Publications by authors named "David W Altchek"

138 Publications

Arthroscopic-Assisted Coracoclavicular Ligament Reconstruction: Clinical Outcomes and Return to Activity at Mean 6-Year Follow-Up.

Arthroscopy 2021 04 2;37(4):1086-1095.e1. Epub 2020 Dec 2.

Sports Medicine Institute, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, U.S.A.

Purpose: To report clinical and functional outcomes including return to preinjury activity level following arthroscopic-assisted coracoclavicular (CC) ligament reconstruction (AA-CCR) and to determine associations between return to preinjury activity level, radiographic outcomes, and patient-reported outcomes following AA-CCR.

Methods: A institutional registry review of all AA-CCR using free tendon grafts from 2007 to 2016 was performed. Clinical assessment included Single Assessment Numeric Evaluation (SANE) score and return to preinjury activity level at final follow-up. Treatment failure was defined as (1) revision acromioclavicular stabilization surgery, (2) unable to return to preinjury activity level, or (3) radiographic loss of reduction (RLOR, >25% CC distance compared with contralateral side). SANE scores, return to activity, and RLOR were compared between patients within each category of treatment failure, by grade of injury, and whether concomitant pathology was treated.

Results: There were 88 patients (89.8% male) with mean age of 39.6 years and minimum 2-year clinical follow-up (mean 6.1 years). Most injuries were Rockwood grade V (63.6%). Mean postoperative SANE score was 86.3 ± 17.5. Treatment failure occurred in 17.1%: 8.0% were unable to return to activity, 5.7% had RLOR, and 3.4% underwent revision surgery due to traumatic reinjury. SANE score was lower among patients who were unable to return to activity compared with those with RLOR and compared with nonfailures (P = .0002). There were no differences in revision surgery rates, return to activity, or SANE scores according to Rockwood grade or if concomitant pathology was treated.

Conclusions: AA-CCR with free tendon grafts resulted in good clinical outcomes and a high rate of return to preinjury activity level. RLOR did not correlate with return to preinjury activity level. Concomitant pathology that required treatment did not adversely affect outcomes. Return to preinjury activity level may be a more clinically relevant outcome measure than radiographic maintenance of acromioclavicular joint reduction.

Level Of Evidence: IV (Case Series).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arthro.2020.11.045DOI Listing
April 2021

Return to Play After Biceps Tenodesis and Transfer in a Young, Athletic Population.

Orthopedics 2021 Jan 3;44(1):e13-e18. Epub 2020 Nov 3.

The goal of this study was to investigate the level of play that can be expected in a young, athletic population after biceps tenodesis and transfer. The authors hypothesized that both return to play rates and clinical improvement would be high after biceps tenodesis and transfer among young athletes. They conducted a retrospective review of patients who underwent biceps tenodesis and transfer procedures with a minimum follow-up of 24 months. Eligible patients were contacted for consent and asked to complete a questionnaire on patient-reported, shoulder-specific outcome measure scores, level of postoperative play, and other relevant information. The study included 41 patients with a mean age of 21.3 years. Patients reported a mean Kerlan-Jobe Orthopaedic Clinic (KJOC) score of 71.7, Disabilities of the Arm, Shoulder and Hand (DASH)-Sports score of 21.3, Single Assessment Numeric Evaluation (SANE) score of 79.4, and Numeric Rating Scale (NRS) pain score of 1.8. Scores for all patient-reported outcome measures were statistically better (P<.05) for patients who underwent biceps transfer (n=24) compared with biceps tenodesis (n=17). Of the participants, 26 (63%) played a primary overhead throwing sport. Most of the patients (95%) returned to play, and of those who returned to play, 67% returned to their preoperative level or higher. Although biceps tenodesis and transfer procedures have been designated primarily for older patients with biceps-labral complex injuries, the high return to play rates and outcome scores of patients in this case series show that biceps tenodesis and transfer can provide effective surgical treatment for a younger athletic population with biceps-labral complex injuries. [Orthopedics. 2021;44(1):e13-e18.].
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3928/01477447-20201009-03DOI Listing
January 2021

Ulnar Collateral Ligament Tear Location May Affect Return-to-Sports Rate but Not Performance Upon Return to Sports After Ulnar Collateral Ligament Reconstruction Surgery in Professional Baseball Players.

Am J Sports Med 2020 09 18;48(11):2608-2612. Epub 2020 Aug 18.

Hospital for Special Surgery, New York, New York, USA.

Background: The number of ulnar collateral ligament (UCL) tears in professional baseball players is increasing. UCL reconstruction (UCLR) is the treatment of choice in players with failed nonoperative treatment who wish to return to sports (RTS). It is unknown if UCL tear location influences the ability of players to RTS or affects their performance upon RTS.

Purpose/hypothesis: The purpose was to compare the RTS rate and performance upon RTS in professional baseball players who underwent UCLR based on UCL tear location (proximal vs distal). It was hypothesized that no difference in RTS rate or performance upon RTS will exist between players with proximal or distal UCL tears.

Study Design: Cohort study; Level of evidence, 3.

Methods: All professional baseball players who underwent primary UCLR by a single surgeon between 2016 and 2018 were eligible for inclusion. Players with purely midsubstance tears or revision UCLR were excluded. Tear location was determined based on preoperative magnetic resonance imaging (MRI) and intraoperative findings. RTS rate and performance were compared between players with proximal versus distal UCL tears.

Results: Overall, 25 pitchers (15 proximal and 10 distal tears) and 5 position players (2 proximal and 3 distal) underwent primary UCLR between 2016 and 2018. Of the 25 pitchers, 84% were able to RTS. Of the 5 position players, 80% were able to RTS. Among the total cohort of pitchers and position players, 12 out of 17 (71%) players with proximal tears were able to RTS, while of the 13 distal tears, 13 out of 13 (100%) players were able to RTS ( = .05). With regard to performance data, pitchers with distal tears had higher utilization postoperatively and, as such, allowed statistically more hits ( = .03), runs ( = .015), and walks ( = .021) postoperatively. However, the WHIP ([walks + hits]/innings pitched) was not different between players with proximal or distal tears, indicating that efficacy in games was not significantly different between groups.

Conclusion: Professional baseball players who sustain a distal UCL tear and undergo UCLR may be more likely to RTS than those who sustain a proximal UCL tear and undergo UCLR. Players with distal UCL tears who underwent UCLR saw higher utilization postoperatively than those with proximal UCL tears. Further work is needed in this area to confirm this result.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0363546520947090DOI Listing
September 2020

Development and Validation of the Hospital for Special Surgery Anterior Cruciate Ligament Postoperative Satisfaction Survey.

Arthroscopy 2020 07 10;36(7):1897-1903. Epub 2020 Mar 10.

Hospital for Special Surgery, New York, New York, U.S.A.

Purpose: To develop and validate a standardized patient satisfaction measurement tool for adult patients undergoing primary anterior cruciate ligament reconstruction (ACLR).

Methods: A 4-phase iterative process that included item generation and pilot survey development, item reduction, survey readability, and survey validation was used. To develop and validate the Hospital for Special Surgery ACL Satisfaction Survey (HSS ACL-SS), 70 patients were included in the survey development phase and 77 patients were included in the validation phase. The HSS ACL-SS was compared with other currently used ACLR outcome measures including the International Knee Documentation Committee score, Tegner-Lysholm score, Short Form 12 (SF-12) Mental Component Score, and SF-12 Physical Component Score. Test-retest reliability, internal consistency, convergent and discriminant validity, and floor and ceiling effects were assessed.

Results: The HSS ACL-SS consists of 10 items identified by patients as being important for satisfaction after ACLR. In the validation phase, the mean score on the HSS ACL-SS (of 50) among all patients was 37.9 ± 9.9 (range, 10-50). Statistically significant positive correlations were seen between the HSS ACL-SS score and the International Knee Documentation Committee score (r = 0.351, P = .002) and Tegner-Lysholm score (r = 0.333, P = .003). No statistically significant correlation was found between the satisfaction score and the SF-12 Mental or Physical Component Score. The lowest possible score (10 of 50 points) was achieved in 1 patient (1.3%) and the highest possible score (50 of 50 points) was achieved in 7 patients (9.1%), indicating no significant floor or ceiling effects of the instrument. Internal consistency for all 10 items was strong (Cronbach α, 0.995). The mean intraclass correlation coefficient between test and retest responses was 0.701, indicating moderate agreement.

Conclusions: The HSS ACL-SS is a validated and reliable patient-derived satisfaction measure with excellent psychometric properties for active adults undergoing ACLR. The results of this study show that the HSS ACL-SS may be a useful tool to measure postoperative patient satisfaction.

Level Of Evidence: Level II, development of diagnostic or monitoring criteria in consecutive patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arthro.2020.02.043DOI Listing
July 2020

Upper Extremity and Hip Range of Motion Changes Throughout a Season in Professional Baseball Players.

Am J Sports Med 2020 02 31;48(2):481-487. Epub 2019 Dec 31.

Division of Sports and Shoulder, Hospital for Special Surgery, New York, New York, USA.

Background: Loss of upper and lower extremity range of motion (ROM) is a significant risk factor for injuries in professional baseball players.

Purpose/hypothesis: The purpose was to determine changes in ROM in professional baseball players over the course of a single season and their careers. We hypothesized that pitchers and position players would lose ROM, specifically total shoulder motion (total ROM [TROM]) and hip internal rotation (IR), over the course of a season and their careers.

Study Design: Case series; Level of evidence, 4.

Methods: Upper and lower extremity ROM measurements were recorded during pre-, mid-, and postseason on all professional baseball players for a single organization between 2011 and 2018. ROM measurements were compared for pitchers and position players over the course of the season and their careers. Also, ROM measurements over the pre-, mid-, and postseason were compared between pitchers and position players.

Results: A total of 166 professional baseball players (98 pitchers, 68 position players) were included. Pitcher hip external rotation (ER; .001), IR ( .010), and TROM ( .001) for lead and trail legs decreased over the course of the season. Pitcher shoulder ER ( = .005), TROM ( .042), and horizontal adduction ( .001) significantly increased over the course of the season. Position player shoulder flexion ( .046), hip ER ( .001, lead leg; .001, trail leg), and hip TROM ( .001; .002) decreased over the course of the season. Position player shoulder ER ( .031) and humeral adduction ( .001) significantly increased over the course of the season. Over the course of pitchers' careers, there was decreased shoulder IR ( .014), increased shoulder horizontal adduction ( .001), and hip IR ( .042) and hip TROM ( .027) for the lead leg. Position players experienced loss of hip TROM ( .010, lead leg; .018, trail leg) over the course of their careers. Pitchers started with and maintained more shoulder ER and gained more shoulder TROM over a season as compared with position players.

Conclusion: Pitchers and position players saw overall decreases in hip ROM but increases in shoulder ROM over the course of the season and career.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0363546519894567DOI Listing
February 2020

Reconstruction of the Medial Ulnar Collateral Ligament of the Elbow: Biomechanical Comparison of a Novel Anatomic Technique to the Docking Technique.

Orthop J Sports Med 2019 Jul 17;7(7):2325967119857592. Epub 2019 Jul 17.

Investigation performed at the Mayo Clinic, Rochester, Minnesota, USA.

Background: In recent years, understanding of the anatomy of the ulnar collateral ligament (UCL) has evolved, demonstrating that the insertional footprint of the UCL on the ulna is more elongated and distally tapered than previously described. Current UCL reconstruction configurations do not typically re-create this native anatomy, which may represent a potential area for improvement.

Purpose/hypothesis: The purposes of this study were (1) to describe a novel anatomic UCL reconstruction technique designed to better replicate the native UCL anatomy and (2) to biomechanically compare this with the docking technique. The hypothesis was that the ultimate load to failure for the anatomic technique would not be inferior to the docking technique.

Study Design: Controlled laboratory study.

Methods: A total of 16 fresh-frozen cadaveric upper extremities (8 matched pairs) were utilized. One elbow in each pair was randomized to receive UCL reconstruction via the docking technique or the novel anatomic UCL reconstruction technique with palmaris tendon autograft. Following reconstruction, biomechanical testing was performed by applying valgus rotational torque at a constant rate of 5 deg/s until ultimate mechanical failure of the construct occurred. Maximal torque (N·m), rotation stiffness (N·m/deg), and mode/location of failure were recorded for each specimen.

Results: The mean ultimate load to failure for elbows in the docking technique group was 23.8 ± 6.1 N·m, as compared with 31.9 ± 8.4 N·m in the anatomic technique group ( = .045). Mean rotational stiffness was 1.9 ± 0.7 versus 2.3 ± 0.9 N·m/deg for the docking and anatomic groups, respectively ( = .338). The most common mode of failure was suture pullout from the graft, which occurred in all 8 (100%) docking technique specimens and 7 of 8 (88%) specimens that underwent the anatomic UCL reconstruction technique.

Conclusion: Ultimately, the anatomic UCL reconstruction technique demonstrated superior strength and resistance to valgus torque when compared with the docking technique, and this was comparable with that of the native UCL from prior studies. Increased initial strength may allow for earlier initiation of throwing postoperatively and potentially shorten return-to-play times.

Clinical Relevance: Current UCL reconstruction techniques do not accurately reproduce the UCL insertional anatomy on the ulna. The novel anatomic technique described may result in more natural joint kinematics. This study demonstrated load-to-failure rates that are significantly higher than with the docking technique and consistent with the native ligament, as reported from previous studies. These findings may serve as a foundation for future clinical study and optimization of this technique.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2325967119857592DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6852368PMC
July 2019

Do Professional Baseball Players With a Higher Valgus Carrying Angle Have an Increased Risk of Shoulder and Elbow Injuries?

Orthop J Sports Med 2019 Aug 27;7(8):2325967119866734. Epub 2019 Aug 27.

Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA.

Background: There are many risk factors for shoulder and elbow injuries in professional baseball pitchers. The elbow carrying angle has not been studied as a potential risk factor.

Purpose/hypothesis: The aim of this study was to determine whether elbow carrying angle is a risk factor for shoulder or elbow injuries in professional baseball pitchers. We hypothesized that pitchers with a higher elbow carrying angle would be less likely to sustain an injury during the season than pitchers with a lower elbow carrying angle.

Study Design: Cohort study; Level of evidence, 2.

Methods: All professional pitchers for a single baseball club during the 2018 season had the carrying angle of both elbows measured at spring training by a single examiner. The pitchers were followed prospectively throughout the season. Shoulder and elbow injuries were recorded prospectively.

Results: A total of 52 pitchers (21 [40%] Major League Baseball and 31 [60%] Minor League Baseball) were included. During the season, 23 (44%) pitchers became injured. The mean carrying angle in the throwing arm was 12.5° ± 4.2° versus 9.9° ± 2.8° in the nonthrowing arm ( < .001). Comparing the injured and noninjured groups, there were no differences in level of play ( = .870), throwing hand dominance ( = .683), batting hand dominance ( = .554), throwing-side carrying angle ( = .373), nonthrowing-side carrying angle ( = .773), or side-to-side difference in carrying angle ( = .481).

Conclusion: The elbow carrying angle was not associated with an injury risk during a single season in professional baseball pitchers.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2325967119866734DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6712761PMC
August 2019

Magnetic Resonance Imaging Grading System for Tears of the Latissimus Dorsi and Teres Major.

Orthop J Sports Med 2019 Mar 4;7(3):2325967119826548. Epub 2019 Mar 4.

Hospital for Special Surgery, New York, New York, USA.

Background: Recent awareness of latissimus dorsi/teres major (LD/TM) injuries has led to an increase in diagnoses. No magnetic resonance imaging (MRI) classification system specific to the LD/TM exists, nor has tear severity been correlated with ability to return to sport (RTS).

Purpose/hypothesis: The purpose of this study was to report a novel MRI classification system for LD/TM tears as well as to correlate tear grade with performance and RTS. We hypothesized that the new MRI classification system would have high intra- and interobserver reliabilities and that players with higher grade tears would require operative management.

Study Design: Cohort study (diagnosis); Level of evidence, 3.

Methods: All patients with LD/TM tears diagnosed by MRI who were under the care of 2 orthopaedic surgeons were included. On 2 occasions 60 days apart, MRIs were reviewed and graded by 2 authors using a new classification system. Intra- and interobserver reliabilities were calculated. Timing from injury to RTS was recorded, and performance upon RTS was analyzed.

Results: The proposed grading system had excellent intra- and interrater reliabilities (Cohen kappa >0.850). A total of 20 male patients (mean ± SD age, 26 ± 9.3 years) with LD/TM tears were included (80% were baseball pitchers). Of the 16 players treated operatively, 5 were initially treated nonoperatively by an outside physician but could not RTS (all professional baseball pitchers); 2 of these players had grade IIIA tears and 3 of the players had grade IVA tears. Regardless of initial treatment, ultimately 100% of the professional baseball players were able to RTS at a mean of 8.7 ± 3.3 months, although the initial nonoperative management failed for some of these players and they needed surgical intervention. No statistically significant differences were found between pre- versus postoperative performance in those professional players who were treated surgically.

Conclusion: The proposed MRI-based grading system for LD/TM tears had excellent reliability. This system may allow physicians to better advise patients and all involved health care providers. Consideration should be given to acutely treat grade III and IV tears with operative repair.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2325967119826548DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6700928PMC
March 2019

Revision Ulnar Collateral Ligament Reconstruction in Professional Baseball: Current Trends, Surgical Techniques, and Outcomes.

Orthop J Sports Med 2019 Aug 14;7(8):2325967119864104. Epub 2019 Aug 14.

Peachtree Orthopedics, Atlanta, Georgia, USA.

Background: Ulnar collateral ligament (UCL) reconstruction of the elbow is commonly performed on professional baseball pitchers. Recent reports have suggested that revision rates are on the rise and may be higher than previously thought.

Purpose: To provide a comprehensive report on current trends, surgical techniques, and outcomes of revision UCL reconstructions performed on professional baseball pitchers between 2010 and 2016.

Study Design: Case series; Level of evidence, 4.

Methods: The Major League Baseball Health and Injury Tracking System (HITS) was used to compile records of all revision UCL reconstructions performed on professional baseball pitchers between 2010 and 2016. Player data and outcomes were obtained from HITS, and surgical details were obtained from operative reports. Descriptive statistical analysis was performed on epidemiologic data. Outcomes (return to play [RTP] rates, RTP times, subsequent injuries, and subsequent surgeries) were compared across the most common surgical techniques (docking vs modified Jobe) and graft sources (palmaris longus autograft vs hamstring autograft).

Results: A total of 69 professional baseball pitchers underwent revision UCL reconstruction from 2010 to 2016 at an average of 1424 days (47 months) after their primary surgery. A trend was seen toward increasing numbers of revision surgeries over time ( = 0.441; = .104). The most commonly used tunnel configuration was the modified Jobe technique (n = 41; 59.4%), and the most commonly used graft was hamstring autograft (n = 34; 49.3%). A majority (76.6%) of pitchers achieved RTP, and 55.3% were able to return to the same level of play. Mean time to RTP was 436 days (14.5 months) for players with a palmaris longus autograft versus 540 days (18 months) for those with a hamstring autograft ( = .108). Further, the mean time to RTP was 423 days (14 months) for the docking technique versus 519 days (17 months) for the modified Jobe technique ( = .296). Similar rates of subsequent injuries and surgeries were noted between the 2 revision techniques and 2 most commonly used graft constructs.

Conclusion: Revision UCL reconstruction showed relatively high RTP rates (77%), but only 55% of players returned to their same level of play. Mean time to RTP was shorter than that found in other, smaller investigations. Although general trends were seen toward decreased time to RTP for the docking technique and palmaris longus autograft, these differences did not reach statistical significance.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2325967119864104DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6696849PMC
August 2019

Comparison of Outcomes Based on Graft Type and Tunnel Configuration for Primary Ulnar Collateral Ligament Reconstruction in Professional Baseball Pitchers.

Am J Sports Med 2019 04 21;47(5):1103-1110. Epub 2019 Mar 21.

Division of Sports Medicine, Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA.

Background: Professional baseball pitchers are at high risk for tears of the ulnar collateral ligament (UCL) of the elbow, often requiring surgical reconstruction. Despite acceptable published return-to-play outcomes, multiple techniques and graft types have been described.

Purpose: This study compares UCL reconstruction (UCLR) outcomes based on tunnel configuration and graft type.

Study Design: Cohort study; Level of evidence, 3.

Methods: After approval from our institutional review board and Major League Baseball (MLB), 566 professional baseball pitchers who underwent UCLR between 2010 and 2014 were identified and included. The following patient characteristics were analyzed: age, pitching role (starter vs reliever), level of play (MLB vs Minor League Baseball [MiLB]), and throwing side dominance. Surgical factors analyzed included reconstruction technique, graft type, and concomitant procedures. Primary outcome measures consisted of the ability to return to play at any level (RTP), ability to return to the same level of play (RSL), time to return, subsequent elbow injuries, and need for subsequent or revision elbow surgery. The effects of patient and surgical factors on outcomes were analyzed using multivariate linear and logistic regression modeling.

Results: The RTP rate was 79.9%, and the RSL rate was 71.2%. Grafts used to reconstruct the UCL included the palmaris longus autograft (n = 361, 63.7%), the gracilis autograft (n = 135, 23.8%), and other grafts (n = 70, 12.5%). Surgical techniques utilized were the docking technique (n = 171, 30.2%), the modified Jobe technique (n = 290, 51.2%), and other techniques (n = 105, 18.6%). There were no significant differences in the time to RTP or RSL based on reconstruction technique or graft type. RTP rates were similar for the docking versus modified Jobe technique (80.1% vs 82.4%, respectively; P = .537) and for the 2 primary graft types (83.1% for palmaris longus vs 80.7% for gracilis; P = .596). The rate of subsequent elbow surgery was 10.5% for the docking technique versus 14.8% for the modified Jobe technique ( P = .203), and the rate of revision UCLR was 2.9% versus 6.2% for the docking versus modified Jobe technique, respectively ( P = .128). Significant trends toward an increasing use of the palmaris longus autograft ( P = .023) and the docking technique ( P = .006) were observed. MLB pitchers were more likely than MiLB pitchers to RTP ( P < .001) and RSL ( P < .001), but they required a longer time to return (mean difference, 35 days; P = .039) and had a higher likelihood of subsequent elbow (odds ratio [OR], 3.58 [95% CI, 2.06-6.23]; P < .001) and forearm injuries (OR, 5.70 [95% CI, 1.99-16.30]; P = .004) but not subsequent elbow surgery. No specific variables correlated with the rates of subsequent elbow surgery or revision UCLR in the multivariate analysis. The use of concomitant ulnar nerve transposition did not affect outcomes.

Conclusion: Surgical outcomes in professional baseball players are not significantly influenced by UCLR technique or graft type. There was a high rate (46.3%) of subsequent throwing elbow injuries. MLB pitchers were more likely to RTP and RSL, but they had a higher frequency of subsequent elbow and forearm injuries than MiLB pitchers. Both the docking technique and the palmaris longus autograft are increasing in popularity among surgeons treating professional baseball players.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0363546519831705DOI Listing
April 2019

On-field Management of Shoulder and Elbow Injuries in Baseball Athletes.

Curr Rev Musculoskelet Med 2019 Jun;12(2):67-71

Department of Sports Medicine and Shoulder Surgery, Hospital for Special Surgery, 525 E. 71st Street, New York, NY, 10021, USA.

Purpose Of Review: The goal of this review article is to help medical personnel of all levels and backgrounds identify and appropriately manage on-field acute shoulder and elbow injuries in the baseball athlete. This article discusses the most common acute shoulder and elbow injuries in baseball players along with recommendations for appropriate on-field management.

Recent Findings: Shoulder and elbow injuries are very common in baseball players and can be problematic because of the unique demands placed on the shoulder and elbow during the throwing and swinging motions. While many shoulder and elbow injuries in baseball players are chronic, some acute injuries, including dislocations and fractures, require urgent on-field management. Evaluation should begin with a broad assessment to rule out life-threatening emergencies prior to performing a neurovascular evaluation of the affected extremity. Red-flag signs during examination, such as difficulty breathing, asymmetric pulses, weakness, and limb discoloration, require emergent treatment. In the absence of an emergency, the evaluating medical team should complete a basic neurovascular exam before performing any further on-field care. Contusions, dislocations, and fractures are the most commonly seen acute shoulder and elbow injuries in baseball athletes. Athletic trainers and physicians caring for these athletes should be familiar with these injuries and their appropriate on-field management.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s12178-019-09535-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6543043PMC
June 2019

Injuries of the Biceps and Superior Labral Complex in Overhead Athletes.

Curr Rev Musculoskelet Med 2019 Jun;12(2):72-79

Department of Sports Medicine and Shoulder Surgery, Hospital for Special Surgery, New York, NY, USA.

Purpose Of Review: To summarize the current anatomy, biomechanics, presentation, treatment, and outcomes of injuries to the biceps and superior labral complex in overhead athletes.

Recent Findings: The biceps and superior labral complex is composed of anatomically distinct zones. The inability to accurately diagnose biceps lesions contributes to continued morbidity especially as arthroscopy and advanced imaging fail to fully evaluate the entire course of the biceps tendon. Superior labrum anterior and posterior (SLAP) repair, long head of biceps tenodesis, and tenotomy are the most common operative techniques for surgical treatment of biceps-labral complex (BLC) pathology. Labral repair in overhead athletes has resulted in mixed outcomes for athletes and is best indicated for patients under age 40 years old. Injuries to the BLC are potentially challenging injuries to diagnose and treat, particularly in the overhead athlete. SLAP repair remains the treatment of choice for high-level overhead athletes and patients younger than 40 years of age, while biceps tenodesis and tenotomy are preferred for older patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s12178-019-09539-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6542958PMC
June 2019

The Middle and Distal Aspects of the Ulnar Footprint of the Medial Ulnar Collateral Ligament of the Elbow Do Not Provide Significant Resistance to Valgus Stress: A Biomechanical Study.

Orthop J Sports Med 2019 Feb 11;7(2):2325967118825294. Epub 2019 Feb 11.

Division of Sports and Shoulder, Hospital for Special Surgery, New York, New York, USA.

Background: The medial ulnar collateral ligament (UCL) insertion of the elbow has been shown to extend distally beyond the sublime tubercle. The contribution to valgus stability of the distal aspect of the footprint is unknown.

Purpose/hypothesis: The purpose of this study was to determine the contribution of each part of the UCL footprint to the elbow valgus stability provided by the UCL. It was hypothesized that the distal two-thirds of the ulnar UCL footprint would not contribute significantly to valgus stability provided by the UCL.

Study Design: Descriptive laboratory study.

Methods: Fifteen cadaveric arms were dissected to the capsuloligamentous elbow structures and potted. A servohydraulic load frame was used to place 5 N·m of valgus stress on the intact elbow at 30°, 60°, 90°, and 120° of flexion. The UCL insertional footprint was measured and divided into thirds (proximal, middle, and distal). One-third of the UCL footprint was elevated off the bone (leaving the ligament in continuity), and the elbow was retested at the same degrees of flexion. This was repeated until the entire UCL footprint on the ulna was sectioned. Each elbow was randomized for how the UCL would be sectioned (sectioning the proximal, then middle, and then distal third or sectioning the distal, then middle, and then proximal third). Ulnohumeral joint gapping (millimeters) was recorded with a 3-dimensional motion capture system using physical and virtual markers. Two-group comparisons were made between each sectioned status versus the intact condition for each flexion angle.

Results: When the UCL was sectioned from distal to proximal, none of the ligaments failed prior to complete sectioning. When the UCL was sectioned from proximal to distal, 3 of the 6 ligaments failed after sectioning of the proximal third, while 2 more failed after the proximal and middle thirds were sectioned. Of the specimens with the distal third of the ligament sectioned first, no significant differences were found between intact, distal third cut, and distal plus middle thirds cut at all flexion angles.

Conclusion: The middle and distal thirds of the insertional footprint of the UCL on the ulna did not significantly contribute to gap resistance at 5 N·m of valgus load. The proximal third of the footprint is the primary resistor of valgus load.

Clinical Relevance: This cadaveric biomechanical study demonstrated that the middle and distal thirds of the native UCL insertion onto the ulna did not significantly contribute to valgus resistance at the elbow. When a UCL reconstruction is performed, the proximal third of the UCL insertion may be the most clinically important portion of the ligament to reconstruct.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2325967118825294DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6378449PMC
February 2019

The lateral collateral ligament complex of the elbow: quantitative anatomic analysis of the lateral ulnar collateral, radial collateral, and annular ligaments.

J Shoulder Elbow Surg 2019 Apr 6;28(4):665-670. Epub 2018 Dec 6.

Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA.

Background: Injury to the lateral ulnar collateral ligament (LUCL) complex of the elbow often results in posterolateral rotatory instability. Although surgical reconstruction of the LUCL is often required, gaps in our understanding of the LUCL complex remain. The purpose of this study was to provide a robust and accurate characterization of the lateral elbow ligamentous complex.

Methods: The LUCLs, radial collateral ligaments, and annular ligaments in 10 cadaveric elbows were 3-dimensionally digitized and reconstructed using computed tomography. Surface areas, origin and insertion footprint areas, distances between perceived footprint centers and geometric footprint centroids, distances to key landmarks, and ligament isometry were measured.

Results: The mean surface area of the LUCL was 229.3 mm. The mean origin and insertion footprint areas were 26.0 mm and 22.9 mm, respectively. The mean distance between the apparent centers and the geometric centroids of the footprints was 1 mm. The center of the LUCL origin was 10.7 mm distal to the lateral epicondyle and 8.2 mm from the capitellar articular margin. The center of the LUCL insertion was 3.3 mm distal to the apex of the supinator crest. The LUCL showed anisometric properties as elbow flexion increased (P < .001).

Conclusions: The LUCL origin center was 10.7 mm from the lateral epicondyle, whereas the insertion center was 3.3 mm from the apex of the supinator crest. The visually estimated footprint centers were generally within 1 mm of the geometric centroid. These geometries and distances to key landmarks will be informative for surgeons seeking to perform anatomic ligament reconstruction procedures.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jse.2018.09.019DOI Listing
April 2019

Electrodiagnostic evidence of suprascapular nerve recovery after decompression.

Muscle Nerve 2019 02 4;59(2):247-249. Epub 2018 Dec 4.

Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.

Introduction: The purpose of this study was to determine whether surgical arthroscopic decompression or ultrasound-guided aspiration of a paralabral cyst would result in suprascapular nerve recovery from axonal regeneration based on electrodiagnostic testing.

Methods: Nine patients with preoperative electromyography (EMG) evidence of suprascapular neuropathy due to paralabral cysts at the suprascapular or spinoglenoid notch were prospectively studied. Eight patients underwent arthroscopic surgical decompression, and 1 patient underwent ultrasound-guided aspiration. Postoperative EMG was performed in all patients to evaluate nerve regeneration.

Results: Three (33%) patients had cysts at the suprascapular notch, whereas 6 (67%) patients had cysts at the spinoglenoid notch. All patients showed complete electrophysiological recovery after decompression.

Discussion: Decompression of paralabral cysts at the suprascapular or spinoglenoid notch resulted in postoperative EMG evidence of nerve recovery. Long-term studies with a greater number of patients are required to elucidate time to recovery. Muscle Nerve 59:247-249, 2019.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/mus.26354DOI Listing
February 2019

The Quality of Online Resources Available to Patients Interested in Knee Biologic Therapies Is Poor.

HSS J 2018 Oct 8;14(3):322-327. Epub 2018 Aug 8.

Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA.

Background: As the use of biologic therapies for the management of knee pathology continues to expand, it is more likely that patients will turn to the Internet to gather information on this topic. Given the lack of scientific consensus on the use of biologics, care providers must understand what information is available online.

Questions/purposes: The purpose of this study was to evaluate the quality of websites that patients may use to educate themselves on knee biologics.

Methods: Websites were identified using search terms relevant to multiple biologic therapies available for knee pathology. Websites were scored based on an author-derived grading rubric, with a total of 25 possible points relating to the role of knee biologics in the diagnosis, evaluation, and treatment of knee pathology. Websites were categorized based on the source (e.g., physician-operated website vs. industry-related website). Reading level was assessed with the Flesch-Kincaid readability test.

Results: The initial search yielded 375 results, with 96 websites meeting final inclusion criteria. Mean website score was poor, at 6.01 of the 25 possible points (24.0%). Physician websites were the most common, with 60% of the articles identified. Industry-related websites scored the lowest (mean, 3.2 ± 0.97) while hospital-related websites scored the highest (mean, 8.3 ± 2.93). Overall, websites published from hospitals or orthopedic professional societies had significantly higher scores than other websites. The search term "knee PRP" yielded higher-quality results than "knee platelet rich plasma." Similarly, "knee BMAC" led to better results than "knee bone marrow aspirate concentrate." The average reading level was 11.4.

Conclusion: Many online resources are available for patients seeking information about knee biologic therapies, but the quality of websites identified was very poor. Patients should be counseled that the information available online for knee biologic therapy is unreliable. Surgeons should play an increased role in providing resources to patients and educating them on biologic options.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11420-018-9621-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6148578PMC
October 2018

Disease Burden of Medial Epicondylitis in the USA Is Increasing: An Analysis of 19,856 Patients From 2007 to 2014.

HSS J 2018 Oct 21;14(3):233-237. Epub 2018 May 21.

1Department of Orthopaedic Surgery, University of Virginia School of Medicine, PO Box 800159, Charlottesville, VA 22908 USA.

Background: Medial epicondylitis (ME), or "golfer's elbow," is often treated initially by conservative means. Up to 15% of recalcitrant cases require surgical intervention, according to small sample populations, but no national study has determined the incidence of the diagnosis or corroborated the rate of surgical intervention.

Purpose/question: We sought to review the annual incidence of ME, surgical rates, and health care costs in a population setting.

Methods: A national database was queried for ME from 2007 to 2014. Annual rates and the percentage of diagnosed cases subjected to surgical intervention were recorded. Epidemiologic data was reported with descriptive statistics, and the significant trends over time were analyzed using linear regression.

Results: We identified 19,856 cases of ME in the study period. There was a significant increase in the annual incidence and overall incidence per 10,000 patients. The proportion of diagnoses in patients under 65 years of age decreased significantly, while the proportion in those 65 years of age or older significantly increased. The annual number of surgical interventions significantly increased over the study period, although the annual proportion of diagnosed cases proceeding to surgery remained constant. The proportion of patients 65 years of age or older undergoing surgery significantly increased. Total reimbursement for the management of ME during the study period was $1,877,189. While there was a significant increase in the total annual reimbursement, annual per-patient reimbursement did not change significantly.

Conclusions: While the annual incidence of ME and surgical treatment of ME increased significantly from 2007 to 2014, the proportion of cases treated surgically did not. Notably, the proportion of patients 65 years of age or older diagnosed with and being surgically treated for ME has increased in recent years. Total reimbursement for ME has steadily risen, although per-patient reimbursement rates have not significantly changed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11420-018-9617-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6148579PMC
October 2018

Outcome of isolated posterior cruciate ligament reconstruction at mean 6.3-year follow up: a consecutive case series.

Phys Sportsmed 2019 02 13;47(1):60-64. Epub 2018 Sep 13.

a Sports Medicine & Shoulder Service , Hospital for Special Surgery , New York , NY , USA.

Objectives: There is a paucity of reporting on surgical outcomes of isolated posterior cruciate ligament reconstruction (PCLR). We hypothesize that isolated PCL injuries failing nonoperative treatment achieve good outcomes and are able to return to sport following PCLR.

Methods: A retrospective analysis was performed to identify patients with isolated PCL injuries that underwent reconstruction between 2001 and 2014. Patients with multi-ligamentous injury or another concomitant knee pathology were excluded. Medical records were reviewed for demographic, clinical and operative data. Patients were contacted for administration of a telephone-based questionnaire which included the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation form, Lysholm-Tegner scales, Marx activity scale (MAS), return to sport status, and patient satisfaction instruments.

Results: A total of 15 isolated PCL reconstructions in 14 patients with a mean age of 27.5 years (range 17-43) met the study inclusion criteria; mean follow up was 6.3 years (range 1.4-15.2). Pre-operatively, the primary complaint was knee instability in all patients; on physical examination, lack of a firm end point during posterior drawer testing was found in 93% (14/15) of the knees. In total, 12 of 15 knees underwent transtibial, single-bundle PCLR and three of 15 underwent tibial inlay, double bundle PCLR. Graft types included: quadriceps autograft (7/15), Achilles allograft (6/15), and hamstring autograft (2/15). There were no graft failures in our patient cohort. At most recent follow up the mean scores respectively on the IKDC form, Lysholm-Tegner scales and MAS were (standard deviation): 77.3 (16.5), 83.1 (17.9), 6.13 (2.6), and 7.1 (6.0). All fourteen patients were athletes prior to their injury and 79% (11/14) returned to sport and overall patient satisfaction was 9.2/10.

Conclusions: Isolated PCLR provides good outcomes at mean medium-term follow up with restoration of function, high rate of return to sport and overall patient satisfaction.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/00913847.2018.1520053DOI Listing
February 2019

An acute ulnar collateral ligament tear in a professional baseball player while batting requiring ulnar collateral ligament reconstruction.

J Shoulder Elbow Surg 2018 09 24;27(9):e279-e282. Epub 2018 Jul 24.

Division of Sports and Shoulder, Hospital for Special Surgery, New York, NY, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jse.2018.05.040DOI Listing
September 2018

Patient-Related Risk Factors for Infection Following Ulnar Nerve Release at the Cubital Tunnel: An Analysis of 15,188 Cases.

Orthop J Sports Med 2018 May 15;6(5):2325967118772799. Epub 2018 May 15.

Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA.

Background: Although cubital tunnel release is a commonly performed orthopaedic procedure, the overall incidence of and independent risk factors for infection largely remain undefined in the current literature.

Purpose: To establish the rate of postoperative infection after isolated cubital tunnel release and define relevant patient-related risk factors.

Study Design: Case-control study; Level 3.

Methods: All Medicare-insured patients undergoing ulnar nerve decompression at the cubital tunnel from 2010 through 2012 were identified. A multivariate binomial logistic regression analysis was utilized to evaluate the impact of patient-related risk factors for postoperative infection.

Results: A total of 330 (2.17%) postoperative infections were identified in 15,188 cases. The majority (87%) were managed nonoperatively, while 13% required surgical debridement. The most significant risk factors for infection included hemodialysis use (odds ratio [OR], 2.47), chronic anemia (OR, 2.24), age <65 years (OR, 2.08), tobacco use (OR, 1.65), morbid obesity (OR, 1.53), inflammatory arthritis (OR, 1.43), depression (OR, 1.36), hyperlipidemia (OR, 1.33), male sex (OR, 1.32), and chronic lung disease (OR, 1.29).

Conclusion: The present study was adequately powered to determine numerous patient-related risk factors for infection following cubital tunnel release.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2325967118772799DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5956641PMC
May 2018

Osseous Vascularity of the Medial Elbow After Ulnar Collateral Ligament Reconstruction: A Comparison of the Docking and Modified Jobe Techniques.

Orthop J Sports Med 2018 Apr 2;6(4):2325967118763153. Epub 2018 Apr 2.

Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA.

Background: Although vascularity plays a critical role in healing after ulnar collateral ligament (UCL) reconstruction, intraosseous blood flow to the medial epicondyle (ME) and sublime tubercle remains undefined.

Purpose: To quantify vascular disruption caused by tunnel drilling with the modified Jobe and docking techniques for UCL reconstruction.

Study Design: Controlled laboratory study.

Methods: Eight matched pairs (16 specimens) of fresh-frozen cadaveric upper extremities were randomized to 1 of 2 study groups: docking technique or modified Jobe technique. One elbow in each pair underwent tunnel drilling by the assigned technique, while the contralateral elbow served as a control. Pregadolinium and postgadolinium magnetic resonance imaging were performed to quantify intraosseous vascularity within the ME, trochlea, and proximal ulna. Three-dimensional computed tomography (CT) and gross dissection were performed to assess terminal vessel integrity.

Results: Ulnar tunnel drilling had minimal impact on vascularity of the proximal ulna, with maintenance of >95% blood flow for each technique. Perfusion in the ME was reduced 14% (to 86% of baseline) for the docking technique and 60% (to 40% of baseline) for the modified Jobe technique (mean difference, 46%; = .029). Three-dimensional CT and gross dissection revealed increased disruption of small perforating vessels of the posterior aspect of the ME for the modified Jobe technique.

Conclusion: Although tunnel drilling in the sublime tubercle appears to have a minimal effect on intraosseous vascularity of the proximal ulna, both the docking and modified Jobe techniques reduce flow in the ME. This reduction was 4 times greater for the modified Jobe technique, and these findings have important implications for UCL reconstruction surgery.

Clinical Relevance: As the rate of revision UCL reconstructions continues to rise, investigation into causes for failure of primary surgery is needed. One potential cause is poor tendon-to-bone healing due to inadequate vascularity. This study quantifies the amount of vascular insult that is incurred in the ME during UCL reconstruction. While vascular insult is only one of many factors that affects the surgical success rate, surgeons performing this procedure should be mindful of this potential for vascular disruption.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2325967118763153DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5888827PMC
April 2018

Quantitative Anatomic Analysis of the Medial Ulnar Collateral Ligament Complex of the Elbow.

Orthop J Sports Med 2018 Mar 26;6(3):2325967118762751. Epub 2018 Mar 26.

Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA.

Background: A more detailed assessment of the anatomy of the entire medial ulnar collateral ligament complex (MUCLC) is desired as the rate of medial elbow reconstruction surgery continues to rise.

Purpose: To quantify the anatomy of the MUCLC, including the anterior bundle (AB), posterior bundle (PB), and transverse ligament (TL).

Study Design: Descriptive laboratory study.

Methods: Ten unpaired, fresh-frozen cadaveric elbows underwent 3-dimensional (3D) digitization and computed tomography with 3D reconstruction. Ligament footprint areas and geometries, distances to key bony landmarks, and isometry were determined. A surgeon digitized the visual center of each footprint, and this location was compared with the geometric centroid calculated from the outline of the digitized footprint.

Results: The mean surface area of the AB was 324.2 mm, with an origin footprint of 32.3 mm and an elongated insertional footprint of 187.6 mm (length, 29.7 mm). The mean area of the PB was 116.6 mm (origin, 25.9 mm; insertion, 15.8 mm), and the mean surface area of the TL was 134.5 mm (origin, 21.2 mm; insertion, 16.7 mm). The geometric centroids of all footprints could be predicted within 0.8 to 1.3 mm, with the exception of the AB insertion centroid, which was 7.6 mm distal to the perceived center at the apex of the sublime tubercle. While the PB remained relatively isometric from 0° to 90° of flexion ( = .606), the AB lengthened by 2.2 mm ( < .001).

Conclusion: Contrary to several historical reports, the insertional footprint of the AB was larger, elongated, and tapered. The TL demonstrated a previously unrecognized expansive soft tissue insertion directly onto the AB, and additional analysis of the biomechanical contribution of this structure is needed.

Clinical Relevance: These findings may serve as a foundation for future study of the MUCLC and help refine current surgical reconstruction techniques.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2325967118762751DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5888833PMC
March 2018

Summative Report on Time Out of Play for Major and Minor League Baseball: An Analysis of 49,955 Injuries From 2011 Through 2016.

Am J Sports Med 2018 06 9;46(7):1727-1732. Epub 2018 Apr 9.

Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA.

Background: Recent epidemiologic reports have demonstrated rising injury rates in Major League Baseball (MLB) and Minor League Baseball (MiLB). Although several studies have recently been published on specific injuries, the majority of injuries have not yet been formally studied.

Purpose: The purpose of this study is to (1) generate a summative analysis of all injuries that occur in MLB and MiLB, (2) identify the 50 most common injuries, and (3) generate focused reports and fact sheets on the characteristics of each of those diagnoses.

Study Design: Case series; Level of evidence, 4.

Methods: The MLB Health and Injury Tracking System was used to identify injuries occurring in MLB and MiLB players from 2011 to 2016. Injuries were defined as those that occurred during normal baseball activity and resulted in at least 1 day out of play. A multitude of player and injury characteristics were analyzed, and detailed reports of the 50 most commonly occurring injuries were generated.

Results: A total of 49,955 injuries occurred during the study period; 45,123 were non-season ending, and they resulted in 722,176 days out of play. The mean (median) days missed per injury was 16 (6) days. Overall, 39.1% of all injuries occurred in pitchers. The upper extremity was involved in 39% of injuries, while 35% occurred in the hip/groin/lower extremity. Surgery was required in 6.5% of cases, and 9.7% of injuries were season ending. Hamstring strains were the most common injury (n = 3337), followed by rotator cuff strain/tear (n = 1874), paralumbar muscle strain (n = 1313), biceps tendinitis (n = 1264), oblique strain (n = 1249), and elbow ulnar collateral ligament injury (n = 1191). The diagnoses that were most likely to end a player's season were elbow ulnar collateral ligament injury (60% season ending) and superior labrum anterior and posterior tear (50.9% season ending).

Conclusion: Contrary to prior reports relying on disabled list data, the annual number of injuries in professional baseball remained steady from 2011 to 2016. Similar trends were noted for the annual number of days missed and mean days missed per injury. Although the mean days missed per injury was high (16), the median was much lower at 6 days.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0363546518765158DOI Listing
June 2018

Figure-of-8 Reconstruction Technique for Chronic Posterior Sternoclavicular Joint Dislocation.

Arthrosc Tech 2017 Oct 2;6(5):e1749-e1753. Epub 2017 Oct 2.

Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, U.S.A.

Dislocation of the sternoclavicular joint is a rare injury and typically requires high-energy forces applied through the joint. Initial treatment is dependent on the direction of dislocation, with acute reduction indicated for posterior dislocations presenting with signs of tracheal, esophageal, or neurovascular compression. Although most patients do well with conservative treatment after the initial trauma, some can have persistent pain and scapular dyskinesia due to instability or locked dislocation of the sternoclavicular joint. Stabilization of the sternoclavicular joint with reconstruction may be indicated for those with persistent symptoms despite a trial of steroid injections and physical therapy. In this report and video, we present a figure-of-8 reconstruction technique to reduce and stabilize a posterior dislocation of the sternoclavicular joint using a gracilis autograft. Ultimately, this reconstruction technique can be performed in a safe, efficient, and reliable manner when appropriate surgical steps are followed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.eats.2017.06.046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5793942PMC
October 2017

Epidemiology and Disease Burden of Lateral Epicondylitis in the USA: Analysis of 85,318 Patients.

HSS J 2018 Feb 5;14(1):9-14. Epub 2017 Jun 5.

2Department of Orthopedic Surgery, University of Virginia Health System, 400 Ray C Hunt Drive, Charlottesville, VA 22908 USA.

Background: National rates of lateral epicondylitis and surgical treatment are poorly defined. Disease burden of lateral epicondylitis (LE) continues to increase annually. Further study is necessary to optimize treatment algorithms to reduce associated health-care expenditures.

Questions/purposes: The purpose of this study is to review the annual incidence of LE, surgical rates, and associated health-care costs in a population setting.

Methods: A national database was queried for LE from 2007 to 2014. Surgical cases were identified and annual rates were recorded. Demographic and epidemiologic data were reported with descriptive statistics, while trends over time were analyzed using linear regression.

Results: Eighty-five thousand three hundred eighteen cases of LE were identified. The annual incidence per 10,000 patients remained constant ( = 0.304). The proportion of diagnoses in patients <65 years decreased ( ≤ 0.002) and ≥65 years increased ( < 0.001) over the study period. One thousand six hundred ninety-four patients (2%) required operative treatment. The annual rate of surgical intervention remained constant ( = 0.623). The proportion of patients <40 years requiring surgery decreased ( < 0.001) as the proportion of patients ≥65 years needing surgery increased ( = 0.003). Total reimbursement for LE procedures during the study period was $7,220,912. Average per-patient reimbursement was $4263. Both annual total reimbursement ( = 0.006) and per-patient reimbursement rates ( = 0.002) significantly increased.

Conclusion: The annual incidence of LE and rate of surgical intervention have remained constant from 2007 to 2014. The proportion of patients over >65 years diagnosed with, and receiving surgical treatment for, LE has significantly increased in recent years. Total reimbursement and average per-patient reimbursement have steadily risen, demonstrating the increasing burden of cost on the health-care system.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11420-017-9559-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5786580PMC
February 2018

Diagnosis and Treatment of Injuries to the Biceps and Superior Labral Complex in Overhead Athletes.

Curr Rev Musculoskelet Med 2018 Mar;11(1):63-71

Hospital for Special Surgery, Department of Sports Medicine and Shoulder, 535 E 70th St, New York, NY, 10021, USA.

Purpose Of Review: This review discusses the diagnostic and treatment challenges presented by injuries to the biceps and superior labral complex.

Recent Findings: A focused patient history, numerous physical examination maneuvers, and appropriate advanced imaging studies must be utilized to reach an accurate diagnosis. Nonoperative management, even in overhead athletes, has demonstrated relatively good outcomes, while operative outcomes have yielded mixed results. The surgeon must take into account a number of variables when choosing the appropriate surgical procedure: labral repair versus biceps tenodesis. Rehabilitation, either as nonoperative management or as a postoperative protocol, should focus on restoring glenohumeral and scapulothoracic strength, endurance, and full, pain-free range of motion, while correcting any deficiencies in balance or rhythm throughout the overhead motion. Despite the operative treatment challenges that SLAP tears present, with new techniques and proper patient selection, overhead athletes with injuries to the biceps and superior labrum complex can return to sport at a high level.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s12178-018-9460-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5825341PMC
March 2018

Trends in Surgical Practices for Lateral Epicondylitis Among Newly Trained Orthopaedic Surgeons.

Orthop J Sports Med 2017 Oct 4;5(10):2325967117730570. Epub 2017 Oct 4.

Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA.

Background: Much controversy exists regarding the optimal surgical intervention for lateral epicondylitis because of a multitude of options available and the lack of comparative studies. Knowledge of the current practice trends would help guide the design of comparative studies needed to determine which surgical technique results in the best outcome.

Purpose: To review the latest practice trends for the surgical treatment of lateral epicondylitis among newly trained surgeons in the United States utilizing the American Board of Orthopaedic Surgery (ABOS) database.

Study Design: Cross-sectional study; Level of evidence, 3.

Methods: The ABOS database was utilized to identify surgical cases for lateral epicondylitis submitted by Part II board certification examination candidates from 2004 through 2013. Inclusion criteria were predetermined using a combination of International Classification of Diseases, Ninth Revision (ICD-9) and Current Procedural Terminology (CPT) codes. Cases were organized by open and arthroscopic treatment groups and by fellowship training and were analyzed to determine differences in surgical techniques, complication rates, and concomitant procedures.

Results: In total, 1150 surgeons submitted 2106 surgical cases for the treatment of lateral epicondylitis. The number of surgical cases for lateral epicondylitis performed per 10,000 submitted cases significantly decreased from 26.7 in 2004 to 21.1 in 2013 ( = .002). Among all cases, 92.2% were open and 7.8% were arthroscopic, with no change in the incidence of arthroscopic surgeries over the study period. Shoulder and elbow (18.1%) and sports medicine (11.4%) surgeons were more likely to perform surgery arthroscopically compared with hand surgeons (6.1%) ( < .001). There was no difference in overall self-reported complication rates between open (4.4%) and arthroscopic (5.5%) procedures ( = .666). Percutaneous tenotomy, debridement only, and debridement with tendon repair comprised 6.4%, 46.3%, and 47.3% of open treatment, respectively. Sports medicine, hand, and shoulder and elbow surgeons were more likely to repair the tendon after debridement compared with other surgeons, who were more likely to perform debridement alone ( < .001). Hand surgeons were most likely to perform concomitant procedures, of which the majority were neuroplasties.

Conclusion: Although comparative studies are ultimately necessary for determining the optimal surgical technique, researchers should be mindful of the differences in practices according to training and the extent to which concomitant procedures are being performed, as both these factors may confound any future results.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2325967117730570DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5637978PMC
October 2017

Management of ulnar collateral ligament injury in throwing athletes: a survey of the American Shoulder and Elbow Surgeons.

J Shoulder Elbow Surg 2017 Nov 20;26(11):2023-2028. Epub 2017 Sep 20.

Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA.

Background: Amid evidence that the number of ulnar collateral ligament (UCL) reconstructions performed annually is on the rise, there continues to be significant variation among surgeons in the management of UCL injuries. The purpose of this paper was to survey the members of the American Shoulder and Elbow Surgeons (ASES) to assess current trends related to the comprehensive treatment of athletes presenting with UCL injury.

Methods: An online survey was distributed to the active members of the ASES. The survey was composed of 3 sections assessing the demographics of the survey-takers, presenting 7 distinct fictional clinical case scenarios of athletes with UCL injury, and posing a series of more general questions about operative and nonoperative management of UCL injuries.

Results: There were 159 ASES members who responded to the survey (24% of the active membership); 65 respondents (40.9%) reported >15 years of clinical experience. Of the 7 case scenarios presented, a consensus was reached to indicate the patient for surgery in 4 cases. In all 7 cases, when operative management was the preferred option, a consensus was reached to perform UCL reconstruction. The preferred method of UCL reconstruction among respondents was the docking technique (66.0%); 36.3% of respondents used platelet-rich plasma in their treatment of UCL injuries.

Conclusion: The survey presented here shows that an overall experienced and well-trained cohort of surgeons tended to agree and often reached consensus opinions on how to approach UCL injury. Professional athletes and those with complete tears were indicated for surgery by consensus, whereas opinion was more divided on how to treat partial tears or nonprofessionals.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jse.2017.08.005DOI Listing
November 2017

Decreased Shoulder External Rotation and Flexion Are Greater Predictors of Injury Than Internal Rotation Deficits: Analysis of 132 Pitcher-Seasons in Professional Baseball.

Arthroscopy 2017 Sep;33(9):1629-1636

Sports Medicine and Shoulder Service Hospital for Special Surgery, New York, New York, U.S.A.

Purpose: The primary aims of this work were to (1) describe normal range of motion (ROM) profiles for elite pitchers, (2) describe the characteristics of shoulder and elbow injuries in professional pitchers over a 6-year period in one Major League Baseball organization, and (3) identify ROM measures that were independently associated with a future shoulder or elbow injury.

Methods: Over 6 seasons (2010-2015), a preseason assessment was performed on all pitchers invited to Major League Baseball Spring Training for a single organization. ROM measures included shoulder flexion, horizontal adduction, external rotation (ER), internal rotation, as well as elbow flexion and extension, were measured for both the dominant and nondominant arm, and total range of motion and deficits were calculated. All noncontact shoulder and elbow injuries were identified. Using multivariate binomial logistic regression analysis to control for age, height, weight, and all other ROM measures, the factors associated with an increased risk of subsequent shoulder or elbow injury were identified.

Results: A total of 53 shoulder (n = 25) and elbow (n = 28) injuries occurred during 132 pitcher seasons (n = 81 pitchers). The most significant categorical risk factor associated with increased elbow injury rates was the presence of a shoulder flexion deficit >5° (odds ratio [OR] 2.83; P = .042). For continuous variables, the risk of elbow injury increased by 7% for each degree of increased shoulder ER deficit (OR 1.07; P = .030) and 9% for each degree of decreased shoulder flexion (OR 1.09; P = .017). None of the measures significantly correlated with shoulder injuries.

Conclusions: Preseason shoulder ER and flexion deficits are independent risk factors for the development of elbow injuries during the upcoming season. Although prior work has supported the importance of reducing glenohumeral internal rotation deficits in pitchers, this study demonstrates that deficits in shoulder ER and flexion are more significant predictors of subsequent elbow injury.

Level Of Evidence: Level III, retrospective comparative study.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.arthro.2017.03.025DOI Listing
September 2017