Relief pitchers who had revision UCL reconstruction returned to play almost 2 months earlier than starting pitchers.
Courtesy of Thinkstock

AAOS Now

Published 5/1/2013
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Maureen Leahy

Effect of Revision UCL Reconstruction on Return to Play in MLB Pitchers

Study finds relievers more likely than starters to resume preoperative workload

Study data presented at the 2013 American Orthopaedic Society for Sports Medicine (AOSSM) Specialty Day indicate that many Major League Baseball (MLB) pitchers are unable to return to their pre-injury pitch workload following revision ulnar collateral ligament (UCL) reconstruction.

“The available studies currently demonstrate excellent results following primary UCL reconstruction in MLB athletes,” said presenter Kristofer J. Jones, MD, of the Hospital for Special Surgery, New York. “But, recurrent UCL tears are uncommon, and few studies have investigated clinical outcomes following revision UCL reconstruction in this unique cohort.”

Collecting the data
Dr. Jones and his fellow researchers conducted a retrospective review of the MLB disabled list from 1996 to 2009 to identify pitchers who had undergone revision UCL reconstruction while actively assigned to an MLB roster. Using return to play as the primary outcome measure, the researchers hypothesized that although the overall rate of return to play for MLB pitchers might be high, the rate of return to pre-injury workload would be low.

Eighteen pitchers—11 relievers and 7 starters—met the study’s inclusion criterion. Pitchers in both groups were similar in age (mean age = 29 years, range: 22–35 years). Most of the procedures (n = 14) were performed during the latter half of the study period, perhaps reflecting a rise in recognition of the injury, Dr. Jones noted.

Using pre- and postoperative pitching statistics collected from team records, the researchers determined the total number of game appearances before and after surgery for relief pitchers. For starting pitchers, they determined the total number of games started and innings pitched. “These data were ultimately used to determine the overall percentage of postoperative pitch workload relative to pre-injury productivity,” explained Dr. Jones.

Statistical analysis was used to compare time to return to play, innings pitched, objective pitching statistics, and postoperative pitch workload between the two groups.

Return to play high, workload low
The researchers found that, compared to starting pitchers, relief pitchers demonstrated better statistics across the board. Overall, 78 percent of pitchers returned to play within two full seasons (mean time: 18.9 months, range: 12–27 months), with relief pitchers returning almost 2 months earlier than starting pitchers.

Among the starting pitchers, only one approached his pre-injury workload and two transitioned to a relief role. In comparison, three (38 percent) relief pitchers approached their pre-injury workload and two (25 percent) surpassed it.

Interestingly, the researchers also found that pitchers older than age 30 were able to resume a higher percentage of their pre-injury workload. “It’s possible that maturity may play a large role in return to pitching, as older pitchers may be more willing to assume a diminished role or adopt new pitches to compensate for loss of fastball velocity,” said Dr. Jones.

Conclusions
Dr. Jones noted this study was a small, retrospective case series based on data from the MLB disabled list that did not include clinical data such as associated elbow pathology and additional surgical procedures, which would have provided a more detailed assessment of the injury and treatment. Another weakness was that a validated outcome measure was not used.

“Despite these flaws in study design,” he said, “this report represents one of the largest reviews of MLB pitchers who have undergone revision UCL reconstruction. MLB pitchers were able to return to pitching at a high rate, but many were not able to return to their preoperative workload. Starting pitchers returned to their pre-injury workload at lower rates compared to relief pitchers, and it is possible that they may benefit from reassignment to a relief role postoperatively.”

Dr. Jones’ coauthors of “Functional Outcomes Following Revision Elbow UCL Reconstruction in Major League Baseball Pitchers” are Stan Conte, ACT, DPT; Nancy Patterson, ATD; Neal S. ElAttrache, MD; and Joshua S. Dines, MD.

Disclosures: Dr. Jones—no conflicts. Dr. ElAttrache—Arthrex, Inc; American Orthopaedic Society for Sports Medicine. Dr. Dines—Biomet; Biomimetic; Conmed Linvatec; Tornier; Journal of Shoulder and Elbow Surgery; American Journal of Orthopedics; Journal of Shoulder and Elbow Surgery. Mr. Conte and Ms. Patterson—no information.

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org

Bottom Line

  • Little data exist on clinical outcomes following revision UCL reconstruction.
  • This small, retrospective case series found that MLB pitchers are able to return to pitching at a high rate following revision UCL reconstruction.
  • However, many are not able to resume their preoperative pitch workload.
  • Compared to relief pitchers, starting pitchers return to preoperative workload at lower rates.