Spike in Tommy Johns Due to “Pitch Younger, Pitch Faster, Pitch More Often”
The culprit in the recent upsurge in Tommy John surgeries just may be things that happened years ago, says new research. Neal S. ElAttrache, M.D. is a sports medicine specialist with the Kerlan-Jobe Orthopaedic Clinic in Los Angeles, California. Dr. ElAttrache, the team physician for the LA Dodgers, tells OTW, “The number of UCL (ulnar collateral ligament) injuries—and thus Tommy John surgeries—at the professional level has been alarming. We are seeing more primary UCL tears and now also seeing re-tears in players that have undergone previous Tommy John surgery. Some players are having surgery in their teens and early twenties and then experiencing a re-tear several years later, while some re-tear within 18 months of their return to play. As it stands now, just under 1 in 3 pitchers in the professional leagues will have had a Tommy John operation, BUT almost 25% of those who have a Tommy John will not make it all the way back to their previous level of performance.”
“From the data trends we are seeing, it appears that this increase is linked to several things, including the number of innings pitched prior to entering professional baseball, year-round participation and early specialization as a pitcher, and high velocity pitching. When a teen is throwing a ball over 90 mph and doing it year-round, he has a much higher chance of ending up in our office. It may be a sudden tear that brings him in, but it’s usually due to a series of incompletely healed micro-tears that may or may not be symptomatic, but gradually compromise the elbow until it fails.”
“Kerlan-Jobe and ASMI [American Sports Medicine Institute] have conducted independent studies on this topic and are now working together with professional players on this issue. One of the benefits of doing this at the professional level is that it shines a spotlight on the problem. We can say to kids, ‘By early specialization and over-use with year-round participation, you are increasing your chances of injury and hurting your chances of progressing in the big leagues. We have studied this and these practices down-grade you.’ Some parents and coaches think it’s a good idea to play year-round and specialize as a pitcher at age 11, but in fact if they do that before 15/16, they are most likely eliminating the chance that their child will become an elite-level player.”
True Story: How Board Certification Exam Questions Are Created
When the stakes are high, such as they are with board certification, there is no gambling involved…everything is planned out to the last question. Shep Hurwitz, M.D., the executive director of the American Board of Orthopaedic Surgery, told OTW, “The process involved in pulling together the 300+ questions for the board certification and recertification exams each year is enormous. The 40 question writers, some of whom rotate out each year, are given assignments by the chair of the computer-based exam committee. Afterwards, all of the questions are gathered by the National Board of Medical Examiners (NBME), who do their best to put the content into a similar format and language. Answers are always listed from least to most, so that if it is a surgical procedure question then the choices will go from least invasive to joint replacement…that is done to make all of the questions look the same.”
“The questions are then returned to the original writer for editing, who is asked to provide a sentence or two about why the correct answer is the correct answer. They must also support their ‘argument’ with relevant articles from the literature. Once a year all of the writers come together to review each other’s questions. For example, someone writing questions for hand may be partnered with a person writing questions for trauma—it’s a great reality check. If a question seems too esoteric to someone who is not in that specialty then it’s likely that the question will be put in a different pool (i.e., perhaps used for a subspecialty exam). Sometimes, however, questions are so poor that they cannot be salvaged and must be eliminated.”
“The NBME works from a blueprint/formula: 30% of questions must be on adult reconstruction issues, 35% on basic science, 17% on pediatrics, 15% trauma, and a small percentage should be on rehabilitation. Then the ABOS works with the NBME to decide exactly which questions make the cut. Some years it is more than 320 questions and some years it’s less. But we always allow for the fact that a few questions will be thrown out at the end of process.”
“Roughly 15-25% out of the questions are reused; each year we compare performance on previous exams to performance on the current exam (‘equating’). By doing this we can see if the test scores are drifting in a certain direction. We can assess whether the test takers are getting smarter or less smart…or whether the exam is getting harder or easier. If 100% of respondents get a question right then it is too easy and vice versa. Also, the highest 20% performers on the entire exam should get the highest number of correct answers on each question; the lowest 20% should have the lowest number correct. If there is no difference between the top and bottom they we will suspect that the question isn’t telling us what we want to know (i.e., it is not discriminating between good and poor students).”
“Each year about a few months before the exam, the Board meets to review the entire test one last time. This final reality check occasionally catches something of importance. Last year, the board found that a question regarding a child with a painful joint included an X-ray that was clearly an elderly person with arthritis.”
“Finally, we do take security very seriously. While we have never had a breach, the radiology examiners did. Those who cheated were leaving the exam having memorized a few questions…then they immediately went to a website where they entered the information. We are ramping up security to prevent this and other types of issues. After all the intensely difficult work that surgeons must go through, this process must be fair for all.”
Orthopedics Is the MOST Active Volunteer Specialty
With Health Volunteers Overseas (HVO) the focus is on teaching orthopedic surgeons to fish…well, not exactly, but you get the idea. Nancy Kelly, executive director of HVO, tells OTW, “Orthopedics remains the most active area of all of our programs. We are operating16 projects around the world, and sending more than 500 people abroad annually; approximately 110 of those are for our orthopedic program. Our overarching goal is to build local capacity through education and training. We do not set out to do direct service, although naturally that occurs during the course of teaching.”
“In Ghana our project is located at the Accident and Emergency center and is directed by Peter Trafton, M.D. We have roughly 13 trauma and orthopedic residents in the program, with the majority rotating on other services. Additionally there are six general surgical residents and seven house officers (two-year rotating interns) at one time. Medical students rotate through in one month blocks (14 fourth year and 14 sixth year students at a time). The orthopedic residency training program at Komfo Anokye Teaching Hospital (KATH) currently has accreditation from the Ghana College of Surgeons and is now seeking accreditation from the West African College of Surgeons. An evaluation is scheduled for November; the goal is to have a single unified approval for the residents from both colleges. Volunteers remain engaged in the work post-trip, sending articles to their colleagues in Ghana, suggesting approaches, etc. All of this means that these programs are very attractive to those in Ghana who want to pursue training.”
“One of our new projects is in Myanmar, an interesting country that has been popular with our volunteers. We have approximately 12 full-time junior and senior orthopedic surgeons who provide most of the surgical care at two hospitals; the residency program lasts two-three years. After completing the residency, these physicians are considered to be orthopedic surgeons and are sent to work in the rural, more isolated areas in the countryside.”
“My vision is that our work should change over time. Yes, we need to be present for a long time because change takes time, especially with so many constraints. Going forward we will perhaps elevate the kinds of training, for example by providing education that involves more technology. We could undertake distance education in combinations with volunteerism, something that could result in more of an emphasis on the subspecialties. Three years from now I would like the training to be more sophisticated and I would like to see more of the local faculty taking over responsibilities.”
