Revision Ulnar Collateral Ligament Reconstruction

Jeremy R. Bruce, MD; Neal S. ElAttrache, MD; James R. Andrews, MD


J Am Acad Orthop Surg. 2018;26(11):377-385. 

In This Article


Primary UCL Reconstruction

In terms of pitching performance and revision rates after primary UCL reconstruction, conflicting data have been reported. Erickson et al[9] reported high levels of return to play after UCL reconstruction, including improved performance metrics. However, Makhni et al[10] showed a decline in performance metrics after primary UCL reconstruction, with 57% of treated pitchers in one study spending time on the disabled list for arm injuries. Research on the frequency of revision UCL reconstruction also has been inconsistent, with rates ranging from 1% to 15%.[3,7,9–11]

Revision UCL Reconstruction

Revision UCL reconstruction has a high rate of complications because of the formation of scar tissue and adhesions, the presence of distorted anatomy, and the presence of a compromised soft-tissue envelope as a result of the primary procedure. The type of complications seen are similar to those observed after primary reconstruction, including transient ulnar nerve neurapraxia, medial epicondyle fractures, stiffness, heterotopic ossification, graft or implant failure, and continued pain.

Data on outcomes of revision UCL reconstruction are limited; however, research has shown that the results after revision surgery are not as successful as those after primary reconstruction. Dines et al[24] found that 5 of 15 pitchers (33%) returned to preinjury level for at least one season after revision surgery and noted a substantial rate of complications (40%); 12 of these players were professional athletes and 3 were college athletes. Major league pitchers had better odds of returning to play than did minor league pitchers (75% and 14%, respectively).

The largest study to date on revision UCL reconstruction in MLB players reported on the outcomes of 33 pitchers. Of 29 pitchers who underwent revision surgery, 19 (65.5%) returned to play at the professional level.[29] Although pitchers who underwent revision UCL reconstruction had earned run averages and walks/hits per innings pitched similar to those of the age- and position-matched control group, their careers were 0.8 years shorter and they had decreased numbers of wins and innings pitched.

Jones et al[30] reported on 18 MLB pitchers who underwent revision UCL reconstruction and noted that 14 of the pitchers (78%) were able to return to the MLB level within two full seasons. However, starting and relief pitchers were able to resume only 35% and 50% of their previous workloads, respectively. Relief pitchers displayed better pitching statistics than did starting pitchers. Jones et al[30] were unable to analyze differences in surgical approach and techniques, which have been shown to affect outcomes in primary reconstruction.[31]

Liu et al[32] reviewed a cohort of 235 MLB pitchers treated with UCL reconstruction and noted that 13.2% underwent revision surgery; 37% had the revision procedure within 3 years after the primary reconstruction. Only 42.3% of pitchers returned to pitch ≥10 games, and those who returned to the professional level required 20.76 months to return. Pitchers who underwent revision reconstruction had a shorter career, pitched fewer innings, and had fewer total pitches per season than an age- and position-matched control cohort.

Wilson et al[8] reviewed available data for 271 professional pitchers who underwent UCL reconstruction from 2007 through 2014. They found that the average length of career after primary UCL reconstruction was 4.9 years, whereas the length of career after revision UCL surgery was only 2.5 years. Of the 271 pitchers included in the study, 40 (15%) required some type of revision surgery. The rate of primary UCL reconstructions increased substantially from 2007 to 2014, averaging 7.5 procedures/year from 2007 through 2010 to 20.25 procedures/year from 2011 through 2014. However, the rate of revision procedures actually declined from 2 procedures/year from 2007 through 2010 to 0.75 procedures/year from 2011 through 2014. Although some of the results may be attributed to shorter follow-up, some may be attributable to better surgical and rehabilitation techniques.[8]