Time to Return to Play After Arthroscopic Elbow Osteocapsular Arthroplasty in Professional and Elite Baseball Players

Abstract

Background:

Although many reports have described the outcomes of elbow arthroscopic procedures in athletes, a literature review did not identify any study on the outcomes of arthroscopic osteocapsular arthroplasty in baseball players.

Purpose:

To evaluate the clinical outcomes of elite and professional baseball players who underwent arthroscopic elbow osteocapsular arthroplasty to treat degenerative arthritis.

Study Design:

Case series; Level of evidence, 4.

Methods:

Of 421 elite and professional baseball players who underwent arthroscopic elbow spur resection between January 2007 and March 2023, the study included 17 for whom spurs were removed from both the anterior and posterior compartments. After surgery, players who participated in at least 1 officially recognized game were considered to exhibit return to play (RTP). Players who participated in >10 official games were considered to evidence “solid” return to play (sRTP). The RTP and sRTP rates were analyzed according to player position and the time to RTP after surgery. The average duration of competition after surgery but before retirement was also investigated.

Results:

Of the 17 baseball players (mean age, 26.2 years), 13 were pitchers, 2 were catchers, and 2 were fielders. The RTP and sRTP rates of pitchers were 92.3% and 84.6%, respectively; the values were all 100% for both catchers and fielders. The overall RTP and sRTP rates were 94.1% and 88.2%, respectively. The mean time to RTP after surgery was 7.9 months (8.3, 7.5, and 6 months for pitchers, catchers, and fielders, respectively). The mean time to retirement was 4.4 years; 8 players still compete.

Conclusion:

Arthroscopic elbow osteocapsular arthroplasty demonstrated a favorable sRTP rate of 88.2% in elite and professional baseball players with degenerative arthritis.

The elbows of throwing athletes experience consistent valgus extension overload stress that may trigger early arthritic changes.^10,21 Elbow osteoarthritis is common in throwing athletes,^3,22 and baseball pitchers often experience such “overuse” injury. ¹⁷ The many treatment options include anti-inflammatory medications, activity modifications, physical therapy, platelet-rich plasma injection, and arthroscopic debridement. ⁷ However, arthroscopic surgeries have become increasingly common; these include capsular release of a stiff elbow and arthroscopic osteocapsular arthroplasty (OCA). ⁵ Arthroscopic elbow OCA is a surgical technique to treat osteoarthritis that includes 3-dimensional bone reshaping, loose body removal, and a capsulectomy. ¹⁶ Elbow arthroscopy (a complex surgery) significantly aids affected baseball players; both the range of motion (ROM) and the functional score improve significantly. ¹⁰ However, to the best of our knowledge, no study has yet reported the outcomes of arthroscopic OCA in baseball players. Thus, we explored how such surgery might aid elite and professional baseball players with degenerative arthritis. We measured the return-to-play (RTP) rates and used 3-dimensional computed tomography (3DCT) to quantify the olecranon spur resection lengths.

Methods

Patient Selection

This retrospective study was approved by our institutional review board. Our initial search revealed 421 elite or professional baseball players who had undergone arthroscopic olecranon spur resection after diagnosis of valgus extension overload syndrome (VEOS) or osteoarthritis at Neon Orthopaedic Clinic and Konkuk University Hospital. We defined an elite player as someone who possesses exceptional athletic ability, participates in specialized training with coaching, and engages in early competitive experiences. We defined players with osteoarthritis as follows: athletes with osteophytes in the anterior and posterior aspects of the elbow and a reduced ROM compared with the contralateral arm. All operations were performed by a single surgeon (J.-Y.P.) between June 2007 and March 2023. The inclusion criteria were patients who required removal of spurs from both the anterior and elbow posterior compartments and who had physical and radiological follow-up for at least 12 months postoperatively. Patients who underwent only posterior compartment spur removal were excluded. Of the 421 players, 17 met the inclusion but not the exclusion criteria (Figure 1).

Figure 1.

Study flow chart.

Operative Procedure

All operations were performed by the senior author (J.-Y.P.) using a standard protocol. Each patient was placed in the prone position, and general anesthesia was induced. Standard anteromedial and anterolateral ports were placed, and then the anterior compartment of the elbow joint was evaluated. Loose bodies were removed, and the spurs of the coronoid process and coronoid fossa that restricted further elbow flexion were removed. The anterior capsule was released on the humeral side when necessary. Next, an arthroscope was inserted into the olecranon fossa via a soft-spot portal at the anconeus triangle. This portal afforded the visualization required to create a posteromedial portal; this was followed by synovectomy that ensured clear visualization of the olecranon fossa (Figure 2A-1). A further posterolateral portal served as a viewing portal during olecranon tip resection. Any loose body was removed, the olecranon fossa was deepened for patients who had bony spur at the fossa, and olecranon spur resection was performed as described below. During surgery, the extent of olecranon impingement on the olecranon fossa when the elbow was fully extended was carefully examined (Figure 2A-2). Regardless of the resection length, olecranon spur resection was performed until the gap between the olecranon process and olecranon fossa was <1 mm. After resection was completed, with the elbow fully extended, the gap between the olecranon tip and the fossa was examined arthroscopically using a probe to see that the distance was consistent and <1 mm (Figure 2B).

Figure 2.

(A-1) Arthroscopic view of an olecranon fossa spur (F) that impeded the motion of the olecranon tip (T) before the elbow was extended, and (A-2) a view with the elbow fully extended. (B) After spur resection, arthroscopy revealed full elbow extension; there was no impingement.

Clinical Assessment

We used 4 outcome measures: visual analog scale (VAS) pain score, active elbow ROM, Mayo Elbow Performance Score (MEPS), and RTP rate. Elbow ROMs (extension, flexion, and the ROM arc) were checked before surgery and at the 1-year follow-up. Functional outcomes were determined using the MEPS classification: excellent, >89; good, 75 to 89; fair, 60 to 74; and poor, <60.

After surgery, players who played in at least 1 official game were considered to exhibit RTP, and those who appeared in >10 games were considered to evidence solid RTP (sRTP). The RTP and sRTP rates were analyzed according to player position and the pre-RTP time after surgery (the rehabilitation period). Players who retired from competition were recorded; the numbers of seasons during which they played after surgery to retirement were the “competition years.” For players who did not retire, the number of seasons played after surgery to 2023 were the competition years; the mean value was calculated.

Radiological Evaluation

Before surgery, plain radiographs (including anteroposterior and lateral images in both extension and flexion) were obtained, and 3DCT was performed. After arthroscopic OCA, follow-up 3DCT was performed 2 weeks after the surgery to assess the extent of bony spur removal. All patients underwent regular, plain radiographic follow-up at 12 months.

A method that entailed CT sagittal cuts was used to measure olecranon spur resection length. The sagittal cuts in pre- and postoperative 3DCT scans were paired by reference to the anatomic similarity. Two baselines were drawn, as shown in Figure 3, and the intersection point was noted. Then a line was drawn between that point and the olecranon tip; this was the “neon line.” For each pair of CT sagittal cuts, the difference in the length of the neon line was the olecranon spur resection length (Figure 3). The CT sagittal cut with the most prominent olecranon tip was the “olecranon tip cut.” The longest resection lines at either side of the olecranon tip cut were the “ulnar side spur resection length” and the “radial side spur resection length.” All measurements were performed by a single orthopaedic surgeon.

Figure 3.

Measurement of the olecranon spur resection length from preoperative (A) and postoperative (B) 3DCT sagittal cuts. Line A shows the extension of the proximal ulnar posterior cortex and line B shows the extension of the olecranon posterior cortex. Line L is the neon line, the length of which was measured.

Postoperative Protocol

Patients commenced active ROM elbow exercise immediately after surgery. Throwing motions were avoided before 6 weeks postoperatively. Up to that time, rehabilitation focused on strengthening of the periscapular muscles, the rotator cuff, and the flexor-pronator muscle. Because active ROM elbow exercise and strengthening exercise began shortly after surgery, patients were generally ready for an interval throwing program around 6 weeks. An interval throwing program commenced 6 weeks after surgery, and RTP was permitted approximately 3 months postoperatively.

Statistical Analyses

Data are presented as mean ± standard deviation. Comparisons between preoperative findings and the postoperative clinical outcomes were performed using the paired t test (ROM in extension, ROM arc, VAS pain score, MEPS) or the Wilcoxon signed-rank test (ROM in flexion). All analyses were performed using SPSS software (Version 20.0). The level of significance was set to P < .05.

Results

Demographic Characteristics

We treated 17 males of mean age 26.2 years (range, 16-37 years). There were 5 elite players (3 high school, and 2 college players) and 12 professional players. Thirteen of the participants were pitchers, 2 were catchers, and 2 were fielders (Table 1). One of the 5 elite players turned professional in 2023. All operations were on the throwing arms. The mean follow-up duration was 4.4 years (range, 1-13 years). Two patients underwent medial ulnar collateral ligament (MUCL) reconstruction before OCA, and 3 patients had such reconstruction after OCA; all 5 were pitchers (Table 2). No complications developed immediately after OCA. Of the 3 patients who underwent MUCL reconstruction after OCA, 2 had been initially diagnosed with MUCL tears and staged operations were planned. The olecranon spur resection length of the 2 players who underwent staged operations was 3.5 mm, 2.5 mm on the ulnar side, 3.2 mm, 3.3 mm at the olecranon tip, and 4.7 mm, 0.6 mm on the radial side, respectively. One professional pitcher had sustained a partial MUCL tear 4 years before surgery, when he was a high school sophomore, and had undergone rehabilitation. After OCA, he exhibited sRTP 6 months after surgery. However, 9 months postoperatively, medial elbow pain developed during pitching and he was diagnosed with an MUCL tear. He underwent repeat MUCL reconstruction 11 months after OCA. The olecranon spur resection length of this player was 6.4 mm on the ulnar side, 4.7 mm at the olecranon tip, and 4 mm on the radial side.

Table 1.

Player Positions ^a

	Pitchers	Catchers	Fielders	Total
Professional	10	1	1	12
College	2	0	0	2
Below college	1	1	1	3

^aValues are numbers of players.

Table 2.

MUCL Reconstruction Status by Player Position ^a

	Pitchers	Catchers	Fielders	Total
Before OCA	2	0	0	2
After OCA	3	0	0	3

^aValues are numbers of players. MUCL, medial ulnar collateral ligament; OCA, osteocapsular arthroplasty.

Radiological Evaluations

The mean olecranon spur resection lengths were 4.1 mm on the ulnar side, 3.4 mm at the olecranon tip, and 2.9 mm on the radial side (Table 3). The pre- and postoperative radiological features of 1 professional pitcher aged 31 years are shown in Figure 4.

Table 3.

Olecranon Spur Resection Lengths ^a

	Resection length, mm
Ulnar side	4.1 (1.9-8.0)
Olecranon tip	3.4 (1.5-5.9)
Radial side	2.9 (0.3-4.3)

^aValues are expressed as mean (range).

Figure 4.

Pre- and postoperative 3-dimensional computed tomography images of a male professional baseball pitcher aged 31 years. (A) Preoperative sagittal section and (B, C) 3D-reconstructed images. Osteophytes are apparent in both the anterior and posterior elbow compartments. (D) Postoperative sagittal section and (E, F) 3D-reconstructed images. The osteophytes were resected during surgery, and loose bodies were removed.

Clinical Outcomes and RTP Data

The mean total preoperative arc ROM was 107.8°; the mean flexion was 117.1°, and the mean extension loss was 9.8° (Table 4). All except 3 patients had extension limitations and pain. After surgery, the mean arc ROM, flexion, and extension showed statistically significant improvements (P < .05), and the respective values were 119.7°, 124.7°, and 4.4°. The VAS score improved significantly from 6.0 before surgery to 2.9 at the final follow-up (P < .05). MEPS also improved significantly from poor (58.5) before surgery to good (79.1) at the final follow-up (P < .05). The final follow-up MEPS results were excellent (2; 48%), good (13; 32%), and fair (2; 16%).

Table 4.

Clinical Outcomes ^a

Criteria	Before Surgery	After Surgery	P
Extension, deg	9.8 ± 6.9	4.4 ± 5.0	<.05
Flexion, deg	117.1 ± 22.0	124.7 ± 13.5	<.05
ROM arc, deg	107.8 ± 22.0	119.7 ± 13.5	<.05
VAS score	6.0 ± 1.7	2.9 ± 1.7	<.05
MEPS	58.5 ± 13.8	79.1 ± 8.0	<.05

^aValues are expressed as mean ± SD. MEPS, Mayo Elbow Performance Score; ROM, range of motion; VAS, visual analog scale.

The overall RTP and sRTP rates were 94.1% and 88.2%, respectively. The figures were 92.3% and 84.6% for pitchers and all 100.0% for catchers and fielders. The mean pre-RTP period (the rehabilitation period) was 7.9 months, being 8.3, 7.5, and 6.0 months for pitchers, catchers, and fielders, respectively (Table 5). One player who did not exhibit RTP was a professional pitcher. During initial preoperative evaluation, he was diagnosed with a complete MUCL tear, and staged MUCL reconstruction was planned; this was performed 6 weeks after arthroscopic OCA. After surgery, ulnar nerve–related symptoms (paresthesia and a tingling sensation) developed, and he retired; he could not return to the sport. His olecranon spur resection lengths were 2.5 mm on the ulnar side, 3.3 mm at the olecranon tip, and 0.6 mm on the radial side. One player who did exhibit RTP but not sRTP was a professional pitcher. His rehabilitation period was 16 months, and his olecranon spur resection lengths were 4.2 mm on the ulnar side, 3.4 mm at the olecranon tip, and 2.5 mm on the radial side.

Table 5.

RTP and sRTP Outcomes ^a

	Total, n	RTP, n	RTP Rate, %	RTP Period (rehabilitation), mo	sRTP, n	sRTP rate, %
Pitchers	13	12	92.3	8.3	11	84.6
Catchers	2	2	100.0	7.5	2	100
Fielders	2	2	100.0	6.0	2	100
Total	17	16	94.1	7.9	15	88.2

^aRTP, return to play; sRTP, solid return to play.

Retirement and Competition Years

Currently, 9 players have retired, of whom 7 were pitchers and 2 were catchers (Table 6). The retirement rates were 53.8% for pitchers, 100% for catchers, and 0% for fielders. The overall retirement rate was 52.9%. The mean competition years numbered 4 years for the 9 retired players and 4.8 years for the 8 nonretired players. According to position played, the mean competition years numbered 4.2 for pitchers, 6.5 for catchers, and 3.0 for fielders. The overall competition years numbered 4.4 (Table 7).

Table 6.

Demographic Data and Characteristics of Retired Players

Patient	Age, y	Status at the Time of Surgery	Position	No. of Competition Years After Surgery	Total Years of Playing Baseball
1	35	Professional	Pitcher	2	27
2	37	Professional	Pitcher	2	26
3	34	Professional	Catcher	8	32
4	27	Professional	Pitcher	5	21
5	28	Professional	Pitcher	0	18
6	17	High school	Catcher	5	12
7	21	Professional	Pitcher	3	12
8	28	Professional	Pitcher	8	24
9	32	Professional	Pitcher	3	24

Table 7.

Retirement Rates and Competition Years

	Retired Players, n/total	Retirement Rate, %	Years of Competition
Pitchers	7/13	53.8	4.2
Catchers	2/2	100	6.5
Fielders	0/2	0	3.0
Total	9/17	52.9	4.4

Discussion

Elbow pain often develops in throwing athletes; this is common in baseball pitchers from adolescence to adulthood. ²⁰ Tullos and King ²⁴ reported that about half of all pitchers experience elbow and shoulder joint pain. Valgus extension repeatedly applies excess stress to the elbow, often triggering early arthritic changes.^10,21 The elbow joint undergoes rapid movement through an excessive ROM during pitching; the risk of injury is high. During the deceleration phase, the valgus rotational shear force causes the olecranon posteromedial aspect to impinge on the olecranon fossa.^8,18,23 As a result, a bony spur forms on either the olecranon process or the olecranon fossa. ⁴ The spur triggers posteromedial elbow pain during throwing; such pain is typically replicated during the extension impingement test of physical examination. ²

Chronic elbow overuse by throwing athletes creates microtraumas including contracture, MUCL rupture, and osteoarthritic changes.^6,19 Patients with elbow osteoarthritis may present with pain, elbow locking, and limited elbow ROM. Radiographic findings include a bony spur, loose intra-articular bodies, and capsular contracture.

Arthroscopic surgery is increasingly used to treat elbow injuries of athletes. Procedures such as capsular release of a stiff elbow and arthroscopic OCA require advanced level of surgical expertise. ⁵ The appropriate (safe) extent of arthroscopic posterior olecranon resection remains controversial. Earlier studies on arthroscopic treatments of posteromedial impingements suggested that both osteophyte resection and loose body removal should be minimal and that resection should not proceed beyond the osteophyte margin.^2,3 Kamineni et al ¹¹ suggested that olecranon posteromedial tip resections of >3 mm might increase strain on the ulnar collateral ligament (UCL) anterior bundle between 50° and 110° of flexion. Moreover, it has been suggested that any resection of a normal olecranon may affect elbow joint kinematics. ¹² By contrast, Levin et al ¹³ found that UCL strain did not significantly increase even after 8-mm posterior olecranon resections. These previous studies differed in that Kamineni et al ¹¹ used cadaveric arms of a mean age of 78 years but Levin et al used such arms of a mean age of 46 years.

Although many reports have described the outcomes of elbow arthroscopic procedures in athletes, we found only 1 study that focused exclusively on baseball players. Jhan et al ¹⁰ described 15 baseball athletes who underwent elbow arthroscopic procedures that varied in complexity from single-compartment debridement to arthroscopic OCA. However, to the best of our knowledge, no study has focused exclusively on the outcomes of arthroscopic OCA in baseball players. We thus explored the clinical and radiological outcomes of baseball players with degenerative arthritis who underwent arthroscopic OCA. In the present work, we used 3DCT to measure the extent of olecranon resection. Postoperative follow-up entailed monitoring any complications related to the MUCL, which may be related to increased MUCL strain after OCA.

During each operation, we did not follow the “safe” rule suggested by Kamineni et al.^11,12 The mean ulnar side resection length was 4.1 mm, thus greater than the 3 mm that was the safe olecranon posteromedial tip resection length suggested by Kamineni et al.^11,12 The longest resection length was 8.0 mm.

Previous studies have shown that elbow ROM significantly improves after arthroscopic debridement. Adams et al ¹ used elbow arthroscopy to treat 41 patients with primary elbow osteoarthritis. The mean improvements were 14.3° of flexion and 13.0° of extension after >2 years of follow-up. Nguyen et al ¹⁵ reported that 22 patients who underwent elbow arthroscopy exhibited terminal flexion and extension improvements of 19° and 19° at the 1-year follow-up. In a study on baseball players, Jhan et al ¹⁰ reported that 15 throwers who underwent arthroscopic procedures exhibited mean improvements of 14.0° in flexion, 11.0° in extension, and 25.0° in arc ROM at a mean 2.6 years of follow-up. The improvements that we observed were similar to those of previous reports, at a mean 7.6° of flexion, 5.4° of extension, and 11.9° of ROM arc.

Previous studies have also reported significantly improved pain and functional scores after elbow arthroscopic OCA. Galle et al ⁹ found that 46 patients with elbow osteoarthritis experienced a significant improvement in VAS pain score (6.4 before surgery and 1.6 after surgery) and MEPS (57 before surgery and 88 after surgery). Our figures were 6.0 to 2.9 for the VAS score and 58.5 to 79.1 for MEPS.

The sRTP, which would be a more proper determination of meaningful RTP, showed a favorable outcome of 88.2%. The mean time from surgery to RTP was 7.9 months (range, 4-17 months); athletes must plan to take a long break from play. In a previous study, players with VEOS exhibited an RTP time of 6 months after arthroscopic olecranon tip resection; our present figure is longer. ²⁰ Indeed, Jhan et al ¹⁰ reported that the mean time from surgery to RTP was 4.5 months. ¹⁰ However, most patients of previous studies underwent procedures that were less complex than OCA, such as single-compartment debridement or capsular release without bony resection.^10,14 A longer pre-RTP period would be expected for players from whom spurs were removed from both the anterior and posterior compartments. Also, 2 patients had initial MUCL tears and underwent staged operations, which likely delayed their return.

One player who exhibited RTP but not sRTP was a professional pitcher of the first division. His olecranon spur resection length was 4.2 mm on the ulnar side, which was slightly longer than average. After surgery, he joined the second division during rehabilitation but was released; he did not return to the first division. He joined a team of an independent league but retired without sRTP.

Of the 3 patients who underwent MUCL reconstruction after OCA, 2 players with initial MUCL tears underwent staged operations and showed a different outcome. One player was a professional pitcher of the first division and exhibited RTP and sRTP. The other player who did not exhibit RTP underwent staged MUCL reconstruction 6 weeks after arthroscopic OCA. During his rehabilitation period, ulnar nerve–related symptoms (paresthesia and a tingling sensation) occurred after he started pitching. Previous studies have shown that the laxity caused by UCL insufficiency from repetitive overhead throwing may increase medial soft tissue stretching, which predisposes throwing athletes to ulnar neuritis. ⁶ His olecranon spur resection length was below average at all 3 sites. Therefore, although the amount of spur resection performed was not excessive compared with the study average, it may still have contributed to MUCL strain. Future studies are needed to compare the outcomes of OCA between athletes with an initial MUCL tear and those without.

One patient was diagnosed with an MUCL tear 9 months after OCA, and MUCL reconstruction was performed 2 months later. He was a professional pitcher and exhibited a successful RTP and sRTP. His pre-RTP period was 6 months, less than the mean of 7.9 months. The olecranon spur resection length was 6.4 mm on the ulnar side, 4.7 mm at the olecranon tip, and 4 mm on the radial side; all figures were larger than average (3.4 mm at the olecranon tip, 4.1 mm on the ulnar side, 2.9 mm on the radial side). The difference was largest on the ulnar side (1.3 mm at the olecranon tip, 2.3 mm on the ulnar side, and 1.1 mm on the radial side). The relatively large resection of the olecranon ulnar side may have strained the MUCL.

Two patients (1 fielder and 1 catcher) exhibited larger ulnar side resection lengths than did the patient described above, of 6.5 and 8.0 mm, respectively. They evidenced successful RTP and sRTP; the pre-RTP periods were 9 and 5 months, respectively. Therefore, it is difficult to conclude that the ulnar side resection length alone is responsible for the postoperative MUCL tear. However, considering that patient who developed MUCL tear postoperatively underwent ulnar-side olecranon resection that was greater than average, care should be taken to avoid excessive resection during the procedure.

An MUCL tear developed after OCA in 1 pitcher, but not in the catcher or fielder with the larger ulnar-side resection lengths. The player who developed ulnar neuritis symptoms after staged operation and did not exhibit RTP was also a pitcher. Because pitchers are more likely to strain the MUCL than other positions, more studies on greater numbers of living athletes (not cadavers) according to player position are required to determine a safe olecranon spur resection length for young athletes.

Limitations

Our work had several limitations. First, our patient numbers were rather small, and only 43% of eligible patients had at least 12 months of follow-up postoperatively; this may have weakened the statistical analysis. Although 421 patients underwent arthroscopic elbow spur resections, only a few exhibited arthritic changes that were sufficiently severe to warrant spur removal from both the anterior and posterior compartments. Second, this was a retrospective study and there was no control group. We could not balance player numbers in terms of throwing and nonthrowing arm involvement or playing position. Third, our patients played at different levels. The rehabilitation strategies and environments in place for professionals, college players, and lower college students differ greatly; these affect RTP status and the pre-RTP period. Fourth, olecranon spur resection measurement was made by 1 orthopaedic surgeon. Fifth, the resection measurement method we devised was not validated and needs improvement. Preoperative and postoperative CT scans do not share the exact same rotation, and the cuts were paired by the measurer based on anatomic similarity. On both the olecranon ulnar and radial sides, comparisons made using 3DCT sagittal cuts do not reflect the real-world resection directions. Both over- and underestimations are possible. Therefore, further investigations on more accurate measurement methods are necessary.

Conclusion

In baseball players who had degenerative arthritis with either intact MUCLs or MUCLs that required staged reconstruction, arthroscopic OCA with olecranon spur resection to the original anatomic shape afforded favorable sRTP outcomes. However, the surgeon should be aware of the possible effect that excessive olecranon spur resection may have on MUCL strain.