Abstract
Background:
Wrist injuries are common in sports and can result in prolonged time missed from playing. This study aimed to determine in Major League Baseball-players after arthroscopic wrist surgery the return-to-sport (RTS) rate, postoperative career length, and changes in performance compared with preoperative statistics and matched controls.
Methods:
Major League Baseball players who underwent arthroscopic wrist surgery from 1990 to 2019 were identified. Demographic and performance data were collected for each player, and matched controls were identified. Comparisons were made via paired samples Student t tests.
Results:
Twenty-six players (27 surgeries) were identified. The average age of included players was 28.9 ± 2.9 years with an average professional experience of 5.2 ± 3.4 years. Eighty-four percent of players returned to sport, with an average RTS time of 5.0 ± 2.7 months. A statistically significant (P < .05) decrease was seen in preoperative and postoperative runs scored per season (95.6 ± 91.3 vs 41.0 ± 29.5), batting average (BA) (0.270 ± 0.024 vs 0.240 ± 0.036), and average wins above replacement (WAR) (1.5 ± 1.1 vs 0.8 ± 0.9).
Conclusion:
Major League Baseball players who underwent arthroscopic wrist surgery had an RTS rate of 84% at a mean time of 5.0 months. There was no significant difference in performance statistics between cases postoperatively and matched controls overall, with some differences in performance found when categorized by position. However, a significant decrease in performance among case players was observed between preoperative and postoperative performance, including runs per season, BA, and WAR.
Keywords: wrist, anatomy, surgery, specialty, arthroscopy, research and health outcomes, outcomes
Introduction
Wrist injuries are common in sports and can result in prolonged time missed from playing.1,2 Professional baseball players in both Major League Baseball (MLB) and Minor League Baseball (MiLB) are at risk of acute and chronic injuries to their upper extremities. 2 During the seasons between 2011 and 2016, the most common injury mechanism for hand and wrist injuries in professional baseball was batting, and the most common wrist injuries were sprains, contusions, hook of hamate fractures, extensor tendinopathy, and triangular fibrocartilage complex (TFCC) tears. 2 The most frequent wrist surgeries were hook of the hamate excisions, open reduction and internal fixation of scaphoid fractures, carpal tunnel releases, extensor carpi ulnaris stabilization, and TFCC debridement. 2 Infielders were the most commonly injured position for wrist injuries. 2 The same study found that the mean days missed for wrist injuries involving nonoperative treatment and surgical intervention was 22.8 days in all MLB and MiLB players. 2 A similar study that evaluated baseball players after hook of hamate excisions found that there was an earlier return to sport (RTS) than alternative treatment method as well as a limited complication rate. 3 Another previous study showed comparable results for open versus arthroscopic repair of the TFCC but was not focused on outcomes for athletes or baseball players specifically. 4 To the authors’ knowledge, there has been no study to evaluate the RTS rate or time frame nor performance for baseball players after arthroscopic wrist surgery. The purpose of the study was to determine in MLB players after arthroscopic wrist surgery the: (1) RTS rate; (2) postoperative career length; (3) differences between preoperative and postoperative performance; (4) differences in postoperative performance compared with matched control players; and (5) postoperative performance for dominant wrist injuries. The authors hypothesized that MLB players who received arthroscopic wrist surgery would: (1) have an RTS rate of >90%; (2) have no significant difference in the postoperative career length; (3) have no significant differences in preoperative and postoperative performance; (4) have no significant difference in performance when compared with matched control players; and (5) have no significant difference in performance when undergoing surgery on their dominant hand when compared with players who underwent surgery on their nondominant hand.
Materials and Methods
Major League Baseball players who underwent arthroscopic wrist surgeries between 1990 and 2019 were identified through MLB team websites, publicly available internet-based injury reports, player profiles and biographies, and press releases (Figure 1). Searches were performed for all MLB teams and players. This method of data collection was successfully used in previous investigations of professional athletes in the National Football League, National Hockey League, National Basketball Association, and Major League Soccer.5-9
Figure 1.
Flowchart demonstrating inclusion and exclusion criteria.
Note. MLB = Major League Baseball.
All players identified were included in this study as it related to the RTS rate. A player was deemed to RTS if he played in any MLB game after surgery. A player did not RTS if he did not play in any MLB game after surgery. Inclusion criteria were any athletes on an active roster in the MLB before arthroscopic wrist surgery. Players were included if they had arthroscopic wrist surgery as reported by at least 1 source and were confirmed with a second source if possible. Athletes who pursued exclusively nonoperative treatment for their wrist injuries were excluded. Players who had nonarthroscopic wrist surgeries were excluded. Athletes whose surgery dates were not available were excluded. Players who opted out due to COVID were excluded.
Demographic variables, including the player’s age, hand dominance (throwing hand), batting preference (right/left/switch), position, prior professional experience, and date of surgery, were recorded. Players were categorized by their positions, including catcher, first basemen, infielder (second baseman, shortstop, and third baseman), outfielder (including left fielder, centerfielder, and right fielder), and pitcher. No pitchers who underwent arthroscopic wrist surgery and subsequently returned to sport were identified. Performance statistics were collected from http://baseball-reference.com for each player identified before and after arthroscopic wrist surgery. Statistics were collected for regular-season MLB games only; spring training, minor league, and playoff games were excluded. Statistics used in this study included games, plate appearances, runs per season, batting average (BA), on-base percentage, slugging percentage, on-base percentage plus slugging percentage, and wins above replacement (WAR). Wins above replacement is a sabermetric statistic (http://sabr.org/sabermetrics/statistics) used to assess a player’s overall value, and it takes into account fielding, hitting, and base running. A WAR of 2.0 means that over the course of the season, the player contributed to 2 wins more than a “replacement player” (an average player in the MLB). A control group was selected to compare data. Controls were matched to study cases based on position, age, years of experience, body mass index, and performance data before the surgery date. Each control was given an index date that matched the case player’s surgery date to compare postoperative or postindex performance. For example, if a player had surgery 3 years into his career, the control’s index date was 3 years into his career. Player statistics for cases before and after surgery and for controls before and after the index dates were collected and aggregated. Each statistical category was divided by seasons played to account for discrepancies in the number of total seasons played. The 1994 and 1995 MLB strike was taken into account because the definition of a full season in those years was an average of 113 and 144 games, respectively. The number of games played for athletes during that time frame was adjusted to reflect a full 162-game season. All players were included in analyses of RTS, games per season, and career length. A Kaplan-Meier survivorship curve with “retirement” as the endpoint was constructed postoperatively for cases and postindex date for controls. Comparisons between case and control groups and preoperative and postoperative time points were made by use of 2-tailed paired samples Student t tests; P values less than .05 were considered significant.
Results
Thirty-two surgeries among 31 MLB players were analyzed in total (Table 1). Of these players, 84% (n = 27) returned to sport. Only catchers and first basemen had an RTS rate of 100%. Twenty-three (71.9%) of these surgeries occurred within the decade of 2010 to 2020 (Figure 2). Among all case players, the average age was 28.86 ± 2.9 years and the average number of years playing professionally before the surgery date was 5.24 ± 3.4 years (Table 2). The control players had an average age of 28.95 ± 3.0 years and an average preindex experience level of 5.25 ± 3.0 years (Table 2). Outfielders (n = 15) represented the position that underwent the most arthroscopic wrist surgeries (46.9%). The 1-year career survival rate for players undergoing arthroscopic wrist surgery was 84%, whereas the control players had a 1-year MLB career survival rate of 100% (Figure 3). Of the players that did RTS at the professional level, there was an average RTS time of 4.97 ± 2.7 months (150 ± 80.9 days). Those who underwent surgery during their season had an average RTS time of 5.02 ± 3.79 months (151.7 ± 114.5 days), and players who underwent surgery during the off-season had an average RTS time of 4.92 ± 1.12 months (148.6 ± 33.9 days).
Table 1.
Time to RTS by Position.
| Position | N | RTS, n (%) | Months to RTS a , mean ± SD |
|---|---|---|---|
| Catcher | 1 | 1 (100) | 5.66 ± 0 |
| First baseman | 6 | 6 (100) | 7.68 ± 2.68 |
| Infielder | 9 | 7 (77.8) | 2.15 ± 1.32 |
| Outfielder | 15 | 14 (93.3) | 5.19 ± 1.88 |
| Pitcher | 1 | 0 (0) | NA |
| Overall | 32 | 27 (84.4) | 4.97 ± 2.70 |
Note. RTS = return to sport; NA = not applicable.
Months to RTS calculated based on time for those who did return; months calculated as days/30.17.
Figure 2.
Number of wrist arthroscopic surgeries in MLB by decade.
Note. MLB = Major League Baseball.
Table 2.
Presurgery and Preindex Statistics for Cases and Controls by Position a .
| Statistic | Catcher |
First baseman |
Other infielder |
Outfielder |
||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Cases | Controls | P value | Cases | Controls | P value | Cases | Controls | P value | Cases | Controls | P value | |
| Age | 31.7 | 30.3 | NA | 29.3 ± 3.9 | 30.1 ± 3.3 | .591 | 27.4 ± 2.9 | 27.4 ± 3.1 | .902 | 29.2 ± 2.2 | 29.2 ± 2.9 | .925 |
| Exp | 8.1 | 7.3 | NA | 6.8 ± 4.8 | 6.5 ± 3.9 | .644 | 2.9 ± 1.9 | 3.3 ± 1.7 | .320 | 5.5 ± 3.0 | 5.6 ± 3.0 | .896 |
| BMI | 31.5 | 26.9 | NA | 28.1 ± 3.1 | 26.8 ± 2.7 | .400 | 25.8 ± 2.2 | 26.9 ± 2.5 | .351 | 27.4 ± 1.7 | 27.6 ± 1.8 | .781 |
| G/s | 71.2 | 103.9 | NA | 103.2 ± 27.0 | 98.0 ± 42.3 | .774 | 115.8 ± 15.0 | 114.1 ± 47.7 | .920 | 96.4 ± 32.2 | 92.4 ± 44.8 | .791 |
| PA/s | 242.7 | 381.9 | NA | 402.2 ± 142.8 | 377.7 ± 186.4 | .782 | 418.9 ± 86.1 | 458.6 ± 231.8 | .611 | 360.4 ± 156.3 | 333.1 ± 202.4 | .698 |
| BA | 0.240 | 0.234 | NA | 0.286 ± 0.022 | 0.259 ± 0.033 | .096 | 0.261 ± 0.023 | 0.273 ± 0.016 | .198 | 0.266 ± 0.023 | 0.240 ± 0.060 | .111 |
| OBP | 0.315 | 0.313 | NA | 0.365 ± 0.032 | 0.328 ± 0.039 | .168 | 0.333 ± 0.033 | 0.333 ± 0.020 | .967 | 0.330 ± 0.025 | 0.303 ± 0.065 | .121 |
| SLG | 0.394 | 0.390 | NA | 0.474 ± 0.041 | 0.474 ± 0.043 | .974 | 0.396 ± 0.043 | 0.417 ± 0.046 | .477 | 0.429 ± 0.032 | 0.383 ± 0.108 | .155 |
| OPS | 0.710 | 0.702 | NA | 0.839 ± 0.066 | 0.804 ± 0.079 | .424 | 0.728 ± 0.060 | 0.750 ± 0.062 | .593 | 0.759 ± 0.044 | 0.686 ± 0.169 | .132 |
Note. Exp = seasons played in MLB; BMI = body mass index; G/s = games per season; PA/s = plate appearances per season; BA = batting average; OBP = on-base percentage; SLG = slugging percentage; OPS = on-base percentage plus slugging percentage; NA = not applicable.
Values are shown as mean ± SD as calculated by the 2-tailed paired Student t test.
Figure 3.
Kaplan-Meier survival analysis for cases and controls. Zero represents the year of surgery for cases and the index year for controls.
Among case players, a statistically significant (P < .05) decrease was seen between preoperative and postoperative runs per season (95.6 ± 91.3 vs 41.0 ± 29.5), BA (0.270 ± 0.024 vs 0.240 ± 0.036), and average WAR (1.5 ± 1.1 vs 0.8 ± 0.9) (Figure 4). First basemen displayed a statistically significant decrease between presurgery and postsurgery performance in the measures of games per season (103.18 ± 27.0 vs 75.92 ± 30.7), plate appearances per season (402.16 ± 142.8 vs 267.21 ± 134.1), at bats per season (346.93 ± 113.2 vs 253.82 ± 124.0), and walks per season (46.36 ± 29.4 vs 25.74 ± 10.2). Other infielders displayed a statistically significant (P < .05) decrease from presurgery to postsurgery performance in third base runs per season (2.32 ± 1.2 vs 1.40 ± 1.3) and average WAR (1.39 ± 0.9 vs 0.76 ± 0.8). Outfielders showed a statistically significant decrease (P < .05) in stolen bases per season when comparing preoperative and postoperative performance (11.07 ± 11.8 vs 9.01 ± 11.8).
Figure 4.
Average WAR overall and by position before and after surgery and before and after control index date.
Note. WAR = wins above replacement.
No significant differences were seen in data for overall presurgery or preindex demographics, performance, or games per season between cases and controls. In first basemen, a statistically significant (P < .05) difference was observed between cases and controls for postoperative and postindex games per season (75.92 ± 30.7 vs 121.04 ± 45.4), plate appearances per season (267.21 ± 134.1 vs 472.00 ± 209.6), walks per season (25.74 ± 10.2 vs 52.67 ± 23.1), intentional walks per season (2.15 ± 1.3 vs 4.54 ± 2.3), and strikeouts per season (52.24 ± 25.5 vs 98.34 ± 43.4). The other infielders had a statistically significant (P < .05) difference for postoperative and postindex BA (0.229 ± 0.031 vs 0.257 ± 0.022), on-base percentage (0.300 ± 0.040 vs 0.317 ± 0.031), and on-base slugging (0.674 ± 0.070 vs 0.728 ± 0.093) when comparing cases with controls. No significant differences (P < .05) in postoperative or postindex performance were noted between cases and controls.
A statistically significant decrease (P < .05) was observed in runs per season (95.6 ± 91.3 vs 44.1 ± 36.2), BA (0.270 ± 0.020 vs 0.240 ± 0.030), average defensive WAR (0.0 ± 0.5 vs −0.1 ± 0.4), and average offensive WAR (1.2 ± 0.9 vs 0.9 ± 0.9) for players whose operative hand was their dominant hand.
Discussion
This study sought to determine RTS time for professional baseball players undergoing wrist arthroscopy. Secondarily, this study aimed to delineate differences in preoperative and postoperative performance. Ultimately, the RTS rate for players undergoing arthroscopic wrist surgery was 84%. Although most measures of performance were not significantly altered after surgery, there were some notable changes to player performance, including lower average runs per season, lower BAs, and lower WAR. These findings are summarized in Table 3. As a group, first basemen had the greatest number of parameters significantly affected in comparison with both their presurgery performance and in comparison with matched controls (Figure 4). The authors theorize that first basemen may have shown a greater decrease in these parameters than other positions which may be due to the higher frequency with which they receive throws from other infielders to force runners out.
Table 3.
Postsurgery and Postindex Statistics for Cases and Controls by Position a .
| Statistic | Catcher |
First baseman |
Other infielder |
Outfielder |
||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Cases | Controls | P value | Cases | Controls | P value | Cases | Controls | P value | Cases | Controls | P value | |
| Seasons | 3 | 3 | NA | 4.8 ± 3.2 | 4.7 ± 2.3 | .935 | 4.6 ± 3.5 | 4.6 ± 3.2 | .970 | 4.6 ± 2.4 | 4.6 ± 2.4 | .938 |
| G/s | 63.0 | 41.7 | NA | 75.9 ± 30.7 | 121.0 ± 45.4 | .033 | 88.8 ± 21.0 | 102.0 ± 25.1 | .422 | 105.0 ± 70.2 | 93.2 ± 34.1 | .552 |
| PA/s | 228.7 | 147.0 | NA | 267.2 ± 134.1 | 472.0 ± 209.6 | .048 | 304.3 ± 118.5 | 372.5 ± 130.7 | .378 | 416.7 ± 308.0 | 325.66 ± 169.2 | .339 |
| BA | 0.227 | 0.208 | NA | 0.245 ± 0.035 | 0.236 ± 0.056 | .621 | 0.229 ± 0.031 | 0.257 ± 0.022 | .004 | 0.250 ± 0.041 | 0.245 ± 0.021 | .692 |
| OBP | 0.329 | 0.311 | NA | 0.336 ± 0.022 | 0.332 ± 0.036 | .838 | 0.300 ± 0.040 | 0.317 ± 0.031 | .049 | 0.322 ± 0.032 | 0.310 ± 0.023 | .158 |
| SLG | 0.382 | 0.389 | NA | 0.406 ± 0.044 | 0.428 ± 0.089 | .549 | 0.374 ± 0.050 | 0.411 ± 0.066 | .099 | 0.400 ± 0.056 | 0.386 ± 0.042 | .483 |
| OPS | 0.712 | 0.701 | NA | 0.742 ± 0.050 | 0.759 ± 0.125 | .745 | 0.674 ± 0.070 | 0.728 ± 0.093 | .030 | 0.722 ± 0.078 | 0.696 ± 0.056 | .303 |
Note. BMI = body mass index; G/s = games per season; PA/s = plate appearances per season; BA = batting average; OBP = on-base percentage; SLG = slugging percentage; OPS = on-base percentage plus slugging percentage; NA = not applicable.
Values are shown as mean ± SD as calculated by the 2-tailed paired Student t test.
Although players overall showed a decrease in average WAR, differences in WAR became more specific when accounting for hand dominance. For instance, players whose operative hand was their back hand during batting only showed a decrease in average offensive WAR, while players whose operative hand was their glove hand when fielding only showed a decrease in average defensive WAR. This may occur for a variety of reasons, such as pain, weakness, or hesitancy due to fear of reinjury or fear of pain. However, this may suggest that wrist injuries which necessitate arthroscopic wrist surgery itself may have a detrimental effect on player performance.
There are limitations to this study. Matched controls were used for each case player to account for natural changes that may occur in performance over the course of one’s career; however, variability in performance that occurred coincidentally, and not in relation to surgery, may have been simultaneously included in these findings. Furthermore, the small sample size of catchers (n = 1) and pitchers (n = 0) may also create variability in data and does not allow these results to be applied to all positions with equal validity. Although this method of data acquisition has been used in other studies to evaluate a wide variety of injuries in sports, these data are vulnerable to bias or inconsistencies due to their public sources.7,10-17 For instance, some players who underwent wrist arthroscopy may not have been identified for inclusion in the study. Differences in surgeons, surgeon skill, or surgical techniques over time may also contribute to inconsistencies in results. In addition, although the first game played was used as the RTS date, this does not accurately measure the time which it would take for a player to begin returning to exercises, batting, throwing, or other sport-specific activity. Many players with less severe injuries may have pushed their surgery until the off-season, whereas players who received surgery during mid or late season may have missed the rest of their season in addition to the days until the beginning of their next season, artificially inflating their RTS time. However, the 4.92 month RTS time found for players who underwent surgery in-season may suggest that players who receive surgery within the first few months of the regular season may still be able to return in the same season. Although career length was calculated for all included players, this calculation may not be a true measure of career length as some players opted out of the 2020 season due to the COVID pandemic and career length cannot be prospectively calculated for players who are still active on MLB teams.
Conclusion
Major League Baseball players who underwent arthroscopic wrist surgery had an RTS rate of 84% and a mean RTS time of 5.0 months. There was no significant difference in performance statistics between cases postoperatively and matched controls overall, with some differences in performance found when categorized by position. However, a significant decrease in performance among case players was observed between preoperative and postoperative dates, including runs per season, BA, and average WAR.
Footnotes
Ethical Approval: This article does not contain any studies with human or animal subjects and solely utilizes publicly available data.
Statement of Human and Animal Rights: This article does not contain any studies with human or animal subjects.
Statement of Informed Consent: This article does not contain any studies with human subjects or any undisclosed private health information. All data was obtained through publicly available sources.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iDs: Erin I. Orozco 
https://orcid.org/0000-0001-8796-6876
Shari R. Liberman
https://orcid.org/0000-0001-6476-6548
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