Outcomes of Revision Elbow Medial Ulnar Collateral Ligament Reconstruction in Professional Baseball Players: An Analysis of 191 Pitchers From 2010 to 2023

Abstract

Background:

The number of medial ulnar collateral ligament (MUCL) reconstructions is increasing. The epidemiology surrounding revision MUCL reconstructions in professional baseball players has not been well defined.

Purpose/Hypothesis:

The purpose was to report the epidemiology of revision MUCL reconstruction in professional baseball players. The authors hypothesized that the number of revision MUCL reconstructions has increased over time and that the rate of return to sport at the same level of play is <70%.

Study Design:

Case series; Level of evidence, 4.

Methods:

All professional baseball pitchers who underwent revision MUCL reconstruction between 2010 and 2023 were identified using the Major League Baseball Health and Injury Tracking System. Rates of return to play, time to return to play, and return to same level of play were recorded and analyzed for pitchers with a minimum follow-up of 2 years. Surgical variables, including technique and graft choice, were also recorded.

Results:

Overall 191 pitchers (mean age, 26.0 years) underwent revision MUCL reconstruction. The mean time between primary and revision surgery was 1381 days (45 months). Of these players, 130 (68%) were Minor League Baseball pitchers. Hamstring tendon autograft was the most commonly used graft source (n = 90; 47%) when compared with palmaris longus autograft (n = 67; 35%). In terms of tunnel configuration, the modified Jobe and docking techniques were used in equal occurrence (n = 70; 37%). After revision MUCL reconstruction, only 72% of professional baseball pitchers were able to return to play at any level at a mean 556 days (18 months), and only 58% were able to return to the same level of play at a mean 604 days (20 months). The mean time between primary and revision MUCL reconstruction was 45 months (3.75 years).

Conclusion:

Revision MUCL surgery continues to be a challenging problem, where the procedure is complex, rehabilitation timelines are prolonged, and outcomes are not always optimal. Accordingly, the authors recommend that these procedures be performed by surgeons with high levels of experience.

Keywords

medial ulnar collateral ligament (MUCL) reconstruction revision elbow baseball pitcher Major League Baseball (MLB)

Medial ulnar collateral ligament (MUCL) injuries have become increasingly common in professional athletes, especially baseball pitchers.^5,13 Camp et al⁵ found that MUCL injuries are the sixth-most common injury in all of baseball. Unfortunately, the number of MUCL injuries is also increasing in youth and adolescent pitchers.¹⁴ While many MUCL injuries can be successfully managed nonoperatively, nonoperative treatment can fail, and pitchers who wish to continue to pitch at a high level often undergo MUCL reconstruction surgery. Although the literature has demonstrated variability in rate of return to play (RTP) after MUCL reconstruction in professional baseball pitchers, most studies have found an RTP rate between 80% and 90%.^3,14

Even though many players successfully RTP after MUCL reconstruction, some will go on to sustain a subsequent MUCL injury. While recovery time from primary MUCL reconstruction has been well documented, the epidemiology, RTP rates, and timing of RTP after revision MUCL reconstruction in professional baseball players have not been well documented. Some studies have used publicly available data and small case series to examine revision MUCL reconstruction and have shown mostly disappointing results.^6,17,18,23 Camp et al⁴ reviewed the early years of revision MUCL reconstruction within the Major League Baseball (MLB) Health and Injury Tracking System (HITS) and found that 55% of players were able to return to the same level (RTSL) of play. Yet, this study included players until 2016, and given the increase in the number of primary MUCL reconstructions each year, it is believed that the number of revision MUCL reconstructions has risen as well. Furthermore, the surgical details of revision MUCL reconstruction, including graft selection and surgical technique, are unclear.

Therefore, the purpose of this study was to report the epidemiology of revision MUCL reconstruction in professional baseball pitchers. We hypothesized that the number of revision MUCL reconstructions has increased over the study period and that the RTSL rate would be <70%.

Methods

All professional baseball pitchers, MLB and Minor League Baseball (MiLB), who underwent revision MUCL reconstruction were identified using the MLB HITS. Pitchers were identified between 2010 (the first year that the HITS database was established) and 2023. All nonpitchers (ie, position players) and primary MUCL reconstructions were excluded. All data were obtained and analyzed in an anonymous and deidentified fashion, and institutional review board approval was therefore waived by the Mayo Clinic. Player demographic information included age at the time of surgery, right- or left-handedness, primary pitching role (starter vs reliever), level of play (MLB vs MiLB), date of first professional contract, date of primary surgery, and date of revision surgery. Surgical details were obtained from each player’s operative report: type of graft (allograft vs autograft), graft source (eg, palmaris longus, hamstring tendon), and tunnel configuration (eg, modified Jobe, docking technique).

HITS is a centralized database that contains deidentified player information and was developed as a league-wide injury surveillance system in 2010 to record player injuries and injury time.¹⁹ HITS has been used in several previous studies and has been found to be a reliable source of information.^5,9-11

Outcomes including RTP with date and RTSL with date were collected to assess time to RTP and RTSL. All players were included in the analysis of trends over time; however, only players with 2-year minimum follow-up (ie, surgery between 2010 and 2021) were in the outcome analysis for RTP and RTSL.

Statistical Analysis

All demographic data are reported using descriptive statistics. Time intervals are reported as means with standard deviations and medians with corresponding ranges. RTP and RTSL status, handedness, primary role, level at the time of surgery (MLB, MiLB), graft type, and tunnel configuration are reported as number and frequency. Comparisons between groups regarding status of RTP and RTSL and time to RTP and RTSL were made by type of graft and tunnel configuration. An unpaired t test was applied to make pairwise comparisons and reported with mean differences, 95% confidence intervals, and P values. Differences in RTP and RTSL status were compared using a chi-square test. Significance of trends over time was determined by linear regressions, and corresponding R² and P values were provided. Statistical significance was defined as P < .05.

Results

In total, 191 professional baseball pitchers (mean age, 26.0 years; range, 17.6-40.4) underwent revision MUCL reconstruction from 2010 to 2023. The mean time from signing to revision surgery was 2078 days (68 months), and the mean time between primary and revision surgery was 1381 days (45 months). Of these players, 61 (32%) were MLB pitchers and 130 (68%) were MiLB pitchers. Table 1 lists throwing handedness, primary role, graft type, and tunnel configuration. The greatest number of revision MUCL reconstructions was performed in 2023 (n = 27) and the fewest in 2010 and 2011 (n = 4) (Figure 1A). Monthly distribution demonstrates the highest surgery months to be May (17%), June (20%), and July (17%) (Figure 1B). The mean ± SD time from the primary MUCL reconstruction to the revision surgery was 1380.7 ± 1107 days.

Table 1

Demographics for All Professional Pitchers Undergoing Revision Ulnar Collateral Ligament Reconstruction From 2010 to 2023^a

	No. (%)
Age, y
Mean ± SD	26.0 ± 4.1
Median (range)	25.4 (17.6-40.4)
Time from signing to surgery, d
Mean ± SD	2078.0 ± 1397
Median (range)	1798 (5-7271)
Time from primary to revision surgery, d (n = 148)
Mean ± SD	1380.7 ± 1107
Median (range)	999 (247-5665)
Handedness
Right	146 (76)
Left	45 (24)
Primary role
Starter	120 (63)
Reliever	71 (37)
Level at time of surgery
MLB	61 (32)
MiLB	130 (68)
Graft type
Autograft palmaris longus	67 (35)
Autograft hamstring	90 (47)
Unknown/other	34 (18)
Tunnel configuration
Docking	70 (37)
Modified Jobe	70 (37)
Unknown/other	51 (26)

MiLB, Minor League Baseball; MLB, Major League Baseball.

Hamstring tendon autograft was the most commonly used graft source (n = 90, 47%) as compared with the palmaris longus autograft for revision MUCL reconstruction (n = 67; 35%) (Table 1, Figure 2A). No significant differences were found in the types of grafts used over time (P = .238 for palmaris, P = .132 for hamstring). In terms of tunnel configuration, the modified Jobe and docking techniques were used in equal occurrence (n = 70; 37%) (Figure 2B).

When RTP and RTSL were evaluated, only players who had surgery before 2021 were included, which left 142 players. Of these, 102 (72%) were able to RTP and 83 (58%) were able to RTSL (Table 2). RTP and RTSL based on graft choice are shown in Table 3 and by tunnel configuration in Table 4.

Table 2

Outcomes for the 142 Pitchers Undergoing Revision MUCL Reconstruction From 2010 to 2021^a

	No. (%)
Days to RTP at any level (n = 102)
Mean ± SD	556 ± 203
Median (range)	503 (248-1280)
Days to RTSL (n = 83)
Mean ± SD	604 ± 250
Median (range)	591 (252-1805)
RTP at any level
Yes	102 (72)
No	40 (28)
RTSL
Yes	83 (59)
No	59 (41)

MUCL, medial ulnar collateral ligament; RTP, return to play; RTSL, return to same level.

Table 3

Comparisons of Outcomes Based on Type of Autograft Tendon Used (Autograft Palmaris Longus vs Autograft Hamstring Tendons)

	Yes	No	P Value	Days to returnMean ± SD	Mean Difference (95% CI)	P Value
Return to play at any level
Palmaris Longus	36 (77%)	11	946	545 ± 212	43.6	.813
Hamstring	54 (76%)	17		589 ± 197
Return to play at same level
Palmaris Longus	30 (64%)	17	.652	538 ± 186	151.2	.256
Hamstring	43 (60%)	29		689 ± 276

Table 4

Comparisons of Outcomes Based on Tunnel Configuration (Docking vs Modified Jobe Techniques)

	Yes	No	P Value	Days to return (Mean ± SD)	Mean Difference (95% CI)	P Value
Return to play at any level
Docking	37 (80%)	11	0.763	593 ± 195	50.0	0.836
Modified Jobe	47 (70%)	16		543 ± 192
Return to play at same level
Docking	31 (60%)	17	0.646	648 ± 164	37.1	0.069
Modified Jobe	38 (60%)	25		611 ± 300

Discussion

As the number of primary MUCL reconstructions continues to rise, it is only logical that the number of revision MUCL reconstructions will increase as well. Our hypotheses were confirmed, as there was a significant increase in the number of revision MUCL reconstructions from 2010 to 2023. The RTSL rate was only 59% at a mean 604 days, demonstrating a guarded prognosis as compared with primary reconstruction in professional baseball pitchers.

Why primary reconstruction fails among these players is still unknown and is likely multifactorial. Previous studies have evaluated graft type but have found no significant difference in need for revision MUCL reconstruction based on graft type.^2,10-12 Timing of RTS after primary MUCL reconstruction has also been evaluated as a potential risk factor for failure after MUCL reconstruction. Erickson et al⁷ evaluated professional baseball players after primary MUCL reconstruction and determined that, on average, players who required a revision MUCL reconstruction returned to play 2 months earlier than players who did not require a revision surgery. While this difference was not statistically significant, it may be clinically relevant. Interestingly, this study revealed that players who required a revision MUCL reconstruction did so at a mean 3.75 years after the index MUCL reconstruction. What is most interesting about this period is that it often takes players 14 to 18 months to RTP after primary MUCL reconstruction, indicating that, once players returned, the ones who went on to need a revision MUCL reconstruction often did so in the first 2 seasons in which they were back to pitching. This may speak to a larger issue with the player’s mechanics, delivery, velocity, and so forth that place added stress on the medial elbow and can lead to ligament failure.^1,20-22 This also may indicate concerns of durability of historical reconstruction techniques given modern pitching demands. However, according to a study by LaPrade et al,¹⁶ pitchers who RTP after revision MUCL reconstruction did not see a change in their fastball velocity as compared with that before the revision MUCL reconstruction.

While the results after primary MUCL reconstruction have been very good, this study provides a much more concerning picture after revision MUCL reconstruction. Although 80% to 90% of pitchers RTSL after primary MUCL reconstruction, <60% of pitchers in this study were able to RTSL after revision MUCL reconstruction.^5,13 The data from this study parallel the study by Camp et al,⁴ who found a 55% rate of RTSL in professional players after revision MUCL reconstruction until 2016. It does not appear that changes in technique between 2016 and 2021 have improved outcomes. Furthermore, even though the timing of RTP is a significant factor after primary MUCL reconstruction, it is even more detrimental after revision MUCL reconstruction. In this study, it took pitchers a mean 600 days to RTSL after revision MUCL reconstruction, which is roughly 20 months. Depending on when these pitchers underwent surgery, it likely cost them 2 full seasons of play. Therefore, this study suggests that revision MUCL reconstruction has a long way to go before the outcomes can be considered optimal. This is likely why some physicians are experimenting with novel techniques that have not yet been clinically studied. For example, whereas some surgeons will treat a failed MUCL reconstruction with a revision MUCL reconstruction, some now will perform an MUCL repair of the previous graft with or without suture augmentation for certain tear types and indications. This technical modification is aimed to shorten the recovery time from the 600 days seen in the present study. Future work is needed to evaluate the success of this technique.

The annual trend in the number of revision MCUL procedures is also interesting. While the numbers generally slowly increased year over year, there was a steep decline in 2020. Even though the exact reason for this is unknown, the season length and therefore the throwing volume were decreased because of the COVID-19 pandemic in 2020. This decrease in throwing volume may have led to the significant decline in the number of revision MUCL reconstructions as the numbers returned to expected levels in 2021 when players resumed their normal throwing volumes. One last important finding from this study is that there was no significant difference in RTSL rate or timing of RTSL for pitchers who underwent revision MUCL reconstruction with a either palmaris or hamstring tendon autograft or for players who underwent their revision surgery with a modified Jobe technique as compared with a docking technique. These results mirror those of primary MUCL reconstruction where studies have found no differences in RTS rates among surgical techniques.^8,15 Surgeons should feel comfortable using either technique and either graft choice in revision MUCL reconstruction. Furthermore, while the players in this study are professional level, the number of MUCL procedures and therefore revision MUCL procedures in high school and professional players is also increasing.¹⁴ It is likely, although not certain, that the results of this study will translate to revision MUCL reconstruction in lower-level baseball players as well.

Limitations

Although the physicians, trainers, and therapists who enter information into the data sets used in this study take great care to do so correctly, it is possible there were inaccuracies in information entry. However, even if this did occur, it is unlikely that this would have significantly affected the results given the size of the data sets. This study evaluated only professional baseball pitchers, so the results may not be generalizable to the entire population. There may be some players who sustained a retear of their initial MUCL reconstruction and were treated nonoperatively with rest, therapy, biologic injections, and so on. These players were not evaluated in this study. It is also possible that players could have returned to play sooner but, given the seasonal timing, had to wait until the season started and therefore had a longer time to RTP. Last, the scope of the study suggests that the postoperative rehabilitation was likely quite variable across throwers.

Conclusion

After revision MUCL reconstruction, only 72% of professional baseball pitchers were able to RTP at any level at a mean 556 days (18 months), and only 59% were able to RTSL at a mean 604 days (20 months). The mean time between primary and revision MUCL reconstruction was 45 months (3.75 years). Revision MUCL surgery continues to be a challenging problem where the surgery is complex, rehabilitation timelines are prolonged, and outcomes are not always optimal. Accordingly, we recommend that these procedures be performed by surgeons with high levels of experience.

Footnotes

Acknowledgements

The authors acknowledge the Professional Baseball Athletic Trainers Society for its continued efforts in updating the Major League Baseball injury database and for the care of these athletes.

Submitted October 3, 2024; accepted December 20, 2024.

One or more of the authors has declared the following potential conflict of interest or source of funding: B.J.E. is a board or committee member of the American Orthopaedic Society for Sports Medicine and American Shoulder and Elbow Surgeons and has received research support from Arthrex, DePuy, Linvatec, Smith & Nephew, and Stryker; consulting fees from Arthrex and DePuy; and support for education from Arthrex, Pinnacle, Gotham Surgical, and Smith & Nephew. C.L.C. has received consulting fees from Arthrex, research support from Major League Baseball, and publishing royalties from Springer. P.N.C. is a board or committee member of the American Shoulder and Elbow Surgeons and has received royalties from DePuy, Exactech, and Responsive Arthroscopy; consulting fees from DePuy, Exactech, Medical Device Business Services, Encore Medical, Responsive Arthroscopy, and Smith & Nephew; and research support from Smith & Nephew. P.N.C. also holds stock or stock options in TitinKM Biomedical. T.B.G. has received support for education from United Orthopedics. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

ORCID iDs

Brandon J. Erickson

Christopher L. Camp

Peter N. Chalmers

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