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Shanley E, Thigpen CA, Boes N, Bailey L, Arnold A, Bullock G, Kissenberth M. Arm Injury in Youth Baseball Players: A 10-Year Cohort Study. J Shoulder Elbow Surg 2023; 32:S106-S111. [PMID: 36828286 DOI: 10.1016/j.jse.2023.02.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 02/26/2023]
Abstract
BACKGROUND Arm injuries are commonly encountered in baseball as young athletes play into adulthood. The purpose of this study was to examine the incidence of arm injury and risk for surgery in adolescent baseball players followed over a 10-year period from scholastic, age-group, and travel baseball leagues through their highest level of competition. METHODS A prospective study was conducted enrolling middle and high school baseball players in 2010-2012, then followed for 10 years or until retirement from competitive baseball. Players were included if fully participating in team activities at the time of pre-season study enrollment. Players with prior arm (shoulder or elbow) surgery or those diagnosed with time loss arm injury within the past year were excluded. Only shoulder and elbow overuse problems resulting in time-loss from sport and medical attention from a sports medicine physician or orthopedic surgeon were documented as injuries in this study. Musculoskeletal overuse injuries were classified based on the orchard injury classification system. Incidence proportion (IP) and risk ratio (RR) and 95% confidence intervals (CI) for initial injury and injuries requiring surgery were calculated. RESULTS A total of 261 pitchers (Age: 14.2 ± 2.6; Follow-up: 4.2 ± 2.7 years) were enrolled. Twenty percent of the cohort was followed for 7 or more years. The overall injury incidence was 25.6/100 athletes (95% CI=21-31) with a cumulative surgical incidence of 5.4/100 athletes (95% CI= 3.2-8.8). The risk of experiencing shoulder injury (n=25) and elbow injury (n= 38) were similar (n= 38) (RR= 0.7; 95% CI= 0.4- 1.1). The athletes also presented with a similar frequency of requiring surgery regardless of the injured body part. However, the risk of surgery in those playing beyond the high school level was 4.3 times greater (95% CI, 1.2-15.0) than those only playing high school. CONCLUSION This is the first study to follow a large cohort of youth baseball players as they progress, showing a relatively high arm injury incidence. Shoulder and elbow injury incidence was similar but surgical risk increased playing beyond high school, specifically for the elbow. The high injury frequency and burden of care required by young baseball players as reported in this study is concerning and strategies to reduce injury should be investigated.
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Affiliation(s)
- Ellen Shanley
- ATI Physical Therapy; University of South Carolina Center for Effectiveness Research in Orthopedics
| | | | - Nathan Boes
- Steadman Hawkins Clinic of the Carolinas, Prisma Health-Upstate, Greenville, SC, USA
| | - Lane Bailey
- IRONMAN Sports Medicine Institute, Memorial Hermann Health, Houston, TX, USA
| | - Amanda Arnold
- IRONMAN Sports Medicine Institute, Memorial Hermann Health, Houston, TX, USA; Texas Womens University Institute of Health Sciences, School of Physical Therapy
| | - Garrett Bullock
- Department of Orthopaedic Surgery & Rehabilitation, Wake Forest University School of Medicine; Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, University of Oxford, Oxford, UK
| | - Michael Kissenberth
- University of South Carolina Center for Effectiveness Research in Orthopedics; Steadman Hawkins Clinic of the Carolinas, Prisma Health-Upstate, Greenville, SC, USA.
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Bullock G, Thigpen C, Collins G, Arden N, Noonan T, Kissenberth M, Shanley E. Development of an Injury Burden Prediction Model in Professional Baseball Pitchers. Int J Sports Phys Ther 2022; 17:1358-1371. [PMID: 36518836 PMCID: PMC9718727 DOI: 10.26603/001c.39741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 08/16/2022] [Indexed: 11/11/2023] Open
Abstract
Background Baseball injuries are a significant problem and have increased in incidence over the last decade. Reporting injury incidence only gives context to rate but not in relation to severity or injury time loss. Hypothesis/Purpose The purpose of this study was to 1) incorporate both modifiable and non-modifiable factors to develop an arm injury burden prediction model in Minor League Baseball (MiLB) pitchers; and 2) understand how the model performs separately on elbow and shoulder injury burden. Study Design Prospective longitudinal study. Methods The study was conducted from 2013 to 2019 on MiLB pitchers. Pitchers were evaluated in spring training arm for shoulder range of motion and injuries were followed throughout the season. A model to predict arm injury burden was produced using zero inflated negative binomial regression. Internal validation was performed using ten-fold cross validation. Subgroup analyses were performed for elbow and shoulder separately. Model performance was assessed with root mean square error (RMSE), model fit (R2), and calibration with 95% confidence intervals (95% CI). Results Two-hundred, ninety-seven pitchers (94 injuries) were included with an injury incidence of 1.15 arm injuries per 1000 athletic exposures. Median days lost to an arm injury was 58 (11, 106). The final model demonstrated good prediction ability (RMSE: 11.9 days, R2: 0.80) and a calibration slope of 0.98 (95% CI: 0.92, 1.04). A separate elbow model demonstrated weaker predictive performance (RMSE: 21.3; R2: 0.42; calibration: 1.25 [1.16, 1.34]), as did a separate shoulder model (RMSE: 17.9; R2: 0.57; calibration: 1.01 [0.92, 1.10]). Conclusions The injury burden prediction model demonstrated excellent performance. Caution should be advised with predictions between one to 14 days lost to arm injury. Separate elbow and shoulder prediction models demonstrated decreased performance. The inclusion of both modifiable and non-modifiable factors into a comprehensive injury burden model provides the most accurate prediction of days lost in professional pitchers. Level of Evidence 2.
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Affiliation(s)
- Garrett Bullock
- Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis University of Oxford
- Department of Orthopaedic Surgery & Rehabilitation Wake Forest University School of Medicine
| | - Charles Thigpen
- University of South Carolina Center for Rehabilitation and Reconstruction Sciences
- ATI Physical Therapy
| | - Gary Collins
- Centre for Statistics in Medicine University of Oxford
- Oxford University Hospitals NHS Foundation Trust
| | - Nigel Arden
- Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis University of Oxford
- Department of Orthopaedic Surgery & Rehabilitation Wake Forest University School of Medicine
| | - Thomas Noonan
- Department of Orthopaedic Surgery University of Colorado School of Medicine
- University of Colorado Health, Steadman Hawkins Clinic
| | | | - Ellen Shanley
- University of South Carolina Center for Rehabilitation and Reconstruction Sciences
- ATI Physical Therapy
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3
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Brooks JM, Chapman CG, Floyd SB, Chen BK, Thigpen CA, Kissenberth M. Assessing the ability of an instrumental variable causal forest algorithm to personalize treatment evidence using observational data: the case of early surgery for shoulder fracture. BMC Med Res Methodol 2022; 22:190. [PMID: 35818028 PMCID: PMC9275148 DOI: 10.1186/s12874-022-01663-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 06/20/2022] [Indexed: 11/24/2022] Open
Abstract
Background Comparative effectiveness research (CER) using observational databases has been suggested to obtain personalized evidence of treatment effectiveness. Inferential difficulties remain using traditional CER approaches especially related to designating patients to reference classes a priori. A novel Instrumental Variable Causal Forest Algorithm (IV-CFA) has the potential to provide personalized evidence using observational data without designating reference classes a priori, but the consistency of the evidence when varying key algorithm parameters remains unclear. We investigated the consistency of IV-CFA estimates through application to a database of Medicare beneficiaries with proximal humerus fractures (PHFs) that previously revealed heterogeneity in the effects of early surgery using instrumental variable estimators. Methods IV-CFA was used to estimate patient-specific early surgery effects on both beneficial and detrimental outcomes using different combinations of algorithm parameters and estimate variation was assessed for a population of 72,751 fee-for-service Medicare beneficiaries with PHFs in 2011. Classification and regression trees (CART) were applied to these estimates to create ex-post reference classes and the consistency of these classes were assessed. Two-stage least squares (2SLS) estimators were applied to representative ex-post reference classes to scrutinize the estimates relative to known 2SLS properties. Results IV-CFA uncovered substantial early surgery effect heterogeneity across PHF patients, but estimates for individual patients varied with algorithm parameters. CART applied to these estimates revealed ex-post reference classes consistent across algorithm parameters. 2SLS estimates showed that ex-post reference classes containing older, frailer patients with more comorbidities, and lower utilizers of healthcare were less likely to benefit and more likely to have detriments from higher rates of early surgery. Conclusions IV-CFA provides an illuminating method to uncover ex-post reference classes of patients based on treatment effects using observational data with a strong instrumental variable. Interpretation of treatment effect estimates within each ex-post reference class using traditional CER methods remains conditional on the extent of measured information in the data. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-022-01663-0.
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Affiliation(s)
- John M Brooks
- Center for Effectiveness Research in Orthopaedics - Arnold School of Public Health Greenville, 915 Greene Street #302D, 29208, Columbia, SC, 29208-0001, USA. .,Health Services Policy & Management, University of South Carolina Arnold School of Public Health, Columbia, USA.
| | - Cole G Chapman
- Department of Pharmacy Practice and Science, University of Iowa, Iowa City, USA.,Center for Effectiveness Research in Orthopaedics, Greenville, USA
| | - Sarah B Floyd
- Center for Effectiveness Research in Orthopaedics, Greenville, USA.,Clemson University College of Behavioral Social and Health Sciences, Public Health Sciences, Clemson, USA
| | - Brian K Chen
- Health Services Policy & Management, University of South Carolina Arnold School of Public Health, Columbia, USA.,Center for Effectiveness Research in Orthopaedics, Greenville, USA
| | - Charles A Thigpen
- Center for Effectiveness Research in Orthopaedics, Greenville, USA.,ATI Physical Therapy, Greenville, USA
| | - Michael Kissenberth
- Center for Effectiveness Research in Orthopaedics, Greenville, USA.,Prisma Health, Steadman Hawkins Clinic of the Carolinas, Greenville, USA
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Shanley E, Thigpen C, Kissenberth M, Gilliland RG, Thorpe J, Nance D, Register-Mihalik JK, Tokish J. Heads Up Football Training Decreases Concussion Rates in High School Football Players. Clin J Sport Med 2021; 31:120-126. [PMID: 30908329 DOI: 10.1097/jsm.0000000000000711] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 08/24/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The objective of this study was to determine whether football players receiving heads up (HU) training would display a lower rate of sport-related concussion (SRC) compared to those without HU training. DESIGN Prospective cohort. SETTING Scholastic football fields. PATIENTS Two thousand five hundred fourteen scholastic football players during the 2015 to 2016 football season were monitored throughout the football season. INTERVENTIONS Before the preseason, 1 coach from 14 schools received HU training from US football. These schools were matched with 10 control schools performing standard football training [non-heads up (NHU)]. Random monitoring for proper coaching instruction was performed during the season. School athletic trainers monitored injuries and return to sport over the season for all schools. MAIN OUTCOME MEASURES The outcome measures of concussions and associated time loss were determined before data collection began. Injury incidence and rate ratios were calculated to determine program effectiveness. RESULTS During the season, football players sustained 117 concussions (HU = 75; NHU = 42). The HU players displayed a significantly lower concussion rate (4.1 vs 6.0/100 players) compared with NHU teams [rate ratio = 1.5; 95% confidence interval (CI), 1.1-5.4]. The HU group returned to full participation 27% faster than athletes in the NHU group [time loss: 18.2 days (95% CI, 15.8-20.6) vs 24.8 days (95% CI, 19.9-29.7)], respectively. CONCLUSIONS This is the first study to evaluate the impact of the HU program on the incidence of SRC in high school football players. Our data demonstrated that the HU program reduced SRC rates by 33% supporting the use of US HU football training as an effective method to decrease the rate of SRCs in scholastic football. CLINICAL RELEVANCE This study is the first to prospectively explore the effect of HU training on the incidence and recovery from SRC in high school football players.
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Affiliation(s)
- Ellen Shanley
- ATI Physical Therapy, Greenville, South Carolina
- Center for Effectiveness Research in Orthopedics, SmartState Centers, University of South Carolina, Greenville, South Carolina
| | - Charles Thigpen
- ATI Physical Therapy, Greenville, South Carolina
- Center for Effectiveness Research in Orthopedics, SmartState Centers, University of South Carolina, Greenville, South Carolina
| | - Michael Kissenberth
- Center for Effectiveness Research in Orthopedics, SmartState Centers, University of South Carolina, Greenville, South Carolina
- Steadman-Hawkins Clinic of the Carolinas, Greenville Hospital System, Greenville, South Carolina
| | - Robert Gil Gilliland
- Steadman-Hawkins Clinic of the Carolinas, Greenville Hospital System, Greenville, South Carolina
| | - John Thorpe
- Steadman-Hawkins Clinic of the Carolinas, Greenville Hospital System, Greenville, South Carolina
| | - Darryl Nance
- Greenville County School System, Greenville, South Carolina; and
| | | | - John Tokish
- Center for Effectiveness Research in Orthopedics, SmartState Centers, University of South Carolina, Greenville, South Carolina
- Steadman-Hawkins Clinic of the Carolinas, Greenville Hospital System, Greenville, South Carolina
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Lutz A, Thigpen C, Gilliland RG, Thorpe J, Kissenberth M, Shanley E. Lower Extremity Musculoskeletal Injury Is Associated with Increased
Risk of Concussion in High School Athletes. Orthop J Sports Med 2020. [PMCID: PMC7407848 DOI: 10.1177/2325967120s00397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objectives: Previous research indicates that concussion increases the risk of lower
extremity injuries (LE) after return to sport. However, no study has
examined the risk of precedent lower extremity injuries and their
relationship to the development of a sport related concussion (SRC). To
determine if the risk of combined injuries (LE injury-SRC) is elevated in
high school athletes accounting for athlete sport and gender. Methods: 33,386 high school athletes were monitored over 4 seasons. 4223 LE injuries
and 1132 concussions were reported. Injured athletes were identified by
their school athletic trainer (AT) time-loss injury during a team-sponsored
practice or game. ATs documented the date, mechanism, and sport of injury.
Injured athletes were referred to a board-certified sports medicine
physician for diagnoses and follow up care. Cumulative injury rates were
calculated with 95% confidence intervals. Rate ratios were used to compare
frequency of SRC after RTS following a LE injury. Comparisons were made
overall cohort between those participating athletes with and without
isolated and combined injuries as well as by gender. (α=0.05). Results: A cumulative incidence for athletes sustaining an isolated SRC was 2.3/100
athletes (95% CI= 2.1-2.5) and for isolated LE injury was 11.5/100 (95%
CI=11.2-11.9) athletes. Athletes presenting with a LE injury had an
increased risk (RR= 4.7; 95% CI = 4.2-5.2) of sustaining a subsequent SRC
within 1 year when compared to athletes that did not suffer precedent LE
injuries. Male athletes presenting with a LE injury had an increased risk
(RR= 4.9; 95% CI = 4.2-5.7) of sustaining a subsequent SRC within 1 year
when compared to male athletes that did not suffer precedent LE injuries.
Female athletes presenting with a LE injury had an increased risk (RR= 4.4;
95% CI = 3.6-5.2) of sustaining a subsequent SRC within 1 year when compared
to female athletes that did not suffer precedent LE injuries. In football,
presenting with a LE injury had an increased risk (RR= 5.8; 95% CI =
4.5-7.4) of sustaining a subsequent SRC within 1 year when compared to
football athletes that did not suffer precedent LE injuries. Conclusion: Our results are the first to show that high school athletes who suffer a
time-loss LE injury are at 4.4-5.8 times increased risk to suffer a sports
related concussion within the next year. Additional studies are warranted to
confirm these findings.
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Affiliation(s)
- Adam Lutz
- ATI PT, Steadman Hawkins Clinic of the Carolinas
| | | | | | - John Thorpe
- ATI PT, Steadman Hawkins Clinic of the Carolinas
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Longstaffe R, Adams K, Thigpen C, Pill S, Rush L, Alexander R, Hall TM, Siffri P, Kwapisz A, Hawkins R, Tokish JM, Kissenberth M, Tolan S. Is residual tendon a predictor of outcome following arthroscopic rotator cuff repair? A preliminary outlook at short-term follow-up. J Shoulder Elbow Surg 2020; 29:S53-S58. [PMID: 32284306 DOI: 10.1016/j.jse.2020.01.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 01/14/2020] [Accepted: 01/21/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Multiple factors including muscle atrophy, fatty infiltration, smoking, advanced patient age, and increasing tear size have been identified as risk factors for retear after rotator cuff repair. However, little is known about what effect the length of the residual rotator cuff tendon has on the success of repair and patient outcomes. METHODS This study included 64 patients. Patients were stratified based on a residual tendon length of greater than 15 mm (group 1, residual tendon) or 15 mm or less (group 2, no residual tendon). Rotator cuff tendon integrity was then evaluated using ultrasound imaging at 6 months. Outcome measures included the Single Assessment Numeric Evaluation score, visual analog scale score, EQ5D Index score, Global Rating of Change score, and Penn Shoulder Score. RESULTS No differences were found between groups regarding demographic data or repair configuration. Assessment of tendon healing demonstrated an increased rate of tendons that had "not healed" in group 2 (19.3% [n = 5] vs. 13.2% [n = 5]), but this difference was not statistically significant (P = .55). Functional outcome scores improved significantly from preoperatively to final follow-up in both groups and displayed no differences at 6-month follow-up. CONCLUSION A smaller residual tendon length was not a negative predictor of clinical outcomes following arthroscopic rotator cuff repair in patients with short-term follow-up. Although there was a trend toward a decreased rate of healing in patients with smaller residual tendons, this was not significant.
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Affiliation(s)
- Robert Longstaffe
- Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, SC, USA; Pan Am Clinic, Winnipeg, MB, Canada.
| | - Kyle Adams
- Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, SC, USA
| | - Charles Thigpen
- Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, SC, USA; ATI Physical Therapy, Greenville, SC, USA
| | - Stephan Pill
- Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, SC, USA
| | - Lane Rush
- Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, SC, USA; Lane Rush Medical Group, Meridian, MS, USA
| | - Ryan Alexander
- Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, SC, USA
| | - Taylor M Hall
- Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, SC, USA
| | - Paul Siffri
- Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, SC, USA
| | - Adam Kwapisz
- Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, SC, USA; Clinic of Orthopaedics and Pediatric Orthopaedics, Medical University of Lodz, Lodz, Poland
| | - Richard Hawkins
- Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, SC, USA
| | | | - Michael Kissenberth
- Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, SC, USA
| | - Stefan Tolan
- Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, SC, USA
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Floyd SB, Thigpen C, Kissenberth M, Brooks JM. Association of Surgical Treatment With Adverse Events and Mortality Among Medicare Beneficiaries With Proximal Humerus Fracture. JAMA Netw Open 2020; 3:e1918663. [PMID: 31922556 PMCID: PMC6991245 DOI: 10.1001/jamanetworkopen.2019.18663] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
IMPORTANCE Meta-analyses of randomized clinical trials suggest that the advantages and risks of surgery compared with conservative management as the initial treatment for proximal humerus fracture (PHF) vary, or are heterogeneous across patients. Substantial geographic variation in surgery rates for PHF suggests that the optimal rate of surgery across the population of patients with PHF is unknown. OBJECTIVE To use geographic variation in treatment rates to assess the outcomes associated with higher rates of surgery for patients with PHF. DESIGN, SETTING, AND PARTICIPANTS This comparative effectiveness research study analyzed all fee-for-service Medicare beneficiaries with proximal humerus fracture in 2011 who were continuously enrolled in Medicare Parts A and B for the 365-day period before and immediately after their index fracture. Data analysis was performed January through June 2019. EXPOSURE Undergoing 1 of the commonly used surgical procedures in the 60 days after an index fracture diagnosis. MAIN OUTCOMES AND MEASURES Risk-adjusted area surgery ratios were created for each hospital referral region as a measure of local area practice styles. Instrumental variable approaches were used to assess the association between higher surgery rates and adverse events, mortality risk, and cost at 1 year from Medicare's perspective for patients with PHF in 2011. Instrumental variable models were stratified by age, comorbidities, and frailty. Instrumental variable estimates were compared with estimates from risk-adjusted regression models. RESULTS The final cohort included 72 823 patients (mean [SD] age, 80.0 [7.9] years; 13 958 [19.2%] men). The proportion of patients treated surgically ranged from 1.8% to 33.3% across hospital referral regions in the United States. Compared with conservatively managed patients, surgical patients were younger (mean [SD] age, 80.4 [8.1] years vs 78.0 [7.2] years; P < .001) and healthier (Charlson Comorbidity Index score of 0, 14 863 [24.4%] patients vs 3468 [29.1%] patients; Function-Related Indicator score of 0, 20 720 [34.0%] patients vs 4980 [41.8%] patients; P < .001 for both), and a larger proportion were women (49 030 [80.5%] patients vs 9835 [82.5%] patients; P < .001). Instrumental variable analysis showed that higher rates of surgery were associated with increased total costs ($8913) during the treatment period, increased adverse event rates (a 1-percentage point increase in the surgery rate was associated with a 0.19-percentage point increase in the 1-year adverse event rate; β = 0.19; 95% CI, 0.09-0.27; P < .001), and increased mortality risk (a 1-percentage point increase in the surgery rate was associated with a 0.09-percentage point increase in the 1-year mortality rate; β = 0.09; 95% CI, 0.04-0.15; P < .01). Instrumental variable mortality results were even more striking for older patients and those with higher comorbidity burdens and greater frailty. Risk-adjusted estimates suggested that surgical patients had higher costs (increase of $17 278) and more adverse events (a 1-percentage point increase in the surgery rate was associated with a 0.12-percentage point increase in the 1-year adverse event rate; β = 0.12; 95% CI, 0.11 to 0.13; P < .001) but lower risk of mortality after PHF (a 1-percentage point increase in the surgery rate was associated with a 0.01-percentage point decrease in the 1-year mortality rate; β = -0.01; 95% CI, -0.015 to -0.005; P < .001). CONCLUSIONS AND RELEVANCE This study found that higher rates of surgery for treatment of patients with PHF were associated with increased costs, adverse event rates, and risk of mortality. Orthopedic surgeons should be aware of the harms of extending the use of surgery to more clinically vulnerable patient subgroups.
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Affiliation(s)
- Sarah B. Floyd
- Center for Effectiveness Research in Orthopaedics, University of South Carolina, Greenville
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia
| | - Charles Thigpen
- Center for Effectiveness Research in Orthopaedics, University of South Carolina, Greenville
- ATI Physical Therapy, Greenville, South Carolina
| | - Michael Kissenberth
- Steadman Hawkins Clinic of the Carolinas, Prisma Health System, Greenville, South Carolina
| | - John M. Brooks
- Center for Effectiveness Research in Orthopaedics, University of South Carolina, Greenville
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia
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Tokish JM, Alexander T, Kissenberth M, Hawkins R. Response to Burkhart regarding: "Pseudoparalysis: a systematic review of term definitions, treatment approaches, and outcomes of management techniques". J Shoulder Elbow Surg 2018; 27:e56-e57. [PMID: 29332668 DOI: 10.1016/j.jse.2017.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 10/17/2017] [Indexed: 02/01/2023]
Affiliation(s)
| | | | - Michael Kissenberth
- Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, SC, USA
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Shanley E, Arnold A, Hawkins R, Tokish J, Kissenberth M, Wyland D, Thigpen C. SUBSEQUENT ARM INJURY RISK FOLLOWING REHABILITATION AND RETURN TO SPORT. Br J Sports Med 2017. [DOI: 10.1136/bjsports-2016-097372.263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Noonan TJ, Thigpen CA, Bailey LB, Wyland DJ, Kissenberth M, Hawkins RJ, Shanley E. Humeral Torsion as a Risk Factor for Shoulder and Elbow Injury in Professional Baseball Pitchers. Am J Sports Med 2016; 44:2214-9. [PMID: 27281279 DOI: 10.1177/0363546516648438] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Numerous studies have demonstrated that humeral retrotorsion is increased in the dominant arms of throwing athletes. No study has clearly defined the relationship between humeral retrotorsion and shoulder and elbow injury. HYPOTHESIS Uninjured professional pitchers will display more dominant humeral torsion (HT) than professional pitchers who sustain shoulder injuries but less than pitchers who sustain elbow injuries. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS Pitchers from the Colorado Rockies professional baseball organization were recruited for participation for this prospective injury study from 2009 to 2013. HT was assessed using indirect ultrasonographic techniques and was measured prospectively in 255 pitchers before each spring training (average of 2 trials). From the beginning of the preseason to the end of the postseason, overuse upper extremity injuries (shoulder or elbow) were tracked for each participating athlete. All athletes who reported pain or injury to their coach were referred to the organization's athletic trainer for evaluation and classification of each injury. The difference in HT was calculated by subtracting measurement of the dominant arm from the nondominant arm, and 3 separate mixed-model analyses of variance (side × injury group) were used to compare the dominant and nondominant HT between all pitchers who developed an arm injury (shoulder and elbow combined), as well as comparing pitchers who developed a shoulder or elbow injury to those who did not miss games due to shoulder or elbow injury (α = .05). RESULTS During the course of the study, 60 arm (30 shoulder; 30 elbow) injuries were observed; 195 pitchers did not suffer an injury. There were no differences when HT was compared between all injured (shoulder and elbow injuries combined) and uninjured pitchers (P = .13; effect size 0.14). There was a significant interaction effect showing that pitchers who suffered a shoulder injury displayed 4° less dominant humeral retrotorsion compared with pitchers without injury (P = .04) and that pitchers with elbow injury displayed 5° greater humeral retrotorsion (P = .04). In addition, those who suffered an ulnar collateral ligament injury requiring reconstruction (n = 17) also displayed 4(o) greater dominant retrotorsion and 5° less nondominant humeral retrotorsion compared with pitchers who did not suffer an injury (n = 195; P = .05). There was not a significant difference between nondominant HT among pitchers who sustained shoulder and elbow injuries and pitchers without injury. CONCLUSION The results of this study show a contrast in dominant humeral retrotorsion between pitchers who suffered shoulder and elbow injuries compared with those without an injury. Pitchers who sustained shoulder injuries had less dominant humeral retrotorsion compared with noninjured pitchers. In contrast, pitchers who sustained time-loss elbow injuries displayed increased humeral retrotorsion compared with noninjured pitchers. Together, these results suggest that increased adaptive humeral retrotorsion is protective against shoulder injuries but a harmful contributor for elbow injuries in professional pitchers. This is the first study to show differing injury risk profiles for shoulder and elbow injury.
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Affiliation(s)
- Thomas J Noonan
- Steadman Hawkins Clinic-Denver, Greenwood Village, Colorado, USA
| | - Charles A Thigpen
- ATI Physical Therapy, Greenville, South Carolina, USA South Carolina Center for Effectiveness Research in Orthopedics, Greenville, South Carolina, USA
| | - Lane B Bailey
- Memorial Hermann Ironman Sports Medicine Institute, Houston, Texas, USA
| | - Douglas J Wyland
- Steadman Hawkins Clinic of the Carolinas, Greenville, South Carolina, USA
| | | | - Richard J Hawkins
- Steadman Hawkins Clinic of the Carolinas, Greenville, South Carolina, USA
| | - Ellen Shanley
- ATI Physical Therapy, Greenville, South Carolina, USA South Carolina Center for Effectiveness Research in Orthopedics, Greenville, South Carolina, USA
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Thigpen CA, Noonan TJ, Shanley E, Bailey LB, Wyland DJ, Kissenberth M, Hawkins RJ. Humeral Retrotorsion in Pitchers With GIRD: Response. Am J Sports Med 2015; 43:NP19-20. [PMID: 26129963 DOI: 10.1177/0363546515591557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Allen CS, Deyle GD, Wilken JM, Gill NW, Baker SM, Rot JA, Cook CE, Beaty S, Kissenberth M, Siffri P, Hawkins R, Cook CE, Hegedus EJ, Ross MD, Cook CE, Beaty S, Kissenberth M, Siffri P, Pill S, Hawkins R, Erhardt JW, Harris KD, Deyle GD, Gill NW, Howes RR, Koch WK, Kramer CD, Kumar SP, Adhikari P, Jeganathan PS, D’Souza SC, Misri ZK, Manning DM, Dedrick GS, Sizer PS, Brismée JM, Matthijs OC, Dedrick GS, Brismée JM, McGalliard MK, James CR, Sizer PS, Ross MD, Childs JD, Middel C, Kujawa J, Brown D, Corrigan M, Parsons N, Schmidt SG, Grant R, Spryopolous P, Dansie D, Taylor J, Wang H, Silvernail JL, Gill NW, Teyhen DS, Allison SC, Sueki DG, Almaria SM, Bender MA, Kamara M, Magpali A, Mancilla A, McConnell BJ, Montoya RC, Murphy AW, Romero ML, Viti JA, Rot JA, Augustsson H, Werstine RJ, Birmingham T, Jenkyn T, Yung EY, Tonley JC. AAOMPT platform presentations selection. J Man Manip Ther 2011; 19:239-46. [DOI: 10.1179/106698111x12998437860712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Hegedus EJ, Zavala J, Kissenberth M, Cook C, Cassas K, Hawkins R, Tobola A. Positive outcomes with intra-articular glenohumeral injections are independent of accuracy. J Shoulder Elbow Surg 2010; 19:795-801. [PMID: 20655766 DOI: 10.1016/j.jse.2010.03.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2010] [Revised: 03/22/2010] [Accepted: 03/28/2010] [Indexed: 02/01/2023]
Abstract
BACKGROUND Shoulder pain is a common, costly, and recalcitrant affliction. One treatment for shoulder pain is intra-articular injection of corticosteroid. Clinical opinion is that injection guided by palpation is accurate and effective, and there is some evidence to support a positive effect of injection on pain. However, great controversy exists as to the accuracy of injection by palpation, whether or not accuracy is important, and what the effect is of accuracy on pain. METHODS We used a blinded, longitudinal observational design of effectiveness in an effort to determine the accuracy of intra-articular injections and the effect of that accuracy on pain and functional outcomes in patients with various shoulder pathologies. RESULTS Injection accuracy data were captured on 103 patients. Of the 103 blinded injections, 54 received injections that were identified by fluoroscopy as "in" the capsule, whereas 49 were identified as "outside" the capsule; an accuracy rate of 52.4%. In the 4-week follow up, regardless of group assignment or accuracy of the injection, patients improved significantly (P < .01) from pre- to post-injection. Improvement was typically over by 2.5 points in the Numeric Pain Rating Scale (NPRS) categories, over 8 points on the Short-Form McGill Pain Questionnaire (SFMPQ), and over by 13 points on the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH). DISCUSSION Our accuracy rate was within the range reported in the literature. Improvements in all subjects with regard to pain and self-reported function occurred even in light of a wide variance in subject duration of symptoms, multiple injectors with varied training, a blinded approach to injection, and multiple injection approaches. CONCLUSIONS The accuracy of the injection does not appear to depend on the experience of the physician and may be irrelevant in treating shoulder pain of multiple origins.
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Affiliation(s)
- Eric J Hegedus
- Physical Therapy Division, Department of Community and Family Medicine, Duke University School of Medicine, Durham, NC 27708, USA.
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