Chronic Ulnar Collateral Ligament Research Articles

Surgical Interventions for Chronic Ulnar Collateral Ligament Injuries of the Thumb: A Systematic Review.

Background: There is no consensus for the appropriate surgical management of symptomatic chronic ulnar collateral ligament (UCL) injuries of the thumb. The aim of this study is to systematically review the treatment of chronic thumb metacarpophalangeal (MCP) joint UCL injuries to determine the optimal approach to treatment. Methods: A systematic review of PubMed, Medline, Embase and ePub Ahead of Print was performed in accordance with Preferred Reporting of Items in Systematic Review and Meta-Analysis (PRISMA) guidelines. Results: Data from 11 studies using various surgical techniques in 245 thumbs were heterogenous and meta-analysis of results not possible. These data were qualitatively assessed. Direct repair, reconstruction with free tendon grafts and arthrodesis all demonstrated favourable outcomes with patient-reported outcome measures (PROMs). Conclusions: Direct repair can be safely performed more than 2 months following injury. Arthrodesis may be considered in heavy manual labourers or those with osteoarthrosis. Tendon grafting is safe, yet the optimal type and configuration are yet to be determined for reconstructive methods. Level of Evidence: Level III (Therapeutic).

Implant-free anatomical reconstruction of thumb metacarpophalangeal joint chronic ulnar collateral ligament injuries.

A technique is described to treat chronic instability of the metacarpophalangeal joint of the thumb caused by rupture of the ulnar collateral ligament using a palmaris longus tendon graft without implants. Good results were obtained in eight patients.

SURGICAL INTERVENTIONS FOR CHRONIC ULNAR COLLATERAL LIGAMENT INJURIES OF THE THUMB: A SYSTEMATIC REVIEW

There is no consensus for the appropriate surgical management of chronic ulnar collateral ligament (UCL) injuries of the thumb.A systematic review of Pubmed, MEDLINE, EMBASE and ePub Ahead of Print was performed in accordance with Preferred Reporting of Items in Systematic Review and Meta-analysis (PRISMA) guidelines and formal protocol registered with PROSPERO.Two authors collated data from 10 studies that met strict inclusion criteria, using various surgical techniques in 131 thumbs. Results were heterogenous and metanalysis of results not possible. These data were, therefore, qualitatively assessed and synthesised. Bias was assessed using the ROBINS-I tool.Direct repair, reconstruction with free tendon or bone-tissue-bone grafts and arthrodesis all demonstrated favourable outcomes with Patient Reported Outcome Measures. Direct repair can be safely performed more than two months following injury, with a positive mean Disabilities of the Arm, Shoulder and Hand (DASH) score of 13.5 despite evidence of radiographic osteoarthritis. Arthrodesis should be considered in heavy manual laborers or those at risk of osteoarthritis as it provides significant reduction in pain (Mean Visual Analogue Score of 1.2) when compared to other methods. Free tendon grafting has been criticised for failure rates and poor functional grip strength, however collated analysis of 97 patients found a single graft rupture and mean grip strength of 97% (of the contralateral thumb). Bone-tissue-bone grafting was the least effective method across all outcome measures.Studies included were at high risk of bias, however, it can be concluded that delayed direct repair can be performed safely, while arthrodesis may benefit certain patient subgroups. New findings suggest poor efficacy of bone-tissue-bone grafts, but that free tendon grafting with palmaris longus are in fact safe with good restoration of grip strength. The optimal graft and configuration are yet to be determined for reconstructive methods.

Biomechanical comparison of two InternalBrace™ reinforced thumb ulnar collateral ligament reconstruction techniques.

Chronic ulnar collateral ligament ruptures of the thumb metacarpophalangeal joint are often not eligible for direct surgical repair and ligament reconstruction could be considered. Several reconstruction techniques are published, with different types of configurations and fixation methods of the tendon grafts. However, failure of the reconstruction with recurrent instability is still a problem, despite stable graft to bone fixation. Augmentation of the free tendon graft with non-resorbable suture material is gaining popularity, aiming to withstand elongation or rupture of the graft. The purpose of this study was to compare two different augmented ulnar collateral ligament reconstruction methods in a cadaver model. Ten matched pairs of cadaveric upper extremities were used. The thumbs were disarticulated at the trapezometacarpal joint and the ulnar collateral ligament was excised then reconstructed with InternalBrace™ reinforced tendon graft, which was fixed to the bones using either a Tenodesis screw or DX Swivelock® anchor. The thumbs were biomechanically tested with valgus stress, while the force and displacement were simultaneously measured and plotted. The mean (SD) load at clinical failure and maximum load were 19.4 (5.3) and 31.4 (9.5) N in the Tenodesis group, and 21.0 (10.0) and 31.4 (13.9) N in the DX SwiveLock® group, respectively. None of these differences were significant. These results are comparable with previous publications. The Tenodesis screw and the DX SwiveLock® thumb ulnar collateral ligament reconstruction with InternalBrace™ reinforced free tendon graft showed equal strength, both methods are feasible alternatives in the clinical setting.

A Novel Surgical Reconstruction Technique in the Management of Chronic Ulnar Collateral Ligament Tears with Volar Subluxation.

We hypothesized that ulnar collateral ligament reconstruction is inadequate for metacarpo- phalangeal joint stabilization in chronic ulnar collateral ligament injuries with volar subluxation due to dor- sal joint capsule injury. We consecutively performed both ulnar collateral ligament and dorsal joint capsule reconstruction to treat patients with a chronic ulnar collateral ligament tear with volar subluxation. This study aimed to present our preliminary results and experience with this technique in managing such cases. In this retrospective study, 7 patients (6 males, 1 female) who underwent surgical reconstruction of both ulnar collateral ligament and dorsal joint capsule reconstruction for the treatment of chronic ulnar collateral ligament injuries with volar subluxation were included. The mean age was 31 (range = 20-39) years, and the mean follow-up was 15.5 (range = 12-20) months. Several clinical and radio- logical data were recorded. The mean Visual Analogue Scale score significantly improved from 5.7 (range=5-8) to 0.57 (range=0-1) (P < .001). The mean quick- Disabilities of the Arm, Shoulder and Hand was significantly improved from 31.8 (range = 27.3-38.6) preoperatively to 3.2 (range = 0-6.8) at the final follow-up (P < .001). The mean preoperative extension deficit decreased from 18.5° (range = 10°-25°) to 0° (range= 0°-0°) at the final follow-up (P = .022). The mean preoperative flexion deficit increased from 10.7° (range = 0°-20°) to 31.4° (range=25°-35°) postoperatively (P=0.034). The mean key-pinch strength significantly increased from 33.2% (range=27-37) preoperatively to 10.2% (range=6-14) at the final follow-up assessment (P < .001). The mean hand grip strength significantly increased from 18.8% (range=15-23) preoperatively to 6.4% (range = 6-14) at the final follow-up assessment (P < .001). With encouraging short-term clinical outcomes and a lower complication rate, surgical recon- struction of both ulnar collateral ligament and dorsal joint capsule seems to be a safe and effective surgical technique in the management of chronic ulnar collateral ligament tears with volar subluxation.

The Treatment of Chronic Ulnar Collateral Ligament of the Thumb Injury Using Extensor Pollicis Brevis: Surgical Technique

Chronic rupture of the ulnar collateral ligament of the thumb is a complex lesion that typically results in chronic joint instability, functional limitation in pinch, and persistent pain at the metacarpophalangeal (MCP) joint of the thumb. Different surgical techniques have been proposed, including tendon graft and transpositions. In this article, we report our experience in treating chronic ulnar collateral ligament injuries using extensor pollicis brevis tendon in a Sakellarides modified technique. During the surgical procedure, we detach the extensor pollicis brevis proximally and drive the tendon through the neck of the first metacarpal and the base of the proximal phalanx to reconstruct the ligament at the ulnar side. In our experience, the surgical technique provides good MCP joint strength and stability and allows a good functional recovery with few postoperative complications. This technique provides good stability of the MCP joint using an absorbable suture and allows early mobilization of the joint with minimal stiffness.

The effects of rehabilitation on the outcomes of surgically treated acute and chronic thumb metacarpophalangeal ulnar collateral ligament ruptures

The aim of this study was to compare the outcome of patients who received rehabilitation to those who did not receive it after surgical treatment of acute and chronic tears of the ulnar collateral ligament (UCL) of the thumb. Forty-two patients with an acute UCL injury repaired with two soft mini-anchors to bone insertion sites, and 40 patients with a chronic UCL injury reconstructed with autografts were involved in this study. The patients were divided two subgroups depending on rehabilitation. Patient characteristics were not significantly different between the two groups and subgroups. Range of motion, grip strength and pinch strength were evaluated. There was no significant change in terms of grip and pinch strength in patients with acute UCL injury who received rehabilitation after surgical treatment. However, significantly better results were achieved in flexion, extension, ulnar and radial deviation. There was no significant change in pinch strength in patients with chronic UCL reconstructions, but significantly better results were achieved in grip strength, flexion, extension, ulnar and radial deviation. A rigid MCP splint in patients with acute and chronic UCL tears is effective in preventing early ligament insufficiency.

Operative treatment of chronic ulnar collateral ligament humeral origin avulsion fracture in young baseball players.

Chronic ulnar collateral ligament humeral origin avulsion fracture in young baseball players is a rare condition and a difficult problem to treat. Eight high school or college student baseball players with onset of symptoms in their adolescent ages were collected in this series. Their mean age at surgical intervention was 17.8 ± 1.99 years. The fracture was operated on with muscle splitting, ulnar nerve-sparing technique. Suture anchors were employed to fix the avulsed fragment. Visual analog scale, Mayo elbow performance score, and Conway scale were used for objective patient evaluation. The patients were followed up for 30.8 ± 10.2 months. Six patients have achieved solid bony union, and 2 had partial union. All patients showed no medial space widening on followed-up stress films. Visual Analogue Scale score improved from 9 to 0. The Mayo elbow performance score improved from 60 ± 10 to 85 ± 15 points pre- and post-operatively. The Conway scale had 3 excellent, 3 good, and 2 fair results. The average return to pitching occurred 7 months post-operatively at a rate of 75%. The present results indicate that open reduction and fixation with suture anchors is an effective treatment method for chronic ulnar collateral ligament humeral origin avulsion fracture in young baseball players.

Comparison of functional results after early controlled motion for surgical repair of acute and chronic ulnar collateral ligament injury of the thumb

Injuries to the UCL can lead to functional impairment. Rehabilitation is very important for functional results. Early motion after surgery is avoided. Usually the controlled motion starts after the 6th week. The aim of this study was to evaluate functional results of early controlled motion before 6th week. Nineteen patients (18♂/1♀) had an acute UCL rupture, 25 patients (23♂/2♀) had a chronic UCL rupture. Two soft anchors (Mini 1.0 mm) were used to repair ruptured UCL to bone insertion at the acute UCL injury group. For chronic UCL injury group, 3.0 mm bone tunnels were prepared to proximal and distal insertion of UCL and than tendon graft was passed through the tunnels. The tendon graft was stabilized by placing 3.0-mm bioabsorbable suture anchors within the tunnels. The motion was restricted in the 2 week with thumb spica. Dynamic splint and passive ROM exercises were started after 2 week. Active ROM exercises were started after 4 week. There were no significant differences between the two groups in the men/women ratio, mean age, mean follow-up period. All patients regained full stability at MCP joint in acute UCL injury group; 21 patients regained full stability and 4 patients presented with mild laxity (< 10° laxity) in chronic UCL injury group. The ROM of injured MCP joint of thumb was regained at 8–10 week as good as healthy extremity MCP joint of thumb. There were no significant differences between operated and healthy thumb MCP joint in both groups in the grip and pinch strength, flexion, extension, radial deviation, ulnar deviation motions at final control. Glickel grading scale was excellent for 19 patients for acute UCL injury group; it was excellent for 21 patients and good for 3 patients in chronic UCL injury group. Early controlled motions affect functional results positively. Repair with 1-mm soft anchors in acute UCL injury and reconstruction with tendon graft which stabilized by 3-mm bioabsorbable suture anchors within the tunnels in chronic UCL injury provides adequate stability for early controlled motion.

Long-Term Outcomes of Primary Repair of Chronic Thumb Ulnar Collateral Ligament Injuries.

Background: The purpose of this study is to evaluate long-term outcomes of ligamentous repair rather than reconstruction for chronic thumb ulnar collateral ligament (UCL) injuries. Methods: Patients at least 15-years status-post repair of a chronic (greater than 6 weeks) UCL tear were contacted for clinical evaluation, radiographs, and postoperative outcome questionnaires, including the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, visual analog scale (VAS) pain scale, and study-specific questions. Twelve of 21 (57%) living patients were available for long-term, greater than 15-year follow-up (average 24.5 years, range 16.9-35.6). Results: Eighty-eight percent of patients had some degree of osteoarthritis. Increased age at the time of injury and higher DASH scores were correlated with increased grades of the thumb metacarpophalangeal osteoarthritis. Delay to treatment and VAS pain scores had no correlation with radiographic findings. Conclusions: Repair of a chronic UCL injury with available local tissue appears to be a reasonable alternative to ligament reconstruction, resulting in durable long-term outcomes despite the majority of patients progressing to osteoarthritis.

Comparison of results after surgical repair of acute and chronic ulnar collateral ligament injury of the thumb

This study sought to demonstrate that successful outcomes can be achieved with the new technique presented here for chronic ulnar collateral ligament (UCL) injury of the thumb metacarpophalangeal (MCP) joint, as well as with K-wire pinning for acute UCL injury. We followed 19 patients who suffered an UCL rupture (mean follow-up: 14.26±4.65 months) and 32 patients who presented with UCL avulsion fracture (mean follow-up: 16.81±7.54 months). We used a free tendon graft for UCL reconstruction in the UCL rupture group. Both ends of the graft were stabilized with bioabsorbable suture anchors, which were used as biotenodesis interference screws. Closed reduction and K-wire fixation was used in UCL avulsion fracture group. There were no statistically significant differences between operated and contralateral healthy thumb MCP joint in both groups in the grip strength, tip pinch strength, flexion, extension, ulnar deviation, and radial deviation movements at final follow-up. Grip strength, tip pinch strength, ulnar deviation and radial deviation were significantly better in the avulsion group than the rupture group. All patients regained full stability at the MCP joint in avulsion group; 16 patients regained full stability and 3 patients presented with mild laxity (less than 10° laxity) in rupture group. Glickel grading scale used as a functional score was excellent for 30 patients and good for 2 patients in avulsion group; it was excellent for 17 patients and good for 2 patients in rupture group. Our study shows that closed reduction and percutaneous K-wire fixation of acute displaced large UCL avulsion fracture is a simple technique and achieves adequate stability of UCL. For UCL rupture, free tendon reconstruction with bioabsorbable suture anchors provides adequate stability and stable fixation within the tunnels.

Elbow ulnar collateral ligament reconstruction: clinical, radiographic, and ultrasound outcomes at a mean 3-year follow-up

Ulnar collateral ligament (UCL) has the main function to be stress-resistant to elbow valgus overload. Multilayer tears require a reconstruction with a tendon graft. In this study, we report the clinical, radiographic, and ultrasound outcomes after tendon graft reconstruction for symptomatic UCL insufficiency. Among twenty-six subjects underwent elbow UCL reconstruction from 2006 to 2012, fifteen were available to be evaluated at a mean follow-up of 36months. Preoperative assessment included clinical examination and MRI. The outcome measures were the Mayo Elbow Performance Score (MEPS); the Oxford Elbow Score (OES); the Disabilities of the Arm, Shoulder, and Hand (DASH); and the Conway-Jobe Scale. Overall population was postoperatively investigated with X-ray and ultrasound (US). Reconstruction was performed with autograft (palmaris longus) in five cases and allograft (semitendinosus) in ten cases using the figure-of-eight configuration (five cases), the docking technique (eight cases), or a fixation with screws (two cases). We found a significant improvement in postoperative MEPS, OES, and DASH scores (p<0.01). One case was unsatisfied and required an additional procedure of ulnar nerve transposition 12months after the reconstruction. X-ray showed calcifications along the graft in ten cases. At US examination, all the grafts assessed appeared anatomically intact without structural changes, and the dynamic examination showed a slight medial laxity with the valgus stress maneuver without pain or other sign of medial instability. This study confirms the efficacy of the graft reconstruction for chronic UCL insufficiency and introduces fresh insight on the role of musculoskeletal ultrasound to evaluate the reconstructed UCL.

Ultrasonographic Serial Evaluation after Reconstruction of the Ulnar Collateral Ligament and the Common Flexor Tendon of the Elbow in a High School Female Weight Lifter

A 16-year-old female weight-lifter with average records of 70 kg for the snatch event and 90 kg for the clean and jerk event suffered chronic ulnar collateral ligament injury, and underwent ulnar collateral ligament reconstruction. An ultrasonographic evaluation was performed at six weeks, three months, six months, nine months, and one year after the operation. The horizontal and vertical distances measured during the initial ultrasonographic examination as well as at six weeks, three months, six months, nine months, and one year after the operation were 8.4 mm, 2.0 mm, 2.6 mm, 2.8 mm, 2.7 mm, 2.7 mm, and -1.2 mm, 2.4 mm, 1.0 mm, 0.0 mm, 0.0 mm, 0.0 mm, respectively. The lifting records at one year after the operation were 65 kg for the snatch event and 90 kg for the clean and jerk event. The ultrasonographic method of serial examination was useful for evaluation of the rehabilitation program and for deciding on the time to return to competition.

Outcomes After Injury to the Thumb Ulnar Collateral Ligament—A Systematic Review

Rupture of the ulnar collateral ligament (UCL) is a frequent injury of the hand. When untreated, this injury may lead to decreased pinch strength, pain, instability, and osteoarthritis. There is currently no consensus on treatment of acute or chronic UCL injuries. Our primary purpose was to compare nonoperative treatment with surgical repair and surgical reconstruction of thumb UCL injuries. A secondary purpose was to compare graft choice and surgical technique for reconstruction. A systematic review of multiple medical databases was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines with specific inclusion and exclusion criteria. Clinical outcome studies after nonoperative or operative treatment of thumb UCL injuries, with a minimum of 2 years mean follow-up, were included. Pain, range of motion, key-pinch strength, and stability testing were used as outcome measures. Fourteen articles were included and analyzed (293 thumbs). All but 2 were level IV evidence. Mean Quality Appraisal Tool score was 13.1 (55% overall rating study methodological quality). Thirty-two thumbs were treated nonoperatively and 261 operatively. Mean subject age was 33.9 years. There were 200 acute injuries and 93 chronic injuries. Mean study follow-up was 42.8 months. Nonoperative treatment often failed, necessitating surgery. Acute UCL repair and autograft UCL reconstruction for chronic injury led to excellent clinical outcomes, without a significant difference between the 2 groups. After significant delay to treatment or even failed nonoperative treatment, excellent clinical outcomes can be achieved, without a difference between initially treating the injury surgically. Complications after surgery were rare. This review has demonstrated excellent clinical outcomes after surgical treatment of both acute and chronic UCL injury, without any significant difference between repair and reconstruction for acute and chronic injury, respectively.

Primary Repair of Chronic Ulnar Collateral Ligament Injury of Thumb Metacarpophalangeal Joint

Chronic metacarpophalangeal joint injury of the thumb is a common condition presenting as pain or instability. There have been many techniques described for treatment of this injury but they involve some form of ligament reconstruction rather than primary repair of the ligament. We believe reconstruction is not necessary and primary repair can be performed. This technique describes identifying the ligament in a chronic injury and repairing it primarily.

Rupture of the collateral ligament of the metacarpo-phalangeal joint of the thumb.

Rupture of the collateral ligament of the metacarpo-phalangeal joint of the thumb.