Beyond guesswork: how accurate are surgeons at determining the degree of glenoid bone loss in instability surgery?

Background: Accurate measurement of glenoid bone loss (GBL) is critical to preoperative planning in cases of recurrent shoulder instability. The concept of critical bone loss has been established with a value of GBL >13.5% being associated with higher failure rate following arthroscopic Bankart Repair. Advanced imaging, such as magnetic resonance imaging (MRI) scans, can be used to quantify GBL prior to surgery using the best-fit circle technique. Surgeons have traditionally relied on visual inspection of the MRI scan preoperatively or on visual inspection of the glenoid at the time of arthroscopy to determine whether GBL is present. The purpose of this study is to determine if 3 fellowship-trained shoulder surgeons could adequately quantify GBL without using best-fit circle measurements on MRI. Methods: A retrospective review was performed which included 122 patients over an 8-year period that had an arthroscopic Bankart repair performed by 3 fellowship-trained surgeons. In all patients, preoperative MRI scans were retrospectively measured using best-fit circle technique to determine true GBL and compare that to the surgeons' preoperative and intraoperative estimation of GBL. Results: GBL was correctly identified in only 36% (18/50) of patients when the preoperative best-fit circle measurements were not made. Critical bone loss was missed in 9.8% (12/122) of patients in the study group. The estimated mean bone loss in that group by visual inspection was 11.3% compared to 16% true bone loss measured on MRI. Even in the 18 patients with some identified bone loss prior to surgery, critical bone loss was missed in 6 patients when using visual inspection of the MRI or intraoperative inspection alone. Conclusion: Simple visual inspection of glenoid images on MRI scan and visual inspection of the glenoid at the time of surgery are inaccurate in determining the true extent of GBL especially in cases of subtle bone deficiency. Preoperative planning is dependent on the exact degree of bone deficiency and measurement on the MRI scan using the best-fit circle technique is recommended in all cases of instability surgery.

Correlation of Rehabilitation and Throwing Program Milestones With Outcomes After Ulnar Collateral Ligament Reconstruction: An Analysis of 717 Professional Baseball Pitchers.

BACKGROUND: There remains room for improvement in surgical outcomes after medial ulnar collateral ligament reconstruction (MUCLR) in professional pitchers. The role and influence of postoperative rehabilitation on the outcomes of MUCLR are unknown. There is a paucity of clinical data in the current literature comparing the success of various postsurgical rehabilitation protocols after MUCLR. PURPOSE: To summarize the current rehabilitation process for professional pitchers recovering from MUCLR, evaluates what player and surgical factors correlate with outcomes, and determines whether rehabilitation timing and milestones correlate with successful outcomes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: 717 professional baseball pitchers who underwent MUCLR between 2010 and 2016 were identified and included in the analysis. Player characteristics evaluated included age at the time of surgery, throwing side dominance, primary pitching role (starter vs reliever), and level of play (MLB, AAA, AA, A). Surgical factors studied included date of surgery, graft type (palmaris longus autograft vs gracilis autograft), and surgical technique (figure of 8 vs docking vs other). The rehabilitation and throwing progression details were as follows: initiation date; first throw date; dates to start throwing from various distances; longest distance thrown; first flat ground throw date; first mound throw date; and first live batting practice (BP) date. The primary outcomes of interest were the ability to return to play at any level (RTP), the ability to return to the same level (RSL), and the time to RTP/RSL. RESULTS: On average, pitchers threw a baseball for the first time 4.9 months after surgery, with a broad range (2.8-14.9 months). For the 675 (94%) pitchers who were able to progress to mound throwing, the first throws off a mound occurred at a mean of 9.4 months after surgery. Before progressing to the mound, the mean longest long-toss distance reached was 137.5 feet, with a broad range (105-300 feet). A high variation in the time to RTP (7.6-53.9 months) and RSL (8.6-60.7 months) was noted. A total of 599 (84%) pitchers were able to RTP at a mean time of 14.9 ± 4.9 months after surgery (range, 7.6-53.9 months). Also, 528 (74%) pitchers were able to RSL after MUCLR at a mean of 17.4 ± 7 months (range, 8.6-60.7 months) postoperatively. Age was the most significant predictor of RTP (hazard ratio [HR], 1.03 [95% CI, 1.01-1.05]; P = .01) and RSL (HR, 0.96 [95% CI, 0.93-0.99]; P < .01). For every 1-year increase in age, there was a 3% increase in the chance of RTP. Conversely, for every 1-year decrease in age, there was a 4% increase in the chance of RSL. MLB players were more likely to RTP (HR, 1.39 [95% CI, 1.18-1.63]; P < .01) but not necessarily to RSL (HR, 0.90 [95% CI, 0.75-1.08]; P = .24). The time from surgery to any of the rehabilitation milestones of interest (first throw, first flat ground pitching, first mound throwing, and first live BP) did not correlate with RTP or RSL (all, P >.05). The same was true for the greatest long-toss distance thrown before transitioning to the mound. CONCLUSION: Significant variability in the postoperative rehabilitation protocols after MUCLR was observed in 717 professional baseball pitchers. The timing of achievement of throwing progression and rehabilitation milestones postoperatively varied widely but did not correlate with outcomes. Player characteristics-except for player age and professional pitching level-did not correlate with RTP and RSL outcomes. Older pitchers and MLB pitchers were more likely to RTP, but younger players were more likely to RSL. Surgical factors did not correlate with rehabilitation outcomes.

Successful Performance After Ulnar Collateral Ligament Reconstruction: An Analysis of 88 Drafted Professional Baseball Pitchers With a Matched Comparison Cohort.

BACKGROUND: Analysis of pitchers entering the Major League Baseball (MLB) draft after ulnar collateral ligament reconstruction (UCLR) is challenging for team physicians. PURPOSE: (1) To define the characteristics of pitchers drafted after UCLR associated with placement in AAA and MLB professional levels and completion of a career of at least 3 years, (2) to define characteristics placing pitchers at risk for reinjury after surgery, (3) to compare the professional-level placement and career duration of the UCLR cohort with a matched control group, and (4) to evaluate the accuracy of team physician predraft risk assessments to predict elbow reinjury in pitchers with a history of UCLR. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We analyzed pitchers from a single professional baseball team database who were drafted after UCLR from 2010 to 2013. A matched control group based on position and draft year was selected with the MLB database. The following pitcher characteristics were analyzed: age at the time of UCLR, time from UCLR to the MLB draft, pitching role (starter vs reliever), highest level of play attained, body mass index (BMI), throwing-side dominance, and predraft physician risk assessment. Physician assessments to predict risk for elbow reinjury were derived from operative and clinical history and evaluated for accuracy during the follow-up period. Pitcher characteristics were evaluated for correlation with successful AAA or MLB placement with a career duration of at least 3 years and as risk factors for elbow reinjury. The professional-level achievement and career duration of the UCLR cohort were compared with the matched cohort. RESULTS: A total of 88 pitchers matched the selection criteria and had at least 5 years of follow-up (range, 5-8 years). Pitcher age at the time of UCLR (P = .55), throwing-side dominance (P = .41), and BMI (P = .86) did not correlate with AAA- or MLB-level placement. Relief pitchers (P = .03) and pitchers with a longer time from surgery to final follow-up (P = .02) were more likely to reach the AAA or MLB level. Similarly, pitcher age at the time of UCLR (P = .56), throwing-side dominance (P = .27), and BMI (P = .69) did not correlate with a duration of play of at least 3 years. Relief pitchers (P = .03) and pitchers with a longer time from UCLR to the final follow-up (P = .005) were more likely to achieve at least 3 years of play. There was no difference in AAA or MLB placement between the UCLR and matched cohorts (P = .22). The UCLR cohort achieved a higher duration of play than the matched cohort (P = .002). Pitchers with a BMI >25 kg/m2 had a lower risk of elbow reinjury versus players with a BMI ≤25 kg/m2 (P = .012). Patient age at time of UCLR (P = .92), time from UCLR to the MLB draft (P = .18), pitching role (P = .74), and throwing-side dominance (P = .77) did not correlate with elbow reinjury. Physician risk assessment did not accurately predict reinjury (P = .27). Of the 88 patients, 4 (4.5%) required revision UCLR. CONCLUSION: Pitcher age at the time of UCLR, throwing-side dominance, and BMI did not correlate with performance. Relief pitchers and players with a longer time from surgery to final follow-up were more likely to reach AAA and MLB levels and achieve at least a 3-year duration of play. Pitchers with a greater BMI had a lower risk of reinjury. After UCLR, pitchers were able to perform at least as well as the matched nonsurgical cohort. Physician risk assessment at the time of the draft was not accurate at predicting reinjury.

Revision Ulnar Collateral Ligament Reconstruction in Professional Baseball: Current Trends, Surgical Techniques, and Outcomes.

BACKGROUND: Ulnar collateral ligament (UCL) reconstruction of the elbow is commonly performed on professional baseball pitchers. Recent reports have suggested that revision rates are on the rise and may be higher than previously thought. PURPOSE: To provide a comprehensive report on current trends, surgical techniques, and outcomes of revision UCL reconstructions performed on professional baseball pitchers between 2010 and 2016. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The Major League Baseball Health and Injury Tracking System (HITS) was used to compile records of all revision UCL reconstructions performed on professional baseball pitchers between 2010 and 2016. Player data and outcomes were obtained from HITS, and surgical details were obtained from operative reports. Descriptive statistical analysis was performed on epidemiologic data. Outcomes (return to play [RTP] rates, RTP times, subsequent injuries, and subsequent surgeries) were compared across the most common surgical techniques (docking vs modified Jobe) and graft sources (palmaris longus autograft vs hamstring autograft). RESULTS: A total of 69 professional baseball pitchers underwent revision UCL reconstruction from 2010 to 2016 at an average of 1424 days (47 months) after their primary surgery. A trend was seen toward increasing numbers of revision surgeries over time (R 2 = 0.441; P = .104). The most commonly used tunnel configuration was the modified Jobe technique (n = 41; 59.4%), and the most commonly used graft was hamstring autograft (n = 34; 49.3%). A majority (76.6%) of pitchers achieved RTP, and 55.3% were able to return to the same level of play. Mean time to RTP was 436 days (14.5 months) for players with a palmaris longus autograft versus 540 days (18 months) for those with a hamstring autograft (P = .108). Further, the mean time to RTP was 423 days (14 months) for the docking technique versus 519 days (17 months) for the modified Jobe technique (P = .296). Similar rates of subsequent injuries and surgeries were noted between the 2 revision techniques and 2 most commonly used graft constructs. CONCLUSION: Revision UCL reconstruction showed relatively high RTP rates (77%), but only 55% of players returned to their same level of play. Mean time to RTP was shorter than that found in other, smaller investigations. Although general trends were seen toward decreased time to RTP for the docking technique and palmaris longus autograft, these differences did not reach statistical significance.

Comparison of Outcomes Based on Graft Type and Tunnel Configuration for Primary Ulnar Collateral Ligament Reconstruction in Professional Baseball Pitchers.

BACKGROUND: Professional baseball pitchers are at high risk for tears of the ulnar collateral ligament (UCL) of the elbow, often requiring surgical reconstruction. Despite acceptable published return-to-play outcomes, multiple techniques and graft types have been described. PURPOSE: This study compares UCL reconstruction (UCLR) outcomes based on tunnel configuration and graft type. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: After approval from our institutional review board and Major League Baseball (MLB), 566 professional baseball pitchers who underwent UCLR between 2010 and 2014 were identified and included. The following patient characteristics were analyzed: age, pitching role (starter vs reliever), level of play (MLB vs Minor League Baseball [MiLB]), and throwing side dominance. Surgical factors analyzed included reconstruction technique, graft type, and concomitant procedures. Primary outcome measures consisted of the ability to return to play at any level (RTP), ability to return to the same level of play (RSL), time to return, subsequent elbow injuries, and need for subsequent or revision elbow surgery. The effects of patient and surgical factors on outcomes were analyzed using multivariate linear and logistic regression modeling. RESULTS: The RTP rate was 79.9%, and the RSL rate was 71.2%. Grafts used to reconstruct the UCL included the palmaris longus autograft (n = 361, 63.7%), the gracilis autograft (n = 135, 23.8%), and other grafts (n = 70, 12.5%). Surgical techniques utilized were the docking technique (n = 171, 30.2%), the modified Jobe technique (n = 290, 51.2%), and other techniques (n = 105, 18.6%). There were no significant differences in the time to RTP or RSL based on reconstruction technique or graft type. RTP rates were similar for the docking versus modified Jobe technique (80.1% vs 82.4%, respectively; P = .537) and for the 2 primary graft types (83.1% for palmaris longus vs 80.7% for gracilis; P = .596). The rate of subsequent elbow surgery was 10.5% for the docking technique versus 14.8% for the modified Jobe technique ( P = .203), and the rate of revision UCLR was 2.9% versus 6.2% for the docking versus modified Jobe technique, respectively ( P = .128). Significant trends toward an increasing use of the palmaris longus autograft ( P = .023) and the docking technique ( P = .006) were observed. MLB pitchers were more likely than MiLB pitchers to RTP ( P < .001) and RSL ( P < .001), but they required a longer time to return (mean difference, 35 days; P = .039) and had a higher likelihood of subsequent elbow (odds ratio [OR], 3.58 [95% CI, 2.06-6.23]; P < .001) and forearm injuries (OR, 5.70 [95% CI, 1.99-16.30]; P = .004) but not subsequent elbow surgery. No specific variables correlated with the rates of subsequent elbow surgery or revision UCLR in the multivariate analysis. The use of concomitant ulnar nerve transposition did not affect outcomes. CONCLUSION: Surgical outcomes in professional baseball players are not significantly influenced by UCLR technique or graft type. There was a high rate (46.3%) of subsequent throwing elbow injuries. MLB pitchers were more likely to RTP and RSL, but they had a higher frequency of subsequent elbow and forearm injuries than MiLB pitchers. Both the docking technique and the palmaris longus autograft are increasing in popularity among surgeons treating professional baseball players.

Elbow Injuries in the Adolescent Thrower.

PURPOSE OF REVIEW: With an increasing rate of adolescent elbow injuries, especially in throwing athletes, the purpose of this review is to investigate the current literature regarding the diagnosis, treatment, and non-operative and operative outcomes of medial epicondyle fractures, ulnar collateral ligament repair, osteochondritis dissecans of the elbow, and olecranon stress fractures. RECENT FINDINGS: Acceptable outcomes with both non-operative and operative treatments of medial epicondyle fractures have been reported, with surgical indications continuing to evolve. Unstable osteochondritis dissecans lesions, especially in patients with closed growth plates, require operative fixation, and emerging open and arthroscopic techniques including lesion debridement, marrow stimulation, autograft transfer, and allograft transplantation are described with good outcomes. Ulnar collateral repair has emerged as an exciting treatment option for an avulsion of either end of the ligament in young throwing athletes, with faster rehabilitation times than traditional ulnar collateral ligament reconstruction. Olecranon stress fractures are increasing in prevalence, and when a non-operative treatment course is unsuccessful, athletes have a high return-to-play rate after percutaneous cannulated screw placement. With proper indications, non-operative and operative treatment modalities are reported with a high return-to-play and acceptable clinical outcomes for common elbow injuries, including medial epicondyle fractures, ulnar collateral ligament repair, osteochondritis dissecans of the elbow, and olecranon stress fractures, in adolescent throwing athletes. Further research is needed to better define treatment algorithms, surgical indications, and outcomes.

Limited therapeutic benefits of intra-articular cortisone injection for patients with femoro-acetabular impingement and labral tear.

PURPOSE: Intra-articular (IA) hip cortisone injection is commonly performed as a therapeutic modality in patients with femoral acetabular impingement (FAI). To our knowledge, there is no published data evaluating the clinical benefit of these injections. The purpose of this study was to assess the efficacy of therapeutic IA cortisone injection in these patients. METHODS: At our institution, patients with FAI and labral tear prospectively recorded their numerical rating scale (NRS) pain scores pre-injection, during post-injection anaesthetic phase, and at 14 days post-injection. From this cohort, all patients treated with guided IA cortisone injection, no radiographic evidence of arthritis (Tönnis grade 0 or 1) and pain relief during the anaesthetic phase of the IA injection were included. An absolute change of two points on the NRS score was considered the minimal amount of clinically significant pain relief. Pain scores were compared between the different types of steroid injected. RESULTS: Fifty-four patients (35 females, 19 males) with a mean age of 32 ± 12 years were included. Average median pre-injection NRS score was 7.0 (range 2.5-10.0), post-injection anaesthetic phase was 1.0 (range 0.0-5.0), and 14 day post-injection was 5.0 (range 0.0-10.0). As a group, NRS scores significantly diminished from post-injection anaesthetic phase to 14 days post-injection (p < 0.001). At 14 days post-injection, only 20 patients (37 %) and at 6 weeks, only 3 patients (6 %) reported a clinically significant decrease in pain. Average duration of pain relief was 9.8 days. There was no difference in pain reduction between steroid preparations. CONCLUSION: In patients with symptomatic FAI and labral tear, intra-articular cortisone injection has limited clinical benefit as a therapeutic modality. However, anaesthetic-only IA injections for patients who may be candidates for hip arthroscopy can be a useful diagnostic tool.

Outcomes of repeat revision anterior cruciate ligament reconstruction.

BACKGROUND: As anterior cruciate ligament (ACL) reconstruction is performed increasingly in the United States, the rate of revision ACL reconstruction continues to rise. A paucity of literature exists with respect to repeat ACL revision surgery. PURPOSE: To evaluate the functional outcomes of patients who had undergone at least 2 revision ACL reconstructions. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The records of all patients who had undergone repeat revision ACL reconstructions between 1998 and 2009 were retrospectively reviewed. Data collected included patient demographics, operative findings, pre- and postoperative physical examination findings, radiographs, and Tegner, Lysholm, and International Knee Documentation Committee (IKDC) subjective scores. RESULTS: Fifteen patients had undergone repeat revision ACL reconstruction during the study period. Mean age was 27 years (range, 18-57 years). Mean follow-up was 5 years (range, 2-10 years). At the time of repeat revision surgery, new tunnels were drilled in 9 of 15 (60%) cases. Of those, 8 of 9 (89%) were drilled because femoral tunnels were deemed "too anterior." During repeat revision, 11 of 15 (73%) patients were noted to have a meniscal tear, and 9 of 15 (67%) had International Cartilage Repair Society (ICRS) grade 3 or 4 chondral lesions. Mean Lysholm score was 60 preoperatively and increased to 82 postoperatively (P < .001). Mean preoperative IKDC score was 59, which increased to 80 postoperatively (P < .001). Mean preoperative Tegner score was 6.0. Mean postoperative Tegner score was 4.5, with only 4 of 15 (27%) patients having returned to their prior activity level (P < .001). Two patients (13%) sustained a traumatic rerupture. Presence of grade 3 or 4 chondral lesions and body mass index greater than 28 at the time of repeat revision were associated with a "fair" or "poor" outcome by Lysholm score (P = .007 and P = .03, respectively) and IDKC subjective scoring (P = .04 and P = .007, respectively). CONCLUSION: Repeat revision ACL reconstruction may improve the functional outcomes of patients who have failed revision ACL reconstruction. Most patients do not return to prior activity level following repeat revision. Presence of grade 3 or 4 chondral lesions and body mass index greater than 28 were associated with worse outcomes.