Faculty Bibliography

AIMS/UNASSIGNED:The aim of this study was to establish consensus statements on medial patellofemoral ligament (MPFL) reconstruction, anteromedialization tibial tubercle osteotomy, trochleoplasty, and rehabilitation and return to sporting activity in patients with patellar instability, using the modified Delphi process. METHODS/UNASSIGNED:This was the second part of a study dealing with these aspects of management in these patients. As in part I, a total of 60 surgeons from 11 countries contributed to the development of consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered unanimous. RESULTS/UNASSIGNED:Of 41 questions and statements on patellar instability, none achieved unanimous consensus, 19 achieved strong consensus, 15 achieved consensus, and seven did not achieve consensus. CONCLUSION/UNASSIGNED:Most statements reached some degree of consensus, without any achieving unanimous consensus. There was no consensus on the use of anchors in MPFL reconstruction, and the order of fixation of the graft (patella first versus femur first). There was also no consensus on the indications for trochleoplasty or its effect on the viability of the cartilage after elevation of the osteochondral flap. There was also no consensus on postoperative immobilization or weightbearing, or whether paediatric patients should avoid an early return to sport.

AIMS/UNASSIGNED:The aim of this study was to establish consensus statements on the diagnosis, nonoperative management, and indications, if any, for medial patellofemoral complex (MPFC) repair in patients with patellar instability, using the modified Delphi approach. METHODS/UNASSIGNED:A total of 60 surgeons from 11 countries were invited to develop consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest within patellar instability. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered to be unanimous. RESULTS/UNASSIGNED:Of 27 questions and statements on patellar instability, three achieved unanimous consensus, 14 achieved strong consensus, five achieved consensus, and five did not achieve consensus. CONCLUSION/UNASSIGNED:The statements that reached unanimous consensus were that an assessment of physeal status is critical for paediatric patients with patellar instability. There was also unanimous consensus on early mobilization and resistance training following nonoperative management once there is no apprehension. The statements that did not achieve consensus were on the importance of immobilization of the knee, the use of orthobiologics in nonoperative management, the indications for MPFC repair, and whether a vastus medialis oblique advancement should be performed.

PURPOSE/OBJECTIVE:The purpose of this study was to establish consensus statements on the treatment of UCL injuries and to investigate whether consensus on these distinct topics could be reached. METHODS:A modified consensus technique was conducted among twenty-six elbow surgeons and 3 physical therapists/athletic trainers. Strong consensus was defined as 90-99% agreement. RESULTS:Of the 19 total questions and consensus statements 4 achieved unanimous consensus, 13 achieved strong consensus, and 2 did not achieve consensus. CONCLUSION/CONCLUSIONS:There was unanimous agreement that the risk factors include overuse, high velocity, poor mechanics, and prior injury. There was unanimous agreement that advanced imaging in the form of either an MRI or MRA should be performed in a patient presenting with suspected/known UCL tear that plans to continue to play an overhead sport, or if the imaging study could change the management of the patient. There was unanimous agreement regarding lack of evidence for the use of orthobiologics in the treatment of UCL tears as well as the areas pitchers should focus on when attempting a course of non-operative management. The statements that reached unanimous agreement for operative management were regarding operative indications and contraindications for UCL tears, prognostic factors that should be taken into consideration in when performing UCL surgery, how to deal with the flexor-pronator mass during UCL surgery and use of an internal brace with UCL repairs. Statements that reached unanimous agreement for RTS were regarding: portions of the physical exam should be considered when determining whether to allow a player to RTS, unclear how velocity, accuracy, and spin rate should be factored into the decision of when players can RTS and sports psychology testing should be used to determine whether a player is ready to RTS. LEVEL OF EVIDENCE/METHODS:Expert opinion (Level V).

Postoperative rehabilitation is a critical part of the treatment algorithm for patients with shoulder issues. When patients could not go to in-person therapy, many therapists pivoted to a remote option, and several application-based rehabilitation programs emerged. This article will discuss the shift to remote patient rehabilitation and will highlight the benefits and potential pitfalls of remote rehabilitation. It will also discuss ways to monitor patients remotely as they are performing their postoperative rehabilitation exercises. Finally, it will discuss how these remote platforms can be used, and what the user experience is like for the patient and the surgeon.

INTRODUCTION/BACKGROUND:In an effort to preserve bone, humeral stems in reverse total shoulder arthroplasty (RTSA) have gradually decreased in length. The purpose of this study was to compare the immediate postoperative radiographic appearance of short-length with standard-length RTSA stems. METHODS:Patients who underwent RTSA using a press-fit standard-length or short-length humeral implant with a consistent geometry (Univers Revers or Revers Apex) were evaluated in a multicenter retrospective review. Initial postoperative radiographs were used to assess initial alignment and filling ratios. In addition, radiographs were evaluated for early signs of stress shielding and/or loosening. Clinical outcome scores and range of motion were also evaluated. RESULTS:Overall, 137 short-length stems and 139 standard-length stems were analyzed. Initial radiographs demonstrated a significantly higher percentage of stems placed in neutral alignment in the short-stem group (95.6% vs 89.2%, P = 0.045). Similar metaphyseal filling ratios were seen between groups, but a significantly higher diaphyseal filling ratio was observed in the short-stem group (57% vs 34%, P < 0.001). Less calcar osteolysis (2.2% vs 12.9%; P = 0.001) and fewer overall number of radiographic changes (tuberosity resorption, lucencies, and subsidence) (0.7% vs 5.0%; P = 0.033) were seen with short stems compared with the standard-length stems. CONCLUSION/CONCLUSIONS:RTSA with a short-stem humeral implant demonstrates excellent radiographic outcomes, including low rates of loosening and subsidence at 1 year, with less early calcar osteolysis compared with a standard-length stem. LEVEL OF EVIDENCE/METHODS:III (Case-control).

BACKGROUND:While reverse shoulder arthroplasty (RTSA) has excellent reported outcomes and satisfaction, patients often have postoperative limitations in range of motion (ROM), specifically internal rotation. Increased lateralization is thought to improve ROM following RTSA. The purpose of this study was to evaluate the association between radiographic measurements of lateralization and postoperative ROM and clinical outcome scores following RTSA. The authors hypothesized that increased radiographic lateralization would be associated with improved postoperative ROM, specifically internal rotation, but have no significant association with clinical outcome scores. METHODS:Patients who underwent RTSA with a 135° neck shaft angle prosthesis and minimum 2 year clinical and radiographic follow-up were included and retrospectively reviewed. Postoperative radiographs were evaluated for several lateralization measurements including the lateralization shoulder angle (LSA), distance from lateral border of acromion to lateral portion of glenosphere, distance from the glenoid to the most lateral aspect of the greater tuberosity and the distance from the lateral aspect of acromion to the most lateral aspect of the greater tuberosity. Linear regression analyses were utilized to evaluate the independent association of each radiographic measurement of lateralization on forward flexion (FF), external rotation (ER), internal rotation (IR) and the American Shoulder and Elbow Surgeons (ASES) index score at 2 years postoperative. Receiver operator curves (ROC) were constructed to identify and significant thresholds of each radiographic lateralization measurement. RESULTS:203 patients were included. For internal rotation, a greater LSA (p=0.007), shorter acromion to glenosphere distance (meaning more glenoid lateralization) (p=0.005) and a greater acromion to greater tuberosity distance (with the tuberosity more lateral to the acromion) (p=0.021) were associated with improved IR. Overall, ROC analysis demonstrated very little significant data, the most notable of which was the LSA, which had a significant cutoff of 82 degrees (sensitivity 57%, specificity 68%, p = 0.012). CONCLUSION/CONCLUSIONS:Of the numerous radiographic measures of lateralization after RTSA, the LSA is the most significantly associated with outcomes, including improved internal rotation, and a decrease in forward flexion and ASES score. The clinical significance of these statistically significant findings requires further study, as the observed associations were for very small changes that may not represent clinical significance.

BACKGROUND:While results following ulnar collateral ligament reconstruction (UCLR) in baseball players have been well documented, the literature is replete regarding the outcomes following UCLR in javelin thrower. PURPOSE/OBJECTIVE:To report outcomes following UCLR in javelin throwers HYPOTHESIS: UCLR in javelin throwers will result in a high rate of return to play (RTP) similar to that of previously published studies from athletes of other sports. METHODS:All patients who were identified preoperatively as javelin throwers and underwent UCLR between 2011 -2017 with a minimum 2-year follow-up were eligible for inclusion. Patients were assessed with Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow Score (KJOC), Timmerman-Andrews Elbow Score, Conway-Jobe Score, patient satisfaction, return to sport rate questionnaire and the occurrence of any postoperative complications. RESULTS:There were 18 patients who met the inclusion criteria. Complete follow-up was available in 16 (88.9%) patients. The average age at surgery was 21.2 +/- 2.0 (range, 18.6 to 24.9) years. At final follow-up, the average KJOC score and Timmerman-Andrews Elbow Scores were 77.3 (range, 18.7 - 98.4) and 91.8 (range, 70.0 to 100.0), respectively. Outcomes on the Conway-Jobe scale were as follows: excellent (n=6; 37.5%), good (n=4; 25%), fair (n=6; 37.5%). Ten (62.5%) patients returned to play at an average of 12.2 +/- 3.6 (range, 6.0 to 18.0) months after surgery. Two (12.5%) patients sustained a shoulder injury postop; however, neither required surgery. CONCLUSION/CONCLUSIONS:UCLR in javelin throwers results in good outcomes with a low rate of re-injury/re-operation. However, the RTP rate (62.5%) and good/excellent outcomes per the Conway Jobe scale (68.8%) are lower than what has been previously reported in baseball players and javelin throwers. Further investigation regarding outcomes in javelin throwers following UCLR is warranted.

PURPOSE OF REVIEW/OBJECTIVE:As the population continues to age and indications continue to expand, the number of reverse total shoulder arthroplasty (RSTA) procedures has increased significantly. While RTSA is an effective solution to many shoulder problems, it is not without complications. Furthermore, as the number of RTSA procedures increases, so will the number of complications following this procedure. While some complications can be managed with revision RTSA, there are some complications that, unfortunately, cannot. The purpose of this review is to discuss the revision options for failed RTSA. RECENT FINDINGS/RESULTS:While there has been a significant amount of recent literature surrounding RTSA, much of this literature has been aimed at improving outcomes for primary RTSA by improving glenoid placement, maximizing range of motion, etc., or improving outcomes following conversion of another surgery to RTSA [1••, 2, 3]. There has been little evidence surrounding options for failed RTSA that cannot be salvaged to a revision RTSA. These options are limited and often involve resection arthroplasty and hemiarthroplasty, although neither option provides patients with significant function of the shoulder [4, 5•]. Complications following RTSA are becoming more common as the number of RTSA continues to increase. Furthermore, as the indications for RTSA expand, the complications will continue to increase as this implant is used to tackle more difficult problems about the shoulder. When possible, the etiology of the problem with the RTSA should be addressed and may involve component revision, bone grafting, etc. When the problem cannot be solved with revision RTSA, then the patient can be converted to a hemiarthroplasty, or have a resection arthroplasty, with the understanding that their shoulder function will be limited.

Background/UNASSIGNED:There are some professional baseball players who begin their career as a position player and later convert to a pitcher; injury rates in these players are unknown. Purpose/UNASSIGNED:To compare injury rates of professional baseball players who started their career as position players and converted to pitchers with a control group of pitchers who have been only pitchers throughout their professional career. Hypothesis/UNASSIGNED:Injury rates would be lower in the conversion players. Study Design/UNASSIGNED:Cohort study; Level of evidence, 3. Methods/UNASSIGNED:All players who began their professional baseball career as position players and converted to pitchers between 2011 and 2018 were included. All injuries that occurred after they converted to pitchers were included. The conversion players were matched 1 to 1 with a control group of pitchers who entered professional baseball as pitchers and never changed position. Injury rates were compared between groups. The performance between groups was also compared. Results/UNASSIGNED:= .018). Conclusion/UNASSIGNED:Professional baseball players who convert from position players to pitchers are injured at lower rates than control pitchers. Conversion pitchers have lower pitcher usage, which may contribute to their reduced injury rates.

BACKGROUND/UNASSIGNED:Ulnar collateral ligament (UCL) reconstruction (UCLR) is a viable treatment option for patients with UCL insufficiency, especially in the overhead throwing athlete. Within the clinical literature, there is still no universally agreed upon optimal rehabilitation protocol and timing for return to sport (RTS) after UCLR. HYPOTHESIS/UNASSIGNED:There will be significant heterogeneity with respect to RTS criteria after UCLR. Most surgeons will utilize time-based criteria rather than functional or performance-based criteria for RTS after UCLR. STUDY DESIGN/UNASSIGNED:Systematic review; Level of evidence, 4. METHODS/UNASSIGNED:All level 1 to 4 studies that evaluated UCLR with a minimum 1-year follow-up were eligible for inclusion. Studies lacking explicit RTS criteria, studies that treated UCL injury nonoperatively or by UCL repair, or studies reporting revision UCLR were excluded. Each study was analyzed for methodologic quality, RTS, timeline of RTS, and RTS rate. RESULTS/UNASSIGNED:Overall, 1346 studies were identified, 33 of which met the inclusion criteria. These included 3480 athletes across 21 different sports. All studies reported RTS rates either as overall rates or via the Conway-Jobe scale. Timelines for RTS ranged from 6.5 to 16 months. Early bracing with progressive range of motion (ROM) (93.9%), strengthening (84.8%), and participation in an interval throwing program (81.8%) were the most common parameters emphasized in these rehabilitation protocols. While all studies included at least 1 of 3 metrics for the RTS value assessment, most commonly postoperative rehabilitation (96.97%) and set timing after surgery (96.97%), no article completely defined RTS criteria after UCLR. CONCLUSION/UNASSIGNED:Overall, 93.9% of studies report utilizing bracing with progressive ROM, 84.8% reported strengthening, and 81.8% reported participation in an interval throwing program as rehabilitation parameters after UCLR. In addition, 96.97% reported timing after surgery as a criterion for RTS; however, there is a wide variability within the literature on the recommended time from surgery to return to activity. Future research should focus on developing a comprehensive checklist of functional and performance-based criteria for safe RTS after UCLR.