The Fate of Chris Sale’s Left Elbow
Disclosure: The co-authors of this post are lifelong, die-hard, pathological fans of the Boston Red Sox.
At this time of a global public-health emergency, we probably should not be distracted by things like this, but… Yesterday the Boston Red Sox announced that left-handed pitcher Chris Sale, one of the best hurlers in baseball, would undergo Tommy John surgery, otherwise known as ulnar collateral ligament reconstruction (see related Clinical Summary). This, by itself, is not surprising, because by some estimates, one-third of all Major League Baseball pitchers have that operation.
What puts the hitch in our windup is this: In August of 2019, Sale, who was experiencing his worst season ever stat-wise, received an injection of platelet-rich plasma (PRP) in his left elbow and was shut down for the rest of the season. Here we are, 8 months later, and he is facing a surgery that was veritably inevitable and could have happened then rather than now.
PRP has shown promise in treating some musculoskeletal conditions, but its effectiveness in elbow injuries is unproven at best. In response to a surge of research interest in PRP, JBJS recently published an article calling for standardization of PRP preparation protocols and more responsible reporting of methods and findings in the literature so that any positive findings can be replicated in future investigations.
No surgery date for Sale has been announced (most elective orthopaedic surgeries are being postponed to redirect resources to the COVID-19 pandemic), and we don’t know who will perform the surgery. What we do know is that this year is the first of a 5-year, $145 million contract for Sale. While it’s silly to use the words “schedule” or “timeline” for anything now, a best-case scenario would have Sale back on the mound in games in June or July of 2021. We are not privy to the terms of Sale’s contract, but we assume the clock on it is ticking, and several months of an elite pitcher’s career was wasted waiting for a treatment to work that is not backed by any solid science.
Click here for a compendium of JBJS content related to PRP.
Lloyd Resnick
JBJS Developmental Editor
Jason Miller
JBJS Chief Operating Officer
What’s New in Shoulder and Elbow Surgery 2019
Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all such OrthoBuzz summaries. This month, Matthew R. Schmitz, MD, JBJS Deputy Editor for Social Media, selected the most clinically compelling findings from the 50 studies summarized in the October 16, 2019 “What’s New in Shoulder and Elbow Surgery.
Rotator Cuff Repair
–A randomized controlled trial compared immediate and delayed surgical repair of partial-thickness rotator cuff tears.1 No differences in retear rates were found, suggesting that a trial of nonoperative management remains appropriate for partial-thickness tears.
–The search continues for biologic augmentations to improve healing after rotator cuff repair. A study that randomized patients to weekly human growth hormone injections for 3 months or no injections after repair of a large tear found no difference in healing rates.2 Another randomized study of the effect on cuff-repair healing of platelet-rich plasma in a fibrin matrix found no improvement.3 A similar randomized trial of platelet-rich plasma plus thrombin in patients with a single-row repair of the supraspinatus found no differences in clinical outcomes or healing rates.4
–Psychosocial factors have been associated with pain relief and functional improvement after rotator cuff repairs. A longitudinal cohort study found that higher fear-avoidance behavior and alcohol use of ≥1 to 2 times per week compared with alcohol use ≤2 to 3 times per month negatively impacted shoulder pain and function at 18 months postoperatively.5
Osteochondritis Dissecans of the Capitellum
–A study evaluated predictors of success of nonoperatively treating patients with osteochondritis dissecans of the capitellum who did not have fluid underneath the fragment.6 Researchers found that lesion healing was associated with the following:
- Smaller overall lesion size
- No clear margins of the fragment on MRI
- Absence of cyst-like lesions
The authors include a nomogram that clinicians can use to predict healing.
UCL Insufficiency
–A study investigated baseball position-specific factors affecting return to play after ulnar collateral ligament (UCL) reconstruction.7 Investigators found the following:
- Position players returned to play sooner than pitchers, but they had lower rates of return to play.
- Catchers had the lowest likelihood of return to play (58.6%) and pitchers had the highest (83.7%).
These findings could help clinicians set expectations for players undergoing UCL reconstruction.
References
- Kim YS, Lee HJ, Kim JH, Noh DY. When should we repair partial-thickness rotator cuff tears? Outcome comparison between immediate surgical repair versus delayed repair after 6-month period of nonsurgical treatment. Am J Sports Med.2018 Apr;46(5):1091-6. Epub 2018 Mar 5.
- Oh JH, Chung SW, Oh KS, Yoo JC, Jee W, Choi JA, Kim YS, Park JY. Effect of recombinant human growth hormone on rotator cuff healing after arthroscopic repair: preliminary result of a multicenter, prospective, randomized, open-label blinded end point clinical exploratory trial. J Shoulder Elbow Surg.2018 May;27(5):777-85. Epub 2018 Jan 11.
- Walsh MR, Nelson BJ, Braman JP, Yonke B, Obermeier M, Raja A, Reams M. Platelet-rich plasma in fibrin matrix to augment rotator cuff repair: a prospective, single-blinded, randomized study with 2-year follow-up. J Shoulder Elbow Surg.2018 Sep;27(9):1553-63. Epub 2018 Jul 9.
- Malavolta EA, Gracitelli MEC, Assunção JH, Ferreira Neto AA, Bordalo-Rodrigues M, de Camargo OP. Clinical and structural evaluations of rotator cuff repair with and without added platelet-rich plasma at 5-year follow-up: a prospective randomized study. Am J Sports Med.2018 Nov;46(13):3134-41. Epub 2018 Sep 20.
- Jain NB, Ayers GD, Fan R, Kuhn JE, Baumgarten KM, Matzkin E, Higgins LD. Predictors of pain and functional outcomes after operative treatment for rotator cuff tears. J Shoulder Elbow Surg.2018 Aug;27(8):1393-400.
- Niu EL, Tepolt FA, Bae DS, Lebrun DG, Kocher MS. Nonoperative management of stable pediatric osteochondritis dissecans of the capitellum: predictors of treatment success. J Shoulder Elbow Surg.2018 Nov;27(11):2030-7.
- Camp CL, Conte S, D’Angelo J, Fealy SA. Following ulnar collateral ligament reconstruction, professional baseball position players return to play faster than pitchers, but catchers return less frequently. J Shoulder Elbow Surg.2018 Jun;27(6):1078-85. Epub 2018 Mar 23.
April 2019 Article Exchange with JOSPT
In 2015, JBJS launched an “article exchange” collaboration with the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) to support multidisciplinary integration, continuity of care, and excellent patient outcomes in orthopaedics and sports medicine.
During the month of April 2019, JBJS and OrthoBuzz readers will have open access to the JOSPT article titled “Repair of the Ulnar Collateral Ligament of the Elbow: Rehabilitation Following Internal Brace Surgery.”
In this Clinical Commentary based on the authors’ experience with >350 cases, Wilk et al. describe the rehabilitation process used for patients following UCL repair with an “internal brace.” This recent surgical advance in managing incomplete UCL tears enhances elbow joint stability while the ligament is healing.
JBJS JOPA Image Quiz: A Teenager with Thumb Pain After Hand-First Slide
This month’s Image Quiz from the JBJS Journal of Orthopaedics for Physician Assistants (JOPA) describes the case of a 14-year-old boy with a history of a bifid first metacarpal who injured his thumb while sliding hand-first into a base during a baseball game. Anteroposterior and lateral radiographs of the thumb are shown, and findings from the physical exam are detailed in words and photos.
The Image Quiz reviews the function of and injuries to the ulnar collateral ligament (UCL), including the injury classically described as “skier’s thumb.” Pick the best among four possible next steps in diagnosing and treating this injury.
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