Robert A. Jack

Performance and Return to Sport After Sports Hernia Surgery in NFL Players

Background: Recognition, diagnosis, and treatment of athletic pubalgia (AP), also known as sports hernia, once underrecognized and undertreated in professional football, are becoming more common. Surgery as the final treatment for sports hernia when nonsurgical treatment fails remains controversial. Given the money involved and popularity of the National Football League (NFL), it is important to understand surgical outcomes in this patient population. Hypothesis: After AP surgery, players would: (1) return to sport (RTS) at a greater than 90% rate, (2) play fewer games for fewer years than matched controls, (3) have no difference in performance compared with before AP surgery, and (4) have no difference in performance versus matched controls. Study Design: Cohort study; Level of evidence, 3. Methods: Internet-based injury reports identified players who underwent AP surgery from January 1996 to August 2015. Demographic and performance data were collected for each player. A 1:1 matched control group and an index year analog were identified. Control and case performance scores were calculated using a standardized scoring system. Groups were compared using paired Student t tests. Results: Fifty-six NFL players (57 AP surgeries) were analyzed (mean age, 28.2 ± 3.1 years; mean years in NFL at surgery, 5.4 ± 3.2). Fifty-three players were able to RTS. Controls were in the NFL longer (P < .05) than players who underwent AP surgery (3.8 ± 2.4 vs 3.2 ± 2.1 years). Controls played more games per season (P < .05) than post-AP players (14.0 ± 2.3 vs 12.0 ± 3.4 games per season). There was no significant (P > .05) difference in pre- versus post-AP surgery performance scores and no significant (P > .05) difference in postoperative performance scores versus controls post-index. Conclusion: There was a high RTS rate after AP surgery without a significant difference in postoperative performance, though career length and games per season after AP surgery were significantly less than that of matched controls.

Performance and Return to Sport After Achilles Tendon Repair in National Football League Players

Background: Achilles tendon injuries are common in sports, including football. The purpose of this study was to determine (1) return-to-sport rate in National Football League (NFL) players following Achilles tendon repair, (2) postoperative career length and games per season, (3) pre- and postoperative performance, and (4) postoperative performance compared with control players matched by position, age, years of experience, and performance. Methods: Publicly available records were used to identify NFL players who underwent Achilles tendon repair and matched controls were identified. Ninety-five players (98 surgeries) were analyzed (mean age 28.2 ± 2.8 years; mean 5.5 ± 2 .8 years in NFL at time of surgery). Demographic and performance data were collected. Comparisons between case and control groups and preoperative and postoperative time points were made using paired-samples Student t tests. Results: Seventy-one (72.4%) players were able to return to sport in the NFL at a mean of 339.8 ± 84.8 days following surgery. Thirty-one (32%) Achilles tendon repairs were performed during training camp or preseason. Controls (3.6 ± 2.1 years) had a significantly longer NFL career (P < .05) than players who underwent Achilles tendon repair (2.7 ± 2.1 years). There was no significant difference in games per season in subsequent seasons following surgery compared with controls. Postoperative performance scores were significantly worse (P < .05) for running backs (RBs) (n = 4) and linebackers (LBs) (n = 12) compared to preoperative scores. LBs had significantly worse postoperative performance scores when compared to matched controls (P < .05). Conclusion: Following Achilles tendon repair, less than 75% of players returned to the NFL. Postoperative career length was 1 season shorter than matched controls. No difference was observed in the number of games per season played compared to matched controls. Postoperative performance scores were significantly worse for RBs and LBs compared to preoperative and LBs had significantly worse postoperative performance when compared to matched controls. Level of Evidence: Level III, retrospective comparative series.

Performance and Return to Sport After Tommy John Surgery Among Major League Baseball Position Players

Background: The anterior bundle of the medial ulnar collateral ligament (UCL) is the primary restraint to valgus stress at the elbow and is often injured among overhead throwing athletes. Despite prevention strategies, injuries to the elbow UCL are on the rise. Purpose: To determine (1) the return-to-sport (RTS) rate of Major League Baseball (MLB) position players after elbow medial UCL reconstruction, (2) postoperative career length and games per season, (3) pre- and postoperative performance, (4) postoperative performance versus matched control players, and (5) whether position players changed positions after UCL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: MLB players who underwent elbow UCL reconstruction were identified (cases). Demographic and performance data were collected for each player. Matched controls were identified. RTS in MLB was defined as playing in at least 1 MLB game after UCL reconstruction. Comparisons between case and control groups and pre- and postoperative time points were made via paired samples Student t tests. Results: Thirty-three players (34 surgical procedures) were identified with a mean ± SD age of 30.2 ± 4.2 years and a mean experience in the MLB of 6.3 ± 3.9 years at the time of surgery. Twenty-eight players (84.8%) were able to RTS in MLB at a mean 336.9 ± 121.8 days. However, players ≥30 years old demonstrated a significantly lower RTS rate (53.3%) than players <30 years old (89.4%; P < .05). Catchers had a significantly shorter postoperative career length (2.8 ± 1.8 years) versus matched controls (6.1 ± 1.9 years; P < .05). Outfielders had a significantly lower wins above replacement postoperatively (0.8 ± 0.7) versus preoperatively (1.5 ± 1.1; P < .05). There were no performance differences between cases and matched controls. Twelve players (48%) returned to a different position postoperatively. Conclusion: The RTS rate for MLB position players after elbow UCL reconstruction is similar to that of pitchers. Catchers had a significantly shorter career length than that of matched controls. Outfielders performed worse postoperatively versus preoperatively. There is a high rate of position change after Tommy John surgery for infielders and outfielders.

Performance and Return to Sport After Nonoperative Treatment of Clavicle Fractures in National Football League Players

Clavicle fractures are often seen in contact sports. The purpose of this study was to determine (1) return-to-sport (RTS) rate of National Football League (NFL) players following nonoperative treatment of clavicle fractures, (2) posttreatment career length and games per season, (3) pre- and posttreatment performance, and (4) posttreatment performance compared with control players matched by position, age, years of experience, and performance. Public records were used to identify NFL players who underwent nonoperative treatment of clavicle fractures. Demographic and performance data were collected for each player. Matched controls (position, age, experience, and performance) were identified. Control and case performance scores were calculated using a standardized scoring system. Return to sport was defined as playing a minimum of 1 game after treatment. Comparisons between the 2 groups and pre- and posttreatment time points were made using paired-samples Students t tests. Thirty players (32 fractures) were analyzed. Two players fractured their contralateral clavicle. Of the players analyzed, 96.9% were able to RTS at a mean of 244.6±119.6 days. Eight players (27.6%) returned within the same season as their injury. Overall 1-year survival rate posttreatment was 93.5%. Players with nonoperative treatment had career lengths similar to those of controls (P>.05). No significant (P>.05) differences existed in demographic, performance, or games per season data between position groups for cases and matched controls pretreatment and preindex and in posttreatment compared with pretreatment performance scores. Wide receivers played fewer games per season (P=.043) following treatment. No position group had significantly worse posttreatment performance scores when compared with postindex matched controls. [Orthopedics. 2017; 40(5):e836-e843.].

Performance and Return to Sport After Clavicle Open Reduction and Internal Fixation in National Football League Players

Background: Clavicle fractures are common injuries in professional football. Surgical fixation of these injuries may lead to decreased nonunion rates, improved shoulder strength, and decreased residual functional impairment. Purpose: To determine (1) return-to-sport (RTS) rate in National Football League (NFL) players after clavicle fracture open reduction and internal fixation (ORIF), (2) postoperative career length and games per season, (3) pre- and postoperative performance, and (4) postoperative performance compared with control players matched by position, age, years of experience, and performance. Study Design: Cohort study; Level of evidence, 3. Methods: Publicly available records were used to identify players who underwent surgical treatment of a clavicle fracture while playing in the NFL. Demographic and performance data were collected for each player, and matched controls were identified. Control and case performance scores were calculated using a standardized scoring system. RTS was defined as playing in 1 NFL game after surgery. Comparisons between case and control groups at preoperative and postoperative time points were made using paired-samples Student t tests. Results: Seventeen surgeries (16 players) were analyzed. Fifteen players (94.1%) were able to RTS in the NFL at a mean 211.3 ± 144.7 days postsurgery; 7 (44%) returned within the same season as their injury and subsequent fixation. The overall rate of a player’s remaining in the NFL 1 year after surgery was 88.2%. Players who underwent surgery played in a similar number of games per season and had similar career lengths in the NFL as controls (P > .05). There were no significant (P > .05) differences between cases and matched controls presurgery and preindex. There was no difference (P > .05) in postoperative performance scores or games per season compared with preoperative scores or games per season for any position. Quarterbacks (n = 3, P = .049) and running backs (n = 5, P = .039) had significantly worse postoperative performance scores when compared with postindex matched controls. Conclusion: There is a high rate of RTS in the NFL after clavicle fracture ORIF. Players who underwent clavicle fracture ORIF played in a similar number of games per season and had similar career lengths in the NFL as controls. Quarterbacks and running backs had significantly worse postoperative performance scores when compared with postindex matched controls.

Performance and Return to Sport After Forearm Fracture Open Reduction and Internal Fixation in National Football League Players

Background: Forearm fractures are one of the most common upper extremity injuries requiring surgery in professional football. Surgical fixation of forearm fractures may speed recovery and decrease games missed in football. Methods: National Football League (NFL) players who underwent forearm fracture open reduction and internal fixation (ORIF) were identified. Matched controls (position, age, experience, performance) were identified. Control and case performance scores were calculated using a standardized scoring system. Return to sport (RTS) in the NFL was defined as playing in a single NFL game after surgery. Comparisons between case and control groups and preoperative and postoperative time points were made using paired-samples Student t tests. Results: Thirty-six surgeries were analyzed following ORIF. Thirty-three were able to RTS in the NFL at an average of 152.1 + 129.8 days. Controls had a significantly longer NFL career (P < .001) and played in significantly more games per season (P = .026) than players who underwent surgery. There was a significant (P = .013) decrease in games/season for DBs following surgery. No significant difference was seen in postoperative performance scores compared with preoperative scores among any positions, nor in postoperative and postindex performance scores compared with matched controls. Conclusion: There is a high rate of RTS in the NFL following forearm fracture ORIF. Following surgery, players’ careers were 1 year shorter and played nearly 2 fewer games per season than matched controls. Games per season following surgery was significantly lower among DBs when compared with presurgery. Postoperative performance scores were not significantly different compared with preoperative and when compared with matched controls.

Correlation Between Quality of Evidence and Number of Citations in Top 50 Cited Articles in Rotator Cuff Repair Surgery

Background: The number of article citations has been used as a measure for the impact of an article in the medical literature, with little emphasis on quality. Purpose: To (1) identify the top 50 most cited articles related to rotator cuff repair surgery, (2) determine whether there was a correlation between the top cited articles and level of evidence, and (3) determine whether there was a correlation between the top cited articles and study quality. Study Design: Cross-sectional study. Methods: The Web of Science and Scopus online databases were searched to identify the top 50 cited articles in rotator cuff repair surgery. Methodological quality was analyzed for each article using the Modified Coleman Methodology Score (MCMS), Jadad scale, and Methodological Index for Non-Randomized Studies (MINORS). Correlation coefficients were calculated to determine the degree of correlation between the top cited articles and level of evidence and study quality using each quality score. Results: The mean number of citations for each article in each of the 2 databases was 319 ± 187 (range, 177.5-1033.5). Twenty-nine articles (58%) were from the United States. The most common level of evidence was level 4 (54%), with 3 (6%) articles being level 1. There was no significant correlation between the mean number of citations and level of evidence (r s = –0.28), the MCMS (r s = –0.29), and the MINORS score (r s = –0.25). There was a weak negative correlation between the mean number of citations and the Jadad score (r s = –0.36). Conclusion: The top 50 cited articles in rotator cuff repair surgery comprise a variety of years, journals, countries of origin, and study types. Despite being the 50 most cited articles, the most common type of article was the level 4 case series with a poor mean quality assessment score. There was no significant correlation between the mean number of citations and level of evidence or methodological quality using a variety of scores.

Trends in the Body Mass Index of Pediatric and Adult Patients Undergoing Anterior Cruciate Ligament Reconstruction

Background: The body mass index (BMI) in the United States (US) is rising and may be contributing to increased anterior cruciate ligament reconstruction (ACLR) rates. It is currently unknown whether the BMI is increasing in patients who undergo ACLR. Purpose: To determine whether (1) the BMI changed in pediatric and adult patients who previously underwent ACLR or revision ACLR over a 10-year eligibility period, (2) the BMI changed at a greater rate in pediatric or adult patients, and (3) the percentage of overweight and obese patients in the ACLR population was different than that of the general overweight population. Study Design: Case series; Level of evidence, 4. Methods: A retrospective investigation of patients who underwent ACLR by 6 surgeons from June 3, 2005, to June 3, 2015, was conducted. Patients were divided into pediatric (<18 years) and adult (≥18 years) categories. BMI at the time of surgery was defined as underweight (<18.5 kg/m2), normal (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), and obese (≥30.0 kg/m2). Patients with an indeterminate BMI were excluded. Comparisons of overweight and obese patients were made with general population trends determined by the Centers for Disease Control and Prevention (CDC) in a single US state. Pearson (R) and Spearman (R s) correlations were used to determine correlations, Student t tests were used for 2-variable comparisons, analyses of variance were used for multivariable comparisons, and analyses of covariance were used for comparing linear relationships. Results: There were 1305 patients (733 male, 572 female; 409 pediatric, 896 adult) included. Adults requiring surgical revision demonstrated a strong positive correlation with respect to BMI over time (R s = 0.906, P < .01). No other statistically significant trends in the BMI over time were found. The proportion of overweight pediatric patients undergoing ACLR was significantly greater than that of the general overweight pediatric population (P < .05), and the proportion of obese pediatric and adult patients in the general population was greater than that of the obese patients in the study cohort (P < .05). Conclusion: Between 2005 and 2015, the BMI for pediatric and adult patients who underwent ACLR did not demonstrate a significant change over time. However, there was a statistically significant strong positive correlation for increasing BMI in adult patients requiring revision, although the mean BMI in patients who underwent revision was less than that of the general population. In addition, the percentage of overweight pediatric patients undergoing ACLR was significantly greater than that of the general population of overweight patients in a single US state reported by the CDC.

Correlation Between Quality of Evidence and Number of Citations in Top 50 Cited Articles on Elbow Medial Ulnar Collateral Ligament Surgery

Background: Several studies have analyzed the most cited articles in shoulder, elbow, pediatrics, and foot and ankle surgery. However, no study has analyzed the quality of the most cited articles in elbow medial ulnar collateral ligament (UCL) surgery. Purpose: To (1) identify the top 50 most cited articles related to UCL surgery, (2) determine whether there was a correlation between the top cited articles and level of evidence, and (3) determine whether there was a correlation between study methodological quality and the top cited articles. Study Design: Systematic review. Methods: Web of Science and Scopus online databases were searched to identify the top 50 cited articles in UCL surgery. Level of evidence, number of times cited, year of publication, name of journal, country of origin, and study type were recorded for each study. Study methodological quality was analyzed for each article with the Modified Coleman Methodology Score (MCMS) and the Methodological Index for Non-randomized Studies (MINORS). Correlation coefficients were calculated. Results: The 50 most cited articles were published between 1981 and 2015. The number of citations per article ranged from 20 to 301 (mean ± SD, 71 ± 62 citations). Most articles (92%) were from the United States and were level 3 (16%), level 4 (58%), or unclassified (16%) evidence. There were no articles of level 1 evidence quality. The mean MCMS and MINORS scores were 28.1 ± 13.4 (range, 3-52) and 9.2 ± 3.6 (range, 2-19), respectively. There was no significant correlation between the mean number of citations and level of evidence or quality (rs = –0.01, P = .917), MCMS (rs = 0.09, P = .571), or MINORS (rs = –0.26, P = .089). Conclusion: The top 50 cited articles in UCL surgery constitute a low level of evidence and low methodological quality, including no level 1 articles. There was no significant correlation between the mean number of citations and level of evidence or study methodological quality. However, weak correlations were observed for later publication date and improved level of evidence and methodological quality.

Performance and Return to Sport After Thumb Ulnar Collateral Ligament Repair in Major League Baseball Players

Background: Acute ruptures of the ulnar collateral ligament (UCL) of the thumb are common injuries in sports. Surgical repair has yielded excellent results and high return-to-sport (RTS) rates in elite athletes. Purpose: To determine (1) the RTS rate in Major League Baseball (MLB) players following thumb UCL repair, (2) postoperative career length and games played per season, (3) pre- and postoperative performance, (4) postoperative performance compared with matched control players, and (5) whether dominant and nondominant hand injuries respond differently. Study Design: Cohort study; Level of evidence, 3. Methods: MLB players who underwent thumb UCL surgery from August 3, 1987, to September 6, 2016, were identified. Demographic and performance data were collected for each player, and matched controls were identified. RTS in the MLB was defined as playing in at least 1 MLB game after surgery. Comparisons were made by use of paired-samples Student t tests. Results: Twenty-one players were identified, with a mean ± SD age of 31.7 ± 3.9 years and mean experience in the MLB of 8.6 ± 3.3 years at time of surgery. Twenty-one players (100%) achieved RTS in the MLB at a mean 120.0 ± 75.9 days. No significant decrease was found in games per season or career length for any position following surgery. Infielders had a significantly lower rate of postoperative wins above replacement (WAR) compared with preoperatively (P = .006), but no significant differences in postoperative performance score were found compared with controls after the index date. No significant difference was found for performance between players undergoing surgery on their dominant hand and those who had surgery on their nondominant (glove) hand compared with controls. Conclusion: In this study, 100% of MLB players achieved RTS after thumb UCL repair, with in-season players returning at a mean of 8 weeks. Players who underwent thumb UCL repair played in a similar number of games per season and had similar career lengths in the MLB as controls. Infielders had a significantly lower postoperative WAR compared with preoperatively, but no significant postoperative performance score differences were noted when infielders were compared with post–index date matched controls. No significant performance differences were noted with regard to surgery on dominant and nondominant hands.