The effect of subscapularis-specific rehabilitation following total shoulder arthroplasty: a prospective, double-blinded, randomized controlled trial.

BACKGROUND: Patients undergoing a total shoulder arthroplasty (TSA) through a deltopectoral approach will require repair of the subscapularis tendon. There are no universal postoperative guidelines for rehabilitation of the subscapularis specifically. We hypothesize that the addition of a subscapularis-specific regimen will result in improved subscapularis strength and function. METHODS: Adult patients undergoing anatomic TSA for the treatment of primary glenohumeral osteoarthritis were included. Patients were randomized into either the traditional rehabilitation (TR) control group or the subscapularis rehabilitation (SR) group, which consisted of the traditional therapy along with early and additional subscapularis exercises. Baseline demographics, patient-reported outcome measures (PROMs), range of motion (ROM), provocative tests, and subscapularis strength using a handheld dynamometer were measured preoperatively at the initial clinic visit (ICV) as well as 3 months, 6 months, and 1 year postoperatively. The primary outcome of interest was a comparison of subscapularis strength between cohorts relative to preoperative baseline, whereas secondary outcomes were functional, ROM, and PROMs. RESULTS: Sixty-six patients were included in the final analysis (32 TR vs. 34 SR). There were no statistically significant differences between cohorts at the ICV with regard to demographics, baseline subscapularis strength, functional testing, or PROMs. All postoperative time points demonstrated similar subscapularis strength testing between TR and SR groups (P > .05). Additionally, peak and average subscapularis strength testing at 3, 6, and 12 months postoperatively were similar to baseline ICV testing in both groups. Both groups demonstrated improvements across several provocative tests, ROM, and PROM outcome metrics at every postoperative time point as compared to baseline ICV values (P < .05). CONCLUSIONS: Patients undergoing anatomic TSA return to baseline internal rotation strength by 3 months postoperatively and demonstrate significant improvements in function, ROM, and several patient-reported outcome measures. The addition of early and focused subscapularis strengthening exercises does not appear to significantly impact any outcomes when compared to traditional rehabilitation programs.

Time-Driven Activity-Based Costing Accurately Determines Bundle Cost for Rotator Cuff Repair.

PURPOSE: The purpose of this study was to determine the cost of the episode of care for primary rotator cuff repair (RCR) from day of surgery to 90 days postoperatively using the time-driven activity-based costing (TDABC) method. The secondary purpose of this study was to identify the main drivers of cost for both phases of care. METHODS: This retrospective case series study used the TDABC method to determine the bundled cost of care for an RCR. First, a process map of the RCR episode of care was constructed in order to determine drivers of fixed (i.e., rent, power), direct variable (i.e., healthcare personnel), and indirect costs (i.e., marketing, building maintenance). The study was performed at a Midwestern tertiary care medical system, and patients were included in the study if they underwent an RCR from January 2018 to January 2019 with at least 90 days of postoperative follow-up. In this article, all costs were included, but we did not account for fees to provider and professional groups. RESULTS: The TDABC method calculated a cost of $10,569 for a bundled RCR, with 76% arising from the operative phase and 24% from the postoperative phase. The main driver of cost within the operative phase was the direct fixed costs, which accounted for 35% of the cost in this phase, and the largest contributor to cost within this category was the cost of implants, which accounted for 55%. In the postoperative phase of care, physical therapy visits were the greatest contributor to cost at 59%. CONCLUSION: In a bundled cost of care for RCR, the largest cost driver occurs on the day of surgery for direct fixed costs, in particular, the implant. Physical therapy represents over half of the costs of the episode of care. Better understanding the specific cost of care for RCR will facilitate optimization with appropriately designed payment models and policies that safeguard the interests of the patient, physician, and payer. LEVEL OF EVIDENCE: IV, therapeutic case series.

Trends in Patient-Reported Outcomes Measurement Information System Scores Exist Between Day of Surgical Scheduling and Day of Surgery.

PURPOSE: To examine trends in Patient-Reported Outcome Measurement Information System (PROMIS) scores among orthopedic sports medicine patients undergoing surgery who completed PROMIS forms both in the ambulatory (preoperative) setting at the time of surgical scheduling, as well as on the day of surgery (perioperative) prior to their procedure. METHODS: Consecutive patients undergoing various sports medicine-related surgeries were recruited. Patients were included if they were scheduled for surgery and completed preoperative PROMIS on the day of surgical scheduling and on the day of surgery. Patients were excluded if they refused the questionnaire or had been administered perioperative anesthesia, which would interfere with questionnaire completion. Paired samples t-tests were run between preoperative and perioperative PROMIS scores to determine statistical significance. RESULTS: 153 patients were included with an average age of 46.5 years. The average (SD) time between completion of PROMIS questionnaires was 46.5 (44.4) days. The absolute value change in scores between preoperative and perioperative visits was 4.09 for PROMIS UE, 3.59 for PROMIS PF, 3.67 for PROMIS PI, and 4.13 for PROMIS D. The overall net change of scores between preoperative and perioperative visits were -.57 for PROMIS UE CAT, .16 points for PROMIS PF CAT, -.85 points for PROMIS PI CAT, and -2.14 points for PROMIS D CAT. Statistically significant differences in preoperative and perioperative PROMIS PI (P =.042) and PROMIS D (P =.004) scores were found. CONCLUSIONS: Health states-as measured by PROMIS CAT forms completed among patients undergoing orthopedic surgery-can either improve or worsen preoperatively between the time of administration in both the ambulatory and perioperative setting. Despite the existence of these preoperative trends, it is important to consider patient and surgery-specific causes, such as the anatomic region, type of surgical intervention, and timing of preoperative PROMIS administration. LEVEL OF EVIDENCE: III, prognostic.

Patients With Preoperative Clinical Depression Symptomology Experience Significant Improvements in Postoperative Pain, Function, and Depressive Symptoms Following Rotator Cuff Repair.

PURPOSE: To determine the impact of clinical depression on outcomes after rotator cuff repair (RCR), as measured by Patient-Reported Outcomes Measurement Information System (PROMIS) Computer Adaptive Test (CAT) health domains. METHODS: RCR patients were given PROMIS CAT assessments for physical function (PROMIS UE), pain interference (PROMIS PI), and depression (PROMIS D) during preoperative and postoperative clinic visits. PROMIS D scores ≥55 correlate with mild clinical depression; thus patients with PROMIS D scores ≥ 55 were placed in the clinical depression (CD) group, whereas patients with scores <55 were placed in the "no clinical depression" (NCD) group. Categorical variables were compared at preoperative and postoperative (6 months and ≥1 year) timepoints using χ2 tests. Continuous variables were compared using Student's t-tests. RESULTS: Of the 340 RCR patients included in this study, 65 (19.1%) were found to have mild clinical depression preoperatively, with that number being reduced to 23 (6.8%) at 6 months and 19 (5.6%) at ≥1 year after surgery. Compared with preoperative PROMIS scores, CD patients had significant postoperative improvements at 6 months and ≥1 year in mean PROMIS UE (26.7 vs 35.5 vs 38.9; P < .001) and PROMIS PI (67.6 vs 56.7 vs 56.4; P < .001). NCD patients had similar postoperative improvements at 6 months and ≥1 year in mean PROMIS UE (30.8 vs 38.6 vs 46.9; P < .001) and PROMIS PI (61.7 vs 53.0 vs 47.6; P < .001). The improvement in PROMIS scores was similar for the CD and NCD groups in both PROMIS UE (12.2 vs 16.1, respectively) and PROMIS PI (-11.2 vs -14.1, respectively). CONCLUSION: Despite starting with worse PROMIS UE and PROMIS PI scores, patients undergoing RCR with symptoms of CD experienced significant improvement in function, pain, and depressive symptoms. Preoperative depression should not be a contraindication to arthroscopic RCR in patients who are otherwise appropriate operative candidates. LEVEL OF EVIDENCE: Level III, retrospective comparative trial.

Establishing and comparing reference preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores in patients undergoing shoulder surgery.

BACKGROUND: The Patient-Reported Outcomes Measurement Information System (PROMIS) has become increasingly popular among orthopedic surgeons treating shoulder pathology. Despite this, there have been few studies that have described and compared preoperative reference scores for specific shoulder surgical procedures. The primary purpose of this study was to establish and compare baseline preoperative PROMIS scores for 3 common types of shoulder surgery: rotator cuff repair (RCR), total shoulder arthroplasty (TSA), and labral repair (LR). The secondary goal was to stratify these operative groups by diagnosis and compare preoperative PROMIS scores. METHODS: In this cross-sectional study, adult and pediatric patients who underwent surgery for either RCR, TSA, or LR were included. PROMIS-Upper Extremity (UE), PROMIS-Pain Interference (PI), and PROMIS-Depression (D) scores that were collected at each patient's preoperative visit were reviewed. Continuous and categorical variables were compared between operative groups using analysis of variance and χ2 or Fisher exact tests, respectively. Multivariable general linear models were used to identify significant independent predictors of PROMIS scores when controlling for age, sex, and body mass index. RESULTS: A total of 413 patients were included in the study: 272 in the RCR group, 84 in the TSA group, and 57 in the LR group. The average PROMIS-UE score was 39.8 in the LR group vs. 29.9 in the RCR group (P < .001) and 29.6 in the TSA group (P < .001). There was no difference between the mean RCR and TSA PROMIS-UE scores (P = .93). The average PROMIS-PI score was 56.6 in the LR group vs. 62.8 in the RCR group (P < .001) and 63.9 in the TSA group (P < .001). There was no difference between RCR and TSA PROMIS-PI scores (P = .09). The average PROMIS-D score was 43.5 in the LR group vs. 47.7 in the RCR group (P = .004) and 50.3 in the TSA group (P < .001). The TSA group had a higher mean PROMIS-D score than the RCR group (P = .03). For PROMIS-UE scores, age and body mass index were not found to be significant independent predictors (P = .98 and P = .88, respectively). For PROMIS-PI scores, age, body mass index, and sex were not found to be significant independent predictors (P = .31, P = .81, and P = .48, respectively). CONCLUSION: Patients undergoing shoulder LR had higher preoperative function scores and lower pain interference and depression scores than those undergoing TSA and RCR. These baseline PROMIS scores should be taken into consideration when tracking a patient's outcomes after surgery, as a certain score could mean drastically different functional and pain outcomes depending on the underlying pathology.

ß-Hydroxy ß-methylbutyrate free acid alters cortisol responses, but not myofibrillar proteolysis, during a 24-h fast.

This study was a randomised, double-blind, placebo-controlled cross-over trial examining the effects of ß-hydroxy ß-methylbutyrate free acid (HMB-FA) supplementation on muscle protein breakdown, cortisol, testosterone and resting energy expenditure (REE) during acute fasting. Conditions consisted of supplementation with 3 g/d HMB-FA or placebo during a 3-d meat-free diet followed by a 24-h fast. Urine was collected before and during the 24-h fast for analysis of 3-methylhistidine:creatinine ratio (3MH:CR). Salivary cortisol, testosterone, their ratio (T:C), and the cortisol awakening response were assessed. ANOVA was used to analyse all dependent variables, and linear mixed models were used to confirm the absence of carryover effects. Eleven participants (six females, five males) completed the study. Urinary HMB concentrations confirmed compliance with supplementation. 3MH:CR was unaffected by fasting and supplementation, but the cortisol awakening response differed between conditions. In both conditions, cortisol increased from awakening to 30 min post-awakening (P=0·01). Cortisol was reduced from 30 to 45 min post-awakening with HMB-FA (-32 %, d=-1·0, P=0·04), but not placebo (PL) (-6 %, d=-0·2, P=0·14). In males, T:C increased from 0 to 24 h of fasting with HMB-FA (+162 %, d=3·0, P=0·001), but not placebo (+13 %, d=0·4, P=0·60), due to reductions in cortisol. REE was higher at 24 h of fasting than 16 h of fasting independent of supplementation (+4·0 %, d=0·3, P=0·04). In conclusion, HMB-FA may affect cortisol responses, but not myofibrillar proteolysis, during acute 24-h fasting.

When Do Patients Achieve PROMIS Milestones After Rotator Cuff Repair?

Background: Given the variability of the questions asked, the Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) computer adaptive test (CAT) Version 2.0 item bank aids in the evaluation of rotator cuff repair (RCR) rehabilitation by determining when recovery milestones are possible based on the quality of patient responses at certain time points. Purpose: To assess the time point at which patients with RCR were able to achieve specific functional milestones, determined as positive responses to the 5 most frequently asked items on the PROMIS UE CAT Version 2.0. Study Design: Case series; Level of evidence, 4. Methods: The postoperative PROMIS UE CAT Version 2.0 scores of patients who underwent RCR between February 16, 2017, and July 30, 2019, were reviewed with respect to individual PROMIS item, response, and timing of response. A functional milestone was considered achieved if the patient response was "without any difficulty" or "with a little difficulty" to any of the 5 most frequently asked PROMIS items. The percentage of patients in each monthlong postoperative interval who answered with either response was recorded. The logit generalized estimating equations method was used to analyze the association between milestone achievement for each PROMIS item and predictor variables (age, sex, body mass index, smoking status, race, ethnicity, and employment status). Results: A total of 1131 responses from 371 patients were included. The majority of patients attained milestone achievement on 4 of the 5 most frequently asked PROMIS items at time points ranging from 1 to 5 months postoperatively: "Are you able to carry a shopping bag or briefcase?" (by 1 month), "Are you able to put on and take off a coat or jacket?" (by 3 months), "Are you able to pour liquid from a bottle into a glass?" (by 3 months), and "Are you able to carry a heavy object (over 10 pounds/5 kg)?" (by 5 months). For the item "Are you able to put on a shirt or blouse?", the majority of patients did not achieve the milestone by 1 year. Conclusion: These findings support the application of PROMIS UE CAT Version 2.0 milestone achievement in the shared decision-making process and postoperative monitoring, as patients can use this information to determine when they can return to certain activities and providers can apply these standards to identify patients needing additional clinical support.

Pre-Visit Digital Messaging Improves Patient-Reported Outcome Measure Participation Prior to the Orthopaedic Ambulatory Visit: Results from a Double-Blinded, Prospective, Randomized Controlled Trial.

BACKGROUND: Patient-reported outcome measures (PROMs) are metrics that assess physical health, mental health, pain, and satisfaction. However, PROM collection in orthopaedic clinics presents numerous logistical and financial challenges. These challenges are reduced when PROMs are completed before clinic encounters, relieving the workflow constraints of in-office PROM collection. The purpose of this study was to determine the efficacy of 3 different methods with respect to pre-visit electronic PROM completion. METHODS: Consecutive adult orthopaedic patients with no previous PROM participation were enrolled. Patients who registered with the electronic medical record (EMR) patient portal (MyChart) and with active e-mail addresses were randomly assigned to 1 of 3 arms: control (no pre-visit messages), MyChart (EMR patient portal pre-visit messages), and e-mail (e-mail pre-visit messages). The primary outcome measure was pre-visit PROM completion rates in orthopaedic patients, and the secondary outcome measures were time to pre-visit PROM form completion and PROM form completion rates according to patient demographic characteristics. By default, the Patient-Reported Outcomes Measurement Information System (PROMIS) forms were available for completion through the portal by 7 days before scheduled visits. Pre-visit messages were sent 7 days prior to the scheduled visit except in the control group, with reminders sent 3 days prior if still not completed. The patients in each arm who completed all assigned forms were labeled as having total PROM completion, and those who completed at least 1 completed form were considered as having partial PROM completion. Multivariable logistic regression models were used to assess differences in PROM completion rates between study arms. Kruskal-Wallis tests were performed to compare the date of the form completion. RESULTS: A total of 291 patients were included. The pre-visit total completion rates for assigned PROMs were higher in the MyChart arm (49% of 97 patients; p = 0.005) and the e-mail arm (52% of 100 patients; p = 0.002) in comparison with the control arm (30% of 94 patients). Male patients were more likely than female patients to have partial pre-visit PROM completion (odds ratio [OR], 1.74; p = 0.03), and Caucasian patients were more likely to have partial pre-visit PROM completion than African American patients (OR, 2.28; p = 0.01). CONCLUSIONS: Orthopaedic patients receiving either e-mail or patient portal messages demonstrated higher pre-visit PROM completion rates. Pre-visit messaging appears to be a useful strategy for increasing PROM completion rates and limiting the clinical workflow strain imposed by in-clinic PROM administration. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Percutaneous Achilles Tendon Repair Using Ultrasound Guidance: An Intraoperative Ultrasound Technique.

Rupture of the Achilles tendon is a common injury seen in patients of varying ages and activity levels. There are many considerations for treatment of these injuries, with both operative and nonoperative management providing satisfactory outcomes in the literature. The decision to proceed with surgical intervention should be individualized for each patient, including the patient's age, future athletic goals, and comorbidities. Recently, a minimally invasive percutaneous approach to repair the Achilles tendon has been proposed as an equivalent alternative to the traditional open repair, while avoiding wound complications associated with larger incisions. However, many surgeons have been hesitant to adopt these approaches due to poor visualization, concern that suture capture in the tendon is not as robust, and the potential for iatrogenic sural nerve injury. The purpose of this Technical Note is to describe a technique using high-resolution ultrasound guidance intraoperatively during minimally invasive repair of the Achilles tendon. This technique minimizes the drawbacks of poor visualization associated with percutaneous repair, while providing the benefit of a minimally invasive approach.

Maximum subjective outcome improvement is reported by 3 Months following arthroscopic partial meniscectomy: A systematic review.

Purpose: To review patient outcomes in the literature following arthroscopic partial meniscectomy (APM) in order to identify when patients report reaching subjective maximal improvement postoperatively. Methods: A systematic review of the literature from January 2004 to August 2019 was conducted using PRISMA guidelines to identify articles evaluating patient-reported outcome measures (PROMs) up to a minimum of 6 months after APM in patients >18 years old. Studies were excluded if additional interventions were performed such as repairs, ligamentous reconstruction or repair, cartilaginous manipulation, or revision surgery. PROMs were pooled between studies at preoperative, 3 months, 6 months, 1 year, and 2 year time points. Weighted averages were used within a mixed model method in order to account for the differences in sample size and variance among studies. Significant improvements in PROMs at various time intervals were statistically analyzed using minimal clinically important difference. Results: A total of 12 studies including 1663 patients who underwent APM were selected for the review. The pooled cohort consisted of 1033 (62%) males and 630 (38%) females. Significant improvements were demonstrated from preoperative scores to 3 months postoperatively in Knee Injury and Osteoarthritis Outcome Score subcategories, Lysholm, and visual analog scale scores while no differences were found for Tegner and International Knee Documentation Committee scores. Although statistically significant improvement in PROMs remained at all postoperative time points compared to preoperative scores, no significant differences were observed after 3 months postoperatively. Conclusions: Patients undergoing APM had significant mean changes in legacy PROMs by 3 months postoperatively that exceeded given minimal clinically important difference values, without further clinically important improvement reported up to 2 years postoperatively. Study design: Level III, systematic review.

Athletes Perceive Weighted Baseballs to Carry a Notable Injury Risk, yet Still Use Them Frequently: A Multicenter Survey Study.

INTRODUCTION: Weighted baseball use in throwing programs is widespread; however, their use remains controversial. Prior research shows that weighted baseball programs can increase ball velocity but potentially increase throwing arm injuries. This study aims to ascertain perceptions of weighted baseballs among elite baseball players. METHODS: A created online survey questioned common practices, throwing regimens, injury risk factors, and weighted baseball program use. The questions were modeled to ascertain the perceptions of elite baseball players to understand their experience with weighted baseballs. Descriptive statistical analysis was conducted. RESULTS: Three hundred seventy-six baseball players with a mean age of 20 ± 2 years completed the survey; 64% of the players (239/376) were pitchers. 71% (267/376) reported the use of weighted baseballs. Of those, 75% (199/267) thought it made them a better player. Overall, 73% (275/377) thought weighted baseballs are a risk for injury. 17% (46/267) attributed their injury to using weighted baseballs. Overall, participants reported a mean 72% ± 30% likelihood of future weighted baseball use. CONCLUSION: Most of the participating elite adult baseball players reported prior weighted baseball use with a corresponding improvement in pitching performance despite a perceived increased injury risk. Nearly 20% of the players attributed pain or injury to weighted baseball use. Moreover, the players surveyed intend to continue using weighted baseballs because of the perceived performance benefit.

Arthroscopic Repair of Humeral Avulsion of the Glenohumeral Ligament Lesion With Capsular Plication in the Lateral Decubitus Position.

Humeral avulsion of the glenohumeral ligament (HAGL) lesions can lead to persistent shoulder instability. While rare, HAGL lesions may present as a concomitant injury following shoulder dislocation events. Traditionally, an open approach has been used to repair the inferior glenohumeral ligament and restore shoulder stability. Modern arthroscopic techniques and instrumentation have permitted a minimally invasive approach for treating HAGL lesions. While technically demanding, arthroscopic repair of HAGL lesions has demonstrated favorable outcomes with less soft-tissue disruption. The following Technical Note describes a safe and effective method for the arthroscopic repair of HAGL lesions. Our technique highlights the use of the lateral decubitus position, a 70° arthroscope, a curved anchor device, and a 90° SutureLasso device.

The Presence of Preoperative Depression Symptoms Does Not Hinder Recovery After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: The current literature suggests a link between psychosocial factors and poor surgical outcomes in patients with musculoskeletal complaints. However, there remains a limited body of literature examining the effect of depression on outcomes after anterior cruciate ligament reconstruction (ACLR). PURPOSE: The primary purpose of this study was to compare postoperative function patient-reported outcome scores between patients with and patients without preoperative depression symptoms undergoing ACLR. Secondary goals included comparing postoperative pain interference and depression scores between the 2 groups. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: In this single-center retrospective cohort study, pediatric and adult patients who underwent ACLR were included. The Physical Function (PF), Pain Interference (PI), and Depression (D) domain scores of the Patient-Reported Outcomes Measurement Information System (PROMIS) were collected preoperatively and at 6 and 12 months postoperatively. Patients were separated into clinical depression (CD) and no clinical depression (NCD) groups based on their preoperative PROMIS-D score. RESULTS: A total of 82 patients undergoing ACLR were included in this study. Of these, 19 (23%) patients met criteria for the CD group. Preoperatively, the CD group reported lower mean PROMIS-PF (33.3 vs 39.7, respectively; P = .001), higher PROMIS-PI (65.7 vs 59.2, respectively; P <.01), and higher PROMIS-D (62.4 vs 45.1, respectively; P < .001) scores than the NCD group. At 12 months postoperatively, the mean PROMIS-PF scores for the CD and NCD groups were 52.1 and 56.7, respectively (P = .12). The mean 12-month postoperative PROMIS-PI scores for the CD and NCD groups were 52.3 and 47.4, respectively (P = .04). At 12 months after ACLR, there was a substantial improvement in PROMIS-PF and PROMIS-PI scores for both the CD (delta = +18.8 and -13.4, respectively) and NCD (delta = +17.0 and -11.8) groups. CONCLUSION: There was a significant improvement, which exceeded currently accepted minimal clinically important difference values, in PROMIS-PF scores at 12 months after ACLR, regardless of the presence of preoperative depression symptoms. These data suggest that having depression symptoms preoperatively does not significantly hinder a patient's recovery after ACLR.

Older, Male Orthopaedic Surgeons From Southern Geographies Prescribe Higher Doses of Post-Operative Narcotics Than do their Counterparts: A Medicare Population Study.

PURPOSE: We wanted to evaluate opioid prescribing patterns among orthopaedic surgeons and to identify demographics that may be associated with more extensive opioid prescribing habits that could be candidates for targeted education policies. METHODS: Medicare Part D prescriber and prescription information for the most recent available year, 2017, was accessed via a publicly available database offered by the Centers for Medicare and Medicaid. Number of total prescriptions, number of opioid prescriptions, and the total days' supply of opioids prescribed were analyzed for each of 19,219 orthopaedic surgeons. Demographics and board certification status were also recorded. RESULTS: Orthopaedic surgeons who wrote the most opioid prescriptions (>400 per year) also wrote the longest prescription durations (14.1 days/prescription, P < .05 for all comparisons). Surgeons with more than 30 years of experience wrote the longest prescriptions (11.8 days/prescription; P < .001). Male surgeons wrote more opioid prescriptions than female surgeons (151 vs 95, respectively; P < .001). However, female surgeons wrote longer prescriptions than male surgeons (7.5 days/prescription vs 6.1 days/prescription, respectively; P = .01). Surgeons from southern states wrote the most opioid prescriptions (1,386,897) and the longest prescriptions, with an average of 13.0 days per prescription, whereas western states wrote the shortest prescriptions at 10.4 days per prescription (P = .004). CONCLUSION: There are demographic correlations between orthopaedic surgeons and opioid prescribing patterns. In particular, male, older southern surgeons prescribe the highest volumes of opioids. This provides an opportunity for targeted education versus overarching, general policies. Potential directions for future investigation can focus on assessing recent trends in opioid prescriptions among orthopaedic providers. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

The Effect of the Crow Hop on Elbow Stress During an Interval Throwing Program.

BACKGROUND: Postoperative rehabilitation protocols after ulnar collateral ligament (UCL) reconstruction typically involve a structured interval throwing program. In an effort to minimize torque placed on the UCL, athletes are often instructed to throw with a crow hop, even at short throwing distances. However, the effect of the crow hop on medial elbow stress is unknown. PURPOSE/HYPOTHESIS: The purpose was to determine whether elbow stress differs with and without a crow hop across the throwing distances of a typical interval throwing program. We hypothesized that crow hop throws would generate lower torque on the elbow than standing throws at each distance of the interval throwing program. STUDY DESIGN: Controlled laboratory study. METHODS: Healthy high school and collegiate pitchers and position players were recruited from the surrounding area. Each player was outfitted with a wearable athletic sleeve and device that recorded elbow torque (Newton-meters), arm slot (degrees), arm speed (revolutions per minute), and shoulder rotation (degrees). Ball velocity (miles per hour) was measured using a radar gun. Players were instructed to perform 3 crow hop throws and 3 standing throws at distances of 30, 45, 60, 90, 120, 150, and 180 feet. A repeated measures analysis of variance was used to compare ball velocity, elbow torque, arm slot, arm speed, and shoulder rotation between crow hop and standing throws at each throwing distance. RESULTS: Twenty athletes participated in this study (average age, 17.8 years; range, 15-25 years). The average medial elbow torque increased at each distance for both crow hop and standing throws at distances of 30, 45, 60, and 90 feet (P < .05), after which there were no significant increases in elbow torque (P > .05). The average torque was higher for crow hop throws than standing throws at distances of 30 feet (13.9 N·m vs 12.0 N·m; P = .002), 45 feet (21.8 N·m vs 19.3 N·m; P = .005), and 60 feet (28.0 N·m vs 24.5 N·m; P = .02). CONCLUSION: Crow hop throws generated greater medial elbow torque than standing throws at distances up to 60 feet; however, there were no differences in elbow torque at distances greater than 60 feet between the 2 throw types. For both crow hop and standing throws, elbow stress increased at each distance interval up to 90 feet before plateauing at distances greater than 90 feet. The crow hop throwing technique does not reduce medial elbow stress during a simulated interval throwing program, and it may actually increase torque at shorter throwing distances. CLINICAL RELEVANCE: The results of our study indicate that it would be prudent for players to initially perform standing throws at shorter distances and only later be allowed to employ a natural crow hop at greater distances to minimize torque placed on the medial elbow during UCL rehabilitation protocols.

Using Wearable Technology to Evaluate the Kinetics and Kinematics of the Overhead Throwing Motion in Baseball Players.

Recent advancements in wearable technology have made kinetic and kinematic analysis of the throwing motion more accessible to recreational and professional baseball pitchers. Utilization of wearable technology to monitor the pitching motion has several potential applications for injury prevention and postinjury rehabilitation. However, the device must be properly applied to collect meaningful data. Erratic or inconsistent measurements can be caused by inadequate battery charge, incorrect sensor placement, and inadvertent motion capture of fielding maneuvers or other nonpitching throws. These problems can be overcome with a protocol that includes collecting biomechanical data in real time and routinely checking the sensor position throughout the duration of the throwing session. In this article, we outline our protocol for collecting biomechanical data and troubleshooting suboptimal device function during pitching sessions.

Primary Repair of Proximal Ulnar Collateral Ligament Ruptures in Pediatric Overhead Athletes.

Ulnar collateral ligament (UCL) injury is commonly seen in overhead throwing athletes resulting from the repetitive valgus stress placed on the medial elbow. UCL injuries (attenuation, insufficiency, or rupture) can result in medial elbow pain, a loss of pitch velocity and accuracy, and increased fatigue. Diagnosis can be made by performing a thorough physical examination along with imaging if indicated, such as ultrasound or magnetic resonance imaging. Treatment options include nonoperative in recreational athletes or those whose primary positions in sport are not high-volume throwing, such as position players in baseball. If nonoperative treatment fails, or the patient has potential for future high-level overhead activity such as a baseball pitcher, surgical repair or reconstruction may be indicated. This article describes our surgical technique for UCL repair in pediatric baseball pitchers.

Mini-Open Distal Biceps Tendon Repair Using All-Suture Anchors.

Distal biceps tendon ruptures are uncommon injuries that can cause impairment in range of motion and function. While distal bicep tendon repair to the radial tuberosity has been demonstrated to restore function and strength, there is a lack of consensus on the optimal technique. The purpose of this Technical Note and video is to provide our preferred method of repair using an open, onlay-tissue fixation with all-suture anchors (FiberTak; Arthrex) and anatomic positioning of the biceps tendon on the radial tuberosity.

Comprehensive Arthroscopic Shoulder Stabilization in the Lateral Decubitus Position.

Arthroscopic shoulder stabilization offers a safe and effective means for restoring glenohumeral mechanics in the setting of shoulder instability. Modern arthroscopic techniques have allowed improved access and efficiency when treating patients with shoulder instability. However, access to certain areas of the labrum and the creation of safe accessory portals can still prove difficult for the arthroscopic surgeon. Currently, there is debate as to the ideal patient position, portal location, equipment, and technique for addressing anterior-inferior labral pathology. The following article presents a safe and effective approach to accessing the labrum for treatment of shoulder instability in the lateral decubitus position. In addition, this paper highlights the use of accessory portals, including a percutaneous "7-o'clock" portal for suture anchor placement, along with multiple types of suture anchor and suture shuttling techniques.

Effects of two pre-workout supplements on concentric and eccentric force production during lower body resistance exercise in males and females: a counterbalanced, double-blind, placebo-controlled trial.

BACKGROUND: Pre-workout supplements purportedly enhance feelings of energy, reduce fatigue and improve exercise performance. The purpose of this study was to examine the performance effects of caffeinated and non-caffeinated multi-ingredient pre-workout supplements. METHODS: In a counterbalanced, double-blind, placebo-controlled design, eccentric and concentric force production during lower body resistance exercise on a mechanized squat device were assessed after supplement ingestion. Repetitions-in-reserve/RPE and subjective feelings of energy, focus and fatigue were also examined. Twenty-one resistance-trained adults (12 F, 9 M) completed three conditions in random order: caffeinated supplement, non-caffeinated supplement and placebo. Subjects were not informed of the presence of a placebo condition. Thirty minutes after supplement ingestion, a 3-repetition maximum test and 5 sets of 6 repetitions were completed using the squat device. Each repetition involved 4-s eccentric and concentric phases, and the force signal throughout each repetition was sampled from a load cell contained within the squat device. The scaled and filtered force signals were analyzed using customized software. Repeated measures analysis of variance and appropriate follow-up analyses were utilized to compare dependent variables, and relevant effect sizes (d) were calculated. RESULTS: Supplement or placebo ingestion led to similar subjective responses (p > 0.05). Energy (+8 to 44%; d = 0.3 to 0.8) and focus (+8 to 25%; d = 0.3 to 0.5) were acutely increased by supplement or placebo ingestion and decreased as the exercise session progressed. Fatigue was acutely decreased by supplement or placebo ingestion (-7 to 38%; d = -0.1 to -0.6) and increased as the exercise session progressed. Eccentric and concentric forces were unimproved by supplementation during the exercise sets for both sexes. In the non-caffeinated supplement condition only, maximal eccentric force production was lower during sets 3 to 5, as compared to set 1 (p < 0.05). Effect size data indicated that both the caffeinated and non-caffeinated supplements may contribute to small increases in concentric force production in males (+5 to 20%, d = 0.2 to 0.4 relative to placebo), but not females. CONCLUSIONS: As compared to placebo, caffeinated and non-caffeinated multi-ingredient pre-workout supplements failed to improve concentric and eccentric force production. In males, effect size data indicate a possible small benefit of supplementation on concentric force production, although this was not statistically significant. When resistance-trained subjects were unaware of the presence of a placebo, resistance exercise performance was similar regardless of whether a placebo or multi-ingredient supplement was ingested.