonary and cutaneous infections; however, no previous reports of this pathogen causing tenosynovitis exist. This case reports a 73-year-old male renal transplant recipient who presented with chronic extensor tenosynovitis of the right hand caused by M marseillense. The patient was treated with radical extensor tenosynovectomy and 6 months of antibiotic treatment. A review of literature on tenosynovitis caused by atypical mycobacteria was performed. The patient successfully responded to treatment with no complications or recurrence of infection at the 18-month follow-up. Tenosynovitis of the hand caused by atypical mycobacteria is rare. A high index of suspicion is required to prevent a delay in diagnosis, particularly in immunocompromised individuals.