Performance and Return to Play After Surgery for Thoracic Outlet Syndrome in Professional Baseball Players: A Matched Cohort Analysis.

BACKGROUND: Thoracic outlet syndrome (TOS) remains a rare diagnosis but is being recognized as a cause of upper extremity dysfunction in professional baseball players. PURPOSE/HYPOTHESIS: The purpose was to determine performance and return-to-play (RTP) outcomes in professional baseball players after surgical treatment of TOS. The hypothesis was that there would be a high RTP rate in professional baseball players after TOS surgery with no statistical differences in performance between pitchers who had TOS surgery and matched controls. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All professional baseball players who underwent surgical treatment of TOS between 2010 and 2017 were identified using the Major League Baseball Health and Injury Tracking System database. Demographic and performance data (before and after surgery) for each player were recorded. Performance variables were then compared between players who underwent TOS surgery and matched controls. The matching criteria were no history of previous surgeries on affected arm, age at time of surgery, throwing side, level of play (Major or Minor League Baseball), and years of experience playing professional baseball. RESULTS: Overall, 52 players underwent surgery for TOS, of whom 46 (88%) were pitchers. The type of TOS was neurogenic in 69% and venous in 29%. One player had arterial TOS. After TOS surgery, 79% of players returned to play at the same or higher level (RTSP) by 9.5 months and played ≥3 years after surgery. No differences were found in RTSP rate based on the type of TOS. No statistical difference was found in RTP rates between major and minor league players. Pitchers had a 76% RTSP, which was similar to the natural attrition for control pitchers (P = .874). After TOS surgery, pitchers saw a decline in several performance metrics, but these declines were not different from those of control pitchers, indicating that the decline in performance after TOS surgery was no faster than is seen in healthy professional pitchers as they age. CONCLUSION: The rate of RTSP after surgery for TOS in professional baseball players was 79%. There was no difference in RTP based on the type of TOS. Pitchers who underwent surgery for TOS had no significant differences in pitching performance metrics after surgery compared with matched controls.

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.

Hydrogen Peroxide May Reduce the Risk for Revision Surgery and Infection in Primary Shoulder Arthroplasty: Two-year Follow-up From a Prospective, Blinded, Controlled Trial.

BACKGROUND: The purpose of this study was to determine whether the addition of hydrogen peroxide to the preoperative skin preparation for primary total shoulder arthroplasty is associated with a difference in patient-reported outcomes, risk for postoperative infection, and risk for revision surgery at a minimum of 2-year follow-up. METHODS: This was a prospective, blinded, and controlled trial, which included a consecutive series of patients undergoing primary shoulder arthroplasty. The control group underwent standard sterile skin preparation using ethyl alcohol and ChloraPrep applicators, and the peroxide group had the same preparation with the addition of hydrogen peroxide between the alcohol and ChloraPrep applications. We then compared patient-reported outcome scores (American Shoulder and Elbow Surgeons Shoulder Score [ASES], simple shoulder test [SST], visual analog scale [VAS]), infections, and revision surgeries between the two groups at 2-year follow-up. RESULTS: Of the 61 patients included in the original study, 52 of 58 (85%) living patients agreed to participate in this study. No preoperative differences were observed between groups. No difference was observed in ASES, SST, or VAS scores at 2 years. More revision surgeries were done in the control group (7 versus 2, P = 0.268) and Cutibacterium acnes infections (2 versus 0, P = 0.168). CONCLUSION: The addition of hydrogen peroxide to the preoperative skin preparation before primary shoulder arthroplasty is safe, and additional research is warranted to investigate whether it may decrease the risk for revision surgery and postoperative C acnes infection. LEVEL OF EVIDENCE: III.

The Effect of Lateralization and Distalization After Grammont-Style Reverse Total Shoulder Arthroplasty.

BACKGROUND: The purpose of this study is to evaluate the relationship between multiple radiographic measures of lateralization and distalization and clinical outcome scores after reverse total shoulder arthroplasty (RTSA). METHODS: We retrospectively evaluated all RTSAs performed by the senior author between January 1, 2007, and November 1, 2017. We then evaluated the visual analog scale for pain (VAS pain), Simple Shoulder Test (SST), and American Shoulder and Elbow Surgeons (ASES) scores and complication and reoperation rates at a minimum of 2-year follow-up. We measured preoperative and postoperative (2-week) radiographs for the lateralization shoulder angle (LSA), the distalization shoulder angle (DSA), lateral humeral offset (LHO), and distance from glenoid to lateral aspect of the greater tuberosity (GLAGT). A multivariable analysis was performed evaluating the effect of the postoperative radiographic measurements on final patient reported outcomes (ASES scores, SST, VAS pain). RESULTS: The cohort included 216 shoulders from unique patients who had patient reported outcome scores available at a minimum of 2-year follow-up (average, 4.0±1.9 years) for a total follow-up rate of 70%. In the multivariable models, more lateralization (LSA) was associated with worse final ASES scores -0.52 (95% CI: -0.88 to -0.17; p=0.004), and more distalization (DSA) was associated with better final ASES scores 0.40 (95% CI: 0.11, 0.69; p=0.007). More lateralization (LSA) was associated with worse final SST scores -0.06 (95% CI: -0.11, -0.003; p=0.039). Finally, greater distalization (DSA) was associated with lower final VAS pain scores, Ratio = 0.98 (95% CI: 0.96, 1.00; p=0.021). CONCLUSION: Greater distalization and less lateralization are associated with better function and less pain after Grammont-style RTSA. If utilizing a Grammont-style implant, remaining consistent with Grammont's principles of implant placement will afford better final clinical outcomes.

Utility of Superior Augments in Reverse Shoulder Arthroplasty (Exactech, Equinoxe GPS) without Significant Glenoid Deformity.

INTRODUCTION: Superior augment use may help avoid superior tilt while minimizing removal of inferior glenoid bone. Therefore, our goal is to compare superior augments versus no augment baseplates in RSA for patients with rotator cuff dysfunction and no significant superior glenoid erosion. METHODS: A multicenter retrospective analysis of 145 patients who underwent RSA with intraoperative navigation (Exactech, Equinoxe GPS) and three-year follow-up (mean 32-month follow-up, range 20 to 61 months) who had preoperative superior inclination less than 10 degrees and retroversion less than 15 degrees. Patient demographics, radiographic measurements, surgical characteristics, patient-reported outcomes at preoperative and postoperative visit closest to three years, and adverse events at final follow-up were obtained. Operative time, planned inclination, and planned version of the baseplate were obtained. Chi-square test used to compare categorical variables and student t-test used to compare augment and no augment cohorts. RESULTS: The study population consisted of 54 superior augment patients and 91 no augment patients. The augment cohort had lower BMI (27.2 vs. 29.4, p-0.023), higher native superior inclination (5.9 vs. 1.4 degrees, p<0.001). No difference between the augment and no augment cohorts was found regarding age (p=0.643), gender (p=0.314), medical comorbidities (p>0.05), surgical indication (p=0.082), and native glenoid version (p=0.564). The augment cohort had higher internal rotation score (4.6 vs. 3.9, p=0.023), all remaining ROM and PROs preoperatively were not significantly different. At final follow-up, active ROM in all planes was not different between the cohorts. Regarding PROs, the postoperative SAS score was significantly higher (78.0 vs. 73.6, p=0.042), and ASES score trended towards higher (83.6 vs. 77.5, p=0.063) in the augment cohort. The augment cohort had significantly lower proportion of patients planned to have superior baseplate tilt (1.9% vs. 14.3%, p=0.012), and had greater mean inclination correction (6.3 vs. 1.3 degrees, p<0.001), compared to no augment cohort. Adverse events were rare, and there was no significant difference found between the augment and no augment cohorts (5.6% vs. 3.3%, p=0.509). DISCUSSION: Superior augmented baseplate in RSA with minimal superior glenoid erosion is associated with similar ROM and adverse events with somewhat improved postoperative PROs compared to non-augmented baseplates at 3-year follow-up. Additionally, superior augments resulted in a greater proportion of baseplates planned to avoid superior tilt, and trended toward shorter operative times. Further investigation of long-term glenoid baseplate loosening is imperative to fully understand the cost-effectiveness of superior augments in the setting of minimal glenoid deformity.

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.

Symptomatic Coracoid Fracture Nonunion Treated with Arthroscopic Reduction and Suture Anchor Fixation: A Case Report.

CASE: A 15-year-old female rock climber presented with a traumatic coracoid process fracture of her dominant upper extremity that failed extensive nonoperative treatment. She was treated successfully by arthroscopic reduction and suture anchor fixation. CONCLUSION: A novel surgical technique for coracoid fracture that combines arthroscopic reduction with suture anchor fixation can result in expeditious and durable clinical improvement in a young, high-demand athlete.

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

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

Estrogen and testosterone supplementation improves tendon healing and functional recovery after rotator cuff repair.

Failure of healing after rotator cuff repair (RCR) is common. The purpose of the current study was to evaluate the effect of systemic estrogen or testosterone supplementation on tendon healing after RCR. Seventy-two adult male mice were utilized for all experiments. The supraspinatus tendon was transected and repaired with 6-0 Prolene suture on the left shoulder of 51 animals. Mice were segregated into three groups postoperative: (1) vehicle group (VG; n = 18), (2) estrogen group (EST; n = 17), and (3) testosterone group (TST; n = 16). An unrepaired control group (unrepaired, n = 21) did not have surgery. Utilizing these animals, histological analysis, activity testing, biomechanical testing and RNA sequencing (RNA-seq) was performed. At 8 weeks post-RCR, TST, and EST supplementation improved the overall histologic structure of the repaired enthesis site. No differences in ultimate failure loads or stiffness were detected between VG, EST, and TST groups after biomechanical testing. RCR caused a reduction in wheel activity compared to unrepaired controls and supplementation with TST restored wheel activity. RNA-seq analysis indicated that estrogen and testosterone regulated different pathways associated with enthesis healing, including a suppression of inflammatory signaling. Supplementation with sex hormones improved the structure of the repaired tendon enthesis and significantly regulated expression of diverse pathways regulating multiple biological processes. Testosterone administration following RCR restored wheel activity without having a detrimental impact on biomechanical strength. Future human studies of sex hormone supplementation after RCR are warranted as supplementation in an animal model may improve tendon enthesis healing.

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.

Preoperative Planning Software Does Not Accurately Predict Range of Motion in Reverse Total Shoulder Arthroplasty.

BACKGROUND: The purpose of this study was to determine whether preoperative planning software (PPS) accurately predicts clinical range of motion (ROM) in patients with reverse total shoulder arthroplasty 1 year postoperatively with preoperative and postoperative computed tomography (CT) scans. METHODS: This was a retrospective study of 16 reverse total shoulder arthroplasty patients with preoperative and postoperative (CT) scans obtained at least 1 year postoperatively. Clinical ROM was measured in abduction, external rotation at resting abduction, extension, and flexion at a minimum of 1 year postoperatively. All clinical measurements were obtained before generation of PPS ROM values. Using postoperative CT scans, the achieved implant component positions were quantified and then replicated in PPS on the preoperative CT scans. The preoperative predicted ROM was then recorded, both with and without osteophyte removal. Bland-Altman plots were generated within each motion comparing the differences between clinically measured motion and software-predicted motion. RESULTS: The variation in clinically measured ROM in abduction, external rotation at resting abduction, extension, and flexion were 118 ± 27 (65° to 180°), 33 ± 16 (10° to 75°), 56 ± 8 (50° to 65°), and 137 ± 25 (80° to 160°), respectively. Clinically measured motion differed greatly from PPS-predicted ROM, with mean differences of 33 ± 29 (-32 to 93) for abduction, 44 ± 25 (-38 to 57) for external rotation, 44 ± 25 (-35 to 65) for extension, and 54 ± 50 (-51 to 147) for flexion with no significant correlations between clinically measured and PPS-predicted ROM ( P > 0.05). With humeral or humeral and glenoid osteophyte resection, correlations for only flexion became significant ( P = 0.002 for both). CONCLUSION: The passive glenohumeral impingement-free ROM generated from PPS incompletely predicts clinically measured active humerothoracic ROM, possibly because of the unmeasured factors of soft-tissue tension, muscular strength, humeral torsion, resting scapular posture, and, most importantly, scapulothoracic motion. LEVEL OF EVIDENCE: IV.

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

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

Biomechanical comparison of suture bridge rotator cuff repair with and without dermal allograft pledgets.

BACKGROUND: One method to augment rotator cuff repair is to pass dermal allograft pledgets along the sutures that bridge from the medial to the lateral row. It remains unclear whether this augmentation method alters repair biomechanics. METHODS: This was a controlled laboratory study. After an a priori power analysis, 9 pairs of rotator cuffs underwent double-row suture bridge rotator cuff repair, half randomized to augmentation with dermal allograft pledgets passed along the suture bridge sutures. Repairs were then mounted on a material testing system and loaded cyclically 500 cycles to measure applied force and displacement. Repairs then underwent ultimate failure testing, and stiffness, ultimate failure force, and ultimate failure displacement were measured. Paired t tests were performed to compare between groups. RESULTS: There were no differences between groups in construct gapping with cyclic loading after 500 cycles (P = .885). There were no differences between the augmented and control groups in yield force (103.5 ± 5.0 vs. 101.4 ± 5.9 N, respectively, P = .183), stiffness (94.2 ± 13.9 vs. 90.9 ± 13.8, P = .585), or ultimate failure force (255.3 ± 65.8 vs. 285.3 ± 83.2, P = .315). There were no differences between groups in failure modes, with most specimens failing by cuff tissue tearing within or medial to the construct. CONCLUSION: The addition of dermal allograft pledgets does not positively or negatively influence the time-zero biomechanical characteristics of double-row suture bridge rotator cuff repair.

Elbow Ulnar Collateral Ligament Tears in 2023: Evaluation and Management.

The ulnar collateral ligament, also called the medial collateral ligament of the elbow, is the primary stabilizer against valgus loads. This ligament can be traumatically torn, such as in an elbow dislocation, or can tear through attritional damage with overhead sports. Although baseball pitching is the most common contributor, these injuries also occur with volleyball, gymnastics, and javelin throwing. Patients most commonly report a history of medial elbow pain with associated loss of command, control, and throw velocity. The ulnar nerve lies directly superficial to the posterior band of the ulnar collateral ligament and ulnar neuritis is commonly associated with ulnar collateral ligament pathology. Nonsurgical treatment, including rest from activity, flexor-pronator strengthening, and possible platelet-rich plasma injections, can be considered for partial-thickness tears. Surgical treatment can be considered for patients in whom nonsurgical treatment fails and full-thickness tears. Historically, surgical treatment involved reconstruction of the ligament with a tendon graft. Ipsilateral palmaris longus autograft has been the most commonly used graft, but contralateral palmaris, autograft hamstring tendons, and allograft tendon have also been used. This procedure has a high rate of return to play and a low complication rate, but most athletes require 12 to 18 months to fully return. More recently, repair of the ligament, with the addition of a biologic ingrowth ligament augmentation suture, has demonstrated similarly high rates of return to play and low complication rates, with a full return to play in 6 months.

Job satisfaction and practice characteristics of shoulder and elbow surgeons: a survey of American Shoulder and Elbow Surgeons society members.

BACKGROUND: The purpose of this study is to assess the current trends in fellowship training, career satisfaction, practice characteristics, and surgical case volume among shoulder and elbow surgeons. METHODS: A web-based, anonymous 25-item survey was sent to the membership of the American Shoulder and Elbow Surgeons (ASES) in October of 2022. Questions posed included respondent demographics, fellowship training, career satisfaction, practice characteristics, and surgical case characteristics. Descriptive statistics were performed to report demographic information, assess job and training satisfaction rates, and evaluate practice characteristics. Chi-squared and independent samples t-tests were performed to analyze satisfaction rates, job applications, and surgical case volume with regard to years in practice and practice setting. RESULTS: Twenty percent (243/1248) of ASES members satisfactorily completed the survey. Of the 243 ASES member respondents, 97% (236/243) stated that they would pursue their fellowship training again. Ninety-eight percent (239/243) of respondents were satisfied with their specialty choice. One-hundred percent (242/243) were satisfied with their training in shoulder. Seventy-two percent (176/243) were satisfied with their training in elbow. Seventy-four percent (179/243) were satisfied with their job availability and 85% (207/243) were satisfied with their job location. The mean total number of orthopedic surgical cases per year was 393 ± 171. The mean total number of shoulder cases per year was 253 ± 149. The mean total number of elbow cases per year was 41 ± 41. Physicians who have been in practice for 11 years or more were comparatively more satisfied (90% vs. 80%) with their job location (P value = .008) and job availability (81% vs. 64%, P value < .001). Additionally, senior surgeons completed more orthopedic (431 vs. 347, P value < .001) and shoulder (279 vs. 220, P value = .002) cases annually than surgeons earlier in their careers. Satisfaction rates, job applications, and surgical case volume did not associate with practice setting. CONCLUSIONS: The majority of ASES member shoulder and elbow surgeons are satisfied with their training, their case volume and complexity, and their specialty choice. Fewer surgeons are satisfied with their elbow training and overall elbow case volume remains low among shoulder and elbow surgeons. Shoulder and elbow surgeons earlier in their careers perform fewer surgical cases, are less satisfied with their job availability and location, and completed more job applications for their first job after fellowship when compared to more senior surgeons.

Inlay vs. onlay humeral components in reverse total shoulder arthroplasty: a biorobotic shoulder simulator study.

BACKGROUND: Both inlay and onlay humeral implants are available for reverse total shoulder arthroplasty (rTSA), but biomechanical data comparing these components remain limited. This study investigated the effects of inlay and onlay rTSA humeral components on shoulder biomechanics using a biorobotic shoulder simulator. METHODS: Twenty fresh-frozen cadaveric shoulders were tested before and after rTSA with either an inlay or onlay humeral implant. Comparisons were performed between the most commonly implanted configurations for each implant (baseline) and with a modification to provide equivalent neck-shaft angles (NSAs) for the inlay and onlay configurations. Specimens underwent passive range-of-motion (ROM) assessment with the scapula held static, and scapular-plane abduction was performed, driven by previously collected human-subject scapulothoracic and glenohumeral kinematics. Passive ROM glenohumeral joint angles were compared using t tests, whereas muscle force and excursion data during scapular-plane elevation were evaluated with statistical parametric mapping and t tests. RESULTS: Maximum passive elevation was reduced for the inlay vs. onlay humeral components, although both implants caused reduced passive elevation vs. the native joint. Inlay rTSA also demonstrated reduced passive internal rotation at rest and increased external rotation at 90° of humerothoracic elevation vs. the native joint. All preoperative planning estimates of ROM differed from experiments. Rotator cuff forces were elevated with an onlay vs. inlay humeral implant, but simulated muscle excursions did not differ between systems. Compared with the native joint, rotator cuff forces were increased for both inlay and onlay implants and deltoid forces were reduced for inlay implants. Muscle excursions were dramatically altered by rTSA vs. the native joint. Comparisons of inlay and onlay humeral implants with equivalent NSAs were consistent with the baseline comparisons. CONCLUSIONS: Rotator cuff forces required to perform scapular-plane abduction increase following rTSA using both inlay and onlay implants. Rotator cuff forces are lower with inlay implants compared with onlay implants, although inlay implants also result in reduced passive-elevation ROM. Deltoid forces are lower with inlay implants in comparison to the native joint but not with onlay implants. The differences between inlay and onlay components are largely unaffected by NSA, indicating that these differences are inherent to the inlay and onlay designs. In those patients with an intact rotator cuff, decreased rotator cuff forces to perform abduction with an inlay humeral implant compared with an onlay implant may promote improved long-term outcomes owing to reduced deltoid muscle fatigue when using an inlay implant.

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.

Genomic Characterization of 2 Cutibacterium acnes Isolates from a Surgical Site Infection Reveals Large Genomic Inversion.

Background: Cutibacterium acnes is a common commensal of human skin but may also present as an opportunistic pathogen in prosthetic joint and wound infections. Unfortunately, few complete genomes of C. acnes are publicly available, and even fewer are of isolates associated with infection. Here we report the isolation, characterization, and complete genomes of 2 C. acnes isolates from a surgical site infection of an elbow. Methods: We used standard microbiological methods for phenotypic characterization and performed whole genome sequencing on 2 C. acnes isolates using a combination of short-read and long-read sequencing. Results: Antibiotic susceptibility testing showed beta-lactamase negative and low minimal inhibitory concentrations to all antibiotics tested, with the exception of metronidazole. We assembled complete genomes of the 2 isolates, which are approximately 2.5 megabases in length. The isolates belong to the single-locus sequence type (SLST) H1 and the multi-locus sequence type (MLST) IB. Both isolates have similar composition of known virulence genes, and we found no evidence of plasmids but did find phage-associated genes. Notably, the 2 genomes are 99.97% identical but contain a large genomic inversion encompassing approximately half of the genome. Conclusions: This is the first characterization of this large-scale genomic inversion in nearly identical isolates from the same wound. This report adds to the limited numbers of publicly available infection-associated complete genomes of C. acnes.