Thrower\u27s Exostosis of the Shoulder: A Systematic Review with a Novel Classification

Background: A variety of thrower\u27s exostoses are grouped under the term Bennett lesion, which makes understanding diagnosis and treatment difficult. Purpose: To identify all types of reported thrower\u27s and overhead athlete\u27s exostoses and categorize them into a classification system to allow a morphology-based classification. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of all articles pertaining to Bennett lesions and thrower\u27s exostosis was performed. The classification and treatments were evaluated to describe the types, proposed causes, diagnosis, and treatment options. Results: A total of 27 studies were included in the systematic review. The anatomic locations referenced in the study demonstrated posteroinferior, posterior, and posterosuperior glenoid lesions. Aggregate radiographic data demonstrated 158 of 306 patients (52%) with a thrower\u27s exostosis of any type and location. Of these 158 patients with a radiographic lesion, 119 (75%) patients were symptomatic. The locations were posteroinferior in 110 patients (70%), directly posterior in 2 patients (1.3%), posterosuperior in 44 patients (28%), and unknown in 2 patients (1.3%). Avulsed lesions were present in 9 (5.7%) posteroinferior lesions, 0 direct posterior lesions, and 2 (1.3%) posterosuperior lesions. Treatment plans included both nonoperative and operative strategies, but operative intervention was more commonly reported for detached lesions. After operative intervention, only 61% of reported athletes returned to preinjury performance. Conclusion: Based on a comprehensive review of the literature, we identified several anatomic locations for a thrower\u27s exostosis beyond the classic Bennett lesion. We categorized the reported exostoses into a new classification system for description of location and type (subperiosteal or free fragment) of the thrower\u27s exostosis, which may be used to study future treatments. Current treatment strategies recommend that surgical treatment of thrower\u27s exostosis is considered only after exhausting nonoperative management because reported return to sport is variable after surgery. The effectiveness of excision or repair for both subperiosteal and detached lesions has not been established

Return to Play and Performance Following Anterior Cruciate Ligament Reconstruction in the National Women’s Soccer League

Background: The anterior cruciate ligament (ACL) is a commonly injured ligament in athletes, usually requiring ACL reconstruction (ACLR). Hypothesis/Purpose: To compare the return to play (RTP) and performance level of players following ACLR in the National Women’s Soccer League (NWSL). We hypothesized that there would be a high return to play rate following ACLR in the NWSL, but with a decrease in performance. Methods: NWSL players that underwent ACLR were identified by cross-referencing multiple online resources that were identified between the 2013 and 2020 seasons. Players were classified into the following positions: forward, defender, midfielder, and goalkeeper. The following RTP statistics were assessed: games played, games started, percentage of minutes played, and plus/minus net per 90 minutes. A sub-analysis was also performed to divide players based on median age (≤ 24 vs. \u3e25) at time of injury. Since a majority of these outcomes significantly violated the assumption of normality, continuous variables were reported using medians and interquartile ranges and nonparametric testing methods were used throughout the analysis. Results: A total of 30 NWSL athletes underwent ACLR between the 2013 and 2020 seasons. Midfielders constituted the highest percentage of injuries (n=11, 36.7%) followed by forwards (n=10, 33.3%). Of these 30 players, 27 returned to the NWSL post-injury, constituting a 90.0% RTP rate. The median RTP time was 12.1 months [interquartile range (IQR), 10.9 – 14.3 months]. There was a statistically significant decrease in the percentage of minutes played 1-year pre- and post-injury [median 87.9 (IQR: 80.7 – 90.6) vs. 25.1 (IQR: 16.3 – 57.2); p=0.031]. On age based sub-analysis, older players started significantly more games [median 12.0 (IQR: 3.8 – 18.5) vs. 3.0 (0.5 – 6.0); p=0.048)] and had a higher percentage of minutes played [median 63.0 (IQR: 18.8 – 77.3) vs. 14.9 (2.0 – 21.2); p=0.046] 1-year post injury compared to younger players. Conclusion: Our results support the hypothesis that there is a high RTP rate following ACLR in the NWSL. Following injury, players played in a lower percentage of minutes in the season they returned, with older players starting more games and playing a greater percentage of minutes compared to younger players

Making Sense of Hip Preservation Procedural Coding--Getting Paid for Your Work!

Hip preservation and peri-trochanteric procedures are becoming more commonplace for the arthroplasty surgeon. Understanding the reimbursement for these procedures remains a challenge for those looking to expand this portion of their practice. In order to financially maximize the surgeon’s efforts, we present recommendations for hip preservation procedural coding

Optimizing the Double-Row Construct: An Untied Medial Row Demonstrates Equivalent Mean Contact Pressures in a Rotator Cuff Model

Background: The merits of a double-row rotator cuff repair (RCR) construct are well-established for restoration of the footprint and lateral-row security. The theoretical benefit of leaving the medial row untied is to prevent damage to the rotator cuff by tissue strangulation, and the benefit of suture tape is a more even distribution of force across the repair site. These benefits, to our knowledge, have not been evaluated in the laboratory. Hypothesis: Leaving the medial row untied and using a suture bridge technique with suture tape will offer more even pressure distribution across the repair site without compromising total contact force. Study Design: Controlled laboratory study. Methods: A laboratory model of RCR was created using biomechanical research-grade composite humeri and human dermal allografts. The pressure distribution in a double-row suture bridge repair construct was analyzed using the following testing matrix: double-loaded suture anchors with the medial row tied (n = 15) versus untied (n = 15) compared with double-loaded suture tape and anchors with the medial row tied (n = 15) versus untied (n = 15). A digital pressure sensor was used to measure pressure over time after tensioning of the repair site. A multivariate analysis of variance was used for statistical analysis with post hoc testing. Results: The total contact force did not significantly differ between constructs. The contact force between double-loaded suture anchors and double-loaded suture tape and anchors was similar when tied (P = .15) and untied (P = .44). An untied medial row resulted in similar contact forces in both the double-loaded suture anchor (P = .16) and double-loaded suture tape and anchor (P = .25) constructs. Qualitative increases in focal contact pressure were seen when the medial row was tied. Conclusion: An untied medial row did not significantly affect the total contact force with double-loaded suture anchors and with double-loaded suture tape and anchors. Tying the medial row qualitatively increased crimping at the construct\u27s periphery, which may contribute to tissue strangulation and hinder clinical healing. Qualitative improvements in force distribution were seen with double-loaded suture tape and anchors. Clinical Relevance: Both tied and untied medial rows demonstrated similar pressures across the repair construct

High Variability Exists in Reporting Clinical and Patient-Reported Outcome Measures Following Meniscal Surgery

Purpose: To evaluate the variability in outcomes following surgical meniscal repair and compare responsiveness between patient reported outcome measures (PROMs). Methods: A systematic search of the PubMed/MEDLINE and Web of Science databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. A total of 257 unique studies met inclusion criteria. Patient and study attributes were extracted, including pre- and postoperative means for PROMs. Of the studies that met inclusion criteria for responsiveness analysis (2+ PROMs reported, 1-year minimum follow-up; n=172), we compared the responsiveness between PROM instruments using effect size and relative efficiency (RE) if a PROM could be compared to another in at least 10 articles. Results: A total of 18,612 patients (18,690 menisci, mean age = 38.6 years, mean body mass index = 26.3 kg/m2) were included in this study. Thirty-five different PROM instruments were identified, and the mean number of PROMs in each article was 3.6. The most cited PROMs were Lysholm (74.5%) and International Knee Documentation Committee (IKDC) (51.0%). IKDC was found to be more responsive than other PROMs, which include Lysholm (RE=2.29), Tegner (RE=3.90), and Knee Injury and Osteoarthritis Outcome Score (KOOS) Activities of Daily Living (ADL) (RE=1.08). KOOS Quality of Life (QoL) was also more responsive than other PROMs, such as IKDC (RE=1.42) and KOOS ADL (RE=1.43). Lysholm was more responsive compared to KOOS QoL (RE=1.14), KOOS ADL (RE=1.96), and Tegner (RE=3.53). Conclusion: Our study found that IKDC, KOOS QoL, and Lysholm were the most responsive PROMs

Association between Pitch Break on the 4-Seam Fastball and Slider and Shoulder Injury in Major League Baseball Pitchers: A Case-Control Study

Background: Few specific risk factors are known for shoulder injury in professional pitchers. New pitch-tracking data allow for risk stratification based on advanced metrics. Purpose/Hypothesis: The purpose of this study was to determine the association between shoulder injury, pitch frequency, and pitch metrics (velocity, total break, break angle, and spin rate) for the 4-seam fastball, curveball, and slider. We hypothesized that more frequent use of the 4-seam fastball would be associated with shoulder injury. Study Design: Case-control study; Level of evidence, 3. Methods: The Major League Baseball (MLB) database was queried for pitchers who had been placed on the injury list (IL) with a shoulder injury between 2015 and 2019. Injured pitchers were matched 1:1 with controls (pitchers not on the IL with a shoulder injury during the study period), based on age (±1 year), history of ulnar collateral ligament reconstruction, position (starter vs reliever), and pitches thrown during the injury season (±500). Pitch frequency, velocity, horizontal break, vertical break, total break, and spin rate for the season were collected from the Baseball Savant website for the 4-seam fastball, curveball, and slider. Univariate analysis was used to determine group differences for individual variables. Multiple logistic regression was performed to determine odds ratios (ORs) for shoulder injury associated with pitch frequency, velocity, total break, break angle, and spin rate. Covariates included age, position, ulnar collateral ligament reconstruction status, expected weighted on-base average, and total pitches thrown. Results: Overall, 233 injured pitchers were evaluated. The most common reason for IL placement was inflammation (78/233; 33.5%) followed by strain or sprain (61/233; 26.2%). Increased total pitch break was associated with an increased risk of shoulder injury for the 4-seam fastball (OR, 1.340 [95% confidence interval (CI), 1.199-1.509]; P \u3c .001) and slider (OR, 1.360 [95% CI, 1.206-1.554]; P \u3c .001). For the slider, a decreased spin rate (OR = 0.998 [95% CI, 0.997-0.999]; P = .026) and a more vertical break angle (OR = 1.170 [95% CI: 1.073-1.278]; P = .004) were associated with increased risk of injury. Conclusion: Increased pitch break of the 4-seam fastball and slider was associated positively with shoulder injury in MLB pitchers. These findings add to the understanding of throwing injury and ability to detect risk using ball-tracking technology

More Elevated Fastballs Associated with Placement on the Injured List Due to Shoulder Injury

Purpose To evaluate whether impending shoulder injury was associated with changes in pitch location or velocity immediately preceding injury. Methods Pitchers placed on the injured list (IL) due to a shoulder injury between 2015 and 2020 were identified in the Major League Baseball transactions database. Four-seam fastball velocity and frequency of pitch location for each pitch type was collected for each player in the season before placement on the IL and within 1 month of placement on the IL with a minimum of 55 pitches thrown of 1 type. Pitch locations were collected as identified by Baseball Savant’s Game-Day Zones. Game-Day Zones were consolidated into high (above the strike zone midpoint) versus low, arm side (closer to the pitcher’s arm side of the plate) versus opposite side, and within the strike zone versus out of zone. Repeated measures analysis of variance determined differences in four-seam velocity and the location distribution of 4-seam fastballs, change-ups, and breaking balls among each group. Results In total, 267 pitchers were placed on the IL for a shoulder injury with the majority diagnosed with inflammation (89/267) followed by strain or sprain (69/267). Four-seam fastball locations significantly increased above the mid-point of the zone (45.9% vs 42.4%, P = .008) and out of the strike zone (48.5% vs 46.5%, P = .011) within a month before IL placement. There was no significant change in 4-seam fastball velocity immediately before IL placement. Conclusions Pitchers threw more elevated 4-seam fastballs and out-of-zone 4-seam fastballs in the month before IL placement for shoulder injury. These findings suggest that a loss of 4-seam fastball command decreases with impending shoulder injury. Level of Evidence IV, prognostic case series

Injury Rates in Major League Baseball during the 2020 COVID-19 Season

Background: The 2020 Major League Baseball (MLB) season was drastically altered because of the COVID-19 pandemic. The changes included an extended layoff between March and July as well as a shortened preseason. Purpose/Hypothesis: To determine the incidence and epidemiology of MLB injuries in the abbreviated 2020 season compared with prior seasons. We hypothesized that there was an increase in the overall injury rate in the 2020 season compared with the 2018-2019 seasons and that it equally affected all body regions. Study Design: Descriptive epidemiology study. Methods: The MLB transactions database was queried to find players who had been placed on the injury list between 2018 and 2020. Injuries were categorized into upper extremity, lower extremity, spine/core, and other injuries. Incidence per 1000 athlete-exposures was calculated for the prior 2 seasons (2018-2019) and for the 2020 season separately. Incidence for each category was also calculated separately for pitchers and fielders. Incidence rate ratios (IRRs) and confidence intervals were used to compare injury rates in 2018-2019 versus 2020. The z test for proportions was used to determine significant differences between injury incidences. Results: In 2020, the overall incidence rate per 1000 athlete-exposures was almost twice the rate compared with the 2 seasons before COVID-19 (8.66 vs 5.13; IRR, 1.69 [95% CI, 1.53-1.87]; P \u3c .001). Injury incidence increased similarly in 2020 for both pitchers (IRR, 1.68 [95% CI, 1.47-1.91]; P \u3c .001) and fielders (IRR, 1.68 [95% CI, 1.45-1.96]; P \u3c .001). Increases in injury incidence were seen in the upper extremity, spine/core, and other injury categories; however, the incidence of the lower extremity did not change significantly. Conclusion: There was a significant increase in injury incidence for both pitchers and fielders in 2020. Injury rates increased in anatomic zones of the upper extremity and spine/core but were not significantly changed in the lower extremity. The overall increase in injury rate suggests that irregular or insufficient sport-specific preparation prior to the start of the season placed athletes at a greater risk of injury when play resumed

Blood Flow Restriction Training After Patellar INStability (BRAINS Trial)

Background Patellar instability is a common and understudied condition that disproportionally affects athletes and military personnel. The rate of post-traumatic osteoarthritis that develops following a patellar dislocation can be up to 50% of individuals 5–15 years after injury. Conservative treatment is the standard of care for patellar instability however, there are no evidence-informed rehabilitation guidelines in the scientific literature. The purpose of this study is to assess the effectiveness of blood-flow restriction training (BFRT) for patellar instability. Our hypotheses are that this strategy will improve patient-reported outcomes and accelerate restoration of symmetric strength and knee biomechanics necessary to safely return to activity. Methods/Design This is a parallel-group, superiority, randomized, double-blinded, placebo-controlled clinical trial at the University of Kentucky, sports medicine clinic that aims to recruit 78 patients with acute patellar dislocations randomly allocated into two groups: (1) sham BFRT and (2) BFRT. Both groups will receive the current standard of care physical therapy 3 times per week for up to 9 weeks. Physical therapy sessions will consist of typical standard of care treatment followed by BFRT or sham BFRT. Primary outcomes include the Norwich Patellar Instability Scale, quadriceps strength, and imaging and biochemical biomarkers of cartilage degradation. Discussion The current standard of care for non-operative treatment of patellar instability is highly variable does not adequately address the mechanisms necessary to restore lower extremity function and protect the long-term health of articular cartilage following injury. This proposed novel intervention strategy uses an easily implementable therapy to evaluate if BFRT significantly improves patient-reported outcomes, function, and joint health over the first year of recovery. Trial Registration Blood Flow Restriction Training, Aspiration, and Intraarticular Normal Saline (BRAINS) NCT04554212. Registered on 18 September 2020

Stone-Wales Transformation Paths in Fullerene C60

The mechanisms of formation of a metastable defect isomer of fullerene C60 due to the Stone-Wales transformation are theoretically studied. It is demonstrated that the paths of the "dynamic" Stone-Wales transformation at a high sufficient for overcoming potential barriers) temperature can differ from the two "adiabatic" transformation paths discussed in the literature. This behavior is due to the presence of a great near-flat segment of the potential-energy surface in the neighborhood of metastable states. Besides, the sequence of rupture and formation of interatomic bonds is other than that in the case of the adiabatictransformation.Comment: 10 pages, 6 figure