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Heezy1323 last won the day on April 1 2020

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  1. Great job Lucas. Difficult subject to describe using words alone. The analogy I use with patients when I recommend/perform this procedure in conjunction with an ACL reconstruction is that they should try to think of the knee like a steering wheel. The ACL is located in the center of the knee joint (steering wheel), while the ALL is located on the outer (lateral) edge of the steering wheel. Now imagine you are trying to hold the steering wheel of your car, and prevent it from turning. If you hold the steering wheel in the middle (ACL), it is hard to resist the wheel turning forcefully. However, if you hold the steering wheel on the outer portion (where we would typically put our hands), it is much easier to resist the rotation of the steering wheel. This represents the ALL. By performing the lateral extra-articular tenodesis (LET), you are recreating the ALL. This more easily resists the rotation forces that can put extra stress on the ACL. The data on the use of LET is intriguing, but it would be inaccurate (IMO) to say that it is conclusive at this point. I am mostly using the LET in re-do scenarios (such as Royce's) and select first-time surgeries where there is a more extensive injury or some other patient factors. Another interesting question I have not yet seen reported is- what type of graft did Royce have? I would assume he had a patellar tendon graft the first time around, and most commonly the graft is taken from the injured knee (though there are some surgeons who take it from the opposite knee the first time around). One of the (many) challenges of a revision situation is that most typically, the preferred choice for ACL graft was used the first time around. So the options are to go to the other knee and use the same type of graft, or to use a different type of graft from the injured knee (most typically quadriceps tendon or hamstring tendon). This can have an effect on recovery as well (if the 'other' knee requires rehab too, due to the graft harvest). Such a bummer for Royce, he was having such a promising debut. As if the kid needed any more adversity...
  2. Good summary Lucas. I see bone bruises such as this fairly frequently, and they can be present for a number of different reasons. I tend to view them on the MRI images where fluid/edema shows up bright (T2 or PD FS), so I think of them as bright spots on MRI more than dark spots. Most likely, this is a result of the femur slamming into the tibia, causing a bruise just like you might get on your thigh if you accidentally bump into the edge of a table or something like that. Your description of the bone in that area is spot on- I tend to describe it to patients as kind of like a puffy cheeto. It is softer bone than in the shaft of longbones, and as a result is more susceptible to injuries like this. The timetable for recovery is dependent on a number of factors including the specific size and location of the bone bruise, the initial severity, whether it is present on both the femur AND tibia (called a kissing lesion) or on just one side, the alignment of the leg and probably several others. In my experience working with athletes, these always take longer than you think. If I had to guess, I would say 4 weeks would be the minimum for a full return (though I hope I'm wrong). Of course, bone bruises can (and often do) occur with ACL tears, so it's good to hear that the ACL graft appears to be fine. That would be a relative disaster in this case, obviously. This image shows an MRI of a knee with the darker gray areas being normal bone, and the brighter areas being the area of the bone bruise in this particular case.
  3. With respect to the differing timelines, I covered a fair bit of that in this blog post a while back. Obviously, no one would willingly choose a procedure with a 12-18 month recovery when one with an expected 9-12 month recovery is also available. The distinction comes down to location of the tear within the UCL and the overall condition of the ligament. UCL Primary Repair (the shorter recovery procedure) is now being done on more and more elite level pitchers, but it isn't available to anyone and everyone. Only those injuries with certain features. It is being performed on very few cases of those with a prior UCL reconstruction (Rich Hill being the only one I know of- there could be more). Separately, there is some work now being done on adding what is called an 'internal brace' suture to UCL reconstructions. This is something that is done on all UCL Primary Repairs. The thought is that the internal brace helps protect the healing graft, and perhaps would allow for a more aggressive rehab and sooner return to play as a result. While this is an intriguing idea, it is not yet definitively known if/how much this will shorten the recovery timeline for UCL reconstruction. I can go into more detail if readers would like, but I figure I'd put in my $0.02.
  4. I'm an orthopedic surgeon, but not a hand/wrist specialist. The difficult part here for me is- I can't really find any specifics on what surgery Kirilloff had performed. I can only find 'ligament repair' in his wrist. Unfortunately, there are numerous ligaments in the wrist and they may each have different implications. Secondarily, with regards to the cartilage- there are at least 10 bones that I would consider being part of 'the wrist', so there could be cartilage wear between any of those bones (or multiple). If a proposed procedure to remedy this is cutting the ulna and shortening it (what we would call an ulnar shortening osteotomy), the arthritic changes (cartilage wear) probably involve wither the distal radioulnar joint (DRUJ) or the lunate (one of the pebble shaped bones of the wrist). The distal radioulnar joint is the area where the two forearm bones meet just above the wrist. The radius rotates around the ulna as one turns their hand from palm up to palm down position. If there is arthritis between these bones, as is being reported, I'm not aware of any good fixes. Because I don't do much hand/wrist stuff, there may some cutting edge things I'm not aware of. But this, to me, is a pretty significant bummer. I wish I could say different, but I'm not super-optimistic for a resolution of this problem. It's possible more information would change my opinion.
  5. I propose a thought exercise. I believe most would agree (regardless of position on robo umps) that calling balls and strikes in a game of 10-year-olds is easier than at the MLB level. What is the reason, exactly? Presumably, it is because the pitches are coming in much more slowly, and are breaking a much smaller distance. For the sake of argument, let's take this to an extreme. Let's pretend that the ability of pitchers to continue to improve their velocity knows no limit. Let's pretend that, say, 20 years from now it is routine to have pitchers throwing 110-115mph. Perhaps with even more break. What is the upper limit of human ability to make ball/strike calls with reasonable accuracy? Clearly if a baseball is coming in at 200mph, and breaking 30" or something, a human brain has no shot at telling if the ball goes through a defined box- particularly on borderline pitches. And logically, there is also a gradient along the way, such that with increasing velocity and break, the ability of even the best umpires to delineate balls from strikes goes down. Where, precisely, is the threshold at which this becomes 'unacceptable'? We already use computers in thousands of scenarios every day where the ability of the human senses is unable to reasonably discern one situation from another. I view this as no different. I don't believe it's because the umpires are necessarily 'bad' at their job. I just don't think it's reasonable to expect even those most skilled to be able to do this correctly 100% of the time. We've all seen games, series or even careers turn on ball/strike calls that were bad. We either have, or soon will have, the ability to be better. It's time. I can't imagine a scenario where a human is calling balls and strikes even 10 years from now. Merry Christmas TD. All the best to each of you.
  6. Agreed on the good ice/bad ice analogy. Not sure I follow the second paragraph. The purpose of the internal brace is to avoid stretching of the graft (by resisting tension/reducing stress) during it's initial period of relative weakness after implantation, and perhaps some degree of protection of the graft going forward by acting as a sort of 'rebar.' This allows the graft to heal in at a more desirable (i.e. tighter) tension, rather than becoming loosened, as it might without the internal brace in place.
  7. Ok- I'll give it a shot. Hopefully there's something valuable I can share. I did not see the STrib article (my bad, would've liked to read it), but I have been aware of the internal brace concept being utilized with UCL reconstructions for a short time. Feel free to review my prior blog post about UCL injuries. Nomenclature is important here. Recall that UCL repair means that the athlete's own ulnar collateral ligament (UCL) is repaired back to bone. This repair is often protected with an especially strong suture called an 'internal brace'. The internal brace has been around for a number of years. It has been (and is currently) used in a number of other places in the body to protect various ligament or tendon repairs. It began (if I recall correctly) being used to help protect the repair of ligaments at the outside part of the ankle when patients required surgery for chronic ankle instability. With it's success there, it has gradually been expanded to other parts of the body. By way of example, I have used it in basically every one of my ACL reconstructions for the past 2.5 years to protect the healing graft during recovery (somewhere around 150 ACL's). I have also used it to help protect PCL, MCL, patellar tendon and posterolateral corner surgeries in the knee, among others. When the UCL is repaired, the idea is that the tissue of the UCL is healthy/strong enough that it can successfully withstand the forces of pitching once it has become firmly healed back to the bone. The injury in these cases is to the area where the ligament meets the bone, not within the ligament itself. The purpose of the internal brace in this case is to 'protect' the repair. Specifically, when a patient moves the elbow after surgery (even if they aren't doing something demanding such as throwing), there is microscopic movement at the interface between the healing ligament and the bone. In theory, if there is excessive stress at this junction, the healing will be less robust and therefore the ligament less able to withstand substantial forces of throwing later on in the rehab process. By using an internal brace, the idea (as I understand it), is that the relatively small forces of day to day movements of the elbow are now shared between the healing ligament and the internal brace suture. Therefore, this stress is less likely to cause a negative effect on the healing progress of the ligament back to the bone. Hopefully (the idea goes) this results in more strong and robust amount of healing of the ligament when compared to a repair done without an internal brace. (Feel free to review my previous blog post about UCL repair vs. reconstruction here.) That leads us to this particular case with Kenta of a UCL reconstruction performed with an internal brace. This is similar, but not identical to the situation discussed above. Recall that the term 'reconstruction' is used when tissue (almost always a TENDON) from somewhere else (either the patient themselves or in some cases a donor/cadaver) is used to make a NEW ligament. There are numerous reasons why this option might be chosen rather than a repair, but most commonly it is because there is an accumulation of damage to the native ligament that makes it unlikely to be strong enough itself to stand up to the necessary stresses once healed. Indeed, most UCL repairs are performed on young athletes who don't have the same cumulative amount of damage as MLB pitchers. As a result of this, there is an additional variable in these cases of reconstruction. Namely, in addition to successful healing, the TENDON also requires time to 'turn into' a LIGAMENT. This is primarily why the recovery from UCL repair surgery is typically so much shorter than UCL reconstruction --> in a UCL repair the ligament is already a ligament. So it doesn't require time to undergo this transition from tendon tissue to ligament tissue (called ligamentization). (I know this is getting tedious- and I apologize. Hang with me here...) So the use of the internal brace with UCL reconstruction has a slightly different goal than with primary repair (again, as I understand it). Obviously, when you use a tendon to replace a ligament, you have to remove that tendon from the body completely for a short time in order to reimplant it. As a result, the tendon is completely removed from its normal blood supply. Once implanted, the body has to reestablish blood supply to this tendon in its new location in order to keep it alive. This takes some time to accomplish. There have been animal studies done that have shown that the strength of the newly implanted tendon in situations such as this actually goes down for the first few weeks after surgery, then starts to increase again. As a result, there is a period of time after surgery when this graft is vulnerable to 'stretching out' which could compromise the ultimate strength of the graft. The internal brace seeks to avoid this problem by protecting or 'bracing' the graft during this period of time so that it doesn't stretch out and is able to heal in more strongly and at the appropriate tension. How much difference in 'looseness' (what we would call laxity) is too much? Well, during my fellowship with Dr. Andrews we did a study that showed that when placed under stress, the injured elbow opened up on average only 0.3mm (that's a third of a millimeter!) more than their opposite, uninjured elbow. So it appears that it doesn't take much difference in laxity to cause a problem in a thrower's elbow. There is a mountain of data supporting the use of an internal brace with UCL repair. There is very little data available that I am able to find regarding the use of an internal brace with UCL reconstruction. I found one biomechanical paper that showed that the use of an internal brace with UCL reconstruction allowed the biomechanics of the elbow to more closely replicate a normal elbow than when UCL reconstruction was done without internal brace (this was a cadaver study). I was not able to find any clinical data reporting on the success rate of UCL reconstructions done with internal brace compared to those done without. My guess is that this data is coming, just not published yet. Logically, it makes a lot of sense to me that the use of an internal brace in conjunction with a UCL reconstruction would improve the success rate, but medicine doesn't always follow logic. I'll be interested to see the results in the future. Also, I don't know exactly which reconstruction technique Dr. Meister uses, which could potentially have some influence on results as well. One reservation I have about the idea that this internal brace shortens the return to play timeline is that despite the fact that this internal brace likely results in a 'tighter' ligament once healing is complete, the internal brace probably does not do anything to speed up the transition of the tendon tissue into ligament tissue that occurs over time. Perhaps we can be a bit more aggressive with the rehab when an internal brace is present, without as much concern for the new ligament 'stretching out'. But ultimately, the new ligament has to be (very) strong in order to withstand the extreme forces of pitching, especially at the MLB level. Time will tell if this new modification to UCL reconstruction technique will allow for a quicker return to play. I hope it does- 18 months is a darn long time. If you've managed to read this far- thank you. This is pretty dense stuff (sorry...)
  8. This is another HUGE variable in evaluation of these patients. The appearance of the UCL on MRI is often not particularly helpful. Let's go through the scenarios: 1) The UCL looks completely normal (rare at the MLB level): rest and rehab, perhaps a PRP injection 2) The UCL is completely torn, obvious to everyone that the athlete needs surgery (maybe 20% of the time): proceed with surgery in most cases, though on occasion PRP or other means of treatment can be tried. 3) The UCL is somewhere in between. Small to moderate damage, but nothing terrible (this is the case the majority of the time): A huge range of possibilities. Some pitchers can throw for years on a partially torn ligament. Others can have an MRI that looks essentially normal and can't throw without pain despite extensive non-surgery treatments. This is what makes these decisions REALLY hard in a lot of cases. The exact same MRI findings can indicate opposite things in two different patients. Trying to figure out which patients will be successful with non-surgical treatment is tough. And remember, the return to play rate after TJ surgery is quite good (somewhere around 90%), but that still means 1 in 10 will not get back. This is why, in many cases, the athlete has to 'prove' they aren't going to be successful without surgery by trying the rest and rehab route initially before proceeding with surgery. Sometimes the calendar, an athlete's contract status or year in school, or other factors will push us to surgery faster.
  9. This is mostly, but not completely accurate. Hill had a UCL repair in the sense that he did not have a new graft put in place, but simply had a direct repair of his existing ligament tissue. However, he had previously undergone UCL reconstruction in the early 2010s and as such had a repair of a previously reconstructed UCL, which is really a distinct situation from the vast majority of these operations in which the athlete's native ligament is reattached to the bone. Agree with Lucas that we will probably see more of these 'primary repair' operations going forward. Hopefully they will be able to reduce the time needed for recovery for a subset of UCL-injured players.
  10. Agree with Nine of twelve, this pitch looks to have hit him just at or above the wrist, almost certainly on the ulnar side. At the level of the wrist, the ulna is the smaller bone on the small finger side of the forearm. It's obviously hard to say exactly where this pitch hit him- whether it is a fracture of the ulna right at the wrist and into the wrist joint (what we would call intra-articular) or more on the shaft of the ulna (away from the joint a bit, within the bone itself or extra-articular). Neither is ideal, obviously, but you would prefer that the fracture be away from the joint so that there is less risk of damage to the cartilage of the wrist joint. Cartilage has less blood supply and therefore less healing potential when compared to bone. We do occasionally hear about injuries to part of the wrist cartilage in baseball players. This is called the Triangular Fibro-Cartilage Complex (TFCC for short). I believe Carl Crawford and Matt Holliday had this issue some years ago. I am hopeful this is a fracture above the wrist joint, and involves only the bone of the ulna. This would typically be fixed with a plate and several screws to hold the bone in the appropriate position while the body heals the fracture. Healing of these type of fractures often takes around 6-8 weeks. On occasion, ulna fractures can have trouble healing and may heal slowly, or in rare cases not heal at all. In those cases, sometimes additional surgery or other treatments may be needed to get the bone to heal. There are also tendons that glide close to the ulna in this area, and the sheath they glide in could potentially be damaged as well in this case. This can occasionally cause issues for baseball players as well (i.e. Mark Tiexeira). Overall, definitely a bummer for Rooker, who was having a nice start to his career. Without knowing details, it's difficult to comment on the time frame for recovery or the likelihood of this affecting him in the future. Let's hope it's a straightforward fracture and surgery goes smoothly. I know the Twins have an excellent group of physicians to take great care of him. Let me know if folks have questions or would like me to clarify anything. GO TWINS!!!
  11. "Of course there are undoubtably additional factors that put pitchers at risk for arm injuries. Twins Daily’s very own medical expert, Lucas Seehafer, did a great job of illustrating the roll proper mechanics can play in pitcher injury prevention and the increase of specialization at a young age has also been cited as a potential cause of injury. College and minor league pitchers have a much higher rate of Tommy John surgery than their MLB counterparts, which fits our narrative as they’re likely to be throwing a higher mix of fastballs and have less developed mechanics." As a clarification of perspective, there are a greater number of TJ surgeries performed on college and minor league players when compared to MLB; however, there are MANY more players at the college and minor league level than MLB. As such the raw number is higher in college and MiLB, but the rate is much higher in MLB. There is definitely information to take away from this fact (such as early specialization, throwing harder at younger age, year-round play, etc.) but I don't think you can make the correlation to more fastballs meaning higher rate of TJ in these non-MLB players. The Twins and other MLB teams are starting to do some work on managing workload on an individual basis and understanding what stresses each athlete is placing on their elbow (rather than using a universal 'recipe' for every player). This is being done using Motus sleeves and other cutting edge technology (mo-cap, etc.). We are still probably in, like, mile 3 of a 26 mile marathon to understanding all of this, but we are now in a better position from a technology standpoint to make meaningful advancements. I hope we can find a way for me to do fewer TJ surgeries- especially on young players. As much as I love to operate, I'd be totally on board with a dramatic decrease in UCL reconstruction being necessary in the first place.
  12. Tom Verducci posted an article today on SI.com about Noah Syndergaard and the relationship between velocity and elbow injury. I thought it was pretty good. Also, feel free to check out my blog posts about TJ surgery decision-making and techniques, if you're interested.
  13. For those who have a subscription to the Athletic, there is a very interesting article I saw that was a deep dive into the 2019 postseason baseball, indicating that there is some evidence that the balls used in 2019 were a mix of 2019 and 2018 postseason balls. Fascinating for a baseball nerd like me. Thought some others might like it as well. Stay safe, all. heezy
  14. I haven't done 100, but I've done a fair number on appropriate candidates. I see many more teenagers than I do professional athletes in my practice, so it is definitely a good tool to have in the toolbox for this age group. Most don't have the cumulative damage to their ligament that someone who is older might. Good luck to your son! Sounds like he is progressing very well. Being diligent about the rehab is also critical, and it sounds like he has done his part. Nice job!
  15. The studies looking at injury early in the season for pitchers are often skewed IMO because they don't always account accurately for those injuries that have been simmering through the offseason. So if someone (like Sale, Severino etc.) ends up having TJ in March or April, the injury can get recorded as occurring in 'March' or 'April', when in reality it has (in most cases) occurred earlier, was being monitored in hopes that it would improve without surgery, but ultimately doesn't. So it's hard to know how to use that info when calculating injury rates. I do think the injury rate is probably higher earlier in the season, but probably not as dramatically different as some studies seem to show. For position players, I think it is likely more accurate. A very minor point about PRP- the platelets release chemical signalers called cytokines that are somewhat different from hormones. Hormones can make people think things like 'steroids' (which are naturally produced- or sometimes injected- hormones), when what PRP provides is an alphabet soup of things like TGF-beta, IGF, PDGF, VEGF and others that regulate cell activities like inflammation and healing. I just think it is important to make a distinction that injecting PRP is different from a steroid injection (whether anabolic or corticosteroid- which is a whole other discussion).
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