Camp, Christopher L.

Context : A common component within rehabilitation recommendations for baseball pitchers is employment of an interval throwing program. However, there is a lack of a consistent set of advocated guidelines for program content and implementation for athletes at the professional and collegiate levels. Design : Cross-sectional study. Methods : A survey was developed to obtain clinician views regarding the composition and implementation of interval throwing programs for baseball pitchers. The survey was divided into demographic information and sections on criteria to begin throwing programs, frequency of throwing, soreness management, warm-up components, program components and regulation of a program, and criteria to achieve permitting live throwing. Clinicians including physicians, physical therapists, and certified athletic trainers who evaluate and treat musculoskeletal injuries among baseball pitchers at the professional-level and/or collegiate-level clinician received the survey. Responses were tabulated and compared between the professional-level clinician and collegiate-level clinician groups using chi-square analyses with statistical significance set at P ≤ .05. Results : The survey was completed by 166 clinicians (collegiate level = 81, professional-level clinician = 85). There were no statistical differences between groups for allowing warm-up throws, program regulation, maximum distance allowed, managing soreness, or criteria to achieve before permitting live throwing. Between-group differences included criteria to begin a program (≤.03), warm-up distance ( P ≤ .02), nonthrowing warm-up methods ( P ≤ .04), non-warm-up distance ( P ≤ .01), using ratings of perceived exertion ( P < .01), throwing frequency ( P < .01), and program components ( P ≤ .04). Conclusions : Responses appear to mirror interval throwing program designs previously reported in the literature but there are modifications and additions utilized by clinicians at different playing levels.

Background: Abdominal musculature injuries comprise the third most prevalent time-loss injury across professional baseball. Despite increased awareness and prevention attempts in the recent decade, the trends of these abdominal injury numbers in Major League Baseball (MLB) are not fully understood. Purposes: To update the trends in oblique and intercostal injuries, analyze the impact of these injuries based on time out of play, and identify factors that correlate with increased injury severity to help with recovery time prognostication for the sports medicine community. Study Design: Descriptive epidemiology study. Methods: Using the MLB Health and Injury Tracking System, the authors identified all abdominal and core musculature injuries that resulted in time out of play in MLB and Minor League Baseball (MiLB) between the 2011 and 2021 seasons. These were filtered for injuries that resulted in ≥1 days missed (DM) during spring training, the regular season, and postseason. A Student t test was utilized to assess for significant differences for all normally distributed values. Regression analysis was utilized for determining change over time. For all statistical comparisons, the threshold for alpha was set to P < .05. Results: During the study period between 2011 and 2021, there were 4560 total abdominal injuries among 3401 athletes. When filtered for in-season, time-loss injuries defined as spring training, regular season, and postseason, there were 2890 injuries. Of these, 1928 were oblique injuries, 453 were intercostal injuries, and 115 were rectus injuries. The number of oblique injuries each season increased for all of baseball ( P < .001), as well as for MLB ( P = .009) and MiLB ( P = .012) individually. Of the 1928 oblique injuries, 498 (26%) oblique injuries occurred at the MLB level and 1430 (74%) occurred at the MiLB level. Batting and pitching-related injuries comprised 860 (45%) and 729 (38%) oblique injuries, with a total of 18,455 DM and 20,891 DM, respectively. This corresponded to a mean of 22 DM for batting injuries and 29 DM for pitching injuries (mean difference, 7.2; 95% CI, 5.27-9.13; P < .001). Conclusion: This decade-long study on professional baseball revealed a significant increase in abdominal oblique injuries across MLB and MiLB, with the largest number of injuries observed in the 2021 season. Meanwhile, there was a significant decrease in intercostal injuries across professional baseball during these years. Such injuries continue to pose challenges, leading to substantial DM per injury and affecting players from various positions.

Background: Anterior cruciate ligament (ACL) reconstruction (ACLR) can be successful in restoring knee stability. However, secondary ACL injury, either through graft failure or contralateral injury, is a known complication and can significantly impact the ability of a patient to return successfully to previous activities. Purpose: To develop and internally validate an interpretable machine learning model to quantify the risk of graft failure and contralateral ACL injury in a longitudinal cohort treated with ACLR. Study Design: Case-control study; Level of evidence, 3. Methods: An established geographic database of >600,000 patients was used to identify patients with a diagnosis of ACL rupture between 1990 and 2016 with a minimum 2-year follow-up. Medical records were reviewed for relevant patient information and 4 candidate machine learning algorithms were evaluated for prediction of graft failure and contralateral ACL injury in patients after ACLR as identified either on magnetic resonance imaging or via arthroscopy. Performance of the algorithms was assessed through discrimination, calibration, and decision curve analysis. Model interpretability was enhanced utilizing global variable importance plots and partial dependence curves. Results: A total of 1497 patients met inclusion criteria. Among them, 140 (9.4%) had graft failure and 128 (8.6%) had a contralateral ACL injury after index surgery at a median follow-up of 140.7 months (interquartile range, 77.2-219.2 months). The best performing models achieved an area under the receiver operating characteristics curve of 0.70 for prediction of graft failure and 0.67 for prediction of contralateral ACL injury, outperforming a logistic regression fitted on the identical feature set. Notable predictors for increased risk of graft failure included younger age at injury, body mass index (BMI) <30, return to sports <13 months, initial time to surgery >75 days, utilization of allograft, femoral/tibial fixation with suspension/expansion devices, concomitant collateral ligament injury, and active or former smoking history. Predictors of contralateral ACL injury included greater preoperative pain, younger age at initial injury, BMI <30, active smoking history, initial time to surgery >75 days, history of contralateral knee arthroscopies, and involvement in contact sports. Conclusion: Less than 18% of all patients who undergo ACLR should be expected to sustain either a graft failure or contralateral ACL injury. Machine learning models outperformed logistic regression and identified greater preoperative pain, younger age, BMI <30, earlier return to higher activity, and time to surgical intervention >75 days as common risk factors for both graft failure as well as contralateral ACL injury after ACLR. Surgeon-modifiable risk factors for graft failure included allograft and femoral/tibial fixation with a suspension/expansion combination.

Background: Surgical repair of full thickness biceps tears has demonstrated adequate outcomes in short and mid-term studies. However, data on the long-term outcomes of full thickness distal biceps injuries and their treatment are currently lacking. Purpose/Hypothesis: The purpose of this study was to report on patient demographics, injury characteristics, and long-term outcomes for patients with full-thickness distal biceps tears. It was hypothesized that complete distal biceps tears managed operatively would demonstrate robust clinical success at long-term follow-up. Study Design: Case series; Level of evidence, 4. Methods: Patients with magnetic resonance imaging–confirmed, complete distal biceps tendon rupture sustained between 1996 and 2016 were identified. Patients were cross-referenced with a regional geographic database. Results: A total of 66 patients (3 female, 63 male) with a median age of 50.8 years (IQR, 41.5-60.4) and a median clinical follow-up of 14.7 years (IQR, 9.6-17.9 years) were included. Patients who sustained a full-thickness distal biceps tendon tear were likely to be in their early 50s, male, right-hand dominant, current/former smokers, and laborers with a history of traumatic injury during an intentional movement. Most of these patients had pain and supination weakness but no loss of range of motion. All included tears were treated operatively. At final follow-up, patients maintained a majority of near-normal range of motion (median total arc of flexion/extension 140° and supination/pronation 80°), excellent elbow flexion strength (91% of patients had full strength), and adequate elbow supination strength (76% of patients had full strength). The overall complication rate was 24%, with 16 out of 66 patients experiencing some type of complication between infection, rerupture, heterotopic ossification, reoperation, and nerve complications. Overall return to work was 98%, and 85% of those who returned to work did so without restrictions. Conclusion: Complete tears of the distal biceps were most common in patients 50 years of age, male sex, right-hand dominant, and current/former smokers. The most common profession was laborer, and injuries were primarily traumatic in nature during intentional activity. Patients managed operatively demonstrated high rates of success at long-term follow-up with respect to elbow function and clinical outcomes.

Background: Value-based decision-making regarding nonoperative management versus early surgical stabilization for first-time anterior shoulder instability (ASI) events remains understudied. Purpose: To perform (1) a systematic review of the current literature and (2) a Markov model–based cost-effectiveness analysis comparing an initial trial of nonoperative management to arthroscopic Bankart repair (ABR) for first-time ASI. Study Design: Economic and decision analysis; Level of evidence, 3. Methods: A Markov chain Monte Carlo probabilistic model was developed to evaluate the outcomes and costs of 1000 simulated patients (mean age, 20 years; range, 12-26 years) with first-time ASI undergoing nonoperative management versus ABR. Utility values, recurrence 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, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio (ICER). Results: The Markov model with Monte Carlo microsimulation demonstrated mean (± standard deviation) 10-year costs for nonoperative management and ABR of $38,649 ± $10,521 and $43,052 ± $9352, respectively. Total QALYs acquired over the 10-year time horizon were 7.67 ± 0.43 and 8.44 ± 0.46 for nonoperative management and ABR, respectively. The ICER comparing ABR with nonoperative management was found to be just $5725/QALY, which falls substantially below the $50,000 willingness-to-pay (WTP) threshold. The mean numbers of recurrences were 2.55 ± 0.31 and 1.17 ± 0.18 for patients initially assigned to the nonoperative and ABR treatment groups, respectively. Of 1000 samples run over 1000 trials, ABR was the optimal strategy in 98.7% of cases, with nonoperative management the optimal strategy in 1.3% of cases. Conclusion: ABR reduces the risk for recurrent dislocations and is more cost-effective despite higher upfront costs when compared with nonoperative management for first-time ASI in the young patient. While all these factors are important to consider in surgical decision-making, ultimate treatment decisions should be made on an individual basis and occur through a shared decision-making process.

Objectives: Based in part on the results of randomized controlled trials (RCTs) that suggest a beneficial effect over alternative treatment options, the use of platelet-rich plasma (PRP) for the management of knee osteoarthritis (OA) is widespread and increasing. However, the extent to which these studies are vulnerable to slight variations in the outcomes of patients remains unknown. The purpose of this study is to evaluate the statistical fragility of conclusions from RCTs that reported outcomes of patients with knee OA who were treated with PRP versus alternative nonoperative management strategies. Methods: All RCTs comparing PRP to alternative nonoperative treatment options for knee OA were identified. The fragility index (FI) and reverse fragility index (RFI) were applied to assess the robustness of conclusions regarding the efficacy of PRP for knee OA. Meta-analyses were performed to determine the minimum number of patients from one or more trials included in the meta-analysis for which a modification on the event status would change the statistical significance of the pooled treatment effect. Results: In total, this analysis included outcomes from 1993 patients with a mean (± standard deviation) age of 58.0 ± 3.8 years. The mean number of events required to reverse significance (FI) was 4.57 ± 5.85. This corresponded to a fragility quotient of 0.060 ± 0.075, meaning the significance of the results was contingent on 6 events per 100 participants. For non-significant outcome events, the mean number of events required to reverse statistical nonsignificance (RFI) was 4.41 ± 2.22. This corresponded to a reverse fragility quotient of 0.065 ± 0.056, meaning the non-significance of the results was contingent on 6.5 events per 100 participants (Figure 1). Based on random-effects meta-analyses, PRP demonstrated a significantly higher rate of successful outcomes when compared to hyaluronic acid (p = 0.002, odds ratio 95% CI = 2.19 [1.33-3.62]) (Figure 2) as well as higher rates of patient-reported symptom relief (p = 0.019, odds ratio [95% CI] = 1.55 [1.07-2.24]) (Figure 3), not requiring a reintervention after the initial injection treatment (p = 0.002, odds ratio [95% CI] = 2.17 [1.33-3.53]) (Figure 4), and achieving the minimal clinically important difference (MCID) for pain improvement (p = 0.007, odds ratio [95% CI] = 6.19[1.63-23.42]) when compared to all alternative nonoperative treatments. Overall, the mean number of events per meta-analysis required to change the statistical significance of the pooled treatment effect was 8.67 ± 4.50. Conclusions: Individual RCTs evaluating PRP for knee OA possess slight robustness. Upon meta-analysis, PRP demonstrated a significant advantage over HA as well as improved symptom relief, lower rates of reintervention, and more frequent achievement of the MCID for pain improvement when compared to alternative, nonoperative treatment options. Statistically significant pooled treatment effects evaluating PRP for knee OA are more robust than approximately half of all comparable meta-analyses in medicine and healthcare. Future RCTs and meta-analyses should consider reporting fragility indices and quotients to facilitate interpretation of results in their proper context. In addition, the robustness of these findings suggests that reconsideration of the American Academy of Orthopaedic Surgeons clinical practice guidelines around the use of PRP for knee OA may be warranted.

Objectives: Injury to the Medial Ulnar Collateral Ligament (MUCL) is a common setback experienced by many throwing athletes often requiring reconstruction with 12-18 months of rehabilitation. Current reconstructive techniques fail to anatomically restore the MUCL which may contribute to the prolonged course of rehabilitation. In recent years, we described an anatomic MUCL reconstruction with internal brace augmentation which demonstrated improved biomechanical strength when compared to the docking technique in cadaveric specimens. The purpose of this study was to evaluate the postoperative course of both amateur and professional throwing athletes that underwent anatomic MUCL reconstruction with internal brace augmentation. We hypothesized that throwers would return to the same level of play and that return to play (RTP) would be a shorter duration compared to current reported outcomes. Methods: In this surgical technique, the native MUCL is formally repaired. The graft and a suture tape are folded over a suspensory loop and secured in a socket of the medial epicondyle of the humerus to maximize tendon to bone contact. On the ulnar side, the graft and internal brace are secured proximally by two suture anchors on either side of the sublime tubercle and further secured across the sublime tubercle ridge distally to re-create the anatomic triangular insertion of the native ligament. All surgeries were performed by a single surgeon. Patient reported outcomes in addition to date of RTP, level of play, and functional outcomes were retrospectively gathered. All patients initially followed an Accelerated Rehabilitation Protocol and were converted to a Standard Paced protocol if setbacks were encountered. Results: A total of 26 baseball players underwent primary (n=23) or revision (n=3) MUCL reconstruction with the Anatomic Technique. Of these, 15 were professional and 11 were amateur athletes. 92% of throwers returned to play at a mean of 9.9 months following reconstruction. 89% were able to advance through the accelerated postoperative protocol without issues and 85% returned to the same role and level of play. Post injury KJOC scores improved from 41 to 86.9 and SANE scores improved from 32.5 to 95.5. No significant difference was identified in pre-injury versus post-reconstruction throwing velocity, ball spin rate, or horizontal/vertical ball movement. Conclusions: Anatomic reconstruction of the MUCL with internal bracing is a viable option for MUCL injuries. Advantages include increased tendon-bone contact of the reconstruction, multiple fixation points, and anatomic restoration of the MUCL. This technique allowed an expedited return to sport for these baseball athletes.

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]