Collateral Ligament Reconstruction Research Articles

Biomechanical Comparison of Ulnar Collateral Ligament Reconstruction With the Docking Technique Versus Repair With Internal Bracing

Background: The modified Jobe technique of ulnar collateral ligament (UCL) reconstruction has previously been biomechanically compared with primary repair augmented with internal bracing. However, the docking technique has not been compared with repair with internal bracing. Hypothesis: Load to failure, gapping, and valgus opening angle are similar under valgus loading at 90° of flexion between repair with internal bracing and the docking technique for the UCL. Study Design: Controlled laboratory study. Methods: Nine matched pairs of fresh-frozen cadaveric elbows were potted with the forearm in neutral rotation. The palmaris longus tendon graft was harvested, and the bone was sectioned 14 cm proximal and distal to the elbow joint. First, native UCL testing was performed at 90° of flexion with 0.5 N·m preload, followed by a 5 N·m valgus moment to the elbow in cycles of 1, 10, 100, and 1000 at 1 Hz. The specimens were then loaded to failure at a rate of 0.2 mm/s. Next, the elbows were randomly divided into matched pairs to undergo either UCL reconstruction with docking technique or UCL repair augmented with internal bracing. Last, these specimens underwent testing as aforementioned. Results: Load to failure, gapping, and valgus opening angle did not differ significantly between native ligaments that underwent reconstruction or repair with internal bracing, paired native ligaments and reconstructions, paired native ligaments and repairs augmented with internal bracing, or reconstructions and repairs augmented with internal bracing. Conclusion: UCL reconstruction with docking technique and repair augmented with internal bracing provides valgus stability to the medial elbow comparable to the native ligament at 90°. No significant differences were noted between docking reconstruction and repair techniques for load to failure, gapping, or valgus opening angle during cyclic loading at time zero. Clinical Relevance: Our results suggest that UCL repair with internal bracing has a similar biomechanical profile at the time of initial fixation compared with the docking technique of UCL reconstruction.

Effects of Ulnar Collateral Ligament Reconstruction on Pitch Selection in Major League Baseball Pitchers.

Background:Ulnar collateral ligament (UCL) injuries represent one of the most common impairments to the throwing arm of professional pitchers. Return to play and postoperative performance metrics have been studied extensively, but pitch selection before and after surgery has not been evaluated.Purpose/Hypothesis:This study aimed to characterize the effects of UCL reconstruction on pitch selection in Major League Baseball (MLB) pitchers. We hypothesized that pitchers will throw fewer fastballs and a greater percentage of off-speed pitches after undergoing UCL reconstruction.Study Design:Retrospective cohort study; Level of evidence, 3.Methods:Using publicly available data, we evaluated MLB pitchers who underwent UCL reconstruction between 2003 and 2014. Pitching data were collected for the 2 seasons before UCL reconstruction as well as the first 2 seasons after reconstruction; the data consisted of the total number of pitches thrown and the percentage of fastballs, curveballs, changeups, and sliders. Repeated-measures analysis of variance was used with post hoc least significant difference pairwise t tests to evaluate for statistical significance at P < .05.Results:Overall, 87 pitchers (mean age, 28.2 ± 3.5 years) met all inclusion and exclusion criteria. There was a statistically significant difference in the total number of pitches thrown before and after surgery (P < .01) as well as in the percentage of fastballs thrown before and after surgery (P = .02). There was also a statistically significant increase in the use of curveballs between 1 and 2 years postoperatively (7.5% and 8.8%, respectively; P = .01). No other findings were statistically significant.Conclusion:Pitchers who underwent UCL reconstruction were shown to have a statistically significant decline in the percentage of fastballs thrown postoperatively as compared with before injury, with a compensatory trend toward an increased use of curveballs and sliders.

Medial Elbow Pain During the Return-to-Throwing Period After Ulnar Collateral Ligament Reconstruction in Pitchers.

Background:Ulnar collateral ligament reconstruction (UCLR) is common in the sport of baseball, particularly among pitchers. Postoperative return-to-sport protocols have many players beginning to throw at 4 to 5 months and returning to full competition between 12 and 16 months after surgery. Medial elbow pain during the return-to-throwing period often occurs and can be difficult to manage.Purpose:To evaluate the incidence of medial elbow pain and associations with outcomes and revision surgery during the return-to-throwing period after UCLR.Study Design:Case-control study; Level of evidence, 3.Methods:Between the years of 2002 and 2014, all pitchers who underwent UCLR at a single institution were identified. Charts were reviewed for incidence of medial elbow pain during return to throwing, return to sport, and subsequent operative interventions, including revision ulnar collateral ligament surgery.Results:Of a total of 616 pitchers who underwent UCLR during the study period, 317 were included in this study. Medial elbow pain was experienced by 45.1% (143 of 317), with a mean time of complaint of 9.75 months after surgery. The groups with and without pain did not differ statistically with regard to age (pain, 20.6 years; no pain, 20.9 years) or level of competition. Of those who experienced medial elbow pain, 10.5% did not return to sport; 5.6% underwent revision UCLR; and 19.6% underwent other operative procedures at the elbow. Among those who did not experience medial elbow pain when returning to throw, 8.7% did not return to sport, with only 1.7% undergoing revision UCLR and 6.9% undergoing other operative elbow procedures.Conclusion:Of the pitchers evaluated in the study, approximately half reported pain during the return-to-throwing phase after UCLR. Those who experienced medial elbow pain had a higher rate of subsequent surgical intervention.

There is a role for allografts in reconstructive surgery of the elbow and forearm.

Allografts play an important role in tendon, ligament, and bone reconstruction surgery, particularly when suitable available autologous tissue is limited. Enthusiasm for the use of allografts in reconstructive orthopedic surgery has increased over the past decade, with an increase in allograft use in a variety of procedures. The purpose of this review is to provide an overview of the various applications and indications for the use of allografts in reconstructive surgical procedures of the elbow and forearm. MEDLINE/PubMed was searched from 1990 through October 2018 for studies on tendon and bony allografts in elbow and forearm reconstructive surgery. The Achilles tendon allograft is the most frequently used tendinous allograft, predominantly used in distal biceps and triceps reconstruction. Although reconstruction of the ulnar collateral ligament of the elbow is generally performed using autografts, it has been shown that semitendinosus and gracilis allografts may be equally effective. Extensor hallucis longus allografts are recommended for reconstruction of the lateral collateral ligaments in patients with posterolateral rotatory instability, and there may be a role for osteochondral allograft transplantation in capitellar osteochondral defects. In addition, the use of allografts in reconstruction of the interosseous membrane and various bone pathologies (fractures, bone tumors, forearm nonunions) has been described in current literature. There is a large variety of pathology and procedures involving the use of various types of allografts in orthopedic reconstructive surgery of the elbow and forearm.

Concomitant Reconstruction of Anterior Cruciate Ligament and Medial Collateral Ligament Surgical procedure and clinical outcomes

The purpose of this paper was to evaluate the postoperative clinical outcomes of combined anterior cruciate ligament (ACL) and medial collateral ligament (MCL) reconstruction and to briefly describe the surgical procedure. The current study is a retrospective observational analysis, which included 12 patients with acute ACL and grade III MCL injuries. Combined ACL-MCL reconstruction was performed using bone-tendon-bone patellar autograft and semitendinosus and gracilis autograft, respectively. Preoperative and postoperative assessments were performed for each patient using the same protocol. Combined ACL-MCL reconstruction is associated with improved postoperative results. No recurrent knee instability was reported at the end of follow-up period. In conclusion, acute ACL and grade III MCL injuries can be successfully treated by combined ACL-MCL reconstruction, which is an effective option for the treatment of these patients, associated with good clinical results.

Return to Play and In-Game Performance Statistics Among Pitchers After Ulnar Collateral Ligament Reconstruction of the Elbow: A Systematic Review

Background: Injury to the ulnar collateral ligament of the elbow is relatively common among baseball pitchers. Ulnar collateral ligament reconstruction (UCLR) has revolutionized the management of this injury, allowing a greater proportion of pitchers to return to play. Purpose: To assess the return to play and in-game performance specific to baseball pitchers who have undergone primary UCLR. Study Design: Systematic review. Methods: This review was conducted according to the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). The electronic databases MEDLINE, EMBASE, and PubMed were searched for relevant studies, and pertinent data were abstracted. Only studies reporting in-game performance statistics (earned run average [ERA], pitching velocity, innings pitched per season, etc) of pitchers after UCLR were included. The methodological index for nonrandomized studies (MINORS) was used to assess study quality. Results: A total of 14 studies and 1520 pitchers were included in this systematic review. All studies were of level 3 or 4 evidence, and the mean ± SD MINORS score was 14.4 ± 3.0, which indicates fair quality of evidence for nonrandomized studies. The rates of return to any level of pitching after UCLR ranged from 79% to 100%. Subgroup analysis revealed that 79% to 87% of Major League Baseball (MLB) pitchers returned to preinjury levels of pitching. The mean time to return to play was 19.8 ± 13.5 months, and the mean time to return to competition for MLB pitchers was 17.3 ± 2.4 months. Of the 5 studies reporting ERA, 2 cited a significant increase after UCLR, and 1 indicated a significant decrease. Of the 4 studies reporting fastball velocity, 3 cited decreased pitching velocities after UCLR. All studies found that pitchers pitched, on average, fewer innings per game or season after UCLR. Conclusion: There was a high rate of return to pitching after UCLR. However, most studies showed that UCLR was associated with a prolonged recovery and significant decline in pitching performance as objectively measured by in-game statistics. The strength of these conclusions is limited by the quality of the available literature and inconsistencies in the reporting of outcomes.

Athletic Hip Injuries in Major League Baseball Pitchers Associated With Ulnar Collateral Ligament Tears.

Background:Ulnar collateral ligament (UCL) reconstruction is a reliable treatment for elite overhand throwers with UCL tears. In recent years, this procedure has become increasingly common among Major League Baseball (MLB) pitchers. Predisposing factors and associated comorbidities, however, have not been fully elucidated.Purpose/Hypothesis:The purpose of this study was to determine whether professional baseball pitchers who underwent UCL reconstruction had an increased incidence of hip or groin injuries 4 years before or after surgery. We hypothesized that MLB pitchers who sustain hip or groin injuries may be more likely to develop UCL tears because of alterations and overcompensation in the kinetic chain during overhand throwing.Study Design:Cohort study; Level of evidence, 3.Methods:A comprehensive list of all 247 MLB players who underwent UCL reconstruction between 2005 and 2017 was created using publicly accessible online data. The application of inclusion criteria yielded a final sample size of 145 athletes. These athletes’ injury histories were identified and cross-referenced with the official MLB disabled list. Matched controls were generated for a comparison of results.Results:Of the 145 MLB pitchers who underwent UCL reconstruction between 2005 and 2017, 40 (27.6%) endured a proximal lower extremity injury within 4 years of their surgery. Specifically, 16 pitchers sustained hip injuries, 13 suffered hamstring injuries, and 14 experienced groin injuries. A significantly lower rate of hip- and groin-related injuries (17.9%) was identified in matched controls during a similar time frame (P = .049).Conclusion:The results of this study demonstrate that MLB pitchers who required UCL reconstruction sustained a higher frequency of proximal lower extremity injuries both before and after surgery compared with matched controls. This finding is significant as the treatment of antecedent hip lesions, as well as an emphasis on hip and core muscle mobility and strengthening, may help reduce injuries to the UCL.

Pitching Performance After Ulnar Collateral Ligament Reconstruction at a Single Institution in Major League Baseball Pitchers

Background: Ulnar collateral ligament (UCL) reconstruction (UCLR) has shown reliable rates of return to play, with conflicting results on pitching performance after players’ return. Purpose: To evaluate Major League Baseball (MLB) pitching performance before and after UCLR performed at a single institution. Study Design: Cohort study; Level of evidence, 3. Methods: MLB pitchers (minor league players were excluded) who underwent UCLR at our institution between 2002 and 2016 were identified. Player information and return to play were determined including pitching level (MLB vs minor league) and total number of years played after surgery. Pitching performance statistics were evaluated for 3 years before surgery and for 3 years after returning to play including earned run average (ERA), walks plus hits per inning pitched (WHIP), innings pitched, wins above replacement, runs above replacement, and pitch velocity. Results: A total of 54 MLB pitchers were identified, with 46 primary and 8 revision reconstructions. The mean time to return to play was 13.8 months (primary reconstruction: 13.7 months). The majority returned to play with a 94% return rate (primary reconstruction: 96%), and 80% returned to MLB play (primary reconstruction: 82%). Three primary reconstructions required revision surgery. Pitchers played a mean of 3.2 years in MLB and 4.6 years total after surgery (39% still playing). Pitching workload and performance were maintained or improved after surgery. The preoperative ERA was 4.63 versus 4.13 after returning to play (P = .268). Fastball velocity (P = .032), ERA (P = .003), and WHIP (P = .001) worsened the first year after surgery and then improved the second year (ERA: 4.63 to 4.06 [P = .380]; WHIP: 1.35 to 1.32 [P = .221]; fastball velocity: 91.3 to 91.9 mph [P = .097]). Compared with a matched control group, pitchers who had UCLR showed improvements or maintained performance after reconstruction including improved ERA (P = .007), WHIP (P = .025), and fastball velocity (P = .006). Conclusion: MLB players experienced a high rate of return to play and previous level of play after UCLR. Pitching workload was maintained after returning to play. Pitching performance initially decreased the first year after returning and then improved or reverted to previous levels after the first year from UCLR.

Diagnosis and treatment of thumb polydactyly with symphalangism in children

To investigate the diagnosis and treatment of thumb polydactyly with symphalangism in children. Seven cases of thumb polydactyly with symphalangism were treated between January 2013 and May 2017. There were 5 males and 2 females, aged from 10 months to 11 years, with an average age of 3.1 years. The thumb-polydactyly was diagnosed with MRI and it was seen that the base of radial multi-finger and the proximal phalangeal joint were connected by cartilage. All patients were treated with resection, lateral collateral ligament reconstruction, bone osteotomy and internal fixation. The operation was successfully completed, and there was no early complications such as infection and flap necrosis. All patients were followed up 6-23 months (mean, 14.1 months). At last follow-up, there was no deformity finger, scar contracture, and other complications. The extension of the interphalangeal joint was no limited, and the flexion range of the interphalangeal joint was 20-75° (mean, 56.7°). The appearance and function of the thumb was rated as excellent in 3 cases and good in 4 cases by Japanese Society for Surgery of the Hand (JSSH) scoring, with the excellent and good rate of 100%. The thumb polydactyly with symphalangism in children can be combined with clinical manifestations, X-ray film, and MRI examination to diagnose, and can obtain satisfactory results through the reconstruction of lateral collateral ligament, bone osteotomy, and internal fixation.

Total Finger Arthroplasty Using Costal Osteochondral Autograft for Finger Joint Ankylosis: Mid- to Long-Term Clinical Outcomes Up to 11 Years of Follow-Up

There is no financial information to disclose. Costal osteochondral grafting is a technique for providing anatomical and biological reconstruction of articular disorders. We have applied this procedure to the treatment of finger joint ankylosis. The purpose of this study was to clarify the mid- to long-term clinical outcomes of total finger arthroplasty using costal osteochondral autograft for finger joint ankylosis. The metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints were approached dorsally through a longitudinal incision. The periosteum and capsule were elevated concurrent with the collateral ligaments and the volar plate all around the joint (Figure 62-1A). The ankylosed joint was separated at the original joint level. The ends of the phalanx and metacarpus were step-cut for the graft floor (Figure 62-1B). Two pieces of osteochondral graft were harvested from the fifth and sixth ribs and then manually trimmed to form a new MCP/PIP joint with adequate contours using a scalpel (Figure 62-1C). The bony part of the graft was step-cut and stabilized using low-profile screws (Figure 62-1D). Twenty-three finger joints (3 MCP joints and 20 PIP joints) in 23 patients with ankylosis were treated with costal osteochondral autograft with at least 5 years of follow-up. Participants were composed of 19 males and 4 females ranging in age from 18 to 55 years (mean, 33 years). Clinical outcomes including range of finger motion, the Japanese Society for Surgery of the Hand version of the Disability of the Arm, Shoulder, and Hand (DASH-JSSH) score, donor-site disturbances, and radiographic outcomes were evaluated after a mean follow-up of 77 months (range, 60–138 months). Significant improvement in active finger extension-flexion was seen from a preoperative mean of –24°/26° (arc: 2°) to –12°/75° (arc: 63°) at 1 year postoperatively (P < .001) and to –13°/75° (arc: 62°) at latest follow-up (P < .001). Mean preoperative DASH-JSSH score was initially 23.6, improving significantly to 6.6 at 1 year postoperatively, and to 5.2 by latest follow-up (P < .001) (Figure 62-2). Donor-site pain persisted only 1 to 2 weeks after surgery and raised no particular problems. One patient injured the operated finger while playing rugby football 2 years after surgery and needed additional costal osteochondral grafting. Other additional surgeries were collateral ligament reconstruction in 4 patients, corrective osteotomy of the phalanx in 2, and tenolysis in 1. •Total finger arthroplasty using costal osteochondral autograft for finger joint ankylosis showed anatomical and biological reconstruction and provided stable improvement of clinical outcomes with a mean follow-up of 77 months.Figure 62-1BAfter exposure of the ankylosed joint, the bone is separated with a chisel at the original PIP joint. The cut-off ends of the middle and proximal phalanx are step-cut.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 62-1CTwo pieces of osteochondral graft are harvested from the fifth and sixth ribs through an ipsilateral transverse sub-mammary incision. The harvested grafts are trimmed by hand to form the head of the proximal phalanx and base of the middle phalanx. The cartilaginous area of the graft is trimmed using a scalpel. Careful trimming is necessary to form adequate contours.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 62-1DThe bony part of the graft is step-cut and stabilized using low-profile screws. In closure, the central slip is reattached to the base of middle phalanx, and the collateral ligament, periosteum, and volar plate are repaired with 5-0 nylon sutures. A continuous distracting device is applied to the PIP joint to decrease friction between the joint surfaces.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 62-2Comparing range of motion preoperatively, at 1 year postoperatively, and at latest follow-up. *P < .001.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Kerlan-Jobe Orthopaedic Clinic (KJOC) score and scapular dyskinesis test in collegiate baseball players

The Kerlan-Jobe Orthopaedic Clinic (KJOC) score has been used to describe various parameters of throwing shoulder and elbow function for the return to play after a long period of rehabilitation, such as after ulnar collateral ligament reconstruction. No study has yet to identify how scapular dyskinesis (SD) in baseball players affects the KJOC score. This study investigated the relationship of the KJOC score to SD evaluated in collegiate baseball players with and without upper extremity injury. The study participants were 30 male collegiate baseball players (13 pitchers) belonging to the National Collegiate Athletic Association D-I conference. Participants were assessed with the KJOC instrument in the beginning (PRE) and end (POST) of the season. The SD test was conducted (PRE) in shoulder flexion to identify SD RESULTS: The mean value of KJOC score was significantly less in POST than that of PRE for the pitchers with SD (89.3 and 60.5, respectively; P = .001), whereas no difference was found in the KJOC score between PRE and POST for the pitchers without SD. For the position players, no difference in the mean value of KJOC score was found between PRE and POST, regardless of SD. The results of this study provide evidence that collegiate baseball pitchers with mild SD may have lower KJOC scores, particularly setup or relief pitchers.

A Novel Medial Collateral Ligament Reconstruction Technique Using Internally Braced Semitendinosus Autograft.

Medial collateral ligament reconstruction is often performed in knees with multiligamentous injury, and numerous techniques have been previously described. A novel method of internally bracing and reconstructing the medial collateral ligament with a semitendinosus autograft is described. This provides several advantages, including reproducible isometric graft placement, optimized fixation strength, and internal bracing. [Orthopedics. 2018; 41(5):e738-e740.].

Partial Controlled Early Postoperative Weightbearing Versus Nonweightbearing After Reconstruction of the Fibular (Lateral) Collateral Ligament: A Randomized Controlled Trial and Equivalence Analysis

Background: While early weightbearing protocols have been advocated after anterior cruciate ligament (ACL) reconstruction, early weightbearing after fibular (lateral) collateral ligament reconstruction has not been well defined. Purpose: (1) To determine if early partial controlled weightbearing after fibular collateral ligament (FCL) reconstruction resulted in an objective difference in laxity on varus stress radiographs at postoperative 6 months as compared with nonweightbearing, and (2) to determine if there was a difference in pain, edema, range of motion, and subjective patient-reported outcomes between these groups at 3 time points. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Patients were prospectively enrolled from January 2014 to April 2017. Patients who underwent isolated FCL reconstruction or combined ACL and FCL reconstructions were included in this study. Patients were randomly assigned to either a control group (nonweightbearing for 6 weeks) or a treatment group (partial controlled weightbearing at 40% body weight with crutches for 6 weeks). Patient-related data, including knee pain, edema, and range of motion, were collected for all patients at postoperative day 1, 6 weeks, and 6 months. Subjective outcomes were collected preoperatively and at 6 months postoperatively. The primary objective endpoint was varus stability, evaluated by bilateral varus stress radiographs obtained preoperatively and at 6 months postoperatively. Results: Thirty-nine patients were enrolled in the study, with 6-month follow-up obtained for 36 (92%). There was a significant improvement between the preoperative side-to-side difference (SSD) (2.4 ± 1.0) and postoperative SSD (0.2 ± 1.0) for lateral compartment laxity on varus stress radiographs among all patients (P < .001). Clinical and statistical equivalence was found between groups in terms of SSD on varus stress radiographs (P < .001). The SSD in knee edema was significantly lower in the partial early weightbearing group (beta = −0.6 cm, P = .001), but there were no significant group differences in knee pain, flexion, or extension. All patients demonstrated significant improvements in subjective outcome scores between the preoperative and 6-month postoperative conditions (P < .001 for every score measured). Conclusion: Clinical and statistical equivalence was found at postoperative 6 months between the early partial weightbearing and nonweightbearing groups among patients undergoing either an isolated FCL reconstruction or a combined ACL and FCL reconstruction. There were no significant differences observed between the groups regarding knee stability, pain, swelling, range of motion, or subjective outcomes. Given these findings, the authors recommend early partial weightbearing after isolated FCL reconstruction or combined ACL and FCL reconstruction.

Associated Anterior Cruciate Ligament and Fibular Collateral Ligament Reconstruction With Single Femoral Tunnel and Asymmetric Hamstring Tendon Graft

A technique for associated anterior cruciate ligament and fibular collateral ligament reconstruction is shown, using a single hamstring tendon graft, which is prepared asymmetrically, leaving one-third of the length with a single diameter and two-thirds with a double diameter. A single femoral tunnel is created, using an interference screw for fixation and isolation of the grafts. A suspension device is used for tibial fixation, allowing for length adjustment according to the graft's length. The objective of this Technical Note is to provide the orthopaedic surgeon with a resource for anterior cruciate ligament and fibular collateral ligament reconstruction even with short grafts, saving bone stock and avoiding the need for allografts.

Non-Weight Bearing versus Partial Controlled Early Weight Bearing after Reconstruction of the Fibular Collateral Ligament: A Randomized Control Trial

Objectives:To 1) determine if early protected weight bearing after an FCL reconstruction was safe based upon an objective difference in laxity on varus stress radiographs at six months postoperatively between patients who were non-weight bearing versus partial controlled weight bearing during the first six weeks of postoperative rehabilitation and 2) determine if there was a difference in pain, edema, and range-of-motion between these two groups at three different time points.Methods:Patients were prospectively enrolled from January 2014 to April 2017. Patients were included in the study if they were undergoing an isolated FCL reconstruction or combined ACL and FCL reconstructions. Patients were randomly assigned to either a control group, which was non-weight bearing for 6 weeks, or a treatment group with partial controlled weight bearing at 40% body weight with crutches for 6 weeks. Patients were excluded if they were less than 18 years of age, pregnant, undergoing a revision FCL reconstruction, concurrent medial collateral and/or posterior cruciate ligament reconstruction, radial or root meniscal repairs, genu varus alignment in patients with chronic FCL tears, or had a body mass index ≥ 35 kg/m2.Results:Thirty-nine patients were enrolled in the study, with 6 month follow-up obtained in 36 patients (92%). Twenty-five patients (69.4%) had an acute injury (≤ 6 weeks) and 11 patients (30.6%) had a chronic injury (> 6 weeks). The mean time from injury to surgery was 2.3 ± 1.9 weeks and 41.5 ± 37.4 weeks for acute and chronic patients, respectively. There were no significant differences in patient age (p = .157) or BMI (p = .534) between the control and treatment groups. Postoperatively (0-6 months), there were no complications reported and no surgical re-interventions for ligamentous reconstruction failure or arthrofibrosis in either group. There was a significant difference between the preoperative side-to-side difference (SSD) (2.4 ± 1.0) and postoperative SSD (0.2 ± 1.0) for lateral compartment gapping on varus stress radiographs in all patients (p< .001). For the control group, the lateral compartment SSD on varus stress radiographs was reduced from 2.4 ± 1.1 to 0.1 ± 1.1 from preoperative to 6 months postoperative (p < .001). For the treatment group, the SSD on varus stress radiographs reduced from 2.3 ± 0.8 to 0.2 ± 0.8 from preoperative to 6 months postoperative respectively (p < .001). There were no significant differences between the preoperative SSD and postoperative SSD on varus stress radiographs between the control and treatment groups. All patients demonstrated significant improvements in subjective outcome scores (IKDC, WOMAC pain, WOMAC stiffness, WOMAC physical function, WOMAC total, Lysholm, and Tegner scores) between the preoperative and 6 months postoperative conditions (p < .001). There were no significant differences for the outcome measures of pain, edema, and knee range of motion between control and treatment groups at any time points.Conclusion:There were no significant differences between patients who were non-weight bearing compared to early weight bearing at 6 months postoperatively regarding knee stability, pain, swelling, and range-of-motion. We recommend early partial weight bearing following an isolated FCL reconstruction or when combined with an ACL reconstruction because our study found it did not compromise the integrity of the FCL reconstruction graft.

Release Location in a Risk Factor for Ulnar Collateral Ligament Reconstruction in Major League Baseball Pitchers

Objectives:Medial ulnar collateral ligament reconstruction (UCLR) is a common procedure performed for Major League Baseball (MLB) pitchers. The etiology of UCL injury is complex and not entirely understood. The purpose of this study was to use publically available pitch tracking technology (PITCHf/x) to compare the pre-injury throwing mechanics of MLB pitchers who require UCL reconstructive surgery with those of pitchers who have never undergone UCL reconstruction.Methods:Pitch tracking and demographic data on MLB pitchers who had undergone UCL reconstruction between the 2010 and 2017 seasons was gathered. Pitchers were excluded if they did not throw 100 total pitches in each of the three years prior to surgery. Furthermore, only pitch types that a given pitcher utilized more than 25 times in each of the three years prior to surgery were included for individual analysis. Pitch type, release location, and velocity were compared between the UCL reconstructive surgery cohort and a matched-control cohort.Results:The average pitch release location for pitchers who required UCL reconstruction was more lateral in the two years immediately preceding surgery than the control cohort (p=0.001 and p=0.023). Furthermore, a time-based comparison between the year immediately preceding surgery and two years prior showed a more lateral release immediately prior to surgery (p=0.036). Pitchers who required UCL reconstruction throw similar rates of fastballs as the control cohort and the average pitch velocity and fastball velocity were similar between the UCL group and the control group. The control pitchers displayed a significant decrease in average pitch velocity (p=0.005) and average fastball velocity (p=0.012) over the period of the study.Conclusion:Pitch tracking indicates pitch selection and pitch velocity are similar before that the average release point is more lateral preceding UCL reconstruction as compared to the control cohort suggesting that pitch release location might be an independent risk factor for UCL injury and reconstruction. On the other hand, pitch selection and pitch velocity are similar between these cohorts. Powerful technology including PITCHf/x allows for accurate monitoring of factors such as arm position and could potentially be used to identify pitchers at risk for UCL rupture.Figure 1Average pitch release location with error bars for standard eror of the mean. Location is measured as feet from the center of the mound, and left-handed pitchers are normalized to the right handed pitcher. UCL pitchers (dark grey) have a significantly more lateral and lower release locations in Year I (the year immediately prior to surgery) than did the control group (light grey). Furthrmore, the release location of UCL pitchers is more lateral in the Year I than in Year III.

Performance and Return to Sport Following Ulnar Nerve Transposition/Decompression in Professional Baseball Players

Background:Isolated ulnar nerve decompression/transposition is an uncommon surgery amongst professional baseball players.Purpose:To determine the rate of return to sport (RTS) and performance upon RTS in professional baseball players following isolated ulnar nerve decompression/transposition, including those who required an ulnar nerve transposition/decompression following ulnar collateral ligament reconstruction (UCLR), and to determine if outcomes differ between players with isolated ulnar nerve decompression/transposition and matched controls.Hypothesis:There is a high rate of RTS in professional baseball players undergoing isolated ulnar nerve decompression/transposition with no significant difference in RTS rate or performance (specifically related to the primary outcome performance variables of earned run average (ERA), WHIP ((walks +hits)/innings pitched), wins above replacement (WAR), and on base + slugging percentage (OPS)) between cases and controls.Methods:All professional baseball players who underwent isolated ulnar nerve decompression/transposition between 2010-2016 were included. Demographic and performance data (pre and post surgery) for each player was recorded. Performance metrics were then compared between cases and a group of matched controls.Results:Overall 52 players, 83% pitchers (14 who underwent prior UCLR) were included. Most surgeries (92%) were anterior subcutaneous transpositions. Overall, 62% of players were able to successfully RTS and 56% returned to the same or a higher level. There was no significant difference between cases and controls in the majority of performance metrics pre-operative or post-operatively, specifically ERA, WHIP, WAR, and OPS. When players who had a UCLR prior to their ulnar nerve transposition/decompression were compared to controls with a history of a UCLR but who did not go on to have an ulnar nerve transposition/decompression, the only performance difference of all the recorded metrics was cases allowed more walks per 9 innings (4.4 vs. 2.8; p=0.011).Conclusion:Anterior subcutaneous transposition is the most common surgery in professional baseball players to address ulnar nerve compression. Players have a 62% rate of RTS. Upon RTS, players performance compared to matched controls remains the same in the majority of performance metrics including ERA, WHIP, WAR, and OPS. Post-operatively, pitchers with a UCLR prior to ulnar nerve transposition/decompression performed the same as matched controls with prior UCLR.

Comparison of Outcomes Based on Graft Type and Tunnel Configuration for Primary Ulnar Collateral Ligament Reconstruction in Professional Baseball Pitchers

Objectives:Professional baseball pitchers are at high risk for tears of the ulnar collateral ligament (UCL) of the elbow, often requiring subsequent surgical reconstruction. Despite acceptable published return to play outcomes, multiple techniques and graft types have been described. There is a paucity of clinical data in the current literature comparing UCL reconstruction surgical technique and graft type. Even less is known about the risks for subsequent injury, surgery, or revision UCL reconstruction. Accordingly, this study compares UCL reconstruction outcomes based on tunnel configuration and graft type.Methods:Following approval from our institutional review board and Major League Baseball (MLB), 566 professional baseball pitchers who underwent UCL reconstruction between 2010 and 2014 were identified and included. The following patient demographics were analyzed: age, pitching role (starter vs. reliever), level of play (MLB vs. Minor League Baseball [MiLB]), and throwing side dominance. Surgical factors analyzed included reconstruction technique (Docking vs. Modified Jobe), graft type (palmaris longus autograft vs. gracilis autograft), and concomitant procedures. Primary outcome measures consisted of: the ability to return to play at any level (RTP), to return to the same level of play (RSL), the time to return, subsequent elbow injuries, and the need for subsequent or revision elbow surgery. The impact of the patient and surgical factors on outcomes were analyzed using multivariate linear and logistic regression modeling.Results:The overall RTP was 79.9% and RSL was 71.2%. There were no significant differences in the time to RTP or RSL based on reconstruction technique or graft type. RTP rates were similar for the Docking vs. Modified Jobe techniques (80.1% vs. 82.4%; p=0.537) and for the two primary graft types (83.1% for palmaris vs. 80.7% for gracilis; p=0.596). The risk of subsequent elbow surgery was 10.5% for the Docking Technique vs. 14.8% for the Modified Jobe (p=0.203); and the risk for subsequent UCL revision reconstruction surgery was 2.9% vs. 6.2% for the Docking vs. Modified Jobe Techniques, respectively (p=0.128). Significant trends towards an increasing use of palmaris autograft (p=0.023) and the docking technique (p=0.006) were observed. MLB pitchers were more likely than MiLB pitchers to RTP (p<0.001) and to RSL (p<0.001), but they required a longer time to return (mean difference 35 days; p=0.039), had a higher likelihood of subsequent elbow (OR 3.58; 95% CI 2.055 to 6.231; p<0.001) and forearm injuries (OR 5.695; 95% CI 1.99 to 16.302; p=0.004), but not subsequent elbow surgery. No specific variables were noted to be predictive of subsequent elbow or revision surgery in the multivariate analysis.Conclusion:Surgical outcomes in professional baseball players are not significantly influenced by ulnar collateral ligament reconstruction technique or graft type usage. Major League players are more likely to RTP and RSL, but they have a higher frequency of subsequent elbow and forearm injuries. Both the Docking Technique and palmaris autograft are increasing in popularity amongst surgeons treating professional baseball players.

Ulnar collateral ligament reconstruction in athletes using a cortical button suspension technique

A variety of techniques currently exist for ulnar collateral ligament (UCL) reconstruction in symptomatic overhead athletes, all with the potential complication of fracture about the humeral or ulnar tunnels. Far cortical button fixation is a reproducible, biomechanically attractive option; however, no clinical series has been published on this technique to date. This study reports the clinical outcomes, with minimum 2-year follow-up, of a dual far cortical button suspension technique for UCL reconstruction in athletes. A retrospective evaluation was performed of 23 consecutive athletes who underwent UCL reconstruction with the use of ulnar and humeral-sided far cortical button fixation with minimum 2 years of follow-up. Data were collected from electronic medical records and patient telephone calls. The primary outcome was return to sport. Secondary outcomes included Disabilities of the Arm, Shoulder and Hand score, range of motion, and complications. We included 23 athletes with a mean follow-up of 47.2 months (range, 24-81 months). Autograft was used in 22 patients (16 palmaris, 6 gracilis, 1 semitendinosus, and 1 gracilis allograft). Overall, 82.6% (19 of 23) of patients returned to sport. At final follow-up, the average Disabilities of the Arm, Shoulder and Hand score was 3.8, and range of motion averaged 0° to 140°, with 87% (20 of 23) of patients achieving full motion. The visual analog scale score improved from 3.8 preoperatively to 0.2 at the final follow-up (P < .0001). There was 1 reconstruction failure. The humeral and ulnar far cortical button suspension technique provides a new UCL fixation option with theoretically lower concern for tunnel fracture and with predictable return to sport and good functional outcomes.

Forearm Flexor Injuries Among Major League Baseball Players: Epidemiology, Performance, and Associated Injuries

Background: Despite evidence highlighting the importance of the forearm flexor muscles of elite baseball players, no studies have reported on the epidemiology of flexor strains and their associated outcomes. Purpose: To examine the incidence, associated injuries, and outcomes associated with forearm flexor injuries among major and minor league baseball players. Study Design: Cohort study; Level of evidence, 3. Methods: Injury data attributed to forearm flexor injuries among Major League Baseball (MLB) and minor league teams between 2010 and 2014 were obtained from the professional baseball Health and Injury Tracking System. This analysis included the number of players injured, seasonal timing of injury, days spent on the disabled list (DL), preinjury performance data, and subsequent injuries. Results: A total of 134 and 629 forearm flexor injuries occurred in MLB and the minor leagues, respectively. The mean player age was 28.6 and 22.8 years in the MLB and minor leagues, respectively. The mean time spent on the DL for MLB players was 117.0 days, as opposed to 93.9 days in the minor leagues (P = .272). Interestingly, pitcher performance declined in all categories examined leading up to the season of injury, with significant differences in walks plus hits per inning pitched (P = .04) and strike percentage (P = .036). Of MLB players with a forearm injury, subsequent injuries included 50 (37.3%) shoulder, 48 (35.8%) elbow, and 24 (17.9%) forearm injuries. Among injured minor league players, subsequent injuries included 170 (27.0%) shoulder, 156 (24.8%) elbow, and 83 (13.2%) forearm injuries. These rates of subsequent injuries were significantly higher compared with the rates of injuries sustained among players without forearm injuries in both leagues (P < .001). Finally, 26 (19.4%) MLB and 56 (8.9%) minor league players required an ulnar collateral ligament reconstruction, rates that were significantly higher compared with players without a flexor strain (P < .001). Conclusion: Flexor-pronator injuries are responsible for considerable time spent on the DL for elite players in MLB and the minor leagues. The most significant findings of this investigation illustrate that a flexor strain may be a significant risk factor for subsequent upper extremity injuries, including an ulnar collateral ligament tear.