1/9/17 1 Epidemiology of Tommy John Surgery Stan Conte, PT, DPT, ATC Conte Injury Analytics
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EpidemiologyofTommyJohnSurgery
StanConte,PT,DPT,ATCConteInjuryAnalytics
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Definitionof“Epidemic”
• Anepidemicoccurswhenadisease affectsagreaternumberpeoplethanisusualforthatpopulation.• Thisismeasuredbyepidemiologicalstudies• InUCLReconstruction,thesePOPULATIONSareageorcompetitivelevels.• Youth,HS,College,Professional
• Analyzingnotonlytheincidencebuttheincreasesfromyeartoyear.
WhatPublishedEpidemiologicalStudiesareAvailable?
• Petty,Cain,etal,AJSM2004-UlnarCollateralLigamentReconstructioninHighSchoolBaseballPlayers• 50%increaseatASMIfrom1988-94to1995-2003.
• Cain,etal.AJSM,2010.OutcomeofUlnarCollateralLigamentReconstructionoftheElbowin1281Athletes:Resultsin743AthletesWithMinimum2-YearFollow-up• “Manypeopleinvolvedinorganizedbaseballhavereportedariseintheincidenceofseriousarminjuriesinrecentyears,althoughexactstatisticalnumbersarenotavailable”
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TrendsinMedialUlnarCollateralLigamentReconstructionintheUnitedStates:ARetrospectiveReviewofLargePrivate-Payer
DatabaseFrom2007-2011Erickson,Romeo,etal.AJSM.2015
EpidemiologyofMedialCollateralLigamentReconstruction:A10-YearStudyofNYState
Hodges,Ahmad,etal.AJSM:2016
17-18yo
19-20yo
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UCLr MLBPlayersOnly1974-2016Source:baseballheatmaps.com
1 1 3 1 2 4 3 4 16
46 6
10
5 5
810
16 15 15
19
13
17
2022
15
20
17 17
36
20
31
27
20
MLBTJSurgeriesPitchersandPositionPlayers
2000-2011AVGTJS=17 2012-2016AVGTJS=27
TJSurgeriesMLBPlayersbaseballheatmaps.com
0
5
10
15
20
25
30
35
40
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
No.ofTommyJohns2000-2016
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TJSurgeriesMLBPlayersbaseballheatmaps.com
0
5
10
15
20
25
30
35
40
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
No.ofTommyJohns2000-2016
TJSurgeriesMLBPlayersbaseballheatmaps.com
0
5
10
15
20
25
30
35
40
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
No.ofTommyJohns2000-2016
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TJSurgeriesMLBPlayersbaseballheatmaps.com
0
5
10
15
20
25
30
35
40
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
No.ofTommyJohns2000-2016
UCLr (2010-16)40ManRosterOnlyHITSData-JohnD’Angelo(MLB)
32
24
42
30
40
33
20
2010 2011 2012 2013 2014 2015 2016
40ManTJSurgeries
p=.67R2=.04
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UCLr (2010-16)Non-40ManRosterOnlyHITSData-JohnD’Angelo(MLB)
68
81
111
128
115
131
152
2010 2011 2012 2013 2014 2015 2016
Non-40ManTJSurgeriesp =.002R2=.88
Baseballheatmaps.com =386TJSMLBHITSData=786
UCLr (2010-16)AllLevelsCombined
100 105
153 158 155164
172
2010 2011 2012 2013 2014 2015 2016
TJSurgeries40+Non40
P=.006P=.03without2010,2011
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EpidemiologyofUlnarCollateralLigamentReconstructioninMajorandMinorBaseballPitchers:ComprehensiveReportof1,313Cases.
Camp,Christopher,MD,StanConte,PT,DPT,ATC,JohnD’Angelo,BS,StephenFealy,MDSubmittedforPublication
EpidemiologyofUlnarCollateralLigamentReconstructioninMajorandMinorBaseballPitchers:ComprehensiveReportof1,313Cases.
Camp,Christopher,MD,StanConte,PT,DPT,ATC,JohnD’Angelo,BS,StephenFealy,MDSubmittedforPublication
• TheannualrateofprimaryandrevisionUCLreconstructionsrosesignificantlyforalllevelsofplayfrom1974to2015andfrom(p<0.001).• Theoverallmeantimetoreturntoplay(RTP)was436days(14.5months).RTP=anylevel.• TherateofRTPtoanylevelwas93.9%forMLBpitchersvs.76.3%forMiLBpitchers.BothgroupsRTPat83.6%• MLBpitchersRTPattheMLBlevelin73.1%ofcases• ThetimetoRTPwaslonger(by54days)forrevisions(p=0.025)comparedtoprimaries.• Therevisionratewas10.7%
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PrevalenceofUlnarCollateralLigamentSurgeryinProfessionalBaseballPlayers
Conte,etal,AJSMVol.43,No.7(2015)
• Over5,000ProBaseballPlayerssurveyedin2012 season• OverallRateof10%hadTJSurgery• 16%ofAllPitchers• 1in4(25%)MajorLeaguePitchers
• 86%hadsurgeryinpros• 1in7(15%)MinorLeaguePitchers
• 61%hadsurgeryinHSorCollege
Revisions
• Cain,et,al.(AmJSportsMed201038:2426)reportsoutoftheirstudyof743athleteswhounderwentUCLreconstructiononly9or1%hadtoundergorevisions.• Erikson,etal(AmJSportsMed201442:536)reportedoutof177MajorLeaguepitchers,therevisionratewas3.9%.
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OutcomesinRevisionTommyJohnSurgeryinMajorLeagueBaseballPitchers
JosephLiu,M.D.;GrantHGarcia,MD;StanConte,PT,DPT,ATC;NealElAttrache,MD;DavidWAltchek,MD;JoshuaSDines,MD
• Since1999,235MLBpitchersunderwentTJS.• 31pitchers(13.2%)underwentrevisionsurgery• 37%underwentrevisionwithin3yearsoftheirindexprocedure• 26revisionshadmorethan2-yearfollowup• 17(65.4%)pitchedatleastMLBgame• Only11(42.3%)pitchedmorethan10games• AveragereturnMLB=20.76months• RevisionRate=13.2%
RevisionsUpdate- MLBPlayers1996-2016
0
2
4
6
8
10
12
1996 1999 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Revisions1996-2016
ReturntoPlay(1996-2014)=65%(26/40)
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#ofUCLRevisionsperYear,2010-2016
RevisionSurgeriesPerYear-JohnD’Angelo
6 6 7 912
5 5
92
3
23
2015
11
2013
16
11
2012
11
2011
3
1
2014 2016
15
2010
3
0
MinorMLB
StudiesthathavePredictedUCLSurgery
• FastballPitchVelocityHelpsPredictUlnarCollateralLigamentReconstructioninMajorLeagueBaseballPitchers.Chalmers,et,al• AmJSportsMed201644:2130
• MajorLeagueBaseballpitchvelocityandpitchtypeassociatedwithriskofulnarcollateralligamentinjury.Keller,etal.• JShoulderElbowSurg (2016)25,671–675
• PredictorsofUlnarCollateralLigamentReconstructioninMajorLeagueBaseballPitchers.Whitesideetal.• AmJSportsMedpublishedonlineMay6,2016
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FastballPitchVelocityHelpsPredictUlnarCollateralLigamentReconstructioninMajorLeagueBaseballPitchers
PeterN.Chalmers,*yMD,BrandonJ.Erickson,y MD,BrianBall,z ATC,AnthonyA.Romeo,y MD,andNikhilN.Verma,y MD
• Methods:MLBPitchers2007-2015.PitchVelo,number,type(PitchFx),demographics.ExaminedallUCLr priorto2007andafter2012.Putin3categories,“control”,”pre-injury”,“postoperative”.1327Pitchersincludedwith309(26.8%)underwentUCLr.145hadpre-injurydata.• Multivariant Regressionshowed:• PeakpitchvelocitywastheprimaryindependentpredictorofwhetherapitcherunderwentUCLR(P< .001)• Meanvelocity(P=.013),bodymassindex(P=.010),andage(P=.006)beingsecondarypredictors.• However,amodelconstructedwiththesevariablesonlyexplained7%ofthevarianceinUCLRrates.• Pitchcountswerenotsignificantpredictors
MajorLeagueBaseballpitchvelocityandpitchtypeassociatedwithriskofulnarcollateralligamentinjury
RobertA.Keller,MD*,NathanE.Marshall,MD,John-MichaelGuest,BA,Kelechi R.Okoroha,MD,EdwardK.Jung,MD,Vasilios Moutzouros,MD
• Methods:83MLBpitcherswhounderwentprimaryUCLreconstructionwereevaluated.Average Pitchingvelocityandpercentofpitchtypethrown(fastball,curveball,slider,andchange-up)wereevaluated2yearsbeforeandaftersurgery.Datawerecomparedwith83controlpitchersmatchedforage,position,size,inningspitched,andexperience• Conclusion:
• MLBpitcherswhopitchahighpercentageoffastballsmaybeatincreasedriskforUCLinjurybecausepitchingahigherpercentoffastballsappearstobeariskfactorforUCLreconstruction.
• Pitchingmorethan48%fastballswasasignificantpredictorofUCLinjury,becausepitchersoverthisthresholdrequiredreconstruction(P=.006).
• MLBpitchersrequiringUCLreconstructiondonot pitchathighervelocitiesthanmatchedcontrols,andpitchvelocitydoesnotappeartobeariskfactorforUCLreconstruction.
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PredictorsofUlnarCollateralLigamentReconstructioninMajorLeagueBaseballPitchers
DavidWhiteside,*PhD,DouglasN.Martini,PhD,AdamS.Lepley,PhD,ATC,RonaldF.Zernicke,PhD,andGrantC.Goulet,PhD
• Methods:104MLBUCLr pitcherscomparedto104age-positionmatchedcontrolgroup.Usedbinarylogisticregressionandmachinelearningcomputer• Results:6PerformanceMetricsthatwerestatisticallysignificantriskfactors1. Fewerdaysbetweenconsecutivegames(fatigue)2. Smallerrepertoireoftypesofpitches3. Lesspronouncedhorizontalreleasepoints4. Smallerstature(height)5. Greatermeanpitchvelocity6. Greatermean pitchcountspergame
RiskFactorsandPrevention
MorePreventable
1. PitchTypes- Fastballs1. Keller,etal,supports
2. NumberofPitchTypes1. Whiteside,etal,supports
3. MoreRestbetweenOutings1. Whiteside,etal,supports
4. PitchCounts1. Whiteside,etal,supports
5. ReleasePoints1. Whiteside,etal,support
6. Weight1. Chalmers,etal,support
LessPreventable
1. PeakVelocity1. Chalmers,etal,supports
2. MeanVelocity1. Chalmers,etal,support2. Keller,etal,doesnot support
3. Height1. Chalmers,etal,supports
4. Age1. Chalmers,etal,supports
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ThankYou
Conte Injury Analyticsconteinjuryanalytics.com