Michael T. Freehill, MD, FAOA

All Publications

• Glenoid Structural Bone Grafting in Reverse Total Shoulder Arthroplasty: Clinical and Radiographic Outcomes. Journal of shoulder and elbow surgery Sholtis, C., Kha, S. T., Ramakrishnan, A., Abrams, G. D., Freehill, M. T., Cheung, E. V. 2024

  Abstract

  Current options for reconstruction of large glenoid defects in reverse total shoulder arthroplasty (RTSA) include structural bone grafting, utilization of augmented components, or 3D printed custom implants. Given the paucity in the literature on structural bone grafts in RTSA, this study reflects our experience on clinical and radiographic outcomes of structural bone grafts utilized for glenoid defects in RTSA.We identified 33 consecutive patients who underwent RTSA utilizing structural bone grafts for glenoid bone loss between 2008 and 2019. Twenty-six patients with mean clinical follow-up of 4.4 ± 3.9 years and mean radiographic follow-up of 2.7 ± 3.2 years were included. Patient demographic data, peri-operative functional outcomes, radiographic outcomes, complications, and re-operation rates were determined.Between 2008 and 2019, 26 RTSAs were performed utilizing structural autograft or allograft for glenoid defects. There were 20 females (77%) and 6 males (23%), with mean presenting age of 68 years (range 41-86), mean BMI of 29 (range 21-44) and mean Charlson Comorbidity Index of 3 (range 0-8). There were 19 cases of central glenoid defects, and 7 were combined central and peripheral defects. Structural grafts included humeral head autograft (7), proximal humerus autograft (7), iliac crest autograft (7), distal clavicle autograft (2), and femoral head allograft (3). All eighteen revision RTSA cases had simultaneous humeral-sided revision. There was significant postoperative improvement in ASES scores (27.0 ± 12.6 preop vs. 59.8 ± 24.1 postop; p<0.001) and VAS scores (8.1 ± 3.6 preop vs. 3.0 ± 3.2 postop; p<0.001). Range of motion improved significantly for active forward elevation (63 ± 36º preop vs. 104 ± 36º postop; p<0.001) and external rotation (21 ± 20º preop vs. 32 ± 23º postop, p=0.036). Eighty-eight percent (23/26) of cases had successful reconstruction of the glenoid, defined as no visible radiolucent lines nor glenoid component migration at final follow-up. Re-operation rate was 19% (5/26) Postoperative complications included 2 cases of acromial stress fractures that were treated non-operatively, for a total complication rate (including re-operation) of 27% (7/26 cases).The use of structural bone autografts and allografts in RTSA was associated with improved outcome scores and range of motion. A reoperation rate of 19% and total complication rate of 27% were reported for these challenging cases. However, 86% of these complications were not related to structural glenoid reconstruction failure. Structural grafts are a reasonable option for glenoid reconstruction in RTSA cases with glenoid bone loss.

  View details for DOI 10.1016/j.jse.2024.05.008

  View details for PubMedID 38944375

• Youth Pitcher Fatigue: Medial Elbow Laxity, Ultrasonographic Assessment of Flexor-Pronator Mass Energy Depletion, and Association With Pitch Count. Orthopaedic journal of sports medicine Schubert, M. F., Awan, T. M., Sciascia, A. D., Figueroa, E. G., DeMink, J. M., Selak, D. M., Snyder, C. M., Gagnier, J. J., Freehill, M. T. 2024; 12 (6): 23259671241256294

  Abstract

  Ulnar collateral ligament (UCL) injuries in youth pitchers continue to be concerning despite the institution of pitch count limits. Flexor-pronator mass fatigue can lead to diminished dynamic stability, resulting in greater stress on the UCL.To evaluate fatigue of the flexor-pronator mass by assessing changes in medial elbow laxity; noninvasively characterizing alterations in muscle glycogen; and identifying changes in subjective fatigue, strength, range of motion (ROM), pitching velocity, and accuracy with increasing pitches thrown by youth pitchers to their recommended 75-pitch count limit. It was hypothesized that, with increased pitches, medial elbow laxity would increase and that the glycogen content of the flexor-pronator mass would decrease.Descriptive laboratory study.Healthy male pitchers aged 10 years (n = 22) threw 3 sets of 25 pitches with 12 minutes between sets (3 timepoints). Bilateral ulnohumeral joint gapping was measured by applying a standardized valgus force and utilizing ultrasound imaging. Relative changes in muscle glycogen in the bilateral flexor carpi radialis (FCR), and the flexor digitorum superficialis/flexor carpi ulnaris (FDS/FCU) muscles were measured with ultrasound software and recorded as fuel percentiles. Additional measures obtained included subjective fatigue, strength, ROM, velocity, and accuracy.There were no differences in medial elbow joint-line gapping between the throwing and nonthrowing arms or between timepoints. The throwing arm demonstrated a significant decline in fuel percentile of the FCR from baseline to after 75 pitches (P = .05). There were no differences across timepoints for FDS/FCU fuel percentile values. Fatigue measurements for both arms were significantly higher at all timepoints compared with baseline (P≤ .03). Grip strength of the dominant arm after 75 pitches was decreased significantly compared with after 25 pitches (P = .02).Although an increase in medial elbow joint gapping was not demonstrated within the recommended 75 pitch count limit in 10-year-olds, a relative decrease in glycogen stores of the flexor-pronator mass did occur, as well as a decrease in grip strength, with increasing subjective fatigue.This study provides a foundation for further objective testing of physiologic changes that occur with pitching to better guide pitch count limits and improve the safety of young athletes.

  View details for DOI 10.1177/23259671241256294

  View details for PubMedID 38895136

  View details for PubMedCentralID PMC11184999

• High variability among surgeons in evaluation, treatment, and rehabilitation of medial ulnar collateral ligament injuries. JSES reviews, reports, and techniques Sambare, N. D., Chalmers, P. N., Camp, C. L., Bowman, E. N., Erickson, B. J., Sciascia, A., Freehill, M. T., Smith, M. V. 2024; 4 (2): 182-188

  Abstract

  The incidence of elbow medial ulnar collateral ligament (MUCL) injuries has been increasing, leading to advances in surgical treatments. However, it is not clear that there is consensus among surgeons regarding diagnostic imaging, the indications for acute surgery and postoperative rehabilitation. The purpose of this study is evaluate surgeon variability in the presurgical, surgical, and postsurgical treatment of MUCL injuries regarding the imaging modalities used for diagnosis, indications for acute surgical treatment, and postoperative treatment recommendations for rehabilitation and return to play (RTP). Our hypothesis is that indications for acute surgical treatment will be highly variable based on MUCL tear patterns and that agreement on the time to RTP will be consistent for throwing athletes and inconsistent for nonthrowing athletes.A survey developed by 6 orthopedic surgeons with expertise in throwing athlete elbow injuries was distributed to 31 orthopedic surgeons who routinely treat MUCL injuries. The survey evaluated diagnostic and treatment topics related to MUCL injuries, and responses reaching 75% agreement were considered as high-level agreement.Twenty-four surgeons responded to the survey, resulting in a 77% response rate. There is 75% or better agreement among surveyed surgeons regarding acute surgical treatment for distal full thickness tears, ulnar nerve transposition in symptomatic patients or with ulnar nerve subluxation, postoperative splinting for 1-2 weeks with initiation of rehabilitation within 2 weeks, the use of bracing after surgery and the initiation of a throwing program at 3 months after MUCL repair with internal brace by surgeons performing 20 or more MUCL surgeries per year. There were a considerable number of survey topics without high-level agreement, particularly regarding the indications for acute surgical treatment, the time to return to throwing and time RTP in both throwing and nonthrowing athletes.The study reveals that there is agreement for the indication of acute surgical treatment of distal MUCL tears, duration of bracing after surgery, and the time to initiate physical therapy after surgery. There is not clear agreement on indications for surgical treatment for every MUCL tear pattern, RTP time for throwing, hitting and participation in nonthrowing sports.

  View details for DOI 10.1016/j.xrrt.2024.01.011

  View details for PubMedID 38706672

  View details for PubMedCentralID PMC11065763

• Augmented Ulnar Collateral Ligament Repair With Structural Bioinductive Scaffold: A Biomechanical Study. The American journal of sports medicine Lin, K. M., Brinson, K., Atzmon, R., Chan, C. K., Sherman, S. L., Safran, M. R., Freehill, M. T. 2024: 3635465241236465

  Abstract

  Elbow ulnar collateral ligament (UCL) repair with suture brace augmentation shows good time-zero biomechanical strength and a more rapid return to play compared with UCL reconstruction. However, there are concerns about overconstraint or stress shielding with nonabsorbable suture tape. Recently, a collagen-based bioinductive absorbable structural scaffold has been approved by the Food and Drug Administration for augmentation of soft tissue repair.This study aimed to assess the initial biomechanical performance of UCL repair augmented with this scaffold. We hypothesized that adding the bioinductive absorbable structural scaffold to primary UCL repair would impart additional time-zero restraint to the valgus opening.Controlled laboratory study.Eight cadaveric elbow specimens-from midforearm to midhumerus-were utilized. In the native state, elbows underwent valgus stress testing at 30o, 60o, and 90o of flexion, with a cyclical valgus rotational torque. Changes in valgus rotation from 2- to 5-N·m torque were recorded as valgus gapping. Testing was then performed in 4 states: (1) native intact UCL-with dissection through skin, fascia, and muscle down to an intact UCL complex; (2) UCL-transected-distal transection of the ligament off the sublime tubercle; (3) augmented repair with bioinductive absorbable scaffold; and (4) repair alone without scaffold. The order of testing of repair states was alternated to account for possible plastic deformation during testing.The UCL-transected state showed the greatest increase in valgus gapping of all states at all flexion angles. Repair alone showed similar valgus gapping to that of the UCL-transected state at 30° (P = .62) and 60° of flexion (P = .11). Bioinductive absorbable scaffold-augmented repair showed less valgus gapping compared with repair alone at all flexion angles (P = .021, P = .024, and P = .024 at 30°, 60°, and 90°, respectively). Scaffold-augmented repair showed greater gapping compared with the native state at 30° (P = .021) and 90° (P = .039) but not at 60° of flexion (P = .059). There was no difference when testing augmented repair or repair alone first.UCL repair augmented with a bioinductive, biocomposite absorbable structural scaffold imparts additional biomechanical strength to UCL repair alone, without overconstraint beyond the native state. Further comparative studies are warranted.As augmented primary UCL repair becomes more commonly performed, use of an absorbable bioinductive scaffold may allow for improved time-zero mechanical strength, and thus more rapid rehabilitation, while avoiding long-term overconstraint or stress shielding.

  View details for DOI 10.1177/03635465241236465

  View details for PubMedID 38650304

• High Accuracy of Intra-articular Needle Position during Anterior Landmark Guided Glenohumeral Injections. Journal of ISAKOS : joint disorders & orthopaedic sports medicine Bartels, D., Pullen, W. M., Curtis, D., Sherman, S. L., Abrams, G. D., Cheung, E. V., Freehill, M. T., Wang, T. 2024

  Abstract

  Image-guided ultrasound or fluoroscopic glenohumeral injections have high accuracy rates, but require training, equipment, cost, and radiation exposure (fluoroscopy). In contrast, landmark-guided glenohumeral injections do not require additional subspecialist referral or equipment. An optimal technique would be safe, accurate, and have few barriers to implementation. The purpose of this study was to define the accuracy of glenohumeral needle placement via an anterior landmark-guided approach as assessed by direct arthroscopic visualization.A consecutive series of adult patients undergoing shoulder arthroscopy in the beach chair position were included in this study. Demographic and procedural data were collected. Time required to perform the injection, precise location of the needle-tip, and factors that affected accuracy of injection were also assessed.A standardized anterior landmark-guided glenohumeral joint injection was performed in the operating room prior to surgery and location of the needle tip was documented by arthroscopic visualization with a low complication profile and few barriers to implementation. A total of 81 patients were enrolled. Successful intra-articular glenohumeral needle placement by Sports Medicine and Shoulder/elbow fellowship trained orthopaedic surgeons was confirmed in 93.8% (76/81) of patients. Average time to complete the procedure was 24.8 seconds. There were no patient-related variables associated with non-intra-articular injection in the cohort.This study demonstrated a technique of anterior landmark-guided glenohumeral injection has an accuracy of 93.8% and requires less than 30 seconds to perform. This method is safe, yields similar accuracy to image-guided procedures with improved cost-and time-efficiency, and less radiation exposure. No patient-related factors were associated with inaccurate needle placement. Anterior landmark-guided glenohumeral injections may be utilized with confidence by providers in the clinical setting.Level 5.

  View details for DOI 10.1016/j.jisako.2024.03.016

  View details for PubMedID 38574995

• Interval Throwing Programs for Baseball Players: Methodological Assessment of the Quality and Construct of Publicly Available Programs. Sports health Boos, A. M., Sambare, N., Smith, M. V., Freehill, M. T., Bowman, E. N., Erickson, B. J., Chalmers, P. N., Sciascia, A., Camp, C. L. 2024: 19417381241237011

  Abstract

  The quality and interprogram variability of publicly available throwing programs have not been assessed.To (1) identify publicly available interval throwing programs, (2) describe their components and structure, and (3) evaluate their quality, variability, and completeness.Google, Bing, Yahoo; keyword: "interval throwing program."Baseball-specific publicly available programs.Systematic review.Level 4.Independent evaluation by 2 authors using a novel 21-item Quality Assessment Rubric (QAR).Of the 99 included programs, 54% were designed for return from injury/surgery; 42% explicitly stated no expected timeline for completion, and approximately 40% did not provide criteria to initiate the program. Program construction was highly variable. There were broad-ranging shortest (mean: 40±8 ft, range: 20-45 ft) and longest (mean: 150±33 ft, range: 90-250 ft) long toss distances, and variable maximum numbers of mound pitches thrown before returning to game play (range: 40-120, mean: 85). Only 63% of programs provided guidelines for handling setbacks, and standardized warm-ups, arm care, and concomitant training were absent in 32%, 63%, and 47% of programs, respectively. Mean QAR completion rate and QAR item response rate were low (62 ± 4% [range, 24-91%], 62 ± 24% [range, 7-99%], respectively). Finally, only 20 (20%) programs provided at least 1 peer-reviewed reference, most of which were published >10 years ago.Publicly available interval throwing programs are readily available but demonstrate significant interprogram heterogeneity across multiple areas including target audience, program construction, progression, and execution. The quality and consistency of publicly available interval throwing programs is poor at this time, which may limit their utility and effectiveness for baseball players attempting to return to competition. This work identifies a multitude of deficiencies in currently available throwing programs that should be targets of future improvement efforts.

  View details for DOI 10.1177/19417381241237011

  View details for PubMedID 38546157

• Early single sport specialization does not improve pitching velocity, motion, strength, or utilization in high school baseball pitchers. JSES reviews, reports, and techniques Camp, C. L., Erickson, B. J., Bowman, E. N., Freehill, M. T., Smith, M. V., Christoffer, D., Clinker, C., Ishikawa, H., Thomas, L., Chalmers, P. N. 2023; 3 (4): 506-510

  Abstract

  The impact of single-sport specialization on performance and injury risk in youth and adolescent athletes remains debated. The purpose of this study was to determine the incidence of single-sport specialization and its association with pitch velocity, pitcher utilization, range of motion, strength, and injury history.High school pitchers in the Northeastern, Southeastern, Midwestern, and Western Regions of the United States were prospectively recruited. Prior to the season, pitchers were surveyed about their basic demographics, sport participation history, and injury history. At this timepoint, a standardized physical examination was performed and max pitch velocity was measured. They were then prospectively followed over the ensuing high school season, where pitch utilization and counts were followed and injuries were tracked.Across the study, 115 pitchers were recruited, of whom 53% played baseball as their only sport and 47% played other sports. Single- position specialization within baseball was uncommon as 90% of athletes played positions other than pitcher. There were no differences in range of motion, strength, or pitch velocity between multisport athletes and single-sport specialists. Within the multisport group, 26% reported a history of injury, while 38% of the single-sport specialists reported a history of injury (P = .179). There were no significant differences in pitcher utilization between multisport athletes and single-sport specialists. Only a single prospective injury occurred in the 115 players.Although single-sport specialization is common, nearly half of all high school pitchers in this study were multisport athletes. While injury history was generally similar between the two groups, single-sport baseball players did not have the following: improved motion, increased strength, higher ball velocity, or greater pitching volumes during the high school baseball season compared to multisport athletes. Accordingly, single-sport specialization did not have a competitive advantage for these high school pitchers based on the performance factors studied. Further prospective studies are necessary to understand the association between single-sport specialization and injury risk in high school baseball players.

  View details for DOI 10.1016/j.xrrt.2023.04.008

  View details for PubMedID 37928989

  View details for PubMedCentralID PMC10625003

• Validation of Mixed Reality Surgical Navigation for Glenoid Axis Pin Placement in Shoulder Arthroplasty Using a Cadaveric Model. Journal of shoulder and elbow surgery Sanchez-Sotelo, J., Berhouet, J., Chaoui, J., Freehill, M. T., Collin, P., Warner, J., Walch, G., Athwal, G. 2023

  Abstract

  Mixed reality may offer an alternative for computer-assisted navigation in shoulder arthroplasty. The purpose of this study was to determine the accuracy and precision of mixed reality guidance for placement of the glenoid axis pin in cadaver specimens. This step is essential for accurate glenoid placement in total shoulder arthroplasty.Fourteen cadaveric shoulders underwent simulated shoulder replacement surgery by seven experienced shoulder surgeons. The surgeons exposed the cadavers through a deltopectoral approach, and then used mixed reality surgical navigation to insert a guide pin in a pre-planned position and trajectory in the glenoid. The mixed reality system utilized Microsoft Hololens 2 headset, navigation software, dedicated instruments with fiducial marker cubes, and a securing pin. CT scans obtained before and after the procedure were used to plan the surgeries and to determine the difference between the planned and the executed values for the entry point, version, and inclination. One specimen had to be discarded from the analysis because the guide pin was removed accidentally prior to obtaining the post-procedure CT scan.Regarding the navigated entry point on the glenoid, the mean difference between planned and executed values was 1.7±0.8 mm; this difference was 1.2 ± 0.6 mm in the superior-inferior direction and 0.9 ± 0.8 mm in the anterior-posterior direction. The maximum deviation from the entry point for all 13 specimens analyzed was 3.1 mm. Regarding version, the mean difference between planned and executed version values was 1.6±1.2 degrees, with a maximum deviation in version for all 13 specimens of 4.1 degrees. Regarding inclination, the mean angular difference was 1.7 ± 1.5 degrees, with a maximum deviation in inclination of 5 degrees.The mixed reality navigation system utilized in this study allowed surgeons to insert the glenoid guide pin on average within 2 mm from the planned entry point and within 2 degrees of version and inclination. The navigated values did not exceed 3 mm or 5 degrees respectively for any of the specimens analyzed. This approach may help surgeons more accurately place the definitive glenoid component.

  View details for DOI 10.1016/j.jse.2023.09.027

  View details for PubMedID 37890765

• Elbow UCL repair with suture augmentation is biomechanically equivalent to reconstruction and clinically demonstrates excellent outcomes: a systematic review. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association Spears, T. M., Parikh, B., Chalmers, P. N., Smith, M. V., Freehill, M. T., Bowman, E. N. 2023

  Abstract

  PURPOSE: The purpose of the study was to systematically review (1) biomechanical properties of augmented elbow ulnar collateral ligament (UCL) repair compared to reconstruction, and (2) clinical efficacy and complication rates of UCL repair with and without augmentation.METHODS: A systematic review was completed August 15, 2023, identifying articles that (1) biomechanically compared suture augmented UCL repair and reconstruction, and (2) clinically evaluated medial elbow UCL repairs. Search terms included: "UCL repair" OR "internal brace" OR "suture augmentation" AND "UCL reconstruction". For inclusion, biomechanical studies compared augmented repair to reconstruction; clinical studies required clinical outcomes with minimum 6-month follow-up. Biomechanical data included torsional stiffness, gap formation, peak torque, and failure torque. Clinical data included return to previous level of play, time to return, functional outcomes, and complications.RESULTS: Eight biomechanical and 9 clinical studies were included (5 with and 4 without augmentation). In most biomechanical studies, augmented repairs demonstrated less gap formation, with equivalent torsional stiffness, failure load, and peak torque compared to reconstruction. Clinical outcomes in 104 patients without augmentation demonstrated return to previous level of 50-94% for non-professional athletes and 29% for professional baseball pitchers. Suture augmented repairs in 554 patients demonstrated return to previous level from 92-96%, at 3.8-7.4 months, with KJOC scores of 86-95. The overall complication rate for augmented UCL repair was 8.7%; most commonly ulnar neuropraxia (6%).CONCLUSION: Biomechanically, UCL repair with augmentation provided less gapping with equivalent torsional stiffness and failure compared to reconstruction. Clinically, augmented UCL repair demonstrated excellent return to previous level of play and KJOC scores with modest complications and time to return. Augmented UCL repair is biomechanically equivalent to reconstruction and may be a viable alternative to reconstruction in indicated athletes.

  View details for DOI 10.1016/j.arthro.2023.09.030

  View details for PubMedID 37832744

• Evaluation of Mid-term Outcomes Following Shoulder Hemiarthroplasty for Avascular Necrosis of the Humeral Head in Patients 40 Years and Younger. Journal of surgical orthopaedic advances Hrin, M. L., Beck, E. C., Miller, E. M., Weimer, A. S., Robbins, C. M., Matthews, H., Freehill, M. T., Tuohy, C. J., Wiesler, E. R., Graves, B. R., Waterman, B. R. 2023; 32 (2): 118-121

  Abstract

  In order to evaluate postoperative function and failure rates among younger patients undergoing hemiarthroplasty for humeral head avascular necrosis (AVN), data from patients < 40 years treated between December 2008 - January 2018 was retrospectively analyzed. Pain was assessed preoperatively and at final follow up using a visual analogue scale (VAS). The American Shoulder and Elbow Surgeons (ASES) standardized assessment, single assessment numeric evaluation (SANE) score, and patient satisfaction were assessed at final follow up, as well as surgical revision rates. In total, eight shoulders were included in the final analysis, with a follow up of 6.6 + 3.6 years. Analysis indicated a statistical improvement in VAS pain (p = 0.001), while comparison of postoperative function between surgical and non-surgical limbs did not demonstrate statistical differences in SANE or ASES averages (p > 0.05). At final follow up, 25% of patients expressed dissatisfaction; however, there were no cases of revision surgery. In conclusion, younger patients undergoing hemiarthroplasty for humeral head AVN experienced pain improvement and no revisions at short-to-mid-term follow up, but one-in-four indicated dissatisfaction. Level of evidence: IV, case series. (Journal of Surgical Orthopaedic Advances 32(2):118-121, 2023).

  View details for PubMedID 37668650

• Characteristics Associated With Noncompliance of Current Pitch Smart Guidelines in High School Baseball Pitchers Throughout the United States. Orthopaedic journal of sports medicine Erickson, B. J., Bowman, E. N., Camp, C., Freehill, M. T., Smith, M. V., Serio, N., Ishikawa, H., Smith, K., Chalmers, P. N. 2023; 11 (9): 23259671231199085

  Abstract

  Although pitch count and rest guidelines have been promoted for youth and adolescent baseball players for nearly 2 decades, compliance with guidelines remains poorly understood.The purpose of this study was to determine the frequency of compliance with Major League Baseball (MLB) Pitch Smart guidelines as well as the association between compliance and range of motion (ROM), strength, velocity, injury, and pitcher utilization. It was hypothesized that pitchers in violation of current recommendations would have increased strength, velocity, and injury.Case-control study; Level of evidence, 3.This was a prospective, multicenter study of 115 high school pitchers throughout the United States. Pitchers were surveyed about their compliance with current off-season, rest-related guidelines, and history of injury. During the preseason, pitchers underwent standardized physical examinations, and pitch velocity was measured. Pitch counts were collected during the baseball season that followed. Dynamometer strength testing of shoulder forward flexion, and external rotation as well as grip strength was recorded. We compared pitchers who were compliant with recommendations with those who were noncompliant using Student t and Mann-Whitney U tests.Based on preseason data, 84% of pitchers had violated current Pitch Smart guidelines. During the season, 14% had at least 1 violation of the Pitch Smart guidelines. Across both the preseason survey and in-season pitch counts, 89% of players had at least 1 violation of the Pitch Smart guidelines. While there were no significant differences in ROM or strength, the noncompliant group had higher maximum pitch velocity than the compliant group (74 ± 8 vs 69 ± 5 mph [119 ± 13 vs 111 ± 8 kph], respectively; P = .009). Players' self-reported velocity differed significantly from the direct measurement, for both peak velocity (80 ± 6 vs 73 ± 8 mph [129 ± 9 vs 117 ± 13 kph], respectively; P < .001) and mean velocity (73 ± 8 vs 53 ± 27 mph [117 ± 13 vs 85 ± 43 kph], respectively; P < .001).Most high school pitchers were not fully compliant with current Pitch Smart guidelines, and they tended to overestimate their peak velocity by 7 mph (11 kph). Pitchers who threw with greater velocity were at higher risk for violating Pitch Smart recommendations.

  View details for DOI 10.1177/23259671231199085

  View details for PubMedID 37781638

  View details for PubMedCentralID PMC10536850

• Reliability of Ulnar Collateral Ligament Findings on Magnetic Resonance Imaging. Journal of shoulder and elbow surgery Bowman, E. N., Sciascia, A., Freehill, M. T., Smith, M. V., Da Silva, A., Chalmers, P. N. 2023

  Abstract

  Ulnar Collateral Ligament (UCL) tears are common in baseball players. While MRI is the most utilized imaging modality for UCL injuries, the inter-rater reliability of MRI analyzing specific characteristics of UCL pathology has not been defined.The purpose of this study was to define the inter-rater reliability of MRI for evaluating UCL characteristics.Three surgeons analyzed forty-five non-contrast MRIs: 15 without UCL tears, 15 with intra-operatively confirmed partial-thickness tears, and 15 with intra-operatively confirmed full-thickness tears. Findings evaluated included ligament characteristics (peri-ligamentous or osseous edema, ligament hypertrophy, calcifications, partial or full-thickness tearing) and location of the pathology (proximal, mid-substance, or distal). Fleiss' kappa coefficients were utilized to assess inter-observer reliability.There were high rates of agreement for mid-substance (kappa: 0.50) and distal (kappa: 0.69) ligament edema and proximal osseous edema (kappa: 0.48). There were low rates of agreement for proximal ligament edema (kappa:0.08), ligament thickening (kappa: -0.02-0.20), and proximal to mid-substance calcifications (kappa: -0.04-0.10). Mid-substance (kappa: 0.55) and distal full-thickness tears (kappa: 0.63) demonstrated higher agreement than proximal (kappa: 0.29). Proximal partial-thickness tears (kappa: 0.45) had higher agreement than mid-substance (kappa: -0.02) or distal (kappa: -0.02).In our study, there was high inter-rater reliability regarding proximal osseous edema, mid-substance and distal ligament edema and full-thickness tears. There was no agreement for mid-substance and distal partial-thickness UCL tears, but fair agreement for proximal tears. UCL tissue characteristics including ligament thickening and calcifications demonstrated low agreement. Challenges remain in effectively evaluating UCL tissue characteristics on non-contrast MRIs.

  View details for DOI 10.1016/j.jse.2023.06.019

  View details for PubMedID 37481106

• Is it Safe to Throw a Breaking Ball? An Editorial SPORTS HEALTH-A MULTIDISCIPLINARY APPROACH Freehill, M. T. 2023; 15 (4): 476-477

  View details for DOI 10.1177/19417381231172762

  View details for Web of Science ID 001023713600002

  View details for PubMedID 37357684

  View details for PubMedCentralID PMC10293565

• No significant difference in risk of prolonged opioid use following outpatient versus inpatient total shoulder arthroplasty: A propensity matched analysis. Shoulder & elbow Xiao, M., Curtis, D. M., Cheung, E. V., Freehill, M. T., Abrams, G. D. 2023; 15 (3): 292-299

  Abstract

  Background: The purpose of this investigation was to compare rates of filled opioid prescriptions and prolonged opioid use in opioid naive patients undergoing total shoulder arthroplasty (TSA) in inpatient versus outpatient settings.Methods: A retrospective cohort study was conducted using a national insurance claims database. Inpatient and outpatient cohorts were created by identifying continuously enrolled, opioid naive TSA patients. A greedy nearest-neighbor algorithm was used to match baseline demographic characteristics between cohorts with a 1:1 inpatient to outpatient ratio to compare the primary outcomes of filled opioid prescriptions and prolonged opioid use following surgery between cohorts.Results: A total of 11,703 opioid naive patients (mean age 72.5±8.5 years, 54.5% female, 87.6% inpatient) were included for analysis. After propensity score matching (n=1447 inpatients; n=1447 outpatients), outpatient TSA patients were significantly more likely to fill an opioid prescription in the perioperative window compared to inpatients (82.9% versus 71.5%, p<0.001). No significant differences in prolonged opioid use were detected (5.74% inpatient versus 6.77% outpatient; p=0.25).Conclusions: Outpatient TSA patients were more likely to fill opioid prescriptions compared to inpatient TSA patients. The quantity of opioids prescribed and rates of prolonged opioid use were similar between the cohorts.Level of evidence: Therapeutic Level III.

  View details for DOI 10.1177/17585732211060754

  View details for PubMedID 37325386

• Most high school baseball pitchers are using weighted ball throwing programs to increase ball velocity: crosssectional analysis of US high school pitchers. JSES reviews, reports, and techniques Bowman, E. N., Camp, C. L., Erickson, B. J., Freehill, M. T., Smith, M. V., Madia, E., Matthews, M., Simister, S., Wheelwright, C., Ishikawa, H., Chalmers, P. N. 2023; 3 (2): 137-141

  Abstract

  Weighted-ball velocity training programs are popular but may be associated with increased injury risk. The purpose of this study was to determine the current frequency of these programs, as well as their association with range of motion, strength, velocity, injury, and utilization in high school baseball pitchers.This was a multicenter, prospective, community-based study including high schools from the Northeastern, Southeastern, Midwestern, and Western regions of the United States. Preseason pitchers were surveyed about their use of weighted ball velocity programs and history of injury. Preseason pitchers underwent standardized physical examinations and pitch velocity was measured. During a single high school season, pitch counts and injury incidence were prospectively collected.In total, 115 pitchers were recruited, of whom 63% had participated in a weighted ball program. There were no differences in range of motion or strength between groups who used weighted balls and those who did not. Pitchers that utilized weighted ball programs demonstrated a higher average fastball velocity (114.26 vs. 106.22 km/h [71 vs. 66 mph]; P < .001) as well as peak fastball velocity (115.87 vs. 109.44 km/h [72 vs. 68 mph]; P = .001) compared to those that did not use weighted ball programs. Pitchers that utilized weighted ball programs were no more likely to be single-sport athletes (44%) than those who were multisport athletes (49%, P = .667). Within the group who had used a weighted ball program 29% (13/45) reported a history of injury and within the group who had not used a weighted ball program 25% (10/40) reported a history of injury (P = .687). As only a single injury occurred in the entire cohort, comparison of injury rates could not be completed.In this prospective study, the majority of high school pitchers reported using weighted ball programs to increase velocity, and these programs were associated with increased average and peak velocity compared to pitchers who did not use weighted ball programs. There were no significant differences in injury history between the 2 groups. Further study is necessary to understand the injury risk associated with weighted ball programs.

  View details for DOI 10.1016/j.xrrt.2023.01.005

  View details for PubMedID 37588444

  View details for PubMedCentralID PMC10426506

• Game-Day Pitch and Throw Count Feasibility Using a Single Sensor to Quantify Workload in Youth Baseball Players. Orthopaedic journal of sports medicine Freehill, M. T., Rose, M. J., McCollum, K. A., Agresta, C., Cain, S. M. 2023; 11 (3): 23259671231151450

  Abstract

  Pitch count recommendations are used to reduce injury risk in youth baseball pitchers and are based chiefly on expert opinion, with limited scientific support. Furthermore, they only account for pitches thrown against a hitter and do not include the total number of throws on the day a player pitched. Currently, counts are recorded manually.To provide a method using a wearable sensor to quantify total throws per game that is compliant with Little League Baseball rules and regulations.Descriptive laboratory study.Eleven male baseball players (age, 10-11 years) from an 11U (players 11 years and younger) competitive travel team were evaluated over a single summer season. An inertial sensor was placed above the midhumerus of the throwing arm and was worn during baseball games across the season. A throw identification algorithm capturing all throws and reporting linear acceleration and peak linear acceleration was used to quantify throwing intensity. Pitching charts were collected and used to verify actual pitches thrown against a hitter in a game versus all other throws identified.A total of 2748 pitches and 13,429 throws were captured. On the day a player pitched, he averaged 36 ± 18 pitches (23%) and 158 ± 106 total throws (pitches in game as well as all warm-up pitches and other throws during game). In comparison, on a day a player did not pitch, he averaged 119 ± 102 throws. Across all pitchers, 32% of all throws were low intensity, 54% were medium intensity, and 15% were high intensity. The player with one of the highest percentages of high-intensity throws did not pitch as their primary position, while the 2 players who pitched most often had the lowest percentages.Total throw count can be successfully quantified using a single inertial sensor. Total throws tended to be higher on days a player pitched compared with regular game days without pitching.This study provides a fast, feasible, and reliable method to obtain pitch and throw counts so that more rigorous research on contributing factors to arm injury in the youth athlete can be achieved.

  View details for DOI 10.1177/23259671231151450

  View details for PubMedID 36970319

  View details for PubMedCentralID PMC10034293

• Shoulder Surgery Postoperative Immobilization: An International Survey of Shoulder Surgeons. Biology Freehill, M. T., Murray, I. R., Calvo, E., Lädermann, A., Srikumaran, U. 2023; 12 (2)

  Abstract

  There is currently no consensus on immobilization protocols following shoulder surgery. The aim of this study was to establish patterns and types of sling use for various surgical procedures in the United States (US) and Europe, and to identify factors associated with the variations.An online survey was sent to all members of the American Shoulder and Elbow Society (ASES) and European Society for Surgery of the Shoulder and Elbow (ESSSE). The survey gathered member data, including practice location and years in practice. It also obtained preferences for the type and duration of sling use after the following surgical procedures: arthroscopic Bankart repair, Latarjet, arthroscopic superior/posterosuperior rotator cuff repair (ARCR) of tears <3 cm and >3 cm, anatomic total shoulder arthroplasty (aTSA) and reverse TSA (rTSA), and isolated biceps tenodesis (BT). Relationships between physician location and sling type for each procedure were analyzed using Fisher's exact tests and post-hoc tests using Bonferroni-adjusted p-values. Relationships looking at years in practice and sling duration preferred were analyzed using Spearman's correlation tests.In total, 499 surgeons with a median of 15 years of experience (IQR = 9-25) responded, with 54.7% from the US and 45.3% from Europe. US respondents reported higher abduction pillow sling use than European respondents for the following: Bankart repair (62% vs. 15%, p < 0.0001), Latarjet (53% vs. 12%, p < 0.001), ARCR < 3 cm (80% vs. 42%, p < 0.001) and >3 cm (84% vs. 61%, p < 0.001), aTSA (50% vs. 21%, p < 0.001) and rTSA with subscapularis repair (61% vs. 22%, p < 0.001) and without subscapularis repair (57% vs. 17%, p < 0.001), and isolated BT (18% vs. 7%, p = 0.006). European respondents reported higher simple sling use than US respondents for the following: Bankart repair (74% vs. 31%, p < 0.001), Latarjet (78% vs. 44%, p < 0.001), ARCR < 3 cm (50% vs. 17%, p < 0.001) and >3 cm (34% vs. 13%, p < 0.001), and aTSA (69% vs. 41%, p < 0.001) and rTSA with subscapularis repair (70% vs. 35%, p < 0.001) and without subscapularis repair (73% vs. 39%, p < 0.001). Increasing years of experience demonstrated a negative correlation with the duration of sling use after Bankart repair (r = -0.20, p < 0.001), Latarjet (r = -0.25, p < 0.001), ARCR < 3 cm (r = -0.14, p = 0.014) and >3 cm (r = -0.20, p < 0.002), and aTSA (r = -0.37, p < 0.001), and rTSA with subscapularis repair (r = -0.10, p = 0.049) and without subscapularis repair (r = -0.19, p = 0.022. Thus, the more experienced surgeons tended to recommend shorter durations of post-operative sling use. US surgeons reported longer post-operative sling durations for Bankart repair (4.8 vs. 4.1 weeks, p < 0.001), Latarjet (4.6 vs. 3.6 weeks, p < 0.001), ARCR < 3 cm (5.2 vs. 4.5 weeks p < 0.001) and >3 cm (5.9 vs. 5.1 weeks, p < 0.001), aTSA (4.9 vs. 4.3 weeks, p < 0.001), rTSR without subscapularis repair (4.0 vs. 3.6 weeks, p = 0.031), and isolated BT (3.7 vs. 3.3 weeks, p = 0.012) than Europe respondents. No significant differences between regions within the US and Europe were demonstrated.There is considerable variation in the immobilization advocated by surgeons, with geographic location and years of clinical experience influencing patterns of sling use. Future work is required to establish the most clinically beneficial protocols for immobilization following shoulder surgery.Level IV.

  View details for DOI 10.3390/biology12020291

  View details for PubMedID 36829567

• What are the Indications for Medial Ulnar Collateral Ligament Surgery in Baseball Players? An MRI Case-based Study. Journal of shoulder and elbow surgery Bowman, E. N., Smith, M. V., Freehill, M. T., Camp, C. L., Erickson, B. J., Sciascia, A., Da Silva, A., Chalmers, P. N. 2023

  Abstract

  BACKGROUND: Ulnar Collateral Ligament (UCL) tears are common in baseball players. When non-operative management fails; reconstruction or repair may be necessary to restore physical function. There is no clear consensus regarding the indications for surgery based on magnetic resonance imaging (MRI) tear characteristics, or the indications for selecting repair over reconstruction. The purpose of this study was to define the indications for UCL surgery based on MRI and to elucidate indications for UCL repair vs reconstruction.METHODS: Twenty-six orthopedic surgeons who treat baseball players were surveyed. Forty-five MRIs were reviewed: 15 without UCL tears, 15 with intra-operatively confirmed partial-thickness tears, and 15 with full-thickness tears. Factors investigated included ligament characteristics (peri-ligamentous or osseous edema, ligament hypertrophy, calcification, partial or full-thickness tearing) and location (proximal, mid-substance, or distal). Surgeons were given a clinical scenario and asked whether 1) surgery was indicated and 2) whether repair or reconstruction was recommended. Odds ratios (OR) and 95% confidence intervals (95%CI) helped identify significant predictors for both queries.RESULTS: The odds of recommending surgical treatment compared to non-operative treatment were 2.4x more likely for a proximal partial-thickness tear, 3.2x for distal partial-thickness tear, 5.1x for distal full-thickness tear, and 7.0x for proximal full-thickness tear (p<0.001). Significant indications for repair included distal partial (OR=1.6, 95%CI 1.0, 2.1, p<0.001) and full-thickness tears (OR=1.7, 95%CI 1.1, 2.3, p<0.001). Repair was 3x less likely recommended for mid-substance full-thickness tears (OR=3.0, 95%CI -5.0, -1.0, p=0.004). Ultrasound stress testing was requested in 78% of partial tears.CONCLUSIONS: Among surgeons surveyed, the highest odds for recommending operative treatment were proximal full-thickness tears, then distal full-thickness, distal partial-thickness, and proximal partial-thickness tears. Repair was most appropriate for partial and full-thickness distal tears, but relatively contraindicated for complete mid-substance UCL tears. Ultrasound stress testing was frequently requested for partial tears. Given the lack of consensus among surgeons, future prospective registries are necessary to determine whether these factors associate with clinical outcomes.

  View details for DOI 10.1016/j.jse.2023.01.001

  View details for PubMedID 36737035

• First-Time Traumatic Anterior Shoulder Dislocation: Current Concepts. Journal of ISAKOS : joint disorders & orthopaedic sports medicine Nazzal, E. M., Herman, Z. J., Engler, I. D., Dalton, J. F., Freehill, M. T., Lin, A. 2023

  Abstract

  The management of first-time traumatic anterior shoulder dislocations has been a topic of extensive study yet remains controversial. Development of a treatment plan requires an understanding of patient-specific considerations, including demographics, functional demands, and extent of pathology. Each of these can influence rates of recurrence and return to activity. The purpose of this review is to provide a framework for decision-making following a first-time anterior shoulder dislocation, with particular focus on the high-risk young and athletic population. A summary of surgical treatment options and their outcomes is outlined, along with future biomechanical and clinical perspectives.

  View details for DOI 10.1016/j.jisako.2023.01.002

  View details for PubMedID 36706837

• Upper extremity injuries have the poorest return to play and most time lost in professional baseball: a Systematic Review of injuries in major league baseball. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association Tramer, J. S., Castle, J. P., Gaudiani, M. A., Lizzio, V. A., Mcgee, A., Freehill, M. T., Lynch, T. S. 2022

  Abstract

  The aim of this systematic review is to summarize the incidence of injuries occurring in professional baseball and compare player outcomes reported in the literature METHODS: We conducted a systematic review utilizing the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines across three databases (PubMed, MEDLINE, Embase). Inclusion criteria were studies of injury incidences and/or injury outcomes on active MLB athletes and studies published in the English language. Exclusion criteria was non-MLB players, case series and case report studies with a cohort of < 3 players, and/or review articles.A total of 477 articles were identified from the initial search of three databases with 105 studies meeting inclusion criteria. Amongst these articles, the most common injuries studied were elbow (38%), shoulder (14%), hip/groin (11%), hand/wrist (7%), head/face (7%), knee (7%), spine (5%), and foot/ankle (3%). Injuries with the highest incidence included hand/wrist (150.3 per year), hamstring (7.8-73.5 per year), ulnar collateral ligament tears (0.23-26.8 per year), gastrocnemius strains (24.2 per year), and concussions (3.6-20.5 per year). Lowest rates of return to play were seen following shoulder labral tears (40-72.5%), rotator cuff tears (33.3-87%), and UCL tears (51-87.9%). The injuries leading to most time away from sport included elbow UCL tears (average 90.3 days treated non-operatively to 622.8 days following revision reconstruction), shoulder labral tears (average 315-492 days) and ACL tears (average 156.2-417.5 days). Following ACL tears, rotator cuff tears, shoulder labral tears, and hip femoroacetabular impingement (FAI) requiring arthroscopy, athletes had a significantly lower workloads compared to prior to injury upon return to play.Most published investigations focus on elbow injuries of the UCL, with variable RTP and mixed performance following surgery. Ulnar collateral ligament tears, shoulder labral tears, and anterior cruciate ligament tears result in the most missed time. Upper extremity injury such as shoulder labral tears, rotator cuff tears, and UCL tears had the poorest RTP rates. Workload was most affected following ACL reconstruction, rotator cuff repair, shoulder labral repair, and hip arthroscopy for FAI.

  View details for DOI 10.1016/j.arthro.2022.12.024

  View details for PubMedID 36587750

• Sensor Location Matters When Estimating Player Workload for Baseball Pitching. Sensors (Basel, Switzerland) Agresta, C., Freehill, M. T., Zendler, J., Giblin, G., Cain, S. 2022; 22 (22)

  Abstract

  Estimating external workload in baseball pitchers is important for training and rehabilitation. Since current methods of estimating workload through pitch counts and rest days have only been marginally successful, clubs are looking for more sophisticated methods to quantify the mechanical loads experienced by pitchers. Among these are the use of wearable systems. While wearables offer a promising solution, there remains a lack of standards or guidelines for how best to employ these devices. As a result, sensor location and workload calculation methods vary from system to system. This can influence workload estimates and blur their interpretation and utility when making decisions about training or returning to sport. The primary purpose of this study was to determine the extent to which sensor location influences workload estimate. A secondary purpose was to compare estimates using different workload calculations. Acceleration data from three sensor locations-trunk, throwing upper arm, and throwing forearm-were collected from ten collegiate pitchers as they threw a series of pitches during a single bullpen session. The effect of sensor location and pitch type was assessed in relation to four different workload estimates. Sensor location significantly influenced workload estimates. Workload estimates calculated from the forearm sensor were significantly different across pitch types. Whole-body workload measured from a trunk-mounted sensor may not adequately reflect the mechanical loads experienced at throwing arm segments. A sensor on the forearm was the most sensitive to differences in workloads across pitch types, regardless of the calculation method.

  View details for DOI 10.3390/s22229008

  View details for PubMedID 36433603

• Using Sensors for Player Development: Assessing Biomechanical Factors Related to Pitch Command and Velocity. Sensors (Basel, Switzerland) Agresta, C., Freehill, M. T., Nakamura, B., Guadagnino, S., Cain, S. M. 2022; 22 (21)

  Abstract

  Pitching biomechanical research is highly focused on injury prevention with little attention to how biomechanical data can facilitate skill development. The overall purpose of this study was to explore how sensor-derived segment kinematics and timing relate to command and ball velocity during baseball pitching. We used a cross-sectional design to analyze a series of pitches thrown from 10 collegiate baseball pitchers. We collected biomechanical data from six inertial sensors, subjective command from the pitchers, and ball velocity from a radar device. Stepwise regression analyses were used to explore biomechanical variables associated with command for all pitches and ball velocity for fastballs only. We found that only peak forearm linear acceleration was significantly associated with command, whereas several segment kinematic measures were significantly associated with ball velocity. Our results suggest that different biomechanical variables are linked to specific pithing skills. Our findings suggest that end-effector (forearm) movement is more important for pitch command, whereas proximal-to-distal (pelvis, trunk, upper arm, forearm) segmental movement is important for ball velocity.

  View details for DOI 10.3390/s22218488

  View details for PubMedID 36366188

• Biomechanical Comparison of a Novel Multiplanar, Perpendicular Whipstitch With the Krackow Stitch and Standard Commercial Whipstitch. Orthopaedic journal of sports medicine Muscatelli, S., Walley, K. C., Daly-Seiler, C. S., Greenstein, J. A., Sciascia, A., Patterson, D. P., Freehill, M. T. 2022; 10 (8): 23259671221107034

  Abstract

  Background: Using alternating orthogonal suture throws with the looped whipstitch technique may allow enhanced suture fixation.Hypothesis: It was hypothesized that this novel multiplanar, perpendicular looped whipstitch (MP) technique would have improved biomechanical properties compared with the standard looped whipstitch (WS) and Krackow stitch (KS).Study Design: Controlled laboratory study.Methods: A total of 30 cadaveric tibialis anterior tendons were randomly assigned into 3 groups of 10. Tendons were secured to a custom clamp, and the other end was sutured using 1 of 3 techniques: the KS, WS, or novel MP. The MP was performed with alternating orthogonal throws starting right to left, then front to back, left to right, and back to front. Each technique used 4 passes of No. 2 FiberWire spaced 5 mm apart and ending 10 mm from the tendon end. Tendons were preloaded to 5 N, pretensioned to 50 N at 100 mm/min for 3 cycles, returned to 5 N for 1 minute, cycled from 5 to 100 N at 200 mm/min for 100 cycles, and then loaded to failure at 20 mm/min. Elongation was recorded after pretensioning and cycling and was measured both across the suture-tendon interface and from the base of the suture-tendon interface to markings on the suture limbs (construct elongation). One-way analyses of variance were performed, with Bonferroni post hoc analysis when appropriate.Results: There were no differences in cross-sectional area or stiffness among the 3 techniques. The ultimate load for WS (183.33 ± 57.44 N) was less compared with both MP (270.76 ± 39.36 N) and KS (298.90 ± 25.94 N) (P ≤ .001 for both). There was less construct elongation for KS compared with WS and MP for total displacement, measured from pretensioning to the end of cycling (P < .001). All 3 techniques saw a decrease in length (shortening) at the suture-tendon interface during testing. There was more shortening at the suture-tendon interface for WS compared with KS (P = .006).Conclusion: The KS appears superior, as it maximized strength while minimizing construct elongation or graft shortening. The ultimate load of the MP technique was greater than that of the standard technique but not significantly different from that of the KS technique.Clinical Relevance: The KS is preferred. If using a WS, multiplanar, perpendicular passes should be considered.

  View details for DOI 10.1177/23259671221107034

  View details for PubMedID 35982831

• Using Advanced Data to Analyze the Impact of Injury on Performance of Major League Baseball Pitchers: A Narrative Review. Orthopaedic journal of sports medicine LaPrade, C. M., Cinque, M. E., Safran, M. R., Freehill, M. T., Wulf, C. A., LaPrade, R. F. 2022; 10 (7): 23259671221111169

  Abstract

  Major league baseball (MLB) pitchers are at risk of numerous injuries during play, and there is an increasing focus on evaluating their performance in the context of injury. Historically, performance after return to play (RTP) from injury has focused on general descriptive statistics, such as innings or games played, or rate statistics with inherent variability (eg, earned run average, walks and hits per inning pitched, strikeouts per 9 innings, or walks per 9 innings). However, in recent years, MLB has incorporated advanced technology and tracking systems in every stadium, allowing for more in-depth analysis of pitcher-specific data that are captured with every pitch of every game. This technology allows for the ability to delve into the pitching performance on a basis that is more specific to each pitcher and allows for more in-depth analysis of different aspects of pitching performance. The purpose of this narrative review was to illustrate the current state of injury recording for professional baseball pitchers, highlight recent technological advances in MLB, and describe the advanced data available for analysis. We used advanced data in the literature to review the current state of performance analysis after RTP in MLB pitchers after injury. Finally, we strived to provide a framework for future studies to more meticulously assess RTP performance given the current available resources for analysis.

  View details for DOI 10.1177/23259671221111169

  View details for PubMedID 35898207

  View details for PubMedCentralID PMC9310227

• Limited Biomechanical Evidence Behind Single Row Versus Double Row Repair of Subscapularis Tears: ASystematic Review. Arthroscopy, sports medicine, and rehabilitation Xiao, M., Cohen, S. A., Cheung, E. V., Sherman, S. L., Abrams, G. D., Freehill, M. T. 2022; 4 (3): e1193-e1201

  Abstract

  Purpose: To systematically review the literature for studies investigating the biomechanical properties of constructs used to repair isolated subscapularis tears in time zero human cadaveric studies.Methods: A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three electronic databases were searched for studies that reported on the construct technique and biomechanical outcomes for the repair of isolated subscapularis tears in human cadaveric specimens. Ultimate load, gap formation, stiffness, and failure mode were documented. Methodological quality was assessed using the Quality Appraisal for Cadaveric Studies (QUACS) scale.Results: Six articles qualified (104 shoulders [72 single-row, 26 double-row, 6 transosseous]; mean QUACS score 10.5 ± 1) and were analyzed. Studies varied in the number and type of anchors and construct technique (1-2 anchors single-row; 3-4 anchors double-row; bioabsorbable or titanium anchors) and suture(s) used (no. 2 FiberWire or FiberTape), subscapularis tear type (25%, 33%, 50%, or 100% tear), and whether a knotless or knotted fixation was used. In studies that created full-thickness, upper subscapularis tears (Fox-Romeo II/III or Lafosse II), no significant differences were seen in ultimate load, gap formation, and stiffness for knotted versus knotless single-row repair (2 studies) and single-row versus double-row repair (1 study). Double-row repair of complete subscapularis tears demonstrated higher ultimate load, stiffness, and lower gap formation in 1 study. Ultimate load differed between the studies and constructs (single-row: range, 244 N to 678 N; double-row: range 332 N to 508 N, transosseous: 453 N). Suture cutout was the most common mode of failure (59%).Conclusion: Because of the limited number of studies and varying study designs in examining the biomechanical properties of repair constructs used for subscapularis tears, there is inconclusive evidence to determine which construct type is superior for repairing subscapularis tears.Clinical Relevance: Results from biomechanical studies of clinically relevant subscapularis repair constructs are important to guide decision-making for choosing the optimal construct for patients with subscapularis tears.

  View details for DOI 10.1016/j.asmr.2022.01.009

  View details for PubMedID 35747639

• Ulnar Collateral Ligament Reconstruction Does Not Decrease Spin Rate or Performance in Major League Pitchers. The American journal of sports medicine Cinque, M. E., LaPrade, C. M., Abrams, G. D., Sherman, S. L., Safran, M. R., Freehill, M. T. 2022: 3635465221097421

  Abstract

  Ulnar collateral ligament reconstruction (UCLR) is commonly performed in Major League Baseball (MLB) pitchers, with variable reported effects on velocity and traditional rate statistics. Currently, no studies have evaluated spin rate in the context of return to play (RTP) after injury. Greater spin rate has become increasingly sought after in the baseball community, as it is believed to be a vital aspect of pitch effectiveness.The purpose was to evaluate the effect of primary UCLR on fastballs (FB) and sliders (SL) of MLB pitchers in terms of spin rate, velocity, hard-hit rate, and whiff rate. It hypothesized that the post-UCLR FB and SL spin rates, velocity, and whiff rate would be significantly decreased versus their pre-UCLR levels, while the FB and SL hard-hit rates would be higher in comparison with pre-UCLR levels.Case series; Level of evidence, 4.In total, 42 pitchers who underwent UCLR and returned to MLB play were identified from public records from 2016 to 2019. The Statcast system was used to collect spin rate, velocity, hard-hit rate, and whiff rate for 4-seam FB (4FB), 2-seam FB (2FB), and SL for pitchers in the preinjury year as well as the 2 years after return from UCLR. Data were analyzed using the appropriate statistical tests.A total of 36 pitchers met the inclusion criteria, and 31 of the eligible 36 players (86.1%) were able to return to MLB pitching (RTP). There were no significant decreases for 4FB, 2FB, or SL in spin rate, measured in revolutions per minute (rpm), when comparing preinjury levels with the first and second seasons after return. There was a significant decrease in velocity for the 2FB in the first season (92.9 vs 93.7 miles per hour [mph]; P = .045) but not the second season (93 mph; P = .629) after RTP in comparison with pre-UCLR levels. For the 2FB, there was a significant increase in spin rate between preinjury and RTP season 2 (2173.5 vs 2253 rpm; P = .022). For the SL, there was a significant increase in spin rate between preinjury and RTP season 2 (2245.1 vs 2406 rpm; P = .016).A cohort of MLB pitchers who underwent UCLR and returned to the MLB level demonstrated no significant decreases in the spin rate, velocity, whiff rate, or hard-hit rate of 4FB, 2FB, or SL at 2 years after UCLR.

  View details for DOI 10.1177/03635465221097421

  View details for PubMedID 35616521

• Revision Ulnar Collateral Ligament Reconstruction in Major League Baseball Pitchers: Effects of Fastball Velocity and Usage. Journal of shoulder and elbow surgery LaPrade, C. M., Cinque, M. E., Chona, D. V., Sciascia, A. D., Abrams, G. D., Sherman, S. L., Safran, M. R., Freehill, M. T. 2022

  Abstract

  Ulnar collateral ligament (UCL) tears are prevalent in Major League Baseball (MLB) pitchers and can cause significant loss of time with varying reports of impact on performance. Revision UCL reconstruction (UCLR) is becoming increasingly common, with little known about the effects on fastball velocity (FB) and usage (FB%) in this setting.The purpose was to evaluate the effect of revision UCLR on MLB pitchers with respect to post-operative FB velocity and FB% usage at one and two years after return-to-play. The hypothesis was post-operative FB velocity and FB% usage would significantly decrease versus pre-revision levels, and that revision UCLRs would result in significantly decreased FB velocity and FB% usage in comparison to a matched group of MLB pitchers after primary UCLR.Twenty-one pitchers who underwent revision UCLR and returned to MLB play were identified from public records from 2008-2021. The PITCHf(x) system collected FB velocity for four-seam (4FB) and two-seam (2FB) fastballs and total FB% for pitchers in the pre-revision year as well as the two years after return. A matched control group of pitchers who underwent primary UCLR was used for comparison.There were no significant differences in FB velocity between pre-revision levels (4FB 92.9 mph, 2FB 91.4 mph) and years one (4FB 92.5 mph) (2FB 91.2 mph) and two (4FB 93.4 mph) (2FB 91.1 mph) after revision UCLR. FB% decreased from the pre-revision season (60.1) and the first (56.2, p=0.036) and second years (52.5, p=0.002) after return. There were no significant differences between FB velocity or FB% or between the revision and primary UCLR groups.Pitchers returning to the MLB level after revision UCLR can expect similar FB velocity pre-revision FB velocity and to pitchers undergoing primary UCLR; however, they do demonstrate a decrease in FB% usage, which may suggest less confidence in their FB after RTP.

  View details for DOI 10.1016/j.jse.2022.02.026

  View details for PubMedID 35351655

• Anatomic Total Shoulder Arthroplasty: Component Size Prediction with 3-Dimensional Pre-Operative Digital Planning. Journal of shoulder and elbow arthroplasty Freehill, M. T., Weick, J. W., Ponce, B. A., Bedi, A., Haas, D., Ruffino, B., Robbins, C., Prete, A. M., Costouros, J. G., Warner, J. J. 2022; 6: 24715492221098818

  Abstract

  Background: The rate, complexity, and cost of total shoulder arthroplasty (TSA) continues to grow. Technology has advanced pre-operative templating. Reducing cost of TSA has positive impact for the patient, manufacturer, and hospital. The aim of this study was to evaluate the accuracy of implant size selection based on 3-D templating. Our hypothesis was that pre-operative templating would enable accurate implant prediction within one size.Methods: Multicenter retrospective study of anatomic TSAs templated utilizing 3-D virtual planning technology. This program uses computed tomography (CT) scans allowing the surgeon to predict component sizes of the glenoid and humeral head and stem. Pre-operative templated implant size were compared to actual implant size at the time of surgery. Primary data analysis utilized unweighted Cohen's Kappa test.Results: 111 TSAs were analyzed from five surgeons. Pre-operative templated glenoid sizes were within one size of actual implant in 99% and exactly matched in 89%. For patients requiring a posterior glenoid augment (n=14), 100% of implants were within one size of the template and 93% matched exactly. For stemless humeral components (n=87) implanted, 98% matched the pre-operative template within one size with 79% exactly matched. For stemmed components (n=24), 88% of cases were within one size of the preoperative plan and exactly matching in 83%. Humeral head diameter matched within one size of the pre-operative template in 84% of cases and exactly matched in 72%.Conclusion: Pre-operative 3-D templating for TSAs can accurately predict glenoid and humeral component size. This study sets the groundwork for utilization of pre-operative 3-D templating as a potential method to reduce overall TSA costs by managing cost of implants, reducing inventory needs, and improving surgical efficiency.

  View details for DOI 10.1177/24715492221098818

  View details for PubMedID 35669622

• Postoperative Infection: Prevention, Diagnosis, and Treatment Guidelines for the Sports Surgeon. Sports medicine and arthroscopy review Pullen, W. M., Money, A. J., Ray, T. E., Freehill, M. T., Sherman, S. L. 2022; 30 (1): 17-23

  Abstract

  Postoperative infection remains a potentially devastating complication facing the sports medicine surgeon. Infection prevention begins with a thorough history and physical examination to identify patient specific risk factors and aid in risk stratification. Perioperative steroid injections should be used cautiously, with increased time prior to or following surgery being associated with lower infection risk. Sterile preparation with an alcohol containing solution is typically preferred, though there is limited evidence to identify which product is superior. Diagnosis can be challenging with a high index of suspicion needed to identify and appropriately manage patients. Treatment involves prompt irrigation and debridement with deep cultures. Antibiotic coverage should begin with empiric broad treatment and be tailored based on culture results. Early consultation with an infectious disease specialist is recommended to ensure appropriate antibiotic coverage and duration of treatment.

  View details for DOI 10.1097/JSA.0000000000000335

  View details for PubMedID 35113838

• Return-to-play and performance after operative treatment of Achilles tendon rupture in elite male athletes: a scoping review. British journal of sports medicine LaPrade, C. M., Chona, D. V., Cinque, M. E., Freehill, M. T., McAdams, T. R., Abrams, G. D., Sherman, S. L., Safran, M. R. 2022

  Abstract

  To examine the current evidence regarding return-to-play (RTP) and performance after Achilles tendon rupture in elite athletes treated with operative intervention.Scoping review.Published sources identified through a PubMed search of elite athletes, defined as professional or division one collegiate athletes in baseball, basketball, American football or soccer.Our search yielded a total of 2402 studies, with 13 studies fulfilling the study criteria of reporting elite athletes with objective measures of their athletic performance. A total of 709 elite athletes were included from the NBA, NFL, Major League Baseball (MLB), National Collegiate Athletic Association (NCAA) football and professional soccer.Overall, 61%-100% of elite male athletes RTP after Achilles tendon rupture and operative repair. NBA players had inferior performance compared with their preoperative status as well as controls of non-injured players. Studies did not show significantly different performance after Achilles injury for MLB players. Professional soccer, NFL and NCAA football studies reported varying performance after injury.Evidence suggests that sports with explosive plantarflexion demands, such as basketball, may be associated with a greater decrease in performance despite operative intervention after Achilles rupture.

  View details for DOI 10.1136/bjsports-2021-104835

  View details for PubMedID 35144918

• Arthroscopic Single and Double Row Repair of Isolated and Combined Subscapularis Tears Result in Similar Improvements in Outcomes: A Systematic Review. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association Xiao, M., Cohen, S. A., Cheung, E. V., Abrams, G. D., Freehill, M. T. 2021

  Abstract

  PURPOSE: To systematically review the literature to 1) describe arthroscopic subscapularis repair constructs and outcomes in patients with isolated and combined subscapularis tears and 2) compare outcomes following single and double row subscapularis repair in both of these settings.METHODS: A systematic review was performed using PRISMA guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for Level I-IV evidence studies that investigated outcomes after arthroscopic subscapularis repair for the treatment of isolated subscapularis tears or subscapularis tears combined with posterosuperior rotator cuff tears in adult human patients. Data recorded included study demographics, repair construct, shoulder-specific outcome measures, and subscapularis re-tears. Study methodological quality was analyzed using the MINORS score. Heterogeneity and low levels of evidence precluded meta-analysis.RESULTS: The initial search yielded 811 articles (318 duplicates, 493 screened, 67 full-text review). Forty-three articles (2,406 shoulders, 57% males, mean age range 42 to 67.5 years, mean MINORS score 13.4 + 4.1) were included and analyzed. Articles reported on patients with isolated subscapularis tears (n = 15), combined tears (n = 17), or both (n = 11). The majority of subscapularis repairs utilized single-row constructs (89.4% of isolated tears, 88.9% of combined tears). All except for one study reporting on outcome measures found clinically significant improvements after subscapularis repair, and no clinically significant differences were detected in five studies comparing isolated to combined tears. Subscapularis re-tear rates ranged from 0% to 17% for isolated tears and 0% to 32% for combined subscapularis and posterosuperior rotator cuff tears. Outcomes and re-tear rates were similar in studies comparing single-row to double-row repair for isolated and combined subscapularis tears (p > 0.05 for all).CONCLUSION: Arthroscopic subscapularis repair resulted in significant improvements across all outcome measures, regardless if tears were isolated or combined or if repairs were single or double row.

  View details for DOI 10.1016/j.arthro.2021.05.032

  View details for PubMedID 34052379

• The Science and Biomechanics of Long-Toss. Current reviews in musculoskeletal medicine Calcei, J. G., Freehill, M. T. 2021

  Abstract

  PURPOSE OF REVIEW: Overhead throwing is a particularly violent motion that requires a complex sequence of timed muscle activations to efficiently transfer energy up the kinetic chain to throw a ball. Long-toss has long been utilized as a means of increasing shoulder range of motion, strength, and endurance, as well as an important component of rehabilitation in interval throwing programs. The purpose of this review is to assess the current literature on the science and biomechanics of long-toss.RECENT FINDINGS: While long-toss is ubiquitously utilized in throwing programs for pitchers of all ages, the definition of long-toss, as well as its primary function in a throwing program, is debated. Throwing biomechanics in long-toss differ from that of mound pitching, although much of the variation is determined by the type of long-toss: shorter distance and on a line versus maximum distance and not on a line. Biomechanical factors including the kinematic changes of increased maximum glenohumeral external rotation, increased maximum elbow flexion, decreased trunk forward flexion at front foot contact, kinetic changes of increased shoulder internal rotation torque, increased elbow varus torque, and increased elbow extension velocity can occur with maximum distance long-toss throwing. Long-toss is a highly variable training supplement that is used in throwing programs at all levels of baseball competition. Current literature has demonstrated a number of kinetic and kinematic changes in the throwing arm and throwing motion related to increasing long-toss distances. However, the exact benefits of long-toss are difficult to quantify due to the numerous definitions and various utilizations of long-toss.

  View details for DOI 10.1007/s12178-021-09706-7

  View details for PubMedID 33830422

• Reported Technical Aspects of Type II SLAP Lesion Repairs in Athletes. Arthroscopy, sports medicine, and rehabilitation Weick, J. W., Workman, W. B., Bush, C. J., McCollum, K. A., Sugaya, H., Freehill, M. T. 2021; 3 (2): e289-e296

  Abstract

  Purpose: To systematically review the available literature to further describe and report the available data on SLAP repair techniques and the association with outcomes.Methods: A systematic review of literature was performed on manuscripts describing type II SLAP repairs in athletes. Selection criteria included studies reporting exclusively type II SLAP tears without concomitant pathology, minimum 2-year postoperative follow-up, use of anchor fixation, and return to previous level of play data available. We extracted patient outcome as well as surgical construct details from each article. Average outcomes and return to play rates were calculated and substratified further by athlete type. Return to play rates were compared by repair constructs with the Student t test.Results: Initial search resulted in 107 articles. After exclusion criteria were applied, 17 articles were included in the final analysis. Overall, 84% of patients had good-to-excellent results. Of all athletes, 66% returned to previous level of play. There was significant variation in reported technique in terms of anchor number, location, material, suture type, and knotless versus knotted constructs. No significant difference was reported in outcomes in comparison of suture type (P-value .96) or knotted versus knotless constructs (P-value .91). Given the significant variability in reporting, no statistical analysis was felt able to be performed on anchor location and number.Conclusions: Repair of type II SLAP tears in athletes is a difficult problem to treat with overall low return to play despite a high rate of "good" outcomes when assessed by outcome measures. Significant variability exists in surgical technique, as well as reporting of surgical technique, potentially limiting the ability to define the best or most effective technique for SLAP repair.Level of Evidence: IV, systematic review of level III and level IV studies.

  View details for DOI 10.1016/j.asmr.2020.09.003

  View details for PubMedID 34027434

• Introduction OPERATIVE TECHNIQUES IN SPORTS MEDICINE Freehill, M. T., Garrigues, G. E. 2021; 29 (1)

  View details for DOI 10.1016/j.otsm.2021.150795

  View details for Web of Science ID 000651152700002

• The Effect of Straight-Line Long-Toss Versus Ultra-Long-Toss Throwing on Passive Glenohumeral Range of Motion Recovery After Pitching SPORTS HEALTH-A MULTIDISCIPLINARY APPROACH Luo, T., Sciascia, A. D., Stone, A. V., Gwam, C. U., Grimes, C. A., Strahm, J. G., Mannava, S., Naugher, G., Waterman, B. R., Freehill, M. T. 2021: 1941738120980016

  Abstract

  Repetitive throwing in baseball pitchers can lead to pathologic changes in shoulder anatomy, range of motion (notably glenohumeral internal rotation deficit), and subsequent injury; however, the ideal strengthening, recovery, and maintenance protocol of the throwing shoulder in baseball remains unclear. Two strategies for throwing shoulder recovery from pitching are straight-line long-toss (SLT) throwing and ultra-long-toss (ULT) throwing, although neither is preferentially supported by empirical data.ULT will be more effective in returning baseline internal rotation as compared with SLT in collegiate pitchers after a pitching session.Cohort study.Level 3.A total of 24 National Collegiate Athletic Association Division I baseball pitchers with mean age 20.0 ± 1.1 years were randomized to either the ULT group (n = 13; 9 right-hand dominant, 4 left-hand dominant) or SLT group (n = 11; 10 right-hand dominant, 1 left-hand dominant). Measurements (dominant and nondominant, 90° abducted external rotation [ER], internal rotation [IR], and total range of motion [TROM]) were taken at 5 time points across 3 days: before and immediately after a standardized bullpen session on day 1; before and immediately after a randomized standardized ULT or SLT session on day 2; and before practice on Day 3.ULT demonstrated significantly greater final ER compared with baseline (+10°; P = 0.05), but did not demonstrate significant IR changes. Similarly, SLT demonstrated significantly greater post-SLT ER (+12°; P = 0.02) and TROM (+12°;P = 0.01) compared with baseline, but no significant IR changes. Final ER measurements were similar between ULT (135° ± 14°) and SLT (138° ± 10°) (P = 0.59). There was also no statistically significant difference in final IR between ULT (51° ± 14°) and SLT (56° ± 8°) (P = 0.27).The routine use of postperformance, ULT throwing to recover from range of motion alterations, specifically IR loss, after a pitching session is not superior to standard, SLT throwing. Based on these findings, the choice of postpitching recovery throwing could be player specific based on experience and comfort.The most effective throwing regimens for enhancing performance and reducing residual impairment are unclear, and ideal recovery and maintenance protocols are frequently debated with little supporting data. Two strategies for throwing shoulder recovery from pitching are SLT and ULT throwing. These are employed to help maintain range of motion and limit IR loss in pitchers. The routine use of ULT throwing for recovery and to limit range of motion alterations after a pitching session is not superior to SLT throwing.

  View details for DOI 10.1177/1941738120980016

  View details for Web of Science ID 000620309900001

  View details for PubMedID 33539268

• Comparison of mechanical properties between Nice knot, Modified Nice knot, and surgeon's knot. Clinical biomechanics (Bristol, Avon) Friedman, L. G., Quigley, R., Shewman, E., Kirsch, J., Freehill, M. T., Garrigues, G. E. 2021; 90: 105486

  Abstract

  The success of surgical repairs rely on the effectiveness and integrity of the surgical knots used to secure the repair. The purpose of this study is to examine and compare the performance of the Nice knot, the modified Nice knot, and a commonly used combination of surgeons' and square knots with respect to cyclic loading and load-to-failure usiflueng a high-strength suture composed of ultra-high molecular weight polyethylene in the hands of experienced surgeons.Two experienced surgeons threw 3 different knot types 9 times, consisting of the Nice knot, modified Nice knot, and a surgeon's knot utilizing Ultrabraid #2 sutures. Each knot was subject to cyclic loading and load to failure testing.Both surgeons had similar displacement data for the surgeon's knot, while the identity of the surgeon impacted displacement for the Nice knot (p = 0.03) and the modified Nice knot (p = 0.0002). The load to failure for the modified Nice knot (p < 0.001) and the Nice knot (p = 0.001) were significantly impacted by the surgeon tying the knot, while the surgeon's knot was not. Specimens failed where the sutures passed through the loop at the "base" of the knot.The strength and integrity of complex surgical knots are variable between surgeons. While the proposed Modified Nice Knot has a theoretical advantage because the half hitches reinforce the primary knot, in load to failure testing both the Modified Nice Knot and the Nice Knot failed where the suture passed through the loop in the primary knot.

  View details for DOI 10.1016/j.clinbiomech.2021.105486

  View details for PubMedID 34560347

• Pitch Break and Performance Metrics Remain Unchanged in Those who Returned to the Same Level of Play after Ulnar Collateral Ligament Reconstruction in Major League Baseball Pitchers. Journal of shoulder and elbow surgery Platt, B. N., Zacharias, A. J., Uhl, T. n., Freehill, M. T., Conley, C. E., Stone, A. V. 2021

  Abstract

  The ulnar collateral ligament is commonly injured in overhead throwing athletes, particularly baseball pitchers. Pitch movement (break) is a critical aspect to pitching performance. The primary purpose of this study was to determine the changes in pitch velocity, pitch break, angle of break, and pitch performance metrics before and after ulnar collateral ligament reconstruction (UCLR) in Major League Baseball (MLB) pitchers. The secondary purpose was to determine changes in pitch performance metrics before and after UCLR. We hypothesized that pitch break and pitch performance metrics would be unchanged following UCLR.This is a retrospective case series study of pitchers who had undergone primary UCLR between 2008 and 2014. Velocity, horizontal movement (Hmov), and vertical movement (Vmov) of each pitch were collected from PITCHf/x for each pitcher 12-24 months before surgery, 12-24 months after surgery, and 24-36 months after surgery. Overall break was calculated by taking the Pythagorean sum of Hmov and Vmov. Angle of break was determined by taking the inverse tangent of Vmov divided by Hmov. Repeated measures ANCOVA was performed to determine differences in pitch velocity, movement, angle of movement, and performance metrics between pre- and postoperative timeframes. Performance metrics included balls, strikes, swings, fouls, swings and misses, ground balls, line drives, pop ups, fly balls, and home runs. Covariates included age at surgery, time from MLB debut to surgery, innings pitched as starter, innings pitched as reliver, and total pitches thrown.In a cohort of 46 pitchers who underwent UCLR between 2008 and 2014, pitch velocity, movement, and angle were not significantly changed with respect to pre- or postoperative timeframes. In addition, postoperative timeframes had clinically insignificant differences in pitch performance metrics.Pitch break and performance metrics are not significantly affected for pitchers who return after UCLR.

  View details for DOI 10.1016/j.jse.2021.04.036

  View details for PubMedID 34015435

• Outcomes After Resection Arthroplasty Versus Permanent Antibiotic Spacer for Salvage Treatment of Shoulder Periprosthetic Joint Infections: A Systematic Review and Meta-Analysis. Journal of shoulder and elbow surgery Xiao, M., Money, A., Pullen, W. M., Cheung, E. V., Abrams, G. D., Freehill, M. T. 2021

  Abstract

  Although revision to new components is favored following shoulder periprosthetic joint infections (PJI), implant exchange is not always feasible. In certain cases, definitive treatment may be retainment of an antibiotic spacer or resection arthroplasty. The purpose of this investigation was to systematically review the literature for studies reporting on outcomes after resection arthroplasty or permanent antibiotic spacer for salvage treatment of shoulder PJIs.A systematic review was performed using PRISMA guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for Level I-IV studies that reported on the final treatment of periprosthetic shoulder infections using resection arthroplasty or a permanent antibiotic spacer. Data recorded included study demographics, causative infectious organism, shoulder-specific range of motion and outcome measures, and infection eradication rate. Study methodological quality was analyzed using the Methodological Index for Non-Randomized Studies (MINORS) score. Forest plots of proportions and meta-analyses of single means were generated for infection eradication rates and outcomes, respectively. Heterogeneity was quantified using the I2 statistic. A P value of 0.05 was set as significant.The initial search yielded 635 articles (211 duplicates, 424 screened, 57 full-text review). Twenty-three articles (126 resection arthroplasty and 177 retained antibiotic spacer patients, 51% females, mean age range 37 to 78.5 years, mean MINORS score 9.6 + 0.7) were included and analyzed. The pooled infection eradication rate was 82% [72% - 89%] following resection arthroplasty and 85% [79% - 90%] after permanent antibiotic spacer. The pooled mean forward flexion (71.5˚ versus 48.7˚; p < 0.001) and mean American Shoulder and Elbow Surgeons (ASES) score (53.5 versus 31.0; p < 0.001) was significantly higher for patients treated with permanent antibiotic spacer compared to resection arthroplasty. No significant differences were found for mean external rotation (13.5˚ versus 20.5˚; p = 0.07), abduction (58.2˚ versus 50.3˚; p = 0.27), or visual analog scale (VAS) pain (3.7 versus 3.4; p = 0.24) between groups. There was a statistically significant, but not clinically significant, difference in mean Constant score between permanent antibiotic spacer and resection arthroplasty patients (33.6 versus 30.0; p < 0.001).When implant exchange following shoulder PJI is not feasible, permanent antibiotic spacers and resection arthroplasty are both salvage procedures which provide similar rates of infection eradication. Though both can decrease pain levels, permanent antibiotic spacer may result in better functional outcomes compared to resection arthroplasty.

  View details for DOI 10.1016/j.jse.2021.10.016

  View details for PubMedID 34774777

• Pain Management in Shoulder Arthroplasty: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials. Journal of shoulder and elbow surgery Xiao, M., Cohen, S. A., Cheung, E. V., Freehill, M. T., Abrams, G. D. 2021

  Abstract

  Postoperative pain management after total shoulder arthroplasty (TSA) can be challenging. Given the variety of pain management options available, the purpose of this investigation was to systematically review the literature for randomized controlled trials (RCTs) reporting on pain control after shoulder arthroplasty. We sought to determine which modalities are most effective in managing postoperative pain and reducing postoperative opioid use.A systematic review was performed using PRISMA guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for Level I-II RCTs that compared interventions for postoperative pain control after TSA. Pain control measures included nerve blocks and nerve block adjuncts, local injections, patient-controlled analgesia, oral medications, or other modalities. The two primary outcome measures were pain level measured on a 0-10 visual analog scale (VAS) and opioid use. The risk of study bias and methodological quality was analyzed using the Cochrane Collaboration's Risk of Bias 2 (RoB 2) tool. Network meta-analyses were performed for pain VAS at post-surgical timepoints and opioid use using a frequentist approach and random effects model, with heterogeneity quantified using the I2 statistic. Treatments were ranked using the P-score, and statistical significance was set at p < 0.05.The initial search yielded 2391 articles (695 duplicates, 1696 screened, 35 full-text review). Eighteen articles (1358 shoulders; 51% females; mean age range 65 to 73.7 years; four low risk, 12 some risk, and two high risk of bias studies) were included and analyzed. At 4 and 8 hours postoperatively, patients receiving local liposomal bupivacaine (LB) (p < 0.001 for 4 and 8 hours) or local ropivacaine injection (p < 0.001 for 4 hours; p = 0.019 for 8 hours) had significantly more pain compared to patients who received either a continuous (cISB) or single-shot interscalene block (ssISB). No differences (at p<0.05) in opioid use were detected between modalities. P-scores of treatments demonstrated that ssISBs were most favorable at timepoints <24 hours, whereas pain at 24 and 48 hours after surgery was best managed with cISBs or a combination of ssISB with local LB injection.ISBs are superior to local injection alone at managing pain after TSA. ssISBs are optimal for reducing early postoperative pain (< 24 hours), whereas pain at 24 to 48 hours after surgery may be best managed with cISBs or a combination of ssISBs with local LB injection.

  View details for DOI 10.1016/j.jse.2021.06.008

  View details for PubMedID 34284094

• Superior Capsular Reconstruction: A Systematic Review of Surgical Techniques and Clinical Outcomes. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association Gao, I., Sochacki, K. R., Freehill, M. T., Sherman, S. L., Abrams, G. D. 2020

  Abstract

  PURPOSE: To evaluate surgical techniques and clinical outcomes for arthroscopic superior capsular reconstruction (SCR) for treatment of massive irreparable rotator cuff tears.METHODS: A systematic review was registered with PROSPERO and performed using PRISMA guidelines. PubMed, SCOPUS, and Cochrane databases were searched. Studies investigating SCR with reported surgical technique were included. Animal studies, cadaveric studies, review studies, and letters to the editor were excluded. Technical aspects of surgical technique for SCR were analyzed in each article, which included: graft type, glenoid fixation method, greater tuberosity fixation method, graft passage technique, suture management, margin convergence, concomitant procedures, and post-operative rehabilitation protocol. Clinical outcomes, when available, were also analyzed.RESULTS: Three hundred sixty-five articles were screened with 29 found that described surgical technique for SCR. According to the Modified Coleman Methodology Score, 24 articles were poor (scores <55), 4 were fair (scores between 55 and 69), and 1 was good (scores between 70 and 84) with an average score of 25.8 ± 20.9. The most commonly used technique for SCR utilized: acellular dermal allograft, two biocomposite suture anchors for glenoid fixation, transosseus equivalent double-row suture anchor fixation for greater tuberosity fixation with two biocomposite medial row anchors and two biocomposite lateral row anchors, double-pulley technique combined with an arthroscopic grasper and/or pull suture to pass the graft into the shoulder, performance of both anterior and posterior margin convergence, and native rotator cuff repair when possible. Only 8 of the studies reported clinical outcomes, and they showed that SCR provides significant improvement in patient-reported outcomes, significant improvement in shoulder ROM, variable graft failure rates, low complication rates, and variable reoperation rates. There were no studies comparing outcomes between the various surgical techniques.CONCLUSIONS: Many surgical techniques exist for arthroscopic SCR. However, no superior technique was demonstrated, as there were no studies comparing clinical outcomes among these various techniques.

  View details for DOI 10.1016/j.arthro.2020.09.016

  View details for PubMedID 33227320

• Quantifying Throw Counts and Intensities Throughout a Season in Youth Baseball Players: A Pilot Study. Journal of biomechanical engineering Rose, M., McCollum, K. A., Freehill, M. T., Cain, S. 2020

  Abstract

  Overuse injuries in youth baseball players due to throwing are at an all-time high. Traditional methods of tracking player throwing load only count in-game pitches and therefore leave many throws unaccounted for. Miniature wearable inertial sensors can be used to capture motion data outside of the lab in a field setting. The objective of this study was to develop a protocol and algorithms to detect throws and classify throw intensity in youth baseball athletes using a single, upper arm-mounted inertial sensor. Eleven participants from a youth baseball team were recruited to participate in the study. Each participant was given an inertial measurement unit and was instructed to wear the sensor during any baseball activity for the duration of a summer season of baseball. A throw identification algorithm was developed using data from a controlled data collection trial. In this report, we present the throw identification algorithm used to identify over 17,000 throws during the 2-month duration of the study. Data from a second controlled experiment was used to build a support vector machine model to classify throw intensity. Using this classification algorithm, throws from all participants were classified as being "low," "medium," or "high" intensity. The results demonstrate that there is value in using sensors to count every throw an athlete makes when assessing throwing load, not just in-game pitches.

  View details for DOI 10.1115/1.4049025

  View details for PubMedID 33156351

• Optimizing the Double-Row Construct: An Untied Medial Row Demonstrates Equivalent Mean Contact Pressures in a Rotator Cuff Model ORTHOPAEDIC JOURNAL OF SPORTS MEDICINE Stone, A., Luo, T., Sharma, A., Danelson, K. A., De Gregorio, M., Freehill, M. T. 2020; 8 (4): 2325967120914932

  Abstract

  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.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.Controlled laboratory study.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.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.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's 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.Both tied and untied medial rows demonstrated similar pressures across the repair construct.

  View details for DOI 10.1177/2325967120914932

  View details for Web of Science ID 000535799900001

  View details for PubMedID 32426405

  View details for PubMedCentralID PMC7218996

• Thrower's Exostosis of the Shoulder: A Systematic Review With a Novel Classification. Orthopaedic journal of sports medicine Freehill, M. T., Mannava, S. n., Higgins, L. D., Lädermann, A. n., Stone, A. V. 2020; 8 (7): 2325967120932101

  Abstract

  A variety of thrower's exostoses are grouped under the term Bennett lesion, which makes understanding diagnosis and treatment difficult.To identify all types of reported thrower's and overhead athlete's exostoses and categorize them into a classification system to allow a morphology-based classification.Systematic review; Level of evidence, 4.A systematic review of all articles pertaining to Bennett lesions and thrower's exostosis was performed. The classification and treatments were evaluated to describe the types, proposed causes, diagnosis, and treatment options.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's 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.Based on a comprehensive review of the literature, we identified several anatomic locations for a thrower's 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's exostosis, which may be used to study future treatments. Current treatment strategies recommend that surgical treatment of thrower's 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.

  View details for DOI 10.1177/2325967120932101

  View details for PubMedID 32704507

  View details for PubMedCentralID PMC7361505

• Osseous Healing With Nonrigid Suture Fixation in the Arthroscopic Latarjet Procedure. Orthopaedic journal of sports medicine Weick, J. W., Kalia, V. n., Pacheco, E. n., Jacobson, J. A., Freehill, M. T. 2020; 8 (11): 2325967120964489

  Abstract

  The Latarjet procedure is a popular means to surgically address anterior glenohumeral joint instability. Although the Latarjet procedure is becoming increasingly common, challenges persist and include postoperative complications secondary to use of the conventional 2 bicortical fixation screws. Recently, a novel surgical technique using a guided surgical approach for graft positioning with nonrigid fixation via a suture suspensory system has been described.To evaluate healing rates and stability of the grafts in patients who underwent this new Latarjet technique.Case series; Level of evidence, 4.We retrospectively gathered anonymized computed tomography (CT) data sets from a total of 107 patients who underwent nonrigid suture fixation using a cortical button fixation for anterior glenohumeral instability. Of the 107 patients, 45 had CT scans performed at 2 different time periods. The CT scans of each patient were compared by 2 fellowship-trained musculoskeletal radiologists. Data recorded included age, sex, date of scan, initial graft position on the glenoid, presence and degree of graft migration relative to the equator on follow-up scan, and percentage of osseous healing (as assessed by osseous bridging) on the follow-up scan. Descriptive statistics were calculated to evaluate the average migration and average percentage of healing at both time points.Our population (n = 45) consisted of 38 men (84.4%) and 7 women (15.6%). The mean age was 27.1 ± 1.1 years. The mean time between initial CT scan (2 weeks postoperatively) and follow-up CT scan was 26 ± 2 weeks. On follow-up scan, reviewer 1 found 75.6% of patients had greater than 75% healing, and reviewer 2 found 70.2% of patients had greater than 75% healing. The center of the graft was measured at or below the equator on follow-up examination in 43 of 45 (95.6%) patients by reviewer 1 and 44 of 45 (97.8%) patients by reviewer 2.Based on these findings, nonrigid suture fixation using a cortical button device offers an effective alternative to traditional screw fixation for the Latarjet procedure with a high level of osseous healing and minimal graft migration.

  View details for DOI 10.1177/2325967120964489

  View details for PubMedID 33244477

  View details for PubMedCentralID PMC7678400

• Outcomes Evaluation of the Athletic Elbow SPORTS MEDICINE AND ARTHROSCOPY REVIEW Freehill, M. T., Mannava, S., Safran, M. R. 2014; 22 (3): E25-E32

  Abstract

  The high-level athletic population poses difficulty when evaluating outcomes in orthopedic surgery, given generally good overall health and high function at baseline. Subtle differences in performance following injury or orthopedic surgery are hard to detect in high-performance athletes using standard outcome metrics; however, attaining these subtle improvements after injury or surgery are key to an athletes' livelihood. Outcome measures serve as the cornerstone for critical evaluation of clinical outcomes following orthopedic surgery or injury. In the age of "evidence-based medicine" and "pay-for-performance" accountability for surgical intervention, understanding clinically relevant outcome measures is essential for careful review of the published literature, as well as one's own critical review of surgical performance. The purpose of this manuscript is to evaluate clinical outcome measures in the context of the athletic elbow. An emphasis will be placed on evaluation of the 5 most clinically relevant outcome measures for sports-related elbow outcomes: (1) American Shoulder and Elbow Committee; (2) Mayo Elbow Performance Index; (3) Andrews-Timmerman [and its precursor the (4) Andrews-Carson]; and (5) Kerlan-Jobe Orthopaedic Clinic overhead athlete score. A final outcome measure that will be analyzed is "return to play" statistics, which has been published in various studies of athletes' recovery from elbow surgery, as well as, the outcomes metric known as the "Conway-Jobe scale." Although there is no perfect outcomes score for the athletic elbow, the Kerlan-Jobe Orthopaedic Clinic score is the only outcomes tool developed and validated for outcomes for elbow injuries in the overhead athlete, as compared with the Andrew-Timmerman and Conway-Jobe metrics, which were not validated outcome measures for the elbow in this patient population. Despite the Disabilities of Arm, Shoulder, Hand (DASH) (and DASH-Sport module) being validated in the general population, this upper extremity scale is not specific for elbow function.

  View details for Web of Science ID 000340731700004

  View details for PubMedID 25077753

• Biomechanical evaluation of a coracoclavicular and acromioclacicular ligament reconstruction technique utilizing a single continuous intramedullary free tendon graft. Journal of shoulder and elbow surgery Abrams, G. D., McGarry, M. H., Jain, N. S., Freehill, M. T., Shin, S., Cheung, E. V., Lee, T. Q., Safran, M. R. 2013; 22 (7): 979-985

  Abstract

  Reconstruction of only the coracoclavicular (CC) ligaments may restore superior-inferior (S-I) but not anterior-posterior (A-P) stability of the acromioclavicular (AC) joint. Concomitant reconstruction of both the AC and CC ligaments may more reliably restore intact biomechanical characteristics of the AC joint.Ten matched pairs of shoulders were utilized. Five specimens underwent CC ligament reconstruction while an equal number underwent combined AC and CC ligament reconstruction utilizing an intramedullary tendon graft. Each of the reconstructions was compared with the intact contralateral control. Translational and load to failure characteristics were compared between groups.No difference was found in S-I translation between intact specimens and CC-only reconstructions (P = .20) nor between intact specimens and AC/CC reconstructions (P = .33) at 10 Newton (N) loads. Significant differences were noted in A-P translation between intact specimens and CC-only reconstructions (P < .001) but no difference in A-P translation between intact specimens and AC/CC reconstructions (P = .34).The A-P and S-I translational biomechanical characteristics of the AC joint were restored using the new technique described. Reconstruction of the CC ligaments only (versus AC/CC combined) led to significantly increased translational motion in the A-P plane as compared to intact control specimens.

  View details for DOI 10.1016/j.jse.2012.09.013

  View details for PubMedID 23313367

• Diagnosis and Management of Ulnar Collateral Ligament Injuries in Throwers CURRENT SPORTS MEDICINE REPORTS Freehill, M. T., Safran, M. R. 2011; 10 (5): 271-278

  Abstract

  Although ulnar collateral ligament (UCL) injuries are reported most commonly in baseball players (especially in pitchers), these also have been observed in other throwing sports including water polo, javelin throw, tennis, and volleyball. This article reviews the functional anatomy and biomechanics of the UCL with associated pathophysiology of UCL injuries of the elbow of the athlete participating in overhead throwing. Evaluation, including pertinent principles in history, physical examination, and imaging modalities, is discussed, along with the management options.

  View details for DOI 10.1249/JSR.0b013e31822d4000

  View details for Web of Science ID 000294685000005

  View details for PubMedID 23531973

• The Labrum of the Hip: Diagnosis and Rationale for Surgical Correction CLINICS IN SPORTS MEDICINE Freehill, M. T., Safran, M. R. 2011; 30 (2): 293-?

  Abstract

  The treatment of labral pathologic condition of the hip has become a topic of increasing interest. In patients undergoing hip arthroscopy, tears of the acetabular labrum are the most commonly found pathologic condition and most common cause of mechanical symptoms. Although a labral tear may occur with a single traumatic event, often another underlying cause may be already present, predisposing the individual to injury. This article discusses the structure and function of the acetabular labrum, the diagnosis of labral injury through physical examination and imaging modalities, and the current treatment options, including labrectomy, labral repair, and reconstruction.

  View details for DOI 10.1016/j.csm.2010.12.002

  View details for Web of Science ID 000289811500007

  View details for PubMedID 21419957