Citations

Background: The medial ulnar collateral ligament (MUCL) is the primary restraint to valgus force on the elbow. Since the first description of MUCL reconstruction by Jobe et al in 1986, many technical advancements have been implemented to improve outcomes and reduce complications. The docking technique has emerged as one of the most commonly used techniques. Indications: Following repetitive stress on the elbow during the overhead throwing motion, the MUCL may become attenuated, insufficient, or rupture completely. Although nonoperative treatment with rest and therapy is often the initial treatment of choice, individuals who fail conservative measures may require MUCL reconstruction. Technique Description: The major steps of the procedure are (1) harvesting of palmaris longus autograft, (2) incision and exposure, (3) preparation of ulnar tunnel, (4) preparation of docking site on medial epicondyle, (5) graft passage, (6) graft tensioning and length determination, (7) final fixation, and (8) closure. Results: This procedure allows for reconstruction of the MUCL, restoration of valgus stability to the elbow, and return to play rates of 80% to 95%. The docking technique has advantages over previously described MUCL reconstruction techniques in that it minimizes injury to the flexor pronator mass, avoids the ulnar nerve, allows for robust graft tensioning, and reduces the amount of bone removed from the medial epicondyle. Discussion/Conclusion: The docking technique, as described in this video demonstration, is the most common MUCL reconstruction technique used today. When precise surgical steps are followed, complication rates are low and patient outcomes are favorable.

Background: Wrestlers are highly active, young athletes prone to meniscal injuries that often require surgery. However, there is a lack of data evaluating the results of meniscal repair or partial meniscectomy in this cohort. Purpose: To describe the outcomes (subjective function, return to play, complications, reoperation rates, and progression of osteoarthritis) for treatment (meniscectomy or repair) of meniscal injuries in a cohort of competitive wrestlers. Study Design: Case series; Level of evidence, 4. Methods: All competitive wrestlers (high school, collegiate, or professional leagues) with a history of a meniscal injury and isolated meniscal surgery at a single institution between 2001 and 2017 were retrospectively identified. Failure was defined as a reinjury of the operative meniscus by clinical or advanced imaging examination, reoperation, or any additional surgical treatment of the meniscus after the index procedure. All patients were contacted for determination of reinjury rates, current sport status, and International Knee Documentation Committee and Tegner activity scores. Results: Of 85 male wrestlers with isolated meniscal tears, 34% underwent a meniscal repair, and 66% received a partial meniscectomy. Index surgery failed for 9.4% of the cohort. Among wrestlers treated with initial meniscal repair, 21% required a subsequent partial meniscectomy at a mean 2.2 years, and of those treated with partial meniscectomy, 3% underwent a second operation ( P < .001). All secondary operations were revision partial meniscectomies occurring at a mean 3.2 years (95% CI, 0.01-6.4 years) after the index procedure. At final follow-up, 89% of patients were able to return to sport, with 65% returning to wrestling competition. There was significant improvement in the Tegner score from a mean 6.5 (95% CI, 5.9-7.2) preoperatively to 8.3 (95% CI 8.0-8.6) postoperatively ( P < .001). Conclusion: The reoperation rate after meniscal surgery in wrestlers was quite low, but only 65% returned to competitive wrestling. Meniscal repair and partial meniscectomy improved patient-reported outcomes and activity levels at short-term follow-up. However, 21% of wrestlers treated with initial meniscal repair required a subsequent partial meniscectomy at a mean 2.2 years.

Purpose To compare the differences in preoperative pathology, surgical technique, and overall outcomes between patients treated surgically after a single anterior glenohumeral joint dislocation and those undergoing surgery after multiple dislocations. Methods An epidemiologic database was used to identify all patients younger than 40 years undergoing surgery for anterior shoulder instability between January 1, 1994, and July 31, 2016, in a defined geographic area. Patient medical records were reviewed to obtain demographic information, patient history, physical examination findings, imaging findings, clinical progression, surgical details, and outcomes. Comparative analysis was performed between patients who underwent surgery after a single dislocation and those who underwent surgery after multiple preoperative dislocations. Results The study population consisted of 187 patients who had a single anterior shoulder dislocation (n = 55) or multiple anterior shoulder dislocations (n = 132) prior to surgery. The mean follow‐up period was 103.3 months (range, 0.3‐328.4 months). Demographic characteristics were not significantly different between groups. Although the presence of Hill‐Sachs lesions on radiographs was more common in the multiple‐dislocation group (42.1%) than in the single‐dislocation group (18.8%, P = .005), there were no other significant differences in concomitant pathology between groups. Latarjet procedures were more commonly performed in the multiple‐dislocation group (12.5% vs 2.1% in the single‐dislocation group, P = .04). There were no other significant differences in surgical techniques and characteristics between groups. Rates of survival free from recurrent instability ( P = .790), revision surgery ( P = .726), and progression to symptomatic osteoarthritis ( P = .588) were not significantly different between groups. Conclusions Although patients with multiple dislocations prior to surgery were more likely to show radiographic evidence of Hill‐Sachs lesions and undergo the Latarjet procedure than those who received surgery after a single dislocation, no significant differences in outcomes with respect to recurrent instability, revision surgery, or progression to symptomatic osteoarthritis were found between these 2 groups at long‐term follow‐up. Level of Evidence Level III, retrospective comparative study.

Purpose To report the annual incidence of anterior shoulder instability (ASI) diagnosis, injury severity, and surgical stabilization in a U.S. population. Methods An established U.S. geographic database was used to identify patients < 40 years old with diagnoses of ASI from 1994‐2016. Medical records were reviewed to obtain patient demographics, histories, imaging results, and surgical details. Age‐ and sex‐specific incidence rates were calculated and adjusted to the 2010 U.S. population. Poisson regression was performed to examine trends by timeline, sex and age. Results The study population consisted of 652 patients with ASI and a mean age of 21.5 years (range, 3.6‐39.5). Comparing 2015‐2016 to 1994‐1999, we found an increase in the number of dislocations (from 1.0‐1.9; P = 0.016) and total instability events (from 2.3‐3.4; P = 0.041) per patient prior to presentation to a physician. There was a trend in increased diagnosis of bony Bankart and/or Hill‐Sachs on MRI over time, with these lesions documented in 96% of patients undergoing MRI in 2015‐2018 compared to 52.9% in 1994‐1999 ( P < .001). The use of arthroscopic procedures increased and peaked in 2005‐2009 (90% of surgical cases performed). The proportion of open Latarjet procedures increased from 2010‐2014 (14%) and 2015‐2018 (31%). Conclusions The age‐ and sex‐ adjusted incidence of ASI diagnosis in a U.S. population from 1994‐2016 is comparable to that demonstrated in Canadian and European populations. This study demonstrates an increasing number of instability events prior to surgical evaluation, which may correlate with patients’ more commonly presenting with bone loss and requiring more aggressive surgical treatment or that ASI is being more frequently cared for and documented by present‐day orthopedic surgeons. Level of Evidence Level III, cross‐sectional study.

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°; P = .02) on pitches from the mound at 60.5 ft compared with 50.5 ft. Elbow varus torque was lower (–1.5 N·m; P = .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 ( P < .01 for both), with pitches at 60.5 ft having higher velocity (+0.7 m/s; P < .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.

AbstractThe purpose of this study was to determine patient-reported outcomes, hardware removal rates, as well as conversion to arthroplasty at mid-term follow-up following high tibial osteotomy (HTO) with a modern polyetheretherketone (PEEK) system. All PEEK system-based HTOs performed at a single institution between January 2010 and January 2016 with a minimum of 2 years follow-up were reviewed. Rates of postoperative complications, hardware removal and conversion to arthroplasty were calculated. Patient-reported outcomes including visual analog pain scale (VAS), Tegner activity scale, Lysholm, Knee Injury and Osteoarthritis Outcome Score (KOOS), and 36-Item Short Form Survey (SF-36) were obtained. Forty-seven HTOs in 43 patients (mean age: 37.6 ± 10.8 years; 30 M, 13 F) were followed for a mean of 6.0 ± 1.5 years. A total of four postoperative complications occurred in three patients, resulting in an overall complication rate of 6.4%. Hardware removal occurred in three patients at a mean of 0.73 ± 0.53 years after surgery, with overall survival free of hardware removal of 96% (95% confidence interval [CI]: 85–99) at 1 year, 94% (95% CI: 82–98) at 2 years, and 94% (95% CI: 82–98) at 8 years. Conversion to arthroplasty occurred in three patients at a mean of 3.2 ± 1.0 years after surgery, with mean survival of 100% (95% CI: 94–100) at 1 year, 100% (95% CI: 94–100) at 2 years, and 93% (95% CI: 81–98) at 8 years. VAS at rest improved, from 3.1 ± 2.5 preoperatively to 1.1 ± 1.6 postoperatively (p < 0.001). Patients remained active, with a mean Tegner activity scale of 4.4 ± 1.4 at final follow-up and satisfactory Lysholm, KOOS, and SF-36 scores. At mid-term follow-up, medial opening-wedge HTO using a modern PEEK-based system was found to be safe, efficacious, and durable, with satisfactory outcome scores and a low rate of conversion to arthroplasty. PEEK-based implants were found to have low hardware removal rates of 6% at 5 years, which compares favorably to historic metal fixation. This is a Level III study.

Background: The rate of osteoarthritis (OA) in patients with a history of previous anterior shoulder instability (ASI) varies within the literature, with the majority of studies investigating rates after surgical stabilization. ASI appears to lead to increased rates of OA, although risk factors for developing OA in cohorts treated nonoperatively and operatively are not well-defined. Purpose: To determine the incidence of clinically symptomatic OA and identify potential risk factors for the development of OA in patients younger than 40 years with a known history of ASI. Study Design: Case-control study; Level of evidence, 3. Methods: An established, geographically based database was used to identify patients in the United States who were younger than 40 years and were diagnosed with ASI between 1994 and 2014. Patient information, including demographic, imaging, and surgical details, was collected. Comparative analysis was performed between groups with and without OA at final follow-up as well as between patients who underwent surgical and nonsurgical management. Results: The study population consisted of 154 patients with a mean follow-up of 15.2 years (range, 5.1-29.8 years). The mean age at initial instability event was 20.9 years (95% CI, 19.9-22.0 years). Overall, 22.7% of patients developed clinically symptomatic glenohumeral OA. Multivariate analysis revealed that current or former smokers (odds ratio [OR], 4.3; 95% CI, 1.1-16.5; P = .030), hyperlaxity (OR, 10.1; 95% CI, 1.4-72.4; P = .020), laborer occupation (OR, 6.1; 95% CI, 1.02-36.1; P = .043), body mass index (BMI) (OR, 1.2; 95% CI, 1.03-1.3; P = .012), and age at initial instability (OR, 1.1; 95% CI, 1.02-1.2; P = .013) as potential independent risk factors when accounting for other demographic and clinical variables. Conclusion: In a US geographic population of patients younger than 40 years with ASI, approximately one-fourth of patients developed symptomatic OA at a mean follow-up of 15 years from their first instability event. When accounting for differences in patient demographic and clinical data, we noted a potentially increased risk for the development of OA in patients who are current or former smokers, have hyperlaxity, are laborers, have higher BMI, and have increased age at initial instability event. Smoking status, occupation, and BMI are modifiable factors that could potentially decrease risk for the development of symptomatic OA in these patients.

Background: Meniscus root tears are increasingly being recognized. Meniscal extrusion has previously been associated with medial root tears; however, the relationship between secondary meniscal restraints, such as the meniscotibial (MT) ligament, extrusion, and root tears has yet to be formally evaluated. Purpose: To better understand the association between MT ligament competence, medial meniscal extrusion, and medial meniscus posterior root tears (MMPRTs) as well as to determine the progression of meniscal extrusion over time. Study Design: Case series; Level of evidence, 4. Methods: Serial magnetic resonance imaging (MRI) scans were reviewed for patients who showed evidence of medial meniscal extrusion and MMPRTs on at least 1 of ≥2 available MRI scans. All patients were symptomatic at the time of diagnosis. All MRI scans were analyzed independently by 2 board-certified musculoskeletal radiologists. MT ligament disruption, medial meniscal extrusion, and MMPRTs were recorded for each MRI scan. The time between MRI scans, presence of insufficiency fractures, and Outerbridge classification for the medial femur and tibia were also evaluated. Results: Overall, 27 knees in 26 patients were included in this study, with a total of 63 MRI scans analyzed (21 knees with 2 MRI scans, 3 with 3 MRI scans, and 3 with 4 MRI scans). All patients demonstrated clear medial meniscal extrusion and MT ligament disruption before the subsequent development of MMPRTs ( P < .001). Mean extrusion at the time of initial MRI was 3.3 ± 1.1 mm and increased significantly to 5.5 ± 1.8 mm at the time of first imaging with an identified MMPRT ( P < .001). The mean time between initial MRI and the first identification of an MMPRT on later MRI was 1.7 ± 1.6 years. Conclusion: In a sample of 27 symptomatic knees with serial MRI scans both before and after an MMPRT diagnosis, all patients demonstrated MT ligament disruption and associated meniscal extrusion before the development of subsequent medial meniscus root tears. These findings suggest that MT ligament disruption and medial meniscal extrusion represent early and predisposing events contributing to MMPRTs. Therefore, this provides a possible explanation of why meniscal extrusion is not corrected with medial meniscus root repair.

Purpose To compare the (1) rates of complications and reoperations, (2) rate of anterior cruciate ligament (ACL) graft failure, and (3) patient‐reported outcomes (PROs) among patients after hamstring autograft ACL reconstruction (ACLR) with and without independent suture tape reinforcement at a minimum 2‐year clinical follow‐up. Methods We performed a 1:2 matched‐cohort comparison of patients who underwent hamstring autograft ACLR with and without independent suture tape reinforcement between July 2011 and July 2017. Patients were matched according to age, sex, body mass index, preinjury Tegner activity score, and concomitant meniscal injury. Medical records were reviewed for demographic characteristics, additional injuries, and concomitant procedures. PRO scores (including Tegner activity, Lysholm, and International Knee Documentation Committee scores) and physical examination findings were collected both preoperatively and at a minimum of 2 years postoperatively. Results Overall, 108 patients who underwent ACLR were included: 36 patients (mean age, 25.3 years; range, 13‐44 years) with independent suture tape reinforcement and 72 patients (mean age, 24.9 years; range, 13‐54 years) without suture tape reinforcement. Overall, 5 of 36 suture tape patients (14%) and 10 of 72 control patients (14%) underwent reoperations. At an average follow‐up of 26.1 months in the suture tape cohort and 31.3 months in the control cohort, 1 patient in the suture tape cohort and 4 patients in the control cohort experienced graft failure. There were no statistically significant differences between the suture tape and control groups regarding return‐to‐sport rate (89% and 88%, respectively), postoperative International Knee Documentation Committee score (94.4 and 93.8, respectively), and postoperative Lysholm score (95.6 and 94, respectively). There was a statistically significant difference between the suture tape and control groups in postoperative Tegner activity score, at 7.1 (95% confidence interval, 6.5‐7.6) and 6.4 (95% confidence interval, 6.2‐6.6), respectively ( P = .026). Conclusions ACLR with hamstring autograft and independent suture tape reinforcement was performed safely with low rates of complications, graft failure, and reoperations with similar PROs, function, and return‐to‐sport rates when compared with hamstring autograft ACLR without suture tape reinforcement at a minimum 2‐year follow‐up. Level of Evidence Level III, retrospective comparative study.

Background: The rate of elbow medial ulnar collateral ligament (MUCL) injury and surgery continues to rise steadily. While authors have failed to reach a consensus on the optimal graft or anchor configuration for MUCL reconstruction, the vast majority of the literature is focused on the young, elite athlete population utilizing autograft. These studies may not be as applicable for the “weekend warrior” type of patient or for young kids playing on high school leagues or recreationally without the intent or aspiration to participate at an elite level. Purpose: To investigate the clinical outcomes and complication rates of MUCL reconstruction utilizing only allograft sources in nonelite athletes. Study Design: Case series; Level of evidence, 4. Methods: Patient records were retrospectively analyzed for individuals who underwent allograft MUCL reconstruction at a single institution between 2000 and 2016. A total of 25 patients met inclusion criteria as laborers or nonelite (not collegiate or professional) athletes with a minimum of 2 years of postoperative follow-up. A review of the medical records for the included patients was performed to determine survivorship free of reoperation, complications, and clinical outcomes with use of the Summary Outcome Determination (SOD) and Timmerman-Andrews scores. Statistical analysis included a Wilcoxon rank-sum test to compare continuous variables between groups with an alpha level set at .05 for significance. Subgroup analysis included comparing outcome scores based on the allograft type used. Results: Twenty-five patients met all inclusion and exclusion criteria. The mean time to follow-up was 91 months (range, 25-195 months), and the mean age at the time of surgery was 25 years (range, 12-65 years). There were no revision operations for recurrent instability. The mean SOD score was 9 (range, 5-10) at the most recent follow-up, and the Timmerman-Andrews scores averaged 97 (range, 80-100). Three patients underwent subsequent surgical procedures for ulnar neuropathy (n = 2) and contracture (n = 1), and 1 patient underwent surgical intervention for combined ulnar neuropathy and contracture. Conclusion: Allograft MUCL reconstruction in nonelite athletes demonstrates comparable functional scores with many previously reported autograft outcomes in elite athletes. These results may be informative for elbow surgeons who wish to avoid autograft morbidity in common laborers and nonelite athletes with MUCL incompetency.