Dines, Joshua S.

Medial ulnar collateral ligament (MUCL) injuries of the elbow have increased over the past 2 decades, particularly among adolescent and young adult overhead throwing athletes. Over time, operative techniques for MUCL injuries have evolved, with the goals of improving time to return and rates of return to sport and meeting athlete-specific demands. The purpose of this review is to evaluate the state of surgical management of MUCL injuries, assessing indications, techniques, and outcomes. Surgical techniques reviewed included MUCL-augmented repair with internal bracing, traditional reconstruction, reconstruction augmented with internal bracing, and revision MUCL reconstruction. While MUCL reconstruction has been the gold standard of treatment, augmented reconstruction and repair techniques have shown promising outcomes; these strategies emphasize anatomic restoration, preservation of native tissue, and individualized patient selection.

Background: Injury to the medial ulnar collateral ligament (MUCL) is a common setback for throwing athletes, often requiring reconstruction with 12 to 18 months of rehabilitation. The authors previously described a more anatomic technique with improved mechanical strength as compared with the docking technique, which may allow for an accelerated return to sport. Purpose: To evaluate return-to-sport rates, time to return to sport, and the effect on the functional performance of amateur and professional throwing athletes who underwent anatomic MUCL reconstruction with suture tape augmentation. Study Design: Case series; Level of evidence, 4. Methods: A retrospective case series was performed including baseball players who underwent anatomic MUCL reconstruction with suture tape augmentation by a single surgeon from 2018 to 2022. Inclusion criteria consisted of a minimum 2-year follow-up, participation in baseball, and utilization of autograft (palmaris longus or gracilis). Patients who underwent previous MUCL reconstruction were excluded from the study. All patients initially followed an accelerated rehabilitation protocol. Outcome measures were collected, including Kerlan-Jobe Orthopaedic Clinic (KJOC), Single Assessment Numeric Evaluation (SANE), and Conway-Jobe scores, as well as throwing metrics such as ball velocity and spin rate. Results: Thirty-four baseball players (mean ± SD age, 21 ± 3 years) underwent primary MUCL reconstruction. Time of final follow-up was 36.1 ± 10.3 months. Of these, 16 were professional athletes and 18 were amateur. All throwers returned to live gameplay at a mean 10.1 ± 2.0 months after reconstruction (professional, 10.6 ± 2.3; amateur, 9.7 ± 1.8). Furthermore, 97% (94% professional, 100% amateur) advanced through the accelerated postoperative protocol without issues, and 91% (88% professional, 94% amateur) returned to the same role and 85% (75% professional, 94% amateur) to the same level of play. Professional postinjury KJOC scores improved from 42.6 ± 16 to 87.5 ± 8.3 and SANE scores from 25.0 ± 11.2 to 95.6 ± 4.2. Amateur postinjury KJOC scores improved from 35.6 ± 10.7 to 90.9 ± 8.6 and SANE scores from 57.5 ± 16.9 to 95.2 ± 7.2. No significant difference was identified in preinjury versus postreconstruction throwing velocity, ball spin rate, or horizontal/vertical ball movement. The overall failure rate was 2.9%, with 1 professional pitcher requiring revision for graft rupture at 3 years postoperatively. Conclusion: Anatomic reconstruction of the MUCL with suture tape is a viable option for MUCL injuries, allowing an expedited return to sport at 10.1 ± 2.0 months (professional, 10.6 ± 2.3; amateur, 9.7 ± 1.8) in baseball players, with a low failure rate.

Background: Randomized controlled trials (RCTs) evaluating the efficacy of platelet-rich plasma (PRP) for the management of lateral epicondylitis (LE) have been characterized by substantial variability in reported outcomes. The source of this heterogeneity is uncertain. Purpose: To determine the effect of estimated platelet concentration on the efficacy of PRP for the management of LE. Study Design: Systematic review and meta-analysis; Level of evidence, 2. Methods: All RCTs evaluating the efficacy of PRP in managing LE were identified. RCTs were classified according to whether the study documented a platelet concentration factor of PRP representing a greater than 3-fold increase over whole blood or a supraphysiological platelet dose (high-dose vs low-dose PRP). The primary outcome was the mean difference (MD) in the visual analog scale (VAS) score at latest follow-up. Random-effects and mixed-effects meta-analyses were performed, and meta-regression was used to evaluate whether differences in outcomes after treatment with PRP could be explained by differences in the concentration of PRP used. Results: Overall, 13 RCTs with a total of 791 patients were included in this analysis, with 5 that utilized low-dose PRP and 8 that used high-dose PRP. Meta-analysis of VAS scores reported by studies that used high-dose PRP resulted in an MD of −1.31 (95% CI, −1.87 to −0.75) in favor of PRP over all alternative treatment strategies ( P < .001). Meta-analysis of VAS scores reported by studies that used low-dose PRP resulted in an MD of 0.08 (95% CI, −0.51 to 0.68), suggesting no difference in the effect between PRP and all alternative treatment strategies ( P = .79). The platelet concentration factor of PRP used in each RCT was found to be strongly predictive of the VAS score at final follow-up in meta-regression ( P < .001), with 58.5% of the heterogeneity in the outcomes of PRP between studies explained by the platelet concentration factor alone. Conclusion: The platelet concentration of PRP may play a significant role in the outcomes of patients with LE. A direct linear relationship was observed between the platelet concentration factor of PRP used and the magnitude of patient-reported symptom relief after the management of LE with PRP. Clinicians should ensure a supraphysiological platelet concentration when preparing PRP for the management of LE.

AbstractPurposeTo systematically review the literature regarding machine learning in leg length discrepancy (LLD) and to provide insight into the most relevant manuscripts on this topic in order to highlight the importance and future clinical implications of machine learning in the diagnosis and treatment of LLD.MethodsA systematic electronic search was conducted using PubMed, OVID/Medline and Cochrane libraries in accordance with Preferred Reporting Items for Systematic Review and Meta‐Analysis guidelines. Two observers independently screened the abstracts and titles of potential articles.ResultsA total of six studies were identified in the search. All measurements were calculated using standardized anterior‐posterior long‐leg radiographs. Five (83.3%) of the studies used measurements of the femoral length, tibial length and leg length to assess LLD, whereas one (16.6%) study used the iliac crest height difference to quantify LLD. The deep learning models showed excellent reliability in predicting all length measurements with intraclass correlation coefficients ranging from 0.98 to 1.0 and mean absolute error (MAE) values ranging from 0.11 to 0.45 cm. Three studies reported measurements of LLD, and the convolutional neural network model showed the lowest MAE of 0.13 cm in predicting LLD.ConclusionsMachine learning models are effective and efficient in determining LLD. Implementation of these models may reduce cost, improve efficiency and lead to better overall patient outcomes.Clinical RelevanceThis review highlights the potential of deep learning (DL) algorithms for accurate and reliable measurement of lower limb length and leg length discrepancy (LLD) on long‐leg radiographs. The reported mean absolute error and intraclass correlation coefficient values indicate that the performance of the DL models was comparable to that of radiologists, suggesting that DL‐based assessments could potentially be used to automate the measurement of lower limb length and LLD in clinical practice.Level of EvidenceLevel IV.

Purpose To assess the ability of ChatGPT‐4, an automated Chatbot powered by artificial intelligence, to answer common patient questions concerning the Latarjet procedure for patients with anterior shoulder instability and compare this performance with Google Search Engine. Methods Using previously validated methods, a Google search was first performed using the query “Latarjet.” Subsequently, the top 10 frequently asked questions (FAQs) and associated sources were extracted. ChatGPT‐4 was then prompted to provide the top 10 FAQs and answers concerning the procedure. This process was repeated to identify additional FAQs requiring discrete‐numeric answers to allow for a comparison between ChatGPT‐4 and Google. Discrete, numeric answers were subsequently assessed for accuracy on the basis of the clinical judgment of 2 fellowship‐trained sports medicine surgeons who were blinded to search platform. Results Mean (± standard deviation) accuracy to numeric‐based answers was 2.9 ± 0.9 for ChatGPT‐4 versus 2.5 ± 1.4 for Google ( P = .65). ChatGPT‐4 derived information for answers only from academic sources, which was significantly different from Google Search Engine ( P = .003), which used only 30% academic sources and websites from individual surgeons (50%) and larger medical practices (20%). For general FAQs, 40% of FAQs were found to be identical when comparing ChatGPT‐4 and Google Search Engine. In terms of sources used to answer these questions, ChatGPT‐4 again used 100% academic resources, whereas Google Search Engine used 60% academic resources, 20% surgeon personal websites, and 20% medical practices ( P = .087). Conclusions ChatGPT‐4 demonstrated the ability to provide accurate and reliable information about the Latarjet procedure in response to patient queries, using multiple academic sources in all cases. This was in contrast to Google Search Engine, which more frequently used single‐surgeon and large medical practice websites. Despite differences in the resources accessed to perform information retrieval tasks, the clinical relevance and accuracy of information provided did not significantly differ between ChatGPT‐4 and Google Search Engine. Clinical Relevance Commercially available large language models (LLMs), such as ChatGPT‐4, can perform diverse information retrieval tasks on‐demand. An important medical information retrieval application for LLMs consists of the ability to provide comprehensive, relevant, and accurate information for various use cases such as investigation about a recently diagnosed medical condition or procedure. Understanding the performance and abilities of LLMs for use cases has important implications for deployment within health care settings.

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.

Background: Treatment of ulnar collateral ligament (UCL) tears with suture tape augmentation has gained interest given preliminary reports of favorable biomechanical characteristics. No study to date has quantitatively assessed the biomechanical effects of multiple augmentation techniques relative to the native UCL. Purpose: To perform a systematic review and meta-analysis of controlled laboratory studies to assess and comparatively rank biomechanical effects of UCL repair or reconstruction with or without augmentation. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: PubMed, OVID/Medline, and Cochrane databases were queried in January 2023. A frequentist network meta-analytic approach was used to perform mixed-treatment comparisons of UCL repair and reconstruction techniques with and without augmentation, with the native UCL as the reference condition. Pooled treatment estimates were quantified under the random-effects assumption. Competing treatments were ranked in the network meta-analysis by using point estimates and standard errors to calculate P scores (greater P score indicates superiority of treatment for given outcome). Results: Ten studies involving 206 elbow specimens in which a distal UCL tear was simulated were included. UCL reconstruction with suture tape augmentation (AugRecon) restored load to failure to a statistically noninferior magnitude (mean difference [MD], –1.99 N·m; 95% CI, –10.2 to 6.2 N·m; P = .63) compared with the native UCL. UCL reconstruction (Recon) (MD, –12.7 N·m; P < .001) and UCL repair with suture tape augmentation (AugRepair) (MD, –14.8 N·m; P < .001) were both statistically inferior to the native UCL. The AugRecon condition conferred greater load to failure compared with Recon ( P < .001) and AugRepair ( P = .002) conditions. AugRecon conferred greater torsional stiffness relative to all other conditions and was not statistically different from the native UCL (MD, 0.32 N·m/deg; 95% CI, –0.30 to 0.95 N·m/deg; P = .31). Medial ulnohumeral gapping was not statistically different for the AugRepair (MD, 0.30 mm; 95% CI, –1.22 to 1.82 mm; P = .70), AugRecon (MD, 0.57 mm; 95% CI, –0.70 to 1.84 mm; P = .38), or Recon (MD, 1.02 mm; 95% CI, –0.02 to 2.05 mm; P = .055) conditions compared with the native UCL. P-score analysis indicated that AugRecon was the most effective treatment for increasing ultimate load to failure and torsional stiffness, whereas AugRepair was the most effective for minimizing medial gapping. Conclusion: AugRecon restored load to failure and torsional stiffness most similar to the parameters of the native UCL, whereas Recon and AugRepair did not restore the same advantageous properties at time zero. Medial ulnohumeral gapping during a valgus load was minimized by all 3 treatments. Based on network interactions, AugRecon was the superior treatment approach for restoring important biomechanical features of the UCL at time zero that are jeopardized during a complete distal tear.

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 The primary objective of the present study was to investigate how preoperative imaging modalities including 3D computed tomography (CT) scans with preoperative planning software affect implant choice for shoulder arthroplasty. Methods X-ray, uncorrected 2D CT scans, and 3D CT scans from 21 patients undergoing primary arthroplasty were reviewed by five shoulder surgeons. Each surgeon measured glenoid version, inclination and humeral head subluxation, and then selected an anatomic or reverse shoulder arthroplasty implant based only on these imaging parameters. Each surgeon virtually positioned the implant. Agreement between surgeons and changes in plan for individual surgeons between imaging modalities were assessed. Results Average measurements of native version, inclination, and subluxation were similar across all imaging modalities with very good interobserver reliability. Overall, there was a high rate of variability in choice of implant depending on imaging modality. Agreement on implant selection between surgeons improved from 68.6% using x-ray to 80.0% with 3D CT. Introducing age added significant variability, reducing agreement on implant choice to 61.0% with 3D CT. Conclusions The use of preoperative 3D planning changes implant choice in nearly one-third of cases compared to plain radiographs and improves surgeon agreement on implant choice compared to x-ray and 2D CT. Level of evidence: III.

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.