Medial Ulnar Collateral Ligament Reconstruction Research Articles

Anatomic Medial Ulnar Collateral Ligament Reconstruction With Internal Brace Augmentation in Throwing Athletes

Background: Injury to the medial ulnar collateral ligament (MUCL) is a common setback experienced by many throwing athletes often requiring reconstruction with 12 to 18 months of rehabilitation. Current reconstructive techniques fail to anatomically restore the MUCL. This presentation demonstrates the “anatomic technique” for reconstruction of the MUCL supplemented by internal brace augmentation. Indications: Initial injuries of the MUCL can often be managed conservatively; however, many complete tears and those failing nonoperative management are frequently treated with MUCL reconstruction. Technique Description: After graft harvest, a 6-cm incision is created over the medial epicondyle to expose the sublime tubercle and medial epicondyle. Sutures are placed through the torn ligament which are used to formally repair the native ligament. A 4-mm socket is drilled in the MUCL origin of the medial epicondyle, and two 2-mm penetrating sockets are drilled toward the base of the 4-mm socket. The sutures in the native ligament are passed through the sockets and later tied over the bone bridge to complete the native ligament repair. A tight rope is shuttled through the medial epicondyle socket and assembled. The palmaris longus autograft and a suture tape are loaded onto the tightrope and reduced into the humeral socket. On the ulna, soft suture anchors are placed on either side of the sublime tubercle. The distal end of the graft is then sutured utilizing a FiberWire. The graft is secured to the sublime tubercle by tying down the previously placed suture anchors. The suture tapes and internal brace are loaded into a SwiveLock suture anchor, which is fixed distally along the sublime tubercle ridge creating an anatomic reconstruction. Then, the native ligament sutures and tight rope are re-tensioned and tied across the humeral bone bridge for final fixation. Results: In our cohort of 26 professional and amateur throwers, >90% returned to play at the same level at a mean of 9.9 months postoperatively. Discussion/Conclusion: Anatomic reconstruction of the MUCL with internal bracing is a viable option for MUCL injuries and may allow expedited return to sport for most athletes. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Poster 205: Performance and Return to Sport Following Medial Ulnar Collateral Ligament Repair with Internal Brace Augmentation in Professional Baseball Players

Objectives: Medial ulnar collateral ligament (UCL) reconstruction (UCLR) has been the gold standard treatment for symptomatic UCL injuries in throwing athletes. Recently, a novel technique of UCL repair with suture augmentation has been described and shown promising biomechanical as well as clinical results in a few small series of nonprofessional athletes. An added advantage of this technique over UCLR is that it affords the potential ability to return to competitive throwing with an accelerated timeline of 6-7 months as opposed to 12-18 months. No prior work has described the outcomes of this technique in professional athletes. This study aimed to evaluate the frequency and rate of return to prior level of sport as well as athletic performance of professional baseball players following UCL repair with Internal Brace augmentation. Methods: This study included all professional Major League Baseball (MLB) and Minor League Baseball (MiLB) players who underwent primary UCL repair with Internal Brace from January 2016 to June 2021. Demographic and performance data were recorded for each player. Performance metrics were then compared from one year preinjury against one year postoperative metrics. The return to play date was recorded. Univariate statistical analysis was performed to compare preinjury to postoperative performance (p< 0.05 considered statistically significant). Results: Fifteen players met inclusion criteria (8 MLB and 7 MiLB). Mean age was 28.2 +/- 4.06 years at time of surgery. There were 10 pitchers and 5 position players. All injuries were to the dominant extremity. No players underwent revision surgery during the study period. 93.3% (14/15) of players returned to sport and eventually prior level of competition. Average time to return to sport was 11.5 +/- 4.27 months and average time to prior level of competition was 12.1 +/- 4.61 months. When comparing competitive performance of players that returned successfully, one year preinjury to one year postoperatively, there was no statistically significant difference observed in performance [Table 1]. Conclusions: This study demonstrates promising early results of UCL repair with Internal Brace augmentation in professional baseball players. 93.3% of players were able to return to sport in under 12 months. All players, pitcher and position, that returned to sport were able to return to their prior level of play. No statistically significant drop in performance was observed in players that were able to return to play. Further clinical evaluation of UCL repair with Internal Brace augmentation and direct comparison of this procedure with UCL reconstruction is warranted. [Table: see text]

Repair of the Medial Ulnar Collateral Ligament of the Elbow With Internal Brace Augmentation

Background: The medial ulnar collateral ligament (MUCL) is the primary restraint to valgus force across the elbow during throwing. The incidence of MUCL continues to rise, and injuries are common in overhead throwing athletes often leading to elbow pain and instability. While MUCL reconstruction remains the gold standard for high-level throwing athletes with midsubstance tears, MUCL repair remains an option for select athletes and affords good functional outcomes with quicker return to sport compared with reconstruction. Indications: Indications for MUCL repair include acute injuries, proximal or distal avulsions, young and lower demand athletes, non-throwing athletes, or older athletes who may be nearing retirement. Technique Description: An incision is made over the medial elbow from the medial epicondyle to the sublime tubercle. Dissection is carried down to fascia which is split in line with its fibers. The flexor pronator muscle group is bluntly divided, and the ligament exposed. Care is taken to identify and dissect the native ligament. The avulsed portion of the ligament is secured with a 0 FiberWire suture in a running locked whipstitch fashion. The footprint of the avulsed ligament is gently debrided and prepared using a scalpel. The 0-FiberWire suture tails are then loaded onto a suture anchor preloaded with suture tape. This is then secured at the footprint of the ligament. The FiberWires are cut, and the suture tape is then pulled back over the native ligament and fixed at the other attachment site for the ligament. 0-Vicryl sutures are then used to suture the internal brace to the underlying ligament so the construct would move as a single unit. Results: Biomechanical testing has demonstrated that MUCL repair with internal brace augmentation has similar time-zero failure strength when compared with the original Jobe reconstruction technique while also having greater resistance to gapping. In addition, recent literature has shown that well-selected patients can have excellent functional outcomes and quicker return to sport with MUCL repair as opposed to reconstruction. Discussion: Medial ulnar collateral ligament repair with internal brace augmentation can be a successful treatment in the appropriately indicated athlete to allow for good functional results and quicker return to sport. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Medial Ulnar Collateral Ligament Repair With Augmentation: A Systematic Review and Meta-analysis of Preclinical Studies.

Reconstruction is the gold standard treatment for medial ulnar collateral ligament (MUCL) injuries. However, recent studies show a successful and renewed interest in direct suture repair, particularly in young athletes. Repair augmentation with a suture tape may provide greater stability, enabling healing of the MUCL while protecting the repair at higher valgus loads. To perform a systematic review and meta-analysis on whether MUCL repair with augmentation provides a similar biomechanical profile to the traditional MUCL reconstruction. Systematic review. The Cochrane Controlled Register of Trials, PubMed, Medline, and Embase were used to perform a systematic review and meta-analysis using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms: ("ulnar collateral ligament" OR "medial ulnar collateral ligament") AND ("internal brace" OR "augmentation" OR "suture tape"). Data pertaining to certain biomechanical properties (gap formation, failure to torque [ultimate load to failure], stiffness, degree of valgus opening, and modes of failure) were extracted. The pooled outcome data were analyzed by random- and fixed-effects models. A total of 203 abstracts were identified through the aforementioned databases. After abstract and full-text screening, 6 biomechanical studies were included. All were on cadaveric elbows, with 53 repairs with augmentation and 53 reconstructions compared. There were no differences between the 2 in regard to ultimate load to failure (standard mean difference [SMD], -0.34 N·m; 95% CI, -1.36 to 0.68; P = .51) and rotational stiffness (SMD, 0.26; 95% CI, -1.14 to 1.66; P = .72). Despite a trend in resistance to gapping with augmented repair, this was not significant (SMD, -0.53; 95% CI, -1.08 to 0.01; P = .06). Augmented repairs were more likely to fail by pullout or at the suture-tendon/anchor-suture interface (odds ratio [OR], 12.19; 95% CI, 4.17 to 35.62; P < .00001), while failure by fracture was more common with reconstruction (OR, 5.75; 95% CI, 2.07 to 15.99; P = .0008). MUCL augmented repair establishes the required time-zero structural properties without the need for a tendon graft. However, future clinical studies are necessary to determine its true effectiveness as well as its success at higher levels of professional sport.

Correlation of Rehabilitation and Throwing Program Milestones With Outcomes After Ulnar Collateral Ligament Reconstruction: An Analysis of 717 Professional Baseball Pitchers

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.

Using Pitch-Tracking Data to Identify Risk Factors for Medial Ulnar Collateral Ligament Reconstruction in Major League Baseball Pitchers.

Background:Approximately 25% of Major League Baseball (MLB) pitchers undergo medial ulnar collateral ligament reconstruction (UCLR) during their careers.Purpose:To identify risk factors for UCLR that are specific to 2 subgroups of MLB pitchers: right (RHPs)- versus left-handed pitchers (LHPs) and starting (SPs) versus relief pitchers (RPs).Study Design:Case-control study; Level of evidence, 3.Methods:We included 109 MLB pitchers who had undergone UCLR between 2007 and 2019 and had sufficient preinjury data in the 3 years before surgery (T3, T2, T1). A 2:1 matched control cohort was selected for comparison. Pitch velocity, release location, and ball movement were compared between the UCLR and control cohorts in both subgroups in the years before surgery (RHPs vs LHPs and SPs vs RPs). Binary logistic regression was used to identify independent risk factors for UCLR.Results:The mean horizontal release location for the UCLR group was 5.8 cm more lateral than for the control group (P = .028). For all pitchers, every 2.5-cm lateral shift in release location in the years leading up to UCLR equated to a 3.7% increase in the odds of UCLR. For RPs, this risk was more substantial: a 5.8% increase in odds per 2.5 cm. SPs in the UCLR group demonstrated significantly different T1 horizontal release locations compared with SPs in the control group, though not to a statistically significant change over the 3 years before surgery. However, in the 3 years before surgery, the horizontal release location for RPs in the UCLR group moved 2.1 cm more lateral, as compared with 2.7 cm more medial for RPs in the control group (P = .007). For LHPs, a decrease in mean pitch velocity by 1 mph (1.6 km/h) in the years leading up to surgery increased the odds of UCLR by 45%.Conclusion:Increasing lateralization of release point in the years before surgery increased the risk of UCLR, specifically for relievers. Our findings add to the growing body of evidence that release location is an important variable in analyzing the risk of UCLR in MLB and that risk stratification may be dependent on pitcher characteristics such as position, handedness, and weight.

Medial Ulnar Collateral Ligament Reconstruction: A Dual Docking, 4-Ply Reconstructive Technique

Background: Ulnar collateral ligament injuries are common in the overhead-throwing athlete as the anterior band of this ligament is the primary soft tissue static stabilizer to valgus stress during a throwing motion. Various surgical techniques have been described over the past 30 years to address these injuries including Jobe, modified Jobe, docking, 3-stranded docking, Graftlink, and anatomic repairs with good to excellent results. Nevertheless, modifications to these techniques may increase the strength and survival of the reconstruction, which may expedite and optimize postoperative rehabilitation and return to play. Indications: This is a reproducible technique that provides excellent outcomes. We believe a 4-ply construct, with the addition of a high tensile strength suture tape, may provide superior biomechanical properties compared to other reconstructive techniques. Biomechanical testing for this technique is currently underway. Technique Description: Medial ulnar collateral ligament reconstruction using a gracilis autograft passed from proximal to distal, secured at the ulna with a cortical button tension loop construct, and then repassed from distal to proximal with the addition of a high strength suture in parallel to function as an internal brace. Together, this creates a reinforced, 4-ply, ulnar collateral ligament reconstruction with excellent tensile strength. Other advantages of this technique are that it avoids bony bridge fracture between ulnar tunnels, it preserves ulnar bone stock, creates a more anatomic insertion at the sublime tubercle and provides a simple method to tension the entire graft construct. Results: The expected outcomes from this procedure are consistently positive with recent literature reporting greater than 90% of patients having an excellent outcome and over 80% of overhead athletes returning to sport at or above previous level. Conclusion: This specific technique provides a rigid, high-tensile strength reconstruction with excellent outcomes and a high percentage of return to play. Additionally, this technique avoids various technical pitfalls by utilizing cortical button suspensory fixation at the ulna which minimizes complications such as ulnar tunnel conversion and iatrogenic injury to the ulnar nerve when drilling posterior to the sublime tubercle as is necessary with other techniques.

Comparison of a Novel Anatomic Technique and the Docking Technique for Medial Ulnar Collateral Ligament Reconstruction

Background: Current reconstruction techniques do not re-create the distal ulnar collateral ligament (UCL) insertion. Reconstructing the distal extension of the anterior band ulnar footprint may increase elbow stability and resistance against valgus stress after UCL reconstruction (UCLR). Purpose/Hypothesis: The purpose was to test a new technique for UCLR, a modification of the docking technique, aimed at re-creating the distal ulnar footprint anatomy of the anterior band. We hypothesize that this novel “anatomic” technique will provide greater resistance to valgus stress after UCLR when compared with the docking technique. Study Design: Descriptive laboratory study. Methods: Eighteen unpaired cadaveric arms were dissected to capsuloligamentous elbow structures and potted. With use of a servohydraulic load frame, 5 Nċm of valgus stress was placed on the UCL-intact elbows at 30°, 60°, 90°, and 120° of flexion. UCLR was performed on each elbow, randomized to either the docking technique or the anatomic technique. After UCLR, the elbow was again tested at 30°, 60°, 90°, and 120° of flexion. Ulnohumeral joint gapping was calculated using a 3-dimensional motion capture system applied to markers attached to the ulna and humerus. Differences in gapping among the intact state and docking and anatomic techniques were compared using a 2-way analysis of variance with significance set to P < .05. Results: There was no significant difference in gapping between the anatomic and docking technique groups regardless of elbow flexion angle. All reconstructed groups showed increased gapping relative to intact, but all increases were below the clinically relevant level of 1 mm. Conclusion: Ulnohumeral joint gapping and resistance to valgus stress were similar between the anatomic technique and the docking technique for UCLR. Clinical Relevance: This study provides evidence that the anatomic technique is a viable alternative UCLR method as compared with the docking technique in a cadaveric model.

The dynamic rotation axis of ulnohumeral joint during active flexion-extension: an in vivo 4-dimensional computed tomography analysis

BackgroundAs the collateral ligament reconstruction becomes more common to perform, the knowledge between the collateral ligament reconstruction and the elbow rotation axis is still ambiguous. The purpose of this study was to investigate the location of the intersections between the elbow rotation axis and medial and lateral aspect of the humerus.MethodsFour-dimensional computed tomography (4D CT) scan was designed to obtain the images from 8 participants. The instantaneous rotation axis was created according to the trochlea notch of the ulna in the Rapidform XO software. Then the intersections between the instantaneous rotation axis and the medial and lateral aspect of the humerus were identified in the Geomagic Wrap software. Landmark coordinate systems of the distal humerus was created.ResultThe intersections in the medial aspect of the humerus were mostly located in the superior and posterior quadrant and showed the trend from anterior-superior to posterior-superior with the increment of the elbow flexion. The intersections in the lateral aspect of the humerus were mostly located in the middle half of the anterior quadrant and showed the trend from posterior-inferior to anterior-superior with the increment of the elbow flexion.ConclusionThere’s no isometric point for medial collateral ligament (MCL) and lateral ulnar collateral ligament (LUCL) reconstruction. The isometric area for MCL reconstruction should be considered at the superior and posterior quadrant of the medial aspect of the humerus. The isometric area for LUCL reconstruction should be considered at the middle half of the anterior quadrant of the lateral aspect of the humerus.Trial registrationThis work was supported by the National Natural Science Foundation of China [No.81911540488] in 07/01/2019.

Trends in Medial Ulnar Collateral Ligament Repair and Reconstruction From 2007 to 2016: A Population-Based Study of a Large Private Insurance Database.

Background: Ulnar collateral ligament (UCL) reconstruction and UCL repair of the elbow are commonly performed procedures, resulting in high return-to-play rates. Whether the incidence rate of UCL reconstruction vs UCL repair has changed over time is not currently known. Purpose/Questions: We sought to assess temporal trends in the incidence rates of UCL repair and UCL reconstruction and to identify factors associated with UCL reconstruction. We hypothesized that UCL repair would demonstrate an increased incidence overall in recent years with an associated decline in UCL reconstruction rates. Methods: Using the PearlDiver Research Program to query the Humana administrative claims database, we identified patients who had undergone UCL repair and/or reconstruction from 2007 to 2016. Patients were stratified by age (15-19; 20-29; 30-49 years), sex, and year (2007-2011 vs 2012-2016). Poisson regression analysis (continuous variables) was used to calculate the incidence risk ratio (IRR); chi-square tests were performed for categorical variables, and odds ratios were calculated with 95% confidence intervals (CI). Results: The incidence rate of UCL repair was greater in 2012-2016 than in 2007-2011 (IRR: 1.86, 95% CI: 1.16-2.96). The incidence rate of UCL reconstruction vs UCL repair was greater for patients aged 15 to 19 years (IRR: 3.37, 95% CI: 1.97-5.77) but not patients aged 20 to 29 years (IRR: 0.89, 95% CI: 0.49-1.59) as compared with patients aged 30 to 49. Males aged 19 years were more likely than females to undergo UCL reconstruction (IRR: 10.09, 95% CI: 1.37-3.45). Conclusion: While UCL procedures are becoming more popular, our retrospective analysis showed that young males are preferentially treated with UCL reconstruction, warranting further investigation into these trends.

Reconstruction of the Medial Ulnar Collateral Ligament of the Elbow: The Docking Technique

Background: The medial ulnar collateral ligament (MUCL) is the primary restraint to valgus force on the elbow. Since the first description of MUCL reconstruction by Jobe et al in 1986, many technical advancements have been implemented to improve outcomes and reduce complications. The docking technique has emerged as one of the most commonly used techniques. Indications: Following repetitive stress on the elbow during the overhead throwing motion, the MUCL may become attenuated, insufficient, or rupture completely. Although nonoperative treatment with rest and therapy is often the initial treatment of choice, individuals who fail conservative measures may require MUCL reconstruction. Technique Description: The major steps of the procedure are (1) harvesting of palmaris longus autograft, (2) incision and exposure, (3) preparation of ulnar tunnel, (4) preparation of docking site on medial epicondyle, (5) graft passage, (6) graft tensioning and length determination, (7) final fixation, and (8) closure. Results: This procedure allows for reconstruction of the MUCL, restoration of valgus stability to the elbow, and return to play rates of 80% to 95%. The docking technique has advantages over previously described MUCL reconstruction techniques in that it minimizes injury to the flexor pronator mass, avoids the ulnar nerve, allows for robust graft tensioning, and reduces the amount of bone removed from the medial epicondyle. Discussion/Conclusion: The docking technique, as described in this video demonstration, is the most common MUCL reconstruction technique used today. When precise surgical steps are followed, complication rates are low and patient outcomes are favorable.

Is Allograft Reconstruction of the Medial Ulnar Collateral Ligament of the Elbow a Viable Option for Nonelite Athletes? Outcomes at a Mean of 8 Years.

Background:The rate of elbow medial ulnar collateral ligament (MUCL) injury and surgery continues to rise steadily. While authors have failed to reach a consensus on the optimal graft or anchor configuration for MUCL reconstruction, the vast majority of the literature is focused on the young, elite athlete population utilizing autograft. These studies may not be as applicable for the “weekend warrior” type of patient or for young kids playing on high school leagues or recreationally without the intent or aspiration to participate at an elite level.Purpose:To investigate the clinical outcomes and complication rates of MUCL reconstruction utilizing only allograft sources in nonelite athletes.Study Design:Case series; Level of evidence, 4.Methods:Patient records were retrospectively analyzed for individuals who underwent allograft MUCL reconstruction at a single institution between 2000 and 2016. A total of 25 patients met inclusion criteria as laborers or nonelite (not collegiate or professional) athletes with a minimum of 2 years of postoperative follow-up. A review of the medical records for the included patients was performed to determine survivorship free of reoperation, complications, and clinical outcomes with use of the Summary Outcome Determination (SOD) and Timmerman-Andrews scores. Statistical analysis included a Wilcoxon rank-sum test to compare continuous variables between groups with an alpha level set at .05 for significance. Subgroup analysis included comparing outcome scores based on the allograft type used.Results:Twenty-five patients met all inclusion and exclusion criteria. The mean time to follow-up was 91 months (range, 25-195 months), and the mean age at the time of surgery was 25 years (range, 12-65 years). There were no revision operations for recurrent instability. The mean SOD score was 9 (range, 5-10) at the most recent follow-up, and the Timmerman-Andrews scores averaged 97 (range, 80-100). Three patients underwent subsequent surgical procedures for ulnar neuropathy (n = 2) and contracture (n = 1), and 1 patient underwent surgical intervention for combined ulnar neuropathy and contracture.Conclusion:Allograft MUCL reconstruction in nonelite athletes demonstrates comparable functional scores with many previously reported autograft outcomes in elite athletes. These results may be informative for elbow surgeons who wish to avoid autograft morbidity in common laborers and nonelite athletes with MUCL incompetency.

Players' perspectives on successfully returning to professional baseball after medial ulnar collateral ligament reconstruction

As the incidence of ulnar collateral ligament reconstruction (UCLR) surgery continues to rise, an improved understanding of baseball pitchers' perspectives on the postoperative recovery process and return to pitching is needed. The purpose of this study was to analyze pitchers' perspectives on recovery after UCLR. dDuring the 2018 baseball season, an online questionnaire was distributed to the certified athletic trainers of all 30 Major League Baseball (MLB) organizations. These athletic trainers then administered the survey to all players within their organization including MLB and 6 levels of Minor League Baseball. MLB or Minor League Baseball pitchers who had previously undergone UCLR and participated in a rehabilitation program (or were currently participating in one at time of the survey) were included in the study. There were 530 professional pitchers who met inclusion criteria. The majority (81%) of pitchers began rehabilitation within 2 weeks of surgery, with 51% beginning within 1 week. The majority of pitchers began a long-toss throwing program at 5 and 6 months after surgery (27% and 21%), with 52% making their first throw off a mound between 7 and 9 months. The number of pitchers who participated in a weighted ball throwing program decreased significantly after surgery (20%-11%, P < .001). After UCLR, 56% of pitchers reported no changes regarding pitching mechanics or types of pitches thrown, 42% reported changed mechanics, and only 3% either decreased or stopped throwing a certain pitch type. Overall, 54% believed that their current throwing velocity was faster than their velocity before ulnar collateral ligament injury. Twenty percent of pitchers reported experiencing a setback that resulted in temporary stoppage of their rehabilitation program, the most common reason being flexor tightness or tendonitis (53%). Seventy-six percent reported that they were not concerned about sustaining another elbow injury; however, significantly less (61%; P < .001) stated that they would have UCLR again if necessary. Although UCLR is generally reported to have excellent clinical outcomes, 20% of pitchers experienced a significant setback during their rehabilitation and only 61% of pitchers, having gone through UCLR and the subsequent recovery, would be willing to undergo revision surgery and repeat the rehabilitation process if it were to become necessary. In addition, 42% of pitchers felt that they had to alter their throwing mechanics to return to pitching. Surgeons and athletic trainers should aim to understand the UCLR recovery process from the pitchers' perspective to better counsel future patients recovering from UCLR.

Nonoperative Treatment of Ulnar Collateral Ligament Injuries

The anterior bundle of the medial ulnar collateral ligament (MUCL) is the prime valgus stabilizer of the elbow. Athletes who throw overhead, such as baseball players, and javelin throwers, most commonly fall victim to this type of injury as the MUCL is subject to significant loads during the late cocking phase/early acceleration phase of the throwing motion [9,10,11]. The MUCL reconstruction procedure, or one of its variants pioneered by Jobe, has routinely been used to stabilize the medial elbow after MUCL injury. Surgery, however, may not be necessary in all MUCL injuries. This is especially true in younger patients who may present with a more acute form of the injury to the ligament in isolated anatomical areas, and have injuries more along the lines of a sprain, which is an interstitial tear without structural incongruity, or a partial tear. Rettig et al [23] provided the first large series of patients treated with nonoperative management for MUCL injuries, thus demonstrating that MUCL injuries respond to conservative management. A structured return-to-throwing protocol, external stabilization with bracing, physical therapy, and biologic adjuncts such as platelet-rich plasma are potential solutions that may permit athletes to return their preinjury level of play while simultaneously averting the morbidity and longer return-to-play associated with operative treatment.

The History and Evolution of Elbow Medial Ulnar Collateral Ligament Reconstruction: from Tommy John to 2020.

The purpose of this review article is to discuss the evolution of surgical reconstruction of the anterior bundle of the UCL, otherwise known as Tommy John surgery, from Dr. Jobe's initial description in 1986 to present day. In particular, the unique changes brought forth by each new surgical technique, and the reasons that these changes were implemented, are highlighted. The incidence of UCL reconstruction surgery continues to increase significantly, particularly in the 15- to 19-year-old age group. New anatomic understanding of the anterior bundle of the UCL, including the importance of the central fibers and the broad and tapered ulnar insertion, may affect optimal UCL reconstruction techniques in the future. Although return to play rates are generally quite high (80-95%), the mean time to return to play (typically 12-18months for pitchers) is longer than desired. Accordingly, many authors feel that there remains room for improvement in the treatment of this common injury. The Tommy John surgery has evolved in many ways with the development of novel techniques over the last 35years. Currently, overhead throwing athletes undergoing UCL reconstruction have high return to play and low complication rates. Future modifications to the surgery may aim to further improve outcomes and, more importantly, expedite the length of postoperative rehabilitation.

Revision Medial Ulnar Collateral Ligament Reconstruction in Baseball Pitchers: Review of Epidemiology, Surgical Techniques, and Outcomes.

The purposes of this review are to describe the epidemiology, treatment options, and clinical outcomes of revision medial ulnar collateral ligament reconstruction in baseball pitchers. Rates of revision UCL range from 1 to 15% and have slowly increased over the past several years. Revision UCL procedures are associated with higher complication rates, likely due to the distortion of innate anatomy after primary reconstruction. Techniques for reconstruction are largely influenced by the index surgery and integrity of the ulnar and humeral bone tunnels/sockets. Current literature reporting on the outcomes following revision UCL reconstruction is limited to case series and database studies. Mean time between primary reconstruction and revision surgery is approximately 5years and return to play rates range from 47 to 85%. Outcomes following revision UCL reconstruction are relatively guarded compared with those of primary UCL reconstruction with the most studies reporting lower return to play rates, decreased workloads compared with pre-injury levels of play, and shorter career longevity following revision surgery. Future research regarding optimal reconstruction techniques and post-operative rehabilitation are needed as the incidence and demand for this procedure is expected to increase.

Trends in Medial Ulnar Collateral Ligament Repair and Reconstruction in the United States

Trends in Medial Ulnar Collateral Ligament Repair and Reconstruction in the United States

Anatomic and Biomechanical Evaluation of Ulnar Tunnel Position in Medial Ulnar Collateral Ligament Reconstruction

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.

Advanced Baseball Metrics Indicate Significant Decline in MLB Pitcher Value After Tommy John Surgery.

There are conflicting reports regarding the efficacy of Major League Baseball (MLB) pitchers following medial ulnar collateral ligament reconstruction (UCLR). As advanced baseball metrics have revolutionized the way general managers define pitchers' value, the authors believe that these should be used to measure clinical outcomes after UCLR. All MLB pitchers who underwent UCLR from April 1, 1991, through July 1, 2016, were compiled (N=253). Pitcher demographics and statistics were collected for up to 3 full seasons preceding and following surgery. Data for pitching controls (all MLB [AMLB] pitchers) were also collected (N=14,756). Prior to surgery, pitchers with UCLR were significantly better than the AMLB pitchers in nearly all advanced value-based statistics: higher wins above replacement (WAR; 0.93 vs 0.78; 95% confidence interval [CI], 0.80-1.06), lower fielding independent pitching (FIP; 4.23 vs 4.51; 95% CI, 4.12-4.34), lower expected fielding independent pitching (xFIP; 4.17 vs 4.38; 95% CI, 4.06-4.28), higher win probability added (WPA; 0.21 vs 0.05; 95% CI, 0.1-0.32), and higher leverage index (pLI; 1.03 vs 0.96; 95% CI, 0.99-1.06). Pitchers who returned to play after UCLR demonstrated significantly lower value with worse WAR, FIP, WPA, and pLI (P<.05). Conversely, after excluding pitchers who failed to achieve a sustained return to play of greater than 1 year, there were no significant decreases in value after surgery. The authors conclude that, prior to injury, pitchers who have UCLR are more valuable than average MLB pitchers. However, UCLR pitchers perform worse when compared with their presurgical values. This may be affected by players not being able to continue their careers for more than 1 year. [Orthopedics. 2019; 42(6):349-354.].

Influence of Pitching Release Location on Ulnar Collateral Ligament Reconstruction Risk Among Major League Baseball Pitchers.

Background:Medial ulnar collateral ligament (UCL) reconstruction is a common procedure performed among Major League Baseball (MLB) pitchers. The etiology of UCL injury is complex and is not entirely understood.Hypothesis:To better understand risk factors for requiring UCL reconstruction, we hypothesized that pitchers who eventually undergo the procedure will exhibit different throwing mechanics as measured by pitch-tracking data points, such as velocity and release location.Study Design:Case-control study; Level of evidence, 3.Methods:Pitch-tracking and demographic data were gathered for 140 MLB pitchers who had undergone UCL reconstruction between the 2010 and 2017 seasons. Pitch type, release location, and velocity were compared between the surgical cohort and a matched-control cohort.Results:When compared with controls, the mean pitch release location for pitchers who required UCL reconstruction was 12.2 cm more lateral in the year immediately preceding surgery (P = .001). Furthermore, within the surgical cohort, the horizontal release location was 3.4 cm more lateral immediately preceding surgery compared with 2 years earlier (P = .036). Binary logistic regression indicated an odds ratio of 0.51, suggesting a roughly 5% increased odds of UCL reconstruction for every 10 cm of increased lateral release location (P = .048). Both the surgical and the control cohorts threw similar rates of fastballs and had similar mean pitch velocity and fastball velocity. Control pitchers displayed a significant decrease over time in mean pitch velocity (P = .005) and mean fastball velocity, while pitchers in the UCL reconstruction cohort did not (P = .012).Conclusion:Pitch tracking indicates that the mean release point is more lateral in pitchers preceding UCL reconstruction as compared with controls, suggesting that a more lateral pitch release location is an independent risk factor for UCL injury and reconstruction.