Treatment of Grade III Acromioclavicular Separations in Professional Baseball Pitchers: A Survey of Major League Baseball Team Physicians
TAKE-HOME POINTS
- There was no difference in return to previous level of play between professional pitchers treated nonoperatively and operatively for grade III AC separation.
- MLB team physicians prefer nonoperative management for acute grade III AC joint separation in professional pitchers.
- The majority of MLB physicians do not use injections for nonoperative treatment of grade III AC separations; however, use of orthobiologics (eg, PRP) is becoming more commonplace.
- Persistent functional limitations and pain are the most common surgical indications for treatment of grade III AC separation in high level throwing athletes.
- If operative intervention is indicated for grade III AC separation, open coracoclavicular reconstruction and adjunct distal clavicle excision are preferred by most MLB team physicians.
STATISTICS
Descriptive statistics were used for continuous variables, and frequencies were used for categorical variables. Linear regression was performed to determine the correlation between the physician’s training or experience in treating AC joint separations and their recommended treatment. Fischer’s exact test/chi-square analysis was used to compare categorical variables. All tests were conducted using 2-sided hypothesis testing with statistical significance set at P < .05. All statistical analyses were conducted with SPSS 21.0 software (IBM Corporation).
RESULTS
A total of 28 MLB team physicians completed the questionnaires from 18 of the 30 MLB teams. The average age of the responders was 50.5 years (range, 34-60 years), with an average of 18.2 years in practice (range, 2-30 years) and 10.8 years (range, 1-24 years) taking care of their current professional baseball team. About 82% of the team physicians completed a sports medicine fellowship. On average, physicians saw 16.6 (range, 5-50) grade III or higher AC joint separations per year, and operated on 4.6 (range, 0-10) per year.
Nonoperative treatment was the preferred treatment for a grade III AC joint separation in a starting professional baseball pitcher for the majority of team physicians (20/28). No correlation was observed between the physician’s age (P = .881), years in practice (P = .915), years taking care of their professional team (P = .989), percentage of practice focused on shoulders (P = .986), number of AC joint injuries seen (P = .325), or number of surgeries performed per year (P = .807) with the team physician’s preferred treatment. Compared to the proportion reported originally by McFarland and colleagues13 in 1997 (69%), there was no difference in the proportion of team physicians that recommended nonoperative treatment (P = 1).
,If treating this injury nonoperatively, 46.4% of physicians would also use an injection, with orthobiologics (eg, platelet-rich plasma) as the most popular choice (Table 1). No consensus was provided on the timeframe to return pitchers back to a progressive interval throwing program; however, 46.67% of physicians would return pitchers 4 to 6 weeks after a nonoperatively treated injury, while 35.7% would return pitchers 7 to 12 weeks after the initial injury.
Table 1. Treatment Preferences of Grade III AC Separation by MLB Team Physicians
Nonoperativea | |
Yes injection | 13 (46.4%) |
Cortisone | 3 (23.1%) |
Orthobiologic | 10 (76.9%) |
Local anesthetic (eg, lidocaine) | 1 (7.7%) |
Intramuscular toradol | 3 (23.1%) |
No injection | 15 (53.6%) |
Operativea | |
Open coracoclavicular ligament repair | 3 (13.0%) |
Open coracoclavicular ligament reconstruction | 15 (65.2%) |
Arthroscopic reconstruction with graft | 6 (26.1%) |
Arthroscopic repair with implant (ie, tight-rope) | 2 (8.7%) |
Distal clavicle excisionb | 16 (66.7%) |
Would not intervene operatively | 5 (17.9%) |
aRespondents were allowed to choose more than 1 treatment in each category. bChosen as an adjunct treatment.
Abbreviations: AC, acromioclavicular; MLB, major league baseball.
Most physicians (64.3%) cited functional limitations as the most important reason for indicating operative treatment, followed by pain (21.4%), and a deformity (14.3%). About 65% preferred open coracoclavicular ligament reconstruction. No physician recommended the Weaver-Dunn procedure or use of hardware (eg, hook plate). Of those who preferred an operative intervention, 66.7% would also include a distal clavicle excision, which is significantly higher than the proportion reported by McFarland and colleagues13 (23%, P = .0170). About 90% of physicians would return pitchers to play >12 weeks after operative treatment.
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