Camp, Christopher L.

Background: Distal biceps tendon ruptures commonly present in the middle-aged population resulting in deficits of strength and endurance. Operative management has shown improved functional outcome; however, there is not a clear consensus on an ideal surgical method. Indications: Distal biceps tendon repair is indicated for patients with clinical evidence and supporting magnetic resonance imaging confirmation of complete or partial rupture of the biceps tendon. Ideally, surgery is performed within 1 to 2 weeks of the injury to minimize the amount of scar tissue that is formed and the severity of the tendon retraction. Technique Description: A single incision is created on the volar surface of the forearm approximately 15 mm distal to the main flexor crease. After dissection to and retrieval of the biceps tendon, a #2 FiberTag stitch is placed distally and secured in a standard looped, locking fashion. An anchor is then placed in the most proximal aspect of the radial tuberosity and preliminarily placed around the tendon. An all-suture intramedullary cortical button is then placed in the distal aspect of the radial tuberosity. The FiberTag sutures are then shuttled through the button and tightened to anatomically reduce the distal biceps. The sutures on the proximal anchor are then used as supplemental fixation. Results: An anterior, single incision technique provides exposure necessary for dual anchor fixation and anatomic restoration of the distal biceps tendon. Utilizing this approach, patients are found to have improved flexion and pronation at 1 year, lower rates of heterotopic ossification, and lower rates of reoperation. Conclusion: Distal biceps tendon repair through an anterior, single incision provides excellent exposure for surgical repair. Utilizing a dual anchor technique, the distal button allows for anatomic fixation while the proximal suture anchor provides secondary fixation and increases the bone-tendon interface. 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.

Objectives: Osteochondritis dissecans (OCD) of the humeral capitellum is an often painful condition that typically affects the adolescent athlete. There is little consensus on treatment and a scarcity of long-term outcomes data. The purpose of this study was to (1) report the long-term outcomes associated with both operative and non-operative management of capitellar OCD, (2) identify factors associated with failure of non-operative management, and (3) determine whether delay in surgery affects final outcomes. Methods: All patients diagnosed with OCD of the capitellum from 1995-2020 within a defined geographic cohort were included. Medical records, imaging studies, and operative reports were manually reviewed to record demographic data, treatment strategies, and outcomes. Surgical treatment was considered delayed if it occurred more than 6 months after symptom onset. Results: A total of 50 elbows with a mean follow-up of 9.4 years were included. Of these, 7 (14%) were treated non-operatively and never underwent surgery during follow-up, while 43 (86%) underwent surgical intervention: 27 had early surgery and 16 underwent delayed surgery after ≥ 6 months of non-operative treatment. When compared to non-operative management, surgical management resulted in superior MEPI scores (90 vs 83, p=0.05), decreased persistence of mechanical symptoms (9% vs 50%, p<0.01), and better elbow flexion (141° vs 131°, p=0.01) at long-term follow up. Older patients had a trend toward increased failure of non-operative management (p=0.06). The presence of an intra-articular loose body strongly predicted failure of non-operative management (p=0.01; OR 13). Plain radiography and MRI had poor sensitivities for identifying loose bodies (27% and 40%, respectively). Differences in outcomes following early versus delayed surgical management were not demonstrated. Conclusions: Patients with capitellar OCD initially treated nonoperatively failed nonoperative management 70% of the time. Elbows that did not undergo surgery had slightly increased symptoms and decreased functional outcomes compared to those treated surgically. In this cohort, the greatest predictors for failure of non-operative treatment were older age and presence of a loose body; however, an initial trial of non-operative treatment did not adversely impact the success of future surgery at long term follow-up. [Table: see text][Table: see text][Table: see text][Table: see text]

Background: Various metrics have emerged for assessing scientific impact, most of which are based on complex calculations and, in many cases, are not freely available. Moreover, most of these metrics are not intended for assessing the scientific impact of research groups. Cumulative group metrics are proposed as an efficient and cost-effective strategy for measuring group scientific impact. Materials and methods: The authors collected peer-reviewed output in 2020 from two academic orthopedic surgery departments [University of Michigan (UM) and Mayo Clinic Rochester (MC)] and one medical device research department [Arthrex Inc. (AI)]. The sites evaluated the Cumulative Group Number of Publications (CGNP), Cumulative Journal Impact Factor (CJIF), Cumulative CiteScore (CCS), Cumulative SCImago Journal Rank (CSJR), and Cumulative Source Normalized Impact per Paper (CSNIP) for the three institutions. Results: In 2020, UM published 159 peer-reviewed studies, MC published 347 peer-reviewed studies, and AI supported 141 publications. The UM publications achieved a CJIF of 513, a CCS of 891, a CSJR of 255, and a CSNIP of 247. The MC publications achieved a CJIF of 956, a CCS of 1568, a CSJR of 485, and a CSNIP of 508. AI-supported publications achieved a CJIF of 314, a CCS of 598, a CSJR of 189, and a CSNIP of 189. Conclusion: The presented cumulative group metrics are an effective tool to assess the scientific impact of a research group. The cumulative submetrics can further evaluate research groups compared with other departments due to field normalization. Department leadership and funding agencies can utilize these metrics to evaluate research output quantitatively and qualitatively.

Purpose To evaluate the cost‐effectiveness of 3 isolated meniscal repair (IMR) treatment strategies: platelet‐rich plasma (PRP)–augmented IMR, IMR with a marrow venting procedure (MVP), and IMR without biological augmentation. Methods A Markov model was developed to evaluate the baseline case: a young adult patient meeting the indications for IMR. Health utility values, failure rates, and transition probabilities were derived from the published literature. Costs were determined based on the typical patient undergoing IMR at an outpatient surgery center. Outcome measures included costs, quality‐adjusted life‐years (QALYs), and the incremental cost‐effectiveness ratio (ICER). Results Total costs of IMR with an MVP were $8,250; PRP‐augmented IMR, $12,031; and IMR without PRP or an MVP, $13,326. PRP‐augmented IMR resulted in an additional 2.16 QALYs, whereas IMR with an MVP produced slightly fewer QALYs, at 2.13. Non‐augmented repair produced a modeled gain of 2.02 QALYs. The ICER comparing PRP‐augmented IMR versus MVP‐augmented IMR was $161,742/QALY, which fell well above the $50,000 willingness‐to‐pay threshold. Conclusions IMR with biological augmentation (MVP or PRP) resulted in a higher number of QALYs and lower costs than non‐augmented IMR, suggesting that biological augmentation is cost‐effective. Total costs of IMR with an MVP were significantly lower than those of PRP‐augmented IMR, whereas the number of additional QALYs produced by PRP‐augmented IMR was only slightly higher than that produced by IMR with an MVP. As a result, neither treatment dominated over the other. However, because the ICER of PRP‐augmented IMR fell well above the $50,000 willingness‐to‐pay threshold, IMR with an MVP was determined to be the overall cost‐effective treatment strategy in the setting of young adult patients with isolated meniscal tears. Level of Evidence Level III, economic and decision analysis.

Purpose To (1) report the long‐term outcomes associated with both operative and nonoperative management of capitellar osteochondritis dissecans (OCD), (2) identify factors associated with failure of nonoperative management, and (3) determine whether delay in surgery affects final outcomes. Methods All patients who received a diagnosis of capitellar OCD from 1995‐2020 within a geographic cohort were included. Medical records, imaging studies, and operative reports were manually reviewed to record demographic data, treatment strategies, and outcomes. The cohort was divided into 3 groups: (1) nonoperative management, (2) early surgery, and (3) delayed surgery. Delayed surgery (surgery ≥6 months after symptom onset) was considered failure of nonoperative management. Results Fifty elbows with a mean follow‐up period of 10.5 years (median, 10.3 years; range, 1‐25 years) were studied. Of these, 7 (14%) were definitively treated nonoperatively, 16 (32%) underwent delayed surgery after at least 6 months of failed nonoperative treatment, and 27 (54%) underwent early surgical intervention. When compared with nonoperative management, surgical management resulted in superior Mayo Elbow Performance Index pain scores (40.1 vs 33, P = .04), fewer mechanical symptoms (9% vs 50%, P < .01), and better elbow flexion (141° vs 131°, P = .01) at long‐term follow‐up. Older patients trended toward increased failure of nonoperative management ( P = .06). The presence of an intra‐articular loose body predicted failure of nonoperative management ( P = .01; odds ratio, 13). Plain radiography and magnetic resonance imaging had poor sensitivities for identifying loose bodies (27% and 40%, respectively). Differences in outcomes after early versus delayed surgical management were not observed. Conclusions Nonoperative management of capitellar OCD failed 70% of the time. Elbows that did not undergo surgery had slightly more symptoms and decreased functional outcomes compared with those treated surgically. The greatest predictors of failure of nonoperative treatment were older age and presence of a loose body; however, an initial trial of nonoperative treatment did not adversely impact the success of future surgery. Level of Evidence Level III, retrospective cohort study.

» Lateral epicondylitis (LE) or tennis elbow is a common cause of elbow pain in the general population, especially women in the fourth and fifth decades of life who participate in repetitive forceful movements involving the wrist and forearm. » The pathogenesis of this overuse injury is believed to start from an overload event leading to a microtear in or near the origin of the extensor carpi radialis brevis that is subsequently prone to additional injury and structural weakness over time. » Treatment of LE often begins with a wide variety of nonoperative modalities including rest, nonsteroidal anti-inflammatory drugs, bracing, and physical therapy. For recalcitrant symptoms, additional nonoperative therapies are implemented; however, there remains a lack of comparative efficacy between these adjunct treatments. » In this article, we examine the available literature regarding nonoperative management of LE and provide supplementary insight into the effectiveness of current modalities.

AbstractDeep learning has the potential to be one of the most transformative technologies to impact orthopedic surgery. Substantial innovation in this area has occurred over the past 5 years, but clinically meaningful advancements remain limited by a disconnect between clinical and technical experts. That is, it is likely that few orthopedic surgeons possess both the clinical knowledge necessary to identify orthopedic problems, and the technical knowledge needed to implement deep learning‐based solutions. To maximize the utilization of rapidly advancing technologies derived from deep learning models, orthopedic surgeons should understand the steps needed to design, organize, implement, and evaluate a deep learning project and its workflow. Equipping surgeons with this knowledge is the objective of this three‐part editorial review. Part I described the processes involved in defining the problem, team building, data acquisition, curation, labeling, and establishing the ground truth. Building on that, this review (Part II) provides guidance on pre‐processing and augmenting the data, making use of open‐source libraries/toolkits, and selecting the required hardware to implement the pipeline. Special considerations regarding model training and evaluation unique to deep learning models relative to “shallow” machine learning models are also reviewed. Finally, guidance pertaining to the clinical deployment of deep learning models in the real world is provided. As in Part I, the focus is on applications of deep learning for computer vision and imaging.

Purpose To analyze the current literature regarding risk factors associated with medial ulnar collateral ligament (MUCL) injury in baseball players and to serve as a robust source for identifying modifiable risk factors that once optimized, have the potential to reduce injury risk. Methods Comprehensive search of the available literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis guidelines. Studies were included if they evaluated risk factors for MUCL injuries in the elbow of baseball players. Risk of bias assessment was performed via Methodological Index for Non‐randomized Studies (MINORS) scoring system. The Oxford Centre for Evidence‐Based Medicine was used to determine level of evidence. Variables of interest; player age, position, shoulder motion, humeral retrotorsion, joint laxity, strength, balance, geography, velocity, pitch count, pitch types, throwing volumes, and throwing mechanics were recorded. Results Twenty‐one studies were included in this systematic review. MINORS scores ranged from 75 to 87%, and variables demonstrated significant heterogeneity. Performance‐based risk factors for MUCL injury included: increased pitch count (both annual and per game), higher percentage of fastballs thrown, smaller pitch repertoire, and/or a loss of pitching velocity. Biomechanical studies demonstrated the relationship between decreased shoulder range of motion (total ROM, ER, IR, and abduction), increased humeral retrotorsion, increased elbow valgus opening in the throwing arm, lower Y‐Balance score, and increased lateral release position to increased MUCL injury. Conclusions Risk factors for MUCL injury can generally be categorized into 4 primary groups: 1) various player demographics and characteristics, 2) throwing too hard (high velocity), 3) throwing too much (pitch count/volume), and 4) throwing with poor mechanics. In this systematic review, the most significant nonmodifiable risk factors for MUCL injuries included: increased glenohumeral retrotorsion and elbow valgus opening. The most consistent modifiable risk factors included: total shoulder range of motion, pitch count, pitch selection, Y balance score, and lateral release position. Pitch velocity was inconsistent in literature, but most studies found this as a risk for injury. These risk factors may serve as appropriate targets for future evidence‐based injury mitigation strategies. Level of Evidence Level IV, systematic review of Level II‐IV studies.

Background: Baseball pitchers often participate in throwing programs that involve throwing at reduced effort levels to gradually increase the amount of stress experienced across the elbow. It is currently unknown how reduced effort pitching compares with maximum effort with respect to elbow stress and ball velocity. Purpose/Hypothesis: The purpose was to determine the correlation between elbow stress and ball velocity with reduced effort pitching. We hypothesized that decreased perceived effort would disproportionately correlate with elbow stress and ball velocity. Study Design: Descriptive laboratory study. Methods: Ten healthy male high school baseball pitchers threw 5 pitches from a regulation pitching mound at 3 effort levels: maximum effort, 75% effort, and 50% effort. Elbow stress, specifically elbow varus torque, was calculated for all pitches using a validated marker-based 3-dimensional motion capture system. Ball velocity was measured using a Doppler radar gun. Intrathrower variability was calculated for each effort level. Results: Elbow stress and ball velocity decreased with reduced effort throws ( P < .001 and P = .003, respectively). However, the reductions in elbow stress and ball velocity were not proportional. At 75% effort throws, elbow stress measured 81% (intraclass correlation coefficient [ICC], 0.95), and ball velocity measured 90% (ICC, 0.80) of maximum, respectively. At 50% effort throws, elbow stress measured 75% (ICC, 0.93), and ball velocity measured 85% (ICC, 0.87) of maximum. Intrathrower reliability was excellent for elbow stress and ball velocity, with all ICCs ≥0.80. Conclusion: Pitching at a reduced effort level resulted in decreased elbow stress and ball velocity. However, for every 25% reduction in perceived effort, elbow stress decreased by a mean 13%, and ball velocity decreased 7.5%. When baseball pitchers attempt to throw at a reduced effort of maximum, throwing metrics do not decrease proportionately. Clinical Relevance: While pitching at a reduced effort of maximum decreases elbow stress and ball velocity, the decrease is not proportional, subjecting the elbow to more stress than intended. This has significant clinical importance to pitchers, coaches, and medical professionals in the setting of injury prevention and return to sports.

» Hamstring injuries are common among active and athletic individuals, especially those involved in high-speed running, distance running, or sports requiring sudden directional changes. Acute hamstring strains often occur as an eccentric strain during running or a stretch-type injury caused by simultaneous hip flexion and knee extension. Proximal hamstring tendinopathy is an overuse injury of the hamstring tendon as a result of chronic cicatrization of the musculotendinous unit. » Repeated stress to the hamstring tendon leads to increased cellularity of tendon fibers, disruption of collagen, and subsequent microinjury of the tissue that attaches the tendon to bone. » Management of hamstring injuries generally begins with nonoperative modalities consisting of eccentric rehabilitative exercise programs. Although various other treatment modalities are available, the comparative efficacy of these supportive measures is not well differentiated at this time. » In this article, we review the current literature with regard to the nonoperative treatment of hamstring injuries, specifically focusing on acute hamstring muscle strains and proximal hamstring tendinopathy in order to provide supplementary insight on the effectiveness of current modalities.