Venous Thromboembolism Within Professional American Sport Leagues.

Background: Numerous reports have described players in professional American sports leagues who have been sidelined with a deep vein thrombosis (DVT) or a pulmonary embolism (PE), but little is known about the clinical implications of these events in professional athletes. Purpose: To conduct a retrospective review of injury reports from the National Hockey League (NHL), Major League Baseball (MLB), the National Basketball Association (NBA), and the National Football League (NFL) to take a closer look at the incidence of DVT/PE, current treatment approaches, and estimated time to return to play in professional athletes. Study Design: Descriptive epidemiology study. Methods: An online search of all team injury and media reports of DVT/PE in NHL, MLB, NBA, and NFL players available for public record was conducted by use of Google, PubMed, and SPORTDiscus. Searches were conducted using the professional team name combined with blood clot, pulmonary embolism, and deep vein thrombosis. Results: A total of 55 venous thromboembolism (VTE) events were identified from 1999 through 2016 (NHL, n = 22; MLB, n = 16; NFL, n = 12; NBA, n = 5). Nineteen athletes were reported to have an upper extremity DVT, 15 had a lower extremity DVT, 15 had a PE, and 6 had DVT with PE. Six athletes sustained more than 1 VTE. The mean age at time of VTE was 29.3 years (range, 19-42 years). Mean (±SD) time lost from play was 6.7 ± 4.9 months (range, 3 days to career end). Seven athletes did not return to play. Players with upper extremity DVT had a faster return to play (mean ± SD, 4.3 ± 2.7 months) than those with lower extremity DVT (5.9 ± 3.8 months), PE (10.8 ± 6.8 months), or DVT with PE (8.2 ± 2.6 months) (F = 5.69, P = .002). No significant difference was found regarding time of return to play between sports. Conclusion: VTE in professional athletes led to an average of 6.7 months lost from play. The majority of athletes were able to return to play after a period of anticoagulation or surgery. Those with an upper extremity DVT returned to play faster than those with other types of VTE. Further study is needed to look into modifiable risk factors for these events and to establish treatment and return-to-play guidelines to ensure the safety of these athletes

Sequential Sectioning of the Ulnar Collateral Ligament of the Elbow in Cadaveric Arms with Ulnohumeral Laxity Assessed by Dynamic Ultrasonography

Objectives: Injury of the ulnar collateral ligament (UCL), whether acute or chronic, is potentially career-threatening for elite overhead throwing athletes. Dynamic ultrasound (DUS) allows for rapid, cost-effective, non-invasive, and non-radiating evaluation of the UCL and elbow joint both at rest and with applied stress. The purpose of this study was to determine the amount of cadaveric elbow valgus laxity with sequential UCL sectioning using DUS. Our objective was to quantify which portions of the UCL must be injured to cause the varying levels of laxity seen clinically on DUS testing. No prior study has used DUS to quantify valgus joint laxity with sequential cadaveric UCL sectioning. It was hypothesized that the change in laxity due to release of the anterior band of the UCL would be greater than that seen when the posterior and transverse bands were cut. Methods: Twelve cadaveric elbows were dissected free of skin and subcutaneous tissue by an experienced orthopaedic surgeon. Baseline DUS at rest and with applied valgus stress was then performed by an experienced ultrasonographer. Sequential sectioning of the medial elbow soft-tissue stabilizing structures was then carried out with valgus stress applied to the joint at each sectioning interval utilizing a standardized device (Telos, Marburg, Germany). First the transverse band of the UCL was released, followed by the posterior band, then the anterior bundle of the anterior band, the remaining posterior bundle of the anterior band, and finally the complete flexor pronator mass. Results: Mean ulnohumeral laxity in millimeters with 95% CIs was calculated for each step of the sequence. The deltas between each step of the dissection were also calculated with means and 95% CIs. Mean baseline laxity of the unstressed ulnohumeral joint at rest was 3.2 mm (CI, 2.2-4.2); with the addition of valgus stress, mean laxity was 4.7 mm (CI, 3.5-6.0). When the transverse band was cut, ulnohumeral laxity increased to a mean of 5.5 mm (CI, 4.0-7.0). With release of the posterior band, mean laxity was 6.4 mm (CI, 4.3-8.5). When the anterior bundle of the anterior band of the UCL was cut, mean ulnohumeral laxity was 8.4 mm (CI, 5.7-11.0) and when the entire anterior band was released, mean laxity was 10.9 mm (CI, 7.8-14.0). Complete release of the flexor pronator muscle mass resulted in mean ulnohumeral laxity of 15.5 mm (CI, 12.9-18.1). The largest deltas were observed with release of the anterior bundle of the anterior band (2.0 mm; CI, 1.0-3.0), the entire anterior band (2.6 mm; CI, 1.3-3.8), and flexor pronator mass (4.6 mm; CI, 1.3-3.8). Release of the transverse and posterior bands of the UCL resulted in deltas of 0.74 mm (CI, 0.1-1.3) and 0.9 mm (CI, 0.3-1.5) respectively. Conclusion: DUS allows for rapid, cost-effective, non-invasive, non-radiating evaluation of the elbow joint and UCL both at rest and with applied valgus stress. Previous studies have indicated that DUS can identify abnormalities of the UCL associated with chronic degeneration and ligamentous injury including thickening of the anterior band of the UCL as well as hypoechoic foci/calcifications. The results of the current cadaveric study suggest that different changes in clinical laxity are seen on DUS with injury of particular bands of the UCL. Early identification and localization of injury to a particular band of the UCL may allow more appropriate selection of patients who will benefit from operative treatment. © The Author(s) 2013

Evaluation of Rotator Cuff Repair with Concomitant Biceps Tenodesis

Introduction: Surgical rotator cuff repair (RCR) has proven to be an effective treatment for rotator cuff tears. Commonly, rotator cuff tears are associated with concomitant biceps pathology, which are often treated by biceps tenodesis (BT). We hypothesize that patient outcomes will be similar in those that have undergone RCR with concomitant BT and isolated RCR. Methods: This is a retrospective cohort study comparing patients who underwent arthroscopic RCR with arthroscopic or open BT to patients who underwent isolated RCR at a multisurgeon orthopaedic practice during the time period of November 2016 to December 2016. The outcome for comparison is the American Shoulder and Elbow Surgeons score (ASES). Patients with postoperative scores of at least 6 months after surgery were included. The data was collected from the Rothman Institute registry and OBERD. It was analyzed via independent t-test. Results: A total of 53 patients (37 = M; 16 = F) were in the isolated RCR group and 34 patients (27 = M; 7 = F) were in the RCR with BT group. The average age in the isolated RCR group was 58.6 years vs. 58.9 years in the RCR with BT group. There was no statistical difference between postoperative ASES scores (83.69 and 79.43, P = .40) and difference in preoperative and postoperative ASES scores (34.26 and 35.30, P = .85) in the isolated RCR and RCR with BT groups, respectively. Conclusion: There was no significant difference in postoperative ASES scores as well as difference in preoperative and postoperative ASES scores in patients undergoing isolated RCR and RCR with BT. This supports the hypothesis that patients undergoing RCR with BT will have similar outcomes to those undergoing isolated RCR

Pain Management After Outpatient Anterior Cruciate Ligament Reconstruction: A Systematic Review of Randomized Controlled Trials.

BACKGROUND: Effective pain management after anterior cruciate ligament (ACL) reconstruction improves patient satisfaction and function. PURPOSE: To collect and evaluate the available evidence from randomized controlled trials (RCTs) on pain control after ACL reconstruction. STUDY DESIGN: Systematic review. METHODS: A systematic literature review was performed using PubMed, Medline, Google Scholar, UpToDate, Cochrane Reviews, CINAHL, and Scopus following PRISMA guidelines (July 2014). Only RCTs comparing a method of postoperative pain control to another method or placebo were included. RESULTS: A total of 77 RCTs met inclusion criteria: 14 on regional nerve blocks, 21 on intra-articular injections, 4 on intramuscular/intravenous injections, 12 on multimodal regimens, 6 on oral medications, 10 on cryotherapy/compression, 6 on mobilization, and 5 on intraoperative techniques. Single-injection femoral nerve blocks provided superior analgesia to placebo for up to 24 hours postoperatively; however, this also resulted in a quadriceps motor deficit. Indwelling femoral catheters utilized for 2 days postoperatively provided superior analgesia to a single-injection femoral nerve block. Local anesthetic injections at the surgical wound site or intra-articularly provided equivalent analgesia to regional nerve blocks. Continuous-infusion catheters of a local anesthetic provided adequate pain relief but have been shown to cause chondrolysis. Cryotherapy improved analgesia compared to no cryotherapy in 4 trials, while in 4 trials, ice water and water at room temperature provided equivalent analgesic effects. Early weightbearing decreased pain compared to delayed weightbearing. Oral gabapentin given preoperatively and oral zolpidem given for the first week postoperatively each decreased opioid consumption as compared to placebo. Ibuprofen reduced pain compared to acetaminophen. Oral ketorolac reduced pain compared to hydrocodone-acetaminophen. CONCLUSION: Regional nerve blocks and intra-articular injections are both effective forms of analgesia. Cryotherapy-compression appears to be beneficial, provided that intra-articular temperatures are sufficiently decreased. Early mobilization reduces pain symptoms. Gabapentin, zolpidem, ketorolac, and ibuprofen decrease opioid consumption. Despite the vast amount of high-quality evidence on this topic, further research is needed to determine the optimal multimodal approach that can maximize recovery while minimizing pain and opioid consumption. CLINICAL RELEVANCE: These results provide the best available evidence from RCTs on pain control regimens after ACL reconstruction

Youth Single-Sport Specialization in Professional Baseball Players.

Background: An increasing number of youth baseball athletes are specializing in playing baseball at younger ages. Purpose: The purpose of our study was to describe the age and prevalence of single-sport specialization in a cohort of current professional baseball athletes. In addition, we sought to understand the trends surrounding single-sport specialization in professional baseball players raised within and outside the United States (US). Study Design: Cross-sectional study; Level of evidence, 3. Methods: A survey was distributed to male professional baseball athletes via individual team athletic trainers. Athletes were asked if and at what age they had chosen to specialize in playing baseball at the exclusion of other sports, and data were then collected pertaining to this decision. We analyzed the rate and age of specialization, the reasons for specialization, and the athlete\u27s perception of injuries related to specialization. Results: A total of 1673 professional baseball athletes completed the survey, representing 26 of the 30 Major League Baseball (MLB) organizations. Less than half (44.5%) of professional athletes specialized in playing a single sport during their childhood/adolescence. Those who reported specializing in their youth did so at a mean age of 14.09 ± 2.79 years. MLB players who grew up outside the US specialized at a significantly earlier age than MLB players native to the US (12.30 ± 3.07 vs 14.89 ± 2.24 years, respectively; Conclusion: This study challenges the current trends toward early youth sport specialization, finding that the majority of professional baseball athletes studied did not specialize as youth and that those who did specialize did so at a mean age of 14 years. With the potential cumulative effects of pitching and overhead throwing on an athlete\u27s arm, the trend identified in this study toward earlier specialization within baseball is concerning

Does Prior Anterior Cruciate Ligament Reconstruction Affect Outcomes of Subsequent Total Knee Arthroplasty? A Systematic Review.

Background: Anterior cruciate ligament injury may accelerate knee osteoarthritis, and patients with a history of anterior cruciate ligament reconstruction (ACLR) tend to undergo total knee arthroplasty (TKA) at a greater rate than patients without a history of ACLR. Purpose: To compare clinical outcomes of TKA in patients with and without a history of ACLR through a systematic review. Study Design: Systematic review; Level of evidence, 3. Methods: A comprehensive search of the PubMed (MEDLINE), Cochrane Central, and SPORTDiscus databases from inception through November 2018 was performed to identify studies directly comparing outcomes of TKA between patients with and without a history of ipsilateral ACLR. Eligible studies were included in this review if they reported at least 1 outcome measure. Results: Included for review were 5 retrospective case-control studies collectively evaluating TKA outcomes in 318 patients (176 males, 142 females) with a history of ACLR and 455 matched controls. The mean age in the ACLR and control groups was 58.5 years and 60.9 years, respectively. The mean follow-up period after arthroplasty was 3.4 years in the ACLR group and 3.3 years in the control group. The mean time between ACLR and arthroplasty was 21.8 years. Three studies noted greater operative time in the ACLR group than in the control group. No differences in intraoperative blood loss were reported. Greater preoperative extension deficits were noted in the ACLR group in 2 studies. Two studies reported increased preoperative Knee Society Score function scores in the ACLR group, but no differences in postoperative subjective outcome scores were noted in any of the studies. One study reported increased incidence of periprosthetic joint infection and a higher total reoperation rate in the ACLR group, and another study reported an increased incidence of manipulation under anesthesia in the ACLR group. Conclusion: Short- and midterm subjective scores and functional outcomes of TKA appear to be comparable in patients with and without a history of ACLR, although the risk for reoperation after TKA may be greater in patients with prior ACLR. Surgeons should anticipate increased operative time in patients with a history of ACLR. However, the findings of this review must be interpreted within the context of its limitations

Postoperative Considerations Based on Graft Type After Anterior Cruciate Ligament Reconstruction a Narrative Review

Background and Objective: Graft selection for anterior cruciate ligament reconstruction (ACLR) affects rehabilitation throughout the course of postoperative care. Methods: A search of PubMed and EBSCO was performed and abstracts independently reviewed by two authors. This search was also supplemented with additional evidence relevant to each phase of ACLR rehabilitation. Key Content and Findings: Direct implications of graft type on clinical decisions vary throughout treatment phases, transitioning from potential differences in acute postoperative pain management immediately after surgery to facilitating sufficient and appropriate lower extremity loading in subsequent weeks. Regardless of graft type, surgical limb weakness persists throughout the course of rehabilitation; however, harvest site selection for autografts contributes to disproportionate weakness of the harvested muscle group and the potential for surgical-induced tendinopathy. In later phases of rehabilitation, as athletes are transitioning into return to sport (RTS), treatment decisions and protocols are less affected by graft type but expectations for meeting clinical milestones and the time required to do so does differ between graft types. Conclusions: Targeted strengthening interventions to address muscle weakness following graft harvest in autografts should be continued throughout the rehabilitation process. Lingering deficits in quadriceps strength symmetry may also influence time to meet progression and RTS criteria following graft harvest from the extensor mechanism

ChatGPT Can Offer Satisfactory Responses to Common Patient Questions Regarding Elbow Ulnar Collateral Ligament Reconstruction

PURPOSE: To determine whether ChatGPT effectively responds to 10 commonly asked questions concerning ulnar collateral ligament (UCL) reconstruction. METHODS: A comprehensive list of 90 UCL reconstruction questions was initially created, with a final set of 10 most commonly asked questions ultimately selected. Questions were presented to ChatGPT and its response was documented. Responses were evaluated independently by 3 authors using an evidence-based methodology, resulting in a grading system categorized as follows: (1) excellent response not requiring clarification; (2) satisfactory requiring minimal clarification; (3) satisfactory requiring moderate clarification; and (4) unsatisfactory requiring substantial clarification. RESULTS: Six of 10 ten responses were rated as excellent or satisfactory. Of those 6 responses, 2 were determined to be excellent response not requiring clarification, 3 were satisfactory requiring minimal clarification, and 1 was satisfactory requiring moderate clarification. Four questions encompassing inquiries about What are the potential risks of UCL reconstruction surgery? Which type of graft should be used for my UCL reconstruction? and Should I have UCL reconstruction or repair? were rated as unsatisfactory requiring substantial clarification. CONCLUSIONS: ChatGPT exhibited the potential to improve a patient\u27s basic understanding of UCL reconstruction and provided responses that were deemed satisfactory to excellent for 60% of the most commonly asked questions. For the other 40% of questions, ChatGPT gave unsatisfactory responses, primarily due to a lack of relevant details or the need for further explanation. CLINICAL RELEVANCE: ChatGPT can assist in patient education regarding UCL reconstruction; however, its ability to appropriately answer more complex questions remains to be an area of skepticism and future improvement

Outcomes of Arthroscopic vs. Open Biceps Tenodesis for Treatment of SLAP Lesion in Female Patients

Background: Biceps tenodesis (BT) is one alternative treatment to repair of superior labrum anterior to posterior (SLAP) tears. It can be performed as an arthroscopy or open procedure. While there have been studies comparing the outcomes of SLAP repair procedures with BT for the treatment of SLAP tears, literature comparing arthroscopic and open BT for the treatment of SLAP tears is limited. Additionally, no previous study has specifically examined the outcomes of these procedures in female patients. Hypothesis/Purpose: The purpose of this study was to compare outcomes following Arthroscopic BT and Open BT for SLAP tears in females. The authors hypothesized there would be no difference in outcomes between patients who underwent arthroscopic or open procedures. Study Design: Retrospective Cohort (level III) Methods: Female patients who underwent arthroscopic or open BT for treatment of SLAP tears between 1/1/2014 and 9/1/2019 were retrospectively reviewed. Patients undergoing a concomitant procedure were excluded. A minimum of 2 years postoperatively patients completed American Shoulder and Elbow Surgeons (ASES), single assessment numerical evaluation (SANE), and visual analog scale (VAS), and a custom return to activity surveys. Results: This study included 27 female patients; 14 (51.9%) underwent arthroscopic BT and 13 (48.1%) underwent open BT. There was no significant difference between cohorts in terms of age (P = .679), BMI (P = .382), Height (P = .989), Weight (P = .452), laterality of procedure (P = .678), or rate of surgery taking place on the dominant side (P = 1.000). Groups had similar post-operative ASES scores (85.9 vs 73.6, P = .238), SANE scores (81.4 vs 78.6, P = .922), VAS (16.8 vs 32.5, P = .248). Furthermore, rates of participation in sport prior to surgery (P = .236), rate of return to sport following surgery (P = 1.000), and time it took to return to sport (P = .915) were similar between groups. Conclusion: Female patients undergoing surgical treatment of SLAP lesions with either arthroscopic or open BT show comparable subjective outcomes and return to sport at minimum 2 years. Further research is necessary to define precise treatment indications for this pathology in this specific female patient population