Camp, Christopher L.

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.

Abstract Purpose The demographic and radiological risk factors of subchondral insufficiency fractures of the knee (SIFK) continue to be a subject of debate. The purpose of this study was to associate patient‐specific factors with SIFK in a large cohort of patients. Methods Inclusion criteria consisted of patients with SIFK as verified on magnetic resonance imaging (MRI). All radiographs and MRIs were reviewed to assess characteristics such as meniscus tear presence and type, subchondral oedema presence and location, location of SIFK, mechanical limb alignment, osteoarthritis as assessed by Kellgren–Lawrence grade and ligamentous injury. A total of 253 patients (253 knees) were included, with 171 being female. The average body mass index (BMI) was 32.1 ± 7.0 kg/m 2 . Results SIFK was more common in patients with medial meniscus tears (77.1%, 195/253) rather than tears of the lateral meniscus (14.6%, 37/253) ( p < 0.001). Medial meniscus root and radial tears of the posterior horn were present in 71.1% (180/253) of patients. Ninety‐one percent (164/180) of medial meniscus posterior root and radial tears had an extrusion ≥3.0 mm. Eighty‐one percent (119/147) of patients with SIFK on the medial femoral condyle and 86.8% (105/121) of patients with SIFK on the medial tibial plateau had a medial meniscus tear. Varus knees had a significantly increased rate of SIFK on the medial femoral condyle in comparison to valgus knees ( p = 0.016). Conclusion In this large cohort of patients with SIFK, there was a high association with medial meniscus root and radial tears of the posterior horn, meniscus extrusion ≥3.0 mm as well as higher age, female gender and higher BMI. Additionally, there was a particularly strong association of medial compartment SIFK with medial meniscus tears. As SIFK is frequently undiagnosed, identifying patient‐specific demographic and radiological risk factors will help achieve a prompt diagnosis. Level of Evidence Level IV.

Purpose To (1) analyze trends in the publishing of statistical fragility index (FI)–based systematic reviews in the orthopaedic literature, including the prevalence of misleading or inaccurate statements related to the statistical fragility of randomized controlled trials (RCTs) and patients lost to follow‐up (LTF), and (2) determine whether RCTs with relatively “low” FIs are truly as sensitive to patients LTF as previously portrayed in the literature. Methods All FI‐based studies published in the orthopaedic literature were identified using the Cochrane Database of Systematic Reviews, Web of Science Core Collection, PubMed, and MEDLINE databases. All articles involving application of the FI or reverse FI to study the statistical fragility of studies in orthopaedics were eligible for inclusion in the study. Study characteristics, median FIs and sample sizes, and misleading or inaccurate statements related to the FI and patients LTF were recorded. Misleading or inaccurate statements—defined as those basing conclusions of trial fragility on the false assumption that adding patients LTF back to a trial has the same statistical effect as existing patients in a trial experiencing the opposite outcome—were determined by 2 authors. A theoretical RCT with a sample size of 100, P = .006, and FI of 4 was used to evaluate the difference in effect on statistical significance between flipping outcome events of patients already included in the trial (FI) and adding patients LTF back to the trial to show the true sensitivity of RCTs to patients LTF. Results Of the 39 FI‐based studies, 37 (95%) directly compared the FI with the number of patients LTF. Of these 37 studies, 22 (59%) included a statement regarding the FI and patients LTF that was determined to be inaccurate or misleading. In the theoretical RCT, a reversal of significance was not observed until 7 patients LTF (nearly twice the FI) were added to the trial in the distribution of maximal significance reversal. Conclusions The claim that any RCT in which the number of patients LTF exceeds the FI could potentially have its significance reversed simply by maintaining study follow‐ups is commonly inaccurate and prevalent in orthopaedic studies applying the FI. Patients LTF and the FI are not equivalent. The minimum number of patients LTF required to flip the significance of a typical RCT was shown to be greater than the FI, suggesting that RCTs with relatively low FIs may not be as sensitive to patients LTF as previously portrayed in the literature; however, only a holistic approach that considers the context in which the trial was conducted, potential biases, and study results can determine the merits of any particular RCT. Clinical Relevance Surgeons may benefit from re‐examining their interpretation of prior FI reviews that have made claims of substantial RCT fragility based on comparisons between the FI and patients LTF; it is possible the results are more robust than previously believed.

Background: Injury to the medial ulnar collateral ligament (MUCL) is a common setback experienced by many throwing athletes often requiring reconstruction with 12 to 18 months of rehabilitation. Current reconstructive techniques fail to anatomically restore the MUCL. This presentation demonstrates the “anatomic technique” for reconstruction of the MUCL supplemented by internal brace augmentation. Indications: Initial injuries of the MUCL can often be managed conservatively; however, many complete tears and those failing nonoperative management are frequently treated with MUCL reconstruction. Technique Description: After graft harvest, a 6-cm incision is created over the medial epicondyle to expose the sublime tubercle and medial epicondyle. Sutures are placed through the torn ligament which are used to formally repair the native ligament. A 4-mm socket is drilled in the MUCL origin of the medial epicondyle, and two 2-mm penetrating sockets are drilled toward the base of the 4-mm socket. The sutures in the native ligament are passed through the sockets and later tied over the bone bridge to complete the native ligament repair. A tight rope is shuttled through the medial epicondyle socket and assembled. The palmaris longus autograft and a suture tape are loaded onto the tightrope and reduced into the humeral socket. On the ulna, soft suture anchors are placed on either side of the sublime tubercle. The distal end of the graft is then sutured utilizing a FiberWire. The graft is secured to the sublime tubercle by tying down the previously placed suture anchors. The suture tapes and internal brace are loaded into a SwiveLock suture anchor, which is fixed distally along the sublime tubercle ridge creating an anatomic reconstruction. Then, the native ligament sutures and tight rope are re-tensioned and tied across the humeral bone bridge for final fixation. Results: In our cohort of 26 professional and amateur throwers, >90% returned to play at the same level at a mean of 9.9 months postoperatively. Discussion/Conclusion: Anatomic reconstruction of the MUCL with internal bracing is a viable option for MUCL injuries and may allow expedited return to sport for most athletes. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.