- Email: [email protected]
Treatment of Ulnar Collateral Ligament Injuries and Superior Labral Tears by Major League Baseball Team Physicians
Treatment of Ulnar Collateral Ligament Injuries and Superior Labral Tears by Major League Baseball Team Physicians Brandon J. Erickson, M.D., Joshua D. Harris, M.D., Yale A. Fillingham, M.D., Gregory L. Cvetanovich, M.D., Charles A. Bush-Joseph, M.D., Bernard R. Bach Jr., M.D., Anthony A. Romeo, M.D., and Nikhil N. Verma, M.D.
Purpose: To determine practice patterns of Major League Baseball (MLB) team orthopaedic surgeons in addressing the controversial topics of ulnar collateral ligament (UCL) tears, type II SLAP tears, and partial-thickness rotator cuff tear. Methods: Seventy-four MLB team orthopaedic surgeons were surveyed via an online survey system. A 14-question survey was used to assess surgeon experience, technique, and graft choice for UCL reconstruction (UCLR), treatment of type II SLAP tears, and other common pathologic conditions. Results: Thirty team orthopaedic surgeons (41%) responded (mean experience as team physicians: 9.37 6.33 years). Seventeen (56.7%) surgeons use the docking technique for UCLR whereas 20% use the modified Jobe technique. Nineteen (63.3%) use palmaris longus autograft in UCLR. Overall, 28 (93.3%) do not routinely perform elbow arthroscopy or perform an obligatory transposition of the ulnar nerve in patients without preoperative ulnar nerve symptoms. Twenty-eight (93.3%) would repair a type II SLAP tear, whereas only 1 (3.3%) would debride the tear. No surgeon would perform a concomitant biceps tenodesis, either open or arthroscopic. Conclusions: Most MLB team orthopaedic surgeons perform a UCLR using the docking technique with a palmaris longus autograft without concomitant elbow arthroscopy or obligatory transposition of the ulnar nerve. The overwhelming majority of these surgeons would also treat an operative type II SLAP tear with a SLAP repair. Clinical Relevance: The number of UCLRs and SLAP repairs performed on MLB pitchers has significantly increased over the past 10 years. To properly treat these conditions in elite, college, and recreational athletes, it is important to understand how the surgeons who take care of the most elite-level athletes treat them, and how they are able to reproducibly attain excellent outcomes. This study shows how these common shoulder and elbow injuries are treated by those surgeons who care for the most elite overhead-throwing athletes in the world.
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njuries in Major League Baseball (MLB) athletes have become a topic of great concern over the past several years, specifically tears of the ulnar collateral
From the Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A. The authors report the following potential conflict of interest or source of funding: J.D.H. receives support from Arthroscopy. C.A.B-J. receives support from the American Journal of Sports Medicine. B.R.B. receives support from the American Orthopaedic Society for Sports Medicine (AOSSM), Arthrex, ConMed, DJO, Tornier, and Smith & Nephew. A.A.R. receives support from AOSSM, American Shoulder and Elbow Surgeons, Journal of Shoulder and Elbow Surgeons, Orthopedics, Orthopedics Today, Sage, SLACK, and Arthrex. N.N.V. receives support from Arthroscopy, SLACK, Journal of Knee Surgery, Arthrex, Omeros, and Minivasive. Received May 22, 2015; accepted January 15, 2016. Address correspondence to Nikhil N. Verma, M.D., Midwest Orthopaedics at Rush, Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612, U.S.A. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 0749-8063/15473/$36.00 http://dx.doi.org/10.1016/j.arthro.2016.01.034
ligament (UCL) and superior labarum (i.e., SLAP).1 These injuries are most common among pitchers and can lead to a significant amount of time lost from competition.2,3 The active and extended rosters in the MLB consist of 750 and 1,200 athletes, respectively, of which approximately 360 active spots are occupied by pitchers.4 Hence, injuries to pitchers must be dealt with effectively and efficiently to ensure the pitchers are able to return to sport (RTS). The ideal treatment strategy for the various injuries affecting pitchers has yet to be elucidated. Previous studies have shown that MLB pitchers who undergo ulnar collateral ligament reconstruction (UCLR), commonly known as Tommy John surgery, are able to RTS at a rate higher than 80% and perform well on RTS, with no significant differences in many pitching statistics from pre to post surgery.3,5,6 In order to understand how these pitchers were able to achieve successful outcomes, it is necessary to understand how the team physicians
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Table 1. Questionnaire Administered to MLB Team Orthopaedic Surgeons 1. For how many years have you been an MLB team Orthopaedic Surgeon? 2. What is your preferred method of surgical treatment for a symptomatic MLB pitcher with a medial Ulnar Collateral Ligament (UCL) tear that has failed conservative treatment? a. DANE-TJ b. Docking c. Docking Plus d. Jobe e. Modified Jobe f. Hybrid g. ASMI Modification h. Tension Slide i. Bisuspensory j. Ziploop k. UCL Repair l. Other (please specify) 3. When surgically treating a medial UCL tear in your MLB pitcher, how do you address the humerus? a. Tunnel b. Socket c. Anchor d. Other (please specify) 4. When surgically treating a medial UCL tear in your MLB pitcher, how do you address the ulna? a. Tunnel b. Socket c. Anchor d. Other (please specify) 5. When treating an Ulnar Collateral Ligament Tear in your MLB Pitchers, what is your preferred choice of graft? a. Palmaris Longus Autograft b. Palmaris Longus Allograft c. Gracilis Autograft d. Gracilis Allograft e. Toe Extensor Autograft f. Plantaris Autograft g. Achilles Allograft h. Other (please specify) 6. Do you routinely perform elbow arthroscopy at the time of medial UCL reconstruction? a. Yes b. No 7. Do you routinely transpose the ulnar nerve if the MLB Pitcher has no pre-operative ulnar nerve symptoms or exam findings? a. Yes b. No 8. When surgically treating a partial thickness Rotator Cuff Tear of >50% in an MLB Pitcher do you. a. Complete the tear and perform a full thickness repair b. Perform a Partial Articular-Sided Tendon Avulsion (PASTA) Repair c. Other 9. When surgically treating a partial thickness Rotator Cuff Tear of >50% in an MLB Pitcher, do you routinely use a. a. Single Row b. Double Row c. Other (continued)
Table 1. Continued 10. Provided you have decided on surgical treatment, what is your preferred operative treatment of a Type II superior labral anteriorposterior (SLAP) tear in an MLB Pitcher? a. SLAP Repair b. SLAP Debridement c. SLAP repair þ arthroscopic biceps tenodesis d. SLAP repair þ open subpectoralis biceps tenodesis e. SLAP debridement þ arthroscopic biceps tenodesis f. SLAP debridement þ open subpectoralis biceps tenodesis g. Other 11. Do you routinely use Platelet Rich Plasma (PRP) in your treatment of medial or lateral epicondylitis in your MLB Pitchers? a. Yes b. No 12. Do you use Toradol? a. Yes b. No 13. Do you use pre-game local anesthetic injections for any shoulder or elbow condition in MLB Pitchers? a. Yes b. No 14. If so, for which conditions do you use pre-game local anesthetic injections? ASMI, American Sports Medicine Institute; DANE-TJ, David Altcheck, Neal ElAttrache, Tommy John technique; MLB, Major League Baseball; UCL, ulnar collateral ligament.
who are treating these pitchers approach UCL tears. This includes surgical technique, management of the ulnar nerve, graft choice, and whether the surgeon performs a routine elbow arthroscopy. As there are several techniques available for surgeons to choose from, understanding exactly how these surgeons treat elite-level pitchers is important so the success of UCLR can be transferred to both collegiate and high school athletes. Furthermore, Vitale and Ahmad conducted a systematic review of MLB pitchers who underwent UCLR and found that surgical technique and management of the ulnar nerve can play a role in postoperative outcome.7 The disabled throwing shoulder can involve SLAP tears, rotator cuff tears, and other pathologies. The data after treatment of SLAP tears are much more variable, with many studies reporting less than optimal results after surgery.8-10 Hence, it is currently unclear as to the ideal treatment algorithm for MLB pitchers who present with a SLAP tear. The purpose of this study was to determine practice patterns of MLB team orthopaedic surgeons in addressing the controversial topics of UCL tears, type II SLAP tears, and partial-thickness rotator cuff tear. The authors hypothesized that palmaris longus autograft would be the most commonly chosen graft in these elite-level athletes for UCLR and that surgeons would not routinely perform elbow arthroscopy while
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UCLR AND SLAP TEARS IN MLB PITCHERS
performing UCLR. The authors also hypothesized that most surgeons would simply debride type II SLAP tear.
60.00% 50.00% 40.00%
Methods The authors created a 14-question survey (Table 1).11,12 The survey was created on the website SurveyMonkey (http://www.surveymonkey.com) and was sent to 74 MLB team orthopaedic surgeons. A similarly designed study has been performed in National Football League and National Collegiate Athletic Association team physicians regarding treatment of anterior cruciate ligament tears.13 The team surgeons were determined by Internet web searches and direct contact with team public relations departments. In 2013, the survey was sent out a total of 5 times, with the response rates for each round listed in Figure 1. The responses were kept confidential, and the data were organized via the SurveyMonkey web tool. The authors did not know the surgeons’ names. Statistical Analysis Descriptive statistics were calculated for each question. Continuous variable data were reported as mean standard deviation (weighted means where applicable). Categorical data were reported as frequencies with percentages.
Results The survey was sent to 74 MLB team orthopaedic surgeons’ e-mail addresses. Thirty team orthopaedic surgeons (41%) responded (mean experience as team physicians: 9.37 6.33 years). Seventeen (56.7%) surgeons would use the docking technique when performing a UCLR in their MLB pitchers whereas 20% would use the modified Jobe technique, and 3 (10%) of the surgeons answered “other” as they did not have a preferred technique (Fig 2). When addressing the humeral attachment during a UCLR, 14 (46.7%) surgeons do so via a tunnel whereas 13 (43.3%) use a socket. Twenty-six (86.7%) surgeons address the ulnar attachment via a tunnel whereas only 1 (3.3%) uses a socket. Nineteen (63.3%) surgeons use palmaris longus autograft as their graft choice in UCLR of the MLB pitchers, 6 (20%) use gracilis autograft, and 3 (10%) base their decision on a case-by-case basis (Fig 3).
30.00% 20.00% 10.00% 0.00%
Fig 2. Graph of responses to the question “What is your preferred method of surgical treatment for a symptomatic MLB pitcher with a medial Ulnar Collateral Ligament (UCL) tear that has failed conservative treatment?” (ASMI, American Sports Medicine Institute; DANE-TJ, David Altcheck, Neal ElAttrache, Tommy John technique; MLB, Major League Baseball.)
Twenty-eight (93.3%) surgeons do not routinely perform elbow arthroscopy at the time of their UCLR. Twenty-eight (93.3%) surgeons do not routinely transpose the ulnar nerve in pitchers with no preoperative ulnar nerve symptoms or examination findings at the time of UCLR. I addition, 28 (93.3%) surgeons would repair a type II SLAP tear in their MLB pitchers, 1 (3.3%) would simply debride the tear, and the 1 (3.3%) “other” would base the decision on the appearance of the tear at the time of surgery (Fig 4). In pitchers with a partial-thickness rotator cuff tear greater than 50%, 13 (43.3%) surgeons would perform a partial articular-sided tendon avulsion (PASTA) repair, 10 (33%) would simply debride the tear without any additional repair, and 4 (13.3%) would complete the tear and perform a full-thickness repair. Fourteen (46.7%) surgeons would perform a single-row rotator cuff repair when surgically treating a partial-thickness
70.00% 60.00% 50.00% 40.00% 30.00%
Number of Responses Per Round
20.00% 10.00%
20
0.00% Palmaris Longus Autograft
15 Number of Responses
10 5 0 1st round
2nd round
3rd round
4th round
5th round
Fig 1. Number of responses per round of survey e-mails.
Palmaris Longus Allograft
Gracilis Autograft
Gracilis Allograft
Other (please specify)
Fig 3. Graph of responses to the question “When treating an Ulnar Collateral Ligament Tear in your MLB Pitchers, what is your preferred choice of graft?” (MLB, Major League Baseball.)
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100.00% 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% SLAP Repair
SLAP Debridement
Other (Please Specify)
Fig 4. Diagram of responses to the question “Provided you have decided on surgical treatment, what is your preferred operative treatment of a Type II superior labral anteriorposterior (SLAP) tear in an MLB Pitcher?” (MLB, Major League Baseball.)
rotator cuff tear greater than 50% in MLB pitchers, 12 (40%) would base their decision on the size and geometry of the tear, and 4 (13.3%) would use a doublerow technique. Finally, 41% of MLB team orthopaedic surgeons use platelet-rich plasma and 46.7% use toradol, but only 3.3% use pre-game local anesthetic injections. The indication given for pre-game local anesthetic joint injection was acromioclavicular joint pain.
Discussion Most team physicians performed their UCLR via the docking technique using palmaris longus autograft without concomitant elbow arthroscopy or obligatory ulnar nerve transposition. However, most surgeons elected to perform a SLAP repair for an operative type II SLAP tear rather than a simple debridement as was hypothesized. Similar studies have been performed in National Football League and National Collegiate Athletic Association team physicians regarding treatment of anterior cruciate ligament tears.13 Several studies have reported on the success of MLB athletes, most commonly pitchers, as it related to RTS after UCLR.3,5,14 The number of UCLR surgeries is increasing with each year, and understanding the optimal treatment for UCL tears is important moving forward to decrease reoperation rates and ensure a high rate of RTS at levels similar to or better than preinjury.1,3,15-17 This is especially true as the number of UCLR surgeries performed in high school athletes continues to rise.18 A recent systematic review by Vitale et al.7 demonstrated that graft choice and surgical technique appear to play a role in success rates of UCLR in overhead-throwing athletes. This study concluded that the docking technique showed 90% excellent results, with a 3% postoperative ulnar neuropathy complication rate. It also demonstrated that in patients without preoperative ulnar nerve symptoms
who did not routinely have their ulnar nerve transposed, 89% had excellent results whereas only 4% had postoperative ulnar neuropathy. These data correlate well with the practice patterns found in this study. Most surgeons (63.3%) use the docking or docking plus technique when performing a UCLR in their MLB pitchers, and 93.3% do not routinely transpose the ulnar nerve in patients who exhibit no preoperative ulnar nerve symptoms.18,19 No study has directly compared outcomes in patients randomized to elbow arthroscopy or not, or ulnar nerve transposition or not, so it is difficult to conclude with absolute certainty which practice is superior. Studies examining these specific questions are necessary to draw meaningful conclusion. Furthermore, several techniques for UCLR have been reported in biomechanical studies. However, there are no good clinical data to recommend for or against these procedures, and as such, surgeons were not surveyed about these techniques.20,21 Although elbow injuries are a significant cause of morbidity in MLB pitchers, shoulder injuries are also a substantial problem in these athletes. Cohen et al.6 reviewed 28 shoulder and 23 elbow injuries in a total of 44 MLB athletes, 39 of whom were pitchers. They found that pitchers who underwent elbow surgery were more likely to RTS at the same level than those who underwent shoulder surgery. Other studies, both reviewing MLB players22 and non-MLB overheadthrowing athletes,23,24 have found similar results in which players who underwent shoulder surgery saw less reliable results in their postoperative performance compared with preoperative performance. SLAP tears are becoming an increasingly frequent, if not overly used, diagnosis with recent advances in magnetic resonance imaging.25 It is well known that SLAP repairs in patients older than 35 to 40 years do poorly.26 However, the results in elite overhead-throwing athletes has been studied to a lesser degree, although this patient population has been observed to be unable to tolerate alterations in their shoulder kinematics as well as recreational or noneoverhead-throwing athletes do.26-28 Recent evidence has shown that when comparing SLAP repairs to biceps tenodesis in the treatment of SLAP tears in the overhead-throwing athlete, athletes who underwent open subpectoral biceps tenodesis had more reliable return of upper extremity thoracic rotation and neuromuscular control than those who underwent SLAP repair.10 Likewise, Laughlin et al.8 found altered mechanics in 13 collegiate and professional pitchers who underwent SLAP repairs compared with a group of control pitchers. Similarly, Boileau et al.29 found that 60% of patients who underwent repair for a type II SLAP tear were disappointed with their results because of persistent pain, and only 20% were able to
UCLR AND SLAP TEARS IN MLB PITCHERS
RTS at the same preoperative level. This was in comparison to a group of patients who underwent arthroscopic biceps tenodesis instead of a SLAP repair who had a 93% satisfaction rate and an 87% rate of RTS at their previous level. Further research into the optimal treatment of SLAP tears is necessary to properly guide treatment patterns. Limitations The study has several limitations. First, it only evaluated baseball team physicians. Although some of these team physicians take care of athletes in other sports as well, this survey was specifically targeted at answering questions about MLB pitchers. Second, the survey response rate was 41%, which could be falsely low if some of the e-mail addresses were inaccurate. Further, this response rate could introduce selection bias depending on which surgeons did not complete the survey. Third, there is the possibility that some MLB pitchers were treated by surgeons who were not surveyed in this study, and so these results cannot be generalized to all MLB pitchers or all MLB team physicians. Fourth, in reference to MLB players, this study only addressed pitchers, and so the results may have differed if a different position was chosen. Finally, concomitant pathology could have altered the answers to some of the questions, specifically the SLAP questions.
Conclusions Most MLB team orthopaedic surgeons perform a UCLR using the docking technique with a palmaris longus autograft without concomitant elbow arthroscopy or obligatory transposition of the ulnar nerve. The overwhelming majority of these surgeons would also treat an operative type II SLAP tear with a SLAP repair.
References 1. Erickson BJ. The epidemic of Tommy John surgery: the role of the orthopedic surgeon. Am J Orthop 2015;44: E36-E37. 2. Dick R, Sauers EL, Agel J, et al. Descriptive epidemiology of collegiate men’s baseball injuries: National Collegiate Athletic Association Injury Surveillance System, 19881989 through 2003-2004. J Athl Train 2007;42:183-193. 3. Erickson BJ, Gupta AK, Harris JD, et al. Rate of return to pitching and performance after Tommy John surgery in Major League Baseball pitchers. Am J Sports Med 2014;423: 536-543. 4. Castrovince A. Equitable roster rules needed for September. http://m.mlb.com/news/article/39009416. Published 2012. Accessed December 12, 2014. 5. Gibson BW, Webner D, Huffman GR, Sennett BJ. Ulnar collateral ligament reconstruction in Major League Baseball pitchers. Am J Sports Med 2007;35:575-581. 6. Cohen SB, Sheridan S, Ciccotti MG. Return to sports for professional baseball players after surgery of the shoulder or elbow. Sports Health 2011;3:105-111.
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7. Vitale MA, Ahmad CS. The outcome of elbow ulnar collateral ligament reconstruction in overhead athletes: A systematic review. Am J Sports Med 2008;36:1193-1205. 8. Laughlin WA, Fleisig GS, Scillia AJ, Aune KT, Cain EL Jr, Dugas JR. Deficiencies in pitching biomechanics in baseball players with a history of superior labrum anteriorposterior repair. Am J Sports Med 2014;42:2837-2841. 9. McCulloch PC, Andrews WJ, Alexander J, Brekke A, Duwani S, Noble P. The effect on external rotation of an anchor placed anterior to the biceps in type 2 SLAP repairs in a cadaveric throwing model. Arthroscopy 2013;29:18-24. 10. Chalmers PN, Trombley R, Cip J, et al. Postoperative restoration of upper extremity motion and neuromuscular control during the overhand pitch: Evaluation of tenodesis and repair for superior labral anterior-posterior tears. Am J Sports Med 2014;42:2825-2836. 11. Rohrbough JT, Altchek DW, Hyman J, Williams RJ 3rd, Botts JD. Medial collateral ligament reconstruction of the elbow using the docking technique. Am J Sports Med 2002;30:541-548. 12. Thompson WH, Jobe FW, Yocum LA, Pink MM. Ulnar collateral ligament reconstruction in athletes: Musclesplitting approach without transposition of the ulnar nerve. J Shoulder Elbow Surg 2001;10:152-157. 13. Erickson BJ, Harris JD, Fillingham YA, et al. Anterior cruciate ligament reconstruction practice patterns by NFL and NCAA football team physicians. Arthroscopy 2014;30: 731-738. 14. Jones KJ, Conte S, Patterson N, ElAttrache NS, Dines JS. Functional outcomes following revision ulnar collateral ligament reconstruction in Major League Baseball pitchers. J Shoulder Elbow Surg 2013;22:642-646. 15. Makhni EC, Morrow ZS, Luchetti TJ, et al. Arm pain in youth baseball players: A survey of healthy players. Am J Sports Med 2015;43:41-46. 16. Makhni EC, Lee RW, Morrow ZS, Gualtieri AP, Gorroochurn P, Ahmad CS. Performance, return to competition, and reinjury after Tommy John surgery in Major League Baseball pitchers: A review of 147 cases. Am J Sports Med 2014;42:1323-1332. 17. Jiang JJ, Leland JM. Analysis of pitching velocity in Major League Baseball players before and after ulnar collateral ligament reconstruction. Am J Sports Med 2014;42: 880-885. 18. Cain EL Jr, Andrews JR, Dugas JR, et al. Outcome of ulnar collateral ligament reconstruction of the elbow in 1281 athletes: Results in 743 athletes with minimum 2-year follow-up. Am J Sports Med 2010;38:2426-2434. 19. Andrews JR, Timmerman LA. Outcome of elbow surgery in professional baseball players. Am J Sports Med 1995;23: 407-413. 20. Jackson A, Maerz T, Koueiter DM, Andrecovich CJ, Baker KC, Anderson K. Strength of ulnar fixation in ulnar collateral ligament reconstruction: A biomechanical comparison of traditional bone tunnels to the tensionslide technique. J Shoulder Elbow Surg 2012;21:1674-1679. 21. Jackson TJ, Adamson GJ, Peterson A, Patton J, McGarry MH, Lee TQ. Ulnar collateral ligament reconstruction using bisuspensory fixation: A biomechanical comparison with the docking technique. Am J Sports Med 2013;41:1158-1164.
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22. Cerynik DL, Ewald TJ, Sastry A, Amin NH, Liao JG, Tom JA. Outcomes of isolated glenoid labral injuries in professional baseball pitchers. Clin J Sport Med 2008;18:255-258. 23. Stephens SR, Warren RF, Payne LZ, Wickiewicz TL, Altchek DW. Arthroscopic acromioplasty: A 6- to 10-year follow-up. Arthroscopy 1998;14:382-388. 24. Ide J, Maeda S, Takagi K. Arthroscopic Bankart repair using suture anchors in athletes: Patient selection and postoperative sports activity. Am J Sports Med 2004;32:1899-1905. 25. Sheridan K, Kreulen C, Kim S, Mak W, Lewis K, Marder R. Accuracy of magnetic resonance imaging to diagnose superior labrum anterior-posterior tears. Knee Surg Sports Traumatol Arthrosc 2015;23:2645-2650. 26. Provencher MT, McCormick F, Dewing C, McIntire S, Solomon D. A prospective analysis of 179 type 2 superior
labrum anterior and posterior repairs: outcomes and factors associated with success and failure. Am J Sports Med 2013;41:880-886. 27. Denard PJ, Ladermann A, Parsley BK, Burkhart SS. Arthroscopic biceps tenodesis compared with repair of isolated type II SLAP lesions in patients older than 35 years. Orthopedics 2014;37:e292-e297. 28. Erickson J, Lavery K, Monica J, Gatt C, Dhawan A. Surgical treatment of symptomatic superior labrum anterior-posterior tears in patients older than 40 years: A systematic review. Am J Sports Med 2014;28:1274-1282. 29. Boileau P, Parratte S, Chuinard C, Roussanne Y, Shia D, Bicknell R. Arthroscopic treatment of isolated type II SLAP lesions: biceps tenodesis as an alternative to reinsertion. Am J Sports Med 2009;37:929-936.
Purpose: To determine practice patterns of Major League Baseball (MLB) team orthopaedic surgeons in addressing the controversial topics of ulnar collateral ligament (UCL) tears, type II SLAP tears, and partial-thickness rotator cuff tear. Methods: Seventy-four MLB team orthopaedic surgeons were surveyed via an online survey system. A 14-question survey was used to assess surgeon experience, technique, and graft choice for UCL reconstruction (UCLR), treatment of type II SLAP tears, and other common pathologic conditions. Results: Thirty team orthopaedic surgeons (41%) responded (mean experience as team physicians: 9.37 6.33 years). Seventeen (56.7%) surgeons use the docking technique for UCLR whereas 20% use the modified Jobe technique. Nineteen (63.3%) use palmaris longus autograft in UCLR. Overall, 28 (93.3%) do not routinely perform elbow arthroscopy or perform an obligatory transposition of the ulnar nerve in patients without preoperative ulnar nerve symptoms. Twenty-eight (93.3%) would repair a type II SLAP tear, whereas only 1 (3.3%) would debride the tear. No surgeon would perform a concomitant biceps tenodesis, either open or arthroscopic. Conclusions: Most MLB team orthopaedic surgeons perform a UCLR using the docking technique with a palmaris longus autograft without concomitant elbow arthroscopy or obligatory transposition of the ulnar nerve. The overwhelming majority of these surgeons would also treat an operative type II SLAP tear with a SLAP repair. Clinical Relevance: The number of UCLRs and SLAP repairs performed on MLB pitchers has significantly increased over the past 10 years. To properly treat these conditions in elite, college, and recreational athletes, it is important to understand how the surgeons who take care of the most elite-level athletes treat them, and how they are able to reproducibly attain excellent outcomes. This study shows how these common shoulder and elbow injuries are treated by those surgeons who care for the most elite overhead-throwing athletes in the world.
I
njuries in Major League Baseball (MLB) athletes have become a topic of great concern over the past several years, specifically tears of the ulnar collateral
From the Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A. The authors report the following potential conflict of interest or source of funding: J.D.H. receives support from Arthroscopy. C.A.B-J. receives support from the American Journal of Sports Medicine. B.R.B. receives support from the American Orthopaedic Society for Sports Medicine (AOSSM), Arthrex, ConMed, DJO, Tornier, and Smith & Nephew. A.A.R. receives support from AOSSM, American Shoulder and Elbow Surgeons, Journal of Shoulder and Elbow Surgeons, Orthopedics, Orthopedics Today, Sage, SLACK, and Arthrex. N.N.V. receives support from Arthroscopy, SLACK, Journal of Knee Surgery, Arthrex, Omeros, and Minivasive. Received May 22, 2015; accepted January 15, 2016. Address correspondence to Nikhil N. Verma, M.D., Midwest Orthopaedics at Rush, Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612, U.S.A. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 0749-8063/15473/$36.00 http://dx.doi.org/10.1016/j.arthro.2016.01.034
ligament (UCL) and superior labarum (i.e., SLAP).1 These injuries are most common among pitchers and can lead to a significant amount of time lost from competition.2,3 The active and extended rosters in the MLB consist of 750 and 1,200 athletes, respectively, of which approximately 360 active spots are occupied by pitchers.4 Hence, injuries to pitchers must be dealt with effectively and efficiently to ensure the pitchers are able to return to sport (RTS). The ideal treatment strategy for the various injuries affecting pitchers has yet to be elucidated. Previous studies have shown that MLB pitchers who undergo ulnar collateral ligament reconstruction (UCLR), commonly known as Tommy John surgery, are able to RTS at a rate higher than 80% and perform well on RTS, with no significant differences in many pitching statistics from pre to post surgery.3,5,6 In order to understand how these pitchers were able to achieve successful outcomes, it is necessary to understand how the team physicians
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Table 1. Questionnaire Administered to MLB Team Orthopaedic Surgeons 1. For how many years have you been an MLB team Orthopaedic Surgeon? 2. What is your preferred method of surgical treatment for a symptomatic MLB pitcher with a medial Ulnar Collateral Ligament (UCL) tear that has failed conservative treatment? a. DANE-TJ b. Docking c. Docking Plus d. Jobe e. Modified Jobe f. Hybrid g. ASMI Modification h. Tension Slide i. Bisuspensory j. Ziploop k. UCL Repair l. Other (please specify) 3. When surgically treating a medial UCL tear in your MLB pitcher, how do you address the humerus? a. Tunnel b. Socket c. Anchor d. Other (please specify) 4. When surgically treating a medial UCL tear in your MLB pitcher, how do you address the ulna? a. Tunnel b. Socket c. Anchor d. Other (please specify) 5. When treating an Ulnar Collateral Ligament Tear in your MLB Pitchers, what is your preferred choice of graft? a. Palmaris Longus Autograft b. Palmaris Longus Allograft c. Gracilis Autograft d. Gracilis Allograft e. Toe Extensor Autograft f. Plantaris Autograft g. Achilles Allograft h. Other (please specify) 6. Do you routinely perform elbow arthroscopy at the time of medial UCL reconstruction? a. Yes b. No 7. Do you routinely transpose the ulnar nerve if the MLB Pitcher has no pre-operative ulnar nerve symptoms or exam findings? a. Yes b. No 8. When surgically treating a partial thickness Rotator Cuff Tear of >50% in an MLB Pitcher do you. a. Complete the tear and perform a full thickness repair b. Perform a Partial Articular-Sided Tendon Avulsion (PASTA) Repair c. Other 9. When surgically treating a partial thickness Rotator Cuff Tear of >50% in an MLB Pitcher, do you routinely use a. a. Single Row b. Double Row c. Other (continued)
Table 1. Continued 10. Provided you have decided on surgical treatment, what is your preferred operative treatment of a Type II superior labral anteriorposterior (SLAP) tear in an MLB Pitcher? a. SLAP Repair b. SLAP Debridement c. SLAP repair þ arthroscopic biceps tenodesis d. SLAP repair þ open subpectoralis biceps tenodesis e. SLAP debridement þ arthroscopic biceps tenodesis f. SLAP debridement þ open subpectoralis biceps tenodesis g. Other 11. Do you routinely use Platelet Rich Plasma (PRP) in your treatment of medial or lateral epicondylitis in your MLB Pitchers? a. Yes b. No 12. Do you use Toradol? a. Yes b. No 13. Do you use pre-game local anesthetic injections for any shoulder or elbow condition in MLB Pitchers? a. Yes b. No 14. If so, for which conditions do you use pre-game local anesthetic injections? ASMI, American Sports Medicine Institute; DANE-TJ, David Altcheck, Neal ElAttrache, Tommy John technique; MLB, Major League Baseball; UCL, ulnar collateral ligament.
who are treating these pitchers approach UCL tears. This includes surgical technique, management of the ulnar nerve, graft choice, and whether the surgeon performs a routine elbow arthroscopy. As there are several techniques available for surgeons to choose from, understanding exactly how these surgeons treat elite-level pitchers is important so the success of UCLR can be transferred to both collegiate and high school athletes. Furthermore, Vitale and Ahmad conducted a systematic review of MLB pitchers who underwent UCLR and found that surgical technique and management of the ulnar nerve can play a role in postoperative outcome.7 The disabled throwing shoulder can involve SLAP tears, rotator cuff tears, and other pathologies. The data after treatment of SLAP tears are much more variable, with many studies reporting less than optimal results after surgery.8-10 Hence, it is currently unclear as to the ideal treatment algorithm for MLB pitchers who present with a SLAP tear. The purpose of this study was to determine practice patterns of MLB team orthopaedic surgeons in addressing the controversial topics of UCL tears, type II SLAP tears, and partial-thickness rotator cuff tear. The authors hypothesized that palmaris longus autograft would be the most commonly chosen graft in these elite-level athletes for UCLR and that surgeons would not routinely perform elbow arthroscopy while
3
UCLR AND SLAP TEARS IN MLB PITCHERS
performing UCLR. The authors also hypothesized that most surgeons would simply debride type II SLAP tear.
60.00% 50.00% 40.00%
Methods The authors created a 14-question survey (Table 1).11,12 The survey was created on the website SurveyMonkey (http://www.surveymonkey.com) and was sent to 74 MLB team orthopaedic surgeons. A similarly designed study has been performed in National Football League and National Collegiate Athletic Association team physicians regarding treatment of anterior cruciate ligament tears.13 The team surgeons were determined by Internet web searches and direct contact with team public relations departments. In 2013, the survey was sent out a total of 5 times, with the response rates for each round listed in Figure 1. The responses were kept confidential, and the data were organized via the SurveyMonkey web tool. The authors did not know the surgeons’ names. Statistical Analysis Descriptive statistics were calculated for each question. Continuous variable data were reported as mean standard deviation (weighted means where applicable). Categorical data were reported as frequencies with percentages.
Results The survey was sent to 74 MLB team orthopaedic surgeons’ e-mail addresses. Thirty team orthopaedic surgeons (41%) responded (mean experience as team physicians: 9.37 6.33 years). Seventeen (56.7%) surgeons would use the docking technique when performing a UCLR in their MLB pitchers whereas 20% would use the modified Jobe technique, and 3 (10%) of the surgeons answered “other” as they did not have a preferred technique (Fig 2). When addressing the humeral attachment during a UCLR, 14 (46.7%) surgeons do so via a tunnel whereas 13 (43.3%) use a socket. Twenty-six (86.7%) surgeons address the ulnar attachment via a tunnel whereas only 1 (3.3%) uses a socket. Nineteen (63.3%) surgeons use palmaris longus autograft as their graft choice in UCLR of the MLB pitchers, 6 (20%) use gracilis autograft, and 3 (10%) base their decision on a case-by-case basis (Fig 3).
30.00% 20.00% 10.00% 0.00%
Fig 2. Graph of responses to the question “What is your preferred method of surgical treatment for a symptomatic MLB pitcher with a medial Ulnar Collateral Ligament (UCL) tear that has failed conservative treatment?” (ASMI, American Sports Medicine Institute; DANE-TJ, David Altcheck, Neal ElAttrache, Tommy John technique; MLB, Major League Baseball.)
Twenty-eight (93.3%) surgeons do not routinely perform elbow arthroscopy at the time of their UCLR. Twenty-eight (93.3%) surgeons do not routinely transpose the ulnar nerve in pitchers with no preoperative ulnar nerve symptoms or examination findings at the time of UCLR. I addition, 28 (93.3%) surgeons would repair a type II SLAP tear in their MLB pitchers, 1 (3.3%) would simply debride the tear, and the 1 (3.3%) “other” would base the decision on the appearance of the tear at the time of surgery (Fig 4). In pitchers with a partial-thickness rotator cuff tear greater than 50%, 13 (43.3%) surgeons would perform a partial articular-sided tendon avulsion (PASTA) repair, 10 (33%) would simply debride the tear without any additional repair, and 4 (13.3%) would complete the tear and perform a full-thickness repair. Fourteen (46.7%) surgeons would perform a single-row rotator cuff repair when surgically treating a partial-thickness
70.00% 60.00% 50.00% 40.00% 30.00%
Number of Responses Per Round
20.00% 10.00%
20
0.00% Palmaris Longus Autograft
15 Number of Responses
10 5 0 1st round
2nd round
3rd round
4th round
5th round
Fig 1. Number of responses per round of survey e-mails.
Palmaris Longus Allograft
Gracilis Autograft
Gracilis Allograft
Other (please specify)
Fig 3. Graph of responses to the question “When treating an Ulnar Collateral Ligament Tear in your MLB Pitchers, what is your preferred choice of graft?” (MLB, Major League Baseball.)
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100.00% 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% SLAP Repair
SLAP Debridement
Other (Please Specify)
Fig 4. Diagram of responses to the question “Provided you have decided on surgical treatment, what is your preferred operative treatment of a Type II superior labral anteriorposterior (SLAP) tear in an MLB Pitcher?” (MLB, Major League Baseball.)
rotator cuff tear greater than 50% in MLB pitchers, 12 (40%) would base their decision on the size and geometry of the tear, and 4 (13.3%) would use a doublerow technique. Finally, 41% of MLB team orthopaedic surgeons use platelet-rich plasma and 46.7% use toradol, but only 3.3% use pre-game local anesthetic injections. The indication given for pre-game local anesthetic joint injection was acromioclavicular joint pain.
Discussion Most team physicians performed their UCLR via the docking technique using palmaris longus autograft without concomitant elbow arthroscopy or obligatory ulnar nerve transposition. However, most surgeons elected to perform a SLAP repair for an operative type II SLAP tear rather than a simple debridement as was hypothesized. Similar studies have been performed in National Football League and National Collegiate Athletic Association team physicians regarding treatment of anterior cruciate ligament tears.13 Several studies have reported on the success of MLB athletes, most commonly pitchers, as it related to RTS after UCLR.3,5,14 The number of UCLR surgeries is increasing with each year, and understanding the optimal treatment for UCL tears is important moving forward to decrease reoperation rates and ensure a high rate of RTS at levels similar to or better than preinjury.1,3,15-17 This is especially true as the number of UCLR surgeries performed in high school athletes continues to rise.18 A recent systematic review by Vitale et al.7 demonstrated that graft choice and surgical technique appear to play a role in success rates of UCLR in overhead-throwing athletes. This study concluded that the docking technique showed 90% excellent results, with a 3% postoperative ulnar neuropathy complication rate. It also demonstrated that in patients without preoperative ulnar nerve symptoms
who did not routinely have their ulnar nerve transposed, 89% had excellent results whereas only 4% had postoperative ulnar neuropathy. These data correlate well with the practice patterns found in this study. Most surgeons (63.3%) use the docking or docking plus technique when performing a UCLR in their MLB pitchers, and 93.3% do not routinely transpose the ulnar nerve in patients who exhibit no preoperative ulnar nerve symptoms.18,19 No study has directly compared outcomes in patients randomized to elbow arthroscopy or not, or ulnar nerve transposition or not, so it is difficult to conclude with absolute certainty which practice is superior. Studies examining these specific questions are necessary to draw meaningful conclusion. Furthermore, several techniques for UCLR have been reported in biomechanical studies. However, there are no good clinical data to recommend for or against these procedures, and as such, surgeons were not surveyed about these techniques.20,21 Although elbow injuries are a significant cause of morbidity in MLB pitchers, shoulder injuries are also a substantial problem in these athletes. Cohen et al.6 reviewed 28 shoulder and 23 elbow injuries in a total of 44 MLB athletes, 39 of whom were pitchers. They found that pitchers who underwent elbow surgery were more likely to RTS at the same level than those who underwent shoulder surgery. Other studies, both reviewing MLB players22 and non-MLB overheadthrowing athletes,23,24 have found similar results in which players who underwent shoulder surgery saw less reliable results in their postoperative performance compared with preoperative performance. SLAP tears are becoming an increasingly frequent, if not overly used, diagnosis with recent advances in magnetic resonance imaging.25 It is well known that SLAP repairs in patients older than 35 to 40 years do poorly.26 However, the results in elite overhead-throwing athletes has been studied to a lesser degree, although this patient population has been observed to be unable to tolerate alterations in their shoulder kinematics as well as recreational or noneoverhead-throwing athletes do.26-28 Recent evidence has shown that when comparing SLAP repairs to biceps tenodesis in the treatment of SLAP tears in the overhead-throwing athlete, athletes who underwent open subpectoral biceps tenodesis had more reliable return of upper extremity thoracic rotation and neuromuscular control than those who underwent SLAP repair.10 Likewise, Laughlin et al.8 found altered mechanics in 13 collegiate and professional pitchers who underwent SLAP repairs compared with a group of control pitchers. Similarly, Boileau et al.29 found that 60% of patients who underwent repair for a type II SLAP tear were disappointed with their results because of persistent pain, and only 20% were able to
UCLR AND SLAP TEARS IN MLB PITCHERS
RTS at the same preoperative level. This was in comparison to a group of patients who underwent arthroscopic biceps tenodesis instead of a SLAP repair who had a 93% satisfaction rate and an 87% rate of RTS at their previous level. Further research into the optimal treatment of SLAP tears is necessary to properly guide treatment patterns. Limitations The study has several limitations. First, it only evaluated baseball team physicians. Although some of these team physicians take care of athletes in other sports as well, this survey was specifically targeted at answering questions about MLB pitchers. Second, the survey response rate was 41%, which could be falsely low if some of the e-mail addresses were inaccurate. Further, this response rate could introduce selection bias depending on which surgeons did not complete the survey. Third, there is the possibility that some MLB pitchers were treated by surgeons who were not surveyed in this study, and so these results cannot be generalized to all MLB pitchers or all MLB team physicians. Fourth, in reference to MLB players, this study only addressed pitchers, and so the results may have differed if a different position was chosen. Finally, concomitant pathology could have altered the answers to some of the questions, specifically the SLAP questions.
Conclusions Most MLB team orthopaedic surgeons perform a UCLR using the docking technique with a palmaris longus autograft without concomitant elbow arthroscopy or obligatory transposition of the ulnar nerve. The overwhelming majority of these surgeons would also treat an operative type II SLAP tear with a SLAP repair.
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