Camp, Christopher L.

Background: There are limited data comparing the outcomes of similarly matched patients with a medial meniscus posterior root tear (MMPRT) treated with nonoperative management, partial meniscectomy, or repair. Purpose/Hypothesis: The purpose was to compare treatment failure, clinical outcome scores, and radiographic findings for a matched cohort of patients who underwent either nonoperative management, partial meniscectomy, or transtibial pull-through repair for an MMPRT. We hypothesized that patients who underwent meniscus root repair will have lower rates of progression to arthroplasty than patients who were treated with nonoperative management or partial meniscectomy. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent transtibial medial meniscus posterior horn root repair were matched by meniscal laterality, age, sex, and Kellgren-Lawrence (K-L) grades to patients treated nonoperatively or with a partial meniscectomy. Progression to arthroplasty rates, International Knee Documentation Committee and Tegner scores, and radiographic outcomes were analyzed between groups. Results: Forty-five patients were included in this study (15 nonoperative, 15 partial meniscectomy, 15 root repair). Progression to arthroplasty demonstrated significant differences among treatment groups at a mean of 74 months (nonoperative, 4/15; partial meniscectomy, 9/15; meniscal repair, 0/15; P = .0003). The meniscus root repair group had significantly less arthritic progression, as measured by change in K-L grade from pre- to postoperatively (nonoperative, 1.0; partial meniscectomy, 1.1; meniscal repair, 0.1; P = .001). Conclusion: Meniscus root repair leads to significantly less arthritis progression and subsequent knee arthroplasty compared with nonoperative management and partial meniscectomy in a matched cohort based on patient characteristics.

Background: While a large volume of literature has focused on risk factors for anterior shoulder instability, the rates of recurrence are inconsistent and require additional population-based epidemiologic data. Purpose/Hypothesis: The purpose was to report the effect of patient age on the number of instability events before physician consultation, rate of surgical stabilization, recurrent instability, and progression to osteoarthritis in patients <40 years old with anterior shoulder instability, utilizing an established US geographic population. We hypothesized that younger patients would be more likely to experience multiple episodes of instability before evaluation, undergo surgery, and experience recurrent instability after surgical intervention. Study Design: Descriptive epidemiologic study. Methods: An established geographic database of more than 500,000 patients was used to identify patients <40 years of age with anterior shoulder instability between 1994 and 2016. Medical records were reviewed to obtain patient characteristics, history, imaging, surgical details, and outcomes. Patients were divided into 5 groups based on age (≤15, 16-20, 21-25, 26-30, and 31-40 years) at initial instability. Comparative analysis was performed to identify differences between groups. Results: The study population consisted of 654 patients with a mean follow-up of 11.1 years (range, 2.0-25.2 years). This resulted in 118 patients (18%) ≤15 years of age at initial instability; 250 (38%), 16 to 20 years; 110 (17%), 21 to 25 years; 80 (12%), 26 to 30 years; and 96 (15%), 31 to 40 years. Of patients ≤15 years old at initial instability 47% had 3+ instability events, compared with 12% of patients aged 31 to 40 years ( P < .001). At 10 years of follow-up, patients ≤15 and 16 to 20 years old demonstrated the highest recurrent instability rates of 38.8% and 47.1% after nonoperative management, respectively. Patients 16 to 20 years old demonstrated the highest rates of both surgical intervention (40.4%) and recurrence after surgery (24.8%). Patients 31 to 40 years of age were significantly more likely to develop clinically symptomatic osteoarthritis (15.6%) than all other age groups. Conclusion: In a US epidemiologic population of patients <40 years old, the rate of recurrent anterior shoulder instability was roughly one-third after initial physician consultation. Younger patients, particularly those ≤15 and 16 to 20 years of age, were more likely to have experienced multiple instability events at the time of initial evaluation, require surgery, and experience recurrent instability compared with older patients. For every year of decrease in age at initial instability, the risk of recurrent instability or surgical intervention after physician consultation increased by 4.1% and 2.8%, respectively.

Background: As the incidence of ulnar collateral ligament (UCL) surgery continues to rise rapidly, an update on the current prevalence and demographics in professional baseball players is warranted. Hypothesis: The prevalence of UCL reconstruction in Major League Baseball (MLB) and Minor League Baseball (MiLB) players will be higher than that previously reported, and the increase in prevalence will be most notable in MiLB pitchers. Study Design: Cross-sectional study; Level of evidence, 3. Methods: During the 2018 baseball season, an online questionnaire regarding a history of UCL surgery was distributed to the certified athletic trainers of all 30 MLB organizations. These trainers then administered the survey to all players within their organizations, including MLB, MiLB (AAA, AA, High A, Low A, High Rookie, Low Rookie), and Dominican Summer League (DSL) players. Demographics were compared between MLB, MiLB, and DSL players. Results of this 2018 survey were compared with previously published data from the 2012 season to assess the change over time. Results: There were 6135 professional baseball players who completed the survey (66% response rate). The prevalence of UCL reconstruction in all MLB and MiLB players was 13% (637/4928), while the prevalence in DSL players was 2% (20/1207) ( P < .001). The prevalence in all MLB and MiLB players (13%) and pitchers (20%) both increased significantly from 2012 ( P < .001). MLB pitchers reported a higher prevalence of UCL reconstruction than did MiLB pitchers (26% vs 19%, respectively; P < .001). In 2018, the prevalence of UCL reconstruction has increased significantly in MiLB pitchers (19% vs 15%, respectively; P < .001) and pitchers aged 21 to 30 years (22% vs 17%, respectively; P < .001) compared with 2012. Additionally, United States–born pitchers were more likely to have undergone UCL reconstruction compared with Latin America–born pitchers (23% vs 13%, respectively; P < .001). Conclusion: The prevalence of UCL reconstruction has increased significantly in professional baseball players over the past 6 years from 10% to 13%. Ultimately, the prevalence of UCL reconstruction has increased most significantly since 2012 in MiLB pitchers, pitchers aged 21 to 30 years, and pitchers born in the United States.

Background: The variability of throwing metrics, particularly elbow torque and ball velocity, during structured long-toss programs is unknown. Hypotheses: (1) Elbow torque and ball velocity would increase as throwers progressed through a structured long-toss program and (2) intrathrower reliability would be high while interthrower reliability would be variable. Study Design: Descriptive laboratory study. Level of Evidence: Level 3. Methods: Sixty healthy high school and collegiate pitchers participated in a structured long-toss program while wearing a validated inertial measurement unit, which measured arm slot, arm velocity, shoulder rotation, and elbow varus torque. Ball velocity was assessed by radar gun. These metrics were compared within and between all pitchers at 90, 120, 150, and 180 ft and maximum effort mound pitching. Intra- and interthrower reliabilities were calculated for each metric at every stage of the program. Results: Ball velocity significantly changed at each progressive throwing distance, but elbow torque did not. Pitching from the mound did not place more torque on the elbow than long-toss throwing from 120 ft and beyond. Intrathrower reliability was excellent (intraclass correlation coefficient >0.75) throughout the progressive long-toss program, especially on the mound. Ninety-one percent of throwers had acceptable interthrower reliability (coefficient of variation <5%) for ball velocity, whereas only 79% of throwers had acceptable interthrower reliability for elbow torque. Conclusion: Based on trends in elbow torque, it may be practical to incorporate pitching from the mound earlier in the program (once a player is comfortable throwing from 120 ft). Ball velocity and elbow torque do not necessarily correlate with one another, so a degree of caution should be exercised when using radar guns to estimate elbow torque. Given the variability in elbow torque between throwers, some athletes would likely benefit from an individualized throwing program. Clinical Relevance: Increased ball velocity does not necessarily equate to increased elbow torque in long-toss. Some individuals would likely benefit from individualized long-toss programs for rehabilitation.

Objective To report radiographic and magnetic resonance imaging findings, patient-reported outcomes, and complications and/or reoperations following nonarthroplasty surgical intervention for focal glenohumeral cartilage defects. Design A literature search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Patients were included if they possessed a chondral defect of the humeral head, glenoid, or both, which had been treated with a joint preserving nonarthroplasty procedure. Risk of bias assessment was performed using the Methodological Index for Non-Randomized Studies scoring system. Study demographics, surgical technique, imaging findings, patient-reported outcomes, complications, failures, and reoperations were collected. Results Fourteen studies with 98 patients (100 shoulders) met the inclusion criteria. Patient ages ranged from 7 to 74 years. The nonarthroplasty surgical techniques utilized included microfracture (67 shoulders), osteochondral transplantation (28 shoulders), chondrocyte transplantation (4 shoulders), and internal fixation (1 shoulder). The rates of radiographic union and progression of osteoarthritis ranged between 90% to 100% and 57% to 100%, respectively. Visual analog scores ranged from 0 to 1.9 at final follow-up. Mean postoperative ASES (American Shoulder and Elbow Surgeons) shoulder scores ranged from 75.8-100. Mean postoperative CSS (Constant Shoulder Score) scores ranged from 83.3-94. Mean postoperative SSV (Subjective Shoulder Value) ranged from 70% to 99%. Failure and reoperation rates ranged between 0% to 35% and 0% to 30%, respectively, with the most common reoperation being conversion to prosthetic arthroplasty. Conclusions In this systematic review, nonarthroplasty surgical techniques demonstrated acceptable rates of radiographic healing, improved patient reported outcomes, minimal complications, and low rates of failure or reoperation. Joint preserving techniques are likely viable options to prolong function of the native shoulder and provide short- to midterm pain relief in young and highly active patients. Level of Evidence Level IV.

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 ( R 2 = 0.441; P = .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 ( P = .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 ( P = .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.

AbstractThe meniscal ossicle is observed in clinical practice, yet there currently is limited information on its potential clinical significance. The purpose of this study was to assess the clinical presentation, imaging findings, and clinical treatment and outcomes of a series of patients identified as having a meniscal ossicle. An institutional database was reviewed to identify knees with a meniscal ossicle. Clinical presentation, magnetic resonance imaging (MRI), treatment, and outcomes were analyzed. Radiographs were graded using Kellgren–Lawrence (KL) scores. MRIs were reviewed for the presence and location of meniscal ossicles and additional knee pathology. Knee arthroplasty rates were recorded with the remaining patients contacted to obtain final International Knee Documentation Committee (IKDC) and Tegner's scores. Failure was defined as conversion to arthroplasty or failing IKDC score (< 75.4). Forty-five meniscal ossicles in 45 patients (26 males and 19 females) with a mean age of 51 years (standard deviation [SD] = 19.0) were included. Pain was the most common presenting symptom (89%). Forty-two patients (93%) had an associated meniscus root tear on MRI. Eighteen percent of patients that did not have an ossicle on initial imaging subsequently developed an ossicle. Mean KL grades progressed significantly from baseline of 1.84 (SD = 1.0) to 2.55 (SD = 0.93 p < 0.01) on final follow-up. Thirty-nine percent of baseline radiographs showed KL grades of less than 2 compared with only 15% of follow-up radiographs (p = 0.04). Mean IKDC score obtained for patients ≤ 60 at an average follow-up of 3.1 years (SD = 3.2) was 65.2 (SD = 19.0). Eight out of 45 patients (18%) had progressed to total knee arthroplasty (TKA) by latest available follow-up. Sixty-two percent of patients met failure criteria at latest available follow-up. The meniscal ossicle is most commonly found in the posterior horn or root of the medial meniscus and is highly suggestive to be sequelae of a posterior root tear. Therefore, the presence of a meniscal ossicle should alert the orthopaedic surgeon to the high likelihood of the patient having a meniscus root tear. These patients have shown to have poor clinical outcomes and worsening arthritis.

Purpose To report the rate of radiographic union, patient‐reported outcomes, complications, and reoperations after internal fixation of unstable osteochondritis dissecans (OCD) in the skeletally mature knee. Methods A literature search was conducted according to Preferred Reporting Items for Systematic Reviews and Meta‐Analysis guidelines. Patients were included if they were skeletally mature and underwent internal fixation of an unstable OCD lesion of the knee. Risk of bias assessment was performed using the Methodological Index for Non‐randomized Studies scoring system. Surgical technique, rate of union, patient‐reported outcomes, complications, and reoperations were collected. Results Thirteen studies resulted in 148 patients (150 knees) for inclusion. Patient age ranged from 14 to 45 years. Numerous fixation procedures were used, including biodegradable devices (rods, pins, nails, and screws), metal screws, Kirschner wire, and autologous bone sticks. Overall, reported outcome measures were heterogeneous in nature. The rate of radiographic healing ranged from 67% to 100% across 6 studies. Improved subjective results and Hughston criteria on final follow‐up ranged from 83% to 100% across 4 studies each. Mean postoperative Lysholm scores ranged from 42 to 98 in studies that reported them. Both complication and reoperation rates ranged from 0% to 44%. The most commonly performed reoperations were loose body excision and cartilage resurfacing procedures. Conclusions A variety of surgical techniques are available for treatment of unstable OCD lesions in the skeletally mature knee. In this systematic review, internal fixation of the native fragment showed acceptable rates of radiographic union and improved patient‐reported outcomes relative to other techniques. Level of Evidence Level IV, systematic review of level III‐IV studies.

Background: Hamstring strains are the most common injury for professional baseball players and can result in significant time on the disabled list. To date, no study has reported the current trends in hamstring strains in professional baseball. Hypothesis: Professional baseball players would have an increased incidence of hamstring strains from 2011 through 2016. Study Design: Descriptive epidemiology study. Methods: Injury data were prospectively collected from 2011 through 2016 for every Major League Baseball (MLB) and Minor League Baseball (MiLB) team and was recorded in the MLB Health and Injury Tracking System. Data collected for this study included date of injury, activity during injury, time lost, primary injury or reinjury status, and imaging findings as well as player demographic information related to level of play, age, and position for all hamstring injury events. Injury rates were reported as hamstring injuries per number of games. Results: From 2011 to 2016, there were 2633 hamstring strains in professional baseball players. The rate of hamstring strains increased in MLB from a low of 1 injury every 39 games in 2011 to a high of 1 injury every 30 games in 2016. In MiLB, there were 2192 hamstring strains, with 1 injury every 35 games in 2011 compared with 1 injury every 30 games in 2016. The majority of injuries occurred in the infielder positions (37.5%) and resulted from base running (>50%), most commonly from home to first base. The most common hamstring injury was a grade 2 injury to the distal biceps femoris. The mean time missed after a hamstring injury was 14.5 days. Grade 3 and grade 2 hamstring strains resulted in significantly more days missed compared with grade 1 injuries ( P = .005 and P = .002, respectively). The rate of recurrent hamstring injuries was 16.3% for MLB and 14.2% for MiLB. Recurrent hamstring injuries resulted in more time lost than primary injuries (mean, 16.4 vs 14.5 days, respectively; P = .02). A total of 42 injuries were treated with platelet-rich plasma, and 19 were treated with surgery. The number of injuries treated with platelet-rich plasma increased in successive years. Conclusion: The rate of hamstring strains in professional baseball players has increased over the past 6 years and has resulted in a significant loss of playing time. Study results indicated that these injuries are affected by injury characteristics, position played, running to first base, seasonal timing, and history of hamstring injuries.

Objectives: Traditional pitching statistics (ERA, WHIP, etc) have been used as surrogates for pitcher performance without being validated. Even amongst healthy pitchers, the normal variability of these parameters has not yet been established. The purpose of this study was to determine the normal variability of basic and advanced pitching statistics in non-injured Major League Baseball (MLB) pitchers. It is our hope that this work will serve as the foundation for the identification and implementation of validated, pitcher dependent statistical measures that can be used to assess return to play performance following injury. Methods: Publicly available data from MLB Statcast and Pitch/Fx databases was used to analyze all non-injured MLB pitchers during 2015 and 2016 seasons who pitcher greater than 100 innings each season without injury. Traditional and advanced baseball pitching statistics were analyzed. The variability of each parameter was assessed by computing coefficient of variation (CV) between individual pitchers and across all pitchers. A CV below 10 is typically indicative of a relatively constant parameter, and parameters with a CV > 10 are generally considered inconsistent and unreliable. Results: A total of 118 pitchers met all inclusion criteria. For each of these healthy pitchers, 38 basic/traditional parameters and 17 advanced parameters were analyzed. Of the traditional pitcher statistics, only 1 (3%) demonstrated a CV value < 10 (average fastball velocity [FBv]; CV 1.5) (Figure 1). In advanced statistics, 9 of 17 (53%) variables demonstrated acceptable consistency as evidenced by a CV value < 10 (Figure 2). Release position from plate (release_pos_y) along with velocity from the plate (vy0) where the two most constant advanced parameters. When separated by pitch type, these two parameters were the most constant (lowest CV) in every pitch type. Conclusion: The validity and variability of baseball statistics as surrogate markers for performance after injury/surgery have not yet been evaluated. It is critical that baseball statistics undergo proper vetting prior to being used to assess recovery. This study reveals average fastball velocity and release position from the plate to be the least variable basic and advanced baseball statistics in MLB pitchers. In total, only 10 of the 55 statistics analyzed demonstrated acceptable consistency and reliability. This study can be further used to determine the minimum time that each of these variables needs to be followed to ensure an appropriate sample size is obtained to detect significant differences in pre- and post- injury performance. [Figure: see text][Figure: see text]