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.

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

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

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.

Active physical therapy does not improve outcomes after reverse total shoulder arthroplasty: a multi-center, randomized clinical trial.

OBJECTIVE: To compare range of motion (ROM) and patient-reported outcomes (PROs) between a structured home exercise program (HEP) and active, supervised physiotherapy (PT) after primary Reverse total shoulder arthroplasty (RTSA) by performing a multicenter randomized clinical trial. METHODS: Patients undergoing primary RTSA at 2 centers were randomized to either a HEP group, in which they were given a handout and a rope pulley, or a PT group, in which they were given a standardized prescription. Surgical technique and implants were standardized. At baseline, 6 weeks, 3 months, and 1 year postoperatively, we obtained American Shoulder and Elbow Surgeons scores, Western Ontario Osteoarthritis Scores, visual analogue scale for pain scores, and measured ROM via videotape. On video, ROM was then measured by blinded observers. At all study visits, patients were asked how many days per week they were in PT and how many days a week they completed HEP to determine compliance and crossover. An a priori power analysis suggested 29 patients per group, 56 patients total to detect a difference of 30° in active forward elevation with a power of 0.8 at a 2-sided alpha of 0.05. RESULTS: 89 patients were randomized, 43 to PT, and 46 to HEP. We obtained 1-year PRO follow-up on 83 patients (93%) and ROM follow-up on 73 patients (82%). Nine patients (20%) crossed over from HEP to PT and 2 patients (4%) crossed over from PT to HEP. Complications occurred in 13% of HEP and 17% of PT patients (P = .629). Using mixed models that account for baseline values, there were no significant differences between groups in PROs or ROM at final follow-up. CONCLUSION: In this 2-center, randomized clinical trial, there were no significant differences in patient outcomes or ROM between HEP and PT after RTSA. These findings suggest that it may not be necessary to recommend PT as a protocol for all patients after RTSA.

High Survivorship of a Modular Titanium Baseplate Independent of Body Mass Index and Malalignment.

BACKGROUND: Tibial component aseptic loosening remains problematic in primary total knee arthroplasty (TKA). Influential factors include component design, metallurgy, and cement technique. Additionally, reports advocate for longer tibial stem fixation in high body mass index (BMI) patients. We have utilized a single stem length modular titanium baseplate in patients regardless of BMI, bone quality, or malalignment. We report the survivorship of this implant with focus on the impact of elevated BMI and postoperative malalignment. METHODS: We retrospectively reviewed patients who underwent TKA with a single modular titanium baseplate with a cruciate-shaped keel between 2004 and 2018. In total, 2,949 TKAs with a minimum of 1-year follow-up were included. The mean follow-up was 7 years. The primary outcome was component failure stratified by BMI and postoperative malalignment. High viscosity cement was utilized in all cases. Chi-squared and t-tests were used to compare outcome variables across groups. RESULTS: Eighty-five implants (2.8%) were revised with 46 (1.6%) for aseptic loosening. Failure was not associated with BMI, gender, American Society of Anesthesiologists class, or Charlson Comorbidity Index. There was no difference in failure rate by BMI (P = .26) or by malalignment (outside of 3° from neutral mechanical axis) (P = .67). Age was associated with failure as patients with failed TKAs were younger (61 vs 65, P < .01). CONCLUSION: This design of a specific modular titanium base plate with a cruciate-shaped keel and grit blast surface demonstrated 99% survivorship regardless of patient BMI or malalignment over 7-year follow-up period. Consistent cement technique with high viscosity cement indicates that component design remains an important variable impacting survivorship in TKA.