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

Injury Prevention

In any revision surgery, the outcomes are inferior to those of the primary reconstruction, a reality that continues to fuel the drive for prevention of revision surgery. However, despite well-documented risk factors for throwing injuries, many young pitchers continue to perform risky behaviors, increasing their likelihood of UCL injuries. In a 2014 study of 754 young pitchers (aged 9 to 18 years), Yang et al[33] found that 45% of amateur pitchers played in a league without pitch counts, and 44% pitched on consecutive days. The authors also reported that 30% pitched for different overlapping teams, 19% pitched in multiple games on the same day, and 13% pitched competitive baseball for >8 months per year. Athletes engaging in these adverse behaviors had substantially more pitching-related arm pain.[33]

The ASMI has developed guidelines for preventing throwing injuries.[33] These recommendations include no pitching for at least 4 months per year, following limits for pitch counts and rest days, avoiding pitching on multiple teams with overlapping seasons, avoiding playing pitcher and catcher, playing other sports in addition to baseball, and discontinuing pitching when the pitcher develops pain in the shoulder or elbow.[33] The recommendation for appropriate rest was initiated by a study by the senior author (J.R.A.) that found overuse and fatigue to be the strongest association for shoulder and elbow injuries in the baseball pitcher.[34]

The perception of exceptional outcomes with UCL reconstruction may jeopardize adherence to the injury prevention guidelines. In a study of perceptions of Tommy John surgery in which 189 players, 15 coaches, and 31 parents completed questionnaires about the procedure, Ahmad et al[35] found that 31% of coaches, 28% of players, and 25% of parents did not believe that pitch counts were a risk factor for injury. The same study noted that 51% of high school athletes, 37% of parents, and 30% of coaches thought that UCL reconstruction should be done to improve performance in players without an elbow injury.[35] To prevent initial UCL injuries, continued efforts are needed to address public perceptions of the throwing athlete. A focus on the increasing number of revision UCL reconstructions may convince the public to take injury prevention more seriously.

After primary UCL reconstruction, guidelines for injury prevention also recommend appropriate rest and recovery between pitching episodes. Most rehabilitation programs for initial UCL reconstruction allow for interval throwing at 4 months and return to competition by 9 to 12 months.[36] Some research has shown that splinting and rehabilitation work at 90° of flexion places more strain on a graft than does work at full extension to 50°.[36] Throwing at maximum distance (ie, long toss) during the interval throwing program also is discouraged because of alterations in kinematics causing increased graft strain.[37]

Although pitch counts and prevention work for uninjured pitchers are well established, scant research guides these metrics after UCL reconstruction. This has led to controversy over discontinuing pitching at a certain number of innings/pitches per year after this procedure. Many starting pitchers returning for UCL reconstruction have transitioned to relief work, which allows lower overall pitch counts or increased rest between starts. However, to prevent repeated injury and the need for revision reconstruction, research on pitch counts after completed rehabilitation for UCL reconstruction is needed.