High variability among surgeons in evaluation, treatment, and rehabilitation of medial ulnar collateral ligament injuries.

Hypothesis and/or Background: The incidence of elbow medial ulnar collateral ligament (MUCL) injuries has been increasing, leading to advances in surgical treatments. However, it is not clear that there is consensus among surgeons regarding diagnostic imaging, the indications for acute surgery and postoperative rehabilitation. The purpose of this study is evaluate surgeon variability in the presurgical, surgical, and postsurgical treatment of MUCL injuries regarding the imaging modalities used for diagnosis, indications for acute surgical treatment, and postoperative treatment recommendations for rehabilitation and return to play (RTP). Our hypothesis is that indications for acute surgical treatment will be highly variable based on MUCL tear patterns and that agreement on the time to RTP will be consistent for throwing athletes and inconsistent for nonthrowing athletes. Methods: A survey developed by 6 orthopedic surgeons with expertise in throwing athlete elbow injuries was distributed to 31 orthopedic surgeons who routinely treat MUCL injuries. The survey evaluated diagnostic and treatment topics related to MUCL injuries, and responses reaching 75% agreement were considered as high-level agreement. Results: Twenty-four surgeons responded to the survey, resulting in a 77% response rate. There is 75% or better agreement among surveyed surgeons regarding acute surgical treatment for distal full thickness tears, ulnar nerve transposition in symptomatic patients or with ulnar nerve subluxation, postoperative splinting for 1-2 weeks with initiation of rehabilitation within 2 weeks, the use of bracing after surgery and the initiation of a throwing program at 3 months after MUCL repair with internal brace by surgeons performing 20 or more MUCL surgeries per year. There were a considerable number of survey topics without high-level agreement, particularly regarding the indications for acute surgical treatment, the time to return to throwing and time RTP in both throwing and nonthrowing athletes. Discussion and/or Conclusion: The study reveals that there is agreement for the indication of acute surgical treatment of distal MUCL tears, duration of bracing after surgery, and the time to initiate physical therapy after surgery. There is not clear agreement on indications for surgical treatment for every MUCL tear pattern, RTP time for throwing, hitting and participation in nonthrowing sports.

Public Perceptions of Rotator Cuff Tears.

(1) Background: Full-thickness rotator cuff tears (RCTs) impact 25% of those over 60 and 50% over 80; however, minimal data exists on public understanding; (2) Methods: The primary outcome was to determine the public's baseline understanding of RCTs utilizing a 36-question survey regarding anatomy and function, risk factors, diagnosis and treatment options, and expectations. Secondarily, we evaluated the effect of an educational video and informational handout created by the authors to improve understanding. Participants ≥ 18 years were recruited from the senior author's clinic and online discussion platforms over a 5-month period; (3) Results: Baseline surveys were completed by 382 individuals: 56% men, 64% Caucasian, 27% with at least a master's degree, and 56% with very little or no RCT knowledge. Mean correct answer scores improved from 47% to 68% posteducational intervention (p < 0.001). Males, higher education level, healthcare experience, and a higher self-rated understanding of RCTs were significantly correlated with higher survey performance (p < 0.001); (4) Conclusions: The public's knowledge of RCTs at baseline was poor, with demographic factors correlating with survey performance. The educational intervention effectively enhanced participants' understanding. By focusing on common misconceptions, this data can help clinicians align patient expectations and enhance patient outcomes.

Interval Throwing Programs for Baseball Players: Methodological Assessment of the Quality and Construct of Publicly Available Programs.

CONTEXT: The quality and interprogram variability of publicly available throwing programs have not been assessed. OBJECTIVE: To (1) identify publicly available interval throwing programs, (2) describe their components and structure, and (3) evaluate their quality, variability, and completeness. DATA SOURCES: Google, Bing, Yahoo; keyword: "interval throwing program." STUDY SELECTION: Baseball-specific publicly available programs. STUDY DESIGN: Systematic review. LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: Independent evaluation by 2 authors using a novel 21-item Quality Assessment Rubric (QAR). RESULTS: Of the 99 included programs, 54% were designed for return from injury/surgery; 42% explicitly stated no expected timeline for completion, and approximately 40% did not provide criteria to initiate the program. Program construction was highly variable. There were broad-ranging shortest (mean: 40±8 ft, range: 20-45 ft) and longest (mean: 150±33 ft, range: 90-250 ft) long toss distances, and variable maximum numbers of mound pitches thrown before returning to game play (range: 40-120, mean: 85). Only 63% of programs provided guidelines for handling setbacks, and standardized warm-ups, arm care, and concomitant training were absent in 32%, 63%, and 47% of programs, respectively. Mean QAR completion rate and QAR item response rate were low (62 ± 4% [range, 24-91%], 62 ± 24% [range, 7-99%], respectively). Finally, only 20 (20%) programs provided at least 1 peer-reviewed reference, most of which were published >10 years ago. CONCLUSION: Publicly available interval throwing programs are readily available but demonstrate significant interprogram heterogeneity across multiple areas including target audience, program construction, progression, and execution. The quality and consistency of publicly available interval throwing programs is poor at this time, which may limit their utility and effectiveness for baseball players attempting to return to competition. This work identifies a multitude of deficiencies in currently available throwing programs that should be targets of future improvement efforts.

Current concepts: pathology in the overhead athlete's lateral elbow.

The lateral elbow is subjected to increasing compressive force in response to repetitive valgus stress. Alterations or deficiencies in overhead mechanics and the kinetic chain may predispose an athlete to injury. Evaluation includes a focused elbow physical examination and imaging, supplemented by a robust screening of core strength, balance, and mechanics of the kinetic chain. Treatment of osteochondritis dissecans, a common lateral elbow pathology, varies based on stability of the lesion, with variable, but often positive outcomes. Proper pitching mechanics, kinetic chain integrity, and workload management provide potential opportunities for prevention.

Elbow Ulnar Collateral Ligament Repair With Suture Augmentation Is Biomechanically Equivalent to Reconstruction and Clinically Demonstrates Excellent Outcomes: A Systematic Review.

PURPOSE: To systematically review (1) biomechanical properties of augmented elbow ulnar collateral ligament (UCL) repair compared with reconstruction and (2) clinical efficacy and complication rates of UCL repair with and without augmentation. METHODS: A systematic review was completed August 15, 2023, identifying articles that (1) biomechanically compared suture augmented UCL repair and reconstruction and (2) clinically evaluated medial elbow UCL repairs. Search terms included: "UCL repair" OR "internal brace" OR "suture augmentation" AND "UCL reconstruction." For inclusion, biomechanical studies compared augmented repair with reconstruction; clinical studies required clinical outcomes with minimum 6-month follow-up. Biomechanical data included torsional stiffness, gap formation, peak torque, and failure torque. Clinical data included return to previous level of play, time to return, functional outcomes, and complications. RESULTS: In total, 8 biomechanical and 9 clinical studies were included (5 with and 4 without augmentation). In most biomechanical studies, augmented repairs demonstrated less gap formation, with equivalent torsional stiffness, failure load, and peak torque compared with reconstruction. Clinical outcomes in 104 patients without augmentation demonstrated return to previous level of 50% to 94% for nonprofessional athletes and 29% for professional baseball pitchers. Suture augmented repairs in 554 patients demonstrated return to previous level from 92% to 96%, at 3.8 to 7.4 months, with Kerlan Jobe Orthopaedic Clinic scores of 86 to 95. The overall complication rate for augmented UCL repair was 8.7%; most commonly ulnar neuropraxia (6%). CONCLUSIONS: Biomechanically, UCL repair with augmentation provided less gapping with equivalent torsional stiffness and failure compared with reconstruction. Clinically, augmented UCL repair demonstrated excellent return to previous level of play and Kerlan Jobe Orthopaedic Clinic scores with modest complications and time to return. Augmented UCL repair is biomechanically equivalent to reconstruction and may be a viable alternative to reconstruction in indicated athletes. CLINICAL RELEVANCE: UCL repair with suture augmentation is biomechanically equivalent to reconstruction and clinically demonstrates excellent outcomes.

Early single sport specialization does not improve pitching velocity, motion, strength, or utilization in high school baseball pitchers.

Background: The impact of single-sport specialization on performance and injury risk in youth and adolescent athletes remains debated. The purpose of this study was to determine the incidence of single-sport specialization and its association with pitch velocity, pitcher utilization, range of motion, strength, and injury history. Methods: High school pitchers in the Northeastern, Southeastern, Midwestern, and Western Regions of the United States were prospectively recruited. Prior to the season, pitchers were surveyed about their basic demographics, sport participation history, and injury history. At this timepoint, a standardized physical examination was performed and max pitch velocity was measured. They were then prospectively followed over the ensuing high school season, where pitch utilization and counts were followed and injuries were tracked. Results: Across the study, 115 pitchers were recruited, of whom 53% played baseball as their only sport and 47% played other sports. Single- position specialization within baseball was uncommon as 90% of athletes played positions other than pitcher. There were no differences in range of motion, strength, or pitch velocity between multisport athletes and single-sport specialists. Within the multisport group, 26% reported a history of injury, while 38% of the single-sport specialists reported a history of injury (P = .179). There were no significant differences in pitcher utilization between multisport athletes and single-sport specialists. Only a single prospective injury occurred in the 115 players. Conclusion: Although single-sport specialization is common, nearly half of all high school pitchers in this study were multisport athletes. While injury history was generally similar between the two groups, single-sport baseball players did not have the following: improved motion, increased strength, higher ball velocity, or greater pitching volumes during the high school baseball season compared to multisport athletes. Accordingly, single-sport specialization did not have a competitive advantage for these high school pitchers based on the performance factors studied. Further prospective studies are necessary to understand the association between single-sport specialization and injury risk in high school baseball players.

Characteristics Associated With Noncompliance of Current Pitch Smart Guidelines in High School Baseball Pitchers Throughout the United States.

Background: Although pitch count and rest guidelines have been promoted for youth and adolescent baseball players for nearly 2 decades, compliance with guidelines remains poorly understood. Purpose/Hypothesis: The purpose of this study was to determine the frequency of compliance with Major League Baseball (MLB) Pitch Smart guidelines as well as the association between compliance and range of motion (ROM), strength, velocity, injury, and pitcher utilization. It was hypothesized that pitchers in violation of current recommendations would have increased strength, velocity, and injury. Study Design: Case-control study; Level of evidence, 3. Methods: This was a prospective, multicenter study of 115 high school pitchers throughout the United States. Pitchers were surveyed about their compliance with current off-season, rest-related guidelines, and history of injury. During the preseason, pitchers underwent standardized physical examinations, and pitch velocity was measured. Pitch counts were collected during the baseball season that followed. Dynamometer strength testing of shoulder forward flexion, and external rotation as well as grip strength was recorded. We compared pitchers who were compliant with recommendations with those who were noncompliant using Student t and Mann-Whitney U tests. Results: Based on preseason data, 84% of pitchers had violated current Pitch Smart guidelines. During the season, 14% had at least 1 violation of the Pitch Smart guidelines. Across both the preseason survey and in-season pitch counts, 89% of players had at least 1 violation of the Pitch Smart guidelines. While there were no significant differences in ROM or strength, the noncompliant group had higher maximum pitch velocity than the compliant group (74 ± 8 vs 69 ± 5 mph [119 ± 13 vs 111 ± 8 kph], respectively; P = .009). Players' self-reported velocity differed significantly from the direct measurement, for both peak velocity (80 ± 6 vs 73 ± 8 mph [129 ± 9 vs 117 ± 13 kph], respectively; P < .001) and mean velocity (73 ± 8 vs 53 ± 27 mph [117 ± 13 vs 85 ± 43 kph], respectively; P < .001). Conclusion: Most high school pitchers were not fully compliant with current Pitch Smart guidelines, and they tended to overestimate their peak velocity by 7 mph (11 kph). Pitchers who threw with greater velocity were at higher risk for violating Pitch Smart recommendations.

Most high school baseball pitchers are using weighted ball throwing programs to increase ball velocity: crosssectional analysis of US high school pitchers.

Background: Weighted-ball velocity training programs are popular but may be associated with increased injury risk. The purpose of this study was to determine the current frequency of these programs, as well as their association with range of motion, strength, velocity, injury, and utilization in high school baseball pitchers. Methods: This was a multicenter, prospective, community-based study including high schools from the Northeastern, Southeastern, Midwestern, and Western regions of the United States. Preseason pitchers were surveyed about their use of weighted ball velocity programs and history of injury. Preseason pitchers underwent standardized physical examinations and pitch velocity was measured. During a single high school season, pitch counts and injury incidence were prospectively collected. Results: In total, 115 pitchers were recruited, of whom 63% had participated in a weighted ball program. There were no differences in range of motion or strength between groups who used weighted balls and those who did not. Pitchers that utilized weighted ball programs demonstrated a higher average fastball velocity (114.26 vs. 106.22 km/h [71 vs. 66 mph]; P < .001) as well as peak fastball velocity (115.87 vs. 109.44 km/h [72 vs. 68 mph]; P = .001) compared to those that did not use weighted ball programs. Pitchers that utilized weighted ball programs were no more likely to be single-sport athletes (44%) than those who were multisport athletes (49%, P = .667). Within the group who had used a weighted ball program 29% (13/45) reported a history of injury and within the group who had not used a weighted ball program 25% (10/40) reported a history of injury (P = .687). As only a single injury occurred in the entire cohort, comparison of injury rates could not be completed. Conclusion: In this prospective study, the majority of high school pitchers reported using weighted ball programs to increase velocity, and these programs were associated with increased average and peak velocity compared to pitchers who did not use weighted ball programs. There were no significant differences in injury history between the 2 groups. Further study is necessary to understand the injury risk associated with weighted ball programs.

Reliability of ulnar collateral ligament findings in magnetic resonance imaging.

BACKGROUND: Ulnar collateral ligament (UCL) tears are common in baseball players. Although magnetic resonance imaging (MRI) is the most used imaging modality for UCL injuries, the inter-rater reliability of MRI analyzing specific characteristics of UCL pathology has not been defined. The purpose of this study was to define the inter-rater reliability of MRI for evaluating UCL characteristics. METHODS: Three surgeons analyzed 45 noncontrast MRIs: 15 without UCL tears, 15 with intraoperatively confirmed partial-thickness tears, and 15 with intraoperatively confirmed full-thickness tears. Findings evaluated included ligament characteristics (periligamentous or osseous edema, ligament hypertrophy, calcifications, and partial- or full-thickness tearing) and location of the pathology (proximal, midsubstance, or distal). Fleiss' κ coefficients were used to assess interobserver reliability. RESULTS: There were high rates of agreement for midsubstance (κ: 0.50) and distal (κ: 0.69) ligament edema and proximal osseous edema (κ: 0.48). There were low rates of agreement for proximal ligament edema (κ: 0.08), ligament thickening (κ: -0.02 to 0.20), and proximal to midsubstance calcifications (κ: -0.04 to 0.10). Midsubstance (κ: 0.55) and distal full-thickness tears (κ: 0.63) demonstrated higher agreement than proximal (κ: 0.29). Proximal partial-thickness tears (κ: 0.45) had higher agreement than midsubstance (κ: -0.02) or distal (κ: -0.02). CONCLUSIONS: In our study, there was high inter-rater reliability regarding proximal osseous edema, midsubstance, and distal ligament edema and full-thickness tears. There was no agreement for midsubstance and distal partial-thickness UCL tears, but fair agreement for proximal tears. UCL tissue characteristics including ligament thickening and calcifications demonstrated low agreement. Challenges remain in effectively evaluating UCL tissue characteristics on noncontrast MRIs.

What are the indications for medial ulnar collateral ligament surgery in baseball players? An MRI case-based study.

BACKGROUND: Ulnar collateral ligament (UCL) tears are common in baseball players. When nonoperative management fails; reconstruction or repair may be necessary to restore physical function. There is no clear consensus regarding the indications for surgery based on magnetic resonance imaging (MRI) tear characteristics or the indications for selecting repair over reconstruction. The purpose of this study was to define the indications for UCL surgery based on MRI and to elucidate indications for UCL repair vs. reconstruction. METHODS: Twenty-six orthopedic surgeons who treat baseball players were surveyed. Forty-five MRIs were reviewed: 15 without UCL tears, 15 with intraoperatively confirmed partial-thickness tears, and 15 with full-thickness tears. Factors investigated included ligament characteristics (periligamentous or osseous edema, ligament hypertrophy, calcification, partial or full-thickness tearing) and location (proximal, midsubstance, or distal). Surgeons were given a clinical scenario and asked whether 1) surgery was indicated and 2) whether repair or reconstruction was recommended. Odds ratios (OR) and 95% confidence intervals (95% CI) helped identify significant predictors for both queries. RESULTS: The odds of recommending surgical treatment compared to nonoperative treatment were 2.4× more likely for a proximal partial-thickness tear, 3.2× for distal partial-thickness tear, 5.1× for distal full-thickness tear, and 7.0× for proximal full-thickness tear (P < .001). Significant indications for repair included distal partial (OR = 1.6, 95% CI 1.0, 2.1, P < .001) and full-thickness tears (OR = 1.7, 95% CI 1.1, 2.3, P < .001). Repair was 3× less likely recommended for midsubstance full-thickness tears (OR = 3.0, 95% CI -5.0, -1.0, P = .004). Ultrasound stress testing was requested in 78% of partial tears. CONCLUSIONS: Among surgeons surveyed, the highest odds for recommending operative treatment were proximal full-thickness tears, then distal full-thickness, distal partial-thickness, and proximal partial-thickness tears. Repair was most appropriate for partial and full-thickness distal tears, but relatively contraindicated for complete midsubstance UCL tears. Ultrasound stress testing was frequently requested for partial tears. Given the lack of consensus among surgeons, future prospective registries are necessary to determine whether these factors associate with clinical outcomes.

Frozen Shoulder Manipulation with the FEAR Technique: A Retrospective Case Series with Minimum Two-Year Follow-up.

Conservative treatment of adhesive capsulitis fails in up to 30% of patients. Manipulation under anesthesia (MUA) has been shown to be safe and effective, although complications (iatrogenic fracture, glenohumeral dislocation, rotator cuff tears, nerve injuries) have been reported. This study details a novel technique, FEAR (Forward elevation, Extension, Adduction/abduction, and internal and external Rotation), and its results. Medical records review identified 100 patients with a diagnosis of adhesive capsulitis who had at least 6 weeks of physical therapy, with or without corticosteroid injection, with persistence of pain and loss of motion loss. An Institutional Review Board approved phone survey obtained Single Assessment Numeric Evaluation (SANE) scores, visual analog scale (VAS) scores, functional scores, and range of motion, with 43 available for survey. At average 5-year follow-up, 81% had excellent (≥ 90) scores and 77% were pain-free. Patients with diabetes and male patients had significantly lower SANE scores at follow-up. (Journal of Surgical Orthopaedic Advances 31(2):096-099, 2022).

Anterior cruciate ligament reconstruction femoral tunnel drilling preference among orthopaedic surgeons.

BACKGROUND: Anterior cruciate ligament reconstruction (ACLR) technique for femoral tunnel drilling varies substantially, each with advantages and disadvantages. The purpose of this study was to define ACLR femoral tunnel technique predilection among surgeons and to explore factors associated with their preference. METHODS: An 11-question survey regarding ACLR femoral tunnel technique was completed by 560 AANA/AOSSM members. Surgeon and practice demographics and residency and fellowship experiences were evaluated with bivariate and multivariable models for association with surgeon preference. RESULTS: In current practice, 55% of surgeons prefer anteromedial (AM) portal drilling, 32% retrograde, and 14% transtibial (TT). Sports Medicine fellowship experience was the strongest predictor of current practice (p < 0.001), followed by residency technique (p = 0.014). A significant increase in TT drilling was noted for those practicing >15 years TT (29% vs 3%, p < 0.001), with an inverse relationship for retrograde drilling (38% vs 21%, p < 0.001). Number of ACLRs/year and percent Sports specific practice were significant predictors for AM drilling (p < 0.001). Though less than AM and retrograde, TT was more common for those in private practice (17% vs 8%, p < 0.001), and more prevalent in the Midwest/Southeast (19% vs 10%, p = 0.003). Non-significant predictors included highest level of athlete for whom an ACLR had been performed, level of athlete serving as team physician, and Certificate of Added Qualifications status. CONCLUSION: Surgeon training, practice setting, and years in practice significantly predict preference for femoral tunnel drilling technique. Surgeon comfort and confidence in attaining an anatomic reconstruction should drive choice of technique.

Anterior Cruciate Ligament Reconstruction Graft Preference Most Dependent on Patient Age: A Survey of United States Surgeons.

PURPOSE: The purpose of this study was to define the anterior cruciate ligament (ACL) reconstruction (ACLR) graft preference of surgeons and to explore factors associated with their predilection. METHODS: A 15-question survey regarding ACLR graft preference in various situations was completed by 514 American Orthopaedic Society for Sports Medicine and Arthroscopy Association of North America surgeons. Surgeon and practice demographics, along with various patient factors, were evaluated with bivariate and multivariable models for association with surgeon preference. Surgeons were also queried about their preference for their own ACLR. For surgeons who personally sustained an ACL, an additional 6 questions inquired about their experience. RESULTS: Surgeons reported the 5 most important factors in patient graft choice, in order: patient age, graft failure in literature and practice, pivot sport, and patient preference. Autograft patellar and quadriceps tendon were strongly preferred for younger, pivoting athletes (P < .001), among those with fellowship training (47% vs 33%, P = .006), in academic practices (52% vs 44%, P = .003), and in more sports medicine-specific practices, with a higher number of ACLRs performed per year (P < .001). Northeast, Southeast, Midwest, and Southwest surgeons had lower hamstring autograft preference (P < .001). Non-fellowship-trained surgeons preferred hamstring autograft (P = .010). Allograft was preferred for older patients (P < .001). Nonsignificant predictors included highest level of athlete for whom an ACLR had been performed, level of athlete serving as team physician, and years in practice. No factors were associated with surgeon preference for their own ACLR despite deeming these factors important for patients. ACL tears were reported by 13% of respondents, with 86% stating it influenced their decision to enter orthopaedics. CONCLUSIONS: Patient age was the most important factor in graft choice, with patellar and quadriceps tendon autograft the preferred graft for ACLR for younger, pivoting athletes. Fellowship training and practice demographics were also correlated with graft choice for patients. CLINICAL RELEVANCE: Graft preference for ACLR varies among surgeons and is associated with surgeon experience and patient characteristics, including patient age, type of sport, and patient preference.

Upper-extremity blood flow restriction: the proximal, distal, and contralateral effects-a randomized controlled trial.

BACKGROUND: Blood flow restriction (BFR) training with low weight is purported to induce similar physiological changes to high-weight regimens with the benefit of less tissue stress. We hypothesized that low-weight training with BFR would produce increased gains in strength and hypertrophy for muscle groups proximal, distal, and contralateral to tourniquet placement compared with low-weight training alone. METHODS: In this prospective, randomized controlled trial, healthy subjects were randomized into a 6-week low-weight training program either with or without BFR on 1 extremity. Outcome measures included limb circumference and strength. Comparisons were made between the BFR and non-BFR extremities, BFR and control groups, and non-BFR extremity and control groups. RESULTS: A total of 24 subjects (14 BFR and 10 control subjects) completed the protocol. Significantly greater gains were observed in dynamometric strength both proximal (shoulder scaption [30% greater], flexion [23%], and abduction [22%]) and distal (grip strength [13%]) to the tourniquet in the BFR limb compared with both the non-BFR extremity and the control group (P < .05). Arm and forearm circumferences significantly increased in the BFR limb compared with the non-BFR limb and control group (P = .01). The non-BFR extremity demonstrated greater grip strength than the control group (9%, P < .01). No adverse events were reported. CONCLUSION: Low-weight BFR training provided a greater increase in strength and hypertrophy in the upper-extremity proximal and distal muscle groups compared with the control group. The non-BFR extremity showed a significant increase in grip strength compared with the control group, indicating a potential systemic effect.

Predictors of Clinical Outcomes After Proximal Hamstring Repair.

BACKGROUND: Proximal hamstring avulsions cause considerable morbidity. Operative repair results in improved pain, function, and patient satisfaction; however, outcomes remain variable. PURPOSE: To evaluate the predictors of clinical outcomes after proximal hamstring repair. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We retrospectively reviewed proximal hamstring avulsions repaired between January 2014 and June 2017 with at least 1-year follow-up. Independent variables included patient demographics, medical comorbidities, tear characteristics, and repair technique. Primary outcome measures were the Single Assessment Numerical Evaluation (SANE), International Hip Outcome Tool-12 (iHOT-12), and Kerlan-Jobe Orthopaedic Clinic (KJOC) Athletic Hip score. Secondary outcome measures included satisfaction, visual analog scale for pain, Tegner score, and timing of return to sports. RESULTS: Of 102 proximal hamstring repairs, 86 were eligible, 58 were enrolled and analyzed (67%), and patient-reported outcomes were available for 45 (52%), with a mean 29-month follow-up. The mean patient age was 51 years, and 57% were female. Acute tears accounted for 66%; 78% were complete avulsions. Open repair was performed on 90%. Overall satisfaction was 94%, although runners were less satisfied compared with other athletes (P = .029). A majority of patients (88%) returned to sports by 7.6 months, on average, with 72% returning at the same level. Runners returned at 6.3 months, on average, but to the same level 50% of the time and at a decreased number of miles per week compared to nonrunners (15.7 vs 7.8, respectively; P < .001). Postoperatively, 78% had good/excellent SANE Activity scores, but the mean Tegner score decreased (from 5.5 to 5.1). Acute tears had higher SANE Activity scores. The mean iHOT-12 and KJOC scores were 99 and 77, respectively. Endoscopic repairs had equivalent outcome scores to open repairs, although conclusions were limited given the small number of patients in the endoscopic group. Greater satisfaction was noted in patients older than 50 years (P = .024), although they were less likely to return to running (P = .010). CONCLUSION: Overall, patient satisfaction and functionality were high. With the numbers available, we were unable to detect any significant differences in functional outcome scores based on patient age, sex, body mass index, smoking status, medical comorbidities, tear grade, activity level, or open versus endoscopic technique. Acute tears had better SANE Activity scores. Runners should be cautioned that they may be unable to return to the same preinjury activity level after proximal hamstring repair. CLINICAL RELEVANCE: When counseling patients with proximal hamstring tears, runners and those with chronic tears should set appropriate expectations.

Proximal, Distal, and Contralateral Effects of Blood Flow Restriction Training on the Lower Extremities: A Randomized Controlled Trial.

BACKGROUND:: Blood flow restriction (BFR) training involves low-weight exercises performed under vascular occlusion via an inflatable cuff. For patients who cannot tolerate high-load exercises, BFR training reportedly provides the benefits of high-load regimens, with the advantage of less tissue and joint stress. HYPOTHESIS:: Low-load BFR training is safe and efficacious for strengthening muscle groups proximal, distal, and contralateral to tourniquet placement in the lower extremities. STUDY DESIGN:: Randomized controlled trial. LEVEL OF EVIDENCE:: Level 1. METHODS:: This was a randomized controlled trial of healthy participants completing a standardized 6-week course of BFR training. Patients were randomized to BFR training on 1 extremity or to a control group. Patients were excluded for cardiac, pulmonary, or hematologic disease; pregnancy; or previous surgery in the extremity. Data collected at baseline and completion included limb circumferences and strength testing. RESULTS:: The protocol was completed by 26 patients, providing 16 BFR and 10 control patients (mean patient age, 27 years; 62% female). A statistically greater increase in strength was seen proximal and distal to the BFR tourniquet when compared with both the nontourniquet extremity and the control group ( P < 0.05). Approximately twice the improvement was seen in the BFR group compared with controls. Isokinetic testing showed greater increases in knee extension peak torque (3% vs 11%), total work (6% vs 15%), and average power (4% vs 12%) for the BFR group ( P < 0.04). Limb circumference significantly increased in both the thigh (0.8% vs 3.5%) and the leg (0.4% vs 2.8%) compared with the control group ( P < 0.01). Additionally, a significant increase occurred in thigh girth (0.8% vs 2.3%) and knee extension strength (3% vs 8%) in the nontourniquet BFR extremity compared with the control group ( P < 0.05). There were no reported adverse events. CONCLUSION:: Low-load BFR training led to a greater increase in muscle strength and limb circumference. BFR training had similar strengthening effects on both proximal and distal muscle groups. Gains in the contralateral extremity may corroborate a systemic or crossover effect. CLINICAL RELEVANCE:: BFR training strengthens muscle groups proximal, distal, and contralateral to cuff placement. Patients undergoing therapy for various orthopaedic conditions may benefit from low-load BFR training with the advantage of less tissue stress.

Effectiveness of Thrombin-Collagen and Autologous Platelet-Rich Plasma in Total Hip Arthroplasty Hemostasis: A Prospective, Randomized, Controlled Trial.

Bovine derived thrombin-collagen combined with autologous platelet-rich plasma (PRP) has shown promise as a topical, surgical hemostatic agent. The purpose of this study was to determine the effect of thrombin-collagen-PRP on perioperative blood loss in total hip arthroplasty (THA). A prospective, single-blinded, randomized, controlled study comparing thrombin-collagen-PRP use to standard treatment was performed. All patients undergoing elective primary THA for osteoarthritis by a single physician at a single institution were included. Thirty-nine patients were enrolled. There was no significant difference in estimated total blood loss or blood transfusions received. There was no significant difference in operative blood loss, drain output, daily postoperative hematocrit, change in hematocrit, or length of stay. There is insufficient evidence to support the routine use of a topical thrombin-collagen-autologous PRP hemostatic agent in primary total hip arthroplasty. (Journal of Surgical Orthopaedic Advances 27(2):136-141, 2018).

Hyaluronic acid injections for osteoarthritis of the knee: predictors of successful treatment.

PURPOSE: This study aimed to identify patient and treatment factors that predict a favourable response to intra-articular hyaluronic acid (HA) treatment to better guide patient and treatment selection. METHODS: This prospective, observational study evaluated patients with mild-to-moderate (Kellgren-Lawrence grades 1-3) primary knee osteoarthritis treated between March 2013 and May 2016. Patient function and pain scores were assessed by the Western Ontario and McMaster Universities Arthritis Index/Knee Injury and Osteoarthritis Outcome Score (WOMAC/KOOS) and visual analogue scale (VAS) surveys, with response to treatment defined according to the Osteoarthritis Research Society International (OARSI) 2004 criteria. Surveys were completed at each injection and three months post-treatment. Patients were followed an average of 27 months. RESULTS: Of 102 patients, 57% had a positive response. Those at least twice as likely to respond were patients with grades 1-2 osteoarthritis or a positive response to the first injection and those who were ≥60 years. Gender, race, body mass index (BMI), smoking status, HA brand, and initial VAS and WOMAC/KOOS scores were not significant predictors of success. Mean time to arthroplasty following injection series was 11 months (30% of nonresponders, 12% of responders). The VAS strongly correlated with KOOS pain scores and successful outcomes. CONCLUSION: Patients with mild-to-moderate osteoarthritis (grades 1-2) and those responding positively to the first injection were twice as likely to respond positively to the injection series, as were patients ≥60 years. Patients who did not respond positively were more likely to proceed to arthroplasty. The VAS appears to be a reliable method of defining and monitoring treatment success. Judicious patient selection and counseling may improve outcomes associated with intra-articular HA injections.

Tibial Stress Fractures in Athletes.

Tibial stress fractures are common in the athlete. There are various causes of these fractures, the most common being a sudden increase in training intensity. Most of these injuries are treated conservatively; however, some may require operative intervention. Intervention is mostly dictated by location of the fracture and failure of conservative treatment. There are several surgical options available to the treating surgeon, each with advantages and disadvantages. The physician must understand the nature of the fracture and the likelihood for it to heal in a timely manner in order to best treat these fractures in this patient subset.