Dines, Joshua S.

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.

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.

Background: Studies examining the evolution of shoulder and elbow range of motion (ROM) in baseball pitchers over a single season have yielded inconsistent results. Purpose: To evaluate shoulder and elbow ROM in Major League Baseball (MLB) pitchers over a single season and to assess for correlations between these changes and measures of a pitcher’s workload. Study Design: Case-control study; Level of evidence, 3. Methods: Bilateral shoulder ROM (internal rotation [IR], external rotation [ER], and total range of motion [TROM]) was assessed in 92 MLB pitchers pre- and postseason. Shoulder forward flexion (FF) was measured in 64 pitchers, horizontal adduction (HA) was measured in 87 pitchers, and elbow ROM was measured in 86 pitchers. Data collected included demographics (age, height, weight, and body mass index) and measures of workload for pitchers (pitches thrown, innings pitched, and mean fastball velocity). Pitchers were not specifically excluded if they had an injury during the season but had recovered and were actively pitching at the time of postseason measurements. The change in motion from pre- to postseason was measured and the associations with player demographics and workload were calculated by use of the Pearson correlation coefficient. Results: On average, pitchers demonstrated an increase in dominant shoulder ER from 118.8° to 125.4° ( P < .001) and TROM from 173.1° to 181.7° ( P < .001). HA was increased by an average of 15.7° ( P < .001). The average shoulder IR ( P = .189), FF ( P = .432), and elbow ROM (flexion, P = .549; extension, P = .185) remained similar over the span of the season. Average glenohumeral IR deficit did not increase. Pitcher demographics and measures of throwing workload (total pitches thrown, innings pitched, mean fastball velocity) were not significantly correlated with changes in shoulder or elbow ROM. Conclusion: Significant increases in dominant shoulder ER, TROM, and HA were identified in MLB pitchers over the course of a single baseball season. These ROM changes were not correlated with measures of pitching workload.

Purpose To identify any dose‐dependent association between the use of subacromial corticosteroid injections within a year before rotator cuff repair (RCR) and subsequent need for revision rotator cuff surgery. Methods Two large administrative databases were queried for patients undergoing arthroscopic RCR. A minimum of 1 year of preoperative database exposure and 2 years of postoperative database follow‐up were required for inclusion. Patients were stratified into groups that received 0 (control), 1, 2, or 3 or more ipsilateral corticosteroid shoulder injections within the year prior to RCR. The outcome of interest was ipsilateral revision arthroscopic or open RCR or arthroscopic debridement for a diagnosis of rotator cuff tear within 2 years of the index surgery. Revision rates were compared between groups using a multivariate logistic regression analysis controlling for demographic and comorbidity confounders. Results A total of 110,567 patients from the Medicare database and 12,892 patients from the private insurance database were included. There was no association between a single injection within the year prior to RCR and revision surgery in either cohort. The use of 2 or more injections was associated with a significant increase in the risk of requiring revision surgery in both the Medicare (odds ratio [OR], 2.76‐3.26; P < .0001) and private insurance (OR, 2.53‐2.87; P < .0001) populations. Conclusions A single shoulder injection within a year prior to arthroscopic RCR was not associated with any increased risk of revision surgery; however, the administration of 2 or more injections was associated with a substantially increased risk of subsequent revision rotator cuff surgery (OR, 2.53‐3.26). Although causality cannot be established on the basis of this database review, caution is recommended when considering more than 1 shoulder corticosteroid injection in patients with potentially repairable rotator cuff tears. Level of Evidence Level III, retrospective cohort study.

Objectives: Professional baseball pitchers are at high risk for tears of the ulnar collateral ligament (UCL) of the elbow, often requiring subsequent surgical reconstruction. Despite acceptable published return to play outcomes, multiple techniques and graft types have been described. There is a paucity of clinical data in the current literature comparing UCL reconstruction surgical technique and graft type. Even less is known about the risks for subsequent injury, surgery, or revision UCL reconstruction. Accordingly, this study compares UCL reconstruction outcomes based on tunnel configuration and graft type. Methods: Following approval from our institutional review board and Major League Baseball (MLB), 566 professional baseball pitchers who underwent UCL reconstruction between 2010 and 2014 were identified and included. The following patient demographics 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 (Docking vs. Modified Jobe), graft type (palmaris longus autograft vs. gracilis autograft), and concomitant procedures. Primary outcome measures consisted of: the ability to return to play at any level (RTP), to return to the same level of play (RSL), the time to return, subsequent elbow injuries, and the need for subsequent or revision elbow surgery. The impact of the patient and surgical factors on outcomes were analyzed using multivariate linear and logistic regression modeling. Results: The overall RTP was 79.9% and RSL was 71.2%. 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 vs. Modified Jobe techniques (80.1% vs. 82.4%; p=0.537) and for the two primary graft types (83.1% for palmaris vs. 80.7% for gracilis; p=0.596). The risk of subsequent elbow surgery was 10.5% for the Docking Technique vs. 14.8% for the Modified Jobe (p=0.203); and the risk for subsequent UCL revision reconstruction surgery was 2.9% vs. 6.2% for the Docking vs. Modified Jobe Techniques, respectively (p=0.128). Significant trends towards an increasing use of palmaris autograft (p=0.023) and the docking technique (p=0.006) were observed. MLB pitchers were more likely than MiLB pitchers to RTP (p<0.001) and to RSL (p<0.001), but they required a longer time to return (mean difference 35 days; p=0.039), had a higher likelihood of subsequent elbow (OR 3.58; 95% CI 2.055 to 6.231; p<0.001) and forearm injuries (OR 5.695; 95% CI 1.99 to 16.302; p=0.004), but not subsequent elbow surgery. No specific variables were noted to be predictive of subsequent elbow or revision surgery in the multivariate analysis. Conclusion: Surgical outcomes in professional baseball players are not significantly influenced by ulnar collateral ligament reconstruction technique or graft type usage. Major League players are more likely to RTP and RSL, but they have a higher frequency of subsequent elbow and forearm injuries. Both the Docking Technique and palmaris autograft are increasing in popularity amongst surgeons treating professional baseball players.

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.

Background: Although batters are frequently hit by pitch (HBP) in baseball, the effect of HBP injuries remains undefined in the literature. Purpose: To determine the effect of HBP injuries in terms of time out of play, injury patterns resulting in the greatest time out of play, and the value of protective gear such as helmets and elbow pads. Study Design: Descriptive laboratory study. Methods: Based on the Major League Baseball (MLB) Health and Injury Tracking System, all injuries to batters HBP during the 2011-2015 MLB and Minor League Baseball (MiLB) seasons were identified and analyzed. Video analysis was performed on all HBP events from the 2015 MLB season. Multivariate stepwise regression analysis was utilized to determine the predictive capacity of multiple variables (velocity, pitch type, location, etc) on injury status and severity. Results: A total of 2920 HBP injuries resulted in 24,624 days missed (DM) over the 5 seasons. MLB HBP injuries occurred at a rate of 1 per 2554 plate appearances (1 per 9780 pitches thrown). Mean DM per injury were 8.4 (11.7 for MLB vs 8.0 for MiLB, P < .001). Surgery was required for 3.1% of MLB injuries and 1.2% of MiLB injuries ( P = .005). The most common body regions injured were the hand/fingers (n = 638, 21.8%), head/face (n = 497, 17.0%), and elbow (n = 440, 15.7%), and there were 146 (5.0%) concussions. Injury rates and mean DM correlated with velocity in a near linear fashion. Players hit in the head/face (odds ratio, 28.7) or distal upper extremity (odds ratio, 6.4) were more likely to be injured than players HBP in other locations. Players with an unprotected elbow missed 1.7 more days (95% CI, –4.1 to 7.6) than those with an elbow protector ( P = .554) when injured after being HBP. Conclusion/Clinical Relevance: Although HBP injuries occur infrequently in the course of normal play, they collectively represent a significant source of time out of play. The most common body regions injured include the hands/fingers and head/face, and batters hit in these locations are significantly more likely to be injured. After contusions, concussions were the most common injury diagnosis.

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.

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.

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%; P = .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.