Tom Brennan - TJS/UCL Literature

Any baseball fan knows that elbow injuries are a baseball epidemic.

BEFORE THE ARTICLE:

The NY Post reported the following:

After MLB and the MLBPA met for a bit over an hour and a half at MLBPA headquarters in midtown on Sunday — with the union making its first proposal since talks broke down in Jupiter, Fla. on Tuesday — MLB responded by saying the two sides were “deadlocked.”

Two thoughts: 

1) IDIOTS!  

2) Let me be Solomon - I'll split the baby for them.

Now, the article:

As Mets fans, we all know from our current and ex-Met players that needed Tommy John Surgery (TJS or UCL) in their careers: 

deGrom, Syndergaard, Matz, Harvey, Wheeler, Rivera, d'Arnaud, Ginn, Allan, Szapucki, and quite a few others over the years.  

Also, many a college prospect ends up needing TJS, impacting their draft status.  

So, I wondered, what does literature have to say about TJS?  

I dipped my toe in the large pool of articles, and briefly looked at summaries for 4 articles, published on an NIH website.

(one article's link is https://pubmed.ncbi.nlm.nih.gov/34377712/).

In conclusion, I am just throwing this topic out there for your consideration - in case it truly piques your interest - I found, rightly or wrongly, that at the moment, I am not feeling motivated to delve into the issue further at the moment. 

But you might be motivated, and the literature out there is plentiful if you are.  

I imagine every smart MLB team is extremely educated on the subject, because it has to make player decisions based on the best available data.

1) Outcomes in "revision Tommy John surgery" in MLB pitchers (2016 article published by the NIH) (revision TJS is defined as a 2nd Tommy John Surgery):

Background: With the recent rise in the number of TJS, a proportionate rise in revisions is expected. However, much is unknown regarding the current revision rate of TJS, return to play, and change in performance in Major League Baseball (MLB) pitchers.

Methods: Publicly available databases were used to obtain a list of all MLB pitchers who underwent primary and revision Tommy John surgery. Pitching performance preoperatively and postoperatively for pitchers who returned to 1 or more MLB games after revision surgery was compared with controls matched for age and position.

Results: Since 1999, 235 MLB pitchers have undergone TJS; 31 pitchers (13.2%) underwent revision surgery, and 37% underwent revision within 3 years of the index procedure. 26 revisions had more than 2 years of follow-up; 17 pitchers (65.4%) returned to pitch at least 1 major league game, whereas only 11 (42.3%) returned to pitch 10 or more games. 

Of those who returned to MLB competition, the average length of recovery was 20.76 months. Compared with controls matched for age and position, MLB pitchers undergoing revision surgery had a statistically shorter career after revision surgery (4.9 vs 2.6 seasons, P = .002), pitched fewer innings, and had fewer total pitches per season.

Conclusions: The rate of revision TJS is substantially higher than previously reported. For MLB pitchers, return to play after revision surgery is much lower than after primary reconstruction. The overall durability of MLB pitchers after revision ulnar collateral ligament reconstruction decreases significantly compared with controls matched for age and matched controls.

2) Return-to-Play and Competitive Outcomes After Ulnar Collateral Ligament Reconstruction Among Baseball Players: A Systematic Review (Dec. 2020 Article in NIH):

Background: Ulnar collateral ligament (UCL) reconstruction (UCLR) is very common in baseball. However, no review has compared the return-to-play (RTP) and in-game performance statistics of pitchers after primary and revision UCLR as well as of position players after UCLR.

Purpose: To review, synthesize, and evaluate the published literature on outcomes after UCLR in baseball players to determine RTP and competitive outcomes among various populations of baseball players.

Methods: A literature search including studies between 1980 and November 4, 2019, was conducted for articles that included the following terms: ulnar collateral ligament, elbow, medial collateral ligament, Tommy John surgery, throwing athletes, baseball pitchers, biomechanics, and performance. To be included, studies must have evaluated baseball players at any level who underwent UCLR (primary or revision) and assessed RTP and/or competitive outcomes.

Results: A total of 29 studies with relatively high methodological quality met the inclusion criteria. After primary UCLR, MLB pitchers returned to play in 80% to 97% of cases in approximately 12 months; however, return to the same level of play (RTSP) was less frequent and took longer, with 67% to 87% of MLB pitchers returning in about 15 months. 

RTP rates for MLB pitchers after revision UCLR were slightly lower, ranging from 77% to 85%, while RTSP rates ranged from 55% to 78%. RTP rates for catchers (59%-80%) were generally lower than RTP rates for infielders (76%) and outfielders (89%). 

All studies found a decrease in pitching workloads after UCLR. Fastball usage may also decrease after UCLR. Changes in earned run average and walks plus hits per inning pitched were inconclusive.

Conclusion: Pitchers returned to play after UCLR in approximately 12 months and generally took longer to return to their same level of play. Pitchers also returned to play less frequently after revision UCLR. After both primary and revision UCLR, professional pitchers experienced decreased workloads and potentially decreased fastball usage as well. 

Catchers may RTP after UCLR less frequently than pitchers, infielders, and outfielders possibly because of the frequency of throwing in the position. These results will help guide clinical decision making and patient education when treating UCL tears in baseball players.

3) Short-Term Trends in Elbow Ulnar Collateral Ligament Surgery in Collegiate Baseball Players: An Analysis of 25,587 Player-Years (Jul 2021)

Background: Trends over time in the incidence of ulnar collateral ligament (UCL) surgeries in National Collegiate Athletic Association Division I baseball players are currently unknown.

Purpose/hypothesis: The purpose of this study was to evaluate the trends in UCL surgeries over 3 years in Division I baseball programs. We hypothesized that surgical injuries would be consistently high over the course of the study.

Methods: Athletic trainers from Division I baseball programs were invited to participate in an electronic survey over 3 seasons. A total of 155 baseball programs agreed to participate in 2017, 294 programs participated in 2018, and 296 programs participated in 2019. After each of the 3 collegiate baseball seasons, the athletic trainer from each program entered anonymous, detailed descriptive data and surgical information on injured players into a secured database.

Results: During the 3 years of this study, 100% of the enrolled programs successfully completed the survey (155/155 in year 1, 294/294 in year 2, and 296/296 in year 3). This registry of 745 completed surveys over 3 years represented 25,587 player-years from Division I collegiate baseball. 

The percentage of programs with at least 1 UCL surgery during this time was 57% in 2017, 51% in 2018, and 49% in 2019. The majority of these players were pitchers (84% overall from the 3 years). Seniors underwent a significantly lower percentage of the UCL surgeries (8% in 2017, 10% in 2018, and 13% in 2019) than did underclassmen. 

Surgeries were performed most often in-season and least often during the preseason. A slight majority of players undergoing surgery originated from warm-weather states, but the number of these players was never significantly higher than was the number of players from cold-weather states. 

Most surgeries performed each year were UCL reconstruction, but the percentage of UCL repair with ligament augmentation increased each year (10% UCL repairs in 2017, 20% in 2018, and 25% in 2019).

Conclusion: UCL injuries requiring surgery were found to be a major source of morbidity in Division I collegiate baseball, supporting our hypothesis. This study can serve as a baseline for tracking long-term trends in UCL surgeries in collegiate baseball.

4) Return to Play Following Nonoperative Treatment of Partial Ulnar Collateral Ligament Injuries in Professional Baseball Players: A Critically Appraised Topic (2018)

Clinical Scenario: Ulnar collateral ligament (UCL) injuries are highly prevalent in professional baseball players with the success of operative management being well known in the literature. Return to play (RTP) rates following nonoperative management of partial UCL injuries in professional baseball players are not well established in the literature. With a UCL tear being a potential career-ending injury, it is imperative that the best treatment option is provided to these throwing athletes. 

There is an increase in the incidence of UCL surgical rates and a lack of general agreement on nonoperative treatment of partial UCL injuries as reported by the American Shoulder and Elbow Surgeons in 2017. There is also a lack of clarity on when to initiate rehabilitation, which may be due to the limited amount of studies reporting success of RTP rates and time to RTP following conservative interventions of partial UCL injuries. 

Evidence on the RTP rates seen following conservative management of partial UCL tears injuries can help guide health care providers in deciding on the best treatment option for professional baseball athletes who desire to return to their athletic careers. These rates of RTP will add valuable objective input when determining if conservative management is the best choice. To determine the current evidence, inclusion criteria for the literature search consisted of RTP rates following conservative treatment in professional baseball players between inception and 2018. 

Clinical Question: Is there evidence for successful RTP rates in professional baseball players following conservative treatment of a UCL injury? 

Summary of Key Findings: Three retrospective studies met the inclusion criteria and were included. Of those, 2 reported RTP rates following a nonoperative rehabilitation program of a UCL injury, whereas 1 reported RTP rates after injection therapy in subjects who attempted a trial of conservative treatment. All 3 studies considered location and grade of UCL tear. 

Successful RTP rates (66%-100%) were reported in professional baseball players following nonoperative treatment of partial UCL injuries. 

Clinical Bottom Line: Current evidence supports high success with RTP rates up to 100% after nonoperative treatment of grade 1 UCL injuries in professional baseball players and between 66% and 94% for a grade 2 and above. 

There is level C evidence for high RTP rates following nonoperative treatment of partial UCL injuries in professional baseball players.