IC09-L: The Weekend Warrior to the Professional Athlete Moderator(s): Charles A. Goldfarb, MD Faculty: Marc J. Richard, MD, Steven S. Shin, MD, and Sudhir Warrier, MD Session Handouts Friday, October 02, 2020 75TH VIRTUAL ANNUAL MEETING OF THE ASSH OCTOBER 1-3, 2020 822 West Washington Blvd Chicago, IL 60607 Phone: (312) 880-1900 Web: www.assh.org Email: [email protected] All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement or presentation made is to be regarded as dedicated to the public domain. Acute Thumb UCL Tears The Weekend Warrior to the Professional Athlete: • Common sports injury, “skier’s thumb” Management of Thumb UCL Injuries • UCL: 90%; RCL: 10% • Usually distal • When to operate Steven S. Shin MD, MMSc – Complete tear WITH INSTABILITY Director, Orthopaedic Center (compared to opposite thumb) Associate Professor and Executive Vice Chair Department of Orthopaedics – Avulsion fracture that is DISPLACED Cedars-Sinai Health System Los Angeles, California • Earlier Return to Play/Activity? 1 2 Thumb UCL Injury in the WW Thumb UCL Injury in the Pro Athlete • Nondisplaced tears • Nondisplaced tears: play with splint? – Nonoperative – YES: no surgery • Pros: no surgery • Cons: splint for 4-6 weeks, less – NO: predictable outcome • Cast/brace: out for 6 weeks, – Operative less predictable • Pros: earlier motion and RTP (WHEN depends on type of repair), • Surgery: RTP 5-6 weeks more predictable outcome • Displaced tears/Stener • Cons: surgery • Displaced tears/Stener lesions – Early-mid season: fix – Always operative – Late season: wait, then fix 3 4 Thumb UCL Tear: Surgical Options Thumb UCL Repair with IB Augmentation Repair (suture anchor) Repair + Internal Brace ✓ 2.5 mm Anchor in Proximal Phalanx ✓ Suture Tape • Post-op immob x 4 weeks, • Immediate ROM ✓ 3-0 Suture then start ROM • RTP when comfortable, ✓ 3.5 mm Anchor in Metacarpal • RTP 8-12 weeks +/- splint usually 5-6 weeks 2.5mm Anchor Proximal Phalanx Suture Tape LIGAMENT 3.5mm Anchor Metacarpal 5 6 1 CONCLUSION Thumb UCL repair with IB demonstrates greater than 4x load to failure than repair alone at time zero. CONCLUSION Thumb UCL repair with IB demonstrates higher angular stiffness and restores varus/valgus kinematics. 7 8 CASE: UCL Tear, QB Throwing Hand 9 10 Fixed with IB Check Motion 11 12 2 Closure and Intra-Op Video Post-Op • 2 days: – Start ROM – Splint • 10 days: – Throwing smaller ball • 4 weeks: – Throw regulation ball • 5.5 weeks: – First game POD #2 13 14 Conclusion • Talk with your WW/Pro athlete – Explain pros/cons and let them decide • Adding IB to thumb UCL repair offers peace of mind for earlier RTP THANK YOU 15 3 9/2/2020 Sudhir Warrier, MD Speaker has no relevant financial relationships with commercial interest to disclose. 1 All cases discussed in this presentation are in the public domain (general press/websites) The sports personalities have consented to the use of their case‐studies as educational material There is no compromise of privileged information 2 Weekend Warrior Professional Athlete Commonest sport in India CRICKET 3 1 9/2/2020 Dodgers Eden Garden 56000 68000 4 Indian Premier League – 13th edition Prize Money ~ Ten Million $ Highest paid player (2020) ~ 2million $ for 8 weeks Mumbai Indians win IPL 2015 5 Effect of IPL on the Indian Sports scenario Spawned many smaller leagues at the State, District, Suburb and Village level Filip to other sports like Soccer, Tennis, Badminton, Boxing Indigenous sports also spurred on… Kabaddi ($ 400000 prize money) Raised levels of competition – across sports Stressing on Fitness and Performance Focus on injury prevention Seeking world class healthcare for the injured athlete 6 2 9/2/2020 Cricket Cork core ball 5 ½ ounces Baseball Leather cover Speeds exceeding 140 kmph 7 Finger injuries are common in cricket 8 Hand Injuries in an urban private practice sports Industrial Farming Vehicular Industrial Accidents Vehicular accidents Sports Injuries Other Injuries 1990‐ Laud Clinic 9 3 9/2/2020 Hand Injuries in an urban private practice Industrial Farming The weekend Warrior To The Professional sports Vehicular Athlete Industrial Accidents Vehicular accidents Sports Injuries Other Injuries 2019‐ Laud Clinic 10 Our Challenges Fine tuning the Timing of the care (career span/competitions) Highest standards of care (clever innovation) Best Rehab (including counselling!) Strength and Conditioning Re‐integration into the game at the athletes level 11 Elite athlete, 6 weeks from a world cup.. Injured while fielding in a practice a the nets.. 12 4 9/2/2020 13 Volar approach Volar plate lifted off the ulnar side Capsule opened Reduction effected Temporary K wires Plate and screws 14 Why use K wires?? 15 5 9/2/2020 Limitations of your instruments / implants 14mm 18mm 16 17 18 6 9/2/2020 Timing the surgery Discussing the outcome / time frame with the Board and Coach Participate in decision making regarding selection 19 Our Challenges Fine tuning the Timing of the care (career span/competitions) Highest standards of care (clever innovation) Best Rehab (including counselling!) 20 8 month old injury Out of the game! Weak grip Loss of control of the bottom hand 21 7 9/2/2020 22 23 We discussed options • Dorsal approach • Volar approach • Both volar and dorsal approach • Fusion 24 8 9/2/2020 Would the recommended angle be good? 25 Planned the fusion • What is the best position to fuse this joint in an active cricketer (batsman!) • Needs to wrap around the handle and provide support • Should not obstruct the ball when pouching catches! 26 Each player has a different Grip… • The handle of the BAT varies in thickness • The rubber/silicone grip varies 27 9 9/2/2020 35 ° Arthrodesis planned at 35° 28 Arthrofibrosis cleared 29 Excised some small Isolated the Volar Plate Mitek Anchor fragments 30 10 9/2/2020 31 Returned to the sport 32 Consider the role of the player in the team Consider the prime function of the injured part Devise clever solutions 33 11 9/2/2020 Our Challenges Fine tuning the Timing of the care (career span/competitions) Highest standards of care (clever innovation) Best Rehab (including counselling!) Strength and Conditioning Re‐integration into the game at the athletes level 34 8 months post injury 35 MSK-USG reported that the extensor showed tendinosis 36 12 9/2/2020 37 38 8 weeks 39 13 9/2/2020 Innovative approach Crucial role of the Rehab team Outcomes may not be enduring (but should suffice for the athletes active career!) 40 Why do they approach us late? WEEKEND WARRIOR • They need to report back for work the next day • May not be to a demanding job! • Poor initial assessment (including poor x-rays) • Visits a general practitioner first • • Visits an indigenous bone setter! Splinted tightly with bamboo strips and herbal balms 41 Why do they approach us late? PROFESSIONAL ATHLETE • Important member, needed for the crucial next game • Has had seemingly similar episodes in the past and always sailed through (underestimation of the severity) • Team physio / physician misjudges the injury • Poor imaging • Structure of acute healthcare for athletes Team physio meting out • Sponsor / eminence based referrals in smaller cities some on‐field quick‐fix 42 14 9/2/2020 First ray injuries in Indian Boxers A peculiar reason! 43 2010 OLYMPIC GOLD QUEST Not‐for –profit , promotion of sports : Aiming to bridge the gap between Indian athletes and the Worlds best athletes 44 Chronic Dislocation of the first CMCjt He was encouraged to continue boxing in pain Boxed despite pain Important fixtures Until it became intolerable 45 15 9/2/2020 Unstable 46 Stage in career: World cadet champion Transitioning to the senior group At the top of the National rankings A certain pick for the Worlds/Olympics 47 Eaton-Littler AbPL FCR 48 16 9/2/2020 ½ FCR harvested anchor 49 50 51 17 9/2/2020 Went on to win the Nationals – 8 m post op But his long absence from the team allowed a little known contender to gain ground And one loss to him led to the ouster of our patient He leads a life of relative insignificance! Was the timing of the intervention a major factor? 52 Boxer – chronic injury 53 Avulsion fracture of the Abductor Pollicis Longus Existing extra‐articular malunion? 54 18 9/2/2020 55 56 Commonwealth medal Gold Coast, 2018 7yrs post surgery 31 years of age 57 19 9/2/2020 Injuries to Indian boxers at the National and International level • 12 elite boxers (state, national and international) • First ray injuries abound!!! WHY?? 58 Injuries to Indian boxers at the National and International level Practice Tournament Gloves.. Gloves ! Thumbs abducted and extended by 10‐15° This was brought to the notice of the Federation and the coaches Remedial action was taken No similar injuries in the last few years! 59 Boxer chronic injury pain! 60 20 9/2/2020 Only an arthrodesis (fusion) of the joint would help Dilemma regarding the position of fusion He wanted it fused so that he could box! His hand had to get into the glove! 61 Further assessment 62 Angles were calculated.. 63 21 9/2/2020 Competition gloves angles re-calculated 64 Avoided a plate Worries about pain on impact Developed pain on impact Started strength and conditioning With sessions of punching 65 Iliac crest grafts harvested by a Jamshidi needle 66 22 9/2/2020 • Boxer Sumit Sangwan won a silver medal at the Asian Boxing Championships beating the No. 1 and 2 seeds along the way. • From the OGQ website 67 Ensure Absolute stability Confirm Union prior to return to impact exercises 68 Summary Hand Injuries in sports is on the rise in India Organisation of healthcare for sportsmen need revamping Time the intervention – Look for the best window Clever innovation may be called for Remember, they go leather and tongs during rehab Celebrate every victory of our athletes! Its fun!! 69 23 9/2/2020 Marc J.