May 4, 2010

Under The Knife

Dr. Neal ElAttrache Q&A

by Will Carroll

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There are only so many "super surgeons" in sports. While everyone knows Dr. James Andrews and Dr. Frank Jobe, fewer know about Dr. Neal ElAttrache. ElAttrache is the Director of Sports Medicine at the world famous Kerlan-Jobe Clinic and the team orthopaedist for the Los Angeles Dodgers. He might be best known today as the surgeon who rebuilt Tom Brady's knee in 2008, but ElAttrache is also at the forefront of research in baseball. Along with several doctors, including Jobe and Dr. Lewis Yocum, ElAttrache has just published a studythat will help physicians understand the arms of athletes better through a new testing protocol. In a recent conversation recorded for Baseball Prospectus Radio, I had the chance to ask ElAttrache more about his study and the state of the art in sports medicine.

Will Carroll: One of the things you and your team havs done is develop what you call the Overhead Athlete Elbow and Shoulder Score.  Tell us what you’re trying to measure.

Dr. Neal ElAttrache: The existing scores that we use judge how people are doing either with injury, preseason, or after surgery. [They] really didn’t apply very well to the athletes that we were taking care of. A lot of the scores that were out there when you would have someone coming back from injury would deal with, "Can I get my arm over my head? Can I reach a hanger to get my coat off, scratch my back, reach my bra strap?"  With those, when they would score well, you could see coming back from rotator cuff surgery or labral surgery that were scoring in the 90^thpercentile and above. But if you ask them can I throw a baseball or throw a football, the performance was miserable. We weren’t able to assess our patients given the existing scores.  

We needed something that would be much more functional for the people we were taking care of and to be able to communicate, doctor to doctor, team to team, on how somebody is doing before, during, or after a surgery.  We put together a questionnaire that originally had about 25 questions and then we did a statistical analysis and took a couple years to validate the questions. Those questions got whittled down to about 10 important questions where a person would evaluate his own condition and performance, based on the things that were important to his functioning.  For a throwing athlete, those specifically had to do with his pre-injury performance as far as throwing velocity, and things like that. When you look at those questions, they were consistent and able to be scored from person to person for a given injury and it’s much more meaningful.  We found some interesting things based on those that you wouldn’t normally have picked up on a pre-existing scoring sheet. One of those things is the effect of partial-difference rotator cuff tears versus labral tears in throwers.

WC: That’s pretty interesting, tell us what you found in regards to that.

NE:  What was being reported as far as outcomes after labral surgery or SLAP (Superior Labrum from Anterior to Posterior) surgery—I’m sure a lot of the listeners have heard it, SLAP tear or labral tear­—was that if you have a SLAP operation you may never come back, you may never throw again.  So more and more, it was becoming a very disconcerting diagnosis and the outcomes were thought to be more and more dismal.  But when you would look at the research that was out there and people doing the follow-up studies on their patients they were doing labral repairs on, you would see that on the existing scores, pre-existing to the Pro and Jobe scoring system were that they were scoring very high on these other scores, so something wasn’t matching up. What we did was take a look at our patients and found after labral surgery, about 57 percent of the patients were getting back to their previous level of their competition—whether it was the college level, minor-league level, or professional level. And that would have been a little bit less than what we would have hoped for. 

So we broke it down and what we saw was that if you did not have any rotator cuff pathology at all and you had a labral repair, your chances of coming back to a pre-existing level of performance for your injury was over 80 percent. Those were the numbers that we would have hoped to have gotten, because when we were doing an operation on somebody with just a labral tear and repair arm was the impression was that we were getting about 80-90 percent of the guys back.  What was not obvious was that if you really look at what a co-existing rotator cuff problem was, then we saw that those results were far, far lower. If you had a 40-percent thickness—the rotator cuff has thickness, and it’s several millimeters thick—if you can measure the thickness of the rotator cuff, and you can do that arthroscopically, and you can see how much of that tendon has eroded or torn away from the bone, and if it approaches 40 or 50 percent, less than 20 percent of those guys are approaching their previous level of competition after surgery.  Now, they might get back to their sport, they might get back to throwing and pitching, but if you look at their own self assessment, they are not back to their previous level of competition, in their own opinion, which is ultimately the most important judgment, is the person’s own judgment of their competition.  So the rotator cuff tear looked like, and it does look like, is a major actor and major influencing factor in their ability to return. 

WC: Obviously these are some very significant findings. We’ve seen more and more labrum tears and rotator cuff tears.  You talked about going in and visualizing the rotator cuff tear through an arthroscope.  Is this something you can see through an MRI or a similar imaging test because obviously these are the things that would keep you from signing a player.

NE: Well, you can see it and it certainly does give you some level of expectation of what the risk is of that particular player.  Unfortunately when we’re dealing with these issues we’re not dealing with medical certainties, we’re dealing with medical probabilities. And even medical probabilities haven’t been as accurate as we’d like them to be but we’re getting better!  The more we understand about the meaning of some of these findings that we’re seeing on MRI scans and matching them up at the time of surgery, the more meaningful they are to us to predict risk and risk that a patient is going to go down with a given injury and how long they’re going to be able to perform.  Having said that, you’re going to see rotator cuff pathology in a very high percentage of your guys that you’ve made it to the professional level of throwing.  You have to be careful in how much weight you place on that, on how you interpret the MRI.  

And so it’s a little bit more sophisticated than saying there’s an abnormality on the MRI scan so this guy will never be able to pitch, which is probably over-reading the film.  So, not to get into too much detail, when we read it arthroscopically, we’re getting better at, No. 1, picking out the types of rotator cuff problems that will more likely lead to problems and the very exciting advantage is that we’re getting better at fixing them arthroscopically.  Still, we’re not getting results that are analogous to a ligament tear in the knee or something like that with regard to predictable return or outcome, but we’re much better than we use to be.  Some of the things we’re doing now with regard to the rotator cuff are helping us get these guys back.

WC:  I can remember when I first heard you speak about this type of issue. It was back in 2003, at the American Sports Medicine Institute's Injuries in Baseball Course, when you and Jim Andrews were presenting on shoulders.  Obviously, it’s gotten a lot better in terms of results in that period of time.  Do you feel like in the next five years we’re going to make the same types of advances?

NE:  Yes, I think that we’re going to get better.  We’re going to get better at our techniques. Still, we can’t get everybody back, so it should not be something that—you have a sore shoulder, you have an MRI scan, you see some pathology in the cuff, so you go right to rotator cuff repair.  We get our players better, not in the operating room, but in the physical therapy room and in the training room. We’re better at that.  But if they do come to surgery, we certainly have made big advances of it if nothing else is working and doing a career-saving operation. We’re getting better at doing that. Over the next five years, we’re getting better not only at the arthroscopic techniques but also in the biology of feeling and our rehab techniques, so it looks promising and I’m looking forward to seeing what we’re doing over the coming years. 

This interview was edited slightly for readability. Special thanks to Trace Longo and to the Kerlan-Jobe Clinic.