Ulnar Collateral Ligament Reconstruction Surgery Research Articles

Changes in Pitch Velocity and Selection in Major League Baseball Pitchers Following the Ulnar Collateral Ligament Reconstruction.

The ulnar collateral ligament (UCL) is a soft-tissue stabilizer of the elbow, that is commonly injured among baseball pitchers due to excess valgus stress in overheadthrowing motions. The location of a UCL tear typically ranges from the central aspect of the ligamentto an avulsion-type injury at its proximal insertion site on the medialepicondyle of the humerus, or its distal insertion site on the ulna. The effect of UCL reconstruction on pitching performance has become a well-studied topic in medical literature. In our study, we aimed to identify general performance patterns amongst those having undergone UCL reconstruction surgery. Data for patients with UCL reconstruction performed between 2010 and 2020 were extracted from publicly available databases. Pitching data was extracted from Brooks Baseball, a publicly available database for Major League Baseball (MLB) player statistics. We identified patients who played at least one full season after surgery and rehabilitation. Patient characteristics were evaluated for intergroup differences. Of 109 patients with UCL reconstruction, 87 were included in the final analysis. Compared to the preoperative group, the average postoperative fastball usage rate was less despite there being an increase in the off-speed usage rate. Velocity analysis demonstrated shifts of less than 1% for all three pitch groups compared to preoperative velocity average values (all P-values <0.05). Earned Run Average (ERA)+demonstrates a decrease in the postoperative group; this finding was not significant (P=0.61). Patients treated surgically demonstrated a throwing tendency for theirsecondary and tertiary pitches and a decreased usage of fastballs. Further studies areneeded to explore the factors contributing to the change in pitching performance.

Return-to-competition performance of major leagues baseball pitchers undergoing ulnar collateral ligament reconstruction surgery

Return-to-competition performance of major leagues baseball pitchers undergoing ulnar collateral ligament reconstruction surgery

Increasing rates of ulnar collateral ligament repair outpace reconstruction in isolated injuries: review of a Texas surgical database

The gold standard of treatment for ulnar collateral ligament (UCL) injuries has been reconstruction. Despite early repair studies yielding less than satisfactory results, there has been recent renewed interest in UCL repair due to improved outcomes and new technologies. Data regarding clinical use of these procedures are lacking. The purpose of this study was to define the epidemiological trends of UCL repair and reconstruction surgery from 2010 to 2019, compare demographic characteristics of patients undergoing either procedure, and determine incidence of concomitant procedures in each surgical group as well as comparing respective patient-level charges. A retrospective database analysis of UCL surgeries was performed through the Texas Healthcare Information Collection database, a comprehensive and publicly available statewide billing dataset. Inclusion criteria were defined using Current Procedural Terminology billing codes for elbow UCL repair and reconstruction between 2010 through 2019, excluding patients who had concomitant elbow fractures or lateral collateral ligament tears indicative of high-energy trauma. Procedural volume changes, patient demographics, and commonly performed concomitant procedures including elbow arthroscopy, ulnar nerve surgery, and platelet-rich plasma injection were compared. Total patient-level charges were compared across groups. A total of 1664 patients were included, consisting of 484 UCL repairs and 1180 reconstructions. Total UCL surgeries increased eleven-fold when corrected for population growth from 2010 (N=25) to 2019 (N=315). In 2010, repair constituted 23% of all UCL tear surgeries and increased to 40% by the end of 2019. The annual frequency of UCL repair increased at a 5.4% faster rate than UCL reconstruction from 2010 to 2019 (P<.001). There were no significant differences between any demographic data between UCL repair and reconstruction except for rural surgical settings which demonstrated 1.8 times greater odds of undergoing reconstruction (P=.05). There were no differences among commonly associated procedures including ulnar nerve surgery (P=.217), elbow arthroscopy (P=.092), and platelet-rich plasma injection (P=.837) with no differences in patient-level charges at any time point (P=.47). While reconstruction remains more common, the annual frequency of UCL repair is increasing at a faster rate. Since were no demographic differences aside from surgical setting, it can be inferred that patients who were previously receiving reconstruction are instead undergoing repair. This highlights the need for future studies to further identify surgical indications for the two interventions.

Reconstruction Surgeries for Management of Posterolateral Rotatory Instability of The Elbow: A Systematic Review

We aimed to investigate the indications, techniques, and results of lateral ulnar collateral ligament reconstruction (LUCLR) for posterolateral rotatory instability of the elbow (PLRI) by collecting currently available data. Several databases (PUBMED &amp; EMBASE) were explored for articles published between 2010 and 2020. A search strategy was applied. Altogether, 2,583 studies were recovered for possible inclusion. After adjusting for duplicates, revision of methodology, exclusion of non-full text studies, and those in languages other than English, only four studies remained, which included 51 patients, with more males than females (56.9% and 43.1%, respectively). The patients’ mean age was 35.1 years. Eight patients (15.7%) were managed by the Docking technique in one retrospective study, while 43 patients (84.3%) were managed by the trans-osseous technique. Both trans-osseous and Docking techniques are safe and efficient in the management of PLRI cases. The trans-osseous technique has better functional and postoperative results and lesser complications. Mesh Words: posterolateral rotatory instability of the elbow; lateral ulnar collateral ligament reconstruction surgery; systematic review; meta-analysis

Effect of Ulnar Collateral Ligament Reconstruction on Pitch Accuracy, Velocity, and Movement in Major League Baseball Pitchers.

Background:Ulnar collateral ligament (UCL) reconstruction is frequently performed on Major League Baseball (MLB) pitchers. Previous studies have investigated the effects of UCL reconstruction on fastball and curveball velocity, but no study to date has evaluated its effect on fastball accuracy or curveball movement among MLB pitchers.Purpose/Hypothesis:The primary purpose of this study was to determine the effects of UCL reconstruction on fastball accuracy, fastball velocity, and curveball movement in MLB pitchers. Our hypothesis was that MLB pitchers who underwent UCL reconstruction would return to their presurgery fastball velocity, fastball accuracy, and curveball movement. The secondary purpose of this study was to determine which factors, if any, were predictive of poor performance after UCL reconstruction.Study Design:Case-control study; Level of evidence, 3.Methods:MLB pitchers who underwent UCL reconstruction surgery between 2011 and 2012 were identified. Performance data including fastball velocity, fastball accuracy, and curveball movement were evaluated 1 year preoperatively and up to 3 years of play postoperatively. A repeated-measures analysis of variance with a Tukey-Kramer post hoc test was used to determine statistically significant changes in performance over time. Characteristic factors and presurgery performance statistics were compared between poor performers (>20% decrease in fastball accuracy) and non—poor performers.Results:We identified 56 pitchers with a total of 230,995 individual pitches for this study. After exclusion for lack of return to play (n = 14) and revision surgery (n = 3), 39 pitchers were included in the final analysis. The mean presurgery fastball pitch-to-target distance was 32.9 cm. There was a statistically significant decrease in fastball accuracy after reconstruction, which was present up to 3 years postoperatively (P = .007). The mean presurgery fastball velocity of 91.82 mph did not significantly change after surgery (P = .194). The mean presurgery curveball movement of 34.49 cm vertically and 5.89 cm horizontally also did not change significantly (P = .937 and .161, respectively).Conclusion:Fastball accuracy among MLB pitchers significantly decreased after UCL reconstruction for up to 3 years postoperatively. There were no statistically significant differences in characteristic factors or presurgery performance statistics between poor and non--poor performers.

Ulnar Collateral Ligament Tear Location May Affect Return-to-Sports Rate but Not Performance Upon Return to Sports After Ulnar Collateral Ligament Reconstruction Surgery in Professional Baseball Players

Background: The number of ulnar collateral ligament (UCL) tears in professional baseball players is increasing. UCL reconstruction (UCLR) is the treatment of choice in players with failed nonoperative treatment who wish to return to sports (RTS). It is unknown if UCL tear location influences the ability of players to RTS or affects their performance upon RTS. Purpose/Hypothesis: The purpose was to compare the RTS rate and performance upon RTS in professional baseball players who underwent UCLR based on UCL tear location (proximal vs distal). It was hypothesized that no difference in RTS rate or performance upon RTS will exist between players with proximal or distal UCL tears. Study Design: Cohort study; Level of evidence, 3. Methods: All professional baseball players who underwent primary UCLR by a single surgeon between 2016 and 2018 were eligible for inclusion. Players with purely midsubstance tears or revision UCLR were excluded. Tear location was determined based on preoperative magnetic resonance imaging (MRI) and intraoperative findings. RTS rate and performance were compared between players with proximal versus distal UCL tears. Results: Overall, 25 pitchers (15 proximal and 10 distal tears) and 5 position players (2 proximal and 3 distal) underwent primary UCLR between 2016 and 2018. Of the 25 pitchers, 84% were able to RTS. Of the 5 position players, 80% were able to RTS. Among the total cohort of pitchers and position players, 12 out of 17 (71%) players with proximal tears were able to RTS, while of the 13 distal tears, 13 out of 13 (100%) players were able to RTS (P = .05). With regard to performance data, pitchers with distal tears had higher utilization postoperatively and, as such, allowed statistically more hits (P = .03), runs (P = .015), and walks (P = .021) postoperatively. However, the WHIP ([walks + hits]/innings pitched) was not different between players with proximal or distal tears, indicating that efficacy in games was not significantly different between groups. Conclusion: Professional baseball players who sustain a distal UCL tear and undergo UCLR may be more likely to RTS than those who sustain a proximal UCL tear and undergo UCLR. Players with distal UCL tears who underwent UCLR saw higher utilization postoperatively than those with proximal UCL tears. Further work is needed in this area to confirm this result.

A qualitative assessment of return to sport following ulnar collateral ligament reconstruction in baseball players

BackgroundThe rate of ulnar collateral ligament (UCL) reconstruction has been increasing at all levels of play. With excellent outcomes, primary UCL reconstruction has allowed many overhead athletes to return to their pre-injury sport. However, the subjective factors influencing this decision to return to sport have yet to be studied. The aim of this study is to understand the factors influencing an athlete's decision to return to pre-injury level of sport after primary UCL reconstruction. MethodsAn experienced interviewer conducted qualitative, semi-structured interviews of patients aged 18–35 years who had undergone primary UCL reconstruction by one fellowship-trained, Major League Baseball (MLB) team orthopaedic surgeon. All subjects were throwing athletes prior to injury and had a minimum two-year follow-up without revisions. Qualitative analysis was then performed to derive codes, categories, and themes. Patients were surveyed to assess familiarity with UCL reconstruction as well as to obtain Kerlan-Jobe Orthopaedic Clinic (KJOC) Overhead Athlete Shoulder and Elbow score, American Shoulder and Elbow Surgeons Shoulder (ASES) score, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) highlighting current activity and function levels along with sport participation. ResultsTwenty-two athletes were interviewed to elucidate four predominant themes influencing their return to sport: trust in surgeon and care team, innate drive and optimism, misconceptions regarding post-operative athletic ability, and life priorities. A significant difference was noted between patients that returned and those that did not in the KJOC survey and for the statement that UCL reconstruction surgery would improve throwing ability relative to patients’ peak performance three years prior to the surgery. Athletes who did not return to sport cited lifestyle changes and age as limiting factors. ConclusionPatients' decision to return to their pre-injury level of sport after primary UCL reconstruction was based on trust in their care team's reputation, intrinsic personality traits, anecdotal evidence about post-operative outcomes, and lifestyle. This study emphasizes the importance for health care providers to educate patients toward realistic expectations upon return to sport. On a larger scale, this study illustrates the effects the media and anecdotal experiences of a growing population of players undergoing UCL reconstruction have had on the game of baseball and players' decisions to return to sport. Level of evidenceLevel IV.

Direct Comparison of Modified Jobe and Docking Ulnar Collateral Ligament Reconstruction at Midterm Follow-up

Background: The modified Jobe and docking techniques are the 2 most commonly employed techniques for ulnar collateral ligament (UCL) reconstruction among overhead athletes. However, no study has directly compared these techniques performed by a single surgeon. Current comparisons of these techniques have relied solely on systematic reviews and biomechanical studies. Hypothesis: There will be no difference in outcomes or return to play between the modified Jobe and docking techniques in elbow UCL reconstruction surgery. Study Design: Cohort study; Level of evidence, 3. Methods: Twenty-five modified Jobe and 26 docking UCL-reconstructive surgical procedures were performed by a single surgeon, each with a minimum 2-year follow-up. Kerlan-Jobe Orthopaedic Clinic (KJOC) score, Conway Scale, years played, sex, handedness, sport, position, palmaris versus gracilis graft type, concomitant or future arm/shoulder injuries, and need for additional surgery were compared between the groups. Patients who underwent future shoulder or elbow surgery, no matter the cause, were included. Results: No difference was seen between the modified Jobe and docking reconstruction cases in regard to KJOC scores (mean ± SD: 78.4 ± 19.5 vs 72.0 ± 26.0, P = .44), Conway Scale (return to play, any level: 84% vs 82%, P = .61), years played (14.7 ± 6.2 vs 15.2 ± 5.8, P = .52), sex (P = .67), handedness (P ≥ .999), sport (P = .44), position (P = .60), level of competition (P = .59), and future surgery (12% vs 4%, P = .35). Palmaris graft type had significantly higher KJOC scores than hamstring grafts (82.3 ± 20.0 vs 57.9 ± 21.2, P = .001). The mean follow-up was 6.1 years in the modified Jobe group and 7.3 years in the docking group (mean = 6.7, P = .47). Conclusion: The modified Jobe and docking techniques are both suitable surgical options for elbow UCL reconstruction. There was no statistically significant difference between the techniques in regard to return to play, KJOC score, or need for subsequent surgery at 6.7-year follow-up. This is the first direct clinical comparison of these 2 techniques by a single surgeon at midterm follow-up.

Osseous Vascularity of the Medial Elbow After Ulnar Collateral Ligament Reconstruction: A Comparison of the Docking and Modified Jobe Techniques.

Background:Although vascularity plays a critical role in healing after ulnar collateral ligament (UCL) reconstruction, intraosseous blood flow to the medial epicondyle (ME) and sublime tubercle remains undefined.Purpose:To quantify vascular disruption caused by tunnel drilling with the modified Jobe and docking techniques for UCL reconstruction.Study Design:Controlled laboratory study.Methods:Eight matched pairs (16 specimens) of fresh-frozen cadaveric upper extremities were randomized to 1 of 2 study groups: docking technique or modified Jobe technique. One elbow in each pair underwent tunnel drilling by the assigned technique, while the contralateral elbow served as a control. Pregadolinium and postgadolinium magnetic resonance imaging were performed to quantify intraosseous vascularity within the ME, trochlea, and proximal ulna. Three-dimensional computed tomography (CT) and gross dissection were performed to assess terminal vessel integrity.Results:Ulnar tunnel drilling had minimal impact on vascularity of the proximal ulna, with maintenance of >95% blood flow for each technique. Perfusion in the ME was reduced 14% (to 86% of baseline) for the docking technique and 60% (to 40% of baseline) for the modified Jobe technique (mean difference, 46%; P = .029). Three-dimensional CT and gross dissection revealed increased disruption of small perforating vessels of the posterior aspect of the ME for the modified Jobe technique.Conclusion:Although tunnel drilling in the sublime tubercle appears to have a minimal effect on intraosseous vascularity of the proximal ulna, both the docking and modified Jobe techniques reduce flow in the ME. This reduction was 4 times greater for the modified Jobe technique, and these findings have important implications for UCL reconstruction surgery.Clinical Relevance:As the rate of revision UCL reconstructions continues to rise, investigation into causes for failure of primary surgery is needed. One potential cause is poor tendon-to-bone healing due to inadequate vascularity. This study quantifies the amount of vascular insult that is incurred in the ME during UCL reconstruction. While vascular insult is only one of many factors that affects the surgical success rate, surgeons performing this procedure should be mindful of this potential for vascular disruption.

Rehabilitation and Return-to-Play Criteria Following Ulnar Collateral Ligament Reconstruction

Elbow injuries in overhead athletes, particularly ulnar collateral ligament (UCL) injuries to baseball pitchers, continue to increase in number. The reasons for these injuries are multifactorial but typically result from a combination of severe and repetitive valgus elbow stress from pitching large volumes and throwing at peak velocities. These factors and the severity of medial elbow injuries to the UCL complex make it critical to employ a proper criteria-based rehabilitation program in combination with a well-structured set of return-to-play criteria. Together, the rehabilitation process and return-to-play program provide a set of guidelines that help ensure a safe and effective process to aid in returning a throwing athlete back to unrestricted competition as efficiently as possible. This article provides the reader with a 4-phased, criteria-based rehabilitation program for the athlete following UCL reconstruction and a structured set of return-to-play guidelines. The return-to-play progression is a 3-step process that assists in advancing an athlete back to unrestricted competition via a performance, practice, and play sequence. This program uses specific criteria and activities to progress a throwing athlete from high-level performance training, to controlled practice participation and then finally back to play. The program uses not only specific steps but also a combination of testing parameters both subjective and objective to guide the return through the entire rehabilitation process from UCL reconstruction surgery back to unrestricted symptom-free throwing.

Osseus Vascularity of the Medial Elbow Following Ulnar Collateral Ligament Reconstruction: A Comparative Analysis of the Docking and Figure of Eight Techniques

Objectives:The rate of revision medial ulnar collateral ligament (UCL) reconstruction continues to rise annually, and two common modes of failure for are inadequate healing at the bone-tendon interface or bony fracture through drill tunnels. Although, vascularity may play a critical role in these processes, the intra-osseous blood flow to the medial epicondyle (ME) and sublime tubercle (ST) remains undefined. The purpose of this work was to better understand the vascularity of the ME and ST at baseline and to quantify vascular disruption caused by tunnel drilling for the two most common UCL reconstruction techniques: the Figure of Eight and Docking.Methods:Eight matched pairs (16 total specimens) of fresh-frozen cadaveric upper extremities were randomized to one of the two study groups: Docking or Figure of Eight UCL reconstruction. One elbow in each pair underwent drilling of the medial epicondyle and sublime tubercle by the assigned technique, while the contralateral elbow underwent surgical exposure without drilling to serve as a matched control. For all specimens, the brachial artery was cannulated 10 cm distal to the greater tuberosity, and the ulnar artery was cannulated 10 cm proximal to the wrist. All identified remaining vessels were tied off. Pre- and post- gadolinium MRI scans were performed on all study elbows to quantify intra-osseous vascularity by contrast enhancement, which was compared to the contralateral elbow as a matched control. Intra-osseous flow is quantified within a standardized region of interest (ROI) using customized IDL 6.4 software (Exelis, Boulder, Colorado). Following MRI, contrast-enhanced polyurethane latex was injected into all vessels and CT with 3D reconstruction and gross dissection was performed to correlate findings with the MRI and assess vessel integrity.Results:MRI quantification revealed drilling of the ulnar tunnels (which was the same for each group) had a minimal impact on intra-osseous vascularity of the ulna with maintenance of 96% and 99% (p=0.448) of blood flow for the Docking and Figure Eight techniques respectively (Table 1). However, perfusion to the medial epicondyle was reduced 14% (to 86% of baseline) for the Docking Technique and 60% (to 40% of baseline) for the Figure Eight technique (Figure 1). This resulted in a mean difference of 46% in reduced perfusion between the two techniques (p=0.012). Subsequent CT analysis and gross dissection revealed increased disruption of small perforating vessels of the posterior aspect of the medial epicondyle for the Figure of Eight Technique (Figure 1).Conclusion:Although tunnel drilling in the sublime tubercle appears to have minimal effect on intra-osseous vascularity of the proximal ulna, both the Docking Technique and the Figure of Eight Technique reduce flow in the medial epicondyle. This reduction is four times greater for the Figure of Eight Technique, and these findings may have important implications for UCL reconstruction surgery.

Current Trends in Ulnar Collateral Ligament Reconstruction Surgery Among Newly Trained Orthopaedic Surgeons.

Ulnar collateral ligament (UCL) reconstructions are being performed with an increasing annual incidence. The purpose of this study was to evaluate trends in UCL surgery among recently trained orthopaedic surgeons. The American Board of Orthopaedic Surgeons (ABOS) database was used to identify all UCL reconstructions from 2004 to 2013. Procedures were identified by Current Procedural Terminology (CPT) codes and verified by International Classification of Disease, Ninth Revision (ICD-9) codes. Data on surgeon fellowship, practice location, concomitant surgical procedures, and complications were collected. One hundred sixty-four UCL reconstructions were performed by 133 ABOS Part II candidates. The annual incidence increased from 1.52 to 3.46 cases per 10,000 (P = 0.042). Reconstructions were most commonly performed by surgeons with fellowship training in sports medicine (65.9%), hand and upper extremity (18.9%), and shoulder and elbow (9.1%). Most reconstructions were performed in isolation (57.3%), or with ulnar nerve transposition (32.9%) or elbow arthroscopy (9.8%). Concomitant elbow arthroscopy rates decreased significantly (P = 0.022). Complications occurred in 9.8% of cases, although the rates did not significantly change (P = 0.466). UCL reconstructions are being performed with increasing frequency. Concomitant procedure rates remained the same, although arthroscopy was less commonly performed. Complication rates did not change considerably over the observed period. Further study of the surgical trends and associated long-term outcomes is warranted. Level IV.

Major League pitching workload after primary ulnar collateral ligament reconstruction and risk for revision surgery

Literature has attempted to correlate pitching workload with risk of ulnar collateral ligament (UCL) injury; however, limited data are available in evaluating workload and its relationship with the need for revision reconstruction in Major League Baseball (MLB) pitchers. We identified 29 MLB pitchers who underwent primary UCL reconstruction surgery and subsequently required revision reconstruction and compared them with 121 MLB pitchers who underwent primary reconstruction but did not later require revision surgery. Games pitched, pitch counts, and innings pitched were evaluated and compared for the seasons after returning from primary reconstruction and for the last season pitched before undergoing revision surgery. The difference in workload between pitchers who did and did not require revision reconstruction was not statistically significant in games pitched, innings pitched, and MLB-only pitch counts. The one significant difference in workload was in total pitch counts (combined MLB and minor league), with the pitchers who required revision surgery pitching less than those who did not (primary: 1413.6 pitches vs. revision: 959.0 pitches, P = .04). In addition, pitchers who required revision surgery underwent primary reconstruction at an early age (22.9 years vs. 27.3 years, P < .001) and had less MLB experience (1.5 years vs. 5.0 years, P < .001). There is no specific number of pitches, innings, or games that place a pitcher at an increase risk for injury after primary UCL reconstruction. However, correlations of risk may be younger age and less MLB experience at the time of the primary reconstruction.

Predictors of Ulnar Collateral Ligament Reconstruction in Major League Baseball Pitchers

Background: Ulnar collateral ligament (UCL) reconstruction surgeries in Major League Baseball (MLB) have increased significantly in recent decades. Although several risk factors have been proposed, a scientific consensus is yet to be reached, providing challenges to those tasked with preventing UCL injuries. Purpose: To identify significant predictors of UCL reconstruction in MLB pitchers. Study Design: Case control study; Level of evidence, 3. Methods: Demographic and pitching performance data were sourced from public databases for 104 MLB pitchers who underwent UCL reconstruction surgery and 104 age- and position-matched controls. These variables were compared between groups and inserted into a binary logistic regression to identify significant predictors of UCL reconstruction. Two machine learning models (naïve Bayes and support vector machine) were also employed to predict UCL reconstruction in this cohort. Results: The binary linear regression model was statistically significant (χ2(12) = 33.592; P = .001), explained 19.9% of the variance in UCL reconstruction surgery, and correctly classified 66.8% of cases. According to this model, (1) fewer days between consecutive games, (2) a smaller repertoire of pitches, (3) a less pronounced horizontal release location, (4) a smaller stature, (5) greater mean pitch speed, and (6) greater mean pitch counts per game were all significant predictors of UCL reconstruction. More specifically, an increase in mean days between consecutive games (odds ratio [OR], 0.685; 95% CI, 0.542-0.865) or number of unique pitch types thrown (OR, 0.672; 95% CI, 0.492-0.917) was associated with a significantly smaller likelihood of UCL reconstruction. In contrast, an increase in mean pitch speed (OR, 1.381; 95% CI, 1.103-1.729) or mean pitches per game (OR, 1.020; 95% CI, 1.007-1.033) was associated with significantly higher odds of UCL reconstruction surgery. The naïve Bayes classifier predicted UCL reconstruction with an accuracy of 72% and the support vector machine classifier with an accuracy of 75%. Conclusion: This study identified 6 key performance factors that may present significant risk factors for UCL reconstruction in MLB pitchers. These findings could help to enhance the prevention of UCL reconstruction surgery in MLB pitchers and shape the direction of future research in this domain.

Return-to-Play Outcomes in Professional Baseball Players After Medial Ulnar Collateral Ligament Injuries

Background: The medial ulnar collateral ligament (UCL) is the primary static stabilizer to valgus stress of the elbow. Injuries to the UCL are common in baseball pitchers. In the 1970s, reconstructive surgery was developed. Return-to-play (RTP) rates of 67% to 95% after reconstruction have been reported. There is a paucity of published studies among professional baseball players reporting RTP with nonoperative treatment. Purpose: To identify professional baseball players’ ability to RTP after the nonoperative treatment of UCL injuries based on the magnetic resonance imaging (MRI) grade. Study Design: Case series; Level of evidence, 4. Methods: A review of elbow injuries among a professional baseball organization from 2006 to 2011 was performed. MRI was performed on all players. Forty-three UCL injuries were diagnosed. Treatment included rehabilitation, surgery, or both. Rates of RTP and return to the same level of play or higher (RTSP) were calculated and correlated with the MRI grade, location of injury, and player position. MRI grading was as follows: I, intact ligament with or without edema; IIA, partial tear; IIB, chronic healed injury; and III, complete tear. Results: Forty-three UCL injuries in 43 players were diagnosed. Eight had complete tears (grade III), were treated operatively with UCL reconstruction, and had an RTP rate of 75% and RTSP rate of 63% (5/8 returned to the same level and 1 to a lower level). All 8 were pitchers. The remaining 35 players had incomplete injuries (4 grade I, 8 grade IIA, and 23 grade IIB), consisting of 24 pitchers and 11 positional players. Of these 35 players, 1 underwent surgery without attempted rehabilitation, 3 initiated rehabilitation until MRI was performed and then underwent surgery, and 3 underwent surgery after failed rehabilitation. The 7 players who underwent UCL reconstruction surgery had an RTP rate of 100% and RTSP rate of 86% (6/7 returned to the same level and 1 to a lower level). The remaining 28 with nonoperative treatment had both RTP and RTSP rates of 93% (26/28 returned to the same level and 0 to a lower level). Of these, 10 were positional players with an RTSP rate of 90%, and 18 were pitchers with an RTSP rate of 94%. Of all players with incomplete UCL injuries who completed nonoperative rehabilitative treatment (n = 31), 26 had a successful RTSP (84%). Conclusion: Incomplete UCL injuries in professional baseball players can be successfully treated nonoperatively in the majority of cases. Pitchers are more likely to have complete tears leading to surgery. MRI grading of UCL injuries can help predict RTP and the need for surgery.

Pitching Performance and Longevity After Revision Ulnar Collateral Ligament Reconstruction in Major League Baseball Pitchers

Background: Medial ulnar collateral ligament (UCL) reconstruction is a common procedure performed on professional pitchers in Major League Baseball (MLB). Although a great deal is known about primary reconstruction, much less is known about revision reconstruction. Purpose/Hypothesis: The purpose of this study was to evaluate statistical performance, return to play, and career longevity in MLB pitchers after revision UCL surgery, with the hypothesis that pitching performance and career longevity will decline after revision surgery. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 33 MLB pitchers who underwent revision UCL reconstruction surgery (UCL-R group) were identified and compared with 33 age- and position-matched controls (CTL group). Return to play, total years played, and statistical performance were evaluated and compared with controls. Results: After revision surgery, 65.5% of UCL-R pitchers returned to the MLB level. On average, the UCL-R pitchers played 0.8 years less in the majors (P < .01) than did the control pitchers. The UCL-R pitchers who returned to the MLB level had a similar earned run average (UCL-R: 4.88, CTL: 4.76, P = .82) and walks/hits per innings pitched (UCL-R: 1.58, CTL: 1.44, P = .22) compared with the control pitchers. There were significant declines, however, in terms of innings pitched (UCL-R: 36.95, CTL: 75.00, P < .01), walks per 9 innings (UCL-R: 4.75, CTL: 3.49, P < .01), and wins (UCL-R: 1.88, CTL: 4.10, P < .01) as well as nonsignificant declines in wins above replacement (UCL-R: 0.25, CTL: 0.62, P = .06) and runs above replacement (UCL-R: 3.26, CTL: 6.91, P = .07). Conclusion: MLB pitchers who undergo UCL-R have a low rate of return to MLB play and have shortened careers after return. Pitchers who returned to the MLB level maintained performance in several statistics such as earned run average and walks/hits per innings pitched; however, pitchers returned with a significantly decreased workload.

The Effects of Ulnar Collateral Reconstruction on Major League Pitching Performance

Objectives:A tremendous stress is placed on the elbow while pitching a baseball. Due to these stresses, Major League Baseball (MLB) pitchers are at increased risk for Ulnar Collateral Ligament (UCL) injuries. Previous studies have been limited in sample size, but have shown most players return to previous uninjured statistical levels after undergoing UCL reconstruction. We sought the largest cohort of MLB pitchers who have undergone UCL reconstruction and hypothesized that MLB pitchers do not return to their pre-injury statistical level after undergoing UCL reconstruction.Methods:The statistics for 168 major league pitchers, who threw at least one season at the Major League level and subsequently underwent UCL reconstruction, were reviewed. Statistical data including earned run average (ERA), walks and hits per innings pitched (WHIP), win percentage, innings pitched, and salary were compared for the 3 years before and 3 years after undergoing UCL reconstruction. This data was compared to 178 age matched controlled MLB pitchers. All data was analyzed to determine the effects of UCL injury/reconstruction on pitching performance. Risk factors for reconstruction were analyzed using a multivariable generalized estimating equation (GEE) modelResults:Of the pitchers undergoing UCL reconstruction surgery 87% returned to the Major League Level. Of the pitchers that returned, they had a statistically significant decline in their ERA (P=0.001), WHIP (P=0.011), Innings Pitched (0.026), compared to pre-reconstruction performance. Reconstructed pitchers had a statistically significant decline in their pitching statistical performance in the season before their surgery (ERA p=0.014, WHIP p=0.036, Innings pitched p<0.001, Win Percentage p=0.004). Approximately 60% of pitchers requiring UCL reconstruction had surgery with in the first 5 years of being in the Major Leagues. Compared to age matched controls, the reconstructed pitchers had statistically more major league experience at the same age suggesting that arm stress from earlier Major League experience contributed to injury. This was validated by a multivariable GEE model that examined risk factors showing an increase in MLB experience being a risk factor for requiring surgery (p<0.001).Conclusion:This is the largest cohort of MLB pitchers, to date, that have undergone UCL reconstruction. Its results suggest that UCL reconstructive surgery does a tremendous job in allowing players to return to their same level of sport. This study is the first to describe a decline in pitching performance after undergoing reconstruction. It also found that there is a statistically significant decline in pitching performance the year before reconstructive surgery and this decline was found to be a risk factor for requiring surgery. We also found that there is an increased risk of players requiring surgery if they enter the Major Leagues at a younger age.

What are the Risk Factors for Failure after Conservative Treatment of Ulnar Collateral Ligament Injuries of the Elbow in Baseball Players?

Objectives:Recovery from ulnar collateral ligament (UCL) injury of the elbow was previously thought to be beyond hope for baseball players. In recent years, however, surgical treatment of UCL injury in baseball players has resulted in a high return-to-play rate. Meanwhile, the effectiveness of rehabilitation as conservative treatment has been re-evaluated; many players can return to play by improving bodily functions and pitching forms without surgery. The factors that are cause adverse effect on conservative treatment and that bring them to surgery remain yet unclear. To identify the factors that affect to the results of conservative treatment, we prospectively compared the patients who were able to return to play with the patients who failed.Methods:From November 2009 to June 2012 (31 months), 295 baseball players were diagnosed with UCL injury at our facility. Of these, players with pain other than that due to UCL injury, those undergone rehabilitation less than 3 months, and those playing for recreation were excluded. 166 patients who have completed rehabilitation (>3 months) and who could be followed up at a competitive sport level were evaluated in this study. Eighty-two players (age, 16.0 ± 2.0 years) returned to competitive play with conservative treatment (succeeded group) and 84 (age, 18.9 ± 3.8 years) underwent to surgical treatment or could not return to competitive play (failed group). Factors for comparison included existence of ossicle in ligament, presence of symptoms of ulnar nerve disturbance during or after pitching, the extent of UCL injury (partial or complete) on magnetic resonance imaging (MRI), malunion of the medial epicondyle avulsed fragment, DASH sports, etc. They were compared using the statistical software SPSS 20.0.Results:There was an increased risk of negative results in patients with a residual ossicle (relative risk [RR] = 2.6, p<0.01), symptomatic ulnar nerve disorders (RR=2.2, p<0.01), complete UCL injury on MRI findings (RR 4.5, p<0.01) (Tables 1-3), period of pain and DASH score (p<0.01). Complete injury was the most significant factor. Though pitching was stopped for three months, it was a poor return rate of about 33 %. (Table 3) Players with these factors showed a significantly high probability of requiring UCL reconstruction surgery. On the other hand, 82% in players with partial injury could return to play with competitive level. (Table 3).Conclusion:We identified several baseline injuries that may increase the risk of adverse results of conservative treatment in patients with UCL injury in high level baseball players. In UCL injury with a residual ossicle of the ligament-bone junction, repeating sharp pain and remission readily leads to tear of the medial support structure and poor performance. Secondary ulnar nerve symptoms can result from medial instability by UCL injury during extended periods. Thus, these factors were considered to be refractory to conservative treatment. We believe that the results may help in evaluating candidates for surgery for UCL reconstruction.