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Background: Injuries to the medial ulnar collateral ligament (UCL) are common among baseball pitchers due to repetitive stress on the soft tissue stabilizers of the elbow during pitching. Dynamic stress ultrasound (SUS) can be used to evaluate the UCL and ulnohumeral joint to identify anatomic risk factors of those who will require UCL reconstruction (UCLR). Purpose: To determine whether any adaptive or morphological changes detectable on SUS can predict injury to the UCL in professional baseball pitchers. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 203 professional baseball pitchers who underwent SUS at preseason training sessions over the course of 18 years were categorized into 1 of 2 groups: those without a history of shoulder, arm, elbow, or forearm surgery or injuries (healthy cohort; n = 184) and those who underwent UCLR the same season as SUS (UCLR cohort; n = 19). Ligament thickness, joint spacing, and laxity were compared. An additional matched cohort analysis was conducted using 10 players from each group to detect differences in the progression of UCL and ulnohumeral joint measures in the year before injury. Results: The UCLR cohort, when compared with the healthy cohort, had higher relative (ie, nondominant-side measurements subtracted from dominant-side measurements) resting ulnohumeral joint space (median, 0.50 vs 0.20 mm, respectively; P =.006) and higher rates of hypoechoic foci (57.9% vs 30.4%, respectively; P =.030). Players of both groups had similar dominant UCL thickness (P =.161), ulnohumeral joint space at rest (P =.321), space under stress (P =.498), and laxity (P =.796). Groups did not differ in terms of relative UCL thickness, ulnohumeral joint space under stress, or relative laxity. In the year before UCL injury, the UCLR cohort, compared with the matched healthy cohort, had a greater increase in mean dominant UCL thickness (0.94 vs –0.60 mm, respectively; P =.038) and a greater increase in relative median UCL thickness (1.35 vs –0.35 mm, respectively; P =.045). Players in the healthy cohort were statistically older than those in the UCLR cohort (23 vs 22 years, respectively; P =.004). No differences in ulnohumeral stress spacing or laxity were detected. Conclusion: SUS of players who underwent UCLR demonstrated a progressive increase in UCL thickness over 1 year, higher rates of hypoechoic foci, and increased ulnohumeral rest space compared with SUS of uninjured players. [ABSTRACT FROM AUTHOR]

Background: There is a paucity of data analyzing dynamic stress ultrasound (SUS) findings in elite pitchers who have undergone ulnar collateral ligament (UCL) reconstruction (UCLR) and returned to sport. Purpose: To identify longitudinal, perioperative changes in the elbows of professional baseball pitchers who have undergone UCLR and to compare these findings with a matched cohort of healthy pitchers. Study Design: Cohort study; Level of evidence, 3. Methods: This study used prospectively collected data from dynamic elbow SUS analyses of professional baseball pitchers within a single Major League Baseball organization. Pitchers were divided into 2 cohorts: a UCLR cohort and healthy cohort. The UCLR cohort eligibility included availability of (1) SUS from preseason of injury/UCLR and (2) SUS from ≥2 years after surgery. These players were 1:1 matched to players with no history of upper extremity injury to form the healthy cohort. Ligament thickness and ulnohumeral joint space at rest and under stress were directly measured. Joint laxity was calculated by subtracting joint space at rest from joint space under stress. The term "relative" was used to describe calculated differences where nondominant measurements were subtracted from dominant-side measurements. Results: Eight pitchers were included in the UCLR group and matched to 8 healthy pitchers (mean age at initial SUS examination, 19.6 years). At a minimum follow-up of 2 years, there were no significant differences between groups in terms of relative or dominant arm rest space, stress space, or laxity. Longitudinally (final measurements – baseline measurements), the mean relative ulnohumeral rest space decreased in the UCLR group and increased in the healthy group (–0.36 mm vs +0.50 mm; P =.032). The finding of increased UCL thickness in the UCLR group was expected, as UCL grafts are typically thicker than native ligaments. Conclusion: Ulnhohumeral joint stability was achieved after UCLR as indicated by similar rest space, stress space, and joint laxity in dominant arms compared with a matched healthy cohort. A significant decrease in relative rest space after UCLR may represent the achievement of stability in surgery patients. Alternatively, the increase in ulnohumeral rest space seen in the healthy cohort may represent adaptive changes from pitching at a professional level. [ABSTRACT FROM AUTHOR]

Background: The Major League Baseball (MLB) draft is a common route for players to enter professional baseball in the United States. Players taken in earlier rounds are typically higher-performing players. When looking at pitchers specifically, higher performance at the amateur level may be associated with an increased frequency of adaptive change in the throwing elbow. Purpose: To determine whether pitchers taken in earlier rounds of the MLB draft have a greater frequency or extent of pathological change in the elbow, as measured by dynamic stress ultrasound. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Dynamic stress ultrasounds (SUSs) were performed over 18 years on the dominant and nondominant arms of 651 professional pitchers. The 383 drafted players were grouped according to the round in which they were drafted (rounds 1-5, 6-10, 11-20, 21+). Groups were compared with respect to "relative" ulnar collateral ligament (UCL) thickness (dominant-nondominant), relative ulnohumeral joint laxity (joint space distance under stress minus joint space at rest), and the presence of pathology (calcifications, tears, hypoechoic foci, osteophytes). In addition, a subgroup analysis was done to compare the progression of SUS findings over 3 years in players for which data were available. Results: Draft round groups did not differ by age, number of previous spring training, or handedness. Comparing baseline measurements, there was no significant relationship between draft round and relative UCL thickness (P =.932), relative laxity (P =.996), or presence of pathology detectable on SUS (P =.642). However, increased relative UCL thickness was significantly associated with the presence of pathology on SUS (odds ratio, 1.45; 95% CI, 1.26-1.69; P <.001). Longitudinally, there was no significant relationship between draft round and 3-year progression of relative laxity, relative UCL thickness, or clinical progression of pathology. Conclusion: Higher-performing pitchers are drafted earlier in the MLB draft. This may be attributable to peak pitch velocity, in-game performance, visibility gained during player showcases, or any number of other sport-specific variables. However, despite this, there was no significant relationship between draft round and adaptive changes to the elbow or specific properties of the UCL on stress ultrasound. [ABSTRACT FROM AUTHOR]

The decision to seek and undergo treatment for bilateral rotator cuff tears is often complex. The purpose of this study was to investigate patient preferences for undergoing short-interval staged bilateral rotator cuff repair; timing of surgeries; and order of surgeries. A retrospective analysis was performed for patients who underwent bilateral arthroscopic rotator cuff repairs within 12 months at a single institution. Postoperative patient-reported outcomes, satisfaction, and decision-making factors were collected via REDCap surveys. Ninety patients were included (63 men and 27 women; mean age, 58.1 years). The mean time between surgeries was 7.33 months. Forty-two percent of patients had left rotator cuff repair first. Patients reported a mean satisfaction score of 91.6 of 100 with the order of the surgeries and 87.3 of 100 with the timing of the surgeries. Mean postoperative American Shoulder and Elbow Surgeons standardized assessment scores were 94.6 and 93.7 (left vs right shoulder first, respectively) for left shoulders and 94.2 and 93.9 (left vs right shoulder first, respectively) for right shoulders. Mean postoperative Single Assessment Numeric Evaluation scores were 86.5 and 83.9 (left vs right shoulder first, respectively) for left shoulders and 87.3 and 86.0 (left vs right shoulder first, respectively) for right shoulders. Decision-making factors noted as highly important included night pain, function, surgeon recommendation, and daily pain. Most patients who undergo short-interval staged bilateral rotator cuff repair are satisfied with the order and timing of their surgery. Decision-making factors such as night pain and functional limitation play a key role in the timing and order of bilateral rotator cuff repairs. [Orthopedics. 2023;46(6):e347–e352.] [ABSTRACT FROM AUTHOR]

Background: Stress ultrasonography (SUS) has provided clinicians with an alternative means of evaluating ulnar collateral ligament (UCL) injury by dynamically assessing ulnohumeral joint space gapping under applied valgus stress. However, 3 previous cadaveric studies have evaluated the biomechanical effect of partial UCL tears at different anatomic locations with conflicting results. Purpose/Hypothesis: The purpose of this study was to use in vivo data from patients with magnetic resonance (MR)–confirmed partial UCL tears to determine if anatomic partial tear location influenced the resultant stability of the elbow in terms of ulnohumeral joint gapping on SUS. It was hypothesized that no difference would be seen in the amount of ulnohumeral joint gapping based on MR-identified anatomic partial UCL tear location. Study Design: Cohort study; Level of evidence, 3. Methods: All patients diagnosed with elbow injury from 2015 to 2020 were screened to identify competitive baseball pitchers with a partial UCL tear who received an SUS. Partial UCL tear was diagnosed via surgeon and radiologist interpretation of elbow MR imaging (MRI) as well as confirmation at the time of surgery as documented in the operative report. Demographic, injury, and treatment data were collected from the clinic notes, MRI reports, and stress ultrasound reports. Ulnohumeral joint gapping on SUS was calculated as the difference between ulnohumeral joint gapping without valgus stress versus ulnohumeral joint gapping with valgus stress (delta) as performed by a musculoskeletal radiologist. Results: Overall, 60 male baseball pitchers (age, 19.2 ± 2.1 years), including 22 (37%) high school, 26 (43%) collegiate, and 12 (20%) professional pitchers, were evaluated. Regarding the location of partial UCL tears, 32 (53%) pitchers had proximal tears and 28 (47%) had distal tears. The mean delta value cohort was 2.1 ± 1.1 mm, and 34 pitchers (57%) had delta values >2.0 mm. Ulnohumeral joint gapping (high school [1.9 mm] vs collegiate [2.6 mm] vs professional [1.6 mm]; P =.004) and the percentage of pitchers with delta values >2.0 mm (45% vs 77% vs 33%; P =.017) differed based on level of competition. After controlling for age, body mass index, and level of competition in a multivariate linear regression, tear location was not related to ulnohumeral joint gapping (P =.499). Conclusion: No difference was observed in the amount of ulnohumeral joint gapping on SUS in symptomatic baseball pitchers with MR-identified partial UCL tears at differing anatomic locations. The findings of this study are contrary to previous cadaveric studies that have evaluated the effects of UCL tear characteristics on delta laxity. [ABSTRACT FROM AUTHOR]

Background: Medial epicondylitis (ME) is a pathological condition that arises in laborers and athletes secondary to repetitive wrist flexion and forearm pronation causing degeneration of the common flexor tendon. Although nonoperative management has demonstrated high rates of success, no standardized surgical technique has been established for situations when operative management is indicated. Purpose/Hypothesis: The purpose of this study was to perform a systematic review of the surgical treatment options for ME and evaluate the associated patient-reported outcomes (PROs). We hypothesized that surgical management of ME would vary across studies but no technique would prove to be superior. Study Design: Systematic review; Level of evidence, 4. Methods: Searches were conducted using PubMed, EMBASE, Cumulative Index of Nursing Allied Health Literature (CINAHL), SPORTDiscus, and Cochrane databases between 1980 and April 2020. All level 1 to 4 studies were identified that focused on surgical management and PROs in the setting of ME. Description of surgical technique and PROs were required for inclusion. Investigators independently dually abstracted and reviewed the studies for eligibility. Weighted means were calculated for demographic characteristics and available PROs. Results: Overall, 851 studies were identified according to the search criteria. A total of 16 studies met the inclusion and exclusion criteria and therefore were evaluated. Three surgical techniques were found: open (13 studies), arthroscopic (2 studies), and percutaneous (1 study). Descriptions of the open technique were subdivided into those with (7 studies) and without (6 studies) common flexor tendon repair. Analysis included 479 elbows; patients were primarily male (58.3%) with a weighted mean age of 47.2 years. Weighted mean follow-up was 4.6 years. Tennis and manual laborer were the most common sport and occupation, respectively. Surgical success ranged from 63% to 100%, with a low complication rate of 4.3%. Success rates for return to sports and work were 81%-100% and 66.7%-100%, respectively, and only 1 study reported a return to work rate <90%. Conclusion: This systematic review demonstrates that surgical intervention for refractory ME often has a high success rate. Regardless of surgical technique performed, patients generally demonstrated an improvement in PROs, and an encouraging number returned to work with limited complications. Further investigation is necessary to determine superiority among open, arthroscopic, and percutaneous techniques. [ABSTRACT FROM AUTHOR]

Background: Injury of the ulnar collateral ligament (UCL) has become increasingly common, particularly in overhead athletes. There is no consensus on management of the ulnar nerve in UCL reconstruction (UCLR) in patients with preoperative ulnar nerve symptoms, as literature supports both not decompressing the nerve as well as ulnar nerve transposition (UNT). Hypothesis/Purpose: The purpose of this study was to compare subjective clinical outcomes and return-to-sports (RTS) metrics between patients who received UNT during UCLR and a matched cohort who underwent UCLR alone. We hypothesized that there would be no significant difference in patient outcomes or RTS metrics between the cohorts. Study Design: Cohort study; Level of evidence, 3. Methods: Using an institutional database, patients who underwent UCLR with UNT between 2007 and 2017 were retrospectively identified. These patients were matched based on sex, age at surgery (±3 years), and body mass index (±2 kg/m2) to a comparison group that underwent UCLR alone. Patients completed the Kerlan-Jobe Orthopaedic Clinic Shoulder & Elbow (KJOC) score, the Timmerman and Andrews elbow score, the Conway-Jobe scale, and custom patient satisfaction and RTS questionnaires. Results: Thirty patients who underwent UCLR with concomitant UNT and 30 matched patients who underwent UCLR without UNT were available for follow-up at a mean of 6.9 (3.4-9.9) and 8.1 (3.4-13.9) years, respectively. The UNT group reported similar KJOC (78.4 in UNT vs 76.8; P =.780), Conway-Jobe (60% excellent in UNT vs 77% excellent; P =.504), Timmerman and Andrews (86.2 in UNT vs 88.8; P =.496), and satisfaction scores (85.3% in UNT vs 89.3%; P =.512) compared with UCLR group. In terms of RTS rate (84% in UNT vs 93% in UCLR; P =.289) and duration required to RTS (11.1 months in UNT vs 12.5 months in UCLR; P =.176), the 2 groups did not significantly differ. Finally, despite significant differences in preoperative ulnar nerve symptoms (100% in UNT vs 7% in UCLR; P <.001), the 2 groups did not statistically differ in the proportion of patients who experienced postoperative ulnar nerve symptoms (13% in UNT vs 0% in UCLR; P =.112). Conclusion: This matched cohort analysis showed no statistically significant differences in patient-reported outcomes and RTS between patients undergoing UCLR with and without UNT. [ABSTRACT FROM AUTHOR]