1/9/17

1

EpidemiologyofTommyJohnSurgery

StanConte,PT,DPT,ATCConteInjuryAnalytics

1/9/17

2

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”

1/9/17

3

TrendsinMedialUlnarCollateralLigamentReconstructionintheUnitedStates:ARetrospectiveReviewofLargePrivate-Payer

DatabaseFrom2007-2011Erickson,Romeo,etal.AJSM.2015

EpidemiologyofMedialCollateralLigamentReconstruction:A10-YearStudyofNYState

Hodges,Ahmad,etal.AJSM:2016

17-18yo

19-20yo

1/9/17

4

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

1/9/17

5

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

1/9/17

6

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

1/9/17

7

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

1/9/17

8

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%

1/9/17

9

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%.

1/9/17

10

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)

1/9/17

11

#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

1/9/17

12

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.

1/9/17

13

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

1/9/17

14

ThankYou

Conte Injury Analyticsconteinjuryanalytics.com