Publications by authors named "Joshua S Dines"

250 Publications

The Virtual Shoulder Physical Exam.

HSS J 2021 Feb 21;17(1):59-64. Epub 2021 Feb 21.

Sports Medicine Institute, Hospital for Special Surgery, New York City, NY, USA.

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http://dx.doi.org/10.1177/1556331620975033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8077973PMC
February 2021

Patient Experience and Satisfaction with Telemedicine During Coronavirus Disease 2019: A Multi-Institution Experience.

Telemed J E Health 2021 May 7. Epub 2021 May 7.

Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA.

The coronavirus disease 2019 (COVID-19) heralded an unprecedented increase in telemedicine utilization. Our objective was to assess patient satisfaction with telemedicine during the COVID-19 era. Telemedicine visit data were gathered from Stanford Health Care (Stanford) and the Hospital for Special Surgery (HSS). Patient satisfaction data from HSS were captured from a Press-Ganey questionnaire between April 19, 2020, and December 12, 2020, whereas Stanford data were taken from a novel survey instrument that was distributed to all patients between June 22, 2020, and November 1, 2020. There were 60,550 telemedicine visits at Stanford, each linked with a postvisit survey. At HSS, there were 66,349 total telemedicine visits with 7,348 randomly linked with a postvisit survey. Two measures of patient satisfaction were used for this study: (1) a patient's "overall visit score" and (2) whether the patient indicated the highest possible "likelihood to recommend" (LTR) score (LTR top box score). The LTR top box percentage at Stanford increased from 69.6% to 74.0% ( = 0.0002), and HSS showed no significant change (p = 0.7067). In the multivariable model, the use of a cell phone (adjusted odds ratio [aOR]: 1.18; 95% confidence interval [CI]: 1.12-1.23) and tablet (aOR: 1.15; 95% CI: 1.07-1.23) was associated with higher overall scores, whereas visits with interrupted connections (aOR: 0.49; 95% CI: 0.42-0.57) or help required to connect (aOR: 0.49; 95% CI: 0.42-0.56) predicted lower patient satisfaction. We present the largest published description of patient satisfaction with telemedicine, and we identify important telemedicine-specific factors that predict increased overall visit score. These include the use of cell phones or tablets, phone reminders, and connecting before the visit was scheduled to begin. Visits with poor connectivity, extended wait times, or difficulty being seen, examined, or understood by the provider were linked with reduced odds of high scores. Our results suggest that attention to connectivity and audio/visual definition will help optimize patient satisfaction with future telemedicine encounters.
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http://dx.doi.org/10.1089/tmj.2021.0060DOI Listing
May 2021

Intra versus Inter-Pitcher Comparisons: Associations of Ball Velocity with Throwing Arm Kinetics in Professional Baseball Pitchers.

J Shoulder Elbow Surg 2021 Apr 27. Epub 2021 Apr 27.

Sports Medicine Institute Hospital for Special Surgery, New York, NY, USA.

Background: The association between ball velocity and elbow varus torque has shown differences when evaluating within a single pitcher and among a cohort. The impact of increasing ball velocity to additional throwing arm kinetics, in particular shoulder distraction forces, with intra versus inter-pitcher evaluations have not been evaluated, even though these kinetic measures have been implicated in injury risk.

Purpose: To compare intra- versus inter-pitcher relationships between ball velocity and all major kinetics at the shoulder and elbow in professional pitchers.

Methods: 322 professional baseball pitchers threw 8-12 fastball pitches, while simultaneously evaluated with 3D motion capture technology (480 Hz). A linear regression analysis was performed to evaluate pitch velocity as a predictor for peak kinetic values at the shoulder and elbow among pitchers. A mixed-linear model with random intercepts was then created to evaluate ball velocity as a predictor for peak kinetic values when comparing pitches within an individual pitcher.

Results: 91 pitchers were included in the analyses. Ball velocity between pitchers had weak correlations with shoulder distraction force (R=0.228, p-<0.001) and elbow distraction force (R=0.175<0.001) between pitchers. Within an individual pitcher, strong correlations (R > 0.85) were observed for: 1) shoulder internal rotational torque (p<0.001), 2) shoulder horizontal adduction torque (p=0.006), 3) shoulder superior force (p<0.001), 4) shoulder anterior force (p<0.001), 5) elbow varus torque (p<0.001), 6) elbow medial force (p<0.001), 7) elbow anterior force (p<0.001), 8) elbow flexion torque (p<0.001), 9) shoulder distractive force (p<0.001), and 10) elbow distractive force (p<0.001).

Conclusion: Faster pitch velocity is a weak predictor of shoulder and elbow distraction forces experienced among professional pitchers. However, when controlling for an individual pitcher, peak kinetics at the shoulder and elbow can strongly be predicted by ball velocity. Therefore, assuming higher peak throwing arm kinetic values are experienced by pitchers with faster ball velocity is likely an inappropriate assumption among pitchers but may be correct for each individual player who increases pitch velocity.
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http://dx.doi.org/10.1016/j.jse.2021.04.017DOI Listing
April 2021

A Comprehensive Enhanced Recovery Pathway for Rotator Cuff Surgery Reduces Pain, Opioid Use, and Side Effects.

Clin Orthop Relat Res 2021 Mar 16. Epub 2021 Mar 16.

J. T. YaDeau, E. M. Soffin, A. Tseng, H. Zhong, M. A. Gordon, B. H. Lee, K. Kumar, R. L. Kahn, M. A. Kirksey, A. A. Schweitzer, Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA.

Background: Patients often have moderate to severe pain after rotator cuff surgery, despite receiving analgesics and nerve blocks. There are many suggested ways to improve pain after rotator cuff surgery, but the effects of adopting a pathway that includes formal patient education, a long-acting nerve block, and extensive multimodal analgesia are unclear.

Questions/purposes: (1) Does adoption of a clinical pathway incorporating patient education, a long-acting nerve block, and preemptive multimodal analgesia reduce the worst pain during the first 48 hours after surgery compared with current standard institutional practices? (2) Does adoption of the pathway reduce opioid use? (3) Does adoption of the pathway reduce side effects and improve patient-oriented outcomes?

Methods: From September 2018 to January 2020, 281 patients scheduled for arthroscopic ambulatory rotator cuff surgery were identified for this paired sequential prospective cohort study. Among patients in the control group, 177 were identified, 33% (58) were not eligible, for 11% (20) staff was not available, 56% (99) were approached, 16% (29) declined, 40% (70) enrolled, and 40% (70) were analyzed (2% [4] lost to follow-up for secondary outcomes after postoperative day 2). For patients in the pathway cohort, 104 were identified, 17% (18) were not eligible, for 11% (11) staff was not available, 72% (75) were approached, 5% (5) declined, 67% (70) enrolled, and 67% (70) were analyzed (3% [3] lost to follow-up for secondary outcomes after postoperative day 2). No patients were lost to follow-up for primary outcome; for secondary outcomes, four were lost in the control group and three in the pathway group after postoperative day 2 (p = 0.70). The initial 70 patients enrolled received routine care (control group), and in a subsequent cohort, 70 patients received care guided by a pathway (pathway group). Of the 205 eligible patients, 68% (140) were included in the analysis. This was not a study comparing two tightly defined protocols but rather a study to determine whether adoption of a pathway would alter patient outcomes. For this reason, we used a pragmatic (real-world) study design that did not specify how control patients would be treated, and it did not require that all pathway patients receive all components of the pathway. We developed the pathway in coordination with a group of surgeons and anesthesiologists who agreed to apply the pathway as much as was viewed practical for each individual patient. Patients in both groups received a brachial plexus nerve block with sedation. Major differences between the pathway and control groups were: detailed patient education regarding reasonable pain expectations with a goal of reducing opioid use (no formal educational presentation was given to the control), a long-acting nerve block using bupivacaine with dexamethasone (control patients often received shorter-acting local anesthetic without perineural dexamethasone), and preemptive multimodal analgesia including intraoperative ketamine, postoperative acetaminophen, NSAIDs, and gabapentin at bedtime, with opioids as needed (control patients received postoperative opioids but most did not get postoperative NSAIDS and no controls received gabapentin or separate prescriptions for acetaminophen). The primary outcome was the numerical rating scale (NRS) worst pain with movement 0 to 48 hours after block placement. The NRS pain score ranges from 0 (no pain) to 10 (worst pain possible). The minimum clinically important difference (MCID) [12] for NRS that was used for calculation of the study sample size was 1.3 [18], although some authors suggest 1 [13] or 2 [5] are appropriate; if we had used an MCID of 2, the sample size would have been smaller. Secondary outcomes included NRS pain scores at rest, daily opioid use (postoperative day 1, 2, 7, 14), block duration, patient-oriented pain questions (postoperative day 1, 2, 7, 14), and patient and physician adherence to pathway.

Results: On postoperative day 1, pathway patients had lower worst pain with movement (3.3 ± 3.1) compared with control patients (5.6 ± 3.0, mean difference -2.7 [95% CI -3.7 to -1.7]; p < 0.001); lower scores were also seen for pain at rest (1.9 ± 2.3 versus 4.0 ± 2.9, mean difference -2.0 [95% CI -2.8 to -1.3]; p < 0.001). Cumulative postoperative opioid use (0-48 hours) was reduced (pathway oral morphine equivalent use was 23 ± 28 mg versus 44 ± 35 mg, mean difference 21 [95% CI 10 to 32]; p < 0.01). The greatest difference in opioid use was in the first 24 hours after surgery (pathway 7 ± 12 mg versus control 21 ± 21 mg, mean difference -14 [95% CI -19 to -10]; p < 0.01). On postoperative day 1, pathway patients had less interference with staying asleep compared with control patients (0.5 ± 1.6 versus 2.6 ± 3.3, mean difference -2.2 [95% CI -3.3 to -1.1]; p < 0.001); lower scores were also seen for interference with activities (0.9 ± 2.3 versus 1.9 ± 2.9, mean difference -1.1 [95% CI -2 to -0.1]; p = 0.03). Satisfaction with pain treatment on postoperative day 1 was higher among pathway patients compared with control patients (9.2 ± 1.7 versus 8.2 ± 2.5, mean difference 1.0 [95% CI 0.3 to 1.8]; p < 0.001). On postoperative day 2, pathway patients had lower nausea scores compared with control patients (0.3 ± 1.1 versus 1 ± 2.1, mean difference -0.7 [95% CI -1.2 to -0.1]; p = 0.02); lower scores were also seen for drowsiness on postoperative day 1 (1.7 ± 2.7 versus 2.6 ± 2.6, mean difference -0.9 [95% CI - 1.7 to -0.1]; p = 0.03).

Conclusion: Adoption of the pathway was associated with improvement in the primary outcome (pain with movement) that exceeded the MCID. Patients in the pathway group had improved patient-oriented outcomes and fewer side effects. This pathway uses multiple analgesic drugs, which may pose risks to elderly patients, in particular. Therefore, in evaluating whether to use this pathway, clinicians should weigh the effect sizes against the potential risks that may emerge with large scale use, consider the difficulties involved in adapting a pathway to local practice so that pathway will persist, and recognize that this study only enrolled patients among surgeons and the anesthesiologists that advocated for the pathway; results may have been different with less enthusiastic clinicians. This pathway, based on a long-lasting nerve block, multimodal analgesia, and patient education can be considered for adoption.

Level Of Evidence: Level II, therapeutic study.
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http://dx.doi.org/10.1097/CORR.0000000000001684DOI Listing
March 2021

Arthroscopic-Assisted Removal of Proximal Humerus Locking Plates With Capsular Release Significantly Improves Range of Motion and Function.

Arthrosc Sports Med Rehabil 2021 Feb 30;3(1):e211-e217. Epub 2021 Jan 30.

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

Purpose: To investigate the clinical outcomes following the arthroscopic removal of proximal humerus locking plates for symptomatic hardware after open reduction and internal fixation (ORIF) of proximal humerus fractures.

Methods: Patients who underwent arthroscopic removal of hardware (ROH) with capsular release due to pain and/or immobility after receiving locking plates to treat proximal humerus fractures from 2009 to 2016 were identified. Operative and clinic records were reviewed to obtain demographic information, concomitant procedures during ROH, and pre- and postoperative active shoulder range of motion. Postoperative patient-reported outcomes included the QuickDASH, PROMIS Pain Intensity, Constant, and University of California, Los Angeles shoulder rating scale.

Results: In total, 88 patients were included. Patients were evaluated at a minimum of 6 weeks postoperatively after ROH. Patients with pre- and postoperative active range of motion values demonstrated significant improvements in mean forward elevation (n = 69; 78.4%; 115.1° to 152.1°, < .001), abduction (n = 29; 33.0%; 70.9° to 138.7°, < .001), external rotation (n = 49; 55.7%; 43.7° to 58.6°,  = .012), and internal rotation (n = 45; 51.1%; 25.7° to 61.9°, < .001). Patients also reported positive patient-reported scores, including the QuickDASH (4.1 ± 7.8), PROMIS Pain Intensity (3.5 ± 0.9), Constant (84.6 ± 10.7), and University of California, Los Angeles shoulder rating scale (33 ± 2.9), which were measured 70.6 ± 26.6 months postoperatively. There were no surgical complications, no arthroscopic cases were converted to open, but 2 reported refractures (2.3%).

Conclusions: Arthroscopic-assisted removal of proximal humerus locking plates significantly improves motion and function while allowing for management of concomitant shoulder pathology and potentially avoiding open surgery complications. Given that patients undergoing this procedure frequently have multiple comorbidities, arthroscopic-assisted removal with smaller incisions may minimize risks while restoring shoulder mobility. Therefore, arthroscopic ROH for patients experiencing symptomatic hardware after ORIF is recommended.

Level Of Evidence: Level IV, therapeutic case series.
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http://dx.doi.org/10.1016/j.asmr.2020.09.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7879204PMC
February 2021

The Virtual Shoulder and Knee Physical Examination.

Orthop J Sports Med 2020 Oct 20;8(10):2325967120962869. Epub 2020 Oct 20.

Sports Medicine Institute, Hospital for Special Surgery, New York, New York, USA.

The COVID-19 crisis has forced a sudden and dramatic shift in the way that clinicians interact with their patients, from outpatient encounters to telehealth visits utilizing a variety of internet-based videoconferencing applications. Although many aspects of pre-COVID-19 outpatient sports medicine care will ultimately resume, it is likely that telehealth will persist because of its practicality and because of patient demand for access to efficient and convenient health care. Physical examination is widely considered a critical obstacle to a thorough evaluation of sports medicine patients during telehealth visits. However, a closer reflection suggests that a majority of the examination maneuvers are possible virtually with limited, if any, modifications. Thus, we provide a comprehensive shoulder and knee physical examination for sports medicine telehealth visits, including (1) verbal instructions in layman's terms that can be provided to the patient before or read verbatim during the visit, (2) multimedia options (narrated videos and annotated presentations) of the shoulder and knee examination that can be provided to patients via screen-share options, and (3) a corresponding checklist to aid in documentation.
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http://dx.doi.org/10.1177/2325967120962869DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7871077PMC
October 2020

Anterior glenohumeral instability: Current review with technical pearls and pitfalls of arthroscopic soft-tissue stabilization.

World J Orthop 2021 Jan 18;12(1):1-13. Epub 2021 Jan 18.

Department of Sports Medicine and Shoulder Surgery, Hospital for Special Surgery, New York, NY 10021, United States.

The glenohumeral joint (GHJ) allows for a wide range of motion, but is also particularly vulnerable to episodes of instability. Anterior GHJ instability is especially frequent among young, athletic populations during contact sporting events. Many first time dislocators can be managed non-operatively with a period of immobilization and rehabilitation, however certain patient populations are at higher risk for recurrent instability and may require surgical intervention for adequate stabilization. Determination of the optimal treatment strategy should be made on a case-by-case basis while weighing both patient specific factors and injury patterns (, bone loss). The purpose of this review is to describe the relevant anatomical stabilizers of the GHJ, risk factors for recurrent instability including bony lesions, indications for arthroscopic open surgical management, clinical history and physical examination techniques, imaging modalities, and pearls/pitfalls of arthroscopic soft-tissue stabilization for anterior glenohumeral instability.
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http://dx.doi.org/10.5312/wjo.v12.i1.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7814310PMC
January 2021

Superior capsule reconstruction using a single 6-mm-thick acellular dermal allograft for massive rotator cuff tears: a biomechanical cadaveric comparison to fascia lata allograft.

J Shoulder Elbow Surg 2021 Jan 5. Epub 2021 Jan 5.

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

Background: Success of superior capsule reconstruction (SCR) using both fascia lata (FL) and human acellular dermal (ACD) allografts have been reported. One possible explanation for a discrepancy in outcomes may be attributed to graft thickness. SCR with commercially available 3-mm-thick ACD allograft is not biomechanically equivalent to FL. Our hypothesis was that SCR with a single 6-mm-thick ACD allograft will restore the subacromial space distance (SubDist) and peak subacromial contact pressures (PSCPs) to intact shoulder and will be comparable to SCR with an 8-mm FL allograft.

Methods: Eight cadaveric shoulders were tested in 4 conditions: intact, irreparable supraspinatus tear (SST), SCR FL allograft (8-mm-thick), and SCR single ACD allograft (6-mm-thick). SubDist and PSCP were measured at 0°, 30°, and 60° of glenohumeral abduction in the scapular plane. Parameters were compared using a repeated measures analysis of variance with Tukey post hoc test, and graft dimensions were compared using a Student t test.

Results: SST had decreased SubDist (P < .05) and increased PSCP (P < .05) compared with the intact state. At all angles, the SCR ACD allograft demonstrated increased SubDist compared with the tear condition (P < .001), with no difference between grafts. Furthermore, there was decreased PSCP after both ACD and FL SCR compared with the intact condition, with no difference between grafts at 0° (P = .006, P = .028) and 60° abduction (P = .026, P = .013). Both ACD and FL grafts elongated during testing.

Conclusions: Our results suggest SCR with a single 6-mm-thick ACD allograft is noninferior to FL regarding SubDist and PSCP while completely restoring the superior stability of the glenohumeral joint compared with the intact state.
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http://dx.doi.org/10.1016/j.jse.2020.11.015DOI Listing
January 2021

The Evidence Behind Weighted Ball Throwing Programs for the Baseball Player: Do They Work and Are They Safe?

Curr Rev Musculoskelet Med 2021 Feb 6;14(1):88-94. Epub 2021 Jan 6.

Mayo Clinic Sports Medicine, Charlton LC 200 First Street SW, Rochester, MN, 55905, USA.

Purpose Of Review: Weighted baseball throwing programs have gained significant attention recently. They have been promoted as proven option for pitchers wishing to increase their throwing velocity and improve throwing mechanics. However, there is some concern that, if not applied properly, they may increase injury risk. In this review, we aim to (1) give a brief description of the potential mechanisms through with weighed ball programs that could improve throwing velocity, (2) summarize the available evidence regarding their effectiveness in increasing throwing velocity, (3) summarize the evidence on injury risk, and (4) propose directions for future studies.

Recent Findings: Initial research on weighted ball programs was published in the 1960s. Recently there has been an increase in research as interest from baseball organizations, instructors, players, and medical providers has grown. A recent randomized controlled trial demonstrated that pitching velocity can be increased through a 6-week weighted ball program; however, with that, they found that the rate of injury also increased. An earlier systematic review outlined 10 studies that evaluated weighted ball programs effect on pitching velocity and reported that 7 studies described increases in throwing velocity, while most studies did not comment on injury risk. They note that the results on rate of injury have been variable, likely secondary to the variability in time and intensity of different programs. The inconsistency in the methodology of weighted ball programs and studies has made it challenging to draw (scientifically) meaningful conclusions. Nevertheless, several studies have offered empirical evidence in support of the claim that weighted ball programs can increase pitching velocity through improved throwing mechanics. At the same time, these studies have emphasized the improvements in performance, while the potential effects on injury mechanisms have been less well understood. There is a need for improved standardization of these programs to allow for future study and subsequent modification to optimize performance.
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http://dx.doi.org/10.1007/s12178-020-09686-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7930148PMC
February 2021

Superior Capsule Reconstruction: A Glimpse into the Future?

HSS J 2020 Dec 18;16(Suppl 2):503-506. Epub 2020 Sep 18.

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

The recent study by Mihata et al., [10] "" (. 2019;101:1921-1930), was the first case series published examining long-term clinical and radiographic outcomes of superior capsule reconstruction (SCR) for irreparable rotator cuff tears. This article is a critical review of how the aforementioned study fits into a growing literature surrounding the use of SCR for irreparable rotator cuff tears and how these results may impact clinical and operative decision-making for this patient population. The series compares clinical and radiographic data taken pre-operatively with data taken at 1 year and 5 years post-operatively in a group of 30 patients who underwent SCR utilizing tensor fascia lata autograft. While the results of the study suggest that a healed SCR graft utilizing this specific technique successfully restored shoulder function and prevented progression of rotator cuff arthropathy, it is important to appreciate the limitations of this small, retrospective case series. Nonetheless, the study represents an important addition to the expanding literature surrounding this significant topic. In this report, we shed light on the current state of this novel operative technique and the ongoing controversies revolving around graft material and thickness.
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http://dx.doi.org/10.1007/s11420-020-09796-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7749914PMC
December 2020

Survivorship of a Medialized Glenoid and Lateralized Onlay Humerus Reverse Shoulder Arthroplasty Is High at Midterm Follow-up.

HSS J 2020 Dec 9;16(Suppl 2):293-299. Epub 2019 Dec 9.

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

Background: Reverse shoulder arthroplasty (RSA) is a common treatment of a variety of disabling shoulder conditions. The purpose of this study was to determine revision-free survivorship after RSA using a medialized glenoid and lateralized onlay-type humerus implant and to identify etiologies of revision.

Methods: All RSAs performed using the Comprehensive Reverse Shoulder System (Zimmer Biomet, Inc.; Warsaw, IN, USA) at one institution from 2008 to 2014 were identified through a retrospective review. Charts were reviewed to determine whether the RSA was a primary or revision surgery. Patients were contacted by telephone, and survivorship was defined as no subsequent surgery after RSA. Of the 526 RSAs performed, responses were obtained from 403 patients (77%). A Kaplan-Meier analysis was performed to determine survivorship over time. A test was used to determine differences between revision rates after RSA.

Results: Minimum follow-up was 3 years, and average follow-up was 4.83 ± 1.60 years. Survivorship was 96% at 2 years and 93% at 5 years after RSA. Revisions were performed for instability ( = 8), humeral tray-taper junction failure ( = 5), acute fracture ( = 4), infection ( = 3), glenoid loosening ( = 3), osteolysis ( = 1), or notching ( = 1). Fourteen of the 151 patients (9.2%) who had surgery prior to RSA required revision after RSA. Having shoulder surgery prior to RSA was associated with higher rates of subsequent revision after RSA.

Conclusion: Overall, survivorship after RSA using a medialized glenoid and lateralized onlay-type humerus RSA is high, and prostheses implanted in native shoulders have lower rates of revision at midterm follow-up. Instability (1.9%) was the most common reason for revision.
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http://dx.doi.org/10.1007/s11420-019-09721-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7749889PMC
December 2020

Effects of Mound Versus Flat-Ground Pitching and Distance on Arm Mechanics and Elbow Torque in High School Pitchers.

Orthop J Sports Med 2020 Dec 10;8(12):2325967120969245. Epub 2020 Dec 10.

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

Background: Although the monitoring of a pitcher's throwing arm workload has become a hot topic in both research and the pitching world, the impact of mound height and distance still remains unclear.

Purpose: To compare the kinetics and kinematics between pitches from a mound and flat ground at 2 different distances.

Study Design: Descriptive laboratory study.

Methods: A total of 21 healthy high school varsity baseball pitchers (age, 16.2 ± 1.3 years; weight, 73.6 ± 11.0 kg; height, 181.3 ± 6.4 cm) participated in this study. Players were fitted with a motusBASEBALL sensor and sleeve. Each pitcher was instructed to pitch 5 fastballs under 4 conditions: mound at 60.5 ft (regulation distance), flat ground at 60.5 ft, mound at 50.5 ft, and flat ground at 50.5 ft. Linear mixed-effects models were used to account for both intra- and interplayer variability. A multivariable model was used to evaluate the association of mound pitching, flat-ground pitching, and their distances (50.5 ft and 60.5 ft), and their interaction to arm speed, arm slot, arm rotation, elbow varus torque, and ball velocity.

Results: There were no statistically significant effects of mound, flat-ground, or distance variation on arm speed or shoulder rotation. Arm slot was significantly higher (+3.0°; = .02) on pitches from the mound at 60.5 ft compared with 50.5 ft. Elbow varus torque was lower (-1.5 N·m; = .02) on mound pitches at 60.5 ft compared with 50.5 ft. Pitches thrown from the mound displayed significantly faster ball velocity compared with flat-ground pitches at both distances ( < .01 for both), with pitches at 60.5 ft having higher velocity (+0.7 m/s; < .01).

Conclusion: Contrary to long-standing notions, the study results suggest that pitching from the mound does not significantly increase stress on the elbow compared with flat-ground pitching. Lower elbow varus torque and faster ball velocity at the regulation distance compared with the reduced distance indicate that elbow stress and ball velocity may not correlate perfectly, and radar guns may not be an appropriate surrogate measure of elbow varus torque.

Clinical Relevance: A better understanding of the kinetic and kinematic implications of various throwing programs will allow for the designing of programs that are driven by objective data with aims directed toward injury prevention and rehabilitation in baseball pitchers.
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http://dx.doi.org/10.1177/2325967120969245DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7734513PMC
December 2020

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

The impact of prior ipsilateral arthroscopy on infection rates after shoulder arthroplasty.

J Shoulder Elbow Surg 2020 Oct 15. Epub 2020 Oct 15.

Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA. Electronic address:

Background: Patients frequently undergo interventions before shoulder arthroplasty, including injections and arthroscopy. Although the potential impact of injections on postoperative outcomes such as infection has been well studied, it is less clear whether prior arthroscopy has an impact on infection rates after shoulder arthroplasty. The purpose of this study was to determine whether prior ipsilateral shoulder arthroscopy is associated with an increased risk of postoperative infection after shoulder arthroplasty.

Methods: Patients who underwent shoulder arthroplasty, including hemiarthroplasty, total shoulder arthroplasty, or reverse shoulder arthroplasty with a minimum of 1-year preoperative database exposure, were queried using Current Procedural Terminology codes from 2 large insurance databases, including both private-payer (Humana, 2008-2017) and Medicare (2006-2014) data. Patients with procedures for infection, fractures, or without laterality data were excluded. Those who underwent ipsilateral shoulder arthroscopy within 2 years before their arthroplasty were identified and compared with controls who did not undergo prior arthroscopy. Each database was analyzed separately. Periprosthetic infection within 1 year after arthroplasty was queried for each group and compared using a logistic regression analysis with control for demographic and comorbidity confounders.

Results: A total of 9362 Medicare patients and 17,716 private-payer patients were included in the study. Of these, 486 (5.2%) Medicare patients and 685 (3.9%) private-payer patients underwent prior arthroscopy. In the Medicare database, prior arthroscopy was also associated with a postarthroplasty infection rate of 3.9% as compared with 1.9% in the control group (odds ratio: 1.96, 95% confidence interval: 1.20-3.22, P = .003). Similarly, in the private insurance cohort, prior shoulder arthroscopy was associated with a postarthroplasty infection rate of 2.9% as compared with 1.4% in the control group (odds ratio: 1.85, 95% confidence interval: 1.13-3.03, P = .005).

Conclusion: Shoulder arthroscopy performed within 2 years before shoulder arthroplasty is associated with a higher infection rate in the first year after shoulder arthroplasty.
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http://dx.doi.org/10.1016/j.jse.2020.09.019DOI Listing
October 2020

Delay to Arthroscopic Rotator Cuff Repair Is Associated With Increased Risk of Revision Rotator Cuff Surgery.

Orthopedics 2020 Nov 1;43(6):340-344. Epub 2020 Oct 1.

The purpose of this study was to determine the association between time from the diagnosis of rotator cuff tear to repair and the rate of subsequent revision surgery for re-tear. A national insurance database was queried from 2007 to 2016 for patients who underwent arthroscopic rotator cuff repair after a diagnosis of rotator cuff tear with minimum 5-year follow-up. On the basis of time from diagnosis to repair, patients were stratified into an early (<6 weeks), a routine (between 6 weeks and 12 months), or a delayed (>12 months) repair cohort. The rates of subsequent revision rotator cuff repair were compared pairwise between cohorts with Pearson's chi-square tests. Multivariate logistic regression was used to adjust for patient demographics and comorbidity burden. A total of 2759 patients were included, with 1510 (54.7%) undergoing early repair, 1104 (40.0%) undergoing routine repair, and 145 (5.3%) having delayed repair. The overall revision rate at 5-year follow-up was 9.6%. The revision rate was higher in the delayed group (15.2%) relative to the early (9.9%) and routine (8.3%) groups (P=.048 and P=.007, respectively). On multivariate analysis, delayed repair was associated with increased odds of revision surgery (odds ratio, 1.97; P=.009) compared with routine repair. Delayed rotator cuff repair beyond 12 months of diagnosis was associated with an increased risk of undergoing subsequent revision rotator cuff repair while controlling for age and comorbidity burden. [Orthopedics. 2020;43(6):340-344.].
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http://dx.doi.org/10.3928/01477447-20200923-02DOI Listing
November 2020

Does Having a Rotator Cuff Repair Before Total Shoulder Arthroplasty Influence Outcomes?

Orthop J Sports Med 2020 Aug 25;8(8):2325967120942773. Epub 2020 Aug 25.

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

Background: The number of rotator cuff repairs (RCRs) is increasing each year. Total shoulder arthroplasty (TSA) is a successful treatment option for patients with glenohumeral osteoarthritis with a functioning rotator cuff.

Purpose/hypothesis: The purposes of this study were to report the outcomes of TSA in patients with ipsilateral RCR and determine whether patients with a history of ipsilateral RCR who subsequently underwent TSA had differences in outcomes compared with matched controls who underwent TSA with no history of RCR. We hypothesized that patients with prior RCR will have significant improvements in clinical outcome scores, with no difference in outcomes after TSA compared with those with no prior RCR.

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

Methods: Patients eligible for inclusion were those with a history of prior RCR who underwent TSA at a single institution with a minimum 2-year follow-up between 2000 and 2015. Outcomes for this group, including American Shoulder and Elbow Surgeons (ASES) scores, were reported and then compared with a matched control group of patients who underwent TSA with no history of prior RCR. Controls were matched based on age, sex, and preoperative ASES score.

Results: Overall, 14 patients (64% males; mean ± SD age, 65.1 ± 11.1 years) underwent prior ipsilateral RCR before TSA. ASES scores significantly improved from 42.9 to 78.5 at 2 years and to 86.6 at 5 years. When compared with 42 matched control patients (matched 1:3) who underwent TSA with no history of RCR, there was no significant difference in ASES scores at 2 years (78.5 vs 85.3; = .19) and 5 years (86.6 vs 90.9; = .72) between the prior RCR and no RCR groups.

Conclusion: TSA in patients with a history of prior ipsilateral RCR led to significant improvements in clinical outcomes. No difference in clinical outcomes at 2 or 5 years after TSA was found between patients with and without a history of prior ipsilateral RCR.
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http://dx.doi.org/10.1177/2325967120942773DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7450454PMC
August 2020

Scapular Ring Preservation: Coracoacromial Ligament Transection Increases Scapular Spine Strains Following Reverse Total Shoulder Arthroplasty.

J Bone Joint Surg Am 2020 Aug;102(15):1358-1364

Hospital for Special Surgery, New York, NY.

Background: Scapular fractures following reverse total shoulder arthroplasty (RSA) are devastating complications with substantial functional implications. The role of the coracoacromial ligament (CAL), which is often transected during surgical exposure for RSA, is not fully known. We hypothesized that the CAL contributes to the structural integrity of the "scapular ring" and that the transection of this ligament during RSA alters the scapular strain patterns.

Methods: RSA was performed on 8 cadaveric specimens without evidence of a prior surgical procedure in the shoulder. Strain rosettes were fixed onto the acromial body (at the location of Levy type-II fractures) and the scapular spine (Levy type III). With use of a shoulder simulator, strains were recorded at 0°, 30°, and 60° glenohumeral abductions before and after CAL transection. The deltoid and glenohumeral joints were functionally loaded (middle deltoid = 150 N, posterior deltoid = 75 N, and joint compression = 300 N). Maximum principal strains were calculated from each rosette at each abduction angle. A repeated-measures analysis of variance with post hoc analysis was performed to compare the maximum principal strain at each abduction angle.

Results: With the CAL intact, there was no significant difference between strain experienced by the acromion and scapular spine at 0°, 30°, and 60° of glenohumeral abduction. CAL transection generated significantly increased strain in the scapular spine at all abduction angles compared with an intact CAL. The maximum scapular spine strain observed was increased 19.7% at 0° of abduction following CAL transection (1,216 ± 300.0 microstrain; p = 0.011). Following CAL transection, acromial strains paradoxically decreased at all abduction angles (p < 0.05 for all). The smallest strains were observed at 60° of glenohumeral abduction at the acromion following CAL transection (296 ± 121.3 microstrain; p = 0.048).

Conclusions: The CAL is an important structure that completes the "scapular ring" and therefore serves to help distribute strain in a more normalized fashion. Transection of the CAL substantially alters strain patterns, resulting in increased strain at the scapular spine following RSA.

Clinical Relevance: CAL preservation is a modifiable risk factor that may reduce the risk of bone microdamage and thus the occurrence of fatigue/stress fractures in the scapular spine following RSA.
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http://dx.doi.org/10.2106/JBJS.19.01118DOI Listing
August 2020

Surgical treatment for recurrent shoulder instability: factors influencing surgeon decision making.

J Shoulder Elbow Surg 2021 Mar 25;30(3):e85-e102. Epub 2020 Jul 25.

Duke Sport Science Institute, Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.

Background: The optimal surgical approach for recurrent anterior shoulder instability remains controversial, particularly in the face of glenoid and/or humeral bone loss. The purpose of this study was to use a contingent-behavior questionnaire (CBQ) to determine which factors drive surgeons to perform bony procedures over soft tissue procedures to address recurrent anterior shoulder instability.

Methods: A CBQ survey presented each respondent with 32 clinical vignettes of recurrent shoulder instability that contained 8 patient factors. The factors included (1) age, (2) sex, (3) hand dominance, (4) number of previous dislocations, (5) activity level, (6) generalized laxity, (7) glenoid bone loss, and (8) glenoid track. The survey was distributed to fellowship-trained surgeons in shoulder/elbow or sports medicine. Respondents were asked to recommend either a soft tissue or bone-based procedure, then specifically recommend a type of procedure. Responses were analyzed using a multinomial-logit regression model that quantified the relative importance of the patient characteristics in choosing bony procedures.

Results: Seventy orthopedic surgeons completed the survey, 33 were shoulder/elbow fellowship trained and 37 were sports medicine fellowship trained; 52% were in clinical practice ≥10 years and 48% <10 years; and 95% reported that the shoulder surgery made up at least 25% of their practice. There were 53% from private practice, 33% from academic medicine, and 14% in government settings. Amount of glenoid bone loss was the single most important factor driving surgeons to perform bony procedures over soft tissue procedures, followed by the patient age (19-25 years) and the patient activity level. The number of prior dislocations and glenoid track status did not have a strong influence on respondents' decision making. Twenty-one percent glenoid bone loss was the threshold of bone loss that influenced decision toward a bony procedure. If surgeons performed 10 or more open procedures per year, they were more likely to perform a bony procedure.

Conclusion: The factors that drove surgeons to choose bony procedures were the amount of glenoid bone loss with the threshold at 21%, patient age, and their activity demands. Surprisingly, glenoid track status and the number of previous dislocations did not strongly influence surgical treatment decisions. Ten open shoulder procedures a year seems to provide a level of comfort to recommend bony treatment for shoulder instability.
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http://dx.doi.org/10.1016/j.jse.2020.07.003DOI Listing
March 2021

The Effect of Patient Characteristics and Comorbidities on the Rate of Revision Rotator Cuff Repair.

Arthroscopy 2020 09 9;36(9):2380-2388. Epub 2020 Jul 9.

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

Purpose: To describe the national rates of failed primary rotator cuff repair (RCR) requiring revision repair, using numerous patient characteristics previously defined in orthopaedic literature, including smoking history, diabetes mellitus (DM), hyperlipidemia (HLD), vitamin D deficiency, and osteoporosis to determine which factors independently affect the success of primary RCR.

Methods: A combined public and private national insurance database was searched from 2007 to 2016 for all patients who underwent RCR. Current Procedural Terminology codes were used to identify RCRs. Laterality modifiers for the primary surgery were used to identify subsequent revision RCRs. All patients who did not have a linked laterality modifier for the RCR Current Procedural Terminology code were excluded from the study. Basic demographics were recorded. International Classification of Diseases Ninth Revision codes were used to identify patient characteristics including Charlson Comorbidity Index, smoking status, DM, obesity, HLD, vitamin D deficiency, and osteoporosis. Patient age categorized as <60, 60-69, 70-74, or 75+ years old. Dichotomous data were analyzed with χ testing. Multivariable logistic regression was used to characterize independent associations with revision RCR.

Results: Included in the study were 41,467 patients (41,844 shoulders, 52.7% male patients) who underwent primary arthroscopic RCR. Of all arthroscopic RCRs, 3072 patients (3463 shoulders, 53.5% male patients) underwent revision RCR (8.38%). In both primary and revision RCR, patients age 60 to 69 years were most prevalent, accounting for 38.4% and 37.6% of the cohorts, respectively. The average time from primary RCR to revision was 414.9 days (median 214.0 days). Increasing age and male sex (odds ratio [OR] 1.10, P = .019, 95% confidence interval [CI] 1.02-1.19) were significantly predictive of revision RCR. Of the remaining patient characteristics, smoking most strongly predicted revision RCR (OR 1.36, P < .001, CI 1.23-1.49). Obesity (OR 1.32, P < .001, CI 1.21-1.43), hyperlipidemia (OR 1.09, P = .032, CI 1.01-1.18), and vitamin D deficiency (OR 1.18, P < .001, CI 1.08-1.28) also increased risk of revision RCR significantly. DM was found to be protective against revision surgery (OR 0.84, P < .001, CI 0.76-0.92). Overall comorbidity burden as measured by the Charlson Comorbidity Index was not predictive of revision RCR.

Conclusions: Smoking, obesity, vitamin D deficiency, and HLD are shown to be independent risk factors for failure of primary RCR requiring revision RCR. However, despite the suggestions of previous studies, DM, osteoporosis, and overall comorbidity burden did not demonstrate independent associations in this study.

Level Of Evidence: IV, Case Series.
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http://dx.doi.org/10.1016/j.arthro.2020.05.022DOI Listing
September 2020

Technology Used in the Prevention and Treatment of Shoulder and Elbow Injuries in the Overhead Athlete.

Curr Rev Musculoskelet Med 2020 Aug;13(4):472-478

Sports Medicine and Shoulder Surgery Service, Sports Medicine Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.

Purpose Of Review: To review the current technology available for the prevention and treatment of shoulder and elbow injuries in the overhead athlete.

Recent Findings: Shoulder and elbow injuries are common in recreational and high-level overhead athletes. Injury prevention in these athletes include identifying modifiable risk factors, offering effective preventative training programs, and establishing safe return-to-sport criteria. The advent and use of technologies and wearable devices with concomitant development of software and data analytic programs has significantly changed the role of sports technology in injury identification and prevention. Over the last few decades, leveraging new technologies to better understand and treat patients has become an increasing focus of healthcare. Technologies currently being applied to the treatment of the overhead athlete include kinesiotaping, heart rate monitors, accelerometers/gyroscopes, dynamometers/force plates, camera-based monitoring systems (optical motion analysis), and inertial sensor monitoring units. Advances in technology have made it possible to acquire large amounts of data on athletes that may be used to guide treatment and injury prevention programs; however, literature validating the clinical efficacy of many of these technologies is limited. Further research is needed to continue to allow team physicians to provide better, cost-efficient, and individualized care to the overhead athlete using technology.
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http://dx.doi.org/10.1007/s12178-020-09645-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7340695PMC
August 2020

The Role of Biologic Agents in the Non-operative Management of Elbow Ulnar Collateral Ligament Injuries.

Curr Rev Musculoskelet Med 2020 Aug;13(4):442-448

Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA.

Purpose Of Review: Injuries to the elbow ulnar collateral ligament (UCL) are especially common in the overhead throwing athlete. Despite preventative measures, these injuries are occurring at increasing rates in athletes of all levels. UCL reconstruction techniques generally require a prolonged recovery period and introduce the potential for intraoperative complications prompting investigations into more conservative treatment measures based on specific patient and injury characteristics. The purpose of this review is to describe the current literature regarding the use of biologic augmentation in the management of UCL injuries. Specifically, this review will focus on the basic science background and clinical investigations pertaining to biologic augmentation utilizing platelet-rich plasma (PRP) and autologous stem cells.

Recent Findings: Despite some evidence supporting the use of PRP therapy in patients with partial UCL tears, there is no current consensus regarding its true efficacy. Similarly, due to a lack of clinical investigations, no consensus exists regarding the utilization of autologous stem cell treatments in the management of UCL injuries. Management of UCL injuries ranges from non-operative treatment with focused physical therapy protocols to operative reconstruction. The use of biologic augmentation in these injuries continues to be investigated in the orthopedic community. Currently, no consensus exists regarding the efficacy of either PRP or autologous stem cells and further research is needed to further define the appropriate role of these treatments in the management of UCL injuries.
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http://dx.doi.org/10.1007/s12178-020-09637-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7340701PMC
August 2020

State of the Union on Ulnar Collateral Ligament Reconstruction in 2020: Indications, Techniques, and Outcomes.

Curr Rev Musculoskelet Med 2020 Jun;13(3):338-348

Sports Medicine and Shoulder Service, Sports Medicine Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.

Purpose Of Review: There has been a marked increase in the number of ulnar collateral ligament reconstructions performed annually and an associated increase in the amount of recent literature published. It is paramount that surgeons remain up to date on the current literature, as modern indications and surgical techniques continue to improve clinical outcomes.

Recent Findings: Our understanding of ulnar collateral ligament (UCL) injuries, treatment indications, and surgical techniques for UCL reconstruction continues to evolve. Despite the rapidly increasing amount of published literature on the topic, a clear and concise surgical algorithm is lacking. Studies have suggested a trend towards improved clinical outcomes and decreased complications with various modifications in UCL reconstruction techniques. Current sport-specific outcome studies have reported conflicting results regarding the effect of UCL reconstruction on an athlete's performance upon returning to sport. With the rising incidence of UCL reconstruction and growing media attention, UCL injuries, reconstruction techniques, and return to sport following UCL surgery are timely topics of interest to clinicians and overhead throwing athletes. Several technique modifications have been reported, and these modifications may lead to improved outcomes and lower complication rates. Studies assessing sport-specific outcome measures will be necessary to provide a more critical and informative analysis of outcomes following UCL reconstruction.
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http://dx.doi.org/10.1007/s12178-020-09621-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7251011PMC
June 2020

The History and Evolution of Elbow Medial Ulnar Collateral Ligament Reconstruction: from Tommy John to 2020.

Curr Rev Musculoskelet Med 2020 Jun;13(3):349-360

Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, 200 First Street, Rochester, MN, USA.

Purpose Of Review: The purpose of this review article is to discuss the evolution of surgical reconstruction of the anterior bundle of the UCL, otherwise known as Tommy John surgery, from Dr. Jobe's initial description in 1986 to present day. In particular, the unique changes brought forth by each new surgical technique, and the reasons that these changes were implemented, are highlighted.

Recent Findings: The incidence of UCL reconstruction surgery continues to increase significantly, particularly in the 15- to 19-year-old age group. New anatomic understanding of the anterior bundle of the UCL, including the importance of the central fibers and the broad and tapered ulnar insertion, may affect optimal UCL reconstruction techniques in the future. Although return to play rates are generally quite high (80-95%), the mean time to return to play (typically 12-18 months for pitchers) is longer than desired. Accordingly, many authors feel that there remains room for improvement in the treatment of this common injury. The Tommy John surgery has evolved in many ways with the development of novel techniques over the last 35 years. Currently, overhead throwing athletes undergoing UCL reconstruction have high return to play and low complication rates. Future modifications to the surgery may aim to further improve outcomes and, more importantly, expedite the length of postoperative rehabilitation.
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http://dx.doi.org/10.1007/s12178-020-09618-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7251039PMC
June 2020

Revision Medial Ulnar Collateral Ligament Reconstruction in Baseball Pitchers: Review of Epidemiology, Surgical Techniques, and Outcomes.

Curr Rev Musculoskelet Med 2020 Jun;13(3):361-368

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

Purpose Of Review: The purposes of this review are to describe the epidemiology, treatment options, and clinical outcomes of revision medial ulnar collateral ligament reconstruction in baseball pitchers.

Recent Findings: Rates of revision UCL range from 1 to 15% and have slowly increased over the past several years. Revision UCL procedures are associated with higher complication rates, likely due to the distortion of innate anatomy after primary reconstruction. Techniques for reconstruction are largely influenced by the index surgery and integrity of the ulnar and humeral bone tunnels/sockets. Current literature reporting on the outcomes following revision UCL reconstruction is limited to case series and database studies. Mean time between primary reconstruction and revision surgery is approximately 5 years and return to play rates range from 47 to 85%. Outcomes following revision UCL reconstruction are relatively guarded compared with those of primary UCL reconstruction with the most studies reporting lower return to play rates, decreased workloads compared with pre-injury levels of play, and shorter career longevity following revision surgery. Future research regarding optimal reconstruction techniques and post-operative rehabilitation are needed as the incidence and demand for this procedure is expected to increase.
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http://dx.doi.org/10.1007/s12178-020-09619-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7251017PMC
June 2020

Elbow Ulnar Collateral Ligament Injuries: Indications, Management, and Outcomes.

Arthroscopy 2020 05 27;36(5):1221-1222. Epub 2020 Feb 27.

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

Ulnar collateral ligament (UCL) injuries continue to be a major source of morbidity in baseball players. The throwing motion creates nearly supraphysiological levels of valgus stress on the medial elbow, placing these athletes at high risk of UCL injury. The incidence of injury continues to rise at an alarming rate, especially among adolescent baseball pitchers. Certain risk factors for UCL injury have been identified, including pitch velocity, fewer days between outings, and overall workload. Treatment of UCL injuries depends on the type of tear. Low- to medium-grade partial UCL tears (i.e., grade I or II tears) are usually amenable to a period of rest and a graduated throwing program. Recently, platelet-rich plasma has been described as another treatment modality to consider in a throwing athlete with a partial UCL tear, although robust clinical data are currently lacking. Most athletes can return to competitive throwing in 3 to 4 months after nonoperative management of a low-grade partial UCL tear. Indications for surgical management of a UCL injury are a complete (type III) tear or failure of extensive conservative management after a partial UCL tear. UCL reconstruction remains the gold standard for operative management of a complete UCL tear. Both the modified Jobe technique and the docking technique have shown excellent results with return-to-play rates between 80% and 90%. Recently, UCL repair with collagen-dipped suture tape augmentation has gained some popularity. However, long-term results are lacking, especially in elite athletes. Time to return to play after UCL reconstruction is variable. Most athletes return to full competition in 12 to 15 months, although professional pitchers often require 15 to 18 months to return to their previous level of competition. Revision rates remain low (1%-7%), yet the revision rate is expected to rise as the number of UCL reconstructions performed in the United States continues to increase.
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http://dx.doi.org/10.1016/j.arthro.2020.02.022DOI Listing
May 2020

Magnetic resonance imaging of the failed superior capsular reconstruction.

Clin Imaging 2020 Apr 13;60(2):172-176. Epub 2019 Nov 13.

Department of Radiology & Imaging, Hospital for Special Surgery, New York, NY, USA.

Background: Superior capsular reconstruction (SCR) of the shoulder is an increasingly common procedure in the treatment of patients with massive, irreparable rotator cuff tears lacking significant osteoarthritis. Post-operatively, the appearance of failed grafts has only been described in isolated case reports and review articles.

Methods: From January 2016 through December 2017, surgical records at a single tertiary-care facility were queried to identify all patients undergoing SCR. Patient records were reviewed for patient demographic information, reason for post-operative MRI, and post-operative surgeon assessment. 74 patients underwent SCR, of whom 12 received a follow-up MRI post-operatively. One patient was excluded due to missing records; the remaining 11 patients comprise the study cohort. Post-operative MRIs were obtained at mean six months after surgery.

Results: On review of post-operative MRIs, three distinct locations of failure were identified. Four patients (40%) had midsubstance failure of the allograft with all glenoid and humeral head fixation remaining intact. One patient (10%) had complete detachment of the allograft from both glenoid and humeral head fixation. Five patients (50%) had detachment of the allograft from the glenoid.

Conclusion: In this series of ten failed SCRs, the most common mode of failure was loss of fixation on the glenoid, followed closely by midsubstance rupture. We found no instances of isolated fixation failure on the humeral head. This series illustrates the need for careful imaging in patients whose post-operative course suggests clinical failure. These findings suggest that strengthening glenoid fixation may provide better clinical outcomes as this procedure becomes more common.

Level Of Evidence: III - Retrospective study.
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http://dx.doi.org/10.1016/j.clinimag.2019.10.006DOI Listing
April 2020