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Return to Play and Performance After Revision Ulnar Collateral Ligament Reconstruction in Major League Baseball
Michael A Mastroianni1, Brian F Timoney1, Morgan R Dillon2
1Department of Orthopedics, Columbia University Medical Center, New York, New York, USA.
Background:
While return to performance has been characterized after primary ulnar collateral ligament (UCL) surgery, it has not been well defined after revision UCL reconstruction (rUCLR), particularly in Major League Baseball (MLB) pitchers.
Purpose:
To evaluate return to performance in MLB pitchers after rUCLR.
Study Design:
Descriptive epidemiology study.
Methods:
Return-to-play (RTP) analysis was conducted on 61 MLB pitchers who underwent rUCLR from January 2014 to November 2024 and compared to the results of 129 MLB pitchers who underwent primary UCL surgery during the 2018 to 2023 seasons, when pitch-tracking metrics became widely available and were used in a previous study. Return-to-performance analysis was then conducted according to inclusion criteria on 20 MLB pitchers who underwent rUCLR compared to 40 uninjured controls and 54 pitchers who underwent primary UCL surgery. Paired and unpaired t tests were conducted to compare pre- to postoperative metrics and between groups. The percentage of pitchers who returned to their preoperative performance in each metric was also recorded. The penalized likelihood logistic regression of Firth was used to evaluate for predictive factors.
Results:
The mean age was 28.00 ± 4.16 years. After rUCLR, 1.6% returned to play at 1 year, 44.1% at 2 years, and 63.2% at 3 years postoperatively, with a mean of 605 ± 163 days. Revision UCLR resulted in significantly reduced RTP rates at 2 years (P < .001) and 3 years (P = .01) compared to 71.9% and 82% at 2 and 3 years, respectively, after primary UCL surgery. Overall, 14.3% of pitchers returned to their pre-revision FanGraphs wins above replacement (fWAR) 3 seasons after surgery, suggesting that only a small proportion of pitchers ultimately provide the same value to teams after rUCLR. Stuff+ demonstrated the clearest decline after revision UCLR compared to matched controls and pre-revision levels (P < .05). Fastball velocity, Pitching+, and fWAR return to performance were reduced in the second or third season back compared to primary UCL surgery (P < .10). Only 16.7% of pitchers returned to full performance during their third season back from injury. No preoperative pitching factors were identified as predictors of return to fWAR or full performance.
Conclusion:
Only 63% of MLB pitchers returned to play after rUCLR, and a majority did not return to full performance, defined as returning to 5 key preoperative metrics (expected fielding-independent pitching, fWAR, velocity, fastball velocity, and spin rate). These data suggest that after rUCLR, MLB pitchers RTP at lower rates and typically at decreased performance compared to pre-revision levels and after primary UCL surgery.
