Robert A. Keller

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

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

The effects of medial ulnar collateral ligament reconstruction on Major League pitching performance

BACKGROUND Medial ulnar collateral ligament (MUCL) reconstruction is commonly performed on Major League Baseball (MLB) pitchers. Previous studies have reported that most pitchers return to presurgical statistical performance levels after MUCL reconstruction. METHODS Pitching performance data--specifically, earned run average (ERA), walks and hits per inning pitched (WHIP), winning percentage, and innings pitched--were acquired for 168 MLB pitchers who had undergone MUCL reconstruction. These data were averaged over the 3 years before surgery and the 3 years after surgery and also acquired from 178 age-matched, uninjured MLB pitchers. RESULTS Of the pitchers who had MUCL reconstruction surgery, 87% returned to MLB pitching. However, compared with presurgical data, pitching performance declined in terms of ERA (P = .001), WHIP (P = .011), and innings pitched (P = .026). Pitching performance also declined in the season before the surgery compared with previous years (ERA, P = .014; WHIP, P = .036; innings pitched, P < .001; winning percentage, P = .004). Compared with age-matched control pitchers, the MUCL reconstruction pitchers had significantly more major league experience at the same age (P < .001). CONCLUSION MUCL reconstruction allows most players to return to pitching at the major league level. However, after MUCL reconstruction, there is a statistically significant decline in pitching performance. There appears to be a statistically significant decline in pitching performance the year before reconstructive surgery, and this decline is also a risk factor for requiring surgery. In addition, there is an increased risk of MUCL reconstruction for pitchers who enter the major leagues at a younger age.

Liposomal bupivacaine versus interscalene nerve block for pain control after shoulder arthroplasty: a prospective randomized trial

HYPOTHESIS Our hypothesis was that in patients undergoing shoulder arthroplasty, a prospective randomized trial would find no significant differences in average daily pain scores of those treated with interscalene nerve block (INB) vs. local liposomal bupivacaine (LB). METHODS Sixty patients undergoing primary shoulder arthroplasty were assessed for eligibility. Study arms included either intraoperative local infiltration of LB (20 mL bupivacaine/20 mL saline) or preoperative INB, with a primary outcome of postoperative average daily visual analog scale scores for 4 days. Secondary outcomes assessed included opioid consumption, length of stay, and complications. Randomization was by a computerized algorithm. Only the observer was blinded to the intervention. RESULTS Three patients were excluded, all before randomization. A total of 57 patients were analyzed. Outcomes showed a significant increase in pain in the LB group between 0 and 8 hours postoperatively (mean [standard deviation] 5.3 [2.2] vs. 2.5 [3.0]; P = .001). A significant increase in intravenous morphine equivalents was found in the INB group at 13 to 16 hours (mean [standard deviation] 1.2 [0.9] vs. 0.6 [0.7]; P = .01). No significant differences were found in any variable after postoperative day 0 between the 2 groups. CONCLUSION An increase in early postoperative pain on the day of surgery was found with LB, whereas the INB group required more narcotics at the end of the day. After the day of surgery, there were no significant differences found in any variables. These findings suggest that LB provides similar overall pain relief as INB, with no increase in complications or length of stay and a decrease in narcotic requirements on the day of surgery.

Major League Baseball pitch velocity and pitch type associated with risk of ulnar collateral ligament injury

BACKGROUND The number of Major League Baseball (MLB) pitchers requiring ulnar collateral ligament (UCL) reconstructions is increasing. Recent literature has attempted to correlate specific stresses placed on the throwing arm to risk for UCL injury, with limited results. METHODS Eighty-three MLB pitchers who underwent primary UCL reconstruction were evaluated. Pitching velocity and percent of pitch type thrown (fastball, curve ball, slider, and change-up) were evaluated 2 years before and after surgery. Data were compared with control pitchers matched for age, position, size, innings pitched, and experience. RESULTS The evaluation of pitch velocity compared with matched controls found no differences in pre-UCL reconstruction pitch velocities for fastballs (91.5 vs. 91.2 miles per hour [mph], P = .69), curveballs (78.2 vs. 77.9 mph, P = .92), sliders (83.3 vs. 83.5 mph, P = .88), or change-ups (83.9 vs. 83.8 mph, P = .96). When the percentage of pitches thrown was evaluated, UCL reconstructed pitchers pitch significantly more fastballs than controls (46.7% vs. 39.4%, P = .035). This correlated to a 2% increase in risk for UCL injury for every 1% increase in fastballs thrown. Pitching more than 48% fastballs was a significant predictor of UCL injury, because pitchers over this threshold required reconstruction (P = .006). CONCLUSION MLB pitchers requiring UCL reconstruction do not pitch at higher velocities than matched controls, and pitch velocity does not appear to be a risk factor for UCL reconstruction. However, MLB pitchers who pitch a high percentage of fastballs may be at increased risk for UCL injury because pitching a higher percent of fastballs appears to be a risk factor for UCL reconstruction.

Athletic Performance at the NFL Scouting Combine After Anterior Cruciate Ligament Reconstruction.

Background: Anterior cruciate ligament (ACL) injuries are common and potentially career ending in the National Football League (NFL). Although statistical performance has been demonstrated after ACL reconstruction, functional performance is not well defined. Purpose/Hypothesis: The purpose of this study was to determine the functional performance of NFL combine participants after ACL reconstruction compared with an age-, size-, and position-matched control group. The hypothesis was that there would be no difference between players after ACL reconstruction as compared with controls in functional athletic performance. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 98 NFL-caliber athletes who had undergone primary ACL reconstruction and participated in the NFL scouting combine between 2010 and 2014 were reviewed and compared with an age-, size-, and position-matched control group. Data recorded for each player included a 40-yard dash, vertical leap, broad jump, shuttle drill, and 3-cone drill. Results: With regard to speed and acceleration, the mean 40-yard dash time for ACL-reconstructed players was 4.74 seconds (range, 4.33-5.55 seconds) compared with controls at 4.74 seconds (range, 4.34-5.38 seconds; P = .96). Jumping performance was also similar, with a mean vertical leap for ACL-reconstructed players of 33.35 inches (range, 23-43 inches) and broad jump of 113.9 inches (range, 96-136 inches) compared with respective values for the controls of 33.22 inches (range, 23.5-43.5 inches; P = .84) and 113.9 inches (range, 92-134 inches; P = .99). Agility and quickness testing measures also did not show a statistically significantly difference, with ACL-reconstructed players performing the shuttle drill in 4.37 seconds (range, 4.02-4.84 seconds) and the 3-cone drill in 7.16 seconds (range, 6.45-8.14 seconds), respectively, compared with respective times for the controls of 4.37 seconds (range, 3.96-5.00 seconds; P = .91) and 7.18 seconds (range, 6.64-8.24 seconds; P = .75). Conclusion: This study suggests that after ACL reconstruction, high-caliber athletes can achieve equivalent levels of performance with no statistically significant differences compared with matched controls. This information is unique when advising high-level athletes on athletic performance after ACL reconstruction, suggesting that those who fully recover and return to play appear to have no decrement in athletic performance.

Ulnar Collateral Ligament and Elbow Adaptations in High School Baseball Pitchers

Background: Baseball pitchers have adaptive changes in the soft tissues of the throwing elbow. Hypothesis: High school baseball pitchers would show adaptive changes in the ulnar collateral ligament (UCL), such as calcifications and hypoechoic foci, thickening, and increased ulnohumeral joint laxity, on dynamic ultrasound (DUS). Study Design: Cross-sectional study. Level of Evidence: Level 3. Methods: Twenty-two asymptomatic high school pitchers, designated as their primary position by their coach, underwent DUS and physical examination of the throwing and nonthrowing elbows prior to the start of the season. UCL substance consistency and thickness, ulnohumeral joint space widening, and soft tissue elbow structures were evaluated. Results: The mean age of the cohort was 16.9 years. Calcifications of the UCL were similar, being present in 7 of 22 (32%) throwing elbows versus 8 of 22 (36%) nonthrowing elbows (P = 0.11). UCL hypoechoic foci also were similar between elbows: 2 of 22 (9%) throwing elbows versus 0 of 22 nonthrowing elbows (P = 0.11). UCL thickness was also found to be similar in both elbows (throwing arm, 6.54 mm vs nonthrowing, 6.71 mm; P = 0.48). Ulnohumeral joint laxity unloaded (throwing arm, 3.13 mm vs nonthrowing, 3.17 mm; P = 0.835) and loaded (throwing arm, 3.87 mm vs nonthrowing arm, 4.11 mm; P = 0.30) was similar between elbows. Throwing elbows showed posteromedial olecranon spurring in 36%, effusions in 27%, and synovitis in 9%. Conclusion: High school pitchers show limited adaptive changes in the elbow, including UCL calcifications, hypoechoic foci, posteromedial olecranon spurring, and effusions. However, these changes are similar to those seen in the nonthrowing elbow, and these younger athletes lack findings seen in professional and collegiate pitchers such as UCL thickening and increased ulnohumeral joint space laxity. Clinical Relevance: Preseason ultrasound examination of the high school pitching elbow lacks the adaptive changes to the elbow as seen in professional pitchers. These changes likely occur later in a pitcher’s career.

Relative individual workload changes may be a risk factor for rerupture of ulnar collateral ligament reconstruction

BACKGROUND With an increasing number of Major League Baseball (MLB) players undergoing ulnar collateral ligament (UCL) reconstruction, there remains limited literature on appropriate post-reconstruction workload management to limit the risk of reinjury. METHODS A total of 28 MLB pitchers who underwent primary UCL reconstruction surgery and subsequently required revision reconstruction were identified and compared with 137 MLB pitchers who underwent primary reconstruction but did not later require revision surgery. Games pitched, pitch counts, and innings pitched were evaluated and compared 3 years before and after primary reconstruction. Results were then compared between groups. RESULTS Pitchers who later required revision increased their games pitched by 14.1% after reconstruction whereas the no-revision group pitched 13.6% fewer games than before reconstruction (P < .01). Inning workload was reduced by 9.8% after surgery (89.8 innings after vs 99.6 innings before) for the revision group compared with the no-revision group, which threw 26% fewer innings after surgery (86.3 innings after vs 116.7 innings before) (P = .05). In addition, the revision group pitched 6.6% more pitches after reconstruction, 1138.9 pitches, compared with before reconstruction, 1068.6 pitches. Pitchers who did not require revision, in contrast, pitched 19.6% fewer pitches after reconstruction than before reconstruction (P = .08). CONCLUSIONS This studys findings suggest that MLB pitchers who require revision UCL reconstruction after returning to play following primary UCL reconstruction pitch at or above their pre-primary UCL reconstruction workload whereas control pitchers who do not require revision pitch significantly less, below their pre-primary UCL reconstruction workload.

Pain Assessment After Anterior Cruciate Ligament Reconstruction: Bone-Patellar Tendon-Bone Versus Hamstring Tendon Autograft.

Background: Anterior cruciate ligament (ACL) reconstruction is a common outpatient procedure that is accompanied by significant postoperative pain. Purpose: To determine differences in acute pain levels between patients undergoing ACL reconstruction with bone–patellar tendon–bone (BTB) versus hamstring tendon (HS) autograft. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 70 patients who underwent primary ACL reconstruction using either BTB or HS autografts consented to participate. The primary outcome of the study was postoperative pain levels (visual analog scale), which were collected immediately after surgery and for 3 days postoperatively. Secondary outcome measures included opioid consumption (intravenous morphine equivalents), hours slept, patient satisfaction, reported breakthrough pain, and calls to the physician. Results: Patients treated with BTB had increased pain when compared with those treated with HS in the acute postoperative period (mean ± SD: day 0, 6.0 ± 1.7 vs 5.2 ± 2.0 [P = .066]; day 1, 5.9 ± 1.7 vs 4.9 ±1.7 [P = .024]; day 2, 5.2 ± 1.9 vs 4.1 ± 2.0 [P = .032]; day 3, 4.8 ± 2.1 vs 3.9 ± 2.3 [P = .151]). There were also significant increases in reported breakthrough pain (day 0, 76% vs 43% [P = .009]; day 1, 64% vs 35% [P = .003]) and calls to the physician due to pain (day 1, 19% vs 0% [P = .041]) in the BTB group. There were no significant differences in narcotic requirements or sleep disturbances. Overall, the BTB group reported significantly less satisfaction with pain management on days 0 and 1 (P = .024 and .027, respectively). Conclusion: A significant increase in acute postoperative pain was found when performing ACL reconstruction with BTB compared with HS. Patients treated with BTB were more likely to have breakthrough pain, decreased satisfaction with their pain management, and to contact their physician due to pain. These findings suggest a difference in early postoperative pain between the 2 most common graft options for ACL reconstruction. Patients should be informed of the differences in acute postoperative pain when deciding on graft choice with their physician.

Return to Play After Revision Anterior Cruciate Ligament Reconstruction in National Football League Players

Background: National Football League (NFL) players who undergo anterior cruciate ligament (ACL) reconstruction have been shown to have a lower return to play (RTP) than previously expected. However, RTP in the NFL after revision ACL reconstruction (RACLR) is not well defined. Purpose/Hypothesis: The purpose of this study is to determine the RTP of NFL players after RACLR and evaluate factors that predict RTP. Our hypothesis was that more experienced and established players would be more likely to RTP after RACLR. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 24 NFL players who underwent RACLR between 2007 and 2014 were reviewed and evaluated. Return to NFL play, time to return, seasons and games played prior to and after revision surgery, draft status, and demographic data were collected. Overall RTP was determined, and players who did RTP were compared with those unable to RTP. Data were also compared with control players matched for age, position, size, and experience. Results: After RACLR, 79% (19/24) of NFL players returned to NFL regular-season play at an average of 12.6 months. All players who were drafted in the first 4 rounds, played in at least 55 games, or played 4 seasons of NFL play prior to injury were able to RTP. Players drafted in the first 4 rounds of the NFL draft were more likely to RTP than those who were not (odds ratio, 0.1; 95% CI, 0.01-1.00; P = .05). Those who returned to NFL play played in significantly less games and seasons after their injury than before (P = .01 and P = .01, respectively). However, these values did not differ when compared with matched controls (P = .67 and P = .33). Conclusion: NFL players who RTP after RACLR do so at a similar rate but prolonged time period compared with after primary ACL reconstruction. Athletes who were drafted in earlier rounds were more likely to RTP than those who were not. Additionally, player experience prior to injury is an important factor when predicting RTP after RACLR.

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

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