Steven F. DeFroda

Risk Stratification for Ulnar Collateral Ligament Injury in Major League Baseball Players A Retrospective Study From 2007 to 2014

Background: Ulnar collateral ligament (UCL) injury has become increasingly common in Major League Baseball (MLB) players in recent years. Hypothesis: There is a significant difference in preinjury fastball velocity between MLB pitchers with tears and matched controls without UCL injury. Pitchers with injuries are throwing harder and getting injured earlier in their MLB careers. Study Design: Cohort study; Level of evidence, 3. Methods: From 2007 to 2014, a total of 170 documented UCL injuries (156 pitchers, 14 position players) occurred in MLB. Inclusion criteria for this study consisted of any player who tore his UCL in MLB during this time frame. There were 130 regular-season tears (April-September). From this group, 118 players who pitched more than 100 innings prior to tear were matched to subjects with no tear and were compared using a logistic regression analysis. A subgroup of “early tear” players who threw less than 100 career innings (n = 37) was also identified and compared with the larger tear group using a logistic regression analysis. Results: Of the 130 tears that occurred during the regular season, a significantly larger number (62%) occurred in the first 3 months (P = .011). The rate of UCL tears per MLB player (P = .001) was statistically significant. In the group of 118 matched tears, the mean fastball velocity was greater in the tear group (91.7 mph) compared with the control group (91.0 mph; P = .014). Furthermore, relief pitchers made up a greater percentage of the early tear group (<100 innings) compared with the later tear group (P = .011). Sixteen of the 170 UCL tears (9.4%) were recurrent tears, with 5 of 16 experiencing both tear and retear within the past 4 years. Conclusion: There is a statistically significant difference in the mean fastball velocity of pitchers who injure their UCL. Small increases in pitcher fastball velocity are a main contribution to the increased rate of tear in MLB. In addition, there has been an increased incidence of injury in the first 3 months of the season. Finally, early tears are more likely to occur in relief pitchers than starters.

Epidemiology of lower extremity injuries presenting to the emergency room in the United States: Snow skiing vs. snowboarding

PURPOSE To quantify and compare the incidence of lower extremity injuries in skiers and snowboarders who present to emergency rooms in the United States. METHODS Cross-sectional study of lower extremity injuries in skiers and snowboarders that were evaluated in emergency rooms in the United States. The National Electric Injury Surveillance System (NEISS) database was queried from January 1st, 2014 and December 31st, 2014 and the reported cases of lower extremity injuries in skiers and snowboarders were examined. RESULTS An estimated total of 13,381 snow skiing and 6061 snowboarding lower extremity injuries presented to the emergency department in 2014 representing a national incidence of 42 injuries per 1,000,000 person-years for skiers and 19 injuries for snowboarders. The most common region of the lower extremity that was injured was the knee for skiers (47%) and the lower trunk (e.g. pelvis, hip, lumbar spine) for snowboarders (34%). The incidence of injuries in the pediatric and young adult population in skiers (62 per 1,000,000 person-years) and snowboarders (40 per 1,000,000 person-years) was significantly higher than the incidence of these injuries in adult population (35 and 12 per 1,000,000 person-years respectively) (P<0.01). The incidence of these injuries was significantly higher in males compared to females in both skiing (46 per 1,000,000 person-years vs. 38 per 1,000,000 person-years, P<0.01) and snowboarding (30 per 1,000,000 person-years vs. 9 per 1,000,000 person-years, P <0.01). The rate of injuries from 2010 to 2014 for skiers remained stable while snowboarding injuries down trended approaching significance. CONCLUSION The incidence of lower extremity injuries in skiers was higher than that of snowboarders in 2014, with the 0-19year old age group and males being those most likely to sustain an injury. The most common region of the lower extremity that was injured was the knee for skiers and the lower trunk (e.g. pelvis, hip, lumbar spine) for snowboarders. Physicians and consumers alike should be aware of this data when considering participation in these sports as well as strategies for injury prevention.

Current Concepts in the Diagnosis and Management of Traumatic, Anterior Glenohumeral Subluxations

Traumatic anterior glenohumeral subluxations comprise the majority of glenohumeral instability events and are endemic in young athletes. Unlike the definitive complete dislocation event, subluxation events may often be more subtle in presentation and, therefore, may be overlooked by clinicians. Glenohumeral subluxation events are associated with a high rate of labral tears as well as humeral head defects. While less is known of the natural history of these injuries, young athletes are at risk for recurrent instability events if not properly diagnosed and treated. While reports of surgical treatment outcomes isolated to subluxation events are limited, arthroscopic and open Bankart repair have been shown to result in excellent outcomes. The purpose of this paper is to review the etiology and pathoanatomy of traumatic anterior glenohumeral subluxations as well as to review the appropriate evaluation and management of patients with this injury.

Challenges of Fracture Management for Adults With Osteogenesis Imperfecta

Osteogenesis imperfecta is caused by qualitative or quantitative defects in type I collagen. Although often considered a disease with primarily pediatric manifestations, more than 25% of lifetime fractures are reported to occur in adulthood. General care of adults with osteogenesis imperfecta involves measures to preserve bone density, regular monitoring of hearing and dentition, and maintenance of muscle strength through physical therapy. Surgical stabilization of fractures in these patients can be challenging because of low bone mineral density, preexisting skeletal deformities, or obstruction by instrumentation from previous surgeries. Additionally, unique perioperative considerations exist when operatively managing fractures in patients with osteogenesis imperfecta. To date, there is little high-quality literature to help guide the optimal treatment of fractures in adult patients with osteogenesis imperfecta. [Orthopedics. 2017; 40(1):e17-e22.].

Comparison of 30-Day Morbidity and Mortality After Arthroscopic Bankart, Open Bankart, and Latarjet-Bristow Procedures: A Review of 2864 Cases:

Background: Surgical intervention for anterior shoulder instability is commonly performed and is highly successful in reducing instances of recurrent instability. Purpose: To determine and compare the incidence of 30-day complications and patient and surgical risk factors for complications for arthroscopic Bankart, open Bankart, and Latarjet-Bristow procedures. Study Design: Cohort study; Level of evidence, 3. Methods: All arthroscopic Bankart, open Bankart, and Latarjet-Bristow procedures from 2005 to 2014 from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) prospective database were analyzed. Baseline patient variables were assessed, including the Charlson Comorbidity Index (CCI). Outcomes measures included length of operation, length of hospital stay, need for hospital admission, 30-day readmission, and 30-day return to the operating room. Binary logistic regression was performed for the presence of any complications after all 3 procedures. Results: There were 2864 surgical procedures (410 open Bankart, 163 Latarjet-Bristow, and 2291 arthroscopic Bankart) included. There was no significant difference with regard to age (P = .11), body mass index (P = .17), American Society of Anesthesiologists class (P = .423), or CCI (P = .479) for each group. The Latarjet-Bristow procedure had the highest overall complication rate (5.5%) compared with open (1.0%) and arthroscopic (0.6%) Bankart repairs. The Latarjet-Bristow procedure had significantly longer mean operative times (P < .001) in addition to the highest 30-day return rate to the operating room (4.3%; 95% confidence interval, 1.2%-7.4%). Smoking status was an independent predictor of a postoperative complication (P = .05; odds ratio, 8.0) after Latarjet-Bristow. Conclusion: Surgical intervention for anterior shoulder instability has a low rate of complication (arthroscopic Bankart, 0.6%; open Bankart, 1.0%; Latarjet-Bristow, 5.5%) in the early postoperative period, with the most common being surgical site infection, deep vein thrombosis, and return to the operating room.

Differentiating Radiculopathy from Lower Extremity Arthropathy

Low back and lower extremity pain are among the most common complaints encountered by physicians. Distinguishing pain due to primary extremity pathology versus lumbar radiculopathy can be challenging. Careful physical examination and appropriate imaging with plain radiographs and advanced studies as needed are important in determining the cause of lower extremity complaints. Over-utilization of advanced imaging may reveal otherwise asymptomatic spinal pathology and can lead to an incorrect diagnosis. In patients in whom surgical intervention is being considered by a spine or arthroplasty surgeon, intra-articular or epidural steroid injections may help to reveal the underlying cause of pain via short-term symptomatic relief. Additionally, patients presenting with vague lower extremity pain after recent or distant joint arthroplasty should be considered for potential failure or infection of their implant before assuming the symptoms are coming from the lumbar spine.

Closed traumatic finger tip injuries in patients with artificial nails: removal of UV gel and acrylic nails

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Physical Therapy Protocols for Arthroscopic Bankart Repair

Background: Outcomes after arthroscopic Bankart repair can be highly dependent on compliance and participation in physical therapy. Additionally, there are many variations in physician-recommended physical therapy protocols. Hypothesis: The rehabilitation protocols of academic orthopaedic surgery departments vary widely despite the presence of consensus protocols. Study Design: Descriptive epidemiology study. Level of Evidence: Level 3. Methods: Web-based arthroscopic Bankart rehabilitation protocols available online from Accreditation Council for Graduate Medical Education (ACGME)–accredited orthopaedic surgery programs were included for review. Individual protocols were reviewed to evaluate for the presence or absence of recommended therapies, goals for completion of ranges of motion, functional milestones, exercise start times, and recommended time to return to sport. Results: Thirty protocols from 27 (16.4%) total institutions were identified out of 164 eligible for review. Overall, 9 (30%) protocols recommended an initial period of strict immobilization. Variability existed between the recommended time periods for sling immobilization (mean, 4.8 ± 1.8 weeks). The types of exercises and their start dates were also inconsistent. Goals to full passive range of motion (mean, 9.2 ± 2.8 weeks) and full active range of motion (mean, 12.2 ± 2.8 weeks) were consistent with other published protocols; however, wide ranges existed within the reviewed protocols as a whole. Only 10 protocols (33.3%) included a timeline for return to sport, and only 3 (10%) gave an estimate for return to game competition. Variation also existed when compared with the American Society of Shoulder and Elbow Therapists’ (ASSET) consensus protocol. Conclusion: Rehabilitation protocols after arthroscopic Bankart repair were found to be highly variable. They also varied with regard to published consensus protocols. This discrepancy may lead to confusion among therapists and patients. Clinical Relevance: This study highlights the importance of attending surgeons being very clear and specific with regard to their physical therapy instructions to patients and therapists.

Diagnosis and Management of Traumatic Patellar Instability in the Pediatric Patient

Instability of the patella is a common cause of knee pain and dysfunction in pediatric and adolescent patients and can be due to several factors. Although some patients will recall a specific traumatic event others may not, requiring the diagnosis to be made on the basis of physical examination and imaging. Congenital dislocation and connective tissue disorders should also be considered, even in the setting of trauma. There are radiographic parameters that may identify causes of instability such as trochlear and patellar abnormalities, and magnetic resonance imaging can identify signs of trauma such as bony edema, loose osteochondral fragments, and increased tibial tubercle-trochlear groove distance. The first line of treatment for instability is most commonly nonoperative in nature; however, there are many options for operative management in the event of severe chondral injury or recurrent dislocation. Surgical management to best restore stability of the patellofemoral joint varies depending on the skeletal maturity of the patient and the source of instability (ligamentous, osteocartilaginous, or both). A combination of soft tissue, bony, and anatomic ligamentous repair or reconstruction is used to best augment patellar tracking and optimize patient outcome. [Orthopedics. 2017; 40(5):e749-e757.].

Risk Factors for Hospital Admission Following Arthroscopic Bankart Repair

Arthroscopic Bankart repair, a commonly performed procedure in the United States, is usually done on an outpatient basis. All instances of arthroscopic Bankart repair from 2005 to 2014 from the American College of Surgeons National Surgical Quality Improvement Program prospective database were analyzed. Both univariate analysis and binary logistic regression were performed to determine risk factors for admission following surgery. Of 2291 patients undergoing arthroscopic Bankart repair, 173 (7.6%) required inpatient hospital admission following surgery. Univariate analysis found the following to be associated with admission: female sex (P=.009), age older than 40 years (P<.001), white race (P=.002), body mass index greater than 30 kg/m2 (P=.001), and American Society of Anesthesiologists class greater than 3 (P<.001). Independent predictors of admission on multivariate analysis included female sex (odds ratio [OR], 1.58; 95% confidence interval [CI], 1.06-2.10; P=.023), increasing age (per year) (OR, 1.03; 95% CI, 1.02-1.04; P<.001), diabetes (OR, 2.70; 95% CI, 2.30-3.10; P=.006), and longer operation time (per minute) (OR, 1.010; 95% CI, 1.009-1.011; P<.001). This study identified a 7.6% rate of admission following arthroscopic Bankart repair, with diabetes, female sex, increasing age, and longer operation time being independent risk factors for admission. Knowledge of these risk factors is important when setting patient expectations preoperatively and for optimizing care to obtain the best short-term outcome. [Orthopedics. 2017; 40(5):e855-e861.].