Brandon C. Cabarcas

Radiographic Predictors of Elbow Injury and Surgery in Major League Baseball Pitchers

Objectives: To evaluate predictive ability of asymptomatic screening MRI’s of Major League Baseball (MLB) pitchers and compare associated findings with future DL placement, pitching statistics, and elbow surgery. Methods: A total of 40 consecutive asymptomatic elbow MRI’s in MLB pitchers at a single organization were analyzed from 2005 - 2017. Asymptomatic MRI was defined as a screening MRI at time of contract signing having been performed at least 6 months prior to DL placement for any elbow-related injury. Publicly available DL data, career innings pitched, career games started, career pitch count, and career max velocity of pitch were obtained. A blinded investigator examined each MRI for pathological signals. Data was analyzed on players that were eventually placed on the DL compared to those with no DL placement. Results: 40 consecutive elbow MRIs of MLB players were reviewed. The average age of the injured cohort was 28.3 ± 3.2 years (16 players) and 28.8 ± 5.5 years (24 players) for the non-injured cohort. There was no statistical difference in age, handedness, height, weight, or pitching stats between the injured and non-injured cohorts. Abnormal radiographic signal intensity in the UCL (p<0.001) and humeral elevation of the UCL (p=0.01) were significantly associated with future DL placement. Those injured spent an average of 200.7 days and 191.7 days in the DL with signal in the UCL and those with humeral elevation of the UCL, respectively. Ulnar elevation/signal of the UCL (p=0.06), and posteromedial impingement (p=0.08) were approaching statistical significance. Of those injured 68.8% (11/16) underwent elbow surgery. Findings of ligament signal intensity (p<0.001), ulnar-sided UCL elevation (p=0.018), humeral-sided UCL elevation (p=0.002), and posteromedial impingement (p=0.042) were all significantly associated with future surgery. There was no significant correlation between injury and radiocapitellar or ulnohumeral chondral lesion, bone edema, loose bodies, or flexor-pronator mass muscle defect. The presence of a flexor-pronator mass muscle defect was associated with a significantly reduced number of innings pitched (53.7 ± 74.3 vs. 304.4 ± 305.5 innings, p=0.0317), games started (5 ± 7.1 vs. 40.1 ± 49.0 games, p=0.004), and pitch count (680.5 ± 919.9 vs. 40.1 ± 49.0 pitches, p=0.022). The presence of ligament signal (26.2 ± 37.1 vs. 51.7 ± 56.5 games, p=0.036) and ulnar elevation (6.3 ± 9.3 vs. 41.2 ± 9.3 games, p=0.003) was associated with significantly fewer games started. The presence of bone edema was associated with significantly decreased pitch count (1451.2 ± 1746.8 vs. 4128.0 ± 4718.0 pitches, p=0.023). There was no association between humeral UCL elevation, flexor-pronator mass tendon, or posteromedial impingement with innings pitched, games started, or pitch count. Conclusion: The heavy demand placed on the elbow joint in professional pitching produces degenerative changes visible on MRI prior to any symptoms, as demonstrated in previous studies. Specific degenerative changes in the UCL Ligament, particularly humeral sided elevation of the UCL, are significantly associated with future injury. Radiographic Findings on Elbow MRI as Related to Placement on Disabled List and Pitching Stats N (%): Injury vs. Non-Injury Relation to Injury (p) Relation to DL days (p) Relation to Future Surgery (p) Relation to inningsPitched (p) Relation to GamesStarted (p) Relation to Pitch Count (p) Relation to Max Pitching Velocity (p) Radiocapitellar Chondral Lesion Diffuse: 1 (6.25%)0 (0%) Focal: 2 (12.5%)3 (12.5%) None: 13 (81.3%)21 (87.5%) N.S. N.S. N.S. N.S. N.S. N.S. N.S. Ulnohumeral Chondral Lesion Diffuse: 0 (0%)0(0%) Focal: 1 (6.25%)0 (0%) None: 15 (93.8%)24 (100%) N.S. N.S. N.S. N.S. N.S. N.S. N.S. ArticularCartilage Bone Edema 3 (18.8%)3 (12.5%) 0.6678 0.5961 1 0.5661 0.9471 0.0227 0.0788 UCL Ligament Signal Heterogeneity/Hyperintensity 15 (93.8%)1 (4.2%) p < 0.001 N.S. p < 0.001 0.0563 0.1487 0.0357 0.8186 Ulnar-Sided Elevation/Signal 3 (18.8%)0 (0%) 0.06373 0.3591 0.0177 0.1010 0.0032 0.1829 0.8683 Humeral-Sided Elevation/Signal 9 (56.3%)3 (12.5%) 0.0103 0.7240 0.0018 0.7778 0.7134 0.2167 0.9052 Frank UCL Tear 0 (0%)0 (0%) N.S. N.S. N.S. N.S. N.S. N.S. N.S. Flexor-Pronator Mass Defect 1 (6.3%)1 (4.2%) 1 N.S. 1 0.0317 0.0035 0.0223 N.S. Flexor-Pronator Mass Tendon Signal 8 (50%)2 (29.2%) 0.2046 0.0261 1 0.8311 0.7951 0.9657 0.7875

Randomized Prospective Trial of Arthroscopic Rotator Cuff With or Without Acromioplasty: No Difference in Patient-reported Outcomes at Long-term Follow-up

Objectives: To evaluate long-term clinical outcomes after arthroscopic rotator cuff repair with and without acromioplasty. Methods: Between 2007-2011, prospectively-enrolled patients undergoing arthroscopic repair for full-thickness rotator cuff tears were previously randomized into either acromioplasty or non-acromioplasty groups. Patients with death, advanced neurologic conditions, or subsequent shoulder arthroplasty were excluded. Baseline and long-term follow-up questionnaires, including the American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test (SST), University of California-Los Angeles (UCLA), Visual Analog Scale (VAS) for pain, and Constant scores were obtained. Rates of revision rotator cuff surgery, or secondary reoperation were recorded. Averages with standard deviation (SD) were calculated, and t-tests were utilized to compare outcomes of interest between cohorts. Results: After exclusion of 5 additional patients from the short-term follow-up study, 66 of 90 patients (73.3%) were available at 92.4 months (±10.5). Comparison of baseline demographics and intraoperative information revealed no significant differences, including age, gender, workers compensation, acute mechanism of injury, tear size, degree of retraction, and surgical technique (e.g. single- vs. double-row). At final follow-up, there were no statistically significant differences according to ASES (p=0.33), VAS pain (p=0.79), Constant (p=0.17), SST (p=0.05), UCLA (p=0.19), and SF-12 (p=0.79) in patients with and without acromioplasty (Figure 1). One patient with acromioplasty (2.9%) and two patients without acromioplasty (6.3%) sustained atraumatic recurrent rotator cuff tear with secondary repair (p=0.99). Conclusion: Combined acromioplasty and rotator cuff repair offer no significant long-term benefits in patient-reported outcomes or secondary surgery when compared to arthroscopic rotator cuff repair alone. Figure 1

Analysis of Publication Trends for the 2011-2015 American Orthopaedic Society for Sports Medicine Annual Meeting Abstracts

Background: Academic conferences are sources of novel research that can influence clinical decision making. Orthopaedic surgery maintains a relatively high rate of publication compared with other surgical subspecialties, and sports medicine conferences hold an even higher rate within the subspecialty. The American Orthopaedic Society for Sports Medicine (AOSSM) annual meetings have been shown to have among the highest rates of publication for accepted abstracts. Purpose: To determine differences between 2-year publication rates of poster and podium abstracts accepted into the AOSSM annual meetings and identify factors associated with publication. Study Design: Cross-sectional study. Methods: The AOSSM archives were queried for all accepted poster and podium presentations for annual meetings from 2011 through 2015. Google Scholar and MEDLINE databases were used to determine which abstracts transitioned into journal articles. Publication rates were compared based on publication 2 years following presentation. Logistic regression was performed to demonstrate which variables were most correlated with successful publication. Data on publication impact factor and number of citations were collected by use of the InCites database. Results: Of 628 abstracts accepted during this period, 265 were poster presentations and 363 were podium presentations. Overall, 44.7% of abstracts presented were accepted into peer-reviewed journals within 2 years of presentation. No statistical difference was found between poster and podium presentations for journal publication (P = .328). Poster presentations were published in journals with statistically lower impact factor (P = .005) and had a statistically lower number of citations (P < .001) compared with podium presentations. Multivariate logistic regression analysis demonstrated that only number of authors was correlated with publication (P = .003). Conclusion: Podium and poster presentations accepted into AOSSM conferences had equal rates of publication within 2 years and should influence decision making equally. The relative impact of podium presentations appeared to be greater, which suggests that the AOSSM selects podium presentations that will have greater clinical impact. Increasing number of coauthors was the only factor found to be correlated with publication.

How many innings can we throw: does workload influence injury risk in Major League Baseball? An analysis of professional starting pitchers between 2010 and 2015

BACKGROUNDnThere has been increasing interest regarding the association between pitch counts, as well as total workload per season, and the risk of injury among Major League Baseball (MLB) starting pitchers.nnnMETHODSnWe used publicly available databases to identify all MLB starting pitchers eligible for play who made at least 5 starts in seasons between 2010 and 2015. For all included pitchers, annual pitching statistics (number of starts, total season pitch counts, total season inning counts, and average pitch count per game started) and annual disabled list (DL) information (time on DL for any reason and time on DL related to upper extremity, lower extremity, or axial body injury) were collected. A multiple logistic regression analyzed games started, pitch counts, innings pitched, and pitches per start during all previous seasons as a risk factor for injury in the current season, controlling for previous injury.nnnRESULTSnA total of 161 starting MLB pitchers met the inclusion criteria. With the exception of total innings pitched from 2010-2011 being significantly associated with DL placement in 2012 (no DL, 310.5u2009±u200997.5 innings; DL, 344.7u2009±u200985.9 innings; Pu2009=u2009.040), no other finding for starts, pitch counts, innings, or pitches per start in the cumulative years from 2010-2014 had a significant association with pitcher placement on the DL for any musculoskeletal reason or for an upper extremity reason between 2011 and 2015.nnnCONCLUSIONSnIn this study, we demonstrate that there is no association between preceding years of cumulative pitches, starts, innings pitched, or average pitches per start and being placed on the DL for any musculoskeletal reason.

Establishing maximum medical improvement following reverse total shoulder arthroplasty for rotator cuff deficiency

BACKGROUNDnSince US Food and Drug Administration approval of the reverse prosthesis in 2003, the incidence of shoulder arthroplasty in the United States has risen dramatically. With increasing demand, efforts have shifted from traditional volume-based health care models to more patient-centered care. The purpose of this systematic literature review is to establish the time point of maximum medical improvement (MMI) following reverse total shoulder arthroplasty (rTSA).nnnMATERIALS AND METHODSnWe conducted a systematic review of studies reporting validated patient-reported outcome measures (PROMs) across multiple postoperative time points following rTSA. Established minimal clinically important difference values for PROMs specific to shoulder arthroplasty were used to determine significant clinical improvement. The time point beyond which significant improvement did not occur was established as MMI.nnnRESULTSnMMI occurred at 1 postoperative year following rTSA. When preoperative measures were compared with 1-year postoperative outcomes, all but 1 PROM demonstrated significant clinical improvement (Pu2009<u2009.001). There were no significant improvements between any 2 subsequent time points beyond 1 year (Pu2009>u2009.050). Range of motion significantly improved between preoperative and 1-year levels (Pu2009<u2009.001). No PROMs or range-of-motion parameters significantly improved beyond 1 year (Pu2009>u2009.999).nnnCONCLUSIONSnPatients achieved MMI at 1 postoperative year following rTSA. Patients showed rapid improvements in subjective symptoms within the first 3 months and continued to gradually improve until 1 year. Surgeons should counsel patients with these evidence-based expectations for clinical recovery, particularly the time frame of expected improvements in pain, function, and range of motion, as well as risks of and plans of action for postoperative complications.

Comparative analysis of work-related outcomes in hemiarthroplasty with concentric glenoid reaming and total shoulder arthroplasty

BACKGROUNDnAnatomic total shoulder arthroplasty (aTSA) has demonstrated high levels of return to work, although there are fears of glenoid component loosening with higher work demand.nnnMETHODSnA retrospective query was performed of all patients who received hemiarthroplasty with ream-and-run resurfacing (Hemi RR) between 2005 and 2014. Included patients were matched to an aTSA cohort by age, body mass index, sex, and hand dominance. Preoperative and postoperative work status, by level of duty and occupation, was collected.nnnRESULTSnTwenty-five patients receiving Hemi RR and 28 patients receiving TSA completed this questionnaire (82.8% compliance). Mean follow-up was 69.1u2009±u200924.8 months. In total, 100% of Hemi RR patients returned to work, and 89.3% of TSA patients returned to work (Pu2009=u2009.091). The Hemi RR patients had higher rates of return to work for heavy-duty workers only (7 of 7 vs. 2 of 4, Pu2009=u2009.038), although only 1 patient in the TSA group reported failure to work was due to shoulder reasons. Mean duration of return to work was 2.5u2009±u20094.8 months for patients receiving Hemi RR and 1.98u2009±u20092.6 months for those receiving TSA (Pu2009=u2009.653).nnnCONCLUSIONSnHemi RR had a high return to heavy-duty work, likely due to fewer surgeon-imposed restrictions. The results of this study may help manage return to work expectations after Hemi RR according to the level of duty and suggest Hemi RR is a viable option for heavy-duty laborers with end-stage glenohumeral arthritis.

Treatment of Partial Thickness Rotator Cuff Tears in Overhead Athletes

Purpose of ReviewTo review the etiology, classification, presentation, evaluation, treatment strategy, and outcomes in overhead athletes with partial thickness rotator cuff tears.Recent FindingsDespite advances in surgical repair techniques, return to play following surgical repair of partial rotator cuff tears remains modest at best.SummaryOverhead athletes may be particularly prone to rotator cuff pathology due to the supraphysiological strains within the tendon during the throwing motion, as well as mechanical stress with contact between the undersurface of the rotator cuff and the glenoid. The true prevalence of partial tears may be underestimated given the high incidence of asymptomatic tears. Both dynamic ultrasound and enhanced contrast MRI have improved our understanding of this pathology. For most overhead athletes, nonoperative management is the most common course. Despite advances in imaging, diagnosis, and surgical techniques, our ability to return these patients to their elite level is modest at best when nonoperative management fails and surgical treatment is performed. If a surgical route is needed, debridement alone is the most frequent procedure given concerns of over constraint and poor return to play with surgical repair of the partial thickness rotator cuff tear.

Double-Row Arthroscopic Subscapularis Repair: A Surgical Technique

The subscapularis is the strongest rotator cuff muscle in the shoulder. Until recently, most surgical repairs were performed through an open approach. Furthermore, the reporting of arthroscopic repair techniques and outcomes is fairly limited. This is likely due to the difficulty involved in all-arthroscopic repairs and the relative rarity of this injury compared with injuries of the other rotator cuff tendons. Arthroscopic subscapularis repair can be challenging, even for an expert surgeon, and attempting a double-row repair adds further complexity. Given these issues, this article provides techniques to allow for successful arthroscopic double-row subscapularis repair and avoid potential complications. The key features of an arthroscopic double-row repair include portal placement, surgical technique, and tips to avoid potential pitfalls, all of which are discussed.

Arthroscopic Massive Rotator Cuff Repair and Techniques for Mobilization

Massive rotator cuff tears, as classified by size or tendon involvement, are challenging to repair due to scarring, retraction of the tendons, and difficult visualization. Left untreated, these injuries can lead to fatty infiltration and reduced acromiohumeral distance that precludes future repair. The high rate of failure in these patients often impedes an anatomical repair. However, advanced mobilization techniques of the supraspinatus help facilitate a reduction of an otherwise irreparable tear. By performing this repair, more costly procedures may be avoided, such as a superior capsular reconstruction and reverse total shoulder arthroplasty. This Technical Note presents our preferred technique of an all-arthroscopic, medialized repair with double interval slides for the treatment of a massive rotator cuff tear.

Arthroscopic Superior Capsular Reconstruction and Over-the-Top Rotator Cuff Repair Incorporation for Treatment of Massive Rotator Cuff Tears

Massive rotator cuff tears pose significant clinical and surgical challenges for orthopaedic surgeons and increased morbidity to the patient. Left untreated, this pathology can lead to inability to perform daily activities, weakness, pain, and eventual cuff tear arthropathy. Several treatment options exist for irreparable cuff tears, such as reverse shoulder arthroplasty and tendon transfers. However, there exists significant concern for high complication rates and unpredictable clinical outcomes following such treatments. Superior capsular reconstruction (SCR) represents a viable alternative in treating irreparable cuff tears, providing biomechanical stability and improving pain related to this pathology by reducing superior humeral instability and subacromial impingement. Over-the-top repair of the native rotator cuff tendons with incorporation of the SCR allograft may provide surgeons the opportunity to perform a robust repair in situations where arthroplasty or other more invasive procedures were once the only options. The authors present a surgical technique with associated pearls and pitfalls for their preferred procedure of SCR with incorporation of the native rotator cuff in transosseous equivalent double-row repair for the treatment of massive, irreparable rotator cuff tears.