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AAOS Now

Published 4/1/2017
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Terry Stanton

Study: Increased Workload After Tommy John Surgery Increases Re-tear Risk

A study of 28 Major League Baseball (MLB) pitchers who underwent revision surgery after primary ulnar collateral ligament (UCL) reconstruction (Tommy John surgery) found that they had pitched at or above their pre-primary UCL workload, while pitchers who did not require revision pitched significantly less—below their pre-reconstruction workload.

These findings indicate that relative changes in workload may be a risk factor for re-rupture, said Robert A. Keller, MD, who presented the study at the AAOS Annual Meeting. “Pitchers returning after UCL reconstruction should be counseled on workload restrictions based on each individual pitcher's pre-injury workload, and caution should be exercised if a pitcher reaches or works beyond pre-injury workload level,” he said. The study group of 28 MLB players who had undergone primary UCL reconstruction between 1996 and 2012 and had subsequently required revision reconstruction was compared with a control cohort of 137 MLB pitchers who underwent primary reconstruction and did not require a revision reconstruction.  Players in each group were identified using methods similar to those of previous studies, ie, via team websites, press releases indicating players had undergone UCL reconstruction, personal websites, and baseball statistical websites. Players were excluded from both cohorts if they were not pitchers, failed to return to sport after primary reconstruction, or played only minor league baseball without returning to MLB. Three full seasons leading up to primary UCL reconstruction were compared with three full seasons post-UCL reconstruction to allow for an adequate representative workload before and after primary reconstruction. This approach, Dr. Keller said, also allowed assessment of the revision group versus the control group not only in cumulative workload, but also in trends of workload progression over time. Minor league statistics were also included because, the authors noted, “many pitchers pitched rehabilitation appearances in the minor leagues,” and “these league outings were important to include as similar workload and stresses are placed on the throwing elbow as in major league outings (same mechanics, distance from mound to plate, attempt to retire batters, etc).”  In evaluations of the pitching workload for the 3 years prior to and 3 years after primary UCL reconstruction, significant differences were seen between pitchers that required revision surgery and those who did not. In pitchers who would later require revision surgery, the workload metrics were higher post-reconstruction as compared with pre-reconstruction. In contrast, the no-revision pitchers had lower workloads post-reconstruction. Specifically, pitchers in the revision group pitched an average of 4.3 games more post– compared to pre–primary surgery (post– 34.8 games versus pre–30.5 games), while those in the no-revision group pitched an average of 5.1 fewer games post–primary surgery relative to their pre–primary surgery workload baseline (post– 32.5 games versus pre– 37.6 games). Thus, as the authors reported, revision pitchers increased their games pitched 14.1 percent postreconstruction, whereas those that did not require revision surgery pitched 13.6 percent less than their prereconstruction workload (P < 0.01). In evaluating innings pitched, the revision group's total inning workload was reduced slightly, by 9.8 percent, or an average of 9.8 innings postoperatively versus preoperatively The no-revision group had a significantly reduced average postreconstruction of 30.4 innings, or a 26 percent reduction  postoperatively (P = 0.05). A similar trend was seen in total pitches before and after reconstruction. The revision group pitched 6.6 percent more pitches postreconstruction (1,138.9) compared to prereconstruction (1,068.6). In contrast, those who did not require revision pitched 19.6 percent less postreconstruction (1,266 pitches) than prereconstruction (1,574.2 pitches), although these differences between the groups did not reach statistical significance (P = 0.08). Reducing the re-tear risk
Dr. Keller said he and his fellow researchers conducted the study because, “With an increasing number of MLB players undergoing Tommy John surgery, the burden of postoperative management to limit the risk of re-tear has increased.” He continued, “There is currently a paucity of medical literature on how to appropriately manage a post–Tommy John pitcher, and as a result, organizations and their medical personnel have implemented arbitrary pitch counts and inning limits for players. Thus, there is a significant amount of controversy and retrospective questioning of the management of post–Tommy John athletes upon their return to pitching by players, team personnel, and the media.” Previously, Dr. Keller said, his group, along with one other study “looked to see if there was a one-size-fits-all pitch, inning, and/or game count that would place a player at risk for re-tear, and both studies found no one-size-fits-all throwing workload.” He recalled hearing Neal S. ElAttrache, MD (senior author of the study), telling a player, “I cannot give you a new ligament that is better than the one God gave you.” This statement, he said, “prompted us to come up with the idea of evaluating individualized throwing workload measurements. And we could evaluate this by comparing pitchers pre–Tommy John workload and the workload that damaged the ligament 'that God gave them,' and compare it to their post–Tommy John workload.” Dr. Keller said another interesting finding in the study is that “those who later went on to revision surgery returned to sport almost 2 months later than pitchers that did not require revision surgery (13.7 versus 15.2 months). These numbers may suggest that if a player is at the year mark after surgery and is still struggling and having setbacks in his return to throw program, he may be at a high risk for re-injury.” In future studies, he said, “We need to continue to find ways to limit the rise of primary Tommy John [injuries] and thus revision Tommy John surgery. It would be ideal to find innovative ways to assess inherent biologic breakdown due to sports participation so we can intervene before ligament injury that requires surgery.”   Dr. Keller's coauthors of “Pre– and Post–Ulnar Collateral Ligament Reconstuction Workload and Its Risk for Revision Surgery,” are Nima Mehran, MD; Lafi Khalil; and Neal S. ElAttrache, MD. Details of the authors' disclosures as submitted to the Orthopaedic Disclosure Program can be found in the Final Program; the most current disclosure information may be accessed electronically at www.aaos.org/disclosure Terry Stanton is the senior science writer for AAOS Now. He can be reached at tstanton@aaos.org

Bottom Line

  • A study of 28 MLB pitchers who underwent revision surgery after primary UCL reconstruction found that they had pitched at or above their preprimary UCL workload, while pitchers who did not require revision pitched significantly less—below their prereconstruction workload.
  • The study group of 28 MLB players who had undergone primary UCL reconstruction between 1996 and 2012 and had subsequently required revision reconstruction was compared with a control cohort of 137 MLB pitchers who underwent primary reconstruction and did not require a revision reconstruction. 
  • These findings may indicate that relative changes in workload may be a risk factor for re-rupture.