UCL Surgery: 3 New Epidemiological Studies

Stan Conte, PT, DPT, ATC Conte Injury Analytics

Santa Clara University Baseball Medicine Conteinjuryantalytics.com

Epidemiology of Ulnar Collateral Ligament

Reconstruction in Major and Minor League Baseball Pitchers:

Comprehensive Report of 1,429 Cases.

Christopher L. Camp, MD, Stan Conte, DPT, ATC, John D’Angelo, BS , Stephen A. Fealy, MD

Accepted for Publication

Journal of Shoulder and Elbow Surgery. 2018

Demographics- Comparison Studies

• Sample SizeSurgeries

0

400

800

1200

1600

Camp Cain Erickson Makhani

••

• 1

• 14

In Research: Size Matters

Demographics

• Sample Size • Professional Level Professional Pitchers Only

0

400

800

1200

1600

Camp Cain Erickson Makhani

386

Demographics

• Sample Size • Professional Pitchers • Sources of Data • Revisions (Erikson, Camp) • MLB (34%) vs MiLB (66%)

• Camp, et al, Uses 3 different sources to collect data including HITS. • Years of Data: 47 versus 27

(Erickson)

Study Surgeries Pro MLB MiLB Revisions Year of Study Sources

Camp 1429 1429 490 939 95 (6.7%) 1974-2016HITS, Heatmaps,

Web

Cain 1281 234 45 188 9 (1%) 1988-2006 Single Institution

Erickson 179 179 179 0 7 (3.9%) 1986-2013 HITS, Web

Makhani 147 147 147 0 NR 1999-2011 BP, Heatmaps

Incidence-Is the Epidemic Continuing?

YES!

Incidence-Minor League Increases?

At what age do Professional Pitcher undergo UCL surgery?

Age at Time of Surgery

  N Mean (SD) Range Median

All Pitchers 1,429 24.4 (4.1)

16.5 to 48.0 23.6

MLB 490 27.5 (3.9) 20.6 to 48.0 26.8

MiLB 939 22.8 (3.2)16.5 to

36.2 22.4

Primary UCL 1,334 24.2 (4.0) 16.5 to

48.0 23.5

Revision UCL 95 27.3 (4.5)

18.8 to 40.4 26.3

• On average, MLB players were 4.7 years older at the date of surgery than MiLB players(p<0.001).

• (Players undergoing revision UCL reconstruction were 3.1 years older than those undergoing primary surgery (p<0.001).

Once a Pro, What is Average time to TJS?

• The mean time from the beginning of the pitcher’s professional career until surgery was 4.6 ± 5.2 years. • MiLB(3.0 years) pitchers

undergoing surgery earlier in their careers compared to MLB pitchers (7.4 years) • 3.0 vs. 7.4 years is statistically

significant (p< 0.001) . • All Primary UCL surgeries = 4.3

years • Revisions average over 7 years.

Time from start of professional career to surgery

  N Mean (SD) Range Median

All Pitchers 1,429 4.6 (5.2) 0 to 26.5 3.5

MLB 490 7.4 (3.8) 0 to 26.5 6.5

MiLB 939 3.0 (2.7) 0 to 18.2 2.2

Primary UCL 1,334 4.3 (3.6) 0 to 26.5 3.3

Revision

UCL95 7.1 (4.8) 1.0 to

19.9 6.1

Time to Return to Play-Pitchers

• Overall: 14.5; 16.8 months • MLB Only: 14.4; 18.0 Months • MiLB Only: 14.6; 16.3 Months • Primary Only: 14.4; 16.9

Months • Revisions Only: 15.5; 17.2

Months

Return to Play (Data taken from 2005-2014,2 year follow up, 853 Primary)

Percentage Able to Return to Any Level

  % Diff p-value

MLB 94.60%15.60% <0.001

MiLB 79.00%

Primary Surgery 83.90%

3.20% 0.477 Revision Surgery 80.70%

Percentage Able to Return to Prior Professional Level

MLB 80.00%10.90% 0.004

MiLB 69.10%

Primary Surgery 73.40% 9.90% 0.145

• Any Level • MLB: 94% (Erickson, et al) • MiLB: Only 79% • Primary Surgeries Only: 83% • Revisions: 81%

• Prior Level • MLB: 80% • MiLB: Only 69% • Primary Surgeries: 73%

Statistically Significant difference between MLB and MiLB return to play

Survivorship: How long do they last?Overall survivorship defined as length of time free from revision and

still playing at any professional level

Overall Survivorship (years)*

  N Mean (SD) Range Median

All Pitchers 949 3.8 (3.4) 0 to 22 3

MLB 367 4.8 (3.2) 0 to 18 4

MiLB 582 3.2 (3.3) 0 to 22 2

Primary UCL 881 3.9 (3.4) 0 to 22 3

Revision UCL

68 2.9 (2.8) 0 to 14 2

• All UCLr =3.8 ± 3.4 years. (Range 0-22 years)

• MLB = 4.8 years • MiLB = 3.2 years • MLB pitchers demonstrated increased

survivorship compared to MiLB pitchers (4.8 vs. 3.2 years; p<0.001).

• Comparing the overall career length (time from start of professional career to retirement), longer careers were noted for MLB pitchers (12.5)compared to MiLB pitchers (6.5) (p<0.001)

Revisions

 Revision Surgery*   Time (days) Between Primary and

Revision Surgery  N (%) p-value   Mean (SD) Range MedianAll Pitchers 95 (6.7%)     1,413 (1,089) 177 to 4,735 1,085

MLB 46 (9.4%) 0.004   1,816 (1,203) 177 to 4,735 1,417

MiLB 49 (5.2%)   1,034 (813) 317 to 3,801 693

Following Ulnar Collateral Ligament Reconstruction, Professional Baseball

Position Players Return to Play Faster but Less Frequently than Professional Pitchers

Christopher L. Camp, MD, Stan Conte, DPT, ATC, John D’Angelo, BS. Stephen Fealy, MD

Accepted for Publication Journal of Shoulder and Elbow Surgery

Demographics: Catchers overrepresented• 167 Surgeries • 48 MLB (29.3%) • 119 MiLB (70.7%) • Catchers: 47 (28.1%) • Infielders: 62 (37.1%) • Outfielders: 58 (34.7%)

Incidence-Increased since 1984

• Since the first UCL reconstruction was performed in a professional position player in 1984, the annual incidence of all procedures has risen steadily • Statistically significant:

(R2=0.626, p<0.001) .

Incidence: Increase occurs in Minor Leagues

Return to Play-By Position  Percent Able to Return

to Play Overall  

Any Level 75.5%

Prior Level 68.8%Primary Surgery  

Any Level 76.2%

Prior Level 69.3%Revision Surgery  

Any Level 60.0%Prior Level 60.0%

Catchers  Any Level 58.6%

Prior Level 50.0%Infielders  

Any Level 75.6%

Prior Level 77.8%Outfielders  

Any Level 88.9%Prior Level 74.1%

• Overall: Less than for Pitchers • 75% (Any Level); 69% (Prior Level)

• Revisions with poor RTP • 60%

• Catcher have worse RTP • 59% (Any Level); ; 50% (Prior

Level)

• Outfielders have best RTP • 89% (Prior Level); 74% (Prior Level)

Return to Play Time

Time (days) Until Return to Play

  N Mean (SD) Range Median

Time (days) Until Return to Play at Any Professional Level

Catchers 24 363 (121.6) 191 to 812 342.5 Infielders 34 294 (87.1) 154 to 648 276 Outfielders 35 375 (144.0) 105 to 780 345

Time (days) Until Return to Play at Prior Professional Level

Catchers 20 423 (215.8) 215 to 1,176 373 Infielders 31 357 (232.6) 154 to 1,445 297 Outfielders 26 392 (147.0) 205 to 694 357

• Surprising Longer RTP Times for all positions than expected. • Outfielders: 13.1

months(Median: 11.5) • Infielders the quickest: 9.2

Months (Median: 9.2) • Catchers 11.5 months

(Median: 11.4 months)

Pitchers compared to Position Players

Revisions-Position Players

 Revision Surgery*

  Time (days) Between Primary and Revision Surgery

  N (%) p-value

  Mean (SD) Range Median

All Position Players 8 (4.8%)     800 (854.3)

272 to 2,840 423

MLB 4 (8.2%) 0.235   1,145 (1,160)378 to 2,840 682.5

MiLB 4 (3.4%)   454 (196.7) 272 to 731 405.5 Catchers 4 (8.5%)

0.245

  365 (67.4) 272 to 433 378 Infielders 1 (1.6%)   952 (0) --- 952

Outfielders 3 (5.2%)  1,328

(1,319.0)413 to 2,840 731

*For revision surgery analysis, only players having their primary surgery prior to surgery 2014 were included.

• 4 Catchers, 3 OF and 1 IF • Revision Rate: Catchers(8.5%): OF (5.2%),

IF(1.6%) • Average time from Primary to Revision: 26.6

months • Range was huge (9 months to 94.4 months)

Incidence of Elbow Ulnar Collateral Ligament Surgery in Collegiate Baseball Players

Marcus A. Rothermich, MD Stan A. Conte, PT, DPT, ATC

Kyle T. Aune, MPH Glenn S. Fleisig, PhD E. Lyle Cain, Jr., MD Jeffrey R. Dugas, MD

Accepted for Publication Orthopedic Journal of Sports Medicine. 2018

UCL Surgery increasing in Youth Baseball

Epidemiology of Medial Collateral Ligament Reconstruction: A 10-Year Study of NY State

Hodges, Ahmad, et al. AJSM: 2016

Trends in Medial Ulnar Collateral Ligament Reconstruction in the United State:

2007-2011 Erickson, Romeo, et al. AJSM. 2015

Methods and Design of the Study

• Contacted 15 Conferences (52%) and 157 Division 1 Baseball Programs

• Picked Conferences with diverse geographical locations

• 155/157(98.7%) agreed to participate

• Online de-ID electronic survey at end of year

• 155/155 (100%) Programs completed the survey.

Surgeries per Program

• 134 Total UCL Surgeries • 0.86/School • Surgery Rate of 2.53% (Total

population of 5,295 players) • 67 (43%) had NO UCL

Surgeries • 88 (57%) had at least One

Surgery • 29 (22%) had more the One.

Surgery Demographics

• Average Age: 19.7 years • 86% were Pitchers • Starters (43%); Relievers

(57%) • Underclassmen (66%) • Majority of Surgeries

performed ”In-Season” (49%)

Surgical Procedures

• Only 99/134 responses on specifics of surgery • Primary UCL Reconstruction:

97% • 84% Reconstruction • 16% were Primary Repairs with

augmentation

• 4 (3%) were Revisions • 36% had Ulnar Nerve

Transpositions

Cold Weather versus Warm Weather States

• The survey asked where the players had attended high school.

• Players were then put in subcategories of Warm and Cold States consistent with other studies.

• Incidence was 2.21 for Cold and 2.71 for Warm.

• This was NOT Statistically Significant.

• This was in contrast to Zarmski’s Study that showed Warm states were statistically significantly higher

Thank You

Length of Career after TJS

Length of Career in Seasons**

  N Mean (SD) Range Median

All Pitchers 947 8.8 (5.1)0.8 to 28.5 7.8

MLB 366 12.5 (4.5)

1.1 to 28.5 11.9

MiLB 581 6.5 (3.9)0.8 to 25.0 5.6

Primary UCL 879 8.7 (5.0) 0.8 to

28.5 7.7

Revision UCL 68 10.8 (5.5)

1.1 to 23.3 10.3

• MLB Pitchers = 12.5 seasons • MiLB Pitchers = 6.5 seasons • Primary UCL’s = 8.7 seasons • Revisions = 10.8 seasons