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Buchanan TR, Hones KM, Hao KA, Kamarajugadda S, Portnoff B, Wright JO, King JJ, Wright TW, Kim J, Schoch BS, Roach RP, Aibinder WR. Rehabilitation Protocols in Elbow Medial Ulnar Collateral Ligament Injuries: A Systematic Review of Articles Published in the Last 20 Years. Sports Health 2025; 17:460-469. [PMID: 38702939 PMCID: PMC11569531 DOI: 10.1177/19417381241249125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2024] Open
Abstract
CONTEXT Elbow medial ulnar collateral ligament (UCL) injuries have become increasingly common in athletes. Despite this, rehabilitation protocols appear to vary drastically, which may explain the clinical equipoise regarding optimal management. OBJECTIVE This systematic review reports rehabilitation characteristics reported after UCL injuries and compares reported outcomes based on early versus delayed rehabilitation. DATA SOURCES Our search utilized PubMed/MEDLINE, Embase, Web of Science, and Cochrane to identify all articles on UCL rehabilitation published between January 1, 2002 and October 1, 2022. STUDY SELECTION Studies in English with ≥5 patients that reported rehabilitation protocols for UCL injuries were evaluated. STUDY DESIGN Systematic review. LEVEL OF EVIDENCE Level 4. DATA EXTRACTION Data included sample characteristics, time to achieve physical therapy milestones, outcome scores, and return-to-play (RTP) rate and timing. RESULTS Our review included 105 articles with a total of 15,928 elbows (98% male; weighted mean age, 23 years; follow-up, 47 months), with 15,077 treated operatively and 851 treated nonoperatively. The weighted mean time patients spent adhering to nonweightbearing status was 42 days. The mean time until patients were given clearance for active range of motion (ROM) 15 days, full ROM 40 days, and elbow strengthening exercises 32 days. The mean time until all restrictions were lifted was 309 days. The mean time to begin a throwing program was 120 days. Across all rehabilitation characteristics, protocols for patients undergoing nonoperative management started patients on rehabilitation earlier. After UCL reconstruction, earlier active ROM (≤14 days), elbow strengthening (≤30 days), no restrictions (≤180 days), and throwing (≤120 days) postoperatively led to earlier RTP without a negative effect on functional outcome scores. CONCLUSION Current literature provides a spectrum of protocols for elbow UCL rehabilitation, regardless of management. Nonoperative patients began ROM activities, strengthening, and throwing programs sooner than operative patients, and earlier milestones led to earlier RTP.
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Affiliation(s)
| | - Keegan M. Hones
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, Florida
| | - Kevin A. Hao
- College of Medicine, University of Florida, Gainesville, Florida
| | | | - Brandon Portnoff
- Department of Orthopedic Surgery, Brown University, Providence, Rhode Island
| | - Jonathan O. Wright
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, Florida
| | - Joseph J. King
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, Florida
| | - Thomas W. Wright
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, Florida
| | - Jongmin Kim
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, Florida
| | - Bradley S. Schoch
- Department of Orthopaedic Surgery, Mayo Clinic, Jacksonville, Florida
| | - Ryan P. Roach
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, Florida
| | - William R. Aibinder
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
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Peebles LA, Blackwood NO, Verma A, O'Brien MJ, Lintner DM, Kraeutler MJ. Medial Ulnar Collateral Ligament Reconstruction With Allograft Provides Excellent Clinical Outcomes, High Rates of Return to Play, and a Low Incidence of Postoperative Complications: A Systematic Review. Arthroscopy 2025; 41:1113-1122. [PMID: 38593928 DOI: 10.1016/j.arthro.2024.03.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/19/2024] [Accepted: 03/23/2024] [Indexed: 04/11/2024]
Abstract
PURPOSE To perform a systematic review evaluating clinical outcomes in patients undergoing medial ulnar collateral ligament reconstruction (MUCLR) with soft-tissue allograft. METHODS A systematic review of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary outcomes evaluated were patient-reported outcome scores, return to play (RTP) rates, incidence of postoperative complications, and rates of graft rupture or mechanical failure. RESULTS The literature search identified 395 articles, and 5 studies met final inclusion criteria after full-text review. A total of 274 patients were analyzed in the included studies and follow-up ranged from 3.0 to 7.6 years. Two studies (number of patients = 141) reported outcomes exclusively of MUCLR with allograft, whereas 3 studies (number of patients = 133) reported outcomes in patients undergoing MUCLR with either allograft or autograft. Allograft sources included gracilis, semitendinosus, plantaris, peroneus longus, and palmaris longus. Level of patient athletic competition ranged from recreational athletes to the professional level; however, nonathletes in the setting of trauma were also included. The RTP rate after MUCLR with soft-tissue allograft was 95.3%, and 89.3% of patients returned to a similar or greater level of play postoperatively. The Timmerman-Andrews score was reported in 2 studies, and the means postoperatively ranged from 94.55 to 97. Postoperative complication rates were low (range, 0% to 20%), and there were no reported incidences of allograft rupture or mechanical failure. CONCLUSIONS Based on the available data, soft-tissue allograft for MUCLR in athletic patient populations provides excellent clinical outcomes, high rates of RTP, and low rates of postoperative complications and graft failure at short-term follow-up. There remains a lack of high-quality evidence directly comparing autograft versus allograft outcomes in elite overhead-throwing athletes to support allograft as an acceptable alternative for MUCLR in this patient population. LEVEL OF EVIDENCE: Level IV, systematic review of Level III-IV studies.
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Affiliation(s)
- Liam A Peebles
- Tulane University School of Medicine, New Orleans, Louisiana, U.S.A..
| | | | - Arjun Verma
- Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
| | - Michael J O'Brien
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
| | - David M Lintner
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, Texas, U.S.A
| | - Matthew J Kraeutler
- Department of Orthopedics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, U.S.A
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Tarazona D, ElAttrache N, Meister K. Management of UCL Injuries: Primary and Revision. Clin Sports Med 2025; 44:173-193. [PMID: 40021251 DOI: 10.1016/j.csm.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2025]
Abstract
Ulnar collateral ligament injuries are prevalent among baseball players with an increasing incidence, especially in younger athletes. Diagnosis relies on history, examination, and MRI, with dynamic imaging playing an expanding role. Nonoperative management prioritizes cessation of throwing, correcting kinetic chain deficiencies, and gradual rehabilitation. The decision between reconstruction and repair is based on tear characteristics, tissue quality, patient goals, position, and timing of injury. Primary surgery generally results in high return-to-play rates. Revision surgery has less favorable outcomes with more complications. Emerging trends include the use of hybrid reconstruction techniques for challenging cases and platelet-rich plasma to augment nonoperative care.
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Affiliation(s)
- Daniel Tarazona
- Cedars-Sinai Kerlan-Jobe Institute, 6801 Park Terrace, Suite 500, Los Angeles, CA 90045, USA
| | - Neal ElAttrache
- Cedars-Sinai Kerlan-Jobe Institute, 6801 Park Terrace, Suite 500, Los Angeles, CA 90045, USA; Kerlan Jobe Orthopaedic Foundation
| | - Keith Meister
- TMI Sports Medicine and Orthopedics, 3533 Matlock Road, Arlington, TX 76015, USA.
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Dugas JR, Froom RJ, Mussell EA, Carlson SM, Crawford AE, Tulowitzky GE, Dias T, Wilk KE, Patel AN, Kidwell-Chandler AL, Ryan MK, Atkinson AW, Manush AH, Rothermich MA, Ithurburn MP, Emblom BA, Cain EL. Clinical Outcomes of Ulnar Collateral Ligament Repair With Internal Brace Versus Ulnar Collateral Ligament Reconstruction in Competitive Athletes. Am J Sports Med 2025; 53:525-536. [PMID: 39891035 DOI: 10.1177/03635465251314054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2025]
Abstract
BACKGROUND The increasing prevalence of ulnar collateral ligament (UCL) injuries, particularly in young athletes, necessitates optimization of treatment options. The introduction of UCL repair with internal bracing offers an exciting alternative to traditional UCL reconstruction. PURPOSE To compare midterm outcomes between UCL repair with internal bracing and UCL reconstruction in competitive athletes. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS The authors identified competitive athletes who underwent primary UCL repair with internal bracing or UCL reconstruction between 2013 and 2021 and were at least 2 years postsurgery. To have qualified for repair, patients must have shown complete or partial UCL avulsion from the sublime tubercle or medial epicondyle. Relevant patient, injury, operative, and revision surgery data were collected via chart review. Preoperative American Shoulder and Elbow Surgeons Elbow assessment form (ASES-E), Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow (KJOC), and Andrews-Carson scores were obtained from an ongoing data repository. ASES-E, KJOC, and Andrews-Carson scores, and return-to-sport (RTS) data were collected at follow-up. Linear regression modeling controlling for relevant covariates was utilized to compare patient-reported outcome (PRO) scores between groups. Proportions of athletes who successfully returned to sport and proportions of subsequent revision procedures between groups were compared using chi-square tests. Lastly, for those with baseline questionnaire data, the authors compared magnitude of change between preoperative and postoperative scores between groups using linear regression modeling with baseline scores and follow-up time as the covariates, and follow-up scores as the dependent variable. RESULTS A total of 461 athletes were eligible for inclusion with complete clinical and outcome data available (mean age at surgery, 19.1 years; 92% male). The UCL repair group had a significantly shorter follow-up time than the UCL reconstruction group (4.4 vs 6.3 years; P < .01). When controlling for follow-up time, the groups did not differ in ASES-E, KJOC, or Andrews-Carson scores at follow-up. There was no significant difference in proportion of revisions between UCL repair (9%) and UCL reconstruction (8%) (P = .77). Of the 268 athletes with complete follow-up in the repair group, 247 attempted to return to their preinjury sport, and 241 (98%) were able to RTS. Six athletes reported that they were unable to RTS due to limitations from their surgery. Of the 155 athletes with follow-up in the reconstruction group, 147 attempted to return to their preinjury sport; 145 (99%) were able to successfully RTS, and 2 were unable to return due to limitations from their surgery. The 2 groups, repair with internal brace versus reconstruction, did not statistically differ in the proportions that returned to preinjury sport (P = .20) but did differ regarding time in months to return to practice (6.7 ± 3.5 vs 10.2 ± 11.7) (P < .01) and time in months to return to competition (9.2 ± 4.6 vs 13.4 ± 13.3) (P < .01). CONCLUSION Athletes who underwent UCL repair with internal brace reported excellent midterm PROs statistically similar to those after UCL reconstruction, including proportion successfully returning to preinjury sport. There was no significant difference in revision rates between procedures. However, athletes who underwent UCL repair had a statistically significantly shorter time to RTS.
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Affiliation(s)
- Jeffrey R Dugas
- Andrews Sports Medicine and Orthopaedic Center, Birmingham, Alabama, USA
- American Sports Medicine Institute, Birmingham, Alabama, USA
- Investigation performed at the American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Ryan J Froom
- Andrews Sports Medicine and Orthopaedic Center, Birmingham, Alabama, USA
- American Sports Medicine Institute, Birmingham, Alabama, USA
- Investigation performed at the American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Eric A Mussell
- Andrews Sports Medicine and Orthopaedic Center, Birmingham, Alabama, USA
- American Sports Medicine Institute, Birmingham, Alabama, USA
- Investigation performed at the American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Sydney M Carlson
- Andrews Sports Medicine and Orthopaedic Center, Birmingham, Alabama, USA
- American Sports Medicine Institute, Birmingham, Alabama, USA
- Investigation performed at the American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Anna E Crawford
- Andrews Sports Medicine and Orthopaedic Center, Birmingham, Alabama, USA
- American Sports Medicine Institute, Birmingham, Alabama, USA
- Investigation performed at the American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Graham E Tulowitzky
- American Sports Medicine Institute, Birmingham, Alabama, USA
- Investigation performed at the American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Travis Dias
- American Sports Medicine Institute, Birmingham, Alabama, USA
- Investigation performed at the American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Kevin E Wilk
- American Sports Medicine Institute, Birmingham, Alabama, USA
- Champion Sports Medicine, Birmingham, Alabama, USA
- Investigation performed at the American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Arsh N Patel
- American Sports Medicine Institute, Birmingham, Alabama, USA
- Investigation performed at the American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Ariel L Kidwell-Chandler
- American Sports Medicine Institute, Birmingham, Alabama, USA
- Investigation performed at the American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Michael K Ryan
- American Sports Medicine Institute, Birmingham, Alabama, USA
- Prevea Health Orthopaedics & Sports Medicine, Green Bay, Wisconsin, USA
- Investigation performed at the American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Andrew W Atkinson
- Andrews Sports Medicine and Orthopaedic Center, Birmingham, Alabama, USA
- American Sports Medicine Institute, Birmingham, Alabama, USA
- Investigation performed at the American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Andrew H Manush
- American Sports Medicine Institute, Birmingham, Alabama, USA
- Investigation performed at the American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Marcus A Rothermich
- Andrews Sports Medicine and Orthopaedic Center, Birmingham, Alabama, USA
- American Sports Medicine Institute, Birmingham, Alabama, USA
- Investigation performed at the American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Matthew P Ithurburn
- American Sports Medicine Institute, Birmingham, Alabama, USA
- Department of Physical Therapy, School of Health Professions, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Investigation performed at the American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Benton A Emblom
- Andrews Sports Medicine and Orthopaedic Center, Birmingham, Alabama, USA
- American Sports Medicine Institute, Birmingham, Alabama, USA
- Investigation performed at the American Sports Medicine Institute, Birmingham, Alabama, USA
| | - E Lyle Cain
- Andrews Sports Medicine and Orthopaedic Center, Birmingham, Alabama, USA
- American Sports Medicine Institute, Birmingham, Alabama, USA
- Investigation performed at the American Sports Medicine Institute, Birmingham, Alabama, USA
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Flores DV, Huang BK. Postoperative Imaging in the Throwing Athlete. Semin Musculoskelet Radiol 2025; 29:112-123. [PMID: 39933545 DOI: 10.1055/s-0044-1796632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2025]
Abstract
Overhead throwing subjects the shoulder and elbow to substantial stresses, resulting in unique injury patterns that need to be recognized to allow appropriate treatment and return to sport. At the elbow, the ulnar collateral ligament (UCL) is the primary static restraint to valgus stress and the most commonly injured structure. UCL reconstruction is the most frequent surgical procedure in throwers and may be performed along with ulnar nerve transposition and flexor-pronator mass procedures. Posteromedial impingement and valgus extension overload syndrome are related entities that result in intra-articular pathology, such as osteophytes or bodies lodged within the olecranon fossa, also warranting excision at the time of UCL reconstruction. Shoulder injuries involve the rotator cuff (partial-thickness articular-sided tear), labrum (superior anteroposterior labral tear), and capsule (glenohumeral internal rotation deficit). Surgical options such as cuff repair, labral debridement or repair, and capsular release or tightening therefore target these structures.
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Affiliation(s)
- Dyan V Flores
- Department of Radiology, Radiation Oncology and Medical Physics, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Department of Medical Imaging, The Ottawa Hospital, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Brady K Huang
- Department of Radiology, Division of Musculoskeletal Imaging and Intervention, University of California, San Diego Medical Center, San Diego, California
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Kholinne E, Ng ZH, Anastasia M, Singjie LC, Kwak JM, Jeon IH. Surgical Outcomes of Lateral Ulnar Collateral Ligament Reconstruction Versus Repair for Posterolateral Rotatory Instability of the Elbow: A Systematic Review and Meta-analysis. Orthop J Sports Med 2025; 13:23259671241299831. [PMID: 39780951 PMCID: PMC11707775 DOI: 10.1177/23259671241299831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Accepted: 04/12/2024] [Indexed: 01/11/2025] Open
Abstract
Background The aim of surgical treatment for posterolateral rotatory instability (PLRI) of the elbow is to restore the integrity of the lateral ulnar collateral ligament (LUCL), with ligamentous reconstruction being the preferred option for recurrent symptomatic PLRI. However, there is no clinical evidence demonstrating the superiority of reconstruction versus repair. Treatment options currently depend on the cause of the LUCL injury and surgeon preference. Purpose To review studies comparing surgical outcomes of LUCL reconstruction versus repair in treating PLRI of the elbow. Study Design Systematic review; Level of evidence, 4. Methods This review was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A literature search was conducted on PubMed, Medline (via EBSCO), ProQuest, and ScienceDirect databases using the following keywords: "(lateral ulnar collateral ligament reconstruction)" OR "(lateral ulnar collateral ligament repair)" AND "(outcome)." Excluded were studies in languages other than English, those that included terrible triad injury, transolecranon fracture, radial head arthroplasty involvement, associated procedures, animal studies, and biomechanical studies. A total of 193 studies were identified after the initial search. The primary outcome measure was the Mayo Elbow Performance Score, which was compared between studies using a random-effects model. Results Overall, 20 studies (N = 646 patients) were included, with 445 of 646 patients (68.8%) in the LUCL reconstruction group and 201 of 646 patients (31.1%) in the LUCL repair group. All injuries in the included studies were traumatic. The LUCL reconstruction group had a longer follow-up period compared with the LUCL repair group (72.05 ± 43.51 vs 36.86 ± 21.19 months, respectively). The postoperative range of motion arc was similar in both the repair and reconstruction groups (135.02°± 15.33° vs 133.60°± 8.84°, respectively). Both LUCL repair and LUCL reconstruction resulted in good to excellent outcomes on patient-reported outcome measures; however, a superior rate of return to activity and a lower complication rate were found after LUCL reconstruction versus LUCL repair (8.3% vs 14.9%). Ulnar nerve event (2.3%) was the most common complication in both groups. Conclusion Findings indicated that LUCL reconstruction had a superior rate of return to activity and a lower complication rate compared with LUCL repair.
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Affiliation(s)
- Erica Kholinne
- St Carolus Hospital, Jakarta, Indonesia
- Faculty of Medicine, Universitas Trisakti, Jakarta, Indonesia
| | - Zhan Herr Ng
- Department of Trauma and Orthopaedic Surgery, Queen Alexandra Hospital, Portsmouth, UK
| | - Maria Anastasia
- St Carolus Hospital, Jakarta, Indonesia
- Department of Orthopedic and Traumatology, Udayana University, Bali, Indonesia
| | - Leonard Christianto Singjie
- St Carolus Hospital, Jakarta, Indonesia
- Department of Orthopedic and Traumatology, Hasanuddin University, Makassar, Indonesia
| | - Jae-Man Kwak
- Department of Orthopedic Surgery, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu, Republic of Korea
| | - In-Ho Jeon
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Spears TM, Luchinni P, Camp CL, Bowman EN. Current Concepts in the Surgical Management of Elbow Medial Ulnar Collateral Ligament Injuries. J Am Acad Orthop Surg 2024:00124635-990000000-01209. [PMID: 39993227 DOI: 10.5435/jaaos-d-24-00839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2024] [Accepted: 11/21/2024] [Indexed: 02/26/2025] Open
Abstract
The elbow medial ulnar collateral ligament (UCL) serves as the primary soft tissue restraint to valgus stress and is therefore critical to the stabilization of the elbow in overhead-throwing athletes. Injuries to the UCL present with medial elbow pain and altered performance. Reconstruction of the UCL is the "gold standard" for surgical treatment; however, rehabilitation after reconstruction can take 12 to 18 months. Recent advances in technique have led to an increased interest in augmented UCL repair, which boasts a quicker return to sport at 6 months on average. Appropriate candidates for repair may include athletes with proximal or distal avulsions with otherwise adequate quality UCL tissue. Augmented repair is biomechanically equivalent to reconstruction and clinically demonstrates high rates of return to play (>90%). Recently, augmented reconstruction has emerged as a technique to merge the benefits of reconstruction with repair, although clinical outcomes have yet to be defined.
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Affiliation(s)
- Thomas M Spears
- From the Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN (Spears, Camp, and Bowman) and Mayo Clinic, Rochester, MN (Luchinni and Camp)
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Klein B, Bartlett LE, Brancato C, Paci JM. Inverted Mattress Knotless Repair of Medial Ulnar Collateral Ligament Avulsion Injury Using Flat Braided Suture Internal Brace. Arthrosc Tech 2024; 13:103124. [PMID: 39780893 PMCID: PMC11704883 DOI: 10.1016/j.eats.2024.103124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 05/10/2024] [Indexed: 01/11/2025] Open
Abstract
Direct repair of ulnar collateral ligament (UCL) injuries with suture augmentation has been successful in properly selected patients lacking chronic attritional wear of the medial elbow. Described is a Speed-Fix technique for direct UCL repair using SutureTape, with InternalBrace augmentation. The Speed-Fix repair technique uses an inverted mattress knotless repair with a knotless SwiveLock anchor and FiberTape suture, which allows for theoretical compression at the repair site. However, the proposed technique uses a 0.9-mm SutureTape to decrease tissue pullout and an InternalBrace to provide time-zero repair stability. For patients with ulnar nerve pathology, a pronator mass elevation was used for exposure, whereas a muscle-splitting approach was used for those without ulnar nerve pathology. With this technique, all patients were able to return to sport and were able to do so at an accelerated rate without repair failures.
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Affiliation(s)
- Brandon Klein
- Northwell Orthopedics, New Hyde Park, New York, U.S.A
| | | | | | - James M. Paci
- Orlin & Cohen Orthopedic Group, Smithtown, New York, U.S.A
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Varady NH, Parise S, Kunze KN, Brusalis CM, Williams RJ, Altchek DW, Dines JS. Favorable Outcomes Following Elbow Ulnar Collateral Ligament Reconstruction and Repair, Though Repair Associated with Increased Risk of Revision Surgery. Arthroscopy 2024:S0749-8063(24)00903-4. [PMID: 39532212 DOI: 10.1016/j.arthro.2024.10.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2024] [Revised: 10/22/2024] [Accepted: 10/28/2024] [Indexed: 11/16/2024]
Abstract
PURPOSE To assess the risk of revision surgery following repair versus reconstruction of the medial ulnar collateral ligament (UCL) of the elbow in a national sample of patients in the United States. METHODS This was a retrospective cohort study of young patients (≤35 years old) who underwent primary UCL reconstruction or repair for an isolated medial UCL injury of the elbow from October 2015 through October 2022 in a large national database (PearlDiver). Patient demographic data, comorbidities, surgical details, and concomitant ulnar nerve procedures were collected. Time-to-event analyses were used to assess the risk of revision UCL surgery between groups. Two-year complication rates, including ulnar neuropathy, were also assessed. RESULTS In total, 1,820 patients (69.9% reconstruction, 30.1% repair) with an average follow-up of 2.9 years met inclusion criteria. The estimated 2-year revision-free survival (95% confidence interval) was 99.5% (99.1%-99.9%) for UCL reconstruction compared to 97.9% (96.4%-99.3%) for UCL repair (unadjusted log-rank P = .032). UCL repair remained associated with an increased risk of revision UCL surgery after adjusting for confounding variables (hazard ratio, 2.94; 95% confidence interval, 1.07-8.09; P = .037). Complication rates were similar between reconstruction and repair, including the incidence of ulnar neuropathy (13.8% vs 14.5%, P = .78). CONCLUSIONS In this study, we found that UCL repair was associated with a significantly higher risk of revision UCL surgery than UCL reconstruction in a national sample. Importantly, however, overall failure rates were low, and complication rates were similar between procedures. These findings support the overall favorable outcomes of UCL repair while suggesting it may not necessarily be the optimal treatment for all patients. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Nathan H Varady
- Department of Sports Medicine, Hospital for Special Surgery, New York, New York, U.S.A..
| | - Suhas Parise
- Department of Sports Medicine, Hospital for Special Surgery, New York, New York, U.S.A
| | - Kyle N Kunze
- Department of Sports Medicine, Hospital for Special Surgery, New York, New York, U.S.A
| | | | - Riley J Williams
- Department of Sports Medicine, Hospital for Special Surgery, New York, New York, U.S.A
| | - David W Altchek
- Department of Sports Medicine, Hospital for Special Surgery, New York, New York, U.S.A
| | - Joshua S Dines
- Department of Sports Medicine, Hospital for Special Surgery, New York, New York, U.S.A
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Malige A, Uquillas C. Performance-Based Outcomes after Revision Ulnar Collateral Ligament Surgery in Professional Pitchers. Clin J Sport Med 2024; 34:454-461. [PMID: 38349193 DOI: 10.1097/jsm.0000000000001206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 12/18/2023] [Indexed: 02/16/2024]
Abstract
OBJECTIVE To compare performance in baseball pitchers before and after revision ulnar collateral ligament (UCL) surgery using performance metrics. DESIGN Case series. SETTING Public online database. PATIENTS OR PARTICIPANTS Players who underwent revision UCL surgery between 2015 and 2021 were identified. Players were included if they were Minor League (MiLB) or Major League (Major League baseball [MLB]) pitchers. Players were excluded if they were not pitchers, if they underwent their revision surgery as an amateur, or if there is no record of their primary reconstruction surgery. INTERVENTIONS Revision UCL surgery (repair or reconstruction). MAIN OUTCOME MEASURES Return to sport (RTS) rate, RTS time, pitch velocity, and pitch spin rate. RESULTS Sixty-five pitchers underwent revision UCL surgery. MiLB pitchers had a shorter RTS time after their primary surgery (15.62 vs 20.77 months, P < 0.01) compared with MLB pitchers but similar RTS times after their revision reconstruction (19.64 vs 18.48 months, P = 0.44). There was also no difference in return to play (RTP) rate overall after primary versus revision reconstruction ( P = 1.00). Major League baseball pitchers also had decreased RTS time after primary compared with revision reconstruction (15.62 vs 19.64 months, P < 0.01) but similar RTP rates ( P = 0.28). Finally, MLB pitchers had similar pitch breakdowns, velocities, and spin rates before and after their primary and revision repair or reconstruction. CONCLUSIONS Both revision UCL repair and reconstruction can return pitchers to preinjury performance levels. Pitchers and teams should be properly counseled on realistic RTP times and postsurgery performance when discussing revision UCL surgeries.
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Affiliation(s)
- Ajith Malige
- Kerlan Jobe Orthopaedic Clinic, Los Angeles, California
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Malige A, Uquillas C. Ulnar collateral ligament repair in professional baseball players. Clin Shoulder Elb 2024; 27:278-285. [PMID: 39138948 PMCID: PMC11393434 DOI: 10.5397/cise.2023.01109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 03/18/2024] [Indexed: 08/15/2024] Open
Abstract
BACKGROUND While initial reports of surgical repair of ulnar collateral ligament tears are promising, studies detailing post-repair outcomes are lacking. This study explores the effectiveness of ulnar collateral ligament (UCL) repair in returning professional baseball players to their pre-injury level of play. Our hypothesis is that professional baseball players undergoing UCL repair will have successful outcomes and high return to sport rates after surgery. METHODS Publicly available databases were utilized to search for data on professional baseball players who underwent UCL repair from 2016 to 2021. Players undergoing primary UCL repair with an internal brace were included. Amateur players were excluded as were those undergoing revision UCL repair or UCL reconstruction. RESULTS Of the 11 pitchers who underwent UCL repair, minor league baseball (MiLB) pitchers returned to the sport at an average of 17.5 months. MiLB pitchers had similar earned run averages (ERAs), games played, innings pitched, and walks plus hits per inning pitched ratios (WHIPs) before and after surgery. Four major league baseball (MLB) pitchers (80%) returned to the sport at 9.55 months. MLB pitchers played fewer games and pitched fewer innings than before the surgery, but their ERAs and WHIPs were similar before and after surgery. Pitch velocity and spin rates after surgery varied based on pitch type. The seven positional players who underwent UCL repair showed no differences in batting or fielding performance before and after surgery. CONCLUSIONS UCL repair can successfully return both pitchers and positional players at both the MiLB and MLB levels to play at pre-injury performance levels. Repair can be considered as an option for qualifying injuries in players hoping to maximize performance after surgery with minimal recovery time. Level of Evidence: IV.
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Affiliation(s)
- Ajith Malige
- Kerlan-Jobe Orthopaedic Clinic, Los Angeles, CA, USA
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Bi AS, Lin CC, Anil U, Rokito AS, Jazrawi LM, Erickson BJ. Trends in Elbow Ulnar Collateral Ligament Repairs and Reconstructions and an Analysis Between Low- and High-Volume Surgical Centers: A 10-Year Study in New York State. Orthop J Sports Med 2024; 12:23259671241246811. [PMID: 38799547 PMCID: PMC11128166 DOI: 10.1177/23259671241246811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 10/29/2023] [Indexed: 05/29/2024] Open
Abstract
Background Elbow ulnar collateral ligament (UCL) reconstruction (UCLR) is the gold standard for operative treatment of UCL tears, with renewed interest in UCL repairs. Purpose To (1) assess trends in rates of UCLR and UCL repair and (2) identify predictors of complications by demographic, socioeconomic, or surgical center volume factors. Study Design Descriptive epidemiology study. Methods Patients who underwent UCLR or UCL repair at New York State health care facilities between 2010 and 2019 were retrospectively identified; concomitant ulnar nerve procedures among the cohort were also identified. Surgical center volumes were classified as low (<99th percentile) or high (≥99th percentile). Patient information, neighborhood socioeconomic status quantified using the Area Deprivation Index, and complications within 90 days were recorded. Poisson regression analysis was used to compare trends in UCLR versus UCL repair. Multivariable regression was used to determine whether center volume, demographic, or socioeconomic variables were independent predictors of complications. Results A total of 1448 UCL surgeries were performed, with 388 (26.8%) concomitant ulnar nerve procedures. UCLR (1084 procedures; 74.9%) was performed more commonly than UCL repair (364 procedures; 25.1%), with patients undergoing UCL repair more likely to be older, female, and not privately ensured and having undergone a concomitant ulnar nerve procedure (all P < .001). With each year, there was an increased incidence rate ratio for UCL repair versus UCLR (β = 1.12 [95% CI, 1.02-1.23]; P = .022). The authors identified 2 high-volume centers (720 UCL procedures; 49.7%) and 131 low-volume centers (728 UCL procedures; 50.3%). Patients undergoing UCL procedures at high-volume centers were more likely to be younger and male and receive workers' compensation (all P < .001). UCL repair and ulnar nerve-related procedures were both more commonly performed at low-volume centers (P < .001). There were no significant differences in 3-month infection, ulnar neuritis, instability, arthrofibrosis, heterotopic ossification, or all-cause complication rates between low- and high-volume centers. The only significant predictor for all-cause complication was Medicaid insurance (OR, 2.91 [95% CI, 1.20-6.33]; P = .011). Conclusion A rising incidence of UCL repair compared with UCLR was found in New York State, especially among female patients, older patients, and nonprivate payers. There were no differences in 3-month complication rates between high- and low-volume centers, and Medicaid insurance status was a predictor for overall complications within 90 days of operation.
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Affiliation(s)
- Andrew S. Bi
- Department of Sports Medicine, NYU Langone Health, New York, New York, USA
| | - Charles C. Lin
- Department of Sports Medicine, NYU Langone Health, New York, New York, USA
| | - Utkarsh Anil
- Department of Sports Medicine, NYU Langone Health, New York, New York, USA
| | - Andrew S. Rokito
- Department of Sports Medicine, NYU Langone Health, New York, New York, USA
| | - Laith M. Jazrawi
- Department of Sports Medicine, NYU Langone Health, New York, New York, USA
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Lin KM, Brinson K, Atzmon R, Chan CK, Sherman SL, Safran MR, Freehill MT. Augmented Ulnar Collateral Ligament Repair With Structural Bioinductive Scaffold: A Biomechanical Study. Am J Sports Med 2024; 52:1483-1490. [PMID: 38650304 DOI: 10.1177/03635465241236465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
BACKGROUND Elbow ulnar collateral ligament (UCL) repair with suture brace augmentation shows good time-zero biomechanical strength and a more rapid return to play compared with UCL reconstruction. However, there are concerns about overconstraint or stress shielding with nonabsorbable suture tape. Recently, a collagen-based bioinductive absorbable structural scaffold has been approved by the Food and Drug Administration for augmentation of soft tissue repair. PURPOSE/HYPOTHESIS This study aimed to assess the initial biomechanical performance of UCL repair augmented with this scaffold. We hypothesized that adding the bioinductive absorbable structural scaffold to primary UCL repair would impart additional time-zero restraint to the valgus opening. STUDY DESIGN Controlled laboratory study. METHODS Eight cadaveric elbow specimens-from midforearm to midhumerus-were utilized. In the native state, elbows underwent valgus stress testing at 30o, 60o, and 90o of flexion, with a cyclical valgus rotational torque. Changes in valgus rotation from 2- to 5-N·m torque were recorded as valgus gapping. Testing was then performed in 4 states: (1) native intact UCL-with dissection through skin, fascia, and muscle down to an intact UCL complex; (2) UCL-transected-distal transection of the ligament off the sublime tubercle; (3) augmented repair with bioinductive absorbable scaffold; and (4) repair alone without scaffold. The order of testing of repair states was alternated to account for possible plastic deformation during testing. RESULTS The UCL-transected state showed the greatest increase in valgus gapping of all states at all flexion angles. Repair alone showed similar valgus gapping to that of the UCL-transected state at 30° (P = .62) and 60° of flexion (P = .11). Bioinductive absorbable scaffold-augmented repair showed less valgus gapping compared with repair alone at all flexion angles (P = .021, P = .024, and P = .024 at 30°, 60°, and 90°, respectively). Scaffold-augmented repair showed greater gapping compared with the native state at 30° (P = .021) and 90° (P = .039) but not at 60° of flexion (P = .059). There was no difference when testing augmented repair or repair alone first. CONCLUSION UCL repair augmented with a bioinductive, biocomposite absorbable structural scaffold imparts additional biomechanical strength to UCL repair alone, without overconstraint beyond the native state. Further comparative studies are warranted. CLINICAL RELEVANCE As augmented primary UCL repair becomes more commonly performed, use of an absorbable bioinductive scaffold may allow for improved time-zero mechanical strength, and thus more rapid rehabilitation, while avoiding long-term overconstraint or stress shielding.
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Affiliation(s)
- Kenneth M Lin
- Department of Orthopaedic Surgery, Division of Sports Medicine, Stanford University, Redwood City, California, USA
| | - Kenneth Brinson
- School of Medicine, Stanford University, Redwood City, California, USA
| | - Ran Atzmon
- Department of Orthopaedic Surgery, Assuta Ashdod Medical Centre, Ashdod, Israel
| | - Calvin K Chan
- Department of Orthopaedic Surgery, Division of Sports Medicine, Stanford University, Redwood City, California, USA
| | - Seth L Sherman
- Department of Orthopaedic Surgery, Division of Sports Medicine, Stanford University, Redwood City, California, USA
| | - Marc R Safran
- Department of Orthopaedic Surgery, Division of Sports Medicine, Stanford University, Redwood City, California, USA
| | - Michael T Freehill
- Department of Orthopaedic Surgery, Division of Sports Medicine, Stanford University, Redwood City, California, USA
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Erickson BJ. Editorial Commentary: Ulnar Collateral Ligament Repair With Suture Augmentation May Be Superior to Reconstruction for Proximal or Distal Tears With Good- Quality Tissue. Arthroscopy 2024; 40:1356-1357. [PMID: 38219110 DOI: 10.1016/j.arthro.2023.10.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 10/27/2023] [Indexed: 01/15/2024]
Abstract
Ulnar collateral ligament (UCL) tears in the elbow have been rising in recent years, most specifically in baseball players. Although many of these tears occur in professional (minor and major league) baseball pitchers, there has been a dramatic rise in UCL injuries in adolescents, at a rate of 9% per year. Although some UCL tears can be treated conservatively, those that fail conservative treatment often require surgical intervention to allow players to return to sport. Although UCL reconstruction has been the gold standard in surgical treatment for many years, UCL repair with suture augmentation has grown in popularity. Initial results of UCL repair with suture augmentation have been promising, and a recent review comparing UCL repair with suture augmentation from both a biomechanical and clinical outcome perspective confirms that UCL repair may be superior to reconstruction for patients with proximal or distal tears and good quality UCL tissue for repair.
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Spears TM, Parikh B, Chalmers PN, Smith MV, Freehill MT, Bowman EN. Elbow Ulnar Collateral Ligament Repair With Suture Augmentation Is Biomechanically Equivalent to Reconstruction and Clinically Demonstrates Excellent Outcomes: A Systematic Review. Arthroscopy 2024; 40:1343-1355.e1. [PMID: 37832744 DOI: 10.1016/j.arthro.2023.09.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 09/22/2023] [Accepted: 09/22/2023] [Indexed: 10/15/2023]
Abstract
PURPOSE To systematically review (1) biomechanical properties of augmented elbow ulnar collateral ligament (UCL) repair compared with reconstruction and (2) clinical efficacy and complication rates of UCL repair with and without augmentation. METHODS A systematic review was completed August 15, 2023, identifying articles that (1) biomechanically compared suture augmented UCL repair and reconstruction and (2) clinically evaluated medial elbow UCL repairs. Search terms included: "UCL repair" OR "internal brace" OR "suture augmentation" AND "UCL reconstruction." For inclusion, biomechanical studies compared augmented repair with reconstruction; clinical studies required clinical outcomes with minimum 6-month follow-up. Biomechanical data included torsional stiffness, gap formation, peak torque, and failure torque. Clinical data included return to previous level of play, time to return, functional outcomes, and complications. RESULTS In total, 8 biomechanical and 9 clinical studies were included (5 with and 4 without augmentation). In most biomechanical studies, augmented repairs demonstrated less gap formation, with equivalent torsional stiffness, failure load, and peak torque compared with reconstruction. Clinical outcomes in 104 patients without augmentation demonstrated return to previous level of 50% to 94% for nonprofessional athletes and 29% for professional baseball pitchers. Suture augmented repairs in 554 patients demonstrated return to previous level from 92% to 96%, at 3.8 to 7.4 months, with Kerlan Jobe Orthopaedic Clinic scores of 86 to 95. The overall complication rate for augmented UCL repair was 8.7%; most commonly ulnar neuropraxia (6%). CONCLUSIONS Biomechanically, UCL repair with augmentation provided less gapping with equivalent torsional stiffness and failure compared with reconstruction. Clinically, augmented UCL repair demonstrated excellent return to previous level of play and Kerlan Jobe Orthopaedic Clinic scores with modest complications and time to return. Augmented UCL repair is biomechanically equivalent to reconstruction and may be a viable alternative to reconstruction in indicated athletes. CLINICAL RELEVANCE UCL repair with suture augmentation is biomechanically equivalent to reconstruction and clinically demonstrates excellent outcomes.
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Affiliation(s)
- Thomas M Spears
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Bhavya Parikh
- Zucker School of Medicine/Northwell at Northshore and Long Island Jewish, Manhasset, New York, U.S.A
| | - Peter N Chalmers
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, U.S.A
| | - Matthew V Smith
- Department of Orthopedic Surgery, Washington University, Chesterfield, Missouri, U.S.A
| | - Michael T Freehill
- Department of Orthopedic Surgery, Stanford University, Redwood City, California, U.S.A
| | - Eric N Bowman
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A..
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Gerard NO, Clark SC, O’Brien MJ, Mulcahey MK, Savoie FH. Operative Treatment of Ulnar Collateral Ligament Injury in Female Athletes. Orthop J Sports Med 2024; 12:23259671241235600. [PMID: 38510319 PMCID: PMC10953010 DOI: 10.1177/23259671241235600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 09/06/2023] [Indexed: 03/22/2024] Open
Abstract
Background Ulnar collateral ligament (UCL) reconstruction has been the standard surgical intervention for elite male athletes with UCL insufficiency. Recently, UCL repair and augmentation with an internal brace has been increasingly performed. Purpose To evaluate the clinical and functional outcomes as well as return-to-sport rate after UCL repair in female athletes. Study Design Case series; Level of evidence, 4. Methods Included were 15 female athletes (mean age, 16.5 ± 3.5 years) who underwent UCL repair between 2011 and 2021 at a single institution. Data collected included age, sport played, competition level, symptom onset, previous surgeries, mechanism of injury, surgical intervention, and return to sport. Patients were contacted via phone at minimum 24-month follow-up, and postoperative outcomes were evaluated using the Mayo Elbow Performance Score (MEPS) and the Single Assessment Numeric Evaluation (SANE). Results Of the 15 female athletes, there were 4 cheerleaders, 3 softball players, 2 volleyball players, 2 soccer players, 1 gymnast, 1 tennis player, 1 dancer, and 1 javelin thrower. Ten of the 15 athletes (67%) competed at the high school level, 4 (26%) at the collegiate level, and 1 patient (7%) was a recreational volleyball player. In all patients, there was an acute onset of symptoms after injury. Ten patients underwent UCL repair with an internal brace (67% of athletes), while 5 underwent standard UCL repair. The median MEPS for athletes with and without an internal brace was 100 (range, 80-100). There was no significant difference of MEPS (P = .826) or SANE scores (P = .189) between the patients who received an internal brace and those who did not. Thirteen of the 15 athletes (86.7%) returned to sport. Conclusion The UCL injuries in the female athletes in this study were the result of acute trauma. Primary UCL repair, both with and without internal bracing, was an effective surgical treatment for returning these athletes to sport.
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Affiliation(s)
| | - Sean C. Clark
- Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Michael J. O’Brien
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Mary K. Mulcahey
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Felix H. Savoie
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
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Walton C, Reis RJ, Welsh ME, Friedman RJ, Eichinger JK. Ulnar Collateral Ligament Repair With Internal Brace Using Linked Knotless Suture Anchors. Arthrosc Tech 2024; 13:102874. [PMID: 38584631 PMCID: PMC10995640 DOI: 10.1016/j.eats.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 11/01/2023] [Indexed: 04/09/2024] Open
Abstract
This article presents an adaptation of the internal brace ulnar collateral ligament (UCL) repair technique using knotless suture anchors, which shows promise for improved postsurgical functionality and a shortened recovery period in patients with UCL injuries. Traditional methods of UCL reconstruction often require a lengthy 12- to 18-month recovery period, presenting a significant challenge for athletes keen to return to their sport. The modified technique uses smaller sutures and drill holes, thereby eliminating the need for larger anchors and simplifying the surgical process. Furthermore, we provide a comprehensive exploration of the rehabilitation protocol involved after surgery, which includes various phases of physical therapy and use of the "thrower's ten" program to improve shoulder and elbow stability, strength, and mobility. This technique paves the way for a promising alternative to traditional UCL reconstruction or repair methods, with the potential to significantly enhance clinical outcomes, improve recovery times, and positively impact athletes' lives.
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Affiliation(s)
- Chase Walton
- Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Robert J Reis
- Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Megan E Welsh
- Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | | | - Josef K Eichinger
- Medical University of South Carolina, Charleston, South Carolina, U.S.A
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18
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Savoie FH, O'Brien MJ. Medial elbow injuries in the throwing athlete. J Shoulder Elbow Surg 2024; 33:457-465. [PMID: 37844833 DOI: 10.1016/j.jse.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/04/2023] [Accepted: 09/04/2023] [Indexed: 10/18/2023]
Abstract
There has been an epidemic increase in injuries to the elbow in our youth sports over the past 15 years. Initially, career-ending elbow injuries occurred almost exclusively in the professional population. The landmark procedure developed by Dr. Frank Jobe, colloquially termed "Tommy John surgery" after the initial player in whom he performed the surgical procedure, allowed roughly two-thirds of professional athletes to return to play at or near the same level. As the surgical procedure became more widespread, modifications of the technique by Jobe and many other contributors raised the return-to-play level to 85%-94% of players regaining the ability to return to sport at the preinjury level. Almost simultaneously, the emphasis on velocity in the professional ranks led to an unintentional increase in stress on the throwing elbow. This was magnified in our athletes by the advent of year-round sports, as well as the formation of "showcase" events to demonstrate skills and measure velocity. This, unfortunately, has resulted in an increase in both repetitive stress injuries and acute traumatic injuries in our young athletes. The purpose of this article is to discuss age-related injuries from both a preventative standpoint and a treatment standpoint.
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Affiliation(s)
- Felix H Savoie
- Department of Orthopaedic Surgery, Tulane University, New Orleans, LA, USA.
| | - Michael J O'Brien
- Shoulder and Elbow Services, Tulane University, New Orleans, LA, USA
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Moran J, Kammien A, Cheng R, Amaral JZ, Santos E, Modrak M, Kunze KN, Vaswani R, Jimenez AE, Gulotta LV, Dines JS, Altchek DW. Low Rates of Postoperative Complications and Revision Surgery After Primary Medial Elbow Ulnar Collateral Ligament Repair. Arthrosc Sports Med Rehabil 2024; 6:100828. [PMID: 38313860 PMCID: PMC10835117 DOI: 10.1016/j.asmr.2023.100828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 11/02/2023] [Indexed: 02/06/2024] Open
Abstract
Purpose To evaluate the incidence of early postoperative complications and revision surgery in patients who underwent primary medial ulnar collateral ligament (MUCL) repair with minimum of 2-year follow-up. Methods A retrospective review of a national insurance database was conducted to identify patients with MUCL injuries who underwent primary MUCL repair between 2015 to 2020 with minimum 2-year follow-up. Patients >40 years of age and those who had concomitant elbow fractures or dislocations, lateral UCL injures, medial epicondylitis, elbow arthritis, or a history of previous elbow injury/surgery were excluded. The number of patients who underwent a concomitant ulnar nerve procedure (transposition or decompression) during the primary MUCL repair was recorded. Complications within 90 days of surgery and the incidence and timing of subsequent ipsilateral ulnar nerve surgery or revision MUCL surgery were assessed. Results A total of 313 patients (63.6% male) were included. The mean age was 20.3 ± 6.9 years, and mean follow-up was 3.7 ± 1.3 years. Concomitant ulnar nerve transposition or decompression was performed in 34.2% (N = 107). The early postoperative complication rate was 7.3% (N = 23). The most common complication was ulnar neuropathy (5.8%, N = 18). Wound complications, elbow stiffness, and medial epicondyle fractures were much less common (N = 5). Sixteen of 18 (88.9%) patients with postoperative ulnar neuropathy underwent transposition or decompression at the time of primary repair. Of these 18 patients, 5 (27.8%) underwent a subsequent ulnar nerve surgery (1 primary and 4 secondary), with the majority occurring within 6 months. The incidence of revision MUCL surgery was low (1.0%, N=3), with all 3 patients undergoing MUCL reconstruction. Conclusion There was a low incidence of early postoperative complications (7.3%) and 2-year revision MUCL surgery (1.0%) in young patients who underwent primary MUCL repair with no additional ligamentous, fracture, and dislocation-related diagnoses. All 3 (1.0%) MUCL revisions underwent reconstruction. Level of Evidence Level IV, therapeutic case series.
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Affiliation(s)
- Jay Moran
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Alexander Kammien
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Ryan Cheng
- Hospital for Special Surgery, New York, New York, U.S.A
| | - Jason Z. Amaral
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Estavao Santos
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Maxwell Modrak
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Kyle N. Kunze
- Hospital for Special Surgery, New York, New York, U.S.A
| | - Ravi Vaswani
- Hospital for Special Surgery, New York, New York, U.S.A
| | - Andrew E. Jimenez
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
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Shahien AA, Beason DP, Slowik JS, Fleisig GS, Dugas JR, Cain EL. Ulnar Collateral Ligament Repair With Suture Tape Augmentation: Can You Overtighten? Am J Sports Med 2024; 52:485-491. [PMID: 38251875 DOI: 10.1177/03635465231220382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
BACKGROUND There has been a renewed interest and, recently, wider implementation of ulnar collateral ligament (UCL) repair in throwing athletes because of improvement in ligament repair technology and corresponding outcome data. PURPOSE To compare the biomechanical parameters and failure mode between 2 brace-tightening techniques for UCL repair. STUDY DESIGN Controlled laboratory study. METHODS Eleven matched pairs of cadaveric arms were procured. One limb from each pair underwent UCL repair with suture tape augmentation with either (1) attempted restoration of physiologic ligament tension or (2) maximal tension. Each specimen was subjected to 10 cycles of subfailure valgus torque at 90º of flexion in the intact state after UCL avulsion and then after UCL repair. Specimens were then torqued to failure. Articular contact mechanics, linear gap distance, angular displacement, failure torque, failure stiffness, and suture tape pull-through length were recorded. Two-way analysis of variance and paired t tests were used to test for statistical differences. RESULTS There was a significant effect (P = .01) of tightening on joint contact area. There was a significant decrease in gap distance (P = .03) and angular displacement (P = .004) from the torn condition to the repaired condition for the maximum tension group, without a significant difference in gap distance from the intact condition. Failure torque and stiffness were not significantly different between groups, although there was a significant difference (P = .001) in the overall suture tape pull-through length. CONCLUSION Although there are potential physiologic changes at time zero-including significant decreases in contact area, normalized gap distance, and normalized angular displacement with maximal tension repair-examination of failure biomechanics suggests that these effects may be mitigated over time within the construct by suture tape pull-through at the tape-anchor interface. Neither method of UCL repair with suture tape augmentation resulted in overconstraint of the elbow joint compared with the native ligament biomechanics. CLINICAL RELEVANCE As more long-term outcome data from UCL repair with suture tape augmentation emerge, there will be wider implementation with various techniques to tension the suture tape. Examining the potential biomechanical sequelae of the UCL repair construct applied under maximal tension will help further refine recommendations for surgeons who utilize this technique for UCL repair.
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Affiliation(s)
- Amir A Shahien
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - David P Beason
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | | | - Glenn S Fleisig
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Jeffrey R Dugas
- American Sports Medicine Institute, Birmingham, Alabama, USA
- Andrews Sports Medicine and Orthopaedic Center, Birmingham, Alabama, USA
| | - E Lyle Cain
- American Sports Medicine Institute, Birmingham, Alabama, USA
- Andrews Sports Medicine and Orthopaedic Center, Birmingham, Alabama, USA
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21
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Bixby EC, Ahmed R, Skaggs K, Swindell HW, Fortney TA, Ahmad CS. Factors Important to Patient Decision-Making After Ulnar Collateral Ligament Injury in Competitive High School and Collegiate Baseball Players. Orthop J Sports Med 2023; 11:23259671231183486. [PMID: 37465208 PMCID: PMC10350754 DOI: 10.1177/23259671231183486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 03/31/2023] [Indexed: 07/20/2023] Open
Abstract
Background Patients are faced with several treatment decisions after an ulnar collateral ligament (UCL) injury: nonoperative versus operative treatment, repair versus reconstruction, and immediate versus delayed surgery. Purpose/Hypothesis The aim of this study was to investigate the factors important to patients when deciding which treatment to pursue after a UCL injury. We hypothesized that (1) length of time away from sports and seasonal timing would be important to patients and (2) treatment decision-making would be heavily influenced by how many and which seasons of their baseball career would be missed. Study Design Cross-sectional study. Methods High school and collegiate baseball players with UCL tears treated at an academic institution were surveyed retrospectively on their sports participation at the time of injury and their UCL injury treatment decisions. Respondents rated the influence of various factors on a 5-point Likert scale, and they selected the top 3 factors and the single most important factor influencing their treatment decisions. Multiple logistic regression analysis was used to assess the relationship between player characteristics and factors important to their treatment decision. Results A total of 83 athletes completed the survey; 40 were in high school and 43 were in college at the time of injury; 7 were treated nonoperatively and 76 underwent surgery (66 immediately and 10 in a delayed fashion), 10 with UCL repair and 66 with UCL reconstruction. The ability to play competitive baseball in the long term was very important or extremely important to 90% of players, while the ability to play in the short term was very important or extremely important to 17%. Length of recovery and seasonal timing were also important factors for 53% and 54% of players, respectively, and almost all (90%) highly valued advice from a surgeon. Possible failure of nonoperative treatment leading to increased time away and the possible loss of 2 consecutive baseball seasons heavily influenced decision-making in 41% of respondents. Conclusion Survey respondents were driven by the desire to play baseball in the long term. Treatment decisions were influenced by the length of recovery and by the seasonal timing of their injury, both of which affect how many and which seasons of baseball a player may miss. Patients found advice from their surgeon to be extremely important to decision-making.
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Affiliation(s)
- Elise C. Bixby
- Columbia University Irving Medical Center, New York, New York, USA
| | - Rifat Ahmed
- Columbia University Irving Medical Center, New York, New York, USA
| | - Kira Skaggs
- Columbia University Irving Medical Center, New York, New York, USA
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Kerzner B, Kaplan DJ, Khan ZA, Smith SR, Obioha OA, Jawanda H, Jackson GR, Gopinatth V, Sivasundaram L, Verma NN. Ulnar Collateral Ligament Internal Bracing Repair Technique for High-Grade Partial Proximal Tears in the Throwing Athlete. Arthrosc Tech 2023; 12:e1225-e1232. [PMID: 37533907 PMCID: PMC10391346 DOI: 10.1016/j.eats.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 03/17/2023] [Indexed: 08/04/2023] Open
Abstract
The use of ulnar collateral ligament (UCL) repair with concomitant internal bracing for throwing athletes is a viable treatment option, but must take into account tear location, ligament quality, the expected length of the athlete's career, desire to advance to the next level of competition, and age. There has been increased interest in repair of UCL injuries in overhead athletes due to advancements in surgical technique, as well as improved technologies of anchor and suture material. In addition, return to sport can be accelerated compared to reconstruction. In this Technical Note, we demonstrate an ulnar collateral ligament repair technique, with internal bracing augmentation for high-grade partial proximal tears in the throwing athlete that is reliable, strong, and easily reproducible.
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Affiliation(s)
- Benjamin Kerzner
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Daniel J. Kaplan
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Zeeshan A. Khan
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Shelby R. Smith
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Obianuju A. Obioha
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Harry Jawanda
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Garrett R. Jackson
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Varun Gopinatth
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Lakshmanan Sivasundaram
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Nikhil N. Verma
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
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Boksh K, Mishra P, Akram N, Abdolrazaghi S, Singh H. Medial Ulnar Collateral Ligament Repair With Augmentation: A Systematic Review and Meta-analysis of Preclinical Studies. Orthop J Sports Med 2023; 11:23259671231158373. [PMID: 37152548 PMCID: PMC10159257 DOI: 10.1177/23259671231158373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 01/17/2023] [Indexed: 05/09/2023] Open
Abstract
Background Reconstruction is the gold standard treatment for medial ulnar collateral ligament (MUCL) injuries. However, recent studies show a successful and renewed interest in direct suture repair, particularly in young athletes. Repair augmentation with a suture tape may provide greater stability, enabling healing of the MUCL while protecting the repair at higher valgus loads. Purpose To perform a systematic review and meta-analysis on whether MUCL repair with augmentation provides a similar biomechanical profile to the traditional MUCL reconstruction. Study Design Systematic review. Methods The Cochrane Controlled Register of Trials, PubMed, Medline, and Embase were used to perform a systematic review and meta-analysis using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms: ("ulnar collateral ligament" OR "medial ulnar collateral ligament") AND ("internal brace" OR "augmentation" OR "suture tape"). Data pertaining to certain biomechanical properties (gap formation, failure to torque [ultimate load to failure], stiffness, degree of valgus opening, and modes of failure) were extracted. The pooled outcome data were analyzed by random- and fixed-effects models. A total of 203 abstracts were identified through the aforementioned databases. Results After abstract and full-text screening, 6 biomechanical studies were included. All were on cadaveric elbows, with 53 repairs with augmentation and 53 reconstructions compared. There were no differences between the 2 in regard to ultimate load to failure (standard mean difference [SMD], -0.34 N·m; 95% CI, -1.36 to 0.68; P = .51) and rotational stiffness (SMD, 0.26; 95% CI, -1.14 to 1.66; P = .72). Despite a trend in resistance to gapping with augmented repair, this was not significant (SMD, -0.53; 95% CI, -1.08 to 0.01; P = .06). Augmented repairs were more likely to fail by pullout or at the suture-tendon/anchor-suture interface (odds ratio [OR], 12.19; 95% CI, 4.17 to 35.62; P < .00001), while failure by fracture was more common with reconstruction (OR, 5.75; 95% CI, 2.07 to 15.99; P = .0008). Conclusion MUCL augmented repair establishes the required time-zero structural properties without the need for a tendon graft. However, future clinical studies are necessary to determine its true effectiveness as well as its success at higher levels of professional sport.
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Affiliation(s)
- Khalis Boksh
- Department of Trauma and Orthopaedics,
University Hospitals of Leicester NHS Trust, Leicester, UK
- Khalis Boksh, BSc(Hons),
MBChB, MRCS, Department of Trauma and Orthopaedics, University Hospitals of
Leicester NHS Trust, Infirmary Square, Leicester, LE1 5WW, UK (
)
| | - Pranav Mishra
- Department of Trauma and Orthopaedics,
University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Nimra Akram
- Department of Trauma and Orthopaedics,
University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Sina Abdolrazaghi
- Department of Trauma and Orthopaedics,
University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Harvinder Singh
- Department of Trauma and Orthopaedics,
University Hospitals of Leicester NHS Trust, Leicester, UK
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Spivey MG, Constantinescu DS, Costello JP, Kao DS, O’Connell RS, Vap AR. The Rate of Medial Ulnar Collateral Ligament Repair Is Increasing While Reconstruction Remains the Most Common Procedure Overall Among Early-Career Orthopaedic Surgeons. Arthrosc Sports Med Rehabil 2023. [DOI: 10.1016/j.asmr.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
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Erickson BJ, Hurley ET, Mojica ES, Jazrawi LM. Ulnar Collateral Ligament Tears: A Modified Consensus Statement. Arthroscopy 2023; 39:1161-1171. [PMID: 36796550 DOI: 10.1016/j.arthro.2022.12.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 12/08/2022] [Accepted: 12/29/2022] [Indexed: 02/18/2023]
Abstract
PURPOSE The purpose of this study was to establish consensus statements on the treatment of UCL injuries and to investigate whether consensus on these distinct topics could be reached. METHODS A modified consensus technique was conducted among twenty-six elbow surgeons and 3 physical therapists/athletic trainers. Strong consensus was defined as 90-99% agreement. RESULTS Of the 19 total questions and consensus statements 4 achieved unanimous consensus, 13 achieved strong consensus, and 2 did not achieve consensus. CONCLUSION There was unanimous agreement that the risk factors include overuse, high velocity, poor mechanics, and prior injury. There was unanimous agreement that advanced imaging in the form of either an MRI or MRA should be performed in a patient presenting with suspected/known UCL tear that plans to continue to play an overhead sport, or if the imaging study could change the management of the patient. There was unanimous agreement regarding lack of evidence for the use of orthobiologics in the treatment of UCL tears as well as the areas pitchers should focus on when attempting a course of non-operative management. The statements that reached unanimous agreement for operative management were regarding operative indications and contraindications for UCL tears, prognostic factors that should be taken into consideration in when performing UCL surgery, how to deal with the flexor-pronator mass during UCL surgery and use of an internal brace with UCL repairs. Statements that reached unanimous agreement for RTS were regarding: portions of the physical exam should be considered when determining whether to allow a player to RTS, unclear how velocity, accuracy, and spin rate should be factored into the decision of when players can RTS and sports psychology testing should be used to determine whether a player is ready to RTS. LEVEL OF EVIDENCE Expert opinion (Level V).
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Affiliation(s)
| | - Eoghan T Hurley
- NYU Langone Health, New York, NY, USA; Sports Surgery Clinic, Dublin, Ireland; Duke University Medical Center, Durham, NC, USA
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Orthobiologic Treatment of Ligament Injuries. Phys Med Rehabil Clin N Am 2023; 34:135-163. [DOI: 10.1016/j.pmr.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Wilk KE, Thomas ZM, Arrigo CA, Campbell AM, Shahien A, Dugas JR. The Use of the Internal Brace to Repair the UCL Injury of the Elbow in Athletes. Int J Sports Phys Ther 2022; 17:1208-1218. [PMID: 36518840 PMCID: PMC9718695 DOI: 10.26603/001c.39614] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 10/22/2022] [Indexed: 11/12/2023] Open
Affiliation(s)
- Kevin E Wilk
- Vice President National Director Clinical Education & Research Champion Sports Medicine, Select Medical
- Director of Rehabilitative Research American Sports Medicine Institute
| | | | | | - Ashley M Campbell
- Director of Rehabilitation Nashville Hip Institute at TOA
- School of Physical Therapy Belmont University
| | - Amir Shahien
- Orthopaedic Surgeon, Fellow American Sports Medicine
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Increasing rates of ulnar collateral ligament repair outpace reconstruction in isolated injuries: review of a Texas surgical database. JSES Int 2022; 7:192-197. [PMID: 36820426 PMCID: PMC9937821 DOI: 10.1016/j.jseint.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background The gold standard of treatment for ulnar collateral ligament (UCL) injuries has been reconstruction. Despite early repair studies yielding less than satisfactory results, there has been recent renewed interest in UCL repair due to improved outcomes and new technologies. Data regarding clinical use of these procedures are lacking. The purpose of this study was to define the epidemiological trends of UCL repair and reconstruction surgery from 2010 to 2019, compare demographic characteristics of patients undergoing either procedure, and determine incidence of concomitant procedures in each surgical group as well as comparing respective patient-level charges. Methods A retrospective database analysis of UCL surgeries was performed through the Texas Healthcare Information Collection database, a comprehensive and publicly available statewide billing dataset. Inclusion criteria were defined using Current Procedural Terminology billing codes for elbow UCL repair and reconstruction between 2010 through 2019, excluding patients who had concomitant elbow fractures or lateral collateral ligament tears indicative of high-energy trauma. Procedural volume changes, patient demographics, and commonly performed concomitant procedures including elbow arthroscopy, ulnar nerve surgery, and platelet-rich plasma injection were compared. Total patient-level charges were compared across groups. Results A total of 1664 patients were included, consisting of 484 UCL repairs and 1180 reconstructions. Total UCL surgeries increased eleven-fold when corrected for population growth from 2010 (N = 25) to 2019 (N = 315). In 2010, repair constituted 23% of all UCL tear surgeries and increased to 40% by the end of 2019. The annual frequency of UCL repair increased at a 5.4% faster rate than UCL reconstruction from 2010 to 2019 (P < .001). There were no significant differences between any demographic data between UCL repair and reconstruction except for rural surgical settings which demonstrated 1.8 times greater odds of undergoing reconstruction (P = .05). There were no differences among commonly associated procedures including ulnar nerve surgery (P = .217), elbow arthroscopy (P = .092), and platelet-rich plasma injection (P = .837) with no differences in patient-level charges at any time point (P = .47). Conclusion While reconstruction remains more common, the annual frequency of UCL repair is increasing at a faster rate. Since were no demographic differences aside from surgical setting, it can be inferred that patients who were previously receiving reconstruction are instead undergoing repair. This highlights the need for future studies to further identify surgical indications for the two interventions.
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Fury MS, Liu T, Cai W, O'Donnell EA, Oh LS. Change in humeral anchor position significantly affects isometry in ulnar collateral ligament repair: a 3-dimensional computer modeling study. J Shoulder Elbow Surg 2022; 31:2328-2338. [PMID: 35798228 DOI: 10.1016/j.jse.2022.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 05/18/2022] [Accepted: 05/30/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Medial ulnar collateral ligament (UCL) repair utilization is increasing in recent years, bolstered by shorter rehabilitation and satisfactory clinical outcomes. Although previous literature has illustrated the importance of tunnel position on restoring graft isometry in reconstruction, there remains a paucity of literature guiding anchor placement in UCL repair. The purpose of this study is to design a 3-dimensional (3D) elbow model to understand the effect of anchor location on UCL repair isometry. METHODS A 3D computer model of an elbow joint was created using computed tomographic and magnetic resonance imaging MRI scans from a single patient. The humeral and ulnar attachments of the UCL were plotted using 3 methodologies: (1) geometric cloud mapping and (2) quantitative measurements from the anatomic studies by Camp et al and (3) Frangiamore et al. A 3.5-mm-diameter clockface was placed on each attachment site, which allowed for simulation of 12 distinct 1.75-mm deviations in anchor position. The 3 models were ranged through 0°-120° at 10° increments, and the 3D distances were measured between the ligament centroids. The humeral and ulnar anchors were sequentially repositioned around the clockfaces, and construct lengths were again measured to evaluate changes in isometry. A paired Student t test was performed to determine if there was a significant difference in isometry between the humeral and ulnar anchor deviations. RESULTS Using method 1, the UCL repair length at 90° of elbow flexion was 26.8 mm. This construct underwent 13.6 mm of total excursion for a 46.4% change in length throughout its arc of motion. Method 2 produced a 19.3-mm construct that underwent 0.8 mm of excursion for a 3.9% length change throughout the arc. Method 3 produced a 24.5-mm construct that underwent 2.3 mm of excursion for a 9.4% length change. Identifying ligament footprints using the quantitative anatomic measurements from Camp et al and Frangiamore et al improved construct isometry through 120° of flexion (length changes of 3.9% and 9.4%, respectively) when compared to using the geometric cloud technique alone (46.4% length change). Humeral anchor deviations produced a significant increase in repair construct excursion compared with ulnar anchor deviations (P < .001). CONCLUSION When performing UCL repair, small deviations in humeral anchor position may significantly influence ligament repair isometry. Using quantitative anatomic data may help identify anchor positions with improved repair isometry. Particularly when addressing detachments of the humeral footprint, surgeons should be critical of the humeral anchor position in order to restore native anatomy and optimal biomechanics.
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Affiliation(s)
- Matthew S Fury
- Harvard Combined Orthopaedic Residency Program, Massachusetts General Hospital, Boston, MA, USA.
| | - Tianyu Liu
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Wenli Cai
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Evan A O'Donnell
- Sports Medicine Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Luke S Oh
- Sports Medicine Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
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30
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Fathi A, Haratian A, Treloar J, Bolia IK, Hasan LK, Weber AE, Petrigliano FA. Pain Is the Most Frequently Cited Reason Athletes Fail to Return to Sport After Ulnar Collateral Ligament Surgery: A Systematic Review and Meta-analysis. Orthop J Sports Med 2022; 10:23259671221128257. [PMID: 36313005 PMCID: PMC9608054 DOI: 10.1177/23259671221128257] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/02/2022] [Indexed: 11/15/2022] Open
Abstract
Background No previous systematic review to our knowledge has examined the reasons that athletes fail to return to sport (RTS) after ulnar collateral ligament (UCL) surgery. Purpose To report the rate of failure to RTS after UCL surgery and identify reasons that preclude an athlete's ability to successfully RTS. Study Design Systematic review; Level of evidence, 4. Methods This study was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We searched the PubMed, Scopus, and SPORTDiscus databases for studies on athletes who underwent either UCL reconstruction or repair that reported RTS rates and identified reasons for failure to RTS. Data were collected on the number of athletes included, average age, sport played, operative technique, average follow-up, rate of failure to RTS, and reasons for failure to return. A random-effects model was used to conduct the meta-analysis. Results Included were 26 studies reporting on 1019 athletes. Primary or revision UCL reconstruction was performed in 913 patients (89.6%), while the remaining 106 patients (10.4%) underwent UCL repair. The pooled rate of failure to RTS after UCL reconstruction or repair was calculated to be 11.4% (95% CI, 8.4-14.7). A significantly higher estimated proportion of athletes failed to return because of elbow-related reasons compared with non-elbow-related reasons (55.3% vs 40.6%; P = .0352). Persistent pain (29/103; 28.2%) was the most common reason for failure to return, followed by elbow limitations and other unspecified elbow problems (19/103; 18.4%). There was moderate evidence for publication bias and study heterogeneity across the included studies. Conclusion This meta-analysis estimated the rate of failure to RTS after UCL surgery as 11.4%, with the majority of athletes unable to return because of elbow pain. Future studies reporting outcomes and providing details as to why athletes are unable to RTS can better inform sport surgeons on factors precluding RTS and can guide clinical practice to better help athletes achieve their postoperative goals.
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Affiliation(s)
- Amir Fathi
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Aryan Haratian
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Joshua Treloar
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Ioanna K. Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Laith K. Hasan
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Alexander E. Weber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Frank A. Petrigliano
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA.,Frank A. Petrigliano, MD, Keck Medicine of USC, 1520 San Pablo Street, Suite 2000, Los Angeles, CA 90033, USA ()
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Rothermich MA, Pharr ZK, Mundy AC, Fleisig GS, Mussell EA, Ryan MK, Bernier HM, Ostrander B, Slowik JS, Emblom BA, Cain EL, Dugas JR. Clinical Outcomes of Ulnar Collateral Ligament Surgery in Nonthrowing Athletes. Am J Sports Med 2022; 50:3368-3373. [PMID: 36112993 DOI: 10.1177/03635465221120654] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Ulnar collateral ligament (UCL) surgery continues to demonstrate excellent clinical outcomes and a high return-to-play (RTP) rate with a low complication rate. Recent studies have demonstrated similar clinical outcomes for baseball players who have undergone either UCL reconstruction or UCL repair. In comparison, few studies have assessed the clinical outcomes of UCL surgery for nonthrowing athletes. PURPOSE/HYPOTHESIS The primary objective of this study is to provide clinical outcomes of UCL surgery performed in nonthrowing athletes at a single institution with a minimum 2-year follow-up. Our hypothesis was that these patients would have similar clinical outcomes, complication rates, and RTP rates when compared with throwing athletes. LEVEL OF EVIDENCE Case series; Level of evidence, 4. METHODS From our longitudinal elbow registry, 40 nonthrowing athletes were identified who underwent UCL surgery (repair or reconstruction) between 2011 and 2019. Participant characteristics were recorded: age, sex, laterality, arm dominance, sport, level of competition, and type of surgery (UCL repair or reconstruction). Outcomes included RTP rate and average time, American Shoulder and Elbow Surgeons (ASES) scores, and complications. RESULTS From the 40 patients eligible for inclusion in this study with a minimum 2-year follow-up, 37 (93%) were successfully contacted: 16 male (43%) and 21 female (57%). Mean ± standard deviation age at the time of surgery was 18.0 ± 3.7 years. From the 37 technical procedures, 28 (76%) were UCL repairs and 9 (24%) were UCL reconstructions. For these patients, 15 (41%) had partial tears, 20 (54%) had complete tears, 1 (3%) had a medial epicondyle avulsion, and 1 (3%) had an unspecified pathology. Sports included football (n = 11), gymnastics (11), cheerleading (7), wrestling (4), volleyball (2), basketball (1), and acrobatics (1). Quarterbacks were excluded from the football patients, as quarterbacks are throwing athletes. Level of competition included high school (n = 26), college (8), professional (2), and youth sports (1). The RTP rate was 93% (26/28) at a mean 7.4 months for UCL repair and 100% (9/9) at a mean 10.0 months for UCL reconstruction. Mean ASES scores were 94.4 and 98.7 for UCL repair and reconstruction, respectively. Complications were low, with 2 patients in the UCL repair group requiring ulnar nerve transposition for ulnar nerve paresthesia. CONCLUSION In nonthrowing athletes, patients undergoing UCL repair and UCL reconstruction show favorable outcomes at minimum 2-year follow-up. RTP and clinical outcomes are consistent with previous studies in baseball players as well as a parallel ongoing study conducted on non-baseball throwing athletes.
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Affiliation(s)
| | - Zachary K Pharr
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Andrew C Mundy
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Glenn S Fleisig
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Eric A Mussell
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Michael K Ryan
- Andrews Sports Medicine & Orthopaedic Center, Birmingham, Alabama, USA
| | | | - Brook Ostrander
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | | | - Benton A Emblom
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - E Lyle Cain
- Andrews Sports Medicine & Orthopaedic Center, Birmingham, Alabama, USA
| | - Jeffrey R Dugas
- Andrews Sports Medicine & Orthopaedic Center, Birmingham, Alabama, USA
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Romeo AA, Erickson BJ, McClish SJ, Shirk S, Wijdicks C. Biomechanical comparison of novel ulnar collateral ligament reconstruction with internal brace augmentation vs. modified docking technique. J Shoulder Elbow Surg 2022; 31:2001-2010. [PMID: 35500811 DOI: 10.1016/j.jse.2022.03.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 03/13/2022] [Accepted: 03/21/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Ulnar collateral ligament (UCL) reconstruction (UCLR) is a common surgery among baseball pitchers. UCL repair combined with augmentation using high-strength tape, referred to as an internal brace, was developed as an alternative to UCLR in select patients with the benefit of allowing these athletes to return to sport (RTS) faster. A combined UCLR with an internal brace may allow players indicated for a UCLR to RTS more expeditiously. METHODS Twenty-four cadaveric elbows were divided into 3 groups: 12 specimens into the modified docking (MD) group, 6 into the double-docking (DD) group, and 6 into the double docking with internal brace augmentation (DDA) group. This allowed a 1:1 comparison of the MD to the DD and the MD to the DDA. Valgus cyclic testing of native and reconstructed specimens was executed at 90° elbow flexion. After preconditioning, all specimens were cycled between 2 and 10 Nm for 250 cycles. Reconstructed specimens continued to a torque test to catastrophic failure step. Outcome data included intracyclic stiffness, maximum cyclic rotational displacement, gap formation, and failure torque. RESULTS Cyclic stiffness of the constructs remained constant throughout the entirety of the torque-controlled cycling phase. The DDA group resulted in a 38% increase in cyclic stiffness from native testing (not statistically significant) and a statistically significant 54% increase from the MD (P = .002). The DDA mean cyclic stiffness was significantly greater than the Native (P < .001), DD (P = .025), and MD (P < .001) groups. Between reconstruction groups, mean gap formation was greatest among the MD group (2.51° ± 1.59°) and least for the DDA group (1.01° ± 0.57°) but did not reach statistical significance. CONCLUSION Tape augmentation to the modified UCLR (DDA group) improved cyclic stiffness and reduced gap formation compared with the MD group.
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Vaswani R, White A, Dines J. Medial Ulnar Collateral Ligament Injuries in Contact Athletes. Curr Rev Musculoskelet Med 2022; 15:474-482. [PMID: 35917095 PMCID: PMC9789220 DOI: 10.1007/s12178-022-09785-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/09/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW The purpose of this article is to review medial ulnar collateral ligament (UCL) injuries in contact athletes. UCL injuries in overhead throwing athletes are typically chronic attenuation due to repetitive valgus stress on the elbow during the throwing motion. As such, UCL reconstruction is commonly performed for these athletes. In contrast, UCL injuries in contact athletes are usually acute ligament tears or avulsions of a ligament with otherwise normal tissue. Nonoperative treatment is typically the first-line treatment for partial injuries. UCL repair may work well for acute complete injuries and may avoid the donor site morbidity of UCL reconstruction. RECENT FINDINGS Most of the literature regarding UCL injuries have been performed in baseball players. Historically, UCL repair has had poor outcomes in baseball players due to the chronic ligament attenuation. Therefore, much of the recent literature has focused on outcomes of UCL reconstruction, which are generally excellent. However, there is a paucity of literature studying outcomes of UCL injuries in contact athletes and those studying UCL repair. One recent study looked at a new technique for UCL repair with collagen-coated fiber tape augmentation in baseball players and found good short-term outcomes. UCL injuries in contact athletes occur typically as acute tears or avulsions. While UCL reconstruction has typically been recommended as the accepted treatment for UCL tears that require operative treatment, UCL repair may be a good alternative in contact athletes.
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Affiliation(s)
- Ravi Vaswani
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY, USA.
| | - Alex White
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY, USA
| | - Joshua Dines
- Sports Medicine Institute, Hospital for Special Surgery, New York, NY, USA
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MacKenzie JS, Osbahr DC. Repair of the ulnar collateral ligament: a review of current trends and outcomes. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Steffes MJ, Heaps BM, ElAttrache NS, Haselman WT. Outcomes After Medial Ulnar Collateral Ligament Graft Repair in Professional Baseball Pitchers With Minimum 2-Year Follow-up. Orthop J Sports Med 2022; 10:23259671221092728. [PMID: 35547610 PMCID: PMC9083042 DOI: 10.1177/23259671221092728] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 02/08/2022] [Indexed: 11/15/2022] Open
Abstract
Background Rerupture of the reconstructed ulnar collateral ligament (UCL) is becoming more frequent at the professional level of baseball. However, there is no literature describing outcomes after UCL graft repair. Purpose To evaluate rerupture rate, return to play, performance upon return, and patient-reported outcomes after a novel UCL graft repair technique. Study Design Case series; Level of evidence, 4. Methods All included patients underwent UCL graft repair after a previous UCL reconstruction, pitched in at least 1 professional baseball game before repair, and were at least 2 years postprocedure within the same 10-year time period. The authors evaluated patient characteristics and performance metrics, including wins, losses, win percentage, earned run average, innings pitched, walks and hits per inning pitched, for the 2 seasons before and after the procedure. Patients were contacted to assess UCL rerupture, timing of return to sport, current level of competition, Conway score, and Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow Score. Results Six players met the inclusion criteria. All had proximal UCL graft ruptures and underwent flexor-pronator tendon repair in combination with graft repair. At a mean (±SD) follow-up of 56.7 ± 37.8 months, no reruptures were encountered, and the mean KJOC score was 87.9 ± 14.6. Of the 6 pitchers who underwent UCL graft repair, 4 (67%) returned to professional pitching at a mean of 17 ± 6 months. Three of the 6 (50%) achieved an excellent Conway score, signifying a return to prior level of sport. There was no significant difference in demographic or preoperative pitching performance metrics between players who did and did not return to pitching. For those players who returned to professional pitching, there was no significant difference between preprocedure and postprocedure performance statistics. Conclusion Repair of the UCL graft appears to yield comparable rates of return to play and performance with revision UCL reconstruction. This technique serves as a viable alternative for proximal avulsion ruptures of the UCL graft.
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Affiliation(s)
| | - Braiden M. Heaps
- Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, California, USA
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Elbow Ulnar Collateral Ligament Injuries in Throwing Athletes: Diagnosis and Management. J Hand Surg Am 2022; 47:266-273. [PMID: 35246298 DOI: 10.1016/j.jhsa.2021.11.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 08/04/2021] [Accepted: 11/15/2021] [Indexed: 02/02/2023]
Abstract
Ulnar collateral ligament (UCL) injuries of the elbow are common in overhead throwing athletes. With throwing, the elbow experiences substantial valgus stress and repetitive microtrauma can lead to injury. Increasing rates of injury among both youth and professional throwers has resulted in a "UCL epidemic." Ulnar collateral ligament reconstruction ("Tommy John Surgery") became a part of the public consciousness after Tommy John returned to professional baseball after a UCL reconstruction with Dr Frank Jobe for what was once considered a career-ending injury. Partial tears and some athletes with complete UCL injuries can be managed without surgery. Since the introduction of UCL reconstruction, technical modifications have aimed to decrease complications and increase return-to-play rates. Ulnar collateral ligament repair has reemerged as a potential surgical option for some throwers. Future prospective and comparative studies are necessary to better define the optimal operative treatment for these injuries.
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Baron JE, Westermann RW, DeMik DE, An Q, Wolf BR. Trends in Medial Ulnar Collateral Ligament Repair and Reconstruction From 2007 to 2016: A Population-Based Study of a Large Private Insurance Database. HSS J 2022; 18:116-121. [PMID: 35087341 PMCID: PMC8753544 DOI: 10.1177/1556331621997810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 02/03/2023]
Abstract
Background: Ulnar collateral ligament (UCL) reconstruction and UCL repair of the elbow are commonly performed procedures, resulting in high return-to-play rates. Whether the incidence rate of UCL reconstruction vs UCL repair has changed over time is not currently known. Purpose/Questions: We sought to assess temporal trends in the incidence rates of UCL repair and UCL reconstruction and to identify factors associated with UCL reconstruction. We hypothesized that UCL repair would demonstrate an increased incidence overall in recent years with an associated decline in UCL reconstruction rates. Methods: Using the PearlDiver Research Program to query the Humana administrative claims database, we identified patients who had undergone UCL repair and/or reconstruction from 2007 to 2016. Patients were stratified by age (15-19; 20-29; 30-49 years), sex, and year (2007-2011 vs 2012-2016). Poisson regression analysis (continuous variables) was used to calculate the incidence risk ratio (IRR); chi-square tests were performed for categorical variables, and odds ratios were calculated with 95% confidence intervals (CI). Results: The incidence rate of UCL repair was greater in 2012-2016 than in 2007-2011 (IRR: 1.86, 95% CI: 1.16-2.96). The incidence rate of UCL reconstruction vs UCL repair was greater for patients aged 15 to 19 years (IRR: 3.37, 95% CI: 1.97-5.77) but not patients aged 20 to 29 years (IRR: 0.89, 95% CI: 0.49-1.59) as compared with patients aged 30 to 49. Males aged 19 years were more likely than females to undergo UCL reconstruction (IRR: 10.09, 95% CI: 1.37-3.45). Conclusion: While UCL procedures are becoming more popular, our retrospective analysis showed that young males are preferentially treated with UCL reconstruction, warranting further investigation into these trends.
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Affiliation(s)
- Jacqueline E. Baron
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA, USA,Jacqueline E. Baron, MD, Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA 52246, USA.
| | - Robert W. Westermann
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
| | - David E. DeMik
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
| | - Qiang An
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
| | - Brian R. Wolf
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
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Lee SJ, Bedford BB, Kim AH, Rahman OF, Zbeda RM. Elbow Osteochondral Allograft Transplantation and Lateral Ulnar Collateral Ligament Repair with Internal Brace: A Case Report. JBJS Case Connect 2022; 12:01709767-202203000-00024. [PMID: 35050925 DOI: 10.2106/jbjs.cc.21.00615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 23-year-old woman with an Osborne-Cotterill lesion and posterolateral rotatory instability (PLRI) of the elbow was treated with osteochondral allograft transplantation (OCA) and lateral ulnar collateral ligament (LUCL) repair with internal brace. Two years after surgery, she reported resolution of pain and returned to all recreational activities. She reported no mechanical symptoms and no episodes of postoperative instability. CONCLUSION PLRI can present with an Osborne-Cotterill lesion in addition to LUCL injury. The purpose of this case report was to describe the use of OCA to manage bony defects in the capitellum in addition to LUCL repair for patients with PLRI.
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Affiliation(s)
- Steven J Lee
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY
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Seah RB, Mak WK, Bryant K, Korlaet M, Dwyer A, Bain GI. Four-dimensional computed tomography scan for dynamic elbow disorders: recommendations for clinical utility. JSES Int 2022; 6:182-186. [PMID: 35141694 PMCID: PMC8811401 DOI: 10.1016/j.jseint.2021.09.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Four-dimensional computed tomography (4D CT) is rapidly emerging as a diagnostic tool for the investigation of dynamic upper limb disorders. Dynamic elbow pathologies are challenging to diagnose, and at present, limitations exist in current imaging modalities. OBJECTIVE We aimed to assess the clinical utility of 4D CT in detecting potential dynamic elbow disorders. METHODS Twenty-eight elbow joints from 26 patients with symptoms of dynamic elbow pathology were included in this study. They were first assessed by a senior orthopedic surgeon with subsequent qualitative data obtained via a Siemens Force Dual Source CT scanner (Erlangen, Germany), producing two- and three-dimensional "static" images and 4D dynamic "movie" images for assessment in each clinical scenario. Clinical assessment before and after scan was compared. RESULTS Use of 4D CT scan resulted in a change of diagnosis in 16 cases (57.14%). This included a change in primary diagnosis in 2 cases (7.14%) and secondary diagnosis in 14 cases (50%). In 25 cases (89.29%), the 4D CT scan allowed us to understand the pathological anatomy in greater detail which led to a change in the management plan of 15 cases (53.57%). CONCLUSION 4D CT is a promising diagnostic tool in the management of dynamic elbow disorders and may be considered in clinical practice. Future studies need to compare it with other diagnostic modalities such as three-dimensional CT.
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Affiliation(s)
| | - Wai-Keong Mak
- Department of Orthopaedic Surgery, Sengkang General Hospital, Singapore
| | - Kimberley Bryant
- Clinical and Research Imaging Centre, SAHMRI, Adelaide, SA, Australia
| | - Mishelle Korlaet
- Department of Orthopaedic Surgery and Trauma, Flinders University, Bedford Park, SA, Australia
| | - Andrew Dwyer
- Department of Orthopaedic Surgery and Trauma, Flinders University, Bedford Park, SA, Australia
| | - Gregory I. Bain
- Department of Orthopaedic Surgery and Trauma, Flinders University, Bedford Park, SA, Australia
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Anvari A, Fathi A, Bolia IK, Piatt E, Hasan LK, Haratian A, Weber AE, Petrigliano FA. Utilization of Internal Bracing in Elbow Medial UCL Stabilization: From Biomechanics to Clinical Application and Patient Outcomes. Orthop Res Rev 2021; 13:201-208. [PMID: 34703328 PMCID: PMC8541765 DOI: 10.2147/orr.s321890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 10/08/2021] [Indexed: 11/23/2022] Open
Abstract
Ulnar collateral ligament (UCL) reconstruction has been successfully utilized to treat symptomatic UCL insufficiency in overhead athletes. Despite the overall success of the procedure, attempts have been made to improve upon the original technique with the goal of hastening return to sport. Most recently, there has been interest in repairing or reconstructing the native ligament with internal brace (IB) augmentation. Biomechanical cadaveric studies assessing UCL repair with IB augmentation have attempted to evaluate the efficacy of this treatment; however, the literature is seemingly divided on its benefit. Preliminary clinical studies suggest internal bracing may allow a faster return to sport than conventional techniques. The purpose of this review was to provide an analysis of the current evidence on IB augmentation in UCL repair of the elbow as it pertains to biomechanical advantages/disadvantages, reported surgical techniques, and clinical outcomes in comparison with traditional UCL reconstruction techniques.
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Affiliation(s)
- Andre Anvari
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Amir Fathi
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Ioanna K Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Eric Piatt
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Laith K Hasan
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Aryan Haratian
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Alexander E Weber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Frank A Petrigliano
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
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Rothermich MA, Fleisig GS, Lucas HE, Ryan MK, Emblom BA, Cain EL, Dugas JR. Early Complications of Ulnar Collateral Ligament Repair With Collagen-Coated Suture Tape Augmentation. Orthop J Sports Med 2021; 9:23259671211038320. [PMID: 34646900 PMCID: PMC8504244 DOI: 10.1177/23259671211038320] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 05/04/2021] [Indexed: 11/12/2022] Open
Abstract
Background: Recent innovative techniques have led to renewed interest in ulnar collateral ligament (UCL) repair. Although early outcome data regarding the clinical outcome of overhead athletes undergoing UCL repair with augmentation have been encouraging, long-term data are still needed to evaluate both the appropriate indications and success rate for this procedure. Purpose: To describe and evaluate the acute complications seen in a large cohort of patients who underwent UCL repair with internal brace augmentation at a single institution. Study Design: Case series; Level of evidence, 4. Methods: We performed a retrospective chart review of a prospectively collected database, consisting of all patients who underwent UCL repair with internal brace augmentation utilizing a collagen-dipped FiberTape at our institution from August 2013 to January 2020. Patient characteristics, injury setting, side of surgery, and concomitant ulnar nerve transposition procedures were recorded. Early complications of UCL repair (within 6 months of the procedure) were evaluated and characterized as either minor or major, depending on whether the patient required a return to the operating room. Results: Of the 353 patients who underwent UCL repair at our institution with a minimum of 6-month follow-up, 84.7% (299/353) reported no complications, 11.9% (42/353) reported minor complications—including ulnar nerve paresthesia, postoperative medial elbow pain, and postoperative superficial wound complications—and 3.4% (12/353) required a return to the operating room because of a major complication requiring ulnar nerve exploration/debridement, primary ulnar nerve transposition, or heterotopic ossification excision. Conclusion: The low major complication rate identified in this study further validates the efficacy of the UCL repair with the internal bracing augmentation technique. Longer term follow-up data are needed to more adequately assess the outcomes and durability of this procedure.
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Affiliation(s)
| | - Glenn S Fleisig
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Hunter E Lucas
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Michael K Ryan
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Benton A Emblom
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - E Lyle Cain
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Jeffrey R Dugas
- American Sports Medicine Institute, Birmingham, Alabama, USA
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Griffith R, Bolia IK, Fretes N, Murray IR, Meyer J, Weber AE, Gamradt SC, Petrigliano FA. Return-to-Sport Criteria After Upper Extremity Surgery in Athletes-A Scoping Review, Part 2: Ulnar Collateral Ligament of the Elbow Procedures. Orthop J Sports Med 2021; 9:23259671211021825. [PMID: 34395685 PMCID: PMC8358522 DOI: 10.1177/23259671211021825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 02/24/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND There is a lack of consensus to guide patient return to sport (RTS) after elbow ulnar collateral ligament surgery (eUCLS). PURPOSE To describe the reported RTS criteria after eUCLS in the athletic population. STUDY DESIGN Scoping review; Level of evidence, 4. METHODS This scoping review was performed by adhering to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Scoping Review) guidelines. We searched 5 electronic databases (MEDLINE, Scopus, SPORTDiscus, Embase, Google Scholar Advanced) and the gray literature for English-language studies that reported at least 1 RTS criterion in athletes after eUCLS. Data were extracted and summarized as frequencies or arithmetic mean and standard deviation. RESULTS Included were 14 studies and 1335 athletes with a mean age of 21.4 ± 1.1 years. Time from surgery (range, 6-16 months) was the most common RTS criterion used, and it was reported by all 14 of the included articles. RTS criteria reported less often were pain (3/14; 21%), successful completion of a throwing program (3/14; 21%), muscle strength of the forearm muscles (1/14; 7%), and "normal" range of motion and muscle strength of the elbow and shoulder joints on the operated upper extremity (1/14; 7%). All studies used 1 to 5 of the above RTS criteria. CONCLUSION Only 14 studies reported 1 or more RTS criteria after eUCLS in athletes, and time was the most common RTS criterion used. Our results highlight the need for a coordinated effort among surgeons, physical therapists, and athletic trainers in order to establish evidence-based RTS criteria after eUCLS in athletes so athletes can safely to sport and prolong their athletic careers.
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Affiliation(s)
- Rebecca Griffith
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Ioanna K. Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Nickolas Fretes
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Iain R. Murray
- Department of Orthopaedic Sports Medicine, Stanford University, Redwood City, California, USA
| | - John Meyer
- Meyer Institute of Sport, Los Angeles, California, USA
| | - Alexander E. Weber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Seth C. Gamradt
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
| | - Frank A. Petrigliano
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California, USA
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Rothermich MA, Fleisig GS, Conte SA, Hart KM, Cain EL, Dugas JR. Short-Term Trends in Elbow Ulnar Collateral Ligament Surgery in Collegiate Baseball Players: An Analysis of 25,587 Player-Years. Orthop J Sports Med 2021; 9:23259671211016846. [PMID: 34377712 PMCID: PMC8330484 DOI: 10.1177/23259671211016846] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/15/2021] [Indexed: 11/16/2022] Open
Abstract
Background Trends over time in the incidence of ulnar collateral ligament (UCL) surgeries in National Collegiate Athletic Association Division I baseball players are currently unknown. Purpose/Hypothesis The purpose of this study was to evaluate the trends in UCL surgeries over 3 years in Division I baseball programs. We hypothesized that surgical injuries would be consistently high over the course of the study. Study Design Descriptive epidemiology study. Methods Athletic trainers from Division I baseball programs were invited to participate in an electronic survey over 3 seasons. A total of 155 baseball programs agreed to participate in 2017, 294 programs participated in 2018, and 296 programs participated in 2019. After each of the 3 collegiate baseball seasons, the athletic trainer from each program entered anonymous, detailed descriptive data and surgical information on injured players into a secured database. Results During the 3 years of this study, 100% of the enrolled programs successfully completed the survey (155/155 in year 1, 294/294 in year 2, and 296/296 in year 3). This registry of 745 completed surveys over 3 years represented 25,587 player-years from Division I collegiate baseball. The percentage of programs with at least 1 UCL surgery during this time was 57% in 2017, 51% in 2018, and 49% in 2019. The majority of these players were pitchers (84% overall from the 3 years). Seniors underwent a significantly lower percentage of the UCL surgeries (8% in 2017, 10% in 2018, and 13% in 2019) than did underclassmen. Surgeries were performed most often in-season and least often during the preseason. A slight majority of players undergoing surgery originated from warm-weather states, but the number of these players was never significantly higher than was the number of players from cold-weather states. Most surgeries performed each year were UCL reconstruction, but the percentage of UCL repair with ligament augmentation increased each year (10% UCL repairs in 2017, 20% in 2018, and 25% in 2019). Conclusion UCL injuries requiring surgery were found to be a major source of morbidity in Division I collegiate baseball, supporting our hypothesis. This study can serve as a baseline for tracking long-term trends in UCL surgeries in collegiate baseball.
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Affiliation(s)
| | - Glenn S Fleisig
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Stan A Conte
- Conte Injury Analytics LLC, Scottsdale, Arizona USA
| | - Karen M Hart
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - E Lyle Cain
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Jeffrey R Dugas
- American Sports Medicine Institute, Birmingham, Alabama, USA
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O'Connell R, Hoof M, Heffernan J, O'Brien M, Savoie F. Medial Ulnar Collateral Ligament Repair With Internal Brace Augmentation: Results in 40 Consecutive Patients. Orthop J Sports Med 2021; 9:23259671211014230. [PMID: 34377711 PMCID: PMC8320562 DOI: 10.1177/23259671211014230] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 02/03/2021] [Indexed: 11/28/2022] Open
Abstract
Background: Medial ulnar collateral ligament (MUCL) repair has been proven to be effective in nonprofessional overhead-throwing athletes, with faster and higher rates of return to play (RTP) than the more traditional Tommy John reconstruction. Biomechanical studies and clinical data suggest that MUCL repair augmented with a collagen-coated internal brace may be an effective treatment option in this patient population. Purpose: To evaluate the functional outcomes of young nonprofessional athletes who underwent MUCL repair with internal brace augmentation for medial elbow instability. The hypothesis was that these patients will have high rates of RTP and improved functional outcomes. Study Design: Case series; Level of evidence, 4. Methods: Nonprofessional overhead athletes treated with MUCL repair with internal brace augmentation between 2015 and 2017 were prospectively evaluated for a minimum of 1 year. Preoperatively, all patients had evidence of medial elbow pain caused by MUCL insufficiency, as confirmed by signal changes on magnetic resonance imaging and valgus instability on arthroscopic examination. These findings did not allow them to participate in their chosen sport or profession, and each patient had failed nonoperative treatment. Postoperative outcomes were evaluated using the Overhead Athlete Shoulder and Elbow Score of the Kerlan-Jobe Orthopaedic Clinic. Complications were recorded and detailed. Results: A total of 40 nonprofessional overhead athletes were included in this study (35 men and 5 women; mean age, 17.8 years [range, 14-28 years]). The mean follow-up time was 23.8 months (range, 12-44 months). The mean postoperative Kerlan-Jobe Orthopaedic Clinic score was 92.6 (range, 64-100). Overall, 37 athletes (92.5%) returned to play or profession at the same level or higher at a mean time of 6.9 months (range, 2-12 months). Three patients did not RTP: 1 was limited by a concomitant medical diagnosis, and the other 2 chose not to resume athletics after the procedure but remained symptom free. Conclusion: In the nonprofessional athlete, primary MUCL repair with internal brace augmentation is a viable alternative to traditional repair techniques or reconstruction, allowing for a rapid RTP and promising functional outcomes.
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Affiliation(s)
- Robert O'Connell
- Department of Orthopaedic Surgery, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Marcus Hoof
- School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - John Heffernan
- Proliance Puget Sound Orthopaedics, Lakewood, Washington, USA
| | - Michael O'Brien
- Department of Orthopaedic Surgery, School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Felix Savoie
- Department of Orthopaedic Surgery, School of Medicine, Tulane University, New Orleans, Louisiana, USA
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Lee SJ, Rabinovich RV, Rahman OF, Bedford BB. Elbow ulnar collateral ligament reconstruction using suture tape augmentation. JSES REVIEWS, REPORTS, AND TECHNIQUES 2021; 1:145-150. [PMID: 37588142 PMCID: PMC10426713 DOI: 10.1016/j.xrrt.2020.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Affiliation(s)
- Steven J. Lee
- Chief, Surgery of the Hand and Upper Extremity, Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY, USA
| | - Remy V. Rabinovich
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY, USA
| | - Omar F. Rahman
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY, USA
| | - Benjamin B. Bedford
- Assistant Fellowship Director, Sports Medicine, Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY, USA
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46
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Roth TS, Beason DP, Clay TB, Cain EL, Dugas JR. The Effect of Ulnar Collateral Ligament Repair With Internal Brace Augmentation on Articular Contact Mechanics: A Cadaveric Study. Orthop J Sports Med 2021; 9:23259671211001069. [PMID: 33997066 PMCID: PMC8076780 DOI: 10.1177/23259671211001069] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 12/16/2020] [Indexed: 11/17/2022] Open
Abstract
Background: There has been renewed interest in ulnar collateral ligament (UCL) repair in throwing athletes because of a greater understanding of UCL injuries, improvement in ligament repair technology, and potentially expedited rehabilitation time and return to play relative to UCL reconstruction. Purpose: To evaluate elbow articular contact and overall joint torque after UCL reconstruction and repair augmented with a collagen-coated fiber tape, InternalBrace. Study Design: Controlled laboratory study. Methods: Ten matched pairs of cadaveric arms (mean age, 41 ± 11 years) were dissected to expose the UCL. Each specimen was secured into a custom test fixture at 90°, and 1 specimen from each pair underwent either a modified Jobe UCL reconstruction or UCL repair with InternalBrace. Each specimen underwent 10 cycles of elbow valgus angular displacement between 0° and 5° at a rate of 1 deg/s in the intact state, after UCL avulsion, and then after UCL reconstruction or repair. Articular contact mechanics and overall joint torque and stiffness were recorded. Results: Contact mechanics of reconstructed and repaired specimens were not significantly different. Both reconstruction and repair procedures returned the overall resistance of the joint to valgus torsion to near-intact levels. UCL repair tended to restore joint torque more closely to the intact state than did reconstruction, given that reconstruction showed a nonsignificant trend toward lower torque than the intact state (P = .07). Conclusion: Neither UCL reconstruction nor UCL repair with InternalBrace overconstrained the elbow joint, as both groups had similar contact pressures compared with the native joint. Both procedures also restored elbow joint torque and stiffness to levels not statistically different from the intact state. Clinical Relevance: Given the sound biomechanical properties of UCL repair with InternalBrace, it may have a significant role as treatment for UCL injuries.
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Affiliation(s)
- Travis S Roth
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - David P Beason
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - T Bradley Clay
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - E Lyle Cain
- American Sports Medicine Institute, Birmingham, Alabama, USA.,Andrews Sport Medicine and Orthopaedic Center, Birmingham, Alabama, USA
| | - Jeffrey R Dugas
- American Sports Medicine Institute, Birmingham, Alabama, USA.,Andrews Sport Medicine and Orthopaedic Center, Birmingham, Alabama, USA
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47
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Danilkowicz RM, O'Connell RS, Satalich J, O'Donnell JA, Flamant E, Vap AR. Increase in Use of Medial Ulnar Collateral Ligament Repair of the Elbow: A Large Database Analysis. Arthrosc Sports Med Rehabil 2021; 3:e527-e533. [PMID: 34027465 PMCID: PMC8129461 DOI: 10.1016/j.asmr.2020.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 12/20/2020] [Indexed: 11/28/2022] Open
Abstract
Purpose To assess the current national rate of medial ulnar collateral ligament (MUCL) repair of the elbow and delineate the patient demographics of those undergoing repair. Methods A retrospective review and analysis of a national private insurance database was conducted covering 2007-2017 using Pearl Diver technologies. All patients diagnosed with a MUCL injury and those who underwent repair were included using Clinical Modification and Current Procedural Terminology code 24345, referencing repair of the ulnar collateral ligament of the elbow with local tissue. The extracted data included patient age at time of procedure, sex, race, region, year of surgery, insurance type, hospital setting, and any associated diagnoses with 90 days of the repair procedure. Standard descriptive methods characterized our study sample to calculate frequency counts and percentages. Means with respective standard deviations and/or standard errors, and 95% confidence intervals were calculated and reported for continuous variables, whereas frequencies and percentages were reported for categorical variables. Pearson χ2 tests were used to determine differences between group proportion categorical variables. Significance was considered at a P ≤ .05. Results From 2007 to 2014, MUCL injuries showed an upward trend in incidence per 100,000 from 4.59 to 7.19 (56% increase) within the database population. Accordingly, the incidence of MUCL repair rose from 0.016 to 0.49 (2962%). However, from 2015-2017 there was a drop in both categories, as injury incidence fell from 7.19 to 1.48 whereas repair rates dropped from 0.49 to 0.012. The ages undergoing repair show a significant peak in 15-24-year-olds. The incidence of MUCL repair was greatest in the West and South (P < .01). Male patients had a greater incidence of MUCL injury, and a greater incidence of MUCL repair per 100,000 persons compared to females (P < .01). Conclusions MUCL repair has emerged as a viable alternative to reconstruction in select indications. The impetus for this change may be to provide a quicker return to sport and fewer complications, largely due to recent improvements in surgical technique for MUCL repair. As anticipated, the incidence of MUCL repair had steadily increased in the United States from 2007 to 2014, with a subsequent relatively inexplicable decrease primarily in 2017, according to the database utilized in this study. The 15-24 year-old age group encompassing young athletes has the greatest incidence of repair by a significant margin. Level of Evidence IV, Therapeutic Case Series.
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Affiliation(s)
| | - Robert S O'Connell
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia, U.S.A
| | - James Satalich
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia, U.S.A
| | | | | | - Alexander R Vap
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia, U.S.A
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Bogdanov JM, Bolia IK, Benvegnu N, Michener LA, Weber AE, Petrigliano FA. Rehabilitation Following Ulnar Collateral Ligament Reconstruction in Overhead-Throwing Athletes. JBJS Rev 2021; 9:01874474-202104000-00004. [PMID: 33819204 DOI: 10.2106/jbjs.rvw.20.00154] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» The prevalence of ulnar collateral ligament (UCL) injury and UCL reconstruction (UCL-R) continues to rise, causing morbidity in overhead-throwing athletes. » Postoperative rehabilitation protocols are essential for proper healing of the reconstructed ligament and safely returning athletes to competition, yet there is no uniformly accepted standard of care. » UCL-R rehabilitation has traditionally been guided by expert opinion and conventional wisdom rather than scientific studies, resulting in substantial variability in rehabilitation practices, time to return to play, and outcomes. » Current research efforts aim to closely investigate the biomechanical implications of UCL-R and overhead throwing to better guide rehabilitation and to improve competitive performance and outcomes. » Additional biomechanical and scientific studies on rehabilitation modalities and timing are warranted for systematic analysis, optimization, and standardization of UCL-R rehabilitation.
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Affiliation(s)
- Jacob M Bogdanov
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California
| | - Ioanna K Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California
| | - Neilen Benvegnu
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California
| | - Lori A Michener
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, California
| | - Alexander E Weber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California
| | - Frank A Petrigliano
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, California
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49
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Hadley CJ, Edelman D, Arevalo A, Patel N, Ciccotti MG, Dodson CC. Ulnar Collateral Ligament Reconstruction in Adolescents: A Systematic Review. Am J Sports Med 2021; 49:1355-1362. [PMID: 32791013 DOI: 10.1177/0363546520934778] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Ulnar collateral ligament (UCL) reconstruction is an established surgical technique to restore UCL deficiency, especially in the overhead throwing athlete. Over the past decade, the number of patients requiring UCL reconstruction has increased significantly, particularly in the adolescent patient population. Return-to-play rates after UCL reconstruction reported in the literature have ranged from 33% to 92%, and a recent systematic review noted a return-to-play rate of 89.40% in all high school athletes. PURPOSE To evaluate the outcomes, particularly return-to-play rates and subjective outcome scores, of UCL reconstruction of the elbow in adolescent throwing athletes. STUDY DESIGN Systematic review. METHODS A systematic review of the literature was conducted via the electronic databases Embase, PubMed, and Cochrane. Studies that reported on outcomes, particularly return-to-play rates, in adolescent throwing athletes met the inclusion criteria and were included in our analysis. Studies that did not report on adolescent throwing athletes and studies that reported on adolescent throwing athletes but did not specify the return-to-play outcomes for these athletes were excluded from our analysis. RESULTS Nine studies met the inclusion criteria and were included in this review. There were 404 baseball players and 10 javelin throwers included in our analysis. A total of 349 of the 414 patients (84.30%) were successfully able to return to play at the same level of competition or higher. Successful rates of return to prior performance ranged from 66.67% to 91.49% in our analysis. Javelin throwers had a mean 80.00% rate of return to prior performance, while baseball players had a mean return-to-play rate of 84.40%. Complications were evaluated for 8 (88.9%) studies and 283 (68.4%) patients. There were 11 (3.9%) reported complications and 5 (1.8%) reoperations. CONCLUSION The findings of this systematic review revealed that adolescent patients are generally able to return to their preinjury level of performance or higher with limited complications. Further investigation is necessary to determine long-term outcomes for return to play after UCL reconstruction of the elbow in adolescent throwing athletes.
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Affiliation(s)
| | - David Edelman
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alfonso Arevalo
- Philadelphia College of Osteopathic Medicine-Orthopedic Surgery, Philadelphia, Pennsylvania, USA
| | - Nimit Patel
- Orthopedic Partners, North Franklin, Connecticut, USA
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50
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Mills FB, Misra AK, Goyeneche N, Hackel JG, Andrews JR, Joyner PW. Return to Play After Platelet-Rich Plasma Injection for Elbow UCL Injury: Outcomes Based on Injury Severity. Orthop J Sports Med 2021; 9:2325967121991135. [PMID: 33796592 PMCID: PMC7983438 DOI: 10.1177/2325967121991135] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 10/23/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Ulnar collateral ligament (UCL) injuries of the elbow are uncommon in the general population but prevalent in the athletic community, particularly among baseball players. Platelet-rich plasma (PRP) injection therapy has become a popular nonoperative adjuvant treatment for such injuries to help reduce recovery time and avoid surgery. Purpose/Hypothesis: To analyze patient outcomes by injury severity and identify injury types that responded most favorably and unfavorably to PRP treatment. It was hypothesized that PRP therapy would prove to be most beneficial in the treatment of lower-grade, partial UCL tears and less effective in the treatment of more severe, complete UCL tears. Study Design: Cohort study; Level of evidence, 3. Methods: A cohort of 50 patients with UCL injuries in their dominant elbow, diagnosed by MRI (magnetic resonance imaging) arthrogram, underwent PRP therapy in conjunction with an established rehabilitation program. UCL injuries were classified by MRI as low-grade partial tear (Type I), high-grade partial tear (Type II), complete tear (Type III), or tear in more than 1 location (Type IV). Results: In total, 24 of 39 (61.5%) Type I and II tears, 3 of 3 (100%) Type III tears, and 1 of 8 (12.5%) patients with Type IV tears responded to UCL PRP injection therapy and were able to return to play without surgery. Ten patients required subsequent UCL PRP injections, of which 3 (30%) were able to return to sport without surgery. Conclusion: PRP treatment for Types I and II UCL tears shows great promise when combined with physical therapy and a rehabilitation program. Type III UCL tears demonstrated a high rate of success, although with low cohort numbers. Type IV UCL tears did not appear to respond well to PRP injection therapy and often required surgical intervention or cessation of sport. Therefore, PRP treatment does not appear to be appropriate for patients with complete Type IV UCL tears but may enhance recovery and improve outcomes in throwing athletes with Types I, II, and III UCL injuries.
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Affiliation(s)
| | | | - Nicholas Goyeneche
- The Andrews Institute for Orthopaedics & Sports Medicine, Gulf Breeze, Florida, USA
| | - Joshua G Hackel
- The Andrews Institute for Orthopaedics & Sports Medicine, Gulf Breeze, Florida, USA
| | - James R Andrews
- The Andrews Institute for Orthopaedics & Sports Medicine, Gulf Breeze, Florida, USA
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