The flexor-pronator muscles (FPM) and their common tendon (CT) are essential in protecting the medial ulnar collateral ligament against elbow valgus stress during pitching. This study aimed to investigate the effect of repetitive pitching on FPM strength and CT stiffness.

Fifteen healthy males (mean age: 21.8 ± 1.3 years old) with over 5 years of baseball experience performed a series of 100 full-effort fastball pitches. We measured grip and isolated digital flexion strength of the second, third, and fourth digits before and after the pitching task. The decline in muscle strength was determined using the rate of change in muscle strength after pitching relative to that before. CT stiffness was measured using a hand-held myotonometer device at rest and during grip motion at 50% maximum voluntary contraction. The increase in CT stiffness during grip motion relative to rest was calculated as the augmentation rate of CT stiffness. Statistical analyses were performed to compare the changes in grip strength, digital flexion strength, and CT stiffness due to pitching. Additionally, the reduction rate of muscle strength was compared among various strength variables. Correlation coefficients were used to evaluate the relationships between the augmentation rate of CT stiffness after pitching and the reduction rate in any muscle strength.

Grip and isolated digital flexion strengths decreased significantly after pitching (P < .01). The decline in muscle strength was significantly higher for all isolated digital strengths than that for grip strength (P < .05). CT stiffness was augmented with grip motion compared to that at rest pre- and postpitching (P < .001). However, no change in CT stiffness due to pitching was observed, regardless of the grip motion (P > .05). Additionally, a lower augmentation rate of CT stiffness after pitching was moderately associated with the greater reduction rate of the second digital flexion strength (r = 0.607, P = .016) without other relationships.

This study found reduced grip and digital flexion strength after pitching; with no change in CT stiffness. However, given the consequences of correlation analyses, individuals with a more prominent reduction in second digital flexion strength due to pitching were impaired in CT stiffness augmentation after pitching. Digital flexion strength represents the strength of the flexor digitorum superficial; therefore, this study suggests that forearm FPM, particularly the second digit of the flexor digitorum superficial, is an important factor for enhancing CT stiffness.

This study aimed to examine the effect of flexion on valgus carrying angle in the human elbow using a dynamic elbow testing apparatus.

Active elbow motion was simulated in seven cadaveric upper extremities. Six electromechanical actuators simulated muscle action, while 6 degrees-of-freedom joint motion was measured with an optical tracking system to quantify the kinematics of the ulna with respect to the humerus as the elbow was flexed at the side position. Repeatability of the testing apparatus was assessed in a single elbow over five flexion-extension cycles. The varus angle change of each elbow was compared at different flexion angles with the arm at 0° of humerothoracic abduction or dependent arm position.

The testing apparatus achieved excellent kinematic repeatability (intraclass correlation coefficient, >0.95) throughout flexion and extension. All elbows decreased their valgus carrying angle during flexion from 0° to 90° when the arm was maintained at 0° of humerothoracic abduction. Elbows underwent significant total varus angle change from full extension of 3.9° ± 3.4° (P = .007), 7.3° ± 5.2° (P = .01), and 8.9° ± 7.1° (P = .02) at 60°, 90°, and 120° of flexion, respectively. No significant varus angle change was observed between 0° and 30° of flexion (P = .66), 60° and 120° of flexion (P = .06), and 90° and 120° of flexion (P = .19).

The dynamic elbow testing apparatus characterized a decrease of valgus carrying angle during elbow flexion and found that most varus angle changes occurred between 30° and 90° of flexion. All specimens underwent varus angle change until at least 90° of flexion.

Our model establishes the anatomic decrease in valgus angle by flexion angle in vitro and can serve as a baseline for testing motion profiles of arthroplasty designs and ligamentous reconstruction in the dependent arm position. Future investigations should focus on characterizing motion profile change as the arm is abducted away from the body.

The flexor pronator mass (FPM) is an important dynamic stabilizer to valgus stress at the elbow and has been reported to protect against ulnar collateral ligament (UCL) injury. Active gripping and pronation have demonstrated reduced ulnohumeral joint space and change in material properties of the UCL when examined in vivo via ultrasound. No studies have utilized ultrasonography and shear wave elastography to characterize the medial elbow's response to FPM activation under valgus stress. This cross-sectional, repeated measures study aims to characterize medial elbow changes in UCL and FPM tissue stiffness and joint space width (JSW) during valgus stress with incremental FPM activation through gripping.

Thirteen participants (6 male, 7 female) aged 18-40 year with a BMI < 30 and no history of upper extremity injury were included in this study. Elbows were placed in a telos stress device at 30° of flexion and a 100N valgus stress was applied. Participants then activated the FPM by gripping a spherical dynamometer at 100, 75, 50, 25, and 0% of maximal grip strength. UCL thickness, ulnohumeral (UH) JSW, UCL stiffness, and FPM stiffness were measured for each condition and compared via a two-way repeated measures ANOVA and a post hoc Fischer's Least Significant Difference test.

Men and women showed no baseline differences in UCL thickness or UH JSW. JSW was significantly wider under valgus load, 2.22 ± 0.42 mm vs. 2.99 ± 0.46 mm in males and 2.15 ± 0.41 mm vs. 2.99 ± 0.55 mm in females (p < 0.05). No statistically significant differences were demonstrated in UH JSW by gripping force magnitude and differences by sex were not observed. Additionally, no significant changes in tissue stiffness were observed during dynamic conditions for shear wave velocities for either the UCL or FPM.

Gripping does not change UH JSW or medial elbow tissue stiffness in the joint testing configuration and external loading conditions applied in this study. This suggests that gripping may not be as protective during the high valgus stress observed in baseball pitching as believed, and that the influence of FPM activity may be joint position or load dependent.

The contraction of the flexor pronator muscles (FPMs) plays an important role in stabilizing the elbow joint in baseball players. However, the influence of different types of contractions on the medial joint space (MJS) in high school baseball players is not well understood. This study aimed to elucidate the effects of individual or combined contractions of the FPMs, specifically the flexor carpi ulnaris, flexor digitorum superficialis (FDS), pronator teres (PT), palmaris longus, and flexor carpi radialis, on the MJS in high school baseball players. We hypothesized that contractions, particularly of the FDS, PT, and flexor carpi radialis, would lead to a narrowing of the MJS.

The study included 36 high school baseball players who executed 9 different contraction tasks related to the FPMs (including a resting state) in a randomized order. The MJS was measured using ultrasound equipment and compared with the resting state. The Friedman test, as a repeated-measures one-way analysis of variance, was performed, followed by Steel's test for multiple comparisons. All analyses were conducted using EZR software, with a significance level set at 5%.

The repeated-measures one-way analysis of variance and the Friedman test revealed a significant difference among the 9 contraction tasks (P < .001). Using Steel's test, a significant reduction in the MJS (mean ± standard deviation) was observed compared with the resting state (4.8 ± 1.2 mm), particularly in contraction tasks involving the PT (4.0 ± 1.0 mm, P = .017), FDS and PT (4.0 ± 1.1 mm, P = .007), and flexor carpi ulnaris, FDS, and PT (4.0 ± 1.1 mm, P = .008).

Incorporating the PT into contraction tasks significantly reduced the MJS, emphasizing the important role of the PT in elbow joint stability. More work is required to see if the results of this study can be used to develop injury prevention and rehabilitation strategies.

Baseball is one of the most popular sports among youth athletes in the United States, and among these players, pitchers are at a particularly high risk of sustaining an injury. Overuse of the arm from repetitive pitching is a common mechanism for injury. Despite the attention that overuse injury has received, little is known regarding the mechanism that leads to elbow injury. This study aims to determine the effect of increasing pitch count on elbow flexion at ball release in a youth pitching cohort. The authors hypothesize that elbow flexion would increase as pitch count increases.

Study subjects included volunteers from youth baseball players from local teams and public advertisements. Retroreflective markers attached to bony landmarks were placed on the players according to International Shoulder Group recommendations. Pitchers threw an indoor simulated game. Three-dimensional marker trajectories were collected using a 12-camera optical motion capture system, and ball velocity was captured using a radar gun. Voluntary maximal isometric strength of the internal and external rotators was evaluated before and after pitching. Paired 2-tailed t tests were performed to determine if a significant change occurred between the fresh and fatigued sets.

Twelve adolescent male pitchers were recruited. Eleven of 12 pitchers completed the prescribed 6 sets of 15 pitches, culminating in a 90-pitch simulated game. The ball speed in the second set was found to be the highest in all pitchers and was considered the "peak set" (P = .021), whereas ball speed was the slowest in the sixth set of pitches and was therefore considered the "fatigue set" (P = .001). There was a moderate but statistically significant inverse correlation between elbow flexion at ball release and maximum internal rotation velocity (P = .005). Elbow flexion at ball release was also significantly positively correlated with shoulder abduction at ball release (P = .004). Elbow flexion at ball release was not significantly correlated with ball velocity (P = .108).

In a simulated game laboratory setting, increasing pitch count was associated with increasing elbow flexion angle at ball release in youth baseball pitchers. These findings demonstrate that pitching with fatigue may cause biomechanical changes that have been associated with increased rates of elbow injury in the adult throwing population. Further investigation on the association between elbow flexion angle and elbow injury in the youth baseball population is needed.

Numerous studies have investigated pitching kinematics associated with elbow varus torque, but these studies were limited in the parameters analyzed and/or the number of pitchers tested.

The purpose of this work was to evaluate numerous kinematic parameters in a large sample of elite adult pitchers. It was hypothesized that several kinematic parameters would be associated with variations in elbow varus torque.

Descriptive laboratory study.

A deidentified biomechanical database of 523 pitchers (425 professional; 98 collegiate) was analyzed. For each pitcher, 21 kinematic parameters and normalized elbow varus torque (% body weight × height) were calculated. A stepwise multivariate linear regression model evaluated significant findings. In addition, biomechanical differences were identified between the high- and low-torque groups using Mann-Whitney U tests.

Forty percent of the variance in normalized torque was explained by 11 kinematic parameters. Comparison of the high- and low-torque groups demonstrated significant differences in 10 of these parameters (all except pelvic angular velocity). Compared with the low-torque group, the high-torque group had greater ball velocity, shoulder abduction at foot contact, elbow flexion at foot contact, maximum knee extension velocity during arm acceleration, maximum elbow extension velocity during arm acceleration, and trunk contralateral tilt at ball release. In addition, the high-torque group had lower upper trunk tilt at foot contact, shoulder external rotation at foot contact, maximum external rotation, and shoulder abduction at ball release.

Normalized elbow varus torque was associated with ball velocity and 10 other kinematic parameters. Ball velocity and 9 of these kinematic parameters were significantly different between the high-torque and low-torque groups. These parameters may be related to increased pitch velocity but also increased load within the throwing elbow.

This study provides pitchers, coaches, and trainers with objectives for modification of pitching mechanics to reduce elbow torque and possible risk of injury, particularly kinematics in the early phase of the pitching motion.

Ligamentous elbow dislocations often affect young patients with high functional and athletic demands. After reduction and clinical examination of joint stability, further treatment options are, therefore, the subject of controversial debate. In order to be able to advise patients adequately, an assessment of the possible return-to-sport based on experience is necessary. This study examines the medium to long-term return-to-sports after conservative treatment of a ligamentous elbow dislocation.

In this clinical study, 42 patients (47.6% female, 52.4% male) who were treated conservatively for a ligamentous elbow dislocation at our clinic were surveyed. Conservative treatment was carried out for at least 6 weeks. Exclusion criteria were concomitant bony lesions requiring surgery, a tendency to dislocate between 30 and 130° of flexion after reduction, a positive apprehension test after reduction, and athletes with medial pop-up/instability and high valgus stress as part of their sporting activities. The Disabilities of the arm, shoulder and hand (DASH), the sport-DASH and the subjective elbow value (SEV) were tested. The sport-DASH was correlated with gender, age, arm dominance, and the type of sport practiced. Descriptive statistics and significant differences were determined using statistical analyses.

The average age was 42.7 years (range 22-75). After an average follow-up after 4.5 years, the mean value of DASH was 2.44 (SD 4.77), the mean value of sports DASH was 4.17 (SD 11.04) and the mean value of SEV was 94.93% (SD 6.40). There were no significant differences in sports DASH depending on gender (p = 0.81), age (p = 0.68), dislocation side in relation to the dominant arm (p = 0.54) or the type of sport practiced (p = 0.94, p = 0.65, p = 0.71). 2 patients (4.8%) underwent surgery after 6 and 8 weeks of conservative treatment due to persistent elbow stiffness.

In our patient cohort, a very good return-to-sports after conservative treatment of ligamentous elbow dislocation was demonstrated, taking into account the above exclusion criteria. Factors such as age, gender, the side of the dislocation in relation to the arm dominance, and the type of sport had no influence on the outcome of our study. The data help practitioners to advise patients better when deciding on treatment and the question of a possible return to sport.

Repetitive pitching causes immediate changes in the medial elbow joint. However, the recovery process from these changes is not clear.

The purpose of this study was to investigate the recovery of the medial elbow joint in the 24-hour period after pitching. The hypothesis was that while some recovery will occur at 24 hours after repetitive pitching, this would not be a complete return to baseline.

Controlled laboratory study.

A total of 26 high school baseball pitchers participated (mean age, 16.0 ± 0.5 years). Participants threw 100 pitches (5 sets of 20 pitches). Medial elbow joint width as well as strain ratios of the ulnar collateral ligament (UCL) and forearm flexor-pronator muscles (FPMs) were measured and followed for 24 hours after pitching. The data before pitching and at each time point after pitching were compared. The standard error of measurement (SEM) and minimal detectable change with 95% confidence interval (MDC95) were calculated using measurements before pitching.

The medial elbow joint width significantly increased by 0.84 mm immediately after pitching (P < .05), but this was not maintained at 24 hours. The UCL strain ratio significantly decreased by 1.64 immediately after pitching (P < .05), but this was not maintained at 18 hours after pitching. The strain ratio of the FPMs significantly decreased by 0.09 immediately after pitching (P < .05) but significantly increased by 0.13 at 24 hours (P < .05). The SEM for medial elbow joint width was 0.06 mm, and the MDC95 was 0.18 mm (maximum change: 0.84 mm immediately after pitching). The SEM for UCL strain ratio was 0.85, and the MDC95 was 2.35 (maximum change: 1.64 immediately after pitching). The SEM for strain ratio of the FPMs was 0.08, and the MDC95 was 0.22 (maximum change: 0.13 at 24 hours).

After 100 pitches, stability against elbow valgus laxity recovered within 24 hours. UCL and FPMs showed statistical characteristic changes, but those changes were within the minimal detectable change.

Pitchers' medial elbow joint tissue recovered to baseline at 24 hours after pitching. This suggests that it may be acceptable to resume low-intensity throwing after a 24-hour rest period after 100 repetitive pitches while also considering the condition of the rest of the body.

Prosthetic joint infection (PJI) following radial head arthroplasty (RHA) is a rare, yet devastating complication. Current treatment options for PJI comprise debridement, antibiotics, and implant retention (DAIR); resection arthroplasty; and one- or two-stage revision. Two-stage revision is the current gold standard for the treatment of PJI at the hip, shoulder, and knee, and involves using an antibiotic spacer to maintain limb length and soft tissue tension. Despite the widespread use of this technique in the treatment of PJI at other sites, its use in the treatment of RHA PJI has not been described. In this report, we illustrate the use of a novel polymethylmethacrylate (PMMA) spacer construct for the treatment of RHA PJI by the two-stage revision in a male patient. This method shows promising results, with the spacer maintaining structural integrity for four months.

Ulnar collateral ligament (UCL) injuries in professional baseball remain a significant problem with debate as to which are the greatest risk factors. Currently, it is unknown if hand size should be considered a predictor for UCL injury. A larger or smaller hand size could have implications on fatigue of the forearm musculature and thus varying amounts of strain seen by the UCL. The purpose of this study was to investigate if there is a correlation between hand size and history of UCL tear requiring a reconstruction. We hypothesize that a smaller hand size will be correlated with higher UCL reconstruction (UCLR) rates in professional baseball players.

One-hundred and eighty-nine professional players from one Major League Baseball organization were recruited in this retrospective study. Four different measurements were used for hand size including the distance from the tip of long finger to wrist crease (closed fingers), the distance from the thumb tip to the small fingertip (closed fingers), the distance between thumb tip and small fingertip (spread fingers), and a modified Nirschl measurement (closed fingers). Statistical analysis including t-test, Chi-squared test, Pearson correlation, and binary logistic regression were performed to determine the statistical significance between these hand size measurements and a history of UCLR.

There were 25/189 (13.2%) players with a history of UCLR surgery. The mean age of UCLR group (23.6 ± 3.3 years) was younger than the non-UCLR group (26.2 ± 3.6) (P = .001). Statistical analysis demonstrated the distance between thumb tip and small fingertip (spread fingers) was smaller in the UCLR group compared to the non-UCLR group (20.33 ± 1.18 cm vs. 20.98 ± 1.03 cm; P = .024) and the modified Nirschl measurement (closed fingers) was shorter in the UCLR group (14.45 ± 0.7 cm vs. 14.86 ± 0.91 cm; P = .013). Findings were most notable in players aged less than 21 years with UCLR rates of 57.1% versus players aged more than 21 years (9.7%) (P < .001). Statistical analysis demonstrated a correlation and regression between injury probability and hand measurements (P = .01).

This study demonstrated that a smaller hand size did correlate with a history of UCLR in this professional baseball population of players. Further studies are warranted to investigate these associations.

Baseball pitching injuries can be related to fatigue. Changes in grip and pinch strength over the course of professional baseball games are unknown.

Grip and pinch strength will decrease as the number of innings pitched increases; injured pitchers will have a lower grip strength than uninjured pitchers.

Prospective cohort study.

Level 3.

Minor league pitchers for 1 affiliate of a single organization were included. Changes in dominant and nondominant grip, and middle and index finger pincer strength were recorded pregame and after each inning, and compared between players who sustained a shoulder/elbow injury and those who did not.

Of 41 pitchers included, 6 sustained a shoulder (n = 2) or elbow (n = 4) injury during the study period. Average grip strength for all pitchers was 124.5 ± 17 lb pregame and increased slightly after the first inning (125.2 ± 17 lb), then declined slowly after the second (120.7 ± 18.5 lb), third (119.2 ± 24 lb), and fourth (113.1 ± 19.6 lb) innings. There was a slight uptick in grip strength in the fifth (118.5 ± 23.6 lb) and sixth (121.3 ± 21.8 lb) innings, but pregame levels were not reached. Evaluating uninjured and injured pitchers, the grip strength of injured pitchers was lower at all timepoints. As a percentage of uninjured pitchers grip strength, injured pitcher grip strength was 94.8% pregame, and 97.9%, 95.4%, 81.8%, 87.7%, 82.3%, and 74.5% after the first to sixth innings, respectively.

Dominant arm grip strength generally declined over the course of a game in professional baseball pitchers. Injured pitchers generally had weaker grip strength and a steeper decline in grip strength during games compared with uninjured pitchers.

Incremental loss of grip strength may increase injury risk in professional baseball pitchers.

The present study aimed to compare the functional outcomes of hinged external fixators and non-external fixation in open elbow arthrolysis (OEA) for post-traumatic elbow stiffness (PTES) and to evaluate their applicability and limitations in patients with posttraumatic elbow stiffness.

The clinical data of patients with PTES treated with OEA at our hospital between March 2015 and June 2022 were retrospectively analyzed. The assessed variables were the operation time, intraoperative blood loss volume, duration of hospitalization, and treatment costs. The elbow range of motion (ROM), Mayo Elbow Performance Score (MEPS), shortened disabilities of the arm, shoulder and hand questionnaire (Q-DASH) score, Oxford Elbow score (OES), Broberg and Morrey score (BMS), visual analog scale (VAS) for pain, and complications such as pin tract infection and heterotopic ossification were compared between patients with and without hinge external fixation. We also compared the baseline characteristics and functional outcomes of patients with and without hinge external fixation.

A total of 156 patients (48 patients with hinged external fixators and 108 patients without external fixators) diagnosed with PTES were included in this study. The mean follow-up was 15.8 ± 3.6 months. Compared with patients without external fixators, those with external fixators showed significantly greater improvements in elbow flexion and extension ROM (59.6° ± 26.1° vs. 46.2° ± 26.2°, p = 0.004) but had a significantly longer duration of hospitalization (p < 0.001), significantly longer operation time (p < 0.001), significantly higher treatment costs (p < 0.001), and significantly greater intraoperative blood loss volume (p < 0.001). There were no significant differences between the two groups in terms of improvement in elbow rotation ROM, MEPS score, VAS score for pain, OES score, Q-DASH score, BMS score, or incidence of complications.

The use of a hinged external fixator in open arthrolysis for posttraumatic elbow stiffness may result in short-term improvements in flexion-extension range of motion but is accompanied by increased blood loss, longer operative time, extended hospitalization, and higher costs. Further studies are needed to confirm these findings.

Not applicable.

High elbow varus torque during baseball pitching has been identified as a potential cause of ulnar collateral ligament injury in baseball pitchers. In general, elbow varus torque increases as ball velocity increases across pitchers. However, studies incorporating within-subject analyses report that not all professional pitchers have a positive relationship between elbow varus torque and ball velocity (T-V relationship). It remains unknown whether collegiate pitchers show the same trend as professionals in their T-V relationships. The current study investigated the T-V relationship of collegiate pitchers focusing on both across and within pitchers. Division 1 collegiate pitchers (n = 81) were assessed for elbow torque and ball velocity during pitching. Both across- and within-pitcher T-V relationships were significant (p < 0.05) using linear regression. However, more variance in elbow varus torque was explained using the within-pitcher relationship (R2 = 0.29) than the across-pitcher relationship (R2 = 0.05). Of the 81 pitchers, nearly half (n = 39) had significant T-V relationships, while the other half (n = 42) did not. Our findings indicate that the T-V relationship should be assessed on an individual basis as T-V is pitcher-specific.

This study examined the changes in the medial elbow joint space width and forearm flexor strength due to repetitive pitching and analysed the relationships among these factors. Thirty-one collegiate baseball players pitched seven sets of 15 pitches each. The medial elbow joint space width, grip strength, and forearm flexor strengths were measured before pitching and after each set. These parameters were compared at baseline and after pitching for each set. Additionally, the relationships between changes in the medial elbow joint space and forearm flexor strength were examined for each set. The medial elbow joint space width significantly increased after four sets compared to baseline values. Compared to baseline values, grip strength decreased significantly after one set, wrist flexion and radial deviation after six, and ulnar deviation after five. However, changes in the medial joint space compared to baseline values after each set were not significantly correlated with changes in forearm flexor strength variables. Therefore, repetitive pitching causes an increase in elbow valgus laxity and a decrease in forearm flexor strength. However, the decrease in forearm muscle strength does not explain the increase in elbow valgus laxity.

An important aspect of the pitching motion is the lead leg knee angle, from initial lead foot contact to ball release, which can influence pitching performance and injury potential. Understanding the implication of this angle is essential to appropriately coach baseball pitchers. Therefore, the purpose of this study was to determine the lead leg knee flexion influence on both ball velocity and the elbow varus moment. Kinematic and kinetic data were collected using standard optoelectronic motion capture methods from 121 collegiate pitchers and analysed using a random intercept, mixed effects regression model to evaluate the association between the knee angle on peak ball velocity and peak elbow varus moment, independently. Statistically significant associations between the knee flexion angle and ball velocity as well as with the elbow varus moment were noted. The data indicated that a 10° increase in knee flexion at ball was associated with a 2.1 Nm reduction in the peak elbow varus moment (p = 0.021, r2 = 0.12) and a 0.2 m/s reduction in peak ball velocity (p = 0.010, r2 = 0.11). This study provides scientific evidence that the lead knee flexion angle influences both upper extremity stresses and ball velocity.

Injury to the elbow is very common in the throwing athlete and can potentially lead to long absences from play and, in the most severe scenarios, medical retirement. The throwing motion is a highly complex series of movements through the entire kinetic chain that results in very high angular velocities and valgus forces at the elbow joint. The repetitive nature of overhead throwing in combination with the high levels of accumulated force at the elbow puts both pediatric and adult athletes at risk of both acute and chronic overuse injuries of the elbow. This review provides an update on common injuries in the throwing athlete and covers clinical presentation, diagnosis, and treatment of these injuries.

The purpose of this study was to evaluate the sensitivity of three arthroscopic techniques for intraoperative assessment of posterolateral rotatory instability (PLRI).

The study was performed using six fresh frozen cadaveric upper extremities. The three arthroscopic tests were the modified ulnohumeral drive through test, the annular drive through test, and proximal radioulnar joint instrumentation. Sequential soft tissue sectioning was performed to create four stages of instability: baseline, transection of the anterior half of the lateral collateral ligament complex (i.e., the radial collateral ligament), transection of the posterior half of the LCL complex (i.e., the lateral ulnar collateral ligament), and finally the release of the common extensor origin. Each test was repeated with the elbow at 90-degrees flexion in neutral rotation and at 45-degrees extension in full supination.

Each test appropriately identified loss of the lateral ulnar collateral ligament. The modified ulnohumeral drive through test and the annular drive through test were most sensitive for loss of the radial collateral ligament. Elbow position did not affect test sensitivity.

Each of the tests identified PLRI with high sensitivity, regardless of elbow position. The ulnohumeral and annular ligament drive through tests were more sensitive for radial collateral ligament disruption.

Overhead athletes are particularly susceptible to elbow valgus extension overload syndrome and development of pathologic changes in the posteromedial elbow. Though arthroscopic débridement/osteophyte resection is frequently performed, few studies have analyzed the outcomes of this procedure and none have specifically addressed professional level athletes.

We hypothesized that following posteromedial elbow débridement, Major League Baseball (MLB) pitchers would exhibit a higher rate of ulnar collateral ligament (UCL) reconstruction than baseline incidence in the existing literature, along with a decline in pitching performance.

Using publicly accessible websites, MLB athletes undergoing posteromedial elbow débridement from 2007 to 2022 were identified. Demographic information, procedure details, return to play (RTP) information, return to the disabled/injured list (DL/IL), subsequent UCL reconstruction, and pitching statistics were analyzed. Pitching performance metrics included earned runs average, walks plus hits per innings pitched, innings pitched, and fastball velocity.

A total of 39 MLB players, including 26 pitchers, were included. Within the first three seasons after surgery, 82.1% (n = 32) of players returned to play at the MLB level at a mean time of 176.1 ± 69 days. Pitchers exhibited a RTP rate of 76.9% (n = 20) at 175.8 ± 16 days. A total of 38.5% (n = 10) of pitchers returned to the DL/IL for elbow-related issues within three seasons. Subsequent UCL reconstruction was seen only in pitchers, with a frequency of 19.2% (n = 5). No statistically significant differences between single season preoperative/postoperative pitching metrics were identified. A small but significant (P < .05) decrease in fastball velocity (94.4 vs. 92.84; P = .02) was observed over a three-season comparison.

Contrary to our hypothesis, this study demonstrates that posteromedial elbow débridement is a viable surgery in MLB athletes, with RTP rate of 82.1% and no increase in rate of UCL reconstruction. Furthermore, there was no significant difference in single season preoperative and postoperative statistical pitching performance. However, over three years postoperatively, there was a 38.5% rate of return to the DL/IL for ongoing elbow ailment and a significant decrease in pitch velocity, raising some concern over the longevity of postoperative improvements.

The adopted treatment for chronic elbow PLRI is lateral ulnar collateral ligament reconstruction. However, the most frequently reported complication after primary reconstruction is recurrent instability - up to 25 %. It was thus hypothesized that enhancing the secondary stabilizers will provide successful results with a lower rate of recurrent instability in comparison to techniques with primary reconstruction only. This study aimed to demonstrate a novel surgical technique involving secondary stabilizers.

In this retrospective study of 29 cases with chronic PLRI the mean duration of symptoms was 39.6 ± 4.9 months. The mean age was 47.9 years with mainly male patients. The surgeries were performed by one senior surgeon at a single institution. The Mayo Elbow Performance Score (MEPS) and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) were recorded.

The mean follow-up was 36.8 ± 7.7 months. The MEPS score improved significantly from 59.8 ± 13.1 to 84.7 ± 7.6 (p < 0.001). 23/29 patients (79.2 %) had converted to good and excellent results (MEPS >75 points). The DASH score improved from 40.8 ± 4.6 to 20.9 ± 7.2 (p < 0.001). The total complication rate was 10.3 % (N = 3). No recurrent instability was recorded in comparison to 12.2 % for primary reconstruction only, as reported in the literature (p < 0.05).

Enhancing the secondary stabilizers by utilizing an adjacently located autograft provided good and excellent results with no recurrent instability. This novel surgical procedure is easy to reproduce and provides a safe and reliable alternative in cases of chronic PLRI when compared to techniques with primary reconstruction only.

Hip flexibility is an important biomechanical factor for a baseball pitcher. However, there have been limited investigations into the association between upper-extremity joint stresses and ball velocity and hip flexibility, as assessed via motion patterns during the pitch. The purpose of this study was to provide a detailed kinematic description of the lead hip during the pitch and determine the association between lead hip motion and both ball velocity and the elbow varus moment. This study was a secondary analysis of the kinematic and kinetic data previously collected on 99 collegiate-level baseball pitchers using standard optoelectronic motion capture. Significant associations were noted between lead hip internal rotation and both peak ball velocity and the elbow varus moment. The data indicated that for every 10° increase in internal lead hip rotation, ball velocity increased by 0.6 m/s (P < .001, r2 = .26), and the elbow varus moment increased by 5 N·m (P < .001, r2 = .33). The results of this study suggested that internal hip rotation may be an important means of identifying pitchers that may be at risk for future injury.

To compare performance in baseball pitchers before and after revision ulnar collateral ligament (UCL) surgery using performance metrics.

Case series.

Public online database.

Players who underwent revision UCL surgery between 2015 and 2021 were identified. Players were included if they were Minor League (MiLB) or Major League (Major League baseball [MLB]) pitchers. Players were excluded if they were not pitchers, if they underwent their revision surgery as an amateur, or if there is no record of their primary reconstruction surgery.

Revision UCL surgery (repair or reconstruction).

Return to sport (RTS) rate, RTS time, pitch velocity, and pitch spin rate.

Sixty-five pitchers underwent revision UCL surgery. MiLB pitchers had a shorter RTS time after their primary surgery (15.62 vs 20.77 months, P < 0.01) compared with MLB pitchers but similar RTS times after their revision reconstruction (19.64 vs 18.48 months, P = 0.44). There was also no difference in return to play (RTP) rate overall after primary versus revision reconstruction ( P = 1.00). Major League baseball pitchers also had decreased RTS time after primary compared with revision reconstruction (15.62 vs 19.64 months, P < 0.01) but similar RTP rates ( P = 0.28). Finally, MLB pitchers had similar pitch breakdowns, velocities, and spin rates before and after their primary and revision repair or reconstruction.

Both revision UCL repair and reconstruction can return pitchers to preinjury performance levels. Pitchers and teams should be properly counseled on realistic RTP times and postsurgery performance when discussing revision UCL surgeries.

Elbow stability arises from a combination of bony congruity, static ligamentous and capsular restraints, and dynamic muscular activation. Elbow trauma can disrupt these static and dynamic stabilizers leading to predictable patterns of instability; these patterns are dependent on the mechanism of injury and a progressive failure of anatomic structures. An algorithmic approach to the diagnosis and treatment of complex elbow fracture-dislocation injuries can improve the diagnostic assessment and reconstruction of the bony and ligamentous restraints to restore a stable and functional elbow. Achieving optimal outcomes requires a comprehensive understanding of pertinent local and regional anatomy, the altered mechanics associated with elbow injury, versatility in surgical approaches and fixation methods, and a strategic rehabilitation plan.

The retrospective study reviewed the clinical and radiological outcomes of patients treated with radiocapitellar joint plasty.

10 children with missed Monteggia fracture (MMF) were reviewed. The average time from injury to operation was 20 months. The average age of children who underwent the operation was 10.5 years. 6 flat and 4 domed radial heads were included. 7 type I and 3 type III MMF were identified based on the Bado classification. All children with MMF were treated by open radial head reduction with radiocapitellar joint plasty and ulnar osteotomy (UO).

The average union time was 4.9 ± 2.6 months. The average osteotomy angle to reduce the radial head was 15.7 ± 3.5°, and the average lengthening of the ulna was 8.2 ± 3.2 mm. The average preoperative flexion range of motion was 110.5 ± 9.1°, and the postoperative flexion range of motion was 138.8 ± 15.1° (p < 0.05). The average preoperative extension range of motion was 10.1 ± 3.2°, and the postoperative extension range of motion was 5.5 ± 3.3° (p < 0.05). The average preoperative pronation range of motion was 78.8 ± 8.7°, while the postoperative pronation range of motion was 81.1 ± 5.6° (p > 0.05). The average preoperative supination range of motion was 68.3 ± 9.7°, and the postoperative supination range of motion was 80.1 ± 7.8° (p < 0.05). The preoperative Kim score was 66.5 ± 10.9°, and the postoperative Kim score was 88.1 ± 12.6 (p < 0.05). The radial head was completely reduced in 9 patients, and subluxation in 1 patient. Osteoarthritis of the radiocapitellar joint was observed in 2 patients.

Radiocapitellar joint plasty is effective surgical intervention for MMF with radial head deformity. It yields favorable functional outcomes while ensuring continued radial head reduction.

Injuries in professional baseball players have become exceedingly common. Efforts to mitigate injury risk have focused on the kinetic chain, shoulder motion, and so forth. It is unclear whether grip strength is related to injury risk in professional baseball pitchers.

The purpose of this study was to determine if grip strength was a risk factor for injury. It was hypothesized that pitchers with weaker grip strength would have a higher likelihood of sustaining a shoulder or elbow injury compared with pitchers with stronger grip strength.

Case-control study; Level of evidence, 3.

All professional pitchers from a single Major League Baseball organization were included. Dominant and nondominant grip strength were measured after each pitching outing throughout the 2022 season. Injuries over the course of the season were recorded, and data were compared between pitchers who sustained a shoulder or elbow injury and those who did not.

Overall, 213 pitchers were included, of whom 53 (24.9%) sustained a shoulder or elbow injury during the season. The mean grip strength for all pitchers was 144.0 ± 20.8 lb (65.3 ± 9.4 kg). The mean dominant-arm grip strength was 142.6 ± 20.8 lb (64.7 ± 9.4 kg) for pitchers who did not sustain a shoulder or elbow injury and 148.2 ± 20.9 lb (67.2 ± 9.5 kg) for pitchers who did sustain an injury, with no significant group difference in grip strength (P > .05). Furthermore, there were no significant differences in change in grip strength over the course of the season between the groups.

There was no significant difference in mean grip strength or change in grip strength over the course of a single season between professional baseball pitchers who sustained a shoulder or elbow injury and those who did not.

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.

In baseball pitchers, the association of fatigue with overuse injury and decline in pitching performance has been discussed frequently, but the scientific data concerning their interrelationships have been inconsistently reported. The purpose of this narrative review is to summarize and explore the evidence regarding acute changes in pitching biomechanics and performance from repetitive throwing motions among baseball pitchers. Muscle fatigue from repetitive throwing not only decreases muscle output but also disturbs the kinetic chain of baseball pitching. In addition, repetitive throwing can impair the proprioceptive and kinesthetic functions needed for accurate joint position sense in the shoulder and elbow. Consequently, these changes negatively affect ball velocity and pitching accuracy, two critical aspects of overall pitching performance. Moreover, the cumulative loading caused by fatigue contributes to the high prevalence of overuse injuries, particularly in the elbow and shoulder joints. Thus it is important to comprehensively understand the relationships among changed pitching mechanics, deteriorated performance, and musculoskeletal injury originating from muscle fatigue due to repetitive pitching.

Overhead throwing activity induces elbow valgus loading. The medial elbow dynamic stabilizers are thought important for medial elbow joint protection, but the effects of repetitive pitching on stabilizing function are largely unknown. This study aimed to investigate changes in the dynamic stabilizers during repetitive pitching, as well as factors related to dynamic stabilizing ability. Our hypothesis was that repetitive pitching would reduce dynamic stabilizer function, hence reducing the ability to minimize elbow valgus load.

Thirty high school baseball pitchers (age, 16.6 ± 0.5 years) participated. Each participant pitched 100 times (5 blocks of 20 pitches). Prior to and after 100 pitches, medial elbow joint width and strain ratios, indicating the hardness of the ulnar collateral ligament (UCL) and forearm flexor-pronator muscles (FPMs), were measured using ultrasound at rest (non-contraction) and during gripping (contraction). Pre- and post-pitching data were compared using the paired t test. Multiple regression analysis was used to investigate factors related to the change rate of medial elbow joint width during gripping.

Medial elbow joint width during gripping significantly increased from before pitching to after pitching (P < .001). Both the UCL and FPM strain ratios after pitching significantly decreased (ie, softer tissue) compared with those before pitching (P = .001 and P = .006, respectively). The ratio of the UCL and FPM strain ratios (UCL/FPM) during gripping prior to pitching was significantly and independently correlated with the change rate of medial elbow joint width during gripping (β = 0.44, P = .016).

Pitching 100 balls induces a significant reduction in dynamic stabilizing ability against elbow valgus laxity. High school baseball pitchers should limit themselves to <100 pitches per game or should rest after 100 pitches before resuming. Furthermore, the ratio of hardness (UCL/FPM) during dynamic stabilization associated with gripping prior to pitching was significantly related to the change rate of elbow valgus laxity during dynamic stabilization. Maintaining the FPMs harder relative to the UCL during gripping prevents elbow valgus laxity associated with repetitive pitching and may protect the medial elbow joint during repetitive pitching.

Although the ulnar collateral ligament reconstruction procedure has been increasing in popularity annually owing to its stable postoperative outcomes, the number of revision surgeries following ulnar collateral ligament reconstruction has increased. The success of the initial reconstruction surgery and further improvement in the return-to-play rates of the initial surgery are crucial. In this study, we report on ulnar collateral ligament reconstruction using the twisting technique, which aims to enhance the strength of the graft (palmaris longus tendon) to improve return-to-play rates.

We investigated the return-to-play rate and period in 60 cases (2016-2021) that underwent ulnar collateral ligament reconstruction using the twisting technique and 211 cases (2007-2019) that did not use the twisting technique. The twisting technique involved inserting the graft through the bone tunnel and then twisting the doubled tendon.

According to the Conway-Jobe scale, the twisting technique group had 98.3% excellent, 1.7% good, 0% fair, and 0% poor results, with a mean return-to-play period of 9.8 months. The non-twisting technique group had 86.7% excellent, 9.0% good, 1.9% fair, and 2.4% poor results, with a mean return-to-play period of 11.4 months. The two groups showed significant differences in return-to-play rate (P = .020) and period (P = .022).

The clinical results of the twisting technique showed that the return-to-play rate of the twisting technique group was higher after than before the procedure, and the return-to-play period was shortened by more than 1 month. The twisting technique may improve the results of ulnar collateral ligament reconstruction surgery.

Pyrocarbon promises to be an optimal material choice for radial head arthroplasty (RHA) due to an elastic modulus comparable to the radial diaphysis and thus providing higher biocompatibility. Primary objective was to determine the complications and revision rates related to the usage of these prostheses. The secondary objective was to assess the clinical and radiological outcomes of Pyrocarbon RHAs.

Pyrocarbon RHAs have good clinical and radiological outcomes with low complications and revisions.

Ovid MEDLINE and Embase databases were used to search for studies on outcomes and complications of the RHAs using Pyrocarbon radial head prostheses. The systematic review was designed in accordance with the PRISMA guidelines and included studies were appraised using the MINORS tool. Complications and RHA revision rates were assessed. Functional outcomes were reviewed using PROMs (like MEPI, DASH and BMS), post-op range of motion (using goniometer) and grip strength (using the dynamometer). Postoperative radiological outcomes like peri-prosthetic lucency, radial neck osteolysis, radio-capitellar congruence, capitellar erosion, overstuffing/understuffing and osteoarthritis were reported using radiographs.

A total of 12 studies cumulatively reporting 353 patients who underwent Pyrocarbon RHAs were included in the review. The mean age of patients across the studies ranged from 47 to 54 years of which 50.5% were males. The majority of radial head replacements were done for acute trauma (87.5%) with the remainder done for arthritis (1.7%) and trauma sequelae (10.8%). Mean follow-up period in the selected studies ranged from 18 to 110 months with minimum follow-up across all studies being 12 months. Modular Pyrocarbon (MoPyC, Tornier™) was the implant of choice in ten studies while two studies used the Ascension Pyrocarbon radial head (Ascension Orthopaedics™). Ten studies demonstrated mean MEPI ranging from 75.5 to 96. Mean extension deficit ranged from 6 to 19 degrees, mean flexion from 120 to 140 degrees, mean pronation from 71 to 87 degrees and mean supination from 63 to 85 degrees. Relative grip strength ranged from 69 to 96% of the contralateral limb. Revisions due to implant-related reasons (intra-prosthetic dissociation, prosthetic fracture, peri-prosthetic loosening, radio-capitellar subluxation and understuffed/overstuffed elbow) was 6.8% (24/353). Radial stress shielding and peri-prosthetic lucency was reported in 10 to 100% of patients across different studies but symptomatic implant loosening leading to revision remained rare (2%, 7/353). Radio-capitellar congruence was reported in 81% to 100% cases while capitellar erosion ranged from 0% to 89%. Pyrocarbon implants specific complications included head-neck intra-prosthetic decoupling (1.1%) and pyrocarbon head fractures (0.9%). In total, 5.7% cases underwent re-surgery due to non-RHA related reasons.

The pyrocarbon RHA shows good functional outcome, range of motion and low revision rates. This aligns with the working hypothesis of this review. However, pyrocarbon radial head implants have implant-specific complications like pyrocarbon radial head fractures and intra-prosthetic decoupling between stem and head. Despite promising in vitro biomechanical properties, capitellar wear is still a common finding with pyrocarbon RHAs. Despite these factors, pyrocarbon radial head implants are a viable option for radial head arthroplasty.

II; Systematic review.

Treatment of ulnar collateral ligament (UCL) tears with suture tape augmentation has gained interest given preliminary reports of favorable biomechanical characteristics. No study to date has quantitatively assessed the biomechanical effects of multiple augmentation techniques relative to the native UCL.

To perform a systematic review and meta-analysis of controlled laboratory studies to assess and comparatively rank biomechanical effects of UCL repair or reconstruction with or without augmentation.

Systematic review and meta-analysis; Level of evidence, 4.

PubMed, OVID/Medline, and Cochrane databases were queried in January 2023. A frequentist network meta-analytic approach was used to perform mixed-treatment comparisons of UCL repair and reconstruction techniques with and without augmentation, with the native UCL as the reference condition. Pooled treatment estimates were quantified under the random-effects assumption. Competing treatments were ranked in the network meta-analysis by using point estimates and standard errors to calculate P scores (greater P score indicates superiority of treatment for given outcome).

Ten studies involving 206 elbow specimens in which a distal UCL tear was simulated were included. UCL reconstruction with suture tape augmentation (AugRecon) restored load to failure to a statistically noninferior magnitude (mean difference [MD], -1.99 N·m; 95% CI, -10.2 to 6.2 N·m; P = .63) compared with the native UCL. UCL reconstruction (Recon) (MD, -12.7 N·m; P < .001) and UCL repair with suture tape augmentation (AugRepair) (MD, -14.8 N·m; P < .001) were both statistically inferior to the native UCL. The AugRecon condition conferred greater load to failure compared with Recon (P < .001) and AugRepair (P = .002) conditions. AugRecon conferred greater torsional stiffness relative to all other conditions and was not statistically different from the native UCL (MD, 0.32 N·m/deg; 95% CI, -0.30 to 0.95 N·m/deg; P = .31). Medial ulnohumeral gapping was not statistically different for the AugRepair (MD, 0.30 mm; 95% CI, -1.22 to 1.82 mm; P = .70), AugRecon (MD, 0.57 mm; 95% CI, -0.70 to 1.84 mm; P = .38), or Recon (MD, 1.02 mm; 95% CI, -0.02 to 2.05 mm; P = .055) conditions compared with the native UCL. P-score analysis indicated that AugRecon was the most effective treatment for increasing ultimate load to failure and torsional stiffness, whereas AugRepair was the most effective for minimizing medial gapping.

AugRecon restored load to failure and torsional stiffness most similar to the parameters of the native UCL, whereas Recon and AugRepair did not restore the same advantageous properties at time zero. Medial ulnohumeral gapping during a valgus load was minimized by all 3 treatments. Based on network interactions, AugRecon was the superior treatment approach for restoring important biomechanical features of the UCL at time zero that are jeopardized during a complete distal tear.

The aims of this study were to summarize (1) the historical knowledge of the posterolateral elbow dislocation (PLED) pattern and the biomechanical, radiographic, and clinical data that engendered its evolution; and (2) to help clinicians better understand the management of PLED.

A literature search was performed using Ovid, Scopus and Cochrane Library, and the Medical Subject Headings vocabulary. Results are discussed as a chronologic review of the relevant literature between 1920-2022.

In 1966 Osborn and Cotterill were the first to describe posterolateral rotatory instability (PLRI) causing the PLED. Several theories on PLED were then published by others surgeons as our understanding of elbow biomechanics continued to improve. Multiple treatment protocols have been designed based on the aforementioned theories. Conservative and surgical treatment for PLED provides excellent functional outcomes. However, high rates of persistent pain stiffness and instability have been reported long-term, and no single approach to treatment has been widely accepted.

Despite a growing body of biomechanical evidence, there is no consensus surgical indication for the treatment of PLED. Both conservative and surgical management result in satisfactory functional outcomes after PLED. However, elevated rates of residual pain, and instability have also been described and may limit heavy labor and sports participation. The next challenge for elbow surgeons will be to identify those patients who would benefit from surgical stabilization following PLED.

The optimal limb position during stress ultrasound (SUS) evaluation of elbow valgus laxity has not been standardized.

To compare 2 elbow positions (at 90° and 30° of flexion) and report which position method better represents the increased valgus laxity characteristics of baseball players.

Controlled laboratory study.

Eighteen college baseball players with no history of elbow pain or elbow disorders who belonged to a college baseball club between April and November 2021 participated in this study. The medial elbow joint space (MEJS) was recorded by ultrasonography at rest and under valgus stress, and the difference in MEJS between the conditions was considered the valgus laxity. For all participants, the MEJS was recorded at 90° and 30° of elbow flexion. In the 90° of flexion position, the participant was positioned in the supine position with abduction and external rotation of the shoulder, and 2.5 kgf of valgus stress was applied proximally to the wrist. In the 30° of flexion position, the participant was positioned in the sitting position with abduction and external rotation of the shoulder, and 3.0 kgf of valgus stress was applied to the ulnar head. Valgus laxity on the throwing and nonthrowing sides was compared between the 2 elbow positions using paired t tests or Wilcoxon signed-rank tests after checking the normality.

There was a significant difference in valgus laxity on the throwing side between the 90° and 30° of flexion positions (1.9 vs 1.1 mm, respectively; P = .002), whereas no significant difference between positions was seen on the nonthrowing side (P = .06).

SUS with the elbow flexed at 90° more clearly detected valgus laxity in the study participants than the 30° of flexion position.

The quantitative evaluation of valgus laxity is important for baseball players to assess the risk of ulnar collateral ligament injury.

A double cortical button technique for ulnar collateral ligament reconstruction (UCLR) has advantages including significant control over graft tensioning, less concern about graft length, and minimized risk of bone tunnel fracture compared with traditional UCLR techniques. This double cortical button technique was recently found to be noninferior in mechanical performance to the traditional docking technique regarding joint strength, joint stiffness, and graft strain. However, clinical outcomes have not been compared between these UCLR techniques. Therefore, the purpose of this study was to determine whether baseball players who underwent UCLR with a double cortical button (double button) technique have similar return-to-sport (RTS) outcomes to baseball players who underwent UCLR with the traditional docking (docking) technique.

Baseball players who underwent primary UCLR from 2011 to 2020 across 2 institutions were identified. Included patients were contacted to complete a follow-up survey evaluating reoperations, RTS, and functional outcome scores. Functional outcome surveys include the Kerlan-Jobe Orthopaedic Clinic score, the Conway-Jobe score, the Andrews-Timmerman elbow score, and the Single Assessment Numeric Evaluation score.

Overall, 78 male baseball players (age: 18.9 ± 2.4 years) with an average follow-up of 3.1 ± 2.4 years were evaluated, with 73 of the players being baseball pitchers. Players in the double button group more frequently received palmaris longus autografts (78% vs. 30%) and less frequently received gracilis autografts (22% vs. 58%) compared with players in the docking group (P = .001); however, all other demographic factors were similar between the groups. All players in the double button group were able to RTS in 11.1 ± 2.6 months, whereas 96% of players in the docking group were able to RTS in 13.5 ± 3.4 months (P > .05). All postoperative outcomes and patient-reported outcomes were statistically similar between the groups and remained similar after isolating pitchers only and after separating partial-thickness from full-thickness UCL tears (all P > .05).

RTS and other postoperative outcomes may be similar between baseball players who underwent UCLR with the double button technique and the docking technique. Although future research may be necessary to strengthen clinical recommendations, these findings provide the first clinical outcomes in light of a recent cadaveric study finding similar elbow strength, joint stiffness, and graft strain compared with the docking technique.

Elbow pain is common among youth baseball players and elbow MRI is increasingly utilized to complement the clinical assessment.

To characterize, according to skeletal maturity, findings on elbow MRI from symptomatic youth baseball players.

This IRB-approved, HIPAA-compliant retrospective study included pediatric (<18 years of age) baseball players with elbow pain who underwent MRI examinations between 2010 and 2021. Two radiologists, blinded to the outcome, independently reviewed examinations to categorize skeletal maturity and to identify osseous and soft tissue findings with consensus used to resolve discrepancies. Findings were compared between skeletally immature and mature patients and logistic regression models identified predictors of surgery.

This study included 130 children (115 boys, 15 girls): 85 skeletally immature and 45 mature (12.8±2.3 and 16.2±1.0 years, respectively, p<0.01). Kappa coefficient for interobserver agreement on MRI findings ranged from 0.64 to 0.96. Skeletally immature children, when compared to mature children, were more likely to have elbow effusion (27%, 23/85 vs 9%, 4/45; p=0.03), medial epicondyle marrow edema (53%, 45/85 vs 16%, 7/45; p<0.01), avulsion fracture (19%, 16/85 vs 2%, 1/45; p=0.02), and juvenile osteochondritis dissecans (OCD, 22%, 19/85 vs 7%, 3/45; p=0.04), whereas skeletally mature children were more likely to have sublime tubercle marrow edema (49%, 22/45 vs 11%, 9/85; p<0.01) and triceps tendinosis (40%, 18/45 vs 20%, 17/85; p=0.03). Intra-articular body (OR=4.2, 95% CI 1.5-47.8, p=0.02) and osteochondritis dissecans (OR=3.7, 95% CI 1.1-11.9, p=0.03) were independent predictors for surgery.

Differential patterns of elbow MRI findings were observed among symptomatic pediatric baseball players based on regional skeletal maturity. Intra-articular body and osteochondritis dissecans were independent predictors of surgery.

Elbow ulnar collateral ligament (UCL) injuries can result in significant functional impairment in throwing and overhead athletes. UCL reconstruction and repair are proven treatments to restore stability, but the efficacy of nonoperative management is unclear.

To determine the rate of return to sports (RTS) and return to previous level of play (RTLP) in athletes sustaining medial elbow ulnar collateral ligament (UCL) injuries treated nonoperatively.

Systematic review; Level of evidence, 4.

A literature search was performed using Scopus, PubMed, Medline, the Cochrane Database for Systematic Review, and the Cochrane Central Register for Controlled Trials according to the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Inclusion criteria were limited to level 1 to 4 human studies reporting on RTS outcomes after nonoperative management of UCL injuries.

A total of 15 studies, consisting of 365 patients with a mean age of 20.45 ± 3.26 years, were identified. Treatment primarily consisted of platelet-rich plasma (PRP) injections with physical therapy (n = 189 patients; n = 7 studies) versus physical therapy alone (n = 176 patients; n = 8 studies). The overall RTS rate was 79.7% and the overall RTLP rate was 77.9%. Increasing UCL injury severity grade was associated with lower RTS rates. The RTS rate for proximal tears (89.7%; n = 61/68) was significantly greater than that for distal tears (41.2%; n = 14/34) (P < .0001). No significant difference in RTS rate was seen in patients treated with PRP versus those who did not receive PRP (P = .757).

For athletes undergoing nonoperative management of UCL injuries, the overall RTS and RTLP rates were 79.7% and 77.9%, respectively, with excellent outcomes in grade 1 and grade 2 UCL injuries, specifically. The RTS rate for proximal tears was significantly higher than that for distal tears. Athletes were most commonly treated with PRP injection and physical therapy.

The aim of this study was to assess the patient demographics, epidemiology, mechanism of injury, and natural history of sublime tubercle avulsion injuries.

A multicenter retrospective study was performed in which sublime tubercle avulsion injuries were identified by surgeon records and database query of radiology reports. Demographic data and imaging were reviewed for each case, and injuries were classified as type 1 (isolated injuries with a simple bony avulsion or periosteal stripping) or type 2 (complex injuries with an associated elbow fracture or dislocation). Treatment modality and evidence of radiographic healing at a minimum of 3 months were collected.

Forty patients (78% male) with a median age of 15 years (range, 8 to 19 years) were identified with sublime tubercle avulsion injuries. Sixty-eight percent of cases (n=27) were determined to be type 1 injuries, and 32% (n=13) were classified as type 2 injuries. The majority of type 1 injuries (59%) occurred via a noncontact mechanism in overhead-throwing athletes, whereas 100% of the type 2 injuries were sustained via a contact mechanism. Type 1 injuries presented in a delayed manner in 19% of cases, whereas no type 2 injuries (0%) were delayed in presentation. Type 1 injuries infrequently underwent surgical intervention (19%), whereas 54% of type 2 injuries required surgery. Of those that did not undergo initial surgical management at a minimum of 3-month radiographic follow-up, 9/11 (82%) of type 1 injuries and 0/4 (0%) of type 2 injuries demonstrated evidence of healing. Only 1 case required reoperation (type 2 injury).

This series of adolescents with sublime tubercle avulsion injuries expands our understanding of the epidemiology of this rare injury, which was previously only described as a noncontact injury in baseball players. Type 1 injuries are more likely to occur via a noncontact mechanism and generally demonstrate radiographic evidence of healing after a period of rigid immobilization. Conversely, type 2 injuries are more likely to undergo initial surgical intervention, and those managed nonoperatively are less likely to achieve radiographic healing. Further studies are needed to elucidate treatment protocols and long-term functional outcomes.

Level IV-case series.

For more than one century, understanding the injury mechanism leading to the terrible triad of the elbow (TTE) was a significant challenge for surgeons. We aimed to summarize: (1) the history of the treatment of TTE and (2) the increasing scientific knowledge that supported its evolution. Five electronic databases were searched between 1920 and 2022. Results were reported as a comprehensive review of the relevant literature. Between 1940 and 1980, surgical exploration allowed observation of complex elbow instability involving both radial head, coronoid process, and ligament(s) injuries. In 1966, Osborne introduced the concept of posterolateral rotatory instability as the first mechanism injury to explain the complex elbow instability. From 1980 to 1995, a biomechanical revolution by American pioneers critically improved our understanding of elbow instability. After 1992, a few unifying theories and surgical protocols were provided, but those have divided the surgeons' population. The formalization of the TTE treatment allowed avoiding of terrible short-term outcomes. However, post-traumatic osteoarthritis (PTOA) at long-term follow-up is still an issue. No consensual surgical protocol for the treatment of TTE has been widely accepted. While the outcomes of the TTE have been improved, the rate of PTOA at long-term follow-up is still high regardless of the treatments. The terrible triad has given way to the subtle triad with persistent microinstability of the elbow. The next challenge for elbow surgeons is to diagnose and fix this persistent subclinical instability after surgery in order to prevent the onset of PTOA.

Ulnar collateral ligament (UCL) injuries occur frequently in baseball players, and UCL reconstruction is performed when nonoperative treatment fails.

To compare a novel all-suture anchor method of UCL reconstruction with a method using bone tunnels (Ito method) by investigating the displacement against valgus torque and the failure strength.

Controlled laboratory study.

Eight fresh-frozen cadaveric upper extremities (mean age, 82.0 years) were utilized in this study. To evaluate the displacement against valgus torque, the valgus stability test was performed for 4 anterior oblique ligament (AOL) conditions: intact AOL, resected AOL, reconstructed using the anchor method, and reconstructed using the Ito method. The load-to-failure test was performed to evaluate the failure strength of the anchor and Ito methods. Displacement against valgus load was compared between conditions using the repeated-measures 2-way analysis of variance with Bonferroni post hoc test, and failure strength between the anchor and Ito methods was compared using the unpaired t test.

Displacements of the intact AOL and anchor method were significantly greater than those of the resected AOL at both 60° and 90° of flexion (intact AOL: P = .005 and P < .001, respectively; and anchor method: P = .024 and P < .001, respectively). The displacement of the Ito method at 90° of flexion was significantly greater than that of the resected AOL (P = .003), but no significant difference was observed at 60° of flexion (P = .109). There were no significant differences in displacement between the anchor and Ito methods at any flexion angle, nor was there a significant difference in failure torque between the anchor and Ito methods (16.3 ± 3.1 vs 17.6 ± 2.3 N·m, respectively; P = .537).

The displacement and failure strength against a valgus load after UCL reconstruction using a suture anchor on the ulnar side were equal to those using bone tunnels.

UCL reconstruction using a suture anchor on the ulnar side is simpler and less invasive than using bone tunnels, with similar outcomes.

Baseball pitching induces a large elbow valgus load, stressing the ulnar collateral ligament (UCL). Flexor-pronator mass (FPM) contraction contributes to valgus stability; however, repetitive baseball pitching may weaken the FPM contractile function. The present study investigated the effects of repetitive baseball pitching on the medial valgus stability measured using ultrasonography. We hypothesized that repetitive pitching would decrease elbow valgus stability.

This was a controlled laboratory study. Fifteen young male baseball players at the collegiate level (age: 23.0 ± 1.4 years) were enrolled. The medial elbow joint space was measured using ultrasonography (B-mode, 12-MHz linear array transducer) in the following three conditions: at rest (unloaded), under 3 kg valgus load (loaded), and under valgus load with maximal grip contraction to activate FPM (loaded-contracted). All measurements were performed before and after the pitching tasks, which comprised five sets of 20 pitches. Two-way repeated-measures analysis of variance was applied to determine changes in the medial elbow joint space. The post hoc test with Bonferroni adjustment was applied to assess the changes within the time and condition.

The medial elbow joint space was significantly greater under the loaded than the unloaded and loaded-contracted conditions both before and after pitching (P < .001). In the loaded-contracted condition, the medial elbow joint space significantly increased after repetitive baseball pitching (P < .001).

The results of the present study indicated that repetitive baseball pitching reduced the elbow valgus stability. This reduction could be attributed to the decreased FPM contractile function. Insufficient contraction may increase the tensile load on the UCL with pitching. FPM contraction plays a role in narrowing the medial elbow joint space; however, repetitive baseball pitching reduced the elbow valgus stability. It has been suggested that sufficient rest and recovery of the FPM function are required to reduce the UCL injury risk.

The term Monteggia-like lesions or Monteggia equivalent injuries includes fractures of the proximal ulna with dislocation and dislocation fractures of the radial head from the proximal radio-ulnar joint. The complexity of the injury requires a dedicated understanding of the anatomical structures and their biomechanical properties. Particularly due to the rarity, the complication and revision rates are high. A conservative treatment is not usually effective. Three-dimensional imaging by computed tomography is part of the surgical preparation. The goal of surgical treatment is osteosynthetic reconstruction of the fractures and restoration of joint congruency. In cases of nonreconstructable radial head fractures, radial head arthroplasty may be necessary. In addition to reconstruction of the bony stabilizers, refixation of the ligamentous structures is essential for treatment success. The combination of complex fracture patterns and possible dislocation positions in the ulnohumeral, radiohumeral and proximal radio-ulnar joints poses a great challenge to the surgeon. The most frequent complications are peri-implant infections, implant failure, loss of reduction, stiffness or instability. Especially the anatomical configuration of the proximal ulna is complex and requires accurate reconstruction. Therefore, reconstruction of the proximal ulna in length and rotation, including the coronoid process, is considered to be a key factor in the surgical treatment of Monteggia-like injuries.

Missed monteggia-type injuries in children can result in chronic radial head dislocation with anatomic changes and osteoarticular remodeling of the radial head. In later stages, joint reconstruction is impossible and a functional radial head distalization can be a therapy option in symptomatic patients.

From 2010 to 2018, 46 patients (18 female and 28 male, mean age 11.8 (4-20)) with chronic radius head dislocation treated in our institution were retrospectively analyzed. A radial head distalization was performed in symptomatic patients at the time of ulna lengthening and angulation by use of an external ring fixator. We analyzed the surgical and radiographic data as well as the clinical outcome of the patients measured by DASH and Mayo Elbow score.

16 patients (6 female, 10 male) fulfilled the criteria for functional radial head distalization. Main reason was Monteggia injury in 11 cases, and radial head fracture in 5 cases. Average follow-up was 5.1 years (range 1-9, SD 2.1). Mean time from injury was 4.14 years (range: 4 months to 12 years, SD 3.5 years). Mean duration of external fixation was 106 days (range 56-182, SD 31.2), lengthening was 21.3 mm (range 12-42, SD 8.8). Average degree of sagittal angulation 14.8° (0-32°, SD 10.7°), coronal angulation 4.4° (0-25°, SD 7.3°). DASH score showed a good result with 2.4, and the MAYO Elbow Score was excellent (95/100). No secondary luxation of the radius head was detected.

Radial head distalization with external ring fixator can be a therapy option for chronic radius head dislocations in symptomatic patients without losing stability of the elbow joint in contrast to radial head resection.

In baseball pitching, resultant elbow varus torque reaches the peak value of 50-120 N m, exceeding the joint failure limit that risks damage to the ulnar collateral ligament (UCL). In-vivo methodology is lacking to assess whether pitchers have sufficient muscular strength to shield UCL and how strongly the elbow musculature must contract to minimize valgus loading on UCL. This study introduces a method to assess relative percentages of muscular varus strength required to unload the UCL. The maximum voluntary isometric varus strength (MVIVS) produced by the medial elbow musculature and the maximum resultant varus torques at elbow in pitching fastballs and other types were measured for two professional pitchers. Simulation was conducted to determine the relative percentages of MVIVS required to unload the UCL to varying degrees and the impact of athletes' previous UCL reconstruction on the relative percentages was examined. The maximum resultant varus torque in pitching was found to range 72-97%MVIVS depending on the type of pitch. The elbow musculature had to produce 21-49%MVIVS to avoid acute failure of intact UCL whereas the corresponding requirements were 39-63%MVIVS for UCL reconstructed joint. The method offers new insight into baseball pitcher's training/rehabilitation and physical assessment to reduce the risk of UCL injury.

Terrible triad injuries of the elbow are complex injuries which can result in long term complications and significant disability. They must be identified correctly, and managed appropriately in order to maximise functional outcomes. A clear understanding of the bony and ligamentous anatomy is essential to plan appropriate surgical reconstruction to provide elbow stability. Urgent reduction of the elbow, followed by 3-dimensional imaging and surgical repair or replacement of the injured structures is the mainstay of treatment in the majority of cases. This review presents a summary of the relevant anatomy and the evidence for the management of these complex injuries.