Outcomes of Surgical Treatment for Multiligament Knee Injuries in a Cohort Including Competitive Athletes With Long-Term Follow-Up.

Background: There is a paucity of outcomes data on surgical reconstruction for multiligament knee injury (MLKI) in the orthopaedic literature. Purpose: To examine functional and return-to-sports (RTS) outcomes and revision rates after single-stage reconstruction for MLKIs in a cohort containing a large proportion of competitive athletes over a 20-year period. Study Design: Case series; Level of evidence, 4. Methods: We identified all patients at our institution who underwent surgical reconstruction for an anterior cruciate ligament (ACL) or bicruciate (ACL-posterior cruciate ligament) MLKI between 2001 and 2020 and had ≥2 years of postoperative outcome data. Patient-reported outcomes were evaluated using the International Knee Documentation Committee (IKDC) form, a surgical satisfaction survey, and questions about subsequent knee surgery and RTS administered via telephone. Summary statistics for all outcomes data were calculated, and predictors of IKDC scores at follow-up were examined using univariable linear regression. Results: Out of 151 patients eligible for this study, outcomes data were collected in 119 patients (79%). The mean follow-up time was 8.3 ± 4.4 years, and the mean IKDC score at follow-up was 79 ± 17. A total of 83 competitive athletes were included; 62 of these athletes attempted to return to preinjury sport. Among the 62 who attempted RTS, 50 (81%) were successful, and 12 were unable to return due to limitations from their surgery. At follow-up, 112 of the overall cohort of 119 patients (94%) were either satisfied or very satisfied with their surgical outcome, and 91% stated the surgery met or exceeded their expectations. In addition, 24% had subsequent ipsilateral knee operations after their index multiligament knee reconstruction. Older age at surgery and female sex were associated with worse IKDC scores at follow-up. Conclusion: Despite the severity of the injuries in our cohort, we found high levels of patient-reported function and a high rate of successful RTS in the competitive athletes. Older age and female sex were associated with worse patient-reported knee function at follow-up.

The Development and Execution of An Orthopaedic Sports Medicine Fellowship Surgical Skills Assessment.

BACKGROUND: Assessment of orthopaedic surgery trainees is traditionally based on subjective evaluation by faculty. The recent push for value-based health care has placed a premium on improving patient outcomes. As a result, surgical training evaluations for orthopaedic trainees are evolving to include more objective measures to evaluate competency. PURPOSE: To develop and subsequently demonstrate the efficacy of a novel surgical skills assessment for orthopaedic sports medicine fellows. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A team of 14 fellowship-trained orthopaedic sports medicine surgeons developed objective scoring rubrics for anterior cruciate ligament reconstruction (ACLR) and rotator cuff repair (RCR) using a modified Delphi process. Rubrics were designed based on 10 surgical steps with a grading scale (1-5) based on core competencies with a maximum summative score of 50. Fourteen orthopaedic fellows across a regionally diverse group of sports medicine-accredited fellowship programs were invited to complete both an ACLR and RCR in a surgical skills laboratory at the beginning and end of their fellowship year. Individual surgical steps, overall performance, and total procedure time were evaluated by a single sports medicine surgeon for both sessions. RESULTS: Thirteen of 14 fellows completed both pre- and post-fellowship assessments. For the ACLR procedure, the pre-fellowship mean summative score was 25.4 (SD, 4.4) and the post-fellowship mean summative score was 38.6 (SD, 4.1), which was a statistically significant improvement (P < .001). For the RCR procedure, the pre-fellowship mean summative score was 26.6 (SD, 5.4) and the post-fellowship mean summative score was 38.8 (SD, 4.3), which was also a statistically significant improvement (P < .001). The mean time to completion for the ACLR procedure was 82.3 minutes (SD, 4.3 minutes) pre-fellowship, which improved to 69.7 minutes (SD, 11.6 minutes) post-fellowship (P = .002). The mean time to completion for the RCR procedure was 85.5 minutes (SD, 5.0 minutes) pre-fellowship, which improved to 76.4 minutes (SD, 7.0 minutes) post-fellowship (P < .001). CONCLUSION: This surgical skills program represents the first standardized and reproducible instrument for the evaluation of 2 arthroscopic sports medicine procedures in the United States. Orthopaedic sports medicine fellows improved significantly in aggregate over their fellowship year with regard to the ACLR and RCR. The described program has the potential to serve as both a training tool and formal orthopaedic sports medicine fellow assessment.

The Relationship Between All-Suture and Solid Medial-Row Anchors and Patient-Reported Outcomes for Double-Row Suture Bridge Rotator Cuff Repair.

Background: The use of all-suture anchors for rotator cuff repair is increasing. Potential benefits include decreased bone loss and decreased damage to the chondral surface. Minimal evidence exists comparing outcomes among medial-row anchor fixation methods in double-row suture bridge rotator cuff repair. Purpose: To compare the clinical outcomes between all-suture and solid medial-row anchors in double-row suture bridge rotator cuff repair. Study Design: Case series; Level of evidence, 4. Methods: A total of 352 patients (mean age at surgery, 60.3 years) underwent double-row suture bridge rotator cuff repair at our institution. Patients were separated into 2 groups based on whether they underwent all-suture (n = 280) or solid (n = 72) anchor fixation for the medial row. Outcomes data were collected via an ongoing longitudinal data repository or through telephone calls (minimum follow-up time, 2.0 years; mean follow-up time, 3.0 years). Outcomes were evaluated using the American Shoulder and Elbow Surgeons (ASES) standardized shoulder assessment form and the visual analog scale (VAS). The same rehabilitation protocol was administered to all patients. The proportions of patients meeting previously published Patient Acceptable Symptom State (PASS) thresholds were calculated for the outcome measures, and outcome scores and the proportions of patients meeting PASS thresholds between groups were compared using linear and logistic regression, respectively. Results: The groups did not differ in terms of age at surgery, sex distribution, rotator cuff tear size, or number of medial-row anchors used. The solid anchor group had a longer follow-up time compared with the all-suture anchor group (3.6 ± 0.7 vs 2.8 ± 0.8 years, respectively; P < .01). After controlling for follow-up time, the solid and all-suture anchor groups did not differ in ASES scores (89.6 ± 17.8 vs 88.8 ± 16.7, respectively; P = .44) or VAS scores (1.1 ± 2.1 vs 1.2 ± 2.1, respectively; P = .37). Similarly, after controlling for follow-up time, the solid and all-suture anchor groups did not differ in the proportions of patients meeting PASS cutoffs for the ASES (84.7% vs 80.7%, respectively; P = .44) or the VAS (80.6% vs 75.0%, respectively; P = .83). Conclusion: Double-row suture bridge rotator cuff repair using all-suture anchors for medial-row fixation demonstrated similar excellent clinical outcomes to rotator cuff repair using solid medial-row anchors.

Long-term Outcomes of Multiligament Knee Injuries in American Football Players.

BACKGROUND: Long-term outcomes for isolated anterior cruciate ligament (ACL) reconstructions in competitive American football athletes are well reported in the literature, but little data currently exist regarding multiligament knee injury (MLKI) reconstruction outcomes. PURPOSE: To examine patient-reported and return-to-sport outcomes of competitive American football athletes who underwent primary, single-staged, multiligament knee reconstruction. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We identified patients from our institution's prospectively collected data repository between 2001 and 2020 who underwent single-staged surgical reconstruction of an MLKI sustained during competitive participation in American football. We assessed patient-reported outcomes at a minimum of 2 years after surgery using the International Knee Documentation Committee (IKDC) Subjective Knee Form and questions regarding surgical satisfaction and return to sport. Successful return to sport was defined as a return to preinjury level of competition. We summarized all outcome data and compared outcomes between 2-ligament and >2-ligament groups and between ACL-only MLKI injury and bicruciate MLKI injury groups using independent t test for IKDC scores and chi-square test for return to sport. Additionally, we evaluated predictors of postoperative IKDC scores using linear regression and predictors of return to sport using logistic regression. RESULTS: Outcome data were successfully collected for 53 of 73 total eligible patients (73%; mean follow-up time, 7.7 ± 4.0 years; all male; mean age at surgery, 18.1 ± 2.7 years). The mean postoperative IKDC score was 84 ± 16. The most common level of preinjury competition was high school (n = 36; 68%), followed by college (n = 10; 19%). Seven patients did not return to sport competition at any level due to limitations from their knee surgery, and 82% of patients that attempted to return to preinjury level of sport were able to do so. A total of 50 patients (94%) were satisfied or very satisfied with their surgical outcome. The 2-ligament (n = 39) and >2-ligament (n = 14) groups did not significantly differ in IKDC scores (P = .96) or proportions with successful return to sport (P = .77). Similarly, the ACL-MLKI injury (n = 39) and bicruciate MLKI injury (n = 14) groups did not significantly differ in IKDC scores (P = .89) or proportions with successful return to sport (P = .77). Age and body mass index were not significantly associated with IKDC scores or successful return to sport at follow-up (all P > .05). CONCLUSION: This study may represent the largest cohort of competitive American football athletes evaluated for longitudinal outcomes after multiligament knee reconstruction. Despite the severity of these injuries, we found good knee-related function and that the large majority of athletes who attempted to return to sport were successful. The majority of athletes (94%) were satisfied with their operative treatment.

Ulnar Collateral Ligament Repair With Suture Tape Augmentation: Can You Overtighten?

BACKGROUND: There has been a renewed interest and, recently, wider implementation of ulnar collateral ligament (UCL) repair in throwing athletes because of improvement in ligament repair technology and corresponding outcome data. PURPOSE: To compare the biomechanical parameters and failure mode between 2 brace-tightening techniques for UCL repair. STUDY DESIGN: Controlled laboratory study. METHODS: Eleven matched pairs of cadaveric arms were procured. One limb from each pair underwent UCL repair with suture tape augmentation with either (1) attempted restoration of physiologic ligament tension or (2) maximal tension. Each specimen was subjected to 10 cycles of subfailure valgus torque at 90º of flexion in the intact state after UCL avulsion and then after UCL repair. Specimens were then torqued to failure. Articular contact mechanics, linear gap distance, angular displacement, failure torque, failure stiffness, and suture tape pull-through length were recorded. Two-way analysis of variance and paired t tests were used to test for statistical differences. RESULTS: There was a significant effect (P = .01) of tightening on joint contact area. There was a significant decrease in gap distance (P = .03) and angular displacement (P = .004) from the torn condition to the repaired condition for the maximum tension group, without a significant difference in gap distance from the intact condition. Failure torque and stiffness were not significantly different between groups, although there was a significant difference (P = .001) in the overall suture tape pull-through length. CONCLUSION: Although there are potential physiologic changes at time zero-including significant decreases in contact area, normalized gap distance, and normalized angular displacement with maximal tension repair-examination of failure biomechanics suggests that these effects may be mitigated over time within the construct by suture tape pull-through at the tape-anchor interface. Neither method of UCL repair with suture tape augmentation resulted in overconstraint of the elbow joint compared with the native ligament biomechanics. CLINICAL RELEVANCE: As more long-term outcome data from UCL repair with suture tape augmentation emerge, there will be wider implementation with various techniques to tension the suture tape. Examining the potential biomechanical sequelae of the UCL repair construct applied under maximal tension will help further refine recommendations for surgeons who utilize this technique for UCL repair.

Outcomes of Double-Row Rotator Cuff Repair Using a Novel All-Suture Soft Anchor Medial Row.

Background: Few studies have examined the short-term clinical outcomes of rotator cuff repair (RCR) with all-suture anchors for medial row anchor fixation. Purpose: To evaluate clinical outcomes of double-row suture bridge RCR using a novel all-suture medial row anchor. Study Design: Case series; Level of evidence, 4. Methods: We enrolled 179 patients before double-row suture bridge RCR (mean age at surgery, 60.0 years; 63% male patients) at a single institution. All patients underwent RCR with all-suture anchor fixation for the medial row and solid anchor fixation for the lateral row. Preoperative (baseline) and follow-up (minimum follow-up time of 2 years; mean, 2.5 years) clinical outcomes were compared using the American Shoulder and Elbow Surgeons (ASES) score and a 10-point numeric pain rating scale (NPRS). We calculated the proportions of patients meeting previously published Patient Acceptable Symptom State (PASS) thresholds for the ASES (≥78.0) and NPRS (≤1.7). We further compared baseline and follow-up outcome scores and the proportions of patients meeting PASS thresholds using paired t tests and McNemar tests, respectively, and calculated effect size to quantify the magnitude of change from baseline to follow-up. Results: Values significantly improved from baseline to follow-up for ASES (from 45.3 ± 19.8 to 87.3 ± 17.1) and NPRS (from 5.2 ± 2.5 to 1.4 ± 2.1). The proportion of patients meeting PASS thresholds also significantly improved for the ASES (from 6% to 77%) and the NPRS (from 7% to 72%). The magnitude of baseline to follow-up change for all measures was large (all effect sizes ≥1.5). Conclusion: Our study demonstrated excellent short-term clinical outcomes and substantial improvements for patients undergoing double-row suture bridge RCR with all-suture anchors for medial row fixation.

Clinical outcomes of osteochondritis dissecans lesions of the capitellum treated with arthroscopy with a mean follow-up period of 8.3 years.

BACKGROUND AND HYPOTHESIS: Although numerous studies exist evaluating the short-term clinical outcomes of patients who have undergone elbow arthroscopy for osteochondritis dissecans (OCD) of the capitellum, the literature on minimum 2-year clinical outcomes in a large cohort of patients is limited. We hypothesized that the clinical outcomes of patients treated arthroscopically for OCD of the capitellum would be favorable, with improved postoperative subjective functional and pain scores and with an acceptable return-to-play rate. METHODS: A retrospective analysis of a prospectively collected surgical database was performed to identify all patients treated surgically for OCD of the capitellum at our institution from January 2001 to August 2018. The inclusion criteria for this study included a diagnosis of OCD of the capitellum treated arthroscopically with a minimum 2-year follow-up period. The exclusion criteria included any prior surgical treatment on the ipsilateral elbow, missing operative reports, and cases in which any portion of the surgical procedure was performed in an open manner. Follow-up was performed by telephone using multiple patient-reported outcome questionnaires: American Shoulder and Elbow Surgeons-Elbow (ASES-e), Andrews-Carson, and Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow Score (KJOC) questionnaires and our institution-specific return-to-play questionnaire. RESULTS: After the inclusion and exclusion criteria were applied to our surgical database, 107 eligible patients were identified. Of these, 90 were successfully contacted, for a follow-up rate of 84%. The mean age was 15.2 years, and the mean follow-up time was 8.3 years. A subsequent revision procedure was performed in 11 patients, for a 12% failure rate in these patients. The ASES-e pain score was an average of 4.0 on a maximum pain scale of 100, the ASES-e function score was an average of 34.5 of a maximum of 36, and the surgical satisfaction score was an average of 9.1 of 10. The average Andrews-Carson score was 87.1 of 100, and the average KJOC score for overhead athletes was 83.5 of 100. Additionally, of the 87 patients evaluated who played sports at the time of their arthroscopy, 81 (93%) returned to play. CONCLUSION: This study demonstrated an excellent return-to-play rate and satisfactory subjective questionnaire scores with a 12% failure rate following arthroscopy for OCD of the capitellum with a minimum 2-year follow-up period.

The Clinician's Guide to Baseball Pitching Biomechanics.

CONTEXT: Improper baseball pitching biomechanics are associated with increased stresses on the throwing elbow and shoulder as well as an increased risk of injury. EVIDENCE ACQUISITION: Previous studies quantifying pitching kinematics and kinetics were reviewed. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 5. RESULTS: At the instant of lead foot contact, the elbow should be flexed approximately 90° with the shoulder at about 90° abduction, 20° horizontal abduction, and 45° external rotation. The stride length should be about 85% of the pitcher's height with the lead foot in a slightly closed position. The pelvis should be rotated slightly open toward home plate with the upper torso in line with the pitching direction. Improper shoulder external rotation at foot contact is associated with increased elbow and shoulder torques and forces and may be corrected by changing the stride length and/or arm path. From foot contact to maximum shoulder external rotation to ball release, the pitcher should demonstrate a kinematic chain of lead knee extension, pelvis rotation, upper trunk rotation, elbow extension, and shoulder internal rotation. The lead knee should be flexed about 45° at foot contact and 30° at ball release. Corrective strategies for insufficient knee extension may involve technical issues (stride length, lead foot position, lead foot orientation) and/or strength and conditioning of the lower body. Improper pelvis and upper trunk rotation often indicate the need for core strength and flexibility. Maximum shoulder external rotation should be about 170°. Insufficient external rotation leads to low shoulder internal rotation velocity and low ball velocity. Deviation from 90° abduction decreases the ability to achieve maximum external rotation, increases elbow torque, and decreases the dynamic stability in the glenohumeral joint. CONCLUSION: Improved pitching biomechanics can increase performance and reduce risk of injury. SORT: Level C.

Clinical outcomes and return to play in softball players following SLAP repair or biceps tenodesis.

BACKGROUND: Shoulder pain due to labral tears and biceps tendonitis is commonly found in softball players. Surgical options include labral repair and biceps tenodesis. Although past studies are limited by heterogeneous study groups from multiple sports, this is the first study that assesses clinical outcomes and return to play rates for fast-pitch softball players. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate the clinical outcomes and return to play for fast-pitch softball players treated for a superior labrum anterior posterior (SLAP) tear and recalcitrant biceps tendonitis with a biceps tenodesis compared with a traditional SLAP repair. We hypothesized that the biceps tenodesis would have comparable outcomes with a faster return to play compared with SLAP repair. METHODS: We performed a retrospective analysis on fast-pitch softball players treated surgically for SLAP tear, recalcitrant biceps tendonitis, or a combination between 2001 and 2019 at our institution. Inclusion criteria were fast-pitch softball players who underwent biceps tenodesis or a SLAP repair with greater than 2-year follow-up. Exclusion criteria involved slow-pitch softball players, patients with less than 2-year follow-up, and patients who had undergone concomitant procedures on the ipsilateral shoulder at the time of SLAP repair or biceps tenodesis. Follow-up was either self-reported through OBERD, a patient-reported outcomes (PRO)-managing software, or achieved over the phone. Follow-up data included American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, Andrews Carson Score, Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow Score, Numeric Rating Scale for Pain, and our institution-specific return-to-play questionnaire. We statistically compared players who underwent biceps tenodesis or a SLAP repair, and compared pitchers with position players using Student t tests and Fisher exact test with statistical significance determined to be P < .05. RESULTS: From 60 eligible patients identified, follow-up outcome data were successfully captured for 47 (78%). Of the 18 SLAP repair patients, 17 (94%) returned to full competition at an average of 7.9 months. Of the 29 patients who underwent biceps tenodesis, 27 (93%) returned to full competition at an average of 7.1 months. Statistical analysis of PRO scores for each group found no significant differences between any of the measures used to evaluate patient outcomes, including no statistical difference in pitchers compared with position players. CONCLUSION: In conclusion, this study demonstrated comparable outcomes between SLAP repairs and biceps tenodesis procedures among our study group of fast-pitch softball players. There was no significant difference between RTP times between the 2 groups.

Intersurgeon Consistency of Ulnar Collateral Ligament Repair With Internal Brace: A Biomechanical Analysis.

Background: Injury to the ulnar collateral ligament (UCL) of the medial elbow has been treated successfully with ligament repair augmented with internal brace. Previous work has shown that this procedure does not overconstrain the ulnohumeral joint; however, the procedures were conducted by a single surgeon, which controlled for anchor placement and graft tensioning. Purpose/Hypothesis: Our purpose was to evaluate the reproducibility of contact mechanics and joint torque after UCL repair with internal brace as performed by different surgeons compared with repair by a single surgeon. It was hypothesized that there would be no significant difference in elbow contact mechanics, valgus torque, or torsional stiffness between the 2 groups. Study Design: Controlled laboratory study. Methods: Nine pairs of fresh-frozen cadaveric elbows were tested biomechanically under 3 conditions: UCL-intact (UCL-I), UCL-deficient (UCL-D), and UCL-repaired with internal brace augmentation (UCLR-IB). For each pair, 1 elbow was repaired by a single surgeon, and the contralateral elbow was repaired by 1 of 9 other surgeons. Testing consisted of valgus torsion between 0° and 5° with the elbow positioned at 90° of flexion. Ulnohumeral contact mechanics and overall joint torque and stiffness were measured and compared between surgeon groups. Results: There were no statistically significant differences between the single-surgeon and multiple-surgeon groups regarding contact area (P = .83), contact force (P = .27), peak pressure (P = .26), or peak force (P = .30); however, contact pressure was significantly affected (P = .02) by surgeon group. Compared with UCL-I, both UCL-D and UCLR-IB conditions had a significant overall effect on contact area (P = .004) and contact force (P = .05); however, contact pressure (P = .56), peak pressure (P = .27), and peak force (P = .24) were not affected by injury condition. Measurements of elbow torque (P = .28) and stiffness (P = .98) were not significantly different between surgeon groups. Conclusion: UCL repair with internal brace provided consistent results among several surgeons when compared with a single surgeon. The procedure did not lead to joint overconstraint while also returning the ligament to near-intact levels of resisting valgus stress. Clinical Relevance: UCL repair with internal brace augmentation is a reproducible surgical technique that has good clinical outcomes in the literature.

Clinical Outcomes of Ulnar Collateral Ligament Surgery in Nonthrowing Athletes.

BACKGROUND: Ulnar collateral ligament (UCL) surgery continues to demonstrate excellent clinical outcomes and a high return-to-play (RTP) rate with a low complication rate. Recent studies have demonstrated similar clinical outcomes for baseball players who have undergone either UCL reconstruction or UCL repair. In comparison, few studies have assessed the clinical outcomes of UCL surgery for nonthrowing athletes. PURPOSE/HYPOTHESIS: The primary objective of this study is to provide clinical outcomes of UCL surgery performed in nonthrowing athletes at a single institution with a minimum 2-year follow-up. Our hypothesis was that these patients would have similar clinical outcomes, complication rates, and RTP rates when compared with throwing athletes. LEVEL OF EVIDENCE: Case series; Level of evidence, 4. METHODS: From our longitudinal elbow registry, 40 nonthrowing athletes were identified who underwent UCL surgery (repair or reconstruction) between 2011 and 2019. Participant characteristics were recorded: age, sex, laterality, arm dominance, sport, level of competition, and type of surgery (UCL repair or reconstruction). Outcomes included RTP rate and average time, American Shoulder and Elbow Surgeons (ASES) scores, and complications. RESULTS: From the 40 patients eligible for inclusion in this study with a minimum 2-year follow-up, 37 (93%) were successfully contacted: 16 male (43%) and 21 female (57%). Mean ± standard deviation age at the time of surgery was 18.0 ± 3.7 years. From the 37 technical procedures, 28 (76%) were UCL repairs and 9 (24%) were UCL reconstructions. For these patients, 15 (41%) had partial tears, 20 (54%) had complete tears, 1 (3%) had a medial epicondyle avulsion, and 1 (3%) had an unspecified pathology. Sports included football (n = 11), gymnastics (11), cheerleading (7), wrestling (4), volleyball (2), basketball (1), and acrobatics (1). Quarterbacks were excluded from the football patients, as quarterbacks are throwing athletes. Level of competition included high school (n = 26), college (8), professional (2), and youth sports (1). The RTP rate was 93% (26/28) at a mean 7.4 months for UCL repair and 100% (9/9) at a mean 10.0 months for UCL reconstruction. Mean ASES scores were 94.4 and 98.7 for UCL repair and reconstruction, respectively. Complications were low, with 2 patients in the UCL repair group requiring ulnar nerve transposition for ulnar nerve paresthesia. CONCLUSION: In nonthrowing athletes, patients undergoing UCL repair and UCL reconstruction show favorable outcomes at minimum 2-year follow-up. RTP and clinical outcomes are consistent with previous studies in baseball players as well as a parallel ongoing study conducted on non-baseball throwing athletes.

Pelvis and Trunk Energy Flow in Collegiate Softball Pitchers With and Without Upper Extremity Pain.

BACKGROUND: The softball pitch is a full-body motion, where efficient proximal to distal energy flow through the kinetic chain is said to reduce stress at the upper extremity. Although altered trunk kinematic parameters are associated with upper extremity pain in softball pitchers, further research is needed to determine whether differences exist in proximal energy flow between softball pitchers with and without pain. HYPOTHESIS/PURPOSE: To examine pelvis and trunk energy flow during the acceleration phase of the pitch in collegiate softball pitchers with and without upper extremity pain. It was hypothesized that those with upper extremity pain would have less energy flowing into the proximal ends of the pelvis and trunk as well as less energy flowing out of the distal ends of the pelvis and trunk during the acceleration phase when compared with pitchers who did not have upper extremity pain. STUDY DESIGN: Descriptive laboratory study. METHODS: A total of 54 female National Collegiate Athletic Association Division I softball pitchers (age, 20.2 ± 2.0 years; height, 173.5 ± 6.9 cm; weight, 78.5 ± 11.5 kg) were assigned to pain (n = 17) and pain-free (n = 38) groups. Participants pitched 3 maximal effort rise-balls for a strike, and the average of the 3 trials was used for analysis. Kinematic data were collected at 100 Hz using an electromagnetic tracking system. A segment power analysis was performed to quantify energy flow for the pelvis and trunk. The Mann-Whitney U test was used to compare pelvis and trunk energy flow during the acceleration phase of the pitch as well as pitch velocity between collegiate softball pitchers with and without upper extremity pain. RESULTS: No significant differences were found between pelvis and trunk energy flow during the acceleration phase or pitch velocity between collegiate softball pitchers with and without upper extremity pain (all P values >.057). CONCLUSION: Previous research determined that kinematic parameters differ between collegiate pitchers with and without upper extremity pain. However, the current study found no difference in pelvis and trunk energy flow or pitch velocity. Although altered kinematics in collegiate pitchers with upper extremity pain may serve as compensation patterns to maintain pitch velocity and proximal energy flow, future research is needed to confirm this postulation. CLINICAL RELEVANCE: The lack of energy flow differences between upper extremity pain groups suggests that pitchers may adapt their biomechanics to maintain trunk and pelvis energy flow patterns. Coaches, athletes, and clinicians should know that movement adaptations can allow for maintained performance levels but may result in the presence of pain that may manifest in other deleterious and injury-susceptible biomechanics.

Performance and Return to Sport After Meniscal Repair in Professional Baseball Players.

Background: Meniscal repair is an effective treatment option for certain meniscal injuries to preserve meniscal function and limit the progression of knee osteoarthritis. Outcomes after meniscal repair in professional baseball players are not well documented. Purposes/Hypothesis: The purposes of this study were to determine performance and return to sport (RTS) in professional baseball players after meniscal repair and compare the results of medial versus lateral meniscal repair. It was hypothesized that there would be a high RTS rate, with no difference in the rate or timing of RTS between players who underwent medial versus lateral meniscal repair. Study Design: Cohort study; Level of evidence, 3. Methods: All professional baseball players who underwent meniscal repair between 2010 and 2017 were identified using the Major League Baseball Health and Injury Tracking System database. Descriptive information and performance data (before and after injury) for each player were recorded. The rate and timing of RTS were then compared between players who underwent medial versus lateral meniscal repair. Results: Included were 31 patients (mean age, 24 ± 3 years). There were 6 players (19%) who had failed repair, underwent subsequent meniscectomy within 2 years of meniscal repair, and were thus excluded from the performance analysis. Of the remaining 31 players, 68% returned to the same or a higher level of play, and 6% of players returned to a lower level of play. Most repair procedures (60%) were performed using the all-inside technique, and 72% of players underwent lateral meniscal repair. The mean time missed was 187 ± 67 days, and the mean time to RTS at full competitive play was 209 ± 84 days. There were no significant differences in the rate or timing of RTS between players who underwent medial versus lateral meniscal repair (P ≥ .999 and P = .574, respectively). Pitchers saw a decrease in usage but no change in performance after meniscal repair. For batters, most metrics were unchanged, but there was a significant decrease in base stealing and on-base percentage after surgery. Conclusion: The RTS rate after meniscal repair in Major League Baseball players was 74% at a mean of 209 days; 19% of players had failed repair and underwent subsequent meniscectomy within 2 years of repair. No difference in the rate or timing of RTS was observed between players who underwent medial versus lateral meniscal repair.

Performance and Return to Sports After Meniscectomy in Professional Baseball Players.

BACKGROUND: Meniscal injuries are common in athletes across many sports. How professional baseball players respond to partial meniscectomy is not well documented. PURPOSE/HYPOTHESIS: The purpose was to determine the performance and return-to-sports (RTS) rate in professional baseball players after arthroscopic partial knee meniscectomy and compare the results of partial medial meniscectomy versus partial lateral meniscectomy. The hypothesis was that there would be a high RTS rate in professional baseball players after partial meniscectomy with no difference in the RTS rate or timing of RTS between players who underwent partial medial meniscectomy versus partial lateral meniscectomy. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All professional baseball players who underwent arthroscopic partial meniscectomy between 2010 and 2017 were identified using the Major League Baseball Health and Injury Tracking System database. Demographic and performance data (before and after injury) for each player were recorded. The RTS rate and timing of RTS were then compared between players who underwent partial medial meniscectomy versus partial lateral meniscectomy. RESULTS: A total of 168 knees (168 players) underwent arthroscopic partial meniscectomy (mean age, 25 ± 5 years; 46% medial meniscectomy, 45% lateral meniscectomy, and 9% both medial and lateral meniscectomy). The most common mechanism of injury was fielding in the infield on natural grass. Injuries were spread evenly across positions: 18% catchers, 24% infielders, 20% outfielders, and 38% pitchers. The overall RTS rate was 80% (76% returned to the same or a higher level, and 4% returned to a lower level). For performance, pitchers saw significant decreases in usage but significant improvements in performance using the advanced statistics of fielding independent pitching (P < .001) and wins above replacement (P = .011). Hitters saw significant decreases in usage but increases in efficiency as seen by improvements in wins above replacement (P = .003). Of the 79 athletes who returned during the same season, the median time to return to play was 42 days. CONCLUSION: The RTS rate after meniscectomy in professional baseball players was 80%. Player efficiency improved after surgery in pitchers and position players. No difference in the RTS rate or timing of RTS existed between players who underwent partial medial meniscectomy versus partial lateral meniscectomy.

The Impact of COVID-19 on Orthopedic Surgery Fellowship Training: A Survey of Fellowship Program Directors.

Background: The COVID-19 pandemic has had a wide-reaching impact. Graduate medical education of orthopedic surgeons was not spared from the jarring changes. Purpose: We sought to survey fellowship program directors in the field of orthopedic surgery about how the COVID-19 pandemic affected the education of the 2019 to 2020 and 2020 to 2021 fellowship classes and the future of their programs. Methods: In October 2020, an 18-item survey was distributed by an official of the American Academy of Orthopedic Surgeons (AAOS) to the specialty societies that govern fellowship training. Each specialty society then distributed the survey to its respective program directors. A reminder email was sent during the enrollment period. Each respondent was able to complete the survey once. Survey questions were grouped into 3 sections: general information about the fellowship training programs, the impact of COVID-19 on the 2019 to 2020 fellowship class, and the future impact of COVID-19 on the fellowship training programs. Results: Of the 564 accredited orthopedic surgery fellowship programs in the United States, 190 directors responded. Of these, 73.59% reported COVID-19 had a negative impact on the 2019 to 2020 fellowship class. A normal distribution of responses was found regarding didactic and academic learning, research, and mentorship opportunities. A majority of respondents said they believe that there will be no negative impact on patient care the fellows provide in the years to come. Conclusion: Orthopedic surgery fellowship program directors acknowledged that while there were negative effects to training in the pandemic, they did not think these would negatively affect patient care provided by 2019 to 2020 fellows in the short and medium term. They also reported positive outcomes from the experience of the pandemic, including new ways to educate fellows.

Biomechanical Evaluation of Anterolateral Ligament Repair Augmented with Internal Brace.

Injuries to the anterolateral ligament (ALL) of the knee are commonly associated with anterior cruciate ligament (ACL) ruptures. Biomechanical studies have demonstrated conflicting results with regard to the role of the ALL in limiting tibial internal rotation. Clinically, residual pivot shift following ACL reconstruction has been reported to occur up to 25% and has been correlated with poor outcomes. As such, surgical techniques have been developed to enhance rotational stability. Recent biomechanical studies have demonstrated restoration of internal rotational control following ALL reconstruction. The purpose of our study was to understand the biomechanical effects of ACL reconstruction with an ALL internal brace augmentation. We hypothesized that (1) sectioning of the ALL while preserving other lateral extra-articular structures would lead to significant internal rotation laxity and gap formation and (2) ALL repair with internal brace augmentation would lead to reduction in internal rotation instability and gap formation. In total, 10 fresh-frozen cadaveric knees were thawed and biomechanically tested in internal rotation for 10 cycles of normal physiologic torque in the intact, ACL-deficient, ACL/ALL-deficient, ACL-reconstructed, and ALL-repaired conditions. Each condition was tested at 30, 60, and 90 degrees of flexion. Following the final ALL-repaired condition, specimens were additionally subjected to a final internal rotation to failure at 1 degree at the last-tested degree of flexion. Kinematic measurements of angle and linear gap between the femur and tibia were calculated in addition to torsional stiffness and failure torque. As hypothesized, ALL repair with internal brace augmentation significantly reduced internal rotation angular motion and gap formation at flexion angles greater than 30 degrees. Additionally, ALL sectioning produced nonsignificant increases in internal rotation laxity and gap formation compared with ACL-deficient and ACL-reconstructed states, which did not support our other hypothesis.

Early Complications of Ulnar Collateral Ligament Repair With Collagen-Coated Suture Tape Augmentation.

BACKGROUND: Recent innovative techniques have led to renewed interest in ulnar collateral ligament (UCL) repair. Although early outcome data regarding the clinical outcome of overhead athletes undergoing UCL repair with augmentation have been encouraging, long-term data are still needed to evaluate both the appropriate indications and success rate for this procedure. PURPOSE: To describe and evaluate the acute complications seen in a large cohort of patients who underwent UCL repair with internal brace augmentation at a single institution. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We performed a retrospective chart review of a prospectively collected database, consisting of all patients who underwent UCL repair with internal brace augmentation utilizing a collagen-dipped FiberTape at our institution from August 2013 to January 2020. Patient characteristics, injury setting, side of surgery, and concomitant ulnar nerve transposition procedures were recorded. Early complications of UCL repair (within 6 months of the procedure) were evaluated and characterized as either minor or major, depending on whether the patient required a return to the operating room. RESULTS: Of the 353 patients who underwent UCL repair at our institution with a minimum of 6-month follow-up, 84.7% (299/353) reported no complications, 11.9% (42/353) reported minor complications-including ulnar nerve paresthesia, postoperative medial elbow pain, and postoperative superficial wound complications-and 3.4% (12/353) required a return to the operating room because of a major complication requiring ulnar nerve exploration/debridement, primary ulnar nerve transposition, or heterotopic ossification excision. CONCLUSION: The low major complication rate identified in this study further validates the efficacy of the UCL repair with the internal bracing augmentation technique. Longer term follow-up data are needed to more adequately assess the outcomes and durability of this procedure.

Decreased Shoulder and Elbow Joint Loads During the Changeup Compared With the Fastball and Curveball in NCAA Division I Collegiate Softball Pitchers.

BACKGROUND: Baseball leagues have implemented pitch count and pitch type restrictions based on biomechanical concepts associated with pitch type. Softball has not yet adopted these practices, although softball pitchers continue to pitch at a high volume and learn multiple pitches at a young age. PURPOSE: To examine shoulder and elbow kinetics between the fastball, curveball, and changeup, as well as to provide descriptive upper extremity pain data in National Collegiate Athletic Association (NCAA) softball pitchers. STUDY DESIGN: Descriptive laboratory study. METHODS: Study participants consisted of 27 female NCAA Division I softball pitchers (age, 20.2 ± 1.9 years; height, 175.7 ± 5.7 cm; weight, 83.6 ± 12.7 kg). The participants pitched 3 balls of each pitch type, and kinetic data were recorded. A one-way within-participants repeated-measures multivariate analysis of variance was used to determine significant differences in kinetics and pitch speed between pitch types. RESULTS: Results revealed a statistically significant main effect for pitch type (Wilks λ = .087; F = 36.523; P < .001). Post hoc testing showed that the changeup produced less anterior elbow force compared with the fastball (P < .001) and the curveball (P = .012). In addition, the changeup produced less shoulder distraction force compared with the fastball (P < .001) and the curveball (P = .001). Additionally, there was a significant difference in pitch speed between all 3 pitch types (P = .006). The curveball revealed no statistically significant kinetic differences compared with the fastball. CONCLUSION: The fastball and curveball placed similar stress on the upper extremity in collegiate softball pitchers. However, in comparison with the changeup, the fastball and curveball placed increased stress on the upper extremity. More research is needed to fully explain the differences seen between pitch type and injury risk. CLINICAL RELEVANCE: Sports medicine professionals, coaches, and athletes should use the current study results to note these differences in shoulder distraction and elbow anterior forces between softball pitch types. The study results can be used as a reference and basis for future research investigating kinetic differences across varying pitch types.

Short-Term Trends in Elbow Ulnar Collateral Ligament Surgery in Collegiate Baseball Players: An Analysis of 25,587 Player-Years.

BACKGROUND: Trends over time in the incidence of ulnar collateral ligament (UCL) surgeries in National Collegiate Athletic Association Division I baseball players are currently unknown. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate the trends in UCL surgeries over 3 years in Division I baseball programs. We hypothesized that surgical injuries would be consistently high over the course of the study. STUDY DESIGN: Descriptive epidemiology study. METHODS: Athletic trainers from Division I baseball programs were invited to participate in an electronic survey over 3 seasons. A total of 155 baseball programs agreed to participate in 2017, 294 programs participated in 2018, and 296 programs participated in 2019. After each of the 3 collegiate baseball seasons, the athletic trainer from each program entered anonymous, detailed descriptive data and surgical information on injured players into a secured database. RESULTS: During the 3 years of this study, 100% of the enrolled programs successfully completed the survey (155/155 in year 1, 294/294 in year 2, and 296/296 in year 3). This registry of 745 completed surveys over 3 years represented 25,587 player-years from Division I collegiate baseball. The percentage of programs with at least 1 UCL surgery during this time was 57% in 2017, 51% in 2018, and 49% in 2019. The majority of these players were pitchers (84% overall from the 3 years). Seniors underwent a significantly lower percentage of the UCL surgeries (8% in 2017, 10% in 2018, and 13% in 2019) than did underclassmen. Surgeries were performed most often in-season and least often during the preseason. A slight majority of players undergoing surgery originated from warm-weather states, but the number of these players was never significantly higher than was the number of players from cold-weather states. Most surgeries performed each year were UCL reconstruction, but the percentage of UCL repair with ligament augmentation increased each year (10% UCL repairs in 2017, 20% in 2018, and 25% in 2019). CONCLUSION: UCL injuries requiring surgery were found to be a major source of morbidity in Division I collegiate baseball, supporting our hypothesis. This study can serve as a baseline for tracking long-term trends in UCL surgeries in collegiate baseball.