Camp, Christopher L.

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.

AbstractCartilage defects in the knee are common resulting in significant pain and morbidity over time. These defects can arise in isolation or concurrently with other associated injuries to the knee. The treatment of small (< 2–3 cm2) cartilage deficiencies has changed as our basic science knowledge of tissue healing has improved. Advancements have led to the development of new and more effective treatment modalities. It is important to address any associated knee injuries and limb malalignment. Surgical options are considered when nonoperative treatment fails. The specific procedure depends on individual patient characteristics, lesion size, and location. Debridement/chondroplasty, microfracture, marrow stimulation plus techniques, fixation of unstable osteochondral fragments, osteochondral autograft transfer, and osteochondral allograft transplantation, all have roles in the treatment of small cartilage defects.

AbstractPurposeThere is limited data comparing the outcomes of knee arthroplasty for arthritis secondary to meniscus root tear versus primary osteoarthritis. The aim of this 2:1 matched case control series was to compare outcomes in patients who underwent arthroplasty for arthritis following a meniscus root tear (root tear cohort—“RTC”) with a control group of patients with primary osteoarthritis (primary osteoarthritis—“controls”). The authors hypothesized that the meniscus root tear patients would have similar clinical outcomes, return to activity, complication and reoperation rates as their matched controls.MethodsA consecutive series of patients who had a clinically and radiographically confirmed meniscus root tear between 2002 and 2017 at a mean 4.8 year follow‐up that developed secondary arthritis were matched 2:1 by laterality, surgery, age at surgery, date of surgery, sex, and surgeon to a control group of patients with primary osteoarthritis, without a root tear, who underwent arthroplasty. No patients were lost to follow‐up. Patient demographics, Kellgren–Lawrence grades at the time of surgery, pre‐ and post‐operative Knee Society Score pain and function scores, Tegner score, complications, and survival free of reoperation were analyzed between groups.ResultsA total of 225 subjects were identified, including 75 root tear cohort patients (13 UKA, 62 TKA) and 150 control patients. The root tear cohort had significantly lower Kellgren–Lawrence grades than the control group at the time of arthroplasty (p ≤ 0.001), but similar baseline pre‐operative Knee Society Score pain, Knee Society Score function, and Tegner activity scale score. Post‐operatively, Knee Society Score pain scores were comparable, and root tear cohort Knee Society Score function scores statistically significantly improved (p ≤ 0.007). Complication rates and survival free of reoperation at final follow‐up were not statistically significantly different between groups.ConclusionPatients treated with arthroplasty for secondary arthritis after a meniscus root tear demonstrated less severe radiographic arthritis, but similar pre‐operative pain levels compared to matched controls with primary osteoarthritis. The root tear cohort patients demonstrated improved outcomes with respect to function, and similar outcomes with respect to pain, activity level, complication rates, and reoperation rates. The authors conclude that arthroplasty can be a reliable option for selected patients with an irreparable root tear and ongoing pain and dysfunction refractory to non‐operative management, even in the setting of less advanced osteoarthritis on X‐ray.Level of evidenceIII.

Abstract Proximal humerus lesser tuberosity avulsions are uncommon injuries; however, when present, they can be debilitating for patients. As such, they pose a unique clinical challenge. These fractures were traditionally treated through an open approach to the proximal humerus; however, arthroscopic techniques continue to evolve and are increasingly used for these types of injuries. We describe our minimally invasive arthroscopic technique to repair lesser tuberosity avulsions using standard arthroscopic equipment. This method is safe, efficient, and applies basic shoulder arthroscopic techniques. Technique Video video See video under supplementary data.

Objectives: There remains a paucity of data describing the efficacy of non-operative treatment following an index anterior instability event. The purpose of this study was to describe the long-term outcomes of non-operative treatment following index anterior instability event, define the success rate of initial non-operative treatment for anterior shoulder instability, and describe factors that predict conversion to surgery after initial non-operative management to help guide surgical decision making in these patients. Methods: An established geographic database was utilized to identify patients under the age of 40 treated for anterior shoulder instability between 1994 and 2016. Patient demographics, comorbidities, injury characteristics, instability history, activity level, x-rays, advanced imaging, treatment course, and outcomes were evaluated. Patients treated non-operatively for the first 6 months following index instability event were analyzed to determine long-term outcomes, success rate of continued non-operative treatment, and factors associated with conversion to surgery. Results: 739 patients met criteria with an average follow-up of 190 months (range 0.13 to 490 months). Average age was 23.8, mean BMI was 25.6, 9.1% had a history of hyperlaxity, and 83.9% of instability events were due to trauma. 29.7% of patients had a Hill-Sachs lesion on index x-ray, and 6.3% had a bony Bankart. 198 shoulders went on to operative treatment (26.8%) with a mean time to surgery of 62.7 months following initial instability event. At final follow-up, 24.0% reported mild pain, 6.2% as moderate, 0.2% as severe. 13.8% of patients had evidence of glenohumeral arthritis on final follow-up x-rays compared to 1.6% on initial radiographs. Factors associated with conversion to surgery included 2 or more dislocations prior to first clinical evaluation (OR=1.75, p<0.001), labor intense occupation (OR=1.49, p=0.031), Hill Sachs lesion on index x-ray (OR=1.31, p=0.034), and MRI findings including: anteroinferior labral tear (OR=2.15, p<0.001), posteroinferior labral tear (OR=1.38, p=0.049), SLAP tear (OR=1.29, p=0.054), Hill-Sachs lesion (OR=1.85, p<0.001), and glenohumeral cartilage injury (OR=1.26, p=0.041). Conclusion: The majority of patients less than 40 can be definitively treated non-operatively after an initial 6 month episode of non-operative treatment. A small proportion will report pain over the long-term and/or develop glenohumeral arthritis. Multiple factors upon initial evaluation were associated with future conversion to surgery including: increasing number of prior instability events, occupation, and degree of soft tissue injury on MRI.