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Study finds no correlation between number of pitches, risk for revision UCL reconstruction
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Investigators of this study found no correlation between an increased chance for a pitcher to need revision ulnar collateral ligament reconstruction and the number of innings pitched, the number of pitches thrown in the first full season and the number of pitches thrown throughout the pitcher’s career.
“Estimates of return to play are eye-opening,” Anthony A. Romeo, MD, Chief Medical Editor of Orthopedics Today, said in a press release from Midwest Orthopedics at Rush. “Approximately 20% of [Major League Baseball] MLB players will not achieve their preinjury level of performance following this surgery, and it takes the ones who do return to their preinjury level of play an average of 15 months or longer to do so. Preventing a second injury to the elbow is critical as revision surgery is less successful at returning the pitcher to the same level of play.”
He added, “However, it does not appear that instituting limits on the number of innings pitched after a full return to pitching has an impact on preventing revision [ulnar collateral ligament reconstruction] UCLR surgery.”
Romeo and his colleagues identified 154 MLB pitchers from 1974 to 2015 who pitched for at least one full season after they underwent (UCLR). Investigators recorded pitch counts and innings pitched for full season following the UCLR and also recorded the total pitch counts and innings pitched. Players who needed revision UCLR and players who did not were compared with regard to the pitch counts and innings pitched.
Results showed 135 pitchers did not need revision UCLR. Investigators noted the differences were not significant between pitchers who underwent revision UCLR and those who did not with regard to the number of innings pitched within the season following the UCLR and the number of pitches thrown in the season following the reconstruction. They also found no significant differences between the groups for the number of innings pitched in the player’s entire career following the UCLR and the number of pitches thrown in their career following the procedure.
According to researchers, the revision rates were not different between the pitchers who pitched more or less than 180 innings within the full season following the UCLR.
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Disclosures: Romeo reports research support from DJO Surgical, Össur and Smith & Nephew; and receives IP royalties, other financial support, material support and is a paid consultant/ paid presenter for Arthrex Inc. Please see the full study for a list of all other authors’ relevant financial disclosures.
Perspective
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Christopher S. Ahmad, MD
The title of this article is in the form of a question addressing a controversial topic in the management of professional baseball: Should we limit innings pitched after ulnar collateral ligament reconstruction in major league baseball pitchers? The authors answer this question by examining public data on major league baseball pitchers who pitched at least one full season after Tommy John surgery. A cohort of 154 pitchers compared with 19 requiring revision surgery led to a conclusion that the number of innings pitched and number of pitches thrown in the first full season after Tommy John surgery are not associated with an increased risk of revision surgery.
This is an extremely important study since throwing volume guidelines following Tommy John Surgery are not currently based on evidence. The small sample size and use of public data in this study limit that analysis of the many variables that may influence revision surgery. Another important factor relates to seasonal timing that often forces pitchers to return following surgery in the middle of a season with numbers of innings limited by that season itself. This equates to a period of gradual increased pitching volume with an off season of rest before going into a first full season. This study did not analyze the effect of a partial season prior to a full season. Re-injury to the graft may occur in two separate categories. The first is more of an immediate injury within the first 2 years of return and the second is a player who gets reinjured many years after his primary operation. A more recent re-injury from the time of surgery suggests factors related to compromised healing that could include early excessive workloads. A closer look at this particular early failure cohort in the future as sample size increases will be valuable.
Another important feature of injury risk is year-over-year increase in throwing volume. A comparison of throwing volume prior to surgery compared to after surgery in individual pitchers may provide greater insight to revision risk. As an example, if a pitcher has never thrown more than 180 innings prior to surgery, increased risk may be incurred with pitching 180 innings in the season following surgery. Furthermore, data on volume of pitching in minor leagues leading up to the professional level could serve useful in developing workload guidelines.
Finally, while professional athletes are of great interest, our fastest growing population of Tommy John procedures are in the high school- and college-level athletes, and understanding and developing postsurgical work load guidelines for those athletes are extremely important and cannot be derived from the current study. Overall, this study is an excellent contribution in an area that requires ongoing study.
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