long-term outcomes after ulnar collateral ligament...
TRANSCRIPT
1
1
2
3
LONG-TERM OUTCOMES AFTER ULNAR COLLATERAL LIGAMENT 4
RECONSTRUCTION IN COMPETITIVE BASEBALL PLAYERS: 5
A MINIMUM OF 10 YEARS FOLLOW-UP 6
7
Daryl C. Osbahr, MD 1 8
E. Lyle Cain, Jr, MD 2 9
B. Todd Raines, MA, ATC 3 10
Dave Fortenbaugh, PhD 2 11
Jeffrey R. Dugas, MD 2 12
James R. Andrews, MD 2 13
14
1 MedStar Union Memorial Hospital 15
Baltimore, Maryland 16
17
2 American Sports Medicine Institute 18
Birmingham, Alabama 19
20
3 University of Alabama School of Medicine 21
Birmingham, Alabama 22
23
2
ABSTRACT 24
25
Background: Ulnar collateral ligament (UCL) insufficiency was previously considered a career-26
ending injury in baseball players as these throwing athletes were unable to reach or maintain 27
peak performance because no reproducible surgical technique was available for repair or 28
reconstruction. However, the introduction of a reliable modern-day technique for UCL 29
reconstruction has afforded baseball players with excellent results, with return to the same or 30
higher level play from 80% to 90% of the time. Despite these successful results, all previous 31
studies have described only short-term reconstruction outcomes, with less than 3.5 years of 32
average follow-up. 33
34
Purpose: The purpose of this investigation is to evaluate long-term outcomes (minimum 10-year 35
follow-up) after UCL reconstruction in baseball players to elucidate critical information 36
pertaining to the ultimate level and longevity of return to competitive play as well as the long-37
term disability, satisfaction, and subjective findings. 38
39
Study Design: Case Series 40
41
Methods: We identified all UCL reconstructions performed on competitive baseball players by 42
the senior author with a minimum 10-year follow-up. Surgical data were collected prospectively 43
and patients were surveyed retrospectively by telephone using a questionnaire, Conway scale, 44
and Disabilities of the Arm, Shoulder and Hand (DASH) scoring system, including work and 45
3
sports modules, to determine baseball and post-baseball career outcomes at a minimum of 10 46
years after surgery. 47
48
Results: Two hundred fifty-six of 313 patients (82%) were contacted at an average of 12.6 years 49
(range, 10.1 to 17.1 years). The average age at the time of surgery was 22.1 years (range, 15.9 to 50
41.7 years), and the average age at follow-up was 34.7 years (range, 26.4 to 54.5 years). In terms 51
of baseball career outcomes, 83% of these baseball players (89% pitchers) were able to return to 52
the same or higher level of competition in less than one year, but return to same or higher level 53
of play results did vary according to pre-operative level of play (major league: 79%; minor 54
league: 76%; college: 92%; high school: 79%). (p = 0.049) Baseball career longevity after UCL 55
reconstruction was 3.6 years in general and 2.9 years at the same or higher level of play, but 56
major league and minor league baseball players returned for a longer period of time after surgery 57
(p< 0.001). Concomitant procedures at the time of UCL reconstruction (p = 0.007) and post-58
operative elbow surgery (p= 0.015) resulted in a longer career after primary UCL reconstruction. 59
Baseball retirement typically occurred for reasons other than the elbow (86%), except in cases of 60
a post-operative elbow surgery (p < 0.001) or ulnar neuropathy (p = 0.018). Many baseball 61
players also had shoulder problems (34%) or surgery (25%) during the course of their baseball 62
career, and these occurrences most often resulted in retirement due to the shoulder. (p < 0.001) 63
At long-term follow-up, 93% of patients were satisfied, with few reports of persistent elbow pain 64
(3%) and limitation of elbow function (5%) during activities of daily living. In addition, 92% of 65
the baseball players were able to throw currently without elbow pain, and 98% were still able to 66
participate in throwing activities at least on a recreational level. According to the overall DASH, 67
DASH work module, and DASH sports module scoring systems, 10 year minimum follow-up 68
4
scores were 0.80, 1.10, and 2.88, respectively. In addition, many patients were participating in 69
activity/manual labor related jobs (58%) and baseball related activities (61%), including 70
coaching and/or instruction. 71
72
Conclusion: Long-term follow-up of UCL reconstruction in baseball players indicates that most 73
patients are satisfied, with few reports of persistent elbow pain and limitation of elbow function 74
during activities of daily living. During their baseball career, most of these athletes are able to 75
return to the same or higher level of competition in less than one year, with acceptable career 76
longevity and retirement typically for reasons other than the elbow. Regardless of the elbow 77
history, a concomitant history of shoulder problems and/or surgery will most often result in 78
retirement secondary to the shoulder. According to our standardized disability and outcome 79
scale, patients also have excellent results in comparison to the general population after UCL 80
reconstruction during daily, work, and sporting activities. In fact, many patients are able to 81
participate in activity/manual labor related jobs and baseball related activities, including 82
coaching and/or instruction. Overall, baseball players who undergo UCL reconstruction for UCL 83
insufficiency during their baseball career can expect excellent long-term follow-up outcomes in 84
relation to their baseball and post-baseball career, with overall patient satisfaction in the setting 85
of few cases of persistent elbow disability. 86
87
88
Key Words: Elbow, Ulnar Collateral Ligament Insufficiency, Ulnar Collateral Ligament 89
Reconstruction; Tommy John Surgery; Baseball 90
91
5
INTRODUCTION 92
93
Elbow problems in throwing athletes were first documented in professional baseball players in 94
1941 by Bennett.2 During the late cocking and acceleration phases of the throwing motion, the 95
elbow is subjected to excessive valgus stresses which generate tremendous forces to the medial 96
structures of the elbow, and most valgus moments are resisted primarily by the anterior bundle of 97
the ulnar collateral ligament (UCL).13, 20
Repetitive overloading associated with the throwing 98
motion causes microscopic tears in the UCL with subsequent ligament attenuation and failure 99
with the onset of degenerative changes, inability to throw, and chronic, disabling elbow pain.1, 5,
100
11, 22 101
102
Jobe and colleagues were the first to perform a standard operative technique utilizing a figure-of-103
eight ligament configuration.11
Tunnels were utilized for repair or reconstruction of the anterior 104
band of the UCL along with submuscular ulnar nerve transposition. Our preferred operative 105
procedure has employed a modification of the original Jobe technique by elevating the flexor 106
carpi ulnaris (FCU) anteriorly and performing a subcutaneous ulnar nerve transposition.1 We 107
recently published our short-term outcomes for UCL reconstruction in 1281 throwing athletes, 108
including 743 with a minimum of 2-year follow-up.4 In this report, our UCL reconstruction 109
technique resulted in successful return to the same or higher level of play for most athletes (83%) 110
in less than 1 year. 111
112
Our reported results are consistent with other studies detailing that UCL reconstruction may 113
reliably return 80% to 90% of overhead athletes, including baseball players, to their previous or 114
6
higher level of play.5, 8, 12, 17, 19
Despite these successful results, all previous studies have 115
described only short-term reconstruction outcomes, with less than 3.5 years of average follow-116
up. Conway and colleagues, in the only known study with a follow-up period of greater than 3.5 117
years, evaluated Jobe’s original surgical approach (including common flexor-pronator takedown 118
and submuscular ulnar nerve transposition) at an average follow-up of 6.3 years.11
119
120
Therefore, the purpose of our investigation is to evaluate long-term outcomes after UCL 121
reconstruction in baseball players, including a minimum 10-year follow-up. As no known studies 122
exist which analyze long-term outcomes after UCL reconstruction in baseball players, this study 123
will provide critical information pertaining to the ultimate level and longevity of return to 124
competitive play as well as the long-term disability, satisfaction, and subjective outcomes. We 125
hypothesize that UCL reconstruction will allow most baseball players to return to the same or 126
higher level of competitive play, result in a high level of overall satisfaction, and provide high 127
long-term subjective ratings with little long-term disability. 128
129
130
MATERIALS AND METHODS 131
132
We identified all UCL reconstructions performed on competitive baseball players by the senior 133
author with a minimum 10-year follow-up. As previously described, UCL reconstruction was 134
performed through a flexor-pronator muscle elevation approach using a figure-of-8 configuration 135
with an autograft tendon in conjunction with a subcutaneous ulnar nerve transposition.1, 4
(Figure 136
7
1) After surgery, a standardized post-operative 4-phase rehabilitation program for UCL 137
reconstruction was implemented as previously described by Wilk and colleagues.21
138
139
Pre-operative data were obtained prospectively from all patients, including age, position, pre-140
operative level of play, and history of previous shoulder and/or elbow injury. Surgical data were 141
then obtained prospectively for all subjects, including surgery date, graft choice, additional 142
concomitant procedures, and intra-operative complications. All patients were then contacted 143
retrospectively by telephone after a minimum 10-year follow-up period to ascertain information 144
relating to their competitive baseball and post-baseball careers, if applicable. 145
146
Baseball Career Data 147
In terms of their baseball career, each subject’s pre-operative career was evaluated in terms of 148
longevity and levels of competition. Pre-operative competition was counted as the number of 149
active seasons played since the beginning of high school. All pre-operative and post-operative 150
years during which patients were inactive or retired (e.g. disabled list, rehabilitation period, etc.) 151
were not considered active years of play. Furthermore, recreational baseball, including youth, 152
intramural, and adult recreational leagues were not considered active years of competitive play. 153
154
Post-operative outcomes for each subject were classified using a modified version of the Conway 155
Scale.5 This modified Conway Scale ranks outcomes numerically based on the highest post-156
operative level of competition achieved by the subject, as compared to his level of competition at 157
the time of surgery. Outcome scores range from 1 to 4, including 1 as “excellent”, 2 as “good”, 3 158
as “fair”, and 4 as “poor” outcomes. For the current study, the subjects identified as a “Conway 159
8
1” were further divided into 1a and 1b. Conway 1a represented and individual who returned to a 160
higher level of competition for at least one season, and 1b characterized a return to the same pre-161
operative level of competition for at least one season. 162
Each patient’s time to return to throwing and return to competition were confirmed. Return to 163
throwing was defined as the length of time from the date of surgery to beginning the interval 164
throwing program. Return to competition was defined as the length of time from the date of 165
surgery until returning to game competition, if applicable. Additional information was obtained, 166
including post-operative playing status, position, level of play, limitations, and reason for 167
retirement, when applicable. Finally, pre-operative and post-operative elbow and shoulder 168
problems and surgeries were noted. 169
170
Post-Baseball Career Data 171
The remainder of the interview focused on the player’s current health and welfare. These data 172
were collected to evaluate the overall elbow functionality, limitations, and symptoms 173
experienced by each subject in a day to day setting of daily, work, and recreational activities. 174
Variables assessed included overall satisfaction of the UCL reconstruction procedure, day-to-day 175
elbow pain, limitations in elbow function, and elbow pain with recreational throwing. Based on 176
each subject’s current level of competitive throwing, a current Conway score was also assigned, 177
and the current competition status was recorded (active, inactive, or retired). Finally, the 178
Disabilities of the Arm, Shoulder and Hand (DASH) scoring system and its optional work and 179
sports modules were utilized to further evaluate the current symptoms and functionality of the 180
patient’s elbow. 181
182
9
Statistical Analysis 183
The distribution of post-operative and current Conway scores were identified, as were the 184
number of each graft type (ipsilateral palmaris longus, contralateral palmaris longus, 185
contralateral gracilis, and plantaris), reason for retirement (elbow, shoulder, other injury, or non-186
injury), and the frequency of concomitant injuries/surgeries at the time of UCL reconstruction. 187
All of these data was evaluated as based upon the overall group of subjects as well as individual 188
levels of play, including major league, minor league, college, and high school. Furthermore, the 189
percent of individuals with additional elbow surgeries, additional pre-operative elbow surgeries, 190
additional post-operative elbow surgeries, shoulder problems, shoulder surgeries, and post-191
operative neurological problems were also calculated. The percent of subjects involved in post-192
baseball career baseball-related activities and manual labor/activity related jobs were also 193
calculated. In addition, the percent of those individuals involved in throwing sports, non-194
throwing sports, and actively competing in baseball at a competitive level were assessed. The 195
percent of subjects responding “yes” and “no” to elbow pain, limitations with elbow function, 196
and elbow pain when throwing were also calculated. A mean and standard deviation was 197
calculated for the time for return to throwing, time for return to game competition, length of 198
post-operative career, DASH scores, work module DASH scores, and sports module DASH 199
scores. 200
201
Further statistical analyses were performed for eight independent variables, including graft type, 202
concomitant elbow procedures, shoulder problems, shoulder surgeries, additional elbow 203
surgeries, additional prior elbow surgeries, additional post-operative elbow surgeries, and post-204
operative neurological problems. For each of these independent variables, six dependent 205
10
variables were evaluated, including post-operative Conway score, post-operative career 206
longevity, retirement etiology, DASH score, work DASH module, and sports DASH module. 207
Independent t-tests were used to compare the number of years of post-operative competition, 208
DASH score, work DASH module, and sports DASH module, except for analyses of these 209
variables against graft types, which required a one-way ANOVA. For comparison of post-210
operative Conway scores, Mann-Whitney U tests were utilized, except for graft types, for which 211
a Kruskal-Wallis test was performed. Finally, a chi-squared test was utilized for analyzing 212
reasons for retirement. For all tests, the alpha level was set at 0.05. 213
214
215
RESULTS 216
217
Three hundred thirteen baseball players with prospectively collected surgical data were eligible 218
for 10-year minimum follow-up. Two hundred fifty-six athletes (82%) were contacted for 219
follow-up at an average of 12.6 years (range, 10.1 to 17.1 years). The remaining 57 patients 220
could not be reached despite multiple attempts. Of the 256 contacted baseball players, 228 (89%) 221
were pitchers and 28 (11%) were position players, including 10 catchers, 8 outfielders, 6 multi-222
position players, and 4 infielders. In terms of level of play, 24 baseball players were major 223
league, 88 were minor league, 104 were collegiate, and 40 were high school athletes. 224
225
The average age at the time of surgery was 22.1 years (range, 15.9 to 41.7 years), and the 226
average age at follow-up was 34.7 years (range, 26.4 to 54.5 years). Sources of graft tissue 227
included ipsilateral palmaris (71%), contralateral gracilis (14%), contralateral palmaris (9%), and 228
11
plantaris (6%). Thirteen percent (33 players) of the baseball players had at least one pre-229
operative elbow surgery and thirty-four percent (87 players) had a concomitant injury addressed 230
at the time of surgery with both occurrences varying depending upon the pre-operative level of 231
play. (Table 1) Baseball players returned to throwing at an average of 4.2 months ± 0.9 (range, 2 232
to 8 months) and game competition at an average of 11.6 months ± 3.5 (range, 5 to 24 months). 233
234
Baseball Career Data 235
At a minimum of 10-year follow-up, 243 (95%) of the baseball players were retired, while only 236
13 (5%) were still active in competitive baseball. Some baseball players did require post-237
operative elbow surgery or experienced post-operative complications after their primary UCL 238
reconstruction. Nineteen percent (49 players) had at least one post-operative elbow surgery. In 239
fact, 49 players required a total of 59 post-operative surgeries after the primary UCL 240
reconstruction. Of these 59 post-operative surgeries, 30 (51%) were performed for posteromedial 241
impingement which included osteophyte excision. Of the remaining 29 post-operative surgeries, 242
there were eight arthroscopic or open elbow debridements for arthrofibrosis, six revision UCL 243
reconstructions for UCL graft tears, four of six players with medial epicondyle avulsion fractures 244
underwent open reduction internal fixation (two required only immobilization), four ulnar nerve 245
decompressions in three players for persistent ulnar nerve symptoms after ulnar nerve 246
transposition, two lateral elbow debridements for radiocapitellar disease, two general elbow 247
debridements, one of three players with flexor-pronator tears required flexor-pronator repair (two 248
required only non-operative treatment), one hardware removal after open reduction internal 249
fixation of a medial epicondyle avulsion fracture, and one irrigation and debridement for a post-250
operative infection. There was a statistically significant difference between the occurrence of 251
12
post-operative elbow surgery in the major and minor league players compared to the college and 252
high school players. (Table 2) In terms of post-operative ulnar nerve symptoms, 24% of the 253
baseball players had transient ulnar neuropraxia after their UCL reconstruction, but this finding 254
did not vary depending upon pre-operative level of play, including 17% major league, 23% 255
minor league, 30% college, and 18% high school athletes. 256
257
Many of the baseball players had shoulder problems or surgery during the course of their 258
baseball career, as 87 players (36%) had shoulder problems and 65 players (25%) had shoulder 259
surgery. The occurrence of shoulder problems and/or surgery varied as based upon their pre-260
operative level of play, including 46% and 42% for major league, 38% and 30% for minor 261
league, 32% and 23% for college, and 25% and 13% for high school athletes, respectively. 262
Although there was no statistically significant difference in likelihood of a shoulder problem as 263
based upon level of play, there was a statistically significant difference between the occurrence 264
of shoulder surgery in the major and minor league players compared to the college and high 265
school players. (Table 2) 266
267
Return to Play Data 268
According to the Conway scale, 83% of the baseball players returned to the same or higher level 269
of play and varied by pre-operative level of play, which can be visualized in Table 3. In fact, 270
college players (92%) more often returned to the same or higher level of play than major league 271
(79%), minor league (76%), and high school (79%) baseball players. (p = 0.049) Return to play 272
data was also evaluated to determine statistical significance as based upon several independent 273
variables. (Table 4) There was no statistically significant difference between return to play as 274
13
based upon graft choice (p= 0.222) and concomitant injury treatment (p=0.522) at the time of 275
UCL reconstruction. For those patients with post-operative transient ulnar neuropraxia, there was 276
also no statistically significant difference in return to play. (p = 0.642) Return to play according 277
to the Conway scale was not statistically different for those players with a history of an 278
additional elbow surgery. (p = 0.286) This occurrence included whether the additional surgery 279
occurred in the pre-operative (p = 0.590) or post-operative (p = 0.182) setting as referenced to 280
the primary UCL reconstruction. In addition, there was no statistically significant difference in 281
return to play for those players having a history of shoulder problems (p = 0.182) or surgery (p = 282
0.698). 283
284
Longevity Data 285
The overall length of a baseball career after UCL reconstruction was 3.6 years and varied when 286
based upon pre-operative level of play. (Table 5) When assessing career longevity only related to 287
return to the same or higher level of play, the overall baseball career length was 2.9 years and 288
also varied when based upon pre-operative level of play. (Table 5) Longevity data was also 289
evaluated to determine statistical significance as based upon several independent variables. 290
(Table 6) When evaluating graft choice and transient ulnar neuropraxia, there was no statistically 291
significant difference in length of post-operative career at the same or higher level of play. For 292
patients that had a concomitant injury treatment at the time of primary UCL reconstruction, the 293
post-operative career was statistically longer. The post-operative career was not statistically 294
longer for those players having a history of an additional elbow surgery (p = 0.072) or pre-295
operative elbow surgery when compared to the primary UCL reconstruction (p = 0.847). 296
However, this occurrence was statistically significant for those players having post-operative 297
14
elbow surgery when compared to the primary UCL reconstruction. For shoulder pathology, 298
there was no statistically significant difference in length of post-operative career for those 299
players having a history of shoulder problems; however, players who underwent shoulder 300
surgery at some point were more likely to have a longer post-operative career after primary UCL 301
reconstruction. 302
303
Retirement Etiology Data 304
Upon retirement from competitive baseball, most athletes indicated the reason for retirement was 305
based upon a non-injury related etiology followed by shoulder problems, elbow problems, and 306
other injuries. (Table 5) Retirement etiology data was also evaluated to determine statistical 307
significance as based upon several independent variables. (Table 7) There was no statistically 308
significant difference for retirement etiology as based upon graft choice (p = 0.186) or 309
concomitant injury treatment (p= 0.283) at the time of UCL reconstruction. However, patients 310
with post-operative transient ulnar neuopraxia were more likely to retire due to the elbow (p = 311
0.018). When baseball players had an additional elbow surgery (p < 0.001), they were more 312
likely to retire due to the elbow than from another etiology. This included whether the additional 313
elbow surgery was in the pre-operative setting (p = 0.027) or the post-operative setting in relation 314
to the primary UCL reconstruction (p < 0.001). However, those players who had a history of 315
shoulder problems (p < 0.001) or surgery (p < 0.001) were more likely to retire due to the 316
shoulder than from another etiology. 317
318
319
320
15
Post-Baseball Career Data 321
At 10-year minimum follow-up, 93% of the baseball players were satisfied with the results of 322
their UCL reconstruction. Only 3% of the baseball players had elbow pain, while only 5% had a 323
perceived limitation in elbow function. In addition, 92% of the baseball players were able to 324
throw currently without elbow pain, and 98% were still able to participate in throwing activities 325
at least on a recreational level. 326
327
The assessment of DASH scoring showed overall good scores as the overall DASH, DASH work 328
module, and DASH sports module scores were 0.80 ± 4.43, 1.10 ± 6.90, and 2.88 ± 11.91, 329
respectively. There was no statistical difference between pre-operative level of play and the 330
overall DASH (p = 0.334), DASH work module (p = 0.331), and DASH sports module (p = 331
0.205). Post-Baseball Career DASH data was also evaluated to determine statistical significance 332
as based upon several independent variables. (Table 8) 333
334
Based upon graft choice, concomitant injury treatment at the time of UCL reconstruction, 335
shoulder problems, and shoulder surgery, there was no statistically significant difference 336
between DASH, work module, and sports module scores related to elbow disability. For those 337
patients with post-operative transient ulnar neuropraxia, there was a statistically significant 338
difference in lower DASH and DASH sports module scores in relation to elbow disability; 339
however, there was no difference in DASH work module scores. When assessing whether these 340
baseball players had a pre-operative elbow surgery, there was no statistically significant 341
difference in all DASH scores; however, post-operative elbow surgery resulted in a statistically 342
significant lower overall DASH and DASH sports module scores but not DASH work module 343
16
scores. After their competitive baseball careers, many of these baseball athletes were involved in 344
activity/manual labor related jobs and recreational endeavors, and participation occasionally 345
varied as based upon pre-operative level of play. (Table 9) 346
347
348
DISCUSSION 349
350
UCL insufficiency was previously considered a career-ending injury in baseball players as these 351
throwing athletes were unable to reach or maintain peak performance because no reproducible 352
surgical technique was available for repair or reconstruction. With the introduction of a new 353
technique by Dr. Frank Jobe, UCL reconstruction became a reliable procedure to enable 354
throwing athletes to successfully return to play. With modern-day advances in surgical 355
technique, more recent studies show that UCL reconstruction may reliably return athletes to their 356
same or higher level of play from 80% to 90% of the time.5, 8, 12, 17, 19
357
358
Despite these successful results, several questions still exist when considering long-term UCL 359
outcomes. In fact, all current studies evaluating modern-day UCL reconstruction techniques 360
assess only short-term outcomes concerning return to play with an average follow-up of no more 361
than 3.5 years.1, 3, 4, 6, 8, 9, 12, 15, 17, 18
The lack of information relating to long-term outcomes, 362
including baseball and post-baseball career data, provided the basis of our investigation. 363
364
Our results illustrated a successful return to same or higher level of play in 83% of our baseball 365
players, with return to throwing in 4.2 months and return to game competition by 11.6 months. 366
17
In reference to our previous research by Cain and colleagues, the overall return to play results 367
were similar at a longer follow-up interval. In fact, the previous 2-year follow-up case series 368
showed 83% return to the same or higher level of play, with return to throwing in 4.4 months and 369
return to game competition by 11.6 months.4 Our series also identified that 40% of players were 370
actually able to return to a higher level of play after UCL reconstruction, and only 10% were 371
unable to return to competitive baseball (9% recreational level and 1% unable). 372
373
When evaluating return to play after UCL reconstruction, our results are consistent with the 374
previous studies, which report return to same or higher level of play in 80% to 90% of throwing 375
athletes.3, 4, 6, 8, 9, 12, 15, 17, 18
An interesting finding was that successful return to the same or higher 376
level of play varied upon the pre-operative level of play, with college players (92%) more often 377
returning to the same or higher level of play than major league (79%), minor league (76%), and 378
high school (79%) baseball players. These findings corresponded to our 2-year follow-up study 379
by Cain and colleagues which showed better return to the same or higher level of play in college 380
players (88%) than major league (76%), minor league (73%), or high school (83%) players.4 381
382
Many clinicians have debated improved surgical outcomes with different surgical reconstruction 383
techniques, including the figure-of-eight versus docking UCL reconstruction. When evaluating 384
the literature, there are significant variations in the number of patients at each pre-operative level 385
of play within all studies. In fact, the only docking reconstruction technique study with more 386
than 35 patients by Dodson and colleagues reported 90% return to the same or higher level of 387
play in a series that included mostly college baseball players (65.6%) as compared to 388
professional (17.7%) and high school (16.7%) athletes.8 The only other series with more than 35 389
18
baseball players by Thompson and colleagues utilizing a figure-of-eight reconstruction reported 390
82% return to the same or higher level of play in a group of baseball players mostly comprised of 391
professional (65%) baseball players as compared to college (21.7%) or high school/recreational 392
(13.3%) athletes.18
Unfortunately, these two previous studies by Dodson and Thompson do not 393
delineate results as based upon pre-operative level of play.8, 18
For all other studies involving 394
outcomes after UCL reconstruction, the small number of patients makes it difficult to evaluate 395
outcomes according to pre-operative level of play, as there are not enough patients to make 396
reasonable conclusions. Based upon our statistically significant findings of more successful 397
return to play in college players, we should be critical in evaluating the breakdown in pre-398
operative level of play within each study, as results could vary depending upon the percent of 399
baseball players at each level of play. Although UCL reconstruction technique may still be an 400
important component for successful return to play, our results instead indicate that pre-operative 401
level of play is a critical consideration in assessing prognosis for return to the same or higher 402
level of play after UCL reconstruction. 403
404
In conjunction with previous studies evaluating UCL reconstruction outcomes, return to play did 405
not appear to be affected by graft choice.4, 5
In addition, successful return to play as measured by 406
the Conway scale was not affected by other independent variables, including transient ulnar 407
neuropathy, additional elbow surgeries, shoulder problems, or shoulder surgery. Although no 408
other known studies have evaluated these variables in relation to UCL reconstruction, these 409
findings are not surprising considering the Conway scale is based upon short-term return to play 410
with excellent outcomes achieved with return to play for greater than only 12 months. 411
412
19
When assessing the inclusion of concomitant elbow procedures at the time of UCL 413
reconstruction, return to play also appeared to not be affected. This finding should be taken in 414
proper context as not all concomitant injuries confer the same prognosis. In fact, most previously 415
reported concomitant procedures at the time of UCL reconstruction are related to the excision of 416
a posteromedial olecranon osteophyte; however, other more serious injuries may be possible 417
which require additional treatment.4, 5, 14
In a previously reported subpopulation of baseball 418
players with concomitant flexor-pronator injuries, in fact, return to play was much lower with 419
only 12.5% return to the same or higher level of play in 8 athletes.14
Therefore, surgeons should 420
fully consider the type of concomitant procedure when discussing surgical prognosis with 421
baseball players undergoing UCL reconstruction. 422
423
In terms of assessing post-operative baseball career longevity, our minimum of 10-year follow-424
up (average follow-up, 12.3 years) study appeared to be successful in encompassing our 425
subjects’ complete baseball career as 95% were retired with only 5% still active in competitive 426
baseball. Our study is the first known study evaluating longevity of a competitive baseball career 427
after UCL reconstruction. All other modern-day UCL reconstruction outcome studies evaluate 428
only short-term outcomes with no more than 3.5 years follow-up and/or utilize a short-term 429
scoring scale (Conway scale – return to play based upon only 12 months or 1 season).1, 3, 4, 8, 9, 12,
430
15, 17, 18 The overall length of a baseball career after UCL reconstruction in our study was 3.6 431
years but varied when based upon pre-operative level of play. When accounting for only return 432
to same or higher level of play (Conway 1), professional baseball players (major and minor 433
league) interestingly had a shorter length to their post-operative professional baseball career, as 434
they spent a portion of their time at a lower level of play. As baseball career longevity at the 435
20
same or higher level of play is multifactorial, this finding must be taken into proper context. 436
Although this finding could indicate that there is performance attrition after UCL reconstruction, 437
this is not supported with the presented data, as there are not normative values to a baseball 438
career, including in healthy and injured players. Nonetheless, it is critical to understand that 439
successful return to play and continued play at the same level may require frequent evaluation 440
and optimization of throwing mechanics, a well orchestrated throwing program for in-season and 441
off-season athletes, continued monitoring of symptoms or fatigue, and close attention to pitch 442
counts and/or innings limits. These are important factors that must be considered in all throwers 443
to improve, maintain, or obtain health in these high functioning athletes. 444
445
In addition, professional baseball players also appeared to have a longer career after UCL 446
reconstruction than amateur baseball players (college and high school). These occurrences are 447
likely due to the fact that professional baseball players and teams have more expense and time 448
invested into a successful return to play. However, these factors are highly dependent upon many 449
player- and team-specific variables which we are not able to fully evaluate with our present 450
study. 451
452
Baseball career longevity appeared to not be affected by graft choice or transient ulnar 453
neuropathy. However, our results did show that career longevity was increased when a 454
concomitant procedure at the time of primary UCL reconstruction or post-operative elbow 455
surgery was performed. This is counterintuitive to what might be expected but can be possibly 456
explained by several factors. The need for a concomitant elbow procedure or post-operative 457
elbow surgery appeared greatly affected by pre-operative level of play, with professional 458
21
baseball players (major and minor league) more often requiring additional procedures when 459
compared to amateur baseball players (college and high school). As previously stated for our 460
return to play data, this may be related to several circumstances inherent to level of play and 461
invested time in competitive baseball that are not specifically dependent upon the additional 462
elbow procedure alone. Nonetheless, a higher level of pre-operative play, especially with 463
professional baseball players, will likely confer a risk of needing additional elbow surgery; 464
however, the ability to return to play for a significant number of years may not be adversely 465
affected. 466
467
When assessing baseball career longevity, the cause for retirement is extremely important and 468
typically related to injury and non-injury related etiologies. Within our study, we found that over 469
half (57%) of the reasons for retirement were related to non-injury causes; however, shoulder 470
and elbow problems, accounted for 36% of the retirement cases. Despite the reason for 471
retirement, graft choice and concomitant injury treatment did not affect the etiology. As might be 472
expected, however, baseball players with a post-operative elbow surgery or transient ulnar 473
neuropraxia were more likely to retire secondary to elbow problems. 474
475
Based upon previous research, shoulder and elbow injuries in baseball players may often occur 476
concurrently or in succession. Some authors have suggested that these upper extremity injuries 477
may be related in terms of cause and effect; however, little to no research has verified this 478
premise. A recent study by Dines and colleagues provided a possible association with 479
glenohumeral internal rotation deficit in the shoulder and UCL insufficiency in baseball players.7 480
These findings corroborated previous research by Putnam and colleagues which demonstrated 481
22
that shoulder internal rotation moments during throwing may provide the primary protection 482
against valgus loads at the elbow.16
Although we did not find an association between retirement 483
cause when compared to level of return to play, our findings illustrate that shoulder problems 484
and/or surgery may be directly related to the cause of retirement. In addition, a shoulder surgery 485
may impart increased career longevity; however, this finding again is likely multifactorial and 486
related to many player- and team-specific variables which we are not able to fully evaluate with 487
our present study. As shoulder problems (34%) and shoulder surgery (25%) were relatively 488
common occurrences in our group of baseball players, these findings provide important 489
prognostic information and accentuate the need for preventing and properly treating shoulder 490
problems in these overhead athletes. 491
492
Although length and level of return to play as well as the cause of retirement are extremely 493
important factors in assessing success after UCL reconstruction in baseball players, there are no 494
known studies evaluating overall long-term disability and quality of life, especially when 495
considering the post-baseball career. In addition to our success with returning baseball players to 496
play, our results illustrate that UCL reconstruction may afford these athletes with excellent long-497
term outcomes for everyday life, including work and sporting activities. In fact, UCL 498
reconstruction led to high satisfaction (93%) with few cases of persistent elbow pain (3%) and 499
limitation in function (5%). 500
501
DASH scores, including work and sports modules, also appear to indicate excellent results after 502
long-term follow-up for UCL reconstruction. When comparing the DASH scores to normative 503
data from the general population (10.10 ± 14.68), in fact, our group of baseball players had much 504
23
lower scores (0.80 ± 4.31).10
Upon factoring in work and sports related variables, our baseball 505
players also had much lower work module (1.10 ± 6.90 versus 8.81 ± 18.37) and sports module 506
(2.88 ± 11.91 versus 9.75 ± 22.72) scores when compared to those reported for the general 507
population.10
Our lower overall scores when compared to the general population are likely 508
related to the fact that our cohort of baseball players is an active group of young and healthy 509
patients (average age at follow-up is 34.7 years); however, these excellent scores still indicate 510
overall upper extremity health, including during work and sporting activities, in our post-511
operative cohort of patients with minimum 10-year follow-up after surgery. Although patients 512
with post-operative elbow surgery or transient ulnar neuropraxia tended to have higher overall 513
and sports module DASH scores, they were able to function at a high level during work related 514
activities as their work module DASH scores remained low. 515
516
When assessing activity and manual labor activities, 98% of our baseball players are still able to 517
participate in throwing activities at a recreational level, with 92% able to throw without elbow 518
pain. Although a baseball career may be relatively short, most of our baseball players continued 519
their involvement with baseball after their competitive career by participating in baseball-related 520
activities, including coaching and/or instruction. As one might expect, professional baseball 521
players are more likely to participate in baseball activities within their post-baseball career than 522
amateur athletes. As surgeons most often equate UCL reconstruction success in relation to return 523
to competitive play, these findings indicate that there may be long-term advantages to UCL 524
reconstruction within the post-baseball career as many athletes continue to throw and even 525
participate in organized baseball activities. However, one must take caution in interpreting these 526
24
findings, as there are no long-term studies evaluating quality of life and activities after non-527
operative treatment of UCL insufficiency in baseball players. 528
529
Despite our excellent results for baseball career and post-baseball career related variables, 530
several limitations exist when evaluating the findings of this study. First, our rate of follow-up 531
was 82%, as we ideally would be able to have complete follow-up to prevent any potential bias 532
related to those athletes which we could not contact. However, our extended length of follow-up 533
(minimum 10-year) may be expected to have some attrition, and our follow-up rate is even 534
higher than previous studies on UCL reconstruction, including our 2-year follow-up study with 535
79% follow-up.4 Another potential limitation relates to recall bias as many of these players were 536
asked to remember remote details of their baseball and post-baseball career. In most instances, 537
we were able to utilize our prospective and 2-year follow-up databases as well as baseball 538
database internet searches to confirm obtained information. Another limitation is that our data 539
involves a follow-up study detailing one UCL reconstruction technique in baseball players by 540
one surgeon; therefore, there might be some implications for generalizing the results to all UCL 541
reconstruction techniques. Moreover, our group of baseball players is mostly composed of 542
pitchers (90%), which is consistent with other studies evaluating outcomes after UCL 543
reconstruction, and this point should be considered when extrapolating this information to 544
baseball position players as well as other throwing athletes. 545
546
A final limitation to our study is that our data describes results of UCL reconstruction that were 547
performed over 10 years ago. In fact, there may now be differences in diagnostic, surgical, 548
rehabilitative, return to play, and on the field considerations that now allow for improved 549
25
optimization of treatment and recovery from UCL reconstruction. In fact, we are now better at 550
diagnosing these injuries in an expeditious fashion which may result in less severe pathology and 551
subsequently improved outcomes. In addition, our management of these athletes after they have 552
returned to play has improved as we now understand that it may take even 18 to 24 months 553
before achieving optimal on-the-field results after UCL reconstruction, especially in pitchers. By 554
further appreciating the unique nature of the return to play algorithm in these baseball throwers, 555
management and coaches now afford baseball players more time to return to play and are more 556
eagerly involved in improving mechanics, maintaining health, and preventing future injury in 557
these highly skilled and at risk athletes. Despite these limitations, our data appears to be 558
consistent with other short-term case series evaluating UCL reconstruction and may provide 559
important prognostic and preventative long-term information to physicians who treat overhead 560
athletes, especially baseball players. 561
562
563
CONCLUSION 564
565
Based upon baseball and post-baseball career variables, our study is the first to provide important 566
prognostic information relating to long-term outcomes (10-year minimum follow-up) after UCL 567
reconstruction with subcutaneous ulnar nerve transposition in baseball players. In agreement 568
with previous short-term studies concerning a competitive baseball career, our long-term follow-569
up results confirm that UCL reconstruction may be effective in allowing most baseball players 570
(83%) to return to the same or higher level of competition in less than one year. We also present 571
unique prognostic data indicating that career longevity may portend multiple years of active 572
26
return to play (average, 3.6 years), with some variation depending upon the pre-operative level of 573
play. Despite the level and length for return to play, the cause for retirement (86%) typically 574
relates to other reasons independent of the elbow, except in cases of additional post-operative 575
elbow surgery. Interestingly, a concomitant history of shoulder problems and/or surgery will 576
most often result in retirement due to the shoulder and not the elbow. 577
578
In conjunction with their baseball career, long-term follow-up also indicates that most (93%) 579
patients are satisfied, with few reports of persistent elbow pain (3%) and limitation of elbow 580
function (5%) during activities of daily living. Almost all patients are also able to continue 581
participating in recreational throwing activities, with most indicating no pain with throwing. 582
According to our standardized disability and outcome scale, patients also have excellent results 583
after UCL reconstruction during daily, work, and sporting activities. In fact, many patients are 584
able to participate in activity/manual labor related jobs and baseball related activities, including 585
coaching and/or instruction. Overall, baseball players who undergo UCL reconstruction for UCL 586
insufficiency during their baseball career can expect excellent long-term follow-up outcomes in 587
relation to their baseball and post-baseball career, with overall patient satisfaction in the setting 588
of few cases of persistent elbow disability.589
27
REFERENCES
1. Azar FM, Andrews JR, Wilk KE, et al: Operative treatment of ulnar collateral ligament
injuries of the elbow in athletes. Am J Sports Med 28(1): 16-23,2000
2. Bennett GE: Shoulder and elbow lesions of the professional baseball pitcher. JAMA 117: 510-
514,1941
3. Bowers AL, Dines JS, Dines DM, et al: Elbow medial ulnar collateral ligament reconstruction:
clinical relevance and the docking technique. J Shoulder Elbow Surg 19(2 Suppl): 110-117,2010
4. Cain EL,Jr, Andrews JR, Dugas JR, et al: Outcome of ulnar collateral ligament reconstruction
of the elbow in 1281 athletes: Results in 743 athletes with minimum 2-year follow-up. Am J
Sports Med 38(12): 2426-2434,2010
5. Conway JE, Jobe FW, Glousman RE, et al: Medial instability of the elbow in throwing
athletes. Treatment by repair or reconstruction of the ulnar collateral ligament. J Bone Joint Surg
Am 74(1): 67-83,1992
6. Dines JS, ElAttrache NS, Conway JE, et al: Clinical outcomes of the DANE TJ technique to
treat ulnar collateral ligament insufficiency of the elbow. Am J Sports Med 35(12): 2039-
2044,2007
7. Dines JS, Frank JB, Akerman M, et al: Glenohumeral internal rotation deficits in baseball
players with ulnar collateral ligament insufficiency. Am J Sports Med 37(3): 566-570,2009
28
8. Dodson CC, Thomas A, Dines JS, et al: Medial ulnar collateral ligament reconstruction of the
elbow in throwing athletes. Am J Sports Med 34(12): 1926-1932,2006
9. Hechtman KS, Zvijac JE, Wells ME, et al: Long-term results of ulnar collateral ligament
reconstruction in throwing athletes based on a hybrid technique. Am J Sports Med 39(2): 342-
347,2011
10. Hunsaker FG, Cioffi DA, Amadio PC, et al: The American academy of orthopaedic surgeons
outcomes instruments: normative values from the general population. J Bone Joint Surg Am 84-
A(2): 208-215,2002
11. Jobe FW, Stark H, Lombardo SJ: Reconstruction of the ulnar collateral ligament in athletes. J
Bone Joint Surg Am 68(8): 1158-1163,1986
12. Koh JL, Schafer MF, Keuter G, et al: Ulnar collateral ligament reconstruction in elite
throwing athletes. Arthroscopy 22(11): 1187-1191,2006
13. Morrey BF, An KN: Articular and ligamentous contributions to the stability of the elbow
joint. Am J Sports Med 11(5): 315-319,1983
14. Osbahr DC, Swaminathan SS, Allen AA, et al: Combined flexor-pronator mass and ulnar
collateral ligament injuries in the elbows of older baseball players. Am J Sports Med 38(4): 733-
739,2010
15. Paletta GA,Jr, Wright RW: The modified docking procedure for elbow ulnar collateral
ligament reconstruction: 2-year follow-up in elite throwers. Am J Sports Med 34(10): 1594-
1598,2006
29
16. Putnam CA: Sequential motions of body segments in striking and throwing skills:
descriptions and explanations. J Biomech 26 Suppl 1: 125-135,1993
17. Rohrbough JT, Altchek DW, Hyman J, et al: Medial collateral ligament reconstruction of the
elbow using the docking technique. Am J Sports Med 30(4): 541-548,2002
18. Thompson WH, Jobe FW, Yocum LA, et al: Ulnar collateral ligament reconstruction in
athletes: muscle-splitting approach without transposition of the ulnar nerve. J Shoulder Elbow
Surg 10(2): 152-157,2001
19. Vitale MA, Ahmad CS: The outcome of elbow ulnar collateral ligament reconstruction in
overhead athletes: a systematic review. Am J Sports Med 36(6): 1193-1205,2008
20. Werner SL, Fleisig GS, Dillman CJ, et al: Biomechanics of the elbow during baseball
pitching. J Orthop Sports Phys Ther 17(6): 274-278,1993
21. Wilk KE, Arrigo C, Andrews JR: Rehabilitation of the elbow in the throwing athlete. J
Orthop Sports Phys Ther 17(6): 305-317,1993
22. Wilson FD, Andrews JR, Blackburn TA, et al: Valgus extension overload in the pitching
elbow. Am J Sports Med 11(2): 83-88,1983
30
FIGURE LEGENDS
Figure 1. UCL reconstruction surgical approach for the ASMI Modification utilizing a flexor-
pronator elevation ( ) to the UCL along with an ulnar nerve ( ) transposition. Note the
first motor branch of the ulnar nerve ( ) in relation to the medial epicondyle (O) through the
muscle split between the two heads of the flexor carpi ulnaris ( ).
31
TABLE LEGENDS
Table 1. Background Data: Pre-operative Elbow Considerations as Based upon Pre-operative
Level of Play.
* Significant difference among levels (p < 0.05)
Table 2: Background Data: Shoulder History and Post-operative Elbow History as Based upon
Pre-operative Level of Play.
* Significant difference among levels (p < 0.05)
Table 3: Baseball Career Related Data: Post-operative Return to Play According to the Conway
Scale as Based Upon Pre-operative Level of Play.
(NA – Not Applicable)
Table 4: Baseball Career Related Data: Post-operative Conway Scale in Relation to Independent
Variables.
* Significant difference (p < 0.05)
Key: IP (Ipsilateral Palmaris)
CP (Contralateral Palmaris)
CG (Contralateral Gracilis)
PL (Plantaris)
32
Table 5: Baseball Career Related Data: Post-operative Longevity and Retirement Etiology
According to Pre-operative Level of Play.
* Significant difference among levels (p < 0.05)
Table 6: Baseball Career Related Data: Post-operative Conway 1 Longevity in Relation to
Independent Variables.
* Significant difference (p < 0.05)
Key: IP (Ipsilateral Palmaris)
CP (Contralateral Palmaris)
CG (Contralateral Gracilis)
PL (Plantaris)
Table 7: Baseball Career Related Data: Retirement Etiology in Relation to Independent
Variables.
a Statistical significance related to elbow cause (p < 0.05)
b Statistical significance related to shoulder cause (p < 0.05)
Key: IP (Ipsilateral Palmaris)
CP (Contralateral Palmaris)
CG (Contralateral Gracilis)
PL (Plantaris)
Table 8: Post-Baseball Career Related Data: DASH Scores in Relation to Independent Variables.
* Significant difference (p < 0.05)
33
Table 9: Post-Baseball Career Related Data: Baseball Retirement Activities According to Pre-
operative Level of Play.
* Significant difference (p < 0.05)
34
FIGURES
Figure 1.
35
TABLES
Table 1.
Pre-operative Elbow Considerations
Level of Play
Previous elbow
surgery?*
Concomitant elbow
procedure*
Overall 13% 37%
Major League 25% 59%
Minor League 19% 45%
Collegiate 10% 33%
High School 0% 14%
Table 2.
Shoulder History and Post-operative Elbow History
Level of Play Shoulder problems? Shoulder surgery?* Post-operative elbow surgery?*
Overall 34% 25% 19%
Major League 46% 42% 38%
Minor League 38% 30% 28%
Collegiate 32% 23% 11%
High School 25% 13% 10%
Table 3.
Post-operative Conway Scale
Level of Play Higher Level Same Level Lower Level Recreational Unable to Return
Overall 40% 43% 7% 9% 1%
Major League NA 79% 21% 0% 0%
Minor League 45% 31% 13% 9% 2%
Collegiate 38% 54% 1% 8% 0%
High School 58% 23% 3% 15% 3%
Table 4.
Post-operative Conway Scale (N = 256)
Graft Choice
Concomitant
Surgery
Transient Ulnar
Neuropraxia
Postop Elbow
Surgery
Shoulder
Problem
Shoulder
Surgery
Return to
Play IP CP CG PL Yes No Yes No Yes No Yes No Yes No
Excellent 149 22 28 14 70 143 53 160 37 176 76 137 55 158
Good 13 0 5 0 11 7 3 15 9 9 6 12 5 13
Fair 19 1 2 0 5 17 4 18 2 20 4 18 4 18
Poor 2 1 0 0 1 2 2 1 1 2 1 2 1 2
36
Table 5.
Post-operative Longevity Retirement Etiology *
Level of Play Total Years *
Conway 1
Years
Non-
Injury
Elbow
Injury
Shoulder
Injury
Other
Injury
Overall 3.6 ± 3.1 2.9 ± 2.9 57% 14% 22% 7%
Major League 7.5 ± 3.4 3.5 ± 3.3 57% 10% 24% 10%
Minor League 4.2 ± 3.5 2.9 ± 2.9 40% 23% 28% 9%
Collegiate 2.5 ± 1.9 2.8 ± 2.7 70% 8% 17% 5%
High School 2.9 ± 2.8 2.9 ± 2.8 59% 14% 22% 5%
Table 6.
Post-operative Longevity - Conway 1 Years (N = 256)
Postop
Years Graft Choice
Concomitant
Surgery *
Transient Ulnar
Neuropraxia
Postop Elbow
Surgery *
Shoulder
Problem
Shoulder
Surgery
IP CP CG PL Yes No Yes No Yes No Yes No Yes No
Average 3.6 4.1 3.7 2.7 4.3 3.1 3.3 3.7 4.7 3.3 4.0 3.4 4.3 3.4
P Value 0.644 0.007 0.339 0.015 0.102 0.031
Table 7.
Retirement Etiology (N=243; 13 Players Active)
Graft Choice
Concomitant
Surgery
Transient Ulnar
Neuropraxia a
Postop Elbow
Surgery a
Shoulder
Problem b
Shoulder
Surgery b
Conway Scale IP CP CG PL Yes No Yes No Yes No Yes No Yes No
Elbow 104 12 18 6 40 100 29 110 15 124 21 118 17 122
Shoulder 11 0 5 0 7 8 1 15 2 14 3 13 2 14
Non Injury 34 8 6 6 21 33 17 37 13 41 49 5 35 19
Other 24 4 3 2 13 21 14 20 16 18 8 26 6 28
Table 8.
DASH Scores (P Values)
Independent Variables DASH - Overall DASH - Work DASH - Sports
Graft Choice 0.549 0.493 0.846
Concomitant Elbow Procedure 0.278 0.321 0.295
Additional Elbow Surgery 0.029 * 0.184 0.005 *
Pre-operative Elbow Surgery 0.305 0.448 0.198
Post-operative Elbow Surgery 0.042 * 0.180 0.011 *
Transient Ulnar Neuropraxia 0.028 * 0.181 0.024 *
Shoulder Problem 0.453 0.453 0.725
Shoulder Surgery 0.415 0.657 0.824
37
Table 9.
Baseball Retirement Activities
Level of Play
Baseball-Related
Job *
Activity/Manual Labor
Related Job *
Throwing
Recreational Sports
Non-throwing
Recreational Sports
Overall 61% 58% 92% 70%
Major League 92% 75% 100% 71%
Minor League 74% 69% 93% 64%
Collegiate 50% 51% 92% 74%
High School 40% 38% 83% 75%