Jan Fronek

The efficacy of continuous bupivacaine infiltration following arthroscopic rotator cuff repair.

PURPOSE This prospective, randomized, double-blind study with a placebo group and 2 experimental groups evaluated the efficacy of continuous low-dose bupivacaine infiltration by infusion pump after arthroscopic rotator cuff repair. METHODS Sixty patients undergoing arthroscopic rotator cuff repair received a bolus injection in the subacromial space of 35 mL of 0.25% bupivacaine with 1:200,000 epinephrine at surgical closure and were randomized to 1 of 3 groups: 0.25% bupivacaine at 2 mL/hr (n = 20), 0.25% bupivacaine at 5 mL/hr (n = 20), or saline at 5 mL/hr (n = 20) via infusion pump into the subacromial space. Pain was evaluated using the visual analog scale (VAS) and narcotic consumption was measured until 48 hours after surgery and converted to dose equivalents (DE). RESULTS Sixty patients used the infusion pump for a mean of 43.9 hours (range, 15.50 to 50.75 hrs). Mean total narcotic consumption, expressed in DEs, was 2.24 for the 2-mL group, 3.52 for the 5-mL group, and 2.32 for the placebo group. Mean pain score was 2.9 for the 2-mL group, 3.6 for the 5-mL group, and 3.3 for the placebo group. There were no differences in operating room time or infusion pump use time among groups. The 2-mL group had a nonsignificant trend toward less pain and lower narcotic consumption. The 5-mL group evidenced a nonsignificant trend toward more pain and higher narcotic consumption. CONCLUSIONS This study neither supports nor refutes the use of infusion pumps. We hypothesized that the placebo group would experience greater pain than the 5-mL group; however, a nonsignificant trend toward the contrary occurred. A trend toward less pain in the 2-mL group was not significant. LEVEL OF EVIDENCE Level II, randomized controlled trial of therapeutic treatment that lacks statistical significance and narrow confidence intervals.

Shoulder Functional Performance Status of National Collegiate Athletic Association Swimmers Baseline Kerlan-Jobe Orthopedic Clinic Scores

Background: Shoulder trouble, described in the literature as “swimmer’s shoulder,” has been associated with competitive swimmers. The Kerlan-Jobe Orthopedic Clinic (KJOC) Shoulder and Elbow Score is a validated survey used to define functional and performance measures of the upper extremity in overhead athletes. To date, no study has investigated the baseline functional scores for swimmers actively competing in the sport. Purpose: To establish a baseline score for National Collegiate Athletic Association (NCAA) swimmers actively competing in the sport. Study Design: Cross-sectional study; Level of evidence, 3. Methods: After institutional review board approval, the KJOC Shoulder and Elbow Score was administered to 5 NCAA swim teams (N = 99 participants; 46 men, 53 women). The results on 10 specific individual questions and on the total score were calculated according to the survey’s original description. The mean scores were calculated for all participants. The Mann-Whitney U test was used to determine differences between sexes, years swimming, and self-reported injury status. Results: The mean ± SD baseline KJOC score (out of a possible 100) for all participants was 79.0 ± 18.7; the mean score for men was 81.9 ± 15.6 and for women 76.6 ± 20.8. The score for athletes identifying themselves as injured at baseline was 53.9 ± 18.8, compared with 84.4 ± 13.6 for those not reporting as injured (P < .001). Athletes competing ≥11 years had a mean score of 72.0 ± 22.1; those competing ≤10 years scored 86.4 ± 11.4 (P = .007). Conclusion: Baseline scores for swimmers, which were lower than expected, were lower than baseline scores seen in studies of other overhead sports athletes. The data corroborate previous studies identifying swimmers as having a high level of shoulder trouble. Further research is indicated for improving shoulder symptoms and performance in competitive swimmers.

Performance and Injury Characteristics of Pitchers Entering the Major League Baseball Draft After Ulnar Collateral Ligament Reconstruction

Background: Ulnar collateral ligament (UCL) reconstruction (UCLR) has been studied and shown to be a successful procedure for returning overhead athletes to sport. Many studies of Major League Baseball (MLB) players have shown high levels of return to play with successful statistical performance. No study has followed professional advancement of drafted pitchers who underwent UCLR as amateurs when compared with drafted pitchers who did not undergo the procedure before selection in the MLB draft. Hypothesis: There would be no difference in professional advancement, statistical performance, or injury rate between the UCLR and control groups. Study Design: Cohort study; Level of evidence, 3. Methods: Thirty-eight pitchers with a UCLR as an amateur and 114 controls were identified in the MLB draft between 2006 and 2010. Highest level of professional baseball achieved was collected from all players, as well as statistical performance metrics including velocity, wins, earned run average (ERA), and walks and hits per inning pitched (WHIP). Additional data on future injuries were analyzed for days on the disabled list (DL), risk of being placed on the DL, and DL assignment for elbow injury. Results: Thirteen of 38 UCLR pitchers reached the major league level (34.2%) compared with 29 of 114 (25.4%) control pitchers, which was not statically significant (P = .295). The UCLR and control groups were similar for average velocity, peak velocity, innings pitched, games, games started, innings per game, ERA, WHIP, wins, losses, saves, batters faced, and innings pitched per year, as well as hits, runs, home runs allowed, strikeouts, batters walked, and batters struck per inning. The UCLR group had a significantly increased rate of DL assignment when compared with controls (86.8% vs 64.0%; P = .008); however, days on DL (152.8 vs 135.6; P = .723) and DL assignment for elbow injury (45.5% vs 43.8%; P = .877) were similar. Conclusion: There was no difference in the rate of professional advancement among pitchers drafted by the MLB who had undergone UCLR as amateurs compared with controls. Both groups had similar statistical performance. Pitchers in the UCLR group had an increased risk of DL assignment but no increase in the number of days on DL or risk of DL placement for elbow injury.

Effects of Nd:YAG laser on the meniscus of the knee joint

The use of laser energy for arthroscopic surgery of the meniscus has been fraught with difficult problems which include excessive tissue penetration and the need for a gas medium. The use of the Neodynium : Yttrium Aluminum Garnet (Nd:YAG) laser offers better control of the penetration depth as well as the opportunity to operate the laser in a liquid medium. Twenty-two excised menisci and twenty cadaver knee menisci were exposed to contact Nd:YAG laser radiation of a power density at 1 .064 microns. The operating parameters included a range of power levels of 5 to 60 watts and exposure time of 0.5 to 1 0.0 seconds. The laser-induced dissection yielded reproducible layers of cavitation and necrosis, proportional to the power and duration of the beam. Carbonized debris was noted on the edge of the cut surface, particularly at the higher power setting. The more peripheral zone of coagulation remained at constant depth and width when tested within the parameters noted above. The Nd:YAG laser has been observed to section the meniscus cartilage in a very controlled, accurate and safe fashion. For the best tissue effect, impulses of 1 5 - 20 watts applied for 2-4 seconds offer the most efficacious combination for the knee menisectomy. While these findings are promising for the clinical utilization of Nd:YAG laser in arthroscopic surgery, additional work is required on both the technical aspects of the sapphire tip design as well as the longterm sequellae of the laser treated cartilage.

Medial supracondylar stress fracture in an adolescent pitcher

We report the occurrence of a medial supracondylar stress fracture in an adolescent pitcher. To our knowledge, this fracture has not been described in the literature, and awareness of this entity allows initiation of therapy and precludes further unnecessary work-up. The radiographic, computed tomography, and magnetic resonance imaging appearances are reviewed and the mechanism of injury is discussed.

The use of an orthopaedic rating system in major league baseball

Background: Although the majority of Major League Baseball teams use an orthopaedic rating system to evaluate draft picks, little has been published on the topic. Hypothesis: Our goal was to assess the attitudes among Major League Baseball physicians regarding 3 common diagnoses in pitching prospects, through the use of an orthopaedic rating system. Our hypothesis was that the assigned orthopaedic grades would vary among physicians, diagnoses, and operative-versus-nonoperative and recent-versus-past treatment. Study Design: Survey. Level of Evidence: Level 4. Methods: A survey in the form of 12 clinical vignettes was used to query Major League Baseball physicians regarding ulnar collateral ligament (UCL) injuries, type II superior labrum anterior posterior (SLAP) tears, and internal impingement. Respondents graded draft picks using an orthopaedic rating system. The vignettes covered both operative and nonoperative and recent and past treatment (successful return to pitching for 1 year). Results: The orthopaedic grades assigned by respondents were as follows (minimal, moderate, severe risk): past UCL reconstruction (73%, 27%, 0%), recent UCL reconstruction (19%, 77%, 4%), past UCL strain (28%, 60%, 12%), recent UCL strain (0%, 48%, 52%), past SLAP repair (52%, 48%, 0%), recent SLAP repair (4%, 64%, 32%), past SLAP nonoperative (28%, 60%, 12%), recent SLAP nonoperative (0%, 36%, 64%), past internal impingement operative (24%, 68%, 8%), recent internal impingement operative (8%, 32%, 60%), past internal impingement nonoperative (24%, 68%, 8%), and recent internal impingement nonoperative (4%, 48%, 44%). Conclusion: Team physicians are optimistic regarding the outcome of UCL reconstruction. In contrast, UCL strains, type II SLAP lesions, and internal impingement carry a guarded prognosis. For all diagnoses, regardless of treatment, the prognosis improved if a player returned to pitching for 1 full season. Clinical Relevance: This study represents a first step toward developing a standardized orthopaedic rating system that will facilitate more accurate player assessment and clearer communication among physicians.

Professional advancement, performance, and injury characteristics of baseball players entering the Major League Baseball draft after treatment for shoulder injuries

BACKGROUND How shoulder injuries treated before the Major League Baseball (MLB) draft affect the players performance over their career is unclear. The purpose of this study was to determine whether prior shoulder injuries were associated with a difference in the level of performance and advancement of MLB draftees. METHODS Before entering the draft, 119 professional baseball players from 2004 to 2010 were treated for a shoulder injury (73% treated surgically) as an amateur. A 3:1 matched case-control was performed to players without prior shoulder injuries by age, position, round selected, and signing bonus. Follow-up data were collected in 2016, and professional advancement, disabled list time, and in-game performance statistics for pitchers were analyzed and compared. RESULTS Players with a prior shoulder injury had a statistically higher chance to be assigned to the disabled list then controls (P = .03), but there was no difference in disabled list time or professional advancement. Pitchers with a prior shoulder injury pitched a statistically lower number of innings per game than controls (P = .04). All other in-game performance statistics were not statistically different. The type of treatment did not have any effect on future performance or advancement. CONCLUSIONS Professional baseball players treated for prior shoulder injuries at the amateur level were more likely to sustain future disability than their matched controls, but it did not affect professional advancement.