Predictors of Clinical Outcomes After Proximal Hamstring Repair.

BACKGROUND: Proximal hamstring avulsions cause considerable morbidity. Operative repair results in improved pain, function, and patient satisfaction; however, outcomes remain variable. PURPOSE: To evaluate the predictors of clinical outcomes after proximal hamstring repair. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We retrospectively reviewed proximal hamstring avulsions repaired between January 2014 and June 2017 with at least 1-year follow-up. Independent variables included patient demographics, medical comorbidities, tear characteristics, and repair technique. Primary outcome measures were the Single Assessment Numerical Evaluation (SANE), International Hip Outcome Tool-12 (iHOT-12), and Kerlan-Jobe Orthopaedic Clinic (KJOC) Athletic Hip score. Secondary outcome measures included satisfaction, visual analog scale for pain, Tegner score, and timing of return to sports. RESULTS: Of 102 proximal hamstring repairs, 86 were eligible, 58 were enrolled and analyzed (67%), and patient-reported outcomes were available for 45 (52%), with a mean 29-month follow-up. The mean patient age was 51 years, and 57% were female. Acute tears accounted for 66%; 78% were complete avulsions. Open repair was performed on 90%. Overall satisfaction was 94%, although runners were less satisfied compared with other athletes (P = .029). A majority of patients (88%) returned to sports by 7.6 months, on average, with 72% returning at the same level. Runners returned at 6.3 months, on average, but to the same level 50% of the time and at a decreased number of miles per week compared to nonrunners (15.7 vs 7.8, respectively; P < .001). Postoperatively, 78% had good/excellent SANE Activity scores, but the mean Tegner score decreased (from 5.5 to 5.1). Acute tears had higher SANE Activity scores. The mean iHOT-12 and KJOC scores were 99 and 77, respectively. Endoscopic repairs had equivalent outcome scores to open repairs, although conclusions were limited given the small number of patients in the endoscopic group. Greater satisfaction was noted in patients older than 50 years (P = .024), although they were less likely to return to running (P = .010). CONCLUSION: Overall, patient satisfaction and functionality were high. With the numbers available, we were unable to detect any significant differences in functional outcome scores based on patient age, sex, body mass index, smoking status, medical comorbidities, tear grade, activity level, or open versus endoscopic technique. Acute tears had better SANE Activity scores. Runners should be cautioned that they may be unable to return to the same preinjury activity level after proximal hamstring repair. CLINICAL RELEVANCE: When counseling patients with proximal hamstring tears, runners and those with chronic tears should set appropriate expectations.

Major League Baseball Pitching Performance After Tommy John Surgery and the Effect of Tear Characteristics, Technique, and Graft Type.

BACKGROUND: Return to play and player satisfaction have been quite high after ulnar collateral ligament reconstruction (UCLR); however, there has been little reported on how outcomes are affected by surgical technique, graft type, and tear characteristics. PURPOSE: To evaluate surgical techniques, graft type, and tear characteristics on Major League Baseball (MLB) performance after UCLR. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: MLB pitchers who underwent primary UCLR at a single institution were included. Tear characteristics included tear location, tear grade, and acuity. Surgical technique and graft type were also collected. Pitching performance statistics, including earned run average (ERA), walks and hits per innings pitched (WHIP), innings pitched, and fastball velocity were evaluated 3 years before and after UCLR. RESULTS: Forty-six MLB pitchers were identified as having primary UCLR. Return to play was 96%, with 82% returning to MLB play. Technique performed showed no difference in performance. As compared with pitchers with gracilis grafts, pitchers with palmaris grafts were younger ( P = .043), played longer after surgery ( P = .012), and returned to play at 100% (35 of 35) versus 82% (9 of 11, P = .010). When compared with pitchers with proximal tears, pitchers with distal tears pitched at higher velocity (93.0 vs 90.6 mph, P = .023) and had better performance before surgery (ERA, P = .003; WHIP, P = .021); however, those with proximal tears improved to match this performance and velocity after reconstruction. As compared with those having partial tears, pitchers with complete tears played longer after surgery (5.9 vs 4.0 years, P = .033), had a better ERA before injury ( P = .041), and had better WHIP ( P = .037) and strikeouts per 9 innings ( P = .025) after reconstruction. Pitchers with chronic tears had a significant improvement in postoperative ERA, from 4.49 to 3.80 ( P = .040). CONCLUSION: Technique performed and graft type used did not affect performance; however, pitchers with palmaris grafts returned at a higher rate than those with gracilis grafts. Distal tears occurred in pitchers with greater velocity and better performance before injury, yet pitchers with proximal tears matched this performance after reconstruction. Pitchers with complete tears played longer after reconstruction. Pitchers who had partial tears had worse performance before injury and after reconstruction, and those with chronic tears saw a significant improvement in ERA with reconstruction.

Medial Elbow Pain During the Return-to-Throwing Period After Ulnar Collateral Ligament Reconstruction in Pitchers.

BACKGROUND: Ulnar collateral ligament reconstruction (UCLR) is common in the sport of baseball, particularly among pitchers. Postoperative return-to-sport protocols have many players beginning to throw at 4 to 5 months and returning to full competition between 12 and 16 months after surgery. Medial elbow pain during the return-to-throwing period often occurs and can be difficult to manage. PURPOSE: To evaluate the incidence of medial elbow pain and associations with outcomes and revision surgery during the return-to-throwing period after UCLR. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Between the years of 2002 and 2014, all pitchers who underwent UCLR at a single institution were identified. Charts were reviewed for incidence of medial elbow pain during return to throwing, return to sport, and subsequent operative interventions, including revision ulnar collateral ligament surgery. RESULTS: Of a total of 616 pitchers who underwent UCLR during the study period, 317 were included in this study. Medial elbow pain was experienced by 45.1% (143 of 317), with a mean time of complaint of 9.75 months after surgery. The groups with and without pain did not differ statistically with regard to age (pain, 20.6 years; no pain, 20.9 years) or level of competition. Of those who experienced medial elbow pain, 10.5% did not return to sport; 5.6% underwent revision UCLR; and 19.6% underwent other operative procedures at the elbow. Among those who did not experience medial elbow pain when returning to throw, 8.7% did not return to sport, with only 1.7% undergoing revision UCLR and 6.9% undergoing other operative elbow procedures. CONCLUSION: Of the pitchers evaluated in the study, approximately half reported pain during the return-to-throwing phase after UCLR. Those who experienced medial elbow pain had a higher rate of subsequent surgical intervention.

Pitching Performance After Ulnar Collateral Ligament Reconstruction at a Single Institution in Major League Baseball Pitchers.

BACKGROUND: Ulnar collateral ligament (UCL) reconstruction (UCLR) has shown reliable rates of return to play, with conflicting results on pitching performance after players' return. PURPOSE: To evaluate Major League Baseball (MLB) pitching performance before and after UCLR performed at a single institution. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: MLB pitchers (minor league players were excluded) who underwent UCLR at our institution between 2002 and 2016 were identified. Player information and return to play were determined including pitching level (MLB vs minor league) and total number of years played after surgery. Pitching performance statistics were evaluated for 3 years before surgery and for 3 years after returning to play including earned run average (ERA), walks plus hits per inning pitched (WHIP), innings pitched, wins above replacement, runs above replacement, and pitch velocity. RESULTS: A total of 54 MLB pitchers were identified, with 46 primary and 8 revision reconstructions. The mean time to return to play was 13.8 months (primary reconstruction: 13.7 months). The majority returned to play with a 94% return rate (primary reconstruction: 96%), and 80% returned to MLB play (primary reconstruction: 82%). Three primary reconstructions required revision surgery. Pitchers played a mean of 3.2 years in MLB and 4.6 years total after surgery (39% still playing). Pitching workload and performance were maintained or improved after surgery. The preoperative ERA was 4.63 versus 4.13 after returning to play ( P = .268). Fastball velocity ( P = .032), ERA ( P = .003), and WHIP ( P = .001) worsened the first year after surgery and then improved the second year (ERA: 4.63 to 4.06 [ P = .380]; WHIP: 1.35 to 1.32 [ P = .221]; fastball velocity: 91.3 to 91.9 mph [ P = .097]). Compared with a matched control group, pitchers who had UCLR showed improvements or maintained performance after reconstruction including improved ERA ( P = .007), WHIP ( P = .025), and fastball velocity ( P = .006). CONCLUSION: MLB players experienced a high rate of return to play and previous level of play after UCLR. Pitching workload was maintained after returning to play. Pitching performance initially decreased the first year after returning and then improved or reverted to previous levels after the first year from UCLR.

Infection and Rerupture After Surgical Repair of Achilles Tendons.

BACKGROUND: Surgical repair of an Achilles tendon rupture has been shown to decrease rerupture rates. However, surgery also increases the risk of complications, including infection. PURPOSE: To determine the risk factors for infection and rerupture after primary repair of Achilles tendon ruptures. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective review was performed on 423 patients who underwent operative treatment of Achilles tendon ruptures between the years 2008 and 2014. The primary outcome of interest was the total rate of infection, and the secondary outcome of interest was the incidence of rerupture within 2 years of operation. RESULTS: A total of 423 patients were analyzed, with a mean age of 46 years (range, 16-83 years) and a mean body mass index of 31.4 kg/m2 (range, 17-55 kg/m2). The overall infection rate was 2.8%, and the rerupture rate was 1%. The median time between surgery and superficial surgical site infection was 30 days, and the median time between surgery and rerupture was 38 days. Longer tourniquet times (100.3 ± 34.7 minutes vs 69.9 ± 21.4 minutes; P = .04) and greater estimated blood loss (15.0 ± 9.1 mL vs 5.1 ± 12.0 mL; P = .01) were associated with an increased rate of deep surgical site infections. Patients who had longer operation and tourniquet times trended toward higher rerupture rates (P = .06 and .08, respectively). When compared with nonsmokers, current and previous smokers had an increased incidence of superficial or deep surgical site infections (6.25% vs 1.42%; P = .02). Age, sex, race, body mass index, alcohol use, diabetes, past steroid injections, and mechanism of injury did not contribute to complication rates. CONCLUSION: Achilles tendon repairs were associated with a low risk of infection and rerupture. Patients with longer tourniquet times, higher estimated blood loss, and a history of smoking were at increased risk for surgical site infections. Patients with longer operative times had increased rates of rerupture.

The Effect of Intraoperative Hypothermia on Shoulder Arthroplasty.

Limited evidence is available regarding the correlation between intraoperative hypothermia and perioperative complications in shoulder arthroplasty. The purpose of this study was to determine the incidence of intraoperative hypothermia in patients treated with shoulder arthroplasty and its effect on perioperative complications. A retrospective chart review was performed on 657 consecutive patients who underwent shoulder arthroplasty at a single institution between August 2013 and June 2016. Demographic data, surgery-specific data, postoperative complications, length of stay, and 30-day read-mission were recorded. Patients were classified as hypothermic if their mean intraoperative temperature was less than 36°C. Statistical analyses with univariate and multivariate logistic regression were performed to evaluate the association of intraoperative hypothermia with perioperative complications. The incidence of intraoperative hypothermia in shoulder arthroplasty was 52.7%. Increasing age (P=.002), lower body mass index (P=.006), interscalene anesthetic (P=.004), and lower white blood cell count (P<.001) demonstrated increased association with hypothermia. Longer operating room times and increased estimated blood loss were not found to be associated with intraoperative hypothermia. Hypothermia demonstrated no significant association with surgical site infections nor any other perioperative complications. Patients undergoing shoulder arthroplasty showed a high incidence of intraoperative hypothermia. Lower body mass index, increasing age, interscalene anesthetic, and lower white blood cell count were associated with an increased incidence of hypothermia. Contrary to previous studies, intraoperative hypothermia was not found to contribute to perioperative complications in shoulder arthroplasty. [Orthopedics. 2018; 41(4):e523-e528.].

Epidemiology, Workload, and Performance of Major League Baseball Pitchers Placed on the Disabled List.

There is limited information on the effect of pitcher workload, pitch type, and performance of Major League Baseball pitchers placed on the disabled list (DL). This study evaluated demographic, performance, workload, and injury data of 330 Major League Baseball pitchers with 454 injuries who were placed on the DL during the 2014 and 2015 seasons. Upper extremity, lower extremity, core, hip/groin, and other injuries were analyzed, and injury year data were compared with career data as well as against other injury groups. Upper extremity injuries represented 60% of injuries and a mean of 61.4 (SE, 2.6) days on the DL, while lower extremity and core injuries each represented 14% of all injuries. Players with upper extremity injuries returned to play the same season at the lowest rate (67.3%). Starters pitched more mean innings per game (5.31 vs 5.14 innings, P=.012) and threw more mean pitches per game (85.9 vs 82.4 pitches, P=.003) the year of injury compared with their career. There was a decrease in mean fastball velocity (92.2 vs 91.6 mph, P<.001) and percentage of fastballs thrown (60.3% vs 58.5%, P<.001) the year of injury for all injuries. The authors found that upper extremity injuries are the most common, require the most time on the DL, and have the lowest same season return to play rate. Starters pitched significantly more innings and threw more pitches during the year of injury. Pitchers were found to have a decrease in fastball velocity and percentage of fastballs thrown during the year of injury. [Orthopedics. 2018; 41(3):178-183.].

Performance, Return to Play, and Career Longevity After Ulnar Collateral Ligament Reconstruction in Professional Catchers.

PURPOSE: The purpose of our study was to evaluate return to play and postinjury performance of professional catchers who sustained an ulnar collateral ligament (UCL) rupture requiring surgical reconstruction. We looked to evaluate these players to determine the rate of return to play, the level of return to play, and career longevity after surgery as well as how statistical performance is affected by reconstruction. METHODS: Twenty-five professional catchers who underwent UCL reconstruction between 1985 and 2015 were identified and compared with an age-, position-, and competition-matched control group. Priority was placed on level of play, year of injury, age, and years played prior to injury in matching controls. Injury information and demographic data (age at injury, level of play, and career length) were collected from publicly available team websites and press releases. Offensive and defensive performance statistics were collected for 3 years prior to injury and 3 years after return. Return to play, return to level of play, and career after return were also analyzed. RESULTS: The average age at time of UCL injury was 24.4 (standard deviation, 4.5) years old. Return to play for all catchers was 80% (20/25), with only one player not returning to the same previous level of play (95%). Average years in Major League Baseball (MLB) after return was 2.3 years versus 2.6 years in the control group (P = .07), with 4.3 years total (MLB and minors) versus 3.8 years total in the control group (P = .28). There were no changes in offensive or defensive performance before and after injury. CONCLUSIONS: UCL reconstruction in professional catchers can lead to successful outcomes. Catchers can expect a high rate of return to play with high rate of return to previous level of play, similar performance, and no change in career longevity following return from UCL reconstruction. STUDY DESIGN: Level III, case-control series.

Implications of Core and Hip Injuries on Major League Baseball Pitchers on the Disabled List.

PURPOSE: To investigate the frequency of core and hip injuries in Major League Baseball (MLB) pitchers and their impact on performance, workload, and pitch type. METHODS: Demographic, performance data, and injury data were acquired for 330 MLB pitchers with 454 injuries placed on the disabled list (DL) from 2014 to 2015 seasons. Core and hip/groin injuries were analyzed in which injury year data were compared with career data and against other injury groups. RESULTS: Core injuries represented 14% of all injuries and hip/groin injuries represented 7%. Average days on the DL for core injuries were 47.0 (standard deviation 5.6) days and 37.7 (standard deviation 8.1) days for hip/groin injuries. Return from the DL the same season for core injuries was 78% and 73% for hip/groin injuries. Core injuries returned to the DL 46% of the time (73% for noncore injuries) and hip/groin returned 56% of the time (60% for nonhip/groin injuries). No changes in workload were noted except starters with core injuries pitched less innings/game (5.3 vs 4.9 innings/game, P = .031) and more pitches/game (85.5 vs 78.4 pitches, P = .026). Fastball velocity decreased in the core injury group the year of injury (91.6 vs 92.2 mph, P = .001). Core injuries had slightly fewer home runs/9 innings and fewer strikeouts/9 innings; hip/groin injuries had slightly more strikeouts/9 innings, with all other performance statistics no different between the groups including earned run average and wins above replacement. CONCLUSIONS: Core and hip injuries in MLB pitchers result in similar time on the DL compared with other injuries. Pitching workload during the year of injury does not seem to have a significant impact on sustaining a core or hip injury. Although there is a high rate of return to play from the DL, there is a high rate of reinjury in these pitchers more often for other injuries. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Single-Shot Femoral Nerve Block Does Not Cause Long-Term Strength and Functional Deficits Following Anterior Cruciate Ligament Reconstruction.

PURPOSE: To determine if patients treated with a single-shot femoral nerve block have strength and functional deficits at 9-month follow-up. METHODS: Forty-three patients who underwent primary anterior cruciate ligament reconstructions were randomized to receive either a preoperative single-shot femoral nerve block or local infiltration anesthesia for primary pain control. All patients underwent a standardized comprehensive rehabilitation program postoperatively. Isokinetic strength and function was tested using a Biodex machine at 9 months or more postoperatively comparing the operative and nonoperative extremity. RESULTS: No significant difference in strength was found at an average of 10.6 months postoperatively (range, 9-15 months) between the femoral nerve block and control groups. In comparing strength deficits, we found no difference in slow isokinetic extension strength (22.4% vs 27.8%, P = .51), fast isokinetic extension strength (18.5% vs 12.5%, P = .41), slow isokinetic flexion strength (11.0% vs 15.1%, P = .55), and fast isokinetic flexion strength (8.2% vs 4.9%, P = .56) in the femoral nerve block versus control groups, respectively. In terms of functional outcomes, there also was no difference in deficits for single-leg hop distance (P = .12), timed single-leg hop (P = .74), and single-leg triple hop distance (P = .94). Maximal strength noted to be within 15% of the contralateral limb was achieved in 40% of patients and maximal function in 63% of patients at an average of 10.6 months postoperatively. A 13% complication rate was found in patients who received a femoral nerve block (1 with prolonged quadriceps inhibition and 2 with prolonged sensory disturbances). CONCLUSIONS: Our study found a 13% motor/sensory complication rate in patients who underwent femoral nerve block for pain control after anterior cruciate ligament reconstruction. Although these deficits may persist, they are not permanent and are not different when compared with controls at 9-month follow-up. However, maximal strength and function are not fully restored at normal return to play time and rehabilitation should continue long term to maximize recovery. LEVEL OF EVIDENCE: Level I, prospective randomized trial.

Return to play after shoulder instability in National Football League athletes.

HYPOTHESIS: We hypothesized that National Football League (NFL) players sustaining a shoulder destabilizing injury could return to play (RTP) successfully at a high rate regardless of treatment type. METHODS: We identified and evaluated 83 NFL players who sustained an in-season shoulder instability event while playing in the NFL. NFL RTP, incidence of surgery, time to RTP, recurrent instability events, seasons/games played after the injury, and demographic data were collected. Overall RTP was determined, and players who did and did not undergo operative repair were compared. RESULTS: Ninety-two percent of NFL players returned to NFL regular season play at a median of 0.0 weeks in those sustaining a shoulder subluxation and 3.0 weeks in those sustaining a dislocation who did not undergo surgical repair (P = .029). Players who underwent operative repair returned to play at a median of 39.3 weeks. Forty-seven percent of players had a recurrent instability event. For players who were able to RTP, those who underwent surgical repair (31%) had a lower recurrence rate (26% vs. 55%, P = .021) and longer interval between a recurrent instability event after RTP (14.7 vs. 2.5 weeks, P = .050). CONCLUSION: There is a high rate of RTP after shoulder instability events in NFL players. Players who sustain shoulder subluxations RTP faster but are more likely to experience recurrent instability than those with shoulder dislocations. Surgical stabilization of the shoulder after an instability event decreases the chances of a second instability event and affords a player a greater interval between the initial injury and a recurrent event.

Major League pitching workload after primary ulnar collateral ligament reconstruction and risk for revision surgery.

BACKGROUND: Literature has attempted to correlate pitching workload with risk of ulnar collateral ligament (UCL) injury; however, limited data are available in evaluating workload and its relationship with the need for revision reconstruction in Major League Baseball (MLB) pitchers. METHODS: We identified 29 MLB pitchers who underwent primary UCL reconstruction surgery and subsequently required revision reconstruction and compared them with 121 MLB pitchers who underwent primary reconstruction but did not later require revision surgery. Games pitched, pitch counts, and innings pitched were evaluated and compared for the seasons after returning from primary reconstruction and for the last season pitched before undergoing revision surgery. RESULTS: The difference in workload between pitchers who did and did not require revision reconstruction was not statistically significant in games pitched, innings pitched, and MLB-only pitch counts. The one significant difference in workload was in total pitch counts (combined MLB and minor league), with the pitchers who required revision surgery pitching less than those who did not (primary: 1413.6 pitches vs. revision: 959.0 pitches, P = .04). In addition, pitchers who required revision surgery underwent primary reconstruction at an early age (22.9 years vs. 27.3 years, P < .001) and had less MLB experience (1.5 years vs. 5.0 years, P < .001). CONCLUSIONS: There is no specific number of pitches, innings, or games that place a pitcher at an increase risk for injury after primary UCL reconstruction. However, correlations of risk may be younger age and less MLB experience at the time of the primary reconstruction.

Radiostereometric Evaluation of Tendon Elongation After Distal Biceps Repair.

BACKGROUND: Operative repair of distal biceps tendon ruptures has shown successful outcomes. However, little is known about the amount of tendon or repair site lengthening after repair. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate distal biceps tendon repair via intratendinous radiostereometric analysis to analyze tendon lengthening at different time intervals of healing. The hypothesis was that there is significant lengthening after repair. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Eleven patients with distal biceps ruptures requiring operative repair were recruited. During repair, two 2-mm tantalum beads with laser-etched holes were sutured to the distal biceps tendon. Beads were evaluated via computed tomography scans immediately postoperatively and at 16 weeks. Radiographs were obtained at time 0 and then at 4, 8, and 16 weeks postoperatively. Measurements were made using the button-to-bead and bead-to-bead distances to assess repair site elongation as well as tendon elongation over time. After final follow-up, patients filled out the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and underwent ultrasound to confirm the integrity of the tendon. RESULTS: Ten patients had complete ruptures, with 1 having a partial rupture that underwent completion of the tear and subsequent repair. All patients showed statistically significant lengthening after surgery. The mean amount of tendon lengthening after surgery was 22.8 mm (range, 11.2-30.9 mm; P < .05), and the repair site lengthened a mean 17.0 mm (range, 9.6-30.6 mm; P < .05) from surgery to final follow-up. The greatest change in lengthening was noted between time 0 and week 4 (mean, 11.3 mm; P < .05), with the least amount of lengthening between weeks 8 and 16 (mean, 2.6 mm; P < .05). The mean DASH score was 11.2. Final ultrasound evaluations found all tendons to be in continuity. CONCLUSION: All patients undergoing distal biceps tendon repair have significant elongation after surgery, with the greatest amount of lengthening seen in the early postoperative period.

Patient Perceptions of Reimbursement for Arthroscopic Meniscectomy and Anterior Cruciate Ligament Reconstruction.

Historically, patient perceptions of surgeon reimbursement have been exaggerated compared with actual reimbursement. There is limited information about patient perceptions of physician reimbursement for arthroscopic meniscectomy and anterior cruciate ligament (ACL) reconstruction. This study evaluated patient perceptions of physician reimbursement for these procedures and compared perceptions of health care reform between urban and suburban clinics. Surveys were given to 231 consecutive patients, and patients were asked how much they believed a surgeon should be reimbursed for arthroscopic meniscectomy and ACL reconstruction as well as their perception of actual Medicare reimbursement to physicians. Patients were then informed of the actual reimbursement rates and asked additional questions about health care reform. Survey responses were compared in an urban setting vs a suburban setting. On average, patients reported that surgeons should receive $8096 for meniscectomy and $11,794 for ACL reconstruction. Patients estimated that Medicare paid physicians $5442 for meniscectomy and $6667 for ACL reconstruction. In addition, 65% of patients believed that reimbursement for meniscectomy was too low, and 57% of patients believed that reimbursement for ACL reconstruction was too low. Fewer than 2% of patients believed that surgeon salaries should be cut, and 75% believed that orthopedic surgeons should be paid more for subspecialty training. No differences were found in patients' perceptions of reimbursement or health care reform between urban and suburban settings. Patients perceived that the values of meniscectomy and ACL reconstruction were substantially higher than current Medicare reimbursement values and that surgeon salaries should not be cut. [Orthopedics. 2016; 39(5):e904-e910.].

Liposomal Bupivacaine Versus Femoral Nerve Block for Pain Control After Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Trial.

PURPOSE: To compare femoral nerve block (FNB) versus local liposomal bupivacaine (LB) for pain control in patients undergoing anterior cruciate ligament (ACL) reconstruction. METHODS: Eighty-five patients undergoing primary ACL reconstruction were assessed for participation. We performed a prospective randomized trial in accordance with the CONSORT (Consolidated Standards of Reporting Trials) 2010 statement. The study arms included either intraoperative local infiltration of LB (20 mL of bupivacaine/10 mL of saline solution) or preoperative FNB with a primary outcome of postoperative pain levels (visual analog scale) for 4 days. Secondary outcomes assessed included opioid consumption (intravenous morphine equivalents), hours slept, patient satisfaction, and calls to the physician. Randomization was by a computerized algorithm. The observer was blinded and the patient was not blinded to the intervention. RESULTS: One patient declined participation; 2 patients were excluded after randomization. A total of 82 patients were analyzed. Outcomes showed a significant increase in pain in the LB group between 5 and 8 hours postoperatively (mean ± standard deviation, 6.3 ± 2.0 versus 4.8 ± 2.6; P = .01). There were no significant differences between the groups in mean daily pain levels, morphine equivalents, or patient satisfaction when we controlled for graft type, age, body mass index, and sex. Patients receiving an FNB had a nonsignificant increase in number of sleep disturbances on the day of surgery (mean ± standard deviation, 4.4 ± 3.7 v 3.1 ± 2.1; P = .09) and were more likely to call their doctor the following day because of pain (29% v 8%, P = .04). Six patients in the FNB group had either prolonged quadriceps inhibition or sensory disturbance. One patient in the LB group required reoperation for a flexion contracture. CONCLUSIONS: An increase in acute postoperative pain was found with LB compared with FNB for post-ACL reconstruction pain control. After the acute postoperative period, there were no significant differences in opioid consumption or pain control. The occurrence of nerve irritation postoperatively was found to be higher in the FNB group. LEVEL OF EVIDENCE: Level I, prospective randomized trial.

Major League Baseball pitch velocity and pitch type associated with risk of ulnar collateral ligament injury.

BACKGROUND: The number of Major League Baseball (MLB) pitchers requiring ulnar collateral ligament (UCL) reconstructions is increasing. Recent literature has attempted to correlate specific stresses placed on the throwing arm to risk for UCL injury, with limited results. METHODS: Eighty-three MLB pitchers who underwent primary UCL reconstruction were evaluated. Pitching velocity and percent of pitch type thrown (fastball, curve ball, slider, and change-up) were evaluated 2 years before and after surgery. Data were compared with control pitchers matched for age, position, size, innings pitched, and experience. RESULTS: The evaluation of pitch velocity compared with matched controls found no differences in pre-UCL reconstruction pitch velocities for fastballs (91.5 vs. 91.2 miles per hour [mph], P = .69), curveballs (78.2 vs. 77.9 mph, P = .92), sliders (83.3 vs. 83.5 mph, P = .88), or change-ups (83.9 vs. 83.8 mph, P = .96). When the percentage of pitches thrown was evaluated, UCL reconstructed pitchers pitch significantly more fastballs than controls (46.7% vs. 39.4%, P = .035). This correlated to a 2% increase in risk for UCL injury for every 1% increase in fastballs thrown. Pitching more than 48% fastballs was a significant predictor of UCL injury, because pitchers over this threshold required reconstruction (P = .006). CONCLUSION: MLB pitchers requiring UCL reconstruction do not pitch at higher velocities than matched controls, and pitch velocity does not appear to be a risk factor for UCL reconstruction. However, MLB pitchers who pitch a high percentage of fastballs may be at increased risk for UCL injury because pitching a higher percent of fastballs appears to be a risk factor for UCL reconstruction.

Ulnar Collateral Ligament and Elbow Adaptations in High School Baseball Pitchers.

BACKGROUND: Baseball pitchers have adaptive changes in the soft tissues of the throwing elbow. HYPOTHESIS: High school baseball pitchers would show adaptive changes in the ulnar collateral ligament (UCL), such as calcifications and hypoechoic foci, thickening, and increased ulnohumeral joint laxity, on dynamic ultrasound (DUS). STUDY DESIGN: Cross-sectional study. LEVEL OF EVIDENCE: Level 3. METHODS: Twenty-two asymptomatic high school pitchers, designated as their primary position by their coach, underwent DUS and physical examination of the throwing and nonthrowing elbows prior to the start of the season. UCL substance consistency and thickness, ulnohumeral joint space widening, and soft tissue elbow structures were evaluated. RESULTS: The mean age of the cohort was 16.9 years. Calcifications of the UCL were similar, being present in 7 of 22 (32%) throwing elbows versus 8 of 22 (36%) nonthrowing elbows (P = 0.11). UCL hypoechoic foci also were similar between elbows: 2 of 22 (9%) throwing elbows versus 0 of 22 nonthrowing elbows (P = 0.11). UCL thickness was also found to be similar in both elbows (throwing arm, 6.54 mm vs nonthrowing, 6.71 mm; P = 0.48). Ulnohumeral joint laxity unloaded (throwing arm, 3.13 mm vs nonthrowing, 3.17 mm; P = 0.835) and loaded (throwing arm, 3.87 mm vs nonthrowing arm, 4.11 mm; P = 0.30) was similar between elbows. Throwing elbows showed posteromedial olecranon spurring in 36%, effusions in 27%, and synovitis in 9%. CONCLUSION: High school pitchers show limited adaptive changes in the elbow, including UCL calcifications, hypoechoic foci, posteromedial olecranon spurring, and effusions. However, these changes are similar to those seen in the nonthrowing elbow, and these younger athletes lack findings seen in professional and collegiate pitchers such as UCL thickening and increased ulnohumeral joint space laxity. CLINICAL RELEVANCE: Preseason ultrasound examination of the high school pitching elbow lacks the adaptive changes to the elbow as seen in professional pitchers. These changes likely occur later in a pitcher's career.

Athletic Performance at the NFL Scouting Combine After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Anterior cruciate ligament (ACL) injuries are common and potentially career ending in the National Football League (NFL). Although statistical performance has been demonstrated after ACL reconstruction, functional performance is not well defined. PURPOSE/HYPOTHESIS: The purpose of this study was to determine the functional performance of NFL combine participants after ACL reconstruction compared with an age-, size-, and position-matched control group. The hypothesis was that there would be no difference between players after ACL reconstruction as compared with controls in functional athletic performance. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 98 NFL-caliber athletes who had undergone primary ACL reconstruction and participated in the NFL scouting combine between 2010 and 2014 were reviewed and compared with an age-, size-, and position-matched control group. Data recorded for each player included a 40-yard dash, vertical leap, broad jump, shuttle drill, and 3-cone drill. RESULTS: With regard to speed and acceleration, the mean 40-yard dash time for ACL-reconstructed players was 4.74 seconds (range, 4.33-5.55 seconds) compared with controls at 4.74 seconds (range, 4.34-5.38 seconds; P = .96). Jumping performance was also similar, with a mean vertical leap for ACL-reconstructed players of 33.35 inches (range, 23-43 inches) and broad jump of 113.9 inches (range, 96-136 inches) compared with respective values for the controls of 33.22 inches (range, 23.5-43.5 inches; P = .84) and 113.9 inches (range, 92-134 inches; P = .99). Agility and quickness testing measures also did not show a statistically significantly difference, with ACL-reconstructed players performing the shuttle drill in 4.37 seconds (range, 4.02-4.84 seconds) and the 3-cone drill in 7.16 seconds (range, 6.45-8.14 seconds), respectively, compared with respective times for the controls of 4.37 seconds (range, 3.96-5.00 seconds; P = .91) and 7.18 seconds (range, 6.64-8.24 seconds; P = .75). CONCLUSION: This study suggests that after ACL reconstruction, high-caliber athletes can achieve equivalent levels of performance with no statistically significant differences compared with matched controls. This information is unique when advising high-level athletes on athletic performance after ACL reconstruction, suggesting that those who fully recover and return to play appear to have no decrement in athletic performance.

Pre- and Postseason Dynamic Ultrasound Evaluation of the Pitching Elbow.

PURPOSE: To use ultrasound imaging to document changes over time (i.e., preseason v postseason) in the pitching elbow of high school baseball pitchers. METHODS: Twenty-two high school pitchers were prospectively followed. Pitchers were evaluated after a 2-month period of relative arm rest via preseason physical exams, dynamic ultrasound imaging of their throwing elbow, and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) assessment. Players were reevaluated within 1 week of their last game. Dynamic ultrasound images were then randomized, blinded to testing time point, and evaluated by 2 fellowship-trained musculoskeletal radiologists. RESULTS: Average pitcher age was 16.9 years. Average pitches thrown was 456.5, maximum velocity 77.7 mph, games pitched 7.3, and days off between starts 6.6. From preseason to postseason, there were significant increases in ulnar collateral ligament (UCL) thickness (P = .02), ulnar nerve cross-sectional area (P = .001), UCL substance heterogeneity (P = .001), and QuickDASH scores (P = .03). In addition, there was a nonsignificant increase in loaded ulnohumeral joint space (P = .10). No pitchers had loose bodies on preseason exam, while 3 demonstrated loose bodies postseason. The increase in UCL thickness was significantly associated with the number of bullpen sessions per week (P = .01). The increase in ulnar nerve cross-sectional area was significantly associated with the number of pitches (P = .04), innings pitched (P = .01), and games pitched (P = .04). CONCLUSIONS: The stresses placed on the elbow during only one season of pitching create adaptive changes to multiple structures about the elbow including UCL heterogeneity and thickening, increased ulnohumeral joint space laxity, and enlarged ulnar nerve cross-sectional area. LEVEL OF EVIDENCE: Level II prospective observational study.

Pitching Speed and Glenohumeral Adaptation in High School Pitchers.

Glenohumeral internal rotational deficit and increased glenohumeral external rotation are common findings in baseball pitchers. To the authors' knowledge, no study has focused on the adaptation of glenohumeral internal rotational deficit and increased glenohumeral external rotation in relation to pitching speed. This study evaluated changes in range of motion in the throwing shoulder in high school pitchers to determine whether changes in internal and external rotation directly correlate with pitch velocity. The shoulders of 22 high school varsity pitchers were evaluated. Standard goniometric technique was used to measure passive external and internal glenohumeral range of motion in both arms. Measurements were evaluated for statistically significant differences in range of motion. Demographic features, including height, weight, and age, were assessed. Fifteen consecutive in-game pitch speeds were recorded, and the fastest pitch was used for evaluation. Pitch speeds were correlated to the player's glenohumeral internal rotational deficit, increased glenohumeral external rotation, and physical demographics. Average age was 16.9 years. Average external rotation of the throwing arm was significantly greater than that of the nonthrowing arm (143.00° vs 130.32°, P=.005). Average internal rotation of the throwing arm was significantly less than that of the nonthrowing arm (49.50° vs 65.90°, P=.006). Both shoulders had similar total arc of motion (throwing shoulder, 192.54; nonthrowing shoulder, 196.23; P=.822). Average maximum velocity was 77.7 mph (maximum, 88 mph; minimum, 66 mph). Maximum pitch velocity did not correlate with changes in glenohumeral internal rotational deficit (P=.683) or increased glenohumeral external rotation (P=.241). There was also no evidence of correlation between pitch velocity and player age, height, weight, or dominant hand. The stress of pitching creates adaptations to the throwing shoulder, even in young athletes. There appears to be no significant correlation with a pitcher's maximum velocity and the amount of adaptation in shoulder range of motion.