Camp, Christopher L.

Objective: To generate a summative report on the most commonly diagnosed illnesses in Major League Baseball (MLB) and Minor League Baseball (MiLB) athletes with specific attention to their impact based on time out of play. Design: Retrospective analysis. Setting: Injury and illness data from the MLB Health and Injury Tracking System. Participants: All MLB and MiLB athletes active between 2011 and 2016. Assessment of Risk Factors: Illnesses were defined as atraumatic medical diagnoses that occurred during the MLB or MiLB season and resulted in at least 1 day out of play. Main Outcome Measures: Incidence of illness diagnoses and resulting time out play. Results: Eight thousand eight hundred thirty-four illnesses were reported, representing 14.7% of all diagnoses resulting in time out of play. Total days missed (DM) due to illness were 39 614, with a mean of 4.6 (SD 9.9 days) and median 2 DM per diagnosis. The annual incidence of illness per season was 20.3 per 100 athletes. The most common diagnosis was nonspecific viral illness (15.3%), followed by gastroenteritis (13.6%), other gastrointestinal illness (8.3%), influenza (7.0%), and upper respiratory infection (6.2%). Appendicitis (15.2%) and Epstein–Barr virus/cytomegalovirus (9.1%) were the most common season-ending diagnoses. Conclusions: Illnesses represent a significant cause of time out of play in MLB and MiLB. Prevention efforts should focus on limiting the spread of communicable viral, respiratory, and gastrointestinal disease among players, as the majority of diagnoses fell into these categories. This work may be used to guide future research into illness treatment and prevention in professional baseball.

Objective The purpose of this systematic review is to determine (1) current reported treatment options for isolated tibial plateau (TP) cartilage lesions, (2) patient reported outcomes following various treatments, and (3) complication rate and survivorship following various treatments. Design A literature search of PubMed, the Cochrane Library, and CINAHL was conducted adhering to PRISMA guidelines. Patients were included if they had TP cartilage lesions treated with surgery. Lesion characteristics, surgical procedure details, patient reported outcomes, complication, and failure rates were collected. Results Thirteen studies yielded 205 knees with TP cartilage lesions treated surgically. Ages ranged from 12 to 77 years. Surgical techniques included 138 treated with osteochondral allograft transplantation (OCA), 37 treated with osteochondral autograft transfer system (OATS), 11 treated with microfracture, 11 treated with an osteochondral scaffold, and 8 treated with autologous chondrocyte implantation (ACI). The patient-reported outcome measures were heterogeneous, but all reported improvements with the notable exception of one study evaluating microfracture. The rate of complications ranged from 0% to 4.6%. Failure rate ranged from 22% to 46% for OCA and 0% to 16% for OATS. No failures were reported for the additional techniques. Conclusions Various surgical techniques have been utilized for the treatment of TP cartilage lesions. Patient-reported outcome measures were heterogeneous, but improvements were reported following all surgical treatments except for microfracture, which resulted in decreased scores at mid-term follow-up. The complication rate was low for all techniques described. However, the failure rate was higher following unicondylar OCA for salvage treatment of posttraumatic deformities.

Objective The purpose of this systematic review was to determine (1) treatment options for bipolar cartilage lesions of the knee, (2) patient-reported outcomes following various surgical treatments, and (3) complication and failure rates following surgery. Design A literature search of PubMed, the Cochrane Library, and CINHAL was performed using PRISMA guidelines. Patients were included if they had bipolar cartilage lesions of the knee treated surgically. Lesion characteristics, surgical technique, patient-reported outcomes, complication rates, failure rates, and survivorship were recorded. Results Fourteen studies yielded 301 knees treated surgically. Patient age ranged from 15 to 74 years. Surgical techniques included 138 autologous chondrocyte implantation (ACI), 156 osteochondral allograft transplantation (OCA), and 7 osteochondral autograft transfer system (OATS). Seven studies reported a concomitant procedure rate that ranged from 0% to 88%. Eight studies reported that both reciprocal lesions received surgical treatment, while 6 studies did not specify. Lesion size ranged from 1 to 41 cm 2 . All reported postoperative improvements in patient-reported outcomes, but the measures were very heterogeneous. There were no major complications and the rate of minor complications ranged from 0% to 50%. Survivorship ranged from 40% to 100% for OCA, 76% to 95% for ACI, and 100% for the 1 study evaluating OATS. Conclusions Bipolar cartilage lesions of the knee typically involve a large surface area and are most commonly treated with ACI or OCA, while OATS may be an option for smaller lesions. Improvements in mid-term patient-reported outcomes were reported for all surgical procedures and they can be performed safely with a low rate of major complications.

Purpose To (1) define the rate of delayed surgery, between 1 and 10 years after injury, in a population‐based study of patients with posterior shoulder instability (PSI), (2) evaluate predictive factors associated with delayed repair, and (3) identify differences between the nonoperative and operative groups at long‐term follow‐up. Methods A population‐based retrospectively reviewed study of all patients with PSI from January 1, 1994, to December 31, 2015, was performed. Inclusion required a clinical diagnosis of PSI combined with supporting imaging. Complete medical records were reviewed for 2,091 potential cases. Kaplan‐Meier estimates were used to calculate survival. Landmark survival analysis was performed to identify predictors of conversion to surgery. Results The study included 143 patients with PSI, 79 of whom were managed nonoperatively for at least 1 year after diagnosis. After the first year, survival free of surgery was 78.3% at 1 year, 63.1% at 5 years, and 51.5% at 10 years. There was a trend toward increased surgery in patients with a body mass index > 35 ( P = .10; hazard ratio = 2.32; confidence interval, 0.8‐6.8). Nonthrowing athletes (including contact/weight‐lifting athletes) showed a trend toward an increased risk for surgery ( P = . 07). Patients who underwent surgery were significantly more likely to have progression in arthritis ( P = . 02; hazard ratio = 4.0; confidence interval, 1.2‐13.2). Conclusions Nonoperative management was performed for at least 1 year in over half of patients diagnosed with PSI. Overall, long‐term follow‐up demonstrates that 46% of these patients converted to surgery between 1 and 10 years after initial diagnosis. Ultimately, 70% of patients diagnosed with PSI go on to surgical intervention. Patients who underwent surgery at any time point were at an increased risk of radiographic progression of arthritis at a minimum of 5 years of follow‐up. Level of Evidence Level III, cohort study.

Background: During rehabilitation throwing programs, baseball players are commonly asked to throw at reduced levels of effort (ie, 50% effort, 75% effort, etc) to moderate stress to healing tissues. It is currently unknown how changes in players’ perceived exertion compares with changes in actual exertion during structured long-toss programs. Purpose: To determine whether decreased effort correlates with decreased throwing metrics, whether metrics decrease proportionally with reductions in perceived effort, and to quantify intrathrower variability. Study Design: Descriptive laboratory study. Methods: Sixty male high school and collegiate baseball pitchers participated in a structured throwing program. A motusBASEBALL sleeve was worn by all players, which measured elbow varus torque, arm velocity, arm slot, and shoulder rotation. Ball velocity was measured with a radar gun. Each pitcher threw 5 throws a distance of 120 ft with 3 efforts: maximum effort, 75% effort, and 50% effort. Throwing metrics were compared among the 3 levels of effort to see if each 25% decrease resulted in proportional decreases in elbow varus torque and ball velocity. Intrathrower variability was determined for each throwing metric at each degree of effort. Results: All throwing metrics decreased as players decreased their perceived effort ( P < .001). However, these observed decreases were much smaller in magnitude than the decreases in perceived effort. During the 75% effort throws, elbow varus torque was only reduced to 93% of maximum and velocity dropped to 86% of maximum. Similarly, for the 50% effort throws, elbow varus torque remained 87% of max effort torque, while velocity remained 78% of max. Intrathrower reliability was considered excellent for most metrics (intraclass correlation coefficient, >0.75). Conclusion: For every 25% decrease in perceived effort, elbow varus torque only decreased 7% and velocity only decreased 11%. Thus, when players throw at what they perceive to be reduced effort, their actual throwing metrics do not decrease at the same rate as their perceived exertion. Clinical Relevance: Measured effort decreased with decreasing perceived effort, but these were not proportional. This has significant implications for physical therapists, physicians, trainers, coaches, and athletes to understand and monitor elbow stress during the rehabilitation process.

Background: Anterior cruciate ligament (ACL) injury is one of the most frequent orthopaedic injuries and reasons for time loss in sports and carries significant implications, including posttraumatic osteoarthritis (OA). Instability associated with ACL injury has been linked to the development of secondary meniscal tears (defined as tears that develop after the initial ACL injury). To date, no study has examined secondary meniscal tears after ACL injury and their effect on OA and arthroplasty risk. Purpose: To describe the rates and natural history of secondary meniscal tears after ACL injury and to determine the effect of meniscal tear treatment on the development of OA and conversion to total knee arthroplasty (TKA). Study Design: Cohort study; Level of evidence, 3. Methods: A geographic database of >500,000 patients was reviewed to identify patients with primary ACL injuries between January 1, 1990, and December 31, 2005. Information was collected with regard to ACL injury treatment, rates/characteristics of the secondary meniscal tears, and outcomes, including development of OA and conversion to TKA. Kaplan-Meier and adjusted multivariate survival analyses were performed to test for the effect of meniscal treatment on survivorship free of OA and TKA. Results: Of 1398 primary ACL injuries, the overall rate of secondary meniscal tears was 16%. Significantly lower rates of secondary meniscal tears were noted among patients undergoing acute ACL reconstruction within 6 months (7%) as compared with patients with delayed ACL reconstruction (33%, P < .01) and nonoperative ACL management (19%, P < .01). Of the 235 secondary meniscal tears identified (196 patients), 11.5% underwent repair, 73% partial meniscectomy, and 16% were treated nonoperatively. Tears were most often medial in location (77%) and complex in morphology (56% of medial tears, 54% of lateral tears). At the time of final follow-up, no patient undergoing repair of a secondary meniscal tear (0%) underwent TKA, as opposed to 10.9% undergoing meniscectomy and 6.1% receiving nonoperative treatment ( P = .28). Conclusion: Secondary meniscal tears after ACL injury are most common among patients undergoing delayed surgical or nonoperative treatment of their primary ACL injuries. Secondary tears often present as complex tears of the medial meniscus and result in high rates of partial meniscectomy.

AbstractThere is limited evidence guiding management of medial collateral ligament (MCL) avulsions or functional disruptions distal to the medial joint line. This study aims to determine outcomes of a series of patients with grade III distal MCL injuries managed with acute surgical repair. Patients with grade III, distal MCL injuries, with or without multiligament involvement were identified. Demographic, clinical examination, and midterm patient-reported outcomes (PRO) data were collected. Clinical follow-up included physical examination and ligamentous stress testing at a minimum of 6 months. PROs included Lysholm's knee scoring scale, Tegner's activity score, and subjective International Knee Documentation Committee (IKDC) scores at minimum of 2 years follow-up. Of the 24 eligible patients, outcomes data were available for 20 (83%). Of the 20 included patients, 16 had a concomitant anterior cruciate ligament (ACL) injury, 3 had ACL and posterior cruciate ligament (PCL) injuries, and 1 had an isolated MCL injury. Mean time from injury to surgery was 5 weeks. At mean clinical follow-up of 20.3 months, all patients showed valgus stability and satisfactory range of motion (ROM). Anteroposterior stability was normal in all but one patient who demonstrated a 2+ posterior drawer but with firm end points. At a mean follow-up of 5.7 years for PROs, mean Lysholm's score was 91.5 (standard deviation [SD] = 12.2), median Tegner's activity score was 7 (range, 4–9), and mean subjective IKDC score was 88.8 (SD: 9.9). The surgical repair of grade III distal MCL injuries delivered satisfactory clinical and functional outcomes. Future comparative studies with larger patient samples are needed.

Abstract Double radial tears of the lateral meniscus are rare injuries that typically occur in the setting of an acute anterior cruciate ligament rupture. Full‐thickness radial tears of the meniscus body and root render the meniscus nonfunctional from a loss of hoop stress resistance. Repair of these tears can normalize contact pressures in the lateral compartment and delay arthritic changes. We describe our technique for repairing a lateral meniscus body radial tear and concomitant posterior root tear, via inside‐out suture repair and transtibial suture repair, respectively. This investigation was performed at Mayo Clinic. Technique Video video See video under supplementary data.

Purpose To compare patellar bone socket and cortical surface fixation techniques for isolated medial patellofemoral ligament (MPFL) reconstruction and determine whether there was a difference in (1) complication rates, including fracture of the patella; (2) redislocation rates; or (3) patient‐reported outcomes. Methods A literature search was conducted following Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. We included patients who underwent isolated MPFL reconstruction for recurrent patellar instability. Patients with confirmed concomitant or prior ipsilateral knee procedures, multiligament injury, or less than 3 months of follow‐up were excluded. Risk‐of‐bias assessment was performed using the Methodological Index for Non‐randomized Studies (MINORS) system. Studies were classified by surgical technique (patellar bone socket group [group S] vs cortical fixation group [group F]), and complications, redislocations, and patient‐reported outcomes were collected. Results A total of 29 studies yielded 981 patients with MPFL reconstruction for inclusion. Of the patients, 620 underwent a patellar bone socket technique and 361 underwent a cortical fixation technique. Patients ranged in age from 11 to 68 years. Patellar fracture rates ranged from 0% to 17% in group S and were 0% in all group F studies. Mean Kujala scores ranged from 83.5 to 93.6 in group S and from 84.4 to 94.5 in group F. Mean Lysholm scores ranged from 84.6 to 91.7 in group S and from 83.5 to 95 in group F. Redislocation rates ranged from 0% to 21% in group S and from 0% to 13% in group F. Although heterogeneous in nature, complication rates ranged from 0% to 28% in group S and from 0% to 4% in group F. Conclusions MPFL reconstruction techniques with patellar bone sockets showed a larger range of complication rates than cortical fixation techniques, although overall, complications remained uncommon. Clinically, the bone socket group had comparable postoperative redislocation rates and patient outcomes to the group treated with cortical fixation techniques. Level of Evidence Level IV, systematic review of Level I through IV studies.

Background: Avulsion fractures involving the tibial eminence are considered equivalent in etiology to anterior cruciate ligament tears, however there is limited data comparing outcomes of adolescent patients undergoing surgical fixation of tibial eminence fractures to those undergoing anterior cruciate ligament (ACL) reconstruction. Purpose: The purpose of this study was to compare clinical outcomes, subsequent ACL injury rates, and activity levels between adolescent patients who underwent tibial eminence fracture fixation to patients with mid-substance ACL tears who required acute ligament reconstruction. Methods: This study included a group of patients with tibial eminence fractures treated with surgical fixation matched to a group of similar patients with ACL tears treated with reconstruction between the years of 2001 and 2015. Data regarding initial injury, surgical intervention, ACL/ACL graft injury rates, and physical examination findings were recorded. Clinical and functional outcomes were obtained using physical examination, IKDC subjective scores, Lysholm scores, and Tegner Activity levels. Results: Sixty patients with a mean follow-up of 57.7 (24-206) months were included. 20 patients (11 M:9 F) who underwent surgical fixation for tibial eminence fractures (TEF) with a mean age of 11.9 (7-15) years were matched to a group of 40 patients (23 M:17 F) who underwent ACL reconstruction for ACL tears with a mean age of 12.5 (8-15) years. The TEF group demonstrated significantly lower postoperative IKDC (TEF group: 94.0, ACL group: 97.2 (p=0.04)) and Lysholm scores (TEF group: 92.4, ACL group: 96.9 (p=0.02)). The TEF group returned to sport 121 days sooner (p<0.01), but there was no difference in postoperative Tegner scores (TEF group: 7.3, ACL group: 7.6 (p=0.16)). The TEF group demonstrated increased postoperative anterior laxity (p=0.02) and a higher rate of postoperative arthrofibrosis (p=0.04). There was no difference in subsequent ACL injury (p=0.41). Conclusion: Patients with tibial eminence fractures demonstrated lower mean clinical outcome scores compared to patients with ACL tears at minimum 2-year follow up. Additionally, they experienced more postoperative anterior laxity and had a higher rate of postoperative arthrofibrosis. There was no difference in subsequent ACL injury rate. The TEF group returned to sport sooner than the ACL group, but the postoperative activity level was similar.