DEFICIENCIES IN PITCHING BIOMECHANICS IN BASEBALL PITCHERS WITH A HISTORY OF SLAP REPAIR

Baseball pitchers who undergo SLAP (superior labrum, anterior to posterior) repair often have trouble returning to their previous level of performance. While the reason is often assumed to be diminished shoulder range of motion or other mechanical changes, differences in pitching biomechanics following surgery have not been previously studied. Pitching biomechanics were compared retrospectively between collegiate and professional pitchers with a history of a SLAP repair (n=10) and a control group (n=40) with no history of surgery. Full body biomechanics were compared between the two groups. For each comparison, a Student’s t-test was used at an a level of 0.05. Pitchers with history of SLAP repair produce less shoulder external rotation, shoulder horizontal abduction, and trunk forward tilt during pitching than pitchers with no history of injury

Patellofemoral Instability

Recurrent patellofemoral instability is a common cause of knee pain and functional disability in adolescent and young adult patients, resulting in loss of time from work and sports. There are numerous factors that contribute to recurrent patellofemoral instability; these factors include tear of the medial patellofemoral ligament (MPFL), weakening or hypoplasia of the vastus medialis obliquus (VMO), trochlear dysplasia, increased tibial tuberosity-trochlear groove (TT-TG) distance (>20 mm), valgus malalignment, increased Q angle, malrotation secondary to internal femoral or external tibial torsion, patella alta, and generalized ligamentous laxity. A detailed history and a thorough physical examination are crucial to clinch an early, accurate diagnosis. Imaging studies play an important role to confirm the clinical diagnosis and also help to identify concomitant intra-articular pathologies. Initially, nonoperative management (including the use of physical therapy, patellar taping or brace) is offered to patients with acute, first-time patellar dislocations and most patients respond well to this mode of treatment. Surgical treatment is indicated for patients who have post-trauma osteochondral fracture or loose body; predisposing anatomical risk factors; recurrent, symptomatic instability; and who have failed an adequate trial of nonoperative management. Surgical treatments include MPFL reconstruction, proximal or distal realignment procedures, and trochleoplasty. Lateral release is often performed in combination with other procedures and seldom performed as an isolated procedure. An individualized case-by-case approach is recommended based on the underlying anatomical risk factors and radiographic abnormality

Following Anterior Cruciate Ligament Reconstruction With Bone-Patellar Tendon-Bone Autograft, the Incidence of Anterior Knee Pain Ranges From 5.4% to 48.4% and the Incidence of Kneeling Pain Ranges From 4.0% to 75.6%: A Systematic Review of Level I Studies

PURPOSE: To (1) perform a systematic review of level I randomized controlled trials (RCTs) detailing the incidence of anterior knee pain and kneeling pain following anterior cruciate ligament reconstruction (ACLR) with bone-patellar tendon-bone (BPTB) autograft and (2) investigate the effect of bone grafting the patellar harvest site on anterior knee and kneeling pain. METHODS: A systematic review of level I studies from 1980 to 2023 was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The primary outcome evaluated was the presence of donor site morbidity in the form of anterior knee pain or kneeling pain. A secondary subanalysis was performed to assess for differences in the incidence of postoperative pain between patient groups undergoing ACLR with BPTB receiving harvest site bone grafting and those in whom the defect was left untreated. RESULTS: Following full-text review, 15 studies reporting on a total of 696 patients met final inclusion criteria. Patients were followed for an average of 4.78 years (range, 2.0-15.3), and the mean age ranged from 21.7 to 38 years old. The incidence of anterior knee pain, calculated from 354 patients across 10 studies, ranged from 5.4% to 48.4%. The incidence of postoperative pain with kneeling was determined to range from 4.0% to 75.6% in 490 patients from 9 studies. Patients treated with bone grafting of the BPTB harvest site had no significant difference in incidence of any knee pain compared with those who were not grafted, with incidences of 43.3% and 40.2%, respectively. CONCLUSIONS: Based on the current level I RCT data, the incidences of anterior knee pain and kneeling pain following ACLR with BPTB autograft range from 5.4% to 48.4% and 4.0% to 75.6%, respectively. LEVEL OF EVIDENCE: Level I, systematic review of RCTs

Acromioclavicular Joint Reconstruction

Our technique for acromioclavicular joint reconstruction provides a variation on coracoclavicular ligament reconstruction to also include acromioclavicular ligament reconstruction. An oblique acromial tunnel is drilled, and the medial limb of the gracilis graft, after being crossed and passed beneath the coracoid and through the clavicle, is passed through this acromial tunnel and sutured to the trapezoid graft limb after appropriate tensioning. Tenodesis screws are not placed in the bone tunnels to avoid graft fraying, and initial forces on the graft are offloaded with braided absorbable sutures passed around the clavicle

Iliotibial Band Lengthening: An Arthroscopic Surgical Technique

Iliotibial (IT) band syndrome is a common cause of lateral knee pain in runners and cyclists. Many can be treated nonoperatively; however, some may require surgical lengthening of their IT band to achieve optimal pain relief and a return to preinjury level of activity. Several studies have been published detailing surgical lengthening procedures and satisfactory outcomes after these procedures. However, it is important to continue to improve on and optimize outcomes. We present our arthroscopic IT band–lengthening procedure

Arthroscopic Piriformis Release—A Technique for Sciatic Nerve Decompression

Various techniques for piriformis muscle release have been published previously. However, it is imperative we continue to improve on existing techniques as well as develop new ones that may further optimize outcomes. Therefore, we aimed to describe an endoscopic technique for the release of the piriformis muscle in those with symptoms of sciatic nerve compression. Using the posterolateral portal, we are able to perform a complete release of the piriformis from the greater trochanter and the piriformis fossa with care to protect the external rotators and the sciatic nerve. It is our belief that this technique can be easily replicated by practitioners who read this technical note

Patella Footprint Technique—A Surgical Method for Medial Patellofemoral Ligament Reconstruction

Recurrent patella instability is a common condition that may potentiate substantial knee dysfunction resulting in loss of time from work and sports. There are numerous factors that contribute to recurrent patella instability including tearing of the medial patellofemoral ligament (MPFL), shallow trochlea, valgus alignment, externally rotated tibia tubercle, ligamentous laxity, elevated Q angle, and increased tibial tuberosity trochlear groove distance. Reconstruction of the MPFL has been shown to restore patella stability where concomitant pathology is within acceptable limits. Major complications include recurrence from inadequate MPFL reconstruction or failure to address other pathology, patella femoral pain from over constrained MPFL or unaddressed cartilage defects to the patella femoral compartment, or patella fracture. This technique provides a reproducible method of restoring patella stability through MPFL reconstruction while minimizing stress risers in the patella by using suture anchor fixation that creates a ligamentous footprint instead of tendon healing into a socket on the patella

The Addition of a Pericapsular Nerve Group Block for Postoperative Pain Control Does Not Result in Less Narcotic Use After Hip Arthroscopy: A Systematic Review

Purpose: To perform a systematic review of clinical studies evaluating the pericapsular nerve group (PENG) block in patients undergoing hip arthroscopy. Methods: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify comparative studies of patients undergoing the PENG block before hip arthroscopy. The search phrase used was hip arthroscopy pericapsular nerve block. Patients were evaluated based on analgesic consumption, time to discharge from the postanesthesia care unit (PACU), and pain scores (Numeric Rating Scale and visual analog scale). The Modified Coleman Methodology Score was used to evaluate study methodology quality. Results: Five studies (2 Level I, 3 Level III) met inclusion criteria. The 5 studies included the following comparison groups: 0.9% normal saline injection, general anesthesia alone, and general anesthesia with intraoperative pericapsular bupivacaine injection. The 2 randomized controlled trials included in this review reported no significant difference between groups regarding opioid consumption. One of these did not find any statistically significant differences in their secondary outcomes either, including patient satisfaction with analgesia, opioid-related adverse events, or persistent opioid use at 1 week. However, the other 3 studies found significantly lower opioid consumption in patients receiving the PENG block versus the control group intraoperatively, in the PACU, and/or postoperatively. Four studies reported significantly lower pain levels in the PENG block group compared with the control groups, measured differently in each study: 24 hours postoperatively, initial pain score in the PACU, mean score in the PACU, and highest score in the PACU. None of the studies found significantly worse outcomes in the PENG block group compared to the comparison group. Conclusions: Systematic review of randomized controlled trials shows that patients undergoing hip arthroscopy who receive a PENG block do not consume fewer opioids for postoperative pain control than patients who do not receive the block. Level of Evidence: Level III, systematic review of Level I-III studies