|
1
|
Da Silva AZ, Connelly JW, Chalmers PN. Return to Play Throwing Programs. Clin Sports Med 2025; 44:273-289. [PMID: 40021256 DOI: 10.1016/j.csm.2024.05.005] [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
Injuries in overhead throwers are common, and there are limited data on return to throw programs in the literature. This article outlines the criteria that baseball players should meet before initiating throwing and further describes an evidence-based throwing program that can be utilized to aid in the rehabilitation of overhead athletes and optimize chances of returning to same level of throwing. These guidelines may be used for rehabilitation after injury is treated operatively or nonoperatively.
Collapse
Affiliation(s)
- Adrik Z Da Silva
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - James W Connelly
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - Peter N Chalmers
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA.
| |
Collapse
|
|
2
|
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.
Collapse
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
| |
Collapse
|
|
3
|
Erickson BJ, Camp CL, Chalmers PN, Griffith TB, Simon KN, Hebert E, Meister K. Outcomes of Revision Elbow Medial Ulnar Collateral Ligament Reconstruction in Professional Baseball Players: An Analysis of 191 Pitchers From 2010 to 2023. Am J Sports Med 2025; 53:1210-1215. [PMID: 40035615 DOI: 10.1177/03635465251322780] [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: 03/05/2025]
Abstract
BACKGROUND The number of medial ulnar collateral ligament (MUCL) reconstructions is increasing. The epidemiology surrounding revision MUCL reconstructions in professional baseball players has not been well defined. PURPOSE/HYPOTHESIS The purpose was to report the epidemiology of revision MUCL reconstruction in professional baseball players. The authors hypothesized that the number of revision MUCL reconstructions has increased over time and that the rate of return to sport at the same level of play is <70%. STUDY DESIGN Case series; Level of evidence, 4. METHODS All professional baseball pitchers who underwent revision MUCL reconstruction between 2010 and 2023 were identified using the Major League Baseball Health and Injury Tracking System. Rates of return to play, time to return to play, and return to same level of play were recorded and analyzed for pitchers with a minimum follow-up of 2 years. Surgical variables, including technique and graft choice, were also recorded. RESULTS Overall 191 pitchers (mean age, 26.0 years) underwent revision MUCL reconstruction. The mean time between primary and revision surgery was 1381 days (45 months). Of these players, 130 (68%) were Minor League Baseball pitchers. Hamstring tendon autograft was the most commonly used graft source (n = 90; 47%) when compared with palmaris longus autograft (n = 67; 35%). In terms of tunnel configuration, the modified Jobe and docking techniques were used in equal occurrence (n = 70; 37%). After revision MUCL reconstruction, only 72% of professional baseball pitchers were able to return to play at any level at a mean 556 days (18 months), and only 58% were able to return to the same level of play at a mean 604 days (20 months). The mean time between primary and revision MUCL reconstruction was 45 months (3.75 years). CONCLUSION Revision MUCL surgery continues to be a challenging problem, where the procedure is complex, rehabilitation timelines are prolonged, and outcomes are not always optimal. Accordingly, the authors recommend that these procedures be performed by surgeons with high levels of experience.
Collapse
Affiliation(s)
| | - Christopher L Camp
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter N Chalmers
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, USA
| | | | - Karissa N Simon
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Elizabeth Hebert
- Major League Baseball Commissioner's Office, New York, New York, USA
| | - Keith Meister
- TMI Sports Medicine and Orthopedic Surgery, Arlington, Texas, USA
| |
Collapse
|
|
4
|
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.
Collapse
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
| |
Collapse
|
|
5
|
Ciccotti MC, Looney AM, Johnson EE, Hadley CJ, Zoga A, Nazarian L, Ciccotti MG. A Prospective, Randomized Trial of the Modified Jobe Versus Docking Techniques With Gracilis Autograft for Ulnar Collateral Ligament Reconstruction in the Elbow. Am J Sports Med 2025; 53:447-462. [PMID: 39902974 DOI: 10.1177/03635465241305741] [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: 02/06/2025]
Abstract
BACKGROUND Ulnar collateral ligament (UCL)reconstruction (UCLR) has transformed UCL injury from career-ending to career-interruptive. The most common surgical techniques are the modified Jobe and docking techniques. PURPOSE/HYPOTHESIS The purpose of this study was to perform a prospective, randomized comparison of the modified Jobe versus docking techniques in overhead athletes with respect to patient-reported outcomes (PROs), self-reported baseball-specific metrics, imaging, and complications. It was hypothesized that there would be no significant differences between techniques. STUDY DESIGN Randomized controlled trial; Level of evidence, 2. METHODS A single-surgeon, single-blinded, prospective, randomized trial was performed comparing the modified Jobe and docking techniques. Patients were blinded to surgical technique. UCLR was performed with uniform gracilis autograft and identical postoperative rehabilitation. Pre- and postoperative PROs (Kerlan-Jobe Orthopaedic Clinic [KJOC] score, Andrews-Timmerman score, and Conway-Jobe score) were obtained. Pre- and postoperative imaging included stress ultrasound (SUS) and magnetic resonance imaging (including magnetic resonance arthrography). Additional information included demographics, anthropometrics, intraoperative data, complications, and self-reported baseball-specific metrics. RESULTS Eighty patients were randomized, and >80% follow-up was obtained (65/80 [81%]). There were no significant differences with respect to demographics, anthropometrics, preoperative imaging, or preoperative PROs. Surgically, docking had shorter median tourniquet time (91.5 vs 98.0 minutes; P = .001). There were no differences in Andrews-Timmerman score at any time point. Docking demonstrated a higher median KJOC score at 2 years (93.05 vs 79.20; P = .021). There was no difference with respect to return to play (RTP) by the Conway-Jobe scale (80% good to excellent docking vs 69% good to excellent Jobe; P = .501) or time to RTP (13.92 months docking vs 12.85 months Jobe; P = .267). There were no differences in baseball metrics postoperatively. On postoperative SUS, modified Jobe showed greater graft thickness (7.70 vs 6.75 mm; P = .006). Postoperative MRI revealed no differences. There was no difference in complications (Jobe 5.0% vs docking 7.5%; P > .999). CONCLUSION The current study identified high rates of good to excellent results with PROs for both techniques, including RTP rates and times. Docking had shorter tourniquet time and higher 2-year KJOC scores. There were no differences in self-reported baseball-specific metrics or postoperative imaging (except graft thickness for modified Jobe by SUS). As the first prospective, randomized trial evaluating the modified Jobe and docking techniques, this study is the definitive substantiation of these two surgical techniques for UCLR. It provides surgeons with confidence to utilize the technique with which they are most comfortable.
Collapse
Affiliation(s)
| | | | | | | | - Adam Zoga
- Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Levon Nazarian
- Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | |
Collapse
|
|
6
|
Ciccotti MG. Editorial Commentary: Elbow Ulnar Collateral Ligament Repair With Suture Tape Augmentation Versus Reconstruction Should Be Determined Using Precise Imaging and Indications. Arthroscopy 2025:S0749-8063(25)00035-0. [PMID: 39864679 DOI: 10.1016/j.arthro.2025.01.017] [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: 01/09/2025] [Accepted: 01/16/2025] [Indexed: 01/28/2025]
Abstract
Current surgical treatment options for ulnar collateral ligament (UCL) injury of the elbow include both reconstruction and repair. A growing amount of research has evaluated the outcomes of these various techniques in a variety of study designs. Large national database assessment indicates that overall failure rates are low and complication rates are similar between UCL reconstruction and UCL repair techniques. In addition, although the incidence of revision UCL surgery is low, UCL repair is associated with a significantly greater risk of revision than UCL reconstruction. This information is important in counseling our patients and urges us to perform higher-level, comparative research of these 2 surgical techniques in order to more precisely sculpt the optimal treatment algorithm for UCL injury. In my experience, preoperative advanced imaging including magnetic resonance imaging, magnetic resonance arthrography, and stress ultrasound are invaluable in determining the location and degree of UCL injury and, equally importantly, the status of the remaining ligament. These are key factors in deciding whether a particular patient is appropriate for UCL reconstruction or repair according to the indications defined by Dugas (with suture tape augmentation): "complete or partial avulsion of the UCL from either the sublime tubercle or medial epicondyle, without evidence of poor tissue quality of the ligament."
Collapse
|
|
7
|
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.
Collapse
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
| |
Collapse
|
|
8
|
Corbitt AD, Bandy WD. Rehabilitation of an Upper Extremity Weight-Bearing Athlete with an Ulnar Collateral Ligament Injury: A Case Report. Int J Sports Phys Ther 2024; 19:1034-1043. [PMID: 39100938 PMCID: PMC11297479 DOI: 10.26603/001c.120900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 06/17/2024] [Indexed: 08/06/2024] Open
Abstract
Background and Purpose Ulnar collateral ligament (UCL) injury is a common elbow injury among overhead athletes, particularly baseball pitchers. However, limited research exists for non-throwing athletes, especially regarding rehabilitation. The purpose of this case report is to illustrate the use of early weight-bearing activities into the rehabilitation protocol for non-operative management of athletes with a UCL injury. Case Description The subject was a 17-year-old female competitive cheerleader. Two weeks prior, during the performance of an acrobatic skill in which she transitioned to full upper extremity (UE) weight-bearing, she sustained an injury to her right elbow. Physical therapy examination findings indicated a diagnosis of a UCL sprain. Self-reported outcome measures revealed a FOTO score of 69/100 and a Quick Dash score of 43/100. The subject attended 14 therapy sessions over nine weeks to address physical function and performance, which were assessed at intervals during her therapy program. Rehabilitation consisted of therapeutic exercise for the progression of UE functional weight-bearing including planks, ball push-ups, handstands, crab walks, stool pulls, handstand walks, and UE plyometric jumps. Outcomes Along with documented improvement of the standard musculoskeletal examination measures of range of motion, strength, and functional performance, the subject demonstrated no elbow instability and improved FOTO and Quick Dash scores of 98 and 0, respectively. The subject demonstrated 105% limb symmetry index with the return to sport (RTS) UE functional testing of one-armed seated shot-put throw (SSPT) and achieved normative values with the closed kinetic chain upper extremity stability test (CKCUEST). Conclusion This case report highlights the successful treatment of a subject with a UCL injury and the integration of therapy interventions with a focus on UE weight-bearing. Further research on performing high level UE weight-bearing activities during rehabilitation and RTS guidelines is needed.
Collapse
|
|
9
|
Oeding JF, Jurgensmeier K, Boos AM, Krych AJ, Okoroha KR, Moatshe G, Camp CL. Early Surgery for Partial Tears of the Ulnar Collateral Ligament May Be More Cost-Effective and Result in Longer Playing Careers Than Nonoperative Management for High-Level Baseball Pitchers: A Decision-Analytic Markov Model-Based Analysis. Am J Sports Med 2024; 52:2319-2330. [PMID: 38899340 DOI: 10.1177/03635465241255147] [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: 06/21/2024]
Abstract
BACKGROUND Nonoperative management versus early reconstruction for partial tears of the medial ulnar collateral ligament (MUCL) remains controversial, with the most common treatment options for partial tears consisting of rest, rehabilitation, platelet-rich plasma (PRP), and/or surgical intervention. However, whether the improved outcomes reported for treatments such as MUCL reconstruction (UCLR) or nonoperative management with a series of PRP injections justifies their increased upfront costs remains unknown. PURPOSE To compare the cost-effectiveness of an initial trial of physical therapy alone, an initial trial of physical therapy plus a series of PRP injections, and early UCLR to determine the preferred cost-effective treatment strategy for young, high-level baseball pitchers with partial tears of the MUCL and with aspirations to continue play at the next level (ie, collegiate and/or professional). STUDY DESIGN Economic and decision analysis; Level of evidence, 2. METHODS A Markov chain Monte Carlo probabilistic model was developed to evaluate the outcomes and costs of 1000 young, high-level, simulated pitchers undergoing nonoperative management with and without PRP versus early UCLR for partial MUCL tears. Utility values, return to play rates, and transition probabilities were derived from the published literature. Costs were determined based on the typical patient undergoing each treatment strategy at the authors' institution. Outcome measures included costs, acquired playing years (PYs), and the incremental cost-effectiveness ratio (ICER). RESULTS The mean total costs resulting from nonoperative management without PRP, nonoperative management with PRP, and early UCLR were $22,520, $24,800, and $43,992, respectively. On average, early UCLR produced an additional 4.0 PYs over the 10-year time horizon relative to nonoperative management, resulting in an ICER of $5395/PY, which falls well below the $50,000 willingness-to-pay threshold. Overall, early UCLR was determined to be the preferred cost-effective strategy in 77.5% of pitchers included in the microsimulation model, with nonoperative management with PRP determined to be the preferred strategy in 15% of pitchers and nonoperative management alone in 7.5% of pitchers. CONCLUSION Despite increased upfront costs, UCLR is a more cost-effective treatment option for partial tears of the MUCL than an initial trial of nonoperative management for most high-level baseball pitchers.
Collapse
Affiliation(s)
- Jacob F Oeding
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kevin Jurgensmeier
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander M Boos
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron J Krych
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kelechi R Okoroha
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Gilbert Moatshe
- Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway
| | - Christopher L Camp
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
|
10
|
Sinha R, Wyatt CW, Althoff C, Jones JC, Johnson B, Ellis HB, Wilson PL. Avulsion and Soft Tissue Injuries of the Ulnar Collateral Ligament in Children and Adolescents. Am J Sports Med 2024; 52:2101-2109. [PMID: 38800902 DOI: 10.1177/03635465241252156] [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: 05/29/2024]
Abstract
BACKGROUND Although pediatric medial epicondylar fractures and apophysitis are well studied, patterns of subapophyseal avulsion and ligamentous injuries of the medial elbow in this population merit investigation to inform optimal treatment strategies. PURPOSE To describe the occurrence and demographic correlates of ulnar collateral ligament (UCL) avulsion and soft tissue injuries of the pediatric and adolescent elbow. STUDY DESIGN Cross-sectional study; Level of evidence, 3. METHODS An institutional review board-approved review was conducted to identify consecutive patients with medial elbow injuries treated in a tertiary pediatric sports medicine practice between 2016 and 2021. Radiographs were obtained during injury evaluation, and patients with nondisplaced medial epicondylar apophysitis and complete epicondylar fracture were excluded, resulting in 150 patients with soft tissue injuries occurring distal to the medial epicondyle apophysis (subapophyseal) for study. Radiographs were evaluated for bony avulsion of the UCL from either the medial epicondyle proximally or the ulnar sublime tubercle distally. Injuries without radiographic evidence of bony avulsion, but with clinical examination findings consistent with ligamentous injury, were classified as radiographically negative UCL injuries, and magnetic resonance imaging (MRI) was performed to further evaluate these injuries if moderate to severe medial swelling of the elbow or significant concern for medial structural injury was present on examination. These MRI scans were evaluated to classify the UCL injury and assess for periosteal or cartilaginous avulsions. RESULTS A total of 150 patients (mean age, 12.5 ± 3.4 years; 70 female), 55% (150/274) of the entire medial elbow injury population, had a subapophyseal injury. Of these patients, 62 had a bony avulsion detected on radiograph, and 88 had a radiographically negative injury. In addition to the 62 radiographic avulsions, the 61 MRI scans obtained on those radiographically negative injuries revealed 33 complete UCL disruptions, resulting in 63.3% (95/150) of patients sustaining a complete ligamentous disruption. With the MRI scans, 37 (61%) cases of cartilaginous or periosteal avulsion of the UCL were diagnosed. Overall, 66% of all 150 subapophyseal injuries had a bony, cartilaginous, or periosteal UCL avulsion. Patients with cartilaginous (mean age, 10.3 years) and bony (mean age, 10.6 years) avulsions were younger than those with central ligament injury (mean age, 14.2 years) or periosteal (mean age, 14.2 years) avulsions (P = .005). There was a significant association between the mechanism of injury and the location of UCL tear identified on MRI scans: traumatic falls were associated with distal tears, and throwing injuries were associated with proximal tears (P < .001). CONCLUSION UCL central ligament and avulsion lesions may be frequently diagnosed after injury to the pediatric medial elbow, the majority of which are complete injuries, and may require MRI for diagnosis. The mechanism of injury may predict the location of ligamentous injury, and osteocartilaginous avulsions are more likely to present at younger ages than injuries to the soft tissue of the UCL or periosteum. The prevalence of these injuries merits further investigation into best protocols of nonoperative treatment or surgical repair techniques and outcomes.
Collapse
Affiliation(s)
- Rishi Sinha
- Scottish Rite for Children, Dallas, Texas, USA
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Charles W Wyatt
- Scottish Rite for Children, Dallas, Texas, USA
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Claire Althoff
- Scottish Rite for Children, Dallas, Texas, USA
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jacob C Jones
- Scottish Rite for Children, Dallas, Texas, USA
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Ben Johnson
- Scottish Rite for Children, Dallas, Texas, USA
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Henry B Ellis
- Scottish Rite for Children, Dallas, Texas, USA
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Philip L Wilson
- Scottish Rite for Children, Dallas, Texas, USA
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
|
11
|
Hones KM, Simcox T, Hao KA, Portnoff B, Buchanan TR, Kamarajugadda S, Kim J, Wright JO, King JJ, Wright TW, Schoch BS, Aibinder WR. Graft choice and techniques used in elbow ulnar collateral ligament reconstruction over the last 20 years: a systematic review and meta-analysis. J Shoulder Elbow Surg 2024; 33:1185-1199. [PMID: 38072032 DOI: 10.1016/j.jse.2023.10.023] [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: 06/24/2023] [Revised: 10/13/2023] [Accepted: 10/24/2023] [Indexed: 03/09/2024]
Abstract
BACKGROUND Elbow medial ulnar collateral ligament (mUCL) injuries have become increasingly common, leading to a higher number of mUCL reconstructions (UCLR). Various techniques and graft choices have been reported. The purpose of this study was to evaluate the prevalence of each available graft choice, the surgical techniques most utilized, and the reported complications associated with each surgical method. METHODS A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysesguidelines. We queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify all articles that included UCLR between January 2002 and October 2022. We included all studies that referenced UCLR graft choice, surgical technique, and/or ulnar nerve transposition. Studies were evaluated in a narrative fashion to assess demographics and report current trends in utilization and complications of UCLR as they pertain to graft choice and surgical techniques over the past 20 years. Where possible, we stratified based on graft and technique. RESULTS Forty-seven articles were included, reporting on 6671 elbows. The cohort was 98% male, had a weighted mean age of 21 years and follow-up of 53 months. There were 6146 UCLRs (92%) performed with an autograft and 152 (2.3%) that utilized an allograft, while 373 (5.6%) were from mixed cohorts of autograft and allograft. Palmaris longus autograft was the most utilized mUCL graft choice (64%). The most utilized surgical configuration was the figure-of-8 (68%). Specifically, the most common techniques were the modified Jobe technique (37%), followed by American Sports Medicine Institute (ASMI) (22%), and the docking (22%) technique. A concomitant ulnar nerve transposition was performed in 44% of all patients, with 1.9% of these patients experiencing persistent ulnar nerve symptoms after ulnar nerve transposition. Of the total cohort, 14% experienced postoperative ulnar neuritis with no prior preoperative ulnar nerve symptoms. Further, meta-analysis revealed a significantly greater revision rate with the use of allografts compared to autograft and mixed cohorts (2.6% vs. 1.8% and 1.9%, P = .003). CONCLUSIONS Most surgeons performed UCLR with palmaris autograft utilizing a figure-of-8 graft configuration, specifically with the modified Jobe technique. The overall rate of allograft use was 2.3%, much lower than expected. The revision rate for UCLR with allograft appears to be greater compared to UCLR with autograft, although this may be secondary to limited allograft literature.
Collapse
Affiliation(s)
- Keegan M Hones
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Trevor Simcox
- Department of Orthopaedic Surgery, NYU Long Island School of Medicine, Mineola, NY, USA
| | - Kevin A Hao
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Brandon Portnoff
- Department of Orthopedic Surgery, Brown University, Providence, RI, USA
| | | | | | - Jongmin Kim
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Jonathan O Wright
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Joseph J King
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Thomas W Wright
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Bradley S Schoch
- Department of Orthopaedic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - William R Aibinder
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA.
| |
Collapse
|
|
12
|
Ishigaki T, Akuzawa H, Sekine C, Yokota H, Hirabayashi R, Edama M. Elbow valgus stress during towel drills in college baseball players. J Shoulder Elbow Surg 2024; 33:765-772. [PMID: 37865153 DOI: 10.1016/j.jse.2023.09.017] [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: 05/25/2023] [Revised: 09/04/2023] [Accepted: 09/04/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND In baseball players with elbow injuries, towel drills are clinically used before initiating active throwing exercises to gradually increase stress across the elbow. However, elbow valgus torque during towel drills remains unknown. Moreover, towel drills and active ball throws might have different relationships between biomechanical metrics, such as elbow stress, arm slot, and arm speed. Therefore, the aims of this study were 1) to demonstrate the difference in elbow valgus stress between towel drills and active ball throws and 2) to evaluate the correlation between elbow valgus torque and other biomechanical metrics including arm slot and arm speed in towel drills and active ball throws. METHODS Seventeen healthy college baseball players performed three towel drills using a face towel, short foam tube, and long foam tube, followed by full-effort throwing on flat ground. Each participant completed five consecutive trials of each task, and the elbow valgus torque, arm slot, and arm speed were measured using wearable sensors. One-way repeated analysis of variance and post-hoc tests were used to determine the differences in biomechanical metrics among the tasks. Furthermore, the correlation between the elbow valgus torque and other metrics was evaluated using Pearson correlation coefficients. RESULTS Elbow valgus torque was lower in towel drills compared to that of active ball throws; however, the stress during towel drills using a face towel reached almost 80% of the maximum effort of active ball throws. There was no relationship between elbow valgus stress and arm slot in either the towel or active ball throw tasks. However, a higher arm speed was associated with greater elbow valgus torque in towel drills, whereas no relationship between elbow stress and arm speed was found in active ball throws. CONCLUSION Precaution must be taken in athletes following a progressive throwing program because elbow valgus stress reaches almost 80% of the full-effort throw, even when using a face towel in a towel drill. Hence, the subjective intensity must be controlled even in towel drills to gradually increase the medial elbow stress. Moreover, the mechanisms underlying changes in elbow stress may differ between towel drills and active ball throws. Future investigations on the difference between towel drills and active ball throws may help understand the underlying mechanism of alterations in elbow valgus torque during the throwing movement.
Collapse
Affiliation(s)
- Tomonobu Ishigaki
- Athlete Support Research Center, Niigata University of Health and Welfare, Niigata, Japan; Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Japan; Institute of Life Innovation Research Center, Toyo University, Tokyo, Japan.
| | - Hiroshi Akuzawa
- Athlete Support Research Center, Niigata University of Health and Welfare, Niigata, Japan; Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Japan
| | - Chie Sekine
- Athlete Support Research Center, Niigata University of Health and Welfare, Niigata, Japan; Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Japan
| | - Hirotake Yokota
- Athlete Support Research Center, Niigata University of Health and Welfare, Niigata, Japan; Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Japan
| | - Ryo Hirabayashi
- Athlete Support Research Center, Niigata University of Health and Welfare, Niigata, Japan; Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Japan
| | - Mutsuaki Edama
- Athlete Support Research Center, Niigata University of Health and Welfare, Niigata, Japan; Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Niigata, Japan
| |
Collapse
|
|
13
|
Stone MA, Chao L, Huang DT, Parikh HB, Sun M, Kulber DA, Metzger MF. Biomechanical Comparison of Ulnar Collateral Ligament Reconstruction Between Palmaris Longus Autograft and Knee Medial Collateral Ligament Allograft. Orthop J Sports Med 2024; 12:23259671241234685. [PMID: 38524888 PMCID: PMC10958818 DOI: 10.1177/23259671241234685] [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: 08/24/2023] [Accepted: 09/07/2023] [Indexed: 03/26/2024] Open
Abstract
Background Medial ulnar collateral ligament (mUCL) injury can cause significant pain and alter throwing mechanics. Common autograft options for mUCL reconstruction (UCLR) include the palmaris longus (PL) and hamstring tendons. Allograft use may reduce donor site morbidity and decrease function related to PL autografts. Purpose To compare varus stability and load to failure between a novel allograft for UCLR-knee medial collateral ligament (kMCL)-and a PL autograft in human donor elbow specimens. Study Design Controlled laboratory study. Methods A total of 24 fresh-frozen human elbows were dissected to expose the mUCL. Medial elbow stability was tested with the mUCL intact (native), deficient, and reconstructed utilizing the humeral single-docking technique with either a (1) kMCL allograft (n = 12) or (2) a PL autograft (n = 12). A 3-N·m valgus torque was applied to the elbow, and valgus rotation of the ulna was recorded via motion tracking cameras. The elbow was cycled through a full range of motion 5 times. After kinematic testing, specimens were loaded to failure at 70° of elbow flexion, and failure modes were recorded. Results The mUCL-deficient elbows demonstrated significantly greater valgus rotation compared with the intact and reconstructed elbows at every flexion angle tested (10°-120°) (P <.001). Both kMCL- and PL-reconstructed elbows exhibited significantly higher mean valgus rotation compared with the intact state between 10° and 40° of flexion (P < .01). There were no significant differences in valgus rotation at any flexion angle between the kMCL and PL graft groups. When loaded to failure, elbows reconstructed with both kMCL and PL grafts failed at similar torque values (18.6 ± 4 and 18.1 ± 3.4 N·m, respectively; P = .765). Conclusion Fresh-frozen and aseptically processed kMCL allografts demonstrated similar kinematic and failure properties to PL tendon autografts in UCL-reconstructed elbows, although neither graft fully restored kinematics between 10° and 40°. Clinical Relevance Prepared kMCL ligament allografts may provide a viable graft material when reconstructing elbow ligaments while avoiding the potential complications related to PL autografts- including donor site morbidity.
Collapse
Affiliation(s)
- Michael A. Stone
- Cedars-Sinai, Department of Orthopaedic Surgery, Los Angeles, California, USA
| | - Linda Chao
- Cedars-Sinai, Department of Orthopaedic Surgery, Los Angeles, California, USA
| | - Dave T. Huang
- Cedars-Sinai Orthopaedic Biomechanics Laboratory, Los Angeles, California, USA
| | - Harin B. Parikh
- Cedars-Sinai, Department of Orthopaedic Surgery, Los Angeles, California, USA
| | - Michael Sun
- Cedars-Sinai, Department of Orthopaedic Surgery, Los Angeles, California, USA
| | - David A. Kulber
- Cedars-Sinai, Department of Orthopaedic Surgery, Los Angeles, California, USA
| | - Melodie F. Metzger
- Cedars-Sinai, Department of Orthopaedic Surgery, Los Angeles, California, USA
- Cedars-Sinai Orthopaedic Biomechanics Laboratory, Los Angeles, California, USA
| |
Collapse
|
|
14
|
Gopinatth V, Batra AK, Khan ZA, Jackson GR, Jawanda HS, Mameri ES, McCormick JR, Knapik DM, Chahla J, Verma NN. Return to Sport After Nonoperative Management of Elbow Ulnar Collateral Ligament Injuries: A Systematic Review and Meta-analysis. Am J Sports Med 2023; 51:3858-3869. [PMID: 36876746 DOI: 10.1177/03635465221150507] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
BACKGROUND Elbow ulnar collateral ligament (UCL) injuries can result in significant functional impairment in throwing and overhead athletes. UCL reconstruction and repair are proven treatments to restore stability, but the efficacy of nonoperative management is unclear. PURPOSE To determine the rate of return to sports (RTS) and return to previous level of play (RTLP) in athletes sustaining medial elbow ulnar collateral ligament (UCL) injuries treated nonoperatively. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS A literature search was performed using Scopus, PubMed, Medline, the Cochrane Database for Systematic Review, and the Cochrane Central Register for Controlled Trials according to the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Inclusion criteria were limited to level 1 to 4 human studies reporting on RTS outcomes after nonoperative management of UCL injuries. RESULTS A total of 15 studies, consisting of 365 patients with a mean age of 20.45 ± 3.26 years, were identified. Treatment primarily consisted of platelet-rich plasma (PRP) injections with physical therapy (n = 189 patients; n = 7 studies) versus physical therapy alone (n = 176 patients; n = 8 studies). The overall RTS rate was 79.7% and the overall RTLP rate was 77.9%. Increasing UCL injury severity grade was associated with lower RTS rates. The RTS rate for proximal tears (89.7%; n = 61/68) was significantly greater than that for distal tears (41.2%; n = 14/34) (P < .0001). No significant difference in RTS rate was seen in patients treated with PRP versus those who did not receive PRP (P = .757). CONCLUSION For athletes undergoing nonoperative management of UCL injuries, the overall RTS and RTLP rates were 79.7% and 77.9%, respectively, with excellent outcomes in grade 1 and grade 2 UCL injuries, specifically. The RTS rate for proximal tears was significantly higher than that for distal tears. Athletes were most commonly treated with PRP injection and physical therapy.
Collapse
Affiliation(s)
- Varun Gopinatth
- Saint Louis University School of Medicine, St. Louis, Missouri, USA
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA
| | - Anjay K Batra
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA
| | - Zeeshan A Khan
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA
| | - Garrett R Jackson
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA
| | - Harkirat S Jawanda
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA
| | - Enzo S Mameri
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA
| | | | - Derrick M Knapik
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jorge Chahla
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA
| | - Nikhil N Verma
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA
| |
Collapse
|
|
15
|
Jackson GR, Jawanda H, Batra A, Familiari F, Khan ZA, Brusalis CM, Verma NN. Elbow Ulnar Collateral Ligament Repair With Suture Augmentation Results in Good Clinical Results, a Return-to-Play Rate Between 67% and 93%, and a Postoperative Complication Rate Up to 11.9%: A Systematic Review. Arthrosc Sports Med Rehabil 2023; 5:100761. [PMID: 37546384 PMCID: PMC10400855 DOI: 10.1016/j.asmr.2023.100761] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 06/09/2023] [Indexed: 08/08/2023] Open
Abstract
Purpose To review the Kerlan-Jobe Orthopaedic Clinic (KJOC) scores, return-to-play rates, and complications after ulnar collateral ligament (UCL) repair with suture augmentation. Methods A literature search of the PubMed and Scopus databases was conducted on February 17, 2023, using the terms "ulnar collateral ligament," "repair," "internal brace," and "suture augmentation." The search strategy was based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) protocol and included 4 articles published from 2019 to 2022. The inclusion criteria included studies reporting outcomes, return-to-play rates, and/or complications after UCL repair with suture augmentation. The exclusion criteria consisted of non-English language studies, case reports, cadaveric studies, animal studies, letters to the editor, studies with overlapping cohorts, and review articles. The risk of bias was evaluated using the Methodological Index for Non-Randomized Studies (MINORS) criteria. Results The final analysis included 4 studies with 510 patients (457 male and 53 female patients), ranging in age between 17.8 and 27.5 years, treated with repair and suture augmentation for UCL tears. In this review, we found a mean postoperative KJOC score ranging from 87.9 to 92.6. The overall rate of return to play at the preinjury level or at a higher level than the preinjury level ranged from 67% to 93%; the mean time to return to play ranged from 6.7 to 17.6 months. The postoperative complication rate in this review ranged from 0% to 11.9%. Among the complications, the most common were ulnar nerve paresthesia (range, 0%-8.2%) and postoperative medial elbow pain (range, 0%-3.1%). Overall, the reoperation rate ranged from 0% to 3.4%. No reruptures were reported. Conclusions UCL repair with the use of suture augmentation results in postoperative KJOC scores ranging from 87.9 to 92.6, a return-to-play rate between 67% and 93%, and a postoperative complication rate up to 11.9%. Level of Evidence Level IV, systematic review of Level IV studies.
Collapse
Affiliation(s)
- Garrett R. Jackson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
| | - Harkirat Jawanda
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
| | - Anjay Batra
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
| | - Filippo Familiari
- Department of Orthopaedic and Trauma Surgery, Magna Graecia University, Catanzaro, Italy
| | - Zeeshan A. Khan
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
| | - Christopher M. Brusalis
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
| | - Nikhil N. Verma
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
- Midwest Orthopaedics at Rush, Chicago, Illinois, U.S.A
| |
Collapse
|
|
16
|
Nolte PC, Vorm Walde M, Elrick BP, Grützner PA, Porschke F, Schnetzke M. High return to sport rate and good patient-reported outcomes in recreational athletes following simple elbow dislocations. J Orthop Surg Res 2023; 18:453. [PMID: 37355594 DOI: 10.1186/s13018-023-03914-2] [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: 04/15/2023] [Accepted: 06/06/2023] [Indexed: 06/26/2023] Open
Abstract
BACKGROUND The purpose of this study was to investigate outcomes and return to sport metrics in recreational athletes who suffered simple elbow dislocations and were treated operatively or nonoperatively. METHODS The study included patients between the ages of 16 and 65 who were recreational athletes and had experienced a simple elbow dislocation, with at least 2 years having passed since the injury. Patient-reported outcomes including Mayo Elbow Performance Score (MEPS), Subjective Elbow Value (SEV), Oxford Elbow Score (OES) and Visual Analog Scale (VAS) were collected. Return to sport metrics were assessed. RESULTS A total of 44 patients (21 females, mean age 43.8 years [95% CI, 39.1-48.5]) who were recreational athletes before their injury completed follow-up at mean 7.6 years (95% CI, 6.7-8.5). There were 29 patients (65.9%) who were treated operatively. Mean MEPS was 93.3 (95% CI, 90.2-96.4), mean SEV was 94.9 (95% CI, 91.9-97.9) and mean OES was 43.3 (95% CI, 41.3-45.4). A total of 36 (81.8%) patients returned to their pre-injury sport. Mean time to return to sport was 21.7 (95% CI, 16.8-26.5) weeks. There was a significant difference in OES (P = .019) and SEV (P = .030) that favored the nonoperative group; however, no significant differences for MEPS, VAS, satisfaction, arc of motion and return to sport were present between groups. A total of five (11.4%) complications were observed and one (2.3%) required revision. CONCLUSIONS Good outcomes and a high return to sport rate can be expected in recreational athletes following operative and nonoperative treatment of simple elbow dislocations. However, as many as one-in-five patients may not return to pre-injury sport.
Collapse
Affiliation(s)
- Philip-Christian Nolte
- Department for Trauma and Orthopedic Surgery, BG Klinik Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany.
| | - Melina Vorm Walde
- Department for Trauma and Orthopedic Surgery, BG Klinik Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany
| | - Bryant P Elrick
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, USA
| | - Paul-Alfred Grützner
- Department for Trauma and Orthopedic Surgery, BG Klinik Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany
| | - Felix Porschke
- Department for Trauma and Orthopedic Surgery, BG Klinik Ludwigshafen, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Germany
| | - Marc Schnetzke
- German Joint Centre, ATOS Clinic Heidelberg, Heidelberg, Germany
| |
Collapse
|
|
17
|
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).
Collapse
Affiliation(s)
| | - Eoghan T Hurley
- NYU Langone Health, New York, NY, USA; Sports Surgery Clinic, Dublin, Ireland; Duke University Medical Center, Durham, NC, USA
| | | | | | | |
Collapse
|
|
18
|
Scillia AJ, Fasulo SM, Kurowicki J, Varghese JJ, Bedford BB. Tommy John: Elbow Ulnar Collateral Ligament Allograft Reconstruction With Internal Brace. Arthrosc Tech 2023; 12:e193-e199. [PMID: 36879861 PMCID: PMC9984727 DOI: 10.1016/j.eats.2022.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 10/26/2022] [Indexed: 01/21/2023] Open
Abstract
Injuries of the medial ulnar collateral ligament (UCL) of the elbow have previously been career ending for overhead athletes, with gymnasts and baseball pitchers being highly affected. The majority of UCL injuries in this population are chronic, overuse injuries and may be amenable to surgical intervention. The original reconstruction technique, pioneered by Dr. Frank Jobe in 1974, has undergone many modifications over the years. Most notable is the modified Jobe technique developed by Dr. James R. Andrews, which has resulted high rates of return to play and increased career longevity. However, the lengthy recovery time is still problematic. As a way to address the lengthy recovery time, a UCL repair with an internal brace technique improved the time to return to play but has limited applicability to the young patient with an avulsion injury and good tissue quality. Furthermore, there is considerable variety in other published techniques including surgical approach, repair, reconstruction, and fixation. We present here a technique for a muscle splitting, ulnar collateral ligament reconstruction with allograft to provide collagen for longevity and internal brace for immediate stability, early rehabilitation, and return to play.
Collapse
Affiliation(s)
- Anthony J Scillia
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey.,Seton Hall University, South Orange, New Jersey.,Hackensack Meridian School of Medicine, Nutley, New Jersey
| | - Sydney M Fasulo
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey
| | - Jennifer Kurowicki
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey
| | - Jeffrey J Varghese
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, Paterson, New Jersey
| | - Benjamin B Bedford
- Nicholas Institute for Sports Medicine and Athletic Trauma, Lenox Hill Hospital, New York, New York, U.S.A
| |
Collapse
|
|
19
|
Huffman GR, Piper C, Gupta R, Hast MW. Similar Biomechanics Between the Double-Cortical Button and Docking Techniques for Ulnar Collateral Ligament Reconstruction: A Cadaveric Evaluation. Orthop J Sports Med 2023; 11:23259671221123342. [PMID: 36743727 PMCID: PMC9893366 DOI: 10.1177/23259671221123342] [Citation(s) in RCA: 1] [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: 05/11/2022] [Accepted: 07/05/2022] [Indexed: 01/28/2023] Open
Abstract
Background The docking technique is widely used to perform ulnar collateral ligament (UCL) reconstructions because of its high failure torque and reliable clinical outcomes. A double-cortical button technique was recently described, with advantages including the ability to tension the graft at the ulnar and humeral attachments and the creation of single bone tunnels. Purpose/Hypothesis To compare the biomechanics between the docking and double-button UCL reconstruction techniques using cadaveric specimens. We hypothesized that there would be no difference in postoperative stiffness or maximum strength between the techniques. Study Design Controlled laboratory study. Methods Eight matched pairs of cadaveric elbow joints underwent controlled humeral valgus torsion cycles in a test frame. Toe region stiffness, elastic region stiffness, and maximum torque were measured during a 4-step protocol: intact, injured, reconstructed (10 and 1000 cycles), and ramp to failure. Graft strains were calculated using 3-dimensional motion capture. Results After 10 cycles, intact ligaments from the docking and double-button groups exhibited mean ± SD elastic torsional stiffness of 1.60 ± 0.49 and 1.64 ± 0.35 N·m/deg (P = .827), while docking (1.10 ± 0.39 N·m/deg) and double-button (1.05 ± 0.29 N·m/deg) reconstructions were lower (P = .754). There were no significant differences in maximum torque between the docking (3.45 ± 1.35 N·m) and double-button (3.25 ± 1.31 N·m) groups (P = .777). Similarly, differences in maximum graft strains were not significant between the docking (8.1% ± 7.2%) and double-button (5.5% ± 3.1%) groups (P = .645). The groups demonstrated similar decreases in these measures after cyclic loading. Ramp-to-failure testing showed no significant differences in ultimate torque between the docking (8.93 ± 3.9 N·m) and double-button (9.56 ± 3.5 N·m) groups (P = .739). Conclusion The biomechanical behavior of the double-button technique was not significantly different from that of the docking technique. Both reconstruction techniques restored joint stability, but neither fully recapitulated preinjury joint stiffness. Clinical Relevance With its procedural advantages, results preliminarily support the use of the double-button reconstruction technique for UCL reconstruction as a reliable single-tunnel technique for primary or revision cases.
Collapse
Affiliation(s)
- George Russell Huffman
- Department of Orthopaedic Surgery, Penn Medicine, University of
Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christine Piper
- Department of Orthopaedic Surgery, Penn Medicine, University of
Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Richa Gupta
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic
Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael W. Hast
- McKay Orthopaedic Research Laboratory, Department of Orthopaedic
Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Michael W. Hast, PhD, McKay Orthopaedic Research Laboratory,
Department of Orthopaedic Surgery, University of Pennsylvania, 371 Stemmler
Hall, 3450 Hamilton Walk, Philadelphia, PA 19104, USA (
)
| |
Collapse
|
|
20
|
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.
Collapse
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 ()
| |
Collapse
|
|
21
|
Chen AZ, Greaves KM, Fortney TA, Saltzman BM, Trofa DP, Ahmad CS. Psychological Factors Associated With Return to Play After Ulnar Collateral Ligament Reconstruction: A Systematic Review. Orthop J Sports Med 2022; 10:23259671221125746. [PMID: 36225388 PMCID: PMC9549101 DOI: 10.1177/23259671221125746] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/25/2022] [Indexed: 11/15/2022] Open
Abstract
Background The role of psychological factors in return to play (RTP) after ulnar collateral ligament (UCL) reconstruction remains unclear. Purpose To perform a systematic review of the literature to (1) identify the specific psychological factors that affect RTP after UCL reconstruction and (2) determine the proportion of failures to RTP after UCL reconstruction because of psychological factors. Study Design Systematic review; Level of evidence, 4. Methods A systematic review of the literature following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was conducted. We queried the Cochrane Database of Systematic Reviews, Ovid/Embase, PubMed, and Web of Science databases to identify studies examining psychological factors and RTP after UCL reconstruction. Data pertaining to study characteristics and design, clinical and demographic characteristics, and psychological factors were collected. Patients were pooled across included studies, weighted means were calculated, and descriptive statistical analysis was performed. Results A total of 8 studies consisting of 378 patients were included for analysis. The mean time to RTP was 12.2 months, and the overall RTP rate was 89.4%. Psychological factors affecting RTP included loss of interest, fear of reinjury, individual personality traits, personal reasons, and psychological concerns. While clinical factors accounted for 46.2% (n = 24) of failures to RTP, psychological factors comprised 40.4% (n = 21) of the reasons for failure to RTP. The most commonly cited psychological factors affecting RTP were loss of interest (n = 15 [28.8%]) and fear of reinjury (n = 3 [5.8%]). Conclusion Psychological factors represented a substantial proportion of failures to RTP after UCL reconstruction, especially in adolescent athletes. Future prospective studies and multicenter initiatives are needed to more thoroughly evaluate the psychological concerns of patients before and after UCL reconstruction.
Collapse
Affiliation(s)
- Aaron Z. Chen
- Department of Orthopedic Surgery, Columbia University Irving Medical
Center, New York, New York, USA
| | - Kaylre M. Greaves
- Department of Orthopedic Surgery, Columbia University Irving Medical
Center, New York, New York, USA
| | - Thomas A. Fortney
- Department of Orthopedic Surgery, Columbia University Irving Medical
Center, New York, New York, USA
| | - Bryan M. Saltzman
- OrthoCarolina Sports Medicine Center, Charlotte, North Carolina,
USA.,Atrium Health Musculoskeletal Institute, Charlotte, North Carolina,
USA
| | - David P. Trofa
- Department of Orthopedic Surgery, Columbia University Irving Medical
Center, New York, New York, USA
| | - Christopher S. Ahmad
- Department of Orthopedic Surgery, Columbia University Irving Medical
Center, New York, New York, USA.,Christopher S. Ahmad, MD, Columbia University Irving Medical
Center, 622 West 168th Street, PH-11, New York, NY 10032, USA (
)
| |
Collapse
|
|
22
|
Pryhoda MK, Sabick MB. Lower body energy generation, absorption, and transfer in youth baseball pitchers. Front Sports Act Living 2022; 4:975107. [PMID: 36213448 PMCID: PMC9532595 DOI: 10.3389/fspor.2022.975107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 08/22/2022] [Indexed: 11/13/2022] Open
Abstract
An efficient baseball pitch will produce a high-velocity ball while minimizing the risk of injury to the pitcher. This study quantified ground reaction forces and lower body power during the entire pitching motion of youth baseball pitchers to investigate how developing athletes generate and transfer energy from lower limbs to the throwing arm. These data provide a foundation for comparing youth pitching strategy and mechanics to optimal throwing mechanics and may aid in developing appropriate training suggestions for this age group. Full-body three-dimensional (3D) motion capture and force platform data were collected on 23 youth pitchers performing fastballs thrown for strikes. Youth pitchers within this study used a “controlled drop” strategy in which the COM was lowered during the stride phase followed by a weak forward drive motion. Ground reaction forces (GRFs) indicate that the drive leg propels the center of mass (COM) toward the home plate while the stride leg braking force contributes to power generation up the kinetic chain. The stride hip generates energy assisting in energy flow up the kinetic chain as well as the creation of a stable base to rotate the trunk about. The lumbosacral joint generates the most energy of any joint studied, facilitating energy flow up the kinetic chain and underscoring the importance of core strength and coordination in proper pitching mechanics.
Collapse
|
|
23
|
Kemler BR, Rao S, Willier DP, Jack RA, Erickson BJ, Cohen SB, Ciccotti MG. Rehabilitation and Return to Sport Criteria Following Ulnar Collateral Ligament Reconstruction: A Systematic Review. Am J Sports Med 2022; 50:3112-3120. [PMID: 34494905 DOI: 10.1177/03635465211033994] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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 (UCLR) is a viable treatment option for patients with UCL insufficiency, especially in the overhead throwing athlete. Within the clinical literature, there is still no universally agreed upon optimal rehabilitation protocol and timing for return to sport (RTS) after UCLR. HYPOTHESIS There will be significant heterogeneity with respect to RTS criteria after UCLR. Most surgeons will utilize time-based criteria rather than functional or performance-based criteria for RTS after UCLR. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS All level 1 to 4 studies that evaluated UCLR with a minimum 1-year follow-up were eligible for inclusion. Studies lacking explicit RTS criteria, studies that treated UCL injury nonoperatively or by UCL repair, or studies reporting revision UCLR were excluded. Each study was analyzed for methodologic quality, RTS, timeline of RTS, and RTS rate. RESULTS Overall, 1346 studies were identified, 33 of which met the inclusion criteria. These included 3480 athletes across 21 different sports. All studies reported RTS rates either as overall rates or via the Conway-Jobe scale. Timelines for RTS ranged from 6.5 to 16 months. Early bracing with progressive range of motion (ROM) (93.9%), strengthening (84.8%), and participation in an interval throwing program (81.8%) were the most common parameters emphasized in these rehabilitation protocols. While all studies included at least 1 of 3 metrics for the RTS value assessment, most commonly postoperative rehabilitation (96.97%) and set timing after surgery (96.97%), no article completely defined RTS criteria after UCLR. CONCLUSION Overall, 93.9% of studies report utilizing bracing with progressive ROM, 84.8% reported strengthening, and 81.8% reported participation in an interval throwing program as rehabilitation parameters after UCLR. In addition, 96.97% reported timing after surgery as a criterion for RTS; however, there is a wide variability within the literature on the recommended time from surgery to return to activity. Future research should focus on developing a comprehensive checklist of functional and performance-based criteria for safe RTS after UCLR.
Collapse
Affiliation(s)
- Bryson R Kemler
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | - Somnath Rao
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | - Donald P Willier
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Robert A Jack
- Houston Methodist Orthopedics and Sports Medicine, Houston, Texas, USA
| | | | - Steven B Cohen
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | | |
Collapse
|
|
24
|
Solon LF, Castile RM, Smith MV, Lake SP. Mechanical properties and microstructural organization of common ulnar collateral ligament grafts: Palmaris longus and gracilis tendons. J Orthop Res 2022; 40:1865-1871. [PMID: 34786748 DOI: 10.1002/jor.25209] [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: 04/29/2021] [Revised: 10/25/2021] [Accepted: 10/30/2021] [Indexed: 02/04/2023]
Abstract
Ulnar collateral ligament (UCL) injuries are becoming increasingly common. The palmaris longus (PL) and gracilis (GR) tendons are the most common grafts used in UCL reconstructions. While clinical studies have demonstrated relatively similar outcomes for either graft, there is little quantitative data describing these grafts from a material perspective, specifically the mechanical and microstructural properties of these tissues and how they respond under dynamic loading. The purpose of this descriptive laboratory study was to quantify and compare the mechanical and microstructural properties of PL and GR tendons. A total of 13 PL and 11 GR cadaveric human tendons were obtained. Each specimen was divided into three subregions and subjected to preconditioning, ramp-and-hold stress-relaxation and ramp-to-failure testing. Mechanical parameters were computed for each sample, and a polarized light imaging technique was used to simultaneously evaluate dynamic microstructural properties during testing. The PL had larger toe- and linear-region modulus values than the GR. Within the GR, the distal subregion had stronger collagen alignment than the proximal subregion at the zero, transition and linear portions of the stress-strain curve. The PL and GR, have similar mechanical properties and similar microstructural alignment under load. The PL graft has similar properties throughout its length whereas the GR properties exhibited slight differences in strength of alignment along its length. The PL and GR exhibit larger moduli values and more strongly/uniformly aligned collagenous microstructure when qualitatively compared to data previously published on the native UCL.
Collapse
Affiliation(s)
- Lorenzo F Solon
- Department of Biology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Ryan M Castile
- Department of Mechanical Engineering and Materials Science, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Matthew V Smith
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Spencer P Lake
- Department of Mechanical Engineering and Materials Science, Washington University in St. Louis, St. Louis, Missouri, USA.,Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| |
Collapse
|
|
25
|
Looney AM, Fackler NP, Pianka MA, Bodendorfer BM, Fryar CM, Conroy CM, Israel JE, Wang DX, Ciccotti MG, Chang ES. No Difference in Complications Between Elbow Ulnar Collateral Ligament Reconstruction With the Docking and Modified Jobe Techniques: A Systematic Review and Meta-analysis. Am J Sports Med 2022; 50:2324-2338. [PMID: 34491153 DOI: 10.1177/03635465211023952] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The most commonly used techniques for elbow ulnar collateral ligament reconstruction (UCLR) are the docking and modified Jobe figure-of-8 techniques. Previous literature has suggested that UCLR with the docking technique is associated with fewer complications; however, these studies included results from the original classic Jobe technique without controlling for the effects of flexor pronator mass (FPM) detachment and routine submuscular ulnar nerve transposition (UNT). PURPOSE/HYPOTHESIS This study sought to compare the rates of complications and subsequent unplanned surgical procedures between the docking and figure-of-8 techniques. We hypothesized that there would be no significant difference in the rates of complications or subsequent unplanned surgical procedures between the techniques when the FPM was preserved and no routine submuscular UNT was performed. STUDY DESIGN Systematic review and meta-analysis; Level of evidence, 4. METHODS This study was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A series of mixed-effects multivariate metaregression models were implemented using the restricted maximum likelihood method. Complications and subsequent unplanned surgical procedures were modeled as Freeman-Tukey transformed incidence rates for variance stabilization, and nerve-specific complications were assessed as the Freeman-Tukey transformed proportion of cases, with back-transformation to estimate summary effects. RESULTS There were 19 studies eligible for qualitative analysis, consisting of 1788 cases of UCLR (303 docking, 1485 figure-of-8), 18 of which were suitable for quantitative analysis (1769 cases; 291 docking, 1478 figure-of-8). A total of 338 complications were reported (17 for docking, 321 for figure-of-8), the majority of which were nerve related. Additionally, a total of 75 subsequent unplanned surgical procedures were related to the index UCLR procedure. There was no significant difference in the rate of complications (P = .146) or proportion of cases with nerve-specific complications (P = .127) between the docking and figure-of-8 techniques when controlling for FPM preservation versus detachment with submuscular UNT. FPM detachment with submuscular UNT was independently associated with a significantly higher proportion of postoperative nerve-related complications (P = .004). There was also no significant difference in the rates of subsequent unplanned surgical procedures between the docking and figure-of-8 techniques (P = .961), although FPM detachment with routine submuscular UNT was independently associated with a significantly higher incidence of subsequent unplanned surgical procedures. CONCLUSION The results of this study demonstrate no significant difference in the rates of complications or subsequent unplanned surgical procedures between the figure-of-8 and docking techniques for UCLR when controlling for FPM preservation versus detachment with submuscular UNT. With modern muscle-sparing approaches and avoiding submuscular UNT, the modified Jobe technique does not differ significantly from the docking technique in terms of complication rates, proportions of cases with nerve-specific complications, or rates of subsequent unplanned surgical procedures.
Collapse
Affiliation(s)
- Austin M Looney
- Department of Orthopaedic Surgery, Georgetown University Hospital, Washington, DC, USA.,The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Mark A Pianka
- Georgetown University School of Medicine, Washington, DC, USA
| | | | - Caroline M Fryar
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Christine M Conroy
- Department of Orthopedics, Einstein Healthcare Network, Philadelphia, Pennsylvania, USA
| | - Jacob E Israel
- Georgetown University School of Medicine, Washington, DC, USA
| | - David X Wang
- Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Michael G Ciccotti
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Edward S Chang
- Department of Orthopedics, Inova Fairfax Hospital, Falls Church, Virginia, USA
| |
Collapse
|
|
26
|
Griffith TB, Conte S, Poulis GC, Diamond A, D'Angelo J, Camp CL. Correlation of Rehabilitation and Throwing Program Milestones With Outcomes After Ulnar Collateral Ligament Reconstruction: An Analysis of 717 Professional Baseball Pitchers. Am J Sports Med 2022; 50:1990-1996. [PMID: 35532953 DOI: 10.1177/03635465221093995] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There remains room for improvement in surgical outcomes after medial ulnar collateral ligament reconstruction (MUCLR) in professional pitchers. The role and influence of postoperative rehabilitation on the outcomes of MUCLR are unknown. There is a paucity of clinical data in the current literature comparing the success of various postsurgical rehabilitation protocols after MUCLR. PURPOSE To summarize the current rehabilitation process for professional pitchers recovering from MUCLR, evaluates what player and surgical factors correlate with outcomes, and determines whether rehabilitation timing and milestones correlate with successful outcomes. STUDY DESIGN Case series; Level of evidence, 4. METHODS 717 professional baseball pitchers who underwent MUCLR between 2010 and 2016 were identified and included in the analysis. Player characteristics evaluated included age at the time of surgery, throwing side dominance, primary pitching role (starter vs reliever), and level of play (MLB, AAA, AA, A). Surgical factors studied included date of surgery, graft type (palmaris longus autograft vs gracilis autograft), and surgical technique (figure of 8 vs docking vs other). The rehabilitation and throwing progression details were as follows: initiation date; first throw date; dates to start throwing from various distances; longest distance thrown; first flat ground throw date; first mound throw date; and first live batting practice (BP) date. The primary outcomes of interest were the ability to return to play at any level (RTP), the ability to return to the same level (RSL), and the time to RTP/RSL. RESULTS On average, pitchers threw a baseball for the first time 4.9 months after surgery, with a broad range (2.8-14.9 months). For the 675 (94%) pitchers who were able to progress to mound throwing, the first throws off a mound occurred at a mean of 9.4 months after surgery. Before progressing to the mound, the mean longest long-toss distance reached was 137.5 feet, with a broad range (105-300 feet). A high variation in the time to RTP (7.6-53.9 months) and RSL (8.6-60.7 months) was noted. A total of 599 (84%) pitchers were able to RTP at a mean time of 14.9 ± 4.9 months after surgery (range, 7.6-53.9 months). Also, 528 (74%) pitchers were able to RSL after MUCLR at a mean of 17.4 ± 7 months (range, 8.6-60.7 months) postoperatively. Age was the most significant predictor of RTP (hazard ratio [HR], 1.03 [95% CI, 1.01-1.05]; P = .01) and RSL (HR, 0.96 [95% CI, 0.93-0.99]; P < .01). For every 1-year increase in age, there was a 3% increase in the chance of RTP. Conversely, for every 1-year decrease in age, there was a 4% increase in the chance of RSL. MLB players were more likely to RTP (HR, 1.39 [95% CI, 1.18-1.63]; P < .01) but not necessarily to RSL (HR, 0.90 [95% CI, 0.75-1.08]; P = .24). The time from surgery to any of the rehabilitation milestones of interest (first throw, first flat ground pitching, first mound throwing, and first live BP) did not correlate with RTP or RSL (all, P >.05). The same was true for the greatest long-toss distance thrown before transitioning to the mound. CONCLUSION Significant variability in the postoperative rehabilitation protocols after MUCLR was observed in 717 professional baseball pitchers. The timing of achievement of throwing progression and rehabilitation milestones postoperatively varied widely but did not correlate with outcomes. Player characteristics-except for player age and professional pitching level-did not correlate with RTP and RSL outcomes. Older pitchers and MLB pitchers were more likely to RTP, but younger players were more likely to RSL. Surgical factors did not correlate with rehabilitation outcomes.
Collapse
Affiliation(s)
- Timothy B Griffith
- Peachtree Orthopedics, Department of Sports Medicine and Orthopedic Surgery, Atlanta Braves Baseball Club, Atlanta, Georgia, USA.,Head Athletic Trainer/Director of Player Health, Atlanta Braves Baseball Club, Atlanta, Georgia, USA
| | - Stan Conte
- Conte Sports Performance Therapy, Scottsdale, Arizona, USA
| | - George C Poulis
- Head Athletic Trainer/Director of Player Health, Atlanta Braves Baseball Club, Atlanta, Georgia, USA
| | - Adam Diamond
- Physical Therapist, Minnesota Twins Baseball Club, Minneapolis, Minnesota, USA
| | - John D'Angelo
- Office of the Commissioner, Major League Baseball, New York, New York, USA
| | - Christopher L Camp
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
|
27
|
Anderson MJJ, Crockatt WK, Mueller JD, Hellwinkel JE, Alexander FJ, Trofa DP, Ahmad CS. Return-to-Competition Criteria After Ulnar Collateral Ligament Reconstruction: A Systematic Review and Meta-analysis. Am J Sports Med 2022; 50:1157-1165. [PMID: 34181472 DOI: 10.1177/03635465211016839] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Injury to the ulnar collateral ligament of the elbow is common among overhead throwing athletes and can result in significant functional limitations. While surgical reconstruction offers high rates of return to competition, there are no validated or universally accepted guidelines for determining when an athlete can safely resume play. PURPOSE To assess the existing scientific literature for return-to-competition criteria utilized after ulnar collateral ligament reconstruction. STUDY DESIGN Systematic review and meta-analysis; Level of evidence, 4. METHODS The PubMed database was searched for clinical investigations of ulnar collateral ligament reconstruction in overhead throwing athletes published between January 2000 and June 2020. Only studies that had a minimum follow-up of 1 year and included at least 1 specific return-to-competition criterion were considered. RESULTS A total of 15 studies were included in the final analysis, encompassing 1156 patients with an average age of 20.7 years (SD, 2.0 years). Baseball players composed 96.3% of patients for whom sport was specified, and 92.4% of baseball players were pitchers. The most common return-to-competition criterion, identified in 87% of studies, was completion of a return-to-throwing program, which started on average 16.7 weeks (range, 12-18 weeks) after surgery. A return-to-mound program was utilized in 53% of studies, starting on average 7.4 months (range, 6-9 months) postoperatively. Minimum time from surgery was used in 73% studies, with players waiting 7 to 12 months (mean, 9.7; SD, 1.4 months) after surgery before return-to-competition consideration. The overall rate of return to competition at the preinjury level or higher was 85.7% (SD, 8.5%) at an average of 12.2 months (SD, 0.6 months). CONCLUSION In general, we observed a paucity of literature describing the return-to-competition process after ulnar collateral ligament reconstruction in overhead throwing athletes. Only 3 explicit return-to-competition criteria were identified across all studies: completion of a return-to-throwing program, completion of a return-to-mound program for pitchers, and minimum time from surgery. Increased transparency regarding postoperative rehabilitation protocols and further research are necessary to identify and validate sport-specific return-to-competition criteria, which will ultimately help athletes return to play in a safe and timely fashion after ulnar collateral ligament reconstruction.
Collapse
Affiliation(s)
- Matthew J J Anderson
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - William K Crockatt
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - John D Mueller
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Justin E Hellwinkel
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Frank J Alexander
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - David P Trofa
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Christopher S Ahmad
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York, USA
| |
Collapse
|
|
28
|
Hadley CJ, Rao S, Erickson BJ, Cohen SB, Dodson CC, Ciccotti MG, Romeo AA. Ulnar collateral ligament reconstruction in javelin throwers: an analysis of return to play rates and patient outcomes. J Shoulder Elbow Surg 2022; 31:488-494. [PMID: 34687920 DOI: 10.1016/j.jse.2021.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 09/29/2021] [Accepted: 10/06/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although results after ulnar collateral ligament reconstruction (UCLR) in baseball players have been well documented, the literature is replete regarding the outcomes after UCLR in javelin throwers. PURPOSE To report outcomes after UCLR in javelin throwers. HYPOTHESIS UCLR in javelin throwers will result in a high rate of return to play similar to that of previously published studies from athletes of other sports. METHODS All patients who were identified preoperatively as javelin throwers and underwent UCLR between 2011 and 2017 with a minimum 2-year follow-up were eligible for inclusion. Patients were assessed with the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow score, Timmerman-Andrews Elbow score, Conway-Jobe score, patient satisfaction, return to sport rate questionnaire, and the occurrence of any postoperative complications. RESULTS Eighteen patients met the inclusion criteria. Complete follow-up was available in 16 (88.9%) patients. The average age at surgery was 21.2 ± 2.0 (range, 18.6-24.9) years. At the final follow-up, the average Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow score and Timmerman-Andrews Elbow score were 77.3 (range, 18.7-98.4) and 91.8 (range, 70.0-100.0), respectively. Outcomes on the Conway-Jobe scale were as follows: excellent (n = 6; 37.5%), good (n = 4; 25%), fair (n = 6; 37.5%). Ten (62.5%) patients returned to play at an average of 12.2 ± 3.6 (range, 6.0-18.0) months after surgery. Two (12.5%) patients sustained a shoulder injury postoperatively; however, neither required surgery. CONCLUSION UCLR in javelin throwers results in good outcomes with a low rate of reinjury/reoperation. However, the return to play rate (62.5%) and good/excellent outcomes per the Conway-Jobe scale (68.8%) are lower than what has been previously reported in baseball players and javelin throwers. Further investigation regarding outcomes in javelin throwers after UCLR is warranted.
Collapse
Affiliation(s)
| | - Somnath Rao
- Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | | | | | | | | | - Anthony A Romeo
- Shoulder, Elbow, Sports Surgery, Dupage Medical Group, Downers Grove, IL, USA
| |
Collapse
|
|
29
|
Rao S, D'Amore T, Willier DP, Gawel R, Jack RA, Cohen SB, Ciccotti MG. Return-to-Play Rates and Clinical Outcomes of Baseball Players After Concomitant Ulnar Collateral Ligament Reconstruction and Selective Ulnar Nerve Transposition. Orthop J Sports Med 2021; 9:23259671211055428. [PMID: 34881339 PMCID: PMC8646197 DOI: 10.1177/23259671211055428] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 07/14/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Injury to the ulnar collateral ligament (UCL) leading to medial elbow instability and possible ulnar neuritis is common in overhead-throwing athletes. Treatment may require UCL reconstruction (UCLR) and concomitant ulnar nerve transposition (UNT) for those with preoperative ulnar neuritis. Purpose: To evaluate the return-to-play (RTP) rates, clinical outcomes, and rates of persistent ulnar neuritis after concomitant UCLR and UNT in a cohort of baseball players with confirmed preoperative ulnar neuritis. Study Design: Case series; Level of evidence, 4. Methods: Eligible patients were those who underwent concomitant UCLR and UNT at a single institution between January 2008 and June 2018 and who had a minimum of 2 years of follow-up. Additional inclusion criteria were athletes who identified as baseball players and who had a confirmed history of ulnar neuritis. Patients were contacted at a minimum of 2 years from surgery and assessed with the Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow Score, Andrew-Timmerman (A-T) Elbow Score, Mayo Elbow Performance Score (MEPS), Single Assessment Numeric Evaluation (SANE) score, and a custom RTP questionnaire. Results: Included were 22 male baseball players with a mean age of 18.9 ± 2.1 years (range, 16-25 years). The mean follow-up was 6.1 ± 2.4 years (range, 2.5-11.7 years). Preoperatively, all 22 patients reported ulnar nerve sensory symptoms, while 4 (18.2%) patients reported ulnar nerve motor symptoms. At the final follow-up, 7 (31.8%) patients reported persistent ulnar nerve sensory symptoms, while none of the patients reported persistent ulnar nerve motor symptoms. Overall, 16 (72.7%) players were able to return to competitive play at an average of 11.2 months. The mean postoperative patient-reported outcome scores for the KJOC Shoulder and Elbow Score, MEPS, A-T Elbow Score, and SANE score were 77.9 ± 20.9 (range, 14-100), 92.7 ± 12.7 (range, 45-100), 86.1 ± 17.1 (range, 30-100), and 85.5 ± 14.8 (range, 50-100), respectively. Conclusion: This study demonstrated that after concomitant UCLR and UNT for UCL insufficiency and associated ulnar neuritis, baseball players can expect reasonably high RTP rates and subjective outcomes; however, rates of persistent sensory ulnar neuritis can be as high as 30%.
Collapse
Affiliation(s)
- Somnath Rao
- Rothman Orthopaedic Institute, Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - Taylor D'Amore
- Rothman Orthopaedic Institute, Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - Donald P Willier
- Rothman Orthopaedic Institute, Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - Richard Gawel
- Rothman Orthopaedic Institute, Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - Robert A Jack
- Houston Methodist Orthopedics and Sports Medicine, Houston, Texas, USA
| | - Steven B Cohen
- Rothman Orthopaedic Institute, Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - Michael G Ciccotti
- Rothman Orthopaedic Institute, Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| |
Collapse
|
|
30
|
Trofa DP, Constant M, Crutchfield CR, Dantzker NJ, Saltzman BM, Lynch TS, Ahmad CS. Return-to-Sport Outcomes After Primary Ulnar Collateral Ligament Reconstruction With Palmaris Versus Hamstring Tendon Grafts: A Systematic Review. Orthop J Sports Med 2021; 9:23259671211055726. [PMID: 34881347 PMCID: PMC8646802 DOI: 10.1177/23259671211055726] [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: 06/29/2021] [Accepted: 08/10/2021] [Indexed: 11/15/2022] Open
Abstract
Background Ulnar collateral ligament (UCL) reconstruction is the current gold standard of treatment for overhead athletes with a symptomatic, deficient UCL of the elbow who have failed nonoperative treatment and wish to return to sport (RTS) at a high level. The palmaris longus and hamstring tendons are common graft choices, but no study has analyzed the existing literature to assess whether one graft is superior to the other. Purpose To systematically report on the outcomes of UCL reconstruction using palmaris and hamstring autografts. Study Design Systematic review; Level of evidence, 4. Methods A combination of the terms "ulnar collateral ligament," "valgus instability," "Tommy John surgery," "hamstring," and "palmaris longus" were searched in PubMed, Embase, and the Cochrane Library. RTS and return-to-same-level (RSL) rates, patient-reported outcomes, and complications were included for analysis. We used the modified Coleman Methodology Score and risk-of-bias tool for nonrandomized studies to assess the quality of the included studies. Results This review included 6 studies (combined total of 2154 elbows) that directly compared palmaris and hamstring graft use in UCL reconstruction. Follow-up ranged from 24 to 80.4 months, and the mean patient age across all studies was 21.8 years. The mean RSL across all studies and grafts was 79.0%, and the mean RTS was 84.1%, consistent with results previously reported in the literature. The mean RTS and RSL rates for the palmaris graft group were 84.6% and 82%, respectively; the hamstring graft group showed mean RTS and RSL rates of 80.8% and 80.8%. Meta-analysis revealed no significant difference in RSL between the 2 graft groups (odds ratio, 1.06; 95% CI, 0.77-1.46). The combined complication rate of the included studies was 18.2%, with failure rates ranging from 0% to 7.1%. Conclusion Results of this review indicated that both palmaris and hamstring tendon grafts are viable options for primary UCL reconstruction. Graft choice should be determined by a combination of patient and surgeon preference.
Collapse
Affiliation(s)
- David P Trofa
- Department of Orthopedics, Columbia University Irving Medical Center, New York, New York, USA
| | - Michael Constant
- Department of Orthopedics, Columbia University Irving Medical Center, New York, New York, USA
| | - Connor R Crutchfield
- Department of Orthopedics, Columbia University Irving Medical Center, New York, New York, USA
| | - Nicholas J Dantzker
- Department of Orthopedics, Columbia University Irving Medical Center, New York, New York, USA
| | - Bryan M Saltzman
- Department of Orthopedics, Columbia University Irving Medical Center, New York, New York, USA
| | - T Sean Lynch
- Department of Orthopedics, Columbia University Irving Medical Center, New York, New York, USA
| | - Christopher S Ahmad
- Department of Orthopedics, Columbia University Irving Medical Center, New York, New York, USA
| |
Collapse
|
|
31
|
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.
Collapse
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
| |
Collapse
|
|
32
|
Jack RA, Rao S, D'Amore T, Willier DP, Gallivan R, Cohen SB, Dodson CC, Ciccotti MG. Long-Term Sports Participation and Satisfaction After UCL Reconstruction in Amateur Baseball Players. Orthop J Sports Med 2021; 9:23259671211027551. [PMID: 34423061 PMCID: PMC8377318 DOI: 10.1177/23259671211027551] [Citation(s) in RCA: 5] [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: 12/29/2020] [Accepted: 02/15/2021] [Indexed: 11/17/2022] Open
Abstract
Background While the incidence of ulnar collateral ligament reconstruction (UCLR) has increased across all levels of play, few studies have investigated the long-term outcomes in nonprofessional athletes. Purpose To determine the rate of progression to higher levels of play, long-term patient-reported outcomes (PROs), and long-term patient satisfaction in nonprofessional baseball players after UCLR. Study Design Case series; Level of evidence, 4. Methods We evaluated UCLR patients who were nonprofessional baseball athletes aged <25 years at a minimum of 5 years postoperatively. Patients were assessed with the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow Score (KJOC), the Timmerman-Andrews (T-A) Elbow score, the Mayo Elbow Performance Score (MEPS), and a custom return-to-play questionnaire. Results A total of 91 baseball players met the inclusion criteria, and 67 (74%) patients were available to complete the follow-up surveys at a mean follow-up of 8.9 years (range, 5.5-13.9 years). At the time of the surgery, the mean age was 18.9 ± 1.9 years (range, 15-24 years). Return to play at any level was achieved in 57 (85%) players at a mean time of 12.6 months. Twenty-two (32.8%) of the initial cohort returned to play at the professional level. Also, 43 (79.1%) patients who initially returned to play after surgery reported not playing baseball at the final follow-up; of those patients, 12 reported their elbow as the main reason for eventual retirement. The overall KJOC, MEPS, and T-A scores were 82.8 ± 18.5 (range, 36-100), 96.7 ± 6.7 (range, 75-100), and 91.9 ± 11.4 (range, 50-100), respectively . There was an overall satisfaction score of 90.6 ± 21.5 out of 100, and 64 (95.5%) patients reported that they would undergo UCLR again. Conclusion In nonprofessional baseball players after UCLR, there was a high rate of progression to higher levels of play. Long-term PRO scores and patient satisfaction were high. The large majority of patients who underwent UCLR would undergo surgery again at long-term follow-up, regardless of career advancement.
Collapse
Affiliation(s)
- Robert A Jack
- Houston Methodist Orthopedic and Sports Medicine, Houston, Texas, USA
| | - Somnath Rao
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | - Taylor D'Amore
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | - Donald P Willier
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Robert Gallivan
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Steven B Cohen
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | | | | |
Collapse
|
|
33
|
Davey MS, Hurley ET, Gaafar M, Galbraith JG, Mullett H, Pauzenberger L. Ulnar collateral ligament reconstruction of the elbow at minimum 48-month mean follow-up demonstrates excellent clinical outcomes with low complication and revision rates: systematic review. J ISAKOS 2021; 6:290-294. [PMID: 34001506 DOI: 10.1136/jisakos-2021-000614] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 03/21/2021] [Accepted: 04/08/2021] [Indexed: 11/03/2022]
Abstract
IMPORTANCE Tears of the ulnar collateral ligament (UCL) of the elbow occur predominantly as an overuse injury, most commonly affecting throwing athletes, particularly baseball players. UCL reconstruction (UCLR) has been described as an effective treatment modality in the short term. OBJECTIVE The purpose of this study was to systematically review the evidence in the literature to ascertain the clinical outcomes, complication and revision rates in baseball players following UCLR of the elbow at a minimum of 48 months of follow-up. EVIDENCE REVIEW Two independent reviewers performed a search of the literature based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the EMBASE, PubMed and Scopus databases. Clinical studies were included if they reported outcomes of baseball players at a minimum of 48 months following UCLR. FINDINGS Our review included 8 studies including 1104 baseball players (1105 elbows) at mean 69.9 months (48-205) following UCLR. The majority of baseball players were pitchers (92.3%), with a mean age of 22.2 years (13-42). At final follow-up, the overall return to play (RTP) was 95.3%%, with 85.3% returning at pre-injury level. In addition, the mean reported Conway-Jobe score was 86.8%, the revision rate was 6.0% with postoperative neuropathy reported in 2.4% of patients. A total of 479 (43.4%) were professional baseball players, with an overall RTP rate of 97.5% and 82.3% managing to RTP at their pre-injury level. The mean number of career years following UCLR was 4.7 years (0-22). CONCLUSION AND RELEVANCE UCLR provides excellent patient-reported and clinical outcomes to patients at medium-term follow-up with low complication and revision rates. In addition, high rates of RTP at pre-injury level and career longevity were reported by baseball players following UCLR. LEVEL OF EVIDENCE Level IV; Systematic Review.
Collapse
Affiliation(s)
- Martin S Davey
- Department of Orthopaedic Surgery, Sports Surgery Clinic, Dublin, Ireland .,Department of Trauma & Orthopaedics, Galway University Hospitals, Galway, Ireland
| | - Eoghan T Hurley
- Department of Orthopaedic Surgery, Sports Surgery Clinic, Dublin, Ireland
| | - Mohamed Gaafar
- Department of Orthopaedic Surgery, Sports Surgery Clinic, Dublin, Ireland
| | - John G Galbraith
- Department of Trauma & Orthopaedics, Galway University Hospitals, Galway, Ireland
| | - Hannan Mullett
- Department of Orthopaedic Surgery, Sports Surgery Clinic, Dublin, Ireland
| | - Leo Pauzenberger
- Department of Orthopaedic Surgery, Sports Surgery Clinic, Dublin, Ireland
| |
Collapse
|
|
34
|
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.
Collapse
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
| | | | | |
Collapse
|
|
35
|
Looney AM, Wang DX, Conroy CM, Israel JE, Bodendorfer BM, Fryar CM, Pianka MA, Fackler NP, Ciccotti MG, Chang ES. Modified Jobe Versus Docking Technique for Elbow Ulnar Collateral Ligament Reconstruction: A Systematic Review and Meta-analysis of Clinical Outcomes. Am J Sports Med 2021; 49:236-248. [PMID: 32598852 DOI: 10.1177/0363546520921160] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The modified Jobe and docking techniques are the most common techniques used for elbow ulnar collateral ligament (UCL) reconstruction. Previous systematic reviews have suggested that the docking technique results in superior outcomes as compared with the Jobe (figure-of-8) technique. However, these included results from earlier studies in which the flexor-pronator mass (FPM) was detached and an obligatory submuscular ulnar nerve transposition was performed. PURPOSE/HYPOTHESIS The purpose was to compare the outcomes and return-to-play (RTP) time between the docking and figure-of-8 techniques for UCL reconstruction. We hypothesized that there would be no significant difference in the proportion of excellent outcomes between techniques when the FPM was preserved and no obligatory submuscular ulnar nerve transposition was performed. We also hypothesized that there would be no significant difference in RTP time between techniques. STUDY DESIGN Systematic review and meta-analysis. METHODS This study was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. In the primary analysis, techniques were compared in random effects models by using the restricted maximum likelihood method, with weighted effect sizes calculated as the Freeman-Tukey double-arcsine transformed proportion of excellent outcomes for variance stabilization and with summary effects estimated from the inverse double-arcsine transformation per the harmonic mean of the sample sizes. Mean RTP times for techniques were compared in a separate model. RESULTS There were 21 eligible articles identified, with results for 1842 UCL reconstructions (n = 320, docking; n = 1466, figure-of-8). Without controlling for the effects of flexor-pronator detachment and submuscular ulnar nerve transposition, a significantly larger proportion of excellent outcomes was observed with docking reconstruction (86.58%; 95% CI, 80.42%-91.85%) than with figure-of-8 reconstruction (76.76%; 95% CI, 69.65%-83.25%; P = .031); however, there was no significant difference between techniques when controlling for FPM preservation or detachment with submuscular nerve transposition (P = .139). There was no significant difference between techniques in time to return to sports (P = .729), although no reconstructions with FPM detachment and submuscular ulnar nerve transposition were available for RTP time analysis. CONCLUSION There was no significant difference in the proportion of excellent Conway Scale outcomes or RTP time between the docking and modified Jobe techniques for UCL reconstruction when the FPM was preserved and routine submuscular ulnar nerve transposition was not performed.
Collapse
Affiliation(s)
- Austin M Looney
- Department of Orthopaedic Surgery, Georgetown University Hospital, Washington, DC, USA
| | - David X Wang
- Department of Orthopaedic Surgery, Georgetown University Hospital, Washington, DC, USA
| | - Christine M Conroy
- Department of Orthopaedic Surgery, Georgetown University Hospital, Washington, DC, USA
| | - Jake E Israel
- Department of Orthopaedic Surgery, Georgetown University Hospital, Washington, DC, USA
| | - Blake M Bodendorfer
- Department of Orthopaedic Surgery, Georgetown University Hospital, Washington, DC, USA
| | - Caroline M Fryar
- Department of Orthopaedic Surgery, Fairfax Inova Hospital, Falls Church, Virginia, USA
| | - Mark A Pianka
- Department of Orthopaedic Surgery, Georgetown University Hospital, Washington, DC, USA
| | - Nathan P Fackler
- Department of Orthopaedic Surgery, Georgetown University Hospital, Washington, DC, USA
| | - Michael G Ciccotti
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Edward S Chang
- Department of Orthopaedic Surgery, Fairfax Inova Hospital, Falls Church, Virginia, USA
| |
Collapse
|
|
36
|
Glogovac G, Kakazu R, Aretakis AC, Grawe BM. Return to Sport and Sports-Specific Outcomes Following Ulnar Collateral Ligament Reconstruction in Adolescent Athletes: A Systematic Review. HSS J 2020; 16:242-249. [PMID: 33088238 PMCID: PMC7534884 DOI: 10.1007/s11420-019-09689-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 04/18/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND The incidence of elbow injuries and ulnar collateral ligament (UCL) reconstruction in adolescent athletes is increasing. Knowledge and expectations of outcomes following this procedure are necessary for proper counseling and decision-making in this age group. QUESTIONS/PURPOSES We sought to report patient-reported outcomes, rate of return to sport, and rate of complications and reoperation following UCL reconstruction in adolescent athletes. METHODS A systematic review was conducted for adolescent athletes undergoing UCL reconstruction. The primary outcome measure was patient-reported outcome scores, specifically the Conway Scale, the Andrews-Timmerman score, and the Kerlan-Jobe Orthopaedic Clinic (KJOC) score. Secondary outcome measures included return to sport, rate of subsequent procedures, and complication rate. A descriptive analysis was performed. RESULTS Seven studies met the inclusion criteria. The average patient-reported outcome scores ranged from 81 to 87% (Conway, "excellent"), 83.6 to 92.7 (Andrews-Timmerman), and 76 to 89.3 (KJOC). The average rates of return to sport were 84% to preinjury level or higher, 93% to any level, and 57% to a higher level. Complication rates ranged from 0.7 to 11%. Rate of subsequent elbow procedures ranged from 0 to 10%. CONCLUSIONS This systematic review demonstrates favorable outcomes in adolescent athletes following UCL reconstruction. Patient-reported outcome scores and rates of return to sport were comparable with those reported in adult athletes. The procedure is not without risk of complications, and patients and parents should be counseled regarding this risk prior to surgery.
Collapse
Affiliation(s)
- Georgina Glogovac
- Department of Orthopaedics and Sports Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45267 USA
| | - Rafael Kakazu
- Department of Orthopaedics and Sports Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45267 USA
| | - Alexander Constantine Aretakis
- Department of Orthopaedics and Sports Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45267 USA
| | - Brian M. Grawe
- Department of Orthopaedics and Sports Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45267 USA
| |
Collapse
|
|
37
|
Bachmaier S, Wijdicks CA, Verma NN, Higgins LD, Greiner S. Biomechanical Functional Elbow Restoration of Acute Ulnar Collateral Ligament Tears: The Role of Internal Bracing on Gap Formation and Repair Stabilization. Am J Sports Med 2020; 48:1884-1892. [PMID: 32453667 DOI: 10.1177/0363546520921174] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Biomechanical studies have compared augmented primary repair with internal bracing versus reconstruction techniques of the anterior ulnar collateral ligament (aUCL) in the elbow. However, aUCL repair alone has not been compared with augmented repair or reconstruction techniques. HYPOTHESIS Internal bracing of aUCL repair provides improved time-zero stabilization in terms of gap formation, torsional stiffness, and residual torque compared with both repair alone and the modified docking technique, with enhanced valgus stability restoration to that of the native ligament. STUDY DESIGN Controlled laboratory study. METHODS We randomized 8 matched pairs of cadaveric elbows to undergo either augmented aUCL repair or a modified docking technique through use of the palmaris longus tendon. Valgus laxity testing was consecutively performed at 90° of flexion on the intact, torn, and repaired conditions as well as the previously assigned techniques. First, intact elbows were loaded up to 10 N·m valgus torque to evaluate time-zero ligament rotations at valgus moments of 2.5, 5.0, 7.5, and 10 N·m. Rotation controlled cycling was performed (total 1000 cycles) for each surgical condition. Gap formation, stiffness, and residual torque were analyzed. Finally, these elbows and 8 additional intact elbows underwent torque to failure testing (30 deg/min). RESULTS Repair alone revealed low torsional resistance and gapping, similar to the torn state. The augmented repair technique showed significantly higher torsional stiffness (P < .001) and residual torque (P < .001) compared with all other conditions and restored native function. Although reconstruction revealed similar initial stiffness and residual torque compared with an intact ligament, a steady decrease of torsional resistance led to a completely loose state at higher valgus rotations. Analysis of covariance between all groups showed significantly less gap formation for augmented repair (P < .001). The native failure load and stiffness were significantly higher and were similar to those of augmented repair (P = .766). CONCLUSION Internal bracing of aUCL repair restored valgus stability to the native state with statistically improved torsional resistance, loading capability, and gap formation compared with reconstruction, especially at the upper load range of native aUCL function in the elbow. CLINICAL RELEVANCE We found that aUCL repair with an internal brace effectively improves time-zero mechanical characteristics and may provide stabilized healing with accelerated and reliable recovery without the need for a tendon graft.
Collapse
|
|
38
|
Lawton CD, Lamplot JD, Wright-Chisem JI, James EW, Camp CL, Dines JS. State of the Union on Ulnar Collateral Ligament Reconstruction in 2020: Indications, Techniques, and Outcomes. Curr Rev Musculoskelet Med 2020; 13:338-348. [PMID: 32323247 PMCID: PMC7251011 DOI: 10.1007/s12178-020-09621-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW There has been a marked increase in the number of ulnar collateral ligament reconstructions performed annually and an associated increase in the amount of recent literature published. It is paramount that surgeons remain up to date on the current literature, as modern indications and surgical techniques continue to improve clinical outcomes. RECENT FINDINGS Our understanding of ulnar collateral ligament (UCL) injuries, treatment indications, and surgical techniques for UCL reconstruction continues to evolve. Despite the rapidly increasing amount of published literature on the topic, a clear and concise surgical algorithm is lacking. Studies have suggested a trend towards improved clinical outcomes and decreased complications with various modifications in UCL reconstruction techniques. Current sport-specific outcome studies have reported conflicting results regarding the effect of UCL reconstruction on an athlete's performance upon returning to sport. With the rising incidence of UCL reconstruction and growing media attention, UCL injuries, reconstruction techniques, and return to sport following UCL surgery are timely topics of interest to clinicians and overhead throwing athletes. Several technique modifications have been reported, and these modifications may lead to improved outcomes and lower complication rates. Studies assessing sport-specific outcome measures will be necessary to provide a more critical and informative analysis of outcomes following UCL reconstruction.
Collapse
Affiliation(s)
- Cort D Lawton
- Sports Medicine and Shoulder Service, Sports Medicine Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
| | - Joseph D Lamplot
- Sports Medicine and Shoulder Service, Sports Medicine Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Joshua I Wright-Chisem
- Sports Medicine and Shoulder Service, Sports Medicine Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Evan W James
- Sports Medicine and Shoulder Service, Sports Medicine Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Christopher L Camp
- Division of Sports Medicine, Department of Orthopedics, Mayo Clinic, Rochester, MN, USA
| | - Joshua S Dines
- Sports Medicine and Shoulder Service, Sports Medicine Institute, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| |
Collapse
|
|
39
|
Abstract
Ulnar collateral ligament (UCL) injuries can significantly impair the overhead athlete. Reconstruction of the anterior bundle of the UCL (UCL-R) has allowed a high proportion of these individuals to return to their previous level of play. Several techniques for UCL-R are described that produce acceptable results with an overall low complication rate. Transient ulnar neuritis is the most common complication following UCL-R. The rate of UCL injury in young athletes is rising with increased youth involvement and year-round participation in overhead sports. The sports medicine community must broaden its focus to not only treat UCL injuries but also prevent them.
Collapse
Affiliation(s)
- Edward Lyle Cain
- Andrews Sports Medicine and Orthopaedic Center, American Sports Medicine Institute, 805 St. Vincent's Drive, Suite 100, Birmingham, AL 35205, USA.
| | - Mims G Ochsner
- Andrews Sports Medicine and Orthopaedic Center, American Sports Medicine Institute, 805 St. Vincent's Drive, Suite 100, Birmingham, AL 35205, USA
| |
Collapse
|
|
40
|
Swindell HW, Trofa DP, Confino J, Sonnenfeld JJ, Alexander FJ, Ahmad CS. Performance in Collegiate-Level Baseball Players After Elbow Ulnar Collateral Ligament Reconstruction. Orthop J Sports Med 2020; 8:2325967120913013. [PMID: 32341930 PMCID: PMC7168778 DOI: 10.1177/2325967120913013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 12/23/2019] [Indexed: 01/25/2023] Open
Abstract
Background: The increase in ulnar collateral ligament (UCL) elbow reconstructions over the past 20 years has affected younger athletes more than any other age group. Although return to play and postoperative performance have been extensively studied in professional baseball players, outcomes in collegiate baseball players are less known. Purpose/Hypothesis: The purpose of this study was to characterize return to play and changes in performance after UCL reconstruction (UCLR) in collegiate baseball players. We hypothesized that collegiate baseball players would have similar return-to-play rates compared with professional athletes and no significant differences in performance compared with matched controls. Study Design: Cohort study; Level of evidence, 3. Methods: Collegiate athletes undergoing UCLR by a single surgeon were identified. Postoperatively, individual collegiate career paths were analyzed through use of publicly available data from team websites, injury reports, and press releases. Data obtained included time to return to competition, number of collegiate seasons played after surgery, total games started and played, seasonal wins, losses, saves, innings played, hits, earned run average (ERA), home runs, shutouts, strikeouts, walks, and walks plus hit per inning pitched (WHIP). The UCLR group was compared with a matched control group of collegiate pitchers without elbow injury. Results: Of the 58 collegiate baseball players analyzed (mean ± SD age, 19.95 ± 1.19 years), 84.5% returned to play at the collegiate level. Players returned to competition at 16.98 ± 6.16 months postoperatively and competed for 1.60 ± 0.84 seasons postoperatively. In terms of career longevity, 81.0% of collegiate pitchers either completed their collegiate eligibility or remained on active rosters, and 2 players (4.1%) ultimately played at the professional level after UCLR. Compared with a matched cohort, the UCLR group had no significant differences in collegiate pitching performance statistics after surgery. Conclusion: College baseball players returned to play at a rate comparable with the rate published in prior literature on professional pitchers and often completed their collegiate playing eligibility postoperatively. Compared with controls, the UCLR group had no statistically significant differences in pitching performance postoperatively. Further studies are needed to determine the exact reasons why college players retire despite having endured extensive surgical and postoperative rehabilitation processes related to UCLR. Younger populations are experiencing elbow injuries at an increasing rate secondary to increased workloads at the amateur level. As these athletes matriculate into the collegiate ranks, they are at continued risk of sustaining UCL injury, and little explicit information is available on their prospects of return to play and career longevity after UCLR.
Collapse
Affiliation(s)
- Hasani W Swindell
- Department of Orthopedics, Columbia University Medical Center, New York, New York, USA
| | - David P Trofa
- Department of Orthopedics, Columbia University Medical Center, New York, New York, USA
| | - Jamie Confino
- Department of Orthopedics, Columbia University Medical Center, New York, New York, USA
| | - Julian J Sonnenfeld
- Department of Orthopedics, Columbia University Medical Center, New York, New York, USA
| | - Frank J Alexander
- Department of Orthopedics, Columbia University Medical Center, New York, New York, USA
| | - Christopher S Ahmad
- Department of Orthopedics, Columbia University Medical Center, New York, New York, USA
| |
Collapse
|
|
41
|
Mehta MP, Tjong VK, Peterson JG, Christian RA, Gryzlo SM. A qualitative assessment of return to sport following ulnar collateral ligament reconstruction in baseball players. J Orthop 2020; 21:258-264. [PMID: 32322138 DOI: 10.1016/j.jor.2020.03.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 03/26/2020] [Indexed: 01/26/2023] Open
Abstract
Background The rate of ulnar collateral ligament (UCL) reconstruction has been increasing at all levels of play. With excellent outcomes, primary UCL reconstruction has allowed many overhead athletes to return to their pre-injury sport. However, the subjective factors influencing this decision to return to sport have yet to be studied. The aim of this study is to understand the factors influencing an athlete's decision to return to pre-injury level of sport after primary UCL reconstruction. Methods An experienced interviewer conducted qualitative, semi-structured interviews of patients aged 18-35 years who had undergone primary UCL reconstruction by one fellowship-trained, Major League Baseball (MLB) team orthopaedic surgeon. All subjects were throwing athletes prior to injury and had a minimum two-year follow-up without revisions. Qualitative analysis was then performed to derive codes, categories, and themes. Patients were surveyed to assess familiarity with UCL reconstruction as well as to obtain Kerlan-Jobe Orthopaedic Clinic (KJOC) Overhead Athlete Shoulder and Elbow score, American Shoulder and Elbow Surgeons Shoulder (ASES) score, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) highlighting current activity and function levels along with sport participation. Results Twenty-two athletes were interviewed to elucidate four predominant themes influencing their return to sport: trust in surgeon and care team, innate drive and optimism, misconceptions regarding post-operative athletic ability, and life priorities. A significant difference was noted between patients that returned and those that did not in the KJOC survey and for the statement that UCL reconstruction surgery would improve throwing ability relative to patients' peak performance three years prior to the surgery. Athletes who did not return to sport cited lifestyle changes and age as limiting factors. Conclusion Patients' decision to return to their pre-injury level of sport after primary UCL reconstruction was based on trust in their care team's reputation, intrinsic personality traits, anecdotal evidence about post-operative outcomes, and lifestyle. This study emphasizes the importance for health care providers to educate patients toward realistic expectations upon return to sport. On a larger scale, this study illustrates the effects the media and anecdotal experiences of a growing population of players undergoing UCL reconstruction have had on the game of baseball and players' decisions to return to sport. Level of evidence Level IV.
Collapse
Affiliation(s)
- Mitesh P Mehta
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, 676 North St. Clair Street, Suite 1350, Chicago, IL, 60611, USA
| | - Vehniah K Tjong
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, 676 North St. Clair Street, Suite 1350, Chicago, IL, 60611, USA
| | - Joshua G Peterson
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, 676 North St. Clair Street, Suite 1350, Chicago, IL, 60611, USA
| | - Robert A Christian
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, 676 North St. Clair Street, Suite 1350, Chicago, IL, 60611, USA
| | - Stephen M Gryzlo
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, 676 North St. Clair Street, Suite 1350, Chicago, IL, 60611, USA
| |
Collapse
|
|
42
|
Jang SH. Management of Ulnar Collateral Ligament Injuries in Overhead Athletes. Clin Shoulder Elb 2019; 22:235-240. [PMID: 33330225 PMCID: PMC7714305 DOI: 10.5397/cise.2019.22.4.235] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 10/16/2019] [Accepted: 10/22/2019] [Indexed: 11/25/2022] Open
Abstract
Ulnar collateral ligament injuries of the elbow are frequent among overhead athletes. The incidence of ulnar collateral ligament reconstructions (UCLRs) in high-level players has increased dramatically over the past decade, but the optimal technique of UCLR is controversial. Surgeons need to manage the patients’ expectations appropriately when considering the mode of treatment. This article reviews current studies on the management of ulnar collateral ligament injuries, particularly in overhead athletes.
Collapse
Affiliation(s)
- Suk-Hwan Jang
- Department of Orthopedic Surgery, Sports Medicine Research Institute, Inje University Seoul Paik Hospital, Seoul, Korea
| |
Collapse
|
|
43
|
The Mini-open Plication of Medial Collateral Ligament of the Elbow: A New Arthroscopically Assisted Technique. TECHNIQUES IN SHOULDER AND ELBOW SURGERY 2019. [DOI: 10.1097/bte.0000000000000176] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
|
|
44
|
Dutton PH, Banffy MB, Nelson TJ, Metzger MF. Anatomic and Biomechanical Evaluation of Ulnar Tunnel Position in Medial Ulnar Collateral Ligament Reconstruction. Am J Sports Med 2019; 47:3491-3497. [PMID: 31647881 DOI: 10.1177/0363546519880182] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although numerous techniques of reconstruction of the medial ulnar collateral ligament (mUCL) have been described, limited evidence exists on the biomechanical implication of changing the ulnar tunnel position despite the fact that more recent literature has clarified that the ulnar footprint extends more distally than was appreciated in the past. PURPOSE To evaluate the size and location of the native ulnar footprint and assess valgus stability of the medial elbow after UCL reconstruction at 3 ulnar tunnel locations. STUDY DESIGN Controlled laboratory study. METHODS Eighteen fresh-frozen cadaveric elbows were dissected to expose the mUCL. The anatomic footprint of the ulnar attachment of the mUCL was measured with a digitizing probe. The area of the ulnar footprint and midpoint relative to the joint line were determined. Medial elbow stability was tested with the mUCL in an intact, deficient, and reconstructed state after the docking technique, with ulnar tunnels placed at 5, 10, or 15 mm from the ulnotrochlear joint line. A 3-N·m valgus torque was applied to the elbow, and valgus rotation of the ulna was recorded via motion-tracking cameras as the elbow was cycled through a full range of motion. After kinematic testing, specimens were loaded to failure at 70° of elbow flexion. RESULTS The mean ± SD length of the mUCL ulnar footprint was 27.4 ± 3.3 mm. The midpoint of the anatomic footprint was located between the 10- and 15-mm tunnels across all specimens at a mean 13.6 mm from the joint line. Sectioning of the mUCL increased elbow valgus rotation throughout all flexion angles and was statistically significant from 30° to 100° of flexion as compared with the intact elbow (P < .05). mUCL reconstruction at all 3 tunnel locations restored stability to near intact levels with no significant differences among the 3 ulnar tunnel locations at any flexion angle. CONCLUSION Positioning the ulnar graft fixation site up to 15 mm from the ulnotrochlear joint line does not significantly increase valgus rotation in the elbow. CLINICAL RELEVANCE A more distal ulnar tunnel may be a viable option to accommodate individual variation in morphology of the proximal ulna or in a revision setting.
Collapse
Affiliation(s)
- Pascual H Dutton
- Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, California, USA
| | - Michael B Banffy
- Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, California, USA
| | - Trevor J Nelson
- Orthopaedic Biomechanics Laboratory, Cedars-Sinai Medical Center, Los Angeles, California, USA.,Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Melodie F Metzger
- Orthopaedic Biomechanics Laboratory, Cedars-Sinai Medical Center, Los Angeles, California, USA.,Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| |
Collapse
|
|
45
|
Griffith TB, Duralde XA. Successful Performance After Ulnar Collateral Ligament Reconstruction: An Analysis of 88 Drafted Professional Baseball Pitchers With a Matched Comparison Cohort. Orthop J Sports Med 2019; 7:2325967119880820. [PMID: 31763341 PMCID: PMC6851609 DOI: 10.1177/2325967119880820] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background: Analysis of pitchers entering the Major League Baseball (MLB) draft after
ulnar collateral ligament reconstruction (UCLR) is challenging for team
physicians. Purpose: (1) To define the characteristics of pitchers drafted after UCLR associated
with placement in AAA and MLB professional levels and completion of a career
of at least 3 years, (2) to define characteristics placing pitchers at risk
for reinjury after surgery, (3) to compare the professional-level placement
and career duration of the UCLR cohort with a matched control group, and (4)
to evaluate the accuracy of team physician predraft risk assessments to
predict elbow reinjury in pitchers with a history of UCLR. Study Design: Cohort study; Level of evidence, 3. Methods: We analyzed pitchers from a single professional baseball team database who
were drafted after UCLR from 2010 to 2013. A matched control group based on
position and draft year was selected with the MLB database. The following
pitcher characteristics were analyzed: age at the time of UCLR, time from
UCLR to the MLB draft, pitching role (starter vs reliever), highest level of
play attained, body mass index (BMI), throwing-side dominance, and predraft
physician risk assessment. Physician assessments to predict risk for elbow
reinjury were derived from operative and clinical history and evaluated for
accuracy during the follow-up period. Pitcher characteristics were evaluated
for correlation with successful AAA or MLB placement with a career duration
of at least 3 years and as risk factors for elbow reinjury. The
professional-level achievement and career duration of the UCLR cohort were
compared with the matched cohort. Results: A total of 88 pitchers matched the selection criteria and had at least 5
years of follow-up (range, 5-8 years). Pitcher age at the time of UCLR
(P = .55), throwing-side dominance (P
= .41), and BMI (P = .86) did not correlate with AAA- or
MLB-level placement. Relief pitchers (P = .03) and pitchers
with a longer time from surgery to final follow-up (P =
.02) were more likely to reach the AAA or MLB level. Similarly, pitcher age
at the time of UCLR (P = .56), throwing-side dominance
(P = .27), and BMI (P = .69) did not
correlate with a duration of play of at least 3 years. Relief pitchers
(P = .03) and pitchers with a longer time from UCLR to
the final follow-up (P = .005) were more likely to achieve
at least 3 years of play. There was no difference in AAA or MLB placement
between the UCLR and matched cohorts (P = .22). The UCLR
cohort achieved a higher duration of play than the matched cohort
(P = .002). Pitchers with a BMI >25 kg/m2
had a lower risk of elbow reinjury versus players with a BMI ≤25
kg/m2 (P = .012). Patient age at time of
UCLR (P = .92), time from UCLR to the MLB draft
(P = .18), pitching role (P = .74),
and throwing-side dominance (P = .77) did not correlate
with elbow reinjury. Physician risk assessment did not accurately predict
reinjury (P = .27). Of the 88 patients, 4 (4.5%) required
revision UCLR. Conclusion: Pitcher age at the time of UCLR, throwing-side dominance, and BMI did not
correlate with performance. Relief pitchers and players with a longer time
from surgery to final follow-up were more likely to reach AAA and MLB levels
and achieve at least a 3-year duration of play. Pitchers with a greater BMI
had a lower risk of reinjury. After UCLR, pitchers were able to perform at
least as well as the matched nonsurgical cohort. Physician risk assessment
at the time of the draft was not accurate at predicting reinjury.
Collapse
|
|
46
|
Glogovac G, Grawe BM. Outcomes With a Focus on Return to Play for Revision Ulnar Collateral Ligament Surgery Among Elite-Level Baseball Players: A Systematic Review. Am J Sports Med 2019; 47:2759-2763. [PMID: 30597124 DOI: 10.1177/0363546518816960] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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 commonly performed among overhead throwing athletes. Previous studies demonstrated relatively high rates of return to sport after primary reconstruction. Outcomes after revision UCL reconstruction have not been widely studied. PURPOSE To report the rate of return to sport after revision UCL reconstruction among elite-level baseball players. STUDY DESIGN Systematic review. METHODS A systematic review of the literature following the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines was performed for high-level baseball players undergoing revision UCL reconstruction. Study bias was assessed with the Methodological Index for Non-Randomized Studies scoring system. The primary outcome measure was whether the study participants were able to return to sport after revision UCL reconstruction. Secondary outcome measures included career length after revision and pitching performance statistics. Data were summarized with ranges, tables, and weighted averages. A subjective analysis was performed. RESULTS A total of 5 studies met inclusion criteria. The rate of return to sport at preinjury level was 62.8%. Among Major League Baseball pitchers, the rate of return to sport at the preinjury level was 68.8%. The rate of return to sport at the same level or lower (Major League Baseball, minor league, collegiate) was 78.1%. Time to return to sport ranged from 1.3 to 1.7 years. Mean earned run average after revision ranged from 4.87 to 5.04. Mean number of innings pitched per season after revision ranged from 36.95 to 50.5. CONCLUSION This systematic review demonstrated a limited rate of return to preinjury level of sport among elite-level baseball players who underwent revision UCL reconstruction. Pitching durability and career longevity were inferior to results that were reported for players who underwent primary UCL reconstruction alone. This study suggests that outcomes after revision UCL reconstruction are not reliable and elite-level players should be counseled accordingly.
Collapse
Affiliation(s)
- Georgina Glogovac
- Department of Orthopaedics and Sports Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Brian M Grawe
- Department of Orthopaedics and Sports Medicine, University of Cincinnati, Cincinnati, OH, USA
| |
Collapse
|
|
47
|
Hooper PO, Warren J, Silko C, Frangiamore SJ, King D, Farrow LD, Schickendantz MS. Establishing Safe Extra-articular Parameters for Cortical Button Distal Fixation During Ulnar Collateral Ligament Reconstruction. Am J Sports Med 2019; 47:2699-2703. [PMID: 31386563 DOI: 10.1177/0363546519864718] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A variety of methods exist for fixation during ulnar collateral ligament (UCL) reconstruction on the ulna for the overhead throwing athlete. Current biomechanical evidence suggests that cortical button fixation may fail at a higher load and under more cycles than interference screw fixation alone, while also minimizing the risk of fracture. A safe angle for placement of this cortical button has not yet been determined. PURPOSE To define a safe angle for cortical button deployment during UCL reconstruction to avoid violation of the proximal radioulnar joint (PRUJ). STUDY DESIGN Descriptive laboratory study. METHODS Measurements on 100 cadaveric ulna bones, 50 women and 50 men, were obtained referencing the entry point for ulnar fixation, which is 1 cm distal to the ulnar humeral joint line along the medial UCL ridge. Ulnar width at the entry point and distance to the PRUJ were obtained to calculate safe distal angulation, while distance from the entry point to the posterior ulnar crest ulnarly and distance from the PRUJ to the posterior ulnar crest radially were obtained to calculate safe posterior angulation. Ten bony measurements on the same group of specimens were performed by 3 authors to establish an interobserver reliability. Means, quartiles, and outliers were obtained for the calculated angles. Finally, recommended angles of entry were determined to be approximately 1 interquartile range above the upper limit. RESULTS The mean distal angle of entry that was obtained was 11.32° (SD, ±4.80°; 95% CI, 10.37°-12.27°; P < .001). Three upper limit outliers were discovered: 24.20°, 23.4°, and 21.1°. The mean posterior angle of entry was 40.44° (SD, ±6.18°; 95% CI, 39.22°-41.67°; P < .001). There were no outliers for the posterior angle of entry. Interobserver reliabilities were strong for the 4 measurements. CONCLUSION To be safely outside of the PRUJ utilizing a cortical button construct, we recommend 30° distal angulation and 60° posterior angulation for ulnar fixation during UCL reconstruction. Both parameters are 1 quartile above the highest calculated angle of entry. CLINICAL RELEVANCE These data define safe parameters for distal fixation during UCL reconstruction and highlight a clear entry point for reference.
Collapse
Affiliation(s)
- Perry O Hooper
- Cleveland Clinic Sports Health, Garfield Heighs, Ohio, USA
| | - Jared Warren
- Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Christopher Silko
- Cleveland Clinic South Pointe Hospital, Warrensville Heights, Ohio, USA
| | | | - Dominic King
- Cleveland Clinic Sports Health, Garfield Heighs, Ohio, USA
| | - Lutul D Farrow
- Cleveland Clinic Sports Health, Garfield Heighs, Ohio, USA
| | | |
Collapse
|
|
48
|
Fleisig GS, Diffendaffer AZ, Drogosz M, Cain EL, Emblom BA, Dugas JR. Baseball Pitching Biomechanics Shortly After Ulnar Collateral Ligament Repair. Orthop J Sports Med 2019; 7:2325967119866199. [PMID: 31489335 PMCID: PMC6712754 DOI: 10.1177/2325967119866199] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: The probability of returning to competition for injured baseball pitchers is similar after ulnar collateral ligament (UCL) repair as after UCL reconstruction, but the time to return is significantly quicker after UCL repair. Previous research has found no differences in pitching biomechanics between pitchers with and without a history of UCL reconstruction, but pitching biomechanics after UCL repair has not been studied. Hypothesis: There will be significant differences in pitching biomechanics between pitchers returning to play after UCL repair and pitchers with no injury history. Study Design: Controlled laboratory study. Methods: A total of 33 pitchers were tested shortly after UCL repair (9.8 ± 2.6 months) and compared with a matched group of 33 uninjured pitchers. Each group comprised 14 college pitchers and 19 high school pitchers. Shoulder and elbow passive ranges of motion were measured. The biomechanics of 10 fastballs was then collected using a 12-camera automated motion capture system. Ball velocity was measured using a separate 3-camera optical tracking system. Data were compared between the UCL repair group and the control group using the Student t test (significance set at P < .05). Results: There were no differences in passive range of motion or fastball velocity between the 2 groups. There were no differences in joint kinetics during pitching, but 3 kinematic variables showed significant differences. Specifically, the UCL repair group produced less elbow extension (flexion: 27° ± 6° vs 24° ± 4°, respectively; P = .03), less elbow extension velocity (2442 ± 367 vs 2631 ± 292 deg/s, respectively; P = .02), and less shoulder internal rotation velocity (6273 ± 1093 vs 6771 ± 914 deg/s, respectively; P = .049 ) compared with the control group. Conclusion: Elbow extension, elbow velocity, and shoulder velocity differed between pitchers with a recent history of UCL repair and a matched control group, but it is unclear whether this has clinical significance, as there were no differences in ball velocity and passive range of motion. Furthermore, it is unknown whether these few differences in pitching biomechanics resolve with time. Clinical Relevance: Elbow and shoulder kinematics during pitching might not be completely regained within the first year after UCL repair, although passive range of motion and pitch velocity show no difference in comparison to other healthy pitchers.
Collapse
Affiliation(s)
- Glenn S Fleisig
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Alek Z Diffendaffer
- Investigation performed at the American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Monika Drogosz
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - E Lyle Cain
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Benton A Emblom
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Jeffrey R Dugas
- American Sports Medicine Institute, Birmingham, Alabama, USA
| |
Collapse
|
|
49
|
Return to Play Following Nonoperative Treatment of Partial Ulnar Collateral Ligament Injuries in Professional Baseball Players: A Critically Appraised Topic. J Sport Rehabil 2019; 28:660-664. [PMID: 30040021 DOI: 10.1123/jsr.2018-0110] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 05/21/2018] [Accepted: 06/10/2018] [Indexed: 11/18/2022]
Abstract
Clinical Scenario: Ulnar collateral ligament (UCL) injuries are highly prevalent in professional baseball players with the success of operative management being well known in the literature. Return to play (RTP) rates following nonoperative management of partial UCL injuries in professional baseball players are not well established in the literature. With a UCL tear being a potential career-ending injury, it is imperative that the best treatment option is provided to these throwing athletes. There is an increase in the incidence of UCL surgical rates and a lack of general agreement on nonoperative treatment of partial UCL injuries as reported by the American Shoulder and Elbow Surgeons in 2017. There is also a lack of clarity on when to initiate rehabilitation, which may be due to the limited amount of studies reporting success of RTP rates and time to RTP following conservative interventions of partial UCL injuries. Evidence on the RTP rates seen following conservative management of partial UCL tears injuries can help guide health care providers in deciding on the best treatment option for professional baseball athletes who desire to return to their athletic careers. These rates of RTP will add valuable objective input when determining if conservative management is the best choice. To determine the current evidence, inclusion criteria for the literature search consisted of RTP rates following conservative treatment in professional baseball players between inception and 2018. Clinical Question: Is there evidence for successful RTP rates in professional baseball players following conservative treatment of a UCL injury? Summary of Key Findings: Three retrospective studies met the inclusion criteria and were included. Of those, 2 reported RTP rates following a nonoperative rehabilitation program of a UCL injury, whereas 1 reported RTP rates after injection therapy in subjects who attempted a trial of conservative treatment. All 3 studies considered location and grade of UCL tear. Successful RTP rates (66%-100%) were reported in professional baseball players following nonoperative treatment of partial UCL injuries. Clinical Bottom Line: Current evidence supports high success with RTP rates up to 100% after nonoperative treatment of grade 1 UCL injuries in professional baseball players and between 66% and 94% for a grade 2 and above. Strength of Recommendation: There is level C evidence for high RTP rates following nonoperative treatment of partial UCL injuries in professional baseball players.
Collapse
|
|
50
|
Camp CL, Bernard C, Benavitz B, Konicek J, Altchek DW, Dines JS. Reconstruction of the Medial Ulnar Collateral Ligament of the Elbow: Biomechanical Comparison of a Novel Anatomic Technique to the Docking Technique. Orthop J Sports Med 2019; 7:2325967119857592. [PMID: 31763343 PMCID: PMC6852368 DOI: 10.1177/2325967119857592] [Citation(s) in RCA: 14] [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] [Indexed: 01/26/2023] Open
Abstract
Background: In recent years, understanding of the anatomy of the ulnar collateral
ligament (UCL) has evolved, demonstrating that the insertional footprint of
the UCL on the ulna is more elongated and distally tapered than previously
described. Current UCL reconstruction configurations do not typically
re-create this native anatomy, which may represent a potential area for
improvement. Purpose/Hypothesis: The purposes of this study were (1) to describe a novel anatomic UCL
reconstruction technique designed to better replicate the native UCL anatomy
and (2) to biomechanically compare this with the docking technique. The
hypothesis was that the ultimate load to failure for the anatomic technique
would not be inferior to the docking technique. Study Design: Controlled laboratory study. Methods: A total of 16 fresh-frozen cadaveric upper extremities (8 matched pairs) were
utilized. One elbow in each pair was randomized to receive UCL
reconstruction via the docking technique or the novel anatomic UCL
reconstruction technique with palmaris tendon autograft. Following
reconstruction, biomechanical testing was performed by applying valgus
rotational torque at a constant rate of 5 deg/s until ultimate mechanical
failure of the construct occurred. Maximal torque (N·m), rotation stiffness
(N·m/deg), and mode/location of failure were recorded for each specimen. Results: The mean ultimate load to failure for elbows in the docking technique group
was 23.8 ± 6.1 N·m, as compared with 31.9 ± 8.4 N·m in the anatomic
technique group (P = .045). Mean rotational stiffness was
1.9 ± 0.7 versus 2.3 ± 0.9 N·m/deg for the docking and anatomic groups,
respectively (P = .338). The most common mode of failure
was suture pullout from the graft, which occurred in all 8 (100%) docking
technique specimens and 7 of 8 (88%) specimens that underwent the anatomic
UCL reconstruction technique. Conclusion: Ultimately, the anatomic UCL reconstruction technique demonstrated superior
strength and resistance to valgus torque when compared with the docking
technique, and this was comparable with that of the native UCL from prior
studies. Increased initial strength may allow for earlier initiation of
throwing postoperatively and potentially shorten return-to-play times. Clinical Relevance: Current UCL reconstruction techniques do not accurately reproduce the UCL
insertional anatomy on the ulna. The novel anatomic technique described may
result in more natural joint kinematics. This study demonstrated
load-to-failure rates that are significantly higher than with the docking
technique and consistent with the native ligament, as reported from previous
studies. These findings may serve as a foundation for future clinical study
and optimization of this technique.
Collapse
Affiliation(s)
| | | | - Bill Benavitz
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA
| | - John Konicek
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, New York, USA
| | - David W Altchek
- Investigation performed at the Mayo Clinic, Rochester, Minnesota, USA
| | - Joshua S Dines
- Investigation performed at the Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|