Citations

Background: Understanding interactions between multiple risk factors for shoulder and elbow injuries in Major League Baseball (MLB) pitchers is important to identify potential avenues by which risk can be reduced while minimizing impact on player performance. Purpose: To apply a novel game theory–based approach to develop a machine-learning model predictive of next-season shoulder and elbow injuries in MLB pitchers and use this model to understand interdependencies and interaction effects between the most important risk factors. Study Design: Case-control study; Level of evidence, 3. Methods: Pitcher demographics, workload measures, pitch-tracking metrics, and injury data between 2017 and 2022 were used to construct a database of MLB pitcher-years, where each item in the database corresponded to a pitcher's information and metrics for that year. An extreme gradient boosting machine-learning model was trained to predict next-season shoulder and elbow injuries utilizing Shapley additive explanation values to quantify feature importance as well as interdependencies and interaction effects between predictive variables. Results: A total of 3808 pitcher-years were included in this analysis; 606 (15.9%) of these involved a shoulder or elbow injury resulting in placement on the MLB injured list. Of the >65 candidate features (including workload, demographic, and pitch-tracking metrics), the most important contributors to predicting shoulder/elbow injury were increased: pitch velocity (all pitch types), utilization of sliders (SLs), fastball (FB) spin rate, FB horizontal movement, and player age. The strongest game theory interaction effects were that higher FB velocity did not alter a younger pitcher's predicted risk of shoulder/elbow injury versus older pitchers, risk of shoulder/elbow injury increased with the number of high-velocity pitches thrown (regardless of pitch type and in an additive fashion), and FB velocity <95 mph (<152.9 kph) demonstrated strong negative interaction effects with higher SL percentage, suggesting that the overall predicted risk of injury for pitchers throwing a high number of SLs could be attenuated by lower FB velocity. Conclusion: Pitch-tracking metrics were substantially more predictive of future injury than player demographics and workload metrics. There were many significant game theory interdependencies of injury risk. Notably, the increased risk of injury that was conferred by throwing with a high velocity was even further magnified if the pitchers were also older, threw a high percentage of SLs, and/or threw a greater number of pitches.

Background: Assessment of orthopaedic surgery trainees is traditionally based on subjective evaluation by faculty. The recent push for value-based health care has placed a premium on improving patient outcomes. As a result, surgical training evaluations for orthopaedic trainees are evolving to include more objective measures to evaluate competency. Purpose: To develop and subsequently demonstrate the efficacy of a novel surgical skills assessment for orthopaedic sports medicine fellows. Study Design: Case series; Level of evidence, 4. Methods: A team of 14 fellowship-trained orthopaedic sports medicine surgeons developed objective scoring rubrics for anterior cruciate ligament reconstruction (ACLR) and rotator cuff repair (RCR) using a modified Delphi process. Rubrics were designed based on 10 surgical steps with a grading scale (1-5) based on core competencies with a maximum summative score of 50. Fourteen orthopaedic fellows across a regionally diverse group of sports medicine–accredited fellowship programs were invited to complete both an ACLR and RCR in a surgical skills laboratory at the beginning and end of their fellowship year. Individual surgical steps, overall performance, and total procedure time were evaluated by a single sports medicine surgeon for both sessions. Results: Thirteen of 14 fellows completed both pre- and post-fellowship assessments. For the ACLR procedure, the pre-fellowship mean summative score was 25.4 (SD, 4.4) and the post-fellowship mean summative score was 38.6 (SD, 4.1), which was a statistically significant improvement ( P < .001). For the RCR procedure, the pre-fellowship mean summative score was 26.6 (SD, 5.4) and the post-fellowship mean summative score was 38.8 (SD, 4.3), which was also a statistically significant improvement ( P < .001). The mean time to completion for the ACLR procedure was 82.3 minutes (SD, 4.3 minutes) pre-fellowship, which improved to 69.7 minutes (SD, 11.6 minutes) post-fellowship ( P = .002). The mean time to completion for the RCR procedure was 85.5 minutes (SD, 5.0 minutes) pre-fellowship, which improved to 76.4 minutes (SD, 7.0 minutes) post-fellowship ( P < .001). Conclusion: This surgical skills program represents the first standardized and reproducible instrument for the evaluation of 2 arthroscopic sports medicine procedures in the United States. Orthopaedic sports medicine fellows improved significantly in aggregate over their fellowship year with regard to the ACLR and RCR. The described program has the potential to serve as both a training tool and formal orthopaedic sports medicine fellow assessment.

Objectives: Radial tears of the meniscus are increasingly treated with repair instead of partial meniscectomy, with satisfactory short-term clinical outcomes. There remains a paucity of mid- and long-term outcomes data for this preservation technique. The purpose of this study was to 1) evaluate the mid- to long-term clinical outcomes and reoperation rate of radial meniscal repair versus bucket-handle meniscal repair and 2) evaluate the outcomes of both surgeries overtime. We hypothesized that radial repair would provide similar outcomes and reoperation rates to that of bucket-handle meniscal repair in this propensity-matched cohort. Methods: A previously identified cohort of radial meniscal tears without concurrent root injuries undergoing surgical repair at a single institution between 2011 and 2015 were reviewed. Inclusion criteria was patients undergoing repair of full-thickness radial tears. Exclusion criteria were patients who had 1) not consented for research follow-up, 2) <2 year of follow-up, 3) high-grade (Outerbridge grade 3 or 4) chondromalacia, 4) knee dislocations or combined anterior cruciate ligament and posterior cruciate ligament injuries, 5) repair of posterior meniscal root tears, and 6) repair of partial radial tears. Propensity matching was performed based on age at surgery, sex, laterality, body mass index (BMI), and concomitant anterior cruciate ligament reconstruction (ACLR) using a comparison pool of 70 bucket-handle meniscal repairs (BHMR). Reoperation-free survival rates, Tegner Activity Score, visual analog scale (VAS) for pain, and International Knee Documentation Committee (IKDC) scores were analyzed. Results: Twenty-four patients (18 males, 6 females, age 22.8 ± 11.9 years, BMI 26.5 ± 5.8) with radial meniscal repair were included in this study. Eighteen of these patients were successfully propensity matched to 18 bucket-handle meniscal tears for an overall mean follow-up of 10.2 ± 1.7 years (range, 7.3-13.5) (Table 1). The 24 radial tear repairs demonstrated significant and durable postoperative improvements at mean 10.2 years across VAS at rest (3.0 ± 2.5 vs 0.5 ± 1.0, p < 0.001), VAS for pain at use (5.8 ± 2.9 vs 1.4 ± 1.9, p < 0.001) Tegner (2.6 ± 1.4 vs 6.8 ± 2.0, p < 0.001) and IKDC (39.8 ± 12.3 vs 84.1 ± 16.5, p < 0.001) (Table 1). Of patients not undergoing reoperation (19), 100% reported being “Satisfied” 4/19 (21%) or “Very Satisfied” 15/19 (79%). When the 18 radial tear repairs were compared to the 18 BHMT repairs, there was no significant difference across VAS for pain at rest (0.6 ± 1.2 vs 0.3 ± 0.7, p = 0.48), VAS for pain at use (1.6 ± 2.1 vs 1.1 ± 1.3, p = 0.48) Tegner (6.9 ± 2.2 vs 6.4 ± 2.1, p = 0.51) and IKDC (83.4 ± 17.4 vs 82.1 ± 14.1, p = 0.83) (Table 2). Importantly, survival without reoperation rates were not statistically different between the 2 groups at 10-year follow-up (14/18 (78%) vs 16/18 (89%), p = 0.37) (Figure 1). There was no significant difference between clinical outcomes (Tegner and IKDC) at final follow-up in the radial repair group as compared to the 4-year mid-term outcomes (p = 0.58 and 0.19 respectively). For the BHMR group, Tegner scores were not significantly different (p = 0.60) compared with their 4-year timepoint; however, IKDC scores at the final timepoint were significantly lower 93.4 ± 3.4 vs 82.1 ± 14.1 (p = 0.01). Notably, both the radial repair and bucket-handle repairs groups reported final follow-up Tegner scores that were not significantly different from their preinjury Tegner scores (p = 0.70 for the radial group and p = 0.62 for the bucket-handle group). Conclusions: At mean 10-year follow-up, significant clinical improvements and high rates of satisfaction were observed for radial meniscal tear repair. When propensity matched, radial and BHMR demonstrated durable improvements in postoperative VAS for pain, IKDC, and Tegner scores, as well as similar, acceptable reoperation rates. [Figure: see text]

Objectives: Nonoperative management vs. early reconstruction for partial tears of the medial ulnar collateral ligament (MUCL) remains controversial, with the most common treatment options for partial tears consisting of rest, rehab, platelet rich plasma (PRP), and/or surgical intervention. However, whether the improved outcomes reported for treatments such as MUCL reconstruction (UCLR) or nonoperative management with a series of PRP injections justifies their increased upfront costs remains unknown. Thus, the purpose of this study was to compare the cost-effectiveness of an initial trial of physical therapy alone, an initial trial of physical therapy plus a series of PRP injections, and early UCLR to determine the preferred cost-effective treatment strategy for baseball pitchers with partial tears of the MUCL. Methods: A Markov Chain Monte Carlo probabilistic model was developed to evaluate the outcomes and costs of 1,000 simulated pitchers undergoing nonoperative management with and without PRP vs. early UCLR for partial MUCL tears. Utility values, RTP rates, and transition probabilities were derived from the published literature. Costs were determined based on the typical patient undergoing each treatment strategy at our institution. Outcome measures included costs, acquired playing-years (PYs), and the incremental cost-effectiveness ratio (ICER). Results: Mean total costs resulting from nonoperative management without PRP, nonoperative management with PRP, and early UCLR were $22,520, $24,800, and $43,992, respectively. On average, early UCLR produced an additional 4.0 PYs over the 10-year time horizon relative to nonoperative management, resulting in an ICER of $5,395/PY, which falls well below the $50,000 willingness-to-pay threshold (WTP). Overall, early UCLR was determined the preferred cost-effective strategy in 77.5% of pitchers included in the microsimulation model, with nonoperative management with PRP determined the preferred strategy in 15% of pitchers and nonoperative management alone in 7.5% of pitchers. Conclusions: Based on Monte Carlo microsimulation and probabilistic sensitivity analysis, early UCLR was demonstrated to be more cost-effective than an initial trial of nonoperative management for partial tears of the MUCL for the majority of high-level baseball pitchers. It is important to note that this model does not consider the unique experiences, goals, situations, career trajectory, and pitching horizons of individual patients, and thus a shared decision-making discussion should be conducted regarding optimal initial treatment for partial MUCL tears. This is particularly true as many athletes can successfully be treated non-operatively, which generally results in a quicker return to play when successful compared to surgery.

Objectives: Wrestling is a physically demanding sport with young athletes prone to traumatic shoulder instability (SI). However, there is a paucity of data evaluating the results of shoulder instability surgery (SIS) in this cohort of athletes. The purpose of this study is to assess reoperation rates, patient-reported outcomes (PRO), and return to wrestling (RTW) following SIS in a cohort of competitive wrestlers. Methods: All competitive wrestlers with a history of SI and subsequent surgery at a single institution between 1996 and 2020 were identified. All directions of SI (anterior SI [ASI], posterior SI [PSI], and traumatic multidirectional SI [TMDI]) were analyzed. Exclusion criteria included revision SIS and less than 2 years of clinical follow-up. Patients were contacted for determination of reinjury rates, return to wrestling (RTW), and Western Ontario Shoulder Instability index (WOSI) scores. Results: Ultimately, 104 wrestlers were included at a mean follow-up of 5.2 years (range, 2.0 – 22.0). Fifty-eight (55.8%) wrestlers presented for evaluation after a single SI event while 46 (44.2%) sustained multiple events prior to presentation. ASI was the most common direction (n = 79; 76.0%) followed by PSI (n = 14; 13.4%), and TMDI (n = 11; 10.6%). Surgical treatment was most commonly an arthroscopic soft tissue stabilization (n = 88; 84.6%), followed by an open soft tissue repair (n = 13; 12.5%) and open bony augmentation (n = 3; 2.9%) (Table 1). RTW occurred in 57.3% of wrestlers at a mean of 9.8 ± 9.6 months. Recurrent instability was the most common complication in 18 (17.3%) wrestlers. Revision SIS was performed in 15 (14.6%) wrestlers (Table 2). Across the entire cohort, Kaplan-Meier survivorship free from recurrent instability (Figure 1) and revision surgery (Figure 2) was 91.4% and 98.1% at 1 year, 90.4% and 92.5% at 2 years, 71.9% and 70.7% at 5 years, and 71.9% and 66.5% at 10 years, respectively. Pre-operative recurrent instability was an independent risk factor for post-operative recurrent instability (Hazard ratio [HR], 3.8; 95% confidence interval [CI], 1.33 – 11.03; P = .012). Conclusions: Anterior shoulder instability was the most common direction among competitive wrestlers presenting for SIS. Wrestlers with multiple dislocations prior to initial clinical presentation were 3.8 times more likely to experience post-operative recurrent instability.

Abstract Shoulder arthroscopy is a versatile method for treating a variety of shoulder pathologies in a minimally invasive manner. Typically, it is performed with the patient positioned in a beach‐chair or lateral decubitus position with the latter being conventionally preferred for shoulder instability work given the use of traction and creation of a distracted joint. This allows ideal visualization and accessibility of the anterior, inferior, and posterior aspects of the glenoid, labrum, and axillary pouch. Despite the apparent advantages, the lateral decubitus position comes with its own technical challenges. Many of these may stem from surgeon training, experience, and level of familiarity with the positioning and arthroscopic view. This Technical Note demonstrates a reproducible and teachable method for efficient and effective diagnostic shoulder arthroscopy in the lateral decubitus position, along with presenting its associated advantages and disadvantages. Technique Video video See video under supplementary data.

Background: Nonoperative management versus early reconstruction for partial tears of the medial ulnar collateral ligament (MUCL) remains controversial, with the most common treatment options for partial tears consisting of rest, rehabilitation, platelet-rich plasma (PRP), and/or surgical intervention. However, whether the improved outcomes reported for treatments such as MUCL reconstruction (UCLR) or nonoperative management with a series of PRP injections justifies their increased upfront costs remains unknown. Purpose: To compare the cost-effectiveness of an initial trial of physical therapy alone, an initial trial of physical therapy plus a series of PRP injections, and early UCLR to determine the preferred cost-effective treatment strategy for young, high-level baseball pitchers with partial tears of the MUCL and with aspirations to continue play at the next level (ie, collegiate and/or professional). Study Design: Economic and decision analysis; Level of evidence, 2. Methods: A Markov chain Monte Carlo probabilistic model was developed to evaluate the outcomes and costs of 1000 young, high-level, simulated pitchers undergoing nonoperative management with and without PRP versus early UCLR for partial MUCL tears. Utility values, return to play rates, and transition probabilities were derived from the published literature. Costs were determined based on the typical patient undergoing each treatment strategy at the authors’ institution. Outcome measures included costs, acquired playing years (PYs), and the incremental cost-effectiveness ratio (ICER). Results: The mean total costs resulting from nonoperative management without PRP, nonoperative management with PRP, and early UCLR were $22,520, $24,800, and $43,992, respectively. On average, early UCLR produced an additional 4.0 PYs over the 10-year time horizon relative to nonoperative management, resulting in an ICER of $5395/PY, which falls well below the $50,000 willingness-to-pay threshold. Overall, early UCLR was determined to be the preferred cost-effective strategy in 77.5% of pitchers included in the microsimulation model, with nonoperative management with PRP determined to be the preferred strategy in 15% of pitchers and nonoperative management alone in 7.5% of pitchers. Conclusion: Despite increased upfront costs, UCLR is a more cost-effective treatment option for partial tears of the MUCL than an initial trial of nonoperative management for most high-level baseball pitchers.

Abstract A broad range of shoulder pathologies are treated with shoulder arthroscopy due to its minimally invasive nature. Mastering the fundamentals is critical for high‐quality care; this includes patient positioning. Surgeons must consider the advantages and disadvantages of the 2 most prominent patient positions: lateral decubitus and beach chair. The beach‐chair position offers an intuitive anatomic view with the advantage of shoulder maneuverability. Understanding the associated pitfalls related to patient hemodynamics; head, neck, and shoulder positioning; and protection of bony prominences can guide the operative care team to obtaining a safe position for the patient. The purpose of this Technical Note and video is to present and demonstrate a reproducible and teachable method for safely positioning a patient in the beach‐chair position for shoulder arthroscopy, as well as to describe the associated advantages and disadvantages. Technique Video video See video under supplementary data.

Abstract Shoulder arthroscopy is one of the most common orthopaedic procedures. Since its introduction in the 1970s, significant advances have been made in surgical techniques and instrumentation. Shoulder arthroscopy is often performed in either the beach‐chair or lateral decubitus position, and each positioning technique has its own benefits. In this work, we will describe the history of lateral decubitus positioning for shoulder arthroscopy. We outline a detailed guide for safe and consistent lateral decubitus positioning, and key steps of lateral decubitus positioning will be emphasized. Pearls, pitfalls, advantages, and disadvantages of this positioning technique will also be discussed. With appropriate technique, lateral decubitus positioning is safe and effective for arthroscopic treatment of various shoulder pathologies. Technique Video video See video under supplementary data.

Abstract Shoulder arthroscopy is a popular modality for the treatment of shoulder pathology. Since its advent in the 1970s, significant advancements have been made in both technology and technique. Shoulder arthroscopy is performed in either the beach‐chair or lateral decubitus positions, and each position has its unique benefits and considerations. Beach‐chair positioning, initially described in the 1980s, has become the preferred method of positioning for most arthroscopic procedures. In this work, we describe the history of beach‐chair positioning for shoulder arthroscopy. We outline a reproducible and teachable method for consistent and comprehensive diagnostic arthroscopy in the beach‐chair position. Pearls, pitfalls, advantages, and disadvantages of diagnostic arthroscopy in this position are discussed. When properly executed, diagnostic arthroscopy in the beach‐chair position can effectively identify and characterize intra‐articular shoulder pathologies. Technique Video video See video under supplementary data.